ChanBeDu/relevant_section_length · Datasets at Hugging Face

31,898

154,426

33191

Discharge summary

report

Admission Date: [**2150-3-3**] Discharge Date: [**2150-3-6**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: "I think I fell off the bed and hit my head" Major Surgical or Invasive Procedure: Medical management, no surgery indicated History of Present Illness: The patient is a 86 y. o. F transferred from [**Hospital3 4107**] s/p fall out of bed last night. Patient has no recollection of fall, she thinks that she must have pressed the EMS button(wrist bracelet), and was found on floor by EMS. Outside hospital CT report reads bifrontal R>L traumatic SAH, small bilateral IVH in occipital horns, without mass-effect or midline shift, no fracture of skull. She also has a L wrist nondisplaced distal radius FX, splinted. C-spine negative, she was found to have an UTI, which is treated with Levaquin. Past Medical History: diabetes HTN Hypercholesterolemia Depression Constipation Insomnia Bladder incontinence L Hip replacement [**10/2149**] tonsillectomy appendectomy L breast biopsy - calcification cataract surgery bilateral Social History: Lives alone, has a PCA overnight and household chores, does not smoke, does not drink Family History: n/c Physical Exam: PHYSICAL EXAM ON ADMISSION: O: T: 97.3 BP:155/56 HR:81 R 19 O2Sats 100% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERLA bilat EOMs full Neck: C-collar on Extrem: Warm and well-perfused, with non-pitting edema, joints tender with ROM Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**4-13**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: II: Pupils equally round and reactive to light, 3 mm to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to 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, left forearm strength limited to pain - wrist Fx, no abnormal movements, tremors. Strength full power [**6-15**] throughout (except L UE - limited due to pain), no pronator drift Sensation: Intact to light touch, proprioception bilaterally. Reflexes: B T Br Pa Ac Right 1 1 2 1 1 Left not performed - splinted arm 1 1 Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: [**2150-3-5**] 07:00AM BLOOD WBC-7.5 RBC-4.04* Hgb-11.7* Hct-34.7* MCV-86 MCH-29.1 MCHC-33.8 RDW-17.2* Plt Ct-327 [**2150-3-3**] 01:25PM BLOOD WBC-10.6 RBC-4.64 Hgb-13.1 Hct-39.8 MCV-86 MCH-28.3 MCHC-33.0 RDW-16.1* Plt Ct-329 [**2150-3-3**] 01:25PM BLOOD Neuts-84.4* Lymphs-8.0* Monos-6.8 Eos-0.5 Baso-0.4 [**2150-3-5**] 07:00AM BLOOD Plt Ct-327 [**2150-3-4**] 03:04AM BLOOD PT-13.8* PTT-25.5 INR(PT)-1.2* [**2150-3-3**] 01:25PM BLOOD Plt Ct-329 [**2150-3-5**] 07:00AM BLOOD Glucose-79 UreaN-10 Creat-0.6 Na-139 K-4.2 Cl-103 HCO3-25 AnGap-15 [**2150-3-4**] 03:04AM BLOOD Glucose-135* UreaN-12 Creat-0.6 Na-139 K-4.1 Cl-104 HCO3-26 AnGap-13 [**2150-3-3**] 01:25PM BLOOD CK-MB-4 cTropnT-<0.01 [**2150-3-5**] 07:00AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.4 [**2150-3-4**] 03:04AM BLOOD Albumin-3.8 [**2150-3-5**] 07:00AM BLOOD Phenyto-7.2* [**2150-3-4**] 03:04AM BLOOD Phenyto-9.4* CT HEAD W/O CONTRAST [**2150-3-3**] 3:32 PM IMPRESSION: Small areas of cortical contusion/subarachnoid hemorrhage involving the frontal lobes and right temporal lobe. Small amount of intraventricular hemorrhage in occipital [**Doctor Last Name 534**] of left lateral ventricle. No mass effect. No fracture. CT HEAD W/O CONTRAST [**2150-3-4**] 9:30 AM IMPRESSION: Stable small bilateral frontal and right temporal contusions, small areas of subarachnoid hemorrgae in the adjacent sulci,subdural and intraventricular blood compared to the previous study. Brief Hospital Course: The patient is a 86 y. o. F s/p fall out of bed last night with bifrontal R>L traumatic SAH, small bilateral IVH in occipital horns, without mass-effect or midline shift, no fracture of skull. She was admited to ICU for monitoring. CT of head on [**2150-3-4**] hows decrease blood, and she was transfered to the floor. Her diet was advanced without any difficulties, she voids without difficulties, and her exam remained non-focal. Physical therapy was consulted, and they have recommended rehabilitation placement. Patient agrees with the plan. Prior to discharge the patient had a cast placed on left arm she needs to follow up with Orthopedics. Her Dilantin level on [**3-5**] was 7.2 her dose was increased she should have a level checked in a week. Medications on Admission: Senna 187 mg Tab Oral 2 Tablet(s) Once Daily Zocor 10 mg Tab Oral 1 Tablet(s) Once Daily Enalapril Maleate 5 mg Tab Oral 1 Tablet(s) Once Daily M.V.I. Adult -- Unknown Strength 1 Solution(s) Once Daily Lopressor -- Unknown Strength 1 Solution(s) Once Daily Aspirin 81 mg Tab Oral 1 Tablet(s) Once Daily Detrol 2 mg Tab Oral 2 Tablet(s) Once Daily Cymbalta 20 mg Cap Oral 2 Capsule, Delayed Release(E.C.)(s) Once Daily Ambien 10 mg Tab Oral 1 Tablet(s) Once Daily Lasix 40 mg Tab Oral 1 Tablet(s) Once Daily Miralax 17 gram (100 %) Oral Powder Packet Oral 1 Powder in Packet(s) Once Daily Colace 100 mg Cap Oral 1 Capsule(s) Once Daily Tylenol -- Unknown Strength Unknown # of dose(s) , as needed Discharge Medications: 1. Enalapril Maleate 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:*1 * Refills:*0* 8. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Bifrontal SAH with IVH Discharge Condition: Neurologically stable Discharge Instructions: ?????? Take your pain medicine as prescribed, if you experience discomfort ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? 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. ?????? 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 ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 4- 6 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST You will need to make a follow-up appointment to see Dr. [**Last Name (STitle) **] in the orthopedics clinic in 2 weeks: ([**Telephone/Fax (1) 2007**] Completed by:[**2150-3-6**]

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icd9cm

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icd9pcs

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54622

Discharge summary

report

Admission Date: [**2118-4-14**] Discharge Date: [**2118-4-28**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 562**] Chief Complaint: Melena Major Surgical or Invasive Procedure: EGD x2 ([**2118-4-14**] and [**2118-4-21**]) Colonoscopy ([**2118-4-21**]) Endotracheal Intubation History of Present Illness: 88 yo man with h/o A fib on coumadin and CHF presents to ED c/o 3 days of black stools. Denied lightheadedness, CP or SOB at home. Has chronic DOE which is unchanged from baseline. Denies hematemesis. Mild nausea. Patient denies NSAID use. In the ED, digital rectal exam revealed maroon stool in rectal vault and NG Lavage was negative. EGD done showed esophagitis, gastritis, duodenitis as well as Shatzki's ring. Patient was hemodynamically stable on admission. Past Medical History: CHF - diastolic dysfxn (EF > 65% on Echo [**12-16**]) Chronic A fib x 15 years (failed cardioversion) on coumadin AS with valve area 1.0 cm2 Gout Disc surgeries BPH HTN OSA Social History: Lives alone. Denies tobacco, alcohol, illicit drugs. Worked as a lab technician. Is independent of all ADL's. Drives, cooks, and shops for himself. He has no family that he is close to. Family History: NC Physical Exam: T 97.4, 140/70, 91, 24, 100% on 2L GEN - NAD, A&Ox3, slurred speech HEENT - PERRLA, EOMI, MMM NECK - no JVD HEART - nl s1s2, RRR, III/VI holosystolic murmur at apex and II/VI SEM at LUSB radiating to carotids LUNGS - CTAB ABD - soft, mildly distended, NT, NABS, no masses EXT - no edema Pertinent Results: Labs on admission: [**2118-4-14**] 11:30 am Hct 31.5, WBC 4.3, Plts 128, INR 1.9 Na 146, K 4.0, Cl 112, CO2 22, BUN 27, Creat 0.9 CK 93, Trop T 0.01 UA negative Studies: CXR [**2118-4-14**] Heart size is unchanged; bilateral small pleural effusion with atelectasis. No CHF noted. No PNA. EGD [**2118-4-14**]: Schatzki's ring. Erosions in the gastroesophageal junction. Esophagitis in the gastroesophageal junction. Gastric deformity. Erythema in the antrum compatible with gastritis. Ulcers in the duodenal bulb. Erythema in the duodenal bulb compatible with duodenitis. Head CT [**2118-4-15**]: Stable appearance of the brain parenchyma from earlier in the day. No intracranial hemorrhage. KUB [**2118-4-16**]: Features of mechanical small-bowel obstruction. CT abd [**2118-4-17**]: 1. Findings consistent with ileus. There are dilated loops of small bowel with air-fluid levels without transition point. 2. Gallstone. 3. A small amount of fluid around the liver, around the gallbladder and in the pelvis. 4. Cirrhotic liver. 5. Persistent native portosystemic shunt. (right posterior portal vein to right hepatic vein) EEG [**2118-4-19**]: This is an abnormal portable EEG due to the presence of intermittent, focal delta frequency slowing involving the right anterior quadrant. This finding suggests subcortical dysfunction in this region and is a relatively non-specific finding with regard to an evaluation for seizures. In addition, the background rhythm is slowed with occasional generalized delta frequency slowing. This finding suggests deep, midline subcortical dysfunction and it is consistent with an encephalopathy. Note was made of an irregular rhythm with occasional ectopy on the cardiac monitor. No epileptiform abnormalities were seen. CXR [**2118-4-21**]: 1) OG tube terminating in the distal esophagus. It should be advanced to appropriately lie within the stomach. 2) Retrocardiac left lower lobe atelectasis/consolidation. EGD [**2118-4-21**]: - Ulcer in the upper third of the esophagus, Schatzki's ring, grade II esophagitis in the gastroesophageal junction. A. Upper esophagus, mucosal biopsy: 1.) Squamous epithelium with active esophagitis and ulceration. 2.) No neoplasm identified. 3.) Periodic acid-Schiff (PAS) stain for fungi is negative (positive control slide). Colonoscopy [**2118-4-21**]: multiple non-bleeding diverticula in the entire colon and rectal varices. Video Swallow [**2118-4-25**]: Video oropharyngeal swallow study: The study was performed in conjunction with the Speech and Swallow Service. Please refer to their note for recommendations and full details in the online medical record. Various consistencies of barium were administered to the patient. There was premature spillover of thin liquids through straw to the level of the piriform sinuses. There is prolonged AP transport piecemeal swallow for all consistencies. Bolus propulsion is mildly impaired. There is a small amount of ground solid residue in puree consistent in the valleculae, which clears after a subsequent swallow. There was penetration noted for consecutive straw sips of nectar thick liquid. A chin tuck maneuver effectively prevents penetration of straw sips. The barium pill passes freely without holdup. IMPRESSION: No aspiration observed for all consistencies. However, there is moderate oral and mild pharyngeal dysphagia as described Brief Hospital Course: 88 yo man with A fib on coumadin and CHF presents with melena and maroon stool in rectal vault. EGD done in the ED revealed gastritis, esophagitis, and duodenitis with signs of recent bleeding but no active bleeding. He was hemodynamically stable and transferred to the floor. He was noted to be obtunded on HD#2 and was transferred to the ICU. Patient transferred from floor after being intubated for airway protection secondary to altered mental status. Felt that patient may have encephalopathy secondary to GI bleed. Patient started on lactulose while in unit. Patient had CT scan of head and EEG which were both negative. He was given 6 liters of prep for a colonoscopy and put out very minimal stool. Felt that patient may have partial bowel obstruction. Patient's Hct stabalized felt that c-scope not urgent. Patient after 2 days in the unit started to produce stool. Felt better to have c-scope procedure done while patient on sedation and intubated. Patient had c-scope and EGD with push enteroscopy which was negative for any active bleeding. Rectal varacies were indentified. After scope patient was weaned off sedation and exubated. During ICU course patient had witnessed aspiration after coughing out trach tube. Patient was started on antibiotic course for asp. PNA after temperature spike and positive sputum cultures for Klebsiella, E. Coli, and Pseudomonas. PAtient was initially put on levo/ceftaz and flagyl. Later patient kept on just ceftaz and flagyl. Patient's mental status gradually improved while in the ICU and he was transferred back to the floor. 1) Esophagitis, Gastritis, Duodenitis - No signs/symptoms of active bleeding. Etiology unknown. Patient denies recent NSAID use. H.pylori IgG negative. He was Continued on Protonix. He initially receieved 2 units of PRBC in the ED, Hct remained stable during the rest of his hospital course. 2) Delirium. Likely related to encephalopathy precipitated by GIB (elevated ammonia) vs meds from EGD done in ED. Likely with continued delirium after prolonged intubation and ICU stay. His mental status is somewhat improved since starting lactulose although not at baseline. As per PCP, [**Name10 (NameIs) **] was independent of all ADL's, cooking, and driving. - Head CT negative. - EEG done on [**4-19**] with right anterior bursts of delta slowing amidst theta/delta background consistent with encephalopathy. No epileptiform activity. - He was continued on lactulose for a goal of 3 BM's per day. 3) Cirrhosis noted on Abd CT (Abd CT from [**6-15**] with some evidence of cirrhosis). Etiology unclear. Liver Team was involved in his care. DDX includes EtOH (although no known history of EtOH abuse), autoimmune (not likely given [**Doctor First Name **] 1:40, IgG 1210, anti-smooth muscle 1:20), hemachromatosis (Fe studies WNL), infectious (unlikely given negative Hep B and C viral load), Celiac Sprue (TTG WNL), PBC (IgM WNL, AMA pending at discharge ), cardiac congestion. - RUQ U/S ([**4-16**]) w/o ascites - unconjugated bili not elevated, therefore less likely related to cardiac congestion as per liver - continued on lactulose for goal of 3 BM's per day 4) Pneumonia - likely aspiration event when pt extubated. Patient with sputum culture positve for pansensitive Pseudomonas and Klebsiella. Patient remains afebrile, WBC slowly trending down. - He received 7 days of Ceftaz, changed to po levo at discharge. He will continue an additional 7 day course. - Received 4 days of Flagyl, d/c'ed [**4-26**] given sputum culture results 5) Atrial fibrillation. He was moinitored for complete heart block, as pt has significant underlying conduction disease. His HR was well controlled on Metop 12.5 [**Hospital1 **]. His coumadin was d/c'ed given recent GI bleed (last INR 1.7). Decision to restart coumadin to be decided by PCP. 6) CHF - known diastolic dysfunction, treated as outpt with lasix and lisinopril. Currently not in CHF. His lasix was dosed on a prn basis during this admission. He was euvolemic to volume deplete on discharge. His lasix should be restarted if he appears fluid overloaded. 7) BPH - Terazosin restarted at discharge. 8) OSA. Pt is not on BiPAP. SHould have outpt eval. 9) Hypernatremia and contraction alkalosis. Na and Bicarb trending down on day of discharge. Continue to hold lasix as pt appears volume deplete. To be restarted by PCP if indicated. 10) Ileus noted on KUB while in ICU, resolved. Pt had NGT to suction with bilious output in ICU. Tolerating po diet. 11) HTN. BP well controlled. Started on Metoprolol 12.5 mg [**Hospital1 **]. Lisinopril restarted at discharge. Lasix being held as above. 12) FEN - Pt underwent video swallow. He did well on a ground diet with thickened liquids. Medications on Admission: Lisinopril 10 mg po qd Lasix 40 mg po qd Coumadin Terazosin Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO three times a day: please titrate to [**3-17**] BM's per day. 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 6. Terazosin HCl 1 mg Tablet Sig: One (1) Tablet PO once a day: please titrate up as needed. . Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: GI Bleed Aspiration Pneumonia Hepatic encephalopathy Discharge Condition: Stable Discharge Instructions: Please call your primary care physician or return to the hospital if you experience bleeding, confusion, shortness of breath, fever >101,4, or any other concerns. Please assess volume statis and consult PCP regarding lasix. Pt was on lasix 40 mg daily as an outpt. Currently being held secondary to volume depletion. Please consult PCP regarding coumadin. Pt was on coumadin as an outpt for Afib, however currently being held for recent GI Bleed. Followup Instructions: 1. Please follow up with Dr. [**First Name (STitle) 6164**] when you leave rehab. [**Telephone/Fax (1) 5723**] You have the following appointments scheduled: 1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2118-8-30**] 1:15 2. Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2118-10-13**] 2:00

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icd9cm

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Discharge summary

report

Admission Date: [**2186-10-26**] Discharge Date: [**2186-11-3**] Date of Birth: [**2131-5-12**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2186-10-30**] - Coronary artery bypass grafting x4 with left internal mammary artery to the left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the first diagonal coronary artery; reverse saphenous vein single graft from the aorta to the second obtuse marginal coronary artery; as well as reverse saphenous vein graft from the aorta to the posterior descending coronary artery. [**2186-10-27**] - Cardiac Catheterization History of Present Illness: 55 year old male h/o CAD, DM, HTN, CKD who presents to ER with acute SOB. Patient states he was feeling his normal self until approximately 6:00pm today when he began to experience nausea, diaphoresis and SOB. His children were concerned and called 911. The symptoms resolved in the ER. Patient denies any chest discomfort or dizziness during the episode. Patient reports 4 weeks of sub-sternal "heart burn" with exertion, which he thought could also be musculoskeletal related to climbing into his new truck. He describes this pain as a band-like tightness [**4-13**]. Of note patient discontinued all of his home medications (other than insulin) because he felt they caused his weight gain. Patient has baseline 2 pillow orthopnea and intermittent lower extremity edema (not worsened recently). Denies PND, syncope, pre-syncope. . On review of systems, denies stroke, TIA, deep venous thrombosis, pulmonary embolism, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. . In the ED, initial vitals were HR 121, BP 240/110, RR 38, 97% RA. Patient continued to be hypertensive in ER and was started on Nitro ggt. Glucose was 603, no ketones. Patient received ASA, Lasix 40 mg IV, Nitro ggt, Lopressor 5mg IV, Ativan 1 mg and Insulin 10 Units. Admitted to CCU. . Past Medical History: 1. CARDIAC RISK FACTORS:: + Diabetes x 15 years complicated by neuropathy, nephropathy, and retinopathy. Most recent HgA1C 9.[**9-11**]/27/[**2185**]. + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: CAD s/p PCI and stent placement to LAD in [**2179**] -PACING/ICD: None. 3. OTHER PAST MEDICAL HISTORY: Obesity gout kidney stones appendectomy R knee arthoplasty Social History: No tobacco use (smoked cigars in [**2148**]. [**Name (NI) **] wife and children smoke). No EtOH, no illicits. Married, lives with wife. Owns a construction company. Family History: brother and maternal GM with DM mother died of [**Name (NI) **] (thinks brain) father passed away in 60s secondary to trauma and alcohol use Physical Exam: Admission VS: BP=149/85 HR=100 RR=24 O2 sat=94% GENERAL: Obese male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Unable to detect JVD due to obesity. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Distant heart sounds due to body habitus. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Distant lung sounds due to body habitus. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Edema 1+ posterior calves b/l. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Discharge VS T 98.0 BP 113/61 HR 80SR RR 20 O2sat 95%-RA Gen NAD Neuro A&Ox3, nonfocal exam Pulm CTA-bilat CV RRR, no murmur. Sternum stable, incision CDI Abdm soft, NT/+BS Ext warm, 1+ pedal edema Pertinent Results: Discharge [**2186-11-3**] 01:50PM BLOOD Hct-24.2* [**2186-11-3**] 06:00AM BLOOD Plt Ct-151 [**2186-10-30**] 05:09PM BLOOD PT-14.8* PTT-32.2 INR(PT)-1.3* [**2186-11-3**] 06:00AM BLOOD Glucose-97 UreaN-54* Creat-2.9* Na-136 K-3.7 Cl-103 HCO3-25 AnGap-12 [**2186-10-27**] 11:35AM BLOOD %HbA1c-9.5* Admission [**2186-10-26**] 06:50PM BLOOD WBC-8.7 RBC-4.84 Hgb-15.6 Hct-43.9 MCV-91 MCH-32.2* MCHC-35.5* RDW-14.0 Plt Ct-128* [**2186-10-26**] 06:50PM BLOOD Neuts-74.1* Lymphs-18.3 Monos-2.9 Eos-3.7 Baso-1.0 [**2186-10-26**] 06:50PM BLOOD PT-12.6 PTT-23.9 INR(PT)-1.1 [**2186-10-26**] 06:50PM BLOOD Glucose-603* UreaN-37* Creat-2.5* Na-135 K-4.8 Cl-100 HCO3-25 AnGap-15 [**2186-10-26**] 06:50PM BLOOD CK(CPK)-221* [**2186-10-26**] 06:50PM BLOOD CK-MB-11* MB Indx-5.0 proBNP-1621* [**2186-10-26**] 06:50PM BLOOD Calcium-9.3 Phos-4.6* Mg-1.9 [**2186-10-27**] 06:18AM BLOOD %HbA1c-9.2* [**2186-10-27**] 06:18AM BLOOD Triglyc-206* HDL-38 CHOL/HD-6.2 LDLcalc-157* . Cardiac Cath [**2186-10-27**] 1. Coronary angiography of this right dominant system revealed 3 vessel and left main disease unsuitable for PCI. The LMCA had an 80% stenosis distally at the bifurcation of the LAD and LCX. The LAD had mild disease in the previously placed proximal stent and moderate mid-segment disease. The LCX had an 80% ostial stenosis with an 80% stenosis proximally in a high OM1. The RCA had a 50% stenosis in the mid-segment and an 80% stenosis in the proximal right posterolateral branch. 2. Limited resting hemodynamics revealed severely elevated systemic arterial pressure despite a nitroglyercine IV drip with an SBP of 181 mm Hg. The LVEDP was also elevated at 25 mm Hg suggestive of severe diastolic dysfunction. There was no gradient suggestive of aortic stenosis with pullback across the aortic valve. 3. Left ventriculography given renal insufficiency. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe diastolic ventricular dysfunction. ECHO [**2186-10-27**]: The left atrium and right atrium are normal in cavity size. There is moderate symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present.No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Suboptimal image quality. Prominent symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Dilated thoracic aorta. These findings are c/w hypertensive heart. Compared with the prior report (images unavailable for review) of [**2179-6-22**], prominent left ventricular hypertrophy is now identified. [**2186-10-30**] ECHO PRE BYPASS: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is no pericardial effusion. POST BYPASS: Left and right ventricular function is preserved. The aorta is intact. The study is unchanged. [**2186-10-30**] Carotid Ultrasound Minimal plaque with bilateral less than 40% carotid stenosis. CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 29794**] [**Hospital 93**] MEDICAL CONDITION: 55 year old man with s/p cabg REASON FOR THIS EXAMINATION: f/u atx, effusions Final Report CHEST, PA AND LATERAL REASON FOR EXAM: Status post CABG, follow up effusion. Since [**2186-11-1**], all tubes and catheters were removed except right internal jugular catheter ending into the cavoatrial junction. Minimal bilateral pleural effusions are associated with small left basilar atelectasis. There is no volume overload. Lungs are otherwise clear. The cardiomediastinal silhouette is unchanged. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**] DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2186-10-27**] for management of his dyspnea and chest pain. A cardiac catheterization was performed which revealed severe left main and three vessel coronary artery disease. Heparin, beta blockade, a statin and aspirin were started. He ruled in for a myocardial infarction by enzymes. Given the severity of his disease, the cardiac surgical service was consulted. Mr. [**Known lastname **] was worked-up in the usual preoperative manner including a carotid duplex ultrasound which showed no significant internal carotid artery disease. On [**2186-10-30**], Mr. [**Known lastname **] was taken to the operating room where he underwent coronary artery bypass grafting to four vessels. Please see operative note for details. In summary he had a CABG x4 with LIMA-LAD,SVG-OM,SVG-Diag,SVG-PDA. His bypass time was 113 minutes with a crossclamp of 90 minutes. He tolerated the operation well and was transferred to the intensive care unit for monitoring in stable condition. He did well in the immediate postoperative period, however he did have a metabolic acidosis and therefore remained intubated until the morning of POD1 at 6AM. He continued to do well and was transferred from the ICU to the stepdown unit on POD2. The remainder of his post-operative course was uneventful. Once on the floor his chest tubes and epicardial wires were removed. His activity progressed and on POD 4 he was discharged home with visiting nurses. Medications on Admission: patient unsure of medications - states Dr. [**Last Name (STitle) 1576**] reviewed and last note should be correct. As below: ALLOPURINOL - 300 mg Tablet - 1 Tablet(s) by mouth twice a day to prevent gout kidney stones ALPRAZOLAM - 0.5MG Tablet - TAKE ONE BY MOUTH AT BEDTIME FOR ANXIETY, INSOMNIA AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day bp ATENOLOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day bp DOXAZOSIN - 2 mg Tablet - 1 Tablet(s) by mouth at bedtime bp FENOFIBRATE MICRONIZED - 160 mg Tablet - 1 Tablet(s) by mouth once a day with food for triglycerides HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 by mouth once a day bp, unk dose IBUPROFEN - 800MG Tablet - TAKE ONE BY MOUTH TWICE A DAY AS NEEDED FOR FOR PAIN KIDNEY STONES, KNEE, BACK, INSULIN LISPRO PROTAM & LISPRO [HUMALOG MIX 75-25] - 100 unit/mL (75-25) Suspension - inject twice a day 100units per dose, dm LABETALOL - 200 mg Tablet - 1 Tablet(s) by mouth twice a day bp POTASSIUM BICARB-CITRIC ACID - 25 mEq Tablet, Effervescent - 1 Tablet, Effervescent(s) by mouth once a day uncertain dose, instructions. Dr. [**First Name (STitle) 805**] POTASSIUM CITRATE [UROCIT-K 10] - 10 mEq (1,080 mg) Tablet Sustained Release - 1 Tablet Sustained Release(s) by mouth three times a day for balance, hx stones PRAVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day cholesterol SYRINGE-NDL,INS DISPOSABLE - - 40-60 untis twice a day dm u-100 . Medications - OTC ASPIRIN - 325MG Tablet, Delayed Release (E.C.) - TAKE ONE BY MOUTH EVERY DAY FOR PREVENTION ONE TOUCH ULTRA TEST STRIPS - Strip - FOUR TIMES A DAY TERBINAFINE - 1 % Cream - Apply to feet twice daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Fenofibrate Micronized 160 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 9. Insulin Glargine 100 unit/mL Solution Sig: 40u QAM/45u QPM Subcutaneous twice a day: 40 units QAM 45 units QPM. Disp:*1 vial* Refills:*2* 10. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous QAC&HS: as directed. Disp:*1 vial* Refills:*2* 11. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day for 2 weeks. Disp:*28 Tablet Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: vna of greater [**Location (un) **] Discharge Diagnosis: CAD s/p CABGx4 (LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)[**2186-10-30**] LAD stent in [**8-4**] IDDM with retinopathy and neuropathy Hyperlipidemia HTN Gout Nephrolithiasis Chronic kidney disease Anxiety Myocardial infarction Discharge Condition: good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 6 weeksor while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: [**Hospital 409**] clinic in 2 weeks Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**] Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1579**] Patient to call for all appointments Completed by:[**2186-11-3**]

[ "276.2", "250.52", "250.42", "362.01", "278.01", "272.4", "357.2", "404.01", "428.0", "410.71", "250.62", "414.01", "274.9", "V15.81", "428.33", "585.9" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.52", "36.15", "39.61", "88.55", "36.13" ]

icd9pcs

[ [ [] ] ]

13441, 13507

8922, 10419

341, 811

13770, 13777

4044, 5884

14553, 14792

2776, 2919

12115, 13418

8183, 8213

13528, 13749

10445, 12092

5901, 8143

13801, 14530

2934, 4025

2364, 2486

282, 303

8245, 8899

839, 2140

2517, 2578

2162, 2344

2594, 2760

13,941

166,103

9462

Discharge summary

report

Admission Date: [**2188-5-2**] Discharge Date: [**2188-5-10**] Date of Birth: [**2136-11-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Increasing dyspnea; transfer from [**Location (un) **] for evaluation of large pericardial effusion Major Surgical or Invasive Procedure: Pericardiocentesis with drain placement History of Present Illness: Mr. [**Known lastname 32239**] is a 51 male with h/o MVP/MR [**First Name (Titles) **] [**Last Name (Titles) 32241**] s/p pacemaker placement [**2183**] who presents 2.5 weeks after a mechanical MVR with increasing SOB and cough. He was doing well postoperatively until earlier in the week, when he developed a superficial wound infection around his sternotomy incision, and he was started on Keflex. During the workup of the infection, his PCP got [**Name Initial (PRE) **] CXR, blood cultures, INR (>4) and noted that his cardiac silhouette appeared enlarged on the CXR. He requested that he have this followed up at Nishoba with an echocardiogram. He was found to have a moderate sized pericardial effusion, with signs of tamponade. He was transferred to [**Hospital1 18**] CCU for further evaluation and possible pericardiocentesis. . He has recently been feeling well, with his major complaint being a weak voice and feeling SOB when talking. He has reports feeling intermittently diaphoretic. He has not had any chest pain. He has been doing home PT since his surgery, and per report has been progressing well - walking for 10 minutes several times per day. He denies orthopnea, PND, claudication. He denies sick contacts. . ROS: He denies fever, chills, night seats, sore throat, rhinorrhea, headache. He has had a cough productive of clear sputum, that is exacerbated when he talks. He denies abdominal discomfort, nausea, vomiting, diarrhea, constipation, dysuria, frequency, hematuria, hematochezia, melena. . ED COURSE: He was taken directly to the cath lab, where he was found to have presereved (LVEF 55%), well seated mechanical mitral valave without regurgitant flow, and a large, circumferential pericardial effusion (4cm). The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. He was taken directly to the cath lab for pericardiocentesis and drain. Past Medical History: MVP/MR s/p #33 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical/ASD closure [**2188-4-14**] Sinus [**Month/Day/Year 32241**] s/p PM [**2183**] VEA (PVCs, bigeminy) Broken collar bone as teenager Social History: Was working as a correction officer. He is single and lives with his mother. [**Name (NI) **] has never smoked or used alcohol Family History: Maternal GM with colon CA. No CAD / sudden death Physical Exam: VS- 115/60 (pulsus paradoxus 15-20) 75 94% 2L GEN- Anxious appearing male, lying at 30 degrees HOB elevation in NAD HEENT- MMM, anicteric, EOMI, OP clear, no sinus tenderness NECK- supple, no LAD, JVP CV- RRR, mechanical S2, no murmur or rub. CHEST- CTA bilaterally ABD- soft, NT, ND, pos BS, no HSM EXT- no C/C/E; 2+dp pulses; 2+ femoral pulses without bruit NEURO- AAO x 3, MAEW, CN grossly intact SKIN- Healing sternotomy scar, with mild erythema and no purulent drainage or fluctuance Pertinent Results: ECHO [**2188-5-2**]: . Conclusions: Limited views making the study suboptimal. 1. Overall left ventricular systolic function is normal (LVEF>55%). 2.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. 3. A bileaflet mitral valve prosthesis is present.The mitral valve is well seated. No significant gradient obtained across mitral valve. No mitral regurgitation is seen. 4.There is a large pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. . CARD CATH [**2188-5-2**] COMMENTS: 1. The patient received 2 units of FFP prior to the procedure. 2. Upond the third needle pass, successful entry into the pericardial space was achieved and verified by fluouroscopy. 3. The initialy mean peridcardial pressure was 17mmHg and decreased to 0mmHg after removal of 1000cc of grossly blood fluid. 4. Post procedure echo demonstrated a mild to moderate effusion that remained in the posterior area. 5. Pericardial drain was sutured in place. . ECHO [**2188-5-3**] . Conclusions: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular systolic function is borderline normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. A mechanical mitral valve prosthesis is present. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. No right ventricular diastolic collapse is seen. Compared with the prior study (images reviewed) of [**2188-5-2**], the pericardial effusion has signficantly decreased in size. There is no longer evidence of tamponade. Brief Hospital Course: IMPRESSION/PLAN: 51 male with h/o MVP and MR now 2.5 weeks s/p mechanical MVR who presents with a large pericardial effusion with an echo and exam consistent with tamponade. . PERICARDIAL EFFUSION: Initially patient received FFP to reverse anticoagulation, no vitamin K was given. A drain of effusion provided 1 Liter of bloody fluid, HCT 24, consistent with a hemorrhagic effusion. A pericardial drain was placed. His coumadin was discontiued and heparin started 12 hrs after subtherapeutic INR to allow coagulation. Heparin drip was restarted, minimal drain output was noted, and repeat echocardiogram showed a stable small effusion. Coumadin was subsequently restarted at 2mg daily for the first 2 days, his INR remained low, and coumadin was increased to 4mg on [**5-6**]. His INR trended up very slowly on this dose, which was the same dose that had led to a supertherapeutic INR. His other medications including the Keflex and Amiodarone were continued at the same dose as outpatient. . MVR: Valve appears to be functioning well on echo. Coumadin restarted as above, goal INR 2.5-3.5, needs careful monitoring given recent complication and especially while patient is on amiodarone and on antibiotics. Patient was continued on amiodarone for prevention of atrial fibrillation in the setting of recent surgery. . ANEMIA: Stable hct since his discharge 2.5 weeks ago. Hct remained stable during admission, Retic Index was 3.6. No evidence of bleeding or effusion reaccumulation noted. . HTN: Continued outpatient regimen of metoprolol 12.5 mg [**Hospital1 **] . CODE: full Medications on Admission: ASA 81 mg Percocet prn Keflex 500 qid (day [**4-4**]) Ferrous sulfate 325mg Ascorbic acid 500mg Metoprolol 12.5mg [**Hospital1 **] KCl 20meq qd (completed two weeks) Furosemide 40 mg qd (completed two weeks) Amiodarone 200mg [**Hospital1 **] Warfarin 3mg qhs (changed from 4mg qhs by PCP [**Name Initial (PRE) 1262**]) Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Outpatient Lab Work INR checked on [**2188-5-12**]. Please send results to Dr. [**Last Name (STitle) 11375**],[**First Name3 (LF) **] R. Office phone number # [**Telephone/Fax (1) 32242**]. Warfarin 4 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours for 2 days. Discharge Disposition: Home Discharge Diagnosis: Pericardial effusion with tamponade s/p Mechanical mitral valve replacement Discharge Condition: Good, ambulating, afebrile, tolerating PO diet, oxygenating well on room air. Discharge Instructions: If you experience any chest pain, difficulty breathing, excess coughing, passing out, high fever, please seek immediate medical attention. You should have a repeat cardiac echo in about one week to re-evaluate for evidence of increasing effusion. You should see your PCP next week, and should have your INR blood test checked on monday, and have the results faxed to Dr. [**Last Name (STitle) **]. You should also have a follow up appointment with Dr. [**Last Name (STitle) 1911**] next week as scheduled below. Followup Instructions: Dr. [**Last Name (STitle) 1911**] on [**2188-5-14**] at 1:45pm Call your PCP to schedule [**Name Initial (PRE) **] follow-up appointment Please call [**Telephone/Fax (1) 32243**] to schedule a cardiac echo for follow up of your effusion next week, preferably prior to your appointment with Dr. [**Last Name (STitle) 1911**].

[ "423.0", "998.59", "V43.3", "285.9", "V45.01", "E934.2", "997.1", "401.9", "790.92", "V58.73" ]

icd9cm

[ [ [] ] ]

[ "37.0", "99.07" ]

icd9pcs

[ [ [] ] ]

8113, 8119

5330, 6919

414, 455

8239, 8319

3475, 5307

8882, 9212

2899, 2950

7289, 8090

8140, 8218

6945, 7266

8343, 8859

2965, 3456

275, 376

483, 2493

2515, 2739

2755, 2883

7,461

112,506

3860

Discharge summary

report

Admission Date: [**2146-8-24**] Discharge Date: [**2146-8-30**] Service: [**Hospital 878**] HOSPITAL COURSE: This is an 88-year-old right-handed woman with past medical history of myocardial infarction, hypertension, atrial fibrillation, and poor medicine compliance, who was admitted on [**8-24**] after falling off her chair when trying to get up. She notes she had weakness on She was brought to the Emergency Room and was noted to have slurred speech with language intact. She had a right gaze preference, but no gaze paresis. She did not respond to visual threat on the left and had a flattened left nasolabial fold. She was inattentive to said stimuli. Upper and lower extremity strength was normal on the right and was 3+ to 4- and had an upgoing toe also on the left. Diffusion-weighted imaging at the time showed increased signal intensity in the left cerebellum and right hemisphere at MCH distribution, involving the basal ganglia, insula, and parotid lobe. She was treated with intra-arterial TPA by Dr. [**Last Name (STitle) 17302**], and Interventional Radiology team, and there was successful partial revascularization of the distal right MCA branch (M-II). She did well postoperatively, and began to regain strength on the left side. On the evening of [**8-25**], she developed a large groin hematoma that extended to her abdominal wall. Her hematocrit remained stable at 28.0 to 28.4, and CT scan of the abdomen and pelvis showed no retroperitoneal bleed. She was then transferred out of the Intensive Care Unit and onto the Neurology Service. Since transfer, she continued to recover function neurologically. She had been progressing well with physical therapy. She initially complained of bilateral leg pain that has since resolved. On Tele monitoring, she has been noted to have episodes of intermittent rapid atrial fibrillation. She is currently on metoprolol 25 mg [**Hospital1 **] for this. In regard there is anticoagulation for atrial fibrillation, Vascular Surgery recommended to wait one week prior to starting Coumadin. Her hematocrit was stable at 30.1 on the day of discharge. She will follow up with Dr. [**First Name (STitle) 1001**] in the Stroke/[**Hospital 878**] Clinic at [**Hospital1 69**] on [**9-13**] at 4 pm. Phone number [**Telephone/Fax (1) 17303**] at the [**Hospital Ward Name 23**] Clinical Center. MEDICATIONS: Protonix 40 mg po q day, aspirin 325 mg po q day, metoprolol 25 mg po bid, Tylenol 650 mg q4-6 hours prn for pain, Heparin 5,000 units subQ q12, Lasix 20 mg po q day, and Colace 100 mg po bid. DISCHARGE DIAGNOSES: 1. Right middle cerebral artery stroke. 2. Atrial fibrillation. 3. Right groin hematoma. 4. Hypertension. DISPOSITION: Rehab. Diet is cardiac. Condition is stable. Rehabilitation potential excellent. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 17304**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2146-10-12**] 11:27 T: [**2146-10-15**] 07:36 JOB#: [**Job Number 17305**]

[ "V15.81", "438.20", "401.9", "414.01", "436", "428.0", "998.12", "427.31", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "88.41" ]

icd9pcs

[ [ [] ] ]

2604, 3081

119, 2583

56,772

144,226

10093

Discharge summary

report

Admission Date: [**2173-9-17**] Discharge Date: [**2173-10-6**] Date of Birth: [**2102-1-15**] Sex: F Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 1185**] Chief Complaint: fevers, confusion Major Surgical or Invasive Procedure: None History of Present Illness: 71 yo F with PMH significant for ESRD [**1-13**] interstitial nephritis s/p living matched donor transplant in [**2162**] with recent hospitalization for graft failure, initiation of HD, and treatment of UTI/possible pneumonia. During that hospitalization, the patient had large pleural effusions that were tapped and found to be transudative, most likely due to progressive renal failure. The patient was discharged home on [**9-13**] with HD three times per week. The patient underwent dialysis on both Tuesday and Thursday of this week. After the Thursday session, the patient felt generally unwell. She complained of severe, generalized weakness, malaise, and confusion. At home, she did not have the strength to get off of the commode, so was brought by EMS to [**Hospital3 **] hospital for further workup. By report, the patient had a fever to 101 at the OSH and was also slightly hypertensive. She was given fluids and IV ABX (vancomycin, azithromycin, and ceftriaxone)and defervesced with improvement of her mental status. The patient was transfered to [**Hospital1 18**] for further workup. . In ED VS were 101.0 114 182/109 16 96% RA. The patient was fluid resuscitated and elctrolytes were repleted. . On arrival to the floor, vitals were 99, 170/90, 100, 16, 99% RA. The patient still makes some urine and the urine she makes is not bloody or pyuria. The patient also denies SOB or cough and states that her confusion and weakness have slightly improved. The patient also denies abd pain or tenderness around her transplant. The patient has chronic diarrhea that is constant. . Past Medical History: 1. End-stage renal disease secondary to interstitial nephritis and chronic pyelonephritis, status post living related renal transplant by her son in [**2163-8-13**]. 2. Peptic ulcer disease. 3. Depression. 4. Partial abdominal hysterectomy. 5. Hypertension. 6. Rheumatic fever in the [**2121**]. 7. Plantar fasciitis Social History: Lives with her second husband in [**Name (NI) 3615**]. Has three sons. Denies tobacco (life long), occasional alcohol (scotch and vodka on special occasions), last drink 1 mo ago, and no IV drug abuse. On board of directors for arts organization. Family History: Father died of renal cancer at the age of 69. Mother died at the age of 72 of cancer. Sisters (identical twins) age 69 alive without health issues. Sons (3) healthy. 2nd son [**Doctor First Name **] is learning disabled. Eldest son is renal donor. Youngest son [**Name (NI) **] is offering to be renal donor now. Physical Exam: ADMISSION EXAM: VS: 99, 170/90, 100, 16, 99% RA GA: AOx3, fatigued but NAD HEENT: PERRLA. dry mucus membranes with large anterior tongue nodule. no LAD. no JVD. neck supple. Cards: sinus tachycardic, S1/S2 heard. no murmurs/gallops/rubs. Pulm: decreased breath sounds of left base, bronchial breath sounds of L middle lobe, otherwise no wheezes or crackles Abd: soft, nondistended, +BS. no g/rt. slight tenderness to deep palpation around transplanted kidney Extremities: 3+ LE pitting edema to knee, chronic venous stasis ulcers and woody changes Skin: dry Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. sensation intact . DISCHARGE EXAM: GA: AOx3, NAD HEENT: PERRL, moist mucus membranes, NECK: no LAD, no JVD, neck supple. Cards: RRR, S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTA BL Abd: soft, nondistended, +BS. no g/rt. Extremities: No pitting edema NEURO: non-focal Pertinent Results: ADMISSION LABS [**2173-9-18**] 12:30PM BLOOD WBC-5.5 RBC-2.54* Hgb-7.5* Hct-22.9* MCV-90 MCH-29.4 MCHC-32.5 RDW-16.0* Plt Ct-169 [**2173-9-18**] 12:30PM BLOOD PT-15.0* PTT-29.0 INR(PT)-1.3* [**2173-9-18**] 12:30PM BLOOD Glucose-92 UreaN-23* Creat-3.0*# Na-137 K-3.6 Cl-97 HCO3-32 AnGap-12 [**2173-9-21**] 07:30AM BLOOD ALT-8 AST-23 LD(LDH)-313* AlkPhos-76 TotBili-0.6 [**2173-9-18**] 12:30PM BLOOD Calcium-8.5 Phos-2.6* Mg-2.1 [**2173-9-19**] 09:45AM BLOOD tacroFK-9.9 [**2173-9-20**] 07:14AM BLOOD Lactate-1.3 DISCHARGE LABS [**2173-10-6**] 06:33AM BLOOD WBC-9.8 RBC-2.64* Hgb-7.7* Hct-24.7* MCV-93 MCH-29.1 MCHC-31.1 RDW-19.2* Plt Ct-424 [**2173-10-4**] 06:28AM BLOOD Neuts-75.1* Lymphs-17.2* Monos-5.6 Eos-1.7 Baso-0.3 [**2173-10-6**] 06:30AM BLOOD PT-12.4 PTT-32.3 INR(PT)-1.0 [**2173-10-6**] 06:33AM BLOOD Glucose-109* UreaN-32* Creat-3.1* Na-138 K-3.9 Cl-98 HCO3-32 AnGap-12 [**2173-10-6**] 06:33AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.4 PERTINENT LABS [**2173-9-26**] 06:20AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Target-1+ Schisto-1+ Acantho-1+ [**2173-9-28**] 06:30AM BLOOD ESR-107* [**2173-9-25**] 03:42AM BLOOD Parst S-NEGATIVE [**2173-10-2**] 05:09AM BLOOD ALT-12 AST-15 AlkPhos-127* TotBili-0.3 [**2173-9-27**] 06:35AM BLOOD ALT-10 AST-23 LD(LDH)-307* AlkPhos-111* TotBili-0.3 [**2173-9-21**] 07:30AM BLOOD ALT-8 AST-23 LD(LDH)-313* AlkPhos-76 TotBili-0.6 [**2173-9-21**] 07:30AM BLOOD CK-MB-2 cTropnT-0.10* [**2173-9-28**] 06:30AM BLOOD calTIBC-124* VitB12-GREATER TH Ferritn-2478* TRF-95* [**2173-10-6**] 06:30AM BLOOD TSH-65* [**2173-9-28**] 06:30AM BLOOD TSH-30* [**2173-10-6**] 06:33AM BLOOD PTH-209* [**2173-9-30**] 04:53AM BLOOD T4-5.0 calcTBG-0.98 TUptake-1.02 T4Index-5.1 [**2173-10-1**] 05:43AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE [**2173-10-1**] 05:43AM BLOOD RheuFac-13 [**2173-9-28**] 06:30AM BLOOD CRP-125.0* [**2173-9-23**] 01:40AM BLOOD PEP-HYPOGAMMAG IgG-304* IgA-210 IgM-90 IFE-SEE IFE RE [**2173-9-22**] 03:34AM BLOOD PEP-HYPOGAMMAG IgG-270* IgA-174 IgM-63 IFE-NO MONOCLO [**2173-10-1**] 05:43AM BLOOD C3-86* C4-27 [**2173-9-20**] 07:10AM BLOOD HIV Ab-NEGATIVE [**2173-10-4**] 12:32PM BLOOD tacroFK-2.8* . CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY - neg IGG LEGIONELLA PNEUMOPHILA ANTIBODY MISCELLANEOUS TESTING - neg MYCOPLASMA PNEUMONIAE ANTIBODY IGM - neg MYCOPLASMA PNEUMONIAE ANTIBODY, IGG - neg QUANTIFERON-TB GOLD - neg . MICROBIOLOGY [**2173-10-6**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-PRELIMINARY INPATIENT [**2173-10-5**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL - neg [**2173-10-4**] URINE URINE CULTURE-FINAL INPATIENT - no growth [**2173-10-4**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2173-9-30**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL - no growth FUNGAL CULTURE-PRELIMINARY - no growth; ACID FAST SMEAR-FINAL negative; ACID FAST CULTURE-FINAL INPATIENT - negative [**2173-9-30**] JOINT FLUID GRAM STAIN-FINAL - negative; FLUID CULTURE-FINAL INPATIENT - no growth [**2173-9-29**] BLOOD CULTURE Blood Culture - no growth [**2173-9-29**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT - negative [**2173-9-29**] BLOOD CULTURE Blood Culture, Routine-FINAL - no growth [**2173-9-28**] URINE URINE CULTURE-FINAL {GRAM POSITIVE BACTERIA} INPATIENT [**2173-9-27**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2173-9-25**] Blood (CMV AB) CMV IgG ANTIBODY-FINAL - negative CMV IgM ANTIBODY-FINAL INPATIENT - negative [**2173-9-25**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL INPATIENT - negative [**2173-9-25**] SEROLOGY/BLOOD LYME SEROLOGY-FINAL INPATIENT - negative [**2173-9-24**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT - no growth [**2173-9-24**] URINE Legionella Urinary Antigen -FINAL INPATIENT - negative [**2173-9-24**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT - negative [**2173-9-23**] CSF;SPINAL FLUID FUNGAL CULTURE-PRELIMINARY INPATIENT - no growth [**2173-9-23**] CSF;SPINAL FLUID CRYPTOCOCCAL ANTIGEN-FINAL INPATIENT - negative [**2173-9-22**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL INPATIENT - negative [**2173-9-22**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT - no growth [**2173-9-22**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT - no growth [**2173-9-22**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT - no growth [**2173-9-22**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY INPATIENT - negative [**2173-9-21**] URINE URINE CULTURE-FINAL INPATIENT - negative [**2173-9-21**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT - negative [**2173-9-20**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT - negative [**2173-9-20**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT - negative [**2173-9-20**] Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV IgM ANTIBODY-FINAL INPATIENT - negative [**2173-9-19**] Immunology (CMV) CMV Viral Load-FINAL INPATIENT - negative [**2173-9-18**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT - negative [**2173-9-18**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT - negative [**2173-9-17**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] - negative [**2173-9-17**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] - negative . Imaging: PERTINENT STUDIES: CXR [**2173-9-17**] Stable bilateral pleural effusions with left lower lobe consolidation likely compressive atelectasis, though cannot exclude pneumonia LUE US [**2173-9-19**] Occlusive thrombus within the antecubital segment of the left cephalic vein. No DVT. CXR [**2173-9-20**] Bilateral effusions and lower lobe atelectasis stable on the left and increasing on the right. CT HEAD WITHOUT CONTRAST [**2173-9-20**] No acute intracranial pathological process. CT CHEST ABDOMEN AND PELVIS WITH CONTRAST [**2173-9-20**] CHEST: There are bilateral pleural effusions, moderate sized left greater than right with resultant bibasilar atelectasis. There is no focal consolidation. The central airways are patent. There is cardiac enlargement, and there is a small pericardial effusion. A central venous catheter tip is seen at the cavoatrial junction. There is no mediastinal, hilar, or axillary lymphadenopathy. The thyroid is normal appearing. The aorta demonstrates calcification of the arch but is normal in caliber along its course. The central pulmonary arteries appear patent. A focus of calcification abutting the right diaphragm probably represents a granuloma. ABDOMEN: The liver is normal in appearance without focal lesions. The portal veins appear patent. There is no intrahepatic biliary ductal dilatation. The gallbladder is distended but there is no wall thickening, no stones are seen. There is no extrahepatic biliary ductal dilatation. The pancreas appears normal. The spleen is normal appearing. The adrenals are normal bilaterally. The native kidneys are shrunken bilaterally and atrophic. The abdominal aorta is normal in caliber along its visualized course, its major branches appear patent. The stomach is collapsed and therefore not well evaluated. Loops of small bowel are normal in caliber and enhancement. There is no retroperitoneal lymphadenopathy. PELVIS: A transplant kidney is noted within the pelvis. A small density within its parenchyma is too small to characterize. The bladder is unremarkable. The colon is notable for marked diverticulosis, however there is no evidence for diverticulitis. There is diffuse anasarca and stranding of the mesenteric and omental fat. BONES WINDOWS: There is a 11mm ill-defined lytic lesion in the left iliac [**Doctor First Name 362**]. There is multilevel degenerative change with grade 1 retrolisthesis of L1 on L2. IMPRESSION: 1. Moderate bilateral pleural effusions, increased in size compared with prior, with adjacent atelectasis. 2. Distended gallbladder, without wall thickening or radiopaque stones. If there is concern for cholecystitis, this could be better evaluated with abdominal ultrasound. 3. Diffuse anasarca, stranding of the intra-abdominal fat. There is no fluid collection to suggest an abscess. 4. Ill-defined lytic lesion in the left iliac, could be further evaluated with bone scan to exclude active process such as infection or metastasis. 5. Diverticulosis, without diverticulitis. . MRI Brain [**2173-9-23**] No acute intracranial abnormality. Periventricular hyperintensities consistent with white matter disease. . CXR [**2173-9-24**] As compared to the previous radiograph, the right lung apex is unremarkable and shows no evidence of pneumothorax. Moderate left and right pleural effusion. In the interval, the patient was extubated. The other monitoring and support devices are unchanged. . Bone scan [**2173-9-30**] 1. No abnormal activity in left iliac to suggest infection or malignancy. 2. Increased activity in the left lateral femoral condyle, which in the setting of chronic steroid use, may be avascular necrosis. 3. Generalized increased skeletal activity, which is likely due metabolic bone disease. ADMISSION LABS: . EEG: [**Date range (1) 33712**] This is an abnormal continuous ICU monitoring study because of moderate diffuse background slowing and frequent bursts of frontal intermittent rhythmic delta activity (FIRDA). These findings are indicative of moderate diffuse cerebral dysfunction, which is etiologically nonspecific. FIRDA is commonly seen in metabolic encephalopathies, but can also appear with increased intracranial pressure, deep midline structural lesions, and hydrocephalus. Excess diffuse beta activity is likely a medication effect. Brief Hospital Course: 71 year old female with ESRD secondary to interstitial nephritis s/p failed kidney transplant who recently initiated HD. The patient had recently finished a course of levaquin for UTI & possible PNA prior to admission. She presented with fever, confusion, and lethargy following an HD session. She ultimately developed a severe encephalopathy which required transfer to the medical intensive care unit. She completed a course of vancomycin and cefempime for HCAP. LP and broad infectious work-up were unrevealing in terms of her severe encephalopathy which seemed out of proportion to her degree of illness. Her mental status returned to baseline at the time of discharge and she was discharged to acute rehab. . ACUTE CARE: # Respiratory Alkalosis/Tachypnea: the patient had tachypnea with a respiratory alkalosis beginning [**9-20**]. She initially improved with ativan, and her resipiratory status is improved when she is asleep, which may indicate an underlying component of anxiety. However, the extent of the patietn's respiratory alklosis is not explained by anxiety alone. PE ruled out by the CT chest even though it wasn't a CTA protocol. Also her pleural effusions are worse so they may be contributing to the respiratory alkalosis. Lactate was elevated to 3.1 and then resolved to 1.1. Repeat ABG revealed ongoing respiratory alkalosis but the patient did not appear in acute distress. The patient improved for unclear reasons and the etiology of her initial alkalosis and tachypnea remained unclear. Consistently maintained on room air. Most likely was secondary to delirium and not a primary pulmonary issue. Pleural effusions improved over the course of her stay. . # Delirium: waxing and [**Doctor Last Name 688**] orientation. In setting of AMS, fever and pain in her neck, consideration for meningitis, but LP negative. Brain MRI showed periventricular hyperintensities. Infectious workup is negative for CMV, EBV. Blood Cx is negative. Pt was empirically treated with acyclovir, and treatment was stopped upon improvement. Cultures never revealed infection from blood, sputum, stool, or CSF. The patient's mental status improved for unclear reasons. Her tacro level was low on the day her mental status cleared. Pt had just been initiated on ampicillin for lactobacillus UTI; these are likely coincidences and the cause of her improved mental status remains unclear. EEG showed generalized slowing but no seizures. . # Fevers: the patient has had low-grade fevers for one year and continues to be have low grade fevers of around 100 degrees of unclear etiology. Recently treated with levofloxacin for pna/uti in outpatient setting. She is being empirically treated with vanc and cefepime. Lytic lesion seen on CT pelvis could be cocnerning for underlying malignancy; pan-scan does not reveal malignancy and bone scan was not consistent with malignancy, SPEP and UPEP negative. Vanc and zosyn were used for HCAP and she completed a course without a change in clinical presentation. ID consult was obtained and many studies were sent and all were negative (ARBOVIRUS PENDING). Urine, blood cultures obtained and the urine culture did show lactobacillus. Although we don't usually treat this because it is a natural colonizer, the urine was collected straight cath and she was ill appearing so we treated with 7 days of ampicillin. After initiation of the abx, her mental status improved but this is likely coincidence. . # Chest pain: the patient had endorsing chest pain. It seemed like it may be MSK as it comes and goes with movement and is in her clavicle. Unlikely cardiac and EKG is unchanged from prior without ST T wave abnormality. Her troponins are elevated to 0.1 but in the setting of ESRD this is difficult to interpret and CK MB is 2. . CHRONIC CARE: # ESRD on HD: Patient gets dialysis Tuesday, Thursday, Saturday, recently initiated. Continued current immunosuppression on Prednisone (with PCP [**Name Initial (PRE) **]), tacrolimus, with target tacro level [**2-13**]. Her level was 12 when she was on diltiazem in the MICU due to interaction, but when the diltiazem was discontinued, her tacro was continued at the previous dose. Tacro level was then low for unclear reasons and her dose was adjusted to 1 mg q12 hour. . # HTN: Pt's blood pressure was not optimally controlled with her home regimen in the setting of worsening kidney function. We increased her amlodipine to 10 mg qd and switched her metoprolol to labetolol to 200 mg po tid. Will expect to continue to follow and adjust dose. . # DEPRESSION Continued home fluoxetine, decreased venlafaxine to a lower dose. . # NUTRITION: Dobhoff tube in place. Started tube feeds on [**9-24**] per nutrition recs. . # ANEMIA OF CHRONIC DISEASE: Received a unit of pRBCs on [**2173-9-21**] with adequate response. No evidence of active clinical bleeding. Epogen at HD. PO Iron. . MICU COURSE: . #) Mental status / acute delirium: Patient continued on vancomycin and cefepime to complete a 7 day course for HCAP coverage (d/c [**9-25**]). Patient was started on empiric coverage with Acyclovir ([**9-23**]) for HSV encephalitis. Given ongoing delirium, patient underwent IR-guided LP after failed attempts by MICU team and neurology. CSF showed WBC 0 RBC 80 Polys 5 Lymphs 75 Monos 20. Gram stain and culture were negative. Cryptococcal Ag and fungal cx were negative. Fluid was sent for arbovirus, CMV, EBV, HHV6, HSV, JCV, varicella, and VDRL. Clood cultures were NGTD. Blood was sent for lyme, rpr, and CMV, which are pending at the time of transfer. TTE showed no echocardiographic evidence of endocarditis. MRI brain showed no acute intracranial abnormality and periventricular hyperintensities consistent with white matter disease. EEG showed moderate to severe diffuse cerebral dysfunction which is etiologically non-specific. At time of call-out to the floor, her mental status remained quite compromised and is unable to interact meaningfully. . #) A.Fib: On [**9-23**], patient had A.Fib with rate in 140s. She failed to respond to metoprolol 5 mg IV X 3. She was started on a diltiazem gtt, which subsequent conversion to sinus rhythm with rates in 80s. Dilt gtt was discontinued given interaction with tacro. She was started on metoprolol, which was uptitrated to 75 mg [**Hospital1 **]. She is well controlled on oral meds. . ISSUES OF TRANSITIONS IN CARE: #Code: confirmed full #Contact: [**Name (NI) **] [**Name (NI) 33706**], husband, [**Telephone/Fax (1) 33707**] #Medication changes: - STARTED ampicillin on [**9-30**], will need to finish on [**10-9**] - DISCONTINUED metoprolol - STARTED labetolol 200 mg tid - STARTED nephrocaps, DISCONTINUED MVI - CHANGED tacrolimus dose to 1 mg q12h - CHANGED amlodipine to 10 mg qd - CHANGED venlafaxine dose to 37.5 mg qd - STARTED lansoprazole 30 mg qAM #Followup issues: - Pt needs repeat thyroid function test in [**1-15**] weeks (noted to have elevated TSH with normal T4 during admission). - Pt needs speech swallow eval for discontinuation of dobhoff tube Medications on Admission: 1. Amlodipine 5 mg PO daily 2. Calcitriol 0.25 mcg PO daily 3. Fluoxetine 40 mg PO daily 4. Metoprolol tartrate 75 mg PO BID 5. Prednisone 2.5 mg PO daily 6. Sulfamethoxazole-Trimethoprim 400-80 mg PO MWF 7. Tacrolimus 1 mg PO QHS 8. Tacrolimus 1.5 mg PO QAM 9. Venlafaxine 75 mg PO daily 10. Ascorbic acid 1000 mg PO BID 11. Aspirin 81 mg PO daily 12. Cyanocobalamin (vitamin B-12) 500 mcg PO daily 13. Ferrous sulfate 300 mg (60 mg iron) PO BID 14. Folic acid 800 mcg PO daily 15. Vitamin E 1,000 unit PO daily 16. B complex-vitamin C-folic acid 1 mg capsule PO daily 17. Oxycodone 5 mg PO Q4H PRN pain 18. Levofloxacin 750 mg PO daily x 7 days . Discharge Medications: 1. aspirin 81 mg Tablet, Chewable [**Date Range **]: One (1) Tablet, Chewable PO DAILY (Daily). 2. amlodipine 5 mg Tablet [**Date Range **]: Two (2) Tablet PO DAILY (Daily). 3. fluoxetine 20 mg/5 mL Solution [**Date Range **]: 10 ml dose PO DAILY (Daily). 4. labetalol 200 mg Tablet [**Date Range **]: One (1) Tablet PO TID (3 times a day). 5. prednisone 2.5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 6. sulfamethoxazole-trimethoprim 800-160 mg Tablet [**Date Range **]: One (1) Tablet PO Three times a week: Please give after dialysis. 7. tacrolimus 1 mg Capsule [**Date Range **]: One (1) Capsule PO Q12H (every 12 hours). 8. venlafaxine 37.5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 9. ascorbic acid 500 mg Tablet [**Date Range **]: Two (2) Tablet PO BID (2 times a day). 10. cyanocobalamin (vitamin B-12) 250 mcg Tablet [**Date Range **]: Two (2) Tablet PO DAILY (Daily). 11. ferrous sulfate 300 mg (60 mg iron) Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a day). 12. folic acid 1 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 13. calcitriol 0.25 mcg Capsule [**Date Range **]: One (1) Capsule PO DAILY (Daily). 14. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 15. Nephrocaps 1 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a day. 16. ampicillin 125 mg/5 mL Suspension for Reconstitution [**Last Name (STitle) **]: Five Hundred (500) mg PO Q6H (every 6 hours) for 3 days: To complete 10 day course. Discharge Disposition: Home Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Hospital acquired pneumonia ESRD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 33706**], . You were admitted to the hospital with fevers, lethargy, headache, and confusion. Because of these symptoms, there was concern that you had an infection, with the most likely source being your lungs given your recent treatment for pneumonia. Your condition was at one point unstable and required MICU treatment. You were treated with antibiotics. You also continued getting dialysis while here. The nephrologists followed your labs and monitored your kidney function. While there was no clear etiology to your decompensation, we are happy with your recovery and we hope you continue to improve after leaving the hospital. Please note the following changes to your medications: - Please STOP taking metoprolol - Please START to take labetolol 200 mg tablets by mouth three times a day, and have your doctor adjust dose based on your blood pressure. - Please CHANGE your tacrolimus dose to 1 mg by mouth every 12 hours - Please CHANGE your amlodipine dose to 10 mg by mouth daily - Please CHANGE your venlafaxine dose to 37.5 mg by mouth daily - Please START to take Lansoprazole 30 mg by mouth in the morning - Please CONTINUE to take Ampicillin 500 mg every 6 hours and finish on [**10-9**]. - Please STOP taking MVI - Please START to take naprocaps 1 tablet by mouth daily - Please STOP taking vitamin E - Please MAKE SURE that you only receive bactrim after dialysis - Please CONTINUE to take the rest of the medication as prescribed. . It has been a pleasure taking care of you here at [**Hospital1 18**]. We wish you a speedy recovery. Followup Instructions: Please make sure that you have follow up appointment prior to leaving the extended care facility. Department: PULMONARY FUNCTION LAB When: THURSDAY [**2173-11-11**] at 12:10 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: THURSDAY [**2173-11-11**] at 12:30 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: THURSDAY [**2173-11-11**] at 12:30 PM [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]

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Discharge summary

report+report+report+report

Admission Date: [**2138-12-3**] Discharge Date: [**2112-2-8**] Date of Birth: [**2070-1-22**] Sex: M HISTORY OF PRESENT ILLNESS: This is a 68 year old male with a past medical history significant for coronary artery disease, congestive heart failure, and anemia who presents to the Emergency Room with inability to walk. The patient has which he was evaluated in the Emergency Department. The patient was going out to dinner with his wife and was unable to walk secondary to back pain. He also complained of shortness of breath. At baseline he uses home oxygen and a cane. Tonight he was not using his oxygen supplementation. He denies any numbness, weakness, paresthesias, loss of continence of urine or stool, although this has been a Emergency Department. He denies fever, chills, chest pain, myalgias, headaches, visual changes. He notes baseline productive cough, white sputum and stomach upset. PHYSICAL EXAMINATION: Physical examination in the Emergency Room revealed vital signs 99.5, 155/55, heartrate 99, respiratory rate 20 and 94% on 4 liters. Generally, the patient is chronically ill-appearing, propped up in bed on oxygen. Head, eyes, ears, nose and throat, pupils equal, round and reactive to light, extraocular movements intact, mucous membranes moist. No lymphadenopathy. Cardiovascularly, regular rate and rhythm, no murmurs, rubs or gallops. No bruits. No jugulovenous distension. Lungs with decreased breathsounds at the bases, otherwise clear to auscultation. Abdomen is soft, nontender, nondistended, positive bowel sounds. Extremities, left lower extremity edema, baseline. No tenderness in the lower extremities. Tenderness to palpation at L5. Neurological examination, the patient alert and oriented times three. Cranial nerves II through XII intact. Strength 5/5 throughout. Normal sensation to bilateral lower extremities. No saddle anesthesia. Reflexes not illicited. Toes, withdraw bilaterally. Rectal tone normal by Emergency Department physician, [**Name10 (NameIs) **] negative. PAST MEDICAL HISTORY: 1. Coronary artery disease, non-Q wave myocardial infarction in [**2137-11-9**], status post coronary artery bypass graft, catheterization in [**2138-2-7**] showing patent graft with three vessel disease, stent to ramus. 2. Congestive heart failure, ejection fraction 30 to 35%, 2+ mitral regurgitation, 1 to 2+ tricuspid regurgitation on home oxygen. 3. High cholesterol. 4. Diabetes Type 2. 5. Laryngeal cancer, status post resection and radiation. 6. Paroxysmal atrial fibrillation/flutter. 7. Glaucoma. 8. Degenerative joint disease of the cervical spine. 9. Asbestosis. 10. Anemia. 11. On home oxygen, restrictive lung disease. ALLERGIES: Penicillin. HOME MEDICATIONS: Aspirin, Imdur 15 once a day, Zocor 20 once a day, Levoxyl 88 once a day, Captopril 12.5 three times a day, Sotalol 80 and 40, Senna, Alphagan .005 three times a day, Phenol 0.1% twice a day, NPH 31 in the morning, 5 at night, Coumadin 4 mg a day, Lasix 20 mg a day, Protonix 40 mg a day. SOCIAL HISTORY: The patient owns a bar and lives with his wife. [**Name (NI) **] smoking. No tobacco, quit smoking 20 years ago. No drugs. LABORATORY DATA: Initial laboratory studies revealed complete blood count 6.3, hematocrit 26.0, platelets [**2134**], differential 89 segments, 5 lymphocytes. Chem-7 144, 4.3, 103, 30, 30, 1.2, 258. Calcium, magnesium and phosphorus 8.8, 3.0 and 1.9, ALT 10, AST 29, alkaline phosphatase 121, total bilirubin 0.9, albumin 3.7. Initial chest x-ray in the Emergency Department showed cardiomegaly, mild congestive heart failure, left greater than right pleural effusion. Electrocardiogram showed sinus rhythm, primary atrioventricular block, normal axis, left ventricular hypertrophy, no ST changes. HOSPITAL COURSE: [**12-3**], the patient was admitted to the floor. The patient had a computerized tomography scan of the abdomen which showed a moderate wedge deformity of the L1 vertebral body which is new compared to the study of [**2136-8-10**] and degenerative changes of the lower lumbar spine. Radiology recommended an magnetic resonance of the lumbar spine which was subsequently done which showed acute and subacute mild compression of the L1 vertebra without retropulsion or spinal stenosis and also showed a fracture of the distal sacrum at the S4 level and multiple degenerative changes and a small left-sided disc herniation at L5 to S1, displacing the left S1 nerve root. On the floor, the patient was worked up for his anemia which supported chronic disease, [**Year (4 digits) **] negative. The patient received a transfusion for low hematocrit secondary to his coronary artery disease and was transfused for hematocrit of 26. Physical therapy was consulted and worked with the patient. Blood cultures were sent. On [**12-6**], while receiving transfusion for a hematocrit of 25, the patient desated to the mid 80s and received Lasix. Chest x-ray showed a left-sided pulmonary effusion. Arterial blood gases was 7.41, 52 and 64 at the time. Blood cultures were sent. Cardiac enzymes were done which showed a troponin of 10.0 and a creatinine kinase of 29 without electrocardiogram changes. Chest surgery with Dr. [**Last Name (STitle) 954**] was consulted for the left pleural effusion and recommended either a thoracentesis or thoracostomy. On [**12-7**], the patient developed progressive dyspnea and the saturations decreased. The patient was emergently intubated by Anesthesia without complications. The patient on [**12-7**], was transferred to the Medical Intensive Care Unit. Chest x-ray showed on [**12-7**], weak opacification of the left lung field. Chest computerized tomography scan was performed on [**12-7**] which showed a very large left pleural effusion and moderate right pleural effusion and compressive atelectasis, stable calcified pleural plaque and stable left adrenal adenoma. On [**12-7**], the patient had a thoracentesis which was consistent with an exudate. The chest tube was placed on [**12-8**] for a large left pleural effusion by Dr. [**Name (NI) **]. On [**12-10**] the patient had a repeat computerized tomography scan after pleural tap and chest tube which showed persistent small bilateral pleural effusions with partial loculation of the left pleural effusion, decreased markedly since [**9-7**], study, persistent bilateral calcified pleural plaques consistent with asbestos exposure and groundglass opacities, likely the result of pulmonary edema in a stable small noncalcified right lower lobe pulmonary nodule. The patient was taken off of pressors. On [**12-11**] the patient had a computerized tomography scan of the head secondary to poor mental status and inability to wean from the ventilator which showed no evidence of intracranial hemorrhage, no change from prior examination. On [**12-12**], the patient had an magnetic resonance imaging scan and magnetic resonance angiography of the head which showed no evidence of acute infarct, bilateral chronic occipital infarct, ventriculomegaly out of proportion or sulci which could be due to NPH improper setting and magnetic resonance imaging scan showed bilateral distal vertebral changes with greater than 50% stenosis of the distal right vertebral artery. Ultrasound on [**12-11**] showed a posterior effusion in the left lung cavity. On [**12-15**], chest tube was pulled without complications. On [**12-15**], the patient extubation was attempted and failed thought secondary to fatigue or mental status. The patient's oxygen saturation was to the low 60%, low blood pressure. The patient was reintubated without complications. The patient remained on a ventilator with sedation held. Coumadin was held in the setting of previous coagulopathy. The patient was maintained on tube feeds. On [**12-7**], the patient had a left subclavian placed. On [**12-13**], it was rewired. The patient's Metoprolol and Captopril doses were increased secondary to elevated blood pressure. The patient continued to have good RSVI less than 105 but poor mental status. On [**12-25**], the patient went to the Operating Room for emergent bronchoscopy with Dr. [**Last Name (STitle) **]. Tracheostomy was performed due to fibrosis in the neck likely secondary to chemotherapy. An endotracheal tube was placed instead of a tracheostomy tube and sutured in place. The patient tolerated the procedure without complications. Dr. [**Last Name (STitle) 954**] intended to replace the endotracheal tube with a tracheostomy once tract forms in approximately one week, planning for [**Last Name (LF) 2974**], [**1-2**]. Nutrition followed the patient closely. Tube feeds were increased, Promod with fiber to 75 cc/hr, which was tolerated well with patient. The patient was started on Zoloft on [**12-25**] for possible depression. The family notes that they think this is the cause for poor mental status. The patient works with physical therapy and occupational therapy. While in the Unit the patient was started on Levaquin and Ceftriaxone for a total of seven days for possible coverage of aspiration and infiltrate within the left effusion and for gram positive cocci in the sputum which culture showed consistent with oropharyngeal Flora. The patient remained afebrile. The patient was restarted on Vancomycin and Ceftazidime for a Staphylococcus aureus, Methicillin-sensitive within his culture. Penicillin allergy, the patient was started on Vancomycin and Ceftazidime for ventilated-associated pneumonia which was presumed. The patient had central lines removed on approximately [**12-26**] and a right PICC line placed. The patient received additional units of blood for low hematocrit. The patient was complaining of epigastric pain. Cardiac enzymes were checked which ruled out for myocardial infarction. Electrocardiogram was unremarkable. Epigastric pain resolved with bowel regimen and improved. The patient was found to be constipated. The patient continued to do well with weaning on pressor support. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: To rehabilitation. DISCHARGE DIAGNOSIS: 1. L1 vertebral body fracture. 2. Left hemorrhagic pleural effusion, status post chest tube drainage . 3. Right pleural effusion status post thoracentesis consistent with transudate. 4. Status post myocardial infarction, troponin of 10, [**9-6**]. 5. Anemia, status post transfusion. 6. Methicillin-sensitive Staphylococcus aureus pneumonia treated with Vancomycin and Ceftazidime, started no [**12-24**], planned for seven days. 7. Depression, started on Zoloft. 8. Diabetes, NPH 39 and 9. 9. Paroxysmal atrial fibrillation, Sotalol 40 mg b.i.d. 10. Hypertension on Captopril 100 t.i.d., Metoprolol 50 t.i.d., Isordil 20 b.i.d. 11. Hyperlipidemia, Zocor 20 once a day. 12. Hypothyroid, Synthroid 80 mcg once a day. 13. Constipation, the patient given Lactulose, Dulcolax, Colace, as needed. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Last Name (NamePattern1) 21669**] MEDQUIST36 D: [**2138-12-31**] 16:26 T: [**2138-12-31**] 17:45 JOB#: [**Job Number **] Admission Date: [**2138-12-3**] Discharge Date: [**2139-1-6**] Date of Birth: [**2070-1-22**] Sex: M Service: CONTINUATION OF EVENTS ON HOSPITAL COURSE: After patient had tracheostomy with endotracheal tube placed patient was slowly weaned from ventilator, tolerated pressure support 8 and 5, FIO2 of 40 percent. Patient initially planned to have tracheostomy change on [**1-2**]. However, patient appeared to be fatigued from being on low levels of pressure support through the long endotracheal endotracheal tube. In the morning had brief episodes of desaturation and increased CO2. Patient tracheostomy postponed to [**1-5**]. Patient's tracheostomy changed on [**1-5**] without difficulty. Speech and swallow evaluation ordered for the morning of [**1-6**]. Patient's hematocrit drifting down. Anemia work up started. Reticulocyte count normal on [**1-5**]. Patient's hematocrit decreased from 30.4 to 27.6. Patient transfused a unit of blood. Chest x-ray rechecked to evaluate for possible recurrence of hemothorax from [**Month (only) 1096**]. Chest x-ray showed no pleura effusion. Examination on [**1-5**] - vital signs, maximum temperature 99.0, temperature current 98.0, blood pressure 122/43, heart rate 68, breathing at 18 and 99%. Patient's intake and outputs were 2440/50 and 60. Patient on AC 450, rate of 12, 0.5, PEEP of 5. Patient placed on the settings prior to tracheostomy change. Patient to be weaned on pressure support to eventually change to tracheostomy mask. As far as physical examination generally alert, in no acute distress. Cardiovascular regular rate and rhythm, no murmurs, rubs or gallops. Lungs clear to auscultation bilaterally. Abdomen soft, nontender, nondistended, bowel sounds present. Extremities no edema. Neurologic: following commands, moving all extremities, interactive. LABORATORIES FROM [**1-5**]: CBC: 8.4, 27.6, 169. Chem-7: 137, 4.2, 97, 35, 35, 0.8, 38. [**1-2**] blood culture is negative. MEDICATIONS ON DISCHARGE: Heparin 5,000 units subcutaneously q 8, HP 35 in the morning, 5 at night, vitamin C 500 mg b.i.d., zinc sulfate 220 mg p.o. q day, lansoprazole 30 mg q day, metoprolol 50 mg p.o. t.i.d., Captopril 100 mg p.o. t.i.d., Celexa 20 mg p.o. q day, isosorbide dinitrate 20 mg p.o. t.i.d., sotalol 40 mg p.o. b.i.d., aspirin 325 mg p.o. q day, bromindione tartrate 0.15% ophthalmic 1 drop per eye every 8 hours, senna 2 tabs p.o. q.n.s., Colace 100 mg p.o. b.i.d., Levothyroxine sodium 88 mcg p.o. q day, Simvastatin 20 mcg p.o. q. day, Combivent nebulizer treatment q 6, Promote with fiber goal of 75 cc an hour, sliding sale insulin, p.r.n. Dulcolax 10 mg p.o. q day p.r.n. and Ativan [**12-11**] to1 mg q 4 p.r.n. anxiety, Tylenol 325 to 650 mg p.o. q 6 p.r.n. temperature. Projected date of discharge: [**1-6**]. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To rehabilitation. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Last Name (NamePattern1) 21669**] MEDQUIST36 D: [**2139-1-5**] 14:36 T: [**2139-1-5**] 16:17 JOB#: [**Job Number **] Admission Date: [**2138-12-3**] Discharge Date: Date of Birth: [**2070-1-22**] Sex: M Service: MEDICAL ICU This is a discharge summary addendum to the previous addendum from [**2139-1-6**]. HOSPITAL COURSE: On [**2139-1-6**], the patient was noted to have some bleeding at the tracheostomy site and 100 ccs of blood from the nasogastric tube after the patient had pulled the tube twice and it was replaced. On that same day, the patient had repeated episodes of epistaxis, was evaluated by ENT by laryngoscope, visualized an abrasion in the left posterior pharynx, only seen with scope. ENT noted bleeding should stop on its own. The next day the patient received one unit of packed red blood cells. Hematocrit did not increase appropriately. ENT was called back for the repeated bleeding, removed nasogastric tube, inserted a Foley catheter into the left naris and inserted 17 ccs within the balloon which immediately controlled bleeding from oropharynx. Dr. [**Last Name (STitle) 954**] with cardiothoracic surgery who inserted the tracheostomy evaluated the tracheostomy and did not suspect that bleeding was from tracheostomy site. It appeared to be coming from above. On [**2139-1-6**], the patient had a thoracentesis of two liters of serosanguinous fluid from the right lung base consistent with transudate, probably due to congestive heart failure; however, the patient's low albumin may have contributed to this effusion. Posttap chest x-ray showed improvement in lung fields and pleural effusion. The patient evaluated by speech. The patient was unable to phonate. Possible laryngeal cord edema, trauma, limiting ability to aerate. Should be evaluated follow-up by ENT for laryngeal cord injury, paralysis. The patient did not have a swallow evaluation with the bloody secretion prior to the balloon tamponade, not viewed appropriate at that time. Will evaluate for swallow evaluation possibly Monday prior to discharge. The patient worked with physical therapy and making good progress. Would benefit from one to three times a week physical therapy sessions. On [**2139-1-7**], a percutaneous endoscopic gastrostomy was placed by gastroenterology without complications. On [**2139-1-9**], called to see the patient for cellulitis. On the neck, area erythematous, blanching to pressure. The patient was started on Vancomycin as on [**2139-1-2**], had a MSSA culture around tracheostomy site, had deferred antibiotics at the time as the patient was afebrile with no symptoms, however, given the new cellulitis, started the Vancomycin as the patient has a Penicillin allergy. Would recommend a course of ten days as long as the patient continues to improve. The patient was seen by chest surgery who placed the tracheostomy and agrees with the above plan. [**Month (only) 116**] want to add coverage if not responding. The patient also had some bleeding around the percutaneous endoscopic gastrostomy which cleared with a lavage through the percutaneous endoscopic gastrostomy tube. The patient had problems with intermittent bradycardia but was asymptomatic and otherwise vital signs were stable. Also problems with constipation, last disimpacted [**2139-1-10**], with good effect, and tolerated tracheostomy mask on [**2139-1-9**], for five hours and placed back on pressure support [**9-13**] and 40% with good saturation at 96%, volume 330. Tracheostomy mask reattempted [**2139-1-10**], pending at this dictation. MEDICATIONS ON DISCHARGE: (Addition) 1. Vancomycin one gram intravenously q12hours times ten days, started on [**2139-1-10**]. 2. Metoprolol 50 mg p.o. three times a day, hold for heart rate less than 60. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Last Name (NamePattern1) 21669**] MEDQUIST36 D: [**2139-1-10**] 14:53 T: [**2139-1-10**] 15:32 JOB#: [**Job Number 97949**] Admission Date: [**2138-12-3**] Discharge Date: [**2112-2-8**] Date of Birth: [**2070-1-22**] Sex: M Service: NOTE: This is a Discharge Summary Addendum to the previous Addendum from [**2139-1-12**]. HOSPITAL COURSE CONTINUED: The patient had a question of a right middle lobe infiltrate on chest x-ray noted on [**2139-1-11**]. The patient was started on ceftazidime for presumed Medical Intensive Care Unit associated pneumonia. On [**1-12**], the patient underwent a bronchoscopy to further elucidate the question of a right middle lobe infiltrate. It was noted that there was no purulent discharge or tracheoesophageal fistula on bronchoscopy. The patient has remained clinically without pneumonia since his bronchoscopy. On [**2139-1-13**], it was decided that the patient most likely did not have pneumonia and ceftazidime was stopped. The patient had also been on vancomycin for presumed tracheal cuff cellulitis. The area around the cuff was erythematous; however, it was not warm nor was it indurated. It most likely was a result of inflammatory and/or irritative changes to the skin. The patient did not have clinical cellulitis around the tracheal pallor. The patient's vancomycin was stopped. The patient has been weaned off CPAP to a tracheal mask for durations of up to 16 hours on [**1-12**] and on [**1-13**]. The patient has been tolerating these weanings appropriately. The patient was started on Mucomyst for secretion to help decrease the thickness of his secretions. The patient was tolerating his current respiratory support well. The patient was ready for discharge to rehabilitation when rehabilitation is available. [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 98036**] Dictated By:[**Last Name (NamePattern1) 98037**] MEDQUIST36 D: [**2139-1-13**] 14:14 T: [**2139-1-13**] 14:28 JOB#: [**Job Number **]

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icd9cm

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40456

Discharge summary

report

Admission Date: [**2160-5-17**] Discharge Date: [**2160-5-29**] Date of Birth: [**2089-5-27**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1973**] Chief Complaint: Pulled out G-J tube Major Surgical or Invasive Procedure: G-J tube replacement by IR PICC line replacement History of Present Illness: 70 yo male with mental retardation, CP, severe vision impairment, congenital deafness, presents from rehab s/p pulling out his G-J tube. Pt is non-verbal, non-communicative, and pt's brother was unable to be contact[**Name (NI) **] for further information. History obtained from outside medical records and per ED history. Pt was admitted to [**Hospital **] Rehab Watham from [**Hospital 1727**] Medical Center on [**2160-2-26**], after treatment for an MVA in which he sustained a c6-c7 fracture. He suffered respiratory failure, and required tracheostomy, as well as neurogenic bladder for which he has a suprapubic catheter in place. Per report from [**Name (NI) **], pt pulled out his PICC line and his G-J tube; Picc line was replaced [**5-17**]. It remains unclear exactly when pt's G-J was noted to be pulled. He is currently undergoing treatment for pneumonia growing pseudomonas and beta strep with Ceftazime. He also has significant decubitus ulcers, previously noted and receiving wound care at [**Hospital1 **]. . Pt admitted to [**Hospital1 18**] for further care while awaiting replacement G-J tube. . Unable to obtain ROS d/t non-communicative. Past Medical History: Cerebral palsy Mental retardation Legally blind congenital deafness Neurogenic bladder; s/p suprapubic catheter placement hx dCHF L pulmonary apical nodule; further evaluation deferred Hx MVA [**10/2159**]; C6-C7 fracture with incomplete cord injury; resulting LE weakness and neurogenic bladder G-J tube; presumed d/t aspiration risk Social History: Currently residing at [**Hospital **] Rehab. Unable to obtain further history at this time. Family History: Unable to obtain further history at this time. Attempted to contact pt's brother, but not able to reach. Physical Exam: VS: 96.9 Ax 152/80 77 22 98% 35% Tc GEN: chronically ill appearing male, mentally retarded, moves arms freely. Non-toxic. HEENT: eomi, MMM. Neck: Trach in place. No erythema. RESP: Coarse central rhonchi. Good AE. No wheezing. CV: RRR. No mrg. ABD: +BS. Soft, NT/ND. Site of former G-J tube, with some local scar tissue. No bleeding or exudate. Attempted to pass 14 Fr foley catheter, but met resistance; was not attempted further. No complications. Ext: No CEE. Neuro: Non-communicative, but +interactive. Moves UE freely. Pertinent Results: [**2160-5-26**] 06:20AM BLOOD WBC-10.5# RBC-3.38* Hgb-9.0* Hct-29.8* MCV-88 MCH-26.6* MCHC-30.1* RDW-16.2* Plt Ct-265 [**2160-5-21**] 04:24AM BLOOD WBC-6.9 RBC-3.48* Hgb-9.2* Hct-30.0* MCV-86 MCH-26.4* MCHC-30.6* RDW-16.4* Plt Ct-299 [**2160-5-19**] 09:00AM BLOOD WBC-10.8 RBC-3.57* Hgb-9.6* Hct-30.1* MCV-84 MCH-26.8* MCHC-31.9 RDW-17.2* Plt Ct-307 [**2160-5-17**] 03:45PM BLOOD WBC-14.1* RBC-3.53* Hgb-9.6* Hct-29.5* MCV-84 MCH-27.1 MCHC-32.4 RDW-16.3* Plt Ct-296 [**2160-5-29**] 08:26AM BLOOD Neuts-66.4 Lymphs-16.9* Monos-9.3 Eos-6.8* Baso-0.6 [**2160-5-17**] 03:45PM BLOOD Neuts-79.8* Lymphs-12.2* Monos-3.9 Eos-3.5 Baso-0.6 [**2160-5-28**] 03:08AM BLOOD PT-15.4* PTT-37.4* INR(PT)-1.3* [**2160-5-27**] 04:34AM BLOOD PT-13.8* PTT-32.8 INR(PT)-1.2* [**2160-5-17**] 03:45PM BLOOD PT-14.2* PTT-28.6 INR(PT)-1.2* [**2160-5-29**] 08:26AM BLOOD Glucose-122* UreaN-6 Creat-0.4* Na-137 K-4.4 Cl-98 HCO3-35* AnGap-8 [**2160-5-27**] 04:34AM BLOOD Glucose-111* UreaN-8 Creat-0.3* Na-141 K-3.7 Cl-103 HCO3-34* AnGap-8 [**2160-5-19**] 09:00AM BLOOD Glucose-90 UreaN-11 Creat-0.4* Na-135 K-4.1 Cl-99 HCO3-28 AnGap-12 [**2160-5-17**] 03:45PM BLOOD Glucose-93 UreaN-23* Creat-0.4* Na-138 K-4.8 Cl-99 HCO3-31 AnGap-13 [**2160-5-29**] 08:26AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.9 [**2160-5-26**] 06:20AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.9 [**2160-5-19**] 09:00AM BLOOD Calcium-9.6 Phos-2.9 Mg-1.9 [**2160-5-26**] 02:02PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.025 [**2160-5-26**] 02:02PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG [**2160-5-26**] 02:02PM URINE RBC-49* WBC-0 Bacteri-NONE Yeast-NONE Epi-1 [**2160-5-26**] 02:02PM URINE Uric AX-MANY [**2160-5-26**] 02:02PM URINE Mucous-MANY [**2160-5-25**] 12:30AM URINE Hours-RANDOM UreaN-610 Creat-91 Na-81 K-40 Cl-102 [**2160-5-25**] 12:30AM URINE Osmolal-538 [**2160-5-26**] 2:02 pm URINE,SUPRAPUBIC ASPIRATE Source: Suprapubic. **FINAL REPORT [**2160-5-27**]** URINE CULTURE (Final [**2160-5-27**]): GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. [**2160-5-26**] 2:09 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2160-5-28**]** MRSA SCREEN (Final [**2160-5-28**]): No MRSA isolated. [**2160-5-26**] 2:15 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2160-5-28**]** GRAM STAIN (Final [**2160-5-26**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2160-5-28**]): MODERATE GROWTH Commensal Respiratory Flora. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. GRAM NEGATIVE ROD #1. MODERATE GROWTH. GRAM NEGATIVE ROD #2. MODERATE GROWTH. GRAM NEGATIVE ROD #3. MODERATE GROWTH. [**Numeric Identifier 88640**] REPLACE D OR J TUBE, ALL INCL. Study Date of [**2160-5-19**] 2:17 PM IMPRESSION: Successful insertion of a new 16 French MIC feeding tube into pre-existing tract with tip in the jejunum. The tube is ready for use. CHEST (PORTABLE AP) Study Date of [**2160-5-23**] 4:48 PM Tracheostomy tube appears appropriately positioned. Trace lucency outlines the aortic arch and descending aorta which may represent a trace amount of pneumomediastinum, to which attention should be paid on followup examination. The PICC line is again seen in unchanged position. No pneumothorax is appreciated. There is left perihilar haziness and increased opacity within the left hemithorax as well as at the right lung base which is not significantly changed and may reflect pulmonary edema, although a superimposed infection cannot be excluded. Portable TTE (Complete) Done [**2160-5-27**] at 11:20:00 AM The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Pulmonary artery hypertension with right ventricular pressure overload septal pattern. The normal right ventricular cavity size and free wall motion suggests that the pulmonary hypertension is chronic, though cannot exclude acute on chronic process. Brief Hospital Course: 70 yo male with mental retardation, CP, trach collar, suprapubic catheter, LE weakness and neurogenic bladder s/p MVA with cervical neck fracture with incomplete cord injury, and currently undergoing treatment for pneumonia with Ceftazidime, presented from [**Hospital **] rehab s/p pulling out G-J tube, which he needs for nutrition and aspiration risk. 1. Pulled G-J tube Pt presented over the weekend, when IR services were unavailable. He was maintained on IV medications and IV hydration with glucose until G-J tube was replaced on Monday. His G-J tube was replaced on [**2160-5-19**] without complications. He was monitored overnight. His G-J tube is ready for use for medications and tube feeds. 2. Pneumonia, likely aspiration, bacterial Pt was being treated with Ceftazidime at [**Hospital1 **] with a start date of [**2160-5-13**] according to provided records. He was continued on IV Ceftazidime throughout the hospitalization, He was receiving po Vancomycin for c-diff prophylaxis while on ceftazidime. During the hospitalization, he did not have any diarrhea; please note that tube feeds were held as well. During the hospitalization, a cap for his PICC became dislodged, and therefore his PICC was pulled and a new PICC was replaced on [**2160-5-19**]. A CXR confirmed correct placement. On [**5-25**] he was transferred to the [**Hospital Unit Name 153**] due to increasing nursing load with suctioning his copious secretions. His scopalamine patch was removed and agressive suctioning was performed. He markedly improved, and was transferred back to the floor. 3. Moderate Malnutrition Pt was receiving tube feeds prior to his G-J tube being pulled. He was treated with D5NS while awaiting G-J tube replacement. 4. Spinal cord injury Pt' suprapubic catheter remains in place without difficulties. His fentanyl patch was continued, gabapentin and baclofen were held due to loss of GI access. His pain was treated with IV morphine as needed. His previous medications should be resumed at time of discharge. 5 History of respiratory failure; hx trach Respiratory therapy followed throughout the hospitalization. He remained stable on trach collar and received frequent suctioning. He pulled his inner cannula, which was replaced by respiratory therapy. # Mental retardation/CP His quetiapine was held due to loss of GI access, and subsequently resumed. Anxiety was treated with IV ativan as needed, with good response. # Preexisting Decubitus ulcers Wound care was consulted and followed throughout the hospitalization. He was continued on pain control as above. [**Hospital1 18**] wound care Recommendations: 1. Pressure Redistribution - First Step, patient has full thickness pressure ulcers bilateral turning surfaces. 2. Cleanse wounds with commercial wound cleanser. Pat dry. 3. Apply DuoDerm wound gel to bilateral trochanter eschar caps, cover with Mepilex dressing. Change q 3 days. 4. cleanse peri suprapubic catheter skin with warm water and mild soap, rinse and pat dry. Apply Critic aid clear skin barrier ointment daily to peri tube skin. 5. Support nutrition, hydration, and comfort. 6. Assess Trach tube holder for increase pressure to posterior neck. Small stable eschar cap - place Mepilex 4x4 over site. Change q3 days. 7. Right Malleolous - apply Adaptic dressing, 4x4 and wrap with Kerlix, change daily. 8. Reposition patient q 2 hours. . CODE: FULL PPx: SQ Heparin; return to enoxaparin at time of discharge DISP: Discharged to [**Hospital1 **]. Medications on Admission: lorazepam 0.5 mg IV q 4 hr prn morphine 2 mg IV q 4hr prn D5 1/2 NS at 75 cc/hr protein/soy supplement 37 cc/hr via feeding tube baclofen 20 mg q 8hr via feeding tube vancomycin 250 mg TID via feeding tube ceftazidime 1 gm IV q 8 hr water 250 ml q 4hr via feeding tube simethicone 80 mg q 6hr prn via feeding tube nystatin 5 mg po QID bismuth 30 ml q 6 hr prn via feeding tube fentanyl 100 mcg/hr patch q 72 hr lansoprazole 30 mg q day via feeding tube gabapentin 600 mg q 8 hr via feeding tube lactobacillus 1 tab q 8 hr via feeding tube enoxaparin 40 mg SQ q day ascorbic acid 500 mg q day via feeding tube hyoscamine 0.125 mg q 6hr via feeding tube oxycodone 10 mg q 4 hr prn via feeding tube scopalamine patch q 72 hr L-argenine/L-glutamine 1 packet [**Hospital1 **] via feeding tube chlorhexadine 5 ml oral care q 12 hr fluticasone 220mg INH [**Hospital1 **] lidocaine patch q day MVI 5 ml q day docusate 100 mg q 12hr via feeding tube senna 5 mg HS via feeding tube quetiapine 25 mg HS via feeding tube miconazole powder TOP [**Hospital1 **] acetaminophen 650 mg via feeding tube prn Discharge Medications: 1. Lorazepam 0.5 mg IV Q4H:PRN agitation 2. Morphine Sulfate 1-2 mg IV Q4H:PRN pain 3. protein/soy supplement 37 cc/hr via feeding tube 4. baclofen 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO every eight (8) hours: via feeding tube. 5. vancomycin 250 mg Capsule [**Hospital1 **]: One (1) Capsule PO three times a day: via feeding tube, until completion of ceftazidime. 6. ceftazidime 1 gram Recon Soln [**Hospital1 **]: One (1) gm Intravenous every eight (8) hours for 3 days: Anticipate course complete [**2160-5-22**] for 10 day course. . 7. water Liquid [**Month/Day/Year **]: Two [**Age over 90 1230**]y (250) mL PO every four (4) hours: via feeding tube. 8. fentanyl 100 mcg/hr Patch 72 hr [**Age over 90 **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day: via feeding tube. 10. gabapentin 600 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every eight (8) hours: via feeding tube. 11. enoxaparin 40 mg/0.4 mL Syringe [**Last Name (STitle) **]: One (1) inj Subcutaneous once a day. 12. ascorbic acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 13. hyoscyamine sulfate 0.125 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every six (6) hours as needed for abdominal pain: via feeding tube. 14. oxycodone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every four (4) hours as needed for pain. 15. scopolamine base 1.5 mg Patch 72 hr [**Last Name (STitle) **]: One (1) patch Transdermal every seventy-two (72) hours. 16. L-arginine/L-glutamine 1 packet via feeding tube [**Hospital1 **] 17. chlorhexidine gluconate 0.12 % Mouthwash [**Hospital1 **]: Five (5) ML Mucous membrane [**Hospital1 **] (2 times a day). 18. fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 19. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 20. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 21. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 22. quetiapine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime. 23. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) app Topical twice a day. 24. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO three times a day: via feeding tube. 25. 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. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: # Pulled G-J tube # Pneumonia, likely aspiration, bacterial (prior to admission) # Spinal cord injury # History of respiratory failure; required trach # Mental retardation/CP # Decubitus ulcers (pre-existing) Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted after pulling out your G-J tube. You were treated with IV fluids and IV medications while awaiting G-J tube replacement. Your tube was replaced by Interventional Radiology and you are being discharged back to your rehab facility. Followup Instructions: You are being discharged to a rehab facility. Please follow up with your primary care physician within one week of discharge from rehab.

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icd9cm

[ [ [] ] ]

[ "43.11", "38.93" ]

icd9pcs

[ [ [] ] ]

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324, 375

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9230

Discharge summary

report

Admission Date: [**2169-11-20**] Discharge Date: [**2169-11-23**] Service: MEDICINE Allergies: Levofloxacin Attending:[**First Name3 (LF) 2387**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: none History of Present Illness: 82 yo woman Greek-speaking returns from rehab for bleeding/oozing from her trach and PEG sites that were placed on [**11-17**]. She had initially been admitted in [**Month (only) 359**] with complete heart block now s/p pacer. Her long hospital course was complicated by atrial fibrillation requiring multiple DCCV and amiodarone loads, respritory failure, congestive heart failure, chronic metabolic alkolosis, was discharged Saturday to rehab after a trach and PEG were placed by IP. She was sent out on Lovenox and coumadin (for porcine valve and afib). She was doing well at rehab until Sunday night when she began to pull at her tubes. She was placed in restraints. On Monday, she was noted to be oozing from her Peg and trach sites. Her hematocrit at that time was 25 down from 29 on Sunday. She had guiac positive stool and the question of melana at [**Hospital1 **]. In the ED: HCT stable at 25. GI consult saw the patient and clots were cleared after 150cc PEG lavage. Her blood pressure dropped to 70/p but increased then to 97/p after 500cc bolus. Past Medical History: AVR [**2162**] for critial aortic stenosis CHF [**2166**] COPD, CO2 retainer - hx of hypercapnic respiratory failure resulting in intubation in [**2166**] Restrictive lung disease Pancreatitis [**2168**] Hypertension Atrial fibrillation on coumadin s/p broken hip Social History: Sh has 2 very involved children. Family History: Non-contributory Physical Exam: Vitals: T = 100.3, HR = 80 , BP = 111/63 , RR = 15 , SaO2 = 98% on AC 350 TV, PEEP 8, 30%FiO2 General: Pleasant elderly female, appears comfortable, NAD. HEENT: Normocephalic and atraumatic head, no nuchal rigidity, anicteric sclera, dry mucous membranes. adentulous Neck: No thyromegaly, no lymphadenopathy, no carotid bruits. +trach with clotted blood. Gauze with some oozing. Right IJ CVL in place without erythema. Chest: Her chest rose and fell with equal size, shape and symmetry, + exp wheezes on vent CV: PMI appreciated in the fifth ICS in the midclavicular line without heaves or thrills, RRR, normal S1 and S1 II/VI SEM. Pacer in pocket without fluctulance. Abd: Normoactive BS, NT and ND. No masses or organomegaly. PEG site without oozing and tender. large ecchymosis on right side of abdomen. Guiac + with melana. Back: No spinal or CVA tenderness. Ext: NO cyanosis, no clubbing or edema with 2+ dorsalis pedis pulses bilaterally Integument: no rash. multiple ecchymosis. Sacral edema Neuro: A and Ox3 per son. CN [**Name2 (NI) **]-XII symmetrically intact, PERRLA. Pertinent Results: [**2169-11-20**] 06:40PM GLUCOSE-103 UREA N-35* CREAT-0.7 SODIUM-145 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-35* ANION GAP-8 [**2169-11-20**] 06:40PM ALT(SGPT)-10 AST(SGOT)-25 CK(CPK)-14* ALK PHOS-115 AMYLASE-27 TOT BILI-0.4 [**2169-11-20**] 06:40PM ALBUMIN-3.0* CALCIUM-8.2* PHOSPHATE-1.6*# MAGNESIUM-2.1 [**2169-11-20**] 06:40PM WBC-5.5 RBC-2.58* HGB-8.0* HCT-24.9* MCV-97 MCH-31.2 MCHC-32.3 RDW-19.9* [**2169-11-21**] AP PORTABLE UPRIGHT VIEW OF THE CHEST: There are small lung volumes. There is cardiomegaly with bilateral pleural effusions. There is left lower lobe atelectasis. The previously described round ring-like lucency at the right apex is not visualized on the current study. The patient is status post sternotomy with aortic valve replacement. Again noted is a dual lead pacemaker with leads intact. IMPRESSION: 1) Cardiomegaly with bilateral pleural effusions and prominence of the pulmonary vasculature consistent with CHF, not significantly changed compared to the prior study. 2) Left lower lobe atelectasis. [**2169-11-20**] 6:40 pm BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Preliminary): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31704**] FA6B 12:55P [**2169-11-22**]. GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. BEING ISOLATED FURTHER IDENTIFICATION TO FOLLOW. [**2169-11-21**] 12:31 am URINE **FINAL REPORT [**2169-11-22**]** URINE CULTURE (Final [**2169-11-22**]): NO GROWTH. [**Known lastname 31705**],[**Known firstname **] [**Numeric Identifier 31706**] F82 - Urine Specimen Results, Hematology Test Name Value Units Reference Range [**2169-11-20**] 06:40PM Urine Color Straw Urine Appearance Clear Specific Gravity 1.014 1.001 - 1.035 DIPSTICK URINALYSIS Blood LG Nitrite NEG Protein NEG mg/dL Glucose NEG mg/dL Ketone NEG mg/dL Bilirubin NEG EU/dL Urobilinogen NEG EU/dL 0.2 - 1 pH 5.0 units 5 - 8 Leukocytes TR MICROSCOPIC URINE EXAMINATION RBC 21-50* #/hpf 0 - 2 WBC 0-2 #/hpf 0 - 5 Bacteria RARE Yeast NONE Epithelial Cells [**3-10**] #/hpf Brief Hospital Course: 1. Bleeding from Trach and PEG: The patient was admitted for a GI bleed which was actually from the inside of her PEG. She is likely bleeding from the anticoagulation for her afib and valve and her poor nutritional status. She underwent a bronchoscopy on [**11-22**] which did not reveal a bleeding trach site or any abnormalities in the lungs. Two days before discharge, the oozing around the trach and PEG sites had stopped as her INR drifted downward. She will follow up with Dr. [**Last Name (STitle) **] in two weeks and the issue of restarting the coumadin. 2. Hypotension: The patient is initially hypotensive on admission and appeared volume depleted blood loss or due to infection. After one transfusion and fluid, her blood pressure rose and her metoprolol was restarted. She was then transfused a second unit to raise her Hematocrit to above 30. Her CBC should be check again in 1 week. 3. Pulm: Her vent setting were kept the same throught her stay. 4. Hypothyroidsm: The patient's TSH was checked on day of discharge during the last admission. GIven it was high (6.7) and the patient has a history of hypothyroidsm. she was restarted on Levothyoxl. Her TSH should be checked again in 2 weeks and adjustments should be made in her dose. 5. Nutrition: The patient was continued on tube feeds and this will be continued [**Hospital **] rehab. They are currently continuous but can be changed to cycled to allow her to sit up and undergo physical therapy. 6. Access: She was admitted with a R IJ that was removed on day of discharge. 7. ID: The patient had one out of 6 blood cultures positive for GPC in clusters. She was clinically stable without fever and this was felt to be a contaminant. She was given one dose of vancomycin. Her line was removed and the tip was sent for culture. The final speciation and tip culture will need to be followed up by her PCP or Dr. [**Last Name (STitle) **]. Medications on Admission: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 4. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 9. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO q Sat, Tues, Thurs, Sunday. 10. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO q Mon, Wed, Fri. 11. Amiodarone HCl 400 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. 12. Amiodarone HCl 400 mg Tablet Sig: One (1) Tablet PO once a day: Begin this after on [**11-23**]. 13. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous twice a day: d/c when INR>2.0. Disp:*10 * Refills:*2* 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO once a day. 2. Furosemide 40 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) as needed for constipation. 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-6**] Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Miconazole Nitrate 2 % Powder Sig: One (1) Topical every six (6) hours: Apply to affected areas as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: bleeding from Trach and PEG site Discharge Condition: good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 - 3L Followup Instructions: Follow up in Device clinic (located at [**Hospital1 18**], [**Hospital Ward Name **] [**Location (un) **]). call [**Telephone/Fax (1) 21817**] to schedule an appointment You have an appointment with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**12-13**] at 3:30 PM at his office in [**Location (un) **]. Call [**Telephone/Fax (1) 5455**] for directions.

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icd9cm

[ [ [] ] ]

[ "99.04", "96.6", "96.71", "33.21", "96.36" ]

icd9pcs

[ [ [] ] ]

9430, 9501

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231, 237

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53,392

140,406

37969

Discharge summary

report

Admission Date: [**2170-10-17**] Discharge Date: [**2170-10-21**] Date of Birth: [**2101-4-23**] Sex: F Service: NEUROLOGY Allergies: Iodine / Lipitor Attending:[**First Name3 (LF) 8850**] Chief Complaint: Intracranial Hemorrhage. Major Surgical or Invasive Procedure: None. History of Present Illness: [**Known firstname 84837**] [**Known lastname **] is a 69-year-old woman with metastatic melanoma with known brain metastases, s/p whole brain radiation completed on [**2170-10-12**] who presents with 3 days of malaise, nausea, vomiting, HA, and impaired vision. Nausea is exacerbated by food, and she admits to vomiting 'a couple' times daily without blood. She also complains of headache, but is unable to characterize, worse over the last several days and not relieved by tyelenol. Her vision has been progressively decreasing over the last several months, and she is now having problems [**Location (un) 1131**] and knitting. Also, she has had more difficulty walking, but denies falling or hitting her head. She denies seizures or new focal numbness or weakness. She has no recent fevers or chills. She denies CP or SOB. She has had increasing urinary urge incontinece for several weeks but no bowel incontinence. Her husband did note blood in her stool several days ago, which the patient attributes to hemmorhoids. She presented to the ED today after family called radiation oncology clinic concerned about her decline over the last several days. In the ED, inital vitals were temperature 98.6 F, pulse 79, blood pressure 154/91, respiration 20, and oxygen saturation 100% in room air. Patient was given 4mg po dex and 10mg IV along with Tylenol and Zofran. Non-contrast enhanced head CT showed showed new 3cm left occipital hemorrhage with vasogenic edema and smaller right-sided lesion with mass effect, but no cerebral herniation. Neurosurgery was evaluated who recommended conservative therapy, and family agrees not to pursue surgery at this time. Her vital signs on transfer were temperature 98.4 F, blood pressure 147/76, pulse 78, respiration 16, and oxygen saturation 98% in room air. On the floor, patient is sitting up comfortably in bed without complaint. Past Medical History: CAD status post PCI stents Hypertension Hypothyroidism Diabetes mellitus type 2 Asthma Hysterectomy Status post appendectomy Past Oncologic History, Per OMR: Metastatic Melanoma: status post resection of cutaneous melanoma from her right calf in [**2144**]. She did well until [**2168-9-13**] when a right groin mass was discovered. A lymph node dissection was done on [**2168-11-18**]. At that time, staging head MRI revealed the left parietal hemorrhagic metastasis. S/p CTLA-4 antibody on compassionate use complicated by colitis. Now she is status post several CyberKnife radiosurgery treatments for brain mets, last in [**Month (only) **] of this year: (1) CyberKnife radiosurgery to left parietal met on [**2169-1-23**] to [**2159**] cGy, (2) CyberKnife radiosurgery to left lateral temporal and left medial temporal mets on [**2169-2-24**] to 1800 and 2200 cGy respectively, (3) CyberKnife radiosurgery to right basal ganglia [**2169-6-20**] to 2200 cGy, (4) CyberKnife radiosurgery to five lesions on [**2169-6-23**] to 2200 cGy each, (5) Cyberknife radiosurgery to left parieto-occipital (2200 cGy) and left frontal ([**2159**] cGy) on [**2170-1-30**], and 6. Cyberknife radiosurgery to right frontal and right parietal metastases on [**2170-6-29**] to [**2159**] cGy. Also, she recently underwent whole brain cranial irradiation from [**2170-10-8**] to [**2170-10-12**] to [**2159**] cGy over 5 fractions. Social History: She lives at home with husband. She denies tobacco, drugs. She used alcohol very rarely. She has 2 daughters and one son. Family History: There is family history of breast and ovarian cancer, potentially in her maternal grandmother. She believes that her maternal first cousin had melanoma and lung cancer. Both the patient's mother and sister had early coronary artery disease as did her father and two brothers. Physical Exam: ADMISSION EXAMINATION: VITAL SIGNS: Temperature 97.3 F, blood pressure 146/78, pulse 64, respiration 14, and oxygen saturation 98% in room air. GENERAL: Pleasant, elderly woman lying in bed. She is orieted to place and person, has difficulty with year. HEENT: Sclera anicteric, Dry MM, oropharynx clear NECK: Supple, JVP not elevated, no LAD LUNGS: Non-labored on room air. Clear to auscultation bilaterally without no wheezes, rales, ronchi CARDIOVASCULAR: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops ABDOMEN: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly RECTAL: Patient refused EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEUROLOGICAL EXAMINATION: Oriented to person and "[**Hospital1 **]". Cannot recall the year and cannot spell WORLD backwards. Cranial nerves grossly intact, although patient with difficulty tracking on command and visual fields/acuity not tested. Fine tremor UE at rest. Strength 4/5 shoulder abduction, elbow flexion and extension, hip and knee flexion/extension. Patient with difficulty following commands for hand grip. [**5-17**] dorsiflexion and plantar flexion of lower extremities. Sensation grossly intact to light touch. Gait deferred. DISCHARGE EXAMINATION: VITAL SIGNS: Temperature 98.2 F/98.9 Fmax, blood pressure 170/84, pulse 80, respiration 18, and oxygen saturation 99% in room air GENERAL: Appears uncomfortable, tearful, yawns frequently, mild resting tremor UE bilaterally SKIN: Warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, anicteric sclera, MMM CARDIOVASCULAR: RRR, S1/S2, no mrg LUNGS: CTAB, no wheezing/rales but poor inspiratory effort ABDOMEN: Non-distended, +BS, TTP over midline, no rebound/guarding MUSCULOSKELETAL: Moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities NEUROLOGICAL EXAMINATION: Cranial nerves II-XII intact except possible right mouth droop (difficult to tell, as pt does not follow commands well); strength 5/5 upper extremities bilaterally but [**4-17**] left hand grip; prolonged grip with right hand despite asking to let go; [**4-17**] in lower extremities bilaterally Pertinent Results: [**2170-10-17**] CT head: Left occipital and small right frontoparietal hemorrhagic metastases, with surrounding edema, increased since CT of [**2170-1-26**], stable to slightly increased from MRI of [**2170-9-14**], given differences in technique Notable for H/H of 11.7/34.7, and UA with 9WBC, no bacteria or epi cells. LABS: [**2170-10-17**] 12:40PM BLOOD WBC-7.7 RBC-4.19* Hgb-11.7* Hct-34.7* MCV-83 MCH-28.0 MCHC-33.8 RDW-14.6 Plt Ct-285 [**2170-10-17**] 12:40PM BLOOD Neuts-86.2* Lymphs-11.4* Monos-1.9* Eos-0.2 Baso-0.3 [**2170-10-17**] 03:24PM BLOOD PT-11.5 PTT-24.7 INR(PT)-1.0 [**2170-10-17**] 12:40PM BLOOD Glucose-141* UreaN-28* Creat-1.0 Na-138 K-3.2* Cl-97 HCO3-30 AnGap-14 [**2170-10-18**] 03:58AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.0 [**2170-10-21**] 06:45AM BLOOD WBC-7.0 RBC-3.67* Hgb-10.3* Hct-30.1* MCV-82 MCH-28.1 MCHC-34.2 RDW-15.3 Plt Ct-215 [**2170-10-21**] 06:45AM BLOOD Glucose-111* UreaN-24* Creat-0.7 Na-137 K-3.8 Cl-105 HCO3-25 AnGap-11 [**2170-10-21**] 06:45AM BLOOD Calcium-8.9 Phos-2.0* Mg-2.0 Brief Hospital Course: Ms. [**Known lastname **] is a 69-year-old woman with h/o metastatic melanoma with brain metastases, who presents with headache, nausea, and vomiting. She was found to have hemorrhagic metastases and vasogenic edema, admitted for blood pressure control and conservation management. Initially stabilized in MICU then transferred to OMED. (1) ICH: Patient with new hemorrhagic metastases and surrounding vasogenic edema. Neurosurgery consulted, but no surgical intervention at this time. Family agrees to conservative management. Continued Dexamethasone and Keppra. Her blood pressure was controlled with lisinopril and nifedipine with goal SBP <150 4mg IV q6h. Symptomatic relief of nausea and HA with zofran and tylenol. (2) Hypertension: BP well-controlled on Lisinopril 20mg PO BID and Nifedipine 10mg q6h. (3) Metastatic Melanoma: Patient with hemorrhagic brain metastases. Was due to start a new drug on Tuesday (vemurafenib), will start once she arrives home. (4) Diabetes Mellitus: We held metformin and used SSI while in house. (5) UTI: This was found at OSH had >100K pan sensitive enterococcus on UCx. Started Amoxicillin 500 mg PO/NG Q8H Duration: 6 Days for UTI. (6) Diarrhea: She began having diarrhea on day of discharge. No elevation in white count. Could not provide a sample before discharge for testing. Family notified that if symptoms worsened, she can be re-evaluated for c.diff and treated at that time. (7) History of CAD/MI/CHF: Aspirin was held. Lisinopril was continued. Not currently on statin (has lipitor allergy) or beta-blocker. (8) Hypothyroidism: Continued home synthroid. Medications on Admission: - Celexa 20 - Keppra 500 [**Hospital1 **] - Vitamin B12 500 mcg daily - Vitamin D3 1000 units daily - Calcium (1250mg) daily - Tylenol 500 two tablets [**Hospital1 **] prn pain - lorazepam 1mg qhs - Lasix 20mg daily - Lisinopril 20 [**Hospital1 **] - Dexamethasone 1 tablet qam, [**1-14**] tablet qpm - Ibuprofen 400mg 1 tablet [**Hospital1 **] prn pain - Synthroid 75 daily - Metformin 850 daily - Vitamin B6 200mg daily - Tucks 50% topical paids prn hemmorhoids - Zantac Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). Disp:*14 Tablet Extended Release(s)* Refills:*0* 5. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*42 Tablet(s)* Refills:*0* 6. amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 5 days: last dose [**2170-10-25**] PM. Disp:*30 Capsule(s)* Refills:*0* 7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Vitamin B-12 Oral 9. Vitamin D-3 Oral 10. calcium Oral 11. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for pain. 12. lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 14. metformin 850 mg Tablet Sig: One (1) Tablet PO once a day. 15. Vitamin B-6 Oral 16. Tucks 50 % Pads, Medicated Sig: One (1) pad Topical as directed as needed for hemorrhoids. 17. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. Disp:*42 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company **] Discharge Diagnosis: Primary Diagnosis: Intracranial hemorrhage Metastatic melanoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to the hospital with nausea, vomiting, and headaches. You were found to have a bleed in your brain. The neurosurgeons have decided that it is not a good idea to operate, so we are managing this conservatively. Your steroids have been increased to help with the swelling in your brain. The following changes were made to your medications: CHANGED: 1. dexamethasone 4 mg Tablet: 1 tablet by mouth every 8 hours STARTED: 2. amoxicillin 250mg tab: 2 tabs every 8 hours for 5 days (last dose [**2170-10-25**] PM) 3. nifedipine 30 mg Tablet Extended Release: 1 Tablet by mouth daily 4. zofran 4mg tablet: 1-2 tablets every four hours by mouth as needed for nausea STOPPED: 5. ibuprofen Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2170-10-30**] at 2:00 PM With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 13016**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2170-10-30**] at 2:00 PM With: [**Doctor First Name 10838**] [**Name8 (MD) **], NP [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RADIOLOGY When: MONDAY [**2170-11-12**] at 11:55 AM With: RADIOLOGY MRI [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

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icd9pcs

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7277

Discharge summary

report

Admission Date: [**2147-2-24**] Discharge Date: [**2147-3-17**] Service: CHIEF COMPLAINT: Bilateral lower extremities weakness. HISTORY OF THE PRESENT ILLNESS: This is an 80-year-old Caucasian male with a history of acquired factor 8 deficiency, chronic obstructive pulmonary disease, and walking times two days prior to admission. The patient has had periodic episodes in the past six months up to three to four times, which typically lasts one to two days and then resolved by itself. However, at this time, the patient complaints were not resolving and thus, he presented to the emergency department. Sensation and proprioception by report were intact and there had been no incontinence. The patient after which he had an episode of emesis/hematemesis. At that time he was transferred to [**Hospital1 188**] for further evaluation. Mr. [**Known lastname 26907**] was thought to have had hematemesis secondary to small [**Doctor First Name **]-[**Doctor Last Name **] tear and he was not further evaluated. At [**Hospital1 190**] he was noted to have cough and fever. He [**Hospital1 1834**] chest CT per pulmonary recommendations, which showed diffuse emphysema, lunate configuration of the trachea, consistent with tracheomalacia, narrowing of the distal right upper lobe bronchus and some thickening of the wall, which may represent neoplasm. There were also peripheral multifocal opacities especially in the right upper lobe. Mr. [**Known lastname 26907**] [**Known lastname 1834**] bronchoscopy, which showed right upper lobe foreign body, which was notable for evidence of aspiration pneumonia. Thus, he was started on Levaquin and Flagyl for possible aspiration pneumonia, as well as treatment chronic obstructive pulmonary disease flare. He was also seen by the Department of Neurology during his admission, who thought that the main differential diagnosis included AVM versus spinal ischemia as the mechanical cause for his lower extremity weakness and also sensory deficit, especially significant for pain and temperature changes. Mr. [**Known lastname 26907**] [**Known lastname 1834**] MRI on [**2-24**], which showed increased T2 signal in the distal thoracic areas down to his conus consistent with ischemia/demyelination. Repeat MR was done on [**3-6**], which showed diffuse atheromatous disease in the infrarenal abdominal aorta, compression fracture of the left vertebral body and focal stenosis in the origin of the internal mammary artery. The patient was then transferred from the Medicine Service to the Neurology Service. In the intervening days, the patient was prepared for CT guided spinal angiogram on [**2147-3-9**]. The procedure required intubation secondary to the likelihood of the procedure. However, the procedure was unsuccessful secondary to diffuse atherosclerosis in the spinal arteries. Post procedure, the patient was extubated with respiratory distress and re-intubated. The ABG was noted to be peak of 7.20, pCO2 63, pO2 94. At that time, he was reintubated and transferred to the MICU for vent management. He was also treated for chronic obstructive pulmonary disease flare with Albuterol and Atrovent nebs and Solu-Medrol 60 mg IV q.8h. He was quickly weaned off the vent and extubated early on [**2147-3-10**]. At that time, the patient was then transferred to the [**Location (un) 2655**] Service for further management. LABORATORY DATA: Labs on transfer were as follows: White count of 9.9, hematocrit 26.6, platelet count 376,000, PT 14.3, PTT 32.9, INR 1.4, factor 8 level 105. Chem 7 showed the following: sodium 139, potassium 4, chloride 109, bicarbonate 23, BUN 18, creatinine 0.8, blood sugar 108, calcium 7.0, phosphate 1.7, magnesium 1.4, most recent ABG on the morning of [**2147-3-10**] showing a pH of 7.36, pCO2 42, and pO2 100. Chest x-ray on [**2147-3-9**] showed ill-defined opacity in the right middle lobe and the right lower lobes, which were unchanged since the previous examination. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease with pulmonary function tests on [**2147-3-6**] showing FEV1 of 0.59, which is 22% and FEV1/FVC of 63% predicted. 2. Factor 8 inhibitor. 3. Status post right nephrectomy for hematuria, which was complicated by retroperitoneal bleed/hypertension/MAT/ARF/acute renal failure/ARDS/Serratia gram-negative pneumonia. 4. Tracheomalacia status post prolonged intubation after nephrectomy. 5. Hypertension. 6. Hypercholesterolemia. 7. Macular degeneration. 8. Syncope. 9. Polyps. 10. Distal humeral resection for lipoma. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: Mr. [**Known lastname 26907**] is a 60 pack per year smoker. He quit in [**2144**]. He did drink alcohol, but quit in [**2131**]. He currently lives with his wife and he is retired. FAMILY HISTORY: The patient's sister died of a heart attack at the age of 40. His mother died of some unknown gynecological cancer. MEDICATIONS ON ADMISSION: 1. Solu-Medrol 125 mg IV b.i.d. 2. Pepcid. 3. Flovent. 4. Advair. 5. Singulair. 6. Flomax. 7. Proscar. MEDICATIONS ON TRANSFER: 1. Flagyl 500 mg p.o.t.i.d. 2. Flovent MDI 4 puffs b.i.d. 3. Serevent MDI two puffs inhaled b.i.d. 4. Protonix 40 mg p.o.q.d. 5. Senna 2 mg p.o.b.i.d. 6. Colace 100 mg p.o.b.i.d. 7. Flomax 0.4 mg p.o.q.d. 8. Proscar 5 mg p.o.q.d. 9. Albuterol and Atrovent MDIs. 10. Solu-Medrol 40 mg IV q.8h. PHYSICAL EXAMINATION: Examination on transfer: Vital signs revealed the following: Temperature afebrile, pulse 96, blood pressure 131/76, respiratory rate 18, saturating 100% on 50% face tent. GENERAL: This is a moderate obese Caucasian male lying in bed in no acute distress. Face test in place. He is speaking in complete sentences. No accessory muscle use. HEENT: Pupils equal, round, and reactive to light. Extraocular muscles are intact. Anicteric sclerae. Oropharynx clear. Dentures in place on the upper palate, no thyroidectomy or lymphadenopathy. No supraclavicular nodes. CARDIOVASCULAR: No heart sounds could be reliably detected. The PMI was in the correct place. No murmurs, rubs, or gallops could be appreciated. LUNGS: Fine crackles, upper airway sounds bilaterally especially on expiration. ABDOMEN: Normoactive bowel sounds, nontender, nondistended, no masses. Obese abdomen. EXTREMITIES: Clean, dry, and intact, no swelling. There is a left radial artery line in place. NEUROLOGICAL: He is alert and oriented times three. Upper strength: 5/5 strength bilaterally in all muscle groups. Lower extremities: The patient is able to move toes bilaterally. He has most proximal lower extremity weakness, which is worse on the right side, rather than the left. Right side measured around 1+, left side 2+. HOSPITAL COURSE: #1. RESPIRATORY: Mr. [**Known lastname 26907**] has a history of tracheomalacia, chronic obstructive pulmonary disease and recent aspiration pneumonia, which has overall contributed to his shortness of breath and oxygen requirement. He had no oxygen requirement at home. He likely failed extubation secondary to sedation rather than chronic obstructive pulmonary disease exacerbation or pneumonia worsening. During the intervening days, Mr. [**Known lastname 26907**] finished a two-week course of Levaquin and Flagyl for presumed aspiration pneumonia. Repeat bronchoscopy was offered secondary to final rule out of possible neoplasm especially in the right upper lobe with wall thickening. Mr. [**Known lastname 26907**] [**Last Name (Titles) 19125**] on bronchoscopy at this time. His oxygen requirement has been weaned down from four liters to two liters with good results. He is not required further Lasix. He was discharged from the MICU. Mr. [**Known lastname 26907**] continues on Albuterol and Atrovent MDI for his chronic obstructive pulmonary disease. He has also continued on Serevent and Flovent as well. His steroids have been tapered with a quick taper and he will be discharged on those steroids. Pulmonary consultation has been following him throughout his stay and recommend no further intervention at this time. NEUROLOGICAL: Mr. [**Known lastname 26907**]' symptoms were likely secondary to arteriovenous malformation versus spinal ischemia. The main thought is that Mr. [**Known lastname 26907**] suffers from spinal ischemia secondary to diffuse atherosclerosis as seen in his attempted CT angiogram. If this is actually the case, Mr. [**Known lastname 26907**] had no further invention except for physical therapy. He finally did undergo CT myelogram on [**2147-3-15**], which showed degenerative disk disease at multiple levels of the lumbar spine and minimal myelomalacia in the thoracic area. There is no arteriovenous malformation seen. The Department of Neurosurgery had been following, but signed off. The Department of Neurology also signed off shortly after being transferred from the MICU. In the intervening time, Mr. [**Known lastname 26907**]' lower extremity weakness has minimally improved with the ability to internally and externally rotate the right lower extremity with ease. FLUIDS, ELECTROLYTES, AND NUTRITION: Mr. [**Known lastname 26907**] [**Last Name (Titles) 1834**] swallowing study on [**2147-3-13**], which showed the following: Slightly atypical oral preparation with delayed bullous formation. There was intermittent premature spill with thin liquids noted in the hypopharynx. There was mild residue, which was spontaneously cleared by second swallow. There was no aspiration of any consistency. At that time, the Speech and Swallow Department was following and recommendation upright for all p.o., monitoring for signs and symptoms of aspiration, slow pace of p.o. intake and finally soft ground/thin liquid diet. Mr. [**Known lastname 26907**], as stated before, will require ground diet with thin liquids. HEMATOLOGY: Mr. [**Known lastname 26907**] had no signs or symptoms of abnormal bleeding during his hospital stay. His factor 8 level was checked several times and within normal limits. Coagulations were followed carefully with no further need for porcine factor 8 infusions. Mr. [**Known lastname 26907**]' hematocrit was noted to reach a low 26.6 with baselines between 37 to 40. Iron studies, folate, and B12 were all checked, which were within normal limits. All stools were guaiac tested, but there was no further need for transfusions. DISPOSITION: Mr. [**Known lastname 26907**] is full code. He will be discharged to [**Hospital1 **] for rehabilitation. He will need followup with the Department of Neurology, in particular Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Phone #: [**Telephone/Fax (1) 44**], one month after discharge. DISCHARGE MEDICATIONS: 1. Prednisone 5 mg p.o.q.d times two days. 2. Mycostatin powder p.r.n. 3. Albuterol MDI two puffs inhaled q.i.d.p.r.n. 4. Atrovent MDI, two puffs inhaled q.i.d.p.r.n. 5. Proscar 5 mg p.o.q.d. 6. Flomax 0.4 mg p.o.q.h.s. 7. Colace 100 mg p.o.b.i.d. 8. Senna 2 mg p.o.b.i.d.p.r.n. 9. Protonix 40 mg p.o.q.d. 10. Serevent MDI two puffs inhaled b.i.d. 11. Flovent MDI four puffs inhaled b.i.d. DISCHARGE DIAGNOSES: 1. Bilateral lower extremities weakness likely secondary to spinal ischemia/severe atherosclerotic disease 2. Chronic obstructive pulmonary disease. 3. Tracheomalacia. 4. Aspiration pneumonia. 5. Hypertension. 6. Status post right nephrectomy. 7. Factor 8 inhibitor. 8. Hypercholesterolemia. 9. Macular degeneration. 10. Syncope. 11. Polyps. 12. Status post distal humeral resection. [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Name8 (MD) 8073**] MEDQUIST36 D: [**2147-3-16**] 14:30 T: [**2147-3-16**] 14:43 JOB#: [**Job Number 26908**]

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icd9cm

[ [ [] ] ]

[ "96.71", "88.40", "96.04", "33.24", "87.21" ]

icd9pcs

[ [ [] ] ]

4853, 4971

11220, 11861

10799, 11199

4997, 5108

6805, 10776

5459, 6787

101, 3994

5133, 5436

4016, 4634

4651, 4836

65,991

137,256

33707

Discharge summary

report

Admission Date: [**2104-4-15**] Discharge Date: [**2104-4-21**] Date of Birth: [**2073-3-3**] Sex: M Service: SURGERY Allergies: Iodine; Iodine Containing / Pollen Extracts / Shellfish Derived Attending:[**First Name3 (LF) 3376**] Chief Complaint: abdominal pain, nausea and vomiting Major Surgical or Invasive Procedure: Open laparotomy completion colectomy and end ileostomy. History of Present Illness: 31 yoM one week s/p laparoscopic left colectomy for medically refractory Crohn's disease, comes in with worsening abdominal pain, nausea, vomiting, fever and chills over the past 48 hours. Patient states he had mild abdominal pain all weekend, but began vomiting this morning. He has had voluminous ostomy output. Vomitus is described as bilious. Shaking chills with fevers. Minimal urine output per patient. Past Medical History: Crohns disease vs. UC- diagnosed in [**2099**]- initially presented with bloody diarrhea/cramping/weight loss with initial findings of pan-colitis. Micro neg. -[**1-1**] colonoscopy showed patchy ulceration- bx showed chronic colitis- no granuolomas -[**11-30**] colonoscopy patchy inflammation, showed stricturing in prox ascending and transverse colon, normal TI. started 6-MP -[**2-2**] colonoscopy patchy inflammation, stricturing in prox ascending colon - [**4-1**] SBFT - normal - [**2103-1-17**] colonoscopy - had to be stopped at 45 cm due to a stricture that could not be passed with the scope - [**December 2102**] 6-MP stopped in b/c of mild pancreatitis - barium enema [**2103-1-23**] - [**2103-2-15**] MRCP. The pancreas appeared normal. Social History: [**Known firstname 5335**] was born and lived in [**Location **] till the age of 12. Patient denied tobacco/etoh/drugs. Lives with sister and her kids. Single. Family History: Denies any family history of inflammatory bowel disease, cancer or colon polyps. Physical Exam: At discharge: V.S 97.5, 84, 108/73, 20, 97% ra Gen: a and o x3, NAD CV: RRR no m/r/g RESP: LSCTA bilat ABD: soft, nt, nd. ostomy beefy red, incision ota with staples, no s/s of infection EXT: no c/c/e Pertinent Results: Admission labs: [**2104-4-15**] 11:45AM BLOOD WBC-42.5*# RBC-4.38*# Hgb-11.6*# Hct-35.9*# MCV-82 MCH-26.5* MCHC-32.3 RDW-17.0* Plt Ct-699*# [**2104-4-15**] 11:45AM BLOOD Neuts-72* Bands-25* Lymphs-1* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2104-4-15**] 11:45AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL [**2104-4-15**] 11:45AM BLOOD PT-19.8* PTT-28.4 INR(PT)-1.9* [**2104-4-15**] 07:15PM BLOOD Fibrino-341# [**2104-4-15**] 11:45AM BLOOD Glucose-118* UreaN-13 Creat-1.3* Na-133 K-3.9 Cl-92* HCO3-22 AnGap-23* [**2104-4-15**] 11:45AM BLOOD ALT-22 AST-22 CK(CPK)-26* AlkPhos-92 TotBili-1.2 [**2104-4-15**] 11:45AM BLOOD Lipase-20 [**2104-4-15**] 11:45AM BLOOD cTropnT-<0.01 [**2104-4-15**] 11:45AM BLOOD Albumin-3.7 [**2104-4-15**] 03:45PM BLOOD Albumin-2.4* Calcium-7.3* Phos-1.8*# Mg-0.8* [**2104-4-15**] 02:55PM BLOOD Type-ART pO2-96 pCO2-34* pH-7.42 calTCO2-23 Base XS--1 [**2104-4-15**] 11:54AM BLOOD Lactate-7.1* [**2104-4-15**] 07:00PM BLOOD Hgb-8.2* calcHCT-25 O2 Sat-97 [**2104-4-15**] 07:00PM BLOOD freeCa-0.83* Discharge labs: [**2104-4-20**] 08:25AM BLOOD WBC-14.3* RBC-4.08* Hgb-11.3* Hct-34.3* MCV-84 MCH-27.7 MCHC-32.9 RDW-16.6* Plt Ct-412# [**2104-4-17**] 03:30PM BLOOD Neuts-86.8* Lymphs-8.1* Monos-2.3 Eos-2.6 Baso-0.2 [**2104-4-17**] 03:55AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**2104-4-20**] 08:25AM BLOOD Plt Ct-412# [**2104-4-18**] 04:49AM BLOOD PT-15.5* INR(PT)-1.4* [**2104-4-20**] 08:25AM BLOOD ALT-32 AST-20 AlkPhos-228* TotBili-1.6* DirBili-1.0* IndBili-0.6 [**2104-4-21**] 07:40AM BLOOD Calcium-7.7* Phos-3.5 Mg-2.0 [**2104-4-16**] 02:03PM BLOOD IgG-827 [**2104-4-21**] 07:45AM BLOOD Vanco-13.7 . MRSA [**4-15**] negative . [**2104-4-15**] SWAB Site: PERITONEAL GRAM STAIN (Final [**2104-4-15**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. . FLUID CULTURE (Final [**2104-4-17**]): BETA STREPTOCOCCUS GROUP A. SPARSE GROWTH. . [**2104-4-15**] SPUTUM GRAM STAIN (Final [**2104-4-15**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2104-4-17**]): RARE GROWTH OROPHARYNGEAL FLORA. BETA STREPTOCOCCUS GROUP A. SPARSE GROWTH. . 04/21/09STOOL CONSISTENCY: WATERY FECAL CULTURE (Final [**2104-4-17**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2104-4-17**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2104-4-16**]): FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. . BCX: negative . UCX: negative . Brief Hospital Course: 31M who had a laparoscopic left colectomy within the last 2 weeks for Crohn disease with stricture. He presented to the ER on [**2104-4-15**], toxic with a high white count, tachycardia, high fever and diffuse abdominal tenderness. Diagnosis of C. diff colitis was made based on clinical findings and operation was recommended given his level of toxicity and failure to improve with medical therapy. No complications occurred with the surgery and the patient was taken to the [**Hospital Unit Name 153**] for post-operative care. The patient was initially hypotensive to 90s and required aggressive fluid resuscitation. Patient also received both pRBC and FFP. When the stool culture came back as C. diff positive, the patient was started on oral vancomycin and flagyl. Once the patient's blood pressure and hematocrit stabilized, the patient was transferred to the surgical floor on POD3. On POD4 the patient was placed on regular diet and oral medications. Air and stool was being produced from his ostomy appliance. On POD4, the patient's pain was not well controlled and Toradol was given for another 2 more days. . The patient's pain was well controlled and he tolerated a regular diet and po meds. The patient was d/c'd with vanco/flagyl for 14 days to treat c-dif. He will not have the VNA secondary to no insurance. He lives with his sister who is a RN and she will assist with ostomy care and wound checks. The patient will follow up with Dr. [**Last Name (STitle) 1120**] in 1 week and his PCP in one week and/or as needed. All questions were answered. Medications on Admission: PO Ciprofloxacin PO Flagyl tramadol for pain Discharge Medications: 1. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO four times a day as needed for pain for 2 weeks: Please do not exceed more than 4000mg of acetaminophen in 24 hrs. 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain for 2 weeks: Take with food. 4. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 14 days. Disp:*56 Capsule(s)* Refills:*0* 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 14 days. Disp:*56 Tablet(s)* Refills:*0* 6. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain for 1 weeks. Disp:*35 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Toxic Clostridium difficile colitis. Group A streptococcus peritonitis . Secondary: history of crohns, history of cryptogenic organizing pneumonia Discharge Condition: stable tolerating regular diet. Pain well controlled with oral medications. Discharge Instructions: Incision Care: Keep clean and dry. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. -You are being discharged with staples, they will be removed during at your follow up appointment. . Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([**10-9**] lbs) until your follow up appointment. . Medications: 1. MetRONIDAZOLE (FLagyl) 500 mg by mouth every 6 hrs. -You were started on this medication to treat an infection called C-dif -Please take this medication until it is gone. 2. Vancomycin 125 mg by mouth every 6 hrs. -You were started on this medication to treat an infection called C-dif -Please take this medication until it is gone. Followup Instructions: 1. Please call Dr.[**Name (NI) 3377**] office to schedule a follow up appointment. ([**Telephone/Fax (1) 3378**]. 2. Please call your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 31529**], to make a follow up appointment in [**12-28**] weeks. Completed by:[**2104-4-22**]

[ "998.32", "280.9", "008.45", "V44.2", "790.92", "713.1", "277.4", "E878.3", "458.29", "567.29", "998.59", "555.2" ]

icd9cm

[ [ [] ] ]

[ "38.93", "46.23", "45.82" ]

icd9pcs

[ [ [] ] ]

7243, 7249

4836, 6409

359, 417

7449, 7527

2153, 2153

9653, 9985

1835, 1917

6504, 7220

7270, 7428

6435, 6481

7551, 7551

3239, 4813

7567, 9630

1932, 1932

1946, 2134

284, 321

445, 861

2169, 3223

883, 1641

1657, 1819

9,478

117,076

25825

Discharge summary

report

Admission Date: [**2144-9-2**] Discharge Date: [**2144-9-11**] Date of Birth: [**2077-8-14**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Thoracoabdominal aneurysm repair History of Present Illness: 66M c severe diffuse abdominal pain. Patient had dialysis during the day and at the end of the hemodialysis, patient complained on severe abodminal pain. Sudden onset around umbilicus radiating to the back. Patient went to the OSH where they obtained a CT of abdomen that showed aortic aneurysm concerning for rupture. He was then transferred to [**Hospital1 18**]. Past Medical History: ESRD CAD HTN PVD AAA Physical Exam: HR 85 BP 210/70 RR16 98% on 4L Alert and oriented x1 RRR decreased bs at base soft, diffusely tender, moderately distended, + rebound, + guarding + fem palses Pertinent Results: [**2144-9-2**] 10:33PM BLOOD WBC-25.5*# RBC-4.06* Hgb-12.2* Hct-36.7* MCV-91 MCH-30.0 MCHC-33.2 RDW-16.6* Plt Ct-366 [**2144-9-2**] 10:33PM BLOOD PT-11.6 PTT-22.2 INR(PT)-0.9 [**2144-9-3**] 03:45AM BLOOD Fibrino-244 [**2144-9-2**] 10:33PM BLOOD Glucose-211* UreaN-45* Creat-6.6* Na-136 K-4.9 Cl-95* HCO3-25 AnGap-21* [**2144-9-2**] 10:33PM BLOOD CK(CPK)-21* [**2144-9-2**] 10:33PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2144-9-3**] 03:45AM BLOOD Calcium-9.9 Phos-6.7*# Mg-2.3 [**2144-9-3**] 12:19AM BLOOD Type-ART pO2-438* pCO2-41 pH-7.37 calHCO3-25 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED [**2144-9-2**] 10:42PM BLOOD Glucose-205* Lactate-3.0* Na-137 K-5.1 Cl-96* c08/01/05 8:40 pm BRONCHOALVEOLAR LAVAGE **FINAL REPORT [**2144-9-9**]** GRAM STAIN (Final [**2144-9-8**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2144-9-9**]): ~5000/ML OROPHARYNGEAL FLORA. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN--------- 2 I GENTAMICIN------------ <=1 S IMIPENEM-------------- 8 I MEROPENEM------------- 0.5 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S alHCO3-30 Brief Hospital Course: Patient was emergently taken to the operating room and he underwent thoracoabdominal aneurysm repair. Post operatively patient was taken to ICU for recovery. By systems: Neuro - Patient did not move his bilateral lower extremities nor the right upper extremity. Patient underwent CT of the head which did not show any signs of stroke. Per neurology recommendations we planned to obtain an MRI of the spine which we were unable to obtain due to his poor cardiac fuction. CV - Patient continued to require pressors. Towards the end of his hospital stay he had required three different pressors to maintain adequate blood pressue. Resp - He developed pseudomonas pneumonia which required increased ventilatory support and broad spectrum antibiotics. He was never weened from the full ventilatory support GI - He was kept NPO due to development of gut ischemia. Patient had bloody bowel movements and a sigmoidoscopy that showed ischemic colon. He was supported with fluids and TPN. Renal - Patient was placed on CVVHD. He was too unstable for HD. ID - Patient had rising WBC to 59 prior to expiration. He was on broad spectrum antibiotics and he was pan cultured throughout the hospital stay. Heme - He maintained his hct throughout but he developed thrombocytopenia during the hospital stay. His HIT was negative. Endo - Patient was on insulin drip at times to control his blood sugar. Patient developed multi organ failure on last hospital day. After a long discussion with the family. Patient was made DNR then CMO. Patient expired at 8:25 pm on [**2144-9-11**]. Family was present at the time of death. Medications on Admission: Imdur, Calcitral, Lexapro, Norvasc, Iron, Atenolol, Protonix, Nephrocaps, Tums Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: ruptured abdominal aortic aneurysm peripheral vascular disease coronary artery disease Discharge Condition: Death Completed by:[**2144-9-11**]

