ChanBeDu/relevant_section_length · Datasets at Hugging Face

1,332

114,372

50195

Discharge summary

report

Admission Date: [**2121-3-19**] Discharge Date: [**2121-4-3**] Date of Birth: [**2043-6-24**] Sex: M Service: EMERGENCY Allergies: Amiodarone Attending:[**First Name3 (LF) 2565**] Chief Complaint: Respiratory distress. Major Surgical or Invasive Procedure: Intubation with mechanical ventilation Central line placement Tracheostomy Placement of Percutaneous Gastrostomy Tube History of Present Illness: Mr. [**Known lastname **] is a 77 yo M with PMH of CAD/CABG, DM, CRI, AAA/TAA repair, multiple CVA, seizure d/o who presented to the ED w/ respiratory distress. Son reports 4 days of lethargy, decreased POs, 'not walking at all,' and wet, non-productive cough. He also reports subjective fever the morning of admission. His son states that his father did not complain of any chest pain, abdominal pain or dysuria. He has had normal bowel movements. He lives at home with wife and was seen there today by NP who referred him to the ED. He denied abdominal pain/nausea/vomiting/diarrhea/CP/SOB. On arrival to [**Name (NI) **] pt was tachypneic w/ RR 35, BP 198/122, T 101.2 rectally, sats 70s on RA, 85 on NRB, RLL crackles and rhonchi. He had a CXR that showed multilobar pneumonia. He was intubated for respiratory distress with VBG showing 7.28/50/56. Other significant labs were; BNP 2458, Trop 0.06, Lactate 3.4. His blood pressure had been in the high 100's systolic and dropped initially to 90's then to 54/33 after receiving propofol. He then received 6L NS and peripheral dopa was started. A RIJ placed and started on central levophed and dopamine per sepsis protocol (on low dose for both (124/70). He received Levaquin 750mg IV and Ceftriaxone 1gm and was consented for sepsis research study. On arrival to floor, ABG was 7.32/45/327 on AC @100% w/ PEEP 10 and FiO2 was decreased to 60. He was started on fentanyl/versed gtt for sedation, and dopa and levo for BP support. Past Medical History: CAD CABG X 3 VD (70% distal LMCA, 100% PDA/PLV) HTN CHF LEVF 50% ([**11-1**]) MR, TR Anemia (baseline 28.2-33.8) AFib s/p pacer, D/C cardioversion, on Warfarin SDH ([**11-1**]): 3 mm L frontoparietal SDH 12 strokes since [**2105**] DM CRI (baseline Cr 1.5-1.7) LLE cellulitis Surgical History: AAA repair '[**08**] w/ redo in '[**09**] TAA repair '95CAD Social History: Married, lives in [**Location (un) 538**]. Spanish speaking only . He is currently retired, was an independent truck driver. Tobacco remote history, quit over 10 years ago. Alcohol use is rare Family History: Non-contributory Physical Exam: VS: Temp: 100 BP: 155/83 HR:79 RR:19 O2sat100% on AC FiO2 100, PEEP 10 GEN: elderly man, lying in bed, intubated HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: no jvd RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: sedated . on discharge pertinent changes: NECK: trach collar in place ABD: PEG in place, wound c/d/i Pertinent Results: LABORATORY STUDIES [**2121-3-19**] BLOOD WBC-10.6 RBC-5.47# Hgb-15.7# Hct-48.6# MCV-89 MCH-28.7 MCHC-32.3 RDW-13.9 Plt Ct-308# [**2121-3-20**] BLOOD Hct-27.7* [**2121-4-3**] BLOOD WBC-10.0 RBC-3.71* Hgb-10.5* Hct-32.6* MCV-88 MCH-28.2 MCHC-32.0 RDW-14.8 Plt Ct-524* [**2121-4-3**] BLOOD Glucose-147* UreaN-14 Creat-1.3* Na-141 K-3.9 Cl-104 HCO3-30 AnGap-11 MICROBIOLOGY 2/2O URINE - NEGATIVE SPUTUM - NEGATIVE BLOOD - Coag Neg Staph, Neg FLU - Negative Legionella UA Negative [**Date range (1) 101379**] Sputum growing Yeast Blood Cx [**3-20**], [**3-22**] Negative REPORTS AND STUDIES ECHO [**3-21**]: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Overall left ventricular ejection fraction is normal (LVEF 60-70%); however, the basal segments of the inferior septum, inferior free wall, and posterior wall are hypokinetic. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The descending thoracic aorta is moderately dilated. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2119-5-6**], the mitral regurgitation appears reduced; however, this suboptimal study may have underestimated the mitral regurgitation. CXR [**2121-4-1**] In comparison with the study of [**3-31**], there is little overall change. Tubes remain in place in this patient with median sternotomy and pacemaker leads. Hazy opacification of the lower half of the right hemithorax is again seen, consistent with pleural fluid. Some asymmetric pulmonary edema, worse on the right, is suggested. CXR [**2121-4-2**]: IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided single lumen PICC line placement via the right basilic venous approach. Final internal length is 43 cm, with the tip positioned in SVC. The line is ready to use. Brief Hospital Course: A/P: 77 yo M with PMH of CAD/CABG, DM, CRI, AAA/TAA repair, multiple CVA who presented initially with RLL pneumonia, admitted to the MICU intubated [**3-1**] to respiratory distress and hypotension, extubated briefly, then reintubated secondary to increased secretions. . #) Pneumonia/Respiratory Failure: Upon initial presentation, the patient had had 4 days of lethargy, and increased cough with inability to clear sputum. The patient was intubated initially and started on levofloxacin and ceftriaxone. Flagyl was additionally added; The patient's vent was titrated according to ABGs. Ceftriaxone was discontinued on [**3-25**]. The patient was extubated on [**3-26**], but required reintubation the subsequent day for respiratory distress, presumed secondary to thick secretions. A pneumonia was seen on CXR, and the patient was started on zosyn and vancomycin. The patient had a trach, PEG and central line placed on [**2-/2042**]. Pressure support was weaned as tolerated, but he may require more ventilator support for transport. Zosyn and vancomycin are to be continued for an 8 day course for PNA. Zosyn and vanc are to be given via PICC for 1 more days for 8 days total. PICC lines was placed on [**2118-4-2**] and is ok for use. Last day of vancomycin and zosyn will be [**2121-4-4**]. . #) Hypotension/Sepsis: On initial presentation, pt was hypertensive to 200s/100s, but BP began to drop after intubation. IV dopamine and fluids were started, BP increased. The patient was pan-cultured. The patient's pressors were weaned and fluid boluses were given as necessary. Resolved. . #) Hypernatremia: Initial sodium was 160. The patient did not appear volume-overloaded on arrival to the medical floor despite receiving 6 L NS. Most likely cause was thought to be dehydration from not drinking water. The free water deficit was calculated and the patient was given free water to bring his sodium down. His electrolytes were closely monitored. He can continue to get free water with his tube feeds as needed. . #) A-fib/A-flutter: pt has a history of this, controlled on sotolol and metoprolol. During admission, he went into a-fib with rvr and a-flutter but this wsa controlled with uptitration of medications including calcium channel blocker & beta blocker. - Continue lopressor and diltiazam for control (can titrate up if needed) . #) Renal Failure: Cr 1.8 on admission, elevated BUN/Cr ratio suggests at least partial pre-renal etiology although pt has chronic renal insufficiency with baseline Cr of 1.6. Currently, creatinine stable and at baseline, creatinine 1.3 at discharge. . #) Mental Status - Pt still remains largely unarousable despite being off of sedating medications. Per discussion with family, his baseline is poor to start. - continue to hold sedating medications. . #.) Anemia-Pt received 1 U PRBC on [**3-31**] for a Hct of 24.9, with an apppropriate hematocrit elevation. Hematocrit 32.6 at time of discharge. . #) CAD: h/o CAD s/p CABG X 3 VD (70% distal LMCA, 100% PDA/PLV) - continue ASA, statin . #) Pump: last ECHO [**5-4**] = LEVF 50%, no signs of volume overload at present. . #) Hyperlipidemia: continue statin . #) DM: Continue glargine 20 U hs and insulin per sliding scale. . #) F/E/N: IVF prn. Replete lytes PRN. TF at goal. . #) PPx: Bowel regimen, PPI, pneumoboots, heparin SC TID while nonambulatory. . #) Access: PICC . #) Code Status: DNR. Patient would like no CPR, no shock, but vasopressors okay. . #) Communication: [**Name (NI) **] [**Name (NI) **] (wife) [**Telephone/Fax (1) 104708**] Medications on Admission: Amlodipine 10mg QD Aspirin 325mg QD Citalopram 10mg QD Docusate 200mg [**Hospital1 **] Glipizide 5mg QD Keppra 500mg TID Lipitor 20mg QD Lisinopril 5mg QD Metoprolol 100mg QD Senna 187mg tab QD Sotalol AF 80mg [**Hospital1 **] Zyprexa 5mg QD @ 5pm . Allergies: Amiodarone (neurotoxicity), Codeine, PCN Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: per tube. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed: per tube. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day): per tube. mL 4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): per tube. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): per tube. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: per tube. 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5,000 unit injection Injection TID (3 times a day): while nonambulatory. 10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): hold for sbp <100, hr <55 per tube. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 12. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 13. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day: humalog insulin sliding scale.* * Refills:*2* 14. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20) units Subcutaneous at bedtime. 15. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): at 5pm. 16. Citalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 18. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) g Intravenous Q 12H (Every 12 Hours) for 3 doses: To end after PM dose on [**2121-4-4**]. 20. Zosyn 4.5 gram Recon Soln Sig: 4.5 g Intravenous every eight (8) hours for 1 days: To end after PM dose on [**2121-4-4**]. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: PRIMARY Sepsis Pneumonia Atrial Fibrillation Acute Renal Failure SECONDARY Chronic Kidney Disease Stage II Chronic Diastolic Congestive Heart Failure Anemia h/o Subdural Hemorrhage h/o stroke x12 Diabetes Dementia Discharge Condition: afebrile, normotensive, comfortable on trach mask Discharge Instructions: You were admitted to the hospital with respiratory distress and found to have a pneumonia. You were on the ventilator to assist with your breathing while you were treated with antibiotics. Because of your condition, you were not able to be off of the ventilator initially, and underwent a tracheostomy to help with secretions and aspiration. Your medications have changed. Please review your current medication list. You are being discharged to a rehab/skilled nursing facility. If you develop fevers, chills, respiratory difficulty, shortness of breath, or other concerning symptoms, please return to the hospital. Followup Instructions: Please follow-up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks of leaving the hospital. Completed by:[**2121-4-3**]

[ "427.31", "403.90", "785.52", "428.32", "585.2", "038.9", "427.32", "285.21", "428.0", "780.39", "V45.81", "507.0", "518.81", "584.9", "276.0", "486", "V45.01", "250.00" ]

icd9cm

[ [ [] ] ]

[ "43.11", "96.04", "96.6", "99.04", "96.72", "31.1", "38.93" ]

icd9pcs

[ [ [] ] ]

11348, 11419

5409, 8977

293, 413

11678, 11730

3072, 5386

12396, 12538

2531, 2549

9330, 11325

11440, 11657

9003, 9307

11754, 12373

2564, 3053

232, 255

441, 1926

1948, 2304

2320, 2515

66,158

154,318

34903

Discharge summary

report

Admission Date: [**2158-2-14**] Discharge Date: [**2158-2-19**] Date of Birth: [**2099-9-16**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2158-2-14**] coronary artery bypass x 3 (LIMA-LAD, SVG-OM, SVG-PLV), Mitral valve repair (28mm ring) History of Present Illness: This 58 year old white male with silent MI on echocardiography and an abnormal stress test presented for cardiac catheterization recently. significant mitral regurgitation and triple vessel coronary disease were found. Asked to evaluate for surgical revascularization Past Medical History: Hypertension Hyperlipidemia Silent MI Moderate Mitral Regurgitation TIA [**2155**] Glaucoma Sleep Apnea (does not use CPAP) Renal insufficiency Social History: Lives with:alone Occupation:service tech Tobacco:1ppd x 25 years ETOH:denies Family History: +CAD in parents and younger brother Physical Exam: Pulse:65 Resp:18 O2 sat: 99%RA B/P Right:181/93 Left:180/86 Height:5'[**57**]" Weight:185 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft, non-distended & non-tender [x] Extremities: Warm, well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: palp Left: palp DP Right: palp Left: palp PT [**Name (NI) 167**]: palp Left: palp Radial Right: palp Left: palp Carotid Bruit Right:(-) Left:(-) Pertinent Results: PRE BYPASS The left atrium is elongated. No spontaneous echo contrast is seen in the left atrial appendage. A patent foramen ovale is present. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with inferior wall hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened with some tethering at the belly of the anterior leaflet An eccentric, posteriorly directed jet of Moderate to severe (3+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] notified of findings intraoperatively on [**2158-2-14**] at 0810 POST BYPASS s/p CABG and Mitral valve repair w/ half ring. Left ventricular function remains unchanged with inferior hypokinesis and EF 40-50%. Trace mitral regurgitation. No evidence of mitral stensis with mean gradient of 3 mmHg. Aorta intact. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2158-2-14**] where the patient underwent coronary artery bypass x 3 and mitral valve repair with a 28mm ring. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Cefazolin was used for surgical antibiotic prophylaxis. POD 1 found the patient extubated and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support by POD 1. The patient was transferred to the telemetry floor for further recovery. He did develop some confusion on POD 2 and narcotics were discontinued. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Hypertension was managed with lopressor and lisinopril. Norvasc was added for additional blood pressure control. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He did develop a leukocytosis, which was followed. Blood cultures revealed no growth. By the time of discharge the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged onPOD 4 in good condition with appropriate follow up instructions. Medications on Admission: Buproprion 150mg po BID for 3 days, then 1 tab [**Hospital1 **] (pt not taking yet, he is still smoking) Lisinopril 40mg po daily Metoprolol Succinate 100mg po daily Simvastatin 40mg po daily ASA 81mg po daily Nicotine patch-not using yet as he is still smoking Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 9. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day for 4 weeks. Disp:*30 patches* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: coronary artery disease mitral regurgitation s/p coronary artery bypass s/p mitral valve repair Discharge Condition: Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with Ultram 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) 79878**] 6, [**2157**], 1pm ([**Telephone/Fax (1) 170**]) please schedule appointments with: Primary Care Dr. [**Known firstname **] [**Last Name (NamePattern1) 14919**] ([**Telephone/Fax (1) 14918**]) in [**11-19**] weeks Cardiologist Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 62**]) in [**11-19**] weeks Completed by:[**2158-2-19**]

[ "585.9", "518.0", "414.01", "327.23", "403.90", "401.9", "424.0", "272.4", "414.2", "V12.54", "292.81", "E937.9", "412" ]

icd9cm

[ [ [] ] ]

[ "36.12", "35.33", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

5914, 5972

3082, 4513

341, 447

6112, 6206

1724, 3059

6746, 7143

1024, 1061

4826, 5891

5993, 6091

4539, 4803

6230, 6723

1076, 1705

282, 303

475, 745

767, 913

929, 1008

23,906

105,446

51399+59344

Discharge summary

report+addendum

Admission Date: [**2111-1-17**] Discharge Date: [**2111-1-27**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 6114**] Chief Complaint: Fell down; transferred to medicine for CHF mgmt. Major Surgical or Invasive Procedure: None History of Present Illness: Sister [**Name (NI) 106556**] is an 80-yo W w/hx. of CAD s/p CABG x4, AFib, HTN, AS, AI s/p mechanical fall this past weekend outside her [**Hospital3 **] facility w/o LOC and GCS 15. Sustained contusion and lac over L. temporal area and L periorbital/zygomatic region w/nondisplaced zygomatic fx. - not surgically treated. Also had intraparenchymal bleed. Was admitted to OSH then transferred to [**Hospital1 18**] ICU. While there developed NSTEMI and CHF. She was transferred to Med floor today for ongoing mgmt. of her CHF. Per pt., she has been in pain since her hospital admisson mainly in her l. lateral rib cage. Otherwise she denies current SOB, PND (sleeps on one pillow), or lightheadedness, although had complained of SOB earlier today. Reports that while in ICU, had experienced some nausea w/o V. Also denied F/C/other pain. Past Medical History: - CAD s/p CABG x4 in [**2101**] - AFib - AS, AI - HTN - Dyslipidemia - MI in [**2094**]; tx. by PCTA - Lumbar discectomy x2 - Bladder polypectomy - Gout - cataract surgery Social History: Retired nun. No T/A/D Family History: Noncontributory Physical Exam: Gen: Sister [**Name (NI) 106556**] was resting in bed in NAD. Ecchymosis is present in L. periorbital area along w/contusing over l. temple. some bruising also visible in L hand and L knee HEENT: PERRLA, No lymphadenopathy, vision intact. CVS: 2-3/6 systolic murmur best heard at L and R parasternal borders; peripheral pulses intact; slightly elevated JVP; no signs of peripheral edema Pulm: Prominent rales bilaterally [**1-12**] way up lung fields; nl tympany to percussion Abd: soft, ND/NT, +BS Neuro: AOx3; sensation intact in all dermatomes; [**5-14**] muscle strength throughout UE's and LE's; 2+ reflexes bilaterally in all extremities; normal finger-to-nose testing and rapid alternating movements; gait not assessed Pertinent Results: [**2111-1-16**] 06:45PM WBC-14.7* RBC-3.79* HGB-10.8* HCT-34.1* MCV-90 MCH-28.5 MCHC-31.6 RDW-16.9* [**2111-1-16**] 06:45PM PLT SMR-NORMAL PLT COUNT-260 [**2111-1-16**] 06:45PM NEUTS-91.4* BANDS-0 LYMPHS-6.0* MONOS-1.8* EOS-0.5 BASOS-0.4 [**2111-1-17**] 06:10AM GLUCOSE-197* UREA N-49* CREAT-1.5* SODIUM-142 POTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-28 ANION GAP-16 [**2111-1-17**] 06:10AM CALCIUM-9.8 PHOSPHATE-4.7* MAGNESIUM-2.0 [**2111-1-17**] 06:10AM CK(CPK)-114 [**2111-1-17**] 06:10AM CK-MB-9 cTropnT-0.04* [**2111-1-17**] 09:19PM CK(CPK)-269* [**2111-1-17**] 09:19PM CK-MB-28* MB INDX-10.4* cTropnT-0.50* CT Sinus- ? fractures of the left zygomatic arch of left zygomatic arch and left squamus temporal bone of undetermined age. Clinical correlation with point tenderness recommended. CT Head-Stable left subtle contusion and minimally displaced zygomatic arch fracture. ECHO-Conclusions:The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with near akinesis of the basal 2/3rds of the septum. The remaining segments contract well. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Mild to moderate ([**1-11**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Regional left ventricular systolic dysfunction c/w CAD. Mild aortic valve stenosis. Mild aortic regurgitation. Mild-moderate mitral regurgitation. Pulmonary artery systolic hypertension. Brief Hospital Course: CHF Pt. transferred to [**Hospital1 18**] from outside hospital s/p fall at home and was judged to have zygoma fx. not needing intervention. Pt. was transferred to SICU for two days. Serial CXR's showed evidence of CHF, and EKG showed changes suggestive of NSTEMI. TpnT trended up from 0.04 to 0.50 as did CK. On Mon [**1-19**] pt. was transferred to med floor from SICU for further mgmt. and was continued on beta-blocker and lasix. Echo and CXR were obtained for further evaluation, confirming low EF and some akinesis but signs of improvement. Pt. was put on ACE inhibitor and started on nesiritide and monitored throughout week. She showed progressive clinical improvement on this medical regimen along with low Na diet and goal of minus 1L net fluid intake daily and incentive spirometry.TpnT, however, continued to trend upward after a brief drop, reaching 2.02. CK trended down and remained flat and pt. showed no signs of new MI after repeat EKGs. Cardiology consulted and agreed with regimen focusing on diuresis with ACEI. It was decided there was no need to continually monitor Tpn in absence of clinically concerning sx's. Pt. continued to improve and was able to increase activity, and ceased to experience SOB. Spironolactone was added to regimen. Expectation is that she will remain stable and be able to return to acute rehab center after discharge. CAD/Dyslipidemia Pt. had known athersclerosis and was kept on atorvastatin for duration of her hospital stay. NSTEMI/demand ischemia that occurred in SICU was likely exacerbated or caused by coronary occlusion and cardiology consult addressed this during pt.'s course. Pt. will need to continue on statin with plan to have assessment for eventual cardiac catheterization. when she is fully recovered post-discharge, she should obtain MIBI scan/stress test. AFib Pt. had longstanding hx of AF prior to transfer to our ED and SICU. On med floor, pt. was continued on beta blocker for rate control and digoxin to help rhythym. Digoxin levels were monitored and pt. was found to have therapeutic level which trended upward, prompting dose reduction. Level increased again and digoxin was d/c'ed but bb continued. Throughout her course pt. was frequently tachycardic and in non-sinus rhythym. SC heparin was used for prophylaxis, and AF continued to stay under reasonable control during her stay. Following discharge, she can, at her physician's discretion, return to a regular Coumadin regimen with possible aim for cardioversion vs. rate control medical mgmt. Neurological Pt. was evaluated by neurosurgical and orthopedic consult in ED and had head CT as well. There was agreement that injury was nondisplaced zygomatic fx. not requiring invasive repair. However, Coumadin that pt. had been on prior to arrival was d/c'ed for fear of bleeding risk. While on medical service, pt. was prophylaxed with SC heparin and low dose aspirin and remained stable for rest of her stay. She will be instructed to follow up with ophthalmologist and/or orthopedist as needed after discharge. UTI Pt. developed a UTI shown to be Klebsiella pneumonia with pansensitivity. She was treated with a 7 dd course of antibiotic, first with 3 dd.levo. This was suspected to contribute to daily nausea she experienced, and was thus switched to ceftriaxone. Pt. did well throughout week with improvement in nausea sx's. She remained afebrile and Foley was eventually d/c'ed. Pain Pt. was given acetaminophen during her stay and a lidocaine patch as well. SHe mainly experience LUQ/L lower chest pain that resolved upon relief of her constipation via lactulose and enema. Lateral axillary pain was present which was thought to be due to fall and responded well to morphine while in ED then to PO pain meds and lidocaine patch whle on med floor. Hypernatremia Pt. initially presented with upward trend in serum Na. This was addressed by instituting a low Na diet and encouraging free water intake. She responded well, normalized, and remained stable for the duration of her stay. Following discharge, Sr. [**Known lastname 106556**] should return to acute rehab and follow up with her cardiologist to decide on the following issues: 1) how best to address pump function and CAD and 2) how to treat Afib. Per the recommendations of cardiology at [**Hospital1 18**], she would benefit from MIBI stress testing within the following weeks with subsequent catheterization if feasible. As for the arrhythmia, it will be her doctor's discretion whether to focus on rate controlling her, or on returning to a Coumadin regimen with the aim of cardioversion. Her zygomatic and conjunctival injury should also be addressed by follow up in [**2-13**] weeks with optho and/or ortho services. Medications on Admission: norvasc 10', lasix 60', allopurinol 300', atenolol 75', lipitor 40', tramadol 50', lisinopril 40', KCL 40', Colace 100", motrin 800''' prn, amoxicillin 2gm prn proph, coumadin 5', asa 81', SL nitro 0.4' Discharge Medications: 1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*5* 8. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Bumetanide 2 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 12. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 13. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 14. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Left Frontal Lobe Contusion CHF CAD Hyperlipidemia A.fib Discharge Condition: Stable, no SOB, ambulating without dyspnea, no neuro deficits Discharge Instructions: Please take all medications as instructed. Please do not restart your digoxin and follow up with your doctors regarding controlling your heart rate with other medications. Do not start taking your coumadin until told to do so by your doctors,this should be restarted about [**2111-2-8**] but check with your doctors [**First Name (Titles) 5001**] [**Last Name (Titles) 9533**]. If you experience any chest pain, shortness of breath, lower extremity swelling, weight gain, lightheadedness you should seek medical attention. Followup Instructions: 1. Follow-up with Dr. [**Last Name (STitle) 739**] in [**1-11**] wks. Call [**Telephone/Fax (1) 1669**] for an appointment. Please inform the office that you need a Head CT scan prior to your appointment. 2. Follow-up with your outpatient ophthalmologist in 4 wks. 3. Follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] to evaluate a L thyroid calcification noted on the CT scan. Also you need to follow up with Dr. [**Last Name (STitle) **] in regards to your heart failure and atrial fibrillation. It has been recommended that your coumadin be held for 3 weeks until [**2-8**]. 4. You should follow up with your cardiologist about CHF and a.fib management. Name: [**Known lastname 17394**],[**Known firstname **] / SISTER Unit [**Name (NI) **]: [**Numeric Identifier 17395**] Admission Date: [**2111-1-17**] Discharge Date: [**2111-1-27**] Date of Birth: [**2030-2-21**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1513**] Addendum: Re: Medication changes made prior to discharge Brief Hospital Course: # A.fib- Here digoxin level continued to trend down. On discharge, digoxin level was 1.3 however we elected not to restart given her recent toxicity and development of nausea/retching. For now we will continue with beta blocker for rate control. The metoprolol will be swicthed to Toprol XL. # CHF- Added imdur 30mg qday given BP's still in the 140-160 range. Also will change metoprolol 50mg tid to Toprol XL 150mg qday. # [**Name (NI) 16357**] Pt has been on lipitor prior to admission. Her AST/ALT were mildy elevated at 50/56. These should be recheck as an outpatient. For now continued her lipitor. Discharge Medications: 1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 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). Disp:*30 Tablet(s)* Refills:*2* 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*5* 7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Bumetanide 2 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 11. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 12. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 13. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 14. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 3465**] - [**Location (un) 824**] Discharge Diagnosis: Left Frontal Lobe Contusion CHF CAD Hyperlipidemia A.fib Discharge Condition: Stable, no SOB, ambulating without dyspnea, no neuro deficits Discharge Instructions: Please take all medications as instructed. Please do not restart your digoxin and follow up with your doctors regarding controlling your heart rate with other medications. Do not start taking your coumadin until told to do so by your doctors,this should be restarted about [**2111-2-8**] but check with your doctors [**First Name (Titles) 17396**] [**Last Name (Titles) 17397**]. If you experience any chest pain, shortness of breath, lower extremity swelling, weight gain, lightheadedness you should seek medical attention. Followup Instructions: 1. Follow-up with Dr. [**Last Name (STitle) **] in [**1-11**] wks. Call [**Telephone/Fax (1) 8659**] for an appointment. Please inform the office that you need a Head CT scan prior to your appointment. 2. Follow-up with your outpatient ophthalmologist in 4 wks. 3. Follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] to evaluate a L thyroid calcification noted on the CT scan. Also you need to follow up with Dr. [**Last Name (STitle) **] in regards to your heart failure and atrial fibrillation. It has been recommended that your coumadin be held for 3 weeks until [**2-8**]. Also need to have your LFTs closely followed given mild elevation and patient on lipitor. 4. You should follow up with your cardiologist about CHF and a.fib management. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1514**] MD [**MD Number(2) 1515**] Completed by:[**2111-1-27**]

[ "424.1", "401.9", "041.3", "410.71", "V45.81", "276.0", "286.7", "428.0", "851.81", "E885.9", "E934.2", "427.31", "564.00", "873.42", "414.8", "802.4", "599.0", "584.9" ]

icd9cm

[ [ [] ] ]

[ "86.59", "99.07", "00.13" ]

icd9pcs

[ [ [] ] ]

14476, 14549

12358, 12973

277, 283

14650, 14713

2182, 3938

15288, 16252

1403, 1420

12996, 14453

14570, 14629

8711, 8915

14737, 15265

1435, 2163

189, 239

311, 1151

1173, 1347

1363, 1387

82,629

123,405

42106

Discharge summary

report

Admission Date: [**2159-8-26**] Discharge Date: [**2159-8-29**] Date of Birth: [**2116-5-15**] Sex: M Service: MEDICINE Allergies: primaquine / clindamycin Attending:[**First Name3 (LF) 613**] Chief Complaint: Dypsnea, dizziness, and chills Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 30864**] is a 43 year old male with recently [**Known lastname 75629**] HIV/AIDS (CD4 33 on [**2159-8-9**] and now 6 on [**2159-8-27**], viral load 134,000 on [**2159-8-11**]) not yet started on ARVs, recently admitted from [**Date range (3) 91343**] for presumed PCP who now represents with fevers, chills, and dyspnea. . His recent [**Date range (1) 91344**] admission was for 3-4 months of fatigue, mild dyspnea, cough, fevers, malaise, weight loss, and loose stools. He was [**Date range (1) 75629**] with HIV/AIDS and presumptively [**Date range (1) 75629**] with PCP by clinical picture, high LDH, and beta glucan. He was started on Bactrim DS 2 tabs Q8H (Day 1 = [**2159-8-9**]) but developed hyperkalemia on [**8-15**] and therefore was switched to clindamycin 450 mg PO Q6H and primaquine 15 mg daily to complete a 21 day course that should have continued until [**8-30**]. He also started prednisone (Day 1 = [**2159-8-13**]) after developing hypoxia. In addition, he was treated empirically with 5 days of azithromycin/ceftriaxone for community acquired pneumonia before PCP was established. TB was ruled out with 3 negative induced sputums. He required 5L supplemental O2 initially and was weaned off all oxygen before discharge. . Though the patient was discharged with prescriptions for primaquine and clindamycin, he did not fill them, and he did not take antibiotics after he was discharged on [**8-16**]. During initial interviews, the patient said he had taken primaquine and clindamycin until [**8-23**]. He was also prescribed azithromycin 1200mg weekly for MAC prophylaxis but did not take this. However, he felt well and tried to wait until his ID appointment on [**8-27**] because he had no fevers, cough, or dyspnea. Yesterday [**2159-8-26**], he went to work and developed chills, shortness of breath, tachypnea, tremors, and headache. His co-workers called an ambulance to bring him to [**Hospital1 18**] ED. Per EMS, he desaturated to 80s on RA. . In the ED, he was febrile to 104, tachycardic to 144, tachypneic to 30, 94% on 3L. CXR showed improved but diffuse patchy opacities. EKG showed sinus tachycardia. He was given vancomycin 1g IV, zosyn 4.g IV, levofloxacin 750mg IV, acetaminophen 1g PO, ibuprofen, 4L NS, and atrovent nebulizer that improved his symptoms. He was admitted to the ICU but not intubated, then transferred to the floor. . On the floor, the patient said he was still feeling short of breath without chest pain. He continued to have left-sided dull headache and felt "foggy" and "not sharp" but without focal deficits, but the headache improved with ibuprofen and acetaminophen. He felt nauseous but denied vomiting. He also reported rhinorrhea and diarrhea today, as well as pain in his mouth from ulcers. He reported minimal cough, with small amounts of clear and occasionally green sputum. He later felt feverish, and cooling blanket was provided, providing relief. . Review of systems: (+) Per HPI (-) Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting, constipation, abdominal pain. Denies dysuria, genital discharge, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: # HIV/AIDS- Had planned to start HAART as outpatient. Opportunistic infection labs including hepatitis, CMV, and toxoplasmosis were negative for acute infection, but CMV IgG was positive so patient remains at risk for CMV esophagitis. Ophtho consult during previous hospitalization ruled out CMV retinitis. # PCP [**Name9 (PRE) 91345**] presumptively [**Name9 (PRE) 75629**] by clinical picture, high LDH and beta glucan # Saphenous vein thrombophlebitis without DVT Social History: Lives with 2 roommates (one of whom he identifies as HIV positive). Quit smoking 4 years ago, previously 20 years of about 1 cigarette per day. No alcohol or illicits. He bartends and plans to resume school at [**Hospital1 498**] in the spring. No significant travel history recently. No incarceration. Has sex with men and uses protection, but no partners over the past year. Family History: Father died of a heart attack at age 57. Has not kept in touch with mother. Physical Exam: ADMISSION EXAM: VS: Tc/Tmax 96.3/104; HR 92; BP 128/79; RR 14; O2sat 95% RA General: pleasant, NAD EENT: PERRL, EOMI, sclerae anicteric, neck supple, moist mucous membranes, conjuctival hemorrhage on right lower eyelid, tongue with deep furrows, thrush on tongue, ulcer on left lower lip CV: RRR, normal S1, S2, no murmurs / rubs / gallops Pul: clear to auscultation bilaterally w/o wheezes / rhonchi / rales BACK: no focal tenderness, no costovertebral angle tenderness GI: normoactive bowel sounds, soft, non-tender, non-distended, no hepatosplenomegaly MSK: no joint swelling or erythema Extremities: Right second digit with small pustular lesion at tip palpable cord medial thigh at location of prior superficial thrombosis, 2+ pitting edema in left ankle. warm and well perfused, 2+ DP pulses palpable bilaterally LYMPH: no cervical, supraclavicular lymphadenopathy SKIN: no rashes, no jaundice NEURO: awake, alert and oriented x3, CN 2-12 intact, [**3-29**] strength bil, normal sensitivity PSYCH: non-anxious, normal affect Pertinent Results: Admission Labs: [**2159-8-26**] 09:49PM LACTATE-2.7* [**2159-8-26**] 09:47PM GLUCOSE-81 UREA N-24* CREAT-0.8 SODIUM-139 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-20* ANION GAP-17 [**2159-8-26**] 09:47PM estGFR-Using this [**2159-8-26**] 09:47PM ALT(SGPT)-43* AST(SGOT)-29 ALK PHOS-77 TOT BILI-0.4 [**2159-8-26**] 09:47PM LIPASE-66* [**2159-8-26**] 09:47PM WBC-7.8# RBC-4.34* HGB-10.9* HCT-34.5* MCV-80* MCH-25.1* MCHC-31.6 RDW-17.1* [**2159-8-26**] 09:47PM NEUTS-87* BANDS-2 LYMPHS-6* MONOS-1* EOS-2 BASOS-0 ATYPS-0 METAS-0 MYELOS-2* [**2159-8-26**] 09:47PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2159-8-26**] 09:47PM PLT SMR-NORMAL PLT COUNT-205# [**2159-8-27**] 02:20AM BLOOD Neuts-90* Bands-7* Lymphs-0 Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Notable Labs: [**2159-8-27**] 02:20AM BLOOD WBC-8.0 Lymph-4* Abs [**Last Name (un) **]-320 CD3%-60 Abs CD3-192* CD4%-2 Abs CD4-6* CD8%-54 Abs CD8-171* CD4/CD8-0.0* [**2159-8-26**] 09:47PM BLOOD Lipase-66* [**2159-8-27**] 02:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2159-8-26**] 09:49PM BLOOD Lactate-2.7* CXR [**2159-8-26**]: Bilateral diffuse lung opacities, improved from [**8-11**] but similar to [**2159-8-9**]. Baseline radiograph is not available for comparison, so it is unclear whether this return to the [**2159-8-9**] radiograph represents residual pathology. Differential diagnosis as detailed above. Brief Hospital Course: 43 year old male with recently [**Year (4 digits) 75629**] HIV/AIDS (CD4 33 on [**2159-8-9**] and now 6 on [**2159-8-27**], viral load 134,000 on [**2159-8-11**]) not yet started on ARVs, recently admitted from [**Date range (3) 91343**] for presumed PCP who now represents with fevers, chills, and dyspnea in the context of discontinuing primaquine/clindamycin. 1. # Fever, dyspnea: The patient was febrile to 104 in the ED, with bilateral pulmonary infiltrates on CXR, which were improved from previous imaging during last hospitalization. Given his recent admission with PCP pneumonia and not taking primaquine/clindamycin at all after he was recently discharge, the patient was thought likely to have relapse of PCP. [**Name10 (NameIs) **] received vancomycin, zosyn, and levofloxacin in the ED, which was tailored back to clindamycin/primaquine in the MICU, where he was admitted due to subjectively increased work of breathing. He suffered rigors in the MICU which were aborted with acetaminophen and demerol. He was transferred to the medicine floor for further management. On the primaquine and clindamycin, he developed innumberable blanching macular 1mm rashes on his chest, back, and arms. He was initially switched to Bactrim, but given his previous hyperkalemia on Bactrim during last admission, he was switched with one day to atovaquone 750mg twice a day, and he will complete a minimum of a 14 day course, with possible extension to a 21 day course to be determined at his outpatient infectious disease appointment. He had occasional headache that was relieved by ibuprofen and acetaminophen, and he -otherwise rested comfortably and was afebrile for much of his admission on the medicine floor. However, he desaturated to 77% on ambulation and had an elevated A-aO2 gradient of 45 and was started on 40mg prednisone daily. He will taper on the schedule: 80mg daily from [**Date range (1) 16628**], 40mg daily from [**Date range (1) 25165**], 20mg daily from [**Date range (1) 79119**], 10mg daily from [**Date range (1) 91346**], 5mg daily from [**Date range (1) 91347**], then stop. He refused to undergo induced sputum testing, though the diagnosis of PCP was still not definitive. . 2. HIV/AIDS: Patient was recently [**Date range (1) 75629**] with HIV and CD4 33. He had planned to initiate HAART as outpt on [**8-27**]. Repeat CD4 count on this admission was 6. He continued azithromycin 1200mg PO weekly for MAC prophylaxis and nystatin S&S for thrush. ID was consulted re: initiation of HAART, which will be done as an outpatient. MRSA screen, B-glucan, HHV8, histoplasma antigen, and blood culture results were pending at discharge. Cryptococcal antigen was negative. . 3. Eye lesion Ophthalmology evaluated the patient's new right lower palpebral conjunctival red lesion involving the eyelid lateral margin. This lesion was not noted on previous admission. He did not have eye pain or visual changes. There was suspicion of Kaposi's sarcoma, though the differential included pyogenic granuloma, evolving chelazion, or atypical subconjunctival hemorrhage. No acute intervention was recommended, and the patient will follow up as an outpatient. . 4. Left leg edema The patient had pitting edema around his left ankle but not the right. He has history of bilateral greater saphenous vein thrombosis without DVT on his last admission. Throughout hospitalization, he denied any pain in his lower extremities and refused to undergo additional ultrasound examination. He was ordered for subcutaneous heparin and intermittently accepted it, stating that he was walking frequently. . 5. Anemia Hematocrit dropped on the night of admission from 34.5 to 27.8 in the setting of receiving IV fluid. Most likely a dilutional effect. It increased to 31.4 on the day of discharge without need for blood transfusion. MCV was in the low 80s, and the patient was thought to have anemia of chronic disease on prior admission due to high ferritin of 652 with low TIBC of 211 and transferrin 162. . Transitions of care: -MRSA screen, B-glucan, HHV8, histoplasma antigen, and blood culture results were pending at discharge -He did not receive flu shot or pneumovax during this admission to the best of our knowledge. Medications on Admission: 1. Fluconazole 200 PO Q24H (Last Dose 9/30) 2. Nystatin 100,000 unit/mL 5 mL PO QID for Thrush 3. Prednisone 40 mg PO (completed) 4. Clindamycin HCl 450 mg PO Q6H (last dose 10/15) 5. Primaquine 26.3 mg PO daily (last dose 10/6) 6. Albuterol sulfate 90 mcg/Actuation HFA [**11-26**] INH Q4-6H PRN SOB 7. Ipratropium bromide 17 mcg/Actuation HFA [**11-26**] INH Q6H PRN SOB 8. Famotidine 20 mg PO Q12H Discharge Medications: 1. azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (MO) for 2 weeks. Disp:*4 Tablet(s)* Refills:*0* 2. atovaquone 750 mg/5 mL Suspension Sig: Seven [**Age over 90 1230**]y (750) mg PO BID (2 times a day) for 14 days: Take twice a day with a fatty meal. . Disp:*QS 14 day supply* Refills:*0* 3. prednisone 10 mg Tablet Sig: ASDIR Tablet PO once a day: Take 4 tablets twice a day from [**Date range (1) 16628**]. Take 4 tablets daily from [**Date range (1) 25165**]. Take 2 tablets daily from [**Date range (1) 79119**]. Take 1 tablet daily from [**Date range (1) 91346**]. Take 0.5 tablets daily from [**Date range (1) 91347**]. Then stop. . Disp:*70 Tablet(s)* Refills:*0* 4. lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane TID (3 times a day) as needed for mouth pain for 2 weeks. Disp:*QS 2 Week Supply* Refills:*0* 5. [**Hospital 16836**] Medical Equipment Please provide home oxygen via portable system at 2 L/min to be used during activity. Patient with oxygen saturation < 88% with ambulation. 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks: Take while on Prednisone to protect your stomach. . Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PCP pneumonia HIV/AIDS Thrush anemia of chronic disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 30864**]: . You were admitted to [**Hospital1 69**] because you were having fever, chills, shortness of breath, and dizzyness, which was most likely due to your recent diagnosis of PCP [**Name Initial (PRE) 1064**]. You were restarted on antibiotics and steroids during this hospitalization. You will need to continue these for several weeks after discharge. It is also very important that you follow up closely with the specialists listed below. . The following changes were made to your medications: . START taking the following medications: 1. Start taking Atovaquone 750 mg by mouth twice a day. Please take with a fatty meal. You have been given a two week supply of this medication. You will likely need to take this medication for a total of three weeks but because of your insurance status we were only able to obtain a two week supply at this time. Your Infectious Disease doctor will determine the final course of this medication at your visit. 2. Take 4 tablets twice a day from [**Date range (1) 16628**]. Take 4 tablets daily from [**Date range (1) 25165**]. Take 2 tablets daily from [**Date range (1) 79119**]. Take 1 tablet daily from [**Date range (1) 91346**]. Take 0.5 tablets daily from [**Date range (1) 91347**]. Then stop. 3. Start taking Azithromycin 1200 mg by mouth once a week on Mondays. 4. Start using Viscous lidocaine 20 mL by mouth up to four times a day as needed for mouth pain. Please take as you were instructed to during your hospitalization. 4. Start taking Famotidine 20 mg by mouth daily while you are on the Prednisone. This medication will help to protect your stomach while you are on the Prednisone. As above, you have been given a two week supply because of your insurance status. An additional week can be purchased over the counter at any drug store. . STOP taking the following medications: 1. Stop taking Clindamycin HCl 450 mg by mouth every 6 hours. 2. Stop taking Primaquine 26.3 mg by mouth daily. . No other changes were made to your medications and you should continue taking all other medications as previously prescribed. Followup Instructions: Please keep all follow-up appointments as below: . Department: [**Hospital1 7975**] INTERNAL MEDICINE When: FRIDAY [**2159-8-31**] at 12:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 63642**], MD [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site . Department: INFECTIOUS DISEASE When: WEDNESDAY [**2159-9-5**] at 1:30 PM With: URGENT CARE ID [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: [**Hospital3 1935**] CENTER When: THURSDAY [**2159-9-20**] at 9:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7304**], MD [**Telephone/Fax (1) 253**] 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**] Completed by:[**2159-8-30**]

[ "112.0", "136.3", "782.3", "285.29", "042", "373.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13040, 13046

7136, 11162

315, 321

13146, 13146

5628, 5628

15422, 16551

4484, 4562

11835, 13017

13067, 13125

11407, 11812

13297, 15399

4577, 5609

3332, 3579

245, 277

349, 3313

5644, 7113

13161, 13273

11183, 11381

3601, 4070

4086, 4468

26,836

185,922

29462

Discharge summary

report

Admission Date: [**2168-8-3**] Discharge Date: [**2168-8-27**] Date of Birth: [**2119-3-15**] Sex: F Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5883**] Chief Complaint: Right Breast Cancer/SDA Major Surgical or Invasive Procedure: [**8-23**] VAC removal [**8-17**] 1. Right breast latissimus muscle flap 2. Split-thickness skin grafting to latissimus muscle 30 x 15 cm. 3. Local advancement flap closure lateral aspect of right chest. [**8-12**] Right VAC dressing change. [**8-8**] Right chest wound vacuum assisted closure dressing change [**8-3**] 1. Right radical mastectomy 2. Right breast local advancement flap. 3. Vacuum-assisted closure dressing placement History of Present Illness: 49 yo F w/ right breast mass noticed [**3-1**], had it evaluated [**6-29**] and found to have infiltrating poorly differentiated, ER/PR and HER-2/neu negative breast CA. She had 4 cycles of Cytoxan, Adriamycin followed by Taxotere for three cycles every two weeks apart. She was then evaluated for surgical resection and was referred to [**Hospital1 18**] after that was thought unfeasible. She was evaluated here and tried 3 cycles of cisplatin which was not tolerated well. She then rec'd Taxol and Gemzar for 4 cycles (asof [**3-30**]). She then tried XRT with sensitizing carboplatinum for 5 cycles. She was thought to have disease response to this therapy and went ahead with surgical resection. Her course was complicated by difficult to control pain and DVT with PE requiring anticoagulation with lovenox and coumadin. Past Medical History: seasonal allergies s/p port-a-cath PE diagnosed ? at [**Hospital1 1474**] [**Date range (1) 70730**], on lovenox, stopped prior to surgery with coumadin transition Social History: Married, lives with husband. Smoked 1 ppd since age 16, recently down to 1/4 PPD, 4-5 drinks/wk. Family History: Father with carotid stent. A maternal aunt had breast cancer at 65 and never had a recurrence. Maternal uncle had lung cancer. Her mother had [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 4585**]. Physical Exam: PE, at discharge: Pt in NAD, pain well controlled at this time Cardiac: RRR, no M/R/G Chest: CTAB Abd: soft, NT/ND Ext: RUE edema> LUE edema, arm soft, good radial pulse, good capillary refill Skin: Latissimus flap on R chest healing well, warm, well perfused, pale pink, good capillary refill. skin graft site healing well, dressed with vaseline [**Last Name (un) 26535**], kerlex. Pertinent Results: [**2168-8-27**] 07:10AM BLOOD PT-25.6* INR(PT)-2.6* [**2168-8-26**] 06:25AM BLOOD PT-23.0* PTT-38.3* INR(PT)-2.3* [**2168-8-24**] 06:44PM BLOOD PT-20.5* PTT-76.0* INR(PT)-2.0* [**2168-8-23**] WBC-6.5 RBC-3.26* Hct-32.4* Plt Ct-254 [**2168-8-3**] WBC-7.6 RBC-2.65* Hct-25.0*# Plt Ct-164 [**2168-8-3**] 12:15PM BLOOD PT-38.1* INR(PT)-4.2* [**2168-8-18**] 05:29AM BLOOD Glucose-120* UreaN-7 Creat-0.5 Na-136 K-4.3 Cl-100 HCO3-29 AnGap-11 [**2168-8-3**] 08:29PM BLOOD Glucose-108* UreaN-14 Creat-0.6 Na-140 K-3.5 Cl-104 HCO3-29 AnGap-11 [**2168-8-3**] 08:29PM BLOOD ALT-18 AST-27 AlkPhos-56 TotBili-0.8 [**2168-8-18**] 05:29AM BLOOD Calcium-8.0* Phos-4.3 Mg-1.4* [**2168-8-3**] 08:29PM BLOOD Albumin-3.0* Calcium-7.9* Phos-3.8 Mg-1.7 [**2168-8-4**] 04:41AM BLOOD VitB12-272 Folate-17.0 [**2168-8-3**] 08:29PM BLOOD Triglyc-134 [**2168-8-3**] 08:29PM BLOOD TSH-0.51 Brief Hospital Course: Pt: 49yo F s/p right radical mastectomy for poorly invasive carcinoma, grade 3, ER/PR, HER-2/neu negative [**8-3**] 1. Right radical mastectomy 2. Right breast local advancement flap. 3. Vacuum-assisted closure dressing placeme RUE US [**8-6**]: Very limited study demonstrating patency of the right brachial, axillary, and internal jugular vein, without visualization of the subclavian, cephalic, or basilic veins. CTA [**8-6**]: RUL/RLL segmental emboli (acuity unclear), anticoagulation started. [**8-8**] Right chest wound vacuum assisted closure dressing change [**8-9**] transfused 1u prbcs [**8-12**] Right VAC dressing change. [**8-17**] 1. Right breast latissimus muscle flap 2. Split-thickness skin grafting to latissimus muscle 30 x 15 cm. 3. Local advancement flap closure lateral aspect of right chest. [**8-19**] Transfused one unit PRBC for hct 27 and symptoms [**Date range (1) 70731**] VAC to continuous suction for skin graft, pt with R arm in sling, elbow elevated at all times to protect flap blood supply, transfused 1 unit PRBC x 2 for lightheadedness and hct of 27 and 26. [**8-23**] VAC removed in the OR. [**8-24**] INR 2.0. Heparin gtt stopped. [**8-26**] INR 2.3 [**8-27**] Last drain removed INR was 2.6. Her last dose of coumadin was 4mg on [**8-26**] Throughout hospital course pts pain has been managed by chronic pain service. Pt has been anticoagulated: on heparin sliding scale (held for procedures and once pt became therapeutic on coumadin) and coumadin (also held for procedures). Pt d/ced w/ VNA for drain care, dressing changes and INR checks. Pt has OT/PT request in for home safety evaluation and gentle passive ROM to R shoulder Medications on Admission: PREDNISONE 5 mg [**Hospital1 **] ATIVAN 0.5 -1 mg QID FENTANYL 100 mcg/hour--3 patches q 48h MS CONTIN 90 mg [**Hospital1 **] Morphine 15 -45 mg q2-4h NEURONTIN 600 mg TID NYSTATIN 100,000 unit/mL QID Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthrough pain. Disp:*90 Tablet(s)* Refills:*0* 4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q48H (every 48 hours). Disp:*15 Patch 72 hr(s)* Refills:*0* 5. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO bid () as needed for pain. Disp:*100 Capsule(s)* Refills:*0* 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO q tue., [**Last Name (un) **]., sat., sun. Disp:*17 Tablet(s)* Refills:*2* 7. Warfarin 3 mg Tablet Sig: One (1) Tablet PO q mon., wed., fri. Disp:*13 Tablet(s)* Refills:*2* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. MS Contin 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 10. MS Contin 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: R breast cancer Discharge Condition: stable Discharge Instructions: Please return to the hospital if you experience fevers greater then 101.4, chills, or other signs of infection. Also return to the hospital if you experience chest pain, shortness of breath, redness, swelling, or purulent discharge from the incision site. Return if you experience worsening pain or any other concerning symptoms. Certain pain medications may have side effects such as drowsiness. Do not operate heavy machinery while on these medications. Certain pain medications such as percocet or codeine can cause constipation. If needed you can take a stool softner such as Colace (one capsule) or gentle laxative (such as Milk of Magnesia) once per day. Restart taking all your regular medications once you arrive at home. -Please do not shower until your follow-up visit. . Please do not place any pressure on your chest, especially the surgical site. Please keep track of JP drain output for your follow-up visit. Please continue to take antibiotics until your drains are out. If you run out of antibiotics before your drains are removed, please call us immediately to get a refill. . Please resume previous medications as prior to your surgery. Please take pain medications and stool softener as prescribed. . Please follow-up as directed. Followup Instructions: 1. Follow up with Dr. [**First Name (STitle) **] in one week. 2. Please follow up with Dr. [**Last Name (STitle) 11635**]. Please call ([**Telephone/Fax (1) 61002**] to make an appointment. 3. Please follow up with Dr.[**Name (NI) 13339**] office as needed for anticoagulation treatment or other oncologic concerns ([**Telephone/Fax (1) 70732**] 4. Follow up with pain management services for pain control issues ([**Telephone/Fax (1) 19088**].

[ "V58.61", "285.9", "492.8", "196.3", "198.5", "174.8" ]

icd9cm

[ [ [] ] ]

[ "99.04", "85.84", "85.85", "85.47", "93.57", "85.82" ]

icd9pcs

[ [ [] ] ]

6749, 6804

3477, 5181

337, 790

6864, 6873

2589, 3454

8175, 8624

1965, 2171

5433, 6726

6825, 6843

5207, 5410

6897, 8152

2186, 2190

2204, 2570

274, 299

818, 1645

1667, 1833

1850, 1948

8,106

180,959

15805+15806+15807+15838

Discharge summary

report+report+report+report

Admission Date: [**2169-9-16**] Discharge Date: [**2169-10-18**] Date of Birth: [**2131-5-10**] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old gentleman transferred from [**Hospital3 17310**]. The patient reportedly was at work at [**Company 7546**], had a generalized seizure and fell to the ground from a standing position. At the outside hospital, he had a decreased level of consciousness. Head CT was done which demonstrated a subdural hematoma, interparenchymal blood and subarachnoid hemorrhage. The patient has a significant past medical history for ETOH abuse and seizure disorder with a question of poor medication compliance, reported only by the outside hospital. The patient was intubated, sedated, paralyzed and transferred by Med-Flight to [**Hospital6 2018**]. On arrival to [**Hospital6 256**], pupils were equal and reactive to light, 6 mm. He had positive corneal reflex and positive gag reflex. He was still paralyzed. Blood pressure was 248/143. He had right orbital trauma and a right arm hematoma. He was taken for repeat head CT which showed increase in the subdural hematoma, parenchymal blood and temporo-parietal lobe involvement with edema, mass effect and shift. On repeat neurologic exam, pupils were 4 mm and briskly reactive. Positive corneal reflexes. No spontaneous eye opening but responded to verbal stimuli. Withdraws all four extremities. Increased reflexes. Right toes up, left toes down. Blood pressure range 170/30 to 200/100. Titrating Nipride drip to keep systolic blood pressure 120 to 140. Heart rate 90 to 130s. Chest was clear to auscultation. Cardiac revealed a regular rate and rhythm. Abdomen was benign. LABORATORIES ON ADMISSION: White count was 12.1, hematocrit 38, platelets 192. Sodium 139, potassium 2.9, chloride 96, CO2 23, BUN 9, creatinine 1.0, glucose 180. INR was 1.6. HOSPITAL COURSE: The patient was admitted to the Surgical Intensive Care Unit, loaded with Dilantin and continued on a Nipride drip. On [**2169-9-16**], the CT scan showed left hemisphere acute subdural hematoma with left fronto-temporal contusion and no significant subarachnoid blood or intraventricular blood. Stable compared to the CT from six hours prior. CT of the cervical spine showed no fracture. The patient was continued to be monitored in the Surgical Intensive Care Unit. X-rays of the thoracic and lumbar spine showed evidence of a T12 compression fracture. The patient remained intubated and sedated. Pupils were equal, round and reactive to light but sluggish. The patient was not following commands but localizing to pain in all four extremities. Continued on Propofol for sedation. At 7:00 p.m. on [**2169-9-17**], the patient began posturing on the left side and the right side became flaccid. Pupils continued to be sluggish. CT on [**2169-9-18**] showed evolution of the left fronto-temporal contusion and overall mass effect not significantly different from yesterday. Moving all four extremities, right arm less than left arm. Question of a generalized seizure on [**2169-9-18**]. The patient was started on valproic acid. The patient was extubated on [**2169-9-19**]. On [**2169-9-20**], the patient was opening his eyes to voice, turning his head to the examiner, localizing to pain and withdrawing. Stable blood pressure. Pupils equal, round and reactive to light, 5-4 mm and brisk. Patient with purposeful movements of all extremities, left greater than right. He had a repeat head CT on [**2169-9-20**] which showed no change. The patient had a lumbar puncture on [**2169-9-21**] which showed an opening pressure of 34. 20 cc of bloody cerebrospinal fluid was sent for culture, cell count, glucose and protein. Closing pressure was 14. The patient tolerated the procedure well. Lumbar puncture was done secondary to high temperature and a question of meningitis due to attempted ventriculostomy drain placement. The patient needed to be reintubated on [**2169-9-21**] secondary to respiratory distress. On [**2169-9-21**], the patient had blood cultures sent which came back positive for coagulase negative Staphylococcus. The patient was started on Vancomycin for 28 days. On [**2169-9-23**], the patient was awake and attentive. Pupils were 4 to 3 mm and briskly reactive. Localizing sternal rub. Lower extremities moved spontaneously and withdraws to pain x4. Improving neurologically. Weaning sedation and weaning from the ventilator. On [**2169-9-26**], the patient's neurologic status deteriorated. He had a right ventriculostomy drain placed at the bedside which was under high pressure. He tolerated the procedure well. He had a repeat head CT which showed increased edema with more shift to the left. The patient was started on Mannitol. Neurologically, he continued to wax and wane. He would arouse to voice and open his eyes briefly. Pupils were 3 mm and brisk. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2169-10-18**] 10:18 T: [**2169-10-18**] 10:25 JOB#: [**Job Number 36431**] Admission Date: [**2169-9-16**] Discharge Date: [**2169-10-18**] Date of Birth: [**2131-5-10**] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old gentleman who fell at work after having a generalized seizure. He fell from the standing position. He was transferred to [**Hospital3 17310**] where a head CT showed a left subdural hematoma and left fronto-temporal interparenchymal contusion with a small amount of subarachnoid hemorrhage. The patient has a significant history of ETOH abuse in the past. The patient was Med-Flighted to [**Hospital6 256**] for further treatment. On arrival, pupils were equal, round and reactive to light. He had positive corneal reflexes and positive gag reflex but continued to be paralyzed. He had a right arm hematoma. He had a repeat head CT which showed an increase in the subdural hematoma and parenchymal blood with a temporo-parietal contusion. The patient was admitted to the Surgical Intensive Care Unit for close monitoring. HOSPITAL COURSE: On [**2169-9-18**], the patient had a repeat head CT which showed evolution of the left fronto-temporal contusion, overall mass effect and not significantly changed. Moving all four extremities. The right arm was moving less than the left arm, and there was a question of a generalized seizure. The patient was on CPAP with pressure support on the ventilator and being weaned. The patient spiked a temperature to 101.8 and sputum cultures were sent. The patient was extubated on [**2169-9-19**] and tolerated it until [**2169-9-20**] when he required reintubation for an obstruction of his airway and secretions. The patient also had a lumbar puncture done on [**2169-9-21**] for a temperature of 104 to rule out meningitis from attempted ventriculostomy drain placement. Cultures came back negative. The patient did have positive blood cultures for gram negative rods and was on a 14 day course of Vancomycin. The patient had an EEG which showed no seizure activity and continued to improve neurologically until [**2169-9-26**] when his mental status deteriorated. Head CT showed an increase in swelling. He had a ventriculostomy drain placed at that time. Neurologically, he slowly improved after ventriculostomy drain placement. The patient was also started on Mannitol for brain edema. The patient had a repeat head CT on [**2169-9-27**] which showed increase in midline shift, left temporal edema and slight increase in ventricular size with ventricular drain placed. Continued on Mannitol and clinically stable. Continued with strict fluid restriction. On [**2169-9-29**], the patient had a repeat head CT which showed an increase in size of the left subdural hematoma. The patient was taken to the operating room and had a bur hole drainage of the left subdural hematoma without intraoperative complications. Postoperatively, the patient was attending but not following commands, opening his eyes purposefully and moving on the left. Pupils were 3, down to 2.5 mm and brisk. Withdrawing all extremities to pain. He was seen by the Hematology Service for an increasing platelet count. The patient's thrombocytosis was thought to be secondary to inflammation with no immediate treatment required. The patient's platelet count was as high as 1222. Currently, it is 704. On [**2169-10-1**], the patient was opening his eyes. Gaze was conjugate. Pupils were 4, down to 3 mm and brisk. He was withdrawing the left side greater than the right. Not following commands. CT showed stable size of the residual subdural fluid and a small amount of blood in the track from the ventriculostomy drain. On [**2169-10-4**], the patient's eyes would open spontaneously. He was moving his left side spontaneously and withdrawing the right upper extremity. Not following commands. Withdrawing is slower. CT scan showed mild decrease in brain edema. Mannitol was weaned. The patient was awaiting PEG and trach placement. On [**2169-10-9**], the patient self-extubated. The patient tolerated extubation. He was awake, alert and following simple commands. Perseverating on motor exam. Holds arms up off the bed. Right side weaker than the left. The patient had a speech and swallowing evaluation which he passed. He was transferred to the regular floor on [**2169-10-10**]. He remained neurologically awake and alert, moving all extremities, confused and agitated at times with severe receptive aphasia, but slowly improving. He was seen by Physical Therapy and Occupational Therapy and found to require rehabilitation. He continues on Vancomycin currently at 750 mg intravenously q12 hours for gram negative sepsis, until [**2169-10-19**]. MEDICATIONS AT DISCHARGE: 1. Captopril 12.5 mg n.g. t.i.d. 2. Heparin 5000 units subcutaneously b.i.d. 3. Lopressor 150 mg p.o. t.i.d., hold for systolic blood pressure of less than 110 and heart rate less than 55. 4. Multivitamin 1 p.o. q day. 5. Magnesium oxide 400 mg p.o. q day. The patient's condition was stable at the time of discharge. He will follow up with Dr. [**First Name (STitle) **] in one month with repeat head CT. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2169-10-18**] 10:34 T: [**2169-10-18**] 10:40 JOB#: [**Job Number 45475**] Admission Date: [**2169-9-16**] Discharge Date: [**2169-11-10**] Date of Birth: [**2131-5-10**] Sex: M Service: ADDENDUM: The patient was discharged to rehab on [**2169-11-10**] in stable condition. His condition was unchanged from prior discharge summary dated [**2169-10-19**]. Neurologically, awake, alert and oriented times one, moving all extremities strongly, walking independently. He continued to have some expressive aphagia. He was seen by rehab services here at the [**Hospital1 69**] and will follow post surgery with Dr. [**First Name (STitle) **] in one month and Dr. [**Last Name (STitle) 45476**] [**Name (STitle) **] in Neuro Rehab Clinic. He was stable with a Dilantin level of 20.1. On the day of discharge his Dilantin dose is 100 mg po t.i.d., Lopressor 100 mg po b.i.d., Prevacid 40 mg po q day, Tylenol 650 po q 4 hours prn for headache. The patient has been stable and ready for discharge. The patient will follow up with Dr. [**First Name (STitle) **] in one month and [**First Name9 (NamePattern2) 45476**] [**Location (un) **] from Neuro/Behavior in one month as well. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2169-11-10**] 11:49 T: [**2169-11-10**] 14:03 JOB#: [**Job Number 45477**] Admission Date: [**2169-9-16**] Discharge Date: [**2169-11-10**] Date of Birth: [**2131-5-10**] Sex: M Service: ADDENDUM: The patient was discharged to rehab on [**2169-11-10**] in stable condition. His condition was unchanged from prior discharge summary dated [**2169-10-19**]. Neurologically, awake, alert and oriented times one, moving all extremities strongly, walking independently. He continued to have some expressive aphagia. He was seen by rehab services here at the [**Hospital1 69**] and will follow post surgery with Dr. [**First Name (STitle) **] in one month and Dr. [**Last Name (STitle) 45476**] [**Name (STitle) **] in Neuro Rehab Clinic. He was stable with a Dilantin level of 20.1. On the day of discharge his Dilantin dose is 100 mg po t.i.d., Lopressor 100 mg po b.i.d., Prevacid 40 mg po q day, Tylenol 650 po q 4 hours prn for headache. The patient has been stable and ready for discharge. The patient will follow up with Dr. [**First Name (STitle) **] in one month and [**First Name9 (NamePattern2) 45476**] [**Location (un) **] from Neuro/Behavior in one month as well. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2169-11-10**] 11:49 T: [**2169-11-10**] 14:03 JOB#: [**Job Number 45477**]

[ "790.7", "805.2", "289.9", "518.81", "E888.9", "482.41", "780.39", "303.90", "851.42" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.72", "03.31", "02.2", "01.31", "96.6", "96.71", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

6299, 9981

9995, 13511

5421, 6281

1767, 1919

27,172

194,717

49112

Discharge summary

report

Admission Date: [**2110-2-25**] Discharge Date: [**2110-3-28**] Date of Birth: [**2055-11-20**] Sex: M Service: MEDICINE Allergies: Penicillins / Aspirin / Ibuprofen / Ciprofloxacin Attending:[**First Name3 (LF) 943**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Endotracheal intubation IR-guided Liver biopsy PICC placement Post-pyloric dobhoff placed under fluoro on [**3-28**] History of Present Illness: 54M s/p OLT in [**6-4**] c/b sepsis with subsequent exlap in [**8-5**]; he was recently discharged from [**Hospital1 18**] s/p R hip fx repair from a fall (not syncope related). Per report, because the pt is unable to provide a history, he has an altered mental status for the last two days; his VNA referred him to the ER because of his altered mental status and low O2 sats. In the OSH ER he had several bouts of coffee-ground emesis; he did not complain of any fevers/chills/abdominal pain at this time. In speaking with other services, reportedly he was recently being treated for a highly resistent pseudomonal UTI as well as CDiff. Past Medical History: # alcoholic cirrhosis, s/p Liver transplant [**2109-6-6**], [**2109-6-23**] exploration for hematoma and fluid collection # prior ESLD prior w/ascites, hepatorenal syndrome, grade II esophageal varices and portal gastropathy, candidal and bacterial (SBP) peritonitis # colorectal cancer (stage unknown) s/p colectomy in [**11/2108**] # cervical stenosis # hyperlipidemia # hypertension # history of C Diff colitis # anemia with baseline Hct 27-30 # history of Torsades while on ciprofloxacin # depression # history of positive PF4 antibody? # BPH # chronic pancytopenia PSH: s/p colectomy in [**11/2108**] s/p OLT [**2109-6-6**], s/p exlap for hematoma and fluid collection [**2109-6-23**] s/p exlap/LOA [**8-5**] s/p exlap/LOA/washout, temp closure [**8-5**] s/p exlap/abd closure, cmpt separation [**8-5**] s/p trach [**8-5**] s/p R hip fx [**2110-1-23**] Social History: Extensive EtOH prior to 5 years ago. no IVDU. [**Date range (1) 61126**] ppd x30yrs but quit in [**1-5**]. Used to work as construction worker . smoking quit date: [**1-5**] Family History: Denies fhx of early MI, stroke, cancer. Physical Exam: Gen: Thin chronically ill appearing male, intubated, sedated. Atraumatic. HEENT: anicteric, PERRL, EOMI. Neck: Supple, no bruits CV: Bradycardic, nl s1 s2, no m/r/g appreciated Chest: Clear anteriorly Abd: Extensive healing surgical scars, nontender, + bowel sounds Ext: DP/PT 2+, 2+ edema in bilateral lower extremities. Skin: No rashes Neuro: Pt is intubated, unable to assess mental status. Rectal: Guaiac positive in ED. Pertinent Results: [**2110-2-25**] 9:10 pm URINE Source: Catheter. URINE CULTURE (Preliminary): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. SENT [**Hospital1 4534**] FOR COLISTIN SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | AMIKACIN-------------- =>64 R CEFEPIME-------------- 32 R CEFTAZIDIME----------- 32 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 8 I PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ =>16 R [**2110-2-26**] 5:46 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2110-3-3**]** GRAM STAIN (Final [**2110-2-26**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [**2110-3-2**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. RARE GROWTH OROPHARYNGEAL FLORA. YEAST. MODERATE GROWTH. YEAST. SPARSE GROWTH. 2ND TYPE. PSEUDOMONAS AERUGINOSA. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | AMIKACIN-------------- 16 S CEFEPIME-------------- 16 I CEFTAZIDIME----------- 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- =>16 R PIPERACILLIN---------- R PIPERACILLIN/TAZO----- 64 S TOBRAMYCIN------------ =>16 [**2110-3-25**] 05:00AM BLOOD WBC-2.6* RBC-2.43* Hgb-7.7* Hct-22.7* MCV-94 MCH-31.6 MCHC-33.8 RDW-15.3 Plt Ct-66* [**2110-3-18**] 04:00AM BLOOD WBC-3.5* RBC-3.33* Hgb-10.1* Hct-31.6* MCV-95 MCH-30.2 MCHC-31.9 RDW-16.2* Plt Ct-126* [**2110-3-14**] 05:59PM BLOOD WBC-6.8# RBC-3.00* Hgb-9.4* Hct-29.8* MCV-99* MCH-31.3 MCHC-31.5 RDW-16.0* Plt Ct-102* [**2110-3-7**] 05:55AM BLOOD WBC-3.8* RBC-2.98* Hgb-9.6* Hct-28.4* MCV-95 MCH-32.1* MCHC-33.7 RDW-16.7* Plt Ct-84* [**2110-2-28**] 11:11AM BLOOD WBC-3.6* RBC-2.54* Hgb-8.3* Hct-24.9* MCV-98 MCH-32.6* MCHC-33.2 RDW-17.9* Plt Ct-48* [**2110-2-25**] 03:30PM BLOOD WBC-7.7# RBC-3.25* Hgb-10.5* Hct-33.1* MCV-102*# MCH-32.4* MCHC-31.8 RDW-18.2* Plt Ct-74* [**2110-3-21**] 03:27AM BLOOD Neuts-71.2* Bands-0 Lymphs-17.0* Monos-6.4 Eos-5.0* Baso-0.4 [**2110-3-11**] 06:28AM BLOOD Neuts-44* Bands-0 Lymphs-41 Monos-8 Eos-4 Baso-0 Atyps-2* Metas-1* Myelos-0 [**2110-2-25**] 03:30PM BLOOD Neuts-88* Bands-4 Lymphs-4* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2110-3-25**] 05:00AM BLOOD PT-12.2 PTT-33.3 INR(PT)-1.0 [**2110-3-25**] 05:00AM BLOOD Plt Ct-66* [**2110-3-21**] 03:27AM BLOOD Plt Ct-105* [**2110-3-21**] 03:27AM BLOOD PT-13.5* PTT-39.0* INR(PT)-1.2* [**2110-3-17**] 03:30AM BLOOD Plt Ct-116* [**2110-3-17**] 03:30AM BLOOD PT-13.0 PTT-34.5 INR(PT)-1.1 [**2110-3-14**] 10:04PM BLOOD Plt Ct-62* [**2110-3-8**] 06:25AM BLOOD Plt Ct-86* [**2110-2-25**] 08:23PM BLOOD Fibrino-391# [**2110-2-28**] 02:43AM BLOOD Ret Man-6.4* [**2110-3-10**] 06:56AM BLOOD Ret Man-1.5 [**2110-3-27**] 06:15AM BLOOD Glucose-114* UreaN-28* Creat-1.9* Na-139 K-4.0 Cl-106 HCO3-24 AnGap-13 [**2110-3-25**] 05:00AM BLOOD Glucose-106* UreaN-28* Creat-2.3* Na-138 K-4.4 Cl-106 HCO3-24 AnGap-12 [**2110-3-22**] 03:47AM BLOOD Glucose-88 UreaN-23* Creat-2.5* Na-138 K-4.7 Cl-107 HCO3-22 AnGap-14 [**2110-3-20**] 03:10AM BLOOD Glucose-110* UreaN-25* Creat-2.4* Na-138 K-4.4 Cl-106 HCO3-24 AnGap-12 [**2110-3-17**] 03:30AM BLOOD Glucose-174* UreaN-29* Creat-2.7* Na-138 K-4.8 Cl-104 HCO3-26 AnGap-13 [**2110-3-16**] 03:42AM BLOOD Glucose-100 UreaN-31* Creat-3.0* Na-148* K-4.7 Cl-104 HCO3-24 AnGap-25* [**2110-3-15**] 03:04AM BLOOD Glucose-99 UreaN-37* Creat-3.4* Na-143 K-4.9 Cl-110* HCO3-21* AnGap-17 [**2110-3-14**] 06:31AM BLOOD Glucose-95 UreaN-39* Creat-3.6* Na-143 K-4.9 Cl-110* HCO3-26 AnGap-12 [**2110-3-11**] 06:28AM BLOOD Glucose-95 UreaN-39* Creat-4.0* Na-144 K-4.5 Cl-110* HCO3-28 AnGap-11 [**2110-2-27**] 02:07AM BLOOD Glucose-98 UreaN-48* Creat-4.6* Na-141 K-4.0 Cl-116* HCO3-15* AnGap-14 [**2110-2-25**] 08:23PM BLOOD Glucose-167* UreaN-56* Creat-5.0* Na-147* K-4.9 Cl-125* HCO3-9* AnGap-18 [**2110-2-25**] 03:30PM BLOOD Glucose-169* UreaN-62* Creat-5.7*# Na-149* K-4.8 Cl-124* HCO3-14* AnGap-16 [**2110-3-25**] 05:00AM BLOOD ALT-6 AST-18 LD(LDH)-168 AlkPhos-53 TotBili-0.2 [**2110-2-25**] 03:30PM BLOOD ALT-9 AST-15 CK(CPK)-113 AlkPhos-65 TotBili-0.2 [**2110-2-25**] 03:30PM BLOOD Lipase-16 [**2110-3-15**] 02:50PM BLOOD CK-MB-NotDone cTropnT-0.17* [**2110-3-15**] 03:04AM BLOOD CK-MB-NotDone cTropnT-0.21* [**2110-3-14**] 10:04PM BLOOD CK-MB-NotDone cTropnT-0.21* [**2110-3-14**] 05:59PM BLOOD CK-MB-NotDone cTropnT-0.20* [**2110-2-26**] 12:00PM BLOOD CK-MB-8 cTropnT-0.18* [**2110-2-26**] 03:50AM BLOOD cTropnT-0.18* [**2110-2-25**] 08:23PM BLOOD CK-MB-9 cTropnT-0.18* [**2110-2-25**] 03:30PM BLOOD cTropnT-0.21* [**2110-3-27**] 06:15AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.2 [**2110-3-21**] 03:27AM BLOOD Albumin-2.8* Calcium-7.9* Phos-2.9 Mg-1.9 [**2110-3-13**] 06:04AM BLOOD TotProt-5.4* Calcium-8.6 Phos-4.4 Mg-1.9 [**2110-3-22**] 03:47AM BLOOD TSH-22* [**2110-3-24**] 05:48AM BLOOD T3-83 [**2110-3-22**] 03:47AM BLOOD Free T4-1.2 [**2110-3-13**] 06:04AM BLOOD PEP-TWO OR THR IgG-1178 IgA-303 IgM-203 IFE-NO DEFINIT [**2110-3-12**] 04:01PM BLOOD C3-44* C4-12 [**2110-3-27**] 06:15AM BLOOD rapmycn-4.3* [**2110-3-26**] 05:44AM BLOOD rapmycn-4.0* [**2110-3-25**] 05:00AM BLOOD rapmycn-5.1 [**2110-3-24**] 05:48AM BLOOD tacroFK-LESS THAN rapmycn-3.5* [**2110-3-22**] 03:47AM BLOOD rapmycn-2.8* [**2110-3-21**] 03:27AM BLOOD tacroFK-LESS THAN rapmycn-4.6* [**2110-3-20**] 03:10AM BLOOD tacroFK-1.5* rapmycn-6.9 [**2110-3-19**] 05:20AM BLOOD tacroFK-1.9* rapmycn-4.9* [**2110-3-18**] 04:00AM BLOOD tacroFK-3.0* rapmycn-9.4 [**2110-3-17**] 03:30AM BLOOD tacroFK-7.4 rapmycn-4.6* [**2110-3-15**] 01:18AM BLOOD Type-ART Temp-35.9 pO2-238* pCO2-43 pH-7.37 calTCO2-26 Base XS-0 Intubat-NOT INTUBA [**2110-3-15**] 01:18AM BLOOD Lactate-1.8 Na-142 K-5.0 [**2110-3-15**] 01:18AM BLOOD freeCa-1.23 Brief Hospital Course: SICU COURSE: . On admission, patient presented with urosepsis, in respiratory distress and with altered mental status and was intubated for airway control. He was extubated [**3-3**] after diuresis, and was then on 4L NC. Required Dopamine then transitioned to Levophed for a brief period of time on admission. He was quickly transitioned off pressors by HD #3. He received 2 units prbcs for a crit of 23 on [**2-28**]. His hemodynamics were normal for the remainder of his SICU course. A CT head on admission was negative for any acute intracranial process. While he recovered from his urosepsis, his altered mental status improved. His vent settings were gradually weaned down as he was diuresed and he was extubated on HD #6. . He has a h/o MDR psdeudomonas UTI [**12-6**] treated with Amikacin but this was stopped due to renal insufficiency (was admitted during this time and d/ced [**2109-12-24**]). He also had a Femoral neck fracture pinned [**2-3**] at that time was without UTI. Here, he presented w/new pseudomonas UTI sensitive ONLY to Colistin and meropenam and was started on these two ABX. Had normal LFTs and his FK immunosuppresion was initially held but then restarted as he recovered clinically. He had previously been on Micafungin for yeast in his urine, of which the course has been completed. He has also has been treated empirically for C.diff colitis, transiently on flagyl and now finished a course of PO vanc for diarrhea and C. diff prophylaxis. . He was followed by Nephrology for acute on chronic renal failure in the SICU. The renal failure was thought to be due to ATN vs colistin - colistin was discontinued. His Cr slowly trended down over time. Dr.[**Name (NI) 825**] ([**Name (NI) **]) team was contact[**Name (NI) **] early in his SICU course, since he had recently seen Dr. [**Last Name (STitle) 770**] for this UTI. As he was determined NOT to have a residual ureter stent or any forgein object, there was no intervention by [**Last Name (STitle) **]. He has a foley in place, which will likely be discontinued and the patient can continue his prehospitalization routine of self-catheterizations. . Patient was stable to be transferred to the floor. Initially on [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] he had been doing well. He had finished his course of antibiotics and was on PO vanco empirically given his history of C. diff. He had been working well with PT. He did have perisistent renal failure for which he has been followed by renal for colistin/hypotensive ATN. He has also been followed by transplant surgery. . He underwent liver biospy [**3-14**] that was relatively uncomplicated. However, he was noted to have 2 "apneic" events at the time of the liver biospy. He was awakened with no further events. He was transferred to the floor in stable condition. However, as the team was speaking with him, he became unresponsive, with his eyes rolling back into his head and he was noted to be lip smacking. A code blue was called. He was initially pulseless so CPR was initiated. However, after about 20 seconds he seemed to regain consciousness. His BP was 100s sytolic and he was awake and alert. He was put on the rhythm and was found to be in sinus alternating with an SVT at 160s. He then went into NSVT for which he was given amiodarone 150mg IV. After returning to sinus/SVT, he went into polymorphic VT. He maintained his pulse during this time. He was given magnesium 2g with return to sinus rhythm. His VS stabilized. EKG showed sinus bradycardia with no clear ischemic changes. ABG was 7.35/44/128. He had no abdominal pain or other complaints. He was transferred to the MICU. . In the MICU, he had 3 additional episodes of VT/torsades requiring more magnesium as well as cardioversion x2. He was subsequently put on a dopamine gtt to increase his HR and decrease his QTc. HIs arrythmia was thought to be due to medications as well as a contribution from congenital long QTc. Reglan, celexa, lyrica and Bactrim were all stopped. His tacrolimus was switched to sirolimus. He did not have any further episodes of arrythmia in the ICU. His dopamine was stopped on [**3-20**] which he tolerated well. Prior to transfer, a CT scan of the abd mentioned a dilated portal vein, moderate ascites, and anasarca. His urine cx cont to grow pseudomonas for which ID was re-consulted. . Patient was transferred back to the Liver Service: #Bradycardia and long QTc: On telemetry the patient was noted to be bradycardic to 36. Serial EKGs were performed and patient's QTc was 499-536 despite holding all medications that prolong QtC. The patient's HR was mostly in the 50s on telemetry, and he was given standing daily magnesium and potassium. Cardiology was following the patient and decided he was not a candidate for implantable device given his recent infection. They suggested a life vest for outpatient monitoring. Patient remained stable, without chest pain, palpatations or any more events on telemetry. - Cont telemetry - Continue standing daily magnesium - would check weekly electrolytes - f/u in the cardiology clinic in 1 month (End of [**Month (only) 116**]) . # Pseudomonas in urine: Completed full course of meropenem/colistin. Given risks (renal) of treating with colistin, will hold off ABX unless the patient appears clinically infected (currently no fever, dyuria). - if patient spikes fever, please follow up with the [**Hospital **] clinic. . # Acute Renal Failure: [**12-30**] urosepsis, ATN and colistin. Renal function slowly trended down, now down to 1.9, previous baseline 1.5 to 1.8. . # Blood pressure: Patient was not hypotensive on the floor. His baseline BP is 90-110. We planned to use IVF boluses based on altered mental status or decreased urine output but this did not happen. . # s/p Liver Transplant: LFTs and synthetic function relatively stable. Sirolimus level low to 3, increased dose to 3mg and rechecked level today is 4.3 - Patient should have his Sirolimus levels rechecked on [**Month/Day (2) 766**] [**3-31**] before his morning dose. The results should be faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the Liver Center. -the patient will have a follow up appointment with Dr. [**First Name (STitle) **] at the Liver [**Hospital 1326**] Clinic in [**11-30**] weeks. -the transplant coordinator will be in touch after the patient's discharge. . # FEN: Patient not taking in good PO so was started on tube feeds. Patient was willing to eat cakes/muffins and soda but no other foods. -continue tube feeds. Patient has post-pyloric dobhoff in place. Placed [**2110-3-28**] . # Hyperglycemia: Patient noted to be occasionally hyperglycemic and was started on a sliding scale insulin. . Medications on Admission: 1. Citalopram 10 mg PO DAILY 2. Ferrous Sulfate 325 mg PO TID 3. Fludrocortisone 0.1 mg PO DAILY 4. Pregabalin 25 mg PO BID 5. Tacrolimus 2 mg PO Q12H 6. Tamsulosin 0.4 mg PO HS 7. Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY 8. Valganciclovir 450 mg PO EVERY OTHER DAY 9. Epoetin Alfa 10,000 unit/mL QMOWEFR 10. Pantoprazole 40 mg PO once a day. 11. Lovenox 40 mg/0.4 mL Subcutaneous once a day. 12. Morphine 15 mg PO Q8H as needed. 13. Morphine 15 mg Tablet Sustained Release PO Q12H 14. Docusate Sodium 100 mg PO BID 15. Senna 8.6 mg PO BID 16. Metoclopramide 10 mg PO QIDACHS Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inh Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. inh 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for breakthrough pain. 7. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous four times a day as needed for Per SLiding Scale: Please give insulin according to attached scale. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: acute on chronic renal failure urosepsis Discharge Condition: Good, hemodynamically stable, afebrile Discharge Instructions: You were admitted for urosepsis, related to your multi-drug resistant Pseudomonas infection in the urine. You were briefly in the surgical ICU, and were transferred to the floor where you continued to make progress. However, your had a cardiac arrest, likely related to an underlying heart sensitivity to certain medications, and were transferred to the medical ICU. Now you are doing better, and will be discharged to rehab. . If you experience any fever, chills, nausea, vomiting, abdominal pain, chest pain, shortness of breath, or have any other concerns, please [**Name6 (MD) 138**] your MD. . Please follow up with your doctors as below, [**Name5 (PTitle) **] should have your rapamycin levels checked on [**Last Name (LF) 766**], [**3-31**]. Followup Instructions: F/u in 2 months with Dr. [**Last Name (STitle) **] and repeat x-ray. [**Telephone/Fax (1) 103050**] . Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2110-3-19**] 9:30 . Follow up with liver clinic on [**Last Name (LF) 766**], [**3-31**] for lab work. . The Cardiology/[**Hospital **] clinic will call you with an appointment.

[ "V10.05", "707.25", "707.03", "356.9", "585.9", "276.2", "V42.7", "535.50", "427.5", "284.1", "426.82", "518.81", "427.1", "427.89", "530.7", "599.0", "041.7", "584.5" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "50.11", "99.04", "38.93", "96.04", "33.24", "45.13" ]

icd9pcs

[ [ [] ] ]

17471, 17550

9100, 15846

332, 451

17635, 17676

2717, 2774

18473, 18840

2214, 2255

16482, 17448

17571, 17614

15872, 16459

17700, 18450

2270, 2698

271, 294

2809, 9077

479, 1122

1144, 2005

2021, 2198

21,095

164,045

8111

Discharge summary

report

Admission Date: [**2136-11-10**] Discharge Date: [**2136-11-15**] Date of Birth: [**2072-4-5**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4421**] Chief Complaint: Shortness of breath and chest pain. Major Surgical or Invasive Procedure: None History of Present Illness: This 64 year old female with a history of recurrent endometrioid adenocarcinoma with metastases to the liver and intrabominal organs presented to the ED with 7/10 substernal chest pain and shortness of breath. The chest pain and shortness of breath awoke her from sleep the night prior to admission, however in retrospect she states that she has been having some pain and SOB for 4 days but did not seek medical attention. The shortness of breath and chest pain are worse with deep inspiration. The chest pain is sharp and does not radiate to her left arm, jaw, or back. She denies any recent calf pain/lower extremity edema. She traveled in [**Month (only) 216**] to [**Doctor First Name 5256**] by car but otherwise denies any recent travel. In the ED, her vital signs were: Temp 97.5, HR 102, BP 151/63, RR 20, Sat 94% on RA. A CTA was performed which showed bilateral pulmonary embolism. She was initially normotensive and then have one episode of hypotension to about 100s. She remained normotensive. However, given that she has bilateral PE and EKG shows right heart strain, she was admitted to the MICU for observation. She was started on heparin drip in the ED after a negative head CT. ROS: No fevers/chills/melena/hematuria. Positive for RUQ pain that is chronic and related to her liver metastases. Recent 20 pound unintentional weight loss. Past Medical History: PMH: 1. Recurrent metastatic uterine cancer - 6 cycles carboplatin chemo, CT scan [**2136-10-11**] with mets to liver, spleen, retrocaval nodes, and distal ileum serosal soft tissue. Increase solid periumbilical mass. Recently switched to Doxil chemotherapy for disease progression. 2. Hypertension. 3. Arthritis. 4. GERD. 5. Possible mild "lupus" with positive [**Doctor First Name **] antibodies in [**2134**], which is considered equivocal. 6. Right knee meniscus tear repair. 7. Carpal tunnel surgery. 8. Cholecystectomy in [**2124**]. 9. Cesarean section in [**2128**]. Social History: No tobacco or alcohol. She has been widowed for 22 years with four children ranging in age from 46 to 27. She has 12 grandchildren and 4 great grandchildren. She is from [**Doctor First Name 5256**]. She lives in [**Location (un) 86**]. Family History: She had a sister who died of breast cancer at age 57. Her brother died of leukemia at age 58. Physical Exam: Vitals Temp 98.4 Pulse 92, BP 116/67, RR 27, 99% on 2L NC Gen- Mildly tachypneic, not using accessory muscles to breathe, alert, oriented, cooperative female HEENT- MMM, no oral lesions/thrush, JVP to angle of jaw, PERRL Heart- Tachycardic, nl S1S2, no M/R/G Lungs- Crackles bilatterally at the bases, o/w clear Abdomen- Evidence of weight loss with extra skin, anteior suprapubical firm mass, mildly tender RUQ, active BS, no rebound/guarding Ext- No calf tenderness, no edema, 2+ DP, PT pulses Neuro - grossly intact Pertinent Results: [**2136-11-10**] 04:05AM WBC-9.4 RBC-4.04*# HGB-11.7*# HCT-34.9* MCV-86 MCH-28.9 MCHC-33.5 RDW-15.9* [**2136-11-10**] 04:05AM PLT SMR-LOW PLT COUNT-125* [**2136-11-10**] 04:05AM NEUTS-91.9* BANDS-0 LYMPHS-5.3* MONOS-2.5 EOS-0.1 BASOS-0.2 [**2136-11-10**] 04:05AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-1+ BURR-OCCASIONAL TEARDROP-OCCASIONAL [**2136-11-10**] 04:05AM PT-14.7* PTT-33.6 INR(PT)-1.5 [**2136-11-10**] 04:05AM GLUCOSE-164* UREA N-16 CREAT-1.0 SODIUM-135 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-21* ANION GAP-20 [**2136-11-10**] 04:05AM ALT(SGPT)-57* CK(CPK)-71 ALK PHOS-144* AMYLASE-67 TOT BILI-1.3 [**2136-11-10**] 04:05AM cTropnT-0.10* [**2136-11-10**] 04:05AM CK-MB-NotDone [**2136-11-10**] 01:14PM CK-MB-NotDone cTropnT-0.08* [**2136-11-10**] 01:14PM CK-MB-NotDone cTropnT-0.06* [**2136-11-10**] 01:14PM CK(CPK)-58 [**2136-11-10**] 01:14PM CK(CPK)-54 [**2136-11-12**] 12:27AM BLOOD CK-MB-1 cTropnT-<0.01 [**2136-11-12**] 06:55AM BLOOD CK-MB-NotDone cTropnT-0.01 . [**2136-11-10**]: CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There is no significant axillary lymphadenopathy. There are few prominent mediastinal lymph nodes. These are subcentimeter in size. There are two lymph nodes visualized in the AP window which appear more prominent than previously seen. The heart and aorta are unremarkable. There are multiple filling defects within the main pulmonary arteries bilaterally, extending into the segmental and subsegmental branches consistent with pulmonary emboli. There are no pleural or pericardial effusions. The lung window images reveal no areas of consolidation or lung nodules. The airways appear patent to the level of segmental bronchi bilaterally. Mild right basilar atelectasis noted. The visualized portion of the upper abdomen, the imaged portion of the liver again demonstrates multiple areas of low attenuation consistent with hepatic metastases. These are not fully evaluated on this single phase-contrast study. A soft tissue density/node is again visualized in the epicardial fat, measuring 1.3 x 1.5 cm. This appears slightly smaller than previously seen. There are no suspicious lytic or blastic lesions in the osseous structures. CT RECONSTRUCTIONS: Multiple reconstructions confirm the above findings. IMPRESSION: 1. Filling defects within right and left main pulmonary arteries extending to the segmental and subsegmental branches consistent with multiple pulmonary emboli. 2. Metastatic liver disease. . [**2136-11-10**] CT of head: FINDINGS: There is no intracranial mass effect, hydrocephalus, or shift of normally midline structures or major vascular territorial infarction. The density values of the brain parenchyma are within normal limits. Surrounding soft tissue and osseous structures are unremarkable. IMPRESSION: No mass effect or hemorrhage. MRI with and without gadolinium is more sensitive for picking up of brain metastases. . EKG [**2136-11-10**]: Sinus tachycardia at rate 101. Left anterior fascicular block. T wave inversions in leads V1-V3 with flat T waves in lead V4, cannot exclude ischemia. Compared to the previous tracing of [**2135-7-7**] atrial tachycardia and T wave changes are new. Left ventricular hypertrophy voltage is absent. . EKG [**2136-11-11**]: Sinus tachycardia at rate 106. Left anterior fascicular block. Non-specific low amplitude T waves. Compared to the previous tracing of [**2136-11-10**] the T waves are now upright in leads V2-V3. . EKG [**2136-11-12**]: Sinus tachycardia. Left anterior fascicular block. Poor R wave progression could be due to left anterior fascicular block. Non-specific T wave flattening. Compared to the previous tracing of [**2136-11-11**] no significant change. . Labs at discharge: WBC 4.1, Hct 30.9 Plt 227 Glucose 111 UreaN 11 Creat 0.8 Na 135 K 4.8 Cl 101 HCO3 24 ALT 60 AST 54 LD(LDH)430 AlkPhos 171 TotBili 1.1 Brief Hospital Course: The patient is a 64 year old female with a history of recurrent, metastatic uterine cancer who presents with SOB and chest pain, found to have bilateral PEs on chest CT. 1. Bilateral PE- She was started on heparin drip in the ED after a negative head CT. Given that she has bilateral PE and EKG shows right heart strain, she was admitted to the MICU for observation. The patient was hemodynamically stable and then transferred the next day to the OMED service. The heparin drip was switched to Lovenox for long term use. The patient's O2 saturation improved with anticoagulant treatment; at the time of discharge, the patient was saturating in the 95-96% range at rest, and 92% during ambulation on room air. However, given subjective dyspnea and improvement in symptoms with O2, the patient was sent home with O2 supplementation. 2. Metastatic uterine cancer- Further chemo treatment per Dr. [**Last Name (STitle) **]. The patient has known mets to the liver and her elevated enzymes were thought to be secondary to the liver mets. 3. FEN - Cardiac diet, monitor lytes, 4. PPX - PPI, Hep gtt then Lovenox. 5. CODE - The patient expressed the wish to be DNR/DNI during discussions with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **]. 6. Social- The social worker team is exploring the patient's living situation and support system and plans to follow as outpatient. Medications on Admission: Multivitamin Iron 325mg daily HCTZ 25 mg PO daily Discharge Medications: 1. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous Q12H (every 12 hours). 2. Oxygen -Continuous Oxygen Sig: 1-2L of O2 via nasal cannula during ambulation/sleep/rest for shortness of breath 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Outpatient Physical Therapy Pulmonary therapy Please evaluate and treat s/p pulmonary embolism 5. Compazine 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for nausea for 10 days. Disp:*40 Tablet(s)* Refills:*1* 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for pain for 3 days. Disp:*12 Tablet(s)* Refills:*0* 7. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea for 10 days. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Pulmonary embolism Metastatic uterine carcinoma Discharge Condition: Stable Discharge Instructions: Return to the emergency department or call your primary care physician if you develop fever, chills, severe shortness of breath, severe chest pain, nausea, vomiting, abdominal pain, weakness/numbness in either arms or legs, bleeding, coughing up blood or any other worrisome symptoms. . Take your medications as prescribed. . Please, keep your follow-up appointments Followup Instructions: Provider [**Name9 (PRE) **],[**First Name8 (NamePattern2) **] [**Name9 (PRE) 7975**] FAMILY PRACTICE Date/Time:[**2136-11-22**] 11:30 Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21074**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2136-12-7**] 11:00 Provider [**Name9 (PRE) **],[**Name9 (PRE) **] HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[**2136-12-7**] 11:00

[ "401.9", "V10.42", "530.81", "415.19", "197.7", "V15.3", "285.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9540, 9598

7233, 8625

352, 359

9690, 9699

3270, 7042

10115, 10508

2619, 2715

8726, 9517

9619, 9669

8651, 8703

9723, 10092

2730, 3251

277, 314

7061, 7210

387, 1747

1769, 2348

2364, 2603

6,262

187,896

1980

Discharge summary

report

Admission Date: [**2151-11-22**] Discharge Date: [**2151-11-26**] Date of Birth: [**2108-11-3**] Sex: M Service: MEDICAL HISTORY OF PRESENT ILLNESS: This is a 43-year-old Haitian male who is HIV positive with prior CD-4 count in [**10/2151**] of 304 with a viral load less than 50,000 who has chronic kidney disease, history of disseminated tuberculosis, anemia and hypertension who presents with markedly decreased hematocrit of 13 and a history of bright red blood per rectum each day that has been occurring more frequently over the past month, but has been a chronic issue for the past year. The patient was seen in the [**Hospital 2793**] Clinic on [**2151-11-20**] and complained of fatigue. He was noted to have a hematocrit of 14 at that time. He was advised to go to the Emergency Department, but he declined to go immediately as he did present today for evaluation. He denies chest pain, palpitations, fevers, chills, nausea, vomiting, abdominal pain. He does admit to some lightheadeness, fatigue and dyspnea on exertion. He notes that he has bright red blood per rectum with his bowel movements, but also at other times. Laboratory data on presentation was also notable for hyperkalemia 6.2 which is not significantly changed from baseline, and a creatinine of 5.8. In the Emergency Department, the patient received two units of packed red blood cells. He had a bowel movement with dark blood and brown stool with dark clots. PAST MEDICAL HISTORY: 1. HIV/AIDS diagnosed in [**2139**], last CD-4 count 304, viral load less than 50,000 on 11/[**2150**]. 2. History of disseminated tuberculosis diagnosed in [**2140**]. 3. Positive RPR. 4. Chronic renal insufficiency with a baseline creatinine of [**3-20**]. 5. Anemia. 6. Hypertension. 7. Neuropathy. 8. Osteoarthritis of the right knee. 9. History of pneumonia. 10. History of esophagitis. 11. Status post gunshot wound to the abdomen. 12. Depression. ALLERGIES: Bactrim, aspirin. MEDICATIONS ON ADMISSION: 1. Atenolol 100 mg p.o. q d. 2. Neurontin 600 mg p.o. q h.s. 3. Procardia-XL 90 mg q d. 4. Prozac 20 mg p.o. q h.s. 5. Zoloft 100 mg p.o. q d. 6. Bicitra 30 mg. 7. AZT 300 mg p.o. b.i.d. 8. Ziagen 300 mg p.o. b.i.d. 9. Sustiva 600 mg. 10. Clonidine 0.2 mg p.o. b.i.d. 11. Aranesp 30 mg subcutaneously q week. 12. Iron 325 mg p.o. q d. 13. Lasix 40 mg p.o. q d. 14. Minoxidil 25 mg p.o. q d. 15. Remeron 15 mg p.o. q d. 16. PhosLo. 17. Prilosec. 18. Fibercon. 19. Colace. 20. Lactulose. SOCIAL HISTORY: Denies alcohol use, admits to tobacco use, has a history of intravenous drug abuse. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature 98.4, heart rate 82, blood pressure 130/70, respiratory rate 18, pulse oxygenation 100% on room air. GENERAL: He is awake, lucid, alert, comfortable. HEENT: Anicteric sclera. Extraocular movements intact. Pupils are equal, round, and reactive to light and accommodation. Oropharynx without lesions. Moist mucosal membranes. Lips slightly dry. NECK: Supple, no lymphadenopathy. LUNGS: Clear to auscultation in the upper fields. Bibasilar crackles, right greater than left. HEART: Regular rate and rhythm, normal S1/S2, 2/6 systolic ejection murmur. ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. EXTREMITIES: No edema, 2+ distal pulses bilaterally. NEUROLOGICAL: Awake, alert, lucid in conversation, moves all extremities. LABORATORY DATA ON ADMISSION: White blood count 7.8, hematocrit 13.4, platelet count 347, INR 1.0. Electrolytes on admission - sodium 133, potassium 6.2, chloride 104, bicarbonate 18, BUN 65, creatinine 5.8, glucose 97. Urinalysis - 30 protein, no ketones, no leukocytes, 0-2 white blood cells. Calcium 8.4, phosphate 6.3, alkaline phosphatase 306, LDH 199, TSH 1.1. Electrocardiogram on admission shows a heart rate of 89 beats per minute, normal sinus rhythm, slight left axis deviation, normal intervals, new T-wave inversion in V5-6, 0.[**Street Address(2) 1755**] depression in lead II. Chest x-ray shows cardiomegaly, increased interstitial prominence, splenic calcifications, no free air. Tagged RBC scan shows no evidence of gastrointestinal bleed. HOSPITAL COURSE: 1. Gastrointestinal bleed. The patient was admitted to the Intensive Care Unit where he received a total of five units of packed red blood cells during his stay which also included the two units given in the Emergency Department. He remained hemodynamically stable. A colonoscopy done on [**2151-11-24**] revealed only internal hemorrhoids as a possible source of bleeding. The patient had recurrence of bright red blood per rectum during his hospital stay. Following his colonoscopy on [**2151-11-24**], the Gastrointestinal service who had been consulted for management of the patient's gastrointestinal bleeding performed an endoscopy with this occurrence of bleeding on [**2151-11-24**]. A stigmata of recent bleeding was identified at bleeding hemorrhoid site. The Surgery service was consulted and placed four bands on [**2151-11-24**] in a bedside procedure in the Intensive Care Unit. They advised percocet for pain control and aggressive stool softening in addition to an esophagogastroduodenoscopy to rule out possible upper gastrointestinal bleed. An esophagogastroduodenoscopy was performed on [**2151-11-26**]. It revealed a healed ulcer and no evidence of a bleeding source. The patient was discharged on an aggressive stool softening regimen. During his hospital stay, work-up for his gastrointestinal bleed also included stool cultures which were unrevealing as to an infectious source. The patient was noted to have elevated liver function tests during his hospital stay. A right upper quadrant ultrasound was obtained. It showed to small hyperechoic lesions in the left hepatic lobe possibly related to the findings in the spleen of calcifications that are likely related to his prior disseminated tuberculosis infection. There was no evidence of cholecystitis. Prior records show a history of mild elevation of the patient's liver function tests and this is a chronic issue that may have some relation to his [**Doctor Last Name **] medication. His GGT and alkaline phosphatase were the only liver function tests that were elevated during his hospital stay. The patient was continued on a proton pump inhibitor throughout his hospital stay. 2. Infectious disease. The patient had stool cultures during his hospital stay which showed no abnormal bacterial or other growth. He was continued on [**Doctor Last Name **] therapy as previously prescribed throughout his hospital stay. 3. Renal. The patient was given Kayexalate due to hyperkalemia on admission. Abdominal ultrasound did confirm the presence of small hyperechoic kidneys consistent with HIV nephropathy without change from prior studies. The patient was continued on PhosLo during his hospital stay and Calcitriol was added for his hyperparathyroidism. 4. Cardiovascular. The patient was continued on his prior regimen of metoprolol, Procardia, clonidine and minoxidil for control of his hypertension. 5. Fluid/electrolytes/nutrition. The patient remained NPO throughout the initial portion of his hospital stay and was advanced to a full diet at the time of discharge. 6. Hematology. The patient was noted to be markedly anemic during his hospital stay. He was transfused several times and his hematocrit at the time of discharge had risen from 13 to 28, status post five transfusions of packed red blood cells. The patient was also noted to be markedly iron deficient and was given intravenous ferric gluconate prior to discharge. 7. Prophylaxis. The patient was continued on a proton pump inhibitor during his hospital stay. 8. Depression. The patient was continued on fluoxetine and Remeron for control of his depression. DISCHARGE CONDITION: Hemodynamically stable, asymptomatic, afebrile, tolerating full diet, ambulating without difficulty. DISCHARGE STATUS: To home. DISCHARGE MEDICATIONS: 1. Abacavir 300 mg p.o. b.i.d. 2. Efavirenz 200 mg three capsules p.o. q h.s. 3. Gabapentin 300 mg two capsules p.o. q h.s. 4. Mirtazapine 15 mg one tablet p.o. q h.s. 5. Sertraline 100 mg p.o. q h.s. 6. Fluoxetine 20 mg one tablet p.o. q h.s. 7. Zidovudine 100 mg three capsules p.o. q 12 hours. 8. Sodium citrate citric acid 334-500 mg/5 mL, 30 mL p.o. q d. 9. Pantoprazole 40 mg p.o. q d. 10. Metoprolol tartrate 50 mg 0.5 tablets p.o. b.i.d., hold for [**Month (only) **] less than 100 and heart rate less than 60. 11. Ascorbic acid 500 mg one tablet p.o. q d. 12. Colace 100 mg p.o. b.i.d. 13. [**Doctor Last Name **] two tablets p.o. b.i.d. 14. Clonidine 0.2 mg p.o. b.i.d. 15. Calcium acetate 667 mg tablet, one tablet p.o. t.i.d. with meals. 16. Calcitriol 0.25 mcg capsule, one capsule p.o. q d. DISCHARGE DIAGNOSIS: 1. Anemia secondary to blood loss. 2. Hyperphosphatemia. 3. HIV/AIDS. 4. Acute on chronic renal failure. 5. Gastrointestinal bleeding. 6. Internal hemorrhoids. 7. Iron deficiency. 8. Elevated alkaline phosphatase. FOLLOW-UP: Please contact your nurse practitioner at Community Medical Alliance, Ms. [**First Name4 (NamePattern1) 717**] [**Last Name (NamePattern1) 8389**], regarding this hospital stay. Please keep your appointment with Dr. [**Last Name (STitle) 8499**] at [**Telephone/Fax (1) 10893**] for next Wednesday, [**2151-12-1**] at 2:00 p.m. Contact Dr. [**Last Name (STitle) 1366**] for a follow-up appointment in the next two weeks. Please keep the following appointments: Appointment with Dr. [**Last Name (STitle) 8499**] at [**Last Name (un) 10894**] Internal Medicine on [**2151-12-1**] at 2:00 p.m., appointment with Dr. [**Last Name (STitle) 10895**], [**Last Name (un) 6752**] Building Rheumatology on [**2152-1-20**] at 2:00 p.m. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**] Dictated By:[**Last Name (NamePattern1) 1615**] MEDQUIST36 D: [**2151-12-16**] 16:12 T: [**2151-12-19**] 11:53 JOB#: [**Job Number 10896**] cc: [**First Name8 (NamePattern2) 10897**] [**Last Name (NamePattern1) **], M.D. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], M.D. [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D.

[ "535.40", "276.7", "455.2", "042", "403.91", "584.9", "285.1" ]

icd9cm

[ [ [] ] ]

[ "45.23", "45.16" ]

icd9pcs

[ [ [] ] ]

7843, 7974

7997, 8812

8833, 10400

2001, 2497

4189, 7821

167, 1458

3441, 4172

1480, 1975

2514, 2620

10,917

139,661

45717

Discharge summary

report

Admission Date: [**2109-8-10**] Discharge Date: [**2109-8-14**] Date of Birth: [**2036-5-21**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old man with a history of nonflow limiting three vessel disease, status post multiple catheterizations, PCIs for angina with stent most recently two years ago. Patient has a history of hypertension, diabetes, hypercholesterolemia. He was in his usual state of health until early when he awoke with diaphoresis, shortness of breath, difficulty speaking. EMT was called and patient was found to be in complete heart block with heart rate of 20. His blood pressure at that time was 80/42. He was given atropine with no response. He was externally paced at 66 beats per minute and his systolic blood pressure was 150. REVIEW OF SYSTEMS: Significant for one month of intermittent episodes of dizziness, worse over the last week with diaphoresis. His recent medical evaluation reveals one episode of vaguely induced syncope one month ago, but otherwise normal electrocardiogram within the last 30 days per primary care physician's evaluation. His last cardiac catheterization was in [**2107-5-16**] and it showed an ejection fraction of 55%, posterior descending artery with 50% stenosis, his mid left anterior descending was 50% stenosed, proximal left anterior descending was 30% stenosed. His first diagonal was 30% stenosed, left circumflex 30% at OMI. Stress in [**2108-8-15**] showed angina, 7/10 chest pain without electrocardiogram changes. No nuclear mild fixed inferior wall defect. Echocardiogram in [**2107-3-16**] showed mild left ventricular hypertrophy, mild mitral regurgitation with borderline aortic stenosis. Review of systems is significant for increased angina and dyspnea on exertion, decreased exercise tolerance, two pillow orthopnea, paroxysmal nocturnal dyspnea, swelling in the lower extremities and his last anginal attack was one day prior to admission relieved with one sublingual nitroglycerin. He has been requiring increased Lasix doses recently for his lower extremity edema. He denies melena, bright red blood per rectum or pain in his arms. PAST MEDICAL HISTORY: 1. Hypertension. 2. Benign prostatic hypertrophy. 3. Borderline diabetes mellitus. 4. Hypercholesterolemia. 5. Muscular dystrophy, [**Doctor Last Name **] type, diagnosed six to seven years ago with chronically elevated CK. 6. Osteoarthritis. 7. Syncope. 8. Chronic obstructive pulmonary disease. 9. Gastroesophageal reflux disease. 10. Depressi on. OUTPATIENT MEDICATIONS: Imdur 30 q.d., Flomax 0.4 q.d., Effexor SR 75 b.i.d., seroquel 25 q.d., Klonopin, aspirin 325 q.d., Lasix 20 q.d., Glucophage 500 q.d. Monday, Wednesday and Friday, Toprol 50 q.d., Atenolol 50 q.d., Vioxx 50 q.d., Zestril 10 q.d., Zocor 10 q.d. PHYSICAL EXAMINATION: Cardiovascular: Regular rate, normal S1, S2, 2/6 systolic murmur at right sternal border with radiation to carotids. Lungs clear to auscultation bilaterally. No crackles. Abdomen obese with good bowel sounds, high pitch, nontender, nondistended. Extremities: 2+ pitting edema, good perfusion, 2+ dorsalis pedis pulses bilaterally. Neurological: Alert and oriented times three. LABORATORIES: Chem-7: Sodium 135, potassium 5.0, chloride 98, bicarbonate 23, BUN 33, creatinine 1.0, glucose 200. CBC: 9.4, 14.3, 40.9, 129. His CK was 89 with an MB of 10. His troponin was less than 0.3. His PT 13.6, PTT 25.2, INR 1.3. Chest x-ray was a limited exam that showed no evidence of congestive heart failure or infiltrates. HOSPITAL COURSE: This is a 73-year-old man with a history of coronary artery disease, muscular dystrophy who presents with new onset of complete heart block. 1. Cardiovascular system: Complete heart block, ischemic versus sequela of muscular dystrophy leading to conduction abnormality versus excess beta-blocker. A transvenous pacer was placed, but patient had already converted back to sinus, likely from a sympathetic surge during the IJ attempt. His beta-blocker was held. He was monitored on telemetry. EPS study was done and a DDD pacer was placed without complications and chest x-ray showed the pacer was in the proper placement. He was given vancomycin intravenously times four doses. On [**8-13**], after the pacemaker was placed, he developed heart rate in the 140s with palpitations and shortness of breath. He did not have any chest pain or diaphoresis. Patient was given Metoprolol 75 po times one with 25 in the evening and then on the 31st he was started on Toprol XL 75 mg po q.d. Patient's rate came back down to the 80s and he was stable. 2. Coronary artery disease: The patient was ruled out by enzymes. He was continued on aspirin, Isordil, Lisinopril. 3. Pump: He is continued on Lasix 20 q.d. His echocardiogram was repeated on [**8-13**] which showed an ejection fraction of 40-45%, hypokinesis of the basal, inferior and inferolateral walls, no AR and no MI. 4. Pulmonary: Patient was saturating well on room air. 5. Endocrinology: He had a history of "borderline diabetes." His glucoses were normal without any medications between 80 and 113. 6. Hematology: His hematocrit remained above 30. During the hospitalization, he did not require transfusions. 7. Psychiatry: Depression: He was continued on his outpatient Seroquel and Effexor. 8. Renal: His BUN and creatinine were stable. 9. Prophylaxis: He was continued on subcutaneous heparin and pantoprazole. DISCHARGE STATUS: He was full code and he was discharged home with follow-up at the Device Clinic on Tuesday, [**8-20**], at 1 p.m. to be followed up by Cardiologist, Dr. [**Last Name (STitle) **]. DISCHARGE DIAGNOSIS: Complete heart block. [**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**] Dictated By:[**First Name3 (LF) 6774**] MEDQUIST36 D: [**2109-8-20**] 18:38 T: [**2109-8-20**] 18:38 JOB#: [**Job Number 97433**]

[ "272.0", "V45.82", "496", "250.00", "413.9", "426.0", "401.9", "424.0", "425.4" ]

icd9cm

[ [ [] ] ]

[ "37.26", "37.83", "37.72" ]

icd9pcs

[ [ [] ] ]

5725, 6001

3595, 5703

2579, 2825

2848, 3577

827, 2172

161, 807

2194, 2554

25,812

168,103

49056

Discharge summary

report

Admission Date: [**2101-11-2**] Discharge Date: [**2101-11-10**] Service: CCU HISTORY OF THE PRESENT ILLNESS: The patient is an 83-year-old female with a history of hypertension who was admitted to an outside hospital on [**2101-10-23**] with the diagnosis of pyelonephritis and developed hypoxia, was intubated, sustained a non-Q wave MI in the setting of urosepsis and was transferred for interventional cardiac catheterization at [**Hospital1 18**]. She initially presented to the outside hospital with complaints of left flank pain and was found to have a low blood pressure of 99/53 and a positive urine culture for E. coli. The patient was afebrile. After transfer to the floor, the patient developed dyspnea and tachycardia and was found to be hypoxic on 100% nonrebreather. The patient was intubated, received an echocardiogram which showed an ejection fraction of 20% and found to have an increased troponin of 6.2 and CPK of 250. The patient became hypotensive at the outside hospital ICU and was started on dopamine, Neo-Synephrine, IV Lasix, IV heparin, IV Integrelin. The patient had a CT which ruled out PE, but later chest x-ray showed multilobar pneumonia. Renal ultrasound was negative. The patient was started on multiple antibiotics at the outside hospital including levofloxacin, cefuroxime, Cefazolin, ceftriaxone, and gentamicin. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypothyroidism. 3. Status post total abdominal hysterectomy. 4. Osteoporosis. 5. Kidney stones. MEDICATIONS: 1. Synthroid. 2. Hydrochlorothiazide. 3. Miacalcin. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: Vital signs revealed a temperature 98.4, temperature maximum 98.9, pulse 92-106, blood pressure 99/51, respirations 24, pulse oximetry 96% on 40% 02. Ventilator settings: Pressure support [**10-8**], tidal volume 400, respiratory rate 25, FI02 0.4. The ABG was 7.44, 35, 74, 40% on 02. The AA gradient was 167.45. Drips, dopamine 2 micrograms per kilogram per minute; heparin 1,100 units per hour. In general, the patient was an elderly intubated female who appears comfortable. HEENT: Extraocular movements intact. The pupils were equal, round, and reactive to light. The neck revealed no JVD, no carotid bruits. Cardiovascular: Soft, S1, S2, no murmur appreciated. Abdomen: Obese, soft, nondistended, nontender, normal abdominal bowel sounds. Pulmonary: Clear to auscultation anteriorly. Extremities: There were [**1-5**] DPs bilaterally, 1/2 PTs bilaterally, feet warm. Neurological: Alert and able to follow commands. INITIAL LABORATORY RESULTS: White blood cell count 25.4, hematocrit 37.2, platelets 277,000, 88.5% neutrophils, 8.1% lymphocytes. INR was 1.4. PTT 57.8. Chem-7 revealed a sodium of 143, potassium 3.0, chloride 105, bicarbonate 24, BUN 34, creatinine 1.5, glucose 227, anion gap 14, ALT 24, AST 70, CK 255, alkaline phosphatase 105, amylase 62, total bilirubin 0.7, albumin 3.0. Urine creatinine 72, sodium 32, potassium 52. Initial CPK 255, CK MB 36, MB fraction 14.1, troponin greater than 50. Repeat transthoracic echocardiogram done revealed an ejection fraction of 20-25%, severe left ventricular systolic dysfunction, akinesis of the distal one-half of the anterior septum, apex, and distal anterior inferior wall. INITIAL ASSESSMENT: This is an 83-year-old female with a history of hypothyroidism and hypotension who initially presented to an outside hospital with pyelonephritis who later became hypoxic, found to have multilobar pneumonia and ruled in for MI, non-Q wave by cardiac enzymes. The patient required intubation and pressors and was sent to [**Hospital1 18**] for cardiac catheterization. HOSPITAL COURSE: 1. INFECTIOUS DISEASE: The patient was hypotensive and tachycardiac, evidence of pneumonia on CT scan, evidence of UTI on urine culture. The patient was thought to have probable urosepsis. The outside hospital was called. Blood cultures done there were positive for E. coli which was pansensitive. The patient received intravenous fluids for hypotension and was gradually weaned off dopamine. The patient was started initially on levofloxacin and ceftriaxone to treat underlying infections empirically but was switched to just levofloxacin once outside hospital blood cultures were known. The patient had subsequent blood and urine cultures during the hospital course that had no growth. The patient was afebrile by the time of discharge. The patient is to have a full ten day course of levofloxacin. The last day of levofloxacin on [**2101-11-11**]. 2. CARDIAC: A) Pump: The patient had severe left ventricular dysfunction, EF 20% and a rule in for a non-Q wave MI. The MI is probably in the setting of sepsis due to the heart not being able to keep up with increased demand. A poor ejection fraction on the echocardiogram may be situational in sepsis and should be repeated when the patient is out of the hospital for a couple of weeks at least. The patient was maintained on pressor support to keep a MAP above 60 with dopamine and Vasopressin. The patient was gradually able to be weaned off these medications. As the hospital course progressed, the patient became hypertensive and gradually ACE inhibitor, nitrates, and beta blocker were started and titrated up as the patient tolerated. The patient had several episodes of flash pulmonary edema in the setting of hypertension. Future hypertensive events were controlled with Lasix and beta blocker ACE inhibitors. B) Rhythm: The patient had right bundle branch block with left anterior hemiblock which was reportedly old and had been there for several years. The patient had no other ectopy during the hospital course while on telemetry. C) Coronary: The patient was with a non-Q wave MI. The patient had a cardiac catheterization done once the urosepsis picture had cleared. Cardiac catheterization revealed LV ejection fraction of 46%, hypokinesis of the anterolateral and apical portions of the heart, normal mitral valve, normal aortic valve, 60% stenosis of the proximal RCA, 50% stenosis of the mid RCA, 80% stenosis of the mid LAD, 50% stenosis of the distal LAD, 40% stenosis of the proximal circumflex artery. The stenosis in the mid LAD was crossed with a wire and ballooned and stented with two stents. Resting hemodynamics showed mildly elevated right and left heart filling pressures. The patient was started on Plavix and aspirin after her catheterization with stent placement. The patient should be on Plavix for at least 30 days since the stent placement which was [**2101-11-7**]. 3. PULMONARY: The patient was presenting with multilobar pneumonia. Sputum was sent for Gram's stain and culture. Respiratory culture was negative, but the patient had received doses of levofloxacin before this was sent. The patient was successfully weaned off her ventilator within two days and gradually weaned off of all oxygen requirements. 4. RENAL: BUN and creatinine stable at all times. 5. LINES: The patient had a subclavian triple-lumen placed and a left wrist arterial line. These were placed and taken out without complication. DISCHARGE DIAGNOSIS: 1. Urosepsis. 2. Pneumonia. 3. Status post non-Q wave myocardial infarction. 4. Status post stent placement to mid left anterior descending artery. 5. Hypothyroidism. 6. Hypotension. DISCHARGE MEDICATIONS: 1. Imdur 120 mg p.o. q.d. 2. Metoprolol XL 150 mg p.o. q.d. 3. Lisinopril 40 mg p.o. q.d. 4. Plavix 75 mg p.o. q.d. 5. Losartan 25 mg p.o. q.d. 6. Enteric coated aspirin 325 mg p.o. q.d. 7. Lipitor 10 mg p.o. q.d. 8. Synthroid 100 micrograms p.o. q.d. 9. Levofloxacin 250 mg p.o. q.d. on [**2101-11-11**] and then stop. DISCHARGE CONDITION: Good. DISCHARGE STATUS: To home with VNA and PT services. The patient was instructed to take daily weights and report them to PCP. [**Name10 (NameIs) **] patient will receive a call from Dr.[**Name (NI) 10427**] office, her PCP, [**Name10 (NameIs) **] an appointment. The patient is to follow-up with Cardiology with Dr. [**First Name8 (NamePattern2) 1026**] [**Name (STitle) 1016**] on [**2101-11-15**] at 1:30 p.m. in the [**Last Name (un) 2577**] Building. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Name8 (MD) 8279**] MEDQUIST36 D: [**2101-11-10**] 13:27 T: [**2101-11-11**] 05:45 JOB#: [**Job Number **]

[ "458.2", "486", "599.0", "038.42", "410.71", "414.01", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "36.01", "88.53", "36.06", "37.22", "88.56", "99.20", "96.04" ]

icd9pcs

[ [ [] ] ]

7781, 8507

7429, 7759

7216, 7406

3752, 7195

1675, 3735

1394, 1660

80,594

100,873

37413

Discharge summary

report

Admission Date: [**2196-2-10**] Discharge Date: [**2196-2-12**] Date of Birth: [**2152-12-6**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1253**] Chief Complaint: hematochezia Major Surgical or Invasive Procedure: EGD to evaluate for bleeding History of Present Illness: Ms. [**Known lastname 84097**] is a 43 yo female with a remote history of alcohol abuse/use who is 5 days s/p ERCP on [**2196-2-5**] with sphincterotomy for pancreatitis and cholecystitis with jaundice during which a small stone and sludge was extracted from the CBD. She originally presented to the [**Hospital3 **] ED on [**2196-2-4**] with upper abdominal pain, and intractable nausea/vomiting (reportedly going on for 4 years as well as a [**3-2**] yr history of post-prandial RUQ pain), but she had elevated LFTs and WBC (WBC 12.1, ALT 192, AST 433, AP 266, [**Doctor First Name 674**] 319, Lipase 1456, TBili 4). She was sent to [**Hospital1 18**] for the ERCP because CT scan showed a possible cystic mass in the GB fossa vs. enlarged GB, also ? L liver lobe lesion and ? 2 cm pancreatic head lesion. . After the ERCP as described above, she was transferred back to [**Hospital3 6592**]. There, she underwent attempted cholecystectomy on [**2196-2-6**]. The gallbladder could not be removed due to too much inflammation. She did well post-op without significant pain or nausea, and she was discharged on [**2196-2-8**]. The next morning, she passed a dark stool and then had an episode of frank BRBPR. She had one episode of n/v without blood or coffee grounds. Because of this, she presented to her surgeon's clinic. There, she had a presyncopal event and she was transferred back to the [**Hospital1 **] ED, where her SBP was 80 and her HCT was 22 down from 32 postop. She was given IVF, 2U pRBCs, and cefoxitin, and admitted to the ICU. She is being transferred to the [**Hospital1 18**] [**Hospital Unit Name 153**] in preparation for possible ERCP in the morning for presumed post-sphincterotomy bleed. Dr [**Last Name (STitle) 84098**] is the transferring surgeon- pager ([**Telephone/Fax (1) 84099**] (covering surgeon). Past Medical History: history of heavy etoh years ago Social History: history of heavy etoh years ago. reports currently drinking a bottle of wine with a friend about once per week. Roughly 20 pk year history of tobacco, quit 2 weeks ago. Denies IVDU, cocaine. Family History: Father with DM. No liver problems or [**Name (NI) **] disease. Physical Exam: 98.3 79 117/92 12 99%RA . PHYSICAL EXAM GENERAL: Pleasant, well appearing in NAD 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**]. No JVD. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT. Mild TTP over incision site in epigastric area. No rebound or guarding. No HSM. EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: spider angiomata on chest. no palmar erythema. Good capillary refill, 1-2 seconds. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: ADMISSION LABS: . [**2196-2-10**] 06:58AM NEUTS-70.8* LYMPHS-20.2 MONOS-7.0 EOS-1.9 BASOS-0.2 [**2196-2-10**] 06:58AM PLT COUNT-351 . [**2196-2-10**] 06:58AM PT-12.4 PTT-19.9* INR(PT)-1.0 . [**2196-2-10**] 06:58AM GLUCOSE-113* UREA N-10 CREAT-0.4 SODIUM-144 POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-21* ANION GAP-15 . [**2196-2-10**] 06:58AM CALCIUM-8.5 PHOSPHATE-3.0 MAGNESIUM-1.5* [**2196-2-10**] 06:58AM ALT(SGPT)-21 AST(SGOT)-33 ALK PHOS-84 AMYLASE-83 TOT BILI-0.6 [**2196-2-10**] 06:58AM LIPASE-204* [**2196-2-12**] 12:26PM BLOOD WBC-7.0 RBC-3.30* Hgb-10.0* Hct-31.0* MCV-94 MCH-30.4 MCHC-32.4 RDW-17.9* Plt Ct-503*# . ERCP: 14 fluoroscopic ERCP images are included. Images demonstrate cannulation of the common bile duct. Contrast injection demonstrates normal course and caliber of intrahepatic ducts. Filling defects seen in the lower one-third of the CBD represent small stone and biliary sludge per report. Subsequent images demonstrate filling of the cystic duct with irregular appearing contrast suspicious for leak in the region of the gallbladder. . CT AB: 1. Findings are consistent with cholecystitis with contained gallbladder perforation and small fluid collectiom (2.2cm) compressing the duodenum. The extraluminal air could either be due to recently attempted laparoscopic cholecystectomy, or the gallbladder perforation itself. 2. There is no gross intrahepatic biliary ductal dilatation, with only mild intrahepatic ductal dilatation centrally and on the left. 3. Fatty liver with hyperemia along the margin abutting the gallbladder fossa. Brief Hospital Course: 43 yo 5 days s/p ERCP with sphincterotomy and s/p failed lap chole p/w BRBPR. . #. BRBPR: Pt presented with Hct drop, orthostatic symptoms and hematochezia 4 days s/p ERCP with sphincterotomy. Most likely site was considered to be sphincterotomy site given timing of procedure. ERCP team saw patient at admission and performed ERCP on [**2-10**]. ERCP showed no evidence of any localized bleeding. No ulceration seen. Evidence of a previous sphincterotomy was noted in the major papilla. There was no evidence of active or recent bleeding at the sphincterotomy site. Yellow bile was seen at the ampulla and within the duodenum. Cholangiography was not performed. Otherwise normal EGD to third part of the duodenum. Patient has remained hemodynamically stable with no further transfusion requirements or evidence of GI bleeding, and liver function tests and amylase/lipase normalized. . #. pancreatitis/cholecystitis: Both by laboratory values and symptoms, this improved during course. Pt had undergone attempted lap chole at [**Hospital3 **], apparently failed due to inflammation. Ab CT showed contained gallbladder perforation likely secondary to that difficult attempted procedure. However, patient appeared very well clinically, with no fevers or leukocytosis. The Surgical team was not convinced that she had a perforated gallbladder, however. She was taking POs without abdominal pain or nausea/vomiting. She had been started on a course of PO cipro, and given her possible gallbladder perforation, which was changed to clindamycin and flagyl d/t concern of QTc prolongation. This course should be continued for 10 days. She should be seen by Dr. [**Last Name (STitle) 39930**] in 2 weeks for pre-op evaluation, and should be scheduled for open cholecystectomy in [**5-3**] weeks. Of note, imaging at OSH had showed question of underlying masses in gallbladder and pancreatic head. Patient will be scheduled for EUS with probable biopsy; arrangements will be made by the surgical team. . #. history of alcohol abuse: has appearance of hepatomegaly on OSH imaging and increased echogenicity suggesting fatty liver. She has some stigmata of chronic liver disease. Coags borderline, and her albumin low (though this could be stress response). Her bili wnl. Hepatic function appears preserved. Patient should be followed by a PCP to monitor hepatic function and counsel alcohol cessation. . #. prolonged QTc: had prolonged QTC at admission, which resolved after stopping ciprofloxacin for 24 hours. . #. Primary care: Patient does not have PCP. [**Name10 (NameIs) **] was set up for MassHealth and should be referred to PCP in her area. Pt was provided phone numbers to assist with finding a primary care physician. Medications on Admission: ciprofloxacin 500mg [**Hospital1 **] tylenol 1g q 4hr prn pain Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 10 days. Disp:*30 Tablet(s)* Refills:*0* 3. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 10 days. Disp:*40 Capsule(s)* Refills:*0* 4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: # Gastrointestinal bleeding, NOS # Pancreatitis/Cholecystitis # Questionable perforated gallbladder 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. You were admitted for gastrointestinal bleeding, possibly related to the ERCP procedure you had last week. You underwent a repeat ERCP which did not identify any bleeding area. You also had a CT scan which showed a possible small perforation in your gallbladder, which appeared to be contained, although the surgeons are not certain that this is the case. Your blood counts remained stable without further bleeding. You were started on antibiotics for your gallbladder. You will see Dr. [**Last Name (STitle) 39930**] for removal of your gallbladder in [**5-3**] weeks. You should set up an appointment with a primary care physician in your area. . The following changes have been made to your medications: Flagyl and Clindamycin for 10 days Followup Instructions: You will be scheduled for an endoscopic ultrasound prior to your cholecystectomy; the Surgery service will make these arrangements. You will follow up with Surgery (Dr. [**First Name (STitle) **] for cholecystectomy (gallbladder removal) in approx 6 weeks. _______________________________________________ Appointment #1 MD: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] Specialty: Surgery Date/ Time: Monday [**2196-3-21**] at 9 AM Location: [**Hospital1 18**] [**Hospital Ward Name 23**] Building [**Location (un) **], Surgical Specialties, [**Location (un) **], [**Location (un) 86**], MA Phone number: ([**Telephone/Fax (1) 9058**] Special instructions for patient: Appointment #2 MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] Specialty: Gastroenterology Date/ Time: Thursday [**2196-2-18**] at 9:45 AM Location: [**Hospital1 18**] [**Hospital Unit Name 1825**] [**Location (un) **], [**Location (un) **], [**Location (un) 86**], MA Phone number: ([**Telephone/Fax (1) 22346**] Special instructions for patient: Appointment #3 MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**] Specialty: Gastroenterology for Colonoscopy Date/ Time: Wednesday [**2196-3-9**] Location: [**Hospital1 18**] [**Hospital Ward Name 1950**] Building [**Location (un) **], [**Location (un) **], [**Location (un) 86**], MA Phone number: ([**Telephone/Fax (1) 76007**] Special instructions for patient: Please follow up with primary care for ongoing care. Consider calling the number below for primary care near you. Community Health Center [**Street Address(2) 84100**] [**Location (un) 6598**], [**Numeric Identifier 84101**] ([**Telephone/Fax (1) 84102**]

[ "569.3", "794.31", "577.0", "574.10" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

8414, 8420

5044, 7774

285, 316

8564, 8564

3446, 3446

9513, 11229

2471, 2536

7887, 8391

8441, 8543

7800, 7864

8709, 9490

2551, 3427

233, 247

344, 2189

3462, 5021

8578, 8685

2211, 2244

2260, 2455

63,243

169,520

2363

Discharge summary

report

Admission Date: [**2171-12-4**] Discharge Date: [**2171-12-8**] Date of Birth: [**2094-1-5**] Sex: F Service: MEDICINE Allergies: Aspirin / Lopressor Attending:[**First Name3 (LF) 2279**] Chief Complaint: Cough, fever Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 77 yo woman with PMHx sig. for asthma, HTN, afib, DM2 who presents wtih 4 days of productive cough, shortness of breath, and fevers. In the ED, initial VS were: 97.6 111 109/80 18 96% RA. Exam was notable for diffuse wheezes, LLQ abdominal pain, guaiac neg. Labs were notable for WBC 5.3, 9.8% eos. CXR showed no infiltrate. CT abdomen showed "Mild sigmoid diverticulits without drainable fluid collection or extraluminal gas. Focal thickening along left aspect of rectum (2.3x1.8). Recommend follow up when symptoms resolve at which time rectum could be re-valuated." The patient received nebulizers, 125mg solumedrol, IV abx (cipro flagyl), and 1L of NS. Vitals prior to transfer to the floor were: 76 141/84 16 100% 3L nc. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, constipation, BRBPR, melena, or abdominal pain. No dysuria, urinary frequency. Denies arthralgias or myalgias. Denies rashes. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: - Asthma (diagnosed [**2168**], per patient, with baseline peak flow 450-500; no intubations ever. Triggers include her children smoking, dust, and [**Last Name (LF) 12290**], [**First Name3 (LF) **] patient) - Mild systolic CHF (ejection fraction 50% and 55% in two echos in past 12 months) - Question of takotsubo cardiomyopathy ("apical ballooning") on echo from OSH in past three years - Insulin-independent diabetes mellitus (on metformin) - Hypertension - Paroxysmal atrial fibrillation (on warfarin for ~2 years) - Hyperlipidemia - Early dementia with memory loss - Osteoporosis - Depression/anxiety (one psychiatric admission 20-30 years ago for suicidal ideation with plan and "hearing animals talk to me"; no history of suicide attempts) - Glaucoma with no vision in right eye; s/p surgery - Breast ca s/p mastectomy many years ago - Status post cholecystectomy - Status post hysterectomy - Status post "knee surgery" - Obstructive sleep apnea; on CPAP Pertinent Results: CT abd: IMPRESSION: 1. Uncomplicated sigmoid diverticulitis with a question of tiny 9-mm fluid collection within the sigmoid wall, which is too small to drain. No extraluminal gas. 2. 2.3 x 1.8 cm area of thickening along the left aspect of the rectum is mass-like, though may represent adherent stool. Given these findings, we recommend followup imaging or direct visualization following improvement of the patient's acute symptoms. Brief Hospital Course: 77yo female with h/o of asthma/COPD, DMII, paroxysmal Afib and early dementia presents with SOB and abdominal pain, admitted to the ICU after having unstable atrial flutter in the ED. . 1. Atrial Flutter. Patient unstable in ED secondary to fast rate (HR 190s) and poor fluid status from GI illness. She had not been taking diltiazem while ill. She responded to cardioversion and was maintained on PO diltiazem. In the ICU she remained in NSR without aflutter. She was sent home on diltiazem 240mg daily. Coumadin was temporarily held due to supratherapeutic INR. She was given 1mg Vit K for an INR in the range of 7. At the time of discharge her INR was 1.9 and resumed her coumadin. She will follow up at [**Hospital **] clinic early this coming week. . 2. Diverticulitis. Pt had LLQ abdominal pain revealing uncomplicated diverticulitis. Pt was started on Cipro and Flagyl and transitioned from clears to regular diet which she tolerated. She will complete a total 14 day course of antibiotics. Her INR will need careful monitoring as both Cipro and flagyl interact with coumadin. [**Hospital **] clinic was contact[**Name (NI) **] and will follow up with patient. **She will need outpatient colonoscopy within 6 weeks . 3. Asthma exacerbation. Mildly elevated eos. She was given 5 day course of prednisone. Continued inhalers, montelukast. . 4. Depression: continued Buproprion and Citalopram. . 5. Pain: Tramadol and [**Last Name (LF) 12291**], [**First Name3 (LF) **] home regimen . 6. Dyslipidemia: simvastatin . 7. HTN: valasartan was stopped for low-normal BPs. Medications on Admission: - Albuterol 0.083% nebs QID PRN - Bupropion SR 300mg Q24hr - Citalopram 30mg daily - Diltiazem SR 180mg daily - Advair 250-50 1 puff [**Hospital1 **] - Gabapentin 300mg QHS - Ipratropium 0.2mg/ml QID PRN - Combivent 18mcg-103mcg 2 puffs Q4-6H PRN - Lidocaine 5% patch - Metformin 850mg [**Hospital1 **] - Montelukast 10mg daily - Simvastatin 40mg daily - Tobramycin-dexamethasone 0.3%-0.1% OD [**Hospital1 **] - Tramadol 25mg TID PRN - Valsartan 40mg daily - Coumadin 4-6mg daily - Aspirin 81mg daily - Calcium-vitamin D 600mg-400unit [**Hospital1 **] Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 5. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. tobramycin-dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl Ophthalmic [**Hospital1 **] (2 times a day). 8. tramadol 50 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for pain. 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 11. bupropion HCl 300 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 12. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): end date [**12-17**]. . Disp:*28 Tablet(s)* Refills:*0* 13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): End date [**12-17**]. Disp:*19 Tablet(s)* Refills:*0* 14. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 1 days. Disp:*2 Tablet(s)* Refills:*0* 15. diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Disp:*60 Capsule, Sustained Release(s)* Refills:*2* 16. Calcium-Vitamin D 600-400 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 17. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 18. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*2 Disk with Device(s)* Refills:*2* 19. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day. 20. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Disposition: Home With Service Facility: Medical Inc Discharge Diagnosis: Atrial Flutter- hemodynamically unstable, s/p cardioversion Diverticulitis Asthma exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure providing care for you during your hospitalization. You were admitted to the hospital for an asthma attack. You were treated with nebulizers and prednisone for 5 days. You were also found to have a condition called diverticulitis. This is an infection in a pocket of your gut. You were treated with antibiotics with improvement of symptoms. Please resume these antibiotics for a total 14 day course ([**Date range (1) 12292**]). Your heart went into a very fast rhythm called Atrial Flutter. You were shocked out of the rhythm. Your heart remained in a normal rhythm after the shock. We increased your diltiazam dose to better control your rates. Please continue to take your diltiazem medication every day to control your heart rate and protect if from going into a fast rhythm. . The following changes were made to your MEDICATIONS: To treat the divertivulitis: START taking CIPROFLOXAXIN 500mg tablet. Take one tablet twice daily through [**12-17**]. START taking METRONIDAZOLE 500mg tablets, Take one tablet three times daily through [**12-17**]. . To treat your wheezing: START taking PREDNISONE 40mg. Please take one 40mg tablet of PREDNISONE on [**12-9**], after this you will have completed your 5 day course. INCREASE your ADVAIR to 500/50 formulation. Take one puff twice daily. . For heart rate control: INCREASE your DILTIAZAM dose. Please start taking one 240mg tablet daily. .. For anticougulation: DECREASE your COUMADIN. Please start taking one 2mg tablet daily. Be sure to have your INR checked regularly at [**Hospital 2786**] clinic and your coumadin dose will be adjusted accordingly. . Your blood pressures were found to be low-normal. So regarding BP meds: STOP taking your VALSARTAN, can readdress need for more blood pressure control at next PCP [**Name Initial (PRE) **]. Please follow up with your primary care doctor within the next week. You should get a colonoscopy within 6 weeks to assess your colon. This is very important. We also scheduled an appointment for you to follow up with a pulmonologist to better control your asthma. Followup Instructions: **When you see your doctor [**First Name (Titles) **] [**12-11**], please make sure to also schedule a colonscopy within 6 months. Department: HMFP When: MONDAY [**2171-12-9**] at 8:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10092**], 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: [**Hospital3 249**] When: WEDNESDAY [**2171-12-11**] at 8:50 AM With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *******NOTE: : 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: PULMONARY FUNCTION LAB When: WEDNESDAY [**2171-12-18**] at 1:10 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: THURSDAY [**2171-12-19**] at 9:40 AM With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HMFP When: MONDAY [**2172-2-3**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10092**], 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 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]

