ChanBeDu/relevant_section_length · Datasets at Hugging Face

80,260

102,326

15739

Discharge summary

report

Admission Date: [**2164-1-23**] Discharge Date: [**2164-1-26**] Date of Birth: [**2120-8-12**] Sex: F Service: MEDICINE Allergies: Topiramate / Aripiprazole / Shellfish / Bee Pollen Attending:[**First Name3 (LF) 10593**] Chief Complaint: melena Major Surgical or Invasive Procedure: Upper endoscopy with enteroscope History of Present Illness: Ms. [**Known lastname 45209**] is a 43F with a history of alcoholic cirrhosis s/p TIPS, active alcoholism, and prior UGIB attributed to duodenal varix who presents with melena. . She had had a recent admission to the MICU Green with melena, requiring several units of blood, and ultimately underwent an IR guided duodenal varix coiling, balloon dilation of TIPS, and stenting of the Rt hepatic vein, reducing portosystemic pressure from 15 mg to 10 mg. During her most recent admission the pt was tachycardic, hypotensive and required multiple blood transfusions and underwent EGD that showed only mild portal gastropathy and colonoscopy that showed a large volume of blood in the colon and grade 1 external/internal hemorrhoids. She subsequently underwent CTA that showed duodenal varicies that were embolized. She was discharged from the EPT service on [**2164-1-16**], after having received a total total of 11 U pRBC, 2 U plt, 1 U FFP, 2 U Cryo. She endorses tarry stools for the past month. She also endorses [**2-23**] black starry stools a day, with Nausea, but without any vomiting or hematemesis. She also endorses some urinary frequency. . . In the ED, initial VS were 98.6 118 123/61 14 98% room air. She was started on Pantoprazole gtt, octreotide gtt, and Ceftriaxone 1 g IV. her labs were notable for Ca 8.3, AP 123, Tbili 4.1, AST: 69, Alb: 3.0, and a Serum [**Month/Day (1) **] 335. Hepatology consult was called, and the patient was started on pantoprazole and octreotide gtt and received one dose of ceftriaxone. She also received 1 L NS. . On transfer, her vitals were 98.4 97 18 114/64 96% RA. She had a 16 G and an 18G placed. . On arrival to the MICU, she is pleasant, talkative, and without acute complaint. Past Medical History: - Alcoholic cirrhosis s/p TIPS [**9-/2162**] - s/p cholecystectomy [**2153**] - Gastroesophageal reflux disease - Bipolar disorder - Hypertension - Depression/anxiety - Recent burns to both hands [**11/2163**] (housefire) s/p skin grafting from R thigh Social History: Lives with husband and two teenage children in [**Name (NI) 1110**]. Actively drinking alcohol; when she does not drink she gets tremulous in her hands, but no history of DTs/seizure. Active smoker and no history of IVDU per OMR records. Family History: N-C Physical Exam: ADMISSION PHYSICAL EXAM: General: Alert, oriented, no acute distress. Appears tanned. Smells of [**Name (NI) **]. HEENT: MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP flat, no LAD CV: Regular rate and rhythm (borderline tachycardic), normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: Warm, well perfused, 2+ pulses, 1+ edema B Neuro: Mild tremor Skin: Grafting to the first and second digits of the hands bilaterally. DISCHARGE PHYSICAL EXAM: Vitals: 98.8 (Tm 99.3) 122/74 (SBP 110-120s) 76 16 100%RA General: Alert, oriented, no acute distress. HEENT: MMM, oropharynx clear, EOMI, PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: Warm, well perfused, 2+ pulses, 1+ edema B Neuro: Mild fine tremor Skin: Grafting to the first and second digits of the hands bilaterally. bruising of L arm. Pertinent Results: Admission labs: [**2164-1-23**] 09:40PM GLUCOSE-108* UREA N-6 CREAT-0.5 SODIUM-138 POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-23 ANION GAP-13 [**2164-1-23**] 09:40PM ALT(SGPT)-28 AST(SGOT)-69* ALK PHOS-123* TOT BILI-4.1* [**2164-1-23**] 09:40PM LIPASE-47 [**2164-1-23**] 09:40PM cTropnT-<0.01 [**2164-1-23**] 09:40PM ALBUMIN-3.0* CALCIUM-8.3* PHOSPHATE-3.7 MAGNESIUM-1.7 [**2164-1-23**] 09:40PM ASA-NEG ETHANOL-335* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2164-1-23**] 09:40PM WBC-2.6* RBC-3.12* HGB-9.4* HCT-26.9* MCV-86 MCH-30.1 MCHC-35.0 RDW-19.6* [**2164-1-23**] 09:40PM NEUTS-52.5 LYMPHS-33.8 MONOS-10.5 EOS-1.5 BASOS-1.7 [**2164-1-23**] 09:40PM PLT SMR-LOW PLT COUNT-90* [**2164-1-23**] 09:40PM PT-15.8* PTT-37.7* INR(PT)-1.5* Hct trend: [**2164-1-24**] 01:06AM BLOOD Hct-24.6* [**2164-1-24**] 05:44AM BLOOD WBC-2.2* RBC-2.80* Hgb-8.8* Hct-24.3* MCV-87 MCH-31.3 MCHC-36.0* RDW-20.0* Plt Ct-78* [**2164-1-24**] 09:51AM BLOOD Hct-26.3* [**2164-1-25**] 06:19AM BLOOD WBC-1.6* RBC-2.87* Hgb-8.8* Hct-25.6* MCV-89 MCH-30.8 MCHC-34.6 RDW-19.9* Plt Ct-69* Pertinent Interval Labs: [**2164-1-25**] 06:19AM BLOOD PT-17.1* PTT-34.6 INR(PT)-1.6* [**2164-1-24**] 05:44AM BLOOD Glucose-81 UreaN-6 Creat-0.5 Na-136 K-5.0 Cl-107 HCO3-21* AnGap-13 [**2164-1-26**] 09:25AM BLOOD Glucose-87 UreaN-5* Creat-0.5 Na-135 K-3.2* Cl-104 HCO3-23 AnGap-11 [**2164-1-24**] 05:44AM BLOOD ALT-31 AST-95* LD(LDH)-430* AlkPhos-100 TotBili-3.5* [**2164-1-26**] 09:25AM BLOOD ALT-26 AST-52* LD(LDH)-210 AlkPhos-110* TotBili-3.5* [**2164-1-25**] 06:19AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.5* [**2164-1-26**] 09:25AM BLOOD Albumin-2.6* Calcium-8.0* Phos-3.3 Mg-1.4* EGD: Impression: Normal mucosa in the whole Esophagus No evidence of varices, active bleeding, ulcers or rings Mosaic appearance in the fundus and stomach body compatible with Mild portal non bleeding gastropathy Diverticulum in the fundus No evidence of varices, ulcers, masses or active bleeding Varices at the third part of the duodenum (injection) No evidence of active bleeding Otherwise normal EGD to third part of the duodenum RUQ U/S: IMPRESSION: Patent TIPS. Brief Hospital Course: =================== Brief Patient Summary =================== 43F with a history of alcoholic cirrhosis (still actively drinking), history of prior UGIB though now s/p TIPS and duodenal varix embolization, presents with melena. The patient was monitored briefly in the ICU, intubated for airway protection and EGD, was hemodynamically stable, called out to the medical floor, and discharged home, not requiring transfusions. =================== ACTIVE ISSUES =================== # Gastrointestinal bleeding: Patient endorses melanotic stool. She has known duodenal varices prior embolization. EGD on [**1-24**] showed a large duodenal varix which was injected with glue. She was treated with octreotide and PPI. She did not require transfusion. She got 80mg pantoprazole, followed by 8mg/hr. Got IV Octreotide gtt. Received Ceftriaxone 1 g Q24H with plan for 7 days of antibiotics. RUQ U/S showed a patent TIPS. . # PANCYTOPENIA: Likely secondary to liver cirrhosis. Plts and WBC count are comparable to prior values; Hct baseline is upper 20s-lower 30s as above. This was stable. . # ALCOHOLIC CIRRHOSIS: TIPS, portal vein are patent. Current MELD is 16 and Child-[**Doctor Last Name 14477**] class B-C (at limit depending on how ascites s/p TIPS are considered). She remains an active drinker. Followed by Dr. [**Last Name (STitle) 497**] though no recent visit in our system. Transaminases, alk phos are roughly at her baseline; Tbili and INR are higher than prior baseline. Continued Rifaximin 550 mg [**Hospital1 **], lactulose, Folic acid 1 mg Daily, Thiamine HCl 100 mg Daily, Multivitamin Daily. . # ACTIVE ALCOHOLISM: Active drinker, no known history of DTs/seizure. Blood alcohol 335 on arrival to ED. Kept on CIWA scale, but did not require benzodiazepenes. We urged the patient that she needs treatment for her alcoholism, or it will continue to cause her medical problems and likely lead to her death. . ==================== TRANSITIONAL ISSUES ==================== 1. F/U w/ Dr. [**Last Name (STitle) 497**] in [**Hospital **] clinic 2. continue Ciprofloxacin: final day [**1-30**] Medications on Admission: Furosemide 60 mg Daily Lactulose 30 ml PO QID Rifaximin 550 mg [**Hospital1 **] Folic acid 1 mg Daily Thiamine HCl 100 mg Daily Multivitamin Daily Spironolactone 150 mg [**Hospital1 **] Omeprazole 40 mg Daily Lorazepam 0.5 mg Q8H PRN anxiety Discharge Medications: 1. furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). 3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. spironolactone 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety: do not drive or drink alcohol while taking this medication. 10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days: final day [**1-30**]. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: primary diagnoses: melena secondary to duodenal varices alcoholic hepatitis alcoholism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname 45209**], You were admitted to the [**Hospital1 69**] for black, bloody stools. This was from blood vessels in the first part of your small bowel that are bleeding. You had an endoscopy where the gastroenterologist attempted to control this source of bleeding. This bleeding is from portal hypertension, which is caused by your alcohol consumption. It is of the utmost importance that you stop drinking alcohol, as continuing alcohol will cause more damage to your body, and puts you at much increased risk for death within the next year. ADD: ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days: final day [**1-30**]. Followup Instructions: Department: LIVER CENTER When: FRIDAY [**2164-5-4**] at 3:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2195-4-20**] Discharge Date: [**2195-6-23**] Date of Birth: [**2142-7-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: Esophageal cancer Major Surgical or Invasive Procedure: 1. Ileocolostomy/J-Tube 2. Transhiatal esophagectomy 3. Resection conduit 4. Abdominal closure History of Present Illness: Mr [**Known lastname 60925**] is a 52 year-old gentleman with an extensive history of PVD who was scheduled for RLE bypass with Dr. [**Last Name (STitle) **] on [**2194-10-27**]. However, pre-op evaluation revealed a decrease from his baseline HCT of 40 to 31. Colonoscopy and EGD were performed and EGD/bx revealed an esophageal mass biopsied as poor to moderately differentiated SCC. PET CT ruled out metastatic disease. It was 5 cm (34-39 cm from incisors) and was staged as T3N1. He just finished neoadjuvant chemo rad (2 weeks of chemo, 25 days of radTx). Has occasional odynophagia but states that he is taking both liquids and solids and that he tolerates both without any of the food getting stuck in the esophagus. No fevers, chills, nausea or vomiting. Here for pre operative angiographic evaluation which will determine whether surgery is feasible. Past Medical History: Aorto-bifemoral bypass [**8-19**] MI HTN R CEA ([**7-19**]) Knee athroscopy Whipple operation ([**Doctor Last Name 468**]) in [**2192**] for benign pancreatic mass Possible history of SFA angioplasty Social History: Pt lives with family. He works on an assembly line at a brickyard. He formerly smoked 2 PPD x 40 years. He quit 1 month ago. Family History: Father with liver cirrhosis from ETOH use Physical Exam: VS: T; 99.0 HR: 96 SR BP: 98/57 Sats: 96% RA General: NAD HEENT: normocephalic, mucus membranes dry Neck: spit fisutal Card: RRR, normal S1, S2 Resp; decreased breath sounds otherwise clear GI; bowel sounds positive. Wound: abdomen with VAC dressing in place Neuro: awake, alert, with short term memory loss Pertinent Results: [**2195-6-22**] WBC-7.8 RBC-3.19* Hgb-9.1* Hct-27.8* Plt Ct-333 [**2195-6-12**] WBC-7.2 RBC-2.91* Hgb-8.1* Hct-25.2* Plt Ct-360 [**2195-6-22**] Glucose-89 UreaN-20 Creat-0.3* Na-135 K-4.1 Cl-105 HCO3-23 [**2195-6-22**] ALT-45* AST-39 AlkPhos-222* TotBili-0.3 [**2195-6-22**] Albumin-2.9* Calcium-9.0 Phos-3.8 Mg-1.7 Iron-PND [**2195-6-17**] calTIBC-211* Ferritn-544* TRF-162* [**2195-6-12**] Glucose-69* UreaN-20 Creat-0.3* Na-138 K-4.3 Cl-106 HCO3-25 [**2195-6-8**] ALT-34 AST-34 AlkPhos-259* TotBili-0.4 [**2195-6-12**] Albumin-2.7* Calcium-8.9 Phos-3.9 Mg-1.7 Iron-PND CTA ([**5-21**]):1. No evidence of pulmonary embolism. 2. Interval worsening of multifocal pneumonia with partial right middle lobe atelectasis. 3. New mild pulmonary edema. 4. Stable small loculated left pleural effusion and resolution of right pleural effusion after bilateral chest tube removal. CT head ([**5-13**]): 1. No evidence of acute hemorrhage or shift. 2. Bilateral mastoid air cell opacification, unchanged. CT chest ([**5-9**]): 1. Improved aeration to right middle lobe and right lower lobe, however, there is worsening multifocal predominantly ground-glass opacities involving the left lower lobe, right middle lobe, and portions of the right upper lobe. In this patient with secretions within the trachea and proximal bronchi, it is most worrisome for underlying aspiration pneumonitis/or worsening pneumonia. Non infectious etiolgies for this appearance include pulmonary edema or hemorrhage. Small residual right-sided pneumothorax. 2. Small bilateral effusions. 3. Overall decrease in the amount of intra-abdominal free fluid, with slightly increased organization of collection inferior to the porta hepatis. This collection is also decreased in size. CT head([**5-9**]): 1. No acute intracranial process, including no hemorrhage, edema, or mass effect. 2. Opacification of mastoid air cells, and dependent secretions in the sphenoid sinuses. These findings can be seen in patients with prolonged intubation. CT neck ([**5-1**]): 1. Mild fat stranding is identified anterior to the left carotid space, no frank evidence of fluid collection or drainable lesion. Prominent lymph nodes are noted on the left at the level 1B. 2. Unchanged catheter entering in the left lower neck, the distal tip is not identified in this examination. 3. Unchanged right lower and middle lobe consolidations, right chest tube is in place. CTA chest/CT abd/pelvis ([**4-30**]): 1. No PE. 2. Abdominal fluid is within the spectrum of postsurgical change. There is no evidence of leak or abscess. 3. Right lung pneumonia Brief Hospital Course: [**4-22**]: esophagectomy w/ R colonic interposition, left in discontinuity for delayed anastamosis; on arrival to SICU: hypotensive then bradycardic -> V-tach -> V-fib -> shocked x 2 -> regained sinus; required IVF, pressors [**4-23**]: return to OR for anastomosis, ARDS, paralyzed on Cis, HIT panel sent for thrombocytopenia [**4-24**]: increased vent requirements & PEAK/PLATEAU ratio, worsening R pleural effusion, neo @ 0.5, Lasix gtt, fent gtt, midaz gtt, cisatra gtt, hypoxic episode overnight (85% x30 min), started empiric abx [**4-25**]: return to OR for spit fistula, resection of colonic interposition, drains x2, G tube, abd left open; neo 0.6, cis gtt, midaz, fent gtts [**4-26**]: Lasix gtt, weaned vent RR & PEEP, 1U PRBC for Hct 25.8, weaned cisatra gtt [**4-27**]: diuresed neg 3.5L, TPN started, remained on neo [**4-28**]: to OR, L axillary a-line placed, off pressors [**4-29**]: diuresed, tachycardic/tachypneic, leukocytosis [**4-30**]: labile BP, intermittent neo gtt, CT abd/pelvis, albumin x 1 for hypotension, inc leukocytosis [**5-1**] bronch: b/l mucus plugging, Neo restarted, ST depression in V4 p bronch, troponins stable, transient inc in FiO2 and PEEP [**5-2**]: tolerated CPAP/PS, Lasix gtt increased, midaz and neo weaned [**5-4**]: vent weaned, re-bronched, prn pain meds, Vanc/Cipro d/c'd [**5-7**]: T101.6 -> cx, diuresed, desaturated w/ SBT -> CPAP/PS [**5-9**]: confused, CT head/sinus/torso, stool per midline abd wound, 1U PRBCs [**5-10**]: CVL replaced, TPN started, L chest tube d/c'd [**5-11**]: increased volume in TPN for hyperNa, D5W @ 60 -> 100 -> 60, CT d/c'd, started octreotide [**5-12**]: uneven pupils, CT head negative. [**5-13**]: d/c'd vanco, inc NaCl in TPN [**5-14**]: added [**Last Name (un) 2830**] [**5-15**]: decreased RISS for hypoglycemia [**5-16**]: started G TF@10->20, fluc [**5-17**]: d/c'd octreotide, adv TF to goal, stopped TF due to fistula abd draining stool. [**5-18**]: [**1-16**] TPN, Roxicet, d/c Dilaudid, stool coming out of fistula, d/c'd tube feeds, restarted octreotide [**5-19**]: full TPN, d/c'd Roxicet, restarted Dilaudid IV, pulled back drain [**5-20**]: [**Month (only) **] Lopressor to 5q6 [**5-21**]: drain pulled back, d/c'd abx per ID, sudden SOB/tachy/EKG changes, CXR & CTA neg, self-resolved [**5-22**]: [**Last Name (un) 2830**] restarted (x14days per ID), mediastinal drain pulled back [**5-23**]: d/c'd Dilaudid, inc'd insulin in TPN, Lasix 10 [**5-24**]: Lasix 10x2 [**5-25**]: pulled back JP, had NSVT ~10 beats, lytes OK [**5-26**]: PICC placed, d/c'd CVL, mediastinal tube backed up [**5-27**]: d/c'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2830**] [**5-28**]: Transfered to the floor [**5-30**] Mediastinal tube removed [**6-9**] [**Hospital1 **] dsg changes wet to dry, TPN, pulm toilet, octreotide, OOB ambulating with assist. [**6-10**] Derm consult - lesions on hands likely callouses [**6-14**] TF increased to 20qh, slight increase stool output in fistula - [**6-15**] TF stopped again for increase in fistula output. [**6-16**] TPN daily dressing changes increasing activity. Following nutrition labs [**6-17**] Wound debreidment vac dressing applyed to wound 17.5 x 3cm and 1.5 cm deep. [**6-18**] Weak continues on TPN [**6-19**] TPN continues Wound vac dressing changed [**6-20**] TPN 2 grams of protein/day [**6-21**] TPN OOB to chair ambulating in [****] TPN continues 2.2 liters 350 grams of dextrose/130 grams of amino acid/50 g lipid Last albumin 2.9 last wt 53.3 kg -TPN proved\es 2210 calories 130 grams of protein (42 calories/kg). Fistula on neck with drainage bag [**6-22**] J-tube changed and re-sutured Medications on Admission: Diovan 160 mg qd Atenolol 50 mg qd Simvasttin 40 mg qd MVI 1 tab PO qd Discharge Medications: 1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 3. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: 0.5 mL Subcutaneous DAILY (Daily). 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours) as needed. 5. Metoprolol Tartrate 5 mg/5 mL Solution Sig: Five (5) mL Intravenous Q6H (every 6 hours): hold HR < 60 SBP < 100. 6. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL PO Q6H (every 6 hours) as needed for fever; temp> 101.4. 7. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush: Flush PICC line per protocol. 8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed for itching. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Esophageal Cancer Discharge Condition: Stable Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] with questions or concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] appointment on [**7-3**] in the Chest and Disease Clinic at 9:30 am on the [**Location (un) 448**] of the [**Hospital Ward Name 121**] building. Please report 45 minutes early for a chest x/ray prior to your appointment on the [**Location (un) 470**] of the clinical center. Completed by:[**2195-6-30**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2130-8-5**] Discharge Date: [**2130-8-31**] Date of Birth: [**2048-11-28**] Sex: F Service: SURGERY Allergies: Erythromycin Base / Lipitor / Actonel / Lisinopril / Simvastatin / Zetia Attending:[**First Name3 (LF) 473**] Chief Complaint: chest pain, cough Major Surgical or Invasive Procedure: [**8-7**]- cardiac catheterization with balloon angioplasty [**8-12**]- subtotal colectomy, end ileostomy [**8-23**] - R chest pigtail catheter placement [**8-28**]- tracheostomy and PEG placement History of Present Illness: 81 year-old female with DM, HTN, HLD, who presents with chest pain that began the night prior to admission [**8-4**]. She states that she has been having a cough that began the day before she was discharged from her last hospitalization on [**7-13**], that has lingered since that time. In the interim she has been using her albuterol and flovent inhalers, was prescribed a prednisone taper about 2 weeks ago from her pulmonologist and was tried on both azithromycin and levaquin, both of which upset her stomach, she took 2 days of azithromycin and 4 of 5 days of levaquin. During this time she says that she had an increase in the frequency of her sputum and the sputum that had previously been white changed to yellow. Denies any fever/chills, shortness of breath, nausea/vomiting/diarrhea, associated. The night prior to admission, she was sleeping, woke up coughing and then experienced a sharp chest pain that radiated to her back, and worsened with deep inspiration. She has never had pain like this before and she pressed her life line, the ambulance came and there was initial concern for an STEMI. In the ambulance she received ASA and oxygen with resolution of her chest pain. On arrival to the ER it was felt that she was not having an STEMI, she had a CTA that showed no PE or dissection. She was found to have an elevated WBC, and consolidations seen on CT so she was given a dose of levaquin. Past Medical History: PMHx: NSTEMI ([**2130-8-6**]), DM2, HTN, asthma, PR, osteoporosis, right eye blindness [**Doctor First Name **] Hx: Hysteroscopy/D&C [**2120**], s/p excision of benign left breast lesion, repair of left radial fracture [**2120**], cardiac cath [**2127**] and [**2129**] Social History: patient is widowed, currently lives alone, no children, her sister and brother-in-law live in 30 min away. no etoh, no smoking history, but did work with excessive second hand smoke for years, no illicit drug use Family History: Father had [**Name2 (NI) 499**] CA Physical Exam: T 98.4 HR 91 BP 114-121/ 50-63 RR 16-18 SaO2 95-97 % RA GEN: thin, elderly female sitting up in bed in NAD HEENT: EOMI, PERLLA, MMM, o/p clear CV: RRR normal S1,S2 no murmurs. JVP flat. LUNGS: decreased bs bilateral bases, but clear, no wheeze or ronchi ABD: +BS, soft, NT ND no appreciable HSM EXT: no edema, 2+ DP, PT pulses B/L NEURO: A&Ox3, strength 5/5 B/L UE and LE Pertinent Results: [**2130-8-5**] 02:36AM BLOOD cTropnT-<0.01 [**2130-8-5**] 12:40PM BLOOD CK-MB-18* MB Indx-14.0* cTropnT-0.13* [**2130-8-5**] 09:36PM BLOOD CK-MB-13* MB Indx-11.0* cTropnT-0.14* [**2130-8-6**] 07:30AM BLOOD CK-MB-9 cTropnT-0.13* [**2130-8-5**] 02:36AM BLOOD WBC-21.6* RBC-4.57 Hgb-13.8 Hct-42.0 MCV-92 MCH-30.3 MCHC-33.0 RDW-13.4 Plt Ct-279 [**2130-8-8**] 06:35AM BLOOD WBC-10.0 RBC-3.79* Hgb-11.2* Hct-34.6* MCV-91 MCH-29.5 MCHC-32.2 RDW-12.9 Plt Ct-231 [**8-7**] Cardiac Catheterization: 1. Coronary angiography in this right dominant system revealed single vessel disease. The LMCA had no angiographically apparent disease. The LAD and LCX had no areas of stenosis. The RCA had a complex 90% stenosis in the mid-portion. 2. Resting hemodynamics revealed mild systolic hypertension with SBP 148 mmHg, and a widened pulse pressure with a DBP of 60 mmHg. Brief Hospital Course: 81 year-old female presented on [**8-5**] with chest pain and PNA. She was started on levaquin for her PNA and she underwent cardiology evaluation for elevated troponins and EKG changes. She was diagnosed with NSTEMI. Therefore, she underwent cardiac catheterization and balloon angioplasty of her RCA on [**2130-8-7**]. Patient's post-cath course includes being placed on a heparin gtt for atrial fibrillation and stable conservative management of a right groin hematoma. On post-catheterization day #5, the patient went into rapid atrial fibrillation in the early AM. Her HR was in the 150s and SBP in low 80s. Her heart rate was converted back to sinus with Digoxin and her SBP was now in 100s. However, 30 minutes after the patient went into Afib, she complained of severe abdominal pain in her right lower quadrant. General surgery consult was called a little later that morning, as there was concern that the patient displayed peritoneal signs. The general surgery team evaluated the patient 20 minutes after administration of prochlorperazine for nausea, and thus she was slightly sedated. However, she did complain of abdominal pain in mid-abdomen. She had not been passing flatus for the previous 36 hours, and she had one episode of vomiting earlier in the AM. A CT scan of the abdomen/pelvis was ordered on the patient and showed right [**Date Range 499**] and cecum with pneumatosis, areas of portal venous gas seen in liver, and air in veins running through iliac fossa that were likely branches of the portal vein. The patient and her family members were immediately contact[**Name (NI) **] with the gravity of the diagnosis - the patient likely had ischemic injury to her [**Name (NI) 499**] either from a thrombus to a branch of the SMA or she had ischemic [**Name (NI) 499**] from a low flow state that was a consequence of her atrial fibrillation. After thorough discussion between Dr. [**Last Name (STitle) 468**], the patient, and her family members reviewing all the risks and benefits of surgery, the patient was taken emergently to the operating room. Patient underwent exploratory laparotomy on [**2130-8-12**]. Findings included toxic megacolon and ischemic injury extending from the right [**Date Range 499**] through the transverse [**Date Range 499**]. The patient underwent a subtotal colectomy and end ileostomy. Because the patient's case occurred late in the evening on [**8-12**], she was kept intubated postoperatively. The patient's early postoperative course was marked by rapid atrial fibrillation with RVR. During the first 24 hours postoperative, she dropped her pressures to systolic of 50 and required cardioversion and adenosine injections. She was started on an esmolol gtt to control her atrial fibrillation, and this was then changed over to an amiodarone gtt. The patient was transfused one unit of packed red blood cells and was temporarily placed on a dobutamine gtt. The patient was evaluated by cardiology, who recommended that she placed back onto an amiodarone gtt. The patient underwent an ECHO cardiogram on POD 2 that revealed normal LV and RV function and an EF of 55-60%. The patient also had a leukocytosis and an elevation of her LFTs from POD4 through POD7. Concern was raised as to whether the patient could have acute cholecystitis. However, she underwent a right upper quadrant ultrasound on POD5 that showed patient had no evidence of acute cholecystitis, and rather she may have an element of shock liver. The patient's LFTs and WBC eventually normalized. The patient was on and off neosynephrine gtt during this time period, however this was thought to be due to her slightly lower blood pressure as a consequence of propofol - the patient was intubated during this time period and remained on propofol. She was started on tube feeds and this was tolerated to goal. Once the patient's leukocytosis and LFTs improved, the patient was extubated on POD 10. She had slight tachypnea. She was given lasix to remove excess fluid. However, the patient tired out on POD11 and she was re-intubated. CXR post-intubated showed a large right pleural effusion. The patient underwent thoracentesis by the SICU service and 900 cc of transudative pleural fluid was removed. However, post-thoracentesis CXR showed a right basilar pneumothorax. Patient therefore had a right pigtail tube placed in the right chest by IP. Between POD 11 and POD 16, the patient remained intubated and still on-and-off the neosynephrine gtt. After careful discussion with the patient's family regarding the patient's unlikelihood of weaning off the vent, the family consented to having the patient undergo a tracheostomy and PEG placement. The patient underwent PEG and trach on [**2130-8-28**]. The pigtail was removed on POD16 ([**2130-8-28**]). The patient did very well with tracheostomy in place and was able to wean off the vent and onto trach mask by POD 17. The patient was also able to tolerate TF at goal on the PEG. The patient was evaluated once more cardiology on the day before discharge. As she had been off the neosynephrine gtt since POD15, they recommended the patient remain on enteral amiodarone and lopressor for control of her heart rate/rhythm. Furthermore, the patient had remained on a heparin gtt from POD2 through POD 19 for her atrial fibrillation. She was started on coumadin (3 mg qday) on POD17. At the time of discharge, the patient was tolerating trach mask and was off of pressors for greater than 72 hours. She was awake and following commands. She was tolerating goal tube feeds. The heparin gtt was discontinued on POD19 (the day of discharge) and patient was discharged on lovenox bridge. The patient was stable at the time of discharge. Medications on Admission: MFlovent 110mcg 1puff [**Hospital1 **] Glyburide 1.25mg Plavix 75mg-patient stopped secondary to hemoptysis Hydralazine 50mg [**Hospital1 **] Metoprolol 75mg TID Boniva 150mg Every 4th of the month ASA 81mg Fish Oil 1000mg [**Hospital1 **] Red Yeast Rice Extract 600mg TID Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): Administer via G tube. 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Administer via G tube. 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. Disp:*50 ML(s)* Refills:*0* 7. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for Pain. 8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain: via g tube. 9. Warfarin 1 mg Tablet Sig: Three (3) tablets PO DAILY (Daily): via G tube. Check INR daily. Keep INR [**1-17**]. 10. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous twice a day: continue until INR>2. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: threatened STEMI w/ autolysis; toxic megacolon s/p subtotal colectomy and end ileostomy; asthma exacerbation, failure to wean from vent Discharge Condition: stable, working with PT, tolerating TF at goal, tolerating trach mask Discharge Instructions: It was a pleasure being involved in your care, Ms. [**Known lastname **]. You were admitted to [**Hospital1 18**] due to chest pain and were found to have a heart attack, for which you received a cardiac catheterization and balloon angioplasty of a completely occluded vessel. This means the chest pain you were having was due to a blockage in one of the small arteries that supplies your heart. You also had a cough with suspicion for pneumonia so you were started on antibiotics, nebulizers and cough medicine to help your breathing. You were then found to have ischemic [**Hospital1 499**] and required an exploratory laparotomy. You underwent subtotal colectomy with end ileostomy. You spent the remainder of your hospital stay in the ICU due to a heart arrhythmia and inability to wean off the vent. You underwent a gastrostomy feeding tube placement and tracheostomy on [**2130-8-28**]. Continue tube feeds at goal. Stay NPO otherwise. Please continue to take your other medications as listed. Please call your doctor or 911 if you have any further chest pain, difficulty breathing, intractable nausea/vomiting, blood in your urine vomit or stool, fever, chills, signs of wound infection, or any other concerning symptoms. Followup Instructions: 1) Please follow-up with your Pulmonologist Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13293**] in 3 weeks at the [**Hospital6 **]. Please phone [**Telephone/Fax (1) 108553**] to schedule an appointment. 2) Follow-up with your primary care doctor in [**1-17**] weeks. Call Dr. [**First Name (STitle) 9054**] [**Name (STitle) **] [**Doctor Last Name 6481**] at [**Telephone/Fax (1) 4775**] to schedule an appointment. 3) Also, please follow up with your Cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Wednesday in 2 weeks. Call [**Telephone/Fax (1) 8645**] to schedule the appointment.

[ "241.1", "998.12", "785.50", "250.00", "518.81", "E879.0", "518.89", "570", "427.31", "512.1", "557.0", "584.5", "414.01", "493.92", "733.00", "556.9", "511.9", "427.32", "410.71", "272.4", "486", "263.9", "401.9" ]

icd9cm

[ [ [] ] ]

[ "34.04", "31.1", "00.66", "96.72", "33.24", "37.22", "96.6", "38.93", "88.55", "43.11", "99.20", "99.15", "45.79", "96.04", "34.91", "46.21", "00.40", "88.52", "45.13" ]

icd9pcs

[ [ [] ] ]

11065, 11144

3865, 9622

349, 549

11325, 11397

2979, 3842

12681, 13335

2534, 2570

9945, 11042

11165, 11304

9648, 9922

11421, 12658

2585, 2960

292, 311

577, 1993

2015, 2288

2304, 2518

28,109

179,667

1724

Discharge summary

report

Admission Date: [**2155-5-25**] Discharge Date: [**2155-5-28**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: fever, respiratory distress, A-fib with RVR Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yr old male with past medical hx significant for recurrent C-diff and urosepsis, CVA non-verbal with primary progressive aphasia minimally responsive at baseline presenting with volume depletion, respiratory distress and fever. Of note patient was hospice care. . Recent admit [**Date range (1) 6078**] with fever, diarrhea with urosepsis went to [**Hospital1 1501**]. Per report patient appeared lethargic on thursday. MD ordered labs with increasing WBC and low grade fever. Restarted PO vanc for C-diff at that time per daughter [**Hospital1 **] oral vanc via G tube. Appears to have completed course on [**Hospital 2974**] hospice nurse presented to facility and noted patient to be in respiratory distress, tachypneic, lethargic. She felt the patient would not survive the day. G tube was also noted to be clogged and he couldnt get his PO meds or hydration. Patient made comfort measures but daughter emotionally unwell with idea of "starving and withholding IV fluids. Over the course of the night patient looked uncomfortable and did not expire, distressing to the daughter. Attempted IV for hydration but [**Hospital1 1501**] unable to place. Daughter decided to take her father to the [**Name (NI) **] initially for IV hydration. . In the ED, initial vs were: T 101 P 68 BP 122/58 R 12 O2 sat 100%. CXR with no consolidation, EKG A-fibb with RVR 140's. Patient was given morphine 2 mg, flagyl 500 mg IV, vancomycin 1 gram, metoprolol 5 mg IV and zosyn. Lactate 2.8. WBC 16.9 N 61, no bands. HCT 30.9 (baseline 20's). Na 152, Cr 1.9(baseline 0.9-1.1) In discussion with family decided want for IV hydration and abx. She not want any cardiac enzymes or LFT's. Per discussion it would be ok to give usual lopressor but no pressors if unstable. Can give IV fluids. Continue DNR/DNI. On 6L 02. HR 120's. Systolic 95-105. Family is ok with the tachycardia to 120's. 3L NS given. Family wanted limited [**Name (NI) **] draws to once daily. Family decided if G tube clogged to not replace. Ordered vanc IV did not receive and Zosyn which patient received one dose. Admitted to ICU given family still in discussion regarding goals of care and patient with heavy oxygen requirement, a-fibb with RVR. Past Medical History: - Anemia - BPH - Atrial Fibrillation - Benign Hypertension - History of hemorrhagic prostatitis ([**4-/2154**]) - History of Stroke With Late Effects - primary progressive aphasia and dysphagia s/p G tube - Glaucoma - History of MRSA bacteremia - History of Enterococcal bacteremia - History of Fungemia - History of Recurrent UTIs, urosepsis - History of C. diff - History of Obturator Internis abscess Social History: The patient is currently a resident at [**Location (un) 169**] [**Hospital1 1501**]. He has been hospitalized multiple times over the last few months, is generally described as minimally communicative at baseline. The patient is fully dependent for all ADL. Was to go home with hospice but family discussion prior to this patient decided to be brought in to ED for IV hydration only, then change to IV abx but other specific orders as per daughter in regards to management and avoidance of aggressive care. No smoking, no alcohol, no illicit drug use. Aphasic. Pt was on hospice Family History: Non-Contributory Physical Exam: Vitals: HR 140, 106/68, 87% 6L when agitated, RR 32 temp 101.2 General: cachectic ill appearing elderly male tachypneic [**Hospital1 4459**]: Sclera anicteric, MM dry Lungs: poor inspiratory effort, decreased bases. No crackles CV: tachycardic, irregular Abdomen: soft, non-tender based on lack of grimace, non-distended, bowel sounds hypoactive. G tube with small drainage at sides. Able to flush without draw back. Ext: Warm, well perfused, cachectic Skin: no mottling, sacral decub ulcer Neuro: Aphasic, tonic jerks, does not respond to external stimuli. Responsive to sternal rub. Contracted upper and lower extremities, no posturing. Pertinent Results: [**2155-5-25**] 01:15PM [**Year/Month/Day 3143**] WBC-16.9*# RBC-3.30* Hgb-9.9* Hct-30.9* MCV-94 MCH-30.1 MCHC-32.2 RDW-15.9* Plt Ct-277 [**2155-5-26**] 08:12AM [**Year/Month/Day 3143**] WBC-13.3* RBC-2.89* Hgb-8.3* Hct-26.3* MCV-91 MCH-28.6 MCHC-31.4 RDW-15.7* Plt Ct-246 [**2155-5-25**] 01:15PM [**Year/Month/Day 3143**] Neuts-61.0 Lymphs-32.0 Monos-6.1 Eos-0.5 Baso-0.4 [**2155-5-26**] 08:12AM [**Year/Month/Day 3143**] PT-14.1* PTT-26.8 INR(PT)-1.2* [**2155-5-25**] 01:15PM [**Year/Month/Day 3143**] Glucose-89 UreaN-54* Creat-1.9* Na-152* K-4.5 Cl-116* HCO3-27 AnGap-14 [**2155-5-26**] 08:12AM [**Year/Month/Day 3143**] Glucose-118* UreaN-47* Creat-1.9* Na-146* K-4.0 Cl-117* HCO3-22 AnGap-11 [**2155-5-26**] 08:12AM [**Year/Month/Day 3143**] Calcium-8.0* Phos-3.3 Mg-2.4 [**2155-5-25**] 01:31PM [**Year/Month/Day 3143**] Lactate-2.8* [**2155-5-25**] 01:15PM URINE [**Year/Month/Day **]-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2155-5-25**] 01:15PM URINE RBC-0 WBC->50 Bacteri-FEW Yeast-NONE Epi-0 [**5-25**] Urine culture: contaminated [**5-25**] [**Month/Day (4) **] culture: GPCs in clusters -coag negative staph sensitive to gentamicin [**5-26**] C diff negative [**5-25**] Abdominal x-ray PFI: Gastrostomy tube projects over the left upper quadrant. There is new opacity seen in the left hemithorax, new since chest radiograph performed the same day several hours prior. This is incompletely visualized. Please see recent chest radiograph for further characterization. [**5-25**] G tube study: G tube in standard location. Left hemothorax opacity partly seen is unchanged [**5-26**] CXR New heterogeneous opacification in the left lung could be atelectasis alone, but there is new small-to-moderate left pleural effusion, unexplained. Right lung is clear. The heart is difficult to separate from adjacent pleural and parenchymal abnormalities in the left chest. Findings, including the likelihood of major aspiration, were discussed by telephone with Dr. [**Last Name (STitle) 9854**] at the time of dictation. Transvenous right ventricular pacer lead unchanged in standard placement. No pneumothorax. Brief Hospital Course: This is a [**Age over 90 **] year old male with multiple medical issues including progressive aphasia, C-diff colitis, recurrent urosepsis presenting with fever, lethargy, respiratory distress, volume depletion. 1. Leukocytosis/fever: Patient meeting criteria for sepsis. Possible source of infection in urine with + UA, C-diff in addition to meeting two SIRS criteria with temp and elevated WBC. Patient febrile and tachycardic on admission. CXR shows LLL pneumonia. Patient was started on IV Vancomycin and Zosyn for potential pneumonia and UTI coverage. On admission it was unclear if G tube was working, so he was empirically started on IV flagyl given history of recurrent C diff. Once it was clear that G tube was working, he was also started on po Vancomycin. 2. Respiratory distress: CXR shows LLL pneumonia. No evidence of fluid overload or pneumothorax. Unclear whether the patient may have aspirated. Stable on Fio2 35% face mask on admission. Continue Vanc/Zosyn for pneumonia. Patient was started on ipratropium nebulizers. Kept NPO given concern for aspiration. Patient's family did not want patient to have an ABG. . 3. Atrial Fibrillation with Rapid Ventricular Response: Patient presented with rates in 110s-150s. Pt is rate controlled as outpatient on diltiazem 90mg QID, and metoprolol 100mg TID. Patient did not receive BB and CCB for >24 hours. Also did not receive any hydration for >24 hours. Patient also with potential sepsis with fever. Given that G tube wasn't functional at time of admission, patient was given IV lopressor and IV fluid boluses to maintain adequate [**Age over 90 **] pressure and goal HR <120. Once G tube was functional, he was restarted on diltiazem via G tube. . 4. Acute on Chronic Renal Insufficiency: Cr baseline is 0.9 to 1.1. Patient was given IV fluids. Acute renal failure thought to be prerenal in etiology given poor po intake and sepsis. Family did not want further [**Age over 90 **] draws, so unable to follow creatinine. . # Hypernatremia: Free water deficit on admission was >3L. Patient was given 3L NS in ED. Given 2L D5W on admission to ICU. Family did not want further [**Age over 90 **] draws, so unable to assess how this resolved. . # G tube dysfunction: as per NH clogged. As per nurse here able to flush but not return therefore concern for placement. G tube study showed that tube was in correct location. Home medications were started via G tube, and patient received tube feeds while in the ICU. . # Code status/Disposition: Discussed at length goals of care with family. Patient was initially comfort measures only but daughter did not want father to be without basic hydration as was her main concern. Patient is now DNR/DNI without aggressive care. Antibiotics, IV fluids, BP meds were all discontinued on day 2 of admission. Labs were drawn on day 2 of admission, and then stopped. If deteriorates over the day or G tube non functioning will not replace and call to family and comfort measures only will be initiated. Palliative care consult placed. Patient received IV morphine and IV ativan for comfort. Patient died [**2155-5-28**] at 7:20am. Medications on Admission: Diltiazem HCl 90 mg Tablet QID Metoprolol Tartrate 100 mg TID Senna 8.6 mg [**Hospital1 **] Acetaminophen 160 mg/5 mL Solution Sig: [**11-11**] mL PO Q6H PRN Bisacodyl 5 mg Tablet Sig PRN Maalox 200-200-20 mg/5 mL Suspension Sig: 15-30 mL PO QID PRN Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS Dorzolamide-Timolol 2-0.5 % Drops Sig: one drop [**Hospital1 **] Donepezil 5 mg Tablet Sig QHS Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig 5 ml daily. Polyethylene Glycol 3350 100 % Powder Sig one packet daily Brimonidine 0.15 % Drops Sig one drop Q8 hours Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Cefepime 1 gram q 24 x 4 days ended [**5-7**] Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H for 18 days. Ended [**5-21**] Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1. Aspiration pneumonia 2. Urinary tract infection 3. Atrial fibrillation with rapid ventricular response 4. Acute renal failure Discharge Condition: Patient died [**2155-5-28**] at 7:20am Discharge Instructions: Patient died [**2155-5-28**] at 7:20am Followup Instructions: None [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2155-5-28**]

[ "V66.7", "599.0", "038.19", "285.9", "276.0", "518.82", "584.9", "995.92", "585.9", "E879.8", "536.42", "438.11", "787.20", "507.0", "438.82", "427.31" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

10535, 10544

6499, 9640

313, 319

10716, 10756

4306, 6476

10843, 11014

3612, 3630

10506, 10512

10565, 10695

9666, 10483

10780, 10820

3645, 4287

230, 275

347, 2570

2592, 2998

3014, 3596

3,740

130,253

23087

Discharge summary

report

Admission Date: [**2180-12-25**] Discharge Date: [**2181-1-1**] Service: MEDICINE Allergies: Zosyn / Cephalosporins / Vancomycin / Penicillins Attending:[**First Name3 (LF) 348**] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: s/p intubation History of Present Illness: 85 year old female with dementia (non-communicative at baseline), status post multiple prior aspiration penumonias, status post PEG placement in [**7-7**], and history of multiple UTIs presentd this admission as a transfer from [**Hospital3 18648**] in respiratory distress. She was in her usual state of health when her husband noticed gurgling and gasping during tube feeding. The patient was brought to NWH by her husband where she was found to be in respiratory distress, tachypneic to the 30s but without evidence of desaturation. She was on a 100% NRB with SaO2 in the 90s and was intubated (AC TV: 400, RR: 16, PEEP: 5, FiO2: 50%; 7.56/27/492). CXR was unremarkable, but UA was significant with pyuria. She received zosyn and ciprofloxacin. She was next transferred to [**Hospital1 18**] for further management of respiratory distress. In the ED, she recieved IVF, repeat CXR that was unremarkable, and a CTA that was negative for PE, consolidation, or CHF. She was transferred to the ICU and maintained on propofol on the vent (AC TV: 500, RR: 14, PEEP: 5, FiO2: 0.5; 7.47/31/221) until uncomplicated extubation the next day. Past Medical History: 1. Alzheimer's dementia (previously tx'd for presumed Parkinsons with carvidopa which was subsequently discontinued by the patient's husband on [**12-12**]) 2. Aspiration PNA 3. h/o UTI - with R ureteral stent placement 4. Small Bowel Obstruction s/p colon resection 5. h/o CVA 6. Hip fx 7. Dysplasia 8. Psoriasis 9. FUO [**8-6**] 10. s/p PEG placement [**7-7**] 11. s/p appy 12. s/p hysterectomy 13. s/p ORIF L hip Social History: The patient used to work as a nurse. She is currently demented and non-communicative at baseline but opens eyes to voice. The patient is cared for by husband in their home. No tobacco, alcohol or illicit drug use. Family History: Noncontributory Physical Exam: Tc 97 Tm 98.2 BP 91/40 HR 93 RR 18 O2 99% RA I/O 1265/NR Gen - Awake, resting in bed in NAD HEENT - extraocular motions intact, anicteric, MMMI Neck - supple, no jugular venous distention Chest - clear to auscultation anterolaterally, no stridor, no crackles/rhonchi CV - Distant S1/S2, regular rate and rhythm, no murmurs, rubs or gallops, 2+ pulses throughout Abd - soft, nondistended, nontender with normoactive bowel sounds,no masses, G-tube with clean dressing present, well healed inferior midline scar Ext - frail appearing, warm, no clubbing, cyanosis, or edema, pulses 2+ throughout, range of motion limited with rigid limbs Neuro - non-communicative, does not follow commands, regards, intact gag and corneal reflexes, cogwheeling rigidity in BUE, BLE rigiditiy, L hand pill rolling tremor, masked facies. Skin - sacral stage I-II decubitus ulcer Pertinent Results: Admission Labs: [**2180-12-25**] 04:06PM GLUCOSE-146* UREA N-13 CREAT-0.6 SODIUM-140 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-26 ANION GAP-12 [**2180-12-25**] 04:06PM CK(CPK)-244* [**2180-12-25**] 04:06PM CK-MB-2 cTropnT-<0.01 [**2180-12-25**] 04:06PM CALCIUM-9.0 PHOSPHATE-2.7 MAGNESIUM-1.9 [**2180-12-25**] 05:00AM cTropnT-<0.01 [**2180-12-25**] 05:00AM ALBUMIN-3.5 CALCIUM-9.1 PHOSPHATE-3.6 MAGNESIUM-2.1 IRON-44 [**2180-12-25**] 05:00AM calTIBC-254* FERRITIN-67 TRF-195* [**2180-12-25**] 05:00AM WBC-13.9* RBC-4.16* HGB-12.1 HCT-34.2* MCV-82 MCH-29.1 MCHC-35.4* [**2180-12-25**] 05:00AM NEUTS-85.4* BANDS-0 LYMPHS-5.0* MONOS-5.4 EOS-3.8 BASOS-0.3 [**2180-12-25**] 05:00AM PLT COUNT-468* [**2180-12-25**] 05:00AM PT-12.4 PTT-19.2* INR(PT)-1.0 [**2180-12-25**] 05:00AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.022 [**2180-12-25**] 05:00AM URINE BLOOD-LG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD [**2180-12-25**] 05:00AM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE EPI-[**7-13**] . Discharge Labs: [**2180-12-31**] 07:15AM BLOOD WBC-6.5 RBC-3.54* Hgb-10.2* Hct-30.6* MCV-86 MCH-28.7 MCHC-33.2 RDW-14.6 Plt Ct-408 [**2180-12-31**] 07:15AM BLOOD Glucose-127* UreaN-11 Creat-0.4 Na-140 K-4.0 Cl-107 HCO3-26 [**2180-12-31**] 07:15AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.9 . Pertinent Labs: [**2180-12-30**] 06:00AM BLOOD VitB12-712 [**2180-12-25**] 05:00AM BLOOD calTIBC-254* Ferritn-67 TRF-195* [**2180-12-30**] 06:00AM BLOOD TSH-1.5 [**2180-12-30**] 06:00AM BLOOD PEP-PND . Micro: URINE CULTURE (Final [**2180-12-31**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. URINE CULTURE (Final [**2180-12-29**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. URINE CULTURE (Final [**2180-12-26**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [**2180-12-30**] 7:05 am SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST (Pending): [**2180-12-29**] 10:49 pm MRSA SCREEN Site: RECTAL Source: Rectal swab. MRSA SCREEN (Preliminary): RESULTS PENDING. [**2180-12-26**] 6:30 pm BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): . Studies: CHEST (PORTABLE AP) [**2180-12-27**] 8:49 AM FINDINGS: The heart is normal in size. The mediastinal and hilar contours are unchanged compared to the previous study. Again note is made of subglottic narrowing of the upper airway. Note is made of bibasilar plate- like atelectasis, with decreased lung volumes, and elevated bilateral diaphragm. No definite evidence of CHF is noted. Left lower lobe patchy opacity is noted, slightly increased compared to the previous study.IMPRESSION: Small lung volumes with bibasilar atelectasis. Increased opacity in the left lower lobe, representing atelectasis vs. aspiration pneumonia. CHEST (PORTABLE AP) [**2180-12-26**] 9:32 AM The heart size, mediastinal and hilar contours are within normal limits and stable compared with the previous study. The lungs appear clear and there are no pleural effusions. Healed right proximal humeral fracture is incidentally noted. Finally, note is made of interval extubation. There is a tapered appearance of the airway in the glottic and subglottic region. IMPRESSION: 1) No evidence of aspiration or pneumonia. 2) Tapered appearance of glottic and subglottic airway. Post-intubation edema cannot be excluded and clinical correlation suggested. CHEST (PORTABLE AP) [**2180-12-25**] 4:39 AM There are no prior studies available for comparison. There is an endotracheal tube with tip below the thoracic inlet. The tip is located 1.5 cm from the carina. A nasogastric tube is present with tip in the stomach. The proximal port of the nasogastric tube is at or slightly above the level of the GE junction. The heart is not enlarged. There are aortic calcifications. Bandlike opacity is present at the right lower lung zone consistent with atelectasis or scarring. There is blunting of the left costophrenic angle, possibly consistent with an effusion. There is no evidence of congestive heart failure. There are degenerative changes vs. old fracture of the right humeral head. IMPRESSION: 1. Endotracheal tube positioned slightly low, with tip 1.5 cm from the carina. This may be withdrawn 2-3 cm for optimal positioning. 2. Nasogastric tube with proximal port at the GE junction. This may be advanced for optimal positioning. 3. Possible small left pleural effusion. No evidence of CHF. CTA CHEST W&W/O C &RECONS [**2180-12-25**] 7:20 AM PULMONARY CTA: The heart, pericardium, and great vessels are unremarkable. Specifically, there is excellent contrast opacification of the pulmonary vessels and there are no filling defects to suggest the presence of a pulmonary embolis. Scattered calcifications are noted throughout the thoracic aorta. CT CHEST WITH IV CONTRAST: There are several small nodules associated with the thryoid gland. The patient is intubated. The airways are patent through the segmental bronchi bilaterally. There are no pleural effusions. Emphysematous changes are noted within the lungs with a prominent pneumatocele in the suprahilar left upper lobe. There is bibasilar atelectasis but no large consolidations. There are no lymph nodes reaching CT criteria for pathologic enlargement though prominent nodes are noted in the right hilar region. Multi-level degenerative changes are noted in the thoracic spine. A somewhat rounded appearing region of dense material abutting breast parenchyma is seen in the upper-outer quadrant of the right breast measuring approximately 2.5 cm. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Minimal mild bibasilar atelectasis. 3. Emphysema. 4. Prominent nodular density in the upper-outer quadrant of the right breast measuring approximately 2.3 x 2.9 cm. While this may represent normal dense breast parenchyma, correlation with mammogram is recommended. Brief Hospital Course: 85 year old female with dementia, history of multiple prior aspiration pneumonias, and UTIs, with PEG placed who was admitted for respiratory distress in setting of getting tube feeds. . RESPIRATORY DISTRESS: The patient presented with acute onset respiratory distress requiring 1 day of intubation in the ICU for respiratory distress and likely airway edema secondary to zosyn allergy (give at the OSH prior to arrival at [**Hospital1 18**]). Oxygen saturations have been >95% since extubation and the patient does not have an oxygen supplementation requirement. The distress occurred in the setting of tube feeding with an infiltrate seen on chest xray that was suggestive of possible aspiration pneumonia vs. pneumonitis. She was started on ciprofloxacin at admission to cover for aspiration pneumonia. Her temperature spiked to 101.4 the night of [**12-26**] and repeat chest xray showed a larger infiltrate. She was pan-cultured and clindamycin was added for greater anaerobic coverage. The urine and sputum cultures from the outside hospital grew MSSA, and one sputum culture has grown mixed MSSA/MRSA. Blood cultures have had no growth to date. The IV ciprofloxacin and clindamycin were changed to levoquin [**12-28**] after admission to the medicine service. Since a sputum culture was found to have grown MRSA, the antibiotic was changed to linezolid on [**12-29**] (pt has allergy to vancomycin) to cover for MRSA. However, the mixed MSSA/MRSA growth in only one of the sputum cultures obtained, and given the patient's ongoing institutionalization, she is likely colonized with MRSA. Linezolid was discontinued [**12-30**] and the patient remained afebrile without leukocytosis. Repeat urine culture was negative. Blood cultures have had no growth to date. Rectal swab testing for MRSA colonizaiton is still pending. Aspiration precautions were followed. . H/O UTI: The patient has history of multiple enterococcal UTIs in past for which she has successfully undergone right ureteral stent placement. Urinalysis in the ED and repeat UA on the medicine floor appeared positive for infection. However, surveillance culture was negative. Urine cultures from the OSH grew MSSA and proteus. She received multiple antibiotics including ciprofloxacin, levoquin, and finally linezolid. Antibiotic therapy was discontinued [**12-30**]. . DEMENTIA/PARKINSONISM: The patient has many physical signs of Parkinsons and per her husband, was taking carbidopa/levidopa for 5 months before he decided to discontinue it himself on [**2180-12-12**] after running out of the medication. She has not been followed by a neurologist. She has been at baseline mental status per husband(non communicative but opens eyes to verbal stimuli). She has been more somnolent in the mornings after starting mirapex [**12-29**]. By afternoon, she is fully awake and alert. Neurology was consulted and confirmed Parkinsonism but they cannot distinguish parkinson's disease vs the syndrome of parkinsonism. OSH records have been evaluated. B12 and TSH were normal. RPR and SPEP were still pending at discharge to rule out reversible causes of decline. The dopa receptor agonist, Mirapex 0.125mg TID, was started [**12-29**] since the patient has history of worsening mental status on sinemet. . THYROID NODULES (NEW): Several small thyroid nodules were appreciated on CT scan and outpatient evaluation was recommended. . BREAST NODULE (NEW): A2.3x2.9cm breast nodule in the upper outer quadrant of the right breast was seen on CT scan that should be further investigated as an outpatient. . H/O LOW BLOOD PRESSURE: Systolic blood pressure, in the low 100s improved modestly after gentil IV hydration with normal saline at 75ml/hr. Urine lytes demonstrated FeNa=1.1% so IV fluids were discontinued. Serum lytes were unremarkable. . H/O TRACHEAL EDEMA: The patient had tracheal edema most likely due to zosyn allergy vs intubation trauma. She had stridor in the ICU that had resolved upon admittance to the medicine service. She had received 2 benadryl and was clinically improved. . H/O RASH/HYPEREOSINOPHILIA: The patient presented with a blachable pink macular patchy rash on her trunk and limbs that was due most likely to zosyn allergy. Her rash was most likely due to a drug reaction (patient with known allergy to zosyn but was treated with zosyn at OSH). She received benadryl x2 at admission. Peripheral eosinophils increased from 3.8->23% on [**12-25**] but have since consistently trended downwardly. At discharge, the rash had fully resolved. Holding zosyn, penicillin, and vancomycin due to allergy. . Questionable CAD: Cardiac enzymes were negative including Troponin <0.01 x2 over 36 hours. Her aspirin was continued. Consider starting statin, ACEI, and beta blockade as an outpatient. . H/O CEREBROVASCULAR ACCIDENT: The patient's home regimen of aspirin was continued. . ANEMIA: She has a microcytic anemia with Fe studies suggestive of Fe deficiency. Consider supplementing with Fe after G tube feeds tolerated. HCT was stable during hospital admission. . STAGE I DECUBITUS SACRAL ULCER: Application of duoderm dressing every 3 days. Air mattress used with frequent repositioning. . FEN: Tube feeding protocol: Probalance full strength at 45cc/hr, NPO except meds. Nutrition consultation [**12-26**] recommended aggressive aspiration precautions and mouth care. . PRECAUTIONS: heparin SC TID for DVT prophylaxis, aspiration precautions with head of bed elevated >30 degrees, fall precautions, MRSA contact precautions (rectal swab results are pending). . COMMUNICATION: [**First Name8 (NamePattern2) **] [**Known lastname **] [**Telephone/Fax (1) 59467**](husband) . FULL CODE Medications on Admission: 1. ASA 325mg once daily 2. Colace 3. Senna 4. Nexium 20mg once daily 5. Tylenol 6. Generlac 10mg/15ml TID . Allergies: penicillin, zosyn, vancomycin Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Generlac 10 g/15 mL Syrup Sig: Ten (10) g PO three times a day. 8. Pramipexole Dihydrochloride 0.125 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for parkinsons's not responding to sinemet. 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: TLC Visiting Nurses Discharge Diagnosis: aspiration pneumonia urinary tract infection Secondary: Alzheimer's dementia (previously tx'd for presumed Parkinsons with carbidopa which was subsequently discontinued), Aspiration PNA, s/p PEG placement [**8-6**], h/o UTI, R ureteral stent placement, Small Bowel Obstruction s/p colon resection, h/o CVA, Dysplasia, Psoriasis, FUO [**8-6**], s/p appy, s/p hysterectomy, s/p ORIF L hip Discharge Condition: hemodynamically stable in usual state of health breathing comfortably on room air Discharge Instructions: Please take all medications as prescribed and follow up with your doctor appointments. Call your doctor or go to the ED for worsening shortness of breath, fever, chills, cough, urinary frequency, foul smelling urine, lethargy or other concerning symptoms. Followup Instructions: Please follow up with your regular doctor within one week. Call Dr.[**Name (NI) 59468**] office at [**Telephone/Fax (1) 59467**] to make an appointment. You have several small thyroid nodules and a 2.3x2.9cm breast nodule in the upper outer quadrant of the right breast that should be further evaluated.

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icd9cm

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Discharge summary

report

Admission Date: [**2141-9-15**] Discharge Date: [**2141-9-19**] Date of Birth: [**2102-4-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: Confusion Major Surgical or Invasive Procedure: Paracentesis x 2 History of Present Illness: 39f without significant PMH who was found to be pregnant today after recently completing an IVF cycle at [**Location (un) 86**] IVF (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 69050**]) was found by her husband to be very confused on the morning of admission, went to [**Hospital **] Hospital ED where she was found to be hyponatremic and with a hct of 52, felt to be in severe ovarian hyperstimulation syndrome (OHSS) by her ob-gyn, for which she was transferred to [**Hospital1 18**] MICU. For two to three days prior to admission, she complained of a headache, something atypical for her. There does not seem to have been any associated neck pain or stiffness; she took a fioricet called in by her ob-gyn the night prior to admit and went to bed. When she awoke the morning of admission, her husband felt she was quite confused and took her to [**Hospital **] hospital ED. She had no loss of conciousness. At [**Hospital **] Hospital, she had a number of lab abnormalities, all seemingly indicative of hypovolemia, including a Na of 126, Cr of 1.1, hct of 52, a urine osm of 737, and a urine Na < 10. This was discussed with her reproductive endocrinologist, Dr. [**Last Name (STitle) 69050**], who felt this presentation to be quite consistent with OHSS and recommended she be transferred to [**Hospital1 1388**] MICU for supportive care. At the time of admission, she continued to be confused, unable to think through her thoughts, having difficulty finding words but without other focal deficits. She denied headache, neck pain, or neck stiffness. She denied pain anywhere, including in her abdomen, no dyspnea, no nausea or vomiting. She felt her abdomen was a bit swollen for the past week or two, maybe a bit worse over the past few days; her legs did not seem swollen to her. Her husband was at the bedside and felt that her mental status had actually improved since the morning. Past Medical History: None, without prior medical admissions Social History: She is a cinema professor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 1968**] College. She lives with her husband, an art history professor also at [**Doctor Last Name 1968**]. She never smoked nor was she exposed to heavy tobacco smoke. She does not drink heavily or use illicit drugs. Family History: Father had [**Name2 (NI) 1291**]. No known history of CAD, DM, CVA. Physical Exam: t 96.1, bp 111/79, hr 105, rr 14, spo2 100%ra gen- confused but well-appearing, non-tox, nad heent- anicteric, op dry neck- supple, flat veins, no lad, no thyromegaly cv- rrr, s1s2, no m/r/g pul- moves air well, no w/r/r abd- soft, nt, nd, nabs, no hsm, slight distension, ? min fluid wave back- no cva/vert tenderness, no sacral edema extrm- no cyanosis/edema, warm/dry nails- no clubbing, no pitting/color changes/indentations neuro- awake, alert, pt has difficulty finding words, difficulty naming, difficulty thinking of words but comprehension intact; appears oriented, aware of current and recent events, no cn, motor, or cerebellar deficits Pertinent Results: MRI/MRV: Multiple subacute infarcts distributed throughout various vascular territories, primarily within the left and right MCA distributions. The largest is in the right parietal region. There is no evidence of venous sinus thrombosis. . MRA: The circle of [**Location (un) 431**] is normal with normal branch pattern. The left vertebral artery is dominant. There are no aneurysms or significant intracranial atherosclerotic disease. The right A1 segment is hypoplastic. IMPRESSION: Normal circle of [**Location (un) 431**] MRA. . Bilateral lower extrm u/s: No DVT Brief Hospital Course: 39f with little pmh who recently was found to be pregnant after completing cycle of IVF who presents with confusion in the setting of multiple lab abnormalities. . #Stroke -- Her aphasia was initially felt to be encephalopathy from her hyponatremia, but was then noted to be fairly focal with a pronounced aphasia. Neurology was consulted and an MRI/MRV/MRA obtained, showing multiple subacute infarcts mainly in both the right and left MCA distribution. A thrombophilic work-up was sent off. Bilateral lower extremity dopplers were negative, and an echo showed normal EF with no RWMA, and no thrombi. She was continued on enoxaparin throughout her admission, with dose increased to therapeutic doses of Lovenox 60 SC BID, with factor Xa levels to be checked, and followed up at her hematology appointment. Ultimately, it was felt that she certainly may have an underlying hereditary thrombophilia with hypercoagulable labs checked prior to discharge (though the evaluation is still pending) with a superimposed acquired thrombophilia from both IVF's estrogen surge and her pronounced hemoconcentration. She will follow up with hematology. . #Ovarian hyperstimulation syndrome -- She was followed closely by her reproductive endocrinologist, who was quite helpful in the management of this syndrome. During the admission, she was treated supportively with 2 paracenteses for both symptomatic benefit and as the ascitic fluid serves as a VEGF resevoir, the purported mediator of the capillary leak that underlies this syndrome. She was also aggresively volume resuscitated early in the admission, receiving nearly five liters of normal saline her first night in the ICU. She was also treated with enoxaparin, as above, as this state is quite thrombophilic. She had normalization of her sodium, clearance of her mental status, and had good urine output on day of discharge. She will need repeat pelvic ultrasound performed as an outpatient, as well as close monitoring of her b-HCG. . #Hyponatremia -- This was probably hypovolemic in nature. As this syndrome involves a significant degree of third-spacing, she likely became profoundly hypovolemic, prompting the avid retention of both sodium and water, attested to by her urine Na < 10 and her urine osmolarity in the 780's. Her high degree of urine concentration and free water reabsorption subsequently lead to her hyponatremia that resolved over the first few days of her admission with aggressive volume resuscitation. Her sodium was normal at time of discharge. . #Comm -- [**Location (un) 86**] ivf [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 69050**] [**Telephone/Fax (1) 69051**]. Patient is to follow up with reproductive endocrinology, Ob-Gyn, and hematology-oncology. Medications on Admission: None Discharge Medications: 1. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous twice a day. Disp:*60 syringe* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Ovarian hyperstimulation syndrome Hyponatremia Acute renal insufficiency Hypervolemia Pregnancy Subcortical infarcts Discharge Condition: Stable Discharge Instructions: If you develop increased abdominal pain, swelling, or fevers, please call your primary care doctor or go to the emergency room. Followup Instructions: Please follow up with your primary care doctor, Dr. [**Last Name (STitle) 69052**], on Thursday at 2:00 pm. Please follow up with an Ob-Gyn in 1 week. This will be arranged for you by Dr. [**Last Name (STitle) 69050**]. His phone number is [**Telephone/Fax (1) 2664**]. Please follow up with Neurology. The number to call to make the appointment is with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **]. The phone number to call is ([**Telephone/Fax (1) 7394**]. Please follow up with hematology-oncology in two weeks. At that point you can find out your lab results. Your appointment will be made for you, and we will call you with the appointment date and time. Please continue your daily Lovenox injections until your appointment with hematology-oncology.

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icd9cm

[ [ [] ] ]

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icd9pcs

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49674

Discharge summary

report

Admission Date: [**2122-6-28**] Discharge Date: [**2122-7-7**] Date of Birth: [**2067-8-9**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 905**] Chief Complaint: shortness of breath, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: 54 year old man with history of hep C, chronic extremity ulcers, restrictive lung disease, recurrent PE who presents with shortness of breath and confusion. The records of his inital presentation are not clearly documented. He was at home with his wife who found him with left sided back pain and minimal responsiveness. She called EMS. When EMS arrived to his home, he was hypoxic and met by his neighbors. . In the ED, his initial vitals were 98F, 118, 103/64, 25 86%RA->97%NRB. He received empiric lasix 80 IV x1, and levofloxacin 500 mg x1. He was started on a nitroglycerin drip but this was stopped when his [**First Name3 (LF) **] pressure dropped to 70s systolic. An EKG was interpreted as sinus tach with no specific ST-T changes. He voided 550 cc of brown urine without a foley. He received an empiric heparin bolus of 5000 units but the heparin was stopped when his INR came back at >10. He was transfered for further evaluation. ROS: he states that he had a fever 2 days ago. he denies cough or chest pain. He denies abd pain but was having burning on urination. Has pressure in his bladder. He has no rash. Past Medical History: 1)? Buerger's disease vs. livedoid vasculopathy - Per prior notes has had extensive work-ups by Dermatology, rheumatolgy, plastics, etc. Essentially excluded a diagnosis of cryoglobulinemia, while a presumptive diagnosis of Buerger's or LV was made. The patient is on Nifedipine to increase vasodilation and has been counseled to stop smoking many times. 2)Chronic bilateral U+L extremity ulcers - complication of his vaculitis- ? pyoderma grangulosum 3)Chronic pain [**3-7**] multiple ulcers 4)Sinus tachycardia, presumed reflex sympathetic dystrophy 5)Remote history of testicular cancer in [**2092**] status post orchiectomy, with recurrence in [**2101**] treated with XRT and LND. 6)Bilateral PEs [**2120-8-3**], on Coumadin 7)Hypersensitivity pneumonitis versus BOOP versus NSIP (restrictive PFTs FEV1 57%, DSB 61% in [**1-8**]) 8)Hypothyroidism 9)Hepatitis C (genotype 1) Grade inflammation 2, Stage 0 fibrosis [**4-10**] 10)GERD - on PPI at home 11)s/p MVA in [**2084**] with traumatic spleen rupture, bilateral open tibial fractures, and head trauma. 12) influenza pneumonia [**2122-3-6**]. Social History: 1 ppd X 30 yrs. (+) history of IVDU, quit in [**2094**]. No ethanol use. Lives with his wife in [**Name (NI) 1411**]. Currently unemployed Family History: Grandfather s/p MI in 70s. Grandmother died in her sleep of unknown cause in her 70s. No family history of cancer. Cousin with anti-phospholipid antibody. Physical Exam: Upon arrival to the MICU: VS: 99.2F (ax) 114 117/63 16 92%NRB GEN: NAD, talkative HEENT: AT, NC, PERRLA (4->3 bilat), EOMI, no conjuctival injection, anicteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits. no neck stiffness CV: tachy. regular. no m/r/g PULM: no crackles. diffuse rhonchi bilat. no dullness ABD: healed surgical ex-lap scar. soft, NT, mild distension, active bowel sounds, no HSM EXT: warm, dry, dopplerable pulses. sclerosed lower extremity skin. no femoral bruits NEURO: alert & oriented to person, place, date. CN II-XII grossly intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect. awake requiring frequent re-direction Pertinent Results: Labs at [**Hospital1 **]-N 9pm: Na 133 Cl 93 BUN 69 Gluc 106 K 7.6 CO2 21.6 Cr 3.1 AG 19 Ca 7.1 alb 3.1 AP 147 AST 243 ALT 66 tbili 1.68 repeat K 5.1 ABG (15L) 7.44/32/80 CBC: 47.6>41.7<454 diff: 86n/8band/1lymp/5mono INR >10 PTT 73.9 [**2122-6-28**] 03:13AM WBC-39.3*# RBC-5.27 HGB-12.8* HCT-38.8* MCV-74*# MCH-24.3* MCHC-33.1 RDW-16.7* [**2122-6-28**] 03:13AM PLT SMR-HIGH PLT COUNT-485* [**2122-6-28**] 03:13AM NEUTS-82* BANDS-10* LYMPHS-5* MONOS-2 EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* [**2122-6-28**] 03:13AM PT-127.4* PTT-90.2* INR(PT)-17.9* [**2122-6-28**] 03:13AM GLUCOSE-106* UREA N-72* CREAT-3.2*# SODIUM-136 POTASSIUM-5.0 CHLORIDE-96 TOTAL CO2-24 ANION GAP-21* CXR - AP ([**Hospital1 **]-N): wedgeshaped pleural opacities in RLL and LLL with air-bronchogram on LUL, pulmonary vessel engorgement. CT chest - IMPRESSION: Findings compatible with multifocal pneumonia. multiple pathologically enlarged mediastinal lymph nodes at multiple stations ECHO TTE - The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60-70%) There is no ventricular septal defect. 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 masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2121-4-24**], the findings are similar. IMPRESSION: no obvious vegetations seen [**2122-6-28**] 8:40 am SPUTUM Source: Expectorated. **FINAL REPORT [**2122-7-2**]** GRAM STAIN (Final [**2122-6-28**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2122-7-2**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations Rifampin should not be used alone for therapy. STREPTOCOCCUS PNEUMONIAE. RARE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH 2ND TYPE. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. PENICILLIN SENSITIVITY AVAILABLE ON REQUEST. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | STREPTOCOCCUS PNEUMONIAE | | STAPH AUREUS COAG + | | | CEFTRIAXONE----------- <=0.06 S CLINDAMYCIN----------- =>8 R <=0.25 S ERYTHROMYCIN---------- =>8 R <=0.06 S <=0.25 S GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- =>8 R 1 S 0.25 S OXACILLIN------------- =>4 R <=0.25 S PENICILLIN G---------- =>0.5 R <=0.06 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S <=0.5 S VANCOMYCIN------------ <=1 S <=1 S Brief Hospital Course: In brief, the patient is a 54 year old man with chronic upper extremity ulcers of unknown etiology (vasculopathy), interstitial lung disease, recurrent pulmonary embolism who presented with hypoxia, altered mental status, acute renal failure found to have multilobar pneumonia. 1) Hypoxia: The patient presented with bilateral infiltrates, fever, and markedly elevated WBC count with bandemia and imaging was consistent with a multilobar pneumonia. Sputum cultures revealed MRSA. He was empirically started on cefepime and vancomycin then transitioned to oral Bactrim and is to complete a 7 day course. Given his markedly elevated INR it was thought unlikely for him to have had a recurrent PE. Given the wedge-shaped opacities on the chest CT, he had a TTE to evaluate his right sided heart valves which showed no signs of vegetation. His oxygenation improved steadily, but note should be made that given his marked vasculopathy his pulse-oximetry should be measured from either his forehead or ear instead of his fingers. His CT appeared to show a tracheo-esophageal fistula but on review of the images this was thought to unlikely. He passed a bedside and video-swallowing eval and showed no sign of aspiration. Following discharge he should have a follow-up appointment in pulmonary clinic to confirm resolution of his infiltrates, if his infiltrates do not entirely resolve, consideration should be made for lung biospsy to further evaluate his more chronic respiratory symptoms. # Altered mental status: The patient presented with non-focal neurologic exam and following commands appropriately. The likely cause was the significant hypoxia likely exacerbated by his pain medicine regimen. # Coagulopathy: The patient presented with a markedly elevated INR likely induced by coumadin. He showed no evidence of acute bleeding or consumptive coagulopathy. His INR was reversed on arrival but was brought back to therapeutic after he stabilized. # Acute renal failure: The patient presented in non-oliguric renal failure. This was likely of pre-renal etiology given minimal protein in the urine and unremarkable urinalysis. His creatinine normalized rapidly with fluid repletion and treating his pneumonia. # Chronic pain: His pain medicines were decreased on admission given his altered mental status then gradually re-introduced as his pneumonia improved. # Hypothyroidism: There were no acute issues and he remained on his home dose of levothyroxine. Medications on Admission: Warfarin 5 mg daily Pantoprazole 40 mg Q24H Gabapentin 600 mg Q8H Oxcarbazepine 300 mg DAILY Oxycodone 80 mg Q8H Nifedipine SR 30 mg DAILY Levothyroxine 75 mcg DAILY Fluticasone-Salmeterol 250-50 [**Hospital1 **] Tiotropium Bromide 18 mcg DAILY Docusate Sodium 100 mg [**Hospital1 **] Bisacodyl 5-10 mg DAILY (Daily) as needed. Albuterol Sulfate Neb Q6H:prn Oxycodone 30 mg Tablet q6:prn Aloe Vesta 2-n-1 Protective daily Discharge Medications: 1. Warfarin 1 mg Tablet Sig: Six (6) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 4. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. OxyContin 80 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO every twelve (12) hours. 6. Oxycodone 30 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**2-4**] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 days. [**Month/Day (2) **]:*8 Tablet(s)* Refills:*0* 12. Robitussin Cough-Congestion 10-200 mg/5 mL Syrup Sig: [**2-4**] PO every six (6) hours as needed for cough. [**Month/Day (2) **]:*1 bottle* Refills:*0* 13. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 14. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) INH Inhalation twice a day. 15. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) nebulization Inhalation every six (6) hours as needed for shortness of breath or wheezing. 16. Aloe Vesta 2-n-1 Protective Ointment Sig: One (1) Topical once a day: Apply to extremities. 17. Outpatient Lab Work INR check [**2122-7-9**]. Please fax results to PCP, [**Last Name (NamePattern4) **].[**Last Name (STitle) **],[**First Name3 (LF) **] F. [**Telephone/Fax (1) 17753**] Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Pneumonia Discharge Condition: Hemodynamically stable Discharge Instructions: You were admitted into the hospital for treatment of your Pneumonia. You had a severe Pneumonia and you were treated initially in the Intensive Care Unit with Vancomycin. You have been transitioned to Bactrim oral antibiotics. You are to continue on Bactrim twice daily and you are to complete a 7 day course. . Please continue with your remaining mediacations as instructed. . If you experience worsening cough, fevers > 101, shortness of breath, abdominal pain, nausea, vomiting, diarrhea or any other concerning symptoms then please call your doctor or report to the nearest emergency room. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8446**] within [**2-4**] weeks. Please call for your appointment [**Telephone/Fax (1) 17753**]. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

12523, 12594

7643, 9148

312, 319

12648, 12673

3676, 7620

13318, 13638

2766, 2922

10594, 12500

12615, 12627

10147, 10571

12697, 13295

2937, 3657

230, 274

347, 1469

9163, 10121

1491, 2594

2610, 2750

81,085

169,845

48357

Discharge summary

report

Admission Date: [**2144-4-6**] Discharge Date: [**2144-4-14**] Date of Birth: [**2074-6-10**] Sex: M Service: SURGERY Allergies: Phenergan Attending:[**First Name3 (LF) 5547**] Chief Complaint: adenocarcinoma of the descending colon. Major Surgical or Invasive Procedure: 1. Laparoscopic converted to open left colectomy. 2. Takedown of splenic flexure of colon. 3. Wedge biopsy of lesion of left lobe of liver. History of Present Illness: Mr. [**Name14 (STitle) 101858**] is a 69-year-old gentleman with multiple medical comorbidities who presents for resection of adenocarcinoma of the descending colon. Due to comorbidities to include obesity, type II diabetes, diastolic heart failure,hypertension, untreated sleep apnea with secondary pulmonary hypertension, and chronic renal insufficiency, the patient was admitted for pre-op evaluation and administration of contrast by mouth. He reports being in his usual state of health. No recent fevers are reported. Of note, he was hospitalized for a postive stress test and cardiac cath last month. Results included identification of 1. Single vessel coronary artery disease. 2. Mild to moderate aortic stenosis. 3. Marked biventricular diastolic dysfunction. 4. Severe pulmonary hypertension. Past Medical History: 1. Obesity. 2. Type 2 diabetes mellitus on insulin. 3. Hypertension. 4. Diastolic congestive heart failure with preserved EF. 5. Obstructive sleep apnea and secondary moderate pulmonary hypertension. He has been asked to use a CPAP machine, but is reluctant to do so. 6. Degenerative joint disease. 7. Chronic renal insufficiency with a baseline creatinine in the 2-2.3 range. 8. Right acoustic neuroma status post gamma knife radiation therapy with resultant hearing loss. 9. Mild aortic stenosis and mild aortic regurgitation 10. gout. Social History: Married and lives with wife. [**Name (NI) **] four daughters, ten grandchildren. Was laid off from Polaroid around the time the company went bankrupt, is now retired. Is of Italian background, grew up in the [**Hospital3 **]. --Smoked < 5 py, quit 45 y prior --No current EtOH Family History: Father had [**Name2 (NI) 101859**] and peripheral vascular disease, DVTs, and stroke. Mother is alive. Sister with CHF. Physical Exam: At Discharge: Vitals stable GEN: A/Ox3, NAD CV: RRR, no m/r/g RESP: CTAB, no w/r/r ABD: soft, obese, appropriately TTP, +flatus, +BM Incision: midline abdominal OTA with staples, distal erythema improved. Extrem: no c/c/e Pertinent Results: [**2144-4-6**] 05:35PM BLOOD WBC-7.5 RBC-5.12 Hgb-11.4* Hct-37.9* MCV-74* MCH-22.3* MCHC-30.1* RDW-18.4* Plt Ct-251 [**2144-4-8**] 09:08PM BLOOD WBC-10.0 RBC-4.09* Hgb-9.3* Hct-30.4* MCV-74* MCH-22.8* MCHC-30.7* RDW-18.5* Plt Ct-197 [**2144-4-11**] 08:35AM BLOOD WBC-7.0 RBC-4.05* Hgb-9.0* Hct-29.9* MCV-74* MCH-22.3* MCHC-30.2* RDW-19.7* Plt Ct-231 [**2144-4-14**] 07:20AM BLOOD WBC-6.4 RBC-4.69 Hgb-10.5* Hct-34.4* MCV-73* MCH-22.4* MCHC-30.5* RDW-19.0* Plt Ct-290 [**2144-4-6**] 05:35PM BLOOD PT-14.0* PTT-25.1 INR(PT)-1.2* [**2144-4-6**] 05:35PM BLOOD Glucose-141* UreaN-40* Creat-2.0* Na-144 K-3.2* Cl-103 HCO3-28 AnGap-16 [**2144-4-8**] 09:08PM BLOOD Glucose-142* UreaN-38* Creat-2.8* Na-142 K-3.6 Cl-106 HCO3-26 AnGap-14 [**2144-4-12**] 07:25AM BLOOD Glucose-90 UreaN-63* Creat-2.6* Na-143 K-4.6 Cl-107 HCO3-28 AnGap-13 [**2144-4-14**] 07:20AM BLOOD Glucose-122* UreaN-71* Creat-2.7* Na-141 K-3.9 Cl-101 HCO3-29 AnGap-15 [**2144-4-7**] 08:37PM BLOOD CK(CPK)-262* [**2144-4-7**] 08:37PM BLOOD CK-MB-5 cTropnT-0.05* [**2144-4-6**] 05:35PM BLOOD Calcium-10.4* Phos-3.5 Mg-2.2 [**2144-4-7**] 06:50AM BLOOD Calcium-10.0 Phos-2.4* Mg-2.3 [**2144-4-9**] 02:42AM BLOOD Calcium-9.1 Phos-4.7* Mg-2.0 [**2144-4-10**] 07:15AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.4 [**2144-4-13**] 06:20AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.4 [**2144-4-14**] 07:20AM BLOOD Calcium-9.7 Phos-3.9 Mg-2.3 . Pathology Examination Procedure date [**2144-4-7**] DIAGNOSIS: I. Colon, left colectomy (A-Q): 1. Adenocarcinoma, moderately differentiated, infiltrating muscularis propria and extending into pericolic fat, See synoptic report. 2. Fifteen lymph nodes uninvolved by carcinoma (0/15). II. Liver, let lobe, biopsy (R): 1. Bile duct hamartoma. 2. Masson trichrome and iron stains performed (negative). Colon and Rectum: Resection Synopsis MACROSCOPIC Specimen Type: Colonic resection. Location: Left. Specimen Size Greatest dimension: 25 cm. Additional dimensions: 4 cm. Tumor Site: Left (descending) colon. Tumor configuration: Exophytic (polypoid). Tumor Size Greatest dimension: 4 cm. Additional dimensions: 3.2 cm x 0.6 cm. MICROSCOPIC Histologic Type: Adenocarcinoma. Histologic Grade: Low-grade (well or moderately differentiated). EXTENT OF INVASION Primary Tumor: pT3: Tumor invades through the muscularis propria into the subserosa or the nonperitonealized pericolic or perirectal soft tissues. Regional Lymph Nodes: pN0: No regional lymph node metastasis. Lymph Nodes Number examined: 15. Number involved: 0. Distant metastasis: pMX: Cannot be assessed. Margins Proximal margin: Uninvolved by invasive carcinoma: Distance of tumor from closest margin: 95 mm. Distal margin: Uninvolved by invasive carcinoma: Distance of tumor from closest margin: 120 mm. Circumferential (radial) margin: Uninvolved by invasive carcinoma: Distance of tumor from closest margin: 40 mm. Lymphatic Small Vessel Invasion: Absent. Venous (large vessel) invasion: Absent. Perineural invasion: Absent. Tumor border configuration: Pushing. Additional Pathologic Findings: None identified. Clinical: Left colon cancer. . Brief Hospital Course: Mr. [**Known lastname 101860**] operative course was converted from laparoscopic to open due to body habitus and intra-abdominal anatomy. Operative course was otherwise uncomplicated. He was monitored in the PACU, and transferred to the ICU for closer monitoring due to medical co-morbidities. ICU issues included low blood pressure and marginal urine output. Bolused with IV albumin. IV fluid marginalized due to h/o diastolic CHF. SBP's and urine output stabilized. Labwork, included creatinine stable. Transferred to Stone 5 for post-op care. . Started on sips on POD [**1-17**]. Pain well controlled with PCA. Foley placed. Triggered for low SBP to 70's. Bolused with albumin x 1. Urine output decreased to 5cc/hr, bloody. Bolused w/ albumin. IV fluid continued at reduced rate. Renal consulted-ACE-I, [**Last Name (un) **],& nifedipine held; Goal SBP >100 at all times. Daily creatinines checked. Lasix dose gradually increased to home dose as CR's returned to baseline. Urine output improved. SBP's returned to baseline over nect 24-38 hours. Home medications resumed. Foley removed, able to urinated adequate amounts. . Abdominal incision, midline, intact with staples. Distal erythem progressed beyond markings. IV Kefzol started. Erythema improved. No exudate/drainage. Diet advanced at bowel function resumed. Reported flatus and eventual bowel movement prior to discharge. Physical Therapy consulted due to obesity and difficulty moving independently with abdominal incision. PT cleared patient for discharge home with 24 hour supervision, use of rolling walker at home until stonger/more stable, use of bedside commode, & continue with home Physical Therapy. . Patient discharged home with services, PO Keflex for a few more day for incisional erythema. Advised to follow-up with Nephrologist-Dr. [**First Name (STitle) 11916**] within 1 week for creatinine check, and Dr. [**Last Name (STitle) 1924**] in 1 week for staple removal. Medications on Admission: Humalog insulin Sliding Scale, NPH 45 AM and 45 PM, Metoprolol 150 AM, Nifedical XL 30', Lisinopril 40', Triamterene/HCTZ 37.5/25', Avapro 150", Simvastatin 80', Lasix 120 AM, 80 afternoon, 80 PM, KDur 30 AM and 20 PM, Colchicine 0.6", Allopurinol 200', Hectorol 1 AM and 0.5 PM, Omeprazole 40', Alprazolam PRN Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO once a day. 3. Nifedical XL 30 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Triamterene-Hydrochlorothiazid 37.5-25 mg Tablet Sig: One (1) Tablet PO once a day. 6. Avapro 150 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Lasix 40 mg Tablet Sig: Three (3) Tablet PO once a day: In the AM. Total of 120mg. 8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO AFTERNOON (). 10. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Three (3) Capsule, Sustained Release PO QAM (once a day (in the morning)). 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day: In the PM. 13. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO once a day. 14. Doxercalciferol 0.5 mcg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 15. Doxercalciferol 0.5 mcg Capsule Sig: One (1) Capsule PO QPM (once a day (in the evening)). 16. Alprazolam 1 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for anxiety. 17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: Do not exceed 4 grams of acetaminophen in one day. Disp:*45 Tablet(s)* Refills:*0* 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 2 weeks: Take with oxycodone. Hold for loose stools. Disp:*30 Capsule(s)* Refills:*0* 19. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). 20. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 3 days. Disp:*12 Capsule(s)* Refills:*0* 21. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 45Units & 45Units Subcutaneous QAM & QPM. 22. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation for 2 weeks: Hold for loose stools. Take with oxucodone. Disp:*30 Tablet(s)* Refills:*0* 23. Insulin Lispro 100 unit/mL Solution Sig: Per home sliding scale Subcutaneous Before meals & at bedtime. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary: Adenocarcinoma of the descending colon Several small bilobar liver lesions Diastolic CHF Post-op renal hypoperfusion injury Post-op hypotension . Secondary: Obesity., DM2, HTN, ^lipid, Diastolic CHF, OSA with Pulm HTN (suppose to use CPAP but does not), DJD, CRI (2-2.5),Rt acoustic neuroma status post gamma knife radiation therapy with resultant hearing loss, Mild aortic stenosis and mild aortic regurgitation as evidenced on a recent echocardiogram last month, Gout. Discharge Condition: Stable Tolerating a regular, low residue diet Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your staples will be removed at your follow-up appointment with Dr. [**Last Name (STitle) 1924**]. -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. . Diet: -Please continue with a Low residue regular diet until your follow-up appointment with Dr. [**Last Name (STitle) 1924**]. -Please refer to hand-out provided to you per hospital staff. Call Dr. [**Last Name (STitle) 1924**] if you have further questions. . Activity: -Do not get up and walk around without assistance and monitoring to prevent FALLS. Physical Therapy will work with you at home. . Medications: 1. Keflex- This is an antibiotic that you should continue taking for another 3 days to prevent infection of your surgical incision. Call Dr. [**Last Name (STitle) 1924**] with any questions or concerns. Followup Instructions: 1. Please follow-up with your nephrologist Dr. [**First Name (STitle) 10083**] within 1 week to have your creatinine level checked in your blood.Call his office for an appointment. . 2. Please follow-up with Dr. [**Last Name (STitle) 1924**] [**Telephone/Fax (1) 7508**] in [**1-17**] weeks for removal of your incisional staples. . Previous appointments: 1.Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14839**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2144-6-4**] 9:40 2.Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2144-6-4**] 11:15 3.Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2144-6-17**] 11:10 Completed by:[**2144-4-17**]

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icd9cm

[ [ [] ] ]

[ "50.12", "45.75" ]

icd9pcs

[ [ [] ] ]

10437, 10492

5735, 7681

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11016, 11106

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2163, 2286

8042, 10414

10513, 10995

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12287, 13330

2301, 2301

2315, 2524

229, 271

479, 1285

1307, 1849

1865, 2147

52,315

107,578

8643

Discharge summary

report

Admission Date: [**2148-5-24**] Discharge Date: [**2148-5-28**] Date of Birth: [**2073-2-1**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: Shortness of breath and chest discomfort Major Surgical or Invasive Procedure: [**2148-5-24**] 1. Coronary artery bypass graft x4: Left internal mammary artery to left anterior descending artery, and saphenous vein grafts to posterior descending artery and diagonal and obtuse marginal arteries. 2. Endoscopic harvesting of the long saphenous vein. History of Present Illness: 75 year old male with hyperlipidemia, GERD, diastolic dysfunction, who underwent cardiac catheterization in [**2137**] for angina symptoms. He was found to have mild to moderate CAD with a 70% ostial D2 and a 90% mid vessel. His OM1 had a 70% lesion. His RCA was diffusely diseased with a 50% mid an 80% distal. He opted for medical management and has done quite well. He has been exercising regularly walking up to 3 miles daily. Approximately 2 weeks ago he noted some mild shortness of breath while climbing stairs. This would resolve with rest. He also noted some mild chest discomfort with exertion that also would resolve with rest. This also occured during his daily 3 mile walk. He stopped exercising and contact[**Name (NI) **] his doctor. [**First Name (Titles) **] [**Last Name (Titles) 8783**]t a nuclear stress test which was positive for lateral wall ischemia and LV dilation at peak exercise. His Toprol and Lisinopril where increased. He also reports a constant "odd feeling" in the left side of his neck that does not change with exertion or position. He has discussed this concern with Dr. [**Last Name (STitle) 4469**]. He was referred for cardiac catheterization and was found to have three vessel cornoary artery disease and was referred to cardiac surgery for revascularization. Date:[**2148-5-16**] Place:[**Hospital1 18**] Right dominant with ectopic circumflex from right cusp and mild diffuse disease LMCA: distal 60% LAD: 99% small second diagonal LCX: 80% mid with ectopic circumflex RCA: 80% mid, 99% PDA, 100% posterolateral filling from collaterals Past Medical History: CAD- treated medically since [**2137**] Diastolic Dysfunction Mild trivalvular insufficiency Hyperlipidemia GERD Hypertension Basal Cell CA Gout Past Surgical History: s/p Bilateral hernia repair Social History: Race:Caucasian Last Dental Exam:1 month ago Lives with:Wife Occupation:works full time in research for an aviation company. Tobacco:denies ETOH: 1 glass of wine with dinner Family History: Father with CAD and MI, he died in his 70's. Mother died last [**Name (NI) 2974**] of esophageal CA at the age [**Age over 90 **]. 2 brothers with MI in their late 50's early 60's, one with stents and one had CABG Physical Exam: Pulse:59 Resp:12 O2 sat:99/RA B/P Right:156/76 Left:161/88 Height:5'9" Weight:180 lbs General:NAD, alert and cooperative Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] II/VI Systolic Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +2 Left:+2 DP Right: +2 Left:+2 PT [**Name (NI) 167**]: +2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit Right:none Left:none Pertinent Results: [**2148-5-27**] 05:30AM BLOOD WBC-10.2 RBC-3.28* Hgb-10.5* Hct-29.6* MCV-90 MCH-32.0 MCHC-35.4* RDW-14.1 Plt Ct-166 [**2148-5-27**] 05:30AM BLOOD UreaN-24* Creat-1.1 Na-136 K-4.5 Cl-101 [**2148-5-26**] 04:52AM BLOOD Glucose-124* UreaN-32* Creat-1.5* Na-139 K-4.4 Cl-104 HCO3-26 AnGap-13 [**2148-5-24**] TEE PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the aortic root. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. POST CPB: 1. Preserved bo-ventricular systolic function 2. No change in valve structure or function 3. Intact aorta Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2148-5-24**] where the patient underwent coronary artery bypass graft x4: Left internal mammary artery to left anterior descending artery, and saphenous vein grafts to posterior descending artery and diagonal and obtuse marginal arteries. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He did have an increase in creatinine from 1.0-->1.5 and Lasix was changed to oral. Creatinine was back to baseline at the time of discharge. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with visiting nurse services in good condition with appropriate follow up instructions. Medications on Admission: ALLOPURINOL-(Prescribed by Other Provider) - 300 mg Tablet - 1 (One) Tablet(s) by mouth once a day LISINOPRIL -(Prescribed by Other Provider) - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a day METOPROLOL SUCCINATE-(Prescribed by Other Provider) - 50 mg Tablet Extended Release 24 hr - 1.5 (One and a half) Tablet(s) by mouth once a day NITROGLYCERIN [NITROSTAT]-(Prescribed by Other Provider) - 0.4 mg Tablet, Sublingual - [**12-25**] Tablet(s) sublingually as needed for angina ROSUVASTATIN [CRESTOR]-(Prescribed by Other Provider) - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a day Medications - OTC ASPIRIN-(OTC)- 81 mg Tablet - 1 (One) Tablet(s) by mouth once a day CALCIUM CARBONATE -(OTC) - 500 mg calcium (1,250 mg) Tablet - 1 (One) Tablet(s) by mouth once a day FISH OIL-DHA-EPA - (Prescribed by Other Provider) - 1,200 mg-144 mg Capsule - 1 (One) Capsule(s) by mouth three times a day MULTIVITAMIN-(OTC) - Tablet - 1 (One) Tablet(s) by mouth once a day RANITIDINE HCL-(OTC) - 150 mg Tablet - 1 (One) Tablet(s) by mouth once day eye drops daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 4. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. omega-3 fatty acids Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 10. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 1 weeks. Disp:*14 Tablet Extended Release(s)* Refills:*0* 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] VNA Discharge Diagnosis: Coronary artery disease Diastolic Dysfunction Mild trivalvular insufficiency Hyperlipidemia GERD Hypertension Basal Cell CA Gout Past Surgical History: s/p Bilateral hernia repair Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Trace Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Doctor First Name **], Ste 2A, [**Telephone/Fax (1) 170**] Date/Time:[**2148-6-4**] 10:30 Surgeon: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2148-7-1**] 1:15 Cardiologist: Dr. [**Last Name (STitle) 4469**], [**7-9**] at 1:45pm **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:[**2148-5-28**]

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Discharge summary

report

Admission Date: [**2196-10-22**] Discharge Date: [**2196-11-12**] Date of Birth: [**2168-1-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: left arm tingling, diplopia, headaches, polyuria, polydypsia Major Surgical or Invasive Procedure: CRANIOTOMY with resection of pituitary macroadenoma, [**2196-10-28**] PROCEDURE: 1. Left-sided subfrontal and extended pterional approach for resection. 2. Microscopic dissection and resection of tumor at anteriod skull base. 3. Exenteration of frontal sinus. 4. Pericranial pedicle flap for isolation of frontal sinus. 5. Duraplasty using pericranial autograft. Right PICC placed [**2196-11-12**] History of Present Illness: Mr. [**Known lastname **] is a 28 year old man who initially presented to [**Hospital1 18**] on [**10-25**] in [**Location (un) 5503**], MA with 3-4 weeks of arm numbness, associated with headaches, polyuria/polydipsia, and double vision. He reports that he had been having intermittant headaches for several years, but his symptoms had acutely worsened recently and were associated with periods of double vision. He and his family had also noted increased fluid intake/urinary frequency of several weeks durations. Mr. [**Known lastname **] has a whithered right arm with significant contractions; he has limited sensation/movement of this arm. The duration of this malformation is unclear at present, but it is of many years duration. He has not noted any numbness/tingling in his right arm. Mr. [**Known lastname **] [**Last Name (Titles) 15797**] any changes in shoes size, hand size, or facial features. He does not wear rings. He had noted increased sweating particularly at night. He had not had any changes in bowel habits. His libido had recently decreased, but continued to have morning erections. His weight had increased by [**10-18**] lbs. He had not noticed easy bruising, or changes in cold/heat tolerance. . ED course here was notable for brief desaturation to the 70's while sleeping that resolved on stimulation and 2L of nasal O2. Patient was admitted to the floor and continued to by hyperglycemia to 300's-500's. Endocrine was consulted yesterday and recommended broad endocrine work-up given concern for secretory adenoma and possible acromegaly. MRI revealed mass as well as old left sided encephalomalacia concerning for old stroke but family cannot recall event. Also recommended insulin as patient was persistently hyperglycemic. This has so far revealed low LH and FSH, normal TSH, very marginally elevated AM cortisol, low testosterone and HgbA1C 17.0. Patient never really got full trial of insulin sliding scale as persistent elevated blood sugars made surgery concerned and they put him on an insulin drip. As of this morning the patient has a blood glucose of 100-200 on 18 units of IV insulin though he was also on a D5 drip. NSG requested transfer for persistent hyperglycemia and as they do not plan to proceed w/ surgery as an inpatient. Patient has been transitioned to sliding scale once again today w/ persistently elevated BG's in 300's but stable and no gap. . Aside from glucoses other major issue has been impressive apnea and desats while sleeping. He is reportedly doing better on CPAP but yesterday was noted to desat once on room air and, despite finger [**First Name9 (NamePattern2) 53484**] [**Location (un) 1131**] mid80s, ABG revealed O2 sat 91% 7.34/49/63. His paresthesias and weakness have never been supported by exam and have improved on their own. Patient will come to medicine for titration of insulin regimen and awaiting final diagnosis and management of likely [**Hospital1 **] secreting tumor. Endocrine and NSG are following. Past Medical History: None documented; family reports illness when very young at which time he received treatment via right arm injections which resulted in right arm deformity. Social History: Illegal immigrant from [**Country 6257**], immigrated approximately [**2185**]. Speaks some English. Currently lives with father and stepmother in [**Name (NI) 5503**], MA. Did not originally have health insurance; got Health Safety Net insurance prior to discharge. Smokes 1 pack per day, drinks socially, denies drug use. Family History: Patient is unaware of any history of diabetes or other endocrinopathies. Physical Exam: ON ADMISSION: VS; BP 136/106 RR 16 100% RA, wt 160 lbs Gen; young male, lying in bed, NAD, he has underdevelopment of the left side of body.mild coarse facial features, no frontal bossing, HEENT; PERLA, EOMI, no [**Name (NI) **] field defects on confrontation, no diplopia, poor dentition. mucous membranes moist, moderate sized tongue Neck -No goiter, no nodules, no acanthosis nigracans CV; RRR, no murmurs Pulm; CTA b/l, no gynaecomastia Abd; soft, NT, ND, no striae Extr; no edema, [**Last Name (un) **] looks doughy and squared Skin -no bruising, no paucity of facial, axillary and pubic hair genital -normal sized testes Neuro: Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3-->2mm. [**Last Name (un) 12588**] fields are full to confrontation however is not fully cooperative with exam. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Decreased bulk in right arm. Right arm is held flexed at elbow and wrist. Normal bulk and tone otherwise. No abnormal movements or tremors. Uncooperative with formal testing but proximally RUE 4-/5 with 0/5 distally (chronic). LUE [**5-3**] and lower extremities [**5-3**] and symmetric. Sensation: Decreased to light touch in left arm and leg and pinprick in left arm. However, patient is somewhat inconsistent with responses. Toes downgoing bilaterally Coordination: normal on finger-nose-finger on L AT TIME OF DISCHARGE: Vitals - T: BP: HR: RR: 02sat: RA GENERAL: Pleasant, well appearing young man in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. Macroglossia. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. Left hand enlarged, right hand deformity. There is a tender, slightly palpable cord over the cephalic vein on the LUE. SKIN: No rashes/lesions, ecchymoses. NEURO: Alert, oriented to person and place, not to date. Upper ext [**4-3**], LEs 5/5 strength Pertinent Results: ON ADMISSION: [**2196-10-22**] 06:20PM BLOOD WBC-8.0 RBC-4.70 Hgb-13.1* Hct-39.0* MCV-83 MCH-27.7 MCHC-33.5 RDW-16.1* Plt Ct-357 [**2196-10-22**] 06:20PM BLOOD Neuts-62.7 Lymphs-29.9 Monos-4.7 Eos-1.6 Baso-1.1 [**2196-10-22**] 06:20PM BLOOD PT-11.1 PTT-24.8 INR(PT)-0.9 [**2196-10-22**] 06:20PM BLOOD Glucose-307* UreaN-9 Creat-0.6 Na-140 K-3.8 Cl-103 HCO3-26 AnGap-15 [**2196-10-29**] 09:25AM BLOOD Na-151* [**2196-10-29**] 12:34PM BLOOD Na-149* [**2196-10-29**] 03:22PM BLOOD Na-147* [**2196-10-29**] 05:13PM BLOOD Na-146* [**2196-10-29**] 07:36AM BLOOD ALT-18 AST-22 AlkPhos-110 Amylase-68 TotBili-0.3 [**2196-10-29**] 07:36AM BLOOD Lipase-24 [**2196-10-22**] 06:20PM BLOOD Calcium-8.3* Phos-3.8 Mg-1.6 [**2196-11-5**] 04:47PM BLOOD calTIBC-410 VitB12-535 Folate-11.5 Ferritn-53 TRF-315 [**2196-10-23**] 08:35AM BLOOD %HbA1c-17.0* [**2196-10-22**] 06:20PM BLOOD Osmolal-303 [**2196-10-29**] 07:36AM BLOOD Osmolal-305 [**2196-10-22**] 06:20PM BLOOD Prolact-4.2 TSH-0.36 [**2196-11-5**] 06:35AM BLOOD TSH-0.16* [**2196-10-23**] 08:35AM BLOOD T4-6.3 calcTBG-1.06 TUptake-0.94 T4Index-5.9 Free T4-1.0 [**2196-10-31**] 11:23AM BLOOD T4-4.9 T3-45* Free T4-0.74* [**2196-11-6**] 11:43AM BLOOD Free T4-0.65* [**2196-10-23**] 08:35AM BLOOD Cortsol-20.8* Testost-50* [**2196-10-23**] 08:35AM BLOOD FreeTes-0.8* IMAGING: CT head [**2196-10-24**] IMPRESSION: 1. Similar appearance to sellar mass with suprasellar extension with compression of the optic chiasm, worse on the left. 2. Persistent left MCA territory extensive encephalomalacia, unchanged. MR PITUITARY W&W/O CONTRAST [**2196-10-24**] IMPRESSION: 1. Sellar mass with suprasellar extension arising from the pituitary, most consistent with an adenoma. There is compression of the optic chiasm, with relatively greater compression of the left optic nerve. 2. Extensive encephalomalacia along the left MCA territory, consistent with an old infarct. 3. No acute hemorrhage or infarct. POST-OPERATIVE CT Head [**2196-10-28**] IMPRESSION: Expected post-surgical changes are seen, with pneumocephalus and left frontal craniotomy. The previously noted mass has been partially resected. No surrounding hemorrhage is identified. PATHOLOGY [**2196-10-29**]: Pituitary adenoma, growth hormone-positive. Immunostain for [**Hospital1 **], chromogranin, and synaptophysin are positive. Immunostains for ACTH, FSH, LH, TSH, Prolactin, and HMB-45 are negative. DISCHARGE LABS: [**2196-11-12**] 08:30AM BLOOD WBC-9.9 RBC-3.77* Hgb-10.6* Hct-31.7* MCV-84 MCH-28.2 MCHC-33.4 RDW-16.4* Plt Ct-439 [**2196-11-12**] 08:30AM BLOOD Glucose-98 UreaN-14 Creat-0.6 Na-144 K-3.7 Cl-105 HCO3-28 AnGap-15 [**2196-11-6**] 03:04AM BLOOD ALT-25 AST-14 LD(LDH)-209 AlkPhos-103 TotBili-0.3 [**2196-11-12**] 08:30AM BLOOD Calcium-9.0 Phos-5.4* Mg-2.0 [**2196-11-12**] 08:30AM BLOOD Osmolal-299 [**2196-11-11**] 07:15AM BLOOD Vanco-14.8 POST-OPERATIVE ADH, IGF-1, [**Hospital1 **] levels pending at time of discharge. Brief Hospital Course: =========================================== PRESENTATION/SURGERY: [**Known firstname **] [**Known lastname **] is a 28 year old male admitted to neurosurgery at [**Hospital1 18**] on [**2196-10-22**] with a sella mass. [**2196-10-23**] Endocrine consulted regarding high glucose levels (patient was not diabetic previously); Insulin drip was initiated. Head imaging by MRI and CT showed a large 1.9 cm pituitaty tumor. The patient was transferred to medicine on [**2196-10-24**]. While on medicine, the patient's insulin regimen was titrated and normoglycemia was attained. He underwent [**Date Range **] field testing by neuro-opthalmology with their full evaluation in OMR. He also was seen by the sleep consult service due to episodes of witnessed sleep apnea and associated desaturations to the 70s. He was started on CPAP at night and with naps. Overnight from [**Date range (1) 84692**], the patient developed headache and complained of vision changes although bedside [**Date range (1) **] field testing was unchanged from prior. Stat head CT was also unchanged from prior. On the am of [**2196-10-28**], the patient was nauseous and vomiting, was hypertensive, and continued to complain of vision changes. Stat head CT was again done and was concerning for increase in size of suprasellar mass as well as possible hemorrhage within the mass. He was therefore taken to the OR by Dr [**Last Name (STitle) **] for emergent craniotomy and pituitary macroadenoma resection, after which he was taken to the SICU. Only partial resection of mass was possible. Surgery was uncomplicated, with clear border between normal, compressed pituitary tissue, and adenoma. Adenoma was resected from the left optic nerve as well. Post operative course complicated by hypertension >200 noted POD1, w/o imaging evidence of worsening interval swelling/hemorrhage from day of operation. Pathology returned [**Hospital1 **] secreting pituitary macroadenoma. New onset diabetes mellitus was therefore from growth hormone stimulation of IGF-1 causing insulin resistance. It is expected that his diabetes will improve over time with the lesion now removed. ============================================= SICU COURSE: While in the SICU the patient was noted to have persistent polyuria with dilute urine and polydypsia; was found to have post-operative panhypopituitarism with multiple endocrine abnormalities: increased [**Hospital1 **], IGF-1, and cortisol, decreased free T3, FSH, testosterone. Hyperglycemia with A1c = 17.0, C-peptide positive, GAD antibody negative. He was also noted to have a septic superficial thrombophlebitis of the LUE near the antecubital fossa. The pus in this lesion was drained by vascular surgery, and he was treated with intravenous vancomycin. He was transferred to the medicine floor for further management on [**2196-11-5**]. ============================================== MEDICINE HOSPITALIZATION COURSE: Outlined by problem below. . #1: PANHYPOPITUITARISM: #1A Polyuria: Initially thought to be secondary to ADH deficiency or hyperglycemia. Persisted following insulin management of hyperglycemia, making ADH deficiency (diabetes insipidus) or primary polydipsia mixed with DI more likely. NPO/no IVF trial ([**11-5**] midnight to [**11-6**] afternoon) completed, overall put out 13L of dilute urine and took in 0.4L w/o substantial serum concentration; results suggest unmeasured intake of free water/salt during NPO trial. Was able to concentrate urine at end of trial (urine Osm > 400) indicating some ADH secretion/responsiveness. . At time of discharge, was eating/drinking freely, Serum Na and Serum Osm normalized, Uosm concentrated more appropriately with administration of desmopressin. Urine output and polydypsia also improved more towards normal. - 200 mcg DDAVP [**Hospital1 **] is final dose at time of discharge. - ADH levels pending (send out labs) at time of discharge. . #1B Polyphagia: extremely large food intake, possibly secondary to hypothalamic damage. Endocrine did not think likely secondary to metabolic effects of [**Hospital1 **]/IGF-1 given severity of polyphagia. - Continue to follow weights. - Will need nutrition consult/education as outpatient (or prior to discharge from rehab facility) given newly diagnosed diabetes mellitus. [**Month (only) 116**] need calorie restriction if polyphagia persists and blood glucose poorly controlled. . #1C Adrenal Insufficiency: One measured cortisol prior to surgery at 20.8 (normal/high). At maintenance hydrocortisone at time of discharge 20 mg QAM/10 mg QPM. On [**2196-11-10**], held PM cortisone dose and AM cortisol measurement was 8.1. Per endocrine recommendations, kept 20 mg QAM/10 mg QPM dosing. In [**1-1**] weeks, can be reevaluated again to see if this should be continued. Goal is for AM Cortisol to be >10 with PM dose being held, at which point hydrocortisone could be discontinued. . #1D Hyperglycemia: Likely insulin resistance secondary to [**Hospital1 **] activation of IGF-1 secretion/signaling. Normal C-peptide and negative GAD argued against T1DM. Insulin dependence persisted following surgery, may not completely resolve due to incomplete resection of adenoma. - At time of discharge, 70 units glargine QHS and Metformin 500 mg [**Hospital1 **] (Metformin started on [**2196-11-11**]). After two weeks, Metformin dose could be increased to 1000 mg [**Hospital1 **]. - MONITOR BLOOD GLUCOSE VALUES CLOSELY AS DIABETES WILL LIKELY RESOLVE AND LESS INSULIN WILL BE NEEDED AS [**Hospital1 **] AND IGF-1 LEVELS NORMALIZE AND ASSOCIATED INSULIN RESISTANCE IMPROVES. . #1E Thyroid Deficiency: Low TSH (.16) and low T4 (.74) on [**10-31**] suggests pituitary cause of hypothyroidism, likely present prior to surgery given low free T3 on [**10-23**]. However, partial resection of pituitary is also a possibility. [**Month (only) 116**] be complicated by sick euthyroid. Started 100 mcg levothyroxine on [**2196-11-11**]. Patient should have repeat TFTs in [**4-4**] weeks to see if dose needs to be changed. . #1F Testosterone deficiency: low FSH and low testosterone consistent with pituitary failure prior to surgery. Testicles appear grossly normal. - Testosterone will need to be rechecked as an outpatient. [**Month (only) 116**] consider hormone replacement for this young gentleman. . #2. Bacteremia: [**11-1**] blood culture in the context of septic thrombophlebitis grew coagulase negative staphylococcus resistant to oxacillin. Patient was started on vancomycin at that time (now day 10). ID was consulted. A PICC was placed on [**11-12**]. - Patient should be continued on vancomycin 1250 mg tid until [**11-23**] - ID recommends regular vancomycin troughs with a therapeutic goal = 15, and surveillance blood cultures . #3. Status post craniotomy and partial resection of [**Hospital1 **] secreting pituitary macroadenoma on [**10-28**]. Operation was uncomplicated, however, full resection of the tumor was not achieved. Some non adenomatous pituitary tissue remained following resection, however, tissue was significantly compressed. Surgical site has remained clear, dry, and intact without evidence of infection. Sutures and staples have been removed - THE PATIENT IS ON SINUS PRECAUTIONS UNTIL [**11-25**] (no straws, no incentive spriometer, no nose blowing, no CPAP) - Repeat [**Hospital1 **]/IGF-1 levels from [**11-9**] are pending . #4. Social: Primarily Portugese speaking. Illegal immigrant from [**Country 6257**]. Lives with stepmother and father in [**Name (NI) 5503**], father is also an illegal immigrants. Family is having difficulty paying rent secondary to expenses related to the patient's hospitalization; the hospital has advocated on their behalf with [**Location (un) 5503**] housing authority. Currently has Health Safety Net insurance. . #5. Sleep apnea: combination of obstructive and central sleep apnea, with periodic, self resolving desaturations to the low 80s. Has recently completed a sleep study, results are pending. - Patient cannot use CPAP because of sinus rest . #6. Anemia: normocytic with large RDW. Hct fell from mid 40s to low 30s during hospitalization. Studies done [**11-6**] showed Ferritin 53 (low normal), Iron 48 (low normal), TIBC 410 (high normal), transferrin 315, all. Vitamin B12 and folate wnl. Studies consistent with anemia secondary to repeat blood draws, bordering on Fe deficiency. Started Fe sulfate on [**11-7**]. Hct has remained stable in mid-low 30s since initiation of Fe supplementation. . #7. Superficial thrombophlebitis in left cephalic vein. No indication of septic thrombophlebitis; asymptomatic. - We have been treating with warm compresses . #8. Dry eyes and blurry vision: The patient has decreased [**Month/Year (2) **] acuity, L 20/70 -1, R 20/50 -1, which improved with pin hole testing. Ophthalmology has seen the patient and did not find evidence of pathology, and suggested corrective lenses. He has a baseline L RAPD, but has [**Month/Year (2) **] field defect has resolved. - Patient has been on standing eye ointment with eye drops PRN - Outpatient follow-up with neuro-ophthalmology has been arranged. . [**Known firstname 84693**] code status was confirmed as FULL CODE during this admission. He was deemed medically stable and fit for discharge to [**Hospital1 **] acute care rehabilitation on [**2196-11-12**] for completion of his IV antibiotic course. He has close outpatient follow-up scheduled. Medications on Admission: Tylenol prn headaches. Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain / fever. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 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 for constipation. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic QHS (once a day (at bedtime)) as needed for dry eyes. 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-1**] Drops Ophthalmic PRN (as needed) as needed for eye dryness. 9. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Hydrocortisone 5 mg Tablet Sig: Four (4) Tablet PO QAM (once a day (in the morning)). 13. Diphenhydramine HCl 25 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 14. Desmopressin 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): started on [**2196-11-11**]. 16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 17. Lantus 100 unit/mL Solution Sig: Seventy (70) units Subcutaneous at bedtime. 18. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 19. Hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO QPM. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: Diabetes Mellitus Type 2 (secondary to [**Hospital1 **] secreting pituitary macroadenoma) Sleep apnea Adrenal insufficiency Hypothyroidism Diabetes Insipidus Growth hormone secreting pituitary macroadenoma (s/p resection) Superficial septic thrombophlebitis with bacteremia Acromegaly Discharge Condition: Stable, afebrile, blood pressure wnl, no diplopia, no headache, s/p pituitary adenoma resection. Discharge Instructions: Dear [**Known firstname **], you were admitted to the hospital because of headache, changes in vision, and drinking and urinating large amounts. You were found to have a tumor in your head, called a pituitary adenoma. This was removed surgically. As a result of this tumor being removed, you were left with hormone changes that will now require multiple new medications as outlined below. You were deemed medically stable for discharge to a rehabilitation facility on [**2196-11-12**]. You will require close follow-up as an outpatient. . All of your medications at the time of discharge are NEW. IT IS EXTREMELY IMPORTANT FOR YOUR HEALTH THAT YOU TAKE ALL OF THESE MEDICATIONS EXACTLY AS PRESCRIBED AND THAT YOU FOLLOW UP WITH ALL OF YOUR APPOINTMENTS. . Please call your doctor or go to the nearest emergency room if you have increasing shortness of breath, chest pain, you lose consciousness, have a fever >100.4, you have diarrhea or vomiting for more than 24 hours, you have a large increase or decrease in your urination, you develop a headache or changes in vision, you have bleeding, or other concerning symptoms. . It was a pleasure caring for you during this hospital stay. Followup Instructions: The following appointments have been scheduled for you. It is EXTREMELY IMPORTANT that you keep all of these appointments: Provider: [**Name10 (NameIs) **] FIELD SCREENING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2196-11-23**] 2:30 PM Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD (Ophthalmology) Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2196-11-23**] 3:15 PM Provider: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. (Endocrinology) Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2196-11-30**] 12:30 PM [**Doctor Last Name **]/[**Hospital1 **] (sleep study) on [**2197-1-20**] at 2pm in [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]. You will also be contact[**Name (NI) **] by Dr.[**Name (NI) 9034**] office in Neurosurgery ([**Telephone/Fax (1) 2731**]) and Dr. [**First Name (STitle) 30217**] [**Name (STitle) 84694**] office in Nephrology (kidney medicine) [**Telephone/Fax (1) 721**] in order to have follow up appointments made with them. Completed by:[**2196-11-12**]

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icd9cm

[ [ [] ] ]

[ "38.93", "22.42", "02.03", "04.07", "07.61" ]

icd9pcs

[ [ [] ] ]

21155, 21198

9845, 19266

378, 778

21527, 21626

6884, 6884

22860, 23926

4337, 4411

19339, 21132

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2,219

116,784

25373

Discharge summary

report

Admission Date: [**2137-6-9**] Discharge Date: [**2137-6-14**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Anterior ST segment myocardial infarction Major Surgical or Invasive Procedure: Coronary artery catheterization and angioplasty of left anterior descending artery to the right coronary artery Intraaortic Balloon Pump support Swan-Ganz catheterization Catherization results: . 1. Selective coronary angiography demonstrated two vessel coronary artery disease in this left dominant circulation. The LMCA was severely calcified. The proximal LAD was severely calcified and was completely occluded after the takeoff of a large D1 branch. The LCX had a distal tubular stenosis. The OM branches were without angiographically apparent flow limiting disease. The RCA had a proximal 80% stenosis and was a non-dominant vessel. . 2. Resting hemodynamics from right heart catheterization demonstrated severely elevated right and left sided filling pressures (RVEDP=17mmHg and mean PCWP=33mmHg). Cardiac output and index were severely depressed at 2.5 L/min and 1.3 L/min/m2 respectively. Severe pulmonary arterial hypertension was present (64/31). . 3. Left ventriculogram was not performed to reduce contrast load. . 4. PCI of the LAD and diagonal complicated by distal embolization into the diagonal. The LAD had a 20% residual stenosis with distal TIMI 2 flow and poor myocardial perfusion at the end of the procedure. . 5. Successful placement of an 8 French 40 cc IABP via the RFA. <br><br> FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. . 2. Anterior ST segment elevation myocardial infarction. . 3. Severely elevated right and left sided filling pressures. . 4. Cardiogenic shock with placement of intra-aortic balloon assist device. . 5. PCI of the LAD/Diagonal. History of Present Illness: This is an 83 male with a history of hypertension, atrial fibrillation, subdural hematoma ('[**30**] on coumadin), who presented to an outside hospital 20 hours after the onset of substernal chest pain. An EKG performed at the time showed ST segment elevation in V4-V5, Q waves in leads II, III, avF, and atrial fibrillation. The patient received sublingual nitroglycerin X3 with no alleviation of chest pain. A nitroglycerin drip was then started and brought the patient some relief with 2/10 chest pain. Cardiac enzymes at the time showed an elevated CK of 2519. The patient was transferred to [**Hospital1 18**] for a cath. A PTCA was performed to the left anterior descemding artery to the right coronary (10% residual stenosis). A stent was not placed due to low residual flow. At the time the patient was found to have a low cardiac index of 1.3. An intra-aortic balloon pump was placed. The patient received Lasix 40mg IV and 300mg bolus of Plavix. Integrillin, ASA, and Lipitor were also started. Past Medical History: - CAD (unclear history) - Atrial fibrillation - Hypertension - Subdural Hematoma (s/p trauma on coumadin '[**30**]) Social History: Lives with wife, quit tobacco Family History: Non-contributory Physical Exam: Physical Exam on Admission VS: 93 144/71 (PA 58/26) 14 96% 2L Gen: NAD, lying in bed HEENT: neck supple, 7cm JVD Heart: nl rate, irreg rhythm (Atrial fibrillation), S1S2, no G/M/R Lungs: crackles at the bases Abdomen: soft, non-tender, non-distended, +BS; slight discomfort due to IABP R Groin: femoral pulse present, no bruits, no ecchymosis Extremities: feet cold, DP appreciated bilaterally with doppler; no c/c/e Neuro: II-XII grossly intact Pertinent Results: Cardiac Enzymes . [**2137-6-9**] 02:18PM BLOOD CK(CPK)-3071* [**2137-6-9**] 07:40PM BLOOD CK(CPK)-4538* [**2137-6-11**] 07:45AM BLOOD CK(CPK)-686* . [**2137-6-9**] 02:18PM BLOOD CK-MB->500 cTropnT-9.33* [**2137-6-10**] 01:58AM BLOOD CK-MB-486* MB Indx-14.5* cTropnT-22.87* [**2137-6-11**] 07:45AM BLOOD CK-MB-47* MB Indx-6.9* cTropnT-14.51* . Chemistry . [**2137-6-9**] 02:18PM BLOOD Glucose-168* UreaN-32* Creat-1.1 Na-132* K-4.5 Cl-98 HCO3-24 AnGap-15 [**2137-6-14**] 06:25AM BLOOD Glucose-87 UreaN-46* Creat-1.5* Na-135 K-4.3 Cl-100 HCO3-25 AnGap-14 . [**2137-6-9**] 02:18PM BLOOD Calcium-8.2* Phos-3.7 Mg-1.9 [**2137-6-14**] 06:25AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2 . CBC [**2137-6-14**] 06:25AM BLOOD WBC-9.5 RBC-4.20* Hgb-12.4* Hct-37.3* MCV-89 MCH-29.5 MCHC-33.2 RDW-13.6 Plt Ct-198 [**2137-6-9**] 02:18PM BLOOD WBC-15.3* RBC-4.87 Hgb-14.4 Hct-42.5 MCV-87 MCH-29.6 MCHC-33.9 RDW-13.5 Plt Ct-199 Brief Hospital Course: 83M s/p STEMI of LAD and RCA territory, loss of D1 [**1-2**] embolization, transferred to CCU for optimization of hemodynamics in the setting of cardiogenic shock. * Pump: Given cardiac index of 1.3 in cath lab, IABP was placed for optimization of systolic and diastolic pressures. On IABP, cardiac index improved to 1.7, and although patient diuresed successfully with 40mg IV Lasix, nesiritide gtt was started to further improve hemodynamics. On hospital day two, cardiac index improved to 2.3 on nesiritide and IABP, and both were discontinued on hospital day three as patient continued to do improve in function with excellent diuresis on lasix alone (PAP 43/21). Echocardiogram revealed EF<20%, 1+ MR, 1+ TR and global hypokinesis. Lisinopril was initiated for afterload reduction, and at the time of discharge, was uptitrated to 7.5mg QD. Patient was instructed to return for echocardiogram in one month following discharge. Digoxin was continued for additional rate control and to also further improve inotropy as outpatient. Despite poor ejection fraction, patient was considered extremely poor candidate for anticoagulation given history of subdural hematoma. * Rhythm: Atrial fibrillation. Stable throughout hospitalization. Given history of subdural hematoma, patient was not candidate for long-term anticoagulation. Patient did require one dose of IV metoprolol for stable Afib with RVR to improve rate control. * STEMI: Given patient's late presentation (infarct may have begun as early was 3 days before presentation), flow in LAD and RCA despite PTCA were extremely poor, making stent placement impossible. CK peaked at 4538, MB >500 on the evening of hospital day one consistent with transmural infarction. Patient was started on medical management regimen of ASA 325, Plavix 75, Atovastatin 80, with Integrilin for 18 hours post catheterization. Patient tolerated these medications without evidence of intracranial hemorrhage or other site of bleeding. To improve rate control post MI, metoprolol 25 [**Hospital1 **] was initiated. To improve afterload reduction, patient was started on lisinopril as above and titrated to 7.5mg QD. Patient remained chest pain free throughout hospitalization. * Urinary Tract Infection: Patient had a low grade fever (100.5) on hospital day four, and urinalysis revealed sm leuk esterase w/ few bacteria. However, given the fact that this was in the setting of indwelling foley, patient was initiated on bactrim for treatment with an intent to complete a 7 day course as an outpatient. * Dehydration: Patient was initially diuresed aggressively given cardiogenic shock, however, near the time of discharge, patient had mild bump in creatinine (chronic renal insufficiency Cr 1.1-1.2) to 1.5, and urine lytes revealed prerenal (UOsm [**Telephone/Fax (1) 63454**] mg/dL UCreat 86 mg/dL USodium 15 mEq/L). Patient was given 250cc NS for hydration and encouraged to take more PO fluids. At the time of discharge, patient continued to have mild ambulatory desaturations and exhaustion after minimal exertion, and was therefore referred to short term inpatient rehabilitation. Patient was instructed to followup with primary care physician and cardiologist one week and one month respectively following discharge from rehab. Medications on Admission: Digoxin Diltiazem Diovan Lasix Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 6. Pantoprazole Sodium 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* 7. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*2* 8. Metoprolol Succinate 50 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: [**Hospital3 7665**] Discharge Diagnosis: Anterior ST segment elevation myocardial infarction. Discharge Condition: Good Discharge Instructions: You must call 911 first if you experience any chest pain or chest pressure, if you become short of breath, or if you experience any numbness, tingling or pain radiating to your jaw or arms/hands. You can resume normal activities, but you are not to assume any strenous activity such as lifting or pulling until you are cleared by rehabilitation services. Followup Instructions: Draw blood for digoxin level in one week following discharge. Repeat echocardiogram in one month following discharge.