[ "482.1", "995.92", "336.1", "287.5", "441.6", "570", "038.9", "998.0", "403.91", "518.5", "305.1", "557.0" ]

icd9cm

[ [ [] ] ]

[ "33.24", "99.05", "39.95", "99.04", "00.17", "03.31", "48.23", "33.22", "38.93", "39.59", "38.91", "38.95", "99.15", "99.00", "38.44", "88.72", "38.45", "96.72" ]

icd9pcs

[ [ [] ] ]

4384, 4393

2600, 4226

328, 362

4524, 4560

999, 2577

4355, 4361

4414, 4503

4252, 4332

820, 980

274, 290

390, 761

783, 805

8,740

122,212

23914+23915+23916

Discharge summary

report+report+report

Admission Date: [**2142-5-10**] Discharge Date: [**2142-5-16**] Date of Birth: [**2074-10-5**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Syncopal episode x 1 [**2142-4-10**]. Major Surgical or Invasive Procedure: Coronary artery bypass graft x 3. History of Present Illness: 67 yo male presented initially [**2142-4-10**] with syncopal episode while walking his dogs. EKG at that time showed old inferior MI. He was then referred for stress with ST depressions. Cath ([**2142-4-27**]) showed severe inferior HK, EF 50%, LAD serial 50% 70% 50%, LCx 95% prox and 100% mid, RCA 100%. At that time he was referred for CABG. Past Medical History: Hypertension. Hyperlipidimia. Arthritis. Social History: Occasional ETOH. Positive history tob. Pertinent Results: [**2142-5-14**] 05:40AM BLOOD WBC-10.2 RBC-3.19* Hgb-10.3* Hct-29.7* MCV-93 MCH-32.3* MCHC-34.6 RDW-13.0 Plt Ct-140* [**2142-5-13**] 10:50AM BLOOD Neuts-75.4* Lymphs-13.5* Monos-6.7 Eos-4.0 Baso-0.4 [**2142-5-14**] 05:40AM BLOOD Plt Ct-140* [**2142-5-12**] 04:14AM BLOOD PT-14.0* PTT-34.0 INR(PT)-1.2 [**2142-5-14**] 05:40AM BLOOD Glucose-89 UreaN-21* Creat-1.0 Na-140 K-4.2 Cl-104 HCO3-30* AnGap-10 [**2142-5-14**] 05:40AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.9 Brief Hospital Course: Mr. [**Known lastname 60971**] was seen by our service when here for cardiac cath on [**2142-4-27**]. He was senmt home at that time and returned for scheduled surgery [**2142-5-10**]. He proceeded to the OR and underwent a CABG x 3 with LIMA to the LAD, SVG to the OM, and SVG to the RCA. Please see op note for full details. He was unable to extubate on his operative evening. On POD one he was successfully weened and extubated. On POD two he was ready to transferred to the inpatient telemetry floor but no bed was available. Instead, on POD three he was transferred to the floor for ongoing management and monitoring. On POD three he was noted to have a rash on his back and buttocks. He complained of burning and itchiness, relieved with sarna lotion. The rash is thought to be a heat rash. He was also noted to have rashes on his left leg surrounding his endoscopic harvest sites. The rash here is red, not raised, + blanches, no warmth. An outline was placed around this rash with no increase in size. On POD five it was thought that he is likley medically ready to be discharged but is not physically ready and would benefit from an extra day of ambulation and physical therapy. He was discharged home with VNA pn POD 6 ([**2142-5-16**]). Medications on Admission: Lotrel. Lipitor. HCTZ. Naproxen. MVI. Aspirin. Glucosamine. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*0* 8. Atorvastatin Calcium 40 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: Apply to [**Last Name (un) **] on back as needed. Disp:*1 bottle* Refills:*0* 10. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 months. Disp:*30 Tablet(s)* Refills:*2* 11. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) as needed. Discharge Disposition: Home With Service Facility: Greater [**Location (un) 1468**] VNA Discharge Diagnosis: Hypertension. Hyperlipidemia. Arthritis. Appy. Coronary artery disease. S/P coronary artery bypass graft. Discharge Condition: Stable. Discharge Instructions: Shower daily and wash incisions with soap and water. Rinse well. Do not apply any creams, lotions, powders, or ointmenst. No swimming or bathing in tub. No driving for 6 weeks. Schedule follow-up appointments as directed. Call with any sternal drainage, fever, or redness at incision sites. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in 4 weeks. Follow-up with Dr. [**Last Name (STitle) 48918**] in [**3-16**] weeks. Follow-up with Cardiologist in [**2-11**] weeks. Completed by:[**2142-5-16**] Admission Date: [**2142-5-10**] Discharge Date: [**2142-5-16**] Date of Birth: [**2074-10-5**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 60971**] is a gentleman with a history of hypertension and hyperlipidemia who was evaluated by the cardiology service after a syncopal episode on [**2142-4-10**]. He did not have any associated chest pain or palpitations, but an EKG done at his primary care's office revealed evidence of an old myocardial infarction. Because of this syncopal episode he underwent a stress test which demonstrated some ST and T wave abnormalities in the inferior and lateral precordial leads which increased with exercise. He did have nuclear imaging which revealed a large severe inferolateral wall defect that was reversible and an inferolateral wall hypokinesis. He was then referred to cardiology for catheterization and was found to have 3-vessel disease, and then he was brought to the cardiac surgery service for definitive treatment. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. Arthritis. PAST SURGICAL HISTORY: The patient is status post appendectomy, status post carpal tunnel release, status post right shoulder surgery, status post right knee arthroscopy. MEDICATIONS ON ADMISSION: Include Lotrel 5/20 mg p.o. daily, Lipitor 10 mg p.o. daily, hydrochlorothiazide 12.5 mg p.o. daily, naproxen 500 mg b.i.d. p.r.n., glucosamine sulfate 750 mg p.o. b.i.d. p.r.n., MVI p.o. daily, aspirin 81 mg p.o. daily. ALLERGIES: He has no known drug allergies. FAMILY HISTORY: His father had coronary artery disease and a MI in his 60s. His grandfather died of a MI in his 70s. His mother had symptoms consistent with angina in her 50s. SOCIAL HISTORY: He is married and a retired facility's manager. He has a 40-year history of smoking 1 to 2 packs a day. He quit 10 years ago. He denies any frequent EtOH use. PHYSICAL EXAMINATION: His heart rate was 89 in sinus rhythm, his blood pressure is 139/71, he is breathing 17, his O2 saturation is 98% on 2 liters nasal cannula. He is awake and alert. He has no JVD and no carotid bruits. His heart is regular with no murmurs. His chest is clear to auscultation bilaterally. His abdomen is soft and nontender, and his extremities have no edema. PREOPERATIVE LABORATORY DATA: Included a white count of 5.3, hematocrit of 37, platelets of 157, an INR of 1.1, a BUN of 18, a creatinine of 1.2. The remainder of his labs were unremarkable. RADIOLOGIC STUDIES: An echocardiogram done at an outside hospital in [**Month (only) 958**] demonstrated inferior and posterior hypokinesis, an EF of 45%, mild mitral regurgitation, mild tricuspid regurgitation, and mild pulmonary hypertension. The stress test on [**2142-4-17**] demonstrated increased ST segment depression in the inferior and lateral precordial leads, large severe inferolateral wall defect reversible at the base which was fixed at the apex, and inferolateral hypokinesis with an EF of 40%. Cardiac catheterization demonstrated a hypokinetic inferior wall, a 100% RCA occlusion, a 70% LAD occlusion, a 95% proximal circumflex occlusion and a complete distally. He had an EF of 49%. His preoperative EKG showed a sinus rhythm with left shift of his axis and lateral ST-T wave changes, consistent with an old MI. HOSPITAL COURSE: The patient was to the operating room where he underwent a CABG x 3 with a LIMA to the LAD, SVG to OM, and SVG to RCA. Intraoperative events included a difficult intubation and an intraoperative bronchoscopy by the interventional pulmonary team. This showed significant supraglottic swelling and epiglottitis with the 2 vocal cords normal. He was able to be intubated effectively and ventilated and oxygenated fine. Postoperatively, he was taken intubated to the cardiac surgery intensive care unit. He was extubated on postoperative day 1 and did well. His pressors were weaned overnight and remained hemodynamically normal. His chest tubes were discontinued. He was started on diuresis and beta blockade. He was transferred to the floor on postoperative day 3. He did receive a pulmonary toilet and physical therapy. His oxygen has been weaned to off, and he is ready for discharge at this time. On the floor he did develop contact dermatitis which was monitored. There was no relation to any new medications which were introduced, and it was thought to be secondary to the detergent used on the sheets; though we did monitor him to make sure he did not have any systemic significance to his rash. DISCHARGE DISPOSITION: He is going to be discharged to home with home services to follow vital signs, and medications, and sternal wound which has remained clean, dry, and intact. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass grafting x 3. 3. Hypertension. 4. Hyperlipidemia. 5. Supraglottic swelling and difficult airway. MEDICATIONS ON DISCHARGE: Include Colace 100 mg p.o. b.i.d., aspirin 81 mg daily, Lasix 20 mg daily (x 7 days), potassium chloride 20 mEq daily (x 7 days), Percocet 5/325 1 to 2 p.o. q.4h. p.r.n., Lopressor 25 mg p.o. t.i.d., Lipitor 40 mg p.o. daily, Plavix 75 mg p.o. daily (x 3 months), lisinopril 5 mg p.o. daily. DISCHARGE FOLLOWUP: The patient will follow up with Dr. [**Last Name (STitle) **] in 4 weeks. He has also been instructed to follow up with Dr. [**Last Name (STitle) 48918**] in 2 weeks. CONDITION ON DISCHARGE: Good. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**] Dictated By:[**Last Name (NamePattern1) 8958**] MEDQUIST36 D: [**2142-5-16**] 11:48:53 T: [**2142-5-16**] 12:50:18 Job#: [**Job Number 60972**] Admission Date: [**2142-5-10**] Discharge Date: [**2142-5-16**] Date of Birth: [**2074-10-5**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 60971**] is a gentleman with a history of hypertension and hyperlipidemia who was evaluated by the cardiology service after a syncopal episode on [**2142-4-10**]. He did not have any associated chest pain or palpitations, but an EKG done at his primary care's office revealed evidence of an old myocardial infarction. Because of this syncopal episode he underwent a stress test which demonstrated some ST and T wave abnormalities in the inferior and lateral precordial leads which increased with exercise. He did have nuclear imaging which revealed a large severe inferolateral wall defect that was reversible and an inferolateral wall hypokinesis. He was then referred to cardiology for catheterization and was found to have 3-vessel disease, and then he was brought to the cardiac surgery service for definitive treatment. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. Arthritis. PAST SURGICAL HISTORY: The patient is status post appendectomy, status post carpal tunnel release, status post right shoulder surgery, status post right knee arthroscopy. MEDICATIONS ON ADMISSION: Include Lotrel 5/20 mg p.o. daily, Lipitor 10 mg p.o. daily, hydrochlorothiazide 12.5 mg p.o. daily, naproxen 500 mg b.i.d. p.r.n., glucosamine sulfate 750 mg p.o. b.i.d. p.r.n., MVI p.o. daily, aspirin 81 mg p.o. daily. ALLERGIES: He has no known drug allergies. FAMILY HISTORY: His father had coronary artery disease and a MI in his 60s. His grandfather died of a MI in his 70s. His mother had symptoms consistent with angina in her 50s. SOCIAL HISTORY: He is married and a retired facility's manager. He has a 40-year history of smoking 1 to 2 packs a day. He quit 10 years ago. He denies any frequent EtOH use. PHYSICAL EXAMINATION: His heart rate was 89 in sinus rhythm, his blood pressure is 139/71, he is breathing 17, his O2 saturation is 98% on 2 liters nasal cannula. He is awake and alert. He has no JVD and no carotid bruits. His heart is regular with no murmurs. His chest is clear to auscultation bilaterally. His abdomen is soft and nontender, and his extremities have no edema. PREOPERATIVE LABORATORY DATA: Included a white count of 5.3, hematocrit of 37, platelets of 157, an INR of 1.1, a BUN of 18, a creatinine of 1.2. The remainder of his labs were unremarkable. RADIOLOGIC STUDIES: An echocardiogram done at an outside hospital in [**Month (only) 958**] demonstrated inferior and posterior hypokinesis, an EF of 45%, mild mitral regurgitation, mild tricuspid regurgitation, and mild pulmonary hypertension. The stress test on [**2142-4-17**] demonstrated increased ST segment depression in the inferior and lateral precordial leads, large severe inferolateral wall defect reversible at the base which was fixed at the apex, and inferolateral hypokinesis with an EF of 40%. Cardiac catheterization demonstrated a hypokinetic inferior wall, a 100% RCA occlusion, a 70% LAD occlusion, a 95% proximal circumflex occlusion and a complete distally. He had an EF of 49%. His preoperative EKG showed a sinus rhythm with left shift of his axis and lateral ST-T wave changes, consistent with an old MI. HOSPITAL COURSE: The patient was to the operating room where he underwent a CABG x 3 with a LIMA to the LAD, SVG to OM, and SVG to RCA. Intraoperative events included a difficult intubation and an intraoperative bronchoscopy by the interventional pulmonary team. This showed significant supraglottic swelling and epiglottitis with the 2 vocal cords normal. He was able to be intubated effectively and ventilated and oxygenated fine. Postoperatively, he was taken intubated to the cardiac surgery intensive care unit. He was extubated on postoperative day 1 and did well. His pressors were weaned overnight and remained hemodynamically normal. His chest tubes were discontinued. He was started on diuresis and beta blockade. He was transferred to the floor on postoperative day 3. He did receive a pulmonary toilet and physical therapy. His oxygen has been weaned to off, and he is ready for discharge at this time. On the floor he did develop contact dermatitis which was monitored. There was no relation to any new medications which were introduced, and it was thought to be secondary to the detergent used on the sheets; though we did monitor him to make sure he did not have any systemic significance to his rash. DISCHARGE DISPOSITION: He is going to be discharged to home with home services to follow vital signs, and medications, and sternal wound which has remained clean, dry, and intact. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass grafting x 3. 3. Hypertension. 4. Hyperlipidemia. 5. Supraglottic swelling and difficult airway. MEDICATIONS ON DISCHARGE: Include Colace 100 mg p.o. b.i.d., aspirin 81 mg daily, Lasix 20 mg daily (x 7 days), potassium chloride 20 mEq daily (x 7 days), Percocet 5/325 1 to 2 p.o. q.4h. p.r.n., Lopressor 25 mg p.o. t.i.d., Lipitor 40 mg p.o. daily, Plavix 75 mg p.o. daily (x 3 months), lisinopril 5 mg p.o. daily. DISCHARGE FOLLOWUP: The patient will follow up with Dr. [**Last Name (STitle) **] in 4 weeks. He has also been instructed to follow up with Dr. [**Last Name (STitle) 48918**] in 2 weeks. CONDITION ON DISCHARGE: Good. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**] Dictated By:[**Last Name (NamePattern1) 8958**] MEDQUIST36 D: [**2142-5-16**] 11:48:53 T: [**2142-5-16**] 12:50:18 Job#: [**Job Number 60972**]

[ "997.1", "414.01", "782.1", "272.4", "401.9", "427.31" ]

icd9cm

[ [ [] ] ]

[ "36.15", "33.23", "39.61", "36.12" ]

icd9pcs

[ [ [] ] ]

15226, 15384

1395, 2654

359, 395

4381, 4390

913, 1372

4731, 5076

12233, 12394

15405, 15570

2764, 4141

4252, 4360

15597, 15890

11949, 12216

13999, 15202

4414, 4708

11773, 11922

12594, 13981

282, 321

15911, 16080

10827, 11675

11697, 11749

12411, 12571

16105, 16383

22,208

114,989

1864

Discharge summary

report

Admission Date: [**2177-11-24**] Discharge Date: [**2178-1-2**] Date of Birth: [**2098-8-2**] Sex: M Service: MEDICINE Allergies: Benzodiazepines / Terazosin Hcl / Iodine Attending:[**First Name3 (LF) 3283**] Chief Complaint: CHF exacerbation and respiratory failure requiring intubation. Major Surgical or Invasive Procedure: Endotracheal intubation with mechanical ventilation PICC placement, removal Right subclavian line Hemodialysis Bronchoscopy History of Present Illness: The patient is a 79 year old Polish speaking man with a history of diastolic CHF (EF 65% in [**6-24**]), atrial fibrillation (refusing anticoagulation), HTN, DM, CRI who presented with pitting edema and shortness of breath on [**2177-11-24**]. Per nursing home notes, patient's weight had increased 15 pounds from his baseline (dry weight 265). Prior to early [**Month (only) **], patient's urine output was approximately 3-4 liters per day, but had dropped to less than one liter per day, despite lasix dose of 60mg [**Hospital1 **] not changing. . In the ED, diuresis was tried with 120mg IV lasix and 250mg diuril. A COPD flare was suspected and IV solumedrol 80mg and azithromycin 500mg was started. Levofloxacin 250 mg IV was added for a positive UA. As the patient's ABG was 7.25/70/242, Bipap was started and the patient was transferred to the MICU. Past Medical History: -Atrial fibrillation: not on anticoagulation because of lack of adherence -Coronary artery disease: refused catheterization -CHF (diastolic dysfunction with last EF 65% on echo [**6-24**], dry wt 125kg) -CRI (baseline Cr 2.7) -BPH -HTN -DM (diet controlled) -OSA - pulmonary HTN, requiring supplemental night oxygen and BIPAP before intubation -Anemia (baseline hematocrit 23-27) Social History: Married, lives with daugther. Wife lives at [**Hospital1 1501**]. Polish speaking but understands some English. Per pt's daughter (who is researcher at [**Hospital1 18**]) no tobacco, alcohol or other drugs; stopped smoking 40yrs ago (smoked a lot while being captain on a ship) At rehab 2 months prior to admission. Prior captain on a ship. Currently lives in [**Hospital3 2558**]. Family History: No family history of seizures or strokes. Mother died from complications of renal failure. Physical Exam: In MICU: Temp 96.3, BP 102/54; RR 21; O2 93% on 5LNC (off bipap) Gen: increased work of breathing using abdominal accessory muscles on exhalation, responds to commands and moves all 4 extremities. HEENT: PERRLA, NCAT, MM dry Neck: very full, unable to assess JVP, moves neck freely Cor: irreg irreg, s1s2, no r/g/m Pulm: bilateral wheezes, tight sounding throughout lung fields, no crackles Abd; obese, +abd muscle use with each expiration, unable to assess HSM, NT, decreased BS Skin: venous stasis changes in BLE, no rashes Ext: bilateal LE pitting 2+ edema [**Date range (1) 8642**] up calves, w/w/p, weakly +dp pulses bilaterally . On Transfer to Medicine Floor: T:98.6 BP:100/70 HR:80 RR:24 O2saturation:99% on 4L Gen: Obese man laying in bed. Appears older than stated age. Not responsive to voice or sternal rub, but responded only to deep suctioning. HEENT: No conjunctival pallor. No icterus. Slightly dry mucous membranes. NGT in place. NECK: Supple. Could not appreciate any cervical or supraclavicular lymphadenopathy. CV: Irregularly irregular rate and rhythm. Normal S1 and S2. No murmurs, rubs or [**Last Name (un) 549**] appreciated. LUNGS: On anterior chest examination, decreased breath sounds in lower lung fields, bilaterally. ABD: Hypoactive bowel sounds in all four quadrants. Soft. Distended. EXT: Warm and well perfused. No clubbing. No lower extremity edema, bilaterally. 2+ dorsalis pedis and radial pulses, bilaterally. NEURO: Somnolent. Could not perform detailed neurological examination. Pertinent Results: Admission Labs: [**2177-11-24**] 11:07PM TYPE-ART PO2-242* PCO2-70* PH-7.25* TOTAL CO2-32* BASE XS-1 INTUBATED-NOT INTUBA [**2177-11-24**] 11:07PM K+-5.6* [**2177-11-24**] 11:07PM freeCa-1.04* [**2177-11-24**] 09:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2177-11-24**] 09:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2177-11-24**] 09:20PM URINE RBC-21-50* WBC-[**12-8**]* BACTERIA-FEW YEAST-NONE EPI-0-2 [**2177-11-24**] 09:20PM URINE HYALINE-0-2 [**2177-11-24**] 06:07PM GLUCOSE-142* UREA N-114* CREAT-4.7*# SODIUM-135 POTASSIUM-5.9* CHLORIDE-99 TOTAL CO2-28 ANION GAP-14 [**2177-11-24**] 06:07PM CK(CPK)-15* [**2177-11-24**] 06:07PM CK-MB-NotDone cTropnT-0.03* proBNP-[**Numeric Identifier 10420**]* [**2177-11-24**] 06:07PM CALCIUM-7.6* PHOSPHATE-7.3*# MAGNESIUM-3.1* [**2177-11-24**] 06:07PM WBC-6.5 RBC-2.27* HGB-8.0* HCT-24.5* MCV-108*# MCH-35.2* MCHC-32.7 RDW-18.7* [**2177-11-24**] 06:07PM NEUTS-77.1* LYMPHS-10.4* MONOS-10.4 EOS-1.8 BASOS-0.2 [**2177-11-24**] 06:07PM HYPOCHROM-3+ ANISOCYT-2+ MACROCYT-3+ [**2177-11-24**] 06:07PM PLT COUNT-158 . . Microbiology: bronchalveolar ([**12-4**]): citrobacter Urine Cx ([**11-24**]): enterococcus, sensitive to ampicillin Urine Cx ([**12-6**]): negative Tests for MRSA([**12-1**], [**12-8**]) and VRE ([**12-1**]): negative Test for VRE ([**12-8**]): enterococcus, but sensitive to vancomycin and ampicillin Blood Cx ([**11-24**], [**12-6**]): negative catheter tip ([**12-13**]): pending . Hematocrit: Remained in the 20's. Initially 24, increased to 29. Reticulocyte count: 2.2 on [**11-25**]. WBC: 6.5 on admission, increased to 14.8 on [**12-4**], and 11.4 on transfer. Creatinine: 4.7 on [**11-24**], and increased to 5.0. Following temporary dialysis, 2.3. Urea ranged between 114-->154-->117. Na: Elevated to 151 on [**12-8**], but trending down to 144 on [**12-13**]. Troponin: 0.06 on [**12-13**]. BNP: [**Numeric Identifier 10420**] on [**11-24**]. Blood gases: On [**11-24**].25/242/70. Hypercarbic to 89, requiring intubation between [**Date range (1) 10421**]. On transfer on [**12-13**].36/119/54. . STUDIES: Chest Xray([**2177-11-24**]): Very limited radiograph, small bilateral pleural effusions and mild pulmonary edema cannot be excluded. PA and lateral radiographs with improved suspension of respiration is recommended, if feasible. . Chest Xray([**2177-11-28**]): There has been interval placement of a right IJ CVL with the tip extending to the cavoatrial junction. Cardiomegaly is stable. Perihilar interstitial opacities have improved in the interval, compatible with improving pulmonary edema. There are likely bilateral pleural effusions, although the study of limited secondary to patient's body habitus. . Chest Xray([**2177-12-4**]): 1. Standard ET tube placement. 2. Cardiomegaly with no evidence of congestive heart failure on the current chest radiograph. Bilateral atelectasis right more than left, right pleural effusion. . Chest Xray([**2177-12-10**]): 1. Persistent failure and bilateral pleural effusions. 2. Tip of the nasogastric tube not visualized, but below the level of the diaphragm. . PICC placement ([**2177-12-12**]): Successful placement of a 40-cm 4 French single lumen PICC via the right brachial vein. The tip is in the central superior vena cava. The line is ready for use. . Brain MRI ([**2177-12-13**]): No evidence of acute infarct. Moderate brain and medial temporal atrophy. Moderate small vessel disease. . Temporary Catheter Placement([**2177-11-27**]): Uncomplicated ultrasound and fluoroscopically guided temporary dialysis catheter placement via the right internal jugular venous approach with the tip in the right atrium. . Chest Xray [**12-19**]: IMPRESSION: Improvement in the appearance of the previously described cardiac failure and bilateral pleural effusions. . Abdominal CT: [**12-26**] 1. Malpositioned Foley catheter; the balloon is inflated within the penile urethra. 2. Moderate left hydroureteronephrosis to the level of the left ureteovesicular junction without a clear obstructing lesion. No stones are identified within the ureter or bladder. 3. No evidence for diverticulosis or diverticulitis. . Echo: [**12-31**] Conclusions: 1.The left atrium is moderately dilated. The left atrium is elongated. The right atrium is markedly dilated. 2.There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The ascending aorta is mildly dilated. The aortic arch is mildly dilated. 5.The aortic valve is not well seen. No aortic regurgitation is seen. 6.The mitral valve leaflets are moderately thickened. 7.There is no pericardial effusion. . Labs on discharge: WBC: 5.3 Hct: 27.6 Plt: 265 Na: 138 K: 4.2 BUN: 32 Cr: 2.7 Ca: 8.1 Mg: 2.2 P: 4.1 Brief Hospital Course: Mr. [**Known lastname 10422**] is a 79 year old man with a history of diastolic CHF, atrial fibrillation, HTN, DM, CRI who presented with CHF exacerbation requiring intubation and subsequently developed citrobacter PNA. After extubation, he was unresponsive to voice and sternal rub. On [**12-15**] he began responding to questions and following commands. He remained alert, conversant, breathing comfortably on RA. . #) Respiratory Failure: On admission, the patient's ABG was 7.25/70/242, Bipap was started and the patient was admitted to the MICU. Concern for aspiration was noted on [**11-29**], so an NGT was placed on [**11-30**]. Unasyn was started on [**12-3**] for presumed right lower lobe pneumonia. Patient was bronched on [**12-4**] and large secretions were noted in the right and left lower lobes. With worsening hypercarbia, patient was intubated on [**12-5**]. Respiratory failure was felt to be secondary to CHF. Meropenem and vancomycin were added for broader antibiotic coverage. On [**12-6**], citrobacter, sensitive to meropenem, was isolated. Patient was extubated on [**12-9**], requiring 4L supplemental oxygen. He had initially been given methylprednisolone 40mg IV q8 for question of a COPD flare. He was switched to PO prednisone and tapered over the course of his admission. He was slowly weaned down to room air and maintained oxygen saturations of 94-100%. On [**12-13**] the patient was transferred to the floor. The patient received tube feedings without incident. His NG tube was d/c'd on [**12-14**] and could not be replaced after 4 attempts. Speech and swallow evaluated the patient on [**12-16**] and felt he would be able to tolerate medications and ice chips. They were reconsulted on [**12-17**] as the patient's mental status was improving. He completed a 14 day course of meropenem as above on [**12-21**]. He continued to saturate well on RA, requiring 2L NC at night. CPAP was attempted, however the patient refused and repeatedly removed his mask. He was given nebulizers as needed for wheezing. His lung exam at discharge was clear to auscultation bilaterally. . #) Renal Failure: Mr. [**Known lastname 10423**] creatinine at baseline is approximately 2.6. On admission the patient's creatinine was 4.7 and peaked at 5.0. The acute renal failure was likely due to decreased intravascular repletion in setting of CHF. His woresning renal function led to increased fluid retention which caused worsened cardiac congestion. He was placed on temporary dialysis for several days. Dialysis was initiated on [**11-27**] and discontinued on [**12-5**] due to hypotension and tachycardia. On transfer to the floor, he was able to generate sufficient urine output with lasix. On [**12-15**] the patient triggered for hypotension and his lasix was held. His foley was removed on [**12-19**], with resultant good urine output. Ins and outs were difficult to obtain secondary to his incontinence and a foley catheter was eventually replaced. His creatinine remained approximately at his baseline. A small dose of lasix 20mg PO was restarted on [**12-22**]. His medications were dosed appropriately for his creatinine clearance. . #) CHF: Patient's original CHF flare exacerbated by acute renal failure, causing increased fluid retention. He was treated with lasix gtt and nesiritide and even required hemodialysis for management of his volume status. The diuresis was effective and the patient was eventually extubated and was able to be weaned off of oxygen satting well on room air. His lower extremity edema resolved. His dry weight was known to be 265 lbs. On [**12-19**] his weight was repeated and he was at approximately his dry weight. His beta blocker was continued and once his BP stabilized it was titrated up to his outpatient dose. While he was on lower doses of beta blocker he was noted to have breakthrough tachycardia at night, heart rates to the 140s at night. He remained asymptomatic during these episodes and his heart rate quickly returned to [**Location 213**]. However, once his beta blocker was titrated back to outpatient dose, these episodes did not recur. . #) Left hydronephrosis: On [**12-26**] the patient was noted to be hypotensive and complaining of abdominal pain. An abdominal CT was done which revealed a malpositioned foley catheter with the balloon inflated within the prostatic urethra and moderate left hydroureteronephrosis to the level of the left ureteovesicular junction without a clear obstructing lesion. The foley catheter was repositioned with good urine return and he was given a three day course of Ciprofloxacin. He was seen by urology who recommended a catheter for 1-2 weeks until performance status improves, renal imaging in [**1-20**] months to document resolution of the hydronephrosis and follow up with Dr. [**Last Name (STitle) 770**]. . #) Episodes of hypotension: He triggered for hypotension on [**12-26**] PM. Labs and CXR were normal, other vital signs were stable. EKG w/ some deepened ST depressions in I, avL, V5,V6 and flattened T waves in V3, V4. He was noted to be in afib and was put back on telemetry and his cardiac enzymes were cycled and did not change from his baseline mild elevation. He was already on ASA, bblocker. It was felt that this may be related to finally getting up after long hospitalization (pivoted w/ PT 1 hr prior to event), but given his history, 24-36 hrs of "gas pain", and tenderness on abd exam, looked for infectious etiology. Blood cultures and urine cultures remained negative. Abdominal CT with hydronephrosis and traumatic foley placement as above. . #) Mental Status: On [**12-8**], in anticipation of extubation, patient's sedatives were weaned. At that time the patient was noted to have altered mental status, left-sided weakness. On transfer to the floor he was only responsive to deep suctioning. An MRI was done on [**12-13**] which did not reveal any evidence of acute infarct. The neurology team was consulted and felt that his mental status changes were likely toxic metabolic superimposed on an atrophic/ susceptible brain. Initially it was felt that the changes were related to medication as he received ativan on [**12-13**] for MRI scan, and benzodiazepines are known to cause confusion in this patient. However, as his mental status did not resolve for several days the etiology was felt more likely to be increased uremia (renal failure versus steroid) vs. hypernatremia. He was started on D5W to help decrease sodium level. On [**12-15**] he began responding to yes/no questions and following commands. His mental status continued to improve with improving renal function and improvement of his hypernatremia. On the day of discharge the patient was speaking both English and Polish, was oriented x 3 and was able to express his desire to go home. At that time his Na was within normal limits and his kidney function had improved. . #) CAD: Patient has refused cardiac catheterization in past. He had a hypotensive episode in the MICU requiring phenylephrine and had an additional episode of hypotension (SBP 89) while on the floor. Troponins measured on [**12-11**] and were negative (0.05-0.06). He was maintained on his aspirin and beta blocker as above. He was not given an ACE-inhibitor due to his renal function. This can be addressed as an outpatient. His lipid panel was checked on [**11-25**]. There was no evidence of hypercholesterolemia, so statin not needed. The panel was repeated on [**12-16**] and were notable for elevated triglycerides. No new medication was instituted at this admission, however follow up testing is recommended. . #) Anemia: Patient's hematocrit has remained stable during admission, although he required two units of packed red blood cells on [**2177-11-27**]. Macrocytic anemia most likely due to patient's chronic kidney disease or due to bone marrow stimulation from epogen. He was continued on ferrous sulfate and epogen 8000 qM,W,F. . #) BPH: The patient's foley was removed on [**12-20**]. He was initially restarted on flomax and finasteride was added the following day. However, the foley was replaced on [**12-24**] after he began complaining of abdominal pain and a bladder scan revealed >400cc urine in the bladder. In addition he had episodes of hypotension and as he had a foley catheter in place, flomax was discontinued for the possible effects it would have on his blood pressure. . #) Diabetes: He was maintained on an insulin sliding scale for the majority of his hospitalization. During his stay in the ICU, required insulin gtt for four days. On [**12-8**], patient weaned from insulin gtt and started on sliding scale insulin. His blood sugars remained moderately well controlled with dietary modifications. . #) UTI: On admission, patient noted to have a UTI. Started on a 7 day course of ampicillin for pansensitive enterococcus. Subsequent antibiotic modifications for presumed pneumonia provided effective coverage. . #) FEN: Mr. [**Known lastname 10422**] was initially given tube feedings which were continued until his NG tube was removed on [**12-14**]. After a failed attempt at replacement, he did not receive nutrition for 3 days. Speech and swallow evaluated the patient multiple times during this admission. He was initially restarted on PO meds and ice chips, however as his mental status improved he was advanced to pureed foods and prethickened liquids. On [**12-30**] he was delivered the incorrect meal tray and ate a [**Country 1073**] [**Location (un) 6002**] without difficulty. He will need to be reevaluated by speech and swallow in the near future as he likely can eat solid foods. . #) Prophylaxis: As patient was not ambulating, he was maintained on subq heparin and SCD boots. He was placed on a PPI and given a bowel regimen. [**Hospital3 2558**] was called and it was determined that Mr. [**Known lastname 10422**] has received neither his flu shot nor his pneumovax vaccinations. He will be given these prior to discharge. Medications on Admission: Haloperidol 2.5 mg IV HS:PRN anxiety Heparin 5000 UNIT SC TID Acetaminophen (Liquid) 650 mg PO Q4-6H:PRN HydrALAZINE HCl 25 mg PO Q6H Albuterol 6 PUFF IH Q4H Insulin SC (per Insulin Flowsheet) Aspirin 325 mg PO DAILY Ipratropium Bromide MDI 6 PUFF IH Q4H Bisacodyl 10 mg PR HS:PRN Lactulose 30 ml PO Q8H:PRN Calcium Acetate [**2172**] mg PO TID W/MEALS Meropenem 500 mg IV Q24H Docusate Sodium (Liquid) 100 mg PO BID Epoetin Alfa 8000 UNIT SC QMOWEFR MethylPREDNISolone Sodium Succ 40 mg IV Q8H Ferrous Sulfate 325 mg PO DAILY Metoprolol 25 mg PO BID hold for sbp < 100, HR < 55 Finasteride 5 mg PO DAILY Pantoprazole 40 mg IV Q24H Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] Fluoxetine HCl 20 mg PO DAILY Tamsulosin HCl 0.4 mg PO HS Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) inj Injection QMOWEFR (Monday -Wednesday-Friday). 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 5. Docusate Sodium 150 mg/15 mL Liquid Sig: Fifteen (15) mL PO BID (2 times a day). 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 7. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Pantoprazole 40 mg IV Q24H 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb IH Inhalation Q4H (every 4 hours) as needed. 14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 15. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed for gas. 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 17. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB IH Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 18. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 19. Insulin sliding scale 20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 583**] house Discharge Diagnosis: CHF, diastolic (EF 75% on echo [**12-31**] Respiratory failure Chronic renal insufficiency Atrial fibrillation Citrobacter pneumonia BPH Hypertension Diabetes mellitus, type 2, diet controlled Obstructive sleep apnea Anemia Left hydronephrosis, [**2-20**] traumatic foley Toxic metabolic encephalopathy Coronary artery disease Discharge Condition: Stable. The patient remains hemodynamically stable. Discharge Instructions: You were admitted for congestive heart failure. You had fluid in your lungs which made it difficult for you to breathe. You needed to be mechanically ventilated during this time. The fluid was removed from your lungs by putting you on hemodialysis and through different medications. You are now able to breathe on your own. You were also treated for a pneumonia which you developed while in the hospital. As you have heart failure, you should weigh yourself every morning, and call your doctor if weight > 3 lbs from baseline. You should also adhere to a 2 gm sodium diet It is important that you continue to take all of your medications as prescribed. If you begin to experience any chest pain, difficulty breathing, dizziness, lightheadedness, abdominal pain or any other concerning symptoms please call 911 or your doctor immediately. Followup Instructions: You have the following appointments: 1. Dr. [**Last Name (STitle) 770**], [**Telephone/Fax (1) 10424**], on Thursday [**2-5**] at 230. [**Hospital Ward Name 23**] building, [**Location (un) 470**]. 2. [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] at [**2178-1-6**] on 850. You will need additional renal imaging, a renal ultrasound, in [**1-20**] months. You will need a CXR in [**2-21**] days of discharge to rule out silent aspiration as your diet was advanced on [**1-2**].

[ "403.91", "491.21", "585.9", "428.31", "996.31", "349.82", "518.81", "482.83", "584.5", "276.0", "591", "599.0", "416.8", "427.31", "414.01", "327.23", "458.21", "250.00" ]

icd9cm

[ [ [] ] ]

[ "38.93", "00.17", "38.95", "00.13", "96.72", "93.90", "99.04", "39.95", "96.04", "96.6", "33.24" ]

icd9pcs

[ [ [] ] ]

21452, 21508

8904, 14546

363, 489

21879, 21934

3856, 3856

22827, 23385

2201, 2294

19758, 21429

21529, 21858

18987, 19735

21958, 22804

2309, 3837

261, 325

8793, 8881

517, 1381

3872, 8774

14562, 18961

1403, 1785

1801, 2185

1,890

155,480

43665

Discharge summary

report

Admission Date: [**2156-12-4**] Discharge Date: [**2156-12-29**] Date of Birth: [**2080-2-18**] Sex: M Service: MEDICINE Allergies: Quinapril / Heparin Agents Attending:[**First Name3 (LF) 2159**] Chief Complaint: Bacteremia Major Surgical or Invasive Procedure: Right hip fracture revision History of Present Illness: Pt is a 76 yo M with h/o CAD s/p CABG, afib on antiarrthymics, DM, CHF with ICD placement, with previous MRSA bacteremia secondary to R hip septic arthritis treated with IV antibiotics, s/p hemiarthroplasty with removal of hardware, presents to [**Hospital1 18**] from [**Hospital 24356**] hospital for continued medical care and possible surgical evaluation. The patient initially presented to [**Hospital 24356**] hospital with a R hip fracture to which it was replaced in [**7-20**]. He subsequently acquired septic arthritis with MRSA, requiring removal of the hardware and treatment with IV antibiotics. The patient returned to [**Hospital 1474**] Hospital 3 weeks later for secondary revision of his right hip. However, prior to the supposed surgery, the patient was found to have ?????? positive bottles growing acinetobacter of undetermined source. ID was consulted, and the patient was started on Unasyn. Throughout this time, the patient has remained asymptomatic. At some point during his stay there, the patient was switched to Vancomycin/ Zosyn. Moreover, questions were raised as to the possibility of ICD seeding and further infection and bacteremia. Given these concerns, and the need for hip revision, the patient was transferred to [**Hospital1 18**] for further care. . On arrival to the floor, the patient was stable and in good spirits. The patient denied pain of any kind. Additionally, the patient denied fevers/chills, chest pain, SOB, n/v/d, abnormal Bms, dysuria, hip pain, back pain or fatigue. Subsequent blood cultures were negative. . ROS: As per HPI. Patient describes good PO intake and normal BMs Past Medical History: Right hip fracture, s/p total hip replacement [**2156-7-16**] with subsequent MRSA septic arthritis treated with 3 weeks (?) IV antibiotics, s/p girdlestone procedure on [**2156-8-5**] Diabetes Mellitus CAD, s/p MI and 4 vessel CABG in [**2148**] s/p PCM/ICD for NSVT in [**2155**] CHF/mixed cardiomyopathy (partially ischemic) EF of 25% HTN Hyperlipidemia GERD Dementia Anxiety Afib UTI Social History: Pt lives alone, retired worker in a nail company, never smoked, has not had any alcohol for 4 years but prior only drank socially, HCP is sister in law [**Name (NI) **] [**Known lastname **] [**Telephone/Fax (1) 93882**] Family History: Father died age 78 of "bowel problem", mother with [**Name (NI) 93883**], brother with CA unknown primary with mets to bone, no other FH of CAD, CHF, DMII Physical Exam: VS: T 98.1, BP 124/62, HR 74, RR 20, 94% RA Gen: Awake, alert, talkative, appears stated age, NAD HEENT: EOMI, PERRL, anicteric sclera, MMM, poor dentition with missing teeth Neck: supple, no LAD Lung: CTAB, equal expansion, no wheezes or crackles appreciated Heart: RRR, nl S1 S2, no m/r/g Abd: Soft, NT/ND, +BS Back: no CVA tenderness, no visible ulcerations Ext: Well healed R surgical scar over R hip, warm well perfused, with atrophy in lower ext. [**5-19**] strengh bilat, no edema Neuro: CN II-XII grossly intact Pertinent Results: Admission labs: [**2156-12-5**] 12:00AM BLOOD WBC-7.2# RBC-3.87* Hgb-12.3* Hct-35.7* MCV-92# MCH-31.7# MCHC-34.4# RDW-14.7 Plt Ct-208 [**2156-12-5**] 12:00AM BLOOD Neuts-64.5 Lymphs-26.4 Monos-5.4 Eos-3.5 Baso-0.2 [**2156-12-5**] 12:00AM BLOOD PT-14.0* PTT-27.0 INR(PT)-1.2* [**2156-12-5**] 12:00AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-139 K-3.5 Cl-105 HCO3-27 AnGap-11 [**2156-12-5**] 12:00AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.2 . Micro: Blood culture [**12-5**]: NGTD Urine culture [**12-6**]: Mixed flora . Imaging: Bilateral hip films [**12-5**]: There is a composite material femoral prosthesis with a central metal rod in place. Methyl methacrylate is suspected, although depending on the age of the prosthesis, coral has also been used for this purpose. There is bridging heterotopic ossification encircling the entire hip joint. There is no periprosthetic fracture. Alignment is anatomic. The native acetabulum is present. LEFT HIP: No fracture or dislocation. Normal alignment. . TTE [**12-6**]: The left and right atria are moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the basal inferolateral, basal inferoseptal and mid inferior walls. Right ventricular chamber size is normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: 76 yo M with h/o CAD, CABG, CHF s/p ICD, afib, and R hip fracture complicated by septic arthritis and removal of hardware, presents from [**Hospital 1474**] Hospital with acetinobacter bacteremia for continued medical care and possible surgery evaluation. . MICU course: After surgical intervention on [**12-14**], the patient was found to have hypotension and was unable to be weaned from pressors. The patient therefore was transferred to the MICU. The patient was treated for hypotension with fluid boluses and was quickly weaned off pressors (CVPs low prior to boluses). After this the patient had few episodes of hypotension. On [**12-15**] hip films showed dislocation and two attempts were made to reloacte it, unsuccessfully. The patient had multiple epidoses of rapid tachycardia (130s) after this as a result of pain that self resolved. The patient was treated with pain medications, with mild effect. The patient was then taken to the OR again for surgical intervention on the right hip dislocation. After this the patient was returned to the MICU and was stable except for episodes of agitation and tachycardia most closely related to pain. . Bacteremia: Patient was admitted with history of recent septic arthritis with MRSA, as well as positive blood culture for acinetobacter from OSH. Patient was admitted to OSH initially for revision of R hip, however was found to have 1/4 bottles of blood cultures positive for acinetobacter and was transferred her for further workup and management. Patient was initially on Zosyn to treat this and ID was consulted for recommendations. Clinically the patient had no signs of bacteremia with no fever/leukocytosis. There were no localizing signs of infection. Blood cultures drawn here were negative. Given patient's ICD and possible bacteremia echo was obtained to look for signs of endocarditis and was negative. It was determined that blood cultures at the OSH were drawn off of the patient's PICC. The picc was removed. Blood cultures here were negative. Antibiotics were discontinued and the pt remained afebrile with normal wbc count. . Right Hip Repair: Patient had surgical repair of his hip in [**7-20**] which was subsequently reversed due to septic arthritis. Patient was transferred here for further evaluation. was taken to OR initially for hip aspiration. was again taken to the OR 5 days later for open reduction. underwent removal of femoral stem and a circlage wire for greater troch fracture was placed. he was on coumadin and fondaparinux (HIT antibody +ve) for anticoagulation. the pt had mild oozing from the R hip wound. anticoagulation was held secondary to high INR. the oozing decreased and finally stopped. the coumadin was restarted at a dose of 3 mg hs. pain control was achieved with IV ketorolac and dilaudeed. He was started on vit d and ca given recent hip fracture and would benefit from full BMD assessment with subsequent management decisions (pending results) as an out patient. . CHF/Cardiomyopathy: h/o CHF w/ EF of 25%. was not decompensated during this admission. home lasix was held initially as pt was hypotensive. was started on home dose of 40 po daily. was also treated with Metoprolol 25mg [**Hospital1 **], Losartan 100mg qDay. . Afib: patient was continued on Dofetilide for rhythm control. was also on metoprolol 50 q8h. used to be tachycardic during nights without being symptomatic. his metoprolol was titrated up for rate control and the tachycardia resolved. He was treated wtih fundaparinux as a bridge to coumadin post-operatively. . DM: Diabetic diet, RISS . FEN: cardiac/diabetic diet . Ppx: Protonix, bowel regimen . Code: DNR/DNI . Contact: [**Name (NI) **] [**Known lastname **] [**Telephone/Fax (1) 93882**] in law . Medications on Admission: Citalopram 20mg PO qDay Lasix 40mg PO qDay Protonix 40mg PO qDay Mag Hydrox 30ml PO qHS PRN Toprol 50mg PO qDay Vancomycin 0.75g IV q12 Sucralfate 1g PO QID Tylenol 650mg PO q6 PRN Dofetilide 0.25mg PO BID Zosyn 3.375g IV q6 Losartan 100mg PO qDay RISS Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ketorolac Tromethamine 15 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed. 13. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q6H (every 6 hours) as needed. 14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Right hip fracture revision . CHF DM CAD ICD CHF Dementia Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 L . We have started you on tablet dofetilide 250 mcg twice a day and metoprolol 50 mg thrice a day. . If you have chest pain, shortness of breath, palpitations, dizziness, fever, chills, pain in abdomen, blurring of vision please call the physician on call or go to te emergency room . Please take all medications as prescribed. . Your coumadin dose is 3 mg once at night every day Followup Instructions: Please make a follow up appointment with your primary care physician [**Name Initial (PRE) 176**] 2 weeks of discharge. ([**Doctor Last Name **] [**Telephone/Fax (1) 3183**]) . Please check INR within 7 days of discharge. Please adjust the coumadin dose according to the INR.. . Please check the serum phosphate level within 7 days of discharge. The patient has been having low phosphate during this admission . You will get a call from orthopedics ([**Telephone/Fax (1) 2007**]regarding your appointment. Please give them a call if you dont hear from them within 2 weeks. Completed by:[**2156-12-29**]

[ "285.29", "518.5", "V58.67", "414.00", "599.0", "458.29", "V09.0", "250.00", "294.8", "041.11", "707.03", "730.15", "428.0", "427.31", "996.42", "V53.32", "427.89", "428.20" ]

icd9cm

[ [ [] ] ]

[ "81.91", "96.59", "79.35", "38.93", "99.04", "89.49", "00.17", "99.07", "00.75", "80.05", "00.72", "78.65" ]

icd9pcs

[ [ [] ] ]

10642, 10714

5037, 8786

299, 329

10816, 10825

3371, 3371

11379, 11983

2657, 2814

9090, 10619

10735, 10795

8812, 9067

10849, 11356

2829, 3352

249, 261

357, 1990

3388, 5014

2012, 2402

2418, 2641

1,758

184,443

51291

Discharge summary

report

Admission Date: [**2183-8-6**] Discharge Date: [**2183-8-21**] Service:Medicine HISTORY OF PRESENT ILLNESS: This is a 77-year-old male with a history of diabetes mellitus, chronic renal failure on hemodialysis, sent from [**Location (un) **] Dialysis Center for change in mental status. Nephrocaps one once daily, Zestril 20 mg twice a day, RenaGel 2400 three times a day, Niferex 150 once daily, enteric-coated aspirin one once daily, Tums one twice a day, Cardizem 180 once daily, Lopressor 100 once daily, Zyprexa 10 twice a day. HOSPITAL COURSE: He was stable, and his only symptoms in the temperature of 102.1, and mild hyperkalemia with a potassium of 6.0. He was worked up for fever. Urinalysis was negative. Blood cultures and chest x-ray were negative. CT of the abdomen showed colitis in the right lower quadrant vs. ischemic bowel. The patient was started on Flagyl and levofloxacin.CXR also suggested possible RML infiltrate. A head CT and right hip film were performed, as the patient was found next to his bed a week or two ago, confused. Both of these were negative. The patient's white count decreased over time, and he remained afebrile. The levofloxacin 250 every other day and Flagyl 500 by mouth three times a day seemed to be having some effect, though the source of the patient's colitis remained unidentified. On [**8-11**], about one hour after hemodialysis, the patient had a large lower gastrointestinal bleed with bright red blood per rectum. Mental status, when evaluated, was baseline. Blood pressure was 100 to 110 systolic, when it had been running 150 to 180 systolic. Heart rate was now in the 60s to 80s. Intravenous fluids were started at 200 cc/hour. A 16 gauge intravenous was placed in the left medial aspect of the left leg. Nasogastric lavage was negative for blood or coffee grounds. Hematocrit decreased from 35 to 33, and the patient was transfused two units of blood in the Medical Intensive Care Unit. A tagged red blood cell scan was performed, which showed diffuse blood in the cecum. While in the Medical Intensive Care Unit, the patient was hypertensive and had a labetalol drip. When he returned to the floor, he was started on Zestril 40 twice a day, and Toprol XL 100 once daily, as well as Cardizem. Further gastrointestinal workup was postponed according to Gastroenterology consult, as this was felt to be addressable as an outpatient by colonoscopy in a few weeks' time. All of the patient's medications which could affect mental status were held, including Haldol, Benadryl, and he became more clear over time. The aspect of delirium which seemed to be present before was no longer there, and it seemed the patient had a baseline dementia which was now unmasked. Dr. [**Last Name (STitle) **] had a conversation with the family, which resulted in the patient having Do Not Resuscitate/Do Not Intubate status, and the family agreed that the patient should have long-term care due to dementia and chronic gait instability. He completed his 14 day course of levofloxacin and Flagyl. He was seen by Physical Therapy and Occupational Therapy and Speech and Swallow due to concerns about aspiration risk. Pt had video swallow which showed delayed oropharyngeal clearing without evidence of aspiration. Pt has difficluties with pills so advised to crush these and put in pureed foods. Pt is to follow up with Dr. [**Last Name (STitle) 25316**] of Gastroenterology for an outpatient colonoscopy in two or three weeks' time. He is also to f/u with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] for renal and primary care within the next few weeks. Pt also has type 2 Diabetes. He came in on insulin regimen. In house he had a few episodes of hypoglycemia. His standing insulin dose was discontinued and he has had stable glucose with rare requirement for insulin. Woudl maintain on sliding scale of insulin and re-start insulin only if sugars trend upward with improvment in diet. CONDITION ON DISCHARGE: Stable DISCHARGE DIAGNOSIS: 1. Multi-infarct dementia with superimposed delirium secondary to medications and infection. 2. Focal colitis of cecum ?infectious vs. ischemic vs other etiology 3. Hypertension 4. Gait instability likely related to prior CVA and deconditioning 5. ESRD on hemodialysis with hyperphosphatemia 6. RML pneumonia-resolved 7. Sarcoid-pulmonary-old 8. Type 2 DM c/b hypoglycemia, now resolved. DISCHARGE DISPOSITION: Discharged to skilled nursing facility/long-term care DISCHARGE MEDICATIONS: Toprol XL 100 mg by mouth once daily, Zestril 40 mg by mouth twice a day, Protonix 40 mg by mouth once daily, Tiazac 180 mg twice a day,Flagyl 250 tid for 2 days,TUMS 1 tab po bid,Renagel 2400 tid,niferex 150 qd, nephrocap 1 qd [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3022**], M.D. [**MD Number(1) 3023**] Dictated By:[**Last Name (STitle) 18486**] MEDQUIST36 D: [**2183-8-21**] 04:32 T: [**2183-8-21**] 04:56 JOB#: [**Job Number **] cc:[**Hospital1 106414**]

[ "293.0", "294.8", "558.9", "403.91", "250.80", "578.9", "285.9", "486", "275.3" ]

icd9cm

[ [ [] ] ]

[ "39.95", "96.34" ]

icd9pcs

[ [ [] ] ]

4455, 4510

4535, 5059

4041, 4431

567, 3987

121, 549

4012, 4020

26,864

135,017

49897

Discharge summary

report

Admission Date: [**2111-12-9**] Discharge Date: [**2111-12-19**] Date of Birth: [**2056-10-3**] Sex: M Service: ORTHOPAEDICS Allergies: Anti-Inflam/Antiarth Agents Misc. Classf Attending:[**First Name3 (LF) 11261**] Chief Complaint: Right hip pain Hyperglycemia Major Surgical or Invasive Procedure: [**2111-12-9**]: Right hip aspiration [**2111-12-11**]: Right hip I&D [**2111-12-13**]: PICC line placement History of Present Illness: Mr. [**Known lastname **] is a 54 yo M with DM2, PE on coumadin, congenital hip dysplasia s/p THR & multiple hip revisions, cardiomyopathy and multiple other medical problems presents with 5 day duration of sharp R hip pains. R hip pain started suddenly ~5days prior to admission and he was unable to ambulate; pain was poorly controlled at home however did not feel sick. Pain gradually worsened to involve thigh muscles as well as popliteal area, now reported malaise, chills, poor appetite and nausea; this was when he presented to the ED. Denies vomiting or abdominal pains. Of note, pt reports that he has chronically been on ciprofloxacin 500mg po BID since [**1-/2111**] s/p R hip revision c/b infection; he reports that he has accidentally only been taking cipro once daily. This regimen was under the control of Dr.[**Last Name (STitle) 8362**](ID) at [**Hospital3 **] hosp. . ROS: Reports recent improving cough, no rhinorrhea or sorethroat. Denies chestpain or sob. Denies myalgias or arthralgias to other sites however does report chronic backpain. Reports poor compliance with his insulin over the last few days as had poor oral intake. Reports polyuria but no dysuria. Denies diarrhea, constipation, melena or hematochezia. . ED COURSE: T 99.2F BP 104/77 P 121 RR 16 O2sats 95%RA. Ortho c/s in ED, plan for CT guided arthrocentesis of R hip joint. Received Vancomycin 1000mg IV x 1, Levofloxacin 500mg po x 1, regular insulin for blood glucose of 300's and NS x1L. Pt admitted to medicine for further managment. Past Medical History: DM2: A1c 7.0 [**10/2111**]; proteinuria. PE x2 on lifelong coumadin. Congenital hip dysplasia s/p reconstruction at age 10, multiple hip replacement over the years; most recently [**1-/2111**] (R hip revision) Hypertension Hepatitis C (fibrosis on biopsy; followed by Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2643**]) Chronic Pain syndrome Cardiomyopathy (normal cath [**2-/2111**]): EF 50-60% s/p Laminectomy Social History: Pt currently unemployed, lives alone and uses a cane. Denies current tobacco use, quit years ago. No recent EtoH use, quit ~10yrs ago. Denies IVDU. Family History: There is a family history of diabetes. His mother and maternal grandmother both had heart disease. Physical Exam: VS: T 101.9 F BP 110/60 P 79 RR 20 94% RA GEN: Well developed male, lying in bed, winces with movement in bed HEENT: OP clear without lesions Heart: RRR, no murmurs noted Lungs: CTA b/l, no wheezing or rhonchi Abd: obese, +bs, nontender to palpation Ext: R>L warmth, R hip - large scar s/p hip replacements, tender to palpation, hardened & enlarged per pt not new, no erythema noted. Barely moves RLE due to pain. Neuro: AAO x 3 . Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2111-12-10**] 08:30AM 10.3 4.15* 12.2* 36.4* 88 29.3 33.4 12.9 322 [**2111-12-9**] 03:00PM 9.5 4.36* 13.0* 36.7* 84 29.9 35.5* 13.6 337 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [**2111-12-10**] 08:30AM [**Telephone/Fax (2) 104246**] 3.7 89 26 . IMMUNOLOGY CRP [**2111-12-9**] 03:00PM 229.3 . CT guided arthrocentesis [**2111-12-10**] Aspiration of purulent material from right hip joint. Highly suspicious for infection and material is sent for microbiology as well as cell count and differential. . Synovial fluid analysis [**2111-12-10**] WBC 299,000 PMN's 98% Brief Hospital Course: Mr. [**Known lastname **] presented to the [**Hospital1 18**] on [**2111-12-9**] with right hip pain. He was evaluated by the orthopaedic and medical service. He underwent a CT guided aspiration of his right hip and was started on Vancomycin and ciprofloxacin. The CT drainage grew 299K WBC with 98% PMN's. He was also noted to have elevated blood glucose levels and the [**Last Name (un) **] team was consulted in help with blood glucose control. He was also noted to have hyponatremia which was corrected with IV fluid. On [**2111-12-11**] he was transferred to the ICU for better blood glucose control as finger sticks remained elevated over 400. He also have temperature greater than 102, and HR 120's. Later on [**2111-12-11**] he was taken to the operating room and underwent and I&D of his right hip. He tolerated the procedure well and was transferred back to the ICU post operatively. He continued on Vancomycin, Ceftaz, and Clindamycin. On [**2111-12-13**] a PICC line was placed for long term antibiotics. He was also transfused with 2 units of packed red blood cells due to acute post operative anemia. On [**2111-12-14**] the vancomycin and clindamycin was stopped and he remained on ceftaz. He was also transferred to the floor on [**2111-12-14**]. Infectious disease was consulted for antibiotic coverage and length of treatment. On [**2111-12-16**] the ceftaz was discontinued and he was started on Ceftazidime for a 6 week course. . With his history of two pulmonary embolism he is on lifelong coumadin. Goal INR is [**12-20**]. The rest of his hospital stay was uneventful with his lab data and vital signs within normal limits and his pain controlled. He is being discharged today in stable condition. Medications on Admission: Aspirin 325 mg qd Folic acid 2 mg qd Humulin 70/30 30u qam & 32u qpm HCTZ 12.5 mg po qd lipitor 80mg po qd lisinopril 40mg po qd MS contin 30 mg po BID Neurontin 400mg TID Nortriptyline 75mg po QHS Toprol XL 100mg po qd Warfarin 5mg po qd . ALLERGIES: NSAIDS 'pruiritis' no resp.distress Discharge Medications: 1. PICC Care Normal Saline flush 5-10cc SASH/prn Heparin Flush 100unit/cc 3-5cc SASH/prn 2. Outpatient Lab Work Please draw weekly CBC with fidd, Chem 7, LFT's, ESR, and CRP Please fax results to attention Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 432**] 3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. Nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for 1 months. Disp:*90 Tablet(s)* Refills:*0* 8. Ceftazidime-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig: One (1) g IV Intravenous Q8H (every 8 hours). Disp:*3 week supply* Refills:*2* 9. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous twice a day for 1 months. Disp:*60 syringes* Refills:*0* 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 12. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14: INSULIN Insulin SC Fixed Dose Orders Bedtime: Glargine (Lantus) 55 Units Insulin SC Sliding Scale Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 071-099 10 Units 10 Units 13 Units 0 Units 100-149 13 Units 13 Units 16 Units 0 Units 150-199 16 Units 16 Units 19 Units 0 Units 200-249 19 Units 19 Units 22 Units 5 Units 250-299 22 Units 22 Units 25 Units 8 Units 300-349 25 Units 25 Units 28 Units 10 Units 350-400 28 Units 28 Units 28 Units 12 Units Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Right hip infection Acute post operative anemia Discharge Condition: Stable, to home Discharge Instructions: Continue to be weight bearing as tolerated on you right hip . Continue your IV antibiotics as instructed . If you notice any increased redness drainage or swelling, or if you have a temperature greater than 101.5 please call the office or come to the emergency department. Physical Therapy: Activity as tolerated Right Lower extermity: Weight bearing as tolerated Treatments Frequency: Staples/sutures out 14 days after surgery or at follow up appointment. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 7111**] in 2 weeks, please call [**Telephone/Fax (1) 11262**] to schedule that appointment. . Please follow up with Dr. [**Last Name (STitle) **] in infectious disease clinic in 4 weeks, please call [**Telephone/Fax (1) 457**] to schedule that appointment. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2111-12-23**] 4:00 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2112-1-1**] 2:30 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2112-1-6**] 1:00

[ "711.05", "V12.51", "041.85", "V58.61", "402.91", "285.9", "250.02", "428.32", "338.29", "425.4", "V43.64", "996.66", "584.9", "428.0", "755.63", "070.54", "276.1" ]

icd9cm

[ [ [] ] ]

[ "80.15", "38.93", "99.04", "81.91" ]

icd9pcs

[ [ [] ] ]

7917, 7975

3914, 5653

336, 449

8067, 8085

3213, 3891

8591, 9268

2645, 2746

5992, 7894

7996, 8046

5679, 5969

8109, 8382

2761, 3194

8400, 8474

8496, 8568

268, 298

477, 2006

2028, 2464

2480, 2629

5,573

177,000

47817

Discharge summary

report

Admission Date: [**2139-4-5**] Discharge Date: [**2139-4-18**] Date of Birth: [**2066-4-30**] Sex: M Service: MEDICINE Allergies: Amoxicillin Attending:[**First Name3 (LF) 689**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Left IJ hemodialysis catheter placement Right IJ central line placement History of Present Illness: The patient is a 72 year old male with a history of CAD s/p CABG x 2, CHF EF 20%, AFIB, DM2 who presented on [**2139-4-5**] with worsening DOE x 4 weeks, cough, and increased LE edema. Pt reports that 4 weeks prior to presentation, he would be able to climb 10 steps and walk [**1-28**] mile w/o dyspnea - DOE has slowly progressed such that today not able to walk 20 feet w/o dyspnea. Denies dyspnea at rest. Pt also states that he had noticed increased LE edema over past 4 weeks before admission. Finally, he states he has had a cough productive of white sputum x 4 weeks; worse at night and interferes w/ his ability to sleep. On presentation, the patient denied any CP, but stated that one week prior he felt non-radiating sharp substernal CP after climbing 1 flight of stairs. +dyspnea -diaphoresis, -N/V. He has been prescribed SL NTG in past, but never has needed it - during this episode, however, he wished he had it at the time. CP dissipated after resting for 10 minutes and did not recur. Does not actively monitor salt intake. Has increased fluid intake (2-3 L/day now) b/c of sensation of dry mouth when wakes up. General malaise has resulted in missing some medication doses. Pt's PCP was going to start him on digoxin for his AF but the prescription has not been filled b/c of dosing error (prescribed 0.1 mg every other day). Has been taking tylenol (2 tabs 2-3 times daily) for generally unwell feeling. Has been seen multiple times by PCP for worsening DOE. Work-up included CXR ([**3-31**] - no evidence CHF, no infiltrate), echo (EF 20%) and blood cx to r/o endocarditis (pending). ROS: + rhinorrhea, decreased appetite. +wt gain, but not sure how much. Denies orthopnea, PND (but sleeps w/ two pillows for GERD), fevers, chills, night sweats, change in bowel or bladder habits, BRBPR, melena, hematuria, visual changes, weakness in arms or legs. pain in L shoulder w/ movement (longstanding problem) Past Medical History: CAD (CABG [**2109**] AND [**2120**]) CHF w/ EF 20%, diastolic dysfx AF (dating back to [**2134**]) DM (HBA1c [**2138**] = 7.5) CRI GERD PUD gout claudication s/p CCY s/p cataract [**Doctor First Name **] [**1-30**] s/p back surgery Social History: Pt is a retired engineer. Lives w/ wife, daughter and granddaughter. Quit tobacco >15 years ago; 50 pk-yr history. Social EtOH (2 drinks/week), no illicits. Wife is HCP. Daughter is cardiac nurse. Family History: Noncontributory. Physical Exam: T 97.3, BP 103-119/53-70, 87-102, 15-16, 100% RA. Gen: comfortable appearing man, in bed at 40 degrees, speaking in complete sentences without dyspnea, NAD Skin: no rashes, numerous ecchymoses, particularly L forearm, stasis changes LLE HEENT: NCAT, PEERLA (3-->2), EOMI, OP clear w/o erythema, neck supple, no LAD. CV: JVD above ear @90 degrees, 1+ carotid pulses bilaterally w/o bruits, irregular rhythm, rate 75-90, III/VI crescendo-decrescendo murmurSEM, ?gallop, no heave Resp: decreased BS bilaterally in lower [**1-27**] of lung, bibasilar crackles in lower [**1-26**] of lungs Abd: obese, well healed midline incision w/ hernia, + distention/mildly tense, non-tender. Ext: 3+ edema LLE, 2+ edema RLL, non-tender to palpation. Extremities warm. 2+ radial pulses bilaterally. L shoulder: pain on passive forward flexion; non-tender to palpation. Pertinent Results: Admission Labs: WBC-9.1 RBC-3.10* Hgb-10.6* Hct-31.0* Plt Ct-208 Neuts-86.4* Bands-0 Lymphs-7.6* Monos-4.7 Eos-0.7 Baso-0.5 PT-20.6* PTT-39.0* INR(PT)-2.0* Glucose-258* UreaN-84* Creat-2.2* Na-132* K-3.4 Cl-92* HCO3-25 AnGap-18 ALT-32 AST-35 AlkPhos-217* Amylase-50 TotBili-1.5 Lipase-34 proBNP-7947* Cardiac Enzymes: [**2139-4-5**] 02:00PM CK(CPK)-85 CK-MB-NotDone cTropnT-0.07* proBNP-7947* [**2139-4-5**] 08:10PM CK(CPK)-81 cTropnT-0.07* [**2139-4-5**] 09:43PM CK(CPK)-81 CK-MB-3 cTropnT-0.08* [**2139-4-6**] 06:20AM CK(CPK)-78 CK-MB-NotDone cTropnT-0.06* *** Admission Studies: ECG Study Date of [**2139-4-5**] 1:14:06 PM Atrial fibrillation Ventricular premature complexes Consider prior inferior myocardial infarction Prior anteroseptal myocardial infarction Diffuse nonspecific ST-T wave abnormalities Since previous tracing of [**2136-6-12**], ventricular ectopy and further ST-T wave changes present CHEST (PORTABLE AP) [**2139-4-5**] 1:28 PM SEMI-UPRIGHT AP VIEW OF THE CHEST: Patient is status post median sternotomy and CABG. The heart is at the upper limits of normal size. In the interval, there has been upper zone vascular redistribution, vascular engorgement, and perihilar haziness, findings all consistent with mild congestive heart failure. The costophrenic angle is excluded from this study. Small left pleural effusion is likely present. There is no pneumothorax. Osseous structures are unchanged. IMPRESSION: Mild congestive heart failure. Probable small left pleural effusion. UNILAT LOWER EXT VEINS LEFT [**2139-4-5**] IMPRESSION: No evidence of DVT. *** Other Labs: [**2139-4-13**] 05:25AM BLOOD ALT-22 AST-35 LD(LDH)-302* AlkPhos-206* TotBili-1.5 GGT-318* [**2139-4-5**] 02:00PM BLOOD calTIBC-270 VitB12-595 Ferritn-622* TRF-208 [**2139-4-10**] 06:20AM BLOOD Folate-12.2 Ferritn-600* [**2139-4-9**] 06:30AM BLOOD Triglyc-58 HDL-36 CHOL/HD-2.2 LDLcalc-32 [**2139-4-9**] 06:30AM BLOOD Digoxin-0.5* *** Other Studies: CHEST (PORTABLE AP) [**2139-4-13**] 7:10 AM 1. Slightly improving interstitial pulmonary edema. 2. Swan-Ganz catheter terminates in the right upper lobar artery. RENAL U.S. [**2139-4-9**] 9:55 AM IMPRESSION: Diminished intrarenal arterial diastolic flow suggesting chronic small vessel disease. Otherwise, normal renal ultrasound with no hydronephrosis or evidence for renal artery stenosis. ESOPHAGUS [**2139-4-16**] 3:08 PM During the initial swallows, there was no evidence of aspiration. However, after consecutive sips of thick dye and the patient aspirated a small amount. The cough was partially effective in clearing the aspirated barium. The motility of the esophagus appears satisfactory. In the anterior aspect of the distal third of the esophagus there is some irregularity which was incompletely evaluated in this study. This should be further evaluated when the patient comes down tomorrow for a video swallow. IMPRESSION: 1. Mild aspiration during the study. Recommend evaluation by the speech and swallow therapist with a video swallow fluoroscopy. REPEAT BARIUM SWALLOW [**4-17**]: IMPRESSION: Extrinsic compression upon anterior distal esophagus. If there is further clinical concern recommend followup CT exam. VIDEO SWALLOW: mildly reduced oral control and mild pharyngeal residue in the valleculae with all consistencies. Pt also had trace penetration before the swallow with both thin and nectar thick liquids, but he completely cleared the penetration and no aspiration was seen during this study. Based on this study, pt is safe for thin liquids and regular consistency solids. Pt will need to perform repeat swallows as needed to clear the pharyngeal residue which he is sensate to, and often coughs in response to. Spontaneous coughs during this evaluation were never due to aspiration. RECOMMENDATIONS: 1. suggest pt continue with a PO diet of thin liquids and regular consistency solids. 2. Pills whole with thin liquids. 3. Continue with esophageal work- up, especially for reflux, as many of the pt's symptoms may coincide with reflux. CT CHEST W/O CONTRAST [**2139-4-17**] 9:04 PM: CT OF THE CHEST WITHOUT IV CONTRAST: There is a left internal jugular line terminating in the distal SVC. There are extensive vascular calcifications. There are multiple small mediastinal lymph nodes. There are multifocal patchy areas of consolidation in the right upper lobe, left upper lobe, right middle lobe, and bilateral lower lobes. There is a focal area of calcification at the dome of the liver. There is an axial type hiatal hernia. No abnormal masses producing extrinsic compression of the esophagus are identified. There is no definite esophageal wall thickening with areas of the mid esophagus that are underfilled and thus difficult to evaluate for wall thickening. Bone windows reveal no suspicious lytic or sclerotic lesions. IMPRESSION: 1. No abnormal masses producing extrinsic compression of the esophagus are identified. There is no definite wall thickening, with evaluation of the mid esophagus limited due to under filling. 2. Small axial type hiatal hernia. 3. Extensive vascular calcifications including dense coronary artery calcifications in this patient that appears to be status post CABG. 4. Multiple patchy opacities in the lungs concerning for multifocal pneumonia. Given this patient's documented aspiration on the recent barium swallow, this is likely contributory. Brief Hospital Course: [**Hospital3 **] Course: Pt was admitted on [**2139-4-5**] on the [**Hospital1 139**] APG service. He was fluid overloaded with CHF and was diuresed to be negative 3L, however in the setting of decompenstated HF, aggressive diuresis, and initiation of an ACEI, he developed acute renal failure. Despite discontinuation of all diuretics and renal-toxic medications, his creatinine continued to rise over the next two days to 4.2. Additionally, his blood pressures remained very low (80s-100s SBP), though he was asymptomatic and not orthostatic. Accordingly, he was transferred to the CCU for CHF decompensation on [**2139-4-9**]. In the CCU, a central line and swan were placed and the patient was initially maintained on dopamine and vasopressin. His initial numbers were : PCW 33 on admission to CCU , PAP 63/29, CO 4.4, CI 2.07, SVR 855, SVO2 58% --> CO 5.2, CI 2.44 SVR 877, SvO2 61% off milrinone. In addition, he had been on milrinone until [**2139-4-13**]. In the CCU, renal was consulted and CCVH was initiated with HD through a left IJ line. At the end of his CCU course, the patient was a total of 3.8 liters negative. On [**2139-4-14**], the day of transfer to the floor, the patient had diuresed 1 liter the day before on CVVH and was 200 cc+ until noon with little urine output prior to transfer on metalazone and lasix 80 mg PO QD. He was transferred back to the medicine service on [**4-13**]. Diuresis was resumed with lasix and metalozone, with good urine output and stable creatinine at his baseline. From a respiratory stand point, Mr. [**Known lastname 100942**] improved substantially with diuresis; he was able to ambulate without dyspnea, limited only by deconditioning. His significant lower extremity edema, however, persisted. Hospital Course By Issues: Cardiac: CHF Exacerbation: The etiology of this exacerbation is not clear, however might be in part due to increasing fluid intake and salt indiscretion. While he was ruled out for MI during this hospitalization, it is possible he previously had an ischemic event which contributed to this exacerbation On admission, Mr. [**Known lastname 100942**]' CHF regimen included: furosemide 80 mg daily, metolazone 5 mg daily, and spironolactone/HCTZ 25/25 mg daily. He had previously been on a BB but it was discontinued as he is believed to have pulmonary disease, which was exacerbated the BB. It could not be determined whether he had previously been on an ACEI. His outpatient diuretics were continued, though lasix was change to IV and administered [**Hospital1 **], and an ACEI was started. In this setting he developed ARF and was transferred as detailed above to the CCU for tailored therapy. Furthermore, he was hypotensive (80s-100s SBP), though he was asymptomatic from this. His regimen on discharge is lasix and metalozone [**Hospital1 **] and he was diuresing well to this regimen with stable creatinine. He was also started on digoxin 0.125 mg daily. As Mr. [**Known lastname 100942**] has an appointment with the Heart Failure clinic, further modification of his CHF regimen was deferred. He was not restarted on a BB given his history of exacerbation of respiratory dyspnea with atenolol and onset of ARF inconjunction with starting an ACEI during this hospitalization. He should have a repeat echocardiogram when he is euvolemic to assess his actual EF and to guide decisions regarding the need for AICD. CAD: - Mr. [**Known lastname 100942**] has a history of CABG x 2, [**2109**] and [**2120**] and was ruled out for MI. In [**2131**], cath showed 3VD and occlusion of [**3-30**] grafts. - He was continued on ASA and lipitor 80. BB was felt to be contraindicated given his history of pulmonary exacerbation and his relative hypotension. -[**Name2 (NI) **] should follow-up with his cardiologist as an outpatient to discuss the role for cardiac catheterization when he is euvolemic for hemodynamic assessment and to evaluate for ischemic contribution to his worsening CHF. # Rhythm: AFIB since [**2134**]. -Mr. [**Known lastname 100942**] was monitored on telemetry during his stay - he was in afib but HR was routinely in the 70s-90s -he was started on digoxin 0.125 mg daily; it was felt a beta-blocker was contraindicated as detailed previously. - He was anticoagulated with heparin gtt while in the CCU then transitioned to coumadin with a goal INR [**2-27**] # Acute on chronic renal failure: - Mr. [**Known lastname 100942**]' Cr rose from his baseline of 2.0 to a peak of 4.1, but returned to his baseline after CVVH in the CCU. His ARF was likely multifactorial (low-flow state in the setting of decompensated CHF, aggressive diuresis, ACEI). Renal US showed no hydro or renal a stenosis and urine lytes showed a prerenal state. - Many of his medications were discontinued in the setting of ARF and were not restarted at discharge given his CRF. These include glyburide, metformin, and colchicine. #. Cough: likely multifactorial - secondary to pulmonary congestion, related to pneumonia. -Pneumonia - Sputum culture + for H. influenzae, placed on levo 7 day course (renally adjusted). -given the history of exacerbation of cough after drinking fluids, a video swallow was performed which did not demonstrate aspiration. #. Elevated alk phos - has had cholecystectomy in past. Likely related to CHF, especially as level as increased as CHF has worsened. Unlikely cholestasis or congestion given normal LFTs, normal bili, and ******normal GGT. # DM2: discontinued glyburide and metformin given a creatinine clearance of 35. Started on glargine 8, and RISS. At discharge, the pt's creatinine had improved and he was restarted on glargine per Dr.[**Name (NI) 19189**] recs. # Anemia: - Baseline Hct 39-40, this month has ranged 28-30. - Iron studies show chronic disease. -Started epogen qM,W,F and continued iron supplementation. . # Hematuria/UTI -Urine: no longer grossly bloody after removal of foley, only [**3-29**] RBCs on microscopic eval of urine --> hematuria resolved. Pt with UTI treated with levofloxacin. # Esophageal motility - Pt was evaluated for possible aspiration and found to not be aspirating. Additionally, there was a question of something compressing the anterior distal esophagus. This was further evaluated with a CT scan which was normal. # FEN: Placed on low Na, cardiac/DM diet, 1L IVF restriction. Electrolytes were carefully monitored and repleted prn. Patient was placed on standing Mg 800 mg [**Hospital1 **]. Medications on Admission: Warfarin 5 mg M-F, 2.5 mg Sat,Sun Dipyrimidole 25 mg TID Glyburide 1.5 mg daily metformin 1000 [**Hospital1 **] furosemide 80 mg daily metolazone 5 mg daily spironolactone/HCTZ 25/25 mg daily colchincine 0.6 mg daily nexium 20 mg daily vitamin E 400 IU daily Lipitor 20 mg daily Medications on transfer from CCU: ASA 325 mg Atorvastatin 20 mg PO QD Heparin gtt SSI Lantus 6 units QHS Levofloxacin 250 mg PO Q24 Metalazone 5 mg PO QD Lasix 80 mg PO QD Coumadin 5 mg M-Fri. 2.5 mg Sat-Sun PPI Senna Epo 4000 units MWF Iron 325 mg PO QD Discharge Medications: 1. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) mL Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*15 mL* Refills:*2* 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Outpatient Lab Work [**2139-4-20**] Serum Digoxin Level, PT, PTT, INR, Chem10, CBC cc Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 11. Enoxaparin 80 mg/0.8 mL Syringe Sig: 0.7 mL Subcutaneous Q12H (every 12 hours): Your dose is 70 mg every 12 hours. On syringe is 80 mg in 0.8 mL. Please administer 0.7 mL. Disp:*10 syringes* Refills:*2* 12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 13. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 15. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA [**Location (un) 270**] East Discharge Diagnosis: Primary Diagnoses: Decompensated Congestive Heart Failure Acute Renal Failure Secondary Diagnoses: Coronary Artery Disease Atrial Fibrillation Diabetes Mellitus Chronic Renal Insufficiency Anemia Discharge Condition: Stable, with less dyspnea and clearer lungs, with renal function at baseline, but with persistent lower extremity edema. Discharge Instructions: You were hospitalized at [**Hospital1 18**] for exacerbation of your congestive heart failure. The cause of this exacerbation is not certain, but may be related to increased fluid intake and excessive salt intake. After trying to remove some of the excessive fluid with lasix, your kidney function worsened. Accordingly, you were transferred to the ICU for tailored therapy including a form of dialysis, to help remove excess fluid without injurying your kidneys. During the course of your hospital stay, approximately ****XXXX**** liters of excess fluid was removed. Your weight at the time of discharge from the hospital was ******. 1. Take all medications as prescribed. Some of your medications were discontinued (including metformin and colchicine) given your worsened kidney function. At the moment, your diuretic regimen (water pills) includes lasix and metalazone; you should take both medications twice daily. You were started on Epogen for anemia (low red blood cell counts), digoxin for your heart failure and atrial fibrillation, and a short course of levofloxacin for pneumonia. Your coumadin was subtherapeutic at the time of discharge, so you are receiving lovenox shots until your coumadin is therapeutic. 2. Keep all appointments with your medical care providers (see below). 3. You should contact your doctor or return to the hospital if you: -notice an increase in your weight of more than 2 lbs (you should weigh yourself daily) -notice an increase in leg swelling, or increased shortness of breath, worsened cough, become short of breat when lying flat, or frequent awaken in the night short of breath -chest pain/tightness, palpitations, shortness of breath, nausea/vomiting, decreased exercise tolerance (becoming short of breath with less exertion than previously) -fevers, uncontrollable shaking chills -lightheadedness, particularly on standing -coughing up blood, blood in your urine or stools -any other symptoms that are concerning to you. Followup Instructions: 1. Heart Failure Clinic: You have an appointment with [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP, on [**2139-4-29**] @ 10:00AM. Located in [**Hospital Ward Name 23**] Clincial Center. Phone:[**Telephone/Fax (1) 3512**] 2. Primary Care Physician: [**Name10 (NameIs) **] have a follow up appointment with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Tuesday [**2144-4-20**]:30 AM (arrive 15 minutes early) at [**Location (un) **]. [**Location (un) **], [**Telephone/Fax (1) 4775**] . -you were started on digoxin while in the hospital. The blood levels of digoxin should be periodically monitored. You have been given a prescription to have your digoxin level measured on [**4-20**]. Additionally, laboratory work will be done to assess your kidney function, electrolytes, and PT/PTT/INR. Dr. [**Last Name (STitle) **] will follow-up on these results. 3. Cardiology: you have a follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 120**] on Tuesday [**5-26**] at 8:30 AM in [**Location (un) **], [**Telephone/Fax (1) 8645**] 4. Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 120**], or the staff at the Heart Failure clinic may wish to repeat an echocardiogram (ultrasound) of your heart when it is felt that your CHF medication regimen has been optimized to get a better sense of the actual function of your heart. Additionally, Dr. [**Last Name (STitle) 120**] may wish to order a cardiac catheterization as an outpatient to evaluate your coronary artery disease. 5. Other follow-up appointments currently scheduled: Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] [**Location (un) 2788**] CARDIOLOGY-PRIVATE Date/Time:[**2139-8-4**] 11:00 Provider: [**First Name11 (Name Pattern1) 278**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 394**], O.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2139-9-22**] 10:30

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Discharge summary

report

Admission Date: [**2183-7-10**] Discharge Date: [**2183-7-14**] Date of Birth: [**2155-12-22**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2186**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: This is a 27yoM with history of depression with SI who presents from psychiatric facility ([**Hospital 1680**] Hospital) with question of unknown ingestion. Per report, took "something" from roommate. Found with an empty plastic bag. No report of what he could have taken. Brought to [**Hospital1 18**] for evaluation. Unclear if patient was somnolent when found and if that's what prompted the suspicion of ingestion. In ED, initial VS were 97.7, 92, 135/83, 14, 97% 2L. Initial evaluation was unremarkable. However, while in ED, patient became more somnolent and was given narcan 0.4mg diagnostically but did not improve mental status. ABG at that time was 7.31/72/87. Labs were otherwise unimpressive. Given somnolence, patient was admitted to MICU further management. VS prior to admission were: Temp: 98.3 ??????F (36.8 ??????C), Pulse: 62, RR: 14, BP: 108/67, O2Sat: 97% RA. On arrival to the MICU, patient was conscious and speaking and was breathing comfortably on room air. Vitals: 98.1, 86, 140/83, 31, 92% RA. The patient reported he does not recall anything since lunch. He does recall being at [**Hospital 1680**] Hospital and being admitted there after he threatened to commit suicide by overdose of home medications. He does not recall taking an overdose at [**Hospital 1680**] Hospital. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - hypothyroidism (TSH 5.09, T4 0.8 on [**7-9**])-- patient reports compliance with home medication - hepatitis C - depression with suicidal ideation ([**3-20**] past suicide attempts, 1 cutting, [**2-16**] overdose with methadone, cocaine, or heroin) - PTSD (sexually abused at age 7) - IVDU w/ heroin, now on methadone, last used heroin on [**6-3**] (part of reason for recent admission was that he was afraid he would relapse to illicit drug use) - sleep apnea -- used CPAP in past, but hasn't used it in a while Social History: smoker, homeless, IVDU as per PMH/HPI Family History: non-contributory Physical Exam: Admission Exam: Vitals: 98.1, 86, 140/83, 31, 92% RA General: somnolent, but arousable, falls asleep during mid-conversation; when he does fall asleep his O2 sat drops to low 90s/high 80s on RA; no acute distress HEENT: sclera anicteric, MMM, oropharynx clear, EOMI, PERRL (no miosis or mydriasis) Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, systolic murmur 2nd L intercostal space Lungs: no wheezes or rhonchi, initially rales at B/L bases, but they cleared after pt took a couple deep breaths Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred Discharge Exam: VS: T97.6, HR 56, BP 96-135/68-78 RR 16, O2Sat 97% RA (96% on CPAP with O2) Gen: Awake, alert, oriented to self, place, and time HEENT: PERRLA, sclera anicteric, MMM, OP clear Neck: supple, no LAD CV: RRR, soft systolic murmur at the LUSB Lung: CTAB, no w/c/r Abd: soft, NT, ND, BS+, no HSM Ext: warm, dry, 2+ DP pulses, no c/c/e Neuro: A&O, able to carry out a conversation, mental status much improved and more alert compared to the initial presentation. Pertinent Results: Initial Labs: [**2183-7-10**] 10:46PM URINE HOURS-RANDOM [**2183-7-10**] 10:46PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-POS [**2183-7-10**] 10:46PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2183-7-10**] 10:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2183-7-10**] 07:11PM TYPE-ART PO2-87 PCO2-72* PH-7.31* TOTAL CO2-38* BASE XS-6 INTUBATED-NOT INTUBA [**2183-7-10**] 07:11PM LACTATE-0.9 [**2183-7-10**] 07:11PM HGB-13.1* calcHCT-39 O2 SAT-94 CARBOXYHB-2 [**2183-7-10**] 05:20PM GLUCOSE-99 UREA N-13 CREAT-0.9 SODIUM-144 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-34* ANION GAP-10 [**2183-7-10**] 05:20PM estGFR-Using this [**2183-7-10**] 05:20PM ALT(SGPT)-44* AST(SGOT)-27 ALK PHOS-68 TOT BILI-0.3 [**2183-7-10**] 05:20PM ALBUMIN-3.9 [**2183-7-10**] 05:20PM TSH-1.2 [**2183-7-10**] 05:20PM T4-8.5 [**2183-7-10**] 05:20PM LITHIUM-0.8 [**2183-7-10**] 05:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2183-7-10**] 05:20PM WBC-8.1 RBC-4.50* HGB-13.6* HCT-40.5 MCV-90 MCH-30.2 MCHC-33.5 RDW-14.2 [**2183-7-10**] 05:20PM NEUTS-53.7 LYMPHS-36.5 MONOS-5.1 EOS-3.9 BASOS-0.8 [**2183-7-10**] 05:20PM PLT COUNT-227 Pertinent Labs: [**2183-7-11**] RPR- non-reactive Labs on Discharge: [**2183-7-14**] 07:40AM BLOOD WBC-5.8 RBC-4.41* Hgb-13.2* Hct-39.5* MCV-90 MCH-29.8 MCHC-33.3 RDW-13.8 Plt Ct-202 [**2183-7-14**] 07:40AM BLOOD Glucose-108* UreaN-9 Creat-0.8 Na-143 K-3.7 Cl-103 HCO3-36* AnGap-8 [**2183-7-12**] 07:55AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.2 [**2183-7-14**] 07:40AM BLOOD VitB12-PND Folate-PND EKG [**7-10**]: Normal sinus rhythm. Normal tracing. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 64 182 88 [**Telephone/Fax (2) 112370**] 22 Imaging: [**2183-7-10**] - CXR: low lung volumes, no acute cardiopulmonary process [**2183-7-11**] - CT head: There is no evidence of acute intracranial hemorrhage, mass effect, or shift of normally midline structures. There is no cerebral edema or loss of [**Doctor Last Name 352**]-white matter differentiation to suggest an acute ischemic event. A 4 x 3 mm hyperattenuating focus is seen at the level of the foramen of [**Last Name (un) 2044**]. There is no hydrocephalus. Basal cisterns are patent. Globes are intact. Paranasal sinuses and mastoid air cells are well aerated. No fracture. IMPRESSION: A 4 x 3 mm hyperattenuating focus at the level from foramen of [**Last Name (un) 2044**] is most compatible with a colloid cyst. Further assessments with MRI can be considered, if indicated. No hydrocephalus. Brief Hospital Course: 27M w/ hx of PTSD, depression w/ multiple suicide attempts, IVDU now on methadone, hepC, and ?sleep apnea who presents from psychiatric hospital somnolent after suspected ingestion with unknown drug. Patient was observed in the MICU overnight before transferring to the medicine floor. ACUTE ISSUES: # Respiratory Acidosis [**1-16**] sleep apnea, NOS. Acute on chronic based on ABG. Based on presentation, had evidence of hypoventilation. There was a concern for drug overdose, but no causative [**Doctor Last Name 360**] was found. His tox screen showed presence of benzo and methadone which he normally takes. His lithium level was normal. Patient denies ingesting substances. Patient was thought to have central sleep apnea. Therefore, the psychiatry service assisted with medication adjustment to prevent worsening of his respiratory drive. Patient's mirtazepine and gabapentin were held. He was given CPAP while in house at night given that he was noted to have O2 sat in the 70% when he falls asleep. He responded to the CPAP with O2 supplement, and his O2Sat came up to the 90% when asleep. The sleep medicine service plans to see patient in the outpatient setting for a sleep study. Patient was given CPAP with O2 supplement so that he would continued to get bridge therapy while in the psychiatric hospital, awaiting for sleep study. One can consider decreasing Xanax to TID from QID and use Vistaril 12.5-25 mg q6-8 hr while awake for breakthrough anxiety/restlessness. # Altered mental status: Somnolence. Possibly secondary to alleged toxin ingestion, although none was found. Hypercapnea may have contributed partly, but the degree of which is not the sole cause of his mental status. Psychiatry assisted with medication adjustment to prevent worsening of his somnolence. His somnolence improved with holding mirtazepine and gabapentin and with use of CPAP. # ? toxic ingestion. None was found. This was alleged by the outside hospital. His tox screen showed evidence of benzo and methadone, which he was taking. Lithium level was normal. He did not have metabolic derangement or EKG changes. He had minimal LFT abnormalities, which is likely result of underlying hepatitis C. TSH was normal. RPR was non-reactive. It was unlikely narcotics given lack of response to narcan. Patient takes methadone at baseline. # Suicidality / Depression / PTSD. Patient was sectioned 12 by the psychiatry service. His medication were adjusted with discontinuation of mirtazepine and gabapentin. The psychiatry team here does not think it would be safe for patient to restart mirtazepine or gabapentin at this time, given the somnolence that led to his admission. Patient had 1:1 sitter to monitor for safety. Psychiatry suggested decreasing Xanax to TID from QID and using Vistaril 12.5-25 mg q6-8 hrs while awake for breakthrough restlessness and anxiety, but this can be done in the psychiatry hospital. He was thought to be medically stable, and the BEST teaem assisted with bed search. CHRONIC ISSUES: # Hypothyroidism. Patient had normal TSH and T4. He was continued on levothyroxine. # Hepatitis C. Not currently on treatment. ALT is mildly elevate. This will need to be monitored in the outpatient setting. TRANSITIONAL ISSUES: # Follow up: sleep medicine on [**8-13**], psychiatry, and PCP (after discharge from the psychiatric hospital) # Pending - pending B12 and folate Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from [**Hospital 1680**] Hospital records. 1. ALPRAZolam 0.5 mg PO QID 2. albuterol sulfate *NF* 90 mcg/actuation Inhalation QID:PRN 2 puffs QID:PRN wheezing, SOB 3. Citalopram 40 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Lithium Carbonate 600 mg PO BID 7. Methadone 80 mg PO DAILY 8. Mirtazapine 30 mg PO HS 9. Ibuprofen 400 mg PO Q6H:PRN pain 10. Gabapentin 600 mg PO TID mood 11. Prazosin 1 mg PO HS Discharge Medications: 1. ALPRAZolam 0.5 mg PO QID 2. Citalopram 40 mg PO DAILY 3. Ibuprofen 400 mg PO Q6H:PRN pain 4. Levothyroxine Sodium 100 mcg PO DAILY 5. Lithium Carbonate 600 mg PO BID 6. Methadone 80 mg PO DAILY 7. Prazosin 1 mg PO HS 8. albuterol sulfate *NF* 90 mcg/actuation Inhalation QID:PRN 2 puffs QID:PRN wheezing, SOB 9. Acetaminophen 650 mg PO Q6H:PRN pain RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 10. Nicotine Patch 21 mg TD DAILY RX *nicotine 21 mg/24 hour 1 patch daily Disp #*28 Unit Refills:*0 11. Docusate Sodium 100 mg PO BID 12. CPAP 8-15 cm H2O with heated humidifcation. 13. O2 supplement 2L of O2 supplement, titrate to CPAP. Mass Health # [**Telephone/Fax (5) 112371**] Discharge Disposition: Extended Care Discharge Diagnosis: Primary diagnoses: - Acute on chronic respiratory acidosis - Sleep apnea, NOS, now on CPAP - Altered mental status, secondary to possible ingestion and acute on chronic respiratory acidosis Secondary diagnoses: - Depression - Hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 112372**], You were transferred to [**Hospital1 69**] because you were found to be very sleepy at [**Hospital 1680**] Hospital. While you were here, we found that your breathing becomes very slowed and stops at times. This seemed to be a long standing issue based on what you tell us. We checked with [**Hospital **], but they said you did not have sleep study there. Based on some lab tests, it also seems that some of your medications were making your breathing worse. Therefore, the psychiatrists in the hospital helped with medication adjustment and recommended holding off on the Rameron and Neurontin. You were also given a CPAP while you were in the hospital. Your breathing seemed to improve with these changes. Please note the following changes with your medications: - STOP Rameron for now (check with psych) - STOP Neurontin for now (check with psych) - START acetaminophen for pain - START nicotine patch for tobacco smoking Please be sure to follow up with the Sleep Medicine doctor [**First Name (Titles) 3**] [**Last Name (Titles) 19379**]d so that you can get a sleep study to treat the sleep apnea formally. Followup Instructions: You should also be sure to follow up with your primary care doctor at the [**Telephone/Fax (1) 58547**], The Family HealthCare Center at SSTAR, within 1 week of your discharge from the mental health hospital. Department: MEDICAL SPECIALTIES/SLEEP MEDICINE When: WEDNESDAY [**2183-8-13**] at 8:40 AM With: DR. [**First Name (STitle) **]/DR. [**First Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2183-7-14**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11588, 11603

6821, 8328

327, 334

11886, 11886

4089, 5391

13223, 13791

2739, 2757

10833, 11565

11624, 11815

10274, 10810

12037, 13200

2772, 3596

11836, 11865

3612, 4070

10113, 10248

10100, 10102

1692, 2129

266, 289

5462, 6075

362, 1673

6084, 6798

11901, 12013

5407, 5443

9864, 10079

2151, 2667

2683, 2723

32,332

199,767

7557

Discharge summary

report

Admission Date: [**2129-6-3**] Discharge Date: [**2129-6-12**] Date of Birth: [**2067-8-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4963**] Chief Complaint: GI Bleeding Major Surgical or Invasive Procedure: Interventional Radiology Guided Embolization TEE Arthrocentesis History of Present Illness: The patient is a 61 year-old with a history of diet controlled DM and gout who was recently started on ASA/Plavix after cardiac cath with PCI/DES to OM2 and LAD lesions. He developed painless BRBPR and ?melena on [**6-4**] with active GI bleeding in the region of the ascending colon on a tagged RBC scan. He subsequently underwent angiography with embolization of a distal branch of the right colic artery. He was transfused a total of 6 units PRBCs on [**6-4**]. He went back to the ICU with recurrent rectal bleeding on the evening of [**6-6**] (reportedly red blood with a question of melena).The initial plan was to prep him for colonoscopy but this was deferred because he was hemodynamically stable and required further work-up for a possible proximal right common femoral DVT. His HCT did drift back down in the setting of this re bleeding and he was transfused another 2 units PRBCs. A thrombus was NOT confirmed on subsequent CT pelvis, and he was transferred back to the medical floor yesterday. Today he had a single dark maroon/black bowel movement. In general, he reports feeling very well. He denies CP, SOB, abdominal pain, N/V, dysphagia, odynophagia, diarrhea, constipation, fevers, chills or sweats. Past Medical History: New diagnosis of 2v CAD as noted above Diet controlled DM Gout History of esophageal stricture s/p dilation few yrs ago Bilateral knee arthroscopy Right knee surgery Hemorrhoid surgery Social History: Remote smoking history. No alcohol or drug use. Family History: Non-Contributory Physical Exam: VS: 140-160/70-80 HR 70s SR Lungs: CTA Heart: RRR -MRG Abd: NT + BS PV: 2+ fems b/l no bruits. BPs 2+ b/l no edema Neuro: A+O x3. Nonfocal exam Pertinent Results: [**2129-6-3**] 08:35PM GLUCOSE-151* UREA N-42* CREAT-1.8* SODIUM-139 POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-23 ANION GAP-19 [**2129-6-3**] 08:35PM WBC-11.8* RBC-4.49* HGB-12.8* HCT-38.3* MCV-85 MCH-28.4 MCHC-33.3 RDW-13.6 [**2129-6-3**] 08:35PM NEUTS-74.4* LYMPHS-18.3 MONOS-4.3 EOS-2.4 BASOS-0.6 [**2129-6-3**] 08:35PM PLT COUNT-278 [**2129-6-3**] 08:35PM PT-12.0 PTT-29.7 INR(PT)-1.0 [**2129-6-2**] 06:35AM UREA N-21* CREAT-1.2 POTASSIUM-4.6 [**2129-6-2**] 06:35AM estGFR-Using this [**2129-6-2**] 06:35AM CK(CPK)-87 [**2129-6-2**] 06:35AM CK-MB-NotDone [**2129-6-2**] 06:35AM HCT-39.1* [**2129-6-2**] 06:35AM PLT COUNT-224 Brief Hospital Course: The patient is a 61 year-old M who was recently started on ASA/Plavix after cardiac cath with PCI/DES to OM2 and LAD lesions who presented with a GI bleed. 1. BRBPR: Painless BRBPR and ?melena on [**6-4**]. Active GI bleeding in the region of the ascending colon on a tagged RBC scan. Angiography with embolization of a distal branch of the right colic artery performed. Required a total of 6 units PRBCs on [**6-4**]. On the evening of [**6-6**] had repeat red blood with a question of melena. Colonoscopy and upper endoscopy did not reveal a probable source for this bleed, and it may have been old blood that had not yet passed. He remained without further evidence of active bleeding on discharge with non-bloody bowel movements. 2. Concern for hematoma/DVT: On [**6-5**] a right groin mass was noted, status mesenteric anteriogram with R groin access now with R concerning for hematoma. Imaging showed normal right common artery and vein without evidence of aneurysm or hematoma. However, note was made that the waveform in the right common femoral vein had a very flat characteristic, which was thought to be indicative of a proximal DVT in possibly the internal or common iliac veins. While there was no deep vein thrombosis in the right leg, absent variability in the venous waveform of the right common femoral vein was concerning for a more proximal thrombus. On CT, however, there was no CT evidence for venous thrombosis or fluid collection as clinically questioned. 3. Pulmonary nodule: Incidental finding of 5-mm left lower lobe pulmonary nodule was found on CT. As no comparison studies are available to assess stability, [**5-26**] month followup CT examination was recommended. 4. S/p cardiac cath with PCI/DES to OM2 and LAD lesions: Patient bled in the context of s/p MI on blood-thinners. ECHO on this admission showed: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There are multiple small linear, echogenic, mobile elements on the left ventricular side of the mitral valve which may be redundant or torn chordal structures, although a small vegetation cannot be excluded with certainty (clips 61,63, 64). Moderate (2+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . IMPRESSION: Linear echogenic hypermobile elements in the left ventricular cavity below the mitral valve which may represent torn or redundant chordal structures vs. small vegetation. Moderate mitral regurgitation. Mild symmetric LVH with normal cavity size and global biventricular systolic function. Aortic sclerosis without stenosis. Mild aortic dilation. . Subsequent TEE ruled-out the question of vegetation on the heart. . ECG showed: Normal sinus rhythm. Left axis deviation. Left anterior fascicular block. No diagnostic interval change. . The patient was discharged on the following cardiac regimen: 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 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 5: Code: The patient remained full code during this hospitalization. Medications on Admission: On Transfer: Aspirin 81 mg Atorvastatin 40 mg Plavix 75 mg Meds @ home Ibuprofen 800mg x1 daily 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 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). Disp:*40 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Gastrointestinal Bleeding Diabtetes Mellitus - diet controlled Gout Discharge Condition: Good Discharge Instructions: You were admitted to the hospital with gastrointestinal bleeding. you underwent a procedure in Interventional Radiology that identified a bleeding vessel that was embolized. You did, however, devlop further bleeding. You underwent a colonoscopy and upper endoscopy which did not reveal a probable source for this bleed, and it may have been old blood that had not yet passed. An ulcer was discovered and a biopsy was taken. A cardiac echo suggeted that there may be vegetations on your heart, but the more accurate TEE exam then showed that there are no vegetations. . Your blood counts remained stable and you were continued on your medications for your heart attack last week. . Please follow up with your care providors as below. Please take all medications as prescribed - it will be very important to take a stool softner daily to help prevent straining and future bleeding events. It is also important that you remain on your plavix unless directed otherwise by a cardiologist. . Please return to the ER for chest pain, shortness of breath, bleeding in stool, dizziness, or any other concerning symptom. Followup Instructions: Please set-up an appointment with your Primary Care Doctor for this week to review your hospitalization and medication plan. . Provider: [**Name10 (NameIs) 3712**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2129-6-23**] 9:30 Completed by:[**2129-11-13**]

[ "535.60", "535.50", "414.01", "274.9", "584.9", "401.9", "998.11", "V45.82", "E879.8", "250.00", "562.10", "569.82", "V12.72", "285.1", "410.72" ]

icd9cm

[ [ [] ] ]

[ "39.79", "45.25", "88.47", "81.91", "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

7963, 7969

2805, 6804

326, 392

8081, 8088

2135, 2782

9246, 9535

1935, 1953

6952, 7940

7990, 8060

6830, 6929

8112, 9223

1968, 2116

275, 288

420, 1644

1666, 1854

1870, 1919

8,099

168,047

21194

Discharge summary

report

Admission Date: [**2102-9-13**] Discharge Date: [**2102-9-17**] Date of Birth: [**2044-5-3**] Sex: M Service: [**Doctor First Name 147**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: pancreas mass Major Surgical or Invasive Procedure: 1. Whipple procedure [**2102-9-13**] History of Present Illness: 58-year-old gentleman was with an unusual appearing cystic mass in the head of his pancreas. His story began 5 or 6 months ago with an atypical attack of lower abdominal pain that was suprapubic in nature. This led to imaging at another hospital which revealed a cystic lesion in the head of the pancreas that was not simple in its morphology. Currently, he has a largish mass in the lower aspect of the head of the pancreas, an uncinate process which has a thick wall septation and papillary projections. Furthermore, it is intimately adherent to the superior mesenteric vein. All these features are worrisome for amalignant degeneration of a cystic neoplastic process. He had no associated n/v, weight loss, pruritus, jaundice or steatorrhea. Past Medical History: 1. Status post Whipple for pancreatic head mass 2. Diabetes mellitus since [**2090**], insulin requiring 3. Hypertension 4. Coronary artery disease status post MI in [**2093**], status post stent. Stress test [**8-31**] with small territory of partially reversible inferior defect consistent with ischemia on nuclear imaging with no associated angina or EKG changes. 5. Circumcision [**2097**] Social History: 30 pack year h/o smoking. no etoh or drug use currently but heavy etoh in the past. currently in sales at department store. Family History: His family history is not significant for pancreatic cancer, colorectal cancer, melanoma, pancreatitis, gallstones, polyposis, or other cancers. There is a family history of a brother and a sister who each have diabetes and increased blood pressure. Physical Exam: preoperatively, afebrile with stable vital signs. neck supple without lymphadenopathy. heart regular rate and rhythm without murmur. lungs clear to auscultation bilaterally. abdomen soft, nontender, no mass and no scars. no axillary or groin lymphadenopathy. extremities without edema. Pertinent Results: I. Gallbladder (A): No diagnostic abnormalities recognized. II. Pylorus-sparing Whipple resection of the proximal pancreas (B-O): 1. Head of the pancreas: Area of chronic pancreatitis with mild activity and formation of a cystic cavity containing necrotic debris and bacteria. a) Extensive fibrosis. b) No neoplasm identified. 2. Pancreatic and common bile duct resection margins: No diagnostic abnormalities recognized. 3. Duodenum: No diagnostic abnormalities recognized. 4. Three lymph nodes: No diagnostic abnormalities recognized. 5. Separate segment of small intestine: o diagnostic abnormalities recognized. CT head [**2102-9-16**]: Findings consistent with brain edema. Please refer to the nuclear medicine brain scan which failed to demonstrate blood flow to the brain and is consistent with brain death. Brain Scan [**2102-9-16**]: The study is consistent with brain death EEG [**2102-9-16**]: This is a markedly abnormal portable EEG due to the presence of a very low-voltage, slow background rhythm that was present throughout the recording. This finding suggests the presence of a severe encephalopathy. Cortical activity, though abnormal, was seen at all times. Brief Hospital Course: Presented to [**Hospital Ward Name **] as same day admit. Underwent pylorus preserving whipple procedure [**9-13**]. Refer to operative report for details. Did not require transfusions intraoperatively and blood loss estimated at 800cc. Remained intubated in recovery room postoperatively overnight due to length of procedure. Labs drawn per whipple clinical pathway postoperatively and am of POD 1 34.9 and 34.7 respectively. Extubated morning of POD 1 without difficulty. Transferred to floor late afternoon of postoperative day 2. Pain controlled via MSO4 PCA initially. Supplemented by two doses of Toradol. Patient's heart rate difficult to control with high doses of beta blockers intraoperatively. Was placed on lopressor 10 mg IV q 4hrs postoperatively. Heart rate remained 90's to 100's sinus rhythm. Postop EKG unchanged from previous. Postop CXR showed RIJ line in good position without evidence of pneumothorax. Small right pleural effusion seen. Patient was encouraged to use an incentive spirometer post extubation POD 1. Patient was kept NPO with NGT to medium continuous suction POD 1. Patient had made adequate urine POD 0 and 1. Blood sugar difficult to control POD 1 and [**Last Name (un) **] diabetes center consult requested. His first postoperative day was uneventful. However, Mr. [**Known lastname 56151**] suffered an aspiration event early on the morning of postoperative day two. Around 8am on [**9-15**], coded on the floor during am rounds. Found by team to have agonal respirations. There was question of aspiration event as NGT clotted with blood. A code event was called and we were able to revive him initially from asystole. Code consisted of asystole and pulseless electrical activity. Code was noted to be "prolonged", it was 3-5 minutes. However, had hypotension to 40s systolic even after restoration of pulse. Found to have large blood clots in trachea and from ETT s/p intubation, causing him to be initially difficult to ventilate. Bilateral needle decompression and chest tube placement to rule out pneumothorax. After suctioning of ETT clots, ventilation improved. Transferred to SICU. Dropped hematocrit from 34.7 to 12.9. Was noted to cough, gag and move extremities spontaneously for several hours after code. He intially overbreathed the vent. However, the patient became non- verbal and unresponsive overnight and the patient no longer had a corneal reflex, gag, or cough, pupils fixed and dilated. No longer overbreathing vent. After consultation of neurology and performing diagnostic studies, unfortunately, it became very clear that he suffered an anoxic brain injury. After declaration of brain death by our intensive care physicians, we met with the family to discuss this. They elected to withdrawal support at that point and Mr. [**Known lastname 56151**] [**Last Name (Titles) **] on [**2102-9-18**]. Medications on Admission: 1. Micardis 20 mg po qd 2. Lipitor 10 mg po qd 3. Insulin 70/30 22 units qAM, 6 units qPM 4. Atenolol 25 mg po qd 5. ASA; held preop 6. Alleve prn Discharge Disposition: [**Year (4 digits) **] Discharge Diagnosis: Status post pancreaticoduodenectomy Anoxic brain injury Brain death Aspiration pneumonia Diabetes Hypertension History of Coronary artery disease Blood loss anemia Respiratory failure Discharge Condition: Deceased

[ "348.8", "427.5", "414.01", "507.0", "577.1", "250.00", "996.79", "401.9", "998.32", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "34.91", "99.04", "52.7", "99.60", "96.71", "34.04", "45.13", "38.91", "89.64", "96.07", "51.22", "96.04", "42.92" ]

icd9pcs

[ [ [] ] ]

6613, 6637

3536, 6415

346, 385

6864, 6875

2319, 3513

1740, 1992

6658, 6843

6441, 6590

2007, 2300

293, 308

413, 1163

1185, 1581

1597, 1724

68,867

136,211

910

Discharge summary

report

Admission Date: [**2188-10-6**] Discharge Date: [**2188-10-11**] Date of Birth: [**2122-1-10**] Sex: M Service: CARDIOTHORACIC Allergies: Atenolol / Lisinopril Attending:[**First Name3 (LF) 1505**] Chief Complaint: Endocarditis Major Surgical or Invasive Procedure: [**2188-10-7**] - Redo sternotomy, Aortic valve replacement(21mm St. [**Male First Name (un) 923**] Regent Mechanical)/Closure of aortic abscess (Patch pericardium)/Ascending Aorta Replacement(28mm Gelweave graft). History of Present Illness: 66M w h/o bicuspid aortic valve, s/p mechanical AVR (on [**Male First Name (un) **]) in [**2171**] at [**Hospital1 18**]. The ascending aorta was noted to be 4.5cm at the time, and was not replaced. He had an episode of enterococcal aortic valve endocarditis in [**2187-11-13**]. Enterococcal endocarditis was again diagnosed in [**2188-7-13**] with concern for aortic valve ring abscess on echo. The patient was evaluated for the source of his enterococcal bacteremia and mild ischemic colitis and several polyps were found. A polypectomy was performed. An EGD found mild gastritis and he was started on Pantprazole. The patient was discharged on ampicillin and gentamicin on [**2188-7-24**]. He was admitted on [**2188-9-9**] for preoperative workup and cardiac cath. Cardiac cath did not reveal obstructive coronary lesiosn. On admission, the patient exhibited gait instability and neurology was consulted. It was determined that the patient was experiencing vestibulopathy secondary to gentamycin. MRI revealed very small microembolic infarcts which were attributed to his time off [**Date Range **] resulting in subtherapeutic INR, or, less likely, septic emboli. Gentamicin was discontinued and the patient was discharged home on ampicillin, which will continue until surgery. ID has continued to follow him as an outpatient with weekly blood cultures. The patient returns for heparin bridge preoperatively. Past Medical History: -Mechanical AVR [**3-/2172**] -Enterococcal faecalis endocarditis diagnosed in [**11-20**], AVR ring abscess diagnosed [**7-22**] -Hypertension -Hyperlipidemia -Ischemic colitis -Colonic polyps -GERD -Hiatal hernia -Gastritis -Diverticulosis Social History: Lives with wife in [**Name (NI) 6134**], MA. Former smoker. Rare ETOH. Family History: Non-contributory. Physical Exam: Pulse:80 Resp:16 O2 sat:99% B/P Right:122/60 Left:122/64 Height: 5'[**87**]" Weight: 88kg General:WDWN, NAD Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur n 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:n Left:n Discharge Physical VS: T: 97.4 HR 76 SR BP: 109/67 Sats: 97 RA General: 66 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Cardiac: RRR normal S1,S2 good click Resp: clear breath sounds throughout GI: benign Extr: warm [**1-16**]+ edema Incision: sternal clean, dry, intact, margins well approximated no erythema IV: Left PICC site no erythema Neuro: awake, alert oriented. Pertinent Results: [**2188-10-7**] ECHO The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. with mild global free wall hypokinesis. A bileaflet aortic valve prosthesis is present. A paravalvular aortic valve leak is probably present. An aortic annular abscess is seen. Severe (4+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Post bypass S/P AVR with 21 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical valve prosthesis and graft placement. The patient is now on an Epi drip @.04 mcg/kg/min,Nor epinephrine @.14 mcg/kg/min The mean gradient across the aortic valve is 16,with a cardiac index of 2.6 The valve is well seated,with no paravalvular leak. The ejection fraction is estimated at 35% [**2188-10-11**] WBC-6.5 RBC-3.70* Hgb-9.6* Hct-28.8* Plt Ct-121* [**2188-10-10**] WBC-11.4* RBC-3.85* Hgb-9.9* Hct-30.0 Plt Ct-101* [**2188-10-9**] WBC-9.7 RBC-3.78* Hgb-9.7* Hct-29.4* Plt Ct-70* [**2188-10-6**] WBC-4.7 RBC-4.02* Hgb-9.7* Hct-30.7* Plt Ct-159 [**2188-10-11**] Glucose-92 UreaN-23* Creat-1.1 Na-138 K-3.7 Cl-100 HCO3-29 [**2188-10-10**] Glucose-116* UreaN-23* Creat-1.2 Na-132* K-3.8 Cl-97 HCO3-26 [**2188-10-6**] ALT-17 AST-25 LD(LDH)-216 AlkPhos-88 TotBili-0.3 [**2188-10-11**] PT-21.4* INR(PT)-2.0* [**2188-10-10**] PT-19.7* PTT-29.1 INR(PT)-1.8* [**2188-10-9**] PT-16.2* PTT-26.2 INR(PT)-1.4* [**2188-10-7**] PT-15.7* PTT-25.3 INR(PT)-1.4* [**2188-10-7**] PT-17.2* PTT-27.7 INR(PT)-1.5* [**2188-10-6**] PT-15.5* PTT-20.9* INR(PT)-1.4* CXR: [**2188-10-10**]: Right apical pneumothorax is minimal, unchanged since the prior study. The replaced aortic valve and the entire appearance of the cardiomediastinal silhouette is stable. No interval development of pleural effusion has been demonstrated except for minimal amount of most likely presence left pleural effusion. No evidence of pulmonary edema is seen. PICC line: [**2188-10-9**] 44 cm Picc placed in left berachial vein 1. Left PICC tip projects over the expected region of the upper/mid SVC. 2. Removal of ET tube and Swan-Ganz catheter in the interim. 3. Improved retrocardiac opacification compared to [**2188-10-7**]. 4. Bilateral small basilar atelectases. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2188-10-6**] for surgical management of his aortic valve endocarditis. Heparin was started as a bridge to surgery as he had stopped his [**Date Range **] five days prior to admission. He was worked-up in the usual preoperative manner. On [**2188-10-7**], he was taken to the operating room where he underwent a redo sternotomy, a mechanical aortic valve replacement, an ascending aorta replacement and closure of an aortic abscess with patch pericardium. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next 24 hours, he awoke neurologically intact and was extubated. He continued to make steady progress and was discharged to home on postoperative [**2188-10-11**] with [**Location (un) 6138**] Infusion for completion of his IV antibiotics. His [**Location (un) **] will managed by Dr. [**Last Name (STitle) **] as per preoperatively. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician and infectious disease as an outpatient. Medications on Admission: 1. Ampicillin 2 g IV Q4H 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. [**Last Name (STitle) 197**] 2.5 mg Tablet Sig: as directed for mechcanical AVR Tablet PO once a day: take 5mg on mon, wed, fri, sat, sun and 2.5 mg on tuesday and thursday. LAST DOSE [**Last Name (STitle) **] [**2188-10-2**] Discharge Medications: 1. ampicillin sodium 2 gram Recon Soln Sig: Two (2) gm Recon Soln Injection Q4H (every 4 hours) for 2 weeks. Disp:*84 2 gm Recon Soln(s)* Refills:*0* 2. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush: flush w/10 mL NS then 2 mL heparin. Disp:*QS ML(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*2* 8. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 10. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 12. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO as directed : INR Goal 2.0-3.0. 13. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital1 6136**] Home Discharge Diagnosis: Enterococcal endocarditis ([**11-20**] and [**7-22**]) Lower GI bleed Hypertension Aortic insufficiency s/p AVR [**2171**] Iron deficiency anemia Hypercolesterolemia Tachy/brady syndrome Gastroesophageal reflux/erosive gastropathy Colonic adenomas/ resolving ischemic colitis Hiatal hernia Diverticulosis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. 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 [**Telephone/Fax (1) 4314**] Surgeon: Dr. [**Last Name (STitle) **] Cardiologist: Dr. [**Last Name (STitle) 696**] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2188-10-30**] 8:00 Infectious Disease: Dr. [**Last Name (STitle) 6137**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2188-11-3**] 11:30 in the [**Last Name (un) 2577**] Building Ground Floor, [**Last Name (NamePattern1) **], [**Location (un) 86**] Please call to schedule [**Location (un) 4314**] with your Primary Care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 6142**] Labs: PT/INR for [**Telephone/Fax (1) 197**] for Aortic Valve Replacement. Goal INR 2.0-3.0 First draw Monday [**2188-10-13**]. INR [**2188-10-11**] 2.0 Please call Dr. [**Last Name (STitle) **] for further [**Last Name (STitle) **] dosing Completed by:[**2188-10-11**]

[ "348.39", "441.2", "V12.72", "041.04", "E937.8", "280.9", "287.5", "272.0", "553.3", "530.81", "562.10", "518.5", "401.9", "V15.82", "421.0", "424.1" ]

icd9cm

[ [ [] ] ]

[ "38.45", "35.22", "39.61", "38.93" ]

icd9pcs

[ [ [] ] ]

8993, 9049

5741, 6866

302, 519

9398, 9609

3461, 5718

10449, 11343

2343, 2362

7460, 8970

9070, 9377

6892, 7437

9633, 10426

2377, 3442

250, 264

547, 1973

1995, 2238

2254, 2327

31,191

132,820

48310

Discharge summary

report

Admission Date: [**2196-4-17**] Discharge Date: [**2196-4-27**] Date of Birth: [**2119-1-10**] Sex: M Service: CARDIOTHORACIC Allergies: Haldol / Halcion / Ambien Attending:[**First Name3 (LF) 1283**] Chief Complaint: SOB, lethargy Major Surgical or Invasive Procedure: [**2196-4-20**] - Sternotomy redo MVRepair (30mm Band)/CABGx1 (LSVG->PDA) History of Present Illness: 77 y/o male s/p CABG in [**2180**], w/progressive SOB. Echo revealed mod-severe MR, Cath: CAD, unsuccessful PCI > SVG to OM. Past Medical History: chronic systolic CHF AFib COPD GERD NSTEMI CRI HTN TIA BPH Claudication PVD elev. lipids s/p CABG X 3 Bilat. fem-[**Doctor Last Name **] Right CEA x 2 deviated septum repair s/p abd. hernia repair Social History: former smoker, quit [**12-1**] rare ETOH retired lives w/wife Family History: premature CAD Physical Exam: pre-op: General: frail, thin Lungs: bibasilar crackles Cor: SEM abd: abd. hernia extrem: 2+ edema Pertinent Results: [**2196-4-26**] 05:10AM BLOOD WBC-5.8 RBC-3.16* Hgb-8.5* Hct-26.4* MCV-84 MCH-26.9* MCHC-32.2 RDW-16.5* Plt Ct-152 [**2196-4-27**] 05:15AM BLOOD PT-12.4 INR(PT)-1.0 [**2196-4-27**] 05:15AM BLOOD Glucose-91 UreaN-58* Creat-2.1* Na-146* K-3.9 Cl-106 HCO3-28 AnGap-16 TECHNIQUE: Non-contrast head CT. FINDINGS: Well-defined hypodensity is noted of the parasagittal right frontal cortex and subcortical white matter consistent with acute infarction. A smaller area of hypodensity of the left parietal cortex and subcortical white matter is also consistent with acute infarction. There is no evidence of intracranial hemorrhage or mass effect. The cerebral sulci and ventricles are symmetric and age appropriate. The paranasal sinuses and mastoid air cells are clear. No osseous or surrounding soft tissue abnormality is seen. IMPRESSION: Acute infarction of the right frontal and left parietal lobes. Well-defined appearance of the areas of infarction suggest that infarction is over 24 hours old and not hyperacute. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 101770**] (Complete) Done [**2196-4-20**] at 11:55:51 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2119-1-10**] Age (years): 77 M Hgt (in): 66 BP (mm Hg): 134/67 Wgt (lb): 150 HR (bpm): 75 BSA (m2): 1.77 m2 Indication: Intraoperative TEE for redo CABG and AVR ICD-9 Codes: 427.31, 786.05, 786.51, 440.0, 440.20, 424.1, 424.0 Test Information Date/Time: [**2196-4-20**] at 11:55 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW2-: Machine: AW2 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: *6.5 cm <= 5.2 cm Left Ventricle - Ejection Fraction: 25% to 30% >= 55% Aorta - Ascending: *3.7 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec Aortic Valve - Valve Area: *2.3 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Elongated LA. Cannot exclude LAA thrombus. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Severe regional LV systolic dysfunction. Severely depressed LVEF. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Moderately dilated RV cavity. Focal apical hypokinesis of RV free wall. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Complex (>4mm) atheroma in the ascending aorta. Complex (>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral annular calcification. Moderate to severe (3+) MR. TRICUSPID VALVE: Mild [1+] TR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The rhythm appears to be atrial fibrillation. Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: Conclusions- Prebypass: 1. The left atrium is elongated. A left atrial appendage thrombus cannot be excluded. No atrial septal defect is seen by 2D or color Doppler. 2.There is severe regional left ventricular systolic dysfunction with hypokinesia of the apex , inferolateral, inferior and inferior septum. Overall left ventricular systolic function is severely depressed (LVEF= 25-30%%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 3. The right ventricular cavity is moderately dilated with focal hypokinesis of the apical free wall. 4.The ascending aorta is mildly dilated. There are complex (>4mm) atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. 6.The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. Dr. [**Last Name (STitle) 1290**] was notified in person of the results on [**2196-4-20**] at 1015 am. Post Bypass: 1. Patient is receiving an infusion of phenylephrine, milrinone and epinephrine. Patient is A paced. 2. LV systolic function is slightly improved. 3. Annuloplasty ring seen in the mitral position. It appears well seated. There is trivial mitral regurgitation. CHEST (PA & LAT) [**2196-4-27**] 9:14 AM CHEST (PA & LAT) Reason: evaluate for ptx [**Hospital 93**] MEDICAL CONDITION: 77 year old man with s/p mv repair REASON FOR THIS EXAMINATION: evaluate for ptx HISTORY: Previous pneumothorax, to evaluate for persistence. FINDINGS: In comparison with the study of [**4-26**], there is no longer any convincing evidence of pneumothorax. There is still evidence of pleural effusions, more marked on the left with elevation of pulmonary venous pressure in this patient who has undergone a previous CABG procedure. Brief Hospital Course: Admitted pre-operatively for IV heparin drip as pt. had discontinued his Coumadin in preparation for surgery. He was taken to the OR on [**4-20**], underwent a re-do sternotomy, CABG X 1, MV repair (please see operative report for details of surgical procedure). Post-operatively, he was taken to the CVICU, on propofol, epinephrine & milrinone drips. He woke up agitated, and self extubated on post-op day # 1. He weaned off vasoactive drips, and remained stable from a hemodynamic standpoint. As he woke it was noted that he did not appear to be moving his left arm or leg. A head CT was obtained, as was a neurology consult. The CT revealed a right frontal and left parietal stroke. Initially, he had a dobhoff tube placed for nutritional support. Once he was fully awake & alert, speech therapy re-evaluated him, and he was able to take po liquids, and ground or soft solid foods. He was started on anticoagulation at the request of the neurology service, continued on aspirin, and has remained hemodynamically stable. Central lines were taken out prior to transfer to the floor. A limited carotid u/s showed 80-99% stenosis so a vascular consult was obtained. Mediastinal chest tubes were taken out POD #5 and pleural tube POD #6. Repeat full carotid u/s on [**4-27**] showed bilateral 70-79% stenosis. He will need a CTA and follow up with vascular surgery. He was ready for discharge to rehab on [**4-27**]. Medications on Admission: duoneb 2.5/.5, combivent'', asa 81', bumetanide [**2-26**], plavix 75', fish oil, imdur 30', prevacid 15', calcitriol 1mcg weekly, toprol xl 25', coum 5, pravastatin 40', temazepam 30', nitroglycerin .4 prn. Discharge Medications: 1. Pravastatin 20 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO HS (at bedtime). 2. Tramadol 50 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 4. Temazepam 15 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO HS (at bedtime) as needed. 5. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6 hours). 6. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 10. Coumadin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 11. Bumetanide 2 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a day). 12. Combivent 18-103 mcg/Actuation Aerosol [**Last Name (STitle) **]: One (1) Inhalation twice a day. 13. Heparin 5000 units SC TID until INR therapeutic. 14. Acetylcysteine 600 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day: For CTA. 600 mg po twice daily for 2 doses prior to contrast administration and 600 mg po twice daily for 2 doses after contrast administration. . 15. Bicarb for CTA NaHCO3 150 mEq/L D5W at 3.5 ml/kg/hr beginning 1 hour before the imaging study, then NaHCO3 150 mEq/L D5W at 1.2 ml/kg/hr during the imaging study and for 6 hours after study Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: MR/CAD s/p MV Repair, CABG PMHx: afib, MI, CHF s/p CABG, PVD, R CEAx2, BLE angioplasty, lung nodule, CRI Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (STitle) **] 2 weeks. Dr. [**Last Name (STitle) **] 2 weeks. Dr. [**Last Name (Prefixes) **] (Cardiac Surgery) 4 weeks, [**Telephone/Fax (1) 170**]. Dr. [**Last Name (STitle) **] (Vascular Surgery) 2 weeks. CTA aortic arch/great vessels and neck to assess for carotid stenting on [**5-3**] at 4:30 pm in [**Hospital Ward Name 23**] 4 on [**Hospital Ward Name **], [**Telephone/Fax (1) 327**] . Nothing to eat or drink after 3 pm. Dr. [**Last Name (STitle) **] (Thoracic)in 1 month with repeat chest CT, [**Telephone/Fax (1) 170**]. Dr. [**Last Name (STitle) **] (Neurology) in [**7-3**] weeks, [**Telephone/Fax (1) 2574**] Completed by:[**2196-4-27**]

[ "443.9", "553.3", "E878.2", "V12.54", "428.22", "414.02", "V15.82", "530.81", "403.90", "440.0", "E878.1", "433.30", "285.9", "V45.82", "428.0", "434.91", "414.01", "600.00", "997.02", "427.31", "272.4", "433.10", "518.89", "496", "585.9", "998.0", "V45.89", "424.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.33", "36.11", "96.6", "39.64" ]

icd9pcs

[ [ [] ] ]

10260, 10290

6829, 8258

306, 381

10439, 10445

1001, 4771

852, 867

8516, 10237

6372, 6407

10311, 10418

8284, 8493

10469, 10735

10786, 11457

4810, 6335

882, 982

253, 268

6436, 6806

409, 537

559, 757

773, 836

80,656

173,439

7543

Discharge summary

report

Admission Date: [**2166-8-23**] Discharge Date: [**2166-9-4**] Date of Birth: [**2088-10-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor Last Name 10493**] Chief Complaint: fever, hypotension Major Surgical or Invasive Procedure: [**2166-8-23**] right IJ central venous catheter (has since been removed) [**2166-8-27**] left-sided PICC placement History of Present Illness: Mr. [**Known lastname **] is a 77y/o gentleman s/p L ORIF on [**8-16**] (POD 7), p/w temp 104.2 yesterday at rehab with hypotension. [**8-16**] underwent L ORIF of distal femur after falling from ladder. Pt had an uncomplicated hospital course and was d/c'd to [**Hospital3 **] on [**8-20**]. Last night pt had a fever of 104.2 with chills and hypotensive SBP 80s. Pt was taken to [**Hospital6 33**] and pressure in 90s. CXR done and concerning for R sided fluid collection, given Tylenol and transfered to [**Hospital1 18**]. Denies shortness of breath, chest pain or posterior leg pain. Cough started today, productive of non-bloody sputum. Pt admits to dizziness two days ago during rehab and standing up. Pain from surgical site tolerable. Also admits to foul-smelling urine and dysuria for the past 2-3 days and was told at [**Hospital1 **] that he has a UTI. Was not on antibiotics. ED course: slight crackles at lung bases. Triggered for bp 82/50. 100.9 temp. started vanco/cefepime. Right IJ placed and started on norepi 0.12mcg/kg/min. 98/59. HR 94. 99% on 2L, RR25 Past Medical History: 1. Osteoarthritis, bilat knees, s/p R TKA at the [**Hospital1 16549**] 2. history of atrial flutter, afib with an ablation procedure. 3. Moderate Aortic stenosis 4. Hypertension. He is tolerating his current medication. 5. Hyperlipidemia. 5. Chronic anxiety 6. Prostate cancer s/p resection [**2151**] 7. Skin cancer, R thigh CA 8. Hospitalization [**Date range (1) 27564**] for L femur fracture after falling off ladder, s/p ORIF Social History: He is a nonsmoker. He drinks alcohol socially and occasionally, about two or three drinks a week. Family History: nc Physical Exam: ADMISSION EXAM Admit Vitals: T 100.9. BP 98/59. HR 94. SAT 99% on 2L, RR25 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact DISCHARGE EXAM: VS: T98.4 afeb o/n 128/69, 110-120s/60s p100 80s R24 97% RA General: Alert, oriented, no acute distress, pleasant, cooperative HEENT: Sclera anicteric, MMM, EOMI, PERRL Neck: supple, no JVD CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur heard best at the apex, no rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, distended, bowel sounds present, no organomegaly Ext: L lateral leg with diffuse ecchymoses which extends to L lower back, staples intact, no d/c or bleeding, appropriately tender. Calves symmetrical, no tenderness. L foot 1+DP pulse, 2+ DP pulse R foot Neuro: CNII-XII intact, 5/5 strength upper/lower extremities on left, 3/5 strength in right UE with improved supination, strength worse with elbow extension (though improved) than elbow flexion, grossly normal sensation, gait deferred, no facial asymmetry GU: penile swelling, foley intact to gravity Pertinent Results: ADMISSION LABS: [**2166-8-23**] 02:55PM BLOOD WBC-19.9*# RBC-2.49* Hgb-8.2* Hct-24.9* MCV-100* MCH-33.0* MCHC-33.0 RDW-14.0 Plt Ct-256# [**2166-8-23**] 02:55PM BLOOD Neuts-89.0* Lymphs-6.8* Monos-4.0 Eos-0 Baso-0.2 [**2166-8-23**] 02:55PM BLOOD PT-12.8* PTT-28.3 INR(PT)-1.2* [**2166-8-23**] 02:55PM BLOOD Glucose-141* UreaN-25* Creat-0.8 Na-134 K-3.9 Cl-98 HCO3-27 AnGap-13 [**2166-8-27**] 04:25AM BLOOD ALT-200* AST-215* AlkPhos-256* TotBili-2.4* [**2166-8-23**] 02:55PM BLOOD Calcium-8.5 Phos-3.1 Mg-2.1 [**2166-8-23**] 03:06PM BLOOD Lactate-1.7 OTHER PERTINENT LABS: [**2166-8-28**] 03:47AM BLOOD ESR-120* [**2166-8-28**] 03:47AM BLOOD CRP-128.5* [**2166-8-31**] 06:10AM BLOOD VitB12-[**2154**]* Folate-GREATER TH [**2166-8-28**] 03:47AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE [**2166-9-3**] 05:03AM BLOOD Vanco-17.0 DISCHARGE LABS: [**2166-9-3**] 05:03AM BLOOD WBC-11.7* RBC-2.51* Hgb-7.9* Hct-25.1* MCV-100* MCH-31.7 MCHC-31.7 RDW-15.2 Plt Ct-548* [**2166-9-3**] 05:55AM BLOOD PT-25.6* PTT-38.9* INR(PT)-2.5* [**2166-9-3**] 05:03AM BLOOD Glucose-120* UreaN-13 Creat-0.9 Na-136 K-4.1 Cl-103 HCO3-28 AnGap-9 [**2166-9-3**] 05:03AM BLOOD ALT-51* AST-42* AlkPhos-212* TotBili-1.1 [**2166-9-3**] 05:03AM BLOOD Albumin-2.5* Calcium-8.3* Phos-3.6 Mg-2.3 ======================================== URINALYSIS: [**2166-8-23**] 03:20PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015 [**2166-8-23**] 03:20PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2166-8-23**] 03:20PM URINE RBC-1 WBC-5 Bacteri-NONE Yeast-NONE Epi-<1 [**2166-8-23**] 03:20PM URINE CastGr-4* CastHy-1* ======================================== MICRO DATA: [**2166-8-31**] URINE CULTURE - NO GROWTH [FINAL] [**2166-8-28**] BLOOD CULTURE x 2 - NO GROWTH [FINAL] [**2166-8-25**] BLOOD CULTURE x 2 - NO GROWTH [FINAL] [**2166-8-24**] BLOOD CULTURE x 1 - NO GROWTH [FINAL] [**2166-8-23**] URINE CULTURE - NO GROWTH [FINAL] [**2166-8-23**] 2:40 pm BLOOD CULTURE #1. **FINAL REPORT [**2166-8-26**]** Blood Culture, Routine (Final [**2166-8-26**]): STAPH AUREUS COAG +. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 27565**] FROM [**2166-8-23**]. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Aerobic Bottle Gram Stain (Final [**2166-8-24**]): Reported to and read back by DR. [**Last Name (STitle) **]. MORGANSTEIN ON [**2166-8-24**] AT 0550. GRAM POSITIVE COCCI IN CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2166-8-24**]): GRAM POSITIVE COCCI IN CLUSTERS. [**2166-8-23**] 2:55 pm BLOOD CULTURE **FINAL REPORT [**2166-8-26**]** Blood Culture, Routine (Final [**2166-8-26**]): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Aerobic Bottle Gram Stain (Final [**2166-8-24**]): GRAM POSITIVE COCCI IN CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2166-8-24**]): GRAM POSITIVE COCCI IN CLUSTERS. ======================================== ECG [**2166-8-23**] 2:15:40 PM Borderline sinus tachycardia with multiple premature atrial contractions and a single ventricular premature contraction. Incomplete right bundle-branch block. Early anterior R wave transition. Non-specific repolarization abnormalities in the inferolateral leads. Compared to the previous tracing of [**2166-8-16**] the rate is faster and now borderline tachycardic. Computed P-R interval is shorter and no longer prolonged. RSR' pattern is new in lead V1, suggesting incorrect right precordial electrode placement. Early anterior R wave transition is unchanged. T wave amplitude is improved in lead II, V3-V5. Atrial and venticular ectopy are new. Frontal plane axis is slightly less horizontal. ECG [**2166-8-24**] 8:53:20 AM Atrial fibrillation with rapid ventricular response. Compared to the previous tracing atrial fibrillation is new. Otherwise, similar findings are noted. ECG [**2166-8-27**] 11:27:30 AM Normal sinus rhythm. Incomplete right bundle-branch block. Isolated ventricular premature beats. Non-specific ST-T wave changes. Compared to the previous tracing of [**2166-8-25**] the patient is now in sinus rhythm. ECG Study Date of [**2166-8-29**] 12:02:22 PM Sinus rhythm with supraventricular premature depolarizations. Compared to the previous tracing P wave morphology now appears more homogeneous. CXR [**2166-8-23**]: Peripheral reticular opacities raise concern for underlying interstitial lung disease. No acute findings. CXR [**2166-8-23**]: AP supine portable chest radiograph obtained. There is interval placement of a right IJ central venous catheter with tip located in the superior vena cava. There is no pneumothorax. Otherwise, no change. ======================================== FEMUR (AP & LAT) LEFT [**2166-8-23**]: Post-ORIF changes of the left femur without signs of soft tissue gas. FEMUR (AP & LAT) LEFT [**2166-8-30**] The patient is status post open reduction and internal fixation of a left femur fracture, which is maintained in alignment with an intramedullary rod and interlocking screws. As compared to the recent study, the radiographic appearance of the hardware, the visibility and alignment at the fracture site, and adjacent soft tissue structures all appear similar to the previous study. There is no evidence of instrument hardware failure or convincing radiographic evidence of osteomyelitis. ======================================== CTA CHEST [**2166-8-23**]: 1. Left lingular segmental pulmonary embolism 2. Mild pulmonary edema. 3. Bibasilar opacities could represent superimposed infection. 4. Large right renal cyst. 5. Aortic mitral annular and coronary artery calcifications. ECHO [**2166-8-25**]: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. No discrete vegegation is seen (cannot exclude). There is severe aortic valve stenosis (valve area 1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is mild-moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Severe aortic valve stenosis. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Pulomonary artery hypertension. No discrete vegetation is seen (does not exclude endocardits if clinically suggested). Compared with the prior study (images reviewed) of [**2164-8-8**], the severity of aortic stenosis has progressed and pulmonary artery hypertension is now identified. Valve morphology is grossly similar. ======================================== MRI C/T/L-Spine w/ and w/o contrast [**2166-8-26**]: 1. Mid-cervical epidural enhancement and abnormal STIR hyperintensity in the lower cervical vertebral bodies. Taken together, in this patient with known recent bacteremia, fevers, leukocytosis and neck pain, these findings suggest osteomyelitis with epidural extension. There is no definite abscess as yet. 2. Numerous lumbar spinal findings, likely congenital, including diastematomyelia, a tethered cord and a fatty filum terminale. MRI C-Spine w/ and w/o contrast [**2166-8-31**] 1. Findings are suggestive likely of infection/septic arthritis involving the right C5-6 facet joint with adjacent soft tissue inflammatory changes and likely less than 5-mm cm fluid collection in the paraspinal region. 2. Epidural phlegmon posterior to the thecal sac from C2-3 to C7 level without epidural abscess. 3. Mild decrease in epidural enhancement anterior to the thecal sac in the cervical region compared to the MRI of [**2166-8-26**]. 4. Posterior soft tissue changes are unchanged compared to the prior study. No evidence of cord compression. ======================================== CT Head [**2166-8-26**]: 1. No evidence of acute intracranial hemorrhage. 2. Findings consistent with chronic ischemic disease. LIVER OR GALLBLADDER US [**2166-8-28**] 1. Unremarkable appearance of the liver with no hepatic fluid collection and no biliary dilatation seen. 2. No gallstones. The gallbladder is noted to be contracted. 3. Right pleural effusion. No ascites. 4. Two simple right renal cysts. Brief Hospital Course: Mr. [**Known lastname **] is a 77y/o gentleman with HTN and prior AFlutter/AFib s/p ablation, who is s/p L femur ORIF on [**8-16**] after sustaining fall from ladder, was discharged [**8-20**] to rehab and was transferred here from an OSH for septic shock in the setting of MRSA bacteremia and C-spine osteomyelitis. His stay was also notable for diagnosis and treatment of pulmonary embolism, RUE weakness that was likely related to the spine process, and urinary retention requiring foley catheter. He was initially stabilized in the MICU for 1 week, then he was then transferred to the floor and was ultimately discharged to rehab on hospital day 12. #. Sepsis/MRSA bacteremia: resolved. He was transfered to the MICU on Levophed in presumptive septic shock considering his hypotension and fulfilment of SIRS criteria with leukocytosis, fever, tachycardia, and tachypnea. He was followed by ID service. He was initially treated with Vancomycin and Cefepime, but after 5 days his Cefepime was discontinued given clinical suspicion for MRSA and the culture data revealing MRSA-positive blood cultures from admission (which subsequently cleared). TTE was negative for endocarditis. The most likely explanation is that he developed a post-op hematoma, which was complicated by infection and seeding of the blood stream. Subsequent blood cultures were negative and he was discharged on Vancomycin via PICC line for total ~6 weeks (proposed end day is [**2166-10-6**]). He will follow-up at [**Hospital 18**] [**Hospital 4898**] clinic for antibiotic management. #. Neck pain, RUE weakness: C5-C6 facet osteomyelitis. MRI C-spine [**8-26**] suggested osteo. Repeat MRI C-spine on [**8-22**] was initially concerning for worsened fluid collection/?phlegmon, but per review of the imaging, Ortho spine was not concerned for abscess. Per Neurology consult: "Patient has clinical right polyradiculopathy in essentially C5/6 levels (given LMN pattern weakness in C5/6 innervated muscles, reduced tone and dropped reflexes) which may well be related to the significant findings on his MRI which are concerning for an infective process involving the lower cervical region with possible septic arthritis without epidural abscess. His weakness is pretty profound however and should he not improve he may benefit from EMG to better delineate this." He will be treated with Vancomycin via PICC line for total ~6 weeks (proposed end day is [**2166-10-6**]). He will follow-up at [**Hospital 18**] [**Hospital 4898**] clinic for antibiotic management. He should have a repeat MRI in [**2-2**].5 weeks after discharge (as scheduled on d/c paperwork), which will be followed up by the Infectious Disease team. By the time of discharge, he still had significant RUE weakness but improved grip strength and supination. He will follow up with Neurology after discharge. #. Segmental PE: stable, now on Warfarin. He was on Lovenox prophylaxis after his ORIF, but on arrival to [**Hospital1 18**], he underwent CTA due to tachypnea tachycardia, elevated BNP, elevated troponin, and new right bundle branch block on EKG. He was found to have a left lingular segmental pulmonary embolism. Never became very hypoxic and he is comfortable breathing room air. He was bridged to Warfarin using a Heparin drip. He is being discharged on Warfarin with goal INR [**3-7**], for a proposed duration of at least 6 months (to be decided by PCP and Cardiologist). INR on the day of discharge was 2.3 and next INR should be checked tomorrow ([**9-5**]). #. Urinary retention: now has foley. He failed voiding trial and required straight cath x2; subsequent attempts to replace foley were unsuccessful. On [**8-31**], Urology was consulted and foley was placed. He should have a voiding trial on [**9-8**]. If it is preferred, this could occur at [**Hospital1 18**] Urology in Dr.[**Name (NI) 19910**] office [**Telephone/Fax (1) 3331**]. #. s/p left ORIF: stable. No issues this hospitalization; Orthopedic service was following along. Will follow up in Ortho Trauma clinic in ~1 week (as scheduled in d/c paperwork). He was evaluated by PT who recommended discharge to rehab. He is WBAT with walker. #. s/p SVT/AFib in the MICU: resolved. He does have a h/o AFlutter/AFib s/p ablation in the past but in the MICU he did have a few episodes of SVT that resolved with vagal maneuvers. One EKG does suggest AFib. He was started on Diltiazem and this was no longer a problem. [**Name (NI) **] is being discharged on Diltiazem ER 300mg daily. He should follow up with his Cardiologist, Dr. [**Last Name (STitle) **]. #. Elevated transaminases: resolving but still present. On arrival, had transaminitis to the 200's with TBili 2.5. Thought to be likely due to congestive hepatopathy either from low-flow or (resolving) shock liver. RUQ U/S was reassuring without e/o abscess or acute parenchymal changes. Hepatitis B and C serologies were negative. LFTs trended down and by the time of discharge, transaminases were 40-50 and TBili 1.1. Further workup of his mild transaminitis can be deferred to the outpatient setting. #. h/o HTN: BP is stable. While he was acutely ill in the hospital, his Lisinopril was held. He continues on Diltiazem, which was started this admission (see above). If his BP continues to be stable upon discharge, he could certainly be restarted on Lisinopril. #. Hyperlipidemia: stable. He was continued on Atorvastatin. #. Anemia: was transfused, then Hct was stable. Hct>40 before [**8-16**] surgery, but since has been in mid 20s. Per records, MCV usually in low 100s. [**Month (only) 116**] be chronic B12/folate deficiency anemia worsened by acute blood loss from recent surgery. B12 and folate were continued throughout course. He did receive 3u pRBC on [**8-24**] with subsequent Hcts stable. #. Anxiety/Insomnia: stable. He was started on Seroquel at bedtime as needed for insomnia. His Lorazepam was held as it was not needed this admission. #. Transitional issues -Follow-up: with ID/OPAT, Ortho Trauma, Cardiology, Neurology -Keep hip staples in until Ortho follow-up (scheduled) -He should have a repeat MRI 1 week after discharge (as scheduled on d/c paperwork); this will be followed up by ID -He is being discharged on Warfarin with goal INR [**3-7**], for a proposed duration of at least 6 months (to be decided by PCP and Cardiologist). INR on the day of discharge was 2.3 and next INR should be checked tomorrow ([**9-5**]). -He should have a voiding trial on [**9-8**]. If it is preferred, this could occur in [**Hospital 159**] clinic with Dr. [**Last Name (STitle) 9125**] [**Telephone/Fax (1) 3331**]. -Further workup of his mild transaminitis can be deferred to the outpatient setting. -Emergency contact: [**Name (NI) **] (daughter/HCP) [**Telephone/Fax (1) 27566**] -Code status: full code (confirmed) Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR and Rehab. 1. Acetaminophen 1000 mg PO TID 2. Ascorbic Acid 1000 mg PO DAILY 3. Atorvastatin 10 mg PO DAILY 4. Bisacodyl 10 mg PO DAILY:PRN constipation 5. Calcium Carbonate 500 mg PO TID 6. Cyanocobalamin 50 mcg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Enoxaparin Sodium 40 mg SC DAILY Duration: 12 Days [now completed] 9. FoLIC Acid 1 mg PO DAILY 10. Lisinopril 10 mg PO DAILY 11. Lorazepam 0.5 mg PO Q8H 12. Milk of Magnesia 30 mL PO Q6H:PRN constipation 13. Multivitamins 1 TAB PO DAILY 14. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN Pain 15. Polyethylene Glycol 17 g PO DAILY constipation 16. Senna 1 TAB PO BID 17. Thiamine 100 mg PO DAILY 18. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN fever, pain 2. Atorvastatin 10 mg PO DAILY 3. Bisacodyl 10 mg PO DAILY:PRN constipation pt may refuse 4. Cyanocobalamin 50 mcg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. FoLIC Acid 1 mg PO DAILY 7. Milk of Magnesia 30 mL PO Q6H:PRN constipation 8. Multivitamins 1 TAB PO DAILY 9. Polyethylene Glycol 17 g PO DAILY constipation hodl for loose stool 10. Senna 1 TAB PO BID:PRN constipation 11. Thiamine 100 mg PO DAILY 12. Diltiazem Extended-Release 300 mg PO DAILY 13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 14. Warfarin 5 mg PO DAILY16 please adjust level for goal INR [**3-7**] 15. Vancomycin 750 mg IV Q 12H [total of ~6 weeks, proposed end date is [**2166-10-6**], to be determined by ID/[**Hospital 4898**] clinic] 16. Quetiapine Fumarate 25 mg PO HS:PRN Insomnia 17. Pantoprazole 40 mg PO Q24H 18. Aspirin 81 mg PO DAILY 19. Ascorbic Acid 1000 mg PO DAILY 20. Calcium Carbonate 500 mg PO TID 21. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Hospital3 **] ([**Hospital **] Hospital of [**Location (un) **] and Islands) Discharge Diagnosis: PRIMARY sepsis MRSA bacteremia osteomyelitis pulmonary embolus SECONDARY hypertension s/p hip fracture 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 at rehab after your hip operation but were transferred to [**Hospital1 18**] because you were septic from MRSA bacteria in your blood. The bacteria might have caused an infection in the spine at your neck, which is probably related to the weakness you have in your right arm. You are being treated with IV antibiotics for a prolonged duration (~6 weeks). You should follow up with various specialists (appointments listed below). In addition to the infections, you were also found to have a "pulmonary embolus," or a blood clot in your lung. For this, you have been started on a blood thinner called Warfarin. We made the following changes to your medications: -START Vancomycin (total ~6 weeks, proposed end day is [**2166-10-6**]) -START Warfarin (goal INR is [**3-7**]) -START Seroquel as needed for insomnia -START Pantoprazole -START Aspirin 81mg for heart protection -START Diltiazem for heart rate control -STOP Lorazepam -STOP Oxycodone -STOP Lovenox -HOLD Lisinopril (you might be restarted on this as an outpatient) Followup Instructions: ORTHOPEDICS: When: THURSDAY [**2166-9-11**] at 9:50 AM With: [**Name6 (MD) 13978**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage RADIOLOGY (MRI) When: THURSDAY [**2166-9-11**] at 3:35 PM With: RADIOLOGY MRI [**Telephone/Fax (1) 590**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage NEUROLOGY: We are working on a follow up appt in the neurology department within the next 9-15 days. You will be called at rehab with the appointment. If you have not heard within 2 business days or have questions, please call [**Telephone/Fax (1) 44**]. CARDIOLOGY: Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Specialty: Cardiology Location: [**Hospital1 18**] - CARDIAC SERVICES Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 62**] We are working on a follow up appt within the next month with Dr. [**Last Name (STitle) **]. You will be called at the rehab with the appt. If you have not heard within 2 business days or have questions, please call [**Telephone/Fax (1) 62**]. PRIMARY CARE Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD Specialty: Primary Care Address: [**Known firstname **],STE 9A, [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 10492**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]