[ "V45.71", "272.4", "300.4", "250.02", "V88.01", "401.9", "733.00", "365.9", "562.11", "427.32", "428.22", "327.23", "427.31", "428.0", "V10.3", "493.22" ]

icd9cm

[ [ [] ] ]

[ "99.62" ]

icd9pcs

[ [ [] ] ]

7305, 7347

3082, 4655

292, 299

7486, 7486

2623, 3059

9742, 11823

5258, 7282

7368, 7465

4681, 5235

7637, 9719

1090, 1618

240, 254

327, 1071

7501, 7613

1640, 2604

14,432

109,007

20208

Discharge summary

report

Admission Date: [**2168-8-8**] Discharge Date: [**2168-11-19**] Date of Birth: [**2128-10-27**] Sex: F Service: MEDICINE Allergies: Vancomycin / Compazine Attending:[**First Name3 (LF) 1145**] Chief Complaint: MEC chemotherapy followed by syngeneic transplant Major Surgical or Invasive Procedure: hickman placed [**8-10**] intubation intra-aortic balloon pump History of Present Illness: Patient is a 39 year old woman diagnosed with AML in [**2166-11-11**] after presenting for a routine physical exam, CBC revealed white count of 5300 with 40% blasts. Pt noted generalized fatigue at that time. Patient found to have normal cytogenetics, immunophenotyping revealed positive CD34; positive CD13, and positive CD17. Patient underwent induction 7+3; 5+2 in [**Month (only) 404**] of [**2166**], followed by three cycles of consolidation after which she had a bone marrow biopsy with remission in early [**2166**]. Patient remained in remission until [**3-31**] at which time she was found to have relapsed by bone marrow biopsy and underwent reinduction 7+3/5+2(idarubicin and cytarabine). Patient was planned to have synergeneic transplant (she has a twin sister-however this is in the process of being confirmed), with BU/CY containing regimen. She was admitted for a week in [**Month (only) 205**] for neutropenic fevers, hickman was pulled, and patient was treated with Daptomycin. Last bone marrow biopsy on [**7-27**] shows relapsed AML, CD34/CD13 with 26% blast cells. CMV viral load on [**7-27**] was + at 36. . Although her English is limited, patient states that she has been feeling relatively well since her discharge. Uses ativan to help control her nausea, has had occasional diarrhea with the most recent episode this am, denies any blood in stool. She reports feeling tired most of the time, but her appetite and weight have been stable (she initially lost 5-10lbs after chemo). She denies any fever/chills or night sweats. She notes trouble sleeping, which often results in a headache the following morning. She also reports some chest/substernal "discomfort"-particularly in the am, but denies pain or SOB. Patient notes increased anxiety with this hospitalization. Past Medical History: 1) AML, diagnosed in [**10-29**]. (a) normal cytogenetics. (b) positive CD34; positive CD13, and positive CD17. (c) status post 7+3; status post 5+2 in [**2166-11-27**]. (d) bone marrow biopsy with remission in early [**2166**]. (e) she is status post HIDAC consolidation in [**2166-12-28**], complicated by fever and neutropenia with no clear source with an admission in [**2167-1-26**]. (f) status post HIDAC two on [**2167-1-26**] with mild transaminitis (last dose held). (g) She received her third and last cycle of HiDAC consolidation in [**2167-2-26**]. 2) Has noted heavy periods and was recently diagnosed with fibroids. Social History: Patient is from [**Country 3992**] and has lived in the US for 13 years. Formerly worked for an electric company. She is married with two children. She denies use of alcohol or illicit drugs. She has a sister with a human leukocyte antigen match in [**Country 3992**]. She speaks Cantonese and some English. Family History: Non-contributory Physical Exam: VITALS: 103lbs/ 98.1/ 100/18/120/70 100% on RA GEN:awake, alert, pleasant, speaks some english, thin but not cachetic HEENT:atraumatic, sclerae anicteric, no pharyngeal exudate but some whitish coating on tongue. No ulcerations or lesions. NECK:NO LAD, no JVD, no carotid bruits SKIN:warm/dry/ no rashes, +ttp around old hickman site- no edema/erythema CV:tachy, nml S1/S2, + DP pulses strong bilaterally LUNGS:CTA B/L ABDOMEN:soft, nontender, no organomegaly, decreased BS EXT:no C/C/E, normal muscle tone, 5/5 strength in all 4 extremities, symmetric NEURO: CN II-XII relatively intact, A/O x3, no focal deficits (transfer to ICU) Vitals: T 96.0, BP 89/56, HR 130, RR 31, O2 sat 91% RA Gen: lying in bed, intubated, awake HEENT: allocepecia, anicteric, EOMI, PERRL, OP clear w/ MMM Neck: + JVD to angle of jaw CV: Tachycardic, reg s1/s2, could not appreciate M/R/G Pulm: ventilated BS b/l Abd: +BS, soft, NT, ND Ext: warm, 2+ pitting edema extending to thighs and sacram b/l, 1+ pitting edema to mid-arm b/l, + DP pulses b/l Pertinent Results: Labs on admission: GLUCOSE-98 UREA N-10 CREAT-0.4 SODIUM-140 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-28 ANION GAP-12 CALCIUM-9.6 PHOSPHATE-3.7 MAGNESIUM-1.8 . ALT(SGPT)-18 AST(SGOT)-18 LD(LDH)-158 ALK PHOS-44 TOT BILI-0.3 ALBUMIN-4.5 . WBC-2.5* RBC-3.71* HGB-12.1 HCT-35.2* MCV-95 MCH-32.7* MCHC-34.5 RDW-14.9 NEUTS-22* BANDS-0 LYMPHS-63* MONOS-1* EOS-4 BASOS-0 ATYPS-5* METAS-0 MYELOS-0 BLASTS-5* HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL TEARDROP-OCCASIONAL . Labs on expiration: WBC-8.6 RBC-3.14* Hgb-10.6* Hct-31.7* MCV-101* MCH-33.8* MCHC-33.4 RDW-25.5* Plt Ct-20* . PT-15.9* PTT-74.5* INR(PT)-1.7 . Glucose-108* UreaN-67* Creat-1.0 Na-131* K-4.5 Cl-91* HCO3-27 AnGap-18 Calcium-8.7 Phos-5.5* Mg-2.0 . . Imaging: [**11-18**] PCXR: An endotracheal tube ends in satisfactory position 4 cm above the carina. An NG tube curls in the stomach. A Swan-Ganz catheter from the inferior approach ends in the proximal left pulmonary artery. Mild cardiomegaly is unchanged. A small left effusion is stable. Opacity within the left lower lobe and the peripheral right lung base is unchanged. No failure or pneumothorax is seen. IMPRESSION: Lines and tubes in satisfactory position. Opacity in the left lower lobe and the right lateral lung base representing possible pneumonia Vs. atelectasis are unchanged compared to [**2168-11-17**]. . [**11-11**] Cath: FINAL DIAGNOSIS: 1. Cardiogenic [**Month/Year (2) **] with vasodilatory [**Month/Year (2) **] 2. IABP insertion. . [**11-13**] RUQ US: There is a large right-sided pleural effusion. Gallbladder is not distended. There is gallbladder wall thickening. No gallstones are seen. There is possible sludge within the gallbladder. There is no intra- or extra- hepatic biliary ductal dilatation. Common duct measures 3-4 mm. Portal vein appears patent on limited imaging. IMPRESSION: 1. Large right-sided pleural effusion. 2. Gallbladder wall thickening without gallstones identified. The appearance of the gallbladder is not significantly changed compared to the exam of seven days prior. Causes of gallbladder wall thickening include hypoalbuminemia, CHF, liver disease, and other causes of third spacing. If there is continued clinical concern for acalculous cholecystitis, HIDA scan may be performed for further evaluation. Brief Hospital Course: 39 year old female with relapsed AML, admitted for re-induction followed by syngeneic/identical twin allogenic transplant. Patient had been on BMT service for >2 months and was then transferred to the MICU for CHF, including diuresis and afterload reduction therapy initially with hydralazine changed to ACE I (captopril). With these interventions, patient's weight decreased from 130 -> 114 lbs. Course was c/b intermittent episodes of hypotension (below baseline hypotension of SBP 80's - 100's) and lightheadedness. Following stablization after weight loss and transfer to the floor, patient had orthostasis, continued total body edema and continued to complain of dry mouth. Her cardiac managment is otherwise complicated by continuous sinus tachycardia to 120-140's. Patient was then transferred from the floor to [**Hospital Unit Name 196**] for management of heart failure and diuresis. She diuresed well over 2 weeks however was still fluid overloaded. Patient underwent a trial of nesiritide for diuresis while off captopril and then lasix was added the regimen. On [**11-7**], patient diuresed well on lasix with a slight elevation in creatinine to 1.6, but a new anion gap was noted with a lactate of 7. Also, LFT's increased without clear cause. On [**11-10**], patient become hypotensive to 60's overnight with worsening respiratory distress. Unclear whether this was due to sepsis versus cardiogenic [**Month/Year (2) **]. Patient was subsequently transferred to the CCU and intubated due to respiratory distress. A venous blood gas showed a pH of 7.14 and venous lactate of 13. At the time, patient's INR was 4 and her respiratory and hemodynamic status very tenous. Also, with tricuspid vegetation and known endocarditis, it was thought placing a swan would be high risk. As mentioned above, [**Hospital 228**] hospital course also complicated by strep viridans endocarditis with visible vegetations seen on most recent ECHO [**2168-10-19**]. Diagnosed in [**10-1**] treated with 10 days gentamicin and 4 weeks ceftriaxone, generalized anasarca, persistent sinus tachycardia with occasional [**Month/Day (1) 6059**], bilateral pleural effusions, acalculous cholecystitis, portal vein thrombosis, DIC and hemorrhoids. . . * AML - pt was started on syngeneic transplant protocol upon admission on [**2168-8-8**]. Hickman was placed on [**8-10**]. Pt was preconditioned with MEC. Of note patient had PPD/[**Female First Name (un) **] placed. She had positive PPD 12 years ago and was treated for six months - pt can't remember which drug. Patient's chest x-ray was negative, no active symptoms now or during previous chemotherapy. No intervention/treatment necessary at this time after consulting with ID. On [**8-24**] pt was started on Allo Bisulfan/Cytoxan protocol. She was continued on Levofloxacin/Flagyl coverage. Pt also received a PICC line in addition to her R double lumen Hickman. Attemtp to L sided Hickman previously failed secondary to inability to advance the catheter during IR. Pt tolerated transplant well and her ANC gradually increased with resolution of neutropenia. Pt was initially started on Acyclovir. She was also treated with empiric Flucanazole. Acyclovir and fluconazole were to be continued for 6 months after trasplant. At that time peripheral blood did not reveal any blasts, and there was normal trilineage maturation. Pt was believed to be in complete remission from the AML, and did not required chronic blood product transfusion. No further chemotherapy was planned in the near future. If her AML relapsed, her prognosis will be poor. During her MICU stay, there was no evidence of AML recurrence. . * Abdominal pain - The patient complained of right sided abdominal pain of mild severity, worse with palpation, often absent at rest, during her MICU stay. This was attributed to her portal vein thrombosis initially, however patient described early satiety. EGD was unremarkable (some linear gastritis only), and not able to account for the patient's symptoms. The patient was placed on a PPI. A CT w/ contrast on [**10-24**] revealed contracted portal vein thrombosis, cecal wall thickening, possibly secondary to ascites and a question of free air, which was further discussed with radiology and determined to be most likely in the appendix. However, no clear source for her polymicrobial blood cultures was found. Per ID, she was continued on her metronidazole for a 10 day course. She has remained afebrile since. . * CP - patient intermittently complained of CP on several occasions. Repeated EKGs showed no ST changes. Later in the course they were significant for sinus tachycardia. Cardiac enzymes were significant for troponin of 0.05 x 3, which was stable and not trending up, ck-MB was negative. This was thought to represent mild troponin leak secondary to demand ischemia sometimes as could be expected in high catecholamine states that accompanies severe sinus tachycardia. Repeat Echo also showed worsening EF with global hypokinesis. Pt also had an increasing pulmonary artery pressure. V/Q scan was normal and there was only mild pulmonary edema on diagnostic studies. Patient had periodic echocardiograms done showing progressively worse systolic right and left sided function. An echo on [**9-27**], done to evaluate interval changes prior to surgery for suspected cholecystitis, showed worsened EF<20% and new vegetations on the tricuspid valve and the chordae to the tricuspid valve. Subsequent echos supported the data from the earlier echos (EF<20% w/ marked TR). The patient did not complain of CP during her MICU stay. However, on transfer to the BMT floor, she did have several instances of chest pain without EKG changes. Her cardiac enzymes were cycled once with negative CK, and CKMB, and stable troponins. Her chest pain was thought to be secondary to anxiety, often resolving with ativan, and sinus tachycardia, and was treated with morphine and attempts at better rate control. . * CHF - her cardiomyopathy was new since her transplant as a echo prior to transplant revealed normal systolic function. The worsened heart function was believed to be secondary to cytoxan as well as prior anthracycline. She had diffuse anasarca, due to EF <20%, severe tricuspid regurgitation, as well as malnutrition and low albumin with low oncotic pressure. She was managed with lasix, metoprolol 12.5 PO TID, spironolactone 25mg PO TID, and digoxin 0.125 mg PO every other day. It was unclear if her cardiac function would improve. Patient's blood pressure with diuresis was marginal and cardiology consult initially did not believe there was room to add ACE-inhibitor, neither did they believe that she would benefit from afterload reduction. Patient's maximum weight was 130 lbs and she was diuresed to 123 lbs with lasix 20mg PO TID and more recently a lasix drip at 2mg/hr in the MICU. In addition, she had a thoracentesis of her right sided pleural effusion with removal of 1L, and some improvement of her dyspnea. Of note, she has not required supplemental oxygen. Echos demonstrated EF<20% on multiple occasions. She was overall fluid overloaded and responded somewhat to diuresis in the MICU. She was transferred to the floor for CHF optimization when she no longer required MICU level care ([**10-20**]). On the floor, a CXR showed continued failure, which was confirmed by a CT with contrast on [**10-24**]. She was actively diuresed with lasix 40 mg PO QD to 114 lbs, with a consequent increase in her serum Cr from 0.8 to 1.4. A repeat CXR on [**10-31**] showed marked improvement of her asymetric pulmonary edema, though on exam, she continued to have [**11-29**]+ LE edema L>R and ascites. She was also tried on carvedilol per cardiology for rate control with a drop her SBP to the 70s. Cardiology then recommended acebutalol for greater Beta 1 selectivity, but she also did not tolerate this with a drop in SBP to 69, which returned to 85 after 150 cc IV bolus of NS. Her digoxin was titrated to try to improve her rate control and was set at alternating doses of 0.1875 and 0.25 with a resting HR in the 120-130s. She was also started on captopril 6.25 mg PO TID for afterload reduction and for her EF<20%. She was subsequently transferred to cardiology ([**Hospital Unit Name 196**]) for further cardiac management on [**2168-11-1**]. . On cardiology service diuresis was attempted by placing patient on nesiritide drip and supplementing with lasix. Patient initially tolerated this well, was able to lose approximately 5 pounds of water weight. However, lasix was discontinued after 2 days due to elevated creatinine. After 1 week on nesiritide, this also had to be discontinued due to hypotension and development of other medical issues including elevated lactate. Patient was then transferred to the intensive care unit for further monitoring and treatment. . Due to severe hypotension which was thought to be secondary to cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] intra-aortic balloon pump was placed and milronone drip was initiated. Upon presentation to the CCU, the patient was afebrile without white blood cell count or clear souce of infection. However, repeat ECHO showed persistent vegetations and TR. Patient also required vasopressin and levophed to maintain her blood pressure. Attempts at weaning either the balloon pump and vasopressin were unsuccessful. Patient was continued on the balloon pump for 1 week without ability to wean and so was it was subsequently discontinued. Patient expired shortly after balloon pump removal. . *Sinus Tachycardia - Patient was also noted following her chemotherapy to have sinus tachycardia, onset at same time as her above CHF. Her heart rate stayed in the 120's-160's and was also addressed on her transfer to the cardiology service. It was believed that her sinus tachycardia was likely compensatory for her poor ejection fraction with her CHF. A trial of carvedilol and acebutelol was attempted prior to transfer to cardiology, but was not tolerated due to hypotension. On cardiology service a trial of 1mg IV lopressor was attempted with the thought that if her blood pressure tolerated this and her heart rate decreased an oral trial of lopressor could be attempted. However, with the 1 mg IV lopressore, patient's heart rate dropped into 80-90's and her systolic blood pressure dropped to 50's-60's. Therefore no nodal [**Doctor Last Name 360**] was started for her tachycardia. . * [**Name (NI) 6059**] - pt has been on telemetry during her stay. She had two episodes of [**Name (NI) 6059**] lasting apptoximately 12 beats with a background of sinus tachycardia ranging up to 150s. She has been continued on metoprolol 12.5 mg PO TID. She may need evaluation for ICD placement, as this may be related to her cardiomyopathy. This did not come up again during her MICU stay or stay on the BMT floor. While in the CCU, patient had persistant atrial tachycardia. On [**11-14**], heart rate was in the 140's and was hypotensive with systolic in the 60's and MAP in 50's. Patient was shocked 100J to hemodynamically stable atrial tachycardia. Digoxin was discontinued secondary to toxicity. . * Endocarditis - Multiple cultures including fungal and m.fufur cultures were drawn but remained negative. In addition patient completed an empiric 2 week course of daptomycin (given hx of allergy to vancomycin), meropenem, and ambisome. However, a repeat echo showed unchanged size of the vegetatations, and a diagnosis of marantic endocarditis was suspected. If patient develops a fever, infectious endocarditis once again has to be considered and she needs to be broadly cultured including fungal cultures. A subsequent echo showed worsening TR without note of the vegetation on the echo dated [**10-19**]. The patient was tx'd w/ ceftriaxone 2g daily, beginning on [**10-16**] and will need 4 weeks of treatment to be completed on [**2168-11-13**]. Follow up blood cultures and ECHO should be done at that time to ensure bacteremia and tricuspid vegetations have resolved. - h/o strep viridans endocarditis, s/p 10 days gentamicin and currently on CTX (started [**10-16**]) to complete a 4 week course, [**11-7**] repeat ECHO show persistent vegetations on TR. - discontinued CTX change to daptomycin/meropenum day 9 - dc'd caspofungin day 6 - pt grew 100K enterococcus in urine should be covered for VRE with daptomycin - pan-cultured, incl fungal, pulled PICC sent tip for culture - apprec pulm recs, will send sputum cx - US of abdomen consistent with volume overload -> HIDA given persistently incr TB concerning for cholecystitis - worsening skin breakdown at site of balloon cath sutures, being covered with daptomycin - f/u ID recs - appreciate input . # Elevated Lactate and AG: Pt noted to have elevated lactate to 6.57 on [**11-7**], AG = 18/19. Infectious work up did not yield any results. Repeat lactates continued to rise, and on [**11-10**], patient was noted to have a lactate of 13.9 and an anion gap of 25. During this time, patient was persistently hypotensive with SBP in 60's. Therefore likely secondary to hypoperfusion. Patient was transferred to ICU for further managment. . * Acute cholecystitis/Elevated LFTs - pt consistently had tachycardia which was thought to possibly be related to an occult infection. She began developing RUQ pain and US was done suggestive of acute cholecysitis. Her transaminases were elevated to the 200s, but the bilirubin was normal. While being transported to W campus for surgery, her ECHO report came back with worsening LV function and a vegetation on the TV. She was admitted to the MICU after a cholecystostomy tube was placed by IR. General A repeat US showed a decompressed gallbladder. Her transaminases continued to rise above 1000, and a repeat abdominal U/S and CT scan were done, showing a new partial portal vein thrombus. Her transaminases then trended downward and the patient left the MICU w/ unremarkable transaminases. On the BMT floor, her transaminases remained unremarkable. On transfer to cardiology, LFTs were noted to elevate again. Hepatology was reconsulted and believed this rise was secondary to hepatic congestion from right heart failure. Throughtout remainder of time of cardiology service, LFTs began to normalize except for her T. Bili and D. Bili which continued to rise. . * Portal vein thrombosis - patient was started on a heparin drip and continued with a goal PTT 60-80. Her liver abdnormalities resolved on the heparin drip. The patient accidentally partially removed the cholecystostomy drain, her labs remained stable as did the abdominal pain for the next few days and the drain tube was discontinued. Repeat u/s showed consistently decompressed gall bladder. The patient was continued on heparin drip with plans to switch to lovenow injections for continued anticoagulation. A repeat u/s showed persistent thrombus. The heparin drip was d/c at the recommendation of the heme/onc service for concern of HIT. Multiple HIT Ab tests were negative and a serotoninin assay that was reported to be more sensitive for HIT was negative. A CT on [**10-24**] showed a contracted portal vein thrombosis. A RUQ ultrasound on [**2168-11-6**] demonstrated resolution of her portal vein thrombosis. . * RUE swelling, labial swelling - the pt was noted to have a swollen R arm. An US obtained while the pt was in the MICU revealed no clot and was believed to be related to anasarca. In addition, she had labial swelling R>L, concerning for abscess. Fluid was aspirated and negative for infection. Nothing further. . * DIC - On transfer to the MICU the pt was felt to be in early DIC, with increasing LFTs, decreased fibrinogen, increased LDH, and decreasing platelets. She received 6 units of FFP and 1 bag of cryo and serial DIC labs were followed, with improvement over the time she was in the MICU. It was felt that the endocarditis or sepsis were the most likely etiologies, although initial blood cultures did not grow any organisms. The pt was maintained on broad-spectrum antibiotics and antifungals with input from ID. Her DIC resolved, but this was postulated as a possible unifying diagnosis to explain the portal vein thrombosis. On [**11-9**], her fibrinogen was noted to drop, and she was transfused 1 bag of cryoprecipitate. . * Hemorrhoids - On [**8-22**] she started complaining of hemorrhoidal pain c/w large external hemorrhoids. Pt was intially put on stool softeners and eventually made NPO with TPN in order to minimized potential infectious exposure in the rectal area. She was empirically covered for colon flora with Levoquin and Flagyl. Morphine was used for pain control. Pt stool was C. Diff negative x 3. Although she did have intermittent diarrhea that was controlled with Immodium. . Dispo - pt transferred from to cardiology for optimization of her cardiac regimen. Pt then transferred to the unit due to persistent hypotension, elevated anion gap, elevated lactate for further management. . Patient then transferred from cardiology floor to cardiac intensive care unit for persistent sinus tachycardia and hypotension. Due to persistent hypotension refractory to fluid boluses and pressors, an intra-aortic balloon pump was placed in the setting of cardiogenic [**Month/Year (2) **] +/- septic [**Month/Year (2) **]. . ##CARDIAC #ischemia: no known history of prior cath's. . #pump: nonischemic cardiomyopathy/CHF: EF ~10%, likely secondary to chemo toxicity vs [**12-30**] persistant tachycardia. Given improvement with IABP, on milrinone, no WBC, afebrile, no clear source of infection likely in cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] also have an element of septic [**First Name3 (LF) **]. Repeat ECHO show persistent vegetations on TR. - attempted to wean IABP however CI 1.7 on 1:2 - cont max doses of vasopressin, milronine and levophed - keep at goal CVP 16-18 - need to consider insensible losses - total body anasarca, likely related to her low EF. Also likely contributed to by her low Alb (last value = 2.9). . #rhythm: persistant atrial tachycardia. 12/19 HR 140's hypotensive syst 60's MAP 50's required 100J [**First Name3 (LF) **] to stable atrial tach. - dc digoxin given toxicity - monitor on telemetry . #. ID: - h/o strep viridans endocarditis, s/p 10 days gentamicin and currently on CTX (started [**10-16**]) to complete a 4 week course, [**11-7**] repeat ECHO show persistent vegetations on TR. - discontinued CTX change to daptomycin/meropenum day 9 - dc'd caspofungin day 6 - pt grew 100K enterococcus in urine should be covered for VRE with daptomycin - pan-cultured, incl fungal, pulled PICC sent tip for culture - apprec pulm recs, will send sputum cx - US of abdomen consistent with volume overload -> HIDA given persistently incr TB concerning for cholecystitis - worsening skin breakdown at site of balloon cath sutures, being covered with daptomycin - f/u ID recs - appreciate input . # Elevated LFTs/INR: h/o possible acalculous cholecystitis treated successfully with transcutaneous drain, now s/p drain removal. [**11-5**] LFTs trending up again. ? [**12-30**] hepatic congestion from R heart failure vs repeat acalculous cholecystitis vs GVHD vs VOD vs hepatic candidiasis. Pt clinically asymptomatic. RUQ U/S ([**11-6**]) - no liver or GB abnormalities, patent portal vein (previously thrombosed). Hepatology consulted, believe elevated LFTs [**12-30**] hepatic congestion from R heart failure. - [**Month/Day (2) 3539**] gradually elevated from originally event [**11-3**], per liver likely lag in [**Last Name (LF) 3539**], [**First Name3 (LF) 18003**] bili unmeasurable - would like to HIDA scan to assess for recurrence of acalculous cholecystitis however need to remove balloon pump and no portable available - Cont heparin for balloon pump - trend LFTs daily - daily fibrinogen if <100 give cryo - heparin [**Hospital1 **] . #. Thrombocytopenia/DIC: Noted earlier in hospital admission of unknown etiology - all HIT ab's negative x multiple times inlcuding more sensitive HIT test (serotonin assay). Pt was stabilized with stable Plts 50's-60's now stable in 20's. - apprec heme/onc recs, started heparin drip for IABP. - follow plat count, tranfuse if spontaneously bleeds or plat<10K. - consider BM bx . # Skin breakdown/blister: likely [**12-30**] to anasarca and severe fluid overload - wound care - apprec plastics recs - apprec derm . #. Respiratory distress: intubated [**12-30**] unresponsiveness and hypoxia. - plan for extubation today allow pt to speak with family . #. AML: currently without evidence of recurrence of disease however in setting of new thrombocytopenia may benefit from BM bx - concerning nucleated RBCs, ?recurrence - monitor CBC with diff daily to eval for blasts, atyps, etc - cont acyclovir, renally dosed - apprec heme/onc recs . FEN: Holding additional fluids and concentrating fluids given anasarca - cont TF as tolerated - electrolyte repletion - cont anti-emetics . #. Access: left groin triple lumen, IABP placed right femoral vein. . #. PPX: Anzemet/compazine for nausea, on IV heparin . #. Communication: [**Name (NI) **] [**Name (NI) **] (husband) [**Telephone/Fax (1) 54297**] or [**Telephone/Fax (1) 54298**]; [**Doctor Last Name 11923**] (BMT SW, knows pt well) pager [**Numeric Identifier 54299**]; needs translator for any medical discussions . #. Dispo: on [**11-18**] family and patient decided that patient was to be extubated to allow her an opportunity to communicate with her family prior to withdrawal of the intra-aortic balloon pump. Patient expired shortly after discontinuation of the intra-aortic balloon pump from cardiac and respiratory failure. Medications on Admission: ativan PRN for nausea, pt denies any meds OTC or herbal supplements Discharge Disposition: Home Discharge Diagnosis: Cardiomyopathy. Congestive heart failure. Endocarditis (culture positive). Abdominal pain. Acute renal failure. Portal vein thrombosis. Thrombocytopenia. Acalculous cholecystitis. Acute myelogenous leukemia. Anxiety. Discharge Condition: expired Completed by:[**2169-4-26**]

[ "205.00", "785.52", "575.0", "709.8", "391.1", "428.0", "427.0", "286.6", "455.8", "785.51", "625.8", "038.9", "584.9", "452", "573.0", "518.81", "528.0", "995.92" ]

icd9cm

[ [ [] ] ]

[ "96.04", "34.91", "99.15", "41.05", "99.25", "37.21", "37.61", "99.28", "96.6", "00.91", "38.93", "51.01", "00.13", "99.62", "38.99", "96.72" ]

icd9pcs

[ [ [] ] ]

28507, 28513

6681, 28388

334, 398

28773, 28811

4317, 4322

3236, 3254

28534, 28752

28414, 28484

5754, 6658

3269, 4298

245, 296

426, 2231

4336, 5737

2253, 2891

2907, 3220

28,753

182,656

44463

Discharge summary

report

Admission Date: [**2117-8-5**] Discharge Date: [**2117-9-2**] Date of Birth: [**2037-3-13**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin / Macrobid / neomycin-bacitracin-polymyxin Attending:[**First Name3 (LF) 3256**] Chief Complaint: persistent fever Major Surgical or Invasive Procedure: bronchoscopy bone marrow biopsy video speech and swallow History of Present Illness: History of Present Illness ([**Hospital1 18**] [**Location (un) 620**] notes): 80-year-old male with hairy cell leukemia in remission, prostate cancer s/p cystoprostatectomy with ileal stoma, recently s/p cholecystectomy and parastomal hernia repair presents with persistent fever. He originally presented to [**Hospital1 18**]-[**Location (un) 620**] on [**7-5**] for cholecystecomy and parastomal hernia repair. He was discharged on [**7-8**] with Bactrim for an E coli UTI. He returned to the hospital [**7-10**] for recurrent fever and was found to have a postoperative wound. He was treated with ertapenem for Proteus and Klebsiella. He then developed pyoderma gangrenosum about 2 cm above his wound. This was treated with prednisone 60 mg with a planned taper. He was discharged on [**7-17**], however had recurrent fevers and again presented on [**7-20**]. . Since [**7-20**] the patient has continued to spike daily fevers as high as 104 [**8-5**]. Antibiotics included Augmentin for [**7-23**] to [**8-1**], Bactrim for [**8-1**] to [**8-3**], ceftazidime from [**8-3**] to [**8-5**]. Fluconazole was used from [**7-29**] to [**8-4**], at which point it was changed to voriconazole for yeast isolated in his urine. On [**8-5**] antibiotics were changed to Zosyn given persistent fever. The patient underwent 2 CT scans of his torso to help evaluate etiology of fever which revealed LLL consolidation, likely PNA. . On the floor, the patient is asymptomatic and afebrile. Past Medical History: Hairy cell leukemia s/p splenectomy in [**2091**] with replapse in [**2104**] treated with Fludarabine. Recent lab work from outside hospital shows neutropenia and hypogammaglobulinemia Prostate cancer s/p brachytherapy c/b prostatic abscess with extension now s/p cystoprostatectomy and urostomy Mitral valve prolapse w/mild MR CAD h/o klebsiella urosepsis [**9-10**] h/o Bronchopneumonia [**9-11**] Pyoderma gangrenosum Splenectomy in [**2092**] TURP [**2093**] bilateral rotator cuff repairs radical cystoprostatectomy and ileal conduit in [**2112**] I and D of scrotal abscess in [**2112**] right thoracotomy with lung biopsy [**2114**] cholecystecomy in [**2116**] hernia repair around his cystoprostatectomy ileal conduit in [**2116**] Social History: Lives at home with his wife. [**Name (NI) **] 3 daughters. Currently retired. Denies tobacco or drug use. Has 1 ETOH per evening Family History: Non-Contributory Physical Exam: Admission Physical Exam: Vitals: T: 98.0 BP: 109/66 P: 72 R: 18 O2: 99% RA General: Asleep, woke easily to verbal stimuli. Alert, oriented, no acute distress. Slightly hard of hearing. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD Lungs: Bilateral rales at bases, to mid lung on L. No wheezes. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mildly distended, mildly TTP near bandaged wound site. + bowel sounds. no rebound or guarding. Ostomy pink, output clear yellow. Wound site dressing CDI Ext: warm, well-perfused. no cyanosis, clubbing, or edema. Neuro: CN II-XII intact. Strength 5/5 throughout. motor function grossly normal . Discharge Physical Exam: Vitals: 97.6, 159/92, 62, 99RA General: Well NAD, AOx3, but with slow response and blunted affect HEENT: Large eschar on bottom lip Lungs: crackles at the bases bilaterally that do not clear w/ coughing CV: s1 s2 no MRG Abdomen: soft, non tender, surgical dressing in place, osteomy site intact w/ no errythema or signs of breakdown Ext: large subcutaneous hard lesions on right upper arm and hand, ankle edema with sacral edema as well and Pertinent Results: Admission Labs: [**2117-8-6**] 04:55AM BLOOD WBC-7.9# RBC-3.04* Hgb-11.0* Hct-33.3* MCV-109*# MCH-36.0* MCHC-32.9 RDW-15.5 Plt Ct-416 [**2117-8-6**] 04:55AM BLOOD Glucose-116* UreaN-26* Creat-1.0 Na-137 K-4.6 Cl-96 HCO3-26 AnGap-20 [**2117-8-6**] 04:55AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.9 . [**Hospital3 **]: [**2117-8-6**] 05:09PM BLOOD CK(CPK)-11* [**2117-8-6**] 05:09PM BLOOD CK-MB-3 cTropnT-0.05* . Discharge Labs: [**2117-9-2**] 06:11AM BLOOD WBC-4.5 RBC-2.77* Hgb-9.3* Hct-28.8* MCV-104* MCH-33.5* MCHC-32.1 RDW-18.9* Plt Ct-311 [**2117-9-2**] 06:11AM BLOOD Glucose-64* UreaN-34* Creat-0.8 Na-132* K-4.8 Cl-98 HCO3-25 AnGap-14 [**2117-9-2**] 06:11AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.0 ======================================================== Microbiology: Extensive Microbiology workup from [**Hospital1 18**]-[**Location (un) 620**] summarized elsewhere Multiple negative blood and urine cultures Legionalla urinary antigen negative Crytococcal antigen negative C diff negative BAL negative for bacteria, viruses, yeast Respiratory viral culture negative Mycotic blood culture pending . Positive cultures: URINE CULTURE (Final [**2117-8-7**]): YEAST. ~6OOO/ML. GRAM POSITIVE BACTERIA. ~[**2105**]/ML. URINE CULTURE (Final [**2117-8-10**]): PROBABLE ENTEROCOCCUS. ~[**2105**]/ML. URINE CULTURE (Final [**2117-8-20**]): YEAST. 10,000-100,000 ORGANISMS/ML. URINE CULTURE (Preliminary, [**8-23**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. Daptomycin Sensitivity testing per DR [**Last Name (STitle) 31443**] ([**Numeric Identifier 95302**]). YEAST. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 128 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R . [**2117-8-27**] 16:37 B-GLUCAN Test ---- Fungitell (tm) Assay for (1,3)-B-D-Glucans Results Reference Ranges ------- ---------------- <31 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL . CMV Viral Load (Final [**2117-8-31**]): CMV DNA not detected. Performed by PCR. Detection Range: 600 - 100,000 copies/ml. FOR RESEARCH USE ONLY. NOT FOR USE IN DIAGNOSTIC PROCEDURES. This test has been validated by the Microbiology laboratory at [**Hospital1 18**]. . Test Name In Range Out of Range Reference Range --------- -------- ------------ --------------- C difficile Toxin PCR POSITIVE (Semi-Urgent Result) . Test Result Reference Range/Units ASPERGILLUS ANTIGEN 0.1 <0.5 ================================================= Cytology and Pathology: Bronchial washings ([**8-7**]): NEGATIVE FOR MALIGNANT CELLS. Predominantly macrophages, neutrophils, and polymorphous lymphocytes, consistent with reactive inflammatory infiltrate (See Note). Note: Please refer to the corresponding cell block specimen S11-[**Pager number 95303**]H for further characterization and the results of immunohistochemistry studies. . Flow cytometry ([**8-10**]): FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: HLA-DR, FMC-7, Kappa, Lambda, and CD antigens 3, 5, 10, 11c, 19, 20, 22, 23, 25, 103. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. Abnormal B-cell leukemia cells comprise 57% of lymphoid gated events and ~1% of all events. B cells demonstrate a monoclonal Kappa light chain restricted population. They co-express pan B cell markers CD19, 20, 22, along with CD25, CD11c, CD103. They do not express any other characteristic antigens including CD5 or CD10. T cells comprise ~43% of lymphoid gated events. INTERPRETATION Immunophenotypic findings consistent with involvement by recurrence of patient's previously known Hairy cell leukemia. Peripheral blood smear review reveals rare large atypical lymphocytes with cytoplasmic projections. . Bone marrow biopsy ([**8-25**]): pending . Pathology of cell block ([**8-7**]): BAL Cell Block S11-[**Pager number 95303**]H: Reactive lymphoid infiltrate. See note. Note: A section of the cell block demonstrates a lymphoid infiltrate comprised of small-medium sized lymphocytes with small-moderate amounts of cytoplasm and round-oval nuclei with mostly vesicular chromatin. Admixed are smaller lymphocytes with scant cytoplasm and hyperchromatic nuclei. A review of the cytology prep (alcohol fixed, pap stain) demonstrates aggregates of mildly enlarged lymphocytes. By immunohistochemistry on the cell block, pan B-cell marker CD20 highlights scattered B cells while pan T-cell marker CD3 highlights relatively abundant T cells (T cells greater than B cells). TRAP is not present in lymphoid cells but is positive within macrophages; however, DBA44 and CD25 are negative, essentially excluding a hairy cell leukemic infiltrate. Overall the findings are suggestive of non-specific reactive lymphoid infiltrate. No diagnostic morphologic nor immunohistochemical evidence of hairy cell leukemia is seen. ================================================== Imaging: Extensive Imaging from [**Hospital1 18**]-[**Location (un) 620**] summarized elsewhere CT torso on [**8-2**] ([**Location (un) 620**]) revealed bilateral lower lobe lung consolidation consistent with pneumonia, interval improvement on the left but worsening on the right. There is a small left pleural effusion which is new, interval improvement in small peristomal fluid collection. Urinary conduit no longer appears dilated. Other findings are stable. . CT chest ([**8-10**]): FINDINGS: Consolidations in the medial and posterior basal segments of the right lower lobe are increased. A rounded consolidation in the superior segment of the right lower lobe is decreased. Trace effusion on the right is also slightly increased. On the left, consolidation in the basal segment of the lower lobe is decreased; however, there is new consolidation in the superior segment with minimally increased small layering pleural effusion. A calcified right middle lobe granuloma is present (4:124). A 3-mm nodule in the anterior right upper lobe (4:102) is stable over greater than two years from the examination of [**2114-10-6**]. Several prominent lymph nodes at the thoracic inlet and at the left paratracheal station measuring under 10 mm in short axis are similar to the prior examinations. These were present on the exam of [**2113**], prior to the infection, however have now slightly increased in size. For example, a paratracheal node measuring 9 mm (4:96) was 10 mm in [**2117-7-5**] and 6 mm in [**2114-10-6**]. There are vascular calcifications notable within the left main and anterior descending coronary arteries. Pericardial fluid is within physiologic limits. A right-sided PICC is in place with tip in the SVC. No evidence of endobronchial lesion is seen. There is a small hiatal hernia. There is some tortuosity of the aorta, however, no aneurysm is seen. This study is not tailored for evaluation beneath the diaphragm; limited views of the upper abdomen demonstrate slightly heterogeneous liver as compared to prior examinations which could be pathologic, though given timing of contrast, this is most likely perfusional. There is evidence of remote right posterior rib fracture. No concerning osseous lesion is seen. . IMPRESSION: 1. Increased consolidations, predominantly in the medial and posterior basal segments of the right lower lobe, concerning for pneumonia. 2. Decreased consolidations in the superior segments of the right lower lobe and in the basal segments of the left lower lobe. On the left, the appearance on this examination could be entirely explained by atelectasis. 3. Small pleural effusions, left greater than right, increased in size from the prior examination. . CT Chest ([**8-16**]): CT CHEST WITH IV CONTRAST: The imaged thyroid gland is normal. There is no axillary, supra or infraclavicular, or hilar lymphadenopathy. Multiple small mediastinal nodes measure up to 6 mm, not meeting CT criteria for pathologic enlargement. The heart is enlarged with trace pericardial fluid, likely physiologic. Coronary artery atherosclerotic calcification is present. The aorta is of normal caliber throughout. Borderline enlargement of the right main pulmonary artery is noted. There are bibasilar consolidations, left greater than right, which has slightly progressed compared to the prior CT and most likely represent atelectasis. Atelectasis on the left extends adjacent to the aortic knob. A small left pleural effusion is slightly increased. Trace right effusion has decreased. Scattered non-characteristic 2-mm subpleural nodules are unchanged. Airways are patent to the subsegmental level. In the visualized upper abdomen, the spleen is surgically absent. Small hiatal hernia is present. BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified. . IMPRESSION: 1. Increased bilateral consolidations, greater on the left and consistent with atelectasis which extends along the aortic contour and corresponds to findings on chest radiograph. 2. Slightly increased small left pleural effusion. 3. Coronary artery atherosclerotic disease. . CT Chest ([**8-25**]): FINDINGS: The airways are patent to the segmental level. Apico-posterior left upper lobe consolidation has markedly improved. Atelectasis in the lingula has worsened. Bibasilar consolidations left greater than right are grossly unchanged consistent with atelectasis with the exception of a new area of opacity in the lateral right base(3, 47) . Right central line tip is in the lower SVC. Mediastinal lymph nodes are increased in number measuring up to 15 mm in the left lower paratracheal station. There are no enlarged axillary or hilar lymph nodes. Minimal cardiac enlargement and trace pericardial effusion likely physiologic is unchanged. Coronary calcifications in the LAD and circumflex artery are unchanged. A small left and trace right pericardial effusions are unchanged. This examination is not tailored for subdiaphragmatic evaluation. The visualized upper abdomen is unremarkable. The spleen is surgically absent. There are no bone findings of malignancy. Irregularity of the posterior right seventh rib is unchanged. IMPRESSION: Improved consolidation in the left upper lobe, increased atelectasis in the lingula. Stable bibasilar atelectasis, left greater than right. Though there is a new opacity in the lateral aspect of the distal right lower lobe (3, 47) superimposed infection cannot be totally excluded. . Video Speech and Swallow [**2117-8-31**]: COMPARISONS: None available. TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was no gross aspiration or penetration. A barium pill was administered without hold up at any point of the pharynx of esophagus. For details, please refer to the speech and swallow division note in OMR. IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy. Brief Hospital Course: 80-year-old male with hairy cell leukemia in remission, prostate cancer s/p cystoprostatectomy with ileal stoma, recently s/p cholecystectomy and parastomal hernia repair presents with persistent fever. . # Fevers: DDX UTI, PNA, wound infection, pyoderma, leukemia recurrence, vasculitis. [**First Name8 (NamePattern2) **] [**Location (un) 620**] records, the patient was initially treated for a UTI but following multiple cultures and treatment modalities his UA cleared. His wound has been followed by Surgery and is now healing. At the time of admission there was no sign of active infection. Pyoderma gangrenosum could cause fever, but was improving on steroid treatment. Oncology did not believe that this represented a flare of his hairy cell leukemia. CT scan revealed multifocal infiltrates, treated with Vanc/Zosyn for possible pneumonia. Urine culture revealed VRE, treated with linezolid. Bronchoscopy with BAL was performed, revealed neutrophilic predominance in both lobes but no clear signs of infection. Following completion of antibiotic courses for both pneumonia and urinary tract infection, the fevers continued. Chest CT revealed consolidation similar to those seen in [**2114**] when he was diagnosed with pyoderma gangrenosum. He was therefore started on Cyclosporine starting [**8-13**]. After consultation with Pulmonary and Rheumatology experts, his prednisone was increased to better treat presumed pyoderma flare. . On [**2117-8-27**], the patient was transferred back to the MICU in the setting of fevers, rigors, tachycardia, and respiratory distress, with rise in lactate to 9.6. His fevers were attributed to sepsis possibly from VRE UTI; urine cx [**8-23**] positive for VRE. Given patient had not been improving on vanc/zosyn, antibiotic coverage changed to linezolid/meropenem. Upon review of outside pathology by our pathology department the biopsys were determined not to be consistant with pyoderma of the lung. Given desire to minimize immunosuppresssion, prednisone and cyclosporine tapers initiated. Based on bone marrow biopsy results, was also less concern that fevers were secondary to his leukemia. CMV and fungal studies were negative, but a C.diff PCR was positive despite multiple negative toxin tests and the patient treated with PO vancomycin. Patient had been afebrile for 5 days prior to discharge and had been transitioned off of IV antibiotics. . # UTI: patient was initially treated for a UTI as source for his persistant fevers and UA cleared. Patient continued to have fevers and a repeat urine culture grew both yeast and VRE. Patient was sent to the ICU with respiratory failure and concern for sepsis and was therefore treated for these pathogens. Patient was started on 2 week course of Linezolid and Fluconazole to end on [**9-11**]. # Oral Herpes: Patient developed a painful eschar on his bottom lip in response to the high dose immune suppressants. Patient was treated with a 5 day course of acyclovir with improvement in the lesion. . # C Diff: Patient was having high volume stool out put for several days with multiple negative C. Diff toxins. Given his persistant fevers and overall tenuous appearing state of health he was treated emperically with metronidazole. A C diff PCR was sent and returned positive. Patient was then switched to PO vancomycin as had little change in his stooling frequency. His course of PO vancomycin is to end on [**9-16**] days after the linezolid is discontinued. . # Hypoxic respiratory distress: On [**8-27**], patient triggered on the floor for tachycardia, tachypnea and marked nursing concern. Had desat to high 80's on NC, became tachypneic to the 40's and was placed on a NRB. ABG showed 7.49/21/79 with a lactate of 9.6, and he was transferred to the MICU. Received 2L NS, lactate trended down to 3 and respiratory status significantly improved. Was felt that his tachypnea was likely secondary to his underlying acid base disturbance, given elevated lactate and increased oxygen consumption in setting of fever and rigors. His oxygen was quickly weaned from NRB to NC to room air. Repeat CXR showed minimal improvement, and has patient had not been improving on vanc/zosyn for possible HCAP, antibiotics changed to linezolid/meropenem. Meropenem was discontinued after several days without fever and patient continued to be stable on linezolid alone. . # A fib with RVR: The morning following admission, the patient became tachycardic to the 170s with BP 80s/40s. He was found to be in atrial fibrillation, not a known problem for this patient who had previously been in normal sinus [**First Name8 (NamePattern2) **] [**Location (un) 620**] records and transfer exam. As the patient had recently been febrile with chills, his fever was treated with Tylenol and he was given IVF. Metoprolol IV was given with some effect, as his HR slowed to 120-140 and BP rose to 90s/50s. Further fluid boluses were given to support volume status. The patient did not convert to normal rhythm and several hours later became tachycardic and hypotensive to 80s/40s. He was transferred to the ICU for conversion with diltiazem and/or cardioversion. In the MICU, he was loaded with amiodarone and subsequently converted to sinus rhythm, which was maintained with PO amiodarone 300 mg [**Hospital1 **]. He was transferred back to the floor and his rhythm and rate well-controlled with metoprolol for the remainder of his stay. . # Abdominal wound: Patient presented with a healing abdominal wound from recent surgery. Surgery and Wound Care followed the patient during his stay, and a wound vac was placed to facilitate healing. This was removed as the wound healed, and wet-to-dry dressings used. . # Hypertension: Continued metoprolol 50 mg daily, ASA 81mg daily, was also started on lisinopril 5 mg daily prior to discharge for persistantly elevated BPs to the 160s. . # Pyoderma gangrenosum: The patient has a history of PG at an abdominal sugical site and in the pleura. He was on prednisone 20 mg on transfer. This was initially decreased as his skin manifestations removed, but as his pulmonary symptoms increased there was concern for repeat disease in the pleura and lung. His prednisone was increased and cyclosporine started for immune suppression. The pathology slides from [**2114**] were obtained and reviewed by our pathology department. Based on review of data, Pulmonary team ultimately felt it was unlikely the patient had pulmonary involvement of his pyoderma. Rheumatology recommended tapering of prednisone over several weeks. At the time of transfer the patient was recieving 20 mg prednisone daily to be tapered by 5 mg weekly starting on [**9-4**]. Cyclosporine was at 75 mg [**Hospital1 **] at the time of discharge to be decreased to 75 mg daily on [**9-4**] then stopped on [**9-11**]. . # Hyponatremia: The patient was hyponatremic, likely due to hypovolemia, during his stay at [**Location (un) 620**]. On transfer his sodium was low-normal. During his stay, he had periods of hyponatremia in the high 120s to low 130s. He was felt to have a low solute from his ileal conduit and poor PO intake. His NaHCO3 dose was increased to TID with some improvement also thought to have a reset osmostat given the chronicity of his sodium. . # Hairy cell leukemia: Followed by Dr [**Last Name (STitle) **], as well as by the Hematology consult team. Flow cytometry revealed an increased percentage of hairy cells, but not to the point of justifying treatment. A bone marrow biopsy was performed to determine if the HCL had increased to the point that it would justify treatment to reduce fever and pyoderma. Bone marrow biopsy demonstrated 10% of marrow composed of hairy T cells, and per Heme/Onc this degree of involvement does not warrant treament, especially due to risks of neutropenia with treatment. . # Depression: Continued Effexor 75mg daily despite starting on linezolid as patient was clinically stable and on low dose of effexor and difficulty in tapering this medicaiton. Patient should be actively monitored for any signs of fever, extreme hypertension, tachycardia, significantly altered mental status as possible signs of serotonin syndrome. . Inactive Issues: . # Hypothyroidism: Continued levothyroxine 25 mcg daily. . # Glaucoma: Continued Xalatan drops 1 drop OS daily. . # Ileal conduit: Continued 1300 mg sodium bicarb twice daily, later increased to TID. Will need to be seen for reevalution of surgical wound as an outpatient. . # Anemia: While at [**Location (un) 620**], B12 and folate were within normal limits. Iron studies revelead an anemia of chronic inflammation as well as an iron deficiency with an iron saturation of 14%. Iron supplements could be considered on discharge. . Transitional Issues: - follow-up with Surgery re: wound care - follow-up with Dr. [**Last Name (STitle) **] in oncology Medications on Admission: Effexor 75mg daily Levothyroxine 25mcg daily Xalatan drops qHS Lopressor 50mg daily Sodium Bicarb 1300mg [**Hospital1 **] ASA 81 mg daily MVI advil prn fish oil Prednisone 60mg daily . MEDICATIONS ON TRANSFER from [**Hospital1 18**]-[**Location (un) 620**] to [**Hospital1 18**] [**Location (un) 86**]: 1. Zosyn 4.5 grams q.8 hours started on the date of transfer, [**2117-8-5**]. 2. Prednisone 20 mg daily. 3. Aspirin 81 mg daily. 4. Metoprolol 50 mg daily. 5. Levoxyl 25 mcg daily. 6. Effexor 75 mg daily. 7. Sodium bicarb 1300 mg b.i.d. 8. Pepcid 20 mg b.i.d. 9. Heparin 5000 units subcu t.i.d. 10. Tylenol 500 to 1000 mg q.6 hours p.r.n. fever. 11. Xalatan 1 drop OS daily. Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Tablet, Chewable(s) 2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 7. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): to end on [**9-11**]. 10. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. sodium bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): on [**9-4**] switch to 15 mg daily (1.5 tablets), on [**9-11**] switch to 10 mg daily (1 tablet), on [**9-18**] switch to 5 mg (0.5 tablets) for 1 week then stop. 13. cyclosporine modified 25 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours): on [**9-4**] switch to 75 mg (3 capsules) daily for 1 week then stop. 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain or fever. 15. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily): hold for BP <110 systolic and HR<50. 16. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 18. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 19. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): To stop on [**9-11**]. 20. vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six (6) hours: to end on [**9-16**] (five days after stopping linezolid). Discharge Disposition: Extended Care Facility: [**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**] Discharge Diagnosis: PRIMARY: 1. vancomycin resistant enterococcus urinary tract infection 2. yeast infection of the urine 3. hospital acquired pneumonia 4. Oral herpes 5. clostridium difficle infection 6. hairy cell leukemia 7. pyoderma gangrenosum Secondary: 1. s/p Splenectomy 2. prostate cancer 3. mitral valve prolapse 4. s/p ileal conduit Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you here at [**Hospital1 771**]. You were transferred to our hospital for continued management of your fevers. You met with rheumatology, hematology/oncology, pulmonary, cardiology, infectious disease, and urology teams. You were initially treated with prednisone and cyclosporine for pyoderma of the lung, but upon review of your old biopsies by our pulmonologists and pathologists this was felt not to be the cause of your fevers. You started to taper off of your immune suppressants, and were treated with antibiotics and antifungals for a UTI as well as a presumed pneumonia. You were briefly admitted to the ICU for difficulty breathing which was felt to be related to an aspiration event. You were seen by our speech and swallow experts who determined you were not having chronic occult aspirations. You also received treatment for a c. diff infection of your colon. You had a bone marrow biopsy showing that your hairy cell leukemia was stable. You were transitioned to oral antibiotics and sent to a rehab facility to regain your strength. MEDICATION CHANGES: - START PREDNISONE 20mg daily (immune suppressant) to be tapered by 5 mg weekly as directed on your prescription. - START cyclosporine 75mg twice a day (immune suppressant) to be tapered by 75 mg daily as directed on your prescription. - START Bactrim DS 1 tablet three times a week (Monday, Wednesday, Friday) (antibiotic for infection prophylaxis while on immune suppressants). - START Linezolid 600 mg every 12 hours until [**9-11**]. - START Vancomycin 125 mg every 6 hours until [**9-16**]. - START Fluconazole 200 mg Daily until [**9-11**]. - START Lisinopril 5 mg daily - CONTINUE Levothyroxine 25 mcg daily - CONTINUE Daily Multivitamin - CONTINUE Venlafaxine XR 75 mg daily - CONTINUE Sodium Bicarbonate 1300 mg three times daily - CONTINUE Pantoprazole 40 mg daily - CONTINUE Metoprolol XL 50 mg Daily - CONTINUE Latanopros 0.005% 1 drop to both eyes daily - CONTINUE Aspirin 81 mg daily Please seek medical attention for any worsening symptoms. Please keep your follow-up appointments below. Followup Instructions: Department: Hematology/ Oncology Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] When: Please call the office number listed below to make a follow up appointment for 9-15 days after your hospital discharge. Address: [**Last Name (NamePattern1) 8541**],[**Hospital1 **] 450, [**Location (un) **],[**Numeric Identifier 8542**] Phone: [**Telephone/Fax (1) 95304**] Department: Urology Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 365**] Location: [**Hospital 882**] Hospital Address: [**Apartment Address(1) 95305**], [**Location (un) 538**], MA Phone: ([**Telephone/Fax (1) 10884**]

[ "686.01", "486", "276.69", "458.9", "280.9", "401.9", "V55.6", "276.2", "038.0", "202.40", "253.6", "V10.46", "799.4", "112.2", "995.91", "V09.80", "V58.65", "780.60", "311", "507.0", "054.9", "424.0", "244.9", "427.31", "008.45" ]

icd9cm

[ [ [] ] ]

[ "33.24", "41.31", "99.28" ]

icd9pcs

[ [ [] ] ]

27657, 27799

15789, 24017

333, 391

28168, 28168

4076, 4076

30520, 31160

2842, 2860

25496, 27634

27820, 28147

24721, 25473

28351, 29472

4495, 15766

2900, 3584

24594, 24695

29492, 30497

276, 295

419, 1912

24034, 24573

4092, 4479

28183, 28327

1934, 2679

2695, 2826

3609, 4057

52,746

131,685

3437

Discharge summary

report

Admission Date: [**2130-2-20**] Discharge Date: [**2130-2-23**] Date of Birth: [**2067-7-22**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: palpitations x1 week Major Surgical or Invasive Procedure: Cardioversion for Aflutter History of Present Illness: 62 yo male with history of atrial fibrillation on Coumadin presenting with palpitations for one week. He reports being on amiodarone through [**Month (only) 404**] of this year, but then stopping it until the past three weeks. Three weeks ago, he resumed his prior amiodarone dose of 200mg daily. He reports one week of palpitations, DOE, and diaphoresis with any exertion. He eventually presented to the ED with presyncope and diffuse weakness. In addition, he reports one episode of left sided nonradiating chest pain that was self limited after last 10 minutes. He reports PND without orthopnea. He also reports a ferocious appetite without any weight gain. . Returning to [**Hospital1 614**] on Friday, and has a follow up appointment with his cardiologist next Monday. He reports being followed in a coumadin clinic, but notes his last INR was 1.1 on [**1-26**], at which point they kept his dose at 5mg. . In the ED, Initial Vitals: 98.3 78 129/88 16 100% RA - EKG: Likely atrial fibrillation RVR versus atrial flutter - Portable chest x-ray was done - Diltiazem 20 mg IV was given then he was loaded with 60 po dilt. - Labs including troponin - Chest pain resolved - Cardiology consulted: Recommended TEE cardioversion tomorrow. For tonight start heparin without bolus and double up on the evening Coumadin. Most recent vitals prior to transfer: 110, 125/85, 18, 98% on 2 L NC . Currently, he feels well, but is tired from a long day. He denies any current CP or SOB. . REVIEW OF SYSTEMS: Positive for Chronic Low back pain He denies any fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Paroxysmal Afib s/p prior cardioversion, on warfarin and amiodarone sCHF with EF 35-40% HTN Hypertensive Cardiomyopathy Social History: Doesn't smoke, quit 3-4 months ago, used to smoke 1 pack over 4 days for 35 years. Occaisional EtOH, no drug use. Lives alone, fully independent, drives, works as a high school teacher in the culinary arts. Lives in [**Hospital1 614**], visiting his mother with his family in the [**Name (NI) 86**] area. Family History: Not reviewed. Physical Exam: VS - 97.5 149/91 108 20 100% on RA 116.3kg GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, JVP at 6mmHg, no carotid bruits HEART - PMI non-displaced, irregularly tachycardic, slight [**12-26**] murmur at apex LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - +BS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, 1+ bilateral LE edema, 2+ peripheral pulses SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**3-25**] throughout, steady gait DISCHARGE EXAM: VSS, BP 135/70, HR 75 Gen: AOx3 Heart: RRR, widely split S2, 2/6 systolic murmur at apex with radiation into axilla Lungs: CTAB Pertinent Results: ADMISSION LABS [**2130-2-20**] 07:45PM BLOOD WBC-10.2 RBC-5.22 Hgb-13.0* Hct-44.8 MCV-86 MCH-25.0* MCHC-29.1* RDW-15.8* Plt Ct-268 [**2130-2-20**] 07:45PM BLOOD Neuts-61.8 Lymphs-30.9 Monos-3.4 Eos-3.1 Baso-0.8 [**2130-2-20**] 07:45PM BLOOD PT-15.6* PTT-35.6 INR(PT)-1.5* [**2130-2-20**] 07:45PM BLOOD Glucose-111* UreaN-31* Creat-1.5* Na-139 K-4.4 Cl-100 HCO3-28 AnGap-15 [**2130-2-22**] 06:15AM BLOOD ALT-39 AST-38 AlkPhos-146* TotBili-0.7 [**2130-2-21**] 06:30PM BLOOD Lipase-20 [**2130-2-20**] 07:45PM BLOOD proBNP-1803* [**2130-2-20**] 07:45PM BLOOD cTropnT-<0.01 [**2130-2-21**] 07:15AM BLOOD CK-MB-5 cTropnT-<0.01 [**2130-2-21**] 06:30PM BLOOD CK-MB-4 cTropnT-<0.01 [**2130-2-20**] 07:45PM BLOOD Calcium-9.9 Phos-4.0 Mg-2.3 [**2130-2-20**] 08:05PM BLOOD Lactate-1.6 DISCHARGE LABS: [**2130-2-23**] 06:15AM BLOOD WBC-8.9 RBC-5.03 Hgb-12.8* Hct-42.5 MCV-85 MCH-25.4* MCHC-30.0* RDW-16.2* Plt Ct-195 [**2130-2-23**] 06:15AM BLOOD PT-22.0* PTT-77.2* INR(PT)-2.1* [**2130-2-23**] 06:15AM BLOOD Glucose-113* UreaN-38* Creat-1.7* Na-138 K-4.3 Cl-101 HCO3-29 AnGap-12 [**2130-2-23**] 06:15AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.4 [**2130-2-21**] 02:55AM BLOOD %HbA1c-6.4* eAG-137* [**2130-2-20**] 07:45PM BLOOD TSH-5.5* [**2130-2-21**] 06:30PM BLOOD Free T4-1.6 =================== EKG: There appears to be atrial flutter with variable block. Intraventricular conduction delay. Non-specific ST-T wave changes. No previous tracing available for comparison. =================== TTE: The left atrium is mildly dilated. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 25 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. 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. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. ===================== CXR: Cardiomegaly is substantial, unchanged. Mediastinum is unremarkable. Lungs are essentially clear with no evidence of pulmonary edema or increased in pleural effusion. Pneumothorax is not seen. Brief Hospital Course: 62 yo M with hypetensive cardiomyopathy presented with dyspnea on exertion, found to be in aflutter, cardioverted but course complicated by myocardial stunning. . 1. Atrial Flutter: The patient was cardioverted out of atrial flutter into NSR after a TEE did not demonstrate intra-atrial clot. Post-procedure, the patient developed hypotension and bradycardia requiring atropine and dopamine for pressor support. This likely developed in the setting of anesthesia, and multiple medications given during his rapid ventricular rate (diltizem and beta blockers). Additionally, the patient developed a similar reaction while cardioverted in the past. In the CCU, the patient was gradually weaned off dopamine. He remained in sinus with a short run of NSVT noted on telemetry overnight. It was recommended that the patient's primary cardiologist in [**Hospital1 614**] consider ablation to prevent future episodes of atrial flutter. Additionally, amiodarone was recommended at 200mg daily. The patient did not exhibit signs of heart failure. The patient will need to remain on coumadin for at least 1 month after cardioversion. . 2. Hypertensive Chronic Systolic Failure: TTE here showed moderate MR, global LV hypokinesis, and an EF 25-35%. The patient had previously been on lasix 40mg [**Hospital1 **], diltiazem, spironolactone, and coreg. These medications were held in the setting od the patient's recent hypotension and bradycardia. The patient should be restarted on these medications as an outpatient. Also, the patient should be started on an ACEI if indicated as determined by the patient's PCP/Cardiologist. . 3. Elevated Glucose: A1C of 6.4% on admission labs. This should be followed as an outpatient. . TRANSITIONAL ISSUES: - Adjust patient's HF medications. These were held on discharge due to recent hypotension. - Add an ACEI - Establish cardiology follow-up - Control sugars - Discuss role for aflutter ablation in the near future Medications on Admission: Warfarin 5mg daily Diltiazem 30mg tid Amiodarone 200mg daily lasix 40mg [**Hospital1 **] spironolactone 25mg daily carvedilol 6.25mg [**Hospital1 **] rosuvastatin 20mg qhs Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day as needed for weight gain: If your weight is increasing, please take 1 tab [**Hospital1 **] and [**Name6 (MD) 138**] your MD. . 6. Outpatient Lab Work INR bloodwork needs to be drawn on Monday [**2-27**] Discharge Disposition: Home Discharge Diagnosis: Atrial Flutter with Variable Conduction Non-Ischemic Chronic Systolic Heart Failure Myocardidal Stunning after cardioversion 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 because you felt shortness of breath and fatigue. In the ED, we found that you had a fast heart rate. In order to help you feel better, we performed a procedure called a cardioversion after ensuring that there were no blood clots in the heart. After the procedure, you had some stunning of the heart muscle, which required a quick stay in the ICU for monitoring. Your heart muscle recovered and your Blood pressure and heart rate returned to [**Location 213**]. You now have a normal heart rhythm as well. Please follow-up with your cardiologist in [**Hospital1 614**] on Monday. You should also have your coumadin level checked on Monday as well. This is very important to ensure that you do not have a stroke. . MEDICATION CHANGES INCLUDE: HOLD Carvedilol, Spironolactone, and Diltiazem (These will need to be restarted as an outpatient) TAKE Lasix 40mg one-two times per day as needed for weight gain (Please weigh yourself every day and take lasix if your weight is going up by [**11-22**] pounds) TAKE aspirin 81mg once a day by mouth SAME: No change to Warfarin, Amiodarone, and Crestor Followup Instructions: Dr. [**Last Name (STitle) **] [**Name (STitle) 1256**] [**Hospital 15866**] Hospital [**Telephone/Fax (1) 15867**]. Please make sure that you follow-up with this cardiologist on Monday and also have your INR checked as well. Weigh yourself everyday. Eat a low salt diet.

[ "V58.61", "428.22", "425.8", "997.1", "427.31", "428.0", "E879.8", "427.32", "402.91" ]

icd9cm

[ [ [] ] ]

[ "99.62", "88.72" ]

icd9pcs

[ [ [] ] ]

8894, 8900

6151, 7869

333, 362

9069, 9069

3432, 4207

10371, 10646

2617, 2632

8324, 8871

8921, 9048

8128, 8301

9220, 10348

4224, 6128

2648, 3268

3284, 3413

7890, 8102

1886, 2136

273, 295

390, 1867

9084, 9196

2158, 2279

2295, 2601

21,801

135,085

17365

Discharge summary

report

Admission Date: [**2140-8-2**] Discharge Date: [**2140-8-5**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: Dizziness Major Surgical or Invasive Procedure: None History of Present Illness: 83 yo man with MMP including CAD s/p CABG, Cardiomyopathy (EF 35%), PVD, A fib, recent admission [**Date range (1) 48591**] for anemia/epistaxis on coumadin; now presents with bradycardia and elevated digoxin level. For several days he has felt fatigued. This morning he noted increased SOB and dizziness. He checked his pulse and at that time it was 31. Pt was started on Dig 0.125 mg on [**2140-7-13**]. Per ROS, has felt weakness and intermittent dizziness for the past 1.5 wks. Denies diarrhea, nausea, vomiting, visual changes. No episodes of syncope or nearsyncope.On ROS, he states no PND, chest pain, melena, BRBPR or further episodes of epistaxis. On ROS, he states no PND, chest pain, melena, BRBPR or further episodes of epistaxis. Denies dyspnea or orthopnea. Complains of GERD> No LE swelling. No change in UOP; no weight gain. He presented to the ED where his EKG revealed bradycardia (probably sinus w/ APBs) to the 40's w/ prolonged PR at 320 msec; with digoxin level = 3.2. Pts' vitals were initially stable with HR of 44 and BP of 160/44 at 9 am. Sunbsequently, around 1 pm HR dropped to 20s and SBP in 90s (still asymptomatic). Patient admitted to taking his regular dose of digoxin and toprol XL this am. He received Digibind 40 mg x 2 without effect. Was started on isuprel gtt w. good HR responce (50s in sinus). Pt getting x-ferred to CCU for temp wire placement. Past Medical History: 1. CAD s/p CABG x4 in [**2124**], ETT [**12-16**] - 9 min [**Doctor Last Name **] w/ septal akinesis, global hypokinesis with a moderate fixed defect involving entire septum. 2. CHF w/ EF <25%, [**2-14**] + MR, 1+ AR (echo [**12-16**]) 3. hypertension 4. s/p AAA repair 5. PVD s/p stent L CIA 6. CRI(baseline Cr 2.0ish) 7. bilateral CEA 8. dermatomyositis 9. left hernia repair 10. Afib s/p cardioversion, SR on amio 11. GIB [**3-16**] AVM 12. ?large bowel perforation in [**2138**] 13. h/o RLL PNA 14. Epistaxis with discontinuation of coumadin ([**7-17**]) Social History: patient lives with niece in [**Location (un) 2312**] quit smoking 50 y ago occ ETOH no ivdu Family History: noncontributory Physical Exam: Admission: PE: 97.2, 140/70, HR 40-50's, 98% RA, gen: enjoying his sodium-free macaroni heent: JVP ~7cm, mm dry lungs: bibasilar crackles cv: bradycardia, regular, [**3-20**] sys murmur to apex abd: soft, nt ext: w/wp, no edema neuro: moves all ext, face symmetric Pertinent Results: [**2140-8-4**] 07:48AM BLOOD WBC-5.9 RBC-3.61* Hgb-10.2* Hct-30.9* MCV-86 MCH-28.3 MCHC-33.1 RDW-16.2* Plt Ct-137* [**2140-8-3**] 06:00AM BLOOD WBC-5.3 RBC-3.54* Hgb-9.9* Hct-30.9* MCV-87 MCH-28.0 MCHC-32.0 RDW-16.5* Plt Ct-156 [**2140-8-2**] 08:55AM BLOOD Neuts-82.9* Lymphs-10.6* Monos-5.1 Eos-1.1 Baso-0.2 [**2140-8-2**] 08:55AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ [**2140-8-4**] 07:48AM BLOOD Plt Ct-137* [**2140-8-3**] 06:00AM BLOOD Plt Ct-156 [**2140-8-3**] 06:00AM BLOOD PT-12.4 PTT-22.6 INR(PT)-1.0 [**2140-8-2**] 08:55AM BLOOD Plt Ct-226 [**2140-8-2**] 08:55AM BLOOD PT-12.0 PTT-21.2* INR(PT)-0.9 [**2140-8-4**] 07:48AM BLOOD Glucose-127* UreaN-36* Creat-1.5* Na-139 K-4.5 Cl-105 HCO3-28 AnGap-11 [**2140-8-3**] 06:00AM BLOOD Glucose-143* UreaN-52* Creat-2.2* Na-140 K-4.3 Cl-105 HCO3-27 AnGap-12 [**2140-8-2**] 03:40PM BLOOD Glucose-189* UreaN-57* Creat-2.4* Na-139 K-4.3 Cl-104 HCO3-25 AnGap-14 [**2140-8-2**] 08:55AM BLOOD Glucose-118* UreaN-57* Creat-2.7* Na-138 K-4.9 Cl-101 HCO3-25 AnGap-17 [**2140-8-3**] 06:00AM BLOOD CK(CPK)-34* [**2140-8-2**] 03:40PM BLOOD CK(CPK)-41 [**2140-8-2**] 08:55AM BLOOD CK(CPK)-49 [**2140-8-3**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2140-8-2**] 03:40PM BLOOD cTropnT-0.02* [**2140-8-2**] 03:40PM BLOOD CK-MB-NotDone [**2140-8-2**] 08:55AM BLOOD cTropnT-0.03* [**2140-8-2**] 08:55AM BLOOD CK-MB-NotDone [**2140-8-4**] 07:48AM BLOOD Calcium-8.6 Phos-2.0* Mg-2.2 [**2140-8-3**] 06:00AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.3 [**2140-8-2**] 03:40PM BLOOD Calcium-8.5 Phos-3.0 Mg-2.2 [**2140-8-2**] 08:55AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.5 [**2140-8-3**] 06:00AM BLOOD TSH-1.0 [**2140-8-3**] 06:00AM BLOOD Free T4-1.8* [**2140-8-3**] 06:00AM BLOOD Digoxin-4.3* [**2140-8-2**] 08:55AM BLOOD Digoxin-3.2* Brief Hospital Course: This 83 yo man with h/o CAD s/p CABG, PVD, CHF, afib, was admitted with bradycardia in the setting of elevated digoxin level, on amio. His rhythm was initially sinus brady w/multifocal atrial escape beats; on isoproterenol SR w/1st degree block. The etiology of his brady was felt to be dig toxicity in the context of renal failure and amiodarone. Isoproterenol at low dose was used to control brady to 20s w/sbp 90. 2 doses of digibind were given in the ED with transient effect. All nodal agents were held on admission (toprol, amiodarone). Given that renal failure was considered to contribute to dig tox, lasix and ACE inhibitor were initially held. ASA and statin were continued. Given the patient's h/o guaic + stool, PPI was given. Hep SC was used for DVT PPx. The patient was maintained on a low sodium diet. On the patient's second hospital day, he was weaned off isoproterenol. He did well off isoproterenol with no symptomatic bradycardia, and Toprol XL and amio were restarted [**8-4**]. He did well with HR in upper 50s. On [**8-5**], he was restarted on lasix, and fit for a KOH monitor and discharged with VNA. Home PT offered, but pt refused. F/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**8-11**] at 11am. Medications on Admission: Digoxin 0.125 mg po qd (started [**7-13**]) Lasix 80 mg po qd (dose increased [**7-29**]) Toprol XL 25 mg po qd Fosinopril 30 mg po qd Amiodarone 200 mg po qd Pravachol 20 mg po qd Prilosec 20 mg qd Aspirin 81 mg po qd colace FE 325 qd Discharge Medications: 1. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). [**Month/Year (2) **]:*30 Tablet(s)* Refills:*2* 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Year (2) **]:*30 Tablet(s)* Refills:*2* 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Year (2) **]:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Cardiomyopathy Coronary artery disease atrial fibrillation digoxin toxicity Discharge Condition: Stable. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 L Take your medications as directed. Follow up with your primary care physician and cardiologists. Return to the emergency room or call your PCP if you have symptoms of chest pain, shortness of breath, or fainting. Followup Instructions: [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2140-8-11**] 11:00 [**Month/Day/Year 706**] MRI Where: [**Hospital6 29**] [**Hospital6 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2140-8-11**] 12:15 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] ([**Doctor Last Name **] PRACTICE) THE DOCTORS [**Name5 (PTitle) **] ([**Doctor Last Name **] PRACTICE) Where: THE DOCTORS [**Name5 (PTitle) **] ([**Doctor Last Name **] PRACTICE) Date/Time:[**2140-8-17**] 2:50 [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **], MD [**2145-8-26**] AM [**Hospital Ward Name 23**] 6 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**11-9**] 1:15pm [**Hospital Ward Name 23**] 6

[ "V45.81", "428.0", "276.5", "E942.1", "425.4", "584.9", "427.31", "427.89" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6727, 6790

4500, 5770

270, 277

6910, 6920

2726, 4477

7306, 8144

2408, 2426

6057, 6704

6811, 6889

5796, 6034

6944, 7283

2441, 2707

221, 232

305, 1698

1720, 2280

2296, 2392

55,012

180,414

45769

Discharge summary

report

Admission Date: [**2149-1-26**] Discharge Date: [**2149-1-31**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 800**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: This is a [**Age over 90 **] yo M with late stage Alzheimer's, CAD, anemia, who is being sent to [**Hospital1 18**] from [**Location (un) 10059**] with lethargy, fevers to 101.6 and hypotension to the 65/37. [**First Name8 (NamePattern2) **] [**Location (un) 10059**] notes, he had a lisinopril, and then was found to be hypotensive this AM. BS there was 161. There is no other information able to be provided by the patient, as at baseline, he is severely demented. . On arrival to the ED, the patient's vitals were T 99.6R BP 70/38 HR 76 R 20 98%3L. He was given 4.5L NS with no response in his BP. His labs were notable for new acute renal failure, a leukocytosis to 12,000, bicarb of 20, lactate of 1.4 and normal LFT's. CE's were elevated, trop to 0.17 in the setting of sepsis and renal failure. The patient had a penile prosthesis and was unable to be catheterized in the ED for a UA. A bedside bladder scan showed several hundred cc's in the bladder but no distention and urology was called. A CXR was unremarkable, CT abd/pelvis did not show free air/stranding, and an EKG was paced. The ED wanted to place a CVL to initiate pressors for septic shock, but the family reiterated the patient's wishes for DNR/DNI and no procedures, however okayed peripheral pressors and ICU admission for 24 hours. He was started on levophed, but became bradycardic, so was switched to dopamine for ?cardiogenic shock. He was given a dose of vanco/zosyn and admitted to the MICU for further management. . On arrival to the ICU, the patient is screaming out, eyes closed. ROS unable to be obtained. Past Medical History: 1. Coronary artery disease status post coronary artery bypass graft. 2. Cervical spondylosis, wears soft collar at baseline. 3. Prostate cancer - "watchful waiting" 4. BPH status post prostatectomy. 4. Degenerative joint disease. 5. Hypothyroidism. 6. Sleep apnea. 7. Dementia 8. Recent left eye surgery c/b endopthalmitis Social History: Denies alcohol, tobacco, and illicit drugs. Former lawyer Lives with wife in [**Name (NI) 745**] Family History: Mother - CHF Father - died MI age 60s no history of syncope, arrythmia Physical Exam: Vitals: T: 95.6ax BP: 85/52 P: 76 R: 19 O2: 100% 3L General: Eyes closed, screaming out intermittently, restless. NAD. HEENT: Left surgical pupil. Right pupil RRL. Sclerae anicteric, MM dry, oropharynx clear. Poor dentition. Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, or rhonchi but mild bibasilar rales CV: Faint heart sounds, regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild tenderness just below umbilicus, no rebound tenderness or guarding, +BS Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema. Cachectic. Skin: no rashes; scattered ecchymoses Neuro: responds to voice, but has difficulty opening eyes. CN II-XII in tact (except left surgical pupil). Moving ext x 4. Increased tone, resists movement. . Pertinent Results: [**2149-1-26**] 11:20AM WBC-12.2*# RBC-3.26* HGB-9.9* HCT-29.3* MCV-90 MCH-30.2 MCHC-33.6 RDW-14.2 [**2149-1-26**] 11:20AM NEUTS-81.5* LYMPHS-13.2* MONOS-4.9 EOS-0.3 BASOS-0.1 [**2149-1-26**] 11:20AM PT-16.7* PTT-31.3 INR(PT)-1.5* [**2149-1-26**] 11:20AM GLUCOSE-120* UREA N-62* CREAT-2.9*# SODIUM-145 POTASSIUM-4.4 CHLORIDE-112* TOTAL CO2-20* ANION GAP-17 [**2149-1-26**] 02:30PM CK-MB-NotDone cTropnT-0.12* [**2149-1-26**] 04:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . CT abd/pelvis - IMPRESSION: 1. Limited scan without intravenous or oral contrast; wall thickening and pericolonic fat stranding at the distal descending colon/sigmoid could result from colitis or diverticulitis; recommend correlation with colonoscopy or follow up after treatment to exclude underlying neoplasm. 2. Incompletely characterized left renal cyst - consider US. Brief Hospital Course: [**Age over 90 **] yo M with h/o AD, CAD s/p CABG, admitted with shock, likely secondary to dehydration and diverticulitis. . MICU COURSE: On arrival to the ICU, the patient is screaming out, eyes closed. ROS unable to be obtained. The patient requried dopamine 6-12mcg/kg/min, received 1U PRBC and 5L IVF. He was weaned off peripheral dopamine on [**1-27**]. . HYPOTENSION: Patient was admitted with BP 65/37 and required dopamine in ICU as well as 10 L IVF resuscitation. WBC was initially elevated and temp to 101 were suggestive of infection. CT A/P with diverticulitis. He had no growth on blood cultures. No PNA on CXR. UA negative. Feces was equivocal for C.diff. Given CT appearance and tenderness on exam, the most likely source was thouught to be GI. He was started on broad spectrum abx (Vanco, Zosyn, Flagyl), but narrowed to cipro/flagyl to complete a course for diverticulitis. His will complete at 10 day course of cipro/flagyl to be completed on [**2149-2-4**]. . DEMENTIA: Patient with severe AD at baseline, complicated by delerium in hospital setting. His mental status has considerably improved as he has been recovering and he is able to be out of restraints. Per HCP, he has been refusing to take most things by mouth over the past few weeks, and this has been attributed to progressive AD. He will take ice cream and boost shakes, but can not at present given aspiration risk. Discussed with the family that they can consider allowing thin liquids as a comfort measure, with an understanding of the potential for aspiration causing death. Decreased PO likely contributed to hypovolemia on presentation. Family does not want TPN, PICC, G-tube, or invasive measures. Patient was able to take PO medications prior to discharge. . ACUTE RENAL FAILURE: Patient was admitted with BUN/Cr of 62/2.9 that likely prerenal azotemia. However FeNa was 2.6, suggesting an underlying component of ATN. His Cr normalized with IVF. . HYPERNATREMIA: Hypernatremic on admission, but this resolved with D5 1/2 NS. . NSTEMI: Troponins were elevated on admission but trended down. This elevation was likely demand related in the setting of hypotension. He was continued home aspirin, statin. No antihypertensives at this time given hypotension on pressors. . HYPOTHYROIDISM- He was given IV levothyroxane in the ICU and transitioned to home levothyroxane once able to take POs. . Elevated PTT with subq heparin: PTT up to 120s. Low albumin but LFTs otherwise WNL. This resolved with improvement in renal function. Heparin was held in setting of high PTT. . FEN: IVF, replete electrolytes, Soft (dysphagia); Nectar prethickened liquids . Prophylaxis: Subcutaneous heparin once elevated PTT resolved; asp precautions . Access: peripherals . Code: DNR/DNI, no CVL or other procedures. peripheral pressors okay for 24 hours. PICC line would be ok as well. . Communication: [**Known lastname 97519**], wife and HCP. Medications on Admission: Aspirin 81 Rivastigmine 3mg oral [**Hospital1 **] Lactulose prn Levothyroxine 150mcg daily except thursdays Lipitor 10mg daily Mirtazapine 15mg qhs Namenda 10mg [**Hospital1 **] MVI Zaditor gtts OU in pm Zyprexa 2.5mg daily tramadol 50mg q6-8h prn docusate guaifenesin prn MOM prn Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Rivastigmine 3 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Lactulose 10 gram/15 mL Solution Sig: One (1) 15 ml dose PO three times a day as needed for constipation. 4. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day: every day except thursdays. 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. Disp:*8 Tablet(s)* Refills:*0* 9. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 4 days. Disp:*12 Tablet(s)* Refills:*0* 10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Zaditor 0.025 % Drops Sig: One (1) drop OU Ophthalmic at bedtime. 12. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 15. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Location (un) 10140**] - [**Location (un) 10059**] Discharge Diagnosis: DIVERTICULITIS HYPOTENSION ALZHEIMERS DEMENTIA ACUTE RENAL FAILURE HYPERNATREMIA NSTEMI HYPOTHYROIDISM Discharge Condition: Stable Discharge Instructions: You were admitted with low blood pressure and fevers that were likely from an infection. You were treated in the intensive care unit with medications to raise your blood pressure and antibiotics. Once you were doing better, you were switched to oral antibiotics. You should complete all antibiotics as prescribed. If you have new fevers, abdominal pain, lightheadedness, confusion or any other concerning symptoms, please seek medical attention. Followup Instructions: Please follow up with your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 10011**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2149-1-31**]

[ "244.9", "995.92", "785.52", "038.9", "721.0", "780.57", "410.71", "287.5", "562.11", "790.92", "600.00", "715.90", "276.0", "294.10", "285.9", "427.89", "414.00", "E941.2", "V45.89", "584.9", "331.0", "V45.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8756, 8836

4249, 7172

273, 279

8983, 8992

3299, 4226

9490, 9786

2376, 2449

7504, 8733

8857, 8962

7198, 7481

9016, 9467

2464, 3280

222, 235

307, 1898

1920, 2245

2261, 2360

28,268

182,516

799

Discharge summary

report

Admission Date: [**2131-9-2**] Discharge Date: [**2131-9-4**] Date of Birth: [**2073-4-29**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 668**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: s/p exploratory laparotomy, sigmoid colectomy, temporary abdominal closure [**2131-9-3**] s/p exploratory lapartomy, small bowel resection, temporary abdominal closure [**2131-9-4**] History of Present Illness: 58yoF w/ DM+ESRD, s/p L knee meniscus repair c/o abdominal pain x 1 day. Diffuse, severe abdominal pain, not well characterized. Pt states that she had not had BM x 1 week Past Medical History: HTN DM type 2 Anemia [**2-24**] to ESRD CHF Depression Glaucoma ESRD on HD, TThSat, [**2-24**] to diabetic nephropathy, h/o L AVF previously infiltrated OSA Congenital glaucoma with resulting blindness Gout OA Obesity Hyperlipidemia PSH: c-section, umbo hernia repair, orthopedic procedures Social History: Lives at home alone and walks with a cane. The patient well connected with services-PCA 39 hours/week, PT1 for rides to and from all MD appointments ([**Location (un) 5700**] chair lift), has social worker from mass commission from blind, and has VNA who helps with medications. . Quit smoking 3 weeks ago. Smoked [**1-24**] - 1 ppd since age 18 (39 years of smoking-->about 40 pack years). No EtOH. No IVDU. Family History: Mother d. lung ca at 65yrs Father d. small cell lung ca at 63yrs Brother s/p renal transplant Oldest brother had MI at age 60 Physical Exam: T 98.7, HR 70, BP 151/67, RR 16, O2sat 99% RA Gen- NAD, alert Head and neck- AT, NC, soft, supple, no masses Heart- RRR, no murmurs Lungs- CTAB, no rhonchi, no crackles Abd- distended, firm, diffusely tender, lower midline scar, + peritoneal signs Rectal- deferred Ext- warm, well-perfused, no edema Pertinent Results: [**2131-9-2**] 08:30PM HGB-13.9 calcHCT-42 [**2131-9-2**] 08:30PM GLUCOSE-161* LACTATE-1.7 NA+-137 K+-4.4 CL--88* TCO2-31* [**2131-9-2**] 11:45PM GLUCOSE-216* UREA N-57* CREAT-7.8*# SODIUM-136 POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-22 ANION GAP-25* [**2131-9-2**] 11:45PM ALT(SGPT)-19 AST(SGOT)-23 ALK PHOS-143* TOT BILI-0.5 [**2131-9-2**] 11:45PM LIPASE-25 [**2131-9-2**] 10:35PM PT-12.7 PTT-20.2* INR(PT)-1.1 Brief Hospital Course: KUB was non-diagnostic, suboptimal study. CT abdomen showed free intraabdominal air with free fluid. Pt was resuscitated and taken to the OR emergently for perforated viscous. Prior to induction, arterial access was difficult to obtain. Pt was found profoundly hypotensive, requiring multiple pressor support. In the OR, pt was found to have a very redundant sigmoid colon with diverticuli. In particular, there was a long rent in the tenia of the sigmoid colon with significant fecal peritonitis. Affected sigmoid colon was resected with [**Female First Name (un) 3224**] stapler and the abdomen was copiously irrigated. The abdomen was temporarily closed with a [**Location (un) 5701**] bag. Pt returned to the ICU in critical condition. Pt required multiple pressors for hemodynamic support. TEE showed mildly depressed EF 40% with no obvious wall motion abnormality. Pt was maintained on Vancomycin Ciprofloxacin Flagyl. Nephrology consult was obtained and CVVH was planned to initiate on POD#1. On the evening of POD#0, pt had acute desaturation episode w/ apparent cyanosis, requiring FiO2 1.0. CXR was not consistent with CHF or acute pulmonary edema. TEE and EKG did not show evidence of RV strain. Desaturation improved. CVVH was initiated given K 6.7. Given acute worsening of patient's condition, bedside exploratory laparotomy was performed. Remaining colon was viable. Distal 45cm of terminal ileum was ischemic and non-viable, requiring resection. Abdomen was temporarily closed. Despite the second laparotomy, patient remained in critical condition with worsening acidosis. BCx from the prior day showed GNR bacteremia and fungemia. Given the morbid condition of the patient, family requested CMO. Shortly after becoming CMO, patient was in cardiopulmonary arrest. Patient was pronounced dead on [**2131-9-4**] 14:10. PRIMARY CAUSE OF DEATH: cardiopulmonary arrest in minutes SECONDARY CAUSES OF DEATH: perforated sigmoid diverticulitis sepsis Pt did not meet criteria for ME. NEOB declined. Family declined post-mortem examination. Medications on Admission: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Enalapril Maleate 5 mg Tablet Sig: Eight (8) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 8. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 12. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Capsule(s)* Refills:*2* 13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day for 4 weeks: To prevent blood clots (deep vein thrombosis). Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: death Discharge Condition: death Discharge Instructions: n/a Followup Instructions: n/a Completed by:[**2131-9-4**]

[ "995.91", "276.2", "557.1", "038.9", "567.9", "403.91", "569.83", "585.6" ]

icd9cm

[ [ [] ] ]

[ "39.95", "45.62", "38.93", "45.76", "38.91" ]

icd9pcs

[ [ [] ] ]

5794, 5803

2335, 4426

283, 467

5852, 5859

1890, 2312

5911, 5944

1427, 1554

5766, 5771

5824, 5831

4452, 5743

5883, 5888

1569, 1871

229, 245

495, 668

690, 983

999, 1411

63,494

111,189

50821

Discharge summary

report

Admission Date: [**2169-4-14**] Discharge Date: [**2169-4-21**] Date of Birth: [**2088-5-12**] Sex: M Service: SURGERY Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 4748**] Chief Complaint: Speech difficulty Major Surgical or Invasive Procedure: Left CEA per Dr. [**Last Name (STitle) 1391**] on [**2169-4-19**] History of Present Illness: Mr. [**Known lastname 105691**] (previous spelling incorrect as Rhineharist and a new [**Hospital **] medical record was created) is an 80 year old right handed male with complex medical history including prior TIA, possible seizure disorder, now presenting with difficulty speaking. The patient is unable to provide a complete history as a result of his language deficit. He lives alone and cannot provide a proxy at the moment. [**Name2 (NI) **] report intermittent difficulty with balancing his checkbook over the last few days prior to admission. He reported something was wrong on the day of admission with sudden intermittent difficulty speaking associated with right hand numbness and clumsiness. He was brought to [**Hospital1 18**] ED where a head CT revealed question of a left frontal lobe mass. He was evaluated by neurosurgery and admitted for MRI. Two days following his initial admission, MRI reveals subacute infarcts in the inferior division of the L MCA. Neurology was then consulted to evaluate the patient. Upon my comparison of the patient's license in his wallet to his current ID band there is a discrepancy in the spelling of his last name. Revealing that the patient has an extensive previous medical history here at this institution. The patient is able to tell me that his PCP his here at [**Hospital1 18**]. MRI is without any vessel imaging. The patient was taking plavix for coronary and carotid stents and this is currently being held for unclear reasons. The patient is unable to offer any further HPI. At present he denies any headache. He is well aware of his difficulty in speech production. He reports difficulty with handwriting, he is unable to hold a pen in his right hand despite normal strength. He reports right hand diminished sensation. No bowel or bladder incontinence. He reports his gait has been unsteady for ? amount of time. ROS: denies any F/C/NS, + chronic cough and singultus, no chest pain. no abdominal pain. no N/V, no diarrhea, no constipation. Past Medical History: -Hypertension -Peripheral [**Hospital1 1106**] disease, s/p distal aortic stenting -Chronic renal insufficiency -Multiple TIAs in [**2161**]. Then with right hand weakness in [**2164**] and now s/p L ICA stent in [**11-25**] -Autonomic neuropathy, with evidence of both sympathetic and parasympathetic dysfunction on autonomic testing -Prostate cancer s/p brachytherapy -Hyperlipidemia -Gout -Enhancing lesion, thought to be a meningioma in the anterior cranial fossa -? h/o Clivus lesion on MRI, bone scan negative Social History: He lives alone in [**Location 1268**]. Widowed from his second marriage, son lives in [**State 531**] City - [**Name (NI) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name 105692**]. He has a sig other [**Doctor Last Name 636**] "[**Doctor First Name 7019**]" [**Location (un) **]. He is retired from a medical supplier shipping business. He has an 80-pack-year smoking history; he quit 18 years ago. He denies any ETOH or illicit drug use. Family History: No history of neurologic disease. Physical Exam: T 98.3, HR 64, BP 114/36, 16, 100% 2L NC Gen- well appearing, comfortable, upright in bed, cooperative with obvious speech deficit, NAD HEENT: NCAT, OP clear, MMM, Anicteric sclera Neck- no carotid bruits bilat. Left sided neck incision is c/d/i with steri-strips in place CV- RRR, no MRG Pulm- diffuse, prominent expiratory wheezes Abd- protuberant, soft, nd, nt, BS+ Extrem- no CCE Neurologic Exam: MS- alert, arouses easily to voice, attentive to examination, speech is of variable fluency, largely nonfluent, his naming is intact to high and low frequency objects, he makes some frequent paraphasic errors with spontaneous speech, repitition is impaired. He is able to read some simple phrases, but then perseverates and does not read more complex sentences. He is unable to write. No difficulty with praxis for combing hair, brushing teeth. No neglect. CN- PERRL 3-->2mm bilat, EOMI, no nystagmus, VFF to confrontation, his facial musculature appears symmetric, full facial strength, facial sensation diminished to pinprick R V2,V3. hearing intact to FR, palate elevates symm, SCM and trap are [**4-25**], tongue at midline. Motor- increased tone in all extremities, no cogwheeling. no adventitious movements. R pronator drift. Strength is full in all muscles tested including delt, tri, [**Hospital1 **], WE, FE, FF, IP, Q, H, TA, PF, [**Last Name (un) 938**]. Sensory- diminished PP, LT, temperature, prop on right hemibody (face, arm, trunk, leg). Reflexes- Absent [**Hospital1 **], tri, brachioradialis, 1+ patellars, absent ankle jerks. Coordination- intact FNF, slightly slowed [**Doctor First Name 6361**] bilaterally (symmetrically). Gait- poor initiation, shortened stride, unsteady. Pertinent Results: CT Head [**4-14**]: IMPRESSION: 1.6 x 1.3 cm left frontal hyperdense brain mass. MRI is recommended for further evaluation. MR [**Name13 (STitle) 430**] [**4-15**]: IMPRESSION: Multiple foci of slow diffusion consistent with acute infarction in the left MCA [**Month/Year (2) 1106**] distribution, involving the subcortical white matter, likely consistent with embolic disease. No mass lesion or abnormal enhancement is identified at the site of hyperdensity seen on recent CT. Multiple scattered FLAIR hyperintensity areas likely consistent with chronic microvascular ischemic changes in the subcortical white matter. CTA Head and Neck [**4-16**]: IMPRESSION: 1. No evidence of acute intracranial hemorrhage or major territorial infarction. Small regions of embolic infarction within the left MCA territory are better appreciated on the DWI sequence of recent MRI. 2. Severe luminal stenosis involving the right internal carotid artery just distal to its bifurcation, of at least 80%. Significant stenosis is present involving the left internal carotid artery at the cranial aspect of the [**Month/Year (2) 1106**] stent and a short segment beyond with at least 60% stenosis. 3. Mild paraseptal emphysematous changes within the lung apices. 4. Moderate irregularly ulcerated plaque within the aortic arch incidentally noted. Carotid Series Complete [**4-17**] Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right there is significant heterogeneous plaque in the carotid bulb/ICA. on the left there is a patent LT ICA/CCA stent with some mild to moderate narrowing distal to stent . On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are141/33, 160/43, 55/15, cm/sec. CCA peak systolic velocity is 83 cm/sec. ECA peak systolic velocity is 107 cm/sec. The ICA/CCA ratio is 1.9. These findings are consistent with 60-69% stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 70/26, 119/43, 102/31, cm/sec. CCA peak systolic velocity is 72 cm/sec. ECA peak systolic velocity is 123 cm/sec. The ICA/CCA ratio is 1.6. These findings are consistent with 40-59% stenosis. There is antegrade right vertebral artery flow. There is antegrade left vertebral artery flow. Impression: Right ICA stenosis 60-69 Left ICA stenosis 40-59 Brief Hospital Course: Patient is a 80 year old man admitted to Neurosurgery service on [**4-14**] with difficulty speaking and now transferred to Neurology for stroke workup. He has hx of TIA in [**2161**], two admissions for TIA in [**2164**], first with aphasia and then subsequently for right hand weakness, received left ICA stent in [**2164**]. He has been on aspirin, Plavix, and Lipitor since the ICA stenting. He has history of two amnestic episodes and multiple episodes of left-sided weakness. He is being evaluated for possible simple partial seizures and complex partial seizures. He has been on Keppra since [**2167**]. Also hx of autonomic instability both sympathetic and parasympathetic. Hyperlipidemia. PVD. On [**4-14**], he had difficulty speaking. Also noted right hand numbness and clumsiness. Patient was taken to [**Hospital1 18**] ED where Head CT showed question of left frontal mass. Admitted to Neurosurgery. MRI brain on [**4-15**] showed multiple subacute infarcts in the inferior division of the left MCA. No hemorrhages seen. On exam, he has non-fluent aphasia, with alexia and agraphia, right pronator drift, and mild sensory deficits on the right. Etiology could be embolic due to possible restenosis of the left ICA stent, intracranial embolus, or possibly cardioembolic source. CTA showed critical stenosis of the L ICA just distal to the prior stenting hence he was started on heparin gtt and [**Month/Year (2) 1106**] consult was obtained. Given the symptomatic and critical stenosis, patient was taken for L CEA per Dr. [**Last Name (STitle) 1391**]. He tolerated the procedure well and was taken to the [**Last Name (STitle) 1106**] ICU overnight. He was on a nitro drip to keep his systolic pressures below 140 mmHg. This was discontinued on the same night as surgery. On POD 1 his staples were removed from his neck and steri-strips were placed. He was seen and evaluated by PT and OT who recommended rehab. POD#2 stable. rehab screening in progress. POD#3 d/c to rehab. Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 1-2 puffs(s) by mouth every four (4) to six (6) hours as needed ALLOPURINOL - 100 mg Tablet - 1 (One) Tablet(s) by mouth once a day ASA - 325 MG - ONE BY MOUTH EVERY DAY ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth every day ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 (One) Tablet(s) by mouth once a day CHLORPROMAZINE - 10 mg Tablet - 1 Tablet(s) by mouth [**Hospital1 **] prn hiccups CITALOPRAM [CELEXA] - 40 mg Tablet - 1 Tablet(s) by mouth once a day CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once a day DARIFENACIN [ENABLEX] - 7.5 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays(s) both nares every day LEVETIRACETAM [KEPPRA] - 250 mg Tablet - 1 Tablet(s) by mouth twice a day OMEPRAZOLE - 20 mg Capsule daily DOCUSATE SODIUM 100 mg Capsule - 1 Capsule(s) by mouth twice a day FERROUS GLUCONATE - (Prescribed by Other Provider) - 325 mg Tablet - 1 Tablet(s) by mouth once a day SODIUM CHLORIDE - 1,000 mg Tablet, Soluble - one tab po three times a day for orthostatic hypotension Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Recurrent left carotid stenosis history of HTn history of aortic- descending stenosis, s/p thoracic stenting history of chronic renal disease history of recurrent TIA's, stroke-aphasic history of carotid disease s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stenting [**11-25**] history of prostatic Ca s/p brachythearphy history of rt. ueretal stenting history of autonomic neuropathy history of dyslipdemia history of gout Discharge Condition: Stable. Steri-strips over left neck incision. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. Other: *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 1391**] in 4 weeks. Call his office at [**Telephone/Fax (1) 1393**] to schedule that appointment. Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2169-4-25**] 1:00 Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2169-4-25**] 2:00 Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2169-4-25**] 2:30 followup Dr. [**Last Name (STitle) **] [**2169-5-10**] @ 1pm Neuro/stroke , if need to change appointment call [**Telephone/Fax (1) 2574**] Completed by:[**2169-4-21**]

[ "403.90", "996.1", "E878.2", "585.9", "493.90", "433.11", "E849.8", "355.9" ]

icd9cm

[ [ [] ] ]

[ "00.40", "38.12" ]

icd9pcs

[ [ [] ] ]

10766, 10836

7578, 9577

292, 359

11328, 11376

5192, 7555

12907, 13530

3417, 3452

10857, 11307

9603, 10743

11400, 12547

12562, 12884

3467, 3852

235, 254

387, 2394

3869, 5173

2416, 2933

2949, 3401

68,605

198,626

38082

Discharge summary

report

Admission Date: [**2177-8-26**] Discharge Date: [**2177-9-1**] Date of Birth: [**2094-9-18**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2177-8-27**] Mitral valve repair & annuloplasty (28 mm CG Future) [**2177-8-26**] Cardiac Catheterization, coronary angiogram History of Present Illness: This 82 year old female with a known murmur is followed by serial echocardiograms. She presented to an outside hospital in heart failure requiring admission. She was diuresed and discharged. She was referred for surgical evaluation of her mitral valve and was admitted today post cardiac catheterization for Heparin bridge with a plan for surgery the next day. Past Medical History: Mitral Regurgitation h/o Acute diastolic heart failure chronic Atrial fibrillation h/o Deep vein thrombosis Osteoarthritis of left knee with dislocated joint Spinal stenosis Hypertension Left hip bursitis Renal calculi s/p Tonsillectomy s/p repair left wrist fracture s/p Total abdominal hysterectomy s/p Bilateral cataract surgery Social History: Race: caucasian Last Dental Exam:[**5-3**] Lives with:husband Occupation:retired school nurse Tobacco: denies ETOH: denies Family History: father ?MI, grandfather deceased from MI at 65 Physical Exam: admission: Pulse:76 reg B/P Right: 150/70 Left: 160/68 Height:5'3" Weight:68 kg General: No acute distress Skin: Dry [x] intact [x] rigth groin cath site HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] decreased ROM; no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur- 4/6 SEM radiates throughout precordium into carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], well-perfused [x] Edema- none Varicosities: bilateral varicosities with multiple spider veins Neuro: Grossly intact; MAE [**5-28**] strengths; nonfocal exam Pulses: Femoral Right: cath site Left:2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit : right bruit vs murmur Left bruit vs murmur Pertinent Results: [**2177-8-27**] Echo: No spontaneous echo contrast is seen in the left atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened and myxomatous. There is flail of both anterior and posterior leaflets with evidence of torn chordae on both leaflets prolapsing into the left atrium. Severe (4+) mitral regurgitation is seen. There is no pericardial effusion. POSTBYPASS: The patient is on infusions of epinephrine (0.02 mcg/kg/min) and phenylephrine (<1 mcg/kg/min). The repaired mitral valve is not well visualized from all angles but the leaflets are no longer flail and coapt better than before. There is now trace mitral regurgitation without evidence of mitral stenosis (gradient 3 mmHg). Mild aortic insufficiency remains. Left ventricular function remains normal. Normal aortic contours. [**2177-8-26**] 07:00AM BLOOD WBC-6.0 RBC-4.54 Hgb-13.9 Hct-39.8 MCV-88 MCH-30.5 MCHC-34.8 RDW-14.3 Plt Ct-328 [**2177-9-1**] 04:59AM BLOOD WBC-8.8 RBC-3.15* Hgb-9.7* Hct-28.0* MCV-89 MCH-30.8 MCHC-34.7 RDW-14.9 Plt Ct-265# [**2177-9-1**] 04:59AM BLOOD PT-15.6* INR(PT)-1.4* [**2177-8-31**] 02:47PM BLOOD PT-14.5* INR(PT)-1.3* [**2177-8-30**] 04:50AM BLOOD PT-13.4 INR(PT)-1.1 [**2177-8-29**] 05:20AM BLOOD PT-12.2 INR(PT)-1.0 [**2177-9-1**] 04:59AM BLOOD Glucose-95 UreaN-18 Creat-0.7 Na-131* K-4.1 Cl-97 HCO3-26 AnGap-12 [**2177-8-26**] 07:00AM BLOOD Glucose-102* UreaN-12 Creat-0.7 Na-138 K-4.6 Cl-103 HCO3-25 AnGap-15 Brief Hospital Course: Ms. [**Known lastname **] was admitted post cardiac catheterization for Heparin bridge with plan for surgery on [**8-27**]. The cathetreization revealed nonobstructive disease and carotid ultrasound was likewise insignificant. She underwent the usual pre-operative work-up and on [**8-27**] was brought to the Operating Room where she underwent mitral valve repair. 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. Diuresis towards her peroperative weight was instituted and beta blockade resumed. She was transferred to the floor. She remained in atrial fibrillation and temporary pacing wires and CTs were removed per protocols. Coumadin was resumed witha target INR of [**2-25**].5. She was seen by the Physical therapy service for mobility and strength and ready for discharge on POD 5. Arrangements were made for family to stay with her around the clock and her anticoagulation to be managed as preoperatively by>>>>> Medications on Admission: COUMADIN 2 mg M-W-F; 2.5 mg T-TH-S-S - last dose 7/29 at 6pm fosinopril 20/HCTZ 12.5 mg daily lasix 40 mg daily magnesium chloride 128 mg daily toprol XL 50 mg daily KCl 40 mEq daily multivitamin daily glucosamine 200mg/300mg complex daily brewer's yeast 1000 mg daily clindamycin prn dental work Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp. 4. 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* 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. Amiodarone 200 mg Tablet Sig: as ordered Tablet PO BID (2 times a day): two tablets twice daily for two weeks then one tablet twice daily for two weeks then one tablet daily. Disp:*100 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 11. Coumadin 1 mg Tablet Sig: as directed Tablet PO once a day: 2mg Two tablets) M-W-F, 2.5mg(2.5 tablets) T-Th-S-S unless otherwise instructed. Disp:*100 Tablet(s)* Refills:*2* 12. Outpatient [**Name (NI) **] Work PT/INR [**2177-9-3**] then as directed. results to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 85014**] or fax at [**Telephone/Fax (1) 85015**] Discharge Disposition: Home With Service Facility: [**Hospital3 85016**] Discharge Diagnosis: Mitral Regurgitation s/p Mitral valve repair chronic diastolic heart failure chronic Atrial fibrillation h/o deep vein thrombosis Osteoarthritis left knee with dislocated joint Spinal stenosis Hypertension Left hip bursitis Renal calculi s/p Tonsillectomy s/p repair left wrist fracture s/p Total abdominal hysterectomy s/p Bilateral cataract surgery Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Edema none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **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) **] ([**Telephone/Fax (1) 170**]) on [**2177-10-2**] at 1:00 PM Please call to schedule appointments with: Primary Care: Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 85014**]) in [**1-25**] weeks Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 60004**] in [**1-25**] 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 atrial fibrillation Goal INR 2-2.5 First draw: [**2177-9-3**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [**Last Name (STitle) **] Results to Dr. [**Last Name (STitle) **],[**Telephone/Fax (1) 85014**] or FAX [**Telephone/Fax (1) 85015**] Completed by:[**2177-9-1**]

[ "715.96", "212.7", "429.5", "424.0", "427.31", "724.00", "401.9", "V12.51", "428.32", "428.0", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "88.53", "35.12", "88.56", "37.22", "39.61" ]

icd9pcs

[ [ [] ] ]

7319, 7371

4152, 5268

317, 448

7766, 7945

2286, 4129

8782, 9786

1351, 1399

5615, 7296

7392, 7745

5294, 5592

7969, 8759

1414, 2267

258, 279

476, 840

862, 1195

1211, 1335

73,403

182,659

13797+56486

Discharge summary

report+addendum

Admission Date: [**2180-7-11**] Discharge Date: [**2180-7-18**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 45**] Chief Complaint: Bradycardia, anuria Major Surgical or Invasive Procedure: N/A History of Present Illness: Patient is an 89yo male with history of CHD, PAD, [**Hospital **] transferred to [**Hospital1 18**] with bradycardia and anuria. . He presented to OSH with increased fatigue and not feeling well. He was found to be bradycardic to the 40s in the ambulance so he was given 0.5mg atropine prior to arrival to the OSH. While in the ED, vital signs showed HR in 40s and BP 110/80. EKG showed wide-complex rhythm with HR of 46. Patient's home lopressor and digoxin were held (he has not received them in >30 hours). He was not given any other doses of atropine while at OSH. He remained bradycardic there (40s-60s) with generally well-maintained pressures. He had an episode of hypotensio down to 85/40 that responded well to 1L NS bolus. Pressures remained above 110 after that. . Labs were pertinent for K of 5.8, Cr of 1.2 and troponin of 0.07. UA concerning for UTI so she was given ceftriaxone. While at OSH, patient had minimal UOP (205cc urine output today, 30cc from last night). [**Name (NI) **] wife reports excellent urine output on Saturday. Denies any hematuria at that time. He developed hematuria on Sunday that worsened on Monday. . Given lack of ICU level beds at OSH, patient transferred to [**Hospital1 18**] for further management. Of note, patient had IVC filter placed here in [**Month (only) 547**] after being diagnosed with DVT. . Upon transfer, patient was asymptomatic. HR was 57 on arrival to the floor. Vitals signs- T- 97.3, HR- 57, BP- 106/36, RR- 24, SaO2- 97% on 3L NC. Denied dizziness, headache, chest pain, shortness of breath, palipations, syncope. Also denies any vision changes, including seeing halos. Past Medical History: CAD s/p stents CHF EF 59% [**2177**] Peripheral Arterial Disease s/p Left TMA s/p R AKA HTN AF COPD AAA s/p repair [**2167**] DVT [**2159**] OA Anemia s/p L hip replacement R BKA [**2158**] Social History: Social History: Quit smoking 20 years ago. Smoked approx 1 ppd x 50 years. Formerly employed as microbiology teacher. Lives with wife who is a nurse and was one of his former micro students. They do not have any children and live on [**Hospital3 4298**]. Rare ETOH use on holidays. No drug use. Wheelchair bound and dependent on wife for many ADLs Physical Exam: Vitals: T- 97.3, HR- 57, BP- 106/36, RR- 24, SaO2- 97% on 3L NC General: AAO x 1 (to person). No acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Bilateral expiratory wheezes. Good respiratory effort CV: Irregular rhythm- bigeminal. 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, 1+ edema, no clubbing, cyanosis Pertinent Results: Cardiology Report ECG Study Date of [**2180-7-11**] 11:43:10 PM Sinus bradycardia with occasional ventricular premature beats at a rate of 49. Marked low voltage throughout the tracing. Poor R wave progression in leads V1-V6. Compared to the previous tracing of [**2180-5-26**] no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 49 0 72 408/388 0 0 -17 Cardiology Report ECG Study Date of [**2180-7-12**] 9:02:58 AM Normal sinus rhythm, rate 76. Continued severe low voltage in the standard leads and lateral precordial leads. Poor R wave progression. Compared to tracing #1, except for an increase in the rate, no other No diagnostic interval change. Intervals Axes Rate PR QRS QT/QTc P QRS T 76 0 74 366/394 0 0 -26 Cardiology Report ECG Study Date of [**2180-7-13**] 2:25:16 PM Sinus rhythm and non-conducted atrial ectopy as well as ventricular ectopy. Diffuse low voltage. Prior anteroseptal myocardial infarction. Compared to the previous tracing of [**2180-7-12**] no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 63 0 84 354/359 0 0 -63 Portable TTE (Complete) Done [**2180-7-13**] at 8:14:01 AM The left atrium is mildly dilated. 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 to mid inferior hypokinesis and inferolateral akinesis. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (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 ([**2-12**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2190-5-24**], the severity of tricuspid regurgitation and pulmnonary artery systolic hypertension has increased. CHEST (PORTABLE AP) Study Date of [**2180-7-12**] 11:38 AM FINDINGS: As compared to the previous radiograph, today's image is limited by respiratory motion artifacts. Unchanged moderate cardiomegaly, no evidence of overt pulmonary edema. The presence of minimal pleural effusions cannot be excluded. No newly appeared focal parenchymal opacities suggesting pneumonia. DUPLEX DOP ABD/PEL LIMITED Study Date of [**2180-7-12**] 9:30 AM RENAL ULTRASOUND: Right kidney measures 12.7 cm. The left kidney measures 11 cm. There are bilateral anechoic renal lesions, likely represent simple cysts. The largest on the right measures 2.9 x 2.3 x 2.4 cm in the upper pole and the largest on the left in the lower pole measures 2.4 x 2.2 x 2.7 cm. There is no hydronephrosis, mass or stone. RENAL DOPPLER: There is normal acceleration time in the main renal arteries at therenal hila, and the kidneys show no evidence of renal artery stenosis. The RI could not be evaluated due to continued respiratory motion. A Foley catheter is seen in the bladder. IMPRESSION: Bilateral simple renal cysts without hydronephrosis or mass. Equally vascularized kidneys and no evidence of renal artery stenosis. ADMISSION LABS: [**2180-7-12**] 12:20AM BLOOD WBC-9.5 RBC-2.66* Hgb-8.3* Hct-26.8* MCV-101* MCH-31.3 MCHC-31.1 RDW-20.2* Plt Ct-257 [**2180-7-12**] 12:20AM BLOOD Neuts-73.9* Lymphs-19.1 Monos-6.6 Eos-0.1 Baso-0.2 [**2180-7-12**] 12:20AM BLOOD PT-17.0* PTT-42.5* INR(PT)-1.5* [**2180-7-12**] 12:20AM BLOOD Glucose-140* UreaN-32* Creat-1.6* Na-127* K-5.6* Cl-90* HCO3-29 AnGap-14 [**2180-7-12**] 12:20AM BLOOD CK-MB-4 cTropnT-0.06* [**2180-7-13**] 02:15PM BLOOD CK-MB-7 cTropnT-0.05* [**2180-7-12**] 12:20AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.5* [**2180-7-13**] 06:20AM BLOOD calTIBC-235* VitB12-1256* Folate-GREATER TH Hapto-88 Ferritn-574* TRF-181* [**2180-7-12**] 12:20AM BLOOD Cortsol-25.5* [**2180-7-12**] 12:20AM BLOOD Digoxin-1.3 DISCHARGE LABS: Brief Hospital Course: Mr. [**Known lastname 41476**] is an 89 year old gentleman with history of CAD s/p PCI, Afib previously on digoxin and metoprolol, recurrent VTE; presented with bradycardia and ARF, admitted to MICU then transferred to cardiology floor. # Bradycardia: Patient was admitted to MICU from OSH on [**2180-7-11**]. On admission, he was bradycardic in the 40s and asymptomatic. His home metoprolol and digoxin had been held for > 30 hours at this point. He was monitored on telemetry and given IV fluids in the setting of his anuria. HR improved overnight and he was seen by the EP team in the morning. Given the improvement in his HR and BP, they recommended ECHO and close monitoring before making the final decision on placing a PPM, as they thought that bradycardia was related to drug effect from metoprolol and digoxin. Urine output improved drastically with improved cardiac output via improved HR. Patient remained comfortable while in the MICU and was transferred to the floor on [**2180-7-13**]. On the floor, his heart rates remained in the 50s-80s, appearing to be in normal sinus rhythm with frequent PVCs most of the time, and he was asymptomatic. He did have a few runs of NSVT, [**4-13**] beats each; there was one run of 34 beats of possible NSVT seen on telemetry though this may have actually been a run of Afib with RVR when patient was mildly agitated in the setting of having held metoprolol and digoxin, difficult to evaluate on telemetry. # Anuria/Acute Renal Failure: The patient's urine output improved with HR improvement. His creatinine rapidly normalized to 1.0. A renal ultrasound was performed which showed no evidence of hydronephrosis. His lasix was initially held, but was restarted at 40mg qd on [**2180-7-13**], which was half his home dose, increased to his home dose of 80mg daily the following day. # Chronic Obstructive Pulmonary Disease: Patient has COPD and home O2 requirement of 3L at baseline. He remained 100% on 2L of O2 upon discharge and may benefit from decreasing oxygen to keep O2 saturation closer to 93-95%. # Coronary Artery Disease: Patient has history of CAD s/p PCI x 1 in the [**2160**]. He is captopril was held in the setting of relative hypotension but may be restarted as blood pressure tolerates. His aspirin was decreased from 325mg to 81mg because he is also systemically anticoagulated and therefore has higher risk of bleeding. # DVT treatment: The patient has history of new DVT despite being on warfarin, so he is now on enoxaparin. Enoxaparin was held given initially his elevated renal function, but was restarted on [**2180-7-14**] once his renal failure improved. # Hematuria: The patient presented with gross hematuria, which resolved by the time he was transferred to the cardiology floor. Hematuria was most likely due to lovenox in the setting of [**Last Name (un) **]. Once creatinine normalized, patient was restarted on home enoxaparin with no new hematuria. # Patient was FULL CODE during this hospitalization. Medications on Admission: Aspirin 325mg daily Lovenox 120mg SC daily Furosemide 80 mg PO daily (+40mg PRN) Zaroxylin 2.5mg daily Simvastatin 80 mg daily Digoxin 0.125 mg PO daily (held on transfer) Lopressor 12.5mg daily (held on transfer) Captopril 12.5 mg PO BID Flomax 0.4mg qod Fluticasone-salmeterol 100-50 [**Hospital1 **] Albuterol prn MVI PO daily Colace 100mg PO BID Fexofenadine 60 mg PO BID Ativan 1mg qHS Potassium Chloride Robitussin DM Ipratropium/albuterol prn Fibricon [**Hospital1 **] Discharge Medications: 1. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 8. Metolazone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for shortness of breath. 10. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO every other day. 11. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Ativan 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. Fibricor Oral 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 30 days. Discharge Disposition: Extended Care Facility: [**Hospital6 8283**] [**Hospital1 1501**] Discharge Diagnosis: Primary Diagnosis: Bradycardia Secondary Diagnoses: Chronic Obstructive Pulmonary Disease Coronary Artery Disease Chronic Atrial Fibrillation Diastolic Chronic Congestive Heart Failure Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Has Above Knee Amputation. Discharge Instructions: Dear Mr. [**Known lastname 41476**], You were admitted to the hospital because you were found to have low heart rates. A couple of your medications were stopped and you were monitored very carefully. Because you were not feeling lightheaded from the low heart rate, you were felt safe to go home with the medication changes as listed below. The following changes have been made to your medications: - Please STOP taking your digoxin - Please STOP taking your metoprolol - Please DECREASE your aspirin to 81mg because you are already on a lifelong blood thinner enoxaparin (lovenox) - Please STOP your captopril for now until, but it may be restarted soon at the Rehab center or by your primary care physician when your blood pressure can tolerate it Followup Instructions: Please be sure to schedule a follow up appointment with your primary care physician in the next 1-2 weeks. PCP: [**Name10 (NameIs) 41477**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 41478**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**] Name: [**Known lastname 7483**],[**Known firstname 7484**] Unit No: [**Numeric Identifier 7485**] Admission Date: [**2180-7-11**] Discharge Date: [**2180-7-18**] Date of Birth: [**2090-11-3**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2412**] Addendum: # AV Nodal Block: Patient was noted to have a few dropped ventricular beats on telemetry with atrial beats not conducting appropriately, not preceded by PR prolongation. PR intervals were maintained. Patient was asymptomatic completely. He will follow up with cardiologist at next available appointment. Patient's followup appointment was scheduled for Wednesday, [**7-26**] at 1:30pm with Cardiologist Dr. [**Last Name (STitle) **] at [**Hospital1 2946**] office. Discharge Disposition: Extended Care Facility: [**Hospital6 7486**] [**Hospital1 1354**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 2414**] Completed by:[**2180-7-18**]

[ "E941.3", "401.9", "276.7", "E942.1", "584.9", "427.31", "E934.2", "V49.73", "276.1", "285.9", "V12.51", "599.70", "414.01", "V49.76", "V45.82", "427.89", "443.9", "496", "428.0", "428.32", "426.10" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14733, 14957

7533, 10545

237, 242

12566, 12566

3075, 6759

13547, 14710

11071, 12238

12350, 12350

10571, 11048

12769, 13524

7510, 7510

2519, 3056

12403, 12545

178, 199

270, 1925

6775, 7492

12369, 12382

12581, 12745

1947, 2139

2171, 2504

31,782

106,744

34754

Discharge summary

report

Admission Date: [**2103-9-4**] Discharge Date: [**2103-9-11**] Date of Birth: [**2027-6-24**] Sex: F Service: CARDIOTHORACIC Allergies: Lipitor / Vytorin Attending:[**First Name3 (LF) 1505**] Chief Complaint: +ETT during preop w/u for TKR Major Surgical or Invasive Procedure: [**2103-9-4**] Coronary Artery Bypass x 3 (LIMA to LAD, SVG to OM1, SVG to OM2/lPLB) History of Present Illness: 76 yo female was undergoing pre-op evaluation for R TKR and was found to have positive stress test. Cardiac catheterization and coronary angiography revealed 3 vessel disease. The patient has experienced dyspnea on exertion for several years. She was referred for consideration of cabg. Past Medical History: CAD, DM, CVA, htn, hypothyroidism, pancreatic cyst, s/p R CEA, s/p parathyroidectomy Social History: retired lives with husband [**Name (NI) **]: quit 30 yrs ago, 20 pack year hx occasional etoh Family History: mother with RHD Physical Exam: Elderly WF in NAD VSS HEENT: NC/AT, EOMI, oropharynx benign, R CEA scar Neck: supple, FROM, no lymphadeopathy or thyromgaly Lungs: Clear to A+P CV: RRR without R/G/M Abd: +BS, soft, nontender, without masses or tenderness, obese Ext: +bil. edema, without varicosities, pulses Fem 1+ bilat, all others 2+ bilat. Neuro: mild L facial droop Pertinent Results: Iintra-op TEE [**2103-9-4**]: Findings LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). 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. Focal calcifications 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: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral annular calcification. Severe mitral annular calcification. No MS. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] 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. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. Mild (1+) mitral regurgitation is seen. There is a 1 x1 cm echogenic density in the posterior mitral annulus near the P3 region consistent with calcium deposit and MAC. This was conveyed to the surgeon and cross read with Dr.[**Last Name (STitle) **]. Clinical correlation suggested to rule out endocarditis. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**Known lastname **], [**Known firstname **] at11:!5 AM before CPB. Post_Bypass:. Preserved biventricular sytolic function. LVEF 55%. Normal RV systolic function. Trivial MR. Intact thoracic aorta [**2103-9-10**] 04:50PM BLOOD WBC-11.8* RBC-3.23* Hgb-10.0* Hct-28.8* MCV-89 MCH-31.0 MCHC-34.7 RDW-14.1 Plt Ct-343 [**2103-9-4**] 02:21PM BLOOD PT-14.2* PTT-41.6* INR(PT)-1.2* [**2103-9-10**] 04:50PM BLOOD Glucose-89 UreaN-20 Creat-1.1 Na-140 K-4.6 Cl-99 HCO3-32 AnGap-14 [**Known lastname **],[**Known firstname 8207**] [**Medical Record Number 79632**] F 76 [**2027-6-24**] Radiology Report CHEST (PA & LAT) Study Date of [**2103-9-8**] 12:23 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2103-9-8**] SCHED CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 79633**] Reason: r/o effusion [**Hospital 93**] MEDICAL CONDITION: 76 year old woman with REASON FOR THIS EXAMINATION: r/o effusion Provisional Findings Impression: NR SAT [**2103-9-8**] 2:38 PM Bilateral effusions left greater than right, improved right basilar atelectasis, no new consolidations. No PTX. Final Report PA AND LATERAL CHEST ON [**2103-9-8**] AT 12:43 INDICATION: Prior pneumothoraces and chest tubes. COMPARISON: [**2103-9-6**] FINDINGS: There is no PTX visualized. There are bilateral effusions, left greater than right with slightly more blunting at the left CP angle compared to the most recent prior study. There is better aeration at the right base with improvement in previously seen atelectasis. Again noted is some right paratracheal density presumably related to distended or tortuous brachiocephalic vessels. There are no new focal consolidations. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**] Approved: SAT [**2103-9-8**] 3:34 PM Brief Hospital Course: Following a discussion of risks, benefits and alternatives to CABG, the pt was admitted to [**Hospital1 18**] and taken to the operating room on [**2103-9-4**] for CABGx3 with LIMA>LAD, and SVG>OM1, OM2. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU for observation and recovery. POD #1 found the pt extubated, alert and oriented and breathing comfortably. She was neurologically intact and hemodynamics were maintained with epinephrine. The patient was transfered to the floor on POD #1. Chest tubes were discontinued on POD #2 without complication. Her wires were removed on the following day. With pulmonary toilet, lasix, incentive spirometry, and ambulation her breathing improved. She was transferred to the floor on POD 3 after she achieved blood pressure control. She continued to improve and had her BP meds further adjusted. She was discharged to rehab in stable condition on POD #7. Medications on Admission: atenolol 25', norvasc 5', diovan 160', lasix 40', levothyroxine 25', metformin 500''', asa 81', novalin 58am/30pm, vit b 12 Discharge Disposition: Extended Care Facility: [**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**] Discharge Diagnosis: CAD, DM, CVA, htn, hypothyroidism, pancreatic cyst, parathyroidectomy Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**Last Name (STitle) 9751**] in 1 week, [**Telephone/Fax (1) 9752**], please call for appointment Dr [**Last Name (STitle) **],[**First Name3 (LF) **] J. in [**2-25**] weeks ([**Telephone/Fax (1) 16335**]) please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3071**]) Completed by:[**2103-9-11**]

[ "403.90", "411.1", "414.01", "250.00", "577.2", "244.9", "511.9", "585.9", "518.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6883, 6997

5753, 6709

313, 400

7111, 7118

1345, 4720

7630, 8109

954, 971

4760, 4783

7018, 7090

6735, 6860

7142, 7607

986, 1326

244, 275

4815, 5730

428, 719

741, 827

843, 938

11,235

145,044

903

Discharge summary

report

Admission Date: [**2193-12-19**] Discharge Date: [**2193-12-24**] Date of Birth: [**2154-3-3**] Sex: M Service: MEDICINE Allergies: Sulfamethoxazole/Trimethoprim / Lisinopril Attending:[**First Name3 (LF) 6114**] Chief Complaint: fever to 103 degress, chills, fatigue, vomiting x 1 day Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 39 year old man with AIDS, CD4 of 4 in [**4-29**], VL not done, who presented to the ED with 1 day of fevers to 103 degrees at home, rigors and chills. On day of admission, he also had 1 episode of nausea, vomited up food (non-bilious/ non-bloody) that has resolved. Pt. notes chronic cough he associated with his thrush. Also had episode of diarrhea 5 days ago that resolved. Otherwise, the patient denies headache, visual changes, neck pain/stiffness, confusion, chest pain, SOB, pleuritic CP, abdominal pain (has chronic tenderness epigastrically), urinary changes, new rash or joint pain. . On arrival to the ED he was found to have a temperature of 102.9 degrees, HR in 130s, SBP 106/61. Also was found to have a lactate of 7.7, bicarb of 15 (normally in 20s), ARF with cr of 2.5 (baseline 1.1-1.4). He was put on the MUST protocol and a left subclavian line was placed. His initial CVP was 4. Mixed venous sat was 85%. Blood cultures were drawn which grew [**2-28**] bottles gram negative rods. He received doses of vanc/levo. His BP dropped to 70/30, and he received 5 L of NS, levophed started after 3 L and SBP 85. A-line placed - ABG - 7.40/26/137, and the lactate improved to 1.5. He started making urine with up to 60 cc per hour. He was admitted to the MICU. He was continued on the sepsis protocol in the MICU and transfused with 2 units of blood for a HCT of 18. He was weaned from levophedrine around 4 am and has since had a stable BP in the 110's. Patient was then transferred to floor on [**12-20**], at that time he reported feeling much improved, but not quite at his baseline. He denies continued fevers or chills, abdominal pain, diarrhea, nausea, vomiting, or other concerns. He says he is currently almost blind from the CMV retinitis, and [**Doctor Last Name **] detect some light in his left eye. Past Medical History: 1. HIV since '[**77**], now with AIDS, CD4 of 4, complicated by Klebsiella oxytoca pna with pos. BCX (pan-[**Last Name (un) 36**]), [**Last Name (un) 6108**] bacteremia in [**6-28**], cytomegalovirus retinitis currently [**Doctor Last Name **], oroesophageal candidiasis, oral hairy leukoplasia, toxo in [**2184**], anal warts, lipodystrophy. 2. Dermatitis. 3. Hypertension. 4. Hemorrhoids. 5. Anemia. 6. Leukopenia. 7. Angioedema. 8. Ulcerations. 9. Herpes simplex. 10. Shingles. 11. Hepatitis B. 12. Bacterial meningitis. 13. EF of 45% 14. peripheral neuropathy Social History: Lives in JP with his male partner. Denies current alcohol use. Smoked 1 ppd for 15 years, quit in [**2179**]. Used to use marjuana, now on marinol. No IVDA. Family History: father had MI at age 41 mother had salivary cancer in her 60's Physical Exam: V: Tm 102.9 Tc 97.7 P 85 BP 109/69 R20 99% RA Gen: cachectic, blind, pleasant man in no apparent distress Skin: molluscum contagiosum over face. Port-o-cath R chest nontender, no erethema HEENT: pupils 3mm and equal but not reactive to light. OP with thrush over palate and tongue Resp: CTAP B CV: RRR nl s1s2 II/VI SEM at RUSB Abd: soft NTND +BS Ext: no edema 2+ DP pulses Neuro: CN 2-12 intact except for unreactive pupils. Pertinent Results: [**2193-12-19**] 8:50p Ca: 7.7 Mg: 1.0 P: 1.0 D Other Blood Chemistry: Cortsol: 37.5 Normal Diurnal Pattern: 7-10am 6.2-19.4 / 4-8pm 2.3-11.9 [**2193-12-19**] 7:12p Lactate:7.7 Comments: Verified [**2193-12-19**] 6:30p 133 101 34 / AGap=21 -------------183 3.6 15 2.5 \ ALT: 44 AP: 461 Tbili: 0.6 Alb: 3.1 AST: 46 LDH: Dbili: TProt: [**Doctor First Name **]: 69 Lip: 44 91 6.3 \ 7.1 / 213 / 23.8\ N:90 Band:6 L:2 M:1 E:0 Bas:0 Metas: 1 Nrbc: 1 Comments: Verified By Replicate Analysis Notified Dr. [**Last Name (STitle) 6115**] In Er @ 19:20 Pm [**2193-12-19**] Hypochr: 2+ Anisocy: 1+ Poiklo: 1+ Macrocy: 1+ Ovalocy: 1+ Pencil: OCCASIONAL Tear-Dr: OCCASIONAL Comments: MANUAL Plt-Est: Normal PT: 13.3 PTT: 40.0 INR: 1.1 MICRO: 13. [**2193-12-20**] Immunology (CMV) CMV Viral Load-PENDING; 14. [**2193-12-20**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY; 15. [**2193-12-20**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {KLEBSIELLA OXYTOCA}; ANAEROBIC BOTTLE-FINAL {KLEBSIELLA OXYTOCA}; 16. [**2193-12-19**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP., ENTEROCOCCUS SP.}; 17. [**2193-12-19**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-FINAL {KLEBSIELLA OXYTOCA}; 18. [**2193-6-21**] CATHETER TIP-IV WOUND CULTURE-FINAL; [**12-21**] CXRAY: Focal patchy opacities in the right mid zone and probably in the right lower and left lower zones. Given the history, these most likely represent infectious infiltrates. No CHF or gross effusion. [**12-20**] renal, abdominal u/s: IMPRESSION 1. Contracted gallbladder with thickened wall, likely related to postprandial state. 2. Small amount of ascites. 3. Echogenic, enlarged kidneys, consistent with HIV nephropathy. No evidence of hydronephrosis. Brief Hospital Course: A/P: 39 year old man with HIV CD4 4 in [**4-30**] with GNR bacteremia and fever. 1) Presumed line infection - Patient had gram negative bacteremia, Kelbsiella ocitoca sensitive to levo in [**2-28**] blood cultures. Follow up blood cultures negative. Most likely source is the patient's port-o-cath though it is not clinically infected. ID consulted and made recommendation to remove port. The patient was evaluated by surgery (Dr. [**Last Name (STitle) **] who states that if the line is taken out, it would be next to impossible to place another port-o-cath in. In consultation with Dr. [**Last Name (STitle) 4844**] and the patient the decision is made to attempt to treat though the line with a 14 day course of levofloxacin and monitor for signs of infection. Of not a cxray showed a RML diffuse infiltrate. Sputum showed 4+ year and normal oral flora. GI stool cultures were negative to date. CMV viral load is pending at time of discharge. Also, urine was positive for enterococcus sensitive to levo. 2) [**Name (NI) 6116**] - Pt. has baseline transaminase elevation, but alk phos has increased from 200s in [**3-31**] to > 400. GGT elevated to 497 but down from past results. RUQ showed contracted gall bladder and small amount of ascitis. 3) acute on chronic renal failure - Possibly related to sepsis vs med related or HIV nephropathy. Baseline Cr 1.5 in [**5-31**], now elevated to 2.5. Renal U/S showed no hydro but enlarged kindeys consistent with HIV nephropathy. No casts were noted. FENa was 4.4 without diuretics, which suggests that it is most likely HIV nephropathy at new baseline . Creatinine improved to 1.6 on dicharge. Patient will follow up with renal as outpatient. 4) hisstory of hypotension, resolved - Patient was admitted on the MUST protocol: in the ICU, his CVP was kept [**10-8**] with 1 L IVF boluses, UO > 30 cc/ hr with prn 1 L IVF boluses; monitor SVO2, random cortison was normal. He was weaned off levophed after a few hours. His hypovolemia may have been partially due to hypovolemia and parially due to sepsis. . 5) anemia - Patient withchronic anemia, likely related to bone marrow suppression from HIV or related meds. He has required transfusions in the past and had 2 units in-house. . 6) HIV - HAART therapy was discontinued during hospitalization it will be restarted as outpatient. In house patient was maintained on clarithromycin for [**Doctor First Name **] prophylaxis, and dapsone for PCP [**Name Initial (PRE) 1102**]. Patient was maintained on clindamycin and pyrimethamine for history of toxoplasmosis. Patient maintained on clotrimazole troche for thrush. Patient placed on Posaconazole (study drug) QID for refractory oral thrush. . 4) CMV retinitis - On discharge the decision was made to hold foscarnet therapy until patient's creatinine remains stable. The plan is to continue foscarnet as maintenance therapy (rather than treatment therapy as patient has already suffered visual loss from the disease.) The treatment plan is to prevent extrocular manifestations of CMV. . 5) prophylaxis - Patient maintained on PPI, heparin sq and colace. . 6) Access - During hospitalization a L subclavian placed [**12-19**], patient will be discharged with portacath. . 7) FEN - normal diet, boost TID . 8) code - full code - Of note, patient says "short course of intubation" acceptable and plans to discuss with his partner. 9) Dispo - Home with services. Of note, patient receives approximately 6 hours of VNA services (from 10:00-4:30) Patient reported sometimes being alone from 4:30-8:00 p.m. until his partner came home for which he requested some companionship, especially given his recent blindness. However, the patient did not feel unsafe during these time. We will discharge the patient with his current services in place and attempt to find additional support through community assistance and care-for-the-blind programs. We also make recommendations through his VNA to provide additional support for education for the blind. Medications on Admission: according to OMR [**12-16**] and patient ALDARA 5%--Apply to molluscum contagiosum twice a day as needed ATARAX 25MG--Take one by mouth three times a day as needed ATIVAN 0.5MG--One by mouth q 6 hrs as needed for anxiety BOOST --Drink one can three times a day CALCIUM CARBONATE 500MG--One by mouth three times a day CLARITHROMYCIN 500 MG--Take one by mouth twice a day CLINDAMYCIN HCL 300MG--Take one by mouth three times a day CLOTRIMAZOLE 10 MG--One dissolved in your mouth four times a day as needed DAPSONE 100MG--Take one by mouth every day DRONABINOL 2.5MG--Take one by mouth twice a day EPOGEN [**Numeric Identifier **] U/ML--40,000 units sq weekly (PRN in the past) FOSCARNET SODIUM 24MG/ML--4186 mgs iv q 12 hrs IMODIUM A-D 2MG--Take one by mouth four times a day as needed for diarrhea KALETRA 33.3-133.3--Take three by mouth twice a day KETOCONAZOLE 2%--Apply topically twice a day to affected areas LAMIVUDINE 150MG--Take one by mouth twice a day LEUCOVORIN 5 MG--Take two by mouth every day LORATADINE 10MG--Take one by mouth every day (?) NEUPOGEN 300MCG/ML--300 mcg sq every day as directed (in past) NEURONTIN 100MG--One by mouth three times a day NORMAL SALINE 0.9%--1000 cc infusion before each foscarnet dose; two week supply PYRIMETHAMINE 25 MG--Take three by mouth every day RITONAVIR 100MG--Take one by mouth twice a day TENOFOVIR 300 MG--Take one by mouth every day TRAZODONE HCL 50MG--Take one by mouth at bedtime as needed ZYRTEC 10MG--One by mouth every day Discharge Disposition: Home With Service Facility: Uphams Corner Home Care Discharge Diagnosis: Kleibsiella sepsis, enterococcus UTI, ARF Discharge Condition: stable Discharge Instructions: Please return if you experience fever, chills, chest pain, shortness of breath Followup Instructions: Follow up with Nephrology, [**First Name11 (Name Pattern1) 5045**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 6117**], in [**1-29**] weeks for possible biopsy. Provider [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 3670**]: [**Hospital6 29**] DERMATOLOGY Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2194-1-1**] 12:30 Provider [**Name9 (PRE) **] [**Name8 (MD) **], [**Name Initial (PRE) **].D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2194-1-6**] 9:30 Provider [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 3670**]: [**Hospital6 29**] DERMATOLOGY Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2194-1-8**] 1:45 Completed by:[**0-0-0**]