[ "427.31", "410.71", "401.9", "V58.61", "414.01", "599.0", "785.51", "276.5", "593.9" ]

icd9cm

[ [ [] ] ]

[ "36.01", "00.13", "88.56", "37.23", "99.20", "37.61" ]

icd9pcs

[ [ [] ] ]

9017, 9064

4571, 7864

303, 1610

9161, 9167

3644, 4548

9571, 9692

3144, 3162

7945, 8994

9085, 9140

7890, 7922

1627, 1896

9191, 9548

3177, 3625

222, 265

1924, 2941

2963, 3081

3097, 3128

45,918

169,062

33032

Discharge summary

report

Admission Date: [**2172-10-12**] Discharge Date: [**2172-10-21**] Date of Birth: [**2095-1-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2736**] Chief Complaint: Aortic stenosis Decompensated heart failure Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 77F with DM, HTN, Obesity, CRF with Cr of 1.7, carotid artery disease, complete heart block s/p PPM placement, and CHF who presents for heparin gtt in preparation for cardiac catheterization tomorrow. . As per the pt, she has had SOB for the past year now. As per records, her SOB is [**2-11**] critical AS. Her DOE has limited her to [**5-18**] feet. She denies any CP, endorses orthopnea (sleeps in a chair), also endorses PND. She denies any diaphoresis, but notes extensive [**Location (un) **] recently. Seh denies a cough. She denies any N/V, and per the pt, has no known h/o CAD. She does endorse wheezing, a runny nose, and some diarrhea. . On review of systems, she 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. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. . Past Medical History: 1.. CARDIAC RISK FACTORS:(+)Diabetes,(+)Dyslipidemia,(+)Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: PPM 3. OTHER PAST MEDICAL HISTORY: 1. Diabetes mellitus, on oral medications 2. Probable coronary artery disease 3. Hypertension, essential 4. Complete heart block resulting in PPM placement 5. Obesity 6. Chronic renal disease, with creatinine 1.7 mg/dL 7. Carotid artery disease by Carotid [**First Name9 (NamePattern2) 76815**] [**6-17**]. [**2172**]. There was a 40-50% stenosis on the right internal carotid artery and no significant stenoses within the left internal carotid artery. 9. Afib on coumadin 10. HL 11. hypothyroidism Social History: She lives alone. Activity was very restricted because of DOE and obesity. Drove occasionally. Has a daughter who is involved in her care. She does not smoke or drink. denies drugs. Family History: There is a family history of heart disease. There is no family history of hypertension, diabetes, or strokes. Her mother died at age 62 of leukemia, and her father died in his late 40s of cirrhosis. A daughter has right ventricular dysplasia. Physical Exam: DISCHARGE PHYSICAL EXAM: VS: T98.2, BP 122/66, P58, RR 18, 97/RA GENERAL: obese F in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6cm CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. Grade III/VI SEM best heard at LUSB with no radiation. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB. ABDOMEN: obese, soft, NTND. No HSM or tenderness. Abd aorta unable to be palpated. EXTREMITIES: No c/c. trace pitting edema, obese limbs. PULSES: Right: 2+ radial, pulsus parvus et tardus, unable to palp DP Left: 2+ radial, pulsus parvus et tardus, unable to palp DP Pertinent Results: ADMISSION LABS [**2172-10-12**] 08:40PM BLOOD WBC-7.5 RBC-3.40* Hgb-9.1* Hct-28.7* MCV-85 MCH-26.9* MCHC-31.8 RDW-18.0* Plt Ct-291 [**2172-10-12**] 08:40PM BLOOD PT-40.8* PTT-28.8 INR(PT)-4.3* [**2172-10-12**] 08:40PM BLOOD Plt Ct-291 [**2172-10-12**] 08:40PM BLOOD Glucose-136* UreaN-50* Creat-1.9* Na-140 K-4.2 Cl-107 HCO3-20* AnGap-17 [**2172-10-12**] 08:40PM BLOOD proBNP-GREATER TH [**2172-10-12**] 08:40PM BLOOD Calcium-8.6 Phos-3.4 Mg-2.0 ECHOCARDIOGRAM [**2172-10-15**] The left atrium is elongated. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated with moderate global hypokinesis (LVEF = 35 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild to moderate ([**1-11**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, inerolaterally directed jet of mild to moderate ([**1-11**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. CAROTID US [**2172-10-13**]: Impression: Right ICA stenosis <40%. Left ICA stenosis <40%. Slopped waveforms throughout likely cardiac in origin CHEST XRAY FINDINGS: No previous images. There is globular enlargement of the cardiac silhouette with evidence of mild elevation of pulmonary venous pressure. Pacemaker device is in place. One lead is in the region of the right atrium. The other is somewhat medial to the normal position of the apex of the right ventricle, though this may be just placed due to substantial enlargement of the left ventricle. A lateral view would be helpful for precise evaluation. CARDIAC CATHETERIZATION with Valvuloplasty [**2172-10-14**]: COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated no angiographically significant flow-limiting lesions. The LMCA had a 30% stenosis. The LAD had mild luminal irregularities with a 30-40% mid-vessel lesion. The LCx also had luminal irregularities iwth a 30% mid-vessel lesion. The RCA could not be enaged, but non-selective injetion was without focal stenoses. 2. Resting hemodynamics revealed significantly elevated biventricular filling pressures, with an RVEDP of 28mmHg and an LVEDP of 40mmHg. There was severe pulmonary hypertension, with a PA sysolic pressure of 84mmHg. The cardiac index was reduced at 1.49 L/min/m2. There was critical aortic stenosis, with a valculated valve area of 0.27cm2 with a peak to peak simultaneous gradient of 38.6 mmHg across the aortic valve. 3. The ascending aorta and aortic arch were showed significant calcification on fluroscopy. 4. During the procedure with the double-lumen pigtail across the aortic valve, the patient developed severe respiratory distress requiring elective intubation. 5. Successful emergent aortic valvuloplasty with a 20mm x5cm Tyshak II balloon using two inflations resulting in significant improvement in filling pressures and aortic valve area. LVEDP decreased to 25mmHg, CO increased to 4.38 L/min and due to decrease in systolic ejection period, the aortic valve area increased to 0.8 cm2. FINAL DIAGNOSIS: 1. Non-obstructive coronary artery disease. 2. Critical aortic stenosis. 3. Severe cardiac dysfunction, with a reduced cardiac index, severely elevated left and right sided filling pressures consistent with cardiogenic shock. 4. Successful emergent aortic valvuloplasty with 20mm Tyshak II balloon with improvement in hemodyanmics. 5. Elective intubation. CT Thorax non-Contrast [**2172-10-16**]: IMPRESSION 1. Heavy burden of calcific plaque in the ascending aorta without aneurysm, intramural hematoma, or mediastinal hematoma. 2. Enlargement of the main and right and left pulmonary arteries consistent with pulmonary hypertension. 3. Bilateral small pleural effusions, right slightly larger than left. 4. Multiple bilateral nonspecific 3-6 mm ground glass pulmonary nodules. 5. 2.7-cm left adrenal lesion, most probably an adenoma, to be confirmed with dedicated MRI or CT scan of the adrenals. CXR [**2172-10-20**] FINDINGS: As compared to the previous radiograph, there is no relevant change. Unchanged cardiomegaly with enlarged left pulmonary segments. Moderate tortuosity of the thoracic aorta. If signs of pulmonary edema are present, they are minimal. No evidence of pleural effusions. Unchanged mild retrocardiac atelectasis. Unchanged right pectoral pacemaker in situ. Discharge Labs: 137 101 78 ---------------< 183 4.3 25 2.0 Ca: 8.2 Mg: 2.3 P: 3.7 9.0>8.3/26.1<271 PT: 19.0 PTT: 81.7 INR: 1.7 Brief Hospital Course: 77F with DM, HTN, Obesity, CRF with Cr of 1.7, carotid artery disease, complete heart block s/p PPM placement, and CHF who presents with decompensated heart failure in the setting critical/severe AS. . # CAD: Pt has presumed CAD, although has never had PCI or CABG or angiography. Pt had cardiac cath once INR <2. The Cath showed non-obstructive coronary disease. While in house, we continued her medical management with continuation of enalapril. Aspirin was started and Atenolol was changed to Metoprolol for her low EF. . # Acute on Chronic Systolic CHF: Pt has known CHF with recent echo with EF of 50%, repeat here with EF of 35%. Likely diastolic and systolic CHF [**2-11**] AS. JVP of 12 cm c/w volume overload. proBNP>70K. We continued her home atenolol and enalapril, but converted her furosemide to IV with an increased dose in an effort to diurese some fluid off. We did do a repeat ECHO which showed EF of 35% and [**1-11**]+ AR and MR. Of note, her tenous state with the AS and the CHF made it difficult for us to pre-cath hydrate and treat with mucomyst (see below). As the CHF is [**2-11**] AS, valve replacement is indicated. She will see Dr. [**Last Name (STitle) **] for AVR surgical evaluation on [**11-12**] and Dr. [**Last Name (STitle) **] on [**11-17**] for evaluation for percutaneous AVR if surgical AVR is not an option. Given her low EF, Atenolol was changed to Metoprolol at d/c and Furosemide changed to Torsemide. Enalapril was decreased. She needs daily weights, a low Na diet and careful fluid evaluation. . # Aflutter: Pt has PPM in and has h/o arrhythmia, however unclear what kind. We continued her Beta blocker and amiodarone and monitored her on tele. She may be a good candidate for cardioversion on amiodarone (previously DCCV while not on antiarrhythmic) to restore sinus rhythm given heart failure. As we had to reverse her Warfarin in house with Vitamin K, we started a heparin gtt once her INR was <2. We were unable to fully bridge her back to coumadin prior to discharge so she needs a heparin drip until her INR is > 2.0. Her home dose of coumadin is 4mg, currently on 5 mg waiting for a therapeutic INR. . # CRF: Cr of 1.7. On furosemide and enalapril as outpt. We continued with the enalapril and changed to Torsemide. Unfortunately, we were unable to treat with mucomyst and precath hydration given her tenous volume status. We trended her Cr and it has [**Month (only) **] to 2.0 at time of discharge. . # Aortic Stenosis: critical AS requiring possible surgery versus percutaneous AVR. As pt is symptomatic, will require intervention. The following studies were done with reports in the previous section (TTE, Carotid US, cardiac catheterization, and CT angiography). She will need full PFT's as outpt to complete workup along with another ECHO, this has been scheduled for the same day. . # DM: Home meds d/c'ed and was on humalopg sliding scale while here. Given CHF and ARF, metformin and Glyburide has been d/c'ed and Glipizide started. She should continue the sliding scale insulin QID until FS are consistantly < 175. Glipizide will likely have to be titrated up according to fingerstick results. . # Hypothyroidism: Remained stable on home synthroid. Medications on Admission: Atenolol 100 mg PO daily enalapril 20 daily furosemide 60 [**Hospital1 **] metformin 500 mg [**Hospital1 **] levothyroxine 174 mcg daily simvastatin 40 mg daily amiodarone 200 mg daily glyburide 5 mg daily mvi daily iron sulfate 325 daily coumadin 4 mg daily . Discharge Medications: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ferrous sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 6. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical twice a day as needed for rash/itch: to skin folds. 8. torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 11. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 13. insulin lispro 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous four times a day: before meals. Please check FS QID. Can d/c once FS consistantly < 175. 14. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 15. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: per sliding scale units Intravenous continuous: Keep until INR > 2.0. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Aortic Stenosis Acute on Chronic Systolic Congestive Heart Failure Diabetes Mellitus Type 2 Hypertension Atrial Flutter on coumadin Complete Heart Block s/p Pacemaker 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: It was a pleasure taking care of you during your hospitalization. You were admitted to [**Hospital1 18**] for a work up of your aortic stenosis and the possibility of surgery to fix the aortic valve. During the catheterization, your had trouble breathing and a valvuloplasty ws done which opened the aortic valve. This in not a permanant fix of the valve and you will see Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 45821**] to discuss further procedures and possible future valve replacement percutaneously (with catheters). While you were here, we tried to take fluid off in an effort to improve your shortness of breath. You are on a new medicine to keep the fluid off. Otherwise, we completed the work up for the possibility of future procedures which included ultrasounds of your heart and vessels in your neck and a CT scan to look at the vessels in your torso. THE FOLLOWING CHANGES WERE MADE TO YOUR MEDICATIONS: 1. Change Glucatrol to Glipizide to control your diabetes 2. Take Insulin as needed to control your blood sugar until a good dose of the Glipizide and Metformin is found 3. Continue Heparin intravenous until your INR is more than 2. 4. Decrease Enalapril to 5 mg daily 5. Start Miconazole powder to treat the fungal infection in your groin area 6. Change Furosemide to Torsemide 7. Increase Warfain to 5 mg daily 8. Start Aspirin 81 mg daily 9. Stop Metformin because of your heart failure . Please see your physicians as specified below. . Daily weights. Please call provider if weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. Followup Instructions: Name: [**Last Name (LF) 76816**],[**First Name3 (LF) 2747**] H. Address: [**Last Name (un) 76817**], [**Location (un) **],[**Numeric Identifier 29728**] Phone: [**Telephone/Fax (1) 76818**] Appointment: Please make an appt when you return home. Name: [**Last Name (LF) 11493**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6105**] MD Address: [**Apartment Address(1) 28703**], [**Location (un) **],[**Numeric Identifier 28704**] Phone: [**Telephone/Fax (1) 11650**] When: Monday, [**2172-10-26**]:45AM Department: CARDIAC SERVICES When: TUESDAY [**2172-11-17**] at 1:40 PM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SURGERY When: THURSDAY [**2172-11-12**] at 2:00 PM With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**] Building: LM [**Hospital Unit Name **] [**Location (un) 551**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**2172-11-5**] 10:00a PFT [**Hospital Ward Name **] 7 - RM 4 GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX), [**Location (un) **] PULMONARY LAB Department: CARDIAC SERVICES When: THURSDAY [**2172-11-5**] at 9:00 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 Completed by:[**2172-10-22**]

[ "433.10", "278.00", "585.9", "V45.01", "599.0", "428.0", "518.5", "244.9", "584.9", "427.32", "285.9", "785.51", "416.8", "403.90", "428.23", "041.3", "V58.61", "424.1", "250.00" ]

icd9cm

[ [ [] ] ]

[ "35.96", "96.71", "38.91", "37.23", "96.04", "88.56" ]

icd9pcs

[ [ [] ] ]

13619, 13666

8637, 11855

361, 387

13877, 13877

3483, 7173

15673, 17297

2448, 2693

12168, 13596

13687, 13856

11881, 12145

7190, 8477

14060, 15650

8493, 8614

2708, 2708

1628, 1700

278, 323

415, 1517

13892, 14036

1731, 2233

1539, 1608

2249, 2432

2734, 3464

5,384

115,700

50325

Discharge summary

report

Admission Date: [**2151-1-14**] Discharge Date: [**2151-2-25**] Date of Birth: [**2105-10-14**] Sex: M Service: SURGERY Allergies: Penicillins / Quinolones Attending:[**First Name3 (LF) 148**] Chief Complaint: Acute Pancreatitis Major Surgical or Invasive Procedure: #Retrograde SMA stenting with vein patch angioplasty using right greater saphenous vein. #Second look exploratory laparotomy and small bowel resections x 2. #Third look exploratory laparotomy. Ileocecectomy with hand-sewn two-layer side-to-side ileocolostomy. Small bowel resections x 2 with hand-sewn two-layer anastomoses x 2. Gastrostomy tube placement. History of Present Illness: This is 45 year old male who presented to [**Hospital1 18**] on [**2151-1-14**] with a complaint of severe mid-epigastric pain, diarrhea, nausea, malaise and a 7 lb weight loss. Having a know history of pancreatitis thought to be induced by HIV meds. An MRCP was performed and this revealed pancreatitis with pseudocyst formation and extrahepatic biliary ductal dilation. He had acutely worsening of pain earlier on [**1-18**], and underwent CTA of his abdomen. He also had one episode of nausea and vomitting. The CT revealed SMA throbosis and extensive small and large bowel pneumotosis and pneumobilia. He underwent emergent exploratory laparotomy. Past Medical History: . Pancreatitis . HIV diagnosed in [**2137**] (MSM unprotected sex) (CD4 528 [**10-5**]; VL = 0) . Herpes zoster . Condylomata accuminata (surgery scheduled for [**8-9**]) . Thyroid cyst (childhood) Social History: Lives alone in [**Location (un) 86**]. Workes in ed. adminstration at [**University/College 5130**]. Smokes 1 ppd for several yrs. Planned on quitting in [**Month (only) **]. EtOH: 2 martinins/day Drugs: occ. marajuana, cocaine (snorted) in past Family History: Non-contributory Physical Exam: 100.2, 111, 194/115, 22, 99 RA Gen: confused, lethargic HEENT: AT, NC. EOMI, PERRLA, [**3-2**] bilat. Neck: 2+ carotid bilat., no JVD Chest: CTA bilat., RRR, no M/R/G Abd: diffusely severe tenderness, rigid, +rebound, + guarding Rectal: deferred Ext: no C/C/E x 4; +2 radial DT/PT bilat. Pertinent Results: MRCP (MR ABD W&W/OC) [**2151-1-15**] 9:25 AM IMPRESSION: 1. Interval development of pseudocyst within the pancreatic body as described which communicates with the pancreatic duct as well as irregular pancreatic duct within the distal body and tail of the pancreas, however, less prominent than prior examination. These findings favor the sequela of pancreatitis. There is no evidence of pancreatic mass. 2. Extrahepatic biliary ductal dilatation which tapers down to the level of the ampulla where there is prominence of the ampulla, this constellation of findings may be seen in HIV cholangiopathy, however, ampullary mass cannot be excluded. . CT ABD W&W/O C [**2151-1-18**] 6:25 PM IMPRESSION: 1. Occlusion of the proximal SMA and extensive ischemic changes of bowel in the SMA distribution is new from MR [**2151-1-15**]. 2. Origin of the celiac axis is attenuated and may be occluded with reconstitution by distal collaterals. 3. Interval decrease in size of cystic areas of the pancreas consistent with sequela of pancreatitis and possible early pseudocyst formation. 4. Esophagus filled with contrast and other ingested material places patient at risk for aspiration. . CT PELVIS W/CONTRAST [**2151-1-29**] 12:16 PM IMPRESSION: 1. Patent SMA status post stenting of proximal portion. Plaque identified in the SMA just distal to the stent. Distal SMA and branches are widely patent. 2. Hypoattenuation at the origin of the celiac artery consistent with given history of celiac stenosis. The branches of the celiac artery distal to the stenosis remain widely patent. It is unclear if this represents reterograde or anterograde filling. There are significant collateral formation within the abdomen, unchanged. 3. Unchanged size of cystic areas of the pancreas which is inseparable from the duct consistent with either pseudocyst formation vs. IPMT depending on clinical context and chronology in respect to pancreatitis. 4. Small bilateral pleural effusions with adjacent compressive atelectasis. 5. Large areas of nonperfusion in the spleen extending to the periphery consistent with infarction. In the inferior portionof the spleen only a small area in the hilum remains perfused. 6. Status post resection of a large amount of small bowel and portion of ascending colon. The remaining bowel demonstrates wall thickening and enhancing mucosa. No evidence of pneumatosis. Lack of oral contrast precludes evaluation of anastomotic leak. . CT ABDOMEN W/CONTRAST [**2151-2-2**] 6:23 PM IMPRESSION: 1. Large fluid collection within the right abdomen extending down into the pelvis with multiple foci of air and wall enhancement, likely consistent with peritonitis. Hyperdense foci within this fluid collection may represent hemorrhage or spillage of intraluminal bowel contents. There is increased intraperitoneal free air. 2. Markedly abnormal loops of small bowel with dilatation at the small bowel to small bowel anastomotic site. Ischemic bowel cannot be excluded. 3. Unchanged size of cystic areas of the pancreas, which is inseparable from the duct which may represent pseudocyst formation or IPMT. 4. Decreasing small bilateral pleural effusions. 5. Large splenic infarct not changed compared to prior examination. . CT ABDOMEN W/CONTRAST [**2151-2-3**] 12:44 PM IMPRESSION: 1. Dilated contrast-filled duodenum with no contrast passing the proximal duodenojejunal anastomosis, concerning for obstruction. 2. Large enhancing fluid collection within the abdomen extending down to the pelvis with areas of hyperdense attenuation, consistent with hemorrhage. 3. Small bilateral pleural effusion and bibasilar atelectasis. 4. Splenic infarct, unchanged. 5. Widely patent SMA status post stent. Severe narrowing at the origin of the celiac artery. 6. Unchanged size of cystic areas of the pancreas, which is inseparable from the duct may represent pseudocyst formation or IPMT. 7. Markedly abnormal loops of small bowel. Ischemic bowel cannot be excluded. . Brief Hospital Course: He was admitted on [**2151-1-14**] for pancreatitis with pseudocyst formation and failure to thrive. The GI service and Gold Surgery service were consulted and following along. On [**2151-1-18**],he reported acute abdominal pain, nausea and vomiting. A CT revealed occlusion of the proximal SMA and extensive ischemic changes of bowel in the SMA distribution. He emergently went to the OR on [**2151-1-18**] with help from the vascular service. On [**1-18**] he had Retrograde SMA stenting with vein patch angioplasty using right greater saphenous vein. On [**1-20**], Second look exploratory laparotomy and small bowel resections x 2. On [**1-21**], Third look exploratory laparotomy. Ileocecectomy with hand-sewn two-layer side-to-side ileocolostomy. Small bowel resections x 2 with hand-sewn two-layer anastomoses x 2. Gastrostomy tube placement. GI: He was NPO with a NGT. He remained NPO and the G-tube was to gravity. Abd: His abdomen was left open between cases. His abd was closed on [**1-21**] with staples and a dressing in place. FEN: He was ordered for daily TPN and was NPO. On POD 13, his PO diet was slowly advanced. We monitored his Amylase and Lipase and these continued to trend down. ID: He was on Vanco/Cipro/Flagyl. ID was consulted and following along. They said to continue broad spectrum antibiotics. On [**2-1**] all abx were d/c'd. We then noticed a bump in his WBC from 11,000 to 24,000. He was then restarted on Vanc/Cefepime/Flagyl/Fluconazole. Per ID recs, his HAART therapy was held as his CD4 was 381. The other issue was whether his HAART meds would be absorbed due to his short gut. Heme: Heme was consulted for a question regarding anticoagulation. They did not feel it was necessary to anticoagulate at this time and he did not have a coagulation disorder based on lab results (ACA IgG 11.5; ACA IgM13.6*). His HCT was stable post-operatively. On [**2-1**] ASA and plavix were restarted. A surveillance CT was done on [**2151-1-29**] and showed a splenic infarction. He was started on a Heparin gtt on [**2151-1-29**]. CV: He was tachycardic post-operatively, up to 130's. He received several IV fluid boluses while in the ICU and helped with UOP and to decreased HR. Resp: He remained intubated after going to the OR on [**1-18**]. He was extubated on [**2151-1-22**] and doing well. Neuro: He had post-op confusion and was found talking to himself at times. He was easily reoriented and his confusion cleared as he continued to recover. Psych: Psych was consulted for bazaar behavior. He reportedly said his name was [**Female First Name (un) 77233**] and that he lived on a farm. It was not clear if he was having post-op confusion or another form of psychosis... Opthomolgy: Patient had bilateral eye erythema and conjunctival infection. They recommended ointment for corneal dryness. On [**2-2**], he had bleeding and blood coming from the J-tube. His HCT dropped as low as 18.6. His Heparin was stopped and he was transfused 3 units PRBC. His Hct rose to 26 the next day. He had a CT on [**2-2**] and showed a Large fluid collection within the right abdomen extending down into the pelvis with multiple foci of air and wall enhancement, likely consistent with peritonitis. Hyperdense foci within this fluid collection may represent hemorrhage or spillage of intraluminal bowel contents. There is increased intraperitoneal free air. Markedly abnormal loops of small bowel with dilatation at the small bowel to small bowel anastomotic site. Ischemic bowel cannot be excluded. Unchanged size of cystic areas of the pancreas, which is inseparable from the duct which may represent pseudocyst formation or IPMT. Decreasing small bilateral pleural effusions. Large splenic infarct not changed compared to prior examination. He then went to IR for CT guided drainage of this collection. . A repeat CT on [**2-3**] showed Dilated contrast-filled duodenum with no contrast passing the proximal duodenojejunal anastomosis, concerning for obstruction. 2. Large enhancing fluid collection within the abdomen extending down to the pelvis with areas of hyperdense attenuation, consistent with hemorrhage. 3. Markedly abnormal loops of small bowel. Ischemic bowel cannot be excluded. He went to the OR on [**2151-2-4**] for his: 1. Infected intra-abdominal hematoma. 2. Status post small-bowel resection for intestinal ischemia. 3. Human immunodeficiency virus. 4. Enterocutaneous fistula from disintegrated anastomosis, and had a 1. Exploratory laparotomy with washout of infected intra-abdominal hematoma. 2. Externalization of bowel for enteric fistula with tube decompression technique. In the OR there was a huge, bloody, gelatinous hematoma. There was no evidence of overt pus. At the anastomosis the lower catheter into what I felt was the proximal end of this bowel and advanced it upwards of 10 cm into the bowel. I then placed the upper catheter on the abdominal wall into what I felt would be the distal aspect going towards the colon. It was pretty clear that this was the layout in my mind. I then closed over as much of this weak, disintegrated anastomosis with 3-0 Vicryl sutures in multiple places. This allowed us to then funnel omentum around the 2 tubes as they exited the top of this anastomosis. The patient has less than 60 cm of bowel left. Abd/GI: Post-op he had a G-tube, 2 J-tubes, 2 JP drains. He remained NPO with TPN. His midline incision had staples with wicks in place. The wicks were removed on POD 4. His incision was intact and dry. The JP drains were in place and draining bilious fluid. He was having high volume output from the J-tube and JP drains. We were repleating this fluid loss with IV fluid in order to maintain hydration. The JP drains decreased in output with time. His Amylase and Lipase trended down to 138 and 77 on [**2151-2-5**], but then started a slow climb to 544 and 582 on [**2151-2-15**]. On [**2151-2-24**] his G-tube was clamped and his drain output was monitored. His midline incision was healing nicely and his drains remained secure with his skin intact without redness or drainage from around the insertion sites. The staples were removed and steri strips place. ID: He continued on ABX: VANCO/Flagyl, Meropenem ([**2-2**]), Caspofungin for peritoneal fluid cult: [**Female First Name (un) 564**]. The Caspo was then switched to Fluconazole on [**2151-2-9**]. He was clinically stable, afebrile. CD4 209- right on border of needing PCP [**Name Initial (PRE) 1102**]. ID was holding on restarting HAART back up, due to his short gut and the inability to absorb food or medication. His ABX were continued. Next, his antibiotics were slowly stopped, one by one, and he tolerated this fine without fevers or increase in WBC. Heme: His Heparin was stopped due to the bleeding risk and he continued on ASA. Activity: He was being seen by PT and getting up and walking the halls. Pain: pain was controlled with a PCA. FEN: He continued on TPN and will be TPN dependent. Due to the weak anastomosis, short bowel, and his small bowel is not connected and all PO contents would come out the superior J-tube, he will have to remain NPO and on TPN. He is thin and malnurished. Medications on Admission: Remeron 15', ativan 1 PRN, truvada T', Kaletra TT", Bentyl, Lomotil Discharge Medications: 1. Bed KINAIR BED 2. IV Fluid please replace J-tube and G-tube output 1cc:1cc with 1/2NS q8h 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Tablet, Chewable(s) 4. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 5. Hydromorphone 4 mg/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 6. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection ASDIR (AS DIRECTED): see sliding Scale. 7. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): On intact skin only. Leave in place for 12 hours, then off for 12 hours. 9. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1) Intravenous Q4H (every 4 hours). 10. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 11. Diphenhydramine HCl 50 mg/mL Solution Sig: One (1) Injection HS (at bedtime) as needed. 12. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) Injection Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Ischemic Bowel Superior Mesenteric Artery Thrombosis SMA stenting and small bowel resections. HIV Post-op Hypovolemia Deconditioning MalNutrition Discharge Condition: Good Discharge Instructions: * Increasing pain * Fever (>101.5 F) * Persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain . Please take all your medications as ordered. . Continue to ambulate several times per day. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment. Please follow-up with Dr. [**Last Name (STitle) 174**] in 1 month. Call ([**Telephone/Fax (1) 22346**] to schedule an appointment. Please follow-up with Infectious Disease on [**2151-3-25**] at 9:00. Call [**Telephone/Fax (1) 457**] with questions. Completed by:[**2151-2-25**]

[ "560.1", "557.1", "379.91", "V08", "996.74", "997.4", "557.0", "567.82", "579.3", "577.2", "577.0", "576.8", "577.1", "569.81", "998.12", "567.29", "276.52", "289.59", "293.0", "305.1", "998.59" ]

icd9cm

[ [ [] ] ]

[ "45.91", "45.61", "45.73", "38.93", "00.40", "43.11", "45.93", "39.90", "00.45", "54.12", "99.15", "39.50", "54.91", "99.04" ]

icd9pcs

[ [ [] ] ]

14666, 14738

6195, 13385

303, 676

14928, 14935

2204, 6172

15215, 15623

1863, 1881

13503, 14643

14759, 14907

13411, 13480

14959, 15192

1896, 2185

245, 265

704, 1358

1380, 1583

1599, 1847

19,428

123,450

12716

Discharge summary

report

Admission Date: [**2182-12-8**] Discharge Date: [**2182-12-18**] Date of Birth: [**2114-3-25**] Sex: M Service: General Surgery/Hepatobiliary Service HISTORY OF PRESENT ILLNESS: This is a 68-year-old male with a past medical history significant for non-insulin dependent diabetes mellitus and cholecystectomy. The patient transferred from [**Hospital3 **] [**Hospital 107**] Hospital. The patient had originally been admitted for abdominal pain, distention, shortness of breath. The patient had CT scan consistent with increased liver size, pancreatitis and amylase and lipase of 15 and 43 and 17 and 20 respectively. White count 15, hematocrit 51, glucose 666, BUN and creatinine 64 and 2.1 respectively. Initially patient had noted increasing abdominal girth for which primary care provider ordered [**Name Initial (PRE) **] CT which was normal. Increasing abdominal pain prompted Emergency Room visit. The patient reported no nausea, vomiting, no change in bowel habits, no fever, chills, no trauma, no alcohol use. The patient was resuscitated with normalization of electrolytes, placed on insulin drip. CT scan one day prior to admission with non contrast showed hepatitis. The patient was transferred to [**Hospital1 69**] for further treatment and work-up. PAST MEDICAL HISTORY: Includes coronary artery disease, status post stenting times three, type 2 diabetes mellitus, hypertension, colonoscopy two years ago which was normal. EGD three weeks ago was also normal. The patient has hypercholesterolemia and triglyceridemia. PAST SURGICAL HISTORY: Includes cholecystectomy and deviated septum repair. The patient has allergies to Penicillin, tetanus shot and Novocaine. MEDICATIONS: Include Lopressor 100 mg [**Hospital1 **], Glyburide 5 mg q day, Gemfibrozil 600 mg [**Hospital1 **], Monopril 20 mg [**Hospital1 **], Glucophage 500 mg [**Hospital1 **], Simvastatin 20 mg q day, Hydrochlorothiazide 25 mg q day, Felodipine 10 mg q day, Aspirin 325 mg q day, Folate, Protonix 20 mg q day, sublingual Nitroglycerin 0.4 mg prn, Vioxx 25 mg [**Hospital1 **], [**Doctor First Name **] 60 mg [**Hospital1 **], Xanax 0.25 mg, Tylenol prn, Multivitamin, Lasix 40 mg q day and Metamucil. LABORATORY DATA: On admission, white count 13.5, hematocrit 46.5, platelet count 210,000. Electrolytes were 141 sodium, potassium 3.9, BUN 50, creatinine 1.4, ALT 41, AST 30, alkaline phosphatase 66, total bilirubin 1.0, amylase 409, lipase 1079, LD 423. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit, stabilized with hydration on an insulin drip. Hospital day #1, patient with decreased pancreatic enzymes. Abdomen distended, nontender. The patient continued to be afebrile with vital signs stable. Hospital day #2 afebrile, vital signs stable with CT scan showing pancreatitis, no abscess or necrosis. Diabetes service was consulted for additional recommendations for blood glucose control. Hospital day #3 the patient was afebrile, vital signs were stable, the patient's abdomen was soft and improved distention requiring increased amounts of insulin and TPN for control. On hospital day #4 the patient had one episode of abdominal pain overnight, improved at present on the morning of exam and afebrile, vital signs stable. Abdomen was soft, right upper quadrant tenderness. The patient had liquid stool output. Hospital day #5 the patient had improved abdominal pain, no flatus, afebrile, vital signs stable. The patient continued on TPN. The patient was restarted on Lasix due to some shortness of breath experienced by the patient. On hospital day #6 the patient continued to be afebrile with vital signs stable. Abdomen was soft, decreased distention and no tenderness. Patient with Lasix now [**Hospital1 **], high insulin requirement and TPN. On hospital day #8 the patient was now feeling unchanged, afebrile with vital signs stable. The abdomen was soft, moderately distended, nontender. The patient continued with TPN with high insulin requirement. On hospital day #9 the patient was tolerating sips, afebrile, vital signs stable, continued on TPN. Abdomen was soft with nontender and mild distention, positive bowel sounds. Hospital day #10 the patient continued afebrile, vital signs stable, fingersticks with insulin and the TPN somewhat low and patient was started on D10 with maintenance of adequate blood sugars. This combination worked well for the patient. The patient was also advanced to a diabetic diet which he was able to tolerate very well. By hospital day #11 the patient continued with vital signs stable, blood sugars at a good level. The patient was continued on regular diabetic diet, TPN was discontinued and patient was felt to be ready for discharge to follow-up with Dr. [**Last Name (STitle) 468**] and his primary care physician and the [**Name9 (PRE) **] Diabetes Center. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: 1. Status post pancreatitis of unknown etiology as of yet; expected medication related. FOLLOW-UP: Dr. [**Last Name (STitle) 468**] and his primary care physician as well as the [**Last Name (un) **] Diabetes Center for regulation of his blood glucose control. Patient on Lopressor, Lasix, Protonix, sublingual Nitro, Vioxx, Clonidine and Glucophage. MEDICATIONS: To be reviewed and adjusted by patient's primary care physician whom he is to see this week. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**] Dictated By:[**Name8 (MD) 5915**] MEDQUIST36 D: [**2182-12-18**] 20:55 T: [**2182-12-18**] 21:08 JOB#: [**Job Number 33442**]

[ "272.0", "V45.82", "250.62", "787.91", "518.0", "357.2", "577.0", "272.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

4967, 5681

2503, 4885

1592, 2485

200, 1296

1319, 1568

4910, 4946

12,714

153,339

8343

Discharge summary

report

Admission Date: [**2188-2-5**] Discharge Date: [**2188-2-13**] Service: MEDICINE Allergies: Fosamax / Indomethacin Attending:[**First Name3 (LF) 1055**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **]F MMP including diastolic CHF (EF unknown, records from [**Hospital 2586**] pending), HTN, Anemia, Thrombocytosis/Leukocytosis (followed by Hematologist Dr. [**Last Name (STitle) **] at [**Hospital3 2358**]) who presents from [**Hospital3 **] facility with progressive shortness of breath x 6 days. Patient/daughter report that pt was in her USOH (walks with walker at baseline) until 6 days ago, when she began experiencing slight shortness of breath, no associated cough, fever, chills, or diaphoresis. Dyspnea progressed, and when patient woke up this morning, she was noted to be more tachypneic, short of breath, episode lasted 10 minutes. Felt better sitting up in chair. Per report, ? [**Doctor Last Name **] came 3 hours later and O2 sat was 79%, asymptomatic, and patient was then brought to hospital. Patient reports recent medication change 7 days ago, right before onset of symptoms - Avapro was decreased to 150 qd and Hydralazine increased. Daughter reports similar episode of shortness of breath in [**2187-4-25**], diagnosed with CHF exacerbation, did better with fluid removal. No recent weight loss, abdominal pain, nausea, vomiting, diarrhea. + Ankle swelling. No PND + orthopnea. . In ED, VS on arrival were T 97.7; HR 92; BP 142/45; RR 24; O2 Sat 81% RA, 100% NRB --> quickly transitioned to 4L NC, sat'ing 96-97%. Received 3 Combivent nebs with good effect. Kayexalate given for K 5.6. Given ASA 325, Lasix 10 IV, Nitropaste 1", Ceftriaxone/Azithromycin, Lasix 40 IV. . Anemia has been ongoing, family does not want colonoscopy to work-up. Blood transfusions ok. Past Medical History: 2. History of DVT in [**2183-5-25**]. 3. History of upper GI bleed after using Vioxx. 4. Low back pain. 5. Hypertension. 6. Cataracts. 7. Ventral hernia repair in [**2181**]. 8. Pemphigoid. 9. Osteoporosis. 10. Thrombocytosis treated with Agrylin by the hematologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. 11. Peripheral edema. 12. CVA [**9-26**]- chronic right sided weakness 13. Iron deficiency anemia 14. CRI (Baseline ~2.4) 15. Diastolic CHF, EF 70% Social History: Resides at [**Hospital3 **] facility. No ETOH/Tobacco/Drugs. Family History: NC Physical Exam: VITALS: T 98.5; BP 148/62; HR 84; O@ 96% 4L GEN: obese, elderly female in mild resp distress, parodxial respirations, but comfortable HEENT: PERRL. EOMI. MM slightly dry. CV: S1S2 RRR. II/VI systolic murmur at LUSB. LUNGS: Crackles [**11-26**] way up, occ expiratory wheeze ABD: obese, soft, NT/ND. +BS. guiaic positive green stool in ED. EXT: non-pitting edema to calf, trace ankle edema B/L. NEU: AO x 3. RU and RL extremity weakness. LUE 4/5 strength, LLE 4/5 Strength. RUE [**12-30**], RLE [**12-30**]. Sensation intact B/L. R hand in contracted position. Pertinent Results: [**2188-2-5**] 08:35PM POTASSIUM-5.6* [**2188-2-5**] 08:35PM CK(CPK)-34 [**2188-2-5**] 08:35PM CALCIUM-8.9 PHOSPHATE-4.6* MAGNESIUM-2.4 [**2188-2-5**] 02:25PM URINE HOURS-RANDOM [**2188-2-5**] 02:25PM URINE GR HOLD-HOLD [**2188-2-5**] 02:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2188-2-5**] 02:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2188-2-5**] 12:20PM LACTATE-1.2 [**2188-2-5**] 12:06PM GLUCOSE-117* UREA N-62* CREAT-2.3*# SODIUM-141 POTASSIUM-5.6* CHLORIDE-106 TOTAL CO2-22 ANION GAP-19 [**2188-2-5**] 12:06PM CK(CPK)-45 [**2188-2-5**] 12:06PM cTropnT-0.03* [**2188-2-5**] 12:06PM CK-MB-NotDone [**2188-2-5**] 12:06PM WBC-27.7* RBC-2.90*# HGB-8.5*# HCT-24.8*# MCV-85 MCH-29.2 MCHC-34.2 RDW-19.9* [**2188-2-5**] 12:06PM NEUTS-68 BANDS-1 LYMPHS-20 MONOS-5 EOS-0 BASOS-4* ATYPS-0 METAS-2* MYELOS-0 [**2188-2-5**] 12:06PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-2+ POLYCHROM-1+ SCHISTOCY-1+ STIPPLED-1+ ELLIPTOCY-1+ [**2188-2-5**] 12:06PM PLT SMR-NORMAL PLT COUNT-373 [**2188-2-5**] 12:06PM PT-13.7* PTT-24.7 INR(PT)-1.2* [**2188-2-5**] 12:06PM D-DIMER-665* . Lower Extremity U/S [**2-5**]: No evidence of bilateral lower extremity DVT. . CXR [**2-5**]: The heart remains enlarged, with a calcified aortic arch. The pulmonary vasculature is indistinct, and there are new bilateral pleural effusions, consistent with CHF. There is no evidence of pneumonia or pneumothorax. . ECHO [**2-7**]: 1. The left atrium is mildly dilated. 2.There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. 4. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-26**]+) mitral regurgitation is seen. 5. There is a small pericardial effusion. . Repeat CXR [**2-9**]: CHF with interstitial pulmonary edema and pleural effusion appear slightly improved since previous examination of [**2188-2-6**]; however, this may be also partly technical Brief Hospital Course: Patient is a [**Age over 90 **] year-old female with multiple medical problems including CHF (EF70%, diastolic dysfunction), Renal insufficiency, Thrombocythemia who presented with hypoxia, tachypnea, and dyspnea. The following issues were addressed during her hospital stay: . # Hypoxia/Dyspnea/Tachypnea Differential was broad in this patient, and included CHF, Pneumonia, Pulmonary Embolism. Clinical exam with elevated jugular venous pressure, bilateral lower extremity edema, and pronounced crackles on lung examination. CXR was remarkable for gross fluid overload with cephalization of vessels, consistent with CHF exacerbation, and patient has had similar episodes previously. Though D-dimer was 600, further PE work-up was not pursued as we had a more likely explanation for patient's symptoms. CXR was without infiltrate suggestive of pneumonia, and patient was afebrile throughout hospital course. . For management of patient's CHF, patient was aggressively diuresed with IV Bumex (as she had ? allergy to Lasix). Agrylin was held in acute setting as it could contribute to fluid overload. Diuresis was limited by patient's renal function. On HD#2, patient with significant tachypnea and using accessory muscles of respiration. It was felt that patient would benefit from BIPAP, and she was transferred to the ICU for closer monitoring. ABG was within normal limits and was not concerning for hypoxemia or respiratory alkalosis. Patient did well with BIPAP in the unit, and diuresis was continued. ECHO showed diastolic dysfunction with no significant valvular abnormalities to account for symptoms, and findings were consistent with earlier ECHO done 1 year earlier at OSH. Upon transfer to the floor one day later, patient appeared more comfortable, and was no longer using accessory muscles of respiration. Aggressive diuresis was continued, and Zaroxolyn was used to potentiate effects of Bumex. A goal of [**11-25**].5 Liters/day negative was targetted, with good symptomatic improvement. Patient will continue to need gentle diuresis, provided that her renal status will allow. She was discharged home on PO Bumex. Patient also with wheezing on exam, improved with PRN nebulizer treatments, which can continue as needed on discharge. Electrolytes and Creatinine to be monitored at her extended care facility. . # HYPERTENSION Blood pressure medications were adjusted given clinical status. Avapro was discontinued in setting of acute renal failure. Given acute CHF, Diltiazem was used in favor of BB. Patient also started on long-acting nitrate for preload reduction, and hydralazine was used intermittently for blood pressure control, but discontinued on discharge as patient's heart failure is mostly diastolic (and most data supports use of hydralazine in systolic HF patients). Patient with baseline HR in 50s, and marked wheezing with BB use in past, so Diltiazem XR to be used for outpatient BP control. . # ACUTE on CHRONIC RENAL FAILURE Patient's Creatinine rose to a peak of 3.0, with her baseline ~2.4. This was attributed to intravascular volume depletion secondary to diuresis. Avapro was discontinued, and electrolytes were monitored closely and repleted as necessary. Recent ultrasound from OSH was unremarkable for underlying pathology including obstruction. Patient will need further monitoring of Creatinine upon discharge. . # ANEMIA Patient with guiaic positive stools, refuses EGD/Colonoscopy. Had Hct drop to 23.6. It was felt that patient's respiratory status was partially due to anemia, and she was gently transfused 1 unit PRBCs in split units to prevent further volume overload. Renal service also felt that transfusion would assist in diuresis by helping fill intravascular space. Patient tolerated transfusion well, and subsequent Hcts remained stable. Given renal insufficiency, patient started on Epogen and Iron 325 [**Hospital1 **]. . # LEUKOCYTOSIS/THROMBOCYTOSIS Patient with long history of leukocytosis/thrombocytosis, followed by Dr. [**Last Name (STitle) **] at OSH, etiology unclear, but was not an active issue during her hospitalization. Patient was without signs of infection. Agrylin was held in acute phase of CHF exacerbation, as it could contribute to volume overload, and this was re-started upon discharge given rise in platelets. Patient to follow-up with her hematologist regarding this issue. . # THYROID Given fatigue (most likely due to CHF), TSH was checked, which was elevated at 5.3 FT4 was 1.3, WNL. No therapy was started given acute illness, but this should be followed as outpatient. . # HISTORY OF CVA Continued Plavix . # HYPERCHOLESTEROLEMIA Continued Lipitor and Fish Oil pills . # GERD Continued Protonix, to receive Nexium as outpatient . # PSYCHIATRIC Continued Mirtazapine, Lexapro, Aricept . # CODE: DNR/DNI. Confirmed with patient on this admission. Medications on Admission: BP: HCTZ 25, Hydralazine 40 QID, Avapro 150, Norvasc 10 CHF: Bumex 1 QOD Dementia: Aricept 10, Mirtazapine 15, Lexapro 20 GERD: Nexium 40 Thrombocythemia: Agrylin 2.5 Cardiac: Lipitor 10 CVA: Plavix 75 Anemia: Iron 325 [**Hospital1 **] Calcium, Fish Oil, Miacalcin nasal spray Discharge Medications: 1. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 3. Omega-3 Fatty Acids 550 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO twice a day. 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Anagrelide 0.5 mg Capsule Sig: Five (5) Capsule PO qd (). 8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Nitroglycerin 0.2 mg/hr Patch 24HR Sig: One (1) Patch 24HR Transdermal Q24H (every 24 hours). 13. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-26**] Sprays Nasal TID (3 times a day) as needed. 16. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: Two Hundred (200) unit Nasal DAILY (Daily): alternate nostrils each day. 17. Bumex 1 mg Tablet Sig: One (1) Tablet PO once a day: Please have your Creatinine and electrolytes checked on [**2-15**] to ensure your renal function isn't worsening. 18. Diltiazem HCl 120 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. 19. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment Inhalation every six (6) hours as needed for shortness of breath or wheezing. 20. Atrovent 0.02 % Solution Sig: One (1) nebulizer Inhalation every six (6) hours. 21. Epogen 20,000 unit/mL Solution Sig: One (1) injection Injection once a week. Discharge Disposition: Extended Care Facility: [**Location (un) 29523**] at [**Location (un) 29524**] Discharge Diagnosis: Primary 1. Congestive Heart Failure, Diastolic 2. Acute on Chronic Renal Failure 3. Hypertension 4. Anemia Secondary 1. Thrombocytosis 2. Hx CVA 3. Osteoporosis Discharge Condition: oxygenation improved, chest pain free Discharge Instructions: 1. Please take all medications as prescribed 2. Please make all follow-up appointments 3. If you develop chest pain, difficulty breathing, difficulty urinating, or any other concerning signs/symptoms, please contact your PCP or report to the Emergency Department immediately Followup Instructions: Please make an appointment to follow-up with your PCP after discharge from rehab. You will be followed by a doctor at the extended care facility. Completed by:[**2188-2-13**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12425, 12506

5273, 10110

249, 256

12710, 12750

3095, 5250

13073, 13250

2494, 2498

10438, 12402

12527, 12689

10136, 10415

12774, 13050

2513, 3076

190, 211

284, 1889

1911, 2400

2416, 2478

41,976

125,013

35277

Discharge summary

report

Admission Date: [**2201-9-28**] Discharge Date: [**2201-10-1**] Date of Birth: [**2136-7-28**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 594**] Chief Complaint: AMS, fever Major [**First Name3 (LF) 2947**] or Invasive Procedure: none History of Present Illness: 65M presents from nursing home with fevers and change in mental status. Patient is s/p CVA and is nonverbal and does not move his arms or legs at baseline. He usually responds by occasionally smiling and is fairly communicative as much as possible with facial expressions only. He comes in with changes in grimacing and fewer facial expressions, purulent secretions from trach and fever. . In the ED, initial VS were: 98.6, 100, 66/47, 18, 99%RA. On exam the patient was diaphoretic with a tense abdomen. Labs were notable for a WBC 40.4, K 6.9 (hemolyzed), Na 146, AST/ALT 69/25. UA was positive. CXR appeared stable compared to prior. Originally had foley that did not appear to drain. Another foley was placed and drained 2.5L of purulent urine. Started on 0.4mg of levophed with BP response 130s/50s. Received 3L NS, 1G Vancomycin IV, 750MG levofloxacin IV, 2G cefepime IV. A Right fem CVL was placed. . On arrival to the MICU, Pt's VS were 98.6, 101, 142/75, 16, 98% on 50% FiO2 Past Medical History: * Hypertension * Hypothyroidism * H/o CVA (bilateral embolic cerebellar [**2188**], hemorrhagic left thalamic [**2190**]) * Type II Diabetes mellitus * Peripheral neuropathy * Depression * h/o DVT (? - no [**Hospital1 18**] records) * Atrial fibrillation (on coumadin) * Peripheral vascular disease * Hyperlipidemia * Anemia of chronic disease * Tracheostomy and GJ tube for chronic aspiration ([**3-/2200**]) - Portex Bivono, Size 6.0 * C.diff colitis in [**1-29**] requiring total abdominal colectomy with end ileostomy [**1-29**], repeat positive C diff toxin [**2200-5-20**] (outside facility, [**12/2198**] here) Social History: Prior resident of [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], now at [**Hospital 16662**] Nursing Home. Family very involved in care. Patient does not take anything by mouth due to history of aspiration. Spanish-speaking. Patient is a former 60 pack year smoker but quit in [**2183**]. Family History: Patient has a mother with diabetes and brother with heart disease. Physical Exam: ADMISSION EXAM Vitals: T:98.6 BP:117/74 P:85 R:18 O2:99% on 10L humidified mask General: Awake, unresponsive to voice, no acute distress HEENT: PERRL, Sclera anicteric, MMM, oropharynx clear Neck: trach c/d/i, JVP unable to assess [**1-21**] habitus, no LAD CV: Reg rate, normal S1/S2, systolic murmurs at LLB, no radiation Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: mid-line scar, G-tube and colostomy bag in place, soft, non-tender, non-distended, no organomegaly GU: Foley placed Ext: warm, well perfused in upper; marked contractions, lower are cold and 1+ pulses DISCHARGE EXAM General: Awake, unresponsive to voice, no acute distress HEENT: PERRL, Sclera anicteric, MMM, oropharynx clear Neck: trach c/d/i, JVP unable to assess [**1-21**] habitus, no LAD CV: Reg rate, normal S1/S2, systolic murmurs at LLB, no radiation Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: mid-line scar, G-tube and colostomy bag in place, soft, non-tender, non-distended, no organomegaly GU: Foley placed Ext: warm, well perfused in upper; marked contractions, Pertinent Results: ADMISSION LABS [**2201-9-28**] 07:56PM BLOOD WBC-38.8* RBC-5.71 Hgb-12.7* Hct-39.6* MCV-69* MCH-22.3* MCHC-32.2 RDW-15.6* Plt Ct-290 [**2201-9-28**] 07:56PM BLOOD Neuts-90.8* Lymphs-4.9* Monos-4.0 Eos-0.1 Baso-0.2 [**2201-9-28**] 07:56PM BLOOD PT-14.8* PTT-26.0 INR(PT)-1.3* [**2201-9-28**] 07:56PM BLOOD Glucose-327* UreaN-49* Creat-1.2 Na-148* K-4.3 Cl-110* HCO3-24 AnGap-18 [**2201-9-28**] 03:09PM BLOOD ALT-25 AST-69* AlkPhos-72 TotBili-0.6 [**2201-9-28**] 07:56PM BLOOD Calcium-8.4 Phos-3.7 Mg-2.2 PERTINENT LABS [**2201-9-28**] 03:09PM BLOOD T4-10.0 [**2201-9-28**] 07:56PM BLOOD Cortsol-42.1* [**2201-9-28**] 04:02PM BLOOD Lactate-2.7* K-4.4 CXR: [**2201-9-28**] IMPRESSION: Low lung volumes, without acute findings. TTE [**2201-9-29**] There is moderate symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>65%). 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. There is no mitral valve prolapse. No mitral regurgitation is seen. There is a very small pericardial effusion. IMPRESSION: Hyperdynamic LV function. [**2201-9-28**] 3:09 pm BLOOD CULTURE #1. Blood Culture, Routine (Preliminary): PROTEUS SPECIES. PRELIMINARY SENSITIVITY. These preliminary susceptibility results are offered to help guide treatment; interpret with caution as final susceptibilities may change. Check for final susceptibility results in 24 hours. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS SPECIES | CEFEPIME-------------- S CEFTAZIDIME----------- S CEFTRIAXONE----------- S MEROPENEM------------- S PIPERACILLIN/TAZO----- S Anaerobic Bottle Gram Stain (Final [**2201-9-29**]): Reported to and read back by DR. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5386**] ON [**2201-9-29**] AT 0535. GRAM NEGATIVE ROD(S). Brief Hospital Course: 65M w/ multiple medical problems (CVA, trach/peg, afib, DMII etc) presents with septic shock and found to have a Proteus bacteremia from a likely urinary source. . ## Proteus bacteremia - Patient presented from his nursing facility with reports of fevers to 101.3 and decreased responsiveness. On presentation the patient was afebrile, tachycardic, hypotensive and had 2.5L of purulent urine relieved upon foley exchange. Initially labs were notable for WBC 40.4, and a lactate 2.7. The clinical picture was worrisome for septic shock from a urinary source. He required several litters of IVF and Levophed and to support his BP. He received 1 dose of vanc and levo in the ED, which was changed to vanc and [**Last Name (un) 2830**] on the floor due to his history of ESBL Klebsiella and proteus UTI that was [**Last Name (un) 2830**] sensitive. Initial blood cultures grew pan sensitive proteus on hospital day 2. Vancomycin was discontinued, and a PICC was placed for the patient to finish a 14 day course of meropenem, which will complete on [**2201-10-12**]. By discharge the patient was afebrile, off pressors, with a WBC of 6.9, and down trending lactate. . ## Urinary Retention - Likely [**1-21**] longstanding diabetes related neuropathy. His foley that was in place on presentation did not appear to drain. Upon foley exchange in the ED 2.5L of purulent urine was relieved. No medications that exacerbate urinary retention were found on medication review. His foley was maintained for the duration of the admission and should be maintained appropriately upon discharge. . ## [**Last Name (un) **] - On admission Cr 1.6 from baseline of 0.5. The etiology was likely multifactorial and included post renal obstruction as well as decreased perfusion in the setting of septic shock. Upon foley exchange and fluid resuscitation, the Cr trended down to 0.4 at discharge. . ## Atrial Fibrillation - EKG was consistent with Sinus rhythm. The patient was discharged on [**2201-8-13**] with a supratherapeutic INR and instructions to restart home Coumadin when INR was below 3.0. On admission the patient had no record of receiving Coumadin and his INR was 1.2. He was started on a Heparin gtt. Coumadin was started, Heparin gtt was changed to a Lovenox bridge while the patient has a sub therapeutic INR. Please follow the patient's INR with a goal of [**1-22**]. Discontinue Lovenox once INR is therapeutic. . ## Hypernatremia - Likely [**1-21**] free water deficit as patient is on tube feeding. Calculated free water deficit was 2L. Free water was administered via PEG flushes at 250ml Q4H. Sodium trended down over the course of the admission and was 136 upon discharge. Sodium showed be followed initially upon discharge and PEG water flushes should be adjusted accordingly. . STABLE ISSUES: . ## Sacral decubitus ulcer: Granulation tissue with no exudate; wound care team involved in care during this hospitalization. Please continue with standard care. . ## Hypothyroidism - Stable. Continued on home Levothyroxine . ## Type 2 Diabetes: Stable. FS Glucose, SS Insulin during this hospitalization. . ## Peripheral Neuropathy: Continued home Gabapentin and Fentanyl Patch . ## Depression: Continued duloxetine. . ## GERD: Continued lansoprazole . TRANSITIONAL ISSUES: - Pt declared a full code during this hospitalization Medications on Admission: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Neb QID 2. acetylcysteine 20 % (200 mg/mL) Solution [**Month/Day (2) **]: 1 QID 3. ipratropium bromide 0.02 % Solution [**Month/Day (2) **]: One (1) QID 4. baclofen 10 mg Tablet [**Month/Day (2) **]: 1.5 Tablets PO QID 5. duloxetine 30 mg Capsule, Delayed Release(E.C.) 1 PO BID 6. docusate sodium 100 mg Capsule [**Month/Day (2) **]: Two (2) Capsule PO QHS 7. fentanyl 100 mcg/hr Patch 72 hr [**Month/Day (2) **]: One (1) Transdermal Q72H 8. ferrous sulfate 220 mg (44 mg iron)/5 mL Solution: One (1) PO QD 9. gabapentin 300 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO Q8H 10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) PO QD 11. [**Last Name (STitle) 8472**] 100 unit/mL Solution [**Last Name (STitle) **]: Thirty Four (34) units SQ QHS 12. levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: One (1) PO QD 13. mirtazapine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS 14. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 2 Tablet PO Q6H PRN:pain 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) vial Inhalation q2h PRN: SOB or wheezing. 16. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) vial Inhalation q2h PRN: SOB or wheezing. 17. bisacodyl 10 mg Suppository: 1 Rectal HS PRN: constipation. 18. ascorbic acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QD 19. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] 20. senna 8.6 mg Tablet [**Hospital1 **]: 1 PO BID PRN: constipation 21. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension [**Hospital1 **]: 30 ML PO QID PRN: stomach upset 22. Milk of Mag 400 mg/5 mL Suspension 30mL PO QD PRN:Constipation 23. Glucerna Liquid [**Hospital1 **]: One (1) Application PO once a day: 1.2 via feeding pump at 75 mL/hr. Up at 2pm down at 10am. 24. Novolin R 100 unit/mL Solution [**Hospital1 **]: One (1) unit Injection qac: SS 25. multivitamin Liquid [**Hospital1 **]: Five (5) mL PO QD Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours). 2. ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours). 3. baclofen 10 mg Tablet [**Hospital1 **]: 1.5 Tablets PO QID (4 times a day). 4. duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 5. fentanyl 100 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 6. gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO every eight (8) hours. 7. levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 8. mirtazapine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 9. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: One (1) PO Q6H (every 6 hours) as needed for fever or pain. 10. ascorbic acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 11. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for skin irritation. 12. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 15. ferrous sulfate 220 mg (44 mg iron)/5 mL Solution [**Last Name (STitle) **]: One (1) PO once a day. 16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q2H (every 2 hours) as needed for SOB or wheezing. 17. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension [**Last Name (STitle) **]: 15-30 MLs PO QID (4 times a day) as needed for stomach upset. 18. meropenem 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 11 days. 19. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Two (2) PO HS (at bedtime). 20. enoxaparin 80 mg/0.8 mL Syringe [**Last Name (STitle) **]: One (1) Subcutaneous [**Hospital1 **] (2 times a day): Continue until INR is therapeuic (goal [**1-22**]). 21. [**Month/Day (3) 8472**] 100 unit/mL Solution [**Month/Day (3) **]: One (1) 34 units Subcutaneous at bedtime: Monitor FS glucose. 22. Insulin Sliding Scale Please see attached insulin sliding scale 23. warfarin 4 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO once a day. 24. acetylcysteine 20% (200 mg/mL) Solution [**Month/Day (3) **]: 1 QID 25. ipratropium bromide 0.02 % Solution [**Month/Day (3) **]: One (1) vial Inhalation q2hr prn as needed for shortness of breath or wheezing. 26. Milk of Magnesia 400 mg/5 mL Suspension [**Month/Day (3) **]: Thirty (30) ml PO once a day as needed for constipation. 27. Glucerna Liquid [**Month/Day (3) **]: One (1) app PO once a day: 1.2 via feeding pump at 75 mL/hr. Up at 2pm down at 10am. 28. multivitamin Tablet [**Month/Day (3) **]: One (1) Tablet PO once a day. 29. Novolin R 100 unit/mL Solution [**Month/Day (3) **]: per sliding scale Injection QAC. Discharge Disposition: Extended Care Facility: [**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **] Discharge Diagnosis: PRIMARY; Proteus Bacteremia Urinary Tract Infection Hypernatremia Acute Kidney Injury SECONDARY: Atrial Fibrilation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname 8182**], It was a pleasure caring for you during this admission. You were admitted because of your fever and decreased responsiveness. You were found to have a urinary tract infection as well as bacteria in your blood. You were treated with antibiotics, intravenous fluids, and your foley catheter was replaced. A long term intravenous catheter was placed so you can continue receiving antibiotics once you leave the hospital. Please make the following medication changes: 1. Please take your coumadin as instructed based on your INR level. 2. Please continue to take your antibiotics until [**2201-10-12**]. Please make sure that you attend all follow up appointments Followup Instructions: Please attend all follow up appointments: Provider: [**Name10 (NameIs) 706**] CARE,TWO [**Name10 (NameIs) 706**] CARE UNIT Phone:[**Telephone/Fax (1) 446**] Date/Time:[**2201-11-4**] 8:30 Provider: [**Name10 (NameIs) 6122**] WEST OUTPATIENT [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 8243**] Date/Time:[**2201-11-4**] 10:00

[ "V58.61", "285.9", "584.9", "788.20", "995.92", "357.2", "707.20", "785.52", "250.60", "272.4", "311", "V12.54", "244.9", "599.0", "707.03", "530.81", "276.0", "401.9", "038.49", "427.31", "V44.0" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

14575, 14674

5773, 9024

14835, 14835

3557, 4862

15692, 15710

2342, 2410

11262, 14552

14695, 14814

9127, 11239

14970, 15451

2425, 3538

4906, 5750

9045, 9101

15471, 15669

264, 339

15735, 16031

367, 1353

14850, 14946

1375, 1994

2010, 2326

52,848

103,541

42508

Discharge summary

report

Admission Date: [**2172-3-19**] Discharge Date: [**2172-3-24**] Date of Birth: [**2089-12-6**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1185**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: none History of Present Illness: 82M past medical history of renal failure on dialysis, stroke with residual left-sided weakness, recent toe amputation with vascular surgery, and atrial fibrillation on Coumadin, who presents with several episodes of bright red blood per rectum from his nursing home or rehabilitation. The patient reports no sx, he reports taht he has been eating normally (ground food and with a poor appetite at baseline) and has had no abdominal pain, n/v/d/c. The patient has had a large decline in his baseline health over the past month, beginning with vascular surgery in which they did angioplasty on the posterior tibial artery and they initiated [**First Name3 (LF) 4532**] at that time, [**2172-3-3**]. Since then, he has been less mobile and more somnolent, with baseline fatigue and decreased appetite. He is on warfarin for afib/flutter and on Aspirin for his history of CVA. He reports that he had a fall in which he hit his left shoulder and buttock, it is unclear the situation surrounding this but he endorses pain in his left shoulder and lidocaine patch is in place, he reports that this has happened since his admission to [**Hospital1 18**] for surgery at the beginning of [**Month (only) 956**]. . When EMS arrived, he was observed to be "difficult to arouse." In the ED, initial VS: 96.7 111 108/52 22 100% 2L Nasal Cannula. In ED passed 700-800cc of BRPBR. Patient received Pantoprazole bolus +ggt. CTA done and revealed no source of bleeding and stool in the ascending bowel. IR aware for possible angio. VS prior to transfer SBPs 99/50, with a baseline SBP 90-100. Access established is 18g, triple lumen in groin. Received 1u FFP. Received 10mg IV vitamin K. CXR with concern for PNA so started on vanc, zosyn ordered. Missed HD today; last HD on Tuesday, renal consult was obtained and they will not proceed with HD today but do recommend DDAVP. . On arrival to the MICU, the patient is somnolent but responsive and interactive. He had 100cc of bright red blood per rectum with clots, no stool. He remains hemodynamically stable although hypothermic with T 95, HR 80-90 and SBP 100-110/50s, which is his baseline. Past Medical History: - ESRD on HD (Tu, Th, Sat) - h/o CVA w R sided weakness - DM - Glaucoma - Hypercholesteremia - Atrial flutter - PVD - Gout - Vit D Deficiency Social History: Patient lives with daughter but has recently been at rehab in setting of amputation. Has wife who he did not live with. Has a son also in the area. - Tobacco: Former [**2-3**] ppd smoker, quit 10 years ago - Alcohol: no recent EtOH - Illicits: no illegal drug use Family History: Mother-deceased of "heart attack" in old age Father-deceased of "leg wound" in 50s Children-healthy Physical Exam: Vitals: T: 95 BP: 103/62 P: 93 R: 12 18 O2: 97% on 3L NC General: somnolent but arousable. oriented to self, date but not year and says "[**Hospital 882**] Hospital", no acute distress HEENT: dry mucous membranes, oropharynx clear, poor dentition. Pupils are non-reactive. Cloudy pupils Neck: supple, JVP not elevated, no LAD CV: irregular rate, rapid rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: poor air movement bilaterally. decreased breath sounds at the bases. dyspneic with lying supine. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, dopplerable pulses. 2+ edema. Very swollen left UE. LUE fistula with bruit. No large toe on left foot and there are stitches in place. Wound on back of left leg. Neuro: very limited neuro exam [**3-5**] cooperation, 3/5 strength upper/lower extremities, grossly normal sensation, gait deferred but ataxic and not ambulatory at baseline. Baseline weakness on the left noted. Pertinent Results: Initial labs: [**2172-3-19**] 01:30PM WBC-4.6 RBC-2.78* HGB-9.7* HCT-31.2* MCV-112* MCH-34.9* MCHC-31.1 RDW-17.7* [**2172-3-19**] 01:30PM NEUTS-86* BANDS-0 LYMPHS-3* MONOS-8 EOS-2 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [**2172-3-19**] 01:30PM PLT SMR-LOW PLT COUNT-80* [**2172-3-19**] 12:35PM GLUCOSE-219* UREA N-40* CREAT-5.3* SODIUM-137 POTASSIUM-5.4* CHLORIDE-94* TOTAL CO2-33* ANION GAP-15 [**2172-3-19**] 12:35PM ALT(SGPT)-10 AST(SGOT)-31 ALK PHOS-240* TOT BILI-1.2 [**2172-3-19**] 12:35PM LIPASE-40 [**2172-3-19**] 12:35PM ALBUMIN-3.0* CALCIUM-9.0 PHOSPHATE-6.3*# MAGNESIUM-2.6 [**2172-3-19**] 12:10PM PT-40.0* PTT-42.9* INR(PT)-3.9* [**2172-3-19**] 01:30PM TYPE-[**Last Name (un) **] PO2-57* PCO2-66* PH-7.30* TOTAL CO2-34* BASE XS-3 COMMENTS-GREEN TOP [**2172-3-19**] 01:30PM LACTATE-2.4* [**2172-3-19**] 01:34PM HIV Ab-NEGATIVE [**2172-3-19**] 03:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-300 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [**2172-3-19**] 03:10PM URINE RBC-57* WBC->182* BACTERIA-MOD YEAST-NONE EPI-<1 [**2172-3-19**] 03:10PM URINE HYALINE-10* CT angiogram: IMPRESSION: 1. Hyperdense fluid within the sigmoid colon consistent with hemorrhage. No clear source for active bleeding on this mesenteric CTA. No bowel wall inflammation and diverticulosis. 2. Moderate nonhemorrhagic bilateral pleural effusions with associated compressive atelectasis. 3. Moderate simple ascitic fluid, diffuse mesenteric edema and subcutaneous edema consistent with anasarca. CXR: IMPRESSION: Findings suggesting mild-to-moderate pulmonary vascular congestion with bilateral pleural effusions and opacities at the lung bases likely due to associated atelectasis. Brief Hospital Course: 82 year old male with peripheral vascular disease on warfarin, [**Last Name (LF) 4532**], [**First Name3 (LF) **] presenting with painless BRBPR, current hemodynamic stability. In brief, he had GIB in the ICU requiring massive transfusion protocol. Per ICU team, after discussion with family the decision was made to transition him to CMO status and he was managed with CMO protocol morphine gtt on the medical floor. He passed away overnight on [**3-24**]. . # BRBPR: Patient presenting with about 500cc of bright red blood per rectum in the emergency room. It is painless and no hemorrhoids have been visualized. The most likely etiology is diverticular bleed. Also in the ddx is AVM, hemorrhoids, ischemia, ulcer or other etiology of UGIB. Given bright red blood while hemodynamically stable, it was suspected to be a lower GI source. On admission INR 3.9, improved with FFP and vitmain K. He was transfused 1 unit PRBC and one dose of DDAVP 20mcg over one hour given his uremia. A CT angiogram was done that did not reveal a source of bleeding. After reversal of his INR the bleeding slowed, and GI held off on endoscopy. The patient then began passing clots per rectum and was transfused several units, platelets, and FFP. Despite all this, his hct and bp continued to drop. A left femoral CVL was placed and he was started on pressors. A family meeting was held and the decision to transition goals of care to CMO was made. He was taken off pressors. Pt was monitored for Si/Sx of pain, anxiety, discomfort; no vitals, transfusions, hemodialysis, labs were pursued. Pt was maintained on morphine gtt per Comfort Care Guidelines with prn ativan for breakthrough pain or anxiety, with scopolamine patch if necessary for use when suctioning airway. He passed away overnight [**3-24**]. . #Aflutter: patient had atrial fibrillation during his previous hospitalization and was started on metoprolol for rate control and warfarin. The patient was not a considered a candidate for acute intervention but the patient is intolerant of high ventricular rates. Warfarin and metoprolol were held in setting of GIB. . #Peripheral vascular disease: complicated by bilateral gangrene requiring admission at the beginning of [**2172-3-4**], s/p Balloon angioplasty of left posterior tibial artery with additional angioplasty and stenting of left posterior tibial artery occlusion along with amputation of left great toe. He was advised to continue [**Year (4 digits) **] for at least 30 days, until [**2172-4-6**]. His [**Month/Day/Year **] was held given GI bleed. . #ESRD: On dialysis qT-TH-SAT. Last HD tuesday ([**2171-3-18**]) with 3 Kg UF (post HD wt 80, EDW 76.5 kgs). Has working Lt UA AVF for access. The patient has anasarca which is out of proportion of missing one dialysis session. Continued nephrocaps and sevelamer. Received dialysis [**2172-3-21**]. . # Hypotension: the patient's systolic blood pressure is recorded as baseline 90-110 systolic during previous admission. He did have a requirement for pressors in the setting of afib during his previous admission. Current blood pressure is 102/60, which is baseline, but will monitor carefully, especially in the setting of hypovolemia with GIB. . # Baseline Macrocytic Anemia: concern for liver disease although hepatitis work up wsa negative. B12 and folate were high at the beginning of [**Month (only) 956**]. MCV is 112. . #Hx CVA: Residual L-sided weakness. Requires assistance for feeding. - holding home [**Month (only) **] and warfarin . #Hx DM: insulin sliding scale. HgA1c of 6.0 in 01/[**2172**]. Was on lantus 6 units at bedtime. . #Glaucoma: - Continued on brimonidine, latanaprost, dorzolamide eyedrops . #Gout: - Continued on allopurinol Medications on Admission: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 9. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 10. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 14. midodrine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q 8H (Every 8 Hours). 16. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 17. Lantus 100 unit/mL Solution Sig: Six (6) Subcutaneous at bedtime. 18. Warfarin dose is unclear Discharge Medications: none; pt expired Discharge Disposition: Expired Discharge Diagnosis: - Gastrointestinal bleed - End Stage Renal Disease - Diabetes - Atrial flutter - Peripheral vascular disease Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**] Completed by:[**2172-3-24**]

[ "440.20", "272.0", "438.89", "281.9", "V58.66", "274.9", "V49.86", "728.89", "780.65", "V49.71", "250.00", "285.1", "365.9", "585.6", "V58.61", "427.32", "562.12", "427.31" ]

icd9cm

[ [ [] ] ]

[ "38.97", "39.95" ]

icd9pcs

[ [ [] ] ]

11124, 11133

5789, 9502

313, 319

11285, 11294

4058, 5766

11350, 11484

2938, 3039

11083, 11101

11154, 11264

9528, 11060

11318, 11327

3054, 4039

265, 275

347, 2475

2497, 2640

2656, 2922

47,673

126,877

52666

Discharge summary

report

Admission Date: [**2147-4-24**] Discharge Date: [**2147-4-28**] Service: SURGERY Allergies: Codeine / latex Attending:[**First Name3 (LF) 598**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: 89M s/p unwitnessed fall [**4-24**]. Brought to [**Hospital1 18**] ED by EMS, initially conversant and neuro-intact, but decompensated quickly in ED. He was intubated, and work-up revealed SAH, SDH, and intra-ventricular hemorrhages. He also has bilateral non-displaced posterior superior iliac spine fractures. He was hypotensive in the ED, and was started on neo. He was admitted to the TSICU for further evaluation and management. Past Medical History: HTN, CAD, HL, seizure d/o, depression PSH: CABG, pacemaker, prostate radiation/cryoablation Social History: Lives at home with wife Family History: Non-contributory Physical Exam: On admission (after intubation): Constitutional: Thin, pale, intubated VS: P 54 BP 115/67 RR 16 O2Sats 99% 40% FIO2 GCS 8T Gen: thin, cachectic, currently chemically paralyzed and sedated HEENT: traumatic head laceration with profuse bleeding Pupils:2-1.5 mm bilaterally EOMs Neck: Supple. On discharge: VS: 98.0 77 121/78 20 96% RA GEN: Alert, confused HEENT: WNL CHEST: RRR, lungs CTAB ABD: Soft, nontender, nondistended LE: No edema Skin: Head laceration with staples and 2 sutures Pertinent Results: [**4-24**] CTA head - acute right SDH up to 15mm thickness; perimesencephalic cistern SAH; small IVH; large subgaleal hematoma at vertex [**4-24**] CT C-spine - 1. No fracture. 2. Right tentorial subdural hematoma, better evaluated on concurrent head CT. 3. Multiple pulmonary nodules, better characterized on concurrent CT torso. [**4-24**] CT torso - Bilateral, symmetric posterior superior iliac spine, minimally displaced fractures with underlying left hematoma. The fracture line extends anteriorly into the second right neural formen and sacral bone. 2. Innumerable pulmonary nodules, which may be metastatic in origin if the patient has a history of malignancy. If clinically indicated, follow up in 3 months is recommended to document stability or comparison to outside imaging. 3. Infrarenal aneurysmal dilation, measuring up to 4.1 cm. [**4-24**]: CT head-1. Again seen is a similar appearance of right subdural hematoma, which tracks along the falx and tentorium with intraventricular and subarachnoid extension as described above. There is no evidence of new hemorrhage. Continued followup is recommended. 2. Subgaleal hematomas are again noted at the vertex with no evidence of fracture. [**4-26**]: CT Head: No new hemorrhage. Some interval clearance of subdural and intraventricular hemorrhage. [**4-26**]: CT Abd/Pelvis: 1. No evidence for retroperitoneal hemorrhage. 2. Severe right hydronephrosis and right hydroureter with likely obstructing mass in the pelvis. 3. Large scrotal fluid collection, incompletely imaged. 4. 7-mm right lower lobe lung nodule for which three-month followup is recommended. 5. Two infrarenal abdominal aortic aneurysms, as seen previously. 6. Pelvic and vertebral fractures, as seen previously. Labs on admission: [**2147-4-24**] 01:20PM WBC-12.6* RBC-4.51* HGB-13.1* HCT-42.5 MCV-94 MCH-28.9 MCHC-30.8* RDW-14.1 [**2147-4-24**] 01:20PM NEUTS-75.8* LYMPHS-16.2* MONOS-4.3 EOS-3.2 BASOS-0.5 [**2147-4-24**] 01:20PM PT-11.9 PTT-31.5 INR(PT)-1.1 [**2147-4-24**] 01:20PM PLT COUNT-225 [**2147-4-24**] 01:20PM ALT(SGPT)-12 AST(SGOT)-38 CK(CPK)-169 ALK PHOS-66 TOT BILI-0.6 [**2147-4-24**] 01:20PM cTropnT-<0.01 [**2147-4-24**] 01:20PM CALCIUM-8.9 PHOSPHATE-2.8 MAGNESIUM-2.2 [**2147-4-24**] 01:20PM GLUCOSE-99 UREA N-23* CREAT-1.6* SODIUM-142 POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-23 ANION GAP-17 [**2147-4-24**] 03:50PM NEUTS-90.1* LYMPHS-5.5* MONOS-3.2 EOS-0.9 BASOS-0.3 [**2147-4-24**] 03:50PM WBC-27.8*# RBC-3.39* HGB-10.2* HCT-33.6* MCV-99* MCH-30.1 MCHC-30.4* RDW-14.5 [**2147-4-24**] 05:00PM URINE RBC-120* WBC-9* BACTERIA-FEW YEAST-NONE EPI-0 [**2147-4-24**] 05:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [**2147-4-24**] 05:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2147-4-24**] 07:00PM PT-15.7* PTT-32.7 INR(PT)-1.5* [**2147-4-24**] 07:00PM HCT-23.2*# [**2147-4-24**] 07:00PM CALCIUM-6.7* PHOSPHATE-3.2 MAGNESIUM-1.8 [**2147-4-24**] 07:00PM GLUCOSE-170* UREA N-23* SODIUM-141 POTASSIUM-5.0 CHLORIDE-114* TOTAL CO2-18* ANION GAP-14 [**2147-4-24**] 07:08PM TYPE-ART PO2-369* PCO2-39 PH-7.30* TOTAL CO2-20* BASE XS--6 Labs at discharge: [**2147-4-28**] 09:10AM BLOOD WBC-10.8 RBC-3.12* Hgb-9.5* Hct-29.8* MCV-95 MCH-30.3 MCHC-31.8 RDW-14.4 Plt Ct-148* [**2147-4-28**] 09:10AM BLOOD Glucose-100 UreaN-19 Creat-1.3* Na-143 K-3.8 Cl-108 HCO3-21* AnGap-18 [**2147-4-28**] 09:10AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.4 Brief Hospital Course: On [**2147-4-24**] Mr. [**Known lastname **] was admitted to TSICU under the Acute Care Service for management of his traumatic injuries. He was transfused platelets and 3 units of PRBC's given his drop in hematocrit from 42 on admission to 23.2 six hours later. His hematocrit bumped appropriately post transfusion to 33.8. On [**4-25**] he was successfully extubated. His hematocrit again tended down slightly from 33.8 to 29.6, however remained stable this range throughout the remainder of his hospital course. He remained in the TSICU until [**4-26**] for close monitoring and was transferred to the floor at that time. Neurosurgery was consulted on admission for his traumatic SDH, SAH and IVH who recommeded loading the patient with dilantin and starting dilantin TID. His dilantin was later changed to keppra as this is a regular medication for him for epilepsy. He remained alert but oriented X [**12-12**] throughout the remainder of his hospial course. He became slightly agitated and confused at times, attempted to get out of bed and pulling at tubes/lines. He required soft wrist restraints overnight when on the floor as well as intermittent doses of zyprexa. In the morning of [**4-28**] the patient fell out of the chair while sitting in the [**Doctor Last Name **] next the the nurses station. The fall was witnessed and the patient did not hit his head. A full head to toe exam was performed after the fall by the Acute Care Service and no new findings were seen. The patient's neuro exam remained unchanged as well as his mental status. His home aspirin was held as well as any DVT prophylaxis throughout his hospitalization, with neurosurgery recommendations to hold these medications for 7 days from the date of injury. A follow up appointment with a repead head CT was scheduled with Dr. [**Last Name (STitle) **] per neurosurgery recommendations after discharge. Orthopedics was consulted on admission for the patient's bilateral iliac [**Doctor First Name 362**] fractures, who determined the injury to be nonoperative and stable. Recommendations were that the patient could bear weight as tolerated on his bilateral lower extremities and follow up in 4 weeks as an outpatient if needed. An appointment was scheduled in the orthopedic clinic at discharge. Upon re-read of the patients initial imaging, L1-L2 compression deformities were noted. Ortho spine was consulted who recommended LSO brace when OOB for 6 weeks and clinic follow up in 2 weeks. Recommendations were implemented. EP was called on admission to interrogate the patient's pacer given the unclear circumstances around the fall. It was noted that the pacemaker was functioning appropriately with stable lead parameters. No events recorded. Optimal hemodynamic benefit observed with AP-VS at 80 bpm, programmed to ensure VS since less tolerated VP. The patient was monitored on telemetry while on the floor and had multiple nonsustained episodes of v-tach, asymtomatic with stable blood pressure during the episodes. His electrolytes were monitored and repleted as needed. His home metoprolol tartrate dose was restarted when taking PO's. He continued to remain hemodynamically stable. At discharge he was transferred to a facility with telemetry monitoring. Physical therapy was consulted to assess the patient's mobility and safety who recommended discharge to a rehab facility when medically cleared. Speech and swallow therapy was consulted to evaluate the patient's swallow given his altered mental status. He was cleared for nectar thick liquids and ground solids, which he was tolerating at the time of discharge. He was also started on a bowel regimen of stool softeners. Of note, incidental findings of a 7mm lung nodule as well as a right renal mass were noted on the patient's CT scans. Dr. [**Last Name (STitle) 108668**] (the patient's PCP) was noted of these findings and the reports were sent to the PCP at the time of discharge. On [**2147-4-28**] Mr. [**Known lastname **] is afebrile and hemodynamically stable. His neuro status has remained stable and he is without complaints of pain. He is tolerating a regular diet and voiding adequate amounts of urine. He is being discharged to a long-term acute care facility to continue his recovery. Medications on Admission: metoprolol 37.5 mg [**Hospital1 **], keppra 500 mg [**Hospital1 **], simvastatin 40 mg daily, effexor 50 mg daily , ASA 325mg daily Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. senna 8.8 mg/5 mL Syrup Sig: Five (5) mL PO BID (2 times a day) as needed for constipation. 4. docusate sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2 times a day). 5. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 6. venlafaxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 8. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day: ***Hold until [**2147-5-1**], then may resume at patient's home dose of 325 mg aspirin daily. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: s/p fall 1. SDH 2. SAH 3. Bilateral iliac [**Doctor First Name 362**] fractures 4. Superior end plate fracture of L1 Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital after a fall. You sustained multiple injuries including an injury to your head, fractures in your spine and fractures in your pelvis. None of these injuries required operative intervention. You are now being discharged to rehab to continue your recovery. Please follow up at the appointments listed below. Followup Instructions: Orthopaedic Surgery Appointment: PENDING With:Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] Location:[**Hospital1 69**] [**Location (un) 830**], [**Hospital Ward Name 452**] Bldg. Rm 239 [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3573**] **We are working on a follow up appointment with Dr. [**Last Name (STitle) 363**] in the next 2 weeks. You will be called at rehab with the appointment. If you have not heard within 2 business days from your discharge or have questions, please call the above number for your appt.' Department: ORTHOPEDICS When: TUESDAY [**2147-5-30**] at 10:40 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2147-5-30**] at 11:00 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RADIOLOGY When: TUESDAY [**2147-6-6**] at 10:15 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: TUESDAY [**2147-6-6**] at 11:00 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2147-4-28**]

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icd9cm

[ [ [] ] ]

[ "86.59", "96.04", "38.91", "89.45", "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

10140, 10206

4947, 9208

230, 236

10367, 10367

1421, 2641

10907, 12712

879, 897

9390, 10117

10227, 10346

9234, 9367

10542, 10884

912, 1205

1220, 1402

182, 192

4648, 4924

264, 705

2650, 3177

3192, 4628

10382, 10518

727, 822

838, 863

48,177

118,716

36098

Discharge summary

report

Admission Date: [**2132-10-27**] Discharge Date: [**2132-10-29**] Date of Birth: [**2112-9-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3531**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: 20 yo female with no past medical history presents with one day of hematemesis. The patient reports epigastric pain for the past three days. Last night she felt nausea, but denied vomiting. This morning she awoke and vomited dark red blood twice. The previous days she had been taking large amounts of ibuprofen for migraine headaches. On arrival to the ED she had multiple subsequent episodes of hematemesis. She denies current headache, respiratory distress, fevers, or chills. In the ED her initial vital signs were T 97.7 HR 154 BP 124/87 RR 20 o2 100%. She remained tachycardic, which responded minimally to 3 liters of IV fluids. She vomited approximately 1L of blood in the ED. A NG lavage was performed which cleared after 500ccs. GI was consulted and recommended EGD today, will continue to follow. Her labs were significant for a Hct of 35.9, then repeat of 30.9. She was type and crossed for 4 units, and one unit of blood was started en route. The patient was given 8mg zofran and 40mg pantoprazole with resolution of her epigastric pain. Her vital signs on transfer were HR 119 BP 115/80 O2 100% on RA. Review of systems is otherwise negative. Past Medical History: None Social History: Student at [**Last Name (un) **]. The patient has a history of using marijunana and oxycontin recreationally, sober for 3 years. Denies alcohol usage, quit smoking 4 months ago, prior to which she smoked for 2 years. Family History: Mother and father are healthy. Grandmother has unknown liver condition, no other GI conditions or cancers of GIT Physical Exam: T=96.8 BP=125/76 HR=110 RR=21 O2= 100% on RA PHYSICAL EXAM GENERAL: Pleasant, well appearing female in NAD HEENT: NGT in place, normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Tachycardic, but regular. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP flat LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**11-30**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2132-10-27**] 11:51AM WBC-11.8* RBC-4.28 HGB-12.5 HCT-35.9* MCV-84 MCH-29.2 MCHC-34.8 RDW-12.7 [**2132-10-27**] 11:51AM PLT COUNT-327 [**2132-10-27**] 11:51AM PT-13.0 PTT-21.5* INR(PT)-1.1 [**2132-10-27**] 11:51AM ALT(SGPT)-22 AST(SGOT)-21 ALK PHOS-82 TOT BILI-0.4 [**2132-10-27**] 11:51AM LIPASE-27 [**2132-10-27**] 11:51AM GLUCOSE-150* UREA N-26* CREAT-0.8 SODIUM-137 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14 [**2132-10-27**] 02:04PM HCT-30.9* [**2132-10-27**] 02:10PM HGB-11.8* calcHCT-35 [**2132-10-27**] 07:24PM HCT-34.8* [**2132-10-27**] 11:45PM HCT-33.4* [**2132-10-29**] 05:35AM BLOOD WBC-7.3 RBC-4.08* Hgb-12.0 Hct-34.5* MCV-85 MCH-29.4 MCHC-34.7 RDW-12.8 Plt Ct-178 [**2132-10-27**] 11:51AM BLOOD Neuts-69.4 Bands-0 Lymphs-24.7 Monos-3.7 Eos-1.1 Baso-1.0 [**2132-10-29**] 05:35AM BLOOD Plt Ct-178 [**2132-10-27**] 11:51AM BLOOD Glucose-150* UreaN-26* Creat-0.8 Na-137 K-3.9 Cl-103 HCO3-24 AnGap-14 [**2132-10-28**] 04:11AM BLOOD Glucose-88 UreaN-13 Creat-0.7 Na-139 K-3.8 Cl-109* HCO3-23 AnGap-11 [**2132-10-29**] 05:35AM BLOOD Glucose-82 UreaN-13 Creat-0.7 Na-138 K-4.0 Cl-106 HCO3-26 AnGap-10 [**2132-10-27**] 11:51AM BLOOD ALT-22 AST-21 AlkPhos-82 TotBili-0.4 [**2132-10-28**] 04:11AM BLOOD ALT-20 AST-23 LD(LDH)-157 AlkPhos-65 TotBili-0.8 [**2132-10-27**] 11:51AM BLOOD Lipase-27 [**2132-10-27**] 11:51AM BLOOD Albumin-4.2 Calcium-8.3* Phos-2.3* Mg-2.0 [**2132-10-28**] 04:11AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.0 . MICRO: [**2132-10-28**] 4:11 am SEROLOGY/BLOOD Source: Venipuncture. **FINAL REPORT [**2132-10-29**]** HELICOBACTER PYLORI ANTIBODY TEST (Final [**2132-10-29**]): NEGATIVE BY EIA. (Reference Range-Negative). . . [**2132-10-27**] EGD: Findings: Esophagus: Normal esophagus. Stomach: Mucosa: Localized linear erythema and erosion of the mucosa with no bleeding were noted in the antrum. These findings are compatible with gastritis, which is consistent with NSAID-induced gastritis.. Localized A few erosions and erythema of the mucosa with no bleeding were noted in the fundus. These findings are compatible with NSAID-induced ulcer. Duodenum: Normal duodenum. Impression: Linear erythema and erosion in the antrum compatible with gastritis, which is consistent with NSAID-induced gastritis. A few erosions and erythema in the fundus compatible with NSAID-induced ulcer Otherwise normal EGD to third part of the duodenum Recommendations: Please avoid NSAID medications. Please continue PPI PO bid Please check H. Pylori Ab in serum. She needs repeat EGD in 8 weeks Brief Hospital Course: 20F with hemetemesis in the setting of NSAID use for headaches. . # hemetemesis - pt was admitted to the ICU. She received 2U total of PRBCs, and 3L total of IVF. her vital signs remained hemodynamically stable. the GI service was consulted, and she underwent EGD which revealed likely NSAID induced ulcers. no intervention was performed given that her bleeding had stopped. . she was called out to the medical floor. her hematocrit remained stable. h. pylori was sent and was negative (this was pending at time of discharge and she was instructed to f/u with her new PCP [**Name Initial (PRE) 176**] 3-4d). she was started on a regimen of pronotix [**Hospital1 **]. she was instructed to avoid NSAIDs and alcohol as these can exacerbate gastric ulcer formation. she had no further episodes of hemetemesis. she will require repeat endoscopy within 4-6 weeks, and was provided with the phone number and instructed to call to arrange an appointment at her convenience. an appointment was made for her to establish care with a new primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 22160**] [**Hospital6 733**]. . # migraine headaches - pt was diagnosed with migraine headaches ~10y ago, per pt, by a pediatric neurologist (she describes photophobia, some aura, nausea). she has no neurologist in [**Location (un) **]. her migraine headaches resolved prior to arrival on the medical service. she took tylenol only for mild headache. given her history of narcotic dependence, and now NSAID induced ulcers, an appointment was made in the neurology clinic so that her headache regimen could be more appropriately tailored to her specific type of headaches. . # h/o narcotic abuse - pt notes remote history of narcotic abuse, and preferred to avoid narcotic pain medications. Medications on Admission: - seroquel 25mg qhs Discharge Medications: 1. 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* 2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: primary: peptic ulcer disease, NSAID induced. Discharge Condition: tolerating oral diet without difficulty. Discharge Instructions: you were admitted to the hospital after vomiting blood. you were found to have bleeding stomach ulcers, felt due in part to use of NSAIDs. you were started on a medication to reduce stomach acid, called protonix. . it is important that you avoid using NSAID medications (ie. motrin) for your migraine headaches. . the following changes were made in your medication regimen: 1. you were started on protonix. . A lab test to look for infections of the stomach which can cause ulcers is still pending at the time of your discharge. Please call your primary care physician [**Name Initial (PRE) 176**] 1 week to discuss the results of this "H. Pylori" test, her number is listed below. Followup Instructions: you should follow-up with your new primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], at [**Hospital6 733**], on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building, Atrium Suite. An appointment has been made for you with [**2132-11-11**] at 2:15. Please call [**Telephone/Fax (1) **] if you have any questions or concerns. . you should be evaluated in the neurology division for your chronic migraine headaches as you should an appointment has been made for you on with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2132-11-5**] at 1:00PM on [**Location (un) 861**] of the [**Hospital Ward Name 860**] Building. Please call ([**Telephone/Fax (1) 2528**]. . you will require a follow-up endoscopy within 4-6 weeks to ensure your ulcers are healing. please call the [**Hospital **] clinic to schedule this at ([**Telephone/Fax (1) 2233**] upon arriving home to schedule this at your convenience.

[ "304.03", "535.40", "285.1", "346.90", "780.52", "785.0", "276.52", "531.40", "V15.82", "E935.9" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

7565, 7571

5419, 7224

329, 357

7661, 7704

2804, 5396

8437, 9463

1836, 1951

7294, 7542

7592, 7640

7250, 7271

7728, 8414

1966, 2785

278, 291

385, 1557

1579, 1585

1601, 1820

6,939

167,901

7905+55893

Discharge summary

report+addendum

Admission Date: [**2185-10-9**] Discharge Date: Date of Birth: [**2110-4-21**] Sex: M Service: VSU CHIEF COMPLAINT: This is a 75-year-old male admitted to the vascular service on [**2185-10-9**]. The chief complaint is questionable intra-abdominal abscess with sepsis. HISTORY OF PRESENT ILLNESS: This is a 75-year-old gentleman with a known mycotic right iliac aneurysm who underwent ligation in [**2177**]. This was an iatrogenic aneurysm secondary to a cardiac catheterization. The patient was admitted to [**Hospital3 417**] Hospital on [**2185-10-5**], with rigors, fever. A CT scan was obtained of the abdomen which revealed a right common iliac aneurysm distally extending into the internal iliac and associated with inflammatory phlegmon around this area that was also increased in comparison to his CAT scan one year ago. It was also associated with inflammation and stranding in the area. This was thought to be the source of the patient's fever. The patient was transferred to Dr.[**Name (NI) 1392**] service at the [**Hospital1 346**] for further evaluation and treatment. The patient's white count on admission at [**Hospital3 418**] was 12.4 with hematocrit of 36.7. Neutrophils were 87.2, lymphs 5.2, monos 7.4, eos 0.1, basos 0.1. The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] hep 2 was positive. His rheumatoid factor was less than 20. RPR was nonreactive. His Babesiamicroti IgG antibodies showed a titer of less than 1:64. His Lyme disease serology was negative. The patient was begun on vancomycin 1 gm q.12h. with imipenem 500 q.8h. The patient was transferred here for further evaluation and treatment. ALLERGIES: Penicillin, heparin. MEDICATIONS: Medications at the time of transfer included Tylenol p.r.n.; losartan 50 mg daily; Prilosec 40 mg daily; Norpace CR 100 mg daily; atenolol 50 mg daily; Adalat SR 90 mg daily; Zocor 80 mg daily; Asacol 1000 mg t.i.d. PAST MEDICAL ILLNESSES: Crohn disease; history of hypertension; history of atrial fibrillation; history of coronary artery disease, status post angioplasty in [**2171**] of the LAD and first diagonal; history of ATN secondary to gentamicin, resolved; history of GI bleed secondary to Coumadin; history of diverticulosis; history of iatrogenic right common iliac mycotic aneurysm, status post resection; status post fem-fem bypass in [**2169**]. HABITS: Habits include 30 pack years of smoking. He denies alcohol use. PHYSICAL EXAM: Blood pressure was 122/68, respirations 18, pulse 72, temperature 99.6, O2 sat 92% on room air. General appearance - alert, cooperative white male in no acute distress. HEENT exam was unremarkable. The carotids were palpable 2+ without bruits. Lungs were clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended, with bowel sounds x4. Rectal exam was normal prostate, good tone, guaiac positive stool. Femoral pulses showed palpable femoral pulses bilaterally. Popliteals were 1+ bilaterally. Dorsalis pedis, posterior tibial were palpable pulses bilaterally. HOSPITAL COURSE: The patient was admitted to the vascular service. A CT was reviewed from [**10-6**]; there was no bleed. The CTA of [**10-6**] was also reviewed at the time. Blood cultures were obtained. The patient was begun on vancomycin, levofloxacin, and Flagyl. His blood pressure medicines were adjusted for hypertension. A general surgery consult was placed for the findings found on the CT scan. Hospital day 2 the patient's T-max was 102 to 98.4. White count was 13.2. Infectious disease was consulted for recommendations regarding appropriate antibiotics. A WBC-tag scan was done which demonstrated findings consistent with infection in a right iliac aneurysm. Homogenous etiology seems most likely give to the history of mycotic aneurysm and common iliac resection. Other considerations, but less likely, should include enteroiliac fistula given the patient's history of Crohn disease or psoas infection leading to superinfection of the adjacent aneurysm. A CT scan was done which demonstrated unchanged appearance of right common iliac artery thrombosed pseudoaneurysm, unchanged occlusion of the right proximal common iliac artery with retrograde collateral flow. Initial blood, urine cultures were no growth. Stool for C. diff was sent which was negative. Echocardiogram was done to rule out any possibility of intracardiac valvular disease or vegetations. Left ventricle was symmetrically hypertrophied. The right atrial pressure range was 0-5, ventricular cavity was normal, all over systolic function was normal. There was no VSD. The aortic root was mildly dilated at the sinus level, ascending aorta was moderately dilated. Aortic valve leaflets were 3 with mild thickening but no aortic stenosis, no aortic regurgitation. Mitral valves were mildly thickened. There was no mitral valve prolapse. There was trial mitral regurgitation. Tricuspid valves were mildly thickened. There was borderline pulmonary systolic hypertension. There was no pericardial effusion. Arterial studies were done which demonstrated normal studies consistent with patent bypass graft. WBC scan was positive for uptake in the right iliac aneurysm. Outside blood cultures were finalized with E. coli. The patient's ciprofloxacin was changed to aztreonam on [**2185-10-20**]. The vancomycin and Flagyl were continued. The patient transfused on [**2185-10-16**], one unit of packed red blood cells for a hematocrit of 28.6. Post transfusion crit was 32.6 in preparation for abdominal surgery on [**10-17**]. The patient underwent resection of right iliac mycotic aneurysm, ligation of the external iliac, and incision and drainage of the peri-iliac abscess, along with a right ureteral stenting on [**10-17**]. The patient was transferred to the SICU for continued postoperative care. He did require 20 units of packed red blood cells intraoperatively. He did require neo drip to maintain his systolic blood pressures greater than 120. He had an episode on postoperative day 3 of bloody stools with persistent drop in hematocrit requiring transfusion. Stools for C. diff were sent which were negative. The patient was extubated on [**2185-10-19**]. GI consult was placed on [**2185-10-19**]. He did undergo both upper and lower endoscopies. The upper endoscopy demonstrated mild gastritis. The colonoscopy demonstrated diverticulosis. They felt this was the source of the rectal bleeding. Intraoperative cultures were obtained and results were negative as of [**2185-10-20**]. The patient's stent was found to migrate and be curled at the meatus and his ureteral stent was removed without event on [**2185-10-20**]. The patient was transferred out of the SICU on [**2185-10-21**], to the VICU for continued care. He did require Lopressor for his hypertension and tachycardia. He was also transfused 2 units of packed cells for hematocrit of 24.9. Aztreonam was discontinued on [**2185-10-22**], but the ciprofloxacin and Flagyl were continued since the initial cultures were negative. On [**2185-10-23**], the ciprofloxacin was changed to levofloxacin and Flagyl. The patient was transferred to the TSICU on [**2185-10-24**], for persistent temperature tachycardia. The patient was made NPO and was given maintenance fluids. The patient returned to the VICU on [**2185-10-24**]. The patient was transferred to the regular nursing floor on [**2185-10-25**]. Serial hematocrits were continued. The patient's hematocrit stable. Levo and Flagyl were continued. The patient was evaluated by physical therapy on [**2185-10-26**]. They felt at that time the patient was not safe to be discharged to home. PICC line was considered in anticipation for discharge planning on [**2185-10-27**], which was aborted secondary to his temperature elevation of 102 to 101.4. The patient was begun on daptomycin at that time. The patient returned to CT scan for imaging and CT-guided catheter installation and drainage of the aneurysm infected site. Cultures were sent and the patient's temperature defervesced to 97. The patient continued on daptomycin on [**2185-10-28**], along with his levofloxacin and Flagyl. He did spike again to 102.1 to 100.4. Fever curve was monitored and drainage was monitored. The catheter will be removed when appropriate per IR. Repeat pan culturing was done at the time of the temp spike. Urine cultures were negative. Blood cultures were so far negative but not finalized. The initial cultures on the abscess of the psoas muscle are showing gram- positive bacteria which are being isolated for identification. The patient's ciprofloxacin and Flagyl were continued. The patient will require a total of 6 weeks from the date of the initial surgery on [**10-17**]. The patient was also started on linezolid 600 mg q.12h. for a total of 14 days for his VRE. The patient will need to follow up with infectious disease and Dr. [**Last Name (STitle) 1391**] 2 weeks after discharge. DISCHARGE MEDICATIONS: Simvastatin 80 mg daily; mesalamine 800 mg daily; losartan 50 mg daily; disopyramide 100 mg daily; nifedipine 90 mg daily; zolpidem 5 mg at bedtime; Protonix 40 mg daily; Lopressor 37.5 mg t.i.d.; Colace 100 mg b.i.d.; ferrous sulfate 325 mg daily x1 month; ascorbic acid 500 mg b.i.d. x1 month; linezolid 600 mg q.12h. for a total of 14 days; Flagyl 500 mg t.i.d. for a total of 6 weeks (at the time of dictation the patient had 4 weeks remaining of therapy); ciprofloxacin 500 mg q.12h. for a total of 6 weeks (at the time of dictation the patient had 4 weeks of antibiotics to continue). DISCHARGE DIAGNOSES: 1. Infected iliac aneurysm site with ligation and resection of mycotic aneurysm in [**2177**], status post femoral-femoral bypass with [**Doctor Last Name 4726**]-Tex in [**2169**]. 2. E. Coli septicemia, treated. 3. History of hypertension. 4. History of atrial fibrillation. 5. History of gastrointestinal bleed. 6. History of coronary artery disease, status post angioplasty of the LAD and first diagonal in [**2176**], complicated by iatrogenic right iliac aneurysm. 7. History of acute tubular necrosis secondary to gentamicin. 8. History of diverticulosis. 9. History of postoperative gastrointestinal bleed, [**2185-10-18**], secondary to diverticulitis. 10.Postoperative hypertension, treated. 11.Postoperative tachycardia and fever secondary to abscess, retroperitoneal, treated. 12.Blood loss anemia, transfused. INSTRUCTIONS: The patient should monitor his CBC weekly while on antibiotics. He should ambulate essential distances. He may shower but no tub baths. No driving until seen in followup. Follow up with both infectious disease and Dr. [**Last Name (STitle) 1391**] in 2 weeks' time; to call Dr.[**Name (NI) 1392**] office for an appointment at [**Telephone/Fax (1) 1393**], and the office of Dr. [**Last Name (STitle) 4020**] of infectious disease for an appointment at [**Telephone/Fax (1) 28427**] at the same time. MAJOR SURGICAL PROCEDURES: Resection of mycotic aneurysm, ligation of the external iliac artery, and incision and drainage of a periaortic abscess with right ureteral stenting. Upper endoscopy on [**10-18**]. Colonoscopy on [**10-23**]. CT abdomen with CT guided catheter drainage placement on [**10-27**]. CONDITION ON DISCHARGE: Stable. Any addendums to the interval prior to discharge will be dictated at the time of actual discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2185-10-28**] 14:14:56 T: [**2185-10-29**] 00:17:06 Job#: [**Job Number 28428**] Name: [**Known lastname 4990**],[**Known firstname **] J. Unit No: [**Numeric Identifier 4991**] Admission Date: [**2185-10-9**] Discharge Date: [**2185-10-30**] Date of Birth: [**2110-4-21**] Sex: M Service: SURGERY Allergies: Penicillins / Heparin Agents Attending:[**First Name3 (LF) 231**] Addendum: [**2185-10-29**] venous study posotove for rt. femoral vein clot.IVC filter placed. [**Male First Name (un) **] hose to rt. leg [**2185-10-30**] ct drain discontinued.evaluated by PT cleared to go home with home PT and services. d/c home. Major Surgical or Invasive Procedure: resection of mycotic aa,ligation of EIa and I/D of periiliac abcess [**2185-10-17**]+rt. ureteral stenting [**2185-10-17**] EGD [**2185-10-18**] colonoscopy [**10-23**] CT abd scan with ct guided drainage catheter placement [**2185-10-27**] IVC filter placement [**2185-10-29**] d/c ct drain [**2185-10-30**] Discharge Disposition: Home With Service Facility: [**Hospital1 328**] VNA Discharge Diagnosis: dvt. rt. femoral vein [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2185-11-1**]

[ "285.1", "453.42", "V45.82", "272.0", "995.91", "591", "562.12", "038.42", "555.9", "535.50", "567.31", "440.20", "401.9", "447.2", "414.01", "427.31", "998.59", "442.2" ]

icd9cm

[ [ [] ] ]

[ "54.91", "38.7", "59.8", "99.04", "87.74", "38.86", "45.23", "38.66", "45.13" ]

icd9pcs

[ [ [] ] ]

12645, 12699

12311, 12622

9585, 11266

8972, 9564

12720, 12900

3075, 8948

2476, 3057

138, 292

321, 2460

11291, 12273

2,345

169,351

11146

Discharge summary

report

Admission Date: [**2103-8-11**] Discharge Date: [**2103-8-22**] Date of Birth: Sex: Service:Transplant Surgery HISTORY OF THE PRESENT ILLNESS: The patient is a 35-year-old male with a long history of insulin-dependent diabetes mellitus, status post cadaveric renal transplant in [**2102-9-23**] who presented for pancreas after kidney transplant. 1. Type 1 diabetes mellitus times 26 years. 2. End-stage renal disease, status post cadaveric renal transplant in [**2102-9-23**]. 3. Retinopathy, status post laser surgery times two, status post vitrectomy on the left. 4. Neuropathy. 5. GERD. 7. Echocardiogram in [**2102-2-23**] which was normal with an EF of 60%. 8. P thallium in [**2103-3-23**] with no ischemic changes. 9. Unilateral diaphragmatic paralysis. 10. History of seizures secondary to low blood glucose. MEDICATIONS: 1. Insulin pump. 2. Prograf 2 mg b.i.d. 3. Cardizem controlled release 120 mg p.o. q.d. 4. Prinivil 5 mg p.o. q.d. 5. Hydrochlorothiazide 12.5 mg p.o. q.d. 6. Prilosec 20 mg p.o. q.d. ALLERGIES: Morphine which causes nausea and vomiting. SOCIAL HISTORY: No tobacco. No alcohol. PHYSICAL EXAMINATION: On admission, the patient was afebrile with stable vital signs. His physical examination was normal apart from decreased breath sounds in his right base. ADMITTING LABORATORY DATA: CBC 6.4/33.4/229. Chem-7 139/5.8/104/22/37/2/289. PT 12.6, PTT 25.6, INR 1.1. U/A negative. EKG was normal. Chest x-ray showed a raised right hemidiaphragm with no infiltrates. HOSPITAL COURSE: The patient was admitted and routine pretransplant procedures initiated. The patient was taken to surgery on the day of admission. Surgery was uncomplicated and the patient was thereafter transferred to the SICU intubated. The patient was successfully extubated in the SICU without any complications. The patient's postoperative course was uncomplicated apart from some hyperkalemia with potassium up to 6.6. On postoperative day number two, surveillance ultrasound of the transplanted pancreas showed blood flow to the tail of the pancreas. On postoperative day number two, the patient's right JP drain was noted to begin draining some dark output in the morning which was later in the day sent for analysis and was found to be high in lipase and amylase consistent with a leak from his enteric anastomosis. The patient was, therefore, returned to the OR for an exploratory laparotomy. In the OR, the patient was found to have a leak of his duodenal anastomosis as well as a duodenal cuff bleed. The patient's hematocrit had been noted to be trending downwards and the finding of the duodenal cuff bleed explained this trend. The patient's transplanted pancreas was looking healthy and normal. The patient was, thereafter, returned back to the SICU where he had an uncomplicated recovery and was transferred to the floor on postoperative day number three and one. On the Transplant Floor, the patient continued to progress well. He continued to be followed by the Transplant Nephrology Team with his renal function remaining stable. He was also followed by the [**Last Name (un) **] team and remained on an insulin drip for a period with his blood glucose remaining well controlled. On postoperative day number nine/seven, the patient reported some right lower quadrant pain at the site of his JP. He also began to complain of some nausea. Because of this, a CAT scan was ordered on postoperative day number ten/eight, which was found to be normal. The patient's right lower quadrant JP drain was discontinued with some improvement in his pain. The patient was deemed stable for discharge to home on postoperative day number 11/nine. DISCHARGE CONDITION: Stable. FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] in clinic. He is also to follow-up with the Transplant Nephrology Team at the Transplant Center. The patient will also follow-up with the [**Hospital **] Clinic for further management of his diabetic medications. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**] Dictated By:[**Name8 (MD) 997**] MEDQUIST36 D: [**2103-11-20**] 23:07 T: [**2103-11-21**] 06:42 JOB#: [**Job Number 35903**]

[ "998.11", "311", "593.9", "V42.0", "997.4", "250.63", "285.1", "401.9", "276.7" ]

icd9cm

[ [ [] ] ]

[ "45.91", "52.82" ]

icd9pcs

[ [ [] ] ]

3742, 4303

1565, 3720

1180, 1547

1131, 1157

65,950

131,203

8898

Discharge summary

report

Admission Date: [**2165-11-10**] Discharge Date: [**2165-12-10**] Date of Birth: [**2120-7-23**] Sex: M Service: MEDICINE Allergies: Ativan / Latex Attending:[**First Name3 (LF) 358**] Chief Complaint: sepsis, osteomyelitis, cellulitis Major Surgical or Invasive Procedure: R BKA VATS TEE SubClavian access L PICC line History of Present Illness: 45 yo M with spina bifida, paraspinal lipoma treated with high dose dexamethasone for the past 6 weeks, and nonhealing R foot ulcer x 7 years transferred from OSH with whole L leg cellulitis and intermitant chest discomfort. In brief, on arrival in the ED the Pt was in respiratory distress and was transfered to the MICU. The respiratory distress was thought to be secondary to narcotics. He was treated with narcan and his respiratory status improved. He was never intubated. While in the MICU he reported ongoing chest pain. An ECG showed diffuse ST-T changes. An echo was done which showed a pericardial effusion. Cardiology was consulted and he was felt to have pericarditis. The etiology remained unclear, but is most likely infectious. . Regarding his sepsis, in the ED the patient was tachycardic with leukocytosis with PMN predominance and elevated bands. His BCx grew group G Streptococcal bacteremia. The most likely source of infection is the ongoing leg infections potentiated by high dose dexamethasone. He was also noted to have a UTI which grew Klebsiella oxytoca. His lactate was elevated. He was started on vancomycin, pip/tazo, and clindamycin. He was also noted to have multiple, scatted crusted and ulcerated lesions on the skin and OP which are positive for HSV1. He was started on acyclovir. In addition he complained of odynophagia. His exam was consistent with thrush plus HSV esophagitis and he was started on fluconazole. He is still waiting for EGD. Finally, he the above noted chronic R foot ulcer and osteomyelitis for 7 years as well as L leg cellulitis. After much discussion he will have BKA within this admission of the RLLE. . In addition to his multiple clear infections and pericarditis, he also has swollen knees and elbows. A diagnostic tap was negative for pleocytosis, and culture is negative after 24hrs. He also was noted to have transaminitis on admission which has improved somewhat over the past 48 hours. The working diagnosis is hypotension induced liver damage. He has diffuse acne since starting his dexamethasone. The dexamethasone was started to reduce inflammatin around his paraspinal lipoma. He reports worsening urinary incontinence, most likely related to this lesion. He is scheduled to see an OSH neurosurgeon in [**Month (only) 1096**] for this. He has started to be tapered off these steroids. . On the floor tonight he is communicative and stable. He endorses the essential components of his history. He says that the decision to have the amputation is a relief after all the years of infections and pain. His pain is controlled. Past Medical History: Hypothyroidism Spina bifida with tethered cord L2/L4 lipoma Depression Neuropathy Neurogenic bladder L-3 to L-4 stenosis ?cervical angle defect h/o cocaine abuse s/p 6 mos rehab, quit [**12/2162**] h/o MRSA in foot Right foot debridement of skin and subcutaneous tissue [**2165-9-12**] Split-thickness skin graft from right thigh [**2164-9-11**] Foot ulcer x 7 years Social History: Lives alone, with VNA and Home Health services. Girlfriend, [**Name (NI) **] is very involved in health care. Quit smoking 1 year ago. Quit alcohol and cocaine [**2163-1-2**]. Did snort cocaine, no h/o IVDU. Family History: Noncontributory Physical Exam: MICU: T 98.8, HR 126, BP 149/70, RR 8, 90/2L Gen: Somnolent, intermittently apneic, rousable to loud voice HEENT: Pupils pinpoint = 2mm, reactive; crusting lesions on R eyebrow, R upper lip and R anterior neck; symmetric; MMM PULM: CTAB b/l except mild crackles L base posteriorly without wheeze/rale/ronchi CV: Tachycardia, clear S1/S2 without m/g, no audible rub Abd: Mildly distended, +BS, soft, NT, no palpable masses; mild erythema in lower abdomen along hypogastrum, increased erythema L flank Back: No open lesions; 1-2mm papular lesions diffusely GU: Erythematous, mildly TTP scrotum, prepuce with mild erythema and swelling inferiorly Ext: WWP, lower extremity size asymmetry; LLE with diffuse erythema - TTP from knee inferiourly; RLE with diffuse erythema; 4x3cm poorly healing ulcer R foot base with white/green lesion 1x1.5 medially. Skin: With diffuse rash as above on back/chest and forehead (stated to be x 3 weeks per girlfriend); additionally with several shallow/dry ulcerations on L hand with adjacent pustules (not open) Neuro: Sedated, moving all extremities . Medicine: GEN: NAD, sitting in bed, chatting pleasantly, many obvious skin lesions VS: 98.1 127/81 117 18 94% on 2L HEENT: MMM with several OP lesions, no thrush, lip and face scabs and ulcers, no LAD or JVD. Subclavian line in place on the R. CV: RR, NLS1S2 with rub. No M, no S3S4 PULM: Bibasilar crackles greater on the R. No wheezes ABD: BS+, NTND, no masses or HSM LIMBS: wasted bilat LEs with pitting edema, bright red erythema, warm, no crepitus. Wrapped R foot. SKIN: Multiple 0.5-2cm well circumscribed crusted ulcerations, some with vesicles. Fairly diffuse small 2mm red lesions consistent with acne greatest on the back and chest Pertinent Results: ADMISSION LABS: [**2165-11-10**] 02:45PM BLOOD WBC-4.9# RBC-3.74* Hgb-11.9* Hct-35.4* MCV-95 MCH-31.8 MCHC-33.5 RDW-13.6 Plt Ct-335 [**2165-11-10**] 02:45PM BLOOD Neuts-12* Bands-59* Lymphs-7* Monos-10 Eos-0 Baso-0 Atyps-0 Metas-10* Myelos-2* [**2165-11-10**] 02:45PM BLOOD PT-13.4 PTT-25.0 INR(PT)-1.1 [**2165-11-10**] 02:45PM BLOOD Glucose-182* UreaN-26* Creat-0.9 Na-131* K-4.1 Cl-94* HCO3-29 AnGap-12 [**2165-11-10**] 11:00PM BLOOD ALT-213* AST-125* LD(LDH)-1209* CK(CPK)-294* AlkPhos-60 TotBili-0.3 [**2165-11-10**] 11:00PM BLOOD Albumin-2.0* [**2165-11-11**] 03:49AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.8 . DISCHARGE LABS: [**2165-12-9**] 05:01AM BLOOD WBC-14.9* RBC-2.70* Hgb-8.0* Hct-24.7* MCV-92 MCH-29.7 MCHC-32.4 RDW-15.8* Plt Ct-1269* [**2165-12-7**] 05:32AM BLOOD PT-16.7* PTT-30.3 INR(PT)-1.5* [**2165-12-9**] 05:01AM BLOOD Glucose-102 UreaN-7 Creat-0.7 Na-139 K-4.4 Cl-103 HCO3-29 AnGap-11 [**2165-12-5**] 05:05AM BLOOD ALT-15 AST-15 LD(LDH)-216 AlkPhos-71 TotBili-0.2 [**2165-12-7**] 05:32AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.2 [**2165-12-5**] 05:05AM BLOOD Albumin-2.5* Calcium-9.0 Phos-3.7 Mg-1.9 . ADDITIONAL LABS: [**2165-12-8**] 04:26AM BLOOD CK-MB-NotDone cTropnT-0.05* [**2165-12-7**] 06:22PM BLOOD CK-MB-NotDone cTropnT-0.05* [**2165-12-7**] 12:31PM BLOOD CK-MB-NotDone cTropnT-0.06* [**2165-12-7**] 12:00AM BLOOD CK-MB-NotDone cTropnT-0.05* [**2165-11-27**] 03:50AM BLOOD CK-MB-NotDone cTropnT-0.10* [**2165-11-26**] 09:53AM BLOOD CK-MB-NotDone cTropnT-0.14* [**2165-11-26**] 06:13AM BLOOD cTropnT-0.15* [**2165-11-26**] 02:35AM BLOOD CK-MB-NotDone cTropnT-0.17* [**2165-11-25**] 05:16PM BLOOD cTropnT-0.16* [**2165-11-24**] 05:02AM BLOOD TSH-2.5 [**2165-11-24**] 05:02AM BLOOD T3-60* Free T4-1.2 [**2165-11-27**] 12:02PM BLOOD ANCA-NEGATIVE B [**2165-11-21**] 05:23AM BLOOD ANCA-NEGATIVE B [**2165-11-27**] 12:02PM BLOOD [**Doctor First Name **]-NEGATIVE [**2165-11-17**] 12:57PM BLOOD HIV Ab-NEGATIVE . MICROBIOLOGY: [**2165-11-10**] 2:45 pm BLOOD CULTURE **FINAL REPORT [**2165-11-16**]** Blood Culture, Routine (Final [**2165-11-16**]): BETA STREPTOCOCCUS GROUP G. STAPH AUREUS COAG +. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S . [**2165-11-10**] 3:00 pm URINE Site: CLEAN CATCH **FINAL REPORT [**2165-11-12**]** URINE CULTURE (Final [**2165-11-12**]): KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML.. AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . [**2165-11-11**] 5:42 pm SWAB Source: right foot. **FINAL REPORT [**2165-11-15**]** GRAM STAIN (Final [**2165-11-11**]): 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. WOUND CULTURE (Final [**2165-11-15**]): BETA STREPTOCOCCUS GROUP G. MODERATE GROWTH. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S . ANAEROBIC CULTURE (Final [**2165-11-15**]): NO ANAEROBES ISOLATED. [**2165-11-11**] 7:31 pm Direct Antigen Test for Herpes Simplex Virus Types 1 & 2 RIGHT HAND LATERAL. R/O HSV. **FINAL REPORT [**2165-11-14**]** Positive for Herpes Simplex Virus Type 1 by direct antigen staining.. DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final [**2165-11-12**]): NEGATIVE FOR VARICELLA-ZOSTER VIRUS. VARICELLA-ZOSTER CULTURE (Final [**2165-11-14**]): HERPES SIMPLEX VIRUS TYPE 1. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY.. . [**2165-11-15**] 5:46 pm SPUTUM Source: Induced. **FINAL REPORT [**2165-11-17**]** GRAM STAIN (Final [**2165-11-15**]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2165-11-17**]): MODERATE GROWTH OROPHARYNGEAL FLORA. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2165-11-16**]): NEGATIVE for Pneumocystis jirovecii (carinii).. . [**2165-11-20**] 8:16 pm SWAB Source: R heel ulcer. **FINAL REPORT [**2165-11-30**]** GRAM STAIN (Final [**2165-11-20**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2165-11-30**]): BETA STREPTOCOCCUS GROUP G. SPARSE GROWTH. SENSITIVE TO CLINDAMYCIN (MIC= 0.12UG/ML). STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML BETA STREPTOCOCCUS GROUP G | STAPH AUREUS COAG + | | CLINDAMYCIN----------- S <=0.25 S ERYTHROMYCIN---------- 4 R <=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- <=0.25 S PENICILLIN G---------- 0.06 S <=0.03 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Final [**2165-11-24**]): NO ANAEROBES ISOLATED. . IMAGING: TTE (Focused views) Done [**2165-12-2**] at 12:04:23 PM The estimated right atrial pressure is 0-10mmHg. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. Interventricular septal motion is normal. There is a moderate sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. Stranding is visualized within the pericardial space c/w organization. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2165-11-26**], the pericardial effusion is smaller, more echo dense and more concentrated to the posterior LV. . TTE (Complete) Done [**2165-11-26**] at 2:20:21 The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a moderate to large sized pericardial effusion with some stranding/organization within it. There are no echocardiographic signs of tamponade.Compared with the prior study (images reviewed) of [**2165-11-20**] , the pericardial effusion appears similar. . TEE (Complete) Done [**2165-11-20**] at 2:45:56 The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 45 cm from the incisors. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. There is a moderate sized circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: No valvular vegetations noted. Moderate sized circumferential pericardial effusion was noted without echocardiographic signs of tamponade. . TTE (Complete) Done [**2165-11-13**] at 1:38:19 The left atrium is normal in size. 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 aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Small to moderate pericardial effusion, most prominent near the lateral and inferolateral walls. No echo evidence of tamponade physiology. Compared with the prior study (images reviewed) of [**2165-11-10**], the findings are similar. . Portable TTE (Focused views) Done [**2165-11-10**] at 5:55:22 PM The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 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 a small to moderate sized pericardial effusion most prominent inferolateral (1.2cm) and lateral (1.0cm) to the left ventricle with minimal (<5mm) around the apex and anterior to the right ventricle. There is no right atrial or right ventricular diastolic collapse. IMPRESSION: Small-moderate pericardial effusion as described above without 2D echo evidence of tamponade physiology. Preserved global biventricular systolic function. Mild mitral regurgitation. . CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2165-11-29**] 5:34 FINDINGS: No pulmonary artery filling defects are identified to suggest pulmonary embolism. Mild prominence in caliber of the main pulmonary artery is not significantly changed compared to [**2165-11-19**]. A moderate pericardial effusion persists. A left PIC catheter terminates near the cavoatrial junction, unchanged. Multiple scattered prominent mediastinal and hilar lymph nodes are reidentified including a precarinal node which measures 12.3 mm in short axis compared to 9 mm on [**11-19**]. A small left pleural effusion persists. Lung windows again reveal mild predominantly upper lobe centrilobular emphysema. Dependent atelectatic changes are noted at the bases bilaterally. Multiple subcentimeter pulmonary nodules are reidentified including a 4- mm right upper lobe nodule (3:33), which previously measured up to 6 mm. A 2-3mm pulmonary nodule (3:41) in the right upper lobe, previously measured 3-4mm. A previously noted 6-mm nodule in the left upper lobe (3:37) appears unchanged. No definite new nodules are identified. Although this examination is not tailored to evaluate abdominal organs, limited non-contrast evaluation of the upper abdomen is unremarkable. Bone windows reveal no worrisome lytic lesions. IMPRESSION: 1. No evidence for pulmonary embolism. Mild prominent caliber of the main pulmonary artery is not significantly changed. 2. Persistent moderate pericardial and small left pleural effusion. 3. Multiple subcentimeter pulmonary nodules are stable to slightly decreased in size. Recommend continued attention to these findings on short term follow-up chest CT (ie 3- 4 months) to ensure no interval growth. 4. More prminent hilar and mediastinal lymph nodes, perhaps reactive. . CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Study Date of [**2165-11-21**] 3:39 A small amount of layering fluid and mild mucosal thickening is noted in the right maxillary sinus with some mucosal thickening noted near the right ostiomeatal unit. Minimal mucosal thickening is noted in the left maxillary sinus and the left ostiomeatal unit is patent. A small amount of mucosal thickening is noted in the ethmoid air cells and inferior frontal sinus. A trace amount of mucosal thickening is noted in the right sphenoid air cell. There is rightward nasal septal deviation and spurring. The cribriform plates are intact and in the anterior clinoid processes are not pneumatized. The dominant sphenoid sinus septum inserts to the right of midline. No bony dehiscence is identified. The imaged portions of the mastoid air cells are well aerated. IMPRESSION: Fluid and mucosal thickening in the right maxillary sinus extending into the ethmoid and inferior frontal sinuses, possibly consistent with acute sinusitis. . CT LOW EXT W/O C RIGHT Study Date of [**2165-11-19**] 3:36 PM Moderate neuropathic changes involve the mid foot, with deformity and debris. Metallic hardware is unchanged in position. A screw traverses the calcaneocuboid joint. A large staple is located within the calcaneus. A second staple crosses from the talus into the lateral cuneiform. A metallic pin traverses the first interphalangeal joint, which is plantar flexed. A large soft tissue ulceration involves the lateral aspect of the foot. The mouth of the ulceration measures 3.5 cm in diameter. The fifth metatarsal base and cuboid are directly exposed. The degree of osseous destruction at the fifth metatarsal base and cuboid is similar in comparison to the prior study. Since the prior examination, the amount of subcutaneous gas in the lateral aspect of the foot has decreased. A tiny amount of gas is located at the region of the fifth tarsometatarsal joint. No new fluid collections are demonstrated. A small amount of fluid attenuation at the medial aspect of the tibiotalar joint may represent effusion or thickened synovium, unchanged since the prior study. Alignment of the foot is unchanged. Mild prepatellar edema is present. IMPRESSION: 1. Large soft tissue ulceration at the lateral aspect of the foot. Partial destruction of the fifth metatarsal base and cuboid, consistent with osteomyelitis. Since the prior examination, the amount of subcutaneous gas has decreased. 2. Neuropathic changes in the mid foot. 3. Unchanged small tibiotalar effusion or synovial thickening. . CT TORSO W/CONTRAST Study Date of [**2165-11-19**] 3:36 PM CHEST FINDINGS: Mild, bilateral centrilobular emphysema is unchanged. Previously visualized right lung infiltrates are now resolved. In the right upper lobe, a 5x6mm nodule (2:19) is visualized. Additionally sub 5-mm nodules are also visualized in the right upper lobe (2:22, 24). A 6x9mm nodule is now seen in the right middle lobe (2:36). Right basilar atelectasis is unchanged though there has been resolution of the previously described right pleural effusion. A small left pleural effusion persists. In the left upper lobe are two nodules, one measuring 5x5mm (2:14) and the other 6x6mm (2:24). Airways are patent to subsegmental levels bilaterally. The heart and great vessels are normal. A moderate pericardial effusion is unchanged. A left subclavian central venous line ends at the cavoatrial junction. There are scattered mediastinal lymph nodes, none of which meet CT criteria for pathologic enlargement. There is no axillary lymphadenopathy. ABDOMEN FINDINGS: The liver, gallbladder, spleen, adrenal glands, kidneys, stomach and small bowel are unremarkable. A 10x7mm round lipoma is visualized in the pancreatic head (2:73). There is no free gas or free fluid in the abdomen. There is no retroperitoneal, mesenteric or omental lymphadenopathy. PELVIC FINDINGS: The rectum, colon, bladder, prostate and seminal vesicles are unremarkable. There is no free fluid in the pelvis. Scattered inguinal lymph nodes are visualized, none of which meet CT criteria for pathologic enlargement. There is no pelvic lymphadenopathy. OSSEOUS AND SOFT TISSUE FINDINGS: The patient's known spina bifida is visualized with extension of the thecal sac posteriorly measuring 44x54mm in greatest cross-sectional diameter and incomplete fusion of the posterior sacrum. Atrophy of the left gluteal muscles is also visualized, likely a sequela of the patient's neurogenic disorder. There are no suspicious sclerotic or lytic lesions.IMPRESSION: 1. Interval resolution of pulmonary infiltrate and multiple bilateral pulmonary nodules. 2. Resolution of right pleural effusion with residual small left pleural effusion and pericardial effusion. 3. No intra-abdominal or pelvic abscess. 4. Sacral spina bifida. . CT LOW EXT W/O C RIGHT Study Date of [**2165-11-11**] 11:38 AM LEFT FOOT: Patient has a long screw across the calcaneocuboid joint. There are also two large staples in the posterior calcaneus. A large staple is seen within the talus and the lateral cuneiform. The configuration of the hardware is similar to the previous study. There are extensive neuropathic changes and bony destruction seen of the mid and hindfoot. There is fusion across the calcaneocuboid joint. There is a very large ulcer within the inferior lateral aspect of the foot which measures 3.6 cm at its base and there is exposed bone involving the fifth proximal metatarsal and portion of the residual cuboid. There is some gauze material in this defect. Gas is also seen adjacent to the fifth metatarsal extending more distally into the dorsal soft tissues. There is a screw across the first IP joint, unchanged since the prior radiographs. RIGHT FOOT: There are no signs for acute fractures or dislocations. There is a marked amount of soft tissue swelling about the foot and ankle. There are no acute fractures. IMPRESSION: 1. Large ulcer involving the posterolateral aspect of the right foot with a 3.5-cm region of exposed fifth metatarsal. Osteomyelitis is likely given that there is exposed bone to the surrounding air. There is gas seen extending along the fifth metatarsal shaft slight dorsally within the soft tissues of the foot. 2. Postoperative changes throughout the mid and hindfoot as described above with neuropathic changes seen at the midfoot. . CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2165-11-10**] 4:02 CTA CHEST: The pulmonary arteries are patent to the subsegmental level. There are small bilateral effusions and a moderate sized pericardial effusion. There is no central or axillary lymphadenopathy. Bilateral lower lobe atelectasis is noted. Two right upper lobe 4 mm ground glass nodules (4:97,129), should be followed to ensure stability. The airways are patent to the subsegmental level. Mild centrilobular emphysema is noted. Although this exam was not optimized for subdiaphragmatic diagnosis, the imaged intra-abdominal organs are grossly unremarkable except to note a markedly distended stomach with fluid also noted within the distal esophagus. The osseous structures demonstrate no suspicious lytic or blastic lesions. Bilateral gynecomastia is noted. IMPRESSION: 1. No evidence of PE. 2. Moderate pericardial effusion, small bilateral pleural effusions, bibasilar atelectasis. 3. Marked gastric fluid distension. Consider NGT decompression. 4. Emphysema with two ill defined right upper lobe 4 mm ground glass nodules. Recommend 12 month followup to ensure stability. . CARDIAC PERFUSION PERSANTINE Study Date of [**2165-11-18**] Left ventricular cavity size is normal. 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 61%. No comparison is available. IMPRESSION: Normal myocardial perfusion with normal wall motion and EF. . STRESS Study Date of [**2165-11-18**] INTERPRETATION: 45 yo man presents with bacteremia secondary to osteomyelitis was referred to evaluate an atypical chest discomfort prior to surgery. The patient was administered 0.142 mg/kg/min of persantine over 4 minutes. No chest, back, neck or arm discomforts were reported by the patient during the procedure. No significant ST segment changes were noted. The rhythm was sinus tachycardia with no ectopy noted. The hemodynamic response to the persantine infusion was appropriate. Post-infusion, the patient was administered 125 mg aminophylline IV. IMPRESSION: No anginal symptoms or ischemic ST segment changes. Nuclear report sent separately. . MR [**Name13 (STitle) 6452**] W & W/O CONTRAST Study Date of [**2165-11-13**] 7:35 PM FINDINGS: There is expansion of the thecal sac in the lumbosacral spine with posterior clumping of the cauda equina and nerve roots associated with a 5 mm T1 hyperintense lesion at the L5/S1 level, consistent with a lipoma. The exact location of the conus medullaris is unclear, and overall these findings would be consistent with spinal cord tethering. There is lateral deviation of the sacrum with dysplasia of the posterior elements with possible meningocele. There is no evidence for a dermal sinus. No abnormal enhancement is identified. Vertebral body heights and alignment appear normal. Mild disc desiccation at L1/2 is noted with a small disc bulge without significant spinal canal or neural foramen narrowing. The L2/3 level is normal. At L3/4, a small disc bulge produces mild- to- moderate spinal canal and mild neural facet narrowing bilaterally. The L4/5 and L5/S1 disc spaces appear unremarkable. IMPRESSION: 1. Dysplasia of the sacral spine with expansion of the lumbosacral thecal sac with a suggestion of spinal cord tethering and a small lipoma at the L5/S1 level and possible meningocele is seen. 2. Multilevel mild degenerative disc changes, with mild neural foramen and spinal canal narrowing at L3/4. Brief Hospital Course: 45 yo M, with h/o spina bifida and peripheral neuropathy with chronic R foot ulcer, recently diagnosed L-spine lipoma and immunosupressed on dexamethasone x 6 weeks transfered to the floor from the MICU with pericarditis, LLE cellulitis, RLE osteomyelitis and cellulitis, BCx growing group G Streptococcus and MSSA, HSV ulcers of the skin and OP, UTI with Klebsiella, paraspinal lipoma, on steroids to reduce spinal inflammation, and elevated LFTs. He is now s/p R BKA. There was a troponin leak post op. Has been persistently febrile <101 but stable. . # Sepsis/bacteremia (MSSA/GBS bacteremia, RLL osteomyelitis): Pt presented to ED with tachycardia, elevated bands, and GPC in initial blood culture in the setting of immunosuppression with steroids progressively worsening chronic R foot ulcer and bilateral leg cellulitis c/w sepsis. Source of infection most likely related to patient??????s chronic RLE ulcer. Source confirmed as blood and wound cultures grew back group G Streptococcus and MSSA. HIV negative. Urine was positive for Klebsiella which was treated with ceftriaxone. Skin lesions were positive for HSV1 and he was treated with acyclovir. There was oral thrush and odynophagia which was treated with fluconazole. Galactomannin, cryptococcal, and Legionella serologies were negative. Multiple TTEs and a TEE showed no endocarditis but a pericardial effusion with no tamponade physiology. D-B-galactomannin positive as of [**2165-11-19**]. Unclear how to interpret this in the context of Gram pos bacteremia and Hx of Zosyn use as these may lead to false positive results. Ultimately the GBS and MSSA were pan sensitive and treated with 4 weeks of nafcillin. He completed treatment on [**2165-12-9**]. On nafcillin he developed Cdiff and will need to continue PO vancomycin to [**2165-12-23**] - or 2 weeks after completing IV antibiotic therapy. . # Leukocytosis: His WBC elevation is characterized by neutrophilia with normal immature forms consistent with a reactive process. It improved during the hospitalization but never fully normalized. Torso CT [**2165-11-19**] no occult abscesses or LAD with stable pericardial effusions. Sinus CT showed ?mild sinusitis, but on effective ABx and asymptomatic. Pt also became Cdiff positive. He will complete treatment for this as above on [**2165-12-23**]. . # Thrombocytosis: Has developed over this hospitalization. Likely reactive. Pt is on ASA given chest pain on [**2165-12-7**]. As of discharge his PLTs had stabilized and started to fall. . # Fever: Pt had low grade fever persistently after treatement of his obvious infections. Etiology has never been fully clear. DD includes ongoing incompletely treated infection or an occult infection, a drug fever, or rheumatologic problem. [**Name (NI) 227**] LAD, DD includes malignancy that is unmasked by withdrawing dexamethason, although unlikely. [**Doctor First Name **], ANCA, and RF WNL. CTA for PE [**2165-11-29**] showed improving pulmonary nodules, stable effusions of the pericardium and pleural spaces, and stable/improving pulmonary nodules but also mediastinal LAD. Cdiff positive as of [**2165-11-28**]. Originally on metronidazole, but switched to PO vancomycin. Will need Rx until [**2165-12-23**] - 2 weeks after finishing nafcillin. He will need F/U on final VATS results. So far preliminary results are consistent with fibrosis and chronic scarring of the pericardium. . # Pericarditis/pericardial effusion: Etiology most likely infectious and treated with antibiotics. DD of this effusion is low grade infection, suboptimally treated infection, inflammatory process, and malignancy. All are possible in this situation. Multiple ECHOs (TTE and TEE) have been done and [**Last Name (un) **] WNL EF and wall motion with organizing pericardial effusion. As of [**2165-12-2**] the effusion was posterior and organizing and could not be accessed with a needle. VATS on [**2165-12-5**] showed that the percardium was adherent to the epicardium with a fibrous material. Cardiology was consulted and saw no deranged physiology and recommended follow up. On [**2165-12-7**] developed CP with T inv in I II V4-6. Relieved with NL NTG. Unclear if the ECG changes are [**2-23**] pericardial fibrosis as no recent baseline. Also concerning given history of TRP leak post op and hx of cocaine abuse. CEs were negative x 4 and ECG remained unchanged . # Tachycardia: Likely [**2-23**] multiple etiologies including systemic inflammatory response/sepsis, pain, anxiety, and pericarditis. No evidence of tamponade on Echo. VATS showed that the percardium was adherent to the epicardium with a fibrous material. Per cards the tachycardia is physiologic [**2-23**] inflamatory state. Has follow up scheduled with cardiology and cardiothoracic surgery. . # Coping: This has been a long and difficult hospitalization. Pt requested SSRI, which was given. Started on citalopram 20mg PO daily on [**2165-12-9**]. . # Pain control: Pt with a history of cocaine addiction. Adjusting regimen to minimize narcotic exposure with optimal comfort. Pt with many reasons for pain. Standing tylenol plus oxycontin 60mg [**Hospital1 **] as well as gabapentin. PO oxycodone for breakthrough 5-10mg q3hrs PRN. Standing bowel regimen for constipation [**2-23**] narcotics. . # Neurogenic Bladder: On oxybutinin. Foley has been in place this hospitalization. At home pt straight caths himself. . # Troponin leak post op: Unclear if this is due to a perioperative MI or troponin leak from pericarditis. TTE was NL with no major changes from previous ECHOs. . # Joint pain and inflammation: Pt reports having increased bil (L>R) knee pain with decreased ROM. R knee was tapped and not consistent with septic joint. Concern for inflammatory process, possibly secondary to Streptococcal infection. Overall resolved spontaneously with improvement in clinical status. . # R foot ulcer/Osteomyelitis: Chronic issue over past 7yrs; secondary to peripheral neuopathy from spina bifida and tethered cord syndrome; well known to plastics team. Followed by plastics, wound nurse, and podiatry (staffed with podiatry at time of transfer). Ulcer at proximal portion of 5th metatarsal base and portion of the cuboid. Preliminary wound culture positive for group G Strep. CT of foot with probable OM and gas in the soft tissue. Wound cultures continued to grow group B Step and MSSA. Ultimately treated with BKA. Will f/u with vascular in the beginning of [**12-30**] for staple removal. . # Cellulitis: Most likely from organisms of his bacteremia (group G Strep), but could be other Gram positives or even anaerobes and Gram negatives. Dramatic improvement since admission, now resolved. . # HSV: Hand and upper lip ulcerations in setting of immunosuppression. DFA positive for HSV1. Unclear if esophagitis. Held off on EGD for the moment since improved initially with fluconazole so seemed to be Candidal. But since still present we are re-considering EGD. Completed acyclovir treatment on [**2165-11-26**]. . # Odynophagia: Admitted with thrush and on high dose steroids. Considering possible candidia esophagitis. Also considering HSV esophagitis given that patient has HSV1 positive lesions of the OP. Treated with acyclovir plus fluconazole and a PPI. Symptoms resolved on this regimen. . # L-spine Lipoma: MRI showed a lipoma with an element of inflammation with possible compression related to this lesion. He was on dexamethasone 4mg QID. The patient's decadron level was tapered to 4mg TID and then to 3mg TID during admission. Pt scheduled to see neurosurgeon in [**Month (only) 1096**] at OSH. [**Hospital1 18**] neurosurgery recommended discontinuing steroids, which we already were doing. Pt tolerated taper well and has been stable off steroids. . # Sick euthyroid: TSH <0.02. Free T4 (WNL) and T3 (low) c/w subclinical hyperthyroidism. Reports recent change in levothyroxine qday which could exacerbate tachycardia and changes in labs may not be apparent so close to change in dosage. Per endo consult changed to 150ug levothyroxine as euthyroid based on labs. . # Acne: Back, anterior chest wall, forehead. Likely [**2-23**] bacterial overgrowth on dexamethasone. Was treated with steroid taper plus benzoyl peroxide 10% gel and clindamycin topical 1% lotion. . # Lung nodule. Pt has several small lung nodules which will need interval follow up in 3 to 6 months with a non-contrast chest CT. Medications on Admission: Darvocet 1 tab q4-6H PRN pain Dilaudid 4mg po QOD- per patient was using old perscription Oxybutynin 5mg QHS Neurotin 300-600mg [**Hospital1 **] Sudafed 30mg po Q4-6H Baclofen, unknown dose, [**Hospital1 **] PRN Decadron 4mg QID x 3 weeks Fentanyl patch 50mcg q72hrs Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 5. Levothyroxine 75 mcg 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 Q24H (every 24 hours). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 13. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 14. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): Please discontinue after [**2165-12-23**]. 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for L thorax. 17. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. 18. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 21. Chest CT non-contrast Please obtain a non-contrast CT of your chest 3 months after discharge. Discharge Disposition: Extended Care Facility: [**Hospital6 19504**] of [**Location (un) 30940**] - [**Location (un) 30940**] Discharge Diagnosis: Primary diagnosis: Sespsis, cellulitis, osteomyelitis, HSV . Secondary diagnosis: Spina bifida, lipoma, history of substance abuse Discharge Condition: Good, stable vital signs, persistent low grade fevers Discharge Instructions: You were admitted with several infections. We were able to treat most them with long term antibiotics. We had to amputate your right lower leg because the infection in your leg was too severe to treat with medications alone. We discontinued the steroids you came in on, as we believe that these contributed to your infections. You developed fluid around your heart which developed into a scar. We samples this scar to make sure it was not infected. You have had a fast heartbeat. We think that this is your body's reaction to all the inflammation from your infections as well as the scarring of your pericardium. . Please take your medications as prescribed. . Please attend your follow up appointments. . Followup Instructions: Cardiothoracic surgery: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**] Date/Time:[**2165-12-17**] 10:30 Vascular surgery: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2165-12-24**] 9:45 Infectious disease: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2166-1-10**] 11:30 Cardiology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2166-3-11**] 09:00 . Please have a CT of your chest without IV contrast 3 months after discharge Completed by:[**2165-12-10**]

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Discharge summary

report

Admission Date: [**2162-6-21**] Discharge Date: [**2162-6-30**] Date of Birth: [**2135-1-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Insertion of left paracolic drain. History of Present Illness: Mr. [**Known lastname **] is a 27 year old male with past medical history significant for alcohol abuse, peptic ulcer, and a recent month long hospitalization in [**2162-4-27**] for necrotizing pancreatitis which was complicated by respiratory failure, ventilator-associated pneumonia (VAP), acute respiratory distress syndrome(ARDS), Vancomycin-resistant Enterococci (VRE) bacteremia, probable pulmonary embolism (PE) for which he is now on coumadin, Clostridium difficile infection, and acalculous cholysystitis status post PCT drainage. Following his discharge on [**2162-5-26**] he went to rehab on linezolid and reportedly developed a rash so this was stopped. . He was in his usual state of health at home until two prior to admission ([**6-19**]) when he developed fevers, nausea, vomiting, and decreased oral intake. He was brought to the [**Hospital1 18**] ED where he was found to have ARF (Cr 2.1), bandemia (15%), hypotension, tachycardia. He was given 4 L IVF without improvement in blood pressure so a central line was placed and he was started on levophed. He was given Vancomycin, Zosyn, and Quinupristin/Dalfopristin for history of VRE and rash with Linezolid. He had mild abdominal pain and surgery was consulted and did not think there was acute abdominal process. Chest X-ray showed atalectasis. Urinalysis was clear. His creatinine improved with hydration and he had CT abdomen which showed extensive abdominal and peripancreatic fluid collections but overall no change from prior CT abdomen in [**Month (only) **]. He received a total of 8 L of IVF in the ED. VS at time of transfer to the MICU were temperature 99.8, hear rate 133, blood pressure 114/73 on 0.18 levophed, saturation 100% on 2L NC. . During his course in the MICU, the patient was thoroughly evaluated for source of infection. He was able to be weaned off levophed the morning following admission. The patient persisted with sinus tachycardia, but did not develop other episodes of SVT. His blood pressure remained stable off pressors. The patient's home coumadin dosing was held given supratherapeutic INR. ID was consulted and recommended broad spectrum antibiotics including dapto (for VRE given linezolid rash), cefepime, flagyl, and PO vancomycin. Blood and urine cultures as well as c diff toxin were sent and were negative. The patient was also started on pancreatic enzymes for continuing diarrhea. During the course, the patient complained of LLQ abdominal pain that was muscular in nature. Surgery evaluated the patient and did not feel his symptoms were related to intraabdominal process. A CT of the abdomen and pelvis and US of the abdomen revealed persistent but unchanged fluid collections. Per ID, the patient underwent a tagged WBC scan on [**6-24**] that demonstrated strong uptake in the area of the abdominal fluid collection. Interventional radiology placed a percutaneous drain into the left paracolic gutter on [**6-25**]. The patient was still febrile the morning of transfer to the floor. The patient had both a cosyntropin stimulation test and his TSH checked given his SVT and both tests were normal. . On the floor, patient initially noted to be tachycardic to 130s with transient SVT to 180. EKG showed sinus tachycardia. Was given Diltiazem 10 mg IV for SVT to 180s but had no change in HR. He denied any symptoms on the floor. Per ID recommendations, the antibiotics were eventually decreased to Zosyn and PO Vancomycin (for C. diff). The patient continued to have intermittent fevers to approximately 100.5 initially but these subsided over several days. Fluid cultures collected from the intra-abdominal fluid collection grew out Lactobacillus spp., and per ID recommendations, Zosyn was changed to PO Augmentin. Of note, his INR remained subtherapeutic on the floor despite increases in his Coumadin dosing. In preparation for discharge, he was switched from a Heparin bridge to Lovenox, which was to be continued until his INR became therapeutic on Coumadin. . The patient was discharged on [**6-30**] in stable condition and had been afebrile for approximately 48 hours. He was given close follow-up instructions with surgery and infectious diseases. He was referred to a new PCP in the same practice of his prior PCP and they commented that they had a [**Hospital 197**] clinic where he could also be managed. Past Medical History: (+) Per HPI Gastric ulcer disease requiring EGD in [**2159**] with clipping ETOH abuse Necrotizing pancreatitis ([**5-6**]) with hospital course complicated by: - VAP (Ventilator-associated pneumonia) - ARDS (Acute Respiratory Distress Syndrome) - VRE (Vancomycin-resistant Enterococci) bacteremia - Probable PE - Clostridium difficile infection - Acalculous cholysystitis s/p PCT drainage Social History: Pt lives alone. Both mother and father are very involved on his care. He drinks on average 4-5 drinks of whiskey per day 4-5x wk. He does not smoke, and has used marijuana in College, but denies using any other illicit drugs Family History: CAD father at age of 62 Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, minimal diffuse tenderness to palpation (much improved from prior), bowel sounds present, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neurologic: cranial nerves grossly intact Pertinent Results: [**2162-6-30**] 06:20AM BLOOD PT-17.3* PTT-72.1* INR(PT)-1.5* [**2162-6-30**] 06:20AM BLOOD WBC-8.3 RBC-3.43* Hgb-10.1* Hct-30.5* MCV-89 MCH-29.3 MCHC-33.0 RDW-14.9 Plt Ct-763* [**2162-6-29**] 06:15AM BLOOD Neuts-73.7* Lymphs-17.9* Monos-5.3 Eos-2.7 Baso-0.3 [**2162-6-28**] 07:21AM BLOOD Glucose-105* UreaN-1* Creat-0.4* Na-133 K-3.7 Cl-94* HCO3-30 AnGap-13 [**2162-6-23**] 11:12AM BLOOD TSH-1.4 [**2162-6-23**] 11:12AM BLOOD T4-4.6 WOUND CULTURE (Final [**2162-6-29**]): LACTOBACILLUS SPECIES. SPARSE GROWTH. Brief Hospital Course: Mr. [**Known lastname **] is a 27 YOM with history of etoh abuse and recent complicated hospitalization for necrotizing pancreatitis who presented with several days of nausea and fevers. He was found to be severely hypotensive and required extensive intravenous fluid resuscitation and a brief course of pressors and a short stay in the medical ICU during which time he was on broad spectrum antibiotics. After extensive evaluation for an infectious source, a tagged white blood cell scan revealed an intra-abdominal fluid collection as the source of his fevers. A drain was placed into his left paracolic gutter. His hypotension resolved and he was transferred to the floor and his antibiotic regimen was tapered. He continued to have intermittent fevers after transfer from the MICU to the floor. Fluid cultures from the abdominal collection eventually grew out Lactobacillus and the patient was started on Augmentin. He was discharged after being afebrile for approximately 48 hours with close outpatient follow-up. . 1. Hypotension/Sepsis: Mr. [**Known lastname **] was found to be hypotensive in the ED. His hyptension was refrectory to 8L of NS in ED, and he required pressors. In addition he had a bandemia, fever, and ARF which is concerning for sepsis. Potential sources infecitous included intraabdominal (pancreatic, biliary, C diff), bacteremia, with UTI and Pneumonia less likely given normal UA and CXR. Blood and urine cultures were obtained and he was admitted the MICU and was started on Daptomycin (cover VRE, MRSA), cefepime (GNR), and flagyl (anaerobes). He recieved IVF boluses to keep CVP 8-12, MAP > 65, UOP > 40 cc/hr. In addition Levophed was used acheive BP goals. Additionally C. Diff and sputum cx were also obtained, and serial abdominal exams were performed. A RUQ U/S failed to reveal the soucre of the infection. Shortly after admission, Mr. [**Known lastname **] was found to have significant diarrhea with >20 BM daily. The ID service was consulted and C.Diff was determined to be the most likely pathogen causing this septic shock presentation. Until a source of infection could be identified, he was treated with broad spectrum antibiotics: Daptomycin (for possible VRE recurrence), cefepime/flagyl (for possible enteric pathogen), and PO vanco (for possible persistent c diff). Mr. [**Known lastname **] became hemodynamically stable off pressors on the day after admission and a tagged WBC scan was performed to attempt to localize the source of his left lower quadrant tenderness that seemed musculoskeletal in origin. He remained hemodynamically and was transfered to a general medicine floor from the ICU on hospital day 2. The tagged WBC scan showed uptake in a fluid collection in the left paracolic gutter and a drain was placed in the fluid collection which returned fluid with gram positive rods identified as lactobacillus. His antibiotics were narrowed to Augmentin, Vancomycin PO was maintained to cover for incompletly treated C. diff. . # History of PE: Coumadin started [**6-26**] with heparin drip to bridge. Coumadin dose was eventually increased to Coumadin 3 mg by mouth daily but remained subtherapeutic at 1.5 on the morning of discharge. He was transitioned from Heparin to Lovenox on the day of discharge. . # Sinus tachycardia: Likely related to pain or infection. Continued to improve during his hospital stay but will likely persist until infection his underlying process is resolved. Patient was discharged on Metoprolol tartrate 25 mg by mouth twice a day, which has been a stable dose for several days now, but, of note, was lower than his home dose of 50 mg twice a day. . # Acute renal failure: Initially presented with a serum creatinine of 2.1. This responded to intravenous fluids and was resolved by time of discharged. His home dose of Lisinopril was held throughout the hospital course in order to prevent potential worsening of his renal failure. . # Hyponatremia: Sodium was 129 on admission. Most likely due to hypovolemic hyponatremia. Patient responded to intravenous fluids. His last sodium was 133 two days prior to discharge. . # Insomnia: Patient was stable on his home dose of Ambien. His Trazodone was held during his hospital stay. Medications on Admission: lisinopril 5 mg Q day Lopressor 50 mg Q 12 Ambien 10 mg QHS Prevacid 30 mg Q day Thiamine 100 mg Q day Folic acid 1 mg Q day Trazodone 50 mg QHS Coumadin 4 mg Q day Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 2. Zolpidem 5 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO HS (at bedtime). 3. Oxycodone 15 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain for 14 days. Disp:*64 Tablet(s)* Refills:*0* 4. Vancomycin 125 mg Capsule [**Month/Day (4) **]: One (1) Capsule PO Q6H (every 6 hours) for 34 days. Disp:*136 Capsule(s)* Refills:*0* 5. Senna 8.6 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO PRN daily as needed for constipation. Disp:*14 Tablet(s)* Refills:*0* 6. Docusate Sodium 100 mg Capsule [**Month/Day (4) **]: One (1) Capsule PO BID PRN as needed for constipation for 14 days. Disp:*28 Capsule(s)* Refills:*0* 7. Warfarin 1 mg Tablet [**Month/Day (4) **]: Three (3) Tablet PO Once Daily at 4 PM for 1 months. Disp:*90 Tablet(s)* Refills:*0* 8. Amoxicillin-Pot Clavulanate 875-125 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO BID (2 times a day) for 21 days. Disp:*42 Tablet(s)* Refills:*0* 9. Enoxaparin 80 mg/0.8 mL Syringe [**Month/Day (4) **]: One (1) Subcutaneous Q12H (every 12 hours) for 1 weeks. Disp:*14 syringes* Refills:*0* 10. Folic Acid 1 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day. 11. Thiamine HCl 100 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day. 12. Prevacid 30 mg Capsule, Delayed Release(E.C.) [**Month/Day (4) **]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Outpatient Lab Work Please check CBC weekly and fax results to the [**Hospital **] clinic, Attention Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Hospital1 18**] ([**Telephone/Fax (1) 1353**] Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Peritoneal Abscess Necrotizing Pancreatitis Secondary Diagnoses: Sinus Tachycardia Acute Renal Failure (resolved) Insomnia Hyponatremia Pulmonary Embolism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **]: You were readmitted with an infection. It was determined that one of the fluid collections from your recent pancreatitis was infected. You were treated briefly in the ICU but were stabilized with intravenous fluids and antibiotics. You were eventually transitioned to oral antibiotics which you should continue as an outpatient. THESE MEDICATIONS WERE STARTED IN HOSPITAL AND NEED TO BE CONTINUED AT HOME: 1. Augmentin 875 mg by mouth twice a day: needs to be continued through [**7-20**]. 2. Vancomycin Oral Liquid 125 mg by mouth every six hours: needs to be continued until [**8-3**]. 3. Lovenox 80 mg subcutaneous injection twice a day: once your INR is therapeutic for 48 hours, you can stop taking the Lovenox. Your goal INR is 2.0 to 3.0. 4. Coumadin 3 mg by mouth once daily: your coumadin dose will be adjusted by your coumadin clinic. 5. Docusate Sodium 100 mg by mouth twice a day: this medication is for constipation from your pain medications. 6. Senna 1 Tab by mouth daily: this medication is also for constipation related to your pain medications. 7. Oxycodone 15 mg by mouth every six hours as needed for pain. CONTINUE THESE MEDICATIONS: 1. Metoprolol tartrate 25 mg by mouth twice a day: you should continue this medication until you see your primary care physician. ** This dose was changed from what you came in on.** 2. Ambien 10 mg by mouth at night for insomnia. 3. Prevacid 30 mg by mouth once daily. 4. Thiamine 100 mg by mouth daily. 5. Folic acid 1 mg by mouth daily. STOP TAKING THESE MEDICATIONS: 1. Simethicone 2. Trazodone 3. Lisinopril Followup Instructions: You have an appointment with a new primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on [**Last Name (LF) 766**], [**7-5**] at 9:15 AM. His address is [**Street Address(2) 85108**], [**Location (un) **], [**Numeric Identifier 85109**]. His phone number is [**Telephone/Fax (1) 29252**]. ** You need to go to his office tomorrow (Wednesday, [**7-1**]) to have your INR checked. You can go to his office at any time other than 12:00 - 1:30 PM when the office is closed for lunch.** Department: SURGICAL SPECIALTIES When: [**Month (only) **] [**2162-7-12**] at 11:15 AM With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage A CT scan was ordered for you. It should be completed the day before your appointment with Dr. [**Last Name (STitle) 468**] (Surgery). If you do not hear from them to schedule the appointment, you will need to call them to make the appointment at [**Telephone/Fax (1) 327**]. Department: INFECTIOUS DISEASE When: [**Telephone/Fax (1) **] [**2162-7-19**] at 10:30 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: FRIDAY [**2162-7-30**] at 11:00 AM With: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2162-7-1**]

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Discharge summary

report

Admission Date: [**2137-11-26**] Discharge Date: [**2137-12-1**] Date of Birth: [**2084-9-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 25342**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Endoscopic Gastroduodenoscopy with Biopsy Temporary Dialysis catheter placement in Right Femoral Vein PICC line placement History of Present Illness: Patient is a 52yo F with HIV/HCV coinfection (not on Haart, CD4 250s, VL 4K), ESRD on HD - admitted with fever to 104.9. She did not have any pain or cough or urinary/bowel sx. HD stopped early today due to fevers, given vanco there. Here in ED given levo/flagyl/vanco, also recieved gent. Patient has tunnel cath-- recent stripping at [**Hospital1 2177**] 1 wk ago. Patient had a recent admission for esophagitis and [**Doctor First Name 329**] [**Doctor Last Name **] tear for which she was treated with fluc. and acyclovir (d/c'd [**11-15**]). In ed, cxr was neg, blood cx were taken, patient rec'd vanc,levo,flagyl, gent x 1. Also rec'd vanc at dialysis. Past Medical History: HIV: Diagnosed approximately 6 years ago. Never been on antiretroviral therapy. No history of opportunistic infections. No other HIV associated complications. Hepatitis C Hepatitis B Hypertension End-stage renal disease: hypertensive nephrosclerosis. Gets hemodialysis on Tuesday, Thursday, and Saturdays. Has previously been on peritoneal dialysis but that was changed to hemodialysis approximately 1-2 years ago, secondary to complications of peritonitis. Status post burn injury to lower anterior abdomen. Sigmoid colon polyp: Status post polypectomy on [**2136-4-30**], pathology showing adenoma with high-grade dysplasia. No evidence of invasive carcinoma. Social History: Hx of tobacco, denies alcohol or IVDU. Pt says she contracted HIV after being raped several years ago. Family History: No history of diabetes, coronary artery disease, kidney disease, or liver disease. History of colon cancer in her father who died when she was very young. Physical Exam: Temperature 97.7 HR 60 BP 110/66 (113-137)/(66-74) P 56-62 o2 100% RA I/O= 90/0 GENERAL: NAD HEENT: Oropharynx is clear without blood or petechia. No thrush. No scleral icterus. NECK: Supple. tunneled IJ CARDIOVASCULAR: Normal S1, S2. Regular rate and rhythm. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft/nontender/nondistended. No rebound/guarding. No masses. No peritoneal signs. No organomegaly. Positive bowel sounds. EXTREMITIES: Warm and well perfused. +2 bilateral radial and DP pulses. Symmetric pulses. SKIN: No rashes or other lesions noted. NEUROLOGIC: Alert, awake, oriented x3. Motor and sensory grossly nonfocal. Pertinent Results: MICRO: [**2137-11-26**] 1:30 pm BLOOD CULTURE AEROBIC BOTTLE (Final [**2137-11-30**]): REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2137-11-27**] AT 9:25AM. PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES. PSEUDOMONAS AERUGINOSA. 2ND MORPHOLOGY. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- 2 S 2 S CEFTAZIDIME----------- 4 S 4 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ 2 S 2 S IMIPENEM-------------- 2 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- <=4 S <=4 S PIPERACILLIN/TAZO----- <=4 S 8 S TOBRAMYCIN------------ <=1 S <=1 S ANAEROBIC BOTTLE (Pending): . [**2137-11-26**] 2:00 pm BLOOD CULTURE AEROBIC BOTTLE (Final [**2137-11-29**]): PSEUDOMONAS AERUGINOSA. SENSITIVITIES PERFORMED ON CULTURE # 221-4221M [**2137-11-26**]. ANAEROBIC BOTTLE (Pending): . [**2137-12-1**] 6:45 am SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY TEST (Pending): . Cardiology Report ECHO Study Date of [**2137-11-30**] PATIENT/TEST INFORMATION: Indication: ? Endocarditis. Height: (in) 65 Weight (lb): 122 BSA (m2): 1.60 m2 BP (mm Hg): 140/90 HR (bpm): 63 Status: Inpatient Date/Time: [**2137-11-30**] at 11:40 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W000-0:00 Test Location: [**Location 11648**]/[**Hospital Ward Name 121**] 6 Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.0 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 4.1 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.1 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.4 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm) Aorta - Ascending: 3.1 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A Ratio: 0.67 Mitral Valve - E Wave Deceleration Time: 243 msec TR Gradient (+ RA = PASP): <= 20 mm Hg (nl <= 25 mm Hg) Pulmonic Valve - Peak Velocity: 0.8 m/sec (nl <= 1.0 m/s) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC is normal in diameter with >50% decrease collapse during respiration (estimated RAP 5-10 mmHg). LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic function (LVEF>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Moderately thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Calcified tips of papillary muscles. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Echocardiographic results were reviewed by telephone with the houseofficer caring for the patient. Conclusions: The left atrium is normal in size. The estimated right atrial pressure [**4-17**] mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened with a 5mm non-mobile echodensity suggested on the LVOT side of the non-coronary leaflet c/w a possible vegetation. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets and supporting structures are mildly thickened. There is trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Possible vegetation on the aortic valve without evidence for aortic regurgitation. If clinically indicated, a TEE would be better able to define the aortic valve morphology. CLINICAL IMPLICATIONS: Based on [**2127**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2137-11-30**] 14:00. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] J. . DISCHARGE LABS: [**2137-12-1**] 06:45AM BLOOD WBC-2.5* RBC-3.52* Hgb-11.2* Hct-33.3* MCV-95 MCH-31.9 MCHC-33.7 RDW-14.7 Plt Ct-219 [**2137-12-1**] 06:45AM BLOOD Neuts-45* Bands-0 Lymphs-32 Monos-18* Eos-1 Baso-0 Atyps-4* Metas-0 Myelos-0 [**2137-12-1**] 06:45AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-NORMAL Schisto-OCCASIONAL Burr-OCCASIONAL [**2137-12-1**] 06:45AM BLOOD PT-12.2 PTT-32.0 INR(PT)-1.0 [**2137-12-1**] 06:45AM BLOOD Gran Ct-1020* [**2137-12-1**] 06:45AM BLOOD Glucose-85 UreaN-27* Creat-11.7*# Na-135 K-4.0 Cl-96 HCO3-26 AnGap-17 [**2137-12-1**] 06:45AM BLOOD Albumin-3.5 Calcium-10.7* Phos-4.2 Mg-2.3 [**2137-12-1**] 06:55AM BLOOD Genta-2.5* Brief Hospital Course: 53 y/o female with HIV, Hep B, Hep C, HTN, ESRD on HD, with pseudomonal bacteremia, blood cultures quickly cleared, on gent and ceftaz, with evidence of possible aortic valve vegitation on TTE. . 1. Pseudomonal Bacteremia: Blood cultures positive on [**2137-11-26**]. Cleared the next day. Remained clear for several more days. Discharged on gentamycin and ceftazapime. TTE showed possible aortic valve vegitation. She will need TEE on Tuesday [**2137-12-3**] and course of antibiotics (to be given with HD) to be determined by result of TEE. Likely will need at least six weeks. . 2. ESRD: Temporary dialysis line placed Sunday by surgery. Dialysed sunday. Line removed before discharge. Next dialysis should be Tuesday [**2137-12-3**]. She is scheduled for a tunneled line, to be done Tuesday [**2137-12-3**] by IR. Her nephrologist is [**First Name8 (NamePattern2) 3122**] [**Doctor Last Name 1860**]. . 3. HTN: Controled on 5 mg Lisinopril. Metoprolol XL 100 mg QD was held initially because of hypotension and restarted on discharge. . 4. HIV: Last CD4 248. Not on HAART. Needs follow up with [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) 1057**]. . 5. Hep B/Hep C: Stable. Needs to follow upo with [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) 1057**]. . 6. Leukopenia: Trending down. Monocytosis. Not neutropenic (ANC>1000). Needs CBC checked to ensure trend of WBC count. . 7. Anemia: Newly anemic this admission. She is iron deficient, but has a high ferritin and low TIBC consistant with ACD. Needs CBC to trend Hct. . 8. Esophagitis on EGD: Continued on [**Hospital1 **] Pantoprazole. H. pylori serology positive on [**2137-11-11**]. Had H. pylori serology resent and needs to be followed up. Needs esophageal biopsy results followed up. Medications on Admission: Medications at home: Lisinopril 5mg QD Nephrocaps Renalgel/Sevelamer 800 mg Tablet Sig Metoprolol XL 100 mg po qd . Discharged [**2137-11-15**] additionally on: Pantoprazole 40mg [**Hospital1 **] Carbamide Peroxide 6.5 % Drops Acyclovir 200 mg Capsule Capsule PO Q24H Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q48H Discharge Medications: 1. Gentamicin in Normal Saline 60 mg/50 mL Piggyback Sig: Sixty (60) mg Intravenous QHD (each hemodialysis) for 6 weeks. 2. Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) gram Intravenous QHD (each hemodialysis) for 6 weeks. 3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): please check with gastrointestinal doctor before stopping. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Metoprolol Succinate 100 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: Home Discharge Diagnosis: Primary Diagnosis: Pseudomonal Bacteremia secondary to Dialysis Line Infection Aortic Valve Endocarditis Leukopenia Anemia Esophagitis Secondary Diagnosis: End Stage Renal Disease Hypertension HIV Hepatitis C Hepatitis B Discharge Condition: Afebrile. O2 saturation of 100%. Dialysed Sunday [**2137-12-1**]. Ambulatory. Discharge Instructions: You had an infection in your blood which may have caused bacteria to attach to your heart valve. If you notice fever or chills, please call your doctor or come to the emergency room for evaluation. Please come back to [**Hospital1 18**] on Tuesday [**2137-12-3**] at 9:00AM to the [**Hospital Unit Name **]-Fourth Floor Cardiology Department on the [**Hospital Ward Name 12837**] in order to get the ultrasound of your heart. You should not have anything to eat or drink starting Monday night at midnight until after the procedure on Tuesday. You will then go to the Interventional Radiology Department on the [**Hospital Ward Name 517**] in the Clinical Center-[**Location (un) **] to have a new dialysis line placed. Please ask to see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. You will then get dialysis here at [**Hospital1 18**] that day. Please be sure to folow up with Dr. [**Last Name (STitle) 1057**] of the Infectious Disease Clinic for evaluation of your HIV infection and Hepatitis. You can call ([**Telephone/Fax (1) 1300**] to make an appointment. This is very important. Followup Instructions: TEE on Tuesday [**2137-12-3**] to evaluate aortic valve for vegitation IR to place tunneled dialysis line Tuesday [**2137-12-3**] for dialysis H. Pylori results form EGD/Biopsy CBC to evaluate trend of leukopenia Needs to consider starting HAART therapy for HIV infection Completed by:[**2137-12-2**]

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icd9cm

[ [ [] ] ]

[ "39.95", "38.95", "45.16" ]

icd9pcs

[ [ [] ] ]