[ "415.19", "995.92", "482.42", "272.4", "V10.46", "730.28", "V43.65", "V10.83", "401.9", "998.12", "038.12", "788.20", "785.52", "285.1", "427.89", "427.31", "424.1" ]

icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

22225, 22352

13436, 20300

325, 442

22500, 22500

3808, 3808

23748, 25561

2138, 2142

21136, 22202

22373, 22479

20326, 21113

22683, 23330

4644, 13413

2157, 2826

2842, 3789

23359, 23725

266, 287

470, 1548

3824, 4358

4380, 4628

22515, 22659

1570, 2007

2023, 2122

55,115

107,516

29042

Discharge summary

report

Admission Date: [**2197-2-12**] Discharge Date: [**2197-3-4**] Date of Birth: [**2137-12-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3531**] Chief Complaint: Dyspnea. Major Surgical or Invasive Procedure: Inferior vena cava filter placement. History of Present Illness: Mrs. [**Known lastname **] (aka "[**Known firstname 17563**]") is a 59 year old lady with a history of breast cancer (s/p mastectomy) and PEs in [**2189**] who presented to an OSH ED on [**2197-2-12**] unresponsive after having a productive cough for five days. In the field, she had an O2 sat of 47%. In the OSH ED, CXR showed LUL PNA with T of 100.3. Initial labs were notable for CK 49, CKMB 12, TropI 0.06, ABG 7.31/78/19. She was started on CTX/Azithro for CAP and put on BiPAP and transferred to [**Hospital1 18**]. In the [**Hospital1 18**] ED, she was weaned to an NRB and maintained her mental status. She had hemoptysis but was guiac negative. CT showed large bilateral PEs. She received ASA 325mg PO x1, heparin IV, 1LNS, and albuterol and ativan for respiratory distress. Mrs. [**Known lastname **] was transferred to the MICU with VS 99.5, 94, 121/86, 12, 92%NRB. She was awake and responsive, but lethargic. She reported feeling fine but was unclear why her husband brought her to the hospital. In the ICU, on [**2-12**], her oncologist Dr. [**Last Name (STitle) 19**], was emailed about the possibility of Mrs. [**Known lastname **]' letrozole being responsible for her PEs. He wrote back saying OK to hold letrozole for now but that it was unlikely the etiology. Her IV heparin was changed to lovenox, and her diet was advanced, given her hemodynamic stability. She was nervous and sleepless most of the night, and called her sister repeatedly (who then called the unit). The patient appeared to be in opiate withdrawal, so oxycodone was increased but remained below her total home dose. On [**2-13**], Mrs. [**Known lastname **] still required 6L of NC to maintain O2 sat in low 90s. She remained very anxious about her narcotic regimen, so oxycontin 20 mg [**Hospital1 **] was added. Metoprolol was held in the setting of R heart strain; captopril 6.25mg TID was started because SBP increased to 160s. Her husband asked for narcotics for himself, and the house officer refused. On [**2-14**] she was going to be called out but was still requiring 5-6L O2. She also had a mechanical fall. She was very anxious about leaving the ICU. She improved overnight and was called out on [**2197-2-15**]. Vitals on transfer were: HR: 91, BP: 159/106, O2Sat: 91-97% on 2-3L NC. Past Medical History: Breast CA s/p left mastectomy in [**2193**] Chemotheraphy neuropathy, and resultant narcotics addiction Nephrolithiasis Chronic pain Depression/anxiety Pulmonary emboli in [**2189**] Social History: Drinks ~6 oz Vodka daily Smokes: [**12-12**] cigarettes daily for many years Lives with husband in [**Name (NI) 6687**] Narcotics abuse (prior to admission her PCP was prescribing [**Name9 (PRE) 16604**] 40mg PO QID) Family History: Mother had bilateral breast cancer. No other breast or ovarian cancers Father died at age 69. He had a history of arrhythmia She denies any other history of clotting disorders Her maternal mother died at age 69 of a brain aneurysm Her paternal grandmother died at age 45 from stomach cancer Physical Exam: (On admission) VS: 96.9 102/58 94 14 95% NRB; 91% 5L NC GEN: Tearful, alert and oriented, intermittently pausing during speech, overall comfortable appearing. SKIN: Red skin, worse with coughing HEENT: No JVD, neck supple, No lymphadenopathy appreciated CHEST: Wheezes in all lung fields, L sided rhonchi. CARDIAC: S1 & S2 regular without murmur, Left mastectomy ABDOMEN: Tender with guarding but not tense or rigid. Bowel sounds present. EXTREMITIES: Tender L calf, bilateral edema, warm without cyanosis NEUROLOGIC: Alert and appropriate, tearful. CN II-XII grossly intact. . (On discharge) Gen: NAD. Skin: some bruising on abdomen and upper extremities from enoxaparin injections. Chest: CTAB with no adventitious sounds. CV: RRR without murmurs. Abdomen: +BS, soft, nontender, nondistended (bruising as above). Ext: Resolving ecchymoses on left medial thigh/groin and posterior right leg. No edema, warm, well perfused. Neuro: A&Ox3, grossly intact. Psych: Anxious at times, but overall positive affect and goal directed thinking. Pertinent Results: Admission labs: [**2197-2-12**] WBC-8.3 HGB-14.7 HCT-45.0 [**2197-2-12**] NEUTS-78.5* LYMPHS-13.0* MONOS-7.6 EOS-0.6 BASOS-0.2 [**2197-2-12**] GLUCOSE-141* UREA N-13 CREAT-1.0 SODIUM-139 POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-31 . Discharge labs: [**2197-3-3**] WBC-8.3 Hct-36.2 Plt Ct-412 [**2197-3-3**] PT-19.4* PTT-102.6* INR(PT)-1.8* [**2197-3-3**] Glucose-134* UreaN-11 Creat-0.7 Na-138 K-3.8 Cl-101 HCO3-26 [**2197-2-22**] ALT-15 AST-29 LD(LDH)-220 AlkPhos-46 TotBili-0.8 . Relevant studies: [**2197-2-12**] Echo - Right ventricular cavity enlargement with free wall hypokinesis c/w pulmonary embolism. . [**2197-2-13**] Echo - Compared with the prior study (images reviewed) of [**2197-2-12**], right ventricular cavity size is smaller and free wall motion is more vigorous. . [**2197-2-12**] ECG - Sinus rhythm. There are non-diagnostic Q waves in the inferior leads. Non-specific ST-T wave changes. Compared to the previous tracing these findings are new. . [**2197-2-12**] CT Chest - 1. Bilateral, multifocal segmental PE, with significant clot burden resulting in right heart strain. Emboli are seen in vessels supplying the right upper, middle and lower lobes, and the lingula, with extension of embolic material into multiple peripheral vessels supplying both lungs. There are prominent subsegmental PE in vessels supplying the posterior left lower lobe. 2. Enlarged right ventricle and straightened intraventricular septum consistent with right heart strain. No pulmonary infarct at this time. 3. Heterogeneous peribronchovascular nodules in the left upper lobe, could reflect hemorrhage or infectious etiology. Unlikely to represent infarct. Recommend re-imaging after treatment for PE. . [**2197-2-13**] CXR - Portable AP chest radiograph was compared to chest CT from [**2197-2-12**]. The current study demonstrates known opacities in the left perihilar area consistent with known infection. Cardiomegaly is unchanged. Mediastinal position, contour and width are stable. There is no interval development of appreciable pleural effusion and there is no pneumothorax. Brief Hospital Course: Mrs. [**Known lastname **] is a 59 year old woman found unresponsive found to have large bilateral PEs and a LUL PNA. She was transferred from another hospital to [**Hospital1 18**] where she was admitted to the MICU on [**2197-2-12**]. She was transferred to the general medicine floor for several days and was discharged on [**2197-2-21**]. . # Pulmonary Emboli/Left thigh hematoma: The patient had extensive bilateral PEs with hypoxia intially requiring 5L NC. She remained hemodynamically stable throughout her admission. Underlying contributing factors include obesity, smoking, history of PEs, and malignancy. She may also have a hereditary coagulopathy. Heparin gtt was started in the ICU. LENIs were negative for DVT. Echo showed evidence of right heart strain and RV hypokinesis. When hemodynamics remained stable for several hours, heparin was switched to lovenox. Oxygen requirement improved to 3L NC prior to call-out to the medical service. On the medicine floor, Mrs. [**Known lastname **] remained stable and she no longer had an oxygen requirement by the week before discharge. Around [**2-20**] the patient developed a large left groin/thigh hematoma. On ultrasound on [**2197-2-21**] thigh u/s showed the hematoma to be 8 x 5 x 8 cm. She had a [**4-14**] point hematocrit drop, that intially remained stable but on [**2-24**], her hematocrit droppeed from 29 to 25. Her thigh was re-ultrasounded and at the time the hematoma measured 14 x 7.6 x 6.4 cm. Because of the hemaocrit drop and increasing size of hematoma, her lovenox was stopped. She had an IVC filter placed. Upper extremity ultrasound showed DVT in the distal left brachial veins. CT angiogram of the thigh showed no active extravasation of blood. From [**Date range (3) 69967**] she was off anticoagulation. Her hct was stable over these 3 days, so on [**2197-2-27**] she was started on a heparin drip, intially with low goal PTT of 50-70, her hct was stable, and goal was increased to 80. She was started on coumadin on [**2197-3-1**] 7.5mg the first day and then [**Date range (1) 26123**], she recieved 5mg coumadin. Her INRS: [**3-3**] 7am: 1.8 [**3-4**] 6am: 2.2 [**3-4**] 12pm: 2.6 She recieved 1 lovenox injection prior to leaving the hospital in order to completw 24 hour of overlap between therapeutic PT with heparin/lovenox. She was discharged with plan for 4mg coumadin until she ses her PCP on Tuesday [**3-7**]. Given her bleeding earlier in the hospital course, her goal INR is 2-2.5, and she was instructed to return to the hospital with any bleeding, lightheadedness, new hematoma formation. We have also made f/u appointments for Ms. [**Known lastname **] with pulmonary in [**Month (only) **] to follow up the PE and with Interventional radiology to remove the IVC filter (also in [**Month (only) **]). . # Pneumonia: The patient had evidence of a LUL PNA on outside hospital CXR, positive sputum. She was afebrile with no leukocytosis. Torso CT at [**Hospital1 18**] confirmed LUL PNA. Courses of ceftriaxone (7 days) and azithromycin (5 days) were completed. Blood and sputum cultures were negative. On Monday, [**2197-2-20**], Mrs. [**Last Name (STitle) **] had a fever of 101 degrees. She then had a nebulizer treatment and incentive spirometry to see if this reduced her temperature. She also had a repeat chest xray and blood cultures and urinalysis sent. All cultures were negative, and the fever was thought to be from the hematoma. . # COPD flare: The patient was started on prednisone 60mg daily burst and this was stopped after five days without consequence. She received standing ipratropium nebs Q6H and albuterol nebs PRN. As an outpatient she will likely need PFTs when she recovers from her acute illness. . # Alcohol/Opiate Abuse: The patient has a history of alcohol and opiate abuse to which she readily admits. Last drink was the day prior to admission. She was given thiamine/folate. She was on a CIWA scale with lorazepam and did not demonstrate any signs of withdrawal. She was intially given oxycodone 10 mg q4h as needed for pain control given high dose opiate use at home. She later demonstrated symptoms of withdrawal, and this was uptitrated to her total home dose of long- and short-acting opiates. On the medicine floor, she was restated on her home dose of oxycontin 40mg PO QID with good effect. On [**2197-2-22**], the patient was found to be unresponsive. She responded to narcan IV. On further questioning, her husband her brought her extra doses of Oxycontin from home, which she he had taken earlier that evening. Her head CT was negative. The patients oxycontin was held intially. On [**2197-2-25**] she showed signs of narcotic withdrawal-- crampy abdominal pain, tremor, diarrhea, nausea; so was started on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] scale, given 10mg PO oxycodone for [**Doctor Last Name **] >10. FOr the first few days, she required 10mgPO about 3 times a day. After several days on this regimen, she was was switched to 10mg PO Oxycodone twice daily standing. Then, on [**2197-3-3**], this was decreased to Oxycodone 5mg three times a day standing. The patient is intersted in detox programs, and is being dicharged with enough 5mg oxycodone pills to last her until her PCP [**Name Initial (PRE) 648**]. . # Breast Ca: history of breast CA, seen by Dr. [**Last Name (STitle) 19**], thought to be without recurrence. Letrozole was held given rare side effect of DVT. Dr. [**Last Name (STitle) 19**] was contact[**Name (NI) **] and agreed with stopping letrozole temporarily. . # Depression: Patient demonstrated considerable emotional lability. Paxil was continued. Social work was consulted. . # HTN: Mrs. [**Known lastname **] received her home dose of metoprolol during her stay. She was also started on lisinopril 5mg PO daily. Her pressures remained stable throughout admission. . # Chemotherapy Neuropathy: Neurontin was continued. Lasix was held given inital concern for hemodynamics. It was later restarted at her home dose without problems. . Code status was discussed and patient refused to decide code status. Thus, she remained full code. . CONTACT: [**Name (NI) 4906**] [**Name (NI) **] [**Name (NI) 23657**] [**Telephone/Fax (1) 69968**]; Sister [**Name (NI) **] [**0-0-**] Medications on Admission: Medications at home: Lasix 20mg PO daily Neurontin 600mg PO QID Letrozole 2.5mg PO daily Ativan 2mg PO QID Metoprolol XL 25mg PO daily Oxycodone 40mg PO QID Paroxetine 20mg PO daily ASA PRN Thiamine 100mg PO daily Discharge Disposition: Home Discharge Diagnosis: Bilateral pulmonary emboli. Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted to [**Hospital1 18**] from [**2197-2-12**] until [**2197-2-20**] for evaluation and treatment of your pulmonary embolism. You were in the medical intensive care unit for several days before being transferred to the general medicine floor. You were discharged on Monday, [**2197-2-20**]. The following addition was made to your outpatient medications: - Enoxaparin 150 mg/mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). - Lisinopril 5mg daily - Oxygen Followup Instructions: Please schedule a followup appointment with your oncologist, Dr. [**Last Name (STitle) 19**], within one to two weeks. . Please schedule a followup appointment with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **] within two weeks. Call [**Telephone/Fax (1) 52946**]. Completed by:[**2197-3-6**]

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Discharge summary

report

Admission Date: [**2163-10-14**] Discharge Date: [**2163-10-21**] Date of Birth: [**2079-1-17**] Sex: M Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Streptomycin / Citric Acid / Atenolol / Torsemide / Heparin Agents Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: fevers, vomiting, AMS Major Surgical or Invasive Procedure: None History of Present Illness: History of Present Illness: Mr. [**Known lastname 108855**] is an 84yo male with history of CAD s/p stenting, CHF (EF 55%), Afib, prior cardiac arrest and heart block s/p pacer/AICD placement, chronic trach, and recent MRSA bacteremia on vancomycin who presents from rehab with a one day history of fevers and vomiting, as well as AMS. Patient has had several recent admissions, including admission from [**Date range (1) 105469**] for PNA and MRSA bacteremia/sepsis. Was discharged to rehab on vanco, readmitted [**Date range (1) 20211**] for hematuria and GI bleed (blood in ostomy bag), and again readmitted [**Date range (1) 108857**] with persistent fevers and positive MRSA blood cultures. Source of MRSA bacteremia was unclear, and work-up during that time included TTE/TEE negative for vegetations on valves and cardiac pacer leads, and negative tagged WBC scan. PICC was removed and replaced. Patient discharged on planned 6 week course of vanco through [**2163-11-2**]. Hospital course also notable for pseudomonas and klebsiella UTI, treated with 7 day courses of cefepime and tobramycin. Patient had Foley changed during that admission. Was discharged back to [**Hospital1 100**] Senior Rehab. . Since discharge, has been noted to have worsening renal function requiring nephrology consult, and in this setting his diuretic regimen was held. Also had increasing SOB requiring pulmonary consult, with change in vent settings from pressure support to AC mode. Has had recurrent GI bleed requiring transfusion of 2 units pRBCs on [**2163-10-12**], and has been continued on PPI, sucralfate, and iron supplementation. Per report, usually responds to wife, but was less responsive over past 1-2 days. On day of admission had several episodes of vomiting, and per wife was febrile to 101. Sent to ED for further evaluation. . In the ED, initial VS were: 98.2 69 106/51 20 95% assist control. Labs notable for leukocytosis (WBC 14.2) with neutrophil predominance, Hct 26.3 (stable), Na 127, Cr 3.5 (baseline 1.4), lactate 1.2. UA suggestive of recurrent UTI. CXR showed moderate pulmonary edema with bilateral pleural effusions, and was similar to recent prior studies. Given LUE edema, ultrasound obtained which was negative for DVT. Patient received vancomycin and cefepime. Also got ASA given elevated trop of 0.2. ECG showed paced rhythm. Patient had 1L NS hung prior to transfer. VS prior to transfer 100.0 70, 112/82, 15, 99%. . On arrival to the MICU, patient nods yes when asked if he is in pain, but he cannot localize the pain. Appears comfortable when resting in bed, though uncomfortable when examined. . Past Medical History: Rectal cancer s/p excision and XRT ([**2157**]) CAD s/p stents (?[**2159**]) CVA in [**2150**] with residual right hand dysthesia Complete heart block s/p pacemaker H/o cardiac arrest (now with AICD) GI bleed secondary to angiectasias in the duodenum ([**1-/2162**]) s/p cauterization via EGD Atrial fibrillation, not on [**Year (4 digits) **] Systolic CHF (EF 40-45%) S/p Fall with multiple rib fractures ([**2163-6-23**]) MICU admission [**Date range (1) 108856**]/[**2163**] for hemoptysis, bleeding from trach Abdominoperineal resection [**9-/2157**] w/ [**Doctor Last Name **] Social History: Resident of [**Hospital 100**] Rehab; previously had lived in [**Location 745**] with his wife, now w some depression about moving out of their 42 year home. Has two children. Retired computer science professor. - Tobacco: 5 cigars daily for 30 years, quit [**2150**] s/p CVA - Alcohol: Previously [**1-16**] glasses/week, generally per wife "affects him quite a bit," changing his mood and making him sick - Illicits: [**Month/Day (2) 4273**] Family History: Father died in 80s from MI. Mother died in 80s from PE. No family history of colon, breast, uterine, or ovarian cancer. No family history of seizures. Physical Exam: ADMISSION EXAM: General: easily arousable to voice, frequently falls to sleep, oriented to person and place, unable to assess if oriented to time (could not interpret patient's answer), appears comfortable at rest HEENT: PERRL, EOMI, sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP 8-9cm, trach in place CV: RRR, normal S1 + S2, II/VI holosystolic murmur loudest at apex and radiating to axilla Lungs: bilateral rhonchi with scattered crackles, no wheezing Abdomen: bowel sounds present, soft, mildly distended, diffuse mild tenderness to palpation, suprapubic tenderness, ostomy bag in place GU: foley in place Ext: slighty cool, 2+ pulses, venous stasis changes, 2+ edema to knees bilaterally DISCHARGE EXAM HEENT: PERRL, EOMI, sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP 8-9cm, trach in place CV: RRR, normal S1 + S2, II/VI holosystolic murmur loudest at apex and radiating to axilla Lungs: bilateral rhonchi with scattered crackles, no wheezing Abdomen: bowel sounds present, soft, mildly distended, diffuse mild tenderness to palpation, suprapubic tenderness, ostomy bag in place GU: foley in place Ext: slighty cool, 2+ pulses, venous stasis changes, 2+ edema to knees bilaterally Pertinent Results: ADMISSION LABS [**2163-10-14**] 06:25PM BLOOD WBC-14.2*# RBC-3.15* Hgb-8.9* Hct-26.3* MCV-83 MCH-28.2 MCHC-33.8 RDW-15.4 Plt Ct-116* [**2163-10-14**] 06:25PM BLOOD Neuts-82.8* Lymphs-6.4* Monos-10.2 Eos-0.3 Baso-0.4 [**2163-10-14**] 06:25PM BLOOD PT-16.7* PTT-35.8* INR(PT)-1.5* [**2163-10-14**] 06:25PM BLOOD Glucose-108* UreaN-117* Creat-3.5*# Na-127* K-4.5 Cl-85* HCO3-28 AnGap-19 [**2163-10-14**] 06:25PM BLOOD ALT-52* AST-65* AlkPhos-258* TotBili-1.7* [**2163-10-15**] 02:26AM BLOOD Albumin-2.8* Calcium-8.4 Phos-3.5 Mg-2.2 DISCHARGE LABS [**2163-10-21**] 03:32AM BLOOD WBC-4.9 RBC-2.90* Hgb-8.2* Hct-25.5* MCV-88 MCH-28.2 MCHC-32.0 RDW-16.2* Plt Ct-108* [**2163-10-19**] 12:11AM BLOOD PT-16.1* PTT-36.1* INR(PT)-1.4* [**2163-10-21**] 03:32AM BLOOD Glucose-74 UreaN-96* Creat-2.7* Na-140 K-3.7 Cl-102 HCO3-23 AnGap-19 [**2163-10-20**] 03:02AM BLOOD CK(CPK)-21* [**2163-10-21**] 03:32AM BLOOD Calcium-8.4 Phos-4.9* Mg-2.0 MICROBIOLOGY [**10-14**] BLood Culture STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R DAPTOMYCIN------------ S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S [**10-14**] Urine Culture URINE CULTURE (Final [**2163-10-19**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. Sensitivity testing performed by Sensititre. Daptomycin = 1 MCG /ML. YEAST. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ 1 S DAPTOMYCIN------------ S LINEZOLID------------- 1 S TETRACYCLINE---------- =>32 R VANCOMYCIN------------ >256 R [**10-15**] Sputum culture [**2163-10-15**] 7:00 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2163-10-20**]** GRAM STAIN (Final [**2163-10-15**]): THIS IS A CORRECTED REPORT [**2163-10-16**] AT 3:00 PM. Reported to and read back by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 394**]. >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). [**2163-10-16**] PREVIOUSLY REPORTED AS. <10 PMNs and >10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2163-10-20**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. HEAVY GROWTH. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | KLEBSIELLA PNEUMONIAE | | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 16 I <=1 S CEFTAZIDIME----------- 32 R =>64 R CEFTRIAXONE----------- 16 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 8 I 2 S MEROPENEM------------- 8 I <=0.25 S PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ <=1 S =>16 R TRIMETHOPRIM/SULFA---- <=1 S [**10-16**] Sputum Time Taken Not Noted Log-In Date/Time: [**2163-10-16**] 2:50 am SPUTUM **FINAL REPORT [**2163-10-19**]** GRAM STAIN (Final [**2163-10-16**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2163-10-19**]): RARE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. RARE 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. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . YEAST. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S [**10-19**] Urine Culture [**2163-10-19**] 12:29 pm URINE Source: Catheter. **FINAL REPORT [**2163-10-20**]** URINE CULTURE (Final [**2163-10-20**]): YEAST. 10,000-100,000 ORGANISMS/ML.. [**10-15**] RUQ US RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in echotexture without focal lesions. There is no intrahepatic or extrahepatic biliary ductal dilatation. The normal CBD measures 5 mm in diameter. Again noted is a large gallstone, measuring 2.7 cm, in the non-fully distended gallbladder. The gallbladder wall is mildly thickened measuring up to 5 mm, nonspecific. There is normal hepatopetal portal venous flow. The enlarged spleen measures up to 16.6 cm. The visualized IVC, aorta and pancreas are grossly unremarkable. Trace ascites is noted. IMPRESSION: 1. Known cholelithiasis. 2. Mildly thickened gallbladder wall, unchanged and non-specific, could be seen in right heart failure, hypoalbuminemia or other liver disease. No ultrasound findings to suggest acute cholecystitis. 3. Splenomegaly. [**10-15**] LUE US IMPRESSION: No DVT left upper extremity with a left basilic PICC in place. [**10-16**] G-tube check REASON FOR EXAMINATION: Evaluation of the percutaneous gastrostomy tube with bleeding and leakage throughout the tube. AP radiograph of the abdomen after injection of contrast material through the percutaneous gastrostomy is noted. The contrast material is demonstrated in the stomach as well as in the duodenum and jejunum. No definitive evidence of extravasation is noted. If clinically warranted, correlation with cross-sectional imaging might be considered. Wound Care recomendations: Recommendations: 1. Follow pressure ulcer guidelines. Atmos Air. Turn q 2 hours. 2. Cleanse wounds with commercial wound cleanser. Pat dry. 3. Apply Aquacel ag to sacrum wound, cover with 4x4's and Soft sorb dressing, secure with Medipore tape. Change daily. 4. LLE anterior excoriation - cover with Adaptic dressing, place 4x4,and wrap with Kerlix. Secure with paper tape. Change daily. 5. No tape on skin. 6. Left Trochanter - apply Mepilex 4x4 to site, and change q3 days. 7. Cleanse scrotum and perineum area with Aloe Vesta foam cleanser daily. Pat dry. 8. Apply Critic Aid clear skin barrier ointment to scrotal tissue to protect from fluid exposure daily. Elevate scrotum to assist with edema. 9. Waffles bilateral feet. 10. Apply Aquaphor ointment to dry intact skin daily from pharmacy daily. Ostomy Care: LLQ, 1 [**1-18**]", red, flush, os at center, mucocutaneous junction intact, peristomal skin intact with large parastomal hernia. Pouched with [**First Name9 (NamePattern2) 93403**] [**Doctor Last Name **] [**Doctor Last Name **] one piece drainable, Dist # [**Numeric Identifier 24338**], Man # [**Numeric Identifier 20839**]. No-sting barrier wipe, Dist # [**Numeric Identifier **], Man # 3344. Nursing staff to change pouch q Monday and Thursday while her. Brief Hospital Course: 84yo male with extensive cardiac PMH, recent MRSA bacteremia, trach on chronic mechanical ventilation, and chronic foley catheter with recent pseudomonal/klebsiella UTI, who presents now from rehab with fever, leukocytosis, vomiting, and AMS in setting enterococcus and yeast UTI, [**Last Name (un) **], MRSA bacteremia, hematochezia, and Stage 4 sacral decubitus ulcer. . ACUTE ISSUES #. MRSA Bacteremia: Pt had recurrent MRSA bacteremia in the settting of vancomycin treatment. We are particularly concerned about endocarditis from [**Last Name (un) 3941**] given the refractory nature. However, removal of instrumentation is not an option per patietn and family wishes. Source of infection include sacral decubitous ulcer, UTI, ventilation. Pt does not have leukocytosis or fever. Chronic colonization likely. Complete bacterial clearance is unlikely in this setting. OUTPATIENT ISSUES - START Daptomycin indefinitely - PICC line in place, routine care . #. GIB: Pt presented with HCT drop and Bright red blood through ostomy. He received a total of 3 units pRBC blood transfusion. We temporarily stopped tube feeding the setting of GIB, and discontinued his aspirin. His HCT has been stable in the past 48 hours without transfusion. GI has been consulted, and did not feel that the benefit of osteostomy-scope outweighs its risk. OUTPATIENT ISSUES - CONTINUE tube feeding as scheduled - STOP aspirin and anti-platelets forever. - START pantoprazole 40 mg iv bid - CONTINUE ferrous sulfate, sucrafate . #. [**Last Name (un) **]: Pt presented with elevated Cr to 3.5 on admission with anuria. There was muddy brown cast on urine sedimentation, concerning for ATN in the setting of sepsis and tobramycin exposure. We gave him gentle fluid challenge, and his urine output recovered shortly afterwards. His creatinine decreased to 2.7 on the day of discharge. This may or may not ever go back down to his previous baseline. Regardless, he's not anuric and patient and family have refused initiation of dialysis. OUTPATIENT ISSUES - AVOID nephrotoxic medication - DISCONTINUE Lisinopril . #. Hematuria and UTI: Pt has indwelling foley catheter and presented with hematuria and positive UA. Urine culture was notable for VRE, fungus. We treated him with meropenem and fluconazole while he was in the MICU. He received bladder irrigation for hematuria. His hematuria resolved on the day of discharge. Pt was asymptomatic from his UTI. We felt it is impossible to completely treat his UTI. We decided to withdrawal treatment for now to minimize the hepatic and renal drug intoxication. . #. Decubitus ulcer: Pt has a Stage 4 decubitus ulcer over sacrum and left thigh. The pain from decubitous ulcer is his major concern while he was here. He was seen by wound care. They advise supportive care. OUTPATIENT ISSUES - Pleae CHANGE BODY POSITION every 2 hours - Please provide adequate pain management with lidocaine patch, fentanyl, oxycodone. . #. Positive sputum culture: Pt has trach tube. His sputum culture grew multiresistant klebsiella and pseudomonas. Pt remained afebrile, no leukocytosis, left shift or increased sputum production. We felt the complete irradiation was unlikey given his current clinical status and suspect he has permanent colonization. . CHRONIC ISSUES #. Chronic dCHF: Pt has diastolic CHF. We continued his beta-blocker for the need of rate control. We held his lisinopril in an hope of protecting his current kidney function. We held his aspirin in the setting of GI bleeding. We felt that active treatment for his CHF is less of a priority. OUTPATIENT ISSUES - DISCONTINUED Aspirin and all antiplatelet drugs - DISCONTINUED Lisinopril . #. Atrial fibrillation: Pt is AV paced on telemetry. Not on anticoagulation given history of GI bleeding. Rate controlled with carvedilol. OUTPATIENT ISSUES - Per our EP recommendation, they can disable the defibrillator function, while still keep AV pacing, if there is a need in the change of goal of care. . # Depression: Continue citalopram. . TRANSITIONAL ISSUES Pt declared a code status of DNR/DNI. Extensive discussion has occurred between family and care provider team on goal of care. In general, our understanding is that family would like continued conservative treatment, with no invasive procedure, including the use of pressors. We have conveyed clearly to the family that clinical improvement is unlikely in the current situation. Pt's family expressed concerns that patient has not been getting enough comfort care (ie skin, wound, pain). . The wife has expressed continued frustration with being transferred back and forth from rehab to the hospital. We assured her that the care provided to him at rehab is very good. In general, we'd try to limit the number of unecessary hospitalizations. We explained to the family, with the son present in the room, that the patient's condition is stable, but ultimately is declining. We explicity told them that things are probably as good as they'll ever be, and that in the future he will have a slow and steady decline. We are limited in interventions that can be done here in hospital and have conveyed that to his family. . . Medications on Admission: Acetylcysteine 100mg TID intratracheal Carvedilol 6.25mg [**Hospital1 **] Citalopram 20mg daily Docusate sodium 100mg [**Hospital1 **] Ferrous sulfate elixir 325mg daily Folic acid 1mg daily Lidocaine patch daily MVI daily Omeprazole 20mg daily Simethicone 80mg [**Hospital1 **] Sucralfate 1gm TID Fentanyl 12mcg patch Q72hrs Acetaminophen 650mg Q6H prn pain Albuterol inhaler 2 puffs Q4H prn SOB Psyllium 1 teaspoon TID Oxycodone 5mg Q4H prn pain Discharge Medications: OxycoDONE (Immediate Release) 5-10 mg PO/NG Q4H:PRN pain hold for sedation or RR <12 Citrate 25-50 mcg IV Q4H:PRN dressing changes Albuterol Inhaler 6 PUFF IH Q4H:PRN shortness of breath, wheezing Pantoprazole 40 mg IV Q12H Daptomycin 540 mg IV Q48H Acetaminophen (Liquid) 650 mg PO/NG Q6H:PRN pain Fentanyl Patch 12 mcg/hr TP Q72H last changed [**10-13**] @ 12:45 Sucralfate 1 gm PO/NG TID Simethicone 80 mg PO/NG TID Multivitamins 1 TAB PO/NG DAILY Lidocaine 5% Patch 1 PTCH TD DAILY FoLIC Acid 1 mg PO/NG DAILY Ferrous Sulfate (Liquid) 300 mg PO/NG DAILY Docusate Sodium (Liquid) 100 mg PO/NG [**Hospital1 **] Citalopram 20 mg PO/NG DAILY Carvedilol 6.25 mg PO/NG [**Hospital1 **] MVI daily Psyllium 1 teaspoon TID Acetylcysteine 100mg TID intratracheal Pt was administered the flu vaccine [**10-21**] Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: MRSA bacteremia with likely pacemaker colonization, multiple decubitus ulcers, ventilator dependence, acute kidney injury, gastrointestinal bleeding, urinary tract infection, chronic congestive heart failure. Discharge Condition: fair Discharge Instructions: Mr. [**Known lastname 108855**], It was a pleasure taking care of you in the intensive care unit. As you know, the blood stream infection is probably chronic and it would basically be impossible to cure of you that. We believe that your pacemaker is colonized with the bacteria, and it would be impossible to remove it. You also have a urinary tract infection, and you were bleeding somewhere in your intestines. Fortunately the bleeding stopped. You also have a chronic heart failure, which you are aware. Your kidney insufficiency may resolve, but it may not. You were also administered the flu vaccine while you were here. Followup Instructions: Continue with your regularly scheduled appointments as previously scheduled. There are no special appointments that you need to make specifically in regard to your stay here. You were administered the flu vaccine while you were here. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2163-10-22**]

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Discharge summary

report

Admission Date: [**2187-12-12**] Discharge Date: [**2187-12-19**] Date of Birth: Sex: M Service: HEMATOLOGY/ONCOLOGY HISTORY OF THE PRESENT ILLNESS: The patient is a 46-year-old male who is being sent her for management of metastatic melanoma. He is a 46-year-old man who was initially in the [**Hospital 29684**] Clinic at the [**Hospital1 18**] Department of Oncology regarding metastatic melanoma with mets to the brain who is status post craniotomy as well as gamma knife radiosurgery. The patient is status post local excision and sentinel node biopsy in [**2184-8-17**], status post needle biopsy with emergent craniotomy at [**State 792**]Hospital in [**2187-8-17**], status post gamma knife radiosurgery on [**2187-10-25**]. The patient initially presented in [**2184-8-17**] with a scab that did not heal. He went to his dermatologist who performed a biopsy and amelanotic melanoma at site of vaccination on his right shoulder was found. It was described as [**First Name4 (NamePattern1) 10834**] [**Last Name (NamePattern1) **] III with breast-low depth of 1.125 millimeters. A local wide excision and sentinel node biopsy was performed and a lymphoscintigraphy was performed on the morning of surgery which revealed no uptake in the nodal areas other than the right axilla. After this, the patient and his wife went to [**Name (NI) 86**] to get a second opinion at [**Hospital3 7778**]. His case was reviewed there and it was felt that currently no further therapy was indicated or needed. The patient did well and had no symptoms until [**2187-8-17**] when he began to develop memory lapses. His primary care physician recommended [**Name Initial (PRE) **] head CT and MRI of the head which was performed on [**2187-9-14**] which was an MRA and revealed a 2.8 by 2.8 by 3 cm left frontal hemorrhagic mass with a large vasogenic edemic area. A CT scan of the brain the next day confirmed a hemorrhagic mass in the left frontal region measuring approximately 3 cm in diameter. The patient had a needle biopsy and when this procedure was performed, a hemorrhage was found and an emergent craniotomy was performed. He recovered and on day number ten on hospitalization was taken to gamma knife for irradiation. Chest CT was performed on [**2187-9-25**] which revealed suspicious nodules on the right lung, one measuring about 1 cm in diameter, the other 8 mm. He was discharged to [**Hospital **]Hospital on [**2187-9-27**] on Decadron and Dilantin and currently has had no seizures. A few days prior to admission, the patient's wife states that he has had significant decline with increasing abdominal pain, low-grade fevers, and generalized body pruritus. He also has had night sweats, anorexia, episodes of nausea. He was seen in the Hematology/[**Hospital **] Clinic on [**2187-12-5**] and it was decided that the patient should present to the ED; however, he deferred and instead went home. At that time, he was given Benadryl and Megace. In the meantime, the patient had follow-up with a brain MRI at [**Hospital 792**]Hospital to ensure eligibility for the I-[**Doctor First Name **] trial. The Hematology/Oncology Department here was hoping to start him. A [**Doctor First Name 500**] scan was also arranged. The MRI was done the next day and was inconclusive for recurrence versus post gamma knife changes. A few days later, he started to develop shortness of breath, intermittent periods of confusion, generalized pain and restlessness. He was taken on [**2187-12-11**] to [**State **]Hospital where a spiral CT was performed to rule out pulmonary embolus. The patient was sent home with follow-up to see the Hematology/Oncology people here on [**2187-12-12**]. On the day of admission, shortly after waking up at 5:00 a.m., he had sharp stabbing pain which seemed to originate in his abdomen and spread upwards to his chest and neck. Per wife, the patient also appeared quite confused. He called out for his mother at one point and in conversation with [**Doctor First Name **], his wife, referred to the physicians as the adults. The patient has also noticed multiple subcutaneous lesions that have appeared over the last week and seem to be increasing in size and number every day. They are over his neck, scalp, and back. The patient came to the ER via ambulance. PAST MEDICAL/SURGICAL HISTORY: Per the above, but otherwise laparoscopic cholecystectomy in 11/00, tonsillectomy many years ago, and hernia repair in [**2181**]. Also, herniations of L5-S1. ADMISSION MEDICATIONS: 1. Dilantin 300 mg one p.o. q.a.m., 200 mg one p.o. q.p.m. 2. Zantac 150 b.i.d. 3. Decadron taper which was completed by [**2187-11-30**]. 4. Megace started on [**2187-12-6**]. ALLERGIES: The patient is allergic to codeine which produces esophageal spasm. SOCIAL HISTORY: The patient worked as an owner of a company which sells and repairs stretchers mostly of clinics or hospitals. He is the first licensed paramedic in the Common Wealth of [**State 350**]. He has a wife named [**Name (NI) **]. Two children, one 13 and one 8, who live in [**State 350**]. He is a nonsmoker. No ETOH since starting Dilantin. Previously one to three glasses of wine per week. The patient's wife is a lawyer. FAMILY HISTORY: No melanoma or skin cancer. Mother had a history of hypertension, thought to have recent brain aneurysm, currently hospitalized at [**Hospital6 **]. Parental grandfather had [**Name2 (NI) 500**] cancer. Maternal grandmother with stomach cancer and another relative on the patient's mother's side had breast cancer. PHYSICAL EXAMINATION ON ADMISSION: General: The patient is a well-appearing 45-year-old male in no acute distress. Vital signs: Temperature 97.0, pulse 83, blood pressure 120/70, respiratory rate 16, saturating 98% on room air. HEENT: Normocephalic, atraumatic. The extraocular movements were intact. The oropharynx was clear with dry mucous membranes. There was no scleral icterus. The oropharynx was clear. No lesions or exudates were noted. Neck: Supple with lymphadenopathy palpated in the left cervical area. No JVD. Heart: Regular rhythm with no murmurs, clicks, or gallops. Lungs: Clear to auscultation bilaterally. Abdomen: Good bowel sounds, soft, nondistended, tender to palpation in the lower quadrants bilaterally but primarily the left lower quadrant. Extremities: Free of any clubbing, cyanosis, or edema. Neurologic: Cranial nerves II through XII were intact. Strength was [**5-21**] throughout. Toes are downgoing. Skin is clean, dry, and intact. Scalp and back have subcutaneous nodules that are palpated. HOSPITAL COURSE: 1. METASTATIC MELANOMA: The patient was started on biochemotherapy which is off protocol consisting of IL-2, interferon, cisplatin, vinblastine, and dacarbazine. Given a drop of systemic progression, this was felt to be an appropriate approach. The patient started chemotherapy and tolerated it well. Initially during his hospitalization, however, and while getting chemotherapy, the patient developed temperature spikes and chest radiograph was consistent with a right lower lobe pneumonia. The patient was maintained on Levaquin. Otherwise, the patient had an episode of chest pain as well as desaturation down to the 80s on room air and placement of 100% face mask with overnight transfer to the unit for cardiopulmonary decompensation. The patient had a CTA of the chest which revealed the following: Pulmonary-no intraluminal filling defects and heart great vessels were unremarkable. A large anterior mediastinal mass is present which measures 6.2 by 3.7 cm. Second mediastinal mass was adjacent to the aortic arch and measured 1.6 by 1.4 cm and small pericardial effusion was noted. Two nodules were present in the right upper lobe, the largest measuring 15 by 9 mm. There are bilateral moderate sized pleural effusions and posterior dependent atelectasis. Focal area of consolidation is present in the right lower lobe. Pleural based lung density is present in the right lateral lung in the upper lobe which measures 1.0 by 1.9 cm. Rounded hypodensity noted in the spleen measuring approximately 1 cm in diameter. A nonspecific finding. Differential considerations include congenital versus traumatic versus neoplastic. No pulmonary embolism was found. The patient eventually was stable in room air once more. He was continued on Levaquin. Additionally, during his hospitalization, the patient's mental status worsened and the patient had evidence of facial droop. An MR of the head was performed and revealed the following: Status post left frontal craniotomy, an irregular peripherally enhancing mass extending from craniotomy into the left frontal white matter and the superior aspect of the left basal ganglia including caudate nucleus. There is thick irregular dural enhancement contiguous with the 5 by 5 by 4.5 cm mass. There is extensive surrounding edema involving more than anterior half of the centrum semi ovale and extending inferiorly into the left internal and external capsules, the left thalamus and left midbrain as well. There is effacement of the left cerebral sulci, deviation of the anterior septum, pediculum, approximately 1 cm to the right, early uncal herniation with deformity of the left midbrain, although the contralateral ambiens cistern and other basal cisterns are patent. The mass probably represents recurrent tumor given dural enhancement. In the appropriate clinical situation, necrosis might be suggested. There are additional less than 1 cm enhancing lesions consistent with metastatic disease. There is a 5 mm lesion in the anterior medial right frontal lobe with the [**Doctor Last Name 352**] white matter junction, an punctate lesion in the right frontal operculum, 2-3 mm lesion in the right temporal lobe, and a 7 mm lesion in the right aspect of the medulla. The medullary lesion is associated with edema. The right lateral ventricle is normal in size without definite enlargement of temporal [**Doctor Last Name 534**]. The third ventricle is partially effaced. The aqueduct and fourth ventricle are patent. The right cerebral sulci were normal in size for the patient's age. Given these findings, the patient was continued on his Dilantin and was started on Decadron. The patient was maintained on Decadron as well as Dilantin throughout his hospitalization. He completed his course of chemotherapy which he tolerated without further incidence. It should be noted that upon read of the MRI, the patient was initially started on Mannitol given that he did have evidence of herniation. The Mannitol was quickly weaned and the patient was continued on his Decadron as well as Dilantin. 2. GASTROINTESTINAL: The patient was maintained on IVF and p.o. intake when he was able to take p.o. 3. INFECTIOUS DISEASE: The patient was maintained on Levo. He additionally had evidence of cellulitis and was maintained on Keflex. His blood cultures were pending at the time of dictation. 4. FLUIDS, ELECTROLYTES, AND NUTRITION: Electrolytes were repleted p.r.n. The patient had a left subclavian for lines. 5. PROPHYLAXIS: He was on PPI and subcutaneous heparin. 6. CODE: The patient was a full code. 7. COMMUNICATIONS: Communication was with wife. Upon having the Hematology/Oncology physicians reevaluate the patient's MR, it was decided that the patient would benefit from palliative XRT. The patient was to initiate XRT at [**Hospital 792**]Hospital. This was set up by Dr. [**First Name4 (NamePattern1) 16212**] [**Last Name (NamePattern1) **] for follow-up there. DISCHARGE MEDICATIONS: 1. Compazine 10 mg one p.o. q. six hours p.r.n. 2. Zofran 8 mg tablets, one p.o. q. six hours p.r.n. for nausea. 3. Lomotil 2.5-0.025 mg tablet, one to two tablets q.i.d. p.r.n. 4. Dilaudid 2 mg, one to two tablets q. four to six hours for pain. 5. Keflex one tablet p.o. b.i.d. for ten days. 6. Levofloxacin 500 mg tablets, one tablet p.o. q.d. for ten days. 7. Colace 100 mg, one p.o. b.i.d. for constipation. 8. Senna 8.6 mg tablets, one p.o. q.d. p.r.n. constipation. 9. Protonix 40 mg, one p.o. q.d. 10. Dilantin 100 mg, one p.o. q. eight hours. 11. Dexamethasone 4 mg, two tablets p.o. q. four hours. FOLLOW-UP: The patient is to follow-up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] in the Department of Hematology/Oncology on [**2188-1-16**] at 3:30 p.m. and Dr. [**Last Name (STitle) **] at the Department of Hematology/Oncology on [**2188-1-16**] at 3:30 p.m. CONDITION ON DISCHARGE: Fair. He is stable on room air. He had no further deterioration of mental status. He tolerated minimal p.o. intake. Abdominal pain and other pain was well controlled. DISCHARGE DIAGNOSIS: Progressive metastatic melanoma with new mets to the brain and lung. DISCHARGE STATUS: The patient will be discharged to home with services. [**Name6 (MD) 6337**] [**Name8 (MD) **], M.D. [**MD Number(1) 6342**] Dictated By:[**Last Name (NamePattern1) 5843**] MEDQUIST36 D: [**2188-3-14**] 11:12 T: [**2188-3-15**] 22:47 JOB#: [**Job Number 50746**]

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icd9cm

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icd9pcs

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79,962

138,182

35921

Discharge summary

report

Admission Date: [**2137-11-30**] Discharge Date: [**2137-12-6**] Service: OTOLARYNGOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7729**] Chief Complaint: R neck and facial swelling Major Surgical or Invasive Procedure: 1. Incision and debridement right submandibular abcess 2. Teeth extraction History of Present Illness: Patient is a 84 yo female with a 1 week h/o of right neck swelling that has recently spread toward the right side of the face. Associated symtpoms included right gum tenderness around her right lower tooth (she has long history of odontogenic disease). She has trismus, but no respiratory distress or desaturation/stridor. Her PCP started her on oral ciprofloxacin starting on [**11-20**]. She went to an OSH ED the day of admission where a ncek CT with constrast showed a fluid collection in the submandibular space. She was treated at OSH IV unasyn and transferred to [**Hospital1 18**]. Past Medical History: CHF, hypothyroidism, Colon Ca, GERD, COPD, renal failure, vascular disease, abdominal aortic aneurysm (pt informs that last year it was ~4cm), iron deficiency anemia/?myelodysplasia (Hematologist is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (3) **]), HTN, colon resection for colon CA s/p laparotomy 1 month PTA Social History: No etoh, smoking, IVDA. Family History: NC Physical Exam: VS: 98 Gen: Pleasant, NAD, no stridor Eyes: EOMI Face: Slight edema of lower right cheek area NC/NP: Significant crusting with old blood anteriorly bilaterally with dry mucosa (pt reports she has been manipulating her nose and has nasal congestion. Normal nasopharynx. OC/OP: Trismus to ~ 1.5 cm (if with teeth) to ~2cm w/o gum to gum. The gum surrounding the one lower right tooth (anterior/lateral tooth) is very tender to palpation and is erethematous. Floor of mouth is edematous and soft Larynx/HP: The base of tongue is touching the epiglottis, the epiglottis is crip, airway is patent with normal vocal fold motion bilaterally, no significant pooling of secretions of hypopharynx. Neck: Edematous and erethematous indurated right submandibular area extending across midline anteriorly and spreading up toward the right cheek area. Pertinent Results: Labs: On admission [**2137-11-29**] 08:25PM BLOOD WBC-10.1 RBC-2.78* Hgb-8.1* Hct-25.4* MCV-92 MCH-29.2 MCHC-31.9 RDW-17.5* Plt Ct-152 [**2137-11-29**] 08:25PM BLOOD Neuts-44* Bands-3 Lymphs-22 Monos-1* Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-0 Promyel-1* Other-25* [**2137-11-29**] 08:25PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-1+ [**2137-11-29**] 08:25PM BLOOD PT-16.8* PTT-26.2 INR(PT)-1.5* [**2137-11-29**] 08:25PM BLOOD Glucose-101 UreaN-15 Creat-1.1 Na-129* K-3.6 Cl-96 HCO3-24 AnGap-13 [**2137-11-30**] 01:52AM BLOOD Calcium-7.7* Phos-5.0* Mg-1.8 [**2137-11-30**] 01:52AM BLOOD TSH-1.1 [**2137-12-5**] 01:42AM BLOOD Glucose-79 UreaN-17 Creat-0.8 Na-135 K-4.0 Cl-105 HCO3-24 AnGap-10 [**2137-12-4**] 05:48AM BLOOD ALT-15 AST-38 AlkPhos-55 TotBili-0.3 [**2137-12-5**] 07:12PM BLOOD Vanco-9.6* Imaging: CT sinus/face [**2137-11-30**]: 1. Extensive inflammatory changes in the right lateral and anterior neck with packing material/drain in place. Slightly limited by lack of IV contrast, but no discernable fluid collection. 2. Apical lucency about the left lower molar. No periapical lucency seen in the area of concern (right lower tooth). 3. Extensive sinus disease. 4. Cervical lymphadenopathy, likely reactive. Brief Hospital Course: Patient was admitted for a right submandibular abscess. She was preoped, consented, and underwent a right neck I/D on [**2137-11-30**]. Please Dr.[**Name (NI) 20390**] operative note for details. She tolerated the procedure well and was transferred to the SICU intubated. She was continued on unasyn. She returned to the OR the following day for teeth extraction. Please see Dr. [**Name (NI) 81605**] operative note for details. Again she tolerated the procedure well and was transferred to the SICU intubated without events. She was successfully extubated that evening. Patient was started on nasal irrigations. Her home medications were continued. Physical therapy was consulted to improve strength and mobility. She was anemic with a HCT in the low 20s. Her hematologist, Dr. [**Last Name (STitle) **], was contact[**Name (NI) **]. [**Name2 (NI) **] was alreeady aware of her blood smear findings suggestive of myelodysplasia and did not request any further workup or management during this hospital stay. On POD3 she was given 2uPRBCs with lasix and was transferred to the floor. Her hematocrit appropriately bumped to 28 and was stable in the high 20s prior to discharge. Her penrose drain was slowly backed out and removed on POD4. Culture sensitivities returned on POD4, showing MRSA. An ID consult was obtained at that time, recommending switching from unasyn to vancomycin and flagyl. A PICC was successfully placed on POD5. A vancomycin trough level was low at 9.6. We subsequently increased her dosing frequency from QD to [**Hospital1 **]. Another vanco trough should be checked prior to 3rd dose of new [**Hospital1 **] dosing regimen. Her first dose at [**Hospital1 **] interval was on [**2136-12-5**] at 0800. She is to receive IV vancomycin until [**2136-12-19**] (time of f/u in [**Hospital **] clinic). On POD7 she was transferred to a rehab facility in good condition. Please note that she will need to be set up for weekly lab draws (CBC, BUN/Cr, ALT/AST) to be faxed to [**Telephone/Fax (1) 432**] ([**Hospital **] clinic). Medications on Admission: Ciprofloxacin (since [**11-20**]), Toprol XL 100 qd, Levothyroxin 50mcg qd, procrit 400U q 2 weeks, Fe 325mg [**Hospital1 **], prilosec 20mg qd, ocean nasal spray, senna, Ca 500mg qd, albuterol neb TID Discharge Medications: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed. 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-6**] Sprays Nasal QID (4 times a day) as needed. 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 9. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 10. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous every twelve (12) hours. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. Nasal irrigation Saline nasal irrigations QID 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [**Location (un) **] House Nursing Home - [**Location 9583**] Discharge Diagnosis: Right submandibular abcess Discharge Condition: Good Discharge Instructions: Please call your doctor or go to the emergency room if you have a fever >101F, increased swelling/redness/discharge from your wound, difficulty swallowing, shortness of breath, chest discomfort, or any other concerning symptoms. You will need to be set up for weekly lab draws (CBC, BUN/Cr, ALT/AST), which should be faxed to [**Telephone/Fax (1) 432**] ([**Hospital **] clinic). Followup Instructions: Please make an appoitment to see Dr. [**Last Name (STitle) 1837**] in [**12-6**] weeks. Please go to your follow-up appointment with Dr. [**Last Name (STitle) **] (infectious disease) on [**2136-12-19**]. Please make an appointment to see your primary care physician [**Last Name (NamePattern4) **] [**12-6**] weeks. Please make an appointment to see your hematologist in [**12-6**] weeks. Please follow-up with your general surgeon at his request. Completed by:[**2137-12-6**]

[ "528.3", "285.9", "428.0", "530.81", "522.5", "V10.05", "496", "682.0", "244.9" ]

icd9cm

[ [ [] ] ]

[ "23.19", "83.09", "38.93", "83.39" ]

icd9pcs

[ [ [] ] ]

7356, 7444

3596, 5665

296, 375

7515, 7522

2320, 3573

7951, 8435

1439, 1443

5920, 7333

7465, 7494

5691, 5895

7546, 7928

1458, 2301

230, 258

403, 998

1020, 1382

1398, 1423

7,553

191,246

18322

Discharge summary

report

Admission Date: [**2161-10-7**] Discharge Date: [**2161-11-2**] Service: Neurosurgery HISTORY OF PRESENT ILLNESS: This is an 81 year-old female with a past medical history of hypertension transferred from an outside hospital with mental status changes and complaints of headache. The patient was found to have a cerebellar hemorrhage on head CT. The patient was transferred to [**Hospital1 1444**] and had a ventricular drain placed in the Emergency Department and was transferred to the Operating Room for craniectomy and evacuation of cerebellar clot. The patient was lethargic and unresponsive in the Emergency Department at [**Hospital1 69**] and was intubated. Blood pressures were greater then 200 systolic on admission. The patient's course in the Operating Room was unremarkable. Postoperatively, the patient was recovered in the surgical Intensive Care Unit. She was intubated and sedated. Blood pressures were in the 130s/60 postoperatively. Neurologically the patient had trace reactivity of her pupils and they were reactive bilaterally. ICPs ran between 10 and 12 immediately postoperatively. The patient had a positive corneal reflex bilaterally. She had a good cough and gag response. The patient's vent drain was set at 10 cm of water. The patient was given Decadron. Extremities flexed to pain bilaterally. Toes were upgoing bilaterally. Upper extremities were flaccid bilaterally. The patient was started on Ancef for ventricular drain coverage immediately postoperative. Central line was placed on [**10-8**]. Postoperative head CT revealed residual clot in the posterior fossa and fourth ventricle. The patient was neurologically improved off the sedation immediately postoperative. She was placed on fluid restriction on [**10-8**] to reduce swelling and was placed on Mannitol 15 mg q 4 hours again to reduce swelling. The patient's overall prognosis was discussed with the family who decided to make her a do not resuscitate on [**10-9**]. The patient was started on tube feeds on [**10-9**]. The patient was transfused 2 units of fresh frozen platelets on [**10-11**] for an INR of 1.5. Repeat head CT on [**10-12**] revealed no new hemorrhage or infarct. The patient continued to neurologically improve, but was still not following commands at that time. The patient spiked a temperature on [**10-14**]. The subclavian and central line was changed over a guidewire. The patient was pan cultured. The vent drain was increased to 15 cm of water on [**10-15**]. The patient's antibiotics were changed to Vancomycin. Gram positive cocci were found in the blood at that time. MRI performed on [**10-16**] revealed no evidence of infarction of the brain stem, but some flare changes in the left occipital parietal lobe. No change in ventricular size. The patient was found to have Methacillin resistant staph aureus in her blood for which she was continued on Vancomycin and Kefzol. The patient was found to have a sacral decubitus as well on [**10-17**]. The patient was extubated on [**2161-10-16**]. Code status was changed by family to full code status. Kefzol was discontinued. The patient was continued on Vancomycin for MRSA of the blood. The patient's respiratory status worsened on [**10-19**]. The patient was found to have a total lung white out on chest x-ray on the left. The patient was started on Levaquin for broad spectrum coverage. The patient's respiratory status continued to decline on [**10-21**]. She was placed on BiPAP in attempt to avoid reintubation. The patient was placed on aggressive chest physical therapy. Bronchoscopy was performed on [**2161-10-23**], which revealed thick white secretions bilaterally left worse then right and some blood clots. Her ventricular drain was increased to 25 cm of water. The patient was continued on fluid restriction on the [**2161-10-24**]. The patient was reintubated on [**2161-10-24**] secondary to respiratory distress. The patient was continued on Vancomycin and Levaquin. Mild hyponatremia was improving with fluid restriction. The patient received a transfusion of packed red blood cells on [**10-25**] for a low hematocrit. The patient's EBV was clamped on [**10-25**]. Repeat head CT done on [**10-26**] revealed no change in ventricular size status post drain clamping, so on [**2161-10-27**] the patient's ventricular drain was discontinued without difficulty. The patient had a PICC line placed on [**10-29**] for continued antibiotic administration. The patient was discontinued off of Vancomycin and continued on Levofloxacin. The patient underwent tracheostomy and PEG placement as well as repeat bronchoscopy on [**10-30**] without difficulty. The patient was placed on Fluconazole on [**2161-10-31**] for yeast in the urine. The patient was weaned to CPAP on the 11th and 12th, which she tolerated well. The patient had a third bronchoscopy performed on [**11-2**], which revealed bilateral secretions and mucous plugs. The patient continued physical therapy. The patient was following commands on [**11-3**] bilaterally in the upper extremities and wiggling toes bilaterally in the lower extremities. Vent trials were continued. At the time of discharge the patient was on Fluconazole 200 mg once a day on day five, Levofloxacin is day 13 out of 14, Tylenol prn, Colace 100 mg po b.i.d., Bisacodyl 10 mg prn q day, subq heparin 5000 units b.i.d., Desitin powder, Hydralazine 50 mg po q 6 hours, Hydralazine 40 mg intravenously q 8 hours prn, Miconazole, Albuterol inhaler prn, sodium 1 gram tablets po q day, Pepcid 20 mg po q day, Lopressor 25 mg po b.i.d., Lasix 20 mg po b.i.d. The patient is on a sliding scale insulin coverage. The patient is on Procrit weekly. The patient is neurologically stable at the time of discharge to rehab. The patient will require physical therapy and occupational therapy and chest physical therapy at rehab facility. [**Name6 (MD) 742**] [**Name8 (MD) **], M.D. [**MD Number(1) 743**] Dictated By:[**Last Name (NamePattern1) 50491**] MEDQUIST36 D: [**2161-11-2**] 09:21 T: [**2161-11-3**] 09:38 JOB#: [**Job Number 50492**]

[ "041.85", "431", "E879.8", "250.92", "996.62", "518.81", "507.0", "038.11", "276.1" ]

icd9cm

[ [ [] ] ]

[ "33.24", "38.93", "43.11", "96.04", "38.91", "01.39", "96.72", "02.2", "31.1" ]

icd9pcs

[ [ [] ] ]

126, 6178

46,057

188,769

11005

Discharge summary

report

Admission Date: [**2202-6-4**] Discharge Date: [**2202-6-10**] Date of Birth: [**2122-12-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 17865**] Chief Complaint: S/p arrest vs. syncope Major Surgical or Invasive Procedure: Intubation, Right IJ placement, axillary arterial line placement, History of Present Illness: Mr. [**Known lastname **] is a 79 y.o with hx ischemic cardiomyopathy, CRF, DM, PVD, afib d/c from [**Location (un) 620**] yesterday to [**Hospital1 **] admited for AMS change now p/w LOC. Yesterday, at 11:55 am while on bedpan, he was found unresponsive. Compressions were started and pt. "woke up" at 12:10pm. HR was irregular 108, BP 170/78, resp 18, sat 100% NRB. Per EMTS HR 52-73, BP 105-151/54-120, RR 188, 98% venti. . Of note, the patient was recently hospitalization from [**Date range (1) 2728**] for acute mental status change, confusion, disorientation and agitation. He was intubated until [**5-30**], with MRI without evidence of acute stroke, hemorrhage, encephalitis. Evaluated be neuro and ID in the setting of elevated INR. Spiked a fever during admission related to pneumonia. It was thought that the weakness was [**12-21**] bradycaria, poor PO intake and acute renal failure and/or vascular dementia EEG showed no seizures, TEE without thrombus or endocarditis. Cr improved with hydration and held off home Lasix at d/c. He had a mild troponin leak, 2D echo with improvement of EF, BB and CCB held. At d/c HR 60-70. 7/10 [**11-22**] MRSA from blood, PICC placed requiring 2 weeks of vancomycin. Because of a fever during the admission, started on Levofloxacin with plan to continue for 1 week post d/c for asp vs HCAP. During this stay he also had a GIB with coffee ground emesis, Hct stable, started PPI. RUQ U/S NL for elevated bili. . In the ED, he was febrile to 103.2 with hypotension (83/37) so he was admitted tot he MICU. In the ICU, he was briefly on vanc/zosyn for pneumonia, though the CXR was negative. He was then continued on the vanco/levo he was previously on from prior hospital stay. He remained hemodynamically stable in the unit. Past Medical History: - Aortic stenosis with AVR with a bioprosthetic (pericardial) valve - Coronary artery bypass graft times two with saphenous vein graft to left anterior descending and OM - Postoperative atrial fibrillation - Asthma - Diabetes mellitus - Gout - Hyperlipidemia - Hypothyroidism Social History: He lives at home until [**1-25**]. He was independent in his ADLs and IADLs, but family had noted decline in his mental status for the last few weeks prior to admission. No history of smoking, alcohol, or drug abuse. IN rehab since [**1-25**] Family History: Non-contributory. Physical Exam: VS: HR 91, BP 124/42, 95% on 2L, HEENT: elderly male, chronically ill appearing CV: +3/6 systolic murmur Lung: CTA b/l Abd: Soft, NT, ND, bowel sounds present Ext: no edema Pertinent Results: LABS: 137 | 111 | 13 / --------------- 60 3.5 | 21 | 1.3 \ . ALT 6 AST 17 AP 69 LDH 181 T. bili 0.8 . .. \ 9.9 / 7.9 ----- 264 .. / 31.8 \ . Diff: 67.8%, 20%L, 3.9%M, 7.1%, 0.5B . MICROBIOLOGY: [**6-4**] Blood Cultures x 2: pending [**6-4**] Urine Culture: pending [**6-5**] MRSA Screen: pending . STUDIES: . CXR: [**2202-6-4**] IMPRESSION: Despite the long interval since prior exam, there is marked stability in the radiographic appearance of the chest with no definite superimposed acute process. EKG. A. fib at 80 bpm, left axis deviation, LBBB, LVH, st elevations in V2 and V3, unchanged from priors. . TEE [**2202-6-2**] at [**Location (un) 620**]. IMPRESSION: Mildly reduced left ventricular systolic function. Biosprosthetic aortic valve well seated. No evidence of endocarditis on any valves. No significant valvular regurgitations noted. Left atrium moderately dilated with mild spontaneous echo contrast noted. Atherosclerosis of the descending aorta noted. Brief Hospital Course: In summary, Mr. [**Known lastname **] is a 79 year old with an ischemic cardiomyopathy, chronic renal failure, diabetes mellitus, peripheral vascular disease, tachy-brady syndrome who was admitted from rehab for bradycardic arrest versus syncope. He was monitored initially in the MICU because of concern for an out of hospital arrest. He was then transferred to the floor where he was observed for several days, but then became progressively tachycardic and hypotensive with concern for septic shock. He was ultimately intubated and on pressors. After he survived a PEA arrest in the MICU, a family meeting was held and patient was made DNR/DNI with no escalation of care. He passed away on [**6-10**] with his family at the bedside. Septic shock. Patient's source of infection was not clear. Possible etiologies included line sepsis (though PICC line was removed), pneumonia (though sputum cultures were negative), prostethic valve endocarditis (though he had no positive blood cultures and TTE at [**Hospital1 18**] was negative for endocarditis), c. diff (though stool cultures were negative here), abdominal source (patient had nausea and emesis with all meals). Patient had [**11-22**] blood cultures positive for MRSA on [**5-28**] at [**Hospital1 18**]-[**Location (un) 620**] with no clear source (?skin source) and he remained on vanco throughout the hospital stay. Additionally, he had stenotrophomonas and klebsiella in his sputum at [**Hospital1 18**]-[**Location (un) 620**] which was covered by the Levaquin he was being treated with on admission. In the MICU, his antibiotics were broaded to vanco/cefepime/flagyl/levaquin. NO infectious source was found. He required three pressors to maintain his blood pressure. On [**6-9**], he had a PEA arrest, but spontaneous circulation returned after administration of epinephrine, atropine, bicarbonate, and calcium. . Respiratory failure. Patient developed respiratory failure in setting of receiving fluid boluses for hypotension. He was ultimately intubated intubated for respiratory failure. ?Gastric outlet obstruction. Patient had emesis with meals for several days. A KUB shows significant gastric distention consistent with gastric outlet obstruction, but this resolved with NGT suction. . Syncope/ ?Cardiac arrest. Circumstances of the ?cardiac arrest prior to hospital admission were unclear as there is little documentation of the event. It was felt most likely to be vagal event as it occurred while on the bedpan. He reportedly received 15 minutes of chest compressions, but had no fracture ribs and did not receive medications during the "arrest". . Sick Sinus Syndrome. Patient had history of tachy-brady syndrome and was awaiting pacemaker placement prior to his death. All nodal agents were held during his hospitalization. Medications on Admission: Vancomycin 1 gram IV q. 24 until [**6-13**] Coumadin 2 mg 1XD simvastatin 20 mg p.o. daily prevacid 30 mg p.o. daily Ipratropium brombide/albut 0.5/3.0mg Q6H prn nebs aspirin 81 mg p.o. daily stop glyburide allopurinol 100 mg p.o. daily levofloxacin 750 mg p.o. or IV q. 48 hours clotrimazole 30% to both feet [**Hospital1 **] Xalatan eye drops (Latanoprost) 1 drop each eye HS Furosemide 20mg daily Lisinopril 20mg 1XD Insulin Humalog 100U/ml SQ s/s Lansoprazole solutab 30mg daily Levothyroxine 125 mcg daily Phosphorus 1 pkt TID Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Cardiac arrest Septic Shock Respiratory Failure Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "414.8", "585.9", "428.22", "780.2", "250.00", "785.52", "427.81", "995.92", "584.5", "578.0", "274.9", "276.7", "038.9", "427.31", "443.9", "244.9", "V45.81", "486", "263.9", "372.30", "V42.2", "428.0", "518.81" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7439, 7448

4006, 6825

339, 406

7539, 7548

3012, 3983

7604, 7614

2784, 2803

7407, 7416

7469, 7518

6851, 7384

7572, 7581

2818, 2993

277, 301

434, 2208

2230, 2508

2524, 2768

5,460

132,546

15087

Discharge summary

report

Admission Date: [**2118-9-7**] Discharge Date: [**2118-9-14**] Date of Birth: [**2064-3-12**] Sex: M Service: CARDIAC DISCHARGE DIAGNOSIS: Hodgkin's disease 30 years ago status post chemotherapy service, radiation therapy status post splenectomy. ALLERGIES: Codeine, penicillin. PAST SURGICAL HISTORY: Status post splenectomy. MEDICATIONS: Aspirin 325 mg p.o. q.d. HISTORY OF PRESENT ILLNESS: The patient is a 54 year old gentleman with history of Hodgkin's disease 30 years ago, smoking with complaints of one week of discomfort in mid sternum. Episodes occurred every day, mostly at rest, last 1-30 minutes, occasionally associated with left arm weakness and palpitation phoresis. Denies shortness of breath, paroxysmal nocturnal dyspnea, lower extremity edema. The patient never had similar symptoms before. The patient denied pain when exercising. On physical examination, pleasant, cooperative, in no acute distress. Blood pressure 101/81, pulse 102, rate 97% on room air. CV regular rhythm, tachycardiac. Chest clear bilaterally. Abdomen soft and nontender, nondistended. Extremities warm, well perfused, no edema. On discharge, white blood cells 16.4, hematocrit 49.4, platelets 450, sodium 139, potassium 4.8, chloride 103, bicarbonate 22, BUN 20, creatinine 0.7, blood sugar 100, CPK 140. Electrocardiogram; sinus tach at 101, left axis deviation, questionable ST elevation in V2 through V4. Chest x-ray was within normal limits. HOSPITAL COURSE: The patient was admitted to Medicine Service for rule out myocardial infarction. On admission his troponin went up to 7.2, 7.8, 8.2. MB fraction 7. The patient underwent cardiac catheterization on [**9-7**] which showed ejection fraction of 35 to 40%, anterolateral akinesis, inferoapical akinesis, inferior hypokinesis, left main coronary distal 70% stenosis, left anterior descending approximately 90% stenosis. Left circumflex 80% stenosis, ramus ulcerated proximal 80-90% stenosis. She is nondominant. Dermatology consult was also obtained for the patient's left ear from nodular mass on his left ear lobe which felt to be suspicious now and will biopsy at a later date. Preoperatively the patient's vital signs remained stable. The patient is pain free. No complaints. The patient was taken to an Operating [**2118-9-9**] and coronary artery bypass graft times three with saphenous vein graft to ramus and saphenous vein graft to left anterior descending, saphenous vein graft to ramus intermedius, saphenous vein graft to OM was performed. The operation went without complications. The patient had mediastinal tubes placed. The patient was transferred to Surgical Intensive Care Unit in stable condition. Postoperative day number one the patient was extubated without complications, afebrile. Vital signs were stable. Postoperative day number two, febrile, vital signs stable, increased dose of Lopressor. He was transferred to a regular floor. Postoperative day three afebrile, vital signs stable and ambulating, exercising with PT. The patient did have a couple of episodes of lower blood pressure and tachycardia up to 110. The patient did not tolerate Lopressor due to his low blood pressure approximately 80/40 but he remained asymptomatic for this episode. Postoperative day number four, the patient remained afebrile, vital signs stable. He is exercising with PT, no complications or active issues. Discussed the issue of ear lobe mass with Dermatology. They will perform a biopsy on [**9-13**] prior to patient discharge. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient is discharged to home. The patient should follow-up with Dr. [**Last Name (STitle) 70**] in six weeks for postoperative check. The patient should follow-up in two weeks. MEDICATION ON DISCHARGE: Zantac 250 p.o. b.i.d., aspirin enteric coated 325 mg p.o. q.d., Lopressor 75 mg p.o. b.i.d. DR.[**Last Name (STitle) **],[**Known firstname **] 02-358 Dictated By:[**Dictator Info 44053**] MEDQUIST36 D: [**2118-9-13**] 14:42 T: [**2118-9-13**] 14:55 JOB#: [**Job Number 44054**]

[ "414.01", "707.8", "305.1", "410.71", "V10.72" ]

icd9cm

[ [ [] ] ]

[ "37.22", "36.13", "39.61", "88.53", "88.56" ]

icd9pcs

[ [ [] ] ]

160, 303

1499, 3558

327, 393

3820, 4137

422, 1481

3583, 3805

32,175

131,224

53589

Discharge summary

report

Admission Date: [**2191-9-29**] Discharge Date: [**2191-10-2**] Date of Birth: [**2113-8-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1973**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Upper endoscopy History of Present Illness: 78M w/ history of a. fib, HTN, hyperlipidemia, and BPH presents with one week of intermittent upper abdominal "mild heartburn" and progressive weakness, and black stool. He reports that he normally walks [**1-4**] mile walk several times a week and has been more tired at the end of these walks during the days PTA. Furthermore, upon returning from his walk on [**2191-9-29**], he noted "black tarry stool". He denies any episodes like this previously nor does he endorse a history of bright red blood in his stool. He further denies prior ulcers or stomach problems of any kind. He takes ASA daily, but denies use of other NSAIDs. . Following the above episode on [**2191-9-29**], the pt. went to see his primary doctor who did a rectal exam. He was found to be guaiac positive and he was sent to the [**Hospital1 **] [**Location (un) 620**] ED. In the ED labs revealed initial hematocrit of 40.1 and an INR of 2.4. He received 2u FFP and had another black BM in the ED. A repeat hct was 34.6. At that time, the patient had an SBP in the mid 90s that responded to IVF and was in the 110s upon transfer to the [**Hospital1 18**] [**Location (un) 86**]. . Upon admission, NG lavage revealed coffee grounds. GI was consulted and an EGD was performed. The EGD revealed no active bleeding, but old blood in the stomach. An esophageal mass was noted and was biopsied. He received 2U prbcs, 2U FFP on [**2191-9-30**] and hct has been stable since that time. . ROS: negative for f/c/n/v, no cp, no sob, no HA, no visual changes, no hearing changes, no diarrhea prior to day of presentation, no cough, ? slight weight loss over last week. Past Medical History: - BPH - HTN - a. fib, on coumadin, but not on meds for rate control - Hypercholesterolemia **never had a colonoscopy** . All: penicillin-hives Social History: Lives at home with his wife of "52ish" years. Three children and 7 grandchildren all live near by. No tobacco. [**3-6**] drinks per week. Family History: non-contributory Physical Exam: Vitals: 97.3 130/60 84 18 97% RA General: WD, WN, NAD, pleasant man HEENT: OP clear, MMM Neck: supple, no LAD Car: S1, S2, RRR, +II/VI systolic murmur at RUSB Resp: CTAB, no w/c/r Abd: soft, nontender, non-distended, well healed RLQ scars Ext: no pretibial edema, DP 2+ bilaterally Neuro: A+OX3, CN grossly intact Pertinent Results: [**2191-9-30**] 12:50AM BLOOD WBC-9.3 RBC-3.22*# Hgb-10.6*# Hct-31.9*# MCV-99* MCH-32.8* MCHC-33.2 RDW-14.4 Plt Ct-149* [**2191-9-30**] 01:33PM BLOOD Hct-25.8* [**2191-10-2**] 01:03PM BLOOD Hct-33.3* [**2191-10-1**] 03:06AM BLOOD PT-17.2* PTT-25.2 INR(PT)-1.6* [**2191-10-2**] 07:25AM BLOOD PT-14.6* PTT-24.4 INR(PT)-1.3* [**2191-9-30**] 12:50AM BLOOD Glucose-130* UreaN-70* Creat-1.5* Na-141 K-5.4* Cl-112* HCO3-21* AnGap-13 [**2191-10-2**] 07:25AM BLOOD Glucose-104 UreaN-38* Creat-1.2 Na-141 K-4.1 Cl-108 HCO3-24 AnGap-13 [**2191-9-30**] 12:50AM BLOOD ALT-32 AST-20 LD(LDH)-158 AlkPhos-58 TotBili-0.4 [**2191-10-2**] 10:05AM BLOOD %HbA1c-6.2* . [**2191-9-30**] EGD: 1. There was heaped up mucosa noted at the GE junction 2. Old blood in the stomach body 3. Normal mucosa in the first part of the duodenum and second part of the duodenum 4. Otherwise normal EGD to second part of the duodenum Brief Hospital Course: 78M w/HTN and hyperlipidemia presenting with first episode of GI bleed -> hct from 40.1 -> 31.9. . # Acute Blood Loss Anemia secondary to Acute Esophagitis due to NSAIDs: Tarry stool and coffee grounds from NG lavage. His ASA and coumadin were stopped. EGD revealed esophagitis but no active bleed. Patient's Hct was closely followed and remained stable after receiving 2 units packed red cells and FFP. He was put on a PPI [**Hospital1 **]. At the time he left, his stool was brown and Hct stable. On discharge, he was given follow-up with GI and advised to watch for bloody or tarry stools. He also has never had colonoscopy and will need screening colonoscopy as an outpatient. Previously normal hct (last normal in [**3-/2191**] and initially normal on presentation to [**Hospital1 18**] [**Location (un) 620**]). Thus, is acute and appears [**2-4**] to GI blood loss. . # Acute Renal Failure: Pt. w/ baseline Cr approximately 1.1. Creatinine bumped to 1.5 and likely represented prerenal etiology as resolved with IVFs and more significantly after prbc and ffp transfusion. His BUN was elevated likely in the setting of GI bleed. At the time of discharge, his Cr was back to baseline. . # Hypertension - Benign: Given GI bleed, patient's antihypertensive meds were initially held due to worries of his bleeding. At the time of discharge, his ACE inhibitor was restarted. . # Atrial Fibrillation: Patient's CHADS2 score is 2; in the light of his gastritis with GI bleed, his coumadin was stopped. . # Hyperlipidemia: Continue statin at home dose. Medications on Admission: - ASA 81 qday - coumadin 5mg qhs - lisinopril 20 qday - zocor 20 qday Discharge Medications: 1. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day: Please discuss length of treatment with your GI doctor at the follow-up appointment. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: GI Bleed Secondary Diagnoses: Atrial fibrillation on coumadin, HTN Discharge Condition: Improved. Patient's hematocrit had been stable for almost 48 hours. He was not tachycardic, and his blood pressure was 110s-130s systolic. He was not dizzy or lightheaded when he stood up. He was no longer bleeding actively from his bowels. Discharge Instructions: You were admitted with a bleed from your gastrointestinal tract. Your aspirin and coumadin were stopped while you were here. You also had an endoscopy done and tissue was sent for pathology. 1. Please take all medications as prescribed. Do not take aspirin and coumadin until you are instructed to do so by a doctor. 2. Please attend all follow up appointments listed below. 3. Return to the hospital if you develop bright red bleeding from your rectum, lightheadedness, fevers, or any other concerning symptom. Followup Instructions: 1. Please call GI at [**Telephone/Fax (1) 463**] and ask for an appointment with Dr. [**Last Name (STitle) 2473**] in [**1-4**] weeks. It will help if you let them know you were seen by him during your admission. 2. Please call Dr. [**Last Name (STitle) 58**], your primary dotor, and arrange for an appointment in 2 weeks. Completed by:[**2191-11-13**]

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icd9cm

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icd9pcs

[ [ [] ] ]

5664, 5670

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281, 299

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2664, 3560

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2297, 2315

5266, 5641

5691, 5691

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5710, 5719

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46,641

102,672

41972

Discharge summary

report

Admission Date: [**2164-8-22**] Discharge Date: [**2164-8-30**] Date of Birth: [**2094-12-16**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: confusion, speech arrest Major Surgical or Invasive Procedure: right knee aspiration History of Present Illness: 69 yo M with hx HTN, HLD, afib not on anticoagulation, and [**Hospital 23051**] transferred from OSH as a code stroke after episode of confusion this afternoon followed by global aphasia. Per his wife he was in his usual state of health this AM and after lunch time (? 12:00) appeared confused after returning home from the grocery store without groceries and was wandering around the house. He kept saying "I don't know" in response to questions. He went to an OSH and there underwent a noncontrast CT head and then became globally aphasic and not responding to any commands and he was transferred here. Past Medical History: [] Cardiovascular - Atrial fibrillation (not on anticoagulatin), HTN, HL [] Endocrine - DM2, s/p thyroid surgery [] Renal - Chronic nephrolithiasis with CKD [] Gout Social History: No tobacco or illicits. Occasional beers on weekends (not daily). Family History: No strokes or seizures. Physical Exam: At admission: Gen; lying in bed, awake HEENT; jaw clenched CV; irreg, no murmurs Pulm; CTA anteriorly Abd; soft, nt, nd Extr; no edema Neuro; MS; Awake, but does not follow any commands or attempt to speak. CN; PERRL 4mm-->3mm, does not reliably blink to threat on left. Eyes conjugate in midposition. Does not track. Face appears symmetric. Motor; normal tone. able to maintain all limbs symmetrically and antigravity. Sensory; withdraws to pain, but more grimace on right than left with noxous arm stimulation Reflexes; toes mute b/l ______________________________________________ At discharge: awake, alert, intermittently confused, language fluent with intact comprehension, moving all 4 with full power, DTRs 2 and symmetric throughout Pertinent Results: [**2164-8-22**] 05:38PM WBC-9.7 RBC-4.13* HGB-12.9* HCT-36.3* MCV-88 MCH-31.1 MCHC-35.4* RDW-14.0 [**2164-8-22**] 05:38PM PLT COUNT-157 [**2164-8-22**] 05:38PM PT-12.6 PTT-25.9 INR(PT)-1.1 [**2164-8-22**] 05:38PM TSH-1.8 [**2164-8-22**] 05:38PM ALBUMIN-4.4 CALCIUM-8.7 PHOSPHATE-4.6* MAGNESIUM-2.2 [**2164-8-22**] 05:38PM cTropnT-<0.01 [**2164-8-22**] 05:38PM LIPASE-44 [**2164-8-22**] 05:38PM ALT(SGPT)-32 AST(SGOT)-31 LD(LDH)-209 ALK PHOS-91 TOT BILI-0.3 [**2164-8-22**] 05:38PM GLUCOSE-191* UREA N-39* CREAT-2.5* SODIUM-143 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-27 ANION GAP-16 [**2164-8-22**] 06:07PM URINE RBC-1 WBC-5 BACTERIA-FEW YEAST-NONE EPI-0 [**2164-8-22**] 06:07PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300 GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [**2164-8-22**] 06:07PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2164-8-22**] 09:04PM PHENYTOIN-13.8 . [**2164-8-27**]:JOINT FLUID JOINT FLUID ANALYSIS WBC RBC Polys Lymphs Monos NRBC Macro [**2164-8-27**] 14:44 [**Numeric Identifier 961**]* 3000* 88* 0 6 1* 5 Source: Knee JOINT FLUID Crystal Shape Locatio Birefri Comment [**2164-8-27**] 14:44 FEW NEEDLE I/E1 NEG c/w monoso2 . [**2164-8-27**] 2:44 pm JOINT FLUID Source: Knee. **FINAL REPORT [**2164-8-30**]** GRAM STAIN (Final [**2164-8-27**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2164-8-30**]): NO GROWTH. . IMAGING [**2164-8-22**]: CT Head without contrast: FINDINGS: Encephalomalacic changes are present in the right parietal and occipital lobes in the right MCA and PCA territories. There is no acute intracranial hemorrhage. [**Doctor Last Name **]-white matter differentiation remains preserved. The ventricles are normal in size and configuration. Overall, there is little change from the outside hospital CT performed three hours prior. Visualized paranasal sinuses and mastoid air cells are clear. Soft tissues of the orbits are within normal limits. Scout images demonstrate the endotracheal tube ending 3.5 cm above the carina and an OJ tube coursing towards the stomach although the tip is excluded from view. IMPRESSION: Encephalomalacic changes involving the right parietal and occipital lobes. No acute intracranial process identified. Little change since the outside hospital CT performed three hours prior. . [**2164-8-23**]: MR [**Name13 (STitle) 430**] Without Contrast: IMPRESSION: Acute infarcts in the distribution of the left posterior cerebral artery. Chronic right posterior cerebral artery infarct. Brain atrophy. . [**2164-8-22**]: Chest Radiograph: FINDINGS: AP supine portable chest radiograph is obtained. An endotracheal tube is seen with its tip located approximately 3.6 cm above the carina. The NG tube courses into the left upper quadrant with its tip just beyond the GE junction. Lung volumes are low with crowding of bronchovasculature, and no definite sign of pneumonia or CHF. No large pleural effusion or pneumothorax. Bony structures appear grossly intact. IMPRESSION: Appropriately positioned ET tube. OG tube may be advanced slightly for more optimal positioning. . [**2164-8-23**]: EEG: IMPRESSION: This 24 hour video EEG telemetry captured no pushbutton activations and 2 electrographic seizures with no clinical correlation on video. Occasional interictal sharp wave discharges were seen over the left frontal temporal admixed with theta and delta frequency slowing, consistent with a focus of epileptogenicity. The background rhythm demonstrated an 8 Hz maximal posterior predominant alpha rhythm intermixed with theta and delta likely related to a mild to moderate encephalopathy. . [**2164-8-22**]: ECG: Probable sinus tachycardia with first degree A-V block and atrial premature beats. Non-specific inferolateral ST segment depression and T wave changes. No previous tracing available for comparison. . [**2164-8-24**]: TTE: The left atrium is mildly dilated. The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . [**2164-8-24**]: Carotid Studies: Impression: Right ICA with stenosis <40%. Left ICA with stenosis 0%. . [**2164-8-26**]: CT Head Without Contrast: IMPRESSION: 1. Evidence of prior chronic infarction in the right parietooccipital region. 2. Focal ill-defined hypodensities in the left occipital region corresponding with areas of acute left PCA infarcts seen on recent MR study. 3. No new large acute territorial infarction. No hemorrhage or mass effect. . [**2164-8-26**]: Bilateral Knee Plain Films: FINDINGS: Due to swollen joints the patient is unable to internally rotate the knee. Mild soft tissue swelling. The presence of small effusions is likely. Bilateral mild degenerative changes in the femorotibial joint and severe degenerative changes in the femoropatellar joint. No evidence of fracture. No evidence of chronic inflammatory changes . [**2164-8-27**]: EEG: IMPRESSION: This EEG gives evidence mainly for an encephalopathic- appearing abnormality with background slowing and bursts of slowing with suppressive bursts. This would suggest widespread diffuse cortical, as well as subcortical, neuronal dysfunction. There are some asymmetric features suggesting attenuation of background posteriorly on the right and increased epileptiform interictal activity from the left temporal posterior frontal region suggesting there may be more isolated structural damage. . [**2164-8-27**]: ECG: Atrial fibrillation with a controlled ventricular response. Compared to the previous tracing of [**2164-8-23**] the ventricular response has slowed. The lateral ST-T wave changes are less prominent. Otherwise, no diagnostic interim change. . [**2164-8-28**]: EEG: IMPRESSION: This EEG gives evidence for mild to moderate diffuse encephalopathy with superimposed focal slowing over the right posterior quadrant and more significantly fairly continuously across the left temporal and, to a lesser degree, posterior lateral frontal region. The left temporal frontal area also exhibits intermittent interictal epileptic activity spontaneously and two short runs of unsustained but increased frequency discharges. Cardiac monitor continues to be abnormal. Brief Hospital Course: Brief Hospital Course: 69 yo M h/o AF (not on anticoagulation), HTN, HL, DM2, CKD from chronic nephrolithiasis p/w confusion, speech arrest, and convulsive seizure of unclear etiology. [] Seizure - The patient had an episode of confusion (answering "I don't know" to all questions) followed by speech arrest. He was subsequently able to follow commands but would not verbalize. While in the ED of an OSH and en route to a CT scanner, his jaw clenched and he reportedly had a convulsive seizure. He was sedated and intubated and transferred to [**Hospital1 18**] for further care. He was loaded with phenytoin. He had no lateralizing signs on his neurologic exam, and an EEG on [**8-23**] showed no seizure activity but did show intermittent left frontal and temporal sharp waves and intermittent diffuse slowing of the background rhythm. On MRI he was found to have a subacute left occipital-temporal ischemic stroke, likely the etiology of his seizures. He has had no further witnessed seizure activity but was monitored on LTM. He was extubated without difficulty and his mental status has cleared. LTM showed no seizures and it was stopped. On [**2164-8-26**] the patient was found on the floor and was unable to tell how he got there. Out of concern for seizure as the etiology, he was loaded with Keppra and placed on EEG for another 24 hours. Again the EEG failed to show any seizure activity. The phenytoin is slowly being tapered off and the patient is being continued on Keppra 1 g po bid. The patient's alertness level decreased initally when started on the 2 AEDs but has now improved since the phenytoin taper. He has follow up in [**Hospital 878**] clinic. [] Ischemic Stroke - The patient has evidence on his initial NCHCT of an old ischemic stroke affecting the right parietal and occipital lobes, but there were no signs of new areas of infarction. He subsequently had a NC MRI Brain on [**8-23**] which showed a left occipital-temporal ischemic stroke. He was started on warfarin and bridged with a heparin infusion. He is to be maintained at a goal INR of [**2-16**]. Currently his INR is 4.4 and please hold his warfarin until his INR is 2. [] Atrial Fibrillation - The patient was briefly bradycardic to the 40s overnight on [**8-22**] but this resolved. He was on aspirin but not on anticoagulation prior to this event. Throughout the rest of his stay the patient was restarted on his home medications but continued to have episodes of RVR. His diltiazem was increased to 90mg po qid and metoprolol was increased to 25mg po bid. Digoxin 0.125mg po daily was continued as well. EP was consulted and recommended that the digoxin be stopped as they did not feel it was helping. The metoprolol can be increased to tid if needed. The patient's heart rate remained primarily in the 80s on this regimen. Please continue him on telemetry at rehab to ensure he is stable on this regimen. He has an outpatient appointment with cardiology. [] Gout - After transfer to the floor the patient complained of right knee pain as well as minor left ankle tenderness. His home medication allopurinol had been held while he was in the ICU but restarted at transfer. These joints as well as his left knee were warm and swollen. Rheumatology was consulted who tapped the right knee and confirmed crystal proven gout in the joint. Given the large amount of pain the patient was in, we gave him IV steroids x 1 followed by a po prednisone taper. His pain is much improved. After he finishes the prednisone taper, please start colchicine 0.6mg po every other day (renal dosing) to help prevent future flares. He has follow up in [**Hospital 2225**] clinic. [] Hyperglycemia - While on the steroids for his gout flare, his blood sugars have been high. Please continue him on an insulin sliding scale until the prednisone taper is over. [] Chronic renal failure - we contact[**Name (NI) **] his PCP and confirmed that his recent Cr values range around 2.3-2.5. After this we restarted his previous dose of lisinopril per his PCP, 10mg po daily. Medications on Admission: Levothyroxine 50 mcq daily Indomethacin 50 mg TID PRN Sildenafil 50 mg PRN Doxazosin 2 mg daily Metoprolol succinate 25 daily Lisinopril 20 daily Allopurinol 100 daily Pravastatin 40 daily? (not clear which statin the patient was taking) Aspirin 81 daily Digoxin 0.125 mg daily Sodium Bicarbonate 650 TID Diltiazem 90 mg [**Hospital1 **] Atorvastatin 40 daily Discharge Medications: 1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 2. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) tab PO Q6H (every 6 hours) as needed for pain/fever. 3. insulin regular human 100 unit/mL Solution Sig: One (1) unit Injection ASDIR (AS DIRECTED): Insulin sliding scale. 4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-15**] Drops Ophthalmic PRN (as needed) as needed for dryness. 5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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 for Constipation. 15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 16. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 18. prednisone 20 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily) for 2 days: Please taper dose. Give 50mg po daily x 2 days, then 40mg x 2 days, then 20mg x 2 days, then 10mg x 2 days and stop. 19. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO QHS (once a day (at bedtime)) for 4 days. 20. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please hold until INR is less than 2. Goal INR [**2-16**]. 21. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 22. Metoprolol Tartrate 5 mg IV Q8H:PRN tachycardia > 120 hold if SBP<120. Please notify HO by text-page if givein IV MTP. 23. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO every other day: Please start after prednisone is complete. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: left PCA stroke seizures crystal-proven gout atrial fibrillation with RVR Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neurological exam: awake, alert, intermittently confused, language fluent with intact comprehension, moving all 4 extremities with full power. Discharge Instructions: It was a pleasure caring for you during your stay. You were admitted to the hospital for evaluation of your shaking and confusion episodes. These episodes turned out to be seizures. These seizures were coming from the left side of your brain and imaging shows that you had a stroke days to weeks prior on the left side of your brain as well. This damage caused by the stroke is likely the cause of your seizure events. Additionally the [**Doctor Last Name **] imaging showed that you suffered a right sided stroke months previously. -Your seizures were controlled with the help of an anti-seizure medicine. Please continue to take one of these medicines, Keppra 1 g by mouth twice a day. We are currently tapering off your phenytoin. Please take 100mg by mouth at bedtime until (last dose) [**2164-9-3**], then stop. - We have you on a blood thinner, warfarin (coumadin) to decrease the chances of stroke since you have atrial fibrillation. Your INR will have to be measured frequently by blood draws. Your goal INR is [**2-16**]. Currently your INR is high so we are holding the warfarin. Please restart taking 2mg by mouth at night once the INR is 2. Your dose of this medicine will likely change as you are being tapered off phenytoin, which is a medicine that affects your warfarin levels. -During your stay, your hospital course was complicated by atrial fibrillation with a difficult to control heart rate. We consulted the cardiology team, who recommended stop digoxin and continuing on diltiazem and metoprolol at this time. They do not currently feel that you would benefit from any other intervention at this time. -You had knee pain while in the hospital as well. The rheumatology team removed some fluid from your right knee and confirmed crystals present, consistent with a gout flare. Given the amount of pain you were in, we treated you with steroids to decrease the inflammation. Please continue to prednisone taper we have placed you on as written (50mg x2days, 40mg x2days, 20mg x2days, 10mg x2 days, and then stop). You should start taking colchicine 0.6 mg by mouth every other day after finishing this taper to prevent recurrent attacks. Please continue taking allopurinol 100mg by mouth daily. For the long term, you need to be consistently on allopurinol and your dose should be titrated as an outpatient to reach a uric acid level <6. This can be done by rheumatology. Please see them in clinic as scheduled. -While you are on the steroids, your blood sugar has been high. We have asked that you be monitored with a insulin sliding scale while you are on steroids. This can be discontinued afterwards. Followup Instructions: [**Hospital 2225**] clinic: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2164-10-4**] 3:00pm Cardiology clinic: Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2164-10-15**] 1:40pm, [**Hospital Ward Name 23**] Bldg, [**Location (un) **]. [**Hospital 878**] clinic: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2164-11-9**] 10:30, [**Hospital Ward Name 23**] Bldg, [**Location (un) **]

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icd9cm

[ [ [] ] ]

[ "96.04", "81.91" ]

icd9pcs

[ [ [] ] ]

15980, 16052

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339, 363

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Discharge summary

report

Admission Date: [**2199-3-6**] Discharge Date: [**2199-3-9**] Date of Birth: [**2134-9-9**] Sex: F Service: MEDICINE Allergies: Dilantin Kapseal Attending:[**First Name3 (LF) 9160**] Chief Complaint: Hyperkalemia Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 64 y/o F w/ ESRD [**2-21**] IgA nephropathy s/[**Name Initial (MD) **] failed CRT [**2173**] on HD (MWF) through LUE AVF since [**2193**] and recent MVR surgery in [**Month (only) **] [**2198**] presents to ED from rehab with diarrhea, nausea, and chills x2 days. Patient states she has been feeling unwell for 2 days. She has had approximately 14 episodes of diarrhea per day and these have become less frequent today. Also had nausea but no vomiting. Pt states she has been feeling more fatigued since these symptoms started and has had a nonproductive cough for 2 days. Also endorses chills and decreased appetite. She missed HD yesterday because she felt unwell. Denies lightheadednes, bloody stool, abdominal pain, chest pain, shortness of breath, palpitations, vomiting. She has been in rehab since her MVR surgery. . In the ED, initial VS were: T 98.6 P 73 BP 131/63 RR18 SaO2 91% 2L NC. Pt was initially satting in the 80s but improved with O2. K was 7.4 and EKG showed QRS 180 (prior 104). CXR was consistent with volume overload and suggestive of RML pna. Patient was given albuterol, 2g CaGluc, 10 U Insulin, 1 amp D50. After treatment, QRS decreased to 172. She was also given levoloxacin 750mg IV for pneumonia. Renal was consulted and recommended emergent HD for hyperkalemia with associated EKG changes. . On arrival to the MICU, patient states she felt better and her last BM was more formed. She was started on HD upon arrival to the unit. . On the floor, the patient has a slight headache, but otherwise is asymptomatic. Her nausea has resolved and her diarrhea is improved. Past Medical History: 1. Atrial fibrillation/flutter: first diagnosed in [**Month (only) **] [**2195**]. On coumadin 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 8. MVR in [**12/2198**] Social History: Originally from [**Country 65588**], single, used to live by herself in [**Location (un) 686**], and has no children. Has been in the rehab facility since late [**Month (only) **]. Ambulates w/walker at rehab facility. -Tobacco history: 10pyear hx, quit 25yrs ago -ETOH: rarely -Illicit drugs: denies Family History: 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: VS: 97.7, HR 80 BP 113/66 RR 25 SaO2 93% on RA. GEN: alert and oriented x3, NAD CV: RRR, II/VI soft diastolic murmur in 2nd L-IC space, w/ radiation to carotids LUNGS: bilbasilar crackles, R>L ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: thin, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: moving all 4 extremeties, no focal deficits Discharge vitals 98.4 bp126/70 p95 rr20 98% on Room air GEN: alert and oriented x3, NAD CV: RRR, II/VI soft diastolic murmur in 2nd L-IC space, w/ radiation to carotids LUNGS: bilbasilar crackles, R>L ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: thin, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: moving all 4 extremeties, no focal deficits Pertinent Results: [**2199-3-6**] 12:50PM BLOOD WBC-6.9 RBC-3.86*# Hgb-11.3*# Hct-35.5* MCV-92 MCH-29.3 MCHC-31.9 RDW-16.7* Plt Ct-255 [**2199-3-8**] 05:40AM BLOOD WBC-2.5*# RBC-3.66* Hgb-10.2* Hct-34.3* MCV-94 MCH-28.0 MCHC-29.9* RDW-17.3* Plt Ct-141* [**2199-3-8**] 05:40AM BLOOD Neuts-69.8 Lymphs-21.6 Monos-7.7 Eos-0.4 Baso-0.4 [**2199-3-6**] 03:33PM BLOOD PT-18.7* PTT-34.6 INR(PT)-1.8* [**2199-3-7**] 09:04AM BLOOD PT-36.2* PTT-150* INR(PT)-3.5* [**2199-3-8**] 05:40AM BLOOD PT-16.5* PTT-33.7 INR(PT)-1.6* [**2199-3-6**] 03:32PM BLOOD Glucose-95 UreaN-101* Creat-10.3*# Na-132* K-6.2* Cl-95* HCO3-18* AnGap-25* [**2199-3-8**] 05:40AM BLOOD Glucose-85 UreaN-21* Creat-3.7*# Na-136 K-3.7 Cl-94* HCO3-30 AnGap-16 [**2199-3-6**] 01:03PM BLOOD Lactate-1.8 Na-132* K-7.4* Cl-97 calHCO3-20* [**2199-3-6**] 3:34 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2199-3-8**]** MRSA SCREEN (Final [**2199-3-8**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. [**2199-3-8**] Chest X-ray INDICATION: Volume overload, pneumonia, assessment for interval change. COMPARISON: [**2199-3-6**]. FINDINGS: As compared to the previous radiograph, there is a minimal improvement of the reticular opacities. Otherwise, the widespread bilateral parenchymal opacities are unchanged. Unchanged small left pleural effusion, unchanged moderate cardiomegaly. Brief Hospital Course: 63 F w/ ESRD [**2-21**] IgA nephropathy s/p failed cadaveric transplant in [**2173**] on HD (TRS) through LUE AVF since [**2193**] who presented with nausea, vomiting, and diarrhea admitted to ICU for emergent dialysis for volume overload and hyperkalemia. The patient had resolution of her hyperkalemia and volume overload after HD and was transferred to the floor. . # Hyperkalemia: Patient was found to have K 7.4 with prolonged QRS and LBBB. Hyperkalemia felt most likely due to missing HD on day prior to admission. Underwent emergent dialysis with normalization of her potassium level and QRS narrowing back to baseline. She was hemodialysed on [**1-16**], and [**3-9**]. Plan for next HD session on [**2199-3-12**] to return to her normal T,Th,Sa HD schedule. . # Volume overload: Likely related to missing HD due to acute illness. On admission, weight was ~ 3kg higher than dry weight ~ 39.7 Kg. Patient underwent HD with 1.2 and 2.0 L in ultrafiltrate removed during first 2 inpatient sessions. Oxygen requirement of 2L was no longer needed after removal of excess fluid. Due to patient's anuria, she is dependent on HD and importance of maintening dry weight can not be emphasized more clearly. At discharge, she was at her dry weight of 39KG. . # Hypoxia: Oxygen requirement of 2L on admission. Due to chest x-ray suggestive of questionable right middle lobe pneumonia, was started on vancomycin, cefepime and levaquin in setting of report of chills and cough for 2 days prior to admission. RML opacity improved with fluid removal during HD on review of repeat films. Similar opacity on prior films has fluctuated with volume status. Given lack of leukocytosis and fever as well as resolution of oxygen demand after HD, antibiotics were discontinued upon transfer to the floor. She remained afebrile with minimal intermittant cough, felt to be non-infectious in nature. . # Diarrhea: Symptoms improved over hospital course. Given residence in rehab facility and transient course, likely viral in nature. Lack of fever or leukocytosis, and benign abdominal exam, made C. diff unlikely, so this was not checked. # s/p mitral valve replacement: Pt is on coumadin with goal INR 3-3.5. INR was subtherapeutic at 1.8. She was started on a heparin gtt to bridge and her coumadin was increased to 2mg with increase to supratherapeutic levels and subsequently held. She is being discharged on heparin gtt until she reaches therapeutic INR on Warfarin. . #Troponinemia: Likely related to renal failure in the setting of HD. Patient denies chest pain. EKG changes likely related to hyperkalemia. Baseline trop is 0.4. She was continued on her home baby aspirin. . # HLD: Continued statin. . # Afib: Currently in sinus rhythm. Continued Amiodorone. . # Depression: Continued Celexa. TRANSITIONAL ISSUES: * INR - GOAL 3.0-3.5 for mechanical valve. On heparin gtt, warfarin dosing titrated on daily basis as she is very sensitive to slight changes in dose. * ESRD - Resume Tuesday, Thursday, Saturday HD schedule. On renagel, sevelamer, and sensipar * Cardiovascular - restarted low-dose carvedilol, should be given after HD on HD days. * Goal dry weight is 39kg, which was her weight on discharge. Medications on Admission: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 3.ASA 81 mg QD 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Bisacodyl 5mg QD 7. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. Sensipar 30mg Tablet Sig: One (1) Tablet PO once a day. 9. Coumadin dose unknown 10. Nephrocaps 11. Pravastatin 80 mg QD 12. Trazadone 50mg PO Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for SBP<100 or HR<60. Do not give prior to HD. 7. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. 8. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for sbp<100. 10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 13. Senna Concentrate 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. 14. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 15. warfarin 1 mg Tablet Sig: 1-2 Tablets PO Once Daily at 4 PM: Variable dosing based on INR. 16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever/pain. 17. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 18. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: Eight [**Age over 90 1230**]y (850) units/hour Intravenous continuous infusion: HEPARIN PER INSTITUTIONAL POLICY. Discontinue after INR 3.0-3.5. 19. epoetin alfa Injection at dialysis Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: Hyperkalemia Subtherapeutic INR 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 due to electrolyte abnormalities after you missed a dialysis session due to a gastrointestinal illness. Here, you underwent urgent HD to correct your high potassium and signs of fluid overload. You tolerated the dialysis fine and will continue your Tuesday, Thursday, Saturday schedule. Also, we saw that your coumadin level was low while you were here. We gave you an extra dose of coumadin and you will have to continue close monitoring of the INR at rehab. We also added low dose Coreg back to your regimen. Followup Instructions: Once discharged from rehab facility, please schedule an appointment to see your PCP. [**Name10 (NameIs) 30236**] scheduled appointments at [**Hospital1 18**]: Department: CARDIAC SERVICES When: FRIDAY [**2199-4-12**] at 3:00 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**] Completed by:[**2199-3-9**]

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

11069, 11112

5481, 8276

287, 301

11188, 11188

4083, 5458

11908, 12496

3041, 3180

9297, 11046

11133, 11167

8718, 9274

11339, 11885

3195, 4064

8297, 8692

235, 249

329, 1929

11203, 11315

1951, 2705

2721, 3025

29,509

156,656

3924

Discharge summary

report

Admission Date: [**2121-6-6**] Discharge Date: [**2121-6-14**] Date of Birth: [**2052-5-18**] Sex: M Service: MEDICINE Allergies: Bactrim Ds / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 7651**] Chief Complaint: Dyspnea, hypotension, anemia, guaiac positive stools Major Surgical or Invasive Procedure: 1. Cardiac catheterization - one of your coronary arteries was expanded with a balloon to improve blood flow to your heart. No stents were placed. 2. Upper endoscopy (EGD) - no abnormalities were noted in your esophagus, stomach or duodenum 3. Colonoscopy - diverticuli (little out-pouchings) were observed in the wall of your colon. These are very common. Occasionally they can bleed and they may have been the cause of your recent GI bleed, although they were not noted to be bleeding during the colonoscopy study. History of Present Illness: 69M with PMHx significant for MDS, prior ETOH abuse, CAD and systolic CHF (EF 40%) who presented to the ED from his hematologist's office with hypotension, dyspnea, anemia and guaiac positive stools. He complained of worsened dyspnea and his BP was noted to be 87/52, he had black guaiac positive stool on exam. He was given a 250cc NS bolus in the office and referred to the ED. In the ED his VS 85/38 HR 57 RR 18 98.1 99% 2L NC. He was again found to have gross blood on rectal exam at that time. His hematocrit was 24.4 down from recent baseline of 29-30. He had 2 PIVs placed and was given 40mg IV protonix, 1500cc NS, and 1unit PRBCs. NG lavage clear. GI and surgery were consulted. . On ROS he reports having chronic progressive dyspnea for the past 8 months, however he notes that his dyspnea has worsened over the past 1-2 weeks with approximately 4 days of darker stools. These symptoms are associated with decreased energy. He denies lightheadedness or syncope, no nausea, vomiting or hematemesis. No abdominal pain, diarrhea or constipation. He has not had chest discomfort; his anginal equivalent seems to be jaw pain which he will have regularly for which he uses nitro patches and he has noticed an increase in these symptoms lately. No orthopnea or PND. No recent weight gain or increase in LE edema. No recent EtOH or NSAID use. No prior history of GI bleeding or GERD. He reports recent medication changes were an increase in his furosemide in [**3-/2121**] and an increase in his lisinopril from 5 to 10mg last month. Unsure of 'baseline' BP number, states he knows it has been low lately. At last PCP visit was 90/40, prior values for past two months from office visits 120-130s. At time of arrival to the MICU his VS had improved with BP 115/49, he stated he felt like he had more energy after receiving a unit of PRBCs. Denied any pain. Rest of review of systems was negative in detail. Past Medical History: CAD s/p CABG (5-vessel at [**Hospital1 2025**] in [**2098**]) -- CABG: LIMA --> LAD, SVG --> distal RCA, and SVG --> D1, OM1, OM3 -- Cath: [**2120-3-4**]: 1. Short LM with minimial luminal irregularities. 2. Mid LAD chronic total occlusion. Diag with diffuse disease and proximal 75% focal stenosis. 3. Native LCX with 80% mid stenosis. 4. Chronically occluded RCA. 5. Patent LIMA to LAD. 6. SVG to D1 to OM1/OM2 occluded. 7. SVG to PDA 80% proximal and distal stenosis, stented successfully CHF, systolic and diastolic dysfunction Atrial fibrillation Stroke Carotid stenosis Chronic renal insufficiency, baseline cr 1.5 Hypercholesterolemia Subclavian stenosis Anemia (B12 deficiency) Alcoholism Hypogonadism Osteoarthritis Myeolodysplastic syndrome Social History: 25 pack year tobacco, quit 24 years ago. Quit alcohol 26 years ago. Lives with girlfriend in [**Name (NI) **]. Divorced with three children with ex-wife. Family History: Family history non-contributory. Physical Exam: Vitals: T:96.5 BP:115/49 P:59 R:12 O2: 100% RA General: Alert, oriented, no acute distress HEENT: Pale conjunctiva. MM moist. Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, [**1-3**] late systolic murmur, no rads to carotid appreciated. PPM in place, s/p sternotomy. Abdomen:Obese. Soft. Normoactive BS. Non-tender. No rebound/guarding. Negative [**Doctor Last Name **]. Ext: Prominent non-pitting LE edema. Not changed from baseline per patient. Skin: Psoriatic lesions most notable on back/buttocks and abdommen with scattered lesions on chest, legs. Increased erythema peri [**Last Name (un) **]-labial folds, not new per patient. Pertinent Results: [**2121-6-6**] 05:39PM HCT-25.5* [**2121-6-6**] 10:30AM GLUCOSE-112* UREA N-76* CREAT-2.2* SODIUM-138 POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-20* ANION GAP-16 [**2121-6-6**] 10:30AM ALT(SGPT)-11 AST(SGOT)-13 CK(CPK)-30* ALK PHOS-80 TOT BILI-0.5 [**2121-6-6**] 10:30AM CK-MB-NotDone cTropnT-<0.01 [**2121-6-6**] 10:30AM CALCIUM-8.7 PHOSPHATE-4.5 MAGNESIUM-1.8 [**2121-6-6**] 10:30AM WBC-7.2 RBC-2.39* HGB-7.7* HCT-24.4* MCV-102* MCH-32.4* MCHC-31.6 RDW-19.7* [**2121-6-6**] 10:30AM NEUTS-78.9* LYMPHS-9.8* MONOS-7.9 EOS-3.2 BASOS-0.4 [**2121-6-6**] 10:30AM PLT COUNT-189 [**2121-6-6**] 10:30AM PT-26.1* PTT-33.2 INR(PT)-2.5* [**2121-6-6**] 08:38AM UREA N-76* CREAT-2.3* [**2121-6-6**] 08:38AM estGFR-Using this [**2121-6-6**] 08:38AM ALT(SGPT)-12 AST(SGOT)-14 LD(LDH)-185 ALK PHOS-81 TOT BILI-0.6 DIR BILI-0.2 INDIR BIL-0.4 [**2121-6-6**] 08:38AM TOT PROT-6.7 ALBUMIN-3.8 GLOBULIN-2.9 CALCIUM-9.1 [**2121-6-6**] 08:38AM VIT B12-542 [**2121-6-6**] 08:38AM WBC-7.5 RBC-2.37* HGB-7.9* HCT-24.0* MCV-101* MCH-33.2* MCHC-32.8 RDW-19.8* [**2121-6-6**] 08:38AM NEUTS-77.9* LYMPHS-10.5* MONOS-8.3 EOS-3.1 BASOS-0.2 [**2121-6-6**] 08:38AM PLT COUNT-161 [**2121-6-6**] 08:38AM PT-25.7* INR(PT)-2.5* ------------------ Carotid series [**2121-6-10**]: IMPRESSION: 60-69% stenosis in the right and left internal carotid arteries which does not appear significantly changed from the prior exam of [**2121-3-27**]. ------------------ Cardiac catheterization [**2121-6-11**]: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Successful PTCA of the SVG to RCA. Brief Hospital Course: The following problems were managed during this admission: . #1 NSTEMI: Patient was transferred from the MICU to the floor on [**6-8**]. That night, he underwent bowel prep for colonoscopy to investigate source of GI bleed. He reports having a "difficult" night with significant diarrhea and nearly no sleep. Early the following morning (~6:30 am), patient began experiencing jaw/neck pain; as this is his anginal equivalent, an EKG was obtained. EKG showed new ST depression in V5, V6 but the 1st set of cardiac enzymes negative. The pain was similar to his usual once-a-week anginal equivalent pain which is typically responsive to SL nitro. This episode was mostly relieved with SL nitro x 4 tabs and morphine 1 mg IV x 2 doses. After these medications, the pain was gone but patient reports feeling residual "neck pulsations." This symptom prompted a carotid artery US study, which showed 60-70% stenosis bilaterally. The second set of cardiac enzymes returned positive, and the patient was transferred to the cardiology service. He went for cardiac catheterization on [**6-11**]; balloon angioplasty was performed but no stents placed. He had an uneventful recovery from this procedure. . #2 GIB: There was one report of black stool, which was suspicious for upper GI source. DDX included PUD, gastritis. On ED exam, rectal exam was grossly bloody, which could indicate brisk upper bleed versus lower source, ddx includes AVMs, diverticula, mass, hemorrhoids. Pt has been hemodynamically stable since initial resuscitation. No further bleeding episodes in ICU or on the floor. Of note, it seemed as if pt was having oozing intially, as his Hct did not bump as expected after each unit of pRBC. He was transfused a total of 4 U pRBC. However, he had a delayed reponse with rapid Hct rise in subsequent days. Once on the floor, patient had one "dark" bowel movement which was not saved for guaiac; subsequent bowel movements were normal-colored although soft consistency in setting of second colonoscopy prep. EGD was performed which showed no abnormality. Colonoscopy was performed which showed diverticuli with no active bleed. Hct remained stable, near baseline (29-30 per hematology notes). PPI was switched to famotidine 20mg IV BID since pt was on Plavix. . #3 Hypotension. Unclear how long this may have been going on. The patient was not symptomatic with his low blood pressure in terms of lightheadedness or syncope. BPs 90/40 at last clinic visit, this may be in part due to GIB as well as increase in ACEI and lasix recently. Lasix and ACE inhibitor were held during admission to avoid hypotension. . #4 Acute renal failure - acute on chronic renal insufficiency with creatinine 2.3 at admission (baseline cr 1.5-1.6). ACE inhibitor and lasix were held and blood was transfused x 4 units; creatinine improved to 1.1 suggesting that medications/anemia/dehydration may have been contributing factors in this case. . #5 Atrial fibrillation: Pt was in and out of A-fib (vs. sinus) on the tele monitor. His coumadin was held in setting of GI bleed. Patient was instructed to hold coumadin until he could follow up with PCP and the medication could be safely restarted. . #6 Hypercholesterolemia: statin dose increased from 40 mg -> 80 mg in setting of NSTEMI. Medications on Admission: Metoprolol 200mg Daily Nitoglycerin 0.4mg SL PRN Nitropatch 0.1mg/hour Q24 hours Omeprazole 20mg daily Warfarin 2mg daily ASA 325mg VitB12 shots Qmonth Atorvastatin 40mg daily Clopidogrel 75mg daily Lisinopril 10mg daily Furosemide 40mg daily Folic Acid 1mg daily Epo shots 60,000 weekly (fridays) Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 5. Nitro-Dur 0.1 mg/hr Patch 24 hr Sig: One (1) Transdermal once a day. 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain: Repeat up to three times five minutes apart. 8. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 9. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. Procrit 20,000 unit/mL Solution Sig: Three (3) Injection once a week. 12. Colace 100 mg Capsule Sig: [**11-29**] Capsules PO once a day as needed for constipation. Disp:*30 Capsule(s)* Refills:*2* 13. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. Gastrointestinal bleed - unknown origin 2. Non-ST Elevation Myocardial Infarction 3. Acute renal failure Discharge Condition: Good - No further chest, neck or jaw pain; small hematoma at groin site is not expanding; hematocrit is stable and close to baseline; creatinine is stable at 1.1; shortness of breath occurs with mild exertion, but is similar to baseline; vital signs have been stable. Discharge Instructions: You were admitted to [**Hospital1 69**] with a bleed from your gastrointestinal tract. You were admitted to the ICU where you received 4 units of packed red blood cells by transfusion. After you were transferred to the medicine service, you began experiencing chest/neck/jaw pain. An EKG and blood tests showed that you had a minor heart attack. You were transferred to the cardiology service and you went for cardiac catheterization which showed an occlusion of one of your coronary arteries, and balloon angioplasty was used to expand the lumen of the blood vessel to improve blood flow. You also went for an upper endoscopy and a colonoscopy to try to identify the source of the bleeding that you experienced prior to your admission. We made the following changes to your medication regimen: -DO NOT TAKE Coumadin (warfarin) until/unless instructed to do so by your cardiologist or primary care doctor. -DO NOT TAKE Omeprazole as it may interact unfavorably with Plavix. -BEGIN TAKING Ranitidine 150 mg PO twice daily as a substitute medication for omeprazole -BEGIN TAKING Colace 100 mg PO daily as needed to keep stool soft (softer stool may help to prevent future episodes of bleeding from the gastrointestinal tract). Do not take this medication if you are already having soft stool or are having diarrhea. -CHANGE Lisinopril to 5 mg PO daily (down from 10 mg) because your blood pressure has been well-controlled recently and the higher dose may cause it to go too low. -CHANGE atorvastatin to 80mg at bedtime. You can take two 40 mg tablets until your prescription runs out, then take one 80mg tablet at bedtime. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1L Please make appointments with the listed specialists regarding your recent hospitalization. Followup Instructions: 1. Primary care: Please make an appointment with Dr. [**Last Name (STitle) **] (Phone:[**Telephone/Fax (1) 1144**]) for 1-2 weeks after discharge from the hospital 2. Cardiology: You have an appointment with Dr.[**Name (NI) 17483**] (Phone:[**Telephone/Fax (1) 62**]) on [**2121-6-27**] at 10:00am 3. Gastroenterology: You will need to make an appointment for an additional study called a capsule endoscopy study to determine the source of your bleeding. Please call [**Telephone/Fax (1) 463**] to make an appointment with Dr. [**First Name8 (NamePattern2) 1255**] [**Name (STitle) 1256**] and to schedule this study. 4. Hematology: Please call Dr.[**Name (NI) 11574**] office to inform him that you did not receive your usual dose of 60,000u of Procrit on Friday (our injections are only 20,000u). Make an appointment to see him early in the week if he feels that it is a problem that you missed your full dose. Otherwise, see him on Friday for your next dose as you usually would. Completed by:[**2121-6-17**]

[ "433.10", "996.72", "285.1", "238.75", "562.10", "410.71", "427.31", "585.9", "428.0", "578.9", "V12.54", "696.1", "414.01", "428.22", "272.0", "584.9" ]

icd9cm

[ [ [] ] ]

[ "00.40", "45.23", "45.13", "37.22", "99.20", "88.55", "00.66", "88.52" ]

icd9pcs

[ [ [] ] ]

11029, 11087

6210, 9491

346, 865

11239, 11509

4597, 6089

13399, 14418

3783, 3817

9839, 11006

11108, 11218

9517, 9816

6106, 6187

11533, 13376

3832, 4578

254, 308

893, 2819

2841, 3594

3610, 3767

63,327

152,869

366+55209

Discharge summary

report+addendum

Admission Date: [**2118-10-23**] Discharge Date: [**2118-10-30**] Date of Birth: [**2065-7-31**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 3290**] Chief Complaint: cough, respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: 53 yo M w/ h/o Down's syndrome, non-verbal at baseline, hypothyroidism, cataracts, dysphagia s/p G-tube, h/o aspiration pna's, hypoNa on 4Lnc QHS who presents w/ cough and hypoxia from group home. . Per report, patient with acute on chronic cough found to desat to 88% on RA this AM. Looked as if he were in respiratory distress. Per OMR had been empirically treated for pna back in [**6-/2118**] w/ multiple notes documenting cough. . In the ED, initial VS were: 98.2 74 92/50 28 100% nrb. Tmax 100.2. On exam +crackles L>R. Labs notable for Na 127, K 7.4, Cl 90, HCO3 29, BUN 11, Cr 0.7, Glu 121, Lactate 1.7, repeat K 4.4, UA neg leuk/nitr/3wbc/neg bact/epis O, wbc 6, h/h 15/43.4, plt 297. CXR: gastric distention, bibasilar atelectasis. He received zosyn and levo, vanc, 1LNS. Has a 20gauge piv. Past Medical History: Down's syndrome, non-verbal at baseline -B12 deficiency -hypothyroidism -cataracts, legally blind -dysphagia s/p G-tube -h/o aspiration pna's -h/o DVT -h/o cdiff Social History: Lives in group home, siblings very involved in his care. Family History: Non-contributory. Physical Exam: Admission exam: General: Arousable, alert, non-communicative HEENT: Sclera anicteric, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: RR, no mrg Lungs: +Rhonchi Abdomen: PEG placed, soft, NTND GU: + foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge exam: Unchanged from above except for Lungs: CTAB except for occasional scattered ronchi, R>L Pertinent Results: Admissino labs: [**2118-10-23**] 10:55AM BLOOD WBC-6.0 RBC-4.27* Hgb-15.0 Hct-43.4 MCV-102* MCH-35.2* MCHC-34.5 RDW-12.3 Plt Ct-297 [**2118-10-23**] 10:55AM BLOOD Neuts-75* Bands-1 Lymphs-19 Monos-4 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2118-10-23**] 10:55AM BLOOD Plt Smr-NORMAL Plt Ct-297 [**2118-10-23**] 10:55AM BLOOD Glucose-121* UreaN-11 Creat-0.7 Na-127* K-7.4* Cl-90* HCO3-29 AnGap-15 [**2118-10-23**] 10:55AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.3 [**2118-10-23**] 04:28PM BLOOD D-Dimer-627* [**2118-10-23**] 03:03PM BLOOD Type-ART pO2-214* pCO2-39 pH-7.48* calTCO2-30 Base XS-6 [**2118-10-23**] 11:01AM BLOOD Glucose-122* Lactate-1.7 K-4.4 [**2118-10-23**] 03:03PM BLOOD freeCa-1.12 Imaging: -CXR ([**2118-10-23**]) - 1. Coarse bilateral interstitial opacities with more focal opacity in the left lung base. Findings may represent aspiration or pneumonia with mild pulmonary edema. Small left pleural effusion. 2. Gaseous distention of the hepatic flexure of the colon and stomach as described above; correlate clinically. -CTA Chest ([**2118-10-23**]) - 1. No PE or acute aortic syndrome. 2. Bibasilar opacities, likely reflecting components of early pneumonia and atelectasis. However, due to several nodular areas, follow-up chest CT when symptoms resolve is recommended. -CXR ([**2118-10-25**]) - 1. Mild pulmonary edema with bibasilar opacities worrisome for interstitial infection. Discharge labs: [**2118-10-30**] 07:30AM BLOOD WBC-6.7 RBC-3.81* Hgb-13.9* Hct-40.0 MCV-105* MCH-36.6* MCHC-34.8 RDW-13.1 Plt Ct-337 [**2118-10-30**] 07:30AM BLOOD Glucose-94 UreaN-20 Creat-1.0 Na-134 K-4.6 Cl-100 HCO3-26 AnGap-13 Brief Hospital Course: 53 yo M w/ h/o Down's syndrome, non-verbal at baseline, hypothyroidism, cataracts, dysphagia s/p G-tube, h/o aspiration pna's, hypoNa on 4Lnc QHS who presents w/ cough and hypoxia from group home. . # Aspiration Pneumonia/Respiratory Distress: Was initially admitted to the MICU given respiratory distress. Pt had CTA that was negative for PE though notable for bibasilar opacities concerning for pneumonia. He was started on vanc/zosyn for aspiration pna. His O2 requirement was weaned w/ treatment from face mask to nasal cannula at the time of discharge. On the floor, his antibiotics were switched to levaquin and he remained afebrile. . # HypoNa: Chronic per facility records. Improved with IVFs after admission to ICU. Na stable at 134-135 at time of discharge. . # Hypotension: Baseline BP 90s per records. Patient maintained SBP 80s-low 100s, w/ intermittent readings of 70s and he received intermittent fluid bolus while in the ICU. Cortisol was normal. TSH elevated, though free t4 was normal. His urine output remained good and his hypotension was felt to be at baseline and tolerated. Of note urine cx were neg; blood cx grew coag(-) staph from 1 bottle which was felt to be contaminant, subsequent blood cultures showed no growth and he remained afebrile without other signs of bacteremia. . # Down's syndrome, non-verbal at baseline: Appears to be at his recent baseline per family and group home records. . # Hypothyroidism: Continued synthroid . #G-tube - In the ICU there was concern about position of tube, surgery was consulted and felt that tube was properly placed. Wound culture grew [**Female First Name (un) 564**] and he was started on nystatin cream to the site. . #Code status this admission - Full code. Had family meeting with brother, [**Name (NI) **], regarding code status and goals of care. We explained that it is possible that these recurrent aspiration events may continue to occur, and his brother stated that he still wished for full resuscitation, including intubation if necessary. [**Doctor First Name **] stated that the family wanted another neurological evaluation before they made any changes to his code status. The geriatrics team was involved with this meeting and are working on having him reevaluated again. . #Transitional issues -Will need ongoing assessment of neurological function, has follow-up arranged -Will need ongoing assessment of goals of care, started this discussion with his brother, [**Name (NI) **], during this admission Medications on Admission: 1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. levetiracetam 100 mg/mL Solution Sig: 7.5 mL PO BID (2 times a day). 3. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 5. therapeutic multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 6. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Dulcolax 10 mg Suppository Sig: One (1) suppository Rectal once a day as needed for constipation. 8. Kaopectate (bismuth subsalicy) 262 mg/15 mL Suspension Sig: Fifteen (15) mL PO once a day as needed for diarrhea. 9. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal once a day as needed for constipation. 10. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for fever or pain. 11. simethicone 40 mg Strip Sig: One (1) tab PO every four (4) hours. 12. NeutraPhos Sig: One (1) packet twice a day. Discharge Medications: 1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. levetiracetam 100 mg/mL Solution Sig: 7.5 mL PO BID (2 times a day). 3. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 5. therapeutic multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 6. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Dulcolax 10 mg Suppository Sig: One (1) suppository Rectal once a day as needed for constipation. 8. Kaopectate (bismuth subsalicy) 262 mg/15 mL Suspension Sig: Fifteen (15) mL PO once a day as needed for diarrhea. 9. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal once a day as needed for constipation. 10. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for fever or pain. 11. nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical TID (3 times a day). 12. simethicone 40 mg Strip Sig: One (1) tab PO every four (4) hours. 13. NeutraPhos Sig: One (1) packet twice a day. Discharge Disposition: Extended Care Facility: bay cove Discharge Diagnosis: Primary diagnosis: Aspiration pneumonia Secondary diagnoses: Down's syndrome Hypothyroidism Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname 3291**], It was a pleasure taking care of you during your admission at [**Hospital1 18**] for aspiration pneumonia. You were initially admitted to the ICU where you received IV antibiotics. A CT scan of your chest did not show any blood clots in your lungs. You started to improve and were transitioned to oral antibiotics. You completed your full 7 day course of antibiotics in the hospital and will not need to take any more at your group home. Changes to your medications: START nystatin cream topical tid apply to G-tube site Followup Instructions: Department: NEUROLOGY When: THURSDAY [**2118-11-10**] at 9:30 AM With: [**First Name11 (Name Pattern1) 3292**] [**Last Name (NamePattern1) 3293**], MD [**Telephone/Fax (1) 3294**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: BIDHC [**Location (un) **] When: THURSDAY [**2118-11-10**] at 1 PM With: [**First Name11 (Name Pattern1) 3295**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3296**] [**Last Name (NamePattern1) 3297**], MD [**Telephone/Fax (1) 608**] Building: 545A Centre St. ([**Location (un) 538**], MA) None Campus: OFF CAMPUS Best Parking: Name: [**Known lastname 374**],[**Known firstname 63**] Unit No: [**Numeric Identifier 375**] Admission Date: [**2118-10-23**] Discharge Date: [**2118-10-30**] Date of Birth: [**2065-7-31**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 376**] Addendum: ***Meidcation list in discharge summary incorrectly included levofloxacin, the medication list on his discharge instruction sheet is correct. He finished a 7 day course of antibiotics as an inpatient and does not need additional antibiotics after discharge. Discharge Disposition: Extended Care Facility: bay cove [**Name6 (MD) **] [**Last Name (NamePattern4) 377**] MD [**MD Number(2) 378**] Completed by:[**2118-10-30**]

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2102-3-29**] Discharge Date: [**2102-4-11**] Date of Birth: [**2022-3-6**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Severe chest and back pain Major Surgical or Invasive Procedure: [**2102-3-29**] 1. Salvage repair of ruptured thoracoabdominal aortic aneurysm with a 24 mm Dacron interposition tube graft with mesenteric and renal artery implantation using a Carrel patch technique. 2. Left renal artery bypass with a 6 mm Dacron graft. [**2102-3-30**] Re-exploration status post emergent/salvage repair of ruptured thoracoabdominal aortic aneurysm. [**2102-3-31**] Repair of complex diaphragmatic disruption and closure of thoracotomy portion of a thoracoabdominal incision. [**2102-3-31**] Abdominal closure/partial with plastic material and graft, drain placement. [**2102-4-2**], [**2102-4-5**], [**2102-4-8**] Partial closure of abdominal wall defect, change of dressing and drain. [**2102-4-4**] Diagnostic bilateral chest ultrasound and diagnostic and therapeutic right-sided thoracentesis. History of Present Illness: The patient was an 80-year-old woman who presented with acute onset of back pain with hypotension and collapse. The patient was resuscitated at an outside institution which included intubation and a CT scan which showed at least a 9 cm aneurysm within her abdomen and lower thorax. This was a non-contrast study. However, it was felt that she had a ruptured thoracoabdominal aortic aneurysm. The patient was emergently transferred to the [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] where vascular and cardiac surgery were consulted for emergent/salvage repair. Past Medical History: Hypertension Social History: Unknown Family History: Unknown Physical Exam: Deferred - emergently taken to operating room Pertinent Results: Not applicable Brief Hospital Course: Mrs. [**Known lastname 1968**] was emergently brought to the operating room where Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 914**] performed a salvage repair of ruptured thoracoabdominal aortic aneurysm. Her postoperative course was complicated by coagulapathy and multi-system organ failure. Despite additional surgical and medical interventions, she progressively became acidotic and eventually septic. After discussion with her family, and given her poor prognosis, she was eventually made CMO. She expired on [**4-11**]. Medications on Admission: Aspirin, Lasix, Lisinopril, Atenolol, Triameterene/HCTZ Discharge Medications: Not applicable Discharge Disposition: Expired Facility: [**Hospital1 18**] Discharge Diagnosis: Ruptured Thoracoabdominal Aortic Aneursym - s/p repair Multi-system Organ Failure Sepsis Death Discharge Condition: Expired Discharge Instructions: Not applicable Followup Instructions: Not applicable Completed by:[**2102-5-19**]

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icd9cm

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icd9pcs

[ [ [] ] ]

