ChanBeDu/relevant_section_length · Datasets at Hugging Face

59,845

182,430

6365

Discharge summary

report

Admission Date: [**2174-10-6**] Discharge Date: [**2174-10-11**] Date of Birth: [**2113-11-21**] Sex: F Service: MEDICINE Allergies: Ativan / Erythromycin Base / Statins-Hmg-Coa Reductase Inhibitors / [**Female First Name (un) 504**] Type Anesthetics / Bactrim / Lidoderm / cleaning chemicals / strog perfume and scents Attending:[**First Name3 (LF) 783**] Chief Complaint: Shortness of breath, airway obstruction Major Surgical or Invasive Procedure: bare metal tracheal stent placement and removal History of Present Illness: 60 year old female with h/o tracheobronchomalcia s/p trachobronchoplasty in [**6-/2173**] admitted to the medicine service today for observation s/p an elective bronchoscopy with stent placement in cervial trachea. She is awaiting stent removal on [**2174-10-10**]. She was noted to have evidence of severe cervical malacia, severe reflux with supraglottic edema and paradoxical vocal fold motion on laryngoscopy by Dr. [**Last Name (STitle) **] during one of her dyspnea/cyanotic events. . On arrival to the floor, her vitals were stable and she was satting 96% on room air and breathing comfortably. She complained of a sore throat and back pain over her thoracotomy scar. Denied any nausea, HA, dizziness, CP, cough, SOB. . Past Medical History: Trachael bronchomalacia s/p right thoracotomy with tracheobronchoplasty on [**2173-7-2**] GERD s/p lap Toupee fundoplication [**2174-1-21**] Coronaray Artery Disease LAD w/< 30% stenosis Migraines Colonvaginal fistula Vaginitis PSH: Cesarean section x 3 Left Breast Lumpectomy Social History: Denies tobacco, ethanol and drug use. Has exposure to cleaning agents. Works for an electrical company. She is married and lives with family Family History: Mother pancreas ca Father Siblings ovarian ca Offspring Other lung ca Physical Exam: VS: T 97.1, BP 122/82, HR 84, RR 18, SaO2 96% RA GENERAL: Well appearing. NAD. HEENT: MMM. PERRL. EOMI. NECK: Supple, no thyromegaly, no JVD. HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no crackles or wheezes, good air movement, resp unlabored. ABDOMEN: + BS, obese, soft, non-tender, non-distended EXTREMITIES: WWP, no edema SKIN: Well healed thoracotomy scar on right hemithorax. No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-21**] throughout, sensation grossly intact throughout. Pertinent Results: [**2174-10-7**] 06:15AM BLOOD WBC-10.4 RBC-4.55 Hgb-12.9 Hct-39.6 MCV-87 MCH-28.4 MCHC-32.6 RDW-13.5 Plt Ct-284 [**2174-10-7**] 06:15AM BLOOD PT-12.1 PTT-28.9 INR(PT)-1.0 [**2174-10-7**] 06:15AM BLOOD Glucose-94 UreaN-13 Creat-0.7 Na-142 K-3.6 Cl-105 HCO3-27 AnGap-14 [**2174-10-7**] 06:15AM BLOOD ALT-12 AST-14 LD(LDH)-145 CK(CPK)-32 AlkPhos-55 TotBili-0.5 [**2174-10-7**] 06:15AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.9 [**2174-10-9**] 05:57PM BLOOD Type-[**Last Name (un) **] pO2-124* pCO2-38 pH-7.40 calTCO2-24 Base XS-0 Comment-GREEN TOP Brief Hospital Course: Active Issues: # Tracheobronchomalacia: Patient has h/o TBM. She was on the floor and had a stent placed and then removed as a trial to determine whether she would benefit from sugery. Post-operatively she has been stable and weaned from 2 liters oxygen to room air without issue. However, she then developed dyspnea and de-satted to 88% on RA with stridor and rhonchorous breath sounds at which point she was transferred to the MICU. She was placed on heliox and was given IV solumedrol and racemic epinephrine. During her first night in the MICU, she was tried off heliox and was able to tolerate it for 25 minutes before she began coughing and de-satted to the high 80s. During her second day in the MICU, she was taken off heliox and was able to tolerate it. She was monitored for a few hours and did not show any signs of respiratory distress and she was ultimately called out to the floor and started on a po prednisone taper that was to be continued for the next 7 days. On the floor, she was observed overnight and was stable. She was discharged in stable condition with follow up to thoracic surgery and interventional pulmonary. Inactive Issues: # CAD: stable, asymptomatic, continued on ASA 81 mg daily . # GERD: stable, continued on pantoprazole . # Migraines: stable, asymptomatic and continued on topiramate Transitional: [**Doctor Last Name **] of prednisone over the next 4 days. Follow up for thoracic surgery to reevaluate TBM Restart aspirin Medications on Admission: ACETAMINOPHEN-CODEINE - 300 mg-30 mg Tablet - Tablet(s) by mouth as needed for as needed for migraines ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled every four hours as needed for as needed for shortness of breath or wheeze AMITRIPTYLINE - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime GABAPENTIN - 600 mg Tablet - 1 Tablet(s) by mouth three times a day MORPHINE - 30 mg Tablet Extended Release - 1 Tablet(s) by mouth at bedtime ONDANSETRON - 4 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth every eight (8) hours as needed for nausea OXYCODONE - Dosage uncertain OXYCODONE-ACETAMINOPHEN [PERCOCET] - Dosage uncertain PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day severe gerd ROPINIROLE - 0.25 mg Tablet - 1 Tablet(s) by mouth q hs TOPIRAMATE - 100 mg Tablet - Tablet(s) by mouth [**Hospital1 **] ZOLPIDEM - 5 mg Tablet - [**12-19**] Tablet(s) by mouth qhs PRN Medications - OTC ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth Daily MULTIVITAMIN 1 tablet daily Discharge Medications: 1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 3. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QHS (once a day (at bedtime)). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*qs Tablet(s)* Refills:*0* 5. Docu Soft 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* 6. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. prednisone 10 mg Tablet Sig: 1-4 Tablets PO once a day for 4 days: please take 4 tabs on day 2, 3 tabs on day 3, 2 tabs on day 4, 1 tab on day 5. Disp:*qs Tablet(s)* Refills:*0* 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 10. topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 14. racepinephrine 2.25 % Solution for Nebulization Sig: 0.5 ML Inhalation Q4H (every 4 hours) as needed for 5 days: Hold for tachycardia (HR >120) or no respiratory distress . Disp:*qs ML(s)* Refills:*0* 15. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: TBM s/p stent placement and removal Trachael bronchomalacia s/p right thoracotomy with tracheobronchoplasty on [**2173-7-2**] GERD s/p lap Toupee fundoplication [**2174-1-21**] Coronaray Artery Disease LAD w/< 30% stenosis Migraines Colonvaginal fistula Vaginitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs [**Known lastname 24621**]: You came to the hospital with need for a stent placement to evaluate your response after the tracheal stent. You had a good response; however, after the stent removeal you required ICU monitoring for upper airway compromise. You did well on heliox, then slowly coming off the heliox back to room air. You are given a burst of steroid and then a prednisone [**Doctor Last Name 2949**]. You also had slight adverse reaction to succinocholine which you got during anesthesia. Your reaction was fatigue. You recovered to your baseline before your discharge. Please note we made the following changes: Started: # Prednisone Taper for 5 days: 50mg on day 1, 40mg on day 2, 30mg on day 3, 20mg on day 4, 10mg on day 5. # racepinephrine 2.25 % Solution for Nebulization Inhalation Q4H (every 4 hours) as needed for 5 days # Docu Soft 100 mg Capsule Sig: One (1) Capsule PO twice a day. # senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Please note you need to follow up the following doctors listed below. It was a pleasure taking care of you. We wish you well on your road to recovery. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2174-11-8**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**] 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 [**2174-11-8**] at 2:00 PM With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**] 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 [**2175-9-12**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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icd9cm

[ [ [] ] ]

[ "33.23", "33.22", "98.15", "96.05" ]

icd9pcs

[ [ [] ] ]

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12,272

150,046

509

Discharge summary

report

Admission Date: [**2161-9-22**] Discharge Date: [**2161-10-1**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4232**] Chief Complaint: Hypothermia at Dilaysis Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 84 y.o. female with h/o ESRD on HD recent admission for C diff colitis in [**2161-8-6**], a resident at [**First Name4 (NamePattern1) 4233**] [**Last Name (NamePattern1) **], admitted [**2161-9-22**] after she was found to be hypothermic during HD yesterday. The patient with recent stool positive for cdiff at nursing home (C.Diff +[**2161-9-19**]). The patient with h/o nausea and vomiting and diarrhea prior to admission. On the day of admission, the patient was found to be hypothermic c/o chills at HD and was sent to ED for eval. EKG with new T wave inversions in in c/w prior EKG [**2161-8-30**]. In the ED, the patient was treated with ASA, metoprolol 50mg, oxycodone, and dextrose. The patient was admitted to the general medical floor and had T 94.4 on admission BP 124/50; HR71; RR24; O2 sats 93% on RA and 99% on 4L NC. She was placed on a bear hugger and was mentating fine. The patient received Vancomycin IV x one dose, Levaquin x one dose and she is also on Flagyl po. At 5 am today, she found to be confused, persistently hypothermic with T min 93.7, hypotensive with SBP 94/60 in Trendelenberg and intermittent SBP down to 70's, and hypoglycemic to 34 on random finger stick check. She was given NS boluses and dextrose and one hour after dextrose hypoglycemic again. Patient placed on NRB after desatting to 80's on 4L NC. She denies pain, SOB, chest pain, or any discomfort. The patient's mental status has waxed and waned. Past Medical History: 1. ESRD on HD since [**2149**] (Dr. [**Last Name (STitle) 1860**]; MRSA bacteremia from fistula [**5-10**] 2. Atrial Fibrillation 3. Renal Mass on CT since [**2159**] 4. Right Hip Erosive Arthritis; now s/p R hip surgery (hemiarthroplasty) complicated by mental status changes and decreased BP 5. Osteoporosis 6. Anemia 7. Asthma 8. GERD 9. Hypertension 10. PVD/Heel Ulcers - refusing angio 11. C.Diff [**8-10**] treated with Flagyl. C.Diff positive on [**9-19**] at nursing home. 12. Poor PO Intake 13. Depression 14. Low Phos, Mag, and Potassium Social History: Pt currently lives at rehab center but prior to fracture lived alone in [**Location (un) 86**] with a house cleaner who comes several times a week to clean her house. Pt reports quiting smoking 8 years ago. However, the patient does have a 60+ pack year history of smoking. Pt has occasional alcohol use. Family History: Noncontributory. Physical Exam: VS: T 94; HR 70; BP 106/58; RR 18; 93-95% on NRB General: thin, [**Last Name (un) 1425**] AA female lying in bed with NRB HEENT: PER small and RL, EOMI, no scleral icterus Neck: supple, no JVD CV: regular, S1S2, normal Chest: bilateral crackles Abdomen: +BS, soft, [**Last Name (un) **]-tender, mildly distended, no rebound or guarding Extr: 1+ pitting edema bilaterally; bilateral heel ulcers with dressing c/d/i Family History: Unknown Pertinent Results: Imaging: [**2161-9-24**] CXR - Termination of feeding tube within the gastric antrum. Otherwise, no change [**2161-9-23**] CXR - Worsening interstitial edema. Increasing left pleural effusion and left lower lobe atelectasis. [**2161-9-24**] Foot X-Rays - No evidence of osteomyelitis. [**2161-9-22**] CXR - Cardiomegaly and interval development of small bilateral pleural effusions. No overt volume overload identified. Cultures: [**2161-9-25**] Blood (mycotic bottle) - pending [**2161-9-23**] Blood - pending [**2161-9-22**] Blood - pending [**2161-9-22**] Heel Culture - GRAM STAIN (Final [**2161-9-22**]): 1+ GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. WOUND CULTURE (Preliminary): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site STAPH AUREUS COAG +. MODERATE GROWTH. GRAM POSITIVE COCCUS(COCCI). MODERATE GROWTH. BEING ISOLATED FURTHER IDENTIFICATION TO FOLLOW. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. [**2161-9-22**] Urine - pending Brief Hospital Course: Ms. [**Known lastname **] is an 84 year old woman with ESRD on HD and recent admission for C diff colitis who was admitted from her nursing home after she was noted to have recurrence of c. difficile colitis. Originally admitted to the medicine service, the patient to the MICU with hypothermia with T min 93.7, hypotension with systolic blood pressures intermittently falling from 90's to the 70's, and hypoglycemia to 34 on random finger stick check who is adrenally insufficient by [**Last Name (un) 104**] stim. The patient was never in respiratory distress and did not require intubation. Her hypotension improved with IV fluid resuscitaion (3 L NS) and was transferred to floor soon thereafter. While in MICU, She was started on broad spectrum antibiotics, pan cultures and chest x-ray did not reveal any signs of infection. She was found to have Stool cultures were negative for c. diff. toxin. Vancomycin was discontinued in MICU. An cosyntropin stimulation test was performed to determine whether adrenal insufficiency was a cause of her hypotension. This revealed normal AM cortisol levels but a somewhat sluggish response to cosyntropin. The patient was therefore started on high dose steroids. This was tapered off by discharge. Another potential contributing factor behind the patients prior hypotension may have been her poor PO intake and, perhaps, her hypoglycemia. For this reason the patient had a PEG tube placed to aid her nutritional status. The patient's stay on the medical floor was otherwise relatively uneventful, she continued her schedule of dialysis without complication. On discharge she remained afebrile and hemodynamically stable with blood pressures in the normal to high range. In summary, this is an 84 year-old woman with ESRD on HD admitted from nursing home for diarrhea secondary to c. dificile infection who developed hypotension and hypoglycemia. She responded well hemodynamically to IV fluid resuscitation. No potential source of infection was definitively identified but patient did well with broad spectrum antibiotics. It is likely that her hypotension was secondary to intravascular depletion from diarrhea in the setting of poor PO intake and, possibly, borderline adrenal insufficiency. On discharge, she was without signs of infection other than occasional diarrhea, and was hemodynamically stable. She received a PEG tube for feeding to aid her nutritional status. Issues and plan arising from this admission: 1. C. dificile infection. Diarrhea may have been major contributor to hypotension. But patient was likely never septic per se. Pan cultures unrevealing -can continue flagyl for approximately two weeks after discharge. 2. Heel ulcers. Appreciate podiatry input (Dr. [**Last Name (STitle) **]. X-rays did not indicate osteomyelitis. Vascular surgery was [**Last Name (STitle) 4221**]. They had seen the patient on prior admissions and felt the patient needed an angiogram. -to see vascular surgery and receive angiogram as outpatient 3. New T wave inversions but difficult to interpret with electrolyte abnormalities. The patient was ruled out for MI. Repeat EKG's were unchanged. 4. Poor nutritional status/poor appetite: [**Month (only) 116**] also have contributed to hypotension -PEG in place for use in supplementation of pt PO intake. 5. ESRD/ atient of Dr. [**Last Name (STitle) 4234**] (who is aware of patients admission). The patient was dialyzed on schedule during her admission. 6. Hypoglycemia. Most likely from long standing malnutrition and poor po intake. 7. Coagulopathy. Patient on coumadin and INR likely elevated in the setting of Abx use. The patient did receive Vit K IV dose. Coumadin was held prior to the patient getting her PEG tube. 8. Atrial Fibrillation. Currently in sinus. Coumadin was held on prior to the patient getting a PEG. -continuing coumadin 9. Leg swelling (R side) - A LENI ruled out DVT. 10. Depression - continued on Remeron 15mg qHS 11. GERD - Continued on protonix 40mg QD 12. COPD/Asthma - continued on combivent 13. Poor Nutritional Status - PO intake encourage, PEG placed for supplementation. Pt to continue renal, heart healthy, diabetic diet. The code status of this patient is DNR/DNI, confirmed with attending physician. Medications on Admission: Amiodarone 200mg QD Coumadin 1mg QD Toprol XL 50mg [**Hospital1 **] Protonix 40mg QD MVI Nephrocaps Lisinipril 30mg QD Combivent Albuterol PRN Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-7**] Puffs Inhalation Q6H (every 6 hours) as needed. 2. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Fludrocortisone 0.1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 weeks: Please continue for total of three weeks, last day of therapy is [**2161-10-14**]. 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Hypotension. Dehydration. Borderline adrenal insufficiency. End stage renal disease. Discharge Condition: Good. No fevers, blood pressure now in normal/high normal range. Discharge Instructions: Please return patient to hospital if she develops high grade fevers, becomes hypotensive, or has a change in her mental status. Please return patient to hospital if patient develops chest pain, shortness of breath, palpitations, or if she becomes light-headed or dizzy. Please have patient continue all prescribed medications. Please continue patient on her dialysis schedule. Please have patient keep follow up appointments. Followup Instructions: Please continue hemodialysis and follow up with your nephrologist to help manage hemodialysis. Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please follow up with vascular outpatient services at [**Hospital1 **] hospital. We have scheduled an appointment with Dr. [**Last Name (STitle) **] on [**2161-10-15**] at 12:45 PM. his office phone number is [**Telephone/Fax (1) 4235**]. You may need an angiogram, we would like to evaluate why you have ulcers on your heels. Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2161-10-7**] 1:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]

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icd9cm

[ [ [] ] ]

[ "39.95", "43.11", "96.6" ]

icd9pcs

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6746

Discharge summary

report

Admission Date: [**2192-10-18**] Discharge Date: [**2192-10-20**] Date of Birth: [**2120-10-21**] Sex: F Service: MEDICINE Allergies: Codeine / Gentamicin / Shellfish / Morphine Attending:[**First Name3 (LF) 6652**] Chief Complaint: Bright red blood per colostomy bag Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms. [**Known lastname 1024**] is a 71yo female with past medical history of Crohn's Disease s/p total colectomy with end ileostomy, perforated gastric ulcer s/p Bilroth II on home TPN short gut syndrome, on Coumadin presenting with bloody osteomy output. The patient had a dilation of her J-J anastomosis on [**2192-10-16**] with EGD. She held her warfarin starting on Sunday, [**10-14**] in anticipation of the procedure and restarted the warfarin on the day of admission. The patient began to notice increased osteomy output the day prior to admission, she had to change her bag 6x at home. In the ER, 70cc of blood mixed with osteomy output and then 3 hours later, 100cc of dried, old blood is emptied just as she presents to the MICU. The patient does report that she had syncope after standing on the day of admission around noon. She reports that she was standing after emptying her bag in the bathroom, she recalls feeling lightheaded and "the next thing I knew" she was on her back on the bathroom floor. She did not notice any headache, head pain, bruises. Her husband heard her fall and came immediately, she was already awake by the time he was there. He called EMS and she was transferred to [**Hospital 25660**] Hospital. Her baseline hct at Leimeister is 35 (although around 27 at [**Hospital1 18**]) and her hct was 26 with an INR of 1.7. By the time of her presentation at [**Hospital1 18**], 3 hours later, her hematocrit had dropped 3 points. In the ED, initial VS were: 98.8 82 116/56 14 99% RA On arrival to the MICU, the patient appears well. She has no complaints. She does report that her osteomy bag needs to be emptied, and 100cc of dark old blood is produced. Past Medical History: Past Medical History: - Severe Crohn's disease since early 20's, pt reports no flares since [**2160**]'s, not currently on any disease modifying agents - Short gut syndrome (home TPN since [**2166**]) - h/o pancreatitis - PUD, perforated gastric ulcer - Osteopenia - Kidney stones - Multiple catheter-associated DVT's, on long-term coumadin - anemia Past Surgical History: - Antrectomy with Bilroth II ([**2156**]) - Transverse w/ colostomy in [**2149**] and frequent revisions/reversals since then for complications of CD (including abscesses, bowel perfs, and bowel obstructions) - Total colectomy with end ileostomy - Multiple small bowel resections - ccy - appendectomy - Multiple port insertions (current R Hickman catheter in place x8y) Social History: Retired, lives with husband. [**Name (NI) **] EtOH or tobacco use. Family History: Sister with breast cancer. Mother, father, and brother with CAD. Physical Exam: Admission physical exam: Vitals: T: AF BP: 121/79 P: 88 R: 18 O2: 100% on RA 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. Osteomy bag present, about 100cc in the bag. Multiple well healed surgical scars. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, grossly normal sensation, gait deferred. Discharge physical exam: VS - 98.3, 108/56, 80, 18, 98RA Gen: well-appearing caucasian female in NAD HEENT: NCAT, EOMI, PERRL, sclera anicteric, MMM and pale, OP clear. CV: RRR, 2/6 systolic murmur heard best at RUSB, no gallops or rubs. Resp: CTAB, no w/r/r Abd: multiple surgical scars, no bowel sounds, ostomy at RUQ, well-dressed, no erythema around site. Soft, nontender, nondistended, no organomegaly appreciated. Extr: WWP, 2+ peripheral pulses, no e/c/c Neuro: CN II-XII grossly intact, 5/5 strength, no focal deficits MSK: L knee with osteoarthritic deformity, limited ROM [**3-1**] pain Skin: no rashes, bruising, or echymoses. PIV in L hand with surrounding swelling. Pertinent Results: Admission labs: [**2192-10-18**] 12:40PM WBC-6.3 RBC-3.29* HGB-9.9* HCT-28.7* MCV-87 MCH-30.0 MCHC-34.5 RDW-13.6 [**2192-10-18**] 12:40PM PT-19.9* INR(PT)-1.9* [**2192-10-18**] 12:40PM PLT COUNT-177 [**2192-10-18**] 09:33AM GLUCOSE-98 UREA N-55* CREAT-0.7 SODIUM-139 POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-26 ANION GAP-11 [**2192-10-18**] 09:33AM WBC-5.9 RBC-3.09* HGB-9.4* HCT-27.2* MCV-88 MCH-30.3 MCHC-34.5 RDW-13.4 [**2192-10-18**] 04:13AM HGB-7.7* calcHCT-23 [**2192-10-18**] 04:10AM GLUCOSE-154* UREA N-59* CREAT-0.8 SODIUM-135 POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-24 ANION GAP-9 [**2192-10-18**] 04:10AM WBC-5.1 RBC-2.57* HGB-7.7* HCT-23.3* MCV-91 MCH-30.0 MCHC-33.1 RDW-13.3 [**2192-10-18**] 04:10AM NEUTS-74.8* LYMPHS-18.9 MONOS-4.9 EOS-0.9 BASOS-0.5 [**2192-10-18**] 04:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Discharge labs: [**2192-10-20**] 06:40AM BLOOD WBC-4.8 RBC-2.68* Hgb-8.1* Hct-23.6* MCV-88 MCH-30.0 MCHC-34.1 RDW-13.6 Plt Ct-150 [**2192-10-20**] 02:22PM BLOOD Hct-27.7* [**2192-10-20**] 06:40AM BLOOD Glucose-108* UreaN-31* Creat-0.6 Na-140 K-4.0 Cl-104 HCO3-28 AnGap-12 [**2192-10-20**] 06:40AM BLOOD Calcium-8.6 Phos-5.1*# Mg-1.9 Pertinent micro: none Pertinent path: none Pertinent imaging: [**2192-10-18**] EGD: Impression: Stricture with clean based ulcer at the jejunal-jejunal anastomosis. Otherwise normal EGD to third part of the duodenum Brief Hospital Course: 71F with PMH Crohns, multiple abd surgeries, s/p total colectomy and recent EGD for J-J dilation, on coumadin for hx of DVTs, presents with BRB per ostomy and generalized weakness. # BRB per ostomy: Likely attributed to J-J anastomotic dilation done on [**2192-10-16**] in conjunction with coumadin therapy for DVT. Pt received 1 unit pRBC in unit, and hematocrit remained stable. EGD [**10-18**] confirming ulceration of J-J anastomtic site, no active bleeding. She was put on IV protonix, transitioned to high dose oral [**Hospital1 **]. No longer had bloody ostomy output, weakness resolved and she remained hemodynamically stable. Coumadin was held, pt advised to restart [**2192-10-23**] and to watch for warning signs of DVT or PE. Encouraged close follow up with outpatient GI specialist. # Hx of DVT: Pt has history of multiple TPN catheter-associated clots and DVT. She has been on coumadin therapy for over 20 years. Was held [**10-14**] to [**10-16**], she restarted on [**10-17**], then d/c'd again on [**10-18**] due to GI bleed. She also received 2 units FFP for bleeding reversal prior to EGD. GI recommended holding coumadin for 5 days total from [**10-18**] - restart on [**2192-10-23**]. She still received prophylactic dose heparin while in hospital, informed of the warning signs of DVT/PE prior to discharge. # Crohns disease: S/p colectomy and multiple abd surgeries, now with short bowel syndrome. Known hx of strictures, now with J-J anastamosis. Receives TPN for nutritional support through Hickman's catheter. Not on home Crohn's meds. Tolerated regular diet and received TPN while inpatient. #Osteoporosis prevention: Continued home Ca and Vit D. Transitional issues: #restart coumadin [**2192-10-23**] #[**Hospital1 **] PPI for 1 week, then change to daily PPI ongoing Medications on Admission: SODIUM-K+-MAG-CA-CHLOR-ACETATE [NUTRILYTE II] - 35 mEq-20 mEq-5 mEq-4.5 mEq-35 mEq-29.5 mEq/20 mL Solution - 2.5 L at bedtime WARFARIN - 4 mg tablet - one Tablet(s) by mouth daily ACETAMINOPHEN CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 WITH VITAMIN D3] - (Prescribed by Other Provider) - 600 mg calcium (1,500 mg)-400 unit tablet, chewable - 1 tablet(s) by mouth daily CHLOROPHYLL COPPER COMPLEX [NULLO] - (OTC) - 100 mg tablet - 1 Tablet(s) by mouth once a day DOXYLAMINE SUCCINATE - (Prescribed by Other Provider) - 25 mg tablet - one Tablet(s) by mouth once a day FISH OIL-DHA-EPA [FISH OIL] - (OTC) - 1,200 mg-144 mg capsule - one Capsule(s) by mouth daily Discharge Medications: 1. Calcium Carbonate 600 mg PO DAILY 2. Vitamin D 400 UNIT PO DAILY 3. chlorophyll copper complex *NF* 100 mg Oral daily 4. doxylamine succinate *NF* 25 mg Oral daily 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. Omeprazole 40 mg PO BID Duration: 7 Days 1 pill twice daily through [**2192-10-23**], then decrease to 40mg daily ongoing RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*35 Capsule Refills:*0 7. Outpatient Lab Work Please draw a CBC (complete blood count) on Wednesday, [**10-25**]. FAX results to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3707**] at Fax: [**Telephone/Fax (1) 7922**], phone: [**Telephone/Fax (1) 2205**]. ICD-9 code: 285.9 (anemia) Discharge Disposition: Home Discharge Diagnosis: GI bleed from j-j anastamosis after dilation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname 1024**], You were admitted to [**Hospital1 18**] for bloody stool, weakness, and loss of consciousness. You were found to be anemic, presumably from your GI blood loss. You received a blood transfusion and your anemia and symptoms improved. You had an endoscopy which showed ulceration at the site of your recent dilation, but no active bleeding. You were put on an IV medicine to help stop the bleeding. Your blood counts remain stable, and we now feel it safe for you to leave the hospital. WE made the following changes to your medications: START omeprazole 40mg twice daily through [**2192-10-25**], then 40mg once daily ongoing STOP coumadin through [**2192-10-23**], restart on [**2192-10-24**] at prior home dose, have INR checked [**2192-10-25**] Please call your PCP and GI doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] to update them on your admission, and have your CBC drawn midweek to check your blood counts (your PCP will need to order this lab). Off coumadin, you are at higher risk for blood clots. If you experience any sudden shortness of breath, rapid heart rate, chest pain, swelling and pain around your port or in one of your extremities, these are signs of DVT and/or pulmonary embolus and you would need to go to the emergency room. If you continue to have bleeding, please seek immediate care. Followup Instructions: Please call the telephone numbers below to make appointments with your PCP and your gastroenterologist within the next 2 weeks. Name: [**Last Name (LF) 3707**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 2205**] Fax: [**Telephone/Fax (1) 7922**] Name: [**Last Name (LF) 572**], [**First Name3 (LF) **] A Office Phone: ([**Telephone/Fax (1) 2306**] Office Location: [**Last Name (NamePattern1) **], Ste 8E [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 6663**] Completed by:[**2192-10-21**]

[ "E879.8", "579.3", "V45.72", "V58.61", "V12.51", "997.49", "285.1", "534.90", "998.11", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.15" ]

icd9pcs

[ [ [] ] ]

9119, 9125

5878, 7557

342, 347

9213, 9213

4389, 4389

10757, 11537

2937, 3004

8396, 9096

9146, 9192

7707, 8373

9363, 9908

5317, 5855

2463, 2835

3044, 3688

7578, 7681

9937, 10734

268, 304

375, 2067

4406, 5300

9228, 9339

2111, 2440

2851, 2921

3714, 4370

30,985

134,856

53915

Discharge summary

report

Admission Date: [**2114-4-21**] Discharge Date: [**2114-4-26**] Date of Birth: [**2029-6-16**] Sex: F Service: MEDICINE Allergies: Lidocaine / Codeine / Iodine; Iodine Containing / Tylenol Attending:[**First Name3 (LF) 800**] Chief Complaint: Melena. Major Surgical or Invasive Procedure: 1. Endoscopy 2. Colonoscopy History of Present Illness: This is an 84-year-old woman who presented today with the ED after three episodes of melena starting on the afternoon of admission. The patient reports that she was running errands downtown in the morning, and when she got home she saw black stool on the toilet paper. Patient reports that she has long-standing problems with heartburn, and is unable to eat anything sour or spicy. Her heartburn has been worse over the past few weeks, and she said that two nights prior to admission she developed "terrible" heartburn where she felt the acid coming up her throat and she had to "take everything" to try to relieve her pain, including maalox. She denies any recent additional NSAID use besides her daily baby aspirin. She denies vomiting, bright red blood per rectum, or retching. She does endorse GERD symptoms and abdominal pain in the left upper quadrant. She denies any prior episodes of black stools, and she notes that she does not take iron supplements. . Of note, the patient was recently admitted to [**Hospital1 18**] from [**Date range (1) 110593**] for evaluation of chest pain and dizziness. At that time, three sets of cardiac enzymes were negative, and her chest pain was attributed to GERD. Her PPI was increased to [**Hospital1 **] and ranitidine was started. She notes that she was not able to take ranitidine because she felt unwell while taking it. Also of note, during the pt's recent admission (and on [**2113**] outpatient visit to Dr. [**Last Name (STitle) 2161**] in GI) the patient refused EGD. . In the ED, initial vital signs were: 98.7 66 138/64 16 99% RA. Ms. [**Known lastname 22741**] was noted to have guaiac positive dark stool on rectal exam. She was given Pantoprazole 40 mg IV. GI was notified and requested that patient go to ICU for possible urgent EGD overnight and close monitoring of hematocrit. . On the floor, the patient appears comfortable and is very talkative. She denies abdominal pain or GERD symptoms currently. Past Medical History: 1. CAD- s/p emergent CABG in [**2098**] after failed PCI, last cath [**2109**] with 3-vessel native CAD, known occluded SVG-PDA, patent SVG-D1-OM2, s/p PCI to RCA 2. HTN 3. Hypercholesterolemia 4. IBS 5. DJD 6. PVD 7. hiatal hernia 8. hemorrhoids 9. GERD . Cardiac Risk Factors: Dyslipidemia, Hypertension . Cardiac History: CABG, in [**2108**] anatomy as follows: SVG-D1-OM2, SVG-PDA. . Percutaneous coronary intervention, in [**12-23**] anatomy as follows: 3v native CAD, known occluded SVG-PDA. Social History: She lives alone and has elder services. She states she performs ADLs independently. In close contact with her landlady, but is worried that landlady just "wants my money." Her brother recently died, and she denies any other living relatives besides [**Name2 (NI) 12232**] that she is not close with. She formerly worked in bookkeeping, and denies tobacco use. She does endorse a history of alcohol use, but reports that she quit drinking at the age of 35. Family History: There is no family history of premature CAD. Physical Exam: Exam on admission: Vitals: T: BP: 150/61 P: 61 R: 18 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, ronchi CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic murmur at apex 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 Neuro: A+Ox3, CN II-XII intact Motor: Strength 5/5 upper and lower extremities Gait assessment deferred Pertinent Results: [**2114-4-21**] 05:30PM BLOOD WBC-6.1 RBC-3.54* Hgb-11.8* Hct-35.5* MCV-100* MCH-33.4* MCHC-33.3 RDW-14.1 Plt Ct-302 [**2114-4-22**] 06:30AM BLOOD WBC-5.3 RBC-3.45* Hgb-11.4* Hct-34.5* MCV-100* MCH-33.1* MCHC-33.1 RDW-14.0 Plt Ct-279 [**2114-4-21**] 04:20PM BLOOD PT-18.1* PTT-19.8* INR(PT)-1.6* [**2114-4-21**] 04:20PM BLOOD Glucose-119* UreaN-19 Creat-1.2* Na-139 K-5.9* Cl-105 HCO3-24 AnGap-16 [**2114-4-21**] 11:07PM BLOOD ALT-55* AST-75* LD(LDH)-255* CK(CPK)-52 AlkPhos-96 TotBili-0.8 [**2114-4-21**] 04:20PM BLOOD CK-MB-1 cTropnT-<0.01 [**2114-4-21**] 11:07PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2114-4-22**] 06:30AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2114-4-22**] 02:44PM BLOOD CK-MB-NotDone cTropnT-<0.01 . Chest (PA+lateral): The heart is enlarged. There is evidence of previous sternotomy. No failure is present. Costophrenic angles are clear. No evidence of pneumonia or pneumothorax is present. There has been no significant change since the prior film of [**2114-3-19**]. IMPRESSION: No acute process. . COLONOSCOPY [**4-24**]: A single pedunculated 6 mm polyp of benign appearance was found in the ascending colon. A single-piece polypectomy was performed using a cold snare. The polyp was completely removed. Two pedunculated polyps of benign appearance and ranging in size from 4 mm to 5 mm were found in the descending colon. Single-piece polypectomies were performed using a cold snare. The polyps were completely removed. A single sessile 5 mm polyp of benign appearance was found in the sigmoid colon. A single-piece polypectomy was performed using a cold forceps. The polyp was completely removed. A single pedunculated 2.5 cm polyp was found in the sigmoid colon. After polyp removal, a 2 cm clot was seen to form at the site of polypectomy. 7 clips were applied to the polypectomy site and hemostasis was achieved. A single-piece polypectomy was performed using a hot snare in the sigmoid polyp. The polyp was completely removed. Recommend repeat colonoscopy in 3 months due to poor prep. Brief Hospital Course: This is an 84-year-old woman with a history of severe GERD, CAD, paroxysmal afib, and HTN who is admitted for 3 melanotic stools. . # MELENA: The patient was admitted to the MICU for further management. Ms. [**Known lastname 22741**] was monitored overnight and remained hemodynamically stable, with unchanged hematocrit, and was not transfused. The patient was started on a pantoprazole drip, which was changed pantoprazole 40mg [**Hospital1 **]. Her aspirin, Coumadin, and [**Hospital1 25712**] were held in the setting of acute bleed. Patient had endoscopy on [**4-23**], which demonstrated antral gastritis and a pedunculated polyp (likely inflammatory). However, no obvious bleeding source was discovered. A colonoscopy was performed on [**4-24**], which showed numerous polyps including one large polyp in the sigmoid colon, which was thought to be the likely cause of bleeding. Polyp was clipped and patient was observed for 48 hours. Patient will need repeat colonoscopy in 3 months as prep was very poor. After colonoscopy, patient had no more episodes of bleeding and remained hemodynamically stable. Her Coumadin and aspirin continued to be held in the peri-bleed period. These medications can be restarted at the discretion of patient's PCP. [**Name10 (NameIs) **] was re-started. Patient will have GI follow-up as well. . # GERD: Patient continued to complain of GERD-like symptoms throughout the duration of her admission. She had a moderate response to "magic mouth wash" and Maalox. She was continued on home medication of [**Hospital1 **] lansoprazole. (Patient's nurse speculated however, that patient is not taking her medications properly at home). . # PAROXYSMAL ATRIAL FIBRILLATION: Patient continued to be in normal sinus rhythm throughout hospital admission. Her Coumadin, aspirin, and [**Hospital1 25712**] were stopped in light of GI bleed. Her Toprol XL 50mg [**Hospital1 **] was restarted on discharge, but Coumadin and aspirin were held. These medications can be restarted at the discretion of patient's PCP or cardiologist (both of whom were contact[**Name (NI) **] during admission). . # ISCHEMIC CARDIOMYOPATHY: EF from echo in [**2112**] is 30-40%. Lasix was originally held in light of GI bleed, but was restarted toward the end of hospital stay. Patient complained of feeling "swollen" after missing Lasix for a few days. Patient will follow-up with cardiology for further management of heart failure. . # ELEVATED LFTS/PANCREATIC MASS: Patient has elevated LFTs, dilated CBD, and pancreatic masses as seen on abdominal CT in [**2113**]. As per radiology report, masses are likely consistent with intraductal papillary mucinous neoplasm of the pancreas (IPMN). According to GI note, there is malignant potential and these masses will need to be worked up (possible with MRCP). Statin was held in light of elevated LFTs but can be restarted at the discretion of patient's PCP. . # VNA AND INSURANCE: Patient's insurance was unable to pay for both VNA and home PT. Patient needs PT due to a recent fall in the bathroom (and PT could not be canceled). She will be able to reapply for VNA after she finishes with PT. This can be coordinated at discretion of patient's PCP. Medications on Admission: 1. Nitroglycerin 0.3 mg PRN 2. Amiodarone 100 mg PO QHS 3. Atorvastatin 40 mg PO DAILY 4. Furosemide 80 mg PO DAILY 5. Isosorbide Dinitrate 20 mg PO BID 6. Lisinopril 5 mg DAILY 7. [**Year (4 digits) **] Succinate 25 mg PO BID 8. Warfarin 1 mg Daily 9. Aspirin 81 mg 10. Maalox Oral 11. Sucralfate 1 gram PO TID 12. Potassium Chloride 10 mEq PO DAILY 13. Lansoprazole 30 mg Tablet, PO BID Discharge Medications: 1. Amiodarone 200 mg Tablet [**Year (4 digits) **]: 0.5 Tablet PO DAILY (Daily). 2. Nitroglycerin 0.3 mg Tablet, Sublingual [**Year (4 digits) **]: One (1) tab Sublingual q5min as needed for chest pain. 3. Furosemide 80 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily): Take 80mg once a day and 120mg on Sundays. 4. Isosorbide Dinitrate 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a day). 5. Lisinopril 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily). 6. Sucralfate 1 gram Tablet [**Year (4 digits) **]: One (1) Tablet PO TID (3 times a day). 7. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [**Year (4 digits) **]: 15-30 MLs PO QID (4 times a day) as needed for heartburn. 8. Potassium Chloride 10 mEq Capsule, Sustained Release [**Year (4 digits) **]: One (1) Capsule, Sustained Release PO once a day. 9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) [**Year (4 digits) **]: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 10. [**Year (4 digits) **] Succinate 50 mg Tablet Sustained Release 24 hr [**Year (4 digits) **]: One (1) Tablet Sustained Release 24 hr PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Lower GI bleeding, likely from colonic polyps . Secondary: 1. Paroxysmal atrial fibrillation 2. Hypertension 3. High cholesterol Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 22741**], It was a pleasure taking care of you on this admission. You came to the hospital because you were having bloody bowel movements. You had an endoscopy, which showed some irritation (gastritis) and a small polyp. You had a colonoscopy, which showed multiple polyps throughout your colon. A large polyp in your sigmoid colon was clipped and the bleeding stopped. Your blood levels remained stable throughout entire hospital stay. . You were also found to have elevated liver enzymes and your atorvastatin was stopped. This can be restarted at the discretion of your primary care physician. [**Name10 (NameIs) **] also have cysts in your pancreas, which need to be followed up. Your primary care physician might suggest further imaging for this issue. . The following changes were made to your medications: 1. STOP taking atorvastatin 2. STOP taking coumadin until told otherwise 3. STOP taking aspirin until told otherwise . Please take all of your medications as prescribed. Please keep all of your follow-up appointments. . Return to the hospital if you develop chest pain, shortness of breath, continued blood in your stools, trouble swallowing, weakness on any side of your body, dizziness, headache, palpitations, fevers, sweats or any other concerning signs or symptoms. Followup Instructions: Department: [**State **] SQ When: THURSDAY [**2114-5-10**] at 2:00 PM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2114-5-16**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 10314**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage We are working on a follow up appointment with Dr [**Last Name (STitle) 2204**] within the next 4-8 days. You will be called at home with the appointment. If you have not heard or have questions, please call [**Telephone/Fax (1) 2205**]. We are working on a follow up appointment with Dr [**Last Name (STitle) 171**] within the next month. You will be called at home with the appointment. If you have not heard or have questions, please call [**Telephone/Fax (1) 62**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

[ "V45.82", "272.0", "535.40", "530.81", "578.1", "401.9", "427.31", "414.8", "V45.81", "788.1", "211.3", "577.9" ]

icd9cm

[ [ [] ] ]

[ "45.42", "45.16" ]

icd9pcs

[ [ [] ] ]