11946, 11952

8773, 10563

322, 446

12218, 12299

2816, 3821

13462, 13765

1959, 2117

10936, 11923

11973, 11973

10589, 10589

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4071, 4217

474, 1135

7981, 8033

12130, 12197

11992, 12109

1157, 1823

1839, 1943

58,027

187,411

6755

Discharge summary

report

Admission Date: [**2123-1-7**] Discharge Date: [**2123-1-15**] Date of Birth: [**2052-5-9**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2610**] Chief Complaint: confusion, irritability Major Surgical or Invasive Procedure: None this hospitalization History of Present Illness: This is a 70 year-old Female with a PMH significant for dementia, prior CVA, history of deep venous thromboses, rheumatoid arthritis, hypertension and non-healing lower extremity wound brought in by her daughter for worsening confusion and increased irritability. . In the ED, her daughter noted that her mother appeared more irritable and confused over several days, and that she was 'making no sense'. She also noted right foot ulceration with possible purulent drainage for 1-week (which appeared 4-weeks prior). . Of note, the patient was recently evaluated in [**Hospital **] clinic on [**2122-12-30**]. Per her daughter's report, she had been doing well until [**2122-2-20**] when family members started noticing a significant decline in her memory, as well as irritation, agitation and paranoia. She was diagnosed with probable dementia and started on BNZs along with Mirtazapine. She progressed to being unable to care for herself and her daughter brought her to live with her in [**Location (un) 86**] in [**2122-11-22**] (she had been in [**Country 532**] prior to these). A work-up for reversible causes was reassuring, vitamin B-12, folate, TSH were normal. Per the daughter, the daughter reports a leave of absence from work given her mother's full-time needs. She helps to care for her mother in terms of all of her activities of daily living as well as making sure she is safe at home, taking her medication, eating, not wandering outside, etc. She reports that her mother has periods of waxing and [**Doctor Last Name 688**] where her mental status will seem fairly good and then be quite poor to the point she does not even recognize her daughter. She also has periods of irritation as well as paranoia when she feels that people are stealing her belongings. This information was obtained from Dr.[**Name (NI) 25674**] clinic noted. . In the [**Hospital1 18**] ED, initial VS 104.6 120 134/102 22 100% RA. Laboratory studies revealed WBC 15.2, neutrophilia 89.9% without bandemia. Creatinine 0.8. Lactate 2.6. U/A moderately positive. A CXR showed no acute process or focal consolidation. She had evidence of right foot ulceration and drainage and radiographs showed no evidence of infection, just degnerative changes. She was given IV Vancomycin 1 gram and Ciprofloxacin 400 mg IV x 1 to empirically cover her infectious sources. She received Acetaminophen 1000 mg PO x 1. She was resuscitated with 1L NS x 2 for presumed sepsis and transferred to the Medicine floor. VS prior to transfer 100.8 116/65 97 19 100% RA. . On arrival to the floor, history was difficult to obtain given her dementia. Daughter not present. Past Medical History: PAST MEDICAL & SURGICAL HISTORY: 1. Rheumatoid arthritis 2. Hypertension 3. History of CVA 4. History of peptic ulcer disease ([**2110**]) 5. History of thrombophlebitis 6. History of hepatitis B - Per the patient's family, this was diagnosed in [**2112**]. History of HCV antibody positivity with negative HCV viral PCR. 7. Anemia - Appears to have both iron deficient and chronic disease 8. Non-healing left lower extremity wound 9. Cellulitis of the left lower extremity ([**2119**]) Social History: The patient is a retired pediatric psychiatrist. She is currently living with her son and daughter in [**Location (un) **]. Requires assistance with her ADLs. Denies tobacco use or alcohol use; no recreational substance use. Family History: Her father died of an MI in his 70's. Her mother died of Ovarian Ca. Her siblings are healthy. Physical Exam: ADMISSION EXAM: . VITALS: 102.2 151/85 135 32 100% RA GENERAL: Appears in acute distress, Russian-speaking only. Alert and interactive, but grasping abdomen in pain with rigors on exam. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes dry. NECK: supple without lymphadenopathy. JVD not elevated. CVS: Sinus tachycardic with normal rhythm, without murmurs, rubs or gallops. S1 and S2 normal. RESP: Decreased breath sounds anteriorly bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. Stable inspiratory effort. ABD: soft, tender diffusely in the epigastrum with voluntary guarding, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. Inconclusive [**Doctor Last Name 515**] sign. EXTR: no cyanosis, clubbing; trace to 1+ peripheral edema to patellar region; bilateral lower extremity arthritis deformities in her feet; right malleolar ulcer with necrotic debris and granulation tissue; significant dry skin and callus noted; right lower extremity erythema to mid-shin, 2+ peripheral pulses NEURO: CN II-XII intact throughout. Strength 5/5 bilaterally, sensation grossly intact. Gait deferred. . DISCHARGE EXAM: . VITALS: 99.2 97.4 130/60 65 20 98% 2L NC I/Os: 560 / 940 | 700 + Inc GENERAL: Appears in no acute distress, Russian-speaking only. Alert and interactive and not agitated. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. NECK: supple without lymphadenopathy. JVD not elevated. CVS: Regular rate and rhythm, without murmurs, rubs or gallops. S1 and S2 normal. RESP: Decreased breath sounds anteriorly bilaterally with only faint inspiratory crackles throughout the lung bases. No wheezing, rhonchi. Stable inspiratory effort. ABD: soft, non-tender, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. EXTR: no cyanosis, clubbing; trace to 1+ peripheral edema to patellar region; bilateral lower extremity arthritis deformities in her feet; right malleolar ulcer with necrotic debris and granulation tissue consistent with venous stasis ulcer; right lower extremity erythema to mid-shin, 2+ peripheral pulses, ACE wrap in place NEURO: CN II-XII intact throughout. Strength 5/5 bilaterally, sensation grossly intact. Gait deferred. Pertinent Results: ADMISSION LABS: . [**2123-1-7**] 02:37PM BLOOD WBC-15.2*# RBC-5.24 Hgb-11.9* Hct-39.5 MCV-76* MCH-22.8* MCHC-30.2* RDW-17.2* Plt Ct-171 [**2123-1-7**] 02:37PM BLOOD Neuts-89.8* Lymphs-6.9* Monos-3.0 Eos-0 Baso-0.3 [**2123-1-11**] 04:26AM BLOOD PT-13.8* PTT-31.0 INR(PT)-1.3* [**2123-1-7**] 02:37PM BLOOD Glucose-138* UreaN-14 Creat-0.8 Na-138 K-4.0 Cl-101 HCO3-22 AnGap-19 [**2123-1-7**] 02:37PM BLOOD ALT-16 AST-35 LD(LDH)-480* AlkPhos-119* Amylase-66 TotBili-0.5 [**2123-1-10**] 05:24AM BLOOD CK-MB-2 cTropnT-<0.01 [**2123-1-7**] 02:37PM BLOOD Lipase-26 [**2123-1-7**] 02:37PM BLOOD Albumin-4.4 Calcium-9.4 Phos-1.4*# Mg-1.9 [**2123-1-9**] 08:54AM BLOOD calTIBC-373 Ferritn-118 TRF-287 [**2123-1-10**] 05:24AM BLOOD Vanco-12.7 [**2123-1-7**] 02:38PM BLOOD Lactate-2.6* K-3.7 [**2123-1-9**] 06:00PM BLOOD Type-[**Last Name (un) **] pO2-23* pCO2-40 pH-7.36 calTCO2-24 Base XS--3 . DISCHARGE LABS: . [**2123-1-15**] 06:50AM BLOOD WBC-10.1 RBC-4.05* Hgb-9.6* Hct-29.7* MCV-73* MCH-23.6* MCHC-32.2 RDW-17.9* Plt Ct-294 [**2123-1-11**] 04:26AM BLOOD Neuts-90.3* Lymphs-6.4* Monos-2.4 Eos-0.6 Baso-0.3 [**2123-1-15**] 06:50AM BLOOD Glucose-97 UreaN-13 Creat-0.5 Na-140 K-4.0 Cl-106 HCO3-28 AnGap-10 [**2123-1-15**] 06:50AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.2 . URINALYSIS: hazy, pos for LE, negative for Nitr, trace protein, WBC 14 . MICROBIOLOGY DATA: [**2123-1-7**] Urine culture - mixed bacterial flora [**2123-1-7**] Blood culture (x 2) - no growth [**2123-1-8**] Blood culture (x 2) - no growth [**2123-1-9**] MRSA screen - negative [**2123-1-10**] Legionella antigen - negative [**2123-1-11**] C.diff toxin - negative . IMAGING: [**2123-1-4**] CT HEAD W/O CONTRAST - No acute intracranial process. Mild age-related atrophy and mild chronic small vessel ischemic disease. . [**2123-1-7**] CHEST (PA & LAT) - The heart is mild to moderately enlarged. The mediastinal and hilar contours are unremarkable aside from mild unfolding of the descending thoracic aorta. There is no pleural effusion or pneumothorax. The lungs appear clear. . [**2123-1-7**] ANKLE (AP, MORTISE & LA) - No definite evidence for osteomyelitis, but pes planus with destruction of the subtalar joint effusion, degenerative change, and demineralization, all likely chronic findings. . [**2123-1-7**] CT ABD & PELVIS WITH CO - No intra-abdominal abscess or collection. Multiple enlarged right inguinal lymph nodes are likely reactive given patient's history of right foot cellulitis. Metallic material noted in the uterus likely representative of an old IUD without evidence of fluid collection. Tiny bilateral pleural effusions. . [**2123-1-9**] CTA CHEST W&W/O C&RECON - No definite main, lobar, or proximal segmental pulmonary embolus. Multifocal patchy bilateral airspace opacities, right asymmetrically greater than left lung. This may represent multifocal pneumonia or potentially aspiration pneumonia given air space opacity and air bronchograms seen in the superior segments of the lower lobes and also in the posterior right upper lobe. Alternatively, though less likely, this could represent a pulmonary edema type pattern. Moderate bilateral pleural effusions with adjacent compressive atelectasis. . [**2123-1-9**] UNILAT LOWER EXT VEINS - No DVT of the visualized veins in the right lower extremity. The right calf veins were not visualized and thus not interrogated. . [**2123-1-10**] CT LOW EXT W/O C RIGHT - Soft tissue thickening and stranding in the right lower extremity, predominantly distally and anterolaterally. This could represent cellulitis in the appropriate clinical setting. No soft tissue foci of gas to suggest fasciitis or abscess formation. No drainable fluid collections. No acute fracture or dislocation. Moderate degenerative changes at the medial compartment of the knee and proximal tibiofibular joint. Pes planus deformity of the foot with stable marked narrowing and destructive changes at the tibiotalar joint and incompletely seen ankylosis at the subtalar joint. This may represent changes secondary to long-standing rheumatoid arthritis. Achilles tendinosis. . [**2123-1-11**] 2D-ECHO - The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 65%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: IMPRESSION: 70F with a PMH significant for dementia, prior CVA, history of deep venous thromboses, rheumatoid arthritis, hypertension and non-healing lower extremity wound brought in by her daughter for worsening confusion and increased irritability found to have multiple sources of infection and presentation concerning for severe sepsis. . # SEVERE SEPSIS - The patient presented with a few weeks of delirium vs. dementia concerns per her daughter with a progressive decline over several months; this admission with acute irritability and confusion for several days - presenting with fevers, sustained blood pressure, but tachycardia and worsening confusion. She had two apparent infectious sources on admission: right medial malleolar wound with necrotic debris and erythema up to the right patella, and positive UA. CXR negative on admission, and UCx ultimately showed mixed flora. She was initially covered with IV Vancomycin and Zosyn given her high fevers, tachycardia and confusion, concerning for sepsis. She initially responded to 4L of normal saline for IV fluid resuscitation with adequate UOP. Podiatry was consulted regarding her foot wound and discussed debridement, but this was ultimately deferred given that ACS and Vascular Surgery felt this was likely venous stasis dermatitis. Her WBC on admission was 15 and peaked at 22 with improvement following antibiosis. On [**1-9**], the patient developed refractory SVT to the 160s (see below) and hypotension requiring transfer to the MICU for Neosynephrine and Esmolol drips. She also had a new oxygen requirement. SVT spontaneously terminated, and the patient was rescuscitated with 2 liters IV normal saline with restoration of normal blood pressure. Pressors were successfully weaned within 1 hour of arrival to the MICU. Given her history of clot burden, a CTA chest was performed showing no pulmonary embolus, but evidence of multifocal pneumonia with concern for aspiration was noted. Given her clinical worsening, she was empirically covered with Linezolid and Meropenem for broader empiric coverage of her right lower extremity wound and for multifical pneumonia issues. She transferred back to the Medicine floor following hemodynamic stability. Her leukocytosis steadily improved and she remained afebrile. She will complete 14-days of Linezolid and Meropenem (ending [**2123-1-23**]) while at rehab. Her luekocytosis normalized on discharge. . # SUPRAVENTRICULAR TACHYCARDIA - The patient developed a slightly irregular SVT to the 180-190s associated with hypotension on the AM of [**1-9**], concerning for atrial tachycardia with aberrency, refractory to both beta-blockers and adenosine. The most likely etiology was severe sepsis causing metabolic derrangements, given her lack of coronary or structural heart disease and her recent sepsis physiology. Pulmonary embolus was considered, but CTA chest was reassuring. A low-dose beta-blocker was continued following stability of her tachycardia issues. . # DEMENTIA VS. DELIRIUM - Recently seen by Dr. [**Last Name (STitle) **] in gerontology clinic given moderately-progressive decline in mental status with concern for dementia. A reversible work-up with TSH, B12 and folate levels were reassuring. CT head imaging was without acute intracranial process from [**2123-1-4**] and showed mild age-related atrophy and mild chronic small vessel ischemic disease. She had no notable neurologic deficits on exams, nor did she in clinic. Delirium was considered more likely given her waxing and [**Doctor Last Name 688**] status. A U/A obtained in clinic did show some evidence of early urinary tract infection. Lorazepam was recently discontinued in clinic, although Resperidone was continued as it was thought to control her symptoms well. A component of pseudo-dementia or depression was also considered. Vascular dementia is possible given her prior CVA history, although no new neurologic deficits have been noted. Alzheimer's dementia or [**Last Name (un) 309**] body dementia have also been considered. Her acute decompensation has almost certainly been attributed to her sepsis on admission and concern for multiple sources of infection. She was switched to Seroquel, in lieu of Risperidone, this admission. Her QTc was monitored given her antipsychotic needs, and was reassuring. She tolerating evening Seroquel without issue. . # RHEUMATOID ARTHRITIS - Known diagnosis of rheumatoid arthritis (diagnosed 20 years prior in [**2099**]). Patient received Methrotrexate for 20-years and was treated with Remicade from [**2109**]-[**2116**]. She has some swelling of her bilateral MCP joints at baseline. Had been on sulfasalazine as well. Now managed on Ibuprofen only for pain control, no immune modulator therapy. We discontinued NSAIDs for her arthritic pain and utilized standing Tylenol. . # HYPERTENSION - History of hypertension, recent OMR notes reveal a blood pressure in the 136/70 range. Not currently on anti-hypertensives. No evidence of chronic renal failure. . TRANSITION OF CARE ISSUES: 1. Will complete treatment with broad-spectrum empiric antibiotic coverage given aspiration vs. community acquired ICU pneumonia and right lower extremity infection. Linezolid and Meropenem for 14-days (ending [**2123-1-23**]). 2. We discontinued Mirtazapine and Risperidone and she will be maintained on an evening dose of Seroquel. We AVOIDED deliriogenic medications, especially benzodiazepines. 3. Continue low-dose beta-blocker given recent atrial tachycardia issues in the setting of infection. Taper dose as needed once infection resolves. 4. Needs follow-up with [**Hospital 100**] Rehab Infectious Disease specialist, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) 4120**] [**Last Name (Titles) 25675**] and infectious sources. Medications on Admission: HOME MEDICATIONS (confirmed with daughter, records) 1. Ibuprofen 400 mg PO BID 2. Mirtazapine 7.5 mg PO QHS 3. Risperidone 0.25 mg PO BID (liquid formulation) Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)): at 1800 . 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**2-26**] hours as needed for fever or pain. 4. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 5. linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred (600) mg Intravenous Q12H (every 12 hours) for 14 days: started [**2123-1-10**], ending [**2123-1-23**]. 6. meropenem 1 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 14 days: started [**2123-1-10**], ending [**2123-1-23**]. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnoses: 1. Severe sepsis (presumed sources: right lower extremity wound, multifocal pneumonia) 2. Supraventricular tachyarrhythmia 3. Acute delirium . Secondary Diagnoses: 1. Dementia 2. Hypertension 3. Rheumatoid arthritis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Patient Discharge Instructions: . You were admitted to the Internal Medicine service at [**Hospital1 1535**] on CC7 regarding management of your multiple sources of infection and worsening confusion and delirium. You were treated with broad-spectrum [**Hospital1 25675**] and volume resuscitation, which resulted in improvement in your clinical status. You required a brief medical ICU stay for tachycardia which improved with treatment of your underlying infection. Your right foot wound and pneumonia were the presumed sources of infection. You will continue with 14-days total of IV [**Hospital1 25675**]. You were improved following discharge and stable for discharge to a rehabilitation facility. . Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include: dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit, or have a bowel movement. * You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. * You have pain that is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any other concerning symptoms. . CHANGES IN YOUR MEDICATION RECONCILIATION: . * Upon admission, we ADDED: START: Seroquel 12.5 mg by mouth in the evening (at 18:00) START: Linezolid 600 mg IV every 12-hours for 14-days total (started [**2123-1-10**], ending [**2123-1-23**]) START: Meropenem 1 gram IV every 8-hours for 14-days (started [**2123-1-10**], ending [**2123-1-23**]) START: Metoprolol 25 mg by mouth three times daily START: Acetaminophen 325-650 mg by mouth every 4-6 hours as needed for pain . * The following medications were DISCONTINUED on admission and you should NOT resume: DISCONTINUE: Mirtazapine DISCONTINUE: Ibuprofen DISCONTINUE: Risperidone . * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: Department: GERONTOLOGY When: MONDAY [**2123-1-18**] at 10:30 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: SENIOR HEALTH When: THURSDAY [**2123-1-28**] at 2:00 PM With: [**Doctor First Name **] MAIBOR [**Telephone/Fax (1) 719**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

17877, 17943

11077, 16892

326, 353

18222, 18222

6224, 6224

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3787, 3885

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148,209

22702

Discharge summary

report

Admission Date: [**2181-2-6**] Discharge Date: [**2181-3-7**] Date of Birth: [**2123-8-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1850**] Chief Complaint: Difficulty maintaining oxygenation Major Surgical or Invasive Procedure: Intubation and ventilation Bronchoscopy with broncheoalveolar lavage Chest tube placement for pneumothorax Transesophageal echocardiography Esophagogastroduodenoscopy History of Present Illness: 57 M with COPD and diverticulitis who presented to OSH on [**2181-1-28**] with 3 days of SOB, cough, elevated WBC count (to 25 with 2% bands up to 8% on same day). In the ER, the patient was found to be hypotensive, hypoxic and hypercarbic (sats 70% in ED ABG: 6.99/200/?) and he was emergently intubated. At OSH, Head CT negative for bleed; + for sinusitis of maxillary, left sphenoid, frontal sinuses. He also underwent a spiral chest CT on admission which was negative for a PE, but positive for an infiltrate suspicisous for a LLL atelectasis vs PNA, spiculated LUL nodule, and borderline mediastinal LAD. Pt grew out H flu from sputum collected on [**1-28**]. Pt was treated with Levofloxacin, and ceftriaxone for empiric PNA coverage and steroids for COPD flare. Transiently on pressors (dopa); weaned off dopa [**1-30**]. Pt noted to have non-specific EKG changes and ruled in for NSTEMI with troponin leak, peak 2.52 on [**1-28**]. EKG changes resolved. [**2-2**] pt noted to have tube feeds suctioned from ETT so antibiotic coverage broadened to include flagyl. Pt appeared to be improving over hospital course with resolving acidemia, Ph 7.14/66/413 on [**1-28**]--> 7.32/72/69 on [**2-5**] with decreased PEEP 5, FiO2 0.5. No event note found in record, but pt had CT w/ contrast done am on [**2-5**] which showed 75% collapse of L lung, no evidence midline shift. Chest tube placed urgently by general surgery with re-expansion of lung, only 20% residual pneumothorax on CXR post tube placement. Pt transferred to [**Hospital1 18**] for concern about tension PTX given ? difficulty oxygenating. Past Medical History: 1. COPD 2. Diverticulitis/ ? diverticlosis 3. R saphenous DVT started on Lovenox 4. h/o ETOH 5. Tension pneumo noted [**2-5**] s/p chest tube 6. Aspiration of tube feeds Friday on flagyl 7. LUL nodule noted on CT scan 8. NSTEMI, trop I peak 2.52 [**1-28**]( > 0.5 +) Social History: Heavy Alcohol use tobacco 2ppd night auditor at [**Location 58793**] daughter hc proxy Family History: non-contributory Physical Exam: Physical Examination on Admission to MICU: VS: Tc:99.2 HR: 79 BP 101/68 MAP 75 RR 19 SaO2 97% RA Gen: sedated but arousable intubated M opening eyes to voice, squeezed hand to questions. appropriate. HEENT: PEERL. intubated. CV: RRR. Nl S1, S2. No m/r/g. PMI displaced to midline and inferior Chest: coarse breath sounds especially over chest tube site. no wheezes. sl decreased breath sounds at left apex. chest tube in place laterally over left midline. Abd: active BS: soft. ? HM 5 fingewidths beneath costal margin vs tense abdominal muscles. No SM. No caput. No spider angiomatas. Extr: warm. 2+ DP. No edema, cyanosis or clubbing. MAE. Neuro: responds to pain and voice. . Physical Examination on Transfer to Floor: VS: Tc: 99 HR: 70 BP: 124/70 RR: 12 SaO2: 96% on 5L Gen: middle aged caucasian male lying in bed wearing NC in NAD. Conversing in full sentences. HEENT: EOMI, anicteric CV: RRR, S1, S2 Chest: CTAB Abd: soft, NT, Nd Ext: wwp, pneumoboots on, no c/c/e . Pertinent Results: OSH labs [**1-28**]: cbc 25.5/45.8/ 430 Diff 87 p, 2 bands, 6 lymph trop peak 2.52 creat 1.3 hep a neg hep C ab neg heb b s ag neg hep b core neg crp 0.62 esr 2 abg [**2-6**] am 7.43/56/81 ggt 238 alt 166 ast 35 CT w/ contrast [**2-5**]: large left ptx 75% lung volume w/ complete collapse of LLL. no mediastinal shift. Ct w/ contrast abd [**2-5**]: focal thickening of sigmoid colon CXR [**2-6**]: 20% PTX EKG [**1-28**]: tachy sinus 120 ST depressions II,III, AvF EKG [**2-6**]: NSR 75 TWI V2-V3 U tox + bdz, Amphetamine. sputum: [**1-28**] H flu + 1+ GNR On CPAP [**2-3**] sputum [**2-2**]: [**Female First Name (un) **] albicans no org blood cx [**1-28**]: staph epi ox resistant, ses=ns vanco blood cx [**1-29**] NGTD x 3 . . [**2181-2-9**] LE US: "BILAT LOWER EXT VEINS PORT Reason: LE SWELLING [**Hospital 93**] MEDICAL CONDITION: 57 year old man with lower extremity swelling and bilateral thrombophlebitis per osh report. Please examine both legs for dvt. REASON FOR THIS EXAMINATION: ?dvt STUDY: Doppler ultrasound of lower extremity veins. INDICATION: Thrombophlebitis. Rule out DVT. TECHNIQUE: Standard grayscale, pulse wave, and color flow imaging of the lower extremities were performed. COMPARISON: No studies available for comparison. REPORT: RIGHT SIDE: The right common femoral vein, proximal profunda femoral vein, great saphenous vein are identified. These are all patent with normal compressibility, augmentation, and respiratory variation. The right popliteal vein also demonstrates normal compressibility, augmentation, respiratory variation. No evidence of right-sided DVT is seen. LEFT SIDE: Left common femoral vein is clearly identified and demonstrates normal compressibility, augmentation, and respiratory variation. The saphenous vein, popliteal vein, femoral vein, superficial and deep femoral veins are also all identified, demonstrate normal color flow imaging, compressibility, augmentation and respiratory variation.. CONCLUSION: No evidence of above-knee DVT on either side." . . [**2181-2-9**] TTE: "MEASUREMENTS: Left Atrium - Four Chamber Length: 4.8 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.5 cm (nl <= 5.0 cm) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aortic Valve - Peak Velocity: 1.8 m/sec (nl <= 2.0 m/sec) TR Gradient (+ RA = PASP): <= 9 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal mitral valve supporting structures. TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve supporting structures. Physiologic TR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - poor parasternal views. Suboptimal image quality - poor apical views. Suboptimal image quality as the patient was difficult to position. Suboptimal image quality - ventilator. Conclusions: Images limited to the subcostal window. The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is no pericardial effusion." . . [**2181-2-15**] CTA of Abd: "CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Reason: PULSATILE MASS IN ABD R/O AAA Contrast: [**Hospital 13288**] [**Hospital 93**] MEDICAL CONDITION: 57 year old man with copd, recent NSTEMI, w/ pulsatile mass of abdomen. REASON FOR THIS EXAMINATION: r/o abdominal aortic aneurysm CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Pulsatile abdominal mass. TECHNIQUE: CT arteriogram of the abdomen and pelvis was obtained with and without IV contrast. No prior CT scan of the abdomen or pelvis is available. Correlation is made with a chest CT dated [**2181-2-7**]. CT ABDOMEN WITH IV CONTRAST: There are bilateral pleural effusions, right greater than left, with bibasilar atelectasis. A small pneumothorax is seen on the left, with a chest tube in place. Lung bases demonstrate emphysematous changes, as well as suggestion of bronchiectasis. Within a right lower lobe bronchus, a 3 mm focus of debris is noted, possibly representing aspirated mucus, though could be followed on future examinations. Liver, gallbladder, adrenals, kidneys, spleen and pancreas appear grossly unremarkable. Abdominal aorta is normal in size and caliber, without evidence of aneurysmal dilatation. The abdominal aorta measures up to 2.2 cm in maximal axial dimension. Renal arteries are widely patent, with note made of an accessory renal artery on the left. Superior mesenteric artery, celiac artery and inferior mesenteric artery are widely patent. The iliac arteries are normal. CT PELVIS WITH IV CONTRAST: The urinary bladder contains a Foley catheter. Prostate and seminal vesicles appear grossly normal. There is a segment of circumferential thickening involving the sigmoid colon, covering an approximately 5 cm length of the colon. The wall is thickened, measuring up to 1.6 cm. Extensive diverticuli are seen within the sigmoid colon. Dense linear tracts within the lateral wall of the sigmoid colon near the areas of maximal thickness may represent sinus tracts. There is trace inflammatory change surrounding the areas of wall thickening. Though multiple lymph nodes are seen within the left lower quadrant mesentery, none are greater than approximately 5 mm. No free fluid. BONE WINDOWS: No suspicious bony lesions. Bone islands are noted within the left iliac bone, of no significance. Degenerative changes are noted within the spine. IMPRESSION: 1. No evidence of abdominal aortic aneurysm. 2. Circumferential thickening within the sigmoid colon, with suggestion of intramural sinus tracts. Differential considerations include colon carcinoma or acute diverticulitis. Further workup, such as colonoscopy, is advised." . . [**2181-2-20**] CXR Portable: "CHEST (PORTABLE AP) Reason: [**Name (NI) **] FOR PTX [**Hospital 93**] MEDICAL CONDITION: 57M COPD s/p extubation, CT removal [**2-19**]. REASON FOR THIS EXAMINATION: [**Name (NI) **] FOR PTX INDICATION: COPD status post extubation. Chest tube removal [**2-19**]. [**Month/Year (2) **] for pneumothorax. COMPARISON: [**2181-2-19**] at 21:10. Upright AP chest: The left internal jugular central venous catheter is unchanged from the prior study. No pneumothorax. Heart and mediastinal contours are unchanged. Since the exam of [**2-19**], there has been probable interval development of a subpulmonic effusion on the right and associated compression atelectasis at the base. The left lung field is not significantly changed. IMPRESSION: No evidence of pneumatothorax. There may be a developing subpulmonic effusion on the right, with associated atelectasis of the right base." . . [**2181-2-21**] Head CT: "CT HEAD W/O CONTRAST Reason: ALTERED [**Hospital **] [**Hospital 93**] MEDICAL CONDITION: 57 year old man with COPD admitted with hypoxia and hypercarbia. Now extubated and stable but with altered MS REASON FOR THIS EXAMINATION: bleed vs. mass vs ? CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 57-year-old male with COPD admitted with hypoxia and hypercarbia. Now extubated and stable but with altered mental status. ? hemorrhage vs. mass. TECHNIQUE: Contiguous 5-mm axial images were obtained from the vertex to the base of the skull in bone and soft tissue windows. There are no prior studies for comparison. FINDINGS: There is no intracranial hemorrhage. The [**Doctor Last Name 352**]-white matter differentiation is well maintained. There is no mass effect, shift of normally midline structures or hydrocephalus. There is a likely small cyst within the hippocampal region of the left temporal [**Doctor Last Name 534**] posteriorly. This diagnosis could be best confirmed via MRI. Osseous and soft tissue structures are unremarkable. Visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: No acute intracranial abnormality visualized." Brief Hospital Course: A/P: 57 M COPD admitted to OSH with H Flu PNA c/b NSTEMI(peak trop I 2.52), and large left PTX now s/p left chest tube placement transferred to [**Hospital1 18**] for "difficulties oxygenating." -OSH course ([**Date range (1) 58794**]): Pt was admitted to OSH on [**2181-1-28**] with hypoxia, cough, leukocystosis w/bandemia and hypotension. He was intubated for hypercarbic respiratory failure. Imaging revealed sinusitis, infiltrate suspicisou for PNA vs. atelectasis and spiculated LUL nodule. Micro data resulted in postivie H.flu in sputum. Treatment was initiated with antibiotics (CTX, levoquin) for PNA, and steroids for COPD flare. Pt ruled in for NSTEMI, however due to hemodynamic instability, pt did not receive cardiac catheterization. Pt aspirated tube feeds (found in ETT) and PNA coverage expanded to flagyl. Respiratory status showed improving acidemia, worsening hypercarbia and worsening hypoxia prompting a chest CT which showed left lung collapse without midline shift. A chest tube was placed urgently by CT surgery for a pneumothorax and the pt was transferred to [**Hospital1 18**]. -[**Hospital1 18**] MICU COURSE ([**Date range (1) 58795**]): Pt was admitted directly to MICU on dopamine where he was found to be febrile to 101.2, hypotensive to SBP of 70s. Pt was swithced to levophed and started on ceftazidime, vancomycin, levofloxacin, and flagyl. The patient was initially started on MUST protocol for presumed sepsis. He finished his course of antibiotics on [**2181-2-18**], pressors were weaned off, pneumothorax resolved, chest tube was removed on [**2181-2-19**] and extubated successfully on [**2181-2-18**]. The patient was placed on ASA and statin for her NSTEMI, however b-blockers and ACE inhibitors were held due to hypotension. Pt also received CT demonstrating colonic thickening. Once extubated successfully and stable from respiratory standpoint, the patient was transferred to the floor. -[**Hospital1 18**] MICU COURSE ([**Date range (1) 58796**]): Patient was found to have coffee-ground emesis/melena and hypotension and was therefore re-transferred to unit following several boluses of fluid to maintain perfusion pressure. There, patient underwent EGD, which revealed only non-bleeding erosions of stomach and duodenum. H pylori serology was negative. However, patient was found to be bacteremic with MRSA and was treated with vancomycin IV 1.75g q12hours to attain a therapeutic trough level. Due to active bacteremia, patient also underwent a transesophageal echocardiogram which revealed no evidence of endocarditis. Following clearing of cultures and stabilization of blood pressure, patient was called-out to floor and a PICC placed. 1. Pulmonary: Pt originally seen at OSH with SOB, cough, WBC and found to be hypotensive, hypoxic and hypercarbic. Pt was intubated at OSH for respiratory distress complicated by pneumothorax and was transferred to [**Hospital1 18**] for difficult oxygenation. At OSH, CTA neg for PE but positive for infiltrate suggestive of PNA vs. atelectasis in addition to a spiculated lung mass in LUL. At [**Hospital1 18**], pt finished course of abx and pneumothorax resolved with chest tube. Pt was successfully extubated, and chest tube removed without complication following resolution of air leak. A). PNA: Pt tested positive for H.Flu at OSH and received ceftriaxone and levofloxacin. Coverage was expanded at OSH after aspiration event. Coverage was expanded to Vancomycin, levofloxacin, Flagyl and Ceftaz at [**Hospital1 18**]. BAL on [**2181-2-7**] positive for MRSA. Pt finished 14 day course of antibiotics and had minimal sputum following completion of course. B). Hypoxic/Hypercarbic respiratory failure. This was felt to be secondary to H flu pneumonia as above. Pt was transferred to [**Hospital1 18**] intubated. He was successfully extubated on [**2181-2-18**], without further complications. C). COPD: Given patient's emphysematous bullae on radiographic studies, it was felt that pneumothorax was most likely secondary to positive pressure ventilation in the presence of chronic emphysema. Patient was managed with stress dose steroids and nebs as needed without acute issues, and had no evidence of respiratory distress resulting from obstructive physiology. D). PTX: Patient had chest tube placed at outside hospital with successful reduction in size of pneumothorax from 75%-20% of lung and did not have any evidence of tension pneumothorax despite question of difficulty oxygenating. Over the course of hospitalization, left apical pneumothorax continued to improve significantly. Nonetheless, patient had persistent air leak through hospital day 9. On hospital day 11, however, patient underwent a water seal trial with continued resolution of pneumothorax. Therefore, on hospital day 13, patient had chest tube removed successfully. However, it was noted at the time of removal that patient still had persistent leak of air from thoracic cavity from the chest tube site, and sutures were placed at the chest tube site to aid in closure. E). Lung Mass: CT surgery following. Believes mass is malignant appearing and concerning for primary lung CA. Requesting outpatient PET scan, PFT and cardiac work up as well as a follow up appointment for possible VATS/minimally invasive lobectomy. To followup with [**Doctor Last Name 952**] [**Numeric Identifier 58797**] (office: [**Telephone/Fax (1) 170**]). 2. NSTEMI: Pt with reported NSTEMI on transfer from OSH, however given clinical history, most likely due to demand ischemia. Indeed, patient had upper GI bleed while on heparin, and therefore no further anticoagulation was administered. Furthermore, given initial hypotension, beta blockade was held, and patient was only given aspirin and statin for treatment of coronary artery disease. Patient to followup with cardiology following stabilization of critical care issues. 3. UGIB/ANEMIA: Pt with ?hx of esophageal varices and UGIB, had coffee grounds on [**2-7**]. Pt was seen by GI, who recommended conservative therapy with PPI [**Hospital1 **], avoid NSAIDS, and transfusion as necessary. Pt did not receive an EGD or colonoscopy. ---Hct on admit [**2-6**] was 38. Has since trended down to mid-30 range and now on transfer to floor was 28.7. ---Goal Hct >30 given pt's history of NSTEMI. Pt was transfused 2units of PRBCs ---Cont [**Hospital1 **] PPI and avoid NSAIDS. ---Consider re-consulting GI. However given acuity of pt's recent NSTEMI, risk of bowel prep and colonoscopy may outweight the benefit. Ultimately patient to go for colonoscopy as outpatient especially given below. 4. SIGMOID THICKENING: Incidental finding by Abd CT on [**2-15**]. ? divertics vs colon cancer. Given pt's spiculated lung mass very concerning for CA. further work-up advised, colonoscopy as outpatient. 5. AFIB: Pt had episode of rapid afib on [**2-18**], which was treated with iv lopressor, unsuccessfully and ultimately requiring diltiazem gtt to return to sinus bradycardia. 6. Hypotension: Pt was hypotensive on admission and started on DA gtt which was switched to levophed. Pt weaned off dopamine but still unable to be started on bb and ACEI due to hypotension. ---Observe for 4 hours and if stable will start bb and/or ACEI as tolerated. 7. ALCOHOL WITHDRAWAL: On transfer, patient required benzodiazepine gtt for alcohol withdrawal symptoms, and it was noted that patient became intermittently tachycardic (while still intubated) when versed gtt was tapered. Likewise, patient became tachycardic when fentanyl was tapered, and as such both sedative medications were successfully tapered slowly over MICU course. 8. MENTAL STATUS: Pt was sedated with versed gtt and ativan gtt while intubated. Pt with episode of disorientation and dyspnea post extubation. After removal of pain meds and BZD, dyspnea resolved, however pt remained disoriented. Suspect most likely due to above alcohol/BDZ withdrawal. 9. Weakness: Pt with moderate amounts of weakness since transfer from ICU. However it is slightly concerning that the weakness is more pronounced on the right than the left. As the pt suffered an NSTEMI during his hospitalization at the OSH prior to intubation, but no radiographic evidence of stroke. Patient to follow up with neuromuscular specialist re: weakness. 10. DVT: Pt with ? dvt at osh but bilat lower extremity u/s [**2-8**] neg for above-the-knee deep venous thrombosis. Furthermore, given history of GI bleed on anticoagulation, it was felt that risk did not outweigh benefit, and patient was kept on subcutaneous heparin only. . Full code Medications on Admission: MEDICATIONS ON TRANSFER FROM OSH: 1. Levofloxacin 750 once daily 2. Flagyl 3. Ceftriaxone 4. Nystatin 5. Ativan gtt 6. Banana bag 7. Lovenox 90mg [**Hospital1 **] 8. Nitropaste 9. Solumedrol 160mg TID 10. Lasix 40mg [**Hospital1 **] . MEDICATION ON TRANSFER FROM MICU: 1. ASA 2. Lipitor 80mg once daily 3. Heparin sub Q TID 4. Folate 5. Olanzapine 6. Hydrocortisone 25mg IV Q6hours 7. Thiamine 8. Albuterol 9. Atrovent 10. Protonix 40mg IV BID 11. Nicotine TD 12. Nystatin powder 13. Colace 14. MVA . ALLERGIES: NKDA . Discharge Medications: 1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*2 MDI* Refills:*2* 2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 4. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation Q12H (every 12 hours). Disp:*2 inhaler* Refills:*2* 5. Pantoprazole Sodium 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* 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Vancomycin HCl 500 mg Recon Soln Sig: 1.75 g Intravenous Q12H (every 12 hours) for 7 days. Disp:*14 doses* Refills:*0* 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Disp:*2 inhalers* Refills:*2* 13. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch Transdermal DAILY (Daily). Disp:*30 Patch* Refills:*0* 14. saline flush 5cc flush per PICC line PRN 15. Heparin Flush (Porcine) in NS 100 unit/mL Kit Sig: One (1) flush Intravenous QD and PRN. Disp:*30 day supply* Refills:*2* 16. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Take three tablets for 4 days daily, then take two tablets for 4 days daily, then one tablet daily for 4 days, then stop. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: Primary: Haemophilus influenzae and bacterial pneumonia, chronic obstructive pulmonary disease, Pneumothorax, NSTEMI, Atrial Fibrillation, Upper GI bleed, Left Upper Lobe Lung Mass, Sigmoid thickening, Altered Mental Status, Weakness Secondary: Diverticulitis Discharge Condition: Good - Ambulatory sat off O2>92% Discharge Instructions: Please take all of your medications as directed. Please follow up with your primary care physician within ten days of discharge. If you notice any chest pain, palpitations, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, black tarry stools, bright red blood per rectum, please call your PCP. Followup Instructions: PCP: [**Name10 (NameIs) 357**] follow up with your PCP within ten days of discharge. At the time, please make arrangements to follow up with a neurologist, cardiologist, pulmonologist, thoracic surgeon and gastroenterologist. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 58798**] Appointment should be in [**7-22**] days Neurology: Please make arrangements to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 2846**]) regarding your weakness. Cardiology: Please make arrangements to follow up with a cardiologist regarding the ischemic event that your heart suffered during your prior hospitalization as well as the episode of paroxysmal atrial fibrillation at the outside hospital. Thoracic surgery: Please make arrangements to follow up with Dr. [**Last Name (STitle) 952**]. You can call his office at [**Telephone/Fax (1) 170**] to schedule an apppointment. Pulmonary: Please make arrangements to follow up with a pulmonologist regarding COPD. Gastroenterology: Please follow up with gastroenterologist regarding your history of esophageal varices and Upper GI bleed as well as the sigmoid thickening on CT scan. Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Where: GI ROOMS Date/Time:[**2181-3-27**] 8:00 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2181-3-27**] 8:00 [**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 5799**]

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Discharge summary

report

Admission Date: [**2138-3-20**] Discharge Date: [**2138-4-7**] Date of Birth: [**2091-2-17**] Sex: M Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old gentleman with hepatitis C cirrhosis who is high up on the transplant list, who for the last five days prior to admission had been having decreased appetite, fatigue, nausea, and occasional vomiting. The patient's diuretics were recently increased prior to admission to Lasix 40 and Aldactone 100, but they were decreased to Lasix 20 and Aldactone 50 for elevated creatinines. The patient was found to have acute renal insufficiency by laboratories in clinic and was asked to come to the Emergency Department for further evaluation. In the Emergency Department, laboratories revealed a potassium of 6.7 and a creatinine of 4.3. PAST MEDICAL HISTORY: (Significant for) 1. Hepatitis C cirrhosis; requiring liver transplantation, the patient is currently on liver transplant list. 2. Hypertension. 3. History of nephrolithiasis. MEDICATIONS ON ADMISSION: 1. Aldactone 50 mg. 2. Lasix 20 mg. 3. Flagyl 250 mg three times per day. 4. Quinine 325 mg once per day. 5. Protonix 40 mg once per day. 6. Magnesium oxide 800 mg twice per day. 7. Oxycodone 2 mg to 4 mg as needed. ALLERGIES: The patient has allergies to CODEINE (which causes gastrointestinal upset). SOCIAL HISTORY: He lives at home with his wife. [**Name (NI) **] is a past alcohol abuser who now works as a substance abuse counselor. FAMILY HISTORY: Significant for father who died of a myocardial infarction at the age of 38. PHYSICAL EXAMINATION ON PRESENTATION: On admission, the patient was afebrile. He had a blood pressure of 130/58, a pulse of 70, a respiratory rate of 20, and was saturating 97% on room air. He was in no apparent distress. He was anicteric. His pupils were reactive. His extraocular movements were intact. The lungs were clear bilaterally. His cardiac examination showed normal first heart sounds and second heart sounds with a 2/6 systolic murmur at the right upper sternal border. His abdomen was soft, mildly distended, and nontender. He had no peripheral edema. PERTINENT LABORATORY VALUES ON PRESENTATION: He had a white blood cell count of 5.6, his hematocrit was 28.4, and he had platelets of 101. He had an INR of 1.9. Chemistry-7 showed an initial creatinine of 4.2 with a potassium of 6.7. After gentle fluids and treatment for his potassium, he had a repeat potassium of 5.7 and a creatinine of 3.9. He had an alanine-aminotransferase of 57, his aspartate aminotransferase was 166, his alkaline phosphatase was 101, and his total bilirubin was 3.7. PERTINENT RADIOLOGY/IMAGING: An electrocardiogram showed a normal sinus rhythm. There were no peaked T waves. Otherwise, his electrocardiogram was normal. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted for his acute renal insufficiency. His Lasix and his Aldactone were held. His hyperkalemia responded well to his Kayexalate therapy. The patient was noted to have some mild periorbital erythema and edema on the right side of his face. He was initially started on doxycycline for this presumed preseptal cellulitis. The patient's creatinine did initially improve; however, it started to increase again slowly during the course of his hospital stay. Initially, it was felt that the patient's initial presentation of acute renal insufficiency was secondary to aggressive diuresis; however, in the setting of his diuretics being held and his continued increase in his creatinine, it was possible that he could have the initial stages of hepatorenal syndrome. The patient has had elevated creatinines on previous hospitalizations, presumed to be related to hepatorenal syndrome. The patient was started on octreotide and midodrine. Also in the setting of his acute renal insufficiency, his tetracycline was held as it was possible that this could be a contributing factor. An Ophthalmology consultation was obtained which showed just some very mild preseptal cellulitis with no orbital signs or symptoms suggestive of an orbital cellulitis. The patient's doxycycline was discontinued in favor of Keflex. The patient did have urine eosinophils and sediment checked. He had bland sediment which was not consistent with an acute tubular necrosis type picture. The patient was also transfused with 2 units of packed red blood cells for a low hematocrit early on during the course of his hospital stay. The patient did not have any upper endoscopy as his anemia was not suspected to be secondary to esophageal varices. The patient's creatinine continued to rise in the setting of his octreotide and midodrine therapy. Because of this, albumin 25 grams intravenously once per day was also started. On [**2138-3-29**], the patient became encephalopathic. Blood cultures and urine cultures were sent, and he did have an episode of occult-blood positive stools. In the setting of his encephalopathy, his renal function did improve; however, he was transferred to the Unit for further observation. A nasogastric lavage was done in the setting of his occult-blood positive stool. The nasogastric lavage was negative for blood. He did have a STAT head computed tomography which was negative for bleed. All sedatives were discontinued, and he was started on lactulose therapy. A chest x-ray there was negative for a pneumonia. The patient did have serial blood cultures done. He did have a total of [**6-26**] blood cultures positive for methicillin-resistant coagulase-negative Staphylococcus. His mental status did improve on lactulose therapy. The origin of his staphylococcal bacteremia was still uncertain. In this setting, he did have a diagnostic paracentesis done which was negative for spontaneous bacterial peritonitis. The patient was started on vancomycin for his high-grade bacteremia. He did have a transesophageal echocardiogram done which was negative for endocarditis. Per the Infectious Disease staff, it was recommended that he be treated with four to six weeks of vancomycin from the date of his last positive blood cultures which were [**2138-3-30**]. The patient was transferred back to the floor with an improved mental status and improved renal function. He did well on the floor. His hematocrit remained stable. He remained afebrile on vancomycin. The patient also completed a course of levofloxacin for his preseptal cellulitis. For his preseptal cellulitis, he received a total of 10 days of antibiotics which included doxycycline, Keflex, and levofloxacin. The patient did have good nutritional intake while on the floor. His creatinine remained in the 1.6 to 1.9 range on the floor and stable. His baseline creatinine is around 1. He was not started on diuretics at discharge. A peripherally inserted central catheter line was placed for administration of intravenous vancomycin for his high-grade methicillin-resistant Staphylococcus epidermitis bacteremia. The patient was seen by Physical Therapy and was discharged from their service as he had no acute physical therapy needs. The patient did have a candidal infection of his groin area which was treated with topical anti-fungal medications, to which he responded well to. Toward the end of his hospital stay, the patient did have increased diarrhea. His lactulose was held which improved his diarrhea somewhat; however, he did complain of increased diarrhea. He did have Clostridium difficile toxins times three days which were sent. These were negative for Clostridium difficile. The patient was discharged on no diuretics; however, the possibility of restarting Aldactone 50 mg will be considered as an outpatient. He will be discharged with a total course of four to six weeks of vancomycin. The start date on his vancomycin was [**2138-3-30**]. CONDITION AT DISCHARGE: Fair. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Hepatitis C cirrhosis; awaiting liver transplantation. 2. Acute renal failure. 3. Methicillin-resistant coagulase-negative staphylococcal bacteremia; on vancomycin. MEDICATIONS ON DISCHARGE: 1. Miconazole nitrate powder applied three times per day as needed to groin rash. 2. Protonix 40 mg q.12h. 3. Lactulose 30 mL by mouth three times per day (titrated to four to five bowel movements per day). 4. Vancomycin 1 gram intravenously q.12h. (for a total of six weeks); his vancomycin dose will be changed per trough levels and his renal function. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up in the Liver Clinic in two days from discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D. [**MD Number(2) 22654**] Dictated By:[**Last Name (NamePattern1) 11207**] MEDQUIST36 D: [**2138-4-7**] 15:21 T: [**2138-4-9**] 07:33 JOB#: [**Job Number 25451**]

[ "572.8", "070.54", "571.5", "790.7", "584.9", "276.7", "041.19", "E944.4", "789.5" ]

icd9cm

[ [ [] ] ]

[ "88.72", "96.33", "99.04", "99.07", "38.93", "54.91" ]

icd9pcs

[ [ [] ] ]

1524, 2841

7945, 8117

8143, 8503

1055, 1368

8537, 8894

2871, 7873

7888, 7924

165, 826

849, 1029

1385, 1507

30,550

196,322

1630

Discharge summary

report

Admission Date: [**2184-7-6**] Discharge Date: [**2184-7-18**] Date of Birth: [**2146-2-16**] Sex: M Service: MEDICINE Allergies: Aspirin / Nifedipine Attending:[**First Name3 (LF) 3705**] Chief Complaint: Fever, increased pain and right leg discharge. Major Surgical or Invasive Procedure: Debridement and flap closure by vascular surgery. PICC line placement History of Present Illness: Mr. [**Known lastname 9427**] is a 38 year old gentleman with PMH significant for paraplegic [**1-17**] gunshot wounds, bilateral BKA/AKA with history of recurrent osteomyelitis on Vanc/Flagyl with noncompliance now presents with increase pain & worsening ulcer on AKA stump. Of note, the patient has had numerous admissions for IV antibiotics and increased ulcer pain who has left AMA without completing his antibiotic course. Currently, he is complaining of increased pain, stump drainage and smell, and fevers to 101 oral at home. The patient has a significant history of LE osteomyelitis s/p left BKA and more recent incomplete treatment of RLE osteomyelitis. Bone biopsy in [**11-21**] of RLE demonstrated MRSA, corneybacterium, bacteroides with recommended treatment of 6 weeks of vanco and flagyl, but the patient failed to complete the recommended course. Of note, the patient has yet to complete a full 6 week course of antibiotics. The patient has left AMA and since has had a number of admissions with presentation for the same problem with repeated history of leaving AMA prior to completion of therapy including elopement from [**Hospital1 336**] with right IJ in place. The patient was also recently discharge from [**Hospital1 18**] on [**7-2**] AMA after receiving vanco and flagyl but refusing PICC line placement as well as dispo to [**Hospital **] rehab. The patient has been seen by orthopoedics at [**Hospital1 18**] (Dr. [**Last Name (STitle) **] as well as ID with recommendation that surgery would not be considered until patient has completed his 6 week course of antibiotics given patient may require extensive surgery including possible hemi-pelvectomy. He has a history of LE osteomyelitis s/p left BKA and right AKA with more recently partially treated RLE osteo. Bone biopsy of the patient's right lower extremity was performed in [**11/2183**] with micro revealing MRSA, corneybacterium, bacteroides with recommendation for 6 weeks treatment course with Vanc and Flagyl. He has never completed the recommended 6 week course of Vanc, Flagyl per our records. The patient has left AMA and since has had a number of admissions with presentation for the same problem with repeated history of leaving AMA prior to completion of therapy including elopement from [**Hospital1 336**] with right IJ in place. In the ED, VS 99.1 114/68 18 98%RA. In the ED, the patient initially had SBP in the 80s, which was fluid responsive to 2L IVF. He was treated with vanco and pip/tazo as well as morphine for pain. ED labs were significant for WBC of 27.2. Vascular and orthopedic surgery were consulted in the ED. Currently, he continues to complain of right stump pain that radiates to his lower back. ROS is otherwise negative for CP/SOB, n/v/d, HA, abd pain, palpitations. Past Medical History: - Paraplegia secondary to gunshot wound - Neurogenic bladder/bowel, suprapubic catheter - s/p colostomy - Right AKA--osteomyelitis - Left BKA--osteomyelitis - Sickle Cell Trait - Psoriasis - History of MRSA - History of ESBL Klebsiella UTI, no ESBL in [**2183**] at [**Hospital1 18**] - Hx of CVA in [**2172**], right facial droop - Osteomyelitis of right AKA stump - biopsy of bone on [**2183-11-19**]--MRSA, corneybacterium, bacteroides, got two weeks vancomycin/flagyl back in [**11/2183**] and then left AMA - re-admitted [**Date range (1) 9425**] and got course of vancomycin/flagyl again over that time and again left AMA - admitted [**1-19**] to [**1-29**] for the same, pulled out own PICC and again left AMA - admitted [**Date range (1) 9426**], eloped with picc in place Social History: Social History: Patient currently lives with his aunt [**Name (NI) 1139**]: Denies ETOH: Denies [**Name (NI) 3264**]: History of heroin and cocaine use, reports last use 2 months ago Family History: non contributory vis a vis current issues Physical Exam: VS: T 99 P 82 R 18 BP 100/68 98%RA Gen: Somnolent, NAD HEENT: Perrl, eomi, sclerae anicteric, MMM, OP clear without lesions or exudate, neck supple. CV: Nl S1+S2, no m/r/g Pulm: CTAB Abd: S/NT/ND, +bs, colostomy back in place without surrounding erythema. Back: Neg CVA tenderness, scar across L mid back Ext: Hypopigmented buttocks and legs. Left AKA without signs of infection. Right BKA - open wound with discharge, foul smelling. Neuro:AOx3 Pertinent Results: [**2184-7-11**] 05:14AM BLOOD WBC-10.6 RBC-2.93* Hgb-7.2* Hct-22.2* MCV-76* MCH-24.8* MCHC-32.7 RDW-20.8* Plt Ct-406 [**2184-7-9**] 05:59AM BLOOD PT-13.1 PTT-32.5 INR(PT)-1.1 [**2184-7-11**] 05:14AM BLOOD Glucose-94 UreaN-6 Creat-0.4* Na-139 K-3.7 Cl-104 HCO3-30 AnGap-9 [**2184-7-6**] 07:15AM BLOOD ALT-14 AST-29 LD(LDH)-307* CK(CPK)-176* AlkPhos-112 TotBili-0.5 [**2184-7-11**] 05:14AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.7 [**2184-7-6**] 07:15AM BLOOD CRP-192.3* [**2184-7-10**] 09:01AM BLOOD Vanco-8.0* [**2184-7-6**] 07:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Right femur/knee Large soft tissue ulceration in the distal aspect of the right lower extremity with deformity of the proximal right femur including ankylosis of the right hip and severe sclerosis and new bone formation distally. The degree of bony changes limits evaluation for osteomyelitis. No definite evidence of osteomyelitis is seen, although there does appear to be increased bone resorption compared to the most recent comparison radiograph. CT Pelvis Interval further osseous destruction of distal femoral stump and interval increase in size of surrounding soft tissue phlegmon and fluid collections Brief Hospital Course: Mr. [**Known lastname 9427**] is a 38 year old male with PMH significant for paraplegic [**1-17**] gunshot wounds, bilateral BKA/AKA with history of recurrent osteomyelitis on Vanc/Flagyl with noncompliance now presents with increase pain & worsening ulcer on AKA stump. 1. Right nonhealing above the knee amputation: Patient left AMA on [**7-2**] after failing to complete vanco and flagyl therapy. He presented with worsening wound, pain, and fever at home. He was evaluated by vascular surgery who took the patient to the OR and debrided the wound and performed a flap closure. He initially was treated with vancomycin and pip/tazobactam, which was converted post-operatively to vancomycin and amp/sulbactam. The patient's Hct dropped from 29-->24 post operatively, and the patient was given 2 U on [**7-8**]. On [**7-10**] his Hct was noted to be 21.8 but the patient refused ongoing Hct checks and blood transfusions. Subsequently on [**7-11**] the patient triggered on the floor for HR 130s, SBP 88. His Hct was found to be 20.8 and he was noted to have active bleeding from his stump site. He was transfused an additional 2 U of blood, given 1 L NS and vascular evaluated him and changed the dressing. He was transferred to the MICU for hypotension where he was monitored until [**7-12**] when vascular took him to the OR for revision of his stump wound. Over the day on [**7-12**] he was transfused 8 more units of PRBC. He had arterial bleeding ligated and his wound was closed with resolution of his bleeding. After his ligation he remained without bleeding from the site and his Hct increased to 30 on the day of discharge without requiring further transfusion. He was followed by ID, who recommend at least 6 weeks of parenteral antibiotic therapy and he is was supposed be discharged on vanc (goal vanc trough of 15 to 20) and amp/sulbactam. He had a bed at the [**Hospital1 **] for Monday [**7-19**], however he eloped on [**7-18**]. 2. UTI: Patient has past Klebsiella ESBL UTI. Urinalysis performed demonstrated >100k proteus that is pansensitive. The UTI is covered by his amp/sulbactam. 3. Anemia: Patient has documented [**Doctor First Name **], although anemia of chronic disease also likely contributing to patient's anemia. He required multiple transfusions during his hospital stay with stabilization a few days after revision of his wound. His last hematocrit was stable at 30.1. Medications on Admission: Calcipotriene 0.005 % Cream Discharge Medications: Patient eloped and therefore did not get prescriptions for his medications. The medications he should have been discharged with were: 1. Calcipotriene 0.005 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 2. Ampicillin-Sulbactam 1.5 gram Recon Soln Sig: One (1) Recon Soln Injection Q6H (every 6 hours) for 6 weeks. 3. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 8H (Every 8 Hours) for 6 weeks. 4. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 5. Morphine Sulfate 1-2 mg IV Q4-6H:PRN Pain Start: [**2184-7-9**] Hold for sedation 6. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for bladder spasm. 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 9. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Discharge Disposition: Extended Care Discharge Diagnosis: Primary - Nonhealing right leg wound Secondary - Paraplegia secondary to gunshot wound Neurogenic bladder/bowel, suprapubic catheter s/p colostomy Right AKA--osteomyelitis Left BKA--osteomyelitis Sickle Cell Trait Psoriasis History of MRSA History of ESBL Klebsiella UTI, no ESBL in [**2183**] at [**Hospital1 18**] Osteomyelitis of right AKA stump Discharge Condition: Patient eloped with a PICC line in place. Discharge Instructions: Patient eloped therefore we were unable to give him discharge instructions. Followup Instructions: You have been scheduled for a follow up appointment with vascular surgery: Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2184-7-21**] 11:15 You will also need to follow up with infectious disease and an appointment has been made for you: Provider: [**First Name8 (NamePattern2) 4021**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2184-9-20**] 10:00. Completed by:[**2184-7-18**]

[ "785.4", "731.3", "707.19", "V55.3", "V49.75", "730.15", "041.6", "998.11", "V55.5", "997.69", "301.7", "907.2", "285.29", "458.9", "E969", "564.81", "305.60", "285.1", "041.11", "997.62", "599.0", "998.32", "V09.0", "V15.81", "305.50", "344.1", "596.54", "282.5" ]

icd9cm

[ [ [] ] ]

[ "99.29", "99.21", "39.31", "38.93", "84.3", "99.04" ]

icd9pcs

[ [ [] ] ]

9603, 9618

6012, 8432

327, 398

10012, 10056

4774, 5989

10180, 10670

4251, 4294

8510, 9580

9639, 9991

8458, 8487

10080, 10157

4309, 4755

241, 289

426, 3227

3249, 4033

4065, 4235

12,306

117,052

52638

Discharge summary

report

Admission Date: [**2173-3-30**] Discharge Date: [**2173-3-31**] Service: MEDICINE Allergies: Bactrim Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Found unresponsive, cardiac arrest (PEA) Major Surgical or Invasive Procedure: 1. Intubation [**2173-3-30**] 2. Mechanical ventilation 3. Central line 4. Femoral arterial line History of Present Illness: 88 year old woman with dementia (A&OX2), congestive heart failure (EF50%), coronary artery disease with stent to RCA and otherwise three-vessel disease, mild-moderate MR/AR, complete heart block s/p pacemaker, h/o UTI with MDR E. Coli, recent admission for NSTEMI (2/8-9/[**2173**]), who was in her usual state of health until found unresponsive this morning at her nursing home ([**Hospital3 537**]), at 7am. Per the patient's family, she had "not been feeling well" the day prior and had been complaining of left thigh pain. . When EMS arrived at the Nursing Home, patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Score of 3. She was intubated. Patient reportedly had spontaneous movements and faint carotid pulse en route to the hospital. . Upon arrival to the ED, the patient became pulseless upon transfer from stretcher to bed. The initial rhythm was PEA. Chest compressions were started and 1 mg of epinephrine given. Patient had return of spontaneous circulation, although [**Last Name (NamePattern4) **] pressures were systolic 50-60. RIJ central line was placed and levophed gtt started. Patient was bolused 1L normal saline. Patient's [**Last Name (NamePattern4) **] pressure remained labile, from 50-60 to 140s intermittently over a course of 20 minutes before pulse was lost again, with the rhythm being PEA. Patient received an additional 1 mg of Epinephrine. Femoral arterial line was placed. Her pulse returned and her [**Last Name (NamePattern4) **] pressures have been systolic 130s since. She was started on phenylephrine as well as the levophed gtt after the second PEA arrest. . Stat labs returned with Lactate 13.7 and Hct initially 18 (baseline from [**3-24**] was 30), troponin 0.54. Given the hematocrit, patient had FAST done at bedside which was negative, guaiac positive (brown stool), received 2 units of uncrossed pRBC. She received 2mg Versed for sedation but was not started on a drip. Also empirically given Vancomycin/Zosyn. . The patient was sent for CT head and torso. The CT torso showed a left sided retroperitoneal bleed in the setting of PTT of 150 (possibly secondary to heparin flushes for her PICC line). The patient received 50mg IV protamine to reverse the PTT prior to transfer to CCU. Also had received a total of 2.5L normal saline IV. Surgery evaluated patient briefly in the ED following RP bleed seen on CT and did not recommended operative therapy. Upon transfer, patient HR78, BP164/64, vent settings (Assist Control, FiO2100%, RR 28, TV 450) but satting 100%. . On review of systems, patient intubated/sedated and unable to provide history. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: Hypertension Hyperlipidemia CAD s/p NSTEMI in [**3-23**]-9/[**2173**], in [**2169**] with BMS, and another MI in [**6-15**] with stent to proximal RCA Complete heart block status post pacemaker in 03/[**2166**]. 3. OTHER PAST MEDICAL HISTORY: - Asthma - s/p thyroidectomy in [**11/2163**] - Osteopenia, osteoarthritis, and chronic pain - GERD - Chronic diaphoresis: TSH and PPD normal - Glaucoma - Shoulder bursitis - MDR E. coli UTI with bacteremia: sensitive only to Meropenem, Zosyn, Amikacin [**2173-3-9**] Social History: Retired, worked as a [**Month/Day/Year **]. Currently living in senior living home. Has 3 children ([**Last Name (LF) **], [**First Name3 (LF) 402**], and [**Female First Name (un) 108632**]) who live nearby and are very involved in her care. She also has a granddaughter, [**Name (NI) **], who is also involved. -Tobacco history: Denies -ETOH: Denies -Illicit drugs: Denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Mother with MI at age 70. No other cardiac hx, DM, or cancer. Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: Intubated. Synchronous with vent. Responds to commands. HEENT: NCAT. Sclera anicteric. Left pupil round and reactive. Right pupils appears post-surgical. NECK: Right IJ in place. CARDIAC: RRR, normal S1, S2. No m/r/g. LUNGS: Ventillated breath sounds. Clear to auscultation anteriorly. ABDOMEN: Soft, mildly tender. No rebound or guarding. EXTREMITIES: 2+ bilateral pitting edema. NEURO: Oriented x 2. Responds to commands. Moves upper extremities but not lower extremities. Says she can sense light touch in lower extremities. Toes downgoing bilaterally. . DISCHARGE Physical: N/A Pertinent Results: Pertinent Laboratories Results [**2173-3-31**] 05:39PM [**Month/Day/Year 3143**] WBC-10.1 RBC-2.71*# Hgb-8.5*# Hct-24.4* MCV-90 MCH-31.2 MCHC-34.8 RDW-16.7* Plt Ct-72* [**2173-3-30**] 11:00AM [**Month/Day/Year 3143**] WBC-7.2 RBC-2.02* Hgb-5.7* Hct-18.9* MCV-94 MCH-28.4 MCHC-30.3* RDW-20.9* Plt Ct-173 [**2173-3-31**] 04:44PM [**Month/Day/Year 3143**] PT-15.2* PTT-48.1* INR(PT)-1.3* [**2173-3-30**] 11:00AM [**Month/Day/Year 3143**] PT-15.9* PTT-150* INR(PT)-1.4* [**2173-3-31**] 11:09AM [**Month/Day/Year 3143**] Fibrino-138* [**2173-3-31**] 03:01AM [**Month/Day/Year 3143**] Fibrino-149* [**2173-3-30**] 01:59PM [**Month/Day/Year 3143**] Fibrino-124* [**2173-3-31**] 04:44PM [**Month/Day/Year 3143**] Creat-1.3* Na-132* K-4.3 Cl-107 [**2173-3-30**] 11:00AM [**Month/Day/Year 3143**] Glucose-93 UreaN-21* Creat-1.1 Na-141 K-5.1 Cl-104 HCO3-8.0* AnGap-34* [**2173-3-31**] 04:44PM [**Month/Day/Year 3143**] CK(CPK)-951* [**2173-3-31**] 03:01AM [**Month/Day/Year 3143**] ALT-112* AST-458* LD(LDH)-910* CK(CPK)-727* AlkPhos-77 TotBili-1.2 [**2173-3-30**] 11:00AM [**Month/Day/Year 3143**] ALT-51* AST-154* CK(CPK)-336* AlkPhos-99 TotBili-0.3 [**2173-3-31**] 04:44PM [**Month/Day/Year 3143**] CK-MB-14* MB Indx-1.5 cTropnT-0.60* [**2173-3-30**] 01:59PM [**Month/Day/Year 3143**] CK-MB-7 cTropnT-0.49* [**2173-3-31**] 04:44PM [**Month/Day/Year 3143**] Calcium-7.2* Mg-2.2 [**2173-3-30**] 11:00AM [**Month/Day/Year 3143**] Albumin-1.4* Calcium-6.5* Phos-6.1* Mg-2.1 [**2173-3-31**] 05:22PM [**Month/Day/Year 3143**] Type-ART Temp-33.8 pO2-181* pCO2-29* pH-7.20* calTCO2-12* Base XS--15 [**2173-3-31**] 11:27AM [**Month/Day/Year 3143**] Type-ART Tidal V-350 PEEP-5 FiO2-50 pO2-84* pCO2-28* pH-7.33* calTCO2-15* Base XS--9 -ASSIST/CON Intubat-INTUBATED [**2173-3-30**] 03:22PM [**Month/Day/Year 3143**] Type-ART pO2-174* pCO2-27* pH-7.30* calTCO2-14* Base XS--11 Intubat-INTUBATED [**2173-3-30**] 01:57PM [**Month/Day/Year 3143**] Type-ART pO2-444* pCO2-22* pH-7.36 calTCO2-13* Base XS--10 [**2173-3-31**] 05:22PM [**Month/Day/Year 3143**] Lactate-7.6* [**2173-3-31**] 03:12AM [**Month/Day/Year 3143**] Lactate-3.7* [**2173-3-30**] 01:57PM [**Month/Day/Year 3143**] Glucose-181* Lactate-8.3* Na-133* K-3.9 Cl-109 [**2173-3-30**] 11:49AM [**Month/Day/Year 3143**] Lactate-13.7* [**2173-3-30**] 11:07AM [**Month/Day/Year 3143**] Glucose-89 Lactate-14.1* Na-136 K-4.8 Cl-111 [**2173-3-31**] 06:49AM [**Month/Day/Year 3143**] freeCa-1.14 [**2173-3-30**] 01:57PM [**Month/Day/Year 3143**] freeCa-0.93* . STUDIES: CXR [**2173-3-30**]: IMPRESSION: 1. ET tube ending 3.1 cm above the carina. 2. No acute radiographic cardiac or pulmonary process. . CTA TORSO [**2173-3-30**]: 1. Large left retroperitoneal hematoma extending from the left hemidiaphragm into the left pelvis. No areas of active extravasation are identified, although this study was not optimized for evaluation of the distal aorta and iliac vessels. Given the patient's history of recent heparinization, this hematoma could be consistent with a spontaneous retroperitoneal hemorrhage. 2. Nonspecific peripancreatic fat stranding could be due to third spacing or pancreatic trauma. Recommend clinical correlation. 3. Transverse lucency through part of the superior aspect of the L3 vertebral body could represent a fracture of uncertain chronicity. Recommend correlation with physical examination and recent history of trauma. Also recommend further evaluation with MR [**First Name (Titles) **] [**Last Name (Titles) 11197**] for ligamentous injury following resolution of patient's acute illness. 4. Moderate bilateral pleural effusions. 5. Exophytic hypodense left renal lesion is not fully assessed on this study and could be further evaluated with non-emergent ultrasound. 6. No evidence of pulmonary embolism or aortic dissection/aneurysm. 7. Bilateral rib fractures as above, possibly related to recent CPR. . CT HEAD W/O [**2173-3-30**]: IMPRESSION: No acute intracranial process. . MICRO: [**Month/Day/Year 3143**] CX [**2173-3-30**]: PENDING Brief Hospital Course: HOSPITAL COURSE: 88 year old woman with history of coronary artery disease (three vessels) status post three MIs (two NSTEMIS, one unknown), complete heart block status post dual chamber pacemaker, CHF (EF 50%), mild dementia, mild-moderate MR/AR and recent functional decline who presented in hypovolemic shock, PEA arrest two times in setting of severe anemia from large left sided retroperitoneal bleed. Pt was intubated and made full-code initially, with subsequent change to CMO as code status below. . GOALS of CARE: On the day following admission, the patient's condition continued to deteriorate as she developed multiorgan failure in the setting of retroperitoneal bleed, hypovolemic shock and PEA arrest. Multiple family meetings were held on admission indicating full code, despite the patient's prior DNR status during recent hospitalization. On HD 2, a family meeting was held, with two of her daughters, one son and multiple grandaughters were present. The social worker, attending, resident, intern and two nurses were present. The patient was made comfort measures only. The endotracheal tube remained in place at room oxygen. Levophed was discontinued. All non-comfort medications were discontinued. She expired shortly thereafter. . ACTIVE ISSUES: # RETROPERITONEAL BLEED /ACUTE [**Month/Day/Year 3143**] LOSS ANEMIA: The patient came in with a hematocrit of 18.9, elevated PTT. A CTA of her torse revealed a large left retroperitoneal hematoma extending from the left hemidiaphragm into the left pelvis, without obvious extravasation. She had been on heparin SC and flushes with PICC at outside facility. No evidence of trauma on history or exam. Surgery was [**Month/Day/Year 4221**], and recommended reversal of coaugulopathy, serial hematocrits and repeat imaging when the patient was stabilized. Her coagulopathy was reversed with protamine and 2 units of FFP. Hct and coags were monitored. She was transfused 5 total units of PRBC's, with stabilization of Hct. . # PEA ARREST: Two PEA arrests in the [**Hospital1 18**] ED in the setting of hypovolemic shock from large retroperitoneal hemorrhage. She was not placed on cooling protocol given risk of coagulopathy. . # HYPOVOLEMIC SHOCK: Likely secondary to retroperitoneal bleed with two PEA arrests. She initially required 2 pressors and transfusions as outlined above. She was bolused with 500cc to 1 liter normal saline bolues regularly for pressure support receiving nearly 9 liters of volume rescussitation in the CCU. Despite aggressive rescusitation, and ventilatory support, the patient developed multiorgan failure; she was anuric, with evidence of shock liver. An ABG on the afternoon following admission was pH 7.2/29/181/15. Her lactate rose to 7.8 after improvement ovenight from initial insult to 14.1 hematocrit continued to drop and require transfusion support and her extremities were cool and mottled as her condition continued to deteriorate. A family meeting was held to discuss the patient's condition and goals of care. As above, pt was made CMO, and pressors were discontinued. . # RESPIRATORY DISTRESS: Pt required intubation due to inability to protect her airway in setting of PEA arrest. She was monitored on the ventilator with frequent ABG's. Pt was oxygenating well, with respiratory alkalosis due to correcting for metabolic acidosis from lactate. When pt was made CMO, vent settings were maintained at current settings. She expired after pressors were discontinued. . # GUAIAC POSITIVE GASTRIC LAVAGE: Not grossly bloody. As above, coagulopathy reversed with protamine and FFP. Aspirin and Plavix were held. She was started on Protonix IV BID. . # CORONARY ARTERY DISEASE with recent NSTEMI: Known 3VD. She was status post bare metal stent over 12 months ago. and recent admission for medical management of an NSTEMI one week prior. EKG without significant changes although difficult to interpret in setting of demand with bleed. Held aspirin and plavix in setting of retroperitoneal bleed. Continued on atorvastatin. As above, metoprolol and losartan were initially held. CE's were cycled and showed elevated cardiac enzymes in the setting of likely demand ischemia that continued to trend upwards as the patient decompensated. . # CONGESTIVE HEART FAILYRE: Chronic, systolic and diastolic with EF 50%. On admission, she appeared intravascularly depleted (anemic/hemorrhage) but extravascularly volume up with lower extremity edema. Home regimen of furosemide, HCTZ, losartan, and metoprolol were held in setting of hypontension. . # ANION GAP METABOLIC ACIDIOSIS: Likely lactic acidosis in the setting of hypovolemic shock and PEA arrest. Culture date negative at time of patient's death. . INACTIVE ISSUES: . # HYPERTENSION: Home regimen of furosemide, HCTZ, losartan, and metoprolol were held in setting of hypontension. . # ASTHMA: Patient was ventilated on admission. Her lungs were without wheezes. She was continued on albuterol MDI. . # SEVERE OA AND CPPD DISEASE: She was followed by rheumatology as an outpatient and has been on prednisone 10mg to 7.5mg daily. She was placed initially on stress dose steroids. . # GERD: Patient on omeprazole at home. She was started on pantoprazole. . # HISTORY OF FALLS/PRESYNCOPE: Per rheumatology, recent orthostasis and loss of consciousness with question of history of adrenal insufficiency given ongoing prednisone use. Stress-dose steroids were givenin setting of shock and prednisone use at home were started as above. . # DYSLIPIDEMIA: Last lipid panel in [**2-23**] showing Chol 195 TG 63 HDL 65 LDL 117. Her simvastatin was changed to atorvastatin 80 mg daily given NSTEMI during last admission. Continued on same dose of home atorvastatin 80mg daily. . # HYPOTHYROIDISM: Recent TSH 0.36 with free T4 1.4. Continued on home dose of levothyroxine. . # ELEVATED LDH: During previous admission and since [**2170**]. Etiology remains unknown but were trending downward as outpatient. Elevated on admission. . # STAGE III SACRAL DECUBITUS UCLER: Ulcers noted during last admission. Routine wound care continued per prior recommendations. Wound consult nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] and evaluated patient prior to her death. . # GLAUCOMA: Continued latanoprost and brimonidine eye drops. . # DERESSION: Home regimen of mirtazapine, fluoxetine were held on admission. . TRANSITIONAL ISSUES: The patient was made comfort measures only. Patient expired. Autopsy was requested by the family to determine cause of death. Medications on Admission: * Heparin, porcine (PF) 5,000 unit/0.5 mL Syringe Sig: 5000 (5000) units Injection three times a day. * Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). * Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO once a day. * Metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. * Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). * Vitamin D-3 400 unit Capsule Sig: One (1) Capsule PO once a day. * Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). * Albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. * Alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 mL PO four times a day as needed for nausea. * Latanoprost 0.005 % Drops Sig: One (1) drop Ophthalmic qHS. * Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime. * Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three times a day. * Calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. * Docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. * Brimonidine 0.15 % Drops Sig: One (1) drop Ophthalmic twice a day. * Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime. * Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) spray nasal Nasal twice a day. * Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. * Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. * Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO once a day. * Losartan 25 mg Tablet Sig: One (1) Tablet PO once a day. * Potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. * Ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO once a day. * Miralax 17 gram/dose Powder Sig: One (1) packet PO once a day. * Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. * Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. * Meropenem 500 mg IV Q6H Duration: 6 Days end date: [**2173-3-26**] * Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day: end date: [**2173-3-24**] Change to prednisone 7.5 mg on [**2173-3-25**]. * Prednisone 1 mg Tablet Sig: 7.5 Tablets PO once a day: start date: [**2173-3-25**]. * Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. * Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2173-4-1**]

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185,604

39619

Discharge summary

report

Admission Date: [**2135-8-20**] Discharge Date: [**2135-9-30**] Date of Birth: [**2072-12-4**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4691**] Chief Complaint: scrotal pain Major Surgical or Invasive Procedure: [**2135-8-20**] Debridement of perineum total scrotectomy [**2135-8-24**] Exploratory laparotomy with end-colostomy and perineal examination with wound dressing change [**2135-9-2**] testicles resited percutaneous tracheostomy [**2135-9-3**] reexploration of perineum for bleeding [**2135-9-28**] 1. Debridement of open perineal wound skin, subcutaneous tissue. 2. Local advancement flap closure of perineal wound 35 cm2. History of Present Illness: 62M h/o DM, HTN, CAD s/p CABG presented with 2 week h/o scrotal pain/tenderness and malaise. On exam, he was noted to have a large necrotic ulcer at the base of the scrotum and U/S was consistent with air and fluid collection at the base of the scrotum. Additionally, the pt had leukocytosis and elevated lactate, suggestive of Fournier's gangrene. He was taken to the OR emergently for debridement. Stable OR course, required removal of majority of scrotum due to necrosis. Received 1 unit PRBC, on low-dose neo en route to SICU. Past Medical History: DM, HTN, CAD s/p MI ([**2125**]), ?coagulation d/o Social History: Reports [**1-15**] pack per day cigarettes, multiple beers per day, denies illicit drug use. Family History: Non-contributory Physical Exam: Physical Exam: 98.9 98 105/35 16 100 GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender abdomen, erythematous and edematous scrotum with 4x4cm necrotic area on underside, tender to palpation Ext: No LE edema, LE warm and well perfused Pertinent Results: [**2135-8-20**] CT abdomen/pelvis: Extensive subcutaneous emphysema and gas seen within the scrotal sac with associated inflammatory changes extending along the left perineum that is concerning for an infectious process, and with given history of diabetes, is most compatible with Fournier's gangrene. No associated abnormal fluid collections. There is no extension to involve the rectum. [**8-21**] Echo: Mildly depressed left ventricular systolic funciton. Mild mitral regurgitation. [**8-23**] Echo: Compared with the prior study (images reviewed) of [**2135-8-21**], left ventricular function appears similar to slightly worse although views are suboptimal for comparison. Moderate tricuspid regurgitation is now detected. MICRO: [**8-20**], 9, 12 - MRSA: NEG [**8-20**] - Wound cx: 4+ GNRs, GPCs in pairs; mixed bacteria including coag neg staph, corynebacterium diptheroides, and b.frag beta lactamase positive. [**8-20**] - BCx x 1: BACTEROIDES FRAGILIS GROUP. BETA LACTAMASE POSITIVE. [**8-20**] - BCx: neg [**8-21**] - BAL: neg [**8-23**] - BCx x2: neg [**8-25**] - BCx x2: NG [**8-27**] - blood: NG [**8-27**] - mini-BAL: 1+ PMN, neg [**8-27**] - urine: neg [**8-29**] - MRSA neg [**8-29**] - cath tips x2 NG [**8-30**] - urine cx NG [**8-30**] - blood cultures NG [**8-30**] - sputum moderate yeast [**8-31**] - Blood Cx Negative (Fungal/Mycolytic cxs negative as well) [**8-31**] - CMV viral load Negative [**9-5**] MRSA - NG [**9-6**] - Pan culture - Sputum Yeast Sparse growth, UCx - NG, Bcx - P [**9-7**] Blood Cx - P [**9-7**] C diff - negative IMAGING: [**8-20**] CT Abd/pelvis: Gas in scrotal sac concerning for Fournier's sac, with no perirectal extension. No adjacent fluid collections. [**8-20**] CXR: Faint opacity projecting over RML [**8-21**] CXR: Persistent diffuse patchy b/l pulmonary opacities. Slight interval improvement in perihilar region. [**8-21**] Echo: LVEF= 45-50%, 1+ MR [**8-22**] CXR: diffuse b/l infiltrates [**8-23**] CXR: stable [**8-23**] Echo: EF 40%, Eccentric MR jet. 2+ MR. LV inflow pattern c/w restrictive filling abn, with elevated LA pressure. 2+ TR. Mild PA systolic HTN. Septal, apical, and inferior hypokinesis [**8-24**] CXR: slightly improved B pulmonary infiltrates [**8-25**] CXR: stable B pulm infiltrates [**8-25**] RUQ U/S: official pending, thickened GB wall [**8-26**] B/l asymmetrically distributed alveolar and interstitial opacities improved, except worsening of airspace disease in LLL. [**8-27**] CXR - B pulmonary infitrates, worsened, L pleural effusion [**8-28**] CXR - worsened B pulmonary infiltrates [**8-29**] CXR - severe diffuse pulmonary infiltrates [**8-29**] CT torso - Extensive, diffuse and patchy opacities involving all lung fields, c/w ARDS. Severe multifocal PNA remains in the DDx. B/l pleural effusions, moderate on R, small on L. Hyperdense filling in a non-distended GB, could represent a sludge-filled GB or vicarious contrast extraction from prior contrast study. [**8-30**] CXR - Stable, diffuse b/l pulmonary opacifications persist. [**8-30**] TTE - Preserved biventricular systolic function, mild-mod MR, PCWP >18mmHg, compared to findings of prior study from [**8-23**], LV systolic function significantly improved and now normal (LVEF >55%) [**8-31**] Renal U/S: WNL. [**9-1**] CXR showing left subclavian PICC extending to lower SVC. [**9-2**] CXR - No PTX or pneumomediastinum. New R central catheter extends to mid-lower portion of SVC. Diffuse bialteral pulmonary opacifications persist. [**9-4**] MRI - P [**9-4**] RUQ u/s - 1. Gallbladder sludge, with mild gallbladder istention. However, no additional findings to support cholecystitis. 2. Mildly echogenic liver, compatible with fatty infiltration. 3. Right pleural effusion partially imaged. [**9-4**] EEG - moderate to severe encephalopathy, which is non-specific but may be the result of medications, toxic/metabolic disturbances, and infections, among other etiologies. No focal or epileptiform features were seen during this recording. There was no evidence of non-convulsive status epilepticus or subclinical seizures. [**9-5**] CXR - 1. Diffuse bilateral opacities demonstrate no significant change since prior exam. 2. Small left pleural effusion, unchanged. [**9-6**] MRI w/out contrast - acute L sided infarct embolic vs watershed - does not explain global presentation [**9-7**] CXR - no large changes [**9-7**] Bubble study - normal [**9-8**] - Moderate pumonary edema with left lower lobe consolidation and moderate left pleural effusion, unchanged since yesterday but progressively worse. [**9-8**] - 2D Echo: Pulm HTN, Right ventricular overload, diastolic dysfunction--no evidence of right heart strain from PE. [**9-9**] RUQ U/S: Sludge within the gallbladder, but no gallstones. Mild gallbladder wall edema may be attributed to low albumin state. No cholecystitis. No biliary obstruction seen. [**9-11**] CXR - mild decrease in the diffuse bilateral pulmonary opacifications c/w ARDS [**2135-9-23**] Video swallow ; Minor penetration of nectar consistency with no aspiration into the airway. Brief Hospital Course: He was admitted to the ACS service. The following hospital course as dictated per the ACS resident: On HD 1, the patient was taken to the OR for perineal debridement and scrotectomy. He received 1 uPRBC and was transferred to the SICU on propofol and neo. His IVF were held as he appeared to have some pulmonary edema on CXR. On HD2 he was transfused 2 uPRBC for hct of 24.3. He remained tachycardic. On HD 3, he had persistent SOB and increased work of breathing and was intubated. CXR was suggestive of ARDS and he was paralysed and started on the ARDS protocol. On HD 4 the FiO2 and neo were weaned down. [**8-24**]: He was taken to OR for diverting colostomy. It was determined that he did not require further debridement at this time after evaluation in the OR [**8-25**]: Ventilator weaning initiated; his Neo was RUQ U/S was done, weaning vent, no resp effort on PS. albumin x1 w/decreasing uop. weaning neo. vigileo disconnected. TFs started. [**8-26**]: tx 1u prbcs. decreasing uop. Acidotic on MMV- switched to PCV o/n [**8-27**]: fever, re-cultured, hypoxic, CXR worsened, Lasix 10mg x 2 [**8-29**]: CT torso given significant ileus - showed no intraabdominal collections, did show ARDS picture. ~2300 cc TFs aspirated from NGT. New R rad Aline and R SC CVL placed. Changed vent setting to CMV with ARDSnet and paralyzed for dyssynchronous breathing and desats, ordered proning bed. pCO2 increased to 117 with bagging [**2-15**] to vent leak [**2-15**] in line sxn. Increased RR and TV to 8ml/kg with good effect. Spiked fever to 104.4 [**8-30**]: fam mtg, started Reglan. d/c'd Zosyn (possible drug fever) for [**Last Name (un) 2830**] (better bacteroides coverage). Transfused for HCT of 22. Transient T-wave inv. Trop neg, TTE wnl. [**8-31**]: renal c/s, renal u/s, Lasix, hypoglycemic - D20/insulin ggt after hypoglycemic to 50-60. Rotoprone bed d/c'dd. [**9-1**]: start TPN, Lasix/Diuril, fluconazole. d/c cisatra. PICC placed, consented for trach. TFT's wnl. Failed [**Last Name (un) 104**] stim test but asymptomatic. [**9-2**]: abd/perineal erythema, L>R scrotal swelling. Change CVL to HD catheter over wire. Trach+PEG and wound exploration today (bedside). EKG? [**9-2**] bedside subcutaneous pouch was made for testes. Wet to dry over perineum. tracheostomy placed, testicles sutured in groin. Large amt of oozing from trach/line sites- pt received DDAVP, 4 units PRBC, 2 units FFP [**9-3**]: Dropped hct, was transfused multiple units FFP and PRBC, surgery team found arterial bleeder at groin wound site and cauterized. Stable Hct thereafter. Off pressors. [**9-4**]: still unresponsive, EEG and MRI ordered, inc LFTs, RUQ u/s, dusky area on penis - ACS aware and following [**9-5**]: remains unresponsive, EEG pending, neuro consulted to r/o anoxic injury vs. brain death; neuro recommended MRI and LP. Abx dc'd per primary team. [**9-6**]: stopped TPN per ACS, stopped CRRT therapy. Changed NGT to Dobbhoff tube for TFs. D/C'ed CRRT. MRI showing left centrum/ovale likely acute embolic vs. watershed infarct--unlikely resulting in global insult. 300 cc emesis overnight with Dobbhoff lost. Improving neurologic status. [**9-7**]: Desaturated on trach collar, then again on CPAP. CXR without much change, no plugs, improved with increased PEEP/PS. Scheduled for a perc GJ [**9-8**]. Bubble study normal. PT/OT to see, Lopressor increased to 10q6h. Renal recommended intermittent CVHD given 18L positive. [**9-8**]: Tachypneic and increased work of breathing in the AM, responding to nebs and Lasix 40 mg IV. G-J tube placement with IR on hold, will need post-pyloric DHF tube. D/C IVF. 1U PRBC for decreasing Hct trend of 22.6. Concern for PE, empirically begin heparin gtt, 2D echo showing pulm HTN, RV overload, diastolic dysfunction. D/C'ed Insulin gtt, on Insulin SSI. [**9-9**]: Gave Lasix 40 mg IV for diuresis, consider CRRT given volume overload. Propofol gtt for sedation, given increased RR. Restarted empiric Abx coverage Vanc/[**Last Name (un) **]. Renal holding off on HD for now. Lasix repeated mult times. [**9-10**] - Initiated dialysis. [**9-11**] - Bleeding from HD catheter. Stitched, heparin held, given 1 u for hct 21. Only bumped to 22.4, melanotic stool, guaiac positive. Switched H2B to PPI, remeasured Hct in PM ---. Febrile to 101.5, pan-cx'd. CXR shows decreased diffuse bilateral pulmonary opacifications. [**9-12**] - 1 unit PRBC, Hct stable since. Dc'd heparin. Increased SS insulin. HD 1.5L off. Started metolazone and changed Lasix [**Hospital1 **]--> TID, UOP 30-100ml/day, plastics consult pending re: recon of scrotum [**9-13**] - Plastics consulted - plan for OR late week/next week (medial thigh flap, with ?STSG), patient being prepped for EGD/colonoscopy [**9-14**] (TF held/GoLYTELY). Lasix and metolazone increased per renal (held during colonoscopy prep). Trach sutures dc'ed. EGD/CLN performed - EGD clean, melena, no clear bleeding; NPH adjusted to 12U [**Hospital1 **] based on SS [**9-15**] - VAC to wound per plastics--possible OR for medial thigh free flap/STSG? Ostomy with no new melena output. Increased NPH to 20 units [**Hospital1 **]. Increased Lopressor to 50 mg PO BID for HTN. B/L LENIs negative. Renal: held diuretics, goal of -500 cc/day off was achieved. HD planned for AM [**9-16**]. Failed speech/swallow, tolerated PMV. At 1400 had some asymptomatic runs of Vtach, EKG unchanged, Tp 0.19/CK-MB trended. STAT labs showed K+ of 5.9--repeated lytes and 2 amp Ca+ gluc given. LE Doppler neg. [**9-16**]: Abx discontinued, no HD for now, PhosLo added as well as free water boluses 200 q8, Lopressor increased 50 [**Hospital1 **] to 37.5 TID, [**Last Name (un) **] consulted - insulin drip restarted. [**9-17**]: HD line and a-line d/c'ed, free water boluses increased per renal, tips sent for culture [**9-18**]: no plans for HD per renal, wound vac to wall suction (plan to change [**9-19**]), failed bedside swallow study, benefiber discontinued from TFs, pulled dubhoff twice [**9-19**]: TF via Dobbhoff. Free water boluses continued per renal, also 1L D5W per renal. [**First Name8 (NamePattern2) **] [**Last Name (un) **] changed from insulin gtt to ISS w/ Lantus. VAC changed by plastics. [**9-20**]: OR for plastics delayed by primary team until pt has stabilized renal fx, 1U PRBC, changed to bolus TF to improve glycemic control; video swallow ordered [**9-21**]: video swallow done which showed minor penetration of nectar consistency with no aspiration into the airway. He was transferred to the regular nursing unit on a pureed diet w/ nectar thick liquids. He continued to receive TF's via Dobbhoff; of note he required several Dobbhoff replacements as he has self removed the feeding tube intermittently. [**9-22**]: a trigger event was called as he was noted to have rigors & hypotension; a CXR was obtained and he was pan-cultured. PICC was removed and tip sent for culture; blood cultures eventually grew out GNRs. Antibiotics were initiated. [**9-28**]: He was taken to the operating room by Plastics for debridement and flap closure of his wounds. There were no complications, a drain and Foley were left in place and will remain until he follows up next week in [**Hospital 3595**] clinic. He is being discharged on Augmentin and Cipro. [**9-29**]: He was noted to be somewhat delirious felt secondary to the anesthetics received during his operation on the previous day. Over the course of the afternoon and evening his mental status was noted to improve closer to his baseline since transfer out of the ICU which is alert and oriented x1-2. [**9-30**]: He again self removed his Dobbhoff; the decision was made to not replace it as he is more awake and having longer periods of orientation. He will continue on his diet, it is being recommended that Speech re-eval him in order to upgrade his diet. An appetite stimulant may also be considered in an effort to improve/stimulate his appetite. He was followed by Physical and Occupational therapy and is being recommended for rehab after his acute hospital stay. Medications on Admission: ranitidine 150", lisinopril 10', HCTZ 25', fluoxetine 20', metformin 500", glyburide 5', atenolol 25', isosorbide 30', asa 81', nitro PRN Discharge Medications: 1. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO TID (3 times a day) as needed for GERD. 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day) as needed for constipation. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 10. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 12. Pantoprazole 40 mg IV Q24H 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 14. Insulin Glargine 100 unit/mL Solution Sig: Thirty Eight (38) units Subcutaneous at bedtime. 15. Humalog 100 unit/mL Solution Sig: One (1) dose Subcutaneous every six (6) hours as needed for based on sliding scale: per sliding scale. 16. Cipro 500 mg/5 mL Suspension, Microcapsule Recon Sig: Five (5) Suspension, Microcapsule Recon PO every twelve (12) hours for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital1 **] lower [**Doctor Last Name **] Discharge Diagnosis: 1. Fournier gangrene. 2. Hemorrhage from prior incision and debridement. 3. Acute post hemorrhagic anemia. 4. Hemorrhagic shock. 5. Renal failure. 6. Respiratory failure 7. Gram negative bacteremia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: * You were admitted to the hospital with scrotal pain and feeling poorly over a 2 week period. * You were diagnosed with Fourniers gangrene and required many operations and prolonged ICU care but you have been improving daily. * You are being transferred to rehab so that you can continue to build up your strength with physical therapy, soon have your tracheostomy tube removed and your diet further advanced * The long term goal is that you will return home. Followup Instructions: Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 5343**] for a follow up appointment [**2135-10-7**] in the Plastic Surgery Clinic Call the [**Hospital 2536**] Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in [**2-16**] weeks. Completed by:[**2136-2-29**]

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icd9cm

[ [ [] ] ]

[ "45.22", "45.13", "62.5", "43.11", "33.24", "54.12", "33.22", "96.72", "86.74", "39.95", "31.1", "61.3", "86.22", "99.15", "96.6", "46.11" ]

icd9pcs

[ [ [] ] ]

16824, 16897

7004, 15026

316, 748

17139, 17139

1905, 6981

17804, 18132

1508, 1526

15215, 16801

16918, 17118

15052, 15192

17319, 17781

1557, 1886

264, 278

776, 1308

17154, 17295

1330, 1382

1398, 1492

28,857

179,804

2215

Discharge summary

report

Admission Date: [**2100-8-22**] Discharge Date: [**2100-9-3**] Date of Birth: [**2042-6-3**] Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1271**] Chief Complaint: headache Major Surgical or Invasive Procedure: evacuation of SDH craniectomy History of Present Illness: asked to eval this 58 year old african american male who is taking ASA 81 mg daily with c/o of HA x 3 days. CT demonstrates acute on subacute sdh on the right side with MLS 1.2cm. No obvious mass lesion is noted. Pt lethargic at present and most of history taken from brother who is at bedside. Pt was out with family on friday and HA was severe enough that they drove him home. Brother states that pt did not remember the ride home. There are no reprots of sz or LOC nor of any trauma. Past Medical History: HIV HTN High Cholesterol Hypercholesterolemia hypertriglyceridemia overweight hypertension low HDL sedentary lifestyle HIV positive new diagnosis of type 2 diabetes. Social History: seperated from wife/ lives with sister - has a 23 year old son whom he said can make decisions for him. His name is [**Name (NI) 11777**] [**Telephone/Fax (1) 11778**] Family History: No DM, CAD, or cancer in family. Physical Exam: PHYSICAL EXAM upon admission: T: 98 T BP: 192/ 96 HR:88 R 18 O2Sats99 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3-2mm bilaterally EOMIs Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Lethargic, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date (thinks it is the 15th but it is the 16th. language: Speech fluent with good comprehension/ + accent / brother at bedside does not recognize a problem. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields grossly intact. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: ? slight right facial / sensation intact. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-10**] throughout. slight right pronation / no drift. Sensation: Intact to light touch Toes downgoing bilaterally No clonus Pertinent Results: Head CT [**8-30**]: IMPRESSION: No interval change in right subdural and subarachnoid hemorrhage post-craniotomy. Improved leftward subfalcine herniation, with less mass effect on the right lateral and third ventricles today. Head CT [**8-29**]: IMPRESSION: 1. Interval increase in shift of the midline leftward from 6 mm to 9 mm. 2. Stable sized, naturally evolving right temporoparietal subdural hematoma. 3. No evidence of new intracranial hemorrhage. MRI [**8-28**]: FINDINGS: Again a T1 and T2 hyperintense subdural collection identified from frontal to occipital region with air within this collection. There are post- operative changes seen in the right frontotemporal region. A small area of T2 hyperintensity in the right temporal lobe may be the site for biopsy. NO parenchymal enhancement is identified in this region. Following gadolinium mild meningeal enhancement is identified. There is mass effect on the right lateral ventricle with mild midline shift. No evidence of acute infarct identified. IMPRESSION: Status post craniotomy on the right side. Subdural collection is identified on the right which is characteristic of a subdural hematoma. Residual blood products are seen in this region since the previous MRI of [**2100-8-22**]. Post-biopsy changes are seen in the right temporal lobe. There is mass effect on the right lateral ventricle with midline shift and mild uncal herniation with deformity of the brainstem. No acute infarct is identified. Echo: Conclusions: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild to moderate ([**12-8**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: The patient was admitted with a SDH and went to the OR for craniotomy for evacuation on [**2100-8-22**]. He went to the ICU post-operatively and was slow to wake up. His post-op head CT showed decreased midline shift. His mental status improved slowly for the next 2 days and he was transferred to the floor on [**8-26**]. Then on [**8-27**] the patient became unresponsive and repeat CT scan showed increase in blood. He had a bedside tap via burr hole and 50 cc of blood was drained. Repeat CT showed decreased SDH, unchanged brain edema. On [**8-28**] he went back to the OR for a craniectomy. Following the procedure, his CT scan showed decreased SDH and his neurologic exam improved significantly. He was moving all extremities and was conversant by the time of discharge. His mannitol was stopped on [**9-3**]. PT and OT felt the patient was safe to be discharged to rehab. Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fosamprenavir 700 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Hydrochlorothiazide 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 10. Enfuvirtide 90 mg Kit Sig: One (1) Kit Subcutaneous [**Hospital1 **] (). 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QOD (). 12. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). 14. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). 15. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (WE). 16. NPH insulin Sig: Four (4) Subcutaneous every twelve (12) hours. 17. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection four times a day: Dose per insulin sliding scale. 18. Levetiracetam 1500 mg IV BID Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: right SDH Discharge Condition: neurologically improved/stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: You need to have your sutures/staples removed in 10 days. You may have this done at rehab or call the office to set up an appointment. Follow up with Dr. [**Last Name (STitle) 739**] in 4 weeks with a head CT. Call [**Telephone/Fax (1) 1669**] to make appointment. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2100-9-3**]

[ "432.1", "348.2", "348.30", "285.9", "401.9", "780.6", "272.0", "348.5", "042", "250.00" ]

icd9cm

[ [ [] ] ]

[ "01.39", "01.31", "96.04", "96.71", "03.31", "96.6" ]

icd9pcs

[ [ [] ] ]

7484, 7554

5180, 6062

283, 315

7608, 7641

2505, 5157

9027, 9418

1289, 1323

6085, 7461

7575, 7587

7665, 9004

1338, 1354

235, 245

343, 837

1828, 2486

1368, 1546

1561, 1812

859, 1086

1102, 1273

23,018

100,007

50238

Discharge summary

report

Admission Date: [**2145-3-31**] Discharge Date: [**2145-4-7**] Date of Birth: [**2071-6-4**] Sex: F Service: SURGERY Allergies: Penicillins / Dilantin Attending:[**First Name3 (LF) 301**] Chief Complaint: Severe abdominal and back pain Unable to take oral intake. No flatus or bowel movement. Abdominal distention. Major Surgical or Invasive Procedure: Exploratory Laparotomy Lysis of adhesions Small Bowel Resection Jejunosotomy History of Present Illness: Ms [**Known lastname **] is a 73 year old female with a history of multiple abdominal surgeries, pancreatitis and previous SBO. She presented to the Emergency Department on [**2145-3-30**] with complaints of [**11-10**] abdominal pain, radiating to her back that began in the morning. She complains of distention, inability to have a bowel movement, inability to take oral intake, no fever, chills or diarrhea. Past Medical History: Chronic Pancreatitis Migraines Surgical history: Pancreatic diversion, cholecystectomy, appendectomy, small bowel obstruction. Social History: Married, lives with husband who is a retired pediatric infectious disease doctor. Family History: Father: deceased, leukemia Brother: colon cancer Physical Exam: T: 97.9 HR: 79 BP: 153/60 RR: 22 Spo2 100% on RA Constitutional: in pain Head/Eyes: mucous membranes dry ENT/Neck: neck supple Chest/Respiratory: Clear to auscultation Bilaterally GI/Abdominal: Tender to light palpation. Multiple well healed scars + guarding, hypoactive bowel sounds GU: no costovertebral angle tenderness Musculoskeletal: WNL Skin: Dry Neuro: alert & oriented Pertinent Results: [**2145-3-30**] 09:15PM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-139 K-3.8 Cl-103 HCO3-25 AnGap-15 [**2145-3-31**] 10:26AM BLOOD WBC-12.3*# RBC-4.01* Hgb-12.3 Hct-37.1 MCV-93 MCH-30.6 MCHC-33.0 RDW-14.2 Plt Ct-259 [**2145-3-30**] 09:15PM BLOOD ALT-12 AST-22 AlkPhos-89 Amylase-169* TotBili-0.3 [**2145-4-2**] 06:15AM BLOOD Amylase-107* [**2145-3-31**] 10:26AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.6 [**2145-3-31**] 12:44AM BLOOD Lactate-3.1* [**2145-4-2**] 02:10PM BLOOD Lactate-1.9 [**2145-3-30**] 11:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG . ABDOMEN (SUPINE & ERECT) IMPRESSION: Nonspecific bowel gas pattern without evidence of obstruction. . CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST IMPRESSION: 1. High grade small-bowel obstruction. Unusual configuration of a loop of small bowel in the mid abdomen is concerning for closed loop obstruction. There is a moderate amount of free fluid within the abdomen. 2. Ill-defined opacity in the right middle lobe representing infection or BAC and should be further evaluated with PET CT. 3. Thickening of the first portion of the duodenum, of uncertain clinical significance. . CHEST (PORTABLE AP) [**2145-4-2**] 1:51 PM IMPRESSION: Right lower lobe airspace opacity, which could represent pneumonia in the appropriate clinical setting. Small bilateral pleural effusions. Followup to assure resolution is recommended. . CT Chest [**2145-4-2**] IMPRESSION: 1. New right lower lobe pneumonia. Small bilateral pleural effusion and left basilar atelectasis. 2. Ill-defined opacity in the right middle lobe representing either infection or BAC and should be further evaluated once acute issues resolve. 3. No evidence of pulmonary embolus or aortic dissection. 4. Small mediastinal and axillary lymph nodes, which do not meet CT criteria for pathologically enlargement. CXR [**2145-4-6**] IMPRESSION: 1. Improving airspace consolidation in the right lower lung field consistent with resolving pneumonia. 2. Small bilateral pleural effusions. Brief Hospital Course: Ms [**Known lastname **] was admitted through the emergency room on [**2145-3-31**] and taken to the operating room. She underwent an uncomplicated exploratory laparatomy for small bowel resection, jejunosotomy and lysis of adhesions, see op report for details. She was stabilized in the PACU, and transferred to SICU on POD#1. She was extubated, her pain was well controlled with morphine PCA, she remained NPO with NGT and foley catheter. She was initiated on Cefazolin/Flagyl x 24 hours. POD#2 she developed confusion and decreased oxygen saturation, requiring 3L nasal cannula. Narcotics were stopped, CXR and CT of chest were obtained and revealed right lower lobe pneumonia, see pertinent results for details. Vanc/Levo/Flagyl were initiated as well as an ID and medicine consult. She was transferred to SICU. POD#[**4-4**] she remained in SICU, her mental status and respiratory status improved. POD#4 her NGT was removed and she was transferred to [**Hospital Ward Name 121**] 9, she was weaned to room air. Her pain was well controlled with tylenol and small doses of oxycodone. POD#5 she reported flatus followed by multiple loose stools. Stool for C diff was negative. She was started on sips, and tolerated it easily. POD#6 she tolerated clear liquids but no longer wanted to take antibiotics due to frequent stools. CXR was repeated which showed resolving pneumonia. She tolerated a regular diet in the evening without difficulty. Infectious disease team recommended completion of 7 days of Levofloxacin. Clips were removed on POD#7, she was discharged home in stable condition with antibiotics, pain medication and all appropriate follow up appointments. Medications on Admission: Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 6. Trileptal Resume your home dose of trileptal Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 0.5-1 Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. 7. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*7 Tablet(s)* Refills:*0* Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 6. Trileptal Resume your home dose of trileptal Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Internal hernia with necrotic jejunum Pneumonia Discharge Condition: good Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. Activity: No heavy lifting of items [**11-15**] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. If you have a problem with constipation, you should take a stool softener, Colace 100 mg twice daily as needed. You will be given pain medication which may make you drowsy. No driving while taking pain medicine. Followup Instructions: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2145-4-20**] 2:00 You have an appointment to see Dr. [**Last Name (STitle) **] on Friday, [**2145-4-23**] at 3:30. Phone #: [**Telephone/Fax (1) 2723**]. Please see your primary care physician regarding follow up from your CT scan within 1 month. Your CT results and Discharge summary will be faxed to her. Completed by:[**2145-4-7**]

[ "401.9", "997.3", "486", "560.81", "557.0" ]

icd9cm

[ [ [] ] ]

[ "54.59", "45.62" ]

icd9pcs

[ [ [] ] ]

6306, 6312

3718, 5389

390, 469

6428, 6435

1644, 3695

7373, 7857

1177, 1228

5699, 6283

6333, 6407

5415, 5676

6459, 7350

1243, 1625

240, 352

497, 909

931, 1061

1077, 1161

6,566

167,913

20676

Discharge summary

report

Admission Date: [**2187-8-23**] Discharge Date: [**2187-9-2**] Date of Birth: [**2137-3-14**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: Massive hematemesis Major Surgical or Invasive Procedure: Hepatic artery embolization by internventional radiology Paracentesis History of Present Illness: 50 yo male with hx of Hep C and alcohol cirrhosis/ESLD on liver transplant list s/p recent admission during which pt underwent TIPS without complications. Patient returned to [**Hospital1 18**] on [**2187-8-15**] noted to have worsening pedal edema despite TIPS and diuretics. He underwent TIPS dilation on [**2187-8-17**] without complication. Patient also underwent colonoscopy without any significant findings. Patient presented to OSH on [**2187-8-23**] with massive hematemesis and hypotension. Initial Hct was 19, INR at OSH 4.4. Patient transiently placed on octreoltide drip and IV protonix. EGD revealed increased bledding at ampula. Patient was injected with epinephrine without any effect. Patient was then transfered emergently to [**Hospital1 18**]. On arrival, patient was intubated for airway protection, OGT placed with 400 cc of blood return. Patient then had BRBPR. Pt was hypotensive post intubation in the SBP of 90's. Past Medical History: CAD with stent Anemia ETOH abuse Hepatitis C Liver cirrhosis/End stage liver disease History of abdominal wall bleeding w/ paracentesis Social History: Currently unemployed. Lives with wife, a healthcare proxy. Lives in [**Location 21318**]. Has not used drugs x 15 years. No ETOH since [**6-14**]. [**1-12**] pack of cigarrettes/day x 30 years. Family History: Mother 47yo Breast cancer Father CVA Physical Exam: VS: T99.2 BP 115/66 P 89 RR 14 99% on 4L NC Gen: Awake, alert and oriented x3, slightly confused but able to converse without any difficulty HEENT: nc/at, +icteric sclera bilaterally, small conjunctival injection of left sclera, normal oropharynx, mucous membrane moist. neck supple, +R IJ Cor: RRR, nl S1, S2, no M/R/G, no JVD Lungs: CTA bilaterally no crackles, no wheezes, no rhonchi Abd: markedly distended, tympanic to percussion periumbilically and dullness at bilateraly lower quadrants, +fluid wave, ~13 cm umbilical hernia with distension and tense skin, no woozing of fluid. GU: bilateral scrotal edema with +transillumination, no mass palpable. Ext: 3+ pitting edema bilaterally, 1+ DP palpable bilaterally Neuro: alert and oriented x3, CNIII-XII intact, stregths gross intact at all major muscles groups. Sensory not tested. no asterixis or tremor. No nystagmus seen. Gait and coordination deferred. Pertinent Results: [**2187-8-28**] 04:00AM BLOOD WBC-9.9 RBC-4.02* Hgb-12.5* Hct-36.6* MCV-91 MCH-31.2 MCHC-34.3 RDW-18.0* Plt Ct-49* [**2187-8-28**] 04:00AM BLOOD Plt Ct-49* [**2187-8-28**] 04:00AM BLOOD Glucose-153* UreaN-19 Creat-0.3* Na-140 K-3.1* Cl-107 HCO3-24 AnGap-12 [**2187-8-28**] 04:00AM BLOOD ALT-19 AST-39 LD(LDH)-152 AlkPhos-49 Amylase-32 TotBili-22.9* [**2187-8-24**] 7:33 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES **FINAL REPORT [**2187-8-28**]** AEROBIC BOTTLE (Final [**2187-8-28**]): REPORTED BY PHONE TO CARNIVAL,[**Doctor First Name **] @2307 ON [**2187-8-25**]. VIRIDANS STREPTOCOCCI. ANAEROBIC BOTTLE (Final [**2187-8-28**]): VIRIDANS STREPTOCOCCI. CT ABDOMEN WITH CONTRAST: Lung bases are grossly clear except for minimal dependent changes. There is extensive ascites as on the prior examination. The liver contour is nodular and shrunken, consistent with cirrhosis. New metallic coils are seen wihtin the right lobe of the liver, presumbly from the patient's hepatic artery embolization. Additionally, a new TIPS shunt has been placed. The previously identified area of hypervascularity within the medial caudate lobe is not well-visualized on the current examination due to lack of arterial phase of imaging. The portal vein and hepatic veins are patent. The gallbladder contains multiple stones and sludge within the gallbladder neck. The spleen is slightly enlarged. The adrenals and kidneys are within normal limits. The pancreas and stomach are unremarkable. Multiple loops of small bowel appear dilated and thickened, probably a result of the patient's cirrhotic state. Mild small bowel loop dilatation is noted. CT PELVIS WITH CONTRAST: The colon, appendix, urinary bladder and rectum are unremarkable. There is extensive ascites within the pelvis. Note is made of bilateral opening inguinal rings, with a small amount of fluid in the hernias. A subcutaneous anterior abdominal wall fluid collection is noted as on the prior examination, measuring approximately 8.2 cm transverse x 3.2 cm AP. BONE WINDOWS: No suspicious bony lesions. Degenerative changes are seen within the lower lumbar spine. IMPRESSION: No significant change from the prior examination, with changes of portal hypertension and cirrhosis. No evidence of loculated fluid collection or abscess formation. Brief Hospital Course: 1) GI bleed: On admission, pt underwent emergent EGD which showed no bleeding from gastric or esophageal varices but did have bleeding from peri-ampullary region. The area was injected with epinephrine but still had active oozing of blood. Per report, pt had 1-2 L of hematemesis during the procedure. Patient got triple phase CT scan which did not see any active bleed. Patient was then brought to Interventional Radiology to identify the source of the bleed. Pseudoaneurysm of arterial [**Last Name (un) **] of right hepatic artery found and subsequently embolized on [**8-22**]. The hepatic artery pseudoaneurysm was believed to be secondary to eroded TIPS. Patient's Hct was contininued to drop acutely on admission and received multiple transfusion till the embolization. Patient was given total of 12 units of PRBC, 6 units of FFP, one bag of platelets since presentation to OSH. Patient remained in MICU till [**8-28**] where Hct, platelets, and coags were checked frequently. NG lavage from [**8-23**] showed clots and later clearing on [**8-24**]/ Patient was initially on octreotide drip but was discontinued on [**2187-8-25**]. Patient initially remained hemodynamically stable after the embolization procedure. However on [**8-24**], Hct dropped from 32 to 27 and got 4 units of PRBC. On [**8-26**], his Hct continued to drop requiring another 4 units of PRBC and wa brought back to the interventional radiology for repeat intervention. Patient has been hemodynamically stable since then. Patient was then transferred to the medicine floor where he remained slightly hypotensive with SBP of 100's but hemodynamically stable. He required several more therapeutic paracentesis which were all negative for SBP, and his blood pressure tolerated well and his hematocrit remained stable until [**9-2**]. When Hct dropped from 333 to 24 and then to 21 acutely. In the early morning of [**9-2**], he was found to be hypotensive in the 80's systolic but eventually came back up to 100's. Around 7am, he was found to be tachypnic appearing ill. The day before, he got another paracentesis without any complication and any evidence of peritoneal bleed seen in the peritoneal fluid. In the morning of [**9-2**], his abdomen appeared distended but tympanic in nature with less fluid. It was concerning for perforated bowel, so KUB and upright Chest film were ordered which were negative for free air. His initial vital signs were within his usual baseline and within the normal limits, oxygenating well on room air. He was noted to have low grade temp of 100 for the past 1 week with negative workup. He then suddenly became hypotensive with a lactate of 14.5, ABG of 7.40/22/86/14 on RA. MICU was called and pt was resuscitated with IVF and transferred to the ICU. Hct at that time was noted to be 21. He was intubated, and given PRBC but became hypotensive. Repeat ABG showed 6.79/65/66 and eventually deceased. He had multiple ecchymosis and bleed from the all of the line sites which were consistent with the DIC picture. His high lactate, hypotensive state, and underlying metabolic acidosis picture was consistent with the sepsis picture rather than pure GI bleed. Autopsy permission was obtained by his wife. 2)SBP: Patient was initially started on IV Cipro for SBP prophylaxis but was changed to levofloxacin and flagyl for empiric SBP prophylasix. Patient then got ultrasound guided diagnostic/therapeutic paracentesis on [**8-24**] due to high bladder pressure in which 3.5 L of fluid was removed and the peritoneal fluid studies were consistent with SBP (500 WBC 79%PMN's). Patient was started on Zosyn on [**8-24**] after acute rise in WBC from 12 to 24. The peritoneal fluid culture grew strep viridan, so vancomycin was added to zosyn. Patient got another paracentesis on [**8-28**]. Patient got albumin and FFP during the procedure. Patient had a persistent low grade temp of 100's for almost a week with a negative workup including peritoneal fluid culture, blood culture, urine culture, chest x-ray, and CT Abdomen for abscess. It is possible that he had a nidus of infection at his hepatic artery coil that was emolized which eventually caused another bleed on [**9-2**] which led to his demise. 3)Hepatic encephalopathy: After extubation, patient was not oriented and was arguing with the staff that he wanted to leave AMA. After discussing with his wife and the team, he was felt incapacitated to make that decision under worsening of encephalopathy. He has been on lactulose for encephalopathy. On [**8-28**] when transferred to the floor, patient was alert and oriented x3 and more cooperative. Patient was having good response to lactulose and showing improvent in his mental status. 4)Cirrhosis/ascites: As noted above, patient required 2 therapeutic paracentesis to releave abdominal distension. He also has remarkable umbilical hernia that was very tense as his peritoneal fluid reaccumulated. Patient was initially on spironolactone 25 mg po qd and lasix 20 mg IV qd which was changed to spironolactone 50 mg po qd and lasix 40 mg po qd. Prior to this admission, he was not responding well to diuretics as his ascites and pedal edema worsened despite TIPS and diuretics. 5)Renal: Creatinine on admission was 0.6 and has been stable since [**8-25**] when creatinine level went up to 1.2 which was attributed to high contrast/dye load during CTA and angiogram. Patient got mucomyst and aggressive hydration after the CTA and angiogram. The creatinine shortly came down to 0.7 then 0.3 and have been stable since. 6)Respiratory: Patient was initially intubated to protect his airway from massive hematemesis. He remained intubated in the MICU till [**2187-8-27**]. Post-extubation course without any complication. 7)Pneumonia: Chest X-ray from [**2187-6-27**] showing possible new left lobe infiltrate which was thought as new bacterial. Patient was already covered with Vanc and Zosyn for SBP treatment which also should cover for common bacterial pathogens. The repeat Chest X-ray did not appear to consistent with pneumonia. 8)Thrombocytopenia: Patient noted to have thrombocytopenia secondary to liver failure. Patient received one bag of platelets initially. It remained low in 40-70's but has been stable without significant drop in the platelet count. The goal was to transfuse for active bleed or platelet count <10. 9)FEN: Pt was initially on tube feed. After extubaton, speech/swallow service evaluated the patient, and he was tolerating thick liquid since. Patient remained on low sodium low protein diet for his liver disease. In addition, dob hob was placed and tube feeding was started overnight to supplement his nutrition since he was at a catabolic state as it was evident by the low creatinine. Medications on Admission: Spironolactone, Lasix, oxycodone, lactulose, protonix Discharge Disposition: Home Facility: Patient deceased Discharge Diagnosis: 1. GI bleed 2. Sepsis 3. Hepatic artery pseudoaneurysm/rupture s/p coiling 4. SBP 5. End stage liver disease 6. Cirrhosis Discharge Condition: Patient deceased. Completed by:[**2187-9-10**]

[ "070.54", "518.81", "572.2", "567.2", "996.74", "571.2", "578.0", "305.00", "789.5" ]

icd9cm

[ [ [] ] ]

[ "96.72", "54.91", "38.93", "99.05", "99.04", "45.13", "38.91", "96.04", "88.47", "99.29" ]

icd9pcs

[ [ [] ] ]

12036, 12070

5131, 11932

328, 399

12235, 12283

2757, 5108

1767, 1805

12091, 12214

11958, 12013

1820, 2738

269, 290

427, 1378

1400, 1538

1554, 1751

42,326

133,168

35470

Discharge summary

report

Admission Date: [**2181-2-22**] Discharge Date: [**2181-3-2**] Date of Birth: [**2119-6-24**] Sex: F Service: MEDICINE Allergies: Codeine / Morphine / Penicillins / Iodine; Iodine Containing / Prednisone Attending:[**First Name3 (LF) 7651**] Chief Complaint: 3rd degree heart block Major Surgical or Invasive Procedure: pacemaker placement History of Present Illness: Ms. [**Known lastname 4886**] is a 61 year old female with history of seizures, hypothyroidism, CAD who presents from OSH with third degree heart block. Patient is sedated and family not available to provide history. Reportedly this AM patient was found down after using the bathroom. She was taken to [**Hospital3 5365**] and found to be minimally responsive with HR 30s, low BP. She was given atropine x1 with reported improved perfusion. Right IJ placed and patient started on levophed. BP improved after atropine so levophed d/c'd. She was given 4L IVF and started on dopamine gtt. It was determined at [**Hospital1 **] to transfer to [**Hospital1 18**] for further managment. Medics began transcutaneous pacing, placed Aline and intubated patient in transport. Of note, she reportedly had CP in AM but refused to go to ER for evaluation. . The patient denies any chest pain or pressure, new exertional dyspnea, orthopnea, PND or leg edema, palpitations or syncope, claudication-type symptoms, melena, rectal bleeding, or transient neurologic deficits. No change in weight, bowel habit or urinary symptoms. No cough, fever, night sweats, arthralgias, myalgias, headache or rash. All other review of systems negative. In the ED here, HR 70, BP 160/80, vented on AC 100% FiO2. Labs notable for INR 2.1. She was seen by EP. RIJ was exchanged for cordis and temporary wire was placed with good capture. She was also sent for CT head which was negative for acute bleed but showed evidence of subacute/chronic occipital and parietal infarcts. . On arrival to the CCU, the patient was intubated and paced at a rate of 70s. Dopamine was quickly weaned off and BPs have remained stable. She was responsive to some commands. Past Medical History: CAD s/p 3v CABG, MI [**2176**] Hypertension Seizure disorder Hypothyroidism Social History: No tobacco, EtOH or drug use. Family History: FHx noncontributory Physical Exam: Gen: Intubated female, responds to commands. HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. CV: RR - paced, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Clear anteriorly. Abd: Soft, nondistended. Ext: No c/c/e. No femoral bruits. 2+ DP pulses bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Admission Labs [**2181-2-22**] WBC-12.2* RBC-3.33* Hgb-10.2* Hct-31.0* MCV-93 MCH-30.5 MCHC-32.7 RDW-13.8 Plt Ct-428 Neuts-90.5* Lymphs-7.0* Monos-2.3 Eos-0.1 Baso-0.1 PT-22.4* PTT-25.4 INR(PT)-2.1* Glucose-313* UreaN-15 Creat-0.9 Na-140 K-4.3 Cl-111* HCO3-16* AnGap-17 CK(CPK)-70 cTropnT-0.03* Other Labs [**2181-2-23**] Calcium-8.3* Phos-3.4 Mg-1.6 [**2181-2-23**] 12:51AM BLOOD Lactate-1.8 [**2181-2-23**] 06:08AM BLOOD Phenyto-10.8 [**2181-2-22**] 09:15PM BLOOD TSH-5.7* [**2181-2-23**] 12:30AM BLOOD %HbA1c-6.7* [**2181-2-28**] 07:00AM BLOOD VitB12-244 [**2181-2-28**] 07:00AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.8 [**2181-2-25**] 06:08AM BLOOD Albumin-3.5 Calcium-8.8 Phos-2.3* Mg-1.5* [**2181-2-22**] 09:15PM BLOOD cTropnT-0.03* [**2181-2-23**] 11:12PM BLOOD CK-MB-6 cTropnT-0.11* [**2181-2-24**] 05:45AM BLOOD CK-MB-5 cTropnT-0.11* [**2181-2-23**] 11:12PM BLOOD CK(CPK)-142* [**2181-2-24**] 05:45AM BLOOD ALT-93* AST-387* LD(LDH)-527* CK(CPK)-164* AlkPhos-159* TotBili-1.0 [**2181-2-25**] 06:08AM BLOOD ALT-117* AST-149* LD(LDH)-340* AlkPhos-189* TotBili-0.6 [**2181-3-2**] 07:00AM BLOOD PT-12.7 PTT-20.5* INR(PT)-1.0 [**2181-3-2**] 07:00AM BLOOD WBC-7.2 RBC-3.16* Hgb-9.5* Hct-28.8* MCV-91 MCH-30.1 MCHC-33.0 RDW-14.2 Plt Ct-366 Micro [**2181-2-24**] URINE HAFNIA ALVEI. 10,000-100,000 ORGANISMS/ML.. ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ HAFNIA ALVEI | ESCHERICHIA COLI | | AMPICILLIN------------ 8 R =>32 R AMPICILLIN/SULBACTAM-- =>32 R 16 I CEFAZOLIN------------- =>64 R <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 4 S 16 I CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S Blood cx no growth [**2-23**], [**2-24**] x 3 CT head [**2-22**] IMPRESSION: 1. No acute intracranial pathology. Please note MRI is more sensitive for evaluation of acute ischemia. 2. Extensive sequelae of chronic small vessel disease as well as chronic infarcts involving the occipital and parietal lobes bilaterally. Echo [**2-23**] There is mild regional left ventricular systolic dysfunction with anterior wall hypokinesis. The remaining segments contract normally (LVEF = 40%). Right ventricular chamber size and free wall motion are normal. There is no pericardial effusion. IMPRESSION: Limited study. Mild regional left ventricular systolic dysfunction. No pericardial effusion. UE US IMPRESSION: No evidence of DVT. CTA IMPRESSION: 1. No evidence of pulmonary embolus. 2. Findings consistent with pulmonary hypertension. 3. Bibasilar atelectasis, small pleural effusions, bilateral scattered tree-in-[**Male First Name (un) 239**] appearance indicative of an infectious or inflammatory process. 4. Lipoma below the right scapula. P MIBI [**2181-2-28**] IMPRESSION: 1. Severe fixed perfusion defect in the proximal and mid antero-septal and infero-septal wall, and moderate fixed defects in the inferior wall. 2. Septal akinesis and inferior wall hypokinesis. 3. Depressed left ventricular ejection fraction. [**2181-2-28**] Foot XR: IMPRESSION: Oblique non-displaced fracture of the fifth metatarsal and likely transverse non-displaced fracture along the base of the fifth metatarsal. [**2181-2-25**] CXR FINDINGS: No relevant changes compared to the previous radiograph. Moderate cardiomegaly, and no relevant overhydration. Minimal dorsal effusions could be present. Unchanged position of pacemaker. [**2181-2-22**] AP PORTABLE CHEST: Endotracheal and nasogastric tubes are in good position. A right internal jugular temporary pacemaker lead terminates in the right ventricle. No pneumothorax. There are low inspiratory volumes. Apparent widening of the mediastinum is accounted for by supine positioning given this is within normal range on subsequent upright radiographs which are available for review at the time of dictation. Brief Hospital Course: 61 year old female with history of seizures, hypothyroidism, CAD, admitted with third degree heart block. # Third degree heart block: Heart block likely secondary to progression of prior disease vs ischemia related. Pt had permanent pacemaker placed on arrival. The patient was ruled out with 3 sets flat biomarkers. She was initially planned for cardiac cath but refused. She had stress MIBI with only fixed defects. No further arrhythmias or episodes of heart block. She will follow up with Dr. [**Last Name (STitle) **] in device clinic. # Fever: Patient spiked fever [**2100-2-22**]. Culures positive only for urine culture with e-coli and HAFNIA ALVEI both sensitive to cipro. ID was consulted regarding management and she will complete 7 day course of ciprofloxacin. She also was empirically started on vanco due to recent pacemaker placement but this was discontinued as blood cultures were all negative and she remained afebrile. CXR without infiltrate. # Hypoxia: Patient was hypoxic during hospital course so CTA was obtained to eval for PE. CTA negative for PE. her hypoxia resolved and she was satting mid 90s on room air. # Pump: Euvolemic on exam. Echo with mild systolic dysfunction. Continued aspirin, statin, ACE-I, metoprolol. # CAD: No current chest pain, although has h/o MI and CABG. PMIBI as above with fixed defects, no reversible perfusion defect that would suggest benefit from revascularization. Continued ASA, statin, ACE-I and Bblocker as above. # Diabetes mellitus: On oral agents at home with insulin. Admission A1c 6.6. Glucose more elevated after recent dose of steroids. Better last 24 hours. Insulin increased to home dose of 40 u in am. Continued lisinopril. # Seizure disorder: Continued dilantin. No seizures in house. # Metatarsal fx: Bivalve cast placed and will follow up with podiatry. Pt now unable to ambulate independently so will need rehab. # Psychosis: Patient became acutely confused and agitated after receiving prednisone before imaging due to contrast sensitivity. This normalized over the next couple of days. Medications on Admission: Sertraline 100mg daily Dilantin 100mg daily 3 capsules three times/day Coumadin 5mg daily 1-1.5 tablets daily Simvastatin 80mg daily ASA 81mg daily Avandia 4mg daily Levothyroxine 100mcg daily Isosorbide mononitrate 30mg daily Metoprolol 50mg 1 tablet in AM, [**12-29**] tablet qPM Folic acid 1mg Plavix 75mg daily Metformin 500mg [**Hospital1 **] Glimepiride 2mg daily Discharge Medications: 1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 2. Metformin 500 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO twice a day: Start taking on [**2181-3-2**]. 3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day. 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Please check INR on Monday [**2181-3-5**]. 14. Outpatient Lab Work Please check INR on [**2181-3-5**] and call results to Dr.[**Last Name (STitle) 36361**] at [**Telephone/Fax (1) 7164**] 15. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*12 Tablet(s)* Refills:*0* 16. Dilantin Extended 100 mg Capsule Sig: Three (3) Capsule PO once a day. 17. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital **] Health Center Discharge Diagnosis: Complete heart block Urinary Tract Infection Acute on Chronic Systolic Congestive Heart Failure 40% Diabetes Mellitus Type 2 Left 5th Metatarsal Fracture Discharge Condition: stable. Discharge Instructions: You were admitted with complete heart block and required a pacemaker to help keep your heart beating normally. An appointment in the device clinic here at [**Hospital1 18**] was made for next week. Your pacer will be checked and the dressing removed. do not take a shower or bath until after that appt, the dressing needs to stay dry. No lifting more than 5 pounds or lifting your left arm over your head for 6 weeks. You had a fever and a urinary tract infection that was treated with ciprofloxacin. A stress test showed some parts of your heart that were not moving well. Medication changes: 1. Stop taking your Isosorbide Mononitrate (Imdur) 2. Start taking Lisinopril 5mg daily 3. Resume your metformin on Friday [**2181-3-2**]. 4. Take Ciprofloxacin for a total of 7 days, last day on Sunday [**3-4**]. This is to treat a urinary tract infection. 5. Tramadol: take for pain with walking in your left foot. Do not take if this medicine makes you sleepy. . Please call Dr. [**Last Name (STitle) 36361**] if you have any further chest pain, trouble breathing, dizziness or fainting, burning or pain with urination, fevers or increasing confusion. Followup Instructions: [**Hospital **] clinic: [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**]. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2181-3-5**] 11:00 Primary Care: Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 7164**] Date/Time: Office will call you with an appt. . Cardiology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2181-3-30**] 1:20 . Podiatry: Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] Phone: [**Telephone/Fax (1) 25274**] [**3-30**] at 8:20am [**Hospital Ward Name **] [**Location (un) 470**] Completed by:[**2181-3-2**]

[ "799.02", "E928.9", "414.00", "041.4", "426.0", "V45.81", "599.0", "244.9", "428.0", "428.23", "250.00", "401.9", "298.9", "345.90", "825.25", "E947.8" ]

icd9cm

[ [ [] ] ]

[ "37.72", "96.71", "37.83" ]

icd9pcs

[ [ [] ] ]

11352, 11408

7321, 9395

356, 378

11605, 11615

2852, 7298

12813, 13488

2295, 2316

9816, 11329

11429, 11584

9421, 9793

11639, 12213

2331, 2833

12233, 12790

294, 318

406, 2131

2153, 2231

2247, 2279

64,538

127,392

42842

Discharge summary

report

Admission Date: [**2105-2-19**] Discharge Date: [**2105-3-12**] Date of Birth: [**2049-4-29**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 618**] Chief Complaint: Found down in bathroom Major Surgical or Invasive Procedure: [**2105-2-19**]: Left hemicraniectomy & EVD placement [**2105-3-4**]: Tracheostomy/gastrostomy History of Present Illness: (patient intubated and no witness to provide information) 50 yo M with hx of HTN, polysubstance abuse (cocaine, heroin, alcohol), hepC presented to [**Hospital 487**] Hospital with headache and ?fall hitting his head. GCS on arrival was 11 and patient found to have Right sided hemiplegia. NCHCT done at that time revealed large L basal ganglia bleed with minimal midline shift. Pt found to deteriorate from there with subsequent intubation on propofol. Patient was given mannitol 70g and started on nitroprusside gtt for BP > 180. Past Medical History: HTN HepC Substance Abuse/ IVDA Social History: Polysubstance abuse, prior cocaine/heroin alcohol, Family History: non-contributory Physical Exam: ADMISSION: O: T: BP: 155/ 86 HR: 60 R 12 O2Sats 98% Gen: intubated sedated Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2-->1 on R and 3-->2 on left. Visual fields not assessed V, VI: intact doll's eyes VII: IX, X: Palatal elevation symmetrical ---------- Pertinent Results: [**2105-2-19**] 07:40AM WBC-6.2 RBC-4.36* HGB-11.5* HCT-35.6* MCV-82 MCH-26.5* MCHC-32.5 RDW-15.5 [**2105-2-19**] 07:40AM NEUTS-67.0 LYMPHS-26.8 MONOS-4.8 EOS-1.0 BASOS-0.4 [**2105-2-19**] 07:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2105-2-19**] 07:40AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2105-2-19**] 07:40AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG [**2105-2-19**] 07:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2105-2-19**] 07:40AM GLUCOSE-113* UREA N-36* CREAT-2.5* SODIUM-136 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15 [**2105-2-19**] 08:52AM GLUCOSE-102 LACTATE-1.9 NA+-128* K+-4.0 CL--100 [**2105-2-19**] 08:52AM HGB-10.1* calcHCT-30 [**2105-2-19**] NCHCT IMPRESSION: Increasing size of a large left basal ganglia intraparenchymal hematoma, now measuring 4.3 x 2.7 cm. Increasing mass effect with progressive subfalcine herniation measuring 6mm well as well as concern for impending downward transtentorial herniation. Increasing intraventricular hemorrhage with dilatation of the temporal [**Doctor Last Name 534**] of the right lateral ventricle, new from prior and concerning for developing obstructive hydrocephalus. [**2106-2-21**] CT C-Spine IMPRESSION: No acute cervical spine fracture or malalignment. A large expansile cystic lesion in the left mandible associated with an unerupted tooth, likely represents a dentigerous cyst. [**2105-2-21**] EEG IMPRESSION: This is an abnormal EEG because of continuous left hemispheric slowing with sharp features in the left frontocentral region. These findings are suggestive of a focal structural lesion in the left hemisphere. There is diffuse background slowing, indicative of a mild to moderate diffuse encephalopathy, which is etiologically non-specific. There were no clear epileptiform discharges. There were no electrographic seizures. [**2105-2-23**] Portable NCHCT IMPRESSION: Slight interval decrease in size of left parenchymal hemorrhage with persistent but slightly improved mass effect. [**2105-2-27**] Renal US: No evidence of renal artery stenosis. No evidence of hydronephrosis, renal stones, or renal masses. [**2105-3-10**] NCHCT: Left basal ganglia intraparenchymal hemorrhage has decreased in density. Surrounding white matter edema persists. Mild rightward shift of midline structures and mass effect on the left lateral ventricle are not appreciably changed since prior. No new hemorrhage. Detailed assessment of parenchymal changes can be better performed with MRI if necessary and if not CI. Status post left hemicraniectomy with expected evolution of adjacent soft tissue hematoma and fluid collection. EKG [**2105-3-6**]: Sinus bradycardia with sinus arrhythmia. Short P-R interval without other signs of pre-excitation. Left ventricular hypertrophy by voltage criteria. Compared to the previous tracing of [**2105-3-4**] the heart rate is slower. Peaked P waves are no longer seen. Intervals Axes Rate PR QRS QT/QTc P QRS T 49 106 92 [**Telephone/Fax (2) 92520**] 35 WBC Count 8.4 4.0 - 11.0 K/uL Lymphocytes, Percent 24 18 - 42 % Absolute Lymphocyte Count [**2108**] #/uL CD3 Cells, Percent 78 % Absolute CD3 Count 1[**Telephone/Fax (1) 92521**] #/uL CD4 Cells, Percent 25 % Absolute CD4 Count [**Telephone/Fax (1) 92522**] #/uL CD8 Cells, Percent 52 % Absolute CD8 Count 1043* 193 - 685 #/uL CD4/CD8 Ratio 0.5* 0.84 - 3.0 Ratio [**2105-2-21**] 8:49 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2105-2-25**]** GRAM STAIN (Final [**2105-2-21**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. RESPIRATORY CULTURE (Final [**2105-2-25**]): RARE GROWTH Commensal Respiratory Flora. STREPTOCOCCUS PNEUMONIAE. HEAVY GROWTH. Penicillin Sensitivity testing performed by Etest. STAPH AUREUS COAG +. RARE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE | STAPH AUREUS COAG + | | CLINDAMYCIN----------- <=0.25 S ERYTHROMYCIN---------- =>1 R =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- <=0.5 S 0.25 S OXACILLIN------------- =>4 R PENICILLIN G---------- 1 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S <=1 S TRIMETHOPRIM/SULFA---- 4 R <=0.5 S VANCOMYCIN------------ <=1 S <=0.5 S [**2105-2-22**] 10:10 am Mini-BAL **FINAL REPORT [**2105-2-25**]** GRAM STAIN (Final [**2105-2-22**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. RESPIRATORY CULTURE (Final [**2105-2-25**]): ~1000/ML Commensal Respiratory Flora. STREPTOCOCCUS PNEUMONIAE. >100,000 ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # 341-9661E ON [**2105-2-21**]. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested in cases of treatment failure in life-threatening infections.. STAPH AUREUS COAG +. ~8OOO/ML. SENSITIVITIES PERFORMED ON CULTURE # 341-9661E 0N [**2105-2-21**]. [**2105-3-6**] 3:35 pm BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE. GRAM STAIN (Final [**2105-3-6**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. RESPIRATORY CULTURE (Final [**2105-3-10**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # 342-8513W, [**2105-3-6**]. STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Brief Hospital Course: Brief History: 55 yo M h/o HTN, HIV, Hep C, substance abuse p/w depressed LOC and found to have a large L basal ganglia hemorrhage with IVH. He was initially treated with mannitol and an emergent ventriculostomy briefly, then he was taken to the OR for emegent hemicraniectomy. Post-operatively, he was managed in the Neuro ICU with his primary issues being hypertension, respiratory difficulty, infection, and persistent depressed LOC. . [] IPH/IVH - His L basal ganglia IPH and IVH were thought to be secondary to hypertension from cocaine abuse. He did reportedly fall prior to admission, but the deep location of the bleed makes traumatic a less likely etiology. His repeat NCHCTs did not show any significant expansion of the hemorrhage or resultant hydrocephalus. His prior deficits from the hemorrhage were depressed LOC, inattention, L gaze preference, and R hemiplegia. . [] Hypertension - In order to manage his hemorrhage, the patient was placed on several oral antihypertensives but he had poor response to most of them except clonidine. His NG clonidine however resulted in periodic drops in his BP below the desired range (SBP 100-160), so he was switched to a clonidine patch. He intermittently required a nicardipine infusion for further control. He was eventually started on Lisinopril 40 and HCTZ 25 (he did not respond well to hydralizine NG or amlodipine NG for which he was on high doses). His most recent BP regimen is listed below in his discharge medications. PLEASE TITRATE AS NECESSARY. . [] Ventilator-associated pneumonia, Tracheostomy, Stridor - He was intubated perioperatively for respiratory support but twice [**Last Name (un) 92523**] extubation with excessive stridor and respiratory distress. The etiology of the stridor is unknown. He eventually was transitioned to a tracheostomy and his respiratory requirements were downgraded to supplemental O2 by trach mask only. ??????He twice required broad-spectrum IV antibiotic treatment with Vancomycin and Piperacillin-Tazobactam for Streptococcus pneumonia/H. influenzae and coagulase-positive Staphylococcus pneumonia. PLEASE ENSURE THAT HE COMPLETES HIS COURSE SUCH THAT LAST DOSE RECEIVED ON [**2105-3-13**]. . [] Gastrostomy, Pneumoperitoneum - He underwent gastrostomy placement but the next day had abdominal discomfort with a finding of free air under his diaphragm. There was concern for bowel injury so an exploratory laparotomy was performed. There fortunately was no significant pathology found on the open operation. He subseuqently tolerated tube feeds and medications via GT. HE HAS BEEN TOLERATING REPLETE TUBE FEEDS WITHOUT DIFFICULTY ON DISCHARGE. . [] HIV - It was confirmed with his PCP/outpatient ID physician that he does have HIV. However, the recommendation at this time from ID (who discussed this case with his outpatient ID physician) was that HAART therapy was not indicated at this time. . [] Goals of Care and Guardianship - His Code Status was presumed Full. His daughter [**Name (NI) 1022**] [**Name (NI) 732**] ([**Telephone/Fax (1) 92524**]) was contact[**Name (NI) **] and updated, but she did not desire to be his guardian as he has not been a part of her life. The patient's sister is his legal guardian. PENDING STUDIES: None TRANSITIONAL CARE ISSUES: - Please make sure to have the patient follow up with the neurosurgery department at [**Hospital1 18**]. Medications on Admission: enalapril (dose unknown) Discharge Medications: 1. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO DAILY (Daily). 2. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 24H (Every 24 Hours): Last dose [**2105-3-13**]. 3. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours): Last dose on [**3-13**], [**2104**] . 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 5. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. amlodipine 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for oral thrush. 12. therapeutic multivitamin Liquid Sig: One (1) Tablet PO DAILY (Daily). 13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 15. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 16. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 17. oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed for pain. 18. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Transdermal once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Left Cerebral Intraparenchymal Hemorrhage - History of hypertension - History of cocaine abuse/dependence - History of HIV infection - History of Hepatitis C Discharge Condition: Mental Status: Not examinable Level of Consciousness: Intermittently follows simple appendicular commands with his left side. Activity Status: Bedbound, dependent for all ADLs Examination on discharge: Thin male, normal cardiopulmonary examination with eyes open. Does not blink to threat from right visual fields. Reactive and equal pupils. Skull absent on left. Tracheostomized and gastrostomized. Spontaneous purposeful movements of the left arm and responds to commands. Discharge Instructions: Mr. [**Known lastname 732**] was admitted to the neuro-intensive care unit and neurology wards of the [**Hospital1 69**] for the evaluation of a fall and head injury that he sustained following the use of cocaine. He was found to have a large intraparenchymal hemorrhage in his left basal ganglia which ultimately required the placement of an endoventricular drain and a hemicraniectomy. His ICU course was complicated by the development of difficult weaning from the ventilator (requiring a tracheostomy), percutaneous gastrostomy to deliver nutrition and medications as well as two rounds of antibiotics for ventilator associated pneumonia. - Please ensure that Mr. [**Known lastname 732**] is able to see us in follow up at the dates/times listed below. - Please bring Mr. [**Known lastname 732**] to the ED should you notice a change in his neurological examination, persistent fevers, low blood pressures, or any other unexplained signs or complaints. - Do not hesitate to contact us should any concerns or questions arise. - In eight weeks (on or around [**5-13**]) please schedule a follow up appointment for Mr. [**Known lastname 732**] to see [**First Name8 (NamePattern2) **] [**Doctor Last Name **] MDPhD from Stroke Neurology at [**Hospital1 18**]. This can be done by calling [**Telephone/Fax (1) 92525**]. Followup Instructions: ** PLEASE FOLLOW UP with Dr. [**Last Name (STitle) **] from the Department of Neurosurgery at [**Hospital1 18**] on [**2105-4-28**] - CT Scan of head 9:30AM ([**Hospital Ward Name 23**] Building [**Location (un) 861**]) - Meeting with Dr. [**Last Name (STitle) **] at 10:30AM ([**Hospital Unit Name **] [**Location (un) **]) [**Hospital1 69**] ** Please have your rehabilitation staff set up a follow up appointment for Mr. [**Known lastname 732**] to see [**First Name8 (NamePattern2) **] [**Doctor Last Name **] MDPhD from Stroke Neurology at [**Hospital1 18**]. This can be done by calling [**Telephone/Fax (1) 3767**]. - If you would like to follow up with your assigned PCP, [**Name10 (NameIs) **] call Dr. [**Last Name (STitle) 3100**] at [**Telephone/Fax (3) 92526**] to set up a follow up appointment. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2105-3-12**]

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Discharge summary

report

Admission Date: [**2168-9-12**] Discharge Date: [**2168-9-29**] Date of Birth: [**2100-11-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1148**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Temporary HD catheter line placement Tunnelled HD catheter line placement Hemodialysis History of Present Illness: Mr. [**Known lastname **] is a 67 year old gentleman with a past medical history notable for hypertension, ESRD on dialysis, CHF, atrial fibrillation on coumadin, recent MRSA bacteremia on vancomycin, CAD s/p CABG and LAD stenting, and past CVA who presented to the [**Hospital1 18**] on [**2168-9-12**] from his renal dialysis facility because of change in mental status. Mr. [**Known lastname **] has been admitted approximately once per month since [**1-/2168**] for [**Year (4 digits) **], CHF, sepsis, and line infections. His most recent hospital admission to the [**Hospital1 18**] was from [**2168-9-6**] to [**2168-9-8**] for CHF in the setting of poorly controlled hypertension. The patient was discharged on [**2168-9-8**] to his nursing home facility where, per report from [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 32726**] at the home, the patient returned to his baseline state of health. Mr. [**Known lastname **] did well until the evening prior to admission, when the staff found him to be shouting more than normal. At baseline, the patient shouts infrequently in his native Creole language, but the staff noted that he was shouting more frequently last night; they also note that he seemed more confused than normal. In addition, Mr. [**Known lastname **] did not sleep much on the evening prior to admission. He denied any pain symptoms when questioned by the staff. On the morning of admission, the patient was taken to dialysis at [**Location (un) **] Dialysis where he screamed continuously and held his groin area (the site of a femoral line). Due to concern about the patient's change in mental status and possible pain at the femoral line site, he did not undergo his dialysis treatment and was taken to the [**Hospital1 18**] emergency department for evaluation. . In the ED, the patient's vital signs were: T 95.5, HR 90, BP 158/98, RR 16, O2Sat 99/RA. The patient underwent a CT of the head and chest x-ray. The CXR showed chronic LLL consolidation, RLL consolidation that had been noted on the previous admission and has not yet resolved, as well as small bilateral pleural effusions. The CT of the head showed no acute intracranial pathology. The patient was given 1 gram of ceftazidime, 1 gram of vancomycin, epoetin, 5 mcg of paricalcitol, 62.5 mg of ferric gluconate. Mr. [**Known lastname **] was found to be hyperkalemic and to have an INR of 1.3. Given the persistence of the RLL consolidation, the patient was admitted to the [**Hospital1 139**] general medical service for work-up of his mental status change and treatment of pneumonia. . Review of Systems: Per report from [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 32726**] at the Nursing Home, the patient has not had any recent cough, fever, nausea, vomiting, or diarrhea. She says that his blood pressure, heart rate, and oxygen saturation have all been normal over the last several days. . MICU Txfer: Reason for transfer: Bradyacardia and AMS . During his hospitalization, his mental status improved on antibiotics. He was initially treated with Levo/Flagyl, changed to Cefepime and Tobramycin and Flagyl when his cultures grew out Enterobacteriae; subsequently this was changed to Meropenem as it was felt that he may have an ESBL organism. . On [**2168-9-18**], patient was alert and conversing with team. On [**2168-9-19**], patient was found to be unresponsive/lethargic and bradycardic to the 40s. He was in Afib and did not have any changes on his EKG. His pressure was in the 90s at this heart rate. His finger sticks were normal. He was afebrile. His last nodal agents was 9pm on [**2168-9-18**] (he is on metoprolol 25mg [**Hospital1 **]) and his last sedatives were olanzapine at 10am on [**2168-9-18**] and trazodone at 9pm on [**2168-9-18**]. On the floor, he was given atropine x 2 and his heart rate increased to 60s after 1st atropine and his BP increased to the 110s. However, his mentation did not improve. CT of head showed ?stroke, but Neuro consulted and felt not c/w pt presentation. . On Transfer to floor from MICU: Summary of MICU course--The episode of AMS that brought him to the MICU was accompanied by bradycardia and hypotension. He was started on dopamine; as his HR and BP picked up so did his mentation. Neuro was consulted about a finding of possible stroke on CT which they felt was not clinically consistent with his physical exam. . His vitals signs were stable and mental status improved and he was called out to floor. Past Medical History: 1) Left occipital lobe CVA [**2-22**] p/w change in MS [**First Name (Titles) **] [**Last Name (Titles) **], chronic CVAs now on coumadin for likely embolic nature 2) Paroxysmal Afib, rate controlled with tachy/brady, occas 2 sec pauses, best managed with metoprolol 75 tid per cards 3) Chronic eosinophilia unknown etiology, strongyloides sent in [**2-22**] for w/u as well as SPEP/UPEP 4) h/o GI Bleed in [**2167-7-20**] while on asa, plavix, IIb/IIIa post-cath--no EGD or C-scope performed in f/u yet 5) ESRD secondary to HTN, dialysis MWF- followed by Dr. [**First Name (STitle) 805**] 6) h/o bacteremia w/ MRSA (most recently diagnosed on admission from [**8-10**] to [**2168-8-17**]) on Vancomycin until [**2168-9-23**]. 7) h/o pulling out groin lines 8) HTN, controlled 9) CAD s/p NSTEMIS, 2 LAD stents, CABG [**2164**]: last ECHO [**2167-8-27**], EF >55% 10) Hyperlipidemia 11) Diverticulosis 12) Severe Hyperparathyroidism, presumed adenoma, not on vitamin D for this concern 13) chronic anemia 14) chronic transudative pleural effusions 15) h/o neurocysticercosis calcified Social History: Lives in nursing home. No tobacco, etoh, illicit drug use. Transfer paper work from nursing home lists [**First Name4 (NamePattern1) **] [**Known lastname **] as the relative or guardian ([**Telephone/Fax (1) 32722**]. Family History: Mother with hypertension. No history of no strokes, seizures, or heart disease Physical Exam: VS: T: 98.4 (rectal) HR: 54 BP: 124/65 RR: 18 Sat: 100/RA FS: 133 Gen: Patient is laying in bed comfortable. Wasting apparent in temporal region and upper and lower extremities. He moans every few minutes. Patient only understands a few words of English so very difficult to communicate with him. [**Name2 (NI) **] in the presence of a translator, the patient did not provide meaningful answers to questions other than his name. HEENT: Oropharyngeal mucosa without exudates. Pupils minimally reactive bilaterally. Neck supple without LAD. No JVD. CV: Irregularly irregular. Normal S1, S2. S3 appreciated. 1+ carotid, radial pulses. 2+ brachial pulse. Unable to palpate DP, posterior tibial, and popliteal pulses. Pul: Difficult exam because of poor cooperation. Appreciated decreased breath sounds at bases with crackles bilaterally. Abd: Soft, non-tender, positive bowel sounds, no HSM. Ext: Trace edema in LE. Atrophy in upper and lower extremities. Pertinent Results: Admission Labs: [**2168-9-12**] 11:08AM GLUCOSE-137* UREA N-31* CREAT-6.2*# SODIUM-134 POTASSIUM-6.5* CHLORIDE-93* TOTAL CO2-28 ANION GAP-20 K+-6.0* . WBC-5.1 RBC-4.69 HGB-11.9* HCT-36.6* MCV-78* MCH-25.4* MCHC-32.5 RDW-21.6* NEUTS-48.3* LYMPHS-37.5 MONOS-5.4 EOS-8.4* BASOS-0.4 . PT-14.2* PTT-30.7 INR(PT)-1.3* calTIBC-195* VitB12-1530* Ferritn-637* TRF-150* TSH-2.4 . [**2168-9-12**] 12:30 pm BLOOD CULTURE; ENTEROBACTER CLOACAE. (SENSITIVITIES: CEFEPIME S; CEFTAZIDIME R; CEFTRIAXONE R; CIPROFLOXACIN R; GENTAMICIN S; IMIPENEM S; LEVOFLOXACIN I; MEROPENEM S; PIPERACILLIN R; TOBRAMYCIN S) . AEROBIC BOTTLE (Final [**2168-9-18**]): ENTEROBACTER CLOACAE. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 32727**] [**2168-9-12**]. . Final bld cultures on [**10-30**] and [**9-18**] are negative. . Brief Hospital Course: Mr. [**Known lastname **] is a 67 yo w PMHx of HTN, ESRD on dialysis, CHF, atrial fibrillation on coumadin, recently completedcourse of vancomycin for MRSA bacteremia, CAD s/p CABG and LAD stenting, and past CVA who was admitted and treated for mental status changes secondary to Enterobacter bacteremia who's hospitalization was complicated by MICU stay for acute change in mental status and bradycardia which had resolved by discharge. . # Mental status change: Felt to have resolved per family. Patient was initially admitted with change in MS on [**9-12**]. He had an acute decompensation on [**9-19**] for which he was transfered to the MICU. The episode of AMS that brought him to the MICU was accompanied by bradycardia and hypotension. He was started on dopamine; as his HR and BP picked up so did his mentation. Neuro was consulted about a finding of possible stroke on CT which they felt was not clinically consistent with his physical exam. We discontinued his trazadone. Baseline he is oriented to self and to hospital but not which one or year. . # Bacteremia-MRSA and Enterobacter: Positive cultures on [**9-12**] and [**9-15**] with ENTEROBACTER CLOACAE sensitive to meropenum. Initially was treated with Levo/Flagyl, then Cefepime and Tobramycin, changed to Meropenum on [**9-16**]. He had a new left tunneled hemodialysis line put in on [**2171-9-24**]. He completed a 14day course of meropenum on [**2168-9-29**]. Vanco course is complete as on [**9-23**] per last d/c summary. . # CXR with bilateral consolidations/pleural effusions: CXR shows worsening pleural effusions and he has a persistant oxygen requirement. Likely secondary to chronic CHF. Patient will go to NH with 1-2L oxygen. . # Diarrhea: Now resolved. Started while in MICU, c.diff negative x1. . # End Stage Renal Disease: This patient has ESRD and is on dialysis (MWF schedule). Continue with nephrocaps and sevelamer. He had IR guided permanent HD catheter placement [**9-23**]. His INR was reversed with 10 vit K for this procedure. . # Bradycardia: Resolved. Unclear etiology: possibly med effect-received metoprolol on night before MICU admission, ruled out cardiac event with negative cardiac enzymes. Initially some response to atropine, but not sustained. Improved with dopamine and was slowly weaned off. He was monitored on telemetry. His metoprolol was discontinued. . # Hyperparathyroidism: This patient has baseline secondary hyperparathyroidism. Continue with cinacalcet. . # Hypertension: Patient has baseline hypertension normally treated with multiple drugs. Patient had episode of hypotension prompting unit transfer. Which resolved and antihypertensives were slowly added back. At discharge patient was on admission doses of clonidine, amlodipine and lisinopril, but his metoprolol was discontinued. . # Coronary Artery Disease: He was managed with medical management by continuing atorvastatin 80mg and asa 81mg. Metoprolol was discontinued. . # Atrial Fibrillation: Goal INR = 2.0 to 3.0. He was reversed for tunneled line placement. Patient was restarted on coumadin at home dose of 1mg QHS. He should have twice weekly coumadin checks until he stabilizes. . # Mass in R Atrium: We spoke with echo [**Location (un) 1131**] room who read it as a ra "lump". He felt that it was not a myxoma, thrombus, or cancer, but rather more likely hypertrophy. He said that it would not likely increase risk of endocarditis over normal anatomy. He recommended MRI of the heart to better characterize if we felt it should be persued, and that TEE would have limited utility. . # Anemia: Patient with baseline anemia, but slowly worsening over hospital course. Laboratory studies consistent with anemia of chronic disease. Retic count of 2.9 (RI = 2.9*(27.2/45)/2.0 = 0.88 or less than 2% and thus hypoproliferation). Patient received EPO and transfusions. Discontinued iron supplementation. . Medications on Admission: Docusate Sodium 100 mg Capsule One Capsule PO BID (2 times a day) B Complex-Vitamin C-Folic Acid 1 mg Capsule One Cap PO daily Sevelamer 800 mg Tablet One Tablet PO TID (3 times a day). Lactulose 10 g/15 mL Syrup Thirty ML PO DAILY PRN constipation. Trazodone 25 mg PO HS (at bedtime) PRN insomnia Cinacalcet 30 mg Tablet One Tablet PO Daily Aspirin 81 mg Tablet, Chewable One Tablet PO Daily Clonidine 0.2 mg Tablet One Tablet PO TID (3 times a day) Amlodipine 5 mg Tablet One Tablet PO Daily Atorvastatin 80 mg Tablet One Tablet PO Daily Ferrous Sulfate 325 (65) mg Tablet One Tablet PO Daily Pantoprazole 40 mg Tablet, Delayed Release (E.C.) One Tablet, Delayed Release PO Q24H (every 24 hours) Metoprolol Tartrate 25 mg Tablet One Tablet PO BID (2 times a day) Lisinopril 10 mg Tablet One Tablet PO Daily (discharge summary says 20 mg per day, med sheet says 10 mg per day) Vancomycin HCl 1000 mg IV TO BE DOSED AT HEMODIALYSIS (Through [**2168-9-23**]) Coumadin 1 mg Tablet One Tablet PO QPM (discharge summary said to take every other day, med sheet from nursing home says he is getting it every evening) Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous QHD: Please have his hemodialysis unit dose the meropenum after HD until [**2168-9-29**]. 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Please hold for SBP < 100. . 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): titrate to 1BM each day. 8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY; PRN () as needed for constipation. 9. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO three times a day: Please monitor phosphate. . 10. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: Please monitor with INRs. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Docusate Sodium 150 mg/15 mL Liquid Sig: 10ml PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Roscommon Discharge Diagnosis: Primary Bacteremia-enterobacter ESRD on HD CAD s/p CABG A fib h/o MRSA bacteremia Bradycardia Secondary Anemia Discharge Condition: Stable Discharge Instructions: Please take your medications as prescribed. We have discontinued your metoprolol secondary to your bradycardia, the trazadone secondary to change in mental status, and iron discontinued. . Please seek medical attention for chest pain, palpitations, shortness of breath, fever, chills, or if other caregivers [**Name (NI) 32728**] a change in mental status and for any other symptoms concerning to you. Followup Instructions: Please follow-up with the physician at the facility and your PCP in the next 1-2 weeks.