2684, 2723

2002, 2539

346, 1165

2861, 2870

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34662

Discharge summary

report

Admission Date: [**2168-10-17**] Discharge Date: [**2168-10-26**] Date of Birth: [**2124-11-30**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: sternal incision pain, purulent drainage Major Surgical or Invasive Procedure: sternal debridement([**10-18**]) closure with bilat pectoral flaps and sternal plates. ([**10-20**]) History of Present Illness: This 43 year old woman is s/p mitral valve replacement and PFO closure on [**2168-9-19**]. She presented to an outside hospital with eight hours of sternal incision pain and purulent drainage. Blood cultures demonstrated 3/4 bottles positive for Methicillin Sensitive Staph Aureus. Symptoms worsen with deep inspiration. The patient was febrile and found to have WBC 19,000.m She was transferred to [**Hospital1 18**] for evaluation. Past Medical History: Mitral regurgitation Psoriasis Psoriatic arthritis Endometriosis Obesity Social History: Lives with spouse ETOH rare Tobacco 20 year pack history - currently smoking Not currently working Family History: Mother deceased at 62 from cardiomyopathy Physical Exam: Gen: NAD Neuro: alert and oriented, non-focal Pulm: lungs CTAB Cardiac: RRR, frequent PVCs Sternal Incision: no erythema. Wound clean. 2 JPs remain in place. Abd: soft, non-tender, non-distended. Ext: warm, 1+edema Pertinent Results: [**2168-10-25**] 05:23AM BLOOD WBC-8.4 RBC-3.22* Hgb-9.6* Hct-29.6* MCV-92 MCH-30.0 MCHC-32.5 RDW-16.6* Plt Ct-280 [**2168-10-25**] 05:23AM BLOOD Glucose-114* UreaN-18 Creat-0.8 Na-138 K-3.9 Cl-106 HCO3-24 AnGap-12 [**2168-10-23**] 04:47AM BLOOD ALT-10 AST-18 LD(LDH)-216 AlkPhos-83 Amylase-36 TotBili-0.2 [**2168-10-23**] 04:47AM BLOOD Lipase-79* [**Known lastname **],[**Known firstname 8031**] M [**Medical Record Number 79500**] F 43 [**2124-11-30**] Date: [**2168-10-26**] Signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2168-10-26**] Affiliation: [**Hospital1 18**] NEEDS COSIGN Initial Intake Infectious Disease Clinic Outpatient Antimicrobial Management Program Surgeon: [**Last Name (LF) **],[**Name8 (MD) 177**] MD Infectious Disease Fellow: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 111**], MD Infectious Disease Preceptor: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**], MD Infusion Company: [**Location (un) 511**] Home Therapies Phone: 1.[**Telephone/Fax (1) **] Fax: [**Telephone/Fax (1) 79503**] VNA: Home Health and Hospice of [**Location (un) **], NH Phone: [**Telephone/Fax (1) 79504**] Type of Intravenous Access Where placed: RUE [**10-23**] PICC ( X ) Length ( 52cm ) Discharge diagnosis: MSSA sternal wound infection Brief Summary of Patient History: Ms [**Known lastname **] is a 43-year old woman with a history of uncomplicated MVR (bioprosthetic) and closure of PFO in [**2168-9-19**] presenting to [**Hospital 5279**] Hospital on [**10-14**] and transferred to [**Hospital1 18**] on [**10-17**] with sternal wound pain and drainage. She presented to [**Hospital 5279**] Hospital on [**10-14**] with a progressive, 2-day history chest wall pain associated with nausea, shortness of breath, and worsened with movement. In the ER at [**Doctor First Name 5279**], she had a temperature of 100.4, BP 80s/40s, WBC 19K (87% PMN). A TTE demonstrated LVEF 35%, small posterior pericardial effusion, well-seated MV prosthesis. Blood cultures demonstrated ([**3-15**]) demonstrated MSSA, a CT of chest w/ and without contrast demonstrated a "tiny" fluid collection at the midline incision site. Wound cultures demonstrated WBC w/o organisms, although at time of transfer culture was pending. Empiric antibiotics with vancomycin and ceftazidime ([**10-14**]) were continued. During the admission, she remained afebrile, hemodynamically stable, and was transferred for further evaluation. She was taken to OR [**10-18**] for debridement and returned [**10-20**] for sternal plating. Blood cultures at [**Hospital1 18**] [**Date range (1) 60609**] remain negative at time of discharge. Although a swab culture from the wound on [**10-17**] was negative, all 4 intra-operative swab and tissue cultures from [**10-18**] demonstrated MSSA; no swab was taken on [**10-20**] (some necrotic tissue was debrided). A TEE was negative for endocarditis. For the remainder of the admission, she remained afebrile and generally improved. Two anterior chest drains remained intact and in place at the time of discharge (to be removed approx 1 week post-discharge). She had [**1-14**] loose stools daily for several days toward the end of the admission, briefly started empirically on metronidazole, but was C. diff toxin negative x1. She was continued on Nafcillin starting [**10-18**], and should be continued for 6 weeks minimum starting [**10-20**]. In clinic follow-up, duration of antibiotics will be determined, including possible long-term suppression with ciprofloxacin and rifampin, as well as a further discussion with surgery re: plate removal if indicated. PAST MEDICAL HISTORY: ++ Cardiomyopathy with mitral regurgitation ++ Mitral valve replacement, bioprosthetic, [**2168-9-19**] ++ patent foramen ovale closure, [**2168-9-19**] ++ Hypertension ++ Hypercholesterolemia ++ Psoriatic arthritis ++ Endometriosis - R Salpingo-oophorectomy ++ Obesity ++ Depression ++ Panic disorder ++ Narcolepsy [**Hospital 5279**] Hosp (micro [**Telephone/Fax (1) 79505**]): Wound culture ([**10-16**]): light presumptive Staph Blood culture ([**10-15**]) x2: NGTD Blood culture ([**10-14**]): 2/2 bottles MSSA (pan-[**Last Name (un) 36**]) Urine culture ([**10-14**]): NEG Nares culture, MRSA screen ([**10-14**]): NEG [**Hospital1 18**]: Sternal wound swab [**10-17**]: negative (stain w/o PMN/orgs) Intra-op ([**10-18**]) Sternal wound swab x2: MSSA Sternal wound tissue x2: MSSA BCx [**10-17**] x2, [**10-20**], [**10-21**] x2: NEG/NGTD UCx [**10-17**], [**10-21**] NGTD Cath tip Cx [**10-17**] NGTD Cdiff toxin [**10-18**], [**10-23**], [**10-25**]: NEG TEE [**10-18**] LVEF 35-40% no veg MV well-seated LABORATORY REVIEW DATE WBC ESR CRP Cr ALT/AST/tbili *[**10-14**] 19 1.8 *[**10-15**] 121 *[**10-16**] 12 37.4 1.2 [**10-17**] 8.4 125 >300 1.0 14/17/0.5 [**10-18**] 7.8 1.1 11/15/0.3 [**10-19**] 6.2 0.8 [**10-20**] 9.5 0.8 [**10-21**] 11.4 0.9 [**10-23**] 10/18/0.2 [**10-24**] 6.9 0.9 Patient Allergies: NKDA Prescribed Antibiotic Information: Nafcillin 2g IV q4hr x6 weeks minimum, starting [**2168-10-20**] laboratory monitoring required CBC/diff, Chem 12, ESR/CRP qweek All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 6313**] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 14199**] FOLLOW-UP: [**2168-11-18**] 10:00a ID,[**Location (un) **] [**Location (un) **] LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT ID WEST (SB) Brief Hospital Course: The patient was admitted for further management of her sternal wound infection. On [**2168-10-18**] she was brought to the operating room where she underwent sternal debridement and wound VAC placement with the assistance of the plastic surgery team. The patient returned to the operating room on [**10-20**] for chest closure with pectoralis muscle flaps and plating. Please see operative notes for details. Overall the patient tolerated the procedures well and post-operatively was transferred to the CVICU for observation and recovery. By POD 1 (from chest closure) she was hemodynamically stable, extubated, alert and oriented and breathing comfortably. ID was consulted for assistance in antibiotic administration. Nafcillin therapy was initiated per ID recommendations. The patient was transferred to the step down unit on [**2168-10-22**]. She developed diarrhea and was started on Flagyl empirically. Two c-diff toxins were negative. Imodium therapy was initiated. A third c-diff toxin was sent. Her stool frequency decreased to twice a day and began to firm. Only 2 doses of Imodium were taken and Flagyl was stopped. The patient remained in sinus rhythm,however, she continued to have frequent PVCs with non-sustained ventricular tachycardia. Electrolytes were repleted and beta-blocker titrated accordingly. Her ectopy improved dramatically with these treatments. Two JPs remain in place and she is afebrile. ID and Plastic Surgery continued to follow her and she was ready for discharge on [**10-26**]. Arrangements were made for home infusion therapy for Nafcillin and lab draws and follow-up with both infectious disease and plastic surgery. Medications, instructions and restrictions were discussed with the patient before discharge. . Medications on Admission: aspirin 81 mg daily klonopin 1mg [**Hospital1 **] folic acid 1mg daily lasix 10mg tid lopressor 25mg q8h remeron 15mg daily ativan 0.5mg q6h prn anxiety duoneb inh q4h prn lovenox 40mg sq zofran 4mg q6h prn protonix 40mg daily vancomycin 1gIVdaily ceftazidime 2g q12h dilaudid 0.5-1mg IV q1h prn morphine 2mg IV prn Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 weeks. Disp:*56 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 4. 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* 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a day). Disp:*1 15gm* Refills:*0* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO every four (4) hours as needed for loose stool for 2 weeks: after loose stool. No more than 6 a day. Disp:*30 Capsule(s)* Refills:*0* 13. Ibuprofen 200 mg Tablet Sig: Four (4) Tablet PO three times a day for 3 weeks: take with food. Disp:*252 Tablet(s)* Refills:*0* 14. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. Disp:*60 Tablet(s)* Refills:*2* 15. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. Disp:*90 Tablet(s)* Refills:*2* 16. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours) for 6 weeks: as direscted. Disp:*504 grams* Refills:*0* 17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush for 6 weeks. Disp:*QS ML(s)* Refills:*2* 18. Heparin Flush (10 units/ml) 1 mL IV PRN line flush Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 19. saline flush Sig: 1-2 mg Intravenous every 4-6 hours for 6 weeks. Disp:*50 * Refills:*2* 20. Compazine 10 mg Tablet Sig: One (1) Tablet PO every [**4-17**] hours as needed for nausea for 2 weeks. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: homehealth vna of [**Location (un) **] Discharge Diagnosis: sternal wound infection s/p sternal debridement s/p closure with bilat pectoral flaps and sternal plates s/p MVR(tissue) & closure of PFOPsoriasis arthritis endometriosis obesity Discharge Condition: good Discharge Instructions: Take all medications as prescribed. Call for any fever greater than 100.5 report any redness or drainage from wounds no lifting more than 10 pounds for 10 weeks no driving until cleared by plastic surgery Followup Instructions: ) Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2168-11-18**] 10:00 Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **](plastic surgery) next week Dr [**Last Name (STitle) 914**] in 4 weeks from original surgery ([**Telephone/Fax (1) 170**]) Completed by:[**2168-10-26**]

[ "425.4", "041.11", "617.9", "V42.2", "496", "272.4", "327.23", "427.1", "790.7", "278.00", "998.30", "276.8", "311", "E878.1", "787.91", "401.9", "300.01", "347.00", "696.0", "692.9", "424.0", "998.59", "305.1", "787.29", "V85.37" ]

icd9cm

[ [ [] ] ]

[ "77.61", "38.93", "78.51", "88.72", "96.71", "86.74" ]

icd9pcs

[ [ [] ] ]

11838, 11907

7202, 8967

364, 467

12130, 12137

1457, 2743

12390, 12763

1163, 1206

9333, 11815

11928, 12109

8993, 9310

12161, 12367

1221, 1438

284, 326

495, 933

5167, 7179

1046, 1147

41,976

180,546

35275

Discharge summary

report

Admission Date: [**2201-5-12**] Discharge Date: [**2201-5-19**] Date of Birth: [**2136-7-28**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2186**] Chief Complaint: Fevers, early sepsis Major [**First Name3 (LF) 2947**] or Invasive Procedure: None History of Present Illness: 64 year old male with history of CVA (non-verbal at baseline), multiple pneumonias (s/p trach/PEG [**3-/2200**]), atrial fibrillation on coumadin, CDiff s/p colectomy, type 2 diabetes mellitus, peripheral vascular disease and recent admission for UTI/?multifocal pneumonia who presents with fevers to 101.9. The patient initially presented to the hospital for routine G-tube replacement but had with the fever and ?blood suctioned from old G-tube, was sent to the [**Hospital1 18**] ED. The patient also has erythema around the G-tube site and minimal ostomy output. . The patient was most recently admitted 5/11-17/[**2200**] for UTI (Proteus mirabilis, previous Providencia stuartii) and fevers which was treated w/ Cefepime. The patient has a chronic indwelling Foley. The patient also had a potential pneumonia (?aspiration) on CXR with sputum culture growing out Stenotrophomonas maltophilia, Serratia marcescens, Proteus mirabilis and was treated with Tobramycin and Vancomycin. The patient had ongoing issues with blood leaking from his trach site last admission as well, which resolved without intervention, ?trach site or oropharyngeal trauma/bleed. . In the ED, initial vitals were: T99.9, HR83, BP115/67, RR14, 91% on ?trach mask. The patient is nonverbal at baseline but endorsed pain and following commands. His blood pressures gradually drifted to SBP96. He was noted to have active bronchospasms, so respiratory therapy evaluated the patient. He received albuterol neb X1, mucomyst 20% 30 mL X1, Vancomycin IV 1 gram X1 and Zosyn IV 4.5mg X1, Tobramycin 520mg X1, Morphine 4mg IV X1. Bronchospasms resolved and the patient was satting 100% on 35% humidified air via trach mask. Two large bore IV were placed and fluid boluses given as well. CXR showed possible new LLL infiltrate. CT abdomen/pelvis with contrast showed no intrabdominal process, likely multi-focal pneumonia. Labs notable for new leukocytosis to WBC 30.4. Blood and urine cultures sent. Urinalysis shows mild urinary tract infection. The patient also received one dose of Flagyl 500mg IV X1. Lactate 1.3. Upon transfer, vital signs were: Afebrile, BP115/75, HR66, RR 12-13 (7 and shallow when sleeping), 100% O2 sat on 35% facemask. . ROS: Patient denies shortness of breath, endorses pain in RUE and ?lower back. Otherwise, denies complaints but difficult to assess. 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: On admission: VS: Temp: 96.6 BP: 152/91 HR: 75 RR: 18 O2sat 99% on facemask 35% GEN: Pleasant, comfortable, NAD, nods/shakes head to Spanish verbal stimuli HEENT: PERRL, EOMI, anicteric, MMM, no supraclavicular or cervical lymphadenopathy, no JVD but difficult to assess with trach strap RESP: No wheezing/rhonchi/rales with good air movement throughout, ?bilateral crackles R>L anteriorly CV: Regular rate/rahythm, normal S1/S2, no murmurs/gallops/rubs ABD: Non-tender, non-distended, +bowel sounds, soft, GTube sutured in place, slightly macerated skin with chronic skin changes, not warm/tender, ostomy w/ pink granulation tissue and minimal output EXT: No cyanosis/ecchymosis/trace edema. RUE contracted w/ 1+ edema. LUE w/ 1+ edema, less contracted. SKIN: No rashes/no jaundice/lesions NEURO: Alert and oriented, CN grossly intact. Strength and sensation grossly intact. On Discharge: Unchanged. Pertinent Results: [**2201-5-12**] 07:56PM WBC-19.2* RBC-4.48* HGB-10.0* HCT-32.2* MCV-72* MCH-22.3* MCHC-31.0 RDW-15.9* [**2201-5-12**] 07:56PM NEUTS-85.8* LYMPHS-9.5* MONOS-3.1 EOS-1.4 BASOS-0.2 [**2201-5-12**] 07:56PM PLT COUNT-198 [**2201-5-12**] 01:23PM PT-26.7* PTT-31.2 INR(PT)-2.6* [**2201-5-12**] 10:35AM GLUCOSE-175* K+-4.2 [**2201-5-12**] 09:19AM LACTATE-1.3 [**2201-5-12**] 09:15AM TSH-3.0 [**2201-5-12**] 09:15AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR . CT abdomen/pelvis with contrast: 1. Multifocal ground-glass opacities and consolidation with air bronchograms worrisome for either multifocal pneumonia or aspiration. 2. Gastrojejunostomy tube in appropriate position with the distal tip within the jejunum. No evidence of any peri-catheter leakage or extraluminal contrast collections. . CXR: Along with the patchy opacity noted at the left lung base on the prior study, there is now a right basilar opacity. These could reflect confluent edema, atelectasis, aspiration, or pneumonia from other source, or a combination thereof. There is superimposed mild interstitial edema as well. . Discharge labs: . [**2201-5-19**] 08:00AM BLOOD WBC-11.4* RBC-4.57* Hgb-10.4* Hct-32.2* MCV-71* MCH-22.9* MCHC-32.4 RDW-16.9* Plt Ct-216 [**2201-5-19**] 08:00AM BLOOD Neuts-72.7* Lymphs-19.5 Monos-4.3 Eos-2.7 Baso-0.8 [**2201-5-19**] 08:00AM BLOOD Glucose-110* UreaN-16 Creat-0.4* Na-136 K-4.0 Cl-99 HCO3-30 AnGap-11 [**2201-5-19**] 08:00AM BLOOD Calcium-8.4 Phos-1.6* Mg-1.8 Brief Hospital Course: 64 year old male with history of CVA (non-verbal at baseline), multiple pneumonias (s/p trach/PEG [**3-/2200**]), atrial fibrillation on coumadin, CDiff s/p colectomy, type 2 diabetes mellitus, peripheral vascular disease and recent admission for UTI/?multifocal pneumonia who presents with fevers to 101.9. . # Pneumonia: CXR suggestive of PNA in bilateral lower lobes. He was given vanco/zosyn/levoflox/tobramycin, (in past, sputum grew stenotrophomonas). His zosyn was d/c-ed and transitioned to cefepime; tobramycin was also d/c-ed. He was initialy transfered to the unit for close monitoring. Had mini-BAL which showed 10-100,000 colonies GNR. This eventually speciated PSEUDOMONAS AERUGINOSA, SERRATIA MARCESCENS, PSEUDOMONAS AERUGINOSA, and antibiotic coverage was narrowed from Cefepime and Levofloxacin to levofloxacin. - Patient should receive a total of 14 days course of levofloxacin. #G-tube: patient was initially brought here for Gtube replacement, which was performed and tube feeds were restarted without complications. #. C diff s/p colectomy: Patient has history of C diff in the past, and according to [**Hospital1 1501**] records last admission, was most recently positive [**2200-5-20**], treated with PO Vancomycin. Given recent antibiosis and significantly elevated WBC, concern for CDiff despite anatomy. It was doubtful that the patient had a repeat infection given negative Cdiff and lack of colon. Oral vancomycin was discontinued. . # Atrial fibrillation: On coumadin. - Please check INR [**5-20**] and adjust coumadin as needed for therapeutic INR [**1-22**] . # Sacral decubitus ulcer (stage 2): Wound care consult . # Hypothyroidism: Last TSH checked in OMR is 6/[**2199**]. Likely not contributing to current issues. Check TSH (caveat, sick euthyroid) and continued home levothyroxine dose. . # Tyle 2 diabetes mellitus: Stable. Also with history of peripheral neuropathy. Continue Lantus with ISS and gabapentin. . # Hypertension: Not on antihypertensives at faciltiy, monitored. . # History of GI bleed: Stable, continue home lansoprazole. . # History of multiple CVAs: Stable, minimally verbal at baseline. On coumadin at home, therapeutic on admission. Trend daily INR. Continue home neurontin and baclofen. . # Peripheral vascular disease: Stable, monitored . # Communication: Son, HCP [**Name (NI) 39522**] [**Name (NI) 8182**] [**Telephone/Fax (1) 79730**] (cell), [**Telephone/Fax (1) 79726**] (work phone: 7 am-3 pm) # Code: Full (discussed with [**Last Name (un) 39522**]) Medications on Admission: * Fentanyl 50 mcg/hr Patch every 72 hours * Mirtazapine 15 mg Tablet qHS * Glucerna tubefeeds * Insulin glargine 32 units daily with breakfast * Insulin regular human insulin sliding scale * Senna 8.6 mg Tablet twice daily * Duloxetine 30 mg twice daily * Ascorbic acid 500 mg/5 mL Syrup daily * Morphine 10 mg/5 mL Solution [**Last Name (un) **]: 7.5 mL PO Q6H (every 6 hours) as needed for pain * Acetaminophen 325 mg Tablet [**Last Name (un) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain * Magnesium hydroxide 400 mg/5 mL 30 mL daily PRN constipation * Baclofen 15 mg QID * Docusate sodium 50 mg/5 mL Liquid [**Last Name (un) **]: Ten (10) mL PO HS * Levothyroxine 25 mcg Tablet daily * Acetylcysteine 20 % (200 mg/mL) 1mL Q6H * Bisacodyl 10 mg Suppository PRN constipation * Alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension [**Last Name (un) **]: Thirty (30) ML PO QID (4 times a day) PRN stomach upset * Warfarin 3mg daily * Gabapentin 300mg three times daily * Therapeutic multivitamin Five (5) ML PO daily * Lansoprazole 30 mg Tablet,Rapid Dissolve, daily * Miconazole nitrate 2 % Powder [**Last Name (un) **]: One (1) Appl Topical [**Hospital1 **] to right hand * Albuterol nebs QID * Ipratropium negs QID 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. duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. insulin regular human 100 unit/mL Solution [**Hospital1 **]: per sliding scale Injection QACHS: please use sliding scale as pereviously. 5. mirtazapine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 6. fentanyl 50 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. tube feeds glucerna 8. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 9. warfarin 2 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Once Daily at 4 PM: please adjust dosage of this medication to keep INR therapeutic at 2-3. 10. levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 11. gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO three times a day. 12. acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: One (1) ML Miscellaneous Q6H (every 6 hours) as needed for mucus, tachypnea. 13. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 14. ascorbic acid 500 mg/5 mL Syrup [**Hospital1 **]: One (1) PO DAILY (Daily). 15. bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Rectal once a day as needed for constipation. 16. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 17. baclofen 10 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO QID (4 times a day). 18. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 19. morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: 7.5 ml PO Q6H (every 6 hours) as needed for pain. 20. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every six (6) hours as needed for pain. 21. therapeutic multivitamin Liquid [**Last Name (STitle) **]: One (1) PO once a day. 22. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension [**Last Name (STitle) **]: One (1) PO four times a day as needed for stomach upset. 23. Outpatient Lab Work Check INR [**5-20**] then dailyl thereafter and fax results to rehab physician for titration of warfarin; goal INR 2.0-3.0. 24. magnesium hydroxide 400 mg/5 mL Suspension [**Month/Day (4) **]: Thirty (30) ml PO once a day as needed for constipation. 25. levofloxacin 250 mg/10 mL Solution [**Month/Day (4) **]: Seven [**Age over 90 1230**]y (750) mg PO once a day for 7 days: Until [**5-26**] for 14 days total. . Discharge Disposition: Extended Care Facility: [**Hospital 16662**] Nursing Home Discharge Diagnosis: PRIMARY: * G-tube replacement * Hospital-associated pneumonia . SECONDARY: * Sacral decubitus ulcer stage 2 * History of multiple CVAs * Atrial fibrillation Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: It has been a privilege to take care of you at [**Hospital1 18**]. You were hospitalized for a G-tube replacement because your old G-tube had blood draining from it, but the procedure was complicated by fever. Your fever was probably the result of pneumonia. Once the G-tube was replaced, the bleeding stopped. . You were admitted to the Intensive Care Unit for treatment of a pneumonia. Your pneumonia and clinical condition improved with antibiotics. You will continue taking antibiotics via your G-Tube after discharge. . You were initially treated with antibiotics for possible C.Dif because of your history; however, the antibiotics were discontinued because it was deemed low probability that you were re-infected with C.Diff. . Your atrial fibrillation was managed with coumadin as per your usual; you were started on heparin while your INR increased to therapeutic levels. . Your sacral decubitus ulcer was managed by the wound care nurse. . No changes to your medications were made other than as detailed below. - START: Levofloxacin for pneumonia until the prescription is complete - INCREASE: Warfarin from 3mg to 4mg until directed by the rehab physician to decrease the dose back to 3mg Followup Instructions: Department: [**Hospital1 **] SPECIALTIES When: WEDNESDAY [**2201-6-3**] at 9:00 AM With: UROLOGY UNIT [**Telephone/Fax (1) 164**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "250.60", "427.31", "599.0", "041.6", "995.91", "V44.0", "V58.61", "707.03", "996.64", "401.9", "507.0", "038.9", "482.83", "E879.6", "357.2", "707.22", "536.49", "285.9", "V12.54" ]

icd9cm

[ [ [] ] ]

[ "33.29", "97.02", "96.6" ]

icd9pcs

[ [ [] ] ]

12902, 12962

6290, 8811

13163, 13163

4726, 5890

14521, 14795

3719, 3787

10100, 12879

12983, 13142

8837, 10077

13297, 14498

5906, 6267

3802, 3802

4694, 4707

265, 350

378, 2730

3816, 4680

13178, 13273

2752, 3372

3388, 3703

18,351

136,878

21073

Discharge summary

report

Admission Date: [**2127-7-31**] Discharge Date: [**2127-8-7**] Date of Birth: [**2097-10-13**] Sex: F Service: GYN HISTORY OF PRESENT ILLNESS: This is a 29-year-old G1, P1, who was recently admitted to GYN Service with a UTI, questionable hemorrhagic cyst secondary to a large free fluid seen on ultrasound, left lower quadrant pain, and a questionable infected hematoma. Dates of prior admission were [**2127-7-27**] through [**2127-7-29**]. The patient was discharged feeling well with some left lower quadrant pain and afebrile. The patient reported a temperature to 100 degrees at home. and a recurrence of pain that started approximately 2 hours ago and the patient describes it as a [**11-9**] in the left lower quadrant, constant and nonradiating. The patient describes the pain as feeling like gas pains. The patient reports she has been passing gas and had a bowel movement this morning. No nausea. Last p.o. intake was 9 a.m. this morning. The patient also took Dilaudid p.o. for the pain with no effect. On initial admission on [**2127-7-27**], the patient states that the pain began approximately 3 days prior to this and increased in severity gradually. She was seen at [**Hospital3 **] and at that point was told that she had either a ruptured cyst or a pelvic infection. She was given doxycycline and pain medication and discharged to home. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. PAST OB HISTORY: History of one spontaneous vaginal delivery at term in [**Country 4194**]. PAST GYN HISTORY: The patient underwent menarche at 12 years old. She has had regular menses with duration of [**5-5**] days with bleeding. She has no history of STDs. She is sexually active with one partner. MEDICATIONS: Oral contraceptive pills from [**Country 4194**] called Minulet. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies tobacco use, alcohol use or drug use. PHYSICAL EXAM ON ADMISSION: Vitals: Temperature is 98.6 degrees, pulse 95, blood pressure 130/80, and respiration rate 18. The patient is in no apparent distress. Chest exam reveals clear to auscultation bilaterally. Cardiovascular exam reveals a regular rate and rhythm without murmurs, gallops or rubs. Abdominal exam: The abdomen is soft, tender to palpation in the left lower quadrant. No tenderness to palpation on the right. The patient is moderately guarding. She is not distended. The patient has bowel sounds and also suprapubic tenderness to palpation. Extremity exam reveals no clubbing, cyanosis or edema. Pelvic exam shows normal external genitalia. Cervical motion tenderness is present. Left adnexal tenderness. No right adnexal tenderness. No uterine tenderness. LABORATORY DATA ON ADMISSION: CBC showed slightly elevated white count of 11.6, hematocrit was 37.0, platelets were 353,000, and differential was 75 neutrophils, 5 bands, and 11 lymphocytes. UA showed 30 of protein, 3 white blood cells per high-powered field, no bacteria, no yeast, no epithelial cells. All else was negative on UA. Beta hCG was negative. Ultrasound findings were consistent with a hematosalpinx or a pyosalpinx on the left. There is no free fluid. The tubular structure measured 10 x 10 x 6 cm. HOSPITAL COURSE: The patient was admitted to GYN and started on IV doxycycline and Flagyl for a suspected PID. She was also made n.p.o. The following day, the decision was made to bring the patient to the OR for a diagnostic laparoscopy to further characterize the tubular structures seen on ultrasound. The patient was consented. In the OR, diagnostic laparoscopy converted to an exploratory laparotomy due to a large abdominal/pelvic abscess seen via laparoscopy. Upon laparotomy, adherent small bowel and omentum were encountered and General Surgery was called to help with lysis of adhesions. A left pyosalpinx was observed and a left salpingo-oophorectomy was performed. Postoperatively, the patient was transferred to the ICU for hemodynamic monitoring secondary to anticipated sepsis. Serial abdominal exams, fever curve, and white blood count were followed. The patient was given a Dilaudid PCA for pain control. The patient was given IV doxycycline and IV Zosyn to cover bowel flora and Chlamydia. An NG tube was left in place to allow bowel rest. The patient remained afebrile and hemodynamically stable in the ICU and was transferred back to the care of the GYN Service on [**2127-8-3**]. Her NG tube was also removed at this day. Over the course of the next few days, the patient's white blood cell count continued to fall from a peak of 24.4 on [**2127-8-3**] to 9.5 on [**2127-8-7**]. The patient's electrolytes were monitored and repleted as necessary, her diet was advanced as tolerated, and her pain medicine was switched to p.o. Percocet. On discharge, on [**2127-8-7**], the patient was tolerating a regular p.o. diet without nausea or vomiting, was urinating without difficulty, bowel function was intact, and the patient was passing flatus and having bowel movements. She was also able to ambulate without difficulty. Antibiotics at this point were switched to p.o. ciprofloxacin 500 mg b.i.d. for another 7 days to finish out a total 14-day course of antibiotics. The patient's final wound culture was positive for both E. coli and Bacteroides fragilis. The patient is to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. DISCHARGE MEDICATIONS: 1. Ciprofloxacin 500 mg b.i.d. x7 days. 2. Percocet 1-2 tablets q.3-4h. p.r.n. for pain. 3. Ibuprofen 600 mg q.6h. p.r.n. for pain. DISPOSITION: To home. DISCHARGE STATUS: Good. DISCHARGE DIAGNOSES: Pelvic inflammatory disease. Left pyosalpinx. [**First Name11 (Name Pattern1) 1158**] [**Last Name (NamePattern1) 24802**], [**MD Number(1) 24803**] Dictated By:[**Last Name (NamePattern1) 55953**] MEDQUIST36 D: [**2127-8-7**] 22:59:59 T: [**2127-8-8**] 02:48:32 Job#: [**Job Number 34897**]

[ "614.3", "614.0", "038.9", "568.0", "995.91", "041.4", "620.0", "V64.41" ]

icd9cm

[ [ [] ] ]

[ "54.51", "65.49" ]

icd9pcs

[ [ [] ] ]

5694, 6018

5488, 5672

3284, 5465

1442, 1875

165, 1388

2776, 3266

1411, 1418

1892, 1964

15,116

179,218

22732

Discharge summary

report

Admission Date: [**2153-1-2**] Discharge Date: [**2153-1-26**] Date of Birth: [**2089-12-12**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 58850**] is a 63-year-old male with a known history of coronary artery disease, status post a silent myocardial infarction in [**2143**], who presented to [**Hospital3 1280**] Hospital Emergency Department this morning with 8/10 chest pain, epigastric distress, nausea, and shortness of breath. He had ST depressions laterally and ST elevations in V1. These resolved with intravenous nitroglycerin and Lopressor in the Emergency Department. He was taken for cardiac catheterization which revealed 3 plus calcified LAD with a 95 percent proximal occlusion, a 70 to 80 percent proximal circumflex lesion, and 100 percent occluded RCA with collaterals. Echocardiogram revealed 1 to 2 plus mitral regurgitation, trace tricuspid regurgitation, and an left ventricular ejection fraction of 30 percent. He was placed on intravenous Integrilin and transferred to [**Hospital1 1444**] for coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Myocardial infarction. 3. Hypertension. 4. Hypercholesterolemia. 5. Sleep apnea (with BiPAP). 6. Status post abdominal aortic aneurysm repair with two endovascular stents followed by surgical repair with a questionable open bypass of the left femoral artery in [**2152-2-28**] at [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] Hospital. 7. Status post carpal tunnel repair in [**2152-10-30**] with a brief period of postoperative atrial fibrillation. The patient admits to not taking his medications at that time. He was treated with Coumadin for one month without further atrial fibrillation. SOCIAL HISTORY: The patient quit smoking nine years ago. He had an 80-pack-year history. He admitted for four to six beers a day for significant alcohol abuse. He is married and lives with his wife and works as a plant manager. MEDICATIONS AT HOME: Atenolol 100 mg p.o. once daily, Lipitor 40 mg p.o. once daily, aspirin 325 mg p.o. once daily, vitamin D, and fifth medicine is unclear. MEDICATIONS ON TRANSFER: At [**Hospital3 1280**] Hospital he was started on intravenous Integrilin, Lopressor, aspirin, heparin, intravenous nitroglycerin, and antacids. ALLERGIES: He has no known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Neurologically, he was grossly intact without any carotid bruits. His lungs had a few bibasilar crackles. His heart was regular in rate and rhythm with S1 and S2. No murmurs noted. His abdomen was slightly firm, distended, and nontender. His extremities were warm without any edema with positive peripheral pulses. SU[**Last Name (STitle) 42242**]OF HOSPITAL COURSE: The patient was referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] on intravenous Integrilin, nitroglycerin, and heparin. He had epigastric discomfort since his admission which was increasing. Intravenous nitroglycerin was also increased. This was discussed with Dr. [**Last Name (Prefixes) **] and an emergent Cardiology consultation was ordered, but the patient continued to have chest pain. He was seen by a cardiologist. He continued to have chest pain. It was determined the patient was unable to have an intraaortic balloon pump placed for his continuing chest pain due to his three endovascular stents. The patient was seen by Dr. [**Last Name (STitle) 16646**] of Cardiology when he was admitted. Preoperative laboratories were as follows. Sodium was 137, potassium was 3.5, chloride was 99, bicarbonate was 30, blood urea nitrogen was 11, creatinine was 0.7, with a blood sugar of 165. White count was 12.3, hematocrit was 42.9, and platelet count was 204,000. CK's went from 125 to 284 to 725 with troponin's from less than 0.04 to 1.75 to 3.38; ruling the patient in for a significant myocardial infarction. Th[**Last Name (STitle) 1050**] was taken to the Operating Room emergently that evening and underwent emergent coronary artery bypass grafting times three with a LIMA to the LAD, a vein graft to the PDA, and a vein graft to the OM by Dr. [**Last Name (Prefixes) **]. He was taken to the Cardiothoracic Intensive Care Unit in critical condition on an epinephrine drip at 0.05 mcg/kg/min, a nitroglycerin drip at 0.5 mcg/kg/min, a titrated propofol drip, and a Neo-Synephrine drip at 1 mcg/kg/min. In the immediate postoperative period the patient developed several problems. The first was atrial fibrillation which was treated with an amiodarone bolus and started on an intravenous drip. He ultimately required cardioversion by anesthesia and then later repeat cardioversion by Electrophysiology. The second significant incident was the patient's liver function tests rose dramatically given his significant alcohol abuse. A Critical Care consultation was also called. The patient was clearly undergoing alcohol withdrawal and developed delirium tremens. He was continued on amiodarone. Within a day or two he was also seen by the Clinical Nutrition team as the Critical Care team was evaluating his nutritional status and liver function. He remained in the Cardiothoracic Intensive Care Unit all that week. On [**1-12**], he continued with an inability to wean from the respirator. He developed atelectasis which was apparent on his chest x-ray and significant copious secretions. He was awake and was on CPAP with pressure support but continued to require significant pulmonary toilet and was unable to wean from the ventilator. Given these secretions, blood cultures were also sent in addition to sputum cultures. An evaluation by Dr. [**First Name (STitle) **] [**Name (STitle) **] of the Critical Care Pulmonary Service was obtained. The patient's blood cultures grew out gram-positive cocci and sputum secretions grew out coagulase- positive Staphylococcus. The patient was started empirically the next day on vancomycin, Levaquin, and fluconazole. An Infectious Disease consultation was called. The patient was seen by Infectious Disease on [**1-13**]. Please refer to their official consultation note. In addition, the patient remained on amiodarone, digoxin, and was started on carvedilol for beta blockade and management of his atrial fibrillation which continued to be an issue. Clearly, given his respiratory failure, there was great concern about the process going on in his lungs. When the cultures came back, the sensitivities showed a sensitivity to oxacillin. The bronchoscopy secretion and alveolar lavage which was done by Dr. [**Last Name (STitle) **] showed methicillin-resistant Staphylococcus aureus. Blood cultures showed methicillin-sensitive Staphylococcus aureus that came back on [**1-13**]. The patient was changed over. His vancomycin, levofloxacin, and fluconazole were stopped given the lack of sensitivities to his bacteria, and he was switched to intravenous oxacillin. The patient was also initially evaluated by Physical Therapy. He had again failed an extubation wean; again failed in his ability to attempt to wean for extubation on [**1-12**] prior to his bronchoscopy which necessitated a Pulmonary consultation. Given the fact that the patient had very little mobility at that time, heparin was also started for anticoagulation in preparation for Coumadin starting for anticoagulation for his atrial fibrillation. Additional blood cultures and sensitivities came back, and the patient was switched back to vancomycin approximately on [**1-20**]. On [**1-21**], he continued to markedly improve on the CPAP and was ultimately extubated. The patient continued to have mental status issues with confusion and disorientation - from which he would rapidly reorient but then become significantly confused again. The patient had some doses of Haldol to help with this and continued to be dosed with Coumadin once daily in an effort to get him anticoagulated. Finally, on [**1-23**], the patient was transferred to [**Hospital Ward Name 121**] Two. The patient had been treated all along for his delirium tremens and alcohol withdrawal under the direction of the Critical Care team and was on an Ativan drip. On [**1-21**], his white count increased from 12.2 to 12.5. His hematocrit remained stable at 34.6 with a normal platelet count. His creatinine was 0.8. A transesophageal echocardiogram was ordered to rule out endocarditis, and this was done by Cardiology. This was performed on [**1-25**] prior to his discharge and showed no vegetations, a mildly thickened aortic valve, a mildly thickened mitral valve, with mild 1 plus mitral regurgitation, and no evidence of endocarditis. The patient continued to be evaluated and worked on by Physical Therapy and the nurses for significant pulmonary toilet as well as physical therapy while he was out on the floor. He remained on a heparin drip as he became therapeutic with his Coumadin. He was receiving albuterol as needed, and Combivent, and Flovent to assist with his pulmonary toilet. He also remained on carvedilol. Lisinopril had been started at 5 mg also. The patient continued to rapidly improve on postoperative day 22. He was encouraged to ambulate and to increase his oral intake. If the patient ruled out for endocarditis - which he did - he was to be switched over from intravenous vancomycin to oral linezolid and then planned for discharge to home. On postoperative day 23 - the day prior to his discharge - his laboratories were as follows. White count was 10.9, the hematocrit was 31.3, and the platelet count was 407,000. The PT was 17.2, PTT was 64.3, and INR was 1.9 on both heparin and Coumadin. Sodium was 137, potassium was 5.2, chloride was 96, bicarbonate was 30, blood urea nitrogen was 19, creatinine was 1.1, with a blood sugar of 109. The patient's weight was 71.6 (down from his preoperative weight of 81 kilograms). He was saturating 94 percent on room air and was hemodynamically stable and doing very well with a blood pressure of 110/66. The respiratory rate was 18. In a sinus rhythm at 68. He was alert and oriented and nonfocal. His lungs were clear bilaterally. His sternum was stable with no drainage or erythema. He had bowel sounds. No peripheral edema. His left leg incision saphenous vein graft site was healing well. His central venous line had been removed. The pacing wires had been removed. No chest tubes were in place as these had been removed days before. He was switched over to linezolid 600 mg p.o. twice daily. Heparin was discontinued. The patient received Coumadin 3-mg dose that evening in preparation for increasing his INR. His heparin was discontinued that night. He was gain evaluated by Case Management so he could be discharged to home with VNA services. DISCHARGE DISPOSITION: On postoperative day [**1-22**] - the patient was discharged to home with VNA services. He was in a sinus rhythm at 73. The blood pressure was 97/51 and was saturating 97 percent on room air with an unremarkable and much improved physical examination. DISCHARGE DIAGNOSES: 1. Status post emergent coronary artery bypass grafting times three. 2. Coronary artery disease. 3. Ethanol abuse and status post withdrawal. 4. Myocardial infarction. 5. Hypertension. 6. Hypercholesterolemia. 7. Sleep apnea (with BiPAP). 8. Status post abdominal aortic aneurysm with three endovascular stents. 9. Status post left femoral open bypass. 10. Status post carpal tunnel repair on the right. 11. Atrial fibrillation. 12. Pneumonia with bacteremia. 13. Respiratory failure status post surgery. DISCHARGE STATUS: The patient was discharged to home on [**2153-1-26**]. CONDITION ON DISCHARGE: Stable. DISCHARGE FOLLOWUP: 1. The patient was instructed to come to the [**Hospital1 20311**] [**Hospital 409**] Clinic approximately two weeks post discharge. 2. The patient was instructed to see his cardiologist - Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 3659**] - in approximately two to three weeks post discharge. 3. The patient was instructed to see Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in the office in four weeks for his postoperative surgical visit. MEDICATIONS ON ADMISSION: 1. Carvedilol 3.125 mg p.o. twice daily. 2. Lisinopril p.o. once daily. 3. Amiodarone 400 mg p.o. twice daily for one week; then 400 mg p.o. once daily for one week; then 200 mg p.o. once daily. 4. Digoxin 0.125 mg p.o. once daily. 5. Fluticasone propionate 110-mcg actuation aerosol 2 puffs inhaled twice daily. 6. Albuterol ipratropium 103/18 mcg actuation aerosol 1 to 2 puffs inhaled q.6h. 7. Multivitamin capsules one capsule p.o. once daily. 8. Enteric coated aspirin 81 mg p.o. once daily 9. Colace 100 mg p.o. twice daily. 10. Percocet 5/325 one to two tablets p.o. q.6h. as needed (for pain). 11. Coumadin 1 mg p.o. once daily (for [**1-26**], [**1-27**], and [**1-28**]); then the patient was instructed to check with Dr. [**Last Name (STitle) 3659**] - his cardiologist - for continued dosing beyond [**1-28**] and blood draws to evaluate his INR therapeutic level. 12. Linezolid 600 mg p.o. twice daily (for 18 days with the last dose scheduled for [**2153-2-13**]). [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2153-2-22**] 12:01:54 T: [**2153-2-22**] 13:28:20 Job#: [**Job Number 58851**]

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icd9cm

[ [ [] ] ]

[ "93.90", "96.72", "96.6", "39.61", "33.24", "36.12", "36.15", "99.62", "99.04", "88.72", "38.91", "00.17" ]

icd9pcs

[ [ [] ] ]

10869, 11123

11144, 11752

12331, 13609

2824, 10845

2055, 2194

11806, 12305

165, 1106

2220, 2806

1128, 1800

1817, 2033

11777, 11786

23,264

127,812

47587

Discharge summary

report

Admission Date: [**2129-7-22**] Discharge Date: [**2129-7-28**] Date of Birth: [**2079-8-31**] Sex: F Service: ORTHOPAEDICS Allergies: Sulfatrim Attending:[**First Name3 (LF) 11415**] Chief Complaint: fevers, infection of hardware Major Surgical or Invasive Procedure: i/d washout left humerous vac placement [**2129-7-22**] left arm wound closure [**2129-7-25**] History of Present Illness: 49 y/o female s/p removal of hardware and repair of left humerus nonunion w/ bone graft and locking plate on [**7-13**] presented to ED 9 days post operatively w/ an infected wound and fever. Past Medical History: Hep C EtOH abuse Depression Cirrhosis L humerus fracture s/p ORIF [**2129-1-12**]; s/p removal of hardware and repair of left humerus nonunion w/ bone graft and locking plate [**2129-7-13**] Social History: +EtOH abuse +tob denies rec drug use homeless Family History: N/C Physical Exam: 102.3 HR 90 BP 110/71 RR 16 95% RA AOx3, NAD CN II-XII intact RRR CTAB S/F/NT; pelvic wound healing well L arm erythematous w/ oozing serous fluid, warm/tender to touch, indurated, no flutuance Pertinent Results: [**2129-7-22**] 05:19PM GLUCOSE-70 UREA N-11 CREAT-0.6 SODIUM-136 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-21* ANION GAP-11 [**2129-7-22**] 05:19PM ALT(SGPT)-19 AST(SGOT)-33 LD(LDH)-266* ALK PHOS-63 AMYLASE-20 TOT BILI-1.0 [**2129-7-22**] 05:19PM LIPASE-9 [**2129-7-22**] 05:19PM ALBUMIN-2.5* CALCIUM-7.4* PHOSPHATE-2.6* MAGNESIUM-1.2* [**2129-7-22**] 05:19PM WBC-17.3* RBC-2.97* HGB-8.9* HCT-26.9* MCV-91 MCH-30.0 MCHC-33.1 RDW-15.4 [**2129-7-22**] 05:19PM NEUTS-92.1* BANDS-0 LYMPHS-5.3* MONOS-2.4 EOS-0.2 BASOS-0.1 [**2129-7-22**] 05:19PM PT-14.8* PTT-34.6 INR(PT)-1.5 Brief Hospital Course: 49 y/o female s/p removal of hardware and repair of left humerus nonunion w/ bone graft and locking plate on [**7-13**] presented to ED 9 days post operatively w/ an infected wound and fever. The patient was initially admitted to the ICU given transient drops in her blood pressure and concern about sepsis. She was hemodynamically stabilized. On HD 1 she was taken to the OR for washout of the left humeral wound and vac placement. On HD 3 she was taken again to the OR and had the vac removed and the wound closed. After surgery the patient was transfered to the floor where she remained stable and on antibiotics - vancomycin and clindamycin - recommended by the ID team. She was discharged on HD 6 in stable condition. She will remain nwb on her lue. id final rec were cbc bun cr vanco trough weeekly and results faxed to dr [**First Name (STitle) **] at [**Telephone/Fax (1) 1419**] she should follow up on [**2129-8-23**] at 9 30 am in i/d clinic day of dc id dcd her clinda and she was stable to be transfered to rehab Medications on Admission: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 5. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 6. Diphenhydramine HCl 25 mg Capsule Sig: [**1-9**] Capsules PO Q6H (every 6 hours) as needed for pruitis. 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2 hours) as needed for 2 weeks. Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: 0.65-1.3 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Methadone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 12. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day) as needed. 13. Vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln Intravenous Q 12H (Every 12 Hours). Discharge Disposition: Extended Care Facility: [**Hospital6 4657**] - [**Location 1268**] Discharge Diagnosis: infected left humerous Discharge Condition: good to rehab Discharge Instructions: dc to rehab follow up as below keep dsd clean and dry wear sling at all times please have cbc bun cr vanco trough drawn weekly and results faxed to [**Telephone/Fax (1) 100564**] keep vanco trough at 15-20 Physical Therapy: Activity: Activity as tolerated Pneumatic boots Left upper extremity: Non weight bearing Sling: At all times Treatments Frequency: Site: LEFT UPPER EXT Description: LARGE INCISION, SUTURES INTACT. SOME DRAINAGE. Care: DSD TO WOUND Site: L arm dressing Type: Surgical Dressing: Gauze - dry Comment: reinforce dressing as needed Site: L arm dressing Type: Surgical Dressing: Gauze - dry Comment: reinforce dressing as needed Site: L arm dressing Type: Surgical Dressing: Gauze - dry Comment: reinforce dressing as needed Site: L arm dressing Type: Surgical Dressing: Gauze - dry Comment: reinforce dressing as needed Followup Instructions: [**Name6 (MD) **] [**Name8 (MD) **] md [**2129-8-23**] 9:30 am [**Hospital **] clinic [**Hospital **] medical building [**Telephone/Fax (1) 100565**] dr [**Last Name (STitle) **] in 1 week call [**Telephone/Fax (1) 9769**] for appoint [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**] Completed by:[**2129-7-28**]

[ "070.70", "305.00", "571.5", "038.9", "995.91", "998.59", "682.3", "311" ]

icd9cm

[ [ [] ] ]

[ "93.59", "99.04", "86.22", "38.93" ]

icd9pcs

[ [ [] ] ]

4770, 4839

1766, 2807

305, 402

4906, 4921

1160, 1743

5845, 6244

918, 923

3522, 4747

4860, 4885

2833, 3499

4945, 5153

938, 1141

5171, 5288

5311, 5822

236, 267

430, 624

646, 838

854, 902

14,579

168,345

7008

Discharge summary

report

Admission Date: [**2125-5-5**] Discharge Date: [**2125-6-15**] Date of Birth: [**2056-5-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: SOB, chest pain Major Surgical or Invasive Procedure: Cardiac catherization Cardiac catherization with stenting of the left anterior descneding artery intubation central line placement Left thoracotomy with lung biopsy [**Last Name (NamePattern4) 15255**] of Present Illness: Mr. [**Known lastname **] is a 68M with history of 2VD s/p stent placement, CHF (admitted [**2-19**] to [**Hospital 8641**] Hospital), DM2, HTN, hyperlipidemia, past tobacco, and lung CA s/p LUL resection [**2121-12-23**], who presents with chest pain and SOB. Patient awoke @ 3:30 a.m. to urinate and when returning to bed had chest pain [**8-23**], substernal, radiating to left shoulder, accompanied by SOB. No diaphoresis, jaw pain, nausea, vomiting, lightheadedness; did not radiate down arm or to back. Took 2 SL nitro and pain did not resolve (usually does with 1 SLNTG), so wife called 911. [**Name2 (NI) 1194**] resolved after EMS administered NTG spray (~ 7:30 am), and it has not recurred since. Patient states that he has chest pain 3-4 times per week, but is usually relieved with ONE SL nitro. Patient's episodes have been becoming more frequent over last few weeks. He denies exertional or other triggers. Usually relieved with rest. + DOE with minimal activity - able to walk [**11-2**] feet before he usually gets SOB, sometimes has mild associated chest pain. Plan prior to this ED admission was for CABG in [**6-9**] with Dr. [**Last Name (Prefixes) **]. . At OSH patient found to be 81% on RA, BP stable at 129/68. EKG done which showed ST depressions I, II, V3-V6, LVH, and ST elevation of AVR. Trop 1.6, anemic with HCT 30, ARF with Cr 3 ([**1-22**] on [**4-3**]). Patient was started on integrillin but developed hemoptysis and this was stopped. No further therapy and patient was transferred to [**Hospital1 18**] for further evaluation. . Upon arrival to [**Hospital1 18**], patient denied CP, SOB, dizziness, diaphoresis, nausea, vomiting. Patient relates episode of hemoptysis this a.m., but states that this is not new, occurring a couple times a week, unable to quantify amount (coughs, may have BRB, but next cough productive of clear sputum). + cough, worse ever since being intubated in [**2-19**] during catheterization. + chills, no fevers, no weight loss. Past Medical History: - BP: 99-119/43-77, HR 81-107 Sats 89-97% RA Afebrile at home # CAD: - MI [**10-15**] - Cardiac Cath [**2-/2125**], s/p 6 stents (see below) - 50% LMCA unchanged from [**2123**], 60% LAD, 50% OM1 (LCx), dominant RCA was proximally occluded with robust L->R collaterals, # CHF - EF 30% - weight: 206-208 lbs # HTN # Dyslipidemia # DM2 - IDDM # Renal artery stenosis # PVD - s/p aortobifemoral, [**2-/2118**] by Dr. [**Last Name (STitle) **]; right femoral-popliteal in [**2111**]; toe amputations; renal artery graft during aortobifemoral # GERD # Lung Ca s/p LUL resection [**2-15**] - Dr. [**First Name (STitle) **], Dr. [**Last Name (STitle) 6944**] - 3 and 5 cm masses resected - [**2125-2-17**]. CT demonstrated a return of his mediastinal adenopathy back to the baseline that was present in [**2121**]. There is no evidence of recurrent tumor. # Anemia - due to chronic disease, baseline 30s. Most likely due to chronic disease, although nl epogen level. Suspect BM suppression. . Past Surgical History: Right fem-[**Doctor Last Name **] bypass Aortofem BPG [**2118**] Multiple foot surgeries - Bilateral halux amputations, most recent [**2-/2125**] on R Graft in renal artery Endarterectomy Umbilical hernia repair Left upper lobectomy Social History: lives independently with wife, limited mobility lately, ex-smoker 15 years ago x 30 pack year, no etoh. Family History: Mother deceased 54 - DM Father deceased 58 - accident Sister - CAD/MI/STROKE Daughter - bladder ca Physical Exam: PE: Vitals: 93.1 136/52 80 24 100%3L NC Gen: elder, pleasant, male, NAD HEENT: aniceric, no JVD, + 1 carotid bruit's b/l, faint thrills b/l, MMM CV: RRR, nl s1, s2, no extra HS appreciated Lungs: crackles b/l R>L, with decrease breath sounds over LLB Abd: + BS, SNT/ND, no hsm Ext: trace edema, pink, warm, no ulcers, several amputated toes, + 1 palpable R DP, nonpalpable/doplerable L DP, + 1 weak b/l PT. Neuro: AxOx3, patient appropriate Pertinent Results: [**2125-5-5**] Trop-*T*: 0.66 135 104 39 AGap=19 -------------< 121 5.2 17 1.4 CK: 346 MB: 14 MBI: 4.0 84 3.7 \ 8.6 / 328 / 25.5\ N:72.4 L:18.1 M:8.8 E:0.5 Bas:0.3 Hypochr: 1+ Anisocy: 2+ Poiklo: 1+ Microcy: 1+ PT: 14.8 PTT: 31.0 INR: 1.3 [**2125-5-20**] 11:07AM BLOOD ESR-80* [**2125-5-18**] 09:00PM BLOOD Ret Aut-4.5* [**2125-5-8**] 05:30AM BLOOD CK(CPK)-708* [**2125-5-18**] 12:00PM BLOOD ALT-40 AST-46* LD(LDH)-403* CK(CPK)-294* AlkPhos-51 TotBili-0.3 [**2125-6-2**] 04:38AM BLOOD CK-MB-12* MB Indx-15.0* cTropnT-0.26* [**2125-5-8**] 05:30AM BLOOD CK-MB-93* MB Indx-13.1* cTropnT-3.06* [**2125-5-28**] 04:09AM BLOOD Hapto-256* [**2125-5-10**] 05:08AM BLOOD calTIBC-127* Ferritn-1826* TRF-98* [**2125-5-18**] 12:00PM BLOOD TSH-8.6* [**2125-5-8**] 05:30AM BLOOD T4-5.8 T3-62* Free T4-1.2 [**2125-5-29**] 06:00AM BLOOD Cortsol-32.8* [**2125-5-29**] 07:21AM BLOOD Cortsol-39.3* [**2125-5-21**] 11:09AM BLOOD ANCA-NEGATIVE B [**2125-5-21**] 11:09AM BLOOD ANTI-GBM-Test <3 (Negative) Brief Hospital Course: #) [**Name (NI) 7792**] - Pt with known 3VD and was admitted with chest pain. He had [**Name (NI) 7792**] on admission in setting of severe anemia Then, had repeat [**Name (NI) 7792**] on [**5-7**] in setting of high fever and tachycardia with troponin peak of 3.0 and CK pear in the 700's. Cardiac cath repeated on [**5-8**] and unchanged since [**2-/2125**]: LM 50%, mLAD 60%, LCx 60%, T.O. RCA. The enzyme leak was thought to be due to lack of flow through collaterals. CT surgery was consulted, but determined that he was not a CABG candidate due to extensive aortic calcifications, so he was taken back to cath on [**5-17**] and had a single cypher stent placed to his mid-LAD on [**2125-5-17**]. He had decreasing troponins and no further chest pain from that point. He was kept on plavix to 75mg, ASA back to 325, statin, beta blocker, and ACE as tolerated for the remainder of hospitalization. #) Respiratory failure/Hemoptysis/Silent Aspiration - The patient has a history of lung cancer and there was concern for recurrent lung cancer in the setting of hemoptysis and enlarged tracheal nodes on admission. Interventional pulmonary was consulted and performed transbronchial biopsy of the mediastinum, which showed a clot in the right bronchus and negative cytology. His hemoptysis resolved. He was diuresed and his oxygen requirement disappeared. On [**2125-5-18**], the day after cath, he had acutely worsened respiratory distress, fever, and hypotension with worsened CXR and was put on ceftriaxone/vancomycin/azithro for hospital acquired pneumonia. He continued to spike and was changed vanc/zosyn on [**5-21**]. His fevers gradually resolved. On [**5-27**], he became febrile again and Vanc/zosyn were restarted. He was kept on bipap without success for 1 day then intubated. He was put on levophedrine for hypotension on [**5-28**], and meropenem was substituted for vancomycin. During this whole time he was diuresed for potential CHF, but his fluid status was unclear so a swan was placed with initial wedge 62/30 wedge 14-24 CO 5.9 CI 2.6 SVR 1100. He continued to be diuresed. Pulmonary was consulted and performed bronchoscopy with negative cultures and negative cytology. He gradually improved over 3 days and was extubated, but still had a significant oxygen requirement, with PaO2/FiO2 ratio < 200 and bilateral infiltrates. At this point he was changed from the CCU team to the MICU team as his primary problem was respiratory failure. The DDx of his hypoxic respiratory failure was CHF, persistent pneumonia (atypical or other), lymphangitic spread of cancer, silent aspiration, Wegener's, interstitial lung disease. PPD, ANCA, anti-GBM, sputum for cytology and PCP were negative. All sputum cultures showed only oropharyngeal flora. A bedside swallow showed no clinical signs of aspiration but video swallow showed significant aspiration. The decision was made to start empiric steroids, solumedrol 125 Q6H, which appeared to help for 2 days but then he started to become more hypoxic again. He was re-intubated for hypoxia and taken to OR for left sided thoracotomy. Biopsy results showed diffuse alveolar damage consistent with ARDS picture. No obvious signs of BOOP. Steroids were weaned off. Also, culture data grew enterococus from BAL and biopsy site. He was initially treated with vancomycin and transitioned to ampicillin based on sensitivities. ID consultation felt it was contamination and antibiotics were discontinued. #) Pump/CHF - Patient has severe class III symptoms at home with Lasix 40 PO BID dose. Echo [**5-8**] showed: 40% EF, global hypokinesis with + 1 MR. [**First Name (Titles) 907**] [**Last Name (Titles) **] after stenting showed EF >55%. He was agressively diuresed throughout the hospitalization and responded well to frequent doses of 40 IV lasix. Pulmonary artery catheterization showed intermittent high wedge, range [**1-6**]. He was maintained on metoprolol and captopril as tolerated. #) Adrenal insufficiency - For hypotension, [**Last Name (un) 104**] stim was done which bumped from 33-39 so he was started on hydrocort/fludricort. Then he was changed . #) Anemia - Pt has aenmia likely due to chronic disease, baseline 30s with although nl epogen level. Suspect BM suppression. He needed 7 units PRBC throughout hospitalization. #) ARF - Baseline 1.0-1.3, but his creatinine became elevated from agressive diuresis and low BP up to peak of 1.9. His ACE was held but then restarted in the setting of CHF with improvement back to his baseline of 1.1. Then his creatinine started to rise again likley combination of ATN and pre-renal state. #) GI bleeding - on [**6-14**] PM he was noted to have melenotic stools and several point hematocrit drop. #) Code Status - This was discussed and confirmed at multiple points throughout his hospitalization. However, given his progressive decline with increasing renal failure, new gi bleeding, progressive hypoxia, intermittent sepsis, ARDS, ventricular arrythmias he was made DNR/DNI on [**2125-6-14**]. After family meeting on [**2125-6-15**] patient was made CMO and he quickly passed off pressors. Medications on Admission: Lasix 40 [**Hospital1 **] Vytorin 40 [**Hospital1 **] Levothyroxine 0.05 NPH 15units QAM, 20units QPM Reg 10units AM, 15 Lisinopril 10 QD ASA Metoprolol 100 [**Hospital1 **] Iron [**Hospital1 **] Colace Isosorbide mononitrate 60 QD Stopped spironolactone d/t hyperkalemia Discharge Disposition: Home Discharge Diagnosis: Non-ST elevation myocardial infarction Congestive heart failure Anemia Acute renal failure Diabetes NSVT Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "250.00", "440.20", "428.0", "707.8", "414.01", "287.5", "530.81", "599.0", "401.9", "578.0", "V10.11", "V64.1", "038.9", "427.1", "414.8", "285.29", "496", "440.1", "486", "041.4", "584.9", "507.0", "V45.81", "410.71", "516.8", "578.1", "995.91" ]

icd9cm

[ [ [] ] ]

[ "38.91", "99.20", "34.27", "33.24", "37.23", "00.66", "83.82", "38.93", "99.04", "00.45", "88.72", "00.40", "32.29", "96.04", "96.72", "37.22", "33.23", "36.07", "33.27", "33.22", "33.34", "93.90", "88.56" ]

icd9pcs

[ [ [] ] ]

11016, 11022

5555, 10694

329, 2546

11171, 11180

4528, 5532

11236, 11246

3950, 4050

11043, 11150

10720, 10993

11204, 11213

3577, 3812

4065, 4509

274, 291

2568, 3554

3828, 3934

14,757

112,613

1259

Discharge summary

report

Admission Date: [**2135-11-26**] Discharge Date: [**2135-12-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6378**] Chief Complaint: [**Last Name (un) **] pain Major Surgical or Invasive Procedure: cholecystectomy, ileostomy take down History of Present Illness: 85M transferred from surgery. Had colon cancer s/p colectomy [**4-11**], complicated by ileal perf leading to ileostomy. Originally planned for ileosotomy revision on [**11-30**], however, presented to ED [**11-25**] w/ abdominal pain, found to have acute cholecystitis. Past Medical History: 1. PERIPHERAL EDEMA 2. DYSPHAGIA 3. Immune thrombocytopenic purpura 4. GBS like peripheral neuropathy 5. GASTROESOPHAGEAL REFLUX 6. NECK PAIN 7. CHRONIC CONJUNCTIVITIS 8. PERIPHERAL VASCULAR DISEASE 9. Hemorrhoids 10. SEROUS OTITIS 11. BENIGN PROSTATIC HYPERTROPHY 12. HYPERTENSION 13. Right Colon Cancer 14. Rectal ulcers 15. Myelodysplastic syndrome 16. colon cancer s/p colectomy [**4-11**], complicated by ileal perf leading to ileostomy placement 17. Chronic myelomonocytic leukemia on prednisone 18. adrenal insufficiency 19. abdominal abscess [**10-12**] Social History: Founder of Juliard String Quartet. No tobacco, no EtOH, generally lives with wife, however, has been resident of [**Hospital **]. Family History: No colon cancer history. Physical Exam: VS T97.3 P84 BP120/56 RR16 O2Sat98 2LNC 1[**Telephone/Fax (3) 7834**] FS104 125 127 135 GENERAL: NAD NECK: Supple, JVP 4cm, L carotid bruit CARDIOVASCULAR: nl S1, S2, II/VI SEM axilla LUNGS: Continued decreased breath sounds on left base. No rales, wheezes or rhonchi. ABDOMEN: Active bowel sounds, mildly firm, nontender, dressing/wound CDI, 2X2 in place. EXTREMITIES: Warm, continued 2+ edema in lower extremities. Pertinent Results: [**2135-11-26**] 04:00PM WBC-30.7* RBC-3.29* HGB-10.5* HCT-31.7* MCV-96 MCH-32.0 MCHC-33.2 RDW-15.3 [**2135-11-26**] 04:00PM PLT SMR-LOW PLT COUNT-95* [**2135-11-26**] 04:00PM PT-14.1* PTT-33.3 INR(PT)-1.2 [**2135-11-26**] 04:00PM GLUCOSE-84 UREA N-30* CREAT-0.9 SODIUM-136 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-26 ANION GAP-11 [**2135-11-26**] 04:00PM ALT(SGPT)-72* AST(SGOT)-30 CK(CPK)-14* ALK PHOS-89 AMYLASE-69 TOT BILI-0.7 [**2135-11-26**] 04:00PM ALBUMIN-3.7 CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-1.6 [**2135-11-26**] 04:00PM CK-MB-NotDone [**2135-11-26**] 04:00PM cTropnT-0.05* ECHO:The left atrium is normal in size. 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 (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (tape reviewed) of [**2135-7-18**], estimated pulmonary artery systolic pressure is now lower and mitral regurgitation is now less prominent. CXR: No significant interval change in bibasilar opacities with bilateral (right greater than left) pleural effusions RENAL U/S:. The right and left kidneys measure 9.7 and 11.6 cm, respectively. There is no evidence of hydronephrosis. No renal stones or masses are visualized. SPUTUM Culture: GRAM STAIN (Final [**2135-12-4**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2135-12-8**]): MODERATE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | KLEBSIELLA PNEUMONIAE | | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 8 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R =>8 R MEROPENEM------------- <=0.25 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R PIPERACILLIN/TAZO----- 64 I RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- 2 S VANCOMYCIN------------ <=1 S CT ABDOMEN W/CONTRAST [**2135-12-13**] 3:56 PM 1. Bilateral pleural effusions and bibasilar atelectasis. 2. Small perihepatic fluid without locualted fluid collection or associated free air. 3. Slightly dilated loops of small bowel without identifiable transition point. 4. Anasarca. 5. Multiple compression fractures. Brief Hospital Course: 85M MDS/CMML with colon cancer, status post resection complicated by ileotomy requiring ileostomy placement, here for cholecystectomy (for cholecystitis) and ileostomy takedown. Patient presented with abdominal pain and had radiological findings consistent with cholecystitis. Therefore, as patient was scheduled to undergo ileostomy takedown within the week of presentation, patient underwent both cholecystectomy and ileostomy takedown on hospital day 4. Patient initially tolerated the procedure well, however post-operative course was complicated by hypotension requiring transfer to the surgical ICU. Patient was stabilized on pressors and a Swan Ganz catheter was placed. Patient was found to have bilateral pulmonary consolidations with sputum notable for methicillin resistant staphylococcus aureus and klebisiella, therefore, vancomycin and meropenem were administered for treatment based upon susceptibility profiles. Subsequently, patient went into acute renal failure, felt to be secondary to episode of hypotension - medications were adjusted for renal dosing. Patient was stabilized and transferred from the SICU to internal medicine service on hospital day 15. * Cholecystectomy/Ileostomy takedown: Post-operative course was complicated as above, however, surgical wound responded appropriately to [**Hospital1 **] wet-to-dry dressing changes with healing by secondary intention. Of note, at one point during post-op course, wound was thought to be draining purulent material, however, this was self-limited, and at the time of discharge, patient's wound had development of excellent granulation tissue and no evidence of infection. Staples were removed by surgical consultants without complications. * Pneumonia: As noted above, sputum culture returned MRSA and klebsiella, and patiented was started on a course of vancomycin/meropenem, to continue until [**2135-12-20**]. On hospital day 17, patient was noted to have a white count elevation to 60, which prompted an infectious workup, although patient had no clinical signs or symptoms of infection or fever. CT scan revealed no abdominal pathology, however, patient was noted to have large pleural effusions bilaterally, right greater than left, consistent with patient's subjective complaints of dyspnea. On hospital day 18, patient underwent thoracentesis of the right pleural space, removing 2 liters of serosanguinous fluid (negative for bacterial growth and few neutrophils). Right lung expanded appropriately, although patient continued to remain intermittently dyspneic, thought to be due to continued resolving fluid overload, as patient remained afebrile throughout rest of hospital course. Patient had a PICC placed on hospital day 17 in anticipation of discharge on IV antibiotics. Of note, with the exception of a one time low grade temp (100.7) the day prior to discharge, patient afebrile for the entire week prior to discharge. * Acute Renal Failure: Felt to be from ATN secondary to episode of hypotension. Improved in house and at discharge, creatinine was: 1.2 (though during the week prior to discharge Cr was as low as 1.0). His baseline creatinine is 0.8. Patient was grossly volume overloaded, but began mobilizing as renal function recovered. Of note, patient's creatinine improved with further Lasix-mediated diuresis, and during the week prior to discharge patient was given Lasix 40-80mg IV with a goal of 500cc-1L out daily. As patient was having less response to Lasix diuresis in final days prior to discharge, patient was given a one time dose of acetazolamide to stimulate further diuresis as bicarbonate was noted to be 33 (thought to be due to contraction/lasix diuresis). * Increased WBC: Patient has a history of chronic myelomonocytic leukemia, treated with minimal doses of prednisone. Patient was noted to have a sharp elevation of white count on multiple occasions during hospitalization. In discussion with patient's primary hematologist, as infectious causes were ruled out, it was felt that these elevations (to max 60,000, ~30% monocytes) were due to exaggerated white cell production/mobilization secondary to chronic myelomonocytic leukemia. Indeed, no blasts were noted on differential. Patient was treated empirically with oral vancomycin, to be continued 10 days following discharge. Patient's prednisone was tapered to 10mg QOD at the time of discharge. * Anemia/Hemolysis: Patient was found to have elevated LDH 377, with haptoglobin <20, however, no schistocytes on smear and no elevation in coagulation factors were noted. Indeed, LDH continued to trend downwards at the time of discharge (LDH 297). However, patient did require two units of packed red cells over the course of the week prior to discharge, felt to be required secondary to combination of low grade hemolysis (from infection), CMML, and myelodysplastic syndrome. Of note, stool guaiac was negative. Patient was transfused with parameters of hematocrit>30%, as patient has previously been symptomatic below that level, and patient was transfused the day of discharge. * Aspiration/Nutrition: Although patient initially failed a swallow study while in SICU, patient later did well on a second swallow study. Patient did initially require NG tube feeds as PO intake was not adequate. However, a week prior to discharge, patient's NG tube was removed (as he was complaining of inability to eat with tube in place) and given one liter of total parenteral nutrition as a bridge. At the time of discharge, patient was taking between 1000-1600kcal/day of oral nutrition. At the time of discharge, patient's respiratory status was excellent (requiring minimal oxygen), had no signs or symptoms of infection or abdominal pathology, and was eager to pursue aggressive physical rehabilitation. Patient was discharged with instructions to continue Lasix 80mg PO daily, with 20meq Potassium chloride supplementation daily, and hematocrit/Chem7 to be checked four days following discharge. Medications on Admission: Ferrous sulfate fluoxetine folate prednisone 15mg qod prevacid 30mg [**Hospital1 **] Discharge Medications: 1. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous Q24H (every 24 hours) for 1 days. 2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 3. Vancomycin HCl 10 g Recon Soln Sig: One [**Age over 90 **]y Five (125) mg Intravenous Q6H (every 6 hours) for 10 days. 4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QOD (). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl Ophthalmic 3X/WEEK (MO,WE,FR). 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-11**] Puffs Inhalation Q4H (every 4 hours). 8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatments Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatments Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 11. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 12. Meropenem 1000 mg IV Q12H 13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 15. Insulin Regular Human 100 unit/mL Solution Sig: Sliding scale Injection four times a day. 16. Lantus 100 unit/mL Solution Sig: Five (5) units Subcutaneous at bedtime. 17. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. 18. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Congestive heart failure Chronic myelomonocytic leukemia Hypotension Acute renal failure MRSA/Klebsiella Pneumonia Cholecystitis, now status post cholecystectomy Colon cancer, now status post resection and ileostomy takedown Discharge Condition: Fair- still edematous and with 2L nasal cannula O2 requirement Discharge Instructions: Follow up with primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 838**], within one week of discharge. Please call Dr.[**Name (NI) 1863**] clinic to make a followup appointment within two weeks of discharge [**Telephone/Fax (1) 1864**]. Continue to take your medications as directed. You will continue the antibiotics Vancomycin and Meropenem for one more day following discharge. Please call your primary care physician if you have fever, chills, severe abdominal pain, or increasing shortness of breath. Some shortness of breath is expected as your lungs recover from the pneumonia. However, if your oxygen requirement begins to increase, you may need to see a doctor. Followup Instructions: Provider: [**Name10 (NameIs) 395**],[**First Name3 (LF) **] [**Location (un) 2788**] MED/[**Doctor First Name 147**] Where: [**Location (un) 2788**] MED/[**Doctor First Name 147**] Date/Time:[**2136-3-5**] 2:15 Please call Dr.[**Name (NI) 1863**] clinic to make a followup appointment within two weeks of discharge [**Telephone/Fax (1) 1864**]. Please followup with your primary care physician. Recommend followup with Dr. [**Last Name (STitle) 6160**], Hematologist, regarding Chronic myelomonocytic leukemia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6384**] MD, [**MD Number(3) 6385**]

[ "238.7", "276.2", "427.31", "205.10", "287.3", "511.9", "782.1", "574.10", "569.61", "V10.05", "416.8", "V09.0", "482.41", "440.20", "482.0", "428.0", "584.9", "733.13" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.91", "51.22", "89.64", "38.93", "34.91", "46.51" ]

icd9pcs

[ [ [] ] ]

13453, 13525

5603, 11608

291, 329

13794, 13858

1858, 5580

14612, 15263

1379, 1405

11743, 13430

13546, 13773

11634, 11720

13882, 14589

1420, 1839

225, 253

357, 630

652, 1215

1231, 1363

55,441

194,006

47482

Discharge summary

report

Admission Date: [**2121-8-2**] Discharge Date: [**2121-8-7**] Date of Birth: [**2059-9-21**] Sex: M Service: MEDICINE Allergies: Hydrocodone Attending:[**First Name3 (LF) 2817**] Chief Complaint: Difficulty Swallowing / Hypoxia Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 61 yo M with history of metastatic prostate adenocarcinoma recently discharged on [**7-30**] w/ hospice evaluation after being admitted for worsening abdominal pain in the setting of aggressive progression of metastatic disease who now presents with hypoxia and difficulty swallowing. Brought in by his VNA after noting the above. States he was feeling well until the day of admission, without cough, fever, or shortness of breath. Here, found to have initial O2 sat of 90% on RA and SBP of 104/60 with HR of 104 and T 98.7. However, blood pressures subsequently decreased to 70s. Though patient is DNR/I, discussion ensued between treating ED resident and patient regarding goals of care. Patient still declined aggressive measures including intubation, shocks, CPR, CVLs or other invasive treatment. However, he did indicate that he would like to pursue antibiotics as well as peripheral pressors at this time. He was subsequently started on peripheral dopamine with improvement in pressures to the 80s-90s systolic. He was also started on vanc/cefepime and fluconazole after CXR demonstrated focal pna and patient was found to have oral candidiasis on exam. He received a total of 5L of NS. . Of note, patient was also found to be in acute renal failure and hyponatremic. He is also leukopenic, though differential was pending at the time of MICU transfer. . . On the floor, patient is satting 90% on 3L NC when he initially arrived, increased to 94% on 3L NC and shovel mask post nebulizer treatment. Patient unable to speak secondary to sore mouth, but AAOx3, writing on dry-erase board. Denies any abdominal pain. States lower extremity edema has been present and stable since [**Month (only) 547**]. Feels breathing is improving and has no other complaints or concerns. He reconfirms that he does not want intubation, lines, shocks or CPR. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Past Onc History: -prostate cancer s/p robot assisted lap prostatectomy [**Month (only) **] [**2119**] -[**Doctor Last Name **] 4+5 -deferred adjuvant XRT/hormones, underwent surveillance -[**2121-3-9**] developed RUQ pain, found to have liver mets -[**2121-4-24**]- initiated lupron/casodex -[**2121-7-25**]- cycle 1 taxotere for rapidly progressive liver involvement (castrate-resistant disease) . Past Medical History: - HTN - s/p knee surgery Social History: On leave from administration at [**University/College **]. Former social alcohol use but none currently. Lives by himself. Family History: * mother with early colon cancer, now alive & well * sister with mental illness * brother who is healthy 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, 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 Pertinent Results: Admit Labs WBC-1.9* RBC-4.08* Hgb-10.0* Hct-30.6* MCV-75* MCH-24.5* MCHC-32.6 RDW-18.5* Plt Ct-267# Neuts-6 Bands-1 Lymphs-37 Monos-40 Eos-0 Baso-0 Atyps-1 Metas-7 Myelos-1 Promyel-7 NRBC-4 Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-1+ Spheroc-OCCASIONAL Ovalocy-1+ Schisto-OCCASIONAL Burr-1+ Tear Dr[**Last Name (STitle) **]1+ PT-15.4* PTT-39.2* INR(PT)-1.4* Glucose-83 UreaN-46* Creat-1.8* Na-123* K-5.8* Cl-91* HCO3-24 AnGap-14 Albumin-2.3* Calcium-7.1* Phos-3.9 Mg-2.3 ALT-73* AST-429* LD(LDH)-624* AlkPhos-436* TotBili-2.4* CXR ([**8-2**]) - IMPRESSION: 1. Low lung volumes. Infectious consolidation, particularly at the left base, cannot be excluded. Repeat evaluation with improved inspiration would be helpful, and following appropriate diuresis if there is concern clinically for pulmonary edema. 2. Diffusely increased sclerosis in the skeletal structures, consistent with known metastatic prostate cancer. Brief Hospital Course: # Hypotension/Respiratory Distress - On admission, the patient met SIRS criteria by leukopenia, respiratory rate, and heart rate. It was felt that the most likely source was pulmonary. The patient was not interested in invasive procedures, such at intubation or central line insertion. He was also DNR. The patient was interested in temporizing measures such as fluid resuscitation, antibiotics and peripheral pressors. The patient was put on broad-spectrum antibiotic coverage, including vancomycin, cefepime, levofloxacin, and fluconazole. He was also put on peripheral dopamine. The patient received 5L of fluid in the ED as well. In the MICU, the patient was maintained on peripheral dopamine to maintain his blood pressures. He could not receive large amounts of fluids for his hypotension because it was felt that fluid overload was contributing to his shortness of breath. The patient's clinical status continued to worse; and, on [**2121-8-6**], he decided to pursue comfort measures only. Peripheral pressors and antibiotics were stopped, and a morphine drip was started. He expired on [**2121-8-7**]. . # Acute Renal Failure - The patient's baseline creatinine was around 0.8, but his creatinine on admission was 1.8. The patient appeared volume depleted on his initial exam and was hyponatremic and hypotensive. Therefore, his renal failure was thought to be secondary to poor renal perfusion. The patient's creatinine improved after he got fluids. . # Hyponatremia - It was felt that the patient's hyponatremia at presentation was likely hypovolemic hyponatremia. His sodium level began to normalize after he got fluids. . # Hyperkalemia - It was felt that the patient's hyperkalemia on presentation was secondary to his acute renal failure. He did not have any signs of hyperkalemia on EKG, and he was given kayexalate in the emergency department. His potassium level normalized with kayexalate and fluids. . # Leukopenia - The patient presented with a leukpoenia that was likely due to a combination of his recent chemotherapy and marrow suppression in the setting of critical illness. He was put on neutropenic precautions. . # Metastatic Prostate Adenocarcinoma - During his most recent hospital admission, the patient was evaluated for hospice. He also had received palliative chemotherapy on [**2121-7-25**]. On admission, the patient was continued on his outpatient pain regimen of oxycontin and dilaudid. Medications on Admission: 1. Docusate Sodium 100 mg PO BID prn constipation 2. Senna 8.6 mg PO BID prn constipation 3. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL, take 15-30 MLs PO QID (4 times a day) as needed for heartburn 4. Hydromorphone 2-4 mg PO Q3H prn abdominal pain. 5. Lidocaine 5 %(700 mg/patch) Patch daily prn pain 6. Oxycontin 10 mg PO q8h 7. GELCLAIR, One (1) ML TID prn mouth soreness Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "584.9", "276.7", "V10.46", "486", "518.81", "198.5", "276.1", "038.9", "197.0", "995.92", "112.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7663, 7672

4757, 7204

302, 309

7723, 7732

3793, 4734

7788, 7798

3200, 3306

7631, 7640

7693, 7702

7230, 7608

7756, 7765

3321, 3774

2215, 2573

231, 264

337, 2196

3017, 3044

3060, 3184

31,032

121,920

5809

Discharge summary

report

Admission Date: [**2101-3-8**] Discharge Date: [**2101-3-14**] Date of Birth: [**2040-3-6**] Sex: F 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: CABGx4 (Lima>LAD,SVG>OM,SVG>ramus,SVG>PDA) [**3-9**] History of Present Illness: 61 yo F with known CAD s/p PCI/stent, angioplasty, now with angina at rest. Cath showed 3vd and she was transferred for surgery. Past Medical History: PMH: CAD(PTCA of LAD/RCA '[**90**] and BMS of RCA '[**98**]) HTN, ^chol, DM2, obesity, hgba1c 8.6 preop PSH: Tubal ligation, Lumpectomy Social History: no tobacco, etoh Family History: father deceased from MI at age 89 Physical Exam: 5'4" 85.7 kg NAD Lungs CTAB Heart RRR, no M/R/G Abdomen benign Extrem warm, no edema neuro nonfocal exam 2+ bil. radials/DPs NP bil. fems/PTs no carotid bruits appreciated Pertinent Results: [**2101-3-12**] 07:20AM BLOOD WBC-10.3 RBC-3.31* Hgb-8.5* Hct-26.3* MCV-80* MCH-25.6* MCHC-32.2 RDW-15.6* Plt Ct-205 [**2101-3-8**] 07:46PM BLOOD WBC-6.5 RBC-4.32 Hgb-10.5* Hct-34.1* MCV-79* MCH-24.2* MCHC-30.6* RDW-15.3 Plt Ct-247 [**2101-3-12**] 07:20AM BLOOD Plt Ct-205 [**2101-3-8**] 07:46PM BLOOD PT-12.4 PTT-36.8* INR(PT)-1.0 [**2101-3-12**] 07:20AM BLOOD Glucose-53* UreaN-16 Creat-0.9 Na-137 K-4.0 Cl-101 HCO3-29 AnGap-11 [**2101-3-8**] 07:46PM BLOOD Glucose-66* UreaN-20 Creat-1.0 Na-142 K-3.9 Cl-103 HCO3-30 AnGap-13 [**2101-3-13**] 01:00PM BLOOD ALT-21 AST-17 AlkPhos-79 Amylase-55 TotBili-0.4 [**2101-3-13**] 01:00PM BLOOD Lipase-52 [**2101-3-8**] 07:46PM BLOOD CK-MB-3 cTropnT-<0.01 [**2101-3-11**] 05:20AM BLOOD Mg-2.0 [**2101-3-8**] 07:46PM BLOOD %HbA1c-8.6* CHEST (PA & LAT) [**2101-3-13**] 10:06 AM CHEST (PA & LAT) Reason: r/o inf, eff [**Hospital 93**] MEDICAL CONDITION: 61 year old woman with REASON FOR THIS EXAMINATION: r/o inf, eff HISTORY: Rule out effusion, infiltrate. CHEST, TWO VIEWS. The patient is status post sternotomy, with cardiomegaly and borderline ectatic, tortuous aorta. There is blunting of the costophrenic angles posteriorly consistent with small effusions or a small amount of pleural thickening. Minimal blunting is also seen laterally. There is linear atelectasis or scarring in the left greater than right mid zones. No CHF or focal infiltrate is identified. Probable atelectasis at left base as well. IMPRESSION: Cardiomegaly. Small bilateral effusions. Bilateral atelectasis. No definite infiltrate _____ exclude an infiltrate at the left base. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**] Sinus rhythm. Low normal voltage in the limb leads, low voltage in the precordial leads. Left atrial abnormality. QS deflections in leads VI-V2 compatible with anteroseptal myocardial infarction. Significant Q waves in leads III and aVF compatible with inferior wall myocardial infarction. Compared to the previous tracing of [**2101-3-8**] no significant change. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] I. Intervals Axes Rate PR QRS QT/QTc P QRS T 81 170 78 418/454 38 -7 28 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 7405**], [**Known firstname 23068**] [**Hospital1 18**] [**Numeric Identifier 23069**] (Complete) Done [**2101-3-9**] at 5:39:23 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2040-3-6**] Age (years): 61 F Hgt (in): BP (mm Hg): / Wgt (lb): 240 HR (bpm): BSA (m2): Indication: coronary artery disease ICD-9 Codes: 440.0 Test Information Date/Time: [**2101-3-9**] at 17:39 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW03-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Ascending: 3.4 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Findings LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data Conclusions PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on Ms. [**Known lastname **] at 1pm POST-BYPASS: Regional and global left ventricular systolic function are normal. Thoracic aortic contour is intact. Minimal MR. Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2101-3-9**] 17:42 Brief Hospital Course: She was taken to the operating room on [**3-9**] where she underwent a Coronary artery bypass graft. See operative report for further details. She was transferred to the ICU in stable condition. She was extubated later that night. She was given 48 hours of IV vancomycin as she was in the hospital preoperatively. She was hypertensive and required Nipride initially which was weaned to off on POD #1 and she was transferred to the floor. Gently diuresed toward her preop weight and beta blockade titrated. Physical therapy worked with her on strength and mobility. She continued to progress and was ready for discharge home with services POD 5. Medications on Admission: Lopressor XL 100', Metformin 500", Glipizide 10", Actos 30', Lipitor 80', ASA 325', Plavix 75', Zetia 10' 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 once a day. 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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 11. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: CAD now s/p CABG CAD(PTCA of LAD/RCA '[**90**] and BMS of RCA '[**98**]), MI [**2090**] HTN, ^chol, DM2, obesity + PPD Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. SHower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving for one month or until follow up with surgeon. Followup Instructions: Please call to schedule all appointments Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23070**] (Primary care doctor) ([**Telephone/Fax (1) 23071**] 2 weeks Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] (cardiologist) ([**Telephone/Fax (1) 20259**] 2 weeks Dr. [**Last Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**] Wound check appointment [**Hospital Ward Name **] 6 please schedule with RN Completed by:[**2101-3-14**]

[ "401.9", "250.00", "413.9", "V45.82", "272.0", "276.6", "412", "278.00", "E878.2", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9412, 9474

7295, 7944

326, 381

9637, 9645

994, 1853

9975, 10453

749, 784

8100, 9389

1890, 1913

9495, 9616

7970, 8077

9669, 9952

799, 975

280, 288

1942, 7272

409, 539

561, 699

715, 733

2,356

176,708

27934

Discharge summary

report

Admission Date: [**2163-6-14**] Discharge Date: [**2163-6-17**] Date of Birth: [**2087-5-3**] Sex: F Service: MEDICINE Allergies: Codeine / Penicillins Attending:[**First Name3 (LF) 1436**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Heart catheterization History of Present Illness: 76 yo WF with PMH of CAD s/p MI, ?CVA, HTN, tobacco abuse and CRI, who presents with chest pain. The pt reports onset of chest pain on Monday night while watching TV. She initially attributed this to her first prednisone which had been started that day for a gout flare. The patient reported chest pain as sharp, [**9-27**] with radiation to both arms. The chest pain was associated with bilious emesis x [**4-23**] at 9p.m as well as diaphoresis and SOB. She was BIBA to [**Location (un) **] ED at 12MN. At the time, EMT believed her to be in SVT/RAF and gave adenosine 6mg x3 and diltiazem 18mg IV. Her initial ECG was concerning for anterior lateral ischemia. Her CE were significant for CK/MB which trended as follows: 70/na - 389/53 - 487/80 and Trop: 0.12 - 3.14 - 8.93. In addition, her creatinine was 2.4 and blood sugar was 700. She was given ASA 325mg x1, Plavix 300mg x1, morphine 2mg x1, Lopressor 5mg x1, and started on heparin gtt and nitro gtt with resolution of ECG changes. In addition, she was started on insulin gtt at 6 units/hour for a FSBG of >500. She has been pain free since 8AM today. She was transferred to [**Hospital1 18**] for cardiac catheterization. The pt underwent a cardiac catheterization which revealed no significant CAD in LAD, LCx but chronically occluded appearing RCA. An attempt was made to cross the RCA lesion with a guide wire, however she developed bradycardia with transient heart block. She was given Atropine which resulted in tachycardia with possible Afib. LVEDP was 20 at the beginning of cath but during this episode, PCWP was 30 and PaSaO2 was 44%. An IABP was placed during the cardiac catheterization and PaSaO2 inc. to 64%. She was never hypotensive during this episodes. She was given protamine to reverse the hep gtt thinking this episode of hypotension may have been due to tamponade. However the stat TTE did not demonstrate any tamponade physiology. Past Medical History: PAST MEDICAL HISTORY: 1. CAD s/p MI with neg stress test in '[**60**]. 2. CHF 20% in '[**60**] with global hypokinesis. No cath in past. Repeat TTE in '[**61**] with EF of 50%. 2. ?TIA/CVA in '[**60**] without residual defects 3. DM diagnosed today! 4. HTN 5. Hypercholesterolemia 6. Gout of left knee Social History: SOCIAL HISTORY: The patientt lives by herself in [**Location (un) 1439**], with ADL and IADL in tact. Tob: former smoker, 80-120 pack year - 1.5ppd x 60 years but quit after first MI in '[**60**]. EtOH: social drinking every friday. Family History: Mother: HTN and MI at age 74. Two sons and daughter are healthy. Physical Exam: VS: HR: 90, BP: 112/50, RR: 12, SaO2: 100% on NC at 2L GEN: obese elderly female in NAD but alternating between lethargic and interacting. HEENT: PERRL, EOMI, op clear, dry mm NECK: supple, no JVP CV: RRR, distant S1, S2, systolic crescendo-decrescendo murmur with "whistle" quality at apex. Difficult to appreciate due to balloon pump. CHEST: CTA bilaterally ABD: firm, no rebound, guardin', BS + bilaterally, no HSM EXT: wwp, 2+ LE biltarel, + tenderness over Left knee which is also warm GROIN: right groin oozing with sheath in place. No hematoma, no bruits. VASC: bounding radial pulses and 1+ DP Pertinent Results: [**2163-6-15**] 01:30PM BLOOD calTIBC-233* Ferritn-249* TRF-179* . [**2163-6-15**] 05:15AM BLOOD Triglyc-312* HDL-40 CHOL/HD-5.1 LDLcalc-103 . [**2163-6-14**] 09:28PM BLOOD %HbA1c-7.6* . [**2163-6-14**] CARDIAC CATHETERIZATION: 1. Coronary angiography revealed a right dominant system. The LMCA showed no angiographically apparent stenoses. The LAD showed a 40% midsegment stenosis and appeared tortuous. The LCx was a small vessel without significant stenoses. The RCA showed a proximal 100% stenosis with considerable left to right collaterals to the distal segment and RPDA from the LAD. 2. Resting hemodynamics after onset of atrial fibrillation with rapid ventriular response demonstrated severely elevated filling pressures including mean right atrial pressure of 27 mmHg and mean pulmonary capillary wedge pressure of 32 mmHg. Cardiac output was moderately depressed with cardiac index of 2.1 L/min/m2. After restoration of sinus rhythm and balloon pump insertion, hemodynamics markedly improved with mean right atrial pressure of 7 mmHg, PCWP mean of 10 mmHg, and cardiac index of 3.2 L/min/m2. 3. Attempt to angioplasty proximally occluded RCA were complicated by bradycardia with heart block followed by atrial fibrillation with rapid ventricular response, with the hemodynamic changes described above. 4. Unsuccessful attempt to recanalize the totally occluded RCA. 5. Successful insertion of a 7 French IABP. . [**2163-6-15**] TTE: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Cannot exclude basal inferior hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-20**]+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2163-6-14**], left ventricular systolic function now appears much improved although prior study was technically suboptimal. Of note, patient on IABP during today's study. Brief Hospital Course: ASSESSMENT: Ms. [**Known lastname **] is a 76yo F with CAD s/p MI, CVA, DM, HTN, hypercholesterolemia, and long h/o tobacco abuse who presented with acute onset chest pain. . 1. CV: A. Coronary Artery Disease: The pt has known CAD which was confirmed with the finding of an RCA lesion on catheterization. However it is unlikely that her episode of chest pain was an acute plaque rupture. Given the appearance of the lesion, the complication which resulted from the attempt, and presence of collaterals, this is most likely a chronic occlusion. Given the episode of decompensation in the cath lab and the chronic nature of her occlusion, it was decided that no further attempts at catheterization would be attempted, and the patient was medically optimized on ASA, Lisinopril, and Lipitor. Plavix was not considered to be necessary in the absence of stenting. . B. Pump: The pt has a history of CHF with previously low EF of 20% in '[**58**] with documentation of improvement to 50% in '[**61**]. A stat TTE performed in the cath lab during her episode of decompensation revealed a severely depressed LV function with an EF of [**10-7**]%, and an intra-aortic balloon pump was placed emergently. Repeat TTE on the following day revealed an EF of 50%. In the presence of high MAP's in the 24 hours s/p catheterization, the IABP was discontinued without complications. Given the documented acute change in her hemodynamics, this may suggest the presence of a stiff ventricle, possibly myocardial stunning from NSTEMI. Her outpatient regimen of Digoxin was discontinued in the absence of heart failure at time of discharge. Through her hospital course, she was up titrated on her beta-blocker and AceI as tolerated by her BP, with goals to maintain SBP <130 and HR <70. . C. Rhythm: The pt had an episode of bradycardia followed by tachycardia/afib which may be the result of vagal stimulation from attempts to intervene on RCA. She remained in NSR for the remaining duration of the hospitalization. . D. Valve: Some evidence of mitral valve leaflet thickening on TTE. . 2. DM: The pt has admission glucose of 700 (gap of 11) but reported no known diagnosis of diabetes. She was eventually transitioned from an insulin gtt to SSI coverage and finally to oral hypoglycemic [**Doctor Last Name 360**] with good control. Her HgA1C of 7.6 confirmed a new diagnosis of Type II D.M. In the setting of CAD, she was started on an oral TZD [**Doctor Last Name 360**] and instructed to follow-up with her PCP for further management. She received diabetic nutritional counseling prior to discharge. . 3. ARF: On admission to the CCU, Ms. [**Known lastname **] creatinine level was elevated to 1.8, likely secondary to the dye load received by the patient in the cath lab. With post-cath hydration of bicarb in D5W, her renal failure resolved and creatinine treanded towards her baseline. In the setting of improved renal function, her AceI and diuretic medications were up titrated. . 4. Gout: The pt reported an acute flare of gout prior to this hospitalization and continued to have residual evidence of acute flare, particularly with tenderness and decreased mobility in her left knee. Although she was recently started on prednisone for her gout we will avoid this medication given the NSTEMI and potential for "thinning" the LV resulting in free wall perforation. Instead a regimen of allopurinol and colchicine were dosed renally; other alternatives such as NSAIDS or prednisone were considered to be less desirable. . 6. Anemia: Ms. [**Known lastname **] hematocrit remained stable, hovering around 25, both pre and post cath. No evidence of post-cath hematoma. Although her hematocrit has been stable, in the setting of anemia and heart failure, she was electively transfused with one unit PRBC's. . 8. FEN: Patient was started on a cardiac, diabetic, diet with careful repletion of electrolytes to keep k>4 and Mg>2. . . 7. Dispo: Patient was discharged to home at functional baseline per PT evaluation. She was discharged with home VNA services for monitoring of vital signs, assistance with her new medication regimen, and diabetic teaching. . 10. Code status: DNR/DNI. Discussed with patient. ICU consent signed and placed in chart. Medications on Admission: MEDICATIONS ON TRANSFER: 1. Nitro gtt 2. Heparin gtt 3. Insulin gtt with q one hour FS 4. ASA 325mg once daily 5. Plavix 75mg once daily 6. Mucomyst 600mg [**Hospital1 **] 7. Lopressor 5mg IV Q6hours 8. Morphine 2mg IV q 1 hours 9. Protonix 40mg PO once daily 10. Digoxin 0.125mcg once daily . MEDICATIONS AT HOME: Confirmed by [**Doctor First Name **] Pharmacy in [**Location (un) 2624**] ([**Telephone/Fax (1) 68043**]). 1. ASA 81mg once daily 2. Lopressor 50mg [**Hospital1 **] 3. Lisinopril 40mg once daily 4. Lipitor 40mg once daily 5. Lasix 40mg TID 6. Digoxin 0.125mcg once daily 7. Allopurinol 200mg once daily 8. Colchicine 0.6mg [**Hospital1 **] PRN 9. Prednisone 30mg once daily started on Monday for a taper. 10. Protonix 40mg once daily 11. Oxazepam PRN 12. Oxycodone 5mg once daily 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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 3. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*30 Tablet(s)* Refills:*2* 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*15 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: 1) NSTEMI 2) Type 2 DM 3) Acute renal Failure 4) Gout Discharge Condition: Good. Discharge Instructions: 1) You have suffered a heart attack, leading to this hospitalization. You have known coronary artery disease, in multiple vessels. You should call 911 or go to the emergency room if you experience shortness of breath, chest pain, or heart palpitations. . 2) You have a new diagnosis of diabetes and have been started on a once daily oral [**Doctor Last Name 360**] called pioglitazone to help control your blood glucose levels. Your target range for your blood glucose is 80-120. A visiting nursing aide will be coming to your home to help you learn more about how to check your blood glucose levels yourslf and about how to manage this condition. You should also be sure to keep your appointment with Dr. [**Last Name (STitle) **] on [**6-22**] to discuss your diagnosis further. Be aware that on this new medication, you may experience hypoglycemia (blood sugars that are too low). You should not skip meals while taking this medication. If you feel lightheaded or dizzy you should have a sip of [**Location (un) 2452**] juice. . 3) You do not have any evidence of heart failure. It is safe to discontinue or reduce your dose of Lasix. You are being diagnosed with a prescription of 40 mg daily (less that you were taking previously). You may decide with Dr. [**Last Name (STitle) **] that you can discontinue this medication altogether. You can also discontinue taking Digoxin in the absence of heart failure. . 4) You have received a prescription for Ativan. This is a medication to help with your anxiety. You should only take it when you are feeling anxious, and you should not operate a vehicle while under its influence. . 5) The dosage of your medications for gout have been changed to every other day. This is to protect your kidneys. . 6) Continue to take your daily Asprin and Lipitor to protect yourself against progression of heart disease. . 7) Your diet should be a low-salt, cardiac, diabetic diet. Do not skip meals as you are at risk for becoming hypoglycemic. Followup Instructions: Keep your previously scheduled appointment with Dr. [**Last Name (STitle) **] on [**6-22**] to discuss further management of your newly diagnosed diabetes. . Follow-up with Dr. [**Last Name (STitle) 5293**], your cardiologist, in [**1-21**] weeks. . Both Dr. [**Last Name (STitle) 5293**] and Dr. [**Last Name (STitle) **] will receive a copy of your discharge paperwork.

[ "427.31", "285.9", "274.0", "250.00", "584.9", "424.0", "414.01", "425.4", "288.8", "428.0", "496", "300.00", "401.9", "305.1", "410.71" ]

icd9cm

[ [ [] ] ]

[ "99.04", "00.40", "00.66", "37.22", "38.93", "88.72", "89.64", "37.61", "97.44", "88.56" ]

icd9pcs

[ [ [] ] ]

12131, 12180

5871, 10120

292, 316

12278, 12286

3562, 5848

14330, 14705

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242, 254

344, 2261

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101,886

48987

Discharge summary

report

Admission Date: [**2132-11-29**] Discharge Date: [**2132-12-1**] Date of Birth: [**2084-5-28**] Sex: M Service: MEDICINE Allergies: Codeine / Enalapril Attending:[**First Name3 (LF) 30**] Chief Complaint: fever and hypotension at HD. Major Surgical or Invasive Procedure: Femoral tunneled catheter replacement History of Present Illness: 48 yo M w/ h/o ESRD s/p failed transplant, h/o hep B/C/?D, h/o paf on coumadin, h/o sarcoid, h/o pulmonary aspergillosis, and h/o MRSA line sepsis [**5-6**] and presumed recurrence [**10-6**] though cx negative a/w F and hypotn at HD. Patient states he has been having fevers w/ rigors at the last 3 HD sessions. Today blood cx were obtained, vanc was given, and patient was transferred to [**Hospital1 18**] following dialysis. VS on arrival: T 98.6 hr 140 bp 113/42 rr 12 O2 95% RA. While in the ED bp dipped as low as sbp 81. Patient received a total of 3.3 L NS. On ROS, patient reports c/o N and V x couple times over the past couple days (w/o blood). + chills at HD. He was c/o back pain at HD. + cough w/o sputum. No c/o SOB or CP and no sick contacts. [**Name (NI) **] D. No urinary sx (makes about 4 oz urine qd). No rash, HA, neck stiffness. No skin ulcers. . Past Medical History: 1. ESRD s/p failed transplant [**7-4**] now collapsing glomerulonephritis, HD qMWF at [**Location (un) 4265**] 2. Amyloidosis 3. Sarcoidosis 4. Hx of pulmonary aspergillosis - on itraconazole, followed by pulm 5. Hx of hyperkalemia 6. Hep B, C, ? D 7. HTN 8. Hx of IV drug use 9. h/o sinusitis requiring drainage 10. recent epistaxis requiring intubation 11. SPEP/UPEP positive 12. paroxysmal atrial fibrillation - off BB, on coumadin 13. h/o C diff [**3-8**] 14. MRSA line sepsis ([**5-6**]), new tunneled fem line [**5-6**], TTE neg for veg 15. h/o purulent ascites [**3-8**] while on PD 16. gynecomastia 17. iron deficiency anemia 18. renal osteodystrophy 19. adrenal insufficiency - on prednisone 5 mg po qd 20. h/o UE DVT [**3-8**] 21. h/o pancreatitis [**3-8**] ** ECHO [**5-6**]: EF > 55%, 1+ MR Social History: Lives with girlfriend, on disability; 1 packper day x30 years of tobacco use, still currently smoking.No alcohol, but previous history of abuse. Family History: Diabetes Physical Exam: Tm 100.8 in ED Tc 98.8 hr 102 bp 109/57 rr 13 O2 98% on 2 L NC genrl: sleepy but easily arousable, shaking chills heent: perrla (3->2mm), periorbital edema (patient reports common w/ volume overload, op clear - mmm, no sublingual icterus cv: rrr, no m/r/g pulm: bibasilar crackles, no wheeze/ronchi back: no focal spinal tenderness, no CVA tenderness abd: nabs, soft, tender to palpation of RLQ w/o rebound/guarding, scar overlying RLQ from "jumping out a window when he was young and cutting his skin in the process," o/w NT / ND, no masses/hsm extr: no [**Location (un) **], dry skin, unable to palpate DP or PT pulses neuro: a, o x3, strength grossly [**6-5**] bilaterally UE/LE, sensory grossly intact in UE/LE Pertinent Results: [**2132-11-29**] 04:40PM WBC-10.3 RBC-4.83# HGB-15.8# HCT-45.1# MCV-93 MCH-32.7* MCHC-35.0 RDW-14.4 [**2132-11-29**] 04:40PM NEUTS-88.5* BANDS-0 LYMPHS-7.4* MONOS-2.3 EOS-1.5 BASOS-0.4 [**2132-11-29**] 04:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2132-11-29**] 04:40PM PLT SMR-NORMAL PLT COUNT-291# [**2132-11-29**] 04:40PM GLUCOSE-130* UREA N-20 CREAT-6.8* SODIUM-139 POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-24 ANION GAP-20 [**2132-11-29**] 04:40PM CALCIUM-10.4* PHOSPHATE-3.8 MAGNESIUM-1.3* [**2132-11-29**] 05:20PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.017 [**2132-11-29**] 05:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500 GLUCOSE-TR KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-7.0 LEUK-NEG [**2132-11-29**] 05:20PM URINE RBC-0-2 WBC-[**4-5**] BACTERIA-MOD YEAST-NONE EPI-[**4-5**] [**2132-11-29**] 04:53PM LACTATE-1.6 K+-3.7 [**2132-11-29**] 11:10PM PT-26.5* PTT-150* INR(PT)-5.2 [**2132-11-29**] 04:40PM CK(CPK)-22* [**2132-11-29**] 04:40PM cTropnT-0.12* [**2132-11-30**] 05:00AM BLOOD CK-MB-NotDone cTropnT-0.09* [**2132-11-30**] 11:11AM BLOOD CK-MB-NotDone cTropnT-0.09* [**2132-11-30**] 11:11AM BLOOD CK-MB-NotDone cTropnT-0.08* [**2132-11-30**] 05:00AM BLOOD ALT-23 AST-30 CK(CPK)-19* AlkPhos-139* Amylase-144* TotBili-0.4 [**2132-11-30**] 11:11AM BLOOD ALT-19 AST-26 LD(LDH)-177 CK(CPK)-29* AlkPhos-122* TotBili-0.4 [**2132-11-30**] 11:11AM BLOOD CK(CPK)-28* [**2132-12-1**] 06:20AM BLOOD AST-32 LD(LDH)-132 AlkPhos-118* TotBili-0.3 . CHEST (PORTABLE AP) [**2132-11-29**] 4:49 PM Reason: please eval lung fields for infiltrates [**Hospital 93**] MEDICAL CONDITION: 48 year old man with ESRD now with hypotension and lactatemia . REASON FOR THIS EXAMINATION: please eval lung fields for infiltrates HISTORY: End-stage renal disease, now hypotension and lactic acidemia. Question infiltrate. The patient has a history of sarcoid and aspergillomas as well as renal transplant based on the chest CT report from [**2131-12-11**]. CHEST, SINGLE AP VIEW. There is [**Hospital1 **]-apical scarring with upper zone infiltrates. There are calcifications superimposed over the mediastinum and hila and some pleural plaquing in the right mid and lower zones. There is blunting of the left costophrenic angle. Appearances are unchanged compared with [**2132-10-21**]. No superimposed CHF, infiltrate, or gross effusion is identified. Apparent oral contrast in the bowel. IMPRESSION: Appearances are suggestive of scarring related to previous infection and the presence of calcified nodes is suggestive of prior granulomatous infection. ECG [**2132-11-29**]: This Ecg received late and out of sequence Baseline artifact Sinus tachycardia ST-T configuration consistent with early repolarization pattern/ normal variant although baseline artifact makes assessment difficult Since previous tracing of same date, sinus tachycardia rate slower, not suggestive of right atrial abnormality and ST-T wave changes decreased [**2132-11-30**]: HISTORY: Right lower and left lower quadrant pain. COMPARISON: CT from [**2132-5-12**]. TECHNIQUE: MDCT acquired contiguous axial images from the lung bases to pubic symphysis were acquired following the administration of oral and 150 cc of IV Optiray. Nonionic contrast was administered secondary to patient's debility. Coronal and sagittal reconstructions were performed. CT OF THE ABDOMEN WITH IV CONTRAST: Again demonstrated at the lung bases is diffuse pleural thickening with calcifications consistent with prior asbestos exposure. Calcified left paraaortic lymph node is also seen, and additionally, there appears to be calcification along the pericardium. The liver, pancreas, spleen, adrenal glands, stomach, and loops of large and small bowel are all unremarkable. Within the gallbladder, there are at least 2 calcified 2-mm structures, likely representing gallstones. Gallbladder otherwise is collapsed without evidence of pericholecystic fluid. The kidneys again demonstrate multiple subcentimeter low-attenuation lesions, stable in the interval, and too small to fully characterize. No hydronephrosis is noted. Extensive atherosclerotic calcifications are seen within the abdominal aorta, but the aorta is normal in caliber. There is no free air or free fluid. There is no evidence of bowel obstruction. Again demonstrated within the retroperitoneum are several prominent lymph nodes within the aortocaval and left paraaortic region. The largest lymph node measures approximately 14 mm, and is relatively stable since the prior examination. There is no free air or free fluid. CT OF THE PELVIS WITH IV CONTRAST: Transplanted kidney is seen within the right lower quadrant, without evidence of hydronephrosis, renal masses, or perinephric fluid collections. A focal area of hypoenhancement/cortical scarring is again noted within the lateral aspect of the kidney, unchanged. Rectum, sigmoid colon, and pelvic loops of bowel all appear unremarkable, and the appendix is normal in caliber, filled with contrast. Prostate and bladder are within normal limits. There is no free fluid. No pelvic or inguinal lymphadenopathy is demonstrated. A left common femoral central venous catheter is demonstrated with tip in the inferior aspect of the inferior vena cava. BONE WINDOWS: No suspicious lytic or sclerotic lesions are present. CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were essential in confirming the above findings. IMPRESSION: 1. No abnormality noted within either lower quadrant to account for the patient's pain. Stable appearance of the transplanted kidney. 2. Calcified pleural thickening in both lower lobes consistent with prior asbestos exposure. 3. Stable prominent lymph nodes within the retroperitoneum. 4. Stable appearance of the native kidneys with multiple subcentimeter cysts seen, which may represent acquired cystic renal disease vs. polycystic kidney disease. 5. Cholelithiasis. [**Hospital 102855**] MEDICAL CONDITION: 48 year old man with ESRD on HD, s/p multiple episodes of MRSA line sepsis, now w/ fever, GPC on blood cx. REASON FOR THIS EXAMINATION: Please change left shoulder hemodialysis catheter over a wire HEMODIALYSIS CATHETER CHANGE INDICATION: Endstage renal disease on hemodialysis, now with left femoral tunneled dialysis catheter and MRSA line sepsis. Details of the procedure and possible complications were explained to the patient and informed consent was obtained. RADIOLOGISTS: Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 380**]. Dr. [**Last Name (STitle) 380**], staff radiologist, was present for the entire procedure. TECHNIQUE: Using sterile technique and local anesthesia, two Amplatz super stiff wires were advanced into the indwelling left femoral tunneled dialysis catheter. The cuff of the catheter was released by blunt dissection and the catheter was removed over the wire. A new 14-French tunneled dialysis catheter was then placed over the wires with the tip positioned in the IVC just above the confluence of the common iliac veins. This was confirmed by injection of small amount of contrast material. No extravasation of the contrast material was seen. The catheter was secured to the skin. The patient tolerated the procedure reasonably well. There were no immediate complications. CONTRAST MATERIAL: 20 cc of nonionic contrast material were used. IMPRESSION: Exchange of a left femoral tunneled dialysis catheter for a new tunneled dialysis catheter over the wire. Brief Hospital Course: 48 yo M w/ h/o ESRD s/p failed transplant, h/o hep B/C/?D, h/o paf on coumadin, h/o sarcoid, h/o pulmonary aspergillosis, and h/o MRSA line sepsis in [**5-6**] and presumed recurrence in [**10-6**] admitted with fever and hypotension at HD. . # Sepsis: Bcx was drawn at HD on [**11-29**], and vanc was given, and patient was transferred to [**Hospital1 18**] following dialysis. Pt's BP drifted down to 81, tachy at 140 but afebrile in the ED. Patient received a total of 3.3 L NS. Because of hypotension, the patient was observed in the MICU overnight. The patient was continued on IV vanc and gent x i was given. The patient did not require any pressors but received stress dose steroids. Pt had abd tenderness and was covered with flagyl and cipro transiently as there was a concern for GI abscess, but was discontinued on the day of transfer to the floor on [**11-30**] as the CT of abdomen was negative for any intra-abdominal inflammatory processes or abscess. Bcx 1/4 bottles from [**11-29**] grew Staph coag negative species and sensitivities pending. Surveillance blood cultures were drawn and were negative to date. On [**11-30**], the patient had the femoral dialysis catheter exchanged over the wire and tolerated it well. The cath tip culture is negative to date. The patient was continued on iv vancomycin and random vanc levels were checked and if the level<15, additional 1gm of vancomycin was given. The patient was discharged with 14 days of vancomycin to be administered at dialysis or when vanc level <15. . # Troponin leak: No c/o chest pain and unremarkable EKG. Nevertheless, in the MICU enzymes were cycled to confirm CK/CKMB did not increase. . # ESRD: s/p failed transplanted kidney. Continued HD Tues, Thurs,Fri. Renally dosed meds. Continued tacrolimus and Bactrim for prophylaxis. - Hyperphosphatemia- Continued sevelamer and calcium acetate. Renal felt that given elevated calcium simultaneously, the patient may have vit D toxicity. Renal will decrease vit D administration during dialysis. - Hypercalcemia- See above. Per Renal, no acute need for treatment. No IVF given already received 3 L in the MICU. . # PAF: Coumadin was held due to elevated INR 5.2. Once hypotension was resolved, the patient was started on metoprolol for rate control. The patient's INR at time of discharge was 3.1. The patient was instructed to start coumadin 1mg every other day when the level <3.0. INR is to be checked during dialysis and requested to fax the results to Dr. [**Name (NI) 2427**], pt's PCP. [**Name10 (NameIs) **] patient has an appointment with Dr. [**Last Name (STitle) 2427**] on [**2132-12-5**]. . # HTN: Once hypotension resolved with fluids in the MICU, the patient was noted to be hypertensive on the floor. The patient was not taking any antihypertensives as an outpatient recently given hypotension (he has been on Lopressor and diltiazem in the past). We restarted Lopressor, and the patient will f/u with Dr. [**Last Name (STitle) 2427**] for further HTN management. . # H/o pulm aspergillosis: Continued itraconazole. . # Hep B/C: No acute issues. . # Adrenal insufficiency- The patient received stress dose steroids in the MICU. On the floor, the patient was continued on prednisone 5mg qday. . # Depression: Continue sertraline . # PPX: home PPI, bowel reg, and no sc heparin given elevated INR. . # FEN: IVF given in the MICU for hypotension. Continued renal diet. Repleted 'lytes/prn. Continued thiamine, Nephrocaps, and folic acid. . # Full code . # Communication: GF [**Doctor Last Name 2808**] [**Telephone/Fax (1) 102392**] Medications on Admission: 1. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY 2. Thiamine HCl 100 mg PO DAILY 3. Folic Acid 1 mg PO DAILY 4. Itraconazole 200 mg PO BID 5. Calcium Acetate 1200 mg PO TID W/MEALS 6. Pantoprazole Sodium 40 mg PO Q24H 7. Sertraline HCl 50 mg Tablet Sig: 1.5 Tablets PO DAILY 8. Prednisone 5 mg PO DAILY 9. Tacrolimus 0.5 mg daily 10. Docusate Sodium 100 mg PO BID 13. Sevelamer HCl 1600 mg PO TID 14. Lactulose 30 ML PO TID 15. Warfarin Sodium 1 mg PO every other day. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QD (). 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMON,WED,FRI (). 11. Itraconazole 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 14. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous during dialysis on Tues, Thurs, Sat for 14 days: please administer vancomycin 1000mg iv during dialysis and prn if vancomycin level <15. . Disp:*9000 mg* Refills:*0* 16. Outpatient Lab Work Vancomycin random level at dialysis. Also, please check INR and fax results to Dr. [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**] to adjust coumadin dose. Fax number is [**Telephone/Fax (1) 3382**]. 17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO every other day: Take this when your INR is <3.0. Check your INR at dialysis on [**2132-12-2**]. . Disp:*3 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Line sepsis/bacteremia End-stage Renal Disease Adrenal insufficiency Paroxysmal atrial fibrillation Discharge Condition: Stable, afebrile. Discharge Instructions: Return to the emergency department if you develop fever, chills, severe abdominal pain, nausea, vomiting, or any other worrisome symptoms. . Keep your follow-up appointments. Discuss with your primary care physician regarding your hypertension management and coumadin. . Take your medications as instructed. Have dialysis unit check your vancomycin level at dialysis and administer vancomycin. Also, have your INR checked at dialysis tomorrow and start coumadin if your INR<3.0. Followup Instructions: Dialysis at Gambor on Tues, Thurs, and Sat as previously scheduled. . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Date/Time:[**2132-12-5**] 3:30 . Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2133-2-17**] 3:00

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Discharge summary

report

Admission Date: [**2121-5-13**] Discharge Date: [**2121-5-16**] Date of Birth: [**2080-7-12**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3200**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: Endoscopy [**5-13**] History of Present Illness: 40 yo M with T2DM, HTN, h/o CHF, and obesity s/p bariatric surgery presents today to the ED with syncope, transferred to the ICU for GIB. According to the ED report, patient has been having melena since the day prior to admission. Today, experienced lightheadedness at construction (work) with SBP in the 70s, which improved with lying flat. Patient stated that he remember being on the [**Location (un) **] and could not remember how he got to the [**Location (un) 442**] where he was found. He at the time denied any chest pain or SOB. Mental status was A&Ox2 which improved to A&Ox3 after lying flat. FS was 168 in the field per report. Per report, has history of mild-moderate drinking. . He reports only taking ASA 81 mg daily and occasional NSAIDS for headache. Over the last week, he has been having more frequent headaches, so he took a total of 4 tablets of Advil yesterday and on another day this week. He denies any abdominal discomfort, nausea, vomiting, and diarrhea. Report rare drinking, not even once a week. . In the ED, VS Bp 90/48, HR 74, RR 18, O2Sat 100%. Given concern for GIB, patient was started on protonix gtt. Per ED record, ASA 325 mg 1x was given. EKG showed TWI in V3-V6, I, and aVL, with negative trop x1. Atrius cardiology evaluated patient. Per report, he had negative cardiac catheterization in [**2112**], so current will not need a repeat. GI was informed of the patient. At ED, about 150 cc was lavaged, with clear return, but could not draw back all fluid because of resistance. He got a total of 3L of IVF with 1 unit of pRBC, 2 18 g IVs. . On the floor, reports feeling better. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - HTN - T2 DM - HLD - h/o sciatica - chronic systolic heart failure, cardiomyopathy - Obesity, s/p bariatric surgery- Roux-en-Y, 2 years ago - OSA Social History: - works in construction - denies ever smoked - rare EtOH - denies ever had illicit drug use Family History: - father had MI at age 38 and then in late 50s - mother had some GI problem, unable to elaborate - no FH of liver disease Physical Exam: Physical Exam on Arrival to [**Hospital Unit Name 153**] Vitals: T:98 BP:129/78 P:90 R:11 O2: 100%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Rectal: dark brown, guiaic + stool GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2121-5-13**] 09:05AM BLOOD WBC-6.9 RBC-2.84* Hgb-9.3* Hct-26.0* MCV-92 MCH-32.7* MCHC-35.7* RDW-13.2 Plt Ct-213 [**2121-5-13**] 09:05AM BLOOD Neuts-74.9* Lymphs-20.8 Monos-3.0 Eos-0.9 Baso-0.4 [**2121-5-13**] 09:05AM BLOOD PT-12.6 PTT-20.5* INR(PT)-1.1 [**2121-5-13**] 09:05AM BLOOD Glucose-136* UreaN-47* Creat-0.9 Na-143 K-4.1 Cl-109* HCO3-30 AnGap-8 [**2121-5-13**] 09:05AM BLOOD ALT-14 AST-17 CK(CPK)-120 AlkPhos-33* TotBili-0.3 [**2121-5-13**] 09:05AM BLOOD cTropnT-<0.01 [**2121-5-13**] 11:27PM BLOOD CK-MB-3 cTropnT-<0.01 [**2121-5-13**] 09:05AM BLOOD Lipase-26 [**2121-5-13**] 09:05AM BLOOD cTropnT-<0.01 [**2121-5-13**] 11:27PM BLOOD CK-MB-3 cTropnT-<0.01 [**2121-5-13**] 09:05AM BLOOD calTIBC-282 VitB12-509 Folate-6.1 Ferritn-44 TRF-217 [**2121-5-13**] 09:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2121-5-13**] 11:27PM BLOOD Hct-24.9* [**2121-5-14**] 06:11AM BLOOD WBC-5.4 RBC-3.24* Hgb-10.6* Hct-28.8* MCV-89 MCH-32.8* MCHC-36.9* RDW-13.4 Plt Ct-155 [**2121-5-14**] 12:48PM BLOOD Hct-31.1* [**2121-5-14**] 09:55PM BLOOD WBC-5.8 RBC-3.34* Hgb-10.9* Hct-29.6* MCV-89 MCH-32.5* MCHC-36.7* RDW-14.3 Plt Ct-158 [**2121-5-15**] 08:55AM BLOOD Hct-30.4* [**2121-5-16**] 07:50AM BLOOD Hct-32.3* Brief Hospital Course: 40 yo M with h/o obesity s/p bariac surgery, h/o T2DM, HTN, h/o CHF presents syncope [**12-25**] GI bleeding . # UGIB. Most recent outpatient Hct was 36.3, down to 26 on admission. Dark brown, guiaic + stool. Received 1u pRBC from ED. Lactate 0.9. Given history of recent NSAID and prophylaxis ASA use, most likely upper GI source. Higher risk given history of bariatric surgery. GI performed endoscopy at the time of patient's arrival to the [**Hospital Unit Name 153**] and found non-bleeding erosion in the stomach and duodenum. Epi was injected, but study was aborted given his hypoxia. He subsequently received 3 more unit in the ICU with stable hematocrit... - stop all NSAIDS and ASA - Protonix gtt x 48 hrs - Sucralfate 1g QID - NPO - Bariatric surgery following - GI following - IR was informed of patient - Hct Q8h - active type and screen - 2 large bore IV # Hypoxia. Transient down to the upper 70% during endoscopy procedure. Thought [**12-25**] sedatives (6 mg midaz and 300 mcg fentanyl) used during procedure as it improved after receiving 0.4 mg IV naloxone 1x. Since the reversion, hypoxia resolved. # Hypertension. Normotensive on arrive. Holding off on antihypertensives given recent GIB and the potential for re-scoping - hold chlorthalidone, lisinopril, and carvedilol - monitor BP - Pt will see PCP on [**Name9 (PRE) 766**], [**2121-5-19**]. . # Cardiomyopathy/Chronic Systolic HF. EF per last Echo in 40-45%. Unclear about the history of his cardiomyopathy. Most recent EKG prior to admission was in [**2118**] according to Atrius note, but unable to open the image at this time. Right heart cath in [**2112**] was without coronary artery disease. Cardiac enzymes flat. - holding aspirin and carvedilol as mentioned above # FEN: IVF prn, replete electrolytes, NPO - f/u folate, B12, and iron given h/o bariatric surgery- restarted B12 supplement and initiated folate supplement Prophylaxis: pneumoboots Access: peripherals Code: Full Medications on Admission: (based on Atrius note, confirmed with patient) - Carvedilol 12.5 mg tab, 1.5 tab, [**Hospital1 **] - Chlorthalidone 25 mg daily - Clindamycin 1% topical lotion [**Hospital1 **] x 2 months - Lisinopril 40 mg po daily - Vitamin B12 - Vitamin C - ASA 81 mg Discharge Disposition: Home Discharge Diagnosis: Acute blood loss anemia GJ anastamotic ulcer 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 due to gastrointestinal bleeding from an ulcer within your gastric pouch. To treat this ulcer, an endoscopy was performed, you were given intravenous antacid medication and your blood counts were monitored serially, which have stabilized. Additionally, your blood pressure was elevated and a medication called captopril was started. You will be given a prescription for this medication, but please follow-up with your PCP regarding ongoing management of your blood pressure. You must not take NSAIDS (non-steroidal anti-inflammatory drugs) Examples are Aspirin, Ibuprofen, Motrin, Aleve, Nuprin and Naproxen. These agents will cause bleeding and ulcers in your digestive system. You are now preparing for discharge to home with the following instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Followup Instructions: Appointment with PCP made on [**Name9 (PRE) 766**], [**2121-5-19**] at 3:30pm. Appointment in [**Hospital **] clinic on [**2121-6-4**] at 1:30pm. [**Hospital **] clinic will call you for your follow-up endoscopy. Please contact the Bariatric Program Coordinator, [**Doctor First Name 6303**], at [**Telephone/Fax (1) 70439**] at [**Hospital 882**] hospital to make a follow-up appointment within 2 weeks. Please follow-up in [**Hospital **] clinic here at [**Hospital1 18**] Completed by:[**2121-5-16**]

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icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

7012, 7018

4721, 6707

311, 333

7107, 7107

3455, 4698

9251, 9761

2692, 2816

7039, 7086

6733, 6989

7258, 9228

2831, 3436

264, 273

2015, 2395

361, 1997

7122, 7234

2417, 2566

2582, 2676

32,559

160,065

1152

Discharge summary

report

Admission Date: [**2159-1-18**] Discharge Date: [**2159-1-23**] Date of Birth: [**2085-11-19**] Sex: F Service: MEDICINE Allergies: Penicillins / Ace Inhibitors Attending:[**First Name3 (LF) 3853**] Chief Complaint: "hypotension." Major Surgical or Invasive Procedure: None History of Present Illness: 73 yo F with h/o CAD, MI, and HTN sent to the ED from clinic for hypotension. She has had multiple admissions in the past thought to be related to overdosing on anti-hypertensives. Her meds are now distributed daily by a family friend. [**Name (NI) **] her daughter, her [**Name2 (NI) **] pressure was somewhat low last night, but she received her medications anyway. Patient and daughter deny any recent illness or sick contacts. . In the [**Location (un) 620**] ED inital vitals were, BP in the 50s. Bolused with IV fluid then started on dopamine. CT abd/pelvis were normal. She was also given stress dose steroids for concern that her hyponatremia, hyperkalemia and hypotension were due to adrenal insufficiency. On transfer to [**Hospital1 **] [**Location (un) 86**], BP in the 120s and was switched to levophed. . On arrival to the ICU, she is on levophed with pressurse in the 120s. Mentating well. No complaints. Past Medical History: - CAD, s/p MI - HTN - HL - Bilateral breast cancer - OA - Depression - Bipolar Social History: Lives at home (alone) she is a retired engineer. No tobacco since [**2148**], No EtOH, No drugs. She attends a daycare facility. Family History: There is no family history for premature coronary artery disease or sudden cardiac death. Physical Exam: ADMISSION PE Vitals: T: 97.0 68 111/58 12 93% 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, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge PE VS: Tm: 98 TC: 95.7 BP: 148/79 HR: 78 RR: 18 O2 Sats 94% on RA I/O 8: [**Telephone/Fax (1) 7399**] I/O 24: 1130/2300 pain: per above GEN: AAOX3, in NAD HEENT: MMM, oropharynx clear NECK: no lad, no thyromegaly CV: [**1-1**] sytolic murmur RESP: CTAB no wrr ABD: NTND, active BS X4, no HSM EXTR: WWP, pulses 1+ and equal, trace ble edema, no hair on legs c/w PAD DERM: no obvious rashes neuro: CN and MS wnl, strength and sensation also wnl PSYCH: mood and affect wnl Pertinent Results: [**2159-1-18**] CXR IMPRESSION: Blunting of the left costophrenic sulcus that may suggest a small effusion and post-surgical change in the right upper lung; otherwise unremarkable. . EKG [**2159-1-21**] Sinus rhythm. Left atrial enlargement. Non-diagnostic Q waves in the lateral leads. Left axis deviation. Poor R wave progression, possibly consistent with clockwise rotation. Compared to the previous tracing of [**2159-1-18**] there is no important change. . Brief Hospital Course: 73 yo F h/o CAD, MI, and HTN sent to the OSH ED for hypotension, started on pressors and transferred to [**Hospital1 18**]. History of labile [**Hospital1 **] pressure with multiple admissions for hypotension. . # Hypotension Many admissions in the past for hypotension, thought to be related to medication overuse. Currently has medications provided by VNA daily. Found to have a [**Hospital1 **] pressure unreadable in daycare, then 70s at [**Location (un) 620**]. Given fluid bolus and started on dopamine. Concern for adrenal insufficiency and was given stress dosed steroids which were not continued here. Transferred to [**Hospital1 **] [**Location (un) 86**] and switch to levophed. Pressors were weaned over the course of 24 hours and her [**Location (un) **] pressure eventually returned to baseline without further intervention. A free cortisol of 24 ruled out adrenal insufficiency. Her home anti-hypertensives were re-started in a step-wise fashion and arrangements were again made for home medicine reconciliation and VNA. Specific inquiry was made for a Russian VNA as language may be a barrier. Dr. [**Last Name (STitle) 171**] was also called to discussed the patient's anti-HTN regimen. It was decided to discharge the patient on toprol XL 100 QD, lisinopril 40 po QD and HCTZ 25 PO QD. Her BP had normalize for 48-72 hours on the floor and had been hypertensive at times. The list was reviewed with the patients daughter. The patients imdur, lasix and norvasc were stopped and should not re-started until following up with PCP or Cardiologist. It appears that the patient has volume sensitive hypotension with medication overuse as a component. . # Acute Renal Failure with reported h/o CRF Most likely to be prerenal from hypotension, resolved with fluids and pressors. Was discharged with a creatinine of 1.3, peak was 3.8 in house. . # Constipation Patient mvoed bowels in house and was sent home on a bowel regimen . # Bipolar Currently stabilized on medication regimen. Continued lamictal, lorazepam, aricept and melatonin. Lithium had been d/c a while ago according to daughter. . # Transitional Issues: -Patient needs to follow up with Dr. [**Last Name (STitle) 349**], PCP [**Last Name (NamePattern4) **] [**11-27**] weeks for further medication titration -Patient also needs to follow up with her Cardiologist Dr. [**Last Name (STitle) 171**] in [**12-29**] weeks, for further management of HTN and chronic angina -please follow up two pending [**Date Range **] cultures [**2159-1-19**] -the patient should have a basic metabolic panel drawn and faxed to PCP prior to follow up Medications on Admission: Iron 325mg [**Hospital1 **] Lamotrigine 100mg [**Hospital1 **] Gabapentin 400mg daily Ranitidine 150mg [**Hospital1 **] Isosorbide mononitrate SR 30mg daily Docusate sodium 100mg [**Hospital1 **] Fluticasone nasal spray 50mcg per nostril Lasix 20mg daily Vitamin D Metoprolol 75mg daily Aspirin 325mg daily Lisinopril 40mg daily Flaxseed oil 1000mg daily Norvasc 5mg daily Lorazepam 1mg qHS Melatonin 1 tab daily Mobik 7.5mg qHS Aricept 10mg qHS Seroquel SR 400mg daily Simvastatin 20mg qHS Tylenol #3 PRN Hyoscyamine sulfate 125mg QID Spiriva Discharge Medications: 1. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. quetiapine 200 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. melatonin Oral 10. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual QID (4 times a day). 11. gabapentin 400 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*0* 13. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 14. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*0* 15. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 16. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 17. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 18. flaxseed oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 19. Mobic 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 20. donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day. 21. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 22. Omega 3 Fish Oil 684-1,200 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 23. Outpatient Lab Work please get a BMP (lytes BUN, creatinine) and fax to Dr. [**Last Name (STitle) 349**] [**Telephone/Fax (1) 7400**] Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: Hypotension, suspect secondary to excess anti-hypertensive medication Acute Renal Failure Bipolar disorder Coronary artery disease Peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 7395**], You were transferred to [**Hospital1 18**] with very low [**Hospital1 **] pressure which we believe was the consequence of excess [**Hospital1 **] pressure medication. All of your [**Hospital1 **] pressure medicines were stopped and then gradually added back. At the time of discharge we have made the following medication changes: --discontinue lasix --start HCTZ 25 PO QD --Increase metoprolol XL to 100mg daily --cont lisinopril to 40mg daily --Stop Imdur and amlodipine A nurse will come to you home to review your medications with you and your family. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] Location: [**Hospital1 **] INTERNAL MEDICINE Address: [**Location (un) **] [**Apartment Address(1) 5524**], [**Location (un) **],[**Numeric Identifier 7331**] Phone: [**Telephone/Fax (1) 7401**] When: Monday, [**2158-1-28**]:15 AM. Department: CARDIAC SERVICES When: WEDNESDAY [**2159-2-21**] at 3:40 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "585.3", "799.02", "412", "403.90", "E942.9", "V10.3", "E942.6", "715.90", "414.01", "296.80", "276.1", "276.7", "272.4", "E942.4", "564.00", "458.29", "584.5", "E944.4", "724.5", "790.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8369, 8444

3133, 5249

305, 311

8647, 8647

2646, 3110

9419, 9998

1524, 1616

6345, 8346

8465, 8626

5776, 6322

8798, 9396

1631, 2627

251, 267

339, 1260

8662, 8774

5272, 5750

1282, 1362

1378, 1508

9,923

107,778

8252

Discharge summary

report

Admission Date: [**2194-12-30**] Discharge Date: [**2195-1-5**] Date of Birth: [**2127-12-26**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2194-12-30**] - CABGx3 (Lima->Left anterior descending artery, vein->obtuse marginal, vein->posterior descending artery); MVR(27mm Mosaic Porcine Valve) History of Present Illness: 66 y/o female with known [**Month/Day/Year **] artery disease and moderate MR. Admitted for congestive heart failure. Work-up at that time revealed severe MR [**First Name (Titles) **] [**Last Name (Titles) **] artery disease. She was thus referred to Dr. [**Last Name (STitle) 1290**] for surgical management. Past Medical History: -[**Last Name (STitle) **] artery disease status post MI [**2186**], [**2191**] -Hypertension -Congestive heart failure (EF 20-25% in [**2186**], 50% in [**2191**], 35% in [**2194**]) -Chronic Renal Insufficiency (baseline Cr 1.9-2.1 in [**2191**], 3.8 on discharge in [**2194-12-1**], 2.8 on discharge [**2194-12-23**]) -Diabetes Mellitus Type II -Chronic back pain Social History: She has a 30 pack-year history of smoking; she quit in [**2186**]. She does not consume EtOH. Denies illicit substance use. She lives alone and has five daughters. Family History: No family history of CAD or DM. Physical Exam: 72 sr (R) 88/64 (L) 130/60 GEN: NAD HEENT: NCAT, PERRL, Anicteric sclera, OP benign NECK: Supple, FROM, No JVD LUNGS: CTA HEART: RRR, Nl S1-S2, III/VI SEM ABD: Obese, NT, ND, NABS EXT: No varicosities, 2+ pulses, warm, no edema. NEURO: Nonfocal Pertinent Results: [**2195-1-2**] 07:05AM BLOOD WBC-6.4 RBC-2.98* Hgb-8.6* Hct-26.6* MCV-89 MCH-28.9 MCHC-32.4 RDW-16.3* Plt Ct-188 [**2195-1-2**] 07:05AM BLOOD Plt Ct-188 [**2195-1-2**] 07:05AM BLOOD Glucose-112* UreaN-56* Creat-2.8* Na-139 K-4.5 Cl-106 HCO3-22 AnGap-16 [**2195-1-2**] 07:05AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.5 [**2193-12-30**] - ECHO PRE-CPB: 1. The left atrium is markedly dilated. No spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No mass/thrombus is seen in the left atrium or left atrial appendage. 2.No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. 3.Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. No left ventricular aneurysm is seen. There is mild to moderate regional left ventricular systolic dysfunction with global hypokinesis especially of the anterior and inferoseptal walls.. No masses or thrombi are seen in the left ventricle. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 4.Right ventricular chamber size and free wall motion are normal. 5.There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 6.There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Trace aortic regurgitation is seen. 7.The mitral valve leaflets are moderately thickened. The mitral valve leaflets do not fully coapt. No mass or vegetation is seen on the mitral valve. Moderate to severe (3+) mitral regurgitation is seen. The jet is central. There annulus is not dilated. There is bileaflet retraction with moderate MAC. POST-CPB: Pt is on epinephrine infusion. Well-seated bioprosthetic valve in the mitral position with no mitral regurgitation seen. LVEF now 40% on inotropic support. Aortic valve now measures 1.9 cm2 , improved from pre-cpb. Mild AS trace AI. [**2195-1-1**] CXR: There has been interval removal of a left-sided chest tube as well as interval removal of a nasogastric tube and removal of a Swan-Ganz catheter, with the right internal jugular sheath remaining in place. There is no evidence of pneumothorax. The mediastinal contours appear improved, but with a persistent postoperative appearance. No region of consolidation is seen. Pulmonary vascularity appears improved since the prior study. The right costophrenic angle has been excluded from the film. Brief Hospital Course: Ms. [**Known lastname 29293**] was admitted to the [**Hospital1 18**] on [**2194-12-30**] for surgical management of her mitral valve and [**Date Range **] artery disease. She was taken to the operating room where she underwent [**Date Range **] artery bypass grafting to three vessels and a mitral valve replacement using a 27mm mosaic porcine valve. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, she awoke neurologically intact and was extubated. Beta blockade and aspirin were resumed. On postoperative day two, she was transferred to the step down unit for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with he postoperative strength and mobility. [**1-2**] Ms. [**Known lastname 29293**] continued to make steady progress and was discharged to rehab on postoperative day #6. She will follow-up with Dr. [**Last Name (STitle) 1290**], her cardiologist and her primary care physician as an outpatient. Medications on Admission: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO TID (3 times a day). 7. Hydralazine 25 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours). 8. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Continue on your home insulin dose of humalog, as before. 12. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. 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* 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO TID (3 times a day). Disp:*135 Tablet, Chewable(s)* Refills:*2* 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Tablet(s) 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Capsule, Sustained Release(s) 13. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: CAD/MR s/p CABGx3 and MVR(27mm porcine) Cardiomyopathy CRI HTN Diabetes CHF Myocardial Infarction Discharge Condition: stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5)No lifting greater then 10 pounds for 10 weeks. 6)No driving for 1 month. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 18151**] Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2195-1-5**] 10:40 Follow-up with Dr. [**Last Name (STitle) 11493**] in 2 weeks. Follow-up with Dr. [**Last Name (STitle) 27542**] in [**1-4**] weeks. [**Telephone/Fax (1) 27541**] Call all providers for appointments Completed by:[**2195-1-5**]

[ "250.00", "428.0", "414.01", "403.90", "425.4", "585.9", "424.0" ]

icd9cm

[ [ [] ] ]

[ "35.23", "39.61", "36.15", "36.12" ]

icd9pcs

[ [ [] ] ]