10989, 10995

6134, 9365

325, 356

11183, 11183

4094, 6111

12680, 13949

3374, 3420

9804, 10966

11016, 11162

9391, 9781

11333, 12657

3435, 3440

278, 287

384, 2359

3454, 4075

11198, 11309

2381, 2880

2896, 3358

26,645

158,698

2273+2274+2275+55365

Discharge summary

report+report+report+addendum

Admission Date: [**2122-4-16**] Discharge Date: [**2122-4-22**] Date of Birth: [**2052-5-28**] Sex: M Service: Vascular CHIEF COMPLAINT: Right toe ulceration. HISTORY OF PRESENT ILLNESS: This 69-year-old black male, who has a history of type 2 diabetes and right toe ulceration since [**2121-11-15**], which is refractor to conservative treatment. The patient was referred to Dr. [**Last Name (STitle) 1391**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], podiatrist. He was seen in the office on [**Month (only) 404**] of this year, which the pulse exam shows the right foot was a PT of 2+, absent DP on the right and absent DP and PT on the left. Patient underwent arteriogram with right leg runoff on [**2122-2-11**], which demonstrated diffuse aortic magnus, a right common iliac saccular aneurysm of [**4-20**] cm with aneurysmal dilatation of the distal aorta. The left common iliac artery, hypogastric, and common femoral, profunda femoris are without stenosis. The right superficial femoral arteries showed moderate disease. The trifurcation occluded at its origin. The distal peroneal was occluded. The PT is the major runoff vessel, which perfuses the plantar arch in DP. REVIEW OF SYSTEMS: The patient denies claudication or rest pain. Denies chest pain, palpitations. He does admit to three-pillow orthopnea, which is chronic over the last 2-3 years with rare episodes of PND. Does admit to dyspnea on exertion, shortness of breath with walking. Patient underwent a stress on [**2121-9-17**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Results not available at time of dictation. PAST MEDICAL HISTORY: 1. Coronary artery disease with MI in [**2111**] and [**2113**]. 2. Hypertension. 3. GERD. 4. Type 2 diabetes. 5. Right shoulder dislocation. 6. Pneumonia at the age of five or six years of age. 7. Diminished hearing. 8. Right sciatica. 9. Hyperlipidemia. PAST SURGICAL HISTORY: 1. Excision of cyst at L4-5 in the back. 2. Right knee laceration repair. 3. Excision of penile growth.0 4. Lumbar laminectomy. ALLERGIES: Sulfa and penicillin, which causes hives. MEDICATIONS ON ADMISSION: 1. Aspirin enteric coated 81 mg b.i.d. 2. Enalapril 20 mg q.d. in the a.m., enalapril 10 mg q.d. in the p.m. 3. Isosorbide 20 mg b.i.d. 4. Lopressor 150 mg b.i.d. 5. Lipitor 10 mg at h.s. 6. Metformin 1000 mg q.a.m. and 500 mg q.p.m. 7. Glipizide ER 10 mg q.d. SOCIAL HISTORY: The patient lives alone, ambulates independently. He is a former 60 pack year smoker. Alcohol intake is a half a pint of brandy per day or 3-4 beers q.d. PHYSICAL EXAM: Vital signs: Blood pressure 146/75, pulse 62, respirations 20, and O2 saturation 94% on room air. HEENT exam is unremarkable. There is no JVD or carotid bruits. The lung exam shows increased A-P diameter with diminished lung sounds in all lung fields. There are no adventitious sounds. Heart is regular rate and rhythm and is distant in sounding. Abdominal examination was obese, soft, nontender, and nondistended, bowel sounds were present x4. There were no abdominal bruits. The peripheral vascular examination shows right first, second, and third toes with ruborous changes and superficial skin ulcerations. There were no femoral bruits. The neurological exam was unremarkable. Preoperative pulse exam: Femorals were 1+ bilaterally. Popliteals on the right was biphasic signal. DP and PT were monophasic signals. On the left, the popliteal was 2+ palpable with monophasic DP and PT. HOSPITAL COURSE: Patient was admitted to the preoperative holding area on [**2122-4-16**]. He underwent an aortobifem and ligation of multiple iliac aneurysms. The patient tolerated the procedure well. Was transfused 1 unit of packed red blood cells intraoperatively, and was transferred to the PACU in stable condition. An epidural was placed intraoperatively for anesthesia and analgesia control. Immediate postoperatively, the patient was afebrile. He required fluid boluses x3 to improve his urinary output. His physical exam was remarkable for some extremity edema. His white count was 6, hematocrit 38.9, BUN 7, and creatinine of 0.6. Patient remained NPO and was transferred to the VICU for continued hemodynamic monitoring. Postoperative day one, patient had no overnight events. He did require diminish fluid requirements secondary to elevated filling pressures. His epidural remained in place and worsening. He was afebrile. His hematocrit was 37.0, white count 10, BUN 8, creatinine 0.7. His abdominal incisions and groin incisions were clean, dry, and intact. He had a palpable PT bilaterally with biphasic Dopplerable DPs bilaterally. Patient remained in the VICU for continued monitoring and care. On postoperative day two, the patient continued to require Lasix for elevated filling pressures. T max was 38.4 to 38.4. White count was 8.6, hematocrit 32.6 post transfusion 1 unit of pack cells. He was instituted on his preoperative medications. His pulse exam remained unchanged. Incisions were clean, dry, and intact. He continued to be diuresed and cardiopulmonary toilet and incentive spirometry was encouraged. He maintained NPO. He was diuresed to maintain him -1 liter. Regular insulin-sliding scale was used for glycemic control and he remained in the VICU. Postoperative day three, it was noted that he had a low platelet count, but it was stable. He was continued on his preoperative medications. He required a total of 40 of Lasix over the preceding 24 hours for diuresis. His lung sounds improved with some diminished sounds at the bases. Incisions were clean, dry, and intact. His pulse exam showed unchanged. Patient's epidural remained in place for analgesic control, and patient remained in the VICU. On postoperative day four, the PA catheter was converted to triple lumen. Lasix diuresis was continued. Patient was begun on clears as tolerated. Epidural was discontinued. His white count was 6, hematocrit of 33, BUN of 16, creatinine 0.7. He was afebrile. T max 98.6. Examination showed continued rales at the bases. Abdominal exam was minimal bowel sounds. Wounds were clean, dry, and intact and there was some ecchymosis at the inferior aspect of the wound. Pulse exam demonstrated palpable DP and PT on the left and right DP was biphasic with palpable right PT. His Lasix converted to b.i.d. His Foley was discontinued. His electrolytes were repleted, and A line was discontinued. Patient was transferred to the regular nursing floor for continued care. Postoperative day five, he continued to remain afebrile. He passed flatus. Podiatry was requested to see the patient for management of his foot ulcer and appropriate weightbearing status. His diet was advanced as tolerated. Impression was that this was a gentleman status post aortobifem with diminished protective sensation and superficial 1 x 1 cm ulcer at the submedial right hallux with hyperkeratotic borders. There was no drainage and the wound did not probe to bone. Patient had an epithelial base. Recommendations were that an x-ray at this time was not indicated, that this was a superficial tissue lesion that the patient should follow up in [**Hospital **] Clinic one week after discharge for debridement of the hyperkeratotic ulcerations. Patient was evaluated by Physical Therapy on [**2122-4-21**], who felt that he would be able to be discharged to home. On postoperative day six, the patient did have a bowel movement associated with flatus. At discharge, he was afebrile. Wounds were clean, dry, and intact. Lung exam noted some mild expiratory wheezing in the upper lung fields. Patient was discharged to home in stable condition. He should follow up with Dr. [**Last Name (STitle) 1391**] in two weeks' time. He should not drive a car until seen in followup. He should shower only. No tub baths. Prior to discharge, it was noted that patient had developed a temperature. CBC and blood cultures were obtained. Chest x-ray was requested. Results are pending at the time of dictation. Urine C&S and urinalysis were pending at the time of dictation. Discharge was deferred until situation discussed with attending and chest x-ray and urinalysis were reviewed. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg q.d. 2. Metoprolol 150 mg b.i.d., hold for systolic blood pressure less than 100, heart rate less than 60. 3. Enalapril 20 mg q.a.m., enalapril 10 mg q.p.m. 4. Isosorbide dinitrate SA 20 mg b.i.d. 5. Glipizide 10 mg q.d. 6. Oxycodone/acetaminophen tablets [**1-16**] q.4-6h. prn pain. DISCHARGE DIAGNOSES: 1. Right foot ischemic ulcerations with aortoiliac disease status post aortobifemoral bypass. 2. Diabetes type 2 controlled. 3. Hypertension controlled. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2122-4-22**] 08:22 T: [**2122-4-22**] 08:25 JOB#: [**Job Number 11968**] Admission Date: [**2122-4-16**] Discharge Date: [**2094-3-15**] Date of Birth: [**2052-5-28**] Sex: M Service: VASCULAR SURGERY ADDENDUM: This is a continuation of previous discharge summary. The patient's anticipated discharge on [**2122-4-22**] was held secondary to elevated temperature. The job number [**Numeric Identifier 11969**]. The patient's discharge was deferred secondary to a temperature and leukocytosis. Pan cultures were obtained. A chest x-ray was obtained. The patient's chest showed a right lower lobe infiltrate. The patient's stool was positive for C. difficile and blood cultures 4/4 were gram-positive cocci which were MRSA. The patient was continued on vancomycin, levofloxacin, and Flagyl. On [**2122-4-25**], the patient had an episode of weakness and short of breath. Arterial blood gases were 7.57, 25, 59, and 24. EKG with ST depressions in V2 and V3. Rule out was flat, negative enzymes. The patient was transferred to the VICU for continued monitoring. The patient remained in the VICU for 48 hours. He continued to do well and was transferred back to the regular nursing floor on [**2122-4-27**]. Infectious Disease was consulted on [**2122-4-28**] for persistent continued positive blood cultures and intermittent low-grade temperatures 99.62, 100.6. TEE was obtained which was negative for vegetations. The patient was begun on gentamycin, hep the vancomycin. The levofloxacin was discontinued on [**2122-4-25**]. Also, on [**2122-4-29**], the patient complained of right shoulder pain. He has a history of a right rotator tear. Orthopedics was consulted and an intra-articular steroid injection was done with improvement in the patient's pain. A CT of the abdomen was obtained that day and it demonstrated questionable fluid collection around the left distal anastomosis and proximal aortic stenosis. He continued on antibiotics and continued to be followed by Infectious Disease. The [**Last Name (un) **] Service was consulted regarding the patient's diabetic management. The patient had been on Glipizide and Metformin and the Metformin was discontinued secondary to elevated LFTs. Recommendations were made to start Lantus insulin at bedtime. This was instituted. Serial blood cultures taken every 24-48 hours was continued to be positive. Dr. [**Last Name (STitle) **] was requested to see the patient in consultation by Dr. [**Last Name (STitle) 1391**] on [**2122-5-4**]. He recommended a WBC tagged study and a repeat CT of the abdomen because the initial CT reported just usual perioperative reactive changes. A WBC tagged white blood study was done which showed positive uptake in the left groin area and the right shoulder. The vancomycin was discontinued on [**2122-5-5**] and daptomycin was instituted. On [**2122-5-6**], on examination that morning, a new murmur was auscultated and the patient underwent repeat TEE with the results pending at the time of dictation. Repeat CT of the abdomen showed persistent bilateral femoral perigraft fluid, left greater than right. His white count remained stable at 7.1. His creatinine was 0.7. Blood cultures from [**2122-4-25**] to [**2122-4-29**] grew MRSA and on [**2122-5-4**] to [**2122-5-6**] were no growth. On [**2122-5-7**] cultures were pending. The [**2122-5-7**] C. difficile was pending at the time of dictation. ID recommended that we should consider draining the left femoral fluid collection and sending it for culture, although Dr. [**Last Name (STitle) 1391**] and Dr. [**Last Name (STitle) **] felt that this was a seroma and not necessarily an infection process. They also recommended A rehabilitation evaluation for the right shoulder by Orthopedics to exclude joint seeding secondary to increased uptake in the WBC tagged scan. At the time of discharge, the patient was ambulating independently. A PICC line will be placed for continued IV antibiotic therapy for a total of six weeks of antibiotics. Discharge summary dictation regarding discharge medications and instructions will be dictated on the day of discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2122-5-8**] 11:26 T: [**2122-5-8**] 11:33 JOB#: [**Job Number 11970**] Admission Date: [**2122-4-16**] Discharge Date: [**2122-7-4**] Date of Birth: [**2052-5-28**] Sex: M Service: [**Last Name (un) **] ADDENDUM: Mr. [**Known lastname 634**] is now postoperative day No. 79, the date of this dictation is [**2122-7-4**], and since the previous discharge summary, the [**Hospital 228**] hospital course continued to be one of slow and steady progress towards being discharged to a rehabilitation center. However, this morning the patient became in acute respiratory failure complicated by hemodynamic instability, pulseless electrical activity and after 38 minutes was pronounced dead at 6:38 in the morning, [**7-4**]. He had been receiving ongoing treatment with Dr. ___________for Staphylococcus pneumonia as well as graft infection, and the last set of computerized tomography scans showed no worsening in the appearance of these prosthetic materials and their appearance on computerized axial tomography scan. He had also been receiving Coumadin and was a tracheostomy collar, off the ventilator, being diuresed with Lasix and on a beta blocker three times a day. His death was reported to his family and Dr. [**Last Name (STitle) 1391**], and this includes the final discharge summary for him. DISCHARGE DISPOSITION: Death. DISCHARGE DIAGNOSIS: Right foot ischemic ulcerations with aortoiliac disease, status post aortobifemoral bypass. Type 2 diabetes, requiring insulin. Hypertension. Coronary artery disease with myocardial infarction in [**2111**] and [**2113**]. Gastroesophageal reflux disease. Decreased hearing. Right-sided sciatica. Hyperlipidemia. Staphylococcus aureus bacteremia. Staphylococcus aureus pneumonia. Creation of a left axillo to superficial femoral artery bypass with PTFE, secondary to a left femoral pseudoaneurysm after infection of a left limb of the aortobifemoral bypass graft. The patient also had chest tubes placed and removed requiring a procedure in the Operating Room which just resulted in straw-colored fluid evacuation for a loculated left-sided effusion, previously seen on computerized tomography scan. On [**7-1**], the patient underwent flexible bronchoscopy and laryngoscopy which resulted in a Shiley tracheostomy tube placement. Hypernatremia treated with free water. Failure to thrive, malnutrition requiring ventral tube feedings. Volume overload postoperatively. Atrial fibrillation postoperatively. Respiratory failure. Left lower lobe hematoma seen on computerized tomography scan. Severe deconditioning. Drug-induced neutropenia, resolved. Acute renal failure, resolved. CONDITION ON DISCHARGE: Deceased. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 11971**] MEDQUIST36 D: [**2122-7-4**] 07:30:18 T: [**2122-7-4**] 08:20:25 Job#: [**Job Number 11972**] Name: [**Known lastname 1474**], [**Known firstname **] W Unit No: [**Numeric Identifier 1710**] Admission Date: [**2122-4-16**] Discharge Date: [**2122-5-11**] Date of Birth: [**2052-5-28**] Sex: M Service: DISCHARGE MEDICATIONS: 1. Aspirin 81 mg once daily. 2. Metoprolol 75 mg twice a day. 3. Isosorbide dinitrate 20 mg twice a day. 4. Rosuvastatin 10 mg once daily. 5. Oxycodone. 6. Acetaminophen 5 ml 325 one to two q4-6 hours as needed for pain. 7. Enalapril maleate 10 mg qam and 5 mg qpm. 8. Protonix 40 mg once daily. 9. Daptomycin 20 mg intravenous q24 hours for a total of 6 weeks, started on [**2122-5-2**]. 10. Calcium carbonate 500 mg three times a day. 11. Ferrous sulfate 325 mg once daily. 12. Colace 100 mg twice a day. 13. Insulin dosing L-arginine 26 units qhs. 14. Humalog [**Date Range 1711**] scale as follows, breakfast and lunch [**Date Range 1711**] scale glucose if less than 80 no insulin, 81-120 8 units, 121-160 10 units, 161-200 12 units, 201-240 14 units, 241-280 16 units, 281-320 18 units, 321-360 20 units, greater than 360 notify doctor. Dinner Humalog [**Date Range 1711**] scale glucose if less than 80 no insulin, 81-120 6 units, 121-160 8 units, 161-200 10 units, 201-240 12 units, 241-280 14 units, 281-320 16 units, 321-360 18 units, greater than 360 notify doctor. [**First Name (Titles) 1712**] [**Last Name (Titles) 1711**] scale glucose if less than 200 no insulin, 201-240 2 units, 241-280 3 units, 281-320 4 units, 321-360 6 units, greater than 360 notify doctor. DISCHARGE INSTRUCTIONS: Patient should follow-up with Podiatry for hyperkeratotic lesion. You may follow-up with our people or follow-up with own podiatrist. Should follow-up with Dr. [**Last Name (STitle) **] in two weeks. Should call for an appointment. Should follow-up with [**Hospital 616**] Clinic as discussed by [**Last Name (un) 616**], please call for an appointment. Should follow-up with Infectious Disease clinic in two weeks. Should follow-up with orthopedist post discharge. [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**], M.D. [**MD Number(1) 238**] Dictated By:[**Last Name (NamePattern1) 145**] MEDQUIST36 D: [**2122-5-11**] 12:16 T: [**2122-5-11**] 21:17 JOB#: [**Job Number 1713**]

[ "997.2", "444.0", "511.9", "442.2", "510.9", "707.15", "482.49", "998.13", "996.62" ]

icd9cm

[ [ [] ] ]

[ "34.04", "33.23", "38.93", "97.23", "39.25", "88.72", "99.04", "38.86", "89.64", "31.1", "39.29", "96.04", "99.15", "34.91" ]

icd9pcs

[ [ [] ] ]

14712, 14720

8636, 14688

16610, 17902

14742, 16044

2202, 2464

3572, 8289

17927, 18674

1992, 2176

2654, 3554

1263, 1690

159, 182

211, 1243

1712, 1969

2481, 2638

16069, 16587

21,141

133,936

23249+23250

Discharge summary

report+report

Admission Date: [**2175-12-1**] Discharge Date: [**2175-12-12**] Service: CSU CHIEF COMPLAINT: Mr. [**Known firstname 3065**] [**Known lastname 34150**] was transferred from [**Hospital3 35813**] Center for evaluation for cardiac surgery. HISTORY OF PRESENT ILLNESS: This is an 81-year-old male with known coronary artery disease who first presented to [**Hospital3 59745**] Center on [**11-28**] with a complaint of shortness of breath and chest tightness. He was found to be in congestive heart failure and treated with Lasix and nitroglycerin. He was admitted to the Medicine Service and ruled in for a non-ST-myocardial infarction with peak troponin's of 0.81. Now, since that point, was chest pain free. PAST MEDICAL HISTORY: 1. Coronary artery disease first diagnosed two years ago. The patient has had multiple admissions over the last six for congestive heart failure. A catheterization in [**Month (only) 205**] of [**2175**] showed a 75 percent left main, 80 percent circumflex, and 99 percent right coronary artery as well as aortic stenosis with peak gradient of 30 mmHg. The patient declined surgery at that time due to high risk. 2. Aortic stenosis with a mean gradient of 30 with an aortic valve area of 1. 3. Peripheral vascular disease; status post bilateral femoral- to-popliteal bypass seven years ago. 4. Chronic obstructive pulmonary disease. 5. Hypercholesterolemia. 6. Gastroesophageal reflux disease. 7. Macular degeneration; the patient is currently legally blind. ALLERGIES: He states no known drug allergies. MEDICATIONS ON ADMISSION: Include Ecotrin 325 mg once daily, Isordil 40 mg q.6h., labetalol 200 mg q.8h., Monopril 40 mg in the morning, Zocor 60 mg at bedtime, Protonix 40 mg once daily, Lasix 80 mg in the morning and 60 mg in the evening, Tylenol as needed, nitroglycerin as needed, and Colace. SOCIAL HISTORY: Remote tobacco use. He quit six months ago. Prior to that was a pack a day smoker. Restarted recently, and currently smoking 10 cigarettes a day. He denies alcohol use. He denies other recreational drug use. He lives at home with his wife. Worked as a manager of a CVS. He is now retired. PHYSICAL EXAMINATION ON ADMISSION: Temperature was 96.6, his heart rate was 62, his blood pressure was 154/54, his respiratory rate was 18, and his oxygen saturation was 98 percent on room air. In general, somewhat disheveled but in no acute distress. Head, eyes, ears, nose, and throat examination revealed anicteric and not injected. The pupils were equally round and reactive to light. The extraocular muscles were intact. Visual acuity revealed he could count the number of fingers at one to two feet but could not read letters at any distance. The oropharynx was clear. The mucous membranes were moist. The neck was supple. No jugular venous distention. No bruits. The lungs were clear to auscultation bilaterally without rales. Cardiovascular examination revealed distant heart sounds. A regular rate and rhythm. First heart sounds and second heart sounds with a [**3-11**] blowing systolic murmur heard best at the right upper sternal border. The abdomen was soft, nontender, and nondistended. There were normal active bowel sounds. There was a well-healed midline scar. The extremities were warm with 1 plus pitting edema (right greater than left). Dorsalis pedis pulses were 2 plus bilaterally. Neurologically, motor strength was [**5-10**] in the upper and lower extremities. Sensory examination was grossly intact. LABORATORY DATA FROM [**Hospital1 **]: White blood cell count was 7.2, his hematocrit was 36.6, and his platelets were 245. Sodium was 144, potassium was 3.8, chloride was 106, bicarbonate was 27, blood urea nitrogen was 40, creatinine was 1.5, and blood glucose was 102. RADIOLOGY: Electrocardiogram revealed sinus bradycardia with first-degree atrioventricular block. Normal axis with a right bundle branch block. ST depressions in V5 and V6 with Q waves in the inferior leads. A transesophageal echocardiogram done in [**2175-9-6**] showed a normal ejection fraction with left ventricular hypertrophy and left atrial enlargement, moderate mitral regurgitation, mild aortic insufficiency, and mild-to- moderate aortic stenosis. SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Medicine Service and was seen by the Cardiac Surgery Service and accepted for coronary artery bypass grafting as well as aortic valve replacement. He was followed by the Medicine Service until on [**12-5**] the patient was brought to the Operating Room. Please see the Operative Report for full details. In summary, the patient had an aortic valve replacement with a 21 Porcine tissue valve and coronary artery bypass grafting times three with a left internal mammary artery to the left anterior descending, saphenous vein graft to the obtuse marginal, and saphenous vein graft to the posterior descending artery. His bypass time was 137 minutes with a cross-clamp time of 107 minutes. The patient tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient was AV paced at a rate of 88 beats per minute with a mean arterial pressure of 74. He had dobutamine at 10 mcg/kg/minute, Neo-Synephrine at 0.5 mcg/kg/minute, insulin at 2 units per hour, and propofol at 10 mcg/kg/minute. The patient did well in the immediate postoperative period. His blood gases were slightly acidotic. Therefore, he remained intubated throughout the course of the operative day. On postoperative day one, he remained hemodynamically stable. His blood gases had somewhat corrected. He was weaned from the ventilator and successfully extubated. Also on postoperative day, the patient was weaned from his dobutamine as well as Neo-Synephrine drips. He was begun on Lasix as well as beta blockade and remained in the Intensive Care Unit for close hemodynamic monitoring as well as pulmonary toilet. On postoperative day two, the patient was transferred from the Cardiothoracic Intensive Care Unit to [**Hospital Ward Name 121**] Two for continued postoperative care and cardiac rehabilitation. Once on the floor, the patient's temporary pacing wires and chest tubes were removed as was his central venous access. Additionally, on postoperative day three the patient was noted to be in a rapid atrial fibrillation with a ventricular response rate between 120 and 140. He was treated initially with intravenous Lopressor and failed to convert, and ultimately was started on amiodarone. The patient remained in atrial fibrillation for several days; for which he was begun on heparin as well as Coumadin. However, ultimately the patient converted to a normal sinus rhythm and both heparin and Coumadin were discontinued. For several days on the floor, the patient had an uneventful course. His activity level was increased with the assistance of the nursing staff as well as Physical Therapy. He was gently diuresed as he had initially had an increase in his creatinine from a baseline of 1.6 to 2.5 during his initial hospital visit that gradually resolved. Ultimately, by postoperative day seven, it was decided that the patient was stable and ready to be transferred to rehabilitation for continuing postoperative care. At the time of this dictation, the patient's physical examination was as follows. His temperature was 98, his heart rate was 59 (sinus rhythm), his blood pressure was 125/61, his respiratory rate was 20, and his oxygen saturation was 94 percent on room air. His weight was 73.4 kilograms; preoperatively was 70 kilograms. Neurologically, alert and oriented. A nonfocal examination. Pulmonary examination revealed clear to auscultation bilaterally. Cardiac examination revealed a regular rate and rhythm. The sternum was stable. Incision with staples. A small area of eschar at the base of his incision. The staples can be removed on or about [**12-25**]. The abdomen was soft, nontender, and nondistended. There were normal active bowel sounds and a well-healed scar. The extremities were warm and well perfused with 1 to 2 plus edema bilaterally. Saphenous vein graft harvest site is on the left. It is an endoscopic site with Steri-Strips open to air, clean and dry. Laboratory data revealed sodium was 138, potassium was 4.1, chloride was 103, bicarbonate was 26, blood urea nitrogen was 86, creatinine was 2.4, and glucose was 165. Magnesium was 2.7. Hematocrit was 32.2. Prothrombin time was 16, partial thromboplastin time was 64, and INR was 1.7. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: He is to be discharged to a rehabilitation center. DISCHARGE DIAGNOSES: 1. Aortic stenosis; status post aortic valve replacement with a 21 Porcine valve. 2. Coronary artery disease; status post coronary artery bypass grafting times three with a left internal mammary artery to the left anterior descending, a saphenous vein graft to obtuse marginal, and saphenous vein graft to the posterior descending artery. 3. Postoperative atrial fibrillation. 4. Status post aortobifemoral bypass. 5. Peripheral vascular disease. 6. Hypercholesterolemia. 7. Gastroesophageal reflux disease. 8. Chronic obstructive pulmonary disease. 9. Legally blind. DISCHARGE FOLLOWUP: The patient was instructed to follow up with Dr. [**Last Name (STitle) 59746**] [**Name (STitle) 59747**] in two to three weeks and follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] in four weeks. MEDICATIONS ON DISCHARGE: 1. Potassium chloride 20 mEq q.12h. 2. Colace 100 mg twice daily. 3. Aspirin 81 mg once daily. 4. Percocet 5/325 one to two tablets q.4-6h. as needed. 5. Simvastatin 60 mg once daily. 6. Prilosec 40 mg once daily. 7. Metoprolol 50 mg twice daily. 8. Lasix 80 mg twice daily. 9. Amiodarone 400 mg twice daily times one week, then 400 mg once daily times one week, then 200 mg once daily. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2175-12-12**] 11:54:58 T: [**2175-12-12**] 12:36:23 Job#: [**Job Number 59748**] Admission Date: [**2175-12-1**] Discharge Date: [**2175-12-12**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: shortness of breath, chest pain, transferred for CABG Major Surgical or Invasive Procedure: AVR/CABG History of Present Illness: 81 yo male, h/o CAD s/p prior catheterizations (most recent 7/04-2Vd), PVD, AS, presenting with months of shortness of breath and ?chest pain. Pt states that over the past 6 months, he has been in and out of the hospital (8 times), usually for SOB/CHF flares, some cp. He was cath'ed at [**Hospital2 **] [**Hospital3 6783**] on [**2175-7-17**] showing 75% ostial Left main, LAD luminal irregularities, Lcx with 80% ostial/proxima, 90% RCA ostial. Surgery was recommended at this time, but he refused. Most recently, he presented to [**Hospital3 **] center on [**11-28**] with SOB, found to be in CHF, treated with Lasix and nitro. He was admitted, ruled in for NSTEMI with peak tnt 0.81 (now trending down). He denies any chest pain or other symptoms and is currently symptom-free, no sob. Up to a few weeks ago, he states he could walk around for up to an hour (i.e. grocery shopping). Of late, he can only walk ?[**1-6**] blocks, a few steps. He has a baseling 35-45 degree orthopnea, no PND. He is also complaining of right leg pain for the past 2 weeks, hasn't been taking any meds. This has been limiting his ability to ambulate (states pain worse in am, slightly better with walking). Pt transferred here for CABG at this time. Past Medical History: Cardiac History: 1st diagonal ?intervention [**1-6**] yrs ago [**7-9**] Cath: 75% ostial Left main, LAD luminal irregularities, Lcx with 80% ostial/proxima, 90% RCA ostial [**9-9**]: TTE: EF=55%, AV 3.3 m/s (gradient about 30), mild AR, mild TR, mod MR, mild LVH PMH: 1. CAD as above, multiple recent admissions for CHF 2. AS 3. PVD, s/p bilat fem-[**Doctor Last Name **] bypass 7 yrs ago 4. ?COPD 5. Hypercholesterolemia 6. GERD 7. Macular degeneration, legally blind Meds on transfer: ASA 325 Isordil 40 mg q6h Labetalol 200 q8h Monopril 40 qam Protonix 40 mg daily Lasix 80 mg qam, 60 mg qhs Tylenol SL NTG PRN Colace ALL: NKDA, allergice to mushrooms, [**Country 1073**]) Social History: Quit smoking 6 months ago (1ppd), restarted 3 mo ago (10 cigs/d), now quit again no EtOH Lives with wife Retired CVS manager Was independant of ADL's at home Family History: Sister with CAD, s/p stenting age 75 Physical Exam: VS: 98.6 144/60 66 20 93% RA wt-70.7 kg Gen: nad, blind, sitting in bed, comfortable HEENT: PERRL, EOM grossly intact, OP clear Neck: no JVD, no carotid bruits (?radiation of SEM) CV: 2/6 SEM heard best RUSB with radiation to carotids, L>R, no r/g Lungs: CTA Bilat, no w/r/r Abd: protuberant, soft, nt/nd, nabs Groin: bilateral bruits, L>R Extr: PT 2+ bilat, trace bilateral LE edema Neuro: grossly intact, no spinal tenderness, no paraspinal tenderness, positive straight leg-raise on right, nl sensation and strength in LE bilaterally Pertinent Results: OSH: BUN/CR=40/1.5 Hct: 36.6 CK= 83--->81--->69 TNI= 0.03-->0.81--->0.53 cholest=139, TH=115, HDL=37, LDL=79 [**2175-12-1**] 9:45p 141 102 38 90 3.8 30 1.6 CK: 54 MB: 2 Trop-*T*: 0.08 Ca: 8.9 Mg: 2.2 P: 4.3 MCV= 87 WBC= 5.3 Hgb= 10.3 PLT= 206 HCT= 31.3 PT: 13.8 PTT: 24.3 INR: 1.2 EKG: NSR, q's in III, avf, ?ST-T wave abnormalities in precordial leads, ST depr in II, AVL, V4-V6; ST elev V1-V3; no change when compared to EKG from [**9-9**] Brief Hospital Course: A/P: 81 yo female, h/o CAD with recent cath on [**7-9**] showing 2vd, mild-moderate AS, PVD, presenting with multiple admissions for CHF over the past 6 months, transferred from [**Hospital3 **] center for CABG, positive enzymes with no significant EKG transfers. 1. CAD: pt with known 3vd from prior caths, he refused surgery in the past but has agreed to CABG at this time. He had positive troponins, no real EKG changes, no chest pain (just presented with SOB). Pt was evaluated by CT surgery in-house, and surgery is tentatively scheduled for [**12-5**]. TTE report was obtained prior to surgery (EF=55%), UA was negative, and CXR was within normal limits. As per TTE reports, he has mild-moderate AS that may be intervened upon during CABG. CK's were cked until they were flat. He was continued on his ASA, beta blocker, ACEI, statin, and isordil. He remained asymptomatic/chest pain free prior to CABG. 2. CHF: pt with EF=55% as per TTE report from [**9-9**], has had multiple admissions for CHF, on standing lasix, currently seems euvolemic with clear lungs, no peripheral edema. Lasix (80 qam, 60 qhs) was continued in-house. 3. AS: mild-moderate AS, plan for intervention on valve during CABG (gradient approx 30, AV 3/3 m/s) 4. Sciatica: pt with positive right straight leg raise, with pain with ambulation. Pt achieved good pain relief with percocet. He had good rectal tone on exam and no signs of nerve/cord compression. He was evaluated by neurology for this while in-house, prior to CABG. 5. PVD: stable for now, s/p fem-[**Doctor Last Name **] bypass 6. Dispo: He was transferred to CT surgery for CABG. Medications on Admission: Meds on transfer: ASA 325 Isordil 40 mg q6h Labetalol 200 q8h Monopril 40 qam Protonix 40 mg daily Lasix 80 mg qam, 60 mg qhs Tylenol SL NTG PRN Colace ALL: NKDA, allergice to mushrooms, [**Country 1073**]) Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal QD/PRN as needed for constipation. 8. Simvastatin 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x 1 week then 400mg QD x 1 week then 200mg QD. Discharge Disposition: Extended Care Facility: Geriatric Authority Discharge Diagnosis: s/p AVR (#21 porcine)CABGx3 (LIMA->LAD, SVG->OM, SVG->PDA) postop AFib,s/p aorto-bifem bypass, PVD, ^chol,GERD, COPD, legally blind Discharge Condition: good Discharge Instructions: kep wounds clean and dry. OK to shower, no bathing or swiming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds Followup Instructions: Dr [**Last Name (STitle) 59746**] [**Name (STitle) 59747**] in [**2-7**] weeks Dr [**Last Name (STitle) **] in 4 weeks

[ "414.01", "305.1", "997.1", "724.3", "362.50", "410.71", "424.1", "496", "272.0", "530.81", "427.31", "428.0", "443.9" ]

icd9cm

[ [ [] ] ]

[ "36.12", "35.21", "89.60", "39.61", "36.15" ]

icd9pcs

[ [ [] ] ]

17086, 17132

13955, 15598

10649, 10660

17308, 17314

13470, 13932

17513, 17635

12834, 12872

8759, 9344

15857, 17063

17153, 17287

9657, 10539

15624, 15624

17338, 17490

12887, 13451

4315, 8630

10556, 10611

9365, 9631

10688, 11933

2237, 4286

11955, 12433

12659, 12818

8655, 8662

15642, 15834

55,934

169,449

39066

Discharge summary

report

Admission Date: [**2135-5-23**] Discharge Date: [**2135-6-9**] Date of Birth: [**2086-2-27**] Sex: M Service: SURGERY Allergies: Dilantin Attending:[**First Name3 (LF) 148**] Chief Complaint: Pancreatitis with respiratory failure. Transfer from [**Hospital1 10551**] Major Surgical or Invasive Procedure: [**2135-5-24**]: Ultrasound-guided right thoracentesis. History of Present Illness: 49 year-old genleman with seizures on phenobarbital who is transfered from [**Hospital3 5365**] with hemorrhagic pancreatitis and hypoxic respiratory failure with bilateral hemothorax. He was in his prior state of health until [**5-20**] when he started with abdominal pain and vomiting. He initially started with epigastric pain radiating towards the back, band-like. Then, he developed vomit x2. He denied any changes in his bowel movemnets, fevers, dysuria, chills, SOB, chest pain, use of alcohol or illegal substances or smoking. . He went to [**Hospital1 86606**] ER, where his exam showed diffuse abdominal pain. Initial labs showed WBC 18.2 with 9% bands, AST 54, ALT 32, AP 178, Lipase 4350, TB 0.4. CT scan of the abdomen showed edematous pancreas with peripancreatic fluid as well as cholecystitis. His [**Last Name (un) **] was 3 with a predicted 15% mortality. He was admitted to the surgical service, received aggresive IVF, made NPO and started on Zosyn 3.375 g (Day 1 [**5-20**]). He initially improved and WBC went back to normal limits. I do not have lab values to calculate 48 hours [**Last Name (un) **]. . On [**5-23**] he was found to be in respiratory distress with tachycardia and hypocxia with ABG pO2 56% on 40%. There was question of aspiration. Pulmonary was consulted who decided to intubate the patient. Pt underwent administration of etomidate, succinyl choline, pancuronium, cisatracurium and was intubated with ET 8. CXR showed bilateral pleural effusions. Thoracocentesis demonstrated frank red blood. Bronchoscopy bilateral greenish fluid. Diagnosis being considered included CHF vs. PNA vs. ARDS. Unfortunately there is no documentation of bialteral alveolar infiltrates. The lab values showed Na 139, K 3.8, Cl 106, CO2 24, AG 8.9, Glucose 208, BUN 13, creatinine 1.1, Ca 7.8, TP 4.8, Alb 2.7, Glob 2.1, TB 0.8, CPK 255, AST 67, ALT 18, AP 56, TG 175, Chol 120, HDL 19, LDL 66, Trop T 0.01, CK-MB 1.7, NT-proBNP 913. His ABG was 7.48/35/221 on AC 450/20/5/1. . Patient underwent an MRCP showed normal bile duct without evidence of filling defect or obstructing stone. Edematous hemorrhagic pancreatitis without evidence of enhancement. Concerning for necrotizing hemorrhagic pancreatitis. Therefore, it was decided to transfer the patient to [**Hospital1 18**]. . His labs prior to transfer were Na 143, K 2.5, Cl 112, CO2 25, AG 5.7, Glucose 72, BUN 15, creatinine 1.3, BUN 11, Ca 8.0, Phos 1.1, WBC 6.2, HCT 25, PLT 121, Band 7%, Neut 71%, Lymph 15%. Past Medical History: Seizure disorder on phenobarbital: Diagnosed as a child, was on dilantin and was switched to phenobarbital. On [**4-8**] he had 5 seizures and on [**5-7**] he had 3 seizures. CT scan head normal (last [**11-29**]). H/o Depression. Asperger's Syndrome. PAST SURGICAL HISTORY: S/p repair of rectal prolapse in [**2100**]. Tonsillectomy. Wisdom teeth extraction. Myringotomy tubes bilateraly. Social History: He lives by himself in [**Location (un) **], MA in a rooming house. Works at a gas station nearby his home. Denies any current or past alcohol use, smoking or illegal substance use. Family History: Non-contributory. Physical Exam: On Admission: VITAL SIGNS - Temp 101 F, BP 115/85 mmHg, HR 131 BPM, RR 20 X', O2-sat 96% RA GENERAL - well-appearing man in NAD, comfortable, intubated, not jaundiced (skin, mouth, conjuntiva), opens eyes spontaneously, follows commands HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. Positive [**Doctor Last Name 352**] [**Doctor Last Name 4862**] sign, no Cullen. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-25**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2135-5-23**] 09:11PM BLOOD WBC-7.3 RBC-2.73* Hgb-8.9* Hct-26.1* MCV-96 MCH-32.5* MCHC-33.9 RDW-13.9 Plt Ct-140* [**2135-5-26**] 04:50AM BLOOD WBC-8.2 RBC-2.67* Hgb-8.6* Hct-26.2* MCV-98 MCH-32.1* MCHC-32.6 RDW-13.7 Plt Ct-167 [**2135-5-26**] 04:50AM BLOOD PT-15.5* PTT-29.1 INR(PT)-1.4* [**2135-5-26**] 04:50AM BLOOD Glucose-213* UreaN-11 Creat-0.8 Na-143 K-4.2 Cl-109* HCO3-20* AnGap-18 [**2135-5-23**] 09:11PM BLOOD Glucose-112* UreaN-16 Creat-1.2 Na-146* K-3.7 Cl-113* HCO3-26 AnGap-11 [**2135-5-23**] 09:11PM BLOOD ALT-16 AST-51* LD(LDH)-1147* CK(CPK)-385* AlkPhos-42 Amylase-716* TotBili-0.9 [**2135-5-26**] 04:50AM BLOOD ALT-18 AST-31 LD(LDH)-865* AlkPhos-83 TotBili-2.0* [**2135-5-23**] 09:11PM BLOOD Lipase-258* [**2135-5-23**] 09:11PM BLOOD calTIBC-120* VitB12-158* Folate-8.5 Ferritn-788* TRF-92* [**2135-5-23**] 10:13PM BLOOD Type-MIX pO2-188* pCO2-40 pH-7.38 calTCO2-25 Base XS-0 Comment-GREENTOP [**2135-5-24**] 04:10AM BLOOD Type-ART Temp-38.3 PEEP-5 pO2-77* pCO2-39 pH-7.41 calTCO2-26 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [**2135-5-23**] 10:13PM BLOOD Lactate-0.8 . DIAGNOSTICS: [**2135-5-23**] AP CXR: There are low lung volumes. Endotracheal tube tip lies approximately 2.3 cm above the carina. Nasogastric tube extends to the distal stomach. Right central catheter tip is in the lower SVC. There is increased opacification at both bases, most likely consistent with combination of atelectasis and effusion. The possibility of supervening pneumonia would have to be considered if the symptoms are appropriate. . [**2135-5-24**] ECHO: 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 normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . [**2135-5-27**] AP CXR: In comparison with the study of [**5-26**], the degree of pulmonary edema is less prominent. Some of this could reflect the more upright technique. Bilateral pleural effusions are again seen with bibasilar atelectasis. An oblique line at the right base suggests collapse of the right lower lobe. Upper zones are clear. There is marked dilatation of the gas-filled stomach, for which a nasogastric tube might be helpful. . [**2135-5-29**] AP CXR: As compared to the previous radiograph, the malpositioned catheter has been repositioned. Currently, the left PICC line projects with its tip over the mid SVC. The pre-existing bilateral pleural effusions with bilateral subsequent areas of atelectasis have both decreased in size and extent. The retrocardiac lung areas show improved ventilation. There is unchanged size and shape of the cardiac silhouette. No evidence of pneumothorax. IMPRESSION: Correct position of the left-sided PICC line, decrease of bilateral pleural effusions. . [**2135-6-2**] ABD/PELVIC CT W/CONTRAST: 1. Interval progression of necrotizing pancreatitis with no normal pancreatic tissue identified. Immature pseudocyst formation involving the entire panreatic bed and tracking down the left anterior pararenal space. 2. No fistulae or vascular pseudoaneurysms identified. 3. Decrease in extra-pancreatic free fluid. 4. New small pleural effusions and bibasilar atelectasis, left greater than right. 5. Cholelithiasis. Brief Hospital Course: Mr. [**Known firstname **] [**Known lastname **] is a 49M transfered from [**Hospital3 5365**] with hemorrhagic pancreatitis and hypoxic respiratory failure with bilateral hemothorax. He was admitted to the Medical ICU NPO, on IV fluid rescusitation, intubated, with a foley catheter in place, and IV Fentanyl for pain. . MICU COURSE: . #. Hemorrhagic pancreatitis - Patient presented with hemorrhagic pancreatitis with [**Last Name (un) **] of 3 and a 15% mortality. He improved until today when there was the respiratory event (see below). His lipase improved from ~4300 to 258. He has necrotizing/hemorrhagic pancreatitis with diffuse fluid on CT/MRI of OSH without any cyst, pseudocyst or abcess. There is nothing to drain. Conservative management in step up approach has shown to improvement in mortality (NEJM 2 weeks ago). He was initially started on Vanc/Meropenem while we were awaiting the cultures and it was stopped on [**5-25**]. He continued to improve and NGT was pulled on [**5-26**] and he was started on clears. . #. Hypoxic respiratory failure - Patient was improving and had a sudden event with an acute respiratory distress with hypoxia. There was question of aspiration. The patient was intubated, and mechanical ventilation started. Given the nature of the even, the most likely diagnosis is aspiration pneumonitis or aspiration pneumonia. Differential includes PE (he has S1Q3T3), CHF (NT proBNT ~900, but no signs of overload) and ARDS (no bilateral infiltrates). The most likely etiology is aspiration of bilious content. He improved rapidly as well as his CXR, therefore, most likely there is not an infection. On [**2135-5-25**], the patient was extubared. . #. Anemia - Patient with normocytic, normochromic anemia with normal RDW with an HCT of 25 stable from the morning. The most likely etiology is bleeding into abdomen in the setting of pancreatitis. He has history of bloody effusions, which were tapped here and had an HCT <2% ruling out hemothorax. His HCT has been stable. . #. Fever - Patient spiking daily up to 101. Most likely secondarely to pancreatitis and/or aspiration PNA/pneumonitis. We have to rule out infection and bacteremia. Continue to monitor surveillance cultures. . #. Thrombocytopenia - Not on heparin at OSH. Unclear etiology. He improve on its own, despite heparin SQ, suggesting he may have had either consumption secondarely to pancreatitis or marrow supression. Now resolved. . #. Hypernatremia - Mild hypovolemic hypernatremia in the setting of decreased intravascular volume (CVP 8). Improved with IVF. . #. Seizure - Continue Phenobarbital initially IV and when tolerated PO it was switched. . #. Pleural effusions - Most likely secondarely to pancreatitis, given high amylase and peripancreatic fluid collection. We ruled hemothorax with thoracosenthesis and HCT <2%. . #. Gases - Patient has ABG very similar to VBG. Could be ASD/PFO with low preload and positive pressure creating big shunt. TTE ruled out shunt (question PFO, but it would be very small and would not explain labs). . [**Hospital Ward Name **] 9 COURSE: . The patient was transferred to the General Surgical Service on [**2135-5-27**] for further evaluation of gallstone pancreatitis. He was NPO except medications, on IV fluids, with a foley catheter in place, and he recieved Morphine IV PRN and PO acetaminophen for pain with good effect. Prior to transfer, a PICC line was placed, and TPN started. The patient was hemodynamically stable. . The patient responded well to conservative management. He was started on sips of clears on [**2135-5-30**]. Diet was progressively advanced as tolerated to a diabetic regular diet by [**2135-6-1**]. On [**2135-6-1**], the patient was weaned off of the TPN. The foley catheter was discontinued the morning of [**2135-5-31**]. The patient subsequently voided without problem. . [**2135-6-2**] repeat abdominal/pelvic CT revealed interval progression of necrotizing pancreatitis with no normal pancreatic tissue identified. Immature pseudocyst formation involving the entire panreatic bed and tracking down the left anterior pararenal space. No fistulae or vascular pseudoaneurysms were identified. . During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was initially administered when indicated. Labwork was routinely followed; electrolytes were repleted when indicated. . Due to marked damage to the pancreas secondary to necrotizing pancreatitis, the patient developed hyperglycemia, which ultimately developed into insulin-dependent diabtes mellitus. The [**Last Name (un) **] Diabtetes Team was consulted, and insulin regimen started with ongoing and extensive teaching by both [**Last Name (un) **] and the patient's nursing team. Given the Asperger's Syndrome and possible intellectual disability, the patient had a very difficult time understanding the concept of insulin dependence, glucose monitoring, and insulin administration. Given that he lives alone in a rooming house, and has limited resources nad social supports, it was determined that he should be discharged to a skilled nursing facility to continue work on and become proficient in management of his newly-diagnosed IDDM. He will receive further glucose monitoring and insulin administration teaching at the skilled nursing facility. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a diabetic regular diet, ambulating, voiding without assistance, and pain was well controlled. He was discharged to a skilled nursing facility for further follow-up care; expected length of stay less than 30days. He will return in approximately three weeks for a repeat abdominal/pelvic CT to re-evaluate the necrotizing pancreatitis and formation of the pancreatic pseudocyst. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: CURRENT HOME MEDICATIONS: Phenobarbital 120 mg [**Hospital1 **] . CURRENT TRANSFER MEDICATIONS: Ativan 0.5 mg IV q6 hrs Combivent 8 PUFFS INH q6 hrs D50W IV UD Dilaudid 0.25 mg IV q3 hrs PRN pain Diprivan 100 ml IV cont infusion Fentanyl 1000 IV cont infusion Glucagon 1 mg IM UD Glutose 15 G oral PO UD Lopressor 5 mg IV q6 hrs Nexium 40 mg Q24 hrs NS 100 ml IV q8 hrs Zosyn 3.375 g Phenobarbital 120 mg IV q12 hrs Refres plus 2 drops OU Q6H Reglan 10 mg IV q6 hrs Regular insulin SC Q4 hrs Tylenol 650 mg PO Q6 hrs Zofran 4 mg IV q6 hrs PRN nausea Discharge Medications: 1. Phenobarbital 60 mg Tablet Sig: Two (2) Tablet PO twice a day. 2. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 5. Alcohol Pads Pads, Medicated Sig: One (1) pad Topical As directed : Diabetic supply. Disp:*1 box* Refills:*0* 6. Humalog Mix 75-25 KwikPen 100 unit/mL (75-25) Insulin Pen Sig: Twelve (12) units by PEN Subcutaneous twice a day. Disp:*5 3mL PENS* Refills:*2* 7. FreeStyle Lite Strips Strip Sig: One (1) strip In [**Last Name (un) 5153**] four times a day. Disp:*100 strips* Refills:*2* 8. FreeStyle Lancets Misc Sig: One (1) lancet Miscellaneous As directed for glucose monitoring. Disp:*1 box* Refills:*0* 9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Pen Needle 31 X [**6-5**] Needle Sig: One (1) Pen Needle Miscellaneous As directed [**Hospital1 **]. 12. Insulin Lispro 100 unit/mL Solution Sig: 2-4 units Subcutaneous As directed per Humalog Insulin Sliding Scale: Patient should NOT be discharged from [**Hospital1 1501**] on sliding scale; only on Humalog 75/25 Mix. Discharge Disposition: Extended Care Facility: [**Hospital 392**] Rehabilitation & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: 1. Necrotizing pancreatitis 2. Right pleural effusion 3. Type II DM 4. Seizure disorder 5. Respiratory failure - resolved. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-30**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Please follow your recommended diabetic diet, check your fingerstick blood sugars, and administer insulin as instructed. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2135-6-24**] 9:00. Location: [**Hospital Ward Name 23**] 4, [**Hospital Ward Name 516**]. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**] Date/Time:[**2135-6-24**] 11:00. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]. . Please call ([**Telephone/Fax (1) 33013**] to arrange a follow-up appointment with DR. [**Last Name (STitle) 8338**] (PCP) in [**1-22**] weeks. Completed by:[**2135-6-9**]