[ "414.00", "V45.81", "790.92", "790.7", "041.11", "511.9", "428.0", "427.89", "434.91", "V09.0", "285.9", "285.29", "585.6", "783.7", "507.0", "403.91", "288.3", "787.91", "588.81", "427.31", "349.82" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

14768, 14804

8232, 12125

338, 427

14959, 14968

7380, 7380

15419, 15510

6312, 6393

13287, 14745

14825, 14938

12151, 13264

14992, 15396

6408, 7361

3073, 4950

277, 300

455, 3054

7396, 8209

4972, 6060

6076, 6296

79,909

165,784

37891

Discharge summary

report

Admission Date: [**2127-10-12**] Discharge Date: [**2127-10-14**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2597**] Chief Complaint: Transfer from [**Hospital3 **] with ? of a contained rupture of R. common iliac artery Major Surgical or Invasive Procedure: aortic stent repair RCIA aneurysm History of Present Illness: HPI: 87 M passed out while ambulating today. Daughter reports a 5 minute LOC. He complained of right lower back pain and was taken to [**Hospital6 3105**] where he got a CT head, abdomen, and pelvis. He was found to have a large R. common iliac artery aneurysm with a question of a contained rupture. He was transferred to [**Hospital1 18**] for further care. On arrival he was hemodynamically stable. CTA of abdomen was obtained with thin cuts. This confirmed the large R. CIA aneurysm and he was emergently taken to the OR. Denies any pain. Of note, patient had a similar syncopal episode 3 weeks ago and found to be bradycardic. Atenolol was stopped. Past Medical History: PMH: AFib, CVA x 3, HTN, CAD PSH: unknown - scars suggest LIH repair and appendectomy Social History: nc Family History: nc Physical Exam: PE: 98.3 94 129/84 18 98% 4L A&O X 3, NAD L. frontal abrasion Irregularly irregular CTAB Abdomen soft, NT/ND, RLQ scar, L inguinal scar LE warm, no edema Pulses: Fem [**Doctor Last Name **] PT DP R. 2+ 2+ 2+ 2+ L. 2+ 2+ 2+ nonpalp Pertinent Results: [**2127-10-14**] 07:20AM BLOOD WBC-8.3 RBC-3.27* Hgb-9.9* Hct-30.5* MCV-93 MCH-30.1 MCHC-32.3 RDW-16.0* Plt Ct-166 [**2127-10-14**] 07:20AM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-138 K-4.0 Cl-103 HCO3-25 AnGap-14 Brief Hospital Course: [**Known lastname **],[**Known firstname **] was admitted on [**10-12**] with CIA aneurysm. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preparations were made. It was decided that he would undergo: 1. Ultrasound-guided puncture of bilateral common femoral arteries. 2. Bilateral introduction of catheter into aorta. 3. Abdominal aortogram. 4. Endovascular stent graft repair of bilateral common iliac aneurysms with [**Doctor Last Name 4726**] 26 x 14-1/2 by 18 with a right iliac limb extension of 14 [**1-3**] x 10 left iliac limb of 18-1/2 x 13-1/2. 5. Perclose closure of bilateral common femoral arteriotomy. He was prepped, and brought down to the Endo suite room for surgery. Intra-operatively, she was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, transferred to the PACU for further stabilization and monitoring. He was then transferred to the VICU for further recovery. While in the VICU he received monitored care. When stable he was delined. His diet was advanced. When he was stabilized from the acute setting of post operative care, he was transferred to floor status On the floor, he remained hemodynamically stable with his pain controlled. He continues to make steady progress without any incidents. He was discharged home in stable condition. He did receive preoperative hydration. On DC his creatinine is stable. Medications on Admission: coumadin 5', ASA 81', aricept 5', atenolol 50' (? on hold) Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: have your INR followed in th eusual manner. 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day: resume when PCP [**Last Name (NamePattern4) **]. 6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: R. CIA aneurysm Discharge Condition: Stable Discharge Instructions: Division of [**Location (un) **] and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your [**Location (un) **] Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**2-4**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**4-7**] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call [**Date Range 1106**] office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2127-11-17**] 10:30 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2127-11-17**] 11:10 YOUR CARDIOLOGIST NEED TO SEE YOU ASAP. CALL HIS OFFICE AND SCHEDULE AN APPOINTMENT. THIS IS FOR YOUR SYNCOPY EVENTS. HE HAS ALREADY STARTED THE WORK - UP. Completed by:[**2127-10-14**]

[ "285.1", "V58.61", "427.31", "790.29", "V12.54", "401.9", "414.01", "442.2", "780.2", "443.9", "294.8" ]

icd9cm

[ [ [] ] ]

[ "00.47", "39.50", "39.90", "88.47", "88.42", "00.42", "88.48", "00.44" ]

icd9pcs

[ [ [] ] ]

3961, 4036

1745, 3305

350, 386

4096, 4105

1508, 1722

6747, 7230

1215, 1219

3414, 3938

4057, 4075

3331, 3391

4129, 6154

6180, 6724

1234, 1489

224, 312

414, 1070

1092, 1179

1195, 1199

45,928

173,022

46841

Discharge summary

report

Admission Date: [**2158-7-13**] Discharge Date: [**2158-7-21**] Date of Birth: [**2098-9-16**] Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamides) / Morphine Attending:[**First Name3 (LF) 8850**] Chief Complaint: Headache, nausea, vomiting, and malaise. Major Surgical or Invasive Procedure: Ventriculoperitoneal shunt placement. History of Present Illness: [**Known firstname 450**] [**Known lastname **] is a 59-year-old right-handed woman with history of breast cancer diagnosed [**2157-7-15**] and bilateral mastectomies, s/p radiation performed on [**2158-3-17**], presents to the emergency department on [**2158-7-13**] with complaint of 10-day headache, nausea, vomiting, and malaise. CT in the emergency department revealed multiple brain mets with vasogenic edema. Ventriculoperitoneal shunt was placed on [**2158-7-14**] for decompression and follow up CT showed mild decrease in ventricular size. She received her first of 5 scheduled whole brain radiation treatmetns today. At this time she reports her headache is right sided, well controlled at 5/10, and not associated with photphobia, weakness, dysarthria, or dizziness. She has mild discomfort at the site of her venriculopeitoneal shunt in her left lower quadrant of the abdomen. She has some assosicated nausea. She denies chest pain, shortness of breath, abd pain, vomitting, and fever. Review of systems was otherwise essentially negative. The patient 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, heartburn, 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: Stage IIIA breast (ductal carcinoma) cancer, s/p 16 treatments of chemotherapy and currently undergoing radiation therapy. GERD Cholecystectomy Anxiety Social History: She lives in [**Hospital3 **] alone with friends near by. Family History: Other than her personal history, she has no known family history of breast or ovarian cancer. She is not of Ashkenazi [**Hospital1 **] descent. Physical Exam: VITAL SIGNS: Temperature 98.0 F, blood pressure 140/90, pulse 58, respiration 18, and oxygen saturation 96% in room air. GENERAL: Awake, alert, NAD, pleasant, appropriate, cooperative. HEENT: Dressing at VP shunt site c/d/i, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in OP. NECK: Supple, no significant JVD or carotid bruits appreciated. PULMONARY: Lungs CTA bilaterally, no wheezes, ronchi or rales. CARDIOVASCULAR: RRR, normal S1 S2, no murmurs, rubs or gallops appreciated. ABDOMEN: soft, non-tender, non-distended, normoactive bowel sounds, no masses or organomegaly noted. Abdominal pad in place c/d/i. EXTREMITIES: No edema, 2+ radial, DP pulses bilaterally. LYMPHATICS: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. SKIN: No rashes or lesions noted. NEUROLOGICAL EXAMINATION: Her Karnofsky Performance Score is 90. She is awake, alert, and able to follow commands readily. Her language is fluent with good comprehension, naming, and repetition. There is no right/left confusion or finger agnosia. Calculation is intact. Her recent recall is good. Cranial Nerve Examination: Her pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full; there is endgaze nystagmus bilaterally. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. Her face is symmetric. Facial sensation is intact bilaterally. Her hearing is intact bilaterally. Her tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: She does not have a drift. Her muscle strengths are [**4-18**] at all muscle groups. Her muscle tone is normal. Her reflexes are 2- and symmetric bilaterally. Her ankle jerks are 2-. Her toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal dysmetria. Her gait is steady and she can do tandem. She does not have a Romberg, but she has a slight sway. Pertinent Results: MRSA negative [**2158-7-13**] 12:00PM GLUCOSE-90 UREA N-12 CREAT-0.7 SODIUM-135 POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-27 ANION GAP-15 [**2158-7-13**] 12:00PM estGFR-Using this [**2158-7-13**] 12:00PM CALCIUM-9.5 PHOSPHATE-3.9 MAGNESIUM-2.5 [**2158-7-13**] 12:00PM WBC-9.5 RBC-4.80 HGB-14.0 HCT-43.6# MCV-91 MCH-29.1 MCHC-32.1 RDW-13.2 [**2158-7-13**] 12:00PM NEUTS-87.1* LYMPHS-8.0* MONOS-3.9 EOS-0.7 BASOS-0.3 [**2158-7-13**] 12:00PM PLT COUNT-287 [**2158-7-13**] 12:00PM PT-11.5 PTT-22.1 INR(PT)-1.0 [**2158-7-13**] 12:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2158-7-13**] 12:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG CT Head [**2158-7-13**]: 1. Extensive ring enhancing/and nodularly enhancing lesions that with known history is most compatible with extensive metastatic disease seen both supra- and infra-tentorially as described above. Associated vasogenic edema with effacement of the cerebellopontine angles and the perimesencephalic cistern. Mild effacement of the cerebral aqueduct with associated mild ventriculomegaly, however, no associated transependymal migration of CSF is noted. Low lying cerebellar tonsils though foramen of magnum is patent. 2. Recommend MR [**First Name (Titles) 3**] [**Last Name (Titles) 9304**]. These findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at time of study at 12 p.m. on [**2158-7-13**]. CT Head [**2158-7-14**]: (s/p VP shunt) 1. Interval placement of a right frontal ventriculostomy catheter, terminating in the right frontal [**Doctor Last Name 534**]. 2. Stable to minimal decrease in size of the frontal and temporal horns. 3. Persistent vasogenic edema of the left temporal lobe and cerebellum. 4. Stable to miminal improvement of effacement of the cerebellopontine angles and perimesencephalic cistern, and effacement of the cerebral aqueduct. CT Lspine [**2158-7-20**]: 1. No definite focal lytic or sclerotic lesion identified in the lumbar spine. 2. No abnormal nodular enhancement identified in the spinal canal, to suggest leptomeningeal disease. Brief Hospital Course: [**Known firstname 450**] [**Last Name (NamePattern1) **] is a 59-year-old right-handed woman with stage IIIA breast cancer admitted with headache,nausea, vomiting, malaise, found to have new brain metastses. (1) Metastatic Breast Cancer: Patient was discovered to have new brain metastases per CT with increased cerebral edema. A ventriculopeitoneal shunt was placed on [**2158-7-14**] for decompression and follow up head CT showed mild decrease in ventricular size, after which she received her first of 5 scheduled whole brain radiation treatments. She was then transfered from Neurosurgery to OMED for further care, where she received the remaining 4 treatments without complication. She was on 4 mg dexamethasone throughout her stay. She tolerated the treatments well with mild nausea controlled with antiemetics. At no point did she have severe pain. MRI was requested for evaluation of spinal metastases; however, due to the presence of breast expanders, MRI was contraindicated. Instead she received a lumbosacral CT which showed no evidence of leptomeningeal disease. (2) Anxiety: Patient has a history of anxiety, for which she was continued on her home dose of Ativan. (3) Prophylaxis: No subcutaneous heparin given her brain metastses, and ambulation was encouraged. Medications on Admission: LORAZEPAM [ATIVAN] 0.5 mg Tablet [**12-16**] Tablet(s) by mouth every 4-6 hours as needed for nausea or sleep SCALP PROSTHESIS for chemotherapy-induced alopecia VIT B12 (Prescribed by Other Provider) Dosage uncertain VIT E (Prescribed by Other Provider) Dosage uncertain CALCIUM 600 + D (Prescribed by Other Provider) 600 mg (1,500 mg)-200 unit Tablet 2 po once a day MULTIVITAMIN (OTC) Tablet 1 Tablet(s) by mouth once a day Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for HA. Disp:*30 Tablet(s)* Refills:*0* 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Zofran 4 mg Tablet Sig: One (1) Tablet PO every 4-6 hours. Disp:*60 Tablet(s)* Refills:*2* 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for nausea,sleep. Disp:*20 Tablet(s)* Refills:*0* 5. Reglan 5 mg Tablet Sig: Two (2) Tablet PO three times a day: Please take half an hour before meals. Disp:*180 Tablet(s)* Refills:*2* 6. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO three times a day: Please do not stop taking this medication. Your oncologist will instruct you on tapering this medication appropriately. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Metastatic breast cancer to the brain. Discharge Condition: Stable, afebrile. Discharge Instructions: You were admitted to [**Hospital1 18**] for treatment of headache which was discovered to be caused by metastasis of your breast cancer. To reduce intracranial pressure a Ventriculoperitoneal (VP) shunt was place and five treatments of whole brain radiation therapy were given. There were no major complications with your treatment. The following medications were added to your regimen: Dexamethosone, Reglan, Ranitidine, Zofran, Percocet. Please do not drive or drink alcohol while taking narcotics of benzodiazepines. You do not require any special care for the VP shunt. Please return to the Emergency Department if you experience any new headache, difficulty with speech, weakness, sensory loss, difficulty walking, severe nausea and vomiting, chest pain, shortness of breath. Followup Instructions: Please make an appointment when Dr. [**Last Name (STitle) 724**] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19**] are available NEXT WEEK. Call [**Telephone/Fax (1) 1844**] to make your appointment. Please call Neurosurgery for a follow up appointment. You will need a CT scan of your abdomen without contrast in four weeks. This can be arranged for you when you call [**Telephone/Fax (1) 1669**]. [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 6742**] Date/Time:[**2158-7-28**] 1:30 Completed by:[**2158-7-30**]

[ "196.3", "V86.1", "787.01", "174.9", "348.5", "198.3", "784.0" ]

icd9cm

[ [ [] ] ]

[ "92.29", "02.34" ]

icd9pcs

[ [ [] ] ]

9304, 9310

6692, 7987

334, 373

9402, 9421

4490, 6669

10256, 10861

2260, 2406

8463, 9281

9331, 9381

8013, 8440

9445, 10233

2421, 4471

254, 296

401, 1994

2016, 2169

2185, 2244

7,917

136,806

30782

Discharge summary

report

Admission Date: [**2157-6-17**] Discharge Date: [**2157-10-27**] Date of Birth: [**2157-6-17**] Sex: M Service: NB HISTORY: This infant was born at 26-0/7 weeks gestation, the product of an IVF pregnancy with an EDC of [**2157-9-23**]. This infant was born to a 30-year-old G2, P1 mother with prenatal screens blood type A positive, antibody negative, RPR nonreactive, rubella immune, GBS negative. This pregnancy was complicated by cervical incompetence, cervical dilatation, and bulging membranes since [**74**] weeks gestation. Mother was transferred in from [**Hospital3 **] to [**Hospital1 18**]. She remained in [**Hospital1 18**] since [**74**] weeks gestation. She was betamethasone complete on [**2157-6-11**]. This infant was delivered due to concern for chorioamnionitis. This infant was delivered by C-section and emerged breech with Apgars of 4 and 8 and one and five minutes. He was intubated in the delivery for respiratory insufficiency. He was noted to have bruising along the back of the spine and a superficial laceration on the right side. He was taken to the NICU for further management. PHYSICAL EXAMINATION: Vital signs: Physical exam on admission showed a birth weight of 815 grams which is 25 to 50th percentile, length 35 cm which is 50% percentile. Head circumference 23 cm which is 10th percentile. General: On admission to the NICU at birth, the infant had bruising noted above the spine, left thigh, buttocks, and the soles of both feet and toes. HEENT: Normocephalic. Anterior fontanel open and flat. Eyes fused bilaterally. Neck: Supple. Lungs: Very shallow respirations with intercostal retractions and crackles heard bilaterally. CV: Regular rate and rhythm. No murmur. Femoral pulses are palpable bilaterally. Spine: Midline, no dimple. Anus: Patent. Musculoskeletal: Hips are stable. Clavicles intact. Extremities: Well perfused with brisk cap refill. Neuro: Decreased tone in the upper and lowers, but moves all extremities. DISCHARGE PHYSICAL EXAM: Discharge physical exam shows mildly sedated pink skin, warm and dry. HEENT: Anterior fontanel open and flat. Oral: ET tube secure at 10-cm mark at the lip. Normal facies with mild edema. Sclerae clear. Bilateral red reflexes. Ears: Normal. Neck: Supple. Respiratory: Breath sounds clear and equal with mild to moderate subcostal retractions on conventional ventilation with intermittent tachypnea. CV: Normal S1, S2. No murmur. Extremities: Pink and well perfused, generalized edema, pulses normal. Abdomen: Soft and rounded with active bowel sounds. NG tube in place. Patent anus, stooling normally. GU: Normal male GU with scrotal edema present and bilateral hydroceles. Testes are descended. Musculoskeletal: Normal with increased tone during agitation. Moves all extremities well. Reflexes intact. Hips intact. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. Respiratory: The infant had respiratory distress syndrome at birth and was given two doses of surfactant therapy on the newborn day. The infant was started on caffeine citrate for apnea prematurity at two days of age and was extubated to CPAP at that time. The caffeine citrate was discontinued on [**2157-8-4**]. The infant was also started on vitamin A at birth to decrease severity of chronic lung disease. The infant remained on CPAP until [**2157-7-13**], which was day of life 26, at which time the infant was reintubated for increased for work of breathing and apneic spells. The infant remained intubated and was started on Combivent inhaled therapy to help wean the ventilator on [**2157-7-29**]. Was also started on Lasix therapy for chronic lung disease on [**2157-8-1**], and was started on albuterol on [**2157-8-7**], inhaled. Due to increasing edema, Diuril and Aldactone were added to chronic lung medications on [**2157-8-26**]. The infant was given a 14-day course of dexamethasone in preparation for extubation on [**2157-9-6**]. The infant extubated to CPAP six days into that 14-day course of dexamethasone and extubated to CPAP on [**2157-9-11**]. The infant has remained on CPAP until [**2157-10-7**]. An ORL was consulted on [**2157-9-29**] due to increased work of breathing and inability to wean CPAP with intermittent episodes of apnea with bronchospasm and dusky spells, requiring bag-mask ventilation. The consult was done on [**2157-9-29**] by Dr. [**First Name8 (NamePattern2) 1151**] [**Last Name (NamePattern1) 24630**] from ORL. A flexible bronchoscopy was done at the bedside which showed abnormal vocal cord movement thought to be tethered vocal cords at that time and recommendation for full bronchoscopy to be done at [**Hospital3 1810**] was made at that time. The infant remained on CPAP through until [**2157-10-7**] due to worsening blood gases and continued work of breathing. The infant was then intubated. The blood gas prior to intubation was an arterial blood gas of pH of 7.28, CO2 100, pO2 77, bicarb 49, and base excess 15. Currently, the infant is intubated with a 4.0 ET tube orally. The ET tube is at the 10-cm marker at the lip and secured by chest x-ray. ET tube is in mid trachea. His most recent blood gas ABG on [**2157-10-27**] was 7.36/47/90/28/0. The infant is presently on SIMV settings of 27/7 rate 25 FiO2 34-37%. Because of concern about his lung disease, he was started on a course of prednisilone. He was give 2 mg/kd/day for 5 days, 1 mg/kg/day for 5 days, and then 1 mg/kg/day every other day where he is currently. 2. Cardiovascular: The infant required no pressor support in the newborn days of life. An echocardiogram was done on [**2157-7-22**] which was day of life five, which showed a very small PDA less than 1 mm in size with left-to-right flow. At the time, the infant was stable on CPAP and was not treated with Indocin at that time. Follow-up echocardiogram was done on [**2157-6-24**] which showed, again, a small PDA. The infant was again stable on CPAP and room air and not treated with indomethacin at that time. Third echocardiogram was done on [**2157-6-27**] which showed small PDA with 1 mm in size with left-to-right flow, but due to increasing FiO2 at time, indomethacin was started on [**2157-6-28**] and the infant did receive a single course of indomethacin. Follow-up echocardiograms have all shown no further PDA. The echocardiogram on [**2157-8-25**] showed a small ASD with left-to-right flow and right ventricular volume overload. His most recent ECHO was on [**2157-10-10**] it showed no pulmonary hypertension but a small PFO vs ASD was present and there was good bilateral function. At present,the infant has been hemodynamically cardiovascularly stable with normal heart rates and blood pressures. 3. Fluid, electrolytes and nutrition: UVC and UAC were placed on admission to the NICU. The infant was started on parenteral nutrition on the newborn day. Infant was NPO on the newborn day. UAC was discontinued on day two of life. UVC was discontinued on day seven of life when a PICC line was placed at that time. Enteral feedings were initiated on day of life five, [**2157-6-22**]. Enteral feedings were slowly advanced and then briefly held during indomethacin therapy from [**2157-6-28**] to [**2157-6-29**]. Feedings were then reinstated and further advanced. The infant achieved full enteral feeding. On [**2157-7-8**], day of life 21, the PICC line was discontinued at that time. Calories were further advanced and the infant was placed on 30-calorie Similac Special Care, maximum caloric density. The infant has been tolerating feeds well and showing good growth. The calories were subsequently decreased and the infant is presently on 130 milliliters per kilo per day fluid restriction for edema and chronic lung disease and on Similac Special Care 24 calories per ounce. The infant was started on calciferol for osteomalacia on [**2157-9-1**]. At that time, the phosphorus was 3.8. Calcium was 9.5 and the alk phos was 429. The most recent lytes were on [**2157-10-27**]. He had with a sodium of 139, potassium 5.3, chloride 97, CO2 of 35. His D-stick was 86 at the same time. The most recent weight is on the day of transfer, 4560 grams, which is up 80 grams from the day prior. 4. GI: The infant had hyperbilirubinemia and was treated with phototherapy for a peak bilirubin level of 4.4 over 0.3. The infant received a total of eight days of phototherapy. Hyperbilirubinemia is now resolved. He was started on ranitidine therapy on [**2157-9-6**]. The infant was change from ranitidine to omeprazole on [**2157-10-2**]. His abdomnal ultrasound on [**2157-10-25**] was normal. His KUB was done [**2157-10-27**] showed some mildly dilated loops of bowels but was otherwise normal. 5. Hematology: The infant's blood type is A positive, DAT negative. He has received numerous blood product transfusions. The most recent packed cell transfusion was done on [**2157-9-15**] when he was given 20 milliliters per kilo of packed red blood cells for a crit of 29.6. His most recent hct 33.6, plt 387, PT 11.4, PTT 29.3, and INR 1.0 on [**2157-10-27**]. 6. Infectious disease: CBC and blood culture were done on admission to the NICU. The CBC was left shifted with a white blood cell count of 39,000, 58 polys, 5 bands, 1 meta, 6 myelos. The infant was started on ampicillin and gentamicin and given a seven-day course due to presumed sepsis. An LP was done at that time and the findings were within normal limits. Blood culture remains negative. Sepsis evaluation was done on [**2157-6-28**], day of life 11, for increased apneic spells. The infant received 48 hours of vancomycin and gentamicin which were subsequently discontinued when the blood culture remained negative. The CBC at that time was not shifted, but there was neutropenia and the CBC was benign at that time. Sepsis evaluation was done again on [**2157-7-6**] due to increased work of breathing and apneic episodes. A CBC was benign at that time. The infant received 48 hours of vancomycin and gentamicin which were subsequently discontinued when the blood culture remained negative. Sepsis eval was done on [**2157-7-21**], day of life 34, for bag-mask ventilation episodes times three while on the ventilator and deep spells. The CBC at that time was left shifted with a white blood cell count of 15,000, 18 polys, and 23 bands, 1 meta, I:T ratio of 0.42. The infant was started on vancomycin and gentamicin. The blood culture remained negative at that time. The trach aspirate culture grew methicillin-sensitive staph aureus. A lumbar puncture was done at that time which was benign. The infant received 48 hours of vancomycin and gentamicin which were changed to oxacillin on day three of antibiotic therapy due to the trach aspirate culture. The infant received a total of 14 days of antibiotics during that sepsis treatment. CBC and blood culture were done again on [**2157-8-2**], day of life 46, due to worsening respiratory distress. The CBC at that time was not shifted. The infant had just been completing the course of oxacillin at that time. Trach aspirate grew gram-negative rods. The antibiotic therapy was switched to Zosyn and gentamicin at that time. The infant remained on Zosyn and gentamicin for an additional 14 days after the completion of the oxacillin treatment. A repeat trach aspirate culture was sent on [**2157-8-6**] which was positive for proteus, and lumbar puncture was done on [**2157-8-9**] which was benign and grew no bacterium. The infant had an additional sepsis evaluation done on [**2157-8-23**], day of life 67, for increased work of breathing. CBC was benign. The infant was started on vancomycin and amphotericin for concern for yeast infection or concern for fungal infection on trach aspirate culture, so the vancomycin was discontinued after 48 hours, but the amphotericin was continued for a full seven-day course. The infant did have gram-positive cocci and no yeast in the trach aspirate culture at that time. [**2157-10-7**] he became sick again a tracheal aspirate drawn at that time grew staph aureus. He was treated with a 10 days of vanco/gent. Because of prolonged illness and two trach apirates that grew gram negative rods (later noted to be normal flora) on [**2157-10-10**] and [**2157-10-13**] and his history of Proteus, he was also treated with 7 days of Zosyn/gent. His RSV on [**2157-10-10**] was negative. He was treated with 5 days of fluconazole because of his history of yeast and his treatment with vanco/zosyn/gent. His Bcx did not grow any organisms. 7. Neurology: The infant has had numerous neurologic head ultrasounds, all normal, on [**2157-6-20**], [**2157-6-27**], [**2157-7-18**], and [**2157-9-28**]. 8. Sensory: Audiology: No hearing screen has been performed thus far. 9. Ophthalmology: Numerous ophthalmologic exams have been done. The infant did have ROP, most recent exam on [**2157-10-26**] had stage 2 zone 2 bilaterally. Follow up in 2 weeks recommended. 10.Psychosocial: A [**Hospital1 18**] social worker has been in contact with the family. If there are any psychosocial concerns, she can be reached at [**Telephone/Fax (1) 8717**]. There is a sibling who is two years old. Her name is [**Name (NI) **]. Mother has a history of postpartum depression from her previous pregnancy. Mother works as a hairdresser in [**Name (NI) 11333**], [**Location (un) 3844**]. She is married and lives with her husband who works in construction. CONDITION AT DISCHARGE: Guarded. DISCHARGE DISPOSITION: Transfer to [**Hospital3 1810**] for further management. Dr. [**Last Name (STitle) 24630**] from ORL had been following him. Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**] is his pulmonologist. Primary pediatrician is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 72876**] from [**Location (un) 15749**], telephone number [**Telephone/Fax (1) 42721**]. CARE RECOMMENDATIONS: 1. Medications: Neonatal Opium Soulution 0.4 ml po/pg Q4 hours (0.05 mg/kg/daose) Lorazepam 0.4 mg po/pg Q 6 hours Lasix 9 mg (2 mg/kg) po/pg every Monday, Wednesday, and Friday Omeprazole 4.3 (1 mg/kg) mg pg/po daily Chlorathiazide 32 mg (7.5 mg/kg) po/pg Q 12 hours Combivent 2 puffs MDI Q6-8 hours Beneprotein [**1-11**] teast/120 ml of formula po/pg each feed Prednisolone 4.3 mg (1 mg/kg/dose) po/pg every other day metachlopromide 0.43 mg (0.1 mg/kg) po/pg Q 8 hour Sprinolactone 8.6 mg (2 mg/kg) po/pg daily Ferrous Sulfate 0.4 ml (25 mg/ml) po/pg daily Calciferol 400 units po/pg daily KCl 7.5 mEq (3.5 mEq/kg/day) po/pg Q 12 hours Criticaid Clear AF Diaper Cream to diaper rash as needed 2. Iron and vitamin D supplementation: (1) Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. (2) All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units which may be provided as multivitamin preparation daily until 12 months corrected age. 3. Car seat position screening is recommended prior to discharge to home. 4. Numerous state newborn screens have been sent. Most recent results are normal. 5. Immunizations received: The infant has received the hepatitis B vaccine on [**2157-7-16**] and two-month immunizations of PEDIARIX, HIB, and pneumococcal on [**2157-9-30**]. Immunizations recommended: (1) Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants that meet any of the following four criteria: Born less than 32 weeks gestation; born between 32 and 35 weeks with two of the following - either daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; chronic lung disease; or hemodynamically significant congenital heart defect. (2) Influenza immunization is recommended annually in the fall for all infants once they reach six months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts in that of home caregivers. (3) This infant has not received the rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants after following discharge from the hospital if they are clinically stable and at least six weeks but fewer than 12 weeks of age. DISCHARGE DIAGNOSES: Prematurity, born at 26-0/7 weeks gestation, respiratory distress syndrome, chronic lung disease - ongoing, sepsis - treated, patent ductus arteriosus - treated, pneumonia - treated, osteomalacia - ongoing, retinopathy of prematurity - ongoing, tethered vocal cords- ongoing, electrolyte derrangement - ongoing, anemia of prematurity - ongoing, hyperbilirubinemia- resolved, presumed reflux - ongoing. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) **] Dictated By:[**Name8 (MD) 72877**] MEDQUIST36 D: [**2157-10-7**] 01:50:40 T: [**2157-10-7**] 16:01:20 Job#: [**Job Number 72878**]

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icd9cm

[ [ [] ] ]

[ "96.72", "93.90", "03.31", "38.93", "33.23", "96.6", "96.04", "99.83" ]

icd9pcs

[ [ [] ] ]

14289, 14693

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14715, 15479

2923, 14240

1163, 2017

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15516, 16215

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4930+55621

Discharge summary

report+addendum

Admission Date: [**2120-2-20**] Discharge Date: [**2120-2-24**] Date of Birth: [**2058-5-23**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypotension, Right hip and knee pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 2026**] is a 61M w/ ESRD on dialysis with PMH seizure disorder, nonischemic cardiomyopathy EF 50%, ESRD on HD (T/Th/Sat, last session on saturday), hepatitis B, CAD, CVA, recent admission for MRSA bacteremia [**1-25**] line infection on Vancomycin (planned last day [**2120-2-27**]), who presents from dialysis for increased right hip pain and hypotension (70/50) prior to dialysis. Currently blood pressure 101/70. He was asymptomatic on arrival. No weakness or dizziness. discharged [**1-25**] for line sepsis. Has left chest tunneled line now. no pain at the site. He denies CP, abd pain, SOB, cough, fever. He feels well and does not want to be here. PR complains of R leg pain which he states is chronic since CVA in [**2116**], denies any changes in baseline. . In the ED, initial VS were: T 98.8 88 101/70 16 95%. Exam notable for mentating well, but was refusing to take off his pants. Labs were notable for WBC 12.3 with 82.3% PMN's, Hct 36.5, K 6.5, which improved to 6.1, and lactate of 1.9. Trop of 0.11 (elevated previously to 0.16 on last admission). ECG showed peaked T waves. He was given Calcium gluconate, insulin, glucose, and kayexalate. Renal was contact[**Name (NI) **] from [**Name (NI) **]. A central line was placed - attempted R IJ but unable to place and placed L fem line. Cultures were sent and pt was given a dose of Vanc and Cefepime. He was given 1200L fluid 81/46. Mentating well, even in BP in lows 70s. VS prior to transfer 81/46 HR 72 RR 12 O2 sat 95% RA. He was been afebrile since admission. For access pt has 20g in left arm, L femoral line. . On arrival to the MICU, . 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: - CKD stage V, on hemodialysis [**1-25**] HTN - Seizure disorder since mid [**2097**]'s after starting dialysis - [**11/2119**] staph epidermidis bacteremia and CONS bacteremia - [**9-/2119**]: MSSA and VRE bacteremia - MSSA [**12/2117**] and [**4-/2118**] - MSSA HD line infection with septic lung emboli [**9-1**] - Graft excision for infected thigh graft [**2117-5-26**] - Multiple thrombectomies in LUE and R thigh AV fistula - H/o Hepatitis B, treated - Non-ischemic cardiomyopathy - MI [**2086**] per pt - CVA [**2086**] per pt (residual LE weakness) - Hungry bone syndrome status post parathyroidectomy - Pituitary mass - Anemia of chronic disease - s/p PEG tube placement [**2117-10-29**] Social History: Retired piano and organ teacher. Has 2 PhDs (history and music) and prefers to be called "Dr. [**Known lastname 2026**]." Walks with a walker at baseline. Never smoker, no other drug use. Drinks 1 drink/week. Has 2 sisters that live out of state, son died few years ago ("was shot to death"). Family History: Father with DM, mother died at age 41 of renal failure Physical Exam: Vitals: T: 98.2 BP 91/45 leg cuff: P: 76 R:15 O2: 98% General: Alert, oriented, no acute distress, patient annoyed by frequent questions. HEENT: Sclera anicteric, EOMI Neck: supple, NO JVD. Lungs: CTA BL Chest: HD port in place on left, but is non-tender, non-erythematous, witn no pus, fluctuance, or induration noted CV: Regular rate and rhythm, normal S1 + S2 Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: no cyanosis or edema, chronic atrophic skin changes in LE bilaterally, swollen right knee, atrophic muscles in calfs. Multiple scars from prior vascular access in arms b/l. Neuro: CN 2-12 intact, sensation throughout, [**4-27**] stregnth throughout, small pinpoint pupils, EOM intact, A+O x3. Attention intact, [**2-24**] recall at 5 minutes. Mild dysarthria. Subtle right sided facial droop. Wears corrective eyeware. Pertinent Results: HIP MRI: [**2119-2-22**] RESULT PENDING. Right Knee HIP XR: INDICATION: Right knee pain. COMPARISON: Right knee radiograph on [**2120-1-17**]. CT-Torso on [**2117-11-15**]. Single AP view of the pelvis. Additional view of the right hip and two views of the right knee. RIGHT HIP: There is a deformity of the right acetabulum, suggesting an old fracture. Heterotopic ossification is seen in bilateral hips. The SI joints are not visible and probably fused. There is compression deformity of the right femoral head with joint space narrowing and subchondral sclerosis of the acetabulum, not seen on prior CT-Torso on [**2117-11-15**]. This finding is suggestive of avascular necrosis. RIGHT KNEE: Marked muscle wasting is seen in the right lower extremity with marked demineralization. The large spur on the inferior aspect of the patella is unchanged from [**2120-1-17**]. There is no acute fracture or dislocation in the right knee. Impression: Probable old fracture of the right acetabulum along with marked muscle wasting (suggestng paraplegia). Probably fusion of the SI joints may reflect spondyloarthropathy or relate to ? paraplegia. Probable AVN rightfemoral head. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 251**] [**Name (STitle) 20492**] DR. [**First Name (STitle) **] M. [**Doctor Last Name **] Approved: WED [**2120-2-21**] 6:43 PM Knee Aspiratre: NO growth. Blood Cultures: No growth [**2120-2-24**] 05:09AM BLOOD WBC-5.3 RBC-2.95* Hgb-8.3* Hct-25.1* MCV-85 MCH-28.1 MCHC-33.1 RDW-17.4* Plt Ct-259 [**2120-2-23**] 06:19AM BLOOD WBC-5.0 RBC-3.22* Hgb-8.7* Hct-28.5* MCV-88 MCH-27.1 MCHC-30.7* RDW-17.2* Plt Ct-305 [**2120-2-22**] 01:02AM BLOOD WBC-5.0 RBC-3.15* Hgb-8.4* Hct-26.8* MCV-85 MCH-26.6* MCHC-31.3 RDW-18.0* Plt Ct-241 [**2120-2-21**] 04:00AM BLOOD WBC-6.5 RBC-3.58* Hgb-9.7* Hct-31.8* MCV-89 MCH-27.2 MCHC-30.6* RDW-17.3* Plt Ct-343 [**2120-2-20**] 04:31PM BLOOD WBC-10.4 RBC-3.71* Hgb-10.3* Hct-32.6* MCV-88 MCH-27.7 MCHC-31.5 RDW-17.0* Plt Ct-387 [**2120-2-20**] 09:20AM BLOOD WBC-12.3*# RBC-4.13*# Hgb-11.8*# Hct-36.5*# MCV-88 MCH-28.5 MCHC-32.3 RDW-17.1* Plt Ct-451* [**2120-2-20**] 04:31PM BLOOD Neuts-82.0* Lymphs-11.0* Monos-3.5 Eos-2.9 Baso-0.6 [**2120-2-20**] 09:20AM BLOOD Neuts-82.3* Lymphs-12.1* Monos-3.0 Eos-1.9 Baso-0.6 [**2120-2-24**] 05:09AM BLOOD PT-12.0 PTT-32.5 INR(PT)-1.1 [**2120-2-22**] 01:02AM BLOOD PT-12.8* PTT-37.7* INR(PT)-1.2* [**2120-2-20**] 04:31PM BLOOD PT-12.8* PTT-39.3* INR(PT)-1.2* [**2120-2-20**] 04:31PM BLOOD ESR-60* [**2120-2-24**] 05:09AM BLOOD Glucose-85 UreaN-22* Creat-5.4*# Na-145 K-4.4 Cl-104 HCO3-30 AnGap-15 [**2120-2-23**] 06:19AM BLOOD Glucose-103* UreaN-40* Creat-8.3*# Na-138 K-4.0 Cl-99 HCO3-25 AnGap-18 [**2120-2-22**] 01:02AM BLOOD Glucose-86 UreaN-29* Creat-6.0*# Na-138 K-3.7 Cl-100 HCO3-26 AnGap-16 [**2120-2-21**] 04:00AM BLOOD Glucose-81 UreaN-69* Creat-11.1* Na-140 K-4.9 Cl-102 HCO3-16* AnGap-27* [**2120-2-20**] 07:21PM BLOOD Glucose-93 UreaN-64* Creat-10.5* Na-138 K-4.9 Cl-102 HCO3-18* AnGap-23* [**2120-2-20**] 04:31PM BLOOD Glucose-89 UreaN-63* Creat-10.7* Na-138 K-5.1 Cl-100 HCO3-18* AnGap-25* [**2120-2-20**] 09:20AM BLOOD Glucose-108* UreaN-63* Creat-10.5*# Na-138 K-6.5* Cl-98 HCO3-19* AnGap-28* [**2120-2-24**] 05:09AM BLOOD Calcium-8.9 Phos-3.8# Mg-2.0 [**2120-2-20**] 04:31PM BLOOD Cortsol-22.0* [**2120-2-20**] 04:31PM BLOOD CRP-38.7* [**2120-2-24**] 06:26AM BLOOD Vanco-22.3* [**2120-2-23**] 06:20AM BLOOD Vanco-33.8* [**2120-2-21**] 09:13AM BLOOD Vanco-24.7* [**2120-2-20**] 09:20AM BLOOD Vanco-21.4* [**2120-2-20**] 09:33AM BLOOD Lactate-1.9 K-6.1* [**2120-2-20**] 07:50PM BLOOD Lactate-1.1 Brief Hospital Course: Dr. [**Known lastname 2026**] is the 61-year-old male with a past medical history significant for end-stage renal disease who receives hemodialysis on Tuesday Thursday Saturday, non-ischemic cardiomyopathy with an ejection fraction of 40-50%, hepatitis B, coronary artery disease, CVA, MRSA bacteremia secondary to a presumed dialysis line infection (line was subsequently replaced) [**2120-1-25**] on vancomycin until [**2120-2-27**] who presented to the emergency department with a chief complaint of right hip and knee pain as well as asymptomatic hypotension at dialysis (70/50s). During his admission in the MICU, he was hypotensive to the 90??????s/45, however, per report that this is the patients baseline. Furthermore, when the patient receives HD, his blood pressure tends to drop 10-20 points. He reports no symptoms then either. He was treated with meropenem in addition to his vancomycin in the MICU. However, per recommendations of ID, his meropenem was held. There were no acute events in the MICU and he has remained afebrile. His presenting complaint to the emergency department was for his right hip and knee pain. Xrays reveal an acetabular fracture as well as avascular necrosis of the femoral head. The patient notes that he is bound to a scooter at home. Upon review of systems, he denies chest pain, SOB, denies fevers, chills, change in bowel or bladder habits, cough. Patient endorses chronic right/hip and knee pain. He was subsequent transferred to the floor. 1. Hypotension Hypotension: Per record patient has a baseline blood pressure in the low 100s to 90s. This problem seems to be exacerbated by the fluid removal in hemodialysis secondary to his ESRD. Notably the patient does not complain of any sequelae from his hypotension. He has undergone and extensive workup and is being appropriately treated with vancomycin. He is afebrile and without white count. His blood cultures have shown no growth to date. - Vanc dose per HD until [**2120-2-27**]. -Less fluid removal at hemodialysis -Midodrine maintains SBP during HD . 2.ESRD: Patient has long standing history of ESRD. -Electrolyte management per renal -Low phos diet -Nephrocaps 3. Right knee and hip pain: He has been hemodynamically stable but continues to report right knee pain, for which he refused arthrocentesis while in MICU. He agreed to it on [**2-23**], as we expressed concern about possible septic arthritis. Orthopedic Surgery was consulted, and arthrocentesis was performed. They also recommended CT of hip to further evaluate AVN as well as look for fluid collection, though unlikely. Radiology recommended MRI instead, and he had MRI [**2120-2-23**] Currently denies hip pain, states knee feels better. Knee aspirate showed no growth. Will follow up with Ortho oupatient for possible hip replacement. 4. Seizure disorder: Stable and controlled. -Keppra -Oxycarbazepine Medications on Admission: Medications: discharge meds from [**2120-1-25**], confirmed with pt 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO once a day. 5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO HD DAYS (). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO ON HD DAY (). 10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 14. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. 15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily). 16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous with HD for 1 doses: To be dosed based on trough and given on hemodialysis days. (Duration 6 weeks, last day [**2120-2-28**]). Disp:*qS * Refills:*0* 17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. . Discharge Medications: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QHD (each hemodialysis). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO QHD (each hemodialysis). 10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) application Topical once a day. 16. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 17. midodrine 5 mg Tablet Sig: 1.5 Tablets PO WITH DIALYSIS (). Disp:*22 Tablet(s)* Refills:*2* 18. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol): Final Day [**2-28**]. 19. Outpatient Lab Work Please have your CBC (white blood count, hematocrit, platelets) drawn on [**2-27**] and have faxed to PCP [**Name Initial (PRE) **] [**Telephone/Fax (1) 3382**] and dialysis [**Telephone/Fax (1) 12142**] Discharge Disposition: Home With Service Facility: [**Hospital3 20493**] Discharge Diagnosis: Primary: Hypotension secondary to hypovolemia, avascular necrosis of R hip, R knee effusion likely secondary to OA Secondary: CKD stage V on HD, recent MRSA line infection, seizure disorder, s/p distant CVA with residual RLE weakness 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: Mr [**Known lastname 2026**], You were admitted to the hospital with low blood pressure which was likely due to hemodialysis. You were admitted to the ICU out of concern for infection, however we do not think that you had a new infection and continued to treat your known bloodstream infection. The orthopedic and renal (dialysis) consultants aided us in our management. You had pain in your right knee, and a sample was drawn from that. You also had imaging of your hip which showed some degeneration of your right hip, which demonstrated some degeneration. If you have worsening pain in your right hip or knee, you should call [**Telephone/Fax (1) 1228**] to schedule an urgen orthopedics appointment. You should follow with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5322**] at [**Telephone/Fax (1) 1228**] within 1-2 weeks to further evaluate your hip. The following changes have been made to your medications: -START 7.5 mg midodrine prior to dialysis on dialysis days -You will continue antibiotics until [**2120-2-28**], given during dialysis. Because of your heart failure, weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Because you were discharged on the weekend, we were unable to schedule you a follow up appointment with your PCP. [**Name10 (NameIs) 357**] call [**Telephone/Fax (1) 250**] to schedule an appointment with Dr [**Last Name (STitle) **]. You should have CBC labs drawn on Tuesday [**2-27**]. If you have worsening pain in your right hip or knee, you should call [**Telephone/Fax (1) 1228**] to schedule an urgen orthopedics appointment. You should follow with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5322**] at [**Telephone/Fax (1) 1228**] within 1-2 weeks to further evaluate your hip. Department: INFECTIOUS DISEASE When: TUESDAY [**2120-2-27**] at 9:30 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Name: [**Known lastname 3418**],[**Known firstname 3419**] Unit No: [**Numeric Identifier 3420**] Admission Date: [**2120-2-20**] Discharge Date: [**2120-2-24**] Date of Birth: [**2058-5-23**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1472**] Addendum: RESULTS OF HIP MRI PENDING. Follow up final read. Discharge Disposition: Home With Service Facility: [**Hospital3 3421**] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1473**] Completed by:[**2120-2-25**]

[ "276.7", "425.4", "412", "729.89", "285.29", "733.42", "070.30", "438.89", "458.21", "345.90", "719.06", "V45.11", "403.91", "041.89", "790.7", "715.96", "E879.1", "428.22", "428.0", "585.6", "999.32" ]

icd9cm

[ [ [] ] ]

[ "38.97", "81.91" ]

icd9pcs

[ [ [] ] ]

17778, 17980

8191, 11076

340, 347

14842, 14842

4516, 8168

16245, 17755

3520, 3576

12718, 14489

14585, 14821

11103, 12695

15018, 16222

3591, 4497

2025, 2474

264, 302

375, 2006

14857, 14994

2496, 3194

3210, 3504

4,759

179,664

9537

Discharge summary

report

Admission Date: [**2180-6-19**] Discharge Date: [**2180-8-9**] Date of Birth: [**2110-9-11**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old female with diabetes, chronic renal insufficiency, coronary artery disease, systolic congestive heart failure with an ejection fraction of 20%, chronic atrial fibrillation, chronic anemia, and blindness, who was treated for necrotizing fascitis with multi-organ dysfunction. The patient was admitted to [**Hospital6 2018**] on [**2180-6-19**], with the complaint of severe left leg pain for the prior two weeks. Of note, she noted prior poor p.o. intake for approximately one week and recently had her p.o. Lasix dose increased as an outpatient for worsened lower extremity edema. On presentation, the left leg slightly edematous, painful, and warm, with ................... to exam findings. In the Emergency Department, she was afebrile. She had a negative leni. She had multiple laboratory abnormalities including white blood cell measuring 58,000, with bandemia to 15%. Hematocrit was low at 19, and creatinine was 5.9, with bicarbonate of 13, and anion gap of 20. Lactate level measured 7.6. She was also hypoglycemic to the 50s which was refractory to D50 administration and eventually declined to the 20s and as low as 7. There was no history of sulfa nor Metformin use. She received MS04 for pain, packed red blood cells, and over the course of her Emergency Department stay, there was an acute decline in her mental status. A head CT was negative for bleeding. She received a dose of Levofloxacin. On arrival to the MICU, the patient was changed to Kefzol and later switched to Clindamycin and Vancomycin. The patient continued to decline and was noted to exhibit Kussmaul respirations. She was ultimately intubated for airway protection and work of breathing. She had a documented fingerstick of less than 20. She became hypotensive requiring fluid boluses and ultimately pressor support with Phenylephrine. Her urine output was minimal. A PA catheter was placed showing a CBP of 34, PA of 51/34, cardiac output of 2.5, SVR of [**2095**], MVO2 of 28%. CKs rose to greater than 1000, with relatively low MBs, and troponin was 3.9. She was started on Dobutamine with improvement in her cardiac index and MVO2, as was improved in urine output. ................... consultation was obtained with an initial impression that she did not have involvement of the deep tissues but rather this was a superficial process. The patient underwent CT imaging of the leg without contrast which revealed no direct evidence of fasciitis; however, over the following day, she began to develop ..................., and the leg appeared more dusky. She became hypothermic. She was started on Xigriss given the clinical evidence for infection, hypotension, and end-organ hypoperfusion, consistent with severe sepsis. She was later proven to be ................... and was started on ................... replacement therapy. Fluid was culture from the bolus lesions which proved positive for group A strep. Skin biopsy was obtained by Dermatology which was consistent for a leukocyclastic vasculitis. Ultimately Surgery was reconsulted, and the patient underwent above-knee amputation on [**6-29**] with an immediate postoperative complicated by wound bleeding and hypotension. The wound was left open ..................., a Vac dressing was applied which was changed every three days by Vascular Surgery. The wound was felt to be granulating well. The patient was subsequently noted to have a left groin hematoma, possibly from a previous line attempt. The hematoma was monitored by Vascular Surgery and was felt to stabilize. There was no felt to be no indication for evacuation. Ultrasound revealed no pseudoaneurysm. Sanguinous drainage and skin breakdown was noted from the area of the hematoma. It was recommended that ................... ointment be applied to the skin overlying the hematoma. The patient's Intensive Care Unit stay was further complicated by Klebsiella oxytoca sepsis. This was treated with a 21-day course of Meropenem. In addition, she was treated for infection with strep stenotrophamonas with Bactrim isolated from stump wound culture on [**7-21**]. While in the Intensive Care Unit, the patient was noted to have seizure activity. EEG showed nonspecific diffuse wave slowing. Head imaging revealed the presence of recent left middle cerebral artery stroke, ................... The patient was followed by the Neurology Service who recommended that she start on Phenytoin. She ................... profound hypoglycemia, as well as stroke. She was aphasic. She did arouse to tactile stimulation. She was noted to have intermittent eye opening to voice. Her family primary care physician followed her through her hospitalization. She has made a promising recovery and is hopeful further ................... Interestingly the patient was noted to have an elevated PTT throughout the hospital stay. She was found to have lupus anticoagulant; however, efforts toward any coagulation has been difficult, with her intermittent melena throughout her hospital course. She has undergone periodic transfusions with packed RBCs. The patient received and EGD and colonoscopy which revealed diffuse hemorrhagic gastritis. No sites of lower GI bleed were identified. The patient was placed on Protonix 40 mg IV b.i.d., as well as Carafate per recommendation of the Gastroenterology Service. It was recommended that she maintain off all anticoagulants and ................... agents presently. The patient was successfully extubated in [**Month (only) 216**] and transferred to the Medical Floor. She has been hemodialysis as a result of her critical illness and is currently undergoing a regimen of Monday, Wednesday, and Friday, three-times-a-week dialysis. She has been tolerating this well. A tunnel catheter was placed in the right internal jugular vein on [**7-17**]. Since extubation, the patient has been requiring intermittent suction of copious respiratory secretions. She maintains oxygen saturations in the mid 90s without supplemental oxygen. On [**8-1**], the patient was noted to develop a right leukocytosis in the 20,000 range, but she remained afebrile. ................... placement was empirically increased. She has remained hemodynamically stable. Pseudomonas aeruginosa pansensitive was isolated from the sputum, and the patient was started on Zosyn. She had left-sided pleural effusion that has been further evaluated in the Intensive Care Unit. A thoracentesis was performed on [**8-5**] with an exudate of 1.3 L, with ................. 7.45. Chest x-ray performed subsequently revealed no obvious infiltrate. Blood cultures from ................... on [**8-4**] showed ................... Staphylococcus, enterococcus ................... in 2 out of 6 bottles. It was suspected that there may be a contaminant. Blood cultures from both a left upper extremity PICC line and her PermCath showed no growth to date. Blood cultures on [**8-6**] through [**8-7**] showed no growth to date. It was recommended that she be maintained on Zosyn through [**8-15**] to treat both Pseudomonas tracheal bronchitis, as well as possible enterococcus infection. There is low suspicion for the latter. The patient was maintained on tube feeds through a percutaneously placed GJ tube. She has been tolerating the tube feeds well. The patient will subsequently be discharged through a rehabilitation facility. Several family meetings occurred throughout the patient's hospitalization. The family is aware of her critical illness and guarded prognosis. THE PATIENT IS FULL CODE in accordance with their wishes. DISCHARGE MEDICATIONS: Tube feeds, FS Promote with fiber at 65 cc/hr, Reglan 10 mg p.o. t.i.d., Protonix 40 mg IV b.i.d., Dulcolax 5 mg p.o. q.d. p.r.n., Synthroid 37.5 mcg p.o. q.d., Prednisone 20 mg p.o. q.d. tapered to 10 mg daily within a one-week period, Dilantin 150 mg p.o. b.i.d., Tylenol 650 mg p.o. q.i.d., Insulin sliding scale, Sulcrafate 1 g GJ tube 4 times a day, Humalog Insulin sliding scale, Zosyn 2.25 mcg IV q.8 hours through [**2180-8-15**], Mucomyst nebs every 6 hours p.r.n., ................... 10 mg p.o. q.d., TUMS 500 mg p.o. 3 times a day, Silvadene 1% ointment to skin of her hematoma, Albuterol nebs q.4-6 hours p.r.n., Nephrocaps 1 p.o. q.d., Nystatin mouth rinse b.i.d., Epogen 4000 U at every hemodialysis session, Zemproar 2 mg IV at hemodialysis. Additional recommendations that if over the 1-2 months the patient has no active infections, the patient should undergo ACT challenge to reassess the dosage ................... the necessity for the Prednisone for adrenal insufficiency. DISCHARGE DIAGNOSIS: 1. Necrotizing fascitis. 2. Group A streptococcus. 3. Status post left above-knee-amputation on [**6-29**]. 4. Klebsiella oxytoca sepsis. 5. End-stage renal disease, now on hemodialysis. 6. ................... Vascular coagulation, resolved. 7. Hemorrhagic gastritis. 8. Grade 2 internal hemorrhoids, nonbleeding. 9. Episode of profound hypoglycemia. 10. Diabetes mellitus. 11. Adrenal insufficiency. 12. Hypothyroidism. 13. Left MCA stroke. 14. Seizure disorder on Phenytoin. 15. Pseudomonas treated bronchitis. 16. Lupus anticoagulant, likely anti................... syndrome. 17. Ischemic cardiomyopathy with an ejection fraction of 15%. 18. Mitral regurgitation, moderate. 19. Left groin hematoma. CONDITION ON DISCHARGE: Guarded. DISCHARGE STATUS: Discharge to rehabilitation facility. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12157**], M.D. [**MD Number(1) 12158**] Dictated By:[**Last Name (NamePattern1) 32393**] MEDQUIST36 D: [**2180-8-9**] 20:10 T: [**2180-8-9**] 20:19 JOB#: [**Job Number 32394**]

[ "728.86", "535.51", "038.49", "584.9", "410.91", "518.81", "428.0", "482.0", "434.91" ]

icd9cm

[ [ [] ] ]

[ "43.11", "38.93", "39.95", "96.6", "99.15", "45.23", "45.13", "38.95", "84.17", "96.04", "86.11", "96.72", "34.91" ]

icd9pcs

[ [ [] ] ]

7802, 8799

8820, 9532

159, 7779

9557, 9907

30,966

148,111

30651

Discharge summary

report

Admission Date: [**2102-7-12**] Discharge Date: [**2102-7-19**] Date of Birth: [**2079-6-9**] Sex: M Service: SURGERY Allergies: Dilantin Attending:[**First Name3 (LF) 4691**] Chief Complaint: Status post multiple gun shot wounds to abdomen, left thigh and left hand Major Surgical or Invasive Procedure: Exploratory laparotomy, gastrorraphy, hepatorraphy, repair L diaphragm, L superfical femoral artery above knee bypass graft, L superficial femoral vein venorrhaphy, left lower extremity 4 compartment fasciotomies, chest tube placement, fasciotomy closure. History of Present Illness: The patient is a 23 year old male who sustained multiple gunshot wounds to the abdomen, left hand and left thigh. He was brought to [**Hospital1 18**] from an outside hospital where he had been noted to have a gunshot wound to the abdomen with shock and multiple gunshot wounds to a pulseless left lower extremity. the patient was treated with 4 units of type-O blood and evacuated to [**Hospital1 18**]. He arrived at the [**Hospital1 18**] ED hemodynamically stable and was taken to the operating room for definitive care. Past Medical History: Denies Social History: Denies Family History: Non-contributory Physical Exam: On arrival in ED his GCS was 15 and he was hemodynamically stable. HEENT: PERRL, atraumatic Chest: CTAB CV: RRR Abd: wound in the LUQ, + FAST Ext: wound in left thigh, no distal pulses, dusky left foot, left hand wound Pertinent Results: [**2102-7-12**] 09:22AM WBC-10.1 RBC-3.85* HGB-11.5* HCT-33.6* MCV-87 MCH-30.0 MCHC-34.4 RDW-15.3 [**2102-7-12**] 03:45PM GLUCOSE-108* UREA N-10 CREAT-0.9 SODIUM-137 POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-26 ANION GAP-9 [**2102-7-12**] 07:50AM PT-14.9* PTT-36.9* INR(PT)-1.3* [**2102-7-12**] 06:13AM TYPE-ART RATES-9/ TIDAL VOL-690 O2-50 PO2-260* PCO2-38 PH-7.28* TOTAL CO2-19* BASE XS--7 INTUBATED-INTUBATED VENT-CONTROLLED Chest X-ray [**2102-7-19**]: A moderate-sized left pneumothorax with apical lateral, medial, and basilar components shows decrease in size compared to the recent chest radiograph, particularly the medial aspect. Small left pleural effusion has slightly increased in size and there is slight worsening of atelectasis in the left lower lobe. There is otherwise not a substantial change since the prior radiograph performed 1 day earlier. UNILAT LOWER EXT VEINS LEFT [**2102-7-18**] 11:12 AM TECHNIQUE: Left lower extremity venous ultrasound was performed including color and pulsed wave Doppler. FINDINGS: The left common femoral vein, superficial femoral vein, and popliteal vein demonstrate appropriate compressibility and flow with augmentation. Left and right common femoral veins also demonstrate appropriate response to respiratory variation and Valsalva. IMPRESSION: No evidence of left lower extremity DVT. HAND (AP & LAT) SOFT TISSUE LEFT [**2102-7-12**] 8:53 AM FINDINGS: There are tiny punctate radiopaque foreign densities adjacent to the base of the proximal phalanx of the small finger. There is bony irregularity seen of the base of the second proximal phalanx as well as of the second metacarpal head. These findings are consistent with the patient's known gunshot injury. No other fractures are seen. Brief Hospital Course: Admitted to trauma service and taken immediately to operating room for exploration and repair of his wounds. In the operating room he had the above listed procedures. Plastics was consulted for hand injury and they recommended volar splint and no operative interventions. The patient was admitted to the truama intensive care unit intubated and sedated from the operating room. His vital signs remained stable on arrival in the TSICU. He was started on keflex due to his retained bullet fragments. Of note he had palpable dorsalis pedis and posterior tibial pulses in the left lower extremity. His hematocrit remained stable in the TSICU. He was extubated on [**2102-7-13**] and transferred to the floor on [**2102-7-14**]. His hand was examined on [**2102-7-13**] and was found to be neurovascularly intact by the plastics team. His chest tube was placed on water seal on [**2102-7-14**] but was plased back on suction after he was found to have a residual left sided apical pneumothorax. He was taken back to the operating room on [**2102-7-16**] for closure of his fasciotomies. His chest tube was placed on water seal again on [**2102-7-17**] and a chest x-ray on [**2102-7-18**] showed no change in his apical pneumothorax. His chest tube was removed on [**2102-7-18**] without complications. Repeat chest X-rays showed only a slight increase in his apical pneumothorax. Lower extremity ultrasound obtained on [**2102-7-18**] showed no evidence of thrombosis in his left superficial and common femoral veins and popliteal veins. Social work was consulted for the violence protection program. PT was consulted for home care and they cleared him for discharge. He was discharged to home in stable condition on the evening of [**2102-7-19**]. Medications on Admission: None Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: Mulitple gun shot wounds, Left pneumothorax, Left diaphragm rupture, L femoral artery laceration, L superficial femoral vein laceration, hepatic injury, retained bullet in liver, left hand injury, L pneumothorax Discharge Condition: Stable Discharge Instructions: Return to emergency room if you expereince shortness of breath, fever greater than 101, chills, increasing abdominal pain, increasing pain in left leg, increased swelling in left leg, and or any other symptoms that are concerning to you. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in one week. Please call ([**Telephone/Fax (1) 41065**] for an appointment.

[ "904.7", "917.1", "958.4", "E965.0", "958.92", "861.32", "860.1", "862.1", "863.1", "864.14" ]

icd9cm

[ [ [] ] ]

[ "34.04", "83.14", "44.61", "39.30", "83.65", "39.29", "50.61", "34.84" ]

icd9pcs

[ [ [] ] ]

5417, 5436

3276, 5031

341, 599

5692, 5701

1498, 3253

5987, 6112

1225, 1243

5086, 5394

5457, 5671

5057, 5063

5725, 5964

1258, 1478

228, 303

627, 1155

1177, 1185

1201, 1209

6,633

102,588

15357+15358+15406+15407

Discharge summary

report+report+report+report

Admission Date: [**2191-11-10**] Discharge Date: [**2191-11-19**] Date of Birth: [**2118-4-25**] Sex: M Service: Cardiothoracic Surgery CHIEF COMPLAINT: Patient admitted to [**Hospital6 649**] post cardiac catheterization and pre-coronary artery bypass grafting. HISTORY OF PRESENT ILLNESS: 73-year-old man with known coronary artery disease and hypertension as well as diabetes who was transferred to [**Hospital6 256**] from an outside hospital for cardiac catheterization as well as presumed primary PTCA intervention. The patient was in his usual state of health until two to three days ago when he began experiencing indigestion which spread to both arms and increased in intensity, associated with diaphoresis and shortness of breath. He presented to the outside hospital and was found to have ST elevations in 2, 3 and F. He was given Nitroglycerin, heparin and Morphine as well as 2B3A infusion and transferred to [**Hospital6 1760**] for cardiac catheterization. Please see catheterization report for full details and summary. At catheterization, the patient was found to have 80% left main disease, the left anterior descending artery with a 70% and the circumflex with a 70% lesion. He had a PTCA of the first obtuse marginal with a good result. Post intervention EKG showed ST depression and lessening of his ST elevation. He was then transferred to the CCU for further care. PAST MEDICAL HISTORY: 1. Diabetes mellitus, type 2. 2. Hypertension. 3. Hernia repair x2. 4. Cerebrovascular accident. 5. Right total knee replacement. MEDICATIONS PRIOR TO ADMISSION: Hydrochlorothiazide, aspirin, Glucophage, Losartan and Neurontin. ALLERGIES: Percocet and Valium, both of which cause itching. SOCIAL HISTORY: Lives at home by himself. He has a wife who lives in [**Hospital3 **]. He denies alcohol use. Is a current smoker. PHYSICAL EXAMINATION: [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2191-11-18**] 10:14 T: [**2191-11-18**] 10:46 JOB#: [**Job Number 44601**] Admission Date: [**2191-11-10**] Discharge Date: [**2191-11-19**] Date of Birth: [**2118-4-25**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 73-year-old man transferred to [**Hospital6 256**] from an outside hospital after presenting in the emergency room complaining of indigestion radiating to both arms x2-3 days, gradually increasing in intensity and associated with diaphoresis and shortness of breath. At the outside hospital, he was found to have ST elevation in leads 2, 3 and F. After being given Nitroglycerin, Heparin and Morphine as well as 2B3A, the patient was transferred to [**Hospital6 1760**] for cardiac catheterization and angioplasty. PAST MEDICAL HISTORY: Significant for hypertension, type 2 diabetes mellitus, hernia repair x2, right total knee replacement and back surgery. MEDICATIONS PRIOR TO ADMISSION: Hydrochlorothiazide, Losartan, Gabapentin, aspirin and Metformin. ALLERGIES: Percocet and Valium, both of which cause itching. SOCIAL HISTORY: Lives alone. Wife lives at [**Hospital3 **]. Smokes 1 pack per day. Formerly a heavy alcohol user, quit some time ago. As stated previously, the patient was transferred to [**Hospital6 1760**] for cardiac catheterization after having presented at [**Hospital3 **] Emergency Room where he was found to have ST elevations. The patient continued to have pain after the aspirin, Nitroglycerin, Morphine, Heparin and 2B3A and was transferred here where the catheterization revealed a left main 80% lesion, the left anterior descending artery with a 70% lesion and the left circumflex with a 70% lesion. Balloon angioplasty was performed to the distal obtuse marginal artery with a good result. An intra-aortic balloon pump was placed at that time. Following intervention and intra-aortic balloon pump placement, the patient had no further complaints of pain. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98, pulse 72, blood pressure 100/60, respiratory rate 16, oxygen saturation 96%. HEENT: Sclerae anicteric. Moist oral mucosa. Neck is supple. Lungs are clear anteriorly. Heart: Regular rate and rhythm. S1 and S2. Abdomen: Soft, non-tender and non-distended with positive bowel sounds. Extremities: Trace bilateral edema. LABORATORY DATA: WBC 9.0, hematocrit 40.8, platelets 212,000. INR 1.5, PTT 150. Sodium 139, potassium 4.5, chloride 105, CO2 25, BUN 22, creatinine 0.8, glucose 209. HOSPITAL COURSE: The Cardiothoracic Team was consulted. The patient was seen and accepted for coronary artery bypass grafting. On [**2191-11-11**], he was taken to the operating room. Please see the operative report for full details. At that time, he underwent coronary artery bypass grafting x3 with a left internal mammary artery graft to the left anterior descending artery and saphenous vein grafts to the right coronary artery and the obtuse marginal artery. He tolerated the operation well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient had Levophed infusion, Amiodarone infusion, Lidocaine infusion, insulin infusion and Neo-Synephrine infusion. He continued with the intra-aortic balloon pump at 1:1. Despite revascularization, the patient had an eventful postoperative course. In the immediate postoperative period, he was noted to have labile blood pressures as well as a somewhat low cardiac index ranging between 1.5 and 2.0. His medications were adjusted appropriately. He was given volume in an effort to bolster his cardiac index. These efforts were not successful, and the patient was started on a Milrinone drip as well. Additionally, the patient was noted to be hypoxic following his surgery. A chest x-ray showed white-out of his right upper lobe, and the patient then underwent a bronchoscopy which found a large amount of secretions as well as a collapsed right upper lobe with successful re-expansion following bronchoscopy. On postoperative day number one, the patient was hemodynamically stable. His Milrinone was weaned to off. He maintained an adequate cardiac index during that time. Following the discontinuation of the Milrinone, the intra-aortic balloon pump was also weaned and ultimately discontinued on postoperative day number one. On postoperative day number two, the patient remained hemodynamically stable. his Levophed infusion was weaned. His sedation was discontinued, and his ventilator was weaned to CPAP. He continued to have thick secretions, and he was not extubated at that time. On postoperative day number three, the patient's secretions had diminished and he was neurologically appropriate. At that time, he was weaned and successfully extubated. Additionally, his Levophed infusion was weaned to off, during which time he maintained a good cardiac output. Additionally, on postoperative day number three, the sensitivities from the patient's bronchial washings returned and revealed moderate Pseudomonas. At that time, his antibiotic was changed from Levaquin to Ciprofloxacin and Ceftazidime. He remained in the Cardiothoracic Intensive Care Unit for two additional days where he underwent vigorous pulmonary toilet as well as gradual diuresis. On postoperative day number six, the patient was deemed to be stable and ready for transfer to the floor. His Foley catheter as well as all other tubes and lines were discontinued at that time, and he was transferred to the floor for continued postoperative care and cardiac rehabilitation. Over the next several days, with the assistance of physical therapy and the nursing staff, the patient's activity level was gradually increased, and he was deemed stable and ready for transfer to rehabilitation. At the time of this dictation, the patient's physical examination is as follows: Vital Signs: Temperature 97.6, heart rate 67 and in sinus rhythm, blood pressure 139/66, respiratory rate 20, oxygen saturation 96% on 2 liters. Weight preoperatively was 95.3 kg. At the time of this dictation, weight is 98.6 kg. Alert and oriented x3 and conversant. Respiratory: Clear to auscultation bilaterally with a strong productive cough. Heart: Regular rate and rhythm. S1 and S2. No murmur. Sternum is stable. Incision with staples, open to air, clean and dry. Abdomen: Soft, non-tender and non-distended with normoactive bowel sounds. Extremities: Warm and well-perfused with no edema. Right saphenous vein graft harvest site with steri-strips, open to air, clean and dry. LABORATORY DATA ON [**2191-11-18**]: White count 7.2, hematocrit 27.2, platelets 348,000. Sodium 142, potassium 4.2, chloride 103, CO2 31, BUN 35, creatinine 1.1, glucose 114. DISCHARGE MEDICATIONS: Metoprolol 25 mg b.i.d., Lasix 40 mg b.i.d. x10 days, potassium chloride 20 mEq b.i.d. x10 days, aspirin 325 mg q day, Amiodarone 200 mg q day, Glyburide 2.5 mg q day, Combivent 2 puffs q6 hours, Gabapentin 200 mg t.i.d., Ciprofloxacin 500 mg b.i.d. through [**2191-11-21**], Ceftazidime 1 gram q8 hours through [**2191-11-21**], Tylenol 650 mg q4 hours p.r.n. and ibuprofen 600 mg q6 hours p.r.n. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass grafting x3 with a left internal mammary artery graft to the left anterior descending artery and saphenous vein grafts to the right coronary artery and the obtuse marginal artery. 2. Hypertension. 3. Diabetes mellitus, type 2. 4. Hiatal hernia repair x2. 5. Status post cerebrovascular accident. 6. Status post right total knee replacement. DI[**Last Name (STitle) **]ION: The patient is to be discharged to rehabilitation. He is to have follow up in the [**Hospital 409**] Clinic in two weeks, follow up in Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office in four weeks and follow up with his primary care physician in four weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2191-11-18**] 10:35 T: [**2191-11-18**] 11:31 JOB#: [**Job Number **] Admission Date: [**2191-11-10**] Discharge Date: [**2191-11-25**] Date of Birth: [**2118-4-25**] Sex: M Service: ADDENDUM Please refer to the previously-dictated discharge summary covering the period [**2191-11-10**] through [**2191-11-19**]. CHIEF COMPLAINT: The patient had been admitted to [**Hospital1 1444**] post-cardiac catheterization and pre-coronary artery bypass grafting. HOSPITAL COURSE FROM [**2191-11-19**] THROUGH [**2191-11-25**]: The patient's discharge was delayed by five days when the decision was made to continue monitoring his sternal incision, given some persistent serosanguinous drainage from the incision. The patient's sternum remained stable. Repeat chest x-rays obtained revealed no concerning findings. The decision was made to start the patient on Keflex. By the day of discharge, the patient's sternal drainage was much diminished. His incision had no evidence of infection. The patient was ambulating comfortably on the floor. The patient is due for discharge on [**2191-11-25**], which will be postoperative day number 14. DISCHARGE CONDITION: Stable. FO[**Last Name (STitle) 996**]P: The patient is to follow up with Dr. [**Last Name (Prefixes) **] four weeks following discharge. DISCHARGE MEDICATIONS: Identical to the previously-dictated discharge summary, with the addition of Keflex. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 997**] MEDQUIST36 D: [**2191-11-24**] 20:29 T: [**2191-11-25**] 01:46 JOB#: [**Job Number 23857**] Admission Date: [**2191-11-10**] Discharge Date: [**2191-11-27**] Date of Birth: [**2118-4-25**] Sex: M Service: Cardiothoracic Surgery ADDENDUM: On [**2191-11-25**] the patient had no additional complaints and was anxious to leave but continued to have some serosanguinous drainage from his sternal incision. His heart was regular rate and rhythm. His lungs were clear bilaterally. The drainage did not seem to have any evidence of infection. His leg incision was clean, dry and intact. Discharge was postponed because the volume of drainage from his sternum was still concerning and he continued on his Keflex antibiotics. Case management was notified and was involved in the delay of the patient's discharge. On [**11-26**], which was postoperative day 15, again the patient had no complaints but continued to have some drainage. He was in sinus rhythm with a T maximum of 98.1, a blood pressure of 108/62, saturating well on two liters. His incision was unchanged. His lungs continued to be clear. He continued on his antibiotics. That afternoon he had a CT of the chest to continue to monitor his sternal wound. The CT report showed a small amount of fluid associated with the sternotomy that might represent a postoperative lymphocele or seroma. Please refer to the CT report from [**2191-11-26**]. On [**2191-11-27**] the patient was discharged. The discharge medications were previously dictated. Discharge diagnoses were also previously dictated. Th[**Last Name (STitle) 1050**] was to follow up with Dr. [**Last Name (Prefixes) **] in the office approximately four weeks following discharge and was instructed to follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2405**] also within two to three weeks from surgery, and to complete the course of Keflex. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. Dictated By:[**Last Name (NamePattern1) 76**] MEDQUIST36 D: [**2192-3-22**] 11:07 T: [**2192-3-22**] 11:21 JOB#: [**Job Number 44711**]

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icd9cm

[ [ [] ] ]

[ "36.12", "89.64", "42.23", "88.56", "96.71", "37.61", "96.04", "37.23", "88.72", "99.20", "36.01", "33.24", "39.61", "36.15" ]

icd9pcs

[ [ [] ] ]

11465, 11606

9374, 10617

11630, 14093

4650, 8898

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1938, 2316

10635, 11443

2345, 2894

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2917, 3039

3219, 4102

25,131

120,062

47671

Discharge summary

report

Admission Date: [**2199-4-4**] Discharge Date: [**2199-4-12**] Date of Birth: [**2132-3-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Right ankle pain and fever. Major Surgical or Invasive Procedure: -Aspiration of knee fluid on [**2199-4-5**]. -Tunneled dialysis catheter placed on [**2199-4-8**]. History of Present Illness: Patient is a 67 year old woman with a past medical history significant for diabetes mellitus, hypertension, coronary artery disease, COPD and end stage renal disease with recent initiation of dialysis who presents with fever. Patient underwent permcath placement on [**2199-3-25**] and while at hemodialysis on the day of admission she was noted to have opening of the site. The stitches were removed. There was erythema, and she was referred to the [**Hospital1 18**] [**Location (un) 620**] emergency department. When the stitches were replaced and in the [**Location (un) 620**] ED, she was noted to have a temperature of 102.4, HR 130's, BP 150/70, and her oxygen saturation was 95% on room air. She was mentating well. . In addition, the patient relates left lower extremity pain from her big toe up through her left calf, which she states is consistent with her gout pain. She experiences polyarticular gout approximately once a month and believes her current gout flare was exacerbated by a "large" shrimp dinner two nights prior to admission. . Chest X-ray in the [**Location (un) 620**] ER was significant for a questionable left lower lobe pneumonia. Blood work revealed bandemia, as a result blood cultures were sent. The patient received vancomycin and tylenol and was transferred to the [**Hospital1 18**] ER. . In the ED at [**Hospital1 18**], she received ceftriaxone and aspirin. She continued to have left foot pain. Her temperature was 100.7. Heart rate ranged from 111 to the 90's after receiving 500cc of normal saline. Her fever resolved and her blood pressure varied between the 110's to 140's. . When initially evaluated on the floor, the patient reported severe left big toe and calf pain. Further, she endorsed some right big toe and calf pain. The patient reports that this is consistent with her previous gout pain, but more severe in nature. Of note, she has not been taking colchicine lately, as it was discontinued on her most recent discharge from [**Location (un) 620**]. . The patient stated she had one episode of diarrhea with her first dialysis a few days ago. Stool cultures were negative at that time and she has had no diarrhea since. Otherwise, the patient denies cough, chills, fever, shortness of breath, abdominal pain, or dysuria. She also reports neuropathic pins and needles feelings in arms and legs, but states that her neurontin was discontinued for unclear reasons. No other localizing complaints. She is very upset with recent prolonged hospital stays, need for dialysis and misses her family. Past Medical History: 1. Diabetes Mellitus 2. Coronary Artery Disease: Cypher x 2 to left circumflex in [**2196**] and Cypher to LAD after NSTEMI in [**2198-11-21**] 3. Congestive Heart Failure: most recent EF of 45% pre Cypher to LAD in [**2198**] in setting of NSTEMI, pulmonary edema 4. Chronic kidney disease, initiated on HD as above 5. COPD 6. Lung CA, status post resection [**2182**] 7. Neuropathy secondary to DM 8. Gout: [**1-22**] gouty flares every 2-3 months. Patient takes colchicine during flares, and if necessary receives steroid injection at PCP [**Name Initial (PRE) 3726**] 9. Sleep Apnea 10. Obesity 11. GERD: status post endoscopy in [**2198-11-21**] which revealed nonerosive gastritis, reflux disease 12. Depression Social History: The patient has a 50-pack-year-smoking history. She currently smokes and occasionally uses alcohol. No drug use. Patient lives with husband, son and daughter. Family History: Mother died of heart disease at 61. Father died of heart disease at 67. Many members of immediate family with hypertension and diabetes. Physical Exam: (on admission) Vitals: Temp:102.5max/99.6now BP:124/58 HR:86 RR:20 97%2litersO2sat General: NAD, tearful, flat affect HEENT: PERLLA, EOMI, anicteric, MMdry, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules Lungs: crackles at left base, otherwise clear Heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated Chest: permacath with minimal erythema, new stiches placed today, clean dry and intact Abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly Extremities: 1+ edema in right lower extremities, 2+ in left lower extremity; left knee is swollen; both large toes, feet and calves are sore to touch, minimal erythema, some increased warmth compared to upper leg Skin/nails: no rashes Neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. Pertinent Results: IMAGES: -EKG ([**2199-4-4**]): Sinus tachycardia to 105, RSRprime noted in II, no new ST-T changes, intervals OK. . -Ultrasound guided catheter placement ([**2199-4-8**]): Successful placement of 23 cm tip-to-cuff Angiodynamics double-lumen 14.5-French hemodialysis catheter, via the left internal jugular vein, terminating in the right atrium. Ready for use. . -Chest Xray ([**2199-4-6**]): The right central catheter has been removed, and there is no PTX. Subsegmental basilar atelectasis is seen, and the right hemidiaphragm is less elevated. There is some blunting at the left costophrenic sulcus consistent with some fluid. Pulmonary vascular markings are less distended than prior, and there are no new focal consolidations. The heart size is at the upper limits of normal. IMPRESSION: Less distension of the pulmonary vasculature; however, there is additional left pleural fluid visualized - positioning differences may contribute. No new focal consolidations. . -Chest Xray ([**2199-4-5**]): 1. No evidence of DVT bilaterally. 2. 4 cm cystic structure with multiple internal septations in left popliteal fossa, likely representing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4675**] cyst with internal hemorrhage. . -Dopplers of lower extremities ([**2199-4-5**]): No evidence of acute cardiopulmonary abnormalities. . . MICRO: Blood culture ([**Hospital1 18**] [**Location (un) 620**] [**2199-4-4**]): Final. No growth. . Blood culture ([**2199-4-4**], [**2199-4-5**]): Final. No growth. . Blood culture ([**2199-4-6**], [**2199-4-8**]): Pending. . Urine culture ([**2199-4-4**]): Gram positive cocci of approximate 1000. . Urine culture ([**2199-4-6**]): Negative. . Catheter Tip ([**2199-4-5**]): Negative growth. . Knee effusion ([**2199-4-5**]): 60,000WBC, with 98% PMNs. 7500RBC. Monosodium urate crystals. No growth. . . LABS: [**2199-4-12**] 05:30AM BLOOD WBC-11.3* RBC-3.34* Hgb-9.2* Hct-27.9* MCV-84 MCH-27.6 MCHC-33.1 RDW-16.1* Plt Ct-403 [**2199-4-9**] 03:37AM BLOOD WBC-15.2* RBC-2.96* Hgb-8.3*# Hct-24.5* MCV-83 MCH-28.1 MCHC-34.0# RDW-16.2* Plt Ct-298 [**2199-4-5**] 06:45AM BLOOD WBC-21.6* RBC-2.86* Hgb-7.8* Hct-25.4* MCV-89 MCH-27.3 MCHC-30.7* RDW-16.8* Plt Ct-231 [**2199-4-4**] 07:30PM BLOOD WBC-21.7*# RBC-2.93* Hgb-8.1* Hct-25.4* MCV-87 MCH-27.5 MCHC-31.7 RDW-17.0* Plt Ct-228 [**2199-4-10**] 05:35AM BLOOD Neuts-78.9* Lymphs-12.4* Monos-7.0 Eos-1.6 Baso-0.1 [**2199-4-4**] 07:30PM BLOOD Neuts-88.5* Bands-0 Lymphs-6.8* Monos-3.9 Eos-0.3 Baso-0.4 [**2199-4-12**] 05:30AM BLOOD Plt Ct-403 [**2199-4-12**] 05:30AM BLOOD PT-14.9* PTT-25.0 INR(PT)-1.3* [**2199-4-6**] 07:30AM BLOOD PT-14.8* PTT-30.7 INR(PT)-1.3* [**2199-4-4**] 04:30PM BLOOD PT-16.1* PTT-26.9 INR(PT)-1.5* [**2199-4-12**] 05:30AM BLOOD Glucose-81 UreaN-25* Creat-2.3* Na-144 K-3.9 Cl-105 HCO3-32 AnGap-11 [**2199-4-11**] 04:55AM BLOOD Glucose-103 UreaN-27* Creat-2.1* Na-143 K-4.0 Cl-102 HCO3-31 AnGap-14 [**2199-4-5**] 06:45AM BLOOD Glucose-104 UreaN-30* Creat-3.0* Na-141 K-4.3 Cl-101 HCO3-28 AnGap-16 [**2199-4-4**] 04:30PM BLOOD Glucose-196* UreaN-21* Creat-2.5* Na-139 K-3.9 Cl-97 HCO3-32 AnGap-14 [**2199-4-8**] 04:13AM BLOOD CK(CPK)-44 [**2199-4-7**] 10:31PM BLOOD CK(CPK)-21* [**2199-4-5**] 06:45AM BLOOD CK(CPK)-62 [**2199-4-4**] 04:30PM BLOOD CK(CPK)-32 [**2199-4-8**] 04:13AM BLOOD CK-MB-NotDone cTropnT-0.04* [**2199-4-7**] 10:31PM BLOOD CK-MB-NotDone cTropnT-0.05* [**2199-4-5**] 06:45AM BLOOD CK-MB-NotDone cTropnT-0.06* [**2199-4-4**] 04:30PM BLOOD cTropnT-0.06* [**2199-4-4**] 04:30PM BLOOD CK-MB-NotDone proBNP-4175* [**2199-4-12**] 05:30AM BLOOD Calcium-8.4 Phos-2.1* Mg-1.8 [**2199-4-4**] 04:30PM BLOOD Calcium-8.2* Phos-2.1*# Mg-1.5* [**2199-4-6**] 07:30AM BLOOD calTIBC-139* Ferritn-613* TRF-107* [**2199-4-12**] 05:30AM BLOOD Vanco-16.1 [**2199-4-10**] 07:45AM BLOOD Vanco-16.7 [**2199-4-10**] 05:35AM BLOOD Vanco-16.3 [**2199-4-7**] 01:50PM BLOOD Vanco-17.2 [**2199-4-7**] 06:15AM BLOOD Vanco-19.7 [**2199-4-6**] 07:30AM BLOOD Vanco-9.2* [**2199-4-7**] 08:30PM BLOOD Type-ART pO2-55* pCO2-43 pH-7.43 calTCO2-29 Base XS-3 Intubat-NOT INTUBA [**2199-4-7**] 08:30PM BLOOD freeCa-1.07* Brief Hospital Course: Hospital Course/Assessment/Plan: Patient is a 67 year-old woman with a history of diabetes mellitus, hypertension, coronary artery disease, COPD and end stage renal disease with recent initiation of dialysis who presented with fever and right ankle pain. Recently placed permcath appeared infected at outside hospital, so started on vancomycin and transferred to [**Hospital1 18**]. . 1. Fever: Multiple potential etiologies for fever, including pneumonia, septic joint, DVT or gouty flare. Recently placed dialysis line appeared erythematous at outside hospital and had evidence of bandemia, so vancomycin was initiated. [**Hospital3 **] also reported potential left lower lobe pneumonia; however, chest X-ray on [**2199-4-5**] was not suggestive of pneumonia, did show atelectasis at lower lung bases, most likely secondary to volume overload. Patient did report severe foot/knee/calf pain and has history of gout. Patient reported that pain was similar to previous gouty flares, but more severe in nature. She has been off colchicine for a period of time. Ultrasound of lower extremities was normal with exception of [**Hospital Ward Name 4675**] cyst in left popliteal fossa making DVT less likely etiology. Catheter was removed and tip was cultured as there was concern for infected joint. In addition, right knee joint fluid was aspirated, microscopically examined and cultured. All blood cultures (including from [**Hospital3 **] before initiation of vancomycin) and catheter tip revealed no significant growth. Right knee joint fluid showed [**1-25**] PMNs per 1000x field, negative for bacterial growth. There were negative birefringent crystals revealed under microscopic exam consistent with gout. -Fever and elevated white count ascribed to acute flare of gout. Pain controlled with colchicine, steroids, and salsalate. -Cultures were negative. Tunneled dialysis catheter placed on [**2199-4-8**]. Continue two week course of vancomycin (dosed at hemodialysis) through [**2199-4-19**]. Patient also completed seven day course of ceftriaxone for left lower lobe atelectasis. . 2. Gout: Patient reports monthly gout pain, and current episode is consistent with previous gouty flares. Patient has been off daily colchicine for a period of time and also had a large shrimp meal prior to current gout episode. Furthermore, as discussed above, joint fluid aspirate consistent with uric acid crystals (negative birefringence). Uric acid level was 5.1. Patient was put back on Colchicine 0.6mg daily, in addition, was put on Salsalate 500 twice daily per renal consult's recommendation, as patient is also on hemodialysis. In addition, as pain persisted, Prednisone 60mg twice daily was added on [**2199-4-7**] and converted to 20mg daily through [**4-12**]. Patient may be started on allopurinol after discussion with rheumatologist on scheduled appointment on [**2199-5-29**]. Dietary counselling provided during hospitalization. . 3. Cardiovascular: Patient has known coronary artery disease with previous stent placements and hypertension. Has no evidence of ACS at this point. Cardiac enzymes were trended and decreased (Troponin 0.6 on [**2199-4-4**], 0.05 on [**2199-4-7**]). Patient continued to have sinus tachycardia, most likely secondary to fever. She was continued on outpatient medications: aspirin, plavix, statin, beta blocker and ACE inhibitor. Patient had one episode of chest pain on [**4-6**] (pain level [**5-30**]) which was relieved with sublingual nitroglycerin. Most likely due to depressed hematocrit level. No EKG changes were appreciated. -Increased lisinopril to 10mg daily. . 4. Renal: Patient was recently started on hemodialysis for ESRD. New tunneled dialysis catheter placed on [**2199-4-8**]. Two week course of vancomycin to be completed on [**2199-4-19**]. Dosed at dialysis, with goal trough levels 15-20. Hematocrit 21, so received two units of packed red blood cells at dialysis on [**2199-4-8**]. Hematocrit stable in high 20's upon discharge. Will continue epogen at dialysis sessions. Continued on calcitriol and sevelamer. . 5. Diabetes mellitus: Will continue Lantus 35 units qhs and insulin sliding scale. Restarted neurontin for neuropathic pain. . 6. COPD: Continued on singulair. On evening of [**2199-4-7**] patient spiked fever and had sinus tachycardia. She was placed on O2 nasal cannula (91% O2 sat on 1.5L oxygen). Upon auscultation of lungs crackles were heard in lower lung bases. ABG was performed which showed pO2 55mm Hg, pCO2 43mm Hg, and pH of 7.43. Due to severe hypoxemia, fever and sinus tachycardia patient was transferred to MICU. Most likely etiology is fluid overload and immobility, as patient had not received dialysis for several days. Upon next dialysis session, patient's symptoms greatly improved. . 7. GERD: Continued on PPI twice daily. . 8. Heme: Iron studies on [**4-6**] revealed iron 8, TIBC 131, ferritin 613, TRF 107, consistent with anemia of chronic inflammation, most likely secondary to gouty flare and diabetes mellitus. Hematocrit: 21, Hb: 6.7. Appears baseline hematocrit in low to mid 20's. Patient received two units of packed red blood cells at dialysis on [**4-8**]. Hematocrit increased appropriately. Will continue epogen at dialysis sessions. . 9. Depression: Social work consulted. Patient frustrated at chronic hospitalizations and pain. Continued on outpatient paxil. . 10. Prophylaxis: Continued on subcutaneous heparin and protonix during admission. Placed on bowel regimen. . Code: FULL Medications on Admission: 1. Aspirin 81 mg daily 2. Clopidogrel 75 mg daily 3. Metoprolol Tartrate 50 mg PO BID 4. Atorvastatin 80 mg daily 5. Lisinopril 5 mg daily 6. Montelukast 10 mg daily 7. Pantoprazole 40 mg Tablet [**Hospital1 **] 8. Colchicine 0.6 mg QOD 9. Pentoxifylline 400 mg Tablet Sustained Release Sig: One Tablet Sustained Release PO TID. 10. Paroxetine HCl 20mg daily 11. Isosorbide Dinitrate 10 mg TID 12. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Gabapentin 300 mg daily 14. Insulin Lantus 35 units each night 15. Aranesp 16. Lasix 40 mg Tablet QOD 17. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal DAILY (Daily). Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 9. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal DAILY (Daily). 11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 13. MEDICATION Continue on lantus 35 units each night 14. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 17. Salsalate 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 18. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous QHD (each hemodialysis): Continue through [**2199-4-19**]. Goal trough level between 15-20. 19. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO three times a day. 20. Morphine 15 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain for 7 days. Disp:*20 Tablet(s)* Refills:*0* 21. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms. 22. MEDICATION Epogen can be dosed at dialysis treatments. Dialysis center will convey epogen dosing. 23. MEDICATION Continue on insulin lantus: 35 units per night Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: -Gout -ESRD requiring dialysis . Secondary: -Diabetes Mellitus -Coronary Artery Disease: Cypher x 2 to left circumflex in [**2196**] and Cypher to LAD after NSTEMI in [**2198-11-21**] -Congestive Heart Failure: most recent EF of 45% pre Cypher to LAD in [**2198**] in setting of NSTEMI, pulmonary edema -COPD -Lung cancer, status post resection [**2182**] -Peripheral neuropathy secondary to diabetes -Sleep Apnea -Obesity -GERD -Depression Discharge Condition: Stable. Discharge Instructions: -You were admitted for an acute flare of your gout. A diagnostic procedure was performed to confirm the diagnosis. As such, your gout was treated with steroids and pain medications. The nutrition team provided you with information regarding healthy food choices. A follow up appointment with Dr. [**Last Name (STitle) **] (rheumatology) is scheduled for [**Month (only) 116**]. At that time, allopurinol may be added to your regimen. -There was also concern that your hemodialysis catheter was infected. All your blood cultures were negative for infection. It was removed and a new tunneled dialysis catheter was placed on [**2199-4-8**]. You should continue with the scheduled dialysis sessions. You will need to continue on vancomycin through [**2199-4-19**]. This medication can be administered at dialysis. Your epogen will also be arranged at dialysis. -Continue with all medications prescribed on discharge. Your lisinopril has been increased to 10mg daily. Your colchicine has been changed to 0.6mg daily. Your lasix dose has been stopped. Your new medications will be sevelamer 800 mg three times a day, iron supplements three times a day, salsalate 500mg twice a day and morphine as needed. Prescriptions have been provided for these new medications. -Several appointments have been scheduled (see below). -If you experience any chest pain, shortness of breath, fever, chills, or any other concerning symptoms, call your PCP or come to the ED immediately. Followup Instructions: -You have an appointment with Dr. [**Last Name (STitle) 3649**] on Wednesday, [**2199-4-17**] at 12:30PM. You have another appointment with Dr. [**Last Name (STitle) 3649**] on [**2199-5-20**] at 9:00AM. The physician is affiliated with [**Name9 (PRE) **] [**Location (un) 620**]. -You have an appointment with the rheumatologist, Dr. [**First Name (STitle) 2206**] [**Name (STitle) **], on [**2199-5-29**] at 9:00AM. The phone number for this office is [**Telephone/Fax (1) **].

[ "414.01", "496", "428.0", "V10.11", "518.0", "530.81", "585.6", "412", "996.62", "285.21", "V45.82", "274.9", "250.40" ]

icd9cm

[ [ [] ] ]

[ "38.95", "99.04", "39.95", "81.91" ]

icd9pcs

[ [ [] ] ]

17487, 17544

9144, 12437

341, 442

18038, 18048

4983, 9121

19575, 20061

3971, 4109

15365, 17464

17565, 18017

14682, 15342

18072, 19552

4124, 4964

12461, 14656

274, 303

470, 3033

3055, 3775

3791, 3955

6,696

129,488

26329

Discharge summary

report

Admission Date: [**2148-11-17**] Discharge Date: [**2148-12-5**] Date of Birth: [**2074-10-21**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Angina Major Surgical or Invasive Procedure: [**2148-11-20**] - MV Repair and CABGx4(Left internal mammary artery to the left anterior descending artery, vein graft to posterior descending artery, Y-vein graft to the obtuse marginal and diagonal artery) on IABP [**2148-11-18**] - Cardiac Catheterization with placement of an IABP [**2148-11-28**] - s/p R Subclavian Permacath Placement and A-V Fistula Revision History of Present Illness: Mr. [**Known lastname **] is a 74-year-old male with worsening anginal symptoms and suffers from chronic renal insufficiency with a high creatinine. He underwent cardiac catheterization that showed left main tight stenosis with 3-vessel disease. He was also started on dialysis post catheterization. An intraaortic balloon pump was placed and he is presenting for urgent coronary artery bypass surgery. He is noted to have at least 2+ mitral regurgitation. Past Medical History: Hyperlipidemia Hypertension Gout Chronic renal insufficiency Functional AV fistula Polycystic kidney disease Prior Inferior MI Hemodialysis AF w/ DCCV at [**Hospital1 **] Social History: Lives with wife. [**Name (NI) 1403**] in grnaite shop as handy man. Smoked 30 years ago with a 20 year 2 ppd history.2 alcoholic drinks per week. Family History: Mother with diabetes. Physical Exam: 95.9 116/72 84 Regular 97% 3L GEN: Pleasant, Alert gentleman that is using accessory muscles HEENT: NCAT, Anicteric sclera, clear OP, +JVD, no bruits CARDIAC: Tachycardic, difficult to hear heart sounds, Nl S1-S2, LUNGS: Poor inspiratory effort, shallow breathing, crackles [**12-17**] way up lungs with some inspiratory wheezes ABD: Benign EXT: 2+ pulses, no edema. +thrill on AV fistula. Pertinent Results: [**2148-11-18**] 12:00AM CREAT-6.2* POTASSIUM-4.7 [**2148-11-17**] 06:00PM GLUCOSE-95 UREA N-94* CREAT-6.3* SODIUM-140 POTASSIUM-5.3* CHLORIDE-109* TOTAL CO2-13* ANION GAP-23* [**2148-11-17**] 06:00PM ALT(SGPT)-14 AST(SGOT)-43* LD(LDH)-321* CK(CPK)-674* ALK PHOS-77 TOT BILI-0.5 [**2148-11-17**] 06:00PM CK-MB-121* MB INDX-18.0* cTropnT-1.91* proBNP-[**Numeric Identifier 65158**]* [**2148-11-17**] 06:00PM ALBUMIN-4.2 CALCIUM-9.5 PHOSPHATE-5.2* MAGNESIUM-1.5* [**2148-11-17**] 06:00PM WBC-14.7* RBC-3.61* HGB-10.8* HCT-31.3* MCV-87 MCH-30.0 MCHC-34.6 RDW-15.3 [**2148-11-17**] 06:00PM NEUTS-86.6* LYMPHS-8.3* MONOS-4.7 EOS-0.2 BASOS-0.1 [**2148-11-17**] 06:00PM PT-14.4* PTT-40.8* INR(PT)-1.4 [**2148-11-17**] 06:00PM PLT COUNT-170 [**2148-11-18**] ECHO 1.The left atrium is normal in size. The left atrium is elongated. The right atrium is moderately dilated. 2.Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction. Overall left ventricular systolic function is moderately depressed. [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] Resting regional wall motion abnormalities include inferior, lateral, distal septal, inferolateral and apical hypokinesis. 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. [**2148-11-18**] Cardiac Catheterization 1. Selective coronary angiography showed a right dominant system with severe three vessel disease. The LMCA had an ostial 90% stenosis. The LAD wrapped around the apex had had a proximal 90% and 70% stenosis. The mid and distal LAD was diffusely diseased. The LCX had a mid 90% stenosis. The OM1 was subtotally occluded and OM2 had a 90% stenosis. The RCA was proximally occluded and filled via right to right and left to right collaterals. 2. Limited resting hemodynamics showed a normal central aortic pressure (AO mean 81 mmHg). There was no gradient across the aortic valve. The LVEDP was severely elevated (LVEDP 37 mmHg). 3. An IABP was inserted via the right femeral artery using a long 8F sheath. The iliac arteries were tortuous. [**2148-11-19**] Carotid Duplex Ultrasound Mild plaque/wall thickening is present in the carotid arteries bilaterally. However, there is no significant carotid stenosis on either side (evaluated as less than 40% stenosis bilaterally). [**2148-11-19**] Renal Ultrasound Bilateral renal cysts. No evidence of normal renal parenchyma. Underlying masses cannot be excluded. [**2148-11-26**] CXR Stable left base effusion and atelectasis. [**2148-12-2**] CAR Bilateral Pleural effusion, Stable cardiomegaly [**2148-11-25**] EKG Sinus tachycardia Atrial premature complexes Ventricular premature complex Left atrial abnormality Consider left anterior fascicular block and/or pssible prior inferior myocardial infarction Nonspecific ST-T wave changes Since previous tracing of [**2148-11-25**], first degree A-V delay absent and ventricular ectopy seen Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2148-11-17**] for further management of chest pain. He was treated with lasix, heparin and lopressor were started. The renal service was consulted given his creatinine of 6.1. It was assumed that he would likely need to start hemodialysis post cardiac catheterization. On [**2148-11-18**] a cardiac catheterization was performed. This revealed a 90% stenosed left main, a 90% stenosed left anterior descending artery, a 90% stenosed circumflex, a 90% stenosed obtuse marginal and an occluded right coronary artery. Given the severity of his disease, an intra-aortic ballon pump was placed for coronary perfusion. The cardiac surgical service was consulted for surgical management and Mr. [**Known lastname **] was worked-up in the usual preoperative manner. An echocardiogram was performed which showed an ejection fraction of 30-35% and 2+ mitral regurgitation. A carotid duplex ultrasound was performed which revealed mild (<40%)plaque/wall thickening present in the carotid arteries bilaterally. A renal ultrasound was also performed which showed Bilateral renal cysts, no evidence of normal renal parenchyma and underlying mass could not be excluded. Mr. [**Known lastname **] continued to have episodes of atrial fibrillation which was treated with beta blockade. Mr. [**Known lastname **] [**Last Name (Titles) 8783**]t hemodialysis on [**2148-11-19**] prior to cardiac surgery. On [**2148-11-20**], Mr. [**Known lastname **] was taken to the operating room where he underwent coronary artery bypass grafting to four vessels and a mitral valve repair. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname **] again underwent hemodialysis to remove fluid. He underwent a bronchoscopy for secretions. The transplant service was consulted as his fistula appeared to be clotted off. A fistulogram was performed with angiodilation of an outflow stenosis. Mr. [**Known lastname **] continued to have runs of atrial fibrillation and amiodarone was started. On postoperative day two, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was extubated. He again underwent hemodialysis. On postoperative day three, heparin was started for anticoagulation for his atrial fibrillation (Coumadin was started shortly thereafter). Mr. [**Known lastname **] continued to undergo daily hemodialysis for fluid management. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He was transfused for postoperative anemia. On postoperative day seven, Mr. [**Known lastname **] was transferred to the cardiac surgical step down unit for further recovery. A revision was made to his AV fistula by the transplant service on post op day eight. During the remaining one week hospital stay pt slowly improved. He underwent several more times of hemodialysis. His Coumadin was adjusted for a goal INR of 1.5-2. At time of discharge it was 3.2. He will have his INR drawn during dialysis and Coumadin followed by Dr. [**Last Name (STitle) 47285**]. On post-op day fifteen his PICC line removed. He was set up with dialysis as an outpatient at [**Hospital1 **] and was discharged home with VNA services on post op day 15. INR [**12-2**] 2.1, [**12-3**] 3.3, [**12-4**] 3.1, [**12-5**] 3.2 Coumadin dose 12/18 4mg, [**12-2**] 4mg, [**12-3**] 1mg, [**12-4**] and 22 nothing Medications on Admission: Lipitor 80mg QD Methyldopa 250mg [**Hospital1 **] Diovan 160mg QD Norvasc 5mg QD Allopurinol 150mg QD Aspirin 81mg QD Hectoral 0.5mg daily lasix 20mg mondays and thursdays 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): For 2 weeks. Then 400mg daily for 2 weeks. Then 200mg daily until stopped by cardiologist. Disp:*84 Tablet(s)* Refills:*1* 5. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*180 Tablet(s)* Refills:*0* 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-17**] Puffs Inhalation Q4H (every 4 hours). Disp:*1 * Refills:*1* 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 * Refills:*1* 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:*1 * Refills:*0* 10. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 14. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*0* 15. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 16. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Await next INR check ([**2148-12-6**]) and dosing will be adjusted by Dr. [**Last Name (STitle) 47285**] for goal INR between 1.5-2. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 [**2148-11-20**] Mitral Regugitation s/p Mitral Valve Repair [**2148-11-20**] Dyslipidemia Hypertension Gout Chronic renal insufficiency Polycystic kidney disease Prior inferior MI Renal failure with need for hemodialysis Functional AV fistula in place Discharge Condition: Good Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 1 month. Follow-up with cardiologist in 2 weeks. Follow-up with primary care physician [**Last Name (NamePattern4) **] 2 weeks. Completed by:[**2148-12-5**]

[ "584.9", "753.12", "414.01", "996.73", "424.0", "427.31", "428.0", "410.71", "403.91", "585.6" ]

icd9cm

[ [ [] ] ]

[ "37.61", "88.56", "38.95", "39.61", "39.95", "39.42", "36.15", "38.93", "36.13", "37.22", "35.12" ]

icd9pcs

[ [ [] ] ]

11147, 11196

5364, 8847

330, 698

11554, 11560

2007, 5341

11583, 11789

1558, 1581

9069, 11124

11217, 11533

8873, 9046

1596, 1988

284, 292

726, 1185

1207, 1379

1395, 1542

16,554

132,507

42942

Discharge summary

report

Admission Date: [**2162-6-30**] Discharge Date: [**2162-7-13**] Date of Birth: [**2108-12-4**] Sex: F Service: MEDICINE Allergies: Motrin / Compazine / Haldol / Nitrofurantoin / Iodine / Vancomycin Hcl Attending:[**First Name3 (LF) 6701**] Chief Complaint: Sepsis mostly likely caused by UTI Major Surgical or Invasive Procedure: Intubated and extubated History of Present Illness: 53 yo F with PMH HIV last CD4 1068, on HAART, hepatitis B, hepatitis C, h/o ?PE on coumadin, morbid obesity, h/o recurrent UTI last one with ESBL E. coli, OSA and h/o ovarian CA in [**2142**] s/p oophrectomy, present with SOB, CP, cough, N/V diarrhea over the past 4-5 days. Per ED report, she also had chest pain, abdomenial pain, had diarrhea x8. denies any melena, BRBPR. . In the ED: Initial VS: temp 102, tachy 134, bp 159/74, rr 40 89% on? nc. Then became hypotensive to 70/40 for unclear reason and started on levo/neo. An Aline was placed. After initiation of pressors, BP increased to 110/67. IJ was placed. Blood culture were sent. CT chest done showing patchy opacity at the bases. Initial labs remarkable for lavtate of 5.8--->4.5. UA grossly positive. Initial gas: 7.21/49/76--->7.18/57/67--->7.17/58/95 . Received a total of 5L NS and cefepime and flagyl. Anesthesia believe the patient to be a difficult to intubate. . On the floor, patient was somulent, not able to answer any of the questions appropriately. She was able to be weaned off to 1 pressor. Past Medical History: 1. HIV, sexually transmitted, diagnosed [**2150**] on HAART. 2. Hepatitis B and hepatitis C virus also sexually transmitted, diagnosed [**10/2151**], s/p IFN x6 months with failure to suppress VL. 3. Asthma. 4. Ovarian cancer diagnosed [**2142**], status post oophorectomy and chemotherapy. 5. Morbid obesity. 6. S/p MVA with L4-L5 laminectomy in [**2151**], operation c/b infection, including VRE requiring re-exploration and drainage. 7. Chronic back pain 8. Chronic L leg pain 9. Cholecystectomy [**2142**]. 10. Osteoarthritis involving bilateral knees 11. Recurrent UTIs last on [**4-4**] 12 Recurrent cystitis consistent with urethral syndrome or chronic cystitis 13. QT Prolongation -? assocation with abilify 14. S/p tibial fracture on [**2160-11-5**], medically managed Social History: Lives alone in apartment in [**Location (un) 86**], limited contact with family. Only support per patient is a few friends, especially her HCP, [**Name (NI) 18404**] [**Name (NI) **] #[**Telephone/Fax (1) 92678**]. Tobacco: 120 pack-year. Currently smokes half a pack per day, used to smoke up to 3PPD. No current ETOH, but distant use in past. Denies history of illicit drug use. . Family History: Father is deceased and had HTN, CAD. Mother is recently deceased after long course with ESRD, HTN, multiple strokes and CHF. Aunt with neuroblastoma, otherwise no other cancers per patient. . Physical Exam: Vitals: T: 99 BP:99/64 P:104 R: 25 O2: 98% NRB General: in moderate distress, somulent but responsive to commands, obese, flushed HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP/LAD unable to appreciate due to body habitus Lungs: ronchus throughout, unable to appreciate posteriorly due to body habitus CV: tachy, sinus, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, non-tender, non-distended, bowel sounds present, GU: foley present, urine appears concentrated, yellow Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Physical Exam on Day of Discharge: Vitals: T: 97 BP:1199/72 P: 69 R: 18-20 O2: 95-96% RA GENERAL: Obese NAD. Oriented x3.[**Last Name (un) **], awake, approprately responsive to questions. HEENT: NCAT. Sclera anicteric. PER, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. No LAD appreciated NECK: Supple, JVP could not be appreciated due to body habitus. No cartid bruits appreciated CARDIAC: Distant heart sounds due to body habitus, RR, normal S1, S2. No m/r/g appreciated. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB no rhonchi, rales or wheezes ABDOMEN: +BS Soft, NT obese. Surgical scars. No HSM or tenderness could be appreciated but exam limited by body habitus. EXTREMITIES: +1 LE edema. WWP. +2 pulses SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Labs Day of Admission: [**2162-6-29**] 08:05PM PT-21.9* PTT-38.1* INR(PT)-2.0* [**2162-6-29**] 08:05PM PLT SMR-LOW PLT COUNT-88*# [**2162-6-29**] 08:05PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2162-6-29**] 08:05PM NEUTS-70 BANDS-12* LYMPHS-12* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-0 [**2162-6-29**] 08:05PM WBC-5.9 RBC-5.47*# HGB-17.4*# HCT-53.5* MCV-98 MCH-31.7 MCHC-32.5 RDW-15.2 [**2162-6-29**] 08:05PM estGFR-Using this [**2162-6-29**] 08:05PM GLUCOSE-56* UREA N-23* CREAT-1.3* SODIUM-132* POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-19* ANION GAP-24* [**2162-6-29**] 11:30PM CALCIUM-7.8* PHOSPHATE-1.8*# MAGNESIUM-1.3* [**2162-6-29**] 11:30PM ALT(SGPT)-32 AST(SGOT)-43* ALK PHOS-255* TOT BILI-1.5 [**2162-6-29**] 11:30PM GLUCOSE-45* UREA N-27* CREAT-1.6* SODIUM-134 POTASSIUM-3.1* CHLORIDE-100 TOTAL CO2-16* ANION GAP-21* [**2162-6-29**] 11:43PM LACTATE-5.8* [**2162-6-29**] 11:43PM COMMENTS-GREEN TOP [**2162-6-30**] 01:43AM GLUCOSE-78 LACTATE-4.5* [**2162-6-30**] 01:43AM TYPE-ART PO2-76* PCO2-49* PH-7.21* TOTAL CO2-21 BASE XS--8 INTUBATED-NOT INTUBA [**2162-6-30**] 01:43AM URINE GR HOLD-HOLD [**2162-6-30**] 01:43AM URINE UHOLD-HOLD [**2162-6-30**] 01:43AM URINE HOURS-RANDOM [**2162-6-30**] 01:43AM URINE HOURS-RANDOM [**2162-6-30**] 02:52AM PO2-67* PCO2-57* PH-7.18* TOTAL CO2-22 BASE XS--7 [**2162-6-30**] 04:13AM PO2-95 PCO2-58* PH-7.17* TOTAL CO2-22 BASE XS--7 [**2162-6-30**] 04:30AM URINE RBC-0-2 WBC-[**10-16**]* BACTERIA-MANY YEAST-NONE EPI-[**1-29**] [**2162-6-30**] 04:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [**2162-6-30**] 04:30AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.012 [**2162-6-30**] 04:30AM URINE GR HOLD-HOLD [**2162-6-30**] 04:30AM URINE UCG-NEGATIVE [**2162-6-30**] 04:30AM URINE HOURS-RANDOM [**2162-6-30**] 04:30AM URINE HOURS-RANDOM [**2162-6-30**] 08:33AM freeCa-1.08* [**2162-6-30**] 08:33AM GLUCOSE-98 LACTATE-2.3* NA+-136 K+-3.6 CL--104 [**2162-6-30**] 08:33AM TYPE-ART PO2-164* PCO2-59* PH-7.16* TOTAL CO2-22 BASE XS--8 [**2162-6-30**] 09:39AM WBC-33.4* LYMPH-5* ABS LYMPH-1670 CD3-42 ABS CD3-700 CD4-22 ABS CD4-373 CD8-19 ABS CD8-317 CD4/CD8-1.2 [**2162-6-30**] 09:39AM FIBRINOGE-534* [**2162-6-30**] 09:39AM FDP-10-40* [**2162-6-30**] 09:39AM PT-23.8* PTT-39.2* INR(PT)-2.3* [**2162-6-30**] 09:39AM PLT COUNT-69* [**2162-6-30**] 09:39AM WBC-33.4*# RBC-4.10*# HGB-13.3# HCT-41.1# MCV-100* MCH-32.6* MCHC-32.5 RDW-15.1 [**2162-6-30**] 09:39AM CALCIUM-7.2* PHOSPHATE-4.4# MAGNESIUM-1.4* [**2162-6-30**] 09:39AM ALT(SGPT)-84* AST(SGOT)-159* ALK PHOS-149* TOT BILI-1.3 [**2162-6-30**] 09:39AM GLUCOSE-130* UREA N-29* CREAT-1.6* SODIUM-135 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-20* ANION GAP-16 [**2162-6-30**] 10:05AM GLUCOSE-139* LACTATE-2.4* [**2162-6-30**] 10:05AM TYPE-ART PO2-93 PCO2-80* PH-7.11* TOTAL CO2-27 BASE XS-- [**2162-6-30**] 12:27PM URINE EOS-POSITIVE [**2162-6-30**] 12:27PM URINE GRANULAR-[**1-29**]* [**2162-6-30**] 12:27PM URINE RBC-0-2 WBC-[**10-16**]* BACTERIA-MOD YEAST-NONE EPI-[**1-29**] [**2162-6-30**] 12:27PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-MOD [**2162-6-30**] 12:27PM URINE HOURS-RANDOM UREA N-325 CREAT-99 SODIUM-43 POTASSIUM-23 CHLORIDE-33 [**2162-6-30**] 03:31PM WBC-26.6* RBC-4.01* HGB-13.0 HCT-39.8 MCV-99* MCH-32.3* MCHC-32.5 RDW-15.1 [**2162-6-30**] 03:31PM CALCIUM-7.4* PHOSPHATE-4.3 MAGNESIUM-1.4* . Labs Day of Discharge: [**2162-7-13**] 06:56 WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 6.7 3.73* 11.9* 36.9 99* 31.8 32.1 16.3* 284 Neuts Lymphs Monos Eos Baso 72.6* 21.8 2.4 2.5 0.8 . **FINAL REPORT [**2162-7-2**]** Blood Culture, Routine (Final [**2162-7-2**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- =>64 R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 32 I TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [**2162-6-30**]): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO DR. [**Last Name (STitle) **]. [**Doctor Last Name **] [**2162-6-30**] 8:40AM. Aerobic Bottle Gram Stain (Final [**2162-6-30**]): GRAM NEGATIVE ROD(S). . [**2162-6-29**] 8:15 pm BLOOD CULTURE #2. **FINAL REPORT [**2162-7-2**]** Blood Culture, Routine (Final [**2162-7-2**]): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 302-9848B [**2162-6-29**]. Anaerobic Bottle Gram Stain (Final [**2162-6-30**]): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO DR. [**Last Name (STitle) **]. [**Doctor Last Name **] [**2162-6-30**] 8:40AM. Aerobic Bottle Gram Stain (Final [**2162-6-30**]): GRAM NEGATIVE ROD(S). . [**2162-6-30**] 9:39 am BLOOD CULTURE Source: Line-a. **FINAL REPORT [**2162-7-6**]** Blood Culture, Routine (Final [**2162-7-6**]): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 302-9848B [**2162-6-29**]. Anaerobic Bottle Gram Stain (Final [**2162-7-4**]): GRAM NEGATIVE ROD(S). . [**2162-6-30**] 9:38 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2162-7-2**]** MRSA SCREEN (Final [**2162-7-2**]): No MRSA isolated. .Time Taken Not Noted Log-In Date/Time: [**2162-7-1**] 11:11 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2162-7-1**]): [**9-20**] PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2162-7-3**]): RARE GROWTH Commensal Respiratory Flora. YEAST. RARE GROWTH. LEGIONELLA CULTURE (Final [**2162-7-8**]): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): YEAST. . [**2162-7-2**] 9:43 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. MICROSPORIDIA STAIN (Final [**2162-7-6**]): NO MICROSPORIDIUM SEEN. CYCLOSPORA STAIN (Final [**2162-7-5**]): NO CYCLOSPORA SEEN. FECAL CULTURE (Final [**2162-7-4**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2162-7-4**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2162-7-5**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O VIBRIO (Final [**2162-7-4**]): NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [**2162-7-4**]): NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2162-7-4**]): NO E.COLI 0157:H7 FOUND. Cryptosporidium/Giardia (DFA) (Final [**2162-7-5**]): NO CRYPTOSPORIDIUM OR GIARDIA SEEN. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2162-7-2**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). VIRAL CULTURE (Preliminary): No Virus isolated so far. ' [**2162-7-2**] 9:43 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2162-7-4**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2162-7-4**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . [**2162-7-3**] 11:55 am BLOOD CULTURE Source: Line-a-line #1. **FINAL REPORT [**2162-7-9**]** Blood Culture, Routine (Final [**2162-7-9**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY. FINAL SENSITIVITIES. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | CLINDAMYCIN----------- R R ERYTHROMYCIN---------- =>8 R =>8 R GENTAMICIN------------ 4 S 8 I LEVOFLOXACIN---------- 4 R 4 R OXACILLIN------------- =>4 R =>4 R RIFAMPIN-------------- <=0.5 S <=0.5 S TETRACYCLINE---------- <=1 S <=1 S VANCOMYCIN------------ 2 S 2 S Aerobic Bottle Gram Stain (Final [**2162-7-5**]): GRAM POSITIVE COCCI IN CLUSTERS. REPORTED BY PHONE TO [**First Name8 (NamePattern2) 1037**] [**Last Name (NamePattern1) 30891**] #[**Numeric Identifier 92680**] [**2162-7-5**] 01:40PM. . [**2162-7-4**] 7:00 pm BLOOD CULTURE Source: Line-RUE A-line radial. **FINAL REPORT [**2162-7-10**]** Blood Culture, Routine (Final [**2162-7-10**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY. FINAL SENSITIVITIES. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | CLINDAMYCIN-----------<=0.25 S R ERYTHROMYCIN---------- =>8 R =>8 R GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- =>8 R =>8 R OXACILLIN------------- =>4 R =>4 R RIFAMPIN-------------- <=0.5 S <=0.5 S TETRACYCLINE---------- =>16 R =>16 R VANCOMYCIN------------ 1 S 1 S Aerobic Bottle Gram Stain (Final [**2162-7-5**]): GRAM POSITIVE COCCI IN CLUSTERS. REPORTED BY PHONE TO [**Name (NI) 815**], [**First Name3 (LF) **] ON [**2162-7-5**] AT 1814. . [**2162-7-4**] 7:00 pm SPUTUM Source: Endotracheal. [**2162-7-6**] 3:51 am SEROLOGY/BLOOD Source: Line-aline. **FINAL REPORT [**2162-7-7**]** RAPID PLASMA REAGIN TEST (Final [**2162-7-7**]): NONREACTIVE. Reference Range: Non-Reactive. . Blood cultures form [**7-7**], [**7-8**], [**7-11**], [**7-12**] still pending. . CHEST (PORTABLE AP) Study Date of [**2162-6-29**] 11:43 PM PORTABLE AP VIEW OF THE CHEST: Right internal jugular central venous catheter terminates at the cavoatrial junction. No pneumothorax. There is increased interstitial opacity and engorgement of the pulmonary vasculature in the setting of cardiomegaly, compatible with edema. Lung volumes are low. Retrocardiac opacity is likely atelectasis. Mediastinal silhouette is notable only for tortuosity of the thoracic aorta. . CT ABDOMEN and Pelvis W/O CONTRAST Study Date of [**2162-6-30**] 2:48 AM CT CHEST WITHOUT IV CONTRAST: There is patchy opacity at the bilateral lung bases which is slightly more consolidative appearing at the left base and could represent atelectasis, but underlying infection should be considered. Trace left pleural effusion. Heart and great vessels are unremarkable. Right internal jugular central venous catheter terminates in the distal SVC. No pericardial effusion. No pneumothorax. No axillary or hilar lymphadenopathy is noted. Multiple small mediastinal nodes do not meet CT criteria for pathologic enlargement. Airways are patent to the segmental level. CT ABDOMEN WITH IV CONTRAST: Evaluation of the abdominal organs is limited without IV contrast. Within this limitation, there is fatty infiltration of the liver. The gall bladder is surgically absent. There is fatty atrophy of the pancreas. Splenomegaly measuring up to 15 cm is noted. Bilateral adrenal glands are unremarkable. A 5 mm stone is noted in the left proximal ureter with associated mild hydronephrosis. Tiny nonobstructing stone in the right renal pelvis. Non- opacified stomach and intra-abdominal loops of small and large bowel are unremarkable. No free air or fluid in the abdomen. No mesenteric or retroperitoneal lymphadenopathy meeting CT criteria for pathologic enlargement. CT PELVIS WITHOUT IV CONTRAST: The urinary bladder is collapsed around a Foley catheter. Uterus, adnexa, sigmoid colon and rectum are unremarkable. No free fluid in the pelvis. No pelvic or inguinal lymphadenopathy meeting criteria for pathologic enlargement. BONE WINDOWS: Bones are diffusely demineralized. No suspicious lytic or sclerotic osseous lesion is present. There are six non-rib-bearing lumbar vertebral bodies with partial fusion of the L5 and L6 vertebral bodies. There has been slightly increased anterior wedging of the L2 vertebral body compared to [**2160-7-22**]. Compression fractures of T6 and T8 are similar to prior. IMPRESSION: 1. Patchy opacity at the bilateral lung bases which is more consolidative appearing at the left base. Although findings may represent atelectasis, infection is possible. Trace left pleural effusion. 2. 5 mm left ureteral stone with mild hydronephrosis. Tiny nonobstructing right renal stone. 3. Slight progression of L2 compression deformity compared to [**2160-7-22**]. . CT ABDOMEN and PELVIS W/O CONTRAST Study Date of [**2162-7-3**] 3:28 PM FINDINGS: There has been an increase in the small bilateral pleural effusions but more marked progression of the bilateral lower lobe atelectasis. Superimposed consolidation cannot be excluded. No suspicious pulmonary nodule is seen. The visualized heart, great vessels and pericardium are unremarkable in appearance on this non-contrast study. Non-contrast examination of the liver, adrenal glands and pancreas is unremarkable. The gallbladder is surgically absent. The spleen is enlarged measuring approximately 15 cm. This is unchanged compared with previous imaging as far back as [**2152-10-27**]. The right kidney is normal in size measuring approximately 6.4 x 7.2 x 10 cm. There is a tiny 0.2cm calcific density seen in the lower pole of the right kidney. This is not causing any apparent obstruction and is unchanged in position compared with the previous study. No hydronephrosis. No perinephric fat stranding evident. There is a small hypoattenuating lesion in the lower pole of the right kidney which is incompletely characterized on CT but could represent a small AML. The left kidney is swollen, measuring 9 x 6.5 x 11.2 cm with mild perinephric fat stranding. The renal collecting system and ureter are not dilated on this side, so this appearance could be related to urosepsis rather than ureteric obstruction. The previously identified calculus in the proximal left ureter is now seen to lie within the pelvis at the approximate location of the left vesicoureteric junction. This calculus measures approximately 0.3 cm and is not causing any proximal hydronephrosis, although it has not yet passed into the bladder. CT OF THE PELVIS WITHOUT IV CONTRAST: The urinary bladder is collapsed around the Foley catheter. The uterus, adnexal regions, sigmoid colon and rectum are unremarkable. No free fluid is seen. No pelvic lymphadenopathy. OSSEOUS STRUCTURES: Stable compression fractures at L2. IMPRESSION: 1. 0.3cm calculus at the left vesicoureteric junction not causing proximal hydronephrosis. Swelling of the left kidney, likely secondary to pyelonephritis. 2. 0.2-mm calculus in the lower pole of the right kidney, non-obstructing. 3. Stable compression fractures at T6, T8 and L2. . CHEST (PORTABLE AP) Study Date of [**2162-7-3**] 11:26 AM One view. Comparison with [**2162-7-2**]. There is interval improvement in pulmonary vascular congestion. Well defined increased density at the left lung base persists. The heart and mediastinal structures are unchanged. An endotracheal tube, nasogastric tube, and right internal jugular catheter remain in place. IMPRESSION: Interval improvement in pulmonary vascular congestion. . CHEST (PORTABLE AP) Study Date of [**2162-7-5**] 3:35 PM AP UPRIGHT RADIOGRAPH OF THE CHEST: The lung volumes are low. There are bilateral patchy airspace opacities, minimally improved since the prior study particularly in the retrocardiac region where there is better parenchymal aeration. Otherwise there are no significant interval changes. The ET tube, NG tube are in standard location. There has been interval removal of the right IJ catheter. IMPRESSION: Slight improvement in parenchymal aeration otherwise unchanged with multifocal patchy opacities predominantly at the lung bases. . CT LOW EXT W/O C RIGHT Study Date of [**2162-7-6**] 3:11 PM FINDINGS: The study is slightly limited by patient motion. There is a partially healed fracture of the proximal fibula, with evidence of bony bridging about the lateral aspect of the fracture and well-corticated fracture lines through the medial aspect of the fracture. There is a lateral fixation plate and screws transfixing a partially healed fracture of the proximal tibia. The superior most screw extends approximately 2.8 cm beyond the tibial cortex into the soft tissues with small amount of soft tissue density adjacent to the screw tip. There is no lucency about the hardware and no evidence of hardware fracture. The distal tibial diaphyseal fracture is incompletely healed. There is partial healing of the fracture at its proximal aspect, with sclerotic corticated fracture margins superiorly and posteriorly. However, there is an abnormal diastasis of the bone fragments, with irregularity and non-healing of the bone at the anterior aspect of the fracture (best seen on the sagittal images - 1000A:37 and on the axial images (8:129). There is an abnormal lucency within the medullary cavity, surrounded by faint sclerosis, somewhat fuzzy margins, as well as soft tissue density extending beyond the cortex. These findings are concerning for osteomyelitis and intramedullary fluid. Evaluation of the knee joint demonstrates tricompartmental osteoarthritis with tricompartmental osteophytes, sharpening of the tibial spines, osteophytes projecting into the trochlear notch, as well as osteophytes in the patellofemoral compartment. There is subchondral cyst formation. There is a small knee joint effusion. Degenerative changes are seen at the proximal tibiofibular joint with osteophyte formation and sclerosis. The osseous structures are diffusely demineralized. IMPRESSION: 1. Partially united proximal tibial diaphyseal fracture with findings concerning for osteomyelitis as described above. 2. Partially united proximal fibular fracture. 3. Moderate tricompartmental knee joint DJD. 4. Small knee joint effusion. . TEE (Complete) Done [**2162-7-7**] at 2:37:58 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Doctor Last Name **], [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Pulmonary, Critical Care & [**Last Name (un) 9368**] [**First Name (Titles) **] [**Last Name (Titles) **] [**Location (un) 830**], [**Hospital Ward Name 23**] 8 [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2108-12-4**] Age (years): 53 F Hgt (in): 67 BP (mm Hg): 120/62 Wgt (lb): 289 HR (bpm): 78 BSA (m2): 2.37 m2 Indication: Endocarditis. ICD-9 Codes: 424.90, 424.0 Test Information Date/Time: [**2162-7-7**] at 14:37 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: Cardiology Fellow Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2010W004-0:00 Machine: Vivid q-2 Sedation: Versed: 2 mg Fentanyl: 100 mcg Patient was monitored by a nurse throughout the procedure Echocardiographic Measurements Results Measurements Normal Range Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: No atheroma in aortic arch. No atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on aortic valve. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No mass or vegetation on mitral valve. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or vegetation on tricuspid valve. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No vegetation/mass on pulmonic valve. No 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 monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. Local anesthesia was provided by benzocaine topical spray. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). 0.2 mg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe insertion. No TEE related complications. Image quality was suboptimald - poor esophageal contact. Conclusions [**Name2 (NI) **] 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. 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. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No mass or vegetation seen on mitral valve, aortic valve, tricuspid valve, or pulmonic valve. No pathologic valvular regurgitation. Normal biventricular systolic function. . VENOUS DUP UPPER EXT BILATERAL Study Date of [**2162-7-8**] 2:24 PM BILATERAL UPPER EXTREMITY ULTRASOUND: Grayscale and color Doppler son[**Name (NI) 867**] was performed of the right and left subclavian, axillary, brachial, radial, cephalic, and basilic veins and the internal jugular veins. Normal flow, augmentation, compressibility, and waveforms are demonstrated. No intraluminal thrombus is seen. IMPRESSION: No evidence of an upper extremity DVT. Brief Hospital Course: MICU Course: 53 yo F with PMH HIV last CD4 1068, on HAART, hepatitis B, hepatitis C, h/o ?PE on coumadin, morbid obesity, h/o recurrent UTI last one with ESBL E. coli, OSA and h/o ovarian CA in [**2142**] s/p oophrectomy, present with SOB, CP, cough, N/V diarrhea over the past few days. . # Hypotension: The patient was hypotensive on admission and required pressors. Likely multifactorial including dehydration from vomiting and diarrhea as well as sepsis with urine as likely source, though evidence is not clear cut as urne culture only grew out ~1000 cfu's of GNR's, though urinalysis was c/w infection and blood cultures grew out ESBL E. Coli which she has had in previous UTI's/. She was initially treated with IVF and meropenem and continued on meropenem at time of transfer to the floor on [**2162-7-7**]. . # Respiratory distress: The patient presented in respiratory distress and was intubated likely due to acute insult of sepsis on underlying COPD/Asthma. She developed ARDS and was placed on ARDSnet protocol. CTA showed atelectasis vs. PNA; it was negative for PE. Pt was covered for infectious process with meropenem as above. Sputum cultures were consistently negative. She was given nebulizer treatments for symptomatic improvement. She was eventually weaned off the ventilator and successfully extubated. She was then transferred from ICU to the floor for further care. . # Coag Negative Staph Bacteremia: The patient developed coag negative staph bacteremia and spiked fevers. Her A-line was pulled and she was started on linezolid. She had positive cultures the following day off a resited A-line. It too was pulled. She was continued on Linezolid and remained afebrile, with greater than 48 hours of negative cultures at the time of discharge. A TEE was negative for endocarditis and a CT of her R knee was negative for infected hardware / osteomyelitis. [**Date Range 1957**] was consulted and agreed that there was no evidence of osteomyelitis or infected hardware. Outpatient follow-up is planned with [**Date Range **]. . # ARF: The patient presented in acute renal failure likely from poor perfusion. She also had a stone in the L ureter with mild hydronephrosis. Both urology and interventional radiology deferred procedural intervention given that her Cr normalized and the difficulty of procedure given her body habitus and comorbidities. At the time of transfer out of ICU her Cr had normalized. . # Diarrhea: The patient had a large amount of diarrhea. C.Diff and stool cultures were sent and eventually returned negative. She was initially started empirically on Cipro and Flagyl which were dc'd with negative work-up. Diarrhea was most likely secondary to lactulose administration. On transfer out of ICU to the floor diarrhea had resolved. . # Altered Mental Status: The patient alternated between somnolence and agitation during much of her MICU stay. Her home methadone dose was decreased to 10 mg TID with good response. TSH, B12, and ammonia levels were normal. Lactulose was given. At time of transfer to medicine floor, pt mental status had not cleared but was improving. . # HIV: She was continued on home meds and a viral load was nearly undetectable. . # Hepatitis B/C: Continued on home meds ....... Once out of the ICEU and on the medicine floor, pt intial was delerius but had continued improvement over several days. Methadone and other sedating medications were initially held as there was concern that these may be contributing to pt delerium. VS remained stable. Pt continued course of meropenem and linezolid which were complete on [**7-12**] and [**7-13**] respectively. Pt had a bought of several loose stools; C diff was repeated and was negative. Pt also noted increased buring with urination; UA and culture was repeated; these cultures were pending at time transfer to rehab. Pt was afebrile, VS remained stable and delerium cleared prior to day of discharge to rehab. Pt was restarted on coumadin with lovenox bridge with goal of therapeutic INR of [**12-30**] to be monitored in rehab and in outpatient setting. Medications on Admission: - Albuterol Sulfate 90 mcg/Q4H PRN asthma. - Atazanavir 300 mg PO DAILY. - Bisacodyl 10 mg (E.C.) by mouth DAILY prn constipation. - Calcium Carbonate 500 mg TID - Camphor-Menthol .5-0.5 % Lotion QID prn itching - Cholecalciferol (Vitamin D3) 400 unit PO DAILY - Clonazepam 0.5 mg Tablet PO TID. - Cyclobenzaprine 10 mg PO TID prn for spasms - Diphenhydramine HCl 50 mg PO Q6H prn itching - Docusate Sodium 100 mg Capsule PO BID - Duloxetine 20 mg (E.C.) PO DAILY - Emtricitabine-Tenofovir 200-300 mg Tablet PO DAILY - Fluticasone 50 mcg/Actuation Spay 2 Spray Nasal DAILY - Furosemide 40 mg Tablet PO BID - Gabapentin 800 mg Capsule PO QAM, QPM, 2 at bedtime - Hydromorphone 4-8 mg PO Q3H PRN pain. - Methadone 40 mg PO TID prn - Multivitamin PO DAILY. - Ritonavir 100 mg PO DAILY. - Sennosides 8.6 mg Tablet 1-2 Tablets PO BID. - Spironolactone 25 mg PO DAILY - Sumatriptan Succinate 100 mg PO daily prn migraine - Tiotropium Bromide 18 mcg Inhalation DAILY (Daily). - Zolpidem 10 mg PO QHS - Warfarin 5mg PO daily Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. Atazanavir 300 mg Capsule Sig: One (1) Capsule PO once a day. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. 4. Calcium Carbonate 500 mg (1,250 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Topical four times a day as needed for itching. 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO once a day. 7. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO three times a day as needed for spasm. 8. Diphenhydramine HCl 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for itching. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation: hold for loose stool. 10. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Nasal once a day. 13. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO once a day: QAM. 14. Gabapentin 800 mg Tablet Sig: Two (2) Tablet PO at bedtime. 15. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H:PRN as needed for pain: hold for sedation. 16. Methadone 10 mg Tablet Sig: Two (2) Tablet PO three times a day as needed for pain: hold for sedation. 17. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 19. Sennosides 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for constipation. 20. Sumatriptan Succinate 100 mg Tablet Sig: One (1) Tablet PO once a day. 21. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 22. Coumadin 10 mg Tablet Sig: One (1) Tablet PO once a day. 23. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 24. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO twice a day. 25. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a day: lovenox bridge to coumadin total dose of lovenox 130mg [**Hospital1 **], INR goal of [**12-30**]. 26. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous twice a day: lovenox bridge to coumadin total dose of lovenox 130mg [**Hospital1 **], INR goal of [**12-30**]. Discharge Disposition: Extended Care Facility: [**Location (un) 86**] Center for Rehab & Sub-Acute Care - [**Location (un) 2312**] Discharge Diagnosis: Primary: Bacteremia UTI Sepsis - most likely a concequence of UTI . Secondary: Delerium ARDS Pneumonia Asthma 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 because of shortness of breath, chest pain, fever, nausea and vomitting for several days without improvement. You're symptoms worsened when you initially arrived and you had to be admitted to the ICU. Because you vital signs were very unstable you were intubated to help you breath while the cause of your illness was determined and treated. It was found that you had an infection of your bladder and your blood. You received antibiotics and you're condition improved. You were able to be extubated but remained confused. Eventually your condition improved to the point where you no longer required ICU level care and you were transferred to the main medicine floor. After you completed you coures of antibiotics, you were then discharged to an extended care facility to complete your recovery and rehabilitation. . The following changes were made to your medications: - Please DECREASE your dose of methadone to Methadone 20 mg three times a day; this will be titrated at the rehabilitation facility as necessary to your original dose based on your pain needs. - Please STOP taking Zolpidem 10 mg at night. Please discuss the need for this medication with your doctor. - Please STOP taking Clonazepam 0.5mg three times a day; this was stopped given our concern over your confusion and sedation. Please discuss the need for this medication with your doctor. - Please RESTART taking warfarin 10mg daily. Please be sure to have your INR checked per protocol at the rehabilitation facility and then as per your doctors orders once [**Name5 (PTitle) **] return home at you regular [**Hospital3 **]. Goal INR of [**12-30**] - Please START taking lovenox 130mg [**Hospital1 **] while we are waiting for your coumadin to reach the appropriate level. Goal INR of [**12-30**] - Please continue to take all of your other home medications as prescribed. Please be sure to take all medication as prescribed. . Please check INR twice a week until INR level is stable. Continue Lovenox until reaching INR goal of [**12-30**]. Please be sure to have your INR checked at the rehabilitation clinic per anticoagulation monitoring protocol; once discharged please be sure to have your INR checked at your regular [**Hospital 3052**] per your doctors [**Name5 (PTitle) **]. . Please be sure to keep all follow-up appointments with your PCP and other health care providers. . It was a pleasure taking care of you and we wish you a speedy recovery. Followup Instructions: Please be sure to keep all follow-up appointments with your PCP and other health care providers. . Please be sure to have your INR checked at your regular [**Hospital3 **]. Please check INR twice a week until INR level is stable. Continue Lovenox until reaching INR goal of [**12-30**]. . Department: ORTHOPEDICS Name: [**Last Name (LF) 85803**], [**First Name3 (LF) **] PA (works with [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]) Location: [**Hospital6 5242**] CENTER Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 798**] Appt: [**7-15**] at 10:30am When: TUESDAY [**2162-7-20**] at 12:10 PM With: [**Year (4 digits) **] XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2162-7-20**] at 12:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**] Completed by:[**2162-7-14**]

[ "070.70", "787.91", "276.8", "592.1", "112.89", "V09.91", "276.4", "V87.41", "591", "584.9", "995.92", "070.30", "493.20", "790.7", "287.4", "V08", "041.10", "278.01", "785.52", "599.0", "V10.43", "518.81", "338.29", "293.0", "305.1", "038.42", "327.23", "486" ]

icd9cm

[ [ [] ] ]

[ "00.14", "38.93", "96.04", "88.72", "96.72", "96.6", "38.91" ]

icd9pcs

[ [ [] ] ]

37270, 37380

29585, 32390

366, 392

37534, 37534

4415, 11026

40203, 41603

2711, 2905

34747, 37247

37401, 37513

33705, 34724

37717, 40180

2920, 4396

11062, 29562

292, 328

420, 1491

37549, 37693

1513, 2294

2310, 2695

28,479

108,885

33817

Discharge summary

report

Admission Date: [**2180-1-2**] Discharge Date: [**2180-2-9**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: left carotid stenosis symptomatic fem-tibial ASO with arterial insuffiency Major Surgical or Invasive Procedure: diagnostic angiogram via right sfa access [**1-3**] left CEa [**1-4**] left fem at bpg withcomposite reversed and non reversed GSV, venovenostomy, angioscopy and valve lysis [**2180-1-10**] left graft thrombectomy [**2180-1-11**] History of Present Illness: Patient refered to Dr.[**Last Name (STitle) 1391**] for progressive calf claudication with associated left foot /toe gangrene and incidental high grade left carotid stenosis . Admitted for vascular evaluation and left carotid endartectomy. Past Medical History: histroy of hearing loss history of carotid stenosis by ultra sound exam Social History: lives alone, independant ADL's nonsmoker or drinker Family History: mother with PVD s/p amputation Physical Exam: Vital signas afebrile Gen: oriented x3 HEENT: bilateral carotid bruits Heart: RRR noraml S1S2 Lungs: clear to auscultation abd: soft nontender , nondistended, bowel sounds present EXT: left #2 toe with erythema and edema. left foot edematous Pulses: right: palpable femoral , absent [**Doctor Last Name **], dopperable monophasic signal of DP/PT left: palpable femoral, [**Doctor Last Name **],DP dopperable monophasic signal, absent signal PT. Neuro: nonfocal Pertinent Results: [**2180-1-2**] 02:58PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2180-1-2**] 04:10PM PT-13.7* PTT-32.1 INR(PT)-1.2* [**2180-1-2**] 04:10PM PLT COUNT-375 [**2180-1-2**] 04:10PM WBC-6.2 RBC-4.61 HGB-13.7 HCT-40.4 MCV-88 MCH-29.7 MCHC-33.9 RDW-12.8 [**2180-1-2**] 04:10PM CALCIUM-9.7 PHOSPHATE-3.2 MAGNESIUM-2.2 [**2180-1-2**] 04:10PM estGFR-Using this [**2180-1-2**] 04:10PM GLUCOSE-100 UREA N-16 CREAT-0.7 SODIUM-141 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14 Brief Hospital Course: [**2180-1-2**] admitted IV vanco and cipro and flagyl began for erythema and dry gangrene of left foot. Iv hydration began for anticipated angio [**1-3**] [**2180-1-3**] diagnositc angio via rt. femoral access, postangio hypertension requiring IV nitro to control blood pressure. [**2180-1-4**] Ntg weaned . underwent Left CEA. post recovery episodes secondary to intravascular depletion with hypo tension and low urinary out put -fluid resustated [**2180-1-5**] POD#1 requiring adjustment in lopressor dosing and addition of hydralazine for B/P control. Hct 27.6 transfused one unit PRBCS. [**2180-1-6**] POD#2 social service consulted.delined [**2180-1-7**] POD#3 evaluated by physical thearphy. [**2180-1-10**] POD#6 left fem- at pbg with composite GSV. graft failure. IV heparin [**2180-1-11**] POD#[**5-23**] graft thrombectomy with reocclusion of graft. [**2180-1-12**] POD#[**6-24**] evaluating vein conduit. pain control.Evaluated by speeech and swallow, dysphagia secondary to multiple endo trachial entubations and sedation from narcotic thichkened liquids and pureed solids recommended. [**2180-1-17**] POD#13/5 Return to surgery for redo left fem-peroneal bpg with left arm vein [**2180-1-18**] POD#14/6/1 left arm bleeding [**First Name9 (NamePattern2) 78182**] [**Last Name (un) **] hemostasis and transfusion 2 PRBC"S [**2180-1-19**] POD#14/7/2 remains in VICU requiring med adjustment for BP control, rebleed from left arm resolved with manual pressure. transfused 1 unit PRBC's. Still with swallowing diffculties.Coumadin/IV heparin conversion began [**2181-1-20**] PICC line placed. TPN started. [**2180-1-22**] chest pain. enzymes cycled.EKG no alcute changed. [**2180-1-23**] self d/c'd picc line. attempted to place @ bedside.Continues with intermittent delerium and combativness requiring haldol. [**2180-1-24**] INR 5.7 anticoagulation held.repeat bedside swallow evaluation done improvment in swallowing but continues to vomit.bleeding from picc line site, resolved with manual pressure. Transfused.left leg bleeding. INR 17.0 reversed with FFp 6 units and PRBC"s. hematology consulted current bleeding problem secondary to malnutritiion and hypercoaguable state from accumalitve effects of coumadin. Transfered to CVICU.underwent exploration and evacuatiion of groin hematoma. [**2180-1-25**] Rt. IJ placed. cxr without infiltrate but increased pulmonary congestion and pleural effusions L>R.Geratric consult for postoperative delerium.Required Vitamin K 10 x2 and additional 2FFp and @ PRBC's for elevated INR.serial Hct. monitered TPN continued. [**2180-1-26**] started on nicardipine gtt for hypertension. Vanco d/c'd. [**2180-1-28**] Continues to remain NPO per Speech/Swallow assesment to somulent to restart po's continue NPO and TPN.Hct. remains stable Hemetology signs off. Gertology signsoff. [**Date range (1) 78183**] underwent barium swallow- no organic findings but patient does aspirate.Repeat swallowing assesment @ bed side defered secondary to sedation. PT contiune to floow patient. ENT consulted for Vocal cord evaluation secondary to aspiration. VC assesment could not be commpleted secondary to patient's lack of cooperation and confusion. [**2-1**] Trama [**Doctor First Name **] consult for PEG placement.Bed side swallow evaluation with all food consistanceies no apparent evidence of signs or symptoms of aspiration. Schedualed a video swallow for [**2180-2-2**] [**2180-2-2**] swallow study defered secondary to PEG placement by Trama Surgery. [**2180-2-3**] swallow study could not be done- patient refused. Continue NPO and TPn. Peg feed held secondary to nausea earlier on [**2-3**].ENT could not visularized cord secondary to patient's refusal to have procedure done. Will requir ENT followup post d/c when patient has recovered from current hospitalization. [**2180-2-4**] TPN continued. arm skin clips removed.patient to have small bowel follow thru study to determin if any mechanical reasons for persistant vomiting. [**2180-2-4**] SBFT negative for any mechanical reasons . tube feeds slowly advanced [**Date range (1) 78184**] left arm staples d/c'd. left upper arm sutures remain in place and will be d/c'd 10-14day followup kwith Dr. [**Last Name (STitle) 1391**].Foley d/c'd. Tube feed slowly advanced. [**2-8**] reglan strated for intermittent nausea and emesis. Tube feed changes . No further incidences of emesis now on reglan. [**2180-2-9**] D/c'd to rehab stable. Medications on Admission: no meds Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml. PO BID (2 times a day). 3. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation q4h prn (). 4. Haloperidol Lactate 5 mg/mL Solution Sig: 0.5 mg Injection Q4H (every 4 hours) as needed. 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO BID (2 times a day). 8. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 12. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN 10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 units Injection TID (3 times a day). 14. Xopenex 0.63 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation q4h prn. 15. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 16. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 18. Metoprolol Tartrate 5 mg/5 mL Solution Sig: 7.5 mg Intravenous Q4H (every 4 hours) as needed for sbp >180 or hr >100. 19. Haloperidol Lactate 5 mg/mL Solution Sig: 0.5 mg Injection q4h prn as needed for agitation. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: high grade left carotid stenosis, asymptomatic arterial insuffiency , symptomatic and left foot /toe gangrene postoperative hypertension uncontrolled, treated postoperative blood loss anemia, transfused postoperative graft failure postoperative dysphagia to solids postoperative left arm hematoma-stable postoperative left leg wound bleeding postoperative failure to thrive-TPN/TF Discharge Condition: stable Discharge Instructions: left upper arm sutures remain in place until seen in followup with Dr. [**Last Name (STitle) 1391**] 10-14 days Followup Instructions: 10-=14 days Dr. [**Last Name (STitle) 1391**]. Call for an appointment [**Telephone/Fax (1) 1393**] 4 weeks [**Hospital **] clinic for VC evalution, call for appointment [**Telephone/Fax (1) 41**] Completed by:[**2180-2-9**]

[ "998.12", "707.15", "338.18", "285.1", "401.9", "783.0", "560.1", "440.24", "286.7", "784.49", "293.0", "996.74", "263.9", "599.0", "997.5", "433.10" ]

icd9cm

[ [ [] ] ]

[ "38.12", "00.40", "88.42", "86.04", "38.93", "43.11", "38.02", "39.49", "88.48", "96.6", "39.29", "39.56", "99.15" ]

icd9pcs

[ [ [] ] ]

8377, 8447

2077, 6514

334, 566

8872, 8881

1544, 2054

9041, 9268

1015, 1047

6572, 8354

8468, 8851

6540, 6549

8905, 9018

1062, 1525

220, 296

594, 835

857, 930

946, 999

3,560

150,475

3226

Discharge summary

report

Admission Date: [**2148-11-25**] Discharge Date: [**2148-11-29**] Date of Birth: [**2098-3-4**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: Dypnea Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 50yo woman with breast cancer metastatic to bone and lung presenting with shortness of breath that started 1-2 weeks prior to admission. The patient reports feeling "lousy" for several days with nonproductive cough and fever to 101.8. Primary care physisician diagnosed her with viral URI one week prior to admission. Symptoms continued to progress. She was evaluated by her oncologist on the day of admission and was found to have oxygen saturation 68% on room air, increasing to 93% on 4L, then worsening again to the low 90s and requiring NRB. She was treated with 1 dose iv Bactrim after CXR appeared consistent with PCP, [**Name10 (NameIs) **] transferred to ED. In the ED she received a dose of CTX/Azithro, and was transferred to the ICU. Past Medical History: Breast cancer, diagnosed [**2143**] s/p masectomy with reconstruction, mets ot lung and vertebrae, on weekly Gemzar chemotherapy Social History: lives alone, brother in [**Name (NI) **] no tob [**12-29**] glasses wine/day no illicits Family History: mother d. cancer of unknown etiology Physical Exam: T 98.7 HR 95 BP 112/57 RR 27 92%NRB Gen: pleasant, speaking in full sentences, NRB HEENT: PERRL, anicteric, MMM, OP clear Neck: supple, no LAD, no JVP CV: RRR, no m/r/g, nml s1s2 Pulm: rales bilaterally, good air movement Abd: +BS, soft, NT, ND, well healed scar Ext: no c/c/e, 2+ DP pulses B Pertinent Results: [**2148-11-25**] 09:00PM GLUCOSE-101 [**2148-11-25**] 09:00PM CALCIUM-8.3* PHOSPHATE-3.5 MAGNESIUM-2.0 [**2148-11-25**] 09:00PM WBC-13.5* RBC-3.14* HGB-9.8* HCT-30.7* MCV-98 MCH-31.1 MCHC-31.8 RDW-21.4* [**2148-11-25**] 09:00PM NEUTS-72.9* LYMPHS-15.7* MONOS-8.4 EOS-2.0 BASOS-1.0 [**2148-11-25**] 09:00PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-1+ [**2148-11-25**] 09:00PM PLT COUNT-714* [**2148-11-25**] 09:00PM PT-12.6 PTT-23.3 INR(PT)-1.0 [**2148-11-25**] 07:46PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2148-11-25**] 07:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2148-11-25**] 12:30PM UREA N-10 CREAT-0.7 SODIUM-138 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14 [**2148-11-25**] 12:30PM LD(LDH)-750* [**2148-11-25**] 12:30PM WBC-14.5*# RBC-3.35* HGB-10.6* HCT-33.3* MCV-99* MCH-31.6 MCHC-31.8 RDW-21.3* [**2148-11-25**] 12:30PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL BITE-OCCASIONAL FRAGMENT-OCCASIONAL [**2148-11-25**] 12:30PM PLT SMR-VERY HIGH PLT COUNT-710*# [**2148-11-25**] 12:30PM GRAN CT-[**Numeric Identifier 15098**]* CXR: new marked bilateral diffuse interstitial opacities Chest CT: diffuse interstitial ground glass opacities, mediastinal lymphadenopathy Brief Hospital Course: 50yo woman with metastatic breast cancer presenting with dyspnea, fevers, nonproductive cough, and hypoxia. The patient was treated empirically with Bactrim for PCP given her presentation and CT findings, and CTX/Azithromycin for community acquired pneumonia. The differential diagnosis included PCP pneumonia, atypical or viral pneumonia, or pneumonitis caused by her chemotherapy. As induced sputum exam was unsuccessful, she underwent bronchoscopy and bronchoalveolar lavage. Bronchoscopy showed normal mucosa and no lesions. BAL showed no PCP infection, and sputum stain was nondiagnostic. Supplemental oxygen was weaned until the patient was saturating well on nasal canula. She was discharged to home on home oxygen, with instructions to follow-up with your primary care physician in the next week to wean the oxygen. Dr. [**Last Name (STitle) 2036**], her Oncologist, continued to follow the patient in house. She was discharged to home with instructions to complete a 14 day course of antibiotics. The ceftriaxone and azithromycin were changed to po levofloxacin prior to discharge. She is a full code. Medications on Admission: Gemzar- weekly Zometra Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Pneumonia Discharge Condition: good - sats 90% on RA at rest w/ desaturations into the low 80s w/ minimal exertion Discharge Instructions: If you develop worsening shortness of breath, recurrent fevers >101.2, or productive cough, please see your primary care physician or return to the emergency department. Make sure to take your prescribed antibiotic for the next 9 days and to keep yourself well-hydrated. Followup Instructions: Please follow up with your primary care physician and oncologist within two weeks. You will need to be evaluated by your primary care physician to determine if the supplemental oxygen can be weaned off.