8161, 8247

4496, 5559

330, 488

8389, 8398

1731, 4473

8909, 9371

1417, 1450

6538, 8138

8268, 8368

5585, 6515

8422, 8886

1465, 1712

283, 292

516, 828

850, 1218

1234, 1401

31,203

150,916

6426+55754

Discharge summary

report+addendum

Admission Date: [**2146-8-6**] Discharge Date: [**2146-8-12**] Date of Birth: [**2074-8-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Ulcer on heel of left foot. Major Surgical or Invasive Procedure: None. History of Present Illness: Briefly, Mr. [**Known lastname 24413**] is a 71 yo male with PMH significant for DM x15 years on insulin, HTN, and CRI who presents with L heel diabetic foot ulcer possibly [**2-12**] foreign object (glass was removed by podiatry in the ED). Says he started feeling lousy 2 days PTA; says he noticed redness in his foot, red streak tracking up leg, swelling and warmth; also noticed ulcer on left heal from which he elicited blood and pus. Also had feelings of "blood poisoning" and chills at night. Says this has happened before during previous episodes of lower extremity cellulitis. Patient has no sensation in his feet [**2-12**] diabetic neuropathy. He called his podiatrist Dr. [**Last Name (STitle) **] on Saturday and was driven to ED by his daughter. In [**Name2 (NI) **], patient was also found to have bilateral LE DVT. . Of note, patient had recent dental procedure (10 days prior) and was found to have murmur on exam (per patient, doctors in the past have told him that he has a murmur, so this may not be a new finding). Post dental procedure he was hypoglycemic and was hospitalized at [**Hospital1 336**] for a few hours before being discharged home. . In the ED vitals were T 99 BP 175/79 AR 74 RR 24 O2 sat 98% RA. He received Vancomycin 1gm, Zosyn 4.5gm IV, regular insulin 10 units, and was started on a heparin gtt. He was then transferred to the ICU for closer monitoring. In MICU patient was continued on heparin gtt, vanc/zosyn. He was given 2L and observed overnight. Restarted on norvasc, still holding HCTZ and ACEI. Cr was 2.3 on admission, now down to 2.1 (baseline of 1.6) . Today patient denies fevers, N/V. No chest pain, SOB, GI or GU symptoms. Has been tolerating POs with no trouble. Past Medical History: Alcoholic pancreatitis Chronic renal insufficiency Hypertension Type 2 Diabetes Benign prostatic hypertrophy Hematuria s/p cystoscopy in [**2144**] Hyperlipidemia Alcohol dependence Social History: He recently quit smoking cigars, which he took up a few years ago after quitting cigarettes, which he had smoked since the age of 15. He continues to drink a couple of drinks every other day. He is divorced. He served in the Navy for two years on a ship in the Mediterranean. Family History: Mother who died recently at age [**Age over 90 **]. His father died at age 57 ago with coronary artery disease, an aneurysm, and kidney stones. He has two brothers and three sisters among whom there is a history of diabetes, hypertension, stroke but no history of kidney disease. Physical Exam: vitals T 100.8 BP 112/37 AR 66 RR 20 O2 sat 95% RA Gen: Awake, alert HEENT: MMM, stitches in place from recent dental extraction, no ulcers Heart: Sinus rhythm, 2/6 systolic murmur Lungs: CTAB, scattered crackles posteriorly Abdomen: Obese, soft, NT/ND, +BS Extremities: RLE with 1-2+ edema, pulses difficult to palpate; LLE-4x4cm ulcer with surrounding erythema, warmth, and edema. Rectal: Guaiac negative in ED Pertinent Results: [**2146-8-6**] 03:10PM BLOOD WBC-9.2 RBC-4.10* Hgb-12.3* Hct-37.5* MCV-91 MCH-29.9 MCHC-32.7 RDW-13.4 Plt Ct-238 [**2146-8-6**] 03:10PM BLOOD Neuts-83.6* Lymphs-10.2* Monos-4.1 Eos-1.6 Baso-0.5 [**2146-8-6**] 03:10PM BLOOD PT-13.4 PTT-25.6 INR(PT)-1.1 [**2146-8-6**] 03:10PM BLOOD ESR-100* [**2146-8-6**] 03:10PM BLOOD Glucose-501* UreaN-30* Creat-2.3* Na-135 K-3.8 Cl-95* HCO3-27 AnGap-17 [**2146-8-6**] 03:20PM BLOOD Lactate-2.7* Relevant Imaging: 1)Cxray ([**8-6**]): No acute pulmonary process. 2)LE U/S ([**8-6**]): Non-occlusive thrombus in both right and left superficial femoral veins, not extending into popliteal or common femoral veins. 3)L foot xray ([**8-6**]): Extensive chronic bony remodeling involving the metatarsals as described above. There is marked soft tissue swelling around the posterior aspect of the foot with area of lucency indicating subcutaneous gas in the plantar aspect of the heel with an adjacent foreign body. No definite radiographic evidence for osteomyelitis. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT TTE (Complete) Done [**2146-8-8**] at 3:06:05 PM FINAL The left atrium is mildly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. 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. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2144-1-3**], no change. Brief Hospital Course: Mr. [**Known lastname 24413**] is a 71 yo male with past medical history as listed above who presents with fevers, bilateral LE DVTs, L foot ulcer, and hyperglycemia. 1)L heel ulcer/cellulitis: Patient has significant diabetic neuropathy and at baseline has no sensation below the knees. He has an ulcer on the medial aspect of the L heel. Podiatry was consulted in the ED and is following him closely. He was placed on Vancomycin and Zosyn for broad spectrum coverage. Vascular surgery and podiatry was consulted. Vascular surgery felt there was no need for intervention at this time as the patient had decent pulse exam. Podiatry debrided the wound and recommended [**Hospital1 **] dressing changes. The patient was to require a 2 week course of antibiotics. A PICC line was placed in the right arm and the patient was discharged with plans for and additional 7 days of antibiotic therapy. The suggested vancomycin dose is 1g/every 24 hours. This will need to be monitored with vancomycin troughs- goal of 15-20. The PICC line will need to be removed following his last dose of antibiotics. . 2)Bilateral LE DVT: Patient noted to have lower extremity swelling (L>R). U/S in ED showed bilateral superficial femoral clots without extension. The patient was started on a heparin gtt and transferred to the ICU for closer monitoring. In MICU patient was continued on heparin gtt and after several hours of monitoring, he was sent to the medical floor. The patient was transitioned to Coumadin over several days. INR was 2.1 on the day of discharge and heparin gtt was discontinued. Since the patient is only now therapeutic on Coumadin, the future daily dosing will need to be adjusted according to his INR. Goal INR is [**2-13**]. . 3)Systolic murmur: Patient noted to have murmur on exam; per patient this is new for him. No murmur was documented on exam when he saw his nephrologist few months ago. Given fevers and recent dental work, concerned was raised for endocarditis. There is no extra cardiac findings on physical exam but the ESR and CRP is significantly elevated. Echocardiogram was ordered which showed no evidence of valvular vegetations but mild mitral regurgitation was seen. Left ventricular ejection fraction was >55%. 4)Type 2 DM: Patient presented with elevated blood sugars in the ED (501). There was no anion gap. Pt states that he had been compliant with home insulin regimen. It was felt that the patient's elevated glucose was due to his infection. The patient was restarted on his home regimen of NPH [**Hospital1 **] and insulin sliding scale. NPH doses were increased due to continuation of his elevated sugars. He was discharged on a new NPH regimen of 48 units QAM and 44U QPM with Humalog insulin sliding scale. 5)Acute on chronic renal insufficiency: Baseline Cr is 1.6. He is followed by Dr. [**Last Name (STitle) 3271**] here at [**Hospital1 18**]. Likely [**2-12**] diabetic nephrosclerosis and chronic hypertension. Elevated to 2.3 on admission. Likely has a pre-renal component given active infection. He received 2 liters of normal saline and his Cr improved to 2.1. His medications were renally dosed and his HCTZ and Lisinopril were held. His creatinine improved while holding these medications so they were held upon discharge. The benefit and risks of these medications should be discussed further as an outpatient. 6)Hypertension: Patient on HCTZ, Lisinopril, Norvasc, Atenolol at home. No evidence of hypotension in the ED. His HCTZ, Lisinopril, and Atenolol were initially held given his elevated creatinine. His blood pressure increased to sbp's 160-170's and so atenolol was restarted with good control. The patient was discharged on Norvasc and Atenolol. 7)Alcohol abuse: The patient and his family reported a history of ethanol abuse and per the patient, he was drinking [**4-16**] alcoholic beverages per night at home. There was no evidence of ethanol withdrawal through his admission. Social work was consulted to discuss ethanol use with the patient and he appeared committed to maintaining abstinence. 8)Hyperlipidemia: The patient was continued on Simvastatin. Medications on Admission: Amlodipine 10mg PO daily Atenolol 100mg daily Doxazosin 4mg PO QHS Hydrochlorothiazide 25mg daily Lisinopril 40mg PO daily Simvastatin 40mg PO daily Aspirin 81mg daily NPH 40 units SQ [**Hospital1 **] Humalog sliding scale Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) Units Subcutaneous twice a day: 48units AM 44units PM. 6. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours): Last Day [**2146-8-19**]. 7. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Please adjust doses according to INR. 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day): Please instruct patient on proper use and use spacer if available. 10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6:PRN as needed: Please instruct patient on use of inhaler and use spacer if available. 11. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours): Please adjust dose based on trough. 12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 13. Outpatient Lab Work Please Draw INR, Vanco trough, Chem 7 on [**8-13**]. Please Fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**]. #[**Telephone/Fax (1) 445**]. 14. PICC Line Care Please remove right arm PICC following last dose of antibiotic on [**2146-8-19**]. 15. Humalog Sliding Scale Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Cellulitis Diabetic Ulcer Hypertension DVTs Discharge Condition: Pt was hemodynamically stable, afebrile and without pain at the time of discharge. Discharge Instructions: You were admitted for an infection of your left foot and leg. This infection was caused by an injury to your foot. You were seen by the podiatry and vascular surgery consults who feel as though your foot will heal. There is no indication for surgery. It is recommended that you do not stand on your left foot and that you use crutches to help you walk while this wound heals. You should follow-up with both your primary care physician and your podiatrist. You were started on IV antibiotics for your infection. A line was placed in your right arm so that these medications can be continued upon discharge from the hospital. You have been treated for 7 days and you will require an additional 7 days of medication. The last dose of antibiotic should be on [**8-19**]. During your hospitalization, you were found to have worsening of your kidney function. This improved to your baseline with IV fluids. We have held your diuretics and your ACEI during your hospitalization. We recommend not restarting these medications at this time. Please be sure to discuss this change with Dr. [**Last Name (STitle) 131**] and to assess the risks and benefits of this medical therapy. On arrival to the hospital, you were found to have blood clots in both legs. You were started on a new medication (Coumadin) which will thin your blood and help prevent blood clots. You will need to have your blood monitored frequently to determine the appropriate effective dose of this medication. You will need to discuss the long term plan for this medication with your primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 131**]. It was felt that you may have some decreased lung function. You were given inhaled medications which have improved your breathing. We are discharging you with instructions to continue these medicines (Ipatroprium and Albuterol). Again, you should discuss this change with your primary physician to determine if they are effective or needed. We encourage you to decrease your use of alcohol. You are being discharged to a rehabilitation facility. Please inform your care providers if you develop return of redness or tenderness in your left foot, fevers, chills, nausea, vomiting, changes in your urine output, swelling of your legs, shortness of breath or chest pain. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 132**] [**Name Initial (NameIs) **]. Date/Time: [**9-8**], 8am PHONE: [**Telephone/Fax (1) 133**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7198**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2146-12-21**] 2:30 Completed by:[**2146-8-12**] Name: [**Known lastname 4200**],[**Known firstname **] Unit No: [**Numeric Identifier 4201**] Admission Date: [**2146-8-6**] Discharge Date: [**2146-8-12**] Date of Birth: [**2074-8-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 161**] Addendum: Brief Hospital Course Assendum: # Cough: Patient was complaining of cough during his hospitalization and reported some shortness of breath at baseline. He did not exhibit signs of pulmonary infection on XR and it was felt that this symptoms might be related to asthma/copd. The patient was started on Albuterol and Ipatroprium with marked improvement of his symptoms and at the time of discharge, the patient reported breathing better than his baseline. He was discharged with both ipatroprium/albuterol MDIs and instructed to follow-up with this primary care physician. Discharge Disposition: Extended Care Facility: [**Hospital1 49**] - [**Location (un) 50**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 165**] MD [**MD Number(1) 166**] Completed by:[**2146-8-12**]

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Discharge summary

report

Admission Date: [**2176-10-23**] Discharge Date: [**2176-11-1**] Date of Birth: [**2107-8-31**] Sex: F Service: SURGERY Allergies: Nifedipine / amlodipine Attending:[**First Name3 (LF) 158**] Chief Complaint: ischemic bowel Major Surgical or Invasive Procedure: [**2176-10-23**] Exploratory laparotomy, low anterior resection of this resection of the colorectal anastomosis, end colostomy, extensive lysis of adhesions. [**2176-10-25**] Exploratory laparotomy, completion right colectomy, takedown of the stoma and ileostomy. History of Present Illness: [**Hospital Unit Name 153**] admission note: 69 yo F with HTN, T2DM, COPD on 2 L NC (baseline), h/o infrarenal AAA s/p repair complicated by bowel ischemia with multiple bowel surgeries most recently LOA/LAR/end colostomy [**2176-10-23**] and re-exploration with right colectomy and end ileostomy on [**2176-10-25**] transferred from the colorectal service for hypertension up to SBP 200s and tachycardia to the 130s-150s. Per surgery, patient tolerated the surgery without issue. She received a total of 2 pRBC and about 2L of cyrstalloids. Patient has been getting metoprolol intermittently prior to her surgery. Per report, patient was found to be tachycardic up to the 130s with SBP up to the low 200s. Upon reviewing the [**Month (only) 16**], patient was found to have recieved metoprolol 5 mg IV x [**4-11**], hydralazing 10 mg IV x 2. Patient has been on a dilaudid PCA pump and denied pain. EKG showed sinus tachycardia. UOP has been about 748 cc since midnight. Patient has been on vancomycin and zosyn empirically [**2176-10-23**]. Patient was thought to be more confused, ? delirium, so neurology was consulted. Upon arriving to the MICU, patient reports feeling some palpitation, SOB which is slightly worse than baseline. She feels foggy but not confused. UA and cardiac biomarkers were pending at the time of transfer. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough or wheezing. Denies chest pain, chest pressure. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - CAD (TTE [**6-16**] w EF 60%) - DM2 - HTN - COPD on home O2 - Recurrent PNA - h/o interstitial lung disease of hypersensitivity pneumonitis s/p prednisone ~ [**2174**] s/p wedge resection of RML [**6-/2174**] - GERD - Hx thyroid dz - previous smoker - L thalamic ICH w residual mild RLE weakness ([**10/2174**]) - Concern for cryptogenic cirrhosis - lactose intolerance - s/p TAH/BSO unknown - s/p Appy unknown - Tonsillectomy unknown - L lumpectomy [**2171**] - s/p Lung biopsy [**2174**] - s/p open infrarenal AAA repair w/ dacron (Kechejian-[**2175-3-31**]) - s/p Sigmoid colectomy end colostomy ([**Doctor Last Name **]-[**2175-4-2**]) - s/p Hartmann's reversal, SBR, bladder repair, liver bx ([**Doctor Last Name **]-[**2175-11-16**]) - s/p take down of the ileostomy in [**2-/2176**] Social History: - lives at home with boyfriend, [**Name (NI) **] [**Telephone/Fax (1) 88094**] - Does not report a substance use history - Says that she is a social drinker and does not drink very often - Had long smoking history but stopped smoking 5 years ago Family History: Father died age [**Age over 90 **] w/complications of Alzheimer's. Mother is aged 97 w/mild memory issues and is retired RN. Physical Exam: Arrival to [**Hospital Unit Name 153**]: General: drowsy but arousable to voice and answers questions appropriately, oriented x 3 HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRLA Neck: supple, EJ elevated to 2-3 cm above the clavical, IJ did not appear overtly compressable on ultrasound, no LAD CV: regular, tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: diminished breath sounds bilaterally, scatterred wheeze on the right base, no rhonchi or rales Abdomen: firm, non-tender, non-distended, bowel sounds present, no organomegaly, + guarding GU: + foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred. DC Physical Exam: General: A&OX3, does not appear short of breath, pain contolled, tol reg diet, adequate ileostomy output. VS: 98.3, 98.1, 92, 156/80, 16, 96% 2 L, 93% RA Cardiac: RRR, blood pressure much improved Lungs: deminished in bases, baseline abd: flat, soft, stay sutures in place, midline incision with 3-4 cm open area with facial suture exposed scant serous drainage, aquacel rope applied with dsd covering, llq jp drain site closed with steristrips draining scant yellow drianage, no errythema, left sided ileostomy with liquid green output. Lower extrmeities: +1 edema in lower extremitites improved. GYN/GU: voiding without issue, labia with small amount of edema b/l improved Pertinent Results: Admission labs: [**2176-10-24**] 07:25AM BLOOD WBC-11.7*# RBC-3.62* Hgb-9.4* Hct-30.0* MCV-83 MCH-26.1* MCHC-31.5 RDW-18.0* Plt Ct-148* [**2176-10-24**] 07:25AM BLOOD Glucose-116* UreaN-29* Creat-1.3* Na-139 K-4.7 Cl-109* HCO3-22 AnGap-13 [**2176-10-24**] 07:25AM BLOOD Calcium-7.3* Phos-4.8*# Mg-2.1 [**2176-10-23**] 12:29PM BLOOD Lactate-1.0 K-3.9 [**2176-10-23**] 01:49PM BLOOD freeCa-1.03* Notable labs: [**2176-10-26**] 12:30PM BLOOD ALT-5 AST-24 AlkPhos-53 TotBili-0.6 [**2176-10-25**] 04:00AM BLOOD LD(LDH)-207 CK(CPK)-77 [**2176-10-24**] 07:25AM BLOOD CK-MB-3 cTropnT-<0.01 [**2176-10-25**] 04:00AM BLOOD CK-MB-3 cTropnT-<0.01 [**2176-10-26**] 12:30PM BLOOD CK-MB-3 cTropnT-<0.01 [**2176-10-26**] 05:00PM BLOOD cTropnT-<0.01 [**2176-10-27**] 04:51AM BLOOD cTropnT-<0.01 [**2176-10-26**] 12:30PM BLOOD TSH-6.1* [**2176-10-26**] 12:30PM BLOOD Free T4-1.1 Discharge labs: Micro: [**2176-10-24**] 4:50 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): [**2176-10-25**] 6:30 am BLOOD CULTURE Source: Venipuncture 1 OF 2. Blood Culture, Routine (Pending): [**2176-10-26**] 5:00 pm BLOOD CULTURE Site: ARM Blood Culture, Routine (Pending): Studies: [**2176-10-26**] CTA CHEST W&W/O C&RECON 1. Pulmonary edema on a background of centrilobular emphysema. Given normal heart size on the recent chest radiograph, this may be noncardiogenic pulmonary edema. Small-moderate bilateral pleural effusions with adjacent compressive atelectasis. 2. No pulmonary embolism. 3. Moderate atherosclerotic calcifications of unknown hemodynamic significance. 4. Cirrhosis and splenomegaly no completely imaged. [**2176-10-26**] CT HEAD W/O CONTRAST There is no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarct. Ventricles and sulci are minimally prominent, compatible with global age-related volume loss. Basal cisterns are patent. There is no shift of normally midline structures. A hypodense focus in the left thalamus is from prior hemorrhage. Hypodense foci in the left subinsular region and left frontal lobe are unchanged from [**2175-6-16**]. A hypodense focus in the left centrum semiovale (2A:15) may represent a tiny lacune, new from [**2175-6-16**]. Otherwise, [**Doctor Last Name 352**]-white matter differentiation is preserved. No acute osseous abnormality is identified. The visualized paranasal sinuses and mastoid air cells are clear. [**2176-10-26**] CHEST (PORTABLE AP) Patchy opacity at the right lung base could reflect atelectasis, although aspiration or pneumonia could also have this appearance. Followup imaging would be advised. The left lung is grossly clear. No pleural effusions. No pneumothorax. Overall, cardiac and mediastinal contours are stable. A tortuous calcified aorta consistent with atherosclerosis. No evidence of pulmonary edema. Nasogastric tube is seen coursing below the diaphragm with the tip within the stomach and the side port near the gastroesophageal junction. Advancement should be considered to minimize the risk of aspiration. Pathology: pending [**2176-10-25**] Pathology Tissue: STOMA AND TRANSVERSE COLON, [**2176-10-23**] Pathology Tissue: Decending colon, Rectum. CHEST (PORTABLE AP) Study Date of [**2176-10-29**] 6:44 PM In comparison with the study of [**10-29**], there is little overall change. Bibasilar opacification is consistent with bilateral pleural effusions and compressive atelectasis. In the appropriate clinical setting, supervening pneumonia would have to be considered. Brief Hospital Course: The patient was admitted to the inpatient colorectal surgery service after a complicated intraoperative course which can be further described in the operative note. The patient was stable on the inpatient floor, she was monitored closely for hypotension as her pressure was low in during the procedure. On the morning of post=operative day one, the patient's abdominal pain was minimal however, the stoma was noted to be dusky/blue/black, in the afternoon of post-operative day one the stoma was nectrotic. This was monitored overnight into Post-operative day two and the patient remained stable. On the morning of post-operative day two, the patient was stable however, after examinateion with a test tube, the stoma was necrotic past the facia and it was decided by Dr. [**Last Name (STitle) **] that she would be taken to the operating room for an exploratory laparotomy, colectomy, and ileostomy. The patient was then tachycardic and hypertensive post-operatively and transfered to the [**Hospital Unit Name 153**] for closer monitoring. [**Hospital Unit Name 153**] Course Reasons for transfer: Tachycardia and Hypertension 69 yo F with HTN, T2DM, COPD on 2 L NC (baseline), h/o infrarenal AAA s/p repair complicated by bowel ischemia with multiple bowel surgeries most recently LOA/LAR/end colostomy [**2176-10-23**] and re-exploration with right colectomy and end ileostomy on [**2176-10-25**] transferred from the colorectal service for hypertension up to SBP 200s and tachycardia to the 130s-150s # Sinus Tachycardia. EKG excluded atrial fibrillation, multifocal atrial tachycardia, and atrial flutter. Her UA was negative. Blood cultures was NGTD. There was initial concern for possible PNA, but CT chest did not show evidence of consolidation. She was also ruled out of PE based on the CTA chest. Beta blocker withdrawal seems unlikely as she received multiple doses of metoprolol prior to transfer. She did not have any evidence of bleeding and her exam did not show evidence of hypovolemia by bedside ultrasound. There was initial thought of possible heart failure, but patient auto-diuresed for the most part and did not require signifant amount of diuretics. She had extensive surgery prior to her transfer to the [**Hospital Unit Name 153**], making it a result of the stress response certainly possible. Patient was continued on broad spectrum antibiotics given that she was found to have ischemic colon in her second surgery during this admission. She was on esmolol gtt per surgery while in the [**Hospital Unit Name 153**] that was ultimately transitioned to labetolol upon transferring to the surgical floor # Hypertension. Unclear etiology, although may have required additional agents in the past for blood pressure. Patient is unable to take CCB given previous allergy/hypersensitivity reaction. Reports only taking metoprolol 50 mg daily which was confirmed by PCP's record. There was initial concern of beta blocker withdrawal although patient received multiple doses of metoprolol prior to transfer. Esmolol gtt was used for rate control and BP control initially, and was ultimately switched to labetolol for BP control given more alpha action. # Toxic metabolic encephalopathy/Delirium: Patient was noted to be mildly somnolent and inattentive post-operative so neurology was consulted. Per neurology note: "Her motor exam is remarkable for asterixis, which was also superimposed on her finger to nose testing. All of these signs make the toxic-metabolic encephalopathy more likely, which can be common in acutely ill patients. However, given her history of thalamic intraparenchymal hemorrhage, it would be important to control her hypertension as well to prevent further intracranial hemorrhage. In setting of hypertension, PRES can be considered, but also less likely as patient is not complaining of headaches and there is no clinical seizures. She does complain of visual hallucinations, but this can also be consistent with toxic metabolic encephalopathy." Head CT witout contrast showed no acute process. Patient was managed with supportive care for delirium. PCA pump was discontinued as she was having difficulty using it appropriately. # s/p Colectomy [**2-8**] ischemia. Complicated surgical history with total colectomy during this hospital course. She was started on vancomycin and zosyn empirically given the extensive bowel ischemia found on surgery. Her abdominal exam post-operatively improved over time, and she was ultimately transitioned to clears upon transferring back to the surgical floor from the [**Hospital Unit Name 153**]. # COPD on O2 2L. Appears to be at baseline with O2 requirement at the time of her [**Hospital Unit Name 153**] stay. She was continued on home tiotropium and swtiched to advair as symbicort is non-formulary. She was given albuterol and ipratropium nebs as needed. # T2DM, not on any medications at baseline. Patient was kept on sliding scale while in the [**Hospital Unit Name 153**]. # Mood d/o. Celexa was held temporarily when she was NPO in the [**Hospital Unit Name 153**]. Benzodiazepine was also held while she was in the [**Hospital Unit Name 153**] because of underlying delirium. The patient was transferred to back to the inpatient colorectal surgery service. Cardiology followed for hemodynamic monitoring. The patient remained stable. on the inpatient unit. Her diet was advanced as she had appropriate return of bowel function. She had transient shortness of breath. A chest Xray was obtained on [**2176-10-29**] which did not show fluid overload, her shortness of breath was attributed to her baseline COPD. She was given albuterol and atrovent nebulizing treatments which improved her status. She intermittently used nasal canula oxygen as she had done prior to her admission. Physical therapy consulted on the patient, she refused to be discharged to a rehabilitation facility. Her daughter agreed to take her to her house to stay with VNA and home PT. The midline incision was noted to drain and [**2-10**] staples were removed, exposing fascia which drained small amounts of sero-sang drainage. The patient was followed by pastoral care and case managment Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation Inhalation TID 2 puffs 2. Citalopram 10 mg PO DAILY 3. Metoprolol Tartrate 50 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Simvastatin 20 mg PO DAILY 6. Temazepam 15 mg PO HS 7. Aspirin 81 mg PO DAILY 8. Ferrous Sulfate 160 mg PO DAILY 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. Tiotropium Bromide 1 CAP IH DAILY 11. Albuterol-Ipratropium 2 PUFF IH Q6H 12. Ipratropium Bromide Neb 1 NEB IH PRN Shortness of breath or wheeze 13. Albuterol 0.083% Neb Soln 1 NEB IH PRN shortness of breath or wheeze 14. Vitamin D3 *NF* (cholecalciferol (vitamin D3)) 1,000 unit Oral daily 15. Potassium Chloride 10 mEq PO BID Duration: 24 Hours Hold for K > 5.0 16. Estrace *NF* (estradiol) 0.1 mg/g Vaginal 2-3 times a week 1 gram Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Citalopram 10 mg PO DAILY 3. Simvastatin 20 mg PO DAILY 4. Tiotropium Bromide 1 CAP IH DAILY 5. Acetaminophen (Liquid) 650 mg PO Q6H RX *acetaminophen 325 mg [**1-8**] tablet by mouth every six (6) hours Disp #*45 Tablet Refills:*0 6. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 7. Labetalol 250 mg PO TID RX *labetalol 100 mg 2.5 tablet(s) by mouth three times a day Disp #*150 Tablet Refills:*1 8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1-2-1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 RX *oxycodone 5 mg 1/2-1 tablet(s) by mouth every four (4) hours Disp #*35 Tablet Refills:*0 9. Omeprazole 20 mg PO DAILY 10. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation INHALATION TID 2 puffs 11. Vitamin D3 *NF* (cholecalciferol (vitamin D3)) 1,000 unit Oral daily 12. Fish Oil (Omega 3) 1000 mg PO DAILY 13. Ferrous Sulfate 160 mg PO DAILY 14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath if this medication is needed please call your pcp and if symptoms are severe please go to the emergency room for medical attention RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 3 ml every six (6) hours Disp #*20 Each Refills:*0 Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Anastomotic Stricture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a resection of your previous anastomosis and end colostomy formation. Unfortunately, after this first procedure you developed some impaired blood flow to the stoma of the colostomy and you were brought back to the operating room with Dr. [**Last Name (STitle) **] and part of the right colon was removed and an ileostomy was formed. After this procedure, you were taken care of in the intensive care unit to monitor your cardiac issues. You have recovered from this procedure well and you are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. You will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact you regarding these results they will contact you before this time. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. It is very important that you have close follow-up with the Colorectal Surgery Team and the wound ostomy nurses as you are going home to your daughters house and not to rehab. Please make an appointment with your primary care provider to discuss your admission and changes in your cardiac medications. Please pay close attention to your medication list and monitor your blood pressure and heart rate at home. Please call our office or your primary care provider if the top number of you blood pressure is greater than 150 or lower than 90. Please monitor your heart rate occationally at home and call if it is greater than 95 beats in one minute or lower than 60 beats in one minute. If you have any of the following abdominal symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, difficulty with your ileostomy output. You have a new ileostomy. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. You must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. If you find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if you notice your ileostomy output increasing, take in more electrolyte drink such as Gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If you notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. You may eat a regular diet with your new ileostomy. However it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to you by the ostomy nurses. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. The stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as you have been instructed by the wound/ostomy nurses. You will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. You will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until you are comfortable caring for it on your own. You have a long vertical incision on your abdomen that is closed with staples. This incision can be left open to air or covered with a dry sterile gauze dressing if the staples become irritated from clothing. You have a small opening in he incision where he incision line was opened. This should be packed with gazue and changed 2-3 times daily s instructed by the floor nursing staff. The other staples will stay in place until your first post-operative visit at which time they can be removed in the clinic, most likely by the office nurse. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. You also have a small incision where the JP drain was once in place and this was removed prior to discharge. Please monitor this for the signs and symptoms listed above of infection. If the drain site bleeds or drains large amounts of sero-sang fluid requiring you to No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may gradually increase your activity as tolerated but clear heavy exercise with Dr. [**Last Name (STitle) **]. You will be prescribed a small amount of the pain medication Oxycodone. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: Please make a follow-up appointment with [**First Name8 (NamePattern2) 1123**] [**Last Name (NamePattern1) 1124**], NP or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP and the wound/ostomy nurses for 7-10 days after discharge. Please call the Colorectal Surgery Clinic to make this appointment, [**Telephone/Fax (1) 160**]. Please call the is number with any questions or concerns. Please make an appointment with your primary care provider to discuss this admission and the changes in your medication regimen. Completed by:[**2176-11-1**]

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icd9cm

[ [ [] ] ]

[ "38.97", "45.73", "46.10", "48.63", "59.8", "54.59", "46.20" ]

icd9pcs

[ [ [] ] ]

16941, 16996

8596, 14787

299, 567

17062, 17062

5015, 5015

23327, 23894

3406, 3532

15673, 16918

17017, 17041

14813, 15650

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4320, 4996

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1962, 2310

244, 261

595, 1943

5031, 5878

17077, 17189

2332, 3126

3142, 3390

78,442

132,433

35369

Discharge summary

report

Admission Date: [**2124-6-27**] Discharge Date: [**2124-6-29**] Date of Birth: [**2050-6-7**] Sex: F Service: MEDICINE Allergies: Cefepime / Meropenem / Ciprofloxacin / Levofloxacin Attending:[**First Name3 (LF) 2763**] Chief Complaint: Febrile neutropenia Major Surgical or Invasive Procedure: none History of Present Illness: [**Known firstname 37190**] [**Last Name (NamePattern1) **] is a 74-year-old female with relapsed AML who was only recently azacitidine was last admitted on [**6-5**] with neutropenic fever. During this admission she was noted to have pseudomonas bacteremia as well as klebsiella and ecoli in her BAL. She was initially treated with empiric therapy of vancomycin and zosyn. Voriconazole was also started initially but this was scaled back after BAl was negative for fungal infection. She was then discharged home on po cefpodoxime after she decided to go home so she can focus on quality of life instead. Patient now presents again with fever for two days along with some non productive cough and vomiting with bile. In ED she had temp to 104. Labs revealed neutropenia as well as anemia. She was cultured and started on iv zosyn. She's admitted for further care. Past Medical History: . Past Oncologic History: Ms. [**Name13 (STitle) **] was diagnosed with AML in [**2123-3-7**]. She had 7+3 treatment complicated by febrile neutropenia and pneumonia. She has undergone low-dose chemotherapy (cytarabine/idarubicin) as an outpatient. She received 4 cycles of ALFA-low dos cytarabine/idarubicin. Her counts were slow to recover and there was concern over MDS. Responded to neupogen injections. She underwent a bone marrow biopsy in [**Month (only) 547**] which showed 52% blasts. She had no circulating blasts at that time. She received her first cycle of decitibine [**4-21**] to [**4-25**]. She tolerated treatment well per report. On [**4-28**] she had 4% circulating blasts. This increased to 63%. Treated with Azacitadine in [**5-15**]. PAST MEDICAL HISTORY: - AML - Glaucoma with bilateral cataract surgery in [**2103**] and [**2106**] - Lung lesions during induction suspicious for Aspergillus. Social History: From the [**Location (un) 86**] area. No children. Currently living with her brother. She denies alcohol, tobacco, or illicit drugs. Family History: Mother - deceased at age [**Age over 90 **] from Alzheimer's Disease. Father - deceased at age [**Age over 90 **]. She has a brother who is healthy. Physical Exam: VS: 99.0, 140/46, 90/min, rr 20/min, sats97% on ra, GENERAL: fatigued, pleasant, alert and oriented x3 HEENT: EOMI, PERRLA, oropharynx dry, +thrush NODES: No cervical, supraclavicular LAD LUNGS: mild rhonchi bilaterally. HEART: RRR, PSM, no rub/gallop ABDOMEN: Soft, nontender, nondistended, with no palpable masses or hepatosplenomegaly. EXT: No clubbing, cyanosis, or edema SKIN: Resolving drug rash over both legs, 2 flesh colored papules over left forearm surface Pertinent Results: [**2124-6-27**] 04:20PM WBC-1.0* RBC-2.95* HGB-8.9* HCT-25.5* MCV-86 MCH-30.0 MCHC-34.8 RDW-14.7 [**2124-6-27**] 04:20PM NEUTS-0 BANDS-0 LYMPHS-43* MONOS-7 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 BLASTS-49* [**2124-6-27**] 04:20PM PLT SMR-RARE PLT COUNT-7*# [**2124-6-27**] 04:20PM PT-19.3* PTT-41.7* INR(PT)-1.8* [**2124-6-27**] 11:34PM WBC-0.8* RBC-2.62* HGB-8.0* HCT-23.0* MCV-88 MCH-30.7 MCHC-35.0 RDW-14.0 [**2124-6-27**] 11:34PM PLT COUNT-7* [**6-27**] Blood cultures: Gram negative Rods -[**6-27**] CXR: Enlarging left lower lobe opacity, consistent with known invasive aspergillosis. Additional nodules are difficult to evaluate on radiography. -[**6-28**] CXR: Substantial progression of consolidation in and around growing multiple lung nodules, accompanied by new left pleural effusion consistent with active spreading infection, more likely bacterial than fungal due to the rapid change. Mild interstitial edema is also new, presumably reflecting interval volume support. Heart size, however, is normal. -[**6-28**] post intubation: ET tube tip is 7.2 cm above the carina could be advanced couple of centimeters to standard position. Right subclavian catheter tip is in the mid SVC. NG tube tip is out of view below the diaphragm. Cardiomediastinal contours are normal. There is no pneumothorax. A small left pleural effusion is unchanged. Multifocal rounded opacities located throughout both lungs have minimally worsened consistent with worsening multifocal pneumonia Brief Hospital Course: Ms. [**Name13 (STitle) **] is a 74 y/o F with recurrent AML who was admitted to the BMT service on [**2124-6-27**] for neutropenic fevers. She was intially treated with broad spectrum antibiotics, with zosyn and vancomycin. Throughout her time on the floor, her blood pressures were borderline and supported with IV fluids. She continued to have high fevers with a max of 103F, and she had an oxygen requirement which slowly increased to 3 liters. Follow up CXR with her developing oxygen requirement demonstrated multifocal pneumonia. Her blood cultures also returned within 1 day of being drawn with gram stain showing Gram negative rods. Of note the previous week, she has been admitted with pseudomonal bacteremia and pneumonia which was sensitive to zosyn. The evening of [**2124-6-28**] the patient became unresponsive while transferring from the commode to the bed and was unresponsive. A code blue was called and she recieved chest compressions for 3 minutes. She was intubated. The monitor was attached about 2 minutes into chest compressions, which showed sinus tachycardia. At that time, femoral pulse was palpated and chest compressions were stopped, and she was transferred to the ICU. There was a question as to what her code status was, and it appeared that the recent decision was for her to be DNR/DNI. In the ICU, the patient was quickly weaned off down on the vent. She was also hypotensive and recieved about 5L NS for treatment of this. She passed a SBT, and was extubated. After she was extubated the patient was lucent and interactive. Her code status was confirmed, and she expressed the wish to not have anything invasive done, and be DNR/DNI. She was satting well on face mask and interactive. about an hour after being extubated, the patient suddenly became unresonsive. Her O2 saturations started to drift down quickly. She maintained a pulse for several minutes. The patient was made confortable, and within several minutes, she became asystolic as well. Time of death was called at 3:25AM [**2124-6-29**]. MD, nurses at bedside. patient unresponsive to tactile and verbal stimuli. no breath or heart sounds. no pupillary reflex. patients brother [**Name (NI) 382**] and attending notified of the death. Medications on Admission: 1. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 2. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea/anxiety. 5. Calcium Carbonate-Vitamin D3 600mg (1,000mg) -1,000 unit Tablet Sig: One (1) Tablet PO once a day. 6. Prochlorperazine Maleate 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for nausea. 7. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL Mouthwash Sig: One (1) dose Mucous membrane twice a day as needed for indigestion. 8. Brimonidine-Timolol 0.2-0.5 % Drops Sig: One (1) application Ophthalmic at bedtime. 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure GNR bacteremia sepsis febrile neutropenia Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2124-6-29**]

[ "482.1", "038.43", "V87.41", "995.92", "427.5", "365.9", "117.3", "285.9", "780.61", "205.00", "288.00", "287.4", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

7724, 7733

4516, 6752

331, 337

7838, 7848

2993, 4493

7905, 8036

2338, 2490

7695, 7701

7754, 7817

6778, 7672

7872, 7882

2505, 2974

272, 293

365, 1231

2032, 2171

2187, 2322

70,664

176,735

37537

Discharge summary

report

Admission Date: [**2199-1-15**] Discharge Date: [**2199-1-25**] Date of Birth: [**2131-6-2**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: coronary artery bypass graft x3 (LIMA-LAD, SVG to OM, [**First Name3 (LF) **]) History of Present Illness: 67M with history of CAD (non-Q wave MI [**11-27**]) s/p LCX stent, hypertension presents with history of chest pain. He has done well since [**2192**] but recently during a business trip to [**State 8449**] developed chest pressure described as substernal burning/pressure during hiking that relieved with rest and decreased altitude. He returned to [**Location 86**] and had similar symptoms while walking that were relieved with rest and SLNG. Noticed reduced exercise tolerance when working out. He presented to PCP and sestamibi stress test was performed. He developed symptoms and said that he almost past out, there were 1-[**Street Address(2) 1766**] depressions in the inferior and lateral leads, with nuclear images revealed anteroapical ischemia. He underwent outpatient cardiac cath on [**2199-1-15**] which revealed >95% proximal LAD lesion with "non critical" diseases in the left main. Of note, given plavix prior to transfer. He was transferred to [**Hospital1 18**] for further management, possible CABG vs. PCI. Past Medical History: 1. CARDIAC RISK FACTORS:: - Hypertension 2. CARDIAC HISTORY: -CABG: none -PCI: [**11-27**] LCX stent ([**Hospital3 2005**]) -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - cervical radiculopathy - BPH - carpal tunnel syndrome Social History: Married, lives with wife -Retired, president of technology company -Tobacco history: None -ETOH: [**3-28**] drinks wine daily, no withdraw -Illicit drugs: None Family History: Mother - 81 Pneumonia Father - 47 lung cancer Physical Exam: VS: 96.4 117/58 78 95%RA GEN: awake, alert caucasian male in NAD HEENT: oropharynx clear, anicteric NECK: JVP at clavicle, supple CV: S1, S2 regular rhythm, I/VI early systolic murmur LUNG: unlabored resp, CTA bilaterally, no wheezes ABD: soft, ntnd, no gaurding EXT: warm, distal pulses intact, left groin no hematoma, no bruit NEURO: oriented x3, CNII-XII intact, MAE antigravity Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 5259**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 84281**] (Complete) Done [**2199-1-21**] at 9:16:12 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] [**Street Address(2) 15115**] [**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2131-6-2**] Age (years): 67 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: CABG ICD-9 Codes: 786.05, 786.51, 424.1 Test Information Date/Time: [**2199-1-21**] at 09:16 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW1-: Machine: aw1 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Mildly depressed LVEF. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mild (1+) AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: 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 under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is mildly depressed (LVEF= 40 - 45 %), with global distal and apical HK. Mild RV hypokinesis. There are simple atheroma in the descending thoracic aorta. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post-CPB: Patient is AV-Paced, on low dose phenylephrine. Preserved biventricular systolic fxn. 1+ AI, no MR, trace TR. Aorta intact. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2199-1-21**] 10:44 [**2199-1-23**] 05:47AM BLOOD WBC-8.9 RBC-3.01* Hgb-9.8* Hct-28.8* MCV-96 MCH-32.6* MCHC-34.0 RDW-13.8 Plt Ct-171 [**2199-1-21**] 11:26AM BLOOD PT-13.3 PTT-31.3 INR(PT)-1.1 [**2199-1-23**] 05:47AM BLOOD Glucose-132* UreaN-12 Creat-0.8 Na-135 K-4.3 Cl-100 HCO3-28 AnGap-11 Brief Hospital Course: 67 yo male with history of hypertension and CAD s/p Left circumflex stent in [**2192**] with exertional chest burning/pain. He had a positive stress test and was sent to [**Hospital3 **] for cardiac catheterization, which revealed complex Left main and 99% Left anterior descending. Underwent surgical revascularization. He was taken to the operating room on [**2199-1-21**] and underwent coronary artery bypass graft x2 (LIMA-LAD, SVG to [**Last Name (LF) **], [**First Name3 (LF) **]). See operative note for details. Post operatively he was admitted to the ICU intubated and sedated. He awoke neurologically intact, weaned and extubated without difficulty. He was started and betablockers, diuretics and statin therapy. His chest tubes and temporary pacing wires were removed per protocol. He was evaluated and treated by physical therapy for strength and conditioning and cleared for discharge to home. He was discharged to home on post-operative day four. Medications on Admission: -aspirin 81mg daily -atorvastatin 10mg daily -metoprolol 50mg [**Hospital1 **] -SLNG PRN -Naprosyn 500mg [**Hospital1 **] . Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or fever. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*2* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Hypertension,CAD s/p Non-Q Wave Myocardial infarction s/p Left circumflex stent [**11-27**] ,BPH,Carpal tunnel syndrome Coronary artery bypass graft x3 Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Recommended Follow-up:Please call to schedule appointments Surgeon Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care Dr. [**Last Name (STitle) **] [**Name (STitle) 76850**] in [**1-26**] weeks Cardiologist Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-26**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2199-1-25**]

[ "414.01", "V45.82", "600.00", "412", "401.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7592, 7675

5448, 6410

330, 411

7871, 7967

2382, 5425

8472, 9037

1916, 1964

6585, 7569

7696, 7850

6436, 6562

8015, 8449

1979, 2363

1552, 1633

280, 292

439, 1469

1664, 1722

1491, 1532

1738, 1900

9,517

114,349

10690

Discharge summary

report

Admission Date: [**2111-7-9**] Discharge Date: [**2111-7-20**] Date of Birth: [**2049-11-28**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 60-year-old male with a history of diabetes mellitus who was admitted for cardiac catheterization. The patient has been having exertional substernal chest pain and short of breath for months and on the morning prior to admission experienced an episode of chest tightness while leaving the parking lot to have his stress test done. The ETT which was done showed ST segment depression in 2, 3 and AVF and V2 through V5 after 5 minutes and 49 seconds. The patient also had substernal chest discomfort and short of breath which persisted resulting in him being rushed to the [**Hospital3 **] emergency department. On electrocardiogram there was resolution of the ST segment abnormalities. He received nitropaste which relieved his symptoms. CKMB at that hospital was 3.7, troponin were flat and he was transferred to [**Hospital1 188**]. PAST MEDICAL HISTORY: 1. Diabetes mellitus Type 2. 2. Hypertension. 3. Hypothyroidism. 4. Status post right radical nephrectomy in [**2103**]. 5. Arthritis. MEDICATIONS: 1. Atenolol 50 mg q day. 2. Hydrochloraquin 200 mg twice a day. 3. Naproxen 37.5 mg twice a day 4. Glyburide 2.5 mg q day. 5. Accupril 10 mg q day. 6. Synthroid. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He stopped tobacco in [**2090**] and has occasional cigars. Drinks one beer per day. PHYSICAL EXAMINATION: The patient's vital signs were temperature 97.5, heart rate 65, blood pressure 127/67, respiratory rate 20. O2 sat 96% on two liters. Skin was warm, dry and icteric. Head, eyes, ears, nose and throat; Normocephalic, atraumatic. The pupils are equal round and reactive to light. Extraocular movements intact. Positive cataracts. Neck supple,no bruits. Lungs: Clear to auscultation bilaterally. Cardiovascular; S1 and S2 regular rate and rhythm with a harsh systolic ejection murmur radiating to the carotids. Abdomen obese, bowel sounds present, soft, nontender, nondistended. Extremities: No edema. Bilateral palpable dorsalis pedis and posterior tibial pulses, no groin bruits. Neurological: Cranial nerves II to XII grossly intact. Rectal: External hemorrhoids, normal tone, guaiac negative. On admission the patient's white blood count was 12.4, hemoglobin 12.1, hematocrit 34.7. platelet count 247. Prothrombin time 12.5, PTT 25.6, INR 1.0. Urinalysis was negative for nitrates, positive for 100 protein, sodium 142, potassium 4.9, chloride 108, CO2 19, BUN 41, creatinine 1.7, glucose 88. CK was 66. Echocardiogram by bedside done at [**Hospital3 **] showed aortic stenosis, peak gradient greater than 25 mm of mercury. EF of approximately 50% with borderline Left ventricular hypertrophy. Chest x-ray done here was negative. HOSPITAL COURSE: The patient was admitted to the medical service on [**2111-7-9**] with a diagnosis of unstable angina. He was treated with aspirin, Lopressor, nitropaste. Continued on his Ace inhibitor. The patient underwent cardiac catheterization the next day which showed no aortic valve gradient and on coronary angiography a right dominant system LMCA of 50% distal, Left anterior descending mild, left circumflex 99% proximal, right coronary artery 50% proximal and 50% distal stenosis. Based on the above results it was decided that coronary artery bypass graft would be necessary and the patient preoperative workup was completed. He was additionally started on Heparin. On [**2111-7-14**] the patient was taken to the operating room where he underwent three vessel coronary artery bypass grafting with the following grafts: left internal mammary artery to left anterior descending, vein to OM, vein to right coronary artery under general anesthesia. The patient tolerated the procedure well, there were no intraoperative complications and he was transferred to the Cardiac Recovery Unit in normal sinus rhythm intubated on Propofol and Neo drip. The patient was able to be extubated the evening of the operation and from a respiratory standpoint remained stable throughout the rest of his postoperative course. The patient remained in Intensive Care Unit through the next day while he was being weaned off his Neo drip. He was further transfused two units of packed red blood cells for a hematocrit of 22 with repeat hematocrit 26. His urine was also borderline improving with Lasix however, his creatinine had elevated to 2.3 from 1.7 causing his Lasix to be stopped. This hematocrit also decreased to 23.5 for which he received another unit of packed red blood cells. On postoperative day two the patient was transferred to the regular floor after having had his chest tubes removed. He was closely monitored and on postoperative day #3 was found to have some minimal drainage from his sternotomy [**Date Range **], apparently old serosanguinous fluid. Sternum was stable with no clicks. There was no erythema or induration noted. He was empirically started on Ancef and the chest x-ray was obtained which was negative for sternal dehiscence. His [**Date Range **] continued to be monitored. On postoperative day four the patient spiked a temperature to 103, his urine culture found to be positive for E. coli. He was started on Ciprofloxacin. He was also started on Vancomycin. His white blood cell count was elevated to 18 and decreased the next day to 16 and it was felt clinically that his Vancomycin could be discontinued. With respect to his sternal [**Date Range **] the drainage eventually decreased and he was felt to be stable for discharge home on postoperative day 6. He had been afebrile, his white count decreased to 13.3 and he was discharged on Ciprofloxacin for his urinary tract infection. Of note on postop day #3 the patient's BUN and creatinine normalized to 30 and 1.8, his creatinine further decreased to baseline of 1.6 where it stabilized. CONDITION ON DISCHARGE: The patient is stable for discharge home due to the fact that he is ambulated to a level V remains afebrile, tolerating a regular diet. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSIS: 1. Status post three vessel coronary artery bypass graft. 2. Coronary artery disease. 3. Urinary tract infection on Ciprofloxacin. 4. Status post left nephrectomy with transient increase in BUN and creatinine stabilized to baseline. 5. Diabetes mellitus Type 2. 6. Hypertension. 7. Hypothyroidism. 8. Arthritis. DISCHARGE MEDICATIONS: 1. Ciprofloxacin 500 mg p.o. b.i.d. times one week. 2. Lopressor 75 mg p.o. q 12 hours 3. Colace 100 mg p.o. twice a day. 4. Zantac 150 mg p.o. twice a day. 5. Aspirin 81 mg p.o. q day. 6. Synthroid 25 mcg q day. 7. Glyburide 5 mg q day. 8. Percocet one to two p.o. q 4 to 6 hours p.r.n. 9. Tylenol 650 mg p.o. q 4 to 6 hours p.r.n. DISCHARGE INSTRUCTIONS: The patient is discharged to home with visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] care. He is to follow-up with Dr. [**Last Name (STitle) 35025**] in three to four weeks and to follow-up with his primary care physician in one to two weeks. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 2682**] MEDQUIST36 D: [**2111-7-20**] 20:33 T: [**2111-7-20**] 21:44 JOB#: [**Job Number 35026**]

[ "250.00", "V10.52", "411.1", "599.0", "414.01", "496", "244.9", "593.9", "401.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

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6538, 6881

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2894, 5979

6906, 7454

1521, 2876

160, 1010

1032, 1393

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6004, 6169

16,294

184,336

2007

Discharge summary

report

Admission Date: [**2195-2-10**] Discharge Date: [**2195-3-13**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: Right Hip fracture status post mechanical fall Major Surgical or Invasive Procedure: Open reduction and internal fixation of right hip intertrochanteric fracture Intubation Trach and PEG placement PICC placement EGD and colonoscopy History of Present Illness: Pt is an 85yo man who presented to the ED 1 day status post fall, pt relates fall in kitchen while he was attempting to turn around. States he tripped over his own legs, never lost consciousness, and denies associated symptoms before or after the event. Pt fell on his right hip, had immediate pain, layed on the floor for a short while, then was able to ambulate with a walker. This morning pain was mush worse so he presented to the ED where he was found to have a Right Hip fracture. Initially the patient was to be admitted to Orthopaedics, but was then found to have hyponatremia and was admitted to medicine. The pt has no complaints except for hip pain currently. Past Medical History: HTN prosate Ca neuropathy cataracts osteomylitis Social History: Tob: quit 6 years ago, 50yr hx of cigar smoking [**12-1**]/d heavy ETOH in the past Family History: HTN Physical Exam: On presentation: Vitals: 98.8 138/60 78 18 92% RA HEENT: NCAT, PERRL, EOMI Neck: FROM, NT Chest: scattered wheezes bilaterally Cardiac: RRR Abd: soft NT/ND +BS Ext: Limited ROM of R hip secondary to pain, Venous stasis changes BLEs, no edema Pertinent Results: [**2195-2-10**] 02:55PM BLOOD WBC-9.2 RBC-4.25* Hgb-13.5* Hct-37.0* MCV-87 MCH-31.8 MCHC-36.6* RDW-12.8 Plt Ct-172 [**2195-2-11**] 05:21AM BLOOD WBC-9.0 RBC-3.69* Hgb-12.1* Hct-32.4* MCV-88 MCH-32.8* MCHC-37.3* RDW-12.7 Plt Ct-138* [**2195-2-12**] 08:48PM BLOOD WBC-9.1 RBC-3.96* Hgb-12.7* Hct-35.7* MCV-90 MCH-32.0 MCHC-35.5* RDW-12.7 Plt Ct-178 [**2195-2-13**] 05:22AM BLOOD WBC-10.4 RBC-3.42* Hgb-11.2* Hct-30.5* MCV-89 MCH-32.7* MCHC-36.6* RDW-12.6 Plt Ct-173 [**2195-2-12**] 08:48PM BLOOD Plt Ct-178 [**2195-2-13**] 05:22AM BLOOD Plt Ct-173 [**2195-2-13**] 05:22AM BLOOD PT-13.8* PTT-30.7 INR(PT)-1.2* [**2195-2-10**] 02:55PM BLOOD Plt Ct-172 [**2195-2-11**] 05:21AM BLOOD Plt Ct-138* [**2195-2-10**] 02:55PM BLOOD PT-13.0 PTT-27.9 INR(PT)-1.1 [**2195-2-10**] 02:55PM BLOOD Glucose-129* UreaN-11 Creat-0.7 Na-118* K-3.6 Cl-82* HCO3-28 AnGap-12 [**2195-2-10**] 09:20PM BLOOD Glucose-131* UreaN-10 Creat-0.7 Na-119* K-3.5 Cl-86* HCO3-25 AnGap-12 [**2195-2-11**] 05:21AM BLOOD Glucose-102 UreaN-10 Creat-0.7 Na-121* K-3.5 Cl-84* HCO3-27 AnGap-14 [**2195-2-11**] 08:10PM BLOOD Glucose-136* UreaN-16 Creat-0.9 Na-121* K-3.0* Cl-86* HCO3-26 AnGap-12 [**2195-2-12**] 05:05AM BLOOD Glucose-111* UreaN-13 Creat-0.8 Na-123* K-3.6 Cl-89* HCO3-27 AnGap-11 [**2195-2-12**] 08:48PM BLOOD Glucose-131* UreaN-11 Creat-0.8 Na-125* K-4.6 Cl-89* HCO3-29 AnGap-12 [**2195-2-13**] 05:22AM BLOOD Glucose-154* UreaN-9 Creat-0.8 Na-126* K-4.6 Cl-92* HCO3-27 AnGap-12 [**2195-2-12**] 08:48PM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9 [**2195-2-12**] 05:05AM BLOOD calTIBC-276 Ferritn-237 TRF-212 [**2195-2-11**] 05:21AM BLOOD Osmolal-252* [**2195-2-10**] 02:55PM BLOOD Osmolal-253* [**2195-2-11**] 05:21AM BLOOD TSH-0.88 [**2195-2-11**] 05:21AM BLOOD Cortsol-16.1 [**2195-2-13**]: UA >50 RBC 21-50* WBC MOD Bact NONE Yeast 0-2 Epis BC x 4 NGTD CHEST (PA & LAT) [**2195-2-13**] IMPRESSION: No focal consolidations or CHF and no significant change from [**2195-2-10**]. CHEST (PA & LAT) [**2195-2-10**] IMPRESSION: 1. No pneumonia or pneumothorax. 2. Fracture deformities of the right posterior 7th and 8th ribs, clinical correlation is recommended to determine if there is an acute component. 3. Bilateral pleural plaques reflecting asbestos exposure. CT PELVIS ORTHO W/O C [**2195-2-10**] CT OF THE PELVIS WITHOUT CONTRAST: There is a complex fracture line extending through the intertrochanteric region of the right femur. The fracture extends to both the anterior and posterior cortical surfaces. Two main fragments are present. There is slight external rotation of the distal fragment with respect to the proximal fragment. No other pelvic fractures are identified. There is moderately severe concentric joint space narrowing in the left hip joint space with extensive osteophyte formation with subchondral cystic change. No fracture plane is visualized. There is mild joint space narrowing in the right hip with osteophyte formation, much less than on the left. There are colonic diverticula without evidence of acute diverticulitis. The appendix is normal. The bladder wall does not appear thickened. The prostate gland is mildly enlarged with several punctate areas of calcification. There is no free fluid in the pelvis. IMPRESSION: 1. Nondisplaced complex fracture through right femoral intertrochanteric region. 2. Moderate, non-specific, arthropathy of the left hip. CT OF THE PELVIS WITHOUT CONTRAST: There is a complex fracture line extending through the intertrochanteric region of the right femur. The fracture extends to both the anterior and posterior cortical surfaces. Two main fragments are present. There is slight external rotation of the distal fragment with respect to the proximal fragment. No other pelvic fractures are identified. There is moderately severe concentric joint space narrowing in the left hip joint space with extensive osteophyte formation with subchondral cystic change. No fracture plane is visualized. There is mild joint space narrowing in the right hip with osteophyte formation, much less than on the left. . There are colonic diverticula without evidence of acute diverticulitis. The appendix is normal. The bladder wall does not appear thickened. The prostate gland is mildly enlarged with several punctate areas of calcification. There is no free fluid in the pelvis. . ECG [**2195-2-11**] Sinus rhythm. A-V conduction delay. Left atrial abnormality. P-R interval 0.24. Right bundle-branch block. Left anterior fascicular block. . CT pelvis/abdomen [**2-24**]: COMPARISONS: No prior CTs are available on PACs for comparison purposes. TECHNIQUE: MDCT acquired axial images from the lung bases to the pubic symphysis were acquired with intravenous and oral contrast material and displayed with 5-mm slice thickness. Coronal and sagittal reformations were performed. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There are calcified pleural plaques at the lung bases consistent with prior asbestos exposure. There also are bilateral pleural effusions and basal atelectasis. An NG tube is seen with the tip in the antrum. The liver contains multiple hypoattenuating lesions, the largest one measuring 2.6 cm in segment VI. These lesions are consistent with metastases in the context of known prostate cancer. Gallbladder is collapsed. The spleen and adrenal glands appear unremarkable. The kidneys are notable for cortical atrophy and the right kidney contains a hypoattenuating lesion seen on series 2, image 41, which may represent a cyst but a metastatic focus cannot be excluded. The pancreas appears unremarkable and is mostly fatty replaced. In the region of the cecum and ascending colon, note is made of an irregular-appearing bowel wall, and there is the suspicion of pneumatosis in this region. This may be due to infectious colitis, typhlitis or ischemia. Alternatively, the appearance may be caused by fecal material. In the clinical context of bacteremia and guarding, however the concern for pathologic process in the region of the cecum and ascending colon persists. There also is a small amount of fluid tracking down the right paracolic gutter and there is a small amount of fluid surrounding the kidneys and tracking down into the pelvis. As far as this can be evaluated on this study, the aortic tributaries appear patent. No mesenteric or retroperitoneal lymphadenopathy is seen, however there are multiple small retroperitoneal lymph nodes that do not meet size criteria for pathologic enlargement. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: Normal-appearing contrast-filled appendix was visualized. Sigmoid colon and rectum are unremarkable except for sigmoid diverticuli. Bladder is normal, the prostate is enlarged measuring 5.8 cm in transverse diameter. A Foley catheter was seen within the bladder. No pelvic or inguinal lymphadenopathy is seen. There is generalized anasarca. BONE WINDOWS: There is a dynamic hip screw transfixing the right proximal femur. There is DISH in the lower thoracic and lumbar spine. Also degenerative changes with facet arthropathy in the lumbar spine. No suspicious lytic or blastic lesions are seen. IMPRESSION: 1. Possible pneumatosis in the cecum/ascending colon. This may be due to infectious colitis, typhlitis or due to ischemia. Alternatively, the atypical appearance of the bowel wall may be caused by fecal material. 2. Innumerable liver metastases. 3. Calcified pleural plaques indicating prior asbestos exposure. 4. Bilateral basal atelectasis and pleural effusions. 5. No evidence of bowel obstruction. 6. Small amount of ascites. 7. Enlarged prostate consistent with history of prostate cancer. . [**2-28**] CT abd/pelvis: TECHNIQUE: MDCT was used to obtain contiguous axial images from the lung bases to the pubic symphysis without administration of IV contrast. Oral contrast only was administered. This study was compared with [**2195-2-24**] CT scan. CT ABDOMEN WITHOUT IV CONTRAST: Small bilateral pleural effusions and associated compressive atelectasis. Calcified pleural plaques at both lung bases unchanged. NG tube is seen coursing below the diaphragm with its tip in the stomach. Calcified aorta, which is normal in caliber. No pericardial effusion. This study is limited by lack of IV contrast; hypodensities can be seen in the liver, which probably correspond to the innumerable low-density lesions seen on previous CT scan. On this noncontrast study, spleen, splenules, pancreas, stomach, adrenals, kidneys, and small bowel are stable. Nonspecific stranding seen around the kidneys and along both pericolic gutters is unchanged. No distended loops of bowel are identified. No free air. No free fluid. No evidence of obstruction. Appearance of cecum and right colon are stable / slightly improved. Slightly improved transverse colon. Slight thickening of descending colon is probably due to collapse. No significant lymphadenopathy. . CT PELVIS WITHOUT IV CONTRAST: Sigmoid diverticula without diverticulitis. Diverticulosis in left colon. Vascular calcifications. Vessels maintain their normal caliber. Foley within the bladder. Prostate is enlarged. No free fluid or free air or lymphadenopathy. . Total hip prosthesis in right hip. Degenerative changes of the spine. Bone island in left iliac spine. No suspicious lytic or sclerotic lesions identified. . IMPRESSION: . Unchanged/slightly improved appearance of right colon. No definite pneumatosis, or evidence of obstruction. Differential wall enhancement cannot be assessed on this non IV contrast study. . [**3-5**] CHEST, SINGLE AP SUPINE PORTABLE VIEW. . The left costophrenic angle is excluded from the film. Compared with [**2195-3-3**], the ET tube has been removed and a tracheostomy is now present. The tracheostomy tip overlies the trachea at the level of the upper clavicles, in nomimal position. A left-sided PICC line is present, tip at SVC/RA junction. No pneumothorax is detected. Again seen is hyperinflation and multiple calcified pleural plaques. There has been some interval worsening in degree of left lower lobe collapse and/or consolidation. No gross effusion. Doubt CHF. . Micro: negative BCx, UCx, negative for C. Diff . Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2195-3-9**] 04:13AM 13.8* 3.08* 9.6* 28.5* 93 31.2 33.7 14.4 370 [**2195-3-8**] 09:11PM 27.1* [**2195-3-8**] 04:29PM 26.9* [**2195-3-8**] 03:41AM 10.0 2.87* 9.3* 26.4* 92 32.3* 35.0 14.4 329 [**2195-3-7**] 07:33PM 26.2* [**2195-3-7**] 03:41AM 8.8 3.10* 9.9* 28.4* 92 31.8 34.7 14.3 351 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2195-3-9**] 04:13AM 370 [**2195-3-9**] 04:13AM 14.3* 30.4 1.3* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2195-3-9**] 12:29PM 3.5 [**2195-3-9**] 04:13AM 161* 14 0.9 140 3.3 102 30 11 [**2195-3-8**] 04:29PM 161* 12 0.9 141 4.0 106 28 11 [**2195-3-8**] 03:41AM 116* 12 0.9 144 3.6 108 28 12 [**2195-3-7**] 05:08PM 13 1.0 3.0* [**2195-3-7**] 03:41AM 124* 15 1.1 143 3.0* 106 28 12 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2195-3-9**] 12:29PM 2.4 [**2195-3-9**] 04:13AM 8.5 2.1* 1.7 Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calHCO3 Base XS Intubat Vent [**2195-3-8**] 12:25PM ART 36.5 5 103 49* 7.43 34* 6 INTUBATED IMV [**2195-3-8**] 10:23AM ART 36.6 98 37 7.49* 29 4 WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate K [**2195-3-8**] 12:25PM 0.7 [**2195-3-8**] 10:23AM 3.3* HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT [**2195-3-8**] 10:23AM 9.9* 30 CALCIUM freeCa [**2195-3-7**] 12:15PM 1.17 Brief Hospital Course: 85 yo M with h/o of prostate ca, admitted after R hip fracture s/p ORIF [**2-12**], transferred to MICU with hypercarbic respiratory failure, intubated. His MICU course is discussed by problem . #. Hypercarbic respiratory failure: Thought to be likely due to chronic lung disease plus abdominal distention pressing up on his diaphragms +/- aspiration PNA. The patient was was started on vanc/levo/Flagyl for aspiration/nosocomial PNA and aggressive bowel regimen for ileus secondary to narcotics. He completed a one week course of antibiotics, successive CXRs following treatment failed to show any residual or new infiltrate to suggest persistent pneumonia. However, he then continued to have daily fever spikes, and he was empirically treated with a one week course of Vancomycin and Zosyn for possible VAP pneumonia. The patient's ileus improved with bowel regimen and avoiding sedatives and so did his respiratory status. Plan is to wean off ventilator and decrease sedation by adding Haldol/prn for agitation. The patient encountered difficulty weaning, and a trach was discussed with his family/ HCP, would decided to pursue trach placement, which was done by thoracics on [**3-5**]. Sutures from this will need to be removed between [**Date range (1) 11029**], per surgery recs. He was continuously tried on C-PAP and PS with a goal to wean. In addition, he was kept in negative fluid balance on a daily basis, as this seemed to improve his respiratory function although his CXR did not show overt CHF. He was eventually weaned to a trach collar, which he tolerated well. His suctioning frequency also decreased, and he was fitted for a valve by speech therapy, with intentions to undergo a swallow study. . # Anemia/Transient Melena: The patient was anemic, iron studies suggested anemia of chronic disease, possibly secondary to known malignancy. In addition, he had guaiac positive stool output. His hematocrit was monitored on a daily basis, and he was transfused intermittently for HCT <21. He had one episode of melena (about 250 cc) on the morning after his trach/PEG placement, and a drop in his BP to 80's systolic. He was transfused 2 units of PRBCs, and GI was consulted. They recommended continuing on the PPI [**Hospital1 **], and monitoring his hct [**Hospital1 **]; with the thought that his melena was most likely secondary to blood loss from the PEG procedure. The patient's hct continued to trend down, and he underwent an EGD and colonoscopy on [**3-11**] which showed an ulcerated, erythematous lesion in the proximal ascending colon. This was thought to be the explanation for his melena, and a biopsy was taken, with a differential diagnosis including ischemic colitis vs. Crohn's disease vs. neoplasm. The biopsy was still pending at the time of discharge. The EGD revealed a smooth nodule in the fundus of the stomach, which will need to be further evaluated in the future; was otherwise normal. It was thought that the patient's hematocrit should be monitored every 48 hours, or more frequently if melena develops. He should continue on the PPI and follow-up with GI on an outpatient, elective basis for a repeat endoscopy/ EUS to evaluate the nodule seen in the stomach- as this may be possible GIST. GI cleared the patient to restart his Lovenox for DVT prophylaxis, but this may need to be stopped and other prophylaxis measures explored (i.e, filter placement) if he begins to rebleed. . # Ileus/abdominal distension: Likely due to narcotic -induced ileus. Ileus improved with supportive care and avoiding narcotics, and patient was started on tube feeds. He underwent an abdominal CT to evaluate for any pathology, this revealed: 1. Possible pneumatosis in the cecum/ascending colon. This may be due to infectious colitis, typhlitis or due to ischemia. Alternatively, the atypical appearance of the bowel wall may be caused by fecal material. 2. Innumerable liver metastases. 3. Calcified pleural plaques indicating prior asbestos exposure. 4. Bilateral basal atelectasis and pleural effusions. 5. No evidence of bowel obstruction. 6. Small amount of ascites. 7. Enlarged prostate consistent with history of prostate cancer. Given these findings, surgery was consulted to comment on any surgical intervention that would be necessary, none was noted. The patient was started on empiric Flagyl for C-Diff, as he had persistently large volume, greenish, guaiac positive stool output. The abdominal CT was repeated a few days later, and showed slight improvement of previous findings, and still no signs of obstruction. The patient was ruled out for C-Diff with three negative samples and two negative toxin B assays, and the Flagyl was discontinued. The patient was restarted on his tube feeds once his PEG tube was placed, which he tolerated well. He was followed by the nutrition service for tube feed recommendations. . # Acute renal failure: occurred in the setting of hypotension and volume depletion. Creatinine bumped up as high as >2.0. With hydration, creatinine returned to baseline 0.9. . # Hip fracture: s/p mechanical fall and ORIF on [**2-12**]. Initially received too [**Last Name (un) **] narcotics causing ileus and respiratory failure. The patient was continued on Tylenol and avoided narcotics as much as possible. Ortho followed the patient until staples were removed, rec [**Name (NI) 11030**], PT consulted and rec rehab. Patient is to follow up with Dr. [**Last Name (STitle) 1005**] as outpatient in six weeks. He was restarted on Lovenox for DVT prophylaxis. . # Hyponatremia: Initially thought to be SIADH and fluid restriction was enforced. Later, however with fluid restriction, likely became hypovolemic causing renal failure. Hyponatremia resolved with IVF. Patient then became hypernatremic, which again resolved with free water repletion. . # HTN: His Triamterene-Hydrochlorothiazide was discontinued in the setting of hypotension. However, he then became hypertensive on the day prior to discharge, and was started on an ACE for management, this may need to be titrated for optimal BP control. . # Prostate CA: per PCP has had metastatic prostate cancer for last ten years. Can f/u re: prostate CA as outpatient, Casodex was held during his ICU stay. Contact was maintained with his urologist, particularly after his abdominal CT showed liver metastasis. A PSA, CEA, and AFP were sent, all of which returned normal. . He was maintained on Lovenox for DVT prophylaxis, and provided with a PPI [**Hospital1 **] for GI protection. He should follow-up with both his PCP and orthopedist upon discharge from rehab. Medications on Admission: Casodex 50mg QD Triamterene w/ HCTZ 37.5/25 QD Potassium Cl ER 600mg [**Hospital1 **] ASA 81mg QD Flomax 0.4mg QD Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 3. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation QID (4 times a day). 5. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 8. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 9. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. 10. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 11. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed. 12. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 7 days: then back to QD. 13. Haloperidol Lactate 5 mg/mL Solution Sig: 2.5 mg Injection Q4H (every 4 hours) as needed for aggitation. 14. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Right hip intertrochanteric fracture Respiratory failure Aspiration pneumonia ileus lower GI bleed Discharge Condition: Stable Discharge Instructions: You have been discharged to an extended care facility for rehabilitation, your right hip fracture has been repaired. Take medications as perscribed and follow up as indicated. . Please follow up with the ortho clinic in six weeks with Dr. [**Last Name (STitle) 1005**] as instructed below. Followup Instructions: Follow up with Orthopaedics after your discharge from rehab, call ([**Telephone/Fax (1) 2007**] for an appointment with Dr. [**Last Name (STitle) 1005**] (within six weeks) Please follow-up with your PCP upon discharge from rehab as well.

[ "496", "401.9", "584.9", "507.0", "276.50", "820.21", "560.1", "276.1", "285.29", "285.1", "518.81", "276.0", "578.9", "E885.9", "V10.46", "197.7" ]

icd9cm

[ [ [] ] ]

[ "43.11", "38.93", "33.21", "99.04", "45.13", "79.35", "31.1", "45.25", "96.72", "96.6", "96.04" ]

icd9pcs

[ [ [] ] ]

21486, 21556

13322, 19939

307, 455

21699, 21708

1628, 13299

22048, 22291

1345, 1350

20103, 21463

21577, 21678

19965, 20080

21732, 22025

1365, 1609

221, 269

483, 1155

1177, 1227

1243, 1329

24,157

106,319

7131

Discharge summary

report

Admission Date: [**2159-5-7**] Discharge Date: [**2159-5-16**] Date of Birth: [**2082-5-29**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 26543**] was a 76-year-old gentleman with a significant past medical history. He presented to an outside hospital prior to this hospitalization complaining of one month of chest pain and fatigue with exertion. The patient was admitted to that hospital and evaluated for coronary artery disease. He underwent a stress thallium test which was positive. He was transferred to the [**Hospital1 188**] for cardiac catheterization, and this study revealed severe 3-vessel disease. A Cardiology Surgery consultation was performed, and the patient was found to be a suitable candidate to undergo a coronary artery bypass graft. HOSPITAL COURSE: On [**2159-5-10**], Mr. [**Known lastname 26543**] was taken to the operating room at the [**Hospital1 188**] by Dr. [**Last Name (STitle) 1537**] of the Cardiothoracic Surgery Service, and he underwent an on-pump coronary artery bypass graft times two with left internal mammary artery to the left anterior descending artery and a right lesser saphenous to the obtuse marginal. The patient tolerated the procedure well, and he was transferred in a stable condition to the Cardiothoracic Surgery Recovery Unit. Overnight, he was weaned off his pressors and was successfully and uneventfully extubated by the next morning. He required 2 units of packed red blood cells for a low hematocrit. His postoperative course was prolonged and complicated by cardiac arrhythmias requiring amiodarone and diltiazem to control his atrial fibrillation and rapid heart rate. By postoperative day two, his cardiac arrhythmia was not totally controlled, and his creatinine started to rise. He was noted to have labored breathing, and by postoperative day three, the nursing noticed that the patient was more confused than usual and was having problems trying to find words as well as moving his right side. An emergent head CT was obtained, and it revealed an image most consistent with a left posterior cerebral artery infarction. He was evaluated by the Stroke Service and Neurology who recommended to keep his systolic blood pressures at about 140 and to obtain a magnetic resonance imaging with a stroke protocol. By postoperative day five, Mr. [**Known lastname 26543**] continued to be in rapid atrial fibrillation and on intravenous amiodarone drip as well as a maximum diltiazem drip. His neurologic status did not improve, and later that day he became progressively acidotic, and his white blood cell count became elevated. At that point, there was a concern for this patient to be having an ischemic bowel since he developed peritoneal signs. An emergent Surgery consultation was obtained, and the patient was taken to the operating room for an exploratory laparotomy. He was found to have an ischemic bowel, and a small bowel resection times two with an ileocolectomy as well as an aorta to superior mesenteric artery bypass with a Dacron graft was performed since the patient was found to have a thrombosed superior mesenteric artery. The patient received 6 liters of crystalloid and 3 units of packed red blood cells, and after the surgery he was transferred in a critical condition back to the Cardiothoracic Surgery Recovery Unit. These findings were discussed in detail with the family, and there were explained about the seriousness of this patient's condition. Overnight, he was kept on maximum Intensive Care Unit support including amiodarone drip, diltiazem, as well as pressors without significant improvement. His white blood cell count remained elevated, and his acidosis worsened. He was started on continuous venovenous hemofiltration since his creatinine was 2.2. By 6 o'clock in the afternoon, despite the continuous venovenous hemofiltration and the full Intensive Care Unit support, his condition worsened, and General Surgery decided to take him back to the operating room for a second exploratory laparotomy. Once in the operating room, and upon entering the abdominal cavity, the entire bowel was noted to be ischemic. There were no free perforations, and the bypass graft was still patent. The patient's abdomen was closed, and he was transferred back to the Cardiothoracic Surgery Recovery Unit to discuss the prognosis with the family. The operating room findings were discussed with the wife, and after she spoke with Dr. [**Last Name (STitle) **] from the General Surgery Service, she wished to make the patient comfort measures only in light of the global ischemic bowel disease. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] was informed, and all of the pressor support was discontinued. Shortly after the pressor support was stopped, the patient expired in the Cardiothoracic Surgery Recovery Unit. The house officer was called to evaluate the patient and he was found to have no pupil reflex, no corneal, no spontaneous breathing, no gag reflex pulling the ET-tube, no palpable pulse or audible heart sounds. The patient was pronounced dead at 10:06 p.m. on [**2159-5-16**]. His family was notified as well as Dr. [**Last Name (STitle) 1537**]. The Medical Examiner was also notified, and he declined the case. The family did not want a postmortem examination, and the patient will shortly be transferred to the morgue to await further arrangements by the family. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern4) 26544**] MEDQUIST36 D: [**2159-5-17**] 00:35 T: [**2159-5-17**] 10:40 JOB#: [**Job Number **]

[ "401.9", "496", "998.12", "997.02", "427.31", "997.1", "414.01", "557.0", "250.00" ]

icd9cm

[ [ [] ] ]

[ "36.11", "88.53", "37.22", "45.61", "36.15", "54.11", "45.73", "39.26", "88.56" ]

icd9pcs

[ [ [] ] ]

845, 5767

179, 827

15,428

174,740

26082+57480+57489

Discharge summary

report+addendum+addendum

Admission Date: [**2160-2-18**] Discharge Date: [**2160-3-1**] Service: VSU CHIEF COMPLAINT: Abdominal aortic aneurysm. HISTORY OF PRESENT ILLNESS: The patient was referred to Dr. [**Last Name (STitle) 1391**] for evaluation of abdominal aortic aneurysm. She now is admitted for elective open abdominal aortic repair with ventral herniorrhaphy. Initial findings of the aneurysm was on a x-ray for workup for a UTI. PAST MEDICAL HISTORY: Includes rheumatoid arthritis, prednisone dependent and on methotrexate; ischemic heart disease with a myocardial infarction in [**2155**], stress test done on [**2159-11-18**] was without ischemic changes, no perfusion deficits, ejection fraction was 72% with no wall motion abnormalities; also history of GERD; history of urinary tract infections, treated; history of skin cancer; history of MRSA infections; history of UTI sepsis with hypotension. PAST SURGICAL HISTORY: Includes coronary artery angioplasty with stenting to the right coronary artery, proximal mid RCA and distal RCA in [**2156-3-29**]; knee replacements; closed reduction of a olecranon process fracture; open reduction/internal fixation in [**2157**]; hernia repair; a gastric repair; a pelvic fracture in [**2158-8-30**]; hysterectomy. ALLERGIES: A history of multiple drug allergies; which include DEMEROL causing nausea and vomiting; LOPRESSOR causing hypotension; PENICILLIN manifestation no documented; all "[**Last Name (un) **] DRUGS like i.e., NOVOCAINE/LIDOCAINE." MEDICATIONS ON ADMISSION: Aspirin 81 mg daily, atenolol 50 mg daily, Atrovent puffer 2 daily, Colace 100 mg daily, folic acid 1 mg daily, Lipitor 20 mg daily, lorazepam 0.5 mg [**12-31**] tablet daily, prednisone 5 mg in the morning and 2 mg in the evening, Protonix 40 mg daily. Other medications include Actonel 35 mg daily, methotrexate 2.5 mg 6 tablets q. Friday, multivitamins, vitamin D and oyster calcium. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure was 174/84, heart rate was 88, O2 saturation 96% on room air. The patient is 58 inches in height and is 161 pounds (or 73.818 kilograms). GENERAL APPEARANCE: A white female in no acute distress. Pupils are equal, round and reactive to light and accommodation. There are no tremors. HEART: A regular rate and rhythm. Normal S1 and S2 without any extra heart sounds. There are no carotid bruits. LUNGS: With rales/crackles at the bases bilaterally. ABDOMEN: Protuberant, soft, nontender; without bruits. Abdominal aortic prominence could not be felt. EXTREMITIES: Show some pedal edema with dopplerable pedal pulses bilaterally. HOSPITAL COURSE: The patient was admitted to the preoperative holding area on [**2160-2-18**]. She underwent abdominal aortic repair on a infrarenal aortic aneurysm with a tube graft and a ventral hernia repair secondary to compartment separation. The patient tolerated the procedure well and was transferred to the PACU intubated in stable condition. She did have some episodes of hypotension requiring fluid boluses. The patient failed to be extubated and was transferred to the surgical intensive care for ventilatory support. The patient required aggressive diuresis for volume overload and transfusion for blood loss anemia. The patient remained in the ICU. The patient was extubated on postoperative day #5. She continued to do well. Her blood gas was 7.37/46/86/28/0. WBC was 10.6, hematocrit 28.2, BUN 23, creatinine 0.8. The patient continued to remain with JP drains in place. She was transferred to the VICU for continued monitoring and care. She was transfused 1 unit of packed red blood cells for her hematocrit of 23.9 and diuresed. She did have some episodes of SVT which responded to beta blockade. The patient's NG was removed, and sips of clear liquids were begun on [**2160-2-26**]. The patient tolerated these. She did have active bowel sounds, but denied passing flatus. She did require continued diuresis for her postoperative volume overload. The patient was evaluated by physical therapy, and felt that she was a good candidate for rehab at the time of discharge prior to being discharged to home. Ambulation was begun on [**2160-2-26**] to a chair; and on [**2160-2-27**] ambulation in the [**Doctor Last Name **] was begun. JP drainage was monitored and if less than 100 cc for 24 hours would consider discontinuing the JP's. DISCHARGE DISPOSITION: The patient will be transferred to rehab when medically ready. DISCHARGE DIAGNOSES: 1. Abdominal aortic aneurysm; status post open abdominal aortic repair with a tube graft. 2. A ventral hernia with compartment separation; status post repair on [**2160-2-18**]. 3. History of methicillin-resistant Staphylococcus aureus. 4. History of intraoperative and postoperative blood loss anemia; transfused, corrected. 5. Postoperative hypovolemia with hypotension requiring vasopressors; corrected. 6. Postoperative pulmonary edema; diuresed, resolved. 7. Postoperative atelectasis with a the left lower lobe and right middle lobe; improved. 8. Postoperative supraventricular tachycardia; controlled with beta blockade. 9. History of rheumatoid arthritis; prednisone and methotrexate dependent. 10. History of hyperlipidemia; on a statin. 11. History of hypertension; controlled. 12. History of chronic obstructive pulmonary disease; on Atrovent inhalers. 13. History of ischemic heart disease, status post myocardial infarction in [**2155**] with a negative stress test on [**2159-11-18**]. 14. History of diverticulosis; asymptomatic. 15. History of skin cancer. 16. History of a urinary tract infection with sepsis and hypotension; resolved. 17. Status post cardiac stent to the proximal, mid and distal right coronary artery in [**2154-3-30**]. 18. On [**2158-5-31**] knee replacement, open reduction and internal fixation of an olecranon process fracture. 19. Status post hernia repair. 20. Status post gastric repair. 21. Pelvic fracture repair in [**2158-8-30**]. 22. Status post hysterectomy. DISCHARGE MEDICATIONS: Acetaminophen 325-mg tablets 1 to 2 q.4-6h. p.r.n. for pain; folic acid 1 mg daily; methotrexate 2.5-mg tablets 6 q. Friday; aspirin 81 mg daily; miconazole nitrate powder to affected areas b.i.d.; Nystatin suspension 5 cc q. odd day swish-and-swallow; albuterol sulfate inhalations q.4h. p.r.n.; ipratropium bromide inhalation q.4h. as needed; Lopressor 50 mg q.i.d.; prednisone 5 mg q.a.m. and 2 mg in the evening; atorvastatin 20 mg daily. DISCHARGE INSTRUCTIONS: The patient may take showers; no tub baths. She should call us if develops a fever of greater than 101.5. No heavy lifting for a total of 6 weeks. No driving until seen in followup. She should call if there are any changes in her incisional areas, when they become red or drain. She should follow up with both Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1391**] 2 weeks post discharge, and she should call for an appointment at (617) 632-_______ and Dr.[**Name (NI) 6433**] office at ([**Telephone/Fax (1) 6449**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2160-2-27**] 15:02:51 T: [**2160-2-27**] 17:06:12 Job#: [**Job Number 64729**] Name: [**Known lastname 10344**],[**Known firstname **] Unit No: [**Numeric Identifier 11429**] Admission Date: [**2160-2-18**] Discharge Date: [**2160-3-25**] Date of Birth: [**2078-9-2**] Sex: F Service: SURGERY Allergies: Demerol / Lidocaine Attending:[**First Name3 (LF) 231**] Addendum: [**2160-2-27**] fever with WBC 15.1, blood,urine, JP drain c/s obtained. CXR no infiltrate. amylase 250 [**2160-2-28**] WBC improved/ 14.1. onset of nausea with food. NPO. IV fluids began. serial amylase and lipase obtained. [**2160-3-2**] nausea improved. clear liquids began. [**2160-3-3**] diet advanced to full liquids. PT reconsulted for assesment to d/c planning. [**2161-3-4**] diet advance regular diet. PT continued to work with patient.Lipase improving. [**Date range (1) 11430**]/06 placed on TPn. Note abdominal wound with fat necrosis. Patient followed by Pt. [**2160-3-10**] aabdominal staples removed.Normal saline wet to dry dressings continued. [**2160-3-11**] acute SOB associated with desaturation. Patient transfered to VICU for hemodynamic monitering and r/0MI/PE.CT chaest negative for PE. cardiac enzymes negative. EKG no acute changes. Patient agressively diuresed with improvewment of oxygenation. [**2160-3-14**] required IV lasix for dyspnea with improvement in symptoms.Antibiotics discontinued. Cardology reconsulted for recurrent SOB. Recommended diuresis and a chronic lasix dosing. [**2160-3-15**] diet advanced to clear liquids. [**2160-3-16**] repeat ECHO essentially unchange 3/20-23/06 continue wound care. TPN diet advanced to regular food. continue to work with physical thearphy.Evaluated by psychiarty started on mirtazpine and drorubinol with improvement in patient's affect and appetite.VAc wound dressing applied [**2160-3-24**]. Change q2days.no adaptic to wound. wite sppopnge to inferior pole of abd. wound.Moniter cbc while on linezolid. continue calorie counts until patient adequate calories of > 2500/24hr.continue glucose finger sticks ac and hs and regular insulin sliding scale until patient weaned off TPN. fluid balance maintain over next several days negative 1 liter with additional IV lasix as needed. restart lasix 40mgm qd [**2160-3-26**] Major Surgical or Invasive Procedure: abdominal [**Last Name (un) 11431**] aneurysem prepairwith tube graft--Open [**2160-2-18**] Ventral hernia repair with compartment seperation [**2160-2-18**] Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2160-3-25**] Name: [**Known lastname 10344**],[**Known firstname **] Unit No: [**Numeric Identifier 11429**] Admission Date: [**2160-2-18**] Discharge Date: [**2160-3-25**] Date of Birth: [**2078-9-2**] Sex: F Service: SURGERY Allergies: Demerol / Lidocaine Attending:[**First Name3 (LF) 231**] Addendum: linezolid will be continued for total of 7 days to treat UTI, she is day [**4-4**] @ discharge [**3-25**]. ( previous instructions total 14 day) repeat urine c/s post completion of linezold course. Predisone 5mgm qam and 2 mgm qpm ( please note correction on med sheets. Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2160-3-25**]

[ "285.1", "496", "V43.65", "V58.69", "427.89", "998.32", "577.0", "458.29", "276.52", "441.4", "V58.65", "552.21", "599.0", "V45.82", "518.5", "714.0", "428.0" ]

icd9cm

[ [ [] ] ]

[ "53.51", "88.72", "99.00", "99.04", "38.93", "38.44", "99.15", "96.72", "86.28" ]

icd9pcs

[ [ [] ] ]

10675, 10902

9620, 9780

4462, 6033

6057, 6501

1532, 1920

2617, 4353

6526, 9582

930, 1505

1943, 2599

106, 134

163, 431

454, 906

59,278

135,559

40168

Discharge summary

report

Admission Date: [**2161-1-28**] Discharge Date: [**2161-2-6**] Date of Birth: [**2117-5-8**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 613**] Chief Complaint: fever, cough, myalgia and lower abdominal pain Major Surgical or Invasive Procedure: - Intubation [**2161-1-29**] - Bronchoscopy [**2161-1-29**] - PICC placement [**2161-1-30**] - Extubation [**2161-2-3**] - PICC line removal [**2161-2-6**] History of Present Illness: The patient is a 43 yo woman with h/o recently diagnosed HIV (CD4 484, VL 53K on [**2161-1-7**]), Hep C, IVDU, depression and bipolar disorder who presents with LLQ pain and fever to 101.3, cough, diffuse myalgias. Patient reports her symptoms started two days ago with bloating and diffuse intermittent abdominal pain, with some preference for the lower quadrants. Denies N/V/diarrhea. Also reports non productive cough for similar duration, headaches, myalgias and poor PO intake. Denies SOB, nuchal rigidity, nightsweats, recent weight loss. Does note some lower back pain, primarily in buttocks, somewhat like a spasm. Denies hematuria, dysuria. Checked her temperature at home when feeling feverish and saw it was 101.3 and called an ambulance. In the ED, the patient's initial VS were T 98.7, P 85, BP 118/67, R 18, O2 97% on 3L. Her abdomen and back were diffusely tender, so a CT abdomen was performed. She was found to have bibasilar PNA, fatty infiltrate in the liver, and fibroids. She was given Levaquin and Flagyl for treatment of aspiration PNA. Her pain was treated with toradol 30 mg IV and morphine 4 mg. VS at the time of transfer were T 97.6 P 67 BP 92/49 R 16 O2 96% RA. On the floor, patient denies any nausea or abdominal pain. No headaches or cough. Is hungry and feels dehydrated. Past Medical History: -- HIV (diagnosed 1 year ago, followed by Dr. [**Last Name (STitle) **] at [**Hospital1 **]; --- CD4 count 484, VL 53,200 on [**2161-1-7**]; prior HIV neg 4 months prior to dx [**9-/2160**]) -- Hepatitis C (diagnosed 25 years ago from IV heroin use, clean for 6 months, not on Rx) -- Bipolar Disorder -- anxiety -- H/o substance abuse -- h/o MRSA abscesses, requiring I&D in past -- h/o asthma -- C-section ~26 yrs ago Social History: Lives in [**Location 669**] at Ummis, a home for women with HIV. Move here recently from [**Location (un) **]. Grew up on [**Location (un) **]. Denies use of IVDU, heroin, cocaine in the past 6 months. Smokes [**1-18**] ppd for the past 20 years. Reports drank alcohol 15 years ago. No recent travels. + sick women at the home. History of incarceration for 1 year 5 years ago. No history of homelessness. Has one daughter. Not currently in a relationship or sexually active. Family History: None. Physical Exam: On Admission: Vitals: T: 96.8 BP: 85/52 P: 80 R: 20 O2: 95% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear w/o exudates or erythema Neck: supple, JVP not elevated. Single, non-tender, enlarged lymph node in right posterior cervical chain. Lungs: Clear to auscultation bilaterally w/ faint upper airway sounds on inspiration, but otherwise no wheezes, rales, ronchi; good air movement 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 appreciated Back: no vertebral or CVA tenderness Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: oriented x3, CNII-XII intact, no gross sensory or motor deficits, negative pronator drift, gait not assessed On Discharge: GENERAL- Caucasian female in NAD HEENT- NC/AT, PERRLA, EOMI, sclerae anicteric, mucous membrane moist, OP clear NECK - supple, no thyromegaly, no JVD, no LAD LUNGS - minimal RLL crackles, no wheeze or rhonchi. Good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, 2/6 systolic murmur best heard in the lower left sternal border (known TR), no rub or gallop ABDOMEN - soft/NT/ND, diminished bowel sounds, but no organomegaly EXTREMITIES - no c/c/e, 2+ radial and DP pulses bilaterally SKIN - no rashes or lesions NEURO - awake, alert, oriented, CNs II-XII grossly intact Pertinent Results: Labs: [**2161-1-28**] 12:10AM BLOOD WBC-9.7# RBC-3.86* Hgb-12.2 Hct-34.2* MCV-89 MCH-31.7 MCHC-35.8* RDW-12.7 Plt Ct-197 [**2161-1-28**] 12:10AM BLOOD Neuts-83.0* Lymphs-12.5* Monos-3.4 Eos-0.2 Baso-0.9 [**2161-1-28**] 12:10AM BLOOD Glucose-103* UreaN-11 Creat-0.8 Na-132* K-4.0 Cl-99 HCO3-25 AnGap-12 [**2161-1-28**] 12:10AM BLOOD ALT-57* AST-72* LD(LDH)-264* AlkPhos-85 TotBili-1.1 [**2161-1-28**] 12:10AM BLOOD Albumin-4.0 [**2161-1-28**] 12:10AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021 [**2161-1-28**] 12:10AM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2161-1-28**] 12:10AM URINE RBC-0 WBC-[**3-21**] Bacteri-FEW Yeast-NONE Epi-0-2 [**2161-1-28**] 12:10AM URINE CaOxalX-OCC [**2161-1-28**] 02:17AM URINE UCG-NEGATIVE [**2161-1-29**] 08:50AM BLOOD WBC-11.5* Lymph-6* Abs [**Last Name (un) **]-690 CD3%-76 Abs CD3-524* CD4%-32 Abs CD4-218* CD8%-43 Abs CD8-295 CD4/CD8-0.74* [**2161-1-29**] 10:33AM BLOOD Type-ART Temp-37 pO2-92 pCO2-44 pH-7.37 calTCO2-26 Base XS-0 Intubat-NOT INTUBA [**2161-1-29**] 10:57AM BLOOD Type-ART pO2-76* pCO2-49* pH-7.34* calTCO2-28 Base XS-0 [**2161-1-29**] 11:51AM BLOOD Type-ART pO2-55* pCO2-51* pH-7.34* calTCO2-29 Base XS-0 [**2161-1-29**] 10:57AM BLOOD Lactate-1.0 [**2161-1-29**] 11:51AM BLOOD Lactate-1.0 [**2161-1-29**] 02:53PM BLOOD Lactate-0.9 [**2161-1-29**] 04:43PM OTHER BODY FLUID (BAL) Polys-46* Lymphs-3* Monos-25* Eos-2* Macro-24* [**2161-1-30**] 04:18AM BLOOD PT-13.3 PTT-26.2 INR(PT)-1.1 [**2161-1-30**] 04:18AM BLOOD QG6PD-9.1 [**2161-1-30**] 04:18AM BLOOD Ret Aut-2.1 [**2161-1-31**] 04:23AM BLOOD Lipase-24 [**2161-1-31**] 04:23AM BLOOD Triglyc-122 Microbiology: [**2161-1-28**] 09:59AM BLOOD B-GLUCAN- <58 pg/mL (Negative) [**2161-1-28**] Legionella Urinary Antigen: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. [**2161-1-28**] Blood culture x2: No growth [**2161-1-28**] Urine culture: No growth [**2161-1-29**] Rapid Respiratory Viral Screen & Culture. Nasopharyngeal swab and bronchial lavage fluid. Respiratory culture and antigen: Negative for Adenovirus, Influenza A & B, Parainfluenza type 1, 2 & 3, and Respiratory Syncytial Virus. [**2161-1-29**] Blood culture: No growth [**2161-1-29**] HIV-1 Viral Load/Ultrasensitive: 48,500 copies/ml. [**2161-1-29**] 12:47 pm SPUTUM. Source: Endotracheal. Gram Stain > 25 PMN and < 10 epithelial cells/100x field. 1+ GPC in pairs, 1+ Yeast. Sparse growth of commensal respiratory flora. No legionella isolated. Yeast growth. No AFB seen. No AFB isolated (prelim) [**2161-1-29**] BRONCHOALVEOLAR LAVAGE, BRONCHIAL LAVAGE FLUID. 1+ PMN. No microorganisms seen. Yeast ~ 1000/mL. No legionella, fungal, mycobacteria, or CMV isolated. Negative for pneumocystis jirovecii. No AFB seen. [**2161-1-29**] MRSA screen negative [**2161-1-30**] 04:18AM BLOOD B-GLUCAN- 39 pg/mL (Negative) [**2161-1-30**] 04:18AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- 0.1 (Negative) [**2161-1-30**] 5:20 pm SPUTUM. Endotracheal. > 25 PMN and < 10 epithelial cells/100x field. No microorganisms seen. No AFB seen. No culture growth. [**2161-1-31**] SPUTUM. >25 PMNs and <10 epithelial cells/100x field. 1+ GPC in pairs and singly. No growth. No AFB seen. Imaging: [**2161-1-28**] - Chest X-Ray, PA and lateral: At the margin of confluent perihilar opacification, left greater than right, is interstitial abnormality or lymphatic engorgement. The heart is normal in size. There are no pleural effusions or pneumothorax. There is no free air under the diaphragm. IMPRESSION: Probable pneumonia, including atypical varieties such as Legionnaire's disease. - CT ABD & PELVIS WITH CONTRAST: Confluent ground-glass opacities are noted at the lung bases, right greater than left, with relative subpleural sparing. The opacities are mostly bronchovascular in distribution. There are no pleural effusions. The heart is normal in size, with a trace pericardial effusion. Small nodules in the left lateral breast probably represent intramammary lymph nodes. ABDOMEN: There is borderline fatty infiltration of the liver and the spleen is mildly enlarged, measuring 14.7 cm in length. The left, right, and main portal and hepatic veins, splenic vein, superior mesenteric vein, and IVC appear patent. Multiple enlarged celiac and periportal lymph nodes are present. These are non-specific but frequently accompany hepatitis C infection. A number of mildly enlarge paraesphageal nodes are present. The gallbladder and pancreas are normal. There is no intra- or extra-hepatic biliary ductal dilatation. The adrenals are normal. The kidneys enhance and excrete contrast promptly and symmetrically, without masses or hydronephrosis. Multiple bilateral renal hypodensities are too small to characterize, but likely represent cysts. The stomach and small bowel are normal. PELVIS: The appendix is normal. The colon and rectum are normal, with redundancy of the transverse and sigmoid colon. The bladder is distended with urine and appears normal. There is a fibroid uterus, with exophytic component extending from the right fundus measuring 5.6 x 3.7 cm. In addition, there are fluid attenuation adnexal cysts measuring 6 x 5.6 cm on the left and 1.7 x 1.3 cm on the right. Trace free fluid is present in the pelvis. There is no free intraperitoneal air. Scattered calcifications are noted in the abdominal aorta and iliac arteries, with patent branch vessels. Multiple prominent lymph nodes measure up to 10 mm in the retroperitoneum and 5 mm in the mesentery. A large left inguinal lymph node measures 13 mm, and is likely reactive. There is straightening of the lumbar spine. No suspicious lytic or sclerotic osseous lesions are identified. IMPRESSION: 1. Bibasilar ground glass opacities, compatible with bronchpneumonia; ground glass opacities are not specific, however, and could be seen with other causes such as aspiration or hemorrhage. 2. Borderline fatty infiltration of the liver with splenomegaly raising concern for portal hypertension, although splenomegaly may be reactive. Clinical correlation is suggested. 3. Fibroid uterus, with 6 cm left and 1.7 cm right adnexal cysts. Characterization with six weeks is recommended by pelvic ultrasound. 4. Small left lateral breast nodules suggesting intramammary lymph nodes of normal size; correlation with mammography is recommended. - PELVIS U.S., TRANSVAGINAL: Transabdominal ultrasound was initially performed and demonstrates a Nabothian cyst. Transvaginal ultrasound was performed to better visualize the uterus, endometrium and adnexa. The uterus measures 7.0 x 4.8 x 7.5 cm. Within the right wall of the uterus is a 3.7 x 3.1 x 4.7 fibroid. The right ovary measures 2.9 x 2.8 x 2.4 cm. Within it is a well- circumscribed anechoic structure which measures 2.0 x 1.9 x 1.8 cm, consistent with a simple cyst. The right ovary demonstrates normal arterial and venous waveforms. The left ovary measures 5.2 x 5.4 x 5.8 cm. The left ovary contains a 5.4 x 4.6 x 4.8 cm well-circumscribed hypoechoic lesion containing echogenic material with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] pattern, compatible with a hemorrhagic cyst. The left ovary demonstrates normal- appearing arterial and venous waveforms. No free fluid is seen. IMPRESSION: 1. Uterine fibroid. 2. Right ovarian simple cyst 3. Left ovarian hemorrhagic cyst - 6 week follow-up ultrasound is recommended to ensure resolution. [**2161-1-29**] - CXR Portable: As compared to the previous radiograph, there is a further progression of disease. The pre-existing right opacity looks substantially more consolidated than on the previous examination. The pre-existing opacities on the left are unchanged in size and severity. The cardiac silhouette is slightly bigger than on the previous examination. No other changes. - Echo: The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. There is a mass on the tricuspid valve. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. IMPRESSION: there is a small (0.4cm) calcified mass on the tricuspid valve (probably anterior leaflet). This could be simple calcification or a healed vegetation. There is moderate to severe tricuspid regurgitation. The right ventricle appears dilated and is probably hypokinetic given the severity of tricuspid regurgitation. At least mild pulmonary artery hypertension. Normal regional and global left ventricular function. [**2161-2-4**] - Abdominal X ray (portable): Paucity of bowel gas may be due to vomiting, but small-bowel obstruction of fluid-filled loops cannot be excluded. A large amount of formed stool is seen throughout the colon. There is no free intraperitoneal air. IMPRESSION: Paucity of bowel gas may be due to vomiting. Small-bowel obstruction with fluid-filled loops cannot be excluded. If there is high clinical concern for obstruction, CT is the next appropriate imaging step Brief Hospital Course: 43 yo F with HIV, Hepatitis C and history of substance abuse presented with LLQ pain and fever to 101.3, cough, diffuse myalgias. # Pnuemonia, likely atypical pneumonia. Patient's initial presentation with acute onset of fever, cough, myalgia and malaise with interstitial infiltrate on CXR is concerning for atypical pneumonia. Laboratory studies did not reveal any specific pathogen for the pneumonia, but she was started on Levaquin and Flagyl initially. Her antibiotics were switched to ceftriaxone and azithromycin on the floor. A code blue was called at 10:15AM on [**1-28**] for respiratory distress. Patient had been de-satting through the night on non-rebreather. She was tachypneic, but O2Sat was between 80s-95% with low down to 77%. She was very anxious and respiratory distress improved. ABG was obtained after Ativan administration showing 7.37/44/92/26 on 100% NRB (ABGs unable to be obtained earlier in the day). She was transferred to the MICU for observation given continued respiratory distress. Pt's serial ABGs showed progressively worsening hypoxia and hypercarbia (7.34/49/76 -> 7.34/51/55) and she was unable to tolerate BiPAP due to extreme anxiety (which did improve her oxygenation to O2 sats of 99%) so she was intubated in the ICU. She was continued on IV CFTX/Azithromycin, started on prednisone 40 [**Hospital1 **] and IV bactrim 450 mg IV q8H for possible PCP [**Name Initial (PRE) 1064**]. Many viral studies/serologies were sent, all negative to date. She completed a full course of Tamiflu and azithromycin. Pt was extubated on [**2-3**] and did well after extubation. She completed 8 days of vancomycin and 9 days of ceftriaxone. She was weaned off oxygen requirement on day of discharge with O2Sat in the mid-90s and minimal cough. Her symptoms improved during course of admission. She was discharged with a follow-up set up with her primary care physician. # Hypoxic Respiratory failure, likely component of pneumonia and anxiety. Resolved. See above for details. # Abdominal/Back pain. She initially reports intermittent left lower abdominal pain and diffuse upper buttocks pain which started during the latter half of her menses. Fibroid uterus and adnexal cysts were seen on CT scan so pelvic ultrasound was obtained which showed right simple ovarian cyst and left hemorrhagic ovarian cyst. Pain improved with ibuprofen. The cysts should resolve over the course of several cycle and ultrasound follow-up after 6 months could be considered for further evaluation. # HYPONATREMIA - Patient had mild hyponatremia on Day 1. Given her poor PO intake and her febrile state before admission, she most likely has hypovolemic hyponatremia. She was given intravenous fluids and sodium correct on Day 2. # HIV. Patient was diagnosed about a year ago. Her [**Month (only) 1096**] CD 4 count was 484 and viral load was 53,200. During this admission, her viral load is 48,500 with lower CD 4 count, expected in acute illness. She was ruled out for PCP [**Name Initial (PRE) 1064**]. Sputum and BAL did not show any AFB on staining. Currently, her HIV is followed by her primary care physician. [**Name10 (NameIs) **] asks that her status not be told to her daughter. She has a follow-up appointment scheduled for further outpatient management of her HIV status with the potential of starting anti-retrovirals in the near future. # Hepatitis C. Her viral load was 6.1 million copies in 12/[**2160**]. CT abdomen showed borderline fatty infiltrate and mild splenomegaly, raising concern for portal hypertension, although splenomegaly could be reactive given recent illness. Patient has not been treated, but her physician has already discussed to her about starting interferon. Further management is deferred to the outpatient clinic. # Left lateral breast nodule. This was noted on CT scan for concern of intra-mammary lymph node. This was an incidental finding. Patient was advised to have a follow-up breast exam and mammography # Left ovarian hemorrhagic cyst, incidental finding. This was found on transvaginal U/S. Patient as advised to have outpatient ultrasound study to evaluate for resolution. # Anxiety. Likely contributed to her respiratory distress. This was treated with ativan prn. Her Visteril was held on admission because of unclear dosage. She did not require any after being transferred back to the floor from the MICU. She was not discharged on any benzodiazepam as it was not part of her regimen and as there is interaction with suboxone. However, she as discharged with home dose Visteril which was confirmed with her primary care's office. She was advised to follow up with her therapist/psychiatrist. # Substance abuse. Patient reported abstinence for 6 months. She was recently started on suboxone by Dr. [**Last Name (STitle) **]. There was no signs or symptoms of withdrawal while patient was in the hospital. While in the ICU, patient was placed on fentanyl, then later methadone while intubated and immediately post extubation. She was transitioned to short acting oxycodone and then later back to suboxone 8 mg daily on day of discharge without issue. Dr.[**Name (NI) 11410**] nurse was informed of patient's situation. Because of special licensing issue, no suboxone was prescribed to the patient upon discharge. Given the snow storm on the day of her discharge, her primary care physician's office was closed. The on-call physician was informed of her situation and advised patient to call on Saturday, [**2161-2-7**] to obtain prescription for suboxone. # Constipation, likely secondary to significant amount of narcotic use while intubated in the MICU. Resolved. Patient was initially on fentanyl and Versed for sedation while being intubated. Later, propofol was added given difficulty ventilating and agitation. She continued to breath out of synchrony with the ventilator, so cistracurium was administered. As her respiratory status improved, she was extubated and transitioned to methadone as maintenance given her history of substance abuse. The significant narcotic use caused severe constipation with symptoms of nausea and vomiting, confirmed with physical exam, and abdominal X-ray. She did not have bowel obstruction. She was started on aggressive bowel regimen with success on [**2161-2-5**]. # Bipolar disease. Non-active issue. Patient continued with home dose Prozac. Appointment was unable to be set up as the number provided was a fax number, and the phone number did not indicate it being a office number. She was recommended to see her therapist/psychiatrist upon discharge through her primary care physician's arrangement. #. Itching. Non-active. Patient's home dose visteril was held while in house as initially dosage was un-certain. Upon discharge, the dosage was confirmed with Dr.[**Name (NI) 11410**] nurse, and patient was discharged on 50 mg 2 tabs daily which is her home dose. Medications on Admission: Prozac 20 mg 3 tabs daily Vistaril 50 mg 2 tabs daily Suboxone - 8mg once a day calcium and vitamin D 600/400 1 tab [**Hospital1 **] Discharge Medications: 1. Suboxone 8-2 mg Tablet, Sublingual Sig: One (1) tab Sublingual once a day: Please call [**Hospital1 **] Community Health Center on [**2161-2-7**] to obtain prescription. 2. Vistaril 50 mg Capsule Sig: Two (2) Capsule PO once a day. 3. Prozac 20 mg Capsule Sig: Three (3) Capsule PO once a day. 4. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - community-acquired pneumonia Secondary diagnosis - HIV - Hepatitis C - Left lateral breast nodule - Left ovarian hemorrhagic cyst - Uterine fibroid - bipolar disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to the hospital with weakness, fevers and abdominal pain. A CXR showed signs of likely pneumonia which we treated with antibiotics. A CT scan of your abdomen was performed to evaluate your pain- this showed fibroids of your uterus and an ovarian cyst. The ovarian cyst will need to be evaluated further with ultrasound in the following weeks. On the CT imaging, a small left breast nodule was noted. It could be a swollen lymph node given your recent illness. However, this should be followed up by your doctor by further study, such as a mammography. You should also have your HIV and hepatitis C monitored closely. Please note the following changes in your medications: - None **Because Suboxone can only be prescribed by specially trained health care providers, you will have to call [**Hospital1 **] Community Health Center, on Saturday at 9AM. [**Telephone/Fax (1) 3581**]. The on-call doctor has been informed of your situation, and will assist you in obtaining your medication. Followup Instructions: You have a scheduled appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Hospital **] Community Health Center on Tuesday, [**2161-2-10**] at 9AM. If you need to reschedule this appointment, please call [**Telephone/Fax (1) 88217**]271. Psychiatry/Therapy follow up with [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **]. You should have your primary care physician to help you set this up. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2161-2-7**]

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icd9cm

[ [ [] ] ]

[ "96.04", "33.24", "38.97", "96.72" ]

icd9pcs

[ [ [] ] ]

21574, 21580

14044, 20988

348, 506

21813, 21813

4329, 14021

23029, 23616

2793, 2800

21171, 21551

21601, 21601

21014, 21148

21964, 23006

2815, 2815

3700, 4310

262, 310

534, 1842

21620, 21792

2829, 3686

21828, 21940

1864, 2284

2300, 2777

2,990

128,110

53448

Discharge summary

report

Admission Date: [**2153-7-21**] Discharge Date: [**2153-8-31**] Date of Birth: [**2101-2-9**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: cough, fever Major Surgical or Invasive Procedure: bronchoscopy x 3 History of Present Illness: 52yo M well known to service with h/o CAD, CHF, ESRD on HD, restrictive lung dz, resp failure in [**3-29**] requiring trach and PEG, recently admitted [**Date range (1) 109909**] for sepsis from ? abdominal wall abscess, acalculous cholecystitis, RLL PNA. Rx with Vanc and Zosyn improved but developed new PNA after finishing abx. Restarted on zosyn and meropenem for pseudomonas and sent to pulm rehab at [**Hospital1 **] for 7days of abx. Was doing well until ~1week after finishing abx ([**7-16**]) when developed fever and rising WBC. Was started on ertapenem, vanc and flagyl with initial improvement but then had increasing fever, cough and secretions. xferred to [**Hospital1 18**] where CXR showed worsening RLL infiltrate PMH: MVR x2, CHF (EF 10-15%), Afib, EM2, ESRD, Restrictive lung dz, gout, CAD s/p CABG. Sputum from OSH growing Klebsiella/psuedomonas. Past Medical History: -CAD s/p CABG in '[**42**] (LIMA-->LAD) -s/p MVR x 2 in '[**33**] and '[**42**] (St. Jude's valve) -h/o staph endocarditits following 1st MVR -CHF with EF of 15% -h/o brain abscess from septic emboli [**2-26**] endocarditis -afib -DM2 -ESRD on HD (MWF) -h/o GIB [**2-26**] duodenal ulcers -restrictive lung disease [**2-26**] ankylosing spondylitis -gout -resp failure requiring trach/vent since [**3-29**] -PEG placement in [**3-29**] c/b abdominal wall hematoma -h/o NSVT -anemia -h/o acalculous cholecystitis -sacral decubitus ulcer -depression -h/o R LE cellulitis Social History: No tob or ETOH. Currently at [**Hospital **] rehab. Family History: N/C Physical Exam: T-98.6, bp: 68-86/42-73, p-78, rr-25 Vent: AC, TV-350, RR-12, Peep-5, FIO2-50% gen - somnolent, but comfortable, O/P with whitish plaque HEENT - PERRLA, sclera anicteric neck - trach site clean lungs - increased ronchi anteriorly c/v - irreg irreg, mechanical MR abd - diffuse abdominal tenderness in lower quadrants, overall rigid, Gtube side c/d/i LE - 2+ pitting edema, chronic venous stasis changes, no splinter hem. neuro - A+O x 3, no focal signs Pertinent Results: [**2153-7-21**] 10:03PM LACTATE-1.2 [**2153-7-21**] 01:36PM TYPE-[**Last Name (un) **] COMMENTS-NOT SPECIF [**2153-7-21**] 01:36PM LACTATE-2.6* [**2153-7-21**] 12:00PM GLUCOSE-147* UREA N-37* CREAT-2.8*# SODIUM-140 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-27 ANION GAP-15 [**2153-7-21**] 12:00PM CORTISOL-18.6 [**2153-7-21**] 12:00PM VANCO-24.2* [**2153-7-21**] 12:00PM WBC-19.4* RBC-3.45* HGB-10.6* HCT-33.6* MCV-97 MCH-30.8 MCHC-31.7 RDW-19.8* [**2153-7-21**] 12:00PM NEUTS-83.0* BANDS-0 LYMPHS-9.8* MONOS-4.6 EOS-2.2 BASOS-0.4 [**2153-7-21**] 12:00PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-1+ POLYCHROM-3+ STIPPLED-OCCASIONAL [**2153-7-21**] 12:00PM PLT SMR-NORMAL PLT COUNT-321 [**2153-7-21**] 12:00PM PT-25.5* PTT-44.3* INR(PT)-4.3 Brief Hospital Course: Plan: 1. Resp/PNA- Currently on Zosyn/Cipro day 13/21 for pseudomonas in sputum. Completed course of bactrim for stenotrophomonas. Remains afebrile. Persistent R diffuse opacities in RUL/RLL. Continues to be vent dependent on AC. Previous attempts at weaning to PS resulted in hypercapnia, breath stacking. -Continue Zosyn/Cipro for 21 day course -Continue AC; PS trials as tolerated 2. Hypotension- Likely cardiogenic in etiology w/ depressed EF 10-15%. BP controlled w/ pressor support on levaphed. The goal is to wean down the levaphed while maintaining MAPs >50. Will continue to wean as tolerated. On [**8-23**]-->transfused w/ 2U PRBC's to drive up HCT and help maintain intravascular volume, but still unable to wean. Distributive etiology less likely given Negative Blood Cx's to date and appropriate Cortisol response. -[**8-26**] placed ABG to help better assess BP's and titrate Pressors -Cont. Levophed, wean as tolerated to maintain MAP's >50 3. GI: Started on erythromycin to increase GI motility. Tolerating tube feeds w/ goal of 35 cc/hr. No BRB per PEG. HCT stable. Avoid opioid analgesics. Supplement electrolytes prn. [**8-17**]-KUB and CT negative for obstruction. CT shows no dilated bowel or thickened bowel wall. 4.CHF- EF 15%, avoid excess fluid; pressor support as necessary. 5.MVR/Afib- Coumadin increased to 3mg qhs for goal INR of 2.5-3.5. Once INR therapeutic, we can D/C heparin. Heparin currently therapeutic at 60-80 pTT. 6. ESRD- ESRD requiring HD. Brief trial of CVVH on this admission to help reduce a 20+ liter volume overload, but did not tolerate well (increased need for pressor support following tx). Currently on Tu/Th/Sa intermittent HD schedule. Tolerating well and maintains MAP's >60 through tx. +19 L for length of stay. HD has removed between 1-4L per tx. Followed by renal qd. Electrolytes (Chem 10) qd. 7. Pain- Vioxx for back pain (h/o ankylosing spondylitis). Haldol or gentle ativan (0.25) for agitation/anxiety. Avoid opioid analgesics [**2-26**] decreased gut motility. Avoid Ambien [**2-26**] mental status changes. 8. FEN- Tube feeds per nutrition recs, with goal of 35 cc/hr. TPN d/c'd. 9. Access- R. PICC; L. dialysis cath 10. Comm - daily with family 11. Code Status: DNR- Shock treatable rythms, but no compressions. Continue Ventilatory and Pressor Support. Lines ok. Only change from previous Full Code Status is that we will not do compressions [**8-31**] pt had periods of continued desaturation and multiple brochoscopies reveal mucus plugging as well as clot. Eventually the patient was unable to oxygenate adequately and passed away from respiratory failure. Medications on Admission: vanc 1 g IV q MWF (d. 6) flagyl 500 iv tid (d. 6) ertapenem (d. 6) reglan 5 tid asa 81 qd coreg 3.125 [**Hospital1 **] celexa 40 qd epo 15K unis at HD RISS buspar 10 tid haldol 0.5 qhs lantus 15 units qhs lidoderm patch MVI prevacid 30 qd coumadin combivent q 4 vioxx 25 qd oxycodone 5 q4prn TF - renal Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Congestive Heart Failure Discharge Condition: Deceased

[ "707.0", "458.9", "575.10", "482.1", "427.31", "560.1", "428.0", "518.84", "585" ]

icd9cm

[ [ [] ] ]

[ "33.21", "99.15", "51.01", "39.95", "96.6", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

6195, 6274

3210, 5841

320, 338

6342, 6353

2407, 3187

1914, 1919

6295, 6321

5867, 6172

1934, 2388

268, 282

366, 1235

1257, 1828

1844, 1898

57,491

144,324

35328

Discharge summary

report

Admission Date: [**2111-3-3**] Discharge Date: [**2111-3-8**] Date of Birth: [**2036-6-13**] Sex: F Service: CARDIOTHORACIC Allergies: Percocet / Darvocet-N 100 Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2111-3-3**] Mitral Valve Repair History of Present Illness: The patient is a 74 year old female with a history of mitral valve prolapse and mitral regurgitation. She has been followed by serial echocardiograms since [**2095**] and has recently developed increasing dyspnea on exertion and chest pain. She is referred for cardiac surgical evaluation. Past Medical History: Mitral regurgitation, Hyperlipidemia, Osteoporosis, Rheumatoid arthritis, Asthma, Hard of hearing- (hearing aid- right ear), Occasional symptoms of Gastroesophageal reflux disease, status post Bunion surgery, Hammer toe status post surgical correction, status post Hemorrhoidectomy, Remote vertigo Social History: retired denies tobacco rare alcohol lives with significant other, [**Name (NI) **] Family History: Father with an myocaridal infarction in his 60??????s. Physical Exam: 71, 14, 127/44, 127/45, 4'[**12**]", 123lb General: NAD Skin: unremarkable Neck: suple with full ROM Chest: LCTAB Heart: RRR with systolic murmur Abdomen: soft, non-tender, non-distended, +BS Ext: warm/well-perfused, no edema Varicosities: none Neuro: grossly intact Pulses palpable throughout Pertinent Results: [**2111-3-7**] 07:15AM BLOOD WBC-9.0 RBC-3.58*# Hgb-10.7*# Hct-31.2*# MCV-87 MCH-29.8 MCHC-34.2 RDW-14.5 Plt Ct-224 [**2111-3-7**] 07:15AM BLOOD Glucose-129* UreaN-18 Creat-1.0 Na-138 K-4.3 Cl-101 HCO3-30 AnGap-11 [**2111-3-7**] 07:15AM BLOOD Mg-2.2 [**Hospital1 69**] [**Location (un) 86**], [**Telephone/Fax (1) 15701**] Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 80552**],[**Known firstname **] [**2036-6-13**] 74 Female [**Numeric Identifier 80553**] [**Numeric Identifier 80554**] Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **] Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/dif SPECIMEN SUBMITTED: POSTERIOR LEAFLET MITRAL VALVE. Procedure date Tissue received Report Date Diagnosed by [**2111-3-3**] [**2111-3-3**] [**2111-3-7**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/ttl DIAGNOSIS: Mitral valve, posterior leaflet, excision: Valvular tissue with myxoid degeneration. Clinical: Mitral valve disorder. Gross: The specimen is received fresh labeled with the patient's name, "[**Known lastname **], [**Known firstname 2048**]" and the medical record number. It is additionally labeled "posterior leaflet, mitral valve." It consists of a valve cusp with chorda tendinae measuring 2.2 cm along the free edge and 1.0 cm edge to base. The outflow surfaces are white-tan, rubbery and uninvolved by atherosclerosis. The specimen is entirely submitted in A. By his/her signature above, the senior physician certifies that he/she personally conducted a gross and/or microscopic examination of the described specimens(s) and rendered or confirmed the diagnosis(es) related thereto. Immunohistochemistry test(s), if applicable, were developed and their performance characteristics were determined by The Department of Pathology at [**Hospital1 69**], [**Location (un) 86**], MA. They have not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. These tests are used for clinical purposes. They should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of [**2089**] (CLIA - 88) as qualified to perform high complexity clinical laboratory testing. Brief Hospital Course: Ms. [**Known lastname **] was a same day admit and went directly to the operating room where she underwent a mitral valve repair. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one she appeared to be doing well and was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. A small pneumothorax was noted on post chest tube pull CXR. Repeat serial CXr's revealed stable pneumothorax. She had a brief episode of rapid atrial fibrillation which reponded to IV lopressor and IV amiodarone bolus. She was then started on oral amiodarone and maintained sinus rhythm. Ms. [**Known lastname **] was evaluated by physical therapy and cleared for d/c to home with VNA services on POD 4. Medications on Admission: Fluticasone nasal spray, two sprays to each nostril every morning Evista 60mg one tablet every morning Zetia 10mg daily every evening Fish oil 600mg one capsule twice a day Vitamin C 500mg one tablet daily MVI one daily Glucosamine/chondroitin one capsule twice a day Calcium with D 500mg twice a day Aspirin 325mg daily every morning Omeprazole 20mg as needed Discharge Medications: 1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). Disp:*qs * Refills:*2* 2. Ezetimibe 10 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. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 5. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg 2x/day for 1 week, then 200mg 2x/day for 1 week, then 200mg/day until further instructed. Disp:*120 Tablet(s)* Refills:*2* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-26**] Sprays Nasal QID (4 times a day) as needed. Disp:*qs * Refills:*0* 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Mitral regurgitation status post Mitral Valve Repair Secondary: Hyperlipidemia, Osteoporosis, Rheumatoid arthritis, Asthma, Hard of hearing- (hearing aid- right ear), Occasional symptoms of Gastroesophageal reflux disease, status post Bunion surgery, Hammer toe status post surgical correction, status post Hemorrhoidectomy, Remote vertigo Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Dr. [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) **] in [**12-26**] weeks Dr. [**First Name8 (NamePattern2) 20069**] [**Last Name (NamePattern1) **] in [**1-27**] weeks Completed by:[**2111-3-8**]

[ "733.00", "429.5", "493.90", "714.0", "427.31", "272.4", "512.1", "E878.8", "428.9", "424.0" ]

icd9cm

[ [ [] ] ]

[ "35.12", "39.61" ]

icd9pcs

[ [ [] ] ]

7184, 7239

3900, 4828

310, 347

7622, 7628

1490, 3877

8420, 8709

1105, 1161

5239, 7161

7260, 7601

4854, 5216

7652, 8397

1176, 1471

251, 272

375, 668

690, 989

1005, 1089

57,207

194,920

11112

Discharge summary

report

Admission Date: [**2119-4-23**] Discharge Date: [**2119-4-26**] Date of Birth: [**2077-7-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1973**] Chief Complaint: benzo withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 3510**] is a 41 year-old man with depression and polysubstance abuse who presents with benzodiazepine dependence, seeking dual diagnosis admission. He has been struggling to stop using benzodiazepines over the last 3 months, but this has been complicated by failed detox admissions and seizures. He has been taking Clonazepam 10-16mg/day for the last few months for increased depression and anxiety. Stopped Clonazepam the day prior to admission, now with symptoms of benzodiazopene withdrawal, including nausea, loose stool, racing heart, tremors. Had seizure in the setting of benzodizopene withdrawal a few months ago. No fever, vomiting, abd pain. Denies Suicidal/Homicidal ideation, auditory or visual hallucinations. He wants dual diagnosis admission for depression and detox. In the ED, initial VS 96.8 117 153/78 16 98% RA. Psychiatry was consulted and recommended IV ativan 2mg Q20-30min until stable or signs/symptoms of intoxication (nystagmus, unsteady gait) emerge. Once stabilized on ativan, would recommend transition to equivalent dose of PO clonazepam (anticipated 4-6mg TID). He was held under section 12. He was requiring ativan Q1 hour so was admitted to the ICU (total 20 mg IV ativan (every 30min-1 hour)+ 4 mg po ativan + 0.1 clonidine). Vitals on transfer 97.6 107 120/60 20 98% RA. Past Medical History: Asthma Herniated L4-L5 Social History: Occupation: homeless Drugs: 16-18mg clonazepam per day, 2-4mg suboxone per day Tobacco: [**1-1**] PPD Alcohol: rarely Family History: There is no family history of seizure disorder Physical Exam: ROS: GEN: - fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, + Palpitations, - Edema GI: + Nausea, + Vomitting, + Diarhea, - Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: GEN: Uncomfortable Pain: 0/10 HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CCE NEURO: CAOx3, Tremulous, Anxious Pertinent Results: [**2119-4-26**] 07:33AM BLOOD WBC-6.4 RBC-4.12* Hgb-13.2* Hct-37.8* MCV-92 MCH-32.0 MCHC-34.8 RDW-13.9 Plt Ct-233 [**2119-4-25**] 08:03AM BLOOD WBC-11.1* RBC-4.25* Hgb-13.4* Hct-39.0* MCV-92 MCH-31.5 MCHC-34.3 RDW-13.7 Plt Ct-240 [**2119-4-24**] 05:28AM BLOOD WBC-8.5 RBC-4.11* Hgb-12.7* Hct-36.8* MCV-90 MCH-30.9 MCHC-34.6 RDW-13.3 Plt Ct-234 [**2119-4-22**] 11:00PM BLOOD WBC-7.4 RBC-4.05* Hgb-12.7* Hct-37.0* MCV-91 MCH-31.4 MCHC-34.4 RDW-13.0 Plt Ct-302 [**2119-4-22**] 11:00PM BLOOD Neuts-61.4 Lymphs-27.8 Monos-5.9 Eos-4.0 Baso-0.8 [**2119-4-25**] 08:03AM BLOOD PT-13.8* PTT-27.9 INR(PT)-1.2* [**2119-4-26**] 07:33AM BLOOD Glucose-89 UreaN-11 Creat-0.7 Na-141 K-4.5 Cl-104 HCO3-29 AnGap-13 [**2119-4-25**] 08:03AM BLOOD Glucose-50* UreaN-7 Creat-0.8 Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2119-4-24**] 05:28AM BLOOD Glucose-91 UreaN-6 Creat-0.8 Na-138 K-3.6 Cl-108 HCO3-25 AnGap-9 [**2119-4-23**] 12:24PM BLOOD Glucose-112* UreaN-9 Creat-0.7 Na-140 K-3.5 Cl-106 HCO3-28 AnGap-10 [**2119-4-22**] 11:00PM BLOOD Glucose-119* UreaN-21* Creat-0.8 Na-135 K-3.3 Cl-99 HCO3-26 AnGap-13 [**2119-4-24**] 05:28AM BLOOD ALT-84* AST-72* AlkPhos-58 TotBili-0.5 [**2119-4-22**] 11:00PM BLOOD ALT-92* AST-89* AlkPhos-62 TotBili-0.3 [**2119-4-26**] 07:33AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.2 [**2119-4-24**] 05:28AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.3 [**2119-4-22**] 11:00PM BLOOD Calcium-9.2 Phos-3.8 Mg-2.1 [**2119-4-25**] 08:03AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE [**2119-4-22**] 11:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2119-4-25**] 08:03AM BLOOD HCV Ab-POSITIVE* [**2119-4-22**] 11:48PM BLOOD Glucose-115* Lactate-1.4 Na-136 K-3.2* Cl-96* calHCO3-25 [**2119-4-22**] 11:00PM URINE Hours-RANDOM [**2119-4-22**] 11:00PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-POS mthdone-NEG [**2119-4-23**] 7:54 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2119-4-25**]** MRSA SCREEN (Final [**2119-4-25**]): No MRSA isolated. Brief Hospital Course: Mr. [**Known lastname 3510**] is a 41 year old male with a history of depression and poly-substance abuse who presented with benzodiazepime withdrawal and requested detoxification. # Drug Dependence - Benzodiazepime with acute withdrawal: Patient reported Clonazepam 10-16mg/day. Patient demonstrated symptoms of withdrawal including tremors and anxiety. In ED patient required high doses of ativan consequently transferred to ICU for care prior to detox placement. Patient started on Valium 20 mg q1hr prn for CIWA > 10 and transitioned to standing Valium 20 mg po q3hr plus prn dose. This was transitioned to Valium 30mg PO Q3 hours and q2 IV prn. He was transferred to the medicine floor and was given 30mg of po diazepam every 4 hours around the clock, in addition to 10mg every 4 hours as needed for withdrawal symptoms based on the narcotic withdrawal index. The standing dose was later decreased to q6 hours. He was discharged to a detoxification and psychiatric facility on this regimen. The plan is to taper the benzodiazepine dose slowly, at about 10 to 20% daily, to avoid withdrawal. Psychiatry and social work were consulted on this case. # Transaminitis, Chronic Hepatitis C: This was thought to be a manifestation of his substance abuse; however, hepatitis B and C serologies were ordered and pending at discharge. His HCV Ab was positive. Hepatitis B surface Ab was positive and Ag was negative, indicating immunity to hepatitis B. We will notify him of these results and will have to set him up with a PCP, [**Name10 (NameIs) 3**] he did not have one upon discharge. He had been provided with a phone number to find a new [**Company 191**] PCP; however, he will likely need encouragement to do so. # Suboxone Withdrawal: Has symptoms of withdrawal including loose stools. Patient declined clonidine for symptoms due to dry mouth. # Depression: Concern for suicidal ideation on admission but after further history by psychiatry he was deemed to safe. Section 12 reversed - did not need sitter. # Tobacco abuse: Nicotine patch 21mcg daily started; Counseling done. Cessation encouraged. Transitional issues: -PCP [**Name9 (PRE) 702**] or establishing primary care; [**Company 191**] phone number provided -f/u hepatitis b and c serologies: HCV positive. Will give the patient test results and ensure that he has follow-up with a PCP. Medications on Admission: Medications at home: (unable to confirm with [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] at this time): Trazodone 150mg QHS Escitalopram 20mg daily Gabapentin 800mg QID Discharge Disposition: Extended Care Discharge Diagnosis: Benzodiazepine Addiciton Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 3510**]: It was a pleasure taking care of you at [**Hospital1 18**]. You came to the hospital to be treated for benzodiazepine withdrawal. You were treated with diazepam, initially in the intensive care unit and later on the medical floor. You will be transferred to a center that specializes in detoxification and psychiatric needs. Please make the following changes to your medication regimen: -decrease trazodone to 50mg at bedtime -add thiamine 100mg daily -add multivitamin daily -add folic acid 1mg daily -add albuterol inhaler 2 puffs every 6 hours as needed for shortness of breath or wheezing -add diazepam 30mg by mouth every six hours around the clock -add diazepam 10mg by mouth every 4hrs as needed for withdrawal Followup Instructions: Please call your primary doctor to be seen after you are discharge from the detoxification center. If you do not have a primary doctor, please call [**Telephone/Fax (1) 250**] to establish primary care at [**Hospital1 18**]. Completed by:[**2119-5-2**]

[ "292.0", "V60.0", "276.8", "296.90", "304.11", "300.4", "314.01", "305.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7304, 7319

4700, 6810

321, 328

7399, 7399

2653, 4677

8329, 8584

1890, 1938

7340, 7378

7084, 7084

7550, 8306

7105, 7281

2468, 2634

6831, 7058

265, 283

356, 1688

7414, 7526

1710, 1735

1751, 1874

47,263

150,889

33269

Discharge summary

report

Admission Date: [**2138-4-7**] Discharge Date: [**2138-4-10**] Date of Birth: [**2086-11-6**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 613**] Chief Complaint: unintentional calcium channel blocker overdose Major Surgical or Invasive Procedure: CVL placement History of Present Illness: 51 year-old man with Hep C/ETOH cirrhosis, IVDA with history of epidural abscess, chronic back pain, and HTN, who presents after overdosing inadvertantly on calcium channel blocker. He took 10 tabs of pills that he bought on the street (that he thought were methadone) 3 days before admission. The next day he felt lightheaded and nauseous. Then the day of admission he fell out of his bed several times which prompted his mother to call EMS. He denied head strike or loss of conciousness. Denied chest pain, palpitations, shortness of breath, abdominal pain, headache. He initially presented to [**Hospital6 **]. There they discovered the tabs he took were amlodipine 10mg tabs after investigation by a pharmacist. Shortly after arrival, his HR dropped to <20 and he became unresponsive. One round of chest compressions was completed and his HR improved and his pulse returned without further intervention. Medications administered at the OSH included glucagon 8mg, amp bicarb, amp D50, 40 units insulin IV, 30g kayexelate, 3 amps calcium gluconate, 4L NS. He was then med-flighted to [**Hospital1 18**]. En route he was started on levophed for SBP 70/20 MAP 30s. At [**Hospital1 18**], initial vitals were 97.9 83 82/29 on levophed 18 93%4L. Labs were notable for K 5.3, Na 132 HCO3 10 BUN 93 Cr 5.3, INR 1.3, WBC 7.7, HCT 38.3, Plt 155. Serum tox negative. AST 115, ALT 54, Tbili 0.8, Alb 2.9, Lip 50. Lactate 6.6. L CVL placed. Urine output was ~30cc/hr. His levophed was continued, insulin drip started at 40 units/hr, started on calcium chloride drip 2g/hour, D10 75/hr, and was given 1 bolus of intralipid (120cc). He was seen by toxicology who recommended continued high dose insulin, intralipid gtt needed if hemodynamics worsened, and glucose checks every hour. He was started on vanc/Zosyn for possibility of infection. In the MICU he was bolused with 6L IVF for suspected prerenal [**Last Name (un) **] and was seen by Renal who recommended bicarb gtt for acidosis. Vanc/Zosyn were stopped and levophed was weaned. He was started on thiamine, folate, and a MVI for h/o alcoholism. CXR showed no evidence of PNA, and Abdominal U/S showed cirrhosis with a patent portal vein and normal kidneys. He was started on a CIWA protocol for withdrawal. Of note, his hct and platelets dropped following aggressive fluid resuscitation, but his hct has remained stable at 29. He also complained of new rash and pain in L antecubital region; ultrasound showed no evidence of DVT or fluid collection. When transferred to the medical floor, he reported chronic back pain but denied dizziness and headache. He confirms that this was an accidental overdose and denies suicidal ideation. Past Medical History: Cirrhosis secondary to EtOH and hepatitis C polysubstance abuse including IV heroin Epidural abscess and osteomyelitis, s/p back surgery at [**Hospital1 2177**] [**2133**] Chronic back pain HTN nephrolithiasis Social History: Lives with mother. Unemployed for many years. Used to work in carpentry. Smokes 1 pack/week. ETOH 1-2 times per month, history of heavy ETOH prior to [**2125**], IVDA last used heroin 6 months ago, prior to that used cocaine, crystal meth and "everything in the book". Family History: Father heavy ETOH drinker, died of MI. Mother had breast cancer in 80's and an arrhythmia. Sister with substance abuse and hepatitis C. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.1 91 99/31 16 98% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP flat, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops, no spider angiomata Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, no asterixis DISCHARGE PHYSICAL EXAM: VS - T 97.5 BP 109/50 (100s/50s) HR 90 RR 18 99% RA GENERAL - NAD, sitting in chair, eating breakfast HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK - supple, no LAD, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ radial/DP pulses. Large blue-purple ecchymosis in R antecubital area at prior bp cuff site. SKIN - Spider angiomata over L shoulder. No palmar erythema. LUE with petechiae. Bl [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 77249**], taught and shiny. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**3-22**] throughout, sensation grossly intact throughout, DTRs hyperreflexic (3+) and symmetric, cerebellar exam intact. No asterixis. No pronator drift. Pertinent Results: Admission labs: [**2138-4-7**] 12:06PM BLOOD WBC-7.7# RBC-4.01* Hgb-11.8*# Hct-38.3* MCV-95 MCH-29.5 MCHC-30.9*# RDW-16.7* Plt Ct-155 [**2138-4-7**] 12:06PM BLOOD PT-13.9* PTT-35.9 INR(PT)-1.3* [**2138-4-7**] 12:06PM BLOOD Glucose-93 UreaN-58* Creat-5.3*# Na-132* K-5.3* Cl-104 HCO3-10* AnGap-23* [**2138-4-7**] 12:06PM BLOOD ALT-54* AST-115* AlkPhos-151* TotBili-0.8 [**2138-4-7**] 02:05PM BLOOD Calcium-10.1 Phos-6.5*# Mg-1.9 [**2138-4-7**] 12:06PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2138-4-7**] 06:18PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2138-4-7**] 06:14PM BLOOD Type-ART pO2-87 pCO2-26* pH-7.29* calTCO2-13* Base XS--12 Intubat-NOT INTUBA [**2138-4-7**] 12:08PM BLOOD Glucose-88 Lactate-6.6* Na-134 K-4.9 EKG [**2138-4-7**]: Sinus rhythm. Borderline low limb lead voltage. ST-T wave abnormalities. Since the previous tracing of [**2134-2-4**] the rate is faster. ST-T wave abnormalities are more prominent. Clinical correlation is suggested. [**2138-4-8**] ECHO: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 65%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [**2138-4-8**] CXR: FINDINGS: As compared to the previous radiograph, the severity of the pre-existing pulmonary edema has increased. It is now at least moderate. There is no clear evidence of pleural effusions. Unchanged moderate cardiomegaly with tortuosity of the thoracic aorta. No evidence of pneumonia or substantial atelectasis. [**2138-4-8**] Abdominal Ultrasound: IMPRESSION: 1. Coarsened liver echotexture, compatible with known cirrhosis. No focal liver lesion. Patent main portal vein. 2. Normal kidneys. [**2138-4-8**] Upper extremity ultrasound: IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. No fluid collection. Brief Hospital Course: 51 y/o man with Hep C/EtOH cirrhosis, IVDA with history of epidural abscess, and chronic back pain, who presented after suspected calcium channel blocker overdose with bradycardia, hypotension and acute renal failure, transferred from the MICU with improved blood pressure and resolving [**Last Name (un) **]. 1. Calcium channel blocker overdose: In the MICU the patient was treated for presumptive amlodipine overdose since OSH pharmacist identified the pills as such. As previously pointed out, it would be odd for amlodipine to cause bradycardia since it is more selective for L-type calcium channels in the vasculature (as opposed to the nondihydropyridines, verapamil and diltiazem, which can cause bradycardia by acting on cardiac Ca channels). Bradycardia might be expected with amlodipine in high doses, however. Other possible ingestions were ruled out with negative serum tox screen, non-detectable digoxin level. In the MICU the patient was treated with levophed for hypotension, and IVF to keep CVP 8-10. He was started on an insulin gtt given with dextrose, which was stopped when the patient developed hypoglycemia. He received an intralipid bolus in the ED and gtt in the MICU, which was subsequently stopped. His ionized calcium was monitored and repleted. He was weaned off levophed and transferred to the floor. He was monitored on telemetry and did not show any signs of PR prolongation or ST changes. His blood pressure remained >100/50 and his heart rate ranged from 70s-90s. He was asymptomatic on the floor. 2. [**Last Name (un) **]: Creatinine 5.3 on admission. This was attributed to pre-renal [**Last Name (un) **] given mostly hyaline casts on UA, although he may have progressed to mild ATN as well. Renal evaluated patient and felt that he was pre-renal in setting of hypotension. Patient's creatinine improved with IVF and was 2.2 when called out of ICU. Creatinine on discharge was 1.7 and continuing to trend down. 3. Cirrhosis: The patient had a postive HCV Ab and history of EtOH abuse. He was HIV negative during this admission. He likely has some mild impaired synthetic function given INR 1.3 and platelets 67. Abdominal U/S confirmed cirrhosis. He was instructed to follow up with his hepatologist (reportedly at [**Hospital3 **]) after discharge since he reported a desire to seek treatment for his HCV. 4. EtOH abuse: The patient reported a history of EtOH abuse and was tremulous with tongue fasiculations on exam. He was placed on a CIWA protocol, but did not score higher than 3 after being started back on his home clonazepam [**Hospital1 **], raising the possibility that he was withdrawing from benzodiazepines. He was started on a multivitamin, thiamine, and folate to be continued on discharge. He was seen multiple times by social work and was encouraged to follow up with his outpatient treaters. 5. Metabolic acidosis: Initially in the MICU he presented with AG 23 and appropriate respiratory compenstation, likely secondary to lactic acidosis. pH, bicarb, and lactate trended down and remained normal after he was transferred out of the MICU. 6. HTN: Given the patient was admitted with hypotension, his home HCTZ and lisinopril were held during admission and on discharge. 7. Anemia and Thrombocytopenia: During his MICU stay the patient's hct dropped from 38 -> 29 and platelets dropped from 155 -> 72 on day two of admission. No signs of bleeding. Trended CBC which remained stable thereafter. Anemia likely dilutional effect of receiving 6L fluids in the MICU, coupled with dehydration on admission. Thrombocytopenia likely secondary to chronic liver disease with portal hypertension. 8. Opiate dependence: In the MICU his home medications were confirmed with PCP, [**Name10 (NameIs) 19566**] TID methadone for back pain. He was continued on his home methadone 30mg TID. As social work pointed out, continuing this medication may make it difficult for the patient to be accepted into drug recovery/detox programs in the future if he so desires. TRANSITIONAL ISSUES: [ ] HCV viral load sent in case patient follows up with his hepatologist. Medications on Admission: lisinopril 5mg daily methadone 30mg TID clonipin 1mg PO BID HCTZ 12.5mg daily bactroban cream for 7 days percocet 5/325 mg 1 tab PO Q4-6hrs bactrim DS 1 tab [**Hospital1 **] Benadryl PRN itching Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for back pain: Please do not drink alcohol or drive while taking this medication. Disp:*20 Tablet(s)* Refills:*0* 4. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please do not drink alcohol or drive while taking this medication. Disp:*16 Tablet(s)* Refills:*0* 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. methadone 10 mg Tablet Sig: One (1) Tablet PO three times a day: Please do not drink alcohol or drive while taking this medication. Disp:*81 Tablet(s)* Refills:*0* 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Amlodipine toxicity, acute renal failure Secondary diagnoses: Cirrhosis, Hepatitis C, chronic back pain, history of IVDU Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 77250**], It was a pleasure being involved in your care during your hospitalization. You were admitted with low blood pressure and slow heart rate after accidentally taking a large dose of amlodipine, a blood pressure medication. You were treated in the intensive care unit with medications to support your blood pressure and medications to reverse the bad effects of amlodipine. You should follow up with your primary care doctor after discharge. We also found that your liver may have some damage due to alcohol use and hepatitis C. We would encourage you to follow up with the Hepatology team (liver doctors) as an outpatient. The following changes were made to your medications: STOP taking Lisinopril (a blood pressure medication) until you see your doctor STOP taking hydrochlorothiazide (a blood pressure mediction) until you see your doctor STOP taking bactrim (an antibiotic, you already finished a course for cellulitis) ADDED: A multivitamin daily ADDED: Thiamine daily ADDED: Folate daily Followup Instructions: Name: [**Last Name (LF) 77251**],[**First Name3 (LF) **] M Address: 73D [**Last Name (LF) **], [**First Name3 (LF) **],[**Numeric Identifier 59250**] Phone: [**Telephone/Fax (1) 59225**] Appt: [**4-18**] at 1:10pm [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