[ "584.9", "599.0", "995.92", "583.81", "078.5", "996.62", "276.5", "042", "070.30", "285.29", "403.91", "363.20", "038.49" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

10990, 11044

5454, 9455

360, 367

11130, 11139

3530, 5431

11266, 12103

3005, 3069

11065, 11109

9481, 10967

11163, 11243

3084, 3511

265, 322

395, 2227

2249, 2815

2831, 2989

20,925

108,197

6860

Discharge summary

report

Admission Date: [**2142-10-27**] Discharge Date: [**2142-10-31**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: SDH Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [**Age over 90 **] year old man with history of parkinsonism followed by Dr. [**First Name (STitle) 951**] of neurology who presents to ED today with head trauma s/p fall. History is given by daughters. This morning, his 89 year old wife was helping him put his pants on in the morning, when he tried to stand and fell straight forward. He his head directly on the floor, resulting in a large bruise over his left forehead. His wife is sure that there was no LOC prior to or after the fall. The patient was conversant throughout. The family waited at home for an hour prior to coming to ED after contacting PCP. [**Name10 (NameIs) 3754**] has been no evidence of seizures or urinary incontinence since. His daughters tell me that at baseline he has a poor working memory and can only remember events for several minutes. He regularly forgets what his last meal was. He has no major motor deficits. He has fallen twice in the past year. In the [**Hospital1 18**] ED, he presented in a hard collar. A CT C- spine showed marked degenerative change with anterolisthesis of C2-3 and of C5-6. Then, a head CT showed an acute 6mm subdural hematoma over the left frontal convexity with ~1mm midline shift. There is no evidence of acute ischemia around the subdural collection. The L MCA is hyperdense, raising the suggestion of an evolving infarct vs. layering of blood. Past Medical History: parkinsonism high chol s/p CABG, CAD bladder cancer eosinophila-stronglyides Social History: Patient lives with wife in [**Name (NI) 2436**], and daughters describe him to be dependent on someone during the day to perform his ADL's There is no nurse during the weekdays. Family History: Non-contributory Physical Exam: T-99.1 BP-200/90 HR-87 RR-17 Gen: lying in bed in no apparent distress Heent: NCAT, oropharynx clear Neck: supple, no carotid bruits Chest: clear to auscultation b/l CV:regular rate, normal s1s2, no m/r/g Neuro Exam: MS: Patients eyes are open, he is alert to voice. He tells me his correct name, but thinks it is [**2082-5-10**] and we are in [**Country 6171**]. He is able to name [**Doctor Last Name **] forward in 1 minute, but cannot recall the months before decemeber. He can name my watch, wristband, but not clasp. He follows midline commands. He has impressive frontal release signs- a marked b/l grasp, glabellar, snout and L palmonetal reflex. CN: The EOM are intact with no diplopia. Visual file testing was difficult, but all fields are intact with no enxtinction. Pupils are 2->1.5 mm and reactive. Facial muscles symmetric with emotional and command smiles. Tongue midline. Motor: There is cogwheeling with distraction L>R. No resting tremor component. he is mildly bradykinetic. Strength testing was [**6-14**] and robust from our resistance while he was lying down in bed. Reflexes: There are 3+ reflexes throuout. Plantar reflexes extensor left Sensory: He will withdraw to painful stimulus only. He was not able to complete proprioception testing secondary to cooperation. Coordination: not tested. Gait: not tested Pertinent Results: [**2142-10-27**] 12:40PM BLOOD WBC-10.2 RBC-3.93* Hgb-13.4* Hct-39.3* MCV-100* MCH-34.2* MCHC-34.2 RDW-13.2 Plt Ct-186 [**2142-10-27**] 12:40PM BLOOD Neuts-49.6* Bands-0 Lymphs-9.0* Monos-4.5 Eos-36.5* Baso-0.3 [**2142-10-27**] 12:40PM BLOOD PT-13.5* PTT-28.2 INR(PT)-1.2 [**2142-10-27**] 12:40PM BLOOD Glucose-97 UreaN-33* Creat-1.4* Na-128* K-4.7 Cl-96 HCO3-25 AnGap-12 [**2142-10-28**] 02:53AM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.9 Mg-1.8 [**2142-10-29**] 07:20AM BLOOD VitB12-775 Folate-17.3 [**2142-10-28**] 02:53AM BLOOD Phenyto-3.1* [**2142-10-27**] 03:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010 [**2142-10-27**] 03:30PM URINE Blood-SM Nitrite-POS Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2142-10-27**] 03:30PM URINE RBC-10* WBC-33* Bacteri-MANY Yeast-NONE Epi-<1 --- Urine Cx with >100,000 ORGANISMS/ML pan-sensitive E Coli. ---- Head CT: IMPRESSION: 1. Subdural hematoma with additional component of subarachnoid hemorrhage layering adjacent to the left frontal, temporal, and parietal lobes. 2. Small amount of intraventricular hemorrhage. 3. Hyperdensity along tthe left middle cerebral artery most likely blood layering within the region of the left middle cerebral artery. However, if the patient has right sided neurologic symptoms, MRI with diffusion would help in excluding acute infarct. 4. Mild subfalcine shift. Prominence of the ventricles is consistent with involutional change. 5. Chronic small vessel ischemic change and left pontine old infarct. ---- Ct Head 8 hrs later: Stable appearance of left-sided subdural hematoma, subarachnoid hemorrhage and intraventricular hemorrhage. Stable minimal rightward midline shift. ---- C-spine Xray:FINDINGS: Flexion and extension views of the cervical spine demonstrate minimal anterolisthesis of C2 on 3 and minimal anterolisthesis of C4 on 5. There is also minimal retrolisthesis of C5 on 6 and minimal anterolisthesis of C7 on T1. All of these findings appear similar on the flexion and extension views. These degenerative changes are noted. ---- CT C-spine: 1. No fracture of the cervical spine. 2. Marked multilevel degenerative change of the cervical spine with grade I anterolisthesis of C2 on C3 and of C5 on C6. While these findings likely relate to degenerative change, if there is clinical symptomatology referable to these levels, MR of the cervical spine would be more useful for assessing for possible ligamentous injuries. 3. Sclerotic T4 vertebral body lesion may represent a bone island. ---- Head MRI: IMPRESSION: No evidence of acute infarction. Subdural and subarachnoid hemorrhage appears similar compared to the CT scan of [**2142-10-27**]. ---- MRI C-spine: IMPRESSION: 1. No fracture is seen. There is no evidence of edema in the region of the interspinous ligaments, or the anterior or posterior longitudinal ligament. 2. There is some edema at the far posterior tips of the C6 and C7 spinous processes, suggesting injury to the nuchal ligament. 3. There is multilevel spondylosis. As noted on the plain film and CT, there is minimal anterolisthesis of C2 on C3 and of C5 on C6. Osteophytes narrow multiple foramina. ---- CXR: A 19 mm wide nodule at the base of the left lung has grown since [**2142-6-11**] probably not contributing to current clinical decompensation. Moderate atelectasis at the right lung base medially is longstanding, though more severe on today's study. [**Month (only) 116**] be mild bronchiectasis in the right upper lung, but no pneumonia or pulmonary edema. Vascular deficiency suggests COPD. Heart size is normal. Brief Hospital Course: Pt is a [**Age over 90 **] yo male with h/o PD, HTN, CAD who presented with a stable 6 mm left frontal SDH with SAH and small ICH after a mechanical fall. He was admitted to the neuro stepdown unit for close monitoring. We obtained further history to confirm that Mr [**Known lastname **] did not lose consciousness or have another neurological event such as a seizure that may have prompted his fall. It appeared that it was solely a mechanical issue though. 1. C-spine clearance:He had flex/ex films of his C-spine that showed some mild spondylolisthesis, so a CT was recommended. This was obatined and essentially negative for fracture. An MRI was recommended to rulew out ligamentous injury, so this was also obtained. He had only mild ligamentous changes and no neck pain on exam, so his C-spine was cleared. 2. Neuro/SDH: The patient had a stable subdural hematoma after his fall. He had slight mass effect that was not causing symptoms during his admission. He hd a follow-up CT scan that showed no change in the bleed. He then had a follow-up MRI scan scan which showed stability of the bleeding. It also showed no evidence of stroke or other abnormality. Clinically, the patient displayed his baseline memory problems, but was otherwise pleasant and conversant throughout his stay on the floor. He had no complaints and no obvious neurological changes from his baseline. He did have a headache while he was here. Given the bleeding, we wanted to keep his BP well controlled and it stayed in a good range throughout. 3. Pulm:The patient had several episodes of wheezing while he was here. His respiratory rate and oxygen saturations remained normal throughout. A CXR was obtained and showed no obvious reason for these changes, but did show COPD. This may have been causing his wheezing. On speaking with his cregiver, he apparently has similar episodes at home. He was therefore sent home with a nebulizer machine and albuterol q6h prn. Albuterol wasn't used due to his heart condition. 4.CV:Pt was continued on his home antihypertensives and had no issues. He was also continued on his statin. 5.Parkinsonism:Pt was at his baseline neurologically from a Parkinsonism point of view. He was continued on Simemet and Celexa. He was seen by his outpatient neurologist. Also, the PT department taught his caregiver how to care for him better from a Parkinson's point of view. A hospital bed was sent to his house as well. His family wanted to take him home, so they arranged for more constant care for him and had their questions about home care answered by various staff members here. This was an acceptable arangement. They will watch closely to prevent further falls. He will follow up with Dr [**Last Name (STitle) 25922**]. He will see his PCP [**Last Name (NamePattern4) **] [**2-11**] weeks. They can follow-up on his neurologic status, and discuss the need to get repeat CXRs to evaluate the nodule at the base of his left lung. Medications on Admission: Sinemet 25/100 TID Lipitor 40 daily Atenolol 25 daily Lisinopril 20 daily Celexa 10 daily Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atrovent 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*100 nebs* Refills:*2* 7. Nebulizer Please provide 1 nebulizer machine with instructions to patient. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Left subdural hematoma with subarachnoid hematoma --- Parkinsonism CAD s/p CABG Hypercholesterolemia h/o bladder cancer Discharge Condition: Stable neurologically. Out of bed with assistance. Discharge Instructions: Please call your PCP or return to the ED if you have any chest pain, shortness of breath, abdominal pain, seizure, dizziness, or lightheadedness. Also call if you become overly sleepy or if your family has difficulty waking you up from sleep or if you become confused. No changes were made in your medications, except we added an as needed breathing treatment to use for wheezing. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2142-11-16**] 2:30 -- Please see your PCP [**Last Name (NamePattern4) **] [**2-11**] weeks for follow-up. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

[ "852.01", "E885.9", "V45.81", "414.01", "272.0", "V10.51", "041.4", "332.0", "852.21", "599.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10734, 10792

7026, 9999

269, 276

10956, 11010

3407, 4308

11440, 11801

2002, 2020

10140, 10711

10813, 10935

10025, 10117

11034, 11417

2035, 3388

226, 231

304, 1688

4317, 7003

1710, 1789

1805, 1986

58,242

115,825

472

Discharge summary

report

Admission Date: [**2201-8-19**] Discharge Date: [**2201-8-25**] Date of Birth: [**2143-10-4**] Sex: M Service: MEDICINE Allergies: Codeine / Streptokinase / Iodine / Bee Pollens Attending:[**First Name3 (LF) 3991**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 57M with AF on coumadin, h/o dvt, CHF, CAD h/o MI, COPD on 4L home O2, 4 prior intubations for PNA, who presented with 4d of worsening SOB. He was admitted at [**Hospital3 3583**] approximately 5 wks ago for PNA and intubated for approximately 6 days. At baseline, he takes 160mg Lasix TID. He began to feel short of breath 4 days prior to admission at [**Hospital1 18**], with orthopnea, mild cough with one episode of coughing up brown non-bloody sputum, and fever to 100 on the morning of admission, with no prior known fevers. He reports weight loss of 20lb over the past few weeks and more than 80lbs over the past year secondary to poor appetite. He denied any recent sick contact/travel, missed medication doses, or dietary alterations. In the ED, initial vs were T 97.6 HR 120 BP 186/103 RR 20 sat 96% 5L. Prior to transfer to ICU vs were HR 108 afib, BP 131/101, RR 15, 95% on 5L. The patient was given vanco/ceft/azithro (without cultures), nebs, and K repletion. CXR showed cardiomegaly, bilateral pleural effusions R>L, and RML/RLL opacity concerning for PNA. Given the patient's history, he was admitted to the MICU for possible airway control and possible MRSA PNA. Past Medical History: Type II Diabetes on oral agents Systemic Lupus Erythematosus Coronary Artery Disease s/p MI in [**2186**] Hepatitis C COPD with emphysema and asthmatic component (FEV1 60% predicted [**1-6**]) Diastolic Congestive Heart Failure EF 55% in [**3-/2198**] Seizure disorder TIA [**2187**] Colon Cancer s/p resection in [**2194**] without chemotherapy s/p abdominal trauma with subsequent splenectomy and amputation of digits of his left hand Hyperlipidemia Hypertension h/o cocaine abuse Neuropathy and chronic pain on methadone Chronic Atrial Fibrillation on coumadin Obstructive Sleep Apnea on home CPAP Left Total Knee Replacement [**2201**] Social History: Pt lives with his wife, daughter, son and granddaughter. [**Name (NI) **] is on disability. He used to be a diesel mechanic. He served in [**Country 3992**] and was badly injured in an explosion. The patient quit smoking in [**2181**], 4ppd x 20yrs. "Cheats" with cigars on occasion. Last cigar was smoked in [**9-7**]. No alcohol abuse. History of cocaine abuse, but has been clean since [**2181**]. Denies current recreational drug use. Family History: Adopted Physical Exam: Vitals: T: 96.8 BP: 158/96 P: 78 R: 18 O2: 96% 4L NC FS 178 General: alert, oriented, obese male with head of bed elevated to 20 degrees, in no distress HEENT: sclera anicteric, MMM, oropharynx clear Neck: thick, no LAD, no appreciable JVD Lungs: mildly diminished at the bases, no wheezes, crackles, or rhonchi CV: irregularly irregular rate, normal S1 + S2, no m/r/g Abdomen: obese, soft, non-tender, non-distended, midline vertical surgical scar, bowel sounds present, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis, no lower extremity edema, pneumoboots in place Pertinent Results: [**2201-8-19**] 07:45PM BLOOD WBC-13.3* RBC-3.68* Hgb-10.4* Hct-31.5* MCV-86 MCH-28.3 MCHC-33.0 RDW-16.9* Plt Ct-396 [**2201-8-19**] 07:45PM BLOOD Neuts-82.0* Lymphs-12.9* Monos-3.5 Eos-1.0 Baso-0.7 [**2201-8-23**] 10:35AM BLOOD WBC-11.4* RBC-3.18* Hgb-9.1* Hct-27.6* MCV-87 MCH-28.7 MCHC-33.1 RDW-17.6* Plt Ct-412 [**2201-8-19**] 07:45PM BLOOD PT-44.3* PTT-31.3 INR(PT)-4.7* [**2201-8-23**] 10:35AM BLOOD PT-18.2* INR(PT)-1.6* [**2201-8-19**] 07:45PM BLOOD Glucose-198* UreaN-11 Creat-1.0 Na-141 K-3.4 Cl-96 HCO3-35* AnGap-13 [**2201-8-20**] 04:25AM BLOOD Albumin-3.6 Calcium-8.6 Phos-3.7 Mg-2.1 [**2201-8-20**] 04:25AM BLOOD ALT-7 AST-11 LD(LDH)-169 CK(CPK)-38* AlkPhos-112 TotBili-0.4 [**2201-8-19**] 07:45PM BLOOD proBNP-6217* [**2201-8-19**] 07:45PM BLOOD cTropnT-<0.01 [**2201-8-20**] 04:25AM BLOOD CK-MB-1 cTropnT-<0.01 . [**2201-8-19**] 09:45PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 [**2201-8-19**] 09:45PM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2201-8-19**] 09:45PM URINE RBC-0 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0 . Blood cx x2 negative . ECG [**8-19**] Atrial fibrillation 94bpm. Modest low amplitude lateral lead T wave changes are non-specific. Since the previous tracing of [**2201-6-8**] no significant change. . CXR [**8-19**]: IMPRESSION: Right mid to lower lung opacity concerning for pneumonia. Cardiomegaly with bilateral effusions and pulmonary vascular congestion also present. . Echo [**8-20**]: 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. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with borderline normal free wall function. 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. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2200-2-18**], significant systolic and diastolic dysfunction of the left ventricle are now both present. . CXR [**8-20**]: Cardiomediastinal contours are unchanged. The component of the pulmonary edema has resolved. Persistent right mid and right lower lobe opacities concerning for pneumonia are unchanged. The lateral CP angles were not included on the film. Evaluation of pleural effusion included. There is no evident pneumothorax. . Repeat TTE [**2201-8-24**]: The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. The estimated right atrial pressure is 10-15mmHg. The left ventricular cavity is moderately dilated. There is moderate global left ventricular hypokinesis with relative preservation of apical setments. (LVEF = 30%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. 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. Mild to moderate ([**1-31**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2201-8-20**], the severity of mitral regurgitation and the estimated pulmonary artery systolic pressure are slightly reduced. Biventricular cavity sizes and systolic function are similar. Brief Hospital Course: Mr. [**Known lastname 3989**] is a 57 yo man with a PMH of AF on coumadin, h/o DVT, CHF, CAD h/o MI, COPD on home O2 of 4L, h/o of intubation 4 x during previous admissions for pneumonia, on methadone who presented with a 4d history of worsening SOB, principally secondary to CHF. . #. SOB: At baseline, the patient has COPD with 4L of 02 at home. The patient required approximately the same amount of 02 during the ICU and floor course. The shortness of breath was likely multifactorial, with CHF as the major contributor. His SOB and CXR improved with diuresis. He was put on vanc/levo on admission, which was discontinued on [**8-24**] after a 5d course. The consulting pulmonary team did not feel that he had pneumonia. He received nebs and bi-pap in house. . #. Diastolic and systolic CHF: The patient was taking furosemide 160 mg TID at home. The patient has had difficulty with fluid overload in the past. Pro-BNP was 6217. On admission, he had a CXR suggestive of pulmonary edema so was diuresed on a Lasix drip overnight in the MICU, with follow-up CXR showing resolution of the edema and lung exam free of rales. On the floor, he was diuresed with a goal of negative fluid balance 1-2L/d and was euvolemic by discharge, with no crackles or edema. Initially, furosemide 80IV tid was used (equivalent to his home dose), switched to torsemide 100mg daily per cardiology recommendations on [**8-23**]. He was also discharged on spironolactone 12.5 mg, which was started in house. . Past echos had shown diastolic failure with preserved EF, but echo on this admission showed new systolic failure with EF of 30%. Cardiology felt this might be secondary to poorly controlled hypertension and fluid overload rather than interval ischemic event so recommended up-titrating his carvedilol dose, as per below. . #. Afib/History of PE & DVT/anticoagulation: The patient suffers from paroxysmal atrial fibrillation and also has a history of PE and DVTs. He was admitted with supratherapeutic INR of 4.7, so warfarin was initially held, then restarted at half dose on [**8-21**] and full dose on [**8-22**]. . #. Hypertension: Cardiology recommendation is a DBP goal of <80. Carvedilol was titrated to 50 mg TID from 12.5 mg TID. He was at goal at time of discharge. . # Chronic pain: patient was discharged on methadone 10 mg QID, per discussions with patient's PCP about decreasing dose from 20 mg. He takes methadone for chronic knee pain. Medications on Admission: - ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler 1-2 puffs Q4-6H prn cough/wheezing - CAPTOPRIL 12.5 mg PO TID - CARBAMAZEPINE 400 mg PO TID - CARVEDILOL 50 mg Tablet PO BID - FLUTICASONE-SALMETEROL 250 mcg-50 mcg 1 puff po BID - FUROSEMIDE 160mg po TID - HYDROXYCHLOROQUINE 200 mg Tablet PO BID - IPRATROPIUM-ALBUTEROL 0.5 mg-2.5 mg/3 mL Solution NEB inhaled Q6H - ISOSORBIDE DINITRATE 40 mg PO TID - METHADONE 20mg PO Q6H prn pain - NITROGLYCERIN 0.4 mg/Dose Spray prn chest pain - OMEPRAZOLE 20 mg Capsule, Delayed Release(E.C.) PO daily - OXAZEPAM 30 mg Capsule PO QHS - OXYGEN 4L - POTASSIUM CHLORIDE 20 mEq Tab Sust.Rel. Particle/Crystal PO TID - PREGABALIN [LYRICA] 100 mg Capsule PO TID - SIMVASTATIN 80 mg Tablet PO at bedtime - SUCRALFATE 1 gram PO twice a day as needed for heartburn - TIZANIDINE 4 mg Capsule PO QHS - WARFARIN 17.5 mg Tablet once a day. - ASPIRIN - 325 mg PO once a day - ISS - CYANOCOBALAMIN 1,000 mcg Tablet SR PO daily - MULTIVITAMIN by mouth daily (no vit k in mvi) (pharmacy - [**Numeric Identifier 3997**]) Discharge Medications: 1. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Take a half pill. Take in the morning. Disp:*15 Tablet(s)* Refills:*2* 2. Captopril 50 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 3. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*112 Tablet(s)* Refills:*0* 4. Torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. 6. Isosorbide Dinitrate 40 mg Tablet Sig: One (1) Tablet PO three times a day. 7. Warfarin 17.5 mg once a day 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 10. Ipratropium Bromide 0.02 % Solution Sig: [**1-31**] puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 11. Carbamazepine 400 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO three times a day. 12. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. Oxazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 16. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 17. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 18. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for heartburn. 19. Tizanidine 4 mg Capsule Sig: One (1) Capsule PO at bedtime. 20. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 22. Insulin Please follow your home regimen. Discharge Disposition: Home Discharge Diagnosis: congestive heart failure hypertension diabetes mellitus COPD Discharge Condition: Mental status: Alert, orientedx3 Ambulatory status: Ambulatory On home oxygen Discharge Instructions: You were admitted with shortness of breath, likely due to impaired functioning of your heart with fluid in your lungs. You were given diuretics to remove the excess fluid, with recommendations from the cardiology team about the best medication choices. You also received antibiotics, which were then discontinued because the pulmonologists did not think you had pneumonia. Social work saw you to discuss your questions about [**Hospital3 **]. Discharge instructions: 1. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. 2. Avoid salty foods. The following medication changes were made: (1) Lasix was stopped (2) Spironolactone 12.5 mg once a day was added. This is a diuretic. (3) Torsemide 100 mg once a day was added. This is also a diuretic. (4) Captopril was increased to 50 mg three times a day. This is for your blood pressure. (5) Methadone dose was decreased to 10 mg four times a day. No other changes were made to your medications. You were also give a prescription for [**Hospital 3998**] rehab, which is to help your lungs. You have been given the phone number for a pulmonary rehab in [**Location (un) 3320**] by [**Hospital3 3583**], which you had requested. This phone number is [**Telephone/Fax (1) 3999**]50. Please call to schedule an appointment. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [**2201-8-31**] at 2:30 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: TUESDAY [**2201-9-15**] at 12:00 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 [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**] DO 12-BJM

[ "780.52", "428.43", "276.8", "412", "428.0", "355.9", "070.54", "250.00", "338.29", "V12.54", "V58.61", "402.91", "486", "V46.2", "272.4", "V12.51", "345.90", "414.01", "327.23", "V10.05", "496", "427.31", "V45.89", "710.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13194, 13200

7582, 10035

327, 333

13305, 13305

3354, 7559

14750, 15576

2679, 2688

11125, 13171

13221, 13284

10061, 11102

13878, 14727

2703, 3335

268, 289

361, 1542

13320, 13385

1564, 2206

2222, 2663

59,707

188,432

26370

Discharge summary

report

Admission Date: [**2162-9-16**] Discharge Date: [**2162-10-1**] Date of Birth: [**2106-11-13**] Sex: M Service: MEDICINE Allergies: Percocet / Erythromycin Base / Sucralose Attending:[**First Name3 (LF) 2782**] Chief Complaint: AMS Major Surgical or Invasive Procedure: intubation History of Present Illness: 55 YOM with DM c/b neuropathy, HTN, pancreatitis, HCV, anemia, who was found bed minimally responsive, covered in feces by his brother. [**Name (NI) **] seen Tuesday. His BS was measured 407. He was able to stand and pivot to the stretcher. He has history of OD on narcotics earlier this year. He was given 2 mg narcan without effect. Per brother, he was also incontinent of stool at baseline. Brother does not think patient has overdosed. . Initial vital signs: 103.8 119 182/110 20 98% 2L. In ED, patient is awake, protecting airway responding to questions by nodding, uncooperative with neuro exam, but clearly moving all extremeties intentionally with good strength. Patient intermittently becomes more responsive and seems to clear mentally for seconds at a time. Pupils 1.5mm min responsive bilaterally. His labs were notable for WBC of 18.6, Fibrinogen: 537, LDH: 385, Cr of 3.6, UA is notable for blood and protein, negative tox screen, LP was performed and CSF was notable for predominent WBC >300 with polys, but elevated Glucose and low protein was not completely fitting with bacterial meningitis. He underwent a CT head that showed no acute intracranial process. CXR was largely benign. UTox and serum tox were negative. He was given insulin, Vancomycin, CeftriaXONE, Labetalol, Ondansetron, acetaminophen x2, Acyclovir. He was seen by neurology who performed a bedside EEG which showed a pattern consistent with encephalopathy, no clear epileptiform activity or seizures seen. Brief episodes of R arm tremor showed no evidence of seizure activity ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]). Patient has been presistently tachycardic in 120s to 130s, and at present has a mental status which is unlikely to be acceptable to floor nursing and therefore requested to be admitted to MICU. VS: 101, 124, 146/98, 98% 2L. 18G and 20 G. . On floor, remains confused and hypertensive. Past Medical History: Diabete mellitus peripheral neuropathy hypertension pancreatitis HCV (untreated) - [**6-23**] yrs Anemia Depression ADHD Social History: - Tobacco: smoked years ago, quite 10 yrs ago - Alcohol: light drink - Illicits: no drug use Family History: DM. Physical Exam: Admission Physical Exam: Vitals: T: 101.9 BP: 157/73 P:105 R: 18 O2: 97% RA General: in moderate distress, shaking HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachy, Regular 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: 97.8 151/91 62 20 94% RA General: NAD, roused easily to voice HEENT: sclera anicteric, EOMI, PERRL, MMM, OP clear Neck: supple, JVP not elevated, no LAD CV: RRR, normal S1 and S2, no MRG Resp: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abd: soft, non-distended, mildly tender to palpation epigastric region. No rebound or guarding. Incontinent to stool. GU: Foley in place, draining clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing cyanosis or edema Psych: calm and appropriate, some periods of anxiety, some frustration with medical care that can be resolved with explanation Neuro: CN II-XII intact to testing, moves all 4 limbs evenly and spontaneously, strength 5/5 throughout, finger-to-nose reveals difficulty with precise movement. Able to grip objects, some intention tremor. Bedbound. Pertinent Results: Admission Labs: [**2162-9-16**] 12:00PM WBC-18.6* RBC-4.73 HGB-13.6* HCT-38.0* MCV-80* MCH-28.8 MCHC-35.9* RDW-13.2 [**2162-9-16**] 12:00PM PT-12.6 PTT-26.6 INR(PT)-1.1 [**2162-9-16**] 12:00PM FIBRINOGE-537* [**2162-9-16**] 12:00PM ALBUMIN-3.7 [**2162-9-16**] 12:00PM LIPASE-27 [**2162-9-16**] 12:00PM ALT(SGPT)-19 AST(SGOT)-28 LD(LDH)-385* ALK PHOS-74 TOT BILI-0.5 [**2162-9-16**] 12:07PM GLUCOSE-304* LACTATE-2.0 NA+-135 K+-4.6 CL--106 TCO2-17* [**2162-9-16**] 12:00PM UREA N-61* CREAT-3.6* [**2162-9-16**] 12:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2162-9-16**] 12:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN->600 GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2162-9-16**] 12:40PM URINE RBC-2 WBC-2 BACTERIA-FEW YEAST-NONE EPI-1 . [**Hospital3 **]: [**2162-9-16**] 04:34PM CEREBROSPINAL FLUID (CSF) WBC-370 RBC-363* Polys-85 Lymphs-13 Monos-0 Macroph-2 [**2162-9-16**] 04:34PM CEREBROSPINAL FLUID (CSF) WBC-338 RBC-15* Polys-78 Lymphs-11 Monos-9 Atyps-1 Plasma-1 [**2162-9-19**] 06:45PM CEREBROSPINAL FLUID (CSF) WBC-23 RBC-400* Polys-0 Lymphs-88 Monos-1 Atyps-6 Plasma-5 [**2162-9-19**] 06:45PM CEREBROSPINAL FLUID (CSF) WBC-31 RBC-31* Polys-0 Lymphs-93 Monos-1 Atyps-5 Plasma-1 [**2162-9-16**] 04:34PM CEREBROSPINAL FLUID (CSF) TotProt-65* Glucose-147 [**2162-9-19**] 06:45PM CEREBROSPINAL FLUID (CSF) TotProt-78* Glucose-143 [**2162-9-16**] 04:34PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-negative [**2162-9-19**] 06:45PM CEREBROSPINAL FLUID (CSF) EASTERN EQUINE ENCEPHALITIS SEROLOGY-negative [**2162-9-19**] 06:45PM CEREBROSPINAL FLUID (CSF) WEST NILE VIRUS SEROLOGY-Positive [**2162-9-19**] 06:45PM CEREBROSPINAL FLUID (CSF) BORRELIA BURGDORFERI ANTIBODY INDEX FOR CNS INFECTION-negative [**2162-9-19**] 06:45PM CEREBROSPINAL FLUID (CSF) EBV-PCR-negative [**2162-9-19**] 06:45PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-negative [**2162-9-17**] 09:47AM BLOOD CRP-26.7* [**2162-9-18**] 05:40AM BLOOD HIV Ab-NEGATIVE [**2162-9-16**] 12:07PM BLOOD Glucose-304* Lactate-2.0 Na-135 K-4.6 Cl-106 calHCO3-17* . Discharge Labs: [**2162-9-29**] 06:05AM BLOOD WBC-10.6 RBC-3.56* Hgb-10.5* Hct-29.3* MCV-82 MCH-29.4 MCHC-35.8* RDW-14.2 Plt Ct-304 [**2162-9-29**] 06:05AM BLOOD Glucose-123* UreaN-35* Creat-1.8* Na-145 K-3.6 Cl-112* HCO3-22 AnGap-15 [**2162-9-29**] 06:05AM BLOOD ALT-44* AST-31 AlkPhos-97 TotBili-0.3 [**2162-9-29**] 06:05AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.9 . Microbiology: [**2162-9-22**] SPUTUM GRAM STAIN-negative; RESPIRATORY CULTURE-negative [**2162-9-20**] SEROLOGY/BLOOD LYME SEROLOGY-negative [**2162-9-19**] CSF;SPINAL FLUID GRAM STAIN-negative; FLUID CULTURE-negative; VIRAL CULTURE-PRELIMINARY negative [**2162-9-18**] Blood (Toxo) TOXOPLASMA IgG ANTIBODY-negative; TOXOPLASMA IgM ANTIBODY-negative [**2162-9-17**] STOOL FECAL CULTURE-negative; CAMPYLOBACTER CULTURE-negative; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-negative [**2162-9-17**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-negative [**2162-9-17**] SEROLOGY/BLOOD LYME SEROLOGY-negative [**2162-9-17**] SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-negative [**2162-9-16**] URINE URINE CULTURE-negative [**2162-9-16**] BLOOD CULTURE negative [**2162-9-16**] CSF;SPINAL FLUID GRAM STAIN-negative; FLUID CULTURE-negative; FUNGAL CULTURE-negative; CRYPTOCOCCAL ANTIGEN-negative; VIRAL CULTURE-negative [**2162-9-16**] BLOOD CULTURE negative . Imaging: CXR ([**9-16**]): FINDINGS: Single AP semi-erect portable view of the chest was obtained. The patient is rotated slightly to the left. There are relatively low lung volumes that accentuate the bronchovascular markings. Mild bibasilar opacities may relate to low lung volume, although underlying aspiration or infection cannot be entirely excluded. Slight prominence and indistinctness of the hilum could relate to low lung volumes versus mild central vascular engorgement. The cardiac and mediastinal silhouettes are unremarkable. No pleural effusion or pneumothorax is seen. . CT Head ([**9-16**]): FINDINGS: There is no evidence of acute hemorrhage, edema, or large territorial infarction or shift of normally midline structures. The ventricles and sulci appear prominent, consistent with age-related cortical atrophy. There is mild periventricular white matter hypodensities, likely representing the sequela of chronic small vessel ischemic disease. No fractures are identified. The visualized mastoid air cells and paranasal sinuses are clear. IMPRESSION: Generalized cortical atrophy, but no evidence of acute intracranial process. . EEG ([**9-16**]): IMPRESSION: This is an abnormal waking EEG because of a slow and disorganized background with bursts of generalized slowing reaching a maximum of 5.5 Hz. There were brief periods of right arm tremor which had no EEG correlate. No clear epileptiform discharges or electrographic seizures were seen. These findings are indicative of encephalopathy which is etiologically nonspecific. . MR head ([**9-18**]): FINDINGS: There is no evidence for acute ischemia. There is mild prominence of the ventricles, which could reflect volume loss. There are nonspecific periventricular white matter lesions which could reflect small vessel ischemic disease in the setting of underlying vascular risk factors like hypertension or diabetes. No temporal lobe abnormality is seen. Flow voids are maintained. IMPRESSION: On this unenhanced scan, no abnormality of the temporal lobe is seen. There are scattered presumed small vessel ischemic sequelae in the white matter. No acute ischemia. . EEG ([**9-23**]): IMPRESSION: Markedly abnormal EEG due to the low voltage slow background with occasional bursts of generalized slowing. These findings indicate a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. There were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. There were no epileptiform features or electrographic seizures. . Renal ultrasound ([**9-27**]): FINDINGS: The kidneys are normal in appearance and symmetric in size measuring 14.5 on the right and 14.6 on the left. There are no hydronephrosis, stones, or cysts seen bilaterally. Normal and symmetric color flow was seen. Waveforms and resistive indices are normal bilaterally with brisk systolic upstroke and appropriate diastolic flow. Due to difficulty in angle correction secondary to patient participation and body habitus, assessment of velocities is unable to be performed. IMPRESSION: Slightly limited study due to inability to perform angle correction; however, given the presence of normal and symmetric renal size, color flow, pulsed waveforms, and resistive indices, it is unlikely that the patient has renal artery stenosis. . KUB ([**9-29**]): FINDINGS: Two supine and decubitus AP films of the abdomen show a normal pattern of bowel gas with no air-fluid levels or evidence of free air. There is gas in the rectum. The visualized osseous structures are unremarkable. IMPRESSION: No evidence of ileus or obstruction. . CXR ([**9-29**]): SUPINE AP VIEW OF THE CHEST: Compared to the prior exam, bibasilar atelectasis has improved though lung volumes remain low. There is slight improvement in mild pulmonary edema compared to the prior radiograph. Cardiomediastinal silhouette is stable. There is no large effusion or pneumothorax. Brief Hospital Course: 55 YOM with DM c/b neuropathy, HTN, pancreatitis, HCV, anemia, who was found bed minimally responsive, covered in feces by his brother; last seen normal 2 days prior. . # West [**Doctor First Name **] Encephalitis: His inital CSF was borderline for bacterial vs. viral meningitis. Neurology saw the patient in ED and bedside EEG was negative for seizure activity. He received vanc/ceftriaxone/acyclovir prior to MICU admission. He then received ampcillin and steroids in the MICU. ID was consulted. HIV was negative. He soon became agitated and was intubated for agitation and combativeness. MRI head was negative for temporal lobe enhancement. He was continued on vanc/ceftriaxone/amp/acyclovir/steroid. Repeat LP was done in the ICU for viral studies (EBV, CMV, VZV, HSV, WNV, EEE, crypto) RPR, lyme, and toxo. He was extubated on [**9-21**] at noon. Neurology was consulted for seizure-like activity. 24 hour EEG was performed and showed no seizures however he was continued on Keppra until encephalopathy improved, tapered and then d/c on [**10-1**]. Repeat LP was positive for west nile virus on [**9-24**]. Other CNS studies including arbovirus screen, toxoplasma, cryptococcus negative. All remaining antibiotics were stopped at that point. He was transferred to the general medical floor for further management. On the floor he improved and was able to speak, swallow softened foods, regain some meaningful control of his limbs, and regain cognitive function. Physical therapy worked with the patient and recommended rehabilitation care. Still with mild dysarthria with speech and movements of extremities. . # Diabetes mellitus: Initially on insulin drip, transitioned to home regimen including NPH and ISS. . # Hypertension: Found to be in poor control with SBP 150-200. Patient started on amlodipine, clonidine, labetalol, hydralazine, and lisinopril and doses titrated up. The most recent dose increase was [**9-29**]. Given his difficult-to-control hypertension, a renal ultrasound was performed which revealed no artery stenosis. The goal is to continue to uptitrate labetalol as needed and remove hydralazine from his medication regimen. It is hoped that as he is more remote from this infection, his blood pressure control will improve. . # Vomiting: After extubation, patient experienced multiple episodes of vomiting and became mildly hypoxic, requiring 4L oxygen, thought due to aspiration. NG tube was placed on [**9-21**] at that time for decompression given stool in gut. Lactulose was started at that point and NG tube was kept in for feeds. NG tube removed [**9-27**] and the patient was started on liquids and soft solids. He continued to have occasional problems with emesis and nausea, managed with Zofran and Reglan. He was also started on ranitidine. A KUB was checked and showed no evidence of obstruction or ileus. LFTs were also normal and he did not have significant pain making cholecystitis unlikely. West Nile Virus can also commonly cause abdominal pain and nausea as part of its effects. . # Urinary retention - Patient had foley placed in ICU. It was removed on the floor, however was replaced as patient had a bladder scan with > 500cc of urine. Patient does have a history of urinary incontinence. . # Anemia: Hb previously in 15s, in 10s on admission. Possibly secondary to worsening renal function, but more likely due to acute illness. Iron studies consistent with iron deficiency anemia. Hct stable in hospital. . # Chronic Renal Insufficiency: Cr 3.6 on admission, rapidly recovered to baseline (Cr 2.0) with hydration and management of encephalitis. . # HCV (untreated) - [**6-23**] yrs: monitor for now . # Depression: continue Wellbutrin 300mg 24H QD . # Communication: Patient, [**Name (NI) **] (brother) [**Telephone/Fax (1) 65236**] (w) [**Telephone/Fax (1) 65237**] (c) # Code: Full (discussed with patient) . Transitional Issues: - Hypertension management: Titration of regimen as above - continue PT/OT/Speech therapy as needed - d/c foley, conside flomax if patient still having issues with retention Medications on Admission: Amlodipine 10mg QD ASA 325 mg QD Ativan 1mg PO QD prn anxiety Clonidine 0.2mg [**Hospital1 **] Furosemide 40mg QD NPH 18u am 12 pm Metoprolol tartrate 100mg [**Hospital1 **] MVI QD Novolog ISS Wellbutrin 300mg 24H QD Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 5. clonidine 0.3 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. therapeutic multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. ranitidine HCl 15 mg/mL Syrup Sig: One (1) 150 mg PO BID (2 times a day). 14. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 15. insulin lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous QACHS. 16. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for nausea. 18. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital 38**] [**Hospital **] Hospital at [**Hospital1 **] Discharge Diagnosis: Primary: West [**Doctor First Name **] viral meningoencephalitis Secondary: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr [**Known lastname 10378**], It was a pleasure taking care of you at [**Hospital1 827**]. You came to the hospital after being found unconscious by family. You were found to have West [**Doctor First Name **] encephalitis, an infection of the brain. This is a very serious infection that causes difficulty controlling your limbs, staying awake, and even breathing on your own. You were in our ICU for a week with several days on the ventilator to assist your breathing. Initially you were treated with antibiotics for several different possible causes of your infection. Once testing revealed West Nile virus, these antibiotics were stopped as they would not be effective in treating your viral infection. As you improved, you were moved to the general medicine floor to continue your treatment. You received physical therapy, occupational therapy, and speech and swallow therapy. You were started on regular food. However, despite your improvement, this infection has left you with weakness and deconditioning. We therefore recommended that you go to a rehab facility for further care. Your blood pressure was elevated while you were in the hospital. We started a new medication regimen to help control your blood pressure. We made the following changes to your medications: STARTED Lisinopril 40mg by mouth daily Labetalol 600mg by mouth three times daily Clonidine 0.3mg by mouth twice daily Amlodipine 10mg by mouth daily Hydralazine 25mg by mouth four times daily This regimen will be changed as your blood pressure control improves. Followup Instructions: Please follow-up with your primary care physician within one week of discharge from rehabilitation. If you would like to follow up at [**Hospital 18**] [**Hospital3 **], you can call [**Telephone/Fax (1) 250**] to schedule an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Doctor Last Name **], who took care of you while you were in the hospital.

[ "788.29", "311", "453.84", "V58.67", "066.41", "799.02", "276.0", "250.60", "518.81", "453.82", "E849.7", "066.42", "314.01", "E879.8", "303.90", "996.74", "349.82", "584.9", "321.2", "276.2", "585.3", "780.39", "285.21", "357.2", "403.10" ]

icd9cm

[ [ [] ] ]

[ "03.31", "96.6", "96.04", "96.72", "38.97" ]

icd9pcs

[ [ [] ] ]

17309, 17398

11417, 15313

306, 318

17534, 17534

4004, 4004

19253, 19648

2552, 2558

15776, 17286

17419, 17513

15535, 15753

17669, 18936

6143, 11394

2598, 3109

15334, 15509

18965, 19230

263, 268

346, 2276

4020, 6127

17549, 17645

2298, 2421

2437, 2534

3134, 3985

1,521

113,854

16974

Discharge summary

report

Admission Date: [**2126-5-4**] Discharge Date: [**2126-5-16**] Date of Birth: [**2058-2-3**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old female with a history of diabetes, known gallstone disease, transferred from an outside hospital for workup of presumed cholecystitis. The patient had been feeling ill for two weeks prior to her admission to the outside hospital. She was diagnosed with an upper respiratory infection by her primary care physician and given ciprofloxacin. On the day of admission to the outside hospital, she collapsed out of dizziness. At the outside hospital, she had a course significant for a pancreatitis with a lipase of [**2123**], a presumed cholecystitis with right upper quadrant ultrasound consistent with cholecystitis without biliary dilatation, as well as a left upper lobe pneumonia. She received cefuroxime for antibiotics, and a CT scan which showed significant only for pancreatic atrophy. She continued to have respiratory distress and gastrointestinal pain, and was transferred to [**Hospital1 188**] for further workup. PAST MEDICAL HISTORY: 1. Diabetes. 2. Hypertension. HOSPITAL COURSE BY SYSTEM: 1. Neurological: Patient with a normal mental status on her admission. She was sedated for her intubation. She was weaned periodically, and her mental status was noted to be responsive. 2. Cardiovascular: Ischemia: Patient with known coronary artery disease. She was continued on her PR aspirin. Her beta blocker was held secondary to her hypotension. Pump: The patient with a known low ejection fraction of anywhere from 20-40%. She was slightly volume overloaded on her admission, and received dialysis as she was aneuric throughout her admission at [**Hospital1 **]. Afterload reduction was held since she was hypotensive. Rhythm: Patient with known V-tach in the past and AICD placed in [**2125-7-2**] for V-tach on the setting of a myocardial infarction. She had multiple episodes of V-tach while in-house. She was managed on lidocaine and amiodarone drips, and was seen by EP Service. Did receive multiple shocks throughout her admission. Hypotension: Patient was hypotensive likely secondary to sepsis from pneumonia. Was initially placed on phenylephrine to avoid beta action on the heart, and which was eventually changed to norepinephrine. 3. Pulmonary: Patient was admitted with a left upper lobe pneumonia thought to be community acquired. She was continued on levofloxacin for her community acquired pneumonia. She then developed bilateral infiltrates thought to be failure versus ARDS. She was intubated on the third day of her admission for respiratory distress and hypoxia. She did receive invasive PA catheter monitoring which is significant for a wedge of 20, and after three days, a Swan was discontinued. 4. Gastrointestinal: Patient with a transaminitis and pancreatitis by enzymes while she was here. She received multiple right upper quadrant ultrasounds which was not significant for any cholecystitis, but did have gallstones. She received an ERCP with sphincterotomy which revealed gallbladder sludge. However, her right upper quadrant enzymes never totally resolved, and continued to have a pancreatitis. However, she is felt not to have an active cholecystitis throughout this admission. 5. Heme: The patient did have 1 unit of blood transfusion while she was here, but was guaiac negative, had no clear bleeding source. Thrombocytopenia: Unclear origin. She had a negative HIT antibody. 6. Endocrine: Patient on insulin drip while in-house for her diabetes. 7. Infectious Disease: The patient was maintained on Vancomycin, levo, and Flagyl throughout most of her admission to cover right upper quadrant bugs as well as her pneumonia. She initially received two days of meropenem, and this coverage was changed. She was never febrile throughout this admission. Additional MICU course: The patient was considered septic throughout her time. Was continued on antibiotics and pressor support. However, her admission was complicated by multiple episodes of ventricular tachycardia. She eventually had a sustained V-tach which was pulseless. The patient was coded unsuccessfully, and received multiple shocks, and we are unable to get a pulse back. Family was notified, and no postmortem examination was requested. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Dictated By:[**Last Name (NamePattern1) 6834**] MEDQUIST36 D: [**2126-5-22**] 21:16 T: [**2126-5-27**] 08:32 JOB#: [**Job Number 47759**]

[ "584.5", "486", "576.1", "518.81", "577.0", "038.9", "287.5", "427.1", "428.0" ]

icd9cm

[ [ [] ] ]

[ "37.26", "96.04", "39.95", "99.15", "96.71", "00.13", "89.64", "38.93", "51.85" ]

icd9pcs

[ [ [] ] ]

1194, 4636

154, 1114

1136, 1167

17,302

107,277

29901

Discharge summary

report

Admission Date: [**2131-2-28**] Discharge Date: [**2131-3-10**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: sudden onset "inability to walk" [**2131-2-28**] Major Surgical or Invasive Procedure: External ventricular drain placement History of Present Illness: [**Age over 90 **] y/o male who presented with sudden onset "inability to walk" after standing up from watching television. During the event he denied any SOB or chest pain, but he is not sure when all these events transpired today. He went to an outside hospital where a CT scan revealed a bleeding in the left cerebellar vermis (~3cm). He was then referred to this institution where the neurosurgical team saw him. Past Medical History: HTN, reports having "slow speech" that developed 3 months ago ?CVA Social History: Ex-tobacco smoker (last cigarette [**8-/2102**]), no ETOH, no drugs. Lives with wife in [**Hospital3 **] home; he is the primary caretaker for wife who has dementia Family History: unknown Physical Exam: Exam upon admission: T: 97.1 BP: 196/69 HR: 90 R 20 96%O2Sats Gen: WD/WN, comfortable, NAD. HEENT: Pupils: surgical pupils EOMs. facial asymmetry on left. Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Bradycardic. ?bigenimy on code cart. Abd: Soft, NT, BS+ Extrem: Warm. LUE more plethoric, but warm. Neuro: Mental status: Awake/sedated. Cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-14**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Surgical pupils. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: patient not fully cooperative. Left facial droop. VIII: IX, X: [**Doctor First Name 81**]: XII: Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-16**] throughout. +pronator drift on left. Sensation: Intact to light touch. Reflexes: B T Br Pa Ac Right: +2 0 0 0 0 Left: 0 0 0 0 0 Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin: Patient not cooperatiate as he feels nauseated as he has been bradycardic. Pertinent Results: [**2131-2-28**] 07:09PM WBC-18.9* RBC-4.35* HGB-14.6 HCT-41.9 MCV-96 MCH-33.5* MCHC-34.7 RDW-13.0 [**2131-2-28**] 07:09PM NEUTS-89.3* LYMPHS-7.0* MONOS-3.3 EOS-0.1 BASOS-0.3 [**2131-2-28**] 07:09PM PLT COUNT-156 [**2131-2-28**] 07:09PM PT-11.8 PTT-25.5 INR(PT)-1.0 [**2131-2-28**] 10:06PM WBC-16.9* RBC-4.27* HGB-14.3 HCT-41.2 MCV-97 MCH-33.4* MCHC-34.6 RDW-13.0 Head CT [**2131-3-1**](after fall out of bed): 1. Approximate stability of posterior fossa hemorrhage. Equivocal increase in mass effect on fourth ventricle. 2. New small subgaleal hematoma in the right frontal area without associated skull fractures. 3. No new areas of intracranial hemorrhage. Head CT [**2131-3-1**] (after acute MS change): The posterior fossa bleed is again approximately stable in size. However compared to the most recent scan of 21:00 on [**2131-3-1**], there is further decrease in the size of the fourth ventricle. Over the course of the last three head CTs, this has been progressive and may explain the patient's change in mental status. The size of the third ventricle and lateral ventricles is stable. The assessment of the mid-skull is limited due to motion. No new areas of hemorrhage are identified. There is no evidence of new infarction. There is interval progression of the right frontal subgaleal hematoma. Again noted is an old lacunar infarct in the left thalamus and mucosal thickening in the maxillary sinuses. Head CT [**2131-3-7**]: Unchanged cerebellar hematoma, with slight compression and anterior displacement of the fourth ventricle. If the patient remains neurologically stable, the interval time period between examinations could be increased. Brief Hospital Course: [**Age over 90 **] y/o male who presented with sudden onset "inability to walk" after standing up from watching television. He went to an outside hospital where a CT scan revealed a bleeding in the left cerebellar vermis (~3cm). He was then referred to this institution where the neurosurgical team saw him. The initial CT/CTA at [**Hospital1 18**] showed: Hemorrhage within the posterior fossa as described above. Focal fusiform dilatation of the LPCA measuring 2-3 mm. Chronic left thalamus lacunar infarct. The patient did well for the first two day in the ICU and was ready to be transferred to the neuro step down unit on [**2131-3-1**]. However, he fell out of bed that evening so he had a repeat head CT that showed now new bleed. Several hours later he had acute mental status changes and had another CT scan which showed that the original cerebellar bleed had increased and was almost completely occluding the 4th ventricle. An EVD was urgently placed at that time and the patient improved. The EVD was raised from 10cm above the tragus, to 15cm on [**2131-3-4**]. It was raised again to 20cm on [**2131-3-5**] and he was transferred to the step down unit that day. He continued to improve and the drain output was decreasing so we removed it on [**2131-3-7**]. Mr. [**Known lastname 71460**] family member fed him breakfast this morning and he had been on aspiration precautions per speech and swallow evaluation. He aspirated oatmeal and eggs so a CXR was obtained which showed: "No change since prior chest x-ray. No evidence of aspiration." His family decided to make him DNR/DNI on [**2131-3-9**]. Mental status and repiratory decline ensued over the next day and Mr. [**First Name (Titles) 71461**] [**Last Name (Titles) **] on [**2131-3-10**] at 10:50 military time. Medications on Admission: -ativan -trazodone -doxazosin Discharge Disposition: Extended Care Discharge Diagnosis: Left cerebellar bleed Fall from bed Aspiration/Respiratory failure Discharge Condition: Deceased Completed by:[**2131-3-10**]

[ "518.81", "431", "348.5", "873.0", "401.9", "E884.4", "934.8", "812.21" ]

icd9cm

[ [ [] ] ]

[ "86.59", "96.6", "02.2", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

5986, 6001

4116, 5905

316, 355

6112, 6151

2421, 4093

1094, 1103

6022, 6091

5931, 5963

1118, 1125

227, 278

383, 804

1738, 2402

1140, 1447

1462, 1722

826, 895

911, 1078

15,883

155,271

9492

Discharge summary

report

Admission Date: [**2181-2-10**] Discharge Date: [**2181-2-13**] Date of Birth: [**2112-1-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 45**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Name14 (STitle) 32299**] is a 67 year old man with a history of CAD s/p MI x 3, with known two [**Name14 (STitle) 12425**] CAD, ischemic CM with EF 35%, s/p ICD initially for primary prevention that subsequently developed multpile episodes of VT with multiple ablations, most recent [**2178**], h/o slow VT treated with mexiletine and amiodarone (off mex for 1 month) who presents with left lateral chest pain. Patient c/o two days of epigastric burning that he was contributing to reflux. However, on morning of admission patient awoke in a cold sweat with chest pressure in substernal area. He describes this as somewhat similar to his previous anginal pain, but much more mild in nature. Pain has radiated at times to his left shoulder and right shoulder. . On arrival in the ED vials: T 97 HR 109 , BP 110/83 , RR 16, O2 97 % RA. He was given three 81 mg ASA, Simethicone, Maalox, Viscous lidocaine. Patient noted to have an episode of CP in the ED with relief by SL NTG x 1. Initial ECG c/w slow VT, now in SR with LBBB. CXR with ?atelectasis RLL. Hemodynamically stable. . On arrival to the general cardiology floor patient remained with chest pain (apparently may never have been c/p free in ED). Was started on nitro gtt with chest pain increased from [**4-23**] to [**6-23**]. Patient described some radiation to the back and was given 2mg of morphine with improvement in his pain at that time (but not resolution). Was taken for CTA scan of the chest at that point to rule-out dissection/PE. Post-scan he was brought to the CCU for monitoring. Past Medical History: - severe ischemic cardiomyopathy secondary to old inferolateral wall MI - CAD s/p MI x 3 (age 39, 42, 45) - ICD implantation initially for primary prevention of sudden cardiac death, developed recurrent ventricular tachycardia status post multiple ablation, most recent VT ablation in [**2179-6-15**], complicated by laceration of the right iliac artery and significant retroperitoneal hematoma - H/O slow VT suppressed in a combination of amiodarone and mexiletine - H/O GERD and Barrett's esophagus - hyperlipidemia - hypertention - amiodarone-induced thyrotoxicosis with subsequent development of hypothyroidism: risk of recurrence approximately 10%, endocrine evaluated pt in past and thought it was OK to restart; currently on amiodarone. - CKD with baseline Cr 1.4 Social History: Social history is significant for the absence of current or past tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death, but his his 2 brothers are both in their 60's and suffer from CAD, his father had multiple MIs and a CVA in his 80's. Physical Exam: Gen: NAD. Alert and oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of cm. No thyromegaly or nodules. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No murmurs. Distant heart sountds. Chest: ICD implanted in L chest, no erythema, tenderness, or swelling. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Ext: No cyanosis, clubbing. L arm without palpable cord, slightly swollen compared to L. No femoral bruit b/l. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [**2181-2-10**] 11:15PM CK(CPK)-63 [**2181-2-10**] 11:15PM CK-MB-NotDone cTropnT-0.03* [**2181-2-10**] 11:15PM CALCIUM-8.7 PHOSPHATE-2.9 MAGNESIUM-1.9 [**2181-2-10**] 05:00PM GLUCOSE-119* UREA N-34* CREAT-1.6* SODIUM-141 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-30 ANION GAP-14 [**2181-2-10**] 05:00PM CK(CPK)-95 [**2181-2-10**] 05:00PM cTropnT-0.04* [**2181-2-10**] 05:00PM CALCIUM-9.3 PHOSPHATE-3.5 MAGNESIUM-2.1 [**2181-2-10**] 05:00PM WBC-13.6*# RBC-4.98 HGB-15.6 HCT-45.1 MCV-91 MCH-31.3 MCHC-34.5 RDW-14.0 [**2181-2-10**] 05:00PM NEUTS-68.4 LYMPHS-19.9 MONOS-9.0 EOS-2.4 BASOS-0.3 [**2181-2-10**] 05:00PM PLT COUNT-166 [**2181-2-10**] 05:00PM PT-11.4 PTT-28.3 INR(PT)-0.9 CTA -CHEST [**2181-2-11**] IMPRESSION: 1. No evidence of pulmonary embolus or aortic dissection. 2. Unchanged appearance of multiple renal cysts. 3. Cardiomegaly. . CXR [**2181-2-10**] IMPRESSION: Unchanged cardiomegaly. Right basilar atelectasis. No acute intrathoracic process. Brief Hospital Course: Patient is a 69 year old man with ischemic cardiomyopathy, two [**Month/Day/Year 12425**] CAD, p/w known slow VT and chest pain. VT: Likely [**1-16**] scar from underlying ischemic disease. VT resolved spontaneously in ED. Pt had been off mexiletene for 1 month due to limited supply. Restarted on mexilitene, with no further VT, as well as amniodorone.Supply confirmed with patient's pharmacy. . Chest Pain: Pt was initially on ngt/heparin drip but ruled out for MI with negative biomarkers. Did have 1 episode of CP in ICU with 1mm ST elevation and T wave changes, resolved with morphine. ICD evaluated but did not show any misfiring as pt has experienced in past resulting in CP. Majority of CP episodes seem related to severe gerd for which he was treated with pantoprazole, ranitidine, sucralfate and GI cocktail PRN. Pt did have known hx of Lcx, LAD lesions which had not been intervened upon. He received a thallium viability study to evaluate the myocardium supplied by these coronary vessels which showed that these areas were infarcted and thus non viable. . Ischemic Cardiomyopathy: EF 35%. Pt noted to have bibasilar crackles on exam, with peripheral edema. He received IV lasix with good response and became euvolemic. . GERD: hx severe GERD likely etiology repeated episodes CP. GERD controlled with multidrug regimen at home of pantoprazole, ranitidine, sucralfate with GI cocktail PRN given inhouse. Pt to follow up with PCP, [**Name10 (NameIs) **] as o/p. . .# Respiratory: On admission, pt was Tachypneic with hypoxemia. CTA chest ruled out PE but did show sabre shear trachea consistent with obstructive lung disease which should be followed up as o/p by PCP. . #. L femoral bruit: pt with L femoral bruit after L groin arterial access with AV fistula on US. CT pelvis with no fistula but aneurysm. Per [**Name10 (NameIs) 1106**] surgery, OK to use L groin site for catheterization. No intervention planned at this time. A plan was made for him to follow up with Dr [**Last Name (STitle) **] with ultrasound at that time. Medications on Admission: Amiodarone 300 mg Mondays, Wednesdays, Fridays and 200 mg on all other days ( Lipitor 40 mg daily Nexium 40 mg b.i.d. hydrochlorothiazide 25 mg daily levothyroxine 75 mcg daily Ativan 2 mg daily meclizine p.r.n. Toprol-XL 200 mg daily Mexiletine 200 mg b.i.d. (has not been taking in about 1 month due to supplier problems) Ramipril 10 mg daily Zantac 150 mg daily aspirin 81 mg daily sucralfate daily Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: 1.5 Tablets PO QMOWEFR (Monday -Wednesday-Friday). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO QTUTHSA AND SUNDAY (). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 7. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*2* 8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a day: Do not tke more than 3 grams per day. 12. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 13. Lorazepam 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day): Do not take with other medicines or with food. Tablet(s) 15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 16. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Gastroesophageal Reflux Disease Secondary Slow Ventricular Tachycardia Ischemic Cardiomyopathy s/p ICD placement Discharge Condition: stable, good, chest pain free, baseline mental status, baseline ambulatory status . Discharge Instructions: You were admitted to the hospital because you were having chest pain. This was most likely due to your heartburn. You are on medications to control your reflux. You had a thallium study to look at the area of your heart supplied by the blood vessels that are known to be blocked. This showed that these areas of the heart were not viable and no intervention could be done. The following changes were made to your medications: mexilitine 200mg by mouth every 12 hours Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2181-3-15**] 3:00 Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 62**]. You have an appointment on [**2181-3-15**] 3:40pm. Please call his office and have the appointment changed to within the next two weeks. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5340**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2181-3-19**] 9:40 Provider: [**Name10 (NameIs) **], [**Name8 (MD) 1775**], MD: Please call [**Name8 (MD) 1106**] surgery at Phone:([**Telephone/Fax (1) 2867**], [**Hospital Unit Name 8591**]: [**Location (un) 86**] [**Numeric Identifier **], to make an appointment. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]

[ "428.22", "414.00", "403.90", "428.0", "584.9", "272.4", "V45.02", "412", "427.2", "585.9", "414.8", "530.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8700, 8706

4818, 6863

324, 330

8871, 8957

3817, 4795

9595, 10466

2863, 3063

7315, 8677

8727, 8850

6889, 7292

8981, 9572

3078, 3798

274, 286

358, 1920

1942, 2714

2730, 2847

30,924

126,811

10056

Discharge summary

report

Admission Date: [**2179-9-25**] Discharge Date: [**2179-10-4**] Date of Birth: [**2097-5-3**] Sex: F Service: MEDICINE Allergies: Codeine / Morphine Attending:[**First Name3 (LF) 1674**] Chief Complaint: Transfer given power failure. Major Surgical or Invasive Procedure: Lumbar puncture on [**2179-10-1**], tolerated the procedure well. History of Present Illness: Ms. [**Known lastname 26495**] is an 82 year-old female initially admitted to an OSH on [**9-3**] with mental status change in the setting of hyponatremia and hypertension who is now being transferred to [**Hospital1 18**] given a power failure at the OSH. . NOTE: The following history was obtained via discussions with the transferring attending. . Initially presented to an OSH on [**9-3**] with mental status change. Found to be hypertensive (220/60) with a sodium of 118. Also noted to have an INR of 7.0. Course was complicated by respiratory failrue requiring intubation on [**9-8**]. Subsequently extubated on [**9-16**]. Now on BiPAP at night (15/5 with FiO2 0.40). Also noted to be c.diff positive and was started on PO vancomycin. Covering attending at OSH also reports that the patient was on IV vancomycin but she is unsure for what reason. . Given a power failure at the OSH, patient was transferred for further care. . At the time of discharge patient's weight was 158.5 lbs, her dry weight. . In speaking with the husband, he reports that two days prior to admission to the OSH the patient fell. It does not appear that she hit her head. The following day she had problesm getting to the bathroom and would loose her stool while urinating. Two days after falling her she was disoriented; this prompted the husband [**Name (NI) 33606**] to [**Hospital1 18**]. . Past Medical History: 1. Coronary artery disease - Status post stent in [**2167**] - Status post CABG x5 ([**2173-3-15**]): LIMA->LAD; SVG->PDA; sequential->PL; SVG->OM and diag 2. Hyperlipidemia 3. Diabetes mellitus 4. Chronic kidney dissease: baseline SCr 2.0 5. Atrial fibrillation 6. History of deep vein thrombosis times two in the right lower extremity, status post venous ligation with veins left in situ by report. 7. Status post cholecystectomy. 8. Arthritis in both knees, status post steroid injections. 9. Hard of hearing . Family History: NC. Physical Exam: vitals - T 99.6, BP 166/46, HR 87, RR 30, O2 99% on NRB then 98% on hi-flow FM with FiO2 of 0.6. Weight 75.6kg gen - Sleeping but arousable. Not very interactive, but responds to name. heent - JVP elevated at 8-9cm while sitting 45 degrees. Large neck. NG in place. cv - Regular. No murmurs. pulm - Rales noted 3/4 up bilaterally. abd - Soft and mildly distended. Non-tender. ext - Warm with boots on. Mild edema. neuro - Sleepy but arousable. Not cooperative with exam. . Pertinent Results: ---OSH--- . 138 91 59 ----------- 206 4.6 37 2.0 . Ca 9.0 . WBC: 18.6 HCT: 29.7; MCV 83 PLT: 606 . INR: 1.8 . ---ADMISSION--- . 140 92 58 ------------ 249 4.5 35 1.8 . Ca: 9.5 Mg: 2.4 P: 4.0 . WBC: 19.5 HCT: 34.4 PLT: 709 N:85.2 L:6.9 M:4.7 E:2.9 Bas:0.4 PT: 18.8 PTT: 28.8 INR: 1.8 . CXR [**9-25**]:Cardiac size is top normal. Bilateral pleural effusions are small on the left and moderate on the right. There is no pneumothorax. There is mild interstitial pulmonary edema. Patient is post median sternotomy. NG tube tip is out of view below the diafragm. . [**9-26**] CT head w/o contrast: No intracranial hemorrhage. Paranasal sinus and left mastoid abnormalities seen as described above, in part post-surgical in origin. . [**9-27**] TTE: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 11-15mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal LV systolic funciton. . MRI/MRA head [**9-28**]: 1. No acute infarcts or signal abnormalities suggestive of osmotic demyelination. 2. Mild generalized atrophy. 3. Short segment stenoses of the A1 segment of the left ACA and the right MCA bifurcation, which likely represent atherosclerotic changes. . EEG [**9-29**]: Abnormal portable EEG due to the slow and disorganized background and bursts of generalized slowing. These findings indicate a widespread encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. There were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. There were no clearly epileptiform features Brief Hospital Course: MICU COURSE: 82 year-old female with a history of CAD, CKD, DM, Afib who presented to an OSH with mental status change in the setting of hyponatremia and hypertension who is now transferred to the [**Hospital Unit Name 153**] after a power failure at the OSH. . 1. Mental status change: LP, MRI without causation. Pt is responsive, answering name and answering "in hospital" when asked orienting questions. EEG with diffuse encephalopathy. Neurology team at [**Hospital1 18**] felt that the decreased mental status is likely due to hypoxic damage in the septic, peri-intubation period. 2. Respiratory failure: Currently saturating well at 95% on face tent receiving Fio2 35%. Per sign-out from OSH, patient was intubated from [**9-8**] - [**9-16**] with respiratory failure. Appeared volume overloaded on admission. At [**Hospital1 18**] pt has been diuresed about 500cc per day requiring Lasix 120 mg IV bid. At most recent CXR [**2179-10-3**], pleural effusions resolved, pt still has mild interstitial edema. Wt today is 171 lbs. Pt has also been responding to blood pressure control and aldactone. 3. C.Difficile colitis: Completed course of oral/pr vancomycin at [**Hospital3 **] and through [**Hospital1 18**]. C. difficile negative x 3 here at [**Hospital1 18**]. 4. Atrial Fibrillation: Pt currently in sinus rhythm. Continue beta blocker and coumadin. She is currently on coumadin 2 mg po daily for past 2 day (previously held) needs at least qod INRs 5. Aspiration risk: Due to decreased mental status. Will need re-eval and feeding by NG tube until then. 6. Chronic kidney disease: Baseline creatinine 1.8. Currenly at this baseline. 7. Diabetes: On extremely high dose of lantus with Januvia. Please start Januvia if available at rehab and if so be sure to titrate lantus dose - will likely need less. 8. Heel wounds: Please see attached wound care recs. CODE STATUS IS DNR/DNI PER FAMILY. Medications on Admission: (OSH): 1. Labetolol 300mg [**Hospital1 **] 2. Norvasc 10mg daily 3. Aldactone 100mg TID 4. Diamox 250mg TID 5. Bumex 5mg IV PRN for weight (last given on [**9-22**]) 6. Lipitor 40mg daily 7. Imdur 60mg daily 8. Coumadin 5mg 9. Lantus 100 units QAM + RISS 10. Januvia 100mg daily 11. Iron IV 62.5mg daily 12. Procrit 20,000 units weekly (last time [**9-23**]) 13. Mag Oxide 400mg daily 14. Rocaltrol 0.5mcg daily 15. Protonix 40mg daily 16. Lovenox 1mg/kg [**Hospital1 **] 17. Vancomycin 125mg PO QID 18. Vancomycin 1gram IV Q36 hours Discharge Medications: 1. Labetalol 300 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 2. Atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. Warfarin 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY16 (Once Daily at 16). 4. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) treatment Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 7. Aldactone 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 8. Hydralazine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a day. 9. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. Furosemide 120 mg IV BID 11. Calcitriol 0.25 mcg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY (Daily). 12. Insulin Please see attached list: pt will receive insulin Lantus in am and sliding scale throughout day. 13. JANUVIA 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: qpm. Discharge Disposition: Extended Care Facility: [**Hospital1 **]@ [**Hospital 1263**] Hospital Discharge Diagnosis: pneumonia c diff colitis (treated) acute on chronic diastolic heart failure hypoxic brain damage Discharge Condition: Requires 35%FiO2 by face mask to maintain O2 sat > 92%. On tube feeds. When asked name answers correctly '[**Known firstname 1494**].' Otherwise little communication. Discharge Instructions: Return to ER with shortnes of breath, increased oxygen saturation requirements, or other concerning symptoms. Please check potassium and creatinine daily while on IV lasix. Keep strict account of ins/outs with goal even to negative 500cc per day for next several days. Please check INR qod for goal INR [**12-26**] for atrial fibrillation. Followup Instructions: Please follow up with neurology clinic within one month. Call [**Telephone/Fax (1) 2756**] to make appointment. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2179-10-4**]

[ "486", "428.0", "427.31", "348.39", "V58.61", "348.1", "V45.81", "585.9", "272.4", "V45.82", "276.3", "008.45", "511.9", "250.02", "518.83", "414.01", "428.33" ]

icd9cm

[ [ [] ] ]

[ "03.31", "96.6" ]

icd9pcs

[ [ [] ] ]

8836, 8909

5062, 6991

308, 375

9050, 9222

2868, 5039

9612, 9877

2346, 2351

7576, 8813

8930, 9029

7017, 7553

9246, 9589

2366, 2849

239, 270

403, 1792

1814, 2330

287

175,954

16061

Discharge summary

report

Admission Date: [**2167-5-31**] Discharge Date: [**2167-6-6**] _----------------------_ Date of Birth: [**2096-12-21**] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old gentleman with a past medical history of ethmoid cancer resected at [**Hospital6 1129**] in [**2162**]. He had a repeat resection here on [**2167-5-22**] by Ear/Nose/Throat and Neurosurgery. Postoperative course was uneventful. The patient had no cerebrospinal fluid leak. He passed a swallow evaluation and was discharged to rehabilitation on [**2167-5-28**]. He began having mental status changes and seizure activity on the day of admission. He became unresponsive. He had a fever to 102 and was transferred here for further management. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Rheumatoid arthritis. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination his temperature was 97.9, blood pressure was 124/55, heart rate was 72, respiratory rate was 20, and oxygen saturation was 97%. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. Extraocular movements were full. He had bilateral orbital edema. His cardiovascular status revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops. Pulmonary examination was clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended. No masses. Extremity examination revealed no clubbing, cyanosis, or edema. On neurologic examination, he did not open his eyes. He did grasp hand bilaterally. PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed some mild fluid overload; slightly improved. No infiltrates. HOSPITAL COURSE: He was seen by the Ophthalmology Service and ruled out for orbital cellulitis. He had a lumbar puncture and a magnetic resonance imaging with evidence of an epidural versus subdural frontal collection. On [**2167-5-31**] the patient was taken to the operating room for exploration and drainage of a frontal collection. A drain was in place, and the patient was monitored in the Intensive Care Unit postoperatively where he had severe facial swelling, and his eyes were swollen shut. Postoperatively, he was awake and following commands. He was moving all extremities to commands. The fluid collection was sent for a culture. He was seen by Infectious Disease Service. He was placed on vancomycin 1 g q.12h. and ceftazidime 2 g q.8h. for initial antibiotic coverage. The Gram stain showed gram-positive cocci and gram-negative rods from the abscess. The patient had a bone flap removed. Therefore, there was a skull defect. The patient will require six weeks of intravenous antibiotic coverage. His drain was removed on postoperative day four (on [**2167-6-3**]), and he was transferred to the regular floor after being seen by Physical Therapy and Occupational Therapy. He was also re-evaluated by the Swallow Service. He passed the swallow with some modifications. He needs to be on a nectar-thick ground solid diet. Pills need to be crushed and pureed. He needs to maintain aspiration precautions. He should be full upright for all meals, alternating between bites and sips, and two to three swallows for each bite and sip. His dressing was removed, and his incision was clean, dry, and intact. He had a peripherally inserted central catheter line placed on [**2167-6-5**]. He currently continues on gentamicin 100 mg intravenously q.12h. and ceftazidime 2 g intravenously q.8h. He was growing Proteus from the culture from his surgery. The patient was to be discharged on ceftazidime 2 g intravenously q.8h. and ciprofloxacin 500 mg p.o. q.12h.; together for a total of six weeks. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. [**Last Name (STitle) 1906**] at [**Hospital 14852**] in four to six weeks. 2. The patient should also have his staples removed at rehabilitation in 14 days postoperatively. 3. The patient should also be fitted for a helmet due to the bone defect once at rehabilitation. MEDICATIONS ON DISCHARGE: (Medications at the time of discharge included) 1. Pantoprazole 40 mg p.o. q.24h. 2. Metoprolol 25 mg p.o. twice per day. 3. Sodium chloride nasal spray four times per day as needed. 4. Ceftazidime 2 g intravenously q.8h. 5. Folic acid 1 mg p.o. once per day 6. Gentamicin 100 mg intravenously q.12h. (peak and trough levels are pending). CONDITION AT DISCHARGE: The patient's condition on discharge was stable. DISCHARGE STATUS: To rehabilitation. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2167-6-5**] 12:00 T: [**2167-6-5**] 12:19 JOB#: [**Job Number 45954**]

[ "998.59", "324.0", "996.69", "170.0", "496", "790.7", "714.0", "253.6" ]

icd9cm

[ [ [] ] ]

[ "96.71", "83.45", "03.31", "01.23", "38.93" ]

icd9pcs

[ [ [] ] ]

4169, 4525

1784, 3793

3826, 4142

4540, 4884

197, 773

795, 1765

54,610

147,673

19217

Discharge summary

report

Admission Date: [**2150-12-13**] Discharge Date: [**2150-12-28**] Date of Birth: [**2090-5-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2763**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: intubation and mechanical ventilation placecement of right IJ central venous line placement of left radial arterial line paracentesis History of Present Illness: History related by patient's girlfriend, [**Name (NI) 4051**] [**Name (NI) **], although the patient was able to speak in ED and corroborate the history. Mr. [**Known lastname 52368**] is 60 year old male, with HCV cirrhosis, h/o varices, and gastric ulcers, presents with 1 week of worsening dyspnea. The pt's girlfriend reports that two weeks ago the pt developed a "respiratory illness" and was seen in PCP's office and given an antibiotic. The pt never fully improved, and over the past week had worsening dyspnea. On the day prior to admission he developed severe abdominal pain, and then described pain as being "all over," in back, chest and abdomen. He began retching and had some hemoptysis or hematemesis (unclear which), and was noted to have blood in stools. . In the ED, initial vs were: 100.9 80 98/50 24 100%RA. Pt was speaking in [**3-11**] word sentences and described severe pain diffusely. On exam the pt had abdominal guarding and was moaning in pain. Lungs were clear and asterixis was present. EKG was unremarkable. The pt was sent for CT chest and abdomen, and in CT scan BP dropped to 60/30, and the pt was started on dopamine. His BP did not respond to maximum dopamine and the pt was switched to neosyn with good response in BP. He was intubated, a R IJ central line was placed and neo was weaned as pressures were up to SBP 140. Blood cultures and ascitic fluid cultures from dx paracentesis were sent and the pt was given one-time doses of Vancomycin and piperacillin-tazobactam. Following intubation, the pt was unresponsive so Head CT was obtained prior to transfer to MICU. Prelim read of head CT was negative. . On arrival to MICU, pt wa hypothermic. An arterial line was placed and pt was noted to have blood in NGT. Hepatology was contact[**Name (NI) **]. Past Medical History: 1. Hepatitis C cirrhosis w/ portal hypertension, esophageal varices (grade 2 [**2150-6-19**]), and thrombocytopenia. Non responder to interferon monotherapy and to interferon with ribavirin. 2. Hypertension 3. Upper GI bleed due to gastritis. 4. Healed antral ulcer on EGD [**2150-6-19**] 5. Chronic epistaxis Social History: He live alone in [**Location (un) **], no longer drives. Has not drunk alcohol since [**Month (only) 116**]. Has a distant history of iv drug use over 20years ago. He smokes occasionally, [**1-9**] cigarettes a month, but has a 20 year history of smoking [**1-9**] ppd. Family History: Brother with Hep C cirrhosis s/p liver transplant Physical Exam: On admission: Vitals: T: 95 BP: 101/47 P: 62 R: 17 O2: 100% on AC 500/5 FiO2 100%, RR 12 General: Intubated, unresponsive to noxious stimuli, intermittently opening eyes, jaundiced HEENT: Sclera icteric, MMM, oropharynx clear, +intermittent tongue fasciculations, NG tube draining blood Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi, intubated breath sounds CV: Regular rate and rhythm, normal S1 + S2, + [**3-13**] early systolic murmur Abdomen: soft, + distended but not tense, no bowel sounds present, no organomegaly, + bulging flanks, paracentesis site appears clear, no oozing from site GU: No scrotal edema Ext: Warm, well perfused, 2+ pulses UE, LE pulses dopplerable, no clubbing, cyanosis or edema. No petechiae. Pertinent Results: Admission Labs: 8.6 8.1------ 105 25.6 PMN 48%, Bands 33%, Metas 3% . 122 95 27 -------------72 6.5 18 1.24 . LFTs: ALT 107 AST 279 LDH 176 Alk phos 213 Dir bili 18.2 Lipase 81 . Lactate 3.2 . D dimer : >[**Numeric Identifier 3652**] . Paracentesis [**12-13**]: WBC [**Numeric Identifier 6085**], RBC 1750 PMN 87, Lymph 1, Monos 9, EOs 1, Macro 2 . Micro: B. cxr [**12-13**] CLOSTRIDIUM PERFRINGENS. Peritoneal cxr neg x 3 C. Diff neg x 2 influenza DFA A&B negative . Imaging: CtA Chest W&W/O C&Recons, Cta Abd W&W/O C & Recons, CtA Pelvis W&W/O C & Recons [**2150-12-13**] IMPRESSION: 1. No acute aortic abnormality, or central or segmental pulmonary embolus. 2. Cirrhotic liver with moderate ascites and paraesophageal varices. Patent portal vein. 3. Distended gallbladder without other evidence of acute cholecystitis. 4. Moderate emphysematous changes in the lungs. 5. Hypodense liver lesion, not fully characterized. When clinical condition stabilizes, this can be further assessed via multiphasic liver CT or MRI. CXR: [**2150-12-13**] SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: Lung volumes are low, and linear opacities are present at both lung bases, consistent with atelectasis. The upper lung zones are well aerated. The heart is normal in size. There is no hilar or mediastinal enlargement. Pulmonary vascularity is normal. There is no evidence of free intraperitoneal air. There is no pneumothorax. IMPRESSION: Low lung volumes with bibasilar atelectasis. . CT head: [**2150-12-13**] No ICH, midline shift or masses. . Abd US [**2150-12-16**]: 1. Cirrhosis. Patent portal vein with hepatopetal flow. 2. Moderate ascites. Marked place for paracentesis in the left lower quadrant. 3. Distended gallbladder without evidence of stones. . CT abd/pelvis [**2150-12-17**]: 1. Liver cirrhosis with portal hypertension evidenced by ascites and many, including esophageal, varices. 2. Indeterminate liver lesion is seen, which is new since the previous MRI dated [**2150-5-18**], however, is unchanged since previous CT dated [**2150-12-13**]. This should be further evaluated with MRI when the patient is more stable. 3. High density material lying dependently in the fluid in the pelvis, which likely is due to a small amount of blood, probably from reccent paracentesis. 4. Multiple poorly defined peripheral low density areas in the spleen, which is likely due to altered perfusion of the spleen; a finding that has been present since [**2150-5-8**]. 5. Moderate chronic stenosis of the celiac artery at its origin, with the enlargement of mild collaterals from the SMA. No evidence of mesenteric ischaemia. . EGD [**6-/2150**]: Esophagus: Protruding Lesions 4 cords of grade II varices were seen in the gastroesophageal junction and lower third of the esophagus. No stigmata of high bleeding risk. Stomach: Other Helaed antral ulcer. Duodenum: Normal duodenum. . ECHO [**4-/2150**]: The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. Left ventricular systolic function is hyperdynamic (EF>75%). 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. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Hyperdynamic LV systolic function. Mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. . EKG: NSR 75, isolated TWF in III, no ST changes, no peaked T waves, no PR depressions Brief Hospital Course: Mr. [**Known lastname 52368**] is a 60 year old man with history of hepatitis C (s/p interferon rx with no response), cirrhosis, esophageal varices and hyponatremia admitted with dyspnea and diffuse abdominal pain, presenting with peritonitis and dyspnea. . #. Sepsis: The patient presented to the MICU in septic shock, with hypotension, altered mental status and respiratory failure. His sepsis was thought to be due to his peritonitis, as described below. He was initially treated with broad-spectrum antibiotics (vancomycin, zosyn, clindamycin and micafungin), pressors and IVF boluses. He was transfused as needed for anemia and dropping hematocrits. At presentation to the MICU, the patient was also hypothermic (temp of 95 with bear hugger), hyponatremic, hyperkalemic and hypoglycemic--all consistent with sepsis. As these findings could also indicate adrenal insufficiency, steroids were initially added to the patient's regimen. The patient's blood culture from [**12-13**] grew Clostridium Perfringens. Over the course of his hospitalization, the patient was weaned off of pressors (as of [**12-20**]) and steroids [**12-21**]), although Midodrine was continued. His antibiotic regimen was tapered down to just Ciprofloxacin and Clindamycin. By [**12-24**], the patient's peritoneal infection appeared adequately treated, as his paracentesis that day had PMN = 500, 16% PMNs -- down from 17,000 WBC, 87% PMNs on admission -- with a signifantly softer, though somewhat distended, abdomen with normal bowel sounds. Unfortunately, though he initially initially improved, he later became septic again on [**2150-12-27**] in the setting of worsening WBC and abdominal distension. It is unclear what the cause of this was, though it was suspected that it was posisbly a bowel perf or a C diff colitis (cultures were negative). Antibiotics were broadened to vancomycin, piperacillin-tazobactam, metronidazole, and he was started on vasopressors. His hypotension was refractory to multiple pressors ovenright, and he was made CMO in the presence of his girlfriend and son given his poor prognosis. He died within minutes of withdrawaling the pressor support. Family refused autopsy. . #. Peritonitis: The patient's presentation with abdominal pain, prominent neutrophilia on ascitic fluid differential (17,000 WBC, 87% neuts) and significant left-shift on CBC with diff (33% bands) in the setting of a history of variceal bleeding were consistent with an intraperitoneal infection. At the top of the differential, was SBP--however, per Hepatology, his peritoneal WBC could was actually more consistent with bowel perforation. CT scans with angiography x 2 were obtained to evaluate for bowel perforation (or ischemia)--none was seen. Transplant surgery was consulted, and followed the patient throughout his hospitalization, but the patient was too poor of a surgical candidate to undergo surgical exploration to look for microperforation. With antibiotic therapy, eventually tailored to Cipro/Clinda as above, the patient slowly improved, though his sepsis recurred (see above). . #. Leukocytosis: During his hospitalization, the patient developed increased WBC, despite improvement of his peritonitis, as described above. Sputum, urine, and blood cultures were sent agian and were negative; C. diff was negative x 2. . #. Dyspnea/Respiratory Failure: The pt was intubated in the ED given his hypotension, and concern for developing respiratory failure suggested by his tachypnea. The differential for the pt's dyspnea included pneumonia, influenza, PE, ascites or CHF. The pt had a left shift on CBC with diff and his girlfriend reported that he recently had a "respiratory infection" which initially raised concern for a post-viral pneumonia or bacterial pneumonia. The patient's CTA of the chest and CXR subsequently did not show any PE or infectious infiltrate. His initial tachypnea was likely secondary to acidosis as a result of septic shock and peritonitis. He did have evidence of volume overload and CHF given substantial peripheral edema, CXR consistent with fluid overload, and elevated CVP. During his MICU stay, the patient was gradually weaned off of mechanical ventilation, despite a significant PEEP requirement (attributed to his likely substantial intrathoracic pressure resulting from his distended abdomen). He was extubated on [**12-25**]. . #. Altered mental status: The patient was unresponsive after intubation. CT head at admission was unremarkable. Although his neurologic exam difficult, there was no obvious deficit during his MICU stay. His AMS was attributed stage 4 hepatic encephalopathy, given patient??????s severe liver disease and rising bilirubin. His mental status improved over the course while in the MICU, such that at extubation on [**12-25**] he was alert, following commands, but only oriented x 1 (to name only). His hepatic encephalopathy was treated with lactulose (titrated to 3 BMs daily) and Rifamixin. . #. Anemia: Pt's recent baseline hematocrit appears to be ~25-30, and was 21 on MICU admission. Pt was noted to be guaiac positive on exam in ED, and had frank blood in NGT. Suspect that pt has chronic macrocytic anemia secondary to liver disease, with superimposed acute blood loss anemia from variceal bleed or bleeding ulcer. No schistocytes were seen on smear to indicate hemolysis, however his INR more elevated than in the past, and thrombocytopenia is more pronounced--which were concerning for DIC. GI did an EGD to evaluate for UGIB cause on [**12-13**] and no bleeding source was found. Initially, the pt was treated with pantoprazole bolus [**Hospital1 **] and octreotide gtt for likely variceal bleeding, but those were discontinued when his HCT stabilized. His coags and CBC were followed closely, with transfusions as needed for falling Hct. Additionally, 2 units FFP were given prior to any procedures (paracenteses). . #. Hepatitis C Cirrhosis: MELD on admission was 27, discriminate function was 61. On exam, the pt was very jaundiced. Reportedly the pt stopped drinking EtOH in [**Month (only) 116**]. Serum EtOH was negative. Hepatology followed the patient while he was in house. He was continued on lactulose and Rifaximin. Nadolol was held initially, given his hypotension, pressor requirement. LFT's on admission were similar to prior LFT's with the exception of bili, which was markedly elevated at 18, and continued to rise throughout his hospitalization, reaching a peak of -- on --. Direct bilirubin was checked on [**12-25**], and was also elevated [****]. bili 37). The patient underwent repeat abdominal US, which showed --. Direct coombs test was sent, which showed --. His hyperbilirubinemia was attributed to his worsening hepatic function. . #. Acute Renal Failure: Although the patient initially had elevated Cr, thought to be due to sepsis, this resolved during his hospitalization. He had one period where his creatinine bumped again (1.7 -> 0.8 -> 1.5), which raised concern for hepatorenal syndrome. This Cr elevation occurred in the setting of being aggressively diuresed and receiving an IV contrast load for CT abd; however, his urine sodium was <10, making HRS the most likely etiology. As treatment for likely hepatorenal syndrome, he was treated with Midodrine, Octreotide, and Albumin with improvement in his Cr (-- at discharge) and urine output. He was followed by the renal service while in-house. . #. Hypernatremia: Likely due to hepatorenal syndrome. Resolved . #. Gynecomastia: The patient was noted during this admission to have tender gynecomastia with nipple erythema; per his girlfriend, this is his baseline. This is thought to be [**2-9**] liver failure and increased estrogen. Tamoxifen was started. . #. Epistaxis: Due to epistaxis on admssion, ENT was consulted and the patient underwent bilateral nasal packing. He will need to follow up with ENT 1 week after discharge. . #. Thrombocytopenia: Attributed to poor synthetic function in the setting of liver disease. Platelets were trended and transfused PRN. Medications on Admission: Cholestyramine-Aspartame 4 gram Packet Fluticasone [Flovent Diskus] 50 mcg Folic Acid Furosemide 40 mg Tablet daily Lactulose 10 gram/15 mL 2tbsp tid Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] [FIRST-Mouthwash BLM] 400 mg-400 mg-40 mg-25 mg-200 mg/30 mL Mouthwash Swish and spit Nadolol 20 mg daily Pantoprazole 40 mg daily Rifaximin [Xifaxan] 200 mg 2 tab tid Spironolactone 100 mg daily Tolvaptan [Samsca] 30 mg daily Acetaminophen [Tylenol Extra Strength] 500 mg Tablet 2-3 times daily prn Calcium Carbonate 500 mg tid Cholecalciferol (Vitamin D3) [Vitamin D-3] 400 unit Thiamine HCl 100 mg Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Septic shock Discharge Condition: Expired after being made comfort measures only Discharge Instructions: NA Followup Instructions: NA [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]

[ "251.2", "401.9", "428.9", "789.59", "287.5", "276.2", "998.2", "611.1", "070.54", "285.1", "285.29", "571.5", "533.90", "275.3", "995.92", "348.30", "572.3", "784.7", "E870.8", "785.52", "496", "535.50", "283.19", "584.5", "537.89", "038.3", "570", "276.8", "276.0", "567.23", "518.81", "456.21", "276.1" ]

icd9cm

[ [ [] ] ]

[ "39.95", "99.15", "38.95", "45.13", "21.01", "96.72", "38.91", "33.23", "21.21", "96.04", "54.91" ]

icd9pcs

[ [ [] ] ]

16219, 16228

7469, 11855

337, 472

16284, 16332

3803, 3803

16383, 16480

2931, 2982

16192, 16196

16249, 16263

15545, 16169

16356, 16360

2997, 2997

278, 299

501, 2293

5303, 7446

3824, 5294

3011, 3784

11870, 15519

2315, 2627

2643, 2915

7,363

165,081

52357

Discharge summary

report

Admission Date: [**2175-1-16**] Discharge Date: [**2175-1-26**] Date of Birth: [**2108-12-2**] Sex: M Service: MEDICINE Allergies: Sulfonamides / Iodine; Iodine Containing / Phenytoin / Levaquin / Neurontin / Ace Inhibitors Attending:[**First Name3 (LF) 2297**] Chief Complaint: wound infection and pain Major Surgical or Invasive Procedure: wound vac changes PICC placement History of Present Illness: 66y/o M w/ CAD s/p PCI, s/p CABG c/b wound dehiscence x2 and wound infection requiring ciprofloxacin, vancomycin and tobramycin, h/o rib osteomyelitis, tracheal bronchitis/PNA with pseudomonas, CHF, COPD, HTN who is being transferred from NESH for plastic surgery evaluation of his wound dehiscence. He has been severe pain in the area of his wound. The inferior ribs that are exposed in his wound end up rubbing against each other with each exhalation causing severe pain. In addition, his stay there at NESH was c/b acute renal failure (all abx were stopped) and acute blood loss anemia (received 3 units between [**1-12**]/and [**1-13**]/). Patient had been sent out of here on [**12-30**] with a 6 week course of abx but the antibiotics (pseudomonas/acinetobacter) were stopped about [**1-12**] including tobra and vanc. The cipro was stopped earlier. This was dictated by ID consultants at [**Hospital1 **]. . At time of presentation the patient's main complaint is that his chest hurts when he breathes. This is the same pain he has had since his ribs began to rub together. It is not the same as his anginal pain. He has no other complaints. Denies SOB, abd pain, N, V, diarrhea, dizziness, changes in vision/hearing, confusion, or head ache. Past Medical History: CAD - s/p PCI x3 last in [**9-5**] CABG [**9-5**] c/b wound dehiscence s/p pectoralis flap procedure w/ recurrent wound dehiscence and requiring exploration. h/o Pseudomonas PNA Rib osteomyelitis Tracheal bronchitis (cipro, vanco, tobramycin to cover bronchitis and wound infection) CHF last EF was Cath [**9-5**] 44% HTN Hypercholesterolemia Severe COPD on home O2 Lung Cancer - s/p RLL lobectomy [**2166**] no chemo/radiation currently no evidence of recurrent disease GERD and PUD BPH Anemia Depression History of Shingles . Psurg: s/p Appy, s/p chole, s/p cataract surgery, s/p Nissen s/p wound dehiscence and infection Social History: 160 pack year history of tobacco - quit 3 years ago. Admits to occasional ETOH. He lives with his wife. Former [**Name2 (NI) 86**] Globe worker. He requires home oxygen and is on chronic steroids. Family History: Significant for premature coronary artery disease. Father and brothers were diagnosed in their 30's. Physical Exam: T: 98.1 P:72 BP: 119/49 R: 21 Sats 99% PS: set 600(obs 658)/14, PS/Peep: 14/5 GEN: AxOx3, NAD HEENT: EOMI, NGT in place, o/p clear. NECK: supple no LAD CV: RRR, distant heart sounds, CHEST: open sternal wound, mild erythema around wound vac, with exhalation ribs approximate each other and rub. PULM: CTA anteriorly, b/l ABD: soft, NT, ND, +BS EXT: warm and well perfused, no edema Pertinent Results: [**2175-1-16**] 08:38PM GLUCOSE-127* UREA N-50* CREAT-2.3* SODIUM-137 POTASSIUM-5.4* CHLORIDE-104 TOTAL CO2-22 ANION GAP-16 [**2175-1-16**] 08:38PM CALCIUM-8.7 PHOSPHATE-6.0* MAGNESIUM-1.9 [**2175-1-16**] 08:38PM WBC-14.2* RBC-3.57* HGB-10.3* HCT-30.4* MCV-85 MCH-28.8 MCHC-33.9 RDW-15.4 [**2175-1-16**] 08:38PM NEUTS-82* BANDS-4 LYMPHS-8* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 PROMYELO-1* [**2175-1-16**] 08:38PM PLT SMR-NORMAL PLT COUNT-428 [**2175-1-16**] 08:38PM PT-12.8 PTT-26.8 INR(PT)-1.1 . CXR: Chronic interstitial lung disease with interval improvement and left upper lobe opacity. . Chest CT: 1. No mediastinal fluid collection. 2. Increasing size of 13-mm left upper lobe nodule. It may be secondary to an inflammatory or infectious etiology. However, given the background of severe emphysema, bronchogenic carcinoma is also considered. Follow-up CT should be performed in [**6-8**] weeks to exclude further growth. 3. Tiny faint centrilobular nodules more pronounced in the dependent portion of the right lung base may be secondary to infection or aspiration. 4. Over-distended tracheostomy tube cuff. . Renal U/S: Severe left hydronephrosis with cortical thinning is unchanged compared to [**2174-11-3**]. . Brief Hospital Course: A/P: 66 yo M with w/ CAD s/p PCI, s/p CABG c/b wound dehiscence x2 and wound infection requiring ciprofloxacin, vancomycin and tobramycin, h/o rib osteomyelitis, tracheal bronchitis/PNA with pseudomonas, CHF, COPD, HTN who is being transferred from NESH for plastic surgery evaluation of his wound dehiscence. . # Wound Dehiscence: Pt admitted with wound pain. Plastics was consulted and changed his wound vac several times. They did not recommend further operations at this time. His pain was initally controlled with MS Contin with prn morphine but when his pain could not be controlled, he was started on a morphine PCA. This controlled the pain and the pt appeared much more comfortable. The PCA was stopped one day prior to discharge and pt did not require prn pain meds. . # Wound Infection: During the prior admission, cultures from the wound grew pseudomonas [**Last Name (un) 36**] to cipro, acinetobacter [**Last Name (un) 36**] to gent/tobra and MRSA. These abx were discontinued 4 days prior to admission once creatinine started to rise. Pt spiked a temp on hospital day #2 and the antibiotics were resumed per ID recs. On further evaluation, ID believed that pt had completed a sufficient course of antibiotics for his wound infection. An MRI was done of the chest which confirmed no evidence of osteomyelitis or soft tissue collections. . # Fever: Pt spiked a fever on HD#2 associated with resp distress, possibly due to an aspiration event. Pt was started on ciprofloxacin to cover hx of pseudomonas in his sputum and tobramycin to cover acinetobacter. He completed a course of these antibiotics and they were stopped on [**2174-1-24**] after 7 days. . # Acute on CRF: Creatinine 2.3 on admission, above baseline of 1.5 but improved from peak of 2.9. The creatinine improved to 2.1 during the admission but rose to 3.5 after the antibiotics were resumed. Once the tobramycin was stopped, his creatinine trended down and stabilized at 2.9-3.0. . # Respiratory Failure/COPD: Pt is vent dependent but he tolerated trach mask trials well. He rested on pressure support [**10-10**] at night. His lung mechanics are also complicated by his severe COPD and hx of a lobectomy. He was continued on his inhalers. . # Adrenal Insufficiency: Random cortisol was checked and found to be low at 2.4. His prednisone was changed from 5mg qd to hydrocortisone 25mg for a better replacement dose. He had no signs or symptoms of adrenal insufficiency. . # Anxiety: Pt was continued on his home dose of Klonopin for control of his anxiety. Ativan was given once but caused marked lethargy. To have better control of his anxiety, he was started on Buspar. . # Lung Nodule: Pt found to have 13mm lung nodule on chest CT. He will need a follow up chest CT in [**5-7**] weeks. . # FEN: Pt able to tolerate po so NGT was pulled. Calorie counts were insufficient so a PEG tube was placed by GI. Tube feeds were started and pt tolerated well. . # Access: PICC line was changed on [**2174-1-24**] due to malfunctioning port. Medications on Admission: . prednisone 20mg' 2. MVI' 3. tamsulosin 0.4' 4. ISS 5. lactulose 30mg [**Hospital1 **] 6. ambien 10mg' 7. tylenol 650mg q4:PRN 8. lipitor 20mg qhs 9. asa 81mg' 10. alb 3p qid 11. vit c 500mg [**Hospital1 **] 12. calcium acetate 667mg tid 13. clonazepam 0.5mg [**Hospital1 **] 14. plavix 75mg' 15. colace 100mg' 16. lovenox 30mg' 17. fluconazole 200mg' 18. metoprolol 100mg tid 19. montelukast 10mg' 20. morphine sulfate 30mg [**Hospital1 **] 21. miralax 1pkt' 22. ranitidine 150mg [**Hospital1 **] Discharge Medications: 1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 11. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) ML Inhalation q6h () as needed. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 16. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation Q6H (every 6 hours). 17. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation Q6H (every 6 hours). 18. BusPIRone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Hydrocortisone Sod Succinate 100 mg/2 mL Recon Soln Sig: Twenty Five (25) mg Injection Q24H (every 24 hours). 20. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 21. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1) injection Injection three times a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary Diagnoses: 1. Wound Infection 2. Aspiration Pneumonia s/p 7 days of antibiotics 3. COPD, Ventilator Dependence 4. Acute on chronic Renal Failure Secondary Diagnoses: 1. Anxiety Discharge Condition: good, afebrile, stable creatinine, 99% on vent 10/10 Discharge Instructions: Take all medications as prescribed and go to all follow-up appointments. Call your PCP or go to the ED if you experience any of the following symptoms: chest pain, shortness of breath, fevers, chills, or anything else that concerns tou Followup Instructions: Please make an appointment to see your PCP in the next [**2-3**] weeks. Please make an appointment to see the ID physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 4333**] [**Last Name (NamePattern1) 4334**], in [**2-3**] weeks. Call [**Telephone/Fax (1) 457**] to make this appointment. Please have a follow up chest CT in [**5-7**] weeks to monitor the pulmonary nodule. Follow up with Dr. [**First Name (STitle) **] of plastic surgery in the next month. Call ([**Telephone/Fax (1) 1429**] to make this appointment.

[ "998.32", "600.00", "V10.11", "428.0", "585.9", "998.59", "584.9", "V45.81", "V46.11", "E878.2", "401.9", "491.20", "507.0", "272.0", "V44.0", "530.81", "518.83" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "93.59", "96.72", "43.11" ]

icd9pcs

[ [ [] ] ]

9712, 9784

4362, 7387

378, 413

10014, 10069

3093, 4339

10354, 10902

2573, 2675

7937, 9689

9805, 9959

7413, 7914

10093, 10331

2690, 3074

9980, 9993

314, 340

442, 1694

1716, 2342

2358, 2557

20,542

153,559

3493

Discharge summary

report

Admission Date: [**2142-6-4**] Discharge Date: [**2142-6-10**] Date of Birth: [**2066-6-15**] Sex: F Service: MEDICINE Allergies: Penicillins / Aldactone Attending:[**First Name3 (LF) 2485**] Chief Complaint: fatigue, lighteheadedness, decreased Hct Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. [**Known lastname **] is a 75 year old female with a history of intestinal AVM, tranfusion dependent, who was referred from his PCP for [**Name Initial (PRE) **] HCT 23. Patient states that every Monday her hct gets checked and she typically comes in approximately every 10-14 days for transfusions. She states that over the last 2 days she was feeling lightheaded and fatigued. She reported subjective chills the day prior to her presentation but denied any fevers or night sweats. She was called with the HCT result and was told to come to the ED. she normally gets transfused every 10 days. Last HCT was on 21/[**Month (only) **] and was 32.9. She denies any increasing cough, upper respiratory symtpoms, diarrhea, abdominal pain, urinary symptoms, nausea or vomiting, chest pain, or worsening shortness of breath. She does report some blood in her stools over the last 6 months. Past Medical History: 1. Chronic Gastrointestinal bleed [**1-4**] multiple upper GI angioectasias with prior EGD and enteroscopies for eclectrocautery 2. Chronic anemia transfusion dependent w h/o 165 blood transfusions 3. Cirrhosis (NASH v AIH) with portal HTN and ascites 4. Grade II EV, portal gastropathy (last EGD [**2142-3-22**]) 5. Diverticulosis of L side of colon-last colonoscopy [**10-7**] 6. Diastolic CHF dx 12/[**2138**]. 7. COPD on home 02 (3L when symptomatic) 8. Diabetes type 2 9. Hypertension. 10. Hypercholesterolemia. 11. Breast cancer status post right lumpectomy, chemotherapy and radiation therapy. 12. Hypothyroidism 13. Hx of "throat cancer",T1b stage I carcinoma of the glottic larynx, treated with surgery and radiation Social History: Lives in [**Location 686**] with adult son and daughter. Former head start administrator. 20 pack year tobacco history. No EtOH or recent drug use. Family History: CAD No family history of GI bleeding. Physical Exam: Vitals: T:98.3 139/58 P: 89 RR: 16 BP: 139/58 SaO2:100# 3L General: Awake, alert, NAD. HEENT: No LAD, no jvd, oropharinx clear Pulmonary: decreased breath sounds bases. no crackels. Cardiac: RRR, nl. S1S2, no murmus Abdomen: soft, NT/ND, bowel sounds positive Extremities: No edema, distal pulses positive Rigth knee: no erythema, no swellling Skin no rashes. porta cath clean Brief Hospital Course: Mrs. [**Known lastname **] was admitted to the floor and transfused 3 units PRBCs overnight. She reported feeling better after the transfusions although not yet back to her baseline. After her 3rd unit Mrs. [**Known lastname **] became febrile to 101.7 F and was hypertensive and tachycardic to SBP 188 and HR 118. Blood, urine, and stool cultures were sent. A CXR the night prior was negative for pneumonia and her lung exam was clear. Her fever responded well to tylenol, her vitals normalized, and as her repeat Hct was only 28.8 from 22.1, she was pretreated with 25 mg of Benadryl and transfused a fourth unit of PRBCs. However, after a third of the unit was transfused she again spike a fever, this time to 103.5 with SBPs again into te 180s and HR to 115. She complained only of feeling very cold but was rigorous. She was given 1 gram of tylenol and 50 mg of benadryl and a transfusion reaction report was started. The blood bank resident was contact[**Name (NI) **] and hematology oncology was consulted. MICU course: 75 yo woman with a h/o GI angiodysplasia and Q2wk transfusions who presents with fatigue, decreased Hcts, leukocytosis, and increased creatinine from baseline. Now s/p bradycardic arrest, found to have worsening ARF, lactic acidosis, and elevated cardiac enzymes. . #) Bradycardic arrest: She had episodes of aflutter and Wenkebach block during this admission, was likely due to infection, possibly endocarditis given the recent MSSA bactermia, or an MI as the patient had elevated cardiac enzymes. She was noted to have hyperkalemia, but this was unclear [**Name2 (NI) 16053**] this was a hemolyzed samples. She was bradycardic through the first evening in the ICU, she became hypotensive and required dopamine pressor to maintain her pressures. Initially, trancutaneous pacers were placed in order to address her symptomatic bradycardia, but after discussion with family regards to her prognosis, the family decided to withdraw invasive measures. The patient expired with respiratory failure . #) Anion gap metabolic acidosis: Likely due to lactic acidosis combined with uremia. Lactic acidosis likely [**1-4**] hypoperfusion during bradycardic arrest, and possibly sepsis. Her lactate initially improved with hydration, she had a KUB and abdominal exam which did not support a bowel performation. She was treated with normal saline boluses, and bicarb as her acidosis worsened . #) ARF: pt with increasing Cr throughout hospitalization (baseline 1.3-1.5), now 4.7. Likely secondary to hypoperfusion with sepsis, she became anuric, renal was consulted, but dialysis was not indicated, and she expired from respiratory failure. . #) ID/MSSA bacteremia: Pt with h/o multipe blood cultures which grew MSSA, likely source was Port-A-Cath (now removed). Pt continues to have rising WBC count, and now with 1/2 blood cx's positive for GPC in clusters from yesterday. She was started on broad spectrum antibiotics including aztreonam, vancomycin and flagyl as with a pencillin allergy. . #) Elevated cardiac enzymes: Pt had elevated CK-MB and trop s/p bradycardic arrest. Also with ? 1mm STE in subsequent EKG. If ischemia is present, likely demand related. Anticoagulation was held in the setting of chronic GI bleeds. #) Anemia: pt has known GI AVM, likely source of hct drop (pt is transfusion dependent). #) Cirrhosis/elevated LFT's: Pt with known portal HTN and ascites. An ultrasound only showed small amounts of ascites, and a chronic gallstone, without evidence of cholecystitis. She was continued on octreotide, and ciprofloxacin #) Resp failure: Pt intubated during code situation. She was maintained on the ventilator until the family decided to support only comfort measures, and the ventilator was shut off, and she died of respiratory failure. Medications on Admission: Levothyroxine 75 mcg/ day Calcium Acetate 1200 po tid Calcitriol 0.25 mcg daily Atorvastatin 10 mg/day Pantoprazole 40 mg /day Lasix 40mg/day Diltiazem HCl 300 mg sustained release/day Octreotide Acetate 100 mcg/mL [**Hospital1 **] Fluticasone-Salmeterol 250-50 mcg/ [**Hospital1 **] Lorazepam 0.5 mg Tablet [**Hospital1 **] as needed (2 times a day) as needed. sodium Docusate PRN Serovent?? Atrovent 2 puffs daily Glyburide 5mg TID Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Respiratory Failure Sepsis Bradycardia Discharge Condition: Expired Discharge Instructions: Expires Followup Instructions: None

[ "537.82", "250.00", "428.30", "V10.21", "496", "280.0", "401.9", "244.9", "V15.3", "V10.3", "995.92", "276.51", "456.21", "996.62", "427.5", "038.11", "276.2", "584.9", "599.0", "571.5", "572.3" ]

icd9cm

[ [ [] ] ]

[ "96.04", "99.04", "38.91", "86.05", "96.71" ]

icd9pcs

[ [ [] ] ]

6955, 6964

2637, 5676

324, 330

7046, 7055

7111, 7118

2180, 2219

6926, 6932

6985, 7025

6467, 6903

7079, 7088

2234, 2614

5693, 6441

244, 286

358, 1249

1271, 1998

2014, 2164

4,966

145,815

12730

Discharge summary

report

Admission Date: [**2153-9-19**] Discharge Date: [**2153-9-25**] Date of Birth: [**2108-1-21**] Sex: M Service: PURPLE SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 45 year old gentleman who is status post gastric bypass in [**2152**], who has had several admissions in the last several weeks which included problems for postoperative pancreatitis, duodenal stump bleed, multiple episodes of cholangitis, dumping problems, episodes of hypoglycemia. Most recently he has been NPO and receiving TPN. He was admitted through the Emergency Department to the Intensive Care Unit for episode of hypotension. This was following a four day history of right upper quadrant pain. He presented to the Emergency Department with a four day history of right upper quadrant pain and fever for one day with rigors, nausea and vomiting. He was admitted to the Intensive Care Unit through the Emergency Department. PAST MEDICAL HISTORY: 1. Obesity. 2. Malnutrition. 3. Hypoglycemia. PAST SURGICAL HISTORY: 1. Roux-en-y gastric bypass in [**2152-5-10**], with postoperative complications as above. 2 Revision and hepatic jejunostomy [**2152-12-10**]. 3. Revision laparotomy in [**2153-1-10**]. 4. Revision laparotomy with subsequent cholangitis in [**2153-3-10**]. SOCIAL HISTORY: The patient is a nonsmoker, no alcohol. Single parent of one child. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Octreotide 400 mg subcutaneous three times a day. 2. Ciprofloxacin 500 mg p.o. twice a day. 3. TPN. PHYSICAL EXAMINATION: The patient's vital signs on presentation included a temperature maximum of 103.2, temperature current 102.7, blood pressure 83/34, heart rate 118, respiratory rate 23, oxygen saturation 96% in room air. In general, the patient is awake and oriented in no acute distress. Head, eyes, ears, nose and throat - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Cranial nerves II through XII are grossly intact. There is no evidence of any lymphadenopathy or distention. Cardiovascular shows regular rate and rhythm, no murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally. The abdomen is soft, nontender, scaphoid with many surgical incisions well healed without any evidence of any herniation. On deep palpation, he does show some right upper quadrant pain. However, there is negative [**Doctor Last Name **] sign. LABORATORY DATA: On presentation, white blood cell count was 5.4, hematocrit 35.8. Sodium 138, potassium 4.6, chloride 100, CO2 27, blood urea nitrogen 25, creatinine 1.1, glucose 129. Prothrombin time 13.3, partial thromboplastin time 29.0, INR 1.2. ALT 38, AST 44, alkaline phosphatase 144, amylase 78, total bilirubin 2.1, lipase 25, albumin 4.9, lactate of 2.8. Blood cultures are pending. CLINICAL COURSE: Upon presentation to the Intensive Care Unit, the patient remained febrile with a temperature of 103.2. He was started empirically on Zosyn and Vancomycin and Gentamicin. His white blood cell count increased to 7.8. In the Intensive Care Unit, the patient's hypotension responded well to fluid boluses and his vital signs improved. After consulting infectious disease service while in the Intensive Care Unit, the patient had another two sets of blood cultures drawn. At that time, his port-a-cath was also removed and sent for cultures. He was continued on Vancomycin, Zosyn and Gentamicin. His TPN was discontinued. By [**2153-9-21**], the patient's blood cultures had grown six out of six positive for gram positive cocci. He also had positive blood cultures. CT scan also showed evidence of periportal edema and perihepatic fluid collections. Subsequent workup which included assessments by the gastroenterology service, ultrasound, showed no areas that could explain infection. Antibiotics were changed to include Vancomycin. On hospital day five, a PICC line catheter was placed and per infectious disease recommendations, the patient was discharged with a six week course of Vancomycin. DISPOSITION: The patient was discharged to home with visiting nursing care for home intravenous antibiotic therapy. DISCHARGE DIAGNOSES: 1. Presumed line sepsis. 2. Status post gastric bypass. 3. Common bile duct stricture. 4. Dumping syndrome. 5. TPN dependent. FOLLOW-UP: The patient will make plans to have a follow-up visit with Dr. [**Last Name (STitle) **] at which time he can assess the need for longer term intravenous antibiotic therapy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2153-10-20**] 13:53 T: [**2153-10-20**] 15:28 JOB#: [**Job Number 39267**]

[ "790.7", "996.62", "997.4", "287.5", "458.9", "579.3", "576.1", "789.5", "421.0" ]

icd9cm

[ [ [] ] ]

[ "88.72", "86.05", "38.93" ]

icd9pcs

[ [ [] ] ]

4223, 4819

1439, 1546

1025, 1289

1569, 4202

176, 930

952, 1002

1306, 1413

26,724

135,445

10207

Discharge summary

report

Admission Date: [**2177-9-21**] Discharge Date: [**2177-9-24**] Date of Birth: [**2097-6-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7333**] Chief Complaint: s/p pulseless arrest Major Surgical or Invasive Procedure: Intubation Arctic sun cooling/warming protocol History of Present Illness: Mr. [**Known lastname 33556**] is an 80 yo M with PMH of parkinsonism, autonomic instability and labile blood pressures admitted to the CCU following PEA arrest and resuscitation. His wife reports that on the day prior to admission he was in his usual state of health without any complaints. He went to bed at 11pm with his CPAP on. His wife awoke at 1:30AM and noted that he had a strange breathing pattern. She again awoke at 2:30 am and noted that he continued to be breathing strangely and then made several soft choking noises and stopped breathing. She attempted to awaken him with no response so she called EMS who reportedly arrived withing 5-10minutes. . On EMS arrival he was noted to be in PEA arrest he was given 7mg epinephrine, 2mg atropine, 2 amps sodium bicarb, 100mg lidocaine, 300mg amiodarone, DCCV x 5. He was started on amiodarone gtt and dopamine gtt. His pupils were noted to be fixed and dilated by EMS. . On review of systems, his wife denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He does not have any recent fevers, chills or rigors. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. . In the ED, initial vitals were T34.8 rectal 128/77 HR 122 sinus tachycardia RR 18 99% RA. He had an EKG showing sinus tachycardia and a bedside echocardiogram showing hyperdynamic LV function, no wall motion abnormalities. He was started on artic sun protocol however his initial temperature was 34 degrees celsius. He had a head CT which showed evidence of global anoxic insult. He was admitted to the CCU for further care. Past Medical History: Primary autonomic dysfunction - Syncopal events since [**2171**] secondary to orthostatic hypotension - h/o positive tilt table test and othostatic hypotension, followed Dr. [**First Name (STitle) **] at [**Hospital1 18**] Neurogenic bladder - Has had foley catheter for 2 years due to urinary frequency - Patient has not had Foley changed for 4 weeks - h/o Klebsiella and Pseuodomonal UTIs in [**2176**], Enterobacter urosepsis Hypothyroidism Chronic low back pain GERD [**Hospital **] Hospital admission for partial small bowel obstruction and constipation [**8-20**] Empty sella syndrome - endocrine w/u negative Benign bladder mass - s/p cystoscopy and biopsy h/o idiopathic pancytopenia Social History: Patient lives in a house in [**Hospital1 392**], MA with his wife of 56 years who is his main support and primary care provider. [**Name10 (NameIs) **] helps him with all of his IADL's and ADL's, including dressing, showering and medications. He has 5 children and 6 grandchildren. He used to work in the construction business as a manager and has had asbestos exposure in the past. He denies current smoking though he does have a remote history of ~15 pack years of smoking. He denies EtOH or drug use. He does not drive currently. Family History: Mother - DM, passed away at 84 Father - colon CA, passed away at 67 Physical Exam: VS: T=34 celsius on artic sun BP=107/81 HR= 150 regular RR=18 O2 sat= 98% AC 100%/550/16/5 Gen: intubated, unresponsive to any stimulus, no posturing noted HEENT: NC AT, intubated pupils are fixed and dilated at 6mm bilaterally, right pupil appears to be post surgical, left eye with large cataract visible Neck: right EJ 18G iv in place, no significant jvd CV: RRR s1 s2 no appreciable murmur Lungs: CTAB anteriorly, unable to ausculate lung bases as artic sun cooling pads in place, no wheezing Abd: distended, soft, unable to assess for tenderness given mental status, positive bowel sounds Ext: cool, palpable DP's bilaterally Pertinent Results: 72 hour EEG: This is an abnormal video EEG study because of a lack of discernible cortical activity. This study was not performed under a brain death protocol, however. There were no epileptiform features noted. . Head CT without contrast: Markedly limited study secondary to streak artifact from metallic scalp leads. Hypodensities within the bilateral basal ganglia and thalami in addition to decreasing size of the lateral ventricles, which are barely visible, all suggestive of increasing cerebral edema. A repeat evaluation may be obtained once the metallic scalp leads have been removed. These findings were communicated to Dr. [**Last Name (STitle) 4312**] on [**2177-9-22**] at 4:00 a.m. . NOTE ADDED AT ATTENDING REVIEW: I agree with the above interpretation. However, in addition to diffuse hypodensity of the deep grey matter structures, there is strking hypodensity of essentially all cortical grey matter. This is so severe that the cortex is of lower density than the white matter. This is associated with effacement of cortical sulci. These findings indicate severe global cortical edema. Given the history, this is most likely due to global hypoperfusion and infarction. Brief Hospital Course: 80 y/o male with parkinsonism, autonomic instability, who was admitted to CCU following PEA arrest, likely secondary to aspiration, now s/p Arctic sun protocol, re-warmed and off sedation, with anoxic brain injury and worsening cerebral edema on CT scan, with flat lining EEG, no brainstem reflexes, and no spontaneous breathing. . # s/p PEA arrest: unlikely to be from primary cardiac etiology, at this time most like due to hypoxia from possible aspiration event given that main laboratory abnormality is hypoxia and also with new bilateral infiltrate. No evidence of pericardial effusion on echo, no evidence of pneumothorax. No evidence of acute MI on admission. He did have a lactic acidosis, likely [**3-17**] prolonged pea arrest in the field. He was in sinus tachycardia with occasional 2nd degree heart block type I on telemetry since admission. He was bolused with amiodarone and lidocaine in the field and started on an amiodarone gtt by EMS. In the CCU, pt went into PEA arrest again. CPR was performed, epi x 1 and atropine x 1 given, with cardiac function returning within 3-5 minutes. CT scan showed diffuse anoxic brain injury with poor prognosis (flat EEG, CT head showing worsening cerebral edema, physical exam without brainstem reflexes). Pt completed Arctic sun cooling, then warming protocol. His sedation was weaned when re-warmed. Neuro evaluated the patient, and noted absence of brainstem reflexes, fixed dilated pupils, and no response to cold caloric testing. Pt was made DNR/DNI. Amiodarone gtt was discontinued as PEA arrest felt to be very unlikely to be primary cardiac. Apnea test, combined with neuro eval, confirmed brain death and patient was pronounced dead at 4:23 pm on [**2177-9-24**]. Family at bedside, declined autopsy. [**Location (un) 511**] Organ bank felt that pt is not a candidate for organ donation. . #Hypoxia - Most likely etiology of PEA arrest, with significant AA gradient. Unclear etiology at this time, possibly [**3-17**] aspiration event given LLL opacity and air bronchograms on CXR. Pulmonary embolus was a consideration; however no evidence of right heart strain on echocardiogram or PE on CTA. Initially started on vancomycin and zosyn for aspiration pneumonia, but discontinued when family transitioned patient to CMO status. . #Anoxic Brain Injury - head ct on admission with evidence of global anoxic injury likely [**3-17**] prolonged PEA arrest of unknown duration. Pt completed cooling protocol, then rewarmed, with unchanged exam. He was taken off fentanyl/versed with no brainstem reflexes and poor prognosis, as per neuro. 72 hour EEG showed no waveform. . # Hypotesion/Autonomic Instability - long h/o labile BP and severe orthostasis. He is on numerous doses of midodrine at baseline as well as salt tabs. Per his family it is not unusual for him to have blood pressure in the 80's - 90's systolic then up to the 160's in the evening. Anoxic injury likely contributing to labile BP. . # Dispo: patient declared brain dead at 4:23 pm on [**2177-9-24**]. Extubated soon thereafter. Family at bedside, declined autopsy. Patient did not qualify for organ donation. Medications on Admission: AMANTADINE - 100 mg three times a day CARBIDOPA-LEVODOPA 25 mg-100 mg Tablet - 1 Tablet(s) [**Hospital1 **] CITALOPRAM 20mg daily MIDODRINE - 10mg q6am, 10mg q10am, 5mg q2pm and 5mg at 6pm (hold 2pm and 6pm doses for sbp >160) SODIUM CHLORIDE - 1G Tablet - TAKE UP TO TEN TABLETS A DAY TRIMETHOPRIM-SULFAMETHOXAZOLE 800 mg-160 mg Tablet 1 tab [**Hospital1 **] prilosec 20mg daily levothyroxine 50mcg daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: out of hospital PEA arrest, felt to be related to aspiration event Discharge Condition: deceased Discharge Instructions: . Followup Instructions: . Completed by:[**2177-9-24**]

[ "426.13", "427.5", "427.41", "348.5", "276.2", "724.5", "427.89", "327.23", "401.9", "V15.82", "530.81", "348.1", "596.54", "507.0", "V66.7", "244.9", "333.0", "788.30", "338.29" ]

icd9cm

[ [ [] ] ]

[ "99.81", "38.93", "99.60", "96.71", "38.91" ]

icd9pcs

[ [ [] ] ]

9061, 9070

5416, 8577

336, 384

9180, 9190

4205, 5393

9240, 9272

3469, 3538

9033, 9038

9091, 9159

8603, 9010

9214, 9217

3553, 4186

276, 298

412, 2187

2209, 2903

2919, 3453

7,262

149,245

17375

Discharge summary

report

Admission Date: [**2122-5-14**] Discharge Date: [**2122-6-19**] Date of Birth: [**2054-11-10**] Sex: M Service: BLUE SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 67 year-old man transfer from an outside hospital with a presentation of mental status changes and sepsis. He has a history of hypertension, cerebrovascular accidents, diabetes and a left hip surgery for end stage osteoporosis who at the end of [**Month (only) 547**] had been taking large amounts of Percocet for left hip pain. At home on [**2122-5-8**] the patient became combative and the wife called EMS and he was taken to [**Hospital3 1280**] Hospital. There he became hemodynamically unstable and was intubated and started on pressors for circulatory support. He was found to have MSSA positive blood cultures and a transesophageal echocardiogram there was bacterial vegetation. Over the next several days he continued to require pressor support, ventilatory support and developed acute renal failure and increasing abdominal distention. He was transferred to [**Hospital1 69**] for further evaluation and workup and critical care support. PAST MEDICAL HISTORY: 1. Mitral regurgitation. 2. Hypercholesterolemia. 3. Cerebrovascular accident six or seven years ago. 4. Diabetes mellitus. 5. Hypertension. 6. End stage osteoporosis. PAST SURGICAL HISTORY: Left hip surgery, which is not specified. MEDICATIONS AT HOME: 1. Vioxx. 2. Lipitor. 3. Zestril. 4. Metformin. 5. Spironolactone. 6. Aspirin. 7. Zantac. 8. Vitamins. ALLERGIES: Dicloxacillin and sulfa based medications. SOCIAL HISTORY: The patient lives with wife. PHYSICAL EXAMINATION: The patient is hypotensive with a blood pressure of 90/50, tachycardic to 120, breathing at 23 with a sat of 98%. The patient does not follow commands, intubated, grimaces to stimulation. Pupils are equal, round and reactive to light. He had bilateral wheezing on end expiration with rales at the bases. Heart was regular. No murmur noted on examination. Abdomen was distended, firm and tender. Rectal was guaiac positive. The right third digit had purulent drainage and the right foot plantar surface had an open wound, which was clean. The patient had 2+ edema in the bilateral lower extremities. LABORATORIES ON ADMISSION: White blood cell count of 28 with 81% neutrophils, 9% bands, hematocrit 40, INR 1.5, BUN 42, creatinine 1.9 ALT 84, AST 52 and alkaline phosphatase of 378 and a total bilirubin was 0.7. Initial blood gas was 7.37, 34, 134, 20, -4. The patient had a KUB, which demonstrated distention of the right and transverse colon with some dilated loops of small bowel. The cecum was 16 cm. A CAT scan performed demonstrated bilateral pleural effusions, thickening of the descending colon with adjacent fat stranding and small amount of free fluid. Head CT demonstrated a 1.5 cm cerebellar lesion thought to be subacute versus infectious. Of note, the CAT scan demonstrated a right common femoral vein thrombus. HOSPITAL COURSE: The patient presented critically ill. He was immediately placed in the Intensive Care Unit. He required pressor support to maintain his hemodynamics and this was managed via a PA catheter. His initial presenting problems included sepsis from presumed MSSA endocarditis, a cerebellar lesion question an embolic phenomenon, a right third finger necrosis with purulent drainage thought to be embolic phenomenon, a right common femoral vein deep venous thrombosis and descending colon colitis thought to be ischemic in nature and acute renal failure. The patient received aggressive hemodynamic support, ventilatory support. He was placed on broad spectrum antibiotics. In his initial hospital course he continued to spike temperatures and had a persistent leukocytosis. The source for the endocarditis was thought to be secondary to the pain associated with his left hip and a possible osteomyelitis or joint infection. He was evaluated by the orthopedic team and underwent an ultrasound guided tap, which demonstrated gram positive rods of rare growth. He was continued on antibiotics and was weaned off pressor support with improving hemodynamics. Over the next several days his leukocytosis persisted though and the patient did not show signs of improvement and the patient was taken to the Operating Room on [**2122-5-22**] to undergo a left hip incision and drainage and a Girdlestone procedure, which involves removing of the femur head and proximal shaft. This procedure was significant for 10 cc of pus. The patient tolerated this procedure well and was transferred back to the Intensive Care Unit after the surgery. The patient continued to have intermittent temperature spikes and an intermittent need for pressor support to maintain hemodynamics. The patient had numerous line changes blood cultures without any clear indication of the source of his sepsis. The patient had the right common femoral vein thrombosis evaluated by Vascular Surgery and he underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter placement secondary to the contraindication to anticoagulation due to his cerebellar lesions. The patient remained critically ill and was maintained on appropriate therapy for his bacteremia and began to show signs of improvement. He after several weeks of antibiotic therapy the blood cultures have remained negative. The patient's acute renal failure on admission improved and his current creatinine is 0.4. Serial echocardiography of his heart demonstrated a stabilized vegetation. At the end of [**Month (only) 116**] the patient developed a lower gastrointestinal bleed. This required a transfusion of packed red blood cells and the patient underwent a colonoscopy, which demonstrated ischemia of the transverse and proximal descending colon. The patient continued to require resuscitation for the gastrointestinal bleed and on [**6-11**], underwent an exploratory laparotomy. The findings in the Operating Room included a colospleno arterial fistula, which appeared to be chronically bleeding. Also a colojejunel fistula at a separate location. The patient underwent a subtotal abdominal colectomy, control of the splenic hilar erosion bleed, a Hartmann's procedure and ileostomy placement of a feeding jejunostomy tube and a tracheotomy tube placement. The patient tolerated this procedure well and his postoperative course has led to improvement. His hemodynamics have remained stable. He is currently off of pressors. His ventilatory status was improved and the patient is currently on a pressor support of 5 and a PEEP of 5 and undergoing trach mask spontaneous breathing trials. The patient's mental status has cleared and he is awake following commands. The patient remained afebrile and recent cultures have been negative for bacteremia. The patient has been continued on his antibiotic course under the guidance of the infectious disease team. After the surgery the patient did have a trend of a increasing white count and the central line was removed. Postoperative day one the patient was started on tube feeds and this has been advanced to a goal of full strength at 90 cc per hour. The patient is receiving physical therapy and occupational therapy. Seeing as the patient appears to have recovered from his acute illness and demonstrates no bacteremia or septic physiology and improvement in all organ systems the patient is stable for discharge to rehabilitation facility where he will undergo continued therapy. DISCHARGE DIAGNOSES: 1. Endocarditis with multiple embolic phenomenon. 2. Acute renal failure. 3. Ischemic colitis status post total abdominal colectomy Hartmann's procedure with end ileostomy. 4. Respiratory failure status post tracheotomy tube placement. 5. Right common femoral vein thrombosis status post [**Location (un) 260**] filter placement. 6. Septic joint status post Girdlestone procedure. 7. Sepsis/bacteremia with MSSA. 8. Pseudomonas urinary tract infection. MEDICATIONS ON DISCHARGE: 1. Lopressor 50 mg po b.i.d. 2. Heparin 5000 units subq q 8 hours. 3. Nystatin swish and swallow 5 ml q.i.d. 4. Dilaudid 1 mg intravenous q 3 to 4 hours prn. 5. Zosyn 4.5 grams intravenous q 8 hours times seven days. 6. Desonide 0.5% cream topical b.i.d. as needed. 7. Albuterol one to two puffs inhaler q 6 hours prn. 8. Protonix 40 mg po q.d. 9. NPH insulin 16 units q.a.m. and q.p.m. 10. Haldol 1 to 2 mg intravenous prn. DISCHARGE CONDITION: The patient is in stable condition tolerating tube feeds at goal, which is Impact with fiber at 90 cc an hour. The patient is following commands and can undergo physical therapy. The patient's abdominal wound has two small open areas, which can be dressed with a wet to dry dressing change. The patient's ileostomy is functioning well. The patient's follow up will be with Dr. [**Last Name (STitle) **] in two weeks following discharge. The patient will follow up with Dr. [**Last Name (STitle) 284**] in the orthopedics clinic three weeks after discharge. The patient is to follow up with plastics for the finger lesion three weeks after discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**] Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2122-6-18**] 11:16 T: [**2122-6-18**] 12:47 JOB#: [**Job Number 48607**]