[ "V45.89", "287.5", "577.0", "299.80", "574.20", "577.2", "996.1", "276.0", "507.0", "250.00", "311", "584.9", "511.89", "285.1", "345.90", "518.81", "E879.8" ]

icd9cm

[ [ [] ] ]

[ "88.73", "99.15", "34.91", "96.07", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

16616, 16715

8268, 14504

341, 399

16882, 16882

4686, 8245

17761, 18339

3549, 3568

15104, 16593

16736, 16861

14530, 14538

17033, 17738

3217, 3333

3583, 3583

14556, 14604

227, 303

14626, 15081

427, 2919

3597, 4667

16897, 17009

2941, 3194

3349, 3533

78,038

104,979

46894

Discharge summary

report

Admission Date: [**2168-8-10**] Discharge Date: [**2168-8-22**] Date of Birth: [**2100-3-21**] Sex: F Service: SURGERY Allergies: Penicillins / Tetracycline / Erythromycin Base / Latex Attending:[**First Name3 (LF) 1481**] Chief Complaint: nausea/vomiting/diaphoresis Major Surgical or Invasive Procedure: Exploratory laparotomy, lysis of adhesions. History of Present Illness: 68 F presents to [**Hospital1 **] ED with nausea, vomiting, diaphoresis and distended abdomen after recent laparoscopic assisted right colectomy on [**2168-8-2**]. She was discharged from [**Hospital1 18**] on [**2168-8-6**] after in stable condition. She was doing well, tolerating a regular diet until yesterday when she developed the aforementioned symptoms. Past Medical History: Her past medical history is notable for heart disease, status post myocardial infarction in [**2167-8-28**]. She had some stents placed and was on aspirin and Plavix. She was also noted to have pulmonary embolism around this time and has been started on Coumadin and since then, her Plavix has been discontinued. She also has a history of hypertension and diabetes. Past surgeries include a lumbar fusion, tonsillectomy, deviated septum repair, appendectomy, cholecystectomy, hysterectomy and bladder suspension as well as several orthopedic surgeries include rotator cuff surgery and arthroscopies. The patient does not smoke or drink. She is retired and lives with her husband. There is a history of colon cancer in her father. [**Name (NI) **] mother died of a myocardial infarction. Review of systems is notable for a history of interstitial cystitis and arthritis as well as remote history of depression. Social History: Lives with husband Active lifestyle- regularly goes to gym Family History: Non-contributory. Physical Exam: Afebrile, VSS Alert, oriented x 3, NAD RRR CTAB Abdomen soft, appropriately mildly tender, steristrips in place LE warm, no edema Brief Hospital Course: Ms. [**Known lastname 2784**] presented to ED on [**8-10**] with nausea, vomiting, diaphoresis and distended abdomen. She received an exploratory laporatomy with lysis of adhesions for a small bowel obstruction that was found to be the cause of her symptoms. See Dr. [**Name (NI) 45689**] operative note for details. Patient was intubated in the ED d/t inability to protect airway and aspiration. Bronchoscopy was performed after surgery and she was found to have very little aspiration contents in her lower airways. She was admitted to the ICU after surgery d/t intubation and need for neosynephrine for BP control. While in the ICU she was successfull weaned off neosynephrine, and required lopressor for tachycardia. She had a drop in her Hct to 24 and required one unit of blood. She spiked a fever so was given a treatment of cipro, vancomycin, and flagyl. She was successfuly extubated on POD 5 and experienced resp distress that responded with Lasix. She was transferred out of the unit on POD 6. She had episodes of non-responsiveness on the floor for which she received several cardiac work-ups, psychiatry saw her and recommended discontinuing her narcotic pain medicine and her benzodiazepines. She also had a work-up with Neurology which included a 24 hour EEG, MRI and MRA of her head, and several lab tests. All of these were negative. At the time of discharge, she was stable and no longer experiencing these episodes of non-responsiveness. Neurology and her primary team felt that she was able to return to home. Physical therapy saw the patient and recommended home PT. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Venlafaxine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mirtazapine 30 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 5. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. Disp:*20 Suppository(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 12. Codeine Sulfate 15 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: small bowel obstruction Discharge Condition: stable Discharge Instructions: Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in [**1-29**] weeks. Please call [**Telephone/Fax (1) 2981**] to make appointment. Please contact your PCP for [**Name Initial (PRE) **] outpatient MRI of your spine. Neurology recommended this because they feel it is possible that a bulging disc could be contributing to your generalized weakness Completed by:[**2168-8-22**]

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icd9cm

[ [ [] ] ]

[ "96.04", "54.59", "33.24", "96.72" ]

icd9pcs

[ [ [] ] ]

4699, 4754

2004, 3606

342, 388

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4775, 4801

4879, 6021

6036, 6360

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275, 304

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1739, 1799

66,753

157,421

13076

Discharge summary

report

Admission Date: [**2160-6-8**] Discharge Date: [**2160-6-13**] Date of Birth: [**2087-11-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: Hypoxia, hemoptysis Major Surgical or Invasive Procedure: HD History of Present Illness: 72 yo M with PMH of ESRD [**1-8**] DM/HTN on HD, HTN, DMII, GERD, CHF, A-flutter s/p DCCV and ablation on [**5-29**] on coumadin who presented to ED with SOB and found to be hypoxic to 84% which improved to 95% on 4L. No history of smoking. Patient reports that he had been SOB with increasing cough for the last 2 weeks with sputum production. Overnight sputum with 1 tsp blood in it 5-10x overnight. Endorses subacute [**Location (un) **] and increasing orthopnea - can't sleep flat when he used to be able to. Also with decreased exercise tolerance with 1 flight of stairs. Per PCP, [**Name10 (NameIs) **] has had echo with normal EF. Also has had history of heart failure, but has been setting of vol o/l when HD was needed. Saw PCP [**Name9 (PRE) 2974**] and was supratherapeutic to 4 and had been holding it since then. Was also in ED 3 days ago for knee pain and knee was tapped showing 68,000 WBC and 23,000 RBC. Thought to be... In the ED, initial VS: 127/62 85 14 95%4L NC. Got levofloxacin and vancomycin. WBC 15 with left shift. Therapuetic INR at 2.9. Lactate 1.9--->0.9. CXR showed diffuse infiltrates and CT scan showed bilateral perihilar ground glass and solid opacities - concern for pulmonary hemorrhage vs atypical infection and small bilateral non-hemmorrhagic effusions. Upon transfer to the medical floor patient triggered for hypoxia to 74% on RA (unclear why off) and only increased to high 80-low 90's on 6L. Put on NRB up to 95%, back on 6L was 88-92%. He was febrile to 101.4. FFP was started. EKG with irregularly irregular rhythm to 108. Gas showed hypoxia: 7.46/43/54 on 6L nc and decision was made to transfer to the ICU for closer monitoring of respiratory status. Upon transfer to the ICU, patient reports he is very tired as he didn't get to sleep last night. He feels comfortable on the non-rebreather. He denies chest pain, abd pain, hematuria, hematemesis, dark or bloody stools, head ache, change in vision or depressed mood. He does endorse chronic joint pain he attributes to gout and osteoarthritis. He also reports itching. Past Medical History: Hypertension Diabetes type II Dyspepsia Gout Carpal tunnel syndrome ESRD- on dialysis MWF Hyperparathyroidism Carpal tunnel syndrome Peptic ulcer disease AV fistula-left arm CHF Atrial fibrillation/atrial flutter Bunionectomy Social History: Married and lives with his wife in [**Name (NI) 669**]. Works as a Minister. ETOH: NO. Tobacco: NO. Family History: Father had CAD, died at age 84. Physical Exam: GEN: NAD, sitting comfortable, HEENT: sclera anicteric, EOMI, no oral lesions, neck supple CV: irregularly irregular Lungs: mild crackles at bases bilaterally, breathing comfortably on room air, no accessory muscle use Ext: no edema Neuro: CN II-XII grossly intact Psyc: mood, affect appropriate Pertinent Results: [**2160-6-8**] 05:35PM TYPE-ART PO2-54* PCO2-43 PH-7.45 TOTAL CO2-31* BASE XS-4 [**2160-6-8**] 05:35PM LACTATE-0.9 [**2160-6-8**] 09:13AM COMMENTS-GREEN TOP [**2160-6-8**] 09:13AM LACTATE-1.9 [**2160-6-8**] 08:55AM GLUCOSE-113* UREA N-79* CREAT-7.5* SODIUM-134 POTASSIUM-4.6 CHLORIDE-92* TOTAL CO2-27 ANION GAP-20 [**2160-6-8**] 08:55AM estGFR-Using this [**2160-6-8**] 08:55AM CK(CPK)-64 [**2160-6-8**] 08:55AM cTropnT-0.28* [**2160-6-8**] 08:55AM proBNP-[**Numeric Identifier 39982**]* [**2160-6-8**] 08:55AM CALCIUM-9.7 PHOSPHATE-3.3 MAGNESIUM-1.9 [**2160-6-8**] 08:55AM ANCA-NEGATIVE B [**2160-6-8**] 08:55AM CRP-33.7* [**2160-6-8**] 08:55AM WBC-15.5*# RBC-3.55* HGB-11.6* HCT-36.3* MCV-102* MCH-32.6* MCHC-31.9 RDW-17.3* [**2160-6-8**] 08:55AM NEUTS-90.1* LYMPHS-6.0* MONOS-3.3 EOS-0.3 BASOS-0.4 [**2160-6-8**] 08:55AM PLT COUNT-275 [**2160-6-8**] 08:55AM PT-29.1* PTT-31.8 INR(PT)-2.9* [**2160-6-8**] 08:55AM SED RATE-40* [**2160-6-13**] 06:24AM BLOOD WBC-5.3 RBC-3.32* Hgb-10.5* Hct-33.5* MCV-101* MCH-31.7 MCHC-31.4 RDW-16.9* Plt Ct-272 [**2160-6-12**] 06:28AM BLOOD WBC-5.4 RBC-3.10* Hgb-10.1* Hct-31.7* MCV-102* MCH-32.5* MCHC-31.8 RDW-17.0* Plt Ct-253 [**2160-6-11**] 04:59AM BLOOD WBC-8.6 RBC-2.98* Hgb-9.8* Hct-30.0* MCV-101* MCH-32.8* MCHC-32.5 RDW-16.5* Plt Ct-220 [**2160-6-10**] 05:07AM BLOOD WBC-10.0 RBC-3.19* Hgb-10.2* Hct-32.8* MCV-103* MCH-31.9 MCHC-31.0 RDW-17.1* Plt Ct-250 [**2160-6-13**] 06:24AM BLOOD PT-13.2 INR(PT)-1.1 [**2160-6-13**] 06:24AM BLOOD Glucose-124* UreaN-68* Creat-6.5*# Na-136 K-4.8 Cl-95* HCO3-27 AnGap-19 [**2160-6-12**] 06:28AM BLOOD Glucose-73 UreaN-49* Creat-5.3*# Na-135 K-4.4 Cl-95* HCO3-29 AnGap-15 [**2160-6-11**] 04:59AM BLOOD Glucose-79 UreaN-74* Creat-7.0*# Na-135 K-4.3 Cl-96 HCO3-26 AnGap-17 [**2160-6-10**] 05:07AM BLOOD Glucose-138* UreaN-54* Creat-5.7*# Na-135 K-4.3 Cl-95* HCO3-26 AnGap-18 Brief Hospital Course: Patient admitted to the MICU for hypoxia. He was on 6L NC. He was febrile and a CXR and Chest CT were concerning for hemorrhage, infection or fluid. He was treated boradly with antibiotics (vancomycin and cefepime) and cultures were sent. He improved dramatically with dialysis and resultant fluid removal. He was weaned down to 2L nasal canula. A Bronch was discussed but as he was improving it was felt that he could have a bronch outside the ICU where brushings could be done. He spiked a temp to 101 in the ICU. His ICU course was complicated by a-fib with RVR while on HD. He was treated with IV and PO betablocker. On transfer to the floor, he was stable and breathing comfortably on 2 L oxygen with continued hemoptysis improved in terms of quantity. He was continued on PO metoprolol 100 mg tid for Afib. Coumadin and aspirin were initially held after discussion with PCP and cardiologist Dr. [**First Name (STitle) **]. He was seen by pulmonary who decided against a bronch given improving hemoptysis and recommended PO levofloxacin for total ABX of 10 day duration given likely infectious etiology of hemoptysis. They also approved restarting anticoagulation. During his hospital stay, he remained afebrile with normal WBC. For his end stage renal disease, he received dialysis. He got dialysis on friday [**6-13**]. For his Afib, we will discharge on metoprolol succinate 300 mg daily We will ask him to hold amlodipine, to be re-started at discretion of PCP/cardiologist. We will start him on warfarin 2.5 mg daily, with INR check on monday [**6-16**] and f/u appointment with PCP on monday [**6-16**] at which time warfarin dosing can be re-adjusted. His aspirin was also restarted. We recommend a f/u x-ray as an outpatient in 8 weeks. We also recommend referral by his PCP to [**Name Initial (PRE) **] pulmonologist for f/u . Medications on Admission: ALLOPURINOL 150 mg qd AMLODIPINE 10 mg Tablet qd CALCIUM ACETATE 667 mg [**Hospital1 **] SSI GLARGINE 14 units qpm LANSOPRAZOLE 30 mg qd METOPROLOL SUCCINATE 25 mg [**Hospital1 **] - unclear if pt still on after ablation PARICALCITOL Dosage uncertain MIRALAX 17 gram/dose qd WARFARIN 1 mg qd ACETAMINOPHEN 650mg qd ASPIRIN 325 mg qd Discharge Medications: 1. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO once a day as needed for Pain/Fever: do not exceed 4 g per day. 4. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous at bedtime. 5. Humalog 100 unit/mL Solution Sig: SSI Subcutaneous as needed: Please take according to your home sliding scale. 6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Miralax 17 gram/dose Powder Sig: One (1) PO once a day. 8. Warfarin 1 mg Tablet Sig: 2.5 Tablets PO see instructions below: Warfarin 2.5 mg daily. Please have your INR checked routinely as scheduled. Disp:*30 Tablet(s)* Refills:*2* 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 10. Outpatient Lab Work Please have your INR checked on Monday, [**6-16**]. 11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: hemoptysis, likely secondary to pneumonia Afib Diastolic heart failure Secondary Diagnosis: End stage renal disease Diabetes Gout PUD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for cough productive of bloody sputum. You were found to have an elevated INR. Your coumadin and aspirin were temporarily stopped because of the elevated INR. Your INR became normal after correction with FFP and vitamin K. You were treated with antibiotics for likely infection causing the bloody sputum. You were also found to have Atrial fibrillation which was treated with metoprolol. An ECHO procedure was done and showed diastolic heart failure. Please make the following changes to your medications: START levofloxacin 150 mg daily for 4 days START Warfarin 2.5 mg every day. Please have your INR checked on Monday [**6-16**] START metoprolol succinate 300 mg every morning. Stop any previous metoprolol. STOP amlodipine Followup Instructions: The following appointments have been made for you. Please keep all appointments. Please have your INR checked before your appointment on Monday. Name: [**Last Name (LF) **],[**First Name3 (LF) **] L. When: MONDAY, [**6-16**], 12PM Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 11962**]

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

8620, 8626

5092, 6956

332, 336

8824, 8824

3183, 5069

9753, 10139

2819, 2852

7340, 8597

8647, 8647

6982, 7317

8975, 9477

2867, 3164

9506, 9730

273, 294

364, 2435

8759, 8803

8666, 8738

8839, 8951

2457, 2685

2701, 2803

66,641

153,726

49124

Discharge summary

report

Admission Date: [**2131-9-14**] Discharge Date: [**2131-9-25**] Date of Birth: [**2072-3-7**] Sex: M Service: CARDIOTHORACIC Allergies: Tetracycline Attending:[**First Name3 (LF) 1505**] Chief Complaint: Recent admission to OSH for bacteremia and found to have severe aortic stenosis Major Surgical or Invasive Procedure: [**2131-9-14**] Aortic Valve Replacement (21mm St. [**Male First Name (un) 923**] porcine) via hemi-sternotomy [**2131-9-15**] Re-exploration for bleeding [**2131-9-17**] left thoracentesis History of Present Illness: 59 yo male with history of hyperlipidemia, Hodgkin??????s Lymphoma s/p mantle radiation and splenectomy 30 years ago. On [**8-17**] the patient was admitted to [**University/College **]-Hitchcock with symptoms of abdominal pain, chills and a fever of 105 also c/o difficulty breathing and found to have ST depressions laterally. Patient was treated for Gram-negative bacteremia, Cholangitis and pansensitive Klebsiella pneumonia. In the setting of fluid resuscitation, he had an episode of pulmonary edema prompting an echocardiogram, which revealed normal left ventricular function, EF of 55%. He was noted to have severe aortic stenosis with a calculated aortic valve area of 0.8cm2 and a peak gradient of 58mmHg with a mean gradient of 41mmHg there was also associated 1+ aortic insufficiency. The patient underwent an ERCP and had a prophylactic sphincterotomy in which no stones were found. Pt has had a hx of the past few months of chest tightness associated with SOB while walking fast or up a [**Doctor Last Name **]. Denies claudication, edema, orthopnea, PND, lightheadedness. Presented today for elective cardiac cath with [**First Name9 (NamePattern2) 103072**] [**Location (un) 109**] 0.5 cm, peak gradient 37.2 mm Hg, 50% mid-LAD, 50% Dia lesion. CT [**Doctor First Name **] consulted for evaluation for [**Doctor First Name 1291**]. Past Medical History: Aortic Stenosis Hodgkins Lymphoma treated with mantle radiation and splenectomy 30 years ago Hyperlipidemia History of recurrent Pneumonia- last treated [**11-20**] w/ levaquin Left hip repair for acetabulum fracture Recent episode of Cholangitis/Sepsis s/p Tonsillectomy Social History: Race:Caucasian Last Dental Exam: 1 month ago, dental XR 6 months ago Lives with:He is married and has two children. Active Occupation: Works in sales Tobacco: Smoked half a pack a day for five years, but quit over 30 years ago. ETOH:Patient has [**3-18**] alcoholic beverages per week Family History: Patients mother had [**Name (NI) 1291**]/MVR at the age of 80 Physical Exam: Pulse: Resp:12 O2 sat:97% RA B/P Right:121/92 Left: Height:5'8" Weight:172# General:AAO x 3 in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [] Murmur - IV/VII SEM 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: Left: transmitted murmur B/L Pertinent Results: [**2131-9-14**] Echo: Prebypass: No atrial septal defect is seen by 2D or color Doppler. There is severe 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 valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2131-9-14**] at 0945am. Post bypass: Patient is V paced and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. Bioprosthetic valve seen in the aortic position. The valve appears well seated and the leaflets move well. There is trivial central AI. The peak gradient acorss the aortic valve is 22 mm Hg. Aorta is intact post decannulation. [**2131-9-24**] 05:52AM BLOOD WBC-10.8 RBC-4.04* Hgb-11.7* Hct-36.5* MCV-90 MCH-28.9 MCHC-31.9 RDW-16.1* Plt Ct-482*# [**2131-9-19**] 01:06AM BLOOD PT-14.2* PTT-25.1 INR(PT)-1.2* [**2131-9-24**] 05:52AM BLOOD Glucose-104 UreaN-16 Creat-1.0 Na-138 K-4.0 Cl-98 HCO3-34* AnGap-10 PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: [**Month/Day/Year 1291**]. Comparison is made to prior study [**2131-9-21**]. There is mild cardiomegaly and engorgement of the mediastinal vessels. There is no overt CHF. Small right and small to moderate left pleural effusion have decreased in amount. Right lower lobe atelectasis has resolved. Left lower lobe atelectasis has improved. Right IJ catheter tip is in the lower SVC. There is no pneumothorax. Brief Hospital Course: Mr. [**Known lastname 103073**] was a same day admit and was brought to the operating room on [**9-14**] where he underwent an aortic valve replacement. Please see operative report for surgical details. Following surgery he was brought to the CVICU for invasive monitoring. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Early on post-op day one patient became short of breath, hypotensive, tachycardic with decreased urine output. Chest x-ray revealed a widened cardiomediastinal silhouette. Stat echo was ordered to rule out tamponade but patient became even more unstable and he was emergently intubated with opening of his chest in the CVICU. Large amount of clot was removed from around the heart. Patient was stabilized and brought to the operating room for further exploration of his mediastinum. Following surgery he was again transferred to the CVICU in stable but critical condition. Extubated on POD #2. Left thoracentesis performed on POD #3 for hemothorax. Pacing wires removed per protocol. Transferred to the floor on POD #5 to begin increasing his activity level. Mr. [**Known lastname 103073**] developed serosanguinous sternal drainage from the mid-portion of his incision and was started on IV vancomycin. This resolved and the sternum remained stable. He continued to improve and was discharged to home on POD #11 in stable condition. Medications on Admission: Atorvastatin 10mg' Aspirin 81 mg', Two week course of Ciprofloxacin 1 tablet by mouth 2xday 500mg (started on [**2131-8-20**]), Two week course of flagyl 500mg one tablet by PO three times a day ([**2131-8-20**] started) (for cholangitis) 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:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Potassium Chloride 20 mEq Packet Sig: One (1) PO Q12H (every 12 hours) for 7 days. Disp:*14 tabs* Refills:*0* 4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: After 7 days, decrease dose to 200 mg PO daily. Disp:*35 Tablet(s)* Refills:*0* 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. Disp:*28 Capsule(s)* Refills:*0* 9. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 11. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement cardiac tamponade s/p re-explor. for bleeding Past medical history: Hodgkins Lymphoma treated with mantle radiation and splenectomy 30 years ago Hyperlipidemia History of recurrent Pneumonia- last treated [**11-20**] w/ levaquin Left hip repair for acetabulum fracture Recent episode of Cholangitis/Sepsis s/p Tonsillectomy Discharge Condition: Good Discharge Instructions: 1)No driving for one month 2)No lifting more than 10 lbs for at least 10 weeks from the date of surgery 3)Please shower daily. Wash surgical incisions with soap and water only. 4)Do not apply lotions, creams or ointments to any surgical incision. 5)Please call cardiac surgeon immediately if you experience fever, excessive weight gain and/or signs of a wound infection(erythema, drainage, etc...). Office number is [**Telephone/Fax (1) 170**]. 6)Call with any additional questions or concerns Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) **] in [**1-16**] weeks Dr. [**Last Name (STitle) 2036**] in [**12-15**] weeks please call for all appts. Completed by:[**2131-9-25**]

[ "785.51", "518.5", "V58.66", "424.1", "V10.79", "272.4", "423.3", "998.12" ]

icd9cm

[ [ [] ] ]

[ "34.91", "35.21", "39.61", "34.03" ]

icd9pcs

[ [ [] ] ]

8124, 8199

5101, 6499

358, 550

8612, 8618

3290, 5078

9160, 9392

2542, 2605

6788, 8101

8220, 8311

6525, 6765

8642, 9137

2620, 3271

239, 320

578, 1929

8333, 8591

2240, 2526

19,065

153,062

45047+58780

Discharge summary

report+addendum

Admission Date: [**2174-4-21**] Discharge Date: [**2174-5-2**] Date of Birth: [**2105-7-23**] Sex: F Service: CARDIOTHORACIC Allergies: Percocet / Egg/Poultry Attending:[**First Name3 (LF) 5790**] Chief Complaint: Left upper lobe nodule. Major Surgical or Invasive Procedure: VATS, left upper lobe wedge resection, mediastinal lymph node dissection, flexible bronchoscopy History of Present Illness: Ms. [**Known lastname 9220**] is a 68-year-old woman who was noted to have hypoxia in [**2173-9-7**]. A CTA of the chest was done which revealed a nodule in the left upper lobe. Follow-up CT scan showed increased size of this nodule. There was mild FDG avidity of the nodule as well. Past Medical History: 1. CREST syndrome 2. Amyloidosis - cutaneous only. 3. GERD 4. Questionable DM - pt denies, no home meds, but h/o hyperglycemia. 5. HTN 6. Osteoarthritis 7. Depression/anxiety 8. Osteopenia 9. Hepatitis A - Tested positive in [**2169**]. Had elevated LFTs. 10. Rheumatic fever . PSH: Cholecystectomy [**87**]+ yrs ago b/l TKR (5 yrs, 10 yrs, 25 yrs) Social History: Ms. [**Known lastname 9220**] lives alone and is independent. She has never worked outside the home; she was a homemaker. She has been divorced from her husband for 25 years. They have six children, one of whom passed away in an accident several years ago; the remaining five are between the ages of 39 and 50. Three of them live nearby, and she sees them often. She denies tobacco use, alcohol use, IVDU, or tattoos. She is not currently sexually active. Family History: Diabetes mellitus, type II: Mother, one sister, one brother, one daughter [**Name (NI) 3495**] disease: One sister [**Name (NI) 3730**]: Father (bone cancer), two sisters, brother Depression: one sister No family history of CREST syndrome or other autoimmune diseases. Physical Exam: Postoperatively: VITALS: T 97.1, HR 90, BP 130/62, RR 20, O2 sat 93% on 4 L nasal cannula GENERAL: Resting comfortably, no acute distress CARDIO: Regular rate and rhythm, no murmur, rub or gallop LUNGS: Coarse breath sounds on the left ABDOMEN: Soft, present bowel sounds EXTREMITIES: Warm feet, no clubbing, cyanosis, edema Incision: Clean, dry and intact Pertinent Results: [**2174-4-23**] 03:33AM BLOOD WBC-13.8*# RBC-4.76 Hgb-13.6 Hct-40.3 MCV-85 MCH-28.6 MCHC-33.8 RDW-15.7* Plt Ct-278 [**2174-4-22**] 04:41PM BLOOD Glucose-166* UreaN-20 Creat-0.6 Na-136 K-5.4* Cl-100 HCO3-23 AnGap-18 [**2174-4-22**] 06:19PM BLOOD Type-ART pO2-74* pCO2-55* pH-7.36 calTCO2-32* Base XS-3 Intubat-NOT INTUBA Comment-NON-REBREA [**2174-4-24**] 01:58AM BLOOD WBC-15.6* RBC-4.45 Hgb-12.5 Hct-37.5 MCV-84 MCH-28.1 MCHC-33.4 RDW-15.6* Plt Ct-276 [**2174-4-25**] 02:55AM BLOOD WBC-16.4* RBC-4.06* Hgb-11.9* Hct-33.2* MCV-82 MCH-29.2 MCHC-35.7* RDW-15.5 Plt Ct-281 [**2174-4-26**] 03:00AM BLOOD WBC-16.9* RBC-4.27 Hgb-12.5 Hct-34.9* MCV-82 MCH-29.3 MCHC-35.8* RDW-15.7* Plt Ct-279 [**2174-4-27**] 03:45AM BLOOD WBC-20.1* RBC-4.29 Hgb-12.1 Hct-36.8 MCV-84 MCH-28.3 MCHC-33.5 RDW-15.4 Plt Ct-321 [**2174-4-28**] 02:18AM BLOOD WBC-15.3* RBC-4.21 Hgb-11.8* Hct-35.3* MCV-84 MCH-27.9 MCHC-33.3 RDW-15.4 Plt Ct-313 [**2174-4-29**] 03:43AM BLOOD WBC-11.0 RBC-4.26 Hgb-12.0 Hct-36.1 MCV-85 MCH-28.2 MCHC-33.3 RDW-15.2 Plt Ct-330 [**2174-4-22**] 07:11PM BLOOD CK-MB-5 cTropnT-<0.01 [**2174-4-23**] 03:33AM BLOOD CK-MB-4 cTropnT-<0.01 [**2174-4-23**] 03:55PM BLOOD CK-MB-3 cTropnT-<0.01 [**2174-4-25**] 08:51AM BLOOD %HbA1c-6.8* [Hgb]-DONE [A1c]-DONE [**2174-4-26**] 04:45PM BLOOD Type-ART Temp-37.8 Rates-/28 O2 Flow-15 pO2-64* pCO2-37 pH-7.49* calTCO2-29 Base XS-4 Intubat-NOT INTUBA RADIOLOGY: [**4-21**] CXR: There is new postoperative mediastinal widening and mild enlarged cardiac silhouette. Perihilar haziness is new consistent with fluid overload. There are no sizeable pleural effusions or pneumothorax. There is a left chest tube. Mild subcutaneous emphisema is in the left lower chest wall. [**4-22**] CXR: Lower lung volumes, particularly on the right, may explain the greater radiodensity of both lungs but I think there is a component of new, mild pulmonary edema. Marked widening of the postoperative mediastinum on [**4-21**], compared to [**4-12**], is unchanged and while some of this may be due to both lower lung volumes and volume overload and acute cardiomegaly, the findings are concerning for hemorrhage either in the pericardium or mediastinum or both. There is no appreciable left pleural collection; however, a solitary left pleural drain runs along the upper mediastinal contour superior to the aortic arch. [**4-23**] CXR: A left chest tube has been removed and there is no evidence for PTX. Left hemidiaphragm is elevated and there is some density at the left base consistent with an effusion and associated atelectasis. A retrocardiac pneumonia cannot be excluded. The right lung is clear. [**4-23**] CTA: No evidence of pulmonary embolus or thoracic aortic dissection. Postoperative changes within the left upper lobe consistent with resection of previously identified nodule. Atelectasis along the medial aspect of the left lung and bilateral lung bases. [**4-24**] CXR: Central paramediastinal and left retrocardiac opacity shows slight interval improvement with associated slight increase in volume in the left lung, likely due to improving postoperative atelectasis in this patient status post recent left upper lobe resection. Small pleural effusion on the left is unchanged. Cardiac and mediastinal contours are stable in appearance. Mild interstitial edema is present. [**4-25**] CXR: There is worsening opacification in the left hemithorax with only a small amount of residual aerated lung in the left apex and left perihilar region. Associated worsening volume loss is present with further elevation of the left hemidiaphragm. Lung volumes are low. Perihilar haziness has developed in the right lung. Left pleural effusion is again demonstrated with apparent new area of loculation laterally. [**4-26**] CXR: Compared with previous examination, there is better aeration of the left apex, with remaining degree of of opacification of left hemithorax, most likely due to effusion and underlying lung atelectasis. There is no significant change in the degree of aeration of the right lung, considering differences in techniques. [**4-27**] Chest ultrasound: Dynamic ultrasound examination was performed with inspiration, expiration, and sniffing. There is absent diaphragmatic movement on the left with inspiration and expiration and paradoxical elevation of the left hemidiaphragm with the sniff test. Right diaphragmatic motion is normal. At the left base, there is a combination of consolidated lung with some residual hemothorax. No hypoechoic fluid is identified to suggest transudative effusion. [**4-27**] ECHO: Preserved global biventricular systolic function. Pulmonary artery systolic hypertension. No right-to-left intracardiac shunt identified. Compared with the report of the prior study (images unavailable for review) of [**2167-5-5**], pulmonary artery systolic hypertension is now identified. [**4-28**] CXR: Opacification in the left lower lung zone may be a combination of effusion and atelectasis, and remains stable since the prior radiograph. Right lung field is clear. Moderate cardiomegaly and pulmonary congestion in the left upper lobe persists. Overall, no change from the prior radiograph two days ago. [**4-29**] CXR: Right PICC terminates in the proximal right atrium and should be retracted approximately 4 cm to ensure location in the SVC. The chest is otherwise unchanged in appearance with opacification of the left lower lung zone due to a large pleural effusion and atelectasis. Right lung remains clear. Moderate cardiomegaly and pulmonary congestion of the left upper lobe persists. Brief Hospital Course: Ms. [**Known lastname 9220**] was admitted and taken to the operating theater, where she underwent a VATS, left upper lobe wedge resection, mediastinal lymph node dissection, and flexible bronchoscopy. Her operating room course was uncomplicated. She had a pleural [**Doctor Last Name **] to suction, which was then placed to water seal in the immediate post op period, with a stable follow up chest x-ray. It remained on water seal to evaluate the pleural drainage output which was initially somewhat bloody then thinned to serosanguinous with a stable hematocrit. Post-operatively she had issues with pain control, which hampered her motility and oxygenation. Her pain control was optimized and her oxygenation and mobility improved. On the eve of POD1 her oxygen saturation declined and her oxygen requirement increased substantially, requiring transfer to the CSRU for aggressive pulmonary toilet, intermittent BiPap mask ventilation, and monitoring. Her oxygenation requirement decreased with pulmonary toilet and diuresis although serial cxr's showed minimal to no improvement in her left lung collapse due to presumed consolidation. A bronchoscopy was done on POD5, which showed scant secretions. She was tranferred to the [**Hospital Ward Name 121**] 2 nursing unit on POD5, and on arrival was noted to have a low oxygen saturation. An arterial blood gas was drawn, also demonstrating low arterial oxygenation, and she was transferred back to the CSRU. On POD6, she underwent a cardiac echo to rule out structural abnormalities and a chest ultrasound to evaluate diaphragmatic motion and effusion. The ultrasound showed paridoxical motion of the left hemidiaphragm. On POD8, she was seen by physical therapy, who felt that she would be best served by discharge to a rehabilitation facility in order for her to gain strength and respiratory reserve. On POD9, a PICC line was placed for 7 days of IV antibiotics, and due to her very difficult access, and she was transferred back to the [**Hospital Ward Name 121**] 2 nursing unit. On POD10, she was discharged to [**Hospital3 **] center. Medications on Admission: venlafaxine, lisinopril, nifedipine, omeprazole, Salagen, and trazodone. Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 4. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 10. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at bedtime) for 7 days. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. 12. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous Q 12H (Every 12 Hours) for 4 days. 14. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 g Intravenous Q8H (every 8 hours) for 4 days. 15. Insulin Regular Human 100 unit/mL Solution Sig: Sliding scale Injection ASDIR (AS DIRECTED): Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice 61-110 mg/dL 0 Units 0 Units 0 Units 0 Units 111-130 mg/dL 2 Units 2 Units 2 Units 0 Units 131-150 mg/dL 4 Units 4 Units 4 Units 2 Units 151-200 mg/dL 6 Units 6 Units 6 Units 4 Units 201-250 mg/dL 9 Units 9 Units 9 Units 6 Units 251-300 mg/dL 12 Units 12 Units 12 Units 8 Units 301-350 mg/dL 15 Units 15 Units 15 Units 10 Units . Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: plasma cell dyscrasia, amyloidosis, DMt2 diet-controlled, DJD, CREST syndrome, GERD, Raynaud syndrome, anxiety, depression left upper lobe VATs wedge-pathology pending Discharge Condition: deconditioned requiring rehab Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you develop chest pain, shortness of breath, fever, chills, redness or drainage from your chest incision. you may shower on monday. After showering, remove chest tube dressing and cover the site with a clean bandaid daily until healed. No tub bathing or swimming for 3-4 weeks. Followup Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] for a follow up appointment Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 8754**] DERMATOLOGY GEN-[**Doctor First Name 8754**] (NHB) Date/Time:[**2174-6-8**] 1:00 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2174-6-14**] 9:45 Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2174-6-23**] 4:30 Name: [**Known lastname 15288**],[**Known firstname 3551**] Unit No: [**Numeric Identifier 15289**] Admission Date: [**2174-4-21**] Discharge Date: [**2174-5-2**] Date of Birth: [**2105-7-23**] Sex: F Service: CARDIOTHORACIC Allergies: Percocet / Egg/Poultry Attending:[**First Name3 (LF) 3454**] Addendum: On POD 10, the [**Hospital3 643**] facility contact[**Name (NI) **] the service that Ms. [**Known lastname **] would need to be reviewed prior to acceptance. This occurred on POD12, and she was discharged in good condition. Discharge Disposition: Extended Care Facility: [**Hospital 15290**] rehab [**Name6 (MD) **] [**Last Name (NamePattern4) 3455**] MD [**MD Number(2) 3456**] Completed by:[**2174-5-2**]

[ "V18.0", "V12.09", "997.3", "300.4", "530.81", "443.0", "276.6", "518.89", "398.90", "250.00", "710.1", "277.39", "401.9", "E878.8", "715.90", "429.3", "E849.7", "518.0", "273.9" ]

icd9cm

[ [ [] ] ]

[ "93.90", "38.93", "33.22", "33.28", "96.05", "99.21", "40.11" ]

icd9pcs

[ [ [] ] ]

14074, 14265

7846, 9947

313, 410

12503, 12535

2254, 7823

12928, 14051

1590, 1862

10071, 12201

12311, 12482

9973, 10048

12559, 12905

1877, 2235

249, 275

438, 723

745, 1095

1111, 1574

80,472

163,167

25081

Discharge summary

report

Admission Date: [**2124-9-15**] Discharge Date: [**2124-9-19**] Date of Birth: [**2061-7-13**] Sex: M Service: NEUROSURGERY Allergies: Lodine Attending:[**First Name3 (LF) 1835**] Chief Complaint: Headache, left arm weakness Major Surgical or Invasive Procedure: [**2124-9-16**]: Right Craniotomy for evacuation of Subdural History of Present Illness: This is a pleasant 62 year old Left Handed male who presented to [**Hospital3 417**] with headaches for the past 2 days and left arm weakness. He denies any recent trauma or falls. He reports that the headache is about a [**5-16**] on the pain scale and located on the right side of his head on the top. He describes it as a dull aching sensation. He reports that he sought medical care per the urging of his wife given he had left arm "droopiness". He had a head Ct which showed a acute on chronic SDH. He was med flighted to [**Hospital1 18**] and neurosurgery was consulted for further management. Past Medical History: HTN, hypercholesterolemia, vitamin d deficiency Social History: married, works as an auto appraiser, occ alcohol, no recreational drugs, no smoke Family History: no history of bleeding disorders in family Physical Exam: O: T: 98.0 BP: 124/60 HR: 55 R 14 O2Sats 100% RA Gen: WD/WN, comfortable, NAD. HEENT:atraumatic, normocephalic, eyes are clear, ears are clear, nasal passages are patet Pupils: 3-2 mm EOMs full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: GCS 15 E4V5M6 Mental status: Awake and alert, cooperative with exam, normal affect. AOx3, PERRL 3-2mm, EOM intact, pt with slight tremors bilaterally L>R, right facial droop at nasolabial fold, Left pronator drift Motor: LUE 4+/5, RUE [**5-11**], LLE [**5-11**] bilaterally, Sensation: Intact to light touch intact Toes downgoing bilaterally No clonus, negative hoffmans Handedness Right On Discharge: improved weakness. Pt exhibiting a subtle left arm drift Pertinent Results: CT head [**2124-9-16**] - Right acute on chronic SDH (mainly chronic) measuring about 1.3cm at greates diameter located mainly in the right frontoparietal region with midline shift ~.9 cm, uncus compression slightly on basal cisterns. NO hydrocephalus. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the Neurosurgery service to the ICU for Q1 hour neurochecks and SBP control less than 140. Aspirin was held. On [**9-16**] he underwent rightsided craniotomy for evacuation of SDH. Postoperatively the patient was extubated and transferred to the ICU. Postop head CT demonstrated adequate decompression with resolution of midline shift. His headache and leftsided weakness improved to only a subtle left-sided drift. The evening of [**9-16**] the patient developed a maculopapular rash of his face and upper middle chest, thought to be a drug reaction and the perioperative Ancef was switched to clindamycin for the remaining doses and was given a dose of benadryl. On [**9-17**], the patient had a stable neurologic exam and developed a small right periorbital/eyelid hematoma with ecchymosis overnight. He had no other complaints, was mobilized, and awaited a floor bed. He was transferred to the regular floor on [**9-18**] and was seen and evaluated by physical therapy and occupational therapy who felt that he was safe to return home. At the time of discharge he is tolerating a regulat diet, ambulating without difficulty, afebrile with stable vital signs. Medications on Admission: Aspirin fenofibrate -- Unknown Strength Unknown sig lisinopril 20 mg Tab Oral 1 Tablet(s) Once Daily metoprolol tartrate 25 mg Tab Oral 1.5 Tablet(s) Twice Daily simvastatin 20 mg Tab Oral 1 Tablet(s) Once Daily Vitamin D 1,000 unit Cap Oral 1 Capsule(s) Once Daily Vitamin C 250 mg Tab Oral 2 Tablet(s) Once Daily vitamin E 400 unit Tab Oral 1 Tablet(s) Once Daily flaxseed Oral Mucosal Liquid Mucous Membrane Unknown sig Discharge Medications: 1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 8. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day) for 30 days. Disp:*180 Tablet, Chewable(s)* Refills:*0* 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Right Acute on chronic Subdural hematoma Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You may safely resume taking Aspirin on [**2124-9-22**]. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**7-16**] days(from your date of surgery) for a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in [**4-12**] weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[**2124-9-19**]