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51532

Discharge summary

report

Admission Date: [**2146-9-1**] Discharge Date: [**2146-9-14**] Date of Birth: [**2078-1-10**] Sex: M Service: MEDICINE Allergies: Quetiapine Attending:[**First Name3 (LF) 2817**] Chief Complaint: supraglottitis Major Surgical or Invasive Procedure: Emergent Cricothyroidotomy Tracheostomy Placement Mechanical Ventilation PICC line placement History of Present Illness: patient is a 64 yo M with atrial fibrillation on coumadin, [**Hospital 2182**] transferred from an OSH with respiratory distress due to supraglottic edema. He initially presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] because he was 'spitting up blood' after eating a [**Location (un) 6002**] at his rehab. He was found to have supraglottic edema both on exam and in CT scan. He was transferred to [**Hospital1 18**] for airway management. Surgery was called for respiratory distress in the ED and performed an emergent crichothyroidotomy in the OR. ENT was consulted and changed the crich to a tracheostomy. Admission labs pertinent for Hct of 50 (down to 33 on transfer) and INR of 3.0 reversed with 6 [**Location 16678**] and 10 mg vitamin K (given at OSH) down to 1.6. Past Medical History: - Atrial Fibrillation (on coumadin) - s/p Pacer ([**Company 1543**] DDD) - COPD - Hypertension - PVD s/p Aortobifemoral bypass - Hyperlipidemia - Chronic liver disease [**2-22**] EtOH (sober since [**2-/2146**]) - Anemia: h/o maroon stools colonoscopy in [**2146**] with hemorrhoids, colon polyps, adenoma - h/o epistaxis . Social History: Social History: - unemployed. Has a scooter at home. Short term rehab resident at [**Hospital 70637**] Healthcare in [**Location (un) 32944**]. [**Hospital 1094**] health care proxy is his friend [**Name (NI) 892**] [**Name (NI) 16471**], (c) [**Telephone/Fax (1) 106834**], (h) [**Telephone/Fax (1) 106835**]. - Tobacco: +1.5 ppd, no plans for quitting - Alcohol: per records, hx of heavy EtOH use but was abstaining from EtOH since [**2146-6-10**]. - Illicits: none Family History: Family History: father and mother both died of CAD Physical Exam: Vitals: 99 132/54 (90 non-invasive) 20 100% on trach collar. General: elderly M with trach Alert NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: slight expiratory wheeze with otherwise clear breath sounds CV: distant HS, tachycardic, irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, TTP in LUQ and LLQ, non-distended, bowel sounds present, no rebound tenderness or guarding; bruises noted over bilateral lower quadrants. no abdominal rash noted. GU: no foley Ext: limbs cool to touch BL with 1+ DPs, PTs bilaterally; hair loss. Moving all lower and upper extremities to command. Pertinent Results: Images: CXR ([**9-9**]) - FINDINGS: AP single view of the chest has been obtained with patient in semi-upright position. Image field directed towards upper abdomen on purpose so to identify Dobbhoff line which is seen to be located in stomach pointing towards pylorus and duodenum but not having passed of yet. No other remarkable findings. This image has been obtained to complement a previous chest examination obtained two hours earlier. . CT neck (OSH on [**8-31**]): Impression: Edema of the epiglottis, the R lateral oropharynx and the hypopharynx. No discrete abscess. Mild narrowing of the supraglottic airway. Diffuse R maxillary sinusitis. CT neck ([**9-6**]) IMPRESSION: 1. Significant decrease in right supraglottic edema since [**2146-8-31**]. While no definite underlying mass is seen, a mass is difficult to exclude. 2. Numerous lymph nodes at levels 1, 2 and 3, right greater than left, not pathologically enlarged by CT size criteria. These may be reactive. 3. Near-complete opacification of the paranasal sinuses, which may be related to the known nasal packing. 4. 1 cm cystic lesion with wall calcifications in the left vallecula. Recommend direct visualization, when feasible. . CT Chest ([**9-1**]) FINDINGS: . The patient is intubated through tracheostomy. For precise evaluation of the neck and the area of the glottis, please review CT of the neck obtained the same day and the corresponding report. A central venous line terminates at the cavoatrial junction. Pacemaker leads terminate in right atrium and right ventricle. Aorta and pulmonary arteries are normal in diameter. Heart size is normal. There is no pericardial effusion. Extensive coronary calcifications are present. . The evaluation of the airways demonstrate patent trachea, right and left main bronchi as well as the upper lung lobe and right middle lobe bronchial tree. Within the lower lobe, there are bibasal consolidations, with air bronchogram on the right and minimal air bronchogram on the left. Giving their relatively high enhancement, they most likely represent areas of atelectasis, but bibasilar infectious process cannot be excluded and it is accompanied by small amount of pleural effusion. The upper lungs are essentially clear. Severe emphysema is involving the upper lobes, a combination of centrilobular and panlobular type. . The imaged portion of the upper abdomen demonstrates small degree of ascites. Sludge within the gallbladder is noted, but with no evidence of cholecystitis. The pancreatic duct is dilated up to 9 mm, the reason is unclear, and the pancreas is partially imaged. Significant lymphadenopathy is noted in the area of the celiac trunk bifurcation up to 14 mm, and might reflect both neoplastic or infectious etiology. Adrenals, imaged portion of the kidneys, spleen, and imaged portion of the liver are unremarkable. . Extensive degenerative changes are present in the spine, but there are no lytic or sclerotic lesions worrisome for neoplasm or infection. Lateral view demonstrates wedge compression fracture of upper lumbar vertebral body, chronicity undetermined. . EGD ([**2146-9-9**]): Findings: Esophagus: Mucosa: Abnormal mucosa was noted throughout the esophagus. There was 3 inches of circumferential dark mucosa starting at the GE junction. Proximal to that in the distal and mid esophagus there are patchy areas of dark mucosa. This persists despite lavage. it has an ischemic appearance, and most consistent with ischemic injury. There is also evidence of punctate and patchy erythema consistent with esophagitis. Stomach: Mucosa: Patchy discontinuous erythema of the mucosa with no bleeding was noted in the whole stomach. These findings are compatible with gastritis. Duodenum: Normal duodenum. Impression: Abnormal mucosa in the esophagus Erythema in the whole stomach compatible with gastritis Otherwise normal EGD to third part of the duodenum Recommendations: Would check H. Pylori serologies and treat if positive. Continue PPI [**Hospital1 **]. [**2146-9-1**] 09:29PM WBC-15.8* RBC-3.92* HGB-12.4* HCT-37.2* MCV-95 MCH-31.7 MCHC-33.4 RDW-15.7* [**2146-9-1**] 09:29PM PLT COUNT-228 [**2146-9-1**] 09:29PM PT-21.3* PTT-35.7* INR(PT)-2.0* [**2146-9-1**] 04:54PM HCT-33.0* [**2146-9-1**] 04:54PM PT-21.8* PTT-37.3* INR(PT)-2.0* [**2146-9-1**] 11:19AM PLT COUNT-238 [**2146-9-1**] 11:19AM PT-24.6* PTT-39.4* INR(PT)-2.4* [**2146-9-1**] 06:17AM TYPE-ART PO2-105 PCO2-37 PH-7.41 TOTAL CO2-24 BASE XS-0 [**2146-9-1**] 05:25AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.047* [**2146-9-1**] 05:25AM URINE RBC->50 WBC-[**3-25**] BACTERIA-MOD YEAST-NONE EPI-0 [**2146-9-1**] 05:24AM DIGOXIN-0.8* [**2146-9-1**] 02:49AM TYPE-ART PO2-112* PCO2-53* PH-7.37 TOTAL CO2-32* BASE XS-4 [**2146-9-1**] 02:31AM GLUCOSE-137* UREA N-23* CREAT-1.0 SODIUM-135 POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-26 ANION GAP-12 [**2146-9-1**] 02:31AM CALCIUM-8.8 PHOSPHATE-4.1 MAGNESIUM-2.0 [**2146-9-1**] 02:31AM WBC-21.2*# RBC-4.68 HGB-14.6 HCT-44.7 MCV-96 MCH-31.3 MCHC-32.7 RDW-15.6* [**2146-9-1**] 02:31AM PLT COUNT-226 [**2146-9-1**] 02:31AM PT-26.6* PTT-40.8* INR(PT)-2.6* [**2146-9-1**] 12:13AM UREA N-24* CREAT-1.0 [**2146-9-1**] 12:13AM estGFR-Using this [**2146-9-1**] 12:13AM LIPASE-71* [**2146-9-1**] 12:13AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2146-9-1**] 12:13AM WBC-11.3* RBC-5.38 HGB-16.8 HCT-50.9 MCV-95 MCH-31.3 MCHC-33.1 RDW-16.0* [**2146-9-1**] 12:13AM PLT COUNT-216 [**2146-9-1**] 12:13AM PT-30.4* PTT-35.9* INR(PT)-3.0* [**2146-9-1**] 12:13AM FIBRINOGE-550* Brief Hospital Course: Hospital Course: He has remained in the SICU and was co-managed by ENT for the past week. ENT has performed upper airway endoscopy and found no obvious upper airway source of bleeding and deemed that his supraglottic edema has resolved on [**9-6**] neck CT compared to OSH CT. All oropharyngeal packing removed on [**9-5**]. Sputum cultures noted to have M. cattarhalis. He was initially treated with Vancomycin/Unasyn but developed a rash on his abdomen. He is currently being treated with Cipro/Flagyl (Vancomycin d/c-ed) and has received 7 days of antibiotic treatment to date. No signs of deep space neck infection on CT scans. He has been weaned to trach collar and tolerated it for 12 hours prior to being put on PS 5/5 last night for tachycardia and hypertension in the setting of agitation/delerium. He has been guiac positive for several days. His Hct has been stable between 33 and 37 without requiring any blood transfusions. Pacer interrogated by EP on [**9-6**], functioning well. He was started on a heparin gtt yesterday by the SICU team for atrial fibrillation. Dobhoff was placed yesterday, was not migrated post-pyloric but TFs were started anyway. There is a note of history of PE on ENT/surgery admission notes, but this is not confirmed in his PCP [**Name Initial (PRE) 14453**] (PCP has been called for further confirmation). . The morning of transfer, the patient was noted to have 700 ccs of coffee ground emesis. When he vomited this morning, the Dobhoff came out was replaced with TFs. Overnight he was also noted to be slightly hypertensive and tachycardic and was transferred back from trach collar to pressure support. His stools were guiac positive. NG was placed, and lavage performed demonstrated 240 ccs of bilious fluid with specks of brown, no pink tinge or blood noted. GI was consulted and plan to perform an upper endoscopy today. He was slightly hypotensive to SBPs of 90s, but was urinating and mentating well. Responded well to 500 cc NS bolus x1. He was transferred to the MICU for management of possible upper GI bleed. MICU stay: 68 yo M with AF on coumadin p/w respiratory distress, found to have supraglottic edema currently s/p tracheostomy. Transferred to MICU service with question of upper GI bleed. . # GI Bleed: Patient transferred to MICU service for evaluation of possible upper GI bleed given history of hemetemesis on admission, anticoagulation with heparin gtt, and coffee ground emesis. NG lavage without frank blood or pink tinge. Possible patient had upper GI bleed in setting of recent Dobhoff placement (not passed post-pyloric, but was receiving TFs) and recent heparin gtt being restarted vs old blood passing from recent upper airway bleeding. Also with hx of EtOH abuse in the past. Colonoscopy in [**2146**] with history of polyps/adenomas per PCP [**Name Initial (PRE) 14453**]. Endoscopy performed by GI confirms gastritis but with no active bleeding or varices noted. Throughout MICU stay, HCT has been stable without the need for transfusions. Pt has PICC for access. H. pylori was negative. On [**9-11**] pt did have a leak from his trach and had a bronchoscopy done. His trach was pushed in about 1 cm and the leak resolve. # Pseudomonas bacteremia: Patient with rising temperature on transfer to 100. Also with increased secretions around trach. Treated for 7 days with Cipro/Flagyl. Cultures grew Pseudomonas from sputum, catheter tip, and blood, sensitive to cefepime. Rash to unasyn, on cefepime . Cefepime day [**6-3**]. # Hematuria on [**9-14**]: Likely traumatic. Resolving. # Supraglottic edema/ Respiratory distress: Could have occurred in setting of upper airway infection (possibly M. cattarhalis PNA, common in patients with COPD). Other etiologies include a viral illness given evidence of abdominal and cervical LAD on imaging. No evidence of abscesses noted. He has received 7 days of antibiotics. Supraglottic edema appears resolved on [**9-6**] .CT scan and all oropharyngeal packing has been removed. Pt is on sildenafil for pulmonary htn. On [**9-14**] his trach was downsized. He tolerated this well. # MCAT in sputum: Received 7 days of abx with Vanc/Cipro/Flagyl. # Delirium: Patient noted to be agitated at night while on trach collar alone requiring placement back on PS overnight initially. [**Month (only) 116**] be in setting of prolonged hospitalization vs underlying infection. Patient appears alert and oriented today, communicating with team. Restraints are off. Pt did pull out his dobhoff 2-3 times, but not in the last few days. 2 mg of Haldol and ativan prn was used for his agitation. This regimen has worked well. # Atrial fibrillation/wide complex: CHADS2 score is 1 (at minimum). coumadin held for now. Evaluate need for anti-coagulation with Coumadin given CHADS2 score. Increased metoprolol to 50 mg tid. # COPD: Unknown severity but with emphysema on CT scan. MCAT growing in sputum which is common organism found in PNA patients also with underlying COPD. Received 7 days of Vancomycin/ Ciprofloxacin/ Flagyl. continue home inhalers. # PVD: history of on ASA/plavix at home. h/o aortobifemoral bypass. Holding all anticoagulation now in setting of possible bleed. Restarted ASA 81 mg # Abdominal/Cervical LAD: sub-pathologic LAD noted in cervical area and also around celiac trunk. Likely infectious given patient's recent supraglottic edema. Other etiology includes neoplasm. f/u CT scanning is needed in [**4-26**] weeks. # Wedge fractures - Noted in lumbar region on CT scan. Likely in setting of previous prednisone use from COPD. has hx of colon adenomas, but no known history of lung, thyroid, renal, or prostate cancer which can metastazize to bone -> pathologic fracture. Neurologic exam intact in lower extremities. calcium 500 mg PO TID, vitamin D 1000 U daily. vitamin D levels need to bechecked as outpatient. # HTN: metoprolol to 50 mg tid #Right arm [**Date Range **]: U/S with no evidence of DVT Medications on Admission: Imdur 30 mg PO daily Plavix 75 mg PO daily Simvastatin 80 mg PO daily Advair 250/50 1 puff [**Hospital1 **] Viagra 50 mg PO daily (except Thursday) Digoxin 0.125 mcg PO daily Coumadin 7.5 mg PO daily Lopressor 50 mg PO BID ASA 325 mg PO daily Albuterol 90 mcg INH 2 buffs [**Hospital1 **] Florinef 1 mg PO daily Famotidine 20 mg PO daily KCL 20 mEq PO BID Folic Acid 1 mg PO daily Vitamin B12- 100 mc PO daily Discharge Medications: 1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing, sob. 10. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 14. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours). 15. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q6H (every 6 hours) as needed for agitation. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Supraglottic Edema Hypoxic Respiratory Distress Upper Gastrointenstinal Bleed Pseudomonas Bacteremia 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 with [**Location (un) **] in your throat that was compromising your breathing. You had an emergent breathing tube placed in your neck known as a tracheostomy, placed by Ear, Nose, and Throat Doctors. [**First Name (Titles) **] [**Last Name (Titles) **] improved and you have been weaned from the ventilator. You also had a possible GI bleed and had an endoscopy by our GI doctors which did not show any active bleeding or need for intervention. Please start the following medications: Please stop the following medications: Followup Instructions: Please follow up with Dr. [**First Name4 (NamePattern1) 10827**] [**Last Name (NamePattern1) **] on Thursday [**2146-8-29**] at 10:30 am. Please bring your insurance card and a photo ID. Phone Number -- ([**Telephone/Fax (1) 7767**] Office Location: [**Location (un) **], [**Location (un) 55**], [**Numeric Identifier **] Division: Completed by:[**2146-9-20**]

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icd9cm

[ [ [] ] ]

[ "99.15", "31.42", "31.1", "96.6", "21.01", "96.72", "45.13", "33.21" ]

icd9pcs

[ [ [] ] ]

16192, 16292

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175,139

9351

Discharge summary

report

Admission Date: [**2111-4-8**] Discharge Date: [**2111-4-21**] Service: NEUROLOGY Allergies: Tetanus Toxoid / Azithromycin Attending:[**First Name3 (LF) 5018**] Chief Complaint: flank and back pain Major Surgical or Invasive Procedure: CT HEAD W/O CONTRAST MR HEAD W/O CONTRAST MRA BRAIN & NECK W/O CONTRAST Cardiology ECHO RENAL U.S. CT CHEST W/O CONTRAST CT ABDOMEN W/O CONTRAST CT CHEST W/O CONTRAST CTA ABD W&W/O C & RECONS CTA PELVIS W&W/O C & RECONS History of Present Illness: The patient is an 89 year old woman with CAD s/p IMI in [**2103**], PVD, HTN who initially presented to [**Hospital **] hospital with left sided chest/flank pain. A CT scan without contrast was performed which showed a possible intramural thrombus with a 5 cm aneurism extending to the left renal vein, with 2 areas of ulceration. She continued to have back pain so she was transferred to the vascular surgery service at [**Hospital1 18**]. CTA of the abdomen/pelvis here with contrast confirmed the findings. CT scan of the chest without contrast showed possible extension to the thoracic aorta. . During this admission she developed a different pain in the chest, which lasted minutes. Her cardiac enzymes were checked which showed CK peak of 468 on [**4-15**] with MB of 41, index 8.8, and troponin climbing to 5.15. Her renal function also deteriorated during this time, with creatinine from 1.3 to 3.4 today. She was transferred to cardiology for possible cardiac catheterization. . ROS: Currently, she feels frustrated that she's in the hospital. Denies chest pain, flank pain, urinary symptoms. At home she is able to perform activities of daily life without difficulty. She did have previous chest pain, DOE, occasional SOB, and LE edema. All other ROS are negative. Past Medical History: PVD, gout, [**Last Name (un) **] esophagus, GERD, atrial fibrillation, vetigo, skin squamous cell CA s/p excision, Dyslipidemia, Hypertension Social History: Social history is significant for previous tobacco use (25 pack years). There is no history of alcohol abuse. . Family History: Her son had CABG age 50 Physical Exam: O: T: 97.5 BP: 1160/80 HR:89 R 14 O2Sats 100% RA Gen: opens eyes to voice. Moans, agitated and attempting to climb out of bed. HEENT: Has left gaze preference and eyes cross just past midline on right with Doll's. Right lower facial droop. Mouth dry. Neck: Supple. No bruits appreciated Lungs: CTA bilaterally. Cardiac: Irreg irreg. +M S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Moans to voice. Agitated, moaning. Does not regard examiner in the right hemispace. Not following midline or appendicular commands. Cranial Nerves: I: Not tested II: 4mm on left and 4.5 mm on right, reactive. Does not blink to threat in right visual fields. III, IV, VI: Moves eyes just past midline when called from right. V, VII: right facial palsy. VIII: Hearing intact to voice. IX, X: severe dyasrthia [**Doctor First Name 81**]: def XII: Tongue midline without fasciculations. Pertinent Results: [**2111-4-8**] 02:30AM BLOOD WBC-9.7 RBC-3.94* Hgb-12.4 Hct-36.7 MCV-93 MCH-31.4# MCHC-33.7 RDW-14.8 Plt Ct-164 [**2111-4-8**] 02:30AM BLOOD Neuts-84.1* Lymphs-12.3* Monos-2.6 Eos-0.8 Baso-0.3 [**2111-4-8**] 02:30AM BLOOD PT-11.7 PTT-23.5 INR(PT)-1.0 [**2111-4-8**] 02:30AM BLOOD Glucose-167* UreaN-29* Creat-1.4* Na-140 K-4.4 Cl-100 HCO3-28 AnGap-16 [**2111-4-8**] 02:30AM BLOOD CK(CPK)-67 [**2111-4-14**] 05:05PM BLOOD ALT-29 AST-65* AlkPhos-99 Amylase-79 TotBili-0.3 [**2111-4-14**] 05:05PM BLOOD Lipase-44 [**2111-4-8**] 08:11AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.4* [**2111-4-14**] 05:05PM BLOOD Albumin-3.7 [**2111-4-15**] 04:30AM BLOOD Cholest-121 [**2111-4-15**] 04:30AM BLOOD Triglyc-80 HDL-56 CHOL/HD-2.2 LDLcalc-49 [**2111-4-10**] 08:57PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.018 [**2111-4-10**] 08:57PM URINE Blood-LG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-8.0 Leuks-MOD [**2111-4-10**] 08:57PM URINE RBC-0-2 WBC-[**1-19**] Bacteri-MANY Yeast-NONE Epi-0-2 Brief Hospital Course: Patient is a 89 yo RHF with ho PVD, HTN, hyperlipidemia, afib, DMII who was admitted aneurysmal dilatation with intramural thrombus formation complicated by NSTEMI and now clinical left MCA syndrome s/p IV TPA. Patient's event recorded at 11:11 AM [**2111-4-19**]. Patient exam prior TPA is significant for left eye gaze deviation, right hemianopsia, severe dysarthia, not following commands and left arm/face > leg motor weakness. Patient received IV TPA at 1:58 pm. Likely etiology of stroke is cardioembolic with known Afib and recent MI with known hypokinesis/akiniesis in the inferior lateral ventricle (no thrombus visualized on TTE) or thrombus visualized in intraabdominal aortic aneurysm. . #. Neuro: There was minimal improvement in exam the morning following TPA administration (L gaze deviation, weak withdrawal R arm, no speech, does not follow any commands), repeat Head CT at 24 hours showed some R cerebellar hemorrhage and hemorrhage into infarct. Results were discussed with family and she was subsequently made her CMO. She was given Ativan PRN anxiety, Morphine PRN pain and Scopolamine and Levsin for secretions. Palliative care was following. Patient passed away from cardiorespiratory failure on [**2111-4-21**]. . #. NSTEMI with elevated troponin to >5, CK peak at 468 continuing to trend down. likely unstable plaque. Continue to hold on cath until renal failure resolves. currently chest pain free. Continued telemetry. Continued ASA, plavix, BB (target HR 60-70, sbp <130) heparin gtt. Held ACE given renal failure. . #. Pump EF 40% - Received hydration to improve creatinine. Increased BB, held ACEi. . #. Rhythm - NSR, no arrhythmias. monitor by tele . # Acute renal failure - likely secondary to contrast or prerenal etiology. Renal ultrasound showed patent right artery; left kidney old and small in size. Cr starting to trend down following hydration supporting initial CIN likely exacerbated by pre-renal azotemia. Continued to dose adjust meds. Needed to place foley catheter with regard to urinary retention and renal failure. . #. AAA with intramural thrombus - stable per vascular surgery. No plans for OR at this time. Heparin OK. Appreciated vascular recs. . # Bladder spasm - likely related to UTI given spasm, dysuria, and +UA. had 3 days of cipro with no significant improvement in symptoms. Given baseline urinary dysmotility and retention, would prefer to treat as "complicated" UTI and use 7 days of therapy. the current symptoms appear acute worsening of her chronic urinary problems. [**Name (NI) **] growth on multiple UCxs. Treated with empiric cipro x 7 days. Needed foley as above. . #. FEN - PO, low salt diet . #. Access: PIV . #. PPx: heparin GTT, PPI, bowel regimen Medications on Admission: 1. Allopurinol 300 mg daily 2. Aspirin 325 mg daily 3. Centrum 1 tab daily 4. Crestor 10 mg daily 5. Hydrochlorothiazide 25 mg daily 6. Lisinopril 20 mg daily 7. Metoprolol 12.5 mg [**Hospital1 **] 8. Prilosec 20 mg daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Left middle cerebral artery infarct Thoracoabdominal aortic aneurysm NSTEMI Acute renal failure Peripheral vascular disease Secondary: GERD gout Discharge Condition: Deceased [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2111-4-27**]

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icd9cm

[ [ [] ] ]

[ "99.10" ]

icd9pcs

[ [ [] ] ]

7470, 7479

4433, 7168

257, 478

7669, 7823

3389, 4410

2093, 2118

7441, 7447

7500, 7648

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2133, 2704

198, 219

506, 1783

2927, 3370

2719, 2896

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1964, 2077

12,508

137,241

7146

Discharge summary

report

Admission Date: [**2199-5-19**] Discharge Date: [**2199-5-29**] Date of Birth: [**2150-10-21**] Sex: M Service: MEDICINE Allergies: Lisinopril / Hydralazine Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Hypotension, altered mental status Major Surgical or Invasive Procedure: Central line placement Hemodialysis catheter placement EGD x 2 History of Present Illness: Mr. [**Known lastname 931**] is a 48 year old gentleman with history of DM-I s/p pancreatic/kidney transplant s/p failed renal allograft, CAD s/p MI, systolic CHF, PVD s/p femoral angioplasty and distal extremity debridement who is now transferred from [**Hospital1 **] Care for concern for hypotension and delerium. The patient has ESRD presumably [**3-16**] Diabetic Nephropathy and is currenlty maintained on PD dialysis given previous complications with MRSA Bacteremia from line sepsis. Per report, the patient has at baseline low blood pressure with normal SBP 90-100. He has however had more recently been hospitalized at [**Hospital 26580**] Hospital in [**Month (only) 958**] for reported infection of his PD fluid and seizure like activity. The patient was discharged to [**Hospital1 **] where per report his SBP has been in the 50s to 70s for 3 weeks. Multiple evaluations for infection have been negative and he has been empirically treated with Ceftaz and Zyvox. He was empirically treated for adrenal insufficiency for some time and has now been with altered sensorium and delerium for 6 days with additional question of seizure like activity. The patient was seen by Neurology on [**2199-5-17**] given report of seizures. Recommendation was made to check EEG and CT and start Keppra 250mg twice daily. CT revealed vascular calcification but no acute process. Results of EEG are not available, patient is not on Keppra on transfer. On evaluation in the ED the patient dropped his BP to 70s but was fluid responsive to 1L NS with return to SBP 110-120. The patient had blood cultures obtained and was given a dose of Vancomycin (had received Zosyn at OSH as well as Dexamethasone). An attempt at a right central line was unsuccessful. The patient is now transferred to the ICU for ongoing management. Past Medical History: #. Type 1 DM: pt has been off insulin since pancreas transplant - s/p pancreas/kidney transplant in [**2183**] --> - transplanted kidney in RLQ, pancreas in his LLQ - transplanted renal allograft failed #. ESRD, started on dialysis in [**6-19**] - previously on HD complicated by multiple line infections - currently receiving peritoneal dialysis #. CAD - s/p STEMI in [**12-19**] #. Afib - on Amio #. CHF - EF~25% - Mild to moderate aortic stenosis - s/p ICD in [**3-21**], removed for infected leads [**3-16**] MRSA infection #. PVD - s/p angioplasty of right popliteal artery ([**1-/2199**]) - s/p debridement of an ulcer of the right metatarsal head, wet-to-dry dressings #. Squamous Cell Cancer Scalp - s/p excision [**2199-4-10**] #. Hemorragic Stroke in [**2194**] - on Keppra for seizure disorder #. OSA #. s/p removal of penile implant Social History: Mr. [**Known lastname 931**] is married with two step-children. He previously worked for [**Company 11293**] but is now on disability. Health Care Proxy: His wife [**Name (NI) **]. [**Name2 (NI) 1139**]: 2PPD x many years ETOH: Unknown Illicits: Unknown Family History: Brother - deceased from MI at age 52, diabetes Father - deceased from MI at age 53 Physical Exam: Vitals: 97.0 55/37 68 12 100% 2L NC . General: Patient is lying in bed, follows simple commands but clearly confused. Answers inappropriately. HEENT: 7 x 6 cm surgical wound over crown with scalp excised, skull visible beneath. Edges appear to be with some eschar but not obviously infected, no fluctuance or purulent drainage Neck: JVP flat Chest: Few course breath sounds, otherwise relatively CTA anterior and posterior Cor: RRR, normal S1/S2. II/VI systolic murmur at LLSB Abdomen: + PD catheter. Obese, soft, non-tender, + fluid wave [**3-16**] PD fluid Extremity: Right foot with 7 x 3 cm ulcer, surgically debrided. Wound edges appear clean without erythema or purulent drainage. Rectal: Guaiac Positive in ED Pertinent Results: [**2199-5-19**]: WBC 32.1 (94N, L2, M3), Hct 46.8 (MCV 89), Plt 186 INR 1.4, PTT 28.7 . Na 136, K 4.5, Cl 99, CO2 24, urea 28, creat 9.5, glucose 117 Ca 8, phos 4.6, Mag 1.7, albumin 2.1 ALT 50, AST 85, LD 611, AP 78, amylase 78, lipase 26, bili 0.2 CK 937, MB 14, index 1.5, troponinT 0.21 (flat) lactate 3 cortisol 38.2 . paracentesis: 11 WBCs, 3 RBCs . [**2199-5-20**]: TSH: > 100 free T4: 0.17 T3 26 FK506: 5.7 . CXR [**2199-5-19**]: Since the prior study, there appears to have been removal of a left-sided pacemaker/AICD. The cardiac, mediastinal, and hilar contours appear unchanged given differences in technique. The lungs appear clear apart from minimal linear opacity in the left lower lobe peripherally, which was likely present on the prior study and may reflect scar and/or atelectasis. The pulmonary vasculature is not engorged. No definite pleural effusions are seen . [**2198-9-25**]: TEE LEFT ATRIUM: No thrombus/mass in the body of the LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. A mass/thrombus associated with a catheter/pacing wire in the RA or RV. No ASD by 2D or color Doppler. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Depressed LVEF RIGHT VENTRICLE: Normal RV systolic function. AORTA: No atheroma in ascending aorta. Simple atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. No masses or vegetations on aortic valve. No aortic valve abscess. Significant AS is present (not quantified) No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or vegetation on mitral valve. No mitral valve abscess. Mild mitral annular calcification. Calcified tips of papillary muscles. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on tricuspid valve. No abscess of tricuspid valve. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No vegetation/mass on pulmonic valve. Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. . [**2-/2198**]: Echocardiogram EF 25% LEFT ATRIUM: Moderate LA enlargement RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Dilated IVC (>2.5cm) with no change with respiration (estimated RAP >20 mmHg). LEFT VENTRICLE: Moderately dilated LV cavity. Severely depressed LVEF. Transmitral Doppler and TVI c/w Grade II (moderate) LV diastolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated ascending aorta AORTIC VALVE: Moderately thickened aortic valve leaflets. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Significant PR. The end-diastolic PR velocity is increased c/w PA diastolic hypertension. PERICARDIUM: Small pericardial effusion. No echocardiographic signs of tamponade . [**2198-7-25**] Cardiac Cath 1. The LMCA was free of flow limiting disease. The LAD was a large wrap around vessel and had an 80% stenosis in the mid segment after the D1 takeoff. The D1 was subtotally occluded. The Ramus was a relatively small vessel and was also subtotally occluded. The LCx and OM branches were moderate size vessels. The major OM had a 60% stenosis. The RCA was a relatively large vessel with an extensive R-PL system. The RCA was free of flow limiting disease. The R-PDA and R-PL had 60% stenoses each in their mid segments. 2. Left ventriculography demonstrated moderate to severe systolic dysfunction. There was anterolateral, apical, and inferoapical akinesis. The calculated EF was 32%. There was no mitral regurgitation appreciated. 3. Resting hemodynamics from right and left heart catheterization demonstrated normal right heart filling pressures and mild to moderately elevated left heart filling pressures. There was mild pulmonary and systemic arterial hypertension. There was no mitral stenosis appreciated. The calculated cardiac output by the Fick method was 6.4 L/min with an index of 3.0. 4. The mean gradient across the aortic valve was 16mmHg compared to the femoral artery. The estimated aortic valve area was 1.7 cm2. . CT Head (OSH): No acute intracranial process - extensive intracranial calcifications. Frontal lobe low attentuation likely representing old ischemic change and a cortical infarct in the left frontal lobe. - because of slightly atypical features of the left frontal lesion, MRI recommended for follow up non-emergently . ECG: 66, NSR, LAD. Qs V2-V5, Poor RW progression.TWI aVL, unchanged from previous Brief Hospital Course: 48 year old male with history of DM-I, ESRD on PD, CAD, CHF, PVD c/b foot ulcer and recent squamous cell resection who now presents with hypotension and altered mental status. . Mr. [**Known lastname 931**] continued to be significantly hypotensive with SBP in 70's following admission to the MICU. He was started on broad spectrum antibiotics with concern for sepsis (significant leukocytosis and hypothermia). He was bolused with IVFs and started on pressors. Thyroid studies revealed profound hypothyroidism; clinical picture was consistent with myxedema coma. Endocrine was consulted and he was started on IV T3 and T4 replacement. Steroids were also started. ID was consulted regarding possible occult infection/sepsis. Urine, stool, blood, CXR, peritoneal fluid (initially), LP and abdominal CT did not show source of infection. Head and extremity wounds were evaluated by the surgical services. However, subsequent evaluation of PD fluid grew [**Female First Name (un) 564**] albicans and VRE. The catheter was removed. Blood cultures remained negative. He started hemodialysis through a new line. Antibiotics were narrowed to tigecycline and amphoteracin B (later changed to fluconazole). . He acutely decompensated on [**2199-5-23**]. He had multiple melanotic bowel movements associated with a 12 point Hct drop and worsening hypotension. NGT placement resulted in suctioning of 800 cc of dark fluid c/w UGIB. These events also coincided with unexplained increase in PT, PTT, and thrombocytopenia raising concern for DIC. Hematology was consulted. He was aggressively resuscitated with PRBCs, IVFs, FFP, platelets, and DDAVP. Code status was discussed with his family and his DNI status was transiently reversed for elective intubation in preparation for endoscopy. EGD showed diffuse erosions, melena, and clot. Repeat endoscopy the following day showed no active bleeding. Hemodynamics improved and he was easily extubated on [**5-25**]. With continued treatment of his underlying infection and endocrinopathy, hypotension improved and he was able to come off pressors with adequate BP and improved mental status. . Further in the ICU was relatively uneventful until [**2199-5-29**]. He was noted to have worsening hypotension associated with change in mental status. He reported diffuse abdominal pain without rebound or guarding. KUB and labs were obtained. He was bolused with IVFs with initial response. BP again decreased, and norepinephrine drip was started. He acutely went into ventricular tachycardia followed by ventricular fibrillation arrest. Given his DNR/DNI status, no attempts at CPR or cardioversion were attempted. His family was notified and full autopsy will be performed. Medications on Admission: #. Aspirin 81 mg daily #. Toprol-XL 25 mg daily #. Lipitor 40 mg daily #. Amiodarone 200 mg twice a day #. Tacrolimus 1.5mg [**Hospital1 **] #. Prednisone 10 mg daily #. Bactrim SS daily #. Calcitriol .25mg [**Hospital1 **] #. Nephrocaps 1 cap daily #. Renagel #. Zantac 150mg daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Hypotension Cardiopulmonary arrest . Hypothyroidism, myxedema coma Peritonitis (bacterial, fungal) Upper GI bleed Leukocytosis End stage renal disease Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

[ [ [] ] ]

[ "45.13", "38.91", "54.98", "96.04", "00.14", "38.95", "39.95", "03.31", "97.82" ]

icd9pcs

[ [ [] ] ]

12096, 12105

8999, 11734

328, 393

12300, 12310

4236, 8976

12362, 12505

3396, 3481

12068, 12073

12126, 12279

11760, 12045

12334, 12339

3497, 4217

254, 290

421, 2237

2259, 3108

3124, 3380

51,038

132,034

32630

Discharge summary

report

Admission Date: [**2169-10-1**] Discharge Date: [**2169-10-14**] Date of Birth: [**2090-7-26**] Sex: F Service: MEDICINE Allergies: Penicillins / Biaxin / Flagyl / Erythromycin Base Attending:[**First Name3 (LF) 2195**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Intubated, central line History of Present Illness: Eu Critical [**Female First Name (un) 76057**] is a 79 yo F nursing home resident identified as [**Known firstname 335**] [**Known lastname 76058**] ([**Medical Record Number 76059**]) with atrial fibrillation on coumadin and frequent UTIs who was transferred from an OSH for altered mental status. Per report the patient recently was diagnosed with a UTI one week ago and started on Ciprofloxacin on [**9-25**] for 7 day course at her rehab. her son noticed that about 3 days prior to admission, she was noted to be more weak. The afternoon of admission, her son also noticed decreased PO intake, difficulty putting words together, and increasing drowsiness. In the evening, around 7:30 PM, the patient was found to be increasingly lethargic and unable to protect her airway. EMS was called who emergently intubated her in the field. She was transferred to [**Hospital6 20592**]. Her VS were 99.0 122 RR of 8 O2 sat of 78%. Her labs there were significant for a WBC of 31.6, K of 6.9 and Cre of 5.0, INR of 2.6. ABG 7.29/26/463/17. She had EKG changes (peaked T-waves) and received insulin, dextrose, and bicarbonate and IV CFTX 1 gram x1. She was intubated, sedated with propofol, and had a femoral line placed in her R groin. She was transferred to [**Hospital1 18**] for further management. . In the ED, initial VS were 96/70 108 18 100% 98.6% on ventilation ([**Last Name (un) 5487**] vent settings). Patient was intubated and sedated on arrival. She was switched from propofol to fentanyl 100 mcg x1 and midazolam 2 x1. She received 500 mg Flagyl IV x1, Vancomycin 1 gram IV x1, and was started on Levophed 0.09 when her pressures dropped to 60 systolic inthe ED (67/50).. She received 3 L of NS in the ED. Head CT and CXR were obtained in the ED. K was 3.6, Cre down to 3.6. VS on transfer were 99 92/59 112 19 94% on vent settings of PS 10/5 FiO2 of 100%. . On the floor, the patient is intubated, sedated, and unable to answer questions. . Review of systems: Unable to obtain Past Medical History: Atrial Fibrillation on coumadin HTN CKD Hypothyroidism Osteoporosis Rheumatoid Arthritis Cervical Anterior Longitudinal ligament injury Chronic back pain due to compression fractures T12 through L3 Scoliosis Depression h/o diverticulitis h/o recurrent UTIs. . Past Surgical History - possible enterovaginal fistula (unrepaired) - h/o colonic perforation in [**2166**] requiring colostomy and later revision with illeostomy. Social History: Social History: resides in a nursing home (Lifecare of [**Location (un) **]), was transferred there from an ALF due to difficulty with transfering and loss of ability to do ADLs independently. - Tobacco: no smoker - Alcohol: no EtoH - Illicits: none Family History: mother died of breast cancer Physical Exam: Vitals: T: 95 BP: 110/60 P: 90 R: 15 18 O2: 100% on PS 10/5 General: intubated, off sedation, responding to painful stimuli HEENT: bruise below R eye (old per NH report to EMS); Sclera anicteric, MM dry, oropharynx clear Neck: supple, unable to assess JVP, 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, illeostomy draining stool. Ext: poikolothermia, 1+ pulses, cyanosis of fingers and lower extremities. Pertinent Results: [**2169-10-5**] Abd and pelvis: CT OF THE ABDOMEN WITH ORAL CONTRAST ONLY: Again noted within the limited lung bases included on the current exam is bilateral lower lobe opacities, most suggestive of underlying atelectasis. The small effusions have resolved. There is unchanged dense mass, mitral annular calcification, aortic valve calcification and atherosclerotic calcification. Small amount of perihepatic ascites persists. The unenhanced images of the liver are unremarkable with no intrahepatic ductal dilatation identified and surgical clips from prior cholecystectomy noted. There is diffusely increased induration of the peripancreatic fat with the pancreatic parenchyma appearing largely atrophic, but with some scattered calcifications within, which may be vascular or parenchymal in etiology. Remaining unenhanced solid organs show no change from examination four days prior with unchanged prominence to loops of small bowel, likely baseline for this patient. CT OF THE PELVIS WITH ORAL CONTRAST ONLY: A midline ileostomy with a small parastomal hernia is again noted without findings of obstruction. The degree of fluid within the parastomal sac has decreased as has the amount of intrapelvic free fluid. Only a small portion of remaining sigmoid colon appears present, which is decompressed. Uterus does appear to remain in situ and appears unremarkable. Bladder is collapsed with Foley within. No pathologically enlarged pelvic sidewall or inguinal lymph nodes are identified. Air is present within the right femoral vein, which contains a central venous catheter. BONE WINDOWS: No short interval changes to multilevel wedge compression fractures as detailed on the prior examination as well as of old left inferior and superior rami fractures and osteoarthritic changes of the hips. Aggressive-appearing osseous lesions are noted. There is spacing in regions of subcutaneous edema along the left flank and left inferior abdominal wall are again noted, likely related to the patient's known skin inflammation/panniculitis. IMPRESSION: 1. Increased induration surrounding the pancreas suggestive of acute pancreatitis, which may account for the patient's increasing abdominal pain. Please correlate with amylase and lipase. Unenhanced CT images are not specific or sensitive for biliary pathology and dedicated MRCP can be obtained based on clinical suspicion. 2. Interval decrease in amount of intra-abdominal/pelvic ascites. Unchanged appearance to the small bowel and parastomal hernia. The majority of the large bowel has been resected with no findings of enteritis or colitis. 3. Interval resolution of pleural effusions with persistent probable bilateral lower lobe atelectasis. Superinfection cannot be excluded by imaging, but is felt unlikely given its appearance. 4. Central venous catheter within the right femoral vein with air within the vein itself likely related to injection or catheter manipulation. Caratoid study: Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right there is minimal heterogeneous plaque in the ICA. . On the left there is no plaque in the ICA. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 26/9, 30/14, 31/15, cm/sec. CCA peak systolic velocity is 35 cm/sec. ECA peak systolic velocity is 30 cm/sec. The ICA/CCA ratio is <1. These findings are consistent with <40% stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 39/17, 36/12, 33/15, cm/sec. CCA peak systolic velocity is 35 cm/sec. ECA peak systolic velocity is 21 cm/sec. The ICA/CCA ratio is 1.1. These findings are consistent with no stenosis. There is antegrade right vertebral artery flow. There is antegrade left vertebral artery flow. Impression: Right ICA stenosis <40%. Left ICA with no stenosis . [**2169-10-2**] echo: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Moderate mitral regurgitation. [**2169-10-1**] CT abd/pelvis CT OF THE ABDOMEN WITH ORAL CONTRAST ONLY: Included lung bases display small bilateral pleural effusions with probable associated compressive atelectasis involving portions of the right and left lower lobe. Dense atherosclerotic calcifications are noted involving the left coronary territory, including the LAD and circumflex with atherosclerotic calcifications also present within the aortic valve and mitral annular calcification. No pericardial effusion is present. The patient is status post cholecystectomy. Evaluation of solid organs is limited with the lack of intravenous contrast, although unenhanced images of the liver, spleen, pancreas which is largely fatty replaced and contains a few punctate calcifications, adrenal glands, and right kidneys appear unremarkable. Left kidney displays mild atrophy in lower pole. There are no findings of renal obstruction or calculi. Nasogastric tube terminates within the stomach with the stomach appearing unremarkable. The small bowel is noted to be diffusely mildly dilated but without discrete transition point and a lower quadrant ileostomy is present with a small parastomal hernia and a mild-to-moderate amount of surrounding fluid within the hernia seen. No free air or pathologically enlarged lymph nodes are present. A mild amount of simple perihepatic ascites is identified. CT OF THE PELVIS WITH ORAL CONTRAST ONLY: A Foley within a decompressed urinary bladder. The rectal stump and vaginal cuff are likely normal but limited without contrast. A mild amount of free fluid is noted within the pelvic cavity with remaining intrapelvic contents appearing unremarkable. A small amount of fluid as well as induration of the surrounding fat is present within the lower ventral left abdominal wall. There is fairly marked thinning of the rectus sheath noted throughout with a probable region of focal dehiscence in the lower left abdomen without any small bowel loops within. No pathologically enlarged lymph nodes are seen. Atherosclerotic calcification is noted within the aorta and its branch vessels. BONE WINDOWS: There is a fairly symmetrical diffuse muscular atrophy and bilateral healed inferior rami fractures, greater on the left. Healed left superior rami fracture is also moderate underlying S-shaped scoliosis and severe multilevel degenerative changes involving the visualized thoracolumbar spine is again seen including progression of multilevel compressive fractures with the L4 fracture and approximately 50% loss of vertebral body height appearing new from the [**2166-12-11**] lumbar radiographs. None of these display any significant retropulsion of bony fragments into the spinal canal and are largely sclerotic suggesting chronicity. IMPRESSION: 1. Non-dilated, but slightly prominent loops of small bowel throughout, likely represents the patient's normal baseline rather than mild diffuse ileus. No transition point to suggest an obstruction. Parastomal bowel and fluid-containing hernia is present. 2. No findings of intra-abdominal abscess or renal obstruction. Mild amount of intra-abdominal/pelvic ascites. Likely loops of bowel collapsed on vaginal cuff, but can not exclude a mass in this region without IV contrast. 3. Unclear etiology of ventral abdominal wall fluid and surrounding fat stranding within the lower left abdomen extending towards the skin surface. Please correlate with physical examination within this region to evaluate for underlying panniculitis/cellulitis. 4. Small bilateral pleural effusions. Adjacent regions of collapsed lung, suggestive of underlying compressive atelectasis, although superimposed infection cannot be excluded. 5. Diffuse atherosclerotic calcifications including coronary artery calcification and MAC. 6. Multilevel degenerative changes and wedge compression fracture deformity. This appears progressed from the [**2166**] lumbar spine radiograph as detailed above; however, appear chronic in nature. [**10-1**] CT head FINDINGS: There is no hemorrhage, edema, mass effect or evidence for acute vascular territorial infarction. There is prominence of the ventricles and the sulci compatible with age-related parenchymal involution. There is periventricular white matter hypodensity, compatible with small vessel microvascular infarcts. [**Doctor Last Name **]-white matter differentiation is otherwise well preserved and there is no shift of normally midline structures. There is calcification of bilateral carotid siphons and bilateral vertebral arteries. There is dense opacification with chronic changes of the left maxillary sinus. Remaining paranasal sinuses are well-aerated. IMPRESSION: 1. Atrophy and chronic small vessel change but no acute intracranial findings. 2. Near-complete opacification of the left maxillary sinus may reflect chronic changes from sinusitis. [**2169-10-1**] 12:10AM BLOOD WBC-21.4* RBC-3.51* Hgb-11.7* Hct-35.0* MCV-100* MCH-33.5* MCHC-33.5 RDW-17.1* Plt Ct-210 [**2169-10-2**] 02:12AM BLOOD WBC-23.0* RBC-3.25* Hgb-10.7* Hct-32.7* MCV-101* MCH-33.0* MCHC-32.9 RDW-17.2* Plt Ct-183 [**2169-10-2**] 02:12AM BLOOD Neuts-88* Bands-8* Lymphs-0 Monos-2 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1* [**2169-10-2**] 02:12AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-1+ Schisto-OCCASIONAL Burr-1+ [**2169-10-1**] 12:10AM BLOOD Plt Ct-210 [**2169-10-1**] 12:10AM BLOOD PT-37.6* PTT-35.9* INR(PT)-3.9* [**2169-10-3**] 04:12AM BLOOD PT-13.6* PTT-27.3 INR(PT)-1.2* [**2169-10-1**] 05:48AM BLOOD Glucose-116* UreaN-64* Creat-3.8* Na-138 K-4.6 Cl-113* HCO3-14* AnGap-16 [**2169-10-1**] 05:48AM BLOOD ALT-166* AST-285* LD(LDH)-351* AlkPhos-68 TotBili-0.6 [**2169-10-2**] 06:29AM BLOOD CK(CPK)-27* [**2169-10-1**] 12:10AM BLOOD Lipase-75* [**2169-10-2**] 06:29AM BLOOD CK-MB-4.22 cTropnT-0.04* [**2169-10-1**] 05:48AM BLOOD Albumin-2.3* Calcium-8.1* Phos-4.8* Mg-1.5* [**2169-10-1**] 02:45PM BLOOD Hapto-166 [**2169-10-1**] 03:52PM BLOOD D-Dimer-2642* [**2169-10-1**] 05:48AM BLOOD Cortsol-21.2* [**2169-10-1**] 12:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2169-10-1**] 02:37AM BLOOD Type-ART Rates-/16 PEEP-5 pO2-422* pCO2-28* pH-7.24* calTCO2-13* Base XS--13 Intubat-INTUBATED [**2169-10-1**] 12:22AM BLOOD Glucose-138* Lactate-2.0 Na-137 K-3.6 Cl-116* calHCO3-14* [**2169-10-2**] 02:58AM BLOOD Lactate-2.5* [**2169-10-1**] 02:10PM BLOOD freeCa-1.12 [**2169-10-1**] 12:10AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.013 [**2169-10-1**] 12:10AM URINE Blood-LG Nitrite-NEG Protein-150 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD [**2169-10-1**] 12:10AM URINE RBC->50 WBC->1000 Bacteri-MANY Yeast-NONE Epi-0-2 RenalEp-[**7-20**] [**2169-10-1**] 10:30AM URINE Hours-RANDOM UreaN-245 Creat-52 Na-61 K-32 Cl-87 [**2169-10-1**] 12:10AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Brief Hospital Course: MICU Course . # Hypotension: Likely due to septic shock from urosepsis given AMS, hypotension, hypothermia, end organ failure (acute renal failure), urinary bacterial source, and blood pressures unresponsive to aggressive IVFs in the ED requiring pressor support with 3 vasopressors. Patient started on IV Vanc/Cefepime/Cipro and PO Vanco for emperic coverage. AM cortisol normal after stress dose steroids were also empirically started given chronic prednisone use. EKG and ECHO done and no signs of cardiogenic shock, however patient was intermittenetly in atrial fib with RVR which contributed to hypotension. Patient's pressor requirement quickly improved and remained normotensive after HD2. PO Vanco was stopped after C. Diff came back negative. Fem line cath tip grew [**Female First Name (un) **], but felt likely contaminant as patient remained afebrile, all blood cultures were negative. Urine grew E.COLI and enteroc. and sputum grew MRSA. Vanco and cefepime were continued throughout stay. Cefepime regimen completed. Vanco discontinued on [**10-10**]. During IJ insertion attempt, carotid was cannulated with post procedure bleeding which was controlled with direct pressure and two units of FFP. . # Respiratory Distress: Patient noted to be lethargic (likely in setting of urosepsis), intubated for airway protection in the field. Patient successfully extubated on [**10-7**]. Pt held her own post extubation with only upper airway obstruction (snoring) noted when asleep. . # Acute on chronic renal failure: Likely with end organ damage in setting of urosepsis. Cre up to 5.0 at OSH with hyperkalemia. Cre trended down over the coursse of the admission though did not normalize. Urine output remained approx 15 cc/hr. Per discussion with family and renal consult, it was decided that HD would not be pursued. . # Atrial fibrillation: Patient developed RVR, was initially given IV metoprolol and IV diltiazem but rate not well controlled and concern for worsening hypotension so patient placed on amiodarone PO and then gtt once extubated and HR stabilized. Coumadin held because og HCT drop and guaiac positive. . # HTN: currently hypotensive from septic shock. Held all home anti-hypertensives for now. . # Anemia: 48.7 -> 35.5 on transfer to [**Hospital1 18**]. Macrocytic anemia. B12 and folate levels WNL at OSH. Patient guaiac positive but HCTs stabilized, so did not require blood transfusion. . # Rheumatoid arthritis: On Enbrel, holding for now given septic shock. Patient likely immunosuppressed in setting of Enbrel and prednisone. Pt was given 10mg prednisone during her stay in the MICU as she is on home steroids. . # Abdominal pain: CT Abd shows possible pancreatitis. Amylase/lipase checked and mildly elevated. These enzymes eventually trended down and pts exam improved during her stay. # Altered mental status: Likely from sepsis, [**Last Name (un) **] and hypoglycemia. On [**10-10**] pt started on standing haldol for possible sub-acute delirium. Pt also to receive dilaudid for pain. # Hypoglycemia; On [**10-9**] pt noted to be hypoglycemic. Pt has not been receiving feeding for the last few days. She is currently on D5 1/2 NS and dextrose amps. Sugar is currently stable. # Social: after meeting with palliative care, family has decided to pursue hospice care. Pt to receive steroids, haldol for sub-acute delirium and dilaudid for pain and before any painful manipulation. ABX discontinued. No PO access will be obtained. . FLOOR COURSE [**2169-10-10**] - [**2169-10-14**] Ms. [**Known lastname 76058**] was transferred to the floor on the evening of [**10-10**] for managament of comfort measures only. She was transferred on dilaudid for pain management, haldol as needed for aggitation, solumedrol for treatment of ongoing rheumatoid arthritis, dextrose for hypoglycemia and gentle IV hydration. All labs and daily vital signs were discontinued aside from daily figersticks for hypoglycemia. She did well overnight and on the morning after her admission she was briefly alert and oriented x 3 and following basic commands. After extensive discussion with her son on the afternoon after tranfer, it was decided to discontinue daily fingersticks and dextrose for hypoglycemia. It was also decided to start her back on a daily diet as demanded and tolerated, Ms. [**Known lastname 76058**] was asking for icecream. Her son understood that she did not pass the speech and swallow evaluation in the ICU and understood the risks of aspiration and choking with initiating a diet. On the third day after transfer, Ms. [**Known lastname 76058**] was more somnolent, but arousable and responsive to some commands. A meeting with her son, daughter in law, palliative care and the medical team was held. Solumedrol, and IV fluids were discontinued. She was given her food requests as tolerated. On the fifth day after transfer, Ms. [**Known lastname 76058**] was alert and oriented to herself and the year. Medications on Admission: Amlodipine 2.5 mg PO daily Nadolol 20 mg PO BID Cymbalta 30 mg PO BID Levothyroxine 112 mcg PO daily Prednisone 2.5 mg PO BID Coumadin 1 mg PO daily Enbrel 50 mg SQ daily Calcium Vitamin C Vitamin B12 Ferrous Sulfate 325 mg PO daily Vitamin D 1000 U PO daily Neurontin 300 mg PO BID Latanoprost eye drops Ciprofloxacin 500 mg PO BID (start date [**Last Name (un) 5487**]) Ceftriaxone 1 gram IV daily x6 days for E. coli UTI (start date [**2169-9-30**]) Discharge Medications: 1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 2. Hydromorphone (PF) 1 mg/mL Syringe Sig: [**2-11**] Injection Q1H (every hour) as needed for pain / shortnes of breath. 3. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital3 11496**] - [**Location (un) **] Discharge Diagnosis: 1. Urosepis 2. Pneumonia, Atrial Fibrillation w/ RVR, Renal Failure Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted for treatment of urosepsis and pneumonia. You were transferred to the intensive care unit where you required a breathing tube and medications to support you heart. Your kidneys were significantly injured due to your illness. You were treated with strong antibiotics for your pneumonia, urinary tract infections and sepsis. The breathing tube was eventually removed and you no longer needed medications to support your heart. It was decided by your family, because you could no longer participate in your own care to make you comfortable. You were transferred from the intensive care unit to the floor. You were restarted on a regular diet and pain medications. You are being transferred back to your skilled nursing facility to further manage your care. Followup Instructions: None.

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Discharge summary

report+report

Admission Date: [**2151-12-19**] Discharge Date: [**2151-12-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5827**] Chief Complaint: Transfer from PACU post-op with unresponsiveness, hypercarbia, and re-intubation Major Surgical or Invasive Procedure: Right hip repair Endotracheal intubation History of Present Illness: 84 y/o female with h/o dementia, HTN, and old compression fractures who was found down in nursing home with new hip fracture. Per nursing home notes, pt ambulates at baseline, but was found down in her room screaming yesterday, unable to move her right leg. Pt did not remember events around the fall. EMS arrived and brought pt to ED. . In [**Name (NI) **], pt was given 5 mg of morphine and became very somnolent with a RR of 6. She then received 0.5 mg of Narcan and became much more arousable and "out of control". Pt was complaining of diffuse back tenderness so a CT scan was obtained of her c,t and l-spine. The CT of the cervical spine was concerning for a ligamentous tear so neurosurgery was consulted who recommended a cervical MRI. Ortho was also consulted for the hip fracture. . Patient went to the OR today for a right gamma nail procedures and had several pins placed. She received a total of 1400 cc of fluid peri-operatively. She was extubated after the procedure and was initially alert. She then was grimacing and appeared to be in pain, so was given morphine 0.5 mg IV. Then she was noted to be unresponsive. ABG was 7.06/115/91. She was started on CPAP, but appeared to have agonal respirations. She was re-intubated in the PACU and transferred to the MICU. Prior to transfer, she was given propofol and became somewhat hypotensive and required ephedrine. Past Medical History: 1. Dementia, likely Alzheimer's type 2. Osteoporosis 3. HTN 4. Hypothyroidism 5. Colon CA s/p colectomy '[**38**] 6. s/p CCY 7. Thoracic compression fracture 8. Thyroid enlargement Social History: The pt is a resident of [**Hospital3 537**] since [**7-1**]. Family History: Non contributory Physical Exam: T: 98.9 BP: 101/39 P: 89 AC 500x16, 0.5, peep 5, 100% GEN: intubated, sedated, elderly female, intermittently agitated and moving all extremities but not following commands HEENT: anicteric sclera, pupils 4->3 mm bilaterally NECK: cervical collar in place RESP: CTA anteriorly, no w/r/c CV: RRR, I/VI SEM at apex ABD: soft, nt/nd, +bs EXT: R hip wound c/d/i, no ecchymosis or tenderness, 2+ dp/pt pulses bilaterally SKIN: warm/dry Pertinent Results: CT of c-spine [**12-18**]: 1. Exaggerated cervical lordosis with widening of C4/C5 and C5/C5 with slight retrolisthesis of C4 on C5 which may reflect injury to the anterior longitudinal ligament, and therefore, further evaluation with MRI is recommended if clinically warranted. 2. Linearly lucency in the anterior-superior endplate of T2, not seen on prior CT C-spine on [**2151-5-27**], which may represent an acute or subacute fracture as noted above. 3. Opacity in the lung apices bilaterally which is only partially visualized. . CT of t-spine [**12-18**]: Compression deformity of the T6, T11, T12, and L1 vertebrae which appears stable when compared to chest radiograph obtained on [**2151-7-13**], and L-spine obtained on [**2151-5-27**]. . CT of l-spine [**12-18**]: 1. Stable appearance of T12 and L1 compression fracture compared to L-spine radiograph obtained on [**2151-5-27**]. 2. Intra- and extra-hepatic biliary dilatation with common bile duct measuring approximately 9 mm. 3. Left parapelvic cyst. 4 mm kidney stone in the left renal pelvis. . CT head [**12-18**]: No intracranial hemorrhage. . CXR [**12-18**]: The heart size is top normal. The aorta is calcified and tortuous. Biapical scarring/pleural thickening is without change. There is left retrocardiac opacity without obscuration of the adjacent hemidiaphragm. No pleural effusions or pneumothoraces are identified. Pulmonary vasculature is not congested. . CXR [**12-19**]: Single portable radiograph of the chest demonstrates an endotracheal tube with its tip at the level of the clavicular heads. Assessment is limited by patient position. Cardiomediastinal contours are similar to that seen on [**2151-12-18**]. There is biapical pleural thickening. No pneumothorax. No effusion. No consolidation is identified. Previously identified loss of vertebral body height at T6 and T11 is incompletely assessed as there is no lateral view for correlation. The linear interstitial opacities involving the bilateral lung apices and left lower lobe are suboptimally assessed given patient rotation. IMPRESSION: Endotracheal tube with its tip at the level of the clavicular heads. Assessment is slightly limited by patient position. No consolidation. . ** Hip [**12-18**]: acute right intertrochanteric fracture and avulsion of the lesser trochanter . [**2151-12-18**] WBC-8.4 RBC-4.04* Hgb-12.2 Hct-37.5 Plt Ct-251 [**2151-12-19**] WBC-14.5*# RBC-3.31* Hgb-10.3* Hct-31.0* Plt Ct-215 [**2151-12-19**] WBC-13.0* RBC-2.86* Hgb-8.9* Hct-26.6* Plt Ct-188 [**2151-12-20**] WBC-9.5 RBC-2.72* Hgb-8.6* Hct-25.0* Plt Ct-137* [**2151-12-20**] Hct-30.6* [**2151-12-20**] Hct-33.0* [**2151-12-21**] WBC-13.4* RBC-3.86*# Hgb-12.2# Hct-35.4* Plt Ct-148* [**2151-12-22**] WBC-16.1* RBC-4.25 Hgb-13.5 Hct-38.7 Plt Ct-169 [**2151-12-23**] WBC-14.0* RBC-4.01* Hgb-12.4 Hct-36.9 Plt Ct-203 . [**2151-12-18**] Glucose-125* UreaN-25* Creat-1.1 Na-144 K-4.5 Cl-102 HCO3-32 [**2151-12-19**] Glucose-151* UreaN-21* Creat-0.8 Na-143 K-4.6 Cl-108 HCO3-30 [**2151-12-19**] Glucose-151* UreaN-20 Creat-0.9 Na-142 K-4.0 Cl-107 HCO3-23 [**2151-12-20**] Glucose-73 UreaN-19 Creat-0.7 Na-141 K-3.2* Cl-110* HCO3-24 [**2151-12-21**] Glucose-89 UreaN-14 Creat-0.8 Na-139 K-4.3 Cl-107 HCO3-22 AnGap-14 [**2151-12-22**] Glucose-86 UreaN-19 Creat-0.7 Na-139 K-3.6 Cl-102 HCO3-21* [**2151-12-23**] Glucose-81 UreaN-18 Creat-0.5 Na-140 K-3.0* Cl-103 HCO3-24 [**2151-12-18**] CK(CPK)-35 [**2151-12-19**] CK(CPK)-45 [**2151-12-20**] LD(LDH)-173 TotBili-0.8 [**2151-12-23**] Calcium-8.0* Phos-1.5* Mg-1.6 [**2151-12-18**] TSH-9.8* [**2151-12-20**] Free T4-1.1 . [**2151-12-19**] MR Cervical spine No evidence of acute injury to the cervical spine. No evidence of ligamentous disruption or vertebral malalignment. No evidence of marrow edema. Mild degenerative changes. Chronic compression of T2 vertebra. . [**2151-12-21**] CXR Single frontal view of the chest demonstrates no significant interval change from the study earlier today. Cardiomegaly and the mediastinal contours are unchanged. There remains obscuration of the left hemidiaphragm with left retrocardiac opacity representing either atelectasis or consolidation. . [**2151-12-21**] Carotid Series Bilateral less than 40% ICA stenosis. Moderate proximal right CCA stenosis. Brief Hospital Course: This 84 year old woman with dementia and known compression fractures found down at nursing home with a right hip fracture. The following issues were addressed during this hospitalization. . 1. Respiratory failure Pt's initial ABG with respiratory acidosis, likely due to sedation causing CO2 retention, which is similar to what happened in ED, and responded to narcan. CXR did not show any acute reason for this change. Other possibility is that she had an intracranial event intraoperatively that affected her mental status, which is especially concerning given her carotid bruit. However, she is moving all of her extremities and waking up when off sedation, so likely was related to narcotics. Less likely possibility is intracranial event; head CT was negative. She improved in the ICU and was extubated on [**12-20**]. She was called out to the floor on [**12-21**]. She continued to have an oxygen requirement, and CXR showed a possible retrocardiac opacity. She also had a leukocytosis. Given this, she was started on levofloxacin and flagyl, and blood cultures/urinalysis were checked which were negative. She will complete a course of ABx for pneumonia. Her oxygen requirement is most likely [**1-28**] to pneumonia and mechanical limitations of breathing. The pt breathes through her mouth and does not take deep, full breaths. Her respiratory status will continue to be monitored upon discharge at [**Hospital3 537**]. Her respiratory status was stable on the medical floor since arrival from the MICU. Her oxygen requirement did not change. At time of discharge to [**Hospital **], her oxygen requirement had not increased and her respiratory status was stable. . 2. Tachycardia She remained in sinus tachycardia in the MICU and floor. Beta blocker was restarted and increased. She was given some IVF and pain was treated with tylenol and lidocaine TP. PE was considered but pt has several other reasons to be tachycardic such as dehydration and pain. Her oxygen requirement did not increase. With hydration and treatment of her pain, her tachycardia completely resolved. . 3. Fall Unwitnessed, found on floor in nursing home. This has happened in the past without clear etiology. EKG without signs of ischemia, CE negative x 2. UA unremarkable. CT head negative. Other possibilities include TIA/CVA (though no deficits obvious on exam), orthostatic or vasovagal induced syncope, arrhythmia, electrolyte abnormalities. Telemetry was significant only for sinus tachycardia which later resolved. . 4. Right hip fracture Pt had a right hip repair by orthopedics on [**12-19**]. PACU course as above. She was started on physical therapy and will be on lovenox for prophylaxis for 1 month. She will follow up with orthopedics in [**2-27**] weeks (Dr. [**First Name (STitle) 4223**]. . 5. ? cervical injury Neurosurg was consulted regarding widening of C4/C5 with slight retrolithesis of C4 on C5 and linear lucency of T2 and rec cervical MRI to eval for ligamentous injury. Cervical MRI was without new injury or tear, and collar was removed. . 6. Hct drop Unclear etiology, wound looks good without evidence of hematoma, no melena/BRBPR. Likely was volume depleted when found in NH that led to Hct 37, then dropped with IVF. She received a total of 2 U PRBC and hematocrit remained stable. Blood loss was likely post-operative. Hemolysis labs were negative. Her stool was guaiac positive but her HCT was stable and she remained hemodynamically stable. She will need an outpatient colonoscopy. Her HCT will be monitored at [**Hospital3 537**]. . At time of discharge to [**Hospital3 537**], pt was hemodynamically stable. Medications on Admission: Home Meds: Aspirin 325 mg qd Atenolol 25 mg qd Levothyroxine 50 mcg qd Buspirone 5 mg [**Hospital1 **] Mirtazapine 15 mg 1 qhs Donepezil 10mg qhs Namenda 5mg qd Calcitonin (Salmon) 200 unit/Actuation Aerosol 1 spray qd Colace 100 mg [**Hospital1 **] Senna 8.6 mg qd Multivitamin 1 qd Os-Cal 500 + D 500-125 mg-unit [**Unit Number **] [**Hospital1 **] . Meds on Transfer: Metoprolol 5 mg IV Q6H HR Aspirin 325 mg PO DAILY Mirtazapine 15 mg PO HS Atenolol 25 mg PO DAILY Morphine Sulfate 1-5 mg IV PRN PAIN Q5MIN in PACU BusPIRone 5 mg PO BID Multivitamins 1 CAP PO DAILY Calcitonin Salmon 200 UNIT IN DAILY Namenda *NF* 5 mg Oral qd Donepezil 10 mg PO HS Pantoprazole 40 mg PO Q24H Docusate Sodium 100 mg PO BID Promethazine HCl 6.25-12.5 mg IV MRX1:PRN nausea/vomiting PACU Dolasetron Mesylate 12.5 mg IV X1 PRN nausea/vomiting PACU Prochlorperazine 2.5-5 mg IV MRX1:PRN nausea/vomiting PACU Enoxaparin Sodium 40 mg SC DAILY Senna 1 TAB PO BID:PRN Esmolol 5 mg IV TITRATE TO HR < 100 Duration: 3 Doses PACU only Haloperidol 0.25-0.5 mg IV MRX1:PRN nausea/vomiting PACU ONLY. Levothyroxine Sodium 50 mcg PO DAILY Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. Memantine 5 mg Tablet Sig: One (1) Tablet PO qd (). 8. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) spray Nasal 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. 11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily) for 1 months. 14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (): 12 hours on, 12 hours off. 16. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day. 17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. 18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Primary: Pneumonia s/p fall s/p right hip repair . Secondary: Dementia Discharge Condition: The patient was discharged hemodynamically stable, afebrile with appropriate follow up. Discharge Instructions: Please keep all follow up appointments. Please see below. . Please take all medications as prescribed. You were started on 2 antibiotics to treat a pneumonia. Please complete this course of antibiotics as instructed. . You will need to have an outpatient colonoscopy. Your blood count was low and you were given some blood. Your blood count remained stable but your stools were positive for blood so the cause will need to be evaluated. . You were also started on a medication called Lovenox to prevent clots. Please continue to take this until you see Dr. [**First Name (STitle) 4223**]. Followup Instructions: Please follow up with your orthopedic surgeon, Dr. [**First Name (STitle) 4223**], in [**2-27**] weeks by calling ([**Telephone/Fax (1) 2007**] for an appointment. . Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**12-28**] weeks by calling [**Telephone/Fax (1) 608**] for an appointment. Completed by:[**2151-12-27**] Admission Date: [**2151-12-24**] Discharge Date: [**2151-12-24**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3556**] Chief Complaint: s/p cardiac arrest Major Surgical or Invasive Procedure: Ms. [**Known lastname 12056**] is an 84F with hx of dementia, HTN s/p gamma nail procedure for acute right intertrochanteric fracture and avulsion of the lesser trochanter on [**12-19**], who presents s/p cardiac arrest. Pt was discharged from [**Hospital1 **] yesterday to Goaddard house. This AM staff found her in respiratory distress (VS: BP 150/68, p 64, RR 24 O22 sat 89-90%, Temp 96.4) and called 911. When EMS arrived they noted she was apneic and pulseless. She went into PEA arrest, was intubated and was given 3 rounds of epi and atropine. EKG changed to accelerated idioventricular rhythm with pulsues. Pulse was lost again and epi was given. She then converted to pulseles vtach and was shocked and returnd to a narrow complext SVT with return of pulses and BP 124/P. . In the ER the pt was noted to have fixed dilated pupils. She was tachycardic to the 160s in an SVT, she was shocked at 100 J with transient conversion to NSR. She was given 150 mg IV amiodarone. Her HR then dropped to the 80s and she was given atropine 1 mg and epi 1 mg with no pulse. Compressions were initiated and she was given 20 units of vasopressin with return of her pulse. She was given levaquin,flagyl and cefepime and a right femoral line was placed in the ER. After discussion with her HCP it was determined that she was DNR/DNI. Pt was had a CT of the head and CTA and was sent to the ER. History of Present Illness: Ms. [**Known lastname 12056**] is an 84F with hx of dementia, HTN s/p gamma nail procedure for acute right intertrochanteric fracture and avulsion of the lesser trochanter on [**12-19**], who presents s/p cardiac arrest. Pt was discharged from [**Hospital1 **] yesterday to Goaddard house. This AM staff found her in respiratory distress (VS: BP 150/68, p 64, RR 24 O22 sat 89-90%, Temp 96.4) and called 911. When EMS arrived they noted she was apneic and pulseless. She went into PEA arrest, was intubated and was given 3 rounds of epi and atropine. EKG changed to accelerated idioventricular rhythm with pulsues. Pulse was lost again and epi was given. She then converted to pulseles vtach and was shocked and returnd to a narrow complext SVT with return of pulses and BP 124/P. . In the ER the pt was noted to have fixed dilated pupils. She was tachycardic to the 160s in an SVT, she was shocked at 100 J with transient conversion to NSR. She was given 150 mg IV amiodarone. Her HR then dropped to the 80s and she was given atropine 1 mg and epi 1 mg with no pulse. Compressions were initiated and she was given 20 units of vasopressin with return of her pulse. She was given levaquin,flagyl and cefepime and a right femoral line was placed in the ER. After discussion with her HCP it was determined that she was DNR/DNI. Pt was had a CT of the head and CTA and was sent to the ER. Past Medical History: Past Medical History 1. Dementia, likely Alzheimer's type 2. Osteoporosis 3. HTN 4. Hypothyroidism 5. Colon CA s/p colectomy '[**38**] 6. s/p CCY 7. Thoracic compression fracture 8. Thyroid enlargement Social History: The pt is a resident of [**Hospital3 537**] since [**7-1**]. Family History: Non contributory Physical Exam: VS: T 91.6 HR 110 BP 98/64 RR 15 O2 sta 98% AC:450x 16 Presure support [**4-27**] FiO2 100% Gen: pale, ill appering, intubated and sedated patient Heent: Fixed, dilated pupils Neck: supple Cardio: irregularly irregular rhythm, nl S1 S2, no m/r/g Pulm: rhonchi bilaterally Abd: soft but very distended, hypoactive BS Ext: 1+ edema in RLE, IV above left knee Neuro: Sedated, not responding to voice, sternal rub or nailbed pressure Pupils are fixed and dilated LE appear rigid equivocal Babinski's Pertinent Results: [**2151-12-24**] 07:11AM BLOOD WBC-9.4 RBC-3.49* Hgb-11.1* Hct-34.0* MCV-97 MCH-31.9 MCHC-32.8 RDW-14.5 Plt Ct-185 [**2151-12-24**] 07:11AM BLOOD Neuts-78.0* Lymphs-15.0* Monos-6.7 Eos-0.2 Baso-0.2 [**2151-12-24**] 07:11AM BLOOD PT-16.3* PTT-42.2* INR(PT)-1.5* [**2151-12-24**] 07:11AM BLOOD Glucose-215* UreaN-25* Creat-1.1 Na-148* K-3.5 Cl-105 HCO3-23 AnGap-24* [**2151-12-24**] 07:11AM BLOOD ALT-24 AST-36 CK(CPK)-62 AlkPhos-62 Amylase-47 TotBili-0.8 [**2151-12-24**] 07:11AM BLOOD Lipase-57 [**2151-12-24**] 07:11AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2151-12-24**] 07:11AM BLOOD Albumin-2.6* Calcium-8.6 Phos-8.5* Mg-2.4 [**2151-12-24**] 07:15AM BLOOD Glucose-192* Lactate-10.5* Na-145 K-3.7 Cl-107 calHCO3-22 [**2151-12-24**] 07:15AM BLOOD freeCa-1.03* . CTA chest: 1. No pumonary embolism. 2. Atelectasis of the left lower lobe and a mix of consolidation and atelectasis of left upper lobe. Findings are consistent with aspiration and post- obstructive pneumonitis superimposed on left upper lobe pneumonia. 3. Small bilateral pleural effusions. 4. Interstitial edema. 5. Nasogastric tube in a high position with tip near the gastroesophageal junction and side hole in the lower esophagus. Advancement suggested. 6. 5-mm left ureteropelvic junction stone may be obstructing but evaluation of the left kidney is limited as it was included only on the non-contrast series. . CT head:IMPRESSION: Normal brain CT (official read pending when pt expired) Brief Hospital Course: *cardiopulmonary arrest: Ms. [**Known lastname 12056**] was an 84F with a hx of dementia, HTN s/p gamma nail procedure for acute right intertrochanteric fracture and avulsion of the lesser trochanter on [**12-19**], who presented s/p cardiac and respiratory arrest. As per the above HPI, the pt was found to be in respiratory distress and then went into PEA arrest and later pulslesss VT for which she was rescuscitated. She was intubated in the field. In the ER she was started on abx, pressors and had a femoral line placed. She had a CTA negative for PE and a CT head. After d/w her HCP it was then discovered she was DNR/DNI. She was then brought to the ICU. Her HCP, Mr. [**Name (NI) 67377**] (nephew) was contact[**Name (NI) **] again and the options of whether to pursue aggressive care vs. continuation of care without escalation vs. transition to CMO was discussed with him. After discussion with her Mr [**Last Name (Titles) 67377**], it was determined that she was DNR/DNI and this was discussed at her last admission. He confirmed that the patient would not want to be kept alive on life support. He came to the hospital with several family members and after their arrival the pt's abx and pressors were stopped and the ventilator was turned off. She expired shortly thereafter with her family at the bedside. Medications on Admission: Aspirin 325 mg Tablet qd 2. Atenolol 50 mg Tablet qd 3. Levothyroxine 50 mcg Tablet qd 4. Buspirone 5 mg Tablet [**Hospital1 **] 5. Mirtazapine 15 mg Tablet qhs 6. Donepezil 5 mg Tablet qhs 7. Memantine 5 mg Tablet qd 8. Calcitonin (Salmon) 200 unit/Actuation Aerosol one spray intranasally 9. Docusate Sodium 100 mg Capsule [**Hospital1 **] 10. Senna 8.6 mg Tablet [**Hospital1 **] 11. Hexavitamin Tablet qd 12. Pantoprazole 40 mg Tablet q 24 hours 13. Enoxaparin 40 mg/0.4 mL SC qd 14. Acetaminophen 325 mg Tablet q6 hrs 15. Lidocaine 5 %(700 mg/patch) Adhesive Patch 16. Potassium Chloride 20 mEq Packet qd 17. Metronidazole 500 mg TID for 7 days (start day [**12-23**]) 18. Levofloxacin 500 mg Tablet qd for 7 days (start day [**12-23**]) Discharge Medications: pt expired Discharge Disposition: Expired Facility: [**Hospital1 18**] Discharge Diagnosis: Cardiopulmonary arrest Respiratory failure Dementia Personal history of colon cancer Discharge Condition: expired [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

[ "V10.05", "294.10", "997.3", "285.9", "401.9", "331.0", "518.5", "244.9", "E888.9", "820.21", "486" ]

icd9cm

[ [ [] ] ]

[ "96.71", "79.15", "96.04" ]

icd9pcs

[ [ [] ] ]

22031, 22070

19871, 21201

14716, 16103

22199, 22338

18389, 19771

14064, 14641

17839, 17857

21996, 22008

22091, 22178

21228, 21973

13451, 14041

17872, 18370

14658, 14678

16131, 17518

19779, 19848

17540, 17744

17760, 17823

10913, 11657

2,971

164,403

22342

Discharge summary

report

Admission Date: [**2139-7-25**] Discharge Date: [**2139-8-8**] Date of Birth: [**2103-2-7**] Sex: F Service: NSU PRIMARY DIAGNOSIS: Left posterior communicating artery aneurysm. SECONDARY DIAGNOSIS: Subarachnoid hemorrhage. HISTORY OF PRESENT ILLNESS: The patient is a pleasant 36- year-old woman who presented from an outside hospital with the worst headache of her life. She has a history of migraines, but complained that this headache was significantly different and significantly more painful. Her headache was reported as a sudden onset with sharp stabbing pain throughout her head, initially focusing around the periorbital area. She also experienced some difficulties with light complaining of photophobia. Concurrently, she also complained of some stiff pain from neck. She denies any diplopia, dysphagia, weakness, or numbness. On [**2139-7-24**], she went to an outside hospital where a CT was done. Per report the CT was negative and so an LP was performed, which showed 100 white blood cells and 12,000 red blood cells in the first two and 100 white blood cells and 11,000 red blood cells in the fourth. She has subsequently been transferred to [**Hospital1 346**] for further arrangement. PAST MEDICAL HISTORY: She has a history of migraines, but no other significant past medical history. MEDICATIONS: She does not require any medications at home. PHYSICAL EXAMINATION: On examination, she was alert and oriented x3. She appeared very uncomfortable complaining of a significant headache. She was following commands in all four extremities. Her pupils were 4 mm to 2 mm brisk bilaterally. She had full extraocular movements and her face remained symmetric. Her tongue was midline on protrusion. She had 5/5 strength throughout all extremities and had normal sensation in all extremities. Her toes were downgoing with bilateral plantar reflexes and she did not have any clonus. INVESTIGATIONS: A CT of the head performed at [**Hospital1 **] was negative for any subarachnoid hemorrhage. CT angiogram performed showed a PICA aneurysm that appeared lobulated with a 4 mm neck. Her labs on admission were unremarkable. HOSPITAL COURSE: She was admitted to the Neurosurgery Service at [**Hospital1 **]. She was taken to the Intensive Care Unit where an A-line was placed and her blood pressure was monitored for a goal of less than 130 systolic blood pressure using Nipride to titrate. She was started on nimodipine as well as Decadron for her headache. She received q.1h. Neurologic checks. Her course in the hospital was uneventful. During her entire stay, she remained afebrile with stable vital signs. Her blood pressure remained controlled on Nipride. She was taken the subsequent day, on [**2139-7-25**], for an angiogram. She was taken to the operating room for angiography, which confirmed left posterior communicating artery aneurysm, which was coiled in the Angio Suite. She tolerated the procedure well with no complications. Please see procedure note for further details. Postprocedure, she remained afebrile with stable vital signs. Followup CT scans were unchanged. On subarachnoid day four, we started to increase her blood pressure parameters as well as her CVP for systolic blood pressure goals greater than 150 and CVP goals of 6 to 8. She received three days of aspirin, which was subsequently discontinued. She was placed on subcutaneous heparin and she remained in ICU for close monitoring. She continued to complain of a persistent severe headache. Ultimately, CT scan had a slight suggestion of increased pressure and she underwent a lumbar drain placement. She tolerated the procedure well with no complications. The opening pressure was 26 cmH2O. The drain was left in place with the drainage of 10 cc per hour. She had some slight improvement with the drain placement, but then her headaches recurred. She continued to do well in hospital and otherwise had an unremarkable course. Her headache gradually improved. She was seen by the Chronic Pain Service who suggested Fioricet. The lumbar drain was removed. On [**2139-7-31**], she also underwent a repeat angiogram to reassess for vasospasm. There was no evidence of vasospasm on angiogram and good coiling of left PCA was evidenced. She continued to do well in hospital with an uneventful course. She remained neurologically intact. Her vital signs remained stable. She was continued on Dilantin prophylaxis. On subarachnoid day 10, the _______ was weaned and she was started on Midodrine. A goal systolic blood pressure of greater than 110 was targeted. Subsequent days, her blood pressure was kept above 100 and above 85. She remained asymptomatic. No neurologic deficits. She was slowly weaned of her vasopressors. She was subsequently seen by Ophthalmology for blurred vision in the left eye. Neurologic exam was nondiagnostic and ultimately they recommended to followup in the Outpatient Clinic and possibly an angiogram to assess her filling defects or delays of the ophthalmic artery. Ultimately, she went to the floor and continued to do well. She has currently been seen by Physiotherapy and cleared to go home. She is currently stable for discharge home. She has been tolerating good p.o. diet, ambulating independently, and voiding without difficulty. DISCHARGE MEDICATIONS: 1. Dilantin 200 mg p.o. b.i.d. 2. Seroquel 25 mg b.i.d. 3. Neurontin 200 mg q.8 h. p.r.n. 4. Fioricet 1 to 2 tablets p.o. q.8 h. p.r.n. 5. Dilaudid 2 to 4 mg p.o. q.4 h. p.r.n. FOLLOW UP: She has been advised to follow up with Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1132**] in two to four weeks. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**] Dictated By:[**Last Name (NamePattern1) 1361**] MEDQUIST36 D: [**2139-8-8**] 08:33:50 T: [**2139-8-8**] 09:34:46 Job#: [**Job Number 58177**]

[ "430", "729.89", "493.90", "276.8", "530.81", "070.54", "305.1" ]

icd9cm

[ [ [] ] ]

[ "88.41", "89.61", "03.79", "89.62", "99.29" ]

icd9pcs

[ [ [] ] ]

5365, 5544

2198, 5342

5556, 5967

1425, 2180

278, 1238

223, 249

154, 201

1261, 1402

13,740

189,025

51056+51057+51058

Discharge summary

report+report+report

Admission Date: [**2177-1-31**] Discharge Date: [**2177-2-6**] Date of Birth: [**2119-2-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor Last Name 10493**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 57 yo female, bipolar disorder, on dialysis, previously maintained stably for >20 years on Lithium, currently on risperdol. Pt is currently in rehab and according to psych note, she has been more and more manic, grandiose and refusing medications or interaction with team. PCP notes that celebration of the Chinese New Year tipped her over into a state where the NH could no longer manage her. . Acccording to Rehab Facility staff, over recent (last 3) days patient has been sexually inappropriate yelling at a male nurse who she expressed interest in, urinating on the carpet, threw a ball at the dining room window, and was yelling and screaming intermitently. She has been observed speaking on her telephone to 'the Queen of [**Country 651**].' And three days ago in a paranoid manner accused another resident at the rehab facility of stealing her money. She normally is alert, knows the days of the week, which days she goes for dialysis, is not paranoid and is in good behavioral control. There is no clear stressor for this decompensation. . Past Psychiatric Hx: (Obtained from medical record). No hospitalizations since >20 years. Previously multiple hospitalizations for what seem to be manic episodes with psychotic features. Diagnosed as Bipolar d/o. . Patient was stable on Lithium for several years. Patient now treated with Risperdal. However, pt. has been resistant and often non-compliant to increased doses of Risperdal, goal had been 2-4mg PO BID. She has refused her meds for previous 3 days. . Reports cutting wrist in late 60's, but no suicidality or dangerousness otherwise known. Past Medical History: # ESRD on HD - started in [**12-22**], MWF, CKD felt to be d/t Li toxicity # osteoarthritis/DJD # bipolar disorder # h/o pancreatitis [**9-19**] # Pancreatic divisim # Hypertension # h/o nephrogenic diabetes insipidus secondary to lithium # Obesity # Chronic cough # Asthma Social History: Lives in [**Location 577**] alone, consultant, no tob/ETOH/IVDU Family History: Grandmother with DM Physical Exam: Physical Exam: Patient in room on face mask. Heavily sedated from haldol and ativan. Patient in room on face mask, heavily sedated. On exam, somewhat overweight asian female, heavily sedated, responding to sternal rub with a cry and hands raised. Holds eyes closed, not able to follow simple commands. . Speech: Unable to assess.Tp: Unable to assess. Tc: Unable to assess. Mood: Unable to assess. Affect: Unable to assess. I/J: Unable to assess. Cognitive: Unable to assess. . HEENT: no lymphadenopathy. CV: nl S1/S2. Pulm: coarse breath sounds, upper respiratory sounds transmitted. Otherwise CTAB anteriorly. GI: soft and nontender. Ext: L side antecubital region sutures with mild erythema around it (from fistula). R sided dialysis cath with no signs of erythema or edema. Pertinent Results: WBC/HCT/Anemia w/u labs: [**2177-1-31**] 12:51PM WBC-10.7 RBC-2.42* HGB-8.3* HCT-25.8* MCV-107* [**2177-2-6**] 07:50AM BLOOD WBC-8.5 RBC-2.37* Hgb-7.8* Hct-24.9* MCV-105* [**2177-2-1**] 06:40AM BLOOD Ret Aut-6.7* [**2177-2-5**] 07:00AM BLOOD LD(LDH)-325* [**2177-2-5**] 07:00AM BLOOD VitB12-831 Folate-18.7 Hapto-251* [**2177-2-1**] 06:40AM BLOOD calTIBC-246* Ferritn-524* TRF-189* . Chemistry/Endocrine labs: [**2177-1-31**] 12:51PM BLOOD Glucose-95 UreaN-71* Creat-8.1*# Na-142 K-3.7 Cl-100 HCO3-27 AnGap-19 [**2177-2-6**] 07:50AM BLOOD Calcium-10.0 Phos-5.8* Mg-1.9 [**2177-2-1**] 06:40AM BLOOD TSH-0.51 . Toxicology: [**2177-1-31**] 12:51PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Micro: [**2177-1-31**] 02:48PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2177-1-31**] 02:48PM URINE RBC-0 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 [**2177-1-31**] 02:48PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 Ucx [**1-31**]: negative Bcx [**1-31**]: negative . CXR: [**1-31**] Right internal jugular dialysis catheter has been removed and replaced by a left internal jugular catheter, tip directed towards the lateral wall of the superior vena cava and not making the expected downward turn within this vascular structure. There is no pneumothorax. Cardiac silhouette is upper limits of normal in size with left ventricular configuration and there is persistent tortuosity of the thoracic aorta. No definite areas of consolidation are identified, but questionable areas of increased opacity are noted at the right apex medially and in the left retrocardiac area. Brief Hospital Course: A/P: 57 yo female with h/o bipolar disorder, on dialysis, p/w mania, likely bipolar disorder flare. Three days prior to admission she has decompensated and becoming increasingly grandiose and resistant to treatment at her outpatient Rehab Facility. She is normally alert and in good control but has been increasingly hard to manage on Risperdal 1 mg [**Hospital1 **]. There is no clear stressor for this current decompensation. Pt likely having a maniac episode. . # Bipolar Disorder: pt has h/o bipolar disorder. It seems based on the h/o that this is another flare of her BD. Psych evaluated the patient in the ED and has made recommendations. Psych re-evaluated and rec haldol 2mg Q6H standing and PRN dosing for agitation. Pt appears to be more cooperative with 2 days of standing doses of haldol. Holding risperdal per psych. Maintaining 1:1 sitter. Waiting for bed to become available in [**11-18**]. She is medically stable as seen by nl TSH, B12, folate and all cultures (bcx and ucx) are negative to date. Retrocardiac opacities seen on x-ray are old compared to prior CT scan of chest and other x-rays. Pt has no evidence of PNA. Waiting for PSYCH placement. On [**2-5**] had to activate code purple x2 [**1-17**] to agitation and pt trying run out of unit and hitting staff members. Pt had to get 1mg of Ativan and 5 mg Haldol x2. Psych saw pt and rec increasing doses of haldol in order to keep her less agitated. They rec 5 mg PO haldol and 1 mg of at 17:30, 21:30 and 05:30 overnight on [**2-6**]. Total of 25 mg haldol over 24 hours. Pt continues to be agitated, wanting to leave and mentioning she is getting married and is pregnant. - Cont 1:1 sitter - F/u on psych recs . # Renal Failure: pt with h/o chronic renal failure, likely [**1-17**] to lithium use and HTN. Pt started hemodyalisis towards the end of [**2174**]. Pt regularly on HD x3 times a week (MWF). Pt being followed by Renal and getting dyalisis as rec. High phosphate and normal calcium. Will check PTH levels, but pt already on sevelamer and with normal calcium levels, it is not rec to give vitamin D. - Cont sevelamer - F/u on renal recs . # Anemia: new anemia, decreased HCT. Pt was previously on procrit, but has not been receiving it for the past few weeks, this likely explains her anemia, given she is guaiac negative; Retic count is 6.5; hemolysis pannel is unremarkable, haptoglobin is above normal. Iron studies consistent with anemia of chronic disease. - Pt will likely benefit from EPO in dyalisis. Will give EPO in dyalisis. - transfuse if HCT <21 . # HTN: pt has h/o HTN on metoprolol. BP has been under control without metoprolol. If BP elevates will restart metoprolol. . # FEN: replace fluids and electrolytes . # PPX: bowel regimen and SC heparin. . CODE STATUS: DNR/DNI . # Dispo: PSYCH [**11-18**] once bed is available. Medications on Admission: Meds: Nephrocaps 1 PO QD Selevemer 800 mg PO TID Risperidone 1 mg PO QD Ascorbic acid 1000mg PO BID Codeine-guaifenisin 5-10mg Q6prn Metoprolol 12.5 mg PO BID Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 10. Sevelamer 800 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 12. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for agitation. 13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: Deaconness 4 Discharge Diagnosis: Mania-Bipolar Disorder Discharge Condition: Stable Discharge Instructions: Please take your haldol as indicated. If you have any concerns or fell unwell, please return to the Emergency Room. Followup Instructions: Please f/u with psychiatry [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**] Completed by:[**2177-2-6**] Admission Date: [**2177-2-6**] Discharge Date: [**2177-2-7**] Date of Birth: [**2119-2-24**] Sex: F Service: PSYCHIATRY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2448**] Chief Complaint: Evaluation of likely Bipolar exacerbation Major Surgical or Invasive Procedure: Patient coded on Daialysis unit, transferred to MICU 6. History of Present Illness: 57 yo female, bipolar disorder, on dialysis, previously maintained stably for >20 years on Lithium. Per her outpatient PCP she has been managing poorly at her current Nursing Home even as her psychiatrist has been trying to manage her illness with increasing doses of Risperdal. According to his report she has been more and more manic, grandiose and refusing medications or interaction with team. PCP notes that celebration of the Chinese New Year tipped her over into a state where the NH could no longer manage her. Acccording to Rehab Facility staff, over recent (last 3) days patient has been sexually inappropriate yelling at a male nurse who she expressed interest in, urinating on the carpet, threw a ball at the dining room window, and was yelling and screaming intermitently. She has been observed speaking on her telephone to 'the Queen of [**Country 651**].' And three days ago in a paranoid manner accused another resident at the rehab facility of stealing her money. She normally is alert, knows the days of the week, which days she goes for dialysis, is not paranoid and is in good behavioral control. She has not appeared to be obtunded or sedated at any time. There is no clear stressor for this decompensation. Past Medical History: Past Psychiatric Hx: (Obtained from medical record). No hospitalizations since >20 years. Previously multiple hospitalizations for what seem to be manic episodes with psychotic features. Diagnosed as Bipolar d/o. Patient was stable on Lithium for several years. Depakote had to be discontinued for possible link to pancreatitis. Patient has been treated with Risperdal. (but pt. has been resistant and often non-compliant to increased doses of Risperdal, goal had been 2-4mg PO BID) Reports cutting wrist in late 60's, but no suicidality or dangerousness otherwise known. PMH: # ESRD on HD - started in [**12-22**], MWF, CKD felt to be d/t Li toxicity # osteoarthritis/DJD # bipolar disorder # h/o pancreatitis [**9-19**] # Pancreatic divisim # Hypertension # h/o nephrogenic diabetes insipidus secondary to lithium # Obesity # Chronic cough # Asthma Social History: Currently living at [**Hospital **] Healthcare Center Rehab facility ([**Telephone/Fax (1) **]. Previously, lived alone in [**Location (un) 577**]. Reports being engaged x 1 year ago. Mother is closest family member. Sister [**Name (NI) **]: [**Telephone/Fax (1) 106052**]. [**Name2 (NI) **]er [**Name (NI) **]: [**Telephone/Fax (1) 106053**]. Denies etoh, tobacco, drug use; Currently Stox/utox negative. Family History: Unknown Physical Exam: Initial MSE in ED: Patient in room on face mask, heavily sedated. On exam, somewhat overweight asian female, heavily sedated, responding to sternal rub with a cry and hands raised. Holds eyes closed. Speech: Unable to assess. Tp: Unable to assess. Tc: Unable to assess. Mood: Unable to assess. Affect: Unable to assess. I/J: Unable to assess. Cognitive: Unable to assess. Pertinent Results: [**2177-2-6**] 07:50AM GLUCOSE-93 UREA N-36* CREAT-5.5* SODIUM-129* POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-22 ANION GAP-16 [**2177-2-6**] 07:50AM CALCIUM-10.0 PHOSPHATE-5.8* MAGNESIUM-1.9 [**2177-2-6**] 07:50AM WBC-8.5 RBC-2.37* HGB-7.8* HCT-24.9* MCV-105* MCH-32.9* MCHC-31.3 RDW-17.1* [**2177-2-6**] 07:50AM PLT COUNT-218 Brief Hospital Course: Patient arrived to [**Hospital1 **] 4 in the early evening of [**2177-2-6**], and was very somnolent. She was noted to have received Haldol 5 mg and Ativan 1 mg prior to arrival on the unit, and sedated as a result. Her initial evaluation was limited due to her falling asleep repeatedly, but she appeared delusional and expansive in affect. Overnight the patient was agitated, and she received a chemical restraint of Haldol 5mg, Ativan 2mg. Additionally she was noted to have increased heart rate to the 120s, and had an individual O2 saturation [**Location (un) 1131**] in the 60s which returned to the 80s after a nebulizer treatment. Patient's vital signs stabilized overnight. Patient was maintained on the same medications and doses that she had been receiving on the Medical floor, and went to Hemodialysis prior to being seen by the team on the AM of [**2177-2-7**]. During her dialysis treatment, a code blue was called for pulselessness. A code was performed and she was transferred to the Medical Intensive Care Unit. Medications on Admission: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 10. Sevelamer 800 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 12. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for agitation. 13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Medications: Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 10. Sevelamer 800 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 12. Haldol 2.5 mg PO Q6 Hours, 2 mg PO PRN Discharge Disposition: Extended Care Facility: [**Hospital1 18**] MICU 6 Discharge Diagnosis: I. Bipolar Affective Disorder II. Deferred III. Chronic Cough, Osteoarthritis, End Stage Renal Disease Discharge Condition: Patient Coded while on Hemodialysis, and was transferred to the MICU Discharge Instructions: Transferred to MICU Followup Instructions: Transferred to MICU [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2461**] Admission Date: [**2177-2-7**] Discharge Date: [**2177-2-21**] Date of Birth: [**2119-2-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: s/p PEA arrest Major Surgical or Invasive Procedure: Intubation Central line placement Nasogastric tube placement History of Present Illness: 57 yo F w/ h/o bipolar d/o, ESRD on HD (initiated 2mos ago), initially admitted to medicine on [**2177-1-31**] for manic behavior, recently transferred to psych on [**Hospital1 **] 4 yesterday, who is transferred now to MICU after PEA arrest while undergoing HD this afternoon. . Per report, while patient was undergoing HD this afternoon she became hypoxic, then apneic. At approximately 11:20am, patient went into PEA arrest with a narrow complex rhythm. CPR was initiated and code blue called. Patient intubated at approx 11:23am. Given 1mg Epi at 11:25am, then 1mg Atropine at 11:30am. At approx 11:35am, patient regained a pulse (@ 170) and blood pressure (SBP 170). Patient transferred to the MICU for further management. . On arrival to MICU, patient hypotensive w/ SBP's 70-80's. Patient bolused total 2L NS. CVP 12-14. K low at 2.5, given 40mEq KCL. Hct down 24.2 --> 21.1. 1u PRBC's ordered. CXR showed ETT at carina, pulled back 2cm. CXR also w/ bilateral opacities concerning for aspiration. Cultures drawn, and patient started on Vanco and Zosyn. . Patient's PCP present and informed MICU team of DNR/DNI status. This DNR/DNI status is documented in OMR from the 2 most recent d/c summaries dated [**2177-1-8**], and [**2177-2-6**]. Patient's PCP confirms this status. Also documented in most recent progress notes in chart. . I have contact[**Name (NI) **] patient's mother, and 2 sisters [**Name2 (NI) **] and [**Name (NI) **]). There is no formal HCP identified. [**Name2 (NI) 6419**] [**Doctor Last Name **] and [**Doctor First Name **] were unaware of sister's wishes to be DNR/DNI. They were initially uncomfortable with that status and wished for her to be full code. After discussion with the PCP, [**Name10 (NameIs) **] family felt more comfortable and agreed that they would like to uphold the patient's stated wishes that she would like to be DNR/DNI. Past Medical History: # ESRD on HD - started in [**12-22**], MWF, CKD felt to be d/t Lithium toxicity; Revision surgeries to AVF ([**2177-1-21**] most recent) # osteoarthritis/DJD # bipolar disorder # h/o pancreatitis [**9-19**] # Pancreatic divisim # Hypertension # h/o nephrogenic diabetes insipidus secondary to lithium # Obesity # Chronic cough # Asthma - PFT's [**2177-1-23**]: FEV1 1.33(63%); FVC 1.70(60%); FEV1/FVC 78(106%) . PSYCH HISTORY: (per prior notes). No hospitalizations since >20 years. Previously multiple hospitalizations for what seem to be manic episodes with psychotic features. Was stable on Lithium for several years, has also been treated with Risperdal. (but pt. has been resistant and often non-compliant to increased doses of Risperdal, goal had been 2-4mg PO BID). H/o cutting wrist in late 60's, but no suicidality or dangerousness otherwise known. Psychiatrist, Dr. [**Last Name (STitle) 724**] (MMHC): [**Telephone/Fax (1) 20582**] Social History: Lives in [**Location 577**] alone, consultant, no tob/ETOH/IVDU (per prior d/c summary) Family History: DM - grandmother Physical Exam: VS: T: 96.2; HR: 90; BP: 118/64 (on 0.1 levophed); RR 16; O2 97% AC: 500x16/5/0.6 ABG: 7.38/50/190 (on FiO2 100%) CVP = [**11-28**] GEN: middle age woman, lying in bed, intubated HEENT: Pinpoint pupils bilaterally, minimally responsive, anicteric, MMM, OP clear, ETT in place NECK: JVP difficult to assess given habitus CV: RRR, normal s1s2, no murmurs, no S3/S4 CHEST: CTA bilat anteriorly. no crackles/wheezes. ABD: NABS, soft, ND, NT, no masses EXT: no edema NEURO: intubated, not following commands, not responsive to noxious stimuli Pertinent Results: [**2177-2-6**] 07:50AM WBC-8.5 RBC-2.37* HGB-7.8* HCT-24.9* MCV-105* MCH-32.9* MCHC-31.3 RDW-17.1* [**2177-2-6**] 07:50AM PLT COUNT-218 [**2177-2-6**] 07:50AM GLUCOSE-93 UREA N-36* CREAT-5.5* SODIUM-129* POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-22 ANION GAP-16 [**2177-2-6**] 07:50AM CALCIUM-10.0 PHOSPHATE-5.8* MAGNESIUM-1.9 [**2177-2-7**] 11:30AM PT-12.3 PTT-32.5 INR(PT)-1.1 . EKG: NSR @ 93; normal axis/intervals; QTc 470; biphasic PW V1; QW III (unchanged from prior) . CXR: ETT just above carina; bilateral opacities at bases . Brief Hospital Course: . #) PEA arrest/hypotension: Unclear etiology for PEA during dialysis. reports of hypoxia and apnea suggest this as etiology. Unclear reason for apnea, possibly [**1-17**] to OSA, seizure or aspiration event. Hct down to 21 which suggest hypovolemia [**1-17**] blood loss anemia as possibility, but no obvious sources on exam. Lytes relatively normal w/ exception of K which was repleted. Cardiogenic shock unlikely given unchanged EKG. s/p 2L NS and now giving 1u PRBCs. PE also possible, although less likley. CXR w/o evidence of pneumothorax, but evidence of bilateral opacities suggesting aspiration event. Hypotension likely cardiac depression s/p arrest. Echo s/p event w/ normal LV/RV dysfxn. Head CT neg for ICH. s/p 2u PRBCs for low Hct. CTA neg for PE. levophed weaned off. Guaiac negative. Hematocrit and BP remained stable for the remainder of her stay. . # Pneumonia: She was treated with 8 days of Zosyn and vancomycin for suspected aspiration pneumonia. She remain afebrile with flat WBC and stable respiratory status. . # Mental Status: Patient's mental had not improved several days after the event. She inconsistently followed commands. Neurology was consulted to comment on prognosis. MRI showed no structural abnormalities. EEG showed diffuse slowing suggesting mild encephalopathy and L temporal subcortical and cortical dysfunction. The prognosis is unclear as no data is available to guide determination of prognosis in patient with intact brainstem function. Repeat EEG again showed encephalopathy but no seizure activity. Her encephalopathy was felt to be most likely hypoxic encephalopathy with contribution from metabolic abnormalities. Her hypercalcemia was thought to possibly be contributing to her mental status, so she was started on cinacalcet for secondary hyperparathyroidism. She continued to have electrolyte management by hemodialysis. She will follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of Neurology. . #) ESRD ON HD: Patient was started on HD approximately 2 mos ago for renal failure secondary to lithium, with some possible contribution of hypertensive nephropathy. She was followed by Nephrology. She was maintained on hemodialysis on a MWF schedule. She has a L tunnelled HD catheter. . #) Bipolar disorder: Her psychiatric medications were held in the setting of her neurologic dysfunction. Psychiatry was consulted and agreed with this management. Her future requirements for psychiatric medications are unclear at this time. She will likely need periodic reassessment by Neurology and possibly Psychiatry. . #) Anemia: Likely predominantly secondary to renal failure. She received 2U PRBC in the period immediately following her cardiac arrest. She was guaiac negative and had no signs of hemolysis. She received epo with dialysis. Her hematocrit was subsequently stable. . #) Asthma/COPD: Continued on Flovent and atrovent MDI. . #) FEN: Started on tube feeds via NG tube. The family declined PEG tube as they and the team felt it would not be consistent with the patient's wishes. The family requested that the NG tube be maintained for now. . #) Code Status: Extensive family meetings were held with the team, PCP, [**Name10 (NameIs) **] the family regarding the goals of care. The team and family agreed to make the patient DNR/DNI after extubation. Tracheostomy and PEG tube was also felt to be inconsistent with the patient's wishes. Given her unclear neurologic prognosis, the family requested to continue NG tube with tube feeding and hemodialysis for now, but to maintain DNR/DNI. . Medications on Admission: MEDS ON TRANSFER: Nephrocaps PO daily Metoprolol 25 mg PO BID Albuterol NEBS INH Q6H Heparin 5,000u SC TID Pantoprazole 40 mg PO Q24H Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **] Docusate 50 mg/5 mL PO BID Bisacodyl 10 mg PO DAILY prn Acetaminophen 325 mg PO Q4-6H as needed Sevelamer 800 mg 1.5 Tablets PO TID Epoetin Alfa 10,000 unit/mL at HD Haloperidol 5 mg PO Q4-6H as needed for agitation. Lorazepam 1 mg PO Q4-6H as needed. Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Fifty (50) mg PO BID (2 times a day). 2. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000) mg Injection TID (3 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Epoetin Alfa 10,000 unit/mL Solution [**Hospital1 **]: as dir U Injection ASDIR (AS DIRECTED): Defer to dialysis unit. . 5. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. Sevelamer 800 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a day). 7. Lanthanum 500 mg Tablet, Chewable [**Hospital1 **]: Two (2) Tablet, Chewable PO TID (3 times a day). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 11. Cinacalcet 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 12. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Outpatient Lab Work Please check Chem 10 on [**2-28**] and give results to Dr. [**First Name (STitle) 4102**] [**Name (STitle) 4090**] at ([**Telephone/Fax (1) 4923**]. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: s/p PEA arrest Hypoxic encephalopathy Secondary hyperparathyroidism Discharge Condition: good, respiratory status stable Discharge Instructions: Please administer all medications as prescribed. . Please transport patient to all follow up appointments. . Patient is on a MWF dialysis schedule. Followup Instructions: 1) Neurology: [**Name6 (MD) **] [**Name8 (MD) **], MD, PHD; [**Telephone/Fax (1) 1690**]; [**2177-2-26**] at 1:00pm. . 2) Please call PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] ([**Telephone/Fax (1) 21458**], to schedule a follow up appointment. Completed by:[**2177-2-21**]

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icd9cm

[ [ [] ] ]

[ "99.04", "96.6", "39.95", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

27691, 27762

22041, 23086

17826, 17889

27874, 27908

21476, 22018

28104, 28446

20884, 20902

26145, 27668

27783, 27853

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27932, 28081

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17772, 17788

17917, 19795

23102, 25653

19817, 20763

20779, 20868

25697, 26122

29,909

155,069

32435+57803

Discharge summary

report+addendum

Admission Date: [**2167-10-11**] Discharge Date: [**2167-10-27**] Date of Birth: [**2087-4-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 545**] Chief Complaint: fever and RUQ abd pain Major Surgical or Invasive Procedure: ERCP x 2 ([**10-11**], [**10-21**]) Paracentesis x 3 ([**10-15**], [**10-20**], [**10-27**]) Right Internal Jugular CVL ([**10-11**]) History of Present Illness: The patient is an 80 year old woman with history of pancreatic cancer s/p biliary stent 2 weeks ago ([**Hospital1 336**]), GERD, hypertension, and COPD and who is referred from [**Hospital3 3834**] for ERCP. She developed fever and RUQ pain on the day prior to presentation. The pain was brief, dull RUQ abd pain. At the [**Location (un) **] ED she was found to have the following vital signs: T 103.6F HR 96 bp 110/52 94%RA Her labs were most notable for hyperbili and elevated alk phos. She received vanc/levo/flagyl and 1 liters of IVF. She was transfered to [**Hospital1 18**] for futher evaluation. . In the [**Hospital1 18**] ED, her vital signs were 97.1 75 95/64 16 99%RA. A RIJ TLC was placed (and repositioned). She was transferred to the [**Hospital Ward Name **] following ERCP fellow evaluation. . Currently she denies abdominal pain, nausea/vomiting, or increasing in abdominal girth. Past Medical History: GERD Hepatic cirrhosis anxiety CAD COPD Hypertension Hypercholesterolemia s/p cholecystectomy s/p hysterectomy (fibroids) s/p appendectomy Social History: Lives alone in [**Hospital3 **] without family in the US. Immigrated from [**Country 2784**] with husband 40yrs ago. widowed. no children. Most recently was at [**Location (un) 25576**] Center in [**Location (un) **], MA. distant rare cigarrette smoking ([**1-3**] cigarretes per day). no EtOH. Family History: NC Physical Exam: Admission: Vitals: T 96.9 HR 71 BP 99/67 RR O2sat 97% RA Gen: comfortable. chronically ill elderly woman in NAD HEENT: dry mucous membranes edentulous. bilat cataracts. PERRL, EOMI, no scleral icterus Neck: RIJ in place with no surrounding edema Chest: CTAB CV: RRR w/o m/r/g Abd: abd scars (open chole, open appy, open hyst), distended, shifting dullness, soft, NT, active bowel sounds Ext: cool. no edema Skin: no spiders. +palmar erythema Neuro: -MS: alert and oriented x3 -CN: II-XII intact (pupils 4->2mm bilat) -Motor: hand grip, bicep, tricep, plantar flex [**4-4**] bilat -[**Last Name (un) **]: light touch intact to face, hands Pertinent Results: [**Location (un) **] Labs: WBC 15.4 Hct 41.1 Plt 323 78n/11band/8lymph tbili 4.9 dbili 3.1 Alk phos >1000 CK 13 TnI 0.22 (borderline) UA neg leuk, +nit, 10-20WBC, sp [**Last Name (un) **] >1.030 . EKG: sinus @ 90 leftward axis. low voltage in limb leads. poor Rwave progression. TWI I,avL, V4-6. . Studies: CT ([**Location (un) **]) - pneumobilia, ascities, no changes CXR - Recommend 3-cm pullback of right internal jugular central venous line for optimal positioning. Repeat evaluation recommended. No acute cardiopulmonary process. [**Hospital1 18**] Admit Labs: [**2167-10-11**] 01:00PM BLOOD WBC-10.1 RBC-4.10* Hgb-12.0 Hct-35.0* MCV-86 MCH-29.4 MCHC-34.4 RDW-16.9* Plt Ct-245 [**2167-10-11**] 01:00PM BLOOD Neuts-85.7* Bands-0 Lymphs-10.9* Monos-3.0 Eos-0.2 Baso-0.2 [**2167-10-11**] 01:00PM BLOOD PT-14.9* PTT-30.1 INR(PT)-1.3* [**2167-10-11**] 01:00PM BLOOD Glucose-140* UreaN-12 Creat-0.6 Na-135 K-3.7 Cl-102 HCO3-23 AnGap-14 [**2167-10-11**] 01:00PM BLOOD ALT-49* CK(CPK)-12* AlkPhos-869* Amylase-59 TotBili-2.7* [**2167-10-11**] 01:00PM BLOOD Lipase-47 [**2167-10-11**] 01:00PM BLOOD Albumin-2.3* Calcium-7.4* Phos-3.0 Mg-1.7 Other Labs: [**2167-10-12**] 05:26AM BLOOD ALT-33 AST-57* AlkPhos-661* TotBili-1.5 [**2167-10-13**] 03:17AM BLOOD ALT-25 AST-33 LD(LDH)-90* AlkPhos-564* TotBili-0.9 [**2167-10-14**] 06:00AM BLOOD ALT-17 AST-26 AlkPhos-551* TotBili-0.9 [**2167-10-15**] 06:15AM BLOOD ALT-17 AST-31 AlkPhos-636* TotBili-1.0 [**2167-10-18**] 07:15AM BLOOD ALT-10 AST-46* AlkPhos-769* Amylase-94 TotBili-1.0 [**2167-10-20**] 08:25AM BLOOD ALT-7 AST-20 LD(LDH)-126 AlkPhos-622* Amylase-77 TotBili-0.8 [**2167-10-21**] 09:00AM BLOOD ALT-6 AST-18 LD(LDH)-117 AlkPhos-497* TotBili-0.7 [**2167-10-25**] 06:05AM BLOOD ALT-5 AST-14 AlkPhos-310* Amylase-68 TotBili-0.7 [**2167-10-18**] 07:15AM BLOOD Lipase-102* [**2167-10-19**] 06:50AM BLOOD Lipase-64* [**2167-10-23**] 06:35AM BLOOD Lipase-116* [**2167-10-24**] 06:20AM BLOOD Lipase-72* [**2167-10-25**] 06:05AM BLOOD Lipase-109* [**2167-10-26**] 06:30AM BLOOD Lipase-148* [**2167-10-27**] 06:20AM BLOOD Lipase-131* [**2167-10-25**] 06:05AM BLOOD calTIBC-127* VitB12-555 Folate-5.5 Ferritn-82 TRF-98* [**2167-10-15**] 06:15AM BLOOD %HbA1c-5.2 [**2167-10-19**] 06:50AM BLOOD Ammonia-88* [**2167-10-15**] 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE HAV Ab-POSITIVE [**2167-10-27**] 06:20AM BLOOD CEA-12* [**2167-10-18**] 07:15AM BLOOD AFP-2.8 [**2167-10-15**] 06:15AM BLOOD HCV Ab-INDETERMIN [**2167-10-15**] 06:15AM BLOOD HEPATITIS C - RIBA: HEPATITIS C - RIBA Test Result Reference Range/Units HCV AB, RIBA INDETERMINATE NEGATIVE 5-1-1 (P)/C100 (P) NONREACTIVE NONREACTIVE C33C NONREACTIVE NONREACTIVE C22P REACTIVE A NONREACTIVE NS5 NONREACTIVE NONREACTIVE HSOD NONREACTIVE NONREACTIVE BAND REACTIVITY PATTERN INTERPRETATION NO REACTIVE BANDS PRESENT. OR NEGATIVE REACTIVITY TO THE HSOD BAND ONLY. REACTIVITY TO ANY SINGLE HCV ANTIGEN BAND. OR INDETERMINATE REACTIVITY TO ANY HCV ANTIGEN BAND AND TO THE HSOD BAND. REACTIVITY TO AT LEAST TWO POSITIVE HCV ANTIGEN BANDS WHICH ARE ENCODED BY DIFFERENT PARTS OF THE HCV GENOME. THE HSOD BAND IS A CONTROL FOR THE DETECTION OF NON-SPECIFIC REACTIVITY. IT IS NOW KNOWN THAT THE HEPATITIS C VIRUS ( HCV) IS THE CAUSE OF MOST CASES OF NON-A, NON-B HEPATITIS ( NANBH). HOWEVER, PATIENTS WITH NANBH WHO ARE NEGATIVE FOR ANTI-HCV, EVEN AFTER PROLONGED FOLLOW-UP, [**Month (only) **] HAVE ANOTHER VIRAL OR NONVIRAL CAUSE FOR THE LIVER INJURY. IT IS ALSO POSSIBLE THAT THE PATIENT [**Month (only) **] HAVE HEPATITIS C BUT LACK, OR NOT YET HAVE DEVELOPED (DUE TO EARLY INFECTION), OR HAVE RESOLVED AN ANTIBODY RESPONSE DETECTABLE BY THE ASSAYS CURRENTLY AVAILABLE. THE RIBA HCV 3.0 STRIP IMMUNOBLOT ASSAY (SIA) IS LIMITED TO THE DETECTION OF ANTI-HCV IN HUMAN SERUM AND PLASMA. THE PRESENCE OF ANTI-HCV IS INDICATIVE OF PAST OR PRESENT INFECTION BY THE HEPATITIS C VIRUS, BUT DOES NOT ALWAYS NECESSARILY CONSTITUTE A DEFINITIVE DIAGNOSIS. ALL PATIENTS THAT HAVE INDETERMINATE RESULTS SHOULD BE MONITORED FOR AT LEAST 6 TO 12 MONTHS TO DETERMINE IF FURTHER ANTIBODY RESPONSE HAS DEVELOPED. A PATIENT SPECIMEN THAT HAS TESTED REACTIVE BY A LICENSED ANTI-HCV SCREENING PROCEDURE THAT IS FOUND TO BE NEGATIVE BY RIBA HCV 3.0 SIA DOES NOT EXCLUDE THE PATIENT FROM THE POSSIBILITY OF INFECTION WITH HCV. TEST PERFORMED AT: [**Company **] [**Doctor Last Name **] INSTITUTE [**Numeric Identifier 14272**] P.0. BOX [**Numeric Identifier 19430**] CHANTILLY, [**Numeric Identifier 19431**] [**2167-10-18**] 07:15AM BLOOD ALPHA-1-ANTITRYPSIN- normal Ascitic Fluid: ASCITES ASCITES ANALYSIS WBC RBC Polys Lymphs Monos Mesothe Macroph [**2167-10-20**] 02:00PM 167* 106* 13* 53* 0 3* 31* [**2167-10-15**] 02:33PM 185* 120* 11* 27* 0 62* PERITONEAL FLUID ASCITES CHEMISTRY TotPro Glucose Creat LD(LDH) Amylase TotBili Albumin [**2167-10-20**] 02:00PM 1.1 [**2167-10-15**] 02:33PM 2.5 142 0.5 43 74 0.7 1.2 Micro Data: Peritoneal Fluid ([**10-15**]) - negative Urine Cx ([**10-12**] x 2, [**10-11**]) - negative Blood Cx ([**10-11**] x 2) - negative Cytology: Pathology Examination SPECIMEN SUBMITTED: AMPULLARY BIOPSY (1 JAR). Procedure date Tissue received Report Date Diagnosed by [**2167-10-21**] [**2167-10-23**] [**2167-10-27**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 40336**]/stu DIAGNOSIS: Ampullary mucosal biopsy: Adenocarcinoma. Peritoneal Fluid ([**10-13**]) - NEGATIVE FOR MALIGNANT CELLS. Reactive mesothelial cells, histiocytes, lymphocytes and abundant proteinaceous debris. Bile Duct Stent ([**10-13**]) - SUSPICIOUS for malignant cells. Highly atypical glandular epithelial cells, suspicious for adenocarcinoma. Studies: CTA ABD W&W/O C & RECONS [**2167-10-26**] 3:28 PM CT OF THE ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: Lung bases demonstrate mild atelectasis. There is a large amount of ascites throughout the abdomen, unchanged from prior exam. The liver is without focal lesions. Pneumobilia and intrahepatic billiary dilatation is unchanged. Patient is status post cholecystectomy. Spleen is mildly enlarged at 13.7 cm. The previously identified plastic biliary stent has been replaced with a metallic Wallstent with distal tip located within the duodenum. The area of hypoattenuation, which was seen to be surrounding the stent in the head of the pancreas is now no longer seen as it is now occupied by a larger metallic Wallstent and thus the previous findings are most likely related to a very dilated common bile duct. Pancreatic ductal dilataton is minimally increased and measures up to 8 mm and can be followed to its insertion into the common bile duct distally. In this region, there is no evidence of mass. The adrenal glands are within normal limits. Subcentimeter hypodensities are seen within bilateral kidneys, too small to characterize. Multiple prominent lymph nodes are seen within the retroperitoneum and in the peripancreatic region which are unchanged and do not meet CT criteria for pathologic enlargement. The abdominal aorta maintains a normal contour. The celiac, SMA, [**Female First Name (un) 899**] are normally opacified. The portal vein, SMV and splenic vein are pain. Intra- abdominal loops of large and small bowel maintain a normal caliber without evidence of obstruction. No intraperitoneal free air is identified. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, bladder are within normal limits. Large amount of free fluid is identified within the pelvis. No lymphadenopathy is evident. BONE WINDOWS AND SOFT TISSUES: No suspicious lytic or sclerotic lesion is identified. A hemangioma is again identified in the vertebral body of L3. Diffuse anasarca is noted. IMPRESSION: 1. Status post replacement of previously noted plastic biliary stent with a metallic Wallstent. The previosly described abnormal hypodensity around the plastic biliary stent is no longer apparent as the space is now occupied by a larger metallic stent and thus the findings on the prior exam is most likely attributable to a focally dilated common bile duct. 2. Extensive ascites throughout the abdomen and pelvis, unchanged. ERCP BILIARY&PANCREAS BY GI UNIT [**2167-10-21**] 2:50 PM FINDINGS: Eight fluoroscopic images obtained during ERCP were submitted to be evaluated by radiology. No radiologist was present during the procedure. The scout images demonstrate a plastic stent. Cannulation and opacification of the biliary duct is seen. The common bile duct is dilated and demonstrates a focal malignant appearing stricture in the lower third of the common bile duct. Small filling defects within the lower common bile duct are noted may represent stones. As per GI report, sludge and stones were extracted successfully from the CBD using a balloon catheter. Metal biliary stent was placed across the lower CBD stricture. IMPRESSION: Successful ERCP with extraction of CBD stones and metal stent placement across the lower CBD stricture. US ABD LIMIT, SINGLE ORGAN [**2167-10-19**] 9:56 AM LIVER AND GALLBLADDER ULTRASOUND: Comparison was made with the prior CT study dated [**2167-10-13**]. Liver is heterogeneous in echotexture, likely representing cirrhosis, with atrophic right lobe and pneumobilia as seen on the CT study. No intrahepatic ductal dilatation is noted except for pneumobilia. No definitive focal liver lesion is identified. Portal vein is patent bilaterally with appropriate waveforms. The gallbladder is not visualized. CBD measures 2 mm. IMPRESSION: Heterogeneous echogenicity of the liver representing cirrhosis with pneumobilia and large ascites. Patent portal veins. The evaluation of the pancreas is extremely limited, and please refer to the official report of CT scan for the pancreatic finding. CT ABDOMEN W/CONTRAST [**2167-10-13**] 2:57 PM CT OF THE ABDOMEN WITH IV CONTRAST: Small bilateral pleural effusions are noted. The lung bases are clear. There is massive ascites throughout the abdomen. The liver is without focal lesions. Pneumobilia is noted from prior stent placement. The gallbladder is not visualized. The spleen is mildly enlarged at 13.6 cm. Surrounding the stent in the head of the pancreas, there is a 1.6 cm hypodense lesion. This appears to have some ring enhancement and possibly represents a very dilated common bile duct containing the stent in its center. The pancreatic duct is dilated measuring up to 6 mm and can be followed to its insertion into the common bile duct distally. In this region, there is no evidence for a mass. The adrenal glands are unremarkable. In both kidneys, there are subcentimeter hypodense lesions which are too small to characterize but likely represent simple cysts. There are small lymph nodes in the retroperitoneum in the paraaortic region that do not meet criteria for pathologic enlargement. A borderline peripancreatic node is seen measuring 1.0 cm in short axis. CT OF THE PELVIS WITH IV CONTRAST: Again noted is massive ascites throughout the pelvis. Anasarca is also noted. Small and large bowel loops are normal other than diverticula in the sigmoid colon. There is no pelvic lymphadenopathy. On bone windows, there is a hemangioma in the vertebral body of L3. No concerning osteolytic or osteosclerotic lesions are seen. IMPRESSION: 1. Abnormality in the head of the pancreas likely represents a focally dilated common bile duct filled with sludge. A short interval followup CT possibly after stent removal is recommended to exclude a pancreatic mass. 2. Extensive ascites throughout the abdomen and pelvis and small bilateral pleural effusions as well as anasarca could be related to CHF. 3. Sigmoid diverticulosis. ECG ([**10-11**]): Sinus rhythm. The Q-T interval is prolonged. Left axis deviation. There are tiny R waves in the inferior leads consistent with possible prior inferior myocardial infarction. There is a late transition with anterolateral ST-T wave changes consistent with prior anterior myocardial infarction. Non-specific lateral ST-T wave changes. Low voltage. No previous tracing available for comparison. ERCP BILIARY&PANCREAS BY GI UNIT [**2167-10-11**] 3:14 PM FINDINGS: Six fluoroscopic images obtained during the ERCP procedure were submitted to be evaluated by radiology. No radiologist was present during the procedure. The scout image demonstrate a plastic biliary stent. Cannulation and opacification of the biliary tree demonstrate a dilated common bile duct with multiple filling defects in the lower portion. As per GI report, the biliary stent was replaced. IMPRESSION: Successful ERCP with replacement of a biliary stent. Dilated CBD with multiple filling defects likely represent stones. Brief Hospital Course: The patient is an 80 year old woman with likely biliary cancer, biliary obstruction s/p stenting presenting with cholangitis. Initially admitted to MICU due to hypotension. [**Hospital **] transferred to the floor. . # Cholangitis Underwent an initial ERCP as above with placement of a plastic stent. Was placed on Cipro/Flagyl (ultimately completed a two-week course). Initial cytology from stent raised suspicion of adenocarcinoma in the biliary tree. Patient's Alk Phos continued to trend up. Per the biliary team, patient required a repeat ERCP with placement of a metal stent. The patient was about to have the repeat procedure when she refused due to discomfort. Ultimately, with the help of the social workers, the patient agreed to have the repeat procedure. During the repeat ERCP (see above for report) the patient was found to have a malignant-appearing stricture in the distal CBD. A metal stent was placed across the stricture. Cytology from the ampulla was sent and showed an adeoncarcinoma. The patient's AlkPhos trended down after the procedure. Her diet was slowly advanced and she was able to tolerate a regular diet. . # Hypotension: Resolved with 2 L fluids over the initial 24-48 hrs. Likely related to cholangitis discussed above. SBPs ranged from mid-90s to 100s (also influenced by being on Lasix and aldactone). . # Biliary Adenocarcinoma Cytology above showed evidence of an adenocarcinoma of the biliary tree. Initial CT scan raised the suspicion of a pancreatic mass, however this was not seen in repeat CT scan after metal stent was placed. Patient will need to be set up with oncology follow up. Given patient's distance from [**Hospital1 18**], this will be arranged near her home by her PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. . # Cirrhosis/Ascites She had significant ascites on exam and imaging. Viral hepatitis serologies were sent, and were positive for HAV antibody, prior HBV exposure, and HCV indeterminate (per RIBA as above). Alpha Fetal Protein was negative. Hepatic U/S showed normal portal flows. She underwent 3 separate therapeutic paracenteses with studies as above (no evidence of SBP, SAAG of 1.1). In each of these 3-4 L of fluid were removed. She was given Albumin 25g during the last two paracenteses. Cytology from peritoneal fluid was negative. Transaminases were within normal limits. At time she appeared to have some element of confusion and was noted to have asterixis on exam c/w hepatic encephalopathy. She also had an ammonia of 88. She was started on Lactulose with improvement in her symptoms. On discharge she was AAOx3 and conversing appropriately. She was started on Lasix and Aldactone, with the doses titrated up as her blood pressure would allow. She will need outpatient GI follow up and continued paracenteses. . # Zoster: Patient was diagnosed with zoster in left upper buttocks. Was given acyclovir for 7 day course. . # CAD: No current symptoms with non-specific changes on EKG. Cardiac enzymes negative for acute ischemia. Was maintained on ASA. She was not maintained on a beta blocker due to her low blood pressure. . # COPD: No current issues. Continue on inhalers. . # Anxiety/Trigeminal Neuralgia: Continue on home carbamazepine. Prior to discharge had slight discomfort with neuropathic pain when eating. . # Dispo - she was seen by physical therapy who clared her for return back to her [**Hospital3 **] facility with services in place. Medications on Admission: Carbamazepine 100 mg [**Hospital1 **] prilosec OTC 20 mg daily Lopressor 12.5 mg [**Hospital1 **] aldactone 25mg [**Hospital1 **] tylenol 650mg q4h:prn Milk of Magnesium 30mL daily:PRN Ducolax PR daily:prn compazine 5mg q8:prn Discharge Medications: 1. Carbamazepine 200 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): [**Month (only) 116**] substitute 100mg tablet. Disp:*30 Tablet(s)* Refills:*2* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three times a day: Hold if having [**1-3**] bowel movements daily. Disp:*2700 ML(s)* Refills:*2* 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*1 MDI* Refills:*2* 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Primary: Cholangitis Cirrhosis with ascites Possible cholangiocarcinoma Herpes Zoster Secondary: Hypertension Coronary Artery Disease COPD Discharge Condition: Afebrile, vital signs stable. Tolerating regular diet. Ambulating with walker. Discharge weight - 119 lbs. Discharge Instructions: You were admitted with an infection of your bile ducts. You underwent an ERCP 2 times (the second time a metal stent was placed in your bile ducts). During your first ERCP, the biopsies show that you may have cancer of your bile ducts. You also have cirrhosis of your liver with a resulting fluid accumulation (ascites) in your belly. To help with the symptoms, you underwent a paracentesis 3 times (the last being today, [**10-27**]). . You will need to follow up with your doctor as below. He can arrange for you to see a gastroenterologist (liver doctor) so that you can continue to have fluid drained from your belly as you need it. He can also arrange for you to see an oncologist if necessary regarding the possible cancer of your bile ducts. . Please call your doctor or return to the emergency room if you have increasing belly pain, nausea, fevers, chest pain, or shortness of breath. Followup Instructions: PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 13740**] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 16827**]. Follow up with Nurse Practitioner [**First Name (Titles) **] [**Last Name (Titles) 2974**] [**2167-10-30**] at 10AM. Name: [**Known lastname 12413**],[**Known firstname 12414**] Unit No: [**Numeric Identifier 12415**] Admission Date: [**2167-10-11**] Discharge Date: [**2167-10-27**] Date of Birth: [**2087-4-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2403**] Addendum: CA19-9 was sent and still pending at the time of discharge. This will need to be followed up. Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services [**Name6 (MD) **] [**Last Name (NamePattern4) 2404**] MD [**MD Number(2) 2405**] Completed by:[**2167-10-29**]

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icd9cm

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icd9pcs

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22905, 23113

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339, 474

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18807

Discharge summary

report

Admission Date: [**2145-9-30**] Discharge Date: [**2145-10-14**] Date of Birth: [**2084-4-20**] Sex: M Service: THORACIC SURGERY/MICU/[**Location (un) 259**] HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 51497**] is a 61 year-old male with a one year history of nonsmall cell lung cancer who was transferred from an outside hospital to Cardiothoracic Surgery on [**2145-9-30**]. The patient originally presented to the outside hospital on [**9-18**] with nausea and vomiting and found to have a small bowel obstruction. A CT of the chest also revealed a right sided pleural effusion as well as an obstructing right upper lobe mass. CT scan of the abdomen showed small bowel obstruction secondary to diffuse abdominal metastases and the patient underwent exploratory laparotomy with small bowel resection on [**9-23**]. His postoperative course was complicated by fevers and he was initially treated with Zosyn. By report all blood and urine cultures were negative. The patient was then transferred to [**Hospital1 69**] on [**9-30**] for further management of the right upper lobe obstructing mass. On admission the patient denies any chest pain, shortness of breath or dizziness. He did complain of a cough productive of clear sputum. PAST MEDICAL HISTORY: 1. Stage four nonsmall cell lung cancer diagnosed in [**2144-9-3**] status post chemo/radiation with metastases to the abdomen. 2. Paroxysmal atrial fibrillation. 3. Small bowel obstruction secondary to abdominal mets status post small bowel resection. MEDICATIONS AT HOME PRIOR TO HOSPITAL ADMISSION: Prednisone 20 mg po q day started by the patient's primary care physician for shortness of breath. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient was an electrician with the [**State 350**] National Guard. He retired last year. He lives on [**Location (un) **]. He has never been married and has no children. The patient has a 30 pack year cigarette smoking history. He quit in the [**2122**]. He drinks every once in a while and denies any intravenous or recreational drug use. FAMILY HISTORY: The patient denies any family history of cancer. PHYSICAL EXAMINATION ON TRANSFER TO THE MEDICINE SERVICE: Temperature max 98.9. Current temperature 98.8. Blood pressure 145/84. Heart rate 97. Respiratory rate 20. Oxygen saturation 98% on 1 liter nasal cannula. In general, the patient is awake, alert, appears his stated age and in no acute distress. He is cooperative with the examination, but very grouchy. HEENT examination pupils are round and reactive to light. Extraocular movements intact. Sclera anicteric. Oropharynx is clear. Neck is supple. Chest examination coarse breath sounds on the right greater then left, no wheezing, no dullness to percussion with decreased breath sounds at the right lung base. Cardiovascular examination regular rate and rhythm. Abdominal examination soft, nontender, nondistended with good bowel sounds. A well healing midline scar with mild erythema. Extremities no lower extremity edema. Neurological examination alert and oriented times three. Cranial nerves II through XII grossly intact. Strength 5 out of 5 in the upper and lower extremities. Sensation intact to light touch in the upper and lower extremities. LABORATORIES ON TRANSFER FROM THE CARDIOTHORACIC SURGERY SERVICE TO THE MEDICINE SERVICE: White blood cell count is 4.4, hematocrit 26.4, platelets 399, creatinine 0.7, glucose 112. Chest x-ray shows large medial right upper lobe mass with opacification at the right heart border due to collapse or consolidation of the right lower lobe. There is an irregular pleural thickening on the right apex as well as the chest wall. There is a hydropneumothorax at the right apex. The left lung is clear with gross interstitial markings. HOSPITAL COURSE: 1. Lung cancer: The patient was transferred from an outside hospital following small bowel resection for further management of the right upper lobe obstructing tumor. The patient was initially admitted to the Thoracic Surgery Service. Interventional pulmonary was consulted. On [**10-1**] interventional pulmonary performed a rigid bronchoscopy with placement of the right upper lobe stent. A chest tube was also placed into the right chest wall for evacuation of the right pleural effusion. Steroids, which had been started at the outside hospital were continued for the patient's wheezing and dyspnea. On [**10-4**] the chest tube was removed following resolution of the pleural effusion. The patient's steroids were slowly tapered over the course of a week. Zosyn had also been started at the outside hospital for postoperative fever and the patient was continued on Zosyn intravenously. He was eventually switched to Flagyl and Levofloxacin po and received a total of 18 days of antibiotics. His postoperative fever was believed to be due initially to postoperative pneumonia, however, the patient continued to have low grade fevers to 100 despite antibiotics. Multiple blood cultures and sputum cultures and urine cultures were obtained, which were all negative. It was believed that the continued fevers on antibiotics was possibly due to either tumor fever or a drug reaction to the antibiotics. Following stent placement and chest tube removal the patient continued to have intermittent shortness of breath and worsening cough and he was taken by interventional pulmonary for a repeat bronchoscopy on [**10-12**] for removal of mucous plug. Following this repeat bronch the patient symptomatically felt better, but continued to require oxygen by nasal cannula at 2 liters. Following discussion with the patient, interventional pulmonary decided to attempt photodynamic therapy. On [**10-8**] he received his infusion of Photofrin followed by light treatment on [**10-12**] and finally a bronchoscopy to clean out necrotic tissue on [**10-13**]. The patient tolerated this procedure well without any complications. Throughout the hospital course the patient was continued on aggressive chest CT, incentive spirometry, Albuterol nebulizers, Atrovent nebulizers and cough syrup. A physical therapy consult was obtained and they determined that he would require outpatient chest physical therapy as well as home oxygen therapy. At the time of discharge the patient's cough and shortness of breath had much improved and he was arranged to follow up with outpatient chest physical therapy. 2. Fever: The patient was transferred from an outside hospital on Zosyn intravenously for postoperative fever. It was believed the cause of his fevers to be due to a post obstructive pneumonia. He was continued on Zosyn intravenously initially in his hospital course and was eventually switched to po antibiotics when the patient was tolerating po well. He was started on Flagyl and Levofloxacin to complete the total 18 day antibiotic course. The patient continued to have low grade fevers to 100 despite these antibiotics. Multiple blood cultures, urine cultures and sputum cultures all returned negative. It was believed the cause of his continued fevers to be due to either tumor fever or drug reaction. 3. Atrial fibrillation: The patient has a history of paroxysmal atrial fibrillation, which was detected at the outside hospital. At [**Hospital1 69**] the patient had one brief 10 second episode of what appeared to be atrial fibrillation. The patient was asymptomatic during this episode. The patient had no further episodes of atrial fibrillation throughout the remainder of the hospital course. 4. Small bowel obstruction: The patient had a small bowel resection on [**9-23**] at the outside hospital for small bowel obstruction due to lung metastases. At the time of transfer the patient was tolerating po and having bowel movements and he continued to have [**Last Name **] problem throughout the remainder of his hospital course. 5. Diarrhea: The patient complained of multiple loose bowel movements - up to four bowel movements a day. Multiple samples were tested for C-diff all of which returned negative and the patient's diarrhea eventually subsided. No cause was found for this diarrhea. 6. Anemia: On transfer to [**Hospital1 69**] the patient's hematocrit was 26. Anemia studies were consistent with an anemia of chronic disease, although the patient was already on iron supplements. His hematocrit remained stable at 26 throughout most of the hospital course. On the day prior to discharge his hematocrit decreased to 23.5. A repeat hematocrit confirmed this decrease and the patient received 1 unit of packed red blood cells. The morning following his transfusion his hematocrit had appropriately increased. The patient's stool was also tested for blood, but found to be guaiac negative. He was discharged on his iron supplements. 7. Methemoglobinemia: On [**10-11**] while receiving his light treatment the patient's O2 sats dropped to 54%. An arterial blood gas showed 16% methemoglobinemia and the patient received Methylene blue times one dose empirically. The cause for his methemoglobinemia was believed to be due to the Lidocaine with a possible contribution for Metoclopramide, which the patient had been taking for nausea and vomiting and from Benzonatate, which the patient had been taking for his cough. The patient was transferred to the Medical Intensive Care Unit for observation following the procedure. His O2 sats remained stable and he developed no signs of symptoms of cyanosis, so the following day he was able to be transferred back to the Medicine [**Hospital1 **]. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is discharged back to his home in [**Hospital3 **]. His sister will be living with him and he will be receiving chest physical therapy as an outpatient. The patient was also discharged with home O2. DISCHARGE DIAGNOSES: 1. Malignant pleural effusion. 2. Stage four nonsmall cell lung cancer status post right bronch stent placement and photodynamic therapy. 3. Paroxysmal atrial fibrillation. 4. Anemia of chronic disease. 5. Methemoglobinemia. 6. Small bowel obstruction status post small bowel resection. DISCHARGE MEDICATIONS: 1. Iron polysaccharide complex 150 mg po b.i.d. 2. Levofloxacin 500 mg po q day for two more days. 3. Metronidazole 500 mg po t.i.d. for two more days. 4. Metoprolol 125 mg po b.i.d. 5. Lorazepam 0.5 mg po q 4 to 6 hours prn anxiety. 6. Megestrol 40 mg po t.i.d. 7. Guaifenesin/dextromethorphan syrup po q 4 hours prn cough. 8. Albuterol one puff inhaled 4 to 6 hours prn. 9. Ipratropium one puff q 6 hours prn. FOLLOW UP PLANS: The patient is asked to follow up with his oncologist Dr. [**Last Name (STitle) 51498**] at [**Hospital 40262**] Hospital for further chemotherapy. The patient prior to hospital admission had discussed with Dr. [**Last Name (STitle) 51498**] trying another round of chemotherapy after the patient regained his strength. He is also asked to follow up with his primary care physician in one to two weeks. The patient was also given information concerning his outpatient chest rehab. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Last Name (STitle) 51499**] MEDQUIST36 D: [**2145-10-14**] 03:05 T: [**2145-10-15**] 12:47 JOB#: [**Job Number 51500**]