[ "289.59", "421.0", "711.05", "569.81", "518.81", "453.8", "557.9", "424.0", "584.9" ]

icd9cm

[ [ [] ] ]

[ "89.64", "96.04", "80.85", "31.1", "96.72", "45.79", "77.85", "38.7", "99.15", "46.74", "38.91", "46.23", "46.39", "96.6" ]

icd9pcs

[ [ [] ] ]

8505, 9443

7559, 8021

8047, 8483

3030, 7538

1430, 1598

1366, 1409

1668, 2290

175, 1145

2305, 3012

1167, 1342

1615, 1645

62,514

175,466

53958

Discharge summary

report

Admission Date: [**2108-4-8**] Discharge Date: [**2108-5-2**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 348**] Chief Complaint: right shoulder twitching, altered mentation Major Surgical or Invasive Procedure: intubation History of Present Illness: The patient is a [**Age over 90 **] year old woman with a recent history of frequent seizures with right face and shoulder twitching who returns to [**Hospital1 18**] with reports of altered mentation and recurrence of right shoulder twitches. Her history from her recent admission is as follows: on [**2108-2-18**] she was found down at her residence and was noted to be bradycardic, hypotensive, hypothermic, and lethargic. She was transported to an ED at Upstate [**Location (un) **] Hospital in NY where she had a cardiopulmonary arrest and was intubated and resuscitated. The intubation was difficult and she was found to have a mediastinal mass (multinodular goiter with papillary microcarcinoma, which was removed). She had a complicated hospital course with hospital-associated pneumonia, lung collapse s/p bronchoscopy, sepsis, corneal abrasion/chemosis, perioperative anemia from blood loss, and then confusion. She was started on quetiapine initially for suspected ICU-related delirium. However, she started showing clinical signs of seizures (sudden behavioral arrest, blank stare, eye deviation to the left and down) which resolved with low dose of lorazepam. Despite reportedly unremarkable head imaging, she was thought to potentially has PRES (unclear what the blood pressure measurements were at the time). She was started on Levetiracetam 750 mg [**Hospital1 **] for seizure prevention. An EEG done at that time reportedly suggested potential epileptiform foci but no seizures were seen. She was discharged to a rehab but per her family did not return to her prior highly functional baseline mental status. On [**2108-3-21**], she was even more lethargic than usual and did not respond promptly to sternal rub. She was observed as having right face and right shoulder twitches with associated bowel/bladder incontinence which ceased with diazepam 2.5 mg given twice. She had a normal blood sugar of 81 at that time and otherwise normal vital signs after the episode. She was transferred to [**Hospital1 **] for further management where she was given two loading doses of Fosphenytoin 500 mg with some improvement in the focal motor activity. Neurology was consulted there and recommended increasing Levetiracetam to 1000 mg [**Hospital1 **] and continuing Phenytoin. She had an unremarkable NCHCT. She was found to have a UTI and was started on Ceftriaxone on [**3-21**]. She was thought to potentially have pneumonia as well, but chest imaging did not reveal an infiltrate so this was stopped. An EEG was obtained which potentially showed frequent left parasagittal epileptiform discharges, so she was transferred to [**Hospital1 18**] for further care. Upon arrival, her mental status was already improving, so further changes to medications were not made at that time. Her EEG showed frequent GPEDS and PLEDs. She continue to improve in mental status, eventually was transitioned to a single [**Doctor Last Name 360**] again (Levetiracetam 1000 [**Hospital1 **]), and was sent to [**Hospital 38**] Rehab in stable condition. Past Medical History: [] Neurologic - Seizures (s/p cardiac arrest, ? hypoxic brain injury), Recent ? Posterior Reversible Leukoencephalopathy Syndrome (clinical diagnosis at onset of seizures) [] MSK - Left hip fracture (s/p ORIF) [] Cardiovascular - Recent cardiac arrest, HTN, HL, reportedly CAD [] Pulmonary - Recent hypoxic respiratory failure [] Endocrine - Multinodular goiter with papillary carcinoma (s/p resection, discovered during difficult intubation) [] Ophthalmologic - Corneal abrasion/chemosis Social History: Until recently living independently, driving. Previously at [**Location (un) 22092**] on the [**Doctor Last Name **] but was at [**Hospital 38**] rehab post-[**Hospital1 **] discharge. No tobacco, ETOH, or illicit drug use. Family History: Ovarian cancer (mother) Physical Exam: At admission: VS T: 98.7 HR: 67 BP: 123/64 RR: 17 SaO2: 100% RA General: NAD, lying in bed comfortably. Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions Neck: Supple, no nuchal rigidity, no meningismus Cardiovascular: RRR, no M/R/G Pulmonary: Equal air entry bilaterally, no crackles or wheezes Abdomen: Soft, NT, ND, no guarding Extremities: Warm, no edema, palpable radial/dorsalis pedis pulses Skin: No rashes or lesions Neurologic Examination: - Mental Status - Lethargic, but easily arouses to voice and keeps her eyes open for about a minute if continuously stimulated by voice or non-noxious stimuli. Smiles. Inattentive. Follows midline commands (opens/closes eyes, sticks out tongue) but not appendicular commands consistently. No verbalization. - Cranial Nerves - [II] PERRL 3->2 brisk. VF full to threat. [III, IV, VI] Tracks to the left but has difficult crossing midline to the right. [V] Corneals present bilaterally. [VII] No facial asymmetry at rest. [XII] Tongue midline. - Motor - No tremor or asterixis or myoclonus currently. Extends RUE to noxious. Flexion withdraws LUE to noxious. Triple flexes both LE to noxious, R > L. - Sensory - Response to noxious all four extremities. - Reflexes =[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc] L 2 2 2 2 2 R 2 2 2 2 1 Plantar response extensor bilaterally. - Coordination - Unable to assess at the time of examination. - Gait - Unable to assess at the time of examination. DISCHARGE: deceased Pertinent Results: [**2108-4-8**] 04:20PM BLOOD WBC-7.1 RBC-3.73* Hgb-11.2* Hct-36.7 MCV-98 MCH-30.0 MCHC-30.5* RDW-15.7* Plt Ct-455* [**2108-4-9**] 06:20AM BLOOD WBC-4.0 RBC-3.12* Hgb-9.6* Hct-30.6* MCV-98 MCH-30.7 MCHC-31.4 RDW-15.8* Plt Ct-345 [**2108-4-8**] 04:20PM BLOOD Neuts-75.4* Lymphs-15.8* Monos-5.2 Eos-3.4 Baso-0.2 [**2108-4-9**] 12:20PM BLOOD PT-11.2 PTT-64.5* INR(PT)-1.0 [**2108-4-8**] 04:20PM BLOOD Glucose-64* UreaN-16 Creat-0.8 Na-145 K-4.8 Cl-109* HCO3-20* AnGap-21* [**2108-4-9**] 12:20PM BLOOD ALT-13 AST-26 CK(CPK)-103 AlkPhos-113* TotBili-0.3 [**2108-4-9**] 06:20AM BLOOD CK-MB-8 cTropnT-0.13* [**2108-4-9**] 12:20PM BLOOD CK-MB-15* MB Indx-14.6* cTropnT-0.20* [**2108-4-8**] 04:20PM BLOOD Calcium-10.4* Phos-2.9 Mg-1.5* [**2108-4-9**] 06:20AM BLOOD Phenyto-16.7 [**2108-4-9**] 06:23AM BLOOD Phenyto-18.7 [**2108-4-9**] 02:15PM BLOOD Type-ART pO2-365* pCO2-39 pH-7.37 calTCO2-23 Base XS--2 [**2108-4-8**] 05:20PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012 [**2108-4-8**] 05:20PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD [**2108-4-8**] 05:20PM URINE RBC-10* WBC-61* Bacteri-FEW Yeast-FEW Epi-0 [**2108-4-8**] 05:20PM URINE CastHy-4* [**2108-4-9**] 02:07PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2108-4-9**] 02:07PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2108-4-9**] 02:07PM URINE RBC-3* WBC-8* Bacteri-FEW Yeast-RARE Epi-0 [**2108-4-9**] 02:07PM URINE CastHy-19* MICRO data: RESPIRATORY CULTURE (Preliminary): Further incubation required to determine the presence or absence of commensal respiratory flora. STAPH AUREUS COAG +. MODERATE GROWTH. [**4-8**] CXR: FINDINGS: Single portable frontal chest x-ray demonstrates no acute intrathoracic process. Blunting of the costophrenic angles with fluid seen in the minor fissure represents trace bilateral pleural effusions which are unchanged from prior study. The cardiac silhouette is enlarged with stable left ventricular predominance. Calcifications are again noted within the aortic arch, as are clips within the left neck. There is no pneumothorax. There are no suspicious osseous lesions. IMPRESSION: Probable tiny bilateral pleural effusions, unchanged from prior. No acute intrathoracic process. [**4-9**] CXR: IMPRESSION: AP chest compared to [**4-8**] at 4:21 p.m.: New endotracheal tube ends at the level of the aortic apex, between 4.5 cm from the carina, in standard placement. Lungs are low in volume but clear. Moderate cardiomegaly is stable. There is no pleural abnormality or evidence of central lymph node enlargement. Thoracic aorta is heavily calcified but not focally dilated. [**4-9**] NCHCT: FINDINGS: There is mild brain atrophy seen. There is no evidence of midline shift or hydrocephalus. No evidence of intra- or extra-axial hemorrhage seen. IMPRESSION: No acute abnormalities. MICU imaging: CXR [**4-19**]:NG tube tip is out of view below the diaphragm likely in the stomach. ET tube tip is in the standard position 3.9 cm above the carina. Left PICC tip is in the lower SVC. There is no pneumothorax. Moderate-to-large right and small-to- moderate left pleural effusion are grossly unchanged allowing the difference in positioning of the patient. Cardiomediastinal contours are unchanged and there is mild vascular congestion. CXR [**4-20**]: Endotracheal tube tip is 4 cm above the carina, orogastric tube ends into the stomach, and left-sided PICC line tip is in lower SVC. Since [**2108-4-19**], mild right pleural effusion has improved, while left lower lung opacity, probably a combination of effusion and atelectasis is better. Mild pulmonary vascular engorgement is similar. Mildly enlarged heart size, mediastinal and hilar contours are unchanged. No new discrete opacities in the lungs CXR [**4-21**]: IMPRESSION: An enteric tube follows a course similar to the enteric tube in place yesterday, ending in the left upper quadrant, presumably but not definitively in the stomach. There is no pneumothorax. Left PIC line ends low in the SVC. Moderate cardiomegaly and small bilateral pleural effusions have increased. Atelectasis at both lung bases is stable. Brief Hospital Course: Ms. [**Known lastname 110651**] is a [**Age over 90 **]F with hx of cardiopulmonary arrest c/b seizures presents from rehab with unresponsiveness and muscle twitches concerning for seizure activity. Found to have a UTI which likely lowered seizure threshold. Shortly after admission patient was seen to have ongoing twitching despite increase keppra dose and was loaded with Fosphenytoin with resultant hypotension/bradycardia and transfer to the NeuroICU. Neuro ICU course: In the NeuroICU, she was intubated and started on Levophed for hypotension. Neuro exam significant for increased level of arousal since starting AEDs, but has since declined again. She continues to have decreased movement on the left compared to RUE. NCHCT unrevealing, EEG shows PLEDs. On [**4-19**] the patient continued to be lethargic. She was noted to be tachypneic and O2 sats decreased from 99% on RA to 82%. Face mask and then non-rebreather were placed initially with good response, but again decreased to 79% on non-rebreather. Anesthesia was called stat and the patient was intubated prior to transfer to MICU for further care. The patient's son was called prior to intubation and he confirmed full code. # Respiratory failure: While in the MICU, the patient was experiencing hypoxic respiratory failure precipitated by volume overload evidenced by history of IVF administration and presence of pleural effusions, improving with diuresis. Oxygenation improved with diuresis, but AMS may have led to airway compromise as she was minimally responsive off of sedation. Successfully extubated on [**4-21**] and maintained on face mask for 24 hours prior to call out from the MICU. On the floor, the patient was maintained on 40% face mask. She initially remained DNR, but ok to intubate, but after reassessing goals of care with the patient's son [**Name (NI) 382**], she was made DNR/DNI and transitioned to CMO. Face mask was continued for comfort. # PNA - patient spiked a temperature to 101 on morning of [**4-20**]. Patient was empirically started on vanc/cefepime on [**4-20**] for HCAP and potentially ventilator associated PNA. Sputum gram stain grew out GPCs, and culture grew coagulase positive staph aureus. Patient was continued on vanc/cefepime. The patient's antibiotics were discontinued on the medicine floor after she was made CMO. # Hypotension: Patient has had intermittent hypotensive episodes treated with gentle fluid bolus and minimal pressor requirement. Weaned off pressors on [**4-20**]. Likely in the setting of sepsis from PNA. Patient was treated with antibioitcs as above. Patient was normotensive prior to transfer from MICU and remained normotensive on the floor. # Flash Pulmonary Edema: Prior to unit transfer, patient received 2L IVF on the floor, overnight IVF and an additional liter of IVF from meds given on the day of transfer. She developed acute respiratory distress with sats to low 80's on NRB. CXR showed worsening pleural effusions and pulmonary edema. She received 20mg of IV lasix, was intubated, and transferred to the unit. Recent Echo showed mild MR [**First Name (Titles) **] [**Last Name (Titles) **] 60%. Etiology of pulmonary edema may be fluid overload in the setting of diastolic dysfunction vs. acute MI, however CE down from previous so unlikely. Patient underwent gentle diruresis and respiratory status improved. While on the floor, the patient was gently diuresed. However, this was also stopped once the patient was made CMO. # Seizure disorder: Patient is on valproate and levetiracetam for seizure prophylaxis. She is also on continual EEG monitoring. Balanced the therapeutic value of AED's with the side affect of sedation/AMS. Neuro continued to follow the patient while on the floor and decreased her medication doses. Once she was made CMO, her AED's were converted to IV and were continued for her comfort. # h/o Cardiac arrest with anoxic injury: Patient had cardiac arrest in [**Month (only) 958**] of this year with anoxic injury and subsequent development of seizure disorder. Etiology is unclear but cards eval considered prolonged QT-syndrome. QT prolonging agents were avoided during this hospitalization. # Hypernatremia: Patient with mildly elevated sodium levels while in the MICU. Free water deficit calculated to be 1L. Was treated with gentle D5W hydration. While on the floor, her sodium levels remained within normal limits. # Goals of care: Patient has a poor prognosis from a medical standpoint given the recent cardiac arrest and complicated hospital course involving three intubations and ICU admissions over the past few months. Discussed goals of care with son, and the likely negative outcome of a repeat cardiac arrest and resuscitation would be outside of patient's wishes, and agrees to DNR. The patient was ultimately also transitioned to DNI and she was made CMO. Pall care consult was also obtained to help optimize patient comfort. Medications on Admission: ASA 325 Daily Levetiracetam 1000 [**Hospital1 **] (solution), Metoprolol tartrate 25 [**Hospital1 **], Bisacodyl 10 daily, Heparin SC, Potassium 40 mEq daily, Acetaminophen PRN, Docusate/Senna, Multivitamin Discharge Medications: NONE Discharge Disposition: Expired Discharge Diagnosis: primary diagnosis: seizure disorder hypoxic respiratory failure Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2108-5-3**]

[ "518.4", "V15.88", "V15.51", "348.1", "276.2", "518.81", "482.41", "401.9", "997.31", "682.3", "285.9", "348.39", "276.0", "345.90", "414.01", "458.9", "E879.8", "V10.89", "410.91", "V12.53", "V49.86", "272.4", "599.0", "V10.87", "275.3", "V66.7", "511.9", "041.11" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.91", "38.93", "89.19", "96.04", "96.6", "33.24" ]

icd9pcs

[ [ [] ] ]

15259, 15268

10033, 14972

293, 305

15376, 15386

5745, 7298

15438, 15471

4153, 4178

15230, 15236

15289, 15289

14998, 15207

15410, 15415

4193, 4632

7339, 10010

209, 255

333, 3382

15308, 15355

4656, 5726

3404, 3895

3911, 4137

3,748

150,022

18712+18713+56976

Discharge summary

report+report+addendum

Admission Date: [**2178-8-3**] Discharge Date: [**2178-8-11**] Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old male with a history of hypertension presenting to the [**Hospital1 1444**] Emergency Department after outpatient work-up of a known dissecting aortic hematoma, found to have new ascending aortic dissection on MRI. The patient had a [**1-26**] week history of intermittent chest pain, no shortness of breath, no nausea, no vomiting, no numbness, weakness or tingling. Comorbidities include hypertension. SOCIAL HISTORY: The patient is a nonsmoker, no alcohol use. PHYSICAL EXAMINATION: On presentation the patient's heart rate was 68, blood pressure 160/75, respiratory rate 18, saturating at 97%. The patient was in no apparent distress, alert and oriented x 3. Lungs were clear to auscultation bilaterally. Heart was regular rate and rhythm. Abdomen was soft, nontender, nondistended. The patient had 2+ bilateral dorsalis pedis pulses and 2+ bilateral radial pulses, no numbness or sensation was noted. MRI of the chest included findings of: 1. New type A aortic dissection limited to the ascending aorta. No evidence of aortic regurgitation, pericardial effusion, or dissection into the aortic vessels. Increased aneurysmal dilatation of the ascending aorta to 4.8 cm. 2. Stable descending thoracic aortic intramural hematoma. 3. Slightly increased bilateral pleural effusion. 4. Substantial adventitial enhancement likely related to inflammatory components. HOSPITAL COURSE: A CT surgery consultation was called and the patient's preoperative diagnosis was subacute aortic dissection. Procedure was an ascending aortic replacement with #28 Gelweave and resuspension of the aortic valve on [**2178-8-3**]. The pericardium was reapproximated. A-line, Swan-Ganz catheter, and CVP/RA catheter were in place. Ventricular and atrial wires were in place and mediastinal tubes x 2 were in place. The patient tolerated the procedure well. Please see the operative note. The patient was transferred to the recovery unit in normal sinus rhythm on a Neo-Synephrine drip. The patient was transfused three units of packed red blood cells postoperatively with Neo-Synephrine and propofol drips off, on vancomycin prophylaxis with temperature of 100.8, heart rate of 98 paced, blood pressure of 94/53, respiratory rate 24 on SIMV of 0.5/700 x 10, 4/5/5 with an arterial blood gas of 7.39/34/172/21/-3. The patient's I's and O's were 6050 in, 790 out, 315 of that urine output. WBC's were 22.9, hematocrit 34.6, platelet count 317. Electrolytes were within normal limits, significant for creatinine of 1.4. Examination was unremarkable. The patient was noted to have right hand weakness, decreased grasp strength and limited abduction/adduction of the right phalanges, full range of motion of the wrist and proximal upper extremity, no other neurological defects were noticed, except for possible slight right lower extremity weakness. A CT of the head was obtained showing focal areas of hypoattenuation involving [**Doctor Last Name 352**] and white matter located with the posterior right temporal lobe and in the left occipital lobe representing likely recent infarct. There were also lacunar infarcts in the right cerebellum, which are probably old. There was no acute intracranial hemorrhage. A neurology consultation was called to evaluate this possible new stroke. Their recommendations included keeping the hematocrit over 30, hypertensive control, hyperglycemic control, cholesterol panel. Their feelings were that this probably represented an embolic stroke secondary to atrial fibrillation. The patient was weaned off drip. White count was stabilized. Blood pressure was within normal limits, and the patient was being seen by occupational therapy and physical therapy. The patient had serial neurologic examinations being performed. The patient was transferred to the floor in stable condition. The rest of the [**Hospital 228**] hospital course was unremarkable. Overall the patient was afebrile with good urine output, a stabilized and decreased white count, and examination remarkable for persistent decrease in strength of grasp and abduction/adduction of the fingers with slight improvement. The patient was diuresed and continued on cardiac medications throughout the course of the hospital stay. Physical therapy and occupational therapy continued to follow, and the patient was discharged to a rehabilitation center in stable condition. DISCHARGE DIAGNOSES: 1. Ascending aortic dissection. 2. Hypertension. 3. Status post cerebrovascular accident. DISCHARGE MEDICATIONS: 1. Lopressor 75 mg p.o. b.i.d. 2. Lasix 20 mg p.o. b.i.d. An addendum will note the duration and any other discharge medications added. DISCHARGE INSTRUCTIONS: 1. The patient will call the office of Dr. [**Last Name (STitle) **] if experiencing bleeding, infection, or fevers of greater than 101.5. 2. The patient was instructed to follow up at the office of Dr. [**Last Name (STitle) **] in four weeks' time. CONDITION ON DISCHARGE: Stable. The patient is status post ascending aortic replacement with a #28 Gelweave and resuspension of aortic valve. [**Known firstname 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 3365**] MEDQUIST36 D: [**2178-8-11**] 04:09 T: [**2178-8-11**] 07:31 JOB#: [**Job Number 51297**] Admission Date: [**2178-8-3**] Discharge Date: [**2178-8-11**] Service: CARDIOTHORACIC SURGERY: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 51298**] is an 83-year-old male presenting to [**Hospital1 **] Emergency Department after workup for a known descending aortic hematoma, noted on MRI to have a new ascending aortic dissection. The patient has had a [**1-26**] week history of chest pain. Denying shortness of breath, nausea, or vomiting, numbness, weakness, or tingling. PAST MEDICAL HISTORY: Hypertension. Upon presentation, the patient's heart rate was 68, blood pressure was 160/75, respirations were 18, and patient satting at 97% on room air. The patient appeared to be in no apparent distress. Examination included chest was clear to auscultation bilaterally. Regular, rate, and rhythm, and soft, nontender, nondistended abdomen. The patient had +2 bilateral DPs, and +2 bilateral radial pulses. The patient denied numbness and sensation was intact. MRI of the chest was done on [**2178-8-3**]. Impression included the following: 1. New type A aortic dissection limited to the ascending aorta. No evidence of aortic regurgitation, pericardial effusion, or dissection into the arch vessels. Increase aneurysmal dilatation of ascending aorta to 4.8 cm. 2. Stable descending thoracic aortic intramural hematoma. 3. Slightly increased bilateral pleural effusions. 4. Substantial adventitial enhancement likely related to inflammatory components. A CT Surgery consult was requested and patient was administered Esmolol to keep systolic blood pressure less than 140. Patient was status post descending aortic replacement with a #28 Gelweave and re-suspension of aortic valve on [**8-3**]. Preoperative diagnosis was subacute aortic dissection. Please see op note. The pericardium was left reapproximated. Lines included an A line, a Swan-Ganz catheter, CVP/RA catheter. Wires included ventricular and atrial. Tubes included mediastinal x2. Upon transfer to the recovery unit, the patient was in normal sinus rhythm on a Neo drip. Patient tolerated the procedure well. On postoperative day one, the patient was transfused 3 units of packed red blood cells overnight, and had a low cardiac index of less than 3. The Neo and propofol drips were off, and patient had a temperature of 100.8, heart rate of 90 A paced, blood pressure of 94/53, respiratory rate of 24. Was on SIMV 0.5/700 x10, [**3-28**]. Arterial blood gas of 7.39/34/172/21/-3. The patient had 6,050 in, 790 out, 315 of that was urine output and 85 was chest tube. Laboratories included a white count of 22.7, hematocrit of 35.6, and platelets of 317. Electrolytes were significant for a creatinine of 1.4. Physical examination was unremarkable, and plan was wean to extubation, diurese, continue Vancomycin prophylaxis. Throughout the hospital course, the patient was noticed to have right hand weakness. Symptoms consistent with a left cerebrovascular event. CT scan of the head was obtained and findings included focal areas of hypoattenuation involving [**Doctor Last Name 352**] and white matter located in the posterior right temporal lobe and in the left occipital lobe. Lacunar infarctions in the right cerebellum, which are probably old. There is no acute intracranial hemorrhage. The weakness included a weak grasp/abduction of the right hand and slight decrease in strength in the right lower extremity. Patient had full range of motion of the right wrist and proximal upper extremity. By postoperative day two, all drips were off. The patient was on Vancomycin prophylaxis and diuresing. Temperature was 101.3. Rest of the vital signs were within normal limits. Patient was sating at 99% on 5 liters. White count had come down to 12.8. Occupational and Physical Therapy consults were called. Patient had several episodes of rapid atrial fibrillation controlled with Lopressor, and was given Haldol prn for confusion. A Neurology consult was called to evaluate the right upper extremity weakness. Their recommendations included tight hyperglycemic control, blood pressure control, and to keep the hematocrit over 32, optimize cerebral oxygenation perfusion setting of an old stroke. The rest of the [**Hospital 228**] hospital course was unremarkable. The upper extremity weakness was being monitored despite improvement daily. The patient had been afebrile. Blood pressure was stable and transferred to the floor with no problems. Overall, the patient was afebrile with stable vital signs, improving right hand grasp strength, being seen by OT, PT, ambulating, voiding, and tolerating a cardiac/diabetic diet without problems. Patient was discharged to rehabilitation center in stable condition. DISCHARGE DIAGNOSIS: Subacute aortic dissection status post ascending aortic replacement with a #28 Gelweave and re-suspension of aortic valve. COMORBIDITIES: Hypertension. [**Known firstname 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 3365**] MEDQUIST36 D: [**2178-8-11**] 03:29 T: [**2178-8-11**] 07:09 JOB#: [**Job Number 51299**] Name: [**Known lastname 9526**], [**Known firstname **] Unit No: [**Numeric Identifier 9527**] Admission Date: [**2178-8-3**] Discharge Date: [**2151-2-22**] Date of Birth: [**2095-7-16**] Sex: M Service: ADDENDUM TO HOSPITAL COURSE: On the day of discharge, the patient's physical examination revealed his lungs were clear to auscultation bilaterally. His heart was regular in rate and rhythm. His abdomen was soft, nontender, and nondistended. He had no peripheral edema. His sternum was clean, dry, and intact with surgical clips in place. His discharge laboratories revealed white blood cell count was 12.8, hematocrit was 32.9%, and platelets were 387,000. Sodium was 142, potassium was 4.3, chloride was 105, bicarbonate was 30, blood urea nitrogen was 28, creatinine was 1.4, and blood glucose was 105. Magnesium was 2.2. His discharge chest x-ray showed a small left effusion; otherwise clear. ADDENDUM TO MEDICATIONS ON DISCHARGE: 1. Lopressor 75 mg by mouth twice per day. 2. Colace 100 mg by mouth twice per day as needed. 3. Tylenol 325-mg tablets one to two tablets by mouth q.4-6h. as needed. 4. Lasix 20 mg by mouth once per day (times seven days). 5. Potassium chloride 20 mEq by mouth once per day (times seven days). ADDENDUM TO DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. In addition to following up with Dr. [**Known firstname 255**] [**Last Name (NamePattern1) 256**] in four weeks, the patient was to follow up with his primary care physician (Dr. [**Last Name (STitle) **] in one to two weeks following discharge from rehabilitation. 2. The patient was to follow up with his cardiologist in two weeks from discharge from rehabilitation. [**Known firstname **] [**Last Name (NamePattern1) 358**], M.D. [**MD Number(1) 359**] Dictated By:[**Doctor Last Name 9528**] MEDQUIST36 D: [**2178-8-11**] 11:32 T: [**2178-8-11**] 11:34 JOB#: [**Job Number 9529**]

[ "511.9", "E878.2", "427.31", "441.01", "424.1", "997.02" ]

icd9cm

[ [ [] ] ]

[ "39.61", "38.45", "35.11" ]

icd9pcs

[ [ [] ] ]

4575, 4666

4689, 4827

10284, 10962

11694, 12007

10980, 11668

4851, 5102

12040, 12671

657, 1547

5652, 6014

6037, 10262

589, 634

5127, 5623

58,526

169,827

42136

Discharge summary

report

Admission Date: [**2118-8-21**] Discharge Date: [**2118-8-26**] Date of Birth: [**2082-3-21**] Sex: F Service: MEDICINE Allergies: Levaquin / lisinopril Attending:[**First Name3 (LF) 1973**] Chief Complaint: Vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 36 Year old Female with PMH diabetes type I, gastroparesis and frequent admissions for [**Hospital 39217**] transferred from [**Hospital3 **] Hospital for DKA. She states that she has been feeling subjective fever, chills and drenching sweats for 2 days. Around the same time, she developed nausea and began vomiting the day of admission. Vomitus is described as yellow and containing recently consumed food. The symptoms resembled prior episodes of DKA and she presented to [**Hospital3 417**] Hospital. She states that she has been taking her insulin as prescribed and does not miss doses; however her finger sticks have been ranging 150-400. She states also that she had a headache the day before admission and took her blood pressure noting systolic ~200 and took her home dose of metoprolol with improvement. At [**Hospital3 417**] Hospital, her initial vitals were 144/106, HR 118. Labs were remarkable for VBG 7.65, glucose 339. A peripheral line was unable to be placed, and thus a femoral central venous catheter was placed. She was started on an insulin drip at 5 units/hour. She vomited again and frank blood was noted, blood pressure was 210/110, she was started on pantoprazole IV drip, given metoprolol 5mg x3 and started on labetalol drip and transferred to [**Hospital1 18**] for further management. Of note, she was recently admitted to the [**Hospital1 18**] MICU for DKA [**2118-7-7**] to [**2118-7-12**] for DKA which was thought to have been somewhat precipitated by her menstrual cycle, no other precipitating factor was identified. According to the documentation, she was on an insulin drip for the first 4 days of her hospitalization due to labile blood sugars and difficulty tolerating oral intake. [**Last Name (un) **] was consulted who recommended changing levemir 22units QAM and 12 units QHS to lantus 25 Units QPM and long acting birth control or IUD. She was also started on Amlodipine 10mg for better blood pressure control. Finally, she also recently had left vitrectomy for diabetic retinopathy. On arrival to the ED, initial Vitals were P 95 BP 154/78 RR 24 O2 100%. Labs were remarkable for Cr 5.1 (recent baseline 3.7-5.7, though Cr was 2.3 on [**3-/2118**]), K 3.6, venous blood gas showed 7.26/36/85, HCO3 14 with AG:21. Trop-T was 0.09. UA showed glucose 1000, ketone 10 She was given 60meq PO K, one liter IVNS, insulin drip was continued at 5 units/hour and she was admitted to the MICU for further management. Vitals on transfer were 124/68 62 99% ra RR 22. On arrival to the MICU, Vitals were BP:138/88 P:103 SaO299% on Room air. She stated that she was fatigued and was without other complaints. She states that she has had hemetamesis prior and that her GI doctor at [**Hospital3 **] has done endoscopy showing gastritis. Review of systems: (+) Per HPI (-) Denies headache. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure. Denies abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Type 1 diabetes mellitis w/ neuropathy, nephropathy, and retinopathy - multiple past episodes of DKA HTN - 5 years gastroparesis - 2.5 years CKD - stage III, baseline Cr 2.4-2.5, proteinuria L1 vertebral fracture - [**2117-7-17**] Systolic ejection murmur Vitrectomy Left eye [**8-15**] Social History: Patient lives at home in [**Location (un) **] with her 10 y/o daughter and boyfriend. She has no history of EtOH, tobacco, or illicit drug use. Previously employed as ED tech, she is currently unemployed and seeking disability. Family History: Both parents have HTN and T2DM. Grandfather had an MI in his 40s. Physical Exam: ADMISSION EXAM T:98.6 BP: 138/88 P:103 RR 18 SaO2 99% RA General: Alert, oriented, no acute distress HEENT: eye patch present over left eye. L>R ansiocoria, pupils reactive. Neck: supple, JVP not elevated, no LAD CV: SEM best heard at the right upper sternal border. Regular rate and rhythm, normal S1 + S2 Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Overweight, soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley inplace Ext: Right femoral catheter in place dressing C/D/I. Otherwise warm, well perfused, 2+ pulses. Discharge exam: T 97.6, BP 130/80, P 79, RR 19, O2 99 RA GENERAL - Comfortable, appropriate HEENT - Left eye injected LUNGS - Fine crackles at bilateral bases. Otherwise no adventitious sounds. HEART - II/VI SEM at RUSB, nl S1-S2 ABDOMEN - soft/NT/ND EXT- WWP Pertinent Results: ADMISSION LABS ============== [**2118-8-21**] 03:30AM BLOOD WBC-9.3# RBC-3.97* Hgb-10.5* Hct-31.9* MCV-80* MCH-26.5* MCHC-33.0 RDW-15.0 Plt Ct-356 [**2118-8-21**] 12:19PM BLOOD WBC-8.6 RBC-3.33* Hgb-8.7* Hct-27.4* MCV-82 MCH-26.1* MCHC-31.7 RDW-15.3 Plt Ct-311 [**2118-8-21**] 03:30AM BLOOD Glucose-345* UreaN-62* Creat-5.1* Na-139 K-3.6 Cl-105 HCO3-14* AnGap-24* [**2118-8-21**] 03:30AM BLOOD ALT-9 AST-12 LD(LDH)-227 AlkPhos-99 TotBili-0.5 [**2118-8-21**] 03:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2118-8-21**] 05:28AM BLOOD Type-[**Last Name (un) **] pO2-85 pCO2-36 pH-7.26* calTCO2-17* Base XS--9 Intubat-NOT INTUBA Comment-GREEN TOP [**2118-8-21**] 04:05AM BLOOD Glucose-325* Lactate-2.7* Na-136 K-3.6 Cl-110* DISCHARGE LABS: ================ [**2118-8-26**] 06:16AM BLOOD WBC-6.1 RBC-3.19* Hgb-8.7* Hct-26.5* MCV-83 MCH-27.2 MCHC-32.8 RDW-15.4 Plt Ct-249 [**2118-8-26**] 06:16AM BLOOD PT-8.3* PTT-30.8 INR(PT)-0.8* [**2118-8-26**] 06:16AM BLOOD Glucose-98 UreaN-43* Creat-5.1* Na-137 K-4.3 Cl-108 HCO3-22 AnGap-11 [**2118-8-26**] 06:16AM BLOOD Calcium-7.9* Phos-4.8* Mg-2.1 RELEVANT: ============= [**2118-8-26**] 06:16AM BLOOD WBC-6.1 RBC-3.19* Hgb-8.7* Hct-26.5* MCV-83 MCH-27.2 MCHC-32.8 RDW-15.4 Plt Ct-249 [**2118-8-26**] 06:16AM BLOOD Glucose-98 UreaN-43* Creat-5.1* Na-137 K-4.3 Cl-108 HCO3-22 AnGap-11 [**2118-8-21**] 03:30AM BLOOD cTropnT-0.09* [**2118-8-21**] 08:59AM BLOOD CK-MB-4 [**2118-8-21**] 12:12PM BLOOD CK-MB-4 cTropnT-0.09* [**2118-8-21**] 04:05AM BLOOD Glucose-325* Lactate-2.7* Na-136 K-3.6 Cl-110* [**2118-8-22**] 09:06AM BLOOD Lactate-1.7 [**2118-8-24**] 05:14AM BLOOD calTIBC-328 Ferritn-26 TRF-252 [**2118-8-24**] 05:14AM BLOOD Calcium-7.9* Phos-4.0 Mg-2.0 Iron-22* [**2118-8-21**] 03:30AM BLOOD ALT-9 AST-12 LD(LDH)-227 AlkPhos-99 TotBili-0.5 [**2118-8-24**] 05:14AM BLOOD Ret Aut-1.6 [**2118-8-21**] 03:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009 [**2118-8-21**] 03:30AM URINE Blood-SM Nitrite-NEG Protein-300 Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2118-8-21**] 03:30AM URINE RBC-<1 WBC-3 Bacteri-NONE Yeast-NONE Epi-0 [**2118-8-21**] 03:30AM URINE Mucous-RARE [**2118-8-21**] 03:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG MICROBIOLOGY ============ [**2118-8-21**] 3:30 am BLOOD CULTURE Site: ARM **FINAL REPORT [**2118-8-27**]** Blood Culture, Routine (Final [**2118-8-27**]): GRAM POSITIVE RODS. UNABLE TO SPECIATE. Anaerobic Bottle Gram Stain (Final [**2118-8-23**]): GRAM POSITIVE ROD(S). CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. Reported to and read back by DR. [**Last Name (STitle) 69759**],[**First Name3 (LF) **] PAGER [**Numeric Identifier 91393**] @ 14:20 [**2118-8-23**]. Time Taken Not Noted Log-In Date/Time: [**2118-8-21**] 5:57 am URINE ADDED TO SPEC #65440H [**8-21**] 4:12A. **FINAL REPORT [**2118-8-22**]** URINE CULTURE (Final [**2118-8-22**]): NO GROWTH. [**2118-8-24**]: BCX x 2: no growth to date RADIOLOGY ========= [**2118-8-25**]: INDICATION: 36-year-old female with DKA and hematemesis, now requiring follow-up imaging for opacity on prior chest radiograph. COMPARISON: Comparison is made with chest radiographs from [**2118-8-24**] and [**2118-8-23**]. FINDINGS: PA and lateral images of the chest demonstrate well expanded lungs, which are generally clear. There are bilateral pleural effusions seen on the lateral but not on the frontal views. The retrocardiac opacity previously visualized has resolved. The chest radiograph is otherwise unchanged. There is no pneumothorax. Cardiomediastinal silhouette is unremarkable. IMPRESSION: Bilateral pleural effusions. Resolution of previously visualized retrocardiac opacity. [**2118-8-24**]: INDICATION: 36-year-old female with type 1 diabetes and hypoxemia. COMPARISON: Comparison is made with chest radiographs from [**2118-8-23**] and [**2118-8-21**]. FINDINGS: PA and lateral images of the chest demonstrate marked improvement in the vascular congestion seen on previous imaging. A small left pleural effusion is seen. There is an opacity, best seen on the lateral view, in the retrocardiac space which suggests a left lower lobe pneumonia or possibly atelectasis. There is no pleural effusion on the right. There is no pneumothorax. Cardiomediastinal silhouette is unremarkable. IMPRESSION: Improvement in previously seen diffuse vascular congestion. Retrocardiac opacity concerning for left lower lobe pneumonia or possibly atelectasis. Left pleural effusion. These findings were communicated via Radiology Critical Findings Dashboard at 4:53 p.m. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: A 36 year old female with PMH Diabetes type I complicated by nephropathy and frequent presentation with DKA presents with DKA and hematemesis. ACTIVE ISSUES: # Type 1 DM Uncontrolled with Diabetic Ketoacitosis: Prior triggers have included menstrual cycle changes, she states that she has been taking her OCP regularly. She states that she is compliant with insulin therapy and has not missed doses or run out of insulin. Symptoms of fever/chills are suggestive of an infectious precipitant however UA negative and CXR. Her anion gap closed while on insulin gtt and she was transitioned to an insulin regimen dictated by [**Last Name (un) **]. [**Last Name (un) **] consult moved her pre-prandial sliding scale insulin to post-prandial due to the gastroparesis. # Acute Blood Loss Anemia due to Hematemesis: With history of wretching hematemesis is likely related to [**Doctor First Name 329**] [**Doctor Last Name **] tear. The differential includes peptic ulcer, gastritis (which she has had in the past). Remained hemodynamically stable. She was continued on [**Hospital1 **] PPI. Should be followed up as outpatient. # Benign Hypertension: Patient with reports of systolic BP >200 prior to admission. She was perscribed Amlodipine 10mg daily on prior discharge however she never filed the RX. Initially unable to tolerate oral intake. Once taking PO she was started on PO labetalol, and her amlodipine was increased to 10mg. # Diabetic Retinopathy: Patient is s/p vitrectomy [**8-15**]. She was seen by her outpatient ophthalmologist, [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) **], while in-house for follow-up. Drops were continued as per ophthalmology CHRONIC ISSUES: # Anemia: Iron studies suggest iron deficiency anemia possibly on top of an anemia of chronic disease or CKD. She was started on iron supplements. This should be followed up as an outpatient. # Contraception: continued OCP while in hospital as this has been thought to contribute to DKA in the past. Continued on [**Doctor First Name **]. # Continuity of Care: We discussed the challenges that having her care fragmented across multiple different health care systems can create, and she expressed an interest in consolidating her care. Because of a longterm relationship with her nephrologist who is affiliated with [**Hospital3 **], she will continue with her PCP and nephrologist at [**Hospital3 **], in addition to [**Last Name (un) **] providers. She was encouraged to join support groups at [**Last Name (un) **], and explore ambulatory services. TRANSITIONAL ISSUES: - F/u bcx x 2 from [**2118-8-24**] - Full code Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Citalopram 20 mg PO DAILY 2. Duloxetine 30 mg PO DAILY 3. Furosemide 20 mg PO PRN edema 4. Metoprolol Succinate XL 25-75 mg PO HS dose adjusted according to BP 5. Promethazine 25 mg PO Q6H:PRN nausea 6. Glargine 25 Units Bedtime Insulin SC Sliding Scale using REG Insulin 7. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 8. Tobramycin-Dexamethasone Ophth Susp 1 DROP LEFT EYE QID 9. Cyclopentolate 1% 1 DROP LEFT EYE [**Hospital1 **] 10. [**Doctor First Name **] *NF* (norethindrone (contraceptive)) 0.35 mg Oral Daily Discharge Medications: 1. [**Doctor First Name **] *NF* (norethindrone (contraceptive)) 0.35 mg Oral Daily 2. Citalopram 20 mg PO DAILY 3. Cyclopentolate 1% 1 DROP LEFT EYE [**Hospital1 **] 4. Duloxetine 30 mg PO DAILY 5. Furosemide 20 mg PO PRN edema 6. Tobramycin-Dexamethasone Ophth Susp 1 DROP LEFT EYE QID 7. Amlodipine 10 mg PO DAILY hold for SBP < 100 RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Ferrous Sulfate 325 mg PO TID RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth three times daily Disp #*90 Tablet Refills:*0 9. Labetalol 100 mg PO BID hold for HR < 60 or sitting SBP < 150 (standing SBP < 100) RX *labetalol 100 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 10. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 11. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every eight hours Disp #*30 Tablet Refills:*0 12. Diphenoxylate-Atropine 1 TAB PO Frequency is Unknown 13. Promethazine 25 mg PO Q6H:PRN nausea 14. Glargine 25 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Diabetic ketoacidosis Insulin-dependent diabetic mellitus SECONDARY DIAGNOSES: Hypertension Gastroparesis Chronic Kidney Disease Anemia Hematemesis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 10132**], It was a pleasure to participate in your care here at [**Hospital1 1535**]! You were admitted with uncontrolled blood sugars from diabetic ketoacidosis. You were treated in the medical intesive care unit and then transferred to the regular medical floor after your sugars stabilized. Your blood pressures were also high while in the hospital and we modified your blood pressure regimen. We noticed that you had some bloody vomit, likely caused by a tear in your esophagus secondary to the trauma caused by vomiting. You should follow up with your physicians (see below) for further management. We wish you the best of luck! Medications Started: Amlodipine (for blood pressure) Labetolol (for blood pressure) Ferrous Sulfate (for anemia) Omeprazole (for bleeding when vomiting) Zofran (for nausea) Medications Changed: Insulin sliding scale (we changed your insulin sliding scale. Please be sure to follow revised scale) Medications Stopped: Midodrine (we changed your blood pressure medications to amlodipine and labetolol) Metoprolol (we changed your blood pressure medications to amlodipine and labetolol) Followup Instructions: Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] When: Monday [**8-29**] at 2pm Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2378**] Name: [**Last Name (LF) **], [**Name8 (MD) 8726**] MD Specialty:Nephrology When: Thursday [**9-1**] at 1:15pm Location: [**Hospital **] MEDICAL CARE, P.C. Address: [**Street Address(2) 8727**], STE 125E, [**Hospital1 **],[**Numeric Identifier 8728**] Phone: [**Telephone/Fax (1) 8729**] *We were unable to reach your Primary Care office as they are closed on Thursdays. Please call them to make a follow-up appointment for in one week from discharge. When you have your appointment with Dr.[**First Name (STitle) 805**] please discuss a follow-up EGD as well. Name: [**Last Name (LF) **],[**First Name3 (LF) **]-[**Doctor First Name **] Phone: [**Telephone/Fax (1) 85219**]

[ "530.7", "V58.67", "250.63", "583.81", "536.3", "250.43", "250.13", "285.1", "584.9", "285.21", "362.01", "403.11", "250.53", "585.5" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

14245, 14251

9767, 9911

292, 298

14463, 14463

4905, 5664

15789, 16800

3961, 4028

13095, 14222

14272, 14350

12423, 13072

14614, 15766

5680, 9744

4043, 4624

14371, 14442

4640, 4886

12348, 12397

3120, 3390

243, 254

9926, 11454

326, 3101

14478, 14590

11470, 12327

3412, 3700

3716, 3945

26,777

131,801

1316

Discharge summary

report

Admission Date: [**2151-6-28**] Discharge Date: [**2151-7-15**] Date of Birth: [**2089-6-25**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Mitral Valve Replacement (31mm St. [**Male First Name (un) 923**] Mechanical), Coronary Artery Bypass Graft x 1 (LIMA to LAD), Mediastinal Lymph node biopsy History of Present Illness: 62 y/o male with known mitral stenosis who presented to OSH with shortness of breath and found to be in congestive heart failure. Echo done there showed severe mitral stenosis and he was transferred to [**Hospital1 18**] for further care. Past Medical History: Mitral Stenosis, Hypertension, Hyperlipidemia, Atrial Fibrillation, Anemia, Obstructive Sleep Apnea, Hemorrhoids, Benign Prostatic Hypertrophy, Hypothyroidism, Diverticulosis, Prostate Cancer s/p XRT/Chemo, Stroke, s/p Cataract surgery Social History: Retired. Quit smoking 30 yrs ago after 2ppd x 20 yrs. Denies ETOH use. Family History: Negative for premature heart disease. Physical Exam: VS: 60 12 138/81 5'[**54**]" 112kg Gen: WDWN male in NAD Skin: Unremarkable HEENT: EOMI, PERRL, NCAT Neck: Supple FROM Chest: CTAB -w/r/r Heart: RRR +SEM Abd: Soft, NT/ND, +BS, +obese Ext: Warm, well-perfused, -edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**2151-7-15**] 05:45AM BLOOD WBC-12.8* RBC-2.95* Hgb-8.4* Hct-25.4* MCV-86 MCH-28.6 MCHC-33.2 RDW-16.6* Plt Ct-463* [**2151-7-14**] 05:55AM BLOOD Hct-28.4* [**2151-7-13**] 05:20AM BLOOD Hct-24.6* [**2151-7-15**] 05:45AM BLOOD PT-37.7* INR(PT)-4.0* [**2151-7-14**] 04:44PM BLOOD PT-37.7* INR(PT)-4.1* [**2151-7-13**] 05:20AM BLOOD PT-40.0* INR(PT)-4.3* [**2151-7-12**] 05:30AM BLOOD PT-25.4* PTT-87.1* INR(PT)-2.5* [**2151-7-15**] 05:45AM BLOOD Glucose-95 UreaN-25* Creat-1.2 Na-135 K-3.9 Cl-99 HCO3-25 AnGap-15 [**2151-7-14**] 05:55AM BLOOD Glucose-100 UreaN-25* Creat-1.2 Na-131* K-3.7 Cl-95* HCO3-26 AnGap-14 [**7-6**] Echo: PRE-BYPASS: The left atrium is markedly dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve shows characteristic rheumatic deformity. There is moderate valvular mitral stenosis (area 1.0-1.5cm2). Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on mr. [**Known firstname 8096**] at 8:30AM. POST_BYPASS: Normal RV systolic function. Intact thoracic aortic contour. There is a mechanical prosthesis in the mitral positions, with the two leaflets opening and closing well and the transmitral gradient is 2mm of Hg. There is no residual MR [**First Name (Titles) **] [**Last Name (Titles) **]. [**First Name (Titles) **] [**Last Name (Titles) 8097**]c function is 50%. CHEST (PA & LAT) [**2151-7-11**] 11:19 AM CHEST (PA & LAT) Reason: interval change [**Hospital 93**] MEDICAL CONDITION: 62 year old man with CABG/MVA SJ REASON FOR THIS EXAMINATION: interval change PA AND LATERAL CHEST ON [**2151-7-11**] AT 11:19 INDICATION: Recent cardiac surgery. Check for interval change. COMPARISON: [**2151-7-8**]. FINDINGS: Direct comparison of the frontal view shows less density in the left lower lung field. There is continued evidence of bilateral plate-like atelectasis. Upper lungs remain clear. Cardiomegaly is no different. The lateral view does not show significant differences compared to a prior lateral view from [**2151-6-30**]. IMPRESSION: Slightly improved aeration of the left lower lung field on the frontal view but overall little meaningful interval change. Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 6402**] was transferred from OSH with severe mitral stenosis and congestive heart failure. On [**6-29**] he underwent a cardiac cath which revealed one vessel coronary artery disease. He was then appropriately worked up for pending surgery. Thoracic surgery was consulted due to finding of hilar and mediastinal adenopathy. He also required dental clearance prior to surgery. He was medically managed while awaiting surgery. On [**7-6**] he was brought to the operating room where he underwent a mitral valve replacement, coronary artery bypass graft and mediastinal lymph node biopsy. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics and gently diuresed towards his pre-op weight. Later this day he was transferred to the telemetry floor for further care. On post-op day two he had episode of rapid atrial fibrillation and was given increased beta blockers, amiodarone and magnesium. Chest tubes and epicardial pacing wires were removed per protocol. He remained in atrial fibrillation and was started on coumadin for his mechanical valve. His sodium dropped and he was started on a fluid restriction. EP was consulted for continued rapid atrial fibrillation/flutter, he was restarted on an amiodarone drip and cardioversion was planned. Sodium improved with IV lasix. He was cardioverted to NSR on [**7-14**]. He remained in NSR, was cleared by physical therapy and was ready for discharge home on POD #9. Medications on Admission: Meds on transfer: Amiodarone 200mg qd, Coumadin 5mg qd, Lisinopril 10mg [**Hospital1 **], Simvastatin 40mg qd, Flomax 0.4mg qd, Zetia 10mg qd, Metoprolol XL 50mg qd, Synthroid 125mcg qd, Lasix 40mg qd, K-Dur, MVI, Spironolactone 25mg qd, Bumetamide IV Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days: then 200 daily ongoing. Disp:*35 Tablet(s)* Refills:*0* 10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 2 days: check INR [**7-17**] with results to Dr. [**Last Name (STitle) **] as prior to surgery. Disp:*60 Tablet(s)* Refills:*0* 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 13. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Mitral Stenosis s/p Mitral Valve Replacement Coronary Artery Disease s/p Coronary Artery Bypass Graft x 1 Congestive Heart Failure PMH: Hypertension, Hyperlipidemia, Atrial Fibrillation, Anemia, Obstructive Sleep Apnea, Hemorrhoids, Benign Prostatic Hypertrophy, Hypothyroidism, Diverticulosis, Prostate Cancer s/p XRT/Chemo, Stroke, s/p Cataract surgery Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 8098**] in [**3-14**] weeks Dr. [**Last Name (STitle) **] in [**2-10**] weeks Completed by:[**2151-7-15**]

[ "394.2", "V15.82", "785.6", "V10.46", "458.29", "414.01", "521.00", "280.9", "401.9", "416.0", "276.1", "514", "427.31", "427.32", "398.91", "272.4", "V15.3", "244.9", "523.40", "997.1" ]

icd9cm

[ [ [] ] ]

[ "40.11", "99.61", "88.53", "88.56", "35.24", "39.61", "37.23", "36.15", "23.19" ]

icd9pcs

[ [ [] ] ]

8037, 8093

4305, 6010

341, 499

8491, 8497

1468, 3557

9008, 9183

1131, 1170

6312, 8014

3594, 3627

8114, 8470

6036, 6036

8521, 8985

1185, 1449

282, 303

3656, 4282

527, 767

789, 1027

1043, 1115

6054, 6289

75,567

106,747

47986

Discharge summary

report

Admission Date: [**2188-6-6**] Discharge Date: [**2188-6-13**] Date of Birth: [**2103-9-22**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3151**] Chief Complaint: abdominal pain, hypotension Major Surgical or Invasive Procedure: Esophago-gastro-duodenoscopy History of Present Illness: Pt is an 84 yo man with history of chronic CHF (EF 40%), pulmonary HTN, severe TR, diabetes type 2 now controlled off meds, afib on warfarin and congestive cirrhosis, who presents with abdominal pain and hypotension. Pt is currently residing at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], where he had complaints of abdominal pain. Pt says that a day and a half ago he had some right sided sharp, fleeting pain [**9-15**], non-radiating, lasting for a few seconds. He says he has never had this pain before and denies any nausea and vomiting. He last had a small, loose, non-bloody, non-black bowel movement yesterday. Says he has been passing gas. He says he has been quite hungry, and hasn't really eaten anything for the last 3-4 days since "no one gave me food." He has only been drinking 1 cup of water and maybe [**12-9**] cup of gingerale daily. He noticed that his urination has decreased over the last day. He says he last 10 lbs over the last week. He feels cold, but denies fever or chills. . In the ED, initial vital signs were trigger for hypotension 84/61 - per EMS, BPs labile on route. Exam was notable for pt was able to answer questions, no somnolent, did not assess for asterixis, irregular heart rate, significant bruising and petechiae across the chest wall, no chest tenderess; no back/flank bruising; guiaic positive, light brown stool. EKG was vpaced 80. Cards was consulted for elevated trop, but not concerned in setting of elevated Cr, and pt with no chest pain. CXR showed a decrease in pulmonary vascular engorgement, otherwise stable from prior. CT torso prelim read showed no acute abnormalities to explain pain, and only small ascites. Bedside u/s showed no pericardial effusion, and only minimal ascites. Labs were notable for hyponatremia (125 from 135 most recently), mildly decreased Hct from baseline 31-32 to 29. Lactate 1.0. Cr was notable for elevation of 2.0 from 1.4, AST, AP and lipase all mildly elevated. Tox screen not sent. He was given 1L NS. Concern for infection, though WBC normal with normal diff, and given one dose of Zosyn, and Vanc ordered, but not yet given. UA and Urine cultures not yet sent. For access he has 2, 18g. . Vital signs prior to transfer T96.8, 81, 94/51, 16, 100% 2L NC. . On the floors, he currently feels weak, and hungry, but does not have any abdominal pain right now except for when he presses on his right side. . He had a recent admission [**5-27**] for similar presentation of abdominal pain, ileus, volume overload. He had acute on chronic systolic heart failure, at which point his diuresis was uptitrated. He was given a 3 day course of acetazolamide for contraction alkalosis. He also had hyponatremia and [**Last Name (un) **] attributed to heart failure and poor forward flow that improved with diuresis. Then his Cr was 2.2, and decreased to 1.4 on the day of discharge. Had upgrade to pacemaker at that time ([**Hospital1 **]-v pacemaker placed [**5-28**]). His abdominal pain then was attributed to ascites. He had a diagnostic para that was negative for SBP. . He was seen 2 days ago in heart failure clinic, where he appeared dry, weight 113 from 115 on discharge (was 135 on last admission), and metolazone dose was decreased from 5mg daily to 2.5mg MWF. . ROS: Positive as above. Also notable for some SOB when he coughs, but this is unchanged from prior. Also endorses knee pain from chronic arthritis. He currently denies any fevers, night sweats, chest pain, palpitations, nausea, vomiting, constipation, bloody or black stools, hematuria, pain with urination though occasional "burning" at the end of his penis. Past Medical History: 1. Diabetes type 2 now on no medication 2. Dyslipidemia. 3. Hypertension. 4. Atrial fibrillation on coumadin 5. Hyperthyroidism, on methimazole. 6. Anemia. 7. Dysphagia. 8. Arthritis. 9. Chronic kidney disease. 10. Moderate-to-severe tricuspid regurgitation. 12. Systolic heart failure. 13. Sick sinus syndrome with complete heart block s/p pacemaker, now with revision [**5-/2188**] 14. Pulmonary hypertension. 15. Mild diabetic retinopathy. 16. PVD, lower extremity venostasis. 17. Cirrhosis from chronic congestive hepatopathy - though unclear how pt received this diagnosis Social History: He previously lived alone in [**Location 1268**]. His daughter and grandchildren live nearby and would like him to move in with them but he refuses. He is currently at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42905**] skilled nursing and would not like to return there. He denies alcohol, tobacco, and IVDU. Family History: He has no known family history of premature coronary artery disease or sudden death. His mother died of a CVA. His father died of cancer. His son survived lymphoma. Physical Exam: On admission in ICU: VS: Temp: 97 BP: 115/54 HR: 81 RR: 16 O2sat 100% 2LNC Wt 49.6kgs GEN: elderly gentleman, pleasant, lying down in bed, very thin, comfortable, NAD HEENT: PERRL, EOMI, anicteric, very dry MM, op without lesions, NECK: thin, no supraclavicular or cervical lymphadenopathy, elevated JVP to just above clavicle CVS: irregular, 3/6 systolic murmur loudest at RUSB without apparent radiation, S1 and S2 wnl CHEST: left-sided pacer with steri-strips in place, ecchymoses across entire chest, extending to left side of rib cage RESP: no use of access mm, decreased at right base 1/3 up with faint crackles, no wheezes ABD: +NABS, soft, mild tenderness to palpation in right flank, no epigastric tenderness, no masses or hepatosplenomegaly, neg [**Doctor Last Name **] sign EXT: warm, very thin, muscle wasting, no edema, no cyanosis SKIN: no jaundice, right medial ulcer on shin ~ 3cm, ~ 2cm healing ulcer on left medial leg below knee, with some erythema of buttocks but no frank skin breakdown NEURO: AAOx2, states [**2187**], but says [**5-15**], Cn II-XII intact. 5/5 strength throughout. gait deferred On day of discharge: VS: Tmax:98.6, Tcurrent:98.6, BP:98/40, HR: 80, RR:20 General: NAD, generally weak HEENT: PERRL, EOMI, slightly dry mucous membranes Neck: no JVD CHEST: left-sided pacer with steri-strips in place, swelling and ecchymoses over pacer pocket, echhymoses over chest, left and right RESP: lungs CTAB, but for decreased breath sounds at right lung base Abdomen: bowel sounds active, nontender, soft, voluntary guarding, no rebound EXT: cachectic, no edema, cyanosis, or clubbing, ulcers over heels, healing venous ulcers on lower legs Pertinent Results: ADMISSION LABS: [**2188-6-6**] 04:40PM BLOOD WBC-7.5 RBC-4.20* Hgb-9.3* Hct-29.6* MCV-71* MCH-22.2* MCHC-31.5 RDW-18.4* Plt Ct-228 [**2188-6-6**] 04:40PM BLOOD Neuts-72* Bands-0 Lymphs-12* Monos-14* Eos-2 Baso-0 [**2188-6-6**] 04:40PM BLOOD PT-15.0* PTT-34.3 INR(PT)-1.3* [**2188-6-6**] 04:40PM BLOOD Ret Aut-2.1 [**2188-6-6**] 04:40PM BLOOD Glucose-153* UreaN-101* Creat-2.0* Na-123* K-7.5* Cl-79* HCO3-36* AnGap-16 [**2188-6-6**] 04:40PM BLOOD ALT-27 AST-120* CK(CPK)-115 AlkPhos-189* TotBili-0.7 [**2188-6-6**] 04:40PM BLOOD cTropnT-0.25* [**2188-6-6**] 11:21PM BLOOD Calcium-8.2* Phos-4.4 Mg-2.6 Iron-52 [**2188-6-6**] 11:21PM BLOOD calTIBC-307 Ferritn-131 TRF-236 [**2188-6-6**] 11:50PM BLOOD %HbA1c-6.7* eAG-146* [**2188-6-6**] 04:40PM BLOOD Lipase-188* DISCHARGE LABS: [**2188-6-13**] 07:15AM BLOOD WBC-11.0 RBC-3.85* Hgb-8.2* Hct-28.4* MCV-74* MCH-21.2* MCHC-28.8* RDW-19.0* Plt Ct-221 [**2188-6-13**] 07:15AM BLOOD PT-16.4* PTT-30.3 INR(PT)-1.4* [**2188-6-12**] 06:40AM BLOOD Ret Aut-2.9 [**2188-6-13**] 07:15AM BLOOD Glucose-147* UreaN-67* Creat-1.2 Na-135 K-4.4 Cl-95* HCO3-33* AnGap-11 [**2188-6-11**] 06:25AM BLOOD ALT-25 AST-32 LD(LDH)-214 AlkPhos-201* TotBili-0.8 [**2188-6-11**] 06:25AM BLOOD Lipase-113* [**2188-6-13**] 07:15AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.1 [**2188-6-12**] 06:40AM BLOOD Hapto-19* [**2188-6-6**] 11:50PM BLOOD %HbA1c-6.7* eAG-146* URINE: [**2188-6-6**] 11:21PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008 [**2188-6-6**] 11:21PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2188-6-6**] 11:21PM URINE Hours-RANDOM UreaN-383 Creat-24 Na-63 K-35 Cl-35 [**2188-6-6**] 11:21PM URINE Osmolal-311 MICRO: BLOOD CX x2 [**2188-6-6**]: FINAL NEGATIVE URINE CX [**2188-6-6**]: FINAL NEGATIVE MRSA SCREEN [**2188-6-6**]: NO MRSA ISOLATED STUDIES: CT TORSO [**2188-6-6**]: IMPRESSION: 1. No retroperitoneal hematoma or intrathoracic hemorrhage. 2. Moderate right pleural effusion with resolution of previously visualized left pleural effusion. Interval improvement in aeration of the superior segment right lower lobe patchy opacity, which may be an area of improving infection or atelectasis. 3. Stable cardiomegaly. 4. Cirrhosis with small amount of ascites. 5. Right renal cysts, better characterized on prior renal ultrasound. CXR [**2188-6-6**]: IMPRESSION: Stable appearance of chest radiograph in comparison to prior study from [**2188-5-29**] with minimal improvement in previously visualized vascular engorgement. CT ABD & PELVIS W/O CONTRAST [**2188-6-6**]: CT OF THE CHEST WITHOUT IV CONTRAST: Again visualized is a moderate right pleural effusion with adjacent airspace atelectasis which has remained stable in comparison to prior study from [**2188-5-16**]. Previously visualized left pleural effusion has, however, since resolved. Previously visualized area of patchy opacity within the superior segment of the right lobe is again seen, but appears less confluent. Bronchiectasis changes are again visualized throughout the right lower lobe. Sub-4mm pleural-based nodules are again visualized within the right upper lobe and lingula, stable in comparison to prior studies (2:18 and 36). The lungs are without any new consolidations. The heart remains massively enlarged as seen previously, with extensive atherosclerotic calcifications of the coronary arteries. Pacemaker leads appear stable. Note is again made of gynecomastia. There is stable mediastinal lymphadenopathy, with the largest node in the precarinal region measuring up to 12 mm, likely reactive. CT OF THE ABDOMEN WITHOUT ORAL OR IV CONTRAST: Evaluation of the abdominal structures is again limited by the lack of intravenous contrast. The liver appears to be shrunken with a nodular contour. Stable calcification is again visualized in segment VI. There is a small amount of abdominal ascites, decreased in comparison to prior study from [**2188-5-16**]. The pancreas is atrophic but stable. The kidneys are also atrophic bilaterally, but stable with no evidence of hydronephrosis or stones. Two stable hypodensities again visualized within the interpolar region of the right kidney (2:72 and 75), compatible with cysts and better characterized on the renal ultrasound from [**2188-3-28**]. The patient remains status post splenectomy with a small amount of splenosis in the left upper quadrant, which remains unchanged. The stomach, visualized loops of small and large bowel, and bilateral adrenal glands are within normal limits. The abdominal aorta has extensive atherosclerotic changes, but normal in caliber and contour. Pathologic lymphadenopathy through the abdomen.No retroperitoneal hematoma is present and there is no free air. CT OF THE PELVIS WITHOUT ORAL OR IV CONTRAST: The bladder, rectum, and visualized portions of sigmoid colon are within normal limits. There is a small amount of free fluid in the pelvis. No retroperitoneal hematoma is present. No pelvic lymphadenopathy by CT size criteria. OSSEOUS STRUCTURES: Multilevel degenerative changes are again visualized throughout the thoracolumbar spine with anterior and posterior osteophytes and uncovertebral hypertrophy. A stable focus of calcification is again visualized at L5-S1 disc space. No suspicious lytic or blastic osseous lesions. IMPRESSION: 1. No retroperitoneal hematoma or intrathoracic hemorrhage. 2. Moderate right pleural effusion with resolution of previously visualized left pleural effusion. Interval improvement in aeration of the superior segment right lower lobe patchy opacity, which may be an area of improving infection or atelectasis. 3. Stable cardiomegaly. 4. Cirrhosis with small amount of ascites. 5. Right renal cysts, better characterized on prior renal ultrasound. DUPLEX DOPP ABD/PEL [**2188-6-7**]: IMPRESSION: 1. Coarse echotexture of the liver, with lobulated contour compatible with cirrhosis. No distinct hepatic lesions. Hepatic vasculature is patent. 2. Small amount of ascites. 3. Small right pleural effusion. 4. Cholelithiasis without evidence of cholecystitis. [**2188-6-13**] EGD Birth Date: [**2103-9-22**] (84 years) Instrument: GIF-H180 ([**Numeric Identifier 101235**]) ID#: 054 20 81 Medications: MAC Anesthesia Indications: cirrhosis rule out varices Dysphagia Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. A physical exam was performed. The patient was administered moderate sedation. Supplemental oxygen was used. The patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the 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. Findings: Esophagus: Other No varices Stomach: Mucosa: Two erosions of the mucosa was noted in the body on the greater curve. Patchy erythema of the mucosa was noted in the antrum. These findings are compatible with gastritis. Duodenum: Flat Lesions A single medium angioectasia was seen in the distal bulb. Impression: No varices Erosion in the [**Last Name (un) 67230**] greater curve Erythema in the antrum compatible with gastritis Angioectasia in the distal bulb Otherwise normal EGD to third part of the duodenum Recommendations: If any questions or you need to schedule an [**Telephone/Fax (1) 682**] or email at [**University/College 21854**] Additional notes: FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology Brief Hospital Course: Pt is an 84 yo man with history of chronic systolic CHF (last EF 40%), pulmonary HTN, severe TR, diabetes type 2 now controlled off meds, afib on warfarin and congestive cirrhosis, who presents with abdominal pain and hypotension, and found to have acute on chronic renal insufficiency, hyponatremia and alkalosis. Pt was initially admitted to the MICU given hypotension. He was given IVF's and his SBP improved into the 100s. . #. Hypotension: Likely [**1-9**] hypovolemic etiology given clinically dry, elevated BUN/Cr, recent increased diuresis and poor po intake. Patient in clinic recently noted to have weight of 115 lbs down from 135 lbs between [**5-30**] and [**6-4**]. Pt had no s/s infection and no leukocytosis to suggest infectious etiology or sepsis. He was given IVF's and his BP improved. He was given one dose of Zosyn in the ED, though this was not continued on admission. Cultures were sent. UA was unremarkable, and CXR without infiltrate. He was not continued on antibotics, and was given fluid resuscitation with IVF boluses. His SBP was in the 100s on discharge. His hypotension was felt most likely to overdiuresis, and thus his spironolactone and furosemide dosages were decreased as per medication reconcillation. We also lowered his dose of Metoprolol given his borderline hypotension in house; this can be uptitrated in the future as needed. We also discontinued the patient's metolazone. . #. Acute on Chronic systolic CHF: With volume status restored, patient had slight volume overload and diuretics were slowly re-introduced. This was evidenced by right pleural effusion and increased requirement for oxygen at rest. Physical exam of right lung base and symptoms of dyspnea improved over a few days when diuretics were re-introduced at lower dose. ACE-i/[**Last Name (un) **] was held because of hypotenstion. . #. Abdominal pain: Unclear etiology, but seemed to have resolved prior to admission. DDx includes constipation vs. SBP vs. cholelithiasis vs. pancreatitis vs. ileus vs. gastritis. Lipase is elevated, though clinically pt has no epigastric pain, and clinical story of location of pain and duration is not c/w pancreatitis. Pt is passing gas and had BM so ileus less likely, in addition to no obstruction seen on CT. Cholelithiasis certainly possible given brief intermittent pain, that has now since resolved. Elevated alk phos and AST could be explained by intermittent cholelithiasis. Given guaiac positive stools, gastritis also possible, though intermittent nature makes this less likely. LFTs were within normal limits, and RUQ u/s showed no evidence of infection, although it did show coarse echotexture of the liver, with lobulated contour compatible with cirrhosis, a small amount of ascites, a small right pleural effusion, and cholelithiasis without evidence of cholecystitis. #. Dysphagia: Patient was seen in hospital for a speeh and swallow evaluation. They recommend a diet of soft moist solids and thin liquids, as well as further evaluation by speech and swallow at his facility. #. GI bleed: Patient's Hct trended down in house and stool was confirmed to be guiac positive. Upper endoscopy showed no varices, but erosions in the stomach and vascular ectasia of the duodenum. No varices were seen. His coumadin was held for this procedure and re-started afterwards. On discharge, his Hct was trending upwards to 28.4 from 25 two days prior, and there was no frank blood or melena ever observed in his stool. This is likely a slow, chronic GI bleed and felt to be stable. Iron supplements continued. # Acute on chronic renal insufficiency: Likely pre-renal in setting of poor po intake, and diuresis as discussed above. ATN also possible given BP slightly lower than baseline. Post-obstructive etiologies much less likely on the differential. FeUrea 31%, suggestive of pre-renal etiology. He was given IVF's as discussed above and Cr was trended down to 1.2 on discharge, which is his baseline. # Metabolic Alkalosis with resp compensation: Pt has significant alkalosis with HCO3 of 36 on admission, has been higher up to 39. Suspect that this is contraction alkalosis [**1-9**] overdiuresis. ABG obtained showed 7.44/55/79/39, suggestive of respiratory compensation. Lytes were trended with correction of bicarb to 33 on day of discharge. # Elevated troponin: Trop was elevated to 0.25 from prior 0.11. However, in the setting of elevated Cr, this is the most likely etiology. Reassuring that EKG unchanged, and pt has no chest pain. CK, MB were stable upon a recheck during admission. #. Hyponatremia: Hypovolemic hyponatremia as evidenced by picture of dehydration as discussed above. Na much lower from baseline by ~ 10pts. Diuretics were held and he was given IVF's. Na was trended up to 135 on discharge secondary to IVF, good PO intake, and the holding of his diuretics. #. Anemia: Microcytic, suspect iron deficiency. Possible etiologies include upper slow bleed given brown stools, such erosions and duodenal ectasia. No reported bloody or black stools, which is reassuring. Hct on admission is 29, and baseline is closer to 31-33. However, suspect that this is hemoconcentrated given picture of dehydration as discussed above. Volume status was restored and Hct recovered to 28 on d/c. Fe studies and retic count were sent, which showed no evidence of hemolysis, and without reticulocytosis to suggest bleeding. Iron studies were wnl. Patient was discharged back on his home dose of 20 mg daily of omeprazole. # Atrial fibrillation: Chronically on Warfarin, for CHADS 4 (CHF, HTN, Age and Diabetes). However, INR subtherapeutic on admission to 1.3. Listed on dc summary and in some nursing notes per rehab, but not on primary list. Held Toprol XL initially given hypotension. Placed on heparin gtt briefly, but on discharge was therapeutic on Coumadin at 5.5 mg Daily at 2.1. Metoprolol was re-started at 25mg PO daily before d/c. # Lower extremity wounds: Exam c/w venous stasis ulcers with no evidence of superinfection. Wound was consulted for care. # Diabetes: last A1c from [**12/2187**] 6.6. Not currently on any medications for diabetes. Suspect that he no longer requires meds given his weight loss. Placed on QID FS and ISS, and was discharged on diet control for diabetes. # Hyperthyroidism: TSH 3.7 on [**2188-5-17**]. Besides weight loss, likely [**1-9**] issues of poor po intake & diuresis, no other s/s hyperthyroidism. Continued on methimazole 5mg daily. Transitional Issues: - Please monitor weights daily for change greater than 3 lbs in weight gain - Please have the patient follow-up with his CHF clnic, whom has been managing his medications. - Please follow-up 7/1 Blood cultures for any signs of microorganism growth (NGTD) - Please monitor fluid status daily, with low threshold to uptitrate spironolactone back to prior dosing. Medications on Admission: -aldactone 50mg 9pm, 25mg qam -K-dur 10meq daily -metolazone 2.5mg MWF -ASA 81mg daily -Docusate 100 [**Hospital1 **] -Methimazole 5mg daily -Torsemide 20mg 3 tabs [**Hospital1 **] -oxygen 2L NC -toprol XL 50mg daily -prilosec 20mg daily -MVI -calcium carb 500 tid -ferrous suldate 325mg q8pm -VitD 400u 2 tabs daily. -warfarin 5.5mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day. 5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO three times a day. 8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. warfarin 5 mg Tablet Sig: ASDIR Tablet PO Once Daily at 4 PM: Please take warfarin 5.5 mg Daily at 4 PM. 11. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day: hold for SBP<100. 12. Aldactone 25 mg Tablet Sig: One (1) Tablet PO twice a day. 13. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for constipation. 14. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. 15. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: Palm [**Hospital 731**] Nursing Home - [**Location (un) 15749**] Discharge Diagnosis: Primary: Volume depletion, Slow gastrointestinal bleed Secondary: dysphagia, chronic systolic CHF (EF 40%), Diabetes, Dyslipidemia, HTN, atrial fibrillation, sick sinus syndrome s/p pacemaker placment, hyperthyroidism, liver cirrhosis, anemia, CKD, pulmonary hypertension, venous peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Last Name (Titles) 101236**], You were admitted to the hospital because you had an episode of abdominal pain and your blood pressure was very low. In the hospital, you were given IV fluids and your blood pressure increased. We held your usual diuretics and you were able to eat soft foods well. Your level of red blood cells dropped for a few days and we were worried about you losing blood into your GI tract because we found evidence of a slow blood loss in your stool. An upper endoscopy showed an abnormal blood vessel in the stomach that may be leading to slow blood loss. There were no rapidly bleeding vessels seen in this study. In the hospital your red blood cell level stabilized and began to rise. You were discharged from the hospital with a plan to decrease some of your diuretics and follow up with your doctor about the slow bleeding in your stomach. Please make the following changes in your medications: - STOP taking Metolazone - STOP taking Potassium Chloride 10meq daily - CHANGE your dose of Torsemide to two 20mg tabs twice daily (previously you had been taking 60 mg twice a day) - CHANGE aldactone to 25mg twice daily (previously you were taking 50mg in the night and 25mg in the morning) - DECREASE your dose of Toprol XL to 25 mg Daily (previously you had been taking 50 mg Daily) - START senna 8.6 mg Tablet: Take 2 tablets at night as needed for constipation - START acetaminophen 325 mg Tablet: Take 1-2 Tablets PO every six (6) hours as needed for fever or pain. - START Miralax 17 gram Powder in Packet: Take One (1) packet PO once a day as needed for constipation Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 251**] D. Location: [**Hospital3 249**] [**Hospital1 **]/EAST Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 250**] **Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge** Department: CARDIAC SERVICES When: FRIDAY [**2188-6-20**] at 2:00 PM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: THURSDAY [**2188-8-7**] at 3:00 PM With: [**Doctor First Name 900**] [**Name8 (MD) 901**], 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

[ "242.90", "403.90", "428.0", "535.41", "789.00", "276.3", "416.8", "280.9", "V45.01", "362.01", "585.3", "787.20", "276.1", "250.50", "424.2", "427.31", "571.5", "428.42", "584.9", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

23182, 23273

14629, 21080

331, 362

23625, 23625

6865, 6865

25528, 26446

4990, 5157

21853, 23159

23294, 23604

21489, 21830

23801, 25505

7643, 14606

5172, 6846

21101, 21463

264, 293

390, 4025

6881, 7627

23640, 23777

4047, 4627

4643, 4974

62,465

120,413

2819

Discharge summary

report

Admission Date: [**2103-9-26**] Discharge Date: [**2103-9-27**] Date of Birth: [**2030-12-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: esophagogastroduodenoscopy History of Present Illness: Mr. [**Known lastname 13123**] is a 72 year old male with a history of hypertension, hypercholesterolemia, chronic dyspepsia and duodenal polyp s/p resection on [**2103-9-25**] who presents to the emergency room with bright red blood per rectum. The procedure was uncomplicated. He left the hospital at 2 PM. He began to experience some abdominal bloating and gassiness. He started having bright red blood per rectum at 9 PM and presented to the hospital. This was associated with some mild lightheadedness and dizziness without chest pain, shortness of breath, nausea, vomiting, abdominal pain, dysuria, hematuria, let pain or swelling. He reports a similar presentation with bleeding after a colonoscopy a number of years ago. . In the ED, initial vs were: T: 98.0 P: 77 BP: 117/67 R: 16 O2 sat 98% on RA. He had two 18 g peripheral IVs placed. Blood pressures were in the 110s systolic. He received three liters of normal saline and protonix 40 mg IV x 1. NG lavage showed dried blood which cleared with 500 cc lavage. EKG showed normal sinus rhythm, normal axis, no acute ST segment changes, no change compared to prior dated [**2103-3-31**]. He had a CXR which showed no acute process. He is admitted to the MICU for further management. . On arrival to the MICU he reports having a total of 5 bloody bowel movements. He otherwise feels much better after receiving IVF. Past Medical History: Duodenal adenoma s/p resection [**2103-9-25**] Colon Cancer diagnosed in [**2100**] s/p right colectomy Hypertension Hypercholesterolemia Prostate cancer Basal cell carcinoma of the back Hiatal hernia s/p appendectomy s/p prostatectomy s/p bilateral knee replacements Social History: He lives with his wife. [**Name (NI) **] is retired from the newspaper business. No smoking, alcohol or illicit drug use. Family History: No family history of GI malignancies or bleeding disorders. Physical Exam: Vitals: T: 97.4 BP: 135/60 P: 71 R: 16 O2: 98% on 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 Rectal: gross blood in rectal vault . On discharge: T96.5 HR65 143/73 RR18 98%RA No bleeding currently, exam otherwise unchanged Pertinent Results: Upper endoscopy [**2103-9-25**]: A single sessile 2cm non-bleeding polyp was found in the second part of the duodenum. A piece-meal polypectomy was performed via endoscopic mucosal resection (EMR) technique using a hot snare over a saline pillow. The polyp was completely removed. APC was performed to the edges of the polypectomy site. . CXR (wet read): No acute cardiopulmonary process . EKG: EKG showed normal sinus rhythm, normal axis, no acute ST segment changes, no change compared to prior dated [**2103-3-31**]. . Labs: [**2103-9-25**] 10:00PM BLOOD WBC-11.6*# RBC-4.39* Hgb-12.9* Hct-39.0* MCV-89 MCH-29.3 MCHC-33.0 RDW-13.6 Plt Ct-250 [**2103-9-26**] 09:30AM BLOOD Hct-26.0* [**2103-9-27**] 08:40AM BLOOD WBC-6.5 RBC-3.95* Hgb-12.2* Hct-35.1* MCV-89 MCH-31.0 MCHC-34.9 RDW-13.7 Plt Ct-177 [**2103-9-27**] 01:56AM BLOOD PT-13.0 PTT-27.9 INR(PT)-1.1 [**2103-9-27**] 01:56AM BLOOD Glucose-91 UreaN-17 Creat-0.9 Na-142 K-3.5 Cl-111* HCO3-27 AnGap-8 [**2103-9-27**] 01:56AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.1 Brief Hospital Course: In summary, Mr [**Known lastname 13123**] is a 72 year old male with a history of hypertension, hypercholesterolemia, chronic dyspepsia and duodenal polyp s/p resection on [**2103-9-25**] who presents to the emergency room with bright red blood per rectum and was found to be bleeding from the polypectomy site. . Upper gastrointestinal bleeding: Pt presented with BRBPR was found to be bleeding at the duodenal polypectomy site on EGD. He was transferred to the MICU and bleeding was controlled with epinephrine injection and cauterization. His crit initially dropped to 26 but then improved to the low 30s with 2 units of PRBCs. His bloody bowel movements cleared and crit was stable while on the floor and pt had good PO intake. He was also treated with IV PPI. Aspirin was held due to bleeding, HCTZ was initially held given GI bleed but restarted on discharge. Additionally, he was discharged on a 5 day total course of cipro/flagyl given that a deep resection of the polyp occurred, placing him at higer risk for infection. He was continued on a PPI and told to restart his aspirin 10 days after discharge. He will f/u with GI in [**2-19**] weeks. . Hyperlipidemia: home atorvastatin was continued . Depression: home sertraline was continued . Hypertension: HCTZ initially held in the context of bleed, but restarted on discharge as he was hypertensive. Medications on Admission: Atorvastatin 20 mg daily Aspirin 81 mg daily Hyrochlorothiazide 25 mg daily Omeprazole 20 mg daily Sertraline 50 mg daily Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 9 doses: Please take for 3 days after you leave the hospital. Disp:*9 Tablet(s)* Refills:*0* 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 doses: Please take for 3 days after you leave the hospital. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed Discharge Condition: Good, asymptomatic, hct stable. Discharge Instructions: You were admitted for an upper GI bleed which was found to be at the site of your prior polypectomy. The bleeding was stopped using cautery and medications. Your blood levels stabilized and your bleeding stopped. You had no additional symptoms that were concerning for GI bleed. . Please take your medications as prescribed and follow up with your physicians as outlined below. When you leave the hospital, please take all of the medications that you had previously been taking when you were admitted to the hospital, except for Aspirin. Please start taking aspirin 81 mg 10 days after you leave the hospital (on [**2103-9-27**]). We also recommend taking 40 mg of your omeprazole once a day. Finally, please take the following antibiotics for three days after you leave the hospital: Metronidazole 500 mg Tablet one tablet every 8 hours Ciprofloxacin 500 mg Tablet one tablet every 12 hours . You should return to the hospital if you have new bleeding, lightheadness, weakness, chest pain, shortness of breath, or any other symptoms that are concerning to you. Followup Instructions: Please follow up with your providers as outlined below: . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2103-10-30**] 12:45 . [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: Internal Medicine/ PCP Date and time: Monday, [**2105-10-7**]:45am Location: [**Street Address(2) 13776**], [**Location (un) 620**] Phone number: [**Telephone/Fax (1) 3393**] . Please keep your previously scheduled appointments as outlined below: . Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2104-2-21**] 10:15 . Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2105-3-13**] 9:15 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "998.11", "V10.83", "V10.46", "401.9", "V43.65", "532.00", "311", "272.0", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

6297, 6303

4018, 5386

343, 371

6362, 6396

2978, 3995

7515, 8511

2234, 2295

5558, 6274

6324, 6341

5412, 5535

6420, 7492

2310, 2867

2881, 2959

276, 305

399, 1786

1808, 2077

2093, 2218

48,169

184,746

49527

Discharge summary

report

Admission Date: [**2178-11-30**] Discharge Date: [**2178-12-16**] Date of Birth: [**2107-1-28**] Sex: M Service: SURGERY Allergies: Allopurinol Attending:[**First Name3 (LF) 6088**] Chief Complaint: cold right foot Major Surgical or Invasive Procedure: [**2178-12-1**] - angiogram right lower extremity, angioJet thrombectomy of the right popliteal artery, right tibioperoneal trunk, and right profunda femoris artery. [**2178-12-1**] - Right groin exploration with embolectomy of superficial femoral artery and profunda femoral artery, below-knee popliteal exploration with embolectomy of tibial and peroneal vessels, vein patch angioplasty of tibioperoneal trunk, 4 compartment fasciotomy, left groin exploration and repair of pseudoaneurysm. [**2178-12-8**] - Right lower extremity washout of Fasciotomies, right lower extremity. History of Present Illness: A 71-year-old man with history of CAD, HTN, hyperlipidemia, and diabetes who presents to [**Hospital1 18**] with complaints of a 5 day history of severe bilateral lower extremity pain, now greater in the right as compared to the left. He presented to his PCP the following day, and, given numbness and pain in his bilateral lower extremities, suggested an MRI to evaluate the patient's spine. As the patient was to undergo MRI testing today, he complained of severe RLE calf pain and asked to be transferred to the ED. The patient's bilateral lower extremity pain was of sudden onset and started while walking in the yard. It started as a 'jolt', shooting down from his buttocks to his calves bilaterally. He sat down, which made the pain better. Since that time, however, he has been unable to walk secondary to severe calf pain. The patient now states that his pain is worse on his right leg compared to his left. He also complains of intermittent numbness, greater in his right leg as compared to his left. The ED has consulted Vascular Surgery because his distal RLE was cool to the touch. The patient continues to complain of severe RLE calf pain. He is unable to walk on it now. He denies any history of claudication. He has no history of a-fib. The pain is not any better when he hangs his leg over the side of the bed. He complains that his right foot feels 'numb' subjectively. He denies any pain in his feet bilaterally. Past Medical History: PMH: obesity, CAD, hypertension, hyperlipidemia, gout, abnormal LFTs, diabetes, anxiety, BPH, colon polyps, lung nodule, diabetic nephropathy, and obstructive sleep apnea PSH: [**2158**]- ex-lap with SBR, patient unaware of reason, [**2173**]- cardiac cath with stent placement, [**2174**]- cholecystectomy Social History: Non smoker, no ETOH lives with sister Family History: Non contributory Physical Exam: VS: T 98.2 P 74 BP 120/101 20 98 RA GENERAL: AAOx3, lying in bed, NAD Chest: CTAB CV: RRR Abd: obese, soft, NT/ND, well healed surgical scars RLE: 2+ Femoral, Biphasic Popliteal, unable to doppler DP, Biphasic PT. Right cooler compared to LLE, but no evidence of mottling. RLE soft throughout. Lateral and medial fasciotomies with beefy wound bed. Right groin wound with bright red wound base. Patient complains of pain when asked to move toes, but denies any pain with toe passive extension/flexion. Sensation normal to light palpation throughout. Pulses LLE: RLE: 2+ Femoral, Popliteal, DP, PT. Denies any pain/numbness. WWP. Pertinent Results: [**2178-12-15**] 06:35AM BLOOD WBC-8.6 RBC-3.33* Hgb-9.8* Hct-28.7* MCV-86 MCH-29.4 MCHC-34.2 RDW-16.2* Plt Ct-612* [**2178-12-14**] 12:43AM BLOOD WBC-10.2 RBC-3.14* Hgb-9.5* Hct-26.9* MCV-86 MCH-30.3 MCHC-35.4* RDW-16.1* Plt Ct-567* [**2178-12-15**] 06:35AM BLOOD Plt Ct-612* [**2178-12-15**] 06:35AM BLOOD Glucose-113* UreaN-19 Creat-1.0 Na-137 K-4.0 Cl-103 HCO3-28 AnGap-10 [**2178-12-15**] 06:35AM BLOOD CK(CPK)-169 [**2178-12-2**] 02:09AM BLOOD CK-MB-53* MB Indx-0.6 [**2178-12-15**] 06:35AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.0 RADIOLOGY: CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Study Date of [**2178-11-30**] 4:10 CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The imaged portion of the liver and spleen are unremarkable. Fat-containing hypodensity in the lower pole of the right kidney likely represents an angiomyolipoma. The left kidney, pancreas, and adrenal glands are unremarkable. The intra-abdominal loops of large and small bowel maintain a normal caliber without evidence of obstruction. Note is made of eventration of the anterior abdominal wall. There is no free fluid, free air, or lymphadenopathy. CT OF THE PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST: The rectum and bladder are unremarkable. The prostate is mildly enlarged. Post-surgical changes are noted involving the sigmoid colon. There is no free fluid or lymphadenopathy. Note is made of bilateral fat-containing inguinal hernias. CTA OF THE ABDOMEN, PELVIS, AND LOWER EXTREMITY: The abdominal aorta is normal in caliber. Aortic atherosclerotic plaque is moderate. The celiac artery, SMA, and [**Female First Name (un) 899**] are patent. The common, internal and external iliac arteries are patent bilaterally. On the right, there is occlusion of the profunda femoris artery (3A:161) with distal reconstitution of the small branches by the lateral circumflex femoral artery. The left profunda femoris artery is patent. The superficial femoral arteries are patent bilaterally, however, on the right, there is abrupt occlusion of the right popliteal artery (3A:285). There is minimal reconstitution of a diminutive right posterior tibial artery via a medial genicular artery as well as tiny anterior tibial and peroneal arteries in the lower two-thirds of the leg. The dorsalis pedis artery on the right is not opacified. On the left, the popliteal artery, anterior tibial, posterior tibial, and peroneal arteries are opacified. Note is made of focal varix involving the left saphenous vein at the level of the mid thigh (6:226). IMPRESSION: 1. Occlusion of the profunda femoris artery on the right with distal reconstitution of the small branches via the lateral circumflex femoral artery. 2. Abrupt occlusion of the right popliteal artery. Minimal reconstitution of a diminutive right posterior tibial artery via an inferior medial genicular artery. The study and the report were reviewed by the staff radiologist. CHEST (PRE-OP PA & LAT) Study Date of [**2178-11-30**] 10:27 PM FINDINGS: The heart size is at the upper limits of normal. No focal consolidation or evidence of acute pulmonary edema detected. No effusion or pneumothorax is identified. There are mild degenerative changes noted within the thoracic spine with anterior osteophyte formation. IMPRESSION: No acute cardiopulmonary process detected. Portable TTE (Complete) Done [**2178-12-3**] at 10:41:55 AM Conclusions The left atrium is dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is mild to moderate regional left ventricular systolic dysfunction with akinesis of the inferior and inferolateral walls. 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 structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: No cardiac source of embolism seen. Focal LV systolic dysfunction consistent with prior infarct. Mild mitral regurgitation. CT PELVIS W/CONTRAST Study Date of [**2178-12-10**] 10:35 AM FINDINGS: CT CHEST: 4-mm right middle lobe (2:37) and 6.6 mm left lower lobe (2:47) lung nodules are unchanged since [**2176-5-21**], chest CT. There is no new lung nodule. Dependent atelectasis is bilateral. Airways are patent to the subsegmental level. There is no pleural or pericardial effusion. There is no mediastinal lymphadenopathy using CT criteria. Coronary artery calcifications are present. CT OF THE ABDOMEN AND PELVIS: A small hiatal hernia is present. Right kidney angiomyolipoma is unchanged. Eventration of the anterior abdominal wall is stable. Postop changes in the sigmoid region are unchanged. A Foley catheter is in place. A 4.6 x 4.8 cm left inguinal hematoma is anterior to the common femoral artery with no signs of acute extravasation. Minimal amount of soft tissue air is also present on the left, in this patient with bilateral inguinal cutaneous surgical staples. Fat stranding is also more marked on the left with more prominent edema. The rest of the abdomen and the pelvis is unremarkable. BONES: L3 presumed hemangioma is unchanged. Degenerative changes of the spine are present. CT ANGIOGRAM: Atherosclerotic aorta with prominent noncalcified plaque in the infrarenal aorta is unchanged. Celiac artery, SMA and [**Female First Name (un) 899**], and bilateral renal arteries are patent. Branches of the right femoral profunda are still occluded but are not entirely evaluated. IMPRESSION: 1. 4.6 x 4.8 cm left inguinal hematoma with soft tissue edema and small amount of soft tissue air, likely related to recent post-op changes. 2. Atherosclerotic aorta with noncalcified plaques. Coronary artery calcifications. 3. Stable lung nodules since [**2175**]. 4. Stable right kidney angiomyolipoma. 5. Stable eventration of the anterior abdominal wall. 6. Persistent occlusion of branches of the right femoral profunda artery. Brief Hospital Course: [**2178-11-30**] The patient was admitted to the vascular surgery service/Dr. [**Last Name (STitle) **] for right lower extremity swelling and pain. Routine nursing, labs, started on a heparin drip, bicarbonate IVF, regular diet, home medication, and made NPO after midnight for a procedure on [**12-1**]. [**12-1**] - the patient underwent angiogram of the right profunda femoris artery and right popliteal artery, thrombectomy of the right popliteal artery, right tibioperoneal trunk, and right profunda femoris artery. The decision was made to convert to an open procedure. Patient then underwent an open thrombectomy, TP trunk vein patch angioplasty, RLE 4-compartment fasciotomy, and L CFA PSA repair. Following the procedure, he was admitted to the ICU for continued monitoring, he was intubated and sedated, he continued on a heparin drip, a foley catheter was in place, bicarb IVF for 6 hours following the procedure, NGT in place, a line in place. [**12-2**] - extubated, continued on heparin drip, transfused 1 unit RBC, diet advanced to clears, oral home medications [**12-3**] - diet advanced to regular. Cardiology consulted, ECHO performed looking for source of embolus but was negative, transferred to the VICU [**12-4**] - heparin drip continued, adjusted as needed to PTT 60-80, coumadin started at 5mg qday, 2 units RBC transfused for falling hematocrit [**12-7**] - transfused 2 units RBC for falling hematocrit, staples removed on right lower extremity, minimal old hematoma drained, IV heparin drip stopped, coumadin therapeutic [**12-8**] - returned to the operating room for right lower extremity washout and vac placement, coumadin adjusted to 2mg qday [**12-9**] - transfused 2 units RBC for hematocrit of 22, responded appropriately, coumadin dose held [**12-10**] - CTA of torso performed, no source of bleeding, heparin drip started, continued coumadin [**12-14**] - vac dressing changed at the bedside, vac dressing applied to right groin, coumadin adjusted to 4mg qhs. Noted to have a small area of the right lateral upper fasciotomy that the muscle tissue is darkened that is concerning for necrosis. [**12-15**] - Vac dressing was taken down for rounds, the area concerning for myonecrosis remain but not extending, no intervention at this time, will follow-up. Vac re-applied after pre-medication and Lidocaine infiltration around groin wound. Physical therapy-out of bed as tolerated. Rehab screening. Restarted oral hypoglycemics. Hct stable. [**2178-12-16**] - Vac dressing continues, taken down and applied NS wet to dry dressing in preparation for discharge. No acute events. Discharged to rehab in good condition. Medications on Admission: AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth once a day COLCHICINE - 0.6 mg Tablet - 1 Tablet(s) by mouth twice a day EZETIMIBE-SIMVASTATIN [VYTORIN [**9-/2150**]] - 10-80 mg Tablet - 1 Tablet(s) by mouth once a day GLIPIZIDE [GLUCOTROL] - (Dose adjustment - no new Rx) - 10 mg Tablet - 1 Tablet(s) by mouth twice a day HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - [**12-24**] Tablet(s) by mouth at bedtime as needed for pain ISOSORBIDE MONONITRATE - 30 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day LISINOPRIL - 40 mg Tablet - 1 Tablet(s)(s) by mouth once a day METHYLPREDNISOLONE - 4 mg Tablets, Dose Pack - taper Tablets(s) by mouth as directed METOPROLOL SUCCINATE [TOPROL XL] - 100 mg Tablet Sustained Release 24 hr - one tablet once a day PIOGLITAZONE [ACTOS] - 30 mg Tablet - 1 Tablet(s) by mouth once a day for diabetes ASPIRIN - 325 MG Tablet, Delayed Release (E.C.) - ONE BY MOUTH EVERY DAY Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day) as needed. 11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. 13. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*20 Tablet(s)* Refills:*0* 17. Regular Insulin Sliding scale Breakfast Lunch Dinner Bedtime Glucose Insulin Dose 0-60 mg/dL 4 oz. Juice 4 61-120 mg/dL 0 Units 121-160 mg/dL 2 Units 161-200 mg/dL 4 Units 201-240 mg/dL 6 Units 241-280 mg/dL 8 Units 281-320 mg/dL 10 Units 321-360 mg/dL 12 Units > 360 mg/dL Notify M.D. 18. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for hypglycemia. Needs recheck creatinine in one week. Disp:*60 Tablet(s)* Refills:*2* 19. Lidocaine HCl 10 mg/mL (1 %) Solution Sig: One (1) ML Injection PREMED FOR GROIN VAC CHANGE (): Inject around groin area prior to vac change. Disp:*400 ML(s)* Refills:*2* 20. Hydromorphone (PF) 1 mg/mL Syringe Sig: One (1) Injection every six (6) hours as needed for breakthrough pain: Prior to vac change. 21. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Adjust dose based on INR for goal [**1-25**]. NB: Pt started on levofloxacin for 1 wk duration [**Date range (1) 81836**]. 22. Sodium Chloride 0.9 % 0.9 % Solution Sig: One (1) ML Injection PRN (as needed) as needed for line flush: 10 mL IV PRN line flush. 23. Outpatient Lab Work 1. Daily INR while on Levoflox for coumadin dose adjustment as needed for goal [**1-25**] 2. Please check BMP and LFTs in one week given that patient was started on metformin [**12-15**] 24. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day for 1 days: for tonight [**7-16**]. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Occlusion of right popliteal artery and right profunda femoris artery likely from an embolic source. history of obesity history of CAD history of HTN history of Hyperlipidemia history of gout history of abnorm LFTs history of DM history of anxiety history of BPH history of colon polyps history of lung nodule history of diabetic nephropathy history of OSA Postoperative Acute anemia requiring multiple blood transfusions Postoperative lower extremity wounds Discharge Condition: Stable INR [**12-16**] 2.4 Hct [**12-16**] 28.3 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. . 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 ([**10-7**] lbs) until your follow up appointment. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2179-1-6**] 12:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2179-1-13**] 11:40 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1142**] Date/Time:[**2179-2-22**] 2:15 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2178-12-23**] 8:45 Completed by:[**2178-12-16**]

[ "E879.8", "518.89", "998.12", "790.6", "285.1", "300.00", "278.00", "414.01", "250.40", "274.9", "327.23", "998.11", "729.5", "338.18", "412", "401.9", "583.81", "444.22", "729.72", "600.00", "272.4", "728.3" ]

icd9cm

[ [ [] ] ]

[ "38.08", "88.48", "83.09", "93.59", "99.04", "38.93", "00.42", "86.04", "99.10", "39.56", "00.44", "39.31", "39.79" ]

icd9pcs

[ [ [] ] ]

16082, 16152

9690, 12360

290, 874

16655, 16705

3443, 9667

18515, 19158

2755, 2773

13342, 16059

16173, 16634

12386, 13319

16729, 16729

16745, 18492

2788, 3424

234, 252

902, 2350

2372, 2683

2699, 2739

50,093

175,829

988

Discharge summary

report

Admission Date: [**2164-4-2**] Discharge Date: [**2164-4-8**] Date of Birth: [**2103-12-24**] Sex: M Service: CARDIOTHORACIC Allergies: bupropion Attending:[**Known firstname 4679**] Chief Complaint: dysphagia Major Surgical or Invasive Procedure: [**2164-4-2**] 1. Laparoscopic jejunostomy feeding tube. 2. Esophagogastroduodenoscopy and balloon dilation of stricture to 18 mm. 3. Biopsy of gastric conduit. [**2164-4-3**] EGD/Esophageal stent placement 4. Bronchoscopy with bronchoalveolar lavage. History of Present Illness: The patient is a 60-year-old gentleman who underwent a minimally-invasive esophagectomy with an intrathoracic anastomosis in [**2163-8-25**]. He has developed metastatic disease to the brain and underwent a craniotomy. He has also had ongoing issues with a productive cough and weight loss. CT scans have not demonstrated evidence for fistula, but have demonstrated pneumonia in the right lower [**Year (4 digits) 3630**]. He was admitted to the hospital for further management. Past Medical History: stage III adenocarcinoma at GE jxn s/p chemoradiation esophagectomy- pathology showed complete response. AF w/ RVR s/p cardioversion [**2163-8-19**] -he does not feel when he is in atrial fibrillation PE ([**7-4**]) & R axillary DVT ([**2163-8-17**]) Rheumatoid arthritis- s/p enbrel, currently on prednisone + PPD (never treated) bilateral pleural effusions (s/p drainage by IP) h/o pericarditis Recent aspiration/pneumonia ([**2164-1-10**])- tx with doxycycline COPD Onc history (Per OMR): [**Date range (2) 6545**]: chemoradiation with cisplatin (75 mg/m2, D1 and D29) and 5-FU (1000 mg/m2/day D1-4, D29-32) [**Date range (1) 6546**]/11: admission for PE (RLL segmental) causing pleuritic chest pain; therapeutic lovenox initiated [**Date range (3) 6547**]: admission with new atrial fibrillation and acute right axillary DVT. CT showed improving PE. Cardioverted. Therapeutic lovenox continued. [**2163-8-26**] PET/CT: Gastrohepatic and left paratracheal lymph nodes now without FDG-avidity. Low level FDG-avid RLL consolidations, non-specific (aspiration/pneumonia vs infarct vs atelectasis). [**2163-9-19**]: esophagectomy, J-tube placement (Dr. [**First Name (STitle) **] -J-tube discontinued [**2163-12-30**] PSHx: -R forearm surgery -minimally invasive eosphagectomy [**2163-9-19**] & J-tube placement -s/p Esophagogastroduodenoscopy and dilation of a stricture ([**1-5**]) Social History: He lives with his wife. [**Name (NI) **] has been on disability for the past ten years related to RA. Formerly was a manager at a bottling plant and [**Location (un) 6350**] [**Location 6351**]. He has four children. He quit smoking in [**2161**], previously smoked 30-35 years, 1-1.5 PPD. He had drinks [**12-26**] cocktails very few weeks. Denies drug use. He has traveled extensively in the Caribbean. No known TB contacts. Family History: His mother and [**Name2 (NI) 1685**] sister have [**Name2 (NI) **]. There is no family history of cancer. No clotting disorders in the family. Physical Exam: ON ADMISSION: ------------- Vitals: BP: 93/69. HR: 84. Temp: 96.8. RR: 16. Pain: 0. O2 Sat%: 94. Weight: 120.2. Height: 64. BMI: 20.6. awake alert, very thin lungs with good air movement heart regular abd soft, not distended . ON DISCHARGE: ------------- VS: stable Gen: A&O X 3, in NAD HEENT: atraumatic Neck: supple Lungs: cta bilaterally no r/w/r CV: RRR s1s2 no m/r/g Abd: soft mildly tender @ j tube site +bs no HSM no stigmata of chr liver dz Ext: no erythema or edema Neuro: CNii-xii grossly intact Pressure ulcer: sacrum, 1cm X 1cm, superficial, no signs of infection Pertinent Results: LABS ON DISCHARGE: ------------------ [**2164-4-8**] 10:20AM BLOOD Glucose-111* UreaN-12 Creat-0.5 Na-134 K-4.4 Cl-101 HCO3-26 AnGap-11 [**2164-4-8**] 10:20AM BLOOD Calcium-7.8* Phos-1.2* Mg-1.8 . IMAGING & STUDIES: ------------------ [**2164-4-3**] EGD/ Esophageal stent placement: A slight narrowing was noted in the mid/upper esophagus at 26 cm likely corresponding to known anastamotic stricture. Once anastamotic stricture was traversed there was a large saccular area identified which was ulcerated and friable - Per Dr. [**First Name (STitle) **], this represents the gastric conduit. Again identified was a 1-2 mm area concerning for fistula. After extensive discussion with Dr. [**First Name (STitle) **], decision was made to place a fully covered metal stent to attempt closure of the fistula and symptom control. A 23 mm x 155 mm Wallflex Esohpagael fully covered metal stent [Ref# 1675; Lot# [**Serial Number 6548**]] was placed successfully into the esophagus under fluoroscopic guidance. Time Taken Not Noted Log-In Date/Time: [**2164-4-2**] 6:03 pm BRONCHOALVEOLAR LAVAGE LEFT LOWER [**Year/Month/Day **]. GRAM STAIN (Final [**2164-4-2**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 4+ (>10 per 1000X FIELD): BUDDING YEAST. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2164-4-5**]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. SECOND MORPHOLOGY. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. YEAST. 10,000-100,000 ORGANISMS/ML [**Last Name (un) **]: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | KLEBSIELLA PNEUMONIAE | | AMPICILLIN/SULBACTAM-- 4 S 8 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S ANAEROBIC CULTURE (Preliminary): NGTD. FUNGAL CULTURE (Preliminary): NGTD. Brief Hospital Course: Mr. [**Known lastname 6352**] was admitted to the hospital and taken to the Operating Room where he underwent Laparoscopic jejunostomy feeding tube placement, Esophagogastroduodenoscopy and balloon dilation of stricture to 18 mm., Biopsy of gastric conduit and Bronchoscopy with bronchoalveolar lavage. He tolerated the procedure well and returned to the PACU in stable condition. After full recovery from anesthesia, he transferred to the surgical floor and was evaluated by the GI service for possible stent placement for the stricture and also to help heal a possible fistulous tract. He was taken to the GI suite on [**2164-4-3**] for placement of a metal stent. He tolerated the procedure well and returned to the Surgical floor in stable condition. The Nutrition service evaluated his nutritional needs and recommended Isosource 1.5 to be cycled at 120 mls/hr over a 12 hour period. His feedings were started slowly and advanced and tolerated well. His pre admission Lovenox was also started for atrial fibrillation and DVT. As his beta blocker was held for 48 hours he had some problems with RAF to 150 after ambulation. His beta blocker was resumed and his rate returned to sinus rhythm at 86 BPM. He had no abdominal pain and his j tube site was clean. He was reluctant to eat much due to his recent problems but realizes that he can have food if he desires. Home care was arranged with VNA, oxygen therapy and tube feeding capabilities. He was discharged to home on [**2164-4-8**]. Medications on Admission: albuterol 90mcg'' q4h prn, amiodarone 100', benzonatate 100 q8h prn cough, lovenox 60/0.6ml'', levothyroxine 100mcg', lorazepam 0.5 qhs prn, metoprolol tartrate 100', omeprazole 40', prednisone 10', tylenol extra-strength 500 q4h prn pain, vitamin D3 400 unit'', guaiatussin AC 100 mg-10 mg/5 ml 1 tsp q4-6h prn cough, mucinex DM 600mg-30mg ER q12h prn cough (not take with benzonatate), senna 8.6'for cough do not take along with benzonatate Discharge Medications: 1. Nutrition Jevity 1.5 @ 120 ml's per hour over 12 hours 6 cans per day disp 1 case refills for 6 months 2. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous Q12H (every 12 hours). Disp:*30 syringes* Refills:*2* 4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Respiratory Therapy O2 at 2-4 liters per minute via nasal cannula, continuous Pulse dose Dx COPD 6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: [**12-26**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 HFA* Refills:*1* 7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 9. levofloxacin 250 mg/10 mL Solution Sig: Thirty (30) mls PO once a day: thru [**2164-4-11**]. Disp:*250 mls* Refills:*0* 10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. Disp:*30 Tablet(s)* Refills:*0* 12. home services Patient to have PT, OT, Speech therapy, VNA nursing, home services, home O2 therapy, Tube feeding, and home suction for comfort and medical management. 13. oxycodone 5 mg/5 mL Solution Sig: [**5-3**] mL PO every 4-6 hours as needed for pain: Do not drink alcohol or drive while taking this medication. Disp:*300 mL* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 6549**] Medical Services Discharge Diagnosis: esophageal cancer severe malnutrition pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: * You were admitted to the hospital with repeated episodes of difficulty swallowing and coughing. A feeding tube was placed to help you maintain your calories. You can also eat soft foods and liquids if you feel like it. * You should continue to take deep breaths and cough to keep your lungs clear. The incentive spirometer will also help. * When you are in [**Last Name (un) 6550**] make sure you turn from side to side every 2 hours to decrease skin breakdown. * Continue Lovenox twice daily. * The VNA will continue to follow you at home. * If you develop any fevers > 101, increased pain, shortness of breath or any other symptoms that concern you, call Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 2348**]. Followup Instructions: Department: [**Hospital3 249**] When: TUESDAY [**2164-4-17**] at 10:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2164-4-17**] at 10:30 AM With: [**Known firstname **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please report 30 minutes prior to your appointment to the Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical Center for a chest xray. Department: RHEUMATOLOGY When: FRIDAY [**2164-5-4**] at 12:00 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2164-4-11**]

[ "427.31", "707.22", "V58.65", "261", "997.49", "707.03", "V10.03", "V12.51", "V12.55", "496", "714.0", "V58.61", "530.3", "482.0" ]

icd9cm

[ [ [] ] ]

[ "46.39", "45.16", "96.6", "33.24", "42.81", "42.92" ]

icd9pcs

[ [ [] ] ]

10129, 10196

6550, 8055

284, 542

10288, 10288

3684, 3684

11222, 12330

2928, 3072

8550, 10106

10217, 10267

8081, 8527

10471, 11199

3087, 3087

6520, 6527

3328, 3665

235, 246

3703, 6451

570, 1054

3101, 3314

6484, 6490

10303, 10447

1076, 2466

2482, 2912

7,394

113,714

43069

Discharge summary

report

Admission Date: [**2196-5-24**] Discharge Date: [**2196-6-1**] Date of Birth: [**2128-3-22**] Sex: F Service: CARDIOTHORACIC Allergies: Lipitor / Codeine / Iodine Attending:[**First Name3 (LF) 2969**] Chief Complaint: Surgical reconstruction of metastatic Breast Cancer to sternum Major Surgical or Invasive Procedure: Left breast CA in past s/p left dorsi/gel implant. Now with metastatic breast Cancer to sternum. S/P sternectomy and reconstruction with [**Doctor Last Name **]-tex mesh to chest wall by Thoracic [**Doctor First Name **] with pedicled left dorsi flap by plastic surgery, 4 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] drains, 2 chest tubes History of Present Illness: 68yo female with h/o L breast CA in past s/p left dorsi/gel implant. Now with metastatic breast CA to sternum. S/P sternectomy and reconstruction with [**Doctor Last Name **]-tex mesh to chest wall by CT [**Doctor First Name **] with pedicled l dorsi flap by us. 4 drains, 2 Chest tubes Past Medical History: Left breast cancer s/p mastectomy and reconstruction, Hypertension, dyslipidemia Social History: Husband died in [**2195-11-30**]. Six children. 50 pk year smoker. ETOH [**5-4**] drinks/wk- now decreased to 4 drinks/wk. Family History: Breast cancer in 2 sisters. One sister deceased from bone cancer. Physical Exam: General: well appaering female in NAD. HEENT: Atraumatic. PEERL. EOMI. Sclera white. Throat -no erythema. Heart: RRR No murmur, no rub. LUNGS: CTA bilat. Chest -ridge noted to left of midline of sternum post surgery. ABD: soft, NT, ND, +BS Extrem: no C/C/E. Pertinent Results: [**2196-5-24**] 07:05PM GLUCOSE-125* UREA N-13 CREAT-0.5 SODIUM-141 POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-21* ANION GAP-13 [**2196-5-24**] 07:05PM WBC-8.4 RBC-3.82* HGB-11.3* HCT-32.8* MCV-86 MCH-29.5 MCHC-34.3 RDW-13.5 [**2196-5-24**] Pathology Tissue: STERNAL MARGIN,PARTIAL [**2196-5-24**] [**Last Name (LF) **],[**First Name3 (LF) 2389**] M. Not Finalized Brief Hospital Course: 68 yo female with T2 N1 stage IIB carcinoma of the left breast with mastectomy and immediate reconstructionin [**2181**] who presents with adeno carcinoma of sternum. Pt was taken to the OR 4/ 26/05 for sternal resection and reconstruction. operative course was uneventful. Pt was kept intubated until POD#1 then weaned to extubate. Pain was managed w/ epidural Bup/Dilaudid). Sternal flap was well profused. Kefzol for JP drain prophylaxis. Chest tubes right/left placed in OR to SXN w/ serosang drainage. JP drains x4 to bulb sxn. POD #3 JP #1 d/c'd and chest tube to water seal. Right chest tube d/c'd and left chest tube clamped then d/c'd on POD#4. Left chest tube and two additional JP's d/c'd on POD #7. Flap continued to heal well. Progressed w/ ambulation, po's and epidural transitioned to po pain med. POD #8 pt d/c'd to home with one remaining JP drain in place and on po keflex until follow up appointment with plastics [**2196-6-10**] for JP drain removal. Medications on Admission: Atenolol 25", Lovastatin, Xanax, Wellbutrin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:*90 Tablet(s)* Refills:*0* 3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 weeks: continue taking until the JP drain is removed AND you have [**Doctor First Name **] told to stop taking the antibiotic. Disp:*56 Capsule(s)* Refills:*0* 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Amoxicillin 500 mg Capsule Sig: Four (4) Capsule PO times one for once days: take all 4 pills one hour prior to your dental appointment. Disp:*4 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Breast CA sternal resection and flap reconstruction Discharge Condition: good. Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] for: shortness of breath, fever, chest pain, or redness or discharge from incision sites. Call Plastic Surgery office for issues with your JP drain [**Telephone/Fax (1) 274**]. for: a follow up appointment Resume medications as previous to hospitalization. Take all medications as directed. Obtain medical alert bracelet to indicate lack of sternal bone. You may shower on thursday; no tub baths for 3-4 weeks. Chest tube dressings may be removed on thursday and replaced with a bandaid. Followup Instructions: Call Dr.[**Doctor Last Name 4738**] office for appointment in [**1-31**] weeks-[**Telephone/Fax (1) 170**]. Please arrive to your Dr. [**Last Name (STitle) **] appointment 45 minutes prior for a follow up Chest XRAY- [**Location (un) **] radiology [**Hospital Ward Name 23**] Clinical Center. You have a Plastic Surgery Clinic appointment on [**2196-6-10**] at 1:30pm- [**Telephone/Fax (1) 274**]. Dr. [**Last Name (STitle) 1435**] office: [**Street Address(2) **]., [**Location (un) **], Ma. Phone [**Telephone/Fax (1) 1416**] Completed by:[**2196-6-3**]

[ "197.2", "272.4", "198.5", "401.9", "V10.3", "198.89" ]

icd9cm

[ [ [] ] ]

[ "77.81", "34.79", "86.74" ]

icd9pcs

[ [ [] ] ]

3899, 3948

2044, 3016

355, 718

4044, 4051

1654, 2021

4659, 5220

1294, 1361

3110, 3876

3969, 4023

3042, 3087

4075, 4636

1376, 1635

253, 317

746, 1034

1056, 1138

1154, 1278

82,579

185,800

53671

Discharge summary

report

Admission Date: [**2102-4-12**] Discharge Date: [**2102-4-14**] Date of Birth: [**2038-12-19**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4393**] Chief Complaint: Hypotension following anesthesia induction Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 63 year old female with a history of HCV cirrhosis and HCC, osteoporosis, ovarian cysts, active smoker for 40 years, who presented to OR for elective RFA as outpatient today and was found to be hypotensive and bradycardic after administration of sedatives for intubation. She underwent induction for anesthesia with propofol, succ, rocuronium, fentanyl with blood pressure dropping from the systolic 90s to 60s. HRs also subsequently dropped to 30s. She received glycopyrolate with HRs recovering to 100s; she then received esmolol to decrease HR. Blood pressure currently in 80s-90s prior to transport to MICU. ECG showed ST depressions in V3-6. Cardiology was consulted in the PACU who felt that ST depressions were likely [**1-19**] demand ischemia from hypotension. Repeat EKGs showed resolution of ST depressions. RFA was postponed given her hypotension and bradycardia. She received a total of 2.5L LR and neosynephrine approximately every 1/2hour for 3 doses. She also received 1gm iv cefazolin. . On arrival to the MICU, pt reports feeling well. Denies chest pain, SOB, palpitations, lightheadedness, headache. States that she was in her usual state of health prior to coming in for procedure today. Took one of her alprazolam 0.25mg last night. Has not eaten for procedure today. Past Medical History: HCV Cirrhosis complicated by HCC Migraines Ovarian cysts Osteoporosis Social History: Rare alcohol use, current smoker (40 pack years). no illicit substances. she works as a customer service representative for her family's framing company. lives with husband. Family History: Giant cell arteritis in her mother and prostate cancer in her father Physical Exam: ADMISSION PHYSICAL EXAM General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, gait deferred . DISCHARGE EXAM: VS: 98.3, BP: 102/63, HR: 69 (69-91), RR: 16, 02: 96% RA GENERAL: Well-appearing woman in NAD, comfortable, appropriate. HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no thyromegaly, no JVD, no carotid bruits. HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding, midline infraumbilical scar EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. LYMPH: No cervical, supra/infra clavicular, axillary LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-22**] throughout, sensation grossly intact throughout, gait exam deferred Pertinent Results: ADMISSION LABS: [**2102-4-12**] 11:48AM BLOOD WBC-2.9* RBC-3.60* Hgb-11.5* Hct-36.0 MCV-100* MCH-31.9 MCHC-31.9 RDW-13.8 Plt Ct-69* [**2102-4-12**] 11:48AM BLOOD Neuts-44.9* Lymphs-43.9* Monos-8.9 Eos-1.5 Baso-0.8 [**2102-4-12**] 04:45PM BLOOD PT-13.7* PTT-33.2 INR(PT)-1.3* [**2102-4-12**] 11:48AM BLOOD Glucose-77 UreaN-16 Creat-0.5 Na-138 K-3.7 Cl-105 HCO3-23 AnGap-14 [**2102-4-12**] 04:45PM BLOOD ALT-117* AST-116* LD(LDH)-163 CK(CPK)-92 AlkPhos-59 TotBili-0.8 [**2102-4-12**] 11:48AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.6 [**2102-4-12**] 04:45PM BLOOD VitB12-756 Folate-12.4 [**2102-4-12**] 05:04PM BLOOD Lactate-1.9 . DISCHARGE LABS: [**2102-4-14**] 07:10AM BLOOD WBC-3.3* RBC-3.46* Hgb-11.3* Hct-34.1* MCV-99* MCH-32.7* MCHC-33.2 RDW-13.7 Plt Ct-62* [**2102-4-14**] 07:10AM BLOOD PT-14.1* PTT-31.2 INR(PT)-1.3* [**2102-4-14**] 07:10AM BLOOD Glucose-108* UreaN-6 Creat-0.5 Na-138 K-3.5 Cl-108 HCO3-24 AnGap-10 [**2102-4-14**] 07:10AM BLOOD ALT-94* AST-85* AlkPhos-63 TotBili-1.2 [**2102-4-14**] 07:10AM BLOOD Albumin-3.2* Calcium-8.3* Phos-2.3* Mg-1.7 . CARDIAC LABS: [**2102-4-12**] 11:48AM BLOOD CK-MB-3 cTropnT-0.06* [**2102-4-12**] 11:48AM BLOOD CK(CPK)-63 [**2102-4-12**] 04:45PM BLOOD CK-MB-8 cTropnT-0.32* [**2102-4-12**] 04:45PM BLOOD CK(CPK)-92 [**2102-4-13**] 02:04AM BLOOD CK-MB-7 cTropnT-0.12* [**2102-4-13**] 02:04AM BLOOD CK(CPK)-106 . MICROBIOLOGY: [**2102-4-13**] 10:43 am URINE Source: CVS. **FINAL REPORT [**2102-4-14**]** URINE CULTURE (Final [**2102-4-14**]): NO GROWTH. . Blood culture pending . IMAGING CT ABDOMEN W/O CONTRAST Study Date of [**2102-4-12**]: PRE-PROCEDURE IMAGING: Limited unenhanced CT scan of the abdomen which demonstrated a macro-nodular contour of the liver with mild segmental atrophy in segment V consistent with known cirrhosis. The spleen is enlarged. There is no ascites. The known segment VIII liver lesion measuring 2.1 x 1.9 cm is redemonstrated as a hypodense lesion (2:14). The segment VI lesion is not well appreciated on non-contrast CT. The lung bases demonstrate bilateral dependent atelectasis and mild middle lobe atelectasis. The heart is normal in size. PROCEDURE: The procedure, risks, benefits, and alternatives were discussed with the patient and written informed consent was obtained during a preprocedure interventional radiology consultation. The consent was reviewed prior to the procedure. A preprocedure timeout was performed discussing the planned procedure, confirming the patient's identity with three identifiers, and reviewing a checklist per [**Hospital1 18**] protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. The patient underwent induction of general anesthesia for the procedure. After prepping the patient, and prior to beginning the procedure, the anesthesiologist noted ST depression on the monitor and the procedure was put on hold. A 12-lead EKG was performed, and based upon these findings, a stat cardiology consult was requested. The procedure was terminated, and general anesthesia was reversed. For information on general anesthesia course/medications administered, please see anesthesia notes. For further information regarding the cardiac event, please see cardiology consultation and inpatient medical records. IMPRESSION: Cancelation of ultrasound/CT-guided radiofrequency ablation secondary to cardiac event during induction of general anesthesia. Cardiology consultation has been performed. The patient will be admitted for observation. . LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Study Date of [**2102-4-12**]: FINDINGS: Limited ultrasound of the abdomen was performed prior to beginning the procedure. Segment VIII liver lesion is visualized under ultrasound guidance. The segment VI lesion was poorly visualized. The planned radiofrequency ablation was terminated prior to beginning the procedure secondary to a cardiac event. Please see details dictated under CT interventional procedure #[**Numeric Identifier 110214**]. IMPRESSION: Limited ultrasound guidance for planned radiofrequency ablation as above. . Portable TTE (Complete) Done [**2102-4-13**] The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60%). Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . CHEST (PORTABLE AP) Study Date of [**2102-4-13**] FINDINGS: There are bilateral basilar opacities, with some element of organization likely representing subacute pneumonia. The upper lung zones are clear. There is no pneumothorax or pleural effusion. Cardiomediastinal silhouette is normal. IMPRESSION: Bibasilar opacities with organization, likely subacute pneumonia. . Cardiovascular Report Cardiac Cath Study Date of [**2102-4-14**] PRELIMINARY REPORT*** COMMENTS: 1. Selective coronary angiography in this left dominant system demonstrated no angiographically-apparant flow limiting coronary artery disease. The LMCA was short but widely patent. The LAD gave off modest calibur diagnoals with a hinge point in D1. The LAD had a 20% ostial lesion, and mild luminal irregularities leading into a 40% proximal-mid tubular lesion. There was a possible intramyocardial segment of the LAD distally, and the distal LAD wrapped around the apex. The LAD had slightly slow flow consistent with mild microvascular dysfunction. The LCX was widely patent and supplied a large OM2, a large calibur OM4/LPL, a small LPL2, and a large left PDA. There Lcx had slightly slow flow consistent with mild microvascular dysfunction. The RCA was a small and non-dominant vessel free of angiographically-apparant flow limiting coronary artery disease. 2. Limted resting hemodynamics revealed a normal systemic arterial blood presure of 128/68 mmHg, and a mildly elevated LVEDP of 22 mmHg. There was no gradient with careful pullback across the aortic valve. FINAL DIAGNOSIS: 1. No angiographically-apparant flow limiting coronary artery disease, with evidence of some athersclerosis and slightly slow flow consistent with microvascular dysfunction. 2. Moderate left ventricular diastolic heart failure. 3. Medical therapy for coronary artery disease with aspirin, betablocker, statin, smoking cessasion, risk factor reduction. Brief Hospital Course: 63 year old female with a history of HCV cirrhosis and HCC, osteoporosis, ovarian cysts, active smoker for 40 years, who presented to OR for elective RFA as outpatient today and was found to be hypotensive and bradycardic after administration of sedatives for intubation. Her EKG was concerning for ST depressions in the setting of hypotension, with a troponin elevation, so patient underwent cardiac catheterization with no angiographical flow limiting disease. . ACTIVE ISSUES: # Hypotension: Pt was found to be hypotensive as low as systolic 60s, likely secondary to medications for induction. Per PACU notes, she received propofol, succ, rocuronium, fentanyl; she was subsequently treated with IVFs, glycopyrrolate, and neosynephrine with BP subsequently rising to 80s-90s. Volume depletion was likely another contributing factor as pt had been NPO since night prior to procedure and was fluid responsive in PACU. She received additional fluid boluses in the ICU, but still required dopamine temporarily overnight following her procedure. She was quickly weaned off and she maintained her blood pressure in the 90's-100's systolic afterwards. . # Bradycardia: This was also thought to be likely from agents given for induction, particularly propofol and succinylcholine. She also received esmolol after she became tachycardic from glycopyrrolate. Her bradycardia resolved over 24 hours. . # ST depressions: EKG showed ST depressions in lead V3-V6 that were new from prior, in setting of bradycardia and hypotension. Her repeat EKG later showed resolution of ST depressions. Pt was evaluated by cardiology who felt that ST depressions were likely from demand ischemia from hypotension and bradycardia. She had a troponin elevation to Trop elevated to 0.32 with mild MB elevation to 8. Given that the patient is being evaluated for transplantation, she underwent a cardiac catheterization which revealed non significant coronary artery disease. She also had a TTE which showed EF >55%, trace AR and MR. . CHRONIC ISSUES: # HCC: Pt with HCV cirrhosis that is well-compensated (Childs [**Doctor Last Name 14477**] A). She has no history of jaundice, encephalopathy, ascites, or esophageal varices. She will need to have her RFA rescheduled and will require an anesthesia evaluation prior to the procedure. . # Osteoporosis: continued home raloxifene, calcium and vitamin D . # Tobacco abuse: Pt was supplied a nicotine patch while in hospital . Transitional Issues: # blood cultures were pending at time of discharge. . # Pt's initial chest xray was concerning for pneumonia, however pt was clinically well and asymptomatic. No antibiotics were started but would have low threshold to initiate treatment for pneumonia if pt develops symptoms. . # Pt will need to have her RFA rescheduled. She should have a pre-op evaluation by anesthesia to determine the safety of the procedure. Medications on Admission: alprazolam 0.25mg prn anxiety vitaminD2 1.25mg (50,000units) once weekly evista 60mg daily sumatriptan 50mg prn calcium with vitamin D 1250mg/1000units Discharge Medications: 1. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 2. Vitamin D2 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 3. raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily (). 4. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO Q 24H (Every 24 Hours). 5. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO once a day as needed for migraine. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: hypotension and bradycardia secondary to anesthesia SECONDARY: Hepatocellular carcinoma hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 32687**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for a radiofrequency ablation, but had complications from the anesthesia so the procedure was stopped. You required a short ICU stay for low blood pressure and a slow heart rate. However, your blood pressure and heart rate returned to [**Location 213**]. You had a heart catheterization to evaluate for any blockages in the heart, and this was normal. We have made no changes to your medications. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 198**] P. Location: [**Location (un) **] FAMILY PRACTICE Address: [**Street Address(2) 19979**], [**Location (un) **],[**Numeric Identifier 3862**] Phone: [**Telephone/Fax (1) 19980**] Appointment: Friday [**2102-4-21**] 10:20am Department: TRANSPLANT When: MONDAY [**2102-4-24**] at 9:20 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage *** You should be contact[**Name (NI) **] by the liver clinic ([**Name (NI) **] [**Name (NI) 23170**]) to reschedule your radiofrequency ablation. You should also be scheduled for a pre-op evaluation by anesthesia. If you do not hear from the clinic within a week, please call [**Telephone/Fax (1) 673**].*** [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**] Completed by:[**2102-4-17**]

[ "346.90", "571.5", "E938.3", "427.89", "305.1", "458.29", "284.19", "794.31", "733.00", "070.54", "155.0", "V64.1" ]

icd9cm

[ [ [] ] ]

[ "88.57", "37.22" ]

icd9pcs

[ [ [] ] ]

13592, 13598

10058, 10523

348, 374

13752, 13752

3349, 3349

14442, 15430

2009, 2079

13153, 13569

13619, 13731

12975, 13130

9681, 10035

13903, 14419

3987, 9664

2094, 2639

2655, 3330

12533, 12949

266, 310

10538, 12072

402, 1707

3365, 3971

13767, 13879

12088, 12512

1729, 1801

1817, 1993

46,262

155,235

3532

Discharge summary

report

Admission Date: [**2158-5-12**] Discharge Date: [**2158-5-18**] Date of Birth: [**2122-5-12**] Sex: F Service: MEDICINE Allergies: Compazine / Cephalosporins / Amoxicillin / Reglan / Imitrex / Erythromycin Base / Penicillins Attending:[**First Name3 (LF) 7299**] Chief Complaint: Cough, pleuritic chest pain and headache admitted to the ICU for hypotension in the setting of fever to 105 Major Surgical or Invasive Procedure: None History of Present Illness: A 36 year old female with past medical history IV drug use, migraines presented to the [**Hospital1 18**] ED with complaints of malaise, fever, chills, dyspnea x 1 days. She reports rinorrhea and sore throat 2 days ago. Yesterday, she developed worsening dyspnea, nonproductive cough and fever to 103. At that time, she also noted pleuritic chest pain. She reports that other residents at her half way house have similar symptoms. . Of note, she was seen in the ED [**5-5**] for headache similar to previous migraines, given medication refill and discharged home, also on [**5-8**] for malaise and lethargy and was observed overnight with improvment, thought to be related to methadone. . In the ED, initial vs were: T105.8 P150 BP130/90 R20 O2 sat 99%RA. She initially complained of headache [**7-7**] and dyspnea with cough. Labs were notable for WBC 5.1, 75% PMN, lactate 1.5, UCG neg, U/A negative. Chest xray showed no effusion or infiltrate. She had a bedside ECHO cardiogram which was negative for vegitations. Patient was given acetaminophen 500mg ketorlac levofloxacin 750mg, Vancomycin 1g, Meropenem 1g, oseltamivir 75mg. She developed hypotension to SBP 90's, a right IJ was placed and she was treated with 4L NS and started on levophed. Vitals on transfer were T103.7 BP142 BP86/40. SBP in 90s. RR 18 99% on RA . On arrival to the ICU vitals were T101.3 P129 BP70/40 R18 O2 sat98%. She reported that headahce has improved since presentation to ED and is now [**3-9**]. Reports continued dyspnea and non-productive cough with bilateral pleuritic chest pain. Denies IV drug use x 1 month. Denies numbness/tingling, denies photophobia, states that she is squinting because she needs her glasses. . Review of sytems: (+) Night sweats, weight gain, (-) Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Multiple suicide attempts IV drug abuse (heroin and cocaine) MRSA pneumonia Endometriosis Hypercholesterolemia Questionable history of Hepatitis C (ab postive, RNA negative) Asthma Migraines Depression Appendicitis Restless leg syndrome Social History: Living at RES in [**Location (un) **] x 1 month. Patient has been homeless for years living in shelters and half way houses. History of IV Drug abuse with heroin and cocaine, denies use in last 4 weeks. Family History: Father hypercholesterolemia, Mother Hypertension, Maternal grandmother CAD. Physical Exam: Admission Physical Exam: Vitals: T101.3 P129 BP70/40 R18 O2 sat98% RA General: Alert young female appearing uncomfortable HEENT: EOMI PEERLA, Sclera anicteric, MMM, oropharynx clear Neck: supple full range of motion, JVP not elevated, no LAD Lungs: Normal tactile fremitus, resonant to percussion. Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: tachycardic 2/6 SEM regular rhythm, normal S1 + S2, Abdomen: well healed surgical scar, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: exceptionally warm to touch, 2+ pulses, no edema. NEURO: CN II-XII intact, no nystagmus DTRs not elicited in patella BL, 2+ in biceps tendon BL, babinski downgoing, sensation to fine touch intact BL Pertinent Results: Admission Labs [**2158-5-12**]: -WBC-5.1 RBC-4.11* Hgb-13.3 Hct-36.7 MCV-89 MCH-32.3* MCHC-36.2* RDW-13.9 Plt Ct-223 -PT-14.7* PTT-35.6* INR(PT)-1.3* -Glucose-128* UreaN-13 Creat-1.0 Na-136 K-3.2* Cl-104 HCO3-19* AnGap-16 -ALT-37 AST-46* LD(LDH)-242 CK(CPK)-126 AlkPhos-113* TotBili-0.3 -Albumin-4.7 Calcium-9.4 Phos-1.7*# Mg-1.7 -TSH-1.1 -ASA-5.1 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-POS Tricycl-NEG -Lactate-1.5 . [**5-12**] Admission CXR: Cardiac, mediastinal and hilar contours are normal. Both lungs are clear with no focal consolidation, pleural effusion or pneumothorax. . Repeat CXR on [**5-12**]: Tip of the new right internal jugular line ends in the upper SVC. There is no mediastinal widening, pneumothorax, or pleural effusion. There is new heterogeneous opacification in the right mid and upper lung zones strongly suggestive of developing pneumonia. Left lung is clear. Heart size normal. No pleural effusion. . [**5-13**] RUQ US Trace ascites in Morison's pouch not amenable to ultrasound-guided paracentesis. . [**5-13**] ECHO TTE The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: no vegetations seen, but suboptimal image quality . RUQ ultrasound: [**5-18**] IMPRESSION: Small periportal nodes, subcentimeteric in short axis diameter.No other remarkable abnormalities noted. . HIV Viral lode was negative All Blood & Urine Cx were all negative for growth Legionella Ag negative Hepatitis C antibody was positive, Viral loade returned without any detectable virus Vaginal G/C PCR pending at the time of this dictation Brief Hospital Course: # Hypotension/Pneumonia: Patient was admitted to the ICU with tachycardia, fever, and hypotension which was felt most likely from acute pneumonia given cough, pleuritis, and opacities on CXR. Pt was covered with Vancomycin/Levofloxacin due to her history of MRSA PNA. She was aggressively fluid resuscitated and supported with pressors with resolution of hypotension. Pt did not require ventilator support and later had significant autodiuresis of large volumes of urine and BP remained stable off pressors. She was called out to the floor with resolution of fevers. Additional infectious work up included multiple negative Urine & Blood Cx, an echo that did not show any vegetations, negative HIV viral load, negative Viral Influenza screen and negative Legionella Antigen. Leukocytosis continued to resolve on Linezolid with high dose Levofloxacin. Pt was continued on Linezolid for an 8 day course and pre-authorization was obtained for po Linezolid on discharge to sober house. Levofloxacin was transitioned to Moxifloxacin to complete the 8 day course due to insurance approval requirements. . # Abnomal LFTs: Pt reports intermittent RUQ pain and initial u/s showed small amount of ascites though not enough for paracentesis and LFTs revealed a mildly elevated transaminases with mild Alk Phos elevation. Hepatitis panel was sent and returned positive for Hep C Ab though Hep C VL was negative. Hep B studies revealed prior immunization and repeated RUQ u/s was performed prior to discharge which showed small periportal lymphadenopathy. These results were discussed with the patient and she was given an appointment to follow up with the liver clinic for further investigation. . # Narcotic addiction: Pt was continued on Methadone at confirmed clinic doses but had an epsiode of somnolence in the ICU thought due to multidrug interaction. There was concern raised for in hospital drug abuse though repeat urine drug screen returned positive for opiates (on Methadone) and barbituates (on Fioricet) without any unexplained positive substances on the screen. Given this concern, all visitors were screened prior to visits. After being transitioned to medical floor, pt was restarted on her home medication regimen including Clonidine, Clonazepam and Methadone with mild intermittent somnolence though no acute episodes of confusion. It was suggested that this regimen may be overmedicating her and pt felt that it was necessary to treat her anxiety and withdrawal. She was discharged with plan for PCP and [**Hospital 2514**] clinic follow up but was not given any refills on these medications. . # Vulvovaginitis: Pt reported symptoms of vaginal itching/burning consistent with prior yeast infections. Symptoms were only somewhat relieved with fluconazole/miconazole cream. Pt endorsed some concern of possible exposure to an STI prior to admission and pelvic exam was performed on [**5-18**] that was significant for vulvar irritation most likely c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Cervical swabs were sent for gonorrhea/chlamydia but were pending at the time of this dictation. We will follow up on the final results. Pt was discharged with a course of miconazole and acidophilus per her request. Medications on Admission: Crestor 40 mg Tablet [**Hospital1 **] Fioricet 50-325-40 mg PO Q4h PRN Headache Mirtazepine 30 mg daily Duloxetine 60 mg daily Topirimate 100 mg [**Hospital1 **] Clonidine 0.1 mg TID Klonopin 0.5 mg TID ibuprofen 800 mg TID Ambien 10 mg QHS Tab ranitidine 150 mg [**Hospital1 **] methadone 60 mg daily propranolol 80 mg [**Hospital1 **] Requip 1mg QHS Discharge Medications: 1. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 2. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:*2 Tablet(s)* Refills:*0* 3. Crestor 40 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO three times a day as needed for headache. 5. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO once a day. 6. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. topiramate 100 mg Tablet Sig: One (1) Tablet PO twice a day. 8. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety/withdrawal. 9. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 10. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 12. methadone 10 mg Tablet Sig: Six (6) Tablet PO once a day. 13. propanolol Sig: Eighty (80) mg twice a day. 14. Requip 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Acidophilus 175 mg Capsule Sig: One (1) Capsule PO twice a day for 10 days. Disp:*20 Capsule(s)* Refills:*0* 16. Miconazole 7 100 mg Suppository Sig: One (1) Vaginal once a day for 7 days. Disp:*7 suppositories* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Bacterial Pneumonia Fevers Hypotension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with fevers and low blood pressure to the intensive care unit. You were found to have a pneumonia and have improved significantly on antibiotics. You will need to continue taking antibiotics for another 2 days to complete the 8 day course. You were also reporting intermittent epigastric pain and underwent a RUQ ultrasound which showed some fluid and mildly enlarged lymph nodes around the liver. This will need to be followed up and you have been scheduled to see the liver specialist, please keep this appointment as shown below. . You were reporting some vulvovaginitis and underwent pelvic exam that was most consistent with yeast candidiasis. You have received two days of fluconazole and you have been given a prescription for miconazole and acidophilus to help clear this infection. There are additional cultures pending from your exam and I will notify you if they return positive. . Followup Instructions: You have a follow up appointment scheduled for [**5-25**] at 11am with Dr. [**Last Name (STitle) **] to help with refills on your medications. Please speak with him about your abnormal liver function tests as these will need follow up. . Department: LIVER CENTER When: MONDAY [**2158-6-19**] at 8:30 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 NEW PCP APPOINTMENT Department: [**Hospital3 249**] When: TUESDAY [**2158-6-13**] at 1:45 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16202**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "785.52", "V12.04", "304.01", "272.0", "296.90", "V15.41", "995.92", "112.1", "482.9", "305.63", "038.9", "275.3", "287.5", "333.94", "293.0", "493.90", "346.90", "300.4", "292.0", "276.8", "309.81" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10889, 10895