[ "486", "V10.3", "198.5", "285.9", "197.0" ]

icd9cm

[ [ [] ] ]

[ "33.24" ]

icd9pcs

[ [ [] ] ]

4395, 4453

3199, 4322

323, 337

4507, 4592

1770, 3176

4912, 5119

1392, 1430

4474, 4486

4348, 4372

4616, 4889

1445, 1751

277, 285

365, 1118

1140, 1270

1286, 1376

1,137

120,833

52349

Discharge summary

report

Admission Date: [**2114-12-18**] Discharge Date: [**2115-1-2**] Date of Birth: [**2067-6-25**] Sex: F Service: MEDICINE Allergies: Penicillins / Naproxen / Dilantin Attending:[**First Name3 (LF) 562**] Chief Complaint: Feces on walls Major Surgical or Invasive Procedure: Hemodialysis HD line placement Re-suturing of permacath site History of Present Illness: 47 yo female with HIV, hep C, hepatic encephalopathy, presented to ER for smearing feces on the wall. Notes from nursing home state rash started [**12-15**], blood shot eyes and low grade temps. Pt states rash is itchy but not painful. Per family members, rash started at least for 1 wk. Rocephin started recently ?date, d/c [**12-15**]. Pt denied any new meds, but is not a reliable historian. Pt recent admit [**2114-12-3**] at [**Hospital3 **] hosp for grand mal seizure, also admit at [**Hospital 108217**] hosp on [**2114-12-8**] for abd pain. In [**Name (NI) **], pt passed a large amount of foul smelling green diarrhea, guaiac + stool and MS has improved. Stool was sent for c-diff and various stool cx. Bcx sent. CT head ordered. Past Medical History: 1. Hepatitis C cirrhosis-genotype 1, VL 6,500,000 [**2114-9-11**]. Incomplete treatment trial with IFN/[**First Name9 (NamePattern2) 108216**] [**Month (only) **]-[**2111-9-22**], stopped due to neutropenia 2. Esophageal varices- [**3-27**] EGD-varices at the gastroesophageal junction, grade I 3. H/o hepatic encephalopathy with multiple admissions for this 4. HIV-([**2114-9-15**]- VL>100,000 copies, CD4 233)- Was off of AVR therapy since late [**2112**] but restarted a few months ago 5. Renal failure secondary to diabetes 6. Diabettes Mellitus 7. GERD 8. Chronic pancreatitis 9. HTN 10. Cholecystectomy Social History: NO current smoking, alcohol, no drug use. The patient has a prior history of heavy alcohol use and has not drank in over a year. 25-pack-year smoking history. prior history of cocaine use/IVDU but quit many years ago. Pt was homeless but now lives at a nursing home. Family History: Mother with type 2 diabetes. Physical Exam: 98.4 78 107/70 18 99%RA Gen: AA female lying in bed in dark, refused to have lights on due to 'lights bothers me', my eyes hurts. HEENT: Conjunctiva injected bilat, Lips with erosions and crust, palate with erythematous lesions. NECK: slightly stiff, no LAD, no JVD CV: reg rate, s1 s2, +harsh systolic murmur loudest at RUSB Abd:+distension, +occasional spider angioma, +dullness to percussion laterally over abd, +tenderness RUQ&over epigastrum,NR/no mass, no pulsation EXT: +2 LE pitting edema with diminished DP pulses. Neuro: lethargic, eye exam difficult due to covered with lots of pus. oriented to person and place. not cooperative. Skin: diffused erythematous lesions including palms and soles with red macules and papules, some lesions excoriated; some lesions on leg non-blanching. Pertinent Results: CXR: No radiographic evidence of acute cardiopulmonary process. [**2114-12-18**] 03:54PM GLUCOSE-83 UREA N-61* CREAT-3.7* SODIUM-134 POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-17* ANION GAP-14 [**2114-12-18**] 03:54PM ALT(SGPT)-19 AST(SGOT)-47* ALK PHOS-135* AMYLASE-395* TOT BILI-0.6 [**2114-12-18**] 03:54PM LIPASE-123* [**2114-12-18**] 03:54PM ALBUMIN-1.9* CALCIUM-6.9* PHOSPHATE-3.9 MAGNESIUM-1.3* [**2114-12-18**] 03:54PM ACETONE-NEG [**2114-12-18**] 03:54PM PHENYTOIN-9.8* [**2114-12-18**] 03:54PM WBC-8.5 RBC-2.77* HGB-8.9* HCT-26.5* MCV-96 MCH-32.1* MCHC-33.5 RDW-18.4* [**2114-12-18**] 03:54PM NEUTS-41* BANDS-2 LYMPHS-20 MONOS-32* EOS-1 BASOS-1 ATYPS-3* METAS-0 MYELOS-0 [**2114-12-18**] 03:54PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL TARGET-OCCASIONAL BURR-OCCASIONAL TEARDROP-OCCASIONAL [**2114-12-18**] 03:54PM PLT SMR-LOW PLT COUNT-113* [**2114-12-18**] 03:54PM PT-14.2* PTT-36.8* INR(PT)-1.4 [**2114-12-18**] 05:21PM AMMONIA-50* [**2114-12-18**] 04:00PM LACTATE-1.8 . MICRO STUDIES: Urine [**12-26**] pend Blood cx [**12-25**], [**12-26**] pend [**2114-12-19**] EYE swab: GRAM STAIN 2+PMNs, no microorg, virus neg. Bacterial cx appears to be cancelled. [**2114-12-19**] RESPIRATORY CULTURE viral cx negative [**2114-12-19**] HSV viral swab oropharynx negative for HSV [**2114-12-19**] CSF: negative Cryptococcus, neg fluid cx, viral cx, fungal cx, with Gram stain showing NO PMNs and no microorganisms. . punch biopsy, skin left anterior thigh: Vacuolar interface dermatitis with pigment laden scale, scattered epidermal Civatte bodies, edema, and superficial dermal pigment incontinence. No epidermal necrosis is seen in this sample, however there is a focal early subepidermal split. The findings are consistent with an interface-type reaction including an interface-type drug reaction and/or a lesion along the spectrum of erythema multiforme/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] syndrome. . MRI head [**12-25**]: 1. Right parietal lobe lesion with susceptibility and questionable adjacent tiny area of enhancement, corresponding to the lesion seen on the patient's prior CT study of [**2114-12-19**]. This likely represents a small focus of hemorrhage versus a vascular malformation. . CXR [**12-25**] IMPRESSION: 1. Right IJ line is in good position. There is no pneumothorax. 2. Focal opacity at the left costophrenic angle consistent with atelectasis or infiltrate. 3. Eighteen millimeter nodule seen in the left mid lung field, which was in a different position on a prior study from [**2114-6-22**]. If clinically indicated, further evaluation with a chest CT is recommended. . CT torso [**12-27**]: heart size mildly enlarged, tunnel dialysis cath in proximal RA; no hilar LAD, bibasilar LAD, no pulm nodules; small left pleural effusion; liver/GB/spleen/bowel unremarkable; suggstion of renal disease; no osseous lesions; large amount of ascites . CT Head [**12-28**]: tiny high attenuation focus representing hemorrhage unchanged from [**12-19**] with small amt of edema; also area of high attenuation below R parietal bone but image limited by motion and is likely motion artifact but new subdural bleed cannot be excluded . Xray L/T/S spine: No fracture . CT Head repeat [**12-28**]: intraventricular hemorrhage in the R occipital [**Doctor Last Name 534**]. . CT head [**12-29**]: Interval increase in degree of hemorrhage present within the septum pellucidum and layering within the lateral ventricles bilaterally with stable appearance of right centrum semiovale foci of hemorrhage. . CT head [**12-30**]: FINDINGS: Hemorrhage within the septum pellucidum is unchanged when compared to prior study. The blood within the occipital horns of the lateral ventricles is also unchanged. The ventricles are stable in size since the prior study. There is no evidence of hydrocephalus. Again noted is a small focus of hemorrhage in the right centrum semiovale which is unchanged when compared to the prior study. IMPRESSION: Stable appearance of the head. Stable hemorrhage within the septum pellucidum and within the lateral ventricles. No new hemorrhage identified. . CT head [**1-1**] Findings: There is a new area of high density in the anterior interhemispheric fissure extending on both sides of the anterior falx cerebri. Some of this may be subdural in nature, but it appears to largely represent subarachnoid blood. It is layering along the right A1 portion of the anterior cerebral artery. Ventricular dimension is unchanged. IMPRESSION: New anterior interhemispheric hemorrhage with features as discussed above. This hemorrhage may be in continuity with the septal hematoma superiorly, but this is indefinite. . Brief Hospital Course: A/P 47 yo female with HIV, hep C, hepatic encephalopathy, presented to ER for change mental status and rash, found to be [**First Name8 (NamePattern2) **] [**Location (un) **] Syndrome based on clinical impression with supporting skin 4mm punch biopsy. Pt then seemed to develop a fibrinogen defect causing IVH and resulting in 2 MICU transfers for IV Amicar. . #IVH: Pt fell off IR table on [**12-28**], resulting in R eye hematoma and laceration. Pt was taken immediately for CT head and neck. C spine was negative for fracture. She had no C spine ttp, so C collar was removed. Pt did have lumbar and thoracic spinous process tenderness so Xray of spine was ordered. On read of head CT, there was the old subcortical small bleed and ?new R parietal bleed vs motion artifact. Xray of spine was negative for fracture. Repeat head CT showed the ?subdural bleed was an artifact, but there was a new area of intraventricular hemorrhage in the R occipital [**Doctor Last Name 534**]. Heme onc was contact[**Name (NI) **] and recommended IV amicar (given it was felt the pt had a fibrin related defect), neuro agreed. The pt was transferred to the MICU for IV amicar for 24 hrs at 0.2 gm/hr after an initial 1 gm loading dose. She was also given cryoprecipitate. Repeat CT head on [**12-29**] revealed interval increase in degree of hemorrhage present within the septum pellucidum and layering within the lateral ventricles bilaterally with stable appearance of right centrum semiovale foci of hemorrhage. Neurosurgery at this time felt the pt had no evidence of hydrocephalus and no obstruction of her 3rd and 4th ventricles (thus there was no further intervention). The pt was started on metoprolol 25 mg [**Hospital1 **] and hydralazine 25 mg po qid to maintain sbp less than 140 (pts sbp was up to 160 on [**12-28**]). Repeat CT head on [**12-30**] revealed stable appearance of the hemorrhage in the lateral ventricle. The pt was again transferred to the floor on [**12-31**] with repeat head CT on [**1-1**]. The pt found to have a new area of high density in the anterior interhemispheric fissure extending on both sides of the anterior falx cerebri. The pt was given plt to maintain above 100, Vit K for INR of 68, and cryoprecipitate to maintain fibrinogen levels greater than 200. She was again transferred to the MICU for IV Amicar infusion while patient was intubated as she was somnolent and unable to protect her airways. Patient's neurological status continued to deteriorate and she remained unresponsive. Patient's family decided to make the patient DNR/DNI and she was extubated. Patient remained apnic after extubated and comfortable on morphine drip. She expired on [**2115-1-2**]. . #. AMS: Her mental status intially appeared to have returned to her baseline after a large bowel movement in the ED. LP was clear essentially ruling out meningitis, especially HSV meningitis. She was initially mostly clear mentally, but at times seems to have short-term memory difficulty. However, neuro was concerned that pt was becoming more encephalopathic so her lactulose was titrated up to 45 q 8 hr prn for 2 BM per day. Following her IVH on [**12-28**], the pts mental status declined, at times only responsive to painful stimuli and not following commands. Patient remained in sub-optimal mental status with acute worsening after re-bleeding discovered on [**1-1**]. . # Bleeding diathesis: Neuro felt that the small rounded density seen in subcortical white matter on head CT from [**12-19**] was not a hemorrhage, but needed to be evaluated by MRI head w/ contrast and susceptibility series given her HIV history. MRI was c/w small hemorrhage vs vascular malformation. This finding was not alarming until the pt developed a subsequent bleed in the pineal region on [**12-28**] , further evolution of bleed on [**12-29**], and new vs extension of bleed into the anterior interhemispheric region. In addition the pt underwent Permacath placement for HD [**2114-12-20**], complicated by persistent oozing at site. Initially it was felt her catheter was oozing secondary to a mechanical complication. However, the pt subsequently developed oozing from her L thigh bx site and bleeding from her nose ([**12-25**]). The DDx of the continued bleeding included mechanical,low plt count, plt dysfunction, and coagulopathy [**1-24**] ESLD and CRF. VWF screen was neg, but in setting of multiple blood products. Factor VIII was wnl. DIC labs (fibrinogen nl) and coags wnl. Pt received 30 mcg DDAVP x3 on [**11-15**], cryo x1 on [**12-22**], FFP on [**12-24**] bag plt [**12-24**], 2 bag plt/10 ug DDAVP/30 ug DDAVP [**12-25**], 30 ug DDAVP on [**12-27**], and plt plus cryo on [**12-28**]. She was taken to IR [****] X 1 with suture placement and dressing, taken back at 3am [**12-23**] for persistent ooze, given silver nitrate cautery, with hemostasis. General surgerywas called, and sutured permacath site on [**12-24**], resutured it [**12-25**] for persistent bleed. Pt was taken to IR on [**12-26**] with thrombin injected around permacath site and new sutures placed. On [**12-28**] pt was taken to IR to examine the permacath for leak, but the pt fell off IR table and further workup was haulted. Heme/onc was consulted for the pts bleeding, and it was felt pts bleeding may be secondary to functional fibrinogenemia in the setting of ESLD (fibrinogen prior ot receiving FFP/cryo this admission was in the 100s). Per heme/onc recs, topical amicar was applied to the pts permacath and thigh bx site, achieving temporary hemostasis. The pts depakote was also discontinued on [**12-28**] given that depakote has been noted to cause bleeding in the setting of surgery. Once the pt was noted to have a new intraventricular hemorrhage in her R occipital [**Doctor Last Name 534**] on [**12-28**], the pt was started on IV amicar per heme/onc recs for emergent bleeding, and the pt was transferred to the unit. Please see above for further course of her IVH. . #. Conjunctivitis: The pt was noted to have bilateral conjuncitivitis with mucopurulent discharge bilaterally. Ophthalmology was consulted for further management in this HIV positive patient. Her conjunctivitis was originally concerning for Neisseria gonorrhea per ophthalmology, cx swab sent, gram stain sent (not done, cancelled test) and viral cx found to be negative. Given possible severe allergy to PCN and ceftriaxone and possibly levoflox, we curbsided ID, and the pt received 6 days of po azithromycin, with erythromycin eye drops. However, on physicial exam [**2039-12-19**] pt still with mucopurulent discharge, and bilateral conjuncitivits. Since she was not improving, Ophtho recommeded starting polysporin ointment. Her mucopurulent discharge resolved on polysporin. On [**2114-12-24**], the decision was made to stop po azithromycin. Artifical tears was ordered for the pt as well. The pt received polysporin ointment qid in house and [**Hospital1 **] after d/c She was ordered artificial tears q 6 hr prn. The pt is to follow up in [**Hospital 2081**] clinic after discharge. . #. Rash: Dermatology was consulted in the ED and felt that this rash was consistent with a [**First Name8 (NamePattern2) **] [**Location (un) **] Syndrome due to Levofloxacin, Ceftriaxone, or Dilantin. Less likely to be caused by oral HSV, and pt was initially tx with IV acyclovir, which was subsequently discontinued. Her skin punch biopsy in the anterior left thigh revealed vacuolar interface dermatitis with pigment laden scale, scattered epidermal Civatte bodies, edema, and superficial dermal pigment incontinence, with no epidermal necrosis, a focal early subepidermal split. The findings are consistent with an interface-type reaction including an interface-type drug reaction and/or a lesion along the spectrum of erythema multiforme/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] syndrome. HSV culture of the erosions present in the patient's mouth were negative for HSV. IV acyclovir was initially started empirically, then discontinued, as it was felt that the risk of nephrotoxicity outweighed the ?benefit. Rocephin, levaquin, and dilantin were held. Per derm, all aromatic anti-convulsants (dilantin, carbamezapine, phenobarbital) should not be given as they cross-react. The pt experienced improvement over a several day course using the following treatments: Triamcinolone ointment 0.1% [**Hospital1 **] over affected area, Bacitracin [**Hospital1 **] topically to vulvar erosions., for mucosal lesions and mouth pain- ordered lidocaine mouthwash prn. . # CRF: On admission the pt had a left AV fistula in place, not yet mature. CrCl is <10 so renally dose meds. Pt started HD on [**12-21**]. Received 2 units pRBCs [**12-21**] and [**12-22**]. Received another unit PRBC on [**12-27**] and on [**12-31**]. Calcitriol, NaHCO3 (will be corrected in HD) were discontinued. . #. ?history of seizure disorder Neuro was consulted for [**12-20**]. Given history of childhood seizures, pt is at risk for further seizures, although we did have her records from [**Doctor Last Name 1263**]. Neuro recommended discontinuing dilantin, and the pt was started depakote 250mg po bid. This was titrated up to 250 mg tid and was subsequently discontinued once it was overlapped with Keppra for 2 days (depakote was discontinued in the setting of bleeding as per above, and due to her liver disease). The pt was then continued on Keppra. . #Fever: Pt spiked temp 101 on night of [**12-24**] and [**12-25**], low grade temp on subsequent nights. Unclear [**Name2 (NI) 108218**]. U cx, C diff [**12-26**] neg. CXR had ? LML nodule and possible LLL loculated effusion, however CT torso from [**12-27**] shows no nodule (nipple shadow on CXR apparently) and small BL pleural effusions, no acute intrab process. Pt also c/o diarrhea at this time, but likely due to SJS. Pt has large ascites and mild mid-ab pain, but SBP unlikely and pt at risk for bleeding with paracentesis. UA, urine cx, stool cx, and blood cx were all repeated on [**1-1**] for continued low grade fevers. A component of the pts IVH could have also been contributing to her fever at that time. . #. Elevated pancreatic enzymes: The pt has known chronic pancreatitis, with her enzymes at baseline levels. The pt is currently off HAART which has been attributed in the past to causing her pancreatitis. CT torso on [**12-27**] was negative for signs of pancreatitis. . 8. Anemia: Recent anemia w/u consistent with anemia of chronic dz, likely from renal failure. Given also has guaiac positive stool, GIB is another source though no overt bleeding. Patient received 2 units pRBCs in HD [**12-21**], 2 units PRBCs [**12-22**] after HD. Baseline 22-25. . #H/o hepatic encephalopathy: no clear signs of encephalopathy during hospitalization. Pt showed no asterixis. Increased ascites on US of abdomen [**12-25**]. Patient was continued on lactulose. . #HIV/HepC: Off HAART Therapy since last admission in [**10-27**] contributing to elevated pancreatic enzymes. Last CD4 was 233 in [**8-27**]. Also coinfected with HepC, Hep B negative. Will hold on HAART at this time in setting of bleed. Last CD4 135 with CD4/CD8 ratio of 0.2. The pt was started on Atovaquone for PCP [**Name9 (PRE) **] on [**12-27**]. . 9. FEN: renal heart dm diet. replete all lytes. . 10. PPX: PPI, lactulose, pneumoboots (holding heparin given guiac + stool, low plt) . 11. Code: Full code -> DNR/DNI-> CMO Medications on Admission: Ceftriaxone (d/c [**12-15**]) Insulin Dilantin (according to notes was not on this [**10-27**]) Levaquin Colace Protonix Lactulose Calcitrol phoslo bicitra Discharge Medications: none Discharge Disposition: Extended Care Discharge Diagnosis: 1. Altered mental status 2. [**First Name8 (NamePattern2) **] [**Location (un) **] Syndrome 3. End-stage renal failure on hemodialysis 4. Conjunctivitis bilateral eyes 5. Human Immunodeficiency Virus 6. Hepatitis C 7. Cirrhosis 8. Type II Diabetes Mellitus Discharge Condition: Deceased Discharge Instructions: none Followup Instructions: none Completed by:[**2115-1-8**]

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icd9cm

[ [ [] ] ]

[ "96.71", "99.06", "86.09", "39.95", "99.07", "99.04", "96.04", "38.95", "86.11", "99.05" ]

icd9pcs

[ [ [] ] ]

19467, 19482

7741, 19232

308, 371

19791, 19801

2940, 7718

19854, 19888

2079, 2110

19438, 19444

19503, 19770

19258, 19415

19825, 19831

2125, 2921

254, 270

399, 1145

1167, 1778

1794, 2063

11,007

118,219

16035

Discharge summary

report

Admission Date: [**2195-8-4**] Discharge Date: [**2195-8-25**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 99**] Chief Complaint: acute renal failure Major Surgical or Invasive Procedure: Tracheostomy PEG History of Present Illness: 83 yo female w/ CRI, htn, h/o CHF, hypercholesterolemia, who p/w hypoxia/respiratory failure, ARF w/ severe acidosis, transferred from OSH for further eval. Pt originally presented to [**Hospital 45887**] [**Hospital 107**] Hospital in [**State 3914**] on [**7-31**] w/ diarrhea & ARF. She p/w 2 weeks of diarrhea (black stool), along w/ nausea and decreased po intake. Saw her PCP 2 days before admission, on [**7-29**] where per records, all labs/stool studies normal except for elevated BUN/creatinine (118/8.4), whihc was up from her baseline of 1.6. Her lisinopril & lasix were held, she was encouraged to take po, and was started on cipro, with plans for close outpt follow-up. On cipro, her stool turned yellow, but she continued w/ profuse diarrhea "every 5 minutes" prompting her to seek further attention 2 days later. Presented to OSH ED on [**7-31**], where her admit labs were notable for BUN 125, creatinine 9.7, Na 135, HCO3 13. U/A was sent which was remarkable for mod blood, large LE, >100 WBC, [**3-28**] RBC, rare bacteria. This later grew out 50,000 org/mL staph aereus. Started on levoflox. Her ARF was thought to be prerenal, and she was put on NS at 125cc/hr. Her BUN/cr slowly improved over the next few days, to 80/5.3 on [**8-4**]. She had good uop, ~1000 mL/day, but was grossly positive for LOS, ~9 liters over 4.5 days. On [**8-3**], she had worsening pain in left foot, prompting an xray which showed focal degenerative arthritis in the first metatarsal phalangeal joint; she was placed on prednisone 20 qd for gout. Also febrile to 101. Chest xray showing LLL pna, small pleural effusion. On afternoon of [**8-4**], developed progressive SOB. In the am, was satting 98% on RA, then dropped to 91% on RA in the afternoon, O2 titrated up, also got ativan for anxiety. Then got MSO4 for respiratory distress. Sats dropped to 80% on NRBM, ABG 7.015/42/78/11, was emergently intubated ~1830, with post intubation ABG 7/042/42/70 (on 80% FiO2). Placed on AC 550/14/5/100, with ABG improved to 7.19/41/88/16 on 100%. Transferred to ICU, where she was diuresed with initialy lasix 80, then lasix 160, with good urine output. Given concerns for her [**Hospital 45888**] transferred to [**Hospital1 18**] for further management. Past Medical History: - GERD - HTN - Hypercholesterolemia - Hypothyroidism; s/p left thyroidectomy - CHF - Anemia - Iron deficiency, Vit B12 deficiency, [**2-25**] CRI - Recurrent cellulitis - h/o pancreatitis s/p ERCP and sphincterotomy [**1-26**] - CRI (baseline Cr 1.6-1.8) - Osteopenia - s/p lumbar surgeries - s/p appy - macular degeneration - COPD - left trochanteric bursitis - osteoporosis - benign familial tremor - hysterectomy [**2180**] - cataracts - inner ear operation [**2170**] - broken toe childhood - left neck surgery - severe cerivcal stenosis Social History: Lives alone, independent in ADLs/IADLs. Retired, worked for father who was bookbinder. Two sons who are attornies, 1 in [**Location (un) 45887**]. + tobacco - 3 ppd, quit 15 yrs ago. No EtOH, no IVDA. Family History: dad, brother - CAD; mom [**12-25**] pna; son- asthma; father- TB Physical Exam: VS T=99.1 HR= 76 BP= 127/33 AC 500/18/10/0.6 GEN: elderly female, intubated, sedated but arousable to pain, in NAD HEENT - PERRLA, EOMI, o/p with ETT in place Neck - soft & supple Pulm - coarse BS on vent CV- RR, no m.r.g Abd- s/nt/nd Ext- W&D, 1+ pitting edema, palpable pulses Pertinent Results: [**2195-8-5**] 12:30AM BLOOD WBC-26.9*# RBC-3.40*# Hgb-9.8* Hct-30.8* MCV-91# MCH-28.8# MCHC-31.7 RDW-13.4 Plt Ct-178 [**2195-8-5**] 12:30AM BLOOD Plt Smr-NORMAL Plt Ct-178 [**2195-8-5**] 12:30AM BLOOD PT-15.0* PTT-28.5 INR(PT)-1.5 [**2195-8-5**] 05:32AM BLOOD Fibrino-926* D-Dimer-5632* [**2195-8-5**] 05:32AM BLOOD FDP-10-40 [**2195-8-5**] 12:30AM BLOOD Glucose-167* UreaN-78* Creat-4.8*# Na-147* K-5.2* Cl-121* HCO3-12* AnGap-19 [**2195-8-5**] 12:30AM BLOOD ALT-20 AST-23 LD(LDH)-378* AlkPhos-64 TotBili-0.2 [**2195-8-5**] 12:30AM BLOOD Albumin-3.2* Calcium-6.7* Phos-5.3*# Mg-1.3* Iron-10* [**2195-8-5**] 12:30AM BLOOD calTIBC-144* VitB12-1442* Folate-19.2 Ferritn-1266* TRF-111* [**2195-8-5**] 12:50AM BLOOD [**Doctor First Name **]-NEGATIVE [**2195-8-5**] 12:50AM BLOOD ANCA-NEGATIVE B [**2195-8-4**] 11:43PM BLOOD Type-ART pO2-170* pCO2-34* pH-7.16* calHCO3-13* Base XS--15 . CT ABD: 1. Allowing for absence of IV contrast enhancement, normal appearance of the bowel without suggestion of ischemic changes. 2. Bilateral moderate sized pleural effusions with probable associated atelectasis, although consolidation cannot be excluded. Clinical correlation is needed. 3. Uncomplicated cholelithiasis. 4. Dilated common bile duct as noted on previous ERCP of [**2193-2-5**]. . TTE: 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5. There is mild pulmonary artery systolic hypertension. . Peritoneal Fluid: negative for malignant cells . Brief Hospital Course: . Ms. [**Known lastname 6944**] is an 83 year-old female with history of CRI, HTN, CHF, who presents with respiratory failure. The following issues were addressed during her hospital course. . 1. RESPIRATORY FAILURE - The patient's respiratory failure was likely multifactorial due to CHF (aggressive volume resucitation) and pneumonia (fevers, bandemia). Less likely possibilities included vasculitis or pulmonary-renal syndrome ([**Doctor First Name **] and ANCA neg). On [**8-6**] a TTE was done, which revealed mild LA enlargement, LVEF >55%, trace AR, 1+ MR, 1+ TR, mild PA systolic HTN. She was initially covered with zosyn and vancomycin to cover for possible nosocomial infection. Eventually MRSA was cultured from her sputum. After these results, Zosyn was discontinued on [**8-9**] and vancomycin was continued for 7 days. She failed a spontaneous breathing trial on [**8-21**], and [**8-10**]. Due to failure to wean, a tracheostomy was performed on [**8-19**]. She was discharged to rehab after tracheostomy. . 2. RENAL FAILURE - She presented with acute on chronic renal failure (baseline Cr 1.6-1.8). This was most likely secondary to pre-renal failure, which progressed to ATN. Urine was also positive for urine eos; however, this is not specific. Abdominal CT was without evidence of hydronephrosis. Renal followed throughout this admission, and there was no indication for emergent hemodialysis. . 3. C DIFF: During this admission, the patient tested postitive for C diff, so she was started on PO flagyl. . 4. GOUT - Patient was diagnosed with gout at an OSH and started on prednisone. Prednisone was held on this admission, given concern for underlying infection. She was started on colchicine during this admission. . 5. DEPRESSION - She had expressed in writing the she wanted to kill herself. However, given her mental status that was waxing and [**Doctor Last Name 688**] and her difficulties with communication, it was not felt that she was a danger to herself. She was evaluate by psychiatry who also cleared her. 5. FEN - On tube feeds via PEG. . 6. Code - full Medications on Admission: Meds (home) protonix 40 qd, evista 60 qd, lipitor 60 qd, lisinopril 2.5 qd, lasix 80 qd, verapamil 360 qd, rocaltrol 250 qd, synthroid .125 [**Last Name (LF) **], [**First Name3 (LF) **] 325, oscal, mvi, atenolol 100 qd, clarniex . Meds (transfer): atenolol 100 QD, synthroid .125 QD, rocalcitriol 250 po QD, lipitor 60 QD, evista 60 QD, norvasc 5 mg po QD, prednisone 20 po QD, xanax prn, tylenol prn, levoflox 250 Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day): until ambulatory. 3. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Three [**Age over 90 **]y Five (325) mg PO DAILY (Daily). 4. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q4-6H (every 4 to 6 hours) as needed. 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 7. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). 8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000 (4000) units Injection QMOWEFR (Monday -Wednesday-Friday). 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 14. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for SBP<100, HR<50 . 16. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed. 17. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 18. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 19. Haloperidol 2 mg IV TID:PRN agitation 20. Morphine Sulfate 0.5-1.0 mg IV Q4H:PRN Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: 1. Respiratory failure: s/p Trach 2. Pneumonia 3. C diff colitis 5. Acute renal failure Discharge Condition: stable, improved from the time of admission Discharge Instructions: Please call your doctor or return to the ER if you experience fever, chills, vomiting, or chest pain. Followup Instructions: Please call your primary care doctor for a follow up appointment after discharge from rehab. You will likely need follow-up with psychiatry for management of depression. Completed by:[**2195-8-25**]

[ "274.0", "584.5", "599.0", "V09.0", "276.0", "008.45", "428.0", "403.91", "285.29", "496", "482.41", "518.84" ]

icd9cm

[ [ [] ] ]

[ "99.04", "43.11", "31.1", "96.72", "96.04", "96.6", "38.91", "38.93", "34.91" ]

icd9pcs

[ [ [] ] ]

9902, 9981

5504, 7609

245, 264

10113, 10158

3726, 5481

10308, 10510

3345, 3411

8076, 9879

10002, 10092

7635, 8053

10182, 10285

3426, 3707

186, 207

292, 2544

2566, 3110

3127, 3329

3,767

103,136

5185

Discharge summary

report

Admission Date: [**2115-8-9**] Discharge Date: [**2115-8-19**] Date of Birth: [**2048-9-18**] Sex: M Service: Thoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old with a history of acute myeloplastic leukemia diagnosed in [**2114-10-1**] who was treated with Ara-C but complicated by infection and myelosuppression. The patient was readmitted on [**8-9**] for an acute myeloplastic leukemia relapse. The patient has been complaining of right pleuritic chest pain, cough, and fevers. A chest CAT scan was done on [**8-10**] which revealed a right upper lobe consolidation. A biopsy of this consolidation showed that it was a mucoid mycosis, and consequently Thoracic Surgery was consulted on [**8-14**] to evaluate the need to resect the right upper lobe. The patient was started on AmBisome and Levaquin while he was admitted on the Oncology Service. PAST MEDICAL HISTORY: (His past medical history was significant for) 1. Questionable aspergillus pneumonia in [**2115-11-1**] which was treated with four weeks of AmBisome. 2. He also has a history of hypertension. 3. Recurrent acute myelogenous leukemia. 4. Gout. 5. Prostate cancer 10 years ago. SOCIAL HISTORY: The patient has a social history significant for cigarette smoking; although he quit. He also has a history of asbestos exposure four years ago and possible tuberculosis exposure since he was working in a tuberculosis institute. FAMILY HISTORY: His family history is significant for father and brother both having prostate cancer. ALLERGIES: The patient is allergic to PENICILLIN, DEMEROL, ASPIRIN. MEDICATIONS ON ADMISSION: He was admitted on Ambien, allopurinol, hydroxyurea, colchicine, Paxil, multivitamin, Tylenol, Ativan. The patient was placed on Levaquin and AmBisome by the Oncology Service on admission. PHYSICAL EXAMINATION ON PRESENTATION: On examination, the patient's temperature was 100.6, pulse was 112, respirations were 20, blood pressure was 140/80, 98% on 35% shovel mask. He saturated 88% on room air. His head, eyes, ears, nose, and throat examination was significant for lymphadenopathy in the cervical and submandibular region. His sclerae were anicteric. No evidence of jugular venous distention or carotid bruits. His pupils were equally round and reactive. Chest examination revealed the patient was noted to right inspiratory and expiratory wheezes with rales. His left chest was clear to auscultation. He was also noted to have palpable axillary lymph nodes including one that was significantly enlarged in the left axilla. His heart was regular rate and rhythm. First heart sound and second heart sound were present. No murmurs or gallops were appreciated. The abdomen was soft and nontender, though moderately protuberant. Extremities were warm with palpable distal pulses. No evidence of edema. Neurologically, he was alert and oriented, and no focal neurologic deficits were noted. PERTINENT LABORATORY DATA ON PRESENTATION: His white blood cell count was 36.1, with a hematocrit of 25.7, and platelets were 44. His electrolytes revealed sodium was 141, potassium was 4.4, chloride was 106, bicarbonate was 27, blood urea nitrogen was 20, creatinine was 1, and blood glucose was 110. RADIOLOGY/IMAGING: He had a chest CT which revealed a right upper lobe opacity measuring 6.7 cm X 8.7 cm; which was increased from his previous CT scan of 4.1 cm X 4.5 cm. There was extensive mediastinal and hilar lymphadenopathy. A CAT scan of his abdomen also showed right basilar nodules in the right base of his lung measuring approximately 8 mm. There was also lymphadenopathy at the porta hepatis and the retroperitoneum. HOSPITAL COURSE: He has been receiving chemotherapy during his admission to the Oncology Service. A biopsy of his left axilla lymph node showed that there was no evidence of disseminated fungal infection. Therefore, discussion with the patient as well as his family was started to determine whether or not they would wish to have this consolidation in his right upper lobe removed. A discussion was also carried in conjunction with the Oncology Service. After much discussion, the decision was made to go ahead with this thoracotomy and resection of his right upper lobe. The patient was then consented for this procedure and was taken to the operating room on [**2115-8-16**]. Intraoperatively, an initial attempt to remove the patient's right upper lobe appeared to be difficult, and the patient had a significant amount of blood loss intraoperatively. He lost approximately 3 liters of blood, requiring a 5-liter transfusion. The patient also received multiple units of platelets. Moreover, it was determined that it was necessary intraoperatively to perform a complete right pneumonectomy. Postoperatively, the patient was transferred to the Recovery Unit in stable condition, though remained intubated. The next morning the patient was transferred to the Cardiac Surgery Recovery Unit where it became extremely difficult to ventilate the patient. Initially, the patient's ventilator was placed on pressure control ventilation, trying to control his airway pressures so that the stump of the side where the pneumonectomy was performed would not be blown out. However, despite a pressure of 30 with a positive end-expiratory pressure of 5, leaving a plateau pressure of around 35, it was very difficult to ventilate the patient. The patient's PCO2 increased precipitously to the 90s. At this point, the patient was then switched over to assist control which temporarily improved his ventilation. However, the patient's creatinine increased from 1 to 1.9. Moreover, his blood pressure began to drop, requiring the addition of Neo-Synephrine to maintain an adequate mean arterial pressure. However, the patient's respiratory status continued to deteriorate despite the fact that we ventilated him. His oxygenation then became a problem requiring high FIO2 of up 100%. We attempted to wean this down slightly to 80%; however, the patient did not tolerate this and required going back to 100%. Next, his blood pressure became an issue again requiring the addition of a second [**Doctor Last Name 360**]; we added Levophed to maintain his blood pressure. Fluid boluses did not appear to help his blood pressure or his perfusion. The patient became progressively acidotic. Moreover, his renal function also deteriorated with his creatinine increasing to 3.7 the next morning, which quickly increased to over 5 the same afternoon. In the morning of [**8-19**], the patient's systolic blood pressure dropped to the 70s despite very high doses of Neo-Synephrine and Levophed. Moreover, his kidney stopped making urine, and his oxygenation became a main issue since the patient was unable to get rid of any of the fluids that he had been receiving. His oxygen saturation dropped into the 80s despite being on 100% FIO2. At this point, the family was then contact[**Name (NI) **] as well as the attending to explain that the patient was not doing well and may not survive. At this point, the family decided to make the patient do not resuscitate; however, they did not withdraw care. Nevertheless; at 7:55 a.m. on [**2115-8-19**], the patient's blood pressure continued to drop, followed by his heart rate, and finally he became asystolic and expired at exactly 7:55 a.m. on [**2115-8-19**]. CONDITION AT DISCHARGE: The patient expired. DISCHARGE STATUS: The patient expired. DISCHARGE DIAGNOSES: 1. Disseminated acute myelogenous leukemia. 2. Status post right pneumonectomy. 3. Multiple organ failure. [**Known firstname 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**] Dictated By:[**Name8 (MD) 20292**] MEDQUIST36 D: [**2115-8-19**] 08:31 T: [**2115-8-24**] 21:24 JOB#: [**Job Number 21208**]

[ "205.10", "117.7", "285.22", "V15.82", "584.9", "V15.84", "998.11", "484.7", "998.0" ]

icd9cm

[ [ [] ] ]

[ "32.5", "33.26", "96.71", "99.25", "33.24", "40.11", "96.04", "41.31", "38.93" ]

icd9pcs

[ [ [] ] ]

1466, 1623

7519, 7883

1650, 3694

3713, 7420

7435, 7498

173, 895

918, 1200

1217, 1448

66,818

160,163

51080

Discharge summary

report

Admission Date: [**2113-5-15**] Discharge Date: [**2113-5-25**] Date of Birth: [**2046-9-28**] Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 1257**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation, mechanical ventilation Replacement of tunneled hemodialysis catheter History of Present Illness: 66 yo french creole speaking female h/o diabetes, end-stage renal disease on HD and hypertension who intially presented to [**Hospital6 **] acutely delirious. She reportedly became acutely altered, not making sense, and combative at home starting at 1300. Her husband brought her to [**Hospital3 **]. In the OSH, she was noted to have a BS > 500 and question of intermittent episodes of muscle rigidity. ?seizure activity. Became responsive only to pain. CT did not show acute process. LP done: no wbc, two rbcs, however no further testing of CSF was provided. She was given Haldol and ativan for agitation and Labetalol 20 IV and hydralazine 10 IV x 2 for blood pressures noted to be 233/103 -> 126/100. No antibiotics given. Transferred to [**Hospital1 18**] for further management. . Upon arrival to the ED, initial VS: 97.2 231/119. Initially triggered for AMS. Labs notable for wbc of 11.2 with left shift. Lactate of 2.6. Gave vanc/cefepime. UA small blood, 300 protein and 300 glucose. CXR: no consolidation. EKG: sinus tachycardia with ST depressions and was given 600 mg PR ASA. Exam also notable for warm, tender left forearm. She notably had a graft created [**12-23**] and subsequently ligated [**1-24**] secondary to steal syndrome. Transplant was called and will see patient when arrives to MICU. . Given her alterd state and concern she wasn't protecting airway, she was intubated. Of note, family confirmed full code status. Two PIVs placed. Noted to have fevers to 40 degrees C and given PR tylenol and toradol. Also, nipride gtt started for severe hypertension (158-267/71-126). Renal was called and felt no acute need for HD at this time. VS prior to transfer: T40 HR 115 154/73 23 100% on AC. . Upon arrival to the MICU, patient was intubated and sedated on propofol and febrile to 104.1. . Review of systems: Unable to obtain Past Medical History: ESRD on HD M/W/F Type 2 diabetes Hypertension GERD Osteomyelitis Glaucoma Hepatitis B Hepatitis C Hemorrhoids C. diff colitis HIT antibody positive Social History: -Home lives with [**Doctor First Name **], her husband -Cigarettes none -Alcohol none -Caffeine light Family History: Noncontributory Physical Exam: On admission: Vitals: T:104 BP:215/89 P: 100 R: O2: 100% AC General: Intubated, sedated, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Chest: right tunneled HD line in place without erythema/warmth or swelling Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, normal S1 + S2, systolic murmur, no rubs 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 or edema. Left old graft is mildly warm, however does not appear erythematous. No fluctuance appreciated. At Discharge: Vitals: T:97.9 BP:150/60 P:70 R:16 O2:98% RA FS 181 General: NARD, comfortable, alert and interactive HEENT: NCAT, PERRL, Sclerae anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD, no carotid bruits Chest: right tunneled HD line in place without erythema/warmth or swelling Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi, resp unlabored and no accessory muscle use CV: RRR, normal S1/S2 Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Left old graft does not appear erythematous. No fluctuance or exudate appreciated. Neuro: awake, A&Ox1 (knows name), CNs II-XII grossly intact, moving all extremities spontaneously with 5/5 strength throughout except LUE [**4-18**] (chronic), sensation grossly intact throughout, DTRs 2+ and symmetric, gait unsteady Pertinent Results: Admission Labs: [**2113-5-15**] 09:00PM BLOOD WBC-11.2* RBC-4.76 Hgb-12.3 Hct-38.6 MCV-81* MCH-25.8* MCHC-31.8 RDW-22.8* Plt Ct-214 [**2113-5-15**] 09:00PM BLOOD Neuts-89.6* Lymphs-6.8* Monos-2.3 Eos-0.6 Baso-0.6 [**2113-5-15**] 09:00PM BLOOD Glucose-83 UreaN-38* Creat-4.8* Na-140 K-4.6 Cl-102 HCO3-23 AnGap-20 [**2113-5-15**] 09:00PM BLOOD CK(CPK)-182 [**2113-5-16**] 12:30PM BLOOD Calcium-8.3* Phos-4.5 Mg-1.9 . Discharge Labs: 134 | 97 | 15 < 132 AGap=11 3.6 | 30 | 3.7 Ca: 8.8 Mg: 1.8 P: 3.5 MCV: 80 3.6 > 9.0 / 26.6 < 158 N:60.1 L:28.9 M:8.6 E:2.2 Bas:0.2 . Micro: [**2113-5-15**] 9:00 pm BLOOD CULTURE Blood Culture, Routine (Final [**2113-5-21**]): NO GROWTH. . [**2113-5-15**] 11:30 pm URINE Site: CATHETER URINE CULTURE (Final [**2113-5-17**]): NO GROWTH. . [**2113-5-16**] 12:22 am BLOOD CULTURE Blood Culture, Routine (Final [**2113-5-22**]): NO GROWTH. . [**2113-5-16**] 1:45 am MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Final [**2113-5-18**]): No MRSA isolated. . [**2113-5-16**] 2:25 am BLOOD CULTURE Source: Line-HD line. Blood Culture, Routine (Final [**2113-5-22**]): NO GROWTH. . [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2113-5-18**]): THIS IS A CORRECTED REPORT [**2113-5-18**]. EQUIVOCAL BY EIA. PREVIOUSLY REPORTED AS POSITIVE BY EIA. Reported to and read back by PAT BOYNKINS [**2113-5-18**] @ 2:35 PM. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2113-5-18**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2113-5-18**]): NEGATIVE <1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. In most populations, 90% of adults have been infected at sometime with EBV and will have measurable VCA IgG and EBNA antibodies. Antibodies to EBNA develop 6-8 weeks after primary infection and remain present for life. Presence of VCA IgM antibodies indicates recent primary infection. . CMV Viral Load (Final [**2113-5-18**]): CMV DNA not detected. . [**2113-5-18**] 11:38 am URINE Source: Catheter. URINE CULTURE (Final [**2113-5-19**]): NO GROWTH. . [**2113-5-15**] CXR: SEMI-UPRIGHT AP VIEW OF THE CHEST: Study is limited due to patient rotation and positioning. Right-sided dual-lumen central venous catheter tip terminates within the proximal right atrium. Heart size is likely mildly enlarged. The lungs are grossly clear without focal consolidation. No pleural effusion or pneumothorax is identified. IMPRESSION: Limited study due to rotation. No acute cardiopulmonary abnormality. . [**2113-5-16**] Ultrasound A/V Fistula: The left brachial artery and the left cephalic vein are patent, presenting with normal Doppler waveforms. The left ligated AV graft is occluded with no evidence of flow. IMPRESSION: Patent left brachial artery and cephalic veins. . [**2113-5-16**] MRA Brain without contrast: There is FLAIR, T2 and diffusion high signal in the splenium of corpus callosum without convincing ADC changes. A further punctate focus of T2 and FLAIR hyperintense lesion is seen in the right occipital white matter, bright on diffusion and ADC map, suggesting a late subacute infarct. Multiple foci of T2 and FLAIR hyperintensities are seen in the subcortical and deep white matter, with confluent signal changes in the parietal lobe white matter and periventricular regions suggesting small vessel ischemic change. The ventricles and sulcal configuration are slightly prominent for patient's age. Susceptibility imaging demonstrates artifacts related with basal ganglia calcifications. Punctate foci of gradient artifacts are seen in the left parietal lobe and both cerebellum which may represent previous microhemorrhage. There is no intracranial mass or mass effect. The visualized paranasal sinuses are clear. Bilateral lens implants are demonstrated. MRA BRAIN: Images are degraded by motion artifact. There is no gross evidence of an aneurysm, vascular malformation or flow-limiting stenosis. The vertebral arteries are codominant. The basilar artery is patent. Both posterior cerebral arteries are visualized. There is probable irregularity and narrowing of the P2 segments. IMPRESSION: 1. Abnormal diffusion signal changes in the splenium of corpus callosum with T2 and FLAIR hyperintensity and no corresponding ADC changes suggesting late subacute infarct. Further punctate focus of subacute infarct in the right occipital white matter. 2. Small vessel ischemic changes in the subcortical and deep white matter. 3. MRA brain image quality is degraded by motion. Within this limitation, no evidence of a large aneurysm or vascular malformation is demonstrated. Probable irregularity and narrowing of the P2 segments, right more than left. . [**2113-5-20**] Right Lower Extremity Ultrasound: FINDINGS: Real-time Grayscale and color Doppler evaluation of the right internal jugular, axillary, brachial, basilic, and cephalic veins were obtained. There is normal compressibility, wall-to-wall color flow, and augmentation throughout. Wall-to-wall color flow was seen in the left subclavian vein. IMPRESSION: No evidence of left upper extremity deep venous thrombosis. Brief Hospital Course: Ms [**Known lastname 106087**] was transferred from [**Hospital6 **] with severe hypertension, fever, hyperglycemia, and AMS. She was admitted to the ICU where she was initially intubated for airway protection. She was extubated safely and became more awake and alert and was called out to the inpatient floor on [**2113-5-20**]. Her hospital course is outlined below. . *) ALTERED MENTAL STATUS: Etiology of altered mental status is unclear. [**Name2 (NI) **] likely is hypertensive emergency or some form of acute toxic-metabolic encephalopathy. She did not appear postictal or infected. After control of her blood pressure and blood sugar, her agitation and unresponsiveness resolved although her confusion did not. She was initially intubated for airway protection but was successfully extubated. Treatment for her altered mental status revolved around treating the other problems which are described below. A MRI/MRA of the head was obtained which showed some chronic/sub-acute changes. Antibiotics were continued empirically to cover for possible infections and were stopped when culture data returned negative. At the time of discharge was breathing room air, feeding herself, following commands, and answering questions though according to both the interpreter and family she was still quite confused. She was followed by neurology and an EEG was performed the day of discharge. She will have neurology followup 4-6 weeks after discharge. She was evaluated by physical therapy and found to have occasional loss of balance with significant distractibility and poor insight, requiring supervision. . *) FEVER: Culture data from CSF was obtained daily from [**Hospital3 **]. All antibiotics were stopped, including acyclovir, given negative cultures and negative PCR. Etiology is unclear and fever resolved quickly without significant leukocytosis. Cultures at [**Hospital1 18**] were also all negative. She remained afebrile off all antibiotics and no clear localizing source was ever found by exam, imaging, or laboratory data. HIV was negative. . *) HYPERTENSIVE EMERGENCY: Patient notably on nifedipine, amlodipine, lasix, hydralazine, labetalol, and lisinopril at home with normotensive readings per records; however, with difficult to control BPs per PCP [**Name Initial (PRE) 12883**]. It is possible that patient missed her multiple medications and as a consequence, became severely hypertensive, resulting in hypertensive emergency. Blood pressures have been better controlled since restarting home meds. Her home medications were titrated as follows: Lasix was stopped as this is likely doing nothing due to her renal failure, and nifedipine was held over the course of her hospitalization as it could not be crushed. Instead, labetalol and lisinopril were increased. It was noted that if her medications were not given on schedule her blood pressure rose rapidly. . *) ESRD: She was followed by nephrology and received hemodialysis T/Th/Sa. Her tunneled line was noted to have one arterial lumen clotted off, and although HD was possible the line was changed by interventional radiology given the potential nidus for infection. . *) DIABETES: Insulin dependent and quite brittle likely due to ESRD. Her glargine was halved and she was maintained with a lispro insulin sliding scale. Her blood sugars remained difficult to control with episodes of hyperglycemia to the 230s and her insulin will need close monitoring as an outpatient. As her oral intake improves she may require 10 units of glargine at bedtime, which was her previous outpatient regimen. . *) MICROCYTIC ANEMIA: Baseline Hct appears to be 25-28% with low MCV likely in low iron state from ESRD. On admission her hct was well above baseline, and it trended down to baseline with hydration. She had no evidence of bleeding. . *) LEUKOPENIA: Her WBC count trended down over the hospitalization. After discussion with pharmacy the most likely culprit medication was thought to be vancomycin; because she is a dialysis patient vancomycin stayed in her system longer. Her WBC count was monitored and stabilized between [**3-17**]. She was never neutropenic. . *) HYPERLIPIDEMIA: Her Simvastatin was continued. Aspirin was added given the possibility of stroke and her risk factors for CAD. . *) GLAUCOMA: Her Timolol, latanoprost, and Apraclonidine eye drops were all continued. . *) TRANSITION OF CARE: Patient was discharged to rehab for continued physical therapy and supervision. She will require the following services: - Physical therapy as needed for evaluation and treatment - Hemodialysis Tuesday, Thursday, Saturday - Follow up with her primary care physician [**Name Initial (PRE) 176**] 1-2 weeks of discharge for blood pressure and blood sugar checks. - Re-check CBC in one week to ensure stabilization of WBC count - Follow up with a neurologist in [**4-19**] weeks; EEG results pending at the time of discharge. Medications on Admission: Medications: per Atrius records Timolol Maleate 0.5 % Ophthalmic Gel Forming Solution instill 1 drop to each eye daily Simvastatin 20 mg daily Lisinopril 10 mg Daily Latanoprost (XALATAN) 0.005 % Ophthalmic Drops INSTILL 1 DROP TO EACH EYE AT BEDTIME Labetalol 200 mg Oral Tablet 1 tablet twice daily Insulin Lispro (HUMALOG) 100 unit/mL Subcutaneous Solution use 2-10 units with meals using the sliding scale Insulin Glargine ([**Date Range **]) 100 unit/mL Subcutaneous Solution inject 10 units subcutaneously at 9pm Hydralazine 50 mg Oral Tablet take one tablet by mouth every 6 hours Furosemide 20 mg Oral Tablet Take 1 tablet daily Apraclonidine (IOPIDINE) 0.5 % Ophthalmic Drops INSTILL 1 DROP IN EACH EYE THREE TIMES DAILY Amlodipine 10 mg Daily Ergocalciferol, Vitamin D2, 50,000 unit Oral Capsule take 1 capsule weekly for 12 weeks Nifedipine 60 mg Oral Tablet Sustained Release DAILY FERROUS SULFATE 325 MG (65 MG IRON) TAB 1 tablet three times daily Discharge Medications: 1. simvastatin 10 mg Tablet [**Date Range **]: Two (2) Tablet PO QHS (once a day (at bedtime)). 2. timolol maleate 0.5 % Drops [**Date Range **]: One (1) Drop Ophthalmic DAILY (Daily). 3. latanoprost 0.005 % Drops [**Date Range **]: One (1) Drop Ophthalmic HS (at bedtime). 4. hydralazine 50 mg Tablet [**Date Range **]: One (1) Tablet PO Q6H (every 6 hours). 5. amlodipine 5 mg Tablet [**Date Range **]: Two (2) Tablet PO DAILY (Daily). 6. acetaminophen 325 mg Tablet [**Date Range **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 7. apraclonidine 0.5 % Drops [**Date Range **]: One (1) Drop Ophthalmic TID (3 times a day). 8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. B complex-vitamin C-folic acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily). 10. aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 11. labetalol 100 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO BID (2 times a day). 12. ergocalciferol (vitamin D2) 50,000 unit Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a week for 10 weeks. 13. ferrous sulfate 325 mg (65 mg iron) Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a day. 14. Colace 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day as needed for constipation. 15. insulin glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Five (5) units Subcutaneous at bedtime. 16. insulin lispro 100 unit/mL Cartridge [**Last Name (STitle) **]: 1-6 units Subcutaneous with meals as needed for elevated blood sugar: 1 unit for blood sugar 150-199, and 1 additional unit for every 50 points that your blood sugar is higher than that. 17. lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 18. ondansetron 4 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea or vomiting. Discharge Disposition: Extended Care Facility: [**Location **] nursing Discharge Diagnosis: PRIMARY: - Hypertensive emergency - Hyperglycemia - Acutely altered mental status, likely toxic-metabolic encephalopathy - Insulin-dependent diabetes SECONDARY: - End-stage renal failure requiring hemodialysis - Chronic microcytic anemia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires supervision and light assistance. Discharge Instructions: Dear Ms [**Known lastname 106087**], It was a pleasure caring for you at [**Hospital1 827**]. You were hospitalized with mental status changes, extremely high blood pressure, and extremely high blood sugar. You were initially in the ICU and you became more alert and were able to go to an inpatient medicine floor. You have been seen by the hemodialysis team for your renal failure and by the neurology team for your mental status changes. Your blood pressure and diabetes have been under better control. You are still confused some of the time and you will be going to rehab to continue to recover. We have made the following changes to your medications: - STOP furosemide (lasix) - STOP nifedipine - CHANGE labetalol to 300mg twice daily - CHANGE glargine (insulin [**Last Name (LF) 8472**], [**First Name3 (LF) **]-acting) to 5mg at night - CHANGE lisinopril to 20mg daily - START nephrocaps - START lansoprazole - START aspirin You should follow up with your primary care doctor within one week after your discharge from [**Hospital1 18**]. You should follow up with a neurologist as below. You had an EEG on [**5-24**] and this result is still pending. Followup Instructions: Follow up with your primary care [**First Name8 (NamePattern2) **] [**Last Name (Titles) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 2573**] within one week to follow up your hospitalization. NEUROLOGIST FOLLOW-UP Department: NEUROLOGY When: WEDNESDAY [**2113-8-2**] at 4:30 PM With: DRS. [**Name5 (PTitle) 43**] & MCLLUDUFF [**Telephone/Fax (1) 44**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2113-5-25**]

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icd9cm

[ [ [] ] ]

[ "39.95", "38.95", "96.04", "96.71", "38.97" ]

icd9pcs

[ [ [] ] ]

17494, 17544

9517, 9899

297, 380

17827, 17827

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46,657

190,835

37378

Discharge summary

report

Admission Date: [**2200-12-10**] Discharge Date: [**2200-12-16**] Date of Birth: [**2126-5-2**] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Bactrim Attending:[**First Name3 (LF) 1271**] Chief Complaint: Fall Major Surgical or Invasive Procedure: . History of Present Illness: 74 yo F with hx afib on coumadin, Parkinson's disease, HTN, HLD, IDDM, presents s/p likely mechanical fall on [**12-9**] PM. She tripped and fell on her left side, hitting the left side of her head. She is unsure why she fell but denies any preceeding lightheadedness, chest pain,weakness, numbness, or LOC before or after the event. She went to Good [**Hospital 84038**] Medical Center and initial CT head showed subtle hyperdensity along anterior falx with possible dural thickening vs. small subdural. A repeat CT head was done five hours later due to worsening agitation which revealed increasing hyperdensity of 1.3 cm along falx consistent with expanding/hyperacute SDH. Initial INR was 2.6 and she was given vitamkin K 10mg IM and 1 unit FFP and was transferred to [**Hospital1 18**] for further management. Past Medical History: A-Fib - on coumadin Parkinson's Disease Hypertension HLD Insulin Dependent Diabetes Social History: Lives in ALF with husband. [**Name (NI) **] etoh, tobacco, or drugs Family History: Non Contributory Physical Exam: On Admittance: Physical Exam; VS; T 97.6 P 85 BP 117/63 RR 20 95% Gen: thin elderly woman, NAD HEENT: MMM, oropharynx clear Neck: Supple. Lungs: CTA bilaterally. Cardiac: irregular, +S1,S2 Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Large ecchymosis over left knee. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, date, knows in hospital but did not know "[**Hospital1 **]." Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Mild L droop, chronic as per patient. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk. Mild cogwheeling at wrists. Mild postural tremor. No pronator drift. 5/5 strength R and L delt, bicep, tricep, WrE. Lower extremity exam limited by pain. IP on R and L appear symmetric (at least 3) and moving antigravity but uncooperative with formal testing. DF and PF on R and L appear [**6-10**]. Sensation: Intact to light touch throughout Reflexes: B T Br Pa Ac Right 1 1 1 tr 0 Left 1 1 1 tr 0 ON Discharge: The patient is neurologically intact. Specifically, she is A&OX3 and moves all extremities well. She has significantly less pain and swelling to the Left leg as she did compared to admit. She is able to move the leg, and has 4/5 strength to her left IP/Ham/Quad. The rash to her back has improved since the Cipro was discontinued yesterday. It remains non-pruritic, and she has no pain associated with it. There is no specific patter or distribution to the rash, and there are no papules or pustules present. There is a possibility of this rash being fungal in nature. her pressure ulcer to her L buttock is currently covered with duoderm dressing. It measures 1.5 x 0.7 cm, and is over 50% yellow and less than 50% red. The ulcer lies over a bony coccyx. There is small yellow drainage from the ulcer. The edges are regular as in a slit or split opening of skin. The surrounding tissue is mildly pink with faint ?satellite lesions. Pertinent Results: [**2200-12-10**] 08:15AM WBC-10.8 RBC-3.37* HGB-9.6* HCT-29.6* MCV-88 MCH-28.3 MCHC-32.4 RDW-14.6 [**2200-12-10**] 08:15AM PT-23.8* PTT-28.0 INR(PT)-2.3* [**2200-12-10**] 01:00PM PT-15.0* PTT-25.1 INR(PT)-1.3* [**2200-12-10**] 07:31PM HCT-24.2* [**2200-12-11**] 02:39AM HCT-21 [**2200-12-15**] 05:05AM BLOOD WBC-7.0 RBC-3.58* Hgb-10.2* Hct-31.3* MCV-87 MCH-28.6 MCHC-32.7 RDW-15.8* Plt Ct-379 [**2200-12-15**] 05:05AM BLOOD PT-13.1 PTT-24.2 INR(PT)-1.1 [**2200-12-15**] 05:05AM BLOOD Glucose-212* UreaN-16 Creat-0.7 Na-139 K-4.0 Cl-101 HCO3-30 AnGap-12 Head CT on admit: Subdural right parafalcine hematoma, 16mm at thickest point, increased from 14 mm at 5AM (OSH reference) with interval increased extension, including along right tentorium. No midlind shift. Repeat Head CT 24 hours later was stable. ECHO: The left atrium is elongated. 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 number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. No significant valvular disease seen. Brief Hospital Course: NEURO/HEME: The patient was admitted to the ICU for Q 1hour neuro checks. A trauma evaluation was requested to rule out any further injuries. A large L knee hematoma was identified, but she had no evidence of hip, knee, or rib fractures, or any other injuries. However, overnight on HD 0 she dropped her HCT from 29 to 21. She recieved 2U of PRBCs, and her repeat crit was 25. It continued to rise throughout her hospitilization, until it remained stable at 31. Aside from her eccymotic and swollen L knee, no other obvious source of bleeding was identified. Her 24 hour repeat head CT was stable, as there was no increase in the falx SDH. Her neurological exam remained intact and unchanged. She reamined an inpatient on the neurosurgery service until placement at a Rehab facility could be found. LOWER EXTREMITY EDEMA: The medicine service was consulted to evaluate her lower extremity edema, which had been increasing for approx 2 weeks prior to her hospitilization, and increased while an inpatient as well. Medicine made an adjustment to her Lasix dosage. They also obtained an Echo which revealed an EF of 55%, therefore, not contributing to the patient's edema. MENTAL STATUS: The medicine service added seroquel to her daily meds, as they felt, along with the patient's family, that she had some slight mental status changes. The patient responded well and was alert and oriented. DERM: She was found to have a Stage II pressure ulcer on her L buttock, which was seen by the wound ostomy RN. She recommended that the patient's ulcer be covered and dressed with Mepilex dressing q 3 days. ORTHO: Ortho was consulted to evaluate the patient's L eccymotic knee. There was no fracture or injury to the knee. They recommended that the knee be ACE wrapped, elevated, and no further follow up necessary. Medications on Admission: coumadin 5, oxycal, exelon, synthroid, sinemet, fosamax, zocor, celexa, arimidex, digoxin, lantus, novilin sliding scale, lasix, kdur Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QWED (every Wednesday). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: [**2-7**] Capsules PO BID (2 times a day) as needed for constipation. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). 9. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO BREAKFAST (Breakfast). 10. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO DINNER (Dinner). 12. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig: One (1) Tablet PO HS (at bedtime). 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 15. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 16. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Baypointe - [**Hospital1 1474**] Discharge Diagnosis: SDH Stage II pressure Ulcer L Knee Hematoma Rash - back Discharge Condition: Good Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? You can resume taking your Aspirin now. ?????? If you were on a medication such as Plavix prior to your injury, you may safely resume taking this IN ONE MONTH. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. You were found to have a colon mass upon admission and you should have an out patient colonoscopy that should be aranged. Please call your PCP for referral. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2200-12-16**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8620, 8679

5320, 6495

312, 315

8779, 8786

3840, 5297

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2883, 3821

268, 274

343, 1163

1988, 2869

6510, 7136

1185, 1270

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27,600

179,310

6165

Discharge summary

report

Admission Date: [**2132-8-4**] Discharge Date: [**2132-8-7**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1666**] Chief Complaint: Chest tightness Major Surgical or Invasive Procedure: [**2132-8-4**]: Flexible cystodcopy, wire & catheter placed by Urology (now out) History of Present Illness: This is a 89 year-old male [**Location 7972**] male with a history of asthma who presents with chest tightness and difficulty taking a deep breath since 9 PM on the evening prior to admission. Patient denies any fevers, chills or cough. He denies any nausea, diaphoresis, vomitting or abdominal pain. The chest tightness improved in a span of [**1-27**] hours, after patient received treatment in ED. However, the patient did have some tachypnea in the ED, and was admitted to MICU for further observation of respiratory status. Otherwise, patient was currently without any complaints, and denies current shortness of breath. Denies any sick contacts. . In the ED, initial vitals were T:98, HR:96, BP:154/96, RR:34, O2Sat: 100% on RA. He received albuterol and ipratropium nebulizers and 125mg IV methylprednisolone, with improvement of his symptoms. Given leukocytosis and possible infiltrate on chest x-ray, he was also started on cefriaxone and azithromycin for pneumonia. Past Medical History: #. Asthma #. Hypertension #. Mild AS #. Chronic renal insufficiency, baseline creatinine ~1.5 #. Benign prostatic hyperplasia #. h/o Urinary obstruction #. Urinary retention, severe urethral stricture #. h/o Bladder stones #. Bilateral small renal cysts (Renal U.S., [**2132-8-5**]) #. DM2, controlled on oral hypoglycemics #. GERD with small axial hiatal hernia, per barium esophagram ([**2132-7-7**]) #. h/o Esophageal spasm #. Esophageal dysmotility, characterized by tertiary contractions per barium esophagram & anterior cervical vertebral body osteophytes giving a minor impression on the cervical esophagus ([**2132-7-7**]) #. HOH, [**Month/Day/Year 1192**] sensorineural hearing loss in both ears #. Osteoarthritis, bilat knees . PSHx: [**2127-7-14**] s/p Suprapubic prostatectomy, cystoscopy flexible [**2127-6-4**] s/p Complex cystometrogram, complex uroflowmetry [**2126-9-4**] s/p Cystometrogram [**2126-1-22**] s/p Cystoscopy, Electrohydraulic litholapaxy, Placement of suprapubic tube [**2126-1-9**] s/p Complex cystometrogram, Intra-abdominal voiding pressure studies with attempted complex uroflowmetry & flexible cystourethroscopy Social History: The patient is a Portuguese speaking man from [**Country 3587**]. He lives at home with his wife. His daughters live nearby. He drinks only occasionally. Previously snuffed tobacco. Denied any recreational drug use. Family History: No history of heart disease or clotting disorders. Physical Exam: DISCHARGE PE: ============ VS: 96.4, 90, 20, 162/80, o2 sat 95% RA GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear, poor dentation NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, S1 S2, 3/6 systolic murmur best @ 2ICS/RSB & apex PULM: [**Month (only) **] BS widely w/ inc AP-Lat diam. Bibasilar/posterior scant fine crackles which clear with DB&C, no wheezes. ABD: Obese/distended, soft, positive bowel sounds EXT: CSM intact, no edema or palpable cords NEURO: alert, oriented to person, place, and time. Face symmetrical at rest & with movement, tongue midline. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: ADMISSION LABS: ============== [**2132-8-4**] 06:29AM CK(CPK)-58 [**2132-8-4**] 06:29AM CK-MB-3 cTropnT-<0.01 [**2132-8-4**] 06:29AM WBC-14.3* RBC-4.41* HGB-12.9* HCT-38.3* MCV-87 MCH-29.3 MCHC-33.6 RDW-13.3 [**2132-8-4**] 06:29AM GLUCOSE-224* UREA N-32* CREAT-1.5* SODIUM-140 POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-21* ANION GAP-18 [**2132-8-4**] 03:15AM LACTATE-1.3 [**2132-8-4**] 03:15AM TYPE-[**Last Name (un) **] PO2-83* PCO2-38 PH-7.37 TOTAL CO2-23 BASE XS--2 [**2132-8-4**] 12:13AM CK(CPK)-75 [**2132-8-4**] 12:13AM cTropnT-<0.01 [**2132-8-4**] 12:13AM CK-MB-NotDone proBNP-434 . IMAGING: ======= [**2132-8-6**] Cardiac Echo (TTE) - The left atrium is elongated. The left atrial volume is increased. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). 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 [**Year (4 digits) 1192**] pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2130-5-15**], the findings are similar. The prior echo assessed aortic valve area as 1.2cm2, however, this should have been 1.8-1.9cm2. . [**2132-8-5**] RENAL U.S. - FINDINGS: The right kidney measures 13.5 cm and the left 12.0 cm. The renal parenchymal thickness and echogenicity are normal without evidence of calculi or hydronephrosis. The right kidney demonstrates a small cyst in the upper pole measuring 1.5 x 1.5 x 1.3 cm. Within the interpolar region of the left kidney, there is a 1.1 x 0.9 x 1.1 cm cyst. The bladder is not fully distended. IMPRESSION: 1. No evidence of hydronephrosis, renal calculi, or solid masses; 2. Bilateral small renal cysts. . [**2132-8-4**] CHEST (PA & LAT) - FINDINGS: There is elevation of the left hemidiaphragm with left pleural thickening. There has been interval decrease in pulmonary interstitial markings when compared to prior exam. However, more confluent opacities in the right perihilar region are noted, which may represent atelectasis. A more nodular density measuring approximately 1 cm is noted in the right lung base which was not seen on prior exam and may represent the nipple. IMPRESSION: Interval decrease in interstitial pulmonary markings. Interval development of right basilar atelectasis. Right lung nodular opacity may represent nipple. Repeat study is recommended with nipple markers. . EKG: === [**2132-8-4**] - Sinus rhythm with atrial premature complexes; Consider left atrial abnormality; Modest nonspecific ST-T wave changes; Since previous tracing of [**2132-8-3**], no significant change. QT/QTc 380/430. . D/C LABS: ======== [**2132-8-7**] 06:11AM BLOOD WBC-12.2* RBC-4.83 Hgb-14.0 Hct-41.9 MCV-87 MCH-29.0 MCHC-33.4 RDW-13.2 Plt Ct-254 [**2132-8-7**] 06:11AM BLOOD Glucose-105 UreaN-36* Creat-1.3* Na-141 K-4.3 Cl-106 HCO3-26 AnGap-13 [**2132-8-7**] 06:11AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2 Brief Hospital Course: # Chest tightness/SOB: Given his leukocytosis (14.3), and ? of LLL infiltrate on CXR, the patient was initially treated as asthma exacerbation precipitated by pneumonia. He was given Prednisone, cefpodoxime and azithromycin. On HD2 the patient was clinically improved, denied SOB and was weaned off O2. During his stay the patient remained without wheezes on exam and it was noted that LLL opacity was unchanged from prior x-ray several years ago. He denied taking advair at home and denied history of asthma. He was also ruled out for MI w/EKGs and cardiac enzymes. He was discovered to have a history of esophageal spasm and this was felt to be a more likely explanation for the chest tightness. GI was consulted and recommended evaluation as an outpatient. His antibiotics were D/C'd on hospital day 2. THe patient received 4 days of steroids (Solumedrol 125 mg IV x's 1 on [**8-4**] in ED; Prednisone 60 mg PO x's 1 on [**8-5**] in ICU; Prednisone 40 mg PO QD x's 2 on floor. He NOT discharged on Prednisone. He was also started on a baby aspirin. Outpatient PFTs have been scheduled for the patient. Omeprazole 20 mg Capsule, Delayed Release was started for GERD/Hiatal hernia/Asthma. . # Urethral Stricture: Patient with h/o BPH s/p multpile urological procedures, including s/p Suprapubic prostatectomy. He was noted to have low urine output and bladder scan showed 360cc residual. It was impossible for staff to pass a foley. Urology was consulted, performed a flexible cystoscopy in the ICU and found severe urethral stricture. They were able to pass small cathether through and left in place. The patient leaked around the catheter, the catheter eventually came out but he continued to have good urine output and post-void bladder scans were performed q4h to ensure he did not have high residual volume. Urology suggested that when patient is stable he will have to be taken to the OR to have the stricture surgically fixed. . # Chronic renal insufficiency: Creatinine 1.3-1.6 baseline and up to 1.8 at presentation. Initially, nephrotoxic agents (lisinopril and glipizide) were held. A Renal U/S, to evaluate for hydronephrosis, was unremarkable. Creataninine at d/c was 1.3. . # Hypertension: The patient was continued on his home dose of nifedipine and was changed from metoprolol succinate to tartrate on admission and his BP was well controlled initially. At discharge, his BP was seen to be creeping back up (162/80) and his home dose of lisinopril was restarted, as his creatinine was back to the reported baseline. Additionally the patient was changed back to his home dose of Toprol XL 50 mg Tablet Sustained Release PO QD. . # Diabetes mellitus - On admission the home Glipizide but this was discontinued and blood sugars covered with SSI and a diabetic diet was prescribed. The patient was discharged on his home Glipizide. . # Sleep Disorder: The patient was on Quetiapine 25mg qHS on admission for "problems sleeping". This was stopped & Trazodone 25 mg PO prn was started. The patient stated he was sleeping well in the hospital, on discharge. Medications on Admission: Advair (states was not taking) Glipizide 10mg daily Lisinopril 20mg daily Nifedipine SR 20mg daily Quetiapine 25mg qHS Metoprolol succinate 50mg Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Inhalation* Refills:*2* 2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Disp:*15 Tablet(s)* Refills:*0* 3. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 4. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 6. Toprol XL 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:*2* 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: ================= Asthma flare . Secondary Diagnosis: =================== #. Hypertension #. Mild symmetric LVH, per echo, LVEF>55% ([**2132-8-6**]) #. Mild AS, Mild to [**Month/Day/Year 1192**] [[**12-26**]+] TR, trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **] systolic hypertension (per Echo [**2132-8-6**]) #. Chronic renal insufficiency, baseline creatinine ~1.5 #. Benign prostatic hyperplasia #. h/o Urinary obstruction #. Urinary retention, severe urethral stricture (per Cysto on [**2132-8-5**]) #. h/o Bladder stones #. Bilateral small renal cysts (Renal U.S., [**2132-8-5**]) #. DM2, controlled #. GERD with small axial hiatal hernia, per barium esophagram ([**2132-7-7**]) #. Esophageal dysmotility, characterized by tertiary contractions per barium esophagram & anterior cervical vertebral body osteophytes giving a minor impression on the cervical esophagus ([**2132-7-7**]) #. HOH, [**Month/Day/Year 1192**] sensorineural hearing loss in both ears #. Osteoarthritis, bilat knees . PSHx: [**2132-8-4**] s/p Flexible cystoscopy [**2127-7-14**] s/p Suprapubic prostatectomy, cystoscopy flexible [**2127-6-4**] s/p Complex cystometrogram, complex uroflowmetry [**2126-9-4**] s/p Cystometrogram [**2126-1-22**] s/p Cystoscopy, Electrohydraulic litholapaxy, Placement of suprapubic tube [**2126-1-9**] s/p Complex cystometrogram, Intra-abdominal voiding pressure studies with attempted complex uroflowmetry & flexible cystourethroscopy Discharge Condition: Stable: no wheezing & o2 sat stable on RA. Discharge Instructions: You were admitted to the hospital chest tightness, some difficulty breathing and a fast heart rate. You were sent to the ICU for observation. Testing showed that you did NOT have a heart attack. Urology was consulted while you were in the ICU and found that your urethra (the tube coming from your bladder that carries urine out of your body through your penis) is very narrowed. They recommend that you come back to the hospital as an outpatient and have a procedure under anesthia to stretch it and make it larger. Please arrange for this with Dr [**Last Name (STitle) 8499**]. We have also scheduled you to have some breathing tests to more closely diagnosis the periodic breathing problems that you experience. . Please call your Primary Care Provider [**Name Initial (PRE) **]/or come back to the Emergency Room if you experience any of the following: trouble breathing that does not go away with the use of your inhalers, temperature > 101.6, shaking chills, chest pain or pressure, pain that is not relieved with medicines, inability to pass your urine, changes in mental status, uncontrolled nausea/vomitting, finger sticks at home that are over 400 mg/dl, blood in your stool or any other health related concerns. . One of your medicines that you were taking when admitted has been stopped: Seroquel. Please do NOT take any more Seroquel. You were started on another medicine to help you sleep at night: Trazodone. Take Trazodone as needed at bedtime if you have trouble sleeping. We have also started you on a baby Aspirin [**Name2 (NI) 24073**] to help prevent heart attacks and a medicine called Omeprazole to help prevent acid reflux. Followup Instructions: PCP: [**Name Initial (NameIs) 2169**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2132-8-22**] 3:00 . PFTs: Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB, [**Hospital Ward Name 2104**] 7, Phone:[**Telephone/Fax (1) 609**], Tuesday Date/Time:[**2132-9-2**] 11:00 . Urology: recommends out-patient dilatation under GA for pin-hole bladder neck; please talk with your Primary Care Provider (Dr. [**Last Name (STitle) 8499**] about this. . GI: recommends an evaluation as an outpatient for your esphogeal spasm; please talk with your Primary Care Provider (Dr. [**Last Name (STitle) 8499**] about this. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**] Completed by:[**2132-8-8**]

[ "250.00", "600.01", "715.36", "585.9", "598.9", "530.81", "530.5", "788.20", "424.1", "403.90", "493.92", "584.9" ]

icd9cm

[ [ [] ] ]

[ "59.8", "57.32", "57.92" ]

icd9pcs

[ [ [] ] ]

11288, 11294

6915, 9996

276, 359

12818, 12863

3648, 3648

14559, 15402

2790, 2843

10192, 11265

11315, 11315

10022, 10169

12887, 14536

2858, 2858

2872, 3629

221, 238

387, 1365

11388, 12797

3664, 6892

11334, 11367

1387, 2536

2552, 2774

19,851

143,529

44319

Discharge summary

report

Admission Date: [**2126-2-6**] Discharge Date: [**2126-2-18**] Date of Birth: [**2061-2-21**] Sex: M Service: MEDICINE Allergies: Motrin / Codeine / Nortriptyline Attending:[**First Name3 (LF) 1070**] Chief Complaint: Low blood pressure, somnolence. Major Surgical or Invasive Procedure: Dialysis I&D of right chest wound History of Present Illness: Mr. [**Known lastname 7493**] is a 64 year-old man with HIV, ESRD on HD, Hep C, Dm II and other multiple medical problems presented to the [**Name (NI) **] with hypotension and somnolence noted at HD. . On [**1-29**] he was seen at HD and had drainage at the left groin site but looked well, he received a dose of vanco empirically and cultures were taken from the wound. . On [**1-31**], he received vancomycin and ceftaz (ceftaz added due to GNR seen on gram stain). Subsequently, swab grew out morganella, ESBL, MRSA, B-hemolytic strep (only growing in the broth). On this day, blood cultures were also drawn. . On [**2-2**], he received another dose of vanc and ceftaz at HD . On [**2-5**], he received vanc and amikacin ([**2-9**] ceftaz resistant organism noted on swab). Blood cultures were noted to have no growth. At this time SBP was noted to be approx 70, but 4kg removed; at the end of dialysis, his blood pressure was noted to be 94/50. . When asked the patient denies fevers, chills, somnolence. He states that he has alot of pain in his back, which his baseline. Denies cough, abdominal pain, nausea, vomiting but states that for several weeks he has had lower extremity wounds that bother him, as well as wounds on his buttocks. Patient reports having dark stools, but no blood. . ED course: Blood pressure 80s/30s in ED. BP up to 110 after fluids; HR 50s. Sats in 90s on 4L NC. Asleep about arousable on exam. Last dialysis yesterday. Has 18G in right femoral. He received vanco/gent in the ED. Past Medical History: 1) HIV: diagnosed in [**2106**], followed by Dr. [**Last Name (STitle) 1057**] at [**Hospital1 18**]. 2) Diabetes Mellitus, type 2, since ~[**2106**] with neuropathy, charcot foot, nephropathy, and ? mild retinopathy. 2) Chronic renal failure on Hemodialysis and graft infections, thrombus: dx approx. [**2115**]. Started HD in 2/[**2118**]. On HD on tues, thurs, sat at [**Doctor Last Name **] hospital. Dialysis unit - ([**Telephone/Fax (1) 17592**] / Nephrologist - Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -([**Telephone/Fax (1) 94989**] 3) [**Female First Name (un) 564**] esophagitis 4) Hepatitis C: genotype IB 5) Congestive heart failure: echocardiogram [**10-15**] w/ EF 50%. 6) Necrotizing Fasciitis: [**2112-10-17**]- [**2113**]: multiple surgeries and circumcision during hospitalization. 7) Hypertension 8) Hypercholesterolemia 9) LE Diabetic ulcers 10) Herpes zoster of the left mandibular distribution of the trigeminal nerve. [**2115**] 11) R suprapatellar abscess: [**2115**]. 12) IVDU (heroin and cocaine) [**2079**]-[**2102**], none since [**2102**] 13) Obesity 15) GI Bleed: [**2117**]. OB positive stool. No frank blood. Negative colonoscopies. 16) Anemia: [**2117**]. Started Epogen. 18) Colonic Polyps 19) Gastritis with large hiatal hernia. 20) Lipodystrophy 21) Charcot foot: dx in [**9-13**]. 22) Colonic AVM: seen on [**3-9**] colonoscopy on the ileocecal valve. Treated with thermal therapy. 23) Positive AFB in sputum: [**2119-11-17**]. MYCOBACTERIUM GORDONAE. No abnormalities on CT chest in [**2121**]. 24) MRSA- grew out from culture from R anterior chest wound Social History: previously lived alone. now basically long care care facility resident. Hx of tobacco abuse (quit 20 yrs ago), hx of alcohol abuse (quit >20 yrs ago), hx of heroin and cocaine abuse (quit >20 yrs ago) Family History: non-contributory Physical Exam: VS T 97.9, BP 116/45, HR 60, 100%2-3L Gen-obese, lying in bed, conversational, interactive CV-RRR, S1, S2 Pulm-CTAB Abdomen-obese, soft, nontender Extremities-bilateral venous stasis changes with skin breakdown, RLE edema>L LE (tense edema) Skin-right upper chest wound-open expressing pus, skin breakdown on inferior aspect of buttocks, testes Lines-R. femoral 18G placed in ED-oozing blood, L.femoral double lumen-C/D/I with area approximate to it that has skin breakdown Brief Hospital Course: 64 yo M w/ HIV, ESRD on HD, Hep C, Dm II and other multiple medical problems here with hypotension and somnolence. . # Sepsis: Patient presented with history of hypotension and likely mental status change. After IVF, his mental status has improved greatly. He had a normal WBC, and has been afebrile. Of note, he has been receiving vancomycin since [**1-29**] and he may be partially treated at the time of presentation. Patient was admitted to the ICU and treated with vanc and meropenem. Blood cultures at the hospital have not shown any growth. The source of this possible infection is not clear and there are multiple possibilities: left dialysis site, left groin fluid collection, right chest wound. Patient patient had I&D of chest wound at bedside. Culture from chest wound without growth. Stopped ABX per ID recs because of concern that we were just selecting for resistent organisms that colonize him chronically. Patient remained afebrile and his WBC was normal throughout hospitalization. Repeat ultrasound of the groin fluid collection did not show any fluid to be drained. It is not entirely clear if the patient ever really had a true bacteremia. He was not discharged with any abx. . #Hypoxia - Patient was on oxygen during his stay. Per patient he usually uses oxygen only at night. However, it is not clear if this is because the patient does not need oxygen or he refuses it as he would refuse to wear his oxygen at times during his hospital stay. He refused to get out of bed despite daily attempts by both the house staff and the nursing staff. The oxygen requirement is likley from atelectasis and should improve if he gets out of bed back at rehab. . #Congestive heart failure - Recently admitted (late [**Month (only) **] [**2125**]) for CHF (SOB requiring intubation), most recent echo showed a low normal EF 50-55%, likely diastolic component. Patient initially recieved a large amount of fluids in the emergency room. He had fluids removed at dialysis during the hospitalization and volume status should be controlled at dialysis as an outpatient. He was restarted on his BB and [**Last Name (un) **]. . ESRD - On HD T, [**Doctor First Name **], Sat at [**Hospital 1263**] Hospital. He recieved dialysis while in the hospital to remove fluids. He tolerated dialysis well. He was continued on his home renal meds. PTH level was checked, noted to be elevated. He was started on calcitriol every other day. . Diabetes: Since ~[**2106**] with neuropathy, last A1c 6.3 in [**2124-11-8**] charcot foot, nephropathy. During hospitalization, he has had problems with low blood sugars. He was not recieving insulin and an insulin blood level checked was low. [**Last Name (un) **] diabetes was consulted. Adrenal insufficiency was ruled out. He was eating and was confirmed to have a snack before bedtime. His sugars were usually low overnight. The etiology is unclear with possible difficulties with gluconeogenesis. He was started on diazoxide to help support his sugars. This should be titrated as needed. He will follow up with [**Last Name (un) **] after discharge. . Coagulopathy: History of multiple clots in grafts and IVC in past, so is now on chronic coumadin. He was also noted to have swelling in his legs r>l but DVT was ruled out with ultrasound. He coumadin was held in house for the draining procedure and was restarted at discharge. . Anemia: Currently baseline appears to be 26-28. Has chronic anemia and had been on epogen. His HCT was stable during the hospitalization. . HIV/HCV: Last CD4 count 331 ([**12-15**]) nadir was 60 in [**2118**]. HCV VL 4,290 IU/mL [**2125-11-19**]. Continued current outpatient medications (ritonavir, stavudine and indinivir). No need for OI ppx as CD4>200 . Hypertesion: Home regimen consists of valsartan, atenolol and norvasc. Meds were held in the unit. Atenolol was changed to metoprolol because of renal failure. Valsartan and lower dose norvasc was restarted. His norvasc can be titrated as need as an outpatient. . Back Pain: Appears to be chronic, has refused MRIs in the past. On methadone and percocet at home. His dose of methadone was decreased because he appeared to be too sleepy at times. This improved with the decreased dose. . Pressure Ulcers: Two small pressure ulcers were noted on his buttocks. Dressings were applied. During his hospitalization, the nursing staff continually tried to get him out of bed, but he would refuse most of the time. Also, a pressure relief bed was ordered for the patient, but he refused the new bed even though the risks of developing ulcers were explained to him. He was warned about the risk of progression and encouraged to get out of bed once he is back to his long term care facility. . Right chest wall wound: present for over a year and has never stopped despite long term antibiotics and multiple surgical explorations. he should not receive antibiotics empirically to cover this wound and local wound care should be employed. Medications on Admission: ALBUTEROL 17 GM--Two puffs four times a day ATENOLOL 25MG--One every day ATIVAN 0.5 mg--one tablet(s) by mouth once COUMADIN 4MG--[**Name6 (MD) **] dialysis md [**Last Name (Titles) **] 160 mg--one tablet(s) by mouth daily HUMULIN N 100U/ML--30 u sq every morning INDINAVIR SULFATE 400 MG--Take 2 tabs by mouth, with ritonavir, twice a day LAMIVUDINE 150 MG--Take after hemodialysis LANCETS 1 BOX--To use with fingerstick (one touch brand) Methadone 10 mg--2 tablet(s) by mouth twice a day for pain. may take additional tablet once a day for breakthrough. NEPHROCAPS 1--Take one tablet by mouth every day NEURONTIN 300 mg--one capsule(s) by mouth twice a day NORVASC 10MG--Take one by mouth every day QUININE SULFATE 200MG--One every day as needed for cramps RITONAVIR 100MG--Take one tablet, with indinavir, twice a day ROXICET 5 MG/325 MG--One by mouth q 4-6 hrs as needed for pain, max 5 per day; #140/28 day supply STAVUDINE 20MG--Take one tablet every day, and after hemodialysis on dialysis days Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-9**] puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY16 (Once Daily at 16): please monitor INR and adjust for goal [**2-10**]. 4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Indinavir 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day): with ritonavir. 6. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO QHD (each hemodialysis). 7. Methadone 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 10. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): with indinavir. 11. Stavudine 20 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours): take after dialysis on dialysis days. 12. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Petrolatum Ointment Sig: One (1) Appl Topical DAILY (Daily): to legs. 16. home oxygen 17. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Diazoxide 50mg/ml, 100mg PO three times daily Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: ESRD on Dialysis Diabetes Type 2 Hypertension HIV Hypoglycemia Discharge Condition: stable Discharge Instructions: You were seen in the hospital for low blood pressures. It was thought that these may be related to an infection. No clear evidence of an infection was found. You will not need to be discharged with abx. You were also noted to have low blood sugars. We started you on a medicine to help increase your blood sugars. . Either return to the emergency room or call your primary care physician if you have any chest pain, shortness of breath, significantly decreased blood sugars, weight gain, fevers, or other symptoms of concern to you. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1085**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2126-3-6**] 12:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2126-3-5**] 10:30 . [**Last Name (un) **] Diabetes: Dr. [**Last Name (STitle) 28007**] on [**3-5**] at 1pm on [**Location (un) 1385**] of [**Hospital **] Clinic. . Resume regular dialysis [**Last Name (LF) **],[**First Name3 (LF) **],Sat at [**Hospital 1263**] Hospital [**Telephone/Fax (1) 95037**] Completed by:[**2126-2-18**]

[ "V09.0", "250.42", "E879.1", "428.0", "250.52", "357.2", "V08", "362.01", "070.70", "038.9", "E849.9", "250.62", "608.89", "998.83", "995.91", "518.0", "286.9", "428.42", "285.21", "996.62", "E849.7", "585.6", "707.05", "403.91" ]

icd9cm

[ [ [] ] ]

[ "86.04", "99.07", "88.73", "38.93", "39.95", "86.28", "99.04" ]

icd9pcs

[ [ [] ] ]

11892, 12046

4352, 9355

324, 360

12153, 12162

12748, 13332

3821, 3839

10407, 11869

12067, 12132

9381, 10384

12186, 12725

3854, 4329

253, 286

388, 1913

1935, 3585

3601, 3805

81,349

141,135

35372

Discharge summary

report

Admission Date: [**2119-4-3**] Discharge Date: [**2119-4-7**] Date of Birth: [**2054-8-6**] Sex: F Service: MEDICINE Allergies: Zosyn Attending:[**First Name3 (LF) 3561**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2119-4-4**] Rigid bronchoscopy with yellow Dumon tracheoscope. Mechanical dilation tracheal stenosis. Silicone tubular stent placement, 16 x 25 mm, first-second tracheal rings. Balloon dilatation. External fixation, tracheal stent. [**2119-4-3**] Flexible bronchoscopy. History of Present Illness: 64y female w/chronic respiratory failure, tracheobronchomalacia, tracheal stenosis secondary to prolonged intubations, previous tracheostomy, ESRD, morbid obesity, OSA. The patient was initially admitted in [**7-5**] and became septic in the setting of severe cellulitis, this was then complicated by ATN/ARF leading to HD (MWF schedule) as well as a-fib w/RVR ( The patient was anti-coagulated for the a-fib but this has been held upon this hospitalization), respiratory failure, ? ARDS, prolonged intubation, and tracheostomy which was reversed [**11-5**]. After reversal she become progressively stridorous and was transfered to [**Hospital1 18**] [**2119-1-20**] for management by the interventional pulm service. At that time bronchoscopy illustrated TBM as well as tracheal stenosis of approximately 70-80% of the tracheal lumen diameter at the level of her previous tracheostomy stoma. Mechanical debridement was undertaken with some moderate symptomatic improvement. Prior to this admission the patient had resided at a nursing home, whereupon she began to have increasing stridor and dyspnea 7 days prior, she was treated with steroids and inhalers without complete resolution. Early am [**4-3**] the patient had continued worsening of her stridor and she was transported to the [**Hospital 80634**] ED, from there she was transfered to [**Hospital1 18**] for admission to the IP service. She was again debrided [**4-4**] with the placement of a silicone tubular stent, 16 x 25 mm, at the level of the first-second tracheal rings. Currently she is resting comfortably, although without significant improvement of symptoms post-stent. She does not have a cough, nausea/vomiting, fever/chills, or change in bowel habits. No chest pain, abdominal pain, or dysuria. Past Medical History: Trachael stenosis hospitalized [**7-5**] prolongued vent had trach placed removed [**12-5**] atrial fibrillation on warfarin ?OSA on CPAP no formal sleep study ESRD on HD MWF has tunneled cath multinodular goiter s/p biopsy Morbid obesity HTN C difficile colitis cellulitis with "fat necrosis" requiring skin grafting, c/b sepsis peripheral neuropathy ?GBS following birth of 2nd child left leg weakness tracheomalatia Chronic leg ulcers Recurrent UTI urinary stress incontinence iron deficiency anemia nephrolithiasis Social History: Nursing home resident at Southpoint. No smoking or EtoH. Husband is a dermatologist. Prior to her severe illness this summer she had been ambulating with a walker. Family History: noncontributory Physical Exam: PE: 98.8 76 82/64 20 99% 2L A&Ox4, NAD Irregular CTAB Upper extremities - short, thick arms. Palpable brachial, ulnar and radial pulses. No previous scars. Abd - obese LE - warm Pertinent Results: [**2119-4-6**] WBC-8.5 RBC-2.98* Hgb-9.0* Hct-28.5* Plt Ct-254 [**2119-4-5**] WBC-9.5# RBC-2.97* Hgb-9.1* Hct-28.0* Plt Ct-325 [**2119-4-4**] WBC-6.3 RBC-3.17* Hgb-9.3* Hct-29.4* Plt Ct-358 [**2119-4-3**] WBC-8.2 RBC-3.21* Hgb-9.7* Hct-30.4* Plt Ct-411 [**2119-4-3**] WBC-14.1* RBC-3.67* Hgb-11.2* Hct-35.4* Plt Ct-412 [**2119-4-6**] Glucose-85 UreaN-25* Creat-4.0* Na-141 K-3.7 Cl-100 HCO3-31 [**2119-4-5**] Glucose-90 UreaN-38* Creat-5.0*# Na-137 K-3.8 Cl-97 HCO3-28 [**2119-4-4**] Glucose-115* UreaN-79* Creat-8.3* Na-137 K-6.0* Cl-99 HCO3-20* [**2119-4-3**] Glucose-122* UreaN-75* Creat-8.0*# Na-138 K-6.1* Cl-97 HCO3-23 A [**2119-4-4**] Culture Site: ENDOTRACHEAL GRAM STAIN (Final [**2119-4-4**]): [**10-22**] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [**2119-4-6**]): RARE GROWTH OROPHARYNGEAL FLORA. CXR: [**2119-4-4**] No evidence of pneumomediastinum or pneumothorax following bronchoscopy and stent placement [**2119-4-3**] 1. Retrocardiac opacity which likely represents atelectasis, but pneumonia is not excluded. 2. Low lung volumes cause crowding of the hilar structures. 3. Cardiomegaly without evidence of pulmonary edema. Chest CT [**2119-4-3**] IMPRESSION: 1. Relatively [**Name2 (NI) 15015**] right and left main bronchus, but no evidence of bronchial collapse. No evidence of tracheal wall thickening or peritracheal edema. The tube should be pulled back by 2-3 cm. 2. Moderate distention of the pulmonary trunk could indicate pulmonary hypertension. Moderate coronary calcifications, numerically increased normal size mediastinal and hilar lymph nodes. No lymphadenopathy. 3. Unchanged bibasilar atelectasis, no larger masses or other opacities. 4. 2 cm right thyroid node. 5. Minimal attenuation differences in the lung parenchyma, potentially due to airtrapping. Brief Hospital Course: Mrs. [**Known lastname 24630**] was transferred on [**2119-4-3**] for trachael stenosis. She had a flexible bronchoscopy which showed a proximal tracheal stenosis and malacia with critical lumen diameter of about 5 mm with significant dynamic collapse during inspiration and expiration. The lesion is located at the 1st and second tracheal ring and has a length of aproximately 1.2cm. At that point, the patient started saturating to be in respiratory distress. She was started on Heliox and non-invasive positive pressure and ventilation. We performed endotracheal intubation for airway protection. She was transferred to the MICU for further management. On [**2119-4-4**] she was taken to the operating room for Rigid bronchoscopy with yellow Dumon tracheoscope. Mechanical dilation tracheal stenosis. Silicone tubular stent placement, 16 x 25 mm, first-second tracheal rings. Balloon dilatation. External fixation, tracheal stent placement. She was extubated in the operating room and transferred back to the MICU for airway monitoring. Her airway remaind stable and was transferred to the floor on [**2119-4-5**]. She was seen by the transplant team for evaluation of a permanent dialysis access. On [**2118-9-7**] a flexible bronchoscopy was done and the Silicon stent was in good position. The renal service followed her throughout her hospital course and she continued on her HD as scheduled. She continued to have brief episodes of atrial fibrillations with a heart rate in the 140's with spontaneous return to sinus rhythm. Her diltiazem dose was increased but her blood pressure would not tolerate the higher dose. Her anticoagulation was held for future testing. Medications on Admission: Coumadin 1mg Po daily Acetaminophen 325-650 mg PO Q6H:PRN Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Ipratropium Bromide Neb 1 NEB IH Q6H Amiodarone 200 mg PO DAILY Lisinopril 2.5 mg PO DAILY Ascorbic Acid 500 mg PO DAILY Lorazepam 0.5 mg PO Q12H: PRN Aspirin 81 mg PO DAILY Bisacodyl 10 mg PO DAILY:PRN Multivitamins 1 TAB PO DAILY Calcium Acetate 1334 mg PO TID W/MEALS Omeprazole 20 mg PO DAILY Clopidogrel 75 mg PO DAILY Sertraline 100 mg PO DAILY Diltiazem Extended-Release 240 mg PO DAILY Senna 2 TAB PO Ferrous Sulfate 325 mg PO Discharge Medications: 1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed. 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a day). 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 15. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Discharge Disposition: Extended Care Facility: Southpointe - [**Location (un) 8973**] Discharge Diagnosis: Trachael stenosis-hospitalized [**7-5**] prolongued vent had trach placed removed [**11-5**] ESRD on HD MWF has tunneled cath cellulitis, requiring skin grafting, c/b sepsis atrial fibrillation on warfarin multinodular goiter Morbid obesity HTN C difficile colitis peripheral neuropathy left leg weakness tracheobronchomalacia Chronic leg ulcers Recurrent UTI urinary stress incontinence iron deficiency anemia nephrolithiasis Discharge Condition: deconditioned Discharge Instructions: Call Dr[**Doctor Last Name **] office [**Telephone/Fax (1) 7769**] if develops increased shortness of breath, cough or sputum production Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 17853**] CLINIC INTERVENTIONAL PULMONARY (SB) Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2119-4-11**] 9:00am in the [**Hospital Ward Name 121**] Building Chest Disease Center [**Location (un) **]. Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2119-4-11**] 10:00am in the [**Hospital Ward Name 121**] Building Chest Disease Center [**Location (un) **]. The chest CT showed a thyroid nodule which requires an ultrasound. This will be undertaken by the Interventional Pulmonary service when she is seen there within the next 2 weeks. Completed by:[**2119-4-10**]

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icd9cm

[ [ [] ] ]

[ "96.71", "31.99", "33.22", "96.04", "39.95", "96.05" ]

icd9pcs

[ [ [] ] ]

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5288, 6975

272, 547

9506, 9522

3321, 5265

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3090, 3107

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72,930

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19794

Discharge summary

report

Admission Date: [**2191-2-22**] Discharge Date: [**2191-2-28**] Date of Birth: [**2139-11-18**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (un) 7835**] Chief Complaint: Diarrhea, decreased PO intake, nausea/vomiting, severe hypotension. Major Surgical or Invasive Procedure: Nephrostomy Tube Placement [**2191-2-24**] History of Present Illness: 51 year old man with metastatic gastric cancer dx [**1-9**] s/p 1 cycle of ECF, recently admitted from [**Date range (3) 53517**] for febrile neutropenia, treated for UTI with cipro, now presenting with diarrhea and poor PO intake. Reports several days of nonbloody diarrhea since Friday. Was given aggressive bowel regimen prior to DC [**2-18**] but was not taking laxatives at home. Was seen at [**Hospital1 2025**] and recieved IVF through port yesterday which improved sx somewhat. Pt with 6 BM today, increasingly watery. Pt has been off tube feeds for past several days due to nausea, diarrhea, vomiting x1 today and yesterday. Endorses weakness while ambulating, fecal urgency. denies feeling dizzy, sob or chest pain. No sick contacts. . Regarding his chemotherapy, the plan had been for pt to start cycle 2 of chemotherapy in clinic tomorrow. Currently pt holding capecitabine. Oncologist referred pt to the ED. On arrival to the ED, initial VS were T 98.5 HR 120 BP (72/55) 83/48 RR 16 SpO2 97% RA. On exam he was pale but overall well appearing, AOx3. Labs significant for lactate of 1.6, WBC 18.2 with 76%PMN and 13 bands. BU/CR 20/1.3. CXR showed no acute process. Pt was given 5.5L of IVF NS, along with vanc/ctx given history of recent UTI. ED unable to place central line [**12-30**] port obstructing the area and started peripheral levophed. Pt was sent for CT abd/pelvis. UA not remarkable. CT showed right hydronephrosis. Urology to see in AM. Pt was taken off levophed prior to transfer. . On arrival to the ICU, pt calm, lying in bed, off pressors. Denies nausea or abdominal pain. 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: Gastric adenocarcinoma stage IV, diffuse type - [**2188**] Developed reflux and postprandial nausea and vomiting - [**1-/2190**] Had an episode of melena - [**9-/2190**] Developed worsening vomiting, difficultly tolerating POs - [**10/2190**] Developed new RUQ pain - [**11/2190**] Referred to GI - [**2190-12-31**] CT abdomen showed gastric thickening, omental enhancement, and colonic thickening concerning for diffuse gastric cancer with intraperitoneal spread - [**2191-1-6**] EGD reveals a large gastric mass, biopsy consistent with gastric adenocarcinoma with signet ring features consistent with diffuse gastric cancer . Other Past Medical History: - Hyperlipidemia. - Herniated disk s/p laminectomy. Social History: - Tobacco: <5 PYs in his teens. - Alcohol: Social only. - Illicits: Denies. - Occupation: Courier, hockey ref. - Exposures: Denies. - Social supports: Lives with wife, extended family is local and involved. Family History: - Mother: Arthritis. - Father: CAD/MI. - Sister: Diagnosed with gastric cancer age 32, died of disease age 34. - 11 other siblings, no cancers among them. - P. cousin: Appendiceal cancer, died in his 50s of this cancer. - P. uncle: [**Name (NI) **] cancer. - P. uncle: [**Name (NI) **] cancer. - M. aunt: [**Name (NI) **] cancer. Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, J tube in place no erythema or swelling GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2191-2-22**] 07:14PM BLOOD WBC-18.3*# RBC-4.73# Hgb-13.7* Hct-42.2 MCV-89 MCH-29.0 MCHC-32.6 RDW-13.7 Plt Ct-571*# [**2191-2-24**] 05:02AM BLOOD WBC-8.6 RBC-3.71* Hgb-10.9* Hct-32.8* MCV-89 MCH-29.4 MCHC-33.2 RDW-13.8 Plt Ct-363 [**2191-2-22**] 07:14PM BLOOD Neuts-75* Bands-13* Lymphs-3* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-2* NRBC-1* [**2191-2-23**] 06:12AM BLOOD Neuts-78.0* Lymphs-15.6* Monos-4.3 Eos-2.0 Baso-0 [**2191-2-23**] 12:24AM BLOOD PT-13.2* PTT-26.2 INR(PT)-1.2* [**2191-2-22**] 07:14PM BLOOD Glucose-137* UreaN-20 Creat-1.3* Na-140 K-4.5 Cl-103 HCO3-24 AnGap-18 [**2191-2-24**] 05:02AM BLOOD Glucose-87 UreaN-7 Creat-1.0 Na-141 K-3.5 Cl-108 HCO3-24 AnGap-13 [**2191-2-23**] 06:12AM BLOOD ALT-35 AST-14 AlkPhos-57 TotBili-0.1 [**2191-2-24**] 05:02AM BLOOD ALT-34 AST-17 LD(LDH)-159 AlkPhos-63 TotBili-0.1 [**2191-2-24**] 05:02AM BLOOD Albumin-2.8* Calcium-7.9* Phos-3.6 Mg-1.7 [**2191-2-22**] 07:26PM BLOOD Lactate-1.6 [**2191-2-22**] 10:41PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.017 [**2191-2-22**] 10:41PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2191-2-22**] 10:41PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0 TransE-<1 Micro: URINE CULTURE (Final [**2191-2-24**]): NO GROWTH. Imaging: CHEST (PORTABLE AP) Study Date of [**2191-2-22**] 7:19 PM IMPRESSION: No evidence of acute cardiopulmonary disease or free air. CT ABD & PELVIS WITH CONTRAST Study Date of [**2191-2-23**] 12:45 AM IMPRESSION: 1. New moderate right hydronephrosis and hydroureter with a delayed nephrogram. The point of obstruction is likely at the distal ureter as there is dilatation of the right ureter all the way to the distal ureter. No distinct stones are visualized, but a recently passed stone cannot be excluded. 2. Again visualized is thickening of the antrum of the stomach with surrounding inflammatory changes consistent with previously visualized gastritis and mesenteritis. . DISCHARGE LABS: [**2191-2-28**] 06:43AM BLOOD WBC-7.1 RBC-3.56* Hgb-10.5* Hct-31.7* MCV-89 MCH-29.5 MCHC-33.1 RDW-14.5 Plt Ct-318 [**2191-2-28**] 06:43AM BLOOD Glucose-103* UreaN-6 Creat-0.9 Na-139 K-3.7 Cl-105 HCO3-27 AnGap-11 [**2191-2-27**] 06:15AM BLOOD ALT-19 AST-13 AlkPhos-58 [**2191-2-28**] 06:43AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.8 Brief Hospital Course: 51yo man with metastatic gastric CA recently started on ECF chemo admitted for N/V/D and severe hypotension requiring pressors in the ED and ICU admission. In the ICU, he was started on ceftriaxone/vancomycin and IV metronidazole for emperic C. diff coverage. He was transferred out of ICU [**2191-2-24**] and right-sided percutaneous nephrostomy tube placed for moderate hydronephrosis. Antiobiotics were stopped. Diarrhea has not occured in the hospital. Nausea improving. . # Nausea/vomiting/diarrhea: Unclear if these symptoms are due to chemotherapy, tube feeds, or gastric CA but recurrence of symptoms and inability to tolerate feeding trial with Fibersource suggests TF as cause, which may have been exacerbated by recent chemo. - Use of semi elemental TF as recommended by Nutrition (Peptamen 1.5 for goal 60ml/hr) has been tolerable, so he will be discharged with these new TF. - Continue scheduled metoclopramide (which was added during admission) and prn zofran. . # Hypotension- Initially the pt presented w/ hypotension after having a couple of days for profuse diarrhea. He did have a leukocytosis w/ bandemia. C.Diff was initally a concern on admission and was started on Vancomycin and Metronidazole. He was given fluid bolus initially and his blood pressure reponded appropriately. He maintained an appropriate blood pressure not requiring further fluid boluses. . #diarrhea - Pt had been taking an increased amount of stool softeners after a prior hospitalization where he was noted to be severely constipated. C.Diff was initially a concern and Flagyl and Metronidazole were started. His diarrhea resolved after leaving the ED though and had no more further diarrhea while in the unit. Vancomycin was discontinued and the decision was made to continue Metronidazole until ruled out for C.diff. We discontinued his stool softener regimen. Pt did not have any more bowel movements so Cdiff was not ruled out, but Metronidazole was discontinued due to low suspicion. . #hydronephrosis - Noted to have right-sided hydronephrosis on CT of abdomen and pelvis. This was felt to be due to obstruction caused by metastatic disease. Urology and Oncology evaluated the pt and have determined a percutaneous nephrostomy tube placement would be appropriate to relieve the hydronephrosis. This was done on [**2191-2-24**]. He will follow up with urology within one month. . # Acute renal failure: In setting of finding right hydronephrosis on CT abd. During last hospitalization pt with [**Last Name (un) **] cr of 1.3, down to 1.0 on discharge. Back up to 1.3 on presentation to the hospital. Likely [**12-30**] dehydration/prerenal state, as unilateral hydronephrosis should not cause [**Last Name (un) **] on it's own in normally functioning kidneys. His Cr returned to baseline after fluid bolus. . # Gastric cancer: patient followed by oncology. The prior plan had been for chemo to be restarted. His out pt oncologist was made aware of the admission and will continue to follow as an outpatient. . # [**Name (NI) 20973**] pt was complaining of persistent nausea with tube feeds. He was started on reglan tid and he tolerated his tube feeds better, but had recurrent symptoms of nausea, vomiting and diarrhea as TF were increased. This prompted change to semi-elemental TF (Peptamen 1.5) which he tolerated well. He will be able to meet caloric requirements with these feedings and maintain hydration with TF and oral liquid intake. Medications on Admission: 1. polyethylene glycol 3350 17 gram Powder in Packet [**Name (NI) **]: One (1) Powder in Packet PO DAILY. 2. docusate sodium 50 mg/5 mL Liquid [**Name (NI) **]: One (1) PO BID. 3. oxycodone-acetaminophen 5-325 mg/5 mL Solution [**Name (NI) **]: 5-10 MLs PO Q4H PRN pain. 4. lorazepam 0.5 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q6H PRN anxiety. 5. cyanocobalamin (vitamin B-12) 500 mcg Tablet [**Name (NI) **]: Two (2) Tablet PO DAILY. 6. ciprofloxacin 500 mg PO Q12H x10 days. course to finish [**2191-2-28**] 7. lansoprazole 30 mg Rapid Dissolve DR [**Last Name (STitle) **] DAILY. Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*0* 8. senna 8.6 mg PO BID PRN constipation. Disp:*60 Tablet(s)* Refills:*0* 9. ZOFRAN ODT 4-8mg Rapid Dissolves PO q8HR PRN nausea. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*0* 10. lactulose 10 gram/15 mL Solution [**Last Name (STitle) **]: 30ml PO BID PRN constipation. Disp:*200 ml* Refills:*0* Discharge Medications: 1. metoclopramide 5 mg/5 mL Solution [**Last Name (STitle) **]: Ten (10) ml PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*1 bottle (473ml)* Refills:*2* 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Last Name (STitle) **]: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 3. sodium chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**11-29**] Sprays Nasal QID (4 times a day) as needed for congestion. 4. docusate sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2 times a day) as needed for Constipation. 5. senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 6. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. 7. Multi-Vitamin HP/Minerals Capsule [**Month/Day (2) **]: One (1) Capsule PO once a day. 8. Peptapen [**Month/Day (2) **]: 1.5 Fullstrength 60ml/hr over 24hrs. Disp:*1 month supply* Refills:*2* 9. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve [**Month/Day (2) **]: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Discharge Disposition: Home With Service Facility: [**Last Name (un) 6438**] Discharge Diagnosis: Hypotension Nausea with Vomiting Diarrhea Gastric Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with low blood pressure, nausea, vomiting and diarrhe. Initially you were admitted to the ICU and required medication to increase your blood pressure as well as aggressive hydration. Due to concern for infection you were started on antibiotics but these were discontinued as there was no evidence of infectious source and your symptoms improved. You were started on a medication for nausea called metoclopromide and restarted on tufe feeds. It is unclear if the symptoms were due to the cancer, chemotherapy or the tube feeds but your tube feeds have been changed to an easier to digest type which you have tolerated better. You also were noted to have an obstruction in your urinary tract and had a nephrostomy tube placed to drain this. Followup Instructions: Department: BIDHC [**Location (un) **] When: MONDAY [**2191-3-7**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10604**], MD [**Telephone/Fax (1) 3329**] Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: SURGICAL SPECIALTIES When: MONDAY [**2191-3-21**] at 3:30 PM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "55.03", "96.6" ]

icd9pcs

[ [ [] ] ]

12282, 12338

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371, 416

12439, 12439

4321, 4321

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264, 333

444, 2047

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12454, 12566

3191, 3244

3260, 3468

58,854

150,436

44386

Discharge summary

report

Admission Date: [**2129-10-28**] Discharge Date: [**2129-11-8**] Date of Birth: [**2056-1-14**] Sex: F Service: MEDICINE Allergies: Aspirin / Folic Acid / Milk / Cephalexin / adhesive / peanuts / Oxycodone Attending:[**First Name3 (LF) 12131**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: 73 year old woman with a history of metastatic adenocarcinoma with unknown primary currently on chemo and [**First Name3 (LF) 16859**] ([**Doctor Last Name **]/taxol [**10-18**]) with recent long admission ([**Date range (1) 95163**]) for difficulty ambulating c/b hyponatremia requiring ICU transfer for hypotonic saline who is now presenting from her rehab facility for worsening mental status. Her medical history was obtained from her husband, her oncology fellow, and records in OMR. She initially presented at the end of [**Month (only) 216**] with bilateral hip pain with worsening LE edema and LUE swelling. Studies revealed a right scapular mass which was found to be adenocarcinoma. A workup for a primary tumor was inconclusive but revealed a spot on her lung which was felt to be the most likely candidate; a colonoscopy was incomplete, a virtual colonoscopy was negative but suboptimal, a capsule study was not done because of a hiatal hernia, and a mammogram was negative. The plan was for palliative chemo/[**Month (only) 16859**] for symptom management and with the hope of adding some time to her life expectency. She was discharged to rehab [**10-19**]. Since then they have been monitoring her sodium levels closely. She was given 2 units of pRBCs last week for worsening anemia after her chemotherapy. Her oncology fellow was concerned that she was getting rectal meds while neutropenic and asked them to start antibiotics which were started yesterday (cipro). According to her husband she has been taking poor PO for the last several days and feeling progressively weaker. Today her husband came in to visit her and noticed that she was stooping over in her wheelchair with her head down and with her eyes closed. When he went to talk to her she was only intermittently responsive and oriented. They called her oncologist who suggested she come in to the ED. Review of records from her rehab facility show that in addition to receiving MS contin 30mg [**Hospital1 **] regularly over the last several days she also received 0.5mg of sublingual ativan on [**10-26**] at 12pm, 4mg of PO dilaudid on [**10-26**] at 4pm (hard to tell exact time), 2mg of PO dilaudid on [**10-27**] at 5pm, and a compazine suppository [**10-27**] at 3:30pm. According to the records she received another 10mg of PO morphine at the rehab prior to their calling EMS although this is not confirmed in the [**Month (only) 16**]. She also was given the flu vaccine the afternoon of [**10-26**]. A course of cipro was completed on [**10-27**] and then restarted later that day. On arrival to the ED she triggered for hypotension to SBPs of 77 which were responsive to fluids with SBPs above 100 after. HRs ranging 90-120. Afebrile. Her mental status was noted to be somnolent but arousable to voice. She was seen in the ED by her oncologist (fellow [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) who agreed that she was significantly altered from before. Labs revealed neutropenia 57% WBC 1.9 and hyponatremia (not as low as before). Since she is on dagibotran a head CT was done which was negative. A CXR showed a possible RLL opacification, blood cultures and urine cultures were drawn and she was started on vanc and merepenem (has a history of a cephalosporin allergy). She was admitted to the ICU for MS monitoring. She received a total of 1.5L IVF in the ED. He also notes that she has been vomiting (he thinks daily) since her last chemotherapy 2 weeks ago. Last Tuesday she received 2 units of pRBCs at [**Hospital **] Hospital. According to her husband she has not been complaining of pain for the last several days but she has seemed more altered. He asked them to not give her too much pain medication. She and her husband have no children and he is her only caregiver. She does have a sister, a [**Name2 (NI) 802**], and many friends. In the ED her husband asked Dr. [**Last Name (STitle) **] how much time she has left. She told him that that if she was not better in next few days she would be worried that her symptoms are due to underlying cancer and not just the chemotherapy and that this would mean a worsening prognosis. Review of systems: (+) Per HPI + recent weight gain since before last admission (in setting of fluids 145 -> 181) + rhinorrhea x weeks + cough, productive of whitish phlegm for the last month, no blood + constipation (intermittently) + rash on left torso (stable for last few weeks) Per husband no diarrhea, fevers, chills above baseline (always cold at baseline), night sweats, headaches, shortness of breath (although on O2 for the last few days at EPIC), chest pain, palpitations, abdominal pain, diarrhea, bloody stools, dysuria, frequency. Past Medical History: - admitted [**Date range (1) 95164**] with difficulty ambulating and hyponatremia - admitted [**Date range (1) 95162**] with LUE swelling and pain and had an ultrasound guided biopsy of her scapular mass [**2129-9-21**] showing adenocarcinoma- metastatic adenocarcinoma of unknown primary - colonic polyps [**2123**] - HTN - osteopenia - primary biliary cirrhosis - eczema - atrial fibrillation s/p PPM [**6-/2129**] on pradaxa (attempted cardioversion last [**Month (only) **]) - s/p appendectomy [**2064**] - s/p arthroscopy knees [**2114**], [**2123**] Social History: Married for 41 years, no children. Husband uses a cane to walk. Her sister and her husband's family live nearby. She is a retired psychiatric social worker. She endorses a 15 year smoking history of 1 pack per day, quit 30 years ago. She stopped drinking alcohol following her diagnosis of PBC but never drank regularly. She enjoys singing, playing the piano. Family History: Mother: [**Name (NI) 11964**] @50. Deceased at age 60 Father: Renal failure after surgery. Deceased at age 51. siblings: sister with MS, ?stomach cancer, living Physical Exam: ICU admission physical exam Physical Exam: Vitals: 98.2 hr 131 124/92 24 99%/2L General: minimally responsive, able to follow simple commands HEENT: Sclera anicteric, dry mucous membranes pupils small but equal and reactive Neck: supple, JVP not elevated, no LAD CV: irregular, tachycardic, 2/6 systolic murmur at the LSB Lungs: diminished breath sounds bilaterally, scattered wheezes, transmitted upper airway sounds, sparse scattered crackles Abdomen: soft, obese, nontender, nondistended, normoactive bowel sounds present, no rebound or guarding GU: foley in place with yellow urine Ext: Warm, well perfused, with 1+ pulses bilaterally. 2+ edema throughout LE. Left arm with significant lymphedema. Skin: red scaling rash across left breast and upper torso, left upper extremity edema, induration Neuro: CN2-12 intact, inattentive but able to follow simple commands Pertinent Results: Admission labs: [**2129-10-28**] 01:30PM BLOOD WBC-1.6*# RBC-3.62* Hgb-10.6* Hct-30.4* MCV-84 MCH-29.3 MCHC-34.9 RDW-14.8 Plt Ct-50*# [**2129-10-28**] 01:30PM BLOOD Neuts-57.5 Lymphs-33.6 Monos-8.0 Eos-0.2 Baso-0.7 [**2129-10-28**] 01:30PM BLOOD PT-18.7* PTT-33.1 INR(PT)-1.8* [**2129-10-28**] 01:30PM BLOOD Glucose-111* UreaN-16 Creat-0.8 Na-127* K-4.4 Cl-88* HCO3-29 AnGap-14 [**2129-10-28**] 01:30PM BLOOD ALT-19 AST-70* CK(CPK)-77 AlkPhos-103 TotBili-0.7 [**2129-10-28**] 01:30PM BLOOD proBNP-5344* [**2129-10-28**] 01:30PM BLOOD Albumin-2.4* [**2129-10-29**] 04:44AM BLOOD Calcium-7.5* Phos-2.6* Mg-1.4* [**2129-10-28**] 01:30PM BLOOD Osmolal-258* [**2129-10-28**] 01:56PM BLOOD Lactate-2.2* [**2129-10-28**] 07:37PM BLOOD freeCa-1.11* Other notable labs: [**2129-10-29**] 04:44AM BLOOD CK-MB-4 cTropnT-0.03* [**2129-10-29**] 03:10PM BLOOD CK-MB-4 cTropnT-0.03* [**2129-10-29**] 04:44AM BLOOD Cortsol-26.2* [**2129-10-29**] 04:44AM BLOOD Fibrino-551* [**2129-10-29**] 04:44AM BLOOD Gran Ct-1230* Discharge labs: [**2129-11-8**] 05:23AM BLOOD WBC-9.1 RBC-2.76* Hgb-7.9* Hct-23.0* MCV-83 MCH-28.7 MCHC-34.4 RDW-16.3* Plt Ct-195 [**2129-11-6**] 06:53AM BLOOD Neuts-65 Bands-0 Lymphs-29 Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2129-11-6**] 07:34PM BLOOD PT-13.4* INR(PT)-1.2* [**2129-11-8**] 05:23AM BLOOD Glucose-92 UreaN-16 Creat-1.1 Na-131* K-3.7 Cl-89* HCO3-38* AnGap-8 [**2129-11-8**] 05:23AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.1 Micro: [**2129-10-29**] URINE Legionella Urinary Antigen -FINAL -NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. [**2129-10-28**] MRSA SCREEN MRSA SCREEN-PENDING [**2129-10-28**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2129-10-28**] URINE URINE CULTURE-FINAL {GRAM POSITIVE BACTERIA} GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. [**2129-10-28**] BLOOD CULTURE Blood Culture, Routine-PENDING Studies: [**2129-10-30**] CHEST PORT. LINE PLACEM Compared with earlier the same day (6:36 a.m.), a right subclavian PICC line has been placed. The tip overlies the uppermost right atrium. No pneumothorax is detected. Otherwise, I doubt significant interval change. Again seen is cardiomegaly, with left lower lobe collapse and/or consolidation and obscuration of left hemidiaphragm. There is also hazy opacity and atelectasis at the right base, probably with a small right effusion. A small left effusion may also be present. Platelike atelectasis is noted in left mid zone. Dual-lead pacemaker again noted. [**2129-10-30**] CHEST (PORTABLE AP) Comparison with the previous study done [**2129-10-28**]. There is increased density at the left lung base with obliteration of the left hemidiaphragm consistent with atelectasis and/or consolidation as before. There is continued evidence for small pleural effusions bilaterally as well. Mediastinal structures are unchanged. A bipolar transvenous pacemaker remains in place. Allowing for differences in technique, there is no definite interval change. IMPRESSION: No significant change. [**2129-10-28**] CT HEAD W/O CONTRAST There is no intracranial hemorrhage, edema, shift of normally midline structures, hydrocephalus, or acute large vascular territorial infarction. Prominence of the ventricles and sulci are consistent with age-related involutional change. Minimal periventricular white matter hypodensity is a nonspecific finding that can be seen in the setting of chronic small vessel ischemic disease. Calcifications are seen in the bilateral cavernous carotid arteries. There is redemonstration of bilateral optic disc drusen. A mucus retention cyst is seen within a posterior right ethmoidal air cell. There is aplasia of the left frontal sinus. The remainder of the visualized portions of the paranasal sinuses and mastoid air cells are well-aerated. IMPRESSION: No acute intracranial process. [**2129-10-28**] CHEST (PORTABLE AP) A single frontal radiograph of the chest was acquired. There is redemonstration of a left-sided pacemaker with associated right atrial and right ventricular leads, not significantly changed. There is new consolidation at the left lung base, representing some combination of atelectasis and/or infection as well as a small left pleural effusion. Streaky right lower lung opacities are likely secondary to atelectasis. There may be a small layering pleural effusion on the right. No pneumothorax is seen. The heart is mildly enlarged, slightly increased compared to the prior study. There is engorgement of the pulmonary vasculature. IMPRESSION: 1. Findings consistent with left lower lung atelectasis and/or pneumonia. 2. New small left pleural effusion and possible small right layering pleural effusion. 3. Increased mild-to-moderate cardiomegaly with pulmonary vascular congestion. Brief Hospital Course: 73 yo F w/ metastatic adenocarcinoma with unknown primary on palliative chemo/[**Month/Day/Year 16859**] admitted with altered mental status. She was admitted to the ICU for hypotension and altered mental status. After a several day stay in the ICU, during which she responded well to diuresis as below, she was transferred to the oncology floor. Her hospital course by problem is as follows: # AMS: At baseline, she is alert and oriented x 3. Prior to arrival was intermittently responsive and difficult to arouse. Slightly improved after admission and able to respond to simple questions. Etiology undetermined, but most likely multifactorial and due to a combination of opioids and hyponatremia. Her mental status improved with correction of her hyponatremia. Initially infection was suspected, potentially of pulmonary origin. She was started on vancomycin and meropenem while in the ICU, however this was discontinued as her mental status improved with improvement of her metabolic abnormalities. She was afebrile throughout her hospital stay. Upon discharge she was alert and oriented to person, place, and time. # Hypotension: Briefly hypotensive in the ED to SBPs 77 which was fluid responsive. Initially thought to be hypovolemia in the setting of poor PO intake at rehab as well as vomiting [**2-24**] chemotherapy. Her hypotension was ultimately attributed to likely right sided heart failure with dilated R ventricle causing intraventricular septal bowing. Diuresis improved her blood pressures, presumably decreasing the size of her right ventricle and augmenting cardiac output. Her right ventricular dilatation is though to be secondary to pulmonary hypertension, of which the etiology is unclear. [**Name2 (NI) **] home metoprolol and lisinopril were initially held on admission given hypotension, but metoprolol was restarted given rapid afib. She was continued on her home sotalol. # PNA: Afebrile but per husband has had cough productive of whitish sputem for last few weeks. Met SIRS criteria on admission with hypovolemia, leukopenia, [**Doctor First Name **] tachypnea. Remained hemodynamically stable s/p fluid resuscitation and subsequent diuresis. Blood cultures sent and were pending at the time of transfer to the floor. She was started emperically on broad coverage with vancomycin and meropenem. These agents were discontinued after transfer to the oncology floor as she remained afebrile, tachypnea had resolved, vital signs were stable, and she was responding well to diuresis. Ultimately, pneumonia was determined to be a highly unlikely causative [**Doctor Last Name 360**] of her altered mental status. # Hyponatremia: Hypervolemic hypotonic hyponatremia. Na 127 which is above recent baseline. Received 1.5L NS in ED. Total body volume overloaded (with LE edema and pulmonary edema on CXR) and per husband she is 40 lbs above her previous weight. She was diuresed with furosemide 40 mg IV boluses to a goal of 1-2L per day while in the ICU. Upon transfer to the floor, she was diuresed with oral torsemide. She lost 10 pounds during her stay in the hospital. She is being discharged off diuretic therapy as her creatinine increased in the preceding two days prior to discharge and would not be able to be monitored effectively. # Pancytopenia: Patient with pancytopenia on arrival to hospital as above s/p first cycle of [**Doctor Last Name **]/taxol. Attributed to persistent bone marrow suppression. Patient's dabigatran (anti-coagulation for a. fib.) temporarily held for platelet nadir of 14,000. Fortunately, her platelets began to rise by hospitalization day 7, and dabigatran was restarted on the day prior to discharge. She received one dose of neupogen on hospitalization day 7. Prior to discharge her WBC was 9.1. # Metastatic adenocarcinoma of unknown primary: Patient recently diagnosed with metastatic adenocarcinoma to left shoulder with unknown primary, status post one cycle of [**Doctor Last Name **]/taxol. Her next planned infusion date was [**2129-11-7**], however further treatment was deferred until re-assessment as an outpatient once she recovered from this acute illness. # Atrial fibrillation: Rate controlled with rate 80-110's. BPs stable with normotensive BPs throughout her hospitalizaton. Maintained sinus rhythm while on oncology floor. She was continued on her home metoprolol and home sotalol doses during her hospitalization. Her dabigatran was temporarily held due to thrombocytopenia as discussed above. # Fluid overload/lower extremitiy edema: Patient with significant total body fluid overload and lower extremity edema, present since last discharge. Attributed to hypoalbuminema in setting of malignancy; diuresed as above with 10 pound weight loss while on oncology floor. ======================================= TRANSITIONAL ISSUES: - Patient was full code during her hospitalization. However, per her husband, she would not want prolonged measures (though okay for short term intubation). - Patient has follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on Monday [**2129-11-14**] at 11:30 a.m. Office: [**Telephone/Fax (1) 6568**]. ***PLEASE CONSIDER DISCONTINUING FOLEY AS SOON AS POSSIBLE*** Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sotalol 80 mg PO BID 2. Ursodiol 500 mg PO BID 3. Acetaminophen 500 mg PO Q6H:PRN pain 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Loratadine *NF* 10 mg Oral prn rash 6. [**Telephone/Fax (1) 95160**] *NF* (cycloSPORINE) 0.05 % OU [**Hospital1 **] 7. Senna 1 TAB PO BID:PRN constipation 8. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN dry eyes 9. Ciprofloxacin HCl 500 mg PO Q12H Duration: 9 Days Stop after dose on [**10-27**]. Treating UTI. 10. Morphine SR (MS Contin) 30 mg PO Q12H hold for rr<12 or if pt sedated 11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath/wheezing 12. Simethicone 40-80 mg PO QID:PRN gas pain 13. Sodium Chloride 1 gm PO BID 14. Ascorbic Acid 250 mg PO DAILY 15. Cyanocobalamin 50 mcg PO DAILY 16. Calcium Carbonate 600 mg PO DAILY 17. Dabigatran Etexilate 150 mg PO DAILY 18. Ferrous Sulfate 325 mg PO DAILY 19. Lisinopril 5 mg PO DAILY 20. Systane *NF* (peg 400-propylene glycol) 0.4-0.3 % OU [**Hospital1 **] 21. Vitamin D 400 UNIT PO DAILY 22. HYDROmorphone (Dilaudid) 2-4 mg PO Q2H:PRN pain do not give if rr<12 or oversedated 23. Sarna Lotion 1 Appl TP QID:PRN itching 24. Milk of Magnesia 30 mL PO DAILY:PRN constipation 25. Bisacodyl 10 mg PR DAILY:PRN constipation 26. Ondansetron 4 mg IV Q8H:PRN nausea 27. Multivitamins 1 TAB PO DAILY 28. Prochlorperazine 25 mg PR Q6H:PRN nausea 29. Lorazepam 0.5 mg PO Q4H:PRN nausea, anxiety 30. Maalox/Diphenhydramine/Lidocaine 15-30 mL PO TID:PRN pain Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath/wheezing 2. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN dry eyes 3. Ascorbic Acid 250 mg PO DAILY 4. Bisacodyl 10 mg PO DAILY:PRN Constipation 5. Calcium Carbonate 500 mg PO DAILY 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Ondansetron 8 mg IV Q 8H 8. [**Hospital1 95160**] *NF* (cycloSPORINE) 0.05 % OU [**Hospital1 **] 9. Sarna Lotion 1 Appl TP QID:PRN itching 10. Senna 1 TAB PO BID:PRN constipation 11. Simethicone 40-80 mg PO QID:PRN gas pain 12. Sotalol 80 mg PO BID 13. Ursodiol 500 mg PO BID 14. Vitamin D 400 UNIT PO DAILY 15. Aquaphor Ointment 1 Appl TP [**Hospital1 **]:PRN first degree [**Hospital1 **] burn 16. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob 17. Metoprolol Tartrate 25 mg PO BID Hold for SBP<100 or HR<60. 18. Silver Sulfadiazine 1% Cream 1 Appl TP [**Hospital1 **] [**Hospital1 **] 2nd degree burn 19. Cyanocobalamin 50 mcg PO DAILY 20. Ferrous Sulfate 325 mg PO DAILY 21. Multivitamins 1 TAB PO DAILY 22. Loratadine *NF* 10 mg Oral prn rash 23. Dabigatran Etexilate 150 mg PO BID 24. Acetaminophen 650 mg PO Q6H 25. Metoclopramide 5 mg PO TID 26. Miconazole Powder 2% 1 Appl TP TID:PRN fungal rash 27. Systane *NF* (peg 400-propylene glycol) 0.4-0.3 % OU [**Hospital1 **] Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: PRIMARY: - Hyponatremia - Metastatic adenocarcinoma, unknown primary - Delirium SECONDARY: - Chronic diastolic congestive heart failure Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mrs. [**Known lastname 95161**], Thank you for choosing [**Hospital1 18**] for your medical care. You were admitted on [**2129-10-28**] for altered mental status at your rehab facility. You required a short stay in the ICU due to low blood pressures and low sodium levels in your blood. Your altered mental status was most likely due to a combination of medications and low sodium levels. These were corrected during your stay. Upon discharge to your rehab facility, please make sure to attend your scheduled appointments as below. Please let the staff at the rehab facility know, or return to the ER, if you experience any of the following: increasing confusion, excessive sleepiness, falls, trouble thinking or speaking, trouble moving part of your body, new or worsening headache, chest pain, palpitations, trouble breathing, cough, fever, chills, abdominal pain, nausea, vomiting, diarrhea, increasing swelling in your legs or arms, or any other symptoms that concern you. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2129-11-14**] at 10:45 AM With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2129-11-14**] at 11:15 AM With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2129-11-14**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 6568**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2158-11-26**] Discharge Date: [**2158-12-5**] Date of Birth: [**2082-5-3**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Vancomycin Attending:[**First Name3 (LF) 165**] Chief Complaint: chest pain, dyspnea Major Surgical or Invasive Procedure: ReDo-Sternotomy, AVR (23mm Pericardial) & MVRepair 28mm annuloplasty History of Present Illness: 76 yo M s/p CABG x 4 in [**2148**], now with severe AS, referred for surgical intervention. Past Medical History: CAD s/p CABG [**2148**] NIDDM Bradycardia s/p dual chamber [**Year (4 digits) 4448**] BPH Total knee replacement Arthritis carotid disease hemorrhoids guaiac + stool Social History: SH: lives alone, has 2 daughters in the area. retired fine arts teacher, current theater clinic. quit tob 45 yers abo no etoh Family History: FH: [**Last Name (un) **] DM 75 died' Mom MI [**26**] Dad MI [**14**] Physical Exam: NAD HR 66 RR 16 BP 137/63 Lungs CTAB Heart RRR SEM well healed MSI, pacer site ACW Abdomen soft, NT, ND Extrem warm, no edema Well healed SVG harvest site, LLE ankle to groin Pertinent Results: [**2158-12-2**] 08:10AM BLOOD WBC-13.7* RBC-3.09* Hgb-9.4* Hct-27.3* MCV-88 MCH-30.3 MCHC-34.3 RDW-15.3 Plt Ct-96* [**2158-12-2**] 08:10AM BLOOD Plt Smr-LOW Plt Ct-96* [**2158-12-2**] 08:10AM BLOOD Glucose-106* UreaN-20 Creat-0.7 Na-133 K-4.1 Cl-97 HCO3-28 AnGap-12 [**2158-12-2**] 08:10AM BLOOD Mg-2.3 [**2158-11-26**] 08:43PM BLOOD %HbA1c-5.4 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 4075**] [**Hospital1 18**] [**Numeric Identifier 96159**] (Complete) Done [**2158-11-29**] at 1:45:04 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] [**Street Address(2) 15115**] [**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2082-5-3**] Age (years): 76 M Hgt (in): 67 BP (mm Hg): / Wgt (lb): 150 HR (bpm): BSA (m2): 1.79 m2 Indication: Intraoperative TEE for AVR/MVR ICD-9 Codes: 440.0, 424.1, 424.0, 424.2 Test Information Date/Time: [**2158-11-29**] at 13:45 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD Test Type: TEE (Complete) 3D imaging. Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Suboptimal Tape #: 2007AW4-: Machine: 4 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.6 cm <= 4.0 cm Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 60% >= 55% Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Ascending: 2.7 cm <= 3.4 cm Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm Aortic Valve - Peak Velocity: *3.6 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *52 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 30 mm Hg Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2 Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Simple atheroma in aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Moderate (2+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate/severe MVP. Moderate mitral annular calcification. Eccentric MR jet. Moderate to severe (3+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate [[**1-17**]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Suboptimal image quality. The patient appears to be in sinus rhythm. Results were Conclusions PRE-BYPASS: 1. The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 3. Right ventricular chamber size is mildly dilated and free wall motion is normal. 4. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Moderate (2+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. There is moderate mitral annular calcification. There is mitral valve prolapse of the posterior (P3 scallop) leaflet. An eccentric, anterior-lateral directed jet of moderate to severe (3+) mitral regurgitation is seen. 7. The tricuspid valve leaflets are mildly thickened. Mild to moderate [2+] tricuspid regurgitation is seen. POST-Bypass: Pt removed from cardiopulmonary bypass on norepinephrine infusion and AV pacing. 1. Mitral valve posterior annuloplasty is noted. There is trace mitral regurgitation. MVA is 2.1 cm2, peak gradient across the valve is 8.1mmHg, with a mean gradient of 4mmHg. 2. In the aortic valve position, there is a bioprosthetic aortic valve. The valve is well seated with good leaflet excursion. No aortic regurgitation is noted. [**Location (un) 109**] is 1.7 cm2 with a maximum gradient of about 20 mmHg. 3. Normal biventricular systolic function. 3. Tricuspid regurgitation remains as noted pre-bypass. 4. Aortic contours are intact post-decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2158-11-30**] 08:03 RADIOLOGY Final Report CHEST (PA & LAT) [**2158-12-3**] 10:41 AM CHEST (PA & LAT) Reason: interval change [**Hospital 93**] MEDICAL CONDITION: 76 year old man with POD 4 Redo sternotomy/AVR/MVR REASON FOR THIS EXAMINATION: interval change PA AND LATERAL OF THE CHEST Assess for interval change. FINDINGS: Two views of the chest are compared to the prior examination dated [**2158-12-1**]. Dual-lead [**Month/Day/Year 4448**] device is again noted stable in course and position with an additional atrial lead unchanged. The patient is status post median sternotomy, CABG and aortic valve replacement. The cardiac silhouette remains mildly enlarged. Low lung volumes are noted. There is a small left pleural effusion associated with left basilar streaky opacities likely reflects underlying atelectasis. Brief Hospital Course: He was admitted preoperatively, however the OR was delayed secondary to a difficult crossmatch. After appropriate blood was available he was taken to the operating room on [**11-29**] where he underwent a redo sternotomy, AVR (tissue) and MV repair. He was transferred to the ICU in critical but stable condition on levophed and propofol. He was extubated the morning of POD #1. He was given linezolid perioperatively as he in allergic to penicillin, vancomycin and was in house pre operatively. He had a labile blood pressure and was weaned from his vasoactive drips on POD #2. He was transferred to the floor on POD #2. Chest tubes and pacing wires removed without incident. He was gently diuresed toward his preop weight. He did well post operatively and was ready for discharge to rehab on POD #6. Pt. is to make all followup appts. per discharge instructions. Medications on Admission: Metformin 500", Finasteride 5', Lipitor 10', Metoprolol 12.5", Omeprazole 20", Doxazosin 1', Fosamax 10 Qweek, Lisinopril 5', MVI, colace, senna, NTG prn. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day. 9. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO once a day. 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. 12. Potassium Chloride 20 mEq Packet Sig: One (1) PO Q12H (every 12 hours) for 2 weeks. 13. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: CAD s/p CABG [**2148**] (LIMA->LAD, SVG->RAMUS, SVG->OM,SVG->PDA) Carotid Disease Diabetes Mellitus Bradycardia s/p PPM BPH Hemorrhoids Guaiac + stool Total Knee Replacement Tonsillectomy osteoarthritis Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. Please contact surgeon at ([**Telephone/Fax (1) 4044**] with any wound issues. 2) Report any fever greater then 100.5 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lifting greater then 10 pounds for 10 weeks from the date of surgery. 5) No driving for 1 month or while taking narcotics. 6) SHOWER daily and pat incisions dry. Followup Instructions: Dr. [**Last Name (STitle) 58**] 2 weeks Dr. [**Last Name (STitle) 120**] 2 weeks Dr. [**First Name (STitle) **] 4 weeks Already scheduled appointments: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2159-2-6**] 2:30 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2159-4-12**] 2:00 Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2159-4-18**] 2:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2158-12-5**]