[ "197.2", "518.0", "512.1", "485", "162.3", "427.31", "285.9", "198.89", "519.1" ]

icd9cm

[ [ [] ] ]

[ "96.05", "34.04", "33.24", "32.28", "34.21" ]

icd9pcs

[ [ [] ] ]

2119, 3832

9893, 10187

10210, 11375

3850, 9605

204, 1266

1288, 1733

1750, 2102

9630, 9872

9,402

122,069

2636

Discharge summary

report

Admission Date: [**2154-8-16**] Discharge Date: [**2154-8-17**] Date of Birth: [**2084-3-11**] Sex: F Service: MEDICINE Allergies: Aspirin / Aleve Attending:[**First Name3 (LF) 297**] Chief Complaint: CHF exacerbation. Major Surgical or Invasive Procedure: None. History of Present Illness: 70 yo F with h/o CHF (LVEF 54%), CAD, ESRD on HD, DM2, GAVE p/w dyspnea. Around 7 pm yesterday pt had episode of diaphoresis/nausea followed by dyspnea one later. Denies associated CP, though did feel mild left posterior neck pain just prior to onset. Sx felt like past episodes of heart failure. Admits to taking in more fluid than allowed by restriction. Ate a salty meal last night off her diet. Has been taking her meds. Given worsening symptoms EMS called. . In [**Hospital1 18**] ED vitals T98, hr 130, bp 208/141, rr 30, satting 99% on 2L NC. Nitro gtt started. Given captopril 25 mg po, lasix 80 mg IV x 1. UOP approx 500 cc. CXR demonstrated interval worsening of pulmonary edema since [**8-12**] (recent admit for CP). EKG with ST@ 110 bpm, no ST-T changes. Labwork cr 5.1. Tpn 0.02 (chronically elevated 0.02-0.04), CK-MB negative. Pt's BP stabilized in the ED to systolics 150s, dyspnea improved. . Pt transferred to the ICU for further monitoring. Past Medical History: --Chronic Gastric Angiodysplasia (GAVE)and consequent chronic low-grade UGIB, and has therefore been advised not to take aspirin or other antiplatelet agents. --DM type II - c/b nephropathy and neuropathy --ESRD - on HD since [**11-30**] --CAD - suspected by stress test ([**Doctor Last Name 4001**]) in [**2153-5-22**]: Mild global hypokinesis. LVEF 43%. Normal myocardial perfusion at the level of stress achieved\; stress [**5-30**]: IMPRESSION: 1. Abnormal myocardial perfusion scan demonstrating new inferior wall ischemia which is hypokinetic. 2. LVEF = 54% --CHF: TTE [**1-28**]: mild concentric left ventricular hypertrophy without dilatation, a left ventricular ejection fraction of 55%, and moderate-to-severe mitral regurgitation, mild-to-moderate tricuspid regurgitation and mild pulmonary hypertension --Anemia: multifactorial (ESRD + iron deficiency [**12-27**] GIB) - colonoscopy on [**2153-8-7**] -> two nonbleeding polyps in sigmoid - EGD [**2153-8-7**] -> sig for erythema, edema, and erosion in the antrum c/w gastritis in addition to erythema in the proximal bulb c/w duodenitis - EGD [**12-31**] demonstated GAVE (duodenal ectasia) --Occult GI bleed [**7-/2153**] with studies as above --Gout Social History: Pt lives with her grandson. She has a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 13233**]. No ETOH, tobacco, or drugs. Family History: [**Name (NI) 1094**] son and daughter have DM. Her son also has HTN. Her mother had an MI in her 80s Physical Exam: Temp 97.2 BP 152/84 Pulse 96 Resp 20 O2 sat 98% Gen - Alert, no acute distress HEENT - extraocular motions intact, anicteric, mucous membranes moist Neck - no JVD appreciated, no cervical lymphadenopathy, left cervial trapezius mild ttp Chest - crackles [**11-26**]-way up bilaterally CV - Normal S1/S2, RRR, no murmurs appreciated Abd - Soft, nontender, mildly distended ventral hernia, normoactive bowel sounds Extr - No edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, non-focal Skin - No rash Pertinent Results: [**2154-8-16**] 02:15AM BLOOD WBC-7.9 RBC-3.98* Hgb-12.7 Hct-39.3 MCV-99* MCH-31.9 MCHC-32.2 RDW-17.7* Plt Ct-191 [**2154-8-17**] 03:20AM BLOOD WBC-7.6 RBC-3.81* Hgb-11.9* Hct-37.4 MCV-98 MCH-31.2 MCHC-31.9 RDW-18.0* Plt Ct-213 [**2154-8-16**] 02:15AM BLOOD Glucose-185* UreaN-50* Creat-5.1*# Na-144 K-4.1 Cl-105 HCO3-25 AnGap-18 [**2154-8-17**] 03:20AM BLOOD Glucose-105 UreaN-32* Creat-4.1*# Na-142 K-3.8 Cl-103 HCO3-28 AnGap-15 Brief Hospital Course: A/P: 70 yo F with h/o CHF (LVEF 54%), CAD, ESRD on HD, DM2, GAVE p/w dyspnea. . Pulmonary edema: Potential precipitants failure include HTN, overload associated with renal failure, dietary indiscretion, ischemia. --cont nitro gtt, will attempt wean today --increase ACE-I, increase BB --continue diuresis with lasix iv prn (pt still making urine) --HD as below --cycle enzymes --daily weights, strict I/Os . CAD: presently w/o CP though ischemia a potential precipitant as above --cont BB, statin, ACE-I --allergic to ASA; other anti-coagulants held in past due to GAVE . ESRD on HD: pt on M-W-F schedule. Renal aware. Will dialyze today. . DM2: --hold home glyburide --ISS . FEN: DM/renal/low Na/HH diet, fluid restrict . ppx: boots, ppi . access: PIVs . Full Code . Communication: son [**Name (NI) **] ([**Telephone/Fax (1) 13235**] HD#2 Pt stable and doing very well after diuresis. Was D/C to home with PCP [**Name9 (PRE) 702**] in 2 weeks. Pt give Rx for new dose of ACEI and Metoprolol Medications on Admission: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain, fever. 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. 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. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO twice a day. Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap 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 With Service Facility: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13089**] Services Discharge Diagnosis: Primary: --CHF exacerbation . Secondary: --Chronic Gastric Antral Vascular Ectasia (GAVE) and consequent chronic low-grade UGIB, has therefore been advised not to take aspirin or other antiplatelet agents. --DM type II - c/b nephropathy and neuropathy --ESRD - on HD since [**11-30**] --CAD - p-MIBI [**5-30**] 1. Abnormal myocardial perfusion scan demonstrating new inferior wall ischemia which is hypokinetic. 2. LVEF = 54% Stress [**5-30**] IMPRESSION: Anginal type symptoms with non-diagnostic EKG changes. --CHF: TTE [**1-28**]: mild concentric left ventricular hypertrophy without dilatation, a left ventricular ejection fraction of >55%, and moderate-to-severe mitral regurgitation, mild-to-moderate tricuspid regurgitation and mild pulmonary hypertension --Anemia: multifactorial (ESRD + iron deficiency [**12-27**] GIB) - colonoscopy on [**2153-8-7**] -> two nonbleeding polyps in sigmoid - EGD [**2153-8-7**] -> sig for erythema, edema, and erosion in the antrum c/w gastritis in addition to erythema in the proximal bulb c/w duodenitis - EGD [**12-31**] demonstated GAVE (duodenal ectasia) --Gout Discharge Condition: Afebrile, vital signs stable. At dry weight 59.5kg. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. . Adhere to 2 gm sodium diet . Fluid Restriction: 1 liter . Please take your medications as prescribed. . Please call your primary care doctor to arrange follow-up within the next two weeks. . You were admitted to the hospital for a congestive heart failure exacerbation. You should call your doctor or return to the ER should you experience any of the following: Severe Increase in pain Fever > 101 Severe pain in chest Numbness/Tingling/Paralysis Severe Dizziness Nausea/Vomiting Severe Chest Pain/SOB Any other symptoms that worry you. Followup Instructions: Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Known firstname 2048**] [**Last Name (NamePattern1) 4223**], within the next two weeks. Call [**Telephone/Fax (1) 7976**] to schedule an appointment. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**] Date/Time:[**2154-12-25**] 10:40 Completed by:[**2154-8-17**]

[ "428.0", "250.60", "403.91", "250.40", "537.82", "397.0", "585.6", "424.0", "357.2", "274.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

6977, 7121

3810, 4807

293, 301

8275, 8329

3355, 3787

8990, 9397

2705, 2807

5996, 6954

7142, 8254

4833, 5973

8353, 8967

2822, 3336

236, 255

329, 1292

1314, 2531

2547, 2689

69,323

137,932

520

Discharge summary

report

Admission Date: [**2199-7-28**] Discharge Date: [**2199-8-5**] Date of Birth: [**2116-9-4**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2610**] Chief Complaint: Chest pain and bright red blood per rectum Major Surgical or Invasive Procedure: Colonoscopy [**2199-8-2**] Bleeding scan [**2199-7-30**] Transfused 6 units PRBC History of Present Illness: 82 yo F with hx of prior CVA with residual R-sided weakness, AS ([**Location (un) 109**] 1.2 cm2), known cecal and splenic flexure masses, recently admitted for sub-sternal chest pressure in the setting of BRBPR and a Hct of 20.8 presents with substernal chest pressure in setting of BRBPR. . Of note the patient was admitted from [**2199-7-13**] through [**2199-7-16**] with BRBPR, acute on chronic anemia and chest pain with ECG changes. The patient was observed in the MICU for 1 day and given a total of 4pRBCs on [**2199-7-13**] that brought her Hct from 20.8 to 30.8. The patients chest pain subsequently resolved and she was discharged home. There was a recommendation for tagged RBC scan during that admission, however she had no further episodes of bleeding during the hospitalization. . Since discharge the patient has had mulitple episodes of BRBPR. Last night the pt noted "significant BRBPR". On the morning of admission patient reported substernal chest pain across her chest that resembled prior episodes of chest pain. She was brought to the ED, where initial VS were 97.8 77 141/48 19 97. Labs were notable for Hct of 20.7 (down from 27.6 on [**7-23**]). ECG notable for NSR 66 STD V3-6. General surgery was consulted. The patient was admitted to MICU for closer monitoring. Past Medical History: -Acute on Chronic GI Bleed ([**2199-7-13**]) with associated CP requiring 4pRBCs -L MCA infarct [**2181**], residual R sided deficits -AS ([**Location (un) 109**] 1.1 cm2 by TTE [**3-2**]) -HTN -Carotid stenosis -Moderate pulm HTN -Cecal and splenic flexure mass ([**4-1**] Bx showed superficial fragments of colonic mucosa with rare dilated crypts, granulation tissue formation and focal ulceration may be seen overlying/adjacent to a mass lesion or may represent superficial sampling of an inflammatory-type polyp) -Diverticulosis -Internal hemorrhoids Social History: H/o tobacco use. 3 children (2 sons, 1 daughter, son in [**Name (NI) 4310**] assists w/ care), many grandchildren. Walks w/ a cane at baseline. Uses meals on wheels. VNA services weekly. Family History: Mother d. cancer, Father d. CAD, children healthy Physical Exam: VS: 98.3 144/58 66 18 97%RA 8H: 0 + 10 / 600+ (BRP) 24H: 300 + 700 / 450+ Gen: awake, sitting on edge of bed, NAD HEENT: EOMI, PERRL, MMM, oropharynx clear without erythema or exudate, neck supple, no JVD, no cervical or supraclavicular LAD CV: RRR, III/VI crescendo-decrescendo murmur radiating to the carotids, no rubs or gallops, nl S1+S2 Lung: CTAB, no wheezes rales or rhonchi Abd: soft, obese, nontender, nondistended, +BS, no rebound or guarding, no HSM Ext: W/WP, no C/C/E, 1+ DP pulses b/l Skin: warm, dry & intact without rashes or lesions Neuro: A+Ox3, CN II-XII grossly intact with no focal deficits. Some residual R-sided strength deficit from prior CVA. Gait not observed. Pertinent Results: ADMISSION LABS: [**2199-7-28**] 04:04PM BLOOD WBC-5.5 RBC-2.23*# Hgb-6.6*# Hct-20.7* MCV-93 MCH-29.7 MCHC-32.0 RDW-16.0* Plt Ct-354 [**2199-7-28**] 04:04PM BLOOD Neuts-65.7 Lymphs-24.5 Monos-5.3 Eos-3.5 Baso-0.9 [**2199-7-28**] 04:04PM BLOOD PT-12.8 PTT-23.8 INR(PT)-1.1 [**2199-7-28**] 04:04PM BLOOD Glucose-99 UreaN-36* Creat-1.1 Na-138 K-4.5 Cl-105 HCO3-24 AnGap-14 [**2199-7-29**] 05:04PM BLOOD Hct-30.7* [**2199-7-29**] 12:22AM BLOOD CK-MB-2 cTropnT-<0.01 [**2199-7-28**] 04:04PM BLOOD cTropnT-<0.01 . DISCHARGE LABS: [**2199-8-5**] 06:45AM BLOOD WBC-6.5 RBC-4.10*# Hgb-11.5*# Hct-36.7# MCV-90 MCH-27.9 MCHC-31.2 RDW-15.1 Plt Ct-465* [**2199-8-5**] 06:45AM BLOOD Glucose-80 UreaN-12 Creat-0.8 Na-144 K-4.7 Cl-110* HCO3-25 AnGap-14 [**2199-8-5**] 06:45AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.2 . [**2199-8-2**] Colonoscopy Report Impression: Mass in the hepatic flexure Mass in the splenic flexure Polyp in the sigmoid colon (polypectomy) Polyp in the rectum Diverticulosis of the whole colon Otherwise normal colonoscopy to Terminal ileum . GI BLEEDING STUDY Study Date of [**2199-7-30**] IMPRESSION: No evidence of active gastrointestinal bleed. . CHEST (PORTABLE AP) Study Date of [**2199-7-28**] 5:20 PM IMPRESSION: Left base linear atelectasis/scarring. Otherwise, no acute cardiopulmonary abnormality. Brief Hospital Course: 82F with hx of prior CVA with residual R-sided weakness, AS ([**Location (un) 109**] 1.2 cm2), known cecal and splenic flexure masses, recently admitted for sub-sternal chest pressure in the setting of BRBPR and a Hct of 20.8 presents with substernal chest pressure in setting of BRBPR. She was ruled out for MI by EKG and enzymes. . # GI Bleed: Admission Hct was 20.7, and pt was transfused a total of 4 units PRBC to maintain a hct in the high 20s to low 30s. Pantoprazole drip started; switched to PO on the floor. She continued to have melenic and frankly bloody bowel movement. NG lavage was negative for UGI bleed; did not show any bile. Tagged RBC scan did not show active bleed. Colonoscopy showed splenic flexure and hepatic flexure masses concerning for malignancy; also showed rectal polyp that was presumed to be the source of bleeding (although was not bleeding at the time of colonscopy). Discussion regarding surgery vs medical management was ongoing throughout admission. Ultimately surgery decided that they would not intervene and recommended that patient follow up as an outpatient or sooner if she were to re-bleed. Patient's aspirin and lisinopril were held. # Substernal Chest Pressure: Resembles prior episode in setting of ECG changes suggestive of ischemia. Cardiac biomarkers negative. Likely demand ischemia in setting of gastrointestinal bleed. Pain resolved and patient's hct was kept in 28-30 range. Statin was continued. . # HTN: BP stable. Antihypertensives were initially held in the setting of bleed, but verapamil was eventually restarted. Lisinopril was discontinued per [**Female First Name (un) **] recommendations. . # Prophylaxis: Pneumatic boots. . # Code: Full code Medications on Admission: ASA 81 mg Simvastatin 20 mg daily Lisinopril 10 mg daily Verapamil 240 mg daily Ferrous sulfate 325 mg daily Vit D Vit C MVI Omega-3 Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Outpatient Lab Work Blood work to be drawn every Monday and Thursday. Check CBC with results faxed to Dr. [**First Name8 (NamePattern2) 4311**] [**Last Name (NamePattern1) 4312**] at [**Telephone/Fax (1) 716**]. 8. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary 1. Lower gastrointestinal bleed 2. Rectal polyp 3. Colonic masses at the hepatic and splenic flexures 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: 1. You were admitted for GI bleeding. You had several studies or procedures performed, and we determined that your bleeding was coming from a rectal polyp. You will need to have blood work as an outpatient, with results faxed to your PCP. [**Name10 (NameIs) **] you have continued bleeding, you should see your PCP or go to your local Emergency Department immediately. 2. You were also found to have two masses in your colon that are concering for cancer. You will need to follow-up with your Surgeon and Gastroenterologist as an outpatient. 3. Should should take your medications as prescribed. - STOP taking aspirin - STOP taking lisinopril 4. It is very important that you keep all of your doctors [**Name5 (PTitle) 4314**]. Followup Instructions: Department: GERONTOLOGY When: TUESDAY [**2199-8-6**] at 4:00 PM With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 719**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: SURGERY When: Thursday, [**8-22**] at 10 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Street Address(2) **]., [**Location (un) **] MA Phone: [**Telephone/Fax (1) 9**] Department: GERONTOLOGY When: TUESDAY [**2199-8-27**] at 3:30 PM With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 719**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: CARDIAC SERVICES When: FRIDAY [**2199-11-29**] at 10:20 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2199-8-6**]

[ "424.1", "211.3", "729.89", "401.9", "438.89", "416.8", "239.0", "719.7", "578.9", "569.0", "562.10", "414.8", "433.10", "285.1" ]

icd9cm

[ [ [] ] ]

[ "45.42" ]

icd9pcs

[ [ [] ] ]

7399, 7456

4666, 6377

356, 439

7610, 7610

3335, 3335

8549, 9828

2561, 2612

6560, 7376

7477, 7589

6403, 6537

7793, 8526

3858, 4643

2627, 3316

274, 318

467, 1760

3351, 3842

7625, 7769

1782, 2340

2356, 2545

46,007

178,313

38381

Discharge summary

report

Admission Date: [**2138-5-11**] Discharge Date: [**2138-5-19**] Date of Birth: [**2075-5-12**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: [**2138-5-11**] Flexible bronchoscopy with BAL; left back evacuation of hematoma with repair of diaphragmatic laceration. History of Present Illness: 62 yo MALE admitted s/p fall. He suffered a fall while intoxicated this a.m. down some stairs. He was on the ground for a few hours, then reportedly managed to crawl to a recliner chair prior to seeking emergency care. He was noted to have left rib fractures from [**4-29**] with consequent pneumothorax s/p chest tube placement and pulmonary contusions. The patient was evaluated in the emergency dept and had shallow breathing though he was able to speak in full sentences. He reports severe pain from below the nipple to above the umbilicus on the left, without radiation to the upper extremity. The pain is exacerbated by breathing, coughing and movement. There is some improvement with narcotic pain medication. He denies any numbness, tingling or motor weakness in any of his extremities. There has been no loss of control of bowel or bladder. The patient denies a history of chronic back pain or back surgery. Past Medical History: HTN, anxiety PSH: Prostatectomy Social History: +EtOH Family History: Noncontirbutory Physical Exam: Upon presentation: T 99.7 BP 123/67 P 87 R 18 SPO293% 6l o2 via nc PAIN [**9-28**] HEENT: PERRL NECK: Soft CHEST: + chest tube LEFT, +large eccymoses LEFT flank, + ttp LEFT chest ABD: soft BACK: deferred N: CN 2-12 GI Light touch intact bilat UE & LE Str 4+ to [**4-23**] bilat UE & LE (some challenge with moving LUE [**1-21**] pain) Pertinent Results: [**2138-5-11**] 10:49PM GLUCOSE-144* LACTATE-2.1* NA+-135 K+-4.8 CL--103 [**2138-5-11**] 10:35PM WBC-9.7 RBC-3.33* HGB-10.4* HCT-29.7* MCV-89 MCH-31.4 MCHC-35.1* RDW-15.2 [**2138-5-11**] 10:35PM PLT COUNT-128* [**2138-5-11**] 10:35PM PT-13.6* PTT-29.8 INR(PT)-1.2* [**2138-5-19**] 08:35AM BLOOD WBC-8.8# RBC-3.20* Hgb-10.0* Hct-30.0* MCV-94 MCH-31.4 MCHC-33.4 RDW-15.9* Plt Ct-315 [**2138-5-17**] 12:00PM BLOOD WBC-18.8*# RBC-3.49* Hgb-11.2* Hct-32.5* MCV-93 MCH-32.0 MCHC-34.4 RDW-15.9* Plt Ct-219 [**2138-5-16**] 07:35AM BLOOD WBC-8.8 RBC-3.27* Hgb-10.2* Hct-29.5* MCV-90 MCH-31.2 MCHC-34.6 RDW-15.7* Plt Ct-238 [**2138-5-15**] 04:46AM BLOOD WBC-7.3 RBC-3.06* Hgb-9.3* Hct-27.4* MCV-90 MCH-30.4 MCHC-34.0 RDW-15.6* Plt Ct-188# [**2138-5-14**] 09:44AM BLOOD Hct-28.1* [**2138-5-14**] 02:06AM BLOOD WBC-6.3 RBC-3.07* Hgb-9.7* Hct-26.9* MCV-88 MCH-31.6 MCHC-36.0* RDW-16.0* Plt Ct-117* [**2138-5-13**] 05:03PM BLOOD Hct-28.1* [**2138-5-13**] 11:29AM BLOOD Hct-28.5* IMAGING: CT chest [**2138-5-11**]: Preliminary Report !! WET READ !! 1. Extensive left neck and chest wall subcutaneous emphysema, accompanied by pneumomediastinum. 2. Moderate-sized left pneumothorax. 3. Small focus of air anterior to the right lung is likely part of pneumoediastinum, however, close followup is recommended as this may develop into a pneumothorax. 4. left [**3-31**] posterior rib fx, with significant displacement of 7th-11th fxs. 5. Hypodense linearity within the spleen may represent a laceration, however, further assessment is limited due to motion artifact. 6. No retroperitoneal or intra-abdominal hematoma. 7. Great vessels appear intact. 8. Right scapula tip fx. 9. Nondisplaced fx of 8th and 9th left thoracic transverse processes . CTOH [**2138-5-11**]: Preliminary Report !! WET READ !! No acute intracranial process. CT C/S Preliminary Report !! WET READ !! No acute fx or traumatic malalignment of the C spine. Mild posterior disc bulge at C4/5 resulting in mild canal narrowing. MRI can be considered if there are localizing neurological symptoms. Extensive L>R soft tissue emphysema, extending to the prevertebral soft tissues. Pneumomediastinum. CXR [**2138-5-11**]: IMPRESSION: Interval placement of left lower thoracic chest tube. CXR [**2138-5-11**]: IMPRESSION: 1. Multiple left lateral displaced rib fractures. 2. Moderate amount of subcutaneous emphysema at the left lateral chest wall. 3. Pneumomediastinum. 4. Left anterior pneumothorax. 5. Patchy opacities at the left lung base may represent atelectasis or contusion. Brief Hospital Course: He was admitted to the trauma service and transferred to the Trauma ICU for further monitoring and analgesia. The Acute Pain Service was consulted for paravertebral catheter placement. He was given an intravenous banana bag; his chest tube output was noted with high output >200cc/hr and he was transfused. Arterial and central lines placed and he was taken to the OR for flexible bronchoscopy with BAL; left back evacuation of hematoma with repair of diaphragmatic laceration. He remained in the ICU and was extubated on [**5-13**]; CT #1 was removed on [**5-14**] and he was transferred to the regular nursing unit. On [**5-15**] the remaining chest tubes were removed. He continued to have pain control issues which were eventually controlled with oral narcotics prior to his discharge. Hepatology was consulted for hyperalbuminemia who recommended following his LFT's which remained mildly elevated and that he follow up with his primary care physician for his baseline mild hyperalbuminemia after discharge. He was evaluated by Physical therapy and recommended for home PT. He was also followed closely by Social Work. Medications on Admission: Atenolol 50mg qd Alprazolam 0.5 tid prn anxiety Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Taclonex Topical 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Tablet, Delayed Release (E.C.)(s) 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Oxycodone 10 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:*35 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: s/p Fall Left rib fractures [**4-29**] Pneumothorax/hemothorax Pneumomediastinum Diaphragmatic laceration Right scapula tip fracture Nondisplaced fractures of T [**7-28**] left transverse process Discharge Condition: Ambulating Tolerating regular diet Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: Your liver enzymes were elevated. We recommend not drinking alcohol or taking tylenol. These will be checked at your follow up appointment. *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving with pain medication or is getting worse. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-28**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Follow up with thoracic surgeon Dr. [**Last Name (STitle) **] in [**12-21**] weeks, call [**Telephone/Fax (1) 66315**] for an appointment. Follow up with Dr. [**Last Name (STitle) **] in [**12-21**] weeks. Call [**Telephone/Fax (1) 1864**] for an appointment. Completed by:[**2138-7-31**]

[ "E880.9", "807.09", "860.4", "958.7", "805.2", "861.21", "811.00", "V10.46", "285.1", "862.0" ]

icd9cm

[ [ [] ] ]

[ "03.90", "34.21", "34.82", "34.22", "34.09", "38.91", "96.04", "96.72" ]

icd9pcs

[ [ [] ] ]

6479, 6554

4442, 5571

322, 446

6794, 6830

1879, 4419

8977, 9270

1491, 1508

5670, 6456

6575, 6773

5597, 5647

6854, 8445

8461, 8954

1523, 1860

274, 284

474, 1395

1418, 1452

1468, 1475

13,995

186,051

2072

Discharge summary

report

Admission Date: [**2153-6-22**] Discharge Date: [**2153-6-26**] Service: NME DATE OF EXPIRATION: [**2153-6-26**] CHIEF COMPLAINT: Acute onset right-sided weakness and aphasia. HISTORY OF PRESENT ILLNESS: This is an 82-year-old male with recent colectomy on [**2153-6-19**] at [**Hospital6 2561**] and with significant cerebrovascular risk factors who is transferred for IA tPA and conventional angiogram for acute- onset aphasia and right-sided weakness. The history is obtained from notes as the family is not available at this time. The patient underwent colonoscopy after having occult blood in his stool, which led to diagnosis of likely stage-D colon adenocarcinoma with liver and omental metastases. The patient was doing well until postoperatively today at 2:15 p.m. when he was noted by his wife to be weak in his chair and not talking. A neurologist who saw him noted right hemiparesis and aphasia. He was apparently following some commands. A CT scan showed early signs of infarction, particularly intracortex, and he is transferred here for further management. PAST MEDICAL HISTORY: Recently diagnosed colon cancer, status post right colectomy on [**2153-6-19**] with possible liver and omental metastases. Coronary artery disease, status post 4-vessel CABG. Hypertension. Hypothyroidism. BPH. Status post tonsillectomy. Status post appendectomy. Status post right hip placement. Status post TURP. MEDICATIONS UPON TRANSFER: 1. Aspirin 81 mg by mouth every day. 2. Synthroid 0.05 mg by mouth every day. 3. Heparin subcutaneously twice a day. 4. Lopressor 12.5 mg by mouth twice a day. 5. Terazosin 1 mg by mouth at bedtime. 6. Zofran 4 mg IV/po every 6 hours as needed. 7. Morphine PCA. MEDICATIONS AT HOME: 1. Diovan. 2. Synthroid. 3. Zocor. 4. Atenolol. 5. Aspirin. ALLERGIES: None. HABITS: Unknown at this time. SOCIAL HISTORY: He is married with 3 children. He is a psychologist and was very active in his research. FAMILY HISTORY: Showed no history of stroke in the parents. PHYSICAL EXAMINATION: Examination upon admission, temperature 97.2 degrees, pulse 84 and regular, blood pressure 142/78, respiratory rate 14. He is saturating 100 percent, nonrebreather. Generally, well-appearing elderly man in no acute distress. Mucous membranes are moist. Lungs are clear to auscultation anteriorly. Heart has regular rate and rhythm with 2/6 systolic murmur at the base. There is no carotid bruits or ocular bruits audible. Abdomen is soft, nontender. Extremities show no pedal pulses or rashes. On mental status exam, the patient opens his eyes, but does not follow or mimic for me any midline spoke commands. There is no verbal output. Cranial nerve exam, the patient blinks less from the right. He blinks well from the left. Optic disc could not be visualized well due to small pupils. Pupils are 2.5 to 1.5 mm reactive to light bilaterally. Eyes occasionally seen gazing to the left but does not get to midline and often has midline gaze. Corneal reflex intact bilaterally. He resists eye opening more forcefully with the left side of the face than the right. Right brow and lip is downturned. On motor exam, there was markedly increased tone in the right upper extremity. On one occasion, there was tonic contraction of the right arm with tremulousness but no overt clonic activity. The right leg is spastic with forced flexion but foot goes well to rotation. In the left arm, he has a sense of gravity, but the right arm does not. There is slight flexion of the right hand to pain. The left leg is immobilized due to catheterization. On coordination exam, he is not able to do finger-to-nose test. Reflexes, his deep tendon reflexes are all present and slightly increased in the right upper extremity. Plantar responses are extensor bilaterally. On sensory exam, his sensation is intact to pain in all four extremities. Non-contrast head CT shows massive cortical distinction in the left intracortex. LABORATORY DATA: At the outside hospital, white count 16.3, hematocrit 34.2, platelets 304, INR 1, PTT 23.8. Sodium 136, potassium 4.5, chloride 102, bicarbonate 23, glucose 141, BUN 30, creatinine 1.3, calcium 8.5, magnesium 1.8, phosphate 1.9, CK 329. Labs at [**Hospital1 69**] showed white count 11.1, hematocrit 32.2, platelets 273, AST 24, ALT 36, alkaline phosphatase 38, total bilirubin 0.6, albumin 2.5, CK 346. HOSPITAL COURSE: Given the suspicion that the patient had a left hemispheric stroke, he was sent for a conventional angiogram, which showed plaque at the bifurcation of the left internal carotid with poor distal flow. IA tPA was administered at the site of plaque but did not result in any appreciable increase in flow. Systolic blood pressure was around 130s to 140s, and he was not given any antiplatelet or anticoagulation therapy. Given further discussion with the family, the family wishes to have the patient comfort measures only given that the prognosis is poor. He was put on a sublingual morphine, sublingual Ativan, and scopolamine. He then passed away on [**2153-6-26**]. DIAGNOSES: Left hemispheric stroke. Metastatic colon cancer. [**First Name11 (Name Pattern1) 1692**] [**Last Name (NamePattern4) 11263**], [**MD Number(1) 11264**] Dictated By:[**Last Name (NamePattern1) 11265**] MEDQUIST36 D: [**2153-7-2**] 18:26:37 T: [**2153-7-3**] 09:03:31 Job#: [**Job Number 11266**]

[ "997.02", "V45.81", "414.00", "197.6", "197.7", "244.9", "E878.8", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "99.10", "88.41", "88.72" ]

icd9pcs

[ [ [] ] ]

1993, 2038

4438, 5450

1755, 1868

2061, 4420

145, 192

221, 1096

1119, 1734

1885, 1976

14,083

185,134

26978

Discharge summary

report

Admission Date: [**2161-11-13**] Discharge Date: [**2161-11-18**] Date of Birth: [**2096-6-9**] Sex: M Service: CARDIOTHORACIC Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 1283**] Chief Complaint: abnormal ETT referred in for urgent cath. Had DOE and shoulder pain. Major Surgical or Invasive Procedure: s/p cabg x4 cardiac catheterization History of Present Illness: 65 yo male admitted to [**Hospital1 **]-[**Location (un) **] on [**11-12**] with DOE and shoulder pain. This has happened for the past 3 weeks. He had a positive myoview on [**11-10**]. He is visiting from [**State 18250**] . Admitted for cardiac cath on [**11-13**]. Past Medical History: BPH ruptured lumbar disc hypothyroidism elev. chol. (cannot take statins) CAD Social History: lives in [**State 18250**] with wife retired munitions expert never used tobacco regularly occasional ETOH use Family History: father with AAA and CAD Physical Exam: HR 67 RR 18 128/94 100% RA sat. NAD lying flat after cath RRR, 3/6 SEM loudest at RUSB lungs CTAB abd soft, NT, ND MAE, alert and oriented x 3 extrems without edema or varicosities PERRL, no carotid bruits skin without rashes Pertinent Results: [**2161-11-18**] 05:50AM BLOOD WBC-6.3 RBC-3.14* Hgb-10.1* Hct-28.6* MCV-91 MCH-32.2* MCHC-35.4* RDW-14.3 Plt Ct-235 [**2161-11-13**] 04:20PM BLOOD WBC-6.1 RBC-4.54* Hgb-14.1 Hct-39.7* MCV-88 MCH-31.1 MCHC-35.5* RDW-13.2 Plt Ct-246 [**2161-11-13**] 04:20PM BLOOD Neuts-70.4* Lymphs-24.7 Monos-3.6 Eos-1.1 Baso-0.2 [**2161-11-18**] 05:50AM BLOOD Plt Ct-235 [**2161-11-13**] 04:20PM BLOOD PT-12.8 PTT-28.9 INR(PT)-1.1 [**2161-11-18**] 05:50AM BLOOD Glucose-96 UreaN-16 Creat-0.9 Na-142 K-3.9 Cl-105 HCO3-27 AnGap-14 [**2161-11-13**] 04:20PM BLOOD Glucose-174* UreaN-13 Creat-0.9 Na-137 K-3.7 Cl-102 HCO3-24 AnGap-15 [**2161-11-13**] 04:20PM BLOOD ALT-18 AST-20 AlkPhos-50 TotBili-0.6 [**2161-11-13**] 04:20PM BLOOD Albumin-4.3 Brief Hospital Course: Cathed after admission on [**11-13**] which revealed: minimal AS, no MR, LVEF 65%, LAD 90% mid at diagonal bifurcation, 80% CX at origin of OM1, 90% distal RCA before PDA.Echo from [**9-14**] showed preserved EF, calcified AV, question of biucuspid AV with at least mild AS, moderate MR, , mild TR, LAE. Referred for urgent CABG to Dr. [**Last Name (STitle) 70**] and IABP was placed in the cath lab. Underwent CABG x4 that evening and was transferred to the CSRU in stable condition.IABP removed by cardiology on POD #1 and he remained on neo drip. Extubated later that day and was weaned off neo by POD #2. He was alert and oriented and hemodynamically stable. He was then transferred out to the floor and his foley and chest tubes were removed. Beta blockade and diuresis were started. He made rapid progress with activity on the floor, pacing wires were removed on POD #4, and was cleared for discharge on POD #5 to home with VNA services. Medications on Admission: plavix 75 mg daily ASA 325 mg daily toprol 12.5 mg daily synthroid 75 mcg daily Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 3 days. Disp:*6 Capsule, Sustained Release(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: s/p cabg x 4 with IABP BPH hypothyroidism ruptured lumbar disc [**2145**] elev. chol (cannot take statins) Discharge Condition: good Discharge Instructions: may shower over incisions and pat dry no lotions, creams or powders on incisions no driving for one month no lifting greater than 10 pounds for 10 weeks Followup Instructions: see Dr. [**Last Name (STitle) 24305**] in [**1-11**] weeks see Dr. [**Last Name (STitle) 11493**] in [**1-11**] weeks See Dr. [**Last Name (STitle) 1290**] in 4 weeks in the office Completed by:[**2161-11-18**]

[ "722.10", "244.9", "272.0", "410.11", "414.01", "600.00", "458.9", "V17.3" ]

icd9cm

[ [ [] ] ]

[ "34.04", "88.56", "36.15", "99.07", "99.05", "37.61", "37.23", "88.72", "88.53", "37.22", "36.13", "39.64", "39.61", "99.04" ]

icd9pcs

[ [ [] ] ]

4122, 4171

1992, 2939

372, 410

4322, 4329

1243, 1969

4530, 4743

952, 977

3069, 4099

4192, 4301

2965, 3046

4353, 4507

992, 1224

264, 334

438, 707

729, 808

824, 936

56,229

141,832

39684

Discharge summary

report

Admission Date: [**2107-2-15**] Discharge Date: [**2107-2-18**] Date of Birth: [**2062-8-16**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Attending Info 87297**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Pleurex catheter placement (right) - [**2-16**] History of Present Illness: This is a 44 year old female with a history of metastatic lung cancer w lg clot burden sp IVC/SVC [**12-22**] picc who presents with 2 days of increased SOB and worsened facial swelling since recent discharge. She was admitted from [**1-26**] to [**2-10**] for recurrent pleural effusion with L sided pleurex placement, pericardial effusion s/p balloon pericardiotomy then 2 pericardial windows w internal drainage, and extensive clot burden. VNA removed 150cc from pleurex cath yesterday. Her VNA drained additional 200cc from the pleurex yesterday with some improvement, but her symptoms worsened today. . In the ED, initial VS were: 98.6 118 128/72 20-30 97% 2L NC. CXR showed new R sided pleural effusion. Echo showed small effusion. IP and cardiac surgery were consulted and recommended pleurex placement in AM. Labs showed WBC 28.3 w bandemia. Blood cultures sent x1. She was given cefepime, vancomycin and levofloxacin. Access includes 22 gauge in L shoulder. ED vitals prior to transfer: afebrile, 124/93, 125, 28, 93% 2L. . On the floor, pt reports no increase in O2 use in the last couple days. She reports DOE but feels comfortable at rest. Denies fever, chills, n/v/d, abd pain, chest pain, oral lesions/ulcers, rashes or worsened extremity swelling. Per pt, planning for outpt chemotherapy in 3 weeks. Past Medical History: - Lung adenocarcinoma with known mets to brain, dx [**6-/2106**]; metastatic to brain s/p cyberknife therapy, malignant pleural and pericardial effusions s/p pericardiocentesis - DVTs s/p IVC and SVC filters - Malignant pleural effusion s/p drainage - PE s/p IVF on chronic lovenox and s/p IVC filter - Mycobacterium gordonae - s/p CCY - s/p pericardiocentesis Social History: She is originally from the [**Country 31115**] in [**2092**], lives with husband. Married. Worked at [**Last Name (un) 59330**]. Husband works in shipping warehouse. No smoking, alcohol, or illicit drug use. . Family History: Mother with diabetes. No family hx of cancer. Physical Exam: ADMISSION EXAM: Vitals: T:99.8 BP:117/79 P:124 R:25 O2:96%/2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: dullness to percussion over R lower lung field, Decreased breath sounds over lower third of R lung, clear to auscultation over L lung, occ rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley cath Ext: warm, well perfused, 2+ distal pulses, diffuse extremity swelling RUE>LUE, no clubbing or cyanosis Pertinent Results: Labs on Admission: [**2107-2-15**] 12:30PM BLOOD WBC-28.2* RBC-2.93* Hgb-9.8* Hct-28.0* MCV-96 MCH-33.4* MCHC-35.0 RDW-15.6* Plt Ct-300 [**2107-2-15**] 12:30PM BLOOD Neuts-60 Bands-18* Lymphs-10* Monos-7 Eos-1 Baso-0 Atyps-1* Metas-2* Myelos-0 Promyel-1* NRBC-4* [**2107-2-15**] 12:30PM BLOOD PT-12.5 PTT-32.1 INR(PT)-1.0 [**2107-2-15**] 12:30PM BLOOD Glucose-175* UreaN-17 Creat-1.1 Na-132* K-3.8 Cl-95* HCO3-25 AnGap-16 [**2107-2-15**] 12:30PM BLOOD ALT-24 AST-37 AlkPhos-146* TotBili-0.4 [**2107-2-15**] 12:30PM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9 Labs on Discharge: [**2107-2-18**] 07:10AM BLOOD WBC-17.5* RBC-3.26*# Hgb-10.5*# Hct-33.0*# MCV-101* MCH-32.2* MCHC-31.9 RDW-18.1* Plt Ct-246 [**2107-2-18**] 07:10AM BLOOD Glucose-83 UreaN-14 Creat-0.9 Na-136 K-5.5* Cl-100 HCO3-23 AnGap-19 [**2107-2-18**] 07:10AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.1 Microbiology: Pleural Cx: No growth Urine Cx: No growth Blood Cx: pending MRSA screen: negative ECHO: Overall left ventricular systolic function is normal (LVEF>55%). There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. The echo findings are suggestive but not diagnostic of pericardial constriction. Compared with the prior study (images reviewed) of [**2107-2-10**], no definite change. CXR: 1. Large right-sided pleural fluid collection with differential attenuation in apex. Given recent preceding study demonstrating small pneumothorax and no intervening CXR demonstrating resolution, a small component of resideual pleural air cannot be excldued. However, given there is no air-fluid level on upright view, if present, it is unlikely to be significant. 2. Opacity within right upper lung likely reflects known hilar mass. However, a concurrent infectious process cannot be excluded. LENIs: IMPRESSION: No evidence of DVT in the bilateral lower extremities. MRV Chest: 1. Partial occlusion of the right internal jugular vein from thrombus, left internal jugular vein is diminutive but patent. 2. Patent right and left subclavian veins. 3. IVC filter and SVC stent are patent. 4. Extensive right upper lobe mass, atelectasis and bilateral pleural effusions, right more than left. Extensive necrotic mediastinal and right supraclavicular necrotic lymph node masses. Bone metastasis in the T2, 3, 4, 5 and manubrium. Brief Hospital Course: 44 W with history of lung adenocarcinoma complicated by brain metastases presenting with two days of dyspnea on exertion, found to have large right-sided pleural effusion .. # Right-sided Pleural Effusion: The patient presented with two days of increased dyspnea and worsening facial swelling since her recent discharge. A large R-sided pleural effusion was seen on imaging and the patient was admitted to the [**Hospital Unit Name 153**] for pleurex catheter placement by Interventional Pulmonology on [**2107-2-16**]. Lovenox was held prior to the procedure, and restarted afterwards. Pleural fluid studies showed Wbc 1000, 74% neutrophils. The pleural fluid culture returned with no growth. The patient was discharged home with instructions to drain the pleurex catheter (on R) every other day or for symptoms until her follow-up with IP. . # Leukocytosis: Likely secondary to a recent four day course of filgrastim. In the Emergency Department she was given a dose of levofloxacin, vancomycin, and cefepime; however, these agents were not immediately continued in the [**Hospital Unit Name 153**] because of the patient's lack of systemic symptoms and complaints supporting infection. Pleural fluid, expectorated sputum culture, urine cultures revealed no growth. Blood cultures obtained in the [**Hospital Unit Name 153**] were pending at the time of discharge. She remained afebrile throughout her hospital course. . # Metastatic lung adenocarcinoma: Patient with adenocarcinoma of the lung discovered in [**6-/2106**], metastatic to right temporal lobe and status-post stereotactic radiotherapy. Recently completed 4 day course of filgrastim. She was also continued on dexamethasone and started on bactrim SS tab for PCP [**Name Initial (PRE) 1102**]. . # History of DVT: She is on chronic lovenox and status-post SVC/IVC filter placement. Lovenox was held overnight prior to R sided pleurex cath placement on [**2107-2-16**] and restarted immediately afterwards. . # Access: History of multiple DVTs including R IJ and cephalic, small non-occlusive residual clot in L lower IJ. R PICC was placed on recent hospitalization and discontinued prior to discharge ([**2107-2-10**]). Bilateral lower extremity ultrasonds were obtained in case of need for femoral line placement and revealed no clot. She underwent MRV imaging of her upper thorax in anticipation of outpatient placement of a port to durable access. She was scheduled with IR port placement in the week following discharge. . # Thrush: Patient started on four day course of fluconozole given throat pain/discomfort and evidence of thrush on exam. . # Code: Full (discussed with patient) Medications on Admission: 1. oxygen Please provide 2-4L oxygen by nasal cannula when ambulating prn 2. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO once a day. 3. ranitidine HCl 150 mg [**Hospital1 **] 4. docusate sodium 100 mg Capsule [**Hospital1 **] 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain 6. acetaminophen 325 mg Tablet 7. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID 8. folic acid 1 mg Tablet 9. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID 11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H 13. enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous Q12H (every 12 hours). 14. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily) as needed for contstipation. 15. filgrastim 300 mcg/mL Solution Sig: Three Hundred (300) mcg Injection Q24H (every 24 hours) for 4 days. 16. morphine 15 mg Tablet Sig: Two (2) Tablet PO every seventy-two (72) hours as needed for pain: To be used for pain from pleurex drainages; do not drive or operate machinery. Discharge Medications: 1. Oxygen Please provide 2-4L oxygen by nasal cannula when ambulating prn 2. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ranitidine HCl 150 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. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 6. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 12. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). 13. morphine 15 mg Tablet Sig: One (1) Tablet PO every twenty-four(24) hours as needed for pain: To be used for pain from pleurex drainages; do not drive or operate machinery. . 14. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 15. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary Diagnosis: - Pleural Effusion - Pericardial Effusion Secondary Diagnosis: - Metastatic Lung Adenocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 87457**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with facial swelling and shortness of breath. You were found to have fluid building up around your right lung. You had a catheter placed in order to drain this fluid. Your symptoms improved significantly during the course of your hospital stay. Please START the following medications after discharge: FLUCONOZOLE for 2 more days BACTRIM SS daily (while you are taking the dexamethasone) On Tuesday, [**2-22**], you will undergo placement of a port (through which they give medications and draw blood). Please check-in on the [**Hospital Ward Name 517**], [**Location (un) 453**], in an area called the Radiology Care Unit. Please DO NOT eat or drink after midnight on the night before your procedure. Please DO NOT take your lovenox the night before or the morning of your procedure. On the evening before, you will also need to take the "pre-operative" shower that was discussed in the hospital with the nursing staff. Please do not take aspirin, NSAIDs (advil or aleve), fish oil, or vitamin E prior to your scheduled procedure. Please continue all other medications as they have been prescribed. If you experience any symptoms that concern you after leaving the hospital, please call your oncologist or return to the emergency room as soon as possible. Followup Instructions: You will receive a call from Dr.[**Name (NI) 86073**] office on [**Name (NI) 766**], [**2-21**] with details about your follow-up appointment. Department: RADIOLOGY CARE UNIT When: TUESDAY [**2107-2-22**] at 8:00 AM [**Telephone/Fax (1) 446**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: MRI When: [**Street Address(1) **] [**2107-2-28**] at 1 PM With: MRI [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Hospital 1422**] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROLOGY When: [**Street Address(1) **] [**2107-2-28**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You will receive a call from Dr.[**Name (NI) 14679**] (Pulmonary) office at some point next week regarding a follow-up appointment for your Pleurex drains. They will see you back in clinic in two weeks time. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 87298**]

[ "162.3", "511.81", "288.60", "198.3", "V58.61", "198.5", "423.8", "V12.51", "112.0" ]

icd9cm

[ [ [] ] ]

[ "34.04" ]

icd9pcs

[ [ [] ] ]

11045, 11094

5502, 8159

311, 361

11254, 11254

3075, 3080

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2336, 2383

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11115, 11115

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11198, 11233

11134, 11177

3094, 3625

11269, 11381

1730, 2093

2109, 2320

62,735

119,425

44480

Discharge summary

report

Admission Date: [**2149-8-10**] Discharge Date: [**2149-8-15**] Date of Birth: [**2066-2-8**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1253**] Chief Complaint: fall, altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 83F s/p 2 falls, found down by son early this AM and then later in afternoon, Family reports some confusion and altered mental status since today. Lives at home alone, reported A0 x3 at baseline. Time down unknown, mechanism of fall unknown. Currently on ASA . Patient poor historian but reports substernal chest pains a few days ago. Denies n/v/jawpain/SOB. Patient reports some chills and diaphoresis a few days ago as well. Denies head trauma or LOC. Denies vision changes/numbmness/tingling/weakness/recent cough/abdominal pain/headache/neck pain/pain anywhere else. Denies urinary complaints . In the ED intial VS were 99 71 137/79 18 98%RA, EKG was reportedly unconcerning and CE were negative x1. Labs were notable for a K of 6.1 (hemolyzed) as well as CK of 240 and an AST of 51. Patient had pelvis and bilateral aknle films that were negative. Head CT showed small right frontal SAH. Neurosurgery did not feel this was the cause of her issues and advised admit to medicine and will follow along. UA was notable for small leuk esterase and 10 WBC's but no bacteria. She received CTX and is admitted to medicine for AMS work up. . Vital prior to transfer were 99.1-71-183/79-20-98. On the floor she is confused and minimally cooperative with exam. . Past Medical History: Hypertension osteoarthritis GERD hyperlipidemia umbilical hernia. Social History: Lives alone, daughter and son live down the street. Does not drive, grocery shop, cook or pay her own bills. Family checks in on her twice daily. No tobacco, alcohol, or illicit drug use. Family History: She has one brother and four sisters who have arthritis and glaucoma, no other known medical problems. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97 162/87 67 20 100%RA Orthostatics: Lying 156/94 P68 Sitting 146/86 P80 Standing uncooperative GENERAL: Elderly confused african american woman in NAD. Arousable but not oriented. HEENT: NC/AT dry MM NECK: Supple HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft but diffusely ttp. Patient does not endorse pain but grimaces with minor palpation + BS. No rebound or guarding EXTREMITIES: WWP no edema SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3. CN 2,3,4,5, 6 intact. CN 7: Patient able to furrow brow and close eyes tightly. Unwilling to grin, show teeth or puff out cheeks but no facial droop was appreciated and NL folds were intact and symmetric. 9,10,11,12 Unable to assess [**1-22**] to poor cooperation btu patient did not appear to have asymmetric deficits. Strength was difficult to assess as well [**1-22**] to poor cooperation but patient had adequate bulk and tone in all 4 extremities and was moving all for spontenously. Reflexes 2+ and symmetric. Cerebellar exam deferred [**1-22**] to poor cooperation. DISCHARGE PHYSICAL EXAM VS 98.4 136/70 71 16 97% RA GENERAL: Elderly woman sitting in bed in NAD HEENT: NC/AT, pupils minimally reactive to light, EOMI, MMM, OP clear NECK: Supple HEART: RRR, no MRG, nl S1-S2. Soft 1-2/6 systolic murmur at RUSB. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: BS+, Soft, moderately tender to palpation over ventral hernia. No rebound or guarding EXTREMITIES: WWP, no edema, bilateral knees have joint deformities [**1-22**] arthritis SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, oriented to person but not place or time. Able to answer some questions correctly. CN II-XII intact. Strength 4+/5 for age and conditioning in upper extremities. Right leg is 4-/5 (poor effort, deconditioned), but cannot lift left lower extremity off the bed on command. Pertinent Results: Admission labs: [**2149-8-10**] 06:34PM BLOOD WBC-7.3 RBC-3.79* Hgb-12.5 Hct-35.1* MCV-93 MCH-32.9* MCHC-35.5* RDW-13.9 Plt Ct-147* [**2149-8-10**] 06:34PM BLOOD Neuts-70.8* Lymphs-22.3 Monos-4.9 Eos-1.6 Baso-0.4 [**2149-8-10**] 06:34PM BLOOD PT-11.7 PTT-23.3 INR(PT)-1.0 [**2149-8-10**] 06:34PM BLOOD Glucose-110* UreaN-26* Creat-0.9 Na-141 K-6.1* Cl-105 HCO3-29 AnGap-13 [**2149-8-10**] 06:34PM BLOOD ALT-21 AST-51* CK(CPK)-240* AlkPhos-52 TotBili-0.6 [**2149-8-10**] 06:34PM BLOOD Lipase-54 [**2149-8-10**] 06:34PM BLOOD cTropnT-<0.01 . Discharge labs: [**2149-8-12**] 05:17AM BLOOD WBC-6.3 RBC-4.36 Hgb-13.8 Hct-40.3 MCV-92 MCH-31.6 MCHC-34.2 RDW-14.0 Plt Ct-168 [**2149-8-13**] 08:59AM BLOOD Glucose-90 UreaN-16 Creat-0.6 Na-146* K-3.7 Cl-111* HCO3-27 AnGap-12 . IMAGING: CT head [**2149-8-10**]: 1. Tiny foci of subarachnoid hemorrhage are noted in a sulcus in the right frontal lobe at the vertex. No significant mass effect or shift of the normally midline structures. 2. Generalized cortical atrophy. . CT C-spine [**2149-8-10**] 1. No evidence of acute cervical spine fracture or prevertebral soft tissue swelling. 2. Multilevel degenerative changes along with mild-to-moderate canal narrowing. The canal narrowing is greatest at C3-C4 with asymmetric posterior disc bulge and resulting canal narrowing to 7 mm. CT is not sensitive for evaluation of intrathecal detail compared to MRI and if suspicion for injury to the thecal sac is high, MR is the recommended study of choice. . Xray Pelvis [**2149-8-10**] Markedly limited study due to factors above. No obvious traumatic injury identified. . Xray B/L ankles [**2149-8-10**] Limited study as above due to osteopenia and patient compliance. No gross fracture or dislocation identified. . CXR [**2149-8-10**] Within limitations, no radiographic evidence of traumatic injury to the chest. The overall morphology of the cardiomediastinal silhouette suggests underlying hypertension with no obvious traumatic sequelae. . CT Pelvis [**2149-8-11**] 1. Acute fracture of the left greater trochanter. 2. Small colon-containing ventral wall hernia with no evidence of obstruction. 3. Diverticulosis without evidence of diverticulitis. Trans-thoracic echo: There is moderate 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>55%). 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. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion Abdominal xray: (wet read) non-specific bowel gas pattern, no evidence of obstruction or free air. moderate amount of stool in distal colon/rectum. Brief Hospital Course: 83 yo W with history of HTN, GERD and OA presenting via ambulance from home after family found her down x2 on the day of admission with acute mental status changes, found to have left trochanter fracture. ACUTE ISSUES: # Fall/AMS: She was found down at home by her family, who also felt that she seemed more confused and disoriented than normal. AMS was likely secondary to pain and poor PO intake/dehydration after fall out of bed, which also resulted in left trochanteric fracture (see below). Also appears to have some degree of dementia at baseline, as her family has noticed increased forgetfulness/confusion, and she does not drive, grocery shop, cook, or pay bills for herself. Given extreme hypertension at times during her admission, hypertensive encephalopathy could have played some role in her mental status changes, however this is less likely. SAH appears to be a result of her fall rather than the cause. UTI was also initially suspected, however repeat UA was negative. She was treated for her pain with scheduled tylenol and PRN morphine, and she was given IV and PO fluids to help with her dehydration. Her mental status did improve, but she continued to be only intermittently oriented to place and time. She likely does continue to have some small degree of delirium superimposed over mild to moderate dementia (family says she is nearly baseline). She is being discharge to skilled nursing facility for acute rehab needs (extremely deconditioned, new hip fracture) and will likely need placement to a nursing home afterward, as she is not safe alone in her home. She should continue scheduled tylenol as well as [**Hospital1 **] oxycodone 2.5 acutely for pain, as she does not reliably request PRN meds, in order to prevent further delirium due to pain. # Hip fracture: Found down at home after falling from bed, which is likely when the injury occurred. Initial pelvic xray was negative, however the patient was not able to actively move her left leg, raising concern for an occult fracture. CT pelvis confirmed a trochanteric fracture. She was seen by the orthopedic surgeons, who felt that surgery was not indicated, given that her fracture is in a non-weight bearing part of the joint. They recommended pain control, weight bearing as tolerated, and physical therapy at a skilled nursing facility. Her pain should be treated with scheduled tylenol as well as [**Hospital1 **] oxycodone (as above). # HTN: Has a past diagnosis of hypertension, however was on no medications on admission. Her blood pressure fluctuated greatly throughout her hospital stay, reaching as high as the 230s at times. She required a 1 day stay in the MICU for closer BP control and monitoring. She improved on a regimen of captopril 12.5 mg TID, however she still had breakthrough high pressures, likely exacerbated by pain. Lisinopril 10 mg and chlorthalidone 12.5 mg were started with subsequent improved BP control. She should have a chem panel checked in one week to ensure normal electrolytes and BUN/Cr. Hold chlorthalidone if SBP is <120, as her pressure can be quite labile. # SAH: Tiny SAH on seen in right frontal cortex on head CT in the ED. Neurosurgery was consulted and felt that this was likely a result of her fall rather than a cause of it. She had no worrisome neurological signs. They recommended follow up with dr. [**First Name (STitle) **] in 4 weeks for a repeat non-contrast head CT to ensure resoluation. # Abdominal pain: Intermittently complained of increased abdominal pain the area of her ventral hernia. No peritoneal signs, rebound or guarding. Passing stool (about every other day), KUB x2 shows no evidence of obstruction or free air. Lactate was normal x3. Pain is likely secondary to constipation, she should continue a good bowel regimen of senna, docusate, miralax, and enemas as needed. TRANSFER OF CARE ISSUES: - assess BP control with lisinopril and chlorthalidone - chem panel on [**8-21**] to ensure normal electrolytes and BUN/Cr with addition of lisinopril to med regimen - PT for L hip fracture - repeat head ct in one month to ensure resolution of SAH Medications on Admission: Nabumetome 500 mg [**Hospital1 **] prn pain ASA 81mg daily Calcium Carbonate + Vitamin D3 Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO twice a day. 3. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO once a day as needed for pain: [**Month (only) 116**] give PRN for breakthrough hip pain. 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Capsule Sig: One (1) Capsule PO once a day. 6. Outpatient Lab Work Please draw chem panel (Na, K, Cl, CO2, BUN, Cr) on [**8-21**] 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily). 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. chlorthalidone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Enemas Please ensure a daily bowel movement; please use a daily (fleets or tap water) enema:prn contstipation 14. Outpatient Lab Work Please check Na, K, Cr on [**2149-8-17**]. If K is 3.5-3.8 please give 40 meq PO. If K is 3-3.4, please give 60 meq PO and recheck potassium. If K < 3.0, [**Name8 (MD) 138**] MD. [**First Name (Titles) **] [**Last Name (Titles) **] is < 136, please discuss with MD, consider encouraging PO intake and potentially holding the chlorthalidone. 15. BP checks Pt BP is elevated. Two medicines were started (lisinopril and chlorthalidone). Please check daily BP and hold blood pressure medicines if sbp < 120. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Left trochanteric hip fracture Dementia Hypertension Subarachnoid hemorrhage Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory (minimally) - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure to take care of you during your stay at [**Hospital1 18**]. You were admitted to the hospital after a fall at home. We found that you had a small break in your left hip, but you do not need surgery to fix it. We have also started you on a blood pressure medicine (lisinopril) because your blood pressures have been very high. Medication changes: START Lisinopril 10 mg daily for blood pressure START Chlorthalidone 12.5 mg daily START acetaminophen (tylenol) 650 mg every 6 hours for pain START oxycodone 2.5 mg twice daily for pain, may take an extra dose of 2.5 as needed if pain is not controlled Followup Instructions: Follow up with PCP on discharge from rehab facility Non-contrast head CT and follow up appointment with Dr. [**First Name (STitle) **] from Neurosurgery in 1 month Department: RADIOLOGY When: THURSDAY [**2149-9-11**] at 10:00 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: THURSDAY [**2149-9-11**] at 10:45 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "715.90", "564.09", "530.81", "820.20", "272.4", "780.97", "E884.4", "852.01", "276.51", "401.0", "294.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13014, 13085

7050, 11177

331, 338

13206, 13206

4056, 4056

14082, 14761

1940, 2045

11318, 12991

13106, 13185

11203, 11295

13403, 13784

4612, 7027

2085, 4037

13804, 14059

264, 293

366, 1625

4072, 4596

13221, 13379

1647, 1715

1731, 1924

72,354

168,065

38751

Discharge summary

report

Admission Date: [**2131-8-16**] Discharge Date: [**2131-8-18**] Date of Birth: [**2062-3-10**] Sex: F Service: MEDICINE Allergies: Aspirin / Sulfasalazine Attending:[**Last Name (un) 85086**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: History of Present Illness: Ms. [**Name13 (STitle) 6608**] is 69yo F with a PMH s/f metastatic lung CA to the brain and spine, history of PEs presenting to ED with dyspnea. She says that her had bilateral shoulder pain that radiated around her back unrelentingly with [**10-7**] pain all night, and that this was a new sharp pain for her that worsened with movement and deep breaths. She was recently hospitalized on [**2131-5-16**] for severe back pain after radiation therapy, where she developed a presumed PE after Lovenox 60 mg twice daily was dc'ed for emergent spine surgery [**1-30**] cauda equina syndrome. Briefly, the patient was initially symptomic with back pain in [**2131-3-29**], at which point a workup discovered compression fractures in her spine, which led to further imaging workup on [**4-23**] by CT that disocvered a 2 cm hyperdense soft tissue mass in the right hilar lymph nodes as well as lytic lesions int he spine. The patient also had an MRI of the brain that showed a R cerebellar lesion with necrosis. Patient was started on Lovenox after a CTA on [**2131-5-4**] showed PEs. The patient has undergone multiple rounds of radiation and chemotherapy for metastases to the back and brain, as well as surgical treatment for metastses in the spine on [**2131-5-17**]. In the ED, initial vs were: Temp:96.5 HR:128 BP:112/68 Resp:24 O(2)Sat:98. Vascular surgery was consulted, who recommended placing an IVC filter. CTA was done which showed multiple clots, right lower lobe infarct, possibly developing peripheral left upper lobe infarct, tumor invasion of the SVC, tumor invasion of the mediastinum, left lower rib fracture, indeterminate chronicity, right pleural effusion with adjacent compressive atelectasis, right sided heart strain. Patient recieved ceftriaxone 1 g x 1 and azithromycin 500 mg x 1 Past Medical History: Hyperlipidemia Goiter Colonic Adenoma Anxiety Depressive Disorder Osteopenia Pulmonary Embolism ([**4-/2131**]) Menopause Thyroglossal duct cyst Cervical carcinoma Social History: Patient is only child and has no children. - Tobacco: Prior smoking history, quit in [**2098**] - etOH: Denies - Illicits: Denies Pt works as an artist and lives with her husband who has residual polio. Family History: Mother had breast cancer, COPD and a pulmonary emboli in her 40s (with negative work-up); recently passed away in 90s. Father had rectal and prostate cancer as well as coronary artery disease. Physical Exam: Vitals: T: 96.5 BP: 113/68 P:110 R:16 O2: 99% on 4 L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry tounge with white plaque, PERRLA Neck: supple, JVP not elevated, no LAD Lungs: Crackles on the left at the bases, unable to ausculate breath sounds on the right CV: Tachycardic, regular rate and rhythm with occasional skipped beats, normal S1 + S2 Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley present Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2131-8-16**] 02:40PM PT-13.7* PTT-28.3 INR(PT)-1.2* [**2131-8-16**] 02:40PM PLT SMR-NORMAL PLT COUNT-293 [**2131-8-16**] 02:40PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL [**2131-8-16**] 02:40PM NEUTS-85* BANDS-7* LYMPHS-4* MONOS-1* EOS-1 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* [**2131-8-16**] 02:40PM WBC-18.5*# RBC-3.82* HGB-10.4* HCT-32.4* MCV-85 MCH-27.3 MCHC-32.2 RDW-16.6* [**2131-8-16**] 02:40PM cTropnT-0.11* [**2131-8-16**] 02:40PM ALT(SGPT)-46* AST(SGOT)-88* CK(CPK)-173 ALK PHOS-620* TOT BILI-0.5 [**2131-8-16**] 02:40PM GLUCOSE-173* UREA N-23* CREAT-0.6 SODIUM-128* POTASSIUM-5.6* CHLORIDE-88* TOTAL CO2-28 ANION GAP-18 [**2131-8-16**] 02:42PM HGB-11.0* calcHCT-33 [**2131-8-16**] 04:00PM URINE AMORPH-MOD [**2131-8-16**] 04:00PM URINE RBC-0-2 WBC-[**6-7**]* BACTERIA-FEW YEAST-NONE EPI-0-2 [**2131-8-16**] 04:00PM URINE BLOOD-MOD NITRITE-POS PROTEIN-75 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-4* PH-7.0 LEUK-MOD [**2131-8-16**] 04:00PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.018 Brief Hospital Course: 69F with stage IV adenoca of the lung with h/o PEs, therapeutically anticoagulated on lovenox at home, presents with shortness of breath, new acute PEs found on CT. With this heavy clot burden, as well as a filling defect in the SVC decision was made to not place IVC filter and not to anticoagulate her any longer. Given likely tumoral invasion into SVC, decision was made to send her to hospice over the weekend. However, patient expired from cardiopulmonary collapse at 5:36AM on Saturday, [**2131-8-18**]. Medications on Admission: patient deceased Discharge Medications: patient deceased Discharge Disposition: Expired Discharge Diagnosis: patient deceased Discharge Condition: patient deceased Discharge Instructions: patient deceased Completed by:[**2131-8-18**]

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Discharge summary

report

Admission Date: [**2192-9-28**] Discharge Date: [**2192-10-29**] Date of Birth: [**2112-7-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 710**] Chief Complaint: fever, hypotension Major Surgical or Invasive Procedure: Aortic valve replacement Central line access PICC line access Intubation Arterial line Thoracentesis Cardiac catheterization History of Present Illness: 80 year old male with hx, CVA, SBO's, prostate CA, recently discharged after ventral hernia repair who presents with fevers, AMS and hypotension. Per the daughter's report, the patient has been drowsy and delerious since discharge but has become more somnolent over the past 3-4 days. Two nights ago, he began spiking fevers. He was diagnosed with a UTI and given several doses of Levofloxacin. Subsuquently, his blood cultures grew GPC's and he got Vancomycin. Today his blood pressure lowered, with SBP's in 80's. His creatinine increased from 0.9-> 1.3 overnight, and his hemoglobin dropped from 10-.7.6 over the past 6 days. He was transfered to [**Hospital1 18**] via ambulance from [**Hospital 100**] Rehab. . Notably on last admission, he was on the surgery service for SBO. This was intially managed conservatively. The patient then developed respiratory distress and hypoxia. He was transfered to the SICU for a question of aspiration PNA vs PE. LENI neg, V/Q scan neg- PE r/o. Eventually, it was decided that he did not have an aspiration PNA and that his tachypnea was [**1-7**] distended abd. He was taken to the OR and found to have an incarcerated hernia which was repaired. He was discharged on [**9-22**] to [**Hospital 100**] Rehab. . In the ED his vital were temp 101.6 pt SBP 97-112/46-67, HR 98 RR 30 SaO2 97% NRB. A CXR was performed with new RUL infitrate. he was tachypnic to 30's and hypoxic. He was given [**Doctor Last Name **]/Zosyn/Levo. He received 3liters NS and 1 units pRBC's w/o improvement of BP. Cr 1.4, baseline 0.9. Trop 0.12. EKG w/o ischemia. Lactate 2.0. He was seen by the surgical service who did not think that his presentation was secondary to an abodominal process or related to his recent surgery. . MEDICINE TRANSFER HPI: 80M with PMH of CVA, small bowel obstruction, metastatic prostate CA, who was admitted on [**2192-9-28**] with fevers, altered mental status and was found to have MRSA bacteremia and aortic valve endocarditis. Prior to his current admission he was admitted from [**Date range (3) 77130**] for small bowel obstruction which was complicated by incarcerated hernia which also required surgical treatment. . He was initially admitted to the MICU for sepsis as he was febrile and hypotensive. Source was initially thought to be PNA given RUL infiltrate on CXR and hypoxia and he was treated with vanc/zosyn/levo. Her was persistently hypoxic and on an NRB mask for a prolonged period of time. He was also anemic on admission with HCT 22 and guaiac positive stools concerning for GI source. In addition, he had a CT on admission showing early SBO. He was treated with an NG tube and fluids. On [**2192-9-30**] his blood cultures came back positive for MRSA and pip/tazo + levofloxacin were d/c'd and he was continued on vancomycin alone. Despite treatment with vancomycin, he continued to have positive blood cultures and fevers. He developed a pleural fluid which was concerning for empyema. A pleuroscentesis showed the fluid was transudative. ID was then asked to consult on the pt. All lines were removed. He had an initial TTE showing no definite valvular vegetation and was felt not to be stable enough for a TEE. Gentamicin was started on for synergy given continued bacteremia. A repeat ECHO showed a large aortic valve vegetation and severe AR meeting criteria for surgery. On the evening of [**9-8**] he was intubated due to increasing oxygen requirements and work of breathing from heart failure due to aortic insufficiency. He was also started on levophed for hypotension. On [**2192-10-11**] he underwent to surgery for a porcine valve replacement and was transfused 9U pRBC perioperatively for a post op HCT of 30. . Post operatively he was cared for in the cardio-thoracic ICU. Regarding his ongoing bacteremia, he was changed from vancomycin + daptomycin to linezolid on [**2192-10-12**] due to BCx positive Staph. aureus intermediately resistant to vancomycin and daptomycin. On [**2192-10-12**] he developed Afib with RBR and was started on amiodarone 400mg [**Hospital1 **] following loading with an IV drip. Per cardiology this was decreased to 400mg daily on [**2192-10-18**]. He is planned to decrease to 200mg PO daily on [**2192-10-24**] and continue at that dose for a week. Regarding his volume status, he is >18L positive this admission. He was started on lasix 20mg IV BID on [**2192-10-12**] which was increased to 40mg IV BID on [**2192-10-18**]. He was extubated on [**2192-10-14**]. Regarding his abdominal pain, on [**2192-10-15**] he had a KUB and RUQ u/s for abdominal pain and concern for SBO vs cholecystitis. The KUB showed non obstructive bowel gas pattern with retained contrast c/w delayed transit. His RUQ ultrasound showed no evidence of cholelithiasis or cholecystitis. He had not moved his bowels in several days and did have bowel movement following lactulose. LFT's were slightly elevated on [**2192-10-11**] but were improved on repeat [**2192-10-15**] . On tranfer to the medicine service his vital signs were 98.4 121/78 71 18 97% on 3L. He remains delerius but responsive. He had pulled out his NG tube that day so cannot get PO meds or feeds. Otherwise he is stable. He denies pain but winces on abdominal exam. He can answer yes or no and at time speaks full sentances. Past Medical History: PMH: # Prostate CA w/ spinal mets (not active for several years; in remission according to his oncologist) # Gastric volvulus s/p gastropexy # Constipation # Depression # Lacunar infarct # Small Bowel Obstruction # Incarcerated hernia s/p bowel resection . PSH: # Gastropexy # Hiatal Hernia Repair Social History: Widowed, NH resident ([**Hospital3 537**]). Grew up in [**Location (un) 17004**], NY and worked as teacher, SW, guidance counselor. Was married and had 2 children; wife passed away in [**2158**]. Daughter is a psychiatrist in [**Location (un) 86**] area. Family History: Son died of a brain tumor at age 19 in [**2160**]. Physical Exam: VITALS: T 99.0 HR90 BP 90/57 RR 20 SAO2 97% NRB, 88% RA and on NC GEN: pale, ill appearing older male HEENT: no JVD, no LAD, no neck stiffness RESP: Clear bilaterally, tachpnic but w/o retractions or pursed lips CARD: tachy, RR, no MRG ABD: well healing midline scar, no distension, no tympany, no TTP, NABS EXTR: warm, well perfused NEURO: AOx1, limited alertness, responds to voice and looks around, answering yes and no but not answering questions SKIN: no rashes . MEDICINE TRANSFER: GEN: NAD, debiliated elderly man VS: 98.4 121/78 71 18 97% 3L HEENT: Very dry MM, no JVD or LAD CV: Distant heart sounds. RR, NL S1S2 no MRG. Pulses 1+ DP bilat and 2+ radial bilat PULM: CTAB, but poor inspiratory effort ABD: BS+, non distended, soft, diffusely tender possibly more on the L. No rebound LIMBS: 3+ LE edema, 1+ UE edema, contractures of the R and and LUE NEURO: PERRLA, reflexes 2+ at the biceps and 1- at the patellas. Toes up bilaterally with clonus on the R. Grasp reflex of the R hand. Difficult to assess otherwise. +Snout, +palmomental Pertinent Results: ADMISSION LABS: [**2192-9-28**] 01:20PM BLOOD WBC-9.3 RBC-2.45* Hgb-7.5* Hct-22.2* MCV-91 MCH-30.7 MCHC-34.0 RDW-15.5 Plt Ct-184 [**2192-9-28**] 01:20PM BLOOD Neuts-85.6* Bands-0 Lymphs-10.1* Monos-4.0 Eos-0.2 Baso-0.1 [**2192-9-28**] 01:20PM BLOOD PT-15.2* PTT-39.9* INR(PT)-1.3* [**2192-9-28**] 01:20PM BLOOD Glucose-102 UreaN-49* Creat-1.4* Na-140 K-3.9 Cl-106 HCO3-22 AnGap-16 [**2192-9-28**] 01:20PM BLOOD ALT-36 AST-45* CK(CPK)-160 AlkPhos-111 TotBili-0.5 [**2192-9-28**] 01:20PM BLOOD Lipase-90* [**2192-9-28**] 01:20PM BLOOD CK-MB-4 cTropnT-0.12* [**2192-9-28**] 01:20PM BLOOD Albumin-2.3* Calcium-7.2* Phos-3.4 Mg-1.8 [**2192-9-28**] 08:21PM BLOOD Type-ART pO2-72* pCO2-27* pH-7.50* calTCO2-22 Base XS-0 Intubat-NOT INTUBA [**2192-9-28**] 01:28PM BLOOD Lactate-2.0 K-3.8 . DISCHARGE LABS: [**2192-10-26**] 04:59AM BLOOD WBC-7.7 RBC-2.92* Hgb-8.8* Hct-26.0* MCV-89 MCH-30.1 MCHC-33.9 RDW-15.3 Plt Ct-152 [**2192-10-26**] 04:59AM BLOOD PT-14.5* PTT-31.3 INR(PT)-1.3* [**2192-10-26**] 04:59AM BLOOD Glucose-103 UreaN-17 Creat-1.2 Na-143 K-3.3 Cl-107 HCO3-26 AnGap-13 [**2192-10-26**] 04:59AM BLOOD Calcium-7.4* Phos-3.3 Mg-2.0 . ADDITIONAL LABS: [**2192-10-5**] 03:25AM BLOOD CRP-209.8* [**2192-10-25**] 05:38AM BLOOD CRP-92.4* [**2192-10-20**] 06:01AM BLOOD PSA-1.0 . STUDIES: [**2192-10-3**] Interventional Radiology - There is no evidence of pneumothorax. Mild decrease in now small right pleural effusion. Left pleural effusion, adjacent atelectasis and pulmonary vascular congestion is stable. Cardiomegaly is unchanged. NG tube tip is in the stomach. Left PICC tip is in the SVC. . [**2192-10-7**] CT chest, abdomen, & pelvis with contrast - IMPRESSION: 1. Findings compatible with pneumonia, most prominent in the left upper lobe. 2. Moderate bilateral pleural effusions with atelectasis or pneumonia in both lower lobes. 3. Mild ectasia of the ascending aorta. 4. Decreased amount of fluid along the incision in the midline anterior abdominal wall. The left pectineus muscle is mildly enlarged and appears to have some fluid attenuation within it. This is likely due to resolving hematoma. 5. Sclerotic bone lesions suspicious for metastases such as from prostate cancer. Recommend further evaluation. 6. New rectal wall thickening compatible with proctitis. . [**2192-10-7**] CT head with & without contrast - CT HEAD BEFORE AND AFTER IV CONTRAST: No evidence of hemorrhage, edema, mass effect, hydrocephalus, or recent infarction is seen on the non-contrast study. Prominence of the ventricles and extra-axial CSF spaces are consistent with age-related involutional change. An old lacunar infarct is noted along the left periventricular white matter. Vascular calcifications are noted along the cavernous carotid and vertebral arteries. The patient is status post bilateral lens replacement; otherwise, the soft tissues appear unremarkable. A right nasogastric tube is noted to be in place. A small mucus-retention cyst is noted in the right maxillary sinus. There is partial opacification of the mastoid air cells bilaterally. Small curvilinear calcification along the left posterior fossa is extra-axial and could represent a small meningioma, or dural calcification. No region of abnormal enhancement is noted after administration of IV contrast. There is normal enhancement of the major arteries of the circle of [**Location (un) 431**]. IMPRESSION: No evidence of acute intracranial abnormality seen. . [**2192-10-8**] ECHO - The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal half of the lateral wall and distal septum. The remaining segments contract well (LVEF 55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are moderately thickened but aortic stenosis is not present. There is a large, 2.3cm mobile vegetation with central lucency is seen on the LVOT side of the non-coronary leaflet aortic valve. At least moderate to severe (3+) aortic regurgitation. The mitral valve leaflets are mildly thickened. No discrete vegetation is seen. Mild to moderate ([**12-7**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2192-10-1**], a large vegetation is now visualized on the aortic valve (vs. focally thickened non-coronary leaflet). The severity of aortic regurgitation is slightly increased. The left ventricular systolic dysfunction also appears new ?emboli to coronary arteries? If clinically indicated, a TEE would be better able to define the aortic valve vegetation and to identify a potential abscess. . [**2192-10-8**] CXR - The right internal jugular line was inserted in the meantime interval. The tip is in mid SVC. There is no pneumothorax. The Dobbhoff tube tip is proximal in the proximal stomach, unchanged compared to the prior study. There is increase in the opacification of the right lung now involving not only the right lower lobe as seen previously but also the right upper lobe which potentially represent a combination of increased pleural effusion and parenchymal abnormality. Given the worsening of the left perihilar opacities these findings may be represented by worsening of bilateral edema or multifocal consolidations. . [**2192-10-9**] Right Lower Extremity Ultrasound - IMPRESSION: No deep venous thrombosis in the right lower extremity. . [**2192-10-10**] Cardiac Cath: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed no obstructive disease. The LMCA was normal and widely patent. The LAD, LCx, and RCA all had diffuse irregularities but no significant obstructive stenoses. 2. There was marked ascending aortic enlargement requiring a JL6 catheter. FINAL DIAGNOSIS: 1. No angiographically significant disease. 2. Marked ascending aortic enlargement. . MR HEAD W & W/O CONTRAST Study Date of [**2192-10-20**] 8:13 PM There is a punctate focus of elevated signal on image 21, series 502 of the diffusion-weighted scans, but which also appears to have slightly elevated signal on the commensurate FLAIR image. Thus, the finding might represent so- called "T2 shine-through" of a previous small vessel infarct. A few additional areas of chronic small vessel infarction, all subcentimeter in size, are seen within the periventricular white matter of both cerebral hemispheres, as well as a few within the right cerebellar hemisphere inferiorly. On diffusion image 15, series 502, there is a punctate area of elevated signal in the right occipital pole that is not seen on the ADC map, and could be an artifact. While many of the provided images are degraded by patient motion, there is no overt sign for the presence of an intracranial mass lesion or shift of normally midline structures. There are no areas of abnormal susceptibility seen within the brain. There is generalized mild brain atrophy. Following the intravenous infusion of gadolinium-DTPA, within the limits of this study, there are no definite signs for the presence of pathological enhancement intracranially. The principal vascular flow patterns are identified. There is extensive high T2 signal within the mastoid sinuses bilaterally, which could indicate an inflammatory process. In turn, this finding could relate to prior intubation. CONCLUSION: Probable chronic small vessel infarction. Extensive bilateral mastoid sinus T2 hyperintensity, which could reflect an inflammatory process. Brief Hospital Course: INITIAL MICU COURSE [**Date range (2) 77131**]: The patient was initially started on Zosyn, Levofloxacin and Vancomycin, pending identification of the cause of his sepsis. Surgery was consulted on admission and did not feel that the patient had a small bowel obstruction. Zosyn and Levofloxacin were stopped on [**9-30**] and Vancomycin continued when he was found to have MRSA in his blood, urine, and sputum. MRSA sepsis was associated with fever, hypoxia, and hypotension. Despite treatment with vancomycin, the patient continued to spike fevers and grow MRSA from blood and sputum cultures. He underwent a thoracentesis to drain accumulating pleural fluid due to concern for empyema. The fluid was transudate in nature. An infectious disease consultation was obtained on [**10-4**] for further assistance. All invasive lines were removed. The patient had a TTE showing no definite valvular vegetation and was felt not to be stable enough for a TEE. Gentamycin was started on [**9-7**] for synergy given continued bacteremia. He had a repeat ECHO on the same day showing a large aortic valve vegetation. On the evening of [**9-8**] the patient was intubated due to increasing oxygen requirements and work of breathing. He was started on levophed for hypotension. After discussion with the patient's daughter, surgical service, and gastroenterology, the patient was transfered to the surgical service on the morning of [**9-10**] for surgery to remove the vegetation and repair the valve. . Hypoxia: Multifactorial with pleural effusions, pulmonary edema, and possible infectious etiology. . RLE Edema: R>L edema was concerning for clot but LENI negative. Patient was on DVT prophylaxis with SC heparin and pneumoboots. . AMS: Likely multifactorial secondary to infection and fever. Per report, he had some degree of altered mental status at rehab following his ventral hernia repair. Head CT was negative for acute intracranial bleed. Venlafaxine was stopped. Initially haldol was given prn agitation, but that too was stopped. . Anemia: Baseline HCT 23-27. No sign of overt bleeding, however, mildly Guiac +. Received 9 units during his MICU course (3 of those the day prior to surgery). . Elevated Troponin: Troponins continuing to rise, no clear ECG changes although some T wave flattening on ECGs. Pt may have septic emboli to coronaries given new wall motion abnormalities and reduced EF on recent echo. . ARF: creatinine increased to 1.4 prior to surgery, like from hypotension, poor perfusion. Pt was given renal protective therapy with sodium bicarb and mucomyst. . On [**2192-10-11**] The patient was transfered to the surgical service for aortic valve replacement with a porcine valve which was uncomplicated. Post operatively he was cared for in the cardio-thoracic ICU. He was changed from vancomycin + daptomycin to Linezolid on [**2192-10-12**] as his sensitivities VISA and dapto-intermediate sensitivity. On [**10-12**] he was started on amiodarone 400mg [**Hospital1 **] following loading with an IV drip for rapid Afib, he was decreased to 400mg daily on [**10-18**]. He was also started on lasix 20mg IV BID on [**10-12**] which was increased to 40mg IV BID on [**10-18**]. He was extubated on [**2192-10-14**]. On [**10-15**] he had KUB and RUQ u/s for abdominal pain and concern for SBO vs cholecystitis. The KUB showed non obstructive bowel gas pattern with retained contrast c/w delayed transit. His RUQ ultrasound showed no evidence of cholelithiasis or cholecystitis. He had not moved his bowels in several days and did have bowel movement following lactulose . LFT's were slightly elevated on [**2192-10-11**] but were improved on repeat [**10-15**]. . He was transferred to the MICU service on [**10-18**] due to continued delirium. . MICU COURSE [**Date range (3) 77132**]: The patient was continue on the Lasix 40mg IV BID but this was stopped on [**2192-10-19**] due to concerns of rising creatinine. He continued to diurese well. An MRI was ordered for further work-up of mental status changes. Mental status waxed and waned but was not markedly changed from admission. Pt would respond to voice occasionally, follow commands sporatically. Moves all extremities. Pt was transferred to the floor on [**2192-10-19**] for further workup. . MEDICINE COURSE [**2192-10-19**] to [**2192-10-26**]: 80M with PMH of CVA, small bowel obstruction, and metastatic prostate CA admitted originally for altered mental status who developed vancomycin and daptomycin intermediate resistant endocarditis with destruction of the aortic valve now s/p valve replacement with persistant delirium. His hospitalization has been complicated by afib with RVR post op. He is also volume overloaded with an estimated 18L positive fluid balance not accounting for error and insensible losses. He is persistently anemic. The DD for his delerium is primary CNS process such as infection, infarct, met, toxic metabolic state, or degenerative process. His bacteremia seems to be cleared and his cardiac status is stable. . # Delirium: Main clinical issue at this point. Likely multifactorial related to toxic metabolic state, medications, possible CNS complications such as infection, infarct, met, or degenerative process. To reduce this we have treated pain with tylenol standing and low dose MS IV if appeared to be in pain. He has not required MS IV in several days. We held sedating and altering medications as much as possible. A head MRI showed no process to explain his delirium. We D/Ced IJ, Foley, and recal tubes. He has a condom cath and an NG tube which he tolerates. The Pt also has ongoing frontal sings including [**Last Name (un) 8752**]-metal, snout, [**Doctor Last Name **], and [**Doctor Last Name 77133**] as well as pathologic Babinski. Has failed speech and swallow examination. . # Atrial fibrillation - he had Afib with RVR post-operatively for which he was started on amiodarone + metoprolol. He is currently in NSR with rate in the 60-70's. He has no h/o afib prior to surgery therefore may have been isolated event in setting of open heart surgery. Has been monitored on tele with no events. Cards had recommended amiodarone 200mg daily for 6 months but CT [**Doctor First Name **] said none is needed since he seems to be in stable sinus rhythm. Holding amio for now. On metoprolol for rate control. . # Anemia: HCT 22 on admission with guaiac positive stools concerning for slow GI bleed. He was transfused 9U pRBC peri-operatively. HCT had been stable ~30 post op. HCT dropping slowly. Likely component of phelbotomy induced anemia in the context of anemia of inflammation. Plan to transfuse if increasingly tachycardic or HCT <21. Could be due to linazolid toxicity. . # UMN signs and possible frontal release signs. Pt with toes up bilat, LE rigidity, reports inability to move legs due to weakness. There is distant concern that he could have epidural abscess [**1-7**] seeding from his endocarditis. Frontal release sings positive for [**Last Name (LF) 77133**], [**First Name3 (LF) **], palmomenal, and snout. Grasp was positive but less so over time. As noted, MRI of the brain showed nothing to explain his delerium or neuro s/s. Held off on imaging of spine as he was clinically improving and afebrile. Given that some of the signs have fluctuated, this may be a component of his delirium . # Stage III Decubitus Ulcer - located on coccyx, followed by wound consult service. On [**Doctor First Name **]-air mattress. Now that he has PO access hopefully improved nutrition will help this. . # Aortic valve endocarditis and bacteremia- now s/p aortic valve replacement with porcine valve. All blood cultures since surgery have been sterile. On strict contact isolation for vancomycin and daptomycin intermediate resistant Staph. aureus. Per ID will continue linezolid to [**2192-11-23**]. No need for further screening BCx. As Staph can seed and cause abscesses which must remain in the DD for ongoing neuro issues, however MRI of the brain is essentially NL. Spine MRI was not done [**1-7**] agitation. Held off on additional imaging as clinical status improving. Most recent CRP was 99, down from 200. Will need weekly CRP to confirm imporvement after his endocarditis. . # Volume Overload - Positive fluid balance over his length of stay with significant pleural effusions and lower extremity edema. Now on furosimide 40mg PO daily (was 20mg IV BID) and diuresing actively. Will need [**Hospital1 **]-weekly check of electrolytes given on active diuresis. Holding Lasix for now since seems euvolemic. . # Abdominal Pain: Now seemingly resolve. Had KUB and abdominal ultrasound which were unrevealing. Not a clear complaint because could distract pt from it. Amylase and LFTs NL. Cdiff negative x 2. Resolved. He had a large BM after tap water enema on [**2192-10-26**]. . # Prostate cancer: Known to have metastatic prostate cancer. PSA WNL [**2192-10-20**] so was holding leuprolide given low PSA. Pt normally received his leuprolide every 4 months of 30 mg IM. He is followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital3 328**]. We gave him a dose of 28.25 mg IM on [**2192-10-26**] (only dose we had here) which is an adequate dose per Dr.[**Name (NI) 77134**] office. . # Hypotension: Not pathologic. SBP 90-110. Hold metoprolol for SBP<90 . # Depression: prior to his prolonged two hospitalizations here he had been treated for depression with Remeron 45 mg qhs, Effexor XR 150 mg tabs (1.5 tabs daily) and Zyprexa 7.5 mg qhs. He has not been on these doses for a couple of months but prior to his hospital stay at the [**Hospital1 18**], at the MACU at [**Hospital 100**] Rehab he was on Effexor 37.5 mg [**Hospital1 **] and Haldol. He is currently not on any of these agents. He would benefit from seeing a psychiatrist once his delirium resolves. . # Nutrition: Patient due to delirium has been aspirating thin liquids and is unable to take po. A dubhoff was placed for enteral nutrition. It came out by accident upon transport from getting a PICC line and an NG tube was put back in. Per daughter [**Name (NI) 3608**], she would like to give him a chance ie two weeks before thinking about a G tube. Medications on Admission: 1. Cholecalciferol 400mg PO DAILY 2. Docusate Sodium 100 mg Two PO BID 3. Senna 8.6 mg PO BID 4. Lupron Subcutaneous 5. Polyethylene Glycol 3350 Oral 6. Aspirin 81 mg PO Daily 7. Calcium Oral 8. Cyanocobalamin Oral 9. Garlic Oral 10. Omega-3 Fatty Acids 1,000 mg PO Daily 11. Haloperidol 1 mg PO TID PRN Agitation. 12. Haloperidol 1 mg Tablet 2.5 Tablets PO QHS 13. Venlafaxine 37.5 mg SR PO BID 14. Ferrous Sulfate 325 mg PO DAILY 15. Heparin SQ 5000 units TID 16. Acetaminophen 325 mg 1-2 Tablets PO Q6H PRN 17. Pantoprazole 40 mg Delayed Release PO Q24H 18. Midodrine 5 mg PO TID 19. Metoprolol Tartrate 25 mg 0.5 Tablet PO BID 20. Bisacodyl 10 mg Suppository Rectal QHS PRN constipation. 21. Docusate Sodium 100 mg PO BID 22. Insulin Regimen Sliding Scale Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Name (NI) **]: 5000 (5000) units Injection TID (3 times a day). 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO four times a day: While [**Last Name (LF) 77135**], [**First Name3 (LF) **] not exceed 4g in 24hrs, please give standing for pain. 6. Heparin, Porcine (PF) 10 unit/mL Syringe [**First Name3 (LF) **]: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 7. Linezolid 600 mg/300 mL Parenteral Solution [**First Name3 (LF) **]: Six Hundred (600) mg Intravenous Q12H (every 12 hours): Please discontinue after [**2192-11-22**]. 8. Polyethylene Glycol 3350 100 % Powder [**Month/Day/Year **]: One (1) PO DAILY (Daily). 9. Lactulose 10 gram/15 mL Solution [**Month/Day/Year **]: 30 mL PO once a day: Titrate up more for constipation. 10. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO twice a day: Hold for SBP <90 and pulse <60. 11. Leuprolide (4 Month) 30 mg Kit [**Month/Day/Year **]: One (1) kt Intramuscular q 4 months: last given on [**2192-10-25**]. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary diagnosis: Staph endocarditis s/p AVR with porcine valve, delirium, stage III sacral decubitus ulcer, post-op afib resolved . Secondary diagnosis: Metastatic prostate cancer, depression Discharge Condition: Stable vital signs, afebrile Discharge Instructions: You were admitted from rehab for fevers. Ultimately you were found to have Staph growing in your blood. We found evidence that a valve in your heart was infected by this Staph and you required surgery to repain the damage done to your aortic valve. We have treated you with long term antibiotics as a result of this infection as well. You have been more delirius during this hospitalization. The cause of this is multi-factorial. . Please continue to take your medications as prescribed. . Please attend your follow up appointments. . Please call your doctor or come to the emergency department if you experience fevers, shortness of breath, palpitations, chest pain, diarrhea, or other concerning symptoms. Followup Instructions: [**Hospital1 18**] PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2192-11-14**] 11:00 - works with PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Hospital1 18**] ID: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2192-12-13**] 9:00 Cardiothoracic surgery will call with a follow up appointment Completed by:[**2192-10-29**]

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icd9cm

[ [ [] ] ]

[ "00.14", "38.93", "35.21", "88.72", "88.56", "39.61", "96.72", "38.91", "37.22", "34.91", "96.6", "96.04" ]

icd9pcs

[ [ [] ] ]

27758, 27837

15263, 25497

335, 462

28075, 28106

7529, 7529

28862, 29384

6393, 6445

26314, 27735

27858, 27858

25523, 26291

13552, 15240

28130, 28839

8327, 13535

6460, 7510

276, 297

490, 5778

28013, 28054

7545, 8311

27877, 27992

5800, 6100

6116, 6377

711

158,767

44891

Discharge summary

report

Admission Date: [**2185-3-22**] Discharge Date: [**2185-5-16**] Service: MEDICINE Allergies: Bactrim / Remeron Attending:[**First Name3 (LF) 1973**] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: Endotracheal Intubation from [**3-22**]/08 through [**4-6**] Tracheostomy on [**2185-4-6**] History of Present Illness: 85 y/o man with h/o CHF, CAD, PVD, and chronic atrial fibrillation on [**Date Range **] who is well known to [**Hospital1 18**] with multiple admissions who presented to the ED from rehab with respiratory distress/dyspnea. CXR at rehab the day PTA with B/L lower lobe PNA. He was also noted to be hypotensive in the ED with SBPs in the 70s. Of note, he was recently admitted to [**Hospital1 18**] for most of [**Month (only) 404**] with FTT and dehydration. . ED course: Vitals on presentation: T 97.9 HR 104 BP 132/68 RR 27 85% NRB improved to 95% RA then 100% NRB. In the ED, the patient was intubated for respiratory distress and increased work of breathing. He was also hypotension with systolics in the 70s which responded with IVF. He was given ceftriaxone, vanc, and azithromycin. From [**Hospital3 2558**]. He had been DNR/DNI but code status was reversed in the ED. Past Medical History: Diastolic CHF, most recent EF 60-65%, on Lasix at rehab PVD s/p right SFA to AT bypass in [**5-9**] CAD, s/p MI in [**2174**], s/p NSTEMI in setting of rapid afib (admission [**5-9**]) Chronic atrial fibrillation, had been on [**Month/Year (2) **] in the past, stopped several months ago for unclear reasons, now on ASA alone T2DM Hypercholesterolemia Hypothyroidism. He was diagnosed with hypothyroidism around [**6-8**]. He had been taking 12.5mcg Synthroid until his recent hospitalization this [**Month (only) 359**] when his Synthroid was increased to 25mcg once daily as his TSH was high at that time. The Synthroid was again increased to 50mcg at [**Hospital 100**] Rehab at unknown day as his TSH was high persistently, according to medical record which was faxed to us from Dr.[**Name (NI) 7753**] office. So his is taking 50mcg once daily now. Recurrent C. Diff colitis. Post-Polio weakness/contracture. He developed polio infection at age of 25 and has bilateral legs weakness and right upper arm weakness. Chronic urinary retention [**3-5**] to BPH Multiple prolonged recent hospitalizations: - [**Date range (1) 96030**]/07 - admitted for Right SFA to DP bypass for severe gangrene of right foot - [**Date range (1) 96031**] - atrial fibrillation, C.diff, hypotension - [**Date range (1) 14447**]/07 - hypotension, UTI, afib with [**Date range (1) 5509**], diarrhea - [**Date range (1) 32799**]/07 - pulmonary edema, pneumonia, afib with [**Last Name (LF) 5509**], [**First Name3 (LF) 282**] [**First Name3 (LF) **] placement, CPAP, pulm edema requiring thoracentesis and bronchoscopy - [**Date range (1) 96032**]/07 - [**Hospital 100**] Rehab - [**Date range (1) 96033**] - [**Hospital3 **], dehydration, acute renal failure and was then transferred to [**Hospital1 69**] for further management of renal failure, fluid overload. His clinical course was complicated by recurrent C. diff colitis, pseudogout in right wrist and UTI. He was discharged to [**Hospital 7137**] Nursing Home [**2185-3-2**]. - 15/08 - [**2185-3-3**] [**Hospital1 18**], FTT, hyperkalemia, ESBL UTI tx with IM gent, chronic c.diff on PO vanc, pseudogout of right wrist, subacute stroke on ASA and Plavix, discharged DNR/DNI s/p [**Hospital1 282**] [**Hospital1 **] placement Concern for depression at recent geriatric visit on [**2185-3-14**], refused to take any antidepressant, tried Remeron in the past but didn't tolerate it because of hallucination, also refused Megace . Social History: SH: Home: normally lives with wife at home but has been in [**Hospital 100**] Rehab. Denies tobacco, etoh, and drugs Family History: n/c Physical Exam: ED Vitals: T-96 HR 90 BP 137/63 RR 28 Sats initially 85% on NRB GENERAL: appears malnourished, but in no acute distress. HEENT: No trauma. Extraocular movement are intact. Clear conjunctivae. NECK: Supple. No thyroid nodule palpable. No JVD, no lymphadenopathy. CARDIOVASCULAR: Irregularly irregular heart rate and rhythm. No heart murmur, no gallops. RESPIRATORY: Distant lung sounds, limited airway movement, no wheezing, no crackle. ABDOMEN: Soft, nontender, nondistended. No hepatosplenomegaly. Bowel sounds are present in all four quadrants. G-[**Hospital **] in place. The site of G-[**Hospital **] is clean and dry. Penis retracted pouch in place. there is leakage of urine around the pouch. the skin on scrotum is not erythematous but wet. EXTREMITIES: No edema, no clubbing, no cyanosis. The extremities are cold secondary to peripheral [**Hospital 1106**] disease. NEURO: Alert, awake, and oriented to the place and person. His language is appropriate. Speech intact. Pertinent Results: [**2185-3-22**] 07:25AM WBC-5.1# RBC-3.29* HGB-9.2* HCT-28.9* MCV-88 MCH-28.0 MCHC-31.8 RDW-14.9 [**2185-3-22**] 07:25AM PLT COUNT-482* [**2185-3-22**] 07:25AM NEUTS-88.9* LYMPHS-6.8* MONOS-3.7 EOS-0.5 BASOS-0.2 [**2185-3-22**] 07:25AM PT-21.5* PTT-41.1* INR(PT)-2.0* [**2185-3-22**] 07:25AM CALCIUM-8.6 PHOSPHATE-6.0*# MAGNESIUM-2.1 [**2185-3-22**] 07:25AM CK-MB-10 MB INDX-9.9* proBNP-[**Numeric Identifier 96036**]* [**2185-3-22**] 07:25AM cTropnT-0.20* [**2185-3-22**] 07:25AM CK(CPK)-101 [**2185-3-22**] 07:25AM GLUCOSE-220* UREA N-42* CREAT-1.1 SODIUM-134 POTASSIUM-5.6* CHLORIDE-101 TOTAL CO2-17* ANION GAP-22* [**2185-3-22**] 07:34AM LACTATE-4.4* K+-5.1 [**2185-3-22**] 10:40AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.012 [**2185-3-22**] 10:40AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD [**2185-3-22**] 10:46AM O2 SAT-80 [**2185-3-22**] 01:27PM CORTISOL-28.5* . **** MICRO **** [**3-22**] respiratory viral screen positive for influenza B antigen [**3-23**] sputum MRSA 2/19,[**3-26**] blood cx PENDING [**3-22**] legionella urinary antigen negative 2/19,[**3-24**] urine cx yeast [**3-23**] urethral fluid yeast AFB Smear (-) x3 [**Date range (3) 96037**] . EKG [**3-22**] Atrial fibrillation, average ventricular rate about 100 per minute. Borderline low limb lead voltage. Complete right bundle-branch block. Non-specific ST-T wave changes. Compared to the previous tracing of [**2185-2-6**] no diagnostic change. **** IMAGING **** CXR [**3-22**] SINGLE SUPINE VIEW OF THE CHEST AT 8:30 A.M.: There has been interval placement of an endotracheal [**Month/Year (2) **], terminating approximately 4.5 cm from the carina. Layering pleural effusions are seen bilaterally, left greater than right. Increased opacity is seen throughout both lungs, likely due to a combination of mild pulmonary edema, pleural effusions, and basilar atalectasis. Cardiomediastinal and hilar silhouettes are unchanged. IMPRESSION: Appropriate position of endotracheal [**Month/Year (2) **]. Layering bilateral pleural effusions and mild pulmonary edema. TTE [**3-23**] The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate to severe global left ventricular hypokinesis (LVEF = 25-30 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with moderate global free wall hypokinesis. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2184-10-18**], there has been marked/diffuse biventricular systolic dysfunction c/w diffuse process (toxin, metabolic, cannot exclude multivessel CAD but less likely as no focality to dysfunction). The left pleural effusion is now much larger. Renal U/S [**3-25**] 1. No evidence of hydronephrosis or mass within the urinary bladder. 2. A 1.9 cm angiomyolipoma of the right kidney. 3. Moderate enlargement of the prostate consistent with BPH. PICC placed on [**3-31**] IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French double-lumen PICC line placement via the right brachial venous approach. Final internal length is 45 cm, with the tip positioned in SVC. The line is ready to use. [**2185-4-2**]: CT SINUS/MANDIBLE/MAXILLOFACIAL WITHOUT CONTRAST: IMPRESSION: Air fluid levels in the sphenoid sinus and in the mastoid air cells. This could be consistent with sinusitis/mastoiditis. Clinical correlation recommended. [**2185-4-2**] Chest CT: IMPRESSION: 1. Probable right lower lobe pneumonia. 2. Bilateral pleural effusions, longstanding, with associated compressive atelectasis. [**2185-4-11**] NON Contrast Head CT: FINDINGS: Evaluation is limited secondary to patient motion. Allowing for these limitations, there is no evidence for intracranial hemorrhage or mass effect. The ventricles, cisterns, and sulci are prominent secondary to involutional changes. Periventricular white matter hypodensities are the sequela of chronic small vessel infarction and area of encephalomalacia in the left occipital lobe indicates prior infarction. There is dense atherosclerotic disease of the cavernous carotid arteries. The visualized paranasal sinuses are clear. There is partial opacification of the mastoid air cells. IMPRESSION: Limited examination secondary to patient motion, there is no evidence of intracranial hemorrhage. MR is more sensitive for the evaluation of acute brain ischemia. Brief Hospital Course: 85 y/o man admitted with respiratory failure and sepsis from influenza A complicated by a MRSA pneumonia. # RESPIRATORY FAILURE: Pt was DNR/DNI prior to this presentation to the ED. Upon arrival to the [**Name (NI) **], pt was in mild respiratory distress with hypotension. Code status was reversed, pt was intubated & aggressively volume resussitated. Pt was found to have Influenza A complicated by an MRSA PNA, he was also noted to have some e/o demand ischemia. ECHO revealed a globally depressed EF of 20-30%, CXR revealed bilateral pulm effusions. Pt was treated with 10 days of Vancmcyin for an MRSA PNA. Pt was having difficulty weaning with RSBIs>100 & low NIFFs. Pt then developped recurrent low grade temps & elevated WBC count. Sputum was +klebsiella and pt was started on Zosyn for VAP & switched to Meropenem (for ESBL producing Klebsiella) to complete a 7 day course of ABx. Pt was intubated for 16 days with NIFFs ranging from -1 to -7. RSBIs ranging from 80-120. Pt has a known h/o post polio syndrome with presumed weak resp muscles and was thought not likely to tolerate extubation. Pt had trach placement on [**2185-4-6**], which he toleratd well. His volume status was optimized via lasix and diuresis, and his respiratory status improved. The ventilator was weaned to pressure support, and then tracheostomy collar with blow-by oxygen. Upon transfer from the MICU, he was tolerating humidified air with good oxygenation and ventilation. After transfer the state lab called, and it was noted that he had a positive AFB Culture on a negative smear specimen drawn ~1 month prior to admission. Infection control was consulted, who felt that the patient could go home once he had ruled out for AFBx3 smears, as far as his contagious risk. He had 3 smears which were negative prior to discharge, and cultures were consistent with MAC. # Bacteremia/Fungemia: Pt was noted to have low grade fevers & rising WBC count on [**4-11**]. Blood cultures from [**4-12**] were + VRE & fungus. Pt was started on Linezolid for 14 day course for bacteremia. Urine Culture was +yeast on [**4-12**] & [**4-15**]. Foley was changed out & Caspofungin was started for a 14day course treating fungemia & funguria. Sputum from [**4-12**] & [**4-14**] was +Klebsiella, pt was treated with a 8 day course of Meropenem for presumed VAP. Patient completed a course of caspofungin and linezolid and subsequently remained afebrile and hemodynamically stable. # Atrial Fibrillation with Labile BP: Pt with h/o chronic A.Fib was noted to have labile BPs thought likely due to agitation & volume. Acheived better rate and BP control with Metoprolol 100mg TID. Diltiazem was added for additional rate control, however, pt had an episode of bradycardia on [**2185-4-3**] and Diltiazem was stopped. Heart rates were generally stable in 80-100's on Metoprolol 100mg TID, Digoxin 0.125mg & low dose ASA 81mg. Anticoagulation was held due to hematocrit drop with ongoing bloody secretions from oropharynx, will defer to outpt cardiologist regarding plan for future anticoagulation, although in light of hospice services, it is unlikely to be significantly adjusted. # Chronic Diastolic and Acute Systolic Heart Failures: Pt with h/o diastolic CHF, found to have globally depressed EF of 25-30% on admission, possible related to viral myocarditis vs sepsis induced cardiomyopathy. ECHO showed no evidence of regional wall motion abnormality thought pt was noted to have evidence demand ischemia in setting of SIRS on admission. LV function was thought likely to recover in 6-8wks, he will likely need follow up echo as outpt. Pt was switched from Captopril to lisinopril for afterload reduction and developped hyperkalemia despite otherwise normal renal function and the ACE-I was discontinued. He was mantained on metoprolol. His lasix was converted to PO and a stable daily regimen to maintain euvolemia was established at 120 mg PO TID. # OROPHARYNGEAL BLEED: Pt was noted to have increased bloody secretions around ETT while on a heparin drip for systemic anticoagulation (for AFib). Heparin was held & ENT was consulted, felt this was likely due to skin breakdown & abrasions under ETT after prolong intubation. Pt received pRBC tranfusions for mild hct drop & bleeding stopped after systemic anticoagulation was held. # Delerium: Pt was noted to be persistently non-responsive to stimuli after extubation. Non con head CT was neg for acute intracran pathology (positive for small vessel Dz), Vit B12 was WNL & EEG showed slowed background and global encephalopathy. Both Ethics & the Pain/Palliative Care were consulted, Olanzapine 5mg [**Hospital1 **] was started for possible underlying delirium. Upon clearing his infections, the patient made considerable improvement in his MS. A passy-muir valve was provided for the trach and the patient appropriately answered questions and followed commands. # UTI - Bacterial: Urine cultures from [**3-27**] were positive for yeast. Pt completed 3 days of Amphotericin CBI. Repeat UAs were +leukocytes & WBCs but no yeast. Foley was changed out on [**2185-4-2**] & repeat urine cultures have been NGTD. # Type 2 DM Controlled: Pt with a history of Type II DM was covered with humalog insulin sliding scale while receiving TF of Nutren Pulm at 45cc/hr. # C. Diff Colitis: Pt with h/o relapsing/recurrent c.diff on a slow po Vancomcyin taper as outpatient. Pt was given treatment dose po Vancomycin at 125mg q6hr while on broad spect Abx. His outpatient taper was re-started on the last day of systemic antibiotics, [**2185-4-29**]. # Left shoulder dislocation: This was noted incidentally on early admission CXR, per ortho, they deferred management until medically stable to tolerate MRI. Repeat shoulder films unable to confirm dislocation, pain was managed with po morphine. #AFB (+) Cultures Cultures at state lab were positive from prior admission. As such he was ruled out with 3xAFB smears which were all negative, and on day of discharge the state lab's cultures were read out at MAC rather than MTB. Medications on Admission: Levothyroxine 100 mcg PO daily Diltiazem HCl 30 mg PO QID Aspirin 81 mg PO daily Miconazole Nitrate 2 % Powder [**Month/Day/Year **]: One (1) Appl Topical TID (3 times a day) as needed. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Month/Day/Year **]: One (1) Inhalation Q6H (every 6 hours) as needed. Simvastatin 5 mg PO MWF Clopidogrel 75 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO DAILY (Daily). Prilosec 20 mg PO daily Calcium Carbonate 500 mg Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet, Chewable PO BID (2 times a day). Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY (Daily). 12. INSULIN Insulin per sliding scale QID. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO every six (6) hours. Vancomycin 125 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO every other day: Last day [**2185-3-9**]. Metoprolol Tartrate 25 mg PO TID 16. Gentamycin Gentamycin 50mg intramuscular q12 hours. Six doses, first dose given on [**2185-3-3**] at 4PM. Megace 200 mg PO BID Levaquin 250 mg PO x 7 days, started on [**2185-3-21**] Ciprofloxacin 500 mg PO BID x 7 days, started on [**2185-3-21**] Milk of Mag Bisacodyl Lantus MVI Colace [**Date Range 197**] (per family, NOT on transfer records) Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Date Range **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Levothyroxine 100 mcg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable [**Date Range **]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Simvastatin 10 mg Tablet [**Date Range **]: 0.5 Tablet PO QMOWEFR (Monday -Wednesday-Friday). 5. Albuterol 90 mcg/Actuation Aerosol [**Date Range **]: 6-10 Puffs Inhalation Q4H (every 4 hours) as needed for SOB. 6. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Date Range **]: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed for SOB. 7. Calcium Carbonate 500 mg Tablet, Chewable [**Date Range **]: One (1) Tablet, Chewable PO TID (3 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 9. Chlorhexidine Gluconate 0.12 % Mouthwash [**Date Range **]: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 10. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID (3 times a day) as needed. 11. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 12. Olanzapine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 13. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a day). 14. Docusate Sodium Oral 15. Morphine 10 mg/5 mL Solution [**Hospital1 **]: One (1) PO Q4 HOURS (). 16. Morphine 10 mg/5 mL Solution [**Hospital1 **]: One (1) PO Q3H (every 3 hours) as needed for respiratory distress or discomfort. 17. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed for Fever. 20. Vancomycin 125 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q8H (every 8 hours) for 14 days, then decrease to 125mg q12hrs for 14 days, then decrease to 125mg once a day for 2weeks then decrease to 125mg every other day for 2weeks then stop. Discharge Disposition: Home With Service Facility: Hospice of the Good [**Doctor Last Name 9995**] Discharge Diagnosis: Respiratory Failure s/p prolonged intubation & tracheostomy MRSA PNA Klebsiella VAP Atrial Fibrillation Candidal UTI MS Changes Discharge Condition: Stable Discharge Instructions: You were admitted with sepsis due to influenza, this was complicated by an MRSA pneumonia. You were also treated for a ventilator assoc pneumonia. You have had a prolonged ICU course including intubation & tracheostomy placement. You will need to continue with vent weaning at the [**Hospital1 1501**]. Followup Instructions: Pls call his PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 96038**] for follow up appointments.

[ "487.0", "428.43", "272.0", "250.00", "831.00", "785.52", "995.92", "427.31", "518.81", "428.0", "482.41", "008.45", "038.9", "E928.9", "112.2", "V09.0", "482.0", "244.9", "999.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

19155, 19233

9758, 15832

246, 340

19405, 19414

4919, 8952

19767, 19947

3884, 3889

17165, 19132

19254, 19384

15858, 17142

19438, 19744

3904, 4900

186, 208

368, 1244

8961, 9735

1266, 3734

3750, 3868

40,474

159,047

7495

Discharge summary

report

Admission Date: [**2116-4-5**] Discharge Date: [**2116-4-10**] Date of Birth: [**2054-3-12**] Sex: F Service: MEDICINE Allergies: Inderal Attending:[**First Name3 (LF) 4654**] Chief Complaint: Fever/SOB Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 62 y/o Cambodian female with PMH of chronic HBV, HTN, asthma, DM and nephrotic syndrome who presents from home with fevers and SOB. History is largely obtained from patient's daughter who is able to interpret. Per the patient's daughter her mom was in her USOH until last evening around midnight. At that time the patient was noted to be calling out for her from the bathroom, screaming. The patient reported that she was unable to urinate and felt chilled and requested the heat be turned up. She was shivering uncontrollably. She complained of SOB and she was given 2 nebs with minimal relief. Temp. at that time was 103 and she was given 2 tylenol. She went to bed and this morning was found by her sun to have continued chills and was very lethargic. EMS was called and Temp. was 105 tympanic. The patient reports that she has had dysuria, inc. unrinary frequency and urgency for the last 2-3 days. Over the last day she has had decreased urine which has looked very concentrated. Per the daughter she has been eating and drinking normally. She has also had a mild cough for the last day. She denies sick contacts. She denies diarrhea or vomiting. He last BM was today and was normal. . In ED the patient's VS were T 104.2 BP 164/60 HR 126 RR 32 93% RA, 99% 3L. CT abd/pelvis was done and showed ? fluid around gallbladder. RUQ US then performed that was negative for cholecystitis. UA was grossly positive. Blood and urine cultures sent. She was given vanc/zosyn, Tylenol 1gm, duonebs x2 and a total of 3L IVF. Spiked a temp to 102.9 and was given an additional 1gm tylenol. Labs were notable for lactate 3.2 which normalized after IVF. She became acutely SOB and tachypneic to 30s. She had audible wheezing on exam. Repeat CXR was done and was negative for flash pulm edema. She was then given solumedrol 125mg IV, duonebs x 2, magnesium 2gm IV, and SL nitro x1. Her RR decreased the the patient's SOB improved. Sats remained 96-100% on 4L. She was admitted ot the ICU given her worsening resp. status in the ED. . On arrival to the ICU the patient is accompanied by her daughter who is able to translate. The patient reports that her SOB is significantly improved, however she still has some mild chest tightness and SOB. She denies nausea, abdominal pain. She endorses some "warmth" in her lower abdomen as well and dysuria. . ROS is positive as per HPI. She denies nausea, vomiting. Her appetite and PO intake have been normal. She denies LE swelling, orthopnea or PND. Denies melena or hematochezia. Past Medical History: 1. Diabetes Mellitus, Type 2: She was diagnosed in [**2104**] and has been followed by Dr. [**Last Name (STitle) 9006**] since that time. She is controlled on insulin. Here most recent HbA1c was < 7%. 2. Chronic Hepatitis B. 3. Stage 2 - Chronic kidney disease (hyperparathyroidism [**2-10**] renal issues). 4. Nephrotic Syndrome. 5. Hypertension. 6. Asthma. 7. Hypertriglyceridemia. 8. CVA/TIA. 9. Raynaud's phenomena. 10. Generalized anxiety disorder. Social History: She lives with her daughter, son and husband. She has 9 children. Her occupation was as a housewife. She was born in [**Country **] living in a rural area. She denies ever smoking cigarettes but does chew betel. She denies alcohol abuse. She came to the United States in [**2090**]. Independent of ADLS: dressing - needs assistance with socks only, ambulating hygiene eating toileting IADLS: dtrs - shopping, dtr- accounting, independent with telephone use, husband food preparation Lives with: family Walks with cane No recent falls. + Visual aides for sewing + Dentures Family History: Daughter and son with asthma; no strokes or seizures in family per granddaughter. Physical Exam: Gen: Appears tired, Cambodian speaking, mild resp. distress, awake, alert, daughter translating [**Name (NI) 4459**]: NCAT, [**Name (NI) 2994**], +periorbital edema, EOMI, OP clear, dry MM, remnants of red chewing tobacco in mouth Neck: supple, JVP not elevated, no cervical LAD Lungs: decreased air movement throughout, audible upper airway wheezing, prolonged exp phase, no rales Heart: nml S1S2, tachy, regular, no m/r/g Abdomen: Obese, distended, soft, NT, no HSM appreciated, no fluid wave, no shifting dullness, hypoactive BS Ext: 1+ edema of bilateral lower extremities. Palpable DP and PT Pulses [**Name (NI) **]: +Buffalo Hump Skin: no rashes, no telangectasias, no caput, no striae Neuro: CN II-XII grossly intact, Strength 4+ RUE, [**3-12**] in RLE, 4+/5 in LLE and LUE, unchanged per daughter. Pertinent Results: [**2116-4-5**] CXR SINGLE FRONTAL VIEW OF THE CHEST: Evaluation is degraded by motion. Lungs are well expanded and clear without consolidation, pleural effusion or pneumothorax. The heart is moderately enlarged, as previously. There is no hilar or mediastinal enlargement. Pulmonary vascularity is not overtly engorged. Soft tissue and bony structures are unremarkable. IMPRESSIONS: Cardiomegaly. Motion artifact [**2116-4-5**] CT abdomen 1. Small amount of fluid surrounding the gallbladder, which is mildly distended. If symptoms correlate to the right upper quadrant, ultrasound is recommended to evaluate for acute cholecystitis. 2. Endometrium prominent for given age and further evaluation may be obtained with pelvic ultrasound on a non-urgent basis. [**2116-4-6**] Echo The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). 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 (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. [**2116-4-8**] KUB: . FINDINGS: The bowel gas pattern is unremarkable, without evidence of obstruction or ileus. No pneumoperitoneum. Soft tissues are unremarkable. Lung bases are clear. Of note, there is moderate cardiomegaly. Visualized osseous structures are unremarkable. . IMPRESSION: Non-obstructive bowel gas pattern. CXR [**2116-4-8**]: . INDICATION: Cough, mild left lower quadrant pain. The lung volumes are relatively low, both hemidiaphragms are slightly elevated. Minimal hypoventilation at the bases of the left lung. Otherwise, the lung parenchyma is normal. No pneumonia, no overhydration. On the lateral radiograph, minimal dorsal pleural effusions are seen. Normal appearance of the hilar and of the mediastinum. Brief Hospital Course: 62 y/o F with DM, diabetic glomerulosclerosis, nephrotic syndrome, chronic hepatitis B, HTN, and asthma was in ICU for Urosepsis and Resp Distress from flash pulm edema following fluid resusitation initially in [**Name (NI) **] - pt stabalized in [**Hospital Unit Name 153**] - cont IV abx for E. Coli UTI and bacteremia/sepsis, called out to medical floor on [**4-7**] for continued care. Pt with slow recovery, changed to po cipro on [**2116-4-9**] -cont to be afebrile, [**4-6**] and [**4-7**] Blood Cx NGTD at time of d/c - plan to d/c to home with home services with details of course as below: # Urosepsis (E. Coli UTI, and E. Coli Bacteremia/Sepsis): urine grew E.coli (pansensitive) - was on IV Ceftriaxone (day 1=[**4-5**]) -> [**4-6**] blood cultures without growth - switched to po Cipro [**4-9**] (pan-sensitive E. Coli) cont to do well for 24h # Respiratory Distress with CHF as below/Chronic Asthma: was initially though to be in setting of sepsis and likley from worsening of Asthma. No evidence of PNA or overt pulm edema - did have mild congestion. Has severe diastolic HF. Received solumedrol (in ICU) but then d/c'ed. Pt sx have been slowly improving - but still with sig DOE on ambulation - suspect component of sig dehabilitation as well with chronic asthma. [**Name (NI) 27410**] pt now showing cont improvement, stable for d/c but still need to cont to recover at home with home VNA services arrange (PT, etc.) - cont nebs - cont Lasix (80 mg [**Hospital1 **]) po - cardiac eval was done as below - eval with CXR/KUB [**4-8**] - neg for acute changes - overall again sx now improving - cont eval with PT at home # Demand Ischemia/Chest pain: elevation in CE with ST dep on admissions; CKs trended down and EKG changes resolved. Thought to be demand in setting of sepsis. Though trop rised initially while other markers falling - delayed effect? later trended down as well (last checked 0.16) - Pt with chest pain early [**4-8**] later completely resolved by itself. Given earlier sx - conted to trend CE assure stability. CE further trended down today, per family has had neg stress test at OSH 2yrs ago - ************would recommend outpt stress eval given findings but would recommend to have infection completely treated prior. - on [**Month/Day (4) **], Statin, ACEI, [**Last Name (un) **] - restarted BB [**4-8**] with room given persistant sx and high risk factor - chest pain free now, no longer need to trend CE - *********PCP to [**Name Initial (PRE) **]/u and consider arranging outpatient stress test following treatment for E. Coli Bacteremia # Recurrent UTI: ********PCP to arrange [**Name9 (PRE) 3782**] Gyn & Urology f/u to look for any structural abnormalities resulting in recurrent UTI of this pt. # Acute on chronic renal failure: Cr was elevated to 1.4, now resolved after IV hydration - resumed ACEI and [**Last Name (un) **] once on medical floor - resume Lasix - Cont. calcitriol # Acute on Chronic Diastolic Heart Failure: contributing to resp distress initially, demand ischemia prior - now more euvolemic, controlled. - resumed Lasix - resumed ACEI, [**Last Name (un) **] # Diabetes: Follwed at [**Last Name (un) **]. Insulin recently changed to glargine [**Hospital1 **] for better control. Also changed to Humalog SS [**First Name8 (NamePattern2) **] [**Last Name (un) **] service here. - Cont. home glargine 35/40 units - Humalog SS [**First Name8 (NamePattern2) **] [**Last Name (un) 387**] recs # HTN: Patient's BP was elevated during hospital course, mostly because her ACEI/[**Last Name (un) **]/Dilt were held - resumed ACEI, [**Last Name (un) **], Dilt - then with cardiac reasons above - BB (metoprolol) started - and titrated to 25mg on day of d/c for both cardiac and HTN management # Hepatitis B: stable, followed by Dr. [**Last Name (STitle) **]. HCC screening has been negative. Last Hep B VL was negative on [**10-14**]. Transaminases slightly above baseline, likely in setting of acute illness. - continune Adefovir # Hypercholesterolemia: - continue statin # h/o CVA: Has residual R-sided hemiparesis - Cont. [**Last Name (LF) 12457**], [**First Name3 (LF) **] #. FEN: Diabetic diet, no IVF . #. PPX: heparin sc, on PPI. Bowel regimen. . # Access: 2 PIV . #. Code: Full, discussed with patient and daughter . # Comm: daughter [**Name (NI) **] [**Name (NI) 27411**] (HCP) [**Telephone/Fax (1) 27412**] Dispo - d/c to home with po abx with home PT, home services with VNA Medications on Admission: Adefovir 10 mg daily Albuterol 2 puffs four times a day as needed Calcitriol 0.25 mcg daily Clotrimazole 10 mg Troche four times a day as needed for thrush Diltiazem HCl 300 mg Capsule, Sust. Release daily Dipyridamole-Aspirin [[**Telephone/Fax (1) **]] 200-25 mg Cap [**Hospital1 **] Advair 100 mcg-50 mcg [**Hospital1 **] Furosemide 80 mg twice a day Lantus 35 units [**Hospital1 **] Ipratropium-Albuterol [DuoNeb] every 4-6 hours as needed Lisinopril 40 mg twice a day Omeprazole 20 mg daily Simvastatin 40 mg daily Valsartan [Diovan] 320 mg daily Aspirin 81 mg daily Docusate Sodium 100 mg Humalog insulin SS Omega-3 Fatty Acids Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 4. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 11. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Adefovir 10 mg Tablet Sig: One (1) Tablet PO daily (). 13. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 14. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days. Disp:*16 Tablet(s)* Refills:*0* 17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating. Disp:*30 Tablet, Chewable(s)* Refills:*0* 18. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 19. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 20. Lantus 100 unit/mL Cartridge Sig: One (1) complex as below Subcutaneous twice a day: Take 35units daily in the morning and 40 units every evening. 21. Insulin Regular Human 100 unit/mL Solution Sig: One (1) sliding scale Injection qac and qhs: as instructed on your sliding scale provided. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: # Urosepsis - Recurrent UTI with bacteremia (E. Coli Bacteremia) # Asthma # Diastolic CHF # Acute on Chronic Renal Failure # Diabetes # Hypertension # Hyperlipidemia # Hepatitis B # history of CVA Discharge Condition: stable, o2 sat 94% RA Discharge Instructions: Your main diagnosis as below was a severe urinary tract infection that spread to the blood and caused a severe infection. This was treated with antibiotics - you are to continue the course as prescribe. Your continued recovery will likely be slow due to your overall lower reserve - continue to work closely with home PT so slowly rebuild back your strength and reserve (reason for difficulty breathing when walking). If your breathing becomes worse all of a sudden, new/worsened chest pain, new fevers, or any other concerning symptoms - call your provider [**Name Initial (PRE) **]/or return to the hospital. Your PCP will refer you to see a urogynocologist or urologist to evaluate further why you had a repeat UTI. Resume your medications, in addition to control your blood pressure and to help your heart we started started metoprolol at 25mg [**Hospital1 **] - you will follow-up with your PCP in regards to this medication - please take till re-evaluated. Check your weight every morning, if you gain more than 2 pounds - take an extra 40mg lasix tab that morning. ***Note the [**Last Name (un) **] doctors have changed your prior insulin regime - 35unit lantus in the morning, and 40units at night, with a new adjusted humolog scale - I have included this scale in your instructions to use. Followup Instructions: Follow-up with your PCP [**Name Initial (PRE) 2169**]: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2116-4-15**] at 12:00. ([**Hospital Ward Name 23**] Building) [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**] Completed by:[**2116-4-10**]

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8493

Discharge summary

report

Admission Date: [**2174-3-9**] Discharge Date: [**2174-3-23**] Date of Birth: [**2095-10-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: AICD firing Major Surgical or Invasive Procedure: - Intubation x 2 - Transesophageal ECHO - Arterial line insertion - Right IJ central line insertion - Aspiration of multiple joints (both knees, right wrist, both olecranon bursae), multiple times - Arthrotomy right wrist with washout and debridement. - Bilateral knee arthrotomies with anterior synovectomies. - Excision right knee prepatellar gout tophi. History of Present Illness: Mr. [**Known lastname 29921**] is a 78 year old male transfered from [**Hospital1 **] [**Location (un) 620**] with a history of CAD and CHF who presents with AICD firing, palpitations, and newly diagnosed colon cancer. He had been in a nursing home and reported fevers and chills at his nursing home for 1-2 days prior to presentation. On the morning of admission his ICD fired several times and so he came to the ED. VS in [**Location (un) 620**] ED were T103.8, O2 sat 89%RA , HR 128, BP 121/39. He was given Vanco/CTX/Azith/Zosyn at [**Location (un) 620**] ED for pneumonia. He was reportedly extremly dry on exam. He was given 4L of IV fluids for tachycardia. Sinus tachycardia evolved into A. fib with RVR and the patient received diltiazem 10mg IV x2. Given concern for PE patient he was transferred to [**Hospital1 18**] for a V/Q Scan. In the ED at [**Hospital1 18**] initial vs were: T97.4, HR 120 BP 124/58, RR 24, O2 sat 89% RA, 4L NC was in mid-90's. Exam was notable for bilateral LE edema and guaiac positive stool. The patient had several episodes of A. Fib with RVR and was given bolus IV diltiazem and started on a diltiazem gtt. V/Q scan was done prior to arrival on the floor. On the floor, the patient complained of total body joint pain involving elbows, knees, ankles, and lower left leg. He denied chest pain, shortness of breath, or other complaints. Prior to arrival on the floor he had received 5L NS. The patient and family report that patient was diagnosed with colon cancer (no known mets) 3 weeks ago. Has recently been treated for a pneumonia/COPD exacerbation as an outpatient and had been with increasing oxygen requirements. Most recently he was at [**Doctor First Name **] house (rehab/nursing home). Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied myalgias. Past Medical History: - Coronary artery disease, status post coronary artery bypass grafting times two. - s/p AICD placement, [**Company **] - CHF (Ef 40-50%), moderate to severe MR, mild-to-moderate AR - COPD/Emphysema, FEV1 0.72 at 28%, FVC 1.32 at 40% [**2-/2174**] - Colon Cancer, newly diagnosed in setting of GI Bleed, From 6 cm above the anus about 12 cm in the sigmoid, a large adenocarcinoma of the rectosigmoid which was sent to biopsy. Biopsy reports adenocarcinoma, moderately differentiated and invasive. - skin CA. - GERD - Gout - HTN - Hypercholesterolemia - Deviated septum. PSH: CABG x2 [**3-/2165**], AICD placement, R ankle pinning 25 years ago Social History: Married with one child. Retired salesman. He does not drink alcohol. Exercises by walking on a treadmill. No known drug allergies. Family History: Non-contributory Physical Exam: Vital Signs: T 100.3, HR 109, BP 119/51, R 20, 96% on 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: WBC-10.3 RBC-3.96* Hgb-8.9* Hct-29.3* MCV-74*# MCH-22.6*# MCHC-30.5* RDW-19.0* Plt Ct-158 Neuts-93.5* Lymphs-4.4* Monos-1.9* Eos-0.1 Baso-0.1 PT-13.4 PTT-36.0* INR(PT)-1.1 ESR-104* Glucose-236* UreaN-60* Creat-1.7* Na-133 K-4.8 Cl-103 HCO3-20* CK(CPK)-34* Calcium-7.6* Phos-4.2 Mg-2.0 UricAcd-9.1* TSH-0.73 CRP-GREATER THAN 300 Lactate-2.2* URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.019 URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG URINE RBC-[**3-10**]* WBC-[**3-10**] Bacteri-FEW Yeast-NONE Epi-0-2 TransE-0-2 URINE AmorphX-MOD Joint Fluid Aspirations: WBC-[**Numeric Identifier 29922**]* RBC-8500* Polys-98* Lymphs-0 Monos-0 Macro-2 Crystal-MOD Shape-NEEDLE Locatio-I/E Birefri-NEG Comment-c/w monoso WBC-[**Numeric Identifier 29923**]* RBC-[**Numeric Identifier **]* Polys-94* Lymphs-2 Monos-4 Crystal-MOD Shape-NEEDLE Locatio-I/E Birefri-NEG Comment-c/w monoso Micriobiology: [**2174-3-9**] 3:10 pm BLOOD CULTURE #2. **FINAL REPORT [**2174-3-13**]** Blood Culture, Routine (Final [**2174-3-13**]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Aerobic Bottle Gram Stain (Final [**2174-3-11**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29924**] @ 1:43A [**2174-3-11**]. GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2174-3-11**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. [**2174-3-10**] 10:53 am JOINT FLUID Source: Kneeleft. **FINAL REPORT [**2174-3-13**]** GRAM STAIN (Final [**2174-3-10**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. REPORTED BY PHONE TO [**First Name5 (NamePattern1) 3049**] [**Last Name (NamePattern1) 29925**] 1410 [**2174-3-10**]. FLUID CULTURE (Final [**2174-3-13**]): STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S [**2174-3-10**] 12:05 pm JOINT FLUID Source: right wrist. **FINAL REPORT [**2174-3-13**]** GRAM STAIN (Final [**2174-3-10**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29926**] 1653 [**2174-3-10**]. FLUID CULTURE (Final [**2174-3-13**]): STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. gram stain reviewed: GRAM POSITIVE COCCI IN CLUSTERS WERE SEEN ([**2174-3-12**]). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S [**2174-3-11**] 3:41 am SPUTUM Source: Expectorated. **FINAL REPORT [**2174-3-14**]** GRAM STAIN (Final [**2174-3-11**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): BUDDING YEAST. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2174-3-14**]): SPARSE GROWTH OROPHARYNGEAL FLORA. ENTEROBACTER CLOACAE. MODERATE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE | STAPH AUREUS COAG + | | CEFEPIME-------------- 2 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN---------<=0.25 S CLINDAMYCIN----------- <=0.25 S ERYTHROMYCIN---------- <=0.25 S GENTAMICIN------------ <=1 S <=0.5 S LEVOFLOXACIN---------- <=0.12 S MEROPENEM-------------<=0.25 S OXACILLIN------------- 0.5 S PIPERACILLIN---------- =>128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S [**2174-3-12**] 8:46 pm STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2174-3-13**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2174-3-13**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [**2174-3-14**] 3:13 am BLOOD CULTURE Source: Line-A-line. **FINAL REPORT [**2174-3-20**]** Blood Culture, Routine (Final [**2174-3-20**]): BACTEROIDES FRAGILIS GROUP. BETA LACTAMASE POSITIVE. Anaerobic Bottle Gram Stain (Final [**2174-3-15**]): GRAM NEGATIVE ROD(S). [**2174-3-18**] 8:59 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2174-3-21**]** GRAM STAIN (Final [**2174-3-18**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2174-3-21**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. OROPHARYNGEAL FLORA ABSENT. YEAST. SPARSE GROWTH. STAPH AUREUS COAG +. SPARSE 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. GRAM NEGATIVE ROD(S). RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S [**2174-3-22**] 12:24 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. GRAM STAIN (Final [**2174-3-22**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH OROPHARYNGEAL FLORA. [**2174-3-22**] 12:24 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2174-3-23**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2174-3-23**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Blood cultures from [**Date range (1) 29927**], [**3-15**], [**3-16**], all no growth Imaging Studies: [**2174-3-9**] ECG - Atrial fibrillation with a rapid ventricular response. Non-specific ST-T wave changes. There are non-diagnostic Q waves in the inferior leads. Compared to the previous tracing atrial fibrillation is new. [**2174-3-9**] V/Q Scan - IMPRESSION: Low likelihood ratio for PE. [**2174-3-9**] CXR AP - IMPRESSION: Relatively stable x-ray examination given differences in depth of inspiration and technique. No acute pulmonary process. [**2174-3-10**] Transthoracic ECHO - The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is moderate regional left ventricular systolic dysfunction with severe inferior, inferolateral and lateral hypokinesis. The remaining segments contract normally (LVEF = 30-35%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. An eccentric, posteriorly-directed jet of moderate (2+) mitral regurgitation is seen ([**Last Name (un) **] 0.2 cm2, regurgitant volume 26 ml/beat). The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. IMPRESSION: No vegetations seen. Moderate regional left ventricular systolic dysfunction, c/w CAD. Mild aortic regurgitation. Moderate mitral regurgitation. Compared with the report of the prior study (images unavailable for review) of [**2165-3-13**], left ventricular systolic function has deteriorated. Mitral and aortic regurgitation severity has increased. [**2174-3-10**] CXR PA & LAT - FINDINGS: In comparison with the earlier study of this date, there is little interval change. The lateral view is suboptimal and adds little to the characterization of the left basilar opacification, which most likely represents atelectasis. [**2174-3-11**] Transesophageal ECHO - No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. Overall left ventricular systolic function is moderately depressed (LVEF= 35-40 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No echocardiographic evidence of left atrial thrombus or valvular vegetations. Moderate mitral regurgitation is present. [**2174-3-12**] Renal Ultrasound - IMPRESSION: 1. Moderate right hydronephrosis. 2. Gallstones and sludge without evidence of cholecystitis. 3. Son[**Name (NI) 493**] [**Name2 (NI) 515**] sign was negative. [**2174-3-15**] Renal Scan - IMPRESSION: Severe impaired bilateral renal function. [**2174-3-15**] RUQ ultrasound - IMPRESSION: Moderately distended gallbladder with cholelithiasis, not significantly changed, but with no specific features for cholecystitis. [**2174-3-16**] CT abdomen/pelvis, non-contrast - IMPRESSION: 1. No evidence of hydronephrosis. Large right parapelvic cyst unchanged. 2. Interval worsening of now consolidation at the lung bases bilaterally, which may represent aspiration, pneumonia or combination of both. Bilateral small effusions. 3. Cholelithiasis. Distention of the gallbladder appears to have slightly increased, which may be related to patient's fasting state. 4. Bilateral renal cysts, not fully evaluated given lack of IV contrast. 5. Previously seen rectosigmoid mass not well appreciated on this non- contrast study. Persistent rectosigmoid fat stranding. [**2174-3-17**] PICC line placement - ADDENDUM: On review of this study in conjunction with the frontal and lateral chest radiographs, the right PICC is identified terminating in the lower SVC or cavo-atrial junction. [**2174-3-22**] KUB - IMPRESSION: No evidence of obstruction. No abdominal free air. Brief Hospital Course: Mr. [**Known lastname 29921**] is a 78 year old male with CAD, CHF, and recently diagnosed colon cancer who presented with AICD firing in the setting of new onset atrial fibrillation with RVR and MSSA bacteremia and septic arthritis. # Sepsis, bacteremia, hypotension: The patient had high grade bacteremia, with blood cultures from [**Hospital1 **] [**Location (un) 620**] turning positive approximately 12 hours after admission to [**Hospital1 18**], eventually yielding MSSA. Admission blood cultures from [**Hospital1 18**] as well as multiple joint aspirations all grew out MSSA. Given his pain on presentation and multiple positive joint aspirations he was felt to have metastatic septic arthritis. The source for initial bacteremia was not clear and transesophageal ECHO showed no evidence of endocarditis. Per recommendations from the infectious disease team, the patient was empirically treated with nafcillin for 6 days and then switched to a combined regimen of ciprofloxacin, cefepime, and flagyl starting the evening of [**3-15**] when his surveillance blood culture from the day prior grew gram negative rods in the anerobic culture bottle (eventually grew B. fragilis). The patient had previously been noted to have gram negative rods in his sputum (Enterobacter cloacae), however, he had no clear evidence of pneumonia by chest x-ray. The patient also required aggressive IV fluid resuscitation on presentation to support his blood pressure and intermittantly required pressors as well. # Atrial fibrillation: The patient initially presented with A. Fib with RVR ?????? apparently a new diagnosis for this patient. His AICD had fired four times prior to admission for heart rates > 180. He was ruled out for an MI with serial cardiac enzymes. The day following admission the electrophysiology consultants performed a TEE that showed no clot in in the heart and no evidence of valvular or pacemaker lead endocarditis. The patient was started on amiodarone and metoprolol and cardioversion was planned as it was felt that he was likely not a candidate for coumadin given his recent GI bleed and colon cancer. However, he spontaneously developed bradycardia at a V-paced rate of 50 bpm post-TEE in the setting of hyperkalemia. He then spontaneously converted to NSR after correction with D50, sodium bicarbonate and insulin. Metoprolol was discontinued due to hypotension and the patient was continued on low dose amiodarone per EP recommendations. The patient went back into atrial fibrillation in the morning of [**3-18**] in the setting of hypoxemia. Metoprolol was unsuccessful and the patient was reloaded with IV amiodarone and spontaneously converted back into NSR. Per family wishes, the AICD was turned off on the evening of [**3-18**]. # Respiratory failure: The patient had a subacute exacerbation with decline over past the past 3-4 weeks. He has COPD at baseline and had recently been treated for a COPD exacerbation and was on a prolonged steroid taper. He was electively intubated on [**3-11**] to perform multiple procedures. Subsequently, he had difficulty weaning from the ventilator, initially due to fluid retention in the setting of agressive IV fluid hydration required to support his blood pressure (he was 17L positive over his length of stay), as well as underlying COPD. The patient was extubated on the afternoon of [**3-17**] and was alert, however, he was reintubated on the morning of [**3-18**] for worsening acidosis and hypoventilation with fatigue overnight. # Acute Renal Failure: The patient initially presented with an elevated creatinine. Initially this was felt to be pre-renal in the setting of sepsis and hypotension and urine lytes were consistent with this hypothesis. Over time, however, his creatinine continued to rise and urine studies became consistent with ATN. No urine eosinophils were identified, thus it was unlikely AIN due to nafcillin. Initial renal ultrasound suggested right-sided hydronoephrosis and urology was consulted, however, non-contrast CT scan subsequently showed no hydronephrosis. Of note, the patient has a mass lesion on the left previously seen on CT done [**2174-2-6**] at BIDN. His creatinine finally stabilized in the 4+ range. Nephrology was also consulted to assist with management. They recommended phosphate binders to treat the patient's hyperphosphatemia and also considered performing renal biopsy, but deferred when the family decided not to persue any further interventions on [**3-18**] and declined dialysis. All medications were renally dosed during the patient's stay. # Septic and gouty arthritis: The patient had a known history of gout. On presentation he was initially given colchicine and prednisone was increased to 40 mg for presumed gout attack. Rheumatology was consulted to aspirate his most painful joints. When the aspirations showed bacteria on gram stain, the steroids were decreased, but then increased again per rheumatology recommendations for gout and slowly tapered off. Colchicine was stopped due to worsening renal failure. Orthopedics was consulted and eventually took the patient to the OR for washout on [**3-12**]. All joints tapped had GPCs on gram stain and eventually grew MSSA. # Abdominal pain: Several days after admission the patient developed abdominal discomfort on exam. Abdominal ultrasound noted sludge in the gallbladder, no other findings were noted. LFTs, amylase, lipase, were all within normal limits and Tbili was mildly elevated. Ultimately it was felt that the pain was secondary to bacteremia or some other process related to the patient's colon cancer. Follow-up non-contrast CT scan of the abodmen and pelvis did not reveal any cause. Contrast CT scan could not be performed secondary to renal failure. # Anemia: The patient was likely anemic from GI bleeding from his colon cancer and also anemia of chronic disease. Per BIDN records his baseline hct was 35-37 prior to his diagnosis of colon cancer. He was transfused with 1 unit of PRBCs on [**3-13**] units on [**3-14**], and 1 unit on [**3-21**]. Hemolysis labs were negative. The patient was guaiac positive. # Thrombocytopenia: The patient did have a decrease in his platelets which may have been multifactorial, including HIT, uremia and DIC. His platelets did stabilize in the 90s. # Colon Cancer: No known mets but with extensive lymphadenopathy in chest on last CT scan. He had an outpatient colorectal surgery appointment scheduled during his admission. Further evaluation was deferred until his acute illness could resolve. # Pressure Ulcers: The patient had some sacral skin breakdown on admission. Local wound care, frequent turns, special mattress, and close monitoring for areas of peripheral necrosis were performed. # Hyperglycemia: The patient has no history of diabetes. His HbA1c was 6.7. He was noted to be hyperglycemic shortly after admission, likely in part due to steroids. He was placed on an insulin sliding scale which was stopped on [**3-21**] as he was no longer taking steroids and was not tolerating tube feeds at goal. # Glaucoma: Eye drops were continued per home regimen. # Code Status: The patient had previously been DNR/DNI. He was electively intubated after discussion with both him and his wife as it was initially felt that his acute illness might be reversible. However, as the patient continued to do poorly despite antibiotic therapy and additional support, the family eventually decided not to persue further agressive therapy and provide comfort measures only. Medications on Admission: (per surgery note from [**2174-2-24**]) -lasix 40', -colchicine 0.6', -flomax 0.4', -simvastatin 20', -lopressor 75", -asa 325', -felodipine SR 5', -NTG PRN, -advair 250/50 QID, -atrovent prn, -albuterol prn, -pilocarpine TID, -xalatan 0.005% opth, -brimerlinidine opth, -mvi, fish oil, vit a, vit c, vit e -ferrous sulfate 325 mg daily -finasteride 5mg daily -aldactone 25mg daily -prilosec 40mg daily -colace 100mg daily -senna -klonopin 0.5mg qhs -percocet 5-325 mg daily -Prednisone 10mg - tapering through [**2174-3-12**] Discharge Medications: Not applicable, patient deceased Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: Methicillin-sensitive Staph. aureus bacteremia and sepsis Metastatic septic arthritis due to MSSA Bacteroides fragilis bacteremia Enterobacter cloacae pneumonia Secondary Diagnoses: Coronary artery disease Congestive heart failure Gout Colon Cancer Chronic obstructive pulmonary disease Hypertension Gastroesophageal reflux disease Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "77.66", "83.94", "38.93", "80.76", "81.91", "80.13", "96.04", "96.72", "96.6", "80.83" ]

icd9pcs

[ [ [] ] ]