5871, 9126

463, 469

10987, 10987

3797, 5848

12081, 12944

2910, 2987

9528, 10866

10916, 10966

9152, 9505

11138, 12058

3027, 3778

315, 425

2222, 2414

497, 2204

11002, 11114

2436, 2674

2690, 2894

3,883

156,977

17896

Discharge summary

report

Admission Date: [**2126-5-13**] Discharge Date: [**2126-5-14**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 85 year-old man with severe vascular disease status post coronary artery bypass graft in [**2125**], peripheral vascular disease, hypertension, and hyperlipidemia who underwent MRI/MRA at [**Hospital 1474**] Hospital three years prior to presentation, which revealed significant bilateral carotid stenosis. The patient has been asymptomatic and had the evaluation in the setting of undergoing a vascular evaluation for claudication. The patient was referred for surgery, however, the patient elected to undergo stenting procedure. The patient had a repeat carotid ultrasound in [**2126-4-25**], which demonstrated severe bilateral stenosis with 90% on the right and 80% on the left. REVIEW OF SYSTEMS: The patient denies any neurological deficits or any significant weakness. He denies melena or bright red blood per rectum. He did report occasional blurry vision, not occurring at the time of admission. PAST MEDICAL HISTORY: 1. Peripheral vascular disease. 2. Hypertension. 3. Hypercholesterolemia. 4. Sick sinus syndrome status post pacemaker. 5. Coronary artery disease status post four vessel coronary artery bypass graft in [**2125-4-24**]. 6. Peripheral vascular disease. 7. Status post hernia and appendectomy. 8. Congestive heart failure with an ejection fraction of 47%. Note, in [**2125**] the patient had a left internal mammary coronary artery to the left anterior descending coronary artery, saphenous vein graft to the diagonal, marginal and right coronary artery. The patient had a pacemaker in [**2125**] for history of Mobitz type 2 block. SOCIAL HISTORY: The patient is retired. He is a former restaurant owner. He is married for 62 years. He has three boys and two girls. He has a 20 pack year history and quit 15 to 20 years ago. The patient drinks about four drinks per week. PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.6, heart rate 56, respirations 17, blood pressure 119/32, satting 97% on room air. The patient is 6' tall and weighs 178 pounds. The patient is a well appearing elderly male in no acute distress. HEENT pupils are equal, round and reactive to light. Extraocular movements intact. Oropharynx is clear. Neck revealed bilateral carotid bruits left much greater then right. The patient's cardiac examination was regular rate and rhythm. Normal S1 and S2. Lungs were clear to auscultation. Abdomen soft, nontender, nondistended. Extremities were cool bilateral with dorsalis pedis pulse dopplerable. Skin revealed a rash throughout, which the patient reports is unchanged. Neurological examination cranial nerves II through XII are intact including visual fields. Strength and sensation were intact in all four extremities. HOSPITAL COURSE: 1. Carotid stenosis: The patient underwent catheterization, which revealed RCCA with normal mild calcifications at the bifurcation. An ICA with serial 70% lesions, which revealed the MCA and faintly the ACA had a focal 90% lesion. The right vertebral had a 90% lesion, which revealed only to the mid cervical region, left vertebral was normal. The patient had a stent to his right internal carotids. The patient tolerated the procedure well and the patient was monitored for hypotension and bradycardia in the setting of recent carotid stent. The patient had a pacemaker so bradycardia was not an issue. He was found to be paced at 60 beats per minute on the arrival to the Coronary Care Unit. The patient's blood pressure was initially stable and the systolic in the 100s, however, overnight the patient's blood pressure dropped to approximately in the 90s and the patient was transiently started on Phenylephrine. The patient tolerated this well. The following morning the patient was bolused with intravenous fluids and his blood pressure remained stable off the Phenylephrine after the boluses. The patient was not restarted on his outpatient medications at the time of discharge. The patient will follow up with Dr. [**First Name (STitle) **] following discharge and Dr. [**First Name (STitle) **] will restart these as his blood pressure tolerates. 2. Renal: The patient had slightly elevated creatinine at 1.6 on the morning after his procedure. This is likely due to hypovolemia. The patient was given fluids that morning and creatinine was rechecked and it was 1.3 prior to discharge. 3. Cardiac: Patient with significant coronary artery disease and peripheral vascular disease. The patient was continued on his aspirin and also given Plavix in light of his carotid stents. The patient's ace inhibitor and beta-blocker were held given his recent carotid stent. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Carotid stenosis. 2. Coronary artery disease. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg q.d. 2. Plavix 75 q.d. 3. Omeprazole 20 q day to be started per Dr.[**Name (NI) 3101**] recommendation. 4. Metoprolol 50 b.i.d. 5. Lisinopril 20 q day per prior home doses. FOLLOW UP PLANS: The patient will follow up with Dr. [**First Name (STitle) **] in three to four days following discharge for further monitoring and evaluation of his blood pressure and possibly restarting his antihypertensives. And addition, the patient will follow up with his primary care physician within the week or two following discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**Name8 (MD) 12502**] MEDQUIST36 D: [**2126-5-15**] 09:14 T: [**2126-5-17**] 10:12 JOB#: [**Job Number 49607**]

[ "414.00", "433.30", "V45.01", "305.1", "V45.81", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.90", "39.50" ]

icd9pcs

[ [ [] ] ]

4834, 4886

4909, 5722

2856, 4750

841, 1047

116, 821

1994, 2839

1069, 1711

1728, 1979

4775, 4813

65,565

144,395

39610

Discharge summary

report

Admission Date: [**2167-8-13**] Discharge Date: [**2167-8-28**] Date of Birth: [**2125-2-9**] Sex: M Service: NEUROSURGERY Allergies: Morphine Attending:[**First Name3 (LF) 5084**] Chief Complaint: refractory epilepsy Major Surgical or Invasive Procedure: [**2167-8-13**]: Left craniotomy left temporal lobectomy History of Present Illness: Mr [**Known firstname **] [**Known lastname 805**] is a 42yo gentleman who has been followed by Dr. [**First Name (STitle) **] as an epileptologist for several years now and also had a VNS placed, which has not given him much relief of his seizures, which are located by several different convergent pieces of data including imaging and physiological EEG monitoring studies to be in the left temporal mesial area. He is a good candidate for a standard left temporal lobectomy, but he was worried previously about speech or language difficulties following surgery. He has progressed with his refractory seizure picture and has reached a point where he feels that it would be better for him to undergo the surgery at this point, especially with the lack of benefit from the vagus nerve stimulator. We talked about whether this would be left in or not. My recommendation would be to leave it in but turn it off following the surgery and leave it off until we can assess the overall outcome from the resective surgery itself. I went over the risks and benefits and details of this with him and we will plan a left temporal lobectomy with an amygdala hippocampectomy in the standard way Past Medical History: Refractory temporal lobe epilepsy Depression Asthma Kidney stones s/p T11-T12 and L5-S1 spinal fusion Social History: divorced, lives alone, no tobacco/etoh/drugs. works as a speech & language therapist Family History: There is no family history of epilepsy or febrile seizures. His paternal uncle has [**Name (NI) 3832**] syndrome, his maternal grandfather had an MI at ages 50 and 70, his mother has breast cancer. Physical Exam: At time of discharge: moves lle/lue spontaneously, r hemiplegic, no spon movement rue/rle. no w/d to pain but has sensory in R side. speech improving, able to say name and answer simple questions with yes/no Pertinent Results: [**8-13**] NCHCT: Status post left temporal lobectomy. Hypodensity within the left inferior parietal and occipital lobes suggests edema; infarction cannot be excluded. [**8-13**] EEG:This is an abnormal continuous ICU monitoring study because of the presence of slowing broadly present broadly over the left hemisphere and loss of fast frequency predominantly in the mid-posterior temporal region on the left. There were a few bursts of generalized slowing suggesting some deep midline compromise. No interictal or sustained epileptic activity was seen. [**8-13**] CTA Head: 1. Hypodensity in the left occipital lobe with cutoff of the left posterior cerebral artery just distal to the P1 segment. These findings may reflect occlusion of the posterior cerebral artery with developing infarct in the occipital lobe. 2. Expected postoperative changes status post left temporal lobectomy, with slightly increased hemorrhage within the surgical cavity. [**8-13**] MRI Brain: 1. Acute infarct in the left occipital lobe and left thalamus as well as within the posterior limb of the internal capsule, corona radiata and insula. The extent of findings is less than on the CT; CT findings may therefore reflect a combination of edema and post-operative swelling. 2. Expected postoperative findings of left temporal lobectomy, with hemorrhage within the operative bed. [**8-14**] CT Head: 1. Loss of [**Doctor Last Name 352**]-white matter junction and hypodense left occipital lobe consistent with evolving, known left PCA infarct. 2. New moderate to severe left cerebral edema with effacement of the left lateral ventricle and new midline shift to the right by 7 mm. [**8-14**] EEG: This is an abnormal continuous ICU monitoring study because of asymmetric background with relative slowing over the left centro-temporal regions with loss of faster frequencies temporally suggestive of focal cortical dysfunction. There are intermittent bursts of generalized slowing suggestive of some deep midline compromise. No interictal or electrographic seizures are seen. MR HEAD W/O CONTRAST [**2167-8-18**] 1. Interval enlargement of the large acute infarction in the left cerebral hemisphere, as detailed above, with increased mass effect and rightward shift of midline structures. 2. The temporal [**Doctor Last Name 534**] of the right lateral ventricle has slightly increased in size, likely due to increased compression of the third ventricle, concerning for impending trapping. 3. Small foci of hemorrhagic transformation in the left thalamus, and possibly also in the left occipital lobe. However, the left occipital hemorrhagic focus may be chronic. CT HEAD W/O CONTRAST [**2167-8-22**] 1. Evolving left PCA infarction with increased hypodensity involving parietal lobe, occipital lobe, and thalamus. Mixed density in the left occipital lobe may represent hemorrhagic conversion. 2. Stable shift of midline structures to the right, approximately 5 mm. Quadrigeminal plate cistern remains patent BILAT LOWER EXT VEINS [**2167-8-22**] No evidence of DVT in either left or right lower extremity. Brief Hospital Course: Pt was electively admitted and underwent a Left craniotomy and left temporal lobectomy. Surgery was without complication. He was extubated and upon awakening was noted to be aphasic and to have right hemiplegia. He was taken for a stat Head CT and then was transferred to the ICU. CT was concerning for possible infarct so a Stroke Neurology consult was called. They recommended EEG, CTA and MRI. These were all performed. The patient was reintubated [**8-13**] PM due to poor neurological exam and airway protection. CE's remained negative. On [**8-14**] his R pupil was noted to be dilated to 8mm but still reactive. He was given a dose of decadron and it came down to 5mm while the left remained at 4mm. Repeat Head CT revealed L PCA infarct, new L edema with MLS & mass effect. Family was updated. On [**8-15**], a swallow evaluation was ordered. On [**8-17**], patient expressed sucidial ideations and psych was consulted. They recommended increasing his zoloft dosing and add remeron qhs. Swallow evaluation resulted in "sips" of small spoonfulls of nectar thick liquid as tolerated w/ 1:1 sitter. Continue non-oral means of nutrition, meds and hydration. MRI head was performed which confirmed L hemispheric infarct. On [**9-19**], no changes were seen in patient. He remained in ICU awaiting a floor bed. On [**8-20**], patient was transferred to the floor. On [**8-21**], calorie counts were started to evaluate patient's food intake and necessity for PEG. Patient has low urine output and received 500cc bolus of NS. U/A was sent and was positive for UTI, he was started on ceftriaxone. On [**8-22**], patient removed dophoff and attempts to replace were unsuccessful. While attempting to give POs, it was noted that patient was pocketing food and aspirating. Chest x-ray was done which revealed atelectasis and question of new L retrocardiac opacity. Patient was made NPO and speech and swallow was reconsulted. On [**8-23**], patient continued to be agitated. On [**8-24**], patient reported abdominal pain in which GI was consulted for. He was started on emperic treatment for [**Female First Name (un) **], if no success, then he would need an EGD. On [**8-25**], patient reported severe itching, he was prescribed benadryl and sarna lotion to help relieve these symptoms. Dilaudid was also discontinued for fear of adverse reaction. LFTs were ordered while patient on fluconazole. On [**8-26**] his diet was advanced. A family meeting was held and rehab placement was discussed. On [**8-27**] his affect was improved and more interactive. Gabapentin was increased per Neurology's recommendations. On [**8-28**] he was seen and examined and his speech was slightly improved. The Neurology team also evalauted him and agreed that his exam has improved gradually. He was screened for rehab on [**8-28**] and was accepted to [**Hospital1 **] in [**Location (un) 86**]. The patient and family were in agreement with this plan and he was subsequently discharged to rehab in the afternoon of [**8-28**] with instructions for followup. All questions were answered regarding his plan of care prior to discharge. Medications on Admission: albuterol sulfate nr lacosamide [Vimpat] Vimpat levetiracetam lorazepam sertraline [Zoloft] Discharge Medications: 1. Acetaminophen 325-650 mg PO Q4H:PRN pain, headache or fever 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze, sob 3. Artificial Tear Ointment 1 Appl LEFT EYE PRN dryness 4. Bisacodyl 10 mg PO/PR [**Hospital1 **] constipation goal: [**12-1**] BM /day 5. Cyclobenzaprine 10 mg PO TID:PRN back pain hold for sedation 6. Clonazepam 0.5 mg PO TID:PRN seizrues 7. Diazepam 5 mg PO Q6H:PRN muscle spasm, anxiety 8. Docusate Sodium (Liquid) 100 mg PO BID 9. Fluconazole 200 mg IV Q24H Duration: 10 Days suspected esophageal Candidiasis. total 14 day course started in hospital 10. Gabapentin 600 mg PO Q8H 11. Heparin 5000 UNIT SC TID 12. HydrALAzine 10-20 mg IV Q4H:PRN sbp>160mmHg 13. HydrOXYzine 25 mg PO Q6H:PRN pruritis 14. LeVETiracetam 1500 mg IV BID 15. Milk of Magnesia 30 mL PO Q6H:PRN constipation 16. Mirtazapine 30 mg PO HS 17. Multivitamins 1 TAB PO DAILY 18. Nystatin Ointment 1 Appl TP QID:PRN pruritis 19. Ondansetron 4 mg IV Q8H:PRN n/v 20. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain 21. Pantoprazole 40 mg IV Q12H 22. Polyethylene Glycol 17 g PO DAILY 23. Sarna Lotion 1 Appl TP QID:PRN pruritis 24. Sertraline 100 mg PO DAILY 25. Sucralfate 1 gm PO TID administer as a slushy 26. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Refractory temporal lobe epilepsy Dysphasia Dysphagia Hemiplegia Esophagitis Back pain Depression Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Craniotomy for Hemorrhage ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Your wound was closed with sutures. Your staples have been removed and you may wash your hair now that they have been removed ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been 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. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[**2167-8-28**]

[ "493.90", "997.02", "345.41", "431", "784.3", "348.81", "599.0", "342.91", "311", "V62.84", "348.5", "112.84", "434.91" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "96.71", "01.53" ]

icd9pcs

[ [ [] ] ]

10009, 10079

5384, 8511

292, 351

10221, 10221

2254, 3634

11448, 11707

1810, 2010

8655, 9986

10100, 10200

8537, 8632

10357, 11425

2025, 2235

233, 254

379, 1567

3643, 5361

10236, 10333

1589, 1692

1708, 1794

73,206

155,402

26527

Discharge summary

report

Admission Date: [**2200-6-5**] Discharge Date: [**2200-6-12**] Date of Birth: [**2144-7-15**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Bee Sting Kit / Azithromycin / Percocet Attending:[**Attending Info 65513**] Chief Complaint: Abdominal pain, pelvic mass Major Surgical or Invasive Procedure: Exploratory laparotomy, omental biopsy History of Present Illness: She is a 55-year-old G0 who just over one year ago was diagnosed with an infiltrating ductal carcinoma, status post breast conservative surgery, negative sentinel lymph node biopsy, and postoperative radiation therapy. She has been in her usual state of health until approximately one to two months ago where she has had progressive abdominal discomfort, pain, anorexia, nausea, weight loss, and fatigue. Recent serum studies were done and were notable for a CA-125 of 677, CA [**16**]-29 of 28, and CEA of less than 1.0. A CT scan of the abdomen and pelvis was performed approximately one week ago. Ascites is noted. Diffuse stranding of the mesentry and omentum in the right upper quadrant is noted, consistent with an omental cake. A left adnexal cystic approximately 5 cm mass is noted and the imaging findings that are concerning for carcinomatosis of ovarian primary. She presented for surgical exploration and possible debulking. Past Medical History: Past Medical History: 1. Mitral valve prolapse. 2. Paroxysmal atrial fibrillation. 3. Infiltrating ductal carcinoma. 4. Left frontal meningioma, that is followed by annual imaging. Past Surgical History: 1. Cholecystectomy. 2. Right ovarian cystectomy. 3. Right oophorectomy. 4. Breast conservative excision. Past OB/GYN History: G0. Menarche at 15 and menopause in [**2194**] in her early 50s. No previous abnormal Paps or treatments for cervical vaginal dysplasia. No significant infections. Up-to-date on mammograms and colonoscopies. Social History: Denies smoking, alcohol, or drug abuse. She works at the switchboard at [**Hospital 4415**]. Family History: See HPI Physical Exam: At pre-op visit: Gen: she is in no acute distress. Her affect is appropriate. HEENT: Her eyes are anicteric. Mouth moist. Neck: Supple. No supraclavicular lymphadenopathy. Heart: Regular rate and rhythm. Lungs: Clear bilaterally. Abdomen is soft and obese. Previous incisions noted. No distinct masses are appreciated. Exam is somewhat limited to habitus. Previous [**Last Name (un) 22790**] incision noted beneath her pannus. Lower extremities without significant pitting edema. External genitalia unremarkable. On speculum exam, the vaginal mucosa is smooth. Cervix is smooth. On rectovaginal exam, irregularities noted in the cul-de-sac, which is firm and nontender consistent with imaging findings. Pertinent Results: [**2200-6-5**] 07:30AM BLOOD PT-16.8* PTT-29.6 INR(PT)-1.5* Brief Hospital Course: Ms. [**Known lastname 7568**] was admitted to the gyn oncology service on [**6-5**]. She was scheduled for an ovarian debulking procedure but the case was delayed due to her elevated INR of 1.5 in the holding area. Her anticoagulation had been discontinued 7 days prior to the procedure. Hematology was curbsided and recommended 10mg IV vitamin K as well as 10 mg SC vitamin K. She received appropriate prophylaxis prior to her dosing and had no reaction. She was taken to the OR on the following day. Please see OMR for details of the procedure. Briefly there was extensive disease and she was not deemed a good candidate for radical cytoreduction. Neoadjuvant chemotherapy is planned. Per post-operative course was complicated by atrial fibrillation with RVR on POD#3. She was transferred to the [**Hospital Unit Name 153**] where she was converted to sinus rhythm on a diltiazem drip. Cardiology was consulted for further management recommendations. Please see OMR. She was given Lovenox while re-starting her Coumadin. The remainder of her post-operative course was uncomplicated. She was discharged on [**6-12**]. Medications on Admission: Albuterol inhaler prn shortness of breath, sotalol 120bid, sotalol 80 daily, warfarin as needed for INR between [**1-8**]. Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation every four (4) hours as needed for sob, wheezing. 2. Sotalol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*1* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 7. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*1* 9. Hospital bed Hospital bed 10. Lovenox 150 mg/mL Syringe Sig: One (1) syringe Subcutaneous twice a day. Disp:*60 syringes* Refills:*0* 11. hospital bed pls provide standard hospital bed 12. tub chair with back pls provide tub chair with back 13. walker pls provide rolling walker 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 15. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for atrial fibrillation. 16. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. Disp:*50 Tablet(s)* Refills:*1* 17. Prochlorperazine Maleate 5 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. Disp:*50 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: All Care VNA & Hospice Discharge Diagnosis: Ovarian cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or return to the hospital if you have: -Increased pain -Redness or unusual discharge from your incision -Inability to eat or drink because of nausea and/or vomiting -Fevers/chills -Chest pain or shortness of breath -Any other questions or concerns Other instructions: -You should not drive for 2 weeks and while taking narcotic pain medications -No intercourse, tampons, or douching for 6 weeks -No heavy lifting or vigorous activity for 12 weeks -You can shower and clean your wound, but do not use perfumed soaps or lotions. Be sure to pat completely dry after washing. -You may resume your regular diet and home medications. Followup Instructions: Oncology: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2200-6-13**] 2:00pm Gyn oncology for staple removal: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 33326**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 5777**] Date/Time:[**2200-6-19**] 1:20pm Primary Care Physician: [**Name Initial (NameIs) 2169**]: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]., MD Phone: [**Telephone/Fax (1) 4775**] Date/time: [**2200-6-12**] 1:45pm Cardiology: Provider: [**Name10 (NameIs) 65514**],[**Name11 (NameIs) **] on the [**Hospital6 29**], [**Location (un) **] on [**2200-6-20**] at 11:30a. [**Name6 (MD) 35354**] [**Name8 (MD) **] MD [**MD Number(2) 65515**]

[ "789.51", "790.92", "183.0", "197.5", "V12.54", "197.6", "225.2", "424.0", "427.31", "V10.3", "327.23", "278.01", "198.89" ]

icd9cm

[ [ [] ] ]

[ "54.11", "54.23" ]

icd9pcs

[ [ [] ] ]

5861, 5914

2902, 4034

339, 380

5973, 5973

2818, 2879

6801, 7596

2056, 2065

4207, 5838

5935, 5952

4060, 4184

6124, 6778

1583, 1928

2080, 2799

272, 301

408, 1352

5988, 6100

1396, 1560

1944, 2040

9,462

135,049

43815

Discharge summary

report

Admission Date: [**2130-2-14**] Discharge Date: [**2130-2-18**] Date of Birth: [**2068-3-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: confusion Major Surgical or Invasive Procedure: none History of Present Illness: 61 y/o F w/ h/o CHF, [**Hospital 2320**] transferred from OSH with confusion and elevated blood sugars. Pt feeling tired [**2130-2-13**], but otherwise well. She does not recall any TIA like symptoms, numbness, weakness, or word-finding difficulty. She apparently went grocery shopping, and upon returning home, was found confused by her husband, who activated EMS. . EMS found patient to be confused, hypertensive to 210/80. At OSH, 168/83, 83, noted to additionally have right eye deviation, urinary incontinence, and blood sugar of 1179. Pt Received 3L NS, started on insulin gtt. Serum ketone +. UA showing protein/glucose/trace ketones. Venous ph 7.33. . On initial presentation to [**Hospital1 18**], VS= 214/77, 84, 11, 98% 3L NC. Pt noted to be vomitting and febrile in ED 101.8. She received levofloxacin, flagyl. anzemet and compazine. Past Medical History: 1. HTN X 10 years 2. IDDM (last HgA1C 12) 3. hyperlipidemia 4. hypothyroidism 5. anemia of renal insufficiency, baseline HCT unclear 6. h/o R frozen shoulder 7. CRI [**3-17**] HTN, DM2 8. s/p ovarian wedge resection (40 years ago) 9. s/p tonsillectomy 10. Recurrent pneumonias (went home on oxygen after last admission) Social History: no current tobacco (quit 35 years ago with 12 pack year history), occ ETOH, no drugs. Lives with her husband. Was able to walk about 2 blocks and one flight of stairs without getting short of breath. Family History: 1. Lymphoma: father; 2. CHF: mother Physical Exam: tm 100.4, bp 170/60, p 93, r 25, 98% 3L nc Arousable to voice, does not follow commands. Atraumatic. PERRL, 4->3 sluggish b/l. OP clr. Dry MM. No cervical/sm/sc LAD. Regular s1,s2. No m/r/g. LCA anteriorly +bs. soft. nt. nd. No c/c/e. Disoriented, speaking in garbled sentences. Does not follow commands. Cannot comply with strength or sensation testing. Does not withdrawl to pain on R arm. Withdrawls to pain on all other extremities. 1+ biceps DTR R, 2+ L. 1+ patellar b/l. + R sided Babinski (upgoing). Pertinent Results: ECG: 80 bpm nl axis, nl int, twi v4-v6. 0.5mm STd in V5. TwIs new compared to [**2-14**] 1826. . Radiology: CXR [**2-14**]:(radiology resident wet read) "Patchy opacity throughout the right middle lobe. _____ signs of volume loss and atelectasis is a diagnostic consideration, given history aspiration cannot be entirely excluded. Recommend close radiological observation and clinical correlation." . head CT [**2-14**]: No hemorrhage or mass effect. . TTE [**7-19**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: MICU Course: . # delerium: presentation was initially concerning for LMCA occlusion given findings particularly in the setting of elevated blood pressure. opiate effect also considered although respiratory rate relatively high. there was also concern for encephalitis given fever and altered mental status. Differential also included hyperosmolar coma given elevated blood sugars. Pt seen by [**Month/Year (2) **] service who recommended empiric acyclovir given fever and altered mental status, as well as MRI/MRA, and LP. However, after one night of fluids, patient's mental status returned to baseline with return of blood sugars to ~100s. [**Month/Year (2) 878**] agreed and so MRI/MRA, LP, acyclovir cancelled. Altered mental status attributed to hyperglycemia. . # hyperglycemia: possibly occurring in the setting of infection as some question of pneumonia. + for urine and serum ketones at OSH but clinically seems more on the spectrum of hyperosmolar coma. AG closed on MICU presentation, pt placed on insulin gtt with rapid resolution of blood sugars to <200. [**Last Name (un) **] consulted and patient returned to outpatient regime. . Multiple myeloma workup performed given h/o of MGUS and concern that evolution to MM may have precipitated sudden elevation of glucose. Skeletal survey negative. SPEP/UPEP pending. . . # fever- initially converning for encephalitis versus PNA, but more likely [**3-17**] pneumonitis/pneumonia in the setting of aspiration. pt switched from levo/flagyl to augmentin. Blood cultures NGTD. . . # cardiac: pt with lateral TWI on presentation, unclear etiology. Did not appear to be rate related subendocardial ischemia. Not classically appearing cerebral Tw. cardiac enzymes negative x 2. EKGs changes returned to baseline with improved BP control. Pt with some diastolic CHF based on TTE [**7-19**], most likely [**3-17**] HTN. No recent coronary angiograph or recent stress test. No evidence of CHF (no edema, JVD). Pt restarted on metoprolol 25 mg po bid, titrated up to 50 mg po bid, and continued on atorvastatin. . . Medical Floor Course: . pt admitted to the medical service hemodynamically stable, without focal neurological deficit, weaned off of insulin gtt with fsbs < 200, with ongoing SBPs 170s-180s, without CP/SOB. . # mental status changes: initially pt considered for meningitis/ infection, however neuro changes resolved with improved with correction of blood sugars. Pt without focal neurological deficits at time of transfer, though ?right carotid bruit, with negative carotid dopplers. Plan is for pt to be followed by [**Month/Day (2) **] clinic in 4 weeks. (will provide with number to call: [**Telephone/Fax (1) 2528**]). . . # hyperglycemia: etiology somewhat unclear, infection possible, reportedly gap and ketone gap positive at OSH, however was negative without ketones at presentation to [**Hospital1 18**]. pt being treated with augmentin 7d course for question of pneumonia, though not clearly evident on CXR. pt seen by [**Last Name (un) 387**], with improved control off insulin gtt with new recs (new humulog sliding scale and glargine 35 units QPM). Pt discharged with plan for follow-up within 4 weeks with PCP and [**Name9 (PRE) **]. . . # multiple myeloma: pt with h/o MGUS, though not active. multiple myeloma workup performed with UPEP pending given h/o of MGUS and concern that evolution to MM may have precipitated sudden elevation of glucose; however, skeletal survey negative. . . # cardiac: regarding ischemia, on presentation EKG with lateral ischemia, resolving at time of transfer. cardiac enzymes unremarkable. pt denies CP/SOB. pt already on aspirin, bblocker, [**Last Name (un) **], statin. regimen uptitrated to improve bp control. regarding pump, pt with some diastolic CHF based on TTE [**7-19**], though no evidence of CHF on presentation (pt without edema, JVD). etiology of dCHF most likely HTN, BP regimen optimized as below. pt continued on home atorvastatin 10 mg po qd. . # htn: pt with h/o htn. restarted on metoprolol 25 [**Hospital1 **] and losartan 50 mg qd in MICU. Upon arrival to the medical floor, her SBPs were ~170-180s. Her metoprol was titrated up to 50 mg po bid. She was then restarted on her amlodipine 5 mg po qdaily and her losartan was increased to 100mg qdaily as her heart rate was in the 60s. . . # fever: afebrile at time of transfer, most likely [**3-17**] pneumonia, possible aspiration. pt without SOB, no cough, no hypoxia at time of transfer to medical service. pt started on augmentin in MICU and will complete 7 day course (day 1 is [**2130-2-15**]). blood cultures and urine cultures NGTD. . . # anemia: pt has chronic anemia likely related to MGUS versus CRI. iron studies were within normal limits. she is presently within her baseline of 25-28. no intervention, pt to be followed by her PCP. . # hypothyroid- pt continued on home synthroid regimen. . . # dispo - home with pcp, [**Name10 (NameIs) **], and [**Last Name (un) 387**] followup. Medications on Admission: Medications on admission: Furosemide 20 mg [**Hospital1 **] Losartan 50 mg PO DAILY Atorvastatin 10 mg PO DAILY Amlodipine 5 mg PO DAILY Aspirin 81 mg PO DAILY Levothyroxine 25 mcg Tablet DAILY Ferrous Sulfate 325 (65) mg PO DAILY Insulin Metoprolol Tartrate 25 mg 1.5 Tablets PO BID Ipratropium Bromide, Two puffs Inhalation four times a day. Albuterol [**2-14**] Inhalation every 4-6 hours PRN shortness of breath . Medications on transfer: augmentin metoprolol losartan 50 daily synthroid 25mcg daily heparin sc 500 tid sc iron 325 daily lipitor 10 daily glarigine 35 u qhs and ISS Discharge Medications: 1. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days: last day [**2130-2-22**]. Disp:*21 Tablet(s)* Refills:*0* 10. INSLULIN (GLARGINE) please take 35 units of glargine QPM (each evening) 11. INSULIN (HUMALOG) please take insulin (humalog) according to the attached sliding scale. 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Discharge Disposition: Home Discharge Diagnosis: primary: hyperglycemia . secondary: hypertension Discharge Condition: stable. Discharge Instructions: Please continue to take all of your medications as prescribed. Your dose of losartan was increased to 100 mg by mouth once daily. Your insulin regimen was modified based on [**Last Name (un) **] recommendations. You should take 35 units of glargine at night. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. . if you have recurrent symptoms of confusion, numbness, weakness, chest pain, shortness of breath, fevers, or chills, or other worrisome symptoms please contact your primary care physician or the emergency department. Followup Instructions: upon arriving home, please arrange to be seen by your primary care physician [**Name Initial (PRE) 176**] 2-4 weeks. . upon arriving home, please contact the [**Name Initial (PRE) **] clinic to arrange a follow-up appointment within 4 weeks. [**Telephone/Fax (1) **]. . upon arriving home, please contact the [**Name (NI) **] Clinic for routine follow-up within 4 weeks. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**] Date/Time:[**2130-3-22**] 10:40 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2130-3-22**] 2:30 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "404.91", "272.4", "428.0", "496", "250.22", "507.0", "285.21", "585.9", "244.9", "428.32" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10123, 10129

3355, 8375

324, 331

10222, 10232

2374, 3332

10836, 11604

1793, 1831

9011, 10100

10150, 10201

8427, 8820

10256, 10813

1846, 2355

275, 286

359, 1214

8845, 8988

1236, 1558

1574, 1777

62,344

172,158

53694

Discharge summary

report

Admission Date: [**2123-9-14**] Discharge Date: [**2123-11-4**] Date of Birth: [**2060-3-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1377**] Chief Complaint: Groin Pain, Abdominal Pain Major Surgical or Invasive Procedure: Paracentesis (multiple) History of Present Illness: The patient is a 63 year old male with a history of alcoholic cirrhosis who presents with 8-10 days of stomach pain and right-sided groin pain. He went to his PCP for this and was sent home with hot packs. This pain got so bad that he decided to stop his diuretics because it was too painful for him to get to the bathroom. A few day PTA, patient was referred to surgery for suspicion of a right inguinal hernia, but was not felt to be a good surgical candidate. He was sent home with codeine for pain control. Patient also reports 3-4 episodes of fevers/chills and nausea/vomiting as far back as 1 month ago, Tmax 103. The pain worsened, and he reported to the ED. . Subsequent ED and ICU course is as follows: Initial CT w/ contrast showed a fluid-filled inguinal hernia but no bowel inside as well as a crescent-shaped area of oral contrast extravasation in the duodenum, with possible perforated DU. CXR showed bilateral pleural effusions, right greater than left. He was also tapped on day of admission, with WBC 2875 (87% PMNs), RBC 1750. No abx were given at this point. His suspected perforated DU was medically managed at this point due to liver failure. He was started on IV PPI [**Hospital1 **], NGT and pressors x 1 day while receiving fluids for treatment of sepsis. His BP resolved to consistent low 100's. He received another tap on [**9-17**] (WBCs 1825, 92% PMNs). Started on Cefepime (day 1 = [**9-17**]) to treat SBP and was kept NPO x 3-4 days while in the unit. Received bicarbonate due to a creatinine bump from IV contrast for repeat CT, which did not show any bowel perforation. It did show continued cirrhosis, ascites, and bilateral pleural effusions. . He was tapped on [**9-17**] for 3 liters, mildly improved with less PMNs. Received 24g albumin, then received 100g on [**9-19**], and 50g today. Started on 150 octreotide/10 midodrine on [**9-18**] for suspicion HRS, despite being on Lasix 40 IV up until transfer (aldactone has been held). . On transfer to floor, patient is hemodynamically stable, comfortably sitting in chair. . Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea, constipation, BRBPR, hematemesis, melena. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. . Past Medical History: Alcoholic Cirrhosis Hypertension Prior alcohol withdrawal seizures Social History: Lives with his wife, has 2 dogs Quit smoking 20 years ago Stopped drinking in [**1-24**] No IVDU Family History: Mother - [**Name (NI) 5895**] disease Father - Prostate cancer Brother - Prostate cancer Sister - Breast cancer Physical Exam: VS - Temp 96.1 F, BP 111/66 , HR 57 , RR 18 , O2-sat 96% RA GENERAL - ill-appearing man in NAD, comfortable, appropriate, slowed speech HEENT - NC/AT, PERRLA, EOMI, +mild scleral icterus, MMM, OP clear NECK - supple, no thyromegaly, no JVD appreciated, no LAD, no carotid bruits LUNGS - decreased BS sounds at bases B/L, up to mid-lung on right, no w/r/r HEART - RRR, nl S1/S2, no m/r/g ABDOMEN - +BS, markedly distended with tense ascites, diffusely tender, no HSM appreciated EXTREMITIES - WWP, 3+ LE edema to thighs B/L, 2+ radial pulses GU - +scrotal edema SKIN - sparse spider angiomata on upper chest, no palmar erythema, no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-19**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, gait not assessed, no asterixis Pertinent Results: Labs on Admission: [**2123-9-14**] 11:40AM BLOOD WBC-27.8*# RBC-3.35* Hgb-11.4* Hct-35.7* MCV-107* MCH-34.2* MCHC-32.0 RDW-15.0 Plt Ct-209 [**2123-9-14**] 11:40AM BLOOD Neuts-83* Bands-10* Lymphs-3* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2123-9-14**] 11:40AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Schisto-OCCASIONAL Burr-1+ [**2123-9-14**] 11:00PM BLOOD PT-24.2* PTT-46.6* INR(PT)-2.3* [**2123-9-14**] 11:40AM BLOOD Glucose-101* UreaN-21* Creat-1.6* Na-131* K-4.6 Cl-97 HCO3-15* AnGap-24* [**2123-9-14**] 11:40AM BLOOD ALT-22 AST-50* AlkPhos-106 TotBili-5.4* DirBili-2.6* IndBili-2.8 [**2123-9-14**] 11:00PM BLOOD Calcium-8.2* Phos-5.2* Mg-1.7 [**2123-9-14**] 11:52AM BLOOD Lactate-8.8* . [**2123-9-14**] 11:00PM WBC-27.2* RBC-3.01* HGB-10.3* HCT-31.4* MCV-104* MCH-34.2* MCHC-32.9 RDW-15.1 [**2123-9-14**] 11:40AM ALT(SGPT)-22 AST(SGOT)-50* ALK PHOS-106 TOT BILI-5.4* DIR BILI-2.6* INDIR BIL-2.8 . [**2123-9-14**] 02:00PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.017 [**2123-9-14**] 02:00PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-SM Urobiln-4* pH-5.0 Leuks-NEG [**2123-9-14**] 02:00PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [**2123-9-15**] 05:26PM URINE Hours-RANDOM Creat-181 Na-LESS THAN Cl-10 [**2123-9-15**] 05:26PM URINE Osmolal-541 . Labs on discharge [**2123-11-4**]: Sodium 139 Potassium 4.3 Chloride 106 Bicarb 26 BUN 68 Creatinine 1.2 Glucose 103 Ca: 11.7 Mg: 2.0 P: 3.8 ALT: 17 AP: 122 Tbili: 5.2 Alb: 3.4 AST: 37 LDH: 137 WBC 8.4 Hb 7.9 HCT 24.1 Plt 89 PT: 22.9 PTT: 47.0 INR: 2.2 . . Ascites: [**2123-9-14**] 03:00PM ASCITES WBC-2875* RBC-1750* Polys-87* Lymphs-0 Monos-13* [**2123-9-14**] 03:00PM ASCITES TotPro-0.6 Glucose-101 LD(LDH)-155 . [**2123-9-17**] 10:13AM ASCITES WBC-1825* RBC-825* Polys-92* Lymphs-2* Monos-6* . [**2123-9-22**] 04:26PM ASCITES WBC-175* RBC-260* Polys-1* Lymphs-13* Monos-0 Macroph-86* [**2123-9-22**] 04:26PM ASCITES Albumin-< 1.0 . [**2123-9-27**] 06:32PM ASCITES WBC-61* RBC-72* Polys-9* Lymphs-16* Monos-3* Mesothe-2* Macroph-70* [**2123-9-27**] 06:32PM ASCITES Albumin-1.0 . [**2123-10-10**] 11:27AM ASCITES WBC-165* RBC-805* Polys-2* Lymphs-44* Monos-0 Mesothe-1* Macroph-52* Other-1* [**2123-10-10**] 11:27AM ASCITES Albumin-2.2 . [**2123-10-20**] 05:39PM ASCITES WBC-110* RBC-1255* Polys-3* Lymphs-19* Monos-0 Macroph-66* Other-12* . . CT Abd/Pelvis [**9-14**]: IMPRESSION: 1. Small curvilinear hyperdense material seen in the retroperitoneum just posterior and superior to the second portion of the duodenum, likely represents extraluminal contrast. This raises concern for duodenal perforation. Evaluation of the duodenum is limited as it is poorly distended with oral contrast. 2. Bilateral large pleural effusions with compressive atelectasis of the lower lobes. 3. Large amount of simple ascites. 4. Nodular hepatic contour, in keeping with the patient's known history of cirrhosis. . . CT Abd/pelvis ([**9-17**]): IMPRESSION: 1. Cirrhosis, ascites, and large bilateral pleural effusions are unchanged. 2. Resulting compressive atelectasis causes right lower lobe and near total left lower lobe collapse. 3. No evidence of bowel perforation. . . UNILAT UP EXT VEINS US LEFT Study Date of [**2123-10-10**] 4:00 PM COMPARISON: No prior studies available for comparison. FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of left subclavian, left axillary, and brachial veins were performed. There is normal compressibility, flow and augmentation in the above veins. The left internal jugular vein demonstrates normal compressibility. The basilic vein is normal. There is thrombophlebitis involving the left cephalic vein. Evidence of thrombus is seen in the cephalic vein with surrounding subcutaneous edema. IMPRESSION: No evidence of DVT in the left upper extremity. Thrombophlebitis of the left cephalic vein. . . RENAL U.S. Study Date of [**2123-10-10**] 4:00 PM COMPARISON: CT of the abdomen and pelvis [**2123-9-17**]. RENAL ULTRASOUND: The right kidney measures 10.0 cm. The left kidney measures 10.3 cm. Both kidneys are normal without evidence of hydronephrosis, [**Name (NI) 79068**] evidence stones or masses. The bladder is partially distended with a Foley catheter in place. Extensive amount of ascites is noted. IMPRESSION: 1. Normal sized kidneys without evidence of hydronephrosis. 2. Large amount of ascites. . . CHEST (PA & LAT) Study Date of [**2123-10-11**] 3:27 PM FINDINGS: An NG tube is seen coursing below the diaphragm with the tip off the film. Cardiomediastinal contours are unchanged. There is increased patchy opacity in the bilateral lung bases with small pleural effusions. No evidence of pneumothorax. IMPRESSION: 1. Small bilateral pleural effusions. 2. Patchy opacities in the lung bases likely representing aspiration. . . CHEST (PA & LAT) Study Date of [**2123-10-14**] 3:50 PM FINDINGS: Patient was examined in sitting semi-upright position using AP and left lateral projections. Comparison is made with the next preceding similar chest examination of [**2123-10-11**]. On previous examinations, suspected and described bilateral patchy opacities on the lung bases have not progressed. They coincide with the bilateral diffuse haze which was related to the well detectable bilateral pleural fluid accumulations in the posterior pleural sinuses and along the posterior chest walls. The basal patchy parenchymal densities have not progressed. Striking is that the left-sided basal haze has regressed and as one now on the lateral view can identify a horizontal air-fluid level, it is suspected that a left-sided pleural tap was performed during the three days examination interval. This also explains much improved visibility of pulmonary structures on the left base and excludes the presence of parenchymal infiltrates in this area. Previously described NG tube remains in unchanged position. Apical areas do not demonstrate any significant pneumothorax on either side. IMPRESSION: No progression of previously identified basal densities. Clearance of left base most likely related to pleural tap. . . CHEST (PA & LAT) Study Date of [**2123-10-20**] 2:59 PM COMPARISON: AP and lateral chest radiograph from [**2123-10-14**] TECHNIQUE: PA and lateral chest radiograph. FINDINGS: Compared to previous examinations, previously described bilateral patchy opacities, greater on the right than the left, show very mild resolution compared to radiograph from [**10-14**]. Bibasilar pleural effusions are again noted, greater on the left than the right. The pleural effusion on the left is new compared to prior. The Dobbhoff tube remains in unchanged position. Apical areas do not demonstrate any significant pneumothorax. There appears to be cephalization of the pulmonary vessels suggestive of pulmonary vascular congestion that is unchanged from prior. IMPRESSION: Minimal interval decrease in previously identified basal opacities. Bilateral pleural effusions with the appearance of slight increase in size of pleural fluid in the left side. . . Cardiology Report ECG Study Date of [**2123-10-30**] 4:17:02 PM Atrial fibrillation with rapid ventricular response. Poor R wave progression. Consider prior anteroseptal myocardial infarction. Compared to the previous tracing of [**2123-9-15**] atrial fibrillation with rapid ventricular response is seen on the current tracing. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] D. Intervals Axes Rate PR QRS QT/QTc P QRS T 123 0 86 312/422 0 -4 3 . . Cardiology Report ECG Study Date of [**2123-11-3**] 12:13:00 AM Probable atrial fibrillation with rapid ventricular response. Borderline low voltage. Since the previous tracing of [**2123-10-30**] the rate is slower. Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 105 0 100 358/436 0 3 17 . . CHEST (PORTABLE AP) Study Date of [**2123-10-30**] 5:44 PM Compared with [**2123-10-20**], the cardiomediastinal silhouette is unchanged, with probable mild cardiomegaly and prominence and splaying of the carina suggestive of left atrial enlargement. The appearance is, however, accentuated by lordotic positioning. There is patchy opacity in the right middle lobe and retrocardiac regions, slightly improved compared with [**2123-10-20**]. Again noted is minimal blunting of right greater than left costophrenic angles, consistent with minimal pleural fluid. There is upper zone redistribution and mild vascular blurring, suggesting mild CHF. A nasointestinal type tube is present, with tip extending beneath diaphragm off film. . . CHEST (PORTABLE AP) Study Date of [**2123-10-31**] 7:38 AM Chest, single AP view centered in the upper abdomen. Detail considerably limited by underpenetration and apparent "noise". The previously identified nasoenteric tube appears to have retracted with tip now overlying the expected site of the gastric fundus. Otherwise, I doubt significant interval change. The thoracic inlet is not included on these views. Abdominal detail is markedly degraded. . . [**Last Name (un) **]-INTESTINAL TUBE PLACEMENT (W/FLUORO) Study Date of [**2123-11-1**] 10:08 AM TECHNIQUE: Fluoroscopic guided nasointestinal tube repositioning. FINDINGS: Under fluoroscopic guidance after use of topical lubricating [**Doctor Last Name 360**], 8 French [**Location (un) 2174**]-[**Doctor First Name 1557**] catheter was seen within the stomach and advanced into the third part of the duodenum. Position was verified with the instillation of 10 cc of Conray contrast medium IMPRESSION: Successful repositioning of 8 French [**Location (un) 2174**]-[**Doctor First Name 1557**] catheter into the duodenum. . . Cardiology Report Stress Study Date of [**2123-11-3**] INTERPRETATION: This was a 63 year old man with liver failure who was referred to the lab from the inpatient floor for an evaluation of new onset atrial fibrillation and shortness of breath prior to liver transplant surgery. He received 0.142mg/kg/min of IV Persantine infused over 4 minutes. He denied any chest, arm, neck or back discomfort, nor any shortness of breath throughout the study. There were no significant ST segment changes noted during the infusion or in recovery. The rhythm was sinus with rare isolated APB's. There was an appropriate hemodynamic response to the Persantine infusion. At 3-4 minutes post infusion, 125mg of IV Aminophylline was given to reverse any potential Persantine side effects. IMPRESSION: No ischemic ECG changes noted and no anginal type symptomsreported with Pharmacological infusion. Appropriate hemodynamic response. Nuclear report filed separately. . . CARDIAC PERFUSION PERSANTINE Study Date of [**2123-11-3**] INTERPRETATION: The image quality is adequate but limited due to left arm and soft tissue attenuation. Left ventricular cavity size is increased. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 67% with an EDV of 164 ml. IMPRESSION: 1. Normal myocardial perfusion. 2. Increased left ventricular cavity size with normal systolic function. . . Brief Hospital Course: The patient is an 63 year old male with alcoholic cirrhosis who presented with SBP and ARF due to HRS, and was initially admitted to the ICU. He is in the process of being listed for transplant. . Brief ICU course: Due to the concern over possible contrast extravasation on CTAP [**9-14**], the patient was admitted to the [**Hospital1 18**] ICU with the potential diagnosis of a perforated duodenal ulcer. He was managed medically with NGT placement, NPO, IV Protonix due to the patient's current poor liver function. A repeat CT scan was performed on [**9-17**] which did not show the area of possible extravasated contrast previously seen on [**9-14**], and the thought was that what was originally read as a perforated PU could have actually been a crescent shaped area of calcified sludge in the patient's gallbladder. The patient's NGT was taken out, and he was allowed to advance to a PO diet. The patient's Hematocrit and BP remained stable throughout his ICU course and the patient was then transferred to [**Hospital Ward Name 121**] 10 in stable condition. . On floor ([**Hospital1 18**] - [**Hospital Ward Name 121**] 10): . # SBP: Initially paracentesis showed predominance of PMNs (WBC 2875 - 87% PMNs) and the patient was covered for SBP on IV Cefepime starting [**9-17**]. A subsequent diagnostic/therapeutic tap was done, showing marked improvement and near resolution of the infection. The 5-day Cefepime course was then converted to SBP prophylaxis of Cipro 250mg PO daily and he continued to do well, without abdominal pain or fevers. When his creatinine continued to worsen (as below), Cipro was implicated as a possible cause of AIN, and changed to Bactrim, which was subsequently switched to Cefpodoxime. Multiple subsequent paracentesis taps were negative for SBP. His SBP prophylaxis was held after starting Vancomycin/Zosyn for a suspected aspiration pneumonia as described below. It was restarted after completing the Vancomycin and Zosyn course. . # Acute Renal Failure: Multifactorial - (1) Hepatorenal Syndrome, (2) AIN, (3) Bactrim-related, and (4) post-obstructive: His hospital course was complicated by an elevated creatinine which was thought to be due to Hepatorenal Syndrome, likely secondary to his SBP, as described above. This diagnosis was made as the patient was non-responsive to an albumin challenge and urine electrolytes showed a Na+ of less than 10, with a pre-renal picture. He was started on a regimen of Midodrine, Octreotide, and daily Albumin with slowly improved creatinine down to 1.3. When his creatinine started trending back up, the Renal team was consulted and believed the clinical picture and urinary sediment were consistent with acute interstitial nephritis (AIN) and Cipro and Omeprazole were discontinued. His Cipro was changed to Bactrim and the creatinine continued to worsen, so this was changed to Cefpodoxime. While his Foley catheter had been discontinued to avoid catheter-associated infections, his edematous genitalia made it very difficult for him to urinate and Urology was called to replace this to eliminate any post-obstructive etiology for his renal failure. His renal function gradually improved over the next few weeks, reaching Cr 1.2-1.3 prior to discharge. This may represent resolving damage from AIN. His Midodrine and Octreotide were stopped on [**2123-10-29**], and his creatinine remained stable at 1.2-1.3 afterwards. He was restarted on Lasix and Spironolactone on [**2123-11-1**] and creatinine remained stable at 1.2. . # Extravascular Volume Overload: Physical exam notable for severe ascites and scrotal edema, anasarca, and decreased B/L breath sounds. Patient was initially on 40 PO lasix QD in an attempt to diurese this extra volume in the ICU, but this complicated a diagnosis of HRS. Therefore, diuretics were held and HRS was treated until creatinine trended toward baseline. Renal recommended restarting diuretics, and he was given a dose of Lasix 80 mg IV once on [**2123-10-14**], with good urine output, but was still net positive. He received several additional doses of Lasix 80 mg IV, with his creatinine remaining stable. Diuretics were discontinued on [**2123-10-18**]. He continued to autodiurese and his Cr slowly but steadily improved. He was restarted on Lasix and Spironolactone on [**2123-11-1**] for additional fluid removal. He had therapeutic paracentesis on [**2123-11-2**] with 6.5 L removed. He tolerated it well and was given Albumin (25%) 37.5 mg afterwards. He was continued on Lasix and Spironolactone at discharge. . # SBP / Ascites: His presenting abdominal pain and fevers were likely due to SBP from increasing ascites while off diuretics. His initial tap showed predominance of PMNs (WBC 2875, 87% PMNs), but was culture negative. Cefepime was started after second tap on [**2123-9-18**] and later stopped. He was restarted on Cefpodoxime 100 mg PO Q12H after his Vancomycin / Zosyn course was completed. He was tapped for 4.6 L on [**2123-10-10**]. He was tapped again on [**2123-11-2**] for 6.5 L. . # Pneumonia: A CXR was performed on [**2123-10-11**] to evaluate his volume status and unexpectedly showed patchy opacities in the lung bases which likely represented aspiration. His WBC count had been increasing over a few days prior to this, but he was afebrile. The findings may have represented aspiration pneumonitis rather than true pneumonia, but given his condition he was started on Vancomycin and Zosyn. His WBC count increased to 13.0 on [**2123-10-12**] and remained elevated at 13-14 since. Repeat CXR on [**2123-10-14**] showed resolution of the left density and no progression of the right density. Speech and swallow evaluation on [**2123-10-14**] did not show any evidence of aspiration. His WBC count remained around 13-14 despite a lack of focal signs of infection. His repeat CXR on [**2123-10-20**] did not show worsening consolidation. The Vancomycin and Zosyn were discontinued on [**2123-10-22**] after a 12 day course. Subsequent CXRs showed continued improvement of the opacities. . # Thrombophlebitis: His left arm was significantly edematous compared to his right. UE ultrasound on [**2123-10-10**] showed no evidence of DVT, but did show left cephalic vein thrombophlebitis. There was no evidence of infection and the thrombophlebitis was not apparently line related. It improved significantly and had resolved by the time of discharge. . # Atrial Fibrillation: His pulse was noted to be rapid and irregular on exam on [**2123-10-30**]. He was completely asymptomatic, with no chest pain, lightheadedness, or SOB. An EKG was obtained which showed atrial fibrillation with rapid ventricular response. He did not have a prior history of AFib. His TSH was checked and was elevated at 6.6. Cardiac enzymes were negative. He was started on telemetry, and converted back to sinus rhythm. He went into AFib again that evening and he was started on Metoprolol 25 mg PO BID. This was decreased to 12.5 mg PO BID after a 4 sec pause. He had another episode of AFib on [**2123-11-2**] from 11:38 to 01:15, which broke spontaneously. He had a persantine stress test on [**2123-11-3**] which was unremarkable. . # Anemia: His Hct dropped from 24.0 on [**2123-10-28**] to 20.9 on [**2123-10-29**]. He did not have any evidence of active bleeding and stool guaiac was negative. He was transfused one units of PRBCs. His Hct was 20.3 on [**2123-10-30**]. He was transfused 2 units PRBCs, with an appropriate increase in Hct. His Hct has since remained fairly stable in the low 20s. . # Hypercalcemia: His Ca started rising on [**2123-10-25**], reaching a peak of 12.2 on [**2123-10-29**], decreasing afterwards to around 11. His phosphate was slightly elevated around the same time, reaching a peak of 5.0 on [**2123-10-26**]. His Alk Phos increased from 69 to 123 on [**2123-10-21**] and has since remained in a similar range. The pattern was consistent with bone resorption, likely from relative immobility. [**Name2 (NI) **] has not had any symptoms of hypercalcemia. . # Liver transplant candidacy: Initial MELD score on admission to the floor was 25. This fluctuated with his creatinine. He is being followed closely by the Transplant Coordinator here at [**Hospital1 18**] and all of his screening tests have been performed while he was an inpatient here. These findings were notable for an elevated CEA of 4.6, but were otherwise normal. His MELD reached a peak of 33 during his stay, but had decreased back to 23 by the time of discharge. . # Nutrition: Due to poor nutritional status, the patient was started on tube feeds through a Dobhoff tube, running at goal rate of 45ml/hr, and tolerated them well. His Dobhoff became clogged overnight on [**2123-10-14**] and was removed. IR was unable to place a new tube on [**2123-10-15**]. A new Dobhoff was placed on [**2123-10-19**], and tube feeds were restarted. His mental status and MELD score improved after restarting tube feeds. His improved nutrition will make him a better transplantation candidate. Please do not remove his feeding tube without discussion with hepatology. . # Poor functional capacity: Per the patient's wife and PT evaluation, the patient was not able to ambulate or care for himself on his own at home. He was then screened for a rehab bed and the physical therapy team determined that he would be best suited for discharge to a rehabilitation center. . Medications on Admission: Furosemide 40 mg Tablet Omeprazole 20 mg Capsule Spironolactone [Aldactone] 100 mg Tablet Multivitamin [One Daily] Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cyanocobalamin (Vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. lactulose 10 gram/15 mL Syrup Sig: 15-30 MLs PO BID (2 times a day): Please adjust for [**3-18**] bowel movements per day. . 8. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. spironolactone 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnoses: Hepatic Encephalopathy Spontaneous Bacterial Peritonitis Acute Interstitial Nephritis Hepatorenal Syndrome . Secondary Diagnosis: Alcoholic Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure treating you at the [**Hospital1 827**]. You were initially admitted for increasing stomach and right-sided groin pain. You had low blood pressures and you were first sent to the intensive care unit. We took a sample of the fluid in your belly and found that you had an infection. You were given antibiotics for this infection. In addition to this, your kidneys were not working up to full capacity, despite the extra fluid that we gave to you. Therefore, we started you on a few more medications to help your kidneys work better. Even though you had a lot of fluid build-up in your legs and scrotum, we had to stop your diuretics during your hospital stay because they can worsen your kidney function. We have made the following changes to your medications: START: Metoprolol Tartrate 12.5 mg by mouth twice daily START: Cefpodoxime 200 mg by mouth daily for SBP prophylaxis START: Ranitidine 150 mg by mouth twice daily START: Lactulose 15-30 mL by mouth twice daily. Adjust to have [**3-18**] bowel movements per day. START: Rifaximin 550 mg by mouth twice daily START: Thiamine 100 mg by mouth daily START: Folic Acid 1 mg by mouth daily START: Cyanocobalamin 100 mcg by mouth daily DECREASED: Spironolactone 50 mg by mouth daily (previously 100 mg daily) Followup Instructions: Department: TRANSPLANT When: TUESDAY [**2123-11-9**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

[ "401.9", "608.86", "584.9", "572.2", "550.90", "537.89", "305.03", "276.7", "782.3", "789.59", "E931.0", "263.9", "572.3", "530.3", "285.9", "572.4", "451.84", "571.1", "580.89", "427.31", "511.9", "571.2", "486", "275.42" ]

icd9cm

[ [ [] ] ]

[ "45.23", "54.91", "96.6", "45.13" ]

icd9pcs

[ [ [] ] ]

25768, 25839

15275, 24732

343, 369

26052, 26052

4046, 4051

27539, 28019

3069, 3182

24898, 25745

25860, 25988

24758, 24875

26228, 26983

3197, 4027

27012, 27516

2496, 2847

276, 305

397, 2477

26009, 26031

4065, 15252

26067, 26204

2869, 2938

2954, 3053

32,583

101,251

31009

Discharge summary

report

Admission Date: [**2170-2-25**] Discharge Date: [**2170-3-3**] Date of Birth: [**2090-12-9**] Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending:[**First Name3 (LF) 783**] Chief Complaint: cough and shortness of breath Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 79 yo F with a past history stage IIIb NSCLC dx in [**2168**], finished chemo/rad in [**6-4**], doing well until 4-5 days ago, when she began to develop SOB, cough, sputum, persistent fevers/chills. She presented to the OSH [**2-25**], and was felt to have post obstructive pna. She had a chest CT, c/w post obstructive PNA. She was given vanco/zosyn and transferred to [**Hospital1 18**] for IP procedure. Of note, her WBC there was 19.5 with a left shift, afebrile, O2sats 93% RA. . ED COURSE: remained afebrile and was seen by IP, plan to bronch and ?stent. She was found to be hypertensive to the 170's/60's and received her regular dose of nadolol. She also received a dose of levofloxacin, zosyn, vanc, motrin and zofran. . IP SUITE COURSE: Pt taken to IP suite for bronch, BAL done, received 50Fentanyl, 2Midaz, underwent a lavage, RUL notable for complete obstruction, 30min post procedure began to cough, notable for acute hypoxia O2 sats 79%. Subsequently placed on 100% NRB, , ABG 7.11/90/150, 40min later VBG 7.16/75/55 transferred to MICU for closer monitoring, BiPAP. . MICU COURSE: Initially started on BiPAP with rapid improvement in ventilation and oxygenation. Sedating meds were minimized and the patient was quickly weened to 2L NC. The patient was continued on Vanc/Zosyn Past Medical History: -NSCLC diagnosed in [**2168**], Stage IIIb, with mets to subcarinal and supraclavicular nodes; XRT/Chemo [**5-/2169**], Onc care at [**Hospital 1562**] Hosp (Dr. [**Last Name (STitle) 27009**], [**Telephone/Fax (1) 66058**]) -Post obstructive PNA [**Hospital 1562**] Hospital [**2169-4-9**], bronch w/MSSA treated with zosyn -COPD ---PFTs: FEV1 of 74% predicted with a predominantly obstructive pattern on flow volume curves. -Hypertension -Hyperlipidemia -Chronic low back pain Social History: The patient lives with her husband in [**Name (NI) 73266**], [**State 350**]. She had a 100-pack-year smoking history, but quit approximately 10 years ago. She denies any alcohol intake. She is currently retired, but previously worked as an office manager. She has seven children. Family History: M: died at the age of 40-lung cancer. F: died at age 63 from myocardial infarction. Sister: kidney cancer Brother: prostate cancer Physical Exam: VS: 97.1 BP 150/80 HR 78 16 93% RA GEN: AOx3, NAD, pleasant HEENT: PERRL, NCAT, no LAD or thyromegaly appreciated RESP: diminished BS on RUL field, minimal end expiratory wheezing/sqeak, no crackles, no accessory muscle use, no paradoxical breathing CV: Reg Nml S1, S2, 2/6 SEM at RUSB ABD: Soft ND/NT +BS EXT: No peripheral edema, warm, 2+DP pulses b/l NEURO: A&Ox, following commands appropriately, no focal deficits, strength 5/5 throughout, sensation intact to gross . Pertinent Results: [**2170-2-26**] 05:15AM BLOOD WBC-17.2* RBC-3.25* Hgb-9.5* Hct-30.5* MCV-94 MCH-29.1 MCHC-31.0 RDW-14.4 Plt Ct-581* [**2170-2-26**] 04:11PM BLOOD WBC-23.3* RBC-3.65* Hgb-10.8* Hct-35.0* MCV-96 MCH-29.7 MCHC-30.9* RDW-14.1 Plt Ct-708* [**2170-2-27**] 05:56AM BLOOD WBC-20.2* RBC-3.54* Hgb-10.5* Hct-33.7* MCV-95 MCH-29.5 MCHC-31.0 RDW-15.2 Plt Ct-617* [**2170-2-28**] 05:35AM BLOOD WBC-16.2* RBC-3.35* Hgb-10.0* Hct-32.5* MCV-97 MCH-29.8 MCHC-30.7* RDW-14.5 Plt Ct-631* [**2170-3-1**] 05:35AM BLOOD WBC-11.5* RBC-3.16* Hgb-9.2* Hct-29.9* MCV-95 MCH-29.2 MCHC-30.9* RDW-15.0 Plt Ct-612* [**2170-2-27**] 05:56AM BLOOD Neuts-95.3* Bands-0 Lymphs-2.3* Monos-1.9* Eos-0.3 Baso-0.1 [**2170-2-26**] 05:15AM BLOOD PT-14.2* PTT-29.1 INR(PT)-1.2* [**2170-3-1**] 05:35AM BLOOD Plt Ct-612* [**2170-2-26**] 05:15AM BLOOD Glucose-91 UreaN-18 Creat-0.8 Na-141 K-4.4 Cl-102 HCO3-30 AnGap-13 [**2170-2-26**] 04:11PM BLOOD CK(CPK)-32 [**2170-2-26**] 04:11PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2170-2-26**] 05:15AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0 [**2170-2-26**] 04:11PM BLOOD Type-ART pO2-150* pCO2-90* pH-7.11* calTCO2-30 Base XS--3 [**2170-2-26**] 04:52PM BLOOD Type-ART Temp-37 pO2-55* pCO2-76* pH-7.17* calTCO2-29 Base XS--2 Intubat-NOT INTUBA [**2170-2-26**] 06:22PM BLOOD Type-ART pO2-81* pCO2-53* pH-7.33* calTCO2-29 Base XS-0 CXR: There obviously is a large right hilar mass with extensive mediastinal and apical components. The visible parts of the right lower lung show increase in interstitial markings that could be suggestive of lymphangosis. The left lung is unremarkable. The size of the cardiac silhouette is borderline. There are no pleural effusions. IMPRESSION: No pneumothorax is detected. OSH CT: Informal read here shows RUL cavitary lesion with air fluid levels surrounded by lunch parenchyma. BAL Cytology: REPORT APPROVED DATE: [**2170-3-1**] SPECIMEN RECEIVED: [**2170-2-27**] 08-[**Numeric Identifier **] BRONCHIAL WASHINGS SPECIMEN DESCRIPTION: Received 7.5ml cloudy fluid. Prepared 1 ThinPrep slide. CLINICAL DATA: H/O NSCLC with new obstructive PNA. PREVIOUS BIOPSIES: [**2169-4-13**] 07-[**Numeric Identifier 73267**] LYMPH NODE [**2169-4-13**] 07-[**Numeric Identifier 73268**] LYMPH NODE REPORT TO: DR. [**First Name11 (Name Pattern1) 734**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] DIAGNOSIS: NEGATIVE FOR MALIGNANT CELLS. Bronchial epithelial cells, squamous cell, macrophages and mixed inflammatory cells. DIAGNOSED BY: [**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) **], CT(ASCP) [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 73269**], M.D. Bronchoscopy report: PREOPERATIVE DIAGNOSIS: 1. Stage 3B nonsmall cell lung cancer. 2. Status post obstructive pneumonia. POSTOPERATIVE DIAGNOSIS: 1. Stage 3B nonsmall cell lung cancer. 2. Status post obstructive pneumonia. SURGEON: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. ASSISTANT: None. INDICATIONS: Mrs. [**Known lastname 73270**] was seen in consultation as well as for a flexible bronchoscopy in the pulmonary procedure unit on [**2170-2-26**]. She is a 79-year-old woman with a past history of right hilar nonsmall cell cancer consistent with adenocarcinoma, concurrent radiation and completed treatment in [**2169-5-28**]. Since that time she has been relatively well. She recently developed a call associated with purulent phlegm as well as a febrile state. She was admitted to the hospital in [**Hospital1 1562**] and then transferred to the [**Hospital1 69**] for evaluation. She was transferred from nursing unit in stable condition. She was placed respiratory and hemodynamic monitoring. DESCRIPTION OF PROCEDURE: Once on monitoring she was administered 2 mg of Darvon and 50 mcg fentanyl for IV sedation. She was topicalized with 1% Xylocaine. Following topicalization, the adult Olympus bronchoscope was passed via the oral route down to the level of the vocal cords. The vocal cords appeared normal. The vocal cords were topicalized with 1% Xylocaine. Following this, the bronchoscope was passed through the vocal cords and into the trachea. The trachea appeared normal. The bronchoscope was advanced down to the level of the right bronchial tree. All the segments and subsegments of the right bronchial's were visualized in sequence. Of note, there was circumferential extrinsic compression of the bronchi of the right upper lobe. There was only the posterior segment of the right upper lobe which did appear to remain even somewhat patent. Unfortunately, it was not possible to fully intubate even the segment. The remainder of the right bronchial tube was inspected and appeared normal. The left bronchial tube was visualized and all appeared normal. 120 ml of sterile saline were instilled into the residual right upper lobe bronchus and 30 ml were aspirated back. Specimens were sent for cytology as well for microbiology including fungal studies. The patient initially tolerated the procedure well, however during the recovery she developed profound hypercapnia with pCO2 rising to 90 and pH associated with this at 711. She was bag mask ventilated in order to try to drive down her CO2. She was transferred to the ICU to the MICU-7 for BIPAP in order to blow off her CO2. There was a suggestion on her desk that she has a CO2 retainer although this was not known preprocedure. Likely the further elevation of the CO2 was on the basis of her medications. The patient was stable at the time of transfer. The results of the bronchoalveolar lavage are pending. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(2) 73271**] Brief Hospital Course: RUL Pneumonia: The patient was initially transferred to [**Hospital1 18**] for consideration of a RUL stent to alleviate what was initially thought to be a post-obstructive pneumonia. The patient tolerated the initial bronchoscopy well but shortly after the patient developed hypoxia and hypercarbia, likely a side effect of the sedation used. She was transferred to the MICU for BiPAP. She rapidly improved with resolution of her hypercarbia and significant improvement in her hypoxia within 12 hours. She was then transferred to the floor in stable condition. The interventional pulmonary service felt that a stent would not be beneficial in her. They felt it would block off more bronchioles than it would open and that the RUL was essentially unsalvagable given the large cavitary lesion seen on CT. There is also high suspicion of a small bronchopleural fistula, given the return of mesothelial cells on the BAL. However, the patient did not show any signs pneumothorax on exam or CXR. She will require close monitoring for this complication. In discussion with interventional pulmonary, it was decided not to pursue drainage of the cavity given the concern for cancer recurrence and the creation of a non-healing tract from the puncture site, greatly increasing her pneumothorax risk. It was decided that she would complete 6 weeks of antibiotics to treat her cavitary pneumonia. A BAL showed no AFB on concentrated smear, ruling out TB. The culture returned with MSSA. The patient was discharged on a 6 week course of Augmentin. She will follow up with her PCP and oncologist and receive a repeat CT scan after completion of her antibiotic course to evaluate for possible progression of her lung cancer. She will also return to interventional pulmonary clinic with her CT in hand for follow up of her possible bronchopleural fistula. Non-small cell lung cancer: The patient was diagnosed with stage IIIb NSCLC in [**4-4**] with chemo/rads treatment completed in [**6-4**]. Her last PET/CT scan in [**12-5**] showed now growth in the tumor per the patient. It is unclear at this time to what extent this RUL process represents a recurrence of her lung cancer as the infectious process is clouding the imaging. However, the BAL did not return any malignant cells. In discussion with her primary oncologist, it was decided not to actively pursue cancer treatment at this time until the infectious process is resolved. She will follow up with her oncologist and should receive a repeat CT scan after completion of her 6 week course of antibiotics. Further cancer treatment will be discussed at this time. She will also follow up with the intervential pulmonary clinic after the completion of her six week antibiotic course to evaluate for interval improvement. HTN: The patient was initially hypertensive on presentation with SBPs in the 170s with associated anxiety. She was continued on her outpatient naldolol and her lisinopril was uptitrated with good effect. Her anxiety was treated with very small doses of Ativan with good effect. Back/Scapula pain: The patient is s/p surgical correction of a cervical spinal body fracture in [**1-5**] with residual chronic neck/back/scapula pain. The pain was initially controlled with motrin was noted to be limited by her back pain by physical therapy. Her pain was then controlled with low dose oxycontin with percocet for break through pain. PPx: Hep SC, PPI Code: Full, confirmed with pt Communication: Duaghter [**Doctor First Name 8513**] [**Telephone/Fax (1) 73272**] H; [**Telephone/Fax (1) 73273**] cell HCP=Husband, pls call daughter to reach husband. Medications on Admission: Nadolol 40 mg p.o. b.i.d. ezetimibe 10 mg p.o. daily lisinopril 5 mg p.o. daily Protonix 40 mg p.o. daily Spiriva 18 mcg daily Discharge Medications: 1. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed. Disp:*30 Tablet(s)* Refills:*0* 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*1* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-7**] MLs PO Q6H (every 6 hours) as needed for COUGH. Disp:*150 ML(s)* Refills:*0* 11. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 6 weeks. Disp:*84 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: Right upper lobe pneumonia Non-small cell lung cancer Hypertension Discharge Condition: All vital signs stable, afebrile, on room air Discharge Instructions: You were admitted with a right upper lobe pneumonia. This pneumonia was severe enough to destroy some of your lung and form a cavity. The interventional pulmonologists used a scope to look into your lungs and take samples for culture. They felt that you would not benefit from a stent as it would probably close off more airways than it opened. Furthermore, draining the cavity with a needle from the outside would leave a non-healing hole that would greatly increase your risk for a collapsed lung. The best course of action is to take 6 weeks of antibiotics to treat the pneumonia and then re-evaluate the lung with another CT scan. You should coordinate this with Dr. [**Last Name (STitle) 27009**]. You will also need to follow up with the interventional pulmonologists here. Please bring the CD of the CT scan with you to this visit. Please take all of your medications as prescribed. Please make all of your recommended follow up appointments. Please call your doctor or return to the emergency room if you experience worsening shortness of breath, chest pain, fevers, chills, severe lightheadedness or any other symptom that concerns you. Followup Instructions: Please schedule a follow up appointment with Dr. [**Last Name (STitle) 69694**] at [**Telephone/Fax (1) 69695**] in the next 2-4 weeks. Please call Dr. [**Last Name (STitle) 27009**] at [**Telephone/Fax (1) 66058**] to schedule a follow up appointment in the next 1-3 weeks. Please schedule a CT scan of your chest after 6wks. Please call the Pulmonary Clinic at ([**Telephone/Fax (1) 513**] to schedule an appointment after you finish your 6 weeks of antibiotics. Please bring the CD of your CT scan to this visit [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "401.9", "496", "799.02", "272.4", "162.8", "584.9", "724.2", "482.41" ]

icd9cm

[ [ [] ] ]

[ "33.24" ]

icd9pcs

[ [ [] ] ]

13841, 13902

8808, 12433

306, 320

14013, 14061

3102, 8785

15258, 15908

2461, 2593

12611, 13818

13923, 13992

12459, 12588

14085, 15235

2608, 3083

237, 268

348, 1643

1665, 2145

2161, 2445

72,675

129,678

54105

Discharge summary

report

Admission Date: [**2137-12-26**] Discharge Date: [**2138-1-16**] Service: MEDICINE Allergies: Zocor Attending:[**First Name3 (LF) 7299**] Chief Complaint: Hematuria with clots and urinary retention. Major Surgical or Invasive Procedure: 1. Cystoscopy, clot evacuation, bladder fulguration. 2. Repeat cystoscopy. History of Present Illness: [**Age over 90 **] M with history of [**Age over 90 **] cancer s/p XRT and brachytherapy in [**2129**] + salvage radiation therapy presents with hematuria and clot urinary retention. He had been seen for the past several months with intermittent hematuria. He has a chronic indwelling urinary catheter and was last seen by Dr. [**Last Name (STitle) **] on [**12-19**] where a cystoscopy was done revealing a edematous bladder consistent with radiation changes, but no active bleeding and no clots within the bladder. He has an 18Fr Coude catheter in place and he noticed his catheter had stopped draining for 12 hours. On arrival to the ED his catheter had begun to drain again. He was hand-irrigated until urine was amber colored. He refused to have a larger catheter placed. He was taught how to hand-irrigate himself and was discharged home. However, he was noted to have blockage of his catheter again when he went home so a decision was made to admit him to the Urology service and to take him to the operating room on [**2137-12-27**] for cystoscopy, clot evacuation, and bladder fulgeration. Past Medical History: Atrial flutter/atrial fibrillation (no anticoag. [**1-29**] bleed) Coronary artery disease s/p CABG Systolic Heart Failure with EF of 30% Severe TR/Pulm HTN and Moderate MR [**First Name (Titles) **] [**Last Name (Titles) 9197**] cancer treated with XRT/brachitherapy complicated by urethral strictures and genitourinary bleeding. Renal artery stenosis s/p stenting Renal insufficiency with baseline creatinine of Prior TIA. Right pleural effusion treated with thoracentesis in [**2134**] Chronic Interstitial Lung disease/pleural plaque H/o GI bleed Social History: Patient lives alone in [**Location (un) **] and was widowed almost one year ago. He has visting nurses and family who help with his home care but is generally independant. He worked in [**Country 532**] as an engineer with significant asbestos exposure. No history of heavy alchohol consuption. Patient is a former smoker, with a 30 pack year history, having quit 20 years ago. Family History: No history of lung cancer. Physical Exam: On arrival to ICU: VS: 98.7 101/37 70, 15, 99% 2LNC GEN: pleasant Russian-speaking male, comfortable, NAD HEENT: MM dry, no conjunctival icterus, pallor, or injection. Neck is supple without LAD or JVD RESP: CTAB, no wheeze or crackles CV: RRR with borderline bradycardia. 3/6 systolic murmur most prominent at USBs ABD: Soft, NT/ND, no HSM, no rebound tenderness or guarding EXT: cool distally, with symmetric palpable pulses bilaterally. No edema. SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. Generalized 4/5 weakness in upper and lower extremities, without focal deficits. Sensation to light touch grossly intact. Gait assessment deferred. Pertinent Results: Admission labs: - [**2137-12-26**] 12:00PM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015 BLOOD-LG NITRITE-POS PROTEIN->300 GLUCOSE-100 KETONE-15 BILIRUBIN-LG UROBILNGN-4* PH-8.5* LEUK-LG RBC->50 WBC->50 BACTERIA-FEW YEAST-NONE EPI-0-2 - GLUCOSE-129* UREA N-73* CREAT-3.7* SODIUM-138 POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-23 ANION GAP-19 - [**2137-12-26**] 09:15AM WBC-8.5# RBC-2.98* HGB-9.6* HCT-29.5* MCV-99* MCH-32.4* MCHC-32.7 RDW-14.8 PLT COUNT-158 - [**2137-12-26**] 09:15AM PT-15.8* PTT-32.5 INR(PT)-1.4* Discharge Labs: Microbiology: [**2137-12-26**] urine culture: KLEBSIELLA PNEUMONIAE. 10,000-100,000 org/ml SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2138-1-7**]: FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. Imaging: [**12-27**] Renal u/s: The right kidney measures 7 cm and is mildly echogenic. A interpolar cyst measuring 1.5 x 1.2 x 1.6 cm shows no internal vascularity or septations and is unchanged in size from [**2137-8-19**]. No hydronephrosis is present. The left kidney measures 9 cm and is diffusely echogenic consistent with medical renal disease. No hydronephrosis or masses are present. IMPRESSION: Diffusely echogenic kidneys consistent with medical renal disease. Right renal cyst with calcifications is unchanged in size. The right renal upper pole lesion seen on the prior CT was difficult to visualize on this examination. . [**12-28**] CXR: Comparison is made to the prior study from [**2135-8-20**]. Median sternotomy wires and cardiomegaly is again seen and unchanged. There is a moderate right-sided pleural effusion as well as pleural plaques along the right chest. This is stable. There is increased prominence of the pulmonary interstitial markings suggesting an element of fluid overload. The aorta is tortuous. There is minimal blunting of the left CP angle suggestive of a small effusion. There is also some increased density at the left base which may represent an early infiltrate versus atelectasis. . [**12-31**] MRI abd/pelvis: There is no hydronephrosis or hydroureter. In fact, there is paucity of fluid within the collecting systems, which may represent reduced production of urine. There is no perinephric fluid or fat stranding. There are multiple bilateral renal cysts that demonstrate slight increase in size compared to MRI of five years ago. The largest on the left measures 1.7 cm. The slightly septated cyst in the right upper pole measures 13 mm, stable from previous exam. The new cystic lesion in the upper pole of the right kidney measures 1.5 cm. On ASL-MRI, it does not demonstrate any flow to suggest a neoplasm. It is also noted that there is paucity of signal in the renal parenchyma on the ASL images. Apparent reduced perfusion in the kidney which may represent a sequela or cause of patient's decreased renal function. The liver is unremarkable. The patient is status post cholecystectomy. The CBD is dilated up to 12 mm in the porta hepatis and tapers normally down to the ampulla. Adrenals, pancreas, and spleen are unremarkable. There is interval increase in the size of bilateral pleural effusions from CT scan of [**2137-7-28**], with associated atelectasis/consolidation. It is also noted that the IVC size in the intrahepatic and infrahepatic portions is large, which may represent fluid overload status. MRI OF THE PELVIS: There is a Foley catheter in a near-empty bladder. There is a small amount of hemorrhagic fluid in the bladder lumen. The bladder wall is significantly thickened up to 15 mm, probably related to prior radiation treatments in conjunction with nondistention. The T2-weighted images through the pelvis are degenerated by motion and breathing artifact, however, a short segment of the distal ureter, about 1.5 cm distal to the left UVJ, appears to be significantly thickened up to 7 mm (7:20). There is no dilation of the ureter proximal to this segment. The right distal ureter is difficult to assess due to motion artifact. There is a small amount of nonhemorrhagic free fluid in the pelvis. There is no adenopathy. IMPRESSION: 1. No hydronephrosis or reversible cause for renal failure identified. 2. No perfusion in the cystic renal mass in the right upper pole of the kidney. Apparent reduced perfusion in the kidney which may represent a sequela or cause of patient's decreased renal function. 3. Thickened bladder and a short segment of distal left ureter thickening without proximal obstruction. 4. New bilateral pleural effusions, atelectasis/consolidation, and increased pelvic free fluid. The case was discussed and reviewed with Dr. [**Last Name (STitle) **] at 5:30 p.m., [**2137-12-31**]. The patient will be brought back for a non-contrast urographic study pre- and post-Lasix administration. . [**1-3**] CXR: Cardiomediastinal silhouette is unchanged including cardiomegaly, post-sternotomy wires and post-CABG changes. Multifocal opacities seen throughout the lungs are redemonstrated, mostly involving the right lower lobe associated with right pleural effusion. Overall, the appearance has slightly improved since the prior study, which is most likely due to improvement of superimposed pulmonary edema. The calcifications of the pleura in the right chest wall are unchanged. . [**1-6**] bladder u/s: The urinary bladder is normally distended. An indwelling Foley catheter is noted with an inflated balloon. Echogenic debris measures with maximum cross-sectional dimension 5.0 x 1.4 x 2.0 cm (TRV x AP x CC), layering in the dependent position of the urinary bladder, compatible with blood clot. There is no free fluid in the visualized pelvic region. IMPRESSION: Echogenic blood clot layering in the otherwise normally-distended urinary bladder. . [**1-8**] CXR: Moderate-to-severe cardiomegaly is longstanding. Moderate right pleural effusion has increased since [**1-3**], after previously decreasing. I doubt that there is pneumonia, and pulmonary vascular congestion is relatively stable so I do not think there is pulmonary edema either. Extensive right pleural calcification is longstanding. . [**1-11**] CXR: There are small bilateral pleural effusions with possible interval increase in pleural fluid on the left. There is an area of focally increased density at the right base that appears increased since the previous study and a small area of pneumonia cannot be excluded. This might be better evaluated by CT if further evaluation is warranted. Interstitial markings are increased and there may be an element of underlying interstitial edema as well. Brief Hospital Course: Mr. [**Known lastname **] is a [**Age over 90 **] y/o Russian M with PMHx of [**Age over 90 9197**] cancer with recent indwelling foley, stage IV CKD (baseline Cr 3.0) and chronic systolic CHF (LVEF 30%) who was admitted on [**12-26**] with anemia, hematuria and clot-related urinary retention. He was initially admitted to the Urology Service for urinary clot retention and was taken to the operating room for cystoscopy, clot evacuation, and bladder fulguration. Pt was admitted to [**Hospital Unit Name 153**] post procedure due to urosepsis from Klebseilla UTI. Pt developped presumed ATN and worsening renal failure post procedure. Pt had some recovery of renal function but developped recurrent hematuria requiring multiple blood transfusions. During this prolonged admission, he required multiple urologic procedures for recurrent hematuria with obstructive clotting. On [**1-8**], he was taken for cystoscopy which was complicated by an episode of acute hypercarbic respiratory failure thought due to procedural sedation. He was again transferred to the [**Hospital Unit Name 153**] and his acidosis improved with BiPaP. Pt was transferred back out to the medicine floor on [**1-11**]. While on the medicine floor, the continuous bladder irrigation was discontinued and his hematocrit stabilized at 25-27. Foley was removed and he did had any acute issues with retention. He did have one transient episode of scant hematuria which resolved spontaneously. Pt continued to have normal UOP with mildly elevated PVRs and stable creatinine. Urology recommended avoiding a foley unless pt develops severe pain or acute obstruction given his severe hematuria. . Specific issues: C diff: Pt was noted to have a rising leukocytosis and Cdiff toxin returned positive. Symptoms were improving on po Flagyl and he was discharged with a prescription to complete another 10 days of flagyl at home. . Acute on chronic renal failure: By the time of discharge, his renal function seemed stabilized at a creatinine of 3.6-3.9. He had been adequately diuresed for his acute systolic heart failure and was clinically euvolemic on lasix dose of 40mg twice daily. Lisinopril was stopped and follow up labs will be drawn 4 days after discharge and forwarded to Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]. Pt will be seen in [**Hospital 191**] [**Hospital 1944**] clinic on [**1-30**]. . Acute on chronic systolic CHF: Pt was hypervolemic after fluid rescucitation in the ICU and required diuresis with IV lasix. He was discharged on a new home dose of lasix 40mg [**Hospital1 **] which was confirmed with Dr. [**Last Name (STitle) **]. . [**Last Name (STitle) 9197**] cancer/cystitis: PSA had been slowly increasing over past one year. Pt is now s/p cytoscopy and fulguration. Dr. [**Last Name (STitle) **] recommended starting Casodex as an inpatient but this has been deferred after d/w patient and daughter. . Atrial fibrillation: Rate controlled, all anticoagulation held in setting of hematuria. . # Code status: DNR/DNI Medications on Admission: Active Medication list as of [**2137-12-26**]: Medications - Prescription CALCITRIOL - 0.25 mcg Capsule - 1 (One) Capsule(s) by mouth once a day CHOLESTYRAMINE/ASPARTAME - 4G Packet - ONE PACKET MIXED IN WATER TWICE DAILY AT LEAST ONE HOUR AFTER FUROSEMIDE DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] - (Dose adjustment - no new Rx; receiving in [**Hospital **] clinic) - 100 mcg/0.5 mL Syringe - inject 1 s/c once a month ENALAPRIL MALEATE [VASOTEC] - 20 mg Tablet - 1 Tablet(s) by mouth Daily ESCITALOPRAM [LEXAPRO] - 5 mg Tablet - 1 Tablet(s) by mouth once a day FLUTICASONE - 50 mcg Spray, Suspension - 1 spray(s) nas once a day 1 spray each nostril qd FUROSEMIDE - 80 mg Tablet - 1 Tablet(s) by mouth once a day IPRATROPIUM BROMIDE - 21 mcg Spray, Non-Aerosol - [**12-29**] sprays(s) each nostril three times a day as needed for runny nose (give 0.03% strength) morning, lunch, dinner as needed NITROGLYCERIN - 0.4MG Tablet, Sublingual - ONE TABLET UNDER THE TONGUE AS NEEDED FOR CHEST PAIN, CAN REPEAT EVERY 5 MINUTES UP TO 3 OMEPRAZOLE - (Not Taking as Prescribed: ? Dr. [**Last Name (STitle) **] asked him not to take?) - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day for one month, then decrease to 20 mg [**Hospital1 **] TERAZOSIN - 2 mg Capsule - 1 Capsule(s)(s) by mouth hs Medications - OTC COMPRESSION STOCKINGS - Misc - knee high compression stockings, 15-25 mm Hg graduated daily diagnosis venous stasis disease. FERROUS SULFATE - (Dose adjustment - no new Rx) - 325 mg (65 mg Iron) Tablet - 1 Tablet(s) by mouth twice a day INCONTINENCE GUARD - Pad - USE DAILY FOR FECAL INCONTINENCE DUE TO RADIATION PROCTITIS LOPERAMIDE [IMODIUM A-D] - 2 mg Tablet - 30 tablets Tablet(s) by mouth take one pill once a day as needed for diarrhea POLYVINYL ALCOHOL [ARTIFICIAL TEARS] - Drops - 1 gt ou three times a day Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for prn pain,headache,fever, insomnia. 2. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*90 Capsule(s)* Refills:*2* 3. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 4. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*20 Tablet(s)* Refills:*0* 5. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 6. Aranesp (polysorbate) Injection 7. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 8. ipratropium bromide 0.03 % Spray, Non-Aerosol Sig: One (1) Nasal three times a day as needed. 9. Outpatient Lab Work Please draw labs on [**2138-1-20**] including a CBC, basic metabolic panel with Ca, Mg, Phos and forward results to Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] at [**Hospital1 18**]. Fax # [**Telephone/Fax (1) 3382**] Fax # [**Telephone/Fax (1) 9420**] Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: Hematuria Hypotension klebsiella UTI s/p [**Location (un) **] cancer s/p XRT and brachytherapy Cdiff Diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with blood in your urine and blockage to your urine flow. You were managed in the ICU and the bleeding was relieved by urologic procedures. In addition, you had an infection in your urine and you have completed a course of antibiotics. You will need to continue taking Flagyl 500mg twice daily for another 10 days to ensure resolution of the diarrhea from Cdifficile . Medication changes: 1.stop enalapril 2.stop flomax 3.stop cholestyramine 4.start Calcium Acetate 337mg TID 5.start Flagyl 500mg [**Hospital1 **] for another 10 days Please take all of your medications as prescribed and follow up with the appointments below. -No vigorous physical activity for 2 weeks. -Expect to see occasional blood in your urine -Tylenol should be your first line pain medication -Make sure you drink plenty of fluids to help keep yourself hydrated -You may shower and bathe normally. -Resume all of your home medications, except for Enalapril. Please follow up with your PCP and Nephrology regarding this. -If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Followup Instructions: You have a follow up appointment with Dr. [**Last Name (STitle) 1520**] in the [**Hospital 1944**] clinic at [**Hospital3 **] on [**1-30**] at 8:10am. . Please call Dr. [**Last Name (STitle) **] if you have any issues related to recurrent bleeding or pain with urination at ([**Telephone/Fax (1) 4276**] . Department: CARDIAC SERVICES When: WEDNESDAY [**2138-1-22**] at 10:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2138-1-22**] at 11:30 AM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2138-2-4**] at 10:30 AM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "788.20", "584.5", "041.3", "458.9", "585.4", "428.0", "428.23", "416.8", "424.0", "287.5", "008.45", "427.31", "596.0", "596.7", "185", "V49.86", "424.2", "E879.2", "276.2", "599.0", "414.00", "404.91", "285.1", "518.5", "595.82", "909.2" ]

icd9cm

[ [ [] ] ]

[ "38.93", "57.0", "57.32", "58.6", "57.49" ]

icd9pcs

[ [ [] ] ]

16247, 16322

10249, 13302

258, 335

16476, 16476

3194, 3194

17810, 19037

2459, 2487

15221, 16224

16343, 16455

13328, 15198

16627, 17014

3749, 10226

2502, 3175

17034, 17787

175, 220

363, 1471

3211, 3732

16491, 16603

1493, 2045

2061, 2443

28,190

163,622

43687

Discharge summary

report

Admission Date: [**2155-5-9**] Discharge Date: [**2155-5-14**] Date of Birth: [**2072-12-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5893**] Chief Complaint: transfer for respiratory distress Major Surgical or Invasive Procedure: placement of right internal jugular central venous catheter History of Present Illness: 82M w/ hypothyroidism, afib on Coumadin, HTN, CAD, s/p [**First Name3 (LF) **] under general anesthesia on [**2155-4-18**] after he became jaundiced and US & CT Abdomen on [**2155-4-15**] revealed marked biliary dilatation. During [**Date Range **], he received sphincterotomy and biliary stent due to high grade stricture. He did not tolerate the procedure well, was intubated, sent to the [**Hospital Unit Name 153**], & required Neosynephine for shock and completed a course of Levo/Flagy for biliary organisms. All cultures negative. . Patient sent to rehab on [**2155-4-25**] and was sent to [**Hospital3 **], [**Location (un) **], MA ([**Telephone/Fax (1) 93909**]) after having respiratory distress. imaging notable for large pleural effusions. Outside vital signs: 101.2 140 72/60 90% FiO2. Pateint was initially given CTX/Levo/Clinda for broad spectrum abx, then changed to Imipenem. patient reports that he's had a nonproductive cough for 3 weeks with an acute onset of SOB within the past 24 hours. he denies chest pain ,lightheadedness, palpitations, abdominal pain. he does report increasing diarrhea for the past 3 weeks. Past Medical History: Biliary stricture s/p [**Telephone/Fax (1) **] sphincterotomy and stent on Aptil 18, [**2154**] CAD, MI in [**2106**] Echo showed old IPMI. stress echo in [**5-7**] showed no e/o ischemia. Afib: diagnosed 06. underwent DCCV in [**9-6**]. now back in afib. HTN Obesity Gout Hypothyroidism Shrapnel in his face during WWII s/p removal Social History: He is a widow with two daughters. [**Name (NI) **] is retired. quit smoking 42 yrs back. smoked for 1 yr. quit etoh 6 yrs back. was a social drinker. Family History: no h/o Ca, CAD, DM Physical Exam: as of [**2155-5-9**] 08:01 PM Tcurrent: 36.2 ??????C (97.2 ??????F) HR: 113 (101 - 122) bpm BP: 95/47(60) {79/26(40) - 100/70(66)} mmHg RR: 13 (13 - 24) insp/min SpO2: 100% Heart rhythm: SA (Sinus Arrhythmia) CVP: 7 (7 - 8)mmHg O2 Delivery Device: Nasal cannula SpO2: 100% Physical Examination General Appearance: Well nourished, No(t) Overweight / Obese Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t) Dullness : ), (Breath Sounds: Bronchial: in RLL, Diminished: diffusely) Abdominal: Soft, Non-tender, Bowel sounds present, Distended, tympanitic Extremities: Right: 3+, Left: 3+, No(t) Clubbing Skin: Not assessed, No(t) Rash: , No(t) Jaundice Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Movement: Not assessed, Tone: Not assessed Pertinent Results: [**2155-5-9**] 06:37PM WBC-34.8*# RBC-3.70* HGB-13.2* HCT-40.9 MCV-111* MCH-35.6* MCHC-32.2 RDW-16.2* [**2155-5-9**] 06:37PM NEUTS-86* BANDS-10* LYMPHS-0 MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2155-5-9**] 06:37PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ TARGET-OCCASIONAL TEARDROP-1+ PAPPENHEI-OCCASIONAL [**2155-5-9**] 06:37PM PLT SMR-NORMAL PLT COUNT-295 [**2155-5-9**] 06:37PM PT-25.9* PTT-32.2 INR(PT)-2.6* [**2155-5-9**] 06:37PM GLUCOSE-83 UREA N-51* CREAT-1.7* SODIUM-136 POTASSIUM-5.4* CHLORIDE-103 TOTAL CO2-28 ANION GAP-10 [**2155-5-9**] 06:37PM CALCIUM-7.9* PHOSPHATE-3.5 MAGNESIUM-2.2 [**2155-5-9**] 09:47PM TYPE-ART TEMP-36.2 RATES-/18 O2 FLOW-6 PO2-72* PCO2-44 PH-7.37 TOTAL CO2-26 BASE XS-0 INTUBATED-NOT INTUBA VENT-SPONTANEOU [**2155-5-9**] 09:47PM LACTATE-1.9 [**2155-5-9**] 7:08 pm BLOOD CULTURE Source: Line-CVL 1 OF 2. **FINAL REPORT [**2155-5-13**]** Blood Culture, Routine (Final [**2155-5-13**]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. VANCOMYCIN Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 2 S AP CHEST 6:16 P.M. [**5-9**] HISTORY: Respiratory distress. Cough and hypoxia. Assess volume status. IMPRESSION: AP chest compared to [**4-19**] through [**4-21**]: Right lung base is elevated yet heart, mediastinum is shifted to the right indicating that whatever pleural effusion is present is offset by a greater volume of right middle and lower lobe collapse. There is mild congestion in the right upper lobe, but not in the left. The heart is mildly to moderately enlarged but unchanged and mediastinal vascular engorgement is present indicating the heart failure if any is probably limited to the right side. Right subclavian line tip projects over the right atrium. Gaseous distention of the stomach is moderately severe. Findings were reported to clinical caregiver after interpretation of the subsequent radiograph. Brief Hospital Course: 82 M w/ recent admission for painless jaundice s/p [**Month (only) **] with sphincterotomy and biliary stent c/b hypoxia requiring intubation, admitted with septic shock; source unclear, but differential diagnostic considerations included pneumonia, infectious diarrhea, or less likely cholangitis. Blood cultures grew out methicillin-resistant staph aureus on hospital day two, and pt continued on vancomycin. With his compromised respiratory status, intubation was discussed with the family, but since he had an underlying malignancy of the biliary tree and numerous co-morbid conditions, his family decided that it was in his best interest to to avoid intubation. He was therefore treated with antibiotics, supportive care for septic shock including volume resuscitation directed by CVP monitoring, vasopressors, and euglycemic control. Cortisol levels responded appropriately to ACTH stimulation and so steroids were not used. Thoracentesis was considered for large pleural effusions, but given his family's stated goals of care, invasive procedures were declined, especially with the increased risk of hemothorax as he was anticoagulated with coumadin on admission. After 72 hours of ICU-level management of septic shock, hemodynamics stabilized but oxygenation did not improve, and his mental status declined. He developed acute renal failure despite supportive care for septic shock. His daughters decided to withdraw supportive measures that were likely only prolonging his life without meaningful benefit, given that he was unlikely to recover to his pre-hospital functional status and also had a likely malignant lesion of the biliary tract. Narcotics and benzodiazepines were used to control pain and agitation. On hospital day 5, the patient expired with his daughters at his bedside. Last rites were administered by hospital's catholic chaplain. An autopsy was requested, specifically to evaluate the nature and extent of the patient's incompletely diagnosed biliary tract malignancy. Medications on Admission: Atrovent Warfarin 5 mg daily Nadolol 20 daily Losartan 50 daily ASA 81 Niaspan ER 750 Triamterene 50 mg qod Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: methicillin resistant staph aureus septicemia with septic shock; biliary obstruction with goblet cell metaplasia s/p biliary stenting Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a

[ "518.81", "V09.0", "156.9", "038.11", "244.9", "995.92", "511.9", "V58.61", "785.52", "401.9", "274.9", "576.2", "584.9", "427.31", "278.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8167, 8176

5979, 7980

348, 409

8353, 8363

3211, 5956

8415, 8421

2121, 2141

8139, 8144

8197, 8332

8006, 8116

8387, 8392

2156, 3192

275, 310

437, 1581

1603, 1937

1953, 2105

18,921

150,037

15930

Discharge summary

report

Admission Date: [**2193-6-27**] Discharge Date: [**2193-7-9**] Date of Birth: [**2126-1-13**] Sex: F Service: MEDICINE Allergies: A.C.E Inhibitors Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: PICC line placed Right bundle branch ablation History of Present Illness: 67 year old woman with end-stage non-ischaemic dilated CMP, s/p bioprosthetic MVR and ASD repair in [**2188**], s/p biventricular ICD, chronic a fib, HTN, HL, DM2 admitted to hospital in [**State 45679**] with CHF (NYHA Class IV). Well-known to us here. She was transferred to CCU for milrinone and insertion of PICC line for home milrinone therapy. . At baseline, she is able to ambulate between her living room and kitchen with some difficulty and sob, although she has been chronically fatigued. . She recently had a prolonged admission to [**Hospital1 18**] ago for CHF which improved drastically on milrinone drip (CO 2.0 increased to 4.0) and was discharged. Approximately three weeks ago, she became short of breath while at rest and sleeping, and required home Oxygen (2L) at night (and occasionally during the day), with good response. Approximately two weeks ago, she had an episode of hyperkalemia, and subsequently discontinued her spironolactone and digoxin with good effect. Over the last two weeks, her healthcare provider in [**State 32926**] discontinued her diovan, and lopressor,due to concerns about low BP (systolics in the 80-90 range). She has subsequently developed symptoms of CHF with LE edema, five pound weight, DOE, orthopnea, PND. She therefore presented to OSH [**6-26**] where she was found to be in CHF and started on a lasix drip (no record of net diuresis). There her dyspnea and her energy improved, although she did have an episode of N/V after morphine. . She denied any loss of consiousness, blurry vision, fever, chest pain, productive coughs, or hemoptysis / hematemesis /hematochezia. . Her cardiac risk factors include: history of HTN, type II diabetes, hyperlipidemia, age greater than 65, and heredity. Past Medical History: -Valvular heart disease s/p bioprosthetic MVR and ASD repair in [**2188**] -Dilated CM with an LVEF < 10% (secondary to rheumatic heart dx) -S/p BiV ICD -Type 2 DM -HTN -Hyperlipidemia -CRI (BUN 69, CREAT 2.5, K 5.3) -GERD -PAF -S/p TAH -sleep apnea Social History: Lives with her husband, has 2 adult children. Used to work as a nurse's aid, now retired. She is a pastor. Never smoked, denies etoh, denies illicit drugs. Originally from [**Male First Name (un) 1056**]. Family History: There is no known family history of premature coronary artery disease or sudden death. Sister had uterine cancer. Mother with DM died of "[**Last Name **] problem." Her son has a similar cardiomyopathy and may be a candidate for a heart transplant. Physical Exam: VS: T 98.7/97.1 , BP 75/45 (70-90)/(40-60), HR 93(90-120) , RR 18 (17-25) , O2 100% on 4L . Gen: 67 year-old woman in NAD, on O2 resting comfortably in bed, Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 12 cm. CV: Diffuse PMI. Rapid, irregularly irregular rhythm, normal S1, S2. No murmurs appreciated Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Mild bilateral crackles at the bases. No wheezing or rhonchi. Abd: Soft, NTND, No HSM appreciated. Bowel sounds heard in four quadrants. Ext: trace pedal edema. Diabetic foot exam was not significant for ulcers. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; 1+ DP/PT [**Name (NI) 2325**]: Carotid 2+ without bruit; 1+ DP/PT Neurologic exam: no focal deficits on examination. Pertinent Results: EKG on admission demonstrated: with no significant change compared with prior dated [**2193-4-23**] which demonstrated (Atrial fibrillation with ventricular paced rhythm). . [**2193-7-3**] Echocardiogram: The left ventricular cavity is severely dilated. Overall left ventricular systolic function is severely depressed (LVEF= <20 %). The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. The aortic valve leaflets are mildly thickened. A bioprosthetic mitral valve prosthesis is present. No mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. . 2D-ECHOCARDIOGRAM performed on [**2193-4-19**] demonstrated: (TEE) Severe nearly static spontaneous echo contrast is seen in the left atrial appendage and there is probable thyombus formation. The left atrial appendage emptying velocity is depressed (<0.2m/s). No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is severely depressed (Left Ventricle - Ejection Fraction: <= 10%). There right ventricular free wall is hypokinetic. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The prosthetic mitral leaflets appear normal. The motion of the mitral valve prosthetic leaflets appears normal. The transmitral gradient is normal for this prosthesis (although gradient difficult to judge in setting of low output state). Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. . CARDIAC CATH performed on [**1-26**] demonstrated: [**1-26**] c cath COMMENTS: 1. Coronary angiography of this right dominant circulation revealed no significant CAD. 2. Resting hemodynamics showed mildly elevated right and left ventricular filling pressures and mildly elevated pulmonary artery pressures. The cardiac index was slightly depressed at 2.2. There was a step-up of oxygen saturation at the mid right atrial level, suggesting a left-to-right shunt. The PQ/PS ratio was 2. 3. Right atriography showed no evidence of a shunt. Brief Hospital Course: Hospital Course: 67 yo woman with end stage Class IV heart failure with EF <10%, non-ischemic cardiomyopathy s/p biventricular pacemaker admitted with worsening heart faillure and volume overload, now s/p RBB ablation and diuresis. 1. Cardiac: a. Pump: Class IV heart failure, non-ischemic cardiomyopathy with [**Hospital1 **]-V pacemaker/defibrillator admitted with worsening heart failure and volume overload likely [**12-28**] to medication discontinuation. Initially started on milrinone gtt however she did not tolerate this [**12-28**] to hypotension with SBP's <70. Diuresed on IV lasix and metolazone with good effect. She had RBB ablation resulting in complete heart block for rate control as she had Afib with rapid conduction down native pathway likely contributing to hypotension. Immediately following ablation she had significant increase in blood pressure resulting in increased afterload and flash pulmonary edema requiring intubation for short period of time. Post ablation she was started on dobutamine gtt and diuresis was continued with good effect. Aggressive diuresis was discontinued once she developed contraction alkalosis and a bump in creatinine. She had complete resolution of pleural effusions and pulmonary edema on chest xray prior to discharge. She was discharged on dobutamine 10mcg/kg/min gtt and digoxin -tolerate SBP's in the 70's - lasix 20 mg qday on discharge -coumadin was restarted prior to discharge given increased risk of embolic complications in setting of advanced heart failure -continue spironolactone 25mg daily -all other prior cardiac medications were discontinued . b. Ischaemia: no signs of coronary artery disease on recent cath continue aspirin -simvastatin was discontinued as no sign of atherosclerotic disease . c. Rhythm: s/p RBB ablation, now in paced rhythm with [**Hospital1 **]-V pacer set at 100bpm -occasional PVC's on tele, blood pressure more stable with resultant rate control . 2. Acute renal failure: baseline creatinine 1.1-1.2, creatinine increased during admission [**12-28**] aggressive diuresis, stable and trending down on discharge with creatinine of 1.3 on discharge - euvolemic on discharge -lasix 20mg po daily for maintenance, follow daily weights to guide dose adjustment -will not use [**Last Name (un) **] as she did not tolerate trial as she developed hypotension requiring 12 hours of dopamine gtt. . 3. Flash Pulmonary edema requiring intubation - following RBB ablation she had immediate increase in SBP to 120's. This abrupt increase in afterload likely caused flash pulmonary edema as explanation for acute respiratory distress which developed at the end of the EP procedure. Felt that respiratory failure was impending and she was intubated and started on dopamine gtt. She responded well to this treatment and she was extubated without event 48 hours later and switched back from dopamine to dobutamine. . 4.Productive cough - with crackles on exam L greater than right; possible pneumonia given 2 days of intubation during this admission. Treat with levofloxacin q 48 hours for empiric therapy. Will continue for total of 7 day course as outpatient. . 5. Anxiety - noted to have episodes of anxiety periodically resulting in worsening shortness of breath. Responded well to standing ativan TID. This was continued as an outpatient. . 6. Diabetes: rare need for ISS during admission, not on outpatient antidiabetics -no indication for antidiabetic regimen on discharge . 7. FEN/GI: low-salt, 1L fluid restriction. PPI. K and Phos repleted througout admission as needed. - continue spironolactone -monitor K periodically as outpatient . 8. Prophylaxis: PPI, she was maintained on heparin gtt during much of admission for embolic disease prophylaxis, restarted on coumadin in preparation for discharge. -daily INR check arranged upon discharge given that she was d/c'd on levofloxacin which is known to increase INR. INR on D/C 1.4 . 9. Code: full, discussed with family and patient [**2193-6-28**] . 10. Dispo - discharged to home with VNA for daily INR checks and assistance with dobutamine gtt and pump, blood pressure monitoring with plan to report findings to Dr. [**First Name (STitle) 437**]; she will follow up with Dr. [**First Name (STitle) 437**] on tuesday of the week following discharge. Medications on Admission: Coumadin Ambien Lasix 80 mg twice a day, Diovan 80 mg twice a day, Aldactone 25 mg daily, digoxin 0.125 mg daily, simvastatin 20 mg daily, Claritin 10 mg daily, multivitamin daily, aspirin 81 mg daily, Prilosec 20 mg twice a day, metoprolol short acting 12.5mg twice a day Discharge Medications: 1. Dobutamine in D5W 1,000 mcg/mL Parenteral Solution Sig: As directed Intravenous Infusion: 5-10 mcg/kg/min IV DRIP TITRATE TO SBP 70-100 Current weight 61kg. . Disp:*1 QS* Refills:*2* 2. Saline Flush 0.9 % Syringe Sig: One (1) Injection PRN. Disp:*30 syringe* Refills:*5* 3. Heparin Flush 100 unit/mL Kit Sig: Five (5) Intravenous PRN. Disp:*150 units* Refills:*5* 4. Infusion pump 5. Outpatient Lab Work Please check daily INR by VNA. 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Tablet, Chewable(s) 7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime): take as directed, your doctor will adjust the dose based on your blood level. Tablet(s) 9. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every other day for 5 days: take one pill every other day starting tomorrow [**2193-7-10**] with the last dose on [**2193-7-14**]. . Disp:*3 Tablet(s)* Refills:*0* 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO every morning: check your weight every day, this medication my be adjusted if your weight fluctuates. Disp:*30 Tablet(s)* Refills:*2* 11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO three times a day: this medication is to help with your feeling of shortness of breath and anxiety. You can take this before bed to help with sleep. Disp:*90 Tablet(s)* Refills:*1* 13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other day: take the first dose [**2193-7-10**]. Disp:*15 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 11485**] VNA Discharge Diagnosis: Decompensated Heart Failure End-stage Class IV Heart Failure Secondary Diagnoses: Acute Renal Failure Discharge Condition: Fair Discharge Instructions: You were admitted to the hospital because you had too much fluid and your heart was failing. You were started on a medication called dobutamine to help you heart pump more efficiently. In addition, you had a procedure called "AV node ablation" to slow down your heart rate to allow your heart to work better. . Several changes were made to your medications during this admission. Please take only the medications that you are prescribed on discharge. You will no longer be taking many of your prior home medications. Your home medications that were stopped are diovan, simvastatin, and metoprolol. Your dose of lasix and digoxin were decreased. . You should take your digoxin every other day, starting on [**2193-7-10**]. . You will also be taking levofloxacin every other day starting tomorrow [**2193-7-10**] for a total of 3 doses. The last dose will be on [**2193-7-14**]. This medicine was to treat for a possible pneumonia. You will also be taking an antibiotic for three more doses . You should take all of your medications as directed. The visiting nurse will check your blood pressure and help you with the dobutamine pump. In addition, they will check your blood level and talk with your doctor [**First Name (Titles) **] [**Last Name (Titles) 11878**] the dose of your coumadin. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: you should not drink more than 1500ml of fluid per day. . Call your doctor or return to the emergency department if you develop chest pain, trouble breathing, light headedness, fainting, bleeding that doesn't stop or any other concerning symptoms. Followup Instructions: You have an appointment ot see DR. [**First Name (STitle) 437**] on Tuesday [**2193-7-16**] at 1:00pm.

[ "285.9", "327.23", "V45.02", "416.8", "250.00", "V45.01", "425.4", "428.40", "V15.81", "V42.2", "511.9", "398.90", "276.3", "428.0", "518.81", "427.1", "427.31", "458.9", "486", "584.9", "790.92", "300.00" ]

icd9cm

[ [ [] ] ]

[ "37.34", "89.64", "96.04", "96.72", "38.93", "37.27" ]

icd9pcs

[ [ [] ] ]

12764, 12820

6431, 6431

304, 352

12967, 12974

3900, 6408

14691, 14797

2645, 2895

11066, 12741

12841, 12903

10768, 11043

6448, 10742

12998, 14668

2910, 3828

12924, 12946

245, 266

380, 2132

3845, 3881

2154, 2407

2423, 2629

77,746

152,886

36898

Discharge summary

report

Admission Date: [**2161-11-16**] Discharge Date: [**2161-11-23**] Date of Birth: [**2113-11-18**] Sex: F Service: SURGERY Allergies: Penicillins / Codeine Phos/Acetaminophen Attending:[**First Name3 (LF) 1556**] Chief Complaint: patient admitted for weight-reduction surgery Major Surgical or Invasive Procedure: 1. laparoscopic gastric bypass 2. exploratory laparoscopy History of Present Illness: 47yo female with longstanding morbid obese refractory attempt to weight loss by nonoperative means. Her preoperative weight is 334.2 pounds. Given her height, this translates to a body mass index of 50.8 kg/m2. Her previous unsuccessful attempts at weight loss have included work with a registered dietitian, work with her primary care physician, [**Name10 (NameIs) 83306**], [**Name11 (NameIs) **] Watchers, South Beach diet, [**Doctor Last Name 1729**] diet, taking off pounds sensibly (TOPS), and diet workshop. Past Medical History: Past medical history is significant for: 1. Depression and anxiety. 2. Hypertension. 3. Type 2 diabetes mellitus. 4. Hyperlipidemia with delineated triglycerides. 5. Obstructive sleep apnea requiring BiPAP. 6. Severe gastroesophageal reflux. 7. Fatty liver. 8. Iron deficiency anemia. 9. Stress urinary incontinence. 10. Low back pain. Social History: former smoker, but quit many years ago. She does not drink excessively or use drugs. She is a homemaker, married, lives with her husband and two sons Family History: significant for stroke, obesity, and hyperlipidemia Physical Exam: upon admission: General: AOx3, NAD CV: RRR, S1/S2 appreciated without M/R/G Chest: CTA bilaterally Abdomen: obese, soft, nontender, and nondistended. no organomegaly or masses appreciated, umbilical hernia noted which appears to be incarcerated. Extremities: no clubbing, cyanosis, or edema. Brief Hospital Course: Ms [**Known lastname 9241**] is a 48yo female presenting to [**Hospital1 18**] on [**2161-11-16**], for laparoscopic Roux-en-Y gastric bypass surgery. She tolerated the anesthesia and the procedure well however postoperatively, it was noted that the patient had decreasing hematocrit in the PACU and upon arrival to the floor. Patient returned to the operating room on [**2161-11-17**], for exploratory laparoscopy that revealed no active sources of bleeding. Post-operatively she experienced a desaturation and she was re-intubated and transferred to a surgical intensive care unit. Her hematocrit continued to trend downward and the patient was transfused 2units packed red blood cells. On post-operative day [**3-15**], the morning hematocrit necessitated additional transfusion. Her hematocrit levels stabilized on post-operative day [**4-13**]. She was successfully extubated on post-operative day [**5-15**] and was subsequently transferred to the floor. She was slowly advanced to Stage I diet through postoperative day [**8-17**] when she was advanced to Stage II and Stage III, which she tolerated well. She is being discharged, afebrile, with normal hemodynamics, tolerating an oral diet and with pain well controlled on oral medications. Medications on Admission: Atenolol 75 mg daily, HCTZ 25 mg daily, Metformin [**2152**] mg daily, Gemfibrozil 1200 mg daily, Omeprazole 20 mg daily, baby aspirin 81 mg daily, Cymbalta 30 mg daily, Iron 65 mm daily, antihistamine as needed, daily multivitamin and vitamin D Discharge Medications: 1. Roxicet 5-325 mg/5 mL Solution Sig: [**6-21**] ml PO every four (4) hours as needed for pain. Disp:*500 ml* Refills:*0* 2. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day as needed for constipation. Disp:*500 ml* Refills:*0* 3. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day: Please take for one month. Disp:*600 ml* Refills:*0* 4. Actigall 300 mg Capsule Sig: One (1) Capsule PO twice a day: Please take for 6 months. Open capsule and place in drink. Disp:*60 Capsule(s)* Refills:*5* 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 6. Citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 7. Gemfibrozil 600 mg Tablet Sig: Two (2) Tablet PO once a day. 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 10. Multivitamin Tablet Sig: One (1) Tablet PO twice a day. 11. Medication Please hold your glipizide and omeprazole Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary Diagnosis: Obesity Discharge Condition: Stable Discharge Instructions: Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Diet: Stay on Stage III diet until your follow up appointment. Do not self advance diet, do not drink out of a straw or chew gum. Medication Instructions: Resume your home medications, CRUSH ALL PILLS. You will be starting some new medications: 1. You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. 2. You should begin taking a chewable complete multivitamin with minerals twice a day. No gummy vitamins. 3. You will be taking Zantac liquid 150 mg twice daily for one month. This medicine prevents gastric reflux. 4. You will be taking Actigall 300 mg twice daily for 6 months. This medicine prevents you from having problems with your gallbladder. 5. You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. 6. You must not use NSAIDS (non-steroidal anti-inflammatory drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and Naproxen. These agents will cause bleeding and ulcers in your digestive system. Activity: No heavy lifting of items [**11-26**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], RD,LDN Phone:[**Telephone/Fax (1) 305**] Date/Time:[**2161-12-3**] 2:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**] Date/Time:[**2161-12-3**] 2:30

[ "458.29", "250.00", "507.0", "998.11", "997.39", "V85.4", "571.8", "280.9", "552.1", "278.01", "625.6", "272.4", "724.2", "401.9", "530.81", "799.02", "327.23", "300.4", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "33.24", "45.13", "54.21", "96.71", "39.98", "96.04", "44.38", "99.04" ]

icd9pcs

[ [ [] ] ]

4434, 4485

1898, 3157

349, 409

4556, 4565

6756, 7063

1511, 1564

3453, 4411

4506, 4506

3183, 3430

4613, 5179

1579, 1581

264, 311

6399, 6733

437, 956

4525, 4535

5204, 6387

1596, 1875

978, 1326

1342, 1495

23,091

105,815

18824

Discharge summary

report

Admission Date: [**2196-7-18**] Discharge Date: [**2196-8-21**] Date of Birth: [**2138-1-19**] Sex: F Service: OMED HISTORY OF ILLNESS: This patient is a 58-year-old woman with a complicated hospitalization originally admitted for debulking nephrectomy of the right kidney on [**2196-7-18**]. She was diagnosed with renal cell carcinoma in [**1-/2196**] after having shortness of breath and anemia refractory to intravenous iron. MBS was found on bone marrow biopsy. The patient developed congestive heart failure at that time through idiopathic dilated cardiomyopathy, and hepatosplenomegaly was found back on a CT scan that was done in 02/[**2195**]. During that CT scan a right renal mass was located. Biopsy revealed renal cell carcinoma. Patient was also noted to have lung metastases, but a clear report of this diagnosis is not well elucidated. POST SURGICAL CARE AFTER HER NEPHRECTOMY ON [**2196-7-18**]: 1. Was complicated by congestive heart failure and a 15 liter fluid overload. 2. A left IJ clot after line placing requiring anticoagulation and leading to hematoma at nephrectomy site that required a 10-unit transfusion until stable. 3. A 21-day intubation with multiple failed attempts secondary to pulmonary edema. 4. Recurrent hypertension urgency after extubation. 5. Profound anxiety that was difficult to control as the patient is intolerant, having paradoxical reactions to benzodiazepines. Patient recently had mental status changes in the Critical Care Unit and had a head CT through which new brain metastases were diagnosed. Patient was admitted to the Oncology Medicine service on [**2196-8-17**]. Prior to the admission, 29 days prior to this, patient could ambulate well while walking for 30 minutes without shortness of breath, dyspnea on exertion, or pain. She had normal coronary arteries per catheterization at [**Hospital 336**] Hospital in [**1-/2196**], and she had lost 30 pounds within six months, and had presented with hypoalbuminemia. On transfer to the Oncology Medicine service the patient was on 4 liters of oxygen nasal cannula, had sats in the high 90s but desaturated frequently overnight, requiring BIPAP, which she often refused. Her most recent ejection fraction was documented as 55% improved from the 25% noted three weeks ago, requiring a CCU stay. She could not ambulate secondary to weakness, and she spoke softly, if at all, due to vocal cord dysfunction status post extubation. She tolerated only honey nectar diet and was on aspiration precautions. She was also being treated for a urinary tract infection. VITALS ON ADMISSION TO THE ONCOLOGY MEDICINE SERVICE: Temperature 96.6, blood pressure 119/58, pulse of 114, respirations 28, and a 97% saturation on 4 liters of nasal cannula. She is obese, pale, and has atrophic arms and legs. She is sitting up, awake, and alert, writing down on paper that she is frustrated being a mute. Pupils are equal and reactive to light. Her conjunctivae are anicteric. She has no appreciable jugular venous distention. Cardiovascular exam: She has a regular rate and rhythm; normal S1 and S2 and a positive S3 with no murmurs, rubs, or gallops. Radial and dorsalis pedis pulses are 1+ bilaterally. Respiratory: She has poor effort and better air movement on the left versus the right without crackles or wheezes. Abdomen is obese, soft, mildly distended without tympany or tenderness. Extremities are pale, dry, and have edema to the knees 2+. IMPRESSION: 1. The impression was that she was an unfortunate 58-year-old woman with right renal cell carcinoma and metastases to her lung and newly diagnosed metastases to her brain status post nephrectomy for 29 days, severely malnourished, and deconditioned. 2. Her oncologic issues were renal cell carcinoma in which treatment options were discussed with Dr. [**Last Name (STitle) **]. Neurosurgery was considering stereotactic surgery for the metastases, and Radiation Oncology was following the patient through the CCU stay into the OMED stay. 3. Her CHF was compensated, but she has hypervolemic, but diuresis was continued with Lasix and well maintained. Respiratory status: She had clear lungs and a known history of chronic obstructive pulmonary disease and asthma, and the hypoxia was thought to be multifactorial. She had large metastases as well as CHF. She was maintained on BIPAP every evening and nasal cannula throughout the day. 4. Endocrine: The patient was hypothyroid, and Levothyroxine was continued. For renal her creatinine was 1.8; at baseline, was 0.8 on admission. She had one kidney and was expected to have compensation by that point. It was felt that she was intervascularly dry, and she was given fluids occasionally in order to mobilize the edema that was present and perfuse her kidneys better. 5. Per Infectious Diseases she had a urinary tract infection. She was on Ciprofloxacin. 6. For Hematology she had anemia present since [**94**]/[**2195**]. Her hematocrit was stable. She was maintained on iron every day and was given only prophylactic doses of Heparin subq given her risk of bleeding at her nephrectomy site. 7. For gastrointestinal she had no acute concerns, but she was covered with a bowel and nausea regimen and Protonix prophylaxis. She was given tube feeds to improve her nutrition and was tolerating these well. 8. For deconditioning Physical Therapy and Occupational Therapy were consulted to improve her status and set up home services for when she was ready for discharge. All these plans were discussed with the family as well as with Dr.[**Name (NI) 47540**] team. As her diuresis was maintained and she was preparing for discharge, the patient was continuing to receive tube feeds, and on the evening of [**2196-8-20**] she was found, by the nurse, unresponsive in her room. A code was called. Patient was found to have vomited on her tube feeds. She was resuscitated and intubated and taken to the [**Hospital Unit Name 153**]. She was maintained on pressors and mechanical ventilation until her family arrived, at which time a plan of care was discussed with them and the medical time. The family felt that it was best to extubate her and to provide comfort measures. The patient was pronounced dead at 9:26 a.m. on [**2196-9-10**] with her family at her side. Dr. [**Last Name (STitle) **] and primary team were made aware. [**Name6 (MD) 6337**] [**Name8 (MD) **], M.D. [**MD Number(1) 6342**] Dictated By:[**Last Name (NamePattern1) 47889**] MEDQUIST36 D: [**2196-10-26**] 18:08 T: [**2196-10-27**] 20:27 JOB#: [**Job Number 51537**]

[ "196.2", "197.0", "998.12", "424.0", "189.0", "428.0", "496", "425.4", "198.3" ]

icd9cm

[ [ [] ] ]

[ "00.13", "96.04", "34.91", "39.79", "88.45", "40.3", "99.15", "55.51", "96.6", "38.93", "96.72", "89.64" ]

icd9pcs

[ [ [] ] ]

5,130

130,616

17509

Discharge summary

report

Admission Date: [**2142-2-25**] Discharge Date: [**2142-3-9**] Date of Birth: [**2079-2-10**] Sex: F Service: Fenard Intensive Care Unit CHIEF COMPLAINT: Airway obstruction secondary to anterior neck mass. HISTORY OF PRESENT ILLNESS: A 63-year-old white female without significant past medical history presented with anterior cervical mass unknown pathology, intubated for airway obstruction prior to admission to the [**Hospital1 **] came from [**Hospital 8**] Hospital. Basically there she was admitted after some malaise, weakness, and cough, and progressively worsening shortness of breath and stridor for which she required intubation. On the day prior to admission, she had bilateral lower extremity weakness. Started on steroids for consideration of spinal cord compression secondary to metastatic disease. PAST MEDICAL HISTORY: None. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: None. MEDICATIONS ON TRANSFER: 1. Allopurinol 30 [**Hospital1 **]. 2. Decadron 10 qid. 3. Heparin 5,000 subQ [**Hospital1 **]. 4. Protonix 80 [**Hospital1 **]. 5. Klonopin. 6. Multivite. 7. Morphine. 8. Zofran. SOCIAL HISTORY: Widowed and lives with her son. Fifty pack year history. No EtOH. PHYSICAL EXAMINATION: On presentation, she was alert, answering questions, comfortable. Neck: Large 8 x 6 cm mass overlying trachea, nontender, supraclavicular nodes. Respiratory: Clear to auscultation bilaterally. Decreased breath sounds on the right posteriorly. S1, S2 no murmurs. Abdomen is soft, nontender, and bowel sounds present. Extremities: No edema. Neurologic is alert and oriented times three. Able to write answers to questions. Strength: 0/5 bilateral lower extremities, [**4-2**] bilateral upper extremities. INITIAL LABORATORIES: White count 8, hematocrit 32.5, platelets 403. Chem-7: 125, 3.6, 95, 24, 12, 0.6, glucose of 110, calcium 8.5. TSH, T4 and T3 from the outside hospital. CT scan from outside hospital showing mediastinal mass, neck mass, lymphadenopathy. Biopsy was also done at the outside hospital. Pathology was pending on that. HOSPITAL COURSE: For cord compression, the patient was given XRT and high dosed steroids for 3-4 days, and then when there was no sign of improvement, that was stopped. Neurosurgery was initially consulted, however, the patient did not respond and had increasing ventilation requirement. Respiratory: The patient was intubated throughout her stay, and had increasing requirements initially. Cardiovascular: She was stable. Endocrine: She was on high dosed steroids initially and then that was turned down. Oncology: Pathology from the outside hospital eventually revealed very undifferentiated carcinoma. No treatment options were available per the Oncology service. FEN: Was stable. She, at time of expiration, had been CMO for about five days and off any nutritional supplements and all medications were stopped. Her contacts were her sons, [**Name (NI) **] [**Name (NI) 805**] and [**First Name8 (NamePattern2) 4648**] [**Name (NI) 805**]. Her pain was controlled with Morphine and Ativan. Patient remained in the Fenard Intensive Care Unit through until the 11th when she became unresponsive, not breathing any longer. At that time, she had been comfort measures only for several days. She was pronounced dead at 3:45 pm on [**2142-3-9**]. Autopsy was refused and declined by her family. Family was notified immediately of the patient's death. DISCHARGE DIAGNOSES: 1. Expiration. 2. Widely metastatic undifferentiated carcinoma. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**Last Name (NamePattern1) 48872**] MEDQUIST36 D: [**2142-3-14**] 14:11 T: [**2142-3-15**] 04:31 JOB#: [**Job Number 48873**]

[ "198.5", "197.0", "336.9", "285.9", "196.0", "276.5", "518.81", "199.1" ]

icd9cm

[ [ [] ] ]

[ "92.29", "96.04", "38.91", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

3498, 3823

2125, 3477

928, 935

1250, 2107

172, 225

254, 838

960, 1141

861, 906

1158, 1227

21,514

117,388

1998

Discharge summary

report

Admission Date: [**2108-5-15**] Discharge Date: [**2108-5-18**] Date of Birth: [**2047-9-9**] Sex: M Service: MEDICINE Allergies: Compazine / Codeine / Atenolol Attending:[**First Name3 (LF) 2745**] Chief Complaint: hypertensive emergency Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 60 y.o.m. with HTN, anxiety, depression, personality disorder, PTSD, COPD, h/o PE with multiple admissions for malignant hypertension who is admitted to the ICU for hyertensive emergency. He was seen in [**Company 191**] today for chest pain during a regular routine f/u appt. Has had CP for 3 days on left side, radiating down left arm, unchanged with rest or exertion. Pressure is constant. Also with 10/10 HA and vision blurriness as well as photophobia and ataxia/difficulty with gait. BP was elevated to 210/110 at [**Company 191**], equal in both arms. Sent to ED for evaluation. In the ED vitals were 99.3, 66, 192/103, 16, 98%2L. Given aspirin 325 mg daily, nitro 0.4 mg SL with no relief. Received one percocet for pain. Head CT negative. Neuro consult did not find any deficits but inadequate exam because he was uncooperative and therefore an MRI was recommended which was negative. EKG without ischemic changes. CTA chest without PE or aortic dissection. Started on nitro gtt for goal SBP 180 and he was admitted to the ICU for titration of BP. Currently the patient is minimially communicative but endorses chest pain, HA, vision blurriness, and ataxia as above. Also states that he is anxious and hasn't gotten his clonopin for the day. Also endorsed nausea, emesis, abdominal discomfort, and SOB, but unable to elaborate on any of these symptoms. After this examiner left the room, he voiced a stream of thoughts to the nurse that included stating he has not had a solid meal since his girlfriend died a couple of months ago and that he has been taking his meds intermittently and the reason he showed up at clinic today was to get meds refilled as he had run out Past Medical History: - Multiple admission for malignant HTN after drug abuse and not taking medications. Normal P-MIBI [**6-28**], normal EF on echo [**3-29**]. MRI of Kidneys were negative for RAS. TSH was normal. No stigmata of Cushings Disease and random AM cortisol normal. - PE: s/p IVC filter, recent admit for PE [**11/2107**], on lovenox SC x 4 weeks. - Heroin abuse: methadone maintenance clinic Habit Management; per pt, quit 20 yrs ago - Hepatitis B previous infection, now sAg negative - Hepatitis C, undetectable HCV RNA [**3-29**] - COPD - Gastroesophageal reflux disease - PTSD - Anxiety / Depression - Antisocial personality disorder - Microcytic Anemia baseline 27 - Vit B12 deficiency Social History: Past heroin abuse, now on methadone. No recent illicits. Denies current smoking (but found to have sig history in past). Denies alcohol. Military history ([**Country **] veteran), Homeless, living with a friend. Girlfriend of many years died 2 weeks ago while having CABG (per his report, due to undisclosed clonidine abuse). Former chemical salesman, currently on disability. Family History: Father died of MI, mother of pancreatic CA. Physical Exam: HR: 64 (64 - 64) bpm BP: 187/109(127) {187/109(127) - 187/109(127)} mmHg RR: 7 (7 - 7) insp/min SpO2: 97% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 94.1 kg (admission): 94.1 kg Height: 67 Inch General Appearance: Well nourished, No acute distress, Anxious Eyes / Conjunctiva: PERRL, no scleral icterus Head, Ears, Nose, Throat: Normocephalic Cardiovascular: RRR. no M/R/G. nl S1,S2 Respiratory / Chest: CTA Bilaterally Abdominal: Soft, Bowel sounds present, Tender: in all 4 guadrants, nonspecific, no rebound or guarding, no HSM Extremities: 2+ DP pulses. no edema Skin: Warm no rash Neurologic: A/O x 3. no SI/HI Pertinent Results: [**2108-5-15**] MRI/MRA BRAIN: FINDINGS: BRAIN MRI: There is no evidence of acute infarct seen. There is mild periventricular hyperintensities due to minimal changes of small vessel disease. There is no midline shift or hydrocephalus. IMPRESSION: No evidence of acute infarct. MRA OF THE HEAD: The head MRA demonstrates normal flow signal within the arteries of anterior and posterior circulation. The distal left vertebral artery ends in posterior inferior cerebellar artery, a normal variation. There is no vascular occlusion or stenosis seen. There is no evidence of an aneurysm greater than 3 mm in size. IMPRESSION: Normal MRA of the head. [**2108-5-15**] CTA CHEST: IMPRESSION: No evidence of pulmonary embolism or thoracic aortic dissection. [**2108-5-15**] CT HEAD: IMPRESSION: No evidence of acute intracranial hemorrhage. [**2108-5-15**] CXR: IMPRESSION: No acute cardiopulmonary disease. Brief Hospital Course: The patient is a 60 y.o.m. with HTN and multiple admissions for malignant hypertension, anxiety, depression, PTSD, COPD who presents with hypertensive emergency with signs of end organ damage. # Malignant Hypertension ?????? Etiology mednoncompliance. Workup in the past has been negative to identify causes other than essential hypertension. No evidence of intracerebral hemorrhage or infarcts. [**Month (only) 116**] have hypertensive encephalopathy which is characterized by HA, nausea, and vomiting, but the brain MRI did not show any evidence of edema. Other neurologic symptoms such as vision blurriness and ataxia, as well as cardiac symtpoms of chest pain and [**Last Name (un) **] are likely the result of hypertension and end organ damage. He was started on nitro gtt with goal SBP<160. He was then switched to metoprolol, amlodipine, and clondine PO. He has a history of non-compliance, and clondine can cause rebound hypertension. His BP was well controlled on discharge. Patient instructed in importance of taking his meds faithfully. # Chest pain - Patient with risk factors including hypertension and h/o tobacco in the past as well as family history. No hypercholesteremia or diabetes. EKG and story not c/w ACS. CTA without PE or aortic dissection. Reproducible on exam. Likely due to costrochondritis as well as hypertensive emergency. 3 sets of cardiac enzymes were negative. Patient was continued on aspirin and b-blocker. # [**Last Name (un) **] - Cr mildly elevated at 1.3, likely due to malignant hypertension. Was elevated to 1.6 during last admission with similar presentation. # COPD - Currently stable. - Continue tiatroprium and fluticasone # H/O PE - Treated with lovenox. IVC filter in place. No evidence of recurrent PE. # Psych - Ah/o depression, anxiety, PTSD, personality disorder. Also homeless. Psych consult recommended current psych meds, no evidence of active suicidal ideation. # Substance Abuse - Tox screen negative. - Continue methadone at outpatient dose (per last discharge in [**Month (only) **], dose confirmed) Medications on Admission: Methadone 135 mg daily (rx by methadone clinic) Clonazepam 1mg TID prn Duloxetine 60 mg daily Aspirin 325mg daily Tiatroprium daily Pantoprazole daily Fluticasone 2 puffs [**Hospital1 **] Seroquel 150 mg QHS Amlodipine 10 mg daily Metoprolol 25 mg [**Hospital1 **] Clonidine 0.6 patch Qtues Discharge Medications: 1. Methadone 10 mg/mL Concentrate Sig: One [**Age over 90 10973**]y Five (135) mg PO DAILY (Daily). 2. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 7. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day) as needed for constipation. 8. Quetiapine 50 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). Disp:*90 Tablet(s)* Refills:*2* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 10. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 11. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Clonazepam 2 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hypertensive Emergency Chest Pain Discharge Condition: Vital Signs Stable Discharge Instructions: Return to ED if having vision changes, severe headache, prolonged nausea and vomiting. Followup Instructions: Patient to f/u with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5717**].