[ "715.90", "272.0", "V45.81", "427.89", "599.0", "401.9", "414.00", "250.00", "600.00", "V45.01", "396.2" ]

icd9cm

[ [ [] ] ]

[ "00.14", "35.21", "88.72", "89.45", "35.12", "39.61" ]

icd9pcs

[ [ [] ] ]

10049, 10121

7910, 8776

310, 381

10368, 10375

1132, 7187

10878, 11512

851, 922

8981, 10026

7224, 7275

10142, 10347

8802, 8958

10399, 10855

937, 1113

251, 272

7304, 7887

409, 502

524, 691

707, 835

4,516

142,853

13944

Discharge summary

report

Admission Date: [**2129-3-10**] Discharge Date: [**2129-3-18**] Date of Birth: [**2052-6-2**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This 76-year-old gentleman had known aortic stenosis and was referred for cardiac catheterization because of progressive symptoms. He had been diagnosed with aortic stenosis in the early [**2107**] and severity had been followed over the years with echocardiograms. He had a cardiac catheterization at [**Location (un) **] [**Hospital **] Hospital in [**2125-3-11**] which also revealed clean coronaries, with an ejection fraction of 65%, and moderate aortic stenosis. He had been very active in the past, but he has recently had decreased exercise tolerance and progressive shortness of breath. He was referred in for cardiac catheterization at the medical center. Prior to his admission on [**3-8**], he had an echocardiogram done which showed an normal ejection fraction, mild-to-moderate concentric left ventricular hypertrophy, left ventricular diastolic reduced, and aortic sclerosis, severe aortic stenosis, and mild mitral regurgitation. PAST MEDICAL HISTORY: (Past medical history includes) 1. Aortic stenosis. 2. Hypertension. 3. Hypercholesterolemia. 4. Gout. 5. Benign prostatic hypertrophy. 6. Polio. 7. Gastroesophageal reflux disease. PAST SURGICAL HISTORY: (Past surgical history includes) 1. Hernia repair times two. 2. Transurethral resection of prostate. 3. Right carotid endarterectomy in [**2128-6-8**]. MEDICATIONS ON ADMISSION: Prior to admission he was on aspirin, Accupril, Sectral, Pravachol, Prilosec, Klor-con, and Procardia. PHYSICAL EXAMINATION ON PRESENTATION: On examination by the cardiothoracic resident, his lungs were clear. His heart was regular in rate and rhythm with a normal first heart sound and second heart sound. His abdomen was soft and nontender with bowel sounds. He had reasonable veins in his extremities. PERTINENT LABORATORY DATA ON PRESENTATION: His preoperative laboratories showed a white blood cell count of 8.7, hematocrit of 40, platelet count of 321,000. Sodium 142, potassium 4.7, chloride 106, bicarbonate 27, blood urea nitrogen 24, and creatinine of 1.2. His INR was also 1. RADIOLOGY/IMAGING: He came in for cardiac catheterization which was performed on [**3-8**] in preparation for his valve surgery which showed an ejection fraction of 67%, aortic stenosis, and normal coronary arteries. HOSPITAL COURSE: He was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] of Cardiothoracic Surgery who noted his history, and his very tight aortic stenosis, and preserved left ventricular function and was consented for aortic valve replacement. On [**3-10**], he underwent aortic valve replacement with a 21-mm [**Last Name (un) 3843**]-[**Doctor Last Name **] bioprosthetic valve through minimally invasive approach. The patient had some difficulties in the operating room prior to leaving, had an intra-aortic balloon pump placed, and was started on an epinephrine drip, and went to the unit on an epinephrine drip and a propofol drip, in stable condition despite some critical time in the operating room. On postoperative day one, the patient remained A-paced at 80s, balloon was on 1:1 and was weaned to 1:2 over the course of the day. He remained intubated and sedated. His heart was regular in rate and rhythm. His abdomen was benign, and he had increased breath sounds on the right. His white blood cell count was 14.2, with a hematocrit of 25.7 postoperatively. His postoperative blood urea nitrogen was 22, with a creatinine of 1. The plan was to try and wean his epinephrine down as his balloon was being weaned, and he was started on captopril for afterload reduction and continued on his perioperative antibiotics. He was seen by Case Management and was initially consulted by Physical Therapy. The patient also got a bronchoscopy by Dr. [**Last Name (STitle) 14968**] which showed minimal-to-moderate thickened white secretions on the right side greater than the left. On postoperative day two, he was transfused 1 unit of packed red blood cells and his cardiac index dropped, and the patient was started on dobutamine. At this point, he was on a levofloxacin drip, Flagyl, albuterol, Zantac, captopril, hydralazine, as well as some of his oral medications. Temperature maximum was 102.6. He was also started on some amiodarone. His dobutamine was at 5, his insulin drip was at 2. By the time of examination, his Neo-Synephrine had been off two hours. The balloon was at 1:1 initially. His hematocrit dropped to 21.1, for which he did receive a transfusion. He remained intubated and sedated. Balloon remained in. He was switched over to synchronized intermittent mandatory ventilation. He continued on his dobutamine and was transfused. Cultures were sent, and he remained on his levofloxacin and Flagyl antibiotics. On postoperative day three, he required increased MA on his pacer and [**Hospital1 1516**] pads were placed. He remained on his levofloxacin and Flagyl as well as amiodarone, nitroglycerin at 0.5, dobutamine at 5, propofol at 50, and his balloon remained at 1:1. He remained arteriovenous paced at approximately 77 with a temperature maximum of 101.1. His blood pressure was 114/52, with a central venous pressure of 13. He had an output of 3.8, with an index of 1.9. His mixed venous was 60%. His hematocrit came back up to 24.9, and his white blood cell count decreased to 11.1. Blood urea nitrogen and creatinine remained stable. He remained intubated and sedated and continued on his perioperative antibiotics while cultures were pending. On [**3-13**], he was also seen by Electrophysiology fellow who was called emergently to place a temporary pacing wire. He had an episode of complete heart block with no escape. He was paced with [**Hospital1 1516**] pads that had been placed and now had an escape junctional rhythm. Consultation was done by Dr. [**First Name4 (NamePattern1) 8797**] [**Last Name (NamePattern1) 41703**]. Please refer to her note in the chart. The patient did remain intubated and sedated and was somewhat rhonchorous, maintaining a good blood pressure of 107/58 on dobutamine at 5, amiodarone at 0.5, and nitroglycerin drip. It was commented on by Electrophysiology that the patient had probably suffered a myocardial infarction on the prior day (on the same day that he had the episode of complete heart block). They recommended re-bolusing the patient with amiodarone and changing his drip, and getting thyroid and liver studies, and they made recommendations for his pacemaker, and discussed his care with Dr. [**Last Name (STitle) 73**] who was the attending. His first creatine phosphokinase was 4614, the second was 3308, and the third was 2461. Attending cardiologist also recommended getting a transthoracic echocardiogram. A transthoracic echocardiogram was not obtained as the patient had a transesophageal echocardiogram over the weekend which showed a depressed inferior wall and a valve that was functioning well and seeded well. On postoperative day four, the patient remained on an amiodarone drip at 1, dobutamine at 5, propofol at 30, continued on levofloxacin and Flagyl, continued on hydralazine and captopril for afterload reduction. His wires were not capturing which had resulted in him getting a transvenous pacemaker. On postoperative day four, his white blood cell count was 14.8, with a temperature of 100.4. His hematocrit was 28.9, with a platelet count of 128,000, a potassium of 4.3. His lactate was 1.4. He was hemodynamically stable at that point with a blood pressure of 123/54, and remained V-paced at 80. He removed all four extremities to pain stimuli and remained intubated and somewhat sedated. His lungs were clear bilaterally, and the rest of his examination was benign. He was started on tube feeds as tolerated and continued on his perioperative antibiotics. He was seen again by Dr. [**Last Name (STitle) **] who recommended continuing the amiodarone and considering another transesophageal echocardiogram. He was also followed that day by Electrophysiology who continued to follow him. He was seen by Clinical Nutrition for management of his tube feeds. On postoperative day five, he had first-degree AV block with a heart rate in the 60s, and a blood pressure of 129/58, while he remained intubated and sedated. His lungs were clear bilaterally. His dressings were clean, dry, and intact. He remained on amiodarone at 1, dobutamine at 5, propofol at 50; again, with afterload reductions continuing. His white blood cell count was 15.2, with a hematocrit of 27.9, blood urea nitrogen 25, creatinine of 1.1. Thyroid-stimulating hormone was 3.7. ALT 101, AST 141, alkaline phosphatase 115, and a total bilirubin of 0.5. He was neurologically stable. He continued with respiratory support and continued on sliding-scale insulin. His blood sugar was 181 that morning, per Intensive Care Unit protocol. The patient remained in critical condition and was followed by Cardiology and also Electrophysiology for this prolonged P-R. They recommended maintaining his temporary V-pacing wire for now as backup. On postoperative day six, his amiodarone (which had been shut off) was restarted. There was a question of whether he was in atrial fibrillation. He had a temperature maximum of 100.6, with a blood pressure of 102/39, with a heart rate of 111, in atrial fibrillation. He remained on pressure support and CPAP. He remained intubated and sedated. He had coarse breath sounds bilaterally with a question of decreased breath sounds on the right. Heart had normal first heart sound and second heart sound. His white blood cell count was 13.5, and hematocrit holding at 27.4. His blood urea nitrogen rose to 30 with a creatinine of 1. There was a discussion about weaning his dobutamine and continuing his ventilatory support. His electrolytes were repleted as necessary, and he continued on his levofloxacin and Flagyl waiting for the final cultures. He was followed again on postoperative day six by Electrophysiology and was seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] also. He recommended continuing the amiodarone, and he recommended settings for his pacemaker and adding lidocaine if necessary if there was any recurrent ventricular tachycardia. He had episodes of ventricular tachycardia in the 115 to 120 range which had prompted the additional consultation, and he discussed the likelihood that some arteriovenous node ischemia. A Pulmonary consultation was also obtained for the patient's hypoxemia which continued to develop. They recommended the possibility of getting a spiral CT to rule out a pulmonary embolus, and to get an echocardiogram to rule out any shunt, and possibly transfusing him to increase his hematocrit. They recommended some plans to help with his positioning and adjustments in his positive end-expiratory pressure. Please refer to their consultation note on [**3-16**]. On [**3-17**], the patient continued on amiodarone at 1, dobutamine at 2.5, dopamine at 3, lidocaine at 2, morphine at 2. The patient remained intubated and sedated with a temperature maximum of 101.5, with a blood pressure of 124/62. Again, his heart rate was in the 60s, in first-degree AV block. His blood gas became more acidotic with a pH of 7.3, and a gas of 78/26/19/-7. His blood urea nitrogen rose to 35 with a creatinine of 1.2. His AST and ALT came down to 57 and 55. His alkaline phosphatase was still 204. His lactate was 1.2, and mixed venous of 51%. Amylase was 92 with a lipase of 188. He was also receiving albuterol through his tube. He remained on a CMV, and his lungs were somewhat clearer that morning, but the patient had some continuing hypoxemia and was critically ill with continuing acidosis. He was transfused another unit of packed red blood cells and final cultures were still pending. The patient did remain on levofloxacin and Flagyl. Pulmonary consultation came by again, and they evaluated his potential venous match. He was also seen by Cardiology who again noted his recurrent rapid ventricular tachycardia for which he was on lidocaine. At this point, he was evaluated he was in sinus rhythm with first-degree AV block in the 70s. He remainder sedated and paralyzed and on CMV ventilation. He was in atrial fibrillation at 70 at the time. Also, examination with a blood pressure of 130/62. His pulmonary artery pressures were 56/22, with central venous pressure of 7. He had an output of 4.2 with an index of 2. Again, Cardiology commented on suspected postoperative inferior myocardial infarction complicated by conduction and excessive ventricular tachycardia. Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 70**] decided to have the patient have a cardiac catheterization, and his lidocaine was subsequently decreased to 1 mg. On [**3-17**], he went back to the catheterization laboratory which showed that the patient had a 70% lesion of his right coronary and a proximal total occlusion of his circumflex. Please note that on postoperative day four, his intra-aortic balloon pump was pulled. He completed his cardiac catheterization on [**3-17**]. His blockage was treated with a stent. He had a stent placed to his left circumflex and his intra-aortic balloon pump was replaced in the catheterization laboratory. He was started on Integrilin for an 18-hour course at that point. On postoperative day eight, his balloon remained at 1:1. He remained on vancomycin, levofloxacin, and Flagyl. His amiodarone was at 0.5, his dobutamine was at 1.3, his dopamine was at 1.5, his Integrilin drip was at 2, his lidocaine drip was at 1, morphine sulfate drip at 2, and propofol at 10. In addition, he had received Plavix and aspirin post stenting and continued with that therapy. He was transfused 2 units of packed red blood cells, and his hematocrit was 26.8. His lactate was 1.7 with a mixed venous of 55%. His blood urea nitrogen rose slightly to 36, with a creatinine of 1.2, and a potassium of 5. He remained intubated and sedated. His incisions were clean, dry, and intact. He had coarse breath sounds on the right. His heart was regular in rate and rhythm. He was in first-degree AV block with a heart rate of 62, blood pressure of 100/53. He was continued with support. His arterial blood gas was 7.37/31/61/19. He also received subcutaneous heparin for his immobile state. He was seen by the Pulmonary staff. Pulmonary did not see any clear indication of paralysis at this point, and recommended beginning his diuresis, now status post the catheterization and coronary intervention as his cardiac issues improved. They recommended weaning his positive end-expiratory pressure as his FIO2 allowed. He did not have any obvious pulmonary infection at that point and recommended rechecking his intravenous position with a chest x-ray. At 3 p.m. on [**3-18**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of Cardiothoracic Surgery was called emergently following the patient having a cardiac arrest. The patient was stable until he was turned. Cardiopulmonary resuscitation was begun. The patient's head and neck was acutely swollen. His abdomen was markedly distended, and they were unable to ventilate the patient. Both sides of his chest were prepared and draped. His left chest had a tube inserted with a large pleural effusion which drained under pressure. A right chest tube was inserted with a huge amount of air under pressure and a large amount of effusion was drained. Cardiopulmonary resuscitation continued, but the patient was in asystole and ventricular fibrillation. He had multiple defibrillations with epinephrine boluses and sodium bicarbonate given. The patient had his left chest prepped and draped. He was turned and a left lateral thoracotomy was performed so the patient could be defibrillated intrathoracically. Normal sinus rhythm was obtained with a blood pressure of 70/40. The balloon pump was not turned off, and epinephrine drip was begun with blood pressure rising to 130/70. The left chest was closed after a chest tube was reinserted. Dr. [**Last Name (STitle) **] discussed with the family. Total cold time was approximately 30 minutes. The abdomen was slightly softer. Diagnosis was probable tension pneumothorax. Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **], and Dr. [**Last Name (STitle) 11743**] were present. The patient's prognosis was poor, and Dr. [**Last Name (STitle) 70**] was informed. The patient remained with a very poor prognosis. The family was informed. The patient's wife came in to see him. The patient was on maximal support with his balloon pump in place, and the patient expired at approximately 5 p.m. on [**3-18**]. The patient expired in the Cardiothoracic Intensive Care Unit. DISCHARGE DIAGNOSES: 1. Status post aortic valve replacement. 2. Status post inferior myocardial infarction, complicated with complete heart block. 3. Status post left coronary stenting. 4. Cardiogenic shock. 5. Hypertension. 6. Hypercholesterolemia. 7. Aortic stenosis. 8. Gout. 9. Benign prostatic hypertrophy. 10. Polio. 11. Gastroesophageal reflux disease. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 76**] MEDQUIST36 D: [**2129-3-21**] 11:17 T: [**2129-3-23**] 08:28 JOB#: [**Job Number 41704**]

[ "785.51", "410.41", "427.41", "486", "426.0", "424.1", "E878.1", "997.3", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.91", "88.56", "36.06", "37.22", "37.61", "36.01", "35.21", "37.78" ]

icd9pcs

[ [ [] ] ]

17030, 17692

1550, 2466

2485, 17008

1367, 1523

179, 1130

1153, 1343

12,798

148,215

649

Discharge summary

report

Admission Date: [**2198-9-20**] Discharge Date: [**2198-9-23**] Service: MEDICINE Allergies: Penicillins / Amiodarone Hcl Attending:[**First Name3 (LF) 425**] Chief Complaint: PEA arrest Major Surgical or Invasive Procedure: None History of Present Illness: History was obtained from his son and [**Name (NI) **] records: Mr. [**Known lastname 4924**] is a [**Age over 90 **] year old male with a PMH significant for severe MR, ischemic cardiomyopathy with severe left ventricular dysfunction with an EF of 30% in [**2197-2-12**], NSVT, and a history of ischemic bowel due to overdiuresis. He was in his usual state of health until a few days ago when he started feeling very weak and fatigued. . His son went to pick him up tonight, and as they were walking toward the car, he became fatigued and weak, to the point where he wanted to go back in the house. They turned around and as they were walking toward the house, he progressively became weaker to the point where his son had to carry him and lay him on a bench. They called EMS, and between the time that they called EMS and their arrival (~5 minutes or longer) he became pulseless and apneic. . On arrival, EMS found him to be apneic and pulsless. They began CPR and gave 1mg of epinephrine. He went into ventricular tachycardia, and he was shocked once at 200J, and given 1mg of lidocaine and put on a lidocaine drip. He was intubated and bagged in the field. CPR was performed for 15 minutes. . In the ED his VS were BP: 150/70, HR: 60, RR: being bagged. He was placed on the lidocaine drip. His ET tube placement was verified on chest x-ray. A left IJ CVL was placed. He was persistently hypotensive for 40 mins to 80's, ranging 80's to 100's so he was started on Dopamine and arctic sun protocol. Neuro exam prior to sedation (fentanyl/versed) was positive for gag, blink, pupils 1mm non-reactive, biting tube, not moving extremities, not withdrawing from pain. A-line attempt in L wrist failed. CXR clear. Noted to have melana. After discussion with the family, arctic sun protocol was stopped. . Per the son, he denied any recent complaints of chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, or lightheadedness. The only significant positive symptoms were weakness and fatigue x2 days. . On arrival to the floor, vitals were BP 102/53, HR 72, RR 17, and O2 sats of 100% on AC 450/14/5/100% FiO2. He was intubated and sedated. Past Medical History: 1. Severe mitral regurgitation with severely depressed LV and RV function. 2. Chronic atrial fibrillation, currently off warfarin due to GI bleeding. 3. Initial VVI pacemaker placed in [**2189**] due to symptomatic bradycardia. 4. Ischemic cardiomyopathy and congestive heart failure, status post an upgrade to a BiV pacemaker in [**2192-3-12**]. 5. Nonsustained VT. 6. Prior syncopal episodes in the past due to hypovolemia. 7. Ischemic bowel disease in the setting of over diuresis. 8. Coronary artery disease status post CABG x3 in [**2181**] with a LIMA to the LAD, SVG to the circumflex and acute marginal. Social History: Social history is significant for the absence of current tobacco use. 50 pack year history of smoking, quit 56 years ago. There is no history of alcohol abuse. Patient lives with wife in [**Location (un) 55**] condominium. No home nurses, no home oxygen dependence. Ambulates with walker and independent with ADLs. Son lives in [**Location 1514**] helps often. Wife with declining dementia per records. Family History: There is no family history of premature coronary artery disease or sudden death. Brother died of MI at 64, sister died of MI at 72. Mother died at 30 from complications from PNA. Father died at 46 during cholecystectomy. Physical Exam: On Admission: VS: T= BP= 102/53 HR=72 RR=17 O2 sat=100% on AC 450/14/5/100% FiO2 GENERAL: Intubated and sedated. Elderly gentleman. HEENT: NCAT. Sclera anicteric. pupils 1mm, non reactive, ovoid. NECK: Supple with JVP of ~8cm. CARDIAC: PMI located in 5th intercostal space, laterally displaced. normal rate, irregular rhythm, 3/6 systolic murmur at the left lower sternal border, and [**4-17**] harsh holosystolic murmur at the apex, radiating to the axilla. Palpable thrills, + heave. LUNGS: Contusion over his sternum. Lungs CTAB, breath sounds equal, distant, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Clubbing in upper and lower extremities. 1+ radial pulse. Trace to 1+ pitting edema in the LE bilaterally. SKIN: multiple skin tears on the upper extremities bilaterally. PULSES: Right: Carotid 2+ Left: Carotid 2+ Pertinent Results: [**2198-9-20**] 06:50PM BLOOD WBC-12.5* RBC-2.47* Hgb-7.9* Hct-26.4* MCV-107* MCH-31.8 MCHC-29.7* RDW-14.6 Plt Ct-212 [**2198-9-20**] 11:12PM BLOOD WBC-9.8 RBC-2.08* Hgb-7.2* Hct-21.0* MCV-101* MCH-34.8* MCHC-34.4# RDW-14.4 Plt Ct-141* [**2198-9-21**] 05:02PM BLOOD WBC-13.3* RBC-2.97* Hgb-9.8* Hct-29.0* MCV-98 MCH-32.8* MCHC-33.7 RDW-17.3* Plt Ct-181 [**2198-9-22**] 11:50PM BLOOD WBC-10.8 RBC-3.22* Hgb-10.6* Hct-30.2* MCV-94 MCH-33.0* MCHC-35.2* RDW-18.2* Plt Ct-106* [**2198-9-23**] 04:51AM BLOOD WBC-10.7 RBC-3.34* Hgb-10.7* Hct-32.1* MCV-96 MCH-32.1* MCHC-33.3 RDW-17.6* Plt Ct-123* [**2198-9-20**] 06:50PM BLOOD Neuts-74* Bands-2 Lymphs-15* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2198-9-23**] 04:51AM BLOOD Neuts-86.5* Lymphs-7.7* Monos-5.2 Eos-0.2 Baso-0.4 [**2198-9-20**] 06:50PM BLOOD Plt Ct-212 [**2198-9-20**] 06:50PM BLOOD PT-15.2* PTT-39.6* INR(PT)-1.3* [**2198-9-20**] 11:12PM BLOOD Plt Ct-141* [**2198-9-21**] 04:44AM BLOOD PT-14.2* PTT-33.1 INR(PT)-1.2* [**2198-9-22**] 05:43AM BLOOD PT-14.8* PTT-49.7* INR(PT)-1.3* [**2198-9-22**] 05:43AM BLOOD Plt Ct-117* [**2198-9-23**] 04:51AM BLOOD PT-14.6* PTT-32.1 INR(PT)-1.3* [**2198-9-23**] 04:51AM BLOOD Plt Ct-123* [**2198-9-20**] 06:50PM BLOOD Glucose-305* UreaN-98* Creat-2.3* Na-141 K-4.0 Cl-99 HCO3-16* AnGap-30* [**2198-9-20**] 11:12PM BLOOD Glucose-313* UreaN-100* Creat-2.1* Na-140 K-3.7 Cl-99 HCO3-29 AnGap-16 [**2198-9-21**] 05:02PM BLOOD Glucose-106* UreaN-93* Creat-2.0* Na-146* K-3.9 Cl-106 HCO3-28 AnGap-16 [**2198-9-22**] 05:43AM BLOOD Glucose-175* UreaN-89* Creat-2.1* Na-147* K-4.0 Cl-105 HCO3-30 AnGap-16 [**2198-9-23**] 04:51AM BLOOD Glucose-90 UreaN-85* Creat-2.1* Na-144 K-4.1 Cl-103 HCO3-31 AnGap-14 [**2198-9-20**] 06:50PM BLOOD ALT-51* AST-59* CK(CPK)-113 AlkPhos-51 [**2198-9-21**] 04:44AM BLOOD ALT-56* AST-62* LD(LDH)-279* CK(CPK)-423* AlkPhos-47 TotBili-1.3 [**2198-9-21**] 05:02PM BLOOD CK(CPK)-754* [**2198-9-22**] 05:43AM BLOOD CK(CPK)-680* [**2198-9-20**] 06:50PM BLOOD cTropnT-0.09* [**2198-9-21**] 04:44AM BLOOD CK-MB-21* MB Indx-5.0 cTropnT-0.49* [**2198-9-21**] 05:02PM BLOOD CK-MB-19* MB Indx-2.5 cTropnT-0.38* [**2198-9-22**] 05:43AM BLOOD CK-MB-9 cTropnT-0.29* [**2198-9-20**] 06:50PM BLOOD Albumin-3.8 Calcium-8.2* Phos-6.7* Mg-2.9* [**2198-9-21**] 04:44AM BLOOD Calcium-8.1* Phos-6.0* Mg-2.9* [**2198-9-22**] 05:43AM BLOOD Calcium-8.4 Phos-5.1* Mg-2.9* [**2198-9-23**] 04:51AM BLOOD Calcium-8.2* Phos-4.0 Mg-2.8* [**2198-9-20**] 11:12PM BLOOD TSH-3.1 [**2198-9-20**] 06:50PM BLOOD Digoxin-0.3* [**2198-9-20**] 06:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2198-9-20**] 07:03PM BLOOD pH-7.23* Comment-GREEN [**2198-9-21**] 12:04AM BLOOD Type-ART pO2-149* pCO2-50* pH-7.40 calTCO2-32* Base XS-5 [**2198-9-21**] 11:28AM BLOOD Type-[**Last Name (un) **] pO2-38* pCO2-48* pH-7.40 calTCO2-31* Base XS-3 [**2198-9-20**] 07:03PM BLOOD Glucose-286* Lactate-9.4* Na-141 K-3.8 Cl-101 calHCO3-20* [**2198-9-21**] 12:04AM BLOOD Lactate-1.2 [**2198-9-20**] 07:03PM BLOOD Hgb-7.9* calcHCT-24 O2 Sat-72 [**2198-9-21**] 12:04AM BLOOD O2 Sat-98 . Chest X-Ray [**2198-9-20**]: SINGLE AP VIEW OF THE CHEST: A dual-lead pacing device is unchanged. There has been a prior median sternotomy and CABG. An endotracheal tube tip lies 4 cm from the carina. An NG tube tip is in stomach. There is a left internal jugular line, with tip obscured by the overlying pacer leads, though likely lies within the mid SVC. The heart is top normal in size. Mildly increased interstitial markings suggest mild fluid overload. There is no pneumothorax. IMPRESSION: 1. Endotracheal tube tip 4 cm from carina, in appropriate position. 2. Mild vascular congestion. The study and the report were reviewed by the staff radiologist . Chest X-Ray [**9-23**]: FINDINGS: Comparison is made to the previous study from [**2198-9-20**]. The endotracheal tube has been removed. There is a left IJ central venous catheter and a Dual-lead left-sided pacemaker with intact leads tips. There has been interval development of the left retrocardiac opacity and a left-sided pleural effusion. The opacity may be due to combination of atelectasis or developing infiltrate. [**Year (4 digits) **] to resolution is recommended. There are no signs of overt pulmonary edema. There is unchanged persistent cardiomegaly. Brief Hospital Course: Mr. [**Known lastname 4924**] is a [**Age over 90 **] year old male with a PMH significant for severe MR, ischemic cardiomyopathy with severe left ventricular dysfunction with an EF of 30% in [**2197-2-12**] s/p CABG, NSVT, and a history of ischemic bowel due to overdiuresis that presents after a PEA arrest, inutbated, with a dropping hematocrit. . # Respiratory Failure: on [**2198-9-23**], we were called to the patients bedside as he was unresponsive. He was breathing and had a pulse. He was transitioned to his bed from the chair. He was given fluids wide open in the setting of SBPs in the 60s. His code status had been discussed with him on [**2198-9-22**], and he declared his wish to be DNI. He became apneic, was unresponsive, and a pulse was lost at 1500 on [**2198-9-23**] and the patient expired. . # PEA arrest: He became apneic and pulsless in the field he was given 1mg epi, leading to VT. He was shocked once at 200J and given 1mg of lidocaine and then placed on a drip. He was intubated and hemodynamically stable on admission. He was successfully extubated the day after admission. His blood pressure was stable in the 80s-90s during his stay until he expired. . # GI bleed: Pt had guiac postivie melanotic stools in the ED. He has a history of ischemic bowel in the setting of overdiuresis. His baseline hematocrit is 31. On admission it had fallen to 26->24->21. He recieved 4units of blood with a transfusion goal of greater than 30. On [**9-23**] his hematocrit was 32. . # Heart failure: Pt had end stage heart failure s/p CABG, with severe MR complicated by a GI bleed and transient hypotension, s/p PEA arrest. He required his home torsemide dose between units of blood due to his fragile fluid balance. He responded however, he appeared fluid overloaded on the morning of [**9-23**]. He had rhonchorus breath sounds and a weak cough. He was given 40mg of IV lasix to help diurese in the setting of recieving 4 units of blood and a worsening chest x-ray concerning for pleural effusion. . # Mental Status: Patient was unresponsive upon hitting the floor s/p PEA arrest. Intubated and sedated. Not following commands. He improved greatly after his extubation and appeared to be close to his baseline. . # DMII: On oral hypoglycemics at home. We held oral medications in house, but gave ISS to cover hypergylcemia. . # BPH: on finasteride and tamsulosin for BPH treatment, we held his medications in the acute setting. Medications on Admission: Carvedilol 3.125mg PO BID Digoxin 62.5mcg PO every other day ([**1-13**] 125mcg tab EOD) Lisinopril 5mg PO daily Torsemide 40mg PO daily ASA 81mg PO daily Pantoprazole 40mg daily Gabapentin 100mg PO TID Glipizide 5mg PO daily Tamsulosin 0.4mg PO daily Finasteride 5mg PO daily Docusate Sodium 100mg PO daily Vitamin B complex MVI Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired [**Month/Day (2) **] Instructions: N/A Completed by:[**2198-9-23**]

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icd9cm

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icd9pcs

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11878, 11887

9008, 11037

246, 252

11938, 11947

4671, 8985

3543, 3765

11850, 11855

11908, 11917

11495, 11827

11971, 12049

3780, 3780

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280, 2471

3794, 4652

11052, 11469

2493, 3106

3122, 3527

2,187

151,746

7994

Discharge summary

report

Admission Date: [**2134-1-3**] Discharge Date: [**2134-1-13**] Date of Birth: [**2087-11-5**] Sex: M Service: MEDICINE Allergies: Cephalosporins / Morphine / Fentanyl Attending:[**First Name3 (LF) 689**] Chief Complaint: Lethargy, txf from OSH with presumed urosepsis Major Surgical or Invasive Procedure: Left femoral line foley catheter changed History of Present Illness: Mr. [**Known lastname **] is a 46 year old male with multiple medical problems pertinently including DM2 and morbid obesity, being transferred from OSH with presumed urosepsis. He presented to [**Hospital1 **] [**Location (un) 620**] on the morning of transfer c/o 3 days of increasing lethargy and AMS. By his report he has been feeling "out of it" for the last 3 days, but can't quite articulate why. He says he's been very weak and actually fell once, however on further questioning and review of the notes this has been going on for months. He denies any headache, photophobia, neck stiffness. ROS positive for cough over the last week or so, occasionally productive of sputum, as well as shortness of breath, however he says this is also a chronic problem. Denies any fevers, chills, abdominal pain. Has a chronic foley in place for about a year and denies any pain at the foley site or change in urine color. His colostomy output has not changed in consistency or quantity. He is unsure if he has had any recent medication changes, and mentions that he takes a lot of anti-anxiety medications. . At the OSH he was found to be virtually unresponsive, hypotensive to the 80s systolic. ABG 7.36/64/95 on RA. WBC was 10, with a positive UA (+nitrite, +LE, 20-50 WBC, mod bact). He received 2L NS, vanco/zosyn and was transported to [**Hospital1 18**]. . On arrival in the ED here, systolics were 80-90 but improved with 2 L IVF. He had a central line placed in R groin, however has not required pressors. . On arrival to the [**Hospital Unit Name 153**] the patient's vitals were 97.1, HR 53, BP 158/103, RR 11, O2 100% on 4L NC. He was responsive, albeit sluggish. . Of note, patient has been treated for numerous UTIs in the past, most recently had proteus UTI in [**11-7**], sensitive to Augmentin and cefuroxime. Has also had pseudomonal and klebsiella UTIs in the last 1-2 years. Past Medical History: 1) DM2 diagnosed [**2114**] with triopathy: Creatinine has been as low as 0.8 in the last couple of years, however widely fluctuant, as high as 2 in the recent past. 0.9 in [**1-7**]. 2) COPD, on home O2. Multiple episodes of respiratory failure requiring intubation in recent years. Most recently, was admitted in [**12-6**] with a perforated transverse colon requiring partial colectomy and transverse colostomy. This course c/b anticipated respiratory failure and anticipatory tracheostomy, pseudomonal and MRSA PNA. Also with acalculous cholecystitis requiring cholecystostomy tube. Had G-tube placed. 3) OSA on CPAP 3) VRE 4) s/p tracheostomy, as above in [**1-7**] 5) HTN 6) CHF: During hospitalization in [**10-20**] it was thought that failure contributed to his respiratory failure. Last echo was in [**12-6**] at which time LVEF thought to be roughly normal, however very poor study and RV not visualized. Not on lasix. 7) Anemia of chronic disease, multiple transfusions in the past 8) s/p BKA for chronic LE ulcer 9) TIA in [**2125**]. 10) Difficult intubation; fiberoptic guidance in [**Month (only) 359**] of [**2131**]. 11) Urinary retention. 12) Osteoarthritis. 13) Depression. 14) C. Difficile in [**2129**]. 15) Hypogonadism. 16) Morbid obesity . PAST SURGICAL HISTORY: 1. Bilateral carpal tunnel release in [**2123**]. 2. Hydrocele repair in [**2126-4-3**]. 3. Quadriceps tendon repair in [**2127**]. 4. Status post partial resection of transverse colon, end transverse colostomy, mucus fistula, jejunostomy tube and percutaneous tracheostomy on [**2132-12-16**]. Social History: Lives home alone with VNA. Denies etoh. Remote cigar smoking, no cigarettes. No IVDU or marijuana. Has 1 brother, [**Name (NI) **]. Family History: Non-contributory Physical Exam: 97.1, HR 53, BP 158/103, RR 11, O2 100% on 4L NC Gen: Morbidly obese caucasian male appearing slightly dyspneic but otherwise comfortable. MS: AAO x 3, responds to questions appropriately however very slow to respond. HEENT: PEARL, dry MM. Neck: JVP unable to evaluate Cor: RR, normal rate, distant HS Lungs: Scattered expiratory wheezes anteriorly Abd: NABS, soft, colostomy bag with brown stool, appears C/D/I, second ostomy with gauze C/D/I. Extr: RLE with erythematous plaque/patch circumferentially around distal tibia (patient reports chronic), 2+ pitting and weeping edema with a couple of vesicles. LLE s/p BKA, stump covered with dressing. Extremities cold. Neuro: Moves all extremities. Pertinent Results: [**2134-1-3**] 09:56AM GLUCOSE-72 UREA N-24* CREAT-1.2 SODIUM-144 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-32 ANION GAP-9 [**2134-1-3**] 09:56AM WBC-9.4 RBC-3.29* HGB-9.9* HCT-29.2* MCV-89 MCH-30.3 MCHC-34.1 RDW-15.8* [**2134-1-3**] 09:56AM NEUTS-74.6* BANDS-0 LYMPHS-18.6 MONOS-2.6 EOS-3.5 BASOS-0.7 [**2134-1-3**] 09:56AM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ STIPPLED-1+ [**2134-1-3**] 09:56AM PLT COUNT-259 [**2134-1-3**] 09:56AM PT-12.4 PTT-25.7 INR(PT)-1.0 [**2134-1-3**] 01:15AM URINE HOURS-RANDOM [**2134-1-3**] 01:15AM URINE UHOLD-HOLD [**2134-1-3**] 01:15AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019 [**2134-1-3**] 01:15AM URINE BLOOD-SM NITRITE-POS PROTEIN->300 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-9.0* LEUK-MOD [**2134-1-3**] 01:15AM URINE RBC-1 WBC-1 BACTERIA-MANY YEAST-NONE EPI-0 [**2134-1-3**] 01:15AM URINE HYALINE-1* [**2134-1-3**] 01:15AM URINE 3PHOSPHAT-MANY AMORPH-MOD [**2134-1-3**] 01:08AM LACTATE-1.3 [**2134-1-3**] 12:53AM GLUCOSE-85 UREA N-28* CREAT-1.4* SODIUM-144 POTASSIUM-3.9 CHLORIDE-112* TOTAL CO2-28 ANION GAP-8 [**2134-1-3**] 12:53AM CALCIUM-7.5* PHOSPHATE-2.4* MAGNESIUM-1.7 [**2134-1-3**] 12:53AM WBC-8.3 RBC-2.89* HGB-9.2* HCT-25.0* MCV-87 MCH-31.8# MCHC-36.8*# RDW-15.2 [**2134-1-3**] 12:53AM PT-13.4* PTT-26.2 INR(PT)-1.2 _ _ _ _ _ _ _ _ _ ________________________________________________________________ CHEST (PORTABLE AP) [**2134-1-3**] 6:27 AM There is a tracheostomy tube. The cardiac silhouette is markedly enlarged. There is blunting of both costophrenic angles, right greater than left, consistent with pleural effusions. There is no evidence for overt pulmonary edema or focal consolidation. Brief Hospital Course: 46 year old male with DM2, morbid obesity, p/w hypotension, positive UA, and presumed narcotics abuse. These issues resolved w/ decreased pain meds and fluid resuscitation. New finding of [**Female First Name (un) **] growing in blood cx taken [**2134-1-3**] and proteus miribilis in urine - hemodynamically stable. . #) UTI: Has history of recurrent UTIs, resistant to multiple antibiotics. UA collected on [**1-3**] grew mixed flora - likely fecal contaminants. Repeat U/A after changing foley showed proteus miribilis. Started abx to treat given hx multiple UTIs in this pt w/ diabetes and indwelling catheter. Gave 5 days of 14 day course of cefpodoxime. Discussed whether pt needed to have foley in place - pt feels that he can't make it to the bathroom in time and does not want to use urinal. Risk of recurrent infection was explained but pt wants to keep foley. Condom cath not possible due to retracted penis. He will need a repeat U/A after completion of abx. . #) [**Female First Name (un) **] in blood cx: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 28631**] growing in 1 bottle from [**2134-1-3**]; uncertain whether cultures were taken prior to fem line placement or after. Repeat mycolytic cx sent and LFTs normal - fluconazole started w/ 7 of 14 days remaining. Ophtho consult to eval for chorioretinitis - no evidence of fungemia. Pt clinically stable at discharge and subsequent cultures unrevealing thusfar. . #) pain control: pt was taking MS contin 100mg tid at home, but unclear why he has been taking this - possibly for multiple chronic joint pain. He was restarted on MS contin 15mg tid; dose changed to [**Hospital1 **] and required only few additional doses of MS IR. He exhibited no signs of withdrawal during this admission. He gave permission to contact Dr. [**Last Name (STitle) 24792**] who prescribes his pain meds. Also, SW [**First Name8 (NamePattern2) 7905**] [**Last Name (NamePattern1) **] spoke w/ his brother who is concerned that pt is overmedicating himself at home. Now, all his providers - psychiatrist, pain MD [**First Name (Titles) **] [**Last Name (Titles) 3390**] all made aware of his pain regimen and of each other. Will send copy of discharge summary to his providers; request that his [**Last Name (Titles) 3390**] address issue of narcotics contract. . #) HTN: Intially hypotensive but responded w/ IVF resuscitation. Metoprolol was restarted at 25mg po bid - home dose is 100mg po bid. Titrated up to 75mg [**Hospital1 **] for persistently elevated BP but dose limited by HR in 30s to 50s. Also restarted clonidine 0.6mg po bid and added lisinopril. BP was better controlled on lisinopril 40mg but creatinine increasing so decreased dose to 30. Considered MRA of renal arteries given resistance to multiple hypertensive regimen, but unable to perform this study due to pt's habitus. We decided to continue medical management at this time. Added on amlodipine 10mg qd w/ BP ranging in 130s to 140s prior to discharge. . #) ?hip dislocation: pt c/o persistent L hip pain and requesting X-ray. On exam, pt had full ROM and not tender at joint insertion site. Imaged both L hip and R shoulder - these did not show evidence of fracture or dislocation. Likely that pt is deconditioned from prolonged hospitalization - he has not been out of bed since admission. Would work more aggressively w/ PT to get him out of bed. . #) Confusion/lethargy: Patient clearly slow to respond to questions, but is much more alert at discharge; reports sluggishness at home. Mental status clearer with time and reduced narcotic dose. . #) Hypotension: Did not meet criteria for SIRS as WBC < [**Numeric Identifier 890**], no fever, HR < 90, RR < 20, however did have mild leukocytosis with positive UA, therefore presumed urosepsis at intial presentation. However additioal history was obtained from pt's brother of large amount of narcotics use to explain hypotension and lethargy. Initially treated with broad spectrum ABX but then held awaiting culture results. Hypotension resolved quickly with IV fluids. . #) ARF: 1.4, up from 0.9 1 year ago. BUN also elevated, most likely pre-renal in the setting of hypotension. Back to baseline after IVF. . #) Anemia: Baseline appears to be around 29, currently 27, however was 30 at OSH prior to fluids. No signs of active bleeding. Guaiac negative ostomy output. . #) DM2: Good control w/ outpatient regimen of lantus 44 units [**Hospital1 **], plus RISS. . #) PPx: Continued protonix. SC heparin. Bowel regimen. . #) FEN: diabetic diet. . #) Access: PIV; fem line in [**Hospital Unit Name 153**] . #) Code status: full - discussed w/ pt. HCP is [**Name (NI) **] [**Name (NI) **], his brother. Medications on Admission: Paxil 40 mg [**Hospital1 **] Neurontin 600 mg QID Flonase 1 spray [**Hospital1 **] Flovent 1 puff [**Hospital1 **] Protonix 40 mg daily Combivent 2 puffs [**Hospital1 **] Reglan 10 mg TID Lantus 44 units [**Hospital1 **] Clonidine (Catapres) 6 mg [**Hospital1 **]? Metoprolol 100 mg [**Hospital1 **] Klonopin 2 mg TID Lorazepam 2 mg daily Xanax 1 mg TID Astelin 1 spray [**Hospital1 **] Lasix 40 mg [**Hospital1 **] Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 8. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO tid prn. 10. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Loratadine 10 mg Tablet Sig: One (1) Tablet PO qd (). 13. Clonidine 0.2 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 18. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. 19. Insulin Glargine 100 unit/mL Solution Sig: One (1) Subcutaneous sliding scale: Please refer to insulin sliding scale. 20. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 21. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 22. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 23. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 24. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 10 days. 25. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) 1110**] Discharge Diagnosis: Primary: somnolence secondary to narcotics overuse recurrent UTIs hypertension [**Female First Name (un) **] in blood culture acute renal failure . DM2 COPD OSA on CPAP VRE s/p tracheostomy, as above in [**1-7**] CHF Anemia of chronic disease s/p BKA for chronic LE ulcer Urinary retention Depression Morbid obesity Discharge Condition: stable Discharge Instructions: Please return for further care if you have fevers, chills, dizziness, weakness, shortness of breath, chest pain, fainting, sleepiness, or any other symptoms that are concerning to you. . Take all your medications only as directed. . Make sure to work with your physical therapist to make sure you regain your former strength and mobility. . Keep you appointments as listed for you below. Followup Instructions: Eye clinic appointment at [**Last Name (un) **] [**Telephone/Fax (1) 28632**] or [**Hospital1 18**] [**Location (un) 442**] eye clinic [**Telephone/Fax (1) 253**] Completed by:[**2134-1-13**]

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icd9cm

[ [ [] ] ]

[ "38.93", "57.95" ]

icd9pcs

[ [ [] ] ]

13995, 14082

6632, 11354

342, 385

14442, 14451

4828, 6609

14887, 15081

4076, 4094

11821, 13972

14103, 14421

11380, 11798

14475, 14864

3614, 3911

4110, 4809

256, 304

414, 2303

2325, 3591

3927, 4060

17,819

165,546

1970

Discharge summary

report

Admission Date: [**2174-7-10**] Discharge Date: [**2174-7-14**] Date of Birth: [**2118-7-21**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 10842**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization Central line placement History of Present Illness: Mr. [**Known lastname 10843**] is a 55 year old man with recently diagnosed dilated cardiomyopathy (EF 30%), current tobacco use and past IV drug and alcohol abuse (clean x10 years) who p/w progressive shortness of breath. . The patient was in his USOH until a few months ago when he noticed increasing shortness of breath during his regular weight-training exercise circuit. While he used to be able to do several sets without stopping, he soon found that he needed to stop every few sets to catch his breath. While he used to be able to walk indefinitely, he now doubts that he could go for more than a mile. The episodes of shortness of breath have not been associated with any chest pain. Over the past few weeks he has also begun to notice PND and orthopnea, although he denies any lower extremity edema or recent weight gain (baseline weight 173-175). He reports a nonproductive cough, but notes that he has it chronically and that it's likely related to his smoking. He denies any recent fevers, chills, nausea, vomiting or palpitations. . Over the past ~2 weeks he has also experienced periodic episodes of chest pain that are unrelated in time to his episodes of shortness of breath. He describes the pain as "burning," and notes that it's located in the mid-epigastric area. The episodes of pain last varying amounts of time (5 - 30 minutes). The pain does not radiate, and is not associated with any lightheadedness, diaphoresis, nausea or vomiting. He notes that the pain is similar to his reflux pain, and that it typically improves with food or drink. . Finally, the patient notes that he has had "eye waviness" for "the longest time." Approximately 2 months ago he "went blind in one eye" while waiting in line at a store. It is unclear what workup was pursued at that time but an ultrasound of his carotids was normal. Last week he experienced an episode of "eye blurriness" while he was working to fix an air conditioner; it lasted about 15 minutes. In both cases, the eye symptoms have not been associated with any headache, aura, chest pain or shortness of breath, but he does recall some lightheadedness. . On the floor the patient complained of some epigastric pain but notes that it was imrpoving as he ate. He denied any shortness of breath or eye symptoms. Past Medical History: Dilated cardiomyopathy: Recent stress ECHO with EF 30%, global hypokinesis, no wall motion abnormalities. h/o substance abuse (see below) Social History: The patient lives in [**Location 4628**] with his wife, although he notes that the marriage is not a particularly good one. He works in floor covering. He has an extensive history of substance abuse. Before going clean approximately 10 years ago, he used use heroin, cocaine, marijuana and percocets while also drinking 24 beers plus hard alcohol daily. He has not had any alcohol or illicit drugs since quitting 10 years ago. He is a current smoker (2ppd x ~30 years) but expresses interest in quitting. Family History: Extensive family history of substance abuse Physical Exam: Vitals: T 98, HR 98 irreg, BP 100/80, RR 20 unlabored, O2 sat 97 RA. General: On physical exam, the patient was a muscular man in NAD. HEENT: Head NCAT. PEERL 3= >2. Sclerae anicteric. OP nonerythematous without exudate. Neck: No LAD or thyromegaly. Pulm: Lungs clear to auscultation. CVS: No carotid bruits, +JVD. Regular rate but irregular rhythm. NL S1 and S2. +S3. No murmurs or rubs. Abd: Soft, NT, ND, +BS. Liver at RCM. Ext: No edema, extremities WWP. Distal pulses strong bilaterally. No rash. Neuro: A&O x 3. Pertinent Results: Chemistries: Na 136, K 5.3, Cl 104, CO2 21, BUN 30, Cr 1.3, Glu 124. CBC: WBC 8.7, HCT 55.3, Plt 168. Diff: 62N, 28L, 5M, 2E, 3B. Cardiac: CK 160, MB 7, TnT <0.01. Coagulation: PT 12.9, PTT 26.9, INR 1.1. Other: D-dimer 750. EKG: Sinus tachycardia at 109 bpm, +PVCs, left axis deviation, new LBBB, ?LVH. . CXR: Moderate cardiomegaly but appearance suggestive of underlying pericardial effusion. Slight redistribution of upper lung zone pulmonary vasculature without overt evidence of CHF. No focal consolidations, pleural effusions or pneumothoraces. . Cardiac Cath [**2174-7-11**] COMMENTS: 1. Selective coronary angiography of this right dominant system deminstarted no evidence of epicardial coronary artery disease. The LMCA was patent. The LAD was patent and demonatrated a distal myocardial bridge. The LCX and the RCA were both widely patent. 2. Resting hemodynamics revealed a severely elevated right and left sided filling pressures with RVEDP of 26 mm Hg and LVEDP of 28 mm Hg. The cardiac index was severely depressed at 1.3 l/min/m2. There was a central aortic hypotension wuth SBP of 88-90 mm Hg. Dobutamine infusion at 5 mcg/kg/min was started. 3. Left ventriculography was deferred. 4. A yellow VIP PA line was placed in the lab for close hemodynamic monitoring and a tailored therapy in the CCU. FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Severe systolic and diastolic ventricular dysfunction. 3. Severely elevated right and left sided filling pressures. 4. Severely depressed cardiac index. 5. Central aortic hypotension. . ECHO [**2174-7-13**] Conclusions: 1.The left atrium is mildly dilated. The left atrium is elongated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe global left ventricular hypokinesis with relative sparing of the basal lateral and inferolateral hypokinesis. Overall left ventricular systolic function is severely depressed. 3. Right ventricular chamber size is normal. Right ventricular systolic function appears depressed. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. 5.The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. 6.The estimated pulmonary artery systolic pressure is normal. 7.There is no pericardial effusion. . DISCHARGE LABS [**2174-7-14**] 05:15AM BLOOD WBC-7.9 RBC-6.49* Hgb-19.6* Hct-58.4* MCV-90 MCH-30.1 MCHC-33.5 RDW-16.2* Plt Ct-143* PT-15.0* PTT-28.9 INR(PT)-1.4* Glucose-86 UreaN-25* Creat-1.2 Na-140 K-4.3 Cl-100 HCO3-28 AnGap-16TotProt-6.7 Calcium-9.1 Phos-3.6 Mg-2.2 Ferritn-118 Triglyc-102 HDL-31 CHOL/HD-4.7 LDLcalc-94 LDLmeas-102 TSH-3.6 [**Doctor First Name **]-POSITIVE Titer-PND PEP-PND HIV Ab-PND Brief Hospital Course: ASSESSMENT AND PLAN: 55 year old man with recently diagnosed dilated non ischemic CMP (EF 15-20%), current tobacco use and past IV drug and alcohol abuse (clean x 10 years) who presented with progressive shortness of breath, found to have clean coronaries on catheterization, with development of hypotension in the lab, admitted to CCU for tailored therapy. . # [**Name (NI) 4964**] Pt with newly diagnosed CHF/cardiomyopathy of unclear etiology who presented for catheterization to evaluate for ischemic disease. In the cath lab he was found to have normal coronaries, however did have elevated left and right sided pressures. He was also noted to be hypotensive which did require pressors. Because he was initally dobutamine dependent, he was transferred to the CCU. The dobutamine was quickly titrated off and BP remained in the low 100's. He was then restarted on his CHF regimen including metoprolol, [**Last Name (un) **], lasix. Repeat ECHO showed dilated cardiomyopathy with severe global HK and EF of 15-20% without valve disease. EP was consulted for possible ICD placement. Given the new diagnosis they would like further work-up and evaluation. At time of discharge he had several tests pending including HIV, SPEP. His TSH was normal, as was ferritin. Possible causes for his cardiomyopathy now that ischemia and valvehas been ruled out includes alcholic induced(former heavy ETOH use), amyloidosis, HIV, tachycardic, sarcoid, hemochromotosis(normal ferritin makes unlikely). He will need an outpatient stress test and Holter monitor to evaluate for arrhythmias and non-sustained VT. We also added spironolactone prior to discharge. Digoxin and warfarin will also have to be consider in this patient with severe cardiomyopathy, but that will be discussed as an outpatient. Nutrition saw th patient to discuss low sodium diet. his weight remained stable on his current regimen and he was discharged without chest pain or SOB. His baseline weight is around 175 pounds. . # Chest pain: Very atypical in nature, likely non ischemic, burning in nature, exacerbated by irritants such as caffeine, relieved with fluids/food. Started on PPI with good effect for GERD. . # Cr elevation: Cr 1.3 on admission now improved to 1.1 s/p cath. remained stable throughout stay. . # Smoking cessation: Patient reports smoking 2 ppd x several years but no smoking for the past 2 days. Expresses interest in quitting, however refused nicotine patch or gum due to side effects. Will discuss with patient options in regards to smoking cessation classes on discharge. . # Ocular symptoms/?TIA: Had some visual changes which resolved prior coming to the hospital. No further events in house. Carotids clean, no further symptoms. . # FEN: Low sodium diet . # Code: full . Patient being discharged home on CHF regimen. Discussed importance of weigh himself each day and follow up with cardiology and taking meds. Also discussed smoking cessation. . Unfortunately at this time because of his severe heart condition he cannot return to work as a construction worker. This type of exertional work is not safe for him at this time. We anticipate it will be longer then a year before he may return to this type of work and even this may not be possible. He has worked in this field for over 30 years and patient is upset about this recommendation but understands the risks of returning to work. Medications on Admission: Candesartan lasix beta blocker (started Thursday [**7-7**]) Discharge Medications: 1. 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* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Toprol XL 50 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: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Congestive heart failure SECONDARY DIAGNOSES Dilated cardiomyopathy h/o substance abuse Discharge Condition: Stable. Asymptomatic. Discharge Instructions: Please come back to the hospital or see your primary care provider if you develop any chest discomfort, shortness of breath, palpitations, lightheadedness, nausea/vomiting, sweating or any other concerns. . Please take all of your medications as prescribed. . You should also take your lasix/furosemide daily because you have a moderate degree of heart failure. You should also watch your weight daily. If you experience weight increase of >3 lbs, noticeable leg swelling or worsening shortness of breath especially on exertion please contact your doctor. You should also adhere to a LOW SODIUM diet per recommendations of nutritionist. It is important that you make all follow up appointments as set up. At this time due to your medical condition you cannot return to work as a construction worker. It is unlikely you will be able to return to work for the foreseeable future and you it is possible you may never be able to return to that line of work because of your heart condition. Thus at this time please avoid any heavy lifting or excessive exertion. Followup Instructions: Please follow up with your cardiologist Dr. [**Last Name (STitle) 1147**] (Ph [**Telephone/Fax (1) 5027**]). An appointment has been made for you . Please follow up with your electrophysiology cardiologist DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 285**] on [**7-25**] ([**2174-7-25**]) at 9:00. You are also scheduled for a stress test. You should not eat or drink anything the morning of the test. The STRESS/EXERCISE LAB is located on the [**Hospital Ward Name **] at [**Hospital1 18**] in the [**Hospital Ward Name 23**] Building on the [**Location (un) 436**]. The phone number is [**Telephone/Fax (1) 1566**], please call if you have a problem with making this appointment. The test is scheduled for [**7-19**] ([**2174-7-19**]) at 10:45am.

[ "276.7", "425.4", "303.93", "530.81", "427.1", "428.0", "585.9" ]

icd9cm

[ [ [] ] ]

[ "88.52", "00.17", "88.56", "37.23", "38.93" ]

icd9pcs

[ [ [] ] ]

11170, 11176

6780, 10183

296, 345

11326, 11351

3985, 5306

12464, 13274

3372, 3417

10294, 11147

11197, 11305

10209, 10271

5323, 6757

11375, 12441

3432, 3966

237, 258

373, 2668

2690, 2829

2845, 3356

76,558

186,116

1162

Discharge summary

report

Admission Date: [**2157-12-1**] Discharge Date: [**2157-12-4**] Date of Birth: [**2099-6-29**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**Doctor First Name 1402**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 58 year old male with a history of DM, HTN, dyslipidemia,PVD, CAD with history of MI, who transfered for cardiac catheterization for a question of NSTEMI in the setting of infection. As noted, the patient has a history of CAD, with an MI in [**2152**], for which he PCI to RCA in [**2152**] at [**Hospital1 336**]. The patient has not had any further chest pain since his MI. He reports a baseline exercise tolerance of 5 blocks, limited by fatigue. The patinet was admitted to [**Hospital1 **] [**Location (un) 620**] on [**11-28**], after presenting with complaints of N/V x 1 day. The patients wife was [**Name2 (NI) 7450**] admitted a few days prior with similar GI symptoms, and was diagnosed with viral gasteroenteritis. On presentation the patient was found to be hypotensive in the 80s, febrile to 102.9, was treated with IVF, and one dose of CTX/azythro. The patinet denies any diahrea or bloody stool. He had continued n/v, fever, and mild abdominal discomfort. He was given continued IVF for supportive care in treatment of presumed viral gastroenteritis. His chest XR on admission was unremarkable, and he was satting on 96% on RA. On the evening of [**11-30**] at the OSH, the patient developed acute shortness of breath. A CXR was obtained, which was concerning to the team for infiltrates. He was reportedly started on CXR/Azythro, but no documentation is available that he received those antibiotics. he denies any recent productive cough. Blood cultures were also obtained. In this setting, the patient had ocmplaints of chest pain, similar, but less intense than prior MI. Described chest discomfort as sub-sternal chest pressure, scaled to [**4-23**], radiation to the shoulder. This chest discomfort was relieved with SLNG. An EKG was obtained, which was concerning of a question of lateral ST depressions, and cardiac markers were elevated. The patient was started in heparin, palvix, ASA, and metprolol, and was transfered to [**Hospital1 18**] for cardiac catheterization. While being transported, the patient had continued chest pain, which again was relieved with SLNG. He has been chest pain free since. In the holding area, the patient had continued hypoxia, requiring 100% NRB. He continued to be febrile, spiking a temperature of 101.6 Cardiac catheterization was deffered, and the patient was admitted to the CCU for futher care. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for the absence paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: PCI to RCA at [**Hospital1 336**] in [**2152**] 3. OTHER PAST MEDICAL HISTORY: Sleep apnea Hiatal hernia s/p surgical repair, Depression GERD Retinopathy Gastropathy Nephropathy (Baseline 1.6) PVD s/p status bilateral infrapopliteal revascularization Critical PT lesion successfully treated with athrectomy and PTA. Social History: -Tobacco history: Not a current smoker, Quit smoking: in the [**2118**] -ETOH: Does not drink alcohol -Illicit drugs: None -Retired courier, married with one son. Family History: Father: previous MIs Physical Exam: VS: T=100.8 BP=139/73 HR=93 RR=22 O2 sat= 91% on 6L GENERAL: WDWN male, sleeping, on a NRB slightly tachypic. 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 9 cm. 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. Patient tachypnic, no accessory muscle use. B/l decreased BS at bases with faint crackes, no wheezes or rhonchi. ABDOMEN: Ventral scar, foft, 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: OSH CE: [**2157-12-1**] CK 226 / CKMB 6.50 / Trop 2.52 [**2157-11-30**] 2044 CK 377 / CKMB 13.90 / Trop 2.52 . Admission labs: [**2157-12-1**] 06:10PM GLUCOSE-327* UREA N-39* CREAT-1.7* SODIUM-141 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-19* ANION GAP-23* [**2157-12-1**] 06:10PM CK(CPK)-142 [**2157-12-1**] 06:10PM CK-MB-7 cTropnT-2.15* proBNP-[**Numeric Identifier 7451**]* [**2157-12-1**] 06:10PM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-1.9 [**2157-12-1**] 06:10PM WBC-12.3* RBC-3.90* HGB-11.7* HCT-34.3* MCV-88 MCH-30.0 MCHC-34.1 RDW-13.1 [**2157-12-1**] 06:10PM NEUTS-92.2* LYMPHS-6.4* MONOS-1.3* EOS-0 BASOS-0.1 [**2157-12-1**] 06:10PM PT-13.5* PTT-26.8 INR(PT)-1.2* [**2157-12-1**] 06:02PM URINE HOURS-RANDOM UREA N-533 CREAT-48 SODIUM-81 [**2157-12-1**] 06:02PM URINE OSMOLAL-590 [**2157-12-1**] 06:02PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM . Studies: CXR [**11-30**]: There are bilateral interstitial and alveolar perihilar opacities, consistent with moderate-to-severe pulmonary edema. There is a left basilar opacity which may represent a combination of pulmonary edema, pleural effusion, and atelectasis. However, superimposed consolidation cannot be excluded. The cardiomediastinal silhouette is obscured. There is no pneumothorax. IMPRESSION: 1. MODERATE-TO-SEVERE CONGESTIVE HEART FAILURE. 2.LT BASILAR CONSOLIDATION AND/OR LEFT PLEURAL EFFUSION CANNOT BE EXCLUDED. . EKG [**2157-12-1**]: ST at 100, physiologic left axis, 1mm ST depressions V5, TWI in v4-V6, q waves in III, avF. . TTE ([**12-1**]): The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with akinetic areas involving the posterobasal septum and adjacent posterior wall and the anterior septum and LV apex. A left ventricular mass/thrombus cannot be excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. Brief Hospital Course: 58 year old male with a history of DM, HTN, dyslipdemia and CAD s/p IMI with a troponin leak likely secondary to demand ischemia in the setting of infection. . CORONARY DISEASE The patient was transferred for mildly elevated troponins in the setting of infection. Cardiac cath was deferred secondary to infection and the patient was managed conservatively with aspirin, statin, plavix, integrilin and heparin. The integrilin and heparin were stopped on [**2157-12-3**]. The patient remained chest pain free and his elevated troponins were likely due to demand ischemia and not acute coronary syndrome. A TTE was performed at [**Hospital1 **] [**Location (un) 620**] showing worsened global systolic function and an EF of 35% (decreased from 65%), new posterior wall, anterior septum and apical akinesis. This was likely from cardiac stunning in the setting of demand ischemia or toxic-metabolic in origin due to his infection. His metoprolol was continued and his ACE was held in the setting of acute renal failure. His Lisinopril 20mg PO qday was restarted upon discharge. He was diuresed with Lasix 40 IV BID which was changed to Lasix 60mg PO BID on [**2157-12-3**]. . PNEUMONIA: The patient presented with fever and a CXR with a question of PNA. He was treated with Levofloxacin for 5 days (dose adjusted for renal function). He had no further fevers after admission and improved clnically. His influenza swab was negative and blood cultures were negative. He also had viral gastroenteritis from presentation which resolved. . HYPOXIA: Likely secondary to heart failure and possible pneumonia. This improved with antibiotics and diuretics. Oxygen was weaned and the patient was discharged ambulating well on room air. . DIABETES MELLITUS: The patient had hyperglycemia which was initially managed with an insulin drip given his anion gap and ketoacidosis. His gap closed and his blood sugars improved. He was then started on his home dose of Lantus for basal insulin and an insulin sliding scale. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained and the patient was given instructions to follow-up as an outpatient for better blood sugar control with Dr. [**First Name (STitle) **]. His sliding scale had to be up-titrated for poor glucose control. . ACUTE ON CHRONIC RENAL FAILURE: Creatinine was increased to 2.1 with a baseline of 1.6. UA was sent and medications were adjusted for renal function. The patient's creatinine on discharge improved to 1.8. . DEPRESSION: The patient was continued on his home medications for depression. Medications on Admission: Home Medications: Lantus 70 units daily Plavix 75 mg daily Lisinopril 20 mg daily, Gabapentin 300 mg t.i.d. Lipitor 40 mg a day Toprol XL 50 mg daily Metoclopramide 10 mg t.i.d. Aspirin 325 mg daily Wellbutrin 100 mg b.i.d. Citalopram 60 mg daily. Pantoprazole 20mg daily . Medications at time of transfer: CTX 1g q24 hrs (started [**12-1**], unclear if received) [**Name (NI) 7452**] 36 units daily Simvastatin 80mg daily Albuterol nebs q2h PRN Ambien Gabapentin 900mg qhs Plavix 75mg daily ASA 325mg daily Reglan 10mgTID Tylenol 650mg q6h PRN Wellbutrin 200mg [**Hospital1 **] Zofran HISS Azithro 250mg daily ( started [**12-1**]) Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 3. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO once a day for 1 days. Disp:*3 Tablet(s)* Refills:*0* 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 10. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*0* 11. Lantus 100 unit/mL Solution Sig: Seventy Two (72) units Subcutaneous once a day. 12. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 14. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Demand Ischemia 2. Community-Acquired Pneumonia 3. Viral Gastroenteritis 4. Acute on Chronic Systolic Heart Failure 5. Diabetes Mellitus, Type 2 6. Hypertension Secondary Diagnoses: 7. Depression Discharge Condition: afebrile, hemodynamically stable, normal oxygenation Discharge Instructions: You were transferred to this hosptial due to concern for a heart attack in the setting of having a viral gastroenteritis. It is thought you had a cardiac enzyme leak due to strain on your heart during your infection. You were also found to have acute renal failure. You were started on an antibiotic (levofloxacin) to treat a pneumonia which was found on Chest X-ray. You should take 1 more day of this medication. Changes to your medications: Start taking Lasix 60mg by mouth once a day Take Levofloxacin 750mg by mouth once a day for 1 day more No other medication changes were made. You should see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3649**] in the next 1 week. You should see your cardiologist, Dr. [**First Name (STitle) **] in the next 2-4 weeks. Please follow with Dr. [**First Name (STitle) **] in 2 weeks for your diabetes management. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 L. Go to the emergency room or call your primary doctor if you experience fever > 100.4, chills, chest pain, shortness of breath, lightheadedness, dizziness, abdominal pain, inability to eat or drink, blood in your stool, black stool, or any other symptoms that concern you. Followup Instructions: You will need to follow up with Dr. [**First Name (STitle) **] in the next [**1-17**] weeks. You should see your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3649**] in the next week. Please call [**Telephone/Fax (1) 3070**] to schedule this appointment. Please keep your previously scheduled appointment: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6475**], MD, MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 3070**] Date/Time:[**2158-2-13**] 10:00 Please follow with Dr. [**First Name (STitle) **] for management of your diabetes in 2 weeks.

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icd9cm

[ [ [] ] ]

[ "99.20" ]

icd9pcs

[ [ [] ] ]

11642, 11648

7150, 9745

281, 288

11911, 11966

4887, 5003

13292, 13907

3896, 3918

10428, 11619

11669, 11669

9771, 9771

11990, 12409

3933, 4868

11874, 11890

3339, 3426

9789, 10405

12438, 13269

231, 243

316, 3212

5019, 7127

11688, 11853

3457, 3696

3256, 3319

3712, 3880

77,019

191,871

52592

Discharge summary

report

Admission Date: [**2107-12-25**] Discharge Date: [**2107-12-31**] Date of Birth: [**2025-8-27**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4891**] Chief Complaint: Fever, weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is an 82-year-old man with history of large cell lymphoma treated 6 days ago with R-CHOP (finished five-day burst of prednisone yesterday), who presented to the emergency room with increasing weakness and fever. Patient developed symptoms on the morning of admission, in the ED he was also endorsing rigors and feeling systemically ill. In the ED, initial vital signs were T 100.8, HR 85, BP 125/64, RR 16, satting 97% on room air. Exam was notable for crackles at right base and 3+ pitting edema (stable per daughter). Labs notable for white count of 5.8 with 89% neutrophils and 0% bands, hematocrit of 23.8 (down from recent baseline high 20s), and platelet count of 40 (down from mid to high 200s at time of discharge about three weeks ago). Electrolytes were normal, with creatinine of 1.2 (at baseline) and BUN of 43. INR was 2.3 (patient is on coumadin) and lactate was 1.1. Liver enzymes were within normal limits. Chest x-ray showed persistent left sided masses and resolving infiltrate in the right lower lobe. Urinalysis was negative. Blood and urine cultures were drawn, and patient was given doses of vancomycin, Zosyn, and levofloxacin in addition to 1 liter of intravenous saline prior to admission. He was also given metoprolol 5 mg IV x3 followed by 25 mg orally for AF with RVR to 150. Vitals at time of transfer were BP 112/77, HR 102 (jumped to 140 with minimal exertion), RR 24, satting 93% RA. Patient was admitted to ICU for AF with RVR. Of note, patient was recently admitted to [**Hospital1 18**] [**Date range (1) **] for weakness. During that admission, he was found to have a multifocal legionella pneumonia for which he was treated empirically with vancomycin, cefepime, and levofloxacin. He was ultimately treated with a 14-day course of levofloxacin when cultures returned (finished [**12-14**]). Notably, he was transiently hypotensive with pressor requirement at the beginning of the hospital admission. The hospital course was complicated by AF with RVR, and although patient was started on amiodorone and digoxin initially, as he clinically improved it was decided to stop these two medicines in favor of uptitrating his beta-blocker. He was discharged on 50 mg of metoprolol succinate, once daily. Code status during his previous admission was confirmed as DNR/DNI, and this was again confirmed this admission with the patient and family. ROS: Currently, patient endorses cough. He is without chest pain, shortness of breath, palpitations, lightheadedness or dizziness. 10-system ROS was otherwise negative. Past Medical History: - Large cell lymphoma involving the base of the tongue, completed 6th cycle of Rituxan, Gemzar, and oxaliplatinum on [**11-10**] with limited results and PET showing increased activity in the lung and abdomen. He then started R-CHOP in [**Month (only) 1096**] and finished a burst of prednisone on day prior to admission - Transitional cell carcinoma of bladder in [**2099**] - Atrial fibrillation on coumadin - Chronic obstructive pulmonary disease - Glaucoma - Paget's disease - Gout - Peripheral vascular disease - Degenerative joint disease - ECG with known LAFB, RBBB since [**9-14**] or prior Social History: Lives with his wife and daughter in [**Location (un) 686**]. His daughter is [**Name8 (MD) **] RN. He quite smoking in the [**2057**]. He has a 60-pk-yr smoking history. Family History: Fhx significant for Colon cancer, and other malignancies. Physical Exam: Admission exam: General: elderly gentleman in no acute distress; coughs intermittently during history; cough sounds wet. Vitals: T 98.2, HR 108, BP 126/69, RR 22, O2 sat 92% on 3L by NC HEENT: non-icteric sclera, dry mucus membranes. Neck: supple. Heart: irregularly irregular, rate of about 100 bpm. Lungs: coarse inspiratory sounds in the posterior lung fields, more pronounced on the left. Abdomen: soft, non-tender. Extremities: 2+ pitting edema to mid shins bilateral; dry skin with scaling and hyperpigmentation distally Focused Discharge Examination: General: patient comfortable, no distress. Lungs: good air movement, clear bilaterally with trace rales at the bases. Extremities: trace pitting edema bilaterally. Neuro: patient alert and oriented, appropriate, delirium resolved. Pertinent Results: Labs at Admission: [**2107-12-25**] 07:10PM BLOOD WBC-5.8# RBC-2.41* Hgb-8.0* Hct-23.8* MCV-99* MCH-33.3* MCHC-33.7 RDW-15.5 Plt Ct-40*# [**2107-12-25**] 07:10PM BLOOD Neuts-89* Bands-0 Lymphs-6* Monos-4 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2107-12-25**] 07:10PM BLOOD PT-23.8* PTT-29.3 INR(PT)-2.3* [**2107-12-25**] 07:10PM BLOOD Glucose-98 UreaN-43* Creat-1.2 Na-135 K-4.1 Cl-101 HCO3-30 AnGap-8 [**2107-12-25**] 07:10PM BLOOD ALT-11 AST-18 LD(LDH)-246 CK(CPK)-8* AlkPhos-102 TotBili-0.9 [**2107-12-25**] 07:10PM BLOOD CK-MB-2 cTropnT-0.07* [**2107-12-25**] 07:10PM BLOOD Calcium-8.7 Phos-2.9 Mg-1.6 [**2107-12-25**] 07:20PM BLOOD Lactate-1.1 [**2107-12-26**] 12:17AM BLOOD Hgb-8.3* calcHCT-25 Chest x-ray ([**2107-12-25**]): Mass-like consolidation in the left lung, appearing similar to multiple prior chest radiographs dating back to [**2107-6-18**] concerning for malignancy/metastatic disease, less likely pneumonia. Persistent right basilar opacity, slightly improved though likely represents residual pneumonia versus scarring. Small bilateral pleural effusions. Brief Hospital Course: A/P: In summary an 82-year-old man with history of large B-cell lymphoma s/p 6 cycles of Rituxan, Gemzar, and Oxaliplatinum and most recently R-CHOP, now presents with fevers and weakness, admitted to the intensive care unit for AF with RVR and neutropenia with fever. The source of the infection was later felt to be a urinary tract infection. # Atrial fibrillation: During his most recent admission, patient had been treated transiently with amiodorone and digoxin, although both of these medications were discontinued at time of discharge. As his clinical status improved, he responded well to beta-blockade. He continued to have AFIB with RVR, even on escalating doses of metoprolol. Also received acute dosing of IV metorpolol as well as diltiazem. Eventually placed on 50mg metoprolol qid, with digoxin added on for rate control. The patient underwent a digoxin load prior to transfer out of the ICU, and was then transitioned to 0.125 digoxin daily. This dose was decreased prior to discharge, given the patient's CKD and history of digoxin effects. His warfarin was held during the pancytopenia early in the admission, but was gradually restarted, and will be followed as an outpatient. His internist was notified to restart the [**Hospital3 **] following the patient, and the VNA will draw his labs and send them to the PCP's office. # Fevers, weakness: presented with fevers. Received one dose of levofloxacin then empricially started on vancomycin and cefepime. Vancomycin was discontinued, but the patient was continued on cefeipime while he was neutropenic. Urine cultures were positive for presumed E.Coli, and antibiotics were later tapered based on the culture data. No sputum or blood cultures were positive. The patient was afebrile for 24 hours by time of discharge. # Hypoxia and oxygen requirement: Likely multifactorial, given concern of pneumonia as well as multiple masses in left lung. Thought there might have been a pulmonary edema componenet, but the patient auto-diuresed as his rate was better controlled during his ICU stay. The oxygen requirement and LE edema both resolved prior to discharge. # Large B-cell lymphoma: Patient underwent 6th cycle of Rituxan, Gemzar, and Oxaliplatinum on [**11-10**]. He recently completed R-CHOP therapy five days prior to admission. Oncology is following. # Thombocytopenia/ anemia: Likely secondary to recent chemotherapy. Received several transfusions for HCT<25/ platelets <10. Had febrile reaction to transfusion on [**12-28**], where transfusion was stopped early. Patient was asymptomatic otherwise. No evidence of hemolysis or other causes of anemia. # Lower extremity edema: 1+ pitting edema at baseline. Uses lasix prn, especially after chemotherapy. He did not require lasix dosing on discharge. His daughter will call his internist if his weight increases or he developed LE edema. # Obstructive sleep apnea: During his previous admission, he refused CPAP. He does not use CPAP regularly at home. # Glaucoma/cataracts: The patient will continue on his home doses of Latanoprost and levobunolol. # Emergency Contact: [**Name (NI) **] [**Name (NI) **] (daughter): [**Telephone/Fax (1) 108581**] cell # Code status: DNR/DNI (confirmed this admission) Medications on Admission: MEDS - Advair 500-50 mcg [**Hospital1 **] - Lasix 20 mg daily - Combivent nebs q4h prn for shortness of breath or wheezing - latanoprost 0.005% ophtalmic drops qhs - levobunolol 0.5% ophthalmic drop [**Hospital1 **] - metoprolol 50 mg q24h - omeprazole 40 mg once daily - warfarin 2.5 mg qhs Discharge Medications: 1. digoxin 125 mcg Tablet Sig: [**1-8**] Tablet PO once a day: Please check with Dr [**Last Name (STitle) **] about continuing this medication when you see him. Please call Dr[**Name (NI) 108580**] office if your HR is less than 60. Disp:*30 Tablet(s)* Refills:*0* 2. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours): Please continue this medication until [**2108-1-7**], until the supply runs out. Disp:*15 Tablet(s)* Refills:*0* 3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please have your INR checked on [**2108-1-2**]. . 5. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. levobunolol 0.5 % Drops Sig: One (1) Drop Ophthalmic twice a day: as per prior to this admission. 7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for SOB, wheezing.: per home regimen. 9. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day: Please use this as prior to admission, following your chemotherapy. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 11. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO twice a day: Please take 2 tablets twice daily (increased from your home dose) until you see Dr [**Last Name (STitle) **]. If you notice your heart rate is under 60, please call Dr [**Last Name (STitle) **] sooner. Disp:*120 Tablet Sustained Release 24 hr(s)* Refills:*0* 12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: Please make sure to take a senna on days that you take this medication. Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Americare Discharge Diagnosis: Neutropenic fever Urinary tract infection Atrial fibrillation with rapid rate Lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane), as per baseline functional status. Discharge Instructions: Mr [**Known lastname **], it was a pleasure to care for you during this admission. As you know, you were admitted when you felt cold, and were found to have an infection and a rapid heart rate with your atrial fibrillation. You were started on IV antibiotics for your infection in the ICU, which were later changed to pill antibiotics (cefpodoxime) to complete treatment for a urinary tract infection. When you were first admitted, your blood counts were low, likely due to your recen chemotherapy. This has improved, although your platelets are still lower than your normal. Please be careful about bruising and bleeding. For this your metoprolol dose was increased and digoxin was started. You have tolerated the digoxin better than the last time, although you may not need it long term. Your new medications: 1. Digoxin 0.6125 mg daily 2. Cefpodoxime 200mg twice a day until [**2108-1-17**] Changed medications: 1. We increased your metoprolol from 50mg to 100mg (2 tablets) twice daily. This is a temporary dose until you see Dr [**Last Name (STitle) **] this week. Your other medications should continue without change. Followup Instructions: Please call Dr[**Name (NI) 108580**] office and see if they can move up your appointment to the week of [**1-2**]. He should see you to discuss followup of your urinary tract infection and heart rate (including the new medication digoxin and the need to continue taking it). We have set up visiting nurse services to have your INR checked, but you should go to [**Hospital1 **] Monday if for some reason that does not occur. We have notified [**Hospital1 2292**] (Dr [**Last Name (STitle) **] look for your INR results. Last INR 1.2 on [**2107-12-31**]. Name: [**Date Range 36023**],HIKARU Location: [**Location (un) 2274**]-[**Location (un) **] Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**] Phone: [**Telephone/Fax (1) 36024**] Appointment: Friday [**2108-1-13**] 10:50am You should proceed with seeing Dr [**First Name (STitle) **] as previously scheduled, on [**1-12**], at [**Location (un) 2274**] [**Location (un) **] Oncology. You should call her office sooner if you have questions about your chemotherapy or the next cycle.

[ "715.90", "E933.1", "288.04", "780.61", "440.20", "427.31", "293.0", "200.70", "327.23", "041.4", "284.1", "428.0", "731.0", "599.0", "V58.61", "496" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11288, 11328

5747, 8996

322, 329

11459, 11459

4643, 5724

12832, 13918

3759, 3818

9339, 11265

11349, 11438

9022, 9316

11677, 12809

3833, 4624

267, 284

357, 2932

11474, 11653

2954, 3555

3571, 3743

40,644

118,853

13836

Discharge summary

report

Admission Date: [**2197-6-26**] Discharge Date: [**2197-6-30**] Date of Birth: [**2128-11-17**] Sex: F Service: SURGERY Allergies: Xalatan / Erythromycin Base / Lumigan / Trusopt / Fenoprofen / Glyburide Attending:[**First Name3 (LF) 301**] Chief Complaint: Patient admitted with bleeding after EGD with dilitation. Major Surgical or Invasive Procedure: Status Post EGD x2 History of Present Illness: HPI: 68F s/p lap gastric bypass in [**7-19**] at NWH, underwent an EGD last week for dilatation for inability to tolerate POs of two stenoses ("gastric stump and gastrojejunal") and underwent repeat dilatation today with resultant bleeding. Received 2 pRBCs with a reported hct from 23 to 25, and become hypotensive into the 60s. She then received an additional 2 pRBCS and FFP (INR 1.3). She hsa been on ASA 325 and Plavix 75 for her recent PTCA in [**3-25**]. Past Medical History: PMH: .CAD .Hyperlipidemia .Diabetes .HTN .OA .Gout .Glaucoma Social History: SOCIAL HISTORY: Married, lives with husband in [**Name (NI) 932**]. Five grown children. Retired systems analyst. Family History: FAMILY HISTORY: Mother had MI. Brother with CAD, s/p CABG. Sister with HTN, MI, diabetes. Physical Exam: Tc 98.6, HR 112, BP 144/46, RR 20, O2sat 98% 2L Genl: NAD, CV: tachycardic, reg. rhythm Resp: CTA-B Abd: s/nt/nd Extr: no c/c/e Pertinent Results: [**2197-6-26**] 11:52PM BLOOD WBC-7.3 RBC-2.30*# Hgb-6.9*# Hct-20.1*# MCV-87# MCH-29.8 MCHC-34.2 RDW-17.2* Plt Ct-111* [**2197-6-27**] 09:37AM BLOOD WBC-15.0*# RBC-2.96*# Hgb-8.9*# Hct-25.0* MCV-85 MCH-30.1 MCHC-35.6* RDW-14.8 Plt Ct-227# [**2197-6-28**] 02:35AM BLOOD WBC-11.3* RBC-3.42* Hgb-10.4* Hct-28.3* MCV-83 MCH-30.3 MCHC-36.7* RDW-15.9* Plt Ct-135* [**2197-6-29**] 01:53AM BLOOD WBC-8.2 RBC-3.08* Hgb-9.2* Hct-26.1* MCV-85 MCH-29.7 MCHC-35.0 RDW-15.8* Plt Ct-112* [**2197-6-26**] 11:52PM BLOOD Plt Ct-111* [**2197-6-27**] 09:37AM BLOOD PT-14.2* PTT-31.6 INR(PT)-1.2* [**2197-6-27**] 04:20PM BLOOD Plt Ct-185 [**2197-6-28**] 07:17AM BLOOD PT-11.7 INR(PT)-1.0 [**2197-6-26**] 11:52PM BLOOD Glucose-245* UreaN-48* Creat-1.3* Na-142 K-5.1 Cl-112* HCO3-21* AnGap-14 [**2197-6-27**] 04:20PM BLOOD Glucose-219* UreaN-49* Creat-1.2* Na-148* K-4.0 Cl-113* HCO3-24 AnGap-15 [**2197-6-28**] 02:35AM BLOOD Glucose-161* UreaN-49* Creat-1.1 Na-146* K-3.6 Cl-112* HCO3-27 AnGap-11 [**2197-6-26**] 11:52PM BLOOD Calcium-7.3* Phos-3.2 Mg-1.6 [**2197-6-27**] 04:20PM BLOOD Calcium-7.7* Phos-3.0 Mg-1.5* [**2197-6-28**] 02:35AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.1 [**2197-6-27**] 09:52AM BLOOD Type-ART pO2-354* pCO2-32* pH-7.42 calTCO2-21 Base XS--2 [**2197-6-27**] 05:52PM BLOOD Type-ART pO2-170* pCO2-29* pH-7.48* calTCO2-22 Base XS-0 [**2197-6-28**] 11:08AM BLOOD Type-ART pO2-117* pCO2-40 pH-7.43 calTCO2-27 Base XS-2 Brief Hospital Course: Patient admitted on [**6-26**] with upper gi bleeding after EGD with dilitation for stenosis. She is status post RNY gastric bypass in [**2189**]. Events: [**2197-6-27**] rpt EGD showed large amount of fresh clot and diffuse oozing. [**2197-6-27**] EGD showed no obvious bleeding source, epi injected, clot removed, transfused. [**2197-6-27**] IR showed ? bleed of L gastric artery, embolized [**2197-6-27**] transfused total 9 pRBCs, 4 FFP, 3 plts [**2197-6-28**] hct stable 28.9 -> 29.0 without further blood products [**2197-6-29**] transferred from SICU to floor, hct 26.2 -> 26.1, +1 pRBC, restarted plavix [**2197-6-30**] Progressed to a stage 3 diet without event. No nausea, vomiting or melena. HCT 32.2. Will not place on PPI as will interact and decrease effectiveness of plavix. Have reviewed with patient to come back in for dizziness or return of bleeding. Will discharge today on a stage 3 diet until follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Will have her follow up with pcp in one week. Medications on Admission: Multivitamin one tab daily Colchicine 0.6 mg one tab daily ASA 325 mg one tab daily Plavix 75MG PO daily Vitamin B12 1000 mg one tab daily Lisinopril 10 mg one tab daily Simvastatin 40 mg one tab daily Amytriptiline 20 mg one tab daily Travatan Z eye drops one drop to both eyes every other day NPH Insulin 15 units SC every evening Allopurinol 300 mg one tab daily Cinnamon with chromium 1000 mg one tab twice a day Chromium picolinate 200 mg one tab daily Calcium citrate + Vit D 630mg/400mg one tab daily Coenzyme Q10 100 mg one tab daily Metoclopramide 5 mg one tab one-half to one hour before meals Metoprolol 25 mg one tab twice a day Plavix 75 mg one tab daily Bumex 0.5 mg one tab daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO BID (2 times a day). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. medication Please resume previous medication and follow up with your primary care provider in one week. Discharge Disposition: Home Discharge Diagnosis: Upper GI Study Discharge Condition: Stable Discharge Instructions: You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Followup Instructions: Please call Dr. [**Last Name (STitle) **] office at [**Telephone/Fax (1) 2723**] to make an appointment 2 weeks from discharge. Completed by:[**2197-6-30**]

[ "585.9", "E878.8", "274.9", "998.0", "998.11", "716.90", "403.90", "584.9", "V45.86", "V45.82", "272.4", "285.1", "V58.67", "365.9", "414.01", "250.00" ]

icd9cm

[ [ [] ] ]

[ "38.91", "38.93", "45.13", "44.44", "44.43", "96.04", "96.71", "88.47" ]

icd9pcs

[ [ [] ] ]

5091, 5097

2833, 3856

390, 411

5156, 5165

1397, 2810

6268, 6427

1157, 1233

4602, 5068

5118, 5135

3882, 4579

5189, 6245

1248, 1378

293, 352

439, 907

929, 992

1024, 1125

67,931

126,210

29160

Discharge summary

report

Admission Date: [**2184-11-22**] Discharge Date: [**2184-11-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Elective carotid artery stenting Major Surgical or Invasive Procedure: Right Internal carotid artery stenting History of Present Illness: Ms. [**Known lastname **] is a 84 year old woman with a history of hypertension and hyperlipidemia who presents for carotid artery stenting. . Patient reports seeing her chiropracter in the fall of [**2182**] at which time spinal films were obtained showing possible carotid artery disease. She saw her PCP and in [**2184-9-1**] had carotid US performed which showed severe [**Country **] stenosis. She was referred for carotid angiography and possible revascularization and on [**11-8**] the procedure was perfomed though aborted secondary to hematoma. She returned today for repeat procedure. . On review of systems, she 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. She denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope Past Medical History: Hypertension 1. CARDIAC RISK FACTORS: (-) Diabetes (+) Dyslipidemia (+) Hypertension . 2. CARDIAC HISTORY: -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: None. -PACING/ICD: None. . 3. OTHER PAST MEDICAL HISTORY: - Right cartoid artery stenosis - Glaucoma - Degenerative arthritis, particularly involving the spine - History of [**2181**] Thyroiditis (resolved) - Scoliosis - History of left hip replacement - History of of bleeding duodenal ulcer at age 23 - Chronic kidney disease Social History: -Lives alone; widowed with one son who will possibly accompany her and his name is [**Name (NI) **], his cell phone # [**Telephone/Fax (1) 70157**] -Tobacco history: None -ETOH: Rare -Illicit drugs: None Family History: Three brothers had heart attacks in their 60??????s-80's Physical Exam: VS: T- afebrile BP = 131/55 HR= 58 RR= 18 O2 sat=97% RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were slightly pale, no cyanosis of the oral mucosa. No xanthalesma. NECK: JVD distended but pt laying flat, Carotid bruits b/l L >> R. CARDIAC: PMI located in 5th intercostal space. RR, normal S1, S2, 1/6 SEM at RUSB, [**12-7**] HSM at apex. No r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, CTAB anteriorly and laterally, did not assess posteriorly [**1-3**] position restratint, 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. Faint R femoral bruit, L groin w/ dressin intact, no hematoma. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Femoral 2+ DP 2+ Left: Femoral 2+ DP 2+ . Neuro: see above for mental status exam. CN - VF intact to confrontation, EOMs intact, PRRL, L 3.0mm, R 2.5mm, face symmetric, sensory intact throughout to LT, tongue to midline, palate to midline, shoulder shrug intact. . Motor: 5/5 strength in UE throughout, proximal and distal, flx and extension. LE foot [**4-5**] flx/ext b/l, proximal not assessed [**1-3**] movement restriction. . Sensory: Intact to LT, pin-prick, temperature and proprioception b/l in UE and LE throughout. . Reflexes/Coordination/gait: DTRs 2+ in triceps/biceps, 2+ at patella. Downgoing toes b/l. FTN intact b/l, did not assess LE coordination or gait [**1-3**] movement restriction Pertinent Results: Laboratory values: [**2184-11-22**] 07:52AM BLOOD Creat-1.9* . Imaging/Studies: Catheterization. 1. Stenting of the right internal carotid artery 2. Bilateral renal artery stenosis. Brief Hospital Course: 84 year old woman with a history of hypertension and hyperlipidemia and [**Country **] stenosis, now s/p stent in R ICA, admitted for monitoring. . # ICA stenosis. Pt. tolerated R ICA stenting well. She had no neurological sx at admission to CCU. She denied pain at groin site and exam is unremarkable. Pt was monitored for BP control, w/ goal of > 100 and < 160 mmHg systolic. Her oral anti-hypertensive agents were held while she was in CCU. She remained at bedrest w/ negative neuro checks. Her diltiazem was restarted at discharge at a reduced dose of 60mg extended release daily. Lisinopril was to be held until her follow-up appointment in one month. She was continued on ASA and Plavix as per home regimen. Her laboratory values post procedure were creatinine 1.7, CRIT 27.5, INR 1.2. . # CORONARIES. No known Hx of CAD. Pt was on ASA and Plavix presumably for ICA stenosis and was continued on ASA 81, Plavix, and simvastatin. . # PUMP: Patient had signs of HF clinically. Last Echo LVEF 60%, moderate MR, likely diastolic dysfunction [**1-3**] HTN. Her lisinopril was held on admisison given worsening renal function, with plan to hold medication at discharge and readdress at her follow-up appointment in one month. . # RHYTHM: Sinus rhythm. Monitored on telemetry without events. . # HTN. Patient was normotensive at admission, with goal of > 100 and < 160 mmHg systolic. Outpatient anti-HTN meds were held as described above. . # CKD. Baseline Cr. of 2.1 on [**2184-11-17**], 1.5 on [**11-9**]. Pt. has history of b/l renal artery stenosis and was found to have 90% stenosis on the left and about 80% on right during catheterization for ICA stenting. Pt. was prehydrated and received mucomyst prior to procedure. Plan on discharge was for patient to return in one month for evaluation and possible intervention. Medications on Admission: 1. Aspirin 81mg daily 2. Plavix 75mg daily 3. Diltiazem SR 120mg daily 4. Lisinopril 5mg daily 5. Simvastatin 20mg daily 6. Lumigan 0.03% 1 drop QHS 7. Timolol 0.5% 1 drop [**Hospital1 **] 8. Coenzyme Q10-Vitamin E 50mg-5unit 4 caps daily 9. Glucosamien-Chondroitin-Collagen-Hyaluronic acid 10. Multivitamin Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. Bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic QHS (once a day (at bedtime)) as needed for glaucoma. 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Coenzyme Q10-Vitamin E 50-5 mg-unit Capsule Sig: Four (4) Capsule PO once a day. 8. Glucosam-[**Doctor Last Name **]-Collag-Hyalur Ac 375-300-50-2 mg Capsule Sig: Two (2) Capsule PO once a day. 9. Diltiazem HCl 60 mg Capsule, Sust. Release 12 hr Sig: One (1) Capsule, Sust. Release 12 hr PO once a day for 5 days. Disp:*5 Capsule, Sust. Release 12 hr(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Carotid artery stenosis Secondary: Hypertension, hyperlipidemia, chronic kidney disease. Discharge Condition: Hemodynamically stable and without neurological deficits. Discharge Instructions: You were admitted to [**Hospital1 18**] for elective procedure of placing a stent inside the right artery in your neck. You tolerated the procedure well and there were no complications. You remained overnight in a cardiac critical care unit for observation without complications. It was noted that your renal function had slightly increased from your previous value. During the procedure performed on your neck arteries, you kidney arteries were also examined and showed significant narrowing. You should follow up with Dr. [**First Name (STitle) **] regarding this as below. There was a change made to your medications. Your Lisinopril was stopped. Please do not continue this medicine until you follow up with Dr [**First Name (STitle) **]. Your diltizem (Cardia) dose was reduced to half. You will resume the full dose on Sunday [**11-28**]. If you feel lightheaded or dizzy after taking this medicine please stop and call your PCP or Dr [**First Name (STitle) **]. Should you experience any changes in vision, difficulty with balance, double vision, weakness, numbness, tingling, difficulties with memory, chest pain, shortness of breath or any other symptom concerning to you please call you primary care doctor or go to the nearest emergency room. You were discharged in a hemodynamically stable condition. Please follow up with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **]. You have an appointment scheduled for [**12-28**] at 1pm. If you need to make any changes please call [**Telephone/Fax (1) 62**] Followup Instructions: You have a follow up with your Primary Care Doctor, [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 275**] on [**11-30**] at 2pm. Please call [**Telephone/Fax (1) 6699**] if you need to reschedule this appointment. Please follow up with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **]. You have an appointment scheduled for [**12-28**] at 1pm. If you need to make any changes please call [**Telephone/Fax (1) 62**]

[ "585.9", "433.10", "440.1", "272.4", "403.90" ]

icd9cm

[ [ [] ] ]

[ "00.40", "00.63", "88.42", "00.45", "88.45", "00.61", "88.41" ]

icd9pcs

[ [ [] ] ]

7208, 7214

4110, 5943

297, 337

7356, 7416

3903, 4087

9016, 9499

2243, 2302

6302, 7185

7235, 7335

5969, 6279

7440, 8993

2317, 3884

1623, 1701

225, 259

365, 1494

1732, 2005

1516, 1603

2021, 2227

3,007

128,949

20601

Discharge summary

report

Admission Date: [**2189-4-29**] Discharge Date: [**2189-5-18**] Date of Birth: [**2142-1-9**] Sex: M Service: BLUE SURGERY HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 19419**] is a 47-year-old male, with a past medical history significant for diabetes, hypertension, and hypercholesterolemia, who presented to an outside hospital with a chief complaint of [**10-25**] chest pain and ST elevation, consistent with an anterior myocardial infarction. At the outside institution, an LAD thrombus was discovered and stented. This procedure was complicated by a right external iliac dissection which was surgically repaired. This procedure was complicated by rethrombosis of the coronary stent that was placed prior to the right iliac artery injury. He was then taken back to the cardiac cath laboratory for restenting. Lower extremity angiography obtained during the time of cardiac catheterization showed that the site of the right external iliac artery reconstruction was intact. Following his cardiac procedure, the patient developed an acute abdomen with abdominal distention, and a CT which suggested ischemic colitis with bleeding into the retroperitoneum and intraperitoneal space. He was transferred to this institution on a balloon pump with multiple pressors and a systolic pressure in the 70s. He subsequently became anuric secondary to prolonged hypotension. At the time of transfer, the patient had received 12 units of packed red blood cells, 2 units of FFP, 10 liters of crystalloid. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes mellitus. 3. Hypercholesterolemia. 4. Status post CVA. MEDICATIONS: 1. Glucovance. 2. Avandia. 3. Tricor. 4. Lipitor. 5. Altace. 6. Aspirin. ALLERGIES: No known drug allergies. PHYSICAL EXAM - VITAL SIGNS: Temperature 102.0, pulse 100, blood pressure 153/100, respiratory rate 20, oxygen saturation 100% on room air. In general, the patient was intubated, sedated, and grossly edematous. His heart was tachycardic but regular in rhythm. His lungs had decreased breath sounds bilaterally. His abdomen was extremely distended and tense to palpation. His extremities were grossly edematous. LABORATORY STUDIES: White blood cell count 28, hematocrit 38, platelet count 130, potassium 6.4, BUN 20, creatinine 1.1, blood sugar 325. HOSPITAL COURSE: Given the concern for retroperitoneal bleed, coagulopathy, cardiac shock, and ischemia, he was promptly seen by the surgical service for evaluation. The patient had elevated bladder pressures at 50, but given his overall clinical picture, it was agreed that he should be optimized from a coagulopathy and hemodynamic standpoint before undergoing exploratory laparotomy. The patient was admitted to the coronary care unit and was followed closely with regards to his elevated bladder pressure. He was started on broad-spectrum antibiotics including vancomycin, levofloxacin, and metronidazole for the concern of bacterial transmigration secondary to ischemic colitis. On hospital day #2, after the patient was having progressive fevers with a concern for abdominal perforation, he was taken to the operating room for an exploratory laparotomy. The estimated blood loss for the procedure was 1,000 cc. Intraoperatively, he received 3,000 cc of crystalloid, 2 units of packed red blood cells, 2 units of FFP, and 6 packs of platelets. There was no clot found intraoperatively; however, there was 2 liters of blood present. The bowel was viable with a normal appendix, and there was no evidence of bleeding at the site of the external iliac repair. The patient's intra-aortic balloon pump was removed on hospital day #3. On hospital day #4, the patient was started on TPN. On hospital day #5, the patient was taken back to the operating room where the abdomen was re-explored and closed. He tolerated this procedure well and was discharged to the cardiac surgery recovery unit, after the delayed abdominal closure for abdominal compartment syndrome was performed. The patient did well postoperatively and continued to make urine on his own. He was off pressors by postoperative days #7 and #4, and was receiving TPN for parenteral nutrition. The patient was transitioned from TPN to tube feedings on postoperative days #8 and #5. On postoperative days #9 and #6, the patient was extubated. He was transferred to the floor on postoperative days #11 and #8. At this time, he had sputum cultures which grew coag-positive staph and pseudomonas, and he was therefore treated with ceftazidime and vancomycin. He was advanced to a regular diet on postoperative days #12 and #9. At this time, he was ambulating with the assistance of physical therapy. The patient did have some ongoing tachypnea above his baseline. A blood gas was performed which demonstrated a significant AA gradient. A CT of the chest was done to assess for PE. There was a large clot found at the origin of the right pulmonary artery. He was, therefore, treated with a heparin drip with a goal INR of 2.0-2.3. Given his marked tachypnea, the patient was transferred back to the intensive care unit on postoperative days #13 and #10 for closer monitoring. He was then transferred back to the floor on postoperative days #14 and #11, after having an uneventful ICU course. At this time, the patient was ambulating independently and was tolerating a regular diet. He was maintained on his heparin drip until he was therapeutic with his Coumadin, and was eventually discharged to rehab in good condition. DISCHARGE CONDITION: Good. DISCHARGE DISPOSITION: The patient was discharged to rehab. DISCHARGE DIAGNOSES: 1. Diabetes mellitus. 2. Coronary artery disease. 3. Status post cerebrovascular accident. 4. Acute myocardial infarction. 5. Status post exploratory laparotomy for abdominal compartment syndrome. 6. Mechanical ventilation. 7. Right pulmonary artery embolus. 8. Oliguria. 9. Parenteral nutrition requirement. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po qd. 2. Captopril 6.25 mg po tid. 3. Plavix 75 mg po qd. 4. Colace 100 mg po bid. 5. Coumadin 5 mg po q hs with a goal INR between 2.0 and 3.0. 6. Regular insulin sliding scale, as instructed. 7. Lopressor 25 mg po bid. 8. Protonix 40 mg po qd. FOLLOW-UP PLANS: The patient will be transferred to a rehab facility in the state of [**State 2690**] where he is from. He will be following up with his primary care physician at that time. He was instructed to follow-up with Dr. [**First Name (STitle) 2819**] if he has any other questions or concerns. His staples were removed prior to discharge. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 26023**] MEDQUIST36 D: [**2189-5-15**] 13:04 T: [**2189-5-15**] 13:32 JOB#: [**Job Number 55079**]

[ "415.11", "410.11", "482.1", "998.12", "785.51", "286.6", "518.5", "482.40", "958.8" ]

icd9cm

[ [ [] ] ]

[ "97.44", "96.72", "54.19", "99.15", "96.6", "54.64" ]

icd9pcs

[ [ [] ] ]

5583, 5621

5552, 5559

5642, 5952

5975, 6241

2340, 5530

6259, 6864

173, 1532

1554, 2322

7,275

136,809

43681

Discharge summary

report

Admission Date: [**2139-8-28**] Discharge Date: [**2139-9-1**] Date of Birth: [**2078-11-11**] Sex: M Service: MEDICINE Allergies: Penicillins / Iodine; Iodine Containing / Carbamazepine Attending:[**First Name3 (LF) 800**] Chief Complaint: Shortness of breath, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 93850**] is a 60 year old male with a history of end stage renal disease on [**Known lastname 2286**] (MWF), end stage liver disase secondary to hepatitis C and seizure disorder who was recently admitted to this hopsital from [**2139-8-26**] to [**2139-8-27**] for bradycardia and shortness of breath. He was found to have evidence of volume overload on CXR as well as a potassium of 6.7. EKG showed a junctional bradycardia which resolved with treatment of his hyperkalemia. He received emergent [**Month/Day/Year 2286**] with resolution of his symptoms. He was also started on azithromycin for possible pneumonia on CXR although no fevers or leukocytosis. He was discharged home yesterday afternoon. He was seen by the staff at his facility in the evening and was noted to be in his usual state of health. . He was found on the morning of presentation to be unresponsive in his home. His facility called up to his apartment because transportation was waiting to take him to [**Month/Day/Year 2286**]. When they called his apartment there was no response so they went to check on him and he was found to be minimally responsive on his floor. No acute signs of trauma. They called 911 and he was brought to the emergency room. In the field his initial O2 sats were 89% on RA. His blood pressure was elevated at 220/140. He was placed on CPAP and received nitroglycerin spray. He was brought to the emergency room. . On arrival to the emergency room his inital vitals were T: 96.1 BP: 186/120 HR: 115 RR: 28 O2: 100% on BIPAP EKG showed. CXR showed mild worsening of his volume overload. He was noted to have an approximately 15 second tonic clonic seizure which resolved without treatment. He did not have any head imaging. He was started on a nitroglycerin drip and received aspirin 325 mg x 1. He transiently received BIPAP but was weaned to 4L nasal canula. He was admitted to the MICU for further management. . On arrival to the MICU he is in acute respiratory distress with respiratory rates in the 30s, HR in the 140s, SBP in the 180s on a nitroglycerin drip. He is unable to answer questions at this time. . Past Medical History: - Hypertension - h/o SVT/AVNRT s/p ablation - systolic congestive heart failure w/ EF 45% as well as diastolic dysfunction (echo [**12/2135**]) - Peripheral [**Year (4 digits) 1106**] disease s/p stenting of bilateral common iliac arteries - Epilepsy: began in childhood w/ generalized tonic-clonic seizures. previously treated with phenobarbitol, mysoline, depakote, dilantin, trileptal, tegretol, keppra; most recently Keppra + Lamictal. usual seizure characterized by confusion, disorientation, rare generalized tonic-clonic, followed by Dr. [**First Name (STitle) 437**] - ESRD on hemodialysis; due to idiopathic glomerulonephritis, s/p failed renal Tx x 2 - Hypothyroidism - ESLD [**3-16**] Hepatitis C, not currently on [**Month/Day (2) **] list, followed by Dr. [**Last Name (STitle) 497**] - h/o MRSA line infection - h/o VRE infection - ? amyloid masses b/l shoulders Social History: Lives at [**Hospital3 **] facility on Mission [**Doctor Last Name **] called [**Hospital1 **] at [**Hospital1 1426**], on disability, has two sons. smokes 1ppd x 40 yrs, no etoh, drugs. . Family History: Mother with breast cancer. Father has coronary artery disease and congestive heart failure. Two sons are healthy Physical Exam: On arrival to MICU: Vitals: T: 96.2 BP: 124/40 P: 138 R: 26 O2: 96% on 100% NRB General: Somnolent, tachypneic, diaphoretic, respiratory distress [**Hospital1 4459**]: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated at ear, no LAD, right sided tunelled line in place without erythema Lungs: Crackles diffusely 2/3 up lung bases bilaterally, no rales or ronchi CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: cool, 2+ pulses, no clubbing, cyanosis or edema, right upper extremity fistula without palpable thrill . Exam on Floor: T 98.3 HR 66 BP 121/54 RR 18 SaO2 96% RA GENERAL: pleasant, thin elderly M in NAD [**Hospital1 4459**]: PERRL, EOMI. o/p clear. NECK: Supple no masses CV: RRR nl S1, S2 PMI in 5th IC space, Occasional S3. No m/r/g. LUNGS:Bibasilar crackles to mid-way up lung B/L ABDOMEN: Soft, NT ND. No HSM or tenderness. EXTREMITIES: No edema. 2+ PT, DP pulses B/L SKIN: slightly yellowish (unsure of baseline) No stasis dermatitis or ulcers PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: [**2139-8-27**] 08:55AM WBC-3.2* RBC-3.87* HGB-10.4* HCT-31.3* MCV-81* MCH-26.9* MCHC-33.3 RDW-21.9* [**2139-8-27**] 08:55AM PLT COUNT-175 . [**2139-8-27**] 08:55AM GLUCOSE-89 UREA N-21* CREAT-4.1*# SODIUM-137 POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-28 ANION GAP-15 . [**2139-8-27**] 08:55AM BLOOD CK-MB-NotDone cTropnT-0.06* [**2139-8-27**] 08:55AM BLOOD CK(CPK)-43 [**2139-8-28**] 11:10AM BLOOD CK-MB-5 cTropnT-0.04* [**2139-8-28**] 11:10AM BLOOD CK(CPK)-160 . [**2139-8-28**] 12:43PM ALBUMIN-3.8 CALCIUM-7.6* PHOSPHATE-8.0*# MAGNESIUM-2.1 [**2139-8-28**] 12:43PM ALT(SGPT)-14 AST(SGOT)-37 ALK PHOS-179* TOT BILI-0.6 . [**2139-8-28**] 02:50PM LACTATE-1.8 . [**2139-8-28**] 12:43PM BLOOD TSH-3.3 . CXR: Mild-to-moderate cardiomegaly is unchanged. Moderate pulmonary edema has improved. Aeration in the bases of the lungs has also improved. There is no evidence of pneumothorax. Small right pleural effusion is more conspicuous on today's exam. Central venous catheter is in a standard position. . CT HEAD: IMPRESSION: No acute intracranial pathology. Improvement in aeration of the left maxillary sinus. Brief Hospital Course: 60 year old male with a history of end stage renal disease on [**Month/Day/Year 2286**] (MWF), end stage liver disase secondary to hepatitis C and seizure disorder who was found down by EMS and had witnessed seizure activity in the emergency room. He was transferred from the MICU to the general medical service for further evaluation of his symptoms. His altered mental status was likely related to seizure activity as he has a known history of tonic clonic seizures with post-ictal periods. We found his dilantin level to be subtherapeutic and consulted Neurology about the best way to dose this. He had a one time 300mg dose and then was continued on his outpatient regimen. Follow-up phenytoin levels were therapeutic and he did not require further adjustment. It was unclear if he had missed any doses of his medications and if that is what caused his subtherapeutic level. Blood cultures were obtained as infection could be a possible source of seizure. He was also having pain and tenderness in the right side of his chest around his HD line, and we suspected line infection. He grew out 3/4 bottles of GPC's in clusters from cultures drawn on [**8-28**]. He was afebrile and did not have a white count. He was started on Vancomycin empirically. Culture data returned as coagulase negative staph that was resistant to fluoroquinolones and a number of other antibiotics, so vancomycin treatment was clearly indicated. This was discussed with ID and they formally consulted on this patient. Due to staph bacteremia, a TTE was obtained to rule out endocarditis. The TTE returned negative for valvular vegetation. He remained afebrile, VSS throughout his course on the floors. His BP meds were continued and he attended [**Month/Year (2) 2286**] on [**8-31**]. Home seizure medications (keppra, lamotrigine, phenytoin) were continued as per outpatient regimen. Renal medications (cinacalcet and nephrocaps) were also continued. vitals were monitored closely and electrolytes were obtained and repleted as necessary. He was discharged in stable condition with antibiotics to treat his bacteremia on [**9-1**]. . Communication: Patient, son [**Name (NI) 6978**] [**Telephone/Fax (1) 93898**], [**Name2 (NI) **] [**Telephone/Fax (1) 93897**] . Medications on Admission: Clonidine 0.1 mg PO BID Lisinopril 20 mg daily (previously on 40 mg daily) Rifaximin 200 mg TID Lamotrigine 100 mg 2.5 mg PO BID Metoprolol 50 mg PO TID Aspirin 81 mg daily Phenytoin 200 mg PO BID Levetiracetam 375 PO BID plus 1 tablet after [**Telephone/Fax (1) 2286**] Calcium Carbonate 1000 mg PO QID:PRN Nifedipine 60 mg TID Nephrocaps daily Cinacalcet 90 mg daily Lansoprazole 30 mg daily Discharge Medications: 1. Cinacalcet 30 mg Tablet [**Telephone/Fax (1) **]: Three (3) Tablet PO DAILY (Daily). 2. Clonidine 0.1 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a day). 3. Clopidogrel 75 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO once a day. 4. Lamotrigine 100 mg Tablet [**Telephone/Fax (1) **]: 2.5 Tablets PO BID (2 times a day). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 8. Rifaximin 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 9. Aspirin 81 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 10. Phenytoin Sodium Extended 100 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO BID (2 times a day). 11. Levetiracetam 250 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO BID (2 times a day). 12. Levetiracetam 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QMOWEFR (Monday -Wednesday-[**Last Name (STitle) 2974**]). 13. Nifedipine 60 mg Tablet Sustained Release [**Last Name (STitle) **]: One (1) Tablet Sustained Release PO TID (3 times a day). Discharge Disposition: Home Discharge Diagnosis: 1. Seizure activity with subtherapeutic dilantin levels 2. HD line infection Discharge Condition: Normotensive, afebrile. Discharge Instructions: You were admitted with a [**Last Name (STitle) 2286**] line infection, and seizures. We are treating your infection with an antibiotic called vancomycin which will be infused at [**Last Name (STitle) 2286**]. We think your seizures were secondary to your anti-seizure medication levels being too low, so we gave you an additional dose of dilantin. . We made the following changes to your medications: 1. You will complete a course of antibiotics at [**Last Name (STitle) 2286**]. Dr. [**Last Name (STitle) 1366**] will stop this when you clear the infection. **No other changes were made, please resume your usual medications. . Please follow up with your neurologist, hepatologist, and do your regularly scheduled [**Last Name (STitle) 2286**]. . If you develop any confusion, seizure activity, fevers, chills, or any other concerning symptoms, please return to the emergency department to be evaluated. Followup Instructions: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2139-9-2**] 12:00 Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**] Date/Time:[**2139-9-11**] 8:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2139-9-8**]

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Discharge summary

report

Admission Date: [**2168-8-8**] Discharge Date: [**2168-8-16**] Date of Birth: [**2085-5-23**] Sex: M Service: MEDICINE Allergies: Aspirin / Nsaids / Heparin Agents Attending:[**First Name3 (LF) 2181**] Chief Complaint: Fall with hypotension Major Surgical or Invasive Procedure: Cordis line placement and removal Central line placement and removal in the internal jugular vein Arterial line placement and removal History of Present Illness: HPI: Mr. [**Known lastname 41289**] is a 83 year old male with history of ESRD on hemodialysis, history of multiple DVTs on coumadin, s/p heart transplant in [**2154**] on Cellcept/ Cyclosporine who presented to the ED [**2168-8-8**] after having a fall on the sidewalk. He was recently discharged from the [**Hospital1 18**] ED [**2168-7-8**] for a fall that was thought to be from orthostatic syncope in the setting of medications (ditropan, clonipin, sinamet), autonomic neuropathy and cardiac denervation. He was discharged to rehab. He was on his way home from rehab yesterday when he stopped in at a Sports store. On the way out he fell on the sidewalk. He denies LOC, syncope, palpitaions, or chest pain. By report he was found down confused. . He was taken to [**Hospital1 18**] ED where he was found to have a hematoma on the right eye, skin tear on right hand, and abrasion on right shoulder. Initial vitals were: HR122 BP 102/60 RR 22 Sat 98%RA. Cordis groin line placed and patient received 1L NS. Imaging revealed a left pleural effusion found on chest xray. CT of neck showed rotation of C1 on C2 that could be positional; however, could not exclude rotatory subluxation; moderate to severe narrowing of canal from C5-C7. Fast scan showed fluid in abdomen and given that the patient was on coumadin there was concern for hemoperitoneum. On CT of abdomen/pelvis, fluid not consistent with blood, but bilateral pleural effusions were noted, as was positive caudate hypertrophy (?cirrhosis), 3.1cm infrarenal AAA, and diverticulosis. CT of sinus with nasal bone fracture and periorbital hematoma. Negative CT head. Also given tetanus, fentanyl 75, morphine 4mg. . Initial eval on the floor, he reported pain in both hands and left shoulder. He denied chest pain, shortness of breath, abdominal pain. He again denied presyncopal symptoms prior to fall. Last hemodialysis was on saturday. Cordis was pulled, external jugular line was placed. Patient became hypotensive to the SBP 80-90's, recieved 1L bolus. Out of concern for ongoing hemoperitoneum and lack of adequate IV access, patient was transferred to the MICU. Past Medical History: - Heart transplant ([**Hospital1 1012**] [**2154**], due to idiopathic cardiomyopathy) - hx of multiple syncopal events - sinus arrhthmia and bradycardia - Diabetes - ESRD on HD 3/week (last on Sat, due today); Started dialysis 9 months ago. - muliple DVT ([**3-28**]) on coumadin - Hx of HIT (has required argotroban gtt when off of coumadin) - HTN - Hyperlipidemia - venous insufficiency - restless leg syndrome - hx of multiple superficial skin CA (basal, squamous) - gout Social History: Former opera singer, lives alone but had been in rehab. Smoking history 20 years up to 4 packs, quit [**2131**]. Past couple years occasional alcohol use (1 beer every couple of weeks), prior more extensive history (up to a few years ago, could drink a bottle of wine for a celebration but didnt drink every day) Family History: -Mother died of pancreatitis at 76, also clots -Father died of late-onset Alzheimer's -Sister died of breast cancer at 55 -Brother died of "depression" in 60s -Other brother alive w/ diabetes Physical Exam: Vitals: T: 96.8 BP: 114/76 P: 122 R: 18 O2: 96 RA General: Chronically ill appearing with multiple old and new ecchymoses. nose is bandaged, C collar in place, hands wrapped in kerlix, but alert, oriented, and uncomfortable but no acute distress HEENT: Sclera anicteric, MMM, oropharynx with old blood Neck: supple, + JVD, no cervical vertebral tenderness, ROM intact Lungs: Decreased breath sounds bilateral bases, no w/r/r CV: Regular rate and rhythm, no murmurs, rubs, gallops Abdomen: soft, non-tender, mildly distended, + fluid wave and flank dullness, umbilical hernia, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: skin torn on hands. thin and fragile skin throughout. left anterior shoulder with sutures, ? hematoma at this site, LEs with prominent varicose veins, skin changes c/w venous stasis, cordis in right femoral. 1+ distal pulses, all extremities well perfused. signifcant subcutaneous edema especially in dependent areas. Neuro: motor/sensory intact all extremities. Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema At discharge: same as above except: Comfortable No C collar Improved ecchymoses Pertinent Results: [**2168-8-8**] 04:22PM LACTATE-1.3 [**2168-8-8**] 04:00PM GLUCOSE-119* UREA N-43* CREAT-4.6*# SODIUM-143 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-27 ANION GAP-17 [**2168-8-8**] 04:00PM ALT(SGPT)-9 AST(SGOT)-28 CK(CPK)-111 ALK PHOS-137* TOT BILI-1.1 [**2168-8-8**] 04:00PM LIPASE-28 [**2168-8-8**] 04:00PM cTropnT-0.01 [**2168-8-8**] 04:00PM ALBUMIN-3.6 [**2168-8-8**] 04:00PM TSH-4.0 [**2168-8-8**] 04:00PM WBC-7.2# RBC-3.23* HGB-10.7* HCT-35.1* MCV-109* MCH-33.3* MCHC-30.6* RDW-17.7* [**2168-8-8**] 04:00PM NEUTS-83.1* LYMPHS-9.4* MONOS-5.5 EOS-1.4 BASOS-0.6 [**2168-8-8**] 04:00PM PLT COUNT-122* [**2168-8-8**] 04:00PM PT-27.0* PTT-34.4 INR(PT)-2.6* . Labs at discharge: . Imaging: . Trauma Chest, Pelvic film: IMPRESSION: 1. Large left pleural effusion, and likely pulmonary congestion. 2. Median sternotomy wires. 3. No evidence of pelvic osseous injury on this limited film. . [**8-8**] CT chest/abd/pelvis with contrast: IMPRESSION: 1. Bilateral simple pleural effusions, moderate on the right and larger on the left, with associated atelectasis. There is no hyperdensity to suggest hemothorax. There is no pneumothorax. 2. No evidence of traumatic mediastinal injury. Post-operative changes are compatible with prior heart transplantation. 3. Diffuse free abdominal fluid, without evidence for hemoperitoneum. The liver is nodular in contour, with hypertrophied caudate lobe, suggesting underlying cirrhosis. Clinical and LFT correlation is advised. 4. 3.1-cm infrarenal aortic aneurysm. 5. No traumatic solid organ injury in the abdomen or pelvis. 6. Diverticulosis, without diverticulitis. 7. Degenerative changes in the hips, spine, and right shoulder, without acute fracture. . [**8-9**] CT Chest/Abd/Pelvis: 1. Bilateral pleural effusions, which are simple. No evidence of hemothorax or pneumothorax. Compressive atelectasis/ consolidation of the lungs bilaterally, > left side. 2. Free fluid in the abdomen is simple; no evidence of hemoperitoneum. 3. Undisplaced right anterior 10th rib fracture. . CT sinus: 1. Fractures to the right nasal bone, and bony nasal septum, with fluid and gas filling the nasal passages and nasopharynx. Overlying nasal soft tissue swelling with subcutaneous gas. 2. Periorbital hematoma with no evidence of underlying fracture. 3. Mucosal thickening of the paranasal sinuses, likely inflammatory. . [**8-8**] CT spine: 1. Rotation of C1 on C2 may be positional, however, cannot exclude rotatory subluxation. Correlate clinically, and if there are symptoms concerning for rotatry subluxation, then recommend MRI to evaluate for ligamentous injury. 2. Moderate to severe narrowing of the central canal at the C5-6, C6-7 level. If there is concern for cord injury this could be better evaluated with MRI. 3. Bilateral pleural effusions. 4. Heterogeneous appearing thyroid. Clinical correlation with thyroid function tests recommended, and if clinically indicated, this could be further evaluated with ultrasound. . [**8-9**] CT spine: 1. No fracture. Normal aligment from C2-C3 through C7-T1. Persistent asymmetry between lateral masses of C1 and dens, likely due to scoliosis, but please correlate whether the patient has pain with head rotation, which could suggest atlantoaxial subluxation. 2. Multilevel spondylosis with mild to moderate spinal canal narrowing and multilevel neural foraminal narrowing. 3. Partially imaged pleural effusions. 4. Heterogeneous thyroid, which may be better assessed by [**Name (NI) 13416**], if clinically indicated. . CT head: 1. No evidence of acute intracranial injury. 2. Nasal bone fractures, with mottled density filling the nares. 3. Soft tissue hematoma over the right orbit, with no underlying fracture seen. . R wrist 3 views: No fracture or other traumatic injury in the right wrist. Chronic changes including chondrocalcinosis in the triangular fibrocartilage, vascular calcifications and first CMC degenerative change are noted. . L wrist 3 views: 1) Fracture of the left distal fifth metacarpal, with minimal (cortical width) displacement. 2) Lucency over palmar-lateral soft tissues - clinical correlation requested. . L hand 3 views: 1. Plaster splint applied which obscures the small finger metacarpal fracture. 2. No definite other fractures. If there is concern for additional fractures, recommend further evaluation with cross-sectional imaging. 3. Findings of chondrocalcinosis suggesting CPPD. . L knee 2 views: 1. Marked soft tissue swelling and small-to-moderate joint effusion. 2. Possible articular surface nondisplaced fracture of the patella. No other fracture identified. If clinically indicated, this could be further assessed by CT. 3. Tricompartmental chondrocalcinosis. . Prelim read Abdomen (supine only) film: stool noted in rectum descending and distal transverse cooon. no dilated loops of bowel or free air. vascular calcifications identified. . EKG: low voltage, incomplete RBBB. no change from prior . [**8-9**] TTE: Status post cardiac transplantation in [**2154**]. The left atrium is markedly dilated. The right atrium is markedly dilated. The estimated right atrial pressure is 10-20mmHg. 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 markedly dilated with depressed free wall contractility. 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. Trivial 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 a small to moderate sized pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. Comapred to previous study of [**2168-7-6**], the right ventricle is now dilated and hypopcontractile. Brief Hospital Course: # Fall, ? syncope: Multiple falls over the past year, initially thought to be syncopal/orthostatic secondary to medications and cardiac denervation. Ruled out for MI with normal EKG and negative cardiac enzymes. Transthoracic echocardiogram showed dilated LA, RA, LVEF 70%, small to moderate pericardial effusion and elevated right-sided heart pressures but no overt cause for a syncopal episode. Per discussions with Electrophys, cardiology at [**Hospital1 18**] and transplant cardiology at [**Hospital1 2025**], patient declined pacemaker placement in past at [**Hospital1 2025**] and has no evidence currently of sick sinus, bradycardia or high grade AV block on ECG (But has documented sick sinus in the past). . # Hypotension: Unclear etiology for shock; however after consultation with cardiology, suspect secondary to RV contusion sustained during fall. No evidence of high-grade AV block on ECG. Patient initially required phenylephrine drip, as well as hydrocortisone for pressor support; however, he was weaned off of the phenylephrine drip without incident [**8-12**] with SBPs in 80-90s. Per his pcp, [**Name Initial (NameIs) 228**] blood pressure tends to run SBP 90s. He was normotensive for remaineder of hospital stay. . # Macrocytic Anemia and thyrombocytopenia: Baseline anemia with hematocrit in the 30s. CT scan of abdomen showed density consistent with ascites rather than hemoperitoneum. Suspected likely [**2-23**] medication for immunosuppression. Warfarin was held while in the ICU but patient did not require transfusions. Borderline low platelet count and H/H at baseline of 34 at time of tranfer. . # ESRD on HD: Renal followed while in-house. Patient continued with scheduled hemodialysis Tues, [**Last Name (un) **], Sat. Initially dosed with cefazolin with hemodialysis while sepsis was a concern but after patient ruled out for infectious sources this was discontinued. Sevelamer, nephrocaps continued. . # Ascites: LFTs were largely benign with only mildly elevated alk phos. CT scan of abdomen showed questionable findings of cirrhosis. Hepatitis serologies negative. Paracentesis was not indicated and it was felt that workup could continue on an outpatient basis. . # h/o DVTs on warfarin: warfarin initially held for concern of bleeding, but restarted and INR was therapeutic at time of tranfer. He was dischaged on regimen of alternating doses of 2.5 and 3 mg PO daily. . # Nasal fracture: Patient was evaluated by plastics who felt this was not a surgical issue. . # Hand trauma: Patient was followed by hand surgery while in-house with tid dressing changes for skin tears. L wrist film showed minimally displaced fracture of L 5th metacarpal bone. Hand service placed splint and pt. will f/u in hand clinic after discharge. . # Patellar fracture: Possible articular surface nondisplaced fracture of the patella in L knee, likely related to fall. Pt. did not c/o pain in L knee on exam and had full weight bearing status on L knee at time of transfer. . # s/p Heart transplant: Stable throughout hospital course. Patient was continued on his home doses of immunosuppressants. He was not given atovaquone while inpatient but discharged home on it for PCP [**Name Initial (PRE) 5**]. He was also continued on midodrine. . OUTSTAINDING ISSUES- -sutures in L shoulder (Excisional skin biopsy) and back and hands should be removed on [**8-17**]. -Should follow up closely w/ transplant cardiology at [**Hospital1 2025**]-appointment scheduled for [**8-25**] w/ Dr. [**Last Name (STitle) 41290**]. -Pt not on bisphosphonate, should consider given osteopenia, chronic steroids. -Should be worked up further as outpt. for ascites, ?cirrhosis -full weight bearing status on L knee Medications on Admission: Atovaquone 750 mg/5 mL Suspension daily Calcium Carbonate 500 mg (1,250 mg) Tablet Carbidopa-Levodopa 25-100 mg Tablet at bedtime. Carbidopa-Levodopa 25-100 mg Tablet TIW BEFORE EACH HEMODIALYSIS Clonazepam 0.5 mg Tablet as needed for insomnia. Clotrimazole 10 mg Troche DAILY (Daily). Cyclosporine Modified 25 mg Three (3) Capsule q12 hours. Midodrine 10mg PO TID Mycophenolate Mofetil 500 mg Tablet QAM Mycophenolate Mofetil 500 mg Tablet Two (2) Tablet by mouth QPM Omeprazole 20 mg Capsule, twice a day. Pravastatin 20 mg Tablet Two (2) Tablet by mouth DAILY (Daily). Prednisone 5 mg Tablet One (1) Tablet by mouth DAILY (Daily). Sevelamer HCl 400 mg Tablet Two (2) Tablet by mouth TID Warfarin 3 mg Tablet One (1) Tablet by mouth Once Daily Discharge Medications: 1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane DAILY (Daily). 4. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 8. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TIW (): Please give prior to hemodialysis sessions. 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 13. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 17. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) milliliters PO once a day. 18. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO every other day: take everyother day, alternate with 3 mg dose. 19. Coumadin 3 mg Tablet Sig: One (1) Tablet PO every other day: give everyother day alternating with 2.5mg dose. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**] Discharge Diagnosis: 1. Syncope 2. Nasal fracture 3. Fracture of distal 5th metacarpal 4. Orthostatic hypotension 5. End stage renal disease on hemodialysis 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 due to a fall in the setting of fainting. This resulted in a fracture of your nose and your left pinky finger. It is unclear what caused you to faint. You had low blood pressures, so you were watched in the ICU. The cardiology team discussed having a pacemaker and a biopsy of your heart, but you decided to hold off on these procedures. You were too weak to go home so you are being discharged to a rehab. Followup Instructions: Department: ORTHOPEDICS When: TUESDAY [**2168-8-23**] at 9:10 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2168-8-23**] at 9:30 AM With: HAND CLINIC [**Telephone/Fax (1) 3009**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You have an appointment to follow up with Dr. [**Last Name (STitle) 41290**], your transplant cardiologist, at [**Hospital6 1129**] in the heart transplant center. You are scheduled to see him on Thursday, [**8-25**] at 9:30am. If you need to reschedule this appointment, you should call [**Telephone/Fax (1) 41291**]. You should follow up with Dr. [**Last Name (STitle) 41292**], your primary care physician, [**Name10 (NameIs) **] you are stable at the rehab facility. You can schedule an appointment with him at [**Telephone/Fax (1) 40013**].