[ "268.9", "432.1", "272.0", "693.0", "401.9", "348.4", "E930.5" ]

icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

4895, 4901

2339, 3552

299, 362

4986, 5076

2062, 2316

7029, 7626

1184, 1228

4026, 4872

4922, 4965

3578, 4003

5137, 7006

1243, 1594

1984, 2043

232, 261

390, 998

5091, 5113

1020, 1069

1085, 1168

48,693

172,852

16660

Discharge summary

report

Admission Date: [**2193-9-11**] Discharge Date: [**2193-9-16**] Date of Birth: [**2148-10-8**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: CAD Major Surgical or Invasive Procedure: [**2193-9-11**] CABGx3/Mitral valve repair/PFO closure History of Present Illness: 44 yo F with PMH significant for CAD s/p multiple PCIs and MI in [**2193-1-4**] who presented to [**Hospital3 1443**] with [**Hospital 7792**] transferred to [**Hospital1 18**] on [**6-1**] for cardiac catheterization. It was determined that she was not a surgical candidate at that time. She was readmitted [**8-30**] with left arm pain and chest pressure. She was found to have thrombosis of her left subclavian stent. Vascular was consulted and it was determined that the left arm likely being perfused by vertebral artery and she was admitted and started on a heparin drip. Follow up appointment with Vascular was arranged for post cardiac surgery. Csurg was reconsulted to evaluate for CABG. Past Medical History: 1. CARDIAC RISK FACTORS: IDDM, Dyslipidemia, Hx of Hypertension 2. CARDIAC HISTORY: [**2186**] - Lateral NSTEMI; Single vessel disease - PTCA to D1, Dx w/ Severe Diastolic Dysfunction - EF 45;Anterior, mid and distal septal, apical akniesis [**2186**] - Cath: CYPHER stent to mid-LAD, D1 subtotal occlusion [**2187**] - negative ETT [**2188**] - Nuclear Stress: ECG changes at 64% HR; mod perfusion deficit [**2188**] - Cath: Moderate Single Vessel disease - Left Sublclavian stenosis with Bare Metal Stent [**2190**] - Cath: 40% in-stent stenosis of LAD; no RCA disease - LCX had mild diffuse disease and was also small [**1-/2193**] - Cath: IMI [**1-13**] Endeavor stent x 2 to RCA Ischemic cardiomyopathy with EF 40% IDDM: A1c 13.3% in [**6-/2191**] Hyperlipidemia (last lipids TC 164, Trig 197, HDL 44, LDL 81) Polysubstance Abuse: Heroin (years sober), Cocaine (years sober), Tobacco use Hepatitis C Ab, Negative Viral Load in [**2186**] Obesity Breast Abcess [**2189**] History of tuberculosis exposure s/p 9 months of tx ([**2173**]'s) Left Subclavian Stenosis s/p stenting Social History: Lives with husband and 7 year old son. Smokes <1ppd now, down from [**2-6**] ppd a few months ago, but noted that she will quit today. Smoked since age 12. Prior h/o cocaine use. Hx of substantial heroin IVDU. Denies EtOH or other drugs. No substance use current other than tobacco. Does not work. Family History: Father had MI at 38, died at age 68 of esophageal cancer. Also mother, brother with early CAD. Physical Exam: Admission Physical Exam Pulse:54 Resp:18 O2 sat: 98% RA B/P Right: 82/45-109/61 Left: Height:5'3" Weight:73.7 General:NAD, alert, cooperative Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +1 Left:+1 DP Right: +1 Left:+1 PT [**Name (NI) 167**]: +1 Left:+1 Radial Right: +1 Left:+1 Carotid Bruit Right: none Left:none Pertinent Results: [**2193-9-16**] 04:20AM BLOOD WBC-9.9 RBC-2.99* Hgb-9.2* Hct-25.8* MCV-86 MCH-30.7 MCHC-35.6* RDW-15.1 Plt Ct-196 [**2193-9-11**] 02:22PM BLOOD WBC-19.3*# RBC-3.25* Hgb-9.4* Hct-27.7* MCV-85 MCH-29.0 MCHC-34.1 RDW-14.8 Plt Ct-167 [**2193-9-11**] 03:56PM BLOOD PT-14.0* PTT-34.5 INR(PT)-1.2* [**2193-9-11**] 02:22PM BLOOD PT-14.4* PTT-37.6* INR(PT)-1.2* [**2193-9-16**] 04:20AM BLOOD Glucose-158* UreaN-12 Creat-0.7 Na-134 K-4.2 Cl-99 HCO3-26 AnGap-13 [**2193-9-12**] 02:48AM BLOOD Glucose-93 UreaN-15 Creat-0.5 Na-135 K-4.2 Cl-106 HCO3-21* AnGap-12 [**2193-9-13**] 09:10AM BLOOD ALT-16 AST-29 LD(LDH)-352* AlkPhos-66 Amylase-18 TotBili-0.5 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 1039**] [**Hospital1 18**] [**Numeric Identifier 47169**] (Complete) Done [**2193-9-11**] at 11:09:50 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2148-10-8**] Age (years): 44 F Hgt (in): 66 BP (mm Hg): 123/56 Wgt (lb): 150 HR (bpm): 50 BSA (m2): 1.77 m2 Indication: Intraoperative TEE for CABG, mitral ring annuloplasty and closure of secundum ASD. Aortic valve disease. Chest pain. Coronary artery disease. Left ventricular function. Mitral valve disease. Myocardial infarction. Preoperative assessment. Right ventricular function. Valvular heart disease. ICD-9 Codes: 786.05, 786.51, 424.1, 424.0, 424.2 Test Information Date/Time: [**2193-9-11**] at 11:09 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 #: 2010AW1-: Machine: AW1 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 35% to 40% >= 55% Aorta - Annulus: 2.0 cm <= 3.0 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 10 mm Hg < 20 mm Hg Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Left-to-right shunt across the interatrial septum at rest. Small secundum ASD. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Mild-moderate regional LV systolic dysfunction. Moderately depressed LVEF. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. 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 patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Prebypass A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. Left ventricular wall thicknesses are normal. There is mild to moderate regional left ventricular systolic dysfunction with akinesia of the apex, apical and mid portions of the inferior wall and hypokinesia of the inferoseptal and inferolateral walls.. Overall left ventricular systolic function is moderately depressed (LVEF= 35-40%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. There is a stent noted in the distal arch of the aorta that has a possible clot in it. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2193-9-11**] at 1015am. Post bypass Patient is A paced and receiving an infusion of phenylephrine and epinephrine. LVEF= 35%. Annuloplasty ring seen in the mitral position. There is 1+ residual mitral regurgitation. No mitral stenosis. Mild aortic insufficiency persists. Pledget seen at the site of the small secundum ASD. No flow documented across the interatrial septum. Aorta is intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2193-9-12**] 07:36 ?????? [**2186**] CareGroup IS. All rights reserved. Brief Hospital Course: On [**2193-9-11**] Ms.[**Known lastname 27534**] was taken to the operating room and underwent Coronary artery bypass grafting x 3 (Lima->LAD/Saphenous vein graft->OM/PDA)/Mitral Valve repair (#28mm CG Future ring)/PFO closure with Dr.[**First Name (STitle) **]. Please see operative report for further details. She tolerated the procedure well and was transferred to the CVICU intubated and sedated in critical but stable condition. She was weaned off all pressors, awoke neurologically intact and was extubated without difficulty. Pain Service was consulted for her history of polysubstance abuse. [**Last Name (un) **] was consulted for her uncontrolled Insulin Dependent Diabetes. All lines and drains were discontinued in a timely fashion. Beta-blocker,Aspirin, Statin, and diuresis were initiated. On POD# 2 she was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength of mobility. The remainder of her postoperative course was essentially uneventful. On POD#5 she was cleared by Dr.[**First Name (STitle) **] for discharge home with VNA. All follow up appointments were advised. Medications on Admission: ASA 325mg po daily Plavix 75mg po daily Lipitor 80mg po daily Metformin 500mg po TID NPH 28 units qAM, 30units qPM Humalog 2 units with breakfast, 6units with lunch, ??units with dinner Albuterol 2 puffs q6h PRN SOB Methadone 75mg po daily SL NTG PRN Spiriva 1 unit po daily Plavix - last dose: Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*qs Cap(s)* Refills:*2* 2. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Clindamycin HCl 150 mg Capsule Sig: One (1) Capsule PO every six (6) hours: DC on [**2193-9-20**]. Disp:*120 Capsule(s)* Refills:*2* 12. Methadone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): per [**Hospital 2514**] clinic->resume preop regimen. 13. Lantus 100 unit/mL Cartridge Sig: Thirty Four (34) units Subcutaneous q HS. Disp:*qs * Refills:*2* 14. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) Subcutaneous ACHS: **Per Humolog Sliding Scale. Disp:*qs * Refills:*2* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: HTN, hyperlipidemia, CAD s/p stents, Ischemic Cardiomyopathy, Diabetes, COPD, Polysubstance Abuse: Heroin and cocaine, Hepatitis C, Obesity, Breast Abscess [**2189**], History of TB Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with dilaudid and methadone Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage. 2+ 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 [**Telephone/Fax (1) 1988**] for the following appointments Surgeon: Dr. [**First Name (STitle) **] on [**2193-10-7**] at 1:30pm [**Telephone/Fax (1) 170**] Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2193-9-30**] at 4pm Department: CARDIAC SERVICES When: WEDNESDAY [**2193-9-11**] at 1 PM Department: [**Hospital3 249**] When: TUESDAY [**2193-9-17**] at 9:20 AM With: [**Doctor First Name **] [**Doctor First Name **], RNC [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: VASCULAR SURGERY When: MONDAY [**2193-9-23**] at 2:30 PM With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: MONDAY [**2193-9-30**] at 3:00 PM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**4-8**] weeks [**Telephone/Fax (1) 250**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2193-9-16**]

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icd9cm

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icd9pcs

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199,633

36312

Discharge summary

report

Admission Date: [**2169-7-19**] Discharge Date: [**2169-7-29**] Date of Birth: [**2117-8-31**] Sex: M Service: MEDICINE Allergies: Fish derived Attending:[**First Name3 (LF) 943**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: Paracentesis [**2169-7-27**] Upper Endoscopy with banding x2 in distal esophagus [**2169-7-19**] History of Present Illness: Mr [**Known lastname 26438**] is a 51yoM with h/o PSC cirrhosis c/b ascites, esophageal varices w/ prior hemorrhage, hepatic encephalopathy, prior SBP, portal vein thrombosis, on the transplant list, who initially presented to - PSC Cirrhosis c/b ascites, encephalopathy SBP, and bleeding esophageal varices, on transplant list - Primary sclerosing cholangitis, dx [**2165-10-2**] - portal vein thrombosis - failed TIPS attempt [**12-12**] - History of UGIB in [**10-13**], [**5-29**], [**11/2168**], [**7-/2169**] - HCV: by history, had positive HCV with HCV VL in [**2157**], but on follow up cleared HCV spontaneously - Horseshoe kidney w/intermittent renal insufficiency - Distant history of polysubstance abuse - History of dysphagia with normal barium swallow on [**2167-11-24**] - Typical Angina - Chostrochondritis [**2-12**] - Depression - Back pain - Sleep apnea [**Hospital **] hospital w/ hematemesis. At RIH he received 4 units of FFP and 2 units of PRBCs, and got 2 EGD's without intevention. He was then transferred to the [**Hospital1 18**] SICU. He was not intubated. In the SICU, he has done well. He has remained hemodynamically stable, w/ stable hct, and has required no further blood product transfusion. He got on EGD on [**7-19**], which showed very severe portal gastropathy, duodenitis, and two large varices in distal esophagus that showed stigmata of recent bleeding. Two bands were placed on these varices. He remains on PPI drip, octreotide drip, and carafate 1g QID was started. Also started on ceftriaxone 1g IV daily x5 days for SBP ppx in setting of variceal bleed. He was started on reglan for nausea. He is now called out to the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service. . On arrival to the floor, most recent set of vitals are 98.0 81 133/82 18 97%ra. He is a bit nauseous, but is breathing comfortably and otherwise feels well, w/o complaint. . ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, diarrhea, constipation, BRBPR, hematochezia, dysuria, hematuria. Past Medical History: - PSC Cirrhosis c/b ascites, encephalopathy SBP, and bleeding esophageal varices, on transplant list - Primary sclerosing cholangitis, dx [**2165-10-2**] - portal vein thrombosis - failed TIPS attempt [**12-12**] - History of UGIB in [**10-13**], [**5-29**], [**11/2168**], [**7-/2169**] - HCV: by history, had positive HCV with HCV VL in [**2157**], but on follow up cleared HCV spontaneously - Horseshoe kidney w/intermittent renal insufficiency - Distant history of polysubstance abuse - History of dysphagia with normal barium swallow on [**2167-11-24**] - Typical Angina - Chostrochondritis [**2-12**] - Depression - Back pain - Sleep apnea Social History: Lives with his eldest of 2 sons. [**Name (NI) **] lots of family support (mother, sisters, [**Name2 (NI) 12232**]) - requires 24 hour care at home. Not currently employed, on SSI. - Smoking: quit > 16 yrs ago, 25 pack year history - EtOH: history of abuse, last drink > 22 yrs ago - Drugs: history of polysubstance abuse including cocaine, crack, barbiturates, amphetamines, and marijuana. None for 20 years. Family History: No pertinent family history, including PSC, liver disease, or other gastrointestinal disease. (Has identical twin brother without above conditions). Grandfather with diabetes. Physical Exam: Admission Exam (to medical floor): VS: 98.0 81 133/82 18 97%ra GENERAL: chronically ill appearign Hispanic male, jaundiced, in NAD HEENT: Sclera icteric. MMM. CARDIAC: RRR with no excess sounds appreciated LUNGS: CTA b/l with no wheezing, rales, or rhonchi. ABDOMEN: Distended, non-tender to palpation. No HSM or tenderness appreciated. No gaurding or rebound. EXTREMITIES: Edema half up shins. Warm and well perfused, no clubbing or cyanosis. NEUROLOGY: no asterixis, A1-B2-C3- correct. A+Ox3, executive function intact, moving all extremities, walking about ICU room Discharge Exam: VS: 98.2, 110/77. 63, 20, 100%RA I/O: 100/300 8hr, 1420/800 24hr, BM x 3 Wt 83kg([**7-26**]), 81 kg ([**7-24**]), 79kg ([**7-23**]), 82kg ([**7-22**]) GENERAL: Pleasant, good spirits, chronically ill appearing Hispanic male, jaundiced, in NAD. Complains of abdom distension. HEENT: Sclera significantly icteric, unchanged. Mouth ulcerations resolved. Purpura of left cheek unchanged. CARDIAC: RRR with no excess sounds appreciated LUNGS: CTA b/l with no wheezing, rales, or rhonchi. ABDOMEN: Less distended today, non-tender to palpation. Tympanic anteriorly, dull at dependent areas. No gaurding or rebound. incision in LLQ 7mm, leaking clear ascites, now with 2 stitches in place EXTREMITIES: Wearing socks. Dull red, less induration, decrease in total area of involvement. NEUROLOGY: no asterixis, A+Ox3, A1B2C3 normal. Moving all extremities, ambulating on own without support. Pertinent Results: ADMISSION: [**2169-7-19**] 06:06PM BLOOD WBC-9.1 RBC-3.52* Hgb-10.6* Hct-31.4* MCV-89 MCH-30.1# MCHC-33.7 RDW-20.8* Plt Ct-51* [**2169-7-19**] 06:06PM BLOOD PT-16.6* PTT-33.8 INR(PT)-1.6* [**2169-7-19**] 06:06PM BLOOD Fibrino-152* [**2169-7-19**] 06:06PM BLOOD Glucose-151* UreaN-38* Creat-1.1 Na-132* K-6.5* Cl-96 HCO3-23 AnGap-20 [**2169-7-19**] 06:06PM BLOOD ALT-88* AST-91* LD(LDH)-380* AlkPhos-144* TotBili-19.7* [**2169-7-19**] 06:06PM BLOOD Albumin-4.2 Calcium-9.1 Phos-3.4 Mg-2.0 EGD: Small nonbleeding varices in upper and mid esophagus Two Large varices in distal esophagus, one with red [**Last Name (un) 23199**] sign Very severe portal gastropathy Old blood pooling in fundus but no active bleeding Several discrete areas of prior endoscopic trauma, black in colour that cleared somewhat with irrigation Salt and pepper duodenitis (ligation) Otherwise normal EGD to third part of the duodenum ASCITES: [**2169-7-22**] 03:16PM ASCITES WBC-100* RBC-1575* Polys-37* Lymphs-18* Monos-0 Atyps-1* Macroph-44* [**2169-7-25**] 02:14PM ASCITES WBC-30* RBC-2500* Polys-48* Lymphs-18* Monos-18* Eos-3* Mesothe-3* Macroph-10* [**2169-7-27**] 10:45AM ASCITES WBC-150* RBC-3200* Polys-13* Lymphs-4* Monos-4* Atyps-2* Plasma-2* Mesothe-1* Macroph-73* Other-1* DISCHARGE: [**2169-7-28**] 06:25AM BLOOD Free T4-0.92* [**2169-7-25**] 06:45AM BLOOD TSH-0.25* [**2169-7-29**] 06:00AM BLOOD Albumin-4.7 Calcium-9.7 Phos-2.3* Mg-2.4 [**2169-7-29**] 06:00AM BLOOD ALT-78* AST-70* AlkPhos-130 TotBili-20.9* [**2169-7-29**] 06:00AM BLOOD Glucose-125* UreaN-33* Creat-1.2 Na-133 K-4.7 Cl-99 HCO3-25 AnGap-14 [**2169-7-29**] 06:00AM BLOOD PT-18.4* PTT-48.0* INR(PT)-1.7* [**2169-7-29**] 06:00AM BLOOD WBC-6.2 RBC-3.08* Hgb-9.5* Hct-29.4* MCV-96 MCH-30.9 MCHC-32.3 RDW-23.3* Plt Ct-38* Brief Hospital Course: Mr. [**Known lastname 26438**] is a 51yoM with h/o PSC cirrhosis c/b ascites, esophageal varices w/ prior hemorrhage, hepatic encephalopathy, prior SBP, portal vein thrombosis, who p/w hematemsis/UGIB due to esoph varices, banded in and stabilized in SICU on [**7-19**]. Then stabilized and called out of SICU on [**7-21**]. Course was complicated by worsening of renal function, which has improved in the last two days of admission. Additionally, the patient's course was complicated by a flare of [**Month/Year (2) 82272**] of his b/l lower extremeties. . In regards to the hematemsis, the patient's hct was stable through the remainder of the admission after variceal banding in SICU. The patient did not have melena, hematochezia, or hematemsis for the remainder of the admission. The patient was continued on IV PPI in the SICU and for two days afterwards. Subsequently, the patient was continued on oral PPI. Nadolol 20mg daily was also continued. Ceftriaxone 1mg/day was continued x 5 days for SBP prophylaxis followed by Ciprofloxacin 250mg [**Hospital1 **]. Carafate was continued. Anticoagulation was held. . In regards to the renal function, the patient's Cr increased from a baseline of 1.1 to a peak of 2.0. The worsening renal function was likely related to large volume paracentesis and liver cirrhosis. The patient's diuretics were held, and 25% Albumin at 1mg/kg was continued during the course of his admission until one day before discharge. On day of discharge the patient's Cr was back to baseline at 1.2, and the patient was restarted at half his home dose. . In regards to the patient's leukocytoclastic vasculitis ([**Hospital1 82272**]), it was most prominent on the b/l lower legs. The patient was evaluated by Rheumatology. The patient was then restarted on prednisone and colchicine. The patient's prednisone was tapered per Rheumatology protocol. The skin lesions showed significant subjective and objective improvement during the course of admission. On the day of discharge the patient was no longer complaining of pain, the edema was significantly decreased, and the distribution of the lesions decreased as well. The patient was discharged with prednisone taper and set up with a follow up Rheumatology appointment. (Start Prednisone PO 30mg/day, start taper to goal 10mg daily + Colchicine .6mg daily) . In regards to the patient's decompensated liver cirrhosis (MELD 25-27), Lactulose and Rifaximin were continued given history of hepatic encephalopathy, diuretics were held due to poor renal function until the day of discharge. Anticoagulation was held in regards to the patient's portal vein thrombosis history. Patient required three therapeutic and diagnostic paracenteses. . The patient had several episodes of NSVT, cardiology was consulted, they were not concerned and did not recommend further evaluation. . TRANSITIONAL ISSUES: - Pt's TSH and FT4 were compatible with primary hypothyroidism - HCC Screening [**12/2169**] Medications on Admission: 1. Midodrine 10 mg PO TID 2. Lactulose 60 mL PO QID 3. Acetaminophen 650 mg PO TID:PRN pain 4. Magnesium Oxide 400 mg PO BID 5. Gabapentin 300 mg PO Q8H 6. Simethicone 40-80 mg PO QID:PRN abd pain 7. Lidocaine 5% Patch 1 PTCH TD DAILY 12 hours on, 12 hours off 8. Cholestyramine Light *NF* (cholestyramine-aspartame) 4 gram Oral [**Hospital1 **] 9. Cyclobenzaprine 10 mg PO HS:PRN muscle spasms 10. Ursodiol 500 mg PO BID 11. Torsemide 40 mg PO DAILY 12. Spironolactone 50 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. OxycoDONE (Immediate Release) 20 mg PO Q6H:PRN pain 15. Metoclopramide 10 mg PO QID:PRN nausea, before each meal 16. Pantoprazole 40 mg PO Q24H 17. Ciprofloxacin HCl 250 mg PO Q12H 18. Calcium Carbonate 500 mg PO BID 19. Citalopram 20 mg PO DAILY 20. Fentanyl Patch 50 mcg/hr TP Q72H 21. Rifaximin 550 mg PO BID 22. Vitamin D 800 UNIT PO DAILY 23. Colchicine 0.6 mg PO DAILY 24. Fluconazole 200 mg PO Q24H Duration: 4 Days 25. Vancomycin Oral Liquid 125 mg PO Q6H Duration: 14 Days 28. Haloperidol 1 mg PO HS . MEDICATIONS ON TRANSFER: 1. Metoclopramide 10 mg IV Q6H 2. CeftriaXONE 1 gm IV Q24H 3. Octreotide Acetate 50 mcg/hr IV DRIP INFUSION 4. Citalopram 20 mg PO/NG DAILY 5. OxycoDONE (Immediate Release) 15 mg PO/NG Q6H:PRN Pain >[**6-11**] 6. Pantoprazole 8 mg/hr IV INFUSION 7. Fentanyl Patch 50 mcg/hr TP Q72H 8. Lidocaine 5% Patch 1 PTCH TD DAILY Discharge Medications: 1. Cholestyramine 4 gm PO BID 2. Ciprofloxacin HCl 250 mg PO/NG Q12H 3. Citalopram 20 mg PO DAILY 4. Colchicine 0.6 mg PO DAILY RX *Colcrys 0.6 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Fentanyl Patch 50 mcg/hr TP Q72H 6. Gabapentin 300 mg PO Q8H 7. Lactulose 60 mL PO QID Titrate to [**3-5**] BMs daily. 8. Lidocaine 5% Patch 1 PTCH TD DAILY 9. Metoclopramide 10 mg PO QIDACHS prn nausea 10. Multivitamins 1 TAB PO DAILY 11. OxycoDONE (Immediate Release) 20 mg PO Q6H:PRN Pain >[**6-11**] 12. Pantoprazole 40 mg PO Q24H 13. Nadolol 20 mg PO DAILY hold for HR < 55 RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 14. PredniSONE 25 mg PO DAILY Duration: 4 Days RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*70 Tablet Refills:*0 15. Rifaximin 550 mg PO BID 16. Spironolactone 50 mg PO DAILY Hold for SBP<90. Notify HO if holding. 17. Torsemide 20 mg PO DAILY Hold for SBP<90. Let HO know if holding. 18. Ursodiol 500 mg PO BID 19. Vitamin D 800 UNIT PO DAILY 20. Haloperidol 1 mg PO HS:PRN insomnia 21. Acetaminophen 650 mg PO TID:PRN pain 22. Magnesium Oxide 400 mg PO BID 23. Simethicone 40-80 mg PO QID:PRN abd pain 24. Cyclobenzaprine 10 mg PO HS:PRN muscle spasms 25. Calcium Carbonate Suspension 500 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: -End stage liver disease with acute variceal bleed -acute kidney injury -recurrent ascites Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 26438**], It was a pleasure taking care of you at [**Hospital1 827**]. You were transferred here for continued management of an acute bleed from your esophageal varices which was intervened upon by the gastroenterologists. Your blood counts remained stable, however you began to develop worsened kidney function. We gave you albumin and stopped your water pills intermittently. You kidney function improved, and so we restarted your water pills. You really wanted to leave, so we are okay with you going home, however ideally we would want to watch your kidney function to ensure it does not worsen on the water pills. If you do not feel well for any reason, please call Dr. [**Last Name (STitle) 497**] or seek medical attention. While you were here, your vasculitis worsened and so you were restarted on a steroid (prednisone) taper. You will need to follow this steroid regimen carefully and make sure to schedule a follow up appointment with the Rheumatology specialists. Prior to your leaving us, you were leaking ascites from the site of a recent paracentesis. We placed stitches which seemed to have slowed the leaking. You can use a stoma bag over the incision and empty it intermittently if needed. Please seek medical attention should the area begin leaking more rapidly or become painful or infected looking. You will need to have the stitches removed in 10 days (on Monday [**8-7**]). The following changes were made to your medications: DECREASE Torsemide to 20mg daily (from 40mg daily) STOP Midodrine STOP Warfarin, given your recent bleeding STOP Vancomycin STOP Fluconazole START Nadolol 20mg daily START Colchicine 0.6mg daily Please make sure to follow this steroid tapering regimen to ensure your vasculitis does not flare up: START Prednisone 25mg daily [**Date range (2) 82280**] THEN TAKE Prednisone 20mg daily on [**6-29**] THEN TAKE Prednisone 15mg daily on [**2169-8-7**] THEN TAKE Prednisone 10mg daily until your follow up appointment with Rheumatology. You will need to call to schedule a follow up appointment with Rheumatology: #([**Telephone/Fax (1) 1668**]. You should be seen the week of [**8-14**] to [**2169-8-18**]. Please also continue to get your weekly blood draws. Followup Instructions: You will need to call to schedule a follow up appointment with Rheumatology: #([**Telephone/Fax (1) 1668**]. You should be seen the week of [**8-14**] to [**2169-8-18**]. Dr.[**Name (NI) 948**] office will call you with a follow up appointment for you during the first week of [**Month (only) 216**] as you will have you have a repeat upper endoscopy. If you have any questions, his office number is: #([**Telephone/Fax (1) 3618**]. You should schedule follow up with your Primary Care Provider, [**Name10 (NameIs) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 82264**], within the next week. Completed by:[**2169-8-4**]

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icd9cm

[ [ [] ] ]

[ "42.33", "54.91" ]

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19410

Discharge summary

report

Admission Date: [**2163-2-23**] Discharge Date: [**2163-3-4**] Date of Birth: [**2107-8-7**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Cirrhosis and HCC Major Surgical or Invasive Procedure: liver transplant [**2163-2-23**] History of Present Illness: 55 y.o. male with HCV with cirrhosis and HCC s/p RFA in [**12-22**] of 2 lesions. Current MELD 22 with exception points. He has been called for DCD liver donor from [**State 2748**]. Denies fever, chills, n/v/d or sick contacts. [**Name (NI) **] chest pain or SOB. Has regained all of previously lost weight. Now with good appetite. +complaints of fatigue. Past Medical History: Hepatitis C related cirrhosis who previously failed Interferon and Ribavirin therapy Hepatocellular CA s/p RFA [**12-22**] h/o cocaine use in [**2126**] h/o marijuana h/o ankle fixation bilat repair of L rotator cuff lap liver bx backpain Social History: The patient smoked one pack per day and quit 28 years ago. He does not consume alcohol. Family History: non contributory Physical Exam: 97.5 69 135/87 20 99% 67.8 kg well groomed, slight, skin warm, and dry HEENT- no LAD, oral mucosa pink and moist, no sores, no discharge Lungs-CTA bilaterally Card-RRR, no MRG noted ABD-soft non-distended,non-tender, lap scars well healed, +BS Extremities-no edema, 2+ pedal pulses, warm, well perfused Neuro-EOMI, perrla, a&o x3, no focal defecits noted. serologies [**2163-1-8**] HBsAg neg HBsAb neg HBcAb neg HIV neg HCAb positive, HAV neg, HSV 1&2 negative AFP [**2163-2-23**] 119, CEA 22, PSA 0.3, CA [**75**]-9 32 TSH 4.5 Pertinent Results: On Admission: [**2163-2-23**] PT-14.4* INR(PT)-1.3 FIBRINOGEN-180 WBC-6.4 RBC-4.50* HGB-14.9 HCT-43.3 MCV-96 MCH-33.2* MCHC-34.5 RDW-14.4 PLT COUNT-150 ALT(SGPT)-317* AST(SGOT)-221* ALK PHOS-151* TOT BILI-0.4 UREA N-10 CREAT-0.8 SODIUM-137 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-30 ANION GAP-12 URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG On Discharge:[**2163-3-4**] WBC-11.5* RBC-2.53* Hgb-8.8* Hct-24.3* MCV-96 MCH-34.5* MCHC-36.1* RDW-17.6* Plt Ct-175 Glucose-100 UreaN-10 Creat-0.6 Na-138 K-3.8 Cl-104 HCO3-26 AnGap-12 ALT-114* AST-33 AlkPhos-53 Amylase-192* TotBili-0.4 Brief Hospital Course: Taken to the OR for DCD donor liver transplant on [**2163-2-23**] by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. PV-PV, CBD-CBD (no t tube), branch patch recipient to donor celiac axis, piggyback, no t.tube. See OR report for further details. He received Solu-Medrol and CellCept for induction immunosuppression. He arrived in the SICU on neo and propofol drips. Neo was weaned off. He had two [**Doctor Last Name 406**] drains with serosang drainage. Postop, liver ultrasound was unremarkable. He received several fluid boluses for low PA pressures which improved pressures. He was extubated on POD 0. He did well with LFTs trending down, diet was advanced and he was started on Prograf 2mg [**Hospital1 **] on pod 1. Steroids were tapered according to protocol. The medial JP and Foley were removed on POD 3. He was ambulatory and comfortable with oxycodone. On POD 4, [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] came by to discuss discharge medications for probable d/c on [**3-1**]. He was constipated and received milk of magnesia. On POD 5, JP drain fluid was noted to be bilious appearing, as well, the patient stated he had pain over the right side of incision that worsened through the early morning. JP drain Bili was 8.5. CT abdomen/pelvis was obtained and demonstrated small amount of subhepatic low-density fluid, without features suspicious for abscess or hemorrhage. Started on Zosyn IV for GI coverage. Drain fluid sent for culture, which is shown to be no growth. ERCP on [**3-2**] was done to investigate for potential bile leak. A contained leak at the site of biliary anastomosis was found with successful placement of a 10 French biliary stent. The following day, amylase and lipase were found to be elevated,, recheck the following day showed near normalization. Patient did not have abdominal pain or fever. WBC which was previously elevated continued to normalize. Patient had follow-up U/S on [**3-3**] which showed: Small fluid collection in the porta hepatis and patent and appropriate direction of flow seen in portal veins, hepatic veins, and hepatic arteries. Follow up CT of abdomen is scheduled for next week in conjunction with transplant clinic visit to assess status of collection. Patient sent home on 10 day course of Levaquin secondary to bile leak. One drain was left in place. Patient discharged home with VNA services. Medications on Admission: marinol 5mg [**Hospital1 **], mycelex 10 mg qid, caltrate 600mg [**Hospital1 **], oxycodone prn, Discharge Medications: 1. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 4. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 7. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day. 9. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO twice a day. 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*8 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: ESLD HCV/cirrhosis/HCC Discharge Condition: good Discharge Instructions: Call Transplant office [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, inability to take medications, redness/bleeding/drainage from incision or drain site, jaundice or fluid retention Labs every Monday and Thursday for cbc, chem 10, ast, alt, alk phos, tbili, albumin, and trough prograf level. fax results to [**Telephone/Fax (1) 697**] Followup Instructions: CT/Abd Pelvis with PO/IV Contrast [**2163-3-10**] 7:45 AM [**Location (un) 1951**] [**Hospital Ward Name 23**] Building. Nothing to eat after midnight. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2163-3-10**] 2:40PM [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2163-4-21**] 9:30 [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2163-6-22**] 8:00 2:40 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2163-3-4**]

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icd9cm

[ [ [] ] ]

[ "00.93", "99.07", "38.93", "51.87", "50.59" ]

icd9pcs

[ [ [] ] ]

5941, 5992

2441, 4890

329, 364

6059, 6066

1722, 1722

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1135, 1153

5037, 5918

6013, 6038

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1168, 1703

2194, 2418

272, 291

392, 750

1736, 2181

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1028, 1119

25,178

169,461

12704

Discharge summary

report

Admission Date: [**2148-1-8**] Discharge Date: [**2148-1-10**] Date of Birth: [**2085-5-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 458**] Chief Complaint: lightheadedness Major Surgical or Invasive Procedure: BiVentricular ICD palcement History of Present Illness: 62-year-old man with a history of CAD (sirolimus-eluting stent in LCx in [**2142**]), DM2, dyslipidemia who was transferred from [**Hospital3 **] for EP study with planned ICD placement after having polymorphic VT arrest. The patient presented to [**Hospital3 **] on [**2147-1-5**] with a complaint of lightheadedness x few weeks, at times associated with dyspnea. No chest pain. He has chronic RBBB but developed new LBBB and complete heart block at [**Hospital1 **]. The plan was to have a DD pacemaker placed. On [**2147-1-7**] he had polymorphic VT arrest, requiring defibrillation. Had temporary pacing wire placed. Cardiac enzymes were negative. Also had mild CHF, presumedly from heart block, with echo showing EF 30%, dilated LV, and hypokinesis in apex, septum, anterior wall. Transferred to [**Hospital1 18**] for further management with possible ICD placement. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. On arrival to the CCU, VSS, patient was talking pleasantly. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:: Diabetes (+), Dyslipidemia (+), Hypertension (-) 2. CARDIAC HISTORY: -CABG: [**12/2142**], LIMA -> LAD, SVG -> OM -PERCUTANEOUS CORONARY INTERVENTIONS: [**7-/2142**], stenting of the LCX with a 3.0 x 13 mm sirolimus-eluting stent -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: asthma Social History: -Tobacco history: [**3-6**] pk/day x decades before quitting in [**2131**] -ETOH: social -Illicit drugs: none Family History: No family history of early MI, otherwise non-contributory. Physical Exam: PHYSICAL EXAMINATION: GENERAL: Elderly man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: labs- [**2148-1-8**] 10:00PM BLOOD WBC-8.8 RBC-4.47*# Hgb-15.0# Hct-39.8*# MCV-89 MCH-33.7*# MCHC-37.8*# RDW-14.2 Plt Ct-179 [**2148-1-9**] 05:35AM BLOOD WBC-9.9 RBC-4.63 Hgb-15.0 Hct-41.4 MCV-90 MCH-32.3* MCHC-36.1* RDW-14.2 Plt Ct-199 [**2148-1-9**] 08:23PM BLOOD WBC-8.9 RBC-4.68 Hgb-15.2 Hct-42.0 MCV-90 MCH-32.5* MCHC-36.2* RDW-14.4 Plt Ct-197 [**2148-1-10**] 04:07AM BLOOD WBC-8.1 RBC-4.20* Hgb-13.9* Hct-38.1* MCV-91 MCH-33.2* MCHC-36.6* RDW-14.2 Plt Ct-172 [**2148-1-8**] 10:00PM BLOOD PT-15.8* PTT-26.8 INR(PT)-1.4* [**2148-1-9**] 05:35AM BLOOD PT-16.5* PTT-28.5 INR(PT)-1.5* [**2148-1-9**] 08:23PM BLOOD PT-16.7* PTT-31.6 INR(PT)-1.5* [**2148-1-10**] 04:07AM BLOOD PT-16.8* PTT-32.4 INR(PT)-1.5* [**2148-1-8**] 10:00PM BLOOD Glucose-272* UreaN-12 Creat-0.8 Na-137 K-3.9 Cl-103 HCO3-27 AnGap-11 [**2148-1-9**] 05:35AM BLOOD Glucose-200* UreaN-9 Creat-0.7 Na-137 K-4.0 Cl-102 HCO3-27 AnGap-12 [**2148-1-9**] 08:23PM BLOOD Glucose-238* UreaN-8 Creat-0.7 Na-135 K-4.2 Cl-100 HCO3-25 AnGap-14 [**2148-1-10**] 04:07AM BLOOD Glucose-289* UreaN-13 Creat-0.9 Na-134 K-4.3 Cl-102 HCO3-26 AnGap-10 [**2148-1-8**] 10:00PM BLOOD CK(CPK)-334* [**2148-1-10**] 04:07AM BLOOD CK(CPK)-223* [**2148-1-8**] 10:00PM BLOOD CK-MB-4 cTropnT-0.05* [**2148-1-9**] 05:35AM BLOOD CK-MB-3 cTropnT-0.04* [**2148-1-10**] 04:07AM BLOOD CK-MB-4 cTropnT-0.03* [**2148-1-8**] 10:00PM BLOOD Calcium-8.5 Phos-3.0 Mg-1.6 [**2148-1-10**] 04:07AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.9 Studies- CXR IMPRESSION: 1. Temporary pacer wire inserted through a left subclavian approach with course through the pulmonary artery with tip terminating within the mid right ventricle. 2. Bibasilar atelectasis. ============================== Echo Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.0 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.6 cm <= 5.2 cm Right Atrium - Four Chamber Length: *6.2 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.7 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.7 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 5.6 cm Left Ventricle - Fractional Shortening: *0.16 >= 0.29 Left Ventricle - Ejection Fraction: 20% to 30% >= 55% Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 12 < 15 Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: *3.7 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.67 Mitral Valve - E Wave deceleration time: *138 ms 140-250 ms TR Gradient (+ RA = PASP): 19 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Severely depressed LVEF. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Focal apical hypokinesis of RV free wall. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Mildly dilated ascending aorta. Focal calcifications in ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid valve supporting structures. No TS. Physiologic TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. Conclusions The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20-30 %) secondary to akinesis of the interventricular septum, anterior free wall, and apex. The inferior free wall is also hypokinetic. The interventricular septum is thin and fibrotic (scarred). There is no ventricular septal defect. Right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. = = = = = ================================================================ Discharge CXR Expected appearance of AICD without pneumothorax or concerning pulmonary finding. Brief Hospital Course: 62-year-old man with a history of CAD (sirolimus-eluting stent in LCx in [**2142**]), DM2, dyslipidemia who was transferred from [**Hospital3 **] after having polymorphic VT arrest. # RHYTHM: Polymorphic VT at [**Hospital1 **] requiring defibrillation and then placement of temporary pacing wire. Likely related to bradycardia secondary to heart block. Initially pt was observed overnight with temporary pacing wire. Then, patient had an EP study with placement of a biventricular ICD. Patient was given vancomycin preop and post op and then discharged on 7 day tx of Keflex. He will have device evaluation at his primary cardiologist office next week. He was given 7 days of pain medications for the procedure and given instructions for wound care. CXR was performed after device placement without evidence of complications. # CORONARIES: Patient had a drug eluding stent in LCx in [**2142**]. Cardiac enzymes negative at [**Hospital1 **] by report. Had a elevation in CK that trended down, peak of 334,. which was likely secondary to shock at OSH. He was continued on ASA and plavix. Beta blocker was held secondary to asthma. # PUMP: During hospitalization pt had no acute evidence of heart failure. Reportedly had EF of 30% at OSH echo. Echo was redone and confirmed EF of 30% and showed septal, anterior, apical hypokinesis. Patient was continued on lisinopril 10mg (unknown home dose), therefore, this may need to be adjusted by his cardiologist after discharge. # Diabetes mellitus: Patient was on SSI while in patient, then discharged on home lantus, humalog, and oral hypoglycemics # Dyslipidemia: Patient was continued on his home statin. Patient was discharged home with cardiology f/u planned for next week with device evaluation. Medications on Admission: metformin 1000 mg [**Hospital1 **] clopidogrel 75 mg qday ASA 81 mg qday alb nebs Advair citalopram 20 mg qday lisinopril unknown dose glimepiride 2 mg qday rosuvastatin 40 mg qday Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Lantus 100 unit/mL Cartridge Sig: One (1) unit Subcutaneous at bedtime: please take your normal home dose. 4. Humalog 100 unit/mL Cartridge Sig: Five (5) units Subcutaneous three times a day: with meals. 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for your heart. Disp:*30 Tablet(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 7 days: do not take if sleepy or driving, do not combine with alcohol. Disp:*28 Tablet(s)* Refills:*0* 7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days: antibiotic. Disp:*28 Capsule(s)* Refills:*0* 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 11. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day. 13. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Disposition: Home Discharge Diagnosis: Polymorphic Ventricular Tachycardia s/p cardiac arrest Systolic heart failure, EF 30% Coronary Artery Disease, s/p CABG Hyperlipdemia Diabetes Depression Discharge Condition: hemodynamically stable, afebrile Discharge Instructions: You were transfered to [**Hospital1 18**] due to having polymorphic ventricular tachycardia (an irreglar heart beat) that requiring first a temporary pacemaker at the other hospital and then and biventricular ICD placement. You were given instructions about what activities to avoid after the procedure. You also were started on anitbiotics to prevent infection after the procedure. You will need to be seen by your cardiologist check on your ICD in one week. You also had a echocardiogram that showed systolic heart failure, similar to your echocardiogram at the other hospital. Please keep your follow up appointments. Please take your medications as perscibed. Your new medications are as follows: -Keflex (antibiotic) for 7 days -Lisinopril 10mg once a day (please take this new dose until you see your doctor to discuss your previous dose) -oxycodone to take for chest pain, do not take if sedated, do not drive while on this medication, or combine with alcohol If you have chest pain, shortness of breath, bleeding of your chest wall, firing of your ICD, or any other concerning symptom please seek medical attention or call 911. Weigh yourself daily for your heart failure, if you gain >2lbs per day, call your doctor. Do not eat more than 2g of sodium per day in your diet. Followup Instructions: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 4475**], please call for a follow up appoinmtent Caridologist- please call tomorrow to schedule appointment for 1 week to check your ICD and your medications Completed by:[**2148-1-11**]