[ "V15.81", "300.4", "304.01", "309.81", "301.7", "733.6", "593.9", "403.00", "496", "585.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8658, 8664

4801, 6875

313, 319

8741, 8761

3869, 4149

8896, 8986

3164, 3209

7216, 8635

8685, 8720

6901, 7193

8785, 8873

3224, 3850

251, 275

347, 2047

4650, 4778

4167, 4641

2069, 2753

2769, 3148

1,474

140,051

54016+59566

Discharge summary

report+addendum

Admission Date: [**2106-9-10**] Discharge Date: [**2106-9-24**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 85 -year-old Russian female with a history of critical aortic stenosis, paroxysmal atrial fibrillation, coronary artery disease, status post coronary artery bypass graft, who presents with increasing shortness of breath and chest pain over the past four days prior to admission. The patient was recently admitted for chest pain on [**2106-8-19**]. She had negative CKs, but her troponin was 7.5. During her stay the positive troponin was not acted on and the discharge summary does not comment on it. An echocardiogram was done which revealed the aortic valve area of 0.6 cm2 with an ejection fraction of 55%. The patient was sent home at this time. The patient was seen in clinic on [**2106-9-6**] with a complaint of increasing shortness of breath. The patient initially attributed this to an asthma flare. At this time physical examination revealed clear lungs and no further work up was done. The patient reports progressive shortness of breath and an inability to sleep or lie down. She also reports left sided substernal chest pain without radiation to the neck for four days. Her chest pain was rated a 10 out of 10 on the day prior to admission. She denies any nausea or vomiting, but does note some diaphoresis. The pain is constant. The patient reports that she has had this chest pain before. It is nonexertional pain. She has been using inhalers often without improvement. She denies any fever or chills, but does note a productive cough for four days. The patient also reports a longstanding left sided upper quadrant pain and mentions that she has a history of constipation. In the Emergency Room, the patient was noted to have a blood pressure of 191/75, a pulse of 64, and oxygen saturation of 100% on nonrebreather face mask. She had a jugular venous pressure of 8.0 mm of water and bibasilar crackles. She had a chest x-ray suggestive of congestive heart failure and was started on IV nitroglycerin. The patient became hypotensive to the 80s systolic. She was given small fluid boluses which raised her pressure to 110 systolic. The patient refused BiPAP. The patient continues to have blood pressure swing in the 80s-100s with nitroglycerin titrated on and off. Her respiratory status improved to 93% on four liters and her examination improved slightly. The patient was then admitted to the Medical [**Hospital1 **] for further management. PAST MEDICAL HISTORY: 1. Critical aortic stenosis. On [**2106-8-18**], a transthoracic echocardiogram revealed an ejection fraction of greater than 65%, a peak A-V gradient of 51, a mean A-V gradient of 30, and aortic valve area of 0.6 cm2, left atrial enlargement, mild right atrial enlargement, severe aortic stenosis, 1+ aortic regurgitation, [**12-22**]+ mitral regurgitation, and 1+ tricuspid regurgitation. 2. [**11/2104**] cardiac catheterization, the patient was noted to have an aortic valve area of 1.1 cm2, a gradient of 16, and an ejection fraction of 55%. She was noted to have diffuse mid and distal right coronary artery disease, a left main occlusion of 70%, proximal left anterior descending of 70%, a first diagonal of 70%, and a proximal circumflex of 80%. At this time her left internal mammary artery graft was noted to be normal. 3. Right cerebrovascular accident. 4. Asthma. 5. A DDD pacemaker placed for tachy-brady syndrome. 6. Breast cancer, status post left mastectomy. 7. Atrial fibrillation. 8. Gastroesophageal reflux disease / gastritis. She had negative esophagogastroduodenoscopy in [**7-21**]. 9. Hypercholesterolemia. 10. Increased liver function tests with negative hepatitis B and negative hepatitis C serologies. An ultrasound in [**2106-8-21**] which was normal. ALLERGIES: Include epinephrine, penicillin, and Bactrim. SOCIAL HISTORY: The patient denies any tobacco or alcohol use. Her main health care proxy is her son, [**Name (NI) **] [**Name (NI) **], who lives in [**Name (NI) 5864**]. His phone number is [**Telephone/Fax (1) 110735**]. The patient lives in a nursing home in [**Location (un) 583**]. ADMITTING MEDICATIONS: Aspirin 325 mg po q day, Flovent inhaler two puffs [**Hospital1 **], Imdur 60 mg q day, Protonix 40 mg q day, Senna prn, Warfarin 2.0 mg Monday and Friday, 3.0 mg Tuesday, Wednesday, Thursday, Saturday, and Sunday, latanoprost eye drops, Lasix 20 mg po q day, Atrovent two puffs [**Hospital1 **], Lopressor 50 mg po bid, Synthroid 50 mcg po q day, Neurontin 200 mg po bid, Xalatan eye drops 0.005% q day, .................... 50 mg [**Hospital1 **], Trusopt eye drops [**Hospital1 **], home oxygen, Lactulose prn. PHYSICAL EXAMINATION: Vital signs: blood pressure 117/45, heart rate of 63, respirations 24, O2 saturation 93% on four liters. In general, awake, alert, very uncomfortable. Head, eyes, ears, nose, and throat: extraocular movements are intact, pupils are equal, round, and reactive to light and accommodation, her mucous membranes were moist. Her oropharynx was benign. Neck examination: no lymphadenopathy, jugular venous pressure of 7.0 cm of water. Cardiovascular examination: a II/VI systolic ejection murmur over the right upper sternal border, a II/VI coarse systolic murmur at the apex. The patient has an S1, S2, and S3 noted. She has a prominent PMI. Pulmonary: decreased breath sounds bilaterally at the bases with rales to [**1-23**] bilaterally, diffuse wheezes at the right apex. Her abdomen is protuberant, but soft, diffusely tender, and nondistended. No guarding, no rebound, bowel sounds were present. Extremities: no edema, no cyanosis, 1+ dorsalis pedis and tibialis posterior pulses bilaterally. Breast examination: no masses felt, a previous scar site. No axillary lymphadenopathy. LABORATORY DATA: The patient had an electrocardiogram which was asensed, V-paced at a rate of 64. The patient had a PT of 12.8. Chem 7: sodium of 129, potassium of 4.9, a chloride of 94, bicarbonate of 26, BUN of 15, creatinine of 0.9, glucose of 192. An INR of 5.0, a PTT of 33.7. Urinalysis: negative nitrates, protein of 30, no red blood cells, no white blood cells, no bacteria, less than 1.0 epithelial cell. She had a hematocrit of 38, white blood cell count of 12.8, platelets of 394,000. CKs were 85 and 65, troponin I was less than 0.3. She had a chest x-ray which revealed bilateral pleural effusion, positive cardiomegaly, encephalization consistent with congestive heart failure. HOSPITAL COURSE: The patient was initially admitted to a regular hospital bed for management of her congestive heart failure. She experienced 10 out of 10 substernal chest pain on several occasions, that did not result in an elevation of cardiac enzymes. She was initially treated with nitroglycerin which caused her to become hypotensive. She then required fluid boluses which worsened her heart failure. The patient was subsequently transferred to the Coronary Care Unit for worsening respiratory distress and management of her chest pain. From a pulmonary standpoint, the patient improved dramatically with careful diuresis. Given her presumed preload dependence, our goal was a fluid balance of a negative [**12-22**] liter which was achieved on a 40-80 mg of IV Lasix regimen. By the end of her Coronary Care Unit stay, she was requiring only two liters of oxygen via nasal cannula with saturations of 96%. We aim to maximize her cardiac regimen and titrate up her Lopressor, reaching a goal dose of 37.5 mg tid. The patient continued to have episodes of substernal chest pain on a daily basis. She was ruled out for myocardial infarction several times. Eventually, we managed her chest pain successfully with a regimen of morphine and Lasix. We assumed initially that the aortic stenosis was the cause of the patient's pain given her valve area of 0.6 cm2 noted on transthoracic echocardiogram one month prior. During her stay the patient had an episode of atrial fibrillation. Also notable during her stay, the patient had an episode of atrial fibrillation with rapid ventricular response. We opted to treat her with procainamide in lieu of amiodarone, given her idiopathic transaminase elevations. The patient remained in sinus rhythm thereafter and tolerated the medications. We consulted Cardiac Surgery who did not deem the patient to be a suitable candidate for valve repair given her poor nutritional status and advanced age. The patient's son was extensively involved in these discussions as was the patient's cardiologist, Dr. [**Last Name (STitle) 120**]. It was ultimately decided that a cardiac catheterization was possible valvuloplasty would be the most prudent course of action. The cardiac catheterization was initially postponed after the patient became febrile and was found to have coagulase negative Staphylococcus aureus, line sepsis. The line was pulled and the patient was treated with a five day course of vancomycin per the recommendations of the Infectious Disease service. Three subsequent surveillance cultures were drawn, all of which were negative for greater than 72 hours. The patient was taken to the Catheterization Lab on [**9-22**]. She was found to have only mild to moderate aortic stenosis with a valve area of 0.9 cm2 and a gradient of 27.76 with preserved cardiac output. She was also found to have significant coronary artery disease. Her left internal mammary artery to left anterior descending graft was noted to supply only a tiny atretic thread of mid and distal left anterior descending. She also had 80% distal left main lesion involving the origin of the left circumflex. These lesions were determined to be inoperable. Our focus then became symptomatic treatment. We started the patient on low dose Isordil which she tolerated well. We plan to control her pain with oral agents once she leaves the hospital. Another issue that arose during her stay is her poor nutritional status. We encouraged the patient to eat and supplemented her meals with nutrition shakes. She may ultimately require a gastric tube if this continues once she has passed the acute phase of her illness. The consensus amongst our team and the patient's son is that the patient be transferred to an acute care facility for further management. To this end, we have involved the Physical Therapy service who agree with this assessment. DISCHARGE MEDICATIONS: 1) Procan SR 500 mg po qid, 2) Albuterol metered dose inhaler two puffs q six hours, 3) Atrovent two puffs q six hours, 4) Flovent two puffs [**Hospital1 **], 5) Neurontin 200 mg po bid, 6) Synthroid 50 mcg po q day, 7) aspirin 325 mg po q day, 8) Protonix 40 mg po q day, 9) Metoprolol 37.5 mg po tid, 10) Trusopt eye drops one drop both eyes [**Hospital1 **], 11) latanoprost, 12) Xalatan eye drops one drop both eyes q HS, 13) Alphagan one drop both eyes [**Hospital1 **], 14) Colace 100 mg po tid, 15) Tylenol 650 mg po q four to six hours prn, 16) Lactulose 30 mg to 60 mg po q eight hours and q HS prn, 17) Fleets enema one per rectum prn, 18) Coumadin 5.0 mg po q day, 19) Lasix 40 mg po bid. DISCHARGE DIAGNOSES: 1. Severe coronary artery disease which is inoperable. 2. Moderate aortic stenosis. 3. Hypertension. 4. Atrial fibrillation. FOLLOW UP: The patient should be followed by her primary cardiologist, Dr. [**Last Name (STitle) 120**]. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**] Dictated By:[**Last Name (NamePattern1) 11732**] MEDQUIST36 D: [**2106-9-23**] 14:56 T: [**2106-9-23**] 15:12 JOB#: [**Job Number **] Name: [**Known lastname 18116**], [**Known firstname 18117**] Unit No: [**Numeric Identifier 18118**] Admission Date: [**2106-9-10**] Discharge Date: Date of Birth: [**2021-4-20**] Sex: F Service: ADDENDUM: HOSPITAL COURSE: The patient was noted to have erythema and warmth as well as tenderness over her right heel. She was started on Keflex 500 mg po qid for seven days for treatment of cellulitis. We do not think this has any relation to the catheter site over the right femoral as the patient has excellent pulses throughout and no evidence of any bruit or any vascular compromise to the foot. We will treat her with a ten day course of antibiotics. Also, the patient was noted to have hematocrit of 25.7. Throughout her hospital stay, the patient's hematocrit had fluctuated. She has been noted to be guaiac positive on several occasions, but she has not had any episodes of gross melena or bright red blood per rectum. Anemia work up revealed iron deficiency anemia. We recommend an outpatient colonoscopy once the patient's acute issues have resolved. DISCHARGE MEDICATIONS: Please add to list of medications, Isordil 10 mg po tid. DISCHARGE CONDITION: Stable and chest pain free on the current cardiac regimen. FOLLOW-UP: She should follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2124**] within one week of discharge as well as with Dr. [**Last Name (STitle) **], her primary care provider. [**First Name11 (Name Pattern1) 919**] [**Last Name (NamePattern4) 14808**], M.D. [**MD Number(1) 14809**] Dictated By:[**Last Name (NamePattern1) 1674**] MEDQUIST36 D: [**2106-9-25**] 08:13 T: [**2106-9-27**] 08:55 JOB#: [**Job Number 18136**]

[ "427.31", "424.1", "414.02", "428.0", "578.9", "996.62", "280.0", "V45.81", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12936, 13494

11190, 11320

12856, 12914

11988, 12832

11332, 11970

4754, 6547

118, 2523

2545, 3899

3916, 4731

852

162,589

45513

Discharge summary

report

Admission Date: [**2160-11-2**] Discharge Date: [**2160-11-7**] Date of Birth: [**2108-5-5**] Sex: M Service: MEDICINE Allergies: Phenergan Attending:[**First Name3 (LF) 425**] Chief Complaint: Sustained VT and unresponsiveness Major Surgical or Invasive Procedure: Intracardiac Defibrillator placement History of Present Illness: 52M with history hypertension, narcotics dependence and gastric bypass presented to [**Hospital1 **] [**Location (un) 620**] with several days of nausea, vomiting, and diarrhea. There he was given zofran for nausea after which became unresponsive, noted to be in polymorphic ventricular tachycardia. He was shocked and loaded on amiodarone and then started on amiodarone drip 1mg/min and trasnferred to [**Hospital1 18**]. On arrival he was alert, oriented. Then had episode of VT and became unresponsive shocked with 200J, got another 150 amio gtt and then was changed to lidocaine drip 3mg/min, repleted K 40IV and 40 PO. Still having occasional 8-10 beat runs of VT in the ED. Patient is also complaining of [**7-12**] intermittent chest pain he describes as "irritating" localized to the area around the pacer pads. He received morphine, toradol and rectal aspirin in the ED. He has no recollection of the events surrounding his episodes. He denies any recent or remote episodes of chest pain but does endorse some dyspnea on exertion while climbing stairs. He does have a history of narcotic dependence and was recently on dilaudid 16mg q4h for pain following a complicated right knee replacement. He reports that he has since weaned himself down to 3-4mg PO q4h. He also reports that he recently stopped taking his enoxaprin for DVT ppx 3 days ago. . In the ED, initial vitals were 98.6 62 144/94 18min 100%4L Past Medical History: 1. Asthma 2. Bronchitis 2. HTN 3. Morbid obesity 4. Gout 5. Obstructive Sleep Apnea 6. Bronchitis Social History: Quit tobacco [**2154**], 30 pack-year history Social EtOH Dependence on prescribed narcotics Family History: Non-contributory Physical Exam: Admission physical exam: GENERAL: WDWN [**Male First Name (un) 4746**] in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. NECK: Supple CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: Pacer pads in place. 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. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: radial 2+ DP 2+ Left: radial 2+ DP 2+ Pertinent Results: Cardiac labs: [**2160-11-3**] 12:43AM BLOOD CK(CPK)-49 [**2160-11-3**] 07:07AM BLOOD CK(CPK)-51 [**2160-11-3**] 01:32PM BLOOD ALT-12 AST-20 AlkPhos-109 TotBili-0.4 [**2160-11-4**] 04:29AM BLOOD CK(CPK)-68 [**2160-11-5**] 05:53AM BLOOD CK(CPK)-33* [**2160-11-2**] 07:31PM BLOOD cTropnT-<0.01 [**2160-11-2**] 08:39PM BLOOD cTropnT-<0.01 [**2160-11-3**] 12:43AM BLOOD CK-MB-2 cTropnT-<0.01 [**2160-11-3**] 07:07AM BLOOD CK-MB-2 cTropnT-<0.01 [**2160-11-4**] 04:29AM BLOOD CK-MB-3 cTropnT-<0.01 [**2160-11-5**] 05:53AM BLOOD CK-MB-3 cTropnT-<0.01 Cardiac cath: 1. Selective coronary angiography of this co-dominants system demonstrated single vessel coronary artery disease. The LMCA was large in caliber, with minimal luminal irregularities. The LAD was mildly calcified, with diffuse mild luminal irregularities. A large diagonal branch with luminal irregularities was noted. The distal LAD wraps slighter aorund the apex, with slow flow consistent with microvascular dysfunction. The LCx was large in caliber, with dlow flow consistent with microvascular dysfunction. It supplies a large OM2, LPL, and modest LPDA. A large caliber, patent ramus was noted. The RCA supplyinga modest caliber RPDA and several RV branches was demonstrated. Proximal to mid difuse diease with serial 75% stenoses with TIMI 2 slow flow (similar to LAD and LCx) demonstrated. 2. Limited resting hemodynamics revealed normal left ventricular filling pressures, with an LVEDP of 12 mmHg. There was mild systemic hypertension, with a central aortic pressure of 140/93 mmHg (mean of 113 mmHg.) 3. Limited femoral angiography demonstrated mild profunda plaquing iwht arteriotomy stie at the SFA/PF bifurcation. Closure device not attempted. FINAL DIAGNOSIS: 1. Single vessel coronary artery diease, but diffuse slow flow consistent iwth diffuse microvascular dysfunction. 2. In the absence of symptoms and sentiment that VT was not ischemia induced, no intervention performed at this time, with plan for further evaluation of ischemia. 3. Normal LV diastolic function. 4. Mild systemic hypertension. . Echo: The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is mild to moderate global left ventricular hypokinesis more prominent inferior wall severe hypokinesis (LVEF = 40 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild left ventricular cavity enlargement with global hypokinesis c/w diffuse process (toxin, metabolic, cannot exclude multivessel CAD). Dilated thoracic aorta. Mild mitral regurgitation. Compared with the report of the prior study (images unavailable for review) of [**2156-4-22**], the findings are new. . Nuclear stress test: No ischemic ECG changes noted and no anginal type symptoms reported with Persantine infusion. Appropriate hemodynamic response. Nuclear report below: 1. Probably normal myocardial perfusion. Inferior wall defect most consistent with attenuation. 2. Increased left ventricular cavity size. Moderate systolic dysfunction with global hypokinesis. Brief Hospital Course: 52 year old man with a history of gastric bypass, narcotics dependence, and recent knee replacement who became unresponsive in outside hospital's Emergency Department secondary to polymorphic ventricular tachycardia following administration of zofran for nausea and vomiting. . # VENTRICULAR TACHYCARDIA: Possible etiologies considered were ischemia, electrolyte abnormalities, medication effects, hypoxia, and metabolic causes. An Echo revealed global hypokinesis. Although catheterization revealed a narrowing of the RCA, nuclear stress test did not show any reversible or nonreversible defects to suggest ischemia or infarction. The [**Hospital 228**] medical records, recent and remote past EKGs, and clinical presentation were reviewed, and it was concluded that the patient's hypokalemia, hypomagnesemia in the setting of two QT-prolonging medications contributed to development of VT. All QT-prolonging medications were held, and his electrolytes were repleted. Given the risk that the patient's ventricular tachycardia might return, an ICD was placed. The patient tolerated the procedure well. At the time of discharge, the patient still required two days of antibiotics to complete his course. . # ACUTE SYSTOLIC DYSFUNCTION According to Echo, the patient's EF was 38% with global hypokinesis. The patient showed no evidence of fluid overload and seemed euvolemic upon discharge. The patient was started on 5 mg lisinopril. . # CORONARY ARTERY DISEASE The patient's catheterization showed 80% RCA lesion, and the stress test showed inferior small reversible defect attributed to attenuation. No plans for intervention. The patient will continue on a beta-blocker and aspirin and be started on a statin. . # NARCOTICS DEPENDENCE/CHRONIC PAIN: The patient has a history of significant narcotics dependence. He required 2mg IV dilaudid every 2 hours to prevent withdrawal symptoms. He expressed a desire to wean from narcotics and it is likely that an attempt at self-weaning prompted his initial complaints of nausea and vomiting. Psychiatry was consulted, and they recommmended continuing current doses of Ativan and Dilaudid. The patient would also benefit from inpatient detoxification, and the patient agreed. Unfortunately, the patient did not have insurance to cover such treatment. Instead, he was provided enough medication to last until he could follow up with his primary care physician, [**Name10 (NameIs) 1023**] intends to perform a slow taper. Medications on Admission: Albuterol nebulizers prn TID Metoprolol 25 mg [**Hospital1 **] Dilaudid 16mg PO q4 --> 3-4mg po q4, 2 mg 1-2 tabs q 4 hours prn Neurontin 400mg one PO TID x 14 days Lunesta 3mg one tab at hs Tums prn Phenergan 25 mg PR q 4 hours x 10 doses only ([**11-2**]) Ventolin 2 puffs QID Flovent HSA 110 one puff [**Hospital1 **] Xanaflex 6mg q 8 hours as needed for spasm Tussionex [**1-5**] tsp q 12 hours (normally one tsp) for cough Augmentin x 10 days 400 mg on [**10-31**] ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) Xoma 350 one tab TID as needed for spasm (should be finished) Celexa 40 mg once daily Lorazepam 1 mg 2 tabs TID Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily). 4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation three times a day as needed for shortness of breath or wheezing. 8. cephalexin 500 mg Tablet Sig: One (1) Tablet PO three times a day for 2 days. Disp:*6 Tablet(s)* Refills:*0* 9. hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 10. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for anxiety. 11. Flovent HFA 110 mcg/Actuation Aerosol Sig: One (1) puff Inhalation twice a day. 12. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day. 13. Celexa 10 mg Tablet Sig: Three (3) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Ventricular Tachycardia/Torsades de Pointes related to prolonged QT interval Narcotic Dependence Acute Systolic Dysfunction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You had nausea and vomiting and developed a dangerous rhythm called ventricular tachycardia or torsades de pointes that required a shock to restore a normal rhythm. We were concerned that this could happen again so we implanted an internal cardiac defibrillator (ICD) that will shock you again if the rhythm reoccurs. Please keep the dressing over the incision site until Sunday [**11-9**], you can then take off the gauze dressing, leave the tape strips in place. You can then shower, don't get soap over the incision site. You will return here in 1 week to get the wound checked. You will need to take an antibiotic for 24 hours after you go home to prevent an infection at the ICD site. Call Dr. [**Last Name (STitle) **] right away if the ICD fires. This feels like a very strong kick in the chest. You should avoid any medicines that make you more prone to ventricular tachycardia, we gave you list of these medicines. Other medication changes are: 1. STOP taking Phenergan, Gabapentin, Xoma, Lunesta, Xanaflex, Augmentin and Tussionex 2. Take cephalexin three times a day for 2 days to prevent an infection at the pacer site 3. Start taking Lisnopril to lower your blood pressure and help your heart pump better 4. Start Simvastatin to lower your cholesterol 5. Take Dilaudid 4mg for pain every 4 hours, decrease to 3mg every 4 hours on Monday with further decreases per Dr. [**Last Name (STitle) **] 6. Increase Lorazepam to 2mg every 6 hours as needed for anxiety with further decreases per Dr. [**Last Name (STitle) **]. . We found that your heart function was also weaker than it was a year ago. We did not see any evidence of fluid overload here but you should monitor yourself for swelling in the legs, trouble breathing and a bothersome cough. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 lbs in 3 days. Followup Instructions: Department: CARDIAC SERVICES When: THURSDAY [**2160-11-13**] at 9:30 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital Ward Name **] SURGERY When: WEDNESDAY [**2160-12-17**] at 2:00 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], RD,LDN [**Telephone/Fax (1) 305**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital Ward Name **] SURGERY When: WEDNESDAY [**2160-12-17**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD [**Telephone/Fax (1) 305**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Doctor First Name **] Address: [**Street Address(2) 12840**],[**Apartment Address(1) 12841**], [**Location (un) **],[**Numeric Identifier 12842**] Phone: [**Telephone/Fax (1) 10813**] Appointment: Thursday [**2160-11-13**] 4:30pm Department: CARDIAC SERVICES When: WEDNESDAY [**2160-12-17**] at 3:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please call registration at [**Telephone/Fax (1) 10676**] to complete your insurance information. Thanks.

[ "429.9", "426.82", "292.0", "414.01", "401.9", "427.1", "338.29", "275.2", "276.8", "305.1", "V43.65", "V45.86", "425.4", "304.01" ]

icd9cm

[ [ [] ] ]

[ "37.94", "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

10817, 10823

6400, 8866

302, 341

10991, 10991

2629, 4357

13083, 14760

2036, 2054

9567, 10794

10844, 10970

8892, 9544

4374, 6377

11174, 13060

2094, 2610

229, 264

369, 1788

11006, 11150

1810, 1909

1925, 2020

48,422

134,537

36629

Discharge summary

report

Admission Date: [**2116-5-27**] Discharge Date: [**2116-6-6**] Date of Birth: [**2075-6-6**] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8587**] Chief Complaint: pain rt thigh for 2 days Major Surgical or Invasive Procedure: [**5-27**]: R thigh fasciotomy for necrotizing fasciitis [**5-28**]: R thigh debridement, R knee washout [**5-30**]: R thigh I&D, R knee washout [**6-1**]: R thigh I&D, partial closure, vac placement [**6-3**]: R thigh I&D, wound closure History of Present Illness: 41 yo female transfered from outside hospital with ? necrotizing fascitis Past Medical History: none Social History: lives with husband Family History: n/a Physical Exam: heent wnl chest clear cor rrr abd sft nt nd rt leg wounds healing neuro non focal Pertinent Results: [**2116-6-6**] 05:50AM BLOOD WBC-15.4* RBC-UNABLE TO Hgb-10.1* Hct-28.5* MCV-UNABLE TO MCH-UNABLE TO MCHC-36.9* RDW-UNABLE TO Plt Ct-1091* [**2116-6-4**] 10:40AM BLOOD WBC-18.4* RBC-3.56* Hgb-11.7* Hct-32.3* MCV-91 MCH-32.8* MCHC-36.0* RDW-14.8 Plt Ct-930* [**2116-6-4**] 08:35AM BLOOD WBC-16.8*# RBC-3.52* Hgb-11.3* Hct-31.7* MCV-90 MCH-32.0 MCHC-35.5* RDW-15.0 Plt Ct-933* [**2116-6-3**] 01:04PM BLOOD WBC-10.0 RBC-3.28*# Hgb-10.7*# Hct-29.4* MCV-90 MCH-32.7* MCHC-36.5* RDW-14.3 Plt Ct-623* [**2116-6-3**] 06:30AM BLOOD Hct-28.1* [**2116-6-2**] 05:41AM BLOOD WBC-10.7 RBC-2.60* Hgb-8.5* Hct-23.8* MCV-91 MCH-32.5* MCHC-35.6* RDW-13.4 Plt Ct-578* [**2116-6-1**] 04:57AM BLOOD WBC-10.9 RBC-2.66* Hgb-8.7* Hct-24.6* MCV-92 MCH-32.7* MCHC-35.5* RDW-13.1 Plt Ct-479*# [**2116-5-31**] 01:34AM BLOOD WBC-12.5* RBC-2.73* Hgb-8.7* Hct-25.5* MCV-93 MCH-32.0 MCHC-34.3 RDW-13.3 Plt Ct-314 [**2116-5-30**] 01:47AM BLOOD WBC-12.0* RBC-2.60* Hgb-8.4* Hct-24.2* MCV-93 MCH-32.4* MCHC-34.8 RDW-13.2 Plt Ct-239 [**2116-5-29**] 02:14PM BLOOD Hct-23.0* [**2116-5-29**] 02:04AM BLOOD WBC-19.1* RBC-2.53* Hgb-8.3* Hct-23.3* MCV-92 MCH-32.7* MCHC-35.5* RDW-13.0 Plt Ct-204 [**2116-5-28**] 10:51AM BLOOD WBC-20.5* RBC-2.99* Hgb-9.8* Hct-27.7* MCV-93 MCH-32.7* MCHC-35.3* RDW-13.1 Plt Ct-232 [**2116-5-28**] 02:08AM BLOOD WBC-26.1* RBC-3.12* Hgb-10.1* Hct-29.0* MCV-93 MCH-32.2* MCHC-34.7 RDW-13.1 Plt Ct-270 [**2116-5-27**] 03:25AM BLOOD WBC-16.0* RBC-3.83* Hgb-12.7 Hct-35.5* MCV-93 MCH-33.0* MCHC-35.7* RDW-12.8 Plt Ct-258 [**2116-6-4**] 10:40AM BLOOD Neuts-77.8* Lymphs-17.5* Monos-1.8* Eos-2.6 Baso-0.2 [**2116-5-30**] 01:47AM BLOOD Neuts-74.7* Lymphs-19.0 Monos-1.5* Eos-4.5* Baso-0.2 [**2116-5-27**] 07:36AM BLOOD Neuts-86* Bands-0 Lymphs-4* Monos-3 Eos-7* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2116-5-27**] 03:25AM BLOOD Neuts-87* Bands-3 Lymphs-2* Monos-6 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2116-5-27**] 07:36AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2116-6-6**] 05:50AM BLOOD Plt Smr-VERY HIGH Plt Ct-1091* [**2116-6-4**] 10:40AM BLOOD PT-12.7 PTT-29.5 INR(PT)-1.1 [**2116-6-4**] 08:35AM BLOOD Plt Ct-933* [**2116-6-2**] 05:41AM BLOOD Plt Ct-578* [**2116-6-1**] 04:57AM BLOOD Plt Ct-479*# [**2116-5-31**] 01:34AM BLOOD Plt Ct-314 [**2116-5-30**] 01:47AM BLOOD Plt Ct-239 [**2116-5-29**] 02:04AM BLOOD Plt Ct-204 [**2116-5-28**] 06:37PM BLOOD Plt Ct-217 [**2116-5-28**] 10:51AM BLOOD Plt Ct-232 [**2116-5-28**] 02:08AM BLOOD Plt Ct-270 [**2116-5-28**] 02:08AM BLOOD PT-14.0* PTT-44.1* INR(PT)-1.2* [**2116-5-27**] 06:29PM BLOOD Plt Ct-260 [**2116-5-27**] 06:29PM BLOOD PT-14.3* PTT-44.5* INR(PT)-1.2* [**2116-5-27**] 07:36AM BLOOD Plt Smr-NORMAL Plt Ct-226 [**2116-5-27**] 07:36AM BLOOD PT-15.4* PTT-38.5* INR(PT)-1.4* [**2116-5-27**] 03:25AM BLOOD PT-14.2* PTT-35.4* INR(PT)-1.2* [**2116-5-30**] 01:47AM BLOOD Glucose-143* UreaN-8 Creat-0.6 Na-140 K-3.6 Cl-103 HCO3-33* AnGap-8 [**2116-5-27**] 03:25AM BLOOD Glucose-110* UreaN-9 Creat-1.0 Na-141 K-3.5 Cl-105 HCO3-25 AnGap-15 [**2116-6-4**] 10:40AM BLOOD ALT-33 AST-28 AlkPhos-125* TotBili-1.3 [**2116-5-28**] 02:08AM BLOOD ALT-87* AST-56* AlkPhos-90 TotBili-1.3 [**2116-5-27**] 06:29PM BLOOD ALT-78* AST-51* LD(LDH)-179 AlkPhos-74 TotBili-1.1 [**2116-6-2**] 05:41AM BLOOD Calcium-7.8* Phos-3.1 Mg-2.1 [**2116-6-1**] 04:09PM BLOOD Calcium-7.6* Phos-3.8 Mg-2.2 [**2116-5-31**] 01:34AM BLOOD Calcium-7.6* Phos-3.2 Mg-2.1 [**2116-5-30**] 01:47AM BLOOD Albumin-2.2* Calcium-7.2* Phos-3.4 Mg-2.0 [**2116-5-29**] 02:04AM BLOOD Calcium-8.3* Phos-4.1 Mg-1.5* [**2116-5-28**] 06:37PM BLOOD Calcium-8.8 Phos-3.2 Mg-1.4* [**2116-5-28**] 10:51AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.1 [**2116-5-28**] 02:08AM BLOOD Albumin-2.3* Calcium-8.6 Phos-3.1 Mg-1.9 [**2116-5-27**] 06:29PM BLOOD Calcium-7.7* Phos-2.4* Mg-2.1 [**2116-5-27**] 02:03PM BLOOD Calcium-8.4 Phos-2.4* Mg-2.6 [**2116-5-27**] 07:36AM BLOOD Albumin-2.4* Calcium-6.8* Phos-2.0* Mg-1.1* Iron-<5* [**2116-5-29**] 02:17AM BLOOD Type-ART Temp-37.0 pO2-185* pCO2-40 pH-7.43 calTCO2-27 Base XS-2 [**2116-5-28**] 06:50PM BLOOD Type-ART pO2-170* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 [**2116-5-28**] 02:56PM BLOOD Type-ART Temp-38.6 pO2-139* pCO2-48* pH-7.30* calTCO2-25 Base XS--2 [**2116-5-27**] 06:45PM BLOOD Type-ART pO2-202* pCO2-41 pH-7.37 calTCO2-25 Base XS--1 [**2116-5-28**] 06:50PM BLOOD Lactate-2.0 [**2116-5-28**] 04:58PM BLOOD Glucose-113* Lactate-2.9* Na-135 K-3.5 Cl-107 [**2116-5-28**] 02:24AM BLOOD Lactate-1.8 [**2116-5-29**] 02:17AM BLOOD freeCa-1.16 [**2116-5-28**] 06:50PM BLOOD freeCa-1.14 [**2116-5-28**] 04:58PM BLOOD freeCa-1.41* [**2116-5-28**] 02:56PM BLOOD freeCa-1.07* [**2116-5-28**] 02:24AM BLOOD freeCa-1.27 [**2116-5-27**] 02:10PM BLOOD freeCa-1.14 Brief Hospital Course: pt was admitted to the ortho service and was taken to the or and underwent a rt thigh fasciotomy . She was also seen by the id srevice and was started on vanco zosyn and doxycyclin. she returned to the or many times for washouts and vac changes. the cx came back for group A beta strep X 4 cx and id switched to pcn and clinda. She started to respond to the abx and was extubated and was then tx to the cc6 floor . She returned to the or and had her wounds closed and was doing well. ID decided to switch to iv vanco til [**6-10**] and also decided to give ivig for 2 doses She was doing well with pt and was felt stable to go home with iv services Medications on Admission: none Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*50 Tablet(s)* Refills:*5* 2. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 26 days: continue for 30 days post-operatively. Disp:*52 1* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*50 Tablet, Delayed Release (E.C.)(s)* Refills:*5* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*150 Tablet(s)* Refills:*0* 6. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) g Intravenous Q 12H (Every 12 Hours) for 4 days: last dose: [**2116-6-10**]. Disp:*8 g* Refills:*0* 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO four times a day for 14 days: please continue aspirin until next orthopaedic outpatient visit or otherwise instructed. Disp:*56 Tablet(s)* Refills:*0* 8. Heparin Flush 10 unit/mL Kit Sig: One (1) Intravenous prn as needed for blood draws for 2 days. Disp:*2 1* Refills:*0* 9. Normal Saline Flush 0.9 % Syringe Sig: One (1) Injection prn as needed for for blood draws for 2 days. Disp:*2 1* Refills:*0* 10. Outpatient Lab Work please draw CBC 1 and 2 days following discharge. lab results to be sent to: FAX [**Telephone/Fax (1) 82886**], Attn: Orthopaedic Trauma Service Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: RIGHT thigh necrotizing fasciitis Discharge Condition: Stable/Good Discharge Instructions: Continue to be weight bearing as tolerated for your right leg Please take all medication as prescribed. If you have any increased redness, drainage, or swelling, or if you have a temperature greater than 101.5, please call the office or come to the emergency department. Followup Instructions: Please follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 82887**], NP in orthopaedics in 2 weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment. Physical Therapy: Activity: RLE Weight Bearing As Tolerated Activity: Activity as tolerated Treatments Frequency: keep incision clean and dry. vancomycin 1g IV q12hrs until [**2116-6-10**] please draw CBC 1 and 2 days following discharge Followup Instructions: Please follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 82887**], NP in orthopaedics in 2 weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment. Completed by:[**2116-6-10**]

[ "041.01", "682.2", "998.32", "038.0", "785.52", "728.86", "995.92", "040.82" ]

icd9cm

[ [ [] ] ]

[ "80.16", "38.93", "83.45", "83.14", "80.36", "83.21", "83.65", "80.15" ]

icd9pcs

[ [ [] ] ]

7885, 7968

5637, 6292

342, 582

8046, 8060

887, 5614

8845, 9073

765, 770

6347, 7862

7989, 8025

6318, 6324

8084, 8358

785, 868

8597, 8672

8695, 8822

278, 304

610, 685

707, 713

729, 749

31,942

163,902

54108

Discharge summary

report

Admission Date: [**2125-11-1**] Discharge Date: [**2125-11-9**] Date of Birth: [**2073-1-25**] Sex: M Service: MEDICINE Allergies: Codeine / Compazine / Penicillins / Metformin / Heparin Agents / Ativan Attending:[**First Name3 (LF) 5119**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: EUS [**2125-11-1**] History of Present Illness: Initial H & P is as per Dr. [**First Name4 (NamePattern1) **] [**Last Name (un) 101568**] . Mr. [**Known lastname 110907**] is a 52 yo M ex-smoker and ex-IVDU with severe COPD and multiple COPD exacerbations, chronic trach (on 3L-4L NC at baseline), right hemidiaphragm dysfunction and tracheal stenosis s/p tracheal stent in [**8-16**] who was transferred to the ICU after becoming hypoxic after an endoscopic U/S. According to the patient he had not been feeling well for the last 2 days prior to presentation with worsening SOB, secretions, and hypoxia to the 70s intermittently. No fever or chills. Upon arrival to the GI suite, his O2 sat on 3L was 87%. He underwent endoscopic U/S for evaluation of a pancreatic cyst, but given that the lesion did not appear worrisome for malignancy, no biopsies were performed. After the procedure he become hypoxic to the 70s, suctioned for thick secretions with improvement to the 80s on 3L, but given concern for respiratory distress was transferred to the [**Hospital Unit Name 153**]. Upon arrival he states that his breathing still feels labored. He has chronic back pain which is at 4/10. . Of note, he has had recent admissions [**Date range (1) 12474**] and [**Date range (1) 110908**] for respiratory failure, requiring ICU stay and brief mechanical ventilation. He was treated at that time with high dose steroids and supportive pulmonary care without antibiotics with gradual improvement in his respiratory status and he was discharged back to his nursing home. Past Medical History: 1) Severe O2-dependent COPD 2) Tracheal stenosis s/p stent, stent removal, dilatation, and tracheostomy insertion [**Month (only) 205**]-[**2124-8-9**] (Interventional pulmonology notes report an "A"-shaped stenosis with tracheomalacia at the level of the 1st and 2nd tracheal rings. The stenosis was dilated with a rigid bronchoscope) 3) Diabetes mellitus type 2. 4) Osteoporosis. 5) Hepatitis B. 6) Chronic lower back pain, associated with mid-thoracic vertebral compression fractures from osteoporosis(details unknown). 7) Left 3rd finger amputation. 8) History of intravenous drug use. 9) multi-drug resistant pseudomonas infection, + MRSA sputum/ nasal swab 10) PUD hx of ulcers (gastric/duodenal) 11) chronic right hemidiaphragm elevation - phrenic n. dysfunction Social History: Lives at [**Location **] [**Location **] rehab, extensive smoking history but denies current smoking. Drank heavily in past, last drink long time ago. h/o IVDU but has been clean for past 7 years, does not need methadone maintenance. Family History: NC Physical Exam: Tmax: 37.2 ??????C (98.9 ??????F) Tcurrent: 36.8 ??????C (98.3 ??????F) HR: 88 (80 - 115) bpm BP: 104/73(80) {90/33(55) - 115/82(93)} mmHg RR: 18 (15 - 33) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Height: 67 Inch GEN: NAD HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs - poor air mov't b/l, symmetric wheezes, no crackles. Lung sounds in all lung fields ABD: Firm secondary to abdominal breathing, no distension, no masses palpated, +BS EXT: RLE erythema, slight swelling and warmth, LLE wnl. 2+ dp b/l NEURO: alert, oriented to person, place, and time. Moves all 4 extremities. 3rd digit complete amputation on L hand. SKIN: No jaundice, cyanosis. No ecchymoses. Pertinent Results: [**2125-11-2**] 04:38AM BLOOD WBC-11.0 RBC-4.24* Hgb-11.0* Hct-33.7* MCV-80* MCH-26.0* MCHC-32.7 RDW-13.3 Plt Ct-302 [**2125-11-1**] 01:54PM BLOOD Neuts-73.5* Lymphs-11.3* Monos-9.7 Eos-5.0* Baso-0.5 [**2125-11-1**] 01:54PM BLOOD PT-12.5 PTT-30.6 INR(PT)-1.1 [**2125-11-2**] 04:38AM BLOOD Glucose-131* UreaN-9 Creat-0.6 Na-140 K-4.2 Cl-95* HCO3-40* AnGap-9 [**2125-11-2**] 04:38AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.0 [**2125-11-1**] 02:51PM BLOOD Type-ART pO2-99 pCO2-86* pH-7.30* calTCO2-44* Base XS-12 CXR [**11-1**] IMPRESSION: Lung volumes remain low, with bibasilar atelectasis. Otherwise, no evidence of acute intrathoracic process to account for the new symptoms. EUS: Impression: A 1.9 cm cyst / dilated side branch was noted in the head of the pancreas. Two septations were noted within the cyst. This communicated with the main pancreatic duct. The lesion mostly likely represents a side branch IPMN.The main pancreatic duct and pancreas parenchyma was otherwise normal. Recommendations: Given severe co-morbidities and absence of "alarm features" FNA was not performed. Consider a MRCP in 4 months to follow this lesion. Follow-up with refering physicians as already scheduled. Brief Hospital Course: A/P: Mr. [**Known lastname 110907**] is a 52 yo M w/ severe COPD requiring multiple ICU admissions for mechanical ventilation, tracheal stenosis s/p tracheal stent in [**8-16**] presenting w/ hypoxia after endoscopic U/S performed to eval pancreatic mass. . 1. Hypercarbic respiratory failure/Severe 02 dependent COPD: Upon arrival to the unit the patients symptoms were consistent with prior COPD excerbations. The patient desats to high 70s, and ABG showing hypercarbia to 86 (baseline 70s). Pt was placed in a vent and susequently weaned to PS overnight. The patient lacked an signs of infection on CXR, no leukocytosis and afebrile. The patient was not started on antibiotics. The patient was started on 125mg IV SaluMedrol q8 and albuterol/atrovent nebs Q4/Q2prn. The patient was switched to trach collar in the AM and was tolerating. During the patient's ICU course he was subsequently changed to PO Prednisone with plans for a slow taper. Sputum cultures revealed MRSA, and without evidence for PNA on CXR, the pt was started on Vanc for trachobronchitis. A PICC line was placed and the patient will complete an 8 day course. Azythromycin was also added for potential atypical coverage. The pt was continued on nebs upon arrival to the floor. The patient was continued on advair. THe patient says that his Spiriva was stopped as an outpatient because it caused "urinary leakage." oxygenation requirements improved. . 2. Pancreatic mass: The patient underwent EUS and findings were consistent with IPMN without red flags for invasive disease. Patient should have follow-up with MRCP in 4 months. . 3. Chronic Abdominal/Back Pain: Pt with chronic back pain compliants. He has a history of polysubstance abuse and was high tolerance for pain medication. The patient was started on dilaudid 3mg iv q4h prn in the ICU. This was gradually weaned off. He was continued on his usual prn oxycodone dose of 10-20mg po q4h prn breakthrough pain. He will be discharged back to his long term care facility on his baseline regimen. . 4. Hepatitis B: No active treatment at this time. Outpt management . 5. Diabetes mellitus type 2: FSBS were under relatively good control during hospitalization. FSBS were monitored qac and qhs. He was covered with a RISS. . 5. FEN: Diabetic diet, replete lytes as needed . 6. PPx: On PPI for GERD, pneumoboots. No heparin products give ?allergy. No documented hx of HIT in OMR. Bowel regimen . 7. Code: Full, confirmed with patient and ICU consent signed . 8. Dispo D/c back to [**Doctor First Name 3504**] [**Doctor First Name **] in stable condition. . Contact: [**Name (NI) **] [**Name (NI) 110909**] (mother) [**Telephone/Fax (1) 110910**] Medications on Admission: Albuterol Sulfate nebs Alendronate 70 mg weekly Citalopram 20 mg daily Clarithromycin ? Fluticasone-Salmeterol 2 puff inhaled [**Hospital1 **] Furosemide 20 mg po bid Hydromorphone 2 mg q6hr prn Lispro sliding scale Ipratropium Bromide nebs q4hr Lactulose 30ml [**Hospital1 **] Omeprazole 20mg [**Hospital1 **] Oxycodone 5-10 mg q4hr prn Oxygen - 3L-4L NC Prednisone 10 mg po daily Tiotropium Bromide daily Acetaminophen 650 mg q4hr Bisacodyl 10 mg Suppository prn Calcium + Vit D Cholecalciferol (Vitamin D3) Docusate Sodium 100 mg [**Hospital1 **] Senna Magnesium Hydroxide [Milk of Magnesia] prn Discharge Medications: 1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 3 days: Continue through [**2125-11-12**]. 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO q6h prn as needed for pain. 7. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED): For FSBS 150-200 give 2 units, 201-250 4 units, 251-300 6 units, 301-350 8 units, 350-400 10 units, >400 [**Name8 (MD) 138**] MD. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q4H (every 4 hours). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff Inhalation q4h prn as needed for wheezing, SOB. 10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 11. Oxycodone 5 mg Tablet Sig: 2-4 Tablets PO Q4H (every 4 hours) as needed for pain. 12. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every [**4-15**] hours as needed for pain or fever. 14. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation once a day. 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 18. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. 19. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO daily prn as needed for constipation. 20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 21. Calcium 500 mg Tablet Sig: One (1) Tablet PO three times a day. 22. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO twice a day. 23. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 24. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day: Taper by 10mg every 3 days until you reach baseline dose of 10mg po daily. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: COPD exacerbation MRSA tracheobronchitis Discharge Condition: Good Discharge Instructions: -Transfer back to long term care facility. -Continue vancomycin for 8 day total course. -Continue all medications as prescribed. -Follow up with Dr. [**Last Name (STitle) 4507**] as scheduled -Return to ED if you have worsening shortness of breath, chest pain, or other worrisome signs/symptoms. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2125-12-14**] 11:30 [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2125-11-9**]

[ "V02.54", "724.5", "518.84", "V49.62", "V15.82", "530.81", "250.00", "733.13", "733.00", "338.29", "V44.0", "799.02", "303.93", "577.2", "041.12", "304.03", "070.30" ]

icd9cm

[ [ [] ] ]

[ "45.13", "38.93", "96.71", "97.23" ]

icd9pcs

[ [ [] ] ]

10795, 10949

5050, 7739

340, 362

11034, 11041

3835, 5027

11385, 11738

2971, 2975

8389, 10772

10970, 11013

7765, 8366

11065, 11362

2990, 3816

293, 302

390, 1907

1929, 2701

2717, 2955

12,776

147,119

25251

Discharge summary

report

Admission Date: [**2169-8-9**] [**Month/Day/Year **] Date: [**2169-8-17**] Date of Birth: [**2088-3-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: abdominal pain, confusion Major Surgical or Invasive Procedure: Central Line History of Present Illness: HPI: 81 y/o F w/ recent MRSA and atopic dermatitis & Zerosis who p/w abdominal pain and confusion per NH. She was admitted to the MICU in early [**Month (only) **] with lethargy and hypotension, presumably from sepsis, with 4/4 bottles MRSA. No source was isolated, with a negative urine culture, and negative TTE for vegetations (as TEE could not be performed). Source was thought to be multiple skin excoriations from poor hygiene and extensive atopic dermatitis. Patient was discharged to a nursing facility with IV vancomycin given through a PICC line. She completed the course of antibiotic on [**2169-7-5**] per D/C summary from the [**2169-7-28**]. . While at the [**Hospital1 1501**], she was found to be more lethargic and dehydrated over the last week. On the day of admission, she became more confused. She was bought to [**Hospital1 18**] where she was found to be dehydrated, hypotensive to 70's, not responding to fluids, hypothermic at 96.5, was found to have a lactate of 2.9 and a dirty urine. In the ED, got a right subclavian line, was given almost [**5-13**] lts of warm NS in ED, started on Levophed, received IV Vanc, Levofloxacin, and was transferred to the MICU. . She denies chest pain, cough, SOB, fever, chills, nausea, vomiting, diarrhea, dysuria, confusion. She had a small amount of BRBPR in the ED but denied [**First Name8 (NamePattern2) 691**] [**Last Name (un) 15557**]/hematoschezia. Past Medical History: 1. HTN 2. LE edema 3. Atrophic dermatitis 4. Recent MRSA sepsis from unknown source Social History: Patient is divorced. She is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3064**] survivor, and had moved here to live with her son. She is now at a rehab facility after last hospitalization Family History: Non-contributory Physical Exam: Vitals 91.4, 93/59, 72, 99/shovel mask Gen alert, oriented x3 HEENT glossitis, dry MM, PERLA, EOMI Skin generalized xerosis with multiple erosions throughout Heart distant S1/S2, no m/r/g Lungs CTAB, conducted sounds Abd s/NT/Nd, no guarding/rigidity Ext no edema Neuro/psych: oriented, answering questions appropriately, likely some short term memory loss Pertinent Results: [**2169-8-9**] 11:11PM PH-7.31* COMMENTS-GREEN [**2169-8-9**] 11:11PM GLUCOSE-90 LACTATE-1.2 NA+-145 K+-3.8 CL--120* TCO2-21 [**2169-8-9**] 11:11PM freeCa-0.97* [**2169-8-9**] 10:00PM HGB-7.8* HCT-24.4* [**2169-8-9**] 09:37PM COMMENTS-GREEN TOP [**2169-8-9**] 09:37PM LACTATE-1.5 [**2169-8-9**] 05:55PM COMMENTS-GREEN TOP [**2169-8-9**] 05:55PM LACTATE-2.9* [**2169-8-9**] 04:45PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.024 [**2169-8-9**] 04:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD [**2169-8-9**] 04:45PM URINE RBC-0 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 [**2169-8-9**] 04:05PM GLUCOSE-85 UREA N-24* CREAT-0.9 SODIUM-144 POTASSIUM-4.7 CHLORIDE-111* TOTAL CO2-27 ANION GAP-11 [**2169-8-9**] 04:05PM ALT(SGPT)-34 AST(SGOT)-30 CK(CPK)-31 ALK PHOS-299* AMYLASE-19 TOT BILI-0.4 [**2169-8-9**] 04:05PM LIPASE-14 [**2169-8-9**] 04:05PM cTropnT-<0.01 [**2169-8-9**] 04:05PM CK-MB-NotDone [**2169-8-9**] 04:05PM T4-2.0* [**2169-8-9**] 04:05PM CORTISOL-20.6* [**2169-8-9**] 04:05PM CRP-121.4* [**2169-8-9**] 04:05PM WBC-11.2* RBC-3.80*# HGB-10.3*# HCT-30.8* MCV-81*# MCH-27.1 MCHC-33.5 RDW-16.4* [**2169-8-9**] 04:05PM NEUTS-75.1* LYMPHS-18.6 MONOS-1.5* EOS-4.3* BASOS-0.4 [**2169-8-9**] 04:05PM HYPOCHROM-2+ ANISOCYT-1+ MICROCYT-1+ [**2169-8-9**] 04:05PM PLT COUNT-351 [**2169-8-9**] 04:05PM PT-13.7* PTT-31.0 INR(PT)-1.2* Brief Hospital Course: 81 y/o F w/ recent MRSA and atopic dermatitis & xerosis who p/w abdominal pain and confusion, found to be hypotensive not responsive to fluids, hypothermic, elevated lactate, dirty urine and was being managed for sepsis. Her Bl cx grew MRSA, B-strep, GNR. Urine was growing Klebsiella. Was on pressors. Was also on Vanc, Levo, Unasyn. She continued to be hypothermic. Given her overall prognosis and condition, we had extensive family discussions and it was decided to make her CMO. All care was withdrawn. She expired on [**2169-8-17**]. Medications on Admission: Colace Dulcolax ASA 81 [**Doctor First Name **] Cosopt eye drops Mineral Oil-Hydrophil Petrolat Tacrolimus 0.03 % Ointment [**Doctor First Name **] Medications: NONE [**Doctor First Name **] Disposition: Expired [**Doctor First Name **] Diagnosis: Sepsis [**Doctor First Name **] Condition: EXPIRED [**Doctor First Name **] Instructions: EXPIRED Followup Instructions: EXPIRED [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2169-12-19**]

[ "691.8", "599.0", "038.11", "038.0", "348.31", "785.52", "995.92", "V09.0", "276.51" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

4059, 4600

358, 372

2581, 4036

5002, 5177

2170, 2188

4626, 4979

2203, 2562

293, 320

401, 1823

1845, 1932

1948, 2154

18,851

145,187

4019

Discharge summary

report

Admission Date: [**2200-12-19**] Discharge Date: [**2200-12-27**] Date of Birth: [**2140-7-6**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 60-year-old diabetic male with a known history of coronary artery disease referred for cardiac catheterization secondary to symptoms of dyspnea on exertion and positive stress test. Patient had been doing well since cardiac catheterization in [**Month (only) 216**] and [**2198-12-28**] with percutaneous transluminal angiography and rota/stent. The patient reported that he recently started to experience dyspnea on exertion. Patient reported recent episode of profound shortness of breath while pushing a cart at work recently. The patient had also noticed increased fatigue during sexual intercourse. The patient denied having any chest pain. He had a stress test on [**2200-11-28**] during which he exercised for eight minutes and achieved 71% of his age-predicted heart rate. He had diffuse baseline electrocardiogram changes making his exercise electrocardiogram uninterpretable for ischemia. Nuclear imaging performed moderate reversible defect in the anterior wall, inferior wall, and septum. There was also a moderate, partially reversible defect at the apex. Transient dilation of the left ventricle was also noted. The patient's ejection fraction was 34% with diffuse hypokinesis, most severe at the apex. The patient was referred to the [**Hospital1 1444**] for cardiac catheterization. PAST MEDICAL HISTORY: 1. Non-insulin dependent-diabetes mellitus. 2. Hyperlipidemia. 3. Hypertension. PAST SURGICAL HISTORY: 1. Hernia repair. 2. Penile implant. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Aspirin 325 mg po q day. 2. Atenolol 100 mg po q day. 3. Glucophage 850 mg po bid. 4. Glyburide 10 mg po bid. 5. Lipitor 10 mg po q day. 6. Zestril 20 mg po bid. 7. Imdur 30 mg po q day. 8. Multivitamin tablet q day. 9. Avandia 4 mg q day. HOSPITAL COURSE: The patient was admitted to the [**Hospital1 188**] on [**2200-12-19**] and underwent a cardiac catheterization. Patient was noted to have diffuse 90% instent restenosis of the left anterior descending artery extending beyond the proximal left anterior descending artery stent as well as 40% stenosis of the D1 (jailed by stent). The patient also had 99% mid occlusion of the right coronary artery with the distal right coronary artery filled via left to right collaterals. Cardiothoracic Surgery team was consulted following these findings. Decision was made to take the patient to the operating room for coronary artery bypass graft. The patient was taken to the operating room on [**2200-12-22**], and underwent three-vessel coronary artery bypass graft with a left internal mammary being grafted to the left anterior descending artery, and with saphenous vein graft to the diagonal and to the posterior descending artery. The patient was thereafter transferred to the SICU for continued monitoring. The patient was transferred to the Cardiothoracic Surgery Floor on postoperative day #1 following an uneventful stay in the SICU. The patient had a temperature spike to 101.5 on the night of postoperative day #1, and was pancultured. Cultures were ultimately all negative for infection. Patient was noted to making poor use of his incentive spirometer. The patient had an eventful day on postoperative day #2. Physical therapy was initiated and the patient was able to participate well. Patient's pain was well controlled and his blood glucose was also well controlled. On the night of postoperative day #2, the patient once again spiked a temperature to 101.8. No cultures were drawn at this time, and the patient encouraged to make good use of his incentive spirometry. On postoperative day #3, the patient had two brief episodes of atrial flutter separated in time about a minute. The patient's rhythm strip also indicated that the patient was having frequent PVCs. The patient's dose of Lopressor was increased with no appreciable improvement in the patient's ectopy, and the decision was made to start amiodarone on postoperative day #4. By postoperative day #5, the patient was deemed stable and ready for discharge home. By the time of discharge, the patient was ambulating comfortably on the floor. His pain remained well controlled on Percocet. He had no further episodes of atrial flutter and his rhythm strip revealed minimal ectopy. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Amiodarone 400 mg po bid. 2. Lopressor 25 mg po bid. 3. Percocet 1-2 tablets po q4-6h prn. 4. Colace 100 mg po bid. 5. Enteric coated aspirin 325 mg po q day. 6. Lasix 20 mg po bid. 7. Potassium chloride 20 mEq po bid. 8. Metformin 850 mg po bid. 9. Rosiglitazone 4 mg po q day. 10. Atorvastatin 10 mg po q day. 11. Glyburide 10 mg po bid. FOLLOWUP: The patient was to followup with Dr. [**Last Name (STitle) **] four weeks following discharge. The patient was also to followup with his primary care physician and with his cardiologist following discharge. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Name8 (MD) 997**] MEDQUIST36 D: [**2200-12-28**] 13:12 T: [**2200-12-31**] 07:10 JOB#: [**Job Number 17746**]

[ "411.1", "250.00", "996.72", "414.01", "424.0", "496", "794.31", "401.9", "272.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.15", "37.23", "88.56", "88.53", "89.68", "36.12" ]

icd9pcs

[ [ [] ] ]

4446, 4455

4478, 5306

1956, 4425

1607, 1939

156, 1481

1503, 1584

59,161

114,601

8537+55953

Discharge summary

report+addendum

Admission Date: [**2118-1-14**] Discharge Date: [**2118-1-19**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: Speech difficulties and right sided weakness Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a [**Age over 90 **] year old woman with a history of atrial fibrillation off Coumadin since [**2117-12-31**] in the setting of recent spontaneous hemoperitoneum requiring exploratory laparatomy and splenectomy for grade III splenic laceration, hypertension, prior TIA, and CAD who presents as a CODE STROKE for aphasia and right face/arm weakness. I spoke with [**Doctor First Name **] at [**Telephone/Fax (1) 30046**]. The patient woke up normal this morning, was in the gym doing leg exercises with PT and talking normally. At 10:30 am, PT called to say that she was alert but nonverbal. When evaluated by [**Doctor First Name **] found to have a right facial droop and right arm flaccid, not answering any questions. EMS was called. She was initially sent to [**Hospital6 17032**], where vitals were temp 97.9, bp 122/47, HR 84, RR 20, SaO2 92%. Exam showed right facial droop, right 0/5, and follows commands with her left arm/leg. Head CT reportedly showed no ICH. She was given ASA 300 mg PR and transferred to [**Hospital1 18**]. She was not thought to be a tPA candidate at that time. Her recent medical history is as follows: She was initially admitted to [**Hospital3 7571**]Hospital on [**2117-12-31**] for hematemesis. Her INR was reversed. She underwent gastroscopy which showed no ulcer, but did show gastritis and duodenitis. CT was consistent with intraperitoneal bleed. She received 2 U PRBCs and was transferred to [**Hospital1 2025**] for spontaneous hemoperitoneum of unclear etiology while on Coumadin. She received 2 more U PRBCs on admission to [**Hospital1 2025**] causing her Hct to bump from 24->31, and requiried Neo for a period of time. She underwent an exploratory laparotomy (as her Hct initially appropriately bumped to 31 but then decreased to 27 within hours) and was found intraoperatively to have a grade III splenic laceration so a splenectomy was performed on [**2118-1-3**]. An umbilical hernia was also repaired intraoperatively. She was transferred to the SICU, where post-operatively she had 2 successive runs of ventricular tachycardia (with negative troponins). On POD 3 she was transfused 2 more U PRBCs since her Hct had slowly trended down to 25.5, and this bumped to 36.7 then stabilized at 32. She was sent to rehab on [**2118-1-12**]. On POD 3 she complained of foot pain consistent with her prior diagnosis of gout, and this migrated to other joints to rheumatology was consulted and recommended a prednisone taper and continuing colchicine. Per the discharge summary, the "surgeons did not restart coumadin due to fall risk and need for recent splenectomy due to fall." The report that the cardiologists could restart coumadin as an outpatient "if he determines the risk of stroke from atrial fibrillation is significant." She has been off Coumadin since [**12-31**], and she was not put on an ASA. In the ED, a Code Stroke was called at 13:24, and neurology was immediately at the bedside. In the ED, a Code Stroke was called at 13:24, and neurology was immediately at the bedside. NIHSS Score: 1a. LOC: 0 1b. LOC Questions: 2 (does not answer either question) 1c. Commands: 2 (does not follow either command to open eyes or squeeze either hand) 2. Best Gaze: 2 (left gaze preference not overcome by Doll's eyes) 3. Visual Fields: X (unable to test, but does not BTT on the right) 4. Facial Palsy: 2 (right) 5. Motor Arm: 4 (right) 6. Motor Leg: X (unable to test, as cannot lift either leg off the bed, does wiggle toes bilaterally, but more spontaneous movements of the left foot than the right) 7. Limb Ataxia: X 8. Sensory: X 9. Best Language: 3 (global aphasia) 10. Dysarthria: X 11. Extinction/Neglect: X NIHSS Score Total: 15 Past Medical History: -Atrial fibrillation currently off Coumadin -Hypertension -TIA -CAD s/p MI [**2115**] -Gout -CRI -OA -Spontaneous hemoperitonem of unclear etiology while on Coumadin s/p exploratory laparotomy, and intraoperative splenectomy for grade III splenic laceration discovered intra-operatively [**2118-1-3**] -s/p umbilical hernia repair [**2118-1-3**] -s/p spinal surgery Social History: She has been living in rehab since her recent discharge from [**Hospital1 2025**]. Family History: NA Physical Exam: Physical Examination: VS: temp 97.6, bp 120/76, HR 67, RR 12, SaO2 97% on 4L, FSBG 155 Genl: Awake, does not follow commands HEENT: Sclerae anicteric, no conjunctival injection, oropharynx clear CV: Slightly irregular (but not definitely irregularly irregular), Nl S1, S2, III/VI systolic murmur best at the LUSB, no rubs or gallops Chest: CTA bilaterally anteriorly and laterally, no wheezes, rhonchi, rales Abd: +BS, soft, NTND abdomen, surgical scar in her abdomen clean/dry/intact Neurologic examination: Mental status: Awake, does not follow commands to open/close eyes or squeeze hands bilaterally. Globally aphasic, cannot produce any words, speech nonfluent, cannot read, cannot repeat. Unable to say her age or the month. Cranial Nerves: Pupils equally round at 4 mm and minimally reactive to light. Blinks to threat on the left, but not on the right. Left gaze deviation, and does not pass midline upon Doll's eyes maneuver. Flat right NLF. Motor/Sensation: Decreased tone in her right arm, but normal tone elsewhere. No observed myoclonus, asterixis, or tremor. Cannot move her right arm against gravity, but does keep her left arm extended against gravity. Wiggles toes bilaterally but on the left much more than the right. Does not move her bilateral LE against gravity. Grimmaces to nailbed pressure on the right hand but does not withdraw her arm. Triple flexes her RLE to nailbed pressure. Reflexes: 2+ in right biceps, brachioradialis, triceps and trace on the left. 0 and symmetric in knees and ankles. Toes upgoing bilaterally. Pertinent Results: [**2118-1-14**] 02:10PM PT-12.1 PTT-33.1 INR(PT)-1.0 [**2118-1-14**] 02:10PM WBC-12.0* RBC-3.75* HGB-11.0* HCT-33.8* MCV-90 MCH-29.4 MCHC-32.6 RDW-15.6* [**2118-1-14**] 02:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2118-1-14**] 02:18PM LACTATE-2.4* [**2118-1-14**] 02:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG [**2118-1-14**] 02:43PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2118-1-14**] 11:07PM CK-MB-NotDone cTropnT-0.01 Brief Hospital Course: Ms. [**Known lastname 12184**] was admitted to the neurology service and emergently taken to the interventional angio suite for MERCI retrieval and IA tPA. Clot removal was attempted and she was admitted to the ICU post-procedure. There she was extubated the following days but her deficits persisted with a R hemiplegia and aphasia. She was then transferred to the floor for further care. Her CT head showed some bleeding in the site of her stroke as well as residual contrast. She underwent secondary stroke prevention evaluation with TTE, FLP and A1c. Her exam remained stable however and she did not have consistent ability to follow commands or speak. Her R hemiplegia was persistent as well and she was noted to fail a swallow evaluation twice. Given the extent of her injury, her current status and exam was discussed at length with her HCP- [**Name (NI) **] [**Name (NI) 30047**]. She was also noted to develop PNA and had increasing tachypnea, oxygen requirement and a leukocytosis. Mr. [**Name13 (STitle) 30047**] decided to make her CMO and she was therefore started on morphine, oxygen and scopolamine. She was also started on Ativan for intermittent tachypnea and continued on oxygen for comfort. She will be transferred to inpatient hospice. Medications on Admission: Lopressor 12.5 mg PO q6 hr Zocor 20 mg qhs Lasix 40 mg [**Hospital1 **] Isordil 5 mg [**Hospital1 **] Prednisone taper (it appears that she is currently on 20 mg [**Hospital1 **] x5 doses, then 10 mg [**Hospital1 **] x6 doses then 5 mg [**Hospital1 **] x6 doses) Colchicine 0.6 mg PO every other day Omeprazole 20 mg [**Hospital1 **] Heparin 5000 U SC tid Colace 100 mg [**Hospital1 **] Senna 1 tablet PO bid Dulcolax 10 mg PR daily Tylenol 650 mg PO q6 hr prn Oxycodone 5 mg PO q4 hr prn Discharge Medications: 1. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal ONCE (Once) for 1 doses. 2. Acetaminophen 650 mg Suppository Sig: [**2-12**] Suppositorys Rectal Q6H (every 6 hours) as needed for fever or pain. 3. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO Q1H (every hour) as needed for pain/aggitation. 4. Lorazepam Intensol 2 mg/mL Concentrate Sig: One (1) ML PO Q1H PRN () as needed for aggitation, tachypnea. 5. Oxygen Via Nasal Canuli or face mask as needed for tachypnea Discharge Disposition: Extended Care Facility: [**Hospital3 11496**] - [**Location (un) **] Discharge Diagnosis: Stroke Discharge Condition: R hemiplegia; CMO Discharge Instructions: Comfort measures only Followup Instructions: NA [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Name: [**Known lastname **],[**Known firstname 1194**] Unit No: [**Numeric Identifier 5250**] Admission Date: [**2118-1-14**] Discharge Date: [**2118-1-19**] Date of Birth: [**2025-5-25**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Addendum: Medications modified for discharge. Chief Complaint: . Major Surgical or Invasive Procedure: . History of Present Illness: . Past Medical History: . Social History: . Family History: . Physical Exam: . Pertinent Results: . Brief Hospital Course: . Medications on Admission: .. Discharge Medications: 1. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal ONCE (Once) for 1 doses. 2. Acetaminophen 650 mg Suppository Sig: [**2-12**] Suppositorys Rectal Q6H (every 6 hours) as needed for fever or pain. 3. Lorazepam Intensol 2 mg/mL Concentrate Sig: One (1) ML PO Q1H PRN () as needed for aggitation, tachypnea. Disp:*30 * Refills:*1* 4. Oxygen Via Nasal Canuli as needed for tachypnea 5. Roxanol Concentrate 20 mg/mL Solution Sig: One (1) PO Q1H PRN as needed: pain, aggitation. Disp:*30 * Refills:*1* Discharge Disposition: Extended Care Facility: [**Hospital3 1620**] - [**Location (un) 1621**] Discharge Diagnosis: . Discharge Condition: . Discharge Instructions: . Followup Instructions: . [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 3327**] Completed by:[**2118-1-18**]

[ "715.90", "V45.79", "401.9", "274.9", "412", "276.0", "414.01", "787.20", "438.82", "342.81", "784.3", "433.11", "427.31", "272.0" ]

icd9cm

[ [ [] ] ]

[ "39.74", "00.40", "99.10" ]

icd9pcs

[ [ [] ] ]

10659, 10733

10055, 10058

9895, 9898

10778, 10781

10029, 10032

10831, 10971

9989, 9992

10111, 10636

10754, 10757

10084, 10088

10805, 10808

10007, 10010

4601, 5065

9854, 9857

9926, 9929

5328, 6132

5104, 5312

5089, 5089

9951, 9954

9970, 9973

25,658

119,481

50625

Discharge summary

report

Admission Date: [**2178-3-1**] Discharge Date: [**2178-3-5**] Date of Birth: [**2110-3-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: Elective admission for peripheral angiography Major Surgical or Invasive Procedure: ICD Implantation ([**2178-3-4**]) History of Present Illness: Patient is a 67 y/o M with significant cardiac history, S/P coronary artery bypass graft, admitted for elective peripheral vascular angiography. . Patient had complained of bilateral, left greater than right, lower extremity claudication. Past Medical History: HTN hyperlipidemia CAD - S/P CABG [**2163**] (LIMA->LAD, SVG->D->OM2 jump graft, SVG->LPDA) ischemic cardiomyopathy - EF 15-20% gout spinal stenosis bilateral renal masses s/p L inguinal hernia repair s/p back surgery s/p cataract surgery PVD s/p right external iliac artery stent [**8-/2176**], complicated by LUE hematoma? nerve injury Social History: Single, lives alone. Active smoker of 10 cigarettes per day. Has smoked 1-2 packs per day for 10-15 years. Drinks alcohol [**2-14**] times per week. Retired construction worker. Family History: non-contributory Physical Exam: VS - T 97.0, HR 68, BP 87/51, RR 21, O2 sat 100%, Wt 66.9 kg gen - comfortable HEENT - JVP 12 cm CV - RRR w/ ectopy, no m/r/g chest - crackles 1/3 up bilaterally abd - benign ext - bilat 1+ pitting edema neuro - non-focal Pertinent Results: [**2178-3-2**] 12:13AM BLOOD WBC-5.7 RBC-2.87* Hgb-9.8* Hct-27.2* MCV-95 MCH-34.1* MCHC-36.1* RDW-18.9* Plt Ct-90* . [**2178-3-2**] 12:13AM BLOOD Glucose-130* UreaN-52* Creat-1.4* Na-139 K-3.3 Cl-105 HCO3-23 AnGap-14 [**2178-3-2**] 12:13AM BLOOD Calcium-7.9* Phos-3.9 Mg-1.8 [**2178-3-2**] 12:13AM BLOOD ALT-24 AST-31 LD(LDH)-156 CK(CPK)-27* AlkPhos-172* TotBili-0.3 . [**2178-3-2**] 12:13AM BLOOD PT-13.6* PTT-31.7 INR(PT)-1.2* . [**2178-3-2**] 09:14AM BLOOD cTropnT-0.40* [**2178-3-2**] 11:36AM BLOOD cTropnT-0.41* [**2178-3-2**] 09:31PM BLOOD cTropnT-0.34* . [**2178-3-2**] 09:14AM BLOOD CK(CPK)-115 CK-MB-15* MB Indx-13.0* [**2178-3-2**] 11:36AM BLOOD CK(CPK)-102 CK-MB-14* MB Indx-13.7* [**2178-3-2**] 09:31PM BLOOD CK(CPK)-73 CK-MB-NotDone . CHEST - PORTABLE AP ([**2178-3-1**]): The patient has had median sternotomy. Cardiac silhouette is moderately enlarged. Mild interstitial abnormality, if acute, could be due to mild pulmonary edema. There is no pleural effusion or pneumothorax. No free air is seen below the diaphragm. Brief Hospital Course: Patient was initially admitted to the vascular surgery service. He received a dose of Mucomyst in preparation for planned angiography on HD #2. However, he began to feel "ill" and nauseated, though he did not have any emesis. This was associated with diaphoresis and lightheadedness. He stood to walk to the bathroom, but felt worse and rang for the RN, who found the patient with a heart rate in 180s and SBP in the 60s. An ECG was performed, and showed a wide complex tachycardia with RBBB morphology. Cardiology was called, who recommended DCCV. Patient was loaded with amiodarone 150 IV x 2 without effect. He was then successfullly cardioverted with 150 J and transferred to the CCU. . In the unit, a repeat ECG showed NSR with an underlying LBBB & frequent PVCs. He denied chest pain, SOB, n/v, or diaphoresis. He remained somewhat hypotensive, but was mentating well. He was started on pressor support. He was also continued on his regimen of ASA, Plavix, and pravachol. B-blocker and ACE-I were initially held for hypotension, but were gradually introduced after pressors were weaned off. Cardiac biomarkers were monitored and were mildly elevated, thought to represent strain secondary to his tachycardia vs cardioversion. A primary ischemic event was thought unlikely. He was monitored on telemetry, which initially showed frequent PVCs with several runs of hemodynamically stable and asymptomatic NSVT. However, the frequency of his PVCs and NSVT rapidly decreased within the first several days of hospitalization. . He was evaluated by the electrophysiology service on HD #2, and taken for an EP study on HD #3. A VT ablation was attempted, but was unsuccessful. He was taken back to the EP lab on HD #4 for placement on an ICD, which he tolerated well. He was discharged home on HD #5 in stable condition with plans to follow up for peripheral angiography at a later date. Medications on Admission: Aspirin 325 mg p.o. daily Plavix 75 mg p.o. daily metoprolol 25 mg p.o. b.i.d. lisinopril 10 mg p.o. daily Pravachol 20 mg p.o. daily Lasix 50 mg p.o. b.i.d. Colchicine 0.6 mg 2 tabs p.o. daily methocarbamol 750 mg p.o. q.i.d. Percocet 1 tab every 4 hours p.r.n. for lower extremity pain Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 5. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Lasix Oral 7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Ventricular tachycardia s/p ICD implantation Discharge Condition: Stable Discharge Instructions: 1) Continue your medications as directed. 2) Follow up as directed below. 3) Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Fluid Restriction: 1.5L 4) Call if you have chest pain, shortness of breath, palpitations, lightheadedness, nausea, fevers, or any other concerns. Followup Instructions: 1) Follow up with Dr [**Last Name (STitle) **] in 2 weeks. You will be scheduled to return for an angiogram of your leg. [**Telephone/Fax (1) 2395**] 2) Follow up in Device Clinic on [**2178-3-11**] at 1:30pm Phone:[**Telephone/Fax (1) 59**] 3) Follow up with Dr [**Last Name (STitle) **] (Cardiology) Phone: [**Telephone/Fax (1) 4105**] 4) Follow up with Dr [**Last Name (STitle) **] (Cardiology-Electrophysiology) Phone:[**Telephone/Fax (1) 62**] 5) Follow up with Dr [**First Name (STitle) **] (Cardiology-Peripheral vascular) Phone:[**Telephone/Fax (1) 62**] . Other appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7198**], M.D. Date/Time:[**2178-3-18**] 2:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] INTERNAL MEDICINE Date/Time:[**2178-3-25**] 12:00 Completed by:[**2178-4-10**]

[ "V45.82", "V45.81", "443.9", "427.1", "274.9", "272.4", "401.9", "496", "V15.82", "428.0", "412" ]

icd9cm

[ [ [] ] ]

[ "37.94", "99.62", "37.34", "37.27" ]

icd9pcs

[ [ [] ] ]

5478, 5541

2570, 4457

359, 395

5630, 5639

1512, 2547

6012, 6886

1237, 1255

4795, 5455

5562, 5609

4483, 4772

5663, 5989

1270, 1493

274, 321

423, 663

685, 1026

1042, 1221

49,796

130,491

11895

Discharge summary

report

Admission Date: [**2130-8-5**] Discharge Date: [**2130-9-19**] Date of Birth: [**2063-4-21**] Sex: M Service: MEDICINE Allergies: Percodan / Banana Attending:[**First Name3 (LF) 2641**] Chief Complaint: Transfer for ERCP. Major Surgical or Invasive Procedure: 1) ERCP with sphincterotomy 2) Guillotine Left below the knee amputation 3) Revision of Left below the knee amputation History of Present Illness: 67 year-old male with CHF (EF 45%), diabetes mellitus, atrial fibrillation on warfarin presented to outside hospital after a fall, with malaise and a left heel wound. He denies loss of consciousness on his fall or head strike and reports being on the floor for one hour. He was admitted to outside hospital [**8-3**] where he was found to have temperature of 101F, left heel stage 3 decubitus ulcer with drainage (he was treated with clindamycin for 1.5 weeks prior to admission), INR 17, WBC 29, Total Bili >4, Alk Phos 240, and RUQ ultrasound showing gallstones, thickened gallbladder wall, and normal CBD. Vitamin K 10 mg IV given for INR 17. He had debridement of his left heel ulcer on [**8-4**] at bedside with course complicated by Proteus bacteremia. He also had cholecystitis and a percutaenous drain was placed [**8-4**]. His course was further complicated on [**8-4**] by hypotension with SBP in 70's, confusion, and unresponsiveness. He received IV fluids, levofloxacin, and 2 units PRBC and 1 unit FFP. On [**8-5**], he was transferred to the [**Hospital1 18**] for ERCP evaluation and admitted to the [**Hospital1 18**] ICU. [**Hospital1 18**] ICU Course: In ICU, received Zosyn and Vanco. Patient has been hemodynamically stable. Review of systems: (+) Per HPI and chronic bilateral lower extremity sensory neuropathy, chronic bilateral vision loss, occasional shortness of breath from heart failure, chronic bilateral lower extremity weakness -- left leg more than right from prior strokes. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: C. difficile infection [**1-/2130**]/[**2130**] CAD s/p stent Atrial fibrillation/flutter, on coumadin Congestive heart failure, EF 45% Question of pulmonary HTN OSA Diabetes mellitus on insulin, with retinopathy, neuropathy, and nephropathy Dermatitis stasis of bilateral lower extremitites PVD Stage 4 heel decubitus ulcer Cataract surgery Retina surgery CVA Social History: Lives with wife. Is adopted. Has one adopted child. Quit tobacco in [**2087**], uses alcohol only 2-3 times yearly, and denies illicit drug use. Family History: Unknown since patient is adopted. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 78, 123/53, 17, 94/2L General: Alert, no acute distress, flat affect, slow speech HEENT: Sclera mildly icteric, dry , 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, RUQ TTP with perc chole in place draining dark , non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: 4+ edema of LE with vescicles/crusting and left foot ulcer wrapped and malodourous DISCHARGE PHYSICAL EXAM: Vitals: T98.7, 67, 102/39, 17, 96 RA General: Alert, no acute distress, flat affect, slow speech HEENT: Sclera mildly icteric, dry , oropharynx clear Neck: supple, JVP 8cm, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, dry rales at base which resolve upon multiple breaths, no rhonchi CV: Atrial fibrillation Abdomen: soft, non tender Ext: Left extremity amputation appears well. Minimal swelling on exam of either lower extremities. Pertinent Results: ADMISSION LABS: [**2130-8-5**] 08:43PM BLOOD WBC-22.4* RBC-3.13*# Hgb-8.8*# Hct-26.0*# MCV-83 MCH-28.1 MCHC-33.7 RDW-15.2 Plt Ct-363 [**2130-8-5**] 08:43PM BLOOD PT-17.8* PTT-29.4 INR(PT)-1.6* [**2130-8-5**] 08:43PM BLOOD Glucose-114* UreaN-35* Creat-1.8* Na-136 K-3.7 Cl-99 HCO3-27 AnGap-14 [**2130-8-5**] 08:43PM BLOOD ALT-34 AST-51* AlkPhos-302* TotBili-4.6* DirBili-3.9* IndBili-0.7 [**2130-8-5**] 08:43PM BLOOD Albumin-2.6* Calcium-7.5* Phos-4.3 Mg-2.4 [**2130-8-5**] 08:43PM BLOOD Vanco-21.5* [**2130-8-5**] 09:41PM URINE Color-DkAmb Appear-Cloudy Sp [**Last Name (un) **]-1.018 [**2130-8-5**] 09:41PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-5.0 Leuks-SM [**2130-8-5**] 09:41PM URINE RBC->182* WBC-51* Bacteri-FEW Yeast-MANY Epi-1 [**2130-8-6**] 04:36AM URINE Hours-RANDOM UreaN-609 Creat-89 Na-14 K-55 . MICROBIOLOGY: OUTSIDE HOSPITAL CULTURES: C. diff [**8-3**]: Negative Blood culture [**8-3**], 2 out of 2 bottle: Proteus mirabelis, pan-susceptible Heel wound culture [**8-3**], pan-sensitive Proteus mirabelis Bile drain aspirate collected [**8-4**]: Prelim [**8-5**] many GNR . [**Hospital1 18**] studies: Blood culture X 2 [**8-5**]: No Growth Urine culture [**8-5**]: No Growth MRSA screen [**8-5**]: Negative Bile culture [**8-5**]: No Growth Wound Swab (calcaneus) [**8-10**]: Enterococcus (Amp-sensitive, pen-resistant, vanc-sensitive) Tissue Culture [**8-10**]: Coag negative staph and proteus Stool [**Date range (1) 37484**]: Cdiff negative x 4 Blood Culture, Routine (Final [**2130-9-16**]): CITROBACTER FREUNDII COMPLEX. FINAL SENSITIVITIES. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER FREUNDII COMPLEX | AMIKACIN-------------- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 16 I CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- I GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R . RADIOLOGY: RUQ ultrasound [**8-4**]: Gallbladder distended with numeous gallstones with diffuse gallbladder wall thickening 4mm. Pain in RUQ. Dx of cholecytitis. No biliary duct dilation. Liver WNL, Spleen NL. Ascites tiny along inferior edge of liver. . CXR [**8-5**]: Pulmonary edema, an underlying infectious infiltrate cannot be excluded. . ERCP [**8-7**]: Normal biliary tree (sphincterotomy). Evidence of a percutaneous cholecystostomy tube was seen in good position. Otherwise normal ercp to third part of the duodenum . Discharge Labs: [**2130-9-19**] 05:25AM BLOOD WBC-12.8* RBC-3.58* Hgb-10.1* Hct-31.6* MCV-88 MCH-28.3 MCHC-32.1 RDW-15.6* Plt Ct-434 [**2130-9-19**] 05:25AM BLOOD PT-28.6* PTT-36.9* INR(PT)-2.8* [**2130-9-19**] 05:25AM BLOOD Glucose-186* UreaN-22* Creat-1.2 Na-136 K-4.2 Cl-105 HCO3-22 AnGap-13 [**2130-9-19**] 05:25AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0 [**2130-9-12**] 06:09AM BLOOD VitB12-716 Folate-13.0 Brief Hospital Course: Pt is a 67 yo man with CHF, Afib, DM2, decubitus heel ulcers, recent cholecystitis c/b proteus bacteremia s/p cholecystostomy and ERCP with sphicterotomy, s/p left guillotine BKA now s/p revision L BKA. Hospital course complicated by poor nutrition and citrobacter sepsis. . #Acute Cholecystitis complicated by Proteus Septicemia: Pt was admitted to OSH with presentation of acute cholecystitis and underwent cholecystostomy that was complicated by proteus septicemia of suspected biliary source. There was concern for choledocholithiasis given history of gallstones and elevated total bilirubin. He was transferred to [**Hospital1 18**] for ERCP. ERCP with sphincterotomy performed on [**8-7**] and no gallstones were visualized in CBD. He was treated with IV vanc and zosyn. All blood and biliary cultures in house were negative. Bilirubin and LFTs trended down to normal levels. . #Left state 4 heel decubitus ulcer/osteomyelitis: He was found to have a badly infected decubitus heel ulcer on his left foot which was thought to be contributing to his declining clinical status. Patient was evaluated by podiatry, wound care, ID and vascular surgery for this issue. He was transfered to the vascular floor and underwent guillotine left BKA followed by revision of his BKA days later. He was transfused with 7 units of pRBCs during this period to compensate for significant operative losses and to keep his Hct up given his multiple medical comorbidities. Hct remained stable for the rest of admission. He had a lot of pain at incision site but this was well controlled with Dilaudid. Patient worked with physical therapy and does not require dilaudid as he states no to minimal pain. . #Nutrition: Patient had difficulty eating on his own. He was started on TPN on [**8-15**] and encouraged to take in POs. Was able to drink some Boost/Ensure, however, he was not meeting his caloric needs of 1600cal/day. Primary team wanted to discontinue TPN given risk of infection from the line and preference for using the gut. Patient was extremely resistant to Dobhoff, but finally placed feeding tube on [**9-2**]. Patient did well with tube feeds and TPN was d/c'ed on [**9-3**]. On [**9-8**], patient pulled out his dobhoff and refused to have it put back in. Patient would not be accepted to rehab in malnourished state and unable to take in adequate calories. GI was consulted to discuss the possibility of placing a Peg tube and declined. Pt wants nutrition and states he wants placement of Gtube, citing understanding of its significance and what the process entails. However, at this time, pt appears to be increasing oral intake while on TPN. Only if the pt is not able to meet his daily caloric goals should dobhoff be considered. . # Citrobacter bactermia: Pt spiked a fever in early [**Month (only) 216**]. Blood cultures grew out Citrobacter, urine culture negative. Zosyn was started, the PICC was pulled on [**9-15**] as this was the suspected source despite having not being culture positive itself. The zosyn is to be completed [**2130-9-30**] for a full 2 week course. # Diabetes mellitus: Patient was on insulin, with complications of nephropathy, neuropathy, and retinopathy. Sugars were difficult to control and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained. Sliding scale was adjust per their recs, increase morning Lantus and premeal insulin. # Heart failure, EF 30% and Renal injury: Pt was volume overloaded initially, found to respond well to 80 mg lasix [**Hospital1 **]. However, diuresis elevated the creatinine. Pt has very narrow window between becoming edematous and perfusing kidney. Echo revealed a hypokinetic left ventricle with poor EF. # Atrial fibrillation: Rate controlled with Metoprolol, anti-coagulation with Coumadin which is currently being held for PEG tube placement. # UTI: Patient was urged to remove foley multiple times given risk of infection. He refused as this was not convenient. On [**9-2**], developed dysuria. U/A was positive. Foley removed, completed 7 day course of Bactrim with resoltuion of dysuria. # Guaiac positive stools: Hemodynamically stable with stable blood levels during admission. The patient should have a colonscopy as an outpatient. # Healthcare proxy: [**Name (NI) **] (pt's partner) cell [**Telephone/Fax (1) 37485**], home (her friend's house) [**Telephone/Fax (1) 37486**] # Code status: DNR/DNI (confirmed with [**Name (NI) **], wife and patient) Medications on Admission: Transfer Medications: Tylenol 650mg Q4H prn Albuterol Q2H prn Aztreonam 1G Q8H lat at 1427 Duoneb prn Ferrous sulfate 300mg [**Hospital1 **] with food Lorazepam 1mg IV Q2H prn Metoprolol 5mg Q4H prn Morphine 1-2mg Q1H prn Zofran 4mg Q8H prn Pantoprazole 40 mg IV daily Saccharmyces B 250mg [**Hospital1 **] Sodium chloride 0.9% 1L X1 Tamsulosin 0.4 daily Tas irrigation [**Hospital1 **] Tylenol with codeine Q6H prn Vancomycin 1G IV daily (last 0613) Zosyn 3.375G Q6H (last 1254) Lasix 80mg [**Hospital1 **] Humalog 5U, Lantus 50U Metoprolol XL 25mg [**Hospital1 **] Coumadin 2mg QHS (not yet given) Discharge Medications: 1. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 6. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for yeast . 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig: 4.5 g Intravenous Q6H (every 6 hours) for 10 days: Please treat till [**2130-9-30**]. 13. insulin glargine 100 unit/mL Solution Sig: Twenty Eight (28) Units Subcutaneous qam. 14. insulin lispro 100 unit/mL Solution Sig: Sliding scale Subcutaneous four times a day: Please see sliding scale. 15. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 16. saccharomyces boulardii 250 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary Diagnosis: Decubitus heel ulcers complicated by osteomyelitis s/p L BKA Proteus sepsis Cholecystitis Post-ERCP pancreatitis Citrobacter Sepsis Peripheral vascular disease Urinary tract infection Diabetes Mellitus Malnutrition Secondary Diagnosis: Atrial fibrillation Chronic systolic heart failure Coronary artery disease 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: Dear Mr. [**Known lastname 18473**], You were transferred to [**Hospital1 69**] from [**Hospital6 6640**] following gall bladder removal complicated by a severe, life-threatening blood stream infection. You were treated with a procedure called ERCP which allows for proper drainage of the biliary system. Your blood infection was treated with intravenous antibiotics and was eradicated. Your left heel was involved in this infection, and you subsequently underwent a below-the-knee amputation of your left leg, followed by a revision of the amputation. You had some difficulty with poor nutrition and required TPN, which is food through an IV. It was difficult to place you into a rehab with this IV nutrition. We gave you 1 week to try to eat on your own but you were not able to tolerate enough food to meet your daily caloric needs. We stopped the TPN and placed a tube into your nose for nutrition. You pulled it out and communicated to us that you did not want it replaced. We restarted TPN. Unfortunately, you contracted a blood stream infection during your lengthy stay in the hospital. We started you on antibiotics and removed an IV, which was likely the source of infection. After your blood cultures were clear for 48 hours, we replaced this IV. You will need to have antibiotics till [**2130-9-30**]. Many changes were made to your medications. The updated list of your medications is included. Followup Instructions: Please attend the following appointments: Department: VASCULAR SURGERY When: WEDNESDAY [**2130-9-27**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "576.1", "327.23", "574.00", "348.30", "995.92", "584.9", "427.31", "428.0", "416.8", "707.24", "427.32", "707.07", "585.9", "263.0", "999.31", "682.7", "V45.82", "E879.6", "730.07", "996.64", "428.23", "V58.61", "038.8", "595.0", "250.62", "250.82", "403.90", "577.0", "285.1", "V63.2", "459.81" ]

icd9cm

[ [ [] ] ]

[ "84.15", "51.85", "84.3", "96.6", "99.15" ]

icd9pcs

[ [ [] ] ]

14171, 14242

7564, 12056

296, 417

14617, 14617

4070, 4070

16244, 16598

2919, 2954

12707, 14148

14263, 14263

12082, 12082

14797, 16221

7150, 7541

2994, 3575

1716, 2356

238, 258

12104, 12684

445, 1697

14519, 14596

4086, 7134

14282, 14498

14632, 14773

2378, 2740

2756, 2903

3600, 4051

72,196

155,280

6781

Discharge summary

report

Admission Date: [**2117-10-31**] Discharge Date: [**2117-11-2**] Date of Birth: [**2042-8-13**] Sex: F Service: MEDICINE Allergies: Cephalosporins / Theophylline / Prevacid Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: nausea, vomiting, osteomy output Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 75yoF with a history of COPD on home 02 and chronic prednisone, DM2, HTN who was recently hospitalized in [**Month (only) 216**]-[**2117-9-23**] for ischemic colitis s/p total colectomy with end ileostomy and chronic tracheostomy due to perioperative respiratory failure. She presents with increased watery ostomy ouput, nausea/vomiting, and a UTI. . She was rehabbing at [**Hospital1 **], when according to her daughter, she developed nausea and intermittent vomiting on [**2117-10-26**], and subsequent decreased PO intake. Her ostomy output increased to about 600-800cc daily since [**2117-10-27**], assuming a watery consistency. Urine output trailed off though creatinine remained at baseline around 0.7. She was empirically placed on IV flagyl on [**10-29**] though the initial C dif assay was negative. Otherwise, patient has denied fevers, chills, abdominal pain, chest pain, shortness of breath, dysuria or hematuria. No malaaise or arthralgias. . Of note, she developed a resistant ESBL E coli UTI at rehab on [**2117-10-27**], and has not received treatment thus far due to concern regarding cephalosporin/carbopenem cross reactivity. Her foley was last changed on [**2117-10-26**]. Also, she has progressive anemia with HCT 23-24 in rehab requiring a unit PRBC on [**10-29**] with imrpovement of HCT to 25. She was guiac negative there and in our ED. . She has received multiple antibiotic courses recently: Levaquin for 8 days in [**Month (only) 205**] for pneumonia. Vancoymcyin for cellulitis of her surgical site in early [**Month (only) 462**]. Zosyn/meropenem for ESBL ecoli pneumonia at that time as well. And a 2 week course of zosyn for aspiration pneumonia at [**Hospital1 **] recently completed. . With regard to her respiratory status, she was on 3LNC prior to her surgery for ishemic colitis last month- she failed several attempts to liberate her from the ventilator and eventually developed an ESBL ecoli pneumonia. A tracheostomy was placed at bedside on [**2117-9-22**], and eventually was weaned to nighttime ventilatory support with trach capping during the daytime hours. . In the ED, initial vital signs were T97.9 HR94 BP152/44 RR20 97%4LNC. Received 2LNS. Surgery consulted due to her recent colectomy. UA suggestive of UTI. ID curbsided re: safety of carbopenem use with a cephalosporin allergy, and reassured that cross reactivity is rare. Got meropenem 500mg. C dif sent as well. Prior to transfer, VS BP138/69, P99, RR30,96%3L. . On the floor, initial VS were T98.2 P102 BP135/55 RR14 Sat95/4LNC. She is tired and falling asleep. Denying any pain or discomfort. . 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: 1. Significant COPD, 3LNC baseline 2. CHF, diastolic, with elevated wedge pressure and left-sided filling pressures on [**2114**] cardiac catheterization. 3. Hypertension. 4. Diabetes. 5. Pulmonary hypertension, likely secondary to left heart disease. 6. GERD 7. LGIB in past . Past Surgical History: -s/p CCY -s/p hysterectomy Social History: -Lives with husband, former [**Name2 (NI) 1818**] but none since [**2097**]; no EtOH Family History: Noncontributory Physical Exam: Vitals: T98.2 P102 BP135/55 RR14 Sat95/4LNC General: fatigued appearing but fully oriented x3, answering questions appropriately and no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: coarse breath sounds anteriorly but posteriorly she is clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardic rate and normal rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Ostomy bag draining semi-solid brown stool. GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Back: no CVA tenderness Pertinent Results: Labs: Admission Labs: [**2117-10-31**] 11:55AM BLOOD WBC-12.2* RBC-3.16* Hgb-9.6* Hct-29.3* MCV-93 MCH-30.5 MCHC-32.9 RDW-14.6 Plt Ct-559* [**2117-10-31**] 11:55AM BLOOD Neuts-72.4* Lymphs-17.7* Monos-5.8 Eos-3.3 Baso-0.7 [**2117-10-31**] 11:55AM BLOOD Glucose-126* UreaN-13 Creat-0.7 Na-135 K-4.3 Cl-102 HCO3-23 AnGap-14 [**2117-10-31**] 11:55AM BLOOD Calcium-9.3 Phos-4.0 Mg-1.8 Iron-24* [**2117-10-31**] 11:55AM BLOOD calTIBC-204* Ferritn-324* TRF-157* . Discharge Labs: [**2117-11-2**] 03:15AM BLOOD WBC-9.2 RBC-2.69*# Hgb-8.1*# Hct-25.4*# MCV-94 MCH-30.3 MCHC-32.1 RDW-14.8 Plt Ct-526* [**2117-11-2**] 01:53AM BLOOD Neuts-72.4* Lymphs-19.3 Monos-6.6 Eos-1.2 Baso-0.5 [**2117-11-2**] 01:53AM BLOOD PT-13.0 PTT-31.1 INR(PT)-1.1 [**2117-11-2**] 01:53AM BLOOD Glucose-121* UreaN-11 Creat-0.6 Na-139 K-4.0 Cl-104 HCO3-24 AnGap-15 [**2117-11-2**] 01:53AM BLOOD Calcium-9.0 Phos-2.6* Mg-1.7 . KUB: IMPRESSION: Paucity of bowel gas limits evaluation for luminal distention. No free air is seen . CXR; IMPRESSION: There has been no change in the appearance of the chest with findings at the left lung base which may be chronic . CXR ([**2117-11-1**]): FINDINGS: In comparison with the earlier study of this date, the Dobbhoff tube has been advanced so that the tip lies well in the stomach. Little change in the appearance of the heart and lungs with persistent opacification at the left base consistent with some combination of atelectasis and effusion. . Micro: [**2117-10-31**] 1:15 pm STOOL CONSISTENCY: WATERY **FINAL REPORT [**2117-11-1**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2117-11-1**]): THIS IS A CORRECTED REPORT ([**2117-11-1**] 0710). Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 0710 . Urine; [**2117-10-31**] 1:15 pm URINE Site: CATHETER URINE CULTURE (Preliminary): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Brief Hospital Course: Assessment and Plan: Mrs. [**Known lastname 25731**] is a 75yoF with a history of recent ischemic colitis s/p colectomy and end-ileostomy, COPD, chronic tracheostomy, GERD, HTN admitted for malaise, Nausea and increased ostomy output and UTI. . # INCREASED OSTOMY OUTPUT: C.difficile positive on admission. Multiple case reports of small bowel enteritis secondary to C.diff in setting of total colectomy. GI consulted to ensure proper mgmt in unique setting. After review patient treated with monotherapy with PO vanc. Decision made to d/c flagyl due to concern that flagyl was contributing to nausea, vomiting. Furthermore, patient with signs/sx consistent with mild C.diff therefore monotherapy acceptable. Surgery, consulted in setting of recent colectomy, had no recs and planned to have the patient follow-up with outpatient provider as scheduled. Patient to complete a 7 day course after completion for meropenem. OUTPATIENT ISSUES: -- Continue treatment of C.diff with PO vancomycin until [**2117-11-16**] . # ESBL E COLI UTI: Diagnosed while in house however was asymptomatic. Foley catheter was initially placed however was subsequently removed. OUTPATIENT ISSUES: -- Started meropenem for 10 day course. Last day of meropenem will be on [**2117-11-9**]. . # MALNUTRITION: Patient had chronic nasogastric tube for nutritional supplement. On admission, patients tube was in good position and feeds were continued. There was some concern for tube migration while patient was in prior living facility leading to potential aspiration. Patient has not had prior swallow studies [**2-24**] chronic ventilation. G-tube placement was considered however was tabled until outpatient. Patient and family requested that NG tube be removed to allow patient to try eating on her own. This was honored however patient will need have calorie count and if not meeting nutritional demand, replacement of NG tube will need to occur as well as potential arrangment for PEG tube placement. OUTPATIENT ISSUES: -- Calorie count. If not meeting nutritional demand, replacement of NG tube will need to occur as well as potential arrangment for PEG tube placement . # COPD/RESPIRATORY FAILURE S/P CHRONIC TRACHEOSTOMY: Patient saturating well on home 02 requirement. Continued on nightly vent settings at 12/500/5/30%. Patient maintained on prn nebs, home prednisone 5mg TID. . # DIASTOLIC HEART FAILURE. Held lasix on admission. Restarted prior to admission . # HYPERTENSiON: Normotensive. Patient continued on amlodipine . # ANEMIA: HCT reportedly into the 23-24 range at rehab requiring resuscitation. Hematocrit remained at 25 without any signs or symptoms of bleeding. Iron studies did not show reveal deficiency. No transfusions were necessary. . # GERD. Continued famotidine . # ANXIETY/DEPRESISON. Continued buproprion and ativan . # DIABETES: continued NPH and sliding scale insulin . # Code Status: Full Code (discussed with patient) Medications on Admission: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection TID (3 times a day). 2. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. prednisone 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for anxiety. 8. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 11. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 4 days: continue through [**2117-10-4**] to complete 14 day course. 12. acetazolamide sodium 500 mg Recon Soln Sig: Two Hundred Fifty (250) mg Injection once a day. 13. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 8 days: continue through [**2117-10-8**] to complete 10 day course. 14. Insulin sliding scale Fingerstick Q6HInsulin SC Fixed Dose Orders Breakfast Bedtime NPH 14 Units NPH 24 Units Insulin SC Sliding Scale Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. prednisone 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 8. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation QID (4 times a day) as needed for shortness of breath or wheezing. 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): Last dose on [**2117-11-16**]. 13. Meropenem 500 mg IV Q6H d1= [**10-31**] 14. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 16. NPH insulin human recomb 100 unit/mL Suspension Sig: See instructions units Subcutaneous twice a day: 14 units at breakfast 14 units at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Clostridium Difficle Small Bowel Infection Urinary Tract Infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital because you were having nausea/vomiting and increased output from your ostomy. Your stool studies were positive for an infection called C. difficile. You were started on an antibiotic to help treat this infection. You were also found to have a urinary tract infection which will require antibiotics as well. You were uncomfortable from having the feeding tube in your nose and so removed it with the plan to watch your intake and if you are unable to take in as much as you need, you may have to the tube replaced. Please see the attached list for your medications changes. Followup Instructions: Please be sure to keep the following appointments: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2117-11-4**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2359**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: PULMONARY FUNCTION LAB When: FRIDAY [**2117-12-3**] at 9:40 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: FRIDAY [**2117-12-3**] at 10:00 AM With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "530.81", "401.9", "V58.65", "599.0", "300.4", "250.00", "V46.2", "V44.2", "416.8", "008.45", "428.0", "496", "V45.72", "263.9", "V44.0", "041.49", "428.32" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12683, 12754

6762, 9697

342, 348

12865, 12865

4741, 4747

13675, 14843

3970, 3987

11177, 12660

12775, 12844

9723, 11154

13041, 13652

5215, 6614

3822, 3851

4002, 4722

3027, 3477

270, 304

6649, 6739

376, 3008

4763, 5199

12880, 13017

3521, 3799

3867, 3954

2,215

102,183

27621

Discharge summary

report

Admission Date: [**2105-6-1**] Discharge Date: [**2105-6-29**] Date of Birth: [**2037-7-9**] Sex: F Service: SURGERY Allergies: Aspirin Attending:[**First Name3 (LF) 371**] Chief Complaint: nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: [**6-9**] Exploratory laparotomy, lysis of adhesions, enteroenterostomy [**6-13**] Exploratory laparotomy History of Present Illness: 67 year old female with poorly differentiated pelvic carcinoma (status post surgery, chemo, XRT), with recurrent admissions/emergency room visits for abdominal pain, presenting again with nausea, vomiting, abdominal pain, found to have a small bowel obstruction in the emergency room. Her previous admissions were in [**Month (only) 547**] and [**Month (only) **] with similar complaints. CT scan ([**2105-3-15**]) demonstrated some minimal wall thickening of deep loops of small bowel. GI was consulted and felt that the patient's history was most consistent with partial SBO. A small-bowel follow-through demonstrated a slightly thickened, irregular, aperistaltic loop of small bowel in the distal pelvis but no evidence of obstruction. Her last CT in [**Month (only) **] showed an obstruction at a deflection point in the left lower quadrant. She was again medically treated and improved. She now returns with similar symptoms of nausea, vomiting and abdominal pain since day prior to admission and again is found to have a partial SBO on CT. She has not had a BM in 10 days. She complains of pain worse in RLQ. She says she has lost weight since surgery. No melena or hematochezia. No hematemesis. Past Medical History: 1) Poorly differentiated pelvic carcinoma: From last discharge summary: "Diagnosed with pelvic mass [**5-20**] after having difficulty with urination. MRI was notable for a 4.0 x 4.3 x 7.2 cm heterogeneous cystic and solid pelvic mass anterior to the bladder. Biopsy was consistent with poorly differentiated malignancy. Underwent radical vaginectomy, radical vulvectomy, and anterior pelvic exenteration on [**2104-7-18**]. With urostomy. Taxol on [**2104-9-24**] and then palliative radiation therapy. MRI on [**2104-12-18**] was notable for interval decrease in size of the soft tissue density immediately adjacent to and posterior to the pubic symphysis, compatible with scar and no evidence of disease recurrence elsewhere in the pelvis. 2) Cerebrovascular accident x 2 (cerebellar) 3) Anemia: B12 deficient 4) Asthma 5) Hypertension 6) Hypothyroidism status post thyroidectomy Social History: She is from [**Male First Name (un) 1056**]. She worked as an office cleaner. She has three children. She lives with her brother. She reports a 47-pack year smoking history. She quit after she was diagnosed with cancer. She consumes alcohol on social basis. Family History: Sister died of cancer in [**2100**], type unknown, positive for hypertension, diabetes. Physical Exam: T: 96.8 HR: 102 BP: 110/80 RR: 18 98% RA Gen: no apparent distress HEENT: neck supple, no masses Card: regular rate and rhythm, no murmurs, rubs, or gallops Lungs: clear to auscultation bilaterally, no wheezes, rales, or rhonchi Abd: soft, nontender, incision clean, dry, and intact, ostomy pink and viable Ext: no clubbing, cyanosis, or edema Neuro: CNII-XII grossly intact Pertinent Results: [**6-1**] CT abd/pelvis 1. Small bowel obstruction, at least partial. No distinct transition point is identified, though it appears to be located within the pelvis involving the ileum. There is no free air or significant ascites at this time. Obstructed bowel loops are more dilated than seen in [**2105-5-15**]. 2. Moderate right-sided hydronephrosis, unchanged from the prior exam. Pathology specimen from [**2105-6-9**] Small bowel (3.3 cm): Mild mucosal edema, otherwise unremarkable small bowel. [**6-23**] abdominal Xray No evidence of underlying bowel obstruction. Probable constipation/impaction with a large amount of stool noted within the descending colon, sigmoid, and rectum. Brief Hospital Course: Ms. [**Known lastname 43251**] was admitted to the hospital on [**6-1**] for partial small bowel obstruction. She treated with a nasogastric tube, IV fluids, nothing by mouth, and pain control. PICC placed on [**6-4**] and transferred to general surgery care. TPN started at that time. NGT was clamped and she had significant nausea. She was taken to the operating room on [**6-9**] for LOA and enteroenterostomy and tolerated the procedure well. On POD#1 she had an episode of hypotension and responded well to fluid boluses only transiently so was transferred to the ICU. [**Last Name (un) **] stim test was ordered and was nromal. Levo and flagyl were given and TPN restarted. Was transfused one unit of blood for Hct of 21. Levo and Flagyl were dc'ed after 4 days. Again on [**6-13**] the patient was taken to the OR for exploratory laparotomy to r/o anastomotic leak/peritonitis. No leaks or peritonitis was found on laparotomy. One episode of tachycardia was responsive to fluid bolus, otherwise the patient was hemodynamically stable the remainder of the hospitalization. She was evaluated for confusion and serial neuro exams showed no focal or cognitive deficits below baseline. As bowel function returned diet was advanced and she was weaned from TPN. Pain was controlled on oral pain meds. Pt began working with PT on walking, transfers, and stairs. She was cleared by PT to go home with services. The pt was discharged home with services on POD 20/16. Medications on Admission: Lipitor 20mg Plavix 75mg levothyroxine 137 mcg Combivent Albuterol Fentanyl patch 50mcg q72 Colace Senna Bisacodyl Oxycodone Fluoxetine 20 Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 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): to prevent narcotic-induced constipation. Disp:*60 Capsule(s)* Refills:*2* 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Small Bowel Obstruction pelvic carcinoma Discharge Condition: Good Tolerating Regular diet, no nausea or vomiting. Denies pain, well regulated Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. Activity: No heavy lifting of items [**9-28**] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. You will be given pain medication which may make you drowsy. No driving while taking pain medicine. Followup Instructions: 10 days to 2 weeks in Dr. [**Last Name (STitle) **] clinic. Please call ([**Telephone/Fax (1) 32046**] to schedule appointment

[ "560.81", "530.81", "401.9", "493.90", "244.1", "V10.51", "V55.6", "281.1", "272.0", "591", "V12.59", "458.29", "V15.3" ]

icd9cm

[ [ [] ] ]

[ "54.12", "99.04", "96.07", "38.93", "99.15", "54.59", "45.91" ]

icd9pcs

[ [ [] ] ]

6308, 6365

4057, 5536

297, 405

6449, 6532

3341, 4034

7445, 7575

2838, 2927

5725, 6285

6386, 6428

5562, 5702

6556, 7422

2942, 3322

225, 259

433, 1637

1659, 2546

2562, 2822

22,083

164,176

50474

Discharge summary

report

Admission Date: [**2189-5-28**] Discharge Date: [**2189-6-10**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: fevers hypotension Major Surgical or Invasive Procedure: removal of PICC line History of Present Illness: Pt is an 89 yo man s/p AAA repair [**4-21**] with a complicated post op course including question of incarcerated hernia ([**5-15**]) s/p SBR+hernia repair, ARF, Afib, UTI, C.diff, Achalsia, EGD [**5-13**], hypernatremia, pneumonia, PICC TPN -> [**Month/Day (4) 282**] placement, [**5-22**]. Pt was d/c'd to rehab [**5-26**] and subsequently transferred [**5-28**] to [**Hospital3 417**] Hospital with fever to 101.8, where he was diagnosed with a R PNA. At OSH Pt transferred to ICU treated with broad antibiotic coverage and neo for BP support. He was then directly transferred to [**Hospital1 18**] SICU. He was hemodynamically stable on arrival. He was emperically covered with vanco/piptazo/flagyl (pt with hx of c.diff) . He complained of abdominal pain and an I+ CT abdomen revealed: No definite evidence of graft infection, Moderate right pleural effusion and a distended gallbladder with multiple small stones and a stable R inguinal hernia. Pt was transferred to the floor on [**5-30**]. His INR was noted to be 5.1 at 5pm. His BP was 160/90 and his HR was >150 he was given 10mg IV lopressor. That night at 10 pm he desatted to the 60's on 4L. Patient received 0.25 mg IV Ativan at 9pm. Patient placed on a nonrebreather and 2mg Flumazenil IV pushed and sats returned to the 90's, an ABG prior to flumazenil was 7.36/215/33. EKG was unchanged with no ST changes. Stat labs were drawn and the HCT was found to be 25.6 from 31.5 at 5pm, 5 hours prior and cTropnT was 0.2 from 0.06 on [**5-24**]. He was transfused 1 unit of PRBCs. His CK and CKMB remained flat, his cTropT on [**5-31**] at 8am was 0.22 in the setting of CR of 1.1. Past Medical History: 1. CAD s/p CABG in [**2183**] at [**Hospital3 2358**] 2. CHF w/ EF of 40% on TEE in [**2187**], 1+ AR, 2+MR 3. Hypothyroidism 4. L THR [**5-/2182**] 5. Prostate CA s/p resection+XRT 6. AFib s/p d/c cardioversion [**2182**], on coumadin 7. GERD 8. Hiatal hernia 9. OA 10. Hypertension 11. Dyslipidemia 12. AAA Repair Social History: Widower, former furniture washer. Smoked 3ppd until 20 years ago. No alcohol use. Family History: noncontributory Physical Exam: T 97.8 HR 116 BP 100/65 RR 20 O2SAT 95%3L NC GEN: Thin elderly man lyin gin bed in NAD HEENT: PERRL, OP very dry with crusting CHEST: Scant crackles at the bases bilaterally, no egophany CV:[**Last Name (un) 3526**],[**Last Name (un) 3526**] no MRG ABD:soft nontender, +BS, well healed scar on left flank, and insicion in right inguinal region with CDI steristrips, EXT: no edema SKIN: many ecchymotic regions on arms bilaterally Neuro: AOX 2, person and place, patient mumbles and is very difficult to understand Pertinent Results: CXR - bilateral effusions, pulmonary edema ECHO [**2189-6-3**] The left and right atrium are markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] The right ventricular cavity is mildly dilated with borderline normal systolic function. [Intrinsic right ventricular systolic function may be more depressed given the severity of valvular regurgitation.] The aortic root and ascending aorta are moderately dilated. The aortic valve leaflets (3) are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild to moderate ([**2-8**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Brief Hospital Course: A/P 89 yo man s/p AAA repair and prolonged hospital course with multiple complications from [**4-20**] to [**5-26**] recently tranferred from OSH with fevers and hypotension. His possible sources of infection were felt to be his PICC, a pneumonia, his endograft, C. difficile colitis, or urosepsis. The PICC line was removed and the tip culture had no growth. He had multiple C.diff toxin assasys that were negative. He was seen by the vascular surgery service and had an abdominal CT without evidence of graft infection. His urinalysis was not consistent with a UTI. At an outside hospital, there was a question of a lingular pneumonia; however, his chest x-rays here revealed mainly evidence of congestive heart failure wqith bilateral pleural effusions and no obvious pneumonia. On admission; however, he was started on levofloxacin and metronidazole for possible pneumonia and his fever disappeared for the remainder of his hospital course. His congestive heart failure was difficult to control in the setting of his atrial fibrillation with rapid ventricular response (HR in the 130's to 140's). He had a repeat ECHO that revealed normal LV systolic function with a mildly dilated RV, [**2-8**]+ AR, 3+MR, and 3+TR. He was slowly titrated up on captopril, lopressor, and was diuresed with IV lasix. He was continued on coumadin for stroke risk reduction. His severe valvular dysfunction and diastolic/systolic heart failure made diuresis extremely difficult. After one week of attempted diuresis, Mr. [**Known lastname 59190**] decided that he did not want any further medical treatments except for those that would make him comfortable. His health care proxy, [**Name (NI) **] [**Name (NI) 1968**], was contact[**Name (NI) **] and was in agreement with his decision. He was treated with morphine for his respiratory discomfort, and he died the following day. He was pronounced dead at 9:55 AM on [**2189-6-10**]. His health care proxy, his primary care physician, [**Name10 (NameIs) **] the attending physician were all notified. Medications on Admission: Lisinopril 5', Coumadin 2', Lasix 40', KCl 10', Zithromax 250', Atenolol 37.5', Levothyroxine 88' Discharge Disposition: Extended Care Discharge Diagnosis: suspected pneumonia C. difficile colitis atrial fibrillation with rapid ventricular response moderate tricuspid and mitral regurgitation systolic congestive heart failure malnutrition aspiration coronary artery disease s/p abdominal aortic aneurysm repair Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none

[ "414.01", "458.29", "424.0", "397.0", "486", "427.31", "263.9", "518.84", "458.9", "428.23" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.6" ]

icd9pcs

[ [ [] ] ]

6554, 6569

4355, 6406

280, 303

6869, 6879

3014, 4332

6932, 6939

2447, 2464

6590, 6848

6432, 6531

6903, 6909

2479, 2995

222, 242

331, 1980

2002, 2330

2346, 2431

27,020

161,824

2404

Discharge summary

report

Admission Date: [**2195-11-13**] Discharge Date: [**2195-11-20**] Service: MEDICINE Allergies: Erythromycin Base / Benzodiazepines Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: VTach storm Major Surgical or Invasive Procedure: cardiac catheterization Electrophysiology Study History of Present Illness: 84 year-old male with history of CAD s/p CABG in [**2186**], VT with ICD in [**2186**], systolic dysfunction with EF 30% who is transferred from OSH for recurrent VT. He was brought in to OSH by EMS [**11-12**] after repeated runs of VT with ICD discharges. He had an ICD placed in [**2186**] for history of VT and had been stable on sotalol. However, in late [**Month (only) 216**] his ICD fired, with resultant increase in sotalol dose. On [**2195-11-9**] he had another episode of 310 ms [**First Name (Titles) **] [**Last Name (Titles) **]; he was switched to amiodarone. When he woke up yesterday morning, he had multiple shocks and fell, due to partial unresponsiveness. EMS started lidocaine gtt at 2 mg/min after a 100 mg bolus. Interrogation of his device in the OSH ED suggests 25-27 discharges. His primary cardiologist switched him to amiodarone gtt with 300 mg bolus. He was admitted to their ICU. . Yesterday, at 5 pm, the patient's amiodarone gtt was weaned with recurrent VT and ICD fired additional 9 times. Patient was awake and alert. Amiodarone bolus of 150 mg given. He was transferred to [**Hospital1 **] for EP eval. . Of note, per the patient he had an episode of emesis yesterday, which his daughters report appeared to be coffee-grounds. He has had no further episodes. He denies abdominal pain, black stools, or red stools. His last BM was yesterday. . On review of symptoms, he denies any cough, or hemoptysis. He denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, or syncope. He has been having lightheadedness for the past 2 days. Past Medical History: CAD s/p CABG x 4v in [**2183**], h/o MI in [**2170**] CHF with EF 30%, global hypokinesis h/o VT s/p [**Company 1543**] ICD placement in [**2186**] HTN Dyslipidemia Aortic Stenosis - mild s/p endovascular AAA repair in [**2195-2-26**] h/o bowel obstruction with cecum perforation s/p resection [**2186**] Social History: Social history is significant for the absence of current tobacco use. He quit smoking 20 years ago; 32 pack-year history. There is no history of alcohol abuse. Family History: There is a family history of sudden death in his brother at age 40. Physical Exam: VS: T 98.6, BP 150/85, HR 76, RR 17, O2 98% on 2LNC Gen: WDWN elderly male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 7 cm. CV: RRR, 2/6 systolic crescendo/decrescendo murmur with radiation to carotids. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. bibasilar crackles [**1-1**] of posterior lung fields, no wheeze, or rhonchi. Abd: Obese, slightly distended, with right sided ventral hernia- reducible. mild tenderness in RUQ/RLQ No HSM. normal bowel sounds. No abdominial bruits. Ext: No c/c/e. Skin: BLE venous stasis changes with large superficial veins. Pulses: Right: Carotid 2+ with bruit; Femoral 2+; 2+ DP Left: Carotid 2+ with bruit; Femoral 2+; 2+ DP Pertinent Results: LABS ON ADMISSION [**2195-11-13**] 05:28PM WBC-8.1 RBC-3.49* HGB-11.8* HCT-35.6* MCV-102*# MCH-33.9*# MCHC-33.3 RDW-15.1 [**2195-11-13**] 05:28PM PLT COUNT-222 [**2195-11-13**] 05:28PM VIT B12-131* FOLATE-GREATER TH [**2195-11-13**] 05:28PM TSH-1.1 [**2195-11-13**] 05:28PM CALCIUM-9.0 PHOSPHATE-2.8 MAGNESIUM-2.4 [**2195-11-13**] 05:28PM ALT(SGPT)-18 AST(SGOT)-29 CK(CPK)-380* [**2195-11-13**] 05:28PM GLUCOSE-127* UREA N-25* CREAT-1.5* SODIUM-141 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-23 ANION GAP-16 [**2195-11-13**] 06:07PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2195-11-13**] 06:07PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2195-11-13**] 06:07PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 TTE [**11-14**]: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is small. Overall left ventricular systolic function is low normal (LVEF 50%). There is no ventricular septal defect. The right ventricular cavity is markedly dilated. There is severe global right ventricular free wall hypokinesis. 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 at least mild aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Cardiac Cath [**11-16**]: 1. Coronary angiography in this right dominant system demonstrated an LMCA without angiographically significant disease. The LAD was proximally occluded after D1; the D2 had a 90% lesion at its origin, but was a small vessel. The LCX was a nondominant vessel that was proximally occluded. The RCA was proximally occluded. 2. Graft angiography demonstrated a patent sequential SVG to OM1 and OM3. The OM1 was without critical lesions, the OM3 was widely patent; the inferior pole of OM2 had a 90% lesion at the origin. The SVG to RCA was widely patent. The LIMA to LAD was patent. 3. Limited resting hemodynamics revealed very mild systemic arterial hypertension. 4. Selective angiography showed a tortuous left subclavian artery, but there were no critical lesions or pressure gradient. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent LIMA-LAD and patent SVGs. 3. Tortuous left subclavian without critical lesions or pressure gradient. CXR [**11-19**]: Two views of the chest are compared to the prior examination dated [**2195-11-18**]. Allowing for differences in technique there is no significant interval change. Small bilateral pleural effusions are noted. There is a stable left retrocardiac opacity likely reflects underlying atelectasis and/or consolidation. No pneumothorax is seen. There is a pacer device that projects over the left hemithorax with two leads terminating within the expected region of the right ventricle and one appears to be terminating within the right atrium. Cardiac silhouette remains enlarged. LABS ON DISCHARGE: WBC 8.5 Hct 31.6 Plts 251 Na 142 K 3.7 Cl 105 HCO3 28 BUN 24 Cr 1.7 Glu 123 PT 13.5 PTT 33.4 INR 1.2 Brief Hospital Course: 1) Cardiac Rhythm: The patient was transferred to the [**Hospital1 827**] on [**2195-11-13**] with VT storm. He was loaded with an IV amiodarone drip which was switched to 400 mg amiodarone po bid after 24 hours. On [**2195-11-16**], he underwent cardiac catheterization. To determine if the patient's VT was secondary to ischemia, he had a cardiac catherization. This demonstrated severe native vessel disease but with patent bypass grafts. Specifically, he had a patent sequential SVG to OM1 and OM3. The OM1 and OM3 were widely patent without critical lesions. In the inferior pole of OM2, he had a 90% lesion at the origin. The SVG to RCA was patent as was the LIMA to LAD. On [**2195-11-17**], he underwent diagnostic electrophysiology study. This demonstrated inducible monomorphic ventricular tachycardia in the RV outflow tract and apex which was ablated. In addition, the decision was made to upgrade his pacemaker with an atrial lead to a dual chamber PPM given his history of complete heart block and bradycardia. At the time of discharge, he was on amiodarone 400 mg [**Hospital1 **], which can be switched on amiodarone 400 mg daily on Sunday, [**11-22**]. His pacemaker was interrogated by EP prior to d/c and was functioning properly. He was also started on a heparin gtt and coumadin for occasional atrial flutter and atrial fibrillation during telemetry monitoring. He will complete a 7 day course of keflex and has an appointment to follow-up in device clinic. His beta-blocker may be further titrated up as an outpatient as tolerated. Ischemia: Troponin increased from 0.05 -> 2.5 on admission, likely from shocks. Cath on [**11-16**] showed native 3VD and patent grafts. The patient was continued on an aspirin and statin. ACE-I was held during the hospital admission due to a rising Cr up to 2.4, which at the time of discharge was back down to 1.7. His beta-blocker was also transiently held during the hospital course due to a concern for heart block on telemetry, which was restarted after placement of the dual chamber PPM. His ACE-I may be restarted as an outpatient once his Cr normalizes back to baseline. Pump: With a known EF 30%. As above, the ACE-I and lasix were held during the hospitalization for a bump in Cr, with the lasix being restarted prior to d/c. A TTE during this admission was significant for LVEF 50%, severe right ventricular free wall hypokinesis, mod PA systolic hypertension, and moderate to severe TR. 2) GI: Per the pt and his family, had an episode hematemesis on the day prior to admission. There were no further episodes of hematemesis during the hospital course and his Hct remained stable. The pt was initially placed on a PPI [**Hospital1 **], which was discontinued prior to discharge. Iron studies were significant for vitamin B12 deficieny, and repletion was begun. 3) ARF: With unknown baseline Cr and Cr on admission of 1.5 with peak to 2.4. FeUrea > 50. Pt's acute renal failure thought to be secondary to ATN [**1-30**] contrast induced nephropathy vs. poor forward flow. Meds were renally dosed and ACE-I and lasix were held. At the time of discharge, the pt's Cr was back down to 1.7 and lasix was restarted. He will need to have his ACE-I restarted as an outpatient. Access: PIV Code: FULL Comm: [**Name (NI) 717**] [**Name (NI) 12412**], daughter, [**Telephone/Fax (1) 12413**] Medications on Admission: ASA 81 mg QDay lisinopril 40 mg QDay amlodipine 10 mg QDay atorvastatin omeprazole ranitidine 150 mg QDay allopurinol 100 mg QDay furosemide 40 mg QAM amiodarone 400 MG QDay - started [**11-9**], was on sotalol prior to this Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day. 10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 5 days. 14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16): titrate to INR [**1-31**]. Discharge Disposition: Extended Care Facility: [**Hospital 12414**] Healthcare Center - [**Location (un) 12415**] Discharge Diagnosis: Primary Diagnosis: Ventricular Tachycardia Storm Secondary: Atrial fibrillation, coronary artery disease, Congestive heart failure, hypertension, Dyslipidemia Aortic Stenosis - mild Discharge Condition: stable Discharge Instructions: You were admitted for a heart arrhythmia causing your ICD to fire multiple times. During your hospitalization, you had a cardiac catheterization which showed disease of your native heart vessels, but that your bypass grafts did not have significant blockages. You also had an electrophysiology study that showed you have persistent ventricular tachycardia but we were unable to ablate those areas. Instead we upgraded your pacemaker to a two-chamber pacemaker with good result. Additionally you were started on a new medication: Amiodarone. This medication is to prevent further irregular heart rhythms. This medication can affect your lungs, thyroid, and liver so the function of these organs should be followed by your regular physician. [**Name10 (NameIs) **] new medications include: Coumadin (blood thinner, you should have your INR checked at least twice a week until stable) Metoprolol (Controls your heart rate and decreases risk for having irregular heart rhythm) Cephalexin (To be taken to prevent infections after your pacemaker change, only for a total of 7 days) Please take all medications as prescribed. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: chest pain, shortness of breath, shocks from your ICD, diarrhea/constipation, blood in the stools, or bloody vomit. Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2195-11-27**] 11:00 You should follow up with Dr. [**Last Name (STitle) 8421**] in [**12-30**] weeks after discharge for follow up of your cardiac issues. Please call his office to arrange this. Completed by:[**2195-11-20**]

[ "427.31", "424.1", "V15.82", "787.91", "E879.8", "V12.79", "593.9", "426.0", "584.5", "996.04", "428.0", "427.1", "401.9", "428.22", "412", "272.4", "266.2", "V45.81", "414.01", "V53.32" ]

icd9cm

[ [ [] ] ]

[ "37.34", "37.22", "88.56", "37.94", "37.26", "88.44", "88.57" ]

icd9pcs

[ [ [] ] ]