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Discharge summary

report

Admission Date: [**2182-10-24**] Discharge Date: [**2182-10-30**] Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 2704**] Chief Complaint: Transfer for Carotid angioplasty Major Surgical or Invasive Procedure: carotid stent History of Present Illness: HPI: 83 year old man with a PMHx of DMII, HTN, hyperlipidemia, glaucoma, prostatis presented to an OSH 6days ago with a new onset of aphasia, staring off into space, and inability to respond to aural or visual stimuli. Pt has no recollection of event, but per family, pt suddenly stopped talking, and stared blankly into space, and did not respond to questions. Daughter denies any facial droop or leg/arm weakness. Pt was taken to the OSH ED where he finally recovered function ~1 hour after they began. A head CT was obtained in ED which was normal, FS on ED visit 132. No previous h/o TIAs or CVAs. Workup for the week following admission included negative head CT, MRI/A which didn't reveal any residual CVA, but on MRA showed 80%narrowing of L ICA, occulsion of L ECA, and R carotid occlusion proximally. R sided blood flow obtained by R PCOM. EEG was performed that was normal. ECHO obtained showed cLVH, inferior wall thinning, inferobasal dyskinesis, EF 45-50%, and possible small ASD seen by doppler; no valvular abnormalities seen. Pt was cath'ed at OSH which showed severe diffuse multivessal CAD, with LAD and LCx lesions as below. . After workup, it was believed that pt experiened L sided TIA from stenotic L ICA. Pt with complete R ICA lesion, likely chronic. Pt was transferred to [**Hospital1 18**] for re-cath and carotid stenting as patient refused CEA/CABG at OSH. . On arrival to the CCU after the procedure pt denies any recent TIA sx's; denies any numbness/tingling/weakenss. No CP/SOB/dyspnea. Denies any recent h/o DOE or CP on exertion. He denies any complaints. . Past Medical History: DMII on oral hypoglycemics HTN Hyperlipidemia Prostatitis Glaucoma h/o UTIs . Social History: SocHx: Quit tob >40 yrs ago, [**3-20**] drinks etoh/night (no recent withdrawal sx's or h/o), no IVDU. Lives at home with daughter. Retired. Family History: M HTN, F HTN, B HTN, S CVA/HTN, S HTN Physical Exam: GEN: Pt lying in bed supine in nad. HEENT: PERRL. EOMI. MMM NECK: Supple. No JVD. No carotid bruits appreciated. CV: Bradycardic, nml s1, s2. no r/m/g. Chest: CTAB anteriorly. Abdomen: Soft. NT,ND. +BS. Ext: No edema bilat. DP/PT/Femoral pulses 2+ bilat. R fem groin without hematoma or bruit. NEURO: A&O X3. strength upper and lower extremities [**4-18**] and symmetrical bilaterally. Sensation grossly intact. . Pertinent Results: DATA from OSH. Labs at OSH: K 4.0, bun 19, creat 1.1, INR .92 wbc 4.9 hgb 14.1, hct 42, plt 179 . Imaging: EKG: Bradycardic, nml axis, RBBB, T wave inversions V1-V3 c/w repol with RBBB, no ST elevations/depressions. No previous to compare. . Cath [**10-23**] Right dominant, LMCA nml, LAD severely diffusely diseased, prox LAD severely stentic with serial high grade setnosis in prox and mid-vessel (80-90%) involving take off of two major diagonal branches. Diffuse severe dz in distal LAD. D1 and D2 80-90% stenotic. LCX severely diseased, with 99% stenosis of large branching OM1, 90% diffuse stenosis OM2. R Coronary Severely and diffusely diseased, with serial 99% stensos in the mid-vessel; PDA reconstitutes faintly from the LCA. LV gram shows inferobasal and inferior scar, moderately impaired global systolic fxn. systemic HTN, with elevated LVEDP. . ECHO [**10-21**] cLVH, inferior wall thinning, inferobasal dyskinesis, EF 45-50%, and possible small ASD seen by doppler; no valvular abnormalities seen. . MRI/A MRI/A which didn't reveal any residual CVA, but on MRA showed 80%narrowing of L ICA, occulsion of L ECA, and R carotid occlusion proximally. R sided blood flow obtained by R PCOM. . EEG normal . ----------------Data from [**Hospital1 18**]------------- . [**2182-10-30**] 05:30AM BLOOD WBC-8.2 RBC-3.06* Hgb-10.3* Hct-28.9* MCV-95 MCH-33.8* MCHC-35.7* RDW-13.3 Plt Ct-165 [**2182-10-30**] 05:30AM BLOOD Glucose-147* UreaN-18 Creat-1.0 Na-143 K-4.2 Cl-108 HCO3-25 AnGap-14 [**2182-10-27**] 06:29AM BLOOD ALT-108* AST-78* LD(LDH)-205 AlkPhos-68 TotBili-0.5 [**2182-10-30**] 05:30AM BLOOD ALT-56* AST-21 LD(LDH)-205 AlkPhos-69 TotBili-0.6 [**2182-10-27**] 06:29AM BLOOD calTIBC-255* VitB12-206* Folate-11.7 Ferritn-890* TRF-196* [**2182-10-25**] 04:53AM BLOOD %HbA1c-7.9* [Hgb]-DONE [A1c]-DONE [**2182-10-25**] 04:53AM BLOOD Triglyc-161* HDL-39 CHOL/HD-3.0 LDLcalc-47 [**2182-10-27**] 06:29AM BLOOD TSH-2.6 [**2182-10-28**] 08:50AM BLOOD Parietl-NEGATIVE . MRI [**2182-10-28**] 1) Multiple bilateral small infarcts. Since there is involvement of the posterior circulation, the bilateral middle cerebral artery territories and probably the bilateral anterior cerebral artery territories, the infarcts must be in a watershed distribution. There is possibly infarct due to embolic etiology in the distribution of the right posterior cerebral artery. 2) Tight stenosis at the left A1 origin. 3) Moderate narrowing of the distal vertebral arteries. . Carotid stenting FINAL DIAGNOSIS: 1. Totally occluded right internal carotid artery. 2. Severely diseased left internal carotid artery. 3. Severe central hypertension. 4. Successful placement of stent in left internal carotid artery. 5. Successful employment of filter distal embolic protection. Brief Hospital Course: A/P: 83 year old man with a PMHx of DMII, HTN, hyperlipidemia, glaucoma, prostatis presented to an OSH 6days ago with a new onset of aphasia, staring off into space, and inability to respond to aural or visual stimuli believed to be TIA that after extensive workup was found to have severe diffuse LCx and LAD coronary disease and bilat carotid disease. Pt trasferred to [**Hospital1 18**] for coronary PCI and carotid stenting. . #CAD # Ischemia - Found to have extensive CAD including prox and mid LAD (80-90%), d1 and d2 80-90%, OM1 99%, OM2 90%, RCA 99%. Pt was evaluated by Dr. [**Last Name (STitle) 65682**] and was declined for CABG. He was transferred to [**Hospital1 18**] for coronary PCI. He was continued on ASA, Plavix, BB, statin and ACEI initially. After his carotid stenosis he was hypotensive and BB and ACEI were held initially. BB were resumed slowly as BP tolerated it. Pt was monitored on tele and did not have NSVT alarms. After a discussion between Dr. [**First Name (STitle) **] and his outpt cardiologist, plan was made to defer the cardiac intervention. Statin was held given transiet increase in LFTs. PCP/cardiologist should restart statin once LFTs reurn to baseline. . # PUMP - EF 45-50%. # Rhythm - Sinus brady. . ## TIA - Pt admitted to OSH with sx's of TIA with severe carotid disease. Per OSH records MRI/A without any sign of CVA - likely only TIA. Pt with no neurological deficit or any residual sx's of TIA/CVA. Upon transfer pt underwent carotid stenting of L ICA. Post intervention pt was noted to be confused and neurology service followed pt in house. MRI performed here showed small infarcts in watershed regions, full report above. Pt was continued on ASA and Plavix. . #. HTN - pt with h/o htn. Immediately post carotid intervention pt hypotensive and required pressors overnight. His BP meds were held and BB restarted once BP increased slowly. This should be titrated as outpt with Goal SBP 110-130. . # Change in mental status - DDx includes delirium from medication(pt received ambien post stenting vs. sundowning). Per Dr. [**First Name (STitle) **] likely to be encephalopathy seen in post carotid stenting in patients with severe carotid disease. Of note pt had 2 episodes of fall and confusion, CT scans were negative for CVA after each event. Neurology was following pt during the admission as well. After discussion with family, pt was having [**3-20**] drinks per day prior to admission. His B12 was low and pt was started on IV B12 repletion(see schedule below) along with thiamine. Pt had increased LFTs of ?etiology statin was discontinued and LFTs normalized. Pt had no complaints of muscle pains and unclear how long he's been on statin. Given his CAD statin should be restarted on follow up visit by cardiologist once mental status clears. LFTs should also be monitored. . -B12 repletion schedule - B12 1000mg IM/SQ every day for 1 wk, started [**2182-10-25**]. Followed by 1000mg IM or SQ qweek for 4 weeks then 1000mg IM/SQ q month. . #. DM - On glyburide at home, 5mg qAM, 2.5mg qPM. Continued on outpt regimen and covered with RISS. HgbA1c was 7.9. His diabetic regimen can be changed outpt by PCP. . #. Glaucoma - Cont lumagan (xalatan generic) gtt qhs Medications on Admission: Home Meds: ASA 81' Zocor 20' Glyburide 5qAM, 2.5qPM . On transfer: ASA 325' Plavix 75' Lisinopril 20' Atenolol 25' . Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 10. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection QD (): B12 repletion schedule - B12 1000mg IM/SQ every day for 1 wk, started [**2182-10-25**]. Followed by 1000mg IM or SQ qweek for 4 weeks then 1000mg IM/SQ q month. . 11. Thiamine HCl 100 mg IV DAILY Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: TIA Carotic stenosis CAD Discharge Condition: Stable. Discharge Instructions: Please continue to take allyour medications and follow up with all your appointments. . If you experience severe chest pain that is not relieved with 3 Nitroglycerin tabs, call your cardiologist or return to the emergency room. . If you experience any further episodes of decreased movement, increased confusion, inability to speak, or changes in vision contact your cardiologist or return to the emergency room. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **], Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2182-12-3**] 3:15. . Please call your cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32255**] [**Telephone/Fax (1) 6256**] to setup an appointment in 2 weeks. . Please follow up with Neurologist, DR. [**First Name8 (NamePattern2) 2780**] [**Name (STitle) 2781**] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2182-12-10**] 1:00. Please call her office if you need to be seen sooner or would like to change the appointment. . Please call your PCP to set up an appointment after your appointment with your cardiologist. Completed by:[**2182-10-30**]

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icd9cm

[ [ [] ] ]

[ "00.40", "00.45", "00.63", "88.42", "00.61" ]

icd9pcs

[ [ [] ] ]

9842, 9987

5437, 8679

250, 265

10056, 10066

2651, 5134

10527, 11211

2162, 2201

8847, 9819

10008, 10035

8705, 8824

5151, 5414

10090, 10504

2216, 2632

178, 212

293, 1886

1908, 1988

2004, 2146

11,702

168,672

49781

Discharge summary

report

Admission Date: [**2155-9-24**] Discharge Date: [**2155-9-27**] Date of Birth: [**2079-7-7**] Sex: M Service: SURGERY Allergies: Nsaids Attending:[**First Name3 (LF) 148**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Gastrotomy with exploration and clot evacuation of the stomach and duodenum. 3. Antrectomy. 4. Arteriotomy repair of celiac axis with bovine pericardium. 5. [**Location (un) 5701**] bag closure for temporary abdominal domain control. History of Present Illness: 76-year-old gentleman is known to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**], who performed a distal pancreatectomy on him 2-1/2 years ago for an early stage pancreatic cancer. Mr. [**Known lastname **] has subsequently developed myeloproliferative disease and has had numerous upper gastrointestinal ulcer events over this 2-year period; however, he has remained cancer-free. He was just admitted with upper GI bleed which was fairly mild. He received 2 units of packed red blood cells initially to recover his already low hematocrit. Upper GI endoscopy was futile on the first night of admission given a large amount of blood in the stomach. He was washed out over the next day, when he remained stable. He then had a follow-up endoscopy which revealed a bleeding ulcer in the antrum of the stomach just in a prepyloric position. This was coagulated and cauterized and epinephrine was administered to it. It appeared to be under control at this point in time. However, about 6 hours after, he burst forth with a massive and sudden upper gastrointestinal bleed. Past Medical History: PMHx: Incisional Hernia CHF Pancreatic cancer - Adenocarcinoma, grade I, T3, [**3-12**] LN. s/p subtotal pancreatectomy [**2-19**], Xeloda, Cyberknife, XRT in [**6-20**]. Myelodysplastic syndrome s/p splenectomy - diagnosed 15 years ago, ringed sideroblastic anemia diagnosed via BM biopsy. Multiple GI bleeds [**2-15**] angioectasias from XRT. Anemia Squamous cell carcinoma in-situ T2DM BPH Gout Scarlet fever as a child Diverticulosis PSH: Lami '[**27**], TURP, knee '[**99**], Distal Panc/Splenectomy Social History: The patient was married, had three children and quit tobacco in [**2122**]. Prior to that, he had a 30 pack year history. He used alcohol rarely. He worked as a tax attorney in [**Location (un) 86**]. He lived in [**Location (un) 745**]. Family History: His sister died of congestive heart failure. Physical Exam: on [**2155-9-24**] PHYSICAL EXAM: VITALS: 95.1, 84, 104/41, 97% RA GEN: Moderate distress. HEENT: Old blood in mouth. CV: RRR. No m/r/g. PULM: Clear anteriorly ABD: +BS. Moderate tenderness epigastrium. EXT: No c/c/e. At [**2155-9-27**]: On exam the patient did not respond to verbal or physical stimuli. Absent heart and breath sounds. Absent peripheral pulses. Pupils are fixed and dilated. Pertinent Results: [**2155-9-26**] 05:51PM BLOOD WBC-25.1* RBC-3.53* Hgb-10.6* Hct-29.8* MCV-84 MCH-30.1 MCHC-35.6* RDW-16.0* Plt Ct-36* [**2155-9-26**] 10:23PM BLOOD PT-22.1* PTT-64.7* INR(PT)-2.1* [**2155-9-26**] 10:23PM BLOOD Glucose-73 UreaN-44* Creat-2.1* Na-140 K-4.2 Cl-110* HCO3-10* AnGap-24* [**2155-9-26**] 10:23PM BLOOD ALT-971* AST-2078* CK(CPK)-774* AlkPhos-261* [**2155-9-26**] 10:23PM BLOOD Calcium-8.0* Phos-6.5* Mg-2.1 [**2155-9-26**] 11:33PM BLOOD Type-ART pO2-271* pCO2-33* pH-7.06* calTCO2-10* Base XS--20 [**2155-9-26**] 10:33PM BLOOD Lactate-13.8* EGD [**2155-9-25**]: Large 1 cm gastric ulcer with recent stigmata of bleeding. Successfully treated with epinephrine and cautery. Multiple patchy areas of ulceration in gastric body. Otherwise normal EGD to second part of the duodenum Brief Hospital Course: Admitted for hemoptysis, received 2 units pRBC in ED and admitted to MICU for treatment and evaluation of UGI bleed. Endoscopy attempted [**9-25**] but could not adequate assess due to excessive blood and clot in stomach. Pt. received additional 3U pRBC. O/N on [**9-25**] massive hemoptysis, received 10U pRBC, emergently intubated by anesthesia. On pressors, lactate 12.8, emergently brought to OR for antrectomy, repair of arteriotomy with bovine pericardial patch for upper gastrointestinal hemorrhage and boring ulcer of the posterior gastric wall directly into the celiac access. Intraoperatively the patient received 11 units of FFP, 11 packed red blood cells and 3 platelets. The abdomen was left open with [**Location (un) 5701**] bag in place, and returned to the ICU in critical condition. The patient had a brief post-operative course, experiencing multi organ system failure requiring pressors and ventilatory support in the setting of increasing lactic acidosis. A discussion with the family regarding the patient's poor prognosis led to making the patient CMO. Pressors were discontinued and the patient was extubated, expiring shortly thereafter. Medications on Admission: Allopurinol 300 mg Tablet daily Amlodipine 5 mg [**Hospital1 **] Folic Acid 1 mg daily Furosemide 80 mg [**Hospital1 **] Glipizide 20 mg qAM and 1 tab q pm Hydralazine 25 mg TID Hydroxyurea 500 mg daily Lisinopril 10 mg daily Lorazepam 0.5 mg TID Metformin 1000 mg [**Hospital1 **] Metoprolol 125 mg TID Octreotide 200 mcg q month Pantoprazole 40 mg [**Hospital1 **] Sucralfate 1 gram QID Levitra 20 mg PRN Ambien 5 mg qhs prn Pyridoxine Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1. Upper gastrointestinal hemorrhage. 2. Boring ulcer of the posterior gastric wall directly into the celiac access. 3. Multi-organ system failure Discharge Condition: Death Discharge Instructions: D/C to morgue Followup Instructions: Not applicable

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icd9cm

[ [ [] ] ]

[ "43.89", "39.56", "99.04", "96.04", "38.93", "38.91", "54.11", "44.49", "45.13", "44.43" ]

icd9pcs

[ [ [] ] ]

5455, 5464

3765, 4937

276, 554

5658, 5665

2952, 3742

5727, 5744

2468, 2514

5426, 5432

5485, 5637

4963, 5403

5689, 5704

2563, 2933

225, 238

582, 1667

1689, 2196

2212, 2452

18,254

157,686

47970

Discharge summary

report

Admission Date: [**2198-10-6**] Discharge Date: [**2198-10-19**] Date of Birth: [**2134-9-9**] Sex: F Service: MEDICINE Allergies: Dilantin Kapseal Attending:[**First Name3 (LF) 3256**] Chief Complaint: Nausea and Vomiting Major Surgical or Invasive Procedure: Fine needle aspiration of lymph node History of Present Illness: 3 yo F w/ PMH of IgA nephropathy s/p failed cadaveric transplant on HD via Left AV fistula, Afib/flutter (on coumadin), Diastolic heart failure and hx of malignant hypertension p/w nausea and vomiting x 3 days. Pt reports she was in her USOH when on [**10-3**] she developed nausea vomiting, diarrhea 6-7x/day, and headache. She reports she would start vomiting everytime she would try to drink anything, and then would have diarrhea with incontinece. She missed her dialysis yesterday and on day of admission felt wek and dizzy and called EMS to bring her to the ED. On arrival to the ED her initial vitals were 100.3, 125/61, 16, 97% RA. CXR showed mild pulmonary edema and gave 1L bolus. And labs were signficant for K=5.3, Lactate- 4.2, anion gap of 29, WBC 15.1 with 91.6%PMN and INR=3.3. Renal felt she needed urgent dialysis to assist with hyperkalemia. She had a pneumonia with respiratory failure and hyperkalemia in [**2-/2198**] where she was intubated and treated with Vanc/Cefepime for 7 day course without growth in cultures. . In dialysis, she did not have any ultrafiltrate as she was felt to be below her dry weight. She was AAOx3 and conversant. She was given tylenol and carvedilol and transferred to the floor. . On arrival to the floor her initial VS were 100.1, 176/80, 80, 30, 93%2L. She was difficult to arose, was oriented to person and not answering questions, and no further history was able to be obtained. Patient triggered 1 hour after arriving on the floor, had an ABG which was signficant for 7.57/34/71/32, showing a metabolic alkalosis, metabolic gap acidosis. Patient was complaining of feeling hot and her temp was 102.4, she was given 1g acetaminophen. After 1 hour her O2 sats improved to 98% on 2L, and she was more coherent. And was able togive the following additional history: Patient reports not taking her coumdain x multiple days because unable to keep anything down. She denies sick contacts aside from being in dialysis 3x/week. She denies cough or rhinorrhea. she complains of headache that is frontal with some right facial pain. No changes in vision, no neck stiffness, no tick exposures and does not spend much time outdoors. Past Medical History: 1. Atrial fibrillation/flutter: first diagnosed in [**Month (only) **] [**2195**]. 2. End-stage renal disease on hemodialysis secondary to IgA nephropathy s/p cadaveric kidney transplant in [**2173**] which has eventually failed, and started on hemodialysis in [**2193**]. 3. History of upper GI bleeding on [**2195-2-20**] with evidence of esophagitis, gastric ulcer, and bleeding duodenal vessel s/p clipping, cauterization and PPI. 4. Diastolic heart failure supported by an echocardiography from [**2195-12-21**]. Clinically asx. 5. History of malignant hypertension, which was complicated by seizure on [**2193-5-20**]. Not on antiepileptic meds. Denies h/o CVA. 6. Depression. 7. Rheumatic fever in childhood Social History: Single, lives by herself in [**Location (un) 686**], and has no children. She quit smoking 25 years ago (10-pack-years). She rarely drinks alcohol, and denies illicit drug use. She used to work part-time in a coffee shop, but currently does not work. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Her father died at the age of 80. Her mother died at the age of 64 from lung CA. She has a sister with breast CA. MI in uncle in his 60s. Physical Exam: Physical Exam on Admission: Vitals: 100.1, 176/80, 80, 30, 93%2L General: Somulent, arousable when spoken to and then becomes unresponsive. Responsive to pain with moaning and withdrawal. At times speaking incoherent sentences. HEENT: Sclera anicteric, mild conjunctival pallor. MMM, oropharynx clear Neck: able to move chin to chest on patient, JVP elevated to >10, no LAD appreciated Lungs: Difficult to assess based on patient unable to cooperate with exam, but moving air bilaterally, no obvious crackles rhonchi or wheezes appreciated. CV: Regular rate and rhythm, normal S1 + S2. 2/6 Systolic mumur heard best at the LUSB Abdomen: soft, +[**Doctor Last Name 515**] sign (patient opened eyes and yelled on palpation), and tender in epigastric area. Nondistended, +BS, no rebound or guarding. Ext: warm, well-perfused. no cyanosis, clubbing, or edema. Neuro: Unable to fully assess due to mental status, but moving all four extremities . Physical Exam on Discharge: VS: T 98.2 135/72 84 18 92%RA GENERAL: NAD. Oriented x3. Alert and talkative HEENT: NCAT. Sclera anicteric. NECK: Supple JVP flat CARDIAC: Irregularly irregular with tachycardia. harsh diastolic murmur best heard at LUSB but radiating throughout precordium. No S3/S4 LUNGS: CTAB, decreased breath sounds in b/l bases. No E->A changes ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. Left arm with fistula SKIN: No stasis dermatitis, ulcers, scars, or xanthomas, nails without splinter hemorrhages NEURO: A+Ox3, CN II-XII intact, strength 5/5 in all extremities, speech normal LN: No palpable LN in ant/post neck, submandibula, supraclavicula, axilla, femoral, or popliteal fossa bilaterally Biopsy site in Right supraclavicular region without any erythema, drainage or tenderness. Pertinent Results: ADMISSION LABS: [**2198-10-6**] 10:45AM BLOOD WBC-15.1*# RBC-3.60* Hgb-11.5* Hct-34.1* MCV-95 MCH-31.9 MCHC-33.7 RDW-14.6 Plt Ct-163 [**2198-10-6**] 10:45AM BLOOD Neuts-91.6* Lymphs-6.0* Monos-2.2 Eos-0.1 Baso-0.1 [**2198-10-6**] 10:45AM BLOOD PT-33.6* PTT-32.9 INR(PT)-3.3* [**2198-10-6**] 10:45AM BLOOD Glucose-152* UreaN-73* Creat-12.6*# Na-134 K-5.4* Cl-87* HCO3-23 AnGap-29* [**2198-10-6**] 10:45AM BLOOD ALT-22 AST-20 AlkPhos-71 TotBili-0.3 DirBili-0.2 IndBili-0.1 [**2198-10-6**] 10:45AM BLOOD Lipase-14 [**2198-10-6**] 10:45AM BLOOD Calcium-10.6* Phos-7.3*# Mg-2.2 . LABS ON DISCHARGE: [**2198-10-19**] 06:33AM BLOOD WBC-11.7* RBC-2.74* Hgb-8.3* Hct-26.0* MCV-95 MCH-30.4 MCHC-32.0 RDW-15.5 Plt Ct-306 [**2198-10-16**] 06:45AM BLOOD Neuts-83.1* Lymphs-11.1* Monos-3.4 Eos-2.0 Baso-0.4 [**2198-10-19**] 06:33AM BLOOD Plt Ct-306 [**2198-10-19**] 06:33AM BLOOD PT-15.0* INR(PT)-1.3* [**2198-10-19**] 06:33AM BLOOD Glucose-77 UreaN-35* Creat-6.6*# Na-131* K-4.4 Cl-91* HCO3-25 AnGap-19 [**2198-10-19**] 06:33AM BLOOD ALT-1 AST-19 AlkPhos-77 TotBili-0.5 [**2198-10-19**] 06:33AM BLOOD Calcium-8.8 Phos-5.0*# Mg-2.0 . EKG [**2198-10-6**]: Regular bradycardic rhythm with possible P waves in the late QRS complex or early ST segment. Intraventricular conduction delay. Consider junctional or idioventricular rhythm. Leftward axis. Intraventricular conduction delay of left bundle-branch block type. Q-T interval prolongation. ST-T wave abnormalities. Since the previous tracing atrial tachycardia or atrial fibrillation no longer present. The QRS width is now wider but of similar morphology. Clinical correlation is suggested. . Imaging: CT chest without contrast [**10-14**] IMPRESSION: 1. In view of clinical history and pattern of lung nodules though septic emboli is likely possibility, presence of L2 vertebral body lytic lesion focal and focal lucency in D11 vertebra along with enlarged mediastnal and supraclavicular lymph nodes is concerning for metastatic disease from primary/lymphoma. 2. Bilateral moderate complex pleural effusions. 3. Bilateral atrophic kidneys with parenchymal calcification suggestive of chronic renal disease. 4. Dense mitral annulus calcification and minimal pericardial effusion. . CTA head and neck with and without contrast [**10-14**]: IMPRESSION: 1. Overall unremarkable cranial CTA with no finding to specifically suggest mycotic aneurysm formation, though this imaging modality may be insensitive for this diagnosis. 2. Congenitally hypoplastic left vertebral artery with effective PICA-termination and secondary atherosclerosis with reduced flow, likely accounting for the findings on the prompting recent cranial MRA. 3. No evidence of flow-limiting stenosis or dissection involving the cervical vessels. 4. Markedly abnormal appearance to the limited included lung apices, including several peripheral irregular solid nodular opacities; in the setting of known MSSA endocarditis, these are highly suspicious for septic pulmonary emboli. 5. Large bilateral pleural effusions with patchy ground-glass opacities and interlobular septal thickening, suggestive of pulmonary edema. 6. Extensive superior mediastinal adenopathy, incompletely imaged. This finding is quite striking, and appears unlikely to be accounted for by either #4 or #5, above, and should be correlated with clinical data, i.e. is there a history of malignancy, particularly in the thorax? . COMMENT: A preliminary interpretation of "Patent but attenuated (likely secondary to atherosclerosis) left vertebral artery is a non-dominant vessel. . No aneurysm. Multiple bilateral pulmonary nodules with mediastinal lymphadenopathy, bilateral effusions are concerning for a malignancy," with a recommendation for dedicated chest CT, was posted to CCC by Dr. [**Last Name (STitle) **] (2:20 p.m., [**2198-10-14**]). . As recommended, the findings in the thorax would be better-characterized by CECT of the thorax, to follow. . MRI/MRA head without contrast [**10-13**] IMPRESSION: 1. Numerous small supratentorial and infratentorial infarcts in multiple vascular territories, suggesting embolic etiology. A punctate left medial temporal lobe infarct is new, but others were present on [**2198-10-10**]. Evaluation is otherwise limited in the absence of intravenous gadolinium. 2. No flow in the intracranial left vertebral artery and left posterior inferior cerebellar artery, which represents a change since [**2193-6-4**]. If clinically indicated, this may be better assessed by CTA. 3. MRA has poor sensitivity for mycotic aneurysms, which tend to affect small distal arteries. No evidence of an aneurysm is seen in the proximal intracranial arteries. . TTE [**10-12**] No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. The right atrial appendage ejection velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). There are simple non mobile atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. There is a moderate-sized (1.3 x 0.8 cm) vegetation on the posterior mitral leaflet. Anterior mitral leaflet has some focal thickening, though no definite vegetation is seen there. There is no paravalvular abscess see. Mild (1+) mitral regurgitation is seen. No masses or vegetations are seen on the pulmonic valve, but cannot be fully excluded due to suboptimal image quality. There is no pericardial effusion. . IMPRESSION: Moderate-sized mitral valve vegetation. Mild mitral regurgitation. No paravalvular abscess seen. . MRI head with and without contrast [**10-10**]: IMPRESSION: Scattered foci of slow diffusion seen in bilateral cerebellar and cerebral hemispheres in multiple vascular distributions with no obvious enhancement. Imaging findings are suggestive of thromboembolic shower from a proximal source. Given the lack of enhancement in the lesions, septic emboli are less likely. . MRI cervical spine without contrast [**10-10**]: IMPRESSION: Markedly motion-limited examination: 1. Performed in cooperation with the Hemodialysis service, who will be dialyzing the patient immediately following the examination. The patient provided informed consent for the contrast-enhanced examination. 2. Though the patient consented to, and dialysis arrangements were made, to follow the contrast-enhanced portion of the examination, only enhanced imaging of the brain was possible. 3. The non-enhanced images demonstrate no finding suspicious for discitis, vertebral osteomyelitis or associated abscess, particularly in the cervical spine. 4. Severe multilevel, multifactorial degenerative disease of the cervical spine with canal stenosis and cord remodeling, but no definite intrinsic signal abnormality. 5. Multilevel, multifactorial degenerative disease of the lumbar spine with canal and foraminal stenosis, most marked at the L3-4 and L4-5 levels. 6. Bilateral pleural effusions with associated atelectasis. . CXR [**2198-10-6**] IMPRESSION: Mild interstitial edema likely due to fluid overload. . CT head [**2198-10-6**] MPRESSION: No acute intracranial process. . CXR [**2198-10-6**] FINDINGS: Worsening volume status of the patient, with increasing interstitial edema and development of small bilateral pleural effusions. Otherwise no relevant changes since recent radiograph. . MICROBIOLOGY: [**2198-10-6**] 2:57 pm BLOOD CULTURE Source: Line-dialysis. **FINAL REPORT [**2198-10-9**]** Blood Culture, Routine (Final [**2198-10-9**]): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.5 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Aerobic Bottle Gram Stain (Final [**2198-10-7**]): Reported to and read back by DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5386**] @ 5:49A [**2198-10-7**]. GRAM POSITIVE COCCI. IN PAIRS ANS CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2198-10-7**]): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. . [**2198-10-10**] 6:45 am BLOOD CULTURE RECEIVED SPECIMENS RECEIVED IN LAB @ 12:10PM. **FINAL REPORT [**2198-10-16**]** Blood Culture, Routine (Final [**2198-10-16**]): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. FINAL SENSITIVITIES. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.5 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S Anaerobic Bottle Gram Stain (Final [**2198-10-11**]): GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31704**] @ 3PM [**2198-10-11**]. . Time Taken Not Noted Log-In Date/Time: [**2198-10-18**] 6:55 pm FLUID,OTHER CERVICAL LYMPH NODE. GRAM STAIN (Final [**2198-10-18**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): Brief Hospital Course: 64 y/o F with h/o ESRD on HD, malignant hypertension, atrial fibrillation/atrial flutter presenting with MSSA bacteremia c/b endocarditis and septic emboli to the brain and lung with incidental finding on CT scan of lumbar lytic lesion concerning for malignancy. # MSSA endocarditis: Patient was febrile on admission with an altered mental status with MSSA bacteremia. On TTE she was found to have a vegetation of her Mitral valve leaflet. She was complaining of headaches with a nonfocal neuro exam and pain of her neck. On MRI of her brain she was shown to have scattered embolic infarcts that were consistent with septic emboli. She had a TEE which showed the same lesion of her valve and no abscess and no thrombus in her left atrium or left atrial appendage. We was switched from vancomycin to cefazolin to be dosed with HD as per protocol. She completed 3 days of gentamycin, and will continue: - Cefazolin 2gm IV with Mon/Wed HD and 3gm IV with Friday HD start date: [**2198-10-11**] stop date: [**2198-11-22**] . Laboratory [**Month/Day/Year 7941**] required frequency: [**Month/Day/Year 20515**] - CBC with diff - BMP - LFTs . All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions regarding outpatientantibiotics should be directed to the infectious is closed. . # Lytic lumbar lesion: On CT chest, a lytic lumbar lesion was noted. This, taken in context with mediastinal and supraclavicular lymphadenopathy in addition to bilateral complex pleural effusions was concerning for an underlying malignancy. Specifically, lymphoma, multiple myeloma, or a solid lung, breast tumor were considered. Oncology was consulted for assistance in labs/studies that were necessary while patient was in the hospital. Labs were significant for a normal IgG, IgM and elevated IgA (known IgA nephropathy). In addition, beta2 microglobulin and kappa/lambda light chains were elevated. This, however, may be secondary to systemic infection, and also could be explained by amyloidosis. Given patient's ESRD, amyloid is likely, as she has also had echo evidence of a restrictive cardiomyopathy concerning for amyloid. Multiple myeloma is less likely at this time as SPEP was negative (unable to obtain UPEP as patient is anuric). On HD 12 patient had an ultrasound guided biopsy of a right enlarged supraclavicular lymph node. The results were pending on the day of discharge, and patient will be contact by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from oncology regarding the results and any further workup. Finally, oncology recommends outpatient age appropriate cancer screening including mammogram and colonoscopy. . # Arrhythmia- patient has a history of Afib and was on coumadin. Her INR levels were rising and this was felt to be due to interaction with her antibiotic regimen as she had no other signs of liver failure, or DIC. She had an episode of asymptomatic bradycardia down into the 30s with a junctional rhythm which was nonresponsive to atropine. She was transferred to the CCU during this time for concern of the MV vegetation affecting her conduction system. After her TEE (which was negative for perivalvular abscess and other complications) and her rhythm, which converted back to afib in the low 100s, she was transferred back to the medical floor. Patient was restarted on amiodarone and carvedilol on HD11 as patient was tachycardic, however, on HD12 patient had another episode of bradycardia to 38. She spontaneously converted to sinus rhythm, but amiodarone and carvedilol were discontinued and not restarted prior to discharge. She is to remain off these agents, and will follow-up with cardiology. With regard to her anticoagulation, she met with neurology, and given her septic emboli, it is recommended that she stay of anticoagulation for at least 1 month. Anticoagulation can be re-addressed by PCP and neurology. She was started on aspirin 81 mg daily per neurology. . . # ESRD- patient is s/p failed transplant and is on HD MWF. She continued her HD during her stay with extra sessions in the setting of getting gadolinium for her head MRI. She will need to continue cefazolin with HD, as prescribed. . #Transitional issues: - Patient has LN biopsy results pending re: malignancy work-up. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from oncology will be following up on these labs and will inform PCP if further testing is necessary. Dr. [**First Name (STitle) **] will also contact patient with results - Patient is going to Epic of [**Location (un) 55**] Rehab. Contact #[**Telephone/Fax (1) 9714**] - Carvedilol and amiodarone were discontinued as patient had two episodes of bradycardia. Patient should discuss restarting these medications with PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] needs age appropriate cancer screening including mammogram and colonoscopy - continued treatment of MSSA bacteremia/endocarditis with cefazolin at HD. All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions regarding outpatientantibiotics should be directed to the when clinic is closed. Medications on Admission: Medications per OMR, unable to verify with patient at this time. AMIODARONE - 200 mg Tablet - 1 Tablet(s) by mouth daily AMLODIPINE - (Dose adjustment - no new Rx) (Not Taking as Prescribed: pt states not taking) - 5 mg Tablet - 2 Tablet(s) by mouth once a day CALCIUM ACETATE - (Prescribed by Other Provider) - 667 mg Capsule - 3 Capsule(s) by mouth three times a day with meals and 1 tab with snack CARVEDILOL - 6.25 mg Tablet - 1 Tablet(s) by mouth twice daily CINACALCET [SENSIPAR] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 30 mg Tablet - 1 Tablet(s) by mouth twice daily CITALOPRAM - 40 mg Tablet - 1.5 Tablet(s) by mouth qam LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth once a day PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day Name Brand Only, No Substitutions - No Substitution SEVELAMER CARBONATE [RENVELA] - (Prescribed by Other Provider) - 800 mg Tablet - 3 Tablet(s) by mouth three times a day with meals and 1 tab with snack SODIUM POLYSTYRENE SULFONATE - (Dose adjustment - no new Rx) - Powder - 15grams Powder(s) by mouth every Saturday and Sunday WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 1 Tablet(s) by mouth once a day take up to 4 tablets a day on m-w-f adn 2 tabs on tu-[**Last Name (un) **]-sat sun per inr results Medications - OTC MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1 cap Capsule(s) by mouth once daily Discharge Medications: 1. CefazoLIN 2 g IV QMON please give after dialysis 2. CefazoLIN 2 g IV QWED please give after dialysis 3. CefazoLIN 3 gm IV QFRI Start: [**2198-10-12**] please give after dialysis 4. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. citalopram 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 10. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 14. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS): and 1 tablet with snack. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: PRIMARY: 1. High grade methicillin sensitive staph aureus bacteremia 2. Methicillin sensitive staph aureus endocarditis 3. Septic emboli to brain and lungs 4. Lytic lumbar lesion noted on CT scan . Secondary: 1. Atrial fibrillation/flutter 2. End stage renal disease on hemodialysis 3. Diastolic congestive heart failure 4. Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 101213**], . It was a pleasure taking care of you here at [**Hospital1 771**]. . You were admitted to the hospital for nausea and vomiting, and were noted to have missed one of your dialysis sessions. You underwent dialysis without complication, but developed high fevers. You were found to have bacteria in the blood (bacteremia) and were placed on intravenous antibiotics. We found that this bacteria had made a cluster on your heart valve (endocarditis), and small pieces had broken off and travelled through the blood up to your brain and to your lungs giving you tiny areas of very tiny strokes. You did not have any findings on exam of a stroke. You met with the neurology [**Hospital1 21334**], and will remain off blood thinners for at least 1 month. You were on IV antibiotics which you will continue to receive at dialysis. . You also had a very slow heart rate at one point during your hospitalization you were monitored in the cardiac intensive care unit. You had one other episode of this abnormal rhythm while inpatient and so the decision was made to discontinue the medications that can slow your heart rate (carvedilol and amiodarone). You should discuss these medication changes with your primary care doctor as an outpatient. . Lastly, you had some findings on a CT scan of your chest which were concerning for cancer. You were evaluated by the oncologists who sent several tests to evaluate for cancer which did not give a definitive diagnosis. You had a biopsy of one of the enlarged lymph nodes. The results of this are also pending. The oncologist who saw you in the hospital, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], will be in touch with you and your primary care doctor regarding the results of these tests and further work-up that is necessary. . As you had an extended stay in the hospital, physical therapy felt that you would be safest going to a rehab facility to get stronger prior to going home. . MEDICATION CHANGES: - STOP coumadin. You will need to discuss with your PCP and neurology when it is safe to resume. - STOP amiodarone - STOP carvedilol - STOP calcium acetate - CONTINUE cefazolin with dialysis - START baby aspirin daily . Please seek medical attention for any worsening symptoms. Please keep your follow-up appointments noted below. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: INFECTIOUS DISEASE When: FRIDAY [**2198-10-26**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Please make sure you keep your appointment in [**Hospital 4898**] clinic with the Infectious Diseases [**Hospital **]. [**First Name (Titles) **] [**Last Name (Titles) 21334**] are [**Name5 (PTitle) 7941**] your progress on your antibiotics as well as watching you for any significant side effects. . Department: NEUROLOGY When: TUESDAY [**2198-11-6**] at 7:30 PM With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: INFECTIOUS DISEASE When: FRIDAY [**2198-11-23**] at 9:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13125**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: CARDIAC SERVICES When: WEDNESDAY [**2198-11-21**] at 11:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: [**Hospital3 249**] When: WEDNESDAY [**2198-12-26**] at 2:15 PM With: [**First Name8 (NamePattern2) 48**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2198-10-19**]

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icd9cm

[ [ [] ] ]

[ "88.72", "40.11", "39.95" ]

icd9pcs

[ [ [] ] ]

24716, 24806

16813, 21043

297, 336

25187, 25187

5682, 5682

27830, 29723

3567, 3820

23529, 24693

24827, 25166

22043, 23506

25370, 27366

3835, 3849

4805, 5663

21064, 22017

27386, 27807

238, 259

6277, 16708

364, 2542

5698, 6258

3863, 4777

16790, 16790

25202, 25346

2564, 3282

3298, 3551

16740, 16755

28,620

128,017

9324

Discharge summary

report

Admission Date: [**2192-9-25**] Discharge Date: [**2192-9-30**] Date of Birth: [**2130-3-15**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Mitral regurgitation, coronary artery disease Major Surgical or Invasive Procedure: Mitral valve repair (38mm CE [**Doctor Last Name **] band) CABGx2 (LIMA -> LAD, SVG -> Diag) History of Present Illness: This is a very active 62-year-old male with known mitral regurgitation since [**2151**]. He has been followed with routine surveillance echocardiograms with his latest done on [**2192-5-24**]. The test revealed right and left atrial dilatation with a right atrial pressure of [**4-26**] mm Hg. Left ventricular wall thickness and function were normal. The LVEF was > 55%. The left ventricular cavity was mildly dilated. The right ventricular chamber size and free wall motion were normal. The aortic valve leaflets (3) appeared structurally normal with good leaflet excursion and no AR. The mitral valve leaflets were mildly thickened. They were myxomatous. There was moderate-to-severe mitral valve prolapse. Severe (4+) mitral regurgitation and (2+) TR were noted. There was moderate pulmonary artery systolic hypertension. A comparison of past echocardiograms shows his pulmonary artery pressures are increasing. His PA pressure in [**2-17**] was 29+RA, [**2-18**] it was 35+RA and then in [**5-23**] it increased to 45+RA and on [**2192-5-24**] was 44+RA. In terms of symptoms this gentleman denies chest discomfort, palpitations, shortness of breath, dyspnea on exertion, presyncope, syncope or diaphoresis. He is very active exercising daily walking 45 minutes per day at a brisk rate and climbing 2 flights of stairs with no difficulty. Past Medical History: Mitral regurgitation Basal Cell Ca s/p resection Gilberts Disease Seasonal allergies S/P tonsillectomy [**2190**]: Colon polyps s/p resection S/P vasectomy S/P plantar fasciitis Social History: He is married and works as a pediatrician He does not smoke and consumes approximately [**12-20**] alcoholic beverages per week. Family History: His father died of an MI at age 56 and his brother has CAD s/p stents. Pertinent Results: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.6 cm Left Ventricle - Fractional Shortening: 0.39 >= 0.29 Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Ascending: 2.9 cm <= 3.4 cm Aorta - Arch: 2.0 cm <= 3.0 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 9 mm Hg < 20 mm Hg Findings LEFT ATRIUM: Marked LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Normal LV wall thickness. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Focal calcifications in aortic arch. Normal descending aorta diameter. Focal calcifications in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Moderate/severe MVP. Partial mitral leaflet flail. No MS. [**Name13 (STitle) 650**] (4+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Conclusions Pre Bypass: The left atrium is markedly dilated. Left ventricular wall thicknesses are normal. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are severely thickened/deformed. There is moderate/severe mitral valve prolapse of both the anterior and posterior leaflets. There is partial mitral leaflet flail involving P2 and P3. Severe (4+) mitral regurgitation is seen. Post Bypass: patient is on phenylepherine and atrially paced. Normal biventricluar function. A mitral ring prosthesis is seen. Trivial MR, No MS. [**Name13 (STitle) **] mitral gradient 3.6 mm Hg. Aortic contours intact. Remaining exam is unchanged. All finidings disussed with surgeons at the time of the exam. [**Last Name (NamePattern4) 4125**]ospital Course: Dr. [**Known lastname 24613**] was admitted after undergoing a CABGx2 with MVR. All tubes, lines and wires have been removed. His postoperative course was complicated by pneumothoraces, which delayed removal of chest tubes. These tubes were removed on POD 4, and his chest x-ray was improved. He is now discharged with instructions to follow up with Dr. [**Last Name (Prefixes) **] and his cardiologist and PCP. Medications on Admission: Aspirin 81 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Suppository(s) 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily) for 7 days. Disp:*14 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: CAD, pulmonary hypertension, mitral regurgitation Discharge Condition: Good Discharge Instructions: Shower daily, no bathing or swimming for 1 month No creams, lotions, or powders to any incisions No driving for 1 month No lifting > 10 lbs. for 10 weeks [**Last Name (NamePattern4) 2138**]p Instructions: F/U with Dr. [**Last Name (Prefixes) **] in 4 wks F/U with cardiologist in [**1-21**] wks F/U with Dr. [**Last Name (STitle) 2903**] in [**1-21**] wks Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2192-12-5**] 2:00 Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2192-12-19**] 2:00

[ "458.29", "424.0", "V17.3", "277.4", "V70.7", "416.8", "512.1", "V12.72", "V26.52", "414.01", "V10.83" ]

icd9cm

[ [ [] ] ]

[ "89.64", "36.11", "88.72", "39.61", "34.04", "35.24", "36.15" ]

icd9pcs

[ [ [] ] ]

6959, 7017

367, 462

7111, 7118

2307, 5181

2215, 2288

5719, 6936

7038, 7090

5675, 5696

7142, 7298

7349, 7758

5232, 5649

282, 329

490, 1850

1872, 2052

2068, 2199

15,179

112,175

21618

Discharge summary

report

Unit No: [**Numeric Identifier 56902**] Admission Date: [**2175-12-2**] Discharge Date: [**2175-12-16**] Date of Birth: [**2101-9-15**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 74-year-old gentleman presented to the Cardiology service with history of intermittent chest pressure and dyspnea on exertion for approximately 4-5 weeks. He had an episode of chest pain on the day of admission. He said it did not radiate, but it is also not associated with any nausea, dizziness, vomiting, palpitations, diaphoresis. He said it usually happens when he is lying down while he is short of breath and is relieved by walking around and it seems to happen frequently to him and it lasts about 25 minutes. Recently he complains of shortness of breath even with minimal walking in his house. PAST MEDICAL HISTORY: Diabetes type 1. Hypertension. Hyperlipidemia. SOCIAL HISTORY: He drinks approximately 1-2 drinks per day and has a 30 pack year history of tobacco. FAMILY HISTORY: Noncontributory. He was admitted to the Cardiology service for workup for his chest pain and was started on Heparin, aspirin, beta-blocker, nitroglycerin. Placed on telemetry to determine whether or not he would rule in or out for myocardial infarction. Lisinopril was held because of his renal function. At the time of admission, over the next 48 hours, he was covered by the Cardiology service in preparation for cardiac catheterization, which was determined when he had elevated troponins and ruled in for non-ST-elevation myocardial infarction. Creatinine preoperatively was 1.5. It is unknown what the patient's baseline creatinine was, but the patient was aware of chronic renal insufficiency and patient received hydration prior to going to cardiac catheterization and was covered by Cardiology service, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Cardiac catheterization was performed on the [**8-3**], which revealed severe three-vessel disease with plaquing in the left main, heavily calcified LAD with subtotal occlusions of first septal and diagonal 2. Diagonal 1 had a 70 percent lesion. Circumflex was totally occluded in the A-V groove with moderate plaquing in the OM-3. The right coronary artery had proximal and ostial 80 percent lesions and was totally occluded in the mid portion. Patient also had moderate-to-severe LV diastolic heart failure. His LVEDP was 23 as well as moderate pulmonary artery hypertension and mitral regurgitation. Patient was referred to Dr. [**Last Name (STitle) **]. PAST SURGICAL HISTORY: Also includes appendectomy at age 6. ALLERGIES: He had no known drug allergies. MEDICATIONS AT THE TIME HE WAS SEEN: 1. Glyburide 1.25 mg by mouth daily. 2. Lipitor 10 mg by mouth daily. 3. Hydrochlorothiazide 12.5 mg by mouth daily. 4. Multivitamin by mouth daily. 5. Lisinopril 10 mg by mouth daily. 6. Aspirin 325 mg by mouth daily. PHYSICAL EXAMINATION: On exam, he is 6 feet tall, 109 kg or 240 pounds with a temperature of 96.6, blood pressure 118/62, in sinus rhythm at 76, respiratory rate 20, and saturating 94 percent on room air. He was sitting upright in bed in no distress. He is alert and oriented times three and appropriate. He had no carotid bruits. He had diminished breath sounds at the right base and fine rales at the left base. His heart has regular rate and rhythm with S1, S2 tones and no murmurs, rubs, or gallops. His abdomen is soft, round, nontender, and nondistended with positive bowel sounds. Extremities were warm and well perfused with no peripheral edema. No varicosities noted, but some superficial spider veins. He had 2 plus bilateral radial pulses, 1 plus bilateral dorsalis pedis pulses, 2 plus PT pulse on the right, and a 1 plus PT pulse on the left. PREOPERATIVE LABS: White count is 7.8, hematocrit 29.5, platelet count 261,000. Sodium 139, K 4.3, chloride 105, bicarb 25, BUN 31, creatinine 1.4 with a blood sugar of 137. PT 12.9, PTT 28.7, INR 1.0. ALT 17, AST 17, alkaline phosphatase 38, amylase 36, total bilirubin 0.6. Urinalysis was negative. Preoperative EKG showed sinus rhythm at 71 with PVCs, a left atrial abnormality, and a question of both anteroseptal old myocardial infarction and an old inferior wall myocardial infarction. Additional laboratory work done showed a calcium of 9.0, magnesium 2.0, hemoglobin A1C at 5.8 percent. Preoperative chest x-ray showed background COPD with probable mild CHF and small effusions. Please refer to the x-ray final report dated [**2175-12-2**]. Preoperative CTA of the chest showed no evidence of pulmonary embolism as well as bilateral pleural effusions and increased septal thickening consistent with interstitial edema from mild LV congestive heart failure. It also noted calcified coronaries and aortic atherosclerotic disease. Please refer to the final report dated [**2175-12-2**]. On [**12-6**], the patient underwent coronary artery bypass grafting times four by Dr. [**Last Name (STitle) **] with a LIMA to the LAD, vein graft to the PDA, vein graft to the OM, vein graft to the diagonal. He also underwent mitral valve repair with a 30 mm [**Doctor Last Name 405**] annuloplasty band. He was transferred to Cardiothoracic ICU in stable condition on a propofol drip at 10 mcg/kg/minute, Levophed drip at 0.03 mcg/kg/minute, milrinone drip at 0.1 mcg/kg/minute, and an insulin drip at 2 units/hour. On postoperative day one, he was on a lidocaine drip for premature ventricular contractions. Remained on Levophed, which was weaned during the day, milrinone drip at 0.25, lidocaine drip at 1 mg, and insulin drip at 5 units/hour. Postoperatively, his white count was 11.1, hematocrit 29.4, platelet count 138,000. BUN 34, creatinine 1.6. He remained sedated and intubated on ventilatory support. On postoperative day two, the patient was extubated, remained on milrinone drip, and Natrecor was started at 0.01 for his heart failure. He remained on a lidocaine drip at 1. Aspirin was started and he also began IV Lasix diuresis. He received some Ativan for agitation. His creatinine rose slightly to 1.8. Preoperative echocardiogram estimation of his ejection fraction was 15 percent. Patient was seen by Cardiology everyday for assistance with his congestive heart failure management. He was also seen by the clinical nutrition team. Patient was started on carvedilol beta-blockade, transitioned off his Natrecor. He was weaned off the Levophed and milrinone and remained on the Natrecor drip at 0.01. Diuresis continued. Creatinine decreased slightly to 1.6. He was also seen by Electrophysiology service. At that point, he was off all his drips. The patient was awake and alert on exam, and was also seen by Physical Therapy for initial evaluation, though he remained in the ICU. On postoperative day four, he was hemodynamically stable on no drips. Receiving IV Lasix and carvedilol. Creatinine continued to improve to 1.4. White count dropped to 9.8. Hematocrit was stable at 29. Foley was discontinued. A line was also discontinued. He remained in Cardiothoracic ICU an additional day pending resolution of his ATN and to monitor him closely for ectopy. He was restarted on his lisinopril and seen by Case Management in preparation for moving out to the floor. On the 15th, the patient was transferred out to [**Hospital Ward Name 121**] 2 to begin work with Physical Therapy. He was seen again by the EP fellow to evaluate him for workup for possible ICD in approximately one month postoperatively, also pending whether or not his ejection fraction improved. Patient was also evaluated by the CHF service from Cardiology. On postoperative day six, the patient did have one run of nonsustained V-tach and continued on all of his oral medications. His exam was unremarkable and incisions were clean, dry, and intact. He had positive bowel sounds. Had 1 plus peripheral edema. Decision was made that the patient would follow up with EP postoperatively in one month. Patient was strongly encouraged to work with his incentive spirometer and improve his pulmonary toilet as well as increasing his by mouth intake in all preparation for his probable discharge to home. The following day the patient also had four beats of nonsustained V-tach. He was completely asymptomatic and was waiting clearance so that he can do his physical therapy. His creatinine rose slightly from 1.3 to 1.4. He received additional magnesium repletion. Patient was also seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] of Electrophysiology service and patient went to the EP laboratory on the 18th for a study and received an ICD implant. On postoperative day nine, patient continued to be in sinus rhythm, but had frequent atrial and ventricular ectopic beats status post the ICD being placed. The new pacer site was clean, dry, and intact. His heart rate was irregular. As previously noted, he was saturating 96 percent on 2 liters with a blood pressure of 112/52. His carvedilol was changed to Toprol XL per recommendations of Electrophysiology service with plans to hopefully discharge him if he remains stable for the next 24 hours. His EP device was also interrogated one day prior to discharge. On the 20th, the day of discharge, patient was hemodynamically stable in sinus rhythm at 60, blood pressure 123/61, respiratory rate of 18, and saturating 95 percent on room air. He is alert and oriented. He had a nonfocal neurologic examination. His lungs were clear bilaterally. Incisions were clean, dry, and intact with trace peripheral edema. He was discharged to home with VNA services on [**2175-12-16**]. DISCHARGE DIAGNOSES: Status post coronary artery bypass grafting times four with mitral valve repair. ICD placement. Non-insulin dependent-diabetes mellitus. Hypertension. Hyperlipidemia. DISCHARGE MEDICATIONS: 1. Lisinopril 5 mg by mouth daily. 2. Iron 150 mg by mouth daily. 3. Vitamin C 500 mg by mouth twice a day. 4. Lipitor 10 mg by mouth daily. 5. Amiodarone 400 mg by mouth once a day. 6. Glyburide 1.25 mg by mouth once a day. 7. Lasix 40 mg by mouth once a day times 10 days. 8. Metoprolol 50 mg by mouth daily. 9. Coumadin 5 mg by mouth once a day for two days, then patient is to check with his physician after laboratory draw prior to his next dose. 10. Keflex 500 mg by mouth four times a day for seven days. 11. Potassium chloride 10 mEq by mouth twice a day for 10 days. 12. Percocet 5/325 one tablet by mouth as needed pain every four hours. FOLLOW-UP INSTRUCTIONS: The patient was instructed to followup at the EP Device Clinic on the [**Hospital Ward Name 23**] [**Location (un) 436**] [**Hospital Ward Name 516**] on [**12-26**] at 11:30 a.m. He is also instructed to followup with Dr. [**Last Name (STitle) **], his surgeon for a postoperative surgical visit in one month postoperatively and he was also instructed to followup with Dr. [**Last Name (STitle) 56903**], phone number [**Telephone/Fax (1) 56904**] in [**1-27**] weeks. Patient was instructed to be in contact with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 56905**] for followup of Coumadin dosing with INR blood draws by the VNA service. Again, the patient was discharged home with VNA services on [**2175-12-16**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2176-1-29**] 10:51:01 T: [**2176-1-29**] 11:31:21 Job#: [**Job Number 56906**]

[ "285.9", "593.9", "414.01", "272.4", "250.00", "424.0", "427.1", "997.1", "428.0", "401.9", "411.1" ]

icd9cm

[ [ [] ] ]

[ "37.94", "88.56", "39.61", "37.26", "37.23", "99.04", "36.15", "36.13", "88.72", "00.13", "35.12" ]

icd9pcs

[ [ [] ] ]

998, 2540

9691, 9863

9886, 10566

2564, 2905

2928, 9669

191, 804

10591, 11660

827, 877

894, 981

54,968

192,377

42701

Discharge summary

report

Admission Date: [**2101-12-27**] Discharge Date: [**2102-1-16**] Date of Birth: [**2079-3-26**] Sex: F Service: SURGERY Allergies: Valproic Acid And Derivatives Attending:[**First Name3 (LF) 695**] Chief Complaint: Fulminant Hepatic Failure Major Surgical or Invasive Procedure: Liver transplant with splenectomy History of Present Illness: 22 F hx of bipolar disorder on lamical and depakote, presents from OSH in acute fulminant liver failure. Per family the patient developed a headache three days ago and took between four and six Excedrin. She then developed abd pain, nausea and vomiting the following day. Her nausea, vomiting, and abd pain worsened yesterday and today after becoming lethargic she was taken by her family to [**Hospital3 **] Hospital. Her family denies any empty pill bottles or any suicide attempts. they report she has been happy recently. They do not believe she would have taken an intentional overdose. At [**Hospital3 **] hospital her transaminases were in the 10,000's and her creatinine was 8.86. She had CT abdomen/pelvis and RUQ US before transfer to [**Hospital1 18**]. In the ED her lethargy worsened and she was started on NAC for possible late stage tylenol toxicity. She was evaluated by the renal service for a BUN and creatinine of 72/9.2 and a K of 5.4. Her LFTs and INR are rising and she was seen by hepatology. ROS: unable to obtain as pt lethargic. Past Medical History: PMH: Bipolar disorder, ADD, nondisplaced pelvic fx after MCA PSH: [**2101-12-28**] Right frontal twist drill hole and placement of [**Last Name (un) **] monitor. [**2101-12-30**] Orthotopic deceased donor liver transplant, piggyback, portal vein to portal vein anastomosis, common bile duct to common bile duct anastomosis celiac patch (replaced right hepatic artery) to junction of common hepatic artery and gastroduodenal artery, and splenectomy. Social History: lives with family, current smoker, occasional EtOH, previous drug abuse Family History: NC Physical Exam: PE: [**2101-12-27**] for Consult to Transplant Surgery Phx: 97.7 128/67 79 19 98% on RA GEN: lethargic, arousable HEENT: scleral icterus, jaundiced, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, tender to palpation along upper quadrants guarding, no rebound, normoactive bowel sounds, no palpable masses Ext: No LE edema, LE warm and well perfused Pertinent Results: On Admission: [**2101-12-27**] WBC-11.3* RBC-4.13* Hgb-14.1 Hct-36.1 MCV-88 MCH-34.1* MCHC-38.9* RDW-12.9 Plt Ct-143* Neuts-73* Bands-1 Lymphs-15* Monos-9 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 PT-57.8* PTT-33.4 INR(PT)-5.8* Fibrinogen-41* Glucose-120* UreaN-72* Creat-9.2* Na-136 K-5.4* Cl-89* HCO3-18* AnGap-34* ALT-9830* AST-7027* LD(LDH)-3800* AlkPhos-167* TotBili-14.0* Lipase-447* GGT-81* Albumin-3.4* Calcium-5.3* Phos-10.4* Mg-2.6 Osmolal-312* Ammonia-204* HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-NEGATIVE HAV Ab-POSITIVE HCV Ab-NEGATIVE HCG-<5 AMA-NEGATIVE Smooth-NEGATIVE [**Doctor First Name **]-NEGATIVE IgG-488* IgA-87 IgM-46 HIV Ab-NEGATIVE ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG At Discharge: [**2102-1-16**] WBC-21.1* RBC-2.57* Hgb-7.8* Hct-25.6* MCV-100* MCH-30.6 MCHC-30.7* RDW-17.5* Plt Ct-487* PT-12.4 PTT-18.6* INR(PT)-1.1 Glucose-142* UreaN-111* Creat-2.2* Na-140 K-4.1 Cl-100 HCO3-27 AnGap-17 ALT-39 AST-29 AlkPhos-152* TotBili-1.0 Calcium-8.8 Phos-4.4 Mg-1.8 Albumin-2.3* Calcium-8.6 Phos-4.7* Mg-2.0 tacroFK-19.4 Brief Hospital Course: 22 y/o female who presented from outside hospital with elevated liver enzymes, confusion and lethargy. Her mental status continued to worsen and on the day following admission she underwent placement of a intracranial (ICP monitor) bolt, monitored pressures were within normal limits. Her Bilirubin was 14 on admission and continued to increase. INR was 6.9 on admission, and coagulation factors were aggressively corrected for bolt placement and maintenance. Her creatinine was elevated to 9.2 and she was started on CVVH. AST and ALT decreased, however following multiple psych and social work evaluations and discussions with family and medical evaluation, it was determined this was not a suicide attempt, and was most likely medication induced fulminant liver failure. She was listed as Status One and on [**12-30**] 12 she underwent orthotopic liver transplant and splenectomy. The patient was in the ICU for 11 days following the transplant. She was kept on the CVVH for 5 days following transplant and then started on intermittent HD. Last day of HD was [**2102-1-9**]. Urine output has been increasing daily, and by day of discharge her urine output was more than 2 liters daily. Creatinine was 2.2 on discharge. The AST and ALT dropped daily and were within normal limits by day of discharge. Alk phos was variable throughout hospital stay and was 152 on discharge, and total bilirubin was 1.0. Coagulation studies are within normal limits. Patient has been maintained on tube feeds throughout the hospital stay, and will continue post discharge via post pyloric feeding tube. Tube feeding formula will likely require changing once her renal function normalizes and she will be followed by the transplant nutritionist. All psych meds, (Depakote which she should not restart as this is possibly the medication that caused her liver failure) and Lamictal. Outpatient psych will be arranged and her outpatient psychiatrist will also be notified. Patient is to be transferred to [**Hospital1 **] [**Location (un) 686**], with potential transfer closer to home [**Location (un) 92309**]. She will need daily trough prograf levels this week as levels are high and prograf being held until levels drop. She currently has some tremor due to elevated prograf. Medications on Admission: lamictal 225', lexapro 30', klonopin 1' PRN, depakote 1000', OCP', MVI 1' Discharge Medications: 1. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Follow taper schedule. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. valganciclovir 50 mg/mL Recon Soln Sig: One (1) PO EVERY OTHER DAY (Every Other Day). 7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 8. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): hold for HR<90, SBP<120 . 9. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 10. ipratropium bromide 0.02 % Solution Sig: [**12-12**] Inhalation Q6H (every 6 hours) as needed for SOB/wheeze/congestion. 11. insulin regular human 100 unit/mL Solution Sig: follow sliding scale insulin Injection ASDIR (AS DIRECTED). 12. dextrose 50% in water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: Assess weight daily. 14. tacrolimus 0.5 mg Capsule Sig: HOLD Capsule PO Q12H (every 12 hours) for 2 doses: Please hold PM dose 2/6 and AM dose 2/7. [**Hospital 1326**] clinic will call with dosing regimen. 15. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital1 **], [**Location (un) 686**] Discharge Diagnosis: Fulminant hepatic failure of unknown etiology Bipolar disease Discharge Condition: Mental Status: Clearing Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You will be transferring to [**Hospital **] Rehab in [**Location (un) 686**] Call the transplant office [**Telephone/Fax (1) 11086**] if you have any of the listed warning signs For the remainder of this week, we are requesting daily trough prograf levels to be couriered to [**Hospital1 18**]. All other labs can be q Monday and Thursday You will continue to have blood drawn twice weekly for transplant monitoring No heavy lifting Patient may shower, no tub baths or swimming until further notice Please assess weight daily and call if gains or loses more than 3 pounds in a day or 5 pounds in a week. Will likely need adjustment of lasix. Please do not adjust and medications without first discussing with the transplant clinic at [**Telephone/Fax (1) 673**] Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2102-1-25**] 9:20 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2102-1-18**] 10:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14254**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2102-2-1**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2102-2-1**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2102-1-16**]

[ "577.0", "348.30", "401.9", "286.9", "789.59", "300.00", "305.90", "289.59", "626.0", "287.5", "780.09", "514", "296.80", "570", "276.4", "314.00", "511.9", "275.41", "309.81", "580.89", "305.1" ]

icd9cm

[ [ [] ] ]

[ "50.59", "01.10", "39.95", "41.5", "96.04", "38.95", "50.4", "89.64", "99.15", "96.72", "96.6", "00.93", "38.91" ]

icd9pcs

[ [ [] ] ]

7481, 7549

3558, 5820

315, 351

7655, 7655

2469, 2469

8613, 9428

2020, 2024

5945, 7458

7570, 7634

5846, 5922

7827, 8590

2039, 2450

3204, 3535

250, 277

379, 1440

2483, 3190

7670, 7803

1462, 1914

1930, 2004

30,183

159,130

32881

Discharge summary

report

Admission Date: [**2155-7-31**] Discharge Date: [**2155-8-2**] Date of Birth: [**2120-11-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 2080**] Chief Complaint: hyperkalemia Major Surgical or Invasive Procedure: none History of Present Illness: History of Present Illness: Pt is 34 yo M w/ pmh of ESRD on HD, poorly controlled HTN who presented to the ED w/ a complaint of chest pain. According to the Pt, he awoke this afternoon with substernal chest pain, without radiation, consistent w/ previous episodes that he had in the past. The Pt took 4 sublingal NG and presented to the ED where he was found to be hyperkalemic to 8.1, with ECG changes. In the ED the Pt was chest pain free, and subsequently had an episode of monomorphic Vtach, with pulse, confirmed by ECG. The patient maintained pulse through the entire episode and he was given 2 rounds of insulin 10u IV, 1 amp D50, along with 2 amps bicarbonate and 2 amps Ca gluconate. . Initial vitals in the ED were T 98, BP 127/72, HR 55, 100% RA. Vitals after intervention were T 98.6 P 70 BP 136/83 R 14 O2 99% sat. At the time of interview Pt was undergoing hemodialysis, somnolent and arousable but uncooperative with interview, so information has been obtained from prior notes. . Upon arrival to the floor, Pt's vitals were T 98.4 HR 79 BP 144/91 RR 13 O2 Sat 100% RA. . Review of systems: unable to be obtained, as Pt somnolent and uncooperative with interview Past Medical History: - HTN dx in [**2147**] at age 28 (in Jail), Urgency in [**2151**], lost to follow up and then presented with N/V in Renal Failure in [**2152**]. - ESRD secondary to HTN - started on MWF dialysis in [**12/2152**] - Left Brachiocephalic AVF placed in [**2153**] (after permacaths) - h/o medication non-compliance - h/o substance abuse - h/o right internal jugular vein thrombus associated with HD catheter - h/o pulmonary edema in the setting of hypertensive urgency - h/o intubation in the setting of hypertensive urgency/flash pulmonary edema - dyslipidemia on statin - s/p appendectomy with emergent ex-lap for post-op leak/abcess - multiple admissiona and ED visits for chest pain Social History: He used to work as a plasterer, but is now on disability. Mother died 4 months ago. Tobacco: 1PPD x 20 years, currently 3 cigarettes a day. EtOH/Drugs: Denies recent alcohol, cocaine and marijuana use. Family History: There is no family history of premature coronary artery disease or sudden death. Father - Died at age 36 from unknown cancer Mother - Died at age 58 of MI, had HTN Maternal grandmother - on hemodialysis for end-stage renal disease. Physical Exam: ADMISSION Vitals: T: 98.4 BP: 144/91 P: 79 R: 13 O2: 100 RA General: somnolent but arousable, oriented, no acute distress, currently receiving dialysis and uncooperative with interview and exam 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 Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE Vitals: 98.0, 140/88, 60, 11, 95%RA General: pleasant, NAD, AAO3 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, enlarged/nondisplaced PMI Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Fem line site Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION [**2155-7-31**] PLT COUNT-217 NEUTS-73.7* LYMPHS-17.5* MONOS-6.8 EOS-1.2 BASOS-0.8 WBC-6.6 RBC-4.48*# HGB-12.6*# HCT-39.9*# MCV-89 MCH-28.1 MCHC-31.5 RDW-17.3* CALCIUM-8.6 PHOSPHATE-8.3*# MAGNESIUM-2.2 CK-MB-8 cTropnT-0.11* CK(CPK)-884* estGFR-Using this GLUCOSE-55* UREA N-46* CREAT-10.7*# SODIUM-139 POTASSIUM-8.1* CHLORIDE-91* TOTAL CO2-22 ANION GAP-34* GLUCOSE-58* LACTATE-2.8* NA+-138 K+-9.1* CL--86* TCO2-30 [**Name (NI) 7802**] TOP PT-12.9 PTT-28.8 INR(PT)-1.1 PLT COUNT-206 NEUTS-77.5* LYMPHS-17.1* MONOS-4.8 EOS-0.2 BASOS-0.4 WBC-5.8 RBC-4.11* HGB-11.3* HCT-35.3* MCV-86 MCH-27.5 MCHC-31.9 RDW-17.2* GLUCOSE-134* UREA N-48* CREAT-10.6* SODIUM-143 POTASSIUM-4.4 CHLORIDE-91* TOTAL CO2-30 ANION GAP-26* LACTATE-2.2* K+-4.2 GLUCOSE-172* K+-4.5 SUBSEQUENT LABS [**2155-8-1**] 06:28AM BLOOD WBC-6.1 RBC-4.04* Hgb-10.9* Hct-35.3* MCV-88 MCH-27.0 MCHC-30.9* RDW-17.2* Plt Ct-200 [**2155-8-1**] 06:28AM BLOOD PT-12.7 PTT-29.7 INR(PT)-1.1 [**2155-8-1**] 06:28AM BLOOD Glucose-139* UreaN-17 Creat-6.0*# Na-141 K-4.3 Cl-93* HCO3-35* AnGap-17 [**2155-8-1**] 09:05AM BLOOD K-4.3 [**2155-8-1**] 04:25AM BLOOD K-3.9 [**2155-7-31**] 08:00PM BLOOD Glucose-134* UreaN-48* Creat-10.6* Na-143 K-4.4 Cl-91* HCO3-30 AnGap-26* [**2155-7-31**] 07:00PM BLOOD cTropnT-0.11* [**2155-8-1**] 09:05AM BLOOD CK-MB-PND cTropnT-PND [**2155-8-1**] 09:05AM BLOOD CK(CPK)-PND [**2155-8-1**] 06:28AM BLOOD Calcium-8.5 Phos-5.7*# Mg-1.6 CXR 9/3/9 The lungs are clear without consolidation or edema. The mediastinum is unremarkable. The cardiac silhouette is top normal for size with a left ventricular configuration. No effusion or pneumothorax is noted. A large rim calcified structure again projects within the right upper quadrant, stable across multiple prior studies. No effusion or pneumothorax is seen. A healed posterior left rib fracture is incidentally noted. Brief Hospital Course: SUMMARY This is a 34 yo M w/ hx ESRD on HD, HTN, medication non-compliance, substance abuse, and multiple recent hospital admissions for CP who presented to the ED after an episode of CP and was found to be hyperkalemic to 8.1, and subsequently had an episode of monomorphic Vtach, with sustained pressures. He was treated by resolving the underlying condition: fluids, ca-gluconate and insulin. He was dialyzed twice and responded wonderfully. He spent one night in the MICU and was called out. On the floor, his EKG's showed persistent repolarization abnormalities that were sufficiently concerning that we kept him an extra night. We reviewed the EKG's and the consensus was that these abnormalities, which crossed territories and occurred in the absence of symptoms, were related to the resolving electrolyte disturbance of his presentation. He was discharged to follow up early the following week BY PROBLEM #Hyperkalemia: Pt currently undergoes dialysis MWF and according to the Pt he was dialyzed the day before admission. Although the Pt has a hx of non-compliance w/ medication and follow-up, if the Pt was dialyzed yesterday this level of hyperkalemia 1 day after dialysis is surprising and likely comes in the setting of a significant Potassium load by diet. At the time of arrival to the floor, Pt's Potassium had resolved to 4.4. A nutrition consult was ordered, but he was also educated on potassium containing foods by the team. Serial labs and EKGS as above. # Ventricular Tachycardia: Occured in the setting of hyperkalemia. Followed on tele and serial EKGs. Resolved with electrolyte normalization but left him with subtle repolarization abnormalities. . # Hypertension Held home anti-hypertensives this evening as Pt is being dialyzed. Restarted home antihypertensive regimen [**2155-8-1**] AM w/ appropriate holding parameters. Also level of Pt compliance w/ medications is unclear. A great deal of time was spent in education . # Substance abuse and social issues - Pt unwilling to answer question of most recent use of ETOH and cocaine. But endorses that he continues to abuse substances. Talking with the patient, it is clear that he knows the consequences of his actions and acknowledges that he is not ready to mature. We talked about how with CKD, his ability to 'bounce back' is and his days of tolerating drugs/alcohol with such minimal consequences are limited. He agrees. He says that soon he will 'shape up' and pursue sobriety in effort to acquire a transplant. He also says that the primary reason for the delay in this process is that he has not been impressed by the results of kidney transplantation by the recipients he meets in the community and at Dialysis. TO BE RESOLVED OUTPATIENT 1) Hyperkalemia - must be followed; reinforce dietary education 2) Substance Abuse - education, counselling, support Medications on Admission: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 6. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. PhosLo 667 mg Capsule Sig: Two (2) Capsule PO three times a day. 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 3. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 doses. 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Home Discharge Diagnosis: PRIMARY Hyperkalemia Ventricular Tachycardia SECONDARY ESRD on HD HTN Substance Abuse Discharge Condition: afebrile, ambulating, tolerating regular diet Discharge Instructions: You were admitted for chest pain and abnormal heart rhythm. This was caused by high potassium. Your potassium most likely came from something you ate or took in. We kept you to monitor your heart and check for damage. You must avoid eating too many foods that are high in potassium. You must also continue taking your high blood pressure medicines as well as making your dialysis sessions If you should experience severe chest pain, light headedness, severe nausea/vomitting, then return to the hospital. FOODS WITH HIGH POTASSIUM Dried fruits: raisins, prunes, apricots, dates Fresh fruits: bananas, strawberries, watermelon, cantaloupe, oranges Fresh vegetables: beets, greens, spinach, peas, tomatoes, mushrooms Dried vegetables: beans, peas Fresh meats: [**Country 1073**], fish, beef Fresh juices: [**Location (un) 2452**] Canned juices: grapefruit, prune, apricot FOLLOW UP 1) Primary Care: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2155-8-6**] 3:25; call to reschedule if problems Followup Instructions: Primary Care: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2155-8-6**] 3:25; call to reschedule if problems. [**Name (NI) **] try to reach you for reschedule as well FOODS WITH HIGH POTASSIUM Dried fruits: raisins, prunes, apricots, dates Fresh fruits: bananas, strawberries, watermelon, cantaloupe, oranges Fresh vegetables: beets, greens, spinach, peas, tomatoes, mushrooms Dried vegetables: beans, peas Fresh meats: [**Country 1073**], fish, beef Fresh juices: [**Location (un) 2452**] Canned juices: grapefruit, prune, apricot Completed by:[**2155-8-16**]

[ "276.7", "585.6", "403.91", "412", "427.1", "V45.12", "305.00", "305.60" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

10410, 10416

5777, 8624

329, 335

10547, 10595

3896, 5754

11714, 12353

2493, 2726

9484, 10387

10437, 10526

8650, 9461

10619, 11691

2741, 3877

1475, 1548

277, 291

391, 1456

1570, 2256

2272, 2477

65,454

134,207

45760

Discharge summary

report

Admission Date: [**2103-2-20**] Discharge Date: [**2103-2-22**] Date of Birth: [**2041-9-26**] Sex: F Service: MEDICINE Allergies: Ceclor / Antihistamines / Penicillins / Kiwi (Actinidia Chinensis) / Egg / All Antibiotics Attending:[**First Name3 (LF) 2297**] Chief Complaint: Diverticulitis Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 61 F with a history of asthma, allergies, and fibromyalgia who is admitted to the MICU for desensitization to antibiotics for medical management of diverticulitis. Her symptoms began a little over a week ago with "cramping" abdominal pain "all over" the abdomen and several episodes of loose stool (no blood). She had a general feeling of stomach upset but no nausea/vomiting. Her husband had similar symptoms initially so she assumed she had some sort of gastroenteritis. However, his symptoms subsequently improved, while hers intensified over the following days, until Sunday (two days prior to admission) she had such pain after eating even a small amount at her granddaughter's birthday party that she cried. On Monday (yesterday), she went to see her PCP who referred her to her gastroenterologist Dr. [**Last Name (STitle) 2161**], who has performed past colonoscopies. She saw him at ~3:00 PM yesterday, and he ordered bloodwork and CT abdomen, which revealed WBC elevated to 13 and evidence of diverticulitis on CT. He called her this morning to come into the ED. Because of her allergies to multiple antibiotics, she was admitted to the medical ICU for desensitization. Yesterday she was told to try BRAT diet, so she ate two pieces of toast and some baby bananas yesterday, and a part of a piece of toast today, but otherwise no PO intake. . Of note, she did have a prior episode of diverticulitis 20+ years ago. She states that she cannot remember the exact presentation to determine whether this is similar or not. More recently, she has had abdominal pains related to her fibromyalgia, but she does not think she has had other diverticulitis flares. . Upon arrival to the ED vitals were T 98.4, HR 83, BP 152/63, RR 18, 100% on RA. She received total of 8 mg IV morphine for pain control (initially [**9-17**]). Pelvic US was done to better evaluate ovarian cyst seen on CT with recommendation for further assessment with MR as outpatient. She received 1L IVF in ED. ID consult team was verbally contact[**Name (NI) **] regarding antibiotic choice, but no formal consult was initiated. Vitals prior to transfer to the MICU were T 97.6, BP 124/66, HR 88, RR 16, 95% on RA. . With regard to her allergic history, she has reacted to virtually every antibiotic she has had in the past. She has reported history of reaction to penicillin, bactrim, quinolones (cipro and levo), cephalosporins (ceclor). Reactions have typically included pruritis beginning on face associated with swelling (not immediately, but within a few hours of dosing) of face and lips. She has not experienced throat swelling or anaphylaxis. . REVIEW OF SYSTEMS: (+)ve: As per HPI. Chronic aches from fibromylagia in trunk, limbs. Occasional cough (related to detergents, perfumes), allergic rhinitis but no recent URI. (-)ve: fever, chills, night sweats, fatigue, chest pain (except as related to her chronic pain from fibromyalgia), palpitations, sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency (except as is usual for her, no changes), focal numbness, focal weakness. Past Medical History: - Multiple medication allergies - Allergic rhinitis, conjunctivitis, cough to perfumes/detergents - Asthma (2 prior ED visits but no intubation; last course prednisone [**2085**]) - Migraine headaches - Fibromyalgia (since [**2086**]) - Hypertension - GERD - Hypercholesterolemia - Urinary incontinence (stress) . PAST SURGICAL HISTORY: - "Stomach stapling" (exact surgery unknown) ~25 years ago - Monarch transobturator suburethral sling [**2099**] (intubation for procedure complicated by damage to vocal cords with resulting hoarseness x several months) - Cardiac catheterization, no stents placed Social History: Married with two adult sons. Lives with her husband and [**Name2 (NI) 1685**] son. [**Name (NI) **] older son has two daughters. She works as a psychologist specializing in victims of violent crime. She is a former smoker but quit 11 years ago. She has never been a drinker of alcohol. She has no history of IVDU or other recreational drugs. Family History: Two sons and father have asthma and allergies. Mother had diabetes. Father died age 69 of heart disease, brother died of MI age 43, sister had open heart surgery in her late 50s. Father also had food allergies. Physical Exam: ADMISSION: GEN: Resting in bed, easily rousable, NAD HEENT: PERRL, EOMI, OP clear, MMM NECK: Supple, normal JVP PULM: CTA bilaterally CARD: RRR, 2/6 SEM at base ABD: Soft/obese, TTP concentrated in LLQ and epigastric region, +NABS, no rebound/guarding EXT: 2+ DP pulses bilaterally, non-pitting ankle edema SKIN: Clear PSYCH: Anxious; has difficult time with pharmacist taking medications to dispense own meds Discharge examination notable for improved abdominal pain, otherwise unchanged. Pertinent Results: LABS ON ADMISSION: [**2103-2-19**] 04:05PM PLT COUNT-316 [**2103-2-19**] 04:05PM NEUTS-74.6* LYMPHS-17.5* MONOS-4.9 EOS-2.3 BASOS-0.6 [**2103-2-19**] 04:05PM WBC-13.0* RBC-4.35 HGB-13.5 HCT-40.1 MCV-92 MCH-31.0 MCHC-33.6 RDW-12.4 [**2103-2-19**] 04:05PM estGFR-Using this [**2103-2-19**] 04:05PM UREA N-8 CREAT-0.5 SODIUM-142 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-30 ANION GAP-14 [**2103-2-20**] 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2103-2-20**] 02:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004 [**2103-2-20**] 03:43PM PLT COUNT-326 [**2103-2-20**] 03:43PM NEUTS-64.2 LYMPHS-27.6 MONOS-5.5 EOS-2.1 BASOS-0.7 [**2103-2-20**] 03:43PM WBC-8.3 RBC-4.17* HGB-13.4 HCT-38.0 MCV-91 MCH-32.1* MCHC-35.3* RDW-12.6 [**2103-2-20**] 03:43PM GLUCOSE-107* UREA N-7 CREAT-0.5 SODIUM-140 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-30 ANION GAP-15 CT ABD & PELVIS W/O CONTRAST Study Date of [**2103-2-19**] 4:04 PM IMPRESSION: 1. Findings consistent with acute sigmoid diverticulosis. Noting wall thickening throughout the area, if not recently performed, colonoscopy should be considered in follow-up. 2. Large cystic left ovarian lesion, which is not fully characterized by non-contrast CT. Further characterization with pelvic ultrasound is recommended. 3. Dilatation and wall thickening of the distal esophagus, probably inflammatory. The presence of contrast in the distal esophagus is suggestive either of associated dysmotility or possibly reflux. 4. Status post Roux-en-Y gastric bypass surgery. The presence of contrast within the excluded portion of the stomach suggests a leak across the staple line. PELVIS LIMITED Study Date of [**2103-2-20**] 3:41 PM PELVIS U.S., TRANSVAGINAL Study Date of [**2103-2-20**] 3:41 PM IMPRESSION: An 8.8 x 9.4 x 6.4 cm left adnexal simple cyst, further assessment with MR is recommended. Brief Hospital Course: 61 F with a history of multiple medication allergies and one prior episode of diverticulitis who presents with abdominal pain and CT evidence of non-complicated diverticulitis. Admitted to medical ICU for desensitization to Augmentin for treatment. ACTIVE ISSUES: #. Diverticulitis. Noted on CT scan as above. Has known history of diverticulosis with one prior episode of diverticulitis decades ago, conservatively managed. Patient appeared clinically well, non-acute abdomen, tolerating pain. She was managed with IVF, pain control (of note, felt flushed in response to morphine; was offered dialudid as does not cause histamine release, but declined). She was kept NPO overnight to minimize risk of aspiration in the event that intubation was required during desensitization protocol. She was transitioned to clears and then BRAT diet on hospital day #2. She was desensitized to Augmentin as below with plan for one week course. #. Desensitization to Augmentin. Patient has seen an allergist Dr. [**Last Name (STitle) **] at [**Hospital1 112**] twice in the past for this issue. Antibiotic desensitization to a 3rd generation cephalosporin was recommended in the past, but patient never went through with procedure. Has not had antibiotics in ~15 years. Patient is very wary of medications and states she would generally prefer to have pain/discomfort than to risk a medication. Allergy consult was called, and in conjunction with the patient the decision was made to proceed with desensitization to Augmentin. The protocol was modified to begin with a quarter of the usual protocol dose and to include hydroxyzine instead of benadryl. Desensitization was uneventful and concluded with 500 mg dose (plan for 500 mg PO TID at discharge). However, peripheral eosinophil count rose to 9.1% on differential. Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] regarding this admission. #. Anxiety. Patient is upset that the hospital policy on dispensing home medications involves taking her pills/bottles. She is reluctant to give up medications but also does not want to take hospital formulary meds as may be from different manufacturer -> increased risk of allergic reaction. She took her own alprazolam off formulary but did inform nurses that she had done so. INACTIVE ISSUES: #. Hypertension. Currently normotensive. Continued home Zestril. #. Hypercholesterolemia. Patient's home Zocor pills are unmarked with regard to dose; she was therefore unable to take her own pills without submitting them to the unit omnicell for storage. She did not want to take generic simvastatin for fear of reaction and was unwilling to submit her own Zocor to the omnicell so this medication was held. #. Ovarian cyst. Pelvic ultrasound done in ED as above. Recommendation for MR as outpatient. #. Gastric fistula/leak across the staple line. Noted on CT. Per Dr.[**Name (NI) 55237**] note, he is aware and will plan for further follow up in [**1-11**] months. CODE STATUS: Confirmed full EMERGENCY CONTACT: [**Name (NI) **] [**Name (NI) **] will be HCP (has been her sister in the past, but she would like it to be her son) [**Telephone/Fax (1) 97505**]. Husband [**Name (NI) **] is [**Telephone/Fax (1) 97506**]. TRANSITIONAL CARE: - Patient noted to have large left adnexal cyst on CT imaging. Follow up pelvic ultrasound done as above with recommendation for MRI. Patient scheduled for follow up with OBGYN in [**Hospital1 18**] system. - Leak across gastric bypass staple line noted on CT imaging. Patient will follow up with Dr. [**Last Name (STitle) 2161**] for further management. [**2-21**] --Contact[**Name (NI) **] patient's outpatient allergist, Dr. [**Last Name (STitle) **] [**Name (STitle) 97507**] is to proceed with desensitization, but only using a quarter of the protocol dose --Patient will get hydroxyzine instead of benadryl --Anxious but clinically stable Medications on Admission: - Alprazolam 0.5 mg PO BID - Zocor (name brand only) 40 mg PO daily - Zestril (name brand only) 20 mg PO daily - Zantac (name brand only) 75 mg PO BID - Multivitamin 1 tab PO daily - Calcium PO daily - Vitamin D PO daily - Vitamin E PO daily Discharge Medications: 1. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three times a day for 6 days. Disp:*21 Tablet(s)* Refills:*0* - Alprazolam 0.5 mg PO BID - Zocor (name brand only) 40 mg PO daily - Zestril (name brand only) 20 mg PO daily - Zantac (name brand only) 75 mg PO BID - Multivitamin 1 tab PO daily - Calcium PO daily - Vitamin D PO daily - Vitamin E PO daily Discharge Disposition: Home Discharge Diagnosis: Augmentin desensitization Acute uncomplicated diverticulitis Discharge Condition: Stable Discharge Instructions: You will take augmentin 500mg three times daily for a total of 6 additional days. Please take 500mg tonight at 9pm. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] L. Location: [**Location (un) 4499**] INTERNAL MEDICINE Address: [**Apartment Address(1) 97508**], [**Location (un) 4499**],[**Numeric Identifier 4501**] Phone: [**0-0-**] Appointment: Monday [**2103-2-26**] 12:00pm Department: OBSTETRICS AND GYNECOLOGY When: TUESDAY [**2103-3-27**] at 1:30 PM With: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 15653**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DIV. OF GASTROENTEROLOGY When: MONDAY [**2103-5-28**] at 11:45 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2163**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Completed by:[**2103-2-23**]

[ "V45.86", "401.9", "493.90", "V14.1", "562.11", "V07.1", "E878.8", "300.00", "998.6", "620.2", "530.81", "729.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11878, 11884

7315, 7565

366, 373

11989, 11998

5356, 5361

12162, 13106

4618, 4830

11495, 11855

11905, 11968

11228, 11472

12022, 12139

3976, 4242

4845, 5337

3076, 3617

312, 328

7581, 9589

401, 3057

9607, 11202

5375, 7292

3639, 3953

4258, 4602

22,646

145,098

9202

Discharge summary

report

Admission Date: [**2124-12-6**] Discharge Date: [**2124-12-18**] Date of Birth: [**2061-12-3**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 3266**] Chief Complaint: ascites Major Surgical or Invasive Procedure: Paracentesis x 2 Unsuccessful TIPS x 2 Hepatic artery arterogram Central line placement History of Present Illness: 63 M with cryptogeneic cirrhoiss with complications of hepatic encephalopathy, varicies, CAD, DM 2, who presents with 3-4 weeks of increasing abd girth. He has had 2 prior taps, one with 8 L removed another 3 weeks ago with 6 L removed. Three days prior he fell on his back with no LOC, some LBP. He denies jaundice, confusion, tremor or change in bowel habits. Mild nausea this morning but no vomiting. No F/C/SOB/CP. In past, he has had SOB when ascites was even greater. No LE edema or cough. Frustrated by poor medical options given his liver disease and concominant heart disease. Came from home for further evaluation and possible TIPS procedure. Of note, his liver disease was found after he had bloody emesis in [**2117**]. ROS: no neuro finding, no change in appetite, no wt loss, no GU sxs Past Medical History: 1. Cryptogenic Cirrhosis (from Dr.[**Initials (NamePattern4) 1369**] [**Last Name (NamePattern4) **] note [**1-2**]) [**10/2118**] liver bx: portal and periportal PMN inflammation grade 2, periportal and portal fibrosis stage 3 [**3-30**] liver bx: grad 2 portal and periportal PMN,, mildly predominant macrovasc. statosis and inc in portal and focal periportal fibrosis (stage 2-3) [**6-1**] EGD: recurrent espoh. varicies, 4 bands placed, portal gastropathy [**11-1**] MRI: mod cirrhosis with splenomegaly and splenic varicies, perihep/splenic fluid, nonoccl thrombus in med [**Last Name (un) **] of left portal and ant branches of right protal vein, 4mm arterial ehancement in right liver lobe [**12-1**] CT abd: espohageal, gastrohepatic, [**Last Name (un) 22392**]. varicies, cirrhosis, splenomegaly, min ascites, cholelithiasis, simple right kidney cortical cyst 2. DM 2 with neuropathy 3. Sinusitis 4. Depression 5. CAD: at [**Hospital3 **] had positive stress test, cath showed 3 VD, no intervention PSH: 1. right knee surgery in 9/00 2. ACL repair [**3-30**] 3. Right cataract surgery in [**9-1**] Social History: College educated with degree in chemistry. Worked as a plant manager for many years, short term jobs since then for 10 yrs, now on full time disability, 3 children, sons 37, 24; daughter 32; married for 37 years to current wife Family History: NC Physical Exam: Temp 97 4 BP 100/60 Pulse 79 Resp 18 O2 sat 100% RA Gen - Alert, no acute distress, tired HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes moist Neck - JVP 7 cm, no cervical lymphadenopathy Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - + BS, distanded abd, + fluid wave, NT, uable to feel liver or spleen on exam, marked "X" for tap Back - No costovertebral angle tendernes, non tender spine, no ecchymosis Extr - No clubbing, cyanosis, trace ankle edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, cranial nerves [**2-10**] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact, no asterixis Skin - No rash Pertinent Results: Abd U/s: IMPRESSION: 1. Large amount of abdominal ascites. An appropriate spot was marked on the skin for a paracentesis to be performed by the hepatology service. 2. Findings consistent with liver cirrhosis. Markedly diminutive main portal vein with demonstration of slow hepatopetal flow. Patent hepatic arteries and veins, as discussed above 3. Cholelithiasis. * Cytology for Peritoneal fluid: NEGATIVE FOR MALIGNANT CELLS. * Echo: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 60-70%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. * MRI abd: 1) Cirrhotic liver without focal mass. 2) Partial thrombus within the SMV and extrahepatic main portal vein with some extension its very proximal portion in the hilum. Patent intrahepatic portal venous radicles. Features of portal hypertension as described above. Gallstones without evidence of cholecystitis or choledocholithiasis. * Abd U/S: 1. Cirrhosis. 2. Large amount of ascites. 3. Normal flow in the main and right hepatic arteries. 4. Patent but diminutive portal vein with slow hepatopedal flow. The findings are stable from the prior ultrasound and are consistent with recent MRI findings of nonocclusive portal vein thrombus. * Peritoneal fluid anlaysis: [**2124-12-7**] 09:13AM ASCITES TotPro-1.7 Glucose-137 Creat-0.9 LD(LDH)-76 Amylase-16 TotBili-0.3 Albumin-<1.0 Triglyc-75 [**2124-12-7**] 10:30AM ASCITES Triglyc-74 [**2124-12-7**] 09:13AM ASCITES WBC-112* RBC-1370* Polys-1* Lymphs-79* Monos-18* Mesothe-2* [**2124-12-18**] 11:44AM ASCITES WBC-133* RBC-[**Numeric Identifier 28647**]* Polys-5* Lymphs-67* Monos-22* Eos-1* Mesothe-2* Macroph-2* Other-1* * Urine cx and peritoneal fluid cx pending at time of summary * Labs: [**2124-12-6**] 11:10AM PT-14.9* INR(PT)-1.4 [**2124-12-6**] 11:10AM PLT COUNT-116* [**2124-12-6**] 11:10AM ANISOCYT-1+ MICROCYT-1+ [**2124-12-6**] 11:10AM NEUTS-70.9* LYMPHS-17.0* MONOS-8.5 EOS-3.0 BASOS-0.5 [**2124-12-6**] 11:10AM WBC-4.1 RBC-4.15* HGB-12.3* HCT-35.0* MCV-84 MCH-29.6 MCHC-35.0 RDW-16.3* [**2124-12-6**] 11:10AM AFP-2.9 [**2124-12-6**] 11:10AM ALBUMIN-3.2* CALCIUM-8.3* [**2124-12-6**] 11:10AM ALT(SGPT)-15 AST(SGOT)-29 ALK PHOS-130* TOT BILI-0.7 [**2124-12-6**] 11:10AM UREA N-21* CREAT-1.1 SODIUM-133 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-24 ANION GAP-12 [**2124-12-6**] 11:10AM GLUCOSE-200* [**2124-12-18**] 06:25AM BLOOD WBC-3.8* RBC-3.76* Hgb-10.9* Hct-31.6* MCV-84 MCH-28.9 MCHC-34.3 RDW-16.7* Plt Ct-104* [**2124-12-18**] 06:25AM BLOOD Plt Ct-104* [**2124-12-18**] 06:25AM BLOOD Glucose-72 UreaN-19 Creat-1.0 Na-136 K-3.7 Cl-107 HCO3-23 AnGap-10 [**2124-12-18**] 06:25AM BLOOD ALT-17 AST-29 AlkPhos-143* TotBili-0.8 [**2124-12-18**] 06:25AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9 [**2124-12-7**] 05:55AM BLOOD Triglyc-143 [**2124-12-6**] 11:10AM BLOOD AFP-2.9 Brief Hospital Course: A and P/ 63 M with crytpogeneic liver disease with multiple complications in the past, who has recurrent ascites, and unfortunately due to his 3 VD CAD and several thromboses, he is not a transplant candidate. 1. Liver disease: Pt arrived and was tapped on HD 2 with 8 L fluid removed with albumin replacement. Studies were sent which were negative for cytology, micro, and cell ct did not suggest SBP. An MRI abd showed multiple portal vein clots with some flow. The study was reviewed with IR and it was determined a TIPS could be attempted. After several days, a TIPS was attemepted under GETA with anaesthesia consult given pts 3 VD CAD; the pt was consented tolerated the procedure well however the TIPS was not sucessfully completed. A venogram was obtained which showed no bleeding. Pt had no residual hematoma or complications from femoral vessels being accessed. Liver team and IR reviewed the films again and it decdied that a second attempt at TIPS would be tried a day later with a different approach. Dr. [**Last Name (STitle) 19420**], IR attending tried to perform the procedure under GETA, however was unsuccessful. The hepatic artery was punctured, a stent placed, and angiogram did not show any bleeding. He was trasnferred to the MICU for o/n observation throughout which he was stable. He was then trasnferred to the floor day prior to d/c. Day of d/c a large volume paracentesis was performed (8 L), studies sent, and 50 gm albumin infused post procedure. A pressure dressing applied to site for possible leakage as a large incision was needed to access the fluid. LFTs and bilibrubin remain stable throughout his stay. He was maintained on flagyl, lactulose. He will have liver clinic follow up in [**12-31**] weeks for repeat tap. He was also evaluated by surgery for possible portocaval shunt, however this option was no elected at this time as it would not be the safest for him. He was d/c'd home on lasix and spironolactone. 2. CAD: Stable at present. 3 Vd prvents pt from having a liver transplant. Zetia continued, [**Date Range **] held for TIPS and then restarted per IR. 3. DM 2: Controlled on NPH and SS insulin, FS qid, diabetic diet. NPH doses were reduced when pt was NPO. 4. Depression: Effexor and provigil continued. SW consulted for support and coping. Pt was often sad and frustrated by his course of care, patient advocate alos involved. 5. Back pain: [**1-31**] to fall priro to admission. No neuro defects. Tramadol prn. 6. Full code 7. Dispo: Pt was sent home with liver clinic follow up. He was advised against any long distance travel. D/cd with VNA at home with instructions. 8. TIPS complication: 2nd TIPS attempt complicated by artery puntcutre which was deemed stable. IR Dr[**Name (NI) 31618**] secretary to call pt about f/u US and appt with Dr [**Last Name (STitle) 19420**] in clinic. Medications on Admission: effexor 75 mg qd/37.5 mg prn, flagyl 250 mg [**Hospital1 **], ambien 10 mg [**Last Name (LF) **], [**First Name3 (LF) **], zetia 10 mg qd, provigel 100 mg qd, prevacid 30 mg [**Hospital1 **], lactulose 60 cc qd, NPH 46 u qam/44 u qhs, SS humalog; aldactone and lasix d/c ([**11-26**]) Discharge Medications: 1. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 2. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 7. Lactulose 10 g/15 mL Syrup Sig: Sixty (60) ML PO DAILY (Daily). 8. Modafinil 100 mg Tablet Sig: One (1) Tablet PO qd (). 9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Propranolol HCl 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Tramadol HCl 50 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Modafinil 100 mg Tablet Sig: One (1) Tablet PO qd (). 13. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: 1. Ascites 2. Coronary artery disease 3. Diabetes 4. Depression 5. Back pain Discharge Condition: Good Discharge Instructions: If you have chest pain, shortness of breath, fevers/chills, increasing wt/ascities, please call your PCP or come to the ED. 1. Take all meds 2. Daily wts 3. Low Na diet 4. Attend f/u appointments 5. Per IR fellow Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], can restart [**Last Name (NamePattern4) **] Followup Instructions: Please call your PCP for [**Name Initial (PRE) **]/u in 1 week Liver clinic: Please call [**Telephone/Fax (1) 24157**] to book a f/u appt in early [**Month (only) 404**]. Radiology: You will be contact[**Name (NI) **] by [**Name (NI) 31619**] staff to set up a f/u US and visit.

[ "572.3", "250.60", "357.2", "414.01", "456.21", "998.2", "789.5", "285.9", "571.5", "452" ]

icd9cm

[ [ [] ] ]

[ "38.93", "54.91", "39.90", "88.47", "99.04" ]

icd9pcs

[ [ [] ] ]

11077, 11148

6738, 9587

290, 380

11269, 11275

3375, 6715

11648, 11937

2605, 2609

9922, 11054

11169, 11248

9613, 9899

11299, 11625

2624, 3356

243, 252

408, 1211

1233, 2344

2360, 2589

30,153

176,169

33326+57844

Discharge summary

report+addendum

Admission Date: [**2176-4-5**] Discharge Date: [**2176-4-13**] Date of Birth: [**2093-8-24**] Sex: F Service: MEDICINE Allergies: Levaquin Attending:[**First Name3 (LF) 1828**] Chief Complaint: decreased responsiveness Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 77355**] is an 82 year old female with history of remote breast CA, alcoholic cirrhosis, s/p AVR who was last seen in normal health at 7PM on the evenig prior to admission. On the morning of admission, the patient was found by her roommate slumped over, fully dressed in bed. The patient is reported by EMS records to have been supine in bed, awake, but unresponsive to verbal or painful stimuli, additionally noted to be incontinent of urine and feces. When EMS arrived patient's vitals were 110/64 86 100% RA, unclear RR. The patient was initially sent to [**Hospital 8125**] hospital where she was intubated for airway protection. ABG prior to intubation was 7.42/27/370 on a NRB. Per report the patient was vomiting prior to arrival and prior to intubation. The patient had a CT head which revealed no acute process and had a normal CXR. Given history of distant breast CA a CTA was performed which revealed no evidence of PE or metastatic disease but did reveal a cirrhotic appearing liver and small ascites on abdominal cuts. The patient had a tox screen which was normal. . Per discussion with the patient's family she has been generally in her usual state of health. She has had a few recent med changes including increase in her Xanax dosing from once daily to three times daily approximately 2-3 weeks ago. She has no known history of seizure disorder or large stroke although has had history of microvascular disease. She has not had episodes of hepatic encephalopathy previously, is not currently maintained on lactulose. . ED Course: The patient was maintained on Propofol, reported to be waking up off sedation. The patient was given Levo/Vanc, ceftriaxone for potential infectious etiologies. Past Medical History: #. Breast Cancer - s/p right mastectomy - no recurrent disease known to date #. Alcoholic Cirrhosis - quit ETOH > 10 years ago #. Aortic stenosis s/p AVR #. COPD #. MDS Social History: The patient currently lives in a home with a roommate in [**Hospital **] [**Location (un) 3320**]. She is generally independent in ADL, walks with a walker/cane and has a home health aide once a week. Tobacco: Distant, unclear amount ETOH: Previous history of abuse, thought clean x 10 years per family Illicts: None Family History: Non-contributory Physical Exam: Vitals: T- 99.8 100/50 HR: 96 Vent: AC 1.0 16 (overbreathing 5) x 500 . HEENT: NCAT. Pupils equal and reactive to light. OP: limited view secondary to ET tube. NG tube with clear fluid with some brown debris, trace gastroccult + Neck: JVp visible to 6-7 cm Chest: s/p Right mastectomy. Generally clear to auscultation anterior and posterior without rales, rhonchi or wheezes Cor: RRR, normal S1/S2. No obvious murmurs, rubs or gallops Abd: mod distended, obese, + umbilical hernia. Soft, no guarding with palpation. ? fluid wave Rectal: Performed in ED, brown trace guaiac+ stool Ext: no edema. Feet cool but not cold. DP 2+ bilaterally Neuro: Limited secondary to recent sedation. Patient currently off sedation x 10 minutes. Patient does not respond to voice. Does not open eyes spontaneously or to painful stimuli. Withdraws feet bilaterally to pain, does not respond to painful stimuli to upper extremities. Plantar reflexes: Equivocal bilterally Pertinent Results: [**2176-4-5**] 04:38PM WBC-8.8 RBC-3.40* HGB-11.8* HCT-35.7* MCV-105* MCH-34.6* MCHC-32.9 RDW-16.0* [**2176-4-5**] 04:38PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2176-4-5**] 04:38PM TSH-2.4 [**2176-4-5**] 04:38PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-1.9 [**2176-4-5**] 04:38PM ALT(SGPT)-23 AST(SGOT)-83* ALK PHOS-94 AMYLASE-28 TOT BILI-1.8* [**2176-4-5**] 04:38PM GLUCOSE-109* UREA N-19 CREAT-0.9 SODIUM-148* POTASSIUM-4.3 CHLORIDE-112* TOTAL CO2-26 ANION GAP-14 . Admission ECG: Normal sinus rhythm with right bundle-branch block and occasional premature ventricular contractions. Non-specific ST-T wave abnormalities. No previous tracing available for comparison. . Admission Chest CT: CT OF THE CHEST WITH IV CONTRAST: An endotracheal tube is seen with the tip at 4.5 cm above the carina. An NG tube is also seen with the tip within the stomach. Breathing artifact degrades the quality of the study. The heart is enlarged. The pulmonary artery is normal in size. Ascending aortic graft is seen with no complication noted. There are no filling defects within the main pulmonary artery to the segmental and larger subsegmental branches to suggest pulmonary embolism. However, evaluation of the subsegmental branches is limited due to respiratory motion artifact. Atherosclerotic calcifications within the aorta. Small left- sided pleural effusion with associated compressive atelectasis. The patient is status post right mastectomy. There is suggestion of chronic sternal dehiscense. There is no mediastinal, hilar, or axillary lymphadenopathy. Small 12mm x 8mm focal density is within the central left breast. This study is not designed for the evaluation of the abdomen, however, the visualized portions of the upper abdomen demonstrate a cirrhotic liver, ascites, borderline enlarged spleen and collateral circulation. Tiny granuloma is seen within the spleen. BONE WINDOWS: No suspicious lytic or sclerotic lesions. IMPRESSION: 1. Limited study without evidence of central and segmental PE. 2. Small left-sided pleural effusion with associated atelectasis. 3. Cirrhotic liver, splenomegaly, and ascites, incompletely evaluated. 4. Small mass within the left breast, correlate with recent mammogram, if obtained. Else the pateint would need a formal diagnostic mamogram to evaluate this lesion further. . Admission MR [**Name13 (STitle) 430**]: TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images of the brain were obtained before gadolinium. T1 axial, sagittal and coronal images were obtained following gadolinium. There are no prior examinations for comparison. FINDINGS: Diffusion images demonstrate subtle area of slow diffusion involving both thalami. No cortical infarcts are identified. Pre-gadolinium T1 images demonstrate hyperintensities involving the basal ganglia, predominantly the globus pallidus and putamen, but also involvement of the upper brainstem. Multiple small foci of T2 hyperintensity indicative of mild- to-moderate changes of small vessel disease also identified. Following gadolinium, no abnormal parenchymal, vascular, or meningeal enhancement seen. There is a fluid level in the left maxillary sinus. IMPRESSION: 1. Subtle slow diffusion identified in both thalami could be secondary to global hypoxic event. Clinical correlation recommended. If indicated, a followup examination can help for further assessment. 2. Increased T1 pre-gadolinium signal in basal ganglia could be secondary to hepatic insufficiency. 3. No enhancing brain lesions. 4. Mild-to-moderate changes of small vessel disease. Brief Hospital Course: Ms. [**Known lastname 77355**] is an 82 year old female admitted with decreased responsiveness ultimately attributed to non-convulsive status epilepticus. . #. Decreased Responsiveness: The exact cause of the pt's unresponsiveness and seizure activity remained unclear. There was some evidence on brain MR of changes associated with hypoxia. It was unclear whether these may have triggered the seizures or been a result of them; there was no obvious inciting event to cause respiratory failure. The pt was intubated at an outside hospital for airway protection and transferred to the MICU at [**Hospital1 18**]. A wide differential was considered however extensive laboratory testing was largely un revealing. The pt was seen and followed by the neurology service who made the diagnosis of non-convulsive status epilepticus via serial EEG. She was started on Dilantin. ***At the time of discharge, it was advised that the pt should be transitioned from Dilantin to Keppra. Per the neurology service, this should happen as follows: Dilantin was being given at 100 mg TID at discharge. This should be weaned by 100 mg a day over the next three to four days. Thus, on Sunday, [**2176-4-14**], would advise 100 mg [**Hospital1 **] of Dilantin. On the day of discharge, Keppra was started at 500 mg [**Hospital1 **]. This should be increased by 500 mg daily over the next three to four days to a total dose of 1500 mg [**Hospital1 **].*** If the pt experiences an acute mental status change in the future, consideration should be given to repeat seizure. The pt also continues to be treated with lactulose in case hepatic encephalopathy was contributing her condition. It is expected that this can likely be discontinued in the next 1 to 2 weeks if the pt remains stable. . #. CHF: The pt is thought to carry a diagnosis of CHF based on her home medications, although there was limited data available in the [**Hospital1 18**] system. She was thought to be mildly volume up at admission and was started on low-dose Lasix; after this, she appeared clinically euvolemic throughout her course. The pt's home Coreg continued. Her home digoxin was held; this can likely be restarted in the near future. . #. Cirrhosis: The pt has a history of EtOH cirrhosis. Her most recent INR is 1.3. Her cirrhosis did not appear to be contributing to her clinical picture during her admission. . #. s/p AVR: Bioprosthetic, not on anticoagulation as outpatient. . # Contact: [**Name (NI) **]: [**Name (NI) **] [**Name (NI) 1193**] [**Telephone/Fax (1) 77356**] Daughter: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1193**] [**Telephone/Fax (1) 77357**] Medications on Admission: Digoxin .125mg daily Coreg 3.125mg [**Hospital1 **] Remeron 30mg qhs Duloxetine 30mg daily Xanax .25mg PO tid Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). 2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) 511**] Siani, [**Location (un) 86**] Discharge Diagnosis: Primary: decreased responsiveness non-convulsive seizures . Secondary: history of breast cancer alcoholic cirrhosis COPD CHF Discharge Condition: Vital signs stable. Without seizure activity. Overall improved. Discharge Instructions: -You were admitted with decreased responsiveness and found to be having non-convulsive seizures. We have treated you with anti-seizure medications. You are now being transferred to a rehab hospital for further care. -It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> Lactulose was started. --> Dilantin was started and is now being transitioned to Keppra. --> Lasix was started to help remove excess fluid from your body. --> Your Remeron and Xanax was held as these medications can cause sedation. Talk with your doctor about when or if to restart this. -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. Followup Instructions: Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 36604**] when you are discharged from rehab to schedule a follow-up appointment. Name: [**Known lastname 11310**],[**Known firstname 12535**] Unit No: [**Numeric Identifier 12536**] Admission Date: [**2176-4-5**] Discharge Date: [**2176-4-13**] Date of Birth: [**2093-8-24**] Sex: F Service: MEDICINE Allergies: Levaquin Attending:[**First Name3 (LF) 12537**] Addendum: On the CTA of the chest detailed above, a small mass was noted within the left breast. Correlation with a recent mammogram or acquisition of further imaging if needed is recommended. Discharge Disposition: Extended Care Facility: [**Location (un) **] Siani, [**Location (un) 42**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 12538**] MD [**MD Number(2) 12539**] Completed by:[**2176-4-13**]

[ "V42.2", "345.00", "780.09", "276.1", "305.03", "238.75", "V10.3", "401.9", "518.81", "571.2", "428.0", "285.29", "496", "611.72" ]

icd9cm

[ [ [] ] ]

[ "93.90", "96.72", "96.6", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

12495, 12731

7249, 9900

293, 299

10812, 10878

3607, 7226

11793, 12472

2602, 2620

10061, 10540

10664, 10791

9926, 10038

10902, 11770

2635, 3588

229, 255

327, 2058

2080, 2251

2267, 2586

41,016

182,698

26637

Discharge summary

report

Admission Date: [**2175-9-19**] Discharge Date: [**2175-10-12**] Date of Birth: [**2097-3-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 12**] Chief Complaint: neck pain Major Surgical or Invasive Procedure: anterior C4-6 diskectomy with anterior fusion and posterior fusion intubation extubation History of Present Illness: Mr. [**Known lastname **] is a 78 year old Cantonese speaking male with metastatic NSCLC proven by biopsy on [**2175-9-5**] admitted from clinic p/w severe [**8-27**] neck and intermittent R chest wall pain. Per the famly, the pain has progressed over the past 3 months and has acutely worsened over the past 3 days. The pt's wife also notes that the pt has had difficulty with his balance while walking during the past three days. The patient has also noted bilateraly UE numbness in the past 3 days as well. Previously seen by ortho, evaluated for anterior C5 questionable pathologic fracture; now wearing a soft neck brace for the past month. 10 lbs weight loss over the past month. Pt's family also notes clear rhinorrhea, productive cough w/ yellow sputum x past 2 weeks. Pain poorly controlled at home with tramadol, Tylenol with codeine. Was not able to tolerate MRI during ED workup [**12-20**] pain. He is being admitted to OMED from clinic via ED for pain control and expedited evaluation of his NSCLC and questionable pathologic cervical fracture. . Vitals in the ED were: Temp:99.9 HR:85 BP:179/112 Resp:16 O(2)Sat:98 RA. The patient received 10 mg morphine in ED with pain relief. Past Medical History: Past Oncologic History: NSCLC found after cervical compression fractures. . Other Past Medical History: 1. Hypertension for over 10 years, controlled 2. Hypercholesterolemia for over 5 years, controlled 3. Benign prostatic hypertrophy with some urologic symptoms 4. Possible Parkinson's disease (work-up not performed) 5. Osteoporosis by report. BMD not on file. Social History: The patient is originally from [**Country 651**]. He lives with family in US. He started smoking cigarettes at around age 13 and continues to smoke at age 78. Average of 1 pack plus per day for an estimated 70 pack-years of smoking. Most currently smoking less than 3 cigarettes per day due to pain. Denies heavy alcohol use. Denies exposure to asbestos, radiation or heavy chemicals. Family History: Unknown from mother and father. One brother had nasopharyngeal carcinoma. Denies other family members with cancer. Physical Exam: On admission: GENERAL: Elderly, frail appearing gentleman. He is alert, awake, and oriented x 3. HEENT: PERLA, EOMI, MMM. Anicteric sclerae. No oral lesions. NECK: Supple, flat JVD. No cervical LAD RESPIRATORY: Coarse rhonchi bilaterally, no wheezing. 5cm right anterior chest wall mass present, tender to touch. CARDIOVASCULAR: RRR, nl S1/S2 w/o m/r/g ABDOMEN: Soft, NT/ND, no HS, BS+ EXTREMITIES: WWP, no edema, diminished periperal pulses. MUSCULOSKELETAL: No spinal tenderness. [**2-20**] UE strength, [**3-22**] LE strength bilaterally. Decreased right knee and hip flexion. NEUROLOGIC: CN II-XII grossly intact, sensation to LT intact throughout, no hyper-reflexia noted. Babinski (-). SKIN: No evidence of active rashes. On Dischage: GEN: NAD, thin, responds to voice HEENT: sclera anicteric, CV: RRR, no r/m/g Lungs: coarse breath sounds anteriorly, transmitted upper airways sounds, posterior exam deferred Abd: soft, NT, ND Ext: no edema, warm; Pertinent Results: ADMISSION LABS: . [**2175-9-19**] 12:25PM GLUCOSE-95 UREA N-12 CREAT-0.6 SODIUM-136 POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15 [**2175-9-19**] 12:25PM estGFR-Using this [**2175-9-19**] 12:25PM WBC-5.7 RBC-4.78 HGB-14.2 HCT-41.7 MCV-87 MCH-29.7 MCHC-34.1 RDW-13.8 [**2175-9-19**] 12:25PM NEUTS-80.5* LYMPHS-13.2* MONOS-3.9 EOS-1.3 BASOS-1.0 [**2175-9-19**] 12:25PM PLT COUNT-287 . STUDIES . CT SPINE [**2175-9-19**]: 1. Pathologic fracture of C5 vertebral body. Posterior aspect of C5 likely contacts the spinal cord. If patient can tolerate, MRI of the cervical spineis recommended. Additionally, erosion of the transverse process at this level is present. If indicated, evaluation of the vertebral arteries may be performed with MRA neck or CTA of the neck. 2. Multiple pulmonary nodules, better evaluated on CT examination dated [**2175-9-13**]. 3. Asymmetry of the paraspinal muscles on the right could indicate additional metastatic disease and/or intramuscular hematoma. 4. Multiple additional lucencies in the cervical spine concerning for metastatic disease, most notable in the C7 vertebral body. . MRI SPINE [**2175-9-20**] . IMPRESSION: 1. Metastatic involvement at multiple cervical levels, centered around a C5 vertebral body which demonstrates compression deformity, and retropulsion due to complete invasion by metastatic tumor. There is associated central canal stenosis, with spinal cord compression, though there is no intrinsic cord abnormality at present. 2. Metastatic involvement of T3, L1, and the left iliac bone, with no expansion outside of the bony confines. 3. Mass in the soft tissues of the posterior neck most consistent with hematoma, which should be correlated linically . LENIs [**2175-10-1**]: IMPRESSION: No evidence of right lower extremity DVT. Brief Hospital Course: 78 M w/recently diagnosed NSCLC p/w severe neck pain [**9-19**] s/p anterior C4-6 diskectomy with anterior fusion on [**9-20**] and posterior fusion [**9-21**], admitted to SICU for difficult airway s/p extubation [**9-25**] transferred back to oncology floor [**9-30**] for pain control. . #Agitation: Delirium was initially thought to be due to large amount of narcotics that patient was recieving in ICU and patient was started on haldol. On the oncology floor, the haldol was initially stopped and the pain regimen was modified but the patient continued to have agitation and restlessness. It was felt that the agitation was most likely secondary to either pain or dyspnea associated with mucus/secretion accumulation. Mental status changes may also be related to prolonged hospitalization/sundowning. The patient's agitation/restlessness tended to improve greatly with prn pain medications and/or suctioning. He was started on prn olanzapine for agitation as well. Vitals overnight were held. Our recommendation is to avoid restraints, hold vitals overnight, provide a bed next to a window if at all possible, use pain medications and suctioning as first line treatment for agitation and to use olanzapine as back-up. . #Neck Pain: Secondary to cancer mets as well as post-op pain. Neck pain difficult to assess give patient's mental status and language barriers. Palliative care was consulted to determine an appropriate pain regimen. Patient was NPO after failing speech and swallow several times including video swallow evaluation. His pain was managed with a fentanyl patch and SL morphine. Radiation-oncology was consulted for palliative radiation options and the decision was made with the family not to pursue any radiation at this time. . #Nutrition: The patient failed speech and swallow in the ICU and was made NPO. A doboff was placed but he pulled it out and the decision was made in conjuction with the family not to pursue another doboff. He failed repeat speech and swallow including video swallow study, which was attributed more to post-op changes/neck swelling rather than mental status. Per speech and swallow, the patient will aspirate if he takes POs but we can make pt comfortable and minimize cough by feeding him thin liquids and pureed solids by spoon. Family meeting was held with medical-oncology team, palliative care, and primary oncologist. Decision was made not to pursue feeding tube at this time. . #NSCLC: Biopsy proven on [**2175-7-6**], initially presenting with neck pain and ?pathologic C5 fracture evaluated by orthopedic surgery. CT chest reveals multiple mets. s/p anterior C4-6 diskectomy with anterior fusion on [**9-20**] and posterior fusion [**9-21**]. Patient had previously communicated wishes to family that he would not want chemotherapy or radiation. Family meeting was held and the family again stated that they are not interested in chemotherapy or radiation, and would like patient to go to [**Hospital1 **] with hospice with primary focus on his comfort and pain control. . # PNA: He was started on 7 day cefepime course in SICU for PNA. BAL ctx grew out Moraxella. CXR appeared improved and he completed a 7 day course on [**10-1**]. He remained afebrile throughout hospital course. On [**10-5**], however, he had increased secretions that were thick and yellow. CBC showed new leukocytosis. CXR showed: "As compared to [**2175-9-30**], there is interval improvement of bibasilar aeration but still present bilateral right more than left pleural effusion and right basal opacity, findings that might be representing interval development of new right lower lobe process, but residual findings reflecting the prior process cannot be entirely excluded. No new abnormalities have been demonstrated as compared to multiple prior studies. Bilateral pleural effusion is present, most likely subpulmonic on the right." Vanc and cefepime were initially started but were discontinued after family meeting as antibiotic treatment not in line with goals of care. . #HTN: Has history of HTN. Pt not taking any POs and is not receiving any blood pressure medications given goals of care. BP fluctuates broadly, ranging from SBP 100-170s. . #Tachycardia: He became tachycardic in the SICU and was started on IV metoprolol. HR was regular on the floor. Stopped metoprolol [**10-6**]. . #Incontinence: likely related to mental status. Urine cx negative. Has some urinary retention for which he has a foley. . Note: Pt was made CMO per discussion with the family. He expired the afternoon of [**2175-10-12**] with family by the bedside. Medications on Admission: Simvastatin 20mg daily finasteride 5mg qhs Flomax 0.4mg daily alendronate 70mg q weekly Tylenol with Codeine #3 1 tab q 6hrs prn pain Tramadol 100mg daily Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: metastatic NSCLC Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "733.13", "162.8", "788.30", "196.0", "482.83", "196.1", "198.89", "338.3", "518.0", "338.18", "332.0", "401.9", "564.09", "272.0", "305.1", "336.3", "799.4", "451.82", "788.20", "293.0", "733.00", "198.5", "518.5", "288.60", "511.9", "V85.0", "V49.86", "348.39" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.05", "33.24", "96.72", "81.03", "83.21", "81.62", "81.02", "02.94", "80.51", "77.79", "84.52", "84.51", "77.49", "81.63" ]

icd9pcs

[ [ [] ] ]

10240, 10249

5391, 10002

324, 415

10310, 10319

3561, 3561

10375, 10385

2446, 2563

10208, 10217

10270, 10289

10028, 10185

10343, 10352

2578, 2578

275, 286

443, 1640

3577, 5368

2592, 3542

1766, 2027

2043, 2430

8,896

162,649

52071

Discharge summary

report

Admission Date: [**2183-10-29**] Discharge Date: [**2183-10-31**] Date of Birth: [**2107-1-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: CC:[**Last Name (Titles) 107787**] Major Surgical or Invasive Procedure: none History of Present Illness: This is a 76 yo male w/MMP including right MCA stroke 3 weeks ago for which he was admitted here([**Date range (1) 64208**]) and discharged to rehab who now presents w/mental status changes. Per NH report, he was found to be minimally responsive earlier today w/O2sat in the 80s on RA. He was thought to be in CHF and received lasix x 1. Labs were checked and he was found to have hypernatremia to 160(last Na 145 [**10-23**])and acute renal failure(last Cr 1.5 [**10-23**]). He was then transported via EMS to our ED. . In the ED, Tm 100 rectally BP 150s-190s/40s-50s HR 75 O2sat98%RA. He had elevated cardiac enzymes in the setting of ARF but was w/o sx or EKG changes, though difficult to interpret due to baseline BBB. While in the ED, he had 200cc BRBPR and was started on PPI per GI recs. NG lavage was negative. He was found to have +U/A, received cipro IV x 1. BNP was noted to be significantly elevated from baseline. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: -Coronary artery disease, with CABG in [**2167**] and multiple PCI in [**2-5**], [**5-16**], [**8-17**], last [**12-17**] w/Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 placed -Congestive heart disease, systolic and diastolic, EF 25% in [**2183-10-6**] -Aortic and mitral regurgitation -Arrhythmias: episode of atrial tachycardia ([**2181**]) and episode of phase 4 block secondary to PVC ([**9-/2182**]), s/p pacemaker placement -Peripheral [**Year (4 digits) 1106**] disease Right CEA ([**7-/2168**]) Left fem-bk [**Doctor Last Name **] w/ ISSVG ([**8-/2168**]) Left fem-pt w/ vein ([**12-11**]) Right CFA-ak [**Doctor Last Name **] w/ NRSVG ([**1-11**]) Bilateral 5th toe amps ([**1-11**]) Successful atherectomy of the right anterior tibial and popliteal arteries ([**3-14**]) Successful cryoplasty of the L fem-[**Doctor Last Name **] graft ([**4-13**]) - Hypertension - Diabetes mellitus, Type II - Dyslipidemia - Chronic kidney disease, beaseline Cr ~2.5 - Hemorrhoids - Colonic diverticulosis - GERD - Acalculous cholecystitis s/p indwelling gallbladder catheter - Possible obstructive lung disease, on 2L oxygen at home - Low back and bilateral pain - Lung nodules, found on CT on recent admission Social History: By report, over 60 pack-year history of tobacco use, but quit 3 years ago. History of heavy drinking in the past. Has denied drug use. Lives alone, though family apparently lives in adjacent quarters. Has VNA services at baseline, but recently was discharged to [**Hospital **] Rehab. Family History: No known history of stroke per daughter. Physical Exam: on presentation: Vitals: T: 97.2 BP: 117/61 HR: 85 RR: 20 O2Sat:93%RA wt 69.1 kg GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses Rectal: bright red blood, guiac +; external hemorrhoids EXT: No C/C/E, no palpable cords NEURO: Left sided weakness. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. . Pertinent Results: [**2183-10-29**] 05:50PM WBC-7.0# RBC-2.78* HGB-7.9* HCT-25.4* MCV-91 MCH-28.3 MCHC-31.0 RDW-18.8* [**2183-10-29**] 05:50PM NEUTS-76.7* LYMPHS-17.9* MONOS-3.6 EOS-1.4 BASOS-0.4 [**2183-10-29**] 05:50PM PLT COUNT-226# . [**2183-10-29**] 05:50PM PT-30.1* PTT-34.6 INR(PT)-3.1* . [**2183-10-29**] 05:50PM GLUCOSE-108* UREA N-39* CREAT-1.9* SODIUM-166* POTASSIUM-3.7 CHLORIDE-126* TOTAL CO2-30 ANION GAP-14 [**2183-10-29**] 05:50PM ALT(SGPT)-11 AST(SGOT)-21 LD(LDH)-293* CK(CPK)-362* ALK PHOS-56 TOT BILI-0.5 . [**2183-10-29**] 05:50PM CK-MB-4 proBNP-[**Numeric Identifier **]* [**2183-10-29**] 05:50PM cTropnT-0.11* [**2183-10-30**] 02:08AM BLOOD CK-MB-4 cTropnT-0.09* [**2183-10-30**] 07:08AM BLOOD CK-MB-4 cTropnT-0.09* . [**2183-10-29**] 06:30PM URINE BLOOD-LG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2183-10-29**] 06:30PM URINE RBC->50 WBC-[**10-30**]* BACTERIA-MOD YEAST-NONE EPI-0 [**2183-10-29**] 06:30PM URINE HYALINE-[**2-12**]* . [**2183-10-29**] CT HEAD: Prelim read- evolution of R MCA stroke . [**2183-10-30**] RENAL US: Prelim read- no hydronephrosis Brief Hospital Course: This is a 76 yo male s/p recent right MCA stroke who presents w/severe hypernatremia and MS changes. Patient was actively treated for hypernatremia with fluids, UTI with antibiotics in anticipation of Scope for source of GIB. However, on day 2 of ICU stay, the following occured: I was called to bedside at 0000 on [**2183-10-31**] as patient was noted to be dyspnic with inability to cough up secretions. Rattling breath sounds were noted. RT suctioned oropharynx and noted large amount of red blood. O2 saturation was good on NC, but BP dropped to 70's/palp although patient was still interactive. Continuous oropharyngeal and nasopharyngeal suctioning revealed large amounts of blood and it was decided that 1U of FFP and 1U of PRBC would be transfused. ENT was called for possible epistaxis, but seconds later, patient was noted to be apnic, despite suctioning and repositioning. Fellow was notified and DNR/DNI code status was confirmed. Despite suctioning, respiratory drive did not return and patient expired at 0105 on [**2183-10-31**]. Medications on Admission: ASA 81 daily coreg 25 mg daily Plavix 75mg daily Zocor 80mg daily [**Date Range **] 1mg daily MWF, 2mg Sun/T/Th/Sa glucotrol 5 mg daily HISS Lasix 40mg daily Mag gluconate 500mg TID colace Zantac 150 mg daily Combivent Lactulose Senokot Tylenol Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Patient expired Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired Completed by:[**2183-10-31**]

[ "428.42", "585.3", "403.90", "537.83", "537.84", "041.11", "433.30", "433.10", "496", "396.3", "428.0", "V45.01", "276.0", "427.1", "530.81", "599.0", "455.6", "V15.82", "784.7", "V49.72", "584.9" ]

icd9cm

[ [ [] ] ]

[ "96.07", "99.07", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

6518, 6527

5126, 6182

351, 357

6586, 6603

3967, 4994

6667, 6714

3274, 3316

6478, 6495

6548, 6565

6208, 6455

6627, 6644

3331, 3948

278, 313

385, 1674

5003, 5103

1696, 2952

2968, 3258

18,071

136,026

54441

Discharge summary

report

Admission Date: [**2119-1-8**] Discharge Date: [**2119-1-17**] Date of Birth: [**2056-6-6**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 2641**] Chief Complaint: Fevers, chills, and dyspnea for one day prior to admission. Major Surgical or Invasive Procedure: tunneled dilaysis catheter placement persantine MIBI stress test History of Present Illness: 62 year old man with PMH notable for DM, ESRD, CHF, CAD who presents with fever at home to 101.8 degrees fahrenheit. Pt initially developed a fever and rigors at HD on [**1-7**]. He was asked to come the the ED at that time for further evaluation but declined. In further history, pt reports continued fevers once he returned home. He also experienced dyspnea and chills. He denies cough or abdominal pain. In further ROS, he denies sick contacts, cough, rhinorrhea, sputum, lesions/ulcers anywhere, changes in urinary habits (goes small amt 4-5x/day), changes in bowel but no BM x 3-4 days. On presentation to the ED, the pt's VS were 99.6 95 111/47 22 and 85 % on RA improving to 98% on non-rebreather. He received 1 liter of IV fluids, 2g ceftriaxone, 1 g vancomycin, and 160 mg gentamycin. Pt exerienced some nausea and shaking chills for which he received anzemet, demerol, and tylenol. Renal was consulted and recommended pulling the dialysis catheter under fluoro. Blood cultures (2 bottles) were sent peripherally but not from dialysis catheter. The patient was admitted to medicine. Past Medical History: 1. Type 2 DM complicated by ESRD on HD 2. ESRD on HD 3. Question of lupus anticoagulant 4. Obesity 5. HTN 6. h/o MSSA cellulitis 7. h/o diverticulosis 8. CHF EF 35% 9. Obstructive sleep apnea for which pt uses 3 L oxygen via NC at home 10. PVD s/p RLE bypass 11. Chronic LBP- He is s/p nerve block in clinic 08/25/1004. 12. Vitamin B12 deficiency 13. Renal osteodystrophy 14. CAD s/p CABG '[**13**] and stent to LCX [**2117-3-15**] Social History: Lives at home with wife. Pt does have services. Quit tob 27 years ago. No Etoh Family History: Non-contributory Physical Exam: VS: t99, p100, 149/65, rr30, 92% 3Lnc Gen:sitting back in cardiac chair, mild respiratory distress, accessory muscle use HEENT: PERRL, EOMI, clear OP Neck: thick, supple, no cervical lymphadenopathy CVS: distant HS, RRR Lungs: decreased BS at bases, no c/w/r Abd: soft, mildly tender at LLQ, ND, +BS Ext: bilateral chronic venous stasis changes, 1+ pitting edema bilaterally Pertinent Results: [**2119-1-8**] 08:41a 7.39 / 48 / 85 / 30 / 2 Type:Art; Not Intubated; Nasal Cannula K:3.8 Other Blood Gas: O2-Flow: 5 [**2119-1-8**] 08:17a Color Yellow Appear Hazy SpecGr 1.023 pH 6.5 Urobil Neg BiliNeg LeukNeg BldSm NitrNeg Pro500 Glu250 KetTr RBC0-2 WBC0-2 BactFew YeastNone Epi0-2 Amorp Mod Other Urine Counts CastHy: [**4-8**] [**2119-1-8**] 07:44a Lactate:2.8 [**2119-1-8**] 06:50a SPECIMEN GROSSLY HEMOLYZED 132 93 50 / ------------- 202 6.0 24 5.4 \ Comments: Hemolysis Falsely Elevates K Ca: 8.6 Mg: 1.6 P: 4.6 Comments: Hemolysis Falsely Increases This Result 101 16.4 \ 10.6 / 189 / 31.7 \ N:92.4 L:3.0 M:4.1 E:0.3 Bas:0.2 Macrocy: 2+ PT: 13.7 PTT: 47.3 INR: 1.2 Comments: Note New Normal Range As Of 12a Of [**2118-9-13**] Imaging: CXR [**1-8**]: IMPRESSION: No evidence for CHF or pneumonia. No pneumothorax. CXR [**1-11**] IMPRESSION: Improving congestive heart failure with continued cardiomegaly and small bilateral pleural effusions Echo [**1-10**]: Conclusions: 1. The left atrium is moderately dilated. 2. The left ventricular cavity is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed. 3. The ascending aorta is mildly dilated. 4. The aortic valve leaflets (3) are mildly thickened. 5. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 6. There is mild pulmonary artery systolic hypertension. 7. No obvious cardiac mass or vegetation seen. 8. Compared with the findings of the prior study of [**2118-1-11**], there has been no significant change. Chest CT Angiogram [**1-13**] IMPRESSION: 1) No pulmonary embolis. Pattern of findings in the lung parenchyma suggests volume overload. There is bibasilar atelectasis though pneumonia is not completely excluded. 2) Pathologically enlarged lymph nodes can be secondary to infectious or inflammatory processes. Lymphoma is within the differential diagnosis. Follow up examination following appropriate treatment to assess for resolution. Persantine MIBI stress test [**1-16**]: IMPRESSION: Fixed inferior wall and inferior portion of the lateral wall perfusion defects. Enlarged left ventricle at rest and stress. Moderate global hypokinesis with calculated ejection fraction of 36%. Overall, no significant change since the prior exam. Microbiology: [**2119-1-8**] 6:50 am BLOOD CULTURE LEFT HAND. **FINAL REPORT [**2119-1-11**]** AEROBIC BOTTLE (Final [**2119-1-11**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16051**] @ 0502 ON [**1-9**] - CC7C. STAPH AUREUS COAG +. FINAL SENSITIVITIES. PENICILLIN SENSITIVITY AVAILABLE ON REQUEST. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 1 S OXACILLIN-------------<=0.25 S [**2119-1-8**] 7:00 pm CATHETER TIP-IV Source: hd catheter. **FINAL REPORT [**2119-1-11**]** WOUND CULTURE (Final [**2119-1-11**]): STAPH AUREUS COAG +. >15 colonies. PENICILLIN SENSITIVITY AVAILABLE ON REQUEST. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 1 S OXACILLIN-------------<=0.25 S [**2119-1-11**] 4:00 pm BLOOD CULTURE 2. **FINAL REPORT [**2119-1-17**]** AEROBIC BOTTLE (Final [**2119-1-17**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2119-1-17**]): NO GROWTH. Brief Hospital Course: ## Line infection The patient was febrile on admission and continued to be febrile in the MICU with a temperature on [**1-9**] to 102. His hemodialysis catheter was pulled and the tip was sent for culture. Culture of the tip and blood cultures grew 4/6 bottles of gram positive cultures in pairs and clusters which were sensitive to oxacillin, later determined to be MSSA. The patient was contained on Vancomycin and gentamycin, and the gentamycin was discontinued on [**1-10**] after the sensitivities returned. Surveillance blood cultures since [**1-9**] remained without growth. The vancomycin was changed to oxacillin on [**1-11**], but this was changed back to vancomycin due to the ease of renal dosing for this dialysis patient. He should have a 14 day total course of vancomycin, and will receive levels and doses at dialysis. ## Respiratory distress - SIRS vs. CHF: The patient was initially admitted to medicine, but soon after transfer from the emergency department, the patient developed respiratory distress with an oxygen saturation of 85% on 5 L NC improving to 97% on a nonrebreather. He was tachypneic in the 30s. A MICU evaluation was obtained. ABG showed a blood gas of 7.39/48/85.The patient was then transferred to the MICU given a concern for SIRS response to line infection bacteremia versus CHF from fluid overload. Pt was put on Bipap for his respiratory distress. A temporary hemodialysis catheter was placed and pt had hemodialysis on [**1-9**] which was terminated early secondary to respiratory distress with desats to 81% and rigors. He was put on non-rebreather @10L with improvement to 98%. Respiratory status improved overnight on Bipap. On [**1-10**], pt was able to tolerate HD without complications and was transferred back to medicine. On the medicine floor, he appeared to be fluid overloaded bu physical exam and X-ray from [**1-11**], so fluid was removed during hemodialysis and with Lasix. He was put on an ACE inhibitor and a beta blocker, and kept on fluid restriction. A chest CT angiogram was done which showed no PE. His oxygen saturation gradually improved with fluid removal during dialysis and Lasix until he was stable on [**4-7**] L NC which is his baseline at home. During the admission he was also kept on BiPAP at night for sleep apnea. ## Enlarged mediastinal lymph nodes - The patient was found to have enlarged pulmonary lymph nodes by CTA on [**1-13**] to rule out pulmonary embolism demonstrated bilateral small loculated pleural effusions and 2cm pre-tracheal, 2.2x 3.6cm subcarinal, and 2x 1.5cm R hilar lymph nodes. Per discussion with radiology attending, this was felt to possibly be secondary to CHF (even at 2cm) and that diuresis should continue with repeat CT as outpatient in approximately 2-3 weeks to evaluate for decrease in lymphadenopathy. ## Demand ischemia - The patient had an episode of chest pain on [**1-11**] which was right sided with tenderness to palpation. His EKG was unchanged, but a troponin leak was observed over baseline (0.35-0.55) with an elevated CK. Cardiology was consulted which felt that this was likely demand ischemia. He was continued on aspirin, statin, beta blocker and ACE inhibitor, and Plavix was restarted at the end of his hospitalization. He received a P-MIBI stress test which showed no reversible ischemic areas. ## Non sustained ventricular tachycardia (NSVT) - The patient had 2 separate runs of NSVT on [**1-13**] in the AM while on tele of 5 beats each. He was asymptomatic with a normal magnesium level. He did not have further episodes on telemetry over the next 3 days. His metoprolol was titrated up to a pulse around 60. It was decided to send the patient for outpatient EP evaluation given his low EF, yet the contraindication to an EP study in the setting his line infection. ## End stage renal disease - The patient had a temporary line placed for hemodialysis, which was changed to a tunneled line on [**1-12**]. He underwent dialysis three times a week without incident except as noted above under respiratory distress. Nephrology followed the patient closely and assisted with management of his fluid status. ## Diabetes: He was continued on NPH and insulin sliding scale, adjusted while he was eating less but with fair overall blood sugar control while in the hospital. His topiramate was continued for neuropathic pain and metoclopramide was continued for gastroparesis. ## Anemia: The patient was noted to have chronic anemia. He was transfused 1 unit on [**1-12**] in the setting of demand ischemia with a HCT of 27.5. After this, his HCT was stable at 30. B12 and folate are within normal limits. He continued to get Epogen in dialysis. ## h/o Chronic Pain: Patient has chronic back pain and shoulder pain, and was maintained on OxyContin with oxycodone for breakthrough. ## h/o Depression/anxiety: He was continued on citalopram and given alprazolam in small doses for anxiety. His methylphenidate was discontinued on [**1-12**] given the NSVT arrhythmia and demand ischemia. ## Obstructive Sleep Apnea: He was continued on his home BiPAP machine. ## Constipation: He was given bisacodyl, Dulcolax, senna, and lactulose tid as needed was added on [**1-14**]. ## h/o Lupus Anticoagulant: He was maintained on SQ heparin for DVT prophylaxis especially given this hypercoagulable state. He was maintained on ASA and the Plavix was initially held but restarted toward the end of his hospitalization. ## Code Status: He was full code during the hospitalization. Medications on Admission: Acetaminophen 325-650 mg PO Q4-6H:PRN Heparin 5000 UNIT SC TID Calcium Acetate 1334 mg PO TID W/MEALS Nephrocaps 1 CAP PO DAILY Atorvastatin 80 mg PO DAILY ASA 325 mg po daily Plavix 75 mg po daily Lisinopril 20 mg PO DAILY Pantoprazole 40 mg PO Q24H Citalopram Hydrobromide 60 mg PO DAILY Metoprolol 50 mg PO BID Isosorbide Dinitrate 20 mg PO TID Docusate Sodium 200 mg PO BID Senna 2 TAB PO BID Methylphenidate HCl 10 mg PO BID please only give on non-dialysis days Oxycodone (Sustained Release) 20 mg PO Q12H Oxycodone 5 mg PO Q8H:PRN Zolpidem Tartrate 5-10 mg PO HS:PRN Quinine Sulfate 325 mg PO HS Alprazolam 0.5 mg PO DAILY:PRN Metoclopramide 10 mg PO QIDACHS Topiramate 25 mg PO DAILY Insulin SC 50 units qam, 25 units qpm Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*180 Tablet(s)* Refills:*2* 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 4. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 9. Topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)) as needed for nausea. Disp:*60 Tablet(s)* Refills:*0* 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 12. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)): and also 20 mg every evening. Disp:*90 Tablet(s)* Refills:*2* 13. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 14. Quinine Sulfate 260 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 15. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0* 16. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 17. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. Disp:*1 bottle* Refills:*0* 18. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed. Disp:*20 Tablet(s)* Refills:*0* 19. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 20. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 21. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 22. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO once a day. Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* 23. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous ONCE (once) for 7 days: to be given at dialysis when level < 15. last dose 12/21 if necessary,. Disp:*1 gram* Refills:*5* 24. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) Subcutaneous twice a day: 50 units in the morning, 25 units before bedtime (see attached insulin sliding scale sheet). Disp:*1 bottle* Refills:*10* 25. Insulin Regular Human 300 unit/3 mL Syringe Sig: One (1) Subcutaneous four times a day: check blood sugars 4 times daily and administer according to attached insulin sliding scale. Disp:*1 bottle* Refills:*10* 26. Outpatient Lab Work please check vancomycin level at beginning of each dialysis session until [**2119-1-24**]. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: line sepsis with methicillin sensitive staph aureus (MSSA) congestive heart failure exacerbation nonsustained ventricular tachycardia paratracheal lymphadenopathy demand ischemia end stage renal disease diabetes mellitus anemia of renal failure depression anxiety chronic pain obstructive sleep apnea lupus anticoagulant Discharge Condition: patient was breathing comforably on 4 liters of oxygen, was eating food and able to ambulate. Discharge Instructions: Please take all of your new medications as prescribed. Please schedule your follow up CT appointement and electrophysiology appointment as below. If you have recurrent chest pain, shortness of [**Location (un) 1440**], fevers, chills, or other concerns, please call your primary care physician or return to the emergency department. Followup Instructions: Please call [**Telephone/Fax (1) 327**] to confirm a lung CT scan appintment for [**2118-2-7**]. Follow up with Dr. [**First Name (STitle) 2505**]: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital 4054**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2119-2-10**] 1:30 for follow up of chronic medical issues and CT scan. Please go to dialysis as scheduled each tuesday, thursday, saturday. They will check your vancomycin level and dose to keep you vancomycin level above 15 until [**2119-1-24**]. Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2119-2-13**] 10:20 to follow up for heart failure. Electrophysiology: ([**Telephone/Fax (1) 8793**] to schedule first available new patient appointment for short run of nonsustained centricular tachycardia in the setting of low ejection fraction. Provider: [**Name10 (NameIs) 1947**],[**Name11 (NameIs) 722**] [**Hospital 1947**] CLINIC Where: CC-2 [**Hospital 1947**] UNIT Phone:[**Telephone/Fax (1) 3153**] Date/Time:[**2119-3-10**] 9:20

[ "278.00", "V09.0", "403.91", "285.21", "414.8", "710.0", "780.57", "428.0", "038.11", "995.92", "414.01", "996.62", "E878.4", "250.00" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

16481, 16538

6588, 12096

326, 393

16903, 16998

2515, 6565

17381, 18555

2086, 2104

12878, 16458

16559, 16882

12122, 12855

17022, 17358

2119, 2496

227, 288

421, 1518

1540, 1974

1990, 2070

1,399

108,903

53149+59503

Discharge summary

report+addendum

Admission Date: [**2109-3-7**] Discharge Date: [**2109-3-20**] Date of Birth: [**2034-4-19**] Sex: M Service: [**Company 191**] CHIEF COMPLAINT: Unable to swallow. HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old male with multiple medical problems and recent hospitalization for left lower extremity ulcer infected with methicillin-resistant Staphylococcus aureus. The patient was directly admitted from home for a decreasing ability to take p.o. secondary to throat pain when swallowing. The patient has a history of throat cancer and status post surgery and radiation therapy. The patient denies abdominal pain and nausea but does admit to lack of appetite. He says his clothes are fitting loosely and has apparently lost a lot of weight in the last month or two. The patient states that he was admitted "to get a feeding tube." Of note, the patient has old pacemaker wires in his abdomen which may complicate percutaneous endoscopic gastrostomy tube placement. The patient is also on Coumadin for atrial fibrillation and reportedly has not taken his Coumadin in three days. However, his latest INR drawn on [**3-6**] was 9.5. The patient undergoes hemodialysis on Monday, Wednesday and Friday which should be continued while in the hospital. PAST MEDICAL HISTORY: 1. Congestive heart failure with an ejection fraction of less than 15% by echocardiogram in [**2108-12-21**]. 2. End-stage renal disease (on hemodialysis three times per week). 3. Coronary artery disease; status post myocardial infarction times two, with percutaneous transluminal coronary angioplasty to the circumflex. 4. Chronic obstructive pulmonary disease. 5. Paroxysmal atrial fibrillation (on Coumadin). 6. History of ventricular tachycardia; status post implantable cardioverter-defibrillator placement. 7. Pulmonary hypertension and pulmonary fibrosis secondary to amiodarone toxicity. 8. Hypertension. 9. Status post throat cancer for which he was treated with radiation therapy. 10. History of diabetes. 11. History of colon cancer, status post colectomy. 12. History of gout. 13. Hypothyroidism. 14. Peripheral vascular disease with chronic lower extremity ulcer. MEDICATIONS ON ADMISSION: Digoxin 0.125 mg p.o. q.d., Colace 100 mg p.o. q.d., Synthroid 50 mcg p.o. q.d., Coumadin 4 mg p.o. q.h.s., Tums 1 tablet p.o. t.i.d., Nephrocaps 1 tablet p.o. b.i.d., Xanax 0.25 mg p.o. q.h.s., pravastatin 20 mg p.o. q.h.s., trazodone 50 mg p.o. q.h.s., Tylenol No. 3 p.r.n., levofloxacin 250 mg p.o. q.o.d., Flagyl 500 mg p.o. b.i.d., vitamin C, and vancomycin (which is dosed at dialysis). ALLERGIES: SOCIAL HISTORY: The patient lives with wife at home. He has a daughter who is a nurse and extremely involved in his care. He has no history of tobacco, and no current alcohol use. PHYSICAL EXAMINATION ON PRESENTATION: Temperature of 95.9, blood pressure of 86/63, heart rate of 88, respiratory rate of 20, satting 100% on room air. The patient was a pale, cachectic male lying in bed, and appeared sleepy. Pupils were equal, round, and reactive to light. Mucous membranes were dry. Tongue was red and smooth. Extraocular movements were intact. Heart was irregular. No murmurs. The point of maximal impulse was laterally displaced. Chest had bibasilar crackles, and a pacemaker was noted in the right upper chest wall. The abdomen was soft, normal active bowel sounds, wires were noted in the right abdominal wall. Extremities revealed bilateral pitting edema. Venous stasis changes bilaterally. The patient had a dressing over the left lower leg. His toes were cool with nonpalpable dorsalis pedis pulses. Neurologic examination revealed cranial nerves were intact. The patient was weak but moved all four extremities. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission revealed a white blood cell count of 10.9, hematocrit of 51, platelets of 189 (70 neutrophils, 4 bands, 12 lymphocytes). Sodium of 142, potassium of 5.5, chloride of 104, bicarbonate of 22, blood urea nitrogen of 51, creatinine of 6.2, blood sugar of 131. Albumin of 3.2, calcium of 9.6, phosphate of 4.6, magnesium of 2.1. Iron of 100. INR of 5.1. Digoxin level of 4.2. HOSPITAL COURSE: The [**Hospital 228**] hospital course was quite complicated and marked by two trips to the Intensive Care Unit. Of note, on admission, the patient was noted to be digoxin toxic, and his digoxin was held throughout his hospitalization. There were no electrocardiogram changes concerning for digoxin toxicity, and the patient was asymptomatic. The patient's blood pressure on admission was notably low, in the 80s/50s. According to his family, his blood pressure did run on the low side. It was felt by the team that he was severely dehydrated due to poor oral intake over the past few weeks. He was gently hydrated due a known ejection fraction of 10%. On [**3-8**], status post dialysis, the patient became hypotensive to the 70s and was admitted to the Intensive Care Unit briefly for further monitoring. He received more intravenous fluids at that point. The Medical Intensive Care Unit stay was short, and he was called back out to the floor on [**3-9**]. A percutaneous endoscopic gastrostomy tube was placed on [**3-11**]; and, of note, the patient got 600 cc of lactated Ringer's intraoperatively as well as Fentanyl. Overnight, following the procedure, the patient was persistently hypotensive in the 70s/30s and did not respond to fluid boluses. The patient was admitted back to the Medical Intensive Care Unit on [**3-10**] for hypotension refractory to intravenous fluids. The patient was maintained on a dopamine drip for several days for a blood pressure in the 90s. There was some confusion as to his volume status, not being clear whether he was dehydrated or volume overloaded, and with his low ejection fraction, he had been pushed off the Starling curve. On [**3-15**], the patient was dialyzed off 2 liters of fluid which then enabled the dopamine to be weaned off. Again, on [**3-16**], an additional 2 liters were dialyzed off. The patient was stable off dopamine for 24 hours with a blood pressure in the 90s, and he was transferred out to the floor on [**3-16**]. The patient initially was stable on the floor but was noted to have increasing tachypnea over [**3-17**] and [**3-18**]. On [**3-19**], upon evaluation by the team, the patient was increasingly tachypneic, more somnolent, and was feeling very poorly to the point where he said, "I just want to die." An arterial blood gas was done and revealed an acidosis with a pH of 7.22, a PCO2 of 50, and a PO2 of 129 on 4 liters nasal cannula. A STAT chest x-ray revealed a large right-sided pleural effusion, and when compared with previous x-rays was read as increasing bilateral effusions, right greater than left. The effusion was drained by ultrasound guidance by the Radiology team, and approximately 1.2 liters were taken off. The patient had improved respiratory status after and appeared more comfortable. Fluid studies were pending at the time of this dictation. Other issues during this hospitalization included his nutritional status. The patient was originally treated with intravenous fluid hydration as noted above prior to percutaneous endoscopic gastrostomy tube placement. A gastrojejunostomy tube was placed by Interventional Radiology on [**3-11**] without any complications. The patient tolerated the procedure well and was immediately started on .................... for tube feeds. This was changed to Nepro on [**3-19**] due to his renal failure. The patient continued to tolerate tube feeds well and will be sent home on Nepro tube feeds with a goal of 50 cc per hour. The patient's renal status was basically stable throughout this hospitalization. He continued to be dialyzed on Monday, Wednesday and Friday. There were no complications. Infectious Disease issues included continuation of Flagyl, levofloxacin, and vancomycin for his left lower extremity ulcer. The Vascular team did come by and see the patient and recommended continuing wet-to-dry dressing changes b.i.d. as well as to keep pressure off the leg. The patient was kept in multipoultice boots to prevent further skin breakdown. Hematologic issues included the need for reversal of his supratherapeutic INR which was 9.2 on admission. On the first two days of his hospitalization the patient received several doses of p.o. vitamin K to help reverse his INR. The patient was kept off Coumadin status post percutaneous endoscopic gastrostomy tube placement during his Medical Intensive Care Unit stays and was restarted on Coumadin on [**3-18**]. His INR will need to be followed closely. Social and disposition issues during this hospitalization included the overall goals of care. Initially, the patient and family were very adamant that he should be full code and wanted everything done. It became more clear to the family and the patient during this hospitalization that he was very sick and had multiple medical problems. On [**3-19**], after a thoracentesis, the patient and family had a discussion with the attending and the decision was made to change the patient to do not resuscitate/do not intubate. The plan was to send the patient home with services. Further discussions about goals of care may be carried out with the attending at a future date. DISCHARGE DIAGNOSES: 1. End-stage renal disease. 2. Congestive heart failure with an ejection fraction of 15%. 3. Peripheral vascular disease with chronic left leg ulcer infected with methicillin-resistant Staphylococcus aureus. 4. Bilateral pleural effusions. 5. Chronic atrial fibrillation. 6. Ventricular tachycardia/ventricular fibrillation with implantable cardioverter-defibrillator placement. 7. Status post gastrojejunostomy tube for odynophagia. MEDICATIONS ON DISCHARGE: 1. Nepro tube feeds 50 cc per hour. 2. Coumadin 2 mg p.o. q.h.s. 3. Colace 100 mg p.o. b.i.d. 4. Trazodone 50 mg p.o. q.h.s. 5. Xanax 0.5 mg p.o. q.h.s. 6. Metronidazole 500 mg p.o. b.i.d. 7. Prevacid 30 mg p.o. q.d. 8. Synthroid 50 mcg p.o. q.d. 9. Nephrocaps 1 tablet p.o. q.d. 10. Tums 1 tablet p.o. with meals. 11. Vitamin C 1000 IU p.o. q.d. 12. Levofloxacin 250 mg p.o. q.i.d. 13. Senna 2 tablets p.o. q.d. 14. Vancomycin intravenously (to be dosed at hemodialysis). DISCHARGE STATUS: The patient will be discharged home with services. He will require [**Hospital6 407**] for dressing changes of his leg. The patient will also require close monitoring of his INR and continued followup of his digoxin level. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. [**MD Number(1) 4992**] Dictated By:[**Last Name (NamePattern1) 6765**] MEDQUIST36 D: [**2109-3-19**] 19:02 T: [**2109-3-19**] 20:25 JOB#: [**Job Number 42677**] Name: [**Known lastname 17941**], [**Known firstname 17942**] Unit No: [**Numeric Identifier 17943**] Admission Date: [**2109-3-7**] Discharge Date: [**2109-3-23**] Date of Birth: [**2034-4-19**] Sex: M Service: [**Hospital 17953**] [**Hospital6 534**] Firm ADDENDUM: There is a very detailed Discharge Summary that has already been dictated through the first of [**2109-3-20**]. The purpose of this Discharge Summary is to indicate that the patient eventual date of discharge was [**2109-3-23**]. The patient's discharge status was expired. Of note, between the prior Discharge Summary and this current Discharge Summary is the fact that the patient changed his code status from full code to do not resuscitate/do not intubate. The patient subsequently decided, in conjunction with his family, they agreed to have his cardiac pacemaker deactivated. He similarly agreed to withdraw from any further dialysis treatment. The patient then met with a Palliative Care representative and decided that he wanted to become "comfort measures only" status. As such, vital signs and laboratories were no longer checked. The patient received Ativan for agitation and morphine for air hunger and was found to be unresponsive on the [**2109-3-23**]. The time of death was 7:20 a.m. on [**2109-3-23**]. Therefore, the patient's discharge status was expired, and this Discharge Summary serves as an update from the prior Discharge Summary which details his hospital course through [**2109-3-20**]. The patient's family was aware of the patient's death, and they were present in the hospital, and appropriate arrangements for the patient's body were made by the family. The family declined an autopsy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1949**], M.D. [**MD Number(1) 1950**] Dictated By:[**Last Name (NamePattern1) 506**] MEDQUIST36 D: [**2109-5-2**] 12:29 T: [**2109-5-7**] 12:22 JOB#: [**Job Number **]

[ "707.0", "515", "511.9", "496", "427.31", "276.5", "428.0", "263.9", "585" ]

icd9cm

[ [ [] ] ]

[ "39.95", "34.91", "96.6", "38.91", "44.32" ]

icd9pcs

[ [ [] ] ]

9442, 9884

9911, 10652

2237, 2643

4248, 9421

167, 187

10674, 13066

216, 1287

1310, 2210

2660, 4230

32,500

117,954

48175

Discharge summary

report

Admission Date: [**2138-5-26**] Discharge Date: [**2138-6-5**] Date of Birth: [**2075-3-15**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 552**] Chief Complaint: FUO, altered MS Major Surgical or Invasive Procedure: intubation History of Present Illness: Ms. [**Known lastname 13304**] is a 63 yo F with a h/o EtOH abuse, hemochromatosis, and recent hospitalization for ETOH pancreatitis, who was transferred to the ED from rehab with acute altered mental status. According to her husband she was in her usual state of health when he last spoke to her at 9pm on the evening of admission. He was called by the rehab 2 hours later and informed that she was not making sense and that she was being sent to ED for further evaluation. He reported that when he saw her in the ED she was speaking non-sensically; he had never seen her like this before. On [**2138-5-22**] she was discharged from [**Hospital1 18**] to rehab after a month-long hospitalization, including intubation, for severe alcoholic pancreatitis. In the ED, VS were T 97.6, HR 104, BP 156/88, RR 20, 100% on NC. She was initially evaluated for stroke, noted to have B/L mydriasis, sluggishly reactive to light; but no evidence of herniation/hemorrhage or other acute process on head CT. Negative tox screen except for benzos which were given in the ED. She spiked a fever to 102.4 in ED and had an LP performed, which was normal. She was treated with vanco 1g IV x1, levofloxacin 750mg IV x1, flagyl 500mg IV x1. She was also given NS IV x2L, Bannana bag, mag 2g IV x1, 1mg Ativan x2, tylenol 1g PR, ASA 325. Past Medical History: #. Pancreatitis-- hospitalization [**4-29**] - [**2138-5-22**], on levo/flagyl; MICU stay w/intubation #. EtOH abuse-- heavy drinking of [**1-21**] to whole bottle of wine per day every day for 4-5 years; unclear if she has been drinking since recent discharge from hospital #. Peptic ulcer disease #. Hemochromatosis-- requiring therapeutic phlebotomy (no h/o organ dysfunction) #. OSA-- per sleep study on [**2138-4-2**], patient should be started on auto CPAP with a pressure ranging from 6-10 cm of water; however she hasn't started using CPAP at home yet #. Cognitive impairment-- per husbands report she has been reporting short term memory impairment x3 years; h/o abnormal neuropsych testing Social History: Up until the past month she had been drinking 1 whole bottle of wine per day +/- scotch every day for 4-5 years. Last drink was [**2138-4-26**], husband denies any access to alcohol since. No h/o tobacco or drug use. Prior to her recent pancreatitis she had been working part time as a therapist, previously as a professor. Lives with husband who does not drink. Family History: non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: VS in the [**Hospital Unit Name 153**]: T 103.2, HR 121, BP 155/67, RR 30, 99% NC Gen: appears agitated, non purposeful movements, muttering, moans in response to questions/exam Skin: warm, flushed, no rashes or lesions noted HEENT: pupils 3mm, equal, sluggisly reactive, roving eye movements, will not open mouth, dried blood on tongue/[**Last Name (LF) **], [**First Name3 (LF) **] not open mouth for examination Neck: supple, no LAD, no thyromegaly or thyroid nodules CV: tachycardic, regular rhythm, no appreciable murmur Lungs: unable to cooperate with exam, CTAB Abd: soft, appears to be tender to deep palpation primarily in RLQ, +Bowel sounds, no guarding Ext: no pedal edema Pertinent Results: ADMISSION LABS: Na 132 K 3 CL 102 HCO 26 BUN AST 22 ALT 12 AP 155 Lip 13 CK 36 MB - Trop 0.02 WBC 7.7 HCT 28.1 PLT 390 Serum Tox negative Lactate 1 [**5-26**] CSF 3WBC 7RBC 29protein 76glucose CSF HSV PCR: pending CSF gram stain: no PMN's or microorganisms CSF bacterial/viral cultures: pending Urine Tox positive for benzos (which were given in the ED), otherwise negative UA: trace blood, occ bacteria otherwise neg [**2138-5-26**] BCx: Coag negative staph in [**11-22**] vials [**2138-5-27**] BCx: [**2138-5-28**] BCx: [**2138-5-26**] PICC catheter tip: NGTD C. Diff Toxin A: negative on three samples C. Diff Toxin B: pending [**2138-5-26**] Stool Cx: negative Imaging: [**2138-5-26**] CXR: No acute intrathoracic process. PICC tip in standard location. Limited evaluation fue to low lung volumes. [**2138-5-25**] Head CT: No acute intracranial process. [**2138-5-28**] TTE: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation may be present (clip [**Clip Number (Radiology) **]). The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2138-5-19**], the findings are similar. [**2138-5-28**] Bilateral LE US: [**2138-5-28**] Torso CT with Contrast: Brief Hospital Course: 63 yo WF w/ ETOH abuse, hemachromatosis, PUD w recent admission for severe pancreatitis/ARDS/intubation/MICU transfer was re-admitted on [**5-26**] with acute mental status change. Pt underwent CT head (neg), and LP in ED and was transferred to MICU. LP revealed only 3 WBC w/ lymphocytic predominance, 7 RBCs, 29 pro and 76 gluc. CSF Cx were NGTD. Pt was empirically given one dose of Vanc, levaquin, flagyl. Pt had fever and workup revealed pancreatic pseudocyst w >30% necrosis and levaquin/flagyl were continued. Pt also had resp distress/inability to protect airway and was intubated but quickly extubated within 48 hrs. Due to persistent MS change, pt underwent EEG which showed NCSE and she was loaded on Keppra. Pt's MS improved. MRI showed changes consistent with PRES. Pt was transferred to floor: . 1. Acute mental status change - LP neg for infection. EEG did show seizure activity, therefore loaded on keppra. Recent MRI shows changes of Posterior Reversible Leukoencephalopathy (PRES). Per Neuro, pt will need repeat MRI in 8 weeks and outpt FU w/ Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] at the same time. Of note, per pt's husband and notes, even prior to admission for pancreatitis, pt did have some issues with short term memory and word finding. On the day of discharge pt was alert and oriented X3 and not showing signs of obvious confusion. Given the HTN may have been the underlying etiology behind PRES, pt started on Norvasc and Metoprolol and BP under reasonable range after that. Neurology also wanted Keppra continued. 2. Pancreatic pseudocyst w/ necrosis - CT guided aspirate shows no growth so far. Per GI, pt will be given total 10 d course of Levaquin/Flagyl. Also, [**Name (NI) 653**], Resident on Surgery, and given that Cx is sterile, they do not recommend further interventions for the pseudocyst. 4. Diarrhea - Stool C&S, campy, O&P, and Cdiff X 3 NGTD. [**Month (only) 116**] be related to pancreatitis. Is on pancreatic enzyme replacement. Since infectious workup was neg, and pt was afebrile w nl WBC, pt was started on imodium and improvement in diarrhea was noted. 5. Anemia - Pt had stable anemia noted and had no active signs of bleeding. Pt's stool guaiac was neg X1. Pt has had a colonoscopy in [**2135**] which was neg. 6. Hx depression - Initially pts psych meds were held as diagnosis was unclear and given fever, seretonin syndrome was on differential but these were later restarted. 7. Renal insufficiency - Before admission in [**Month (only) **] cr 0.8-0.9. Cr worsened initially during ICU stay likely [**12-21**] hypotension and improved and stabilized around 1.1-1.2 8. Abnormal thyroid function - Pt had high tSH (19) and low ft2 (0.73). In the setting of recent criticall illness, this likely represents sick euthyroid and therefore, will not start synthroid. Will need recheck in a few weeks by PCP. [**Name10 (NameIs) **] was sent home w/ home services and follow up appt w/ PCP, [**Name10 (NameIs) **] and Neuro Medications on Admission: -Acetaminophen 1000 mg Capsule Sig: [**11-20**] Capsules PO every [**2-23**] hours as needed for pain. -Heparin 5000 SQ TID -Quetiapine 50 mg Tablet PO at bedtime -Oxycodone 5 mg Tablet PO Q4H prn for pain. -Folic Acid 1 mg Tablet PO DAILY -Thiamine HCl 100 mg PO DAILY -Loperamide 2 mg PO QID prn for diarrhea. -Fentanyl 25 mcg/hr Patch Q72 hr -Aspirin 81 mg PO once a day -Omeprazole 20 mg po daily -Venlafaxine 75 mg PO daily -Amlodipine 7.5mg po qhs -psyllium powder 3.7gm [**Hospital1 **] prn Discharge Medications: 1. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: [**11-20**] Caps PO TID W/MEALS (3 TIMES A DAY WITH MEALS): This medication is to help with diarrhea, which pt with pancreatitis can have. Disp:*120 Cap(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): This is for history of Acid Reflux. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): For blood pressure. Disp:*60 Tablet(s)* Refills:*2* 4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for loose stools. Disp:*60 Capsule(s)* Refills:*0* 5. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day) as needed: for loose stools. Disp:*30 Packet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): For Blood Pressure. Disp:*60 Tablet(s)* Refills:*2* 7. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed. Disp:*15 Tablet(s)* Refills:*0* 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Antibiotic. finish course. Disp:*9 Tablet(s)* Refills:*0* 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Antibiotic. Finish course. Disp:*3 Tablet(s)* Refills:*0* 12. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): For Seizures. Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: RPLS. Reversible Posterior Leukoencephalopathy Syndrome Pancreatic pseudocyst Alcohol abuse Hemachromatosis hx of PUD Discharge Condition: Good Discharge Instructions: You were admitted to the hospital with mental status change. You were admitted to the ICU and briefly needed to be put on mechanical ventilation. You were found to have findings on MRI consistent with RPLS, reversible posterior leukoencephalopathy syndrome, which can sometimes be associated with high blood pressure. the EEG also revealed that you were having seizures, so you were started on an anti-epileptic. Neurology wants the MRI to be repeated in ~8 weeks and would like to see you after the MRI. These appointments have been made. You are doing much better from mental status point but should there be any changes, please return to ED You were found to have a pseudocyst around your pancreas. This is a complication from your recent attack of pancreatitis. This was aspirated and it did not show any infection. Gasteroenterology and Surgery were consulted and they recommended 10d antibiotic course but no interventions. You have been made appointment with your GI doctor to follow up on this. You also developed some diarrhea in the hospital but workup did not show any signs of infection. Your diarrhea appears to be slowing down, you may take imodium to help but if your diarrhea worsens or you notice blood in stool or abdominal pain or fevers, please return to ED We checked thyroid function in you. It was mildly abnormal but likely does not represent true thyroid disease. Please have your PCP recheck them in [**4-27**] weeks. Followup Instructions: Please follow up w/ your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2472**] on Tuesday [**2140-6-9**]:45am at [**Hospital3 **]. Please also follow up w/ appts below Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2138-6-24**] 1:00 Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2138-7-24**] 10:35 Provider: [**Name10 (NameIs) 640**] [**Name11 (NameIs) 747**] [**Name12 (NameIs) **], M.D. Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2138-7-24**] 1:00