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327, 686

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13926, 18273

46,034

170,420

38057

Discharge summary

report

Admission Date: [**2169-7-7**] Discharge Date: [**2169-7-10**] Date of Birth: [**2126-12-25**] Sex: M Service: MEDICINE Allergies: Penicillins / Vancomycin Attending:[**First Name3 (LF) 1377**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: Paracentesis [**2169-7-8**] History of Present Illness: Mr. [**Known firstname **] [**Known lastname 84380**] is a 42 year old male with a history of alcoholic cirrhosis who presents with somnolence and left leg discomfort. Patient was scheduled to re-establish care with Dr. [**Name (NI) **] in the liver center today. Upon arriving to the clinic, there was concern about the patient's mental status and his left leg infection. The patient was instructed to go the ED for evaluation. In the ED, he was A and O x 3, but somnolent. His initial VS were 97.5 BP 96/36, HR 59, 99% RA. Given concern for evolving sepsis, he received NS 2.5 liters. LENI was (-) for DVT in left leg. RUQ was also obtained without dopplers, and was equivocal, with possible non-occlusive portal vein thrombosis. Blood and urine cultures were obtained, and the patient was given vancomycin. He apparently had a reaction to vanc, unclear if it was red man's syndrome, but received Solumedrol 125 mg IV x 1 and benadryl 25 mg IV x 1. He then received clindamycin IV. He was then transferred to the unit for management of presumed sepsis in the setting of altered mental status. . Upon arrival to the unit, the patient was somnolent but easily arousable. He endorsed abdmoninal pain, denied n/v/d. He also denied melena, BRBPR, or hematochezia. He denied chest pain of shortness of breath. Remainder of ROS as noted below. He does state that the swelling in his legs is new over the past few days. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Etoh Cirrhosis c/b grade I varices with h/o UGIB, hemorrhoids, ascites, and hepatic encephalopathy - h/o Alcoholic hepatitis - not treated with steroids given UGIB. - Alcohol dependence - hypertension - cholelithiasis - gout - obesity - depression Social History: Lives alone, divorced x2, has three children. Denies tobacco or other IV drug use. Last drink was [**2168-7-28**]. Family History: NC Physical Exam: ON ADMISSION: VS: 113/60, 54, 16, 96% RA GA: AOx3, NAD, somnolent, arousable HEENT: PERRLA. mild scleral icterus. MMM. no LAD. no JVD. neck supple. Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. Extremities: wwp, no edema. DPs, PTs 2+. Skin: Mildly icteric, LLE erythema, warmth on anterior shin with serosanguinous drainage Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 3+ BL (biceps, achilles, patellar). sensation intact to LT, pain, temperature, vibration, proprioception. cerebellar fxn intact (FTN, HTS). gait not assessed. (+) asterixis. . ON DISCHARGE: VS: 97.4, 120/73, 79, 18, 99% on RA General: WD/WN, pleasant, comfortable HEENT: NC/AT, mild scleral icterus, MMM Neck: No LAD, no JVD, neck supple Heart: RRR, nml S1/S2, 3/6 SEM, no rubs or [**Last Name (un) 549**] Pulm: CTAB Abd: Soft, obese, NT, no fluid palpated, liver and spleen not palpated Extremities: WWP, 2+ radial/DP pulses, 2+ edema bilaterally to the knees Skin: LLE warm with erythematous rash demarcated by marker, decreasead in size from yesterday, small amount of serosanguinous drainaga Neuro: A&Ox3, no asterixis, CNs II-XII intact, motor and sensory function grossly intact Pertinent Results: ADMISSION LABS ([**2169-7-7**]): WBC-5.6 RBC-2.31* Hgb-9.6* Hct-28.2* MCV-122* MCH-41.8* MCHC-34.2 RDW-16.8* Plt Ct-55* Neuts-91* Bands-0 Lymphs-4* Monos-3 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 Hypochr-OCCASIONAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Schisto-OCCASIONAL [**Name (NI) **] [**Last Name (STitle) 31525**] [**Name (STitle) **]28.9* PTT-46.6* INR(PT)-2.8* Fibrino-147* Glucose-105* UreaN-44* Creat-1.8* Na-125* K-6.0* Cl-95* HCO3-25 AnGap-11 ALT-38 AST-149* AlkPhos-177* TotBili-10.3* Lipase-34 Albumin-2.4* Calcium-8.9 Phos-3.0 Mg-2.4 VitB12-1892* Folate-GREATER TH Hapto-<5* Ammonia-184* --> 110* cTropnT-<0.01 proBNP-264* BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . URINE: [**2169-7-7**] 02:15PM: Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.012 Blood-MOD Nitrite-NEG Protein-25 Glucose-NEG Ketone-15 Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 CastHy-[**1-27**]* . [**2169-7-7**] 06:28PM: Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-0 CastHy-5* Hours-RANDOM UreaN-536 Creat-93 Na-<10 K-14 Cl-<10 Osmolal-297 bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . DISCHARGE LABS ([**2169-7-10**]): WBC-2.4* RBC-2.13* Hgb-8.9* Hct-26.3* MCV-124* MCH-41.8* MCHC-33.9 RDW-17.2* Plt Ct-27* PT-31.4* PTT-46.3* INR(PT)-3.1* Glucose-77 UreaN-24* Creat-0.8 Na-134 K-3.7 Cl-102 HCO3-25 AnGap-11 ALT-31 AST-69* LD(LDH)-229 AlkPhos-166* TotBili-5.2* Calcium-9.2 Phos-2.9 Mg-1.7 . MICRO: [**2169-7-7**] Blood cx: pending [**2169-7-7**] Urine cx: no growth [**2169-7-7**] Wound cx (left leg): S. aureus coag + rare growth [**2169-7-7**] Periotoneal cx: no growth . IMAGING: [**2169-7-7**] LLE Doppler US: No evidence of left lower extremity DVT . [**2169-7-7**] Portable CXR: There is interval development of left retrocardiac opacity that is worrisome for interval development of infectious process. Lung volumes remain low, but the lungs are otherwise clear. There is no appreciable pleural effusion. There is no pneumothorax. Cardiomediastinal silhouette is stable. . [**2169-7-7**] RUQ U/S: 1. Focal, apparently nonocclusive filling defect in the main portal vein at the porta hepatis, with hepatopetal flow just proximal, with a velocity of 40 cm/sec. This could represent nonocclusive thrombus, or could be artifact. Recommend dedicated liver Doppler evaluation. 2. Moderate ascites. . [**2169-7-7**] CT head: 1. No acute intracranial abnormality. 2. Small locules of gas in the cavernous sinus bilaterally. This is most likely related to peripheral intravenous catheter. 3. Paranasal sinus disease. . [**2169-7-8**] ECHO: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2168-8-19**], no major change. . [**2169-7-8**] RUQ U/S with doppler: pending Brief Hospital Course: 42 year old man with ETOH cirrhosis admitted with altered mental status in the setting of cellulitis. Brief hospital course by problem: . # Altered mental status: CT head neg for acute process. No evidence of hypercarbia on VBG. No meningismus on exam to raise concern for encephalitis or meningitis. Paracentesis negative for SBP. Most likely secondary to hyponatremia and encephalopathy in the setting of infection. Mental status improved with antibiotics, lactulose, and rifaximin. . # LLE cellulitis: Pt was initially treated with vancomycin, however he had a bad reaction to the vancomycin (possibly red man's syndrome), and received solumedrol and benadryl, and was switched to IV clindamycin. Wound culture grew Staph aureus. Pt MRSA negative. The patient remained afebrile with stable vitals and improving [**Last Name (LF) 84982**], [**First Name3 (LF) **] he was switched to PO clindamycin to complete a 7-day course. . # [**Last Name (un) **]: Creatinine was 1.8 on admission. Urine sodium <10, fractional excretion of urea 25%, c/w pre-renal physiology. Patient was fluid overloaded, so he was diuresed with IV lasix and spironolactone, and creatinine normalized. Pt was discharged on 60mg PO lasix QD and 100mg spironolactone QD. . # Hyponatremia: Sodium was 125 on admission, likely secondary to cirrhosis. Sodium normalized. . # ETOH Cirrhosis: RUQ ultrasound without evidence of portal vein thrombosis. Treated with diuretics, lactulose and rifaximin. . # Painful left 2nd toe: Pt states that he had a recent fall and has since had pain in the second toe on the left foot. Foot x-ray was negative for fracture. . # Code status: Full code. . # Outstanding issues: - F/u RUQ ultrasound final read Medications on Admission: 1. Atenolol 50 mg daily 2. Furosemide 60 mg daily 3. MVI 4. Magnesium oxide 400 mg [**Hospital1 **] 5. Folic acid 1 mg daily 6. Lactulose 30 grams [**Hospital1 **] 7. Vicodin 5/500 1 tab daily PRN Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 2. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day. 3. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID. 7. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO once a day PRN pain. 8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY. Disp:*30 Tablet(s)* Refills:*0* 9. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO Q6H. To be taken through [**7-13**]. Disp:*16 Capsule(s)* Refills:*0* 10. Outpatient Lab Work: Please have chem 7 drawn on [**7-16**] and fax results to Dr. [**Name (NI) **]: ([**Telephone/Fax (1) 21178**]. Discharge Disposition: Home Discharge Diagnosis: Primary: - Cellulitis - Acute kidney injury Secondary: - ETOH cirrhosis - Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 84380**], You were admitted with altered mental status and an infection on your left leg which is being treated with antibiotics. . Please continue to take your home medications. We have made the following changes: - STARTED spironolactone 100mg by mouth daily - STARTED clindamycin 300mg by mouth every 6 hours through [**7-13**]. . Please see below for information regarding upcoming appointments. Followup Instructions: You have an appointment with Dr. [**Name (NI) **] on [**8-18**] at 11:40am. The clinic phone number is [**Telephone/Fax (1) 673**]. . We are giving you a prescription to have some lab work done on Monday, and the results will be faxed to Dr. [**Name (NI) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**] Completed by:[**2169-7-10**]

[ "682.6", "276.1", "572.2", "693.0", "V45.79", "311", "401.9", "281.9", "729.5", "789.59", "E930.8", "571.2", "041.11", "584.9", "274.9", "416.8", "456.21", "303.93", "278.00", "287.5" ]

icd9cm

[ [ [] ] ]

[ "54.91" ]

icd9pcs

[ [ [] ] ]

10492, 10498

7710, 7858

307, 336

10629, 10629

3974, 6571

11226, 11639

2602, 2606

9669, 10469

10519, 10608

9448, 9646

10780, 11203

2621, 2621

3358, 3955

1816, 2179

246, 269

364, 1797

6580, 7687

2635, 3344

10644, 10756

2201, 2453

2469, 2586

46,545

193,235

41283

Discharge summary

report

Admission Date: [**2120-6-10**] Discharge Date: [**2120-6-14**] Date of Birth: [**2071-4-29**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2120-6-10**] Coronary artery bypass graft x 3 (Saphenous vein graft to distal right coronary artery, Saphenous vein graft to Obtuse marginal 1, Saphenous vein graft to obtuse marginal 2) History of Present Illness: 49 year old female with past medical history of coronary artery disease and myocardial infarction s/p stenting of RCA and left circumflex. She recently underwent another cardiac cath after complaining of angina and had positive stress test. Cath showed 90% in-stent restenosis in LCX and 80% RCA disease. She is now referred for surgical revascularization. Past Medical History: - Coronary artery disease, status post myocardial infarction in [**2108**], [**2110**] and [**2117**]- s/p stenting on all occasions - Hypothyroidism on Levothyroxine - C-section [**2105**] - Hyperlipidemia - Hypertension - Uterine fibriods s/p embolization - s/p Bilateral uterine artery embolization on [**2119-9-11**] - s/p C-section - s/p Tonsillectomy Social History: Race: Indian Last Dental Exam: N/A Lives with: Husband Contact: [**Name (NI) 4906**] Phone # Occupation: retail pharmacist at a local rehab facility Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx: Other Tobacco use: Denies ETOH: < 1 drink/week [X] [**2-6**] drinks/week [] >8 drinks/week [] Illicit drug use: Denies Family History: Premature coronary artery disease - Father had CABG in early 70's, died 1 month later. Brother with MI in his 40's Physical Exam: Pulse: 71 Resp: 16 O2 sat: 100% B/P Right: 120/83 Left: 108/77 Height: 63" Weight: 171 lbs General: Well-developed female in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [] grade ______ 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 [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: [**2120-6-10**] Echo: PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. There is no aortic valve stenosis. Mild to moderate ([**1-1**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at time of surgery. POST-BYPASS: The patient is in sinus rhythm. The patient is on no inotropes. Biventricular function is unchanged. Mitral regurgitation is unchanged. Tricuspid regurgitation is unchanged. The aorta is intact post-decannulation. [**2120-6-13**] 04:51AM BLOOD WBC-8.7 RBC-3.94* Hgb-9.6* Hct-29.8* MCV-76* MCH-24.4* MCHC-32.2 RDW-17.7* Plt Ct-171 [**2120-6-12**] 06:10AM BLOOD WBC-10.4 RBC-3.90* Hgb-9.4* Hct-29.6* MCV-76* MCH-24.1* MCHC-31.7 RDW-18.0* Plt Ct-165 [**2120-6-11**] 04:08AM BLOOD WBC-11.5* RBC-4.31 Hgb-10.3* Hct-32.5* MCV-75* MCH-23.9* MCHC-31.8 RDW-17.3* Plt Ct-201 [**2120-6-13**] 04:51AM BLOOD Glucose-105* UreaN-10 Creat-0.6 Na-139 K-4.4 Cl-106 HCO3-30 AnGap-7* [**2120-6-12**] 06:10AM BLOOD Glucose-113* UreaN-11 Creat-0.7 Na-135 K-4.9 Cl-103 HCO3-25 AnGap-12 [**2120-6-11**] 04:08AM BLOOD Glucose-100 UreaN-8 Creat-0.5 Na-134 K-4.5 Cl-106 HCO3-23 AnGap-10 Brief Hospital Course: Mrs. [**Known lastname **] was a same day admit and was brought directly to the operating room where she underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. 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. Pain control was an issue and she was treated with Toradol, Dilaudid and Tylenol, which provided good relief. The patient was transferred to the telemetry floor for further recovery. Dr. [**Last Name (STitle) 4922**] was contact[**Name (NI) **] and said that it was acceptable to stop Prasugrel. 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 4the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 80 mg Tablet - 1 Tablet(s) by mouth once a day FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth once a day LEVOTHYROXINE - (Prescribed by Other Provider) - 75 mcg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day PRASUGREL [EFFIENT] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC ASPIRIN [ADULT LOW DOSE ASPIRIN] - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day POLYSACCHARIDE IRON COMPLEX - (Prescribed by Other Provider) - 150 mg Capsule - 1 Capsule(s) by mouth once a day Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Levothyroxine Sodium 75 mcg PO DAILY 5. Metoprolol Tartrate 25 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. [**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg three times a day Disp #*90 Tablet Refills:*0 6. Ranitidine 150 mg PO BID Duration: 2 Weeks RX *ranitidine HCl 150 mg twice a day Disp #*28 Tablet Refills:*0 7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX *tramadol 50 mg every four (4) hours Disp #*75 Tablet Refills:*0 8. Iron Polysaccharides Complex 150 mg PO DAILY 9. Acetaminophen 650 mg PO Q4H:PRN pain, fever 10. HYDROmorphone (Dilaudid) 2-6 mg PO Q3H:PRN pain RX *hydromorphone 2 mg q 3hrs Disp #*40 Tablet Refills:*0 11. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days Hold for K+ > 4.5 RX *potassium chloride 20 mEq daily Disp #*7 Tablet Refills:*0 12. Ibuprofen 600 mg PO Q6H Start once Toradol completed RX *ibuprofen 200 mg every six (6) hours Disp #*120 Tablet Refills:*0 13. Furosemide 20 mg PO DAILY Duration: 7 Days RX *Lasix 20 mg daily Disp #*7 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**Company **] Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 3 Past medical history: - Status post myocardial infarction in [**2108**], [**2110**] and [**2117**] with stenting on all occasions - Hypothyroidism on Levothyroxine - C-section [**2105**] - Hyperlipidemia - Hypertension - Uterine fibriods s/p embolization - s/p Bilateral uterine artery embolization on [**2119-9-11**] - s/p C-section - s/p Tonsillectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with ultram, motrin and Dilaudid as needed Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage. Edema: trace lower extremity 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**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on Date/Time:[**2120-7-17**] 1:30pm in the [**Hospital **] medical office building, [**Doctor First Name **] [**Hospital Unit Name **] WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2120-6-20**] 10:15pm in the [**Hospital **] medical office building, [**Doctor First Name **] [**Hospital Unit Name **] Please call to schedule appointments with your Cardiologist: Dr. [**Last Name (STitle) **] [**Name (STitle) 4922**] in [**2-2**] weeks Primary Care Dr. [**Last Name (STitle) 57356**] Sri Reddi in [**4-4**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2120-6-14**]

[ "272.4", "414.01", "401.9", "E879.0", "244.9", "412", "458.29", "285.1" ]

icd9cm

[ [ [] ] ]

[ "36.13", "39.61" ]

icd9pcs

[ [ [] ] ]

7435, 7480

4176, 5453

321, 512

7938, 8211

2482, 4153

9134, 9976

1653, 1769

6296, 7412

7501, 7562

5479, 6273

8235, 9111

1784, 2463

271, 283

540, 898

7584, 7917

1294, 1637

44,414

191,273

4364

Discharge summary

report

Admission Date: [**2127-5-1**] Discharge Date: [**2127-5-15**] Date of Birth: [**2049-1-30**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: s/p motor vehicle collision Major Surgical or Invasive Procedure: [**5-2**] bilateral chest tubes placed [**5-8**] tracheostomy/PEG placement History of Present Illness: 78 yo M with CAD, CHF, h/o Afib s/p ppm was the restrained driver in a MVC which occurred after he lost consciousness at the wheel. Taken to [**Hospital3 4107**], where C-spine was cleared by imaging and exam and HCT showed no bleed or infarct. Pt was in respiratory distress [**2-4**] b/l rib fx and sternal fx and decision was made to intubate pt for transport to [**Hospital1 **]. Past Medical History: CAD, CHF, afib, DDDR PPM, chronic pleural effusions Social History: 2 sons involved with care Family History: wife in an [**Name (NI) 2481**] home Physical Exam: At the time of arrival, the patient was intubated, respiratory distress but had no other evidence of traumatic injuries Pertinent Results: [**2127-5-1**] 10:11PM TYPE-ART PO2-180* PCO2-38 PH-7.36 TOTAL CO2-22 BASE XS--3 [**2127-5-1**] 10:11PM LACTATE-0.9 [**2127-5-1**] 10:11PM freeCa-1.15 [**2127-5-1**] 10:01PM GLUCOSE-272* UREA N-38* CREAT-1.2 SODIUM-138 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-20* ANION GAP-17 [**2127-5-1**] 10:01PM CK-MB-25* cTropnT-1.21* [**2127-5-1**] 10:01PM CALCIUM-8.2* PHOSPHATE-4.9*# MAGNESIUM-1.6 [**2127-5-1**] 10:01PM WBC-8.3 RBC-3.14* HGB-8.6* HCT-28.4* MCV-90 MCH-27.5 MCHC-30.4* RDW-16.3* [**2127-5-1**] 10:01PM PT-63.3* PTT-57.3* INR(PT)-7.2* [**2127-5-1**] 10:01PM PLT COUNT-248 [**2127-5-1**] 08:34PM TYPE-ART RATES-/20 TIDAL VOL-550 PEEP-10 O2-100 PO2-68* PCO2-50* PH-7.26* TOTAL CO2-23 BASE XS--4 -ASSIST/CON INTUBATED-INTUBATED COMMENTS-RECEIVED W [**2127-5-1**] 08:34PM GLUCOSE-270* [**2127-5-1**] 07:16PM TYPE-ART PO2-78* PCO2-58* PH-7.21* TOTAL CO2-24 BASE XS--5 INTUBATED-INTUBATED [**2127-5-1**] 06:53PM GLUCOSE-285* LACTATE-1.5 NA+-138 K+-4.7 CL--102 TCO2-24 [**2127-5-1**] 06:41PM UREA N-39* CREAT-1.3* [**2127-5-1**] 06:41PM estGFR-Using this [**2127-5-1**] 06:41PM LIPASE-42 [**2127-5-1**] 06:41PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2127-5-1**] 06:41PM URINE HOURS-RANDOM [**2127-5-1**] 06:41PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2127-5-1**] 06:41PM WBC-9.3 RBC-3.38* HGB-9.5* HCT-31.2* MCV-93 MCH-28.0 MCHC-30.3* RDW-16.3* [**2127-5-1**] 06:41PM PT-67.2* PTT-48.2* INR(PT)-7.8* [**2127-5-1**] 06:41PM PLT COUNT-233 [**2127-5-1**] 06:41PM FIBRINOGE-532* [**2127-5-1**] 06:41PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2127-5-1**] 06:41PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2127-5-1**] 06:41PM URINE RBC-[**3-7**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2127-5-1**] 06:36PM TYPE-[**Last Name (un) **] PH-7.43 COMMENTS-GREEN TOP [**2127-5-1**] 06:36PM GLUCOSE-278* LACTATE-1.2 NA+-139 K+-4.6 CL--106 TCO2-19* [**2127-5-1**] 06:36PM HGB-11.1* calcHCT-33 O2 SAT-90 CARBOXYHB-7* MET HGB-0 [**2127-5-1**] 06:36PM freeCa-0.88* Brief Hospital Course: The patient was transferred to [**Hospital1 18**] intubated in respiratory distress with bilateral rib fractures and a sternal fracture, intubated and sedated. Given his bilateral pleural effusions, bilateral chest tubes were placed at the time of admission on [**5-2**]. The patient underwent an echocardiogram shortly after admission which demonstrated marked LV anterior wall hypokinesis, and his serum troponin rose to a highest level of approximately 4. He spiked a fever within 24 hours of admission and cultures were sent. On [**5-3**], the patient had low urine output and was transfused 1U PRBC to improve his hemodynamics. His urine culture grew enterococcus, and he was started on vancomcin. His creatinine continued to rise despite IVF resuscitation, and he was administered tube feeds which were advanced toward goal. Given his rising creatinine despite apparently adequate fluid resuscitation, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18821**] was placed for hemodynamic monitoring. His urine output picked up and his creatinine decreased over time. He had elevated serum glucose levels, and his insulin sliding scale was tightened. On [**2127-5-6**], the patient had a 1 minute episode of ventricular tachycardia, which was self limited and did not recur thereafter. The electrophysiology service was consulted, and recommended switching him to metoprolol from sotalol given his renal dysfunction. He was taken off his home atenolol per their recommendations. He was stabilized on metoprolol prior to the time of discharge. On [**2127-5-8**], the patient underwent tracheostomy and PEG placement which was uneventful. His chest tubes were placed to water seal and removed sequentially thereafter without clinically significant pneumothorax or pleural effusion. He was restarted on coumadin and he was administered free water via his PEG to help correct his hyponatremia. At the time of discharge, he was receiving 100 cc of free water Q4hrs via his PEG tube. Over the next week prior to discharge, the patient's mental status improved slowly. He was tolerating trach collar trials for increasing time periods. He was working with PT to regain his strength. At the time of discharge, the patient's active status and plan by system is as follows: NEURO: Comfortable. Moves all extremities, non focal. Speaking with PMV and communicating appropriately. - Neuro checks Q: routine - Analgesia Roxycodone, Tylenol prn. - Trazodone prn qHS CV: h/o CAD, CHF, afib, hypercholesterolemia, cardiac contusion with low cardiac output. - Metoprolol 25 mg [**Hospital1 **], off home sotalol and atenolol per electrophysiology service - Echo with overall left ventricular systolic function moderately-to-severely depressed (LVEF= 30 %). Repeat echo [**5-6**] unchanged - Pt has DDDR pacemaker, underlying rhythm is CHB, PM set for AV sequential pacing unless atrial rate > 150. - his hematocrit at the time of discharge is 24, but we have intentionally held off on transfusion given his hemodynamic stability; would transfuse for hematocrit less than 21 (given TRICC and CRIT data) PULM: Sternal fx, R [**4-10**] and L [**2-8**] rib fx-bilateral flail, - Ciprofloxacin until [**5-17**] - Perc Trachestomy in situ GI: Tube feeds/PO diet - TF via PEG - Nectar thick liquids and soft solids started [**5-14**] RENAL: Acute on CRF, now improved to 1.2. Hypernatremia, resolving. - free water to 100 q 4 hours HEME: Anemia, coagulopathy. Critical illness vs. mult phlebotomy. - monitor hct, no evidence of persistent bleeding - Coumadin restarted, need to follow INR - D/C SC heparin when INR therepeutic - continue ASA 81 mg QD ENDO: DMII. - restarted oral hypoglycemics [**5-12**] - NPH 20U [**Hospital1 **], can titrate up as needed MSK: Right minimally displaced fracture of the coronoid process of the ulna. -ortho c/s-WBAT, sling for comfort PRN, f/u ortho 4 weeks if pain persists. ID: -Enterococcus UTI sensitive to Vancomycin, 10 day course finished ([**5-4**] amp-[**5-14**]) -Sputum cx with 4+ GNRs on gram stain, sensitive to cefepime/cipro, 7day course planned [**Date range (1) 18822**], switched to PO cipro until [**5-17**] Medications on Admission: -allopurinol 300mg daily -atenolol 50mg daily -actos 30mg daily -glyburide 2.5mg [**Hospital1 **] -lisinopril 40mg daily -simvastatin 80mg daily -sotalol 80mg [**Hospital1 **] -terazosin 2mg qhs -warfarin -prilosec 20mg daily -zoloft 50mg daily -lasix 30mg daily Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: [**1-4**] PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for bowel regimen. 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection every eight (8) hours. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. Oxycodone 5 mg/5 mL Solution Sig: [**1-4**] PO Q4H (every 4 hours) as needed for pain. 10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: will be titrated and followed at rehab facility. 12. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Furosemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 16. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day) as needed for prn constipation. 18. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 19. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 20. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 21. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge Sig: Twenty (20) units Subcutaneous twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: s/p motor vehicle collision; bilateral rib fractures and sternal fracture Blaterl pleural effusions requiring tube thoracostomies Heart failure- systolic Ventricular tachcardia Respiratory failure Acute renal failure Diabetes mellitus Enterococcal urinary tract infection Discharge Condition: stable, mentating well, appropriate and conversant with PMV, tolerating trach collar Discharge Instructions: you will be discharged to a rehab facility for ventilator rehabilitation Followup Instructions: follow-up in trauma surgery clinic in 2 weeks; call to schedule an appointment follow-up with your cardiologist regarding metoprolol therapy (you were previously on atenolol and sotalol) Completed by:[**2127-5-15**]

[ "599.0", "041.04", "403.90", "427.1", "263.9", "518.5", "276.0", "585.9", "861.01", "807.4", "425.4", "428.0", "428.22", "250.00", "780.2", "V53.31", "511.9", "E812.0", "584.9", "813.02" ]

icd9cm

[ [ [] ] ]

[ "43.11", "34.04", "33.22", "96.72", "31.1", "96.6" ]

icd9pcs

[ [ [] ] ]

9689, 9771

3362, 7544

341, 418

10086, 10173

1159, 3339

10294, 10512

966, 1004

7857, 9666

9792, 10065

7570, 7834

10197, 10271

1019, 1140

274, 303

446, 832

854, 907

923, 950

28,701

112,223

48128

Discharge summary

report

Admission Date: [**2156-6-21**] Discharge Date: [**2156-6-24**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 398**] Chief Complaint: UTI/sepsis Major Surgical or Invasive Procedure: none History of Present Illness: 82M with metastatic esophageal CA managed by watchful waiting, diabetes p/w confusion at [**Hospital 27838**] rehab. He was noted by the staff at the rehab to develop difficulty breathing, decreased oxygen sats requiring supplemental oxygen, and bp to the 80s systolic. Of note, at the rehab he had just completeted a course of levofloxacin for a RLL PNA for which he was treated at [**Hospital **]. He was sent to the ED at [**Hospital1 18**] for further evaluation where he was found to have initial vitals T 99.4 bp 146/72 satting 95 on 3L. He afebrile though found to have a lactate of 5.3 with a wbc of 18.4 from 16.9 a couple of days prior. While his bp and pulse were stable, sepsis protocol was initiated given the elevated lactate and central line was placed in the ED. He was given 3L NS in smaller boluses. CXR showed no infiltrates. UA was positive. Vanc/zosyn were started empirically in the ED. He was admitted to ICU. Past Medical History: 1. Esophageal CA 2. HTN 3. gastric ulcers 4. diabetes, has been diet controlled. Status post left knee replacement x3. Status post right knee replacement x2. Social History: The patient is married and lives with his wife in [**Name (NI) 1474**]. He drives and keeps track of the bills. He is a retired deli store owner, and reports a remote tobacco history, rare alcohol use, and no intravenous drug use. Family History: brother with prostate CA. Physical Exam: VS: Temp: 98.2 BP: 127/56 HR: 71 RR: 25 O2sat: 93% 3L GEN: awake, oriented to self, occasional bursts of agitation HEENT: PERRL, eomi, MM dry NECK: no supraclavicular or cervical lymphadenopathy, no jvd RESP: bibasilar crackles CV: RR, S1 and S2 wnl, IV/VI early systolic murmur ABD: soft, moderately distended, no caput medusae EXT: 1+ edema b/l SKIN: no rashes/no jaundice NEURO: MAEW, CN grossly intact, Pertinent Results: [**2156-6-21**] 09:26PM LACTATE-2.1* [**2156-6-21**] 09:26PM O2 SAT-66 [**2156-6-21**] 09:13PM CORTISOL-27.8* [**2156-6-21**] 08:09PM TYPE-ART O2 FLOW-5 PO2-67* PCO2-42 PH-7.34* TOTAL CO2-24 BASE XS--2 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**] [**2156-6-21**] 07:20PM GLUCOSE-58* UREA N-54* CREAT-1.5* SODIUM-138 POTASSIUM-5.1 CHLORIDE-108 TOTAL CO2-22 ANION GAP-13 [**2156-6-21**] 07:20PM WBC-17.0* RBC-3.09* HGB-9.5* HCT-27.6* MCV-90 MCH-30.6 MCHC-34.2 RDW-13.8 [**2156-6-21**] 07:20PM NEUTS-80* BANDS-11* LYMPHS-7* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2156-6-21**] 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-MOD [**2156-6-21**] 04:20PM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-0-2 [**2156-6-21**] 03:42PM LACTATE-5.3* K+-5.3 [**2156-6-21**] 03:40PM ALT(SGPT)-35 AST(SGOT)-54* LD(LDH)-350* CK(CPK)-60 ALK PHOS-303* AMYLASE-22 TOT BILI-0.7 [**2156-6-21**] 03:40PM CK-MB-NotDone cTropnT-0.05* proBNP-2755* [**2156-6-21**] 03:40PM CALCIUM-9.2 PHOSPHATE-4.5 MAGNESIUM-2.3 [**2156-6-21**] 03:40PM HAPTOGLOB-301* [**2156-6-21**] 03:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2156-6-21**] 02:37PM GLUCOSE-83 UREA N-57* CREAT-1.6* SODIUM-137 POTASSIUM-5.7* CHLORIDE-105 TOTAL CO2-24 ANION GAP-14 [**2156-6-21**] 02:37PM PLT COUNT-316 [**2156-6-24**] 03:25AM BLOOD WBC-19.9* RBC-3.24* Hgb-9.8* Hct-28.9* MCV-89 MCH-30.3 MCHC-34.0 RDW-14.2 Plt Ct-307 [**2156-6-21**] 07:20PM BLOOD Neuts-80* Bands-11* Lymphs-7* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2156-6-24**] 03:25AM BLOOD Plt Ct-307 [**2156-6-21**] 03:40PM BLOOD PT-15.3* PTT-34.3 INR(PT)-1.4* [**2156-6-23**] 04:31AM BLOOD Glucose-90 UreaN-42* Creat-1.1 Na-142 K-4.5 Cl-111* HCO3-25 AnGap-11 [**2156-6-22**] 03:20PM BLOOD Glucose-80 UreaN-44* Creat-1.2 Na-141 K-4.4 Cl-109* HCO3-24 AnGap-12 [**2156-6-21**] 03:40PM BLOOD ALT-35 AST-54* LD(LDH)-350* CK(CPK)-60 AlkPhos-303* Amylase-22 TotBili-0.7 [**2156-6-22**] 04:02AM BLOOD Albumin-2.0* Calcium-7.8* Phos-4.0 Mg-2.0 [**2156-6-21**] 09:13PM BLOOD Cortsol-27.8* [**2156-6-21**] 03:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . . Abd US IMPRESSION: 1. Multiple nodules throughout the liver consistent with widespread metastases. 2. Small amount of perihepatic ascites. . KUB: IMPRESSION: No evidence of bowel obstruction or free intra-abdominal air is identified. . CXR: IMPRESSION: Suboptimal study due to markedly reduced lung volumes with no acute consolidation. Right hemidiaphragm elevation. Probable cardiomegaly. This will be better evaluated with PA and lateral views of the chest when the patient could tolerate this. . URINE CULTURE (Final [**2156-6-23**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Trimethoprim/Sulfa sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: A/P: 82M with metastatic esophageal CA, diabetes p/w sepsis. . 1. Sepsis/UTI: Pt had lactate to 5.3 on admission, with elevated WBC. The ource was found to be UTI. He was treated initially with vanc and zosyn. he was admitted under sepsis protocol with SvO2 central venous line placed and received multiple fluid boluses in the ED. His pulse and BP remained stable in the ED, although the lactate was indicative of early sepsis. This resolved with treatment. Urine Cx showed E Coli sensitive to bactrim. At rehab, pyridium can be considered for pain if needed, patient's daughter specifically requested this. . 2. Hypoxia: He was noted to have a new oxygen requirement. This was thought to be [**2-6**] hypoventilation and abdominal distension. BNP was 2755 in the ED, although there was no other evidence of CHF. . 3. Metastatic esophageal CA: Liver US showed worsening metastatic disease with minimal ascites, patent portal vein with hepatopetal flow. DNR/DNI discussion was held with the patient and his son and daughter. The patient expressed a clear desire to be DNR/DNI and also a general preference to avoid further tests or procedures. His goals are palliative. . 4. ARF: Cr was elevated 1.5 and had been 1.5 range at rehab for the past week. His baseline was 1.0 on [**2156-4-1**]. This resolved to 1.1 with IV fluids. His ACE inhibitor was held. . # hyperkalemia: potassium was elevated to 5.7 on [**6-20**] at rehab, and was 5.7 again in ED. Pt is now s/p insulin and kayexalate, with k to 4.9. The potassium remained stable during the rest of the admission. . # confusion: This resolved by hospital day #2. It was likely mutlifactorial, [**2-6**] acute illness, infection, oxycodone at rehab. This resolved by the second hospital day. . # dm2: Oral agents were held and he was covered with RISS. . # htn: Lisinopril was held given the ARF. . FEN: cardiac, diabetic diet . Access: RSC central line PPx: Hep SQ, ppi DISPO: ICU care Contact: [**Name (NI) **] [**Name (NI) **] [**Name (NI) 44908**] [**Telephone/Fax (1) 101480**] Medications on Admission: glyburide 1.25 mg p.o. daily metformin 500 mg p.o. daily lisinopril 40 mg p.o. daily, Detrol LA 4 mg p.o. daily, finasteride 5 mg p.o. daily Prevacid 30 mg p.o.daily. megace 400' percocets Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days: please continue for 14 day course for UTI, day 1=[**6-21**]. 6. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. 7. insulin standard regular insulin slliding scale 8. Outpatient Lab Work CBC and chem-7 within 1-2 days of arrival at rehab Discharge Disposition: Extended Care Facility: Baypointe - [**Hospital1 1474**] Discharge Diagnosis: UTI ARF metastatic esophageal CA Discharge Condition: fair, requiring 2L nasal cannula. Discharge Instructions: You were admitted for a urinary infection. You were also found to have worsening metastatic cancer and we had important discussions regarding the goals of your care. . 2. please have lab work drawn at rehab for CBC and electrolytes within 1-2 days. Followup Instructions: Please call your primary oncologist, Dr. [**Last Name (STitle) **] to update him this week. We have been in contact with him as well. Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**] Date/Time:[**2156-7-1**] 2:00 . Provider [**Name9 (PRE) **] [**Name9 (PRE) 10341**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2156-7-1**] 2:00

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

8927, 8986

5900, 7940

271, 278

9063, 9099

2159, 5877

9396, 9785

1685, 1712

8179, 8904

9007, 9042

7966, 8156

9123, 9373

1727, 2140

221, 233

306, 1240

1262, 1421

1437, 1669

26,014

196,102

44541

Discharge summary

report

Admission Date: [**2102-11-8**] Discharge Date: [**2102-11-10**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14145**] Chief Complaint: admit for pericardiocentesis Major Surgical or Invasive Procedure: Pericardiocentesis History of Present Illness: Pt is a 84 yom with DM2, CAD recent hx of PE early [**10-18**] discharged on coumadin. Pt went for routine echo with cardiologist and found to have a new pericardial effusion and was referred and admitted to [**Hospital1 18**] [**Date range (1) **]. Pt did not have any signs of temponade and did not have any complaints and was discharged home without pericardiocentesis. Pt discharged home on coumadin [**2102-10-26**]. . He states that he has been experienceing mild dyspnea on exertion and fatigue since the PE and has felt moderate fatigue. On follow up appointment pt noted to have increasing size of effusion and pt scheduled for tap. He states that he hasn't had any chest pain or increase in his baseline dyspnea since the last admission. Denies any other complaints of caugh/fevers/chills. Past Medical History: -CAD -R-CEA -DM II -Prostate cancer -Gout -Hypercholesterolemia -CVA -HTN Social History: -Pt lives with wife and son -Positive [**Name2 (NI) **] hx: smoked cigars and pipes 6pipes/day x 20 years, quit 20 years ago -No ETOH, cocaine or other drug use . Family History: F: Died of "enlarged heart" M: Died of ?CVA in 80s Brother: died of MI at 51, another brother with MI in 70s . Physical Exam: T: 98.8 BP: 140/73 HR:66 RR 20 O2sat 95%RA PE: GEN: Pt is a elderly male s/p tap earlier now in no appearent acute distress HEENT: MMM, PERRL, JVP not assessed as pt lying flat post cath. Chest: CTAB anteriorly and laterally. Pericardial tap site - dressing intact, no drainage. CVR: RRR, nl S1, S2, No r/m/g appreciated Abdomen: Soft, Nontender and nondistended with normal bowel sounds Ext: no edema. Wound: R groin site no hematoma, drssing c/d/i. Pertinent Results: [**2102-11-8**] 04:47PM OTHER BODY FLUID TOT PROT-4.5 GLUCOSE-123 LD(LDH)-1472 AMYLASE-28 ALBUMIN-2.5 [**2102-11-8**] 04:47PM OTHER BODY FLUID WBC-[**2097**]* RBC-[**Numeric Identifier 95413**]* POLYS-32* LYMPHS-57* MONOS-9* MACROPHAG-2* [**2102-11-8**] 11:30AM INR(PT)-1.5. . ECG: SR at about 60, nl axis, RBBB, prolonged PR(0.13). . Echo [**2102-11-8**] Conclusions: 1. The left atrium is mildly dilated. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4.There is a large pericardial effusion. There appears to be an echodense material adjacent to the myocardium which is probably fat but can not rule out the presence of a thrombus. There are no echocardiographic signs of tamponade. Of note the size of the efusion at 45degrees elevation is 1.75 cm apically. . Cath 10/26/105 Prelim. COMMENTS: 1. Right heart catheterization revealed slightly elevated left and right heart filling pressures. There was no evidence of tamponade physiology. 2. Difficult tapping of a loculated pericardial effusion. The mean pericardial pressure was 5mm HG, decreasing to 2mm Hg with drainage of 360ml of bloody fluid. 3. A removable IVC filter was placed so thta coumadin could be witheld for 3-4 weeks as the effusion was bloody. If the decision to restart coumadin is made, consider removing the filter. . Echo [**2102-11-10**] 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 aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is a small to moderate sized loculated echo dense pericardial effusion extending anteriorly in the interventricular groove from the mid wall to the apex c/w a hematoma. There is no evidence of right ventricular diastolic collapse. Compared with the prior study (tape reviewed) of [**2102-11-9**], the findings are similar. The loculated echo dense pericardial effusion was also present on review of the prior study. Brief Hospital Course: Impression and Plan - Pt. is a 84 yom with DM, CAD with pericardial effusion on anticogualation for recent PE. Refferred for drain after increase in size. . [] Pericardial effusion - Drain in place will continue to monitor overnight. Previous work up for the effusion included normal TSH 0.3 [**10-18**] and PSA of 0.1 [**10-18**]. DDx for pleural effusion is wide however given the cell count with numerous RBC, this is likely hemorrhagic pericardial effusion. Likely etiology include Malignancy ?????? 26%, Percutaneous interventional procedures ?????? 18%, Postpericardiotomy syndrome ?????? 13%, Complications of myocardial infarction (free wall rupture, thrombolysis) ?????? 11%, Idiopathic ?????? 10% Uremic ?????? 7%, Aortic dissection ?????? 4%, Trauma ?????? 3%, and Other ?????? 8 percent according to a recent study in Chest [**2096**] [**Month (only) **];116(6):1564-9. In conjunction with the history the three most likely are to be melignancy, idiopathic or likely due to anticogulation. - f/u cytology to evaluate for possible malignancy. - Pt was treated with warfarin for PE recently and this can certainly have atributed to the effusion. . [] Cardiac Ischemia - history of CAD per records however no records of cath here. Continue ASA 81, Plavix 75, Atenolol 12.5, Lipitor 20, quinapril 10 and Imdur. No episodes of chest pain or shortness of breath and monitored on tele. . Pump - EF >55% on echo done [**11-8**]. Repeat echo [**11-10**] showed preserved lvef, full report in results section. . Rhythm - SR with RBBB . [] Pulmonary - History of PE - Given recent PE early [**Month (only) **] concerning for repeat event, however given hemorrhagic effusion and IVC filter which was placed today at cath, held anticogulation with coumadin immediately post procedure. - Given hemorrhagic pericardial effusion, pt discharged off coumadin. Will f/u with Dr. [**Last Name (STitle) **]. . [] DM- On home insulin 70/30, 15u qAM, 13u qPM + RISS. [] Prostate Cancer - Continue Casodex. [] HTN - Continue outpt meds, adjust accordingly. [] Code - Full [] dispo - to home. Pt will f/u with cardiologist Dr. [**Last Name (STitle) **]. Medications on Admission: ASA81 Vit E 400 Atenelol 12.5, SLNTG prn, lipitor 20, plavix 75 Iso MN 15, Amoxicillin SBE prophylaxis. Accupirl 10, Folic acid, casodex 50 qd. Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Bicalutamide 50 mg Tablet Sig: One (1) Tablet PO qd (). 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 9. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Pericardial effusion coronary artery disease insulin dependent diabetes mellitus Discharge Condition: Good- patient afebrile and hemodynamically stable, minimal pain. Discharge Instructions: Please continue to take all of your medications every day as instructed. Please call your doctor or return to the hospital if you experience chest pain, shortness of breath, fever, or chills. Followup Instructions: You have an appointment scheduled with Dr. [**Last Name (STitle) **] on Monday, [**11-13**], at 11:00 am. You should also follow up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks, call the number above for an appointment. Completed by:[**2102-11-11**]

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icd9cm

[ [ [] ] ]

[ "37.0", "38.7" ]

icd9pcs

[ [ [] ] ]

7469, 7475

4384, 6535

293, 314

7600, 7667

2055, 4361

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1443, 1556

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7691, 7885

1571, 2036

225, 255

342, 1149

1171, 1246

1262, 1427

28,677

112,372

5686+55689

Discharge summary

report+addendum

Admission Date: [**2123-1-8**] Discharge Date: [**2123-1-21**] Date of Birth: [**2058-3-31**] Sex: F Service: CARDIOTHORACIC Allergies: Lisinopril Attending:[**First Name3 (LF) 922**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2123-1-10**] ERCP [**2123-1-11**] Transjugular Liver Biopsy [**2122-1-30**] Cardioversion History of Present Illness: Mrs. [**Known lastname 6692**] is a 64 year old female who recently underwent a bioprosthetic mitral valve replacement and Maze procedure on [**2122-12-31**]. Her hospital course was rather uneventful and she was discharged on postoperative day seven. She re-presented with multiple vague complaints including RUQ abdominal pain and right flank pain. The pain was described as dull and was rated a [**6-29**]. Patient also admitted to some nausea and vomiting which was associated with some fevers, and chills. She denied rigors, weight loss/gain, bleeding and change in bowel habits. She did describe her urine as a dark, amber color. Initial evaluation was notable for elevated LFT's, elevated BNP, elevated white count, supratherapeutic INR along with a slight increase in creatinine. She was therefore admitted for further evaluation and treatment. Past Medical History: History of Mitral Regurgitation/Stenosis and Atrial Fibrillation s/p Mitral Valve Replacement(Bioprosthesis) and Full Left Sided Maze Procedure on [**2122-12-31**], Diastolic Congestive Heart Failure, Systemic Lupus Erythematosus with History of Lupus Anticoagulant and Hypercoagulable state, Anti-cardiolopin Antibody, History of Stroke [**2106**], History of Coronary Artery Disease - s/p RCA stent in [**2121-1-19**], Dyslipidemia, Asbestos exposure with pleural plaque, s/p Vein ligation and stripping Social History: Married, lives with husband. [**Name (NI) 1403**] as a registered nurse [**First Name (Titles) **] [**Last Name (Titles) **] [**Location (un) 620**]. Smoked 1 [**1-20**] ppd x 30 years, quit 16 years ago. 1 glass red wine/day Family History: There is no family history of premature coronary artery disease or sudden death. Mother - deceased age 76 DM, CAD. Father - deceased age 84, CAD. Two brothers s/p CABG. Daughter - deceased age 36, leukemia. Physical Exam: Vitals: Afebrile, BP 150/70, HR 70, RR 14, SAT 100% RA General: WDWN female in no acute distress HEENT: Oropharynx benign, EOMI, sclera anicteric Neck: Supple, no JVD Lungs: soft bibasilar rales, otherwise CTA bilaterally Heart: Regular rate and rhythm, normal s1s2 Abdomen: Soft, slightly tender to deep palpation in RUQ. normoactive bowel sounds, no ascites, negative [**Doctor Last Name **] sign Ext: Warm, no edema Pulses: 1+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [**2123-1-7**] 06:35AM BLOOD WBC-7.5 RBC-2.95* Hgb-9.1* Hct-26.1* MCV-89 MCH-30.7 MCHC-34.7 RDW-15.0 Plt Ct-120* [**2123-1-8**] 05:20AM BLOOD Neuts-84.9* Bands-0 Lymphs-9.5* Monos-3.8 Eos-1.5 Baso-0.3 [**2123-1-7**] 06:35AM BLOOD PT-42.7* PTT-52.8* INR(PT)-4.7* [**2123-1-7**] 06:35AM BLOOD Glucose-115* UreaN-15 Creat-1.3* Na-135 K-4.0 Cl-101 HCO3-26 AnGap-12 [**2123-1-8**] 05:20PM BLOOD ALT-300* AST-321* AlkPhos-441* Amylase-71 TotBili-1.5 [**2123-1-8**] 05:20AM BLOOD proBNP-7858* [**2123-1-8**] RUQ Ultrasound: 1. Normal gallbladder and liver, with no evidence of cholecystitis or gallstones. 2. Right-sided pleural effusion. [**2123-1-9**] HIDA Scan: Images show prompt uptake of tracer into the hepatic parenchyma. No tracer activity is seen during this time within the gallbladder, biliary tree, or GI tract. The above findings are consistent with cholestasis. [**2123-1-9**] Abdominal MR: 1. Limited study secondary to motion artifact from patient's breathing throughout the examination. 2. Cholangitis involving the left lobe of the liver, better visualized on recent CT. No focal fluid collections identified within the liver. 3. Dilated side branch within the tail of the pancreas likely representing side branch IPMT. [**2123-1-9**] Abdominal CT Scan: 1. Multiple enhancing tubular and rounded hypodensities within the left hepatic lobe, likely representing microabscesses with reactive cholangitis. [**2123-1-9**] Transthoracic ECHO: The left atrium is mildly dilated. 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 aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion which is most prominent posterior to the atria. [**2123-1-11**] RUQ Ultrasound: There is no biliary dilatation identified, but there is pneumobilia seen throughout the liver. The portal vein is patent with hepatopetal flow. Flow is identified in the right hepatic vein, middle hepatic vein and the left hepatic vein. There is no ascites identified. There is a right pleural effusion seen. [**2123-1-14**] Renal Ultrasound: The right kidney measures 12.1 cm, and demonstrates diffusely increased echogenicity. A tiny subcentimeter cyst is identified in the interpolar region. There is no evidence of stone, mass or hydronephrosis. The left kidney measures 13.2 cm. There is no evidence of stone, mass, or hydronephrosis. [**2123-1-21**] 05:42AM BLOOD WBC-8.0 RBC-2.73* Hgb-8.0* Hct-24.1* MCV-88 MCH-29.4 MCHC-33.3 RDW-17.5* Plt Ct-259 [**2123-1-20**] 08:39AM BLOOD WBC-11.4* RBC-3.00* Hgb-8.9* Hct-25.9* MCV-86 MCH-29.5 MCHC-34.1 RDW-16.2* Plt Ct-212 [**2123-1-21**] 05:42AM BLOOD PT-32.1* PTT-47.1* INR(PT)-3.3* [**2123-1-20**] 08:39AM BLOOD PT-26.1* PTT-43.0* INR(PT)-2.6* [**2123-1-19**] 06:00AM BLOOD PT-23.6* INR(PT)-2.3* [**2123-1-21**] 05:42AM BLOOD Glucose-109* UreaN-22* Creat-1.7* Na-136 K-3.6 Cl-97 HCO3-28 AnGap-15 ABDOMEN U.S. (COMPLETE STUDY) [**2123-1-18**] 8:23 AM ABDOMEN U.S. (COMPLETE STUDY) Reason: evaluate for ascites [**Hospital 93**] MEDICAL CONDITION: 64 year old woman with elevated LFTs s/p MVR and MAZE REASON FOR THIS EXAMINATION: evaluate for ascites STUDY: Abdominal ultrasound. INDICATION: 64-year-old female presenting with elevated LFTs. Status post MVR and MAZE procedure. COMPARISONS: MRCP dated [**2123-1-9**] and CT dated [**2123-1-9**]. FINDINGS: Multiple hypoechoic foci present within the left lobe of the liver are consistent in appearance with small abscesses and appear unchanged compared to the recent CT and MR evaluations. These hypoechoic foci appear solid. The right lobe of the liver appears normal in echotexture. There is prominent pneumobilia which is new compared to the previous examinations and consistent with the recent history of ERCP and common bile duct stent placement. A stent is visualized within the common bile duct which measures approximately 6 mm in diameter. There is no intra- or extra-hepatic biliary dilatation. The gallbladder wall appears mildly thickened. There is no pericholecystic fluid or wall edema and overall the gallbladder is not distended. Note is made of prominent sludge within the gallbladder. A small amount of perihepatic free fluid is noted. There are bilateral small pleural effusions. The spleen is prominent in size measuring 12.5 cm in length. Images of the head and body of the pancreas are unremarkable. The pancreatic duct is not distended. The main portal vein is patent with appropriate direction of flow. IMPRESSION: 1. Multiple hypoechoic foci within the left lobe of the liver consistent in appearance with small abscesses. All foci appear solid and non-drainable. 2. Pneumobilia and common bile duct stent placement are new compared to CT and MRI of [**2123-1-9**]. 3. Tiny amount of abdominal ascites. 4. Bilateral small pleural effusions. 5. Gallbladder sludge. Brief Hospital Course: Mrs. [**Known lastname 6692**] was admitted and underwent extensive evaluation. An echocardiogram was unremarkable while the abdominal CT scan was notable for multiple enhancing tubular and rounded hypodensities within the left hepatic lobe, likely representing microabscesses with reactive cholangitis. She was made NPO and pan-cultures were obtained. The ID and hepatology services were consulted along with general surgery. They all agreed with broad spectrum antibiotic therapy. Given her supratherapeutic INR, Warfarin was held and several units of fresh frozen plasma were given. ERCP with stenting was performed on [**1-11**] without complication. The renal service was also consulted as she continued to experience further decline in renal function. Her creatinine peaked to 2.4 on [**1-12**]. Her acute renal failure was attributed to acute tubular necrosis from intravenous contrast. Renal ultrasound was obtained and was unremarkable. Liver biopsy on [**1-12**] revealed no necrosis, changes consistent with cholangitis vs biliary obstruction. Despite antibiotics, she continued to experience intermittent fevers. She remained on broad spectrum antibiotics for ? bartonella and was followed very closely by the ID service. Serial abdominal exams were performed while liver function tests were monitored daily. Antibiotics were titrated accordingly. She was transferred to the floor on [**1-14**]. Her abdominal pain improved as did her liver and renal function. She continued to be diuresed. She awaited return of her creatinine to baseline prior to repeat CT scan. She was seen by EP, Flecainide was dc'd and restarted and cardioversion was successfully performed. She was ready for discharge to rehab on hospital day 14. Medications on Admission: Aspirin 81 qd, Zetia 10 qd, Crestor 20 qd, Flecanide 150 [**Hospital1 **], Lopressor 150 [**Hospital1 **], Warfarin, Vicodin prn Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 7. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). Disp:*120 Tablet(s)* Refills:*0* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*0* 10. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gm Intravenous once a day: until [**2123-2-5**]. Disp:*16 gm* Refills:*0* 11. Ertapenem 1 gram Recon Soln Sig: One (1) gm Intravenous once a day: until [**2123-2-5**]. Disp:*16 * Refills:*0* 12. Outpatient Lab Work Please check a weekly CBC/diff, chem 7, LFTs, and Vanco trough and fax results to [**Hospital **] clinic nurse ([**Telephone/Fax (1) 16411**] 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous once a day as needed. Disp:*16 ML(s)* Refills:*0* 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 15. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Cholestasis with Hepatic Microabscesses, Acute Renal Failure, History of Mitral Regurgitation/Stenosis and Atrial Fibrillation s/p Mitral Valve Replacement and Maze Procedure on [**2122-12-31**], Systemic Lupus Erythematosus with History of Lupus Anticoagulant and Hypercoagulable state, History of stroke, History of Coronary Artery Disease - s/p RCA stent in [**2121-1-19**], Dyslipidemia Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2123-1-27**] 2:40 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2123-1-28**] 11:00 [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2123-2-3**] 2:00 [**Hospital **] clinic [**2123-2-4**] at 1:30 PM LMOB Basement [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 6732**] Weekly CBC, LFT, Chem 7, and Vancomycin trough should be taken and sent to ([**Telephone/Fax (1) 16411**] ([**Hospital **] clinic) Abdominal ultrasound Wednesday [**2123-2-3**] 9 AM [**Location (un) **] [**Hospital Ward Name **] 5B, please do not eat or drink anything after midnight the night before the ultrasound Completed by:[**2123-1-21**] Name: [**Known lastname 3828**],[**Known firstname 194**] [**Last Name (NamePattern1) 471**] Unit No: [**Numeric Identifier 3829**] Admission Date: [**2123-1-8**] Discharge Date: [**2123-1-21**] Date of Birth: [**2058-3-31**] Sex: F Service: CARDIOTHORACIC Allergies: Lisinopril Attending:[**First Name3 (LF) 1543**] Addendum: Patient was found to be HIT negative by seratonin assay on [**2123-1-21**]. Chief Complaint: Right upper quadrant pain Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 7. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). Disp:*120 Tablet(s)* Refills:*0* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*0* 10. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gm Intravenous once a day: until [**2123-2-5**]. Disp:*16 gm* Refills:*0* 11. Ertapenem 1 gram Recon Soln Sig: One (1) gm Intravenous once a day: until [**2123-2-5**]. Disp:*16 * Refills:*0* 12. Outpatient Lab Work Please check a weekly CBC/diff, chem 7, LFTs, and Vanco trough and fax results to [**Hospital **] clinic nurse ([**Telephone/Fax (1) 3830**] 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous once a day as needed. Disp:*16 ML(s)* Refills:*0* 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 15. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 16. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day for 30 days. Disp:*30 Capsule, Sustained Release(s)* Refills:*0* 17. Folamin 2.5-25-2 mg Tablet Sig: One (1) Tablet PO once a day for 30 days. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Location (un) 176**] Of [**Location (un) 407**] [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2123-1-21**]

[ "710.0", "428.0", "V17.3", "V18.0", "584.9", "V45.82", "572.0", "V42.2", "427.31", "428.32", "576.1", "272.4", "795.79", "276.1" ]

icd9cm

[ [ [] ] ]

[ "51.87", "50.13", "38.93", "99.61", "99.07" ]

icd9pcs

[ [ [] ] ]

16444, 16680

8215, 9956

290, 385

12546, 12553

2817, 6352

12852, 14183

2057, 2267

14250, 16421

6389, 6443

12132, 12525

9982, 10112

12577, 12829

2282, 2798

14200, 14227

6472, 8192

413, 1268

1290, 1797

1813, 2041

22,233

196,266

28494

Discharge summary

report

Admission Date: [**2159-9-9**] Discharge Date: [**2159-10-1**] Date of Birth: [**2159-9-9**] Sex: M Service: NB HISTORY/REASON FOR ADMISSION: Prematurity (34-2/7 week gestation). MATERNAL HISTORY: Baby [**Name (NI) **] [**Known lastname 16838**] was [**Known lastname **] to a 36-year- old G3, P1 mother who presented with vaginal bleeding at 34 weeks gestation. History is notable for Zoloft treatment. Prenatal screen: A positive/antibody negative, HBS antigen negative, RPR NR, rubella immune, GBS unknown. There were no maternal risk factors for sepsis in the form of intrapartum fever or premature rupture of membranes. Delivery was by C-section in view of previous section with vaginal bleed. Baby was [**Name2 (NI) **] in good condition. He was active and vigorous, and no resuscitation was required. Apgars were 8 and 9 at 1 and 5 minutes, respectively. He was admitted to the NICU in view of prematurity. PHYSICAL EXAMINATION ON ADMISSION: Birthweight 2210 grams (50th percentile), head circumference 29.5 cm (10th percentile), length 47 cm (50th-75th percentile). On examination, baby appeared well, pink, active, nondysmorphic. He was comfortably breathing in room air with bilateral good aeration. His skin was normal with no cutaneous lesions. Cardiovascular: Pink, well-perfused, S1, S2 normal, no murmur. HEENT normal. Abdomen benign. Genitalia: Normal male. Testes in canals bilaterally, anus patent. Hips bilateral normal. Neurological: Nonfocal and age-appropriate. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: A) RESPIRATORY: Baby [**Known lastname 16838**] did not demonstrate any signs and symptoms of respiratory distress syndrome and was comfortably breathing in room air throughout his hospital stay. He did not have any problems with apnea of prematurity. B) CARDIOVASCULAR: No complications. C) FLUIDS, ELECTROLYTES AND NUTRITION: He was initially started on IV fluids D10W, and feeds were introduced on day 2 of life and advanced to a maximum of 150 mL/kg/D 24 cal/oz feed of Similac by day of life 6. At the time of discharge, he has been on ad lib p.o. feeds of Similac 24 which he has been taking approximately 140-150 mL/kg/D. He has shown good weight gain. Discharge weight 2795 grams (25th-50th percentile), length 49 cm (50th-75th percentile), head circumference 33 cm (50th percentile). D) GI: No complications. Maximum bilirubin was 9 mg/dL on day of life 4. E) HEMATOLOGY: No concerns. Admission hematocrit was 39.2. F) INFECTIOUS DISEASES: No episodes of suspected or proven sepsis. He received IV antibiotics for the first 48 hours for sepsis rule out, at which time blood culture was negative and WBC unremarkable. G) NEUROLOGY: A prominent occiput was evaluated by neurosurgery and thought not to be associated with underlying pathology, but follow-up with that service was recommended two months following discharge. Cranial ultrasound was within normal limits. H) SENSORY: 1) Audiology: He has passed his newborn hearing screening. 2) Ophthalmology: He does fulfill criteria for routine ROP screening. I) PSYCHOSOCIAL: No social concerns. CONDITION AT DISCHARGE: Well. DISCHARGE DISPOSITION: Home. NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **], telephone number [**Telephone/Fax (1) 43144**]. CARE RECOMMENDATIONS: A. Feeds at discharge: Ad lib p.o. feeds of Similac 24 B. Medications: None. C. Car seat position screening--passed. D. State newborn screening test done on [**9-15**], initial report normal, final report awaited. E. Immunizations received: Hepatitis B vaccine on [**2159-9-15**]. F. Immunizations recommended: 1) Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 3 criteria: 1) [**Month (only) **] at less than 32 weeks; 2) [**Month (only) **] between 32 and 35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-aged siblings; 3) With chronic lung disease. 2) Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age (and for the first 24 months of the child's life), immunization against influenza is recommended for household contacts and out-of-home caregivers. G. Follow-up appointments scheduled or recommended: 1) Primary care pediatrician 3-4 days postdischarge; 2) Neurosurgery, Dr. [**Last Name (STitle) 56743**], in [**5-31**] weeks. DISCHARGE DIAGNOSIS: Prematurity (34-2/7 weeks gestation). Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], MD [**MD Number(1) 36250**] Dictated By:[**Doctor Last Name 65692**] MEDQUIST36 D: [**2159-10-1**] 13:32:21 T: [**2159-10-1**] 14:43:30 Job#: [**Job Number 69053**]

[ "V50.2", "765.18", "765.27", "V29.0", "V05.3", "782.1", "V30.01", "778.8" ]

icd9cm

[ [ [] ] ]

[ "64.0", "99.55", "96.07" ]

icd9pcs

[ [ [] ] ]

3169, 3287

4528, 4825

3310, 3319

1551, 3123

3333, 3594

3621, 4506

975, 1522

17,455

134,109

13659

Discharge summary

report

Admission Date: [**2188-1-22**] Discharge Date: [**2188-2-12**] Date of Birth: [**2132-8-26**] Sex: F Service: CARDIOTHORACIC Allergies: Procrit Attending:[**First Name3 (LF) 1267**] Chief Complaint: transfer from [**Hospital3 **] hospital for cardiac catherization and management of chst pain Major Surgical or Invasive Procedure: [**2188-2-1**] - Cardiac Catheterization [**2188-2-5**] - CABGx4 (LIMA->LAD, SVG->Diagonal, SVG->Obtuse Marginal, SVG->Right Coronary Artery) History of Present Illness: 55 yo female with type I diabetes on NPH, Ultralente, and RISS, complicated by retinopathy (blindness), nephropathy, neuropathy, and gastroparesis, with long standing dyspnea on exertion was transferred tonight from [**Hospital3 **] hospital where she was admitted on [**2188-3-20**] for SOB at rest and midsternal chest pressure, and found to have CHF and HTN (240/120). She had negative cardiac enzymes and was diuresed. She had a an elevated d-dimer, but negative LENIs and negative v/q scan. She was continued on her come BP regimen but was also started on norvasc 10mg. Her lisinopril and HCTZ are being held in anticipation of dye load for cath and she started on mucomyst. She asked to be transferred to [**Hospital1 18**] because her nephrologist is Dr. [**First Name (STitle) 10083**]. She was unaware that she was transferred for cardiac catherization/renal arteriogram. Today given Kayexelate for k6.0, that supposedly came down to 5.2, although not included in data sent over. . She was hospitalized [**12-24**] for hypertensive emergency, found to have encephalopathy that rapidly imrpoved (had word finding difficulty, nausea, and vomiting). She was started on diltiazem which was titrated over the past month to 240mg daily. . ROS: She denies PND and orthopnea. Has DOE with stairs. Ambulates without assistance. She has noticed that her pants have been alittle tighter recently. Dry weight around 157. Has had b/l le edema for a few months. Her fingersticks normally are around 150 but in the past few weeks have been 200s and uncontrolled since admission to [**Hospital3 **]. Nephrologist: [**First Name5 (NamePattern1) 10083**] [**Last Name (NamePattern1) 5370**]: [**Doctor Last Name **]/ [**Last Name (un) **] Endocrinologist: seen by [**Last Name (un) **] before, but now has not chosen new doctor. PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 41195**] on [**Hospital3 **] Past Medical History: Type One diabetes- nephropathy, retinopathy, neuropathy, gastroparesis. Cataract- left eye- 2 recent surgeries Blindness in right eye Spina Bifida- back pain when laying down for long periods, difficulty with bending Chronic anemia- on procrit in past (rash), hct stable in high 20s, low 30s CRI: cr baseline (2) HTN: recently hard to control- see HPI Social History: Lives with husband. Independent ADLs. No tobacco history. No etoh. Follows low salt diet, very compliant with meds. Physical Exam: 98.9, 142/60, 90, 16, 92% ra, fs 222 NAD. Middle aged white female. NC/AT. Perrl. Left eye with mild pstosis. MMM. Neck supple. JVP @7cm. Tachy s1/s2, no murmurs. Rales b/l bases. Abd: soft- ntnd, +bs Ext- b/l mild edema, worse distally, right calf slightly more prominent than left- no calf tenderness (no change according to pt) [**Name (NI) 8259**] symmetric Pertinent Results: GLUCOSE-189* UREA N-43* CREAT-2.0* SODIUM-137 POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-20* WBC-7.2 RBC-2.38* HGB-7.9* HCT-23.6* MCV-99* MCH-33.1* MCHC-33.5 RDW-13.5 PLT COUNT-330 - NEUTS-72.7* LYMPHS-15.5* MONOS-7.5 EOS-3.3 BASOS-1.0 At [**Hospital3 **] Hospital: BLE U/S- negative for DVT VQ scan- negative CXR - c/w CHR (repeated here similarly c/w CHF with no infiltrates noted) EKG: OSH echo [**2188-1-1**]: mild LV dysfunction, mild LVH PMIBI: 1. No ischemic symptoms or ECG changes. She had an appropriate hemodynamic response. Image quality is adequate but limited due to breast attenuation, left arm attenuation, and patient motion. 2. The left ventricular cavity size is increased with stress compared to rest. The right ventricle appears normal. Stress perfusion images show a moderate reduction in photon counts involving the mid and distal anterior wall. Rest perfusion images show that this defect is reversible. 3. Stress perfusion images also show a moderate reduction in photon counts involving the entire inferior wall and the basal inferolateral wall. Rest perfusion images show that this defect is reversible. 4. Gated images show mild global hypokinesis. The calculated left ventricular ejection fraction was 45%. IMPRESSION: 1. Reversible, small, moderate intensity perfusion defect involving the LAD (diagonal) territory. 2. Reversible, medium sized, moderate intensity perfusion defect involving the PDA territory. 3. Transient left ventricular cavity dilation consistent with multi-vessel disease. 4. Mild left ventricular systolic dysfunction with mild global hypokinesis. 5. suggestive of three-vessel disease. MRI/MRA kidneys: no RAS or other masses. cardiac catheterization [**2188-2-1**]: 1. Selective coronary angiography of this right dominant system demonstrated three (3) vessel coronary artery disease. The right coronary artery had a proximal 70% lesion along with a mid vessel 50% lesion. The RPDA had a 50% lesion at the origin. The left main demonstrated no angiographic evidence of any flow limiting lesions. The left anterior descending artery was heavily calcified with a 90% mid vessel stenosis partially involving the 2nd diagonal. The left circumflex demonstrated an OM1 with a 70% tubular lesion. 2. Selective angiography of the renal arteries demonstrated a 30% ostial lesion in the left renal artery along with a normal right renal artery. 3. LV ventriculography was deferred due to concerns of her renal function and recent echocardiogram. 4. Limited hemodynamics demonstrated elevated right and left heart filling pressures. No significant pressure gradient recorded across the aortic valve upon pullback from the left ventricle to the aorta. 5. Elevated central pressure (186/80 mm Hg). FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Diastolic congestive heart failure by recent echocardiogram. [**2188-2-5**] ECHO PRE-CPB 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. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is a trivial/physiologic pericardial effusion. POST-CPB There is low normal RV systolic function. Global LV systolic function is also low normal - EF = 50-55%. There is mild apical and septal hypokinesis. Trivial MR. [**Name13 (STitle) **] other changes from pre-CPB. [**2188-2-7**] Chest X-Ray The patient is status post median sternotomy and CABG recently. The appearance of the heart and mediastinum are satisfactory for recent aspiration. The lung volumes are low. No evidence of significant amount of pleural fluid or congestive heart failure is present. No evidence of pneumothorax is seen. The patient's ET tube, Swan-Ganz catheter, NG tube, and two left chest tubes were removed. Brief Hospital Course: Ms. [**Known lastname 12262**] is a 55 yo woman with DM and poorly controlled HTN, admitted with HTN urgency and transferred for cardiac evaluation and renal artery evaluation. On arrival to the outside hospital her BP was found to be 240/120. She was continued there on her usual 5 drug regimen with adequate control. She was subsequently transferred to the [**Hospital1 18**] for further management. Her blood pressure remained relatively easy to control, even after holding her [**Last Name (un) **] and ACE inhibitor. Workup for secondary causes of hypertension was negative for renin/aldosterone and renal artery stenosis. Urine free cortisol was still pending on discharge. After treating her hypertension, however, we believe the she more likely has essential hypertension and may have been noncompliant with her medications, as she was well controlled with no change in her medial regimen. In fact, at one point she developed ATN likely secondary to low blood pressures and her pressure goal was increased with good renal response. The patient's anemia is at her baseline and low retic index confirms that this is likely secondary to her renal disease. She was seen by her outpatient nephrologist, Dr. [**First Name (STitle) 10083**], upon arrival, who confirmed her procrit allergy and states that he is working on making Aranesp available for the patient as an outpatient. A cardiac catheterization was performed on [**2188-2-1**] which revealed severe three vessel disease with a preserved ejection fraction. Given the severity of her disease, the cardiac surgical service was consulted for surgical management. Mrs. [**Known lastname 12262**] was worked-up in the usual preoperative manner and found to be suitable for surgery. On [**2188-2-5**], Mrs. [**Known lastname 12262**] was taken to the operating room where she underwent four vessel coronary artery bypass grafting by Dr. [**Last Name (STitle) **]. Please see operative note for further detail. Postoperatively she was taken to the cardiac surgical intensive care unit. On postoperative day one, Mrs. [**Known lastname 12262**] awoke neurologically intact and was extubated. Beta blockade, a statin and aspirin were resumed. Her glucose levels remained elevated and thus stayed in the intensive care unit for three days for intravenous insulin. A PICC line was placed as she had difficult venous access. The [**Last Name (un) 387**] diabetes service made changes to her diabetes regimen with stabilization of her blood sugars. On postoperative day four, Mrs. [**Known lastname 12262**] was transferred to the cardiac surgical step down unit for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. She remained hemodynamically stable in a normal sinus rhythm throughout her postoperative course. Lisinopril was resumed at half her preoperative dose when her creatinine dropped below her baseline of 2.0 for hypertension and history of proteinuria. Renal function studies will be performed when she follow-s up with her cardiologist in a week. As her potassium was on the high side of normal without potassium supplementation, thus she was discharged on 5 days of lasix without potassium as her weight was still up from her preoperative baseline. Mrs. [**Known lastname 12262**] continued to make steady progress and was discharged home with a visiting nurse and physical therapist on postoperative day seven. She will follow-up with Dr. [**Last Name (STitle) **], her cardiologist, her nephrologist and her primary care physician as an outpatient. ** Discharge summary should be sent to outpt cardiologist Dr. [**Last Name (STitle) 41196**] [**Name (STitle) **] in [**Location (un) 9101**] [**Telephone/Fax (1) 34149**], fax [**Telephone/Fax (1) 41167**].** Medications on Admission: meds on transfer: lisinopril 20 mg [**Hospital1 **] (being held) cardizem CD 240 mg daily cozaar 100 mg qhs hctz 25 mg daily (being held) relgan 10 mh po qid magnesium oxide 200 mg daily protonix 40 mg daily nph- 15 units qam Ultralente- 10 units qam RISS Aspirin 81 mg daily norvasc 10 mg daily (just started) nitropaste [**11-19**] inch in am mucomyst 600 mg [**Hospital1 **] (started pm of [**3-22**]) timolol 0.5% one drop to left eye [**Hospital1 **] prenisolone 1% 1 drop to left eye daily Allergies: procrit- rash Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4* 3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day): 1 drop OS [**Hospital1 **]. Disp:*1 1 months supply* Refills:*2* 4. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily): 1 drop OS QD. Disp:*1 1 Months supply* Refills:*2* 5. insulin Please continue your usual insulin regimen as instuccted. Please keep a log of your blood sugars for your Doctor. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 10. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 13. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20) Units Subcutaneous QAM at breakfast. Disp:*1 Months supply* Refills:*0* 14. Insulin Regular Human 100 unit/mL Cartridge Sig: Sliding Scale Sliding Scale Injection QACHS: Please see sliding scale. Disp:*1 1months supply/Sliding Scale* Refills:*0* 15. Insulin Syringes (Disposable) Syringe Sig: One (1) Box Miscell. As Instructed. Disp:*1 Box* Refills:*0* 16. Alcohol Prep Pads Pads, Medicated Sig: One (1) Box Topical Use on skin prior to fingersticks and Insulin injections. . Disp:*1 Box* Refills:*0* 17. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 18. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: Type I diabetes 44 years Retinopathy Nephropathy Neuropathy Gastroparesis Spina bifida Glaucoma Anemia Right eye blindness CRI CAD s/p CABG Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 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) You may wash you incision and pat dry. No swimming or bathing until it has healed. 5) No lotions, creams or powders to wound until it has healed. 6) No lifting greater then 10 pounds for 10 weeks. 7) No driving for 1 month. 8) Please continue your regular insulin sliding scale with figer sticks before meals and at bedtime. Copy of sliding scale provided. Please continue your daily morning glargine dose of 20 Units. If your blood sugar is below 80, please drink some [**Location (un) 2452**] juice or inject [**11-19**] ampule of D50 and call your physician. [**Name10 (NameIs) **] your Blood sugar is greater then 360, please call your physician. 9) Take all medications a prescribed. 10) An ace inhibitor has been resumed at half the original dose for hypertension and proteinuria. Please have creatinine checked in 1 week when seen by cardiologist. Baseline creatinine is 2.0. Todays creatinine is 1.8. 11) Take lasix 20mg tiwce daily for five days, then stop. 12) Please call with any questions or concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 3278**] in 2 weeks. Follow-up with Dr. [**First Name (STitle) 10083**] in [**11-19**] weeks. Follow-up with Dr. [**First Name (STitle) **] in [**11-19**] weeks [**Telephone/Fax (1) 34149**] [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2188-3-14**] 2:30 [**Last Name (LF) **],[**First Name3 (LF) 1112**] W. [**Telephone/Fax (1) 170**] Follow-up appointment should be in 1 month. Please call all providers for appointments. Completed by:[**2188-2-12**]

[ "365.9", "585.9", "741.93", "584.5", "285.21", "414.01", "276.52", "428.0", "583.81", "250.51", "369.60", "536.3", "428.30", "250.61", "401.9", "357.2", "250.41", "362.01" ]

icd9cm

[ [ [] ] ]

[ "38.93", "37.23", "88.56", "39.61", "36.13", "99.04", "36.15" ]

icd9pcs

[ [ [] ] ]

14293, 14331

7477, 11340

368, 512

14515, 14522

3375, 6137

15794, 16374

11912, 14270

14352, 14494

11366, 11366

6154, 7454

14546, 15771

2988, 3356

235, 330

540, 2464

2486, 2840

2856, 2973

11384, 11889

50,757

113,667

36540

Discharge summary

report

Admission Date: [**2184-5-31**] Discharge Date: [**2184-6-28**] Date of Birth: [**2114-11-23**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2184-5-31**] Aortic valve replacement(23mm CE Magma), two vessel coronary artery bypass grafting(vein grafts to obtuse marginal and PDA), and Aortic endarterectomy [**2184-6-14**] Sternal re-exploration, Evacuation of mediastinal blood and Sternal debridement. [**2184-6-14**] Repair of sternal dehiscence and bilateral pectoralis major musculocutaneous advancement flap. [**2184-6-22**] Dobhoff tube placement History of Present Illness: Mr. [**Known lastname 1007**] is a 69 year-old male with a long history of aortic stenosis followed by serial echocardiograms, recently found to have coronary artery disease as well. He recently had been complaining of dyspnea on exertion along with chest pain and worsening fatigue. Therefore, he was referred for surgical evaluation. Preoperative evaluation was notable for a cirrhotic liver on CT scan. Workup was otherwise unremarkable and he was admitted for aortic valve replacement and coronary artery bypass grafting surgery. Past Medical History: - Aortic Stenosis/Coronary Artery Disease - Type II Diabetes Mellitus - Hypertension - Cirrhosis, Portal Hypertension, with Splenomegaly, Varices and Ascites - Psoriasis - Cataract Surgery Social History: Mr. [**Known lastname 1007**] is a custodian at a retail store. He reports smoking cigars in the past. He denies drinking alcohol. He lives with his wife. Family History: Noncontributory Physical Exam: At the time of admission, Mr. [**Known lastname 1007**] was found to be in no acute distress. 65" 185# Multiple psoriatic plaques were noted on his skin. His lungs were clear to auscultation bilaterally. His heart was of regular rate and rhythm and a III/VI murmur was noted. His abdomen was soft, non-tender, and non-distended with bowel sounds. His extremities were warm and well perfused. Superficial varicosities were noted in his left lower extremity. Neuro was grossly intact. There were 2+ bil. fem/DP/PT/radial pulses. Murmur radiated to both carotids. Pertinent Results: [**2184-6-27**] 04:38AM BLOOD WBC-8.9 RBC-3.27* Hgb-10.4* Hct-32.7* MCV-100* MCH-31.7 MCHC-31.7 RDW-16.7* Plt Ct-181 [**2184-6-28**] 03:04AM BLOOD PT-18.4* PTT-35.0 INR(PT)-1.7* [**2184-6-27**] 04:38AM BLOOD PT-19.4* INR(PT)-1.8* [**2184-6-26**] 06:13AM BLOOD PT-17.6* INR(PT)-1.6* [**2184-6-28**] 03:04AM BLOOD Glucose-108* UreaN-34* Creat-1.7* Na-147* K-4.2 Cl-113* HCO3-25 AnGap-13 [**2184-6-27**] 04:38AM BLOOD Glucose-114* UreaN-33* Creat-1.5* Na-149* K-3.9 Cl-116* HCO3-24 AnGap-13 [**2184-5-31**] Intraop TEE PRE-CPB: 1. The left atrium is normal in size. No spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %). 3. There are complex (>4mm) atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are focal calcifications in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. An epiaortic scan was performed and stored on a different machine. A single plaque was visualized in the ascending aorta adjacent to the pulmonary artery. 4. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is seen. 5. The mitral valve leaflets are moderately thickened. There is mild valvular mitral stenosis (area 1.5-2.0cm2). Trivial mitral regurgitation is seen. POST-CPB: On infusion of phenylephrine. AV pacing. There is a well-seated bioprosthetic valve in the aortic position with no regurgitation seen. A transvalvular gradient was not able to be obtained but there was no evidence of residual stenosis by color flow doppler. Biventricular systolic function is preserved. The aortic contour is normal post decannulation with no alteration seen of the plaque in the proximal aorta. [**2184-6-4**] Abd/Chest CT Scan: CT ABDOMEN: The lung bases demonstrate small bilateral pleural effusions and associated relaxation atelectasis. Heart size is normal. There is no pericardial effusion. The liver contour is nodular consistent with history of cirrhosis. Ill defined approximately 8 x 3 cm lesion in segment V demonstrates patchy peripheral enhancement. The portal vein, SMV, and splenic vein are patent. The gallbladder is unremarkable without evidence of gallstones. There is no intra- or extra- hepatic biliary dilatation. The spleen, pancreas, adrenals, kidneys are unremarkable. The SMV, splenic and portal veins are patent. Severe atherosclerotic calcifications at the origin of the celiac artery and SMA are noted . A replaced right hepatic artery arises from the SMA. Moderate splenic varices are noted. The abdominal loops of small bowel are dilated to 3.4 cm without evidence of pneumatosis, wall thickening or transition point to suggest acute obstruction. Stool is seen to the level of the rectum and there is mild colonic dilation to 5.5 cm. Scattered mesenteric and retroperitoneal nodes do not meet CT size criteria for enlargement. Stranding in the subcutaneous tissues diffusely likely represents anasarca. The kidneys enhance and excrete contrast symmetrically. CT PELVIS: The rectum, sigmoid, and prostate are unremarkable. Air within the bladder is likely secondary to foley catheterization. [**2184-6-14**] Transesophogeal ECHO: 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. No thoracic aortic dissection is seen. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis leaflets appear to move normally. There is severe mitral annular calcification. Physiologic mitral regurgitation is seen (within normal limits). There is a large pericardial effusion. The effusion appears circumferential. No right atrial diastolic collapse is seen. No right ventricular diastolic collapse is seen. Brief Hospital Course: In [**2184-5-31**], Mr. [**Known lastname 1007**] was admitted and underwent a coronary artery bypass grafting times two (SVG to OM and SVG to PDA), aortic valve replacement (23mm CE magna pericardial), aortic endartarectomy. Please see the operative note for details. He tolerated this procedure well and was transferred in critical but stable condition. On the following day the hepatology service was consulted secondary to a pre-operative CT suggesting a cirrhotic liver. This consultation revealed cryptogenic cirrhosis and portal hypertension with no liver failure. By post operative day two he was extubated and weaned from pressors. He was found to be lethargic and disoriented, but with a non-focal exam. He had atrial fibrillation which was initially treated with amiodarone but it then was stopped secondary to his poor liver function. He was transfered to the step down floor on the following day. A nasal-gastric tube was placed for a distended abdomen and a CT scan revealed an ileus. On post-operative day six, sips were initiated and a PICC was placed for access. While his mental status and ileus improved initiatially, both worsened on the 26th and he was returned to the intensive care unit and the [**Last Name (un) **]-gastric tube was replaced. With time his liver function tests improved and he passed his bowels. By post-operative day ten he was transfered back to the step down floor and TPN was begun to boost his nutrition. He had two episodes of atrial fibrillation which resolved with betablockers. His [**Last Name (un) **]-gastric tube was removed on the following day and his diet was advanced. On post-operative day 14 he was noted to have bloody drainage from his mediastinal incision, hypotension, and decrease oxygen saturation. A bedside echocardiogram revealed a circumferential pericardial effusion, so he was taken to the operating room for tamponade. The plastic surgery service joined the cardiac surgery team in the operating room and plated his sternum, performing bilateral myocutaneous advancement flaps. Please see operative note for details. He was brought to the surgical intensive care unit in critical but stable condition. ID consult done for abx management as bone culture grew coag neg. staph. Extubated again on [**6-16**]. Transferred back to the floor on POD #18/13 to begin increasing his activity level. Jaundice noted with elevated bilirubins. Serial C. Diff. cultures were negative. A bedside swallowing evaluation was done on [**6-21**] and he was cleared for ground solids and nectar thick liquids with a chin tuck and strict supervision, but it was recommended that ENT evaluate him first for his dysphonia. Since he was still too drowsy to increase his intake adequately he was fed with TPN and tube feeds for a couple of days. ENT felt on exam that Mr. [**Known lastname **] vocal cords were inflammed but not compromised. He removed his own Dobhoff tube and he began to take in food with supervision. He was diuresed and given albumin for third spacing. He was started on scheduled haldol and his mental status improved markedly. The patient was found suitable for transfer to rehab on POD 28/14. Vancomycin and rifampin are continued for a total of 6 weeks per ID recommendations. The patient was advised of appropriate follow-up. Medications on Admission: Aspirin 162, multivitamin, calcium 1200, B12 1000, omeprazole 20, lisinopril 5, zocor 40, metformin 500, lopressor 25, glipizide 2.5, iron 325, humira pen 40, clobetasol propionate Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet [**Known lastname **]: One (1) Tablet PO BID (2 times a day). 2. Haloperidol 1 mg Tablet [**Known lastname **]: One (1) Tablet PO BID (2 times a day). Tablet(s) 3. Aspirin 81 mg Tablet, Chewable [**Known lastname **]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Known lastname **]: One (1) Inhalation Q6H (every 6 hours). 5. Rifampin 300 mg Capsule [**Known lastname **]: One (1) Capsule PO Q12H (every 12 hours) for 4 weeks. 6. Glipizide 5 mg Tablet [**Known lastname **]: 0.5 Tablet PO BID (2 times a day). 7. 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. 8. Furosemide 40 mg IV BID Start: In am 9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 11. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 12. Metoclopramide 10 mg IV Q8H:PRN nausea 13. Vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: 2.5 Intravenous Q 24H (Every 24 Hours) for 4 weeks: trough goal 15-20, vancomycin 1250mg IV q24h. 14. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection ASDIR (AS DIRECTED): see attached sliding scale. 15. Outpatient Lab Work weekly LFTs, CBC w diff, chem 7, ESR, CRP results to Dr. [**Last Name (STitle) **] ([**Hospital **] clinic) fax: ([**Telephone/Fax (1) 1353**] Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Aortic stenosis coronary artery disease s/p aortic valve replacement,aortic endarterectomy & coronary artery bypass graft X 2 sternal dehiscence and wound infection atrial fibrillation tamponade hypertension psoriasis noninsulin dependent diabetes mellitus hypercholesterolemia prior IMI Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) 914**] (cardiac surgery)in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (PCP) in [**1-16**] weeks ([**Telephone/Fax (1) 3183**]) Dr. [**First Name (STitle) **] (plastic surgery) in 1 week [**Telephone/Fax (1) 1416**] weekly labs to [**Hospital **] clinic Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2184-9-22**] 11:00 Provider: [**Name10 (NameIs) 12082**] CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2184-7-19**] 1:30 Completed by:[**2184-6-28**]

[ "867.0", "560.1", "414.01", "427.31", "571.5", "572.3", "696.1", "276.0", "440.0", "401.1", "424.1", "276.1", "423.3", "998.31", "584.9", "E879.6", "577.0", "276.6", "998.59", "998.11", "730.08", "250.00", "997.4" ]

icd9cm

[ [ [] ] ]

[ "38.91", "36.12", "77.61", "38.14", "99.15", "35.21", "34.03", "83.82", "39.61", "00.40", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

12097, 12169

6790, 10118

341, 757

12500, 12506

2345, 6767

12910, 13581

1725, 1742

10349, 12074

12190, 12479

10144, 10326

12530, 12887

1757, 2325

282, 303

785, 1322

1344, 1534

1550, 1709

72,260

148,924

8577

Discharge summary

report

Admission Date: [**2123-4-15**] Discharge Date: [**2123-4-20**] Date of Birth: [**2057-3-24**] Sex: M Service: SURGERY Allergies: IV Dye, Iodine Containing Attending:[**First Name3 (LF) 1**] Chief Complaint: Left Sided Abdominal Pain Major Surgical or Invasive Procedure: Exploratory laparotomy, extensive lysis of adhesions, small bowel resection with primary anastomosis. History of Present Illness: 66yo male with a history of SBR '[**14**] for Meckel's diverticulum by Dr. [**Last Name (STitle) **]. Has been in usual state of health until yesterday evening, when developed Left sided abdominal pain while beginning dinner. Pain described as crampy and intermittent, [**5-17**]. He endorses nausea and dry heaves, no frank emesis. Last BM 2 days ago, no flatus either since symptoms started. Patient presented to PCP who referred to [**Hospital1 18**] ED for suspected SBO; work-up included labs and CT, leading to surgical consultation. NGT placed and pain controlled with morphine. Past Medical History: PMH: NIDDM, HTN, hyperchol, CRI (baseline Cr 1.2) PSH: ex-lap + SBR '[**14**] ([**Doctor Last Name **]) for obstructing Meckel's diverticulum Social History: Former smoker, quit 30y ago after 0.5ppd x15y. He endorses nightly EtOH ([**2-10**] drinks of scotch-and-water). Mr. [**Known lastname **] lives with his wife and daughter's family in [**Location (un) 2624**]. Retired from [**Company 2318**] Family History: No cancers, GI disorders, nor DM Physical Exam: (On presentation) PE: 96.5 80 112/52 16 97 on RA A&Ox3, NAD. WD WN. fatigues and uncomfortable appearing CTAB RRR soft, mildly distended. tap tenderness along L-side of abdomen. tender to palpation in same area, with referred pain to L-side when palpated elsewhere. no rebound nor guarding. no inguinal hernias. WWP sans c/c/e Pertinent Results: [**2123-4-15**] 03:30PM BLOOD WBC-10.4# RBC-5.43 Hgb-16.3 Hct-47.2 MCV-87 MCH-29.9 MCHC-34.4 RDW-13.7 Plt Ct-278 [**2123-4-16**] 01:23AM BLOOD Hct-33.6* [**2123-4-16**] 06:34AM BLOOD WBC-6.3 RBC-3.56*# Hgb-10.3*# Hct-30.2* MCV-85 MCH-29.1 MCHC-34.2 RDW-14.3 Plt Ct-159 [**2123-4-16**] 02:26PM BLOOD WBC-5.3 RBC-3.49* Hgb-10.0* Hct-29.4* MCV-84 MCH-28.6 MCHC-34.0 RDW-14.0 Plt Ct-142* [**2123-4-17**] 02:05AM BLOOD WBC-6.4 RBC-3.83* Hgb-11.2* Hct-34.7* MCV-91# MCH-29.2 MCHC-32.2 RDW-14.0 Plt Ct-121* [**2123-4-15**] 03:30PM BLOOD Glucose-183* UreaN-35* Creat-1.6* Na-133 K-5.2* Cl-92* HCO3-26 AnGap-20 [**2123-4-15**] 11:05PM BLOOD Glucose-235* UreaN-32* Creat-1.3* Na-134 K-4.8 Cl-103 HCO3-19* AnGap-17 [**2123-4-16**] 06:34AM BLOOD Glucose-151* UreaN-34* Creat-1.9* Na-137 K-5.0 Cl-104 HCO3-24 AnGap-14 [**2123-4-16**] 02:26PM BLOOD Glucose-117* UreaN-25* Creat-1.5* Na-137 K-5.0 Cl-103 HCO3-27 AnGap-12 [**2123-4-17**] 02:05AM BLOOD Glucose-114* UreaN-17 Creat-1.2 Na-133 K-5.5* Cl-104 HCO3-19* AnGap-16 [**2123-4-18**] 07:00AM BLOOD Glucose-177* UreaN-12 Creat-0.9 Na-137 K-4.9 Cl-104 HCO3-29 AnGap-9 [**2123-4-15**] 11:05PM BLOOD CK(CPK)-60 [**2123-4-16**] 06:34AM BLOOD CK(CPK)-77 [**2123-4-16**] 02:26PM BLOOD CK(CPK)-225 [**2123-4-15**] 03:30PM BLOOD Lipase-59 [**2123-4-15**] 03:30PM BLOOD cTropnT-0.05* [**2123-4-16**] 06:34AM BLOOD CK-MB-NotDone cTropnT-0.04* [**2123-4-16**] 02:26PM BLOOD CK-MB-7 cTropnT-0.03* [**2123-4-15**] 03:33PM BLOOD Lactate-2.4* K-5.2 KUB: Findings concerning for small-bowel obstruction. Further evaluation with CT enterography is recommended. CT Abd/Pelvis: : Small-bowel obstruction with transition point in the left lower quadrant with mesenteric edema and stranding. Brief Hospital Course: Mr. [**Known lastname **] presented to the [**Hospital1 18**] ED with symptoms concerning for a complete small bowel obstruction. Given his presentation, the decision was made to proceed to the operating room for surgical management. Mr. [**Known lastname **] [**Last Name (Titles) 1834**] an exploratory laparotomy, extensive lysis of adhesions and small bowel resection with primary anastomosis. Post-operatively, Mr. [**Known lastname **] was noted to have hypotension and low urine output in the PACU. He was resucitated with IVF and albumin. However, his blood pressure and urine output remained low. The patient refused a central line and neosynephrine was started peripherally. Cardiac enzymes demonstrated a rise in troponin and his creatinine rose as well. He was transferred to the SICU for closer monitoring. He received additional fluid resuscitation and a bedside echo was performed to assess the patient's fluid status. After adequate fluid resucitation, the patient remained off pressors. His blood pressure and urine output improved. In addition, the patient's troponin and creatinine improved. Mr. [**Known lastname **] was transferred out of the ICU on POD#2. His NG tube was removed and his diet was slowly advanced once his bowel function returned. The patient's pain was initially controlled with a PCA, but was transitioned to PO pain meds once he started to tolerate a diet. Mr. [**Known lastname **] met all milestones for discharge on POD#5. He was cleared for home by Physical Therapy. He was discharged home in stable condition on POD#5. Medications on Admission: ASA 81 Daily Norvasc 2.5 Daily lisinopril 40 Daily Lasix 20 Daily Actos 45 Daily zocor 20 daily Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day. 3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day: Do not re-start until seeing Primary care physician. 8. Norvasc 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Do no re-start until seeing primary care physician. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr. [**Last Name (STitle) **] for follow-up in [**1-9**] weeks. You may resume your prior diet as tolerated, no strenuous/vigorous activity. Continue to ambulate several times per day. Resume all prior home medications unless otherwise instructed, take all new medications as prescribed. Call the office if you notice redness/drainage from the wound, or low grade fevers. If you experience any of the following symptoms go directly to the emergency room; chest pain, shortness of breath, severe pain not relieved by medication, intractable nausea/vomiting or any other concerning symptoms. Your blood pressure has been well-controlled during your hospital stay, see your primary care physician this week before resuming your home blood pressure medications (norvasc, lisinopril. You may shower, allow water to run over wound, and pat dry, no tub baths, no swimming/soaks. Followup Instructions: Call for follow-up with Dr. [**Last Name (STitle) **] in [**1-9**] weeks; ([**Telephone/Fax (1) 30111**] Completed by:[**2123-4-28**]

[ "E879.8", "569.89", "403.90", "585.9", "250.00", "999.82", "458.29", "E849.7", "272.0", "560.81" ]

icd9cm

[ [ [] ] ]

[ "45.62", "54.59" ]

icd9pcs

[ [ [] ] ]

6167, 6173

3612, 5181

308, 412

6241, 6241

1876, 3589

7294, 7430

1474, 1509

5327, 6144

6194, 6220

5207, 5304

6392, 7271

1524, 1857

243, 270

440, 1031

6256, 6368

1053, 1197

1213, 1458

18,426

138,840

6036

Discharge summary

report

Admission Date: [**2190-2-23**] Discharge Date: [**2190-2-25**] Date of Birth: [**2123-1-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Planned right carotid stent placement for asymptomatic 80% stenosis. Major Surgical or Invasive Procedure: Catheterization and carotid stent placement. History of Present Illness: 67 year-old male with diabetes, hypertension, hyperlipidemia, CAD s/p LAD and Lcx stents in [**2182**], and right carotid stenosis admitted to the CCU after right carotid stent placement with subsequent labile blood pressures. The right carotid stenosis was discovered after he was noted to have a carotid bruit by Dr. [**Last Name (STitle) **]. The patient was asymptomatic. Work-up for carotid bruit included carotid ultrasound with right peak systolic velocities 332, 79, and 109 cm/sec in the ICA, CCA, and ECA respectively, with peak ICA end-diastolic velocity 117. MRI/MRA neck [**2189-12-27**] which showed a high grade and critical, greater than 95% stenosis involving the suprabulbar right ICA, 1 cm above the right carotid bifurcation in the neck. CTA head and neck [**2190-2-5**] showed 60% short segment focal stenosis within [**Country **] without left-sided stenosis. He was referred for percutaneous carotid intervention as part of the CREST study. He has been seen by Dr. [**Last Name (STitle) 911**] as well as Dr. [**Last Name (STitle) **] from neurology for his pre-procedure evaluation. . Catheterization revealed no significant left vertebral disease. The bifurcation of the [**Doctor First Name 3098**]/ECA had mild disease. The [**Country **] had an 80-85% stenosis. There was no significant intracranial disease and there was cross filling via a patent ACOM. An Acculink stent was placed to the right carotid. Final angiography revealed <40% residual stenosis with no dissection or angiographic embolization. The patient was placed on neosynephrine gtt for hypotension which was titrated up to 0.6mcg/kg, although the patient's blood pressure was labile with systolics as high as 200 off neosynephrine. . On cardiac ROS, patient denies chest pain, dyspnea on exertion, claudication, PND, orthopnea, edema, lightheadedness, paroxysmal nocturnal dyspnea, palpitations, syncope or presyncope. The patient denied neurologic complaints. Review of systems otherwise negative in detail. Past Medical History: 1. Coronary artery disease with IMI [**4-/2183**] status post stent to LCX and LAD 2. Hypertension 3. Hyperlipidemia 4. Diabetes 5. Glaucoma Social History: No tobacco or alcohol use. Family History: The patient's sister underwent CABG at age 62. Mother died of CAD at age 83. No family history of sudden death. Physical Exam: VITALS: BP 148/83 HR 86 RR 18 GENERAL: Breathing comfortably, in no acute distress HEENT: Pink conjunctiva NECK: JVP 8cm, no thyromegaly LUNGS: CTAB, no adventitous breath sounds HEART: PMI 5th intercostal space, mid-clavicular line. RRR, normal S1S2 with no M/R/G ABDOMEN: Soft, NABS, non-distended, non-tender, no hepatosplenomegaly EXTREMITIES: No cyanosis or clubbing, trace edema LE SKIN: No stasis dermatitis or ulcers PULSES: Right: Carotid not palpated due to sensitivity but no bruit; femoral arterial line in place, DP 1+ PT 1+ Left: Carotid 2+ DP 1+ PT 1+ Pertinent Results: Labwork on admission: [**2190-2-23**] 07:46PM PLT COUNT-258 [**2190-2-23**] 07:46PM CK-MB-NotDone cTropnT-<0.01 [**2190-2-23**] 07:46PM CK(CPK)-48 [**2190-2-23**] 07:46PM POTASSIUM-4.1 [**2190-2-24**] 06:10AM BLOOD Glucose-132* UreaN-22* Creat-1.1 Na-138 K-4.1 Cl-106 HCO3-22 AnGap-14 . ECG Study Date of [**2190-2-23**] 11:16:30 AM Sinus bradycardia. Incomplete right bundle-branch block. Left anterior fascicular block. Since the previous tracing of [**2186-5-8**] probably no significant change. . C.CATH Study Date of [**2190-2-23**] COMMENTS: 1) Diagnostic angiography revealed a Type 1 aortic arch with no signficant disease. The left vertebral and left [**Doctor First Name 3098**]/ECA/CCA had no significant disease. There was some cross filling by the posterior and anterior communicating arteries. The right ICA had an 80-85% stenosis. 2) Successful PTCA and stenting of the R ICA with a 7.0/10 tapered x30 mm Acculink stent which was postdilated up to 5.0 mm. Final angiography revealed <30% residual stenosis, no dissection, and normal flow. . CHEST (PORTABLE AP) [**2190-2-24**] Compared with [**2186-5-8**], there is a new contour abnormality in the region of the ascending aorta and azygos vein. There is no pneumothorax, cardiomegaly, consolidation, or pleural effusion. . Labwork on discharge: [**2190-2-25**] 04:30AM BLOOD WBC-12.1* RBC-3.36* Hgb-10.6* Hct-29.8* MCV-89 MCH-31.5 MCHC-35.6* RDW-12.9 Plt Ct-218 [**2190-2-25**] 04:30AM BLOOD Glucose-138* UreaN-20 Creat-1.0 Na-142 K-4.0 Cl-109* HCO3-23 AnGap-14 Brief Hospital Course: 67 year-old male with coronary artery disease status post LCx/LAD stents, type II diabetes, admitted for right carotid stent placement for asymptomatic right carotid stenosis as part of CREST study. . 1. Right carotid stenosis: The patient was found to have an 80% ICA stenosis on catheterization. The patient is status post stent without immediate complications. The patient's blood pressure and heart rate were labile during hospitalization secondary to baroreceptor irritation and the patient was monitored in the CCU for 36 hours. The patient was given neosynephrine as needed to keep systolic blood pressure 100-140. The patient's heart rate became as low as 29 during sleep. The patient's vagal response improved with intravenous fluids and exertion. The patient was instructed to hold all anti-hypertensives until blood pressure check at his primary care physician's office. The patient was continued on aspirin, plavix, and vytorin. The patient will follow-up with Drs. [**Last Name (STitle) 911**] and [**Name5 (PTitle) **]. . 2. Possible ascending aortic aneursym: The patient was noted to have a possible ascending aortic aneursym on chest X-ray as above. The patient will have an outpatient MRI/MRA chest for further evaluation. . 3. Coronary artery disease: No active issues during hospitalization. The patient was continued on aspirin, plavix, and vytorin. The patient's beta-blocker and ACE-inhibitor were held for hypotension as above. . 4. Pump: Diastolic heart failure. The patient was euvolemic during hospitalization. The patient's lasix was held for hypotension as above. The patient was instructed to hold his beta-blocker and lasix until blood pressure check at his primary care physician's office. . 5. Rhythm: The patient remained in sinus rhythm with bradycardia to 29 as above during hospitalization without other events on telemetry. The patient's beta-blocker was held as above. . 6. Diabetes mellitus, type II: The patient's metformin was held for 48 hours after contrast administration during catheterization. The patient's ACE-inhibitor was held as above. . 7. Glaucoma: The patient was continued on his outpatient regimen. . Code: Full. Medications on Admission: Aspirin 325mg daily Plavix 75 [**Hospital1 **] -Sun and Monday Vytorin 10/40mg daily Diovan 160mg daily Furosemide 20mg daily Lisinopril 40mg daily Metoprolol 200mg [**Hospital1 **] Glucophage 1000mg [**Hospital1 **] Xalatan eye gtts 1 gtt both eyes qhs Alphagan eye gtts-1gtt both eyes [**Hospital1 **] Cosupt eye gtts-1 gtt both eyes [**Hospital1 **] Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Right internal carotid stenosis status post stent 2. Possible ascending aortic aneursym . Secondary: 1. Coronary artery disease with IMI [**4-/2183**] status post stent to LCX and LAD 2. Hypertension 3. Hyperlipidemia 4. Diabetes 5. Glaucoma Discharge Condition: Afebrile, vital signs stable. Discharge Instructions: You were hospitalized after a procedure to stent your carotid artery. You will have some changes in your blood pressure and heart rate for the next few days because of this. You should hold metoprolol, lisinopril, diovan, and lasix until your blood pressure is rechecked. . While hospitalized, a chest X-ray showed a possible aortic aneursym. Please call the number below to schedule an MRI chest for follow-up. . Please contact a physician if you experience fevers, chills, chest pain, shortness of breath, or any other concerning symptoms. . Please take your medications as prescribed. - Please hold metoprolol, lisinopril, diovan, and lasix until your blood pressure is rechecked. - You can restart metformin tomorrow. . Please keep your follow-up appointments as below. Followup Instructions: Follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 4559**] [**Last Name (NamePattern1) 58**], on Monday, [**3-1**] at 1:00 pm. You will have your blood pressure checked at this time and can discuss restarting your blood pressure regimen. . Please call [**Telephone/Fax (1) 327**] to schedule an MRI of the chest to assess for possible aortic aneursym. . Previously scheduled appointments: Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2190-3-23**] 11:00 . Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2190-3-23**] 1:30 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2190-4-1**] 1:20

[ "414.00", "458.9", "428.0", "357.2", "401.9", "428.30", "V45.81", "433.10", "250.60", "272.0" ]

icd9cm

[ [ [] ] ]

[ "00.40", "88.41", "38.91", "00.61", "00.45", "00.63" ]

icd9pcs

[ [ [] ] ]

7567, 7573

4989, 7162

384, 431

7871, 7903

3422, 3430

8725, 9595

2702, 2816

7594, 7850

7188, 7544

7927, 8702

2831, 3403

4748, 4966

276, 346

459, 2478

3444, 4734

2500, 2642

2658, 2686

74,223

119,946

47549+59013

Discharge summary

report+addendum

Admission Date: [**2125-1-1**] Discharge Date: [**2125-1-8**] Date of Birth: [**2045-11-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: cough, hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 79 y/o M of PMHx of Atrial Fib, Diastolic CHF, Hypertrophic CMP, CAD s/p stenting and hyperthyroidism who presented to the ED with 4 days of productive cough, shortness of breath, progressive DOE, low grade fevers/chills and decreased appetite. In the ED, initial VS were: T 100.1 P 100 BP 155/106 RR 20 Sats 90% on RA. Initial EKG revealed rapid afib and HR trended up into 150-180s, pt was started on dilt gtt at 5mg/hr which acheived good rate control. Portable CXR showed pulmonary edema & possible RUL opacity. Labs revealed a troponin of 0.06, CK 181, MB 3 and lactate of 2.8 that came down to 2.2 after 2L of NS IVF. Pt received Aspirin 325mg, Ceftriaxone 1gram & Levofloxacin 750mg for possible RUL infiltrate. On arrival to the ICU, pt was feeling better but still reporting cough, congestion and shortness of breath. Pt also reported some new abdominal fullness, decreased appetite and subjective fever/chills. He had possible sick contacts from a wake he attended last week. He denied CP but reported orthopnea and progressive DOE. Past Medical History: -Chronic permanent atrial fibrillation -CAD s/p cardiac cath [**2121**] showing a 95% lesion in the proximal LAD, which was stented with a Cypher stent -Prior concern for amyloid cardiomyopathy (had had marked LVH with very enlarged right and left atria). s/p negative abdominal wall fat biopsy [**11/2122**] (Fibroadipose tissue; no diagnostic abnormalities recognized; amyloid stains are negative. The controls are appropriate) -Hypertrophic obstructive cardiomyopathy. An echocardiogram in [**2123-4-30**] showed an LVEF > 65% with a peak resting LVOT gradient of 40 mmHg. This gradient is slightly higher than it had been seen in [**2122-8-30**]. -Chronic wheezing and asthmatic-type symptoms. -Eosinophilia. -Possible strongyloidiasis leading to eosinophilia and even pulmonary symptoms. Treated with ivermectin 25 mg per day for two days -FVC of 60% predicted and FEV1 of 69% predicted. It was no significant change with bronchodilator. -HTN -Hypercholesterolemia -Hyperthyroidism -BPH -OA s/p total knee replacement -OSA on BiPAP at home -pulmonary artery is significantly enlarged at 5.3 cm as well as an enlarged ascending aorta of 4.5 cm Social History: Lives alone at home, completely independent in ADLs. Has a live-in house keeper. Smoked 1ppd x 20yrs, quit 20 yrs ago. [**12-1**] glasses of wine per night. Family History: Mother died of heart disease at young age. Brother has [**Name2 (NI) 499**] ca and CAD. Son recently died of [**Name2 (NI) 499**] ca in his 50's. Physical Exam: Vitals: T: 99.6 BP: 118/88 P: 100 R: 28 O2: 96% on 4L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated to below ear, no LN Lungs: crackles bilaterally [**12-1**] way up posterior lung [**Last Name (un) 18100**], diffuse insp & expiratory wheezes, scattered rhonchi, coughing through exam CV: Irreg/irreg, intermittent S3, gr 2-3 SEM over LSB. Abdomen: soft, NABS, distended, no rebound tenderness or guarding Ext: Warm, 2+ pulses, no apprec. edema Pertinent Results: [**2125-1-1**] 02:05PM BLOOD WBC-7.1 RBC-4.84 Hgb-14.4 Hct-43.0 MCV-89 MCH-29.8 MCHC-33.5 RDW-16.6* Plt Ct-163 [**2125-1-2**] 04:59AM BLOOD WBC-5.7 RBC-4.73 Hgb-13.6* Hct-41.1 MCV-87 MCH-28.7 MCHC-33.0 RDW-16.4* Plt Ct-143* [**2125-1-1**] 02:05PM BLOOD Glucose-181* UreaN-29* Creat-1.4* Na-140 K-3.9 Cl-100 HCO3-24 AnGap-20 [**2125-1-2**] 04:59AM BLOOD Glucose-134* UreaN-29* Creat-1.4* Na-141 K-3.7 Cl-101 HCO3-29 AnGap-15 [**2125-1-1**] 02:05PM BLOOD CK(CPK)-181* [**2125-1-2**] 04:59AM BLOOD CK(CPK)-385* [**2125-1-2**] 12:52PM BLOOD CK(CPK)-383* [**2125-1-1**] 02:05PM BLOOD cTropnT-0.06* [**2125-1-2**] 04:59AM BLOOD CK-MB-5 cTropnT-0.08* [**2125-1-2**] 12:52PM BLOOD CK-MB-6 cTropnT-0.09* [**2125-1-1**] 02:09PM BLOOD Lactate-2.8* [**2125-1-1**] 03:09PM BLOOD Lactate-2.2* [**2125-1-2**] 05:25AM BLOOD Lactate-1.7 Micro: [**2125-1-4**] BLOOD CULTURE Blood Culture, Routine-NGTD [**2125-1-3**] BLOOD CULTURE Blood Culture, Routine-NGTD [**2125-1-3**] URINE Legionella Urinary Antigen - negative [**2125-1-2**] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-FINAL; Rapid Respiratory Viral Antigen Test- positive for RSV [**2125-1-2**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN TEST-neg; DIRECT INFLUENZA B ANTIGEN TEST-neg [**2125-1-1**] URINE Legionella Urinary Antigen - negative [**2125-1-1**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] [**2125-1-1**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Anaerobic Bottle Gram Stain-FINAL EMERGENCY CXR [**2125-1-1**]: Stable cardiomegaly with mild CHF. TTE [**2125-1-4**]: IMPRESSION: Severe symmetric left ventricular hypertrophy with a small LV cavity and preserved systolic function. Dilated and hypertrophied right ventricle with mild systolic dysfunction. Mild aortic regurgitation. Moderate mitral regurgitation. Compared with the prior study (images reviewed) of [**2124-7-25**], severity of mitral regurgitation may be slightly worse. The other findings appear similar. CXR [**2125-1-7**]: New right lower lobe consolidation which could be pneumonia in the appropriate clinical setting. Brief Hospital Course: A/P: 79 yo male with pmh of chronic a.fib, hypertrophic obstructive cardiomyopathy, CAD s/p stent, hyperthyroidism, and diastolic HF who presented with cough, progressive dyspnea now with RSV bronchiolitis complicated by PNA. # RSV bronchiolitis/Hypoxia: His inital dyspnea and hypoxia were likely due to RSV bronchiolitis as the viral screen returned RSV positive. [**Month (only) 116**] also have a component of underlying lung disease contriubuting to his dyspnea. The PNA (as below) may also be contributing to his hypoxia. By the end of his hospitalization he was also slightly volume overloaded. By discharge he was able to maintain RA sats in the mid 90's and dropped to the low 90's on RA with ambulation. He was given a few doses of IV lasix for diuresis and was discharged on his home lasix regimen of 40 mg daily. He was treated with standing xopenex and atrovent nebs as well as flovent. He was discharged on his home advair as well as albuterol inhaler prn. By discharge he was no longer short of breath and had no DOE. # PNA: The patient was noted to have new crackles on exam a few days prior to admission and underwent a CXR which showed a new RML infiltrate likely representing PNA. This was thought to be a community-aquired PNA as there had been a slight suggestion of PNA on his admission CXR. Likely secondary to his RSV bronchiolitis. He was discharged to complete a 5 day course of levofloxacin 750 mg daily. # Atrial Fibrillation: The patient presented in the ED with HR of 100 and developed rapid Afib in the ED. He was started on a Dilt gtt and his rate came down to 100s. He was adimtted to the MICU on the dilt gtt and weaned off overnight and transitioned to PO home meds. TSH WNL. He is on coumadin at home. Metoprolol increased due to persistent a.fib with occasional RVR. Prior to discharge he was started on diltiazem 30 mg qid and placed back on metoprolol XL 100 mg daily. He was discharged on diltiazem 120 mg daily and metoprolol 100 mg daily. He will have telemonitoring so that his vital signs can be monitored occasionally by his PCP from home. He will also follow up with his PCP two days after discharge. # Supratherapeutic INR/hematuria: On admission he was found to have a supratherapeutic INR. His coumadin was held, however given his poor po intake while ill, his INR remained elevated for a few days. During this time he developed hematuria due to foley trauma. His foley was pulled and the hematuria slowly resolved. He was placed back on coumadin once his INR dropped between [**1-2**] and will need frequent INR checks as an outpatient as he was on levofloxacin for PNA. He was discharged on a lower coumadin dose of 3 mg daily due to the levofloxacin. His INR/coumadin dosing is followed by his PCP. # Positive blood cx: The patient was found to have [**1-3**] gram + cocci on admission BCx shortly after admission, however the speciation returned only with 1/4 coag-neg staph. He was initally empirically treated with vancomycin while speciation was pending, however given his lack of source for bacteremia at the time, lack off fever, leukocytosis, and speciation to coag-neg Staph, it was thought that the positive culture was contamination. Vancomycin was stopped after 48 hrs when more recent blood cultures remained clear. A TTE was checked and showed no vegetations. # Chronic Diastolic CHF/HOCM: The patient has known severe HOCM and diastolic CHF. He underwent a TTE here which was stable with normal systolic function and only slightly worse MR. During his hospitalization he was alernatively dry and wet and his lasix was held/given depending on his fluid status. He was discharged on his metoprolol, olmesartan, and home lasix doses. # CAD: The patient had a.fib with RVR in the ED and was found to have slightly elevated troponins. He denied chest pain throughout his hospitalization. CE reveal slightly elevated trops, but his CKs were flat and his EKG was without ischemic changes. Pt noted to have Afib with RVR in [**Last Name (LF) **], [**First Name3 (LF) **] his isolated elevation in trop may be due to acute renal failure vs demand ischemia in setting of RVR and hypoxia. He was continued on his ASA, metoprolol (as above), and atorvastatin. # Hyperthyroid: The patient was continued on his home medication of tapazole 5 mg daily. # Hypertension: The patient was not hypertensive during this admission. He was given valsartan 80 mg daily while hospitalized, but discharge back on olmesartan 20 mg daily (as olmesartan isn't carried in this hospital). He was treated with metoprolol as above. # OSA: The patient was continued on CPAP at night. # BPH: The patient was continued on flomax. # CODE: DNR/DNI, confirmed with the patient. Medications on Admission: Vitamin D 5000 units every other week Lipitor 80 mg daily Flomax 0.4 mg daily Benicar 20 mg daily Tapazole 5 mg daily Aspirin 325 mg daily Furosemide 40 mg daily Omeprazole 40 mg daily Iron 325mg daily Advair inhaler (fluticasone 230 mcg, salmeterol 21 mcg) 1 puff [**Hospital1 **] Toprol 100mg daily Coumadin variable dosing Osteobiflex (vitamin) daily Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary - RSV bronchiolitis Pneumonia- community acquired secondary infection Atrial fibrillation with rapid heart rates Secondary - Obstructive sleep apnea Chronic diastolic heart failure Hypertrophic obstructive cardiomyopathy Hypertension Coronary artery disease Discharge Condition: Stable, satting 95-96% on RA, 90% on RA with ambulation. Discharge Instructions: You were admitted to the hospital with shortness of breath and found to have an infection with RSV virus (respiratory synctial virus). You were treated with nebulizer treatments and slowly improved. You were also found to have a pneumonia and are being treated with antibiotics which you will need to finish as an outpatient. During your hospitalization you were noted to have elevated heart rates due to your atrial fibrillation. You were started on a new medication called diltiazem. Medication changes: 1. You were started on a new medication called diltiazem which you will need to take 120 mg daily. 2. You can take 600 mg of mucinex twice daily to help break up congestion in your lungs. 3. Take 1-2 puffs of albuterol as needed every 4-6 hours for wheezing or shortness of breath. 4. You will need to complete a course of antibiotics for the PNA you were found to have: levofloxacin 750 mg daily for 3 more days. Otherwise continue your outpatient medications as prescribed. 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 fevers, chills, chest pain, increasing shortness of breath, blood in your stool, continued blood in your urine, or black stool. Followup Instructions: An appointment was made for you to follow up with your primary doctor, Dr. [**First Name (STitle) 1395**] ([**Telephone/Fax (1) 2205**]): Wednesday [**1-10**] at 1:45. It is very important that you keep this appointment. You will also need to have your INR checked on Wednesday so that you can be instructed what dose of coumadin to take. Please keep your previously scheduled appointments: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2125-1-30**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2125-1-30**] 12:00 Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2125-2-1**] 2:30 Completed by:[**2125-1-9**] Name: [**Known lastname 5087**],[**Known firstname 16156**] Unit No: [**Numeric Identifier 16157**] Admission Date: [**2125-1-1**] Discharge Date: [**2125-1-8**] Date of Birth: [**2045-11-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 211**] Addendum: Addendum to the [**Hospital 1325**] hospital course: # Acute on chronic diastolic heart failure: The patient initally presented with evidence of volume overload on exam and with an elevated BNP. His initial hypoxia was partially thought to be due to an acute exacerbation of his chronic diastolic heart failure. He was treated with diuresis and his volume overload was felt to have mostly resolved by discharge. He was discharged on his home dose of po lasix. Discharge Disposition: Home With Service Facility: [**Hospital 136**] Homecare [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**] Completed by:[**2125-1-30**]

[ "425.1", "V43.65", "486", "599.70", "428.0", "427.31", "466.11", "790.92", "428.33", "414.01", "242.90", "V45.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14398, 14611

5642, 10395

327, 334

11168, 11227

3478, 5619

12591, 13944

2774, 2922

10878, 11147

10421, 10776

13962, 14375

11251, 11742

2937, 3459

11762, 12568

273, 289

362, 1409

1431, 2582

2598, 2758

77,037

165,588

34977

Discharge summary

report

Admission Date: [**2185-7-27**] Discharge Date: [**2185-8-4**] Date of Birth: [**2164-11-10**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Vancomycin Attending:[**First Name3 (LF) 668**] Chief Complaint: end stage renal disease admitted for renal transplant Major Surgical or Invasive Procedure: [**2185-7-27**] renal transplant History of Present Illness: Patient is a 20-year-old female with ESRD secondary to congenital small right kidney and significant scarring of the left kidney from recurrent infections in childhood. She has been on hemodialysis for one year ([**5-30**]) using a right forearmarm AV fistula (created [**9-29**]) every T-Th-S, at Fresenius [**Location (un) 50909**]. Her last dialysis session was the day prior to admission. Her EDW at admission was 80.5. Patient was hospitalized last week with a UTI. She received IV antibiotics and completed a regimen of Cipro on the day prior to admission. On admission she denied any further urgency, dysuria or cloudy urine and has been afebrile. She has been taking coumadin as she "clots machine off" on dialysis. Past Medical History: - hypertension - ovarian cyst (s/p dermoid ovarian cystectomy) - AVF creation - congenitally small kidneys, right smaller than left Social History: Lives at home with parents, single, currently not working. Denies smoking, ETOH, or illicits. No herbal medications. Family History: Her father had a CABG, diabetes, hypertension, hypercholesterolemia. Mother died of breast cancer. Physical Exam: VSS General: WD/WN, no acute distress, pleasant HEENT: EOMI, PERRL Card: RRR, no M/R/G Lungs: CTA bilaterally Abd: Soft, non-tender, +BS, obese, post-surgical low abdominal incision c/d/i Extr: Right forearm AVF + bruit and thrill, no edema in extremities, + femoral and DPs Neuro: no focal deficits, appropriate, CN II - XII grossly intact Skin: no rashes, warm and dry Pertinent Results: admission [**2185-7-27**]: URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011 URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-SM URINE RBC-1 WBC-83* BACTERIA-FEW YEAST-NONE EPI-1 UREA N-29* CREAT-4.4*# SODIUM-143 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-31 ANION GAP-14 ALT(SGPT)-13 AST(SGOT)-8 ALBUMIN-4.2 CALCIUM-9.7 PHOSPHATE-3.9# MAGNESIUM-2.0 WBC-13.7* RBC-3.52* HGB-10.7* HCT-33.7* MCV-96 MCH-30.5 MCHC-31.9 RDW-14.0 PLT COUNT-264 PT-45.8* PTT-35.5* INR(PT)-4.9* discharge [**2185-8-3**]: WBC-5.9 RBC-2.81* Hgb-8.7* Hct-25.8* MCV-92 MCH-31.0 MCHC-33.7 RDW-13.4 Plt Ct-164 Plt Ct-164 Glucose-111* UreaN-108* Creat-6.1* Na-137 K-4.3 Cl-103 HCO3-19* AnGap-19 Albumin-PND Calcium-9.2 Phos-5.8* Mg-2.4 tacroFK-9.5 imaging: Brief Hospital Course: On [**2185-7-27**], she underwent cadavaric renal transplant. A double J ureteral stent was placed. Urine was made immediately (44-60cc/hr). [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed in the retroperitoneum. Induction immunosuppression was given (solumedrol, cellcept and ATG). Please refer to operative note for complete details. Postop, she was transferred to the SICU when she became hypoxic with O2 sat in 80s and HR 120s. CXR showed pulmonary edema. Cardiac enzymes were sent and were negative. Lasix was given without much change. Nephrology was consulted and recommended dialysis for delayed graft function. U/S of the kidney showed normal vasculature and no hydronephrosis. Respiratory status improved some with dialysis with 2 liters removed, but ATG was suspected as possible cause of pulmonary edema/reaction as she had been exposed to rabbits as a child. Subsequent ATG doses were infused at a slower rate. A total of 5 doses were given. A V/Q scan was done to assess for PE. Findings suggested a low probability of PE. LENIS were negative for DVT. She still had O2 requirements. Higher doses of Lasix were administered. A TTE was done showing LVEF >75% with moderate pulmonary htn. CXR showed increased opacities from previous CXR. She continued to require a facemask. She was hypertensive requiring several antihypertensives to control BP (labetalol drip). Home doses of labetalol and clonidine were resumed and adjusted. Norvasc was added and intermittent Hydralazine was added with improved BP control. A standing dose of lasix was given. Urine output slowly increased. Creatinine started to trend down on postop day 9 to 4.9. O2 requirements decreased without desats. Sodium bicarb po was given for CO2 of 17. On [**8-1**], she transferred out of the SICU. Diet was advanced and tolerated. The JP drain was removed. Vitals were stable. SBP ranged between 130s-150s. Cellcept was well tolerated. Prograf level reached 9.5 on 4mg [**Hospital1 **]. She did experienced a tremor in both hands in feet attributed to prograf. Medication teaching was done. She was ready for discharge to home. Of note, she has a sulfa allergy therefore, she was not on bactrim for pcp prophylaxis and will require monthly pentamidine treatments. She did not receive pentamidine on this admission. Medications on Admission: Labetolol 600 mg [**Hospital1 **], Cartia XT 180 mg [**Hospital1 **], Clonidine 0.3 mg [**Hospital1 **], Coumadin 6 mg daily, Celexa 20 mg daily, Renagel 2400 mg TID w/meals, Prednisone 20 mg daily, Minoxidil 2.5 mg [**Hospital1 **], Doxazosin 8 mg daily, Aspirin 81 mg Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 7. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*1* 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 12. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 13. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). Discharge Disposition: Home Discharge Diagnosis: esrd delayed graft function pulmonary edema htn Discharge Condition: stable Discharge Instructions: please call the Transplant office [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, inability to take any of your medications,abdominal distension, decreased urine output, weight gain of 3 pounds in a day, edema, incision redness/bleeding/drainage Lab work at [**Last Name (NamePattern1) 439**], [**Location (un) 86**] every Monday and Thursday [**Month (only) 116**] shower no tub baths/swimming No driving while taking pain medication No heavy lifting Followup Instructions: Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2185-8-11**] 3:30 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2185-8-18**] 8:40 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK Date/Time:[**2185-8-18**] 10:00 Completed by:[**2185-8-4**]

[ "518.4", "403.91", "589.0", "585.6", "996.81" ]

icd9cm

[ [ [] ] ]

[ "00.93", "39.95", "55.69" ]

icd9pcs

[ [ [] ] ]

6631, 6637

2777, 5115

357, 391

6729, 6738

1960, 2754

7254, 7681

1451, 1553

5436, 6608

6658, 6708

5141, 5413

6762, 7231

1568, 1941

264, 319

419, 1145

1167, 1301

1317, 1435

79,905

189,945

40016

Discharge summary

report

Admission Date: [**2104-10-31**] Discharge Date: [**2104-11-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: Right leg weakness Major Surgical or Invasive Procedure: Intubation History of Present Illness: 87-year-old man with history of CLL with baseline WBC around 50,000, HTN, prior TIA (unknown details), DM, CRI, advanced dementia, transferred from [**Hospital1 **]-[**Location (un) 620**] with new right leg weakness. He was at his day program when he was noted to have right leg weakness. He was "noted not to be walking well," and in another description, stated as "unable to walk," and sent to [**Hospital1 **]-[**Location (un) 620**] for evaluation. His activities at time of onset of weakness, accuity of change, and severity of weakness are unknown. There was no trauma and he did not complain of back pain. He is incontinent at baseline and there was thought to be no change to his baseline cognitive and speech difficulties. . At [**Hospital1 **]-[**Location (un) 620**] he underwent CBC, chem7, CT head, and lumbar spine x-ray (as reported below), and transferred to [**Hospital1 18**] for further evaluation. . In the ED, initial vital signs were T 96.8, HR 65, BP 167/99, RR 18, Sat 96%/RA. In the ED, he reportedly agitated and combative, swinging his arms and kicking at staff members. He was noted to be moving arms and left leg forcefully with less brisk activity of his right leg. The patient was evaluated by the neurology service, who recommended admission to medicine. At the time of transfer to the medical floor, vital signs were T 97.6, HR 50, BP 151/69, RR 18, Sat 98%/RA. . On the medical floor, the patient was not able to provided a history but did not appear to be in any distress. Past Medical History: -CLL with baseline WBC 50,000 -HTN -prior TIA, details unknown -advanced dementia, presumed to be Alzheimer's/vascular. Notes state he is A&Ox0-1 at baseline. Unable to carry a conversion, laughes frequently -congenital single kidney with CRI, baseline Cr 1.5 -History of hernia repair, question BPH and he is status post chemo and radiation. -BPH Social History: Lives at home with daughter who is his power of attorney. Attends day care program. 24 hour support at home from family. Dependent for most ADLs. Walks with a walker. No tobacco, etoh, or drug history. Daughter's ([**Doctor First Name **]) contact info is listed as [**Telephone/Fax (1) 88016**]. Prior to admisison was walking independently but slowly. Family History: unable to obtain Physical Exam: Admission Exam: Vital signs: T 95.8, HR 55, BP 170/77, RR 20, O2 Sat 100%/RA Gen: No acute distress. Laughs inappropriately at any question. HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OP clear. Neck: JVP not elevated. No carotid bruits. Resp: Exam limited by patient cooperation. CTA anteriorly. CV: Bradycardic. Irregular. No M/G/R. Abd: +BS. Soft. NT/ND. No rebound or guarding. Ext: Warm and well-perfused. Neuro: Alert. Laughs inappropriately to questions. Able to state his daughter's name. Otherwise does not answer questions. PERRL. Face symmetric. Palate elevates symmetrically. Tongue protrudes in midline. Strength testing limited by patient cooperation, but left side has more spontaneous movement and seems stronger than the right. This is most prominent in the lower extremities. Patellar and ankle jerk reflexes absent bilaterally. Toe upgoing on right. Unable to elicit plantar reflex on left. Pertinent Results: Labs/Studies: . On [**11-11**]: WBC 64.7; Hct 35.4; Plts 165 Na 143, K 4.1; HCO3 27, Cr 1.2 C. diff negative [**11-5**] blood cultures: negative . [**2104-10-30**] 11:30PM BLOOD WBC-52.4* RBC-4.26* Hgb-12.7* Hct-38.0* MCV-89 MCH-29.9 MCHC-33.5 RDW-14.3 Plt Ct-106* [**2104-10-30**] 11:30PM BLOOD Neuts-11* Bands-0 Lymphs-86* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2104-10-30**] 11:30PM BLOOD PT-14.4* PTT-28.7 INR(PT)-1.2* [**2104-10-30**] 11:30PM BLOOD Glucose-101* UreaN-26* Creat-1.5* Na-140 K-4.8 Cl-102 HCO3-28 AnGap-15 [**2104-10-31**] 09:15AM BLOOD Glucose-100 UreaN-24* Creat-1.4* Na-146* K-3.8 Cl-105 HCO3-28 AnGap-17 [**2104-10-30**] 11:30PM BLOOD CK(CPK)-87 [**2104-10-31**] 09:15AM BLOOD CK(CPK)-133 [**2104-10-30**] 11:30PM BLOOD cTropnT-<0.01 [**2104-10-31**] 09:15AM BLOOD CK-MB-5 cTropnT-<0.01 [**2104-10-30**] 11:30PM BLOOD Calcium-9.1 Phos-3.0 Mg-2.4 [**2104-10-30**] 11:30PM BLOOD VitB12-907* [**2104-10-30**] 11:30PM BLOOD TSH-3.8 [**2104-10-30**] 11:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2104-10-31**] 03:55AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.009 [**2104-10-31**] 03:55AM URINE Blood-TR Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2104-10-31**] 03:55AM URINE RBC-0 WBC-[**3-14**] Bacteri-NONE Yeast-NONE Epi-0 [**2104-10-31**] 03:55AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Reports- [**11-7**] CXR: The right upper lobe opacity already seen on the prior studies from [**11-6**] and minimally [**11-5**] is persistent and is highly worrisome for right upper lobe pneumonia. Bibasilar opacities might represent either part of multifocal infection or atelectasis or aspiration. Cardiomediastinal silhouette is unchanged. Note is made of extremely tortuous ascending aorta. No definitive evidence of pulmonary edema is present. . OSH Head CT There is no evidence of intra- or extraaxial hemorrhage, edema, masses, or acute large territorial infarction. The ventricles, sulci, and cisterns appear symmetric and normal in size and morphology. There is evidence of periventricular hypoattenuation suggestive of small vessel ischemic disease which is unchanged compared with prior. Calcifications of the carotid siphons and vertebral arteries are again visualized. A prior lacunar infarct is seen in the left basal ganglia and appears unchanged. Degenerative changes are seen at the atlantoaxial junction. A retention cyst is seen within the base of the right maxillary sinus. All other sinuses appear well-aerated. IMPRESSION: NO ACUTE INTRACRANIAL ABNORMALITY. OSH lumbar xray IMPRESSION: MULTILEVEL DEGENERATIVE CHANGES INCLUDING DEGENERATIVE DISCOGENIC CHANGE AND LOWER LUMBAR SPINE FACET ARTHROPATHY. SOMEWHAT LIMITED SERIES LIMITING ASSESSMENT FOR NONDISPLACED FRACTURE. MRI Head w/o contrast IMPRESSION: 1. Acute infarct in the white matter of left parietal lobe. 2. Global parenchymal atrophy with extensive changes of microvascular ischemia. Right hip x-ray There are degenerative changes of the right hip with spurring and decreased joint space at the superolateral aspect. No acute bony injury is identified. Small osteophytes about the femoral head and neck junction on the right side are also seen. The left hip demonstrates normal joint space with minimal subchondral sclerosis at the superior acetabulum consistent with early degenerative changes. Mild degenerative change of lower lumbar spine is also visualized. Brief Hospital Course: 87 yoM with CLL with baseline WBC around 50,000, HTN, prior TIA (unknown details), DM, CRI, dementia, transferred from [**Hospital1 **]-[**Location (un) 620**] with new right leg weakness; . # Right-sided weakness: Head CT at [**Location (un) 620**] was neg for a bleed. Since pt was unable to follow directions for an MRI without sedation and possible intubation, and the management would not be affected, the MRI was not done at the OSH. Pt was started on ASA. An xray of the right hip and l-spine showed no fx. Pt was seen by PT and OT. Neuro consult was obtained and recommended MRI of head which showed acute infarct in left parietal lobe and global parenchymal atrophy with extensive changes of microvascular ischemia. The patient was continued on aspirin 325 mg qday. . # Hypoxemic respiratory failure: On [**11-2**], Mr. [**Known lastname 20450**] developed sudden respiratory distress. He ultimately required transfer to the MICU and intubation for ventilatory support. He was treated with broad spectrum antibiotics for a possible aspiration pneumonia and improved gradually over the ensuing days. Per MICU documentation, meetings were held with the patient's HCP to discuss goals of care and he was ultimately made DNI/DNR. He was successfully extubated on [**2104-11-5**] and later transferred to the General Medical floor. . # HTN: His BP was elevated on admission and was allowed to be somewhat elevated following post-ischemic stroke guidelines. He was later started his amlodipine at 5mg. . #Dementia: Pt was reportedly oriented only to person prior to the acute illness. During his hospitalization, he could intermittently answer yes and no to questions. The care team provided frequent reorienting as needed. . # Nutrition: The patient was supported with enteral feeding via NGT due to his risk of aspiration s/p CVA. . # Hypernatremia: Na peaked at 146 but was 143 on the day of discharge. Hypernatremia was attributed to volume depletion and improved with IV fluids and NG tube free water flushes. . # Bradycardia: Seen on EKG. Per daughter this is not new. No clear symptoms. . # NSTEMI likely [**2-12**] demand; troponins trended down and pt showed no signs of volume overload. Treated with beta-blockade. . # DVT prophylaxis was with subQ heparin. . # Communication: daughter [**Name (NI) 88017**],[**First Name3 (LF) **] [**Telephone/Fax (1) 88016**], POA and HCP . *On [**11-11**], the patient was scheduled to be transferred to HSL-MACU in the afternoon. Prior to the transfer, however, the patient was to have a Dobhoff tube placed so that he could receive post-pyloric tube feeds theoretically lowering his risk of subsequent aspiration. IR was unable to successfully place the Dobhoff. The patient was transferred back to the floor. Upon arrival the floor, the patient was snoring. The [**Name8 (MD) 228**] RN was settling him back in bed when ~4:30 pm the RN ([**Doctor First Name **]) witnessed the patient to be snoring and then take a deep breath and stop breathing. The team was called to the room. Oxygen was placed on the patient but he had ceased to breathe. No pulses could be felt. No heart sounds or breath sounds were auscultated for over 1 minute. Neuro exam showed no reflexes. The patient's daughter was notified. She elected to not have an autopsy. The medical examiner waived the case. Medications on Admission: Amlodipine 10mg qday Vit D 1000 units, some days Niacinamide 250mg qday B12 occasionally Discharge Medications: None Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Cardiopulmonary Arrest - expired [**2104-11-11**] Acute Stroke Hypertension Dementia Aspiration Pneumonia s/p intubation . Secondary: Chronic Lymphocytic Leukemia Diabetes - diet controlled Hypertension Chronic Kidney Disease Discharge Condition: N/A Discharge Instructions: . Followup Instructions: .

[ "294.8", "410.71", "204.10", "287.5", "507.0", "518.81", "276.0", "250.00", "V49.86", "434.91", "753.0", "584.9", "331.0", "348.31", "403.90", "294.10", "585.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

10695, 10761

7184, 10527

282, 295

11040, 11046

3571, 7161

11096, 11101

2593, 2611

10666, 10672

10782, 11019

10553, 10643

11070, 11073

2626, 3552

224, 244

323, 1835

1857, 2206

2222, 2577