12119, 12212

7226, 10585

265, 314

12438, 12447

3635, 6299

13832, 14151

2639, 2708

10861, 12096

12233, 12233

10611, 10838

6316, 7070

12471, 13809

2723, 3616

214, 227

7089, 7203

342, 2116

12252, 12417

2138, 2444

2460, 2623

48,755

111,320

4565

Discharge summary

report

Admission Date: [**2160-7-26**] Discharge Date: [**2160-7-30**] Date of Birth: [**2094-1-12**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2736**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Coronary catheterization with Percutaneous Coronary Intervetion to proximal left anterior descending artery with placement of Drug Eluding Stent in the middle left anterior descending History of Present Illness: 66 y/o M hx of HPL, and MI [**2145**] with 90% stenosis of mid-RCA s/p BMS and [**2149**] rheolytic thrombectomy and 90% mid-LAD stenosis s/p DES to LAD who presented to the ED after sudden onset of chest pressure this am while working in his yard. His symptoms were typical of prior episodes when he was having a MI. He was sweating profusely and have crushing, non-radiating chest pain. He says that over the last few weeks he was getting more fatigued with activities he was usually able to do with [**Last Name **] problem. [**Name (NI) **] his wife, with the onset of the chest pressure, he started sweating more than usual and they knew he was having a heart attack. He stated that he tried a SL nitro with no relief, but his prescription was 1 year old. Per his wife he also appeared to lose consciousness for a few minutes while in the car, but was arousable. He was taken by truck back to the house and EMS was called, an EKG was notable for ST elevations and a code STEMI was called. He was taken directly to the cath lab where had systolic BPs ranging from 80-96/50-60s, he recieved 210 cc contrast, was loaded with Plavix 600mg, and started on heparin drip. LHC via the right radial artery revealed 100% occlusion of the mid-LAD within the prior stent. This was stented with a DES. In addition, there was a 80% stenosis of the origin of the diagonal branch within the LAD stent. There was a 3 mm segment of intraluminal filling defect 15 mm distal to the stent likely representing embolized thrombus and patient was started on integrilin drip. Vitals on transfer were 93/66 90 42 92% on 3L. . On arrival to the floor, patient stable, he had complaints of residual chest discomfort with exhalation, but much improved. He described is "when you just had a headache and it goes a way, you know you had a headache not too long ago". Otherwise he had no c/o SOB, cough, arm, neck or jaw pain. Denies f/c, n/v, abdominal pain, LE edema. Past Medical History: - CAD s/p PCI to mRCA '[**45**], mLAD '[**49**], PTCA of mLAD and diag '[**50**], - colon cancer s/p colectomy ([**2149**]) - nephrolithiasis - s/p cholecystectomy - HPL Social History: - Employed as an engineer, married with 3 sons -[**Name (NI) 1139**] history: smokes [**11-26**] ppk per day off and on for over 30 years -ETOH: less than 1 drink per week -Illicit drugs: No Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION: VS: T=98.2 BP=105/49 HR=107 RR=24 O2 sat=97% GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Flat neck veins. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE: GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Flat neck veins. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: [**2160-7-26**] 12:23PM BLOOD WBC-9.5 RBC-4.60 Hgb-14.3 Hct-42.2 MCV-92 MCH-31.0 MCHC-33.8 RDW-13.0 Plt Ct-277 [**2160-7-26**] 06:44PM BLOOD Neuts-82.0* Lymphs-11.9* Monos-5.6 Eos-0.1 Baso-0.4 [**2160-7-26**] 12:23PM BLOOD PT-10.8 PTT-23.6* INR(PT)-1.0 [**2160-7-26**] 06:44PM BLOOD Glucose-134* UreaN-11 Creat-1.0 Na-141 K-4.0 Cl-108 HCO3-23 AnGap-14 [**2160-7-26**] 12:23PM BLOOD CK(CPK)-89 [**2160-7-26**] 12:23PM BLOOD CK-MB-2 cTropnT-<0.01 [**2160-7-26**] 06:44PM BLOOD Calcium-8.9 Phos-2.8 Mg-1.9 [**2160-7-27**] 01:40AM BLOOD HDL-32 CHOL/HD-3.8 LDLmeas-77 . . STUDIES: ([**2160-7-26**]) CXR: In comparison with the study of [**7-26**], there is little overall change. Cardiac silhouette remains within normal limits. Mild indistinctness of pulmonary vessels could reflect some elevated pulmonary venous pressure. No acute focal pneumonia or pleural effusion . . ([**2160-7-26**]) CATH: ASSESSMENT Coronary angiography: right dominant . LMCA: Normal . LAD: 100% occlusion of the mid LAD within the prior stent. There was a 80% stenosis of the origin of the diagonal branch within the LAD stent. The distal LAD was a large disbtribution vessel that supplied the apex. There were small 2nd and 3rd diagonal branches that supplied the anterolateral wall. . LCX: The proximal and distal LCx had minimal lumen irregularities. Threw was a large OMB that supplied the posterolater wall. It was free of significant disease. . RCA: The RCA stent was widely patent. The was a 50% margin stenosis distal to the stent that supplied a large PDA branch and medium size posterolateral branches. . Interventional details . The indication for the procedure was an anterior STEMI. . The procedure was performed from the right radial artery without complications . Unfractionated heparin was used to achieve an ACT > 250 seconds. Eptifibatide was given as a double bolus. . Using a 6Fr XB3.5 guiding catheter and a 0.014 OTW BMW wire, the LAD was dilated with a 2.5 mm balloon. There was lesion rigidity in the distal portion of then stent and a 2.75 mm x 12 mm Apex NC balloon was used to fully expand the stent. A 2.0 mm balloon was used to dilated the diagonal branch prior to additional stent implantation. A 2.75 mm x 14 mm Resolute drug eluting stent was then deployed within the stent and was post dilated with a 3.0 mm balloon to 22 atms pressure. This resulted in no residual stenosis within the stent and TIMI 3 flow into the distal vessel. . There was a 50-60% stenosis of the origin of the diagonal branch but TIMI 3 flow into the distal vessel. . There was a 3 mm segment of intraluminal filling defect 15 mm distal to the stent that likely represented embolized thrombus. It was laminar and seen in the [**Doctor Last Name **] but not the LAO projections. It will be treated with continued antiplatelet therapy and GPIIB-IIIa antagonists for 18 hours. Consideration for long term anticoagulation with warfarin with evidence of an LV aneurysm. . The patient was painfree at the end of the procedure, but the EKG showed improved but persistent ST elevation in the anterior precordial leads. . ASSESSMENT 1. Anterior ST elevation due to LAD stent occlusion 2. Successful drug-eluting stent of the mid LAD PLAN 1. Aspirin 325 mg daily for one month then 81 mg daily thereafter 2. Plavix 75 mg daily 3. Eptifibatide infusion x 18 hours 4. Echocardiogram for LV akinesis: consider anti-coagulation Brief Hospital Course: 66-year-old man with CAD s/p PCI to mRCA '[**45**], mLAD '[**49**], PTCA of mLAD ISR and diag '[**50**], and colon CA s/p colectomy '[**42**] presenting with substernal chest pressure while working in the yard. This is in the setting of increasing fatigue with daily activities. He presented to the ED where his ECG was consistent with an anterior STEMI and he was taken emergently to the cath lab. . ## STEMI - Left heart cath showed an occlusion of the mid-LAD at the site of a previous stent, 80% stenosis at the diag origin, and a 50% margin stenosis distal to the RCA stent. A drug-eluting stent was placed in the mid LAD with TIMI 3 flow into the distal vessel following stent placement. The patient had persistent ST elevations and Q-waves on post-procedure ECG suspicious for LV dyskinesis. He was started on an Integrilin gtt intraop x 18 hours total. Started on Heparin gtt after Integrellin given risk of developing LV Mural thrombus. Pt had an Echo on [**7-28**] that showed Mild symmetric left ventricular hypertrophy with regional left ventricular dysfunction(akinesis) c/w LAD territory MI. Preserved right ventricular function. No pathologic valvular disease. Based on this finding the patient was started on Warfarin with a Lovenox bridge. We continued the patient on Plavix 75mg daily, ASA 81mg daily, Metoprolol XL 150mg daily, atorvastatin 80mg/day. Lisinopril was started on [**2160-7-29**], 2.5mg daily. Given extensive CAD history, patient may benefit from ICD to decrease risk of SCD, will need to consider in > 90 days. His lisinopril could be uptitrated in the future and spironolactone could be initiated if his BP allows these medication changes. . ## TRANSITIONAL - Consider/discuss ICD placement > 90 days post PCI - Start spironolactone and uptitrate ACEI if BP allows - PCP to monitor INR and smoking cessation Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Aspirin 325 mg PO DAILY 2. Simvastatin 40 mg PO DAILY 3. Metoprolol Tartrate 50 mg PO DAILY Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 3. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 4. Lisinopril 2.5 mg PO DAILY hold for SBP < 90 RX *lisinopril 2.5 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 5. Warfarin 5 mg PO DAILY16 please check with your PCP about specific dosing based on the blood level INR RX *warfarin 2 mg 2.5 tablet(s) by mouth daily Disp #*75 Tablet Refills:*2 6. Outpatient Lab Work Chem-7, INR on Thursday [**2160-7-31**] with result to Dr. [**Last Name (STitle) 7842**] at Phone: [**Telephone/Fax (1) 8506**] Fax: [**Telephone/Fax (1) 19406**] ICD-9 428 CHF 7. Enoxaparin Sodium 100 mg SC BID RX *enoxaparin 100 mg/mL one syringe twice a day Disp #*8 Syringe Refills:*2 8. Metoprolol Succinate XL 150 mg PO DAILY hold for SBP<100, HR<60 RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth daily Disp #*45 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: ST elevation myocardial infarction Acute on chronic systolic congestive heart failure Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 19407**], You were admitted for chest pain, which was due to a heart attack. You were evaluated by cardiologist and they performed a procedure that involved opening the blocked vessel and placing a drug eluting stent. After the procedure you had an echocardiogram of the heart that showed the poor movement of the left and lower side of the heart. This poor movement increases your risk of developing a clot in that part of your heart. To prevent clot formation, you will need to take a blood thinner medicine called Warfarin. This is in addition to the Plavix and Aspirin. You will need to have blood levels of the Warfarin checked regularly and communicate with the [**Hospital 3052**] at [**Hospital 1411**] Medical about those results. You will need to use the Lovenox injections until the blood level of Warfarin (called INR) is between 2.0 - 3.0. You can stop Lovenox injections at that time when the [**Hospital3 **] says it is OK. Please stop smoking. Continuing smoking will significantly increase your risk for additional heart attacks, and strokes, not to mention the risks of multiple cancers. Because your heart is weak, please weigh yourself every day in the morning before breakfast. Call Dr. [**Last Name (STitle) 7842**] if weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. Watch for trouble breathing and your legs for signs of swelling. Call Dr. [**Last Name (STitle) 7842**] if you notice any of those symptoms. MEDICATIONS: START Warfarin 5mg by mouth daily, change dose after discussion with your PCP START Clopidogrel(Plavix) 75mg/day and Aspirin 81mg/day, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking this medicine unless Dr. [**First Name (STitle) **] says that it is OK. START Lovenox 100mg injection twice daily Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] S. Specialty: Primary Care Location: [**Hospital **] MEDICAL ASSOCIATES-[**Location (un) **] Address: [**Location (un) 11898**], [**Location (un) **],[**Numeric Identifier 9310**] Phone: [**Telephone/Fax (1) 8506**] Appointment: Tuesday [**2160-8-5**] 3:00pm Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Doctor Last Name 19408**] MD Location: [**Hospital **] MEDICAL ASSOCIATES Department: Cardiology Address: ONE [**Location (un) 542**] ST, [**Location (un) **],[**Numeric Identifier 9311**] Phone: [**Telephone/Fax (1) 8506**] Appointment: Thursday [**2160-8-28**] 10:45am

[ "414.2", "272.4", "428.0", "401.9", "996.72", "414.00", "428.23", "410.11", "427.1", "305.1", "414.01", "V45.82", "E879.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11319, 11325

8179, 10026

315, 500

11470, 11470

4716, 4716

13469, 14121

2905, 3020

10269, 11296

11346, 11449

10052, 10246

11621, 13446

3035, 4697

265, 277

528, 2486

4732, 8156

11485, 11597

2508, 2679

2695, 2889

44,922

147,783

39754

Discharge summary

report

Admission Date: [**2132-12-23**] Discharge Date: [**2132-12-31**] Date of Birth: [**2073-7-26**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2132-12-23**] Aortic Valve Replacement (#19mm St.[**Male First Name (un) 923**] tissue)/Mitral Valve repair (#26mm CE Phsio ring) History of Present Illness: This is a 58yo female with known valvular heart disease and COPD. Recently presented to OSH in [**Month (only) 216**] with chest and epigastric pain along with shortness of breath. Troponins were mildly elevated at that time. She underwent extensive cardiac workup which included echocardiogram and cardiac catheterization which revealed moderate aortic stenosis and insufficiency along with moderate mitral regurgitation. Based upon the above results, she was referred for cardiac surgical evaluation. Her current symptoms include dyspnea on exertion and two pillow orthopnea. She currently denies chest pain, SOB at rest, syncope, presyncope, pedal edema, fevers and chills. Past Medical History: - Aortic Stenosis/Aortic Insufficiency, Mitral Regurgitation - Dyslipidemia - Chronic Obstructive Pulmonary Disease - History of Right Breast Cancer, s/p XRT - Fibromyalgia, Chronic Low Back Pain - Depression - GERD - Tremors - Pulmonary nodules . Past Surgical History: - Right Breast Lumpectomy - Bilateral Elbow - Right shoulder - Hysterectomy - Tonsillectomy Social History: Previously had a cleaning business & worked as a bartender. Lives with her son. -Tobacco: Smokes one-half PPD, 40 pack-year history -ETOH: 3 drinks/week -Illicit drugs: Denies. Family History: Uncle with MI. Father - CVA. Mother - COPD. [**Name2 (NI) **] family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Pulse: 96 O2 sat: 100% room air 124/65 General: Female, appears older than stated age of 58, in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] - decreased at bases Heart: RRR [x] Irregular [] Murmur [**3-2**] mixed diastolic, systolic murmurs Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: None Varicosities: None [x] Neuro: minimal tremors noted. Alert and oriented x3. grossly intact. 5/5 strength in all extremities. No focal deficits noted Pulses: Femoral Right: 1 Left: 1 DP Right: 1 Left: 1 PT [**Name (NI) 167**]: 1 Left: 1 Radial Right: 1 Left: 1 Carotid Bruit: transmitted murmur B carotids, L>R Pertinent Results: [**2132-12-23**] Intraop TEE - PRE-BYPASS: The left atrium is moderately 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. The left ventricular cavity size is top normal/borderline dilated. There is moderate regional left ventricular systolic dysfunction with XXX. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. Moderate to severe (3+) mitral regurgitation is seen. There is no pericardial effusion. POST CPB: 1. Improve global LV systolic function /EF +50% (Epinephrine Infusion) 2. Preserved right ventricular systolci function 3. Full annuloplasty ring identrified in the mitral position. Well seated and no leaflet restriction. Peak gradient = 4 mm Hg. MVA by PHT = > 3 cm2 4. Bioprosthetic valve in aortic position. Well seated and stable with good leaflet excursion. No AI and PG = 19 mm Hg. Intact aorta. No other change. . [**2132-12-31**] WBC-11.0 RBC-3.37* Hgb-10.2* Hct-30.7* Plt Ct-335 [**2132-12-30**] WBC-8.3 RBC-3.17* Hgb-9.6* Hct-29.4* Plt Ct-248 [**2132-12-29**] WBC-8.2 RBC-3.03* Hgb-9.2* Hct-28.1* Plt Ct-168 [**2132-12-28**] WBC-8.1 RBC-3.05* Hgb-9.9* Hct-28.3* Plt Ct-133* [**2132-12-31**] Glucose-111* UreaN-14 Creat-0.8 Na-141 K-4.6 Cl-102 HCO3-30 [**2132-12-29**] Glucose-114* UreaN-11 Creat-0.6 Na-142 K-4.2 Cl-103 HCO3-30 [**2132-12-28**] Glucose-100 UreaN-11 Creat-0.6 Na-141 K-3.4 Cl-103 HCO3-32 [**2132-12-27**] Glucose-115* UreaN-14 Creat-0.6 Na-142 K-3.3 Cl-102 HCO3-29 [**2132-12-26**] Glucose-97 UreaN-17 Creat-0.8 Na-141 K-4.2 Cl-105 HCO3-27 [**2132-12-25**] Glucose-121* UreaN-15 Creat-0.9 Na-137 K-4.2 Cl-102 HCO3-27 [**2132-12-31**] Calcium-9.1 Phos-5.0*# Mg-2.2 Brief Hospital Course: On [**2132-12-23**] patient underwent aortic valve replacement (#19mm St.[**Male First Name (un) 923**] tissue) and mitral valve repair with Dr.[**Last Name (STitle) **]. CROSS CLAMP TIME=105MINUTES. CARDIOPULMONARY BYPASS TIME=128 minutes. Please refer to operative report for further surgical details. She tolerated the procedure well and was transferred to the CVICU for invasive monitoring. She awoke agitated and was given Precedex with good effect and was weaned to extubation on POD1 morning. Later that day she developed mental status changes. She required Lorazepam for agitation and CPAP for hypercarbia secondary to sedation necesssary to prevent self injury. She went into respiratory distress, developed a respiratory acidosis and was reintubated. It was thought that her mental status changes were due to alcohol withdrawl vs toxic metabolic encephalopathy post bypass. She was started on Versed and Fentanyl, new lines were placed and she was kept intubated for several days. On [**2132-12-26**] she was weaned from the ventilator and sedation and extubated without incident. She was given nebulizers and Flovent with a history of smoking and intravenous Tylenol for pain. She weaned off intravenous antihypertensives, was started on PO beta-blockade. All lines and drains were discontinued per protocol and without complication. She remained in the CVICU until postoperative day five due to postoperative confusion and tenuous pulmonary status. She was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. Beta blockade was titrated up for better heart rate control and Lisinopril was added for blood pressure control and depressed LV function(EF 35%). On postoperative day seven, she became slightly tachycardic and short of breath. She was given additional Lasix with improvement in symptoms. She gradually weaned off oxygen with a sat of 92-97% on room air at the time of discharge. At time of discharge, she was ambulating without difficulty, tolerating a full oral diet and surgical incisions were healing well. She continued to progress and was ready for discharge to [**Hospital **] Nursing and Rehab on postoperative day eight. All follow up appointments were advised and arranged prior to discharge. Medications on Admission: ?Aspirin 81 qd, Albuterol MDI prn, Advair 250/50 one puff twice a day, Amitriptyline 50 qhs, Citalopram 40 qd, Cyclobenzaprine 10 qhs, Gabapentin 300 qhs, Zocor 80 qd, Omeprazole 20 qd, Nicotine patch, Vicodin prn, Tylenol 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. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*0* 4. Combivent 18-103 mcg/Actuation Aerosol Sig: [**1-27**] Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*1 1* Refills:*0* 5. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*30 Disk with Device(s)* Refills:*0* 7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever: Do not exceed 4 gms daily. Disp:*30 Tablet(s)* Refills:*0* 9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:*4 Tablet(s)* Refills:*0* 12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 14. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*180 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital 27838**] Rehabilitation & [**Hospital **] Care Center - [**Hospital1 1474**] Discharge Diagnosis: s/p Aortic Valve Replacement (#19mm St.[**Male First Name (un) 923**] tissue)/Mitral Valve repair (#26mm CE Phsio ring) Aortic Stenosis/Aortic Insufficiency Mitral Regurgitation Dyslipidemia Chronic Obstructive Pulmonary Disease History of Breast Cancer, s/p XRT Fibromyalgia, Chronic Low Back Pain Discharge Condition: When to Call 911 You should call 911 or your local emergency number to be taken to the nearest emergency room for any emergency situation, such as: * Chest pain not related to your incision or angina pain, similar to the pain you had prior to surgery * Extreme shortness or breath or difficulty breathing * Severe bleeding, especially if you are on warfarin (Coumadin) * Fainting, severe lightheadedness or changes in mental status When to Call Your Surgeon Call your surgeon ([**Telephone/Fax (1) 1504**] (24 hours a day, seven days a week) if any of the following occur: * Your incision is warm, red or swollen or there is increased tenderness or pain * Any of your incisions have ANY fluid or drainage coming out * You have a fever of 100.5 degrees Fahrenheit or higher * Your weight has gone up more than two pounds in one day or five pounds in a week * You have severe pain or increased swelling in either leg * You have palpitations * You feel dizzy or weak (if severe, call 911) * You notice any of the following, especially if you are on warfarin (Coumadin) o A lot of dark, large bruises o Black or dark bowel movements o Pain, discomfort or swelling in any area, especially after an injury o Severe or unusual headache (if symptoms are severe, please call 911) Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Discharge Instructions Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr.[**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2133-1-28**] at 1:45pm Cardiologist: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2133-1-29**] at 5:00pm Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17025**] in [**1-27**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2132-12-31**]

[ "272.4", "518.52", "276.2", "530.81", "458.29", "496", "396.2", "285.1", "311", "781.0", "729.1", "V17.49", "V10.3", "305.1", "724.2" ]

icd9cm

[ [ [] ] ]

[ "35.12", "96.71", "88.72", "96.04", "35.21", "39.61", "38.93" ]

icd9pcs

[ [ [] ] ]

9363, 9478

4978, 7285

332, 467

9821, 11097

2790, 3753

12133, 12741

1771, 1945

7563, 9340

9499, 9800

7311, 7540

11121, 12110

1467, 1560

1960, 2771

273, 294

495, 1174

1196, 1444

1576, 1755

3763, 4955

27,910

138,196

13154

Discharge summary

report

Admission Date: [**2116-6-14**] Discharge Date: [**2116-6-26**] Date of Birth: [**2041-7-21**] Sex: M Service: CARDIOTHORACIC Allergies: Flomax / Ace Inhibitors Attending:[**First Name3 (LF) 5790**] Chief Complaint: Tracheal stenosis. Major Surgical or Invasive Procedure: 7-0 Portex redo tracheostomy, flexible bronchoscopy, upper endoscopy. History of Present Illness: Mr. [**Known lastname 39325**] is a 74-year-old gentleman who had a previous tracheostomy tube and then suffered breathing difficulties and was found have a tracheal stenosis which was treated with an upper tracheal stent. He underwent removal of that stent and a linear membranous tracheal tear was noted. He also was noted to have significant stenosis in the upper trachea and subglottic and glottic regions. He was referred for redo-tracheostomy. Past Medical History: Tracheal stenosis by bronch ([**2116-5-27**]), Perforated sigmoid colon diverticulitis with peritonitis s/p colostomty([**2116-3-8**]) Coronary Artery Disease Paroxysmal atrial fibrillation Transient Complete Heart Block Diabetes Mellitus typeII Peripheral Vascular disease Hypertension Hypothyroidism Gout, DVT ([**3-7**]) Anxiety Acalculous cholecystitis Pertinent Results: [**2116-6-25**] 08:10AM BLOOD WBC-13.3* RBC-3.91* Hgb-11.0* Hct-32.8* MCV-84 MCH-28.1 MCHC-33.4 RDW-16.7* Plt Ct-560* [**2116-6-18**] 10:28PM BLOOD WBC-17.9* RBC-3.62* Hgb-10.3* Hct-29.7* MCV-82 MCH-28.4 MCHC-34.6 RDW-17.0* Plt Ct-313 [**2116-6-15**] 05:46AM BLOOD WBC-11.9* RBC-3.54* Hgb-9.9* Hct-29.7* MCV-84 MCH-28.0 MCHC-33.4 RDW-17.0* Plt Ct-388 [**2116-6-14**] 07:47PM BLOOD WBC-12.0* RBC-3.74* Hgb-10.7* Hct-30.4* MCV-81* MCH-28.5 MCHC-35.2* RDW-16.6* Plt Ct-361 [**2116-6-25**] 08:10AM BLOOD PT-13.4* PTT-25.5 INR(PT)-1.2* [**2116-6-14**] 07:47PM BLOOD PT-21.8* PTT-26.9 INR(PT)-2.1* [**2116-6-25**] 08:10AM BLOOD Glucose-120* UreaN-26* Creat-1.1 Na-141 K-4.0 Cl-111* HCO3-20* AnGap-14 [**2116-6-14**] 07:47PM BLOOD Glucose-129* UreaN-21* Creat-1.1 Na-142 K-4.2 Cl-111* HCO3-22 AnGap-13 [**2116-6-16**] 02:07AM BLOOD ALT-12 AST-15 AlkPhos-72 TotBili-0.2 [**2116-6-24**] 08:20PM BLOOD Vanco-20.0 [**2116-6-22**] 11:48AM BLOOD Type-ART pO2-103 pCO2-44 pH-7.44 calTCO2-31* Base XS-4 [**2116-6-22**] 11:48AM BLOOD Lactate-1.3 [**2116-6-14**] 08:04PM BLOOD Glucose-130* Lactate-2.0 Na-139 K-4.2 Cl-112 calHCO3-24 [**2116-6-22**] 11:48AM BLOOD freeCa-1.20 [**2116-6-20**] 3:30 pm STOOL FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA [**2116-6-18**] 4:52 pm BLOOD CULTURE STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY [**2116-6-17**] 7:51 pm SPUTUM MRSA [**2116-6-15**] 10:09 am MRSA SCREEN METHICILLIN RESISTANT STAPH AUREUS Brief Hospital Course: 74 yo male with multiple medical problems presented to [**Hospital1 18**] from OSH with dyspnea thought to be caused by tracheal stenosis. Patient arrived complaining of fevers, chills, SOB, DOE. Patient was admitted to the ICU, started on Abx and thought to have tracheal malacia and was scheduled for rigid bronch on [**6-17**]. The bronch was performed without difficulty and the previous stent was removed and the patient was found to have a tracheal tear and significant stenosis in the upper trachea and subglottic and glottic regions. During the postoperative check the CXR showed a moderate right pneumothorax for which a chest tube was placed. A tracheostomy was performed the following day along with a bronch and upper endoscopy [**6-18**]. The patient remained in the SICU postop and was weaned off the vent to trach mask on [**6-21**]. The patient was found to have C-diff and MRSA PNA on [**6-23**] and was treated with the appropriate antibiotics. The patient progressed well and was transferred to the floor on [**6-24**] and was started on anticoagulation for his a-fib with coumadin and lovenox bridge. ENT also evaluated the patient for his tracheal stenosis and recommended placing the patient on aspiration precautions and starting him on Nexium which were all done. The patient was also given a swallowing evaluation which recommended soft solids, thin liquids. The patient was in good condition throughout his transfer to the floor therefore the decision was made to transfer the patient to rehab. Medications on Admission: Coumadin 2.5/5 mg Diltiazem 180 mg once daily Lopressor 50 mg once daily Lipitor 20 mg once daily Pepcid 20 mg once daily Levoxyl 25 mg once daily Allopurinol 100 mg once daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): through [**7-5**]. 8. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Vancomycin 750 mg IV Q 12H Please draw trough prior to 4th dose 10. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): Until INR reaches 1.8 then stop. 11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): To maintain INR 2.0-2.5. 12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 14. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Discharge Disposition: Extended Care Discharge Diagnosis: Tracheal Stenosis Perforated sigmoid colon diverticulitis with peritonitis [**2116-3-8**] s/p colostomy Paroxysmal atrial fibrillation Diabetes mellitus type II Hypothyroidism Gout DVT [**3-7**] Anxiety Acalculous cholecystitis MRSA sputum Discharge Condition: Stable Discharge Instructions: Call Dr.[**Name (NI) 2347**] office ([**Telephone/Fax (1) 170**]) if you experience any of the following symptoms: * Fever (>101 F) or chills * new and continuing nausea or vomiting * Abdominal or chest pain * Shortness of breath * Redness or drainage, swelling, warmth, or pus production around wound site * Any other concerns You may remove your dressings Mon [**2116-5-25**] and shower. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. You may resume your regular diet as tolerated. Resume your home medications as previously directed. Followup Instructions: Follow-up with Dr.[**Name (NI) 2347**] office ([**Telephone/Fax (1) 170**]) on Tuesday [**7-7**] at 10:00 am. Please report to the [**Hospital Ward Name 12837**], [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]. Please report to the [**Location (un) **] radiology for a chest x-ray 45 minutes before your appointment. Follow-up with Dr.[**Name (NI) 14680**] on Tuesday [**7-7**] at 11:30 in the Interventional Pulmonary on the [**Hospital Ward Name 516**] [**Hospital1 **] I floor. Follow-up with Dr. [**First Name (STitle) **] in [**12-3**] weeks call for an appointment [**Telephone/Fax (1) 2349**] Follow-up with Dr. [**Last Name (STitle) 40138**] for coumadin follow-up after discharge from rehab Completed by:[**2116-7-1**]

[ "250.00", "300.00", "244.9", "482.41", "008.45", "V09.0", "V44.3", "401.9", "512.1", "414.01", "443.9", "V12.51", "519.19", "274.9", "427.31", "V12.79" ]

icd9cm

[ [ [] ] ]

[ "45.13", "31.42", "34.04", "33.21", "96.72", "31.1", "96.6", "33.23" ]

icd9pcs

[ [ [] ] ]

5723, 5738

2741, 4264

310, 382

6022, 6031

1261, 2718

6938, 7688

4491, 5700

5759, 6001

4290, 4468

6055, 6915

251, 272

410, 862

884, 1242

21,220

110,171

47445+47446

Discharge summary

report+report

Admission Date: [**2172-7-26**] Discharge Date: [**2172-8-4**] Date of Birth: [**2112-4-1**] Sex: F Service: [**Last Name (un) **] SERVICE: Transplant service. CHIEF COMPLAINTS: Nausea and vomiting, abdominal pain times 2 days. HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old female who presented to the ER with complaints of nausea, vomiting, and abdominal pain times 2 days, status post small- bowel obstruction on [**2172-7-20**], with lysis of adhesions. A past medical history of chronic renal failure, substance abuse, chronic back pain and neutropenia. She was taking anti- hypertensive medications, as well as 4 Tylenol arthritis tablets, and 4 Percocet per day for the 3 days prior to admission. She presented to the ER hypotensive, and a sepsis protocol was initiated. She was given 9 liters of IV fluids, steroids and broad spectrum antibiotics. She was treated with dopamine, vasopressin and levo-fed. Workup in the ED showed a severe anion gap, metabolic gap. The patient had been discharged 2 days prior to admission and had developed lower abdominal pain and initially crampy in nature. The patient then tried to take small amount of soup and vomited an hour later she had to three more episodes of non bloody emesis and no BMs or flatus since prior morning also complained of some 50 and occasional lightheadedness. PAST MEDICAL HISTORY: Positive for type 2 diabetes, pancreatitis, hep C type 1, hypertension. SURGICAL HISTORY: Total abdominal hysterectomy in [**2155**], and small bowel obstruction with resection on [**2172-7-20**]. ALLERGIES: No known drug allergies. MEDICATIONS: Medications at home hydralazine 25 mg p.o. q.6h., atenolol 50 mg p.o. daily, nifedipine 90 mg daily, Percocet p.r.n., lisinopril 40 mg p.o. b.i.d., NPH insulin. PHYSICAL EXAMINATION: 95.7, heart rate 90, BP 77/42, respiratory rate 30, 96% on 4 liters. She was in no acute distress initially. Dry mucous membranes. Collapsed neck veins. LUNGS: Clear. Regular rate and rhythm for heart ABDOMEN: Mildly distended. Decreased bowel sounds, firm but not tense, tender, especially right lower quadrant, with questionable guarding, and rebound. Staples in place. Clean, dry and intact. No hernias. EXTREMITIES: 2+ DP. No clubbing, cyanosis or edema. LABORATORY DATA: Hematocrit was 40 on admission, lactate was 16.5. An NG tube was placed as well as a Foley. A KUB was done initially that demonstrated small bowel obstruction, similar to [**2172-7-19**]. A chest x-ray on admission demonstrated bibasilar atelectasis. No pneumonia or free intra-abdominal air was identified. HOSPITAL COURSE: She was transferred to the surgical intensive care unit. A CT scan was done of her abdomen, without contrast, that demonstrated bilateral pleural effusions, ascites, mesenteric stranding, and soft tissue stranding seen, consistent with third spacing of fluid. It was noted that she was post ileal anastomosis. The anastomotic site appeared patent. Contrast passed through the small bowel and into the colon, without any definite evidence of small bowel obstruction. No free intraperitoneal air was identified. She underwent a liver and abdominal Duplex Doppler exam, that demonstrated thrombus in the left portal vein. The remaining vasculature was patent. Hepatology consult was obtained. She noted that the patient had hep C, genu type 1. Her liver enzymes were elevated in the 1000s. She also had a Tylenol level of 45. Her total bilirubin was elevated at 2.6, AST was 3214, ALT 8538, alkaline phos 171, and total bilirubin 2.6. Amylase was 34 and lipase 8. Her lactate was 16.5. This decreased to 13.4 with treatment. Her INR was 4.4. She was treated for Tylenol overdose with acetylcysteine and IV bicarb. The transplant service was consulted as well, for consideration for liver transplant, as it was noted that the patient had a positive alcohol and cocaine toxicology 2 to 3 months prior to admission. Given former hepatic failure, sedation was minimized. She was intubated. Her LFTs started to trend down. Urine culture from admission was negative. Blood cultures were negative. RPR was negative. Varicella zoster IgG serology was positive, and CMV IgG was positive. CMV IgM was negative. These labs were part of the transplant workup. Her abdomen appeared distended. Her lactate level decreased to 13.7. She continued to be n.p.o. while in the surgical intensive care unit, and pressors were weaned off. Her blood pressure was stabilized in the 148/70 range. CVP is 8. She continued on IV Vancomycin, azofloxacin and Flagyl. She gradually improved. The ventilator was weaned off. Blood pressure pressors were stopped. She continued on Protonix for prophylaxis. Her urine output was improving with autodiuresis. She continued on an insulin drip for hyperglycemia. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8392**] consult was obtained, to help with management of hyperglycemia. Her crit was stable, her IV fluids were adjusted. TPN was utilized well. She was n.p.o. She was extubated on [**2172-7-29**]. Her abdomen was mildly tender diffusely. Incision was clean, dry and intact. Neurologically she was alert most of the time, following commands, and cooperative. Her diet was gradually advanced. She tolerated this without nausea or vomiting. She was transferred out of the surgical intensive care unit on [**2172-7-31**]. For the remainder of her stay, her liver function tests continued to decrease. Her antibiotics were stopped. Her vital signs remained stable. Physical therapy consult was obtained, and she was cleared for home by physical therapy. Her chronic renal insufficiency was back to baseline, with a creatinine of 1.3. Her AST dropped to 112, ALT to 39, alk phos 200 and T bili of 1.4. On [**2172-8-4**] she was discharged home in stable condition. Vital signs were stable. She was afebrile. Abdomen was soft, nontender, nondistended. She was tolerating a regular diet. She is ambulatory. DISCHARGE MEDICATIONS: 1. Hydralazine 25 mg p.o. t.i.d. 2. Nifedipine 90 mg, sustained release, 1 tablet daily. 3. Atenolol 50 mg p.o. daily. 4. Colace 100 mg p.o. b.i.d. 5. Protonix 40 mg p.o. daily. 6. Oxycodone 5 mg, 1 to 2 tablets p.o. p.r.n. q.6h. 7. Glargine 22 units subcutaneous at bedtime. 8. Humalog insulin sliding scale p.r.n. q.i.d. DISCHARGE DIAGNOSES: 1. Chronic renal insufficiency. 2. Hepatitis C virus with elevated liver transaminase, secondary to Tylenol overuse. 3. Dehydration. 4. Diabetes type 2. 5. Metabolic acidosis. 6. Acute and chronic renal insufficiency. DISCHARGE CONDITION: Stable. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1286**], MD [**MD Number(1) 11126**] Dictated By:[**Name8 (MD) 4664**] MEDQUIST36 D: [**2172-8-4**] 11:38:29 T: [**2172-8-5**] 11:58:16 Job#: [**Job Number 100366**] Admission Date: [**2172-8-8**] Discharge Date: [**2172-8-11**] Date of Birth: [**2112-4-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: "I fainted" Major Surgical or Invasive Procedure: Colonoscopy EGD History of Present Illness: This is a 60 yo female with DM2, HepC, and chronic pancreatitis who had a small bowel resection for SBO three weeks ago. She was readmitted last week for acute hepatitis secondary to Tyleonol overdose, which she was taking to control her post-operative pain. Since then, she had been well until last night when her roommate found her unconcious in a chair. Her insulin regimen was recently adjusted by her Endocrinologist at the [**Hospital **] Clinic. She as taking NPH [**Hospital1 **] but was switched to Lantus 22units five days prior. On night of admission, she took her own blood glucose at home and it was 69. Instead of taking the full 22 units, she gave herself 11 units. Half an hour later she passed out on her chair and her roommate found her unresponsive and called EMT. . In the ED, she received D50 and her FS was 416. She was given 5 units of insulin and her FS dropped to 47. She was given D50 again, and then transferred to medical floor for further management. . She also complained of worsening abdominal pain that she's had since her small bowel resection. She had been using oxycodone at home with good effect but she noticed increased pain since admission. . She currently feels well without CP/SOB, N/V/D, fever/chills or dysuria. Past Medical History: # HTN # DM2 # HepC # Chronic pancreatitis # Polysubstance abuse history # Acute hepatitis [**2-27**] Tylenol overdose # Total abdominal hysterectomy in [**2155**] # Small bowel obstruction with resection on [**2172-7-20**]. Social History: She reports cocaine and EtOH use. She reports having 1-2 drinks 2-3 times per week. no tobacco. Family History: non-contributory Physical Exam: VITALS: 99.3 130/66 67 18 97%RA GENERAL: Alert and oriented x 3, no acute distress HEENT: PERRLA, EOMI, oropharynx clear, MMM NECK: Supple, no JVD, no LAD CARD: RRR, Normal S1, S2, No murmurs, gallops or rubs PULM: Clear to ascultation bilaterally, no wheezes, rhonchi or rales ABD: Soft, non-distended, normoactive bowel sounds, generally tender with mild, rebound, no guarding, rectal tone significantly decreased. no perianal anesthesia. EXT: Warm, well perfused, 1+ LE edema, 2+ DP/PT pulses bilaterally NEURO: Non-focal, mobilizing all extremities Pertinent Results: [**2172-8-8**] 08:11AM BLOOD WBC-4.7 Hct-25.8* Plt Ct-123* MCV-97 . [**2172-8-8**] 08:30AM BLOOD PT-13.6* PTT-29.6 INR(PT)-1.2* . [**2172-8-8**] 08:11AM BLOOD Na-133 K-4.0 Cl-101 HCO3-21* UreaN-12 Creat-1.0 Glucose-400* . [**2172-8-9**] 06:00AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.5* Albumin-3.1* . [**2172-8-8**] 08:11AM BLOOD ALT-56* AST-47* AlkPhos-237* Amylase-75 Lipase-11 TotBili-1.0 . [**2172-8-8**] 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . [**2172-8-8**] 06:45AM URINE RBC-0 WBC-[**7-4**]* Bacteri-FEW Yeast-NONE Epi-0-2 . [**2172-8-8**] 06:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-SM . [**2172-8-8**] 06:22PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . . XRAY ABDOMEN ([**2172-8-8**]): 1. Nonspecific bowel gas pattern. No evidence of obstruction or free air. 2. Pancreatic calcifications. . ULTRASOUND RUQ ([**2172-8-8**]): 1. No evidence of cholelithiasis or acute cholecystitis. 2. Diffuse calcifications seen within the pancreas, consistent with changes of chronic pancreatitis, as was seen on recent CT scan. . COLONOSCOPY ([**2172-8-11**]): A single semi-pedunculated 7 mm polyp of benign appearance was found in the hepatic flexure. A single-piece polypectomy was performed using a hot snare. The polyp was not retrieved. . EGD ([**2172-8-11**]): Normal esophagus. Stomach: Excavated Lesions A single, linear ulcer-erosion was found in the antrum of the stomach. Cold forceps biopsies were performed for histology at the stomach antrum. Duodenum: Normal duodenum. . Brief Hospital Course: 60 year old female with DM2 and recent small bowel resection for SBO admitted for hypoglycemia seizure, course complicated by GI bleed. . # DM2 Her regular endocrinologist is Dr. [**Last Name (STitle) 3617**] at the [**Hospital **] Clinic. Her insulin was adjusted per recommendations from [**Last Name (un) **]. On this admission, she was put initially put on a conservative insulin sliding scale with Lantus 8mg QHS and then titrated up to Lantus 11mg QHS with a regular insulin sliding scale at discharge. She will follow up with Dr. [**Last Name (STitle) 3617**] at clinic. . # ABDOMINAL PAIN: It is likely post-operative pain. RUQ was negative for choleysistitis. Surgery was consulted and they felt that it is unlikely that her anastomosis is comprimised. Her abdominal pain was controlled with Dilaudid and then with oxycodone when she improved. She was discharged on low-dose oxycodone as needed. She will follow up with Dr. [**Last Name (STitle) **] who performed the surgery. . # GI BLEED: She had two bloody bowel movements during this hospitalization. One was bright red and one was melena, both guaiac postive. Her Hct remained stable between 25-26. Colonoscopy showed a 7mm polyp but otherwise unremarkable. EGD revealed a linear ulcer in the stomach but otherwise unremarkable. No sources of bleed were identified. She will followup with GI at clinic. The plan is to get a small bowel follow-through, and possibly a capsule study later on. She will continue Protonix at home. . # UTI: Her UA showed leukocytes and she finished 3 days of levoquin. She was asymptomatic and repeat UA was negative. . # TRANSAMINITIS: Resolving from her tylenol overdose on her last admission. . # HYPERTENSION: She was on metoprolol, nifedipine and lisinopril. She did not need hydralazine which she took at home. . # FOLLOWUP; She will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31573**] (PCP). Medications on Admission: # Colace 100mg [**Hospital1 **] # Protonix 40mg Daily # Lisinopril 40mg [**Hospital1 **] # Nifedipine XR 90mg Daily # Hydralazine 25mg TID # Atenolol 50mg Daily # Oxycodone 5mg Q6H 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. 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* 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: PRIMARY DX: Hypoglycemic seizure GI bleed UTI SECONDARY DX: Diabetes Chronic renal insufficiency Htn H/O substance abuse Chronic pancreatitis Discharge Condition: Hemodynamically stable, afebrile, ambulating. Discharge Instructions: Please follow up with all appointments. Take medication as prescribed. If you feel tremulous or light headed, seek medical attention immediatly. Call your doctor if you continue to have blood in your stool and if you have worsening abdominal pain. Followup Instructions: *** REGARDING YOUR GI BLEED *** 1. Schedule a 'small bowel follow-through' for this week. The number is: ([**Telephone/Fax (1) 2233**]. This is a study to make sure your bowels are stable after your recent surgery. 2. Schedule to see a gastroenterologist at their clinic to follow-up with your GI bleed. You should schedule this meeting after your 'small bowel follow-through.' He will interpret the study for you. The number to call is: ([**Telephone/Fax (1) 2306**]. 3. Schedule an appointment with your primary care physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31573**]. His clinic number is: [**Telephone/Fax (1) 250**]. ------------------ Here are your other appointments: # Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2172-8-13**] 9:10 # Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2172-8-20**] 3:20 # Provider: [**Name10 (NameIs) **] [**Doctor Last Name **] [**Doctor Last Name 22344**], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2172-9-15**] 3:30 # Provider: [**Name10 (NameIs) **], call ([**Telephone/Fax (1) 9011**] to schedule f/u Completed by:[**2172-8-24**]

[ "V08", "280.9", "585.3", "V45.3", "V58.67", "724.2", "780.39", "070.70", "584.9", "276.51", "965.4", "E932.3", "518.81", "570", "285.1", "403.91", "789.06", "250.82", "578.1", "303.90", "E850.4", "211.3", "599.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "45.42", "96.04", "96.71", "45.16", "99.15" ]

icd9pcs

[ [ [] ] ]

14161, 14167

11206, 13152

7259, 7276

14353, 14401

9558, 11183

14700, 16018

8950, 8969

6414, 6643

13387, 14138

14188, 14332

13178, 13364

2653, 6038

14425, 14677

8984, 9539

1835, 2635

7208, 7221

7304, 8570

8592, 8817

8833, 8934

14,100

119,877

3276

Discharge summary

report

Admission Date: [**2191-7-14**] Discharge Date: [**2191-7-17**] Date of Birth: [**2133-6-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 663**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EGD History of Present Illness: This is a 58 year old male with CAD, s/p CABG and recent PCI ([**6-27**]) on plavix and asa who presented to OSH w/presyncope/cp/weakness/diaphoreis and SOB. The patient also reported a history of black tarry stool and lightheadedness for 1 wk with fatigue and DOE. At the OSH on [**7-14**], in addition to shortness of breath, the patient was also found to have inferolateral ST depressions and was then transferred here to [**Hospital1 18**]. At OSH, Hct 31 and he received 2L IVF. In the [**Hospital1 18**] ED, the patient was started on integrillin and heparin boluses as he had mild SSCP and continued EKG changes. Shortly thereafter, Hct was unfortunately down to 25; integrillin and heparin were stopped and the patient was transfused 2U PRBCs. Guiaic positive stools were appreciated and the and was taken for EGD after large black guiaic positive BM in ED. EGD showed blood in the fundus, adherent clot to lower third of esophagus, likley evidence of [**Doctor First Name 329**] [**Doctor Last Name **] tear. The patient was subsequently intubated for airway protection and a clip was placed at the site of a 2cm M-W tear; 4 epi injections were also applied to area with control of bleeding. He has denied any NSAID use or abd pain. He had, however, recently been started on plavix and full strength asa from a baby asa alone after recent PCI with stent placement. A followup EGD was performed which showed no bleeding at the site of the clip and M-W tear, but there was erosion in GE junction with active bleeding (which was treated with termal therapy for hemostatic control.). The patient was subsequently extubated. In total, the patient received 9units of PRBCs. Past Medical History: * cabg [**2182**] LIMA->LAD, svg-> am, pda, om1, d1, d2, and ramus. * [**2181**] 3 stents to LAD * [**2191**] PCI of the SVG to OMII on [**6-27**] * htn * hyperlipidemia * prior imi Social History: carpenter, no smoking or etoh use. lives at home with wife. Family History: positive for cardiac disease. no history of GI bleeds. Physical Exam: VITALS: T98.7 P70 BP 119/69 R18 Sat 100%RA GEN:: lying in bed, alert and conversational, no acute distress HEENT: PERRL, MMM, clear OP, neck veins not elevated CHEST: CTAB no wheezes, rales or rhonchi CV: RRR no murmurs ABD: soft, obese, NT/ND, +BS EXT no edema, 2+DP pulses bilaterally NEURO: alert and orientedx3, II-XII intact, full strength 5/5 in all extremities Pertinent Results: [**2191-7-17**] 06:20AM BLOOD WBC-10.1 RBC-4.10* Hgb-12.0* Hct-34.6* MCV-84 MCH-29.3 MCHC-34.8 RDW-14.8 Plt Ct-132* [**2191-7-16**] 06:16PM BLOOD Hct-33.2* [**2191-7-16**] 11:59AM BLOOD Hct-32.8* [**2191-7-14**] 03:25PM BLOOD WBC-16.1*# RBC-2.98*# Hgb-8.5*# Hct-25.3*# MCV-85 MCH-28.7 MCHC-33.8 RDW-13.8 Plt Ct-306 [**2191-7-17**] 06:20AM BLOOD Plt Ct-132* [**2191-7-16**] 05:39AM BLOOD Plt Ct-102* [**2191-7-14**] 03:25PM BLOOD D-Dimer-239 [**2191-7-16**] 05:39AM BLOOD Glucose-111* UreaN-17 Creat-0.8 Na-142 K-3.7 Cl-110* HCO3-25 AnGap-11 [**2191-7-14**] 03:25PM BLOOD Glucose-146* UreaN-59* Creat-0.8 Na-137 K-4.3 Cl-107 HCO3-18* AnGap-16 [**2191-7-16**] 05:39AM BLOOD Calcium-8.0* Phos-2.3* Mg-2.0 [**2191-7-15**] 06:08AM BLOOD Lactate-1.1 ------- EGD [**7-15**] 1am Findings: Esophagus: Mucosa: An adherent clot with active oozing was noted in the lower third of the esophagus. Due to repeated epsidoes of vomitting patient was intubated for airway protection and endoscopy was repeated. The clot was dislodged with a polypectomy snare and revealed a 2cm [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear. Single [**Company 2267**] Endo clip was deployed with successful hemostasis. 4 1 cc.Epinephrine 1/[**Numeric Identifier 961**] injections were applied for hemostasis with success. Stomach: Contents: Clotted and liquid blood was seen in the fundus. Duodenum: Normal duodenum. Other findings: No blood was noted in duodenum. Impression: Blood in the fundus Adherent clot in the lower third of the esophagus No blood was noted in duodenum. Otherwise normal egd to second part of the duodenum Recommendations: Protonix IV bid Keep NPO Serial Hct, transfuse to keep Hct greater than 30. ------ EGD [**7-15**] 9am Findings: Esophagus: Lumen: A small size hiatal hernia was seen. Excavated Lesions The esophageal mucosa distal to the clip placement (within the hiatal hernia) was abnormal and was noted to be actively oozing. [**Hospital1 **]-CAP Electrocautery was applied for hemostasis successfully. Other The previously placed clip was seen in the distal esophagus. There was no bleeding directly associated with this lesion. Stomach: Contents: Bilious fluid was seen in the stomach. Duodenum: Normal duodenum. Impression: 1- Bilious fluids in stomach 2- The previously placed clip was seen in the distal esophagus. There was no bleeding directly associated with this lesion. 3- Erosion in the gastroesophageal junction with active bleeding (thermal therapy for hemostatic control) 4- Small hiatal hernia Recommendations: High dose (double dose) PPI Serial HCT, transfuse as necessary Carafate slurry 4x/day when extubated and taking PO. ICU monitoring for at least another 24 hours given high risk of bleeding ------ CHEST (PORTABLE AP) [**2191-7-15**] 2:02 AM FINDINGS: ET tube is seen with the tip approximately 5 cm above the carina. Again seen are median sternotomy wires and clips from prior CABG. The pulmonary vasculature is within normal limits. There is scattered atelectasis noted at the left lung base, which obscures the left costophrenic angle. No right-sided pleural effusion is seen. The soft tissue and osseous structures are normal. IMPRESSION: An ET tube is seen with the tip approximately 5 cm above the carina. Brief Hospital Course: * GI/CV: As discussed previously, the patient was found to have a significant [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear which was treated with emergent EGD and multiple blood transfusions (9 units). Documentation of EGD and associated interventions are documented above. Etiology of the M-W tear was cryptic insofar as the patient denied vomiting, abdominal pain, coughing. Etiology of the patient's initial presentation with chest pain and inferolateral ST depressions on EKG, on the other hand, was attributed to anemia and consequent demand ischemia. In total, the patient received 9 units of blood and serial Hct revealed no evidence of continued bleeding. The patient's diet was advanced and outpatient medications were reinitiated, including aspirin, plavix, statin, betablocker, and ace-i. The patient did not demonstrate any further evidence of bleeding on the [**Hospital1 **] floor as seen with serial Hcts. At discharge he was able to tolerate a regular house diet. The patient was advised to follow up with his PCP [**Name Initial (PRE) 176**] 3 days of discharge to have another Hct check and discuss long term screening for another possible episode of bleeding in the future. Medications on Admission: asa plavix zestril lipitor atenolol hctz vitamin c niacin flax seed oil niacin mvi Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 4 weeks: After 4 weeks, take 1 tablet daily. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Outpatient Lab Work Check a CBC within 3 days. Values should be reported to the patient's PCP. Discharge Disposition: Home Discharge Diagnosis: GI bleed, [**Doctor First Name 329**]-[**Doctor Last Name **] tear Discharge Condition: good Discharge Instructions: * Take all of your medications. Note: you should take protonix 40 mg twice daily for a minimum of 4 weeks. After that time, you may take 40 mg once a day. Discuss this change with your GI doctor. * Have a CBC checked within 3 days of hospital discharge * Make an appointment with your GI doctor within 5 days of hospital discharge * Seek medical attention for: black stool, blood per rectum, lightheadedness, dizziness, nausea, vomiting, diarrhea, abdominal pain, chest pain, shortness of breath, or any other concerning symptoms * See your PCP [**Name Initial (PRE) 176**] 5-7 days of hospital discharge for a follow up appointment * Do not smoke or drink alcohol Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2191-7-19**] 3:10 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 2207**] Date/Time:[**2191-8-1**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2191-8-1**] 10:30 ***Make an appointment with your GI doctor within 5 days of discharge from the hospital

[ "V45.81", "411.89", "401.9", "V45.82", "272.4", "530.7", "285.1" ]

icd9cm

[ [ [] ] ]

[ "42.33", "99.04" ]

icd9pcs

[ [ [] ] ]

8250, 8256

6097, 7325

322, 327

8367, 8373

2808, 6074

9089, 9823

2345, 2402

7458, 8227

8277, 8346

7351, 7435

8397, 9066

2417, 2789

274, 284

355, 2047

2069, 2252

2268, 2329

45,410

103,487

5267

Discharge summary

report

Admission Date: [**2179-10-22**] Discharge Date: [**2179-11-16**] Date of Birth: [**2104-10-10**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor / Lisinopril Attending:[**First Name3 (LF) 165**] Chief Complaint: shortness of breath/chest pain x 3.5 weeks Major Surgical or Invasive Procedure: [**2179-10-29**] Coronary artery bypass grafting x4: Left internal mammary artery to the left anterior descending, saphenous vein graft to the obtuse marginal, saphenous vein graft to the posterior descending artery and saphenous vein graft to the diagonal . [**2179-11-1**] Exploratory laparotomy and liver biopsy History of Present Illness: 75M with a history of atrial fibrillation, HTN, diastolic heart failure, ESRD s/p renal transplant in [**2176**], CAD s/p 2-vessel PCI/DESx2 in [**3-/2178**], possible new inferolateral reversible defect on p-MIBI in [**12/2178**], worsening exertional CP/SOB over the last month. He also complains of significant claudication symptoms. He describes the chest pain as sub-sternal, squeezing/sharp with radiation to his arms. He has been pre-medicating himself with nitroglycerin prior to exertion. He also complains of orthopnea, PND and cough productive of whitish sputum. He has been experiencing abdominal pain for the past month (RUQ) a/w mild nausea, no vomiting/diarrhea/constipation. History of mild dilation of distal aorta. No recent long travel, no recent surgeries. Came to ED today because granddaughter called his cardiologist who recommended evaluation. He denies fevers, chills, and diaphoresis. In the ED, initial vitals were 99 75 155/70 18 95% RA. No new EKG changes. Labs significant for TnT 0.05, CK:MB 135:3, BUN/Cr 35/2.2, proBNP 3083 and INR 1.1. The patient was totally chest pain-free in the emergency department. Patient given aspirin 81mg x 4. Vitals on transfer were 58 110/85 24 96%. On arrival to the floor, the patient is borderline tachypnic and in mild respiratory distress. He is actively wheezing, complaining of orthopnea and PND. REVIEW OF SYSTEMS On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence syncope or presyncope. Past Medical History: Coronary artery disease Acute systolic heart failure Atrial fibrillation PMH: Coronary Artery Disease s/p stents to OM and LCx Myocardial Infarction [**2167**] and [**2176**] Hypertension Hyperlipidemia Atrial Fibrillation Diastolic heart failure ESRD, s/p renal transplant [**2176**] Peripheral vascular disease H/o CMV infection c/b pancytopenia Dry eye syndrome GERD H/o Gastrointestinal bleed Past Surgical History S/p left brachiocephalic AV fistula S/p L3-L4 spinal fusion Social History: Patient lives alone and is divorced. He has 2 children and 5 grandchildren. His granddaughter is frequently with him and helps with his meds. He has a distant smoking history, quit 20yrs ago. Denies EtOH and illicits. Family History: Brother worked with tiles and passed from lung disease at age 59. Father died at age 79 of cancer. Mother died at 82 of old age. Other siblings alive in their 80s and otherwise healthy. No family history of early MI, arrhythmia, cardiomyopathy, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS- T= 97.4 BP= 161/77 HR= 62 RR= 20 O2 sat=96% GENERAL- Mild respiratory distress. 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 14 cm. CARDIAC- PMI located in 5th intercostal space, midclavicular line. Irregular rhythm, normal S1, variably split S2. [**1-8**] systolic murmur at RUSB. No thrills, lifts. No S3 or S4. LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Diffuse wheezes. Fine crackles 1/4 up lung fields. ABDOMEN- Soft, NTND. No HSM. RUQ tenderness worse with inspiration. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES- No c/c/e. No femoral bruits. SKIN- No stasis dermatitis, ulcers, scars, or xanthomas. PULSES- Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: ECHOCARDIOGRAM [**2179-10-23**] The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 45-50 %). Overall left ventricular systolic function is mildly depressed. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction c/w CAD. Moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2177-1-30**], regional wall motion abnormalities are new and systolic function is not as vigorous. . [**2179-10-25**] Cardiac Cath: 1. LMCA and three vessel heavily calcified coronary artery disease, progressed from [**2178-3-3**], with moderate in-stent restenosis of the OM1 stent, mild in-stent restenosis of the AV groove CX, and stable collateralized chronic totally occlusive in-stent restenosis of the RCA. 2. Systemic systolic arterial hypertension. 3. Moderate-severe left ventricular diastolic heart failure in the setting of known mild regional left ventricular systolic dysfunction. 4. Routine post-TR Band care. 5. Reinforce secondary preventative measures against CAD, hypertension, left ventricular systolic dysfunction and diastolic heart failure. 6. Suboptimal imaging due to body habitus. 7. Cardiac surgery evaluation for suitability for CABG, although distal targets are not ideal. There are no lesions appealing for PCI, and presence of heavily calcified LMCA stenosis extending past the origin of the LAD is strong relative contraindication to PCI. 8. Heparin infusion without bolus may be resumed in 6 hours as clinically indicated. . [**2179-10-26**] Carotid Doppler: Impression: Right ICA with<40% stenosis. Left ICA with <40% stenosis. [**2179-11-16**] 08:45AM BLOOD WBC-7.5 RBC-2.68* Hgb-8.2* Hct-26.5* MCV-99* MCH-30.6 MCHC-30.9* RDW-20.1* Plt Ct-143* [**2179-11-15**] 03:40PM BLOOD WBC-6.0 RBC-2.54* Hgb-8.0* Hct-24.7* MCV-97 MCH-31.4 MCHC-32.3 RDW-20.1* Plt Ct-130* [**2179-11-15**] 06:31AM BLOOD WBC-8.2 RBC-2.68* Hgb-8.1* Hct-25.8* MCV-96 MCH-30.3 MCHC-31.5 RDW-19.6* Plt Ct-140* [**2179-11-14**] 05:15AM BLOOD WBC-10.5 RBC-2.83* Hgb-8.8* Hct-27.8* MCV-98 MCH-31.0 MCHC-31.5 RDW-20.0* Plt Ct-156 [**2179-11-16**] 08:45AM BLOOD PT-14.1* INR(PT)-1.3* [**2179-11-15**] 03:40PM BLOOD PT-14.7* INR(PT)-1.4* [**2179-11-14**] 05:15AM BLOOD PT-15.2* PTT-35.7 INR(PT)-1.4* [**2179-11-16**] 08:45AM BLOOD Glucose-161* UreaN-46* Creat-5.4*# Na-132* K-4.5 Cl-94* HCO3-24 AnGap-19 [**2179-11-15**] 03:40PM BLOOD Glucose-131* UreaN-32* Creat-4.2*# Na-135 K-3.8 Cl-97 HCO3-25 AnGap-17 [**2179-11-15**] 06:31AM BLOOD Glucose-160* UreaN-77* Creat-8.6*# Na-131* K-4.7 Cl-93* HCO3-19* AnGap-24* [**2179-11-14**] 05:15AM BLOOD Glucose-117* UreaN-62* Creat-7.5*# Na-135 K-4.6 Cl-93* HCO3-22 AnGap-25* [**2179-11-13**] 05:20AM BLOOD Glucose-110* UreaN-47* Creat-6.0*# Na-133 K-4.5 Cl-96 HCO3-24 AnGap-18 Brief Hospital Course: Mr. [**Known lastname **] is a 75 year old male with a history of atrial fibrillation, diastolic heart failure, hypertension, and renal transplant in [**2176**], CAD s/p 2-vessel PCI in [**3-/2178**], possible new inferolateral reversible defect on p-MIBI in [**12/2178**], and worsening exertional heart failure symptoms over the last month. On catheterization he was found to have progression of three vessel coronary artery disease and was scheduled for bypass grafting. While his work-up was ensuing he was diuresed and his heart failure symptoms began to abate. Renal saw him in consult for end stage renal disease secondary to hypertensive nephropathy. His baseline creatinine due to allograft nephropathy was 2.3-2.7. On [**11-1**] Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a coronary artery bypass grafting times four (LIMA to LAD, SVG to PDA, SVG to OM, SVG to Diag). Please see the operative note for details. He tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. On the following day he was extubated and neurologically intact. He [**Last Name (Titles) 1834**] hemodialysis for hyperkalemia and fluid overload, and continued to need periodic hemodialysis post-operatively. On post-operative day three a lasix infusion was started for oliguria and fluid overload but he did not respond sufficiently to it, and by the following day he was reintubated with acute acidosis. He [**Last Name (Titles) 1834**] a left chest tube placement for 1100mL of serous drainage. He was also started on broad spectrum antibiotics with a white blood cell count of 27 thousand. He went into atrial fibrillation with a controlled ventricular response and was given beta blockers. The transplant staff was asked to consult given concern for mesenteric ischemia and an exploratory laporatomy was performed [**2179-11-1**]. Please see the operative note for details. This procedure revealed normal intra-abdominal organs, although a liver biopsy was performed intra-operatively later indicated acute hepatic ischemia. His ex-lap wound healed poorly so a wound VAC was placed to aid healing. He extubated successfully on post-operative day six. He was thrombocytopenic and was found to be HIT positive. Hematology was consulted as he was autoanticoagulated with an INR in the mid twos. Hemodialysis was aborted after an infiltration of his AV fistula. A temporary HD catheter was placed and CVVHD was performed. A serotonin assay was performed to assess for the need for anticoagulation. His SRA was negative and subcutaneous Heparin was started for DVT prophylaxis. The decision was made to not start Coumadin for chronic atrial fibrillation, given that he was not on Coumadin preop and had a history of GI bleed. His leukocytosis resolved and his antibiotics were discontinued. He had a large amount of serous drainage from his abdominal wound and this was opened by the transplant team and VAC dressings were applied. By the time of discharge on POD 18, he was tolerating a full oral diet with some loose stools (C diff negative [**11-12**]), ambulating with assistance and his wound was healing well with eschar at the lower pole. His liver functiion tests continued to decrease. Pravastatin was stopped due to elevated liver function tests and this should be restarted once LFT's have normalized. Calcitriol was also stopped due to an elevated phosporus by the renal transplant team. Tacrolimus levels were stable and he is to continue at his current dose of 1 mg in the AM and 0.5 mg Q HS with tacrolimus levels to be followed. VAC dressing x 2 were changed to the abdominal wound on [**2179-11-15**] and last HD was [**2179-11-15**] through left arm fistula. It was felt that the patient was safe for transfer to [**Hospital **] Rehab in [**Location (un) 86**] at this time. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pravastatin 80 mg PO DAILY 2. Allopurinol 100 mg PO BID 3. Tacrolimus 1 mg PO QAM 4. Tacrolimus 1 mg PO QPM 5. Metoprolol Succinate XL 100 mg PO BID 6. Arava *NF* (leflunomide) 20 mg Oral daily 7. Amlodipine 10 mg PO DAILY 8. Furosemide 40 mg PO DAILY 9. Calcitriol 0.5 mcg PO DAILY 10. Aspirin 325 mg PO DAILY 11. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY Discharge Medications: 1. Arava *NF* (leflunomide) 20 mg Oral daily Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 2. Aspirin EC 81 mg PO DAILY 3. Tacrolimus 1 mg PO QAM 4. Acetaminophen 650 mg PO Q4H:PRN fever, pain 5. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN indigestion 6. Calcium Acetate 1334 mg PO QIDWMHS 7. Tacrolimus 0.5 mg PO QPM 8. Glargine 20 Units Breakfast Insulin SC Sliding Scale using REG Insulin 9. Metoprolol Tartrate 25 mg PO TID 10. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR 11. Nephrocaps 1 CAP PO DAILY 12. Pantoprazole 40 mg PO Q24H 13. Quetiapine Fumarate 25 mg PO HS:PRN sleep 14. Heparin 5000 UNIT SC TID Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Coronary artery disease Acute systolic heart failure Atrial fibrillation PMH: Coronary Artery Disease s/p stents to OM and LCx Myocardial Infarction [**2167**] and [**2176**] Hypertension Hyperlipidemia Atrial Fibrillation Diastolic heart failure ESRD, s/p renal transplant [**2176**] Peripheral vascular disease H/o CMV infection c/b pancytopenia Dry eye syndrome GERD H/o Gastrointestinal bleed Past Surgical History S/p left brachiocephalic AV fistula S/p L3-L4 spinal fusion Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Sternal pain managed with Tylenol Sternal Incision - healing well, no erythema or drainage, eschar at lower pole VAC changes Q 72 hours to abdominal wound - last changed [**2179-11-15**] Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2179-12-7**] 1:30 Cardiologist Dr. [**Last Name (STitle) **] [**2179-12-23**] at 3:20pm [**Hospital Ward Name 23**] 7 Translant Surgeon:Provider: [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **] MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-11-24**] 9:15 Renal: Dr [**Last Name (STitle) **] [**2180-1-24**] @ 8:40 AM Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) 1576**],[**First Name3 (LF) 1575**] [**Telephone/Fax (1) 6662**] in [**4-8**] 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** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2179-11-16**]

[ "V45.82", "416.8", "V15.82", "276.52", "585.2", "998.59", "428.43", "V85.32", "289.84", "E878.0", "276.7", "996.72", "276.4", "403.90", "530.81", "278.00", "428.0", "995.92", "584.5", "518.52", "785.52", "038.9", "411.1", "570", "412", "427.31", "414.01", "996.81", "272.4" ]

icd9cm

[ [ [] ] ]

[ "34.04", "96.04", "54.11", "36.15", "36.14", "39.61", "96.71", "88.56", "37.22", "39.95", "89.64", "50.11" ]

icd9pcs

[ [ [] ] ]

13235, 13306

8117, 11985

332, 650

13830, 14076

4569, 8094

14863, 15828

3243, 3543

12471, 13212

13327, 13809

12011, 12448

14100, 14840

3558, 3568

3590, 4550

250, 294

678, 2485

2507, 2989

3005, 3227

28,650

151,064

1965

Discharge summary

report

Admission Date: [**2110-10-30**] Discharge Date: [**2110-11-10**] Service: MEDICINE Allergies: Penicillins / Flagyl Attending:[**First Name3 (LF) 898**] Chief Complaint: Fever, hypotension, bradycardia Major Surgical or Invasive Procedure: PICC placement Serial wound debridement History of Present Illness: 83 year old Russian-speaking female with a history of HTN and a 6 month-old sacral/coccygeal ulcer from a chemical burn/?radiation burn with 24-48h day of redness and induration surrounding the wound, low-grade fever, and confusion (per pt's son). No other associated sx. No pain in area of wound, no diarrhea, abdominal pain, cough, URI symptoms, dysuria. . In the ED, Tmax 100, BP 80/40 (usual SBP reportedly 100-110) HR 94. Labs remarkable for Na 128, Cl 93, lactate 1.0, WBC 11.9 w/ 75% PMNs. Blood cultures were drawn. The patient was given Clindamycin 600 mg IV x 1 and Vancomycin 1 g IV x 1 and 1L IVFs. . On floor, temp to 101.4, SBPs to 70s, given 2L IVFs with SBPs to low 80s and decreased UO, concern for sepsis. Started on aztreonam for gram negative coverage given PCN allergy, and transferred to MICU. Past Medical History: -bilat knee replacement c/b epidural hematoma leading to cauda equina synprome s/p decompressive laminectomy [**10-25**] -hx UTI sepsis -hx c. diff colitis -HTN -obesity -cervical spondylitis -urinary incontinence -depression Social History: She lives by herself at home but son lives nearby and is involved with her care. Pt ambulates with walker at baseline up to 500 feet per son and was independent with [**Name (NI) 5669**]. Originally from [**Country 532**] (she was a physician). No alcohol or tobacco use. Family History: No family history of diabetes, neuropathy Physical Exam: On admission to MICU: V/S: Wt 105 lbs. T 97.8 BP 78/45 HR 53 RR 14 O2sat 97% RA GEN: thin elderly woman, comfortable, NAD HEENT: NC/AT EOMI PERRL anicteric OP clear w/ dry MM NECK: supple, 2+ carotid pulses, no JVD, LAD PULM: CTAB, no crackles, no wheezes on poosterior exam CV: RRR nl S1S2 2/6 SEM best appreciated at RUSB, radiating throughout precordium ABD: soft, NT prominent reducible ventral hernia, normoactive BS BACK: 8 cm circular indurated, hard ulcer w/ central necrotic eschar, surrounding erthythema and induration, no warmth, no tenderness, minimal exudate, no crepitus, no fluctuance EXT: warm, 2+ DPs NEURO: A+Ox2 (person/place); CN III-XII intact, FS in all 4 extremities . On discharge: 97.7 94/66 (90-98/58-72) 60 (58-70) 16 98%RA Physical exam was largely unchanged on discharge. Pertinent Results: [**2110-10-30**] 03:45PM LACTATE-1.0 [**2110-10-30**] 03:30PM GLUCOSE-103 UREA N-19 CREAT-0.6 SODIUM-128* POTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-29 ANION GAP-11 [**2110-10-30**] 03:30PM WBC-11.9*# RBC-4.12* HGB-12.6 HCT-36.3 MCV-88 MCH-30.5 MCHC-34.6 RDW-13.7 [**2110-10-30**] 03:30PM NEUTS-75.7* LYMPHS-15.7* MONOS-7.5 EOS-0.9 BASOS-0.2 [**2110-10-30**] 03:30PM PLT COUNT-287 . ECHO: The left atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . MRI Pelvis: 1. Study limited by motion artifact. No definite evidence of osteomyelitis. 2. No evidence of large collection. 3. Two foci of abnormal signal seen within the left sacral ala, of uncertain clinical significance. 4. Diffuse anasarca. Free fluid seen within the pelvis. Brief Hospital Course: 83 y/o Russian-speaking F h/o HTN, dementia, and 6 month-old sacral/coccygeal ulcer from a chemical burn presents with wound infection. The patient was admitted briefly to the floor and then transferred to the intensive care unit with hypotension, leukocytosis, fever and bradycardia, likely representing sepsis. It was felt the most likely source was her wound infection. She had a negative urinanalysis as well as a negative chest xray, showing no no evidence of pulmonary process. Her EKG on admission to the unit showed sinus bradycardia, no ST changes. The patient was initially treated for adrenal insufficiency given her concurrent bradycardia, hyponatremia and borderline hyperkalemia. She was fluid resuscitated, which stabilized her blood pressure and corrected her hyponatremia, making the cause likely hypovolemic hyponatremia. . The wound infection was initially treated with vancomycin, aztreonam and clinda in the unit. On HD1, coverage was changed from clinda to Flagyl, despite a listed allergy as there was no history of side effects while the patient was taking Flagyl. She has tolerated the Flagyl while in the hospital without difficulty. Infectious disease was consulted for input on antibiotic management. The patient had a MRI during this admission to rule out osteomyelitis, which it did. She is discharged to complete a two week course of the above antibiotics per Infectious disease. Plastic surgery was consulted for wound care while the patient was in the ICU. They performed serial debridements throughout this hospital course. Wound care was also involved in monitoring the progress of healing. The patient should follow up with plastics as needed for wound care following discharge. . Also while in the intensive care unit, the patient had short bursts of atrial fibrillation with RVR which broke spontaneously. It was originally thought to be a tachy-brady syndrome. After transfer to the floor, EP was consulted. It was felt the patient most likely has PAF. She was monitored on telemetry with few episodes of tachycardia on the floor. As she has had an epidural hematoma while on coumadin, it was felt she is not a candidate for coumadin. This decision was discussed with her son [**Name (NI) 382**] at the time. Telemetry was discontinued and heart rate with routine vitals has been stable in the fifties to seventies. The patient was started on low-dose aspirin for both stroke reduction and cardiac benefit. . The patient has baseline anemia, likely caused by chronic disease. Her hematocrit has been stable throughout her hospitalization. She was taking iron as an outpatient which was held througout this course as she was having issues with constipation. The iron can be restarted once the patient is having regular bowel movements. . For her depression and dementia the patient was continued on her outpatient medication regimen, including Celexa, Namenda and Aricept. . Her anti-hypertensive was initially held in the setting of her hypotension. She was restarted on her enalapril prior to discharge, which she tolerated well. . Throughout her hospitalization, the patient benefited from having her family present for frequent reorientation (and given that she is non-English speaking). . CONTACT: [**Name (NI) **] [**Name (NI) 10817**], [**First Name3 (LF) **], HCP ([**Telephone/Fax (1) 10818**]) Medications on Admission: Enalapril Citalopram Namenda Aricept Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever,pain. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-24**] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for constipation. 5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid (). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Last day: [**2110-11-23**]. 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Last day [**2110-11-23**]. 12. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): Apply to sacal wound [**Hospital1 **]. 13. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) flush Intravenous DAILY (Daily) as needed. 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours): last day: [**11-23**]. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary: Sacral Ulcer- infected, Paroxysmal Afib Secondary: HTN Dementia Discharge Condition: Stable, afebrile. Discharge Instructions: You were admitted to this hospital with an infection in the wound on your back. The plastic surgery and infectious disease teams were consulted. A PICC line was placed; you will need to be treated with IV antibiotics for a total 2 weeks (until [**2110-11-23**]). You also need wound care as listed. . Please continue to take all medications as prescribed. Let your doctor know immediately if you develop worsening pain, fevers, or any other concerning symptoms. . We did not change any of your medications other than adding 3 types of antibiotics and an aspirin to your daily routine. Followup Instructions: Follow up with your PCP [**Name Initial (PRE) 176**] 10 days of leaving rehab. Call [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 133**] for an appointment. . Follow up with Plastic surgery for wound care as needed after leaving rehab. The phone number is ([**Telephone/Fax (1) 2868**].

[ "427.81", "780.6", "285.29", "276.52", "278.1", "280.9", "V43.65", "V58.61", "564.09", "682.8", "789.59", "041.11", "041.84", "720.0", "294.8", "V09.0", "401.9", "788.39", "V14.0", "427.31", "785.4", "458.8", "V58.66", "276.1", "278.00", "311", "707.03", "255.41", "698.8", "553.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "86.22" ]

icd9pcs

[ [ [] ] ]

8862, 8933

3959, 7326

261, 303

9050, 9070

2599, 3936

9706, 10018

1710, 1754

7413, 8839

8954, 9029

7352, 7390

9094, 9683

1769, 2467

2481, 2580

190, 223

331, 1152

1174, 1402

1418, 1694

3,860

184,752

4116

Discharge summary

report

Admission Date: [**2178-10-27**] Discharge Date: [**2178-12-8**] Date of Birth: [**2125-3-19**] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 53 year-old woman with a history of morbid obesity, chronic obstructive pulmonary disease and asthma who presented with five days or productive cough, fever and shortness of breath. She was in her usual state of health namely on home oxygen as needed and stairs and thus leave her home until [**2178-10-22**] when she developed a cough and rhinorrhea. She began to wheeze and noted green sputum with her cough. She had fevers, chills and a temperature to 102 on the 14th. She became bed bound from her increasing dyspnea. She has not had chest pain for the last four to five years. Her last hospitalization was two years ago for an asthma flare. She PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Asthma requiring occasional hospitalization. 3. Chronic obstructive pulmonary disease. 4. Type 2 diabetes mellitus since [**2162**] on insulin complicated by chronic renal insufficiency with a baseline creatinine of 2.1 to 2.3 and complicated by gastroparesis on Reglan. 5. Hypothyroidism. 6. Anemia with a history of a GI bleed from peptic ulcer disease secondary to H-pylori infection in [**2176**] requiring transfusions. 7. History of vaginal cancer status post total abdominal hysterectomy and bilateral salpingo-oophorectomy in [**2161**]. 8. Gastroesophageal reflux disease. 9. Depression. 10. Hypertension. MEDICATIONS ON ADMISSION: 1. Synthroid 100 mcg po q day. 2. [**Last Name (un) **]-Dur 200 mg po b.i.d. 3. Reglan 10 mg po q.i.d. 4. Ventolin as needed. 5. NPH 30 units subcutaneously b.i.d. 6. Vasotec. 7. Regular insulin 10 units subcutaneously t.i.d. 8. Home oxygen prn. ALLERGIES: Erythromycin. FAMILY HISTORY: Her father had [**Name2 (NI) 499**] cancer and heart disease. Her mother had lymphoma. SOCIAL HISTORY: Ms. [**Known lastname **] [**Last Name (Titles) 18038**] "a lot for a long time." she recently quit. She denies alcohol or intravenous drug abuse. She lives alone in [**Location (un) **]. She has limited mobility, although she is able to ambulate with a front wheeled walker, though not recently due to her illness. She is currently applying for a motorized wheel chair. She has a homemaker who comes in a couple of times a week to help her out at home and to feed her five cats. She is a full code. She has no health care proxy, but her next of [**Doctor First Name **] is her brother [**Name (NI) **] whose phone number is [**Telephone/Fax (1) 18039**]. PHYSICAL EXAMINATION: She was afebrile with a temperature of 99.1, pulse 92, blood pressure of 116/48. Respiratory rate 24 and an oxygen saturation of 93% on 6 liters face mask. Her HEENT examination was unremarkable. It was impossible to see jugulovenous distention, because of body habitus. Her weight was 450 pounds in a woman who is about 5'5". Her lungs revealed poor air exchange with diffuse bilateral expiratory wheezes. Her heart was regular with distant heart sounds and no apparent murmurs or gallops. Her abdomen revealed an enlarged pannus and was morbidly obese. There is an erythematous confluent weeping papular rash on the left side of her panus that extended onto her thigh. Her skin was indurated with scale and plaque evident. Her abdomen was nontender and with good bowel sounds. Her extremities were with 2+ pitting edema of her bilateral lower extremity to the knees. Her neurological examination revealed a woman who was awake and oriented times three, although quite somnolent. Her cranial nerves were grossly intact. LABORATORY: On presentation her white count was 8.8 with a normal differential. Hematocrit 31 and her platelet count was 388. Her sodium was 136, potassium 4.8, chloride 101, bicarb 24, BUN 44, creatinine 2.7. Her glucose was 172. Her arterial blood gases on presentation was 7.09, 88 and 107. Her chest x-ray revealed bilateral lung base opacities consistent with pneumonia or aspiration, although the film was limited due to body habitus. HOSPITAL COURSE: 1. Pulmonary: This 53 year-old woman with a history of morbid obesity was admitted with a chronic obstructive pulmonary disease exacerbation due to a viral upper respiratory infection versus pneumonia. She initially received Solu-Medrol, nebulizers and supplemental oxygen in the Emergency Room. She was admitted to the floor, but had increasing lethargy, tachypnea and acidosis with a pH of 7.09 that led to intubation. Her intubation was incredibly difficult and took over an hour and required fiberoptic intubation. She was then transferred to the MICU. She was started on Solu-Medrol for her chronic obstructive pulmonary disease exacerbation, which was eventually changed to Prednisone and slowly tapered. She is now off steroids. She initially received Albuterol and Atrovent nebulizers q 2 to 4 hours, which was slowly decreased until her wheezing stopped. She was switched to Combivent and had no wheezing for the last three weeks of her hospitalization. She failed weaning off of the ventilator and underwent a bedside tracheostomy on [**2178-11-6**]. She is required to return to assist control with a respiratory rate of 12 tidal volume 600, FIO2 40% during her various febrile episodes. She is currently weaned to 40% trach mask during the day and pressure support ventilation of 5 with a PEEP of 5 and an FIO2 of 40% at night. On these setting she has good ventilation and oxygenation. She is tolerating Passey-Muir valve well and is able to speak. 2. Cardiac: Ms. [**Known lastname **] suffered an acute myocardial infarction with electrocardiogram changes and a troponin peak of 13 during a septic episode on [**2178-11-1**]. She was initially placed on aspirin, but that was stopped, because of a history of gastrointestinal bleed and a drop in her hematocrit. She was maintained on Lopressor with no evidence of bronchospasm at her current dose. She was successfully diuresed after receiving many liters of fluid while septic. Although it is difficult to assess her fluid status given her body habitus, she is likely close to being euvolemic right now. 3. Infectious disease: Ms. [**Known lastname **] received Levofloxacin initially for a community acquired pneumonia. Septic physiology was revealed by Swan parameters on [**11-1**] although no organism or source was identified. She received a ten day course of vancomycin, Ceftazidime and Flagyl for this. She then developed MRSA pneumonia and MRSE line sepsis on the [**10-19**] for which she received a ten day course of Vancomycin. She has sputum that is colonized with Acinetobacter. She now has a right thigh cellulitis for which she is receiving a fourteen day course of Oxacillin. Her urine is colonized with yeast. She will not require Fluconazole unless she has clinical signs of a urinary tract infection. Treatment of this is unlikely to be successful until she is no longer requiring long term Foley catheter. 4. Renal: She came in with an acute on chronic renal failure. Her BUN and creatinine peaked at 127 and 5.0 respectively and slowly fell to baseline. She is now at 33 and 1.9. Her baseline creatinine ranges between 2.1 and 2.3. Her Enalapril was initially held, but eventually restarted without a bump in her creatinine. She has maintained good urine output once her initial acute renal failure improved. Her episode of acute renal failure was complicated by metabolic acidosis that was treated with bicarbonate orally and has since resolved. The bicarbonate has been stopped. 5. Gastrointestinal: Due to her body habitus, she was not a candidate for a PEG or a GJ tube placement after consulting interventional radiology, general surgery and gastroenterology. She initially had a high residual while she had poor GI motility as she was impacted. This resolved by the end of her hospital course with aggressive bowel regimen and this impaction. She had good tolerance of tube feeds via a feeding tube with no residuals until she pulled out. She is now on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 1800 calorie diet. She had a slow drop in her hematocrit with guaiac positive stools. An esophagogastroduodenoscopy was done, which was negative to the duodenum. She required multiple transfusions and her hematocrit stabilized at around 28. A GI consult recommended colonoscopy as an outpatient especially given her family history of [**Last Name (NamePattern4) 499**] cancer. She is on Protonix given her history of gastroesophageal reflux disease. She has two port PICC line in place with one port received for TPN if it should become necessary. 6. Endocrine: There was difficulty controlling her blood sugars and administering insulin effectively given her initial anasarca. She was on an insulin drip for two to three weeks, but was eventually switched to NPH and her sliding scale with good control. The key to good control is administration with long insulin needles into areas without edema namely her upper arms. She now has finger sticks that range in the low to mid 100s. 7. Skin: Her initial pan cellulitis was appropriately treated and resolved completely with excellent skin care. She developed a lower extremity cellulitis of her right thigh late in her hospital stay and had a fourteen day course of Oxacillin. She currently has near resolution of that cellulitis with three days of antibiotics to go. CONDITION ON DISCHARGE: Greatly improved. DISCHARGE DIAGNOSES: 1. Morbid obesity. 2. Asthma. 3. Chronic obstructive pulmonary disease exacerbation due to pneumonia status post tracheostomy placement. 4. Type 2 diabetes complicated by chronic renal insufficiency and gastroparesis. 5. Hypothyroidism. 6. Anemia. 7. Peptic ulcer disease with a history of a gastrointestinal bleed. 8. Vaginal cancer status post TAH/BSO. 9. Gastroesophageal reflux disease. 10. Depression. 11. Hypertension. 12. MRSA pneumonia. 13. MRSE line sepsis. 14. Right lower extremity cellulitis. 15. Recent acute myocardial infarction. 16. Acute renal failure, resolved. 17. Metabolic acidosis, resolved. DISCHARGE MEDICATIONS: 1. Synthroid 100 mcg po q day. 2. Lopressor 37.5 mg po b.i.d. 3. Reglan 10 mg po q.i.d. 4. Combivent 8 puffs MDI q 4 hours. 5. NPH 20 units subcutaneously b.i.d. 6. Vasotec 40 mg po q.d. 7. Lasix 60 mg po q.d. 8. Regular insulin sliding scale as per page one. 9. Pericolace two caps po q.d. 10. Miconazole powder to affected areas b.i.d. 11. Protonix 40 mg po q.d. 12. Senna two tabs po q.d. 13. Oxacillin 2 grams intravenous q 6 hours until [**2178-12-11**]. 14. Dulcolax 10 to 15 mg po/pr prn. 15. Lactulose 30 cc po q 6 hours prn. DISCHARGE STATUS: To [**Hospital3 672**] Rehab. Will require: 1. Finger sticks checked q.i.d. 2. Colonoscopy as an outpatient. 3. Follow up with primary care physician. [**Name6 (MD) 2467**] [**Last Name (NamePattern4) 10404**], M.D. [**MD Number(1) 10405**] Dictated By:[**Name8 (MD) 1552**] MEDQUIST36 D: [**2178-12-8**] 15:14 T: [**2178-12-8**] 14:21 JOB#: [**Job Number 18040**] cc:[**Hospital3 18041**]

[ "584.9", "276.2", "996.62", "493.21", "410.91", "682.6", "038.11", "486", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.72", "45.13", "38.91", "89.64", "38.93", "96.04", "31.1" ]

icd9pcs

[ [ [] ] ]

1865, 1954

9611, 10243

10267, 11289

1561, 1848

4155, 9546

2657, 4137

166, 855

878, 1534

1971, 2634

9571, 9590

3,995

163,125

46668+58934

Discharge summary

report+addendum

Admission Date: [**2105-2-13**] Discharge Date: [**2105-2-26**] Date of Birth: [**2031-8-31**] Sex: M Service: Cardiothoracic Surgery HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 73-year-old male with a two-month history of recurrent chest pain with burning and a positive exercise Myoview study in [**2104-12-3**], with an ejection fraction of 28% at the time. The patient was referred for cardiac catheterization which revealed extensive two-vessel disease for which the patient was referred for coronary artery bypass grafting to Dr. [**Last Name (Prefixes) **]. Catheterization showed left anterior descending coronary artery 90%, LCX 80%, OM 80%, RCA dominant with 20-30% mid stenosis, ejection fraction of 37%, moderate left femoral artery stenosis. PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease. 2. Psoriasis. 3. Hypertension. 4. Peripheral vascular disease. 5. Chronic sinusitis. 6. Anxiety. 7. History of silent myocardial infarction x 2. 8. Bilateral renal cysts. 9. History of colonic polyps. 9. History of gout. PAST SURGICAL HISTORY: 1. Right lung tumor resection in [**2092**] x 2, ? malignant. 2. Esophageal tumor resection in [**2092**]. 3. Left inguinal hernia repair in [**2101**]. 4. Right forearm tumor resection in [**2101**]. 5. Tonsillectomy. 6. Appendectomy. 7. Prostate reduction in [**2086**]. 8. Right leg bypass for claudication in [**2087**] with accidental resection of nerve with residual right knee numbness. 9. Colonoscopy 1-2 years prior to this admission and colon polyp removal. MEDICATIONS ON ADMISSION: 1. Lisinopril. 2. Nexium. 3. Diazepam 5 mg b.i.d. 4. Aspirin 81 mg q. day. 5. Flonase. 6. Multivitamins. 7. Citrucel. 8. Ibuprofen. 9. Atenolol. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient has smoked one pack per day x 57 years and admits to two drinks a day x 20 years. PHYSICAL EXAMINATION: The patient was afebrile with vital signs stable. Lungs: Coarse breath sounds bilaterally, no wheezing noted. Heart: Regular rate and rhythm with occasional skipped beats, no murmurs noted. HOSPITAL COURSE: The patient underwent coronary artery bypass grafting x 3 and tolerated the procedure well. He was extubated on postoperative day one. He was transferred to the floor on postoperative day two and on the evening of postoperative day number two to the morning of postoperative day number three the patient began to feel restless and agitated, and having problems with shortness of breath. The patient eventually necessitated reintubation and was transferred back to the unit for closer monitoring and sedation. He was noted to have purulent secretions with tracheobronchitis on a bronchoscopy done shortly after intubation by Dr. [**Last Name (STitle) 952**]. The patient was believed to have had some problems with delirium tremens from the history of alcohol use. The patient was also started on antibiotics secondary to sputum appearance which eventually grew Gram-negative rods. The patient was eventually extubated on postoperative day seven again and was transferred to the floor where he continued to do well. He was weaned off of Ativan and was eventually cleared by physical therapy ambulating well, tolerating a regular diet and with good p.o. pain control. He was felt to be ready for discharge to home on postoperative day number ten. FO[**Last Name (STitle) 996**]P: The patient will follow up with Dr. [**Last Name (Prefixes) **] in four weeks, Dr. [**First Name (STitle) **] in one to two weeks, and the cardiologist in two to three weeks. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg p.o. b.i.d. 2. Amiodarone 400 mg q. day for one month. 3. Aspirin 325 mg q. day. 4. Tylenol 650 mg q. 4 hours p.r.n. 5. Percocet 1-2 tablets p.o. q. 4-6 hours p.r.n. 6. Colace 100 mg p.o. b.i.d. 7. Protonix 40 mg q.d. 8. Levofloxacin 500 mg q.d. x 7 days. 9. Albuterol ipratropium inhaler 1-2 puffs q. 6 hours p.r.n. 10. Folic acid 1 mg q. day. 11. Thiamine 100 mg q. day. 12. Milk of Magnesia 30 mL q.h.s. p.r.n. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: Status post coronary artery bypass graft x 3. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 5915**] MEDQUIST36 D: [**2105-2-26**] 12:02 T: [**2105-2-26**] 12:13 JOB#: [**Job Number 99072**] cc:[**First Name (STitle) 99073**] Name: [**Known lastname 15845**], [**Known firstname **] Unit No: [**Numeric Identifier 15846**] Admission Date: [**2105-2-16**] Discharge Date: [**2105-2-26**] Date of Birth: Sex: M Service: The operation was a coronary artery bypass graft from LIMA to the LAD and saphenous vein graft to the OM. Please see operative note for further details. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**] Dictated By:[**Name8 (MD) 2182**] MEDQUIST36 D: [**2105-2-26**] 12:11 T: [**2105-2-26**] 12:15 JOB#: [**Job Number 15847**] cc:[**Last Name (Prefixes) 15848**]

[ "401.9", "466.0", "414.01", "443.9", "530.81", "291.0" ]

icd9cm

[ [ [] ] ]

[ "36.11", "36.15", "96.72", "96.04", "33.24", "39.61" ]

icd9pcs

[ [ [] ] ]

3655, 4089

4171, 5181

1612, 1819

2167, 3632

1108, 1585

1954, 2149

819, 1084

1836, 1931

4114, 4150

6,252

196,542

47861

Discharge summary

report

Admission Date: [**2182-4-9**] Discharge Date: [**2182-4-20**] Date of Birth: [**2131-11-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: abdominal mass Major Surgical or Invasive Procedure: Percutaneous liver biopsy Colonoscopy EGD History of Present Illness: 50yo M w/ a PMH of EtOH abuse and psychiatric disorder p/w fatigue, anorexia, and abdominal mass. Pt states that he has had worsening fatigue over last 1-2 weeks, accompanied with early satiety, decreased appetite and weakness. However, over last several days, has noted increased abdominal girth and tenderness in his RUQ, particularly when trying to lay on his stomach. He has been spending 18-20 hrs/day in bed due to fatigue and noted a hard mass in his RUQ. He describes 2 different types of abdominal pain - constant, gnawing pain in his RUQ and then crampy, throbbing, intermittent pain that he imagines is his colon/constipation. Denies fevers, chills, night sweats, weight loss, CP, SOB, palpitations, nausea, vomiting. + Dysphagia to solids (for years). + constipation, no BM in 8 days. Denies dysuria or frequency. Denies melena, dark or tarry stools, or BRBPR. Denies swelling, rash, itching in his skin. Denies LH, dizziness, vision changes or URI sx. Has chronic nonproductive cough from smoking. Went to his PCP's office today and was sent to the ED for immediate evaluation. . In the ED, VS were T 99.1, BP 172/98, HR 99, RR 16, sats 96% on RA. He had labs drawn which showed a transaminitis, elevated alk phos and elevated bilirubin. He also has a mildly elevated lipase. He underwent a CT a/p which revealed massive hepatomegaly, c/w severe acute hepatitis, and stranding around the pancreatic head c/w pancreatitis. He also had dilated bowel loops by my read, along with LAD seen by radiology. KUB was negative for obstruction. He was admitted to medicine for further workup of his abdominal mass. Past Medical History: GERD EtOH abuse paranoid schizophrenia w/ bipolar features Social History: Lives in [**Hospital3 28354**]. Is psychiatrically disabled. Is not currently sexually active. MSM. Has h/o unprotected oral sex w/ partners he knows are hep B and hep C positive. Had negative HIV test [**1-5**] yrs ago. Currently smokes [**1-5**] ppd. Used to smoke >3 ppd x 35 yrs. Quit recreational drugs (mostly marijuana, never IVDU) and EtOH in [**11-7**]. Used to drink heavily, would not state how much. Was previously in Navy. Family History: F died in war. M is alive and well. No fam hx of CAD, DM, liver disease. Physical Exam: VS - T 98.9, BP 160/80, HR 96, RR 18, sats 96% on RA Gen: WDWN middle aged male in NAD. HEENT: Sclera mildly icteric. EOMI, PERRL, OP clear, no exudates or erythema. No JVD, no LAD. CV: RR, normal S1, S2. No m/r/g. Lungs: Crackles at R base, otherwise clear. Abd: Soft, distended. Massive hepatomegaly, with liver edge down into RLQ and extending across midline. No appreciable splenomegaly. No frank tenderness, but palpation is uncomfortable. + BS. Ext: No edema. 2+ PT, radial pulses bilaterally. Skin warm, clammy. No jaundice, no peripheral stigmata of liver disease. Neuro: AAOx3. No asterixis. Pertinent Results: . Liver biopsy: Metastatic small cell neuroendocrine carcinoma in fibrotic stroma (trichrome stain examined); see note. Note: On immunohistochemical staining, the cancer is focally positive for chromogranin, negative for S-100 protein and synaptophysin, and shows dot-like cytoplasmic staining with the AE1-AE3/Cam 5.2 cytokeratin cocktail, is strongly positive for cytokeratin 7 and negative for cytokeratin 20. The CK7/CK20 staining pattern strongly favors the lung as the primary site for the cancer. The iron stain is non-contributory. . [**2182-4-9**] CT a/p: Findings c/w severe hepatitis, including ascites, although no CT evidence of cirrhosis; stranding about pancreatic head suggestive of pancreatitis; no biliary obstruction; periportal lymphadenopathy, non-specific but often seen with infectious hepatitis . [**2182-4-9**] KUB: No evidence of small bowel obstruction or free air. Moderate amount of stool throughout the colon. . CT head: No evidence of intracranial hemorrhage, no change from [**2180-6-2**]. . CT chest: 1. Large spiculated left upper lobe lung mass which radiologically most likely representing primary lung tumor with extensive mediastinal involvement. 2. Increased pericardial effusion. 3. New right lower lobe atelectasis. 4. Known liver enlargement and involvement by tumor. 5. Bilateral adrenal enlargement which may be either due to bilateral hyperplasia or a metastatic involvement. 6. Moderate emphysema. 7. Old rib fractures . Bone scan: pending Brief Hospital Course: 50M w/ a PMH of EtOH abuse and psychiatric disorder p/w fatigue, anorexia, found to have metastatic lunch cancer to liver, pancreas and abdomen. . # METASTATIC SMALL CELL LUNG CANCER: The patient initially presented with hepatomegaly and was found to have innumerous nodules as well as a pancreatic head mass. Hepatology was consulted and a percutaneous liver biopsy was performed which was consistent with a neuroendocrine small cell lung primary. Oncology was consulted. Chest CT confirmed the presence of a spiculated lung mass and mediastinal lymphadenopathy. Bone scan was performed and is pending. Tumor markers CEA and CA [**93**]-9 were elevated, but AFP normal; 5-HIAA and chromogrannin are pending. He underwent EGD and colonoscopy which was unrevealing. Due to the metastatic disease, his liver functions slowly worsened and he developed signs of hepatic encephalopathy; the patient was given lactulose titrated to 4 bowel movements per day with improvement in his symptoms. Hepatitis panel negative for A/B/C viruses. MELD 13, [**Last Name (un) 26460**] score/discriminant function is 16. Given the new diagnosis and worsening of his liver function, the Oncology team hoped to initiate chemotherapy as an inpatient. . On the morning of [**2182-4-19**], the patient developed worsening mental status changes, tachypnea and increasing abdominal distansion and tenderness. CXR was unrevealing, however, ABG revealed a lactated of 8. He was started on broad spectrum antibiotics for suspicion of SBP, or other abdominal source of infection; he was transferred to the [**Hospital Unit Name 153**]. Upon arrival to the [**Hospital Unit Name 153**], his respiratory status further deteriorated and he was intubated. He was continued on Vancomycin, Zosyn, and flagyl for evolving sepsis. On the morning of [**2182-4-20**], the patient further deteriorated, and required 3 pressors to maintain his blood pressure. . A family meeting was held at approximately 10:00 AM [**2182-4-20**]; at that meeting his parents requested that the goals of care be changed to comfort measures only, given his underlying metastatic disease and overall poor prognosis. Supportive care was withdrawn. The patient passed away quietly at 1410pm. An autopsy was requested by his mother, [**Name (NI) **] [**Name (NI) **]. Medications on Admission: clozaril 200mg PO QAM, 100-200mg PO QPM clonapin 0.5mg PO TID wellbutrin 100mg PO BID campral 333mg PO TID omeprazole [**Hospital1 **] (can't remember dose) ranitidine 150mg PO QHS Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Metastatic nonsmall cell lung cancer Sepsis Liver failure Discharge Condition: Deceased Discharge Instructions: NA Followup Instructions: NA

[ "572.2", "530.81", "492.8", "518.5", "995.91", "162.8", "573.3", "295.30", "458.9", "305.1", "197.8", "198.89", "197.7", "570", "303.93", "038.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "45.23", "50.11", "45.13" ]

icd9pcs

[ [ [] ] ]

7376, 7385

4801, 7118

330, 373

7487, 7497

3282, 4226

7548, 7553

2571, 2645

7349, 7353

7406, 7466

7144, 7326

7521, 7525

2660, 3263

276, 292

401, 2020

4235, 4778

2042, 2102

2118, 2555

65,154

183,945

26364

Discharge summary

report

Admission Date: [**2139-3-30**] Discharge Date: [**2139-4-1**] Date of Birth: [**2090-11-9**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2290**] Chief Complaint: Syncope, upper GI bleed Major Surgical or Invasive Procedure: Mechanical ventilation EGD x 2 Intubation History of Present Illness: MICU HPI: This is a 48-year-old man with a history of chronic HCV, traumatic brain injury, who was visiting his psychiatrist Dr. [**Last Name (STitle) 6496**] on the [**Hospital Ward Name **] for a scheduled visit when he had a syncopal episode. [**Hospital Ward Name 23**] code team responded. He was noted to have BPs in 70s, HR 130s, FS of 207 and was brought to ED. Here, he denied any pain (though he was felt to be an unreliable historian), but did endorse dizziness prior to falling to the ground. He received 2L of NS. Labs were notable for Hct of 19. He denied any dark stools, nausea, vomiting, hematemesis, BRBPR, or abdominal pain. Upon arrival to the ED vitals were: T 97.4, HR 130, BP 90/56, RR 20, O2 sat 98% 4L. NG lavage was performed after noting the Hct and returned frank blood. Patient removed his own NGT and refused replacement. Also pulled out an IV in the ED. His exam was notable for distended belly, guaiac negative. The liver team was contact[**Name (NI) **] as he is followed here for his HCV, and recommended starting protonix gtt which was done in the ED. MEDICINE HPI: 48M with DM, bipolar disorder, and HCV who syncopized at his psychiatrists office and was taken to the ED. In the ED he was found to have an H/H of 7.2/19.6 from a baseline of 13.6/37.9. He was admitted to the MICU where he received a total of 5 units of pRBC. He underwent EGD which revealed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear. The lesion was clipped, local hemostasis was achieved, and his H/H stabilized. . On questioning, he denies any history of GERD, gastritis, UGIB, LGIB, swallowing foreign objects, pills stuck in his throat, easy bleeding or bruising as with brushing his teeth or normal activities. He did vomit x 2 on Sunday after going to [**Company 44769**]. He denies any diarrhea or fever, sick contacts, or a history of recurrent vomiting. He says when he went to his psychiatrists office he felt weak and shaky like a "head rush" and the next thing he remembers he was in the ED. . At this time he feels well and is hungry. He has no other complaints. . Review of Systems: (+) Per HPI (-) Review of Systems: GEN: No fever, chills, night sweats, recent weight loss or gain. HEENT: No headache, sinus tenderness, rhinorrhea or congestion. CV: No chest pain or tightness, palpitations. PULM: No cough, shortness of breath, or wheezing. GI: No nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel habits, no hematochezia or melena. GUI: No dysuria or change in bladder habits. MSK: No arthritis, arthralgias, or myalgias. DERM: No rashes or skin breakdown. NEURO: No numbness/tingling in extremities. PSYCH: No feelings of depression or anxiety. All other review of systems negative. Past Medical History: - Type II diabetes - Diabetic neuropathy on gabapentin - HCV: Genotype 1, biopsy [**9-/2137**] with features c/w chronic viral hepatitis C with Grade 2 inflammation and Stage 3 fibrosis; per liver clinic note [**1-/2138**] has chronically elevated transaminases - Coronary artery disease s/p stent placement (~[**2137**], [**Location (un) **]) - Traumatic brain injury (~5 years ago) - Dementia believed to be due to TBI - Bipolar disorder on Seroquel and Fluphenazine and Venlafaxine Social History: - Lives with caretaker. [**Name (NI) **] mother and sister in [**Name (NI) 108**]. Goes to day program Tuesday to Friday. - Tobacco: 1PPD, started age 18 - etOH: Per notes at times smells of etOH, but Pt denies, heavy drinking in the past, supposedly sober since the 80s - Illicits: In the past, sober by report since the 80s Family History: - Father: died age of 56, he is uncertain as to the cause of death - Mother: alive and well in [**Name (NI) 108**] Physical Exam: MICU: GEN: Awake in bed, WDWN milddle aged man, responding to questions, NAD HEENT: Conjunctiva slightly pale, pupils reactive, EOMI NECK: No JVD, supple PULM: CTA bilaterally CARD: Tachycardic to ~100s, no M/R/G ABD: Mildly distended with bowel gas to percussion, NT, soft, +BS, no rebound/guarding EXT: No edema SKIN: Clear NEURO: Oriented to place [**Hospital1 **], date [**3-30**] PSYCH: Somewhat flat affect, poor insight during history taking MEDICINE ADMISSION: VS: T 98.6 P 87 BP 132/84 R 20 96% on room air GEN: AOx3, NAD HEENT: MMM, no JVD, neck supple, no cervical, supraclavicular, or axillary LAD Cards: RR S1/S2 normal, no murmurs/gallops/rubs Pulm: No dullness to percussion, CTAB no crackles or wheezes Abd: BS+, soft, NT, no rebound/guarding, no HSM Limbs: No LE edema, no tremors or asterixis Skin: No rashes or bruising, many tattoos Neuro: Grossly nonfocal DISCHARGE: GEN: NAD, pleasant VS: T 98.1 Tm 98.6 P 88(78-91) BP 132/80 (123-152/68-86) R 20 96% on RA HEENT: MMM, no OP lesions, no LAD, JVP not elevated CV: RR, no MRG PULM: CTAB with bibasilar crackles ABD: BS+, NTND, no HSM LIMBS: no LE edema, no tremors or asterixis NEURO: Grossly nonfocal Pertinent Results: Admission: [**2139-3-30**] 11:12AM BLOOD WBC-13.9*# RBC-2.02*# Hgb-7.2*# Hct-19.6*# MCV-97 MCH-35.8* MCHC-36.9* RDW-13.8 Plt Ct-265 [**2139-3-30**] 01:30PM BLOOD PT-14.2* PTT-31.1 INR(PT)-1.2* [**2139-3-30**] 11:12AM BLOOD Glucose-170* UreaN-42* Creat-1.4* Na-131* K-4.5 Cl-99 HCO3-21* AnGap-16 [**2139-3-31**] 04:16AM BLOOD Calcium-8.3* Phos-2.1* Mg-1.8 Discharge: [**2139-4-1**] 05:40AM BLOOD WBC-5.4 RBC-3.39* Hgb-11.2* Hct-30.7* MCV-90 MCH-33.0* MCHC-36.5* RDW-16.1* Plt Ct-174 [**2139-4-1**] 05:40AM BLOOD PT-12.0 PTT-26.7 INR(PT)-1.0 [**2139-4-1**] 05:40AM BLOOD Glucose-109* UreaN-10 Creat-0.8 Na-135 K-4.0 Cl-104 HCO3-27 AnGap-8 [**2139-4-1**] 05:40AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.7 HCT trend: [**2139-3-30**] 11:12AM BLOOD Hct-19.6*# [**2139-3-30**] 04:00PM BLOOD Hct-23.3* [**2139-3-30**] 10:31PM BLOOD Hct-24.8* [**2139-3-31**] 04:16AM BLOOD Hct-29.0* [**2139-3-31**] 07:43AM BLOOD Hct-30.2* [**2139-3-31**] 02:43PM BLOOD Hct-29.1* [**2139-4-1**] 12:05AM BLOOD Hct-29.5* [**2139-4-1**] 05:40AM BLOOD Hct-30.7* Brief Hospital Course: 48M with HCV, DM, s/p traumatic brain injury, and bipolar disorder who presented with syncope and was found to have a [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear of the esophagus which was successfully clipped. His H/H has stabilized and he did well clinically. He was DCed to home with close follow up. # Syncope: Due to bleeding. Treated as below. Orthostatics negative. Defered additional syncope work up as an obvious cause has been identified. # [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear: Seems to be from his history of recent vomiting. It is not entirely clear why he developed this. GI followed and interevened in the MICU. Held off on PPI at DC per GI as no obvious gastritis. # Diabetes: Pt report taking insulin glargine 80 units SQ HS, but did no require nearly this much insulin. Discharged on insulin glargine 20 units SQ HS and HISS with PCP follow up. # CAD: Review of records shows CAD s/p stending in [**2137**]. Unclear if on outpatient ASA. Given recent bleed, held off on restarting and will defer to PCP. # Acute kidney injury: On admission had creatining of 1.4 mg/dL. Improved to baseline of 0.9 mg/dL s/p IFV and blood. # HCV: Genotype 1, biopsy [**9-/2137**] with features c/w chronic viral hepatitis C with Grade 2 inflammation and Stage 3 fibrosis; per liver clinic note [**1-/2138**] has chronically elevated transaminases. No evidence of decompensated liver disease so will hold off on PPx abx s/p GIB. . # Bipolar disorder: Continued home Quetiapine Fumarate 400 mg PO/NG QAM, Quetiapine Fumarate 500 mg PO/NG QHS, Venlafaxine XR 75 mg PO DAILY, and Fluphenazine 10 mg PO QHS. MICU COURSE: This is a 48-year-old man with a history of chronic HCV and traumatic brain injury who was found to have Hct of 19 with frank blood in the stomach after a syncopal episode at a routine doctor's visit. . # SYNCOPE: Likely secondary to orthostasis from blood loss given drop in hematocrit. EGD demonstrated [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear in the esophagus with overlying clot. Lesion was clipped by GI with excellent hemostasis. Patient was transfused 5 units and hematocrit rose to 30.2. Patient had also improved symptomatically, and reported no dizziness or palpitations. He had no more episodes of vomiting or hematemesis. Mr. [**Known lastname 13621**] remained on telemetry overnight. . #. LOW HEMATOCRIT/GI BLEED: Likely from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear as seen on EGD. As above, hemostasis was acheived with clipping and patient had no more episodes of hematemesis. He was transfused 5 units and remained hemodynamically stable. He was originally placed on octreotide and PPI drip, both of which were discontinued after the results of the EGD. . #. AIRWAY PROTECTION: Patient was intubated for airway protection due to large amounts of blood. He was successfully extubated after the EGD. . #. ACUTE RENAL FAILURE: Likely pre-renal in setting of GI bleed. Creatinine resolved with stabilization of hemodynamics. . #. HEPATITIS C: Managment deferred to outpatient providers. . #. DIABETES: Patient with type II DM and HgbA1C of 13.2% in [**2137**]. Insulin sliding scale was initiated while patient was admitted. . #. PSYCHIATRIC ISSUES, TRAUMATIC BRAIN INJURY: Per psychiatric notes, patient has carried multiple diagnoses including bipolar disorder and schizoaffective disorder. He has a history of impulsivity since childhood, now compounded by traumatic brain injury/early dementia. Psychiatric medications were continued once patient was able to take POs. Medications on Admission: - Type II diabetes - Chronic hepatitis C virus (biopsy [**9-/2137**] with features c/w chronic viral hepatitis C with Grade 2 inflammation and Stage 3 fibrosis; per liver clinic note [**1-/2138**] has chronically elevated transaminases) - Coronary artery disease s/p stent placement (~[**2137**], [**Location (un) **]) - Traumatic brain injury (~5 years ago) Discharge Medications: 1. Seroquel 400 mg Tablet Sig: One (1) Tablet PO QAM. 2. Seroquel 400 mg Tablet Sig: One (1) Tablet PO at bedtime: with 100 mg pill for total of 500 mg at bedtime. 3. Seroquel 100 mg Tablet Sig: One (1) Tablet PO at bedtime: with 400 mg pill for total of 500 mg at bedtime. 4. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 5. fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 7. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twenty (20) units Subcutaneous at bedtime. 8. Humalog KwikPen 100 unit/mL Insulin Pen Sig: 2-10 units Subcutaneous as directed by your sliding scale. Discharge Disposition: Home Discharge Diagnosis: Primary - [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear Secondary: - Type II diabetes - Diabetic neuropathy on gabapentin - HCV: Genotype 1, biopsy [**9-/2137**] with features c/w chronic viral hepatitis C with Grade 2 inflammation and Stage 3 fibrosis; per liver clinic note [**1-/2138**] has chronically elevated transaminases - Coronary artery disease s/p stent placement (~[**2137**], [**Location (un) **]) - Traumatic brain injury (~5 years ago) - Dementia believed to be due to TBI - Bipolar disorder on Seroquel and Fluphenazine and Venlafaxine Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for syncope (passing out). We found that the reason you passed out was very low blood counts. We did an endoscopy (special study of your esophagus) to find your source of bleeding and identified a tear in your esophagus. We repaired the bleeding vessel and you improved. If you vomit it is very important that you call your doctor so that you do not develop another tear in your esophagus. MEDICATION CHANGES: - REDUCE glargin insulin (Lantus) to 20 units at bedtime - Continue your Humalog insulin sliding scale as you have been doing - Continue your other medications as you have been taking them Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] M. Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 26335**] Phone: [**Telephone/Fax (1) 23281**] Appt: [**4-7**] at 11am Department: COGNITIVE NEUROLOGY UNIT When: TUESDAY [**2139-4-14**] at 9:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: LIVER CENTER When: TUESDAY [**2139-4-21**] at 4:00 PM With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2139-4-3**]

[ "357.2", "V15.52", "070.54", "584.9", "250.60", "V45.82", "530.7", "294.8", "296.80", "V58.67", "285.9", "571.5" ]

icd9cm

[ [ [] ] ]

[ "42.33", "45.13" ]

icd9pcs

[ [ [] ] ]

11319, 11325

6453, 10135

327, 371

11947, 11947

5402, 6430

12801, 13673

4075, 4192

10545, 11296

11346, 11926

10161, 10522

12098, 12568

4207, 5383

2597, 3204

12588, 12778

264, 289

399, 2543

11962, 12074

3226, 3715

3731, 4059

16,755

105,312

4415

Discharge summary

report

Admission Date: [**2188-8-19**] Discharge Date: [**2188-8-28**] Date of Birth: [**2125-3-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: intubation central line placement History of Present Illness: 63 yo with ESRD, DM, CAD, CHF, who presents after an episode of syncope today. The patient went to the commode today felling fine, but then suddenly fell forward and hit her head and her left arm. She thinks that she might have fallen asleep and only recalls mild lightheadedness which is a common symptom for her when she gets up to the commode. She did not loose consciousness and recalls the event in detail. She was not able to get up from the floor becaus eof the weakness in her legs at baseline until her husband came to help her. She then had one episode of non-bloody vomitus. Her husband called EMS who brought her to [**Hospital6 **]. At [**Hospital1 34**] the patient reportedly was lethargic and a head CT was done that was negative for bleed. The patient reported pain in her L arm and a humerus XR showed a comminuted surgical neck fracture with less than half shaft width of lateral displacement. A CT of her spine was negative for fracture. A CXR was read as CHF. The patient was transfered to [**Hospital1 18**] for further management. . ED course: CXR was done and showed new R perihilar and RLL infiltrate. The patient underwent a CTA that did not show any PE but confirmed a right lower lobe as well as dependent right upper lobe and medial left lower lobe infiltrate that was concerning for infection. The pt was given Vanco, Levo and Flagyl. . ROS: negative for CP, SOB, cough, secretions, abdominal pain, diarrhea, constipation, f/c/ns, weight loss, dysuria, changes in the color of the urine or stool. The patient reports that she was feeling a little weaker since her recent admission for coag neg bacteremia but had been feeling fine otherwise. Past Medical History: 1. DM2 since her 40s, dialysis since [**2-3**] 2. ESRD [**2-1**] DMII, on MWF HD, followed by Dr. [**First Name (STitle) 805**] 3. h/o MRSA cellulitis of bilateral LE 4. HTN 5. Hyperlipidemia 6. Hypothyroidism 7. CAD s/p CABG [**2179**], NSTEMI in [**9-2**] during admission; echo [**3-4**] with EF 35%, moderate to severe MR 8. Anemia 9. Osteoporosis 10. Depression 11. h/o right hip fx s/o ORIF 12. PVD 13. Sleep apnea 14. On Home 3L O2, PFTs [**2186**] with restrictive pattern, pulmonary HTN 15. R Charcot Foot 16. Restless Leg Syndrome 17. Pulmonary hypertension Social History: The patient lives with her husband who is her primary caregiver. She denies past or present tobacco use. She denies alcohol or IV drug use. Patient previously worked as a secretary. Family History: Father - Deceased with MI at 60 Sister - Breast cancer Mother - 60s, CAD Son with DM Physical Exam: VS T 97.5 BP 104/90 HR 71 RR 21 O2Sat 99% on NRB Gen: NAD, AAOx3 HEENT: NC/AT, PERRLA, dry mm NECK: no LAD, JVD not visulized, no carotid bruit COR: S1S2, regular rhythm, SEM II/VI over LUSB, no r/g PULM: limited due to patients limited ability to turn; decreased breathsounds in R base, crackles b/l ABD: + bowel sounds, soft, nd, nt, indurated area L lateral to the umbilicus, umbilical hernia Skin: warm extremities, no rash, 0.5cm dry open wound on L malleolus, EXT: dopplerable DP, charcot deformity of the R foot, trace edema, no CVA tenderness Neuro: following commands, PERRLA, reflexes 2+ b/l inupper extremities, 1+ patella, absent achilles reflex Pertinent Results: EKG: SR, LA, HR 70, borderline PR interval, intraventricular conduction delay with QRS prolongation to 170ms. No change from prior. . CTA: 1. No PE. 2. Marked cardiomegaly with evidence of right heart dysfunction and congestion. 3. Consolidation of much of right lower lobe, as well as dependent right upper lobe and medial left lower lobe may be due to aspiration or infection. 4. Small-moderate partially loculated right pleural effusion. 5. Chronic right hemidiaphragmatic elevation. 6. Evidence of pulmonary arterial hypertension. . CT head: negative for bleed, old left parietal infarct. CT spine: negative for fracture . XR humerus L: comminuted surgical neck fracture with less than half shaft width of lateral displacement. CONCLUSION: 1. Consolidation in the right lower, right upper and medial left lower lobe, slightly increased in extent compared to prior examination, may be due to infection or aspiration. 2. Small right pleural effusion. 3. Pulmonary arterial hypertension. 4. Large pelvic cystic mass, probably arising from the right adnexal region. This finding is concerning for ovarian malignancy, considering presence of ascites and omental nodularity. 5. Old fracture deformities of inferior right pubic ramus, right lower posterior ribs. Impacted fracture of the left humeral neck and fracture of the right humeral neck, dedicated films can be obtained if clinically indicated.. L3 compression fracture new since [**2186-8-31**]. 6. Thyroid nodule. 7. Left adrenal nodule. Brief Hospital Course: A/P: 63 yo with ESRD, DM, CAD, CHF, s/p syncopal event presenting with hypercarbic respiratory failure, mild fluid overload and L humerus fracture. . # Hypercarbic respiratory failure. Was intubated for airway protection and hypercarbic respiratory failure thought to be due to CHF and restrictive lung disease due to body habitus (kyphoscoliosis/abdominal distention) and splinting from pain. Patient has chronic CO2 retention at baseline and also O2 dependent with 3Lat baseline. Was treated with dialysis and was extubated on [**8-25**]. Patient breathing comfortably on [**3-2**] L NC at time of discharge. . # Syncopal event. This was thought to be due to a vasovagal episode after micturation. No evidence of carotid stenosis, no significant aortic valve disease on recent ECHO. Cardiac enzymes were only mildly elevated with peak CK-MB of 12 on [**8-10**]. Troponins peaked at 0.8 on [**8-25**]. . # Abdominal mass/ascites. This is likely be to ovarian cancer. Elevated CEA and CA-125 are consistent with malignancy. Patient was seen by gyn oncology who felt she was not a surgical candidate - this was discussed with the pt. and her family and they understood this and the uncertain but likely very poor prognosis. They elected to treat symptomatically, and not pursue specific further therapy. . # DM: Patient was treated with an insulin sliding scale during ICU stay. She will need to resume her home dose of 37 [**Location 18993**] at night if her po intake increases and her blood sugars are elevated. At the time of discharge she was being managed on SSI alone. . # ESRD. Patient received dialysis during hospitalization, and should continue TIW as outpatient. . # Humerus fracture. Patient suffered a humerus fracture during syncopal episode. There was a mild displacement. She was treated with Morphine prn and Tylenol RTC for pain control. She was seen by orthopedic surgery and her arm was placed in a sling - they recommended nwb and maintenance of arm in sling with outpatient follow up in 4 weeks. . # Code:Pt. and family elect DNR/DNI. No pressors per family. Medications on Admission: Amlodipine 5 mg once a day Aspirin 81 mg once a day B complex once a day Cozaar 50mg 4 times a week Digoxin 125mcg, [**1-1**] alternating with 1 tablet po Q4days Gabapentin 200mg QHS Klonopin 1mg, 1 tablet QHS, 2mg before dialysis Lipitor 10 mg--1 tablet(s) by mouth at bedtime Mirapex 0.125 mg--[**1-1**] tablet(s) by mouth at 6pm and again QHS Nephrocaps 1 capsule(s) by mouth once a day Synthroid 50 mcg--1 tablet(s) by mouth once a day TOPROL XL 100 mg--1 tablet(s) by mouth at bedtime ZOLOFT 100 mg--1 tablet(s) by mouth q am Daypro 600mg, 2 tbl with food Calcium Acetate 667 mg 2tb TID W/MEALS Clopidogrel 75 mg Tablet Sevelamer 800 mg 3 Tablet PO TID Glargine 37U, HISS Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 3. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO Q6pm and QHS (). 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 12. Insulin Lispro 100 unit/mL Solution Sig: as per sliding scale units, insulin Subcutaneous ASDIR (AS DIRECTED): see attached sliding scale. units, insulin 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 14. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 18. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. 19. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 20. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: Likely ovarian cancer Lt. humeral fracture Multilobar, community-acquired pneumonia Hypercarbic respiratory failure requiring mechanical ventilation Discharge Condition: stable Discharge Instructions: Take all medications as prescribed. Call the Orthopedic department at [**Hospital1 **] to arrange a follow up appointment for four weeks from the time of discharge: ([**Telephone/Fax (1) 2007**] Call the Gynecology Department at [**Hospital1 18**] to arrange follow up should you elect to pursue further treatment for the abdominal mass that was found during this admission: ([**Telephone/Fax (1) 18994**] Call and arrange a follow up appointment with your primary doctor for within one month of leaving the hospital [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Followup Instructions: Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2188-9-16**] 11:10 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7380**],MD MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 457**] Date/Time:[**2188-9-30**] 9:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2189-1-1**] 11:00

[ "486", "V45.81", "518.81", "V66.7", "515", "293.0", "428.0", "403.91", "780.57", "183.0", "E888.9", "812.01", "585.6", "250.40", "416.0", "412", "427.81", "780.2", "244.9", "458.9" ]

icd9cm

[ [ [] ] ]

[ "39.95", "93.90", "38.93", "96.6", "96.71", "93.59", "96.04" ]

icd9pcs

[ [ [] ] ]

9771, 9838

5166, 7267

323, 358

10031, 10040

3646, 4183

10714, 11184

2865, 2951

7994, 9748

9859, 10010

7293, 7971

10064, 10691

2966, 3627

276, 285

386, 2059

4192, 5143

2081, 2650

2666, 2849

28,243

146,470

34106+57894

Discharge summary

report+addendum

Admission Date: [**2180-6-13**] Discharge Date: [**2180-6-18**] Date of Birth: [**2115-3-1**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: CABGx2(LIMA-LAD, SVG-PDA)[**6-13**] History of Present Illness: Ms. [**Known lastname 78650**] is a 65 year-old woman with known coronary artery disease who underwent a cardiac catheterization in response to a complaint of chest pain. The catheterization revealed three vessel disease. She was referred to cardiac surgery for surgical correction of this pathology. Past Medical History: 1. CAD - EF of 45% 2. Leukemia - AML treated from [**2174**] to [**2175**] with chemotherapy. Now in remission. 3. Htn 4. NIDDM - controlled with diet 5. CRI - diagnosed last month 6. Hyperlipidemia 7. Anemia 8. Osteoporosis 9. cataracts 10. s/p appendectomy in the 80's 11. history of ace-I intolerance due to cough and hyperkalemia Social History: Social history is significant for the <1 year pack history of tobacco; patient quit >30 years ago. There is no history of alcohol abuse. The patient drinks a glass of wine occasionally. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: At the time of discharge Ms. [**Known lastname 78650**] was found to be awake, alert, and oriented. There were scattered wheezes upon auscultation of her lungs. Her heart was of regular rate and rhythm. Her mediastinal incision was clean, dry, and intact. The sternum was stable. Her abdomen was soft, non-tender, and non-distended. Her extremities were warm with +1 upper and lower extremity edema. Her left leg vein harvest sites were clean, dry, and intact. Pertinent Results: [**2180-6-18**] 09:30AM BLOOD WBC-9.4 RBC-3.30* Hgb-9.9* Hct-29.9* MCV-91 MCH-30.1 MCHC-33.2 RDW-15.3 Plt Ct-312 [**2180-6-18**] 09:30AM BLOOD Plt Ct-312 [**2180-6-18**] 09:30AM BLOOD Glucose-168* UreaN-49* Creat-1.7* Na-132* K-3.7 Cl-98 HCO3-20* AnGap-18 Brief Hospital Course: On [**2180-6-13**] [**Known firstname **] [**Known lastname 78650**] underwent a coronary artery bypass grafting times two (LIMA to LAD, SVG to PDA). The surgery was performed by Dr. [**First Name (STitle) **] [**Name (STitle) **]. She tolerated the procedure well and was able to be transferred in critical but stable condition to the surgical intensive care unit. Her chest tubes and [**Location (un) 1661**]-[**Location (un) 1662**] drain were removed and she was weaned from her pressors. She was extubated on post-operative day one. She transferred to the surgical step-down floor by post-op day two. She was placed on nebulizers and her lasix was increased to address increased wheeziness. Her respiratory status improved with this treatment, but because her creatinine rose transiently, her lasix was decreased. Her epicardial wires were removed. By post-operative day five her creatinine had improved and she was otherwise medically ready for discharge to rehab. Medications on Admission: plavix 75 aspirin 325 metoprolol 100 amlodipine 5 isosorbide 20 [**Hospital1 **] gemfibrozil 600 [**Hospital1 **] Nitropatch 0.4 Timpotic 0.5% OU Procrit Q2wk Ca/Vit Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while taking pain medication. Disp:*60 Capsule(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed. Disp:*60 puffs* Refills:*0* 6. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed. Disp:*60 puffs* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 5165**] Discharge Diagnosis: CAD s/p CABG this admission HTN, lipids, AML s/p chemotx [**2175-3-7**], NIDDM, CRI, Anemia, osteoporosis, RLE DVT, cataracts, s/p appy Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **],[**First Name3 (LF) 177**] J. [**Telephone/Fax (1) 62315**] 2 weeks Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8098**] 2 weeks Dr. [**Last Name (STitle) **] 4 weeks Completed by:[**2180-6-18**] Name: [**Known lastname 12664**],[**Known firstname **] T Unit No: [**Numeric Identifier 12665**] Admission Date: [**2180-6-13**] Discharge Date: [**2180-6-18**] Date of Birth: [**2115-3-1**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 741**] Addendum: Discharge medications were amended to include an insulin sliding scale and timoptic eye drops. Major Surgical or Invasive Procedure: CABGx2(LIMA-LAD, SVG-PDA)[**6-13**] Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while taking pain medication. Disp:*60 Capsule(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed. Disp:*60 puffs* Refills:*0* 6. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed. Disp:*60 puffs* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 11. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): sliding scale to keep blood sugars 80-120. Disp:*qs u* Refills:*2* 12. Timoptic 0.5 % Drops Sig: One (1) Ophthalmic once a day: place to both eyes daily. Disp:*qs * Refills:*2* Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 8807**] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2180-6-18**]

[ "733.00", "V15.82", "285.9", "428.23", "413.9", "205.01", "585.9", "V12.51", "403.90", "276.2", "272.4", "428.0", "250.00", "518.5", "414.01" ]

icd9cm

[ [ [] ] ]

[ "99.07", "36.15", "36.11", "99.04", "39.61" ]

icd9pcs

[ [ [] ] ]

7699, 7893

2155, 3134

6033, 6071

4941, 4949

1875, 2132

5262, 5995

1291, 1373

6094, 7676

4782, 4920

3160, 3327

4973, 5239

1388, 1856

281, 293

397, 701

723, 1069

1085, 1275

78,968

115,795

41426

Discharge summary

report

Admission Date: [**2179-4-6**] Discharge Date: [**2179-4-12**] Date of Birth: [**2152-4-24**] Sex: F Service: MEDICINE Allergies: Penicillins / Tetracycline Attending:[**First Name3 (LF) 2290**] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: Endotracheal Intubation (tube placed at outside hospital) Mechanical Ventilation Bronchoalveolar Lavage/bronchoscopy Central venous line placement History of Present Illness: Mrs [**Known lastname 77625**] is a 26 yo female with history of obesity, childhood asthma, smoker, poorly controlled diabetes. She initially presented to [**Hospital3 **] ED with cough, fever, chills, myalgias, N/V/D x2 days with progressive SOB in the setting of several recent sick contacts. She had also been non-compliant with her diabetes medications with glucose elevated to 537 with no gap. On arrival to the ED, vitals were remarkable for T 103, HR 140, satting 91% on 2 L, WBC elevated to 16.4. ABG showed hypercarbic respiratory failure and the pt was intubated. Right subclavian was placed and she was started on moxifloxacin, albuterol, duonebs and insulin. She was transfererred to the CHA ICU on [**2179-3-29**]. . At [**Hospital 8**] hospital, she was treated with tamiflu and started on ceftriaxone and azithromycin for PNA, which was broadened to vanc, cefepime, gent on [**4-4**] with persistent fevers. Treatment was based on her presenting symptoms however CT chest on [**3-31**] did not show any consolidations, CTA did not show any evidence of PEs, however per OSH report there was concern for tracheomalacia. Extubation was attempted on [**4-1**] but failed. There was also concern for sepsis and she was started on solumedrol 60 [**Hospital1 **] but did not require pressors. Cxs were negative with the exception of 1 blood cx growing coag negative staph. HIV test was ordered and was pending on transfer. Aspergillis serology was sent due to elevated IGE levels. CT head was done to eval for sinus infection and was pending. She was also treated for cdiff with PO vanco given new diarrhea with abx (cdiff assay pending). She was treated with insulin and started on tube feeds. CEs were drawn and found to be mildly elevated with a normal EKG, therefore enzymes were trended and this was thought to be due to demand ischemia. ECHO showed EF 70%, mild RA enlargement, mild PHTN, mild MR, TR. She was transferred for further work-up of her respiratory distress and possible bronchial stenting. . On the floor, pt is intubated and sedated, opens eyes to voice but is otherwise not responsive. Past Medical History: Asthma Bipolar d/o NIDDM ADHD obesity Hemorrhoids Social History: Most of care at [**Hospital1 2177**], 5 year old son [**Name (NI) 449**]. Lives with mother who is also chronically ill and med non-compliant per report. Tobacco, EtoH, illicit drug denies. Family History: Mother: Diabetes Physical Exam: Admission Physical Exam: Vitals: T:101.6 BP:142/60 P:54 R: 16 O2:95 % on vent General: NAD, opens eyes to voice, intubated HEENT: Sclera anicteric, MMM, oropharynx clear, PERRLA, OG tube in place Neck: supple, JVP not elevated, no LAD Lungs: Rhonchorous throughout CV: Distant heart sounds, RRR, no MRG Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, mild edema bilaterally. NEURO: opens eyes to voice, moves all extremities freely Pertinent Results: Admission Labs: [**2179-4-6**] 03:28AM BLOOD WBC-11.1* RBC-3.31* Hgb-9.4* Hct-28.8* MCV-87 MCH-28.4 MCHC-32.7 RDW-13.5 Plt Ct-266 [**2179-4-6**] 03:28AM BLOOD Neuts-71.7* Lymphs-21.6 Monos-6.3 Eos-0 Baso-0.4 [**2179-4-6**] 03:28AM BLOOD PT-13.1 PTT-21.5* INR(PT)-1.1 [**2179-4-6**] 03:28AM BLOOD Plt Ct-266 [**2179-4-6**] 03:28AM BLOOD Glucose-184* UreaN-20 Creat-0.7 Na-143 K-4.5 Cl-104 HCO3-32 AnGap-12 [**2179-4-6**] 03:28AM BLOOD ALT-64* AST-39 LD(LDH)-260* CK(CPK)-138 AlkPhos-44 TotBili-0.4 [**2179-4-6**] 03:36PM BLOOD CK(CPK)-129 [**2179-4-6**] 03:28AM BLOOD CK-MB-1 cTropnT-<0.01 [**2179-4-6**] 03:36PM BLOOD CK-MB-1 cTropnT-<0.01 [**2179-4-6**] 03:28AM BLOOD Albumin-3.5 Calcium-9.3 Phos-6.0* Mg-2.6 [**2179-4-6**] 03:32AM BLOOD Type-ART pO2-86 pCO2-55* pH-7.39 calTCO2-35* Base XS-6 [**2179-4-6**] 03:32AM BLOOD Lactate-2.1* [**2179-4-6**] 03:32AM BLOOD freeCa-1.26 [**4-6**] CXR: Endotracheal tube tip is approximately 1 cm above the carina. Retraction 3 cm is recommended. Lung volumes are low. Pulmonary vascular congestion is likely secondary to low lung volumes. Heart size is within normal limits given low lung volumes. No focal consolidation, pleural effusion, or pneumothorax is seen on this single view. [**4-8**] ECHO: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a very small pericardial effusion. Microbiology [**4-8**] Rapid Resp Viral Screen: negative [**4-8**] BAL: GRAM STAIN (Final [**2179-4-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): commensal flora LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Preliminary): negative FUNGAL CULTURE (Preliminary): negative ACID FAST SMEAR (Preliminary): negative ACID FAST CULTURE (Preliminary): negative [**4-8**] Blood Cx: pending [**4-8**] Urine Cx: yeast >100,000 [**4-7**] CVL tip culture: negative [**4-7**] Sputum culture: --gram stain: >25 PMNs and <10 epithelial cells/100X field; 2+ YEAST --respiratory culture pending --fungal culture pending [**4-6**] Urine legionella antigen negative [**4-6**] Blood cultures: pending [**4-6**] Stool: negative for C. diff [**4-6**] Urine: Yeast >100,000 ORGANISMS/ML. Brief Hospital Course: 26 yo female admitted to OSH([**Hospital1 **]->[**Hospital1 8**]->[**Hospital1 **]) for respiratory distress, intubated and treated with abx with minimal improvement in sxs, persistent fever, med flighted to [**Hospital1 18**] for further management. She initially was treated in the Medical Intensive Care Unit ([**Date range (1) 90132**]), and then she was transferred out to the floor. Her brief hospital course, organized by problem, was as follows: # Respiratory failure: History of course prior to transfer to [**Hospital1 18**] somewhat unclear, though per notes/reports on initial presentation patient c/o cough, sputum production and shortness of breath, which raises concern for PNA, however this was not confirmed by imaging. History also suggestive of possible influenza given reports of fevers and myalgias, though patient tested negative for flu and completed course of treatment with oseltamivir. Shecompleted treatment course of vanc/cefepime ([**Date range (1) 90133**]). Other viral illnesses and atypical infections including PCP and legionella were also considered, however were not confirmed by testing. HIV test was negative. Patient was slowly weaned from the vent and was extubated on [**2179-4-8**] without difficulty. She was also followed by infectious disease. She was scheduled for pulmonary follow-up at [**Hospital1 18**]. An albuterol inhaler was prescribed on discharge. #. Fevers: Patient continued to have persistently high fevers during her first few days of hospitalization. As with her respiratory failure discussed above, the etiology of fevers unclear, and differential included PNA (completed vanc/cefepime course), C. diff (though stool negative x4), viral infection (completed ostelmavir course), drug fever, NMS (CK within normal limits, no new pharmaceuticals). Patient does have possible immune compromise in setting of poorly controlled IDDM. Blood cultures, urine cultures and sputum cultures were consistently negative for bacterial growth. Patient eventually deferveshed and was afebrile for >24 hours prior to being transferred to the floor. # Leukocytosis: The patient had a significant leukocytosis upon arrival. The most likely source was felt to be respiratory, however given the very unclear history she was repeatedly re-cultured from blood, urine and sputum. Blood, urine, sputum cultures remained largely negative or were still pending at the time of transfer to the floor, however patient's leukocytosis had trended down as she clinically improved. A CBC should be repeated by her PCP at her next visit to trend he leukocytosis. # Diarrhea: The patient was intially started on PO vanco at OSH for presumed Cdiff, however upon arrival [**Hospital1 18**] was notified her toxin studies were negative x2. Negative X2 in house as well. Diarrhea likely antibiotic associated, with less concern for other infx etiologies given the development of her symptoms while in hospital. She had serial abdominal exams. # EKG changes: Upon presentation to the MICU, she had new TWI on EKG and a slightly prolonged QTc. Recent w/u at OSH with elevated CEs concerning for demand ischemia based on cardiology review. Pt now with new septal t-waves concerning for ischemia. Her cardiac enzymes were trended and did not bump. Her home aspirin and statin were continued and she was monitored on telemetry. She had a repeat EKG prior to transfer from the MICU with resolution of the changes. # Bipolar d/o: patient was intubated and sedated upon arrival, however from OSH records it was apparent that she was on several psychoactive medications and she carried a diagnosis of bipolar disorder. She was continued on her home medications including lithium, lorazepam, seroquel, risperidone, and trazadone. Her lithium levels were monitored. Once she was extubated and could converse, psychiatry was consulted for help with management of her psychiatric medications. They recommended using haldol for agitation and following up with her outpatient psychiatrist Dr. [**Last Name (STitle) **]. Social work was also consulted as it was felt that the patient may have difficultly caring for herself and her young son, as her uncontrolled blood sugars likely played a part in this episode. She was told to call her psychiatrist the Wed/Friday of discharge for follow-up as no appointments could be scheduled for her the day of discharge. # NIDDM: The patient had a recent diagnosis of diabetes, with a HbA1c of 13.5. Per OSH records, she had apparently been non-compliant with her medications and was requiring very large doses of insulin. She was continued on an insulin drip for her first few days in the MICU and then weaned to an insulin sliding scale. [**Last Name (un) **] was consulted, and she was started on lantus 40 units, with 15 units humalog w/meals plus sliding scale. She was also restarted on metformin 500mg [**Hospital1 **] once she started eating (recommendation to uptitrate to 1000mg [**Hospital1 **] [**First Name8 (NamePattern2) **] [**Last Name (un) **]). Additionally an anti-GAD was sent to assess DM1 vs DM2 which was still pending upon her transfer from the ICU. Once stable they recommend she receive an eye exam, baseline check of renal function, lipid panel, a review of her psych meds which could contribute to her hyperglycemia and a dietary review. [**Last Name (un) **] saw the patient prior to discharge and recommended an increase in her Lantus to 44 U if her AM blood sugars remained elevated > 200. She was given insulin teaching and set up with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] endocrinologist and teaching RN within 10 days of discharge. # Anemia: The patient had a normocytic anemia upon presentation. Her hematocrit was closely monitored and it remained stable. She had iron studies sent which showed Fe, TIBC, transferrin within normal limits. Her ferritin was elevated which may suggest anemia of chronic disease, or perhaps was functioning as an acute phase reactant. Stools were guaic negative. # Nutrition: She received tube feeds while she was intubated, and she was followed by nutrition. Once she was extubated, her diet was rapidly advanced to a diabetic, consistent carbohydrate diet. Medications on Admission: Home medications (from OHS records): Asa 81mg benztropine mesylate diphenydromine glipizide 10 [**Hospital1 **] lisinopril 5 mg daily lithium 300 qhs lithium 600 [**Hospital1 **] lorazepam 1 mg TID metformin 1000 mg [**Hospital1 **] Necon 1/35 P day risperdone 1.5 qhs seroquel 50 mg qhs simvastatin 10 mg . Meds on transfer from OHS: insulin gtt vanco 250 mg PO vanco 1500 IV colace 200 mg solumedrol 60 mg IV BID cefepime 2 grams IV q 12 gentamycin 550 mg IV q 24 seroquel 50 mg q HS Lithum 600 [**Hospital1 **] Lithium 300 mg q HS duonebs midazolam gtt fentanyl gtt ASA Pravastatin 20 mg daily Lisinopril 5 mg daily Risperadol 6 mg q HS Famotidine 20 mg IV q 12 Heparin 5000 q8 tylenol PRN Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*2* 4. risperidone 1 mg/mL Solution Sig: 6 mg PO HS (at bedtime). 5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*12 Tablet(s)* Refills:*2* 6. lithium carbonate 300 mg Capsule Sig: Two (2) Capsule PO EVERY MORNING AT 0800 (). 7. lithium carbonate 300 mg Capsule Sig: Three (3) Capsule PO QHS (once a day (at bedtime)). 8. Seroquel 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. trazodone 50 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 10. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Lantus 100 unit/mL Solution Sig: Forty (40) U Subcutaneous QAM. Disp:*12 mL* Refills:*2* 12. insulin lispro 100 unit/mL Solution Sig: One (1) injection Subcutaneous four times a day: per attached sliding scale. Disp:*20 mL* Refills:*2* 13. lancets Misc Sig: One (1) lancet Miscellaneous twice a day. Disp:*1 box* Refills:*2* 14. syringe (disposable) 50 mL Syringe Sig: One (1) syringe Miscellaneous four times a day. Disp:*1 box* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: Respiratory Failure Secondary Diagnosis: Insulin Dependent Diabetes Mellitus Bipolar Disorder Discharge Condition: Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted with respiratory distress requiring admission to the ICU, intubation, and mechanical ventilation. The cause of your respiratory failure was thought to be due to a viral infection. No bacterial infection was identified. You were taken off the breathing machine and did well. The following changes were made to your medicaton. 1. Insulin: Take 40 [**Location 17632**] (LONG ACTING INSULIN) at night and the insulin sliding scale with meals as directed. If your blood sugars are greater than 200 tomorrow morning ([**4-13**]), please increase your Lantus to 44 U at breakfast. 2. Decrease metformin from 1 gram twice a day to 500 mg twice a day since you are on insulin now. 3. Started trazodone 50 mg by mouth at night for sleep 4. We held your benztropine because we did not get confirmation from your psychiatrist that you take this medication. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 251**] C. Location: [**Hospital3 **] HEALTH CENTER Address: [**State **], [**Location (un) **],[**Numeric Identifier 38978**] Phone: [**Telephone/Fax (1) 14167**] Appt: [**4-14**] at 11am Name: [**Last Name (LF) 3310**],[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD Location: [**Hospital6 **] Address: [**Location (un) 11452**] [**Last Name (un) 19988**] 9, [**Location (un) **],[**Numeric Identifier 18406**] Phone: [**Telephone/Fax (1) 63382**] Apppt: IMPORTANT*****Please call the office this Wed or Friday morning at 7:30am to book a same day appt. Dr [**Last Name (STitle) **] did not have any sooner appts patient should call on Wed or Fri morning this week to book a same day appt. Put this above in appts Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2378**] Appt: [**4-19**] at 10AM [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] NP Appt: [**4-19**] 11AM with the Nurse Educator Department: PULMONARY FUNCTION LAB When: WEDNESDAY [**2179-4-28**] at 3:30 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2179-4-28**] at 4:00 PM With: DR. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2179-4-13**]