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Discharge summary

report

Admission Date: [**2144-9-2**] Discharge Date: [**2144-9-8**] Date of Birth: [**2060-10-15**] Sex: F Service: MEDICINE Allergies: Aspirin / Sulfa (Sulfonamide Antibiotics) / Nafcillin / Tylenol Attending:[**First Name3 (LF) 759**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: 83F with h/o SVT, G6PD def., PE on coumadin, chronic low back pain and RA on prednisone presents with altered mental status from home. Per son, for the past day she has been acting more confused and occasionally saying things that don't make sense. Complaining of abdominal pain, diarrhea. Pt. a poor historian. Family says that she has had abdominal pain. Pt. states that she had been constipated for the past few days, causing abdominal pain. She took some form of laxative and has been having diarrhea since. Diarrhea has been non-bloody and she currently denies abdominal pain. She denies pain with defication. No dysuria, but does note some increased urinary frequency. Has history of SVT for which she takes metoprolol and verapamil. She states she did not take her medications today. In the ED, initial VS were: T 99.4 HR 150 BP 76/34 RR 18 Sat 99%RA. DRE was notable for FOBT-negative brown stool. Of note, she had a rectal temp of 103 in the ED. Labs were notable for Na 135, K 4.5, Lactate 3.5, Cr 0.9, WBC 23.2 PMN 89%, H/H 10/32, PT: 32.8 PTT: 43.6 INR: 3.2. AST 142 ALT 57. Clean UA. EKG was done and notable for sinus tachycardia. CXR no concern for PNA or CHF. CT abd/pelvis prelim report stated thickened rectum, inflammatory changes, maybe proctitis but no frank abscess. new L4 vertebral body fracture from [**Month (only) 958**] (patient is moving lower extremities well). C diff sent. [**Month (only) **] culutures sent. She was given stress dose steroid (unclear if on prednisone at home), benadryl (given history of allergy to tylenol listed as pruritus), ciprofloxacin 400 mg IV, flagyl 500 mg IV, morphine 5 mg IV. She received a total of 5L NS in the ED. Vital signs on transfer: 102.2 118 121/62 22 100% On arrival to the MICU, Pt. is somewhat somnolent, but answering questions appropriately. She complains of back pain and b/l leg pain, which she states is chronic. Of note, she received an epidural steroid injection on [**2144-7-15**]. She denies abdominal pain, nausea, vomiting. No chest pain, shortness of breath. Does complain of chronic cough, no change. She received 1 more liter NS. Lactate down to 1.3. BPs remained stable and HR down to 90s. Past Medical History: ##PAST MEDICAL HISTORY: -Tuberculosis in the setting of methotrexate and remicaid treatment for RA. Diagnosed in [**7-20**]. Treated with DOT for four months. -Refractory anemia with ringed sideroblasts dx by BMB in '[**33**]. Baseline Hct 23 to 27. -Rheumatoid arthritis on Methotrexate and Remicaide infusions. -Left shoulder mass - ganglion vs. cyst by MRI report in [**2134**]. -Glucose 6-phosphate deficiency. -Sickle cell trait by Hgb Electrophoresis. -Supraventricular tachycardia, likely atrial per cardiology -Bilateral PE, dx'd [**2135-8-15**] for w/u for pulmonary HTN. -History of HSV 2 skin R thigh -Hepatitis B core Ab and surface Ab positive, surface Ag negative in [**2121**]'s -Low back pain. -Recurrent genital rash. -Recurrent otitis media. -Allergic rhinitis. Social History: Patient was born in [**Location (un) 4708**] and moved to the US in [**2112**]. [**Name (NI) **] husband died 40 years ago. She used to work in hotels and as a home health aide. She has never smoked, drank etoh or done any drugs. She lives with her son and grandson in [**Location (un) 686**]. Family History: Significant for diabetes mellitus in her mother. Daughter died at age 38 of "tongue cancer." . #Allergies: Patient denies allergies, but with history of G6PD, pt should avoid aspirin and Sulfa meds. THIS HOSPITAL ADMISSION found to be allergic to nafcillin. eosinophilia and bone marrow suppresion Physical Exam: Admission Physical Exam Vitals: T:99.5 BP:109/75 P:111 R: 21 O2: 100% on 2LNC General: Alert and oriented x3, no acute distress, somnolent, but answering questions appropriately. HEENT: Sclera anicteric, dry mucous membranes, poor dentition, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: tachycardic, regular, normal S1 + S2 no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No tenderness to palpation over spine. Neuro: grossly intact, but patient not very cooperative with exam. B/l leg strength appears intact. Discharge Physical Exam Vitals: Tc 98.8, BP 131/82, HR 81, RR 18, O2 99% RA 5 BM General: Alert and oriented x3, no acute distress, appropriate HEENT: Sclera anicteric, MMM, poor dentition, EOMI, PERRL CV: RRR, normal S1 + S2 no murmurs, rubs, gallops Lungs: CTAB anteriorly, no wheezes or ronchi anteriorly. Nml work of breathing. Abdomen: soft, non-distended, bowel sounds present, tender to palpation in epigastrium Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No tenderness to palpation over spine. Neuro: CNs II-XII intact. Strength full [**4-18**] in upper and lower extremities for her baseline strength and conditioning. Pertinent Results: ADMISSION LABS: [**2144-9-1**] 08:30PM PT-32.8* PTT-43.6* INR(PT)-3.2* [**2144-9-1**] 08:30PM PLT COUNT-370 [**2144-9-1**] 08:30PM NEUTS-88.9* LYMPHS-8.1* MONOS-2.3 EOS-0.4 BASOS-0.3 [**2144-9-1**] 08:30PM WBC-23.2*# RBC-3.22* HGB-9.9* HCT-32.2* MCV-100* MCH-30.8 MCHC-30.8* RDW-24.8* [**2144-9-1**] 08:30PM ALBUMIN-4.1 [**2144-9-1**] 08:30PM LIPASE-38 [**2144-9-1**] 08:30PM ALT(SGPT)-57* AST(SGOT)-142* ALK PHOS-64 TOT BILI-1.4 [**2144-9-1**] 08:30PM estGFR-Using this [**2144-9-1**] 08:30PM GLUCOSE-115* UREA N-17 CREAT-0.9 SODIUM-135 POTASSIUM-6.7* CHLORIDE-98 TOTAL CO2-24 ANION GAP-20 [**2144-9-1**] 08:33PM LACTATE-3.5* K+-4.5 [**2144-9-1**] 08:45PM URINE [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG [**2144-9-1**] 08:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006 PERTINENT LABS: [**2144-9-3**] 06:35AM [**Month/Day/Year 3143**] ALT-94* AST-100* AlkPhos-66 TotBili-0.7 [**2144-9-4**] 07:55AM [**Month/Day/Year 3143**] CRP-98.9* [**2144-9-4**] 07:55AM [**Month/Day/Year 3143**] ESR-26* [**2144-9-5**] 06:20AM [**Month/Day/Year 3143**] ESR-51* MICROBIOLOGY: [**2144-9-1**] 8:30 pm [**Month/Day/Year 3143**] CULTURE times 2 **FINAL REPORT [**2144-9-7**]** [**Month/Day/Year **] Culture, Routine (Final [**2144-9-7**]): NO GROWTH. [**2144-9-2**] 3:19 am MRSA SCREEN **FINAL REPORT [**2144-9-4**]** MRSA SCREEN (Final [**2144-9-4**]): No MRSA isolated. [**2144-9-1**] 10:35 pm STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT [**2144-9-2**]** C. difficile DNA amplification assay (Final [**2144-9-2**]): Reported to and read back by DR. [**Last Name (STitle) 14775**] [**2144-9-2**], 10:25AM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). [**2144-9-2**] 10:10 am URINE Source: Catheter. **FINAL REPORT [**2144-9-3**]** URINE CULTURE (Final [**2144-9-3**]): NO GROWTH. [**2144-9-2**] 8:00 pm [**Month/Day/Year 3143**] CULTURE Source: Venipuncture. **FINAL REPORT [**2144-9-8**]** [**Month/Day/Year **] Culture, Routine (Final [**2144-9-8**]): NO GROWTH. [**2144-9-6**] 4:43 pm URINE Source: CVS. **FINAL REPORT [**2144-9-7**]** URINE CULTURE (Final [**2144-9-7**]): NO GROWTH. IMAGING: CXR [**9-1**]: IMPRESSION: Mild stable cardiomegaly. No overt evidence of pneumonia or CHF. CT abdomen [**9-1**]: IMPRESSION: 1. Thickened rectal wall with surrounding fat stranding and presacral fluid suggesting proctitis. 2. Burst fracture of the L4 vertebral body with relative preservation of body height, new compared to [**2144-2-13**], though appearance does not appear acute. Correlate for prior injury. 3. Multiple splenic hypodensities of unclear etiology. Minimally increased in size and number compared to [**2138**], possibly representing combination of splenic cysts and/or hemangiomas. MRI L-Spine W & W/O CONT IMPRESSION: 1. Epidural intrinsically T1 hyperintense collection anteriorly at L3 which likely represents a hematoma. Superimposed infection cannot be excluded. 2. Burst fracture of L4 as seen on the prior abdominal CT with associated hematoma. Compression of the L2 vertebral body appears non acute. 3. Severe multilevel degenerative changes of the lumbar spine as described above. 4. Marked hypointensity of the bone marrow is again seen on all sequences which may reflect sequela of chronic anemia, diffuse infiltrative process, or myeloproliferative disease with sclerosis. DISCHARGE LABS: [**2144-9-8**] 07:30AM [**Month/Day/Year 3143**] WBC-5.1 RBC-2.55* Hgb-7.8* Hct-25.6* MCV-101* MCH-30.6 MCHC-30.3* RDW-25.2* Plt Ct-330 [**2144-9-8**] 07:30AM [**Month/Day/Year 3143**] PT-23.3* PTT-39.7* INR(PT)-2.2* [**2144-9-8**] 07:30AM [**Month/Day/Year 3143**] Glucose-82 UreaN-5* Creat-0.6 Na-142 K-4.3 Cl-104 HCO3-30 AnGap-12 [**2144-9-8**] 07:30AM [**Month/Day/Year 3143**] Calcium-8.5 Phos-3.9# Mg-1.8 Brief Hospital Course: ASSESSMENT: 83 y/o woman h/o SVT, bilateral PE on coumadin, chronic low back pain, and rheumatoid arthritis who was admitted to the ICU w/ AMS, fever, hypotension, and low back pain, and was found to have c diff colitis as well as concern for infected back hematoma. BRIEF HOSPITAL COURSE BY PROBLEM: ACTIVE ISSUES: #Septic Shock/C. Diff Colitis: [**3-18**] SIRS criteria (leukocytosis, tachypnea, fever, tachycardia) and C diff positive. Fevers to 103. Initially hypotensive upon arrival to ED to 70/40 and tachycardic to 150. Lactate was 3.4. Patient received 5L NS in ED and [**Month/Day (4) **] pressure responded adequately. Transfered to MICU, where she received another 3L NS, resulting in hemodynamic stability. Never required pressor support. CT abdomen showed inflammation of rectum. C. Diff positive. Started on PO vanc and IV flagyl initially, narrowed to PO vancomycin alone. Patient will need to complete a full course, end date [**2144-9-18**]. #Epidural hematoma: Given recent injection and worsening low back pain, other potential source of sepsis was epidural abscess. Started on IV vanco/ceftriaxone. MRI showed L4 epidural hematoma. Initial concern for infection, but after discussion with ID/Neurosurgery/Neuroradiology, felt less likely an infection and antibiotics were stopped. Also had burst fracture of indeterminate age at L4 that Nsurg recommended a TLSO brace when out of bed. Hematoma alternatively could have been from burst fracture. [**Year (4 digits) **] Cx NGTD at time of discharge. She was not discharged on IV antibiotics, and will follow-up with ortho spine on [**2144-9-30**]. # L4 Burst fracture: Discovered on MRI, not present on imaging from [**2144-2-13**], but is unclear whether it is acute or chronic. Was seen by neurosurgery as well as pain service. Neurosurgery recommended bedrest with HOB <30 degrees until braced. Ortho spine also saw the patient while in house and also agreed with conservative management and follow-up as an outpatient. The patient has an appointment with outpatient orthopaedic spine on [**2144-9-30**]. #AMS: Secondary to septic encephalopathy/hypotension, improved significantly back to baseline with fluid resuscitation and antibiotics. #Tachycardia: History of SVT, developed narrow complex tachycardia while off home metoprolol 25mg [**Hospital1 **] and verapamil 40mg daily, resolved after fluid and restarting home meds. She was monitored on telemetry throughout and continued on her home medications. #Adrenal Insufficiency: The patient received stress dose steroids in the setting of her infection and chronic prednisone use at home. Then, she was rapidly tapered and subsequently maintained on her home prednisone dose. Plan is to continue home prednisone dosing. #Pulmonary Embolism: The patient has been on chronic warfarin since [**2134**] when she had bilateral PEs. INR on presentation supratherapeutic at 3.2, warfarin held, restarted on [**2144-9-6**]. INR on day of discharge was 2.1. INR will need to be monitored while at rehab in light of antibiotics for treatment of C. diff infection. #HCT drop: HCT dropped from 32 on admission to 23, likely hemoconcentrated, baseline crits ~25 secondary to ACD, sideroblastic anemia, G6PD deficiency, and sickle cell trait. No evidence of active bleeding. Hematology consulted, and recommended against transfusion as patient has received many transfusions in the past and there is concern for iron overload. HCT remained stable on several re-checks. Remained hemodynamically stable. INACTIVE ISSUES: #RA/Pain: This is a chronic issue, but the patient has increased pain currently in her lower back and right leg, presumably [**1-16**] the epidural hematoma. She was seen by the chronic pain service, who recommended continuing her home tizanidine, lidocaine patch, and gabapentin. Steroid course as above. #G6PD: stable; continued folic acid 3 mg daily, and avoided NSAIDs/sulfa drugs. #GERD: stable; continued home omeprozole. #Allergic Rhinitis: stable; maintained on Fexofenadine 60 mg (home loratidine not on formulary). #Transitional issues: - Ortho Spine follow-up for hematoma/burst fracture on [**9-30**], [**2143**]. - Complete C. diff treatment; [**2144-9-18**] is the last day of treatment. - Monitoring INR in light of oral antibiotic regimen for treatment of C. diff, adjusting coumadin dosing as needed. - Ensure compliance with TLSO brace Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from webOMR. 1. Albuterol Inhaler [**12-16**] PUFF IH Q6H:PRN shortness of breath 2. Alendronate Sodium 70 mg PO QMON 3. Citalopram 20 mg PO DAILY 4. Fexofenadine 60 mg PO DAILY 5. FoLIC Acid 3 mg PO DAILY 6. Gabapentin 300 mg PO HS 7. Lidocaine 5% Patch 1 PTCH TD DAILY 12 hours on. 12 hours off 8. Metoprolol Tartrate 25 mg PO BID 9. Verapamil 40 mg PO Q12H 10. Warfarin 6 mg PO DAILY16 11. Oxybutynin 2.5 mg PO BID 12. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain 13. PredniSONE 10 mg PO DAILY 14. Tizanidine 2 mg PO DAILY 15. Cyanocobalamin 1000 mcg PO DAILY 16. Omeprazole 20 mg PO DAILY 17. Pyridoxine 100 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler [**12-16**] PUFF IH Q6H:PRN shortness of breath 2. Citalopram 20 mg PO DAILY 3. Fexofenadine 60 mg PO DAILY 4. FoLIC Acid 3 mg PO DAILY 5. Gabapentin 300 mg PO HS 6. Lidocaine 5% Patch 1 PTCH TD DAILY 12 hours on. 12 hours off 7. Metoprolol Tartrate 25 mg PO BID 8. Omeprazole 20 mg PO DAILY 9. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain 10. Pyridoxine 100 mg PO DAILY 11. Tizanidine 2 mg PO DAILY 12. Verapamil 40 mg PO Q12H 13. Vancomycin Oral Liquid 125 mg PO Q6H 14. Alendronate Sodium 70 mg PO QMON 15. Cyanocobalamin 1000 mcg PO DAILY 16. Oxybutynin 2.5 mg PO BID 17. PredniSONE 10 mg PO DAILY 18. Warfarin 6 mg PO DAILY16 Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) **] Discharge Diagnosis: Primary: Sepsis from C difficile colitis Spinal epidural hematoma Secondary: Rheumatoid arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you during your hospitalization at [**Hospital1 69**]. You were admitted because of fevers, low [**Hospital1 **] pressure, and altered mental status. You were found to have an infection of your large intestine known as C difficile - this is being treated with antibiotics and is improving. You were also found to have a hematoma (collection of [**Hospital1 **]) near your spine, likely from one of your epidural injections. There was concern that this was infected based on an MRI. We had the Infectious Disease doctors [**Name5 (PTitle) 788**] [**Name5 (PTitle) **] who felt that is was ok to treat this with watchful waiting. The neurosurgereons saw you as well and felt that there was no need for a surgical intervention at this time. You also had a fracture of one of your vertebrae. The neurosurgeons recommended that you wear a brace when you walk around to help this heal and lessen your pain. You will need to wear this brace at all times while up out of bed. Take all medications as instructed. You will complete a course of antibiotic called Vancomycin which is taken by mouth after discharge from the hospital. The last date of this antiobitic will be [**2144-9-18**]. You will need to have your coumadin level checked regularly while on this antibiotic; the rehab facility will do this for you. Please keep all hospital follow-up appointments. Your [**Hospital 14776**] hospital appointments are listed below. Upon discharge from your rehab facility, please make a follow-up appointment with your primary care physician. Followup Instructions: Department: INFECTIOUS DISEASE When: WEDNESDAY [**2144-9-9**] at 1:30 PM With: [**First Name8 (NamePattern2) 1955**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: RADIOLOGY When: FRIDAY [**2144-9-11**] at 1:15 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 Department: ORTHOPEDICS When: WEDNESDAY [**2144-9-16**] at 11:10 AM With: [**Name6 (MD) 8741**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: WEDNESDAY [**2144-9-30**] at 11:20 AM With: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1652**] Building: [**Location (un) 8170**] [**Location (un) **] MA

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icd9cm

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Discharge summary

report

Admission Date: [**2133-8-7**] Discharge Date: [**2133-8-31**] Date of Birth: [**2061-7-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 8388**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Intubation and mechanical ventilation Temporary dialysis catheter placement Paracentesis Bronchoscopy with broncheoalveolar lavage Upper endoscopy History of Present Illness: Pt is a 72 year old male with a history of COPD, GERD, hypertension, and alcohol abuse who was recently hospitalized at [**Hospital1 18**] from [**2133-7-11**] to [**2133-7-23**] for decompensated alcoholic cirrhosis, acute kidney injury and bilateral deep venous thrombosis. Course was also complicated by altered mental status attributed to hepatic encephalopathy and anemia requiring transfusion of 2 units of packed red blood cells. During prior admission, nutrition was a major challenge and pt continually removed dobhoff. He was also noted to have large ascited (SBP negative). Furthermore, a EGD revealed portal gastropathy and no varices. He was ultimately discharged to rehab and followed up in clinic, where he was informed that he is a poor transplant candidate due to continued etoh abuse and malnourishment. He presented to OSH ED today for coughing as well as vomitting coffee ground emesis, increased ascites and upper abdominal pain as well as acute renal failure with Cr >3.0. Because he get's his care at [**Hospital1 18**], he was transferred here. In the ED, triage vitals were Temp: 97 HR: 130 BP: 102/71 Resp: 18 O(2)Sat: 97 Normal. He was intubated for airway protection and OG returned 600cc of black fluid. A diagnostic paracentesis was performed at bedside, results pending. He was guaiac negative. Received a triple lumen in RIJ and 20G in arm. He was started on fentanyl/midaz drip and given 2g ctx, 80/8 of pantoprazole as well as octreotide. On arrival to the MICU, he is tachycardic, but otherwise hemodynamically stable. He is sedated and intubated. Past Medical History: EtOH Cirrhosis GERD Vitamin D deficiency COPD Folate deficiency Helicobacter pylori Hypertension Breast nodule/lump/mass Erectile dysfunction Tobacco dependence Social History: Has been living in [**Country 4194**], has help from maid. Smokes [**12-15**] ppd, approx 75 pack year history. Claims he drinks half gallon of vodka or rum per day for many years. No illicit drug. Former police officer. Family History: Paternal grandfather and father with diabetes. Mother with [**Name (NI) 2481**] and breast cancer. Maternal grandmother and sister with alcoholism. Brother with COPD. Physical Exam: Admission PE: General: intubated HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, no MRG Lungs: CTAB Abdomen: Distended and fluctuant, not tender GU: foley in place Ext: 2+ peripheral edema Neuro: moving all extremities spontaneously Discharge PE: VS: 98.6, Tm 98.6, 70-90s, 120-140s/60-80s, 18-20, 99-100% RA I/O: 2090 (TF, PO) + 50 (IV) / DNV + 400cc stool General: Ill appearing, encephalopathic, lying in bed, does not move L arm, A&Ox1, in NAD HEENT: eyes open, EOMI, PERRL, dry mucous membranes with yellowish coating on tongue, scleral icterus Cardiac: RRR, no murmurs Lungs: bilateral BS anteriorly, CTAB Abd: Distended, soft, nontender, no rebound or guarding, +BS, tympanic centrally and dull to percussion in dependent areas. Extr: 1+ edema of LE distally bilaterally, R>L; L hand slightly cool to touch with 2+ radial pulse and edema of distal L arm Neuro: A&Ox1 (not to time or place), intermittently follows commands, L arm flaccid and pt does not move; 5/5 strength in R arm and bilateral LE, no asterixis Pertinent Results: Admission labs: [**2133-8-6**] 04:28PM PT-18.5* PTT-37.6* INR(PT)-1.7* [**2133-8-6**] 04:28PM PLT COUNT-196 [**2133-8-6**] 04:28PM WBC-8.4 RBC-3.12* HGB-10.8* HCT-34.4* MCV-110* MCH-34.6* MCHC-31.3 RDW-16.0* [**2133-8-6**] 04:28PM ALT(SGPT)-40 AST(SGOT)-43* ALK PHOS-177* TOT BILI-0.6 [**2133-8-6**] 04:28PM UREA N-35* CREAT-3.0*# SODIUM-142 POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-28 ANION GAP-14 [**2133-8-7**] 11:25AM GLUCOSE-106* UREA N-35* CREAT-3.3* SODIUM-140 POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-26 ANION GAP-13 [**2133-8-7**] 01:25PM TYPE-ART PO2-157* PCO2-49* PH-7.38 TOTAL CO2-30 BASE XS-3 [**2133-8-7**] 03:00PM HCT-31.2* [**2133-8-7**] 08:00PM URINE RBC-13* WBC-33* BACTERIA-FEW YEAST-FEW EPI-1 [**2133-8-7**] 11:33PM HCT-34.5* [**2133-8-7**] 11:46PM HGB-11.4* calcHCT-34 . Pertinent labs: [**2133-8-26**] HEPARIN DEPENDENT ANTIBODIES Negative COMMENT: Negative for Heparin PF4 Antibody Test by [**Doctor First Name **] [**2133-8-20**] 03:54AM BLOOD Fibrino-208 [**2133-8-16**] 06:20AM BLOOD Triglyc-193* [**2133-8-17**] 05:53AM BLOOD TSH-0.98 [**2133-8-17**] 05:53AM BLOOD Cortsol-28.6* [**2133-8-8**] 12:28PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.009 [**2133-8-8**] 12:28PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [**2133-8-8**] 12:28PM URINE RBC-143* WBC-80* Bacteri-FEW Yeast-MOD Epi-<1 [**2133-8-9**] 10:16AM URINE Hours-RANDOM UreaN-248 Creat-79 Na-65 K-32 Cl-64 [**2133-8-9**] 10:16AM URINE Osmolal-330 [**2133-8-24**] 04:04PM ASCITES WBC-200* RBC-449* Polys-13* Lymphs-3* Monos-0 Mesothe-7* Macroph-77* TotPro-2.3 Glucose-107 LD(LDH)-88 TotBili-1.6 Albumin-1.5 Polys-88* Lymphs-2* Monos-4* Eos-1* Other-5* Pertinent microbiology: [**2133-8-8**] 2:06 pm PERITONEAL FLUID GRAM STAIN (Final [**2133-8-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2133-8-11**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2133-8-14**]): NO GROWTH. FUNGAL CULTURE (Final [**2133-8-21**]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2133-8-9**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [**2133-8-24**] 4:04 pm PERITONEAL FLUID: now growth [**2133-8-13**] 1:42 am STOOL: C Diff neg [**2133-8-23**] 2:38 pm STOOL: C Diff neg [**2133-8-14**] 12:44 pm BRONCHOALVEOLAR LAVAGE BROCHIAL LAVAGE.. GRAM STAIN (Final [**2133-8-14**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2133-8-16**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 112377**] [**2133-8-14**]. GRAM NEGATIVE ROD(S). ~[**2120**]/ML. FURTHER WORKUP ON REQUEST ONLY. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. LEGIONELLA CULTURE (Final [**2133-8-21**]): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2133-8-14**]): SPECIMEN NOT PROCESSED DUE TO: QUANTITY NOT SUFFICIENT. FLOOR NOTIFIED DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 355PM [**2133-8-14**]. [**2133-8-14**] 10:00 pm URINE NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. [**2133-8-7**] 11:25 am BLOOD CULTURE: NO GROWTH [**2133-8-14**] 9:42 am BLOOD CULTURE: NO GROWTH [**2133-8-15**] 2:59 am Blood Culture, Routine (Final [**2133-8-21**]): NO GROWTH. [**2133-8-23**] 10:30 am BLOOD CULTURE: NO GROWTH . Cath tip cx [**8-26**]: no significant growth C diff [**8-30**]: neg . BAL [**8-14**]- Bronchial lavage: NEGATIVE FOR MALIGNANT CELLS. Pulmonary macrophages, bronchial epithelial cells and many neutrophils. . >>Pertinent imaging: [**2133-8-7**] EGD- Friability and granularity in the esophagus, with bleeding after biopsy at GE junction. Congestion, friability and granularity in the stomach Normal mucosa in the duodenum . EGD PATHOLOGY FROM BIOPSY- Squamous and gastric type glandular mucosa with focal ulceration, acute and chronic inflammation, foveolar hyperplasia and multilayered epithelium. No well developed intestinal metaplasia seen . [**2133-8-13**] EGD- Mild Esophagitis in prox esophagus Necrotic esophagus with evidence of healing overlying 2 cords of Grade 1 varices Severe portal gastropathy Refluxing bile from pylorus Severe duodenitis, worst in the bulb Normal jejunum Otherwise normal EGD . [**2133-8-14**] EGD- Successful NJT/OGT placement Grade 1 Varices New shallow based ulcer at distal esophagus (5 oclock) Healing necrotic esophagus from mid to distal esophagus Severe Portal Gastropathy Severe duodenitis D1/D2 Otherwise normal EGD to third part of the duodenum . [**8-9**] MRI head, neck and MRA- IMPRESSION: Slow diffusion in the right frontal and parietal lobes involving the motor cortex and supplemental motor area compatible with acute/subacute ischemia. No evidence of hemorrhage. Foci of increased DWI signal in the left precentral gyrus and left parietal lobe may represent additional foci of ischemic involvement or artifact. Possible narrowing of the left vertebral artery V3/V4 segments. Paucity of the left MCA branches may be technical. MRA is limited by motion artifact. . Transthoracic echocardiogram [**8-10**]- IMPRESSION: Suboptimal image quality. Patent foramen ovale. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No valvular pathology or pathologic valvular flow identified. Mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2133-7-15**], a patent foramen ovale is identified on the current study (saline contrast not utilized on the prior study). . CT abd/pelvis w/o contrast [**8-12**]- 1. Limited study due to lack of intravenous contrast material. Large intra-abdominal ascites with cirrhotic liver. 2. Oral contrast retained within a tubular stomach which pools within the fundus and body. Thick walled antrum ? due to third spacing. No contrast is seen within small bowel. No free air. NG tube in place. 3. Moderate bilateral pleural effusions with overlying atelectasis. 4. Wall thickening of the pylorus, ascending and transverse colon is non-specific in the non-specific in the setting of ascites and may be due to third spacing. . RUQ ultrasound [**8-22**]- 1. Moderate volume ascites and coarsened hepatic echotexture without evidence of biliary obstruction. 2. Diffuse gallbladder wall thickening with sludge. This could be related to the patient's ascites and third spacing. . Discharge Labs: [**2133-8-31**] 05:31AM BLOOD WBC-15.3* RBC-2.46* Hgb-7.9* Hct-25.7* MCV-105* MCH-32.1* MCHC-30.6* RDW-20.3* Plt Ct-107* [**2133-8-31**] 05:31AM BLOOD PT-12.5 INR(PT)-1.2* [**2133-8-31**] 07:15AM BLOOD Glucose-118* UreaN-35* Creat-3.0* Na-140 K-4.8 Cl-99 HCO3-32 AnGap-14 [**2133-8-31**] 05:31AM BLOOD ALT-72* AST-104* AlkPhos-292* TotBili-4.7* [**2133-8-31**] 07:15AM BLOOD Calcium-8.9 Phos-1.7* Mg-2.1 [**2133-8-31**] 05:31AM BLOOD PTH-PND Brief Hospital Course: 72M etoh cirrhosis presented with worsening ascites and UGIB, admitted initially to the MICU and transferred to the floor. . >> Active issues: . # End stage cirrhosis: Currently not a transplant candidate at [**Hospital1 18**] due to continued drinking, age, comorbidities. Multiple family meetings were held discussing that age, comorbidities (renal failure, stroke) would make it extremely dangerous for patient to undergo transplant. Family requested transfer to [**Hospital1 2025**] for further evaluation but transfer denied by Liver and Medicine services at [**Hospital1 2025**]. . # Leukocytosis: WBC uptrended starting [**8-19**]. Pt remained afebrile and hemodynamically stable. Concern for acalculous cholecystitis given T bili uptrended with RUQ U/S [**8-22**] showing diffuse gallbladder wall thickening with sludge. Pt also with intermittent RUQ tenderness on exam. Pt with prolonged ICU stay and critical illness putting at high risk for acalculous cholecystitis, but percutaneous drainage too high risk in this pt per IR attending. Diagnostic paracentesis neg for SBP [**8-24**] so not cause of leukocytosis and abd pain. Could also be related to temp HD line infection but culture when line removed was neg. Pt put on Zosyn [**8-24**] and completed 7d course with some improvement in WBC count and bili though not normalized. T bili peaked at [**7-22**] and downtrend was reassuring for improvement in acalculous cholecystitis. Unlikely worsening pneumonia as patient appropriately treated (grew MRSA, completed 14d course of vancomycin with good troughs), ruled out for c.diff, spontaneous bacterial peritonitis, bacteremia. Pt recultured [**2133-8-23**] with negative bl cx and C diff. Pt anuric. Repeat C diff [**8-30**] again neg. Pt completed 7d course of Zosyn on [**8-30**]. Pt with persistence of mild leukocytosis with WBC count of 15 on day of discharge but in setting of downtrending bili we were reassured of improvement with coure of zosyn for acalculous cholecystitis. . # Renal failure: likely related to hepatorenal syndrome, possibly in combination with hypotension from GIB. Patient failed albumin challenge Hospital day 5 showed increasing urine output, underwent diuretic challenge with 200mg IV lasix followed by 12.5mg 25% albumin, put out 270cc/8hrs (0.49cc/kg/hr). HD started on [**2133-8-18**] for volume control, patient continued on MWF schedule. Temporary line appeared infected on [**2133-8-26**] and was removed with neg culture. Pt had new temp line placed by IR [**8-27**] and it was tunneled on [**8-28**]. Pt continued on HD with fluid removal as needed. . # Abdominal pain and distension: During ICU stay KUB showed gastric outlet obstruction but CT and EGD did not show any anatomic dysfunction. A post pyloric feeding tube was placed for feeding and a OG tube was placed for stomach decompression (dc'd on [**8-20**]). Subsequent KUBs showed air in the small and large bowel. C.diff was negative. Hycosamine was given to relax the pylorus. Paracentesis in the ICU only yielded 500cc (no SBP). He was started on HD on [**8-18**] for volume control. Patient developed RUQ pain, with rising AST/ALT and Tbili upon transfer to the floor on [**8-23**]. Repeat paracentesis was not consistent with SBP. Repeat RUQ ultrasound [**8-22**] showed diffuse gallbladder wall thickening with biliary sludge concerning for acalculous cholecystitis. Percutaneous drainage was not performed as interventional radiology felt risk of death was too high. Antibiotics were broadened to include Zosyn per above. Abdominal pain was very transient and resolved. After zosyn course, pt put back on Cipro for SBP ppx on [**8-31**]. . # Embolic stroke: While in the ICU, patient had acute onset of left sided weakness and brain imaging showed an embolic stroke in the R MCA likely from a known DVT and patent foramen ovale. Aspirin and coumadin were held due to GI bleed. Patient worked with OT as left upper extremity began to develop contractures. ASA restarted. IVC filter placed [**8-10**]. Pt will be unlikely to resume anticoagulation in the setting of GIB. Pt also evaluted by PT and speech and swallow. Pt started on pureed solid and nectar thick diet based on bedside eval. Pt will need to continue speech therapy and may need video swallow in the future to further advance his diet. . # Ventilatory associated pneumonia: RLL pneumonia noted [**8-16**], and patient failed spontaneous breathing trial on ventilator. Bronchoscopy performed and BAL (as well as endotracheal sputum) grew MRSA. He was started on vancomycin on [**8-16**] and completed 14d course. . # UGIB: does not have h/o of gastric varices. Patient underwent upper endoscopy by GI on hospital day 1. Was noted to have severe esophagitis, a biopsy was taken with copious bleeding from the site noted following biopsy. Patient required 2u pRBCs and was maintained briefly placed on Levophed, blood pressure improved and pressors were discontinued. Patient's HCT relatively stable. Last transfusion [**8-21**]. . # Anemia: H/H slowly downtrending with Hct of 25.7 [**8-31**]. Will need to continue to trend H/H and tranfuse for Hct <21. . # AMS: Cirrhosis exacerbated by GI bleed. Intubated for airway control due to GI bleed, lucid hospital day 4 s/p extubation, oriented to place, stated desire to be full code. Patient placed on rectal lactulose while remaining NPO, transitioned to oral lactulose hospital day 5 but having increased encephalopathy. Mental status improved and patient able to follow commands and speaking in full sentences, though often fluctuated. Continued on lactulose on floor with no ongoing asterixis. Pt persisted A&Ox1. AMS thought to be multifactorial in setting of no asterixis and sufficient BMs on latulose. Thought likely due to combination of hospital delirium, infection, CVA, and some degree of hepatic encephalopathy. Pt A&Ox1 at time of discharge. . # Lower extremity DVT: Patient has history of bilateral lower extremity DVTs (started on warfarin on [**7-10**]). Warfarin was held on admission in the setting of his GI bleed. IVC filter placed on [**8-10**]. . # Thrombocytopenia: Platelets decreased from 232 on [**8-7**] to 39 on [**8-17**]. PICC placed on [**2133-8-15**]. Was exposed to heparin in [**Month (only) 205**] and may have been exposed during HD at the beginning of admission. Fibrinogen was not decreased significantly. HIT antibodies were negative. Platelets improved and were stable throughout course on the floor. . # Hypophosphatemia: Pt with frequently low phos levels requiring supplementation. PTH checked on day of discharge and returned elevated after discharge at 91. This is likely cause of low phos. No elevations in calcium levels. No intervention indicated. Just monitoring of labs biweekly as planned. . # EtOH abuse: Patient drinking up until time of admission. Was sedated for intubation, therefore did not require CIWA scale for withdrawal. . # COPD: Continued with nebulizers. . Transitional Issues: # Full Code # Pt requiring daily neutraphos for hypophosphatemia. Please continue until no longer needed based on labs. # Pt will need biweekly lab monitoring (CBC, INR, LFTs, Chem10) and tranfusion for Hct <21. # If T bili uptrends, especially in setting of worsening leukocytosis or fever, please call liver center (Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 2422**]. # Pt will cont HD M, W, F # Pt will need to continue TFs, PT, OT, and speech and swallow. If S&S wishes to advance diet further, a video swallow may be needed at their discretion. # Studies pending at time of discharge: PTH, peritoneal fluid acid fast culture from [**8-8**] # F/u with Dr. [**First Name (STitle) **] in liver clinic and with transplant surgery re: permanent HD access. # Pt will be discharged off anticoagulation in the setting of recent GIB. He has recent h/o bilateral LE DVTs s/p IVC filter. Unlikely to be good candidate for anticoagulation in the future because of GIB risk. Medications on Admission: Folic acid 1 mg PO daily Magnesium oxide 400 mg PO daily Tiotropium 18 mcg 1 capsule inhalation daily Thiamine 100 mg PO daily Cyanocobalamin 1000 mcg PO daily Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea/wheezing 2. Heparin 5000 UNIT SC TID 3. 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. 4. Hyoscyamine 0.125 mg SL QID 5. Pantoprazole 40 mg IV Q12H 6. Rifaximin 550 mg PO BID 7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing/shortness of breath 8. Heparin Flush (1000 units/mL) 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line flush Dialysis Catheter (Temporary 2-Lumen): DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. 9. Lactulose 30 mL PO BID Titrate to 3 BMs daily 10. Ciprofloxacin HCl 500 mg PO/NG Q24H 11. Neutra-Phos 2 PKT PO DAILY Duration: 5 Days Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: PRIMARY Diagnosis: # Severe gastritis and esophagitis # End stage renal disease requiring hemodialysis # Right sided embolic stroke # Ventilator associated pneumonia # Acalculous cholecystitis SECONDARY DIAGNOSIS: # Alcohol cirrhosis # Chronic obstructive pulmonary disease # Gastrointestinal reflux disease # Hypertension # History of deep venous thrombosis Discharge Condition: Verbal- occasional confused Left sided hemiparesis, unable to ambulate Discharge Instructions: Dear Mr [**Known lastname **], It was a pleasure taking care of you during your admission to [**Hospital1 18**]. You were admitted with an upper gastrointestinal bleed and worsening renal function. You required blood transfusions and blood pressure support. You required intubation to support you through this period. Your kidneys did not recover their function, and you were started on hemodialysis, which you will need to continue long-term. You had a pneumonia which was treated with antibiotics. You also had an infection in your gallbladder, which was treated with antibiotics as well. Though you do have fluid in your abdomen (ascites) it was not infected. You also had a large stroke affecting the left side of your body. You cannot be given anticoagulation given your recent bleed. You had a tube placed to give you feedings as you were unable to take food by mouth enough to support your nutritional needs. Please follow-up at the appointments listed below. Please see the attached list for changes to your medications. Followup Instructions: Department: LIVER CENTER When: THURSDAY [**2133-9-10**] at 12:00 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: THURSDAY [**2133-9-10**] at 3:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2133-8-31**]

[ "305.1", "434.11", "572.2", "285.1", "572.4", "041.11", "456.21", "458.9", "511.9", "575.0", "261", "530.81", "537.0", "530.19", "275.3", "789.59", "518.81", "401.9", "997.31", "530.89", "453.81", "453.41", "571.2", "745.5", "998.11", "303.90", "584.5", "276.8", "287.5", "518.0", "518.4", "572.3", "276.0", "496", "427.1", "342.00", "V49.87", "288.60", "530.21" ]

icd9cm

[ [ [] ] ]

[ "96.04", "54.91", "39.95", "38.7", "96.72", "45.16", "38.93", "96.71", "38.95", "38.97", "33.24", "45.13", "38.91", "96.6" ]

icd9pcs

[ [ [] ] ]

20136, 20208

11120, 11248

312, 461

20612, 20685

3829, 3829

21774, 22461

2525, 2693

19298, 20113

20229, 20229

19113, 19275

20709, 21751

10654, 11097

2708, 3022

6060, 6966

6999, 10638

18107, 19087

3036, 3810

264, 274

11263, 18086

489, 2087

20444, 20591

3845, 4635

20248, 20423

4651, 6024

2109, 2271

2287, 2509

393

167,210

49331

Discharge summary

report

Admission Date: [**2147-1-27**] Discharge Date: [**2147-2-1**] Date of Birth: [**2086-2-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1377**] Chief Complaint: Tumor thrombus extending into right atrium Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a very pleasant 60 yo man with a PMH of cirrhosis [**12-30**] a combination of EtOH and chronic Hepatatis C who was transferred from an OSH with extensive HCC and tumor/thrombus extending up his IVC into his RA. . He was initially on the surgical service for possible thrombectomy, but he is not currently a surgical candidate given the extent of the tumor thrombus. . He is being transferred to the medical service for palliative care. . The pt denies any pain or discomfort currently. He denies chest pain, shortness of breath or abdominal pain or discomfort. He denies recent hematemesis, melena or hematochezia, although he did present to the OSH with hematemesis requiring banding of a variceal bleed. Past Medical History: Cirrhosis [**12-30**] chronic Hepatitis C and EtOH Social History: smoker, denies EtOH for last 2 years Family History: Non-contributory Physical Exam: Vitals: T: 98.8 BP: 92/44 P: 71 R: 19 SaO2: 100% on 2L General: Awake, drowsy, NAD, pleasant, cooperative HEENT: EOMI, no scleral icterus, MM dry Neck: no significant JVD Pulmonary: Lungs with ronchi anteriorly Cardiac: RR, soft S1 S2, no murmurs, rubs or gallops appreciated Abdomen: NT, moderately distended, normoactive bowel sounds Extremities: trace edema bilaterally Skin: no rashes or lesions noted. Neurologic: Alert, oriented x 3. Pertinent Results: Abd/pelvis CT: 1. Findings consistent with multifocal hepatocellular carcinoma with large infiltrative lesion in right posterior lobe of the liver with associated extensive most likely bland thrombus expanding the entire right portal venous system, and tumor thrombus infiltrating the middle hepatic and right hepatic vein. 2. Tumor thrombus from the hepatic veins extends into the intrahepatic IVC and extends cranially approximately 1.5 cm into the right atrium. 3. Likely bland tumor thrombus extends approximately 1 cm into the main portal vein. The splenic vein, left portal vein, and SMV all remain present. 4. Moderately large amount of ascites surrounding the liver. No definite peritoneal carcinomatosis. Brief Hospital Course: 60 yo M with cirrhosis presented from OSH with diffuse HCC and tumor thrombus extending into the right atrium. # Tumor thrombus: no intervention possible. Given the prognosis, palliative care was consulted, and the patient was made CMO. He should be given pain medicine (hydromorphone PO while still aware enough, then subl,ingual morphine concentrate) without concern for respiratory status or somnolence. He should be treated with lactulose for encephalopathy so that he may have as much time as possible with his family. He should also be given lorazepam for agitation and Livsin for secretions. Medications on Admission: Vancomycin Piperacillin-tazobactam Pantoprazole Heparin SC tid Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2 hours) as needed for pain, dyspnea, restlessness. 3. Morphine Concentrate 20 mg/mL Solution Sig: 10-30 mg PO q1hr as needed for pain, restlessness, dyspnea. 4. Lorazepam Intensol 2 mg/mL Concentrate Sig: 1-2 mg PO q2hr as needed for restlessness, dyspnea. 5. Levsin 0.125 mg/mL Drops Sig: 0.125-0.25 mg PO q4hr as needed for secretions. 6. Acetaminophen 650 mg Suppository Sig: One (1) suppository Rectal every 4-6 hours as needed for fever or pain. Discharge Disposition: Extended Care Facility: [**Last Name (un) 57733**] - [**Location (un) 2203**] Discharge Diagnosis: Primary: Hepatocellular carcinoma Tumor thrombus involving the inferior vena cava and right atrium Cirrhosis Chronic Hepatitis C Discharge Condition: Comfortable Discharge Instructions: Please take all medications as prescribed. Please do not withhold pain medication for decreased respiratory rate or somnolence. If the patient is in pain or agitated, please treat. Followup Instructions: None [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

[ "070.54", "155.0", "198.89", "571.5", "789.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3840, 3920