[ "403.90", "303.91", "327.23", "533.70", "585.9", "577.1", "345.3", "437.2", "311", "275.0", "285.9", "577.2" ]

icd9cm

[ [ [] ] ]

[ "89.14", "88.72", "96.71", "97.49", "52.11", "03.31", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

10627, 10685

5367, 8377

330, 342

10847, 10854

3586, 3586

12347, 12947

2823, 2841

8925, 10604

10706, 10826

8403, 8902

10878, 12324

2881, 3567

274, 292

370, 1698

4424, 5344

3602, 4415

1720, 2422

2438, 2807

21,125

194,881

5222

Discharge summary

report

Admission Date: [**2148-3-14**] Discharge Date: [**2148-3-20**] Date of Birth: [**2089-4-7**] Sex: F Service: NEUROSURGERY Allergies: Levofloxacin / Cipro / Ivp Dye, Iodine Containing Attending:[**First Name3 (LF) 1835**] Chief Complaint: Ataxia, nausea and headache Major Surgical or Invasive Procedure: Left para suboccipital craniotomy for decompression of cyst on [**2148-3-15**]. History of Present Illness: 57-year-old female well known to our service with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**]-Lindau disease. She has had a resection of a left cerebellar hemangioblastoma on [**2144-5-12**] Dr [**First Name (STitle) **] because it was enlarging, s/p ventriculoperitoneal shunt placement, by Dr [**Last Name (STitle) **] on [**2147-12-5**], for impending obstructive hydrocephalus, s/p fractionated Cyberknife radiosurgery to a superior cerebellar and an inferior cerebellar hemangioblastomas, to a total dose of 6,000 cGy (600 cGy x 5 fractions) and 2,500 cGy (500 cGy x 5 fractions) respectively from [**2147-12-19**] to [**2147-12-28**], and s/p resection of a metastatic renal cell carcinoma in the conus by Dr [**Last Name (STitle) **] on [**2148-2-21**]. Her cerebellar hemangioblastomas were found after a seizure in [**2128**] and [**2129**]. She had been free of seizures for 15 years. A large left cerebellar hemangioblastoma was removed in [**State 4565**] in [**2130**]; During staging evaluations, renal tumors and liver cysts were found. She underwent bilateral partial nephrectomies in [**2131-4-9**]. In [**2138**] metastases from her renal tumors were found in her liver and in her thyroid. She received IL-2 and alpha-interferon at [**Hospital6 1129**] for 9 months and tolerated it. Her liver metastases went away. She had a partial thyroidectomy. Her systemic disease is stable. She is not aware of any cystadenoma in her broad ligament or edolymphatic sac tumors. She has been doing relatively well at home recovering from her recent spine surgeries. Approximately 0100 the day of admission she noted nausea, ataxia and headache she arrived here after talking with Neuro oncology clinic. Past Medical History: 1-Renal cell carcinoma 2-[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau dz. 3-Large left cerebellar hemangioblastoma removal in [**Location (un) **] Count, [**State 4565**] in [**1-/2131**] 4-Resection of a left cerebellar hemangioblastoma on [**2144-5-12**] by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], 5- s/p ventriculoperitoneal shunt placement, by [**First Name8 (NamePattern2) **] [**Doctor Last Name **] on [**2147-12-5**], for impending obstructive hydrocephalus, 6- s/p fractionated Cyberknife radiosurgery to a superior cerebellar and an inferior cerebellar hemangioblastomas, to a total dose of 6,000 cGy (600 cGy x 5 fractions) and 2,500 cGy (500 cGy x 5 fractions) respectively from [**2147-12-19**] to [**2147-12-28**]. 7-Seizure [**2130**];seizure free for 15 years. 8-Bilateral partial nephrectomies in [**2131-4-9**]. 9-Partial thyroidectomy. 10- Liver mets from renal cell carcinoma treated with IL-2 and alpha-interferon at [**Hospital6 1129**] for 9 months and tolerated it. Her liver metastases went away. Social History: Quit tobacco 30 yrs ago, rare ETOH use, lives with husband. She works as a purchasing [**Doctor Last Name 360**]. She has three children and one of them has [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**]-Lindau disease. Her ethnic background is Irish and [**Doctor First Name 533**]. Family History: Her father, paternal grandmother, and her sister also have [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21354**] disease. Physical Exam: O: T:97.5 BP: 158/81 HR: 76 R 18 O2Sats 95% Gen: Sleepy but arrousable remembered examiner from prior admission by name HEENT: Pupils: 3mm slightly reactive EOMs full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Back well healing thoracic lumbar incision Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech thick/garbled good comprehension and repetition. Naming intact. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-12**] throughout. No pronator drift Sensation: Intact to light touch, Toes downgoing bilaterally Coordination: + bilateral dysmetria, difficulty with heal to shin MRI: Large cystic lesion in cerebellum with surrounding edema ventricles unchanged since [**2-5**] MRI Pertinent Results: [**2148-3-14**] 11:26PM SODIUM-129* [**2148-3-14**] 11:26PM OSMOLAL-292 [**2148-3-14**] 04:52PM GLUCOSE-124* UREA N-22* CREAT-1.2* SODIUM-136 POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17 [**2148-3-14**] 04:52PM NEUTS-81.2* LYMPHS-15.7* MONOS-2.7 EOS-0.1 BASOS-0.3 [**2148-3-14**] 04:52PM WBC-3.8* RBC-5.52* HGB-15.2 HCT-45.6 MCV-83 MCH-27.5 MCHC-33.3 RDW-17.4* [**2148-3-14**] 04:52PM HYPOCHROM-1+ ANISOCYT-1+ MICROCYT-1+ [**2148-3-14**] 04:52PM PLT COUNT-354 MRA BRAIN W/O CONTRAST [**2148-3-14**] 6:26 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST FINDINGS: 1. Interval increase in size of cystic lesion with mural nodule. This is likely consistent with hemangioblastoma given the patient's history of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**]-Lindau syndrome. The peripheral enhancement and rapid growth are worrisome, however, and metastasis cannot be excluded. 2. Multiple foci of abnormal enhancement primarily in both cerebellar hemispheres are stable compared to the prior examination. MRA CIRCLE OF [**Location (un) **] IMPRESSION: 1. Normal circle of [**Location (un) 431**] MRA. CT HEAD W/O CONTRAST [**2148-3-16**] 10:07 AM CT HEAD W/O CONTRAST FINDINGS: Intracranial air has significantly improved with a small focus still present at the surgical site. A very small postoperative 5-mm hemorrhage is present at the surgical site that is unchanged from [**2148-3-15**] at 10:40. No extraaxial hemorrhage is identified. The patient is status post suboccipital craniotomy. A cystic heterogeneous structure appears unchanged from [**3-14**]. Ventricular catheter tip is in place, the lateral ventricles are not dilated. The cisterns, and sulci demonstrate no effacement in the cerebral hemispheres. Surrounding hypodensity within the cerebellum secondary to edema or encephalomalacia is unchanged. IMPRESSION: Improving intracranial air. Small 5-mm hemorrhage at the surgical site that is unchanged from yesterday. Brief Hospital Course: Pt seen and examined in the ED. Pt admitted to the Neurosurgery service. Pt admitted to the ICU for q1 neuro checks. The patient was placed on decadron 4q6, mannitol 50 q6, MRI, WAND study in AM. On [**3-15**] the patient was taken to the OR for a L para craniotomy and stereotactic drainage of hemangioblastoma cyst. From the OR, the patient was transfered to the ICU. She was following commands post-operatively in the ICU. Her exam, speech, and nausea slowly improved. On [**3-17**] the patient was transfered to the step-down unit and diet was started. She was also evaluated by PT and OT which both recommended rehab placement. She began lumbar XRT on [**3-18**] which will continue for 12 treatments. The radiation oncology team will coordinate her treatment once she is discharged to rehab. On [**2148-3-20**] the patient was tolerating a regular diet without nausea, had good pain control with PO pain meds, and was neurologically stable. She was subsequently discharged to rehab. Medications on Admission: Decadron, Levoxyl, Phenobarital Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Decadron 4 mg Tablet Sig: 0.5 Tablet PO twice a day: Please take 2mg by mouth 2 times a day till you see Dr. [**Last Name (STitle) **] in clinic. Please discuss the continuation with him at that time. Disp:*40 Tablet(s)* Refills:*0* 3. Phenobarbital 30 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*55 Tablet(s)* Refills:*0* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): take while on steroids. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 7 days. 12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) for 7 days: to start after [**Hospital1 **] doses finish. gabapentin will be discontinued completely after these 7 daily doses. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: cerebellar hemangioblastoma, cystic lesion in the posterior fossa with incipient herniation. Discharge Condition: neurologically stable. Discharge Instructions: Restart you home medications as usual. Please take newly prescribed medications as instructed. Have sutures removed [**3-25**] at rehab. You may remove the dressing in 2 days. Please keep you incision dry until you see Dr. [**Last Name (STitle) **] in clinic. * Increasing pain * Fever (>101.5 F) or Vomiting * Inability to eat or drink * Reddness/swelling/discharge from wounds * Anything that concerns you Followup Instructions: 1. Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Please call [**Telephone/Fax (1) 1669**] to make that appointment. 2. Follow-up with neuro oncology as previously scheduled

[ "198.4", "V10.52", "244.0", "197.7", "237.5", "759.6", "V45.2", "780.39" ]

icd9cm

[ [ [] ] ]

[ "01.24", "92.29" ]

icd9pcs

[ [ [] ] ]

9802, 9881

7201, 8201

341, 423

10018, 10043

5196, 7178

10503, 10698

3639, 3779

8283, 9779

9902, 9997

8227, 8260

10067, 10480

3794, 4122

274, 303

451, 2191

4339, 5177

4137, 4323

2213, 3296

3312, 3623

5,331

142,049

6177

Discharge summary

report

Admission Date: [**2118-4-19**] Discharge Date: [**2118-4-28**] Date of Birth: [**2049-7-21**] Sex: M Service: CARDIAC S. DATE OF DISCHARGE: Pending awaiting rehabilitation bed. CHIEF COMPLAINT: Increased chest pain and shortness of breath. HISTORY OF THE PRESENT ILLNESS: The patient is a 68-year-old gentleman with a known history of coronary artery disease and recent onset of atrial fibrillation. The patient complained of increased symptoms of dyspnea and angina. He underwent cardiac catheterization, which revealed three-vessel disease. He is now admitted for coronary artery bypass graft. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction 2. Recent onset atrial fibrillation in the past eight weeks. 3. Tuberculosis. The patient was hospitalized for two months in the [**2095**]. 4. Hypertension. 5. Noninsulin dependent diabetes mellitus. 6. Gastroesophageal reflux disease. 7. Prostate carcinoma status post XRT and brachytherapy. 8. CVA times three in [**2098**], [**2108**], and [**2111**]. 9. Hypercholesterolemia. PAST SURGICAL HISTORY: 1. Right carotid endarterectomy in [**2109**]. 2. Stomach repair status post multiple stab wounds in the [**2075**]. 3. Benign tumor left axillary area, probably [**2075**]. 4. Back surgery in [**2089**]. MEDICATIONS ON ADMISSION: 1. Plavix discontinued [**4-11**]. 2. Detrol 2 mg b.i.d. 3. Atenolol 75 mg in the AM; 50 mg q.PM. 4. Glyburide 3 mg b.i.d. 5. Lipitor 10 mg h.s. 6. Amitriptyline 10 mg q.d. 7. Zestril 30 mg q.a.m. and 10 mg q.p.m. ALLERGIES: The patient is allergic to ASPIRIN, WHICH CAUSES INCREASED FACIAL SWELLING AND INCREASED SHORTNESS OF BREATH. HOSPITAL COURSE: The patient underwent coronary artery bypass graft times on [**2118-4-19**]. The patient was taken to the CSRU intubated and on Milrinone and nitroglycerin drips. The patient was extubated on postoperative day #1. He was started on Amiodarone for atrial fibrillation. On postoperative day #2, the patient was slightly agitated and required Haldol. The blood pressure was labile and he needed antihypertensive medication. The patient continued to be in atrial fibrillation. He made slow progress over the next couple of days. He had some episodes of wheezing, which improved with treatment with nebulizers. The patient progressively improved in his mental status and he was more oriented in the next couple of days. On [**2118-4-24**], while on the bedside commode, the patient had a brief period of unresponsiveness for about 30 seconds. The heart rate and blood pressure were stable at this point. The patient was transferred to the regular floor in stable condition on postoperative day #6. While on the floor, the mental status again improved significantly. He was left confused and more oriented. He was started on heparin drip for atrial fibrillation and on Coumadin. The pacing wires were discontinued on postoperative day #7. He stayed in house until he became therapeutic on his Coumadin. He was ready for discharge to rehabilitation on postoperative day #9. MEDICATIONS ON DISCHARGE: 1. Lopressor 75 mg b.i.d. 2. Lasix 20 mg q.d. times one week. 3. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq q.d. times one week. 4. Colace 100 mg b.i.d. 5. Zantac 150 mg b.i.d. 6. Amiodarone 400 mg q.d. times one month. 7. Atrovent and Albuterol nebulizers q.4h.p.r.n. 8. Lisinopril 30 mg q.a.m., 10 mg q.p.m. 9. Coumadin 3 mg q.d. with goal INR 1.8 to 2.5. The primary care physician is to follow the INR after discharge from rehabilitation. 10. Glyburide 3 mg b.i.d. 11. Lipitor 10 mg h.s. 12. Tylenol with codeine one to two tablets q.4h. to 6h.p.r.n. CONDITION ON DISCHARGE: Stable. The patient is being discharged to a rehabilitation facility. FO[**Last Name (STitle) **]P CARE: The patient is to followup with Dr. [**First Name (STitle) **], primary care physician in two weeks and Dr. [**Last Name (Prefixes) **] in four weeks. INR has to be checked twice q.week at rehabilitation and will be followed by the primary care physician post discharge. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 2209**] MEDQUIST36 D: [**2118-4-28**] 11:43 T: [**2118-4-28**] 14:15 JOB#: [**Job Number 2674**]

[ "427.31", "780.2", "413.9", "458.2", "424.0", "401.9", "530.81", "414.01", "250.00" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

3134, 3740

1359, 1704

1722, 3108

1123, 1333

218, 625

647, 1100

3765, 4416

2,187

128,059

7996

Discharge summary

report

Admission Date: [**2134-4-21**] Discharge Date: [**2134-4-26**] Date of Birth: [**2087-11-5**] Sex: M Service: MEDICINE Allergies: Cephalosporins / Morphine / Fentanyl Attending:[**First Name3 (LF) 2297**] Chief Complaint: Fever, hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 46 yo M well known to our service with a history of morbid obesity, OSA, COPD, chronic trach, DM presenting to the ED from [**Hospital **] rehab with fever to 105 and hypoxia. He was on PS 12/5, 40% and desatted today to the 70s. He was transferred to the [**Hospital1 18**] ED. He was found to have a temp of 105.4, sinus tach to 140-150s, SBP 100-120s. CXR was sig. for increased bilateral pleural effusions and LUL infiltrate/edema. He was treated with Vanco/Meropenem/Bactrim IV. Cultures were taken. Fi02 was increased to 100% with PEEP 15 and improvement in his oxygenation to upper 90s. He was bolused a total of 850 cc NS. His fever was treated with tylenol/cooling blanket with improvement. RLE US was negative for DVT. Past Medical History: 1) DM2 diagnosed [**2114**] with triopathy: Creatinine has been as low as 0.8 in the last couple of years, however widely fluctuant, as high as 2 in the recent past. 0.9 in [**1-7**]. 2) COPD, on home O2. Multiple episodes of respiratory failure requiring intubation in recent years. Most recently, was admitted in [**12-6**] with a perforated transverse colon requiring partial colectomy and transverse colostomy. This course c/b anticipated respiratory failure and anticipatory tracheostomy, pseudomonal and MRSA PNA. Also with acalculous cholecystitis requiring cholecystostomy tube. Had G-tube placed. 3) OSA on CPAP 3) VRE 4) s/p tracheostomy, as above in [**1-7**] 5) HTN 6) CHF: During hospitalization in [**10-20**] it was thought that failure contributed to his respiratory failure. Last echo was in [**12-6**] at which time LVEF thought to be roughly normal, however very poor study and RV not visualized. Not on lasix. 7) Anemia of chronic disease, multiple transfusions in the past 8) s/p BKA for chronic LE ulcer 9) TIA in [**2125**]. 10) Difficult intubation; fiberoptic guidance in [**Month (only) 359**] of [**2131**]. 11) Urinary retention. 12) Osteoarthritis. 13) Depression. 14) C. Difficile in [**2129**]. 15) Hypogonadism. 16) Morbid obesity . PAST SURGICAL HISTORY: 1. Bilateral carpal tunnel release in [**2123**]. 2. Hydrocele repair in [**2126-4-3**]. 3. Quadriceps tendon repair in [**2127**]. 4. Status post partial resection of transverse colon, end transverse colostomy, mucus fistula, jejunostomy tube and percutaneous tracheostomy on [**2132-12-16**]. Social History: Lives home alone with VNA. Denies etoh. Remote cigar smoking, no cigarettes. No IVDU or marijuana. Has 1 brother, [**Name (NI) **]. Family History: Non-contributory Physical Exam: PE: 101.5 125 106/36 96% AC 14x550, 15, 100%Fi02 GEN: A+O x 3, diaphoretic HEENT: PERRL, EOMI, MMM CV; Tachy, regular, no m/r/g LUNGS: distant, no crackles/wheezes ABD: soft, NTND +BS, +colostomy/ostomy, surgical scar EXT: s/p BKA left, right with no edema, improved erythema NEURO: moving all extremities Pertinent Results: Micro: [**4-23**] - C DIFF: negative [**4-23**] - Cath Tip Cx: negative [**4-22**] - BLOOD CX x 2: pending [**4-22**] - URINE CX: negative [**4-21**] - blood cultures x 3 pending, fungal isolators pending, Ucx pending; Sputum GRAM STAIN: >25 PMNs and <10 epi, GPC's; CULTURE: GNRs x 2-> sparse oral pharyngeal flora [**4-21**] - blood/fungal cultures pending [**4-21**] - urine culture pending- U/A negative [**4-12**] - urine 10-100,000 Acinetobacter sensitive to tobra/bactrim/gent [**4-11**] - sputum ACINETOBACTER BAUMANNII | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- 16 I 16 I CEFTAZIDIME----------- =>64 R =>64 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 2 S 2 S IMIPENEM-------------- 8 I 8 I LEVOFLOXACIN---------- 4 I MEROPENEM------------- 8 I PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- 64 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2134-4-26**] 04:49AM BLOOD WBC-5.7 RBC-2.86* Hgb-8.6* Hct-24.8* MCV-87 MCH-30.1 MCHC-34.8 RDW-16.5* Plt Ct-191 [**2134-4-24**] 03:15AM BLOOD WBC-4.5 RBC-2.27* Hgb-6.7* Hct-20.0* MCV-88 MCH-29.5 MCHC-33.7 RDW-16.9* Plt Ct-190 [**2134-4-23**] 03:59AM BLOOD WBC-6.5 RBC-2.50* Hgb-8.0* Hct-22.2* MCV-89 MCH-32.0 MCHC-36.1* RDW-17.0* Plt Ct-184 [**2134-4-21**] 05:53AM BLOOD WBC-13.6* RBC-2.78* Hgb-8.1* Hct-24.2* MCV-87 MCH-29.1 MCHC-33.3 RDW-16.9* Plt Ct-242 [**2134-4-26**] 04:49AM BLOOD Neuts-62.9 Lymphs-22.3 Monos-4.3 Eos-9.9* Baso-0.6 [**2134-4-25**] 04:30AM BLOOD Neuts-55.4 Lymphs-29.1 Monos-3.4 Eos-11.3* Baso-0.7 [**2134-4-21**] 05:53AM BLOOD Neuts-86.2* Bands-0 Lymphs-8.8* Monos-2.4 Eos-2.3 Baso-0.4 [**2134-4-26**] 04:49AM BLOOD PT-14.2* PTT-29.5 INR(PT)-1.3* [**2134-4-24**] 03:15AM BLOOD PT-13.5* PTT-28.7 INR(PT)-1.2* [**2134-4-22**] 02:45AM BLOOD PT-13.6* PTT-28.9 INR(PT)-1.2* [**2134-4-21**] 05:53AM BLOOD PT-13.9* PTT-29.8 INR(PT)-1.2* [**2134-4-21**] 12:40AM BLOOD Fibrino-588*# D-Dimer-2558* [**2134-4-25**] 04:30AM BLOOD Glucose-124* UreaN-36* Creat-1.7* Na-140 K-3.7 Cl-101 HCO3-31 AnGap-12 [**2134-4-24**] 03:15AM BLOOD Glucose-182* UreaN-39* Creat-1.7* Na-139 K-3.5 Cl-100 HCO3-29 AnGap-14 [**2134-4-23**] 03:59AM BLOOD Glucose-211* UreaN-37* Creat-1.9* Na-136 K-4.2 Cl-98 HCO3-28 AnGap-14 [**2134-4-21**] 05:53AM BLOOD Glucose-217* UreaN-38* Creat-1.8* Na-135 K-6.2* Cl-100 HCO3-27 AnGap-14 [**2134-4-25**] 04:30AM BLOOD ALT-8 AST-10 LD(LDH)-181 AlkPhos-32* TotBili-0.3 [**2134-4-22**] 10:48AM BLOOD LD(LDH)-182 TotBili-0.4 [**2134-4-21**] 05:53AM BLOOD proBNP-2283* [**2134-4-26**] 04:49AM BLOOD Calcium-8.6 Phos-5.4* Mg-1.6 [**2134-4-25**] 04:30AM BLOOD Calcium-9.0 Phos-5.0* Mg-1.6 [**2134-4-22**] 10:48AM BLOOD calTIBC-239* VitB12-671 Folate-7.8 Hapto-176 Ferritn-645* TRF-184* [**2134-4-22**] 10:48AM BLOOD TSH-2.1 [**2134-4-26**] 04:49AM BLOOD Tobra-PND [**2134-4-25**] 08:07AM BLOOD Type-ART Temp-36.7 Rates-/22 Tidal V-365 PEEP-10 FiO2-40 pO2-83* pCO2-44 pH-7.45 calHCO3-32* Base XS-5 Intubat-INTUBATED [**2134-4-24**] 02:26PM BLOOD Type-ART pO2-90 pCO2-48* pH-7.44 calHCO3-34* Base XS-6 Brief Hospital Course: A/P: 46 yo M with MMP presenting with fever and hypoxia. . # Hypoxic respiratory failure: Now requiring high fi02 and PEEP to oxygenate. CXR with increasing bilateral effusions and infiltrates. Has had multiple resistant organisms grow from his sputum including Acinetobacter, pseudomonas, citrobacter, MRSA. Completed 2 courses for VAP at last admission. Possibility of PE is also raised. Pt was on PPX heparin TID. LE us negative for DVT. He underwent trach change on [**4-24**]. He was on Vanco/Meropenem/Bactrim initially but this was changed to vanco/iminipenem/tobramycin for double coverage for VAP. Her respiratory culture only grew out oral pharyngeal flora. Her CXR as of [**4-26**] showed stable bilateral pleural effusion and opacities. There was initial consideration to tap the effusion but his respiratory status remained stable. He was also continued on lasix for diuresis of possible fluid overload to his pleural effusion. He was also continued his albuterol and atrovent inhalers. . # Fever: Lactate 2.5. Sources include PNA, UTI, line infection, clot. He was discharged on course of Vanco for RLE cellulitis during prior admission. During this admission, his lactate improved and central line was d/c after concern of line infection. He has remained afebrile since [**4-23**] with temperature in the 97-98F. His culture came back notably w/ actinobacter 10-100,000 colonies sensitive to tobramycin and intermediate to iminipenem. He is finish out w/ total 8 days of vanco/iminipenm/tobramycin for actinobacter UTI and possible VAP. . # Renal insufficiency: His creatine also slowly improved during this admission from 1.9 to 1.5. His medications including antibioitics were adjusted renally and his urine output was monitored closely. He was continued on lasix and repleted electrolytes carefully. . # Anemia: It has remained stable around 22-24. His anemia is consistent w/ anemia of chronic disease. His stools were guiaced and continued to follow his hct daily. His ferritin 645 (not consistent w/ iron defiency anemia), so his iron replacement was stopped. . #hypertension: He was taken off his labetolol and captopril given initiall concern of sepsis and respiratory failure. On the day of discharge, he was to be restarted on low dose captopril and uptitrated as tolerated. . # FEN: He was initially NPO for high PEEP requirements. He was restarted on diabetic diet once he was stabilized and his PEEP requirement on trach came down. . # PPX: He was continued on sc heparin TID (7500 units tid given his weight), PPI, peridex . # Contact: Brother [**Name (NI) **] . # Code: Full Medications on Admission: Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg PO Q12H (every 12 hours). 5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane TID (3 times a day). 8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**1-4**] Tablet, Sublinguals Sublingual PRN (as needed) as needed for chest pain. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Fluticasone 110 mcg/Actuation Aerosol Sig: Eight (8) Puff Inhalation [**Hospital1 **] (2 times a day). 13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 8-10 Puffs Inhalation QID (4 times a day). 14. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) ml PO DAILY (Daily). 15. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 16. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold if sbp<100, pulse<55. 17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 18. Clonazepam 1 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 20. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 21. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): hold if sbp<90. 22. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Ten (10) ML Intravenous DAILY (Daily) as needed. 23. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg Injection Q6H (every 6 hours) as needed. 24. Lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4 hours) as needed. 25. Furosemide 10 mg/mL Solution Sig: Eighty (80) mg Injection DAILY (Daily). 26. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 7 days. 27. Insulin Glargine 100 unit/mL Cartridge Sig: Sixty (60) units Subcutaneous twice a day: see additional sliding scale order. 28. Humalog 100 unit/mL Cartridge Sig: as dir units Subcutaneous four times a day: Sliding Scale FS<60 give oj, [**Name8 (MD) 138**] md FS61-120 mg/dL: 0 units 121-160 mg/dL: 2 units 161-200 mg/dL 4 201-240 mg/dL 6 241-280 mg/dL 8 281-320 mg/dL 10 321-360 mg/dL 12 361-400 mg/dL 14 >400 [**Name8 (MD) 138**] md. 29. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day). Discharge Medications: 1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4-6H (every 4 to 6 hours) as needed. 2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 8-10 Puffs Inhalation QID (4 times a day). 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Eight (8) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 8-10 Puffs Inhalation Q6H (every 6 hours). 5. Albuterol 90 mcg/Actuation Aerosol Sig: 8-10 Puffs Inhalation Q4H (every 4 hours) as needed. 6. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane TID (3 times a day). 7. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 1.5 ml Injection TID (3 times a day). 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 10. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral PRN (as needed). 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 12. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 13. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed. 14. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed for nausea. 15. Furosemide 10 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 16. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 17. Clonazepam 1 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 18. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 19. Insulin Glargine 100 unit/mL Solution Sig: Sixty Seven (67) unit Subcutaneous twice a day: please also check glucose 4 times per day. FS<60 give oj, [**Name8 (MD) 138**] md FS61-120 mg/dL: 0 units 121-160 mg/dL: 2 units 161-200 mg/dL 4 201-240 mg/dL 6 241-280 mg/dL 8 281-320 mg/dL 10 321-360 mg/dL 12 361-400 mg/dL 14 >400 [**Name8 (MD) 138**] md. . 20. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 2 days. 21. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 4 days. 22. Tobramycin Sulfate 40 mg/mL Solution Sig: One (1) Injection Q48H (every 48 hours) for 6 days. 23. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed. 24. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 25. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 26. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 27. Outpatient Lab Work please check daily CBC, electrolytes, creatine, and coagulation please check tobramycin trough at 11pm on [**4-27**] and should be <2.0 please dose iminepem according to daily creatine clearance please check vanco trough level tomorrow and trough should be [**5-12**] 28. Captopril 25 mg Tablet Sig: One (1) Tablet PO three times a day: please titrate up as indicated for BP<130/80. Pt's captopril dose prior to admission was 75mg tid. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: actinobacter UTI hypoxic respiratory failure pneumonia right lower extremity cellulitis line infection acute renal failure chronic renal insuffiency diastolic heart dysfunction anemia of chronic disease diabetes Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:2L fluid restriction Please call if recurrent fever, chills, chest pain, shortness of breath, abdominal pain. please take all of your medications as listed in discharge summary please call hospital for followup on micro results [**Telephone/Fax (1) 4645**] please check for daily labs including electrolytes (ca/phos/mg), CBC and coagulation. please check tobramycin level at 11pm on [**4-27**] and keep trough level <2 please check vancomycin trough level on [**4-27**], and keep trough level [**5-12**] please adjust iminipenem according to creatine clearance please consider stopping phoslo once phosphate level normalizes please uptitrate captopril (meds on admission) as BP stablizes; held per low blood pressure; and then restart labetolol slowly please remove PICC line once pt finishes antibiotic therapy Followup Instructions: please call for followup with your primary care physician [**Last Name (NamePattern4) **] [**1-4**] weeks

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Discharge summary

report

Admission Date: [**2191-4-22**] Discharge Date: [**2191-4-26**] Date of Birth: [**2128-11-6**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: [**2191-4-22**] 1. Mitral valve repair with [**Month/Day/Year 37169**] leaflet (P2) resection and ring annuloplasty using an [**Doctor Last Name **] 32-mm Physio II ring. 2. Coronary artery bypass grafting x1, with a reversed saphenous vein graft from the aorta to the first obtuse marginal coronary artery. 3. Endoscopic right greater saphenous vein harvesting. 4. Resection of [**Doctor Last Name 8813**] valve mass. History of Present Illness: 62 year old male with strept viridans mitral valve endocarditis who has completed his 6 weeks treatment with antibiotics. Follow up TEE was performed on [**3-30**]. TEE shows partial [**Month/Year (2) 37169**] leaflet flail with moderate to severe mitral regurgitation. Also notable for small mass on [**Month/Year (2) 8813**] valve. Dr.[**Last Name (STitle) 914**] has been following Mr.[**Known lastname 37170**] progression and the pt has been seen in clinic to discuss plans for surgical correction/timing of his mitral valve. He presents for cardiac cath today, preop MVR, and coronary artery, single vessel disease was revealed. Past Medical History: Endocarditis - Strept. Viridans moderate mitral regurgitation,MVP, myxomatous leaflets moderate pulmonary hypertension,emphysema,hyperlipidemia [**Doctor Last Name 9376**] syndrome Past Surgical History:s/p colonoscopy with polypectomy [**2190-12-14**] ORIF for right both column acetabular fracture in [**2188**] multiple R rib fractures and pneumothorax requiring chest tube [**2-/2189**] Social History: Lives with: spouse Occupation: construction Tobacco: 40 pack year quit ETOH: 1-2 drinks per week Family History: cardiac none - cancer -lung father, GI mother Physical Exam: Pulse:66 Resp:18 O2 sat: 96% B/P 111/71 Height: 68" Weight: 184 General:pleasant, A&O x3, NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur SEM III/VI Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:2+ Left:2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: Left: Radial Right: Left: Carotid pulses 2+(B), no bruits appreciated Pertinent Results: [**2191-4-22**] Intra-op Echo: Conclusions PRE-CPB:1. The left atrium is mildly dilated. No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. 2. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Overall left ventricular systolic function cannot be reliably assessed due to severe MR. 3. Right ventricular chamber size and free wall motion are normal. 4. The [**Month/Day/Year 8813**] root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three [**Month/Day/Year 8813**] valve leaflets. The [**Month/Day/Year 8813**] valve leaflets (3) are mildly thickened. There is a probable [**Month/Day/Year **] on the [**Month/Day/Year 8813**] valve. There are filamentous strands on the [**Month/Day/Year 8813**] leaflets consistent with Lambl's excresences (normal variant). There is no [**Month/Day/Year 8813**] valve stenosis. Trace [**Month/Day/Year 8813**] regurgitation is seen. 6. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. Torn mitral chordae are present. 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). Dr. [**Last Name (STitle) 914**] was notified in person of the results. POST-CPB: On infusion of phenylephrine. Sinus rhythm. Well-seated annuloplasty ring in the mitral position. No MR, no MS. [**First Name (Titles) **] [**Last Name (Titles) **] is no longer visible post bypass. AI remains trace. Biventricular systolic function is preserved. [**Last Name (Titles) **] contour is normal post decannulation. [**2191-4-25**] 04:20AM BLOOD WBC-6.4 RBC-3.42* Hgb-10.7* Hct-30.7* MCV-90 MCH-31.3 MCHC-34.9 RDW-13.4 Plt Ct-98* [**2191-4-25**] 04:20AM BLOOD Glucose-110* UreaN-13 Creat-0.9 Na-140 K-4.0 Cl-99 HCO3-35* AnGap-10 [**2191-4-24**] 06:15AM BLOOD WBC-8.1 RBC-3.44* Hgb-10.8* Hct-30.7* MCV-90 MCH-31.5 MCHC-35.2* RDW-13.5 Plt Ct-78* [**2191-4-24**] 06:15AM BLOOD Glucose-133* UreaN-16 Creat-0.9 Na-139 K-4.1 Cl-100 HCO3-32 AnGap-11 [**2191-4-26**] 04:20AM BLOOD WBC-6.9 RBC-3.35* Hgb-10.6* Hct-29.9* MCV-89 MCH-31.6 MCHC-35.4* RDW-13.3 Plt Ct-128* [**2191-4-26**] 04:20AM BLOOD UreaN-12 Creat-0.8 Na-139 K-4.0 Cl-100 Brief Hospital Course: The patient was brought to the operating room on [**2191-4-22**] where the patient underwent Mitral Valve repair, CABG x 1, and resection of [**Date Range 8813**] leaflet mass with Dr. [**Last Name (STitle) 914**]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. All OR cultures were negative at the time of discharge and it was determined that no antibiotics were needed. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with VNA services in good condition with appropriate follow up instructions. Medications on Admission: ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled every 6 hours as needed FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Dose adjustment - no new Rx) - 100 mcg-50 mcg/Dose Disk with Device - 1 puff(s) inhaled daily rinse mouth after use SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once daily TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 1 capsule inhaled once a day Medications - OTC ASPIRIN [ASPIR-81] - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day B COMPLEX VITAMINS [VITAMIN B COMPLEX] - (Prescribed by Other Provider) - Dosage uncertain FERROUS SULFATE - (OTC) - Dosage uncertain FISH OIL-DHA-EPA - (OTC) - 1,200 mg-144 mg Capsule - 2 Capsule(s) by mouth once a day Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 2. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 5 days. Disp:*10 Tablet Extended Release(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation twice a day. 7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 9. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA Discharge Diagnosis: Endocarditis - Strept. Viridans moderate mitral regurgitation,MVP, myxomatous leaflets moderate pulmonary hypertension,emphysema,hyperlipidemia [**Doctor Last Name 9376**] syndrome Past Surgical History:s/p colonoscopy with polypectomy [**2190-12-14**] ORIF for right both column acetabular fracture in [**2188**] multiple R rib fractures and pneumothorax requiring chest tube [**2-/2189**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Trace edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2191-5-4**] 10:30 Surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**], [**2191-5-17**] 1:45 Cardiologist Dr. [**Last Name (STitle) 1147**], [**5-23**] at 9:45am Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 37171**] in [**3-8**] weeks ID: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] **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:[**2191-4-26**]

[ "277.4", "429.5", "272.4", "416.8", "414.01", "424.0", "V12.09", "424.1", "492.8" ]

icd9cm

[ [ [] ] ]

[ "36.11", "39.61", "35.33", "35.11" ]

icd9pcs

[ [ [] ] ]

8480, 8531

5279, 6544

317, 754

8966, 9134

2665, 5256

9922, 10649

1966, 2014

7428, 8457

8552, 8733

6570, 7405

9158, 9899

8755, 8945

2029, 2646

270, 279

782, 1420

1442, 1623

1851, 1950

59,375

131,051

34844

Discharge summary

report

Admission Date: [**2158-1-7**] Discharge Date: [**2158-1-12**] Date of Birth: [**2109-9-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 18369**] Chief Complaint: AMS Major Surgical or Invasive Procedure: none History of Present Illness: 48 year old male with metastatic renal cell cancer, st. post nephrectomy and debulking surgery 2-3 weeks ago and spinal surgery. Pt.'s sister called ONC stating he has been getting progressively more confused. Ca was 11.8 on [**2158-1-2**]. . In the ED, initial vs were: BP 128/74 P 108 R 20@99%2L O2 sat. Patient was given Vanc and Zosyn. 7 L IVF w/ minimal UOP. 106, 110/68, 25, 95% on 3L NC. . On the floor, he complains of thirst, mild RLQ pain and dyspnea on exertion. Also endorses subjective confusion, decreased appetite. Denies fevers. + cough, occasionally productive of sputum. No CP. + some constipation. No dysuria. Feels diffusely weak. Endorses some double vision but this is chronic. Past Medical History: - Metastatic renal cell ca: bone scan on [**9-9**] was repeated that showed intense uptake in the L2 vertebral body and L3 pedicle with correlative lesions on CT and MRI, and multiple additional abnormal sites of tracer uptake in the left parietal skull and ninth and tenth ribs and anterior left first rib. - Atrial fibrillation, was on coumadin but stopped prior to the surgery for his kidney - Depression - HTN Social History: Smoking: nonsmoker, quit [**2157-9-21**] Alcohol: none, quit drinking 10 yrs ago, drank heavily prior Drugs: none Born: Windott MI Lives: [**Location 4288**], lives with sister [**Name (NI) **] Relationship: single, 2 kids 1 boy 23 1 girl 28 STD's: none Occupation: worked in a steel mill for about 30 yrs Family History: Mother: deceased, had htn, on dialysis, Father: alive age 85, cabg Ca: ?mother may have had a lung nodule in late life Physical Exam: Vitals: T: BP: 96/64 P: 118 R: 20 O2: 92% on 4L NC General: Somewhat toxic appearing, lethargic, NAD, breathing comfortably HEENT: Dry MM, pupils unequal (R pupil irregular), EOMI but eyes appear to be dysconjugate Neck: supple, JVP not elevated, no LAD, RIJ in place Lungs: + occasional rhonchi bilaterally with poor air movement throughout CV: tachycardic, irregular, no murmurs, rubs, gallops Back: Vertical midline scar w/ minimal erythema, mild R CVA tenderness Abdomen: soft, minimally tender in RLQ, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2158-1-11**] 10:31AM BLOOD WBC-32.0* RBC-3.33* Hgb-10.7* Hct-31.2* MCV-94 MCH-32.1* MCHC-34.2 RDW-16.2* Plt Ct-173 [**2158-1-6**] 10:40PM BLOOD WBC-21.3* RBC-3.94* Hgb-12.4* Hct-35.1* MCV-89 MCH-31.4 MCHC-35.3* RDW-14.9 Plt Ct-179 [**2158-1-6**] 10:40PM BLOOD Calcium-12.7* Phos-2.4* Mg-2.0 Brief Hospital Course: A 48 yo M with metastatic renal cell carcinoma s/p R nephrectomy and debulking surgery presents w/ altered mental status, hypercalcemia, leukocytosis and hypoxia. . # Altered mental status: On presentation, the patient was noted to have hypoxia, hypercalcemia, anemia and worsening mental status. CT head and MRI did not show evidence of metastatic disease, his altered mental status was felt to be multifactorial from his worsening metastatic disease, lactic acidosis, hypercalcemia, hypoxia. He was admitted to the ICU and stabilized, given lasix and bisphspohanates and IV fluids for hypercalcemia, treated with broad spectrum ABX for possible post obstructive pneumonia, given oxygen. He had episodes of Afib with RVR, was started on digoxin and metoprolol and his HR remained between 100-110. He was also started on a heparin gtt. . Once transferred to the floor he was noted to have a leukocytosis despite ABX, C. Diff was ruled out and this was felt to be a stress response. His heparin gtt was stopped given his risk of bleeding. The oncology team planned to start sumatinib if the patient's status improved to the point he could tolerate chemo. However, his mental status continued to decline, he was unresponsive to antibiotics, and his blood pressure was marginal with IVF and he started to become anasarcic. He then was unable to take PO medications and it was decided that he could not get chemo. His family was consulted daily, and always at the bedside. We discontinued medications except for those that would make the patient comfortable. He passed away with his family at the bedside . Medications on Admission: Buproprion SR 150mg PO Qday Carvedilol 3.125mg PO BID Digoxin 250mcg PO Qday Methadone 10mg PO Q4h Omeprazole 20mg PO Qday Prochlorperazine 10mg PO Q8 Simvastatin 10mg PO QHS Colace 100mg PO Qday Discharge Disposition: Expired Discharge Diagnosis: patient deceased Discharge Condition: pt. deceased

[ "198.89", "789.59", "V15.82", "276.2", "189.0", "V45.73", "288.60", "427.31", "285.9", "198.5", "275.42" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4839, 4848

2977, 3152

318, 324

4908, 4923

2659, 2954

1840, 1960

4869, 4887

4618, 4816

1975, 2640

275, 280

352, 1061

3167, 4592

1083, 1500

1516, 1824

2,473

104,994

8748

Discharge summary

report

Admission Date: [**2155-7-23**] Discharge Date: [**2155-7-24**] Date of Birth: [**2101-10-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Chief complaint: acute renal failure, hyperkalemia Reason for ICU admission: Hypotension not responsive to 4L NS . Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 1356**] is a 53 year old male with CAD s/p MI, HTN, type 2 DM, PVD, who [**Known lastname 1834**] right groin exploration and femoral patch redo last week who presented to clinic today with fatigue for one week. He denies fevers, chills, nausea, vomiting, shortness of breath, diarrhea, constipation, abdominal pain. He does report significant surgical incision pain at right groin without significant drainage. In addition, he reported one hour of chest pressure several days ago while at rest which resolved and has not recurred. . In the ED, vitals were T 98.1, 74/47, 69, 18, 100% on RA. He was given 4LNS with only transient improvements of his blood pressure. In the ED, his blood pressure 70s-90s/ 50s-60s. A fast exam was performed in the ED and was negative. His bedside echo was unremarkable. He was not given antibiotics. . Upon arrival to the MICU, patient denied chest pain, lightheadedness, thirst, fevers, chills, dysuria, cough, shortness of breath, diarrhea, or any other concerning symptoms. Past Medical History: CAD s/p MI HTN DM, Type 2 Hyperlipidemia Peripheral Vascular Disease s/p L SFA stent/angioplasty [**8-26**] Arthritis Spinal spenosis Chronic back pain Bilateral knee surgery S/p liver orthotopic liver [**Month/Year (2) **] for ETOH cirrhosis Social History: Patient is a retired cook. He smoked 2 PPD for 40 years, but has since quit. He is a former alcoholic, but has been sober for 6 years Family History: Father died 42 years old from MI. Physical Exam: VS: HR 68, BP 118/60, RR 19, 96% on RA Gen: NAD, well appearing HEENT: EOMI, moist mucous membranes CV: RRR, no m/r/g, distant heart sounds Pulm: CTA b/l, no crackles, wheezes Abd: obese, soft, NT, ND Ext: severe right groin tenderness along the upper aspect of the surgical incision, +warm, but no visible drainage, right sided 2+pitting edema Neuro: AxOx3, moving all extremities Pertinent Results: [**2155-7-24**] 05:00AM BLOOD WBC-5.1 RBC-2.80* Hgb-8.3* Hct-25.6* MCV-91 MCH-29.6 MCHC-32.5 RDW-14.8 Plt Ct-217 [**2155-7-23**] 02:35PM BLOOD WBC-5.8 RBC-2.97* Hgb-8.9* Hct-26.7* MCV-90 MCH-29.8 MCHC-33.1 RDW-15.4 Plt Ct-266 [**2155-7-23**] 09:45AM BLOOD WBC-8.1 RBC-2.69* Hgb-8.3* Hct-24.6* MCV-92 MCH-30.7 MCHC-33.5 RDW-15.1 Plt Ct-265 [**2155-7-24**] 05:00AM BLOOD Neuts-66.2 Lymphs-26.2 Monos-5.3 Eos-1.8 Baso-0.5 [**2155-7-23**] 02:35PM BLOOD Neuts-69.0 Lymphs-24.2 Monos-4.9 Eos-1.6 Baso-0.4 [**2155-7-24**] 05:00AM BLOOD Plt Ct-217 [**2155-7-24**] 05:00AM BLOOD PT-12.8 PTT-29.1 INR(PT)-1.1 [**2155-7-23**] 02:35PM BLOOD Plt Ct-266 [**2155-7-23**] 02:35PM BLOOD Plt Ct-266 [**2155-7-23**] 02:35PM BLOOD PT-13.0 PTT-28.4 INR(PT)-1.1 [**2155-7-23**] 09:45AM BLOOD Plt Ct-265 [**2155-7-24**] 03:46PM BLOOD UreaN-28* Creat-2.1* Na-137 K-5.3* Cl-109* HCO3-21* AnGap-12 [**2155-7-24**] 05:00AM BLOOD Glucose-56* UreaN-30* Creat-2.1* Na-138 K-5.3* Cl-107 HCO3-21* AnGap-15 [**2155-7-23**] 10:44PM BLOOD Glucose-199* UreaN-34* Creat-2.2* Na-136 K-5.3* Cl-108 HCO3-20* AnGap-13 [**2155-7-23**] 07:31PM BLOOD Glucose-181* UreaN-36* Creat-2.2* Na-136 K-5.9* Cl-109* HCO3-20* AnGap-13 [**2155-7-23**] 02:35PM BLOOD Glucose-147* UreaN-43* Creat-2.8* Na-135 K-5.5* Cl-103 HCO3-24 AnGap-14 [**2155-7-23**] 09:45AM BLOOD UreaN-40* Creat-2.7* Na-132* K-6.2* Cl-99 HCO3-24 AnGap-15 [**2155-7-24**] 05:00AM BLOOD ALT-17 AST-17 LD(LDH)-195 CK(CPK)-41 AlkPhos-36* TotBili-0.2 [**2155-7-23**] 02:35PM BLOOD ALT-19 AST-17 AlkPhos-45 TotBili-0.2 [**2155-7-23**] 09:45AM BLOOD ALT-20 AST-19 AlkPhos-43 TotBili-0.2 [**2155-7-23**] 02:35PM BLOOD Lipase-11 [**2155-7-24**] 05:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2155-7-24**] 05:00AM BLOOD Albumin-3.4 Calcium-8.6 Phos-3.2 Mg-2.2 [**2155-7-23**] 10:44PM BLOOD Calcium-8.2* Phos-2.7 Mg-1.6 [**2155-7-23**] 07:31PM BLOOD Calcium-7.5* Phos-2.9 Mg-1.6 [**2155-7-23**] 02:35PM BLOOD Albumin-3.8 [**2155-7-23**] 09:45AM BLOOD Albumin-4.1 Calcium-9.4 Phos-4.1 Mg-1.8 [**2155-7-23**] 09:45AM BLOOD tacroFK-5.4 [**2155-7-23**] 02:35PM BLOOD LtGrnHD-HOLD [**2155-7-23**] 10:48PM BLOOD Type-[**Last Name (un) **] Comment-GREEN TOP [**2155-7-23**] 02:36PM BLOOD Comment-GREEN TOP [**2155-7-23**] 10:48PM BLOOD Lactate-1.2 [**2155-7-23**] 02:36PM BLOOD K-5.2 . CXR-IMPRESSION: Normal chest radiograph . u/s groin-IMPRESSION: Hematoma without evidence for pseudoaneurysm. Brief Hospital Course: Mr. [**Known lastname 1356**] is a 53 yo male with PVD, HTN, HL, CAD s/p MI, s/p liver [**Known lastname **] for alcoholic cirrhosis, admitted to the MICU for hypotension. . Hypotension. Patient had significant hypotension in the ED that required 4L of NS to normalize, and patient is now normotensive in the MICU. Perhaps hypotension is related to overdiruesis with home lasix dose, and med effect from several antihypertensives, however there is concern for early sepsis in this patient who is immunosuppressed with cellcept and prograf. Patient has significant right groin pain, making the surgical site the most likely source of infection. Normal lactate is reassuring. Significant blood loss is less likely given Hct is stable over the past week. Another possibility is cardiac etiology of hypotension given transient chest pressure several days ago, but this seems less likely in the setting of unchanged EKG. PT covered with vanco/zosyn overnight. He was switched to bactrim/cipro in am. U/S showing hematoma but no sign of abscess. Pt given IVF and home diuretics and anti-hypertensives held with good effect. Home BP meds except ACEI and diuretic were resumed upon discharge. . Acute Renal failure. Patient has baseline creatinine between 1.8 and 2, now with rising Creatinine to 2.8. He likely has pre-renal ARF as it responded to 4LNS bolus, though it remains above baseline. Prograf may be causing the elevated Cr as well, but dose was lowered today. Cr returned to near baseline. Prograf and cellcept continued. . Hyperkalemia. Likely secondary to renal failure and groin hematoma resorption. No EKG changes. Pt got 2 doses of kayexylate. He will have labs drawn in a few days and results will be sent to his hepatologist. In addition, his baseline K is around 5. . Right groin wound. Patient is s/p femoral graft removal and replacement due to infection last week. Now with significant wound tenderness. No clear evidence of drainage. U/S showing small hematoma, no sign of abscess. Cilostazol 50mg [**Hospital1 **]. Per vascular, pt may stop the cipro and resume his normally scheduled dosing of bactrim. . S/p Liver [**Hospital1 **]. Patient is s/p liver [**Hospital1 **] in [**2150**] for alcoholic cirrhosis. Currently on prograf and cellcept. Prograf dose reduced today from 5 mg [**Hospital1 **] to 4 mg [**Hospital1 **]. Immunosuppressants continued. Bactrim ppx continued. . CAD s/p MI. Patient has EKG without ischemic change. S/p chest pressure 4 days ago. - consider echo if not clear source of hypotension . HTN. - hold home antihypertensives (Lisinopril, atenolol, nifedepine) . DM, Type 2. - NPH and ISS - follow fingersticks . Hyperlipidemia. - continue lipitor . Peripheral Vascular Disease s/p L SFA stent/angioplasty [**8-26**] Cilostazol 50 mb [**Hospital1 **] - vascular following . Medications on Admission: Fosamax 70 mg weekly Atenolol 50 mg daily Lipitor 40 mg daily Cilostazol 50 mb [**Hospital1 **] Cipro 500 q 12 hours Nexium 40 mg daily Tricor 145 mg daily Lasix 20 mg every other daily Hydromorphone 2-4 mg q 4-6 hours NPH 48 q am, 28 qpm with HISS Lisinopril 5 mg daily Cellcept [**Pager number **] mg [**Hospital1 **] Nifedipine 30 mg daily Viagra prn Tacrolimus 4 mg [**Hospital1 **] Detrol LA 4 mg [**Hospital1 **] Trazodone 100 mg prn insomnia Bactrim [**Hospital1 **] Aspirin 325 daily Calcium Carbonate 1500 [**Hospital1 **] Discharge Medications: 1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Cilostazol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for PVD. 4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 10. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2 times a day). 11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours. 14. Nifedipine 30 mg Tablet Extended Rel 24 hr (2) Sig: One (1) Tablet Extended Rel 24 hr (2) PO once a day. 15. Calcium Carbonate 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: see below Subcutaneous twice a day: 48 units qam 28 units qpm. 17. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous as directed. 18. Outpatient Lab Work chemistry panel, including potassium. to be done [**7-26**]. Fax results to Patient Phone: ([**Telephone/Fax (1) 1582**] Patient Fax: ([**Telephone/Fax (1) 12173**] Discharge Disposition: Home Discharge Diagnosis: Major: hypotension due to hypovolemia acute renal failure hyperkalemia . s/p R.femoral vascular surgery s/p liver [**Telephone/Fax (1) **] Discharge Condition: stable Discharge Instructions: You were admitted for low blood pressure and fatigue. For the low blood pressure you were given IVF and your home diuretics were stopped. Your low blood pressure resolved. You also were evaluated by the vascular surgery team and [**Telephone/Fax (1) 1834**] a groin ultrasound that showed a small hematoma but no evidence of infection or aneurysm. In addition, you had mild renal failure that resolved with the above treatments. . You should not take your lasix or lisinopril until you see your liver doctor. However your other blood pressure medications, atenolol and nifedipine should be resumed upon discharge. . You should see your liver doctor within 1 week of discharge. . Please continue to take you medications as prescribed and follow up with the appointments below. . You also had elevated blood potassium. For this you were given a dose of kayexylate. You should be sure to have this blood level checked either at your PCP or liver doctor's office within 2 days. . Followup Instructions: Please make sure you follow up the liver service within 1 week of discharge. . Please also be sure to follow up with your PCP. . Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2155-7-31**] 4:00 . Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2155-8-19**] 10:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2155-8-19**] 10:00

[ "458.8", "401.9", "440.4", "998.12", "584.9", "V42.7", "414.01", "E878.2", "440.20", "250.00", "276.52", "272.4", "412", "276.7" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9849, 9855

4806, 7627

432, 439

10038, 10047

2389, 4783

11072, 11625

1936, 1971

8210, 9826

9876, 10017

7653, 8187

10071, 11049

1986, 2370

294, 394

467, 1502

1524, 1769

1785, 1920

12,530

193,604

758

Discharge summary

report

Admission Date: [**2169-8-9**] Discharge Date: [**2169-8-12**] Date of Birth: [**2094-11-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Bradycardia (slow heart rate) Major Surgical or Invasive Procedure: Implantation of a Pacemaker ([**Company 1543**] VDD type single lead) History of Present Illness: Mr. [**Known firstname 1975**] [**Known lastname 5512**] is a 74 yo [**Known lastname 595**]-speaking male with ESRD on HD, h/o mild CAD, hypertension, dyslipidemia, diastolic dysfunction, who presented to hemodialysis today and was found to be bradycardic. He completed hemodialysis without any complications and had 2.5L of fluid removed. He had a heart rate of ~38 (35-40 per report) and was asymptomatic. He denied having any previous episodes of bradycardia. He denied any chest pain, palpitations, shortness of breath, leg swelling, lighheadedness, diziness, nausea, or vomiting. He was sent to the emergency room for further evaluation. . In the ER his VS were T98.7F, BP 189/81mmHg, HR 40, RR 24, SpO2 97% RA. His physical exam was normal; orthostasis, valsalva were not done. He received aspirin 81 mg. Hct was at his baseline of 35, cardiac enzymes were CK: 103, MB: 7 and Trop-T: 0.27. Cardiology was consulted and suggested admission to CCU for monitoring and possible PPM in AM. Prior to transfer to CCU: HR 34, BPM 190/80 mmHg, SpO2 99% RA, RR 18. . He has had one hospital admission ([**11-17**]) for bradycardia in the past in the setting of severe hyperkalemia (K=8.9). At that time he was treated with atropine and ended up with a wide-complex tachycardia requiring intubation and pressors. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST CARDIOVASCULAR HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: None. -PACING/ICD: None. - CAD - cath here in [**2155**] with moderate ramus intermedius disease (discrete 50% stenosis) and mild diastolic ventricular dysfunction - History of atrial fibrillation with [**Year (4 digits) 5509**] documented once in the ED in [**3-/2167**] - H/o bradycardia and WCT as above in HPI - ETT [**2153**]: Atypical symptoms in the absence of ischemic ECG changes or reversible defects by thallium to the acheived low level of exercise Social History: Pt lives alone, wife has passed away, retired. [**Year (4 digits) 595**] speaking only. Current smokes [**10-23**] cigs/day for 60yrs, [**1-13**]/wk EtOH, no ilicit drug use. Family History: Non-contributory Physical Exam: VITAL SIGNS - Temp 97.6F, BP 159/73mmHg, 42 HR, RR 13, O2-sat 98% RA GENERAL - well-appearing man in NAD, Oriented x3, comfortable, Mood, affect appropriate. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear, Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - Diffuse wheezing throughout lung fields, specifically in right posterior lungs, resp unlabored, no accessory muscle use. No rales/rhonchi/crackles HEART - PMI located in 5th intercostal space, midclavicular line. Regular rhytm, bradycardic, normal S1, S2. No m/r/g auscultated, although difficult to hear due to diffuse wheezing. No thrills, lifts. No S3 or S4. ABDOMEN - NABS, slightly distended with large kidneys palpable bilaterally, liver palpable in center of the abdomen as likely shifted due to kidney size, no rebound/guarding. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), No c/c/e. No femoral bruits. Lower legs both newly wrapped by home nurse due to stasis ulcers, not unwrapped at this time. LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-16**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, gait not assessed PULSES: Right: Carotid 2+ Femoral 2+ Popliteal Left: Carotid 2+ Femoral 2+ Popliteal 2+ (DP and PT not assessed due to wrapping, will do in am before procedure) Pertinent Results: Admission Labs ([**2169-8-9**]): WBC-7.1 HGB-11.3* HCT-35.6* PLT-207 GLUCOSE-88 UREA N-24* CREAT-4.3* SODIUM-140 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-28 ANION GAP-18 CALCIUM-8.9 PHOSPHATE-3.2 MAGNESIUM-1.7 CK-MB-7, cTropnT-0.27*, CK(CPK)-103 PT-13.2 PTT-39.1* INR(PT)-1.1 CXR ([**2169-8-11**]): Compared with [**2169-8-10**], a single lead right-sided pacemaker is in place, with lead tip over right ventricle. Otherwise, no significant change is detected. No pneumothorax identified. Pleural effusion again noted. Right upper zone calcified granuloma again noted. ECG ([**2169-8-9**]): Sinus rhythm with 2nd degree AV block with 2:1 conduction and occasional ectopic beats. Prolonged PR, RBBB and LAFB. Brief Hospital Course: Mr. [**Known firstname 1975**] [**Known lastname 5512**] is a 74 yo [**Known lastname 595**]-speaking male with h/o ESRD on HD, HTN, HL, and mild CAD who presented with asymptomatic bradycardia and underwent pacemaker placement. # Bradycardia - Patient presented with bradycardia consistent with 2nd degree AV block. His heart rates were in the 30's-40's at this time. He received a [**Company 1543**] single-lead pacemaker. He had difficult access for the pacemaker, and required multiple sticks on the right side. He ended up having it placed via axillary access on the right side, with some bleeding during the procedure. His pacemaker was in the correct place via follow-up CXR and an interrogation the morning after the procedure showed a normally functioning pacemaker. He had one episode of chest pain after an attempt at pacemaker insertion that was associated with no ECG changes and no elevation in cardiac enzymes. This pain was not thought to be cardiac-related. # Hypertension - Patient with persistent hypertension while in the CCU. His BP was highest post-dialysis, as he does not take his medications the morning before dialysis. We increased his dose of clonidine 0.2mg po daily to 0.2mg po bid. We continued his lisinopril, diovan, amlodipine, and HCTZ. His BP stabilized by the time of discharge on these medications, although he would likely benefit from outpatient BP monitoring. # CAD - Patient with history of coronary artery disease (last cath [**2155**] showed 50% lesion of ramus intermedius)who presented with asymptomatic bradycardia. It was felt that his bradycardia was unlikely to be related to current ischemia, and patient's ECG was not suggestive of ischemia or infarct. He was continued on aspirin 81mg po daily and he was started on simvastatin 40mg po daily. # Pump - Last echo in [**3-20**] showed mildly depressed systolic function, with LVEF = 55% and inferior/inferolateral hypokinesis. It was felt that his pump would benefit most from optimal blood pressure control. # Chronic Kidney Disease Stage V on HD - patient dialyzed MWF while in house, and has follow-up with dialysis clinic. His electrolytes were monitored and repleted, and calcium acetate and nephrocaps were continued. Aspirin 81mg po daily was also continued. # Peripheral [**Date Range **] Disease - patient with significant peripheral [**Date Range 1106**] disease and recently seen by [**Date Range 1106**] here at [**Hospital1 18**]. He missed an appointment for arterial studies (noninvasive) which he was an inpatient, and it was attempted to get these studies as an inpatient but they were not completed before discharge. The studies were ordered again as an outpatient. Asthma/COPD - Patient with long-standing asthma and COPD with wheezing at baseline. He presented with diffuse wheezing that improved with his home medications and albuterol. Medications on Admission: ADMISSION MEDICATIONS: Calcium acetate 667 mg po TID Hysocyamine sulfate 0.375 mg PO Daily Ondansetron 8 mg PO PRN nausea Donepezil 5 mg PO QHS Citalopram 10 mg PO Daily Clonazepam 0.5 mg PO QHS Lisinopril 20 mg PO BID Fexofenadine 180 mg PO Daily NephroCaps 1 cap po Daily Tiotropium bromide 18 mcg 2 puff PO Daily Montelukast 10 mg PO Daily Valsartan 80 mg PO Daily Amlodipine 7.5 mg Daily B Complex-Vitamin C - Folic Acid 1 mg capsule Daily Clonidine 0.2mg po daily HCTZ 12.5mg po daily Aspirin 81 mg PO Daily SL Nitroglycerin prn Discharge Medications: 1. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12 hr Sig: One (1) Capsule, Sust. Release 12 hr PO DAILY (Daily). 3. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for for nausea. 4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*1* 16. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 18. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 19. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 20. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for for pain. 21. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: Primary diagnosis: Second degree heart block Secondary diagnoses: End Stage Renal Disease on Hemodialyis COPD/Asthma Coronary Artery Disease Hypertension Dyslipidemia Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital due to a slow heart rate (bradycardia). You were given a pacemaker ([**Company 1543**] VDD) in order to speed up your heart rate. You will need to keep the dressing over the pacer clean and dry for one week until you go to the device clinic. You should wear a sling for 24 hours after your pacemaker placement. You cannot shower but may take a bath as long as the dressing stays dry. You cannot lift your right arm over your head for 6 weeks, no swimming or tennis. No carrying more than 5 pounds for 6 weeks with your right arm. Please see the discharge instructions regarding pacemakers that was given to you at discharge. Please call Dr. [**Last Name (STitle) 5102**] if you notice any increasing swelling, bruising, bleeding or increasing pain at the pacer site. If the pacer site is sore, you can take Tylenol. Also call Dr. [**Last Name (STitle) 5102**] for fevers, chills, dizziness, chest pain or trouble breathing. You were started on simvastatin 40mg by mouth daily to help lower your cholesterol and prevent your risk of heart attacks in the future. In addition, your dose of clonidine was doubled because your blood pressure was high during your hospital stay. Followup Instructions: Please follow-up at your dialysis clinic on [**Last Name (LF) 766**], [**2169-8-14**] as previously scheduled. Your dialysis clinic should draw a vancomycin level AFTER dialysis and should give you one dose of vancomycin if your level is low. After that, you will not need any more vancomycin. Please schedule an appointment with the cardiology device clinic ([**Telephone/Fax (1) 5518**]) in 1 week. This clinic will help make sure your pacemaker is working correctly. Please schedule an appointment with your primary care doctor, Dr. [**Last Name (STitle) 5102**] in the next 2 weeks. The phone number is [**Telephone/Fax (1) 5105**]. Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time: [**2169-8-17**] 8:00 (for venous imaging of the lower extremities) Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2169-8-22**] 2:45 (Podiatry) Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time: [**2169-8-24**] 8:40 (Transplant Medicine)

[ "747.63", "585.6", "V10.46", "440.20", "426.0", "403.11", "427.31", "427.81", "198.5", "285.21", "493.20" ]

icd9cm

[ [ [] ] ]

[ "37.72", "88.67", "37.83", "39.95" ]

icd9pcs

[ [ [] ] ]

10502, 10577

5130, 8016

343, 415

10789, 10798

4400, 5107

12059, 13174

2794, 2812

8600, 10479

10598, 10598

8042, 8042

10822, 12036

8065, 8577

2827, 4381

10665, 10768

2072, 2585

274, 305

443, 1933

10617, 10644

1955, 2052

2601, 2778

20,946

142,701

21220+57229

Discharge summary

report+addendum

Admission Date: [**2196-6-19**] Discharge Date: [**2196-6-28**] Service: CARDIOTHORACIC Allergies: Antihistamines / Latex Attending:[**First Name3 (LF) 2969**] Chief Complaint: SOB Major Surgical or Invasive Procedure: colonscopy History of Present Illness: Patient is an 84 y/o female with hx of CHF and R hilar mass discharged home from thoracics with oxygen therapy. Presents with SOB. Past Medical History: CHF, HTN, TIA, Diverticular disease, Afib, scoliosis, migraines Social History: former smoker 1ppd x 20-50 yrs -quit 35 yrs ago occas etoh Family History: mother died at age 81 -etiology unclear. father died age 68 of CAD. Physical Exam: 97.9 60 132/69 17 94% RA looks well RRR wheezes and crackles at base with productive cough soft abdomen 2+ ankle edema Pertinent Results: [**2196-6-19**] 01:00PM GLUCOSE-97 UREA N-16 CREAT-0.7 SODIUM-136 POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-26 ANION GAP-19 [**2196-6-19**] 01:00PM WBC-10.6 RBC-4.80 HGB-14.5 HCT-40.3 MCV-84 MCH-30.2 MCHC-36.0* RDW-13.5 [**2196-6-19**] 01:00PM NEUTS-74.7* LYMPHS-17.7* MONOS-6.1 EOS-1.0 BASOS-0.6 Brief Hospital Course: Patient was first admitted for aggressive pulmonary toilet, nebs, additional Lasix and chest physical therapy. Patient developed brisk bleeding for the rectum and was transferred to the intensive care unit for observation and serial hematocrits. GI was consulted and performed colonoscopy. Non bleeding diverticulosis was discovered. Patient was transferred to floor for additional pulmonary toilet. Patient was discharged home when baseline respiratory status was established. Patient was also evaluated by radiation oncology for probable metastasis and will follow up for additional treatment. Recieved first treatment last day of hospital course. Patient seen by cardiology; on echo, (LVEF>55%). Medications on Admission: zoloft toprol XL lisinopril ASA lasix plavix Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 9. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at bedtime) for 7 days. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. 15. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection ASDIR (AS DIRECTED). 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: CHF, diverticulitis malignant spindle cell tumor- day one/ten of XRT [**2196-6-28**] Discharge Condition: good Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office if you have any chest pain, or shortness of breath. Follow up w/ your cardiologist and PCP when you leave rehab. Followup Instructions: Call Dr.[**Doctor Last Name 4738**] office if you have any questions [**Telephone/Fax (1) 170**]. Thoracic [**Doctor First Name **] service. Name: [**Known lastname 10530**],[**Known firstname 1940**] Unit No: [**Numeric Identifier 10531**] Admission Date: [**2196-6-19**] Discharge Date: [**2196-6-28**] Date of Birth: [**2111-10-23**] Sex: F Service: CARDIOTHORACIC Allergies: Antihistamines / Latex Attending:[**First Name3 (LF) 9814**] Addendum: patient was in sinus upon discharge, echo: rhythm appears to be atrial fibrillation. Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] [**First Name11 (Name Pattern1) 3549**] [**Last Name (NamePattern1) 9816**] MD [**MD Number(2) 9817**] Completed by:[**2196-6-28**]

[ "197.0", "562.12", "V15.82", "401.9", "427.31", "428.0", "V10.89", "455.3", "244.9" ]

icd9cm

[ [ [] ] ]

[ "92.24", "45.23" ]

icd9pcs

[ [ [] ] ]

4409, 4651

1137, 1839

240, 252

3578, 3584

815, 1114

3788, 4386

592, 661

1934, 3347

3470, 3557

1865, 1911

3608, 3765

676, 796

197, 202

280, 412

434, 499

515, 576

19,764

123,852

31032

Discharge summary

report

Admission Date: [**2154-5-14**] Discharge Date: [**2154-5-23**] Date of Birth: [**2089-12-1**] Sex: F Service: MEDICINE Allergies: Zofran Attending:[**First Name3 (LF) 443**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: This is an obese 64 year old woman with a medical history significant for MR, DM, HTN, Hyperlipidemia, pulmonary HTN with cor pulmonale, obstructive and restrictive pulmonary disease, chronic afib on coumadin, recently cardioverted (with one month of flecanide preceding DCCV), now transferred from [**Location (un) **] ICU for bradycardia, hypotension and ARF with supratherapeutic INR. . The patient had noticed fevers up to 103 during end of [**Month (only) 958**]/beginning of [**Month (only) 547**]. She denied any more recent F/C/N. Also no cough, sinus problems, diarrhea. She cannot walk more than a few feet at baseline due to chronic lung disease. Her baseline SOB worsened several months ago but did not change significantly since then. The patient felt nauseous for the last two weeks but contributed to her baseline GERD. She also noted 30 lbs weight gain, increased LE edema and somewhat decreased urine output during this time period. . The patient was started on flecanide one month ago for DCCV at [**Hospital1 18**]. She was cardioverted successfully on [**2154-5-10**] but developed weakness, dizziness (with three falls over the weekend) and further inability to void over the last three days. Her beta blocker was discontinued on [**2154-5-13**]. Patient went to the ER at [**Location (un) **] on [**2154-5-13**] and was found to be bradycardic in the 40s (although known to be slightly bradycardic in the past), have a Creatinine of 5.6 and hypotension requiring a dopamine drip via PIV (no CVL placed due to an INR of 10.7). She also received atropine and her HR went up to the 50s. In addition, she was gently hydrated with IVF at 100cc/hr after an initial IVF bolus of 500cc (unclear total volume based on OSH records but estimated 1-2L). Labs at the OSH revealed a BUN/Cr of 76/5.8, a WBC of 11, BNP of 125 and CPK of 63 with troponin I of 0.04. A CXR showed cardiomegaly but no infiltrate. EKG revealed RAD with first degree AV block. . On transfer, she was still on a dopamine drip at 11 mcg/kg/min but her BP was 113/84 with a HR in the 50s. The admission EKG was essentially unchanged from one in the morning at the OSH. She denied any CP or recent increase in SOB. She was admitted to the CCU for further workup and treatment. Past Medical History: * Mitral regurgitation * Hypertension * Hyperlipidemia * Diabetes * Neuropathy * Depression * Pulmonary hypertension with cor pulmonale * Obstructive and restrictive pulmonary disease * Chronic afib, on coumadin, cardioverted on [**2154-5-10**] with one month of flecanide * Obesity * Chronic Anemia, treated with weekly iron infusions * Stool positive for occult blood 1 year ago * Sleep apnea - uses CPAP * Home oxygen 2L NC continuous . PAST SURGICAL HISTORY: * Cholecystectomy & Knee surgery done simultaneously last year - had to be reintubated post operatively and was intubated for less than one day * Benign Tumor removed from right leg * Appendectomy Social History: Married, recently moved to [**Location (un) 86**], Mass from NY. 70 pack/year history of cigarette smoking but quit 15 yrs ago. Only rare alcohol consumption. Family History: NC Physical Exam: VS: T 97.0, BP 113/84 (on dopamine), HR 54, RR 21, O2 92-100% on 4L NC Gen: Obese middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Very dry MM. Neck: Supple with distended EJ, no JVP appreciable. CV: Bradycardic, regular HR, normal S1, S2. 2/6 systolic murmur over precordium without any PMI. No radiation to carotids. No rub or gallop. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were mildly labored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, sparse BS, obese, NTND. Ext: 2+ pitting LE edema up to the knees b/l. No cyanosis or clubbing. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: A&O x3, but disorganized thoughts, moving all extremities, flapping tremor. . Pulses: Right: DP 1+ Left: DP 1+ Pertinent Results: [**2154-5-14**] 08:48PM WBC-12.8* RBC-4.25 HGB-10.7* HCT-33.3* MCV-78* MCH-25.1* MCHC-32.1 RDW-17.7* [**2154-5-14**] 08:48PM NEUTS-90.8* LYMPHS-4.1* MONOS-4.4 EOS-0.2 BASOS-0.5 [**2154-5-14**] 08:48PM CALCIUM-8.4 PHOSPHATE-8.6* MAGNESIUM-2.4 [**2154-5-14**] 08:48PM GLUCOSE-163* UREA N-73* CREAT-6.2* SODIUM-132* POTASSIUM-5.4* CHLORIDE-95* TOTAL CO2-21* ANION GAP-21* . EKG demonstrated sinus bradycardia with HR of 58, RAD and prolonged PR interval and no significant ST changes, with no significant change compared with prior EKG from this morning at OSH. . 2D-ECHOCARDIOGRAM performed on [**2154-4-10**] demonstrated per outside records moderately severe mitral regurgitation, moderately severe pulmonary hypertension but preserved LV function. . TTE on [**2154-5-14**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is dilated. Global RV free wall motion appears grossly preserved (not fully visualized). [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets are mildly thickened. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen (views suboptimal). Moderate to severe [3+] tricuspid regurgitation is seen (views suboptimal). There is no pericardial effusion. . CXR: at OSH with cardiomegaly but no infiltrate. . Abdominal U/S at OSH ([**2154-5-14**]): Abdominal organs wnl, kidneys without hydronephrosis, no free intraabdominal fluid, increased bowel gas. . Renal U/S [**2154-5-15**]: No evidence of hydronephrosis. Four-quadrant ascites. Pulsatile flow within the main portal vein. . Renal U/S [**2154-5-17**]: IMPRESSION: Limited exam. Normal sized kidneys without evidence of hydronephrosis, unchanged from prior. Elevated resistive indices bilaterally, with decreased perfusion and very limited flow detectable in the right kidney. Differential considerations include global hypoperfusion, as well as acute tubular necrosis. . . LABORATORY DATA (see attached): At OSH: BUN/Cr of 76/5.8, WBC of 11, BNP of 125 and CPK of 63 with troponin I of 0.04. Brief Hospital Course: Hospital course: The patient is an obese 64 year old woman with a medical history significant for MR, DM, HTN, Hyperlipidemia, pulmonary HTN with cor pulmonale, obstructive and restrictive pulmonary disease, chronic afib on coumadin, recently cardioverted (with one month of flecanide preceding DCCV). She was transferred from the [**Location (un) **] ICU for bradycardia, hypotension and ARF with supratherapeutic INR. On presentation to [**Hospital1 18**], she was on a dopamine GTT. Her nodal agents were held and she underwent CVVHD, she had a tunneled catheter placed. dopamine was weaned to off and her bradycardia resolved. She remained in NSR. . 1) Hypotension: Probably due to accumulation of nodal blocking agents in the setting of her ARF. Other possibilites were CHF exacerbation with poor forward flow, although her TTE was without LV systolic dysfunction but did show RV hypokinesis. Tamponade was ruled out by echo. She was not septic and did not have adrenal insufficieny. Her TFT's were within normal limits. All nodal agents were held on admission and she was given 1L IVF with bicarbonate. She was initially continued on domapine and started on CVVHD in hopes of aiding in the removal of nodal agents. Dopamine was weaned. She did have one episode of hypotension for which dopamine was up titrated and she was given a 500cc fluid bolus. With time her hemodynamic profile improved and dopamine was turned off. Her home medications were gradually restarted. Regarding the patient's antihypertensive regimen, lopressor was substituted for atenolol, diltiazem was discontinued, losartan was restarted and hydrochlorothiazide was discontinued (in the setting of renal failure). Amytriptaline, which the patient was taking for depression, was held because of it's propensity to cause long QT and the patient's ongoing conduction issues. She tollerated holding the medication well. . 2) ARF: The patient had a baseline Cr of 0.8 in [**11-29**] per OSH note. On admission, the patient had a Cr of 6.2 wtih an AG of 16. The DDx was initially poor forward flow from CHF vs prerenal state / hypotension. Per report an OSH RUS showed no obstruction. Further workup revealed a High FENA and FEurea-35, which is borderline prerenal. However, she had nephrotic range proteinuria. As above, she received HCO3 x 1L on admission. Medications were renally dosed. Initially a temporary femoral dialysis catheter was placed to start CVVHD, this was replaced by a tunnel catheter. After several days of CVVHD the patient began to produce urine and her BUN and Creatinine improved significantly. Renal US showed no hydro, elevated resistive indices bilaterally. Renal was consulted and a workup up for nephrotic/nephritic syndrome was initiated. This work up was unrevealing and the Renal Consultants ultimately felt that the patient's renal failure was likely ATN. She eventually made urine on her own and CVVH was discontinued. Her Creatinine came down to 1.1. . 3) CAD: The pt. did not have chest pain and her cardiac enzymes were negative. . 4) Bradycardia: She responded transiently to atropine given at OSH ER. Flecanide and BB were likely contributing to bradycardia in the setting of ARF. She received calcium gluconate for possible calcium channel blocker toxicity on admission and nodal agents were held. CVVH was initiated. Her heart rate returned to [**Location 213**] and metoprolol was started. . 5) Afib: The patient had recently had DCCV ([**2154-5-10**]) and converted to NSR. At home, she was taking coumadin and flecanide. She is currently in NSR. Flecanide was initially held for bradycardia as was atenolol. When hemodynamically stable, metoprolol and flecanide were started. Also, she initially had a supratherapeutic INR. This was reversed with vit K and 3 units of FFP for line placement. A heparin GTT was started for ease of stopping when the dialysis line needed removal. The line was removed safely, but the cause of the elevated INR was not certain. The patient will be discharged on low dose coumadin with follow up with her PCP and Dr. [**Last Name (STitle) 1911**]. . 6) Pump: A TTE from [**2154-4-10**] at OSH showed preserved LV function. Similarly preserved function on a bedside TTE at [**Hospital1 18**] but with a hypokinetic RV consistent with cor pulmonale. Her BNP at the OSH only 129. She did however have a clinical exam consistent with CHF, including LE edema and weight gain. CVVH was used to slowly remove volume. . 7) Anemia: Her HCT on admission was 33. This fell to 22 over several days. The patient has known iron deficiency anemia, however, it is unclear whether this was the cause of the HCT drop. Her initial hemolysis labs wer negative and her UA was positive for blood. She was transfused 1u of pRBCs and responded appropriately. Further workup revealed iron deficiency anemia. She was started on FeSO4 325mg TID. . 8) Hyperlipidemia: Held fibrate given mimimally elevated LFTs. The patient's elevated LFTs was attributed to poor liver perfusion. The Fibrate was restarted on discharge. . 9) DM: Metformin and rosiglitazone were held. She was covered with a RISS. Upon discharge, she was restarted on metformin and rosiglitazone. . 10) Diabetic peripheral neuropathy: Neurontin was held in the setting of ARF. We continue B6/B12/Folate. The Neurontin was restarted on discharge. . 11) Obstructive and restrictive lung disease: The patient has known OSA with CPAP at home. The patient refused CPAP in house. . 12) Supratherapeutic INR: The patient had an INR of 20 on admission. Likely due to ARF. She received 5mg PO vitamin K at OSH and 5mg IV at [**Hospital1 18**]. Her INR was completely reversed after three bags of FFP for CVL and A-line placement. DIC labs were within normal limits. INR trended up again later during her hospital course. The etiology of the patient's supratherapeutic INR was not certain. She was sent home on 1mg coumadin per day and close follow up with her PCP for an INR check. . 12) Depression: Continued on lexapro. Held amitriptyline due to side affects of QT prolongation. . 13) Neuro: Pt. reported hallucinations, which she has not had previously. This was thought to be due to uremia. Halluicnations eventually resolved once renal function improved. . 14) Arthritis: continued Tylenol 650mg qHS prn. . 15) FEN: cardiac and diabetic diet. Replete lytes prn. Medications on Admission: Flecanide 50mg tab, 1 pill [**Hospital1 **] Atenolol 25mg daily (d/c'd on [**2154-5-13**]) Diltiazem (Cartia XT) 300mg daily Coumadin 2.5mg (no recent dose change) Vitamin B6/B12/Folate (Folbic) daily HCTZ/Lisinopril (Hyzaar) 100-25mg daily Rabeprazole (Aciphex) 20mg [**Hospital1 **] Rosiglitazone (Avandia) 4mg daily Amitriptyline (Elavil) 10mg-2tabs in the am, 1 tab at noon, 2 tabs at bedtime Fenofibrate (Tricor) 145mg daily Escitalopram (Lexapro) 10mg daily Gapapentin (Neurontin) 800mg TID Metformin (Glucophage) 500mg TID Fluticasone/Salmeterol (Advair) disk 100-50, 2 puffs [**Hospital1 **] Tiotropium (Spiriva) 18mcg 1puff [**Hospital1 **] Tylenol arthritis 650mg tabs, 2 at hs Lasix/KCL as needed for increased dyspnea and weigh gain Discharge Medications: 1. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 4 days. Disp:*12 Capsule(s)* Refills:*0* 2. Folbic 2.5-25-2 mg Tablet Sig: One (1) Tablet PO once a day. 3. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Please take only this dosage until seen by a doctor. . Disp:*30 Tablet(s)* Refills:*2* 4. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Flecainide 50 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. 7. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: Two (2) PUffs Inhalation [**Hospital1 **] (2 times a day). 8. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Rabeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 10. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO once a day. Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2* 11. Rosiglitazone 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times a day. 13. Glucophage 500 mg Tablet Sig: One (1) Tablet PO three times a day. 14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation [**Hospital1 **] (2 times a day). 15. Tylenol Arthritis 650 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO at bedtime. 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day as needed for shortness of breath or wheezing: As needed for weight gain or shortness of breath. 17. Losartan 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary Diagnosis: 1. Acute renal failure 2. Hypotension, briefly requiring pressors 3. Bradycardia, likely secondary to atenolol in the setting of ARF 4. Atrial fibrillation, on coumadin and flecanide, s/p recent DCCV, now in SR 5. Elevated INR (off coumadin) of unclear etiology 6. Transient halluzinations, likely secondary to uremia . Secondary Diagnosis: 1. Cor pulmonale 2. Sleep apnea, on home CPAP and 2L O2 3. COPD 4. Hypertension 5. Hyperlipidemia 6. Depression 7. Diabetes mellitus 8. Polyneuropathy 9. Mitral regurgitation Discharge Condition: Afebrile. Hemodynamically stable. Ambulating. Tolerating PO. Discharge Instructions: You have been admitted to the cardiac care unit for a low heart rate and low blood pressure in the setting of acute kidney failure causing your blood pressure medications to accumulate. You briefly needed intravenous medications to keep your blood pressure up. You also were transiently started on dialysis while you were making no urine. Your heart rate and blood pressure have recovered to within normal limits. Your kidney function slowly improved as well and you were transferred to the regular floor. You were seen by physical therapy who felt that you needed home physical therapy to facilitate your recovery. . Please call your primary doctor or return to the ED with fever, chills, chest pain, shortness of breath, nausea/vomiting, spontaneous bleeding or any other concerning symptoms. . Please take all your medications as directed. . Please keep your follow up appointments as below. Please ensure that Dr. [**Last Name (STitle) **] checks an INR on you. Followup Instructions: Please follow up with your primary care doctor ([**Last Name (LF) 12203**],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 35783**] f: [**Telephone/Fax (1) 73294**]) on [**5-24**] at 10am to have your INR checked. Please followup with Dr. [**Last Name (STitle) **] at 10:30am on Monday [**5-27**] for a followup appt. . Dr. [**Last Name (STitle) 1911**] was contact[**Name (NI) **] and will be calling you for a follow up appointment. He plans to see you either on monday, tuesday or wednesday of next week. His office can be contact[**Name (NI) **] at ([**Telephone/Fax (1) 12468**]. Completed by:[**2154-5-23**]

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icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "39.95", "00.17", "99.07", "38.95" ]

icd9pcs

[ [ [] ] ]

15816, 15865

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42,903

128,940

38595

Discharge summary

report

Admission Date: [**2194-1-29**] Discharge Date: [**2194-2-9**] Date of Birth: [**2141-11-21**] Sex: F Service: PLASTIC Allergies: Iodine-Iodine Containing / Cucumber (Cucumis Sativus) Attending:[**First Name3 (LF) 7733**] Chief Complaint: 1. Unstable skin, late effect following radiation therapy. 2. Cervical spondylosis, severe. Major Surgical or Invasive Procedure: 1. Free latissimus dorsi myocutaneous flap from left side of back and chest to posterior neck and thoracic spine region. 2. Local advancement flap closure of donor site (60.0 cm). History of Present Illness: 52F h/o Hodgkin's lymphoma in '[**59**] with radiation-induced cervical kyphosis presenting for elective latissimus dorsi free flap to the neck. The procedure will provide muscle to cover surgical rods placed in an orthopedic procedure to correct the kyphosis at a later date. Past Medical History: PMH: Radiation induced aortic valve damage s/p St. Jude valve replacement (off coumading x6 days, INR 1.6 this am) Radiation induced hypothyroidism Parkinsonian sx [**1-7**] anoxic brain injury '[**79**] PSH: Splenectomy '[**59**] D+C '[**77**] C-section '[**78**] All: Iodine dye Social History: Lives with husband. 1 glass wine/wk. Denies tob/illicits. Physical Exam: On Admission: T:96.2 HR:75 BP:112/60 RR:18 Sats:98 RA Gen- NAD, nontoxic, conversant HEENT-NCAT. PERRL, EOMI. Severe c-spine kyphosis with significantly limited neck extension and ranging left and right. No TTP or pain with movement. CV- RRR, S2 click. 2+ radials b/l. Pulm- CTAB Abd- Soft, NTND. NABS. Extremities: No c/c/e x4 Neuro: [**1-17**] intact. Str [**4-9**] all muscle gps UE/LE b/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] intact to LT x4. Gait Nl. Pertinent Results: [**2194-1-29**] 06:40PM WBC-7.0 RBC-4.17* HGB-12.5 HCT-38.7 MCV-93 MCH-29.9 MCHC-32.3 RDW-13.5 [**2194-1-29**] 06:40PM PT-13.2 PTT-25.9 INR(PT)-1.1 [**2194-1-29**] 06:40PM GLUCOSE-87 UREA N-24* CREAT-0.5 SODIUM-139 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11 [**2194-1-29**] 06:40PM CALCIUM-9.1 PHOSPHATE-3.6 MAGNESIUM-2.5 Brief Hospital Course: The patient was admitted to the plastic surgery service on [**2194-1-29**] for pre-operative assessment and had Free latissimus dorsi myocutaneous flap from left side of back and chest to posterior neck and thoracic spine region with local flap advancement closure of donor site. Please see operative reports for details. The patient tolerated the procedure well and was transferred to the SICU for close flap monitoring. The patient was subsequently transferred to floor with uneventful hospital course. Neuro: Post-operatively, the patient received Dilaudid IV/PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transition ed to oral pain medications. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Foley was removed and patient voided without difficulty. Intake and output were closely monitored. ID: Post-operatively, the patient was started on IV cefazolin, then switched to PO cephalexin. The patient's temperature was closely watched for signs of infection. Prophylaxis: Post operatively the patient received heparin drip with a goal PTT of 50-70. PTT levels were monitored and adjusted appropriately. the patient also received [**Last Name (un) **] dyne boots and when appropriate was encouraged to get up and ambulate as early as possible. At the time of discharge on POD#9 , the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: Synthroid 75 mcg daily carbidopa-levodopa 25-100 x2 tabs TID ropinirole 1 mg tab TID Metoprolol 25 mg [**Hospital1 **] coumadin 3 mg qhs Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO DAILY (Daily). Disp:*45 Tablet, Chewable(s)* Refills:*2* 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 5. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or T>[**Age over 90 **]F: Do not exceed 12 tabs/day or 4000 mg. 7. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times a day. Disp:*28 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **]Hospice Discharge Diagnosis: radiation-induced cervical kyphosis Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted on [**2194-1-29**] for elective latissimus dorsi free flap to your posterior neck area in preparation for an orthopedic procedure to correct your kyphosis. Please follow these discharge instructions. . Activity: 1. You may resume your regular diet. 2. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity until instructed by Dr. [**Last Name (STitle) 5385**]. 3. Continue to avoid turning your head to the right. 4. Continue to avoid sleeping or lying directly on your flap site. 5. Continue to work with Physical Therapy to increase your endurance. You may ask Dr. [**Last Name (STitle) 5385**] at your follow up visit what neck therapy/exercises you can do. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 4. Take prescription pain medications for pain not relieved by tylenol. 5. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softerner if you wish. 6. 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. . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, welling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: Please call Dr.[**Name (NI) 23346**] office to schedule a follow up appointment. . Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**] ([**2194**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 7738**]

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icd9cm

[ [ [] ] ]

[ "38.93", "86.74" ]

icd9pcs

[ [ [] ] ]

5084, 5138

2159, 4035

406, 588

5218, 5218

1795, 2136

7834, 8131

4223, 5061

5159, 5197

4061, 4200

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1292, 1292

274, 368

616, 895

1307, 1776

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1218, 1277

47,522

192,407

21426

Discharge summary

report

Admission Date: [**2152-1-20**] Discharge Date: [**2152-1-28**] Date of Birth: [**2097-3-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2195**] Chief Complaint: ETOH withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: 54y/o homeless M with h/o HTN and ETOH abuse last drink roughly at 6pm on [**1-19**] and arrived to ER with request for detox. Patient last remembers being at [**Location (un) 14927**]yesterday prior to being brought into ER. He states he drinks 12 beers and [**12-21**] of vodka daily and that this has been his regimen for the past month. He has been a lifelong drinker but has increased his ETOH consumption in the last 30 days due to the company he keeps. He has a history of 3 seizures due to ETOH withdrawal and his last seizure was 3 months ago. He has been homeless for the past 6 months and worked as a handyman prior to becoming homeless. He has no family in the [**Location (un) 86**] area. He denies any drug use other than an occasional 'toke' of marijuana. On ROS he denies any fever, chills, has a chronic cough (no change), feels itchy and tremulous. Otherwise unrevelaing ROS Patient has received 15mg PO valium and 20mg IV valium in the ER. Patient also with scabies which was treated with permethrin. Initial plan was to discharge to detox facility but given IV requirement the ER was reluctant to discharge or admit to a medical floor, hence ICU admission. Last ER vitals 99.7, 94, 137/83, 16, 2 l/nc and CXR being obtained. Past Medical History: HTN Social History: Social History: - Tobacco: 1 PPD x30 years - Alcohol: 12 beers and [**12-21**] vodka daily - Illicits: Denies - Homeless x6 months, prior handyman, no family in the area. Requests assistance with detox and living situation. . Family History: Family History: Social History: - Tobacco: 1 PPD x30 years - Alcohol: 12 beers and [**12-21**] vodka daily - Illicits: Denies - Homeless x6 months, prior handyman, no family in the area. Requests assistance with detox and living situation. . Family History: Physical Exam: Admission PE: . 99.7, 94, 137/83, 16, 2 l/nc General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: + diffuse wheezes no 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 very tremulous . Pertinent Results: [**2152-1-21**] 09:00AM BLOOD WBC-8.2 RBC-3.99* Hgb-12.7* Hct-38.0* MCV-95 MCH-31.8 MCHC-33.4 RDW-15.1 Plt Ct-286 [**2152-1-26**] 09:05AM BLOOD WBC-6.8 RBC-4.16* Hgb-13.2* Hct-39.1* MCV-94 MCH-31.7 MCHC-33.8 RDW-14.5 Plt Ct-196 [**2152-1-21**] 09:00AM BLOOD Glucose-107* UreaN-14 Creat-0.7 Na-145 K-4.1 Cl-106 HCO3-25 AnGap-18 [**2152-1-26**] 09:05AM BLOOD Glucose-151* UreaN-19 Creat-0.9 Na-134 K-4.0 Cl-99 HCO3-24 AnGap-15 [**2152-1-21**] 09:00AM BLOOD ALT-39 AST-42* AlkPhos-84 TotBili-0.3 [**2152-1-26**] 09:05AM BLOOD ALT-31 AST-28 AlkPhos-71 [**2152-1-21**] 09:00AM BLOOD Lipase-82* [**2152-1-21**] 09:00AM BLOOD ASA-NEG Ethanol-153* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2152-1-21**] 11:17AM BLOOD calTIBC-419 VitB12-535 Folate-GREATER TH Ferritn-120 TRF-322 Brief Hospital Course: # ETOH withdrawal- His last drink was [**1-19**] at 6PM, patient has history of ETOH related seizures during withdrawal, never been intubated. ETOH level 153 at 0900 [**2151-1-21**]. Positive for benzos but received in the ER several hours prior to urine sample being sent. He was followed on CIWA scales and stopped [**Doctor Last Name **] to require ativan on the 12th. He was discharged on thiamine and folic acid, which he can stop if he stops drinking. Pleas note he received a banana bagin the ED. . Plan going forward: -Salvation Army shelter -Social work gave information about rehab -Re-establish care with PCP [**Name Initial (PRE) 11435**] . # Scabies- In the ED noted on abdomen and upper extremities. Patient was treated with permethrin topical in the ER. 1 treatment fully resolved his symptoms. . ?asthma/COPD - needs o/p work-up with Dr [**Last Name (STitle) 11435**] . HTN - Started on diuril 12.5 mg and lisinopril 5mg, may be able to come off of lisinopril in the future. Dr. [**Last Name (STitle) 56588**] to follow-up. . # Anemia- He was noted to have a borderline anemia with macrocystosis. B12 and folate were normal and we assumed this was secondary to ETOH. . # Elevated transaminases- likely due to ETOH, resolved with abstinence from ETOH Medications on Admission: HCTZ 25mg PO dialy Discharge Medications: 1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. Disp:*1 bottle* Refills:*1* 2. Multi-Vitamins W/Iron Oral 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Chlorthalidone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Alcohol Withdrawl and associated hypertension, malnutrition and anemia. 2. Scabies 3. Bronchitis Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Thank you for letting us take part in your care. You came to the hospital on [**1-20**] requesting "detox" from alcohol use. When doctors examined [**Name5 (PTitle) **], they found that you were experiencing some serious signs of alcohol withdrawl. Alcohol withdrawl is the severe reaction that your body has when withdrawing from alcohol and can be life threatening. Some of the signs that you were experiencing a serious withdrawl include your shaking, high blood pressure, sweats, chills, numbness and headache. To treat your withdrawl symptoms, we started you on a medication called "diazepam." Diazepam replaces alcohol in your body and therefore makes your withdrawl reaction less severe. We Monitored your condition regularly and saw improvement over several days. Because of your alcohol use, you were also found to be suffering from malnutrition as well as a blood condition called "anemia." Anemia is a condition in which your blood does not have enough cells to carry the oxygen that your body needs. Your anemia had two causes. First, excessive alcohol use by itself causes anemia. Second, excessive alcohol prevents you from getting all the vitams and minerals your body needs to make the cells that your blood needs. These vitamins and minerals include Iron, Folate, Vitamin B12 and Thiamine. In addition, when your body does not have enough of these, your nerves can be damaged and you could experience numbness that may become permanent. It is extremely important that you have 3 meals a day and get enough vegetables in your diet. You may also want to consider taking a multi-vitamin or supplements. A third condition you were treated for in the hospital is a rash called "Scabies." Scabies is a skin condition that is caused my small organisms. It causes intense itching and can be spread from one person to another through close skin-to-skin contact. [**Name (NI) **] were treates with a medication that killed these small organisms and gradually, your rash started to resolve. Your skin may continue to itch for some time. Apply Sarna lotion as needed to reduce your itch. Keeping the skin clean and dry and avoiding scratching can help to prevent infection. However, if signs of a skin infection develop and you feel your rash has returned or worsened, please consult a doctor or return to the Emergency Department. As you are well aware from your life long experience, your alcohol is threatening your health and your life. It is very encouraging that you want to stop drinking and are taking the steps to meet your goal. During your hospital stay, you met with Social Work in order to discuss possible paths out of alcohol abuse and homelessness. Please take advantage of the supports that Social Work discussed with you. Seriously consider rejoining Alcoholics Anonymous. Even though they may be "clicky" as you described, joining AA will make it much more likely that you will be able to quit. Although it may seem impossible, you CAN quit drinking and achieve sobriety. Lastly, it is very important that you visit a doctor on a regular basis to re-evaluate your health, especially your blood pressure, nutrition, mental health, and progress in quitting alcohol. The following changes were made to your medications: You were started on diuril 12.5 mg Daily You were started on lisinopril 5mg Daily Followup Instructions: MD: NP[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2795**] Specialty: Interal Medicine Date/ Time: [**2152-2-8**] 10:30am Location: [**Location (un) 27406**], [**Location (un) 86**] MA Phone number: [**Telephone/Fax (1) 11436**] Special instructions for patient: This appointment is a follow up for your hospitalization. You will be reconnected with you Primary Care Physican Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 11435**] after this visit. Completed by:[**2152-2-1**]

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icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

5419, 5425

3501, 4772

331, 337

5569, 5569

2698, 3478

9075, 9593

2160, 2160

4841, 5396

5446, 5548

4798, 4818

5714, 9052

2175, 2679

276, 293

365, 1615

5583, 5690

1637, 1642

1933, 2143

904

158,591

6255+55743

Discharge summary

report+addendum

Admission Date: [**2114-4-10**] Discharge Date: [**2114-4-17**] Date of Birth: [**2083-9-5**] Sex: M Service: MEDICINE Allergies: Lamictal Attending:[**First Name3 (LF) 5893**] Chief Complaint: CC:[**CC Contact Info 24330**] Major Surgical or Invasive Procedure: none History of Present Illness: 30 yo M with PMH of schizoaffective disorder who was found in the street with altered mental status. EMS brought him into the ED. The patient reports that he drank 3 bottles of robitussin to "get high" and had no intention of hurting himself. He does not remember much after that but was told he passed out and EMS brought him to the ED. Prior to this, he denies feeling sick, denies having headaches, fevers, chills, dysuria, diarrhea. . In the ED, he was reportedly combative, irritating to staff. His vitals initially were T 99.8, HR 120, BP 188/107, RR 20, O2 sat 97% RA. Finger stick was 100. Minimal history was obtained. He was found to have large pupils, dry skin and "[**Doctor First Name 13792**] [**Doctor Last Name 13793**]" eyes. The ED staff recognized him from a prior visit a few weeks ago and remembered that he overdoses on cough syrup. A [**Doctor Last Name **] screen and [**Doctor Last Name **] consult were obtained and he was treated as a anticholinergic overdose with 1mg physostigmine. He calmed down with this treatment although had some occasional agitation per report. Given the occassional agitation, he was given 5mg diazepam and placed in 4 pt restraints. He was given 3L NS. His EKG showed sinus tach with nl axis and q waves in II, III, aVF and small q in V5 and 6. TWF in III and aVF but poor baseline. QRS is narrow. . Currently, he is calm, speaking in slow full sentences. He feels thirsty with dry mouth and hungry. Denies headache, fevers, chills, shortness of breath, chest pain, nausea or vomiting, dysuria, hematuria, diarrhea, constipation. Denies suicidal ideations, denies homicidal ideations. Denies feeling depressed. Past Medical History: 1) hx GERD 2) ICU admission ('[**08**]) for fall off of a fire escape ?SA in context of DXM abuse; he was treated for rhabdo, vertebral fracture. 3) h/o Schizoaffective disorder versus bipolar disorder ('[**04**]) with multiple OD's on DXM Per prior psych consult note: multiple psych inpatient admissions from [**2104**]-[**2109**] - [**Hospital1 1680**], [**Doctor First Name 1191**], [**Hospital1 18**] c/l, for agitation (including multiple assaults of hospital staff requiring chemical & physical restraints), delirium. SA by OD in '[**04**] with notable periods of depression and suicidal urges. h/o of AVH, IOR, paranoia, per OMR. Medication trials include: tegretol, effexor, depakote, lithium. Prior psychiatrist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] ([**Telephone/Fax (1) 24328**]). Therapist: [**First Name8 (NamePattern2) 13762**] [**Last Name (NamePattern1) 24329**] ([**0-0-**]). However, pt now states that he sees a new psychiatrist at [**Hospital3 15286**], has seen her once recently Social History: per prior OMR psych note [**7-28**]: Born and lived in CT. Adopted at age 5 months. Good relations with adopted parents. No family abuse history. Completed [**11-22**] year of college. Hx incarceration for assault and battery while using DXM. Multiple incarcerations since for vagrancy. Longstanding h/o DXM abuse starting at age 17 (upwards of [**12-24**] bottles on occasion); +substance abuse treatment @ [**Hospital1 1680**] s/p hospitalization at [**Hospital1 18**]. DXM makes him feel "high and dissociated." He has used ketamine, LSD, mushrooms, while in college. No problems with etoh. No detoxes, sz, dt's. 1 ppd cigarette smoker. The longest period of being drug-free occurred from [**2103**]-[**2106**], during which time he felt bored and was cycling. Currently - denies smoking. Endorses previous marijuana and amphetamines PO and IM. Drinks 4-5 beers every 2 days. No IV drugs. Uses cough medicine to get high Family History: + for depression and thought disorders. Physical Exam: vitals: T HR 87, BP 154/85, O2 sat 95% on RA General: disheveled male in NAD speaking slowly. In four point leather restraints Skin: dry palms, flushed face. Nail polish on nails. HEENT: face flushed, very dry MM and lips, dilated pupils about 10mm responded to light with constriction equally to 4mm. EOMI. mildly injected conjunctiva. No LAD. Full ROM neck CV: RRR no m/r/g Lungs: decreased BS at bilateral bases. Abdomen: no bowel sounds appreciated, soft NTND Ext: No e/c/c. DP 2+ symmetric. Neuro: CNIII- XII in tact. Pupils dilated as described above. Constrict to light. Did not test strength given restraints. Sensation in tact to light touch. Pertinent Results: FRONTAL CHEST RADIOGRAPH: Cardiac and mediastinal contours are unremarkable. There is mild vascular congestion without frank pulmonary edema. There are no focal consolidations or large pleural effusion. The right costophrenic angle is excluded from the image. Multiple clips and fusion hardware are seen within the lower thoracic and within the lumbar spine. IMPRESSION: No evidence of acute cardiopulmonary process [**2114-4-10**] 03:43PM BLOOD WBC-17.5*# RBC-4.81 Hgb-14.8 Hct-42.5 MCV-88 MCH-30.7 MCHC-34.7 RDW-13.1 Plt Ct-243 [**2114-4-11**] 05:24AM BLOOD WBC-11.9* RBC-5.52 Hgb-16.3 Hct-47.3 MCV-86 MCH-29.6 MCHC-34.6 RDW-12.5 Plt Ct-241 [**2114-4-11**] 05:24AM BLOOD Glucose-96 UreaN-8 Creat-0.9 Na-138 K-3.3 Cl-102 HCO3-27 AnGap-12 [**2114-4-11**] 05:24AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.3 [**2114-4-10**] 02:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: 30 yo M with PMH of schizoaffective disorder who presents after drinking 3 bottles of robitussin to "get high." He has a presumed anticholinergic overdose given his clinical picture of low fever, dry axilla, tachycardia, agitation, dilated pupils. In addition, he was given physostigmine in the ED with reported good response. The half life of physostigmine is 15 mins. This medication can be repeated x1 if needed. DDx also includes infection, uremia, head trauma. He has no signs of infection with a negative U/A and clear CXR. Meningitis is always on the ddx but given the history of ingestion, lack of headache or neck stiffness, overdose is more likely. . # Anticholinergic toxicity: No ectopy on telemetry, and no QRS widening - QT prolongation on EKG on initial admit, has resolved. received one dose of physostigmine in the emergency room. Rest of [**Month/Day/Year **] screens were negative including acetaminophen and salicylates which are common co-ingestions. Patient was followed by toxicology consult with no further reccomendations. CIWA scale was within normal limits throughout hospital course. Patient is cleared from a medical standpoint and has no further medical issues other than his psychiatric issues. #Psych: The patient became increasingly agitated and attemtped to leave the hospital, for which a code purple was called and a section 12 ordered with psychiatric input. The psychiatric consult service was concerned for possible bipolar disorder, schizoaffective disorder, or psychosis and felt that the patient would benefit from an inpatient psychiatric stay. He was discharged from the ICU to an inpatient psychiatric facility, after being cleared from a medical standpoint in regards to his anticholinergic toxicity. . #Leukocytosis: Likely leukemoid reaction [**12-23**] to stress. No localizing source of infection and WBC count is within normal limits today. No concern for any underlying infection, patient is cleared from a medical standpoint. . # tobacco abuse: smoking cessation counselling as outpatient Medications on Admission: MVI Discharge Disposition: Extended Care Facility: [**Hospital 1680**] Hospital - [**Location (un) 538**] Discharge Diagnosis: Anticholinergic toxicity Discharge Condition: stable, cleared from medical perspective Discharge Instructions: You were admitted for anticholinergic toxicity. Your toxicity resolved and you were transfereed to inpatient psychiatry. Followup Instructions: inpatient psychiatry Name: [**Known lastname 4152**],[**Known firstname **] Unit No: [**Numeric Identifier 4153**] Admission Date: [**2114-4-10**] Discharge Date: [**2114-4-17**] Date of Birth: [**2083-9-5**] Sex: M Service: MEDICINE Allergies: Lamictal Attending:[**First Name3 (LF) 2403**] Addendum: Patient ultimately not discharged to inpatient psychiatric unit from ICU but transferred to floor as no inpatient psychiatric bed availability. . Spiked fever on transfer to the floor to 102.3 on [**4-12**] evening. Blood, urine cultures and cxr obtained U/A with pyuria. Started on cipro. Urine culture ultimately showed E. coli (sensitive to Cipro). Additionally, small right antecubital phlebitis I and D'ed on [**4-13**]. Patient had fever on night of [**4-13**] and was placed on empiric Vancomycin. He received two doses of Vancomycin. This was subsequently stopped since phlebitis was not clearly source of fevers. It was thought that the Haldol the patient was on was contributing to the fevers. This was stopped on [**4-14**]. The patient subsequently remained afebrile and his leukocytosis resolved. It is still unclear if fevers and leukocytosis were secondary to Haldol vs. the UTI. He will need to remain on the Cipro for his UTI until [**4-26**] (2-week total course given this was catheter-associated). . Psychiatry continued to follow. Valium added to standing regimen. Haldol was stopped as described above. Patient became more and more paranoid and agitated. Was first given Ativan, which worked well. Seroquel was later added per psychiatry's recommendation. This was first given as a PRN, and later made as a standing medication. The patient remained quite paranoid and was agitated at times. 1:1 security sitter maintained. To be transferred to [**Hospital1 3288**] inpatient psychiatry facility. For the time being, Haldol should be avoided. Pertinent Results: CHEST (PORTABLE AP) [**2114-4-12**] 8:33 PM CHEST (PORTABLE AP) Reason: query aspiriation pneumonia [**Hospital 5**] MEDICAL CONDITION: 30 year old man with fever and cough REASON FOR THIS EXAMINATION: query aspiriation pneumonia PROCEDURE: Chest portable AP on [**2114-4-12**]. COMPARISON: [**2113-4-27**]. HISTORY: 30-year-old man with fever and cough, rule out acute aspiration pneumonia. FINDINGS: The lung volumes are low with associated bibasilar minimal atelectasis. No pneumonia or aspiration induced abnormality is noted. The heart size is normal. There is no pleural effusion. Metallic hardware are seen projected over the lumbar spine. The stomach is persistently dilated with air. ============================================================= [**2114-4-16**] 06:45AM BLOOD WBC-6.1 RBC-4.45* Hgb-13.4* Hct-38.0* MCV-85 MCH-30.1 MCHC-35.4* RDW-12.8 Plt Ct-277 [**2114-4-15**] 07:30AM BLOOD WBC-10.3 RBC-4.84 Hgb-14.0 Hct-41.4 MCV-86 MCH-28.9 MCHC-33.7 RDW-12.6 Plt Ct-245 [**2114-4-14**] 08:00AM BLOOD WBC-12.3* RBC-4.76 Hgb-13.6* Hct-40.2 MCV-84 MCH-28.4 MCHC-33.8 RDW-12.5 Plt Ct-234 [**2114-4-13**] 07:25AM BLOOD WBC-14.0* RBC-5.00 Hgb-15.0 Hct-43.7 MCV-87 MCH-30.0 MCHC-34.3 RDW-13.1 Plt Ct-214 [**2114-4-13**] 12:55AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.011 [**2114-4-13**] 12:55AM URINE Blood-NEG Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [**2114-4-13**] 12:55AM URINE RBC-1 WBC-88* Bacteri-NONE Yeast-NONE Epi-0 . Micro: [**4-14**]: Blood Cx x 2: NGTD [**4-13**]: Blood Cx x 2: NGTD [**4-12**]: Blood Cx x 2: NGTD [**2114-4-13**] 12:55 am URINE Source: CVS. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily): Will need taper of this (to 14mg, then 7mg). Started on [**4-10**]. Each patch should be used for 2 weeks, and then completely off (6 week total taper) . 7. Diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever, headache. 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 9 days: Last dose on [**4-26**]. 10. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital 3288**] Hospital - [**Location (un) 164**] Discharge Diagnosis: Anticholinergic toxicity Robitussin (with dextromethorphan) overdose Altered mental status Depression Schizophrenia Fever UTI Phlebitis Discharge Condition: stable, cleared from medical perspective Followup Instructions: Patient transferred to inpatient psychiatry . After discharge from the inpatient psychiatric facility, you can call [**Telephone/Fax (1) 23**] to schedule a primary care appointment in the [**Company 112**] practice (you have not followed up there in over a year) [**Name6 (MD) **] [**Last Name (NamePattern4) 2404**] MD [**MD Number(2) 2405**] Completed by:[**2114-4-18**]

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icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

13504, 13585

5679, 7727

298, 304

13765, 13808

10110, 10214

13831, 14236

4029, 4070

12410, 13481

13606, 13744

7753, 7758

7996, 8118

4085, 4739

229, 260

10316, 12387

10250, 10287

332, 2000

2022, 3067

3083, 4013

32,511

109,960

43284

Discharge summary

report

Admission Date: [**2147-9-19**] Discharge Date: [**2147-9-21**] Service: MEDICINE Allergies: Morphine / Mirtazapine / Ambien Attending:[**First Name3 (LF) 7333**] Chief Complaint: Chest pain and ICD firing at home Major Surgical or Invasive Procedure: defibrillation: 35 J succesfully out of VT History of Present Illness: Mr. [**Known firstname **] [**Known lastname **] is a 86 yo man with h/o CAD s/p MI and CABG in [**2136**], chronic AFib with V-pacing, chronic systolic CHF with EF 20%, recently discharged from CCU for ICD firing, coming with recurrant ICD firing. He initially presented on [**2147-8-29**] with recurrent ICD firing in the setting of sustained VTach and was admitted to our hospial, where he was loaded with amiodarone and discharged to [**Hospital 100**] Rehab on amiodarone 400 Daily. He was followed by EP service and it was decided not to pursue ablation or further hospitalizations given patient preferences and code status (DNR/DNI). Recently patient was in his normal state of health until yesterday afternoon, when he had sudden oppressive substernal chest pain that lasted a 1-2 seconds, that he charachterized as being "shocked". He felt three more episodes like this one and decided to come to our ER. . His VS were T 98.3 F, BP 110 74 mmHg, HR 76 BPM, RR 20 X', SpO2 99%. He did not receive any medications in the ER and was admitted to [**Hospital Unit Name 196**]. A soon as he arrived on the floor he went into VTach at 150s and code blue was called. Initially his SBP was 88 and improve with trendelenburg. He was mentating well throughout the episode. Pads were put in place, but patient ATPx3 and then shocked 35 J succesfully out of his VT. He received 150 mg of IV amiodarone x1. He was transfered to the ICU for further care. . In the ICU he had another episode. Amiodarone 150 mg IV x1 and then infusion at 1 mg/min was started, metoprolol 5 mg IV x1 and then 25 mg of PO metoprolol. Attending was notified and it was discussed with team that knows him that he has been DNR/DNI in the past and that he was made "do not hospitalized". Multiple attempts to contact the family were unsuccessfull. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He does endorses recent constipation for the past two days. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion (though poor exercise capacity), paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Past Medical History: MI X2 (inferior and anteroseptal) - CABG: LIMA to LAD, SVG to OM/PDA ([**Hospital1 112**] [**2136**]) - Afib w/o anticoag (fall risk) - Sustained VTach in [**2146**] s/p admission - PACING/ICD: BiV ICD ([**2122**]?). ICD generator changed to [**Company 1543**] Concerto in [**2145**]. . 3. OTHER PAST MEDICAL HISTORY: - legally blind secondary to glaucoma - Hiatal hernia - Hepatic cysts/hemangioma and lipoma in hepatic flexure - s/p Lt BKA (WWII trauma [**2078**]) - BPH s/p suprapubic prostatectomy ([**2131**]) - s/p cholecystectomy ([**2110**]) - Chronic low back pain - Osteoarthritis - Positive PPD in past - Depression and anxiety Social History: The patient immigrated from [**Country 532**] 20 years ago; lives at [**Hospital1 100**] Senior Center w/ wife. Former oncology surgeon w/ one daughter and grandaughter in [**Name (NI) 86**]. -Tobacco history: None currently -ETOH: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T 96.3, P 120, BP 112/70, R 27, O2 97% on RA . GENERAL - well-appearing man in NAD, Oriented x3, comfortable, Mood, affect appropriate. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear, Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), No c/c/e. No femoral bruits. SKIN - no rashes or lesions. No stasis dermatitis, ulcers, scars, or xanthomas. LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-20**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait . . PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: EKG: AV paced 100% with ventricular rate of 70 BPM, no ST TW changes compared to prior 07/[**2147**]. . Telemetry: Pt with sustained wide-complex tachycardia at rate of 150s. Started suddenly, cannot see PVCs. On [**9-21**], has been 48-72 hours without VT. . On discharge, Na 135, K 3.8, Cl 99, bicarb 24, BUN 17, Cr 1.0 . On discharge, CBC 10.3, Hb 14.1, Hct 42.4, plt 204 . PT: 13.3 PTT: 29.1 INR: 1.1 . CXR [**2147-9-21**]: FINDINGS: As compared to the previous radiograph, there is no evidence of pneumonia. Unchanged course and position of the pacemaker leads. Unchanged moderate cardiomegaly without signs of overhydration. No left-sided pleural effusion, the right sinus is not included on the image. Unchanged tortuosity of the thoracic aorta. Brief Hospital Course: Mr. [**Known firstname **] [**Known lastname **] is a 86 yo man with h/o CAD s/p MI and CABG in [**2136**], chronic AFib with V-pacing, chronic systolic CHF with EF 20%, recently discharged from CCU with ICD firing, now returns with recurrent VT on PO amiodarone. . #. Rhythm - Pt with known VTach and s/p ICD, presented due to ICD firing. Patient went into VT and defibrillated to sinus with 35 J on this admission in the ED. He is on amiodarone at home and was bolused. He was also initially kept on IV lidocaine gtt. Patient was kept on telemetry, had a short run of VT, which resolved, and was not noted to have further events. On prior admission, extensive discussion with patient, family, and cardiology physicians took place, where patient refused ablation, and corroborated DNR/DNI status. Patient stated that he does not want CPR, shocks, intubation. During this admission, we were not able to reach family despite multiple attempts. Patient does not wish to pursue aggressive care, and is NOT TO BE SHOCKED unless his code status changes. We recommend that a family meeting be called when his family is home to discuss goals of care and possibly a "do not hospitalize" plan. He does not wish to have his ICD turned off at this time or to pursue an ablation. . #. Pump - No signs of CHF at this time. Pt with known chronic systolic heart failure with EF of 20%. He was continued on statin, ASA, and metoprolol. ACEi and Lasix were held in setting of hypotension but Lasix was restarted at previous dose at discharge. Please restart Captopril as BP allows. . #. CAD - Pt with known CAD s/p CABG. Chest pain free, other than his VT and shocks. ASA, statin, BB were continued as above. ACEi held as above, due to hypotension. . #. OA - pain was well controlled on Tylenol and oxycodone. . # Low grade temperature: T max 100.4 PO on [**2147-9-20**]. WBC is flat, temp [**Month (only) **] to 98 without Tylenol. BC, urine CX is pending at time of this summary. Urinalysis is negative. CXR shows no acute process. Mild fever likely [**3-20**] atelectasis and immobility. No further workup is warranted unless temp rises again. #. Anxiety - Continued on Ativan home-dose. . #. Code - patient is DNR/DNI. Not to be shocked. Has declined ablation therapy. Medications on Admission: Aspirin 81 mg PO Daily Atenolol 12.5 mg PO Daily Digoxin 125 mcg QOD Dorzolamide 2% Both eyes [**Hospital1 **] Escitalopram 10 mg PO Daily Lasix 120 mg PO BID Isosorbide Mononitrate SR 30 mg Daily Brimonidine 0.15% Both eyes [**Hospital1 **] Latanoprost 0.005% QHS Lorazepam 1.5 mg PO QHS Polyethylene Glycol 3350 100% Powed Daily Simvastatin 10 mg Daily Nitroglycerin 0.3 mg SL PO PRN chest pain Captopril 12.5 mg PO TId Amiodarone 200 mg PO Daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. Dorzolamide 2 % Drops Sig: Two (2) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO once a day. 6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 7. Lorazepam 1 mg Tablet Sig: 1.5 Tablets PO at bedtime as needed for anxiety / agitation. 8. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 11. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Ventricular Tachycardia Chronic Systolic Congestive Heart Failure: EF 20% Hypertension Coronary artery disease Discharge Condition: stable, no VT for 72 hours Discharge Instructions: YOu had a reoccurance of your ventricular tachycardia. We started intravenous amiodarone while you were in the hospital and changed you back to your previous dose of amiodarone on discharge. We talked to you with an interpreter and you stated that you did not want an ablation procedure and did not want your ICD turned off. . Medication changes: 1. Atenolol was changed to Metoprolol twice daily . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet Fluid Restriction: none Followup Instructions: Cardiology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Provider: [**Name10 (NameIs) **] [**Name8 (MD) 93240**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 285**] Date/Time:[**2147-11-3**] 11:30 Completed by:[**2147-9-21**]

[ "401.9", "V45.02", "300.4", "412", "V45.81", "428.0", "427.31", "369.4", "428.22", "V49.75", "414.00", "427.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9670, 9735

5781, 8048

273, 317

9890, 9919

5001, 5758

10521, 10809

3641, 3756

8547, 9647

9756, 9869

8074, 8524

9943, 10270

3771, 4982

10290, 10498

200, 235

345, 2706

3048, 3370

2729, 3017

3386, 3625

11,880

181,778

20794

Discharge summary

report

Admission Date: [**2199-3-14**] Discharge Date: [**2199-3-21**] Date of Birth: [**2123-7-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: rectal bleeding Major Surgical or Invasive Procedure: Upper endoscopy x 2 Colonoscopy History of Present Illness: 75 yoM w/ h/o esophageal cancer s/p chemo and radiation, portal hypertension/cirrhosis [**1-16**] EtOH w/ h/o variceal blead [**2177**], recently dx HCC s/p chemoembolisation [**2199-3-5**] who presents s/p syncope. Pt was on his way to outpt appointment when collapsed; LOC ~ 1 min. No head trauma. No witnessed seizure activity. Pt transported to ED where HR 80, sbp 70. He was noted to have a melena/BRBPR in ED, and pt reported that he had noted several episodes of melena for the last 5 days (unable to quantify exact amount and frequency). He also reported significant NSAID use (ibuprofen 2 tablets QID) In ED initial HCT 16.0; pt received 6 u PRBC, 3 u FFP, 2 L NS, protonix 40 mg IV X 1, octreotide gtt; f/u HCT 14.2. Given persistent hypotension, he was started on a dopamine gtt; received levofloxacin 500 mg IV X 1 and metronidazole 500 mg IV X 1. Pt had EGD in ED which showed no evidence of active bleeding; portal gastropathy, esophageal varices, and small AVM in stomach were noted. Currently pt is sedated following EGD, and further history is obtained from his children. They report that he has had frequent loose BM (~10/day) for the last 10 days and reported mild nausea (although no significant vomiting) and bloating/abdominal distension. No F/C/R. (+) decreased appetite/PO intake. In MICU, pt received the last 3 units of his total 9 units PRBCs, was a total of 12L positive so far over length of stay, had colonscopy that did not reveal a bleeding source though was notable for a diverticulum, polyps in the distal descending colon, angioectasias in the ascending colon, transverse colon and mid-descending colon (thermal therapy), grade 2 internal hemorrhoids. Patient's hct remained stable after his initial presentation, though he continues to have melanotic stools. Also of note, patient's mental status has waxed and waned over admission, worsened over the last night in the setting of receiving Ativan and Ambien. Required 1:1 sitter while in MICU, patient's family says he is somewhat of a "fighter" at baseline, but that he worsened in the last 24h since the above meds were given. Has had mild pain controlled with Tylenol, low dose given hepatic dysfunction. INR has come down with Vit K, FFP. Past Medical History: 1) Esophageal cancer dx [**4-17**] - [**2198-5-3**] EGD: 3 cords grade II varices in lower 3rd of esophagus; stricture @ 26 cm w/ contact bleeding; EUS c/w T3N1Mx - [**2198-8-21**] EGD: - s/p cisplatin and 5FU w/ concurrent radiation therapy completed [**7-18**] - no evidence of residual disease by EGD [**2198-8-21**] -> 2 cords grade II varices in lower third of esophagus with esophageal stenosis at 23 cm -> bx not c/w cancer; likely represents radiation changes 2) cirrhosis (attributed to EtOH) w/ h/o variceal bleed [**2177**] s/p cautery 3) HCC dx [**1-19**] - s/p chemoembolization 4) Arthritis 5) Seasonal allergies Social History: h/o heavy EtOH use; sober [**2176**]-[**2189**]; resumed EtOH; last drink [**12-19**]. Quit tobacco 35 yrs ago ([**2-15**] ppd 30 yrs). Prior fishmarked owner. Married and lives w/ wife Family History: Grandfather died of unknown cancer. Brother w/ "heart disease." sister w/ breast CA Physical Exam: Vitals on admit to MICU: Tc 96.8, pc 80, bpc 119/42, resp 12, 100% NRB Vitals on transfer to medicine floor: 63 138/67 14 100% on 2L Gen: lying in reclining chair, A+Ox3, somnolent but arousable to voice, following commands, NAD HEENT: anicteric, pupils small and minimally responsive, EOM slow to react, MMM, OP clear with no subungal jaundice, neck supple, +JVD, +hepatojugular reflux, +flushed face Chest: RSC portocath C/D/I; lungs with decreased BS at bases b/l c/w small lung volumes, no wheezing, rhonchi or rales Cardiac: RRR, no M/R/G Abd: obese, markedly distended but soft; liver edge 3 cm below RCM, NABS; no caput Genitalia: +scrotal edema Ext: No C/C/E, +trace LE edema b/l, 1+ DP bilaterally Neuro: CN II-XII intact though pupils minimally reactive; sensation to LT intact throughout, 5/5 strength in UE/LE b/l; +asterixis; no tongue fasciculations; linear TP, somnolent but pleasant affect Pertinent Results: Recent labs: [**2199-3-21**] 05:41AM BLOOD WBC-4.6 RBC-3.03* Hgb-9.2* Hct-27.6* MCV-91 MCH-30.5 MCHC-33.4 RDW-18.3* Plt Ct-151 [**2199-3-21**] 05:41AM BLOOD Plt Ct-151 [**2199-3-21**] 05:41AM BLOOD Glucose-123* UreaN-11 Creat-0.6 Na-135 K-3.4 Cl-98 HCO3-32* AnGap-8 [**2199-3-20**] 04:01AM BLOOD ALT-34 AST-70* LD(LDH)-286* AlkPhos-198* TotBili-1.3 [**2199-3-21**] 05:41AM BLOOD Calcium-7.8* Phos-2.1*# Mg-1.4* [**2199-3-20**] 04:01AM BLOOD Albumin-2.4* Calcium-7.4* Phos-3.7 Mg-1.6 [**2199-3-20**] 04:01AM BLOOD Ammonia-<6 [**2199-3-21**] 11:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010 [**2199-3-21**] 11:30AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2199-3-21**] 11:30AM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0-2 [**2199-3-20**] 06:36PM ASCITES WBC-8* RBC-1381* Polys-27* Lymphs-46* Monos-11* Mesothe-7* Macroph-9* [**2199-3-20**] 06:36PM ASCITES Albumin-<1.0 [**2199-3-17**] 04:25AM BLOOD WBC-7.4 RBC-3.51* Hgb-10.3* Hct-30.8* MCV-88 MCH-29.4 MCHC-33.5 RDW-18.6* Plt Ct-159 [**2199-3-17**] 04:25AM BLOOD PT-14.2* PTT-30.6 INR(PT)-1.3 [**2199-3-17**] 04:25AM BLOOD Glucose-120* UreaN-24* Creat-0.6 Na-136 K-3.5 Cl-105 HCO3-25 AnGap-10 [**2199-3-16**] 02:29AM BLOOD ALT-41* AST-52* AlkPhos-135* TotBili-3.4* [**2199-3-15**] 01:06AM BLOOD ALT-51* AST-68* LD(LDH)-336* AlkPhos-144* Amylase-49 TotBili-4.3* DirBili-1.9* IndBili-2.4 [**2199-3-15**] 01:06AM BLOOD Lipase-49 [**2199-3-17**] 04:25AM BLOOD Mg-1.6 [**2199-3-16**] 02:29AM BLOOD Calcium-7.5* Phos-2.4 [**2199-3-14**] 01:16PM BLOOD Albumin-2.2* [**2199-3-15**] 01:06AM BLOOD Hapto-159 [**2199-3-14**] 12:30PM BLOOD TSH-6.0* [**2199-3-14**] 12:30PM BLOOD T4-4.7 [**2199-3-14**] 12:30PM BLOOD AFP-1187* [**2199-3-15**] 01:26AM BLOOD freeCa-1.07* [**2199-3-14**] 09:38PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 [**2199-3-14**] 09:38PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG [**2199-3-14**] 09:38PM URINE RBC-[**2-16**]* WBC-0 Bacteri-OCC Yeast-NONE Epi-0-2 [**2199-3-14**] 09:38PM URINE Eos-NEGATIVE [**2199-3-14**] 09:38PM URINE Hours-RANDOM Creat-67 Na-50 Micro: [**2199-3-21**] URINE INPATIENT no growth [**2199-3-18**] SPUTUM INPATIENT contamination [**2199-3-15**] BLOOD CULTURE INPATIENT no growth [**2199-3-14**] BLOOD CULTURE INPATIENT no growth [**2199-3-14**] URINE INPATIENT no growth Reports: [**2199-3-21**] CXR: 1) Interval resolution of the right upper lobe partial atelectasis and/or infiltration. 2) Minimal degree of left lower lobe infiltration, unchanged. No evidence of new infiltration or pulmonary congestion. [**2199-3-20**] Abd ultrasound: FINDINGS: Four quadrant ultrasound of the abdomen demonstrates a moderate amount of ascites. An appropriate spot within the right lower quadrant of the abdomen was marked for the ordering service, for the purpose of paracentesis. [**2199-3-17**] CHEST, SINGLE AP FILM: History of GI bleed with wheezing. There are low lung volumes. Right subclavian CV line has tip located in region of cavoatrial junction. Allowing for technique, heart size is within normal limits and there is no evidence for CHF. Lungs are grossly clear. [**2199-3-15**] ECG: Sinus rhythm. Compared to the previous tracing the rate has slowed slightly. T waves have normalized in the inferior leads. ST-T wave abnormalities have normalized in leads V4-V6. T wave inversions remain in leads V2-V3. [**2199-3-15**] CT abd/pelv: IMPRESSION: 1. Interval development of a fair amount of fluid within the abdomen and pelvis, which measures Hounsfield units consistent with simple fluid or ascites. Clinical correlation is requested. Low attenuation hemoperitoneum is rarely seen on CT, but there is no sentinel clot sign as described above to indicate bleeding from solid organs. Note that it is somewhat atypical for simple ascitic fluid to collect in the right anterior pararenal space and about the cecum and proximal ascending colon. 2. The appearance of the liver parenchyma is unchanged from [**3-6**]. 3. There is interval development of small bilateral pleural effusions. [**2199-3-14**] GI Bleeding study IMPRESSION: 1) No active bleeding within the bowel. 2) Findings to suggest the possibility of a hematoma within the right upper quadrant. This is possibly a nonspecific finding in light of patient's recent chemo embolization. Clinical correlation is requested. Brief Hospital Course: 75 yoM with h/o esophgeal CA, variceal bleed, HCC s/p recent chemoembolization presents s/p syncopal episode w/BRBPR and melena. . GI bleed: felt to be most likely UGIB from esoph varices, though EGD was not entirely clear as bleeding had stopped. DDx also included PUD, gastric AVM, portal gastropathy, small bowel neoplasm, diverticular bleed, colonic AVM, hematobilia (given recent chemoembolization). Colonoscopy, bleeding scan, CT scan of abdomen and EGD did not reveal bleeding lesion though EGD showed varices that appeared to have bleed sometime recently. Hct was fairly stable after receiving 9 units of PRBCs and 3 Units FFP, though the patient did get one more unit of PRBCs after transfer to the medical floor for hct<28. He was continued on IV protonix [**Hospital1 **] and octreotide gtt initially, and an attempt was made at banding his varices though this was not successful secondary to an esoph stricture that limited passage of the banding device. He will follow up with Dr. [**First Name (STitle) 679**] on an outpatient basis and will need his hct followed closely after discharge. . Wheezing: developed while in the MICU after fluid resuscitation, likely from lung compression by ascites + some element of cardiac asthma. He responded well to lasix while in the unit, and was continued on Lasix 40mg po qd while on the floor with a goal -1L/day until he became volume contracted. Of note, he was 13L positive after agressive resuscitation in MICU. His wheezing went away after diuresis and subsequent paracentesis. . ARF: Cr 5.1 on admit from baseline 0.7 [**2199-3-6**], felt to be primarily prerenal with drop to 0.6 after volume resuscitation. . Hypotension: on admit, resolved with IVF, likely secondary to volume depletion in setting of GI bleed. . Coagulopathy: may be secondary to Vit K deficiency (given poor PO intake), decreased synthetic function given HCC and recent chemoembolization, massive transfusion of PRBC. Cont Vit K 5 mg SC X 3 days, gave FFP x 3 while in unit to correct INR to <1.4. . AG acidosis: on admit, likely secondary to increased lactate and prerenal ARF from hypoperfusion, resolved with IVF. . Altered mental status: developed while in the unit in the setting of Ativan, Ambien, Zyprexa given on one night. It was felt unlikely to be from infection as his WBC count was normal, he had no fever, his UA was negative, his CXR clear, blood cx without growth. All sedating meds were held initially, his mental status cleared, and then low dose (5mg) Ambien was used as needed to help him sleep, at the patient's request. . h/o EtOH abuse: reportedly no EtOH since [**12-19**]. Gave thiamine and folate. Monitored closely for evidence of withdrawal with Ativan prn CIWA scale but no evid of withdrawal while in house. . Oncology: h/o esophageal cancer, hepatoma; possible multiple pulmonary mets, spinal mets, ileum mets on recent CT (although atypical spread for both esophageal cancer and hepatoma). Will need further w/u as outpatient once clinically stabilized. . Communication: Daughter [**Name (NI) 622**] . Code: Full code; confirmed w/ HCP [**Name (NI) 622**] [**Name (NI) 55451**] ([**Telephone/Fax (1) 55452**]). Discussed pt situation at length with daughter [**Name (NI) 622**] on [**2199-3-17**]. Pt and family are aware of pt's guarded prognosis. Per daughter pt has been a "fighter" and states that he is "on his 7th out of 9 lives". Also has stated that "every day extra is a gift". He has also made it clear that he does not want extreme measures to be taken if the cause of his demise is irreversible. He is agreeable to intubation and cardioversion only if there is a strong chance of recovery. If it is known that his emobolization procedure is ineffective and there is nothing else that can be done to save his liver the family is comfortable with taking him home and making him comfortable. Medications on Admission: 1) tylenol prn 2) Prilosec 20 mg PO daily 3) Atenolol 25 mg PO daily 4) Benadryl 25 mg PO QID prn 5) Advil [**12-16**] tab QID 6) FeSO4 325 mg PO daily 7) zantac 150 mg PO BId 8) Dilaudid 2 mg PO q6h prn 9) Aranesp (last dose 3/10) Discharge Medications: 1. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 MDI* Refills:*2* 5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*2* 9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Blood loss anemia Hypovolemic shock GI bleed, likely esophageal variceal bleed Altered mental status Respiratory distress Acute renal failure Coagulopathy Acidosis, anion gap h/o etoh abuse Liver failure Portal hypertension Discharge Condition: Hemodynamically stable, hct stable at ~30 after 10 units resuscitation, no further melena or BRBPR Discharge Instructions: Please continue to take all medications as prescribed and to follow up with your doctors. If you develop bleeding from your mouth or rectum, dark stools, lightheadedness, dizziness, chest pain, shortness of breath, or any other concerning symptoms, go to the nearest Emergency Room for evaluation. Followup Instructions: Please keep the following appointments: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2199-4-11**] 12:00 Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**], Gastroenterology ([**Telephone/Fax (1) 16940**] Tuesday [**2199-3-26**] [**Last Name (NamePattern1) **]. [**Location (un) 858**], [**Hospital Unit Name **] You should also set up an appointment with your primary care doctor in the next week to follow up on the medical issues addressed during this hospitalization. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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icd9cm

[ [ [] ] ]

[ "54.91", "45.13", "99.04", "99.07", "00.17", "45.16", "45.43" ]

icd9pcs

[ [ [] ] ]

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329, 363

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4526, 8988

15004, 15767

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6928

Discharge summary

report

Admission Date: [**2121-10-23**] Discharge Date: [**2121-11-5**] Date of Birth: [**2056-5-19**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old white male with a history of type 2 diabetes and extensive peripheral vascular disease who was initially admitted to the Podiatry Service with a left forefoot cellulitis with associated fevers and chills. There was no trauma or foreign body associated with the cellulitis. Therefore, it was opened and drained. The patient was started on intravenous antibiotics. PAST MEDICAL HISTORY: 1. Type 2 diabetes. 2. Hypertension. 3. Peripheral vascular disease. 4. Hypercholesterolemia. 5. Gastroesophageal reflux disease. PAST SURGICAL HISTORY: 1. Multiple foot surgeries. 2. Right lower extremity bypass. 3. Femoral-popliteal bypass. 4. Aortobifemoral bypass. 5. Graft in the renal artery. 6. Endarterectomy. 7. Umbilical hernia repair. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Glucovance 5/500 mg p.o. b.i.d., hydrochlorothiazide 25 mg p.o. q.d., metoprolol 100 mg p.o. b.i.d., Norvasc 2.5 mg p.o. b.i.d., Zestril 40 mg p.o. q.d., Lipitor 40 mg p.o. q.d., Prilosec 20 mg p.o. q.d. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed the patient was alert and oriented times three. Head, eyes, ears, nose, and throat examination revealed were pupils were equal, round, and reactive to light. Extraocular movements were intact. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sound and second heart sound. No murmurs, gallops or rubs. Lungs were clear to auscultation bilaterally. No wheezes, rhonchi, or rales. The abdomen was soft, nontender, and nondistended. No guarding. Extremities revealed left foot with erythema and edema, an open wound from incision 1 cm long. Dorsalis pedis and posterior tibialis pulses were nonpalpable bilaterally. Left foot was very warm. Good movement, and biphasic on Doppler. ASSESSMENT: This is a 44-year-old male with a past medical history of type 2 diabetes, initially admitted for a left lower extremity cellulitis with hospital course complicated by a non-ST-elevation myocardial infarction, complicated catheterization, and workup of left upper lobe mass found on a pre-catheterization chest x-ray. HOSPITAL COURSE BY SYSTEM: 1. CARDIOVASCULAR SYSTEM: The patient was originally admitted on [**2121-10-23**] for left lower extremity cellulitis to the Podiatry Service. On [**2121-10-25**] the patient developed shortness of breath and bilateral shoulder pain and ruled in for a non-Q-wave myocardial infarction. At that time, the patient was transferred to the C-MED Service. The patient had 1-mm ST elevations in leads I and aVL with 2-mm ST depressions in leads III, aVF, and V3 through V6. The patient did not immediately undergo catheterization given that he was still febrile from his left lower extremity cellulitis, and it was unclear whether or not he would be okay to have stents placed given his history of osteomyelitis. In addition, in the interval between developing the non-Q-wave myocardial infarction, the patient also had some hemoptysis which was followed up with a CT of the chest which showed a left upper lobe mass. Once the patient was afebrile, the patient underwent catheterization. The procedure was complicated by a small dissection. The patient had six stents placed in the right coronary artery. Given these complications, the patient was transferred to the Coronary Care Unit for overnight observation. The patient was then transferred back to the C-MED Service. It should also be noted that the patient also had a echocardiogram after his myocardial infarction which was significant for a moderately dilated left atrium, mild symmetric left ventricular hypertrophy, with a normal left ventricular cavity size, overall left ventricular systolic function preservation; although, mild basal inferior hypokinesis could not be excluded. The right ventricular chamber size and free wall motion were normal. Simple atheroma on the aortic roots were seen. The ascending aorta was mildly dilated. The aortic valve leaflets were thickened. No aortic regurgitation was seen. The mitral valve leaflets were mildly thickened with mild mitral regurgitation. Left ventricular inflow pattern suggested impaired. Ejection fraction of greater than 55% was determined. The patient remained stable on the C-MED Service and was eventually transferred to the General Medicine Service. 2. PULMONARY SYSTEM: The patient apparently had a left upper lobe mass which was seen on chest x-ray one month prior to his presentation with left lower extremity cellulitis at that time. No further workup was done. While in house the patient developed hemoptysis, and a left lower lobe mass was also seen on a follow-up chest x-ray. A CT of the chest was done on [**10-27**] which showed a left upper lobe mass that was speculated which was 3.6-cm X 5.3-cm in size. The patient was seen by the Pulmonary Service in house, and he was preliminarily diagnosed with a likely stage III-B bronchogenic lung cancer. In order to make the full diagnosis, the patient would need a tissue biopsy; however, given his recent myocardial infarction, mediastinoscopy by Cardiothoracic Surgery was deferred until the patient recovered from his acute cardiovascular events. 3. INFECTIOUS DISEASE: The patient was treated for a left lower extremity cellulitis with intravenous antibiotics while he was in house. The patient was treated with ciprofloxacin, Flagyl, and oxacillin for cultures which grew out Staphylococcus coagulase-positive bacteria. The patient had a bone scan to both rule out metastases from his lung mass and also to determine if there was any osteomyelitis. As per Podiatry, no osteomyelitis was suggested, and the patient was continued on oxacillin while in the hospital and changed over to oral dicloxacillin when he was discharged from the hospital. 4. FLUIDS/ELECTROLYTES/NUTRITION: The patient seemed to have some hyponatremia while in the hospital. The patient was fluid restricted. It was unclear whether or not the patient had syndrome of inappropriate secretion of antidiuretic hormone. A hyponatremia workup was initiated while in house, and the patient was to follow up with his primary care physician regarding the results of these tests. DISCHARGE DIAGNOSES: (The patient's discharge diagnoses included) 1. Left lower extremity cellulitis. 2. Non-Q-wave myocardial infarction. 3. Status post catheterization complicated by a small dissection and six stent placement. 4. A left upper lobe mass. 5. Hyponatremia. 6. Anemia. CONDITION AT DISCHARGE: The patient condition on discharge was fair. DISCHARGE STATUS: The patient was discharged to home with [**Hospital6 407**] services. MEDICATIONS ON DISCHARGE: (The patient's discharge medications included) 1. Hydrochlorothiazide 25 mg p.o. q.d. 2. Amlodipine 2.5 mg p.o. b.i.d. 3. Atorvastatin 40 mg p.o. q.d. 4. Pantoprazole 40 mg p.o. q.d. 5. Multivitamin p.o. q.d. 6. Enteric-coated aspirin 325 mg p.o. q.d. 7. Sublingual nitroglycerin 0.4 mg sublingually as needed (for chest pain). 8. Clopidogrel 75 mg p.o. q.d. (for 30 days; with a start date being [**2121-10-31**]). 9. Enoxaparin Sodium 100 mg subcutaneous q.12h. (the patient was to continue taking this from the time of discharge on [**2121-11-5**] until two weeks after that date). 10. Lisinopril 40 mg p.o. q.d. 11. Metoprolol 100 mg p.o. b.i.d. 12. NPH insulin. 13. Dicloxacillin 250 mg p.o. q.d. for seven days (the patient was to take this until [**2121-11-12**]). 14. Glucovance 5/500 mg p.o. q.d. DISCHARGE INSTRUCTIONS/FOLLOWUP: (The patient had multiple follow-up appointments to be made) 1. The patient was to follow up with Cardiology (Dr. [**Last Name (STitle) 73**] in two weeks after his Lovenox course was completed (telephone number [**Telephone/Fax (1) 3312**]). 2. The patient was to follow up with Podiatry Service (Dr. [**Last Name (STitle) **]. The patient needed to follow up with Podiatry when his antibiotic course was complete (telephone number [**Telephone/Fax (1) 543**]). 3. The patient needed dressing changes every day by his visiting nurse. 4. The patient was to follow up with Cardiothoracic Surgery (Dr. [**Last Name (STitle) 175**] in one to two weeks after discharge to reassess whether or not it was time for a mediastinoscopy (telephone number [**Telephone/Fax (1) 170**]). 5. The patient was to follow up with the [**Hospital **] Clinic given his NPH insulin doses after being in the hospital and having increased insulin requirements in the setting of stress (telephone number [**Telephone/Fax (1) 2378**]). 6. The patient was also instructed to follow up with his primary care physician regarding the results of his hyponatremia workup. [**Name6 (MD) **] [**Name8 (MD) **], M.D. Dictated By:[**Name8 (MD) 6369**] MEDQUIST36 D: [**2121-11-11**] 19:07 T: [**2121-11-11**] 20:50 JOB#: [**Job Number 26072**]

[ "998.59", "276.1", "E878.8", "998.2", "681.10", "041.11", "707.15", "410.71", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.01", "37.23", "99.20", "36.06", "86.28" ]

icd9pcs

[ [ [] ] ]

6456, 6736

6914, 7744

1000, 2343

7778, 9132

2371, 6434

734, 973

6751, 6887

157, 553

575, 711