[ "519.19", "305.1", "493.92", "250.00", "780.09", "V15.81", "278.00", "787.91", "518.81", "296.80", "285.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "33.23", "96.71" ]

icd9pcs

[ [ [] ] ]

14749, 14807

6368, 12578

307, 455

14965, 15057

3529, 3529

15969, 17666

2897, 2915

13322, 14726

14828, 14828

12604, 13299

15081, 15946

2955, 3510

5918, 6345

5830, 5885

5630, 5800

247, 269

483, 2600

14889, 14944

3545, 5594

14847, 14868

2622, 2674

2690, 2881

6,576

156,170

5101

Discharge summary

report

Admission Date: [**2102-6-9**] Discharge Date: [**2102-6-14**] Service: MEDICINE Allergies: Erythromycin Base / Ampicillin / Levofloxacin / Clindamycin Attending:[**Last Name (NamePattern1) 1572**] Chief Complaint: Bradycardia Major Surgical or Invasive Procedure: Pacemaker placement History of Present Illness: [**Age over 90 **] y/o gentleman with HTN, CHF, CAD s/p CABG 80s, AF on coumadin has experienced diarrhea since yesterday afternoon. He came to the Emergency Department to better manage his fluid status per PCP [**Name Initial (PRE) **]. In the Emergency Department his HR was found to be in high 30s to low 40s. His baseline has been mid to high 40s for the last few years. Patient has experienced dypnea on exertion with approx 30-40 feet of walking in the last 1 week. Denies chest pain, orthopnea, PND, palpitations, or lower extremity edema. Daughter has noticed that he has gained 5 lbs in the last one week. He has had three loose bowel movements since yesterday afternoon. No new food, blood in stool, fever, chills, or night sweats. Denies any pain. In ED vitals were: HR 35, no CP, BP 130s/60 97%RA. . Past Medical History: CHF (Last known EF 49%) DM2 Hypothyroid Atrial Fibrillation CAD s/p CABG, exercise MIBI [**10-14**] 1) Moderate, fixed defect involving the base of the inferolateral wall. 2) Ejection fraction of 49% with septal and inferolateral wall hypokinesis. CKD Baseline Cr 2.0-2.5 HTN Hx PUD Glaucoma Osteopenia Macular degeneration R eye cataract Left eye blind HOH Upper and lower dentures . Social History: Retired postal worker, lives alone in [**Hospital3 **] but daughter is very involved, organizes meds for him. Widowed 8 years ago. . Family History: Diabetes, HTN Physical Exam: Vitals: T 97.7 BP 140/59 HR 70 RR 18 100% on 2LNC Gen: Alert and jovial. Oriented to person and place. NAD HEENT: PERRL, MMM, OP clear, JVP not elevated Heart: S1S2 regularly regular bradycardic Lungs: Fine bibasilar crackles Abdomen: Soft NTND Extremities: 1+ pitting edema in b/l lower extremities Neuro: spont moves . Pertinent Results: Admit Labs: [**2102-6-9**] 05:15PM BLOOD WBC-4.6 RBC-3.67* Hgb-12.3* Hct-35.4* MCV-97 MCH-33.5* MCHC-34.6 RDW-14.0 Plt Ct-100* [**2102-6-9**] 05:15PM BLOOD PT-24.3* PTT-31.5 INR(PT)-2.4* [**2102-6-9**] 05:15PM BLOOD Glucose-168* UreaN-106* Creat-3.7*# Na-140 K-4.7 Cl-107 HCO3-24 AnGap-14 [**2102-6-14**] 05:55AM BLOOD Glucose-139* UreaN-52* Creat-2.2* Na-140 K-3.8 Cl-111* HCO3-20* AnGap-13 [**2102-6-9**] 05:15PM BLOOD cTropnT-0.03* [**2102-6-9**] 05:15PM BLOOD CK(CPK)-74 [**2102-6-9**] 05:15PM BLOOD CK-MB-NotDone proBNP-3419* [**2102-6-9**] 05:15PM BLOOD Albumin-4.2 Calcium-9.1 Phos-4.2 Mg-2.8* [**2102-6-10**] 05:30AM BLOOD TSH-2.9 [**2102-6-10**] 05:30AM BLOOD Free T4-1.3 [**2102-6-9**] 05:15PM BLOOD K-4.6 . CHEST (PORTABLE AP) [**2102-6-9**]: Mild interstitial edema with cardiomegaly. . TTE [**2102-6-12**]: The left atrial volume is markedly increased (>32ml/m2). Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the septum and inferior wall. The right ventricular cavity is not well seen but appears mildly dilated and probably hypertrophied. The ascending aorta is mildly dilated. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. 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 moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate regional LV systolic dysfunction. Dilatation and probable hypertrophy of the right ventricle, its function cannot be accurately assessed. Moderate pulmonary artery systolic hypertension. Biatrial enlargement. . CHEST (PA & LAT) [**2102-6-14**]: 1. Subtle line at the right lung apex with evidence of some lung markings beyond it, could represent a skinfold. Followup radiograph to definitively exclude pneumothorax is recommended. This was discussed with Dr. [**Last Name (STitle) **]. 2. Left chest wall transvenous pacer with right atrial and ventricular leads in standard location without a left pneumothorax. . Brief Hospital Course: [**Age over 90 **] year old gentleman with hypertension, chronic right heart failure, coronary artery disease status post CABG in [**2083**], atrial fibrillation on warfarin admitted with asymptomtic bradycardia and acute on chronic renal failure in the setting of recent diarrhea and weight gain. # Rhythm: Asymptomatic bradycardia, with history of atrial fibrillation. Pt was admitted to the CCU for close monitoring. Pt remained asymptomatic throughout his stay even though she had heart rates that dropped as low as high 20s. His coumadin was held and he received 2.5mg vitamin K on [**2102-6-11**] in preparation for pace maker placment. Appreciate electrophysiology recommendations. A Pace maker was placed on [**6-13**] without complication. # Pump: Has fine crackles at bases and 1+ edema in BLE. Has right sided heart failure per out patient cardiologist ([**Doctor Last Name **]) and elevated BNP. An ECHO was done which showed EF 30-35%, moderate regional LV systolic dysfunction. Dilatation and probable hypertrophy of the right ventricle. Moderate pulmonary artery systolic hypertension and biatrial enlargement. His Lasix was held for some diarrhea and acute on chronic renal failure. He was discharged on decreased lasix dose of 20 mg twice daily. . #. CAD: History of CAD s/p CABG in 80s. Remained asymtomatic during her stay here. He was continued on his statin. Patient will have device clinic, electrophysiology and cardiology follow up as out patient. . # Diarrhea: 3 large liquid bowel movements which resolved on admission. C.diff test was negative. Most likely due to transient viral infection. . # Chronic Kidney Disease: Unclear baseline. His Cr was 3.7 and trended down to 2.5 (felt to be baseline; but unclear). [**Name2 (NI) **] likely due to poor forward flow in the setting of bradycardia. His home lasix was held in setting of ARF and restarted at decreased dose on discharge. His trandolapril was discontinued during this stay. . # Anemia: Currently at baseline of 34-36. . # Hypothyroidism: TSH and free T4 within normal limits. Continued on home synthroid. . # Depression: Continued home wellbutrin and celexa . Medications on Admission: Synthroid 150 mcg daily Wellbutrin 75 mg daily Lipitor 40 mg daily Lasix 40 mg [**Hospital1 **] Coumadin 1.5 mg daily Januvia 50 mg daily Lutein 6 mg daily Calcium 1 gm [**Hospital1 **] Nexium 40 mg [**Hospital1 **] Starlix 30 mg qam, 60 mg at noon and 30 mg qpm before each meal Precose 25 mg tid Theragram 1 tab qhs Celexa 20 mg daily Mavik 1 mg daily Calcitriol 0.25 mcg MWF Trusopt 2% 1 drop [**Hospital1 **] Betopic 0.5% 1 drop [**Hospital1 **] Xalatan 1 drop daily NTG prn . Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Bupropion 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Coumadin 1 mg Tablet Sig: 1.5 Tablets PO once a day. 6. Sitagliptin 100 mg Tablet Sig: 0.5 Tablet PO daily (). 7. Lutein 6 mg Capsule Sig: One (1) Capsule PO daily (). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Nateglinide 60 mg Tablet Sig: One (1) Tablet PO AT NOON TIME BEFORE MEAL (). 11. Nateglinide 60 mg Tablet Sig: 0.5 Tablet PO IN MORNING AND EVENING BEFORE MEAL (). 12. Precose 25 mg Tablet Sig: One (1) Tablet PO three times a day. 13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO Monday, Wednesday, Friday. 15. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 16. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 17. Betoptic S 0.25 % Drops, Suspension Sig: One (1) Ophthalmic twice a day. 18. Coumadin 1 mg Tablet Sig: 1 and [**1-11**] Tablet PO at bedtime: take 1.5 mg daily. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Bradycardia status post pacemaker placement . Secondary: Coronary Artery Disease Chronic right heart failure History of atrial fibrillation Chronic Renal Insufficiency Hypertension Discharge Condition: Asymptomatic and hemodynamically stable. Discharge Instructions: You were admitted to [**Hospital1 69**] with slow heart rate. You had a pacemaker placed. . Please take the medications as written. You were not sent home with aspirin. You are to restart your coumadin at your regular dose 1.5mg daily on Thursday and continue daily as you had in the past. Your lasix dose was decreased to 20mg twice per day. . Please keep all of the follow up appointments. . If you develop chest pain, shortness of breath or any other concerning symptoms, please call your primary care doctor or come to the Emergency Department. Weigh yourself daily, if greater than 3 pound weight gain in one day call your physician. Followup Instructions: Cardiology follow up: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2102-6-22**] at 1:30 pm. . DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2102-6-20**] 9:30 . Electrophysiologist appointment: Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2102-6-22**] 3:00 . Please make a follow up appointment with your primary care doctor within one week of discharge.Provider: Completed by:[**2102-6-15**]

[ "585.9", "285.21", "V45.81", "244.9", "427.89", "584.9", "250.00", "428.0", "427.31", "V58.61", "008.8", "403.90" ]

icd9cm

[ [ [] ] ]

[ "37.72", "37.83" ]

icd9pcs

[ [ [] ] ]

8427, 8485

4346, 6507

286, 308

8719, 8762

2111, 4323

9450, 9461

1734, 1749

7039, 8404

8506, 8698

6533, 7016

8786, 9427

1764, 2092

9472, 9954

235, 248

336, 1154

1176, 1566

1582, 1718

52,659

128,514

34299

Discharge summary

report

Admission Date: [**2124-9-12**] Discharge Date: [**2124-10-2**] Date of Birth: [**2042-8-8**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2167**] Chief Complaint: asystolic cardiac arrest, respiratory failure Major Surgical or Invasive Procedure: Intubation central line placement, Arterial line placement ERCP with biliary and pancreatic stents placed biloma pigtail catheter placement and removal ERCP for pancreatic stent removal History of Present Illness: 82 yo F with COPD and intestinal malrotation with recent cholecystitis and gallstone pancreatitis s/p cholecystectomy c/b bile leak transferred from the ERCP suite after intra-procedural hypoxia and bradycardic vs. asystolic cardiac arrest. . The patient was admitted with cholecystitis and gallstone pancreatitis to [**Hospital3 20284**] Center 07.02-23.08. A cholecystostomy tube was placed. Post op course was complicated by sepsis (thought due to enterobacter bacteremia though not confirmed in records) complicated by ARDS requiring ICU admission. The pt was then readmitted with fevers/ dysuria on [**2124-8-23**] [**2-26**] apparent E. Coli urosepsis with positive urine and blood cultures. Following initiation of imipenem, cultures cleared by [**2124-8-28**] (imipenem was continued for an estimated [**8-1**] days). Her hospital course was c/b volume overload (documentation of this problem is limited), abdominal pain and emesis necessitating re-operation. Laparoscopic cholecystectomy was converted to open cholecystectomy with Ladd's procedure (fixation of malrotation) on [**2124-9-1**]. She developed post-op anemia with a nadir of Hct 24.7. Her post-op course was complicated by acute on chronic renal failure (Cr peaking 3.0) thought [**2-26**] oliguric ATN that resolved with IVF resuscitation; post-op possible ileus vs. obstruction (documented on plain film on [**2124-9-6**]), and bile leak confirmed by subsequent CT scan and HIDA scan on 08.15-16.08. An ERCP attempted on [**2124-9-11**] at OSH was aborted due to failure to access and repair the biliary tree. . Pt was transferred to [**Hospital1 18**] for emergent ERCP. During the ERCP, the pt developed acutely hypoxia, and subsequent bradycardia and hypotension, leading to the calling of a code blue. Chest compressions were initiated, and 1mg atropine x2 and 1mg epinephrine were administered leading to return of spontaneous, palpable pulse at a rate of 160 with hypotension to the systolics 70-80's. SBP were maintained with a neosynephrine continuous infusion. An attempt was made during rescucitation for central line placement in the internal jugular vein with return of fluid that was serous possibly consistent with aspiration of a pleural effusion. Past Medical History: PMH: - Recent choledocholithiasis and gallstone pancreatitis s/p open cholecystectomy c/b bile leak - Recent multidrug resistent E Coli urosepsis (2/2 blood cx, on [**2124-8-23**]; negative as of [**2124-8-28**]) - CRI baseline Cr 1.5 - Diastolic CHF EF 65%, mild TR - HTN - H/o asthma and COPD - Intestinal malrotation s/p Ladd's procedure . Social History: Spanish speaking only. 2 daughters are her health care proxy. Family History: Non-contributory Physical Exam: PE 98.0 153 119/53 18 99% AC Vt 450 RR 16 FiO2 100% Gen: Intubated and sedated. Minimally responsive. HEENT: Surgical right pupil. CV: Tachycardic. No M/R/G. Pulm: Poor air exchange. No rhonchi or wheezes. Abd: Distended. Active bowel sounds. Ext: 1+ bilateral lower extremity edema. Pertinent Results: OSH labs: EKG ([**2124-8-24**]): Sinus tachycardia to 125. Normal axis and intervals. Downgoing T's in V1. No acute ST or T wave changes. None more recent for comparison. UA ([**2124-9-5**]): 200 WBC, 1 RBC, 2 squams, Pos Leuk Esterase. Ascites fluid cx ([**2124-9-9**]): Few WBC's, no organisms. No growth. Blood cx ([**2124-8-23**]): E. Coli Sensitive to Amikacin (8), Zosyn (<8), Imipenem (<4), Gentamycin (2), all other resistant. ([**2124-8-28**]): No growth.([**2124-8-29**]): No growth. Imaging: OSH CT abd/pelvis ([**2124-9-8**]): Large bilateral pleural effusions. Consolidation in the RLL. unchanged since [**2124-9-4**]. Fluid surrounding the dome of the liver. 13 cm Fluid collection in the gallbladder fossa contiguous with collection extending down the right flank. Air within the gallbladder fossa. Increased abdominal fluid since [**2124-9-4**] which may reflect increased ascites, bile leak or possibly abscess/infection. . U/S guided paracentesis ([**2124-9-8**]): 300cc aspiration of dark brown/green fluid sent for culture and sensitivity. Residual loculated fluid int he gallbladder fossa noted. . HIDA scan ([**2124-9-9**]): Active bile leak with extension into the subhepatic space and right paracolic gutter. . KUB and left lateral decubitus ([**2124-9-6**]): Mild ileus vs. partial small bowel obstruction. . TTE ([**2124-8-1**]): LVEF 65%, Mild AR, TR, minimal pericardial effusion. Mild RV enlargement with normal biventricular function. Abnormal diastolic filling pattern. Mild pulmonary hypertension. . [**Hospital1 18**] [**2124-9-12**] chem7: Na 147, K 4.1, Cl 108, Bicarb 30, BUN/Cr 11/0.6, glucose 82. cbc: WBC 22.9, Hct 31.5, platelets 266 lfts: ALT 35, AST 43, Alk Phos 464, T Bili 0.7, Alb 1.8, T Prot 5.1 INR 1.56, PT 15.4 . CXR [**2124-9-12**]: 1. Right humeral head fracture, only partially imaged. 2. Mild fluid overload. 3. Right central line in the mid SVC, ET tube approximately 3 cm above the carina. [**2124-9-13**]: 143(147) 106 (108) 16(11) 139 AGap=16 4.3 (4.1) 25 (30) 0.8(0.6) Ca: 8.6 Mg: 3.1 (repleted) P: 5.0 (high) CBC: 36.8 (22.9) /29.6 (31.5) / 224 (266) N:91.2 L:6.6 M:1.7 E:0.2 Bas:0.3 LFTs: ALT: 25 AP: 381 Tbili: 0.6 Alb: 2.3 AST: 49 LDH: 554 [**Doctor First Name **]: 113 Lip: 126 ([**2124-9-12**]: ALT 35, AST 43, Alk Phos 464, T Bili 0.7, Alb 1.8, T Prot 5.1 INR 1.56, PT 15.4) . [**2124-9-14**]: 145 (144) 112 (111) 16 (17) 86 AGap=11 4.0 (3.7) 22 (22) 0.6 (0.7) Ca: 7.5 (7.4) Mg: 1.9 (2.1) P: 3.0 (3.9) 25.5 / 27.3 (24.3)/ 201 diff:N:90.6 L:5.8 M:3.3 E:0.2 Bas:0.2 (32.4, 36.8, 22.9) / (24.3, 29.6, 31.5) / (226, 224, 266) PT: 17.4 PTT: 40.1 (37,2) INR: 1.6 ( 1.7) ALT: 29 AP: 314 Tbili: 0.6 Alb: 2.2 AST: 56 [**Doctor First Name **]: 353 (334) Lip: 930 (970) . [**2124-9-15**] 147 (144) 112 (111) 13 (14) 70 AGap=12 3.9 (3.6) 27 (24) 0.6 (0.6) Ca: 8.1 (8.3) Mg: 1.9 (2.3) P: 2.3 (2.7) 19.3 (20.5) /27.2 (27.7) / 218 (218) N:81.7 L:12.8 M:3.4 E:1.7 Bas:0.3 PT: 17.2 (17.4) PTT: 69.4 (40.1) INR: 1.6 (1.6) ALT: 23 (27) AP: 322 (304) Tbili: 0.7 (0.5) AST: 31 (40) LDH: 415 (464) [**Doctor First Name **]: 83 (166, 353) Lip: 171 (329, 930) ' [**2124-9-17**]. 139 102 9 25 ---------< 3.7 31 0.5 Ca 8 Mg 2.6 P 3.1 Alb 2.4 ALT 25 AST 29 AlkPhos 533 Tbil 0.5 22/27.8/ 238 UA + leak 125 WBC Cdif- pending . [**2124-9-19**]: 145 106 9 117 AGap=10 -------------< 3.9 33 0.5 Ca: 8.0 Mg: 2.0 P: 3.3 22.9 / 27.1 / 199 N:73.8 L:17.4 M:6.7 E:1.8 Bas:0.3 coags - not pending yet this am LFTs- ALT 16 AST 22 Alkphos 376* LDH 399* tbil 0.6 . [**2124-9-20**] [**2124-9-20**]: 145 103 11 125 AGap=11 -------------< 3.7 35 0.5 Ca: 7.8 Mg: 1.6 P: 2.4 17.5 (22.9) /25.7/ 167 no diff ALT: 17 AP: 365 Tbili: 0.6 Alb: 2.2 AST: 21 LDH: 361 UA SpecGr 1.017 Leuk Mod RBC 7 WBC 79 BactFew ucx- pending . Micro:Blood ([**2124-8-23**]): E. Coli Sensitive to Amikacin (8), Zosyn (<8), Imipenem (<4), Gentamycin (2) ([**2124-8-28**]): No growth. ([**2124-8-29**]): No growth. Micro-PICC- no growth Micro bile- no growth UCx [**2124-9-12**]: yeast Ucx [**2124-9-18**]- yeast C dif ([**2124-9-17**])- negative Sputum cx [**2124-9-18**]- yeast miniBAL [**2124-9-19**] - yeast . Blood cultures [**2124-9-12**]- pending Ucx [**2124-9-19**]- pending . Urine ([**2124-9-5**]): 200 WBC, 1 RBC, 2 squams, Pos Leuk Esterase. Ascites fluid ([**2124-9-9**]): Few WBC's, no organisms. No growth. [**2124-9-13**]: UreaN:109 Creat:161 Na:27 Osmolal:320 FeNA> 9.39; FeUN 12.4% [**2124-9-12**]: U lytes UreaN:297 Creat:44 Na:69 Osmolal:327 FenA 0.6%, FeUN 36.8% [**2124-9-12**]: BNP - [**Numeric Identifier 78933**] serum Osms:302 . Cardiac enzymes: CK: 139 MB: Pnd Trop-T: Pnd CK: 36 MB: 3 Trop-T: 0.03 CK: 45 MB: 4 Trop-T: 0.03 . Imaging EKG ([**2124-8-24**]): Sinus tachycardia to 125. Normal axis and intervals. Downgoing T's in V1. No acute ST or T wave changes. None more recent for comparison. ECG ([**2124-9-12**]): Sinus tachycardia, no ischemic changes KUB - no obstruction ECHO - EF 75% IR [**2124-9-13**] - percutaneous biliary drain placed ERCP report [**2124-9-15**]- difficult cannulation KUB [**2124-9-19**]: biliary and pancreato-hepatic stents in place. IR [**2124-9-28**]: biloma drain removed ERCP [**2124-9-29**]: pancreatic stent removed Brief Hospital Course: A/P: 82 yo F w/ COPD, CHF, intestinal malrotation s/p Ladd's procedure with cholecystitis and gallstone pancreatitis s/p cholecystectomy c/b ARDS, ATN, ongoing bile leak, and recent urosepsis transferred following intra-ERCP hypoxia followed by bradycardic vs. asystolic cardiac arrest. . # Cholecystectomy c/b Bile Leak: RUQ ultrasound and CT - contrast demonstrated extensive biloma. Biliary drainage was performed on [**9-14**], with retrieval of > 1L. ERCP for stenting was attempted X24 hrs after percutaneous drain was placed (on [**9-15**]). Surgery/GI were consulted and followed for 24hrs to monitor for reaccumulation and recommend imaging. Stenting was performed [**2124-9-15**], and the pancreatic stent was to stay in place for 1 week, and the biliary stent for 8 weeks. Vancomycin and meropenem were empirically started, and then vancomycin was discontinued after day 4 given low suspicion of MRSA, and meropenem continued for a 9 day course. Once biliary drainage dropped to less than 10 cc/day and CT abdomen showed the biloma was much decreased in size, the biloma drain was removed (on [**9-28**]) by IR. The patient returned for ERCP on [**9-29**] and had her pancreatic duct stent removed. She will return in [**Month (only) 359**] to have the biliary stent removal. . # Hypoxic respiratory failure during attempted ERCP: likely precipitated by aspiration vs mucous plug intra-procedure. Also contributing to the primary event is flash pulmonary edema; recent ARDs, COPD flare. Lower suscipsion for r/o PE and anaphylaxis. S/p cardiac arrest Pt was intubated and placed on AC ventilation with phenylephrine. Pt was weaned off phenylephrine by ICU day2. Stress dose steriods for possible anaphylaxis were discontinued ICU day2. Pt was placed on ipratropium and albuterol nebs for possible COPD exacerbation. Pt was started on meropenem 9 day course and vancomycin for 4 day course for broad coverage for both urosepsis and possible aspiration event. Repeat ECHO did not reveal R heart strain. SBTs were attempted daily from ICU day 6 onwards. Pt was switched from AC to CPAP but remained hypercarbic and hyperventilation with low tidal volumes by HD9. She was extubated and transferred to the floor. . # Cardiac Arrest: Precipitated by respiratory failure, with end organ renal and possible liver hypoperfusion. Other possible precipitants including CHF exacerbation, hypovolemia, and PE. Unlikely primary arrhythmia given absence of electrolyte derangement, CAD, and family hx of arrhythmia. Pt was resuscitated by CPR, supported by atropine and epinephrine. Induced hypothermia and maintained at 32degC until 24 hours after return of circulation, and rewarmed passively. . # Leukocytosis: This was persistent despite being on 9 days of meropenem since admission for urosepsis at OSH; sources included urine (UA+) with [**Female First Name (un) **] given her risk factors of indwelling lines/tubes; Gi processes, ARF, and long term broad spectrum antibiotics. PICC from OSH was removed and the tip cultured without growth. Repeat UA and Ucx X2 grew yeast despite being on meropenem and foley changes as well as Sputum cx and miniBAL with + yeast as well. There was concern for fungemia and empiric fluconazole was started for a 1 week course. By day of discharge, her WBC was 14. She had a negative CXR and urinalysis prior to discharge. . # Oliguria/acute on chronic kidney failure: Pt presented with a prerenal ARF picture with Cr 3 (from baseline 1.5) with reported ATN prior to transfer from OSH; with a high likelihood of ATN recurrence in the setting of post-op volume loss and hypotension, hypovolemia related to CHF exacerbation, and 3rd spacing [**2-26**] intraabdominal infection. Pt responded slowly to gentle IVF bolus challenge. Lasix diuresis was initiated ICU day2 after volume repletion. . # Acute on chronic diastolic CHF exacerbation: likely precipitated intraoperatively by arrhythmia/bradycardia, also possible infection and PE and anemia contributing. Finished r/o MI and repeat ECHO demonstrated hyperdynamic function with EF 75% and BNP elevated from transfer levels (998) to >[**Numeric Identifier 3301**]. Lasix diuresis was initiated following percutaneous biliary drainage procedure after volume repletion was achieved. She successfully diuresed and was satting 100% RA by [**9-29**]. She was restarted on her home dose of lasix. Her magnesium and potassium levels will need to be followed as these did require some repletion. . # COPD/asthma: No evidence of exacerbation at this time. She was continued on advair, standing atrovent nebs, albuterol/atrovent as needed. She is not on tiotropium at home, unclear degree of COPD, will hold on starting. This can be started in the future. . # Tachycardia: may be sinus tachycardia [**2-26**] infection (sources see above); also possible atrial tachycardia and was plcaed on verapamil for rate control. Some of the episodes did look like small bursts of SVT on tele. . # Ileus [**2-26**] ongoing bile leak and recent cholecystectomy and ladd's procedure with no evidence of continued obstruction. OSH KUB raised question of SBO vs ileus and showed air fluid levels. Pt was made NPO, and decompressed by NG tube. Repeat KUB showed no sign of obstruction. Pt was started on TFs and transitioned to po. She is tolerating a regular diet. . #Sepsis due to UTI: positive blood cultures and Ucx dating from [**2124-8-23**], but remained negative here, without growth from OSH cx as of [**2124-8-28**] and without growth on cultures drawn here. The foley was changed given a positive yeast culture. A repeat UA [**2124-9-17**] was positive with a positive yeast culture. She was treated with fluconazole as per above (given yeast also on BAL). . # Right humeral head fracture observed on x-ray after resuscitation. Orthopedic surgery was consulted, and repeat AP/lateral x-ray of right femoral head was performed. Ortho recommended a sling for shoulder as needed and non-operative management. She was started on calcium and vitamin D. . # L 10th rib fracture: Likely from CPR. Again, the patient was treated with tylenol and ibuprofen. She was given oxycodone 2.5 mg as needed for pain. Again, nonoperative. She was started on calcium and vitamin D. . # Hypernatremia was noted on [**2124-9-15**]: Na 145; and free water supplied with return to normal levels by [**2124-9-17**]. . # Anemia of chronic disease: transfused 1 unit for HCt 24- bumped to HCt on ICU day 3. Her hematocrit remained stable at 26-30. . # Hypertension. Initially hypotensive. Held home beta-blocker and aspirin pending stabilization and repeat ERCP. Her ASA was held given her stenting and procedures. She was started on verapamil for rate control and her blood pressure was well controlled on this. . # FEN: Diet was advanced as tolerated to regular. She was maintained on aspiration precautions. . # Code: DNR/DNI . # Failure to thrive. She was noted to be deconditioned during her hospital stay. She was discharged home with physical therapy services. She was started on Remeron and a nutrition consult was placed for poor oral intake and this will need to be monitored as an outpatient. . #. Urinary tract infection. Patient was noted to have a persistent leukocytosis without fever for which an infectious workup was done. CXR was negative. Her urinalysis was positive, and she was started on ciprofloxacin on day of discharge. Her sensitivities will need to be followed up. Medications on Admission: Meds: Inpatient: Aspirin 162mg Daily -> d/c'd on [**2124-9-2**] Heparin subq 5000U Primaxin 500mg IV q8h -> d/c'd on [**2124-9-2**] Metoprolol 50mg Twice daily Reglan 5mg IV prior to meals Culturelle 1 tab daily Colace 100mg Twice daily Senna 2 tabs every evening Ceftriaxone 1g x1 dose on [**2124-9-11**] Ferrous sulfate 1 tab . Home meds prior to admission: Vicodin 1-2 tabs every 4 hours as needed Metoprolol 50mg twice daily K-Dur 20mEq daily Lasix 40mg daily Ciprofloxacin 500mg Daily . Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*1 inhaler* Refills:*2* 3. Calcium 600 + D 600-400 mg-unit Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. Disp:*1 inhaler* Refills:*0* 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation [**Hospital1 **] (2 times a day). Disp:*1 device* Refills:*2* 6. Verapamil 180 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q 12H (Every 12 Hours) as needed for rib pain. Disp:*60 Tablet(s)* Refills:*0* 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 10. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital6 486**] of [**Hospital1 487**] Discharge Diagnosis: Biloma Cardiac/respiratory arrest Acute tubular necrosis/acute renal failure Left 10th rib fracture Right humerus fracture COPD Failure to thrive Urinary tract infection Discharge Condition: stable, satting 98% room air Discharge Instructions: You were seen for a biliary leak, and experienced cardiac/respiratory arrest while at ERCP. You had a drain placed in the biliary leakage area by interventional radiology. You also had 2 stents placed--a biliary stent and a pancreatic stent--by ERCP. You had the pancreatic stent removed on [**9-29**]. You will need the biliary stent removed in 8 weeks from [**9-15**]. You also were in congestive heart failure and received lasix to try and remove fluid. . You were started on many new medications. You were started on albuterol, atrovent, and advair inhalers to help your breathing. You were started on verapamil for your blood pressure. Your lopressor (metoprolol) was stopped. You also were given prescription for oxycodone as needed for pain. This is a narcotic and can make you sleepy. You can take aspirin and tylenol as directed to help with your pain. You should also take the calcium and vitamin D supplements to help your bones heal. You should also take Remeron to help with your appetite. . Please call your doctor or return to the ER if you experience any chest pain, shortness of breath, fever, abdominal pain, yellowing of your skin, fainting, or any other concerning symptoms. . Weight yourself daily and if you gain greater than 3 pounds, call your doctor. Restrict your fluid intake to 1 liter or less a day. Eat a low salt diet. . You were started on ciprofloxacin for a urine infection. You should take this for seven days. Followup Instructions: 1. Please come to [**Hospital Ward Name 1950**] Building [**Location (un) **] [**Hospital Ward Name 516**] [**Hospital1 18**] for removal of your biliary stent (gastroenterology department). Your appointment is at 11:30 AM with Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]. You should not eat the night prior to the procedure. 2. Please follow up with Dr. [**Last Name (STitle) 78934**] on Thursday [**10-5**], at 2pm; Please call their office for directions or with any questions at [**Telephone/Fax (1) 78935**]; fax: [**Telephone/Fax (1) 78936**] 3. Please follow up with your primary care doctor, Dr. [**Last Name (STitle) 78937**], on Tuesday [**10-3**] at 1:15 PM. The doctor [**First Name (Titles) **] [**Last Name (Titles) 78938**] at [**Doctor Last Name 78939**] in [**Hospital1 **]. Please call their office at [**Telephone/Fax (1) 78940**] with any questions or if you need to change this appointment time. Fax [**Telephone/Fax (1) 78941**]

[ "576.8", "585.9", "276.0", "285.29", "518.81", "403.90", "288.60", "997.1", "427.89", "491.21", "560.1", "807.01", "577.1", "427.5", "599.0", "997.4", "E927", "783.7", "584.5", "812.09", "428.33", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.60", "96.72", "96.04", "97.56", "51.87", "51.98" ]

icd9pcs

[ [ [] ] ]

18249, 18322

8879, 16324

360, 548

18536, 18567

3617, 8221

20061, 21062

3280, 3298

16866, 18226

18343, 18515

16350, 16843

18591, 20038

3313, 3598

8238, 8856

275, 322

576, 2817

2839, 3183

3199, 3263

17,072

134,921

5603

Discharge summary

report

Admission Date: [**2142-3-27**] Discharge Date: [**2142-3-10**] Date of Birth: [**2090-7-25**] Sex: M Service: [**Doctor Last Name 1181**]/MEDICINE HISTORY OF PRESENT ILLNESS: This is a 51 year old male with a history of insulin dependent diabetes mellitus, end stage renal disease, status post renal transplant times two, who presented to [**Hospital1 69**] with fever, chills and water diarrhea times one to two days. The patient with upper respiratory infection symptoms about two weeks ago which resolved. He started having decreased energy, malaise and developed water diarrhea last week. He seemed to improve over the weekend but started again one day prior to presentation. No blood in the stool or mucus in stool. On the day of admission, he also had fever to 102 and chills. Change in mental status and delirium as per sister. Recent antibiotic treatment for greater than two weeks, last dose about two weeks ago for prophylaxis against lower extremity infection. No abdominal pain, nausea, vomiting. No recent sick contacts. [**Name (NI) **] chest pain or shortness of breath. No recent travel. In the Emergency Department the patient had a temperature of 102.8, blood pressure 70/30. He was briefly on Dopamine. He was given three liters of normal saline, Vancomycin and Ceftriaxone. The patient was admitted to the Medicine Intensive Care Unit service. Blood, urine, cerebrospinal fluid and stool cultures were sent. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus with retinopathy, nephropathy and neuropathy. 2. End stage renal disease, status post living related donor kidney transplant in [**2128**], which was rejected in [**2134**]. CRT in [**2136**]. Baseline creatinine of 0.7 to 1.0. 3. Peripheral vascular disease. 4. Gout. 5. Gastroesophageal reflux disease. 6. Depression. PAST SURGICAL HISTORY: 1. Status post transurethral resection of prostate for benign prostatic hypertrophy. 2. Status post bilateral lower extremity bypass graft, transmetatarsal amputation of the right, first toe amputation on the left. ALLERGIES: Penicillin. MEDICATIONS ON ADMISSION: 1. Insulin sliding scale. 2. Insulin Glargine 11 units once daily. 3. Aspirin 325 mg p.o. once daily. 4. Midodrine 2.5 mg p.o. once daily. 5. Lopressor 12.5 mg twice a day. 6. Prednisone 10 mg once daily. 7. Tacrolimus 0.5 mg p.o. twice a day. 8. Celexa 20 mg p.o. once daily. 9. Depakote 500 mg p.o. once daily. 10. Protonix 40 mg p.o. once daily. SOCIAL HISTORY: The patient lives in an [**Hospital3 **] facility in [**Location (un) 3146**]. He denies any tobacco, alcohol or illicit drug use. PHYSICAL EXAMINATION: Temperature is 98.1, blood pressure 118/40, heart rate ranging from 60s to 100s, respiratory rate 12, oxygen saturation 100% in room air. The patient was not in any acute distress. Neck was supple. No lymphadenopathy, no jugular venous distention. The heart was regular rate and rhythm, with no murmurs. The chest was clear to auscultation bilaterally without any crackles. The abdomen had positive bowel sounds, soft, nontender, nondistended. Extremities showed 2+ dorsalis pedis bilaterally and 1+ edema bilaterally. Left elbow with erythema, swelling and tenderness. LABORATORY DATA: White blood cell count was 12.6, hematocrit 36.6, platelet count 222,000. Chem7 revealed sodium 142, potassium 3.5, chloride 108, bicarbonate 23, blood urea nitrogen 67, creatinine 1.0, glucose 186. Calcium 8.0, magnesium 2.3, phosphorus 2.7, amylase 35 and lipase 5. Urinalysis was negative. Blood cultures, cerebrospinal fluid cultures, urine cultures and stool cultures were sent. Chest x-ray was negative for any signs of pneumonia. Head CT showed no acute hemorrhage or infarction. HOSPITAL COURSE: 1. Infectious disease - The patient was started on Ceptaz, Vancomycin, Flagyl for his unresolving diarrhea. All cultures came back negative and the patient's diarrhea resolved during his hospitalization. The patient received a total of three days of Ceptaz and Vancomycin and four days of Flagyl. 2. Renal - The patient was maintained on his immunosuppressant regimen and his creatinine remained at his baseline level. 3. Cardiovascular - The patient was maintained on intravenous fluids for blood pressure control. Diuretics and beta blocker were held during his admission given his tenuous blood pressure. The patient was continued on Aspirin and Midodrine. By the time of his discharge, his blood pressure had returned to [**Location 213**] and the patient was discharged on all his regular cardiac medications. 4. Endocrine - The patient was maintained on insulin sliding scale as well as insulin Glargine. The patient's blood sugar was well controlled throughout his hospitalization. 5. FEN - The patient was repleted with Potassium throughout his hospitalization. The patient was maintained on diabetic diet. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged to [**Location (un) 22492**] [**Hospital3 400**]. DISCHARGE DIAGNOSIS: Diarrhea. MEDICATIONS ON DISCHARGE: 1. Insulin sliding scale. 2. Insulin Glargine 11 units once daily. 3. Aspirin 325 mg p.o. once daily. 4. Midodrine 2.5 mg p.o. once daily. 5. Lopressor 12.5 mg twice a day. 6. Prednisone 10 mg once daily. 7. Tacrolimus 0.5 mg p.o. twice a day. 8. Celexa 20 mg p.o. once daily. 9. Depakote 500 mg p.o. once daily. 10. Protonix 40 mg p.o. once daily. FOLLOW-UP PLANS: The patient will follow-up with his primary care physician. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Last Name (NamePattern1) 9350**] MEDQUIST36 D: [**2142-3-30**] 14:14 T: [**2142-3-31**] 09:29 JOB#: [**Job Number 22493**]

[ "250.41", "787.91", "458.9", "403.90", "038.9", "996.81", "584.9", "276.5", "V49.73" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5069, 5080

5106, 5465

2145, 2504

3784, 4916

1876, 2119

2677, 3767

5483, 5810

194, 1463

1485, 1853

2521, 2654

4941, 5047

23,550

179,911

12357

Discharge summary

report

Admission Date: [**2174-2-10**] Discharge Date: [**2174-2-17**] CHIEF COMPLAINT: Urosepsis consistent with hypotension and demand ischemia. HISTORY OF PRESENT ILLNESS: This 79-year-old male presents The patient on [**2-8**] had a UTI, was started on Levaquin, then worsened and he went to [**Hospital 1474**] Hospital. The patient had UTI with acute renal failure, creatinine of 3.9, became hypotensive. The patient had EKG change of [**Street Address(2) 1766**] depression in 1 and AVL and V2 through V5. He was transferred to [**Hospital1 69**] after that. The patient reports chest pain for last two weeks with PAST MEDICAL HISTORY: Coronary artery disease status post MI in [**2156**], diabetes, hypertension, increased cholesterol, bladder cancer in [**2169**], status post BCG treatment from [**2169**] to [**2172**], patient had duodenal ulcer consistent with gastritis by EGD in 6/00 and he had complicated gastrointestinal bleed. MEDICATIONS: At home, Zocor 20 mg q d, Lasix, Glyburide, Levaquin, Lisinopril and Lopressor. Patient's meds on transfer from the other hospital are Aspirin 325 mg q d, Nitroglycerin drip, Heparin drip, sliding scale insulin, Protonix 40 mg q d and Tequin 200 mg q d. ALLERGIES: Penicillin causes anaphylaxis. PHYSICAL EXAMINATION: On admission the patient is an obese male, in mild acute distress, temperature 96.4, heart rate 76, blood pressure 110/43, respiratory rate 18, 90% on four liters nasal cannula. Patient's eyes are anicteric, pupils are equal, round, and reactive to light and accommodation, extraocular movements intact, OP clear. Neck supple, no mass, positive JVD. Fine rales at bases on lung exam. CV, regular rate and rhythm, positive S1 and S2, 2/6 systolic ejection murmur. Abdomen distended, positive tense, mild tenderness throughout, positive bowel sounds, no rebound or guarding. Extremities, [**11-24**]+ edema, left greater than right two knees which is chronic. Alert and oriented times three. LABORATORY DATA: On admission, white blood cell count 24.6, hematocrit 37.6, platelet count 171,000, sodium 126, potassium 3.6, chloride 94, CO2 16, BUN 75, creatinine 4.2, glucose 62, calcium 7.3, magnesium 1.5, PO4 = 3.1. CK 66 at 2 a.m. Troponin was less than .3. INR was 1.4. PTT 29.2. EKG showed sinus at 75, 1-[**Street Address(2) 1766**] depression in 1, 2, AVL and V2 through V6. EKG at [**Hospital1 69**] showed sinus rhythm at [**Street Address(2) 38493**] wave changes. ASSESSMENT & PLAN: 79-year-old male with CAD, diabetes, bladder cancer, transferred for management of urosepsis causing demand ischemia. 1. CV: Patient with CAD status post MI. Patient unaware of recent echo or evaluation of heart function. EKG could be consistent with fixed stenosis. Hemodynamically stable. No chest pain currently, receiving Aspirin. Cycle CKs, maintain Heparin per protocol to rule out MI, hold blood pressure medications in setting of recent hypotension, cardiac echo in a.m. 2. Pulmonary: Mild shortness of breath question secondary to increased abdominal distention, PE and chest x-ray negative for CHF. Has reported history of RAD, no PFTs recently. Check ABG to evaluate for hypoxia and acid base status, MDI's prn. 3. Renal: Unknown baseline, ARF by outside hospital report. Patient has a history describing several days of decreased po intake, decreased urine output, no dysuria or hematuria, presumably has UTI by urologist. Likely developed urosepsis given decreased blood pressure and increased white blood cells. Appears to be responding to IV fluid with good urine output at this time. Question role of bladder cancer in causing post obstructive situation. Check renal ultrasound to rule out hydronephrosis and also bladder to rule out obstruction. Send urine lytes, urinalysis and urine culture. Check lytes and replete prn. Check ABG to rule out acid based problems. 4. ID: Urosepsis, no culture data available from outside hospital. Send urinalysis, urine culture, blood cultures, white blood cell count, cover with Levofloxacin and Vancomycin. 5. GI: Patient has complaint of abdominal pain. Patient is not passing gas since last night, no bowel movement in five days, positive distention consistent with ileus given UTI. [**Month (only) 116**] also have mesenteric ischemia given hypotension. Check KUB to evaluate for sepsis/SBO/ileus. Check ABG. The patient will have an NG tube in with IV fluid, check LFTs and pancreatic enzymes. 6. Heme: Patient's hematocrit stable. Platelets normal. Check PTT given Heparin. 7. Endocrine: Diabetes type 2, patient on Glyburide, blood sugars currently in 60's, check fingersticks qid, prophylaxis with Heparin and Protonix. The patient has a peripheral line and a Foley catheter. Patient is a full code. HOSPITAL COURSE: The patient had E. coli positive urine resistant to Fluoroquinolones but sensitive to Aztreonam. Due to Penicillin allergy with 10% Cephalosporin cross reactivity patient was put on Aztreonam 2 mg IV q 8 hours. Patient with left ureter obstruction, had successful placement of left nephrostomy tube to outside drain. Drain to stay in until Dr. [**Last Name (STitle) 38494**], urologist, can evaluate for resolution of obstruction to remove the drain. Patient's creatinine then trended down to normal with creatinine on discharge of 1.5 down from 4.2. Urine output was good. Patient had a CVL placed which was working well until removed prior to discharge. Patient's outpatient urologist, Dr. [**Last Name (STitle) 38494**] is aware of events and will follow. Patient's urine culture on discharge was negative. Patient's blood culture on [**2174-2-11**] showed E. coli in [**1-24**] bottles and on discharge, blood cultures were no growth to date. Stool was negative for C. diff and fecal leukocytes. PICC line was placed so he could continue Aztreonam IV outpatient for a total of 14 days per ID. Patient will be sent to rehab for IV antibiotics and physical therapy. CV: Patient with EKG changes, had cardiac catheterization which showed cardiac output of 7.3, cardiac index of 3.3 with pressures as follows: Wedge pressure 15, PA pressure 30, RV pressure 43/14 and RA pressure of 11. Vessels showed LAD with 40% mid left circ with 40% and RCA was totally occluded distally with collaterals. No intervention was needed. Medical management of his cardiac disease. Patient's Lopressor is at 75 mg tid, Captopril is at 25 mg tid, Zocor 20 mg q d. Patient's blood pressure is 122/56, heart rate 68, he is stable on discharge. Patient is afebrile at 98.6. Patient will follow-up with his primary care doctor, Dr. [**Last Name (un) **] for blood pressure and med changes as needed. Patient may need nitrates as outpatient if angina persists. Patient has sublingual Nitroglycerin for chest pain, no further episodes in hospital. Patient's diabetes is controlled with NPH and sliding scale. We will monitor his output. The patient will continue his Protonix and Miconazole powder as needed. Patient is cleared to go with PT and use a walker. His hematocrit is stable on discharge. Patient will need potassium checked. He will take potassium 40 mEq prn as needed. DISCHARGE MEDICATIONS: Lopressor 75 mg tid, Captopril 25 mg tid, Colace, Protonix 40 mg q d, Zocor 20 mg q d, Pyridium 200 mg tid, Aztreonam 2 gm IV q 8 hours, Nystatin swish and swallow qid, NPH 10 units [**Hospital1 **] and Aspirin 325 mg q d. DISCHARGE DIAGNOSIS: 1. Urosepsis with resolution, status post nephrostomy tube left side. 2. Coronary artery disease. 3. Demand ischemia due to urosepsis. 4. Bladder cancer and diabetes. DISCHARGE CONDITION: Improved, stable. Will follow-up with outpatient urologist, PCP for blood pressure meds, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] for cardiology . [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. Dictated By:[**Last Name (NamePattern1) 4724**] MEDQUIST36 D: [**2174-5-5**] 19:50 T: [**2174-5-5**] 21:46 JOB#: [**Job Number 38495**]

[ "599.0", "041.4", "188.8", "410.71", "250.00", "414.01", "584.9", "593.4", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.57", "38.93", "55.03", "88.53", "37.22" ]

icd9pcs

[ [ [] ] ]

7667, 8105

7228, 7452

7473, 7645

4825, 7204

1297, 4807

93, 153

182, 633

656, 1274

689

149,102

47262

Discharge summary

report

Admission Date: [**2182-3-18**] Discharge Date: [**2182-3-25**] Date of Birth: [**2128-12-27**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2745**] Chief Complaint: Nausea Major Surgical or Invasive Procedure: ERCP Cardioversion History of Present Illness: 53 yo F patient of the good Dr. [**Last Name (STitle) 20867**] with a past medical history significant for ESRD, DM, HCV, HTN, CHF, now with one day of abd pain and emesis. Patient reports she was at the store when she felt onset of intense nausea and suprapubic/epigastric pain. Pt has had vomitting but unable to quantify how many times. Denies constipation, diarrhea, fevers, chills, hematemesis. Denies etoh ingestion or abuse of naroctic medications. Also denies illicits. Although pt has a history of missing HD appointments, she was at her last dialysis session on friday. . In the ED, patient VS significant for 97.1 88 171/85 16 99 on RA. UA looked positive. Abdomen was noted to be soft, and patient was without CVA tenderness. CBC without leukocytosis. Nauasea responded to Zofran 4mg IVx1 and GI cocktain, and abd pain responded to morphine 2mg IVx1. Patient was given NS 500 cc. No abx were administered, though levaquin was ordered as a one time dose. CT A/p prelim read significant for small hiatal hernia, but no other noted abnormalities. Patient was transferred to the Dialysis unit prior to transfer to the medicine floor. At HD, pat had UF 1.3 L off. Initially HTN 200/94, but decreased to 138/79 with UF. Noted to be somnolent at HD, but was not noted to be somnolent in the ED. . Of note, patient was admitted with headache [**3-1**] to [**3-3**] to [**Hospital1 18**]. She presented with HA that was felt to be consistent with migraines. Headache improved with better BP control. Patient high blood pressures likely due to missed HD appointment prior to admission. She as continued on home antihypertensive regimen. Pt was originally treated with CTX for positive UA, and cx only grew mixed [**Hospital1 **]. . At the time of this assessment, patient lethargic but arousable. She is a poor historian secondary to lethargy and slow response. She is reporting vague suprapubic pain, pain at HD line, and HA consistent with her migraine. She is no long having nausea. She denies tongue biting and loss of bowel/bladder continence. . ROS was otherwise essentially negative. The pt denied recent unintended weight loss, fevers, night sweats, chills, dizziness or vertigo, changes in hearing or vision, including amaurosis fugax, neck stiffness, lymphadenopathy, hematemesis, coffee-ground emesis, dysphagia, odynophagia, diarrhea, constipation, steatorrhea, melena, hematochezia, cough, hemoptysis, wheezing, shortness of breath, chest pain, palpitations, dyspnea on exertion, increasing lower extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while walking, joint pain. Past Medical History: -Coag-neg staph (MRSE) HD line infection, catheter changed over a wire on [**2182-1-15**], on vancomycin -ESRD on HD, on HD since [**2181-9-29**]. -DM2 -HTN -hyperlipidemia -Hep C -Chronic diastolic CHF (EF 75% in [**2179**]) -LLL segmental PE ([**2177-1-28**]) -Migraine -Depression -Narcotic dependence, on methadone -Lymphedema -L heel pressure ulcer - ? h/o of seizure one year ago - not on ppx - fracture to her left leg and right wrist in [**3-/2179**] at the [**Hospital1 **] Social History: Lives with mother [**Name (NI) 12335**] [**Name (NI) **] [**Name (NI) 1661**] [**Telephone/Fax (1) 100055**]. Former employee of social services/DSS. 2 sons, 1 daughter. 1 son was murdered ([**2167**]). Smokes 1/2ppd x 20 years. Rare ETOH. Last snorted heroin in [**2173**]. Denies IVDU. Family History: Brother died of MI at 56. Father died of CVA @ 85. Mother has SLE, HTN, asthma. Physical Exam: On admission Vitals: T: 97.3 BP: 154/90 P: 88 R: 20 SaO2: 98% RA FS: 140 General: Lethargic but arousable. NAD. Somewhat slow verbal response. HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in OP Neck: supple, no significant JVD or carotid bruits appreciated Pulmonary: Distant breath sounds, no wheezes, ronchi or rales Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or organomegaly noted. Neg. [**Doctor Last Name 515**]. Extremities: 2+ LE edema, 2+ radial, DP pulses b/l. No cva tenderness. RIGHT side wrist swelling, nontender. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted Skin: no rashes or lesions noted. Neurologic: Alert, oriented x 3. Noted difficulty relating history, marked mostly by slow response but answers are accurate and appropriate. Cranial nerves II-XII intact. 4/5 strength throughout. With lifting of arms, marked tremulousness, but no asterexis. No deficits to light touch throughout. Pertinent Results: ========= Labs ========= [**2182-3-18**] 09:00AM BLOOD WBC-7.9 RBC-4.08* Hgb-12.3 Hct-38.7 MCV-95 MCH-30.1 MCHC-31.7 RDW-17.6* Plt Ct-173 [**2182-3-19**] 01:51PM BLOOD WBC-10.0 RBC-4.34 Hgb-12.8 Hct-40.2 MCV-93 MCH-29.6 MCHC-32.0 RDW-16.9* Plt Ct-203 [**2182-3-20**] 08:00AM BLOOD WBC-9.8 RBC-4.46 Hgb-13.4 Hct-42.3 MCV-95 MCH-30.1 MCHC-31.8 RDW-16.7* Plt Ct-223 [**2182-3-21**] 09:22AM BLOOD WBC-9.3 RBC-4.61 Hgb-13.4 Hct-43.7 MCV-95 MCH-29.1 MCHC-30.6* RDW-16.5* Plt Ct-250 [**2182-3-22**] 05:15AM BLOOD WBC-9.1 RBC-4.18* Hgb-12.6 Hct-39.7 MCV-95 MCH-30.2 MCHC-31.8 RDW-16.2* Plt Ct-230 [**2182-3-23**] 06:59AM BLOOD WBC-6.0 RBC-3.24* Hgb-9.6* Hct-30.4* MCV-94 MCH-29.7 MCHC-31.6 RDW-16.0* Plt Ct-180 [**2182-3-24**] 05:18AM BLOOD WBC-5.2 RBC-3.18* Hgb-9.6* Hct-29.7* MCV-93 MCH-30.1 MCHC-32.3 RDW-15.6* Plt Ct-157 [**2182-3-18**] 09:00AM BLOOD ALT-46* AST-31 LD(LDH)-223 AlkPhos-295* TotBili-0.2 [**2182-3-19**] 01:51PM BLOOD ALT-36 AST-40 CK(CPK)-70 AlkPhos-256* Amylase-179* TotBili-0.4 [**2182-3-20**] 08:00AM BLOOD ALT-41* AST-61* LD(LDH)-248 CK(CPK)-64 AlkPhos-251* Amylase-151* TotBili-0.6 [**2182-3-21**] 09:22AM BLOOD ALT-45* AST-63* AlkPhos-223* Amylase-148* [**2182-3-19**] 01:51PM BLOOD Lipase-239* [**2182-3-20**] 08:00AM BLOOD Lipase-85* [**2182-3-21**] 09:22AM BLOOD Lipase-109* [**2182-3-18**] 03:00PM BLOOD CK-MB-7 cTropnT-0.19* [**2182-3-19**] 01:51PM BLOOD CK-MB-NotDone cTropnT-0.44* [**2182-3-20**] 08:00AM BLOOD CK-MB-5 cTropnT-0.36* [**2182-3-21**] 09:22AM BLOOD CK-MB-8 cTropnT-0.34* ========= Radiology ========= CT abdomen/pelvis 1. Moderate-sized hiatal hernia with distal esophageal wall thickening, new from prior study. Findings likely reflect esophagitis, and can be evaluated with endoscopy and/or upper GI. 2. Diverticulosis without diverticulitis. 3. Fibroid uterus. 4. Oblong hyodense lesion adjacent to the left wall of the bladder, measuring 3.2 cm, similar in size from [**2181-12-5**]. This appears separate from the ovary, and is of uncertain significance or origin. An MR is recommended for further evaluation . CT Head There is no evidence of infarction or hemorrhage. [**Doctor Last Name **]-white matter differentiation is preserved. The ventricles and sulci are normal in size and configuration. The calvarium and soft tissues are normal. The visualized paranasal sinuses and mastoid air cells are clear. . CXR In comparison with study of [**3-1**], the cardiac silhouette is again at the upper limits of normal in size with no evidence of vascular congestion, pleural effusion, or acute pneumonia. ========= Micro ========= URINE CULTURE (Final [**2182-3-19**]): MIXED BACTERIAL [**Month/Day/Year **] ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [**2182-3-25**] 06:59AM BLOOD WBC-4.3 RBC-3.23* Hgb-9.7* Hct-29.6* MCV-92 MCH-29.9 MCHC-32.6 RDW-15.6* Plt Ct-177 [**2182-3-24**] 05:18AM BLOOD WBC-5.2 RBC-3.18* Hgb-9.6* Hct-29.7* MCV-93 MCH-30.1 MCHC-32.3 RDW-15.6* Plt Ct-157 [**2182-3-23**] 02:45PM BLOOD Hct-29.5* [**2182-3-21**] 09:22AM BLOOD Neuts-55.4 Lymphs-34.4 Monos-9.3 Eos-0.2 Baso-0.6 [**2182-3-25**] 06:59AM BLOOD Plt Ct-177 [**2182-3-24**] 05:18AM BLOOD Plt Ct-157 [**2182-3-23**] 12:44AM BLOOD PT-14.2* PTT-41.9* INR(PT)-1.2* [**2182-3-25**] 06:59AM BLOOD Glucose-104 UreaN-45* Creat-6.9* Na-138 K-3.4 Cl-96 HCO3-30 AnGap-15 [**2182-3-24**] 05:18AM BLOOD Glucose-74 UreaN-40* Creat-6.0*# Na-141 K-3.7 Cl-100 HCO3-31 AnGap-14 [**2182-3-23**] 06:59AM BLOOD Glucose-63* UreaN-31* Creat-4.8*# Na-141 K-3.1* Cl-97 HCO3-32 AnGap-15 [**2182-3-25**] 06:59AM BLOOD ALT-38 AST-64* AlkPhos-148* Amylase-138* [**2182-3-24**] 05:18AM BLOOD ALT-39 AST-72* Amylase-48 [**2182-3-23**] 06:59AM BLOOD ALT-38 AST-68* AlkPhos-150* TotBili-0.5 [**2182-3-25**] 06:59AM BLOOD Lipase-36 [**2182-3-24**] 05:18AM BLOOD Lipase-23 [**2182-3-23**] 06:59AM BLOOD GGT-224* [**2182-3-21**] 09:22AM BLOOD Lipase-109* [**2182-3-21**] 09:22AM BLOOD CK-MB-8 cTropnT-0.34* [**2182-3-25**] 06:59AM BLOOD Calcium-8.7 Phos-5.6* Mg-1.7 [**2182-3-24**] 05:18AM BLOOD Calcium-8.4 Phos-6.3* Mg-1.8 [**2182-3-23**] 06:59AM BLOOD TotProt-5.7* Albumin-3.3* Globuln-2.4 Calcium-8.4 Phos-5.3*# Mg-1.8 [**2182-3-18**] 09:00AM BLOOD %HbA1c-7.2* [**2182-3-23**] 06:59AM BLOOD ANGIOTENSIN 1 - CONVERTING [**Last Name (un) **]-PND [**2182-3-22**] 05:46AM BLOOD Lactate-1.5 _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ Blood Cx, Central Line: STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). Brief Hospital Course: ## Abdominal pain: Patient initially reported suprapubic pain, and medical team felt this was secondary to possible cystitis. However, by HD #2 Pain was mostly isolated to RUQ and labs were concerning for pancreatitis. UA significant for > 50 wbc, moderate LE and few bacteria, but cx only shows mixed [**Last Name (LF) **], [**First Name3 (LF) **] less likely UTI or pyelonephritis. Cardiac enzymes elevated, but likely at baseline given renal dysfunction and prior biomarkers in the setting of ESRD. An ERCP was pursued that showed ulcers in the lower third of the esophagus and erythema and congestion in the duodenal bulb compatible with duodenitis. Hiatal hernia. Normal biliary tree and complete pancreas divisum. Otherwise normal ERCP to the third part of the duodenum. Patient was started on double dose PPI and will need repeat EGD with biopsies after 8weeks of therapy. Diet was gradually advanced to regular and abdominal pain much improved. . ## Change in MS: Improved markedly by HD #2. Likely [**12-31**] over medication at home with methadone, Ativan and Seroquel. Given persistent nausea, there was some concern for benzo withdrawal. Patient was placed on a CIWA but did not require any administration. . ## SVT: On [**3-21**], patient was found on routine vitals check to have tachycardia to the 130s. EKG was consistent with Atrial flutter. At the time, patient did not have IV access. The medical team attempted peripheral access without success at first. A trial of po betablockers was initiated but HR did not respond. IV access was finally obtained and with a single dose of IV Lopressor patient dropped her SBP to the 90s. In this setting, patient was transferred to the CCU team for further care. In the CCU, the patient was found to be in new atrial flutter. Poorly controlled pain and adrenergic surge from pancreatitis was considered as the cause of new onset atrial flutter. The patient was initially treated with diltiazem IV with some rate control. She underwent a TTE to rule out presence of thrombus, anticoagulated with a heparin drip, then underwent DC cardioversion. She remained in NSR following. As her TTE showed evidence of LVH, she was also started on standing metoprolol. Patient remained in NSR after transfer back to the floor. . ## ESRD on HD: MWF schedule. Patient continued on HD schedule. Renal followed patient while in house. . ## DMII: Last a1c 9.3 in [**1-7**]. A1c 7.2 implying reasonable control over last several months. FS below 300 in house. Patient continued Lantus and ISS in house with good blood sugar control. . ## Anemia: Patient's hematocrit remained around 29-30 while in house. her baseline appears to be 30-40. Patient did have guiac positive stool in house therefore heparin gtt held. Patient had a work up in [**2179**] for occult GI bleed with normal colonoscopy and EGD demonstrating erythema in antrum consistent with gastritis. . ## Depression: Patient continued on Celexa. . ## Chronic pain: Patient continued on methadone and given PO morphine for breakthrough pain secondary to pancreatitis. . ## Oblong hypodense lesion in bladder noted incidentally on CT of abdomen and pelvis. Patient will need MRI follow up as outpatient. . ## Elevated TSH: TSH elevated to 4.3 during admission. Patient will need outpatient thyroid function tests to evaluate for possible hypothyroidism. . ##: Blood Culture: One set of blood culture from patient's central line grew coag neg staph and diphtheroids. Line was pulled and patient demonstrated no [**Year (4 digits) **] signs of infection therefore this was thought to be contenement. Medications on Admission: Aspirin 81 mg po daily Methadone 20 mg po TID Atorvastatin 20 mg po daily Omeprazole 20 mg po daily Senna 8.6 mg Tablet po BID Cholecalciferol (Vitamin D3) 400 unit Tablet po daily Docusate Sodium 100 mg po BID Nephrocaps 1 tab po daily Quetiapine 100 mg po QHS Calcium Acetate 1334 mg po TID Citalopram 20 mg po daily Nicotine 14 mg/24 hr Patch Amlodipine 5 mg po daily Lantus 8 U QHS Lisinopril 40 mg po daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 14. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every [**5-6**] hours as needed for pain. Disp:*25 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Pancreatitis Gastritis Atrial Flutter Discharge Condition: stable Discharge Instructions: You were admitted for nausea, vomiting, and abdominal pain and developed atrial flutter. You were transferred to the intensive care unit where you were cardioverted and your heart rate returned to [**Location 213**] rate and rhythm. With regard to your abdominal pain, you underwent ERCP which demonstrated severe severe esophagitis. You were given morphine for pain and started on a medication called protonix for your esophagitis. Please avoid NSAIDs including Ibuprofen, Motrin, Advil. . With regard to your medications, your lisinopril was decreased to 10mg daily and you were started on metoprolol 12.5mg 2xday. . On CT scan of your abdomen lesion was noted in your bladder. You will need a follow up MRI as outpatient arranged by your PCP to further evaluate this. . Your thyroid hormone (TSH) was elevated during this admission. You will need further thyroid tests as an outpatient to fully evaluate this. . Please call you doctor if you have chest pain, shortness of breath, nausea, vomiting, increased abdominal pain, or any questions or concerns. Please keep your follow up appointments as outlined below. Followup Instructions: [**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2182-3-29**] 3:00 (cardiology) [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2182-4-11**] 3:00 (nephrology) Provider: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern4) 21383**], MD Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2182-4-5**] 9:00 (gastroenterology) [**2182-4-25**] 02:30p [**Last Name (LF) **],[**Name8 (MD) **], MD [**First Name (Titles) **] [**Last Name (Titles) **] CTR, [**Location (un) **] [**Hospital 191**] MEDICAL UNIT (primary provider)

[ "427.32", "E850.1", "346.90", "250.00", "428.32", "585.6", "070.54", "311", "577.0", "577.9", "530.10", "535.50", "285.9", "969.3", "969.4", "965.02", "E853.8", "428.0", "E853.2", "403.91" ]

icd9cm

[ [ [] ] ]

[ "51.10", "38.93", "39.95", "99.61" ]

icd9pcs

[ [ [] ] ]

15150, 15207

9533, 13147

323, 344

15289, 15298

4969, 9510

16466, 17139

3808, 3889

13609, 15127

15228, 15268

13173, 13586

15322, 16443

3904, 4950

277, 285

372, 2981

3003, 3487

3503, 3792

24,966

120,803

29725

Discharge summary

report

Admission Date: [**2126-2-7**] Discharge Date: [**2126-2-14**] Service: MEDICINE Allergies: Compazine / Prednisone / Sulfa (Sulfonamides) / Codeine / Floxin Attending:[**First Name3 (LF) 425**] Chief Complaint: hypotension s/p syncopal event Major Surgical or Invasive Procedure: Pacemaker placement History of Present Illness: 85F who was tx from [**Hospital1 **] after a reported syncopal event today. Around noon, the patient was in the elevator when she felt faint and hit the back of her head in the elevator. The patient denies losing consciousness. She denied any chest pain, shortness of breath, bowel or bladder incontinence. She reports having breakfast this AM and participating in some physical activity thereafter. She does report that her sugars have been in the 400s the past couple of days. She does ambulate with a cane. . On presentation to [**Hospital1 **], vitals were: T97.8, HR84, BP99/53, R20, O2sat 98%RA.. Her BP later fell to the 80s which was responsive to fluid boluses (received 3L total). Her EKG was noteworthy for atrial fibrillation,intermittent LBBB and biphasic T waves. Head CT was negative. She was started on a heparin gtt for possible ischemia and afib. She later complained of abdominal pain. CT of the abdomen was negative. . The patient was transferred to [**Hospital1 18**] for further care. Her BP ranged from 90-101/38-46, HR 65; however her O2sats were 88%RA which improved to 97% on 3L. Her FS were elevated, about 400. She was treated with insulin. She also received CTX and Flagyll. . Of note she states for the past 2 weeks she hasn't been feeling well. She's lost her appetite. She denies any thoughts of harming herself or harming others. She still enjoys. She feels safe where she lives. . Past Medical History: Diabetes Mellitus Osteoporosis Peripheral neuropathy Macular degeneration Glaucoma Chronic recurrent diarrhea . Social History: SocHx: Smoked for 30 years. Retired secretary. No EtOH use. Lives in ALF. Family History: NC Physical Exam: afeb, HR 66, BP 88-101/41, R17,02sat 100% on 2l GEN: elderly Caucasian female lying on side in mild distress from back pain HEENT: MM dry, OP clear; patient unable to follow finger with eyes ([**2-8**] macular degeneration) Heart: nl rate, S1S2, no gmr LUNGS: CTA b/l, no rrw BACK: RL flank pain to palpation, no spinal tenderness NEURO: III-XII grossly intact Ext: 4/5 strength in upper and lower extremity . PE on transfer to floor: BP 129/64 P 89 RR 20 95% on 3L GEN: elderly Caucasian female, alert, lying comfortably in bed, NAD HEENT: PERRLA, anicteric, mmm, OP clear, no carotid bruit Heart: irregularly irregular, no rubs/murmur/gallop LUNGS: CTA anteriorly NEURO: AAO x3, CN II-XII intact ext: 1+ pedal edema at ankle, DP 1+ bilaterally Pertinent Results: OSH imaging studes CT head: negative CXR: essentially unremarkable . [**2126-2-6**] 10:00PM WBC-8.0 RBC-3.59* HGB-10.9* HCT-32.0* MCV-89 MCH-30.5 MCHC-34.1 RDW-13.0 [**2126-2-6**] 10:00PM NEUTS-92.8* BANDS-0 LYMPHS-6.3* MONOS-0.6* EOS-0.2 BASOS-0 [**2126-2-6**] 10:00PM ALBUMIN-3.1* CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-2.1 [**2126-2-6**] 10:00PM CK-MB-NotDone cTropnT-0.06* [**2126-2-6**] 10:00PM CK-MB-NotDone cTropnT-0.06* [**2126-2-6**] 10:00PM ALT(SGPT)-18 AST(SGOT)-21 CK(CPK)-79 ALK PHOS-74 AMYLASE-36 TOT BILI-0.3 [**2126-2-6**] 10:00PM GLUCOSE-417* UREA N-23* CREAT-1.0 SODIUM-135 POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-26 ANION GAP-15 [**2126-2-6**] 10:27PM LACTATE-1.5 [**2126-2-6**] 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2126-2-7**] 01:45AM PT-12.6 PTT-81.9* INR(PT)-1.1 [**2126-2-7**] 03:22AM WBC-7.9 RBC-3.43* HGB-10.2* HCT-31.1* MCV-91 MCH-29.7 MCHC-32.8 RDW-12.8 [**2126-2-7**] 03:22AM ALBUMIN-3.1* CALCIUM-8.0* PHOSPHATE-3.3 MAGNESIUM-2.1 [**2126-2-7**] 03:22AM CK-MB-NotDone cTropnT-0.06* [**2126-2-7**] 03:22AM CK(CPK)-62 [**2126-2-7**] 03:22AM GLUCOSE-340* UREA N-24* CREAT-1.0 SODIUM-136 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-25 ANION GAP-15 [**2126-2-7**] 08:19AM CK-MB-NotDone cTropnT-0.06* [**2126-2-7**] 08:19AM CK(CPK)-68 [**2126-2-7**] 08:21AM D-DIMER-1509* [**2126-2-7**] 08:21AM PTT-134.3* . TTE [**2-7**]: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with septal hypokinesis (may be in part secondary to a conduction delay). Overall left ventricular systolic function is mildly depressed. 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. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . C/L spine films: 1. Severe diffuse osteopenia. 2. Anterior wedge compression fracture of L1 with approximately 30% loss of height, of indeterminate acuity. 3. Exaggerated thoracic kyphosis, with compensatory exaggerated cervical lordosis. 4. _____ of syndesmophytes in the thoracic spine. Although this can be seen with ankylosing spondylitis, there is only minimal annulus calcification seen in the lumbar spine and equivocal SI joint effusion. Clinical correlation is requested. Nonvisualization of the posterior aspect of an upper thoracic vertebral body is noted. I suspect this is artifactual, but the area is not completely evaluated. No vertebral body compression is seen in this area. 5. Increased interstitial markings in both lungs with biapical pleural thickening. . CXR [**2-12**]: 1. Appropriate pacemaker lead placement. 2. Stable appearance to mild-to-moderate pulmonary edema and moderate-sized bilateral pleural effusions. . B/l LE veins: The right common femoral vein, right saphenofemoral junction, right superficial femoral vein, and right popliteal veins are all normal to compression and augmentation. The left common femoral vein, left saphenofemoral junction, left superficial femoral vein and left popliteal veins are all normal to compression and augmentation. No evidence of any DVT in either lower limb. . Labs at discharge: wbc 6.5 hCT 30.7 pLT 313 K 4.7 Cr 0.7 Brief Hospital Course: A/P: 85 F w/MMP who presents today s/p syncopal episode course complicated by atrial fibrillation and hypotension requiring MICU level of monitoring . 1. Fall s/p syncopal event: Patient was found to have symptomatic paroxysmal atrial fibrillation w/ conversion pauses, sometimes with pauses up to >10 seconds. This was thought to be the cause of her syncope. The patient was also noted to have complete heart block at times. EP was consulted and determined that the patient needed pacemaker placement. A [**Company 1543**] enrhythm dual chamber PCM was placed without complication and CXR confirmed proper lead placement and no pneumothorax. The patient was monitored on tele and after pacer placement she did not have any further pauses or syncopal events. . 2. Atrial fibrillation- Patient was intially placed on heparin drip for bridging to coumadin, however the patient developed hematuria so the heparin was withheld. A nodal [**Doctor Last Name 360**] was withheld intitially given the long pauses, but metoprolol was started for rate control after pacer placement. The patient was in and out of afib with occasional HR into 120's. Her BP remained stable during this time. Her BB was uptitrated to better rate control. She was gradually increased to 50mg tid which she tolerated. Her HR remained in the 70s-80s. Anticoagulation was disussed with the family and after the risks and benefits were explained to them the decision was made to hold off on anticoagulation at this point in time due to her risk for falling. The family stated they understand the risks of stroke without coumadin and did not want anticoagulation at this time. This issue can be readdressed as an outpatient with the patient's PCP. [**Name10 (NameIs) 8675**] was chcked given new onset afib and was normal. . 3. CHF: ECHO [**2126-2-7**] showed EF 45-50% w/ septal HK, 1+ AR/MR. The patient received lasix as needed for diuresis initially, however when she was on the floor the patient did not appear overloaded on exam so she did not require any further diuresis. The patient was started on ASA once hematuria resolved. . 4. Back pain- Most likely [**2-8**] fall. Treated conservatively with tylenol and heat pads. Plain films showed compression fx at L1 probably old. Her tenderness is a the level of the sacrum. She was treated conservatively with minimal tylenol and heat pads. . 5. Fever: the patient was intitially febrile on admission. There was no clear source, although UA was c/w infection. CXR showed no PNA and blood cultures were sent and showed no growth. She was started on empiric coverage with ceftriaxone. She remained afebrile and urine culture was negative. A repeat UA and culture was sent and was also negative as were her blood cultures. She had repeat CXR after pacer placement that again showed no PNA, however the patient has a cough. When no infectious source could be identified her ceftriaxone was discontinued. The patient received 2 days of IV vancomycin post-procedure per protocol and will need to complete a 5-day course of Keflex upon d/c. . 6. Hyperglycemia/DM- Patient was intially hyperglycemic and showed resistance to oral antihyperglycemics; Urine significant for 1000 glucose and 50 ketones. She was initially on an insulin gtt for control which was discontinued after her glucose normalized. [**Hospital **] [**Hospital 982**] clinic was consulted who recommended starting long actin insulin. She was started on lantus 15U qhs and sliding scale. Her lantus was decreased to 10U qhs due to AM FS in 50s. She was started on Repaglinide with meals. . 7. Hypotension- probable [**2-8**] hypovolemia in setting of hyperglycemia and recent h/o of poor PO intake. She responded well to IVF hydration. . 8. Hematuria: Patient developed hematuria while in the ICU. It was thought to be likely [**2-8**] foley trauma/heparin gtt. The hematuria resolved after heparin drip was discontinued. The foley was discontinued after the patient was off bedrest from the procedure. . 9. FEN regular diet; her electrolytes were followed and repleted as needed . 10. Code status: DNR/DNI Medications on Admission: Meds at home: glyburide metformin lasix lisinopril (recently dropped b/c of low BP) neurontin . Meds on transfer to floor: Tylenol prn Calcium carbonate 500mg PO bid Ceftriaxone 1gm IV q24 Cephalexin 500mg PO q8h Anzemet 12.5mg IV q8h prn Colace 100mg [**Hospital1 **] Insulin SS Metoclopramide 10mg IV q6h prn Senna prn Vancomycin 1000mg IV q12 Vitamin D 400U daily Ambien 2.5-5mg PO qhs prn Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for post pr0codeure for 5 days. 4. Repaglinide 0.5 mg Tablet Sig: Two (2) Tablet PO TIDAC (3 times a day (before meals)). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. Discharge Disposition: Extended Care Facility: [**Last Name (un) 7081**] [**Hospital1 **] Discharge Diagnosis: Syncope Paroxysmal a fib with conversion pauses s/p pacemaker placement Diabetes, poorly controlled Fever Hematuria Back pain Macular degeneration Osteoporosis Glaucoma Discharge Condition: Afebrile. Hemodynamically stable. Tolerating PO Discharge Instructions: Please continue to take your medications as prescribed. . If you experience chest pain, worsening shortness of breath, bleeding, inability to eat, or other concerning symptoms call your doctor or come to the emergency room. Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) 3924**] [**Last Name (NamePattern1) 20222**] at [**Hospital1 **] regarding your pacemaker.

[ "398.91", "276.52", "362.50", "396.3", "733.00", "357.2", "780.6", "780.2", "599.7", "E934.2", "427.31", "426.0", "250.62", "427.81" ]

icd9cm

[ [ [] ] ]

[ "37.72", "37.83" ]

icd9pcs

[ [ [] ] ]

11531, 11600

6324, 10443

302, 324

11813, 11863

2802, 2821

12135, 12285

2016, 2020

10887, 11508

11621, 11792

10469, 10864

11887, 12112

2035, 2783

231, 264

6261, 6301

352, 1772

2830, 6242

1794, 1908

1924, 2000

20,084

121,824

21219

Discharge summary

report

Admission Date: [**2124-12-12**] Discharge Date: [**2124-12-22**] Date of Birth: [**2050-4-17**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Stroke (right sided weakness and dysarthria) Major Surgical or Invasive Procedure: PEG placement [**2124-12-21**] History of Present Illness: This is a 74 year-old female with a history of diabetes, hypertension, hyperlipidemia, with known CAD by cath in [**2120**], and diastolic dysfunction transferred from [**Hospital3 46817**] for cardiac catheterization for NSTEMI and found to have a new stroke. Per husband, she had sustained slip and fall(unwitnessed) [**2124-12-11**], found down by her husband and son helped her into bed and she was unsteady on her feet. They brought pt to [**Hospital6 8283**] where CT head was negative but troponins were elevated, TNI 2.21. She was heparinized overnight and transferred on the first boat to [**Hospital1 18**] this AM. Per report at [**Hospital6 8283**], Stroke score 0, verbal w/o focal abnormalities, heparin IV, ASA, plavix for TNI 0.02 came w/new facial droop, slow speech, lethargic, picking at herself. She was transferred here for further evaluation. CT head negative here, MRI/MRA w/acute MCA stroke. Neuro consulted, said no TPA because were unsure of chronicity. TNI here 0.09, EKG w/STD in 1 V5-V6 TWI in III, avF. Cardiology was concerned about NSTEMI. exam also significant for dysarthria (pt's son said started [**12-11**]), right arm drift and diffuse weakness/asthenia. MRI-small b/l strokes. . In the ED, initial vitals were Tm: 98.0 HR: 102 BP: 195-94 RR: 17 O2Sat: 96% on 4L. There, she was found to be somnolent, have a facial droop and right pronator drift. She had a non-contrast head CT which was negative, but the MRI showed acute MCA stroke, L striatocapsular stroke w/ additional small R striatocapsular stroke per Neurology. No evolution of neuro exam. For management of her elevated blood pressures, she received 10mg IV labetalol, hydralazine and metoprolol 5mg IV. The patient was admitted for further evaluation and management. Unable to perform ROS as pt aphasic. Past Medical History: CAD, 3 vessel disease found on cardiac cath [**2120-7-23**]; s/p cabg Diastolic Dysfunction Diabetes Dyslipidemia Hypertension Atrophic Kidney Hx of R retinal artery embolus [**2123-10-18**], when she had presented with visual illusion of a purple flower, started on Plavix at that time in addition to her full ASA 325. Work-up at the time included negative TTE and carotid U/s. Residual decrease VA in that eye. MEDICATIONS: -Metformin 750 Qday -Glyburide [**Hospital1 **] -ASA 325 -Plavix 75 -Candesartan 16 Qday -Fluticasone nasal spray -Lipitor 20 -Metorpolol 50 [**Hospital1 **] Social History: Retired, lives in [**Hospital3 4298**] with husband, helps out at family's flower shop, no hx tobacco, social EtOH, has 2 children, functionally independent at baseline, drives. Daughter [**Name (NI) 402**] [**Telephone/Fax (1) 56188**] Son [**Name (NI) **] and husband [**Name (NI) **] [**Telephone/Fax (1) 56189**] Family History: Non contributory Physical Exam: T 98 HR 86 BP 210/110 [**Month (only) **] to SBP 175 after 10 mg Hydral RR 16 sO2 98% on 2 L nc GEN: looks unwell but no acute distress HEENT: mmm NECK: no LAD; no carotid bruits; no meningismus, limited ROM at neck LUNGS: Clear to auscultation bilaterally HEART: Nitro patch, regular rate and rhythm, normal S1 and S2, no murmurs ABDOMEN: normal bowel sounds, soft, nontender, nondistended EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema MENTAL STATUS: Awake and alert, cooperative with exam, normal affect. Oriented to place, month, day, and date, person. Attention: DOWbw. Language: fluent; repetition: intact; Naming intact; Comprehension intact; moderate dysarthria and hypophonic speech, no paraphasic errors. Prosody: normal. No Apraxia. No Neglect. CRANIAL NERVES: II: Visual fields are full to confrontation, pupils equally round and reactive to light both directly and consensually, 3-->2 mm bilaterally. III, IV, VI: Extraocular movements intact without nystagmus. No ptosis. V: Facial sensation intact to light touch. VII: R facial droop 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. RUE pronator drift with deltoid and triceps 5-, bilat [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] more prominent on IP/hamstrings/dorsiflexion but symmetric bilat. REFLEXES: 1+ throughout, plantar response mute bilat SENSORY SYSTEM: Sensation intact to light touch without extinction to DSS. COORDINATION: Difficulty with FNF in RUE. GAIT: too weak to stand Pertinent Results: [**2124-12-12**] 10:50AM FIBRINOGE-459* PT-13.7* PTT-37.0* INR(PT)-1.2* PLT COUNT-284 NEUTS-78.2* LYMPHS-15.7* MONOS-4.0 EOS-1.5 BASOS-0.6 WBC-9.7 RBC-4.58 HGB-13.6 HCT-39.2 MCV-86 MCH-29.7 MCHC-34.8 RDW-13.6 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.5* GLUCOSE-187* UREA N-13 CREAT-0.6 SODIUM-139 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13 [**2124-12-12**] 11:20AM URINE MUCOUS-RARE HYALINE-0-2 RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ECG: Sinus rhythm at 101 bpm, <1mm STD in 1 V5-V6 TWI in III, avF new compared to old dated [**2120-7-26**]. [**2124-12-12**] 10:50AM CK-MB-11* MB INDX-2.3 [**2124-12-12**] 10:50AM cTropnT-0.09* [**2124-12-12**] 10:50AM CK(CPK)-475* [**2124-12-12**] 08:38PM CK-MB-8 cTropnT-0.07* CT HEAD W/O CONTRAST Study Date of [**2124-12-12**] 10:33 AM IMPRESSION: No evidence of acute intracranial hemorrhage or large vascular territory ischemia. However, if acute stroke is suspected, MRI is recommended. CHEST (PORTABLE AP) Study Date of [**2124-12-12**] 11:59 AM IMPRESSION: Stable cardiomegaly with no signs of failure or acute pneumonia. Density in the aorticopulmonary window may represent clips from prior surgical procedure (closure of PDA). Study Date of [**2124-12-12**] 12:43 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W/O CONTRAST; MR 3D RENDERING W/POST PROCESS 1. Acute infarction of the left corona radiata and the left posterior aspect of the putamen. Focal area of infarction in the right parietal lobe. This distribution is indicative of a central source of emboli-like a cardiac source. 2. Changes consistent with chronic small vessel ischemic disease and old lacunar infarctions. 3. Stenosis of the right M1 segment. TTE (Complete) Done [**2124-12-13**] at 11:01:15 AM IMPRESSION: No cardiac source of embolism identified. Preserved global and regional biventricular systolic function. Mild aortic regurgitation. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Compared with the report of the prior study (images unavailable for review) of [**2120-7-23**], there is now symmetric LVH. The degrees of mitral and aortic regurgitation are slightly less on the current study. TTE (Focused views) Done [**2124-12-13**] at 3:48:37 PM IMPRESSION: Suboptimal image quality. No premature passage of microbubbles into the left heart is seen at rest or with maneuvers. HIP 1 VIEW Study Date of [**2124-12-13**] 7:32 AM Single bedside frontal radiograph of the right hip is normal. No fracture identified and normal appearing right hip CT C-SPINE W/O CONTRAST Study Date of [**2124-12-13**] 9:30 AM IMPRESSION: 1. No fracture or malalignment. 2. Multilevel spondylosis. Mild spinal canal stenosis at C5/6. Brief Hospital Course: This 74 yo woman was admitted with simultaneous NSTEMI (max trop 0.09) and stroke affecting her left corona radiata and posterior putamen resulting in right face, arm, and leg weakness, and dysphagia. The etiology was thought to be more small vessel, but in the context of these events on anti-platelet agents, it was felt she would ultimately benefit from anticoagulation. In the short term, a joint decision between neurology and cardiology was made to hold off on anticoagulation out of fear for hemorrhagic conversion and to continue her aspirin and plavix. Her echo showed preserved EF, no evidence of embolic source and no PFO. Her HgbA1C was 7.2. Her blood sugars were difficult to control in the context of having her home metformin and glyburide held. These were re-started on discharge. Her blood pressures were also difficult to control and after a period of 3 days during which most of her BP meds were held in an attempt to allow her BP to autoregulate in the aftermath of her stroke, she was restarted on her home regimen, and her lisinopril was increased to 10 mg daily. Her lipid panel showed elevated lipids including an LDL of 113, and so her lipitor was increased from 20 to 80 mg daily and zetia 10 mg daily was added. She failed her S/S eval and she subsequently received meds and tube feeds through an NG tube. She was originally scheduled for PEG placement [**2124-12-18**], but this was postponted until [**12-21**] as she was quite hypertensive immediately before the initially scheduled PEG placement. In the meantime, her plavix was DC'd and she was kept on aspirin as the only blood thinnner. After PEG placement [**12-21**], aspirin was DC'd and coumadin was started with a lovenox bridge. On discharge, her neurological exam was significant for right arm and leg weakness in the 4/5 range, dysphagia, and dysarthria with language output limited to stating name and answering simple yes/no questions. Medications on Admission: -Metformin 750 Qday -Glyburide [**Hospital1 **] -ASA 325 -Plavix 75 -Candesartan 16 Qday -Fluticasone nasal spray -Lipitor 20 -Metorpolol 50 [**Hospital1 **] Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 160 mg/5 mL Solution Sig: [**1-19**] PO Q6H (every 6 hours) as needed for fever,ha,pain. 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Candesartan 16 mg Tablet Sig: One (1) Tablet PO Qday (). 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Five (5) units Subcutaneous twice a day. 10. Insulin Lispro 100 unit/mL Cartridge Sig: 6-16 Units Subcutaneous three times a day: Per Insulin sliding scale. . 11. Metformin 750 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 12. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg Subcutaneous Q12H (every 12 hours): Can DC Lovenox when INR is > 2.0. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary diagnosis: stroke and NSTEMI Secondary diagnoses: CAD HTN DM Hyperlipidemia Discharge Condition: Stable right arm and leg weakness in the 4/5 range, dysphagia, and dysarthria with language output limited to stating name and answering simple yes/no questions. Discharge Instructions: You have had a stroke and simultaneous type of heart attack call an NSTEMI. You will need to continue to control your risk factors including your blood pressure, blood sugars, and cholesterol. Your speech has been slowly improving and you should continue to work with speech therapy, as well as physical therapy for your weakness. You should see a nutritionist at rehab to help control your diabetes, especially in the context of having to be on liquid feeds through your PEG tube. Please return to the ER if you experience any sudden weakness, change in sensation, vision, or language, develop any severe headaches, vertigo, seizures, or anything else that concerns you seriously. Followup Instructions: Follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of Neurology [**2125-2-6**], 2pm at the [**Hospital Ward Name 23**] Clinical Center. Call to change or cancel: [**Telephone/Fax (1) 2574**]. Please follow up with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 29822**], especially for having your blood INR followed Completed by:[**2124-12-22**]

[ "V45.81", "250.00", "434.11", "410.71", "414.01" ]

icd9cm

[ [ [] ] ]

[ "88.72", "43.11" ]

icd9pcs

[ [ [] ] ]

11403, 11469

8084, 10016

371, 404

11598, 11762

5004, 8061

12493, 12921

3197, 3215

10225, 11380

11490, 11490

10042, 10202

11786, 12470

3230, 3679

11549, 11577

287, 333

432, 2238

4014, 4985

11509, 11528

3694, 3998

2260, 2846

2862, 3181

356

135,591

14331

Discharge summary

report

Admission Date: [**2132-8-4**] Discharge Date: [**2132-8-13**] Date of Birth: [**2073-10-7**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 59 year-old gentleman with end stage heart disease on the transplant list who presents status post fall six weeks ago. The patient stated that he felt lightheaded while walking to the bathroom and fell backwards on the edge of the tub landing on the upper back. The patient felt mild to moderate pain in the neck and shoulder after the fall, but continued with his every day activities. Three to four days later he noted a band like electric pain across his upper back from shoulder to shoulder as well as neck. He complained of pain to his primary care physician, [**Name10 (NameIs) **] was overlooked during visit due to patient's heart disease as well as patient's evaluation for a rash. The patient went to [**Hospital **] Hospital this morning where a CT of his neck showed a C4 lamina and spinous process fracture and anterior subluxation of C3 on C4 and he was therefore transferred to [**Hospital1 188**] for further management. PAST MEDICAL HISTORY: Cardiomyopathy with congestive heart failure, atrial fibrillation with an EF of less then 10%. Leg edema. He is a cardiac transplant candidate. He has a pacemaker, which is placed on [**2132-7-17**], biventricular. Chronic renal insufficiency. MEDICATIONS ON ADMISSION: Coreg 3.125 mg po q.a.m., Mirapex .25 mg one po b.i.d., Percocet one to two po q 4 hours prn, Zaroxolyn 5 mg two tabs po b.i.d., iron one tab po q day, Dulcolax one po q day, Coumadin 5 mg two tablets b.i.d., Cardura 2 mg po q.h.s., Lasix 20 mg three tablets in the morning and three tablets at night. ALLERGIES: Baclofen. SOCIAL HISTORY: Previous alcohol. Sober since [**2116**]. Positive tobacco history. PHYSICAL EXAMINATION: He was immobilized on a stretcher. He was awake, alert and oriented times three. Cooperative. Temperature 97.6. Blood pressure 110/68. Heart rate 76. Respiratory rate 18. Sats 95% on room air. HEENT pupils are equal, round and reactive to light. Extraocular movements intact. Cranial nerves II through XII intact. Neck immobilized. Chest clear to auscultation bilaterally. Cardiovascular rhythm irregular. Rate normal. No murmurs, rubs or gallops. Abdomen positive, distended, positive bowel sounds. Extremities gross edema bilaterally in the lower extremities. Neurological decreased pin prick sensation in the right upper extremities. Sensation intact to light touch. Strength is 5 out of 5. Deep tendon reflexes are 2+ throughout. LABORATORY: Sodium 139, K 2.8, chloride 95, CO2 31, BUN 63, creatinine 1.6, glucose 105, PT 20.6, PTT 35.8, INR 3.0, AST 47, CK 141, alkaline phosphatase 179, white count was 5.0, hematocrit 30.8, platelets 147. CT of the C spine shows a grade two anterior lysis of C3 and C4 bilateral lamina C4 fractures and narrowing of the spinal canal with no bone fragment, no hematoma and body height was preserved. HOSPITAL COURSE: The patient was admitted initially to the Medical Service and seen by neurosurgery and found to be require cervical fusion to stabilize neck injury. The patient on [**2132-8-6**] underwent a C3 to C5 arthrodesis and lateral mass screw and rod fixation. C4 to C5 spinous process, tension band wiring without intraoperative complications. The patient was monitored in the Surgical Intensive Care Unit postoperative where he remained hemodynamically stable, awake, alert, following commands and moving all extremities. The patient remained stable and was transferred to the floor on [**2132-8-8**] in stable condition. He was seen by physical therapy and occupational therapy and found to be safe for discharge to home. MEDICATIONS ON DISCHARGE: Lasix 60 po b.i.d., Zaroxolyn 2.5 mg b.i.d., K-Ciel 80 milliequivalents per day, Coreg 3.125 po q day, Mirapex .25 mg po b.i.d., Percocet one to two tabs po q 4 hours prn, iron 325 mg po q day, Dulcolax 10 mg po q day, Cardura 2 mg po q.h.s. The patient's Coumadin will be started on one week. He will follow up at [**Hospital 8503**] for a psychiatric evaluation for his heart transplant on [**8-18**]. Follow up with Dr. [**Last Name (STitle) 1327**] on [**8-19**] for staple removal and follow up with Dr. [**First Name (STitle) 2031**] in two weeks to restart his Coumadin. He is in stable condition at the time of discharge. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2132-8-13**] 10:43 T: [**2132-8-13**] 12:03 JOB#: [**Job Number **]

[ "427.31", "V43.3", "E885.9", "593.9", "805.04", "V45.02", "276.8", "428.0", "425.4" ]

icd9cm

[ [ [] ] ]

[ "81.03" ]

icd9pcs

[ [ [] ] ]

3781, 4677

1416, 1742

3032, 3754

1852, 3014

159, 1119

1142, 1389

1759, 1829

67,343

186,604

38969

Discharge summary

report

Admission Date: [**2174-3-18**] Discharge Date: [**2174-3-30**] Date of Birth: [**2093-7-13**] Sex: M Service: CARDIOTHORACIC Allergies: Simvastatin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Flail mitral valve leaflet Major Surgical or Invasive Procedure: left and right heart catheterization,coronary angiography, left ventriculogram [**2174-3-25**]: Mitral valve repair with a triangular resection of the middle scallop of the posterior leaflet of the mitral valve (P2) and a mitral valve annuloplasty with a 28 mm future CG ring. Coronary artery bypass grafting x2 with reverse saphenous vein graft to the marginal branch of the posterior descending artery. [**3-25**]: Re-exploration of mediastinum for postoperative hemorrhage History of Present Illness: 80yoM with h/o AFib, CHF, HTN, Hypercholesterolemia transferred from Caritas [**Hospital6 5016**] for evaluation of flail posterior mitral valve repair. Pt was admitted to [**Hospital6 3105**] in [**9-/2173**] for Legionella pneumonia when he had multilobar infiltrates, received 2-3wk course of oral ABx and resolution of PNA. He was doing well, then had a motor vehicle accident [**9-/2173**] due to syncopal episode at which point per pt he began to have off and on SOB and was told to have a stress test and echocardiogram, the results of which are below, but basically the stress test was negative and the TTE was most significant for flail posterior mitral leaflet with either subchordal rupture or vegetation, 4+ MR, 3+ TR, concentric LVH, and evidence of volume overload. Pt was then admitted to Caritas [**Hospital3 **] for further workup of what appears to be initially most concerning for the vegetation, which included TEE. TEE ruled out vegetation and showed a flail posterior mitral leaflet with subchordal rupture with severe 4+ MR. [**Name13 (STitle) **] there were mostly significant for WBC count 10.3, BUN/Cr 28/1.3-1.4. BCx's negative x3. The pt is transferred to [**Hospital1 18**] for workup of mitral valve repair. ROS significant for increased fatigue, SOB, DOE, occasional PND/orthopnea, occasional palpitations. He also endorses two syncopal episodes in the past several months. He mentions a 30lb wt loss when he was recently diuresed with Lasix, he denies that he's ever had heart failure or swelling before. He feels that his condition has been deteriorating since his episode of PNA. He denies f/c/ns, no CP, no HEENT problems, no n/v/d/c/abdominal pain, no dysuria, no skin changes, no joint changes. Past Medical History: - Dyslipidemia - Hypertension - H/o CHF with diastolic dysfunction - Chronic AFib on Coumadin - HTN - Hyperlipidemia - Scarlet Fever at 8 years old - Pt states he was diagnosed with heart murmur 20 years ago and states has been on treatment for CHF since then - Legionnaires PNA last [**Month (only) 205**] (as above) - Bilateral inguinal hernia x5 months - R eyelid surgery Social History: Lives at home, retired from construction. -Tobacco history: Smoker who quit around 40 years ago, was 2ppd smoker -ETOH: Occasionally -Illicit drugs: none Family History: Non contributory Physical Exam: T=98.7 BP=180/90 HR= 66 irregularly irregular RR= 18 O2 sat=96 on RA GENERAL: WDWN. 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. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Irregular rhythm, normal S1, S2. No r/g. A grade 3 pan systolic murmur best heard at the apex is audible, radiates to the back and to the carotids. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Grade 3 clubbing is present. No c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Discarge [**Month (only) **] [**2174-3-30**] 07:55AM BLOOD WBC-11.1* RBC-4.41* Hgb-12.3* Hct-37.4* MCV-85 MCH-27.9 MCHC-33.0 RDW-14.5 Plt Ct-318# [**2174-3-30**] 07:55AM BLOOD Plt Ct-318# [**2174-3-30**] 07:55AM BLOOD PT-23.3* PTT-33.9 INR(PT)-2.2* [**2174-3-30**] 07:55AM BLOOD Glucose-109* UreaN-24* Creat-1.3* Na-138 K-4.0 Cl-99 HCO3-27 AnGap-16 ADMISSION [**Month/Day/Year **]: [**2174-3-19**] 07:45AM BLOOD WBC-11.1* RBC-5.42 Hgb-14.8 Hct-45.6 MCV-84 MCH-27.3 MCHC-32.5 RDW-14.9 Plt Ct-229 [**2174-3-19**] 07:45AM BLOOD Neuts-64.3 Lymphs-24.9 Monos-6.1 Eos-4.0 Baso-0.7 [**2174-3-19**] 10:10AM BLOOD PT-14.5* PTT-32.7 INR(PT)-1.3* [**2174-3-19**] 07:45AM BLOOD Glucose-99 UreaN-23* Creat-1.4* Na-138 K-3.8 Cl-101 HCO3-26 AnGap-15 [**2174-3-19**] 07:45AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.1 [**2174-3-21**] Cartoid ultrasound 1. 70-79% stenosis of the right internal carotid artery. 2. Less than 40% stenosis of the left internal carotid artery. [**2174-3-22**] cardiac cath COMMENTS: 1. Selective coronary angiography in this right dominant system demonstrated two vessel coronary artery disease. The LMCA was free of angiographically apparent coronary artery disease. The LAD had a 40% stenosis in the proximal vessel, and a 40% stenosis in the distal vessel. There was a small first diagonal branch that had an 80% stenosis. The LCx had mild luminal irregularitites. The mid vessel had an eccentric lesion with a 70% stenosis prior to bifurcating into a large OM1. The lower pole of OM1 had a focal 80% stenosis. There were also serial 40-50% stenoses in the remainder of the first OM branch. The RCA had diffuse 80% proximal and mid vessel stenosis. 2. Resting hemodynamics revealed mildly elevated right and left sided filling pressures with RVEDP 13 mmHg and mean PCWP 16 mmHg. There was moderate pulmonary arterial systolic hypertension PASP 54 mmHg. The cardiac index was preserved at 2.5 l/min/m2. 3. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Moderate pulmonary hypertension. 3. Slightly elevated left sided filling pressures. [**2174-3-22**] CT chest without contrast FINDINGS: 16 x 7 mm left upper lung spiculated nodule adjacent to the ascending aorta (4A:71) has slightly irregular margins. 5 mm nodule in the right middle lung is perifissural (4A:119). Few other bilateral sub 5-mm nodules, the largest in the right middle lobe (4A:140) are noted. The airways are patent to the subsegmental level. Heart size is mildly enlarged. There are small simple right greater than left pleural effusions. There is no pericardial effusion. There are small atherosclerotic calcifications along the ascending and descending aorta. This exam was not optimized for subdiaphragmatic diagnosis. Bilateral high density material in the renal collecting system which represents minimal residual contrast from prior study. Hypodense liver lesions likely representing cysts and gallstones are noted. Bone windows demonstrate no lesion concerning for metastasis or infection and no evidence of acute fracture. IMPRESSION: 1. 16 x 7 mm left upper lung spiculated nodule may represent infectious, inflammatory or neoplastic etiology. Given history of pneumonia, recommend followup in 3 months after therapy to document expected resolution or stability and to excluded neoplatic growth. 2. Small bilateral right greater than left pleural effusions. 3. Scattered borderline enlarged mediastinal lymph nodes and sub-5-mm pulmonary nodules can be followed in 3 months. 4. Moderate cardiomegaly. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.6 m/s Right Atrium - Four Chamber Length: *6.1 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.6 cm Left Ventricle - Fractional Shortening: 0.47 >= 0.29 Left Ventricle - Ejection Fraction: 70% >= 55% Left Ventricle - Stroke Volume: 50 ml/beat Left Ventricle - Cardiac Output: 3.42 L/min Left Ventricle - Cardiac Index: 2.11 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.11 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *19 < 15 Aorta - Sinus Level: 2.8 cm <= 3.6 cm Aorta - Arch: 2.6 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 16 Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - E Wave: 1.7 m/sec Mitral Valve - A Wave: 0.5 m/sec Mitral Valve - E/A ratio: 3.40 Mitral Valve - E Wave deceleration time: 140 ms 140-250 ms TR Gradient (+ RA = PASP): *57 mm Hg <= 25 mm Hg Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. RV function depressed. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Focal calcifications in aortic arch. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Myxomatous mitral valve leaflets. Moderate/severe MVP. Partial mitral leaflet flail. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Eccentric MR jet. Moderate to severe (3+) MR. [**Name13 (STitle) 15110**] to the eccentric MR jet, its severity may be underestimated (Coanda effect). TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid valve supporting structures. No TS. Mild to moderate [[**2-12**]+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets. No PS. Mild 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. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. There is moderate/severe posterior mitral leaflet prolapse. There is partial posterior mitral leaflet flail. An eccentric, anteriorly directed jet of moderate to severe (3+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. There is no pericardial effusion. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Brief Hospital Course: 80yoM with hyperlipidemia, HTN, dCHF, AFib on Coumadin who presented with DOE/fatigue to OSH. Found to have a flail mitral valve due to ruptured chordae tendinae on [**Hospital 86444**] transferred from [**Hospital3 **] to [**Hospital1 18**] for further evaluation. At [**Hospital1 18**] cardiac catheterization showed two vessel coronary artery disease, moderate pulmonary hypertension, and slightly elevated left sided filling pressures. Cardiac surgery was consulted and pt had pre-op work including dental consult, chest CT and corotid ultrasound. The chest CT revealed bilat pulm nodules and thoracic surgery was consulted, they recommended f/u CT in 3 months. Pt went to surgery on [**3-25**] at which time he had a mitral valve repair with a triangular resection of the middle scallop of the posterior leaflet of the mitral valve (P2) and a mitral valve annuloplasty with a 28 mm future CG ring, coronary artery bypass grafting x2 with reverse saphenous vein graft to the marginal branch of the posterior descending artery. His bypass time was 110 minutes with a crossclamp, time of 67 minutes. He tolerated the operation well and was transferred from the operating room to the cardiac surgery ICU in stable condition. The post operative course was complicated by bleeding and on the day of surgery he returned to the operating room for: Re-exploration of mediastinum for postoperative hemorrhage following mitral valve repair and coronary artery bypass grafting. He was kept sedated overnight after the re-exploration, on the following morning sedation was weaned, he woke neurologically intact and he was extubated. He remained hemodynamically stable but remained in the ICU to monitor cardiopulmonary status until POD3 when he was transferred to the stepdown unit. All tubes line and drains were removed according to cardiac surgery protocol. Once on the floor the patient worked with nursing and physical therapy to regain his strength and mobility. He did go into atrial fibrillation on post operative day 4 with a rate of 120's and his Lopressor was titrated up for improved rate control. His INR was 2.2 at the time of discharge and he was continued on his Coumadin at his home dose for INR goal 2-2.5. Lisinopril was also increased for hypertension on post operative day 5. The remainder of his hospital course was uneventful. He was discharged to rehabilitation on POD 5 and is to followup with Dr [**Last Name (STitle) **] in 4 weeks. Medications on Admission: Protonix 40mg qday Lisinopril 2.5mg PO qday ISMN 30mg daily Lasix 20mg PO every other day Coumadin 5mg daily except Saturdays Atenolol 100mg PO qday Digoxin 0.25mg PO every other day Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 4. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Tablet(s) 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day for 2 weeks. 8. Coumadin 5 mg Tablet Sig: as directed to keep INR 2-2.5 Tablets PO once a day: target INR 2-2.5 Home dose 5mg QD except Sundays. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] - [**Location (un) 7658**] Discharge Diagnosis: s/p Coronary Artery Bypass Grafting x2 (reverse saphenous vein graft>Right coronary artery, reverse saphenous vein graft>Obtuse Marginal artery), Mitral Valve repair (28 ring) PMH: Legionella pneumonia [**9-19**] treated with 3 weeks of antibiotics with resolution of nodular infiltrates.Hypertension, hyperlipidemia,chronic AF,long h/o murmur,Scarlet Fever age 8, Bilat hernia repair Herniorraphies, eyelid sx as child Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Sternal wound healing well, no erythema or drainage 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) **] on [**4-28**] @ 1:45PM Please call for appointments: PCP-[**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 63309**] Cardiologist- Dr [**Last Name (STitle) 5423**],[**First Name8 (NamePattern2) **] [**Known firstname **] [**Telephone/Fax (1) 5424**] [**Hospital 409**] clinic in 2 weeks-nurse [**First Name (Titles) **] [**Last Name (Titles) **] appointment before discharge Completed by:[**2174-3-30**]

[ "427.31", "428.32", "424.0", "429.5", "998.11", "414.01", "E878.8", "V58.61", "403.90", "287.5", "428.0", "518.89", "416.8", "V15.82", "585.9", "272.0", "433.10" ]

icd9cm

[ [ [] ] ]

[ "36.12", "39.61", "88.56", "96.71", "34.03", "35.12", "37.23" ]

icd9pcs

[ [ [] ] ]

15536, 15613

11747, 14203

305, 784

16077, 16077

4085, 6040

16823, 17312

3133, 3152

14437, 15513

15634, 16056

14229, 14414

6057, 11724

16306, 16800

3167, 4066

239, 267

812, 2546

16091, 16282

2568, 2945

2961, 3117

52,026

130,360

50576

Discharge summary

report

Admission Date: [**2111-11-14**] Discharge Date: [**2111-11-23**] Date of Birth: [**2031-8-16**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: coronary artery disease Major Surgical or Invasive Procedure: Coronary artery bypass grafts x 3(LIMA-LAD, SVG-DG,SVG-RCA)[**11-17**] History of Present Illness: This 80 year old white male with a history of chronic angina with exertion and negative stress tests. His angina has crescendoed over a two day period to having angina with climbing one flight of stairs.. He was admitted for elective catheterization at [**Hospital6 1109**]. This revealed 3 vessel disease with preserved LV function and he was transferred for revascularization. Past Medical History: Prostate cancer- XRT Diverticulitis colectomy for diverticular disease hyperlipidemia peripheral neuropathy prostatism s/p dual chamber pacemaker implant Social History: remote smoker. rare ETOH use. lives with his wife Family History: noncontributory Physical Exam: Discharge: 98.1 124/64 76 18 No acute distress, oriented, and awake Heart of regular rate and rhythm Lungs clear to auscultation bilaterally Abdomen soft, non-tender, non-distended Extremities warm with 1+ edema Mediastinal incision clean, dry, and intact Sternum stable Left vein harvest sites clean, dry, and intact Pertinent Results: [**2111-11-22**] 07:15AM BLOOD WBC-6.8 RBC-3.37* Hgb-10.6* Hct-30.4* MCV-90 MCH-31.6 MCHC-35.0 RDW-13.8 Plt Ct-263 [**2111-11-22**] 07:15AM BLOOD Plt Ct-263 [**2111-11-22**] 07:15AM BLOOD Glucose-94 UreaN-22* Creat-1.3* Na-135 K-3.9 Cl-97 HCO3-32 AnGap-10 [**2111-11-21**] 03:14AM BLOOD ALT-21 AST-34 LD(LDH)-303* AlkPhos-62 Amylase-32 TotBili-0.6 [**2111-11-22**] 07:15AM BLOOD WBC-6.8 RBC-3.37* Hgb-10.6* Hct-30.4* MCV-90 MCH-31.6 MCHC-35.0 RDW-13.8 Plt Ct-263 [**2111-11-21**] 03:14AM BLOOD WBC-9.0 RBC-3.88*# Hgb-12.1*# Hct-34.5* MCV-89 MCH-31.2 MCHC-35.1* RDW-14.5 Plt Ct-209# [**2111-11-17**] 02:29PM BLOOD WBC-6.7 RBC-2.64*# Hgb-8.3*# Hct-23.7*# MCV-90 MCH-31.6 MCHC-35.2* RDW-13.8 Plt Ct-147* [**2111-11-14**] 07:15PM BLOOD WBC-6.5 RBC-4.08* Hgb-13.0* Hct-37.7* MCV-92 MCH-31.9 MCHC-34.5 RDW-13.2 Plt Ct-235 [**2111-11-21**] 03:14AM BLOOD PT-12.7 PTT-30.8 INR(PT)-1.1 [**2111-11-14**] 07:15PM BLOOD PT-12.2 PTT-27.0 INR(PT)-1.0 [**2111-11-22**] 07:15AM BLOOD Glucose-94 UreaN-22* Creat-1.3* Na-135 K-3.9 Cl-97 HCO3-32 AnGap-10 [**2111-11-14**] 07:15PM BLOOD Glucose-136* UreaN-20 Creat-1.4* Na-139 K-4.4 Cl-104 HCO3-28 AnGap-11 [**2111-11-21**] 03:14AM BLOOD ALT-21 AST-34 LD(LDH)-303* AlkPhos-62 Amylase-32 TotBili-0.6 [**2111-11-14**] 07:15PM BLOOD ALT-18 AST-21 AlkPhos-68 Amylase-56 TotBili-0.2 [**2111-11-22**] 07:15AM BLOOD Mg-2.4 [**2111-11-14**] 07:15PM BLOOD Albumin-4.1 Mg-2.1 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 105287**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 105288**] (Complete) Done [**2111-11-17**] at 12:14:43 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2031-8-16**] Age (years): 80 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Aortic valve disease. Chest pain. Coronary artery disease. Hypertension. ICD-9 Codes: 402.90, 786.51, 440.0, 424.1 Test Information Date/Time: [**2111-11-17**] at 12:14 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 #: 2008AW5-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.7 cm <= 4.0 cm Right Atrium - Four Chamber Length: *5.7 cm <= 5.0 cm Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Aortic Valve - Peak Gradient: 2 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 1 mm Hg Findings LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No spontaneous echo contrast in the body of the RA. A catheter or pacing wire is seen in the RA and extending into the RV. Dynamic interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal LV wall thickness. Normal LV cavity size. 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. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. Mild to moderate ([**12-24**]+) AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Trivial/physiologic 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 patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. 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 simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild to moderate ([**12-24**]+) aortic regurgitation is seen. 7. The mitral valve appears structurally normal with trivial mitral regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 8. There is a trivial/physiologic pericardial effusion. Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] were notified in person of the results. POST-CPB: On infusion of phenylephrine. AV pacing. Well-preserved LV systolic function with improvement of the anteroapical and anteroseptal walls. LVEF is now 45%. 1+ AI, trace MR. Aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] Brief Hospital Course: The patient was transferred her from [**Hospital **] Hospital for surgery following his catheterization. He remained stable and on [**11-17**] was taken to the operating room where triple bypass grafting was performed as noted. Please see operative note for complete details. He weaned from bypass on neosynephrine and Propofol. Epinephrine was begun after surgery for low cardiac outputs and volume was required for low urine output. He was extubated and his permanent pacemaker was interogated on post-operative day one and was found to be functioning normally. His chest tubes and wires were removed. On post-op day 3 he was noted to have orthostatic hypotension. He was given several fluid boluses with improvement in his blood pressure and was transferred to the step down floor. Once on the floor he was noted to be hypotensive, had an episode of syncope and also had word finding difficulty. His hematocrit had dropped from 29 to 23 compared to the previous day. He was brought back to the CVICU. A stat bedside echo was performed and did not find hemopericadium. He was transfused one unit packed red blood cells and his symptoms resolved. Also on post-op day 3 his abdomen became distended and his bowel regimen was increased. By post-operative day 4 his abdomen improved, he was hemodynamically stable and he was transferred to the surgical step down floor. That evening he had atrial fibrillation which converted with lopressor. He worked with physical therapy on strength and balance. He continued to be gently diuresed towards his pre-operative weight and by post-operative day 5 he was ready for discharge to home. Medications on Admission: Atenolol 25mg/D NTG 0.1 mg/hr TD Vytorin 110/10 QD Prilosec 20mg [**Hospital1 **] Flomax 0.4 mg/D Lyrica 75mg [**Hospital1 **] Quinine 324mggg/D ASA81 mg/D Celebrex 200mg/D MVI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0* 7. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 8. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*0* 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts x 3 (LIMA-LAD, SVG-DG,SVG-RCA) s/p permanent dual chamber pacemaker implant h/o prostate cancer hyperlipidemia s/p colectomy peripheral neuropathy h/o diverticulitis Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no lifting more than 10 pounds for 10 weeks no driving for 4 weeks and off all narcotics report any fever greater than 100.5 report any redness of, or drainage from incisions report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) **] in 2 weeks ([**Telephone/Fax (1) 6256**]) at [**Hospital1 **] Heart Center. Dr. [**First Name8 (NamePattern2) 8516**] [**Last Name (NamePattern1) **] in 2 weeks ([**Telephone/Fax (1) 36609**]) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks ([**Telephone/Fax (1) 6256**]) at [**Hospital1 **] Heart Center Please call for appointments Please have your creatinine checked in one week with results to go to Dr [**Last Name (STitle) **] and Dr [**First Name (STitle) **]. Completed by:[**2111-11-23**]

[ "411.1", "272.4", "356.9", "780.2", "V10.46", "428.0", "428.23", "427.31", "414.01", "V45.01" ]

icd9cm

[ [ [] ] ]

[ "36.12", "36.15", "39.61", "99.04" ]

icd9pcs

[ [ [] ] ]

11299, 11361

7812, 9452

347, 420

11629, 11636

1458, 5924

12041, 12604

1088, 1105

9679, 11276

11382, 11608

9478, 9656

11660, 12018

5973, 7789

1120, 1439

284, 309

448, 828

850, 1005

1021, 1072

8,426

101,537

49787

Discharge summary

report

Admission Date: [**2114-1-20**] Discharge Date: [**2114-2-1**] Date of Birth: [**2036-5-13**] Sex: M Service: MEDICINE Allergies: Amiodarone / Quinidine Attending:[**First Name3 (LF) 7333**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Pacemaker placement History of Present Illness: Mr. [**Name13 (STitle) 14077**] is a 77-year-old man with CAD s/p CABG (LIMA-LAD, RIMA-RCA, SVG-OM in [**2089**]) and PCI (DES to SVG-OM in [**2106**]), multiple atrial arrhythmias and tachybrady syndrome s/p multiple ablations and pacemaker placement in [**2106**], chronic systolic heart failure, stage IV CRF, recently admitted in [**12/2113**] for CHF exaceration who presents for CHF management prior to BiV pacemaker upgrade on [**2114-1-22**]. . Per Dr.[**Name (NI) 1565**] [**2114-1-17**] note Mr. [**Name13 (STitle) 14077**] has had increasing cardiac dysfunction primarily due to cardiac dyssynchrony secondary to chronic ventricular pacing. His ejection fraction has over the past four years progressively gone from normal to about 40% with measurements of synchrony being distinctly abnormal. He has hypokinesis of his septum, which is primarily related to his pacemaker. He has increasing fluid retention and inability to get the fluid to his kidneys and perfuse them well. An attempt to decrease the fluid accumulation and increasing Lasix has caused the deterioration of his kidney function, such that his BUN is 101 and creatinine 3.2 with concurrent hypokalemia and hypochloremia despite the concomitant use of Aldactone. Decision made to place BiV pacemarker in attempt to improve cardiac function and secondarily increase his renal perfusion. . On direct presentation from home patient reports ~5lb weight gain with abd distension since [**1-17**] appt. No changes made to medications, no dietary or medications non-complinance. Denies any worsening peripheral edema; stable 2 pillow orthopnea, no PND, no palpitations. . Patient admitted on [**1-20**]; BiV unable to be placed on [**1-22**] due to technically difficult therefore epicardial leads placed on [**1-23**]. Intra-op recevied received total of 15cc contrast. Patient underwent procedure successfully. Placed on coumadin and hep gtt. Patient received a dose of vanco during procedure; keflex continued x2days post. Post-operative course complicated by acute renal failure, nephrology consulted deterioration in function secondary to poor forward flow. . Of note on night prior to transfer patient s/p mechanical fall while walking - denies any preceding dizziness, chest pain, palpitations. . Current cardiac review of systems: denies dizziness, chest pressure, shortness of breath, stable abdominal distention. Denies diaphoresis, n/v. . On review of systems, reports pain at operative when coughing,he reports prior history of stroke, GI bleed in the setting of ASA, plavix; denies bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: CAD Sick sinus syndrome Chronic and diastolic CHF EF 40-45% Paroxysmal afib s/p multiple DCCV, aflutter ablations, and PVI in [**5-/2106**] -CABG: LIMA-LAD, RIMA-RCA, SVG-OM in [**2089**] -PERCUTANEOUS CORONARY INTERVENTIONS: DES to prox SVG-OM in [**9-/2107**] -PACING/ICD: [**Company 1543**] pacer in [**8-/2107**] for SSS PM settings: DDDR mode with a lower rate of 60, an upper track rate of 100, and an upper sensor rate of 110 beats per minute. The mode switch function is ON for atrial rates greater than 145 beats per minute. Of note, the PVARP time is set at 400 milliseconds. 3. OTHER PAST MEDICAL HISTORY: Stage III-IV chronic renal failure (baseline Cr 2.7-3.0) H/o CVA with bilateral lacunar infarcts in [**2100**] with residual left paresthesias and gait dysfunction OSA on CPAP H/o GI bleed on Plavix (now off ASA and Plavix) H/o scarlet [**Year (4 digits) **] Inflammatory bowel disease? Gout Obesity Fatty liver Left ear deafness Social History: Lives in [**State 792**]with his wife. Formerly worked at a dialysis medical device company. - Alcohol: Drinks wine weekly - Tobacco: 80 pack-year history but quit 12 years ago - Drugs: None Family History: Multiple family members with diabetes. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory Physical Exam: VS: T 97.7 100/61 58 94%RA wt: 109.4 kg - 107.6 (on admission) Todays I/O: 530ccin/1235cc UOP GENERAL: WDWN in NAD. Speaking in full sentences without problems. Oriented x3. [**Name2 (NI) **], affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Central line in place. NECK: Supple, unable to assess JVP due to CVL placement CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4, minimal pretibial edema, + abd distension. CHEST: well-healed midline incision scar PPM site: -- bandage on the left anterior chest chest: minimal tenderness, dressing in place: c/d/i -- bandage on the posterior flank, dressing in place: c/d/i LUNGS: Resp were unlabored, no accessory muscle use. Decreased bs at b/l bases with overlying crackles, no wheezes or rhonchi. ABDOMEN: Distended, nontender. No HSM or tenderness. EXTREMITIES: Cool, 1+ pitting edema, skin changes consistent with chronic venous insufficiency. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ . On Discharge: VS: T 97.7 100/61 58 94%RA wt: 104 kg - 107.6 (on admission) GENERAL: WDWN in NAD. Speaking in full sentences without problems. Oriented x3. [**Name2 (NI) **], affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Central line in place. NECK: Supple, unable to assess JVP due to CVL placement CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4, 1+ symmetric LE edema, + abd distension. CHEST: well-healed midline incision scar PPM site: -- bandage on the left anterior chest chest: minimal tenderness, dressing in place: c/d/i -- bandage on the posterior flank, dressing in place: c/d/i -- wound on left knee: dressing in place - c/d/i LUNGS: Resp were unlabored, no accessory muscle use. Decreased bs at b/l bases scant overlying crackles, no wheezes or rhonchi. ABDOMEN: Distended, nontender. No HSM or tenderness. EXTREMITIES: WWP, 1+ pitting edema, skin changes consistent with chronic venous insufficiency. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: On Admission: [**2114-1-20**] 09:33PM WBC-9.2 RBC-3.53* HGB-11.8* HCT-33.3* MCV-94 MCH-33.6* MCHC-35.6* RDW-17.0* [**2114-1-20**] 09:33PM PLT COUNT-172 [**2114-1-20**] 09:33PM GLUCOSE-170* UREA N-104* CREAT-3.4* SODIUM-135 POTASSIUM-3.4 CHLORIDE-94* TOTAL CO2-25 ANION GAP-19 [**2114-1-20**] 09:33PM CALCIUM-9.4 PHOSPHATE-4.0 [**2114-1-20**] 09:33PM PT-19.3* PTT-30.3 INR(PT)-1.8* . On Discharge:[**2114-2-1**] 06:05 WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 7.4 3.26* 11.1* 31.3* 96 33.9* 35.3* 16.6* 241 . UreaN Creat Na K Cl HCO3 AnGap 138 3.9* 130* 3.8 88* 28 18 . INR: 2.2 . Studies TTE: [**1-23**] 1. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. 2. No spontaneous echo contrast is seen in the body of the right atrium. A small mobile echodense mass associated with a pacing wire is seen in the right atrium near the interatrial septum. 3. No atrial septal defect is seen by 2D or color Doppler. 4. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with dyskinesis of the apical anteroseptal and inferoseptal walls, and severe hypokinesis of the mid septum. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). 5. Right ventricular chamber size is normal with borderline normal free wall function and focal hypokinesis of the apical free wall. 6. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 7. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 8. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-10**]+) mitral regurgitation is seen. 9. The tricuspid valve leaflets are mildly thickened. 10. There is a very small pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results at the time of the study. . CXR [**1-25**] Right jugular line ends in the region of the superior cavoatrial junction, as before. As far as one can tell from a frontal view alone, the right atrial lead ends low in the right atrium and right ventricular lead along the floor of the right ventricle. Two epicardial leads projecting over the left heart border are unchanged since [**1-23**]. That procedure was presumably responsible for new small left pleural effusion. Pulmonary edema has resolved since [**1-24**], and lung volumes have improved. Mild cardiomegaly is unchanged, and there is no pneumothorax. . TTE: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis (LVEF = 45 %). Dyssnchrony is not visually apparent. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with borderline normal free wall function. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with mild global hypokinesis. Moderate pulmonary artery systolic hypertension. Increased PCWP. Compared with the prior study (images reviewed) of [**2114-1-22**], left ventricular systolic dysfunction appears more diffuse/global and the estimated pulmonary artery systolic pressure is highe Brief Hospital Course: [**Last Name (un) 14077**] is a 77-year-old man with CAD s/p CABG (LIMA-LAD, RIMA-RCA, SVG-OM in [**2089**]) and PCI (DES to SVG-OM in [**2106**]), multiple atrial arrhythmias and tachybrady syndrome s/p multiple ablations and pacemaker placement in [**2106**], CKD, and chronic systolic heart failure s/p epicardial lead placement via left mini-thoracotomy w/St.[**Male First Name (un) 923**] pacer [**2114-1-23**] with hospital course complicated by acute on chronic renal failure. . # Chronic systolic CHF: EF ~50 via [**12-19**] TTE. Patient is s/p epicardial lead placement on [**1-23**]. Hypothesized that patients worsening CHF symptoms secondary to ventricular dyssynchrony and placement of placemarker will improve forward flow and improve symptoms. Post-procedure patient with persistent volume overload. Patient intermittently diuresised with IV Lasix with good response. Patient transitioned to PO Lasix on [**1-30**] with continued diuresis (~1L/day). Patient discharged on Lasix 60mg PO BID, spironlactone 25mg QD and Metalozone 2.5mg PO every tuesday and friday. Patient continued on metoprolol XL. Repeat TTE demonstrated stable EF ~45% with ventricular synchrony. Surgical site clean, intact with no sign of infection at time of discharge - patient completed 7 day course of Keflex. 1. Monitor weights daily, adjust diuretics as needed for volume optimization. 2. Monitor surgical site, wound care as needed . # Acute on chronic kidney failure, stage 4. Baseline creatinine: 2.7-3.0. On admission patient's creatinine 3.4. After diuresis creatinine improved to 3.0. After procedure, creatinine peak to 4.0 on [**1-25**]. Etiology of [**Last Name (un) **]: poor perfusion secondary to poor forward flow vs contrast-induced nephropathy (however patient received minimal dye load) vs AIN in setting of ppx Abx. Urine and differential without eosinophilia. Renal consulted - hypothesized that elevation secondary to poor forward flow and recommended to continued diuretic use. Patient maintained good UOP throughout stay. Creatinine at time of discharge: 3.9. OUTPATIENT ISSUES: 1. Monitor creatinine regularly and I/O. . # CORONARIES: Patient with history of CAD. Last cardiac catheterization [**2106**] with stenting of SVG to OM. Due to h/o GI bleed not currently on ASA, Plavix. Patient cites 2-3x weekly exertional angina as well as infrequent episodes of angina at rest. Patient with 1/11 Stress echo: Rest and stress perfusion images reveal decreased tracer uptake in the anterior apical region on both stress and rest images with associated apical wall motion abnormality. Patient monitored on telemetry without event and continued on beta-blocker. OUTPATIENT ISSUE: 1. Monitor exertional symtoms and ascert need to repeat stress. . # RHYTHM. Patient with history multiple atrial arrhythmias: atrial fib/flutter, tachybrady syndrome s/p multiple ablations and PPM in [**2106**]. - Rate control. Patient was monitored on telemetry and remained in normal sinus for majority of stay with occassional reversion into atrial fibrillation. Rates consistently 50-70s. - Anticoagulation. CHADS 6. Patient maintained on lovenox daily when INR subtherapeutic. Continued on coumadin. INR at time of discharge: OUTPATIENT ISSUES: 1. Monitor on telemetry for arrhytmias. . # H/o CVA with bilateral lacunar infarcts in [**2100**] with residual left paresthesias and gait dysfunction. Neuro exam monitored. Patient ambulated without problems with the assistance of a walker. . # IDDM. Continue home regimen of lantus, humalog with meals and ISS . # OSA. Home CPAP continued. Medications on Admission: Metoprolol succinate 50 mg PO daily Spironolactone 25 mg PO daily Rosuvastatin 20 mg PO daily Furosemide 60 mg [**Hospital1 **] Metolazone 2.5 mg on Tuesdays Nitroglycerin 0.4 mg SL PRN chest pain Warfarin 2.5mg daily Insulin Glargine 25 units QAM and 50 units QHS Novalog 15 u with breakfast, 20-25 u with dinner, and 20-25 u at bedtime. He skips lunch. ? Calcitriol 0.5 mcg PO daily Allopurinol 300 mg PO daily Colchicine 0.6 mg PO daily prn Omeprazole 40 mg PO daily Multivitamin 1 tab PO daily Calcium Carbonate-Vitamin D3 Vitamin D2 Iron 325 mg PO daily Ascorbic acid Glucosamine Magnesium Zinc sulfate Fish Oil Discharge Medications: 1. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO Every Tuesday and Friday. 2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 3. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 9. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 14. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 15. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day). 16. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 17. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 18. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 19. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for [**Hospital1 **], pain. 20. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 21. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed. 22. calcium carbonate-vitamin D3 Oral 23. ascorbic acid Oral 24. Fish Oil Oral 25. Glucosamine Oral 26. ergocalciferol (vitamin D2) Oral 27. insulin glargine 100 unit/mL Solution Sig: 25units in the AM, 50units in the PM as directed Subcutaneous as directed. 28. Humalog 100 unit/mL Solution Sig: as directed units Subcutaneous four times a day: 20units with breakfast, 25units at lunch, dinner and bedtime. 29. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Chronic Congestive Heart Failure . Secondary: Hypertension Hyperlipidemia Diabetes Discharge Condition: Mental status: clear and coherent Ambulates without asssitance Weight at time of discharge: Discharge Instructions: Dear Mr [**Last Name (Titles) 14077**], it was a pleasure taking care of you . You were admitted to [**Hospital1 18**] for optimization of volume status prior to Biventricular pacemarker placement. Unfortunately the initial attempt to place the pacemarker was unsuccessful and the decision was made to place your pacemarker surgically. You did well after the surgery. . At time of discharge it was determined that you would benefit greatly to participating in a cardiac rehab program to optimize your cardiac function after hospitalization. . CHANGES TO YOUR MEDICATIONS Stay taking metalozone every tuesday and FRIDAY. . No other changes were made to your medication. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2114-2-13**] at 3:00 PM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2114-3-12**] at 11:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2114-3-12**] at 2:00 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: FRIDAY [**2114-4-6**] at 3:20 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2114-2-7**] at 10:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Completed by:[**2114-2-1**]

[ "784.7", "V58.61", "272.4", "428.23", "403.90", "276.2", "427.81", "V58.67", "V53.31", "285.21", "427.31", "585.9", "438.89", "584.9", "438.6", "280.0", "428.0", "327.23", "V45.81", "V45.82", "585.4", "250.00", "781.2" ]

icd9cm

[ [ [] ] ]

[ "88.51", "00.50", "38.94", "04.81", "99.23", "04.89" ]

icd9pcs

[ [ [] ] ]

17223, 17289

10556, 14138

302, 324

17425, 17425

6840, 6840

18236, 19822

4442, 4595

14807, 17200

17310, 17404

14164, 14784

17543, 18213

4610, 5701

3267, 3855

7247, 10533

2660, 3159

243, 264

352, 2641

6855, 7234

17440, 17519

3886, 4217

3181, 3247

4233, 4426