2514, 3115

357, 364

4093, 4107

1769, 2491

4336, 4466

1275, 1293

3229, 3817

3941, 4072

3141, 3206

4131, 4313

1308, 1750

275, 319

392, 1129

1151, 1204

1220, 1259

76,327

171,554

33348

Discharge summary

report

Admission Date: [**2147-12-20**] Discharge Date: [**2147-12-25**] Date of Birth: [**2106-1-28**] Sex: M Service: MEDICINE Allergies: Amoxicillin / Adhesive Bandage / Dicloxacillin Attending:[**First Name3 (LF) 12174**] Chief Complaint: Encephalopathy Major Surgical or Invasive Procedure: Intubation Nasogastric Tube History of Present Illness: HPI: 41 yo M with PMH of pulmonary hypertension, ESLD from alcohol and hepatitis C on [**First Name3 (LF) **] list, known moderate esophageal varices by EGD [**2147-12-7**], who has a history of multiple episodes of unresponsiveness requiring intubation. . On this admission, he was found down at home by his mother with his home CPAP mask off and vomitus around him. Per mother, no vomitus in the mask. EMS called, but pt unable to be intubated in the field. Brought to [**Hospital3 2737**], intubated with Rocuronium for airway protection, OGT placed, which produced 100cc pink-tinged fluid. ABG was 7.39/35/434. Initial labs at [**Hospital **] hosp revealed Hct 23 (BL upon discharge [**2147-12-3**] was 24.5), and he was given 1 units PRBCs at [**Hospital1 **], lactulose 15 ML, along with Ertepenem for aspiration pneumonia. He was transiently hypotensive to SBP 90s, received 2L NS with good effect. Also received Vitamin K 2.5mg IV for INR 1.9 (BL). Ammonia was 480 at [**Hospital1 **]. Blood toxicology positive for benzodiazepines. U/A negative. 2 sets of blood cultures and urine cultures sent. Of note he had outpatient paracentesis on [**2147-12-19**] at [**Hospital1 18**]. Transferred to [**Hospital1 18**] ED as he receives his liver care here. . At [**Hospital1 18**] ED, initial VS= 121/67, HR 86, RR 14, 100% ventilator (AC, FI02 100%, TV 500, RR 19, Peep 5). CT head done b/c of AMS and was unremarkable. CT torso done and wet read shows massive ascites but no other acute pathology. Hepatology consulted, recommended starting octreotide gtt (25mcg bolus, followed by 24mcg/hr) and IV protonix. He also received 1gm vancomycin for gram postive coverage (resp source suspected). . On the floor, patient was doing well and getting ready for discharge, when he was noted to be minimally responsive by the phlebotomist. He was evaluated by nightfloat who found him completely unresponsive to sternal rub and pain (no arousal with ABG). He was on BIPAP overnight but had not gotten his PM lactulose dose though had had several bowel movements during the day. Past Medical History: - HCV and EtOH Cirrhosis with ascites and edema, biopsy diagnosed in [**2139**], last vl 32,600 copies; last MELD 24. - h/o SBP early [**7-27**] on cipro prophylaxis - Grade II esophageal varices - Recurrent hepatic encephalopathy of unclear precipitant - Pulmonary HTN - Hypothyroidism - Anxiety disorder - h/o EtOH abuse, IVDU - osteoperosis of hip and spine per pt - Anemia w/ hx of guaiac positive stool. - pulmonary HTN - echo [**2146-12-28**] unable to assess; EF > 55%, MR slightly increased Social History: Pt lives with his Mother. Pt quit smoking [**5-28**], was smoking 1/3ppd. Quit drinking etoh 11 years ago. Prior remote hx of IVD as teen. No current drug use. Family History: Mother with DM and HTN. Father with rheumatic heart disease. Physical Exam: Vitals 96.1 92 123/67 14 100% on face tent General Cachectic man no distress HEENT PEARL, MMM Pulm Lungs with rhonchi bilaterally CV Regular tachycardic S1 S2 no m/r/g Abd Abd soft +distension with fluid wave, nontender Extrem Warm with 1+ bilateral edema Neuro Does not respond to voice or withdraw to pain, no asterixis Derm +Jaundice, petechiae on feet Pertinent Results: [**2147-12-20**] 05:10PM HCT-26.0* [**2147-12-20**] 05:10PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2147-12-20**] 05:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2147-12-20**] 05:10PM URINE RBC-10* WBC-24* BACTERIA-FEW YEAST-NONE EPI-<1 [**2147-12-20**] 05:10PM URINE GRANULAR-7* HYALINE-4* [**2147-12-20**] 05:10PM URINE MUCOUS-RARE [**2147-12-20**] 02:52PM ASCITES TOT PROT-0.8 GLUCOSE-132 LD(LDH)-47 AMYLASE-29 TOT BILI-0.6 ALBUMIN-<1.0 [**2147-12-20**] 02:52PM ASCITES WBC-17* RBC-570* POLYS-5* LYMPHS-30* MONOS-59* MESOTHELI-2* MACROPHAG-4* [**2147-12-20**] 01:43PM TYPE-ART RATES-/16 TIDAL VOL-500 O2-60 PO2-307* PCO2-30* PH-7.43 TOTAL CO2-21 BASE XS--2 -ASSIST/CON INTUBATED-INTUBATED [**2147-12-20**] 01:43PM LACTATE-1.7 [**2147-12-20**] 08:12AM PH-7.34* COMMENTS-GREEN TOP [**2147-12-20**] 08:12AM GLUCOSE-110* LACTATE-2.1* NA+-139 K+-3.7 CL--112 TCO2-21 [**2147-12-20**] 08:12AM HGB-9.6* calcHCT-29 [**2147-12-20**] 08:12AM freeCa-1.14 [**2147-12-20**] 08:10AM LIPASE-72* [**2147-12-20**] 08:10AM PT-22.8* PTT-49.1* INR(PT)-2.2* [**2147-12-20**] 07:55AM GLUCOSE-118* UREA N-14 CREAT-0.9 SODIUM-141 POTASSIUM-4.5 CHLORIDE-114* TOTAL CO2-16* ANION GAP-16 [**2147-12-20**] 07:55AM ALT(SGPT)-33 AST(SGOT)-66* ALK PHOS-183* DIR BILI-1.2* [**2147-12-20**] 07:55AM ALBUMIN-3.3* CALCIUM-8.4 PHOSPHATE-3.6 MAGNESIUM-2.3 [**2147-12-20**] 07:55AM AMMONIA-213* [**2147-12-20**] 07:55AM ACETONE-NOT DONE [**2147-12-20**] 07:55AM WBC-4.7 RBC-2.85* HGB-9.3* HCT-28.5* MCV-100* MCH-32.7* MCHC-32.7 RDW-19.7* [**2147-12-20**] 07:55AM NEUTS-74.3* LYMPHS-16.9* MONOS-7.8 EOS-0.8 BASOS-0.2 [**2147-12-20**] 07:55AM PLT COUNT-77* [**2147-12-19**] US Guided Paracentesis: INDICATION: 41-year-old man with cirrhosis on liver [**Month/Day/Year **] list; has gained 15 pounds since last paracentesis on [**12-4**]. IMPRESSION: Successful ultrasound-guided therapeutic paracentesis: 6.5 liters obtained. [**2147-12-20**] CT Head: INDICATION: 41-year-old man with altered mental status and hypertension. Comparison is made to the prior head CT of [**2147-11-30**], and MR [**First Name (Titles) **] [**2147-10-28**]. NON-CONTRAST HEAD CT: No edema, masses, mass effect, hemorrhage, or infarction is detected. Ventricles and sulci are mildly prominent consistent with involutional changes. Diffuse periventricular white matter hypodensities are unchanged compared to the prior study and are compatible with small vessel ischemic changes based on the prior MRI. The visualized part of the paranasal sinuses and mastoid air cells are clear. No fracture is identified. IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. Unchanged periventricular white matter hypodensities which are compatible with small vessel ischemic change. [**2147-12-20**] CT ABD HISTORY: 41-year-old man with severe cirrhosis, status post paracentesis yesterday, with 6.5 liters of fluid drainage. Subsequently became hypotensive and required intubation. Evaluate for acute process. TECHNIQUE: Non-contreast helical MDCT images were acquired from the thoracic inlet to the pubic symphysis. Multiplanar reformatted images were obtained in 5-mm slice thickness. COMPARISON: CT abdomen and pelvis with contrast on [**2147-11-5**]. FINDINGS: CT CHEST WITHOUT CONTRAST: The tracheobronchial architecture is patent and normally aerated to the subsegemental levels. The cardiac size is within normal limits. A nasogastric tube is seen in the esophagus. And an endotracheal tube are visualized with the tip terminating slightly superior to the carina. There is no evidence of pneumothorax. There is no evidence of pleural effusion. CT ABDOMEN WITHOUT CONTRAST: There is a large amount of simple ascites in the intraperitoneal cavity. There is no evidence of acute hemorrhage. The liver is again seen with unchanged severe nodularity and shrunken in size, but there is no evidence of focal lesion, allowing for the limits of the non-contrast study. There are numerous small hyperdense gallstones in the gallbladder, also unchanged, but no evidence of acute cholecystitis. The tip of the NG tube is seen terminating at the antrum of the stomach. The stomach, pancreas, duodenum are normal without evidence of abnormality, allowing for the obscuration of the ascites. There is mild thickening of the jejunal wall, unchanged, and likely secondary to the underlying liver disease. The spleen is mildy enlarged, but unchanged. There are unchanged perisplenic and perigastric varices. The adrenal glands and kidneys are unremarkable bilaterally. There is no free air in the intra- abdominal cavity. CT PELVIS WITHOUT CONTRAST: The large amount of ascites is also seen in the pelvis. There is a Foley catheter in the decompressed bladder. The colon is air-filled, but not dilated. There is no evidence of free air in the pelvis. BONE WINDOW: There is no acute fracture or dislocation. There is no evidence of lytic or sclerotic lesions. IMPRESSION: 1. Large amount of abdominal and pelvic ascites. No evidence of hemorrhage. 2. Unchanged severe sclerotic liver. Unchanged significant cholelithiasis without evidence of acute cholecystitis. Unchanged prominent spleen and perisplenic and perigastric varices. Unchanged mild wall thickening of the small bowel in the lower abdomen. 3. No significant changes compared to the prior study. [**2147-12-20**]: HISTORY: 41-year-old man with severe cirrhosis, status post paracentesis yesterday, with 6.5 liters of fluid drainage. Subsequently became hypotensive and required intubation. Evaluate for acute process. TECHNIQUE: Non-contreast helical MDCT images were acquired from the thoracic inlet to the pubic symphysis. Multiplanar reformatted images were obtained in 5-mm slice thickness. COMPARISON: CT abdomen and pelvis with contrast on [**2147-11-5**]. FINDINGS: CT CHEST WITHOUT CONTRAST: The tracheobronchial architecture is patent and normally aerated to the subsegemental levels. The cardiac size is within normal limits. A nasogastric tube is seen in the esophagus. And an endotracheal tube are visualized with the tip terminating slightly superior to the carina. There is no evidence of pneumothorax. There is no evidence of pleural effusion. CT ABDOMEN WITHOUT CONTRAST: There is a large amount of simple ascites in the intraperitoneal cavity. There is no evidence of acute hemorrhage. The liver is again seen with unchanged severe nodularity and shrunken in size, but there is no evidence of focal lesion, allowing for the limits of the non-contrast study. There are numerous small hyperdense gallstones in the gallbladder, also unchanged, but no evidence of acute cholecystitis. The tip of the NG tube is seen terminating at the antrum of the stomach. The stomach, pancreas, duodenum are normal without evidence of abnormality, allowing for the obscuration of the ascites. There is mild thickening of the jejunal wall, unchanged, and likely secondary to the underlying liver disease. The spleen is mildy enlarged, but unchanged. There are unchanged perisplenic and perigastric varices. The adrenal glands and kidneys are unremarkable bilaterally. There is no free air in the intra- abdominal cavity. CT PELVIS WITHOUT CONTRAST: The large amount of ascites is also seen in the pelvis. There is a Foley catheter in the decompressed bladder. The colon is air-filled, but not dilated. There is no evidence of free air in the pelvis. BONE WINDOW: There is no acute fracture or dislocation. There is no evidence of lytic or sclerotic lesions. IMPRESSION: 1. Large amount of abdominal and pelvic ascites. No evidence of hemorrhage. 2. Unchanged severe sclerotic liver. Unchanged significant cholelithiasis without evidence of acute cholecystitis. Unchanged prominent spleen and perisplenic and perigastric varices. Unchanged mild wall thickening of the small bowel in the lower abdomen. 3. No significant changes compared to the prior study. Brief Hospital Course: 41 yo male with ESLD with cirrhosis, pulm HTN, found unresponsive at home, intubated at [**Hospital1 **] for airway protection, now with another episode of unresponsiveness requiring admission to ICU at [**Hospital1 18**]. # AMS and Resp Failure: Patient has had 6 episodes of unresponsiveness requiring intubation in the past two months due to hepatic encephalopathy significantly improved. Upon arrival to ED here, vitals stable with BPs low 100's, HR 70's, ventilated. OGT putting out yellow bile and no blood. Chest CT negative for PNA, but covered with Vanco and Levo in unit empircally; vanco then stopped but Levo continued given GNR and GPR's seen on sputum gram stain. Cipro proph added back on; Abd CT w/ ascites but no evidence ofhemorrhoage post tap. NH3 213, WBC 4.7, LFTS stable. OSH tox screen positive for benzos, but pt received versed for sedation. Patient was extubated. Rifaximin and Lactulose were aggressively adminstered. Of note, patient continued Iloprost. On [**12-23**], however, patient triggered for unresponsiveness and was again transferred to unit, where the patient improved with lactulose and was again called out to floor. # ESLD: [**1-22**] ETOH/HepC, +h/o hepatic encephalopathy, known varices, followed by Dr. [**Last Name (STitle) 497**], on [**Last Name (STitle) **] list. Underwent paracentesis [**2147-12-19**] with 6.5 liters removed. Tbili/LFTs at baseline. Had tense ascites only 24 hours after paracentesis. Lasix and Spironolactone/Nadolol adminstered. Prophylaxed with Cipro. # Precordial Erythema: The new lesion on Mr. [**Known lastname 19420**]??????s chest likely represented a superficial hematoma from repeat sternal rubbing in the setting of elevated INR # Anemia. There was concern for GI bleeding on admission due to pink tinged fluid in NGT at OSH. His recent baseline hct ~22-24 in mid [**11-26**]. Had guiac positive stool. Lavage showed pink fluid. EGD on admission showed non-bleeding esophageal varices. Of note, pt underwent EGD on [**12-6**] demonstrating 4 chords of grade II varices w/o bleeding. Stopped octreotide given low likelihood of variceal bleeding (stable hct, no hematemesis). 2 large bore IVs were maintained. Active type and screen and cross match were obtained initially. # Thrombocytopenia: [**1-22**] liver disease. Platelets within baseline. # hypothyroidism: Continued levothyroxine 88mcg daily # FEN: regular diet. # PPX: pneumoboots, PPI per home regimen. HOLD SQ heparin in setting of elevated PTT # CODE: FULL throughout stay Medications on Admission: Medications at home: Levothyroxine Sodium 88 mcg PO DAILY Omeprazole 20 mg PO Daily Ciprofloxacin HCl 250 mg PO Q24H Rifaximin 200 mg PO TID Furosemide 20 mg PO DAILY Iloprost *NF* 2.5 mcg Inhalation Nine times a day. pulm htn Lactulose 45 mL PO QID Spironolactone 50 mg PO BID Calcium + D 500mg TID Magnesium 140mg Daily Nadolol 20mg PO Daily Discharge Medications: 1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Day (2) **]:*30 Tablet(s)* Refills:*2* 2. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). [**Month/Day (2) **]:*120 Tablet(s)* Refills:*2* 3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Day (2) **]:*30 Tablet(s)* Refills:*2* 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). [**Month/Day (2) **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Day (2) **]:*30 Tablet(s)* Refills:*2* 6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). [**Month/Day (2) **]:*180 Tablet(s)* Refills:*2* 7. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO QID (4 times a day): Must be taken every 6 hours. Increase frequency as needed for increased confusion. Report increases to your doctor. [**Last Name (Titles) **]:*8000 ML(s)* Refills:*2* 8. Iloprost 10 mcg/mL Solution for Nebulization Sig: One (1) Inhalation 6 times daily while awake () as needed for pulmonary hypertension. [**Last Name (Titles) **]:*[**2138**] mL* Refills:*0* 9. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day: Begin this medication on [**2146-12-24**] (after your course of Levofloxacin is completed). [**Date Range **]:*30 Tablet(s)* Refills:*2* 10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: Continue this medication until [**2147-12-24**]. Take your last dose of medication on this day. [**Month/Day/Year **]:*3 Tablet(s)* Refills:*0* 11. Magnesium Oral 12. Calcium 500 + D 500 (1,250)-200 mg-unit Tablet Sig: One (1) Tablet PO once a day. [**Month/Day/Year **]:*30 Tablet(s)* Refills:*2* 13. Clotrimazole 10 mg Troche Sig: One (1) Mucous membrane four times a day. [**Month/Day/Year **]:*120 troches* Refills:*2* 14. Flagyl 375 mg Capsule Sig: One (1) Capsule PO three times a day. [**Month/Day/Year **]:*90 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Primary: Hepatic Encephalopathy Respiratory Failure End Stage Liver Disease . Secondary: Cirrhosis HCV Pulmonary HTN h/o EtOH abuse Anemia Discharge Condition: Fair Discharge Instructions: You were admitted for severe ascites (fluid in abdomen), encephalopathy (changes in brain function because of an increase in bad chemicals in your body), and respiratory failure. You twice required intubation and admission to the intensive care unit. You were given medications, including antibiotics, to treat each of these conditions. 5 Liters of fluid in your abdomen was drained. Levofloxacin was given for pneumonia (infection in your lung). . Please return to the hospital or call your doctor immediately if you experience confusion, changes in vision or hearing, changes in motor function or sensation, chest pain, shortness of breath, fever, nausea, vomiting, severe or worsening abdominal pain, worsening ascites beyond what you experience at baseline, burning on urination, changes in your stool, blood in your sputum, or any other symptom that concerns you. It is extremely important that you take your lactulose exactly as scheduled. . Please keep all of your follow-up appointments. These are critical for your continued evaluation and treatment. Your four (4) appointments are listed below. . Please take all of your medications as prescribed. If you have ANY questions about your medications, it is important to address them immediately. Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 46571**] with any questions about your medications or your medication regimen. Followup Instructions: You have four appointments. It is extremely important that you go to each of these appointments: . 1) Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2147-12-28**] 2:00 . 2) Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2147-12-28**] 2:00 . 3) [**1-11**] with Dr. [**Last Name (STitle) **] (Pulmonary) at 8:45 in [**Apartment Address(1) 77414**]. . 4) [**1-3**] at 10:00 with Dr. [**Last Name (STitle) **]. [**Location (un) **], [**Hospital Ward Name 23**] Building [**Location (un) 858**], neurology. . Completed by:[**2148-3-24**]

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icd9cm

[ [ [] ] ]

[ "96.71", "54.91" ]

icd9pcs

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12552

Discharge summary

report

Admission Date: [**2191-12-23**] Discharge Date: [**2191-12-31**] Service: ACOV MEDICINE NOTE: The following history and physical is as noted by medical house staff, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], pager [**Numeric Identifier 38871**]. DIAGNOSIS: Status post PEA arrest with severe anoxic brain injury. HISTORY OF PRESENT ILLNESS: A [**Age over 90 **] year-old woman with past medical history significant only for atrial fibrillation who had been in an outside hospital when he lost consciousness and fell to the floor while standing. EMS arrived in minutes and she was noted to be in PEA arrest, given epinephrine and shocked with resuscitation. The patient at that time was transferred to the Emergency Room, initially at [**Hospital3 **] where she was found to be hemodynamically stable but with minimal neurologic response. The patient was transferred to the [**Hospital1 190**] and initially admitted to the Fenard Intensive Care Unit with CPKs noted to be 2293 and an elevated troponin. The patient was given beta blocker and aspirin. She was noted to be febrile and was started on ceftriaxone for a question of a left lower lobe infiltrate. The patient's mental status did not improve probably secondary to anoxic encephalopathy. She was seen by neurology. She is now comfort measures only per her family. All medications including antibiotics were therefore discontinued at this time. She was started on a morphine drip for respiratory comfort. The patient was extubated this morning. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Arthritis. 3. Congestive heart failure with pedal edema. 4. Bilateral knee replacement. MEDICATIONS: 1. Digoxin. 2. Furosemide. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She lived at home. No smoking or drinking history. CODE STATUS: Comfort measures only. PHYSICAL EXAMINATION: Vitals: Blood pressure 84/27, pulse 83. Physical examination deferred at this time. HOSPITAL COURSE: The following hospital course was noted by [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) **], M.D., Ph.D. This unfortunate [**Age over 90 **] year-old who had been healthy at home was found to be PEA arrest for greater than 15 minutes before resuscitatory efforts were begun. She unfortunately has suffered anoxic brain injury without hope of functional recovery. This clinical assessment has been made with the medical team along with consult from neurology staff, Dr. [**Last Name (STitle) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient's daughter was asked to make decisions for her based upon what she would have wanted if she were able to appreciate her current poor prognosis and little hope for meaningful functional recovery. Given the patient's grim prognosis the family has made the decision for her to receive comfort care at this time. On [**2191-12-31**] the house staff was called to evaluate the unresponsiveness of Mrs. [**Known lastname 38872**] and o arrival the patient's daughter and attending physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 8771**] [**Last Name (NamePattern1) 951**], was at the bedside. On examination the patient was to responsive to verbal name call. She did not respond to noxious stimulation times two. She did not have heart or lung sounds or pulse after listening for over two minute each. The eyes were widely dilated and not responsive to light. The patient was pronounced deceased at 10:20 A.M. on this date. The family is aware and declined autopsy. The attending physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 8771**] [**Last Name (NamePattern1) 951**], is aware. Thank you for the opportunity to care for this unfortunate [**Age over 90 **] year-old. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] [**First Name8 (NamePattern2) **] [**Doctor First Name **] 12-735 Dictated By:[**Last Name (NamePattern1) 38873**] MEDQUIST36 D: [**2193-5-5**] 11:45 T: [**2193-5-5**] 12:09 JOB#: [**Job Number 38874**]

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icd9cm

[ [ [] ] ]

[ "96.72" ]

icd9pcs

[ [ [] ] ]

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323

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5127

Discharge summary

report

Admission Date: [**2116-5-3**] Discharge Date: [**2116-5-11**] Date of Birth: [**2062-12-24**] Sex: M Service: CCU CHIEF COMPLAINT: Shortness of breath HISTORY OF PRESENT ILLNESS: The patient is a 53 year old man with a history of coronary artery disease, insulin dependent diabetes mellitus for 40 years and a renal transplant in [**2103**] who presented who presented with an increased dyspnea on exertion and shortness of breath at rest, increased over a chronic baseline level. The patient noted symptoms acutely worsened one day prior to admission prompting an Emergency Room visit. In the Emergency Room the patient denied chest pain, palpitations, nausea, vomiting or diaphoresis as well as fever and chills. The patient did note that his usual dose of Lasix was not working. In the Emergency Room he was found to be sating high 90s on 2 liters after 80 mg of Lasix. He was admitted to the [**Hospital Unit Name 196**] floor he was found to have a low saturation. He was put on 100% nonrebreather, sating in the mid 90s. Respiratory rate was 30s to 40s. The patient was given 40 plus 40 of intravenous Lasix without any increased urine output. On the nitroglycerin drip and Morphine the patient was able to diurese 200 cc. The patient's respiratory rate decreased to the 20s. The patient's examination had improved. the patient was taken to the Catheterization laboratory where he was found to be 80% on 100% nonrebreather. The patient was also found to have lateral electrocardiogram changes. He was diaphoretic and not complaining of chest pain but noting paroxysmal nocturnal dyspnea and orthopnea. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus for 40 years with triopathy; 2. Status post renal transplant [**2103**]; 3. Status post bilateral below the knee amputation; 4. Coronary artery disease, with three vessel disease with poor touchdowns, not a surgical candidate with recent in-stent stenosis of the left anterior descending stent treated with brachytherapy; 5. Recent admit for right knee ulcer to [**Hospital3 **]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Pravachol 20 mg p.o. q.d.; Aspirin 325 mg p.o. q. day; Lasix 60 mg p.o. q. day; Enalapril 20 mg p.o. b.i.d.; Lasix 75 mg p.o. q. day; Isordil 20 mg p.o. t.i.d.; Prednisone 10 mg p.o. q.o.d.; Sandimmune 100 mg p.o. q. AM and 50 mg p.o. q. PM; Imuran 50 mg p.o. q. day; Ativan 2 to 4 mg p.o. q. 4 to 6 hours prn; NPH 20 units subcutaneously in the morning and 14 units subcutaneously in the PM; regular insulin sliding scale; Toprol XL 12.5 mg p.o. q. day. SOCIAL HISTORY: The patient is full code. He lives alone. His wife had died recently. The patient quit smoking tobacco 20 years ago. He denied any alcohol use. FAMILY HISTORY: Significant for gastrointestinal and breast cancer. PHYSICAL EXAMINATION: The patient's pulse was 95, blood pressure was 125/38 with MAP 67, respiratory rate 22 and oxygen saturation 97% on 100% nonrebreather. On general examination the patient was a very chronically ill appearing man in no apparent distress who was bolt upright in bed. On head, eyes, ears, nose and throat examination the patient had pupils which were nonreactive. Neck examination revealed no lymphadenopathy and a central venous pressure of approximately 10 cm of water. Cardiac examination revealed a regular rate and rhythm, normal S1 and S2 with no murmurs, rubs or gallops. There was presence of an S3. Pulmonary examination revealed rales up to [**1-19**] of the lung fields with bilateral pleural effusions. On abdominal examination the patient's belly was soft, nontender, nondistended with normal bowel sounds. Extremity examination reveals bilateral below the knee amputations, 2+ edema. There was a left Stage 3 decubitus ulcer of the patella region. LABORATORY DATA: Pertinent laboratory findings revealed a white blood cell count of 9.4, hematocrit 40, platelets 291. The patient had a BUN of 31, creatinine 1.4. The patient's CK was trending downwards. Electrocardiogram revealed normal sinus rhythm at 75 with normal axis, left atrial abnormality, ST elevations V1 through V4, 1 to 3 mm. There were also small Q waves in 3 and F. Chest x-ray showed congestive heart failure with bilateral pleural effusions. [**2115-11-16**], stress MIBI, the patient with reversible moderate inferior and anterior and septal wall defect. Echocardiogram performed [**2116-5-6**], revealed sinus tachycardia with no anxiety, abdominal aortic aneurysm, ST increased V2 to V4, the patient also had biphasic T in V6. Cardiac catheterization, the patient had ejection fraction of 20 to 30% with 100% proximal right coronary artery lesion, 95% recurrent in-stent mid left anterior descending lesion. This focal lesion was dilated successfully. HOSPITAL COURSE: The patient is a 53 year old man with a history of coronary artery disease, myocardial infarction and renal transplant as well as insulin dependent diabetes mellitus and congestive heart failure. 1. Cardiovascular - From the cardiovascular standpoint the patient presented in acute decompensated heart failure in the setting of ischemic heart disease. From a coronary artery disease standpoint the patient has severe three vessel disease. Multiple interventions including recent percutaneous transluminal coronary angioplasty and brachiotherapy to the left anterior descending now presented with recurrent in-stent left anterior descending stenosis, status post percutaneous transluminal coronary angioplasty. The patient was ruled out for myocardial infarction. He was evaluated by Cardiac Surgery who felt that the patient was not a coronary artery bypass candidate. He was continued on Aspirin, Plavix and Beta blockers as well as Pravachol. From a myocardial standpoint the patient had an ejection fraction of 20% with severe hypokinesis, left ventricular hypertrophy, and diastolic dysfunction. He presented with decompensated heart failure. He ruled out for myocardial infarction, however, his congestive heart failure was felt to be secondary to ischemic heart disease. The patient was diuresed with Lasix and eventually a combination of Diuril and Lasix. The patient was started on Natrecor which initially caused some hypotension but then the patient reported improvement in his shortness of breath. He had augmented diuresis while on the Natrecor. The patient was considered for Aldactone although with his history of hyperkalemia this was deferred. Plan was to use BiPAP if the patient were to have further acute pulmonary edema. Post cardiac catheterization the patient had an episode of acute pulmonary edema which was responsive to Morphine and Lasix. The patient was continued on his outpatient heart failure regimen which included Enalapril, Isordil, and Toprol. From a conduction standpoint the patient remained in sinus rhythm and was continued on his Beta blocker. From an endocrine standpoint the patient presented with a history of insulin dependent diabetes mellitus and was maintained on a regimen of NPH and regular insulin sliding scale as per his outpatient regimen. From a renal standpoint the patient is status post renal transplant on an immunosuppressant regimen. He presented at his baseline creatinine. However, with fingerstick diuresis the patient's creatinine climbed from 1.4 to approximately 1.8. His Cyclosporin level of 113 was within normal limits. The renal transplant team followed the patient. His creatinine gradually began to trend down at the end of the [**Hospital 228**] hospital course. Infectious disease - The patient presented with a left knee ulcer near the site of the left below the knee amputation. Vascular surgery was consulted and felt the patient should be on Levofloxacin and Flagyl. They debrided the ulcer. The patient was continued on Levofloxacin and Flagyl for approximately a course of 14 days. The patient had a swab that grew Enterobacter as well as Stenotrophomonas. Infectious Disease was contact[**Name (NI) **] regarding the treatment of his Stenotrophomonas. Given the marked clinical improvement in the ulcer, the feeling was that the Stenotrophomonas was a colonizer and that there was no need to add additional coverage. Vascular Surgery recommended the patient follow up with his vascular surgeon at [**Hospital3 **]. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient was discharged to follow up with Dr. [**Last Name (STitle) **] in Heart Failure Clinic in approximately one to two weeks. The patient will also follow up with his vascular surgeon at [**Hospital3 **] in approximately one week. Due to high likelihood of repeat LAD in-stent stenosis, elective relook angiography with standby for PTCA will be considered in 4 months. DISCHARGE MEDICATIONS: 1. Tylenol 650 mg p.o. q. 4-6 hours prn 2. Pravachol 20 mg p.o. q. day 3. Plavix 75 mg p.o. q. day 4. Cyclosporin 100 mg p.o. q. AM and 50 mg p.o. q. PM 5. Azathioprine 50 mg p.o. q. day 6. Metoprolol XL 2.5 mg p.o. q. day 7. Colace 100 mg p.o. b.i.d. 8. Aspirin, enteric coated 325 mg p.o. q.d. 9. Ativan 0.5 to 1 mg p.o. q. 4-6 hours prn anxiety 10. Flagyl 500 mg p.o. t.i.d. for nine days 11. Levofloxacin 500 mg p.o. q. day for nine days 12. Prednisone 10 mg p.o. q.o.d. 13. Enalapril 20 mg p.o. b.i.d. 14. Lasix 80 mg p.o. q. day 15. Isordil 20 mg p.o. t.i.d. prn 16. Regular insulin sliding scale, NPH 20 units subcutaneously q. AM and 14 units subcutaneously q. PM DISCHARGE INSTRUCTIONS: The patient is to have dry sterile dressings b.i.d. to his left lower extremity ulcer. He will also need daily weights at home with a sitdown scale. Case management was contact[**Name (NI) **] to obtain a sitdown scale for the patient. [**Hospital6 407**] Services will aid the patient in the dressing changes. DISCHARGE DIAGNOSIS: 1. Congestive heart failure 2. Coronary artery disease with three vessel disease status post percutaneous transluminal coronary angioplasty 3. Insulin dependent diabetes mellitus 4. Sepsis, recent 5. Status post bilateral below the knee amputations 6. Left knee ulcer 7. Renal transplant with chronic immunosuppression. [**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**] Dictated By:[**Last Name (NamePattern1) 5246**] MEDQUIST36 D: [**2116-5-10**] 13:33 T: [**2116-5-10**] 15:41 JOB#: [**Job Number 21048**] cc:[**Last Name (NamePattern1) 21049**]

[ "458.2", "997.62", "250.41", "V42.0", "428.0", "369.4", "V49.75", "996.72", "414.01" ]

icd9cm

[ [ [] ] ]

[ "86.28", "97.44", "88.56", "36.01", "37.61", "99.20", "37.23" ]

icd9pcs

[ [ [] ] ]

2798, 2851

8822, 9504

9865, 10513

2160, 2616

4844, 8370

9529, 9844

2874, 4826

154, 175

204, 1647

1670, 2133

2633, 2781

8395, 8799

19,465

156,358

49303

Discharge summary

report

Admission Date: [**2197-4-2**] Discharge Date: [**2197-4-2**] Service: The patient expired on [**2197-4-2**] around 7 pm. HISTORY OF PRESENT ILLNESS: Patient is an 82-year-old female with a past medical history significant for deep venous thrombosis status post IVC filter, asthma, and questionable history of atrial fibrillation. Per daughter on the night prior to admission, the patient attended a concert. Following the concert, the patient "passed out." She was unresponsive. She did not sustain head trauma or lose continence of bowel or bladder. The daughter denies that patient has fevers, chills, nausea, vomiting, or diarrhea. The patient did have progressive shortness of breath over the past two weeks, however. On the Medical floor this morning, the patient was observed to be in severe respiratory distress. Electrocardiogram disclosed atrial fibrillation. Patient was required emergent intubation, and transferred to the CCU. PAST MEDICAL HISTORY: 1. Deep venous thrombosis status post [**Location (un) 260**] filter. 2. Open reduction internal fixation of right hip in [**2195-12-8**]. 3. Asthma. 4. Gastroesophageal reflux disease. 5. Questionable atrial fibrillation. Echocardiogram in [**2195-12-8**] disclosed an ejection fraction of 55%, 1+ AR, 2+ TR, left ventricular hypertrophy. MEDICATIONS: 1. Albuterol inhaler. 2. Prilosec 20 mg a day. 3. Ambien q hs. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives alone. Denies use of alcohol, tobacco, and drugs. The patient is Russian speaking. PHYSICAL EXAMINATION: General: Frail appearing lady, intubated and sedated. Vital signs: Temperature of 94.0, blood pressure 70/50, heart rate 112, respiratory rate assist control 400 x12, 100%, PEEP 5, O2 saturation is 93%. HEENT: pupils are equal, round, and reactive to light. Mucous membranes moist. Oropharynx clear. Neck: Right IJ in place. Heart: Regular, rate, and rhythm, S1, S2, 2/6 systolic ejection murmur. Lungs: Poor air movement in both lungs. Abdomen is soft, nontender, nondistended, positive bowel sounds. Extremities: No clubbing, cyanosis, or edema. LABORATORY DATA: White count 5.6, hematocrit 33.7, platelets 186. Chemistries showed a sodium of 143, potassium 3.5, bicarb 102, chloride 28, BUN 39, creatinine of 1.7 with a glucose of 107. Creatinine kinase was cycled, all less than 80, troponin from 10 am on the morning of [**4-2**] was 3.2. HOSPITAL COURSE: The patient was transferred to the CCU for further management. She was noted to be hypotensive with systolic blood pressure in the 70s. The patient was initially started on dobutamine and dopamine due to initial concern for left ventricular hypokinesis on a preliminary echocardiogram. Repeat echocardiogram disclosed left ventricular hypertrophy with preservation of left ventricular ejection fraction. Dobutamine was discontinued and patient was given fluid boluses. Due to concern for hypovolemia, it was thought that patient may require increased diastolic pressures for preserved pump function. Patient's blood pressure continued to decline and she required administration of dopamine, Neo-Synephrine, and fluids for maintenance of her pressure. Ultimately, these measures failed, and the patient expired on [**4-2**] at 7 pm. CAUSE OF DEATH: Cardiac arrest. [**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**] Dictated By:[**Last Name (NamePattern1) 5092**] MEDQUIST36 D: [**2197-4-3**] 00:05 T: [**2197-4-7**] 08:27 JOB#: [**Job Number 103313**]

[ "410.91", "518.81", "493.90", "799.4", "427.31", "785.51", "780.2", "424.1", "530.81" ]

icd9cm

[ [ [] ] ]

[ "89.64", "89.68", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

2464, 3615

1582, 2446

161, 959

981, 1438

1455, 1559

4,770

166,040

25909

Discharge summary

report

Admission Date: [**2108-1-3**] Discharge Date: [**2108-1-19**] Date of Birth: [**2036-6-26**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 824**] Chief Complaint: Back pain Major Surgical or Invasive Procedure: Right ureteral stent placement and right extracorporeal shockwave lithotripsy [**2108-1-6**] History of Present Illness: 71 yo with hx HTN, kidney stones, AAA, aortic insufficiency (s/p AVR [**10-28**] @ [**Hospital1 2177**]), AAA, CHF has a very large 7x16mm calculus in R kidney which will need lithotripsy according to his urologist, Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 770**]. Pt reports that for the past three months he has has intermittent suprapubic and rt flank pain which is colicky in nature. Pain has been [**9-2**] at worse and has increased in frequency over the past 3 weeks but no dysuria or hematuria. This was initially thought to be due to his prostate but the intermittent nature of the pain along with a normal prostate exam suggested other causes. [**12-19**] CT showed 7 x 16 mm calculus in the right renal pelvis with two smaller stones in the pelvis of the left kidney. Pt was therefore electively admitted for heparin bridge during lithotripsy since the patient needs continuous anticoagulation with mechanical valve. Past Medical History: HTN CHF secondary to AS AS s/p AVR [**9-27**] at [**Hospital1 2177**] AAA nephrolithiasis Social History: Married with 9 children and recently moved from ElSalvador 3 months ago with wife still living there. No hx of EtOH or tobacco. Family History: 2 brothers and a sister with stomach CA, no hx of CAD, stroke or DMII, or kidney problems Physical Exam: Vitals: T:99.2 P:107 R:17 BP: 78 - 141/40 - 80 SaO2: 93% RA General: Awake, alert, in pain HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, slightly distended. painful to light palpation of right upper and lower quadrant. normoactive bowel sounds Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Neurologic: Alert, oriented x 3. CN II-XII intact motor: normal bulk, strength and tone throughout. No abnormal movements noted. sensory: No deficits to light touch throughout. Pertinent Results: CXR AP [**1-3**]: Cardiomegaly with prosthetic aortic valve. No acute cardiopulmonary process seen. CT abdomen and pelvis w/ contrast [**1-8**]: 1. Large right perinephric hematoma with active extravasation of arterial contrast and hypoperfusion of the lower pole of the kidney. There is mass effect on the anterior aspect of the kidney from the surrounding hematoma. A nephroureteric extent is in place with its distal end in the urinary bladder. 2. Gallstones. CT abdomen and pelvis w/ contrast [**1-9**]: 1. Right perinephric hematoma has decreased in size since the prior study, but does not demonstrate active contrast extravasation at this time. 2. Delayed contrast excretion from the inferior pole of the right kidney is noted. 3. Foci of non-dependent air within the bladder. While this may be related to patient's trauma, correlation with U/A is recommended to exclude infection. 4. Gallstones. 5. Tiny pericaridal effusion. KUB [**1-12**]: 1. Prominent jejunal gases in the left upper quadrant, somewhat increased compared to the prior CT scan, without evidence of definite obstruction. Please closely follow by repeated abdominal radiographs. 2. Right ureteral stone, right renal stone, and opacity overlying the right upper quadrant corresponding to right perinephric hematoma seen on most recent CT scan. CT abdomen and pelvis [**1-14**]: Interval increase in size of large right subcapsular and perinephric renal hematoma. This hematoma is compressing the right kidney with a persistent nephrogram consistent with a Page kidney. [**2108-1-3**] 04:30PM BLOOD WBC-5.8 RBC-4.16* Hgb-12.8* Hct-37.2* MCV-89 MCH-30.8 MCHC-34.5 RDW-13.4 Plt Ct-277 [**2108-1-8**] 03:50PM BLOOD WBC-14.7*# RBC-3.56* Hgb-11.6* Hct-33.2* MCV-93 MCH-32.4* MCHC-34.8 RDW-14.7 Plt Ct-253 [**2108-1-9**] 07:54AM BLOOD WBC-10.4 RBC-3.63* Hgb-11.4* Hct-31.8* MCV-88 MCH-31.4 MCHC-35.9* RDW-15.7* Plt Ct-144* [**2108-1-9**] 07:54AM BLOOD Calcium-8.8 Phos-4.4 Mg-1.6 [**2108-1-11**] 04:55AM BLOOD WBC-8.7 RBC-3.96* Hgb-12.3* Hct-33.5* MCV-85 MCH-31.2 MCHC-36.8* RDW-14.9 Plt Ct-135* [**2108-1-14**] 08:30AM BLOOD WBC-7.8 RBC-3.74* Hgb-12.0* Hct-33.9* MCV-91 MCH-32.0 MCHC-35.3* RDW-14.2 Plt Ct-228 [**2108-1-19**] 06:20AM BLOOD Hct-36.5* [**2108-1-3**] 04:30PM BLOOD PT-20.1* PTT-28.6 INR(PT)-2.9 [**2108-1-9**] 01:58AM BLOOD PT-16.7* PTT-28.6 INR(PT)-1.9 [**2108-1-11**] 08:55PM BLOOD PT-13.5* PTT-39.4* INR(PT)-1.2 [**2108-1-14**] 08:30AM BLOOD PT-15.1* PTT-72.3* INR(PT)-1.6 [**2108-1-3**] 04:30PM BLOOD Glucose-89 UreaN-16 Creat-1.0 Na-138 K-4.3 Cl-103 HCO3-26 AnGap-13 [**2108-1-9**] 01:58AM BLOOD Glucose-166* UreaN-15 Creat-1.1 Na-134 K-6.2* Cl-105 HCO3-21* AnGap-14 [**2108-1-9**] 07:54AM BLOOD K-4.9 [**2108-1-11**] 04:55AM BLOOD Glucose-91 UreaN-13 Creat-1.0 Na-140 K-3.7 Cl-102 HCO3-28 AnGap-14 [**2108-1-14**] 08:30AM BLOOD Glucose-106* UreaN-13 Creat-1.0 Na-136 K-3.9 Cl-99 HCO3-25 AnGap-16 [**2108-1-18**] 05:45AM BLOOD Glucose-86 UreaN-12 Creat-0.9 Na-138 K-4.5 Cl-102 HCO3-29 AnGap-12 [**2108-1-3**] 04:30PM BLOOD Calcium-9.4 Phos-3.9 Mg-1.9 Brief Hospital Course: 71 yo with hx HTN, kidney stones, AAA, aortic insufficiency s/p AVR, AAA admitted for coumadin wean with heparin bridge for scheduled lithotripsy for nephrolithiasis. Patient underwent right extracorporial shock wave lithotripsy with r ureteral stent placement on [**1-6**]. Patient underwent surgery and was recovering on [**1-7**] when he had 2 episodes of syncope [**1-7**] and [**1-8**], hypotension and tachycardia with a HCT drop 38->31. He was emergently transfered to the ICU. A CT performed at that time showed large parinephric capsular hematoma with extension into the lower pelvis. . In the ICU, the patient's heparin drip was stopped and anticoagulation reversed. The patient ultimately recieved 8 Units PRBC, 2U FFP, and vitamin K. A 3-way foley was placed on [**2108-1-10**] for hematuria and continuous bladder irrigation was initiated. The patient was hemodynamically stable, holding at a steady HCT and was transferred back to the floor on [**2108-1-10**]. . On the floor, the patient remained stable and anticoagulation was slowly restarted beginning [**2108-1-11**]. A heparin drip and coumadin were started and the patient was monitored closely with frequent HCT checks. He remained stable although with continued right abdominal and flank tenderness as expected. He complained of abdominal bloating and a KUB was performed which revealed minimally dilated small bowel with no obstruction. His bowel regimen was increased for constipation. The foley catheter (and bladder irrigation) was removed on [**2108-1-13**] as hematuria had resolved. The patient was voiding without difficulty after catheter removal. A follow-up CT was performed on [**2108-1-14**] to evaluate the hematoma. It revealed a slight increase in size of the hematoma. The patient's hematocrit remained stable and his pain was controlled. The heparin was discontinued at this time. The patient was transferred to the urology service at this time to continue managment. He remained stable. Coumadin was resumed and the patient's INR and HCT was monitored closely. He continued to have abdominal and flank pain, although this gradually decreased and he was taking only tylenol with an occasional percocet for it's managment in the days leading up to discharge. He was given an additional 2units of PRBCs on [**2108-1-17**] for a very slow drift in his hematocrit. After this his HCT remained greater that 30 and had a hematocrit of 36.5 on the day of discharge. His INR was followed with coumadin dosing and was 3.4 on the day of discharge (goal 2.5-3.5). He was tolerating a regular diet and ambulating well with good pain control and was discharged on [**2108-1-19**] in good condition. He will follow-up closely with Dr. [**Last Name (STitle) 770**] for management of his hematoma and for eventual stent removal. He will follow-up at [**Hospital6 **] for monitoring of his INR beginning on the day after discharge. Medications on Admission: coumadin 5mg alternating with 2.5mg qod metoprolol 50mg [**Hospital1 **] ASA 81mg Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Atorvastatin 10 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). Disp:*60 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 6. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime: Take one tab (2.5mg) alternating with 2tabs (5mg) every other night beginning with one tab [**2108-1-19**]. Disp:*50 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Nephrolithiasis (right) Retroperitoneal hematoma Aortic insufficiency s/p aortic valve repair Congestive heart failure AAA Discharge Condition: Good Discharge Instructions: Please call Dr.[**Name (NI) 825**] office with any questions or concerns. Call if you are experiencing high fevers >101, have a significant increase in your abdominal/back pain, have nausea or vomiting and are unable to take in food and liquids, or have any other symptoms that concern you. You will have your stent removed by Dr. [**Last Name (STitle) 770**]...you will follow-up with him in clinic as to the timing of this. Followup Instructions: Please call Dr.[**Name (NI) 825**] office for your follow-up appointment in [**12-26**] weeks. ([**Telephone/Fax (1) 7707**]. Please follow-up with [**Hospital6 **] to have your INR checked tomorrow morning (Friday [**2108-1-20**]). After that please have your INR checked at least twice a week to ensure it is stable.

[ "592.0", "441.4", "V43.3", "428.0", "564.00", "276.52", "599.7", "458.29", "V58.61", "285.1", "401.9", "592.1", "998.12" ]

icd9cm

[ [ [] ] ]

[ "99.07", "96.48", "59.8", "99.04", "98.51", "00.17" ]

icd9pcs

[ [ [] ] ]

9286, 9292

5568, 8501

322, 417

9459, 9466

2499, 5545

9942, 10267

1678, 1769

8634, 9263

9313, 9438

8527, 8611

9490, 9919

1784, 2480

273, 284

445, 1403

1425, 1517

1533, 1662

30,638

137,226

32541

Discharge summary

report

Admission Date: [**2196-8-12**] Discharge Date: [**2196-8-22**] Date of Birth: [**2138-6-4**] Sex: M Service: NEUROSURGERY Allergies: Heparin Agents Attending:[**First Name3 (LF) 78**] Chief Complaint: Right Leg Weakness Major Surgical or Invasive Procedure: [**2196-8-17**] angiogram with embolization [**2196-8-17**] Posterior thoracic fusion revision History of Present Illness: 58 M renal cell ca with mets s/p T12 vertebrectomy c/b wound infection and revision in [**2194**] by Dr. [**Last Name (STitle) 548**], with one week history worsening R>L weakness, numbness, sensation change with OSH CT showing worsening thoracic mets. Patient was undergoing Chemo therapy until 6 months ago and he elected to stop therapy b/c he did not like how it made him feel. He began metabolic nutritional therapy instead. He began to notice some sensory changes in his right leg about 10 days ago and more recently in the past few days has had difficulty placing weight on it. He denies loss of bowel or bladder function. He did suffer a fall yesterday and landed on his bottom and required help to get back up on his feet. Past Medical History: Renal Cell carcinoma-resected in [**2190**] with bony mets to spine. s/p thoracic instrumented fusion T1-12 on [**2194-1-28**] for extradural mass at T5 and kyphotic collapse at T10 h/o MSSA bacteremia/deep wound infection ([**1-22**]) h/o knee surgery with ? infection at [**Hospital3 **] Rheumatoid arthritis h/o HCV-treated with 6 mo IFN/Riba by Dr [**First Name (STitle) **] in approx [**2189**] History of Tobacco use History of Alcohol use/abuse-clean x 2 years History of Polysubstance abuse including IVD-now clean Depression Social History: Currently lives alone. Family History: Family History: father deceased at 63 yo of heart disease. Physical Exam: Physical Examination on admission to [**Hospital1 18**]: PHYSICAL EXAM: O: T:97.9 BP:169 /67 HR: 60 R 18 O2Sats100 Gen: WD/WN, comfortable, NAD. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT [**Last Name (un) 938**] G Sensation: Intact to light touch, proprioception Reflexes: B T Br Pa Ac Right 1 1 1 0 0 Left 1 1 1 1 1 Toes downgoing bilaterally. [**6-21**] beets of clonus bilaterally Exam upon discharge: R IP -[**4-18**], H -[**5-18**], Q [**5-18**]/, AT 3/5, [**Last Name (un) 938**] [**2-19**], G [**4-18**] LLE full motor BUE full motor Pertinent Results: CT: (Outside Hospital report) comparison made to a CT of the T spine performed on [**2196-3-25**]: further loss of bone in the posterior aspect of the fourth T vertebral body as well as the posterior elements on the left and adjacent left rib. Compression deformity of the fifth T vertebral body nearly completely replaced by tumor. increased degree of osseous destruction when compared to previous study....lit ic lesion involving 6th vertebral body. Large lesion involving ninth T vertebral body and posterior elements on right.... diffuse metastatic lesion of the Thoracic spine, increased in degree of bone loss when compared to previous study MRI [**2196-8-14**] Destructive mass lesions are identified within T4, T5, T9 and T10 vertebrae.As seem on prior exams, the T5 vertebral body is collapsed and there isposterior extension of the soft tissue mass, displacing the spinal cord. The spinal cord does not demonstrate signal abnormality at any imaged level. The T9 and T10 vertebral bodies are partially absent and there is a marked kyphotic deformity centered about these two vertebral bodies, present on prior studies. The spinal canal is not well seen at the T9 and T10 levels due to artifact from the posterior spinal hardware but is likely significantly narrowed by tumor, with its effect on the spinal cord, difficult to assess. No evidence of acute thoracic or lumbar fracture. Bone scan [**2196-8-15**]: Numerous lesions of increased MDP avidity including foci in the mid and upper thoracic spine likely representing metastatic osseous disease. Brief Hospital Course: Pt was admitted to neurosurgery. He was started on pain medication and bowel meds. He was kept flat until was determined that his spine was stable. He underwent intubation for MRI due to claustrophobia on [**2196-8-14**].He was readied for OR. On [**2196-8-17**] he was brought to INR and underwent embolization of thoracic tumor and then proceeded to OR. Post-op course was uneventful- he was transferred to the floor from PACU on [**8-18**], on [**8-19**] he received 2 units PRBC for HCT 23, repeat HCT has been stable. [**8-21**] HCT 30.4 PT/OT evaluated patient and recommended Rehab. On [**8-22**] patient was discharged to Rehab of [**Location (un) **] and Islands. Medications on Admission: Citalopram 20mg QD Nexium 20 QD Colace 100mg [**Hospital1 **] Gabapentin 400 mg TID Folic Acid 1mg qd Zinc sulfate 220mg QD Dilaudid 4mg 3tabs qid methadone 10mg 6tabs every 6hrs. Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. Methadone 10 mg Tablet Sig: Six (6) Tablet PO QID (4 times a day). 9. Hydromorphone 2 mg Tablet Sig: 6-10 mg PO Q6H (every 6 hours) as needed for pain. 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous Q12H (every 12 hours). 14. Dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q12 () for 1 days. 15. Dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q24 () for 1 days. 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for abd folds. 18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for groin/scrotum. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: Metastatic Renal cell carcinoma to spine 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: Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up/ remove dressing POD#2 / begin daily showers POD#4 ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? If you are required to wear one, wear or back brace as instructed ?????? You may shower briefly without / back brace unless instructed otherwise ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake if you experience muscle stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Clearance to drive and return to work will be addressed at your post-operative office visit Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 548**] in 6 weeks with T/L spine Xrays. Call [**Telephone/Fax (1) 2992**] to arrange appt. Completed by:[**2196-8-22**]

[ "336.3", "530.81", "198.5", "311", "E878.1", "996.49", "285.9", "V10.52", "338.3", "714.0", "V87.41", "V15.3" ]

icd9cm

[ [ [] ] ]

[ "81.63", "03.4", "88.49", "81.04", "77.79", "78.69", "96.71", "81.35", "84.51", "96.04", "39.79" ]

icd9pcs

[ [ [] ] ]

6737, 6849

4233, 4911

296, 393

6934, 6934

2642, 4210

8205, 8375

1784, 1829

5142, 6714

6870, 6913

4937, 5119

7117, 8182

1917, 2064

237, 258

421, 1154

6949, 7093

1176, 1712

1728, 1752

2485, 2623

15,733

185,958

48433+59090

Discharge summary

report+addendum

Admission Date: [**2171-8-13**] Discharge Date: [**2171-8-19**] Date of Birth: [**2117-8-11**] Sex: F Service: MICU GREEN HISTORY OF PRESENT ILLNESS: The patient is a 54 year-old female with hepatitis C, stage 4 cirrhosis recently completed a course of pegylated interferon ribavirin treatment, which was stopped secondary to anemia and development of flu like symptoms with low back pain. The patient was seen in the Emergency Department for these symptoms one week ago. Per the OMR notes on [**7-23**] the patient called and reported a fall with a right foot and knee injury. On the 4th the patient called and reported increased back pain. On [**8-5**] the patient came for a follow up visit and was noted to be anemic and went to an outside hospital for a blood transfusion. On [**8-9**] the patient was seen in clinic and noted to have an increased white count of 17. She had blood cultures drawn and went home on the 20th. She was notified that two out of four were positive for staph aureus. The patient refused initial to come in to the Emergency Department and was started on Augmentin 500 b.i.d. The patient eventually returned to the Emergency Department on [**8-12**] secondary to fevers and mental status change. In the Emergency Department she was started on Oxacillin, Ceftriaxone, Gentamycin. She had notable mental status changes and deterioration. She became combative. She was sedated and intubated. Her blood gas at that time was 7.40, 25, 340. She had echocardiogram, CT of the head, abdomen and pelvis, spiked a fever to 102 and was admitted to the MICU for further evaluation. PAST MEDICAL HISTORY: 1. Hepatitis C chronic, biopsied in [**2170-1-19**] with B stage four cirrhosis with inflammation genotype 1 and viral load 91,000. She is followed on a steady protocol with pegylated interferon and ribavirin on [**4-23**]. On [**7-3**] ribavirin was decreased secondary to anemia on [**7-19**]. Ribavirin and interferon was stopped secondary to anemia. 2. Esophagogastroduodenoscopy on [**12-24**] evaluated no varices. 3. Anemia. ALLERGIES: No known drug allergies. MEDICATIONS: Unknown FAMILY HISTORY: Unknown, the patient is adopted. SOCIAL HISTORY: The patient is from the UK. She worked as a nurse for a long time. She has a previous alcohol history notable for one liter of Vodka per day. She denies any alcohol use recently. Tobacco history. The patient's hepatitis C risk factors include a needle stick as a nurse. PHYSICAL EXAMINATION ON ADMISSION: The patient weighed 63.7 kilograms. Temperature 99.4. Heart rate 119 sinus rhythm. Blood pressure 126/60. Respiratory rate 18. On AC setting tidal volume 550, FIO2 .4, sat 14 breathing minute volume 7.8. PEEP of 15, compliance 43. In general, she is sedated and intubated. HEENT mucous membranes are dry. Lips are cracked. Right IJ line in place. Cardiovascular she is tachy, regular rate. 2 out of 6 systolic murmur heard best at the sternal border with no radiatio. Pulmonary examination no wheeze or rhonchi. Clear to auscultation bilaterally. Abdominal examination nontender, nondistended, positive bowel sounds. Liver is palpable 4 cm below the costal margins, nodule, spleen palpable. Extremities bilateral palmar erythema, bilateral petechia over both feet in a stock like distribution and a 2 cm ulcer was noted of the right foot from the lateral aspect over the fifth metatarsal with erythema and scaling of the skin. Skin examination there is spider nevi over the chest and face. Neurological examination the patient is sedated heavily. STUDIES: Electrocardiogram sinus [**Last Name (LF) **], [**First Name3 (LF) **] depressions on V3 and V4. Arterial blood gas 7.40, 25, 307. Cultures from [**8-9**] are positive for staph aureus, lactate is 1.2 down from 3.1. Laboratories, white blood cell count 16, hematocrit 23.8, INR 1.6. Notable other laboratories no viral load. The patient is clear of HCV viral load. Echocardiogram left ventricular ejection fraction 50% and no clear vegetations. Chest x-ray patchy bibasilar infiltrates. HOSPITAL COURSE: 1. Staph aureus sepsis: The patient's white count trended down throughout her hospital course in the Intensive Care Unit. The patient initially spiking fevers, became afebrile and was treated on a course of Oxacillin for an expected treatment course of six weeks. Gentamycin for seven days. The patient was negative for endocarditis by TTE and TEE, murmur, which had previously not been documented, resolved. There were no vegetations noted. CT on [**8-13**] noted hypodense area in both kidneys, which may represent fossae of infarction fro septic emboli, unknown initial source of staph aureus bacteremia. The patient's last surveillance culture is positive on [**8-13**]. All cultures have been negative since that time. There is some concern for a central nervous system spread with a small dural puncture of the central nervous system and a central nervous system leak noted intraoperatively. Concern for mental status change. 2. Osteomyelitis of L4-L5: An MR was performed in light of the patient's initial complaint of back pain with massive lumbar discitis, osteomyelitis and associated epidural and paraspinal inflammatory disease. The patient was evaluated by neurosurgery and taken to the Operating Room for an L4-L5 laminectomy and draining of a small epidural abscess. The patient was noted to have massive amounts of granulation tissue extending likely into the psoas and iliac muscle confluent with the area around the epidural and paraspinal L4-L5 area. No complications since surgery. The patient was continued on Oxacillin for antimicrobial coverage. Cultures of bone were sent to laboratory. Must consider tuberculosis exposure as the patient worked as a health care provider. 3. Osteo of the fifth metatarsal: Films on [**8-13**] showed findings consistent with osteomyelitis of the fifth metatarsal head with marked narrowing of the fifth MTP joint. The patient was taken to surgery at the time of her L4-L5 laminectomy and the fifth metatarsal and proximal phalanx was removed. Cultures of the wound grew staph aureus bacteria consistent with the patient's staph sepsis. The patient was treated with Oxacillin and Gentamycin and followed by podiatry for q.d. dressing changes. 4. A CT performed on [**8-13**] showed a low density region inferior to the right kidney representing a phlegmon or possible soft tissue mass. No appendix was visualized at that time. An MR was repeated, which showed that this retroperitoneal or abdominal phlegmon was in close conjunction with the abscess/granulation tissue extending into the iliac and psoas muscles with the paraspinal abscess. A follow up CT was performed with appendicitis protocol, which demonstrated an intact appendix. Surgery was consulted. The patient is not a surgical candidate and is continued on Flagyl. The patient had a impressive abdominal examination, which started on [**8-15**] and resolved slowly over the next few days. 5. Aspiration pneumonia: The patient initially was admitted with chest x-ray showing bibasilar infiltrates likely a chemical pneumonitis. Post surgical the patient required oxygen. The patient was not on oxygen at home likely secondary to unresolved atelectasis. 6. Mental status changes: The patient's family reports the patient's baseline mental status at home involved "oiling and moaning" unclear if this is a change from her home baseline. Mental status changes are first noted when the patient was extubated on [**8-15**] and drank a quarter of a bottle of NyQuil with pain medications. The patient became increasingly sedated. The patient refused to swallow and had to have an nasogastric tube placed for medication administration. The patient has no focal neurological signs, questionable behavioral psychiatric issues. CT was performed of the head, which showed an underlying left frontal focus likely a meningioma. Unknown of mental status changes involve narcotic administration, alcohol withdraw or underlying psych conditions. 7. Respiratory failure: The patient was intubated upon admission initially on AC. The patient was changed to pressure support on [**8-13**] and extubated postoperative on [**8-15**]. 8. Ischemia: The patient was noted to have ST depressions on admission. The patient was ruled out for myocardial infarction. A repeat electrocardiogram showed resolution of these changes and returned to the patient's baseline. 9. Tachycardia: The patient has remained tachycardic throughout her Intensive Care Unit stay. It is unclear whether this tachycardia is related to pain, alcohol withdraw. The patient has frequent premature ventricular contractions. 10. Anemia: The patient was admitted with a hematocrit of 23. The patient was transfused 2 units of blood without complications and received 2 more units of blood intraoperatively. The patient's hematocrit remained stable. The patient also required many units of fresh frozen platelets intraoperatively to bring down her elevated INR. 11. Cirrhosis/hepatitis C: The patient currently has a no viral load. The patient's albumin is low and INR is elevated. The patient was given albumin 50 grams times two prior to the initiation of tube feeds per liver service. 12. Chololithiasis: The patient was evaluated with a right upper quadrant ultrasound, noted multiple stones in the gallbladder. The gallbladder is without thickening. 13. Alcohol withdraw: Per family's report the patient has not been drinking lately. Upon extubation the patient asked for her purse and removed a bottle of NyQuil and drank one quarter of the bottle indicating a likely recent alcohol history. The patient was placed on a CIWA scale. 14. Syndrome of inappropriate antidiuretic hormone: On the 27th the patient was noted to have a sodium of 132 and a urine sodium of 176. The patient was started on a 1 liter of fluid restriction. Sodium improved. 15. Abdominal and scapula rash: The patient developed a rash with small vesicles and lateral abdomen on the right. These two rashes are nonconfluent and they represent some dermatitis. To be added to the problem abdominal phlegmon, the patient should be CT for liquification of the abscess and recommend IR drain if liquification occurs. 16. Access: The patient has a right IJ and peripheral IVs. 17. Code: Full. Communication is with the patient's daughter [**Name (NI) **] [**Name (NI) **]. DISPOSITION: The patient is being transferred to the [**Location (un) **] firm. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Last Name (NamePattern1) 5713**] MEDQUIST36 D: [**2171-8-19**] 03:46 T: [**2171-8-20**] 13:04 JOB#: [**Job Number 101989**] Name: [**Known lastname 16441**], [**Known firstname **] Unit No: [**Numeric Identifier 16442**] Admission Date: [**2171-8-12**] Discharge Date: [**2171-8-30**] Date of Birth: [**2117-8-11**] Sex: F Service: DISCHARGE ADDENDUM BY PROBLEM: 1. Bacteremia: The patient's blood cultures as noted previously grew methicillin-sensitive Staph aureus. Blood cultures following this positive set remained negative throughout the remainder of the [**Hospital 1325**] hospital course. The patient continued to spike fevers upon transfer to the floor, highest of which was 101, however, over the past week, the patient remained afebrile with no further evidence of active infection. Infectious Disease service is consulted and continued to follow the patient while on floor. The patient was to complete a two week course of levofloxacin and Flagyl to cover gram-negative and anaerobes for any intraabdominal process or aspiration pneumonia given the patient's prior CT findings of multilobar pneumonia. Additionally, the patient was instructed to continue oxacillin for a total of eight weeks for her Staph bacteremia. A followup CT was performed to assess the abdominal phlegmon which was noted on an earlier abdominal CT. The phlegmon was considered to be more amenable to drainage, which was performed through CT guided aspiration in the Interventional Radiology Department. A drain was set in place. Cultures did not show any active infection. Gram stain was negative. The patient drained serosanguinous drainage from that drain site, which was removed one day prior to admission. 2. Mental status changes. Throughout the [**Hospital 1325**] hospital course in the MICU, the patient remained delirious. This was attributed to the fact that she was on sedative medications in addition to being bacteremic, both of which could have contributed to her delirious state. However, upon transfer to the floor, sedatives were weaned on a daily basis as well as pain medications. Patient's mental status slowly began to clear. Psychiatric services were consulted to evaluate the patient and to assist in assessing whether or not there is an axis II component to the patient's mental status. It was deemed that her most likely cause of mental status change was delirium and therefore we weaned her off all of her sedative medications, and as her bacteremia began to clear, the patient's mental status improved dramatically. When she was much more lucid and able to converse with us, she was able to express that she felt very anxious about remaining in the hospital and wanted to return home to be with her family as well as her mother, who is coming into town. 3. Pain: The patient complained of ongoing pain at the L4-L5 site as well as her right foot status post debridement. Patient was maintained on a Duragesic patch, pain medications on a prn basis in order to prevent oversedation. 4. Nutrition: The patient was maintained on nasogastric tube feeds throughout most of her hospital course, however, upon improvement in her mental status, the patient was able to take p.o. diet. Nasogastric tube was discontinued. 5. Hepatitis C cirrhosis: The Hepatology team continued to follow the patient while on service. Her liver function tests remained within normal limits, however, her INR remained elevated at 1.4. Patient was instructed to have her LFTs checked on a weekly basis while remaining on oxacillin and to followup with Hepatology for further management plan regarding her cirrhosis. 6. Lower extremity edema: Three days prior to admission, the patient developed lower extremity edema. An echocardiogram was performed to assess the patient's ejection fraction as well as her rales. There was no change from prior study, in-fact her ejection fraction was normal without any abnormalities in her valves or any wall motion abnormalities. Given the patient's poor nutritional status overall and her activity, we attribute her edema to both of these. The patient was started on Lasix as well as aldactone and diuresed well with improvement in her lower extremity edema. 7. Activity: The patient was maintained on bed rest throughout the rest of her hospital course. Heparin subQ for DVT prophylaxis. Patient was fitted for a brace, and was able to get out of bed to chair with Physical Therapy assistance, and patient was able to ambulate short distances. 8. Shortness of breath: While the patient was in-house, followup CT of her chest showed multilobar pneumonia. A CTA had been performed given the patient's ongoing hypoxemia as well as for positive D dimer during her hospitalization. CTA did not show any evidence of pulmonary embolism, lower extremity Dopplers were performed as well and there was no evidence of DVT. Patient's hypoxemia began to improve upon improvement of her mental status, and with greater inspiratory effort, it is believed that the patient was limited by her brace when making an attempt to inspire, this in addition to her pneumonia contributing to her hypoxemia during her admission. 9. Tachycardia: The patient remained tachycardic throughout most of her hospitalization. The workup for this included a CTA to rule out pulmonary embolus, electrolytes checked to assess for volume status, echocardiogram, telemetry, and serial EKGs. The patient remained in sinus tachycardia. This was likely secondary to her pneumonia as well as her ongoing pain. This continued to improve as the patient was more alert and oriented and when her pain was adequately controlled. 10. Fluids, electrolytes, and nutrition: Patient's creatinine remained stable. Her volume status improved dramatically throughout her hospital course. Due to her lower extremity edema, she was maintained on diuretics throughout the latter half of her hospital course while on the floor. There were no electrolyte imbalances noted on her chemistry profile except for an occasional hypokalemia. Otherwise, her BUN and creatinine remained stable as well as her urine output. DISCHARGE INSTRUCTIONS: The patient is instructed to followup with her PCP within one week of discharge to have her following blood work checked, CBC, LFTs, and chemistry profile. Additionally, the patient is instructed to followup with Podiatry within 7-10 days of discharge to assess her right foot osteomyelitis. The patient is instructed to followup with Dr. [**Last Name (STitle) 16443**] from Hepatology within 1-2 weeks of discharge for management of her hepatitis C cirrhosis. Additionally, the patient is instructed to followup with Neurosurgery within 7-10 days of her discharge for assessment of her L4-L5 diskitis. DISCHARGE MEDICATIONS: 1. Thiamine 100 mg p.o. q.d. 2. Folic acid 1 mg p.o. q.d. 3. Multivitamin one p.o. q.d. 4. Lactulose 30 cc p.o. t.i.d. 5. Fentanyl 25 mcg an hour patch transdermal every three days to be discontinued by her PCP within one week. 6. Aldactone 50 mg p.o. q.d. 7. Lasix 20 mg p.o. q.d. 8. Oxycodone 5 mg every 4-6 hours as needed for severe pain. 9. Oxacillin 2 grams IV q.4h. via PICC line for total of eight weeks. Upon discharge, the patient had completed 16 days out of those eight weeks. DISCHARGE STATUS: The patient is stable. Discharged to rehab. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, MPH[**MD Number(3) 16444**] Dictated By:[**Last Name (NamePattern1) 3217**] MEDQUIST36 D: [**2171-8-30**] 06:55 T: [**2171-8-30**] 06:59 JOB#: [**Job Number 16445**]

[ "038.11", "567.2", "507.0", "733.00", "324.1", "571.5", "070.54", "253.6", "707.14" ]

icd9cm

[ [ [] ] ]

[ "54.91", "77.68", "03.31", "38.91", "38.93", "80.51", "96.04", "77.88", "96.71", "88.72" ]

icd9pcs

[ [ [] ] ]

2169, 2203

17560, 18418

4119, 16906

16931, 17537

168, 1631

2532, 4101

1653, 2152

2220, 2517

29,121

112,970

7296

Discharge summary

report

Admission Date: [**2154-6-28**] Discharge Date: [**2154-7-15**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: colon cancer in transverse colon Major Surgical or Invasive Procedure: laproscopic assisted transverse left colectomy History of Present Illness: Mr. [**Known lastname 7356**] is an 88-year-old gentleman with a history of anemia who underwent a colonoscopy which demonstrated a cancer in the transverse colon. The risks and benefits of the surgery were offered after a surgical consult was obtained. A CT scan demonstrated no evidence of extracolonic tumor and CEA level was 2.5 which was normal. Past Medical History: restless leg syndrome Social History: Lives with his wife. Daughter lives in area. No tobacco or alcohol use. Family History: No significant history Physical Exam: Vitals: afebrile, hemodynamically stable Chest: CTAB Heart: RRR, -MRG Abdoment: Soft, NT, ND, +BS, no masses appreciated on exam. Ext: peripheral pulses palpable Pertinent Results: [**7-5**]- atrial fibrillation with RVR [**2154-7-5**] 09:00PM BLOOD WBC-10.1 RBC-2.97* Hgb-8.6* Hct-24.7* MCV-83 MCH-29.2 MCHC-35.1* RDW-16.2* Plt Ct-255 [**2154-7-6**] 01:08AM BLOOD WBC-10.6 RBC-3.31* Hgb-9.9* Hct-27.7* MCV-84 MCH-29.8 MCHC-35.8* RDW-16.1* Plt Ct-237 [**2154-7-15**] 07:21AM BLOOD PT-33.1* PTT-40.0* INR(PT)-3.6* [**2154-7-14**] 08:55AM BLOOD PT-41.7* PTT-44.1* INR(PT)-4.7* [**2154-7-13**] 06:00PM BLOOD PT-56.1* PTT-43.4* INR(PT)-6.8* [**2154-7-13**] 08:05AM BLOOD PT-60.1* PTT-44.7* INR(PT)-7.4* [**2154-7-12**] 03:00AM BLOOD PT-48.0* PTT-43.7* INR(PT)-5.6* [**2154-7-11**] 06:05AM BLOOD PT-24.0* PTT-39.4* INR(PT)-2.4* [**2154-7-10**] 10:28AM BLOOD PT-22.1* PTT-87.8* INR(PT)-2.2* [**2154-7-9**] 08:30PM BLOOD Glucose-97 Lactate-3.3* Na-127* K-3.9 Cl-103 calHCO3-19* [**2154-7-10**] 02:59AM BLOOD Lactate-3.6* [**2154-7-10**] 01:00PM BLOOD Lactate-1.6 [**2154-7-10**] 08:41PM BLOOD Lactate-1.0 Brief Hospital Course: Mr. [**Known lastname 7356**] was admitted following a colonoscopy which showed an obstruction colon CA at his splenic flexure. He underwent a lap assisted transverse colectomy without complication. An NGT and PICC were placed following the procedure. On [**7-5**] he developed atrial fibrillation with rapid ventricular response. He also removed his NGT, PICC line, and Foley at this point. They were then replaced. He taken to the ICU and placed on lopressor and diltiazem for his atrial fibrillation. Also on [**7-5**] he had a positive C. diff screen and was place on Flagyl. On [**7-8**] he underwent cardioversion successfully for his atrial fibrillation. He was then transferred to the floor. However, on [**7-9**] he was taken back to the ICU for the development of shortness of breath and tachypnea. He was found to have an increasing lactate at this time and also a hematocrit of 24. He was transfused with 1 unit of blood and was doing well the following day. On [**7-12**] he was transfered back to the floor and had an uncomplicated remainder of his hospital stay. Medications on Admission: pamiprexole 25 qhs dihydrochloride Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp:*30 Tablet(s)* Refills:*0* 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:*30 * Refills:*2* 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*5 * Refills:*2* 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 7. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO qhs () as needed for restless legs. Disp:*20 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: obstructing adenocarcinoma at splenic flexure Discharge Condition: stable, to extended care facility Discharge Instructions: Please return if: 1. fever > 101 2. pain/pus around wound site 3. nausea/vomitting 4. inability to pass stool or tolerate oral food Followup Instructions: Please follow-up with Dr. [**First Name (STitle) 2819**] on [**8-1**] at 3:30PM in [**Location (un) 86**]. Please do not take your coumadin per Dr. [**First Name (STitle) 2819**]

[ "997.1", "008.45", "427.31", "560.1", "799.02", "333.94", "458.29", "153.1" ]

icd9cm

[ [ [] ] ]

[ "38.91", "45.74", "99.15", "38.93" ]

icd9pcs

[ [ [] ] ]

4037, 4103

2039, 3131

294, 344

4193, 4229

1098, 2016

4409, 4590

877, 901

3216, 4014

4124, 4172

3157, 3193

4253, 4386

916, 1079

222, 256

372, 725

747, 770

786, 861

71,277

151,505

42428

Discharge summary

report

Admission Date: [**2121-7-21**] Discharge Date: [**2121-8-5**] Date of Birth: [**2046-4-2**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 598**] Chief Complaint: draining abdominal wall abscess Major Surgical or Invasive Procedure: [**2121-7-22**]: Incision and drainage of abdominal wall abscess with intervening subcutaneous tissue [**2121-7-28**]: Endoscopy with over the scope clip placement (OTSC), endoscopic placement of NJ tube History of Present Illness: The patient is a 75M recently discharged from [**Hospital1 18**] after incision, drainage, and VAC dressing placement for midline wound abscess and colocutaneous fistula in the setting of previously known gastrocutaneous fluid. He has a history of repair of antral perforation initially repaired in 1/[**2120**]. He was discharged on [**2121-7-18**] to a rehab facility. Over the following 3 days, there was interval progression of an abscess to the right of his midline incisions which eventually began to drain and became progressively swollen, indurated and tender. He denies fevers, nausea, vomiting, or diarrhea. He had a VAC in place on presentation. Past Medical History: Past Medical History: HTN, CAD, HLD, NIDDM Past Surgical History: PSH: [**2121-1-9**] ex-lap, washout, J tube placement, [**2121-1-3**] ex-lap, [**2120-12-27**] ex-lap, re-[**First Name8 (NamePattern2) **] [**Location (un) **] patch, [**2120-12-22**] Antral [**Location (un) **] patch, Appendectomy, CABG ([**2112**]), L inguinal hernia repair([**2113**]) Social History: Tobacco: denies. EtOH: denies. Recreational drugs: denies. Retired funeral director. Married for more than 40 years. Family History: Mother/Father: DM Physical Exam: On admission: 97.4 93 107/52 18 100%RA Gen: NAD CV: RRR S1 S2 Lungs: CTA B/L Abd: soft, ND, midline wound with clean granulation tissue under VAC dressing (wound ~20x8cm), area of induration and swelling 6cm in diameter R of midline with opening draining purulent/enteric contents that tracks 3cm medially. Tender to palpation. On discharge: Vitals 98.8 82 100/58 16 98%RA GEN: A&O, NAD CV: RRR PULM: CTAB ABD: Soft, NT, ND. Midline wound and RUQ wound with wound vac in place. Pertinent Results: Labs on admission: 145 | 112 | 27 --------------<117 4.4 | 25 |1.3 23.0 > 8.7 < 380 27.4 N:86.2 L:6.7 M:2.9 E:4.0 Bas:0.2 PT: 49.0 PTT: 38.0 INR: 4.9 BILAT LOWER EXT VEINS Study Date of [**2121-7-22**] 3:08 PM No evidence of deep vein thrombosis in either right or left lower extremity. [**2121-7-22**] 5:03 am SWAB Site: ABDOMEN ABD WALL ABSCESS. **FINAL REPORT [**2121-7-25**]** GRAM STAIN (Final [**2121-7-22**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): BUDDING YEAST. WOUND CULTURE (Final [**2121-7-25**]): This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT in this culture.. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. STAPH AUREUS COAG +. SPARSE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | STAPH AUREUS COAG + | | CEFEPIME-------------- 2 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN--------- =>4 R CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 4 S <=0.5 S LEVOFLOXACIN---------- =>8 R MEROPENEM------------- 4 I OXACILLIN------------- =>4 R PIPERACILLIN/TAZO----- S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S CT ABD & PELVIS W/O CONTRAST Study Date of [**2121-7-31**] 11:51 AM IMPRESSION: 1. Status post closure of gastrocutaneous fistula, with a small residual fistulous communication with a minimal amount of oral contrast leaking into the rectus sheath and anterior abdominal wall. 2. Thickening of the right lower anterior abdominal wall with small locules of air, with tethering of the cecum and a loop of terminal ileum, may relate to recent surgery, however a residual fistula is not entirely excluded. UNILAT UP EXT VEINS US LEFT Study Date of [**2121-7-31**] 10:43 PM IMPRESSION: No evidence of deep venous thrombosis in the left upper extremity. Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**2121-7-21**] under the Acute Care Surgery service for management of his abdominal abscess. He was taken to the operating room and underwent incision and drainage of the abscess. Postoperatively he was hypotensive in the PACU prompting transfer to TICU for resuscitation and close monitoring. He was transfused 1 unit of pRBC's for a postop hct of 23.5 with hypotension. On POD#1 he was normotensive and otherwise stable and was transferred to the surgical floor. His hospital course is detailed by systems below: Neuro: He remained alert and oriented throughout his hospitalization. His pain level was routinely monitored. His pain was mainly episodic with vac dressing changes and he was medicated appropriately for this. Cardiovascular: As noted above, he was hypotensive initially postoperatively with a systolic BP in the 70's. This resolved with colloid and crystalloid resuscition. His hematcrit responded appropriately from 23.5 to 27 with transfusion of 1 unit of pRBC's. By POD#1 he remained normotensive with otherwise stable vital signs. Respiratory: Pulmonary toileting and incentive spirometry were encouraged. He remained without respiratory compromise. GI: He was initially kept NPO. Gastroenterology was consulted for question of need for endoscopic intervention of gastrocutaneous fistula. On [**7-28**] he underwent endoscopy with OTSC to attempt to close the opening of the gastrocutaneous fistula and placement of NJ tube for enteral feeding past the point of the fistula. Tube feeds were started and advanced to goal rate on [**7-29**]. On [**7-31**] he had a CT scan to evaluate for resolution of fistula, which showed a small residual fistulous communication (see pertinent results section for details). Therefore, he was kept NPO with tubefeeds. CT scan was scheduled for 2 weeks from discharge for re-evaluation of closure of the fistula at that time. GU: He had acute kidney injury initially with elevated creatinine to 1.3. He was hydrated with IV fluids and urine output was monitored closely. His creatinine normalized at 0.9. MSK: Physical therapy was consulted to evaluate his mobility who recommended discharge to rehab when medically stable. He was encouraged to mobilize out of bed as tolerated. Heme/ID: His coumadin was held initially given need for interventions as discussed above. It was restarted on [**7-29**] at his home dose. He was placed on SC heparin for prophylaxis during his entire stay. He had US of his b/l UE's that were negative for DVT. He was started on broad spectrum antibiotics (vanc/cipro/flagyl) which were later changed to vanc/zosyn, given that his intraoperative wound culture grew pseudamonas. This was continued for a total of 7 days postoperatively and completed on [**7-28**]. At that time he remained afebrile with a normal WBC count. Medications on Admission: Remeron 15 HS, Celexa 30', coumadin 5' alt with 2.5', protonix 40' Discharge Medications: 1. Mirtazapine 15 mg PO HS 2. Pantoprazole 40 mg PO Q24H 3. Citalopram 30 mg PO DAILY 4. Acetaminophen 650 mg PO Q6H:PRN feer/pain 5. Docusate Sodium 100 mg PO BID 6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 7. Senna 1 TAB PO BID:PRN constipation 8. Warfarin 2.5 mg PO EVERY OTHER DAY alternate with 5mg dose 9. Warfarin 5 mg PO EVERY OTHER DAY Alternate with 2.5 mg dose Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital-[**Hospital1 8**] Discharge Diagnosis: Gastrocutaneous fistula Abdominal wall abscess Acute Kidney Injury Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with drainage from your wound and were taken to the operating room for drainage of an abdominal wall abscess. Formation of a connection (fistula) between your stomach and skin was noted. You were later taken for endoscopy by the gastroenterologists for clipping of the opening in attempt to allow the fistula to close. A feeding tube was also placed endoscopically past your stomach into the portion of your small bowel called your jejunum. This is to given you nutrition below the area of the opening in attempt to allow that area to heal. You are now being discharged to rehab to continue your recovery. You will continue to receive tubefeedings for nutrition. You have a follow up appointment scheduled below in [**Hospital 2536**] clinic at which time a CT scan will be performed to evaluate for closure of the fistula. Followup Instructions: Department: RADIOLOGY When: TUESDAY [**2121-8-19**] at 3:30 PM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage ** Please call [**Telephone/Fax (1) 590**] for prep instrustions since this CT scan will be done with a contrast dye.*** Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: TUESDAY [**2121-8-19**] at 4:30 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage ** This appointment replaces the [**8-7**] at 3:15pm appointment that has been cancelled. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2121-8-5**]

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icd9cm

[ [ [] ] ]

[ "54.0", "38.93", "46.74", "38.97", "45.13", "96.6" ]

icd9pcs

[ [ [] ] ]

8975, 9045

5593, 8449

333, 540

9163, 9163

2307, 2312

10229, 11122

1763, 1783

8567, 8952

9066, 9142

8475, 8544

9346, 10206

1316, 1610

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2151, 2288

261, 295

568, 1227

2327, 5570

9178, 9322

1271, 1293

1626, 1747

26,986

185,053

24630

Discharge summary

report

Admission Date: [**2105-10-19**] Discharge Date: [**2105-10-24**] Date of Birth: [**2028-11-14**] Sex: M Service: CARDIOTHORACIC Allergies: Coumadin / Lipitor / Zetia Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2105-10-19**] Mitral Valve Replacement (31mm CE tissue valve), MAZE Procedure History of Present Illness: 76 y/o male c/o dyspnea on exertion with h/o MR/MVP with an ECHO in [**7-11**] showing ruptured chordae and PAF with DCCV in [**7-11**]. He has d/c'd Coumadin secondary to GI bleed. Past Medical History: Mitral Regurgitation, Paroxysmal Atrial Fibrillation s/p DCCV in [**7-11**], TIA ([**5-10**] over 10yrs), Hypercholesterolemia, h/o GI Bleed, Erectile Dysfunction, Hemorrhoids, s/p Polypectomy Social History: Retired Engineer. Quit smoking in [**2061**]. Drinks wine daily. Lives with wife. Family History: Non-contributory Physical Exam: Admission: Gen: WDWN elderly male in NAD Skin: Unremarkable HEENT: EOMI, PERRL, NCAT Neck: Supple, FROM, -JVD Chest: CTAB -w/r/r Heart: RRR w/ 4/6 SEM Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, trace edema Neuro: A&O x 3, MAE, non-focal Discharge: VS 98.0 80 148/70 18 97% Gen: NAD Neuro: A&Ox3, nonfocal exam Pulm: CTA-bilat CV: RRR, no M/R/G. Sternum stable, incision CDI Abdm: soft, NT/ND/NABS Ext: warm, 1+ pedal edema bilat Pertinent Results: Echo [**2105-10-19**]: PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. The mitral valve leaflets do not fully coapt. There is severe mitral annular calcification. There is moderate thickening of the mitral valve chordae. Severe (4+) mitral regurgitation is seen. POST CPB: Preserved [**Hospital1 **]-ventricular systolic function. Bioprosthesis im motral posiiton. Well seated and mechanically stable Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **] across the valve = 3 mm Hg. RADIOLOGY Preliminary Report CHEST (PA & LAT) [**2105-10-22**] 6:00 PM CHEST (PA & LAT) Reason: eval for pneumo s/p chest tube removal [**Hospital 93**] MEDICAL CONDITION: 76 year old man with s/p MVR REASON FOR THIS EXAMINATION: eval for pneumo s/p chest tube removal PA AND LATERAL CHEST FROM [**10-22**] HISTORY: Recent MVR. Possible pneumothorax or pleural effusion. IMPRESSION: PA and lateral chest compared to [**10-15**] through 17: There is no pneumothorax and a small left pleural effusion has decreased since [**10-21**] following removal of the chest tube previously ending left of midline. Left basal atelectasis continues to improve. Lungs are otherwise clear. Cardiomediastinal silhouette has a normal postoperative appearance. DR. [**First Name (STitle) **] [**Name (STitle) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] [**2105-10-19**] 05:13PM UREA N-18 CREAT-1.0 SODIUM-141 CHLORIDE-113* TOTAL CO2-21* [**2105-10-19**] 05:13PM HCT-23.3* [**2105-10-19**] 05:13PM PLT COUNT-206 [**2105-10-19**] 05:13PM PT-13.0 PTT-31.5 INR(PT)-1.1 [**2105-10-19**] 10:57AM WBC-16.6* RBC-3.58* HGB-10.3* HCT-31.0* MCV-86 MCH-28.7 MCHC-33.2 RDW-15.4 [**2105-10-23**] 06:05AM BLOOD WBC-9.9 RBC-3.07* Hgb-9.2* Hct-26.4* MCV-86 MCH-30.0 MCHC-34.8 RDW-15.9* Plt Ct-208 [**2105-10-23**] 06:05AM BLOOD Plt Ct-208 [**2105-10-21**] 02:53AM BLOOD PT-13.2* PTT-31.6 INR(PT)-1.1 [**2105-10-23**] 06:05AM BLOOD Glucose-100 UreaN-26* Creat-0.8 Na-136 K-4.0 Cl-99 HCO3-29 AnGap-12 Brief Hospital Course: Mr. [**Known lastname **] was a same day admit after undergoing all pre-operative work-up as an outpatient. On day of admission he was brought directly to the operating where he underwent a mitral valve replacement and maze procedure. Please see operative report for details. Following surgery he was transferred to the CVIICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics and gently diuresed towards his pre-op weight. On post-op day two he was transferred to the SDU for further care. On post-op day three his chest tubes and epicardial pacing wires were removed. Pt stable for DC Medications on Admission: Amiodarone 200mg qd, Prilosec 20mg qd Discharge Disposition: Home With Service Facility: Home Health of [**Location (un) 5028**] Discharge Diagnosis: Mitral Regurgitation s/p Mitral Valve Replacement Paroxysmal Atrial Fibrillation s/p MAZE Procedure PMH: s/p DCCV in [**7-11**], TIA ([**5-10**] over 10yrs), Hypercholesterolemia, h/o GI Bleed, Erectile Dysfunction, Hemorrhoids, s/p Polypectomy 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. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (STitle) 13517**] in [**1-6**] weeks Dr. [**Last Name (STitle) 5730**] in [**2-7**] weeks Dr. [**Last Name (Prefixes) **] in 4 weeks Completed by:[**2105-10-24**]

[ "511.9", "E878.8", "398.91", "272.0", "998.11", "427.31", "396.2" ]

icd9cm

[ [ [] ] ]

[ "99.05", "39.61", "35.23", "99.04", "37.33", "99.07" ]

icd9pcs

[ [ [] ] ]

4715, 4785

3891, 4627

316, 398

5073, 5079

1434, 2094

940, 958

2499, 2528

4806, 5052

4653, 4692

5103, 5355

5406, 5587

973, 1415

257, 278

2557, 3868

426, 609

631, 825

841, 924

2104, 2462

11,912

115,441

52913

Discharge summary

report

Admission Date: [**2133-4-26**] Discharge Date: [**2133-5-2**] Date of Birth: [**2070-6-27**] Sex: F Service: MEDICINE Allergies: Compazine Attending:[**First Name3 (LF) 1666**] Chief Complaint: Transfer from [**Hospital6 33**] with bright red blood per ileostomy Major Surgical or Invasive Procedure: Ligation of bleeding varix at ostomy site History of Present Illness: 62 yo F h/o hypothyroid, UC s/p colectomy and colostomy 20 yrs ago, tx from [**Hospital3 **] for blood per R sided ileostomy. She first noticed some increased bleeding from her ileostomy about a week PTA. On Friday [**4-24**], she noticed a large amount of bleeding and had to empty her bag of red blood and clots x 3. + LOC at that time and admitted by ambulance to OSH - HCT 19. At OSH, intermittent blood in ostomy and tx x 5u. Abd CT reportedly showed no masses but moderate ascites. EGD showed no evidence of bleeding. Scope through her ileostomy limited by blood. On [**2133-4-26**] she was tx'd here after she put out 1.2liters of blood through her ostomy. In total she got 9u pRBC at the OSH. . . Past Medical History: PAST MEDICAL HISTORY Hypothyroidism Ulcerative colitis . Social History: SOCIAL HISTORY Pt admits to drinking "several" (approx [**4-30**]) glasses of white wine daily. Her last drink was 3days prior to presenting at [**Hospital6 33**]. She does not smoke but her husband smokes 3ppd so is exposed to a lot of second hand smoke. Per her daughter, she has been under a lot of stress lately. Her daughter also reports greater etoh intake (2 bottles wine per day). . She is under a lot of stress at home regarding grandchildren custody issues. Physical Exam: VS: 99.0 (tm=Tc), 93/47 (75-100/33-68), 86 (81-93), sat 94-99% 3L I/O: 24hr: 4.6L/1.4L (LOS: +3.3L) BG: 168, 146 GEN: NAD, interactive, often vague answers. HEENT: OP clear, no sclera under tongue, MMM, PERRL, sclerae anicteric. CV: Normal s1/s2, RRR, no m/r/g PUL: lungs with decreased breath sounds at bases to halfway up lungs, no wheezes. Some crackles at bases. ABD: Soft, NT, midline scar, ileostomy in RLQ without bleeding. Ext: No edema, DP full, RP full Neuro: A&Ox3, speech fluent, voice without fluctuations in tone/strength. CN intact with lateraly nystagmus on extreme gaze. Moves all extremities. No tremor Pertinent Results: ADMISSION LABS: [**2133-4-26**] 11:07PM BLOOD WBC-8.9 RBC-3.52* Hgb-11.1* Hct-31.0* MCV-88 MCH-31.6 MCHC-36.0* RDW-17.0* Plt Ct-126* [**2133-4-27**] 02:49AM BLOOD Hct-25.3* [**2133-4-27**] 09:45AM BLOOD Hct-27.6* [**2133-4-27**] 03:42PM BLOOD Hct-27.3* [**2133-4-26**] 11:07PM BLOOD Neuts-68.3 Lymphs-23.4 Monos-4.8 Eos-3.0 Baso-0.4 [**2133-4-26**] 11:07PM BLOOD PT-16.2* PTT-32.5 INR(PT)-1.5* [**2133-4-26**] 11:07PM BLOOD Plt Ct-126* [**2133-4-26**] 11:07PM BLOOD Glucose-134* UreaN-3* Creat-0.6 Na-141 K-3.3 Cl-111* HCO3-22 AnGap-11 [**2133-4-26**] 11:07PM BLOOD ALT-13 AST-41* LD(LDH)-135 CK(CPK)-68 AlkPhos-77 Amylase-19 TotBili-2.3* [**2133-4-27**] 09:45AM BLOOD DirBili-1.3* [**2133-4-26**] 11:07PM BLOOD Lipase-18 [**2133-4-26**] 11:07PM BLOOD CK-MB-2 cTropnT-<0.01 [**2133-4-26**] 11:07PM BLOOD Albumin-2.3* Calcium-6.8* Phos-2.5* Mg-1.5* [**2133-4-26**] 11:07PM BLOOD TSH-0.59 . [**Name (NI) **] Studies (Pt has had recent blood tx): [**Name (NI) **]: 29 calTIBC: 148 Ferritn: 97 TRF: 114 . Peritoneal Fluid: Albumin < 1 (SAAG ~ 1.4) Protein 0.8 Glucose 93 LDH 44 WBC 23, RBC 2611 N17, L 38, M 10, Mesothelial 12, Macroph 23 Gram Stain negative . Culture data Negative throughout hospital stay . Abd U/S [**4-27**]: 1 Coarsened liver echotexture consistent with fatty infiltration. More advanced forms of liver disease such as fibrosis/cirrhosis cannot be excluded. 2. Small amount of perihepatic ascites. 3 Distended gallbladder containing sludge and wall edema, likely related to underlying liver disease. 4 Slow velocity but hepatopetal flow within the portal vein. 5 Small right pleural effusion. . CXR [**4-27**]: Findings consistent with pulmonary edema from fluid overload with associated pleural effusions. . Tagged RBC Scan [**4-27**]: No active GI bleeding at the time of study. . ECHO [**4-27**]: Conclusions: The left atrium is mildly dilated. The interatrial septum is aneurysmal. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure. Right ventricular chamber size and free wall motion are normal. The aortic root 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. There is an anterior fat pad. . CT abd [**4-28**]: Findings are consistent with cirrhosis, decompensation as evidenced by ascites and varices. (Liver with nodularity and irregularity, no splenomegaly, paraumbilical vein recannulization, bibasilar effusions, GB with stones/sludge.) . CHEST AP [**4-29**]: There is stable appearance of the vascular engorgement, perihilar haziness and diffuse bilateral interstitial opacities representing fluid overload along with small bilateral pleural effusions. . EGD: Impression: Small hiatal hernia Erythema, congestion and mosaic appearance in the antrum and stomach body compatible with portal gastropathy Erythema in the gastroesophageal junction Varices at the lower third of the esophagus Otherwise normal egd to second part of the duodenum Recommendations: Follow-up biopsy results Continue Protonix. Hold Nadolol given low BP and minimal varices. Repeat EGD in 2years. F/U in Liver Ctr upon discharge from hospital. . LENI [**5-1**]: Negative for DVT. . CTA Chest [**5-2**]: 1. No pulmonary embolism. 2. Pulmonary edema with Moderately bilateral pleural effusion. 3. Large amount of intra-abdominal ascites. . Brief Hospital Course: ICU Course: In the ICU she continued to have intermittent bleeding from her ostomy. SBP has remained in the 90s with pt mentating and stable. NG lavage (~500cc) was negative, the patient did not tolerate the procedure well so a complete liter could not be administered. Surgery and GI saw the pt. Surgery put Vicryl and one silk suture in an actively bleeding vessel at the ostomy site on [**2133-4-26**] with subsequent hemostasis. Afterward, a tagged RBC scan failed to reveal any extravazation of blood and HCT remained stable. GI scoped the ostomy and found no further sites of bleeding (superficial scope, not extensive). Ultrasound showed an enlarged liver with fatty infiltration and sluggish portal vein flow with peri-hepatic ascites. The pt was then felt to be stable to tx to the floor. Hospital [**Hospital1 **] Course by Problem: . # SOB: The patient developed shortness of breath during her hospital stay. CXR suggested volume overload, but because of the acuity of onset, the patient was sent for LE dopplers and, eventually, a CTA. She ruled out for PE/DVT and was treated with lasix. Her SOB improved with lasix treatment. The volume overload was thought to be due to her multiple blood transfusions and IVF support while in the ICU. Echo showed no systolic dysfunction and was not suggestive of diastolic dysfunction. . # GI Bleed: When the patient was transferred out of the ICU, sutures were in place. and there was no further bleeding. She was seen by the ostomy nurse and follow-up with surgery was established for after the patient's discharge. . # Anemia - Though the patient's [**Hospital1 **] studies were unreliable due to recent bleed and transfusions, they were suggestive of [**Hospital1 **] deficiency, and the pt was started on [**Hospital1 **]. . # Cirrhosis - During the workup for her GI bleed, imaging repeatedly revealed small to moderate ascites, and liver silhouette suggestive of cirrhosis. The pt has a history of etoh abuse that she was reluctant to talk about. Per her family, she drinks 1-2 bottles of wine each evening. This was thought to be the most likely cause of hepatic dysfunction. PSC was entertained given her history of UC, however there was no ductal change on liver US. There was no sign of [**Hospital1 **] overload suggestive of hemachromatosis. Sm muscle antibody for PBC was weakly positive and not suggestive of this entity. The hepatology service was consulted and suggested nadolol, aldactone, and lasix qd. Hepatitis panel was negative for Hep B, Hep C, and Hep A. EGD revealed no esophogeal varices. Therefore the nadolol was discontinued. . # etoh abuse: The pt was not forthcoming regarding her etoh use. It was an obviously emotional topic for pt and family. She stated she had wine with dinner. Per her daughter she had been drinking heavily (bottles of wine per night) for years. Recent family stresses relating to custody have caused her to escalate her drinking recently per the daughter. Family members also give a history of daily vomiting and shakes if she did not drink. She required very little benzodiazapines per CIWA. She was treted with IV thiamine and PO folic acid. She was seen by SW for etoh abuse counselling and took information regarding rehab, but stated that she did not want to become involved and she would be able to quit drinking on her own. . # Hypotension - The pt had a low blood pressure throughout the hospitalization but was stable. It was felt that this baseline low BP was likely due to cirrhosis. . # h/o hypothyroidism: - TSH was checked and was wnl. Continued prior dose of synthroid 75mcg . # Prurigo Nodularis: The pt had a chronic skin finding over her exposed skin. She had been told in the past that it was due to her nervous habit of scratching her skin. Ddx could include dermatitis herpetiformis, though it would be an odd presentation of this. She was treated with Sarna lotion and the skin remained stable to improved over her hospital course. . # UC - The pt had curative colectomy for her dz. No extra-gi symptoms were apparent. She received ostomy care per ostomy nurse as noted above. . # Ppx: The patient did receive Heparin SQ at this hospitalization. . # Code: Remained Full, confirmed with patient, family. . # Communication: [**First Name4 (NamePattern1) **] [**Known lastname **] home: [**Telephone/Fax (1) 109094**], cell: [**Telephone/Fax (1) 109095**]. PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66568**] ([**Hospital1 112**]). Medications on Admission: MEDS ON TRANSFER Octreotide drip Nexium 40mg twice daily Ativan prn Bannana bag Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Primary: GI Bleed: Bleeding vessel at ostomy New diagnosis of cirrhosis Hypotension Anemia of blood loss and [**Location (un) **] deficiency Secondary: Ulcerative Colitis s/p colostomy Hypothyroid Discharge Condition: Stable HCT x >48 hours, no orthostatic symptoms, O2 saturation on RA while ambulating > 90%, no symptoms of SOB Discharge Instructions: You were admitted with bleeding from your ostomy site. This was caused by dilation of the blood vessels in this area. The dilation was likely caused by your liver disease. Your liver disease may be related to alcohol. You should not drink any alcohol anymore. If you need help as you stop drinking all alcohol, please contact the hospital or the contact alcoholics anonymous directly. You will have a number of follow up [**Location (un) 4314**] to ensure you are treated properly for your liver disease and to prevent further bleeding. Please do not miss [**First Name (Titles) 9278**] [**Last Name (Titles) 4314**]: Dr. [**Last Name (STitle) **] (Colorectal surgery) - he will need to examine your ostomy and the stitches that were placed at this hospitalization. Your appointment is for: [**2133-5-18**] at 1:15pm at the [**Hospital Unit Name **] (facing the ER). It is [**Location (un) 470**], [**Hospital Unit Name **]. Please bring ostomy supplies as he will want to remove your current ostomy bag. You should make an appointment to see your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 66568**], within 2 weeks. You should follow up with the liver team in the next 1-2 weeks. Please call for an appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **]: ([**Telephone/Fax (1) 16686**]. If you develop recurrent bleeding, light headedness, fevers, chills, severe nausea or vomiting or other worrisome symptoms please seek immediate medical attention. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Date/Time:[**2133-5-18**] 1:15 Dr. [**Last Name (STitle) 66568**] (PCP) - pt to call. Pt to call for hepatology follow up: Dr. [**Last Name (STitle) **]: ([**Telephone/Fax (1) 16686**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**] Completed by:[**2133-5-18**]

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icd9cm

[ [ [] ] ]

[ "54.91", "45.16", "99.04", "39.98", "99.07" ]

icd9pcs

[ [ [] ] ]

11516, 11575

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338, 381

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2341, 2341

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230, 300

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1213, 1683

46,105

154,670

36868

Discharge summary

report

Admission Date: [**2110-5-13**] Discharge Date: [**2110-5-15**] Date of Birth: [**2040-5-17**] Sex: M Service: MEDICINE Allergies: Gabapentin / Plavix / Meclizine / Olanzapine Attending:[**First Name3 (LF) 398**] Chief Complaint: LE bleeding Major Surgical or Invasive Procedure: None History of Present Illness: 69 yo M w/hx of CVA in the past, since has been non verbal, has contractures, trach and vent dependent for multiple aspiration pneumonias, and with a PICC and PEG tube who presents with bleeding from his R foot ulcer. Per the patient's daughter he gets accupuncture q month, he had accupuncture today and then was seen by his daughter later in the day who noticed bleeding from his R foot ulcer. He was sent to the [**Hospital1 18**] for evaluation as the blood was seen as "bubbling" and there was a concern for wet gangrene. The patient is unable to provide a history, the daughter is currently not reachable. In the ER he was seen by podiatry In the ER ID was contact[**Name (NI) **] regarding abx choices and given h/o VRE and MRSA linezolid was chosen. VS in the ER were: Tm 100.8 HR 105 BP 105/37 RR 25 O2 100% on FiO2 40%. Past Medical History: s/p CVA, intracerebral hemorrhage chronic and recurrent respiratory failure secondary to aspiration severe malnutrition type II DM GERD h/o VRE, MRSA and C diff infections severe contractures and multiple decubiti (most stage 4) h/o sacral osteomyelitis Social History: Lives at [**Hospital **] Rehab currently, vent dependent. Health care proxy is daughter. Family History: NC Physical Exam: VITAL SIGNS: T 100.8 BP120/59 HR 108 100% on PCV PC 12, PEEP 5, PIP 17, MVe 6.7 GENERAL: the patient is alert and responds to verbal stimuli, moans and is non verbal. Per the ER's discussion with the daughter and [**Name (NI) **] notes this is patient's baseline. the patient is emaciated. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, poor inspiratory effort ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, absent pulses SKIN: multiple decubiti, incluing L greater trochanter, sacral and R 1st MTP joing ulcer which are all stage 4. The 1st MTP joint probes to bone and appears to have a thin layer of pus with some scant bloody drainage. The rest of the ulcers appear clean. NEURO: the patient is alert and responds to commands, EOMI, and PERRL, able to move RUE slightly and has + grip on RUE, rest of extremities are contracted, patient has bilateral upper face motor intact. facial droop on R side. Pertinent Results: [**2110-5-15**] 04:53AM BLOOD WBC-6.9 RBC-2.62* Hgb-8.5* Hct-26.1* MCV-99* MCH-32.5* MCHC-32.7 RDW-17.6* Plt Ct-192 [**2110-5-13**] 06:55PM BLOOD WBC-8.8 RBC-2.96* Hgb-9.8* Hct-29.1* MCV-98 MCH-32.9* MCHC-33.5 RDW-17.6* Plt Ct-227 [**2110-5-14**] 05:24AM BLOOD Neuts-71.0* Lymphs-17.8* Monos-5.5 Eos-5.2* Baso-0.5 [**2110-5-13**] 06:55PM BLOOD Neuts-72.0* Lymphs-16.1* Monos-4.5 Eos-6.8* Baso-0.6 [**2110-5-13**] 06:55PM BLOOD PT-13.9* PTT-29.2 INR(PT)-1.2* [**2110-5-14**] 05:24AM BLOOD ESR-140* [**2110-5-15**] 04:53AM BLOOD Glucose-170* UreaN-68* Creat-1.0 Na-146* K-3.5 Cl-107 HCO3-33* AnGap-10 [**2110-5-13**] 06:55PM BLOOD Glucose-141* UreaN-95* Creat-0.9 Na-144 K-3.9 Cl-103 HCO3-36* AnGap-9 [**2110-5-15**] 04:53AM BLOOD Calcium-9.9 Phos-3.0 Mg-2.0 [**2110-5-14**] 05:24AM BLOOD Calcium-10.5* Phos-3.0 Mg-2.1 [**2110-5-14**] 05:24AM BLOOD CRP-56.5* [**2110-5-13**] 09:22PM BLOOD Lactate-1.6 CXR [**2110-5-14**]: The tracheostomy tip is approximately 7 cm above the carina. The right PICC line tip is at mid right subclavian vein. The heart size is normal. The mediastinal position, contour and width are grossly unremarkable. The patient is hyperinflated. There is a left infrahilar opacity that might represent area of developing infection continuing towards the left lung base but note is made that the left costophrenic angle was excluded from the field of view. No appreciable pleural effusion is demonstrated. FOOT X RAY (BILATERAL): 1. No evidence of subcutaneous gas identified. Diffuse soft tissue swelling is seen in both feet. 2. Irregularity of the lateral cortical margin of the left fifth metatarsal, and osteomyelitis within this region is not excluded. 3. Post-surgical changes involving both fifth digits. 4. Extensive vascular calcifications. Brief Hospital Course: 69 yoM w/ a h/o CVA and trach / vent dependent since his CVA, DM, multiple decubiti presents w/ bleeding from LE infected ulcer and UTI. LOWER EXTREMITY ULCER: He has multiple decubiti. His L 1st MTP joint ulcer and R foot lateral portion ulcer appear infected. We have consulted the infected disease service who suggested zosyn and dapto for a 10 day course for infected ulcer treatment. He has recurrent osteomyelitis and given his resistant organisms chronic suppressive therapy is not warranted. The podiatry service evaluated her and deemed that a bone biopsy would not be helpful as infectious disease had recommended no current treatment. The patient is not systemically ill currently but any antibiotic treatment with broad spectrum antibiotics would not cure his osteo as he would still have multiple stage 4 ulcers with exposed bone. Unfortunately his multiple ulcers are in various locations and surgical approach would not be an option. He has a very low albumin and the extent of his decubiti would make wound healing near extremely difficult. Plan to treat the infected ulcer and continue to monitor for recurrence of infection. First day of treatment [**2110-5-15**]. HYPERNATREMIA: sodium 146, started on free water flushes of 100cc q 6hrs. Please follow his sodium, was 146 on [**2110-5-15**]. URINARY TRACT INFECTION: based on u/a, no culture. [**Hospital1 **] reportedly has a culture from [**2110-5-13**] with enterobacter. Please continue zosyn and follow up sensitivities on this and adjust antibiotics as necessary. Continue zosyn for total 14 day course as recommended by the infectious disease service. First day of treatment [**2110-5-14**]. Foley was changed [**2110-5-15**]. ASPIRATION PNEUMONITIS: no evidence for aspiration pneumonia rather than aspiration pneumonitis. 4+ GNR from sputum, likely colonization. On zosyn for UTI for 14 days regardless. HYPERCALCEMIA: calcium was 10.5 initially, down to 9.9 with some IVF (1L NS). He has a low albumin so his corrected calcium is > than 12 initially. His calcium and vitamin D were held. Please f/u repeat calcium on [**2110-5-17**]. Medications on Admission: Tube feeds Nepro at 45cc/hr Vent Settings PC 12, PEEP 5, FiO2 40%, PIP 17 aspirin 81mg daily calcium carbonate 1250mg po bid dalteparin 2500u sc daily insulin sliding scale lopressor 50mg po q6rs Reglan 10mg IV q 8hrs Miconazole powder Multivitamin Prilosec 20mg daily Zofran 4mg IV q12 hours scopolamine 1.5mg q72hrs sodium bicarb 10cc (8.4%) vitamin D 400 units daily tylenol prn albuterol prn Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale insulin Injection ASDIR (AS DIRECTED). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6HRS (). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72 HRS (). 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Metoclopramide 5 mg/mL Solution Sig: Two (2) Injection Q8H (every 8 hours). 10. Ondansetron 4 mg IV Q 12H 11. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours). 12. Daptomycin 500 mg Recon Soln Sig: Two [**Age over 90 1230**]y (250) mg Intravenous Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: PRIMARY DIAGNOSIS: URINARY TRACT INFECTION INFECTED LOWER EXTREMITY ULCER SECONDARY DIAGNOSIS: DIABETES MELLITUS Discharge Condition: stable, no systemic signs of infection Discharge Instructions: You were admitted with a infected ulcer and urinary tract infection. You will be given 2 weeks of IV antibiotics. Please return to the hospital if you have fevers, elevated wbc count, or chills, bleeding from ulcers or pus from ulcers.\ Followup Instructions: Please check sodium and calcium on [**2110-5-17**] and have free water flushes adjusted as needed. Please follow up with an infectious disease specialist within 2-4 weeks from discharge.

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icd9cm

[ [ [] ] ]

[ "96.6", "96.71" ]

icd9pcs

[ [ [] ] ]

8255, 8334

4557, 6694

316, 322

8492, 8533

2762, 4534

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1479, 1569

60,672

126,609

15591

Discharge summary

report

Admission Date: [**2161-10-19**] Discharge Date: [**2161-10-26**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 3531**] Chief Complaint: melena Major Surgical or Invasive Procedure: [**10-21**]- EGD [**10-22**]- flexible sigmoidoscopy [**10-23**]- colonoscopy History of Present Illness: Mr. [**Known lastname 45083**] is a 89 year-old gentleman with HTN, CAD, BPH, Parkinson's disease presenting from [**Hospital 100**] Rehab nursing home with episode of dark black stool 1 week ago and then 2-3 days ago. This was associated with abdominal pain at that time. Since that time he has had fatigue and malaise. No CP, SOB. No further melena or abdominal pain. His PMD was notified of these episodes, Routine labs were checked at NH which showed HCT 19 so he was referred in to the ED. In the emergency department, initial VS: 99.2 68 137/49 20 100%RA. Exam revealed guaiac positive dark black stool. Labs showed a new anemia with HCT 19 (baseline 30 per rehab) as well as a stable CRI at 1.6 (at baseline). Coags were normal. Trop was 0.03. EKG showed NSR with LBBB and LVH, lateral ST depression in V4-V6. no prior for comparison. Access was obtained with 2 18-gauge PIVs and he was given pantoprazole IV bolus. Blood transfusion for 2 units was planned, with first unit hung in ED. Received 1 L NS. GI was consulted, recommended transfusion and serial HCTs, NGT. Family refused NGT so no NG lavage was performed. He had no melena in the ED. Most recent VS prior to transfer: 97.4 61 127/51 16 100% RA. Currently, he feels fatigued, but otherwise well Past Medical History: Parkinson's, BPH, CAD, CHF Social History: Lives in nursing home Daughter is involved in care Family History: non-contributory Physical Exam: T afebrile BP=.162/60 HR=.62m RR=.16 O2= 100% GENERAL: Pleasant, pale, elderly male, NAD. HEENT: Normocephalic, atraumatic. Conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. [**2-13**] systolic murmurs at the apex, rubs or [**Last Name (un) 549**]. JVP= LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. Pale palmar surfaces and distal extremities. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2161-10-19**] 11:31PM WBC-15.4* RBC-2.43* HGB-7.9* HCT-22.8* MCV-94 MCH-32.4* MCHC-34.5 RDW-15.8* [**2161-10-19**] 11:31PM PLT COUNT-325 [**2161-10-19**] 05:45PM cTropnT-0.03* [**2161-10-19**] 05:45PM CK-MB-5 . [**2161-10-20**] CXR- No acute infiltrates or CHF [**2161-10-21**] GI Bleeding study- Active sigmoid colon bleed. . [**2161-10-21**]- EGD: Small hiatal hernia; otherwise normal EGD to second part of the duodenum, recommend colonoscopy . [**2161-10-22**]- Flexible sigmoidoscopy: unable to visualize internal structures due to copious amts of melena. . [**2161-10-23**]- Colonoscopy: Five polyps noted in cecum, ascending, transverse and descending colon Diverticulosis of the sigmoid colon Heme in the colon Otherwise normal colonoscopy to cecum . Discharge Labs: [**2161-10-25**] 06:15AM BLOOD WBC-13.1* RBC-3.52* Hgb-10.6* Hct-32.5* MCV-92 MCH-30.0 MCHC-32.5 RDW-16.4* Plt Ct-328 [**2161-10-25**] 06:15AM BLOOD Glucose-110* UreaN-22* Creat-1.4* Na-138 K-3.9 Cl-103 HCO3-27 AnGap-12 [**2161-10-26**] 07:05AM BLOOD Hct-30.8* [**2161-10-25**] 06:15AM BLOOD WBC-13.1* RBC-3.52* Hgb-10.6* Hct-32.5* MCV-92 MCH-30.0 MCHC-32.5 RDW-16.4* Plt Ct-328 [**2161-10-24**] 01:24PM BLOOD Hct-30.8* [**2161-10-24**] 05:20AM BLOOD WBC-16.3* RBC-3.45* Hgb-10.9* Hct-31.2* MCV-91 MCH-31.5 MCHC-34.8 RDW-16.5* Plt Ct-330 [**2161-10-23**] 03:37PM BLOOD Hct-32.1* [**2161-10-23**] 04:04AM BLOOD WBC-14.2* RBC-3.35* Hgb-10.4* Hct-30.8* MCV-92 MCH-31.2 MCHC-33.9 RDW-16.6* Plt Ct-341 [**2161-10-22**] 07:40PM BLOOD Hct-34.2* Plt Ct-396 [**2161-10-22**] 03:59PM BLOOD Hct-31.0* [**2161-10-22**] 11:58AM BLOOD Hct-29.9* [**2161-10-22**] 08:01AM BLOOD Hct-30.8* [**2161-10-22**] 02:09AM BLOOD WBC-17.7* RBC-3.89*# Hgb-12.1*# Hct-34.7* MCV-89 MCH-31.1 MCHC-34.8 RDW-16.6* Plt Ct-274 [**2161-10-21**] 03:54AM BLOOD WBC-16.0* RBC-2.82* Hgb-8.6* Hct-26.4* MCV-93 MCH-30.5 MCHC-32.6 RDW-17.2* Plt Ct-310 [**2161-10-20**] 03:17AM BLOOD WBC-15.4* RBC-2.53* Hgb-8.0* Hct-23.4* MCV-93 MCH-31.6 MCHC-34.1 RDW-16.1* Plt Ct-297 [**2161-10-25**] 06:15AM BLOOD Glucose-110* UreaN-22* Creat-1.4* Na-138 K-3.9 Cl-103 HCO3-27 AnGap-12 Brief Hospital Course: Mr. [**Known lastname 45083**] is an 89 year-old gentleman with coronary artery disease, hypertension and Parkinson's disease who was admitted to the ICU with melena and a HCT of 19. . 1. Acute Blood Loss Anemia/GI bleed - The patient was admitted with hematocrit 19. Aspirin was held. The patient was treated with pantoprazole IV BID and received 3 units of PRBCs, with appopriate increase in hematocrit. Following the transfusion, the patient's hematocrit remained stable at 26-28 for 24 hours before falling to 17.0 in the setting of melena. The patient was transfused 4 units PRBCs. Urgent EGD showed no evidence of upper GI bleeding. Tagged red blood cell scan showed a sigmoid colonic source that was not bleeding rapidly enough to be amenable to angiography. The patient was given 2 enemas in preparation for sigmoidoscopy, which was non-diagnostic secondary to a large amount of melena in the patient's colon. Therefore, the patient was prepped for colonoscopy, which showed diverticulosis. The source of the patient's bleeding was felt to be diverticular. He remained stable throughout his hospital course thereafter. The patient was called out to the medical floor on [**2161-10-24**]. His Hct stabilized at 30-32. He will benefit from GI referral within the next few weeks. . 2. Parkinson's disease- Continued Sinemet and Mirapex per home regimen. . 3. CAD, native s/p MI - Held aspirin in setting of GI bleed. Continued other medications. [**Month (only) 116**] consider resuming Aspirin at nursing home if Hct stable. . 4. Urinary dysfunction - Continued tolterodine. A foley catheter was placed in the ICU, this was discontinued on the day of discharge. A voiding trial should be completed at rehab. . 5. Hypoglycemia - On [**10-24**], the patient had hypoglycemia to the 40s in early a.m. This was felt to be secondary to malnutrition in the setting of being NPO for a prolonged period of time. The patient was treated with 1 amp of D50. His diet was advanced and his glucose remained stable thereafter. . 6. CKD, stage III: stable during admission . 7. Leukocytosis: Chronic. [**Month (only) 116**] have been exacerbated from acute bleeding. . 8. Depression: Continued celexa Medications on Admission: Medication List from [**Hospital3 **]: . 1. Acetaminophen 650mg PO BID PRN 2. ASA EC 81 mg PO daily 3. Carbidopa/ Levodopa Cr 50/200 1 tab PO TID 4. Cholecalciferol 1000units once daily 5. Citalopram Hcl 20mg PO daily 6. Systane long lasting eye drops 1 drop OU TID 7. Pramipexole Dihydrochloride 0.125 mg PO TID 8. Tolterodine LA 2mg PO QHS 9. Bisacodyl suppository 10mg PR daily 10. Oxycodone Hcl IR 2.5mg PO q4h pain 11. Clobetasol propionate 0.05% cream 1 appl [**Hospital1 **] Discharge Medications: 1. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig: One (1) Tablet PO TID (3 times a day). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for pain. 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 5. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 7. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): to affected area. 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: 1.3 Tablet, Chewables PO BID (2 times a day). 9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-12**] Drops Ophthalmic PRN (as needed) as needed for dryness. 13. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5) ML PO Q6H (every 6 hours) as needed for pain: avoid with alcohol or driving. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] Discharge Diagnosis: Acute blood loss anemia/GI bleed Diverticulosis CAD, native vessel Hypertension, benign Stage III CKD Parkinson's disease Urinary retention Discharge Condition: Good Discharge Instructions: Patient was admitted with GI bleed. He was transfused a total of 7 units of blood. He underwent EGD, colonoscopy, and bleeding scan, showing bleeding in the sigmoid colon. However, only polyps and diverticulosis was identified. His bleeding was felt to be due to a bleeding diverticulum which stopped spontaneously. His hematocrit remained stable thereafter. . The following medication changes were made: Aspirin STOPPED at discharge. [**Month (only) 116**] be restarted if hematocrit stable on return. . Please have patient follow up with his PCP and gastroenterology within the next 2-4 weeks . Have patient return with recurrent bloody or black stool, abd pain, fevers, chills, chest pain. Followup Instructions: PCP: [**Name10 (NameIs) 1447**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 45084**] in [**1-14**] weeks . Gastroenterology referral with appointment within 4 weeks

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icd9cm

[ [ [] ] ]

[ "45.24", "45.23", "45.13" ]

icd9pcs

[ [ [] ] ]

8791, 8858

4715, 6914

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344, 1609

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1675, 1728

21,738

144,961

4941

Discharge summary

report

Admission Date: [**2144-2-11**] Discharge Date: [**2144-2-20**] Date of Birth: [**2070-7-3**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 425**] Chief Complaint: Transfer for placement of biventricular automatic implantable cardiac defibrillator Major Surgical or Invasive Procedure: -- s/p [**Hospital1 **]-ventricular pacemaker -- s/p TEE with unsuccessful cardioversion -- s/p placement of a Swan Ganz catherter History of Present Illness: 73 yr old female with htn, hyperlipidemia, s/p mechanical AVR w/single vessel CABG w/VG to OM '[**30**]. (s/p stenting of SVG to OM [**2142-11-12**]). admitted to [**Hospital1 1474**] (on [**2-7**]) w/decompensated CHF (BNP > 5000) and ARF (Cr 3.6). She was admitted to [**Hospital 1474**] Hospital after presenting to her PCP's office hypotensive 60/30, w/o radial or carotid pulse. She was also reported to have had a self limited episode of diarrhea and decreased appetite PTP. Fell at home 5 weeks prioor to presenation. She has a non-displaced left posterior rib fracture at 4th/6th and 7th. Trop on admit was 1.9, ck 200's, MB's negative, dig = 2.9, INR = 7.4 . Also noted to be in new ARF (cr 3.6) which was worse than her baseline of 2.1. At the [**Hospital 1474**] Hospital she had several episodes of atrial fibrillation with rapid ventricular repsonse which was broken with IV diltiazem. She also complained of severe dyspnea on exertion and orthopnea, minimal PND, and some LE edema for 1-2 weeks prior to hosp. She denied any chest pain. She denies cough, fevers, chills, but did report a 20-30lbs weight loss over the course of two months, and occasionally loose stools. Patient states that her weight loss was secondary to poor access to food. Upon discharge from hospital the pt had had a friend who was cooking meals for her. Her friend was then admitted to hospital which made it difficult for her to obtain meals. Past Medical History: Dilated CM Hypertension Renal Insufficency (Bl 1.6-2.0) H/o renal artery stenosis-by renal angiogram in [**2138**]-80% calcified L renal artery stenosis, 60% calcified osteal right renal artery stenosis Chronic Atrial fibrillation COPD Hypothyroidsim Osteoarthritis Social History: Distant smoker, quit thirty years ago, prior to that 15 pk year history. No EtOH, lives at home alone. Family History: Father had heart disease-died at age 85, mother lives in a nursing home at age [**Age over 90 **] Physical Exam: P.E. Vitals:T = 92.0, BP = 90-70/57 now 77/57, P = 68-79, RR = 28, 95% on 2L Gen: Thin, chronically appearing female using accessory muscles to breathe. Neck: JVP at mandible CV: Tachy, irregularly irregular, prominent S1, S2, SEM RUSB Lungs: Crackles [**1-16**] of the way up from the bases. Decreased BS at R base. Abdomen: nabs, soft,nt. Extremities: 2+ DPP w/o edema. Neuro: non-focal Pertinent Results: [**2144-2-11**] 09:52PM GLUCOSE-113* UREA N-76* CREAT-2.0* SODIUM-133 POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-20* ANION GAP-19 [**2144-2-11**] 09:52PM CK(CPK)-34 [**2144-2-11**] 09:52PM CK-MB-NotDone proBNP-GREATER TH [**2144-2-11**] 09:52PM CALCIUM-8.4 PHOSPHATE-4.3 MAGNESIUM-2.1 [**2144-2-11**] 09:52PM DIGOXIN-1.4 [**2144-2-11**] 09:52PM WBC-7.9# RBC-3.05* HGB-9.8* HCT-31.3* MCV-102* MCH-32.2* MCHC-31.5 RDW-17.2* [**2144-2-11**] 09:52PM PLT COUNT-361# [**2144-2-11**] 09:52PM PT-14.1* PTT-57.0* INR(PT)-1.2 [**2144-2-11**] 07:59PM TYPE-ART TEMP-33.9 O2 FLOW-2 PO2-54* PCO2-27* PH-7.47* TOTAL CO2-20* BASE XS--1 INTUBATED-NOT INTUBA [**2144-2-11**] 07:59PM GLUCOSE-140* LACTATE-2.6* Echo results from OSH-[**2144-2-10**] EF = 10-15% Mean gradient across AVR =17 with peak of 39 (Mean <25 = mild) Echo [**11/2142**] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.8 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.4 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 5.0 cm (nl <= 5.0 cm) Left Ventricle - Diastolic Dimension: *6.1 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 5.2 cm Left Ventricle - Fractional Shortening: *0.15 (nl >= 0.29) Left Ventricle - Ejection Fraction: *<= 20% (nl >=55%) Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm) Aortic Valve - Peak Velocity: *2.8 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 29 mm Hg Aortic Valve - Mean Gradient: 16 mm Hg Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A Ratio: 0.89 Mitral Valve - E Wave Deceleration Time: 105 msec TR Gradient (+ RA = PASP): *58 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: The left atrium is mildly dilated. RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. LEFT VENTRICLE: The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. RIGHT VENTRICLE: Right ventricular chamber size and free wall motion are normal. AORTA: The aortic root is normal in diameter. AORTIC VALVE: A bileaflet aortic valve prosthesis is present. The aortic prosthesis leaflets appear to move normally. The transaortic gradient is higher than expected for this type of prosthesis. Mild (1+) aortic regurgitation is seen. MITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild mitral annular calcification. There is moderate thickening of the mitral valve chordae. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. TRICUSPID VALVE: There is moderate pulmonary artery systolic hypertension. PERICARDIUM: There is no pericardial effusion. Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 3. A bileaflet aortic valve prosthesis is present. The aortic prosthesis leaflets appear to move normally. The transaortic gradient is higher than expected for this type of prosthesis. Mild (1+) aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. There is moderate thickening of the mitral valve chordae. Mild (1+) mitral regurgitation is seen. 5. There is moderate pulmonary artery systolic hypertension. 6. Compared with the findings of the prior report (tape unavailable for review) of [**2139-10-12**], there is no significant change. Cath [**11-14**]- where she ruled in for an MI COMMENTS: 1. Selective coronary angiography of this right dominant system revealed severe single vessel native coronary artery disease. The LMCA had only mild, diffuse disease. The LAD had a 50% proximal lesion. The LCx was totally occluded at its origin. The RCA had a distal 50% lesion. 2. Vein graft angiography revealed a 90% stenosis of the SVG->OM graft. 3. Resting hemodynamics revealed systemic hypertension. 4. Left ventriculography was not performed because of the patient's elevated creatinine and mechanical valve. 5 . Successful stenting of the SVG-OM was performed with overlapping 3.0 x 15 mm, 3.0 x 18 mm, and 3.5 x 18 mm Zeta stents. [**2144-2-14**] Placement of PA catheter. INDICATIONS FOR CATHETERIZATION: PA catheter placement PROCEDURE: Right Heart Catheterization: was performed by percutaneous entry of the right internal jugular vein, using a 7 French pulmonary wedge pressure catheter, advanced to the PCW position through a 8 French introducing sheath. Cardiac output was measured by the Fick method. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.54 m2 HEMOGLOBIN: 9.7 gms % FICK **PRESSURES RIGHT ATRIUM {a/v/m} 20/20/17 RIGHT VENTRICLE {s/ed} 64/17 PULMONARY ARTERY {s/d/m} 61/32/41 PULMONARY WEDGE {a/v/m} 25/28/24 AORTA {s/d/m} 101/61/73 **CARDIAC OUTPUT HEART RATE {beats/min} 75 RHYTHM AFIB O2 CONS. IND {ml/min/m2} 125 A-V O2 DIFFERENCE {ml/ltr} 79 CARD. OP/IND FICK {l/mn/m2} 2.4/1.6 **RESISTANCES SYSTEMIC VASC. RESISTANCE 1867 PULMONARY VASC. RESISTANCE 567 **% SATURATION DATA (NL) SVC LOW 45 PA MAIN 37 AO 97 TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 30 minutes. Arterial time = 0 minutes. Fluoro time = 1.6 minutes. Contrast: Premedications: ASA 325 mg P.O. Anesthesia: 1% Lidocaine subq. Anticoagulation: Other medication: Fentanyl 12.5 mcg IV COMMENTS: 1. Resting hemodynamics demonstrated elevated right and left sided pressures. Mean RA pressure was 17 mmHg and mean PCWP was 24 mmHg. There was severe pulmonary hypertension with PASP of 61 mmHg. The cardiac output and cardiac index were severely depressed at 2.4 L/min and 1.6 L/min/m2. FINAL DIAGNOSIS: 1. Markely elevated right and left sided filling pressures. 2. Severe pulmonary hypertension. Cardiology Report ECHO Study Date of [**2144-2-12**] PATIENT/TEST INFORMATION: Indication: H/O cardiac surgery with a bileaflet AVR. Chronic CHF. Evaluate left ventricular function prior to ICD placement. Height: (in) 67 Weight (lb): 104 BSA (m2): 1.53 m2 BP (mm Hg): 129/51 HR (bpm): 78 Status: Inpatient Date/Time: [**2144-2-12**] at 14:17 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Tape Number: 2005W100-1:17 Test Location: [**Location 11648**]/[**Hospital Ward Name 121**] 6 Technical Quality: Adequate Echo [**2-15**] REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *5.4 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *6.3 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: *6.2 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 10% to 15% (nl >=55%) Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm) Aortic Valve - Peak Velocity: *2.7 m/sec (nl <= 2.0 m/sec) TR Gradient (+ RA = PASP): *38 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Severe global LV hypokinesis. [Intrinsic LV systolic function depressed given the severity of valvular regurgitation.] No LV mass/thrombus. RIGHT VENTRICLE: Mildly dilated RV cavity. RV function depressed. AORTA: Normal aortic root diameter. AORTIC VALVE: BIleaflet aortic valve prosthesis (AVR). Normal AVR leaflets. Increaed AVR gradient. Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate thickening of mitral valve chordae. Moderate (2+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Conclusions: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] No masses or thrombi are seen in the left ventricle. The right ventricular cavity is mildly dilated. Right ventricular systolic function appears depressed. A bileaflet aortic valve prosthesis is present. The prosthetic aortic leaflets appear normal. The transaortic gradient is higher than expected for this type of prosthesis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Compared with the findings of the study (tape reviewed) of [**2142-11-13**], the severity of mitral regurgitation has increased. Otherwise the findings are probably similar. Brief Hospital Course: A/P 73 y.o. female with h/o CRI, htn, hyperlipidemia, chronic AF and s/p mechanical AVR w/single vessel CABG w/VG to OM 92 (s/p stenting of SVG to OM [**2142-11-12**]), hypothyroid, anxiety d/o, anemia who is transferred from OSH for BiV pacer/ICD. Initially ([**2-7**]) presented with decomp CHF and ARF, also went into af with RVR at OSH. * CV: CHF/Pump Upon admission the patient was found to be in decompensated heart failure. After ruling her out for ischemia we attempted to diurese her with IV lasix without success. We checked an echo which was basically unchanged compared to her echo from [**2141**] except that her mitral-regurgitation had worsened. It was thought that her heart failure was such that it would preclude her from being able to lay flat on the table. She was thus transferred to the intensive care unit for tailored therapy. * Ms. [**Known lastname 4401**] was admitted to the cardiac care unit for tailored therapy since she failed to sufficiently diurese on the floor. A swan ganz catheter was placed which revealed high left and right sided pressures with a low CI so she was started on pressors and lasix. She was initially started on dopamine but failed to have improvement in her cardiac output or urine output. Once she was switched to milrinone she diuresed well on a lasix drip. She put out at least 2 liters, following which her creatinine and cardiac output improved. She went from a cardiac output of 3.9 to 5.3 and clinically felt much better. Her ACE I was restarted prior to sending her to the step down unit but her BB was still held. She was also started on digoxin at renal doses to improve her inotropy. She was started on a low dose beta blocker upon arrival to the floor. In light of her baseline hypotension the holding parameters of her antihypertensives were were lowered so that she could receive them * Rhythm: Upon admission Ms. [**Known lastname 4401**] was in atrial fibrillation. We talked with both her cardiologist Dr. [**Last Name (STitle) **] and her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3314**] who reassured us that she had been anticoagulated since being diagnosed with atrial fibrillation approximately 5 years ago. We thus proceed with plans to attempt cardioversion. Upon transfer to the CCU and successful diuresis a biventricular pacer was placed without complications and then she was DC cardioverted. Following these interventions, she was in sinus rhythm overnight, but then went back into atrial fibrillation. She was then started on amiodarone in attempt to promote pharmacological cardioversion. She tolerated the placement of the procedure well without the formation of a hematoma. She was given darvocet prn for pain which she was already taking for her rib fracture. * Ishemia: After ruling out for an MI she was continued on aspirin and a statin. * Acute on chronic renal insufficiency: Of note, Ms. [**Known lastname 4401**] was found to be in acute renal failure, likely secondary to poor cardiac output in addition to renal artery stenosis. Her baseline creatinine was 2.0 but at admit to the CCU her creatinine was 2.3. Once on the milrinone and after aggressive lasix diuresis, her creatinine fell to 1.6. * Hypotension: The patient has very low blood pressure at baseline often asymptomatic with a SBP in the 80s. We lowered the parameters of her beta blocker dosing to enusre that she received those meds. * Anemia The patient was found to be anemic and was transfused 1 unit PRBCs. She continued to receive EPO since a component of her anemia may be secondary to chronic renal insufficiency. She was not deficient in B12 or folate. She was also guiac negative. * Psych: From the psychiatric standpoint, Ms. [**Known lastname 4401**] was thought to have major depression and endorsed passive suicidal ideations and a poor mood. She had self d/c'd an antidepressant a few weeks before. The patient was started on celexa and seen by social work. * Hypothyroidsim: Upon admission her TSH was 7.8 and T4 = 5.4. We increased her dose of synthyroid to 88 mcg qd. * Osteoporosis: She was continued on fosamax, calcium and vitamin D. * Ppx: She was continued on her PPI. She was switched from coumadin to IV heparin and she was then re-started on warfarin for her atrial fibrillation and aortic valve replacement thus she did not receive sub Q heparin. * Disposition: In light of her continued improvement the patient was discharged to a rehab center to continue physical therapy. Medications on Admission: Outpatient meds: ASA 81 mg qd Coumadin Advair Diskus Digoxin 0.125 mg Levoxyl 75 mcg Fosamax Lasix 60 mg qd Lisinopril 2.5 mg qd Lopid 600 mg po qd Mevacor 40 mg qd Toprol 25 mg po qd Quinine for leg cramps prn Meds on transfer: Toprol XL 25 mg 0.5 tablets [**Hospital1 **] Zocor 40 mg po qd Levoxyl 75 mcg Lasix 60 mg IV bid ASA Combivent inhaler Heparin gtt Discharge Disposition: Extended Care Facility: Baypointe - [**Hospital1 1474**] Discharge Diagnosis: 1. severe CHF (EF 10%) 2. moderate Mitral Regurgitation 3. hypothryoidism 4. chronic atrial fibrillation 5. cachexia Discharge Condition: Good, tolerating po intake, sating well on room air without breathing difficulties. Discharge Instructions: Please go to your PCP's office or to the emergency room if you experience shortness of breath, light headedness, dizziness, or chest pain. Please take all of your medications as prescribed. Followup Instructions: 1. Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2144-2-27**] 2:00 2. Please call [**Telephone/Fax (1) 20525**] to make a follow up appointment with Dr. [**Last Name (STitle) **] in three weeks. 3. Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3314**] at [**Telephone/Fax (1) 3183**] for an appointment in 1 week.

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icd9cm

[ [ [] ] ]

[ "37.21", "99.61", "89.64", "00.50" ]

icd9pcs

[ [ [] ] ]

17253, 17312

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354, 487

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8,323

152,145

47471

Discharge summary

report

Admission Date: [**2173-3-23**] Discharge Date: [**2173-3-27**] Date of Birth: [**2109-6-27**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 63 year old male patient with hypertrophic cardiomyopathy referred for ethanol septal ablation on [**2173-3-10**] with initial diagnosis of hypertrophic cardiomyopathy two years prior, status post syncope. He now reports fatigue, dyspnea on exertion, dizzy spells over a two year period. An echocardiogram in [**2173-2-6**] depression. Cardiac cath on [**3-10**] revealed three vessel disease, at which time he was referred for a CABG plus/minus septal myomectomy. Cardiac cath EF 60 percent, proximal LAD 70 percent occlusion, D1 80 percent occlusion, D2 70 percent occlusion, left circumflex 80 percent occlusion and right coronary artery 100 percent occlusion. PAST MEDICAL HISTORY: Past medical history is hyperlipidemia, hypertension, hypertrophic cardiomyopathy, benign prostatic hypertrophy, sleep apnea with a past surgical history of cholecystectomy. MEDICATIONS: Medications on presentation: Norvasc, 5 mg po daily; Atenolol, 100 mg po daily; Paxil, 25 mg po daily; Pravachol, 20 mg po daily; Verapamil, 80 mg tid; Flomax, 0.4 mg po daily; and Pepcid, prn. PHYSICAL EXAMINATION: On presentation height 5 feet 7 inches tall, weight 215 pounds. Vital signs sinus rhythm with a rate of 53. Blood pressure 155/85. Respiratory rate 19. Oxygen saturation 97 percent on room air. General: Sitting up in bed not in acute distress. Neuro: Alert and oriented times three. Appropriate. Moves all extremities. Respiratory: Clear to auscultation, dim at the right base. Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, rubs or gallops. GI: Soft, obese, nontender, non- distended with positive bowel sounds. Extremities: Warm and well perfused without edema or varicosities. LABORATORY DATA: Labs preop white blood cell count 6.5, hematocrit 41.3, platelets 135. PT 13.2, PTT 28.8, INR 1.1. Sodium 144, potassium 3.9, chloride 109, bicarb 31, BUN 17, creatinine 1.1, glucose 126, ALT 20, AST 17, alkaline phosphatase 44, amylase 83, total bili 1.0, albumin 3.8. Preoperative echo showed an EF of 65 percent, left atrium moderately dilated, severe left ventricular hypertrophy, 1 plus MR and trivial pericardial effusion. HOSPITAL COURSE: The patient was admitted on [**2173-3-23**]. He presented to the operating room and underwent a coronary artery bypass graft times four with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2230**] with a limited LAD saphenous vein graft to OM1, saphenous vein graft to OM2 and saphenous vein graft to the RCA with also a septal myomectomy. Total cardiopulmonary bypass time was 117 minutes with a cross clamp time of 88 minutes. He proceeded to the cardiac surgery Recovery Room with a heart rate of 79 that was atrial paced and mean arterial pressure of 82, CVP of 23 on a Neo-Synephrine drip for support. OR course was uneventful, please see OP note for complete details. His initial postoperative course was uneventful with some poor oxygenation ambulatory changes and extubation late in the evening of his operative day. On postoperative day one he was transferred to the inpatient floor for further recovery and rehabilitation. Both chest tubes were found to have air leak, continued on suction and were not discontinued rehabilitation prior to discharge. Postoperative day two continued also somewhat uneventful, with ongoing leak in his chest tube, increased activity with physical therapy consult and ambulation in hallways. On postoperative day three his chest tubes were to air leak to water seal without further leak and were later discontinued. His Lopressor was increased to 50 mg po bid and also his beta blockade was increased for optimal blood pressure and heart rate control. Late in the evening on postoperative day three the patient was noticed to have a short burst of atrial fibrillation to a rate of 150. He was treated with 25 mg of po Lopressor times one with conversion to sinus rhythm and heart rate of 68. On postoperative day four he was cleared by physical therapy found to be safe for home, was doing well medically and was discharged to home. DISCHARGE STATUS: Home with visiting nurses. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass graft times four and myomectomy on [**2173-3-23**]. 2. Hypertrophic cardiomyopathy. 3. Hypertension. DISCHARGE MEDICATIONS: 1. Lasix, 20 mg po bid for 7 days. 2. Potassium chloride, 20 mEq po bid also for 7 days. 3. Colace, 100 mg po bid. 4. Aspirin, 81 mg po daily. 5. Percocet 5/225, 1 to 2 tablets po q4h prn pain. 6. Flomax, 0.4 mg po daily. 7. Pravastatin, 20 mg po daily. 8. Paroxetine, 20 mg po daily. 9. Lopressor, 50 mg po bid. FOLLOW UP PLANS: The patient should call and make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2230**] in four to six weeks, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 100399**] in two to four weeks, and Dr. [**Last Name (STitle) 73320**] within two to four weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2173-3-29**] 15:04:17 T: [**2173-3-29**] 15:58:22 Job#: [**Job Number 100400**]

[ "401.9", "414.01", "518.0", "427.31", "997.1", "425.1", "997.3", "272.4", "780.57" ]

icd9cm

[ [ [] ] ]

[ "36.15", "38.04", "39.61", "37.33", "88.72", "36.13" ]

icd9pcs

[ [ [] ] ]

4332, 4501

4524, 5438

2358, 4311

1275, 2340

165, 844

867, 1252

29,700

107,313

32782

Discharge summary

report

Admission Date: [**2116-2-3**] Discharge Date: [**2116-2-10**] Date of Birth: [**2037-8-17**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: angina and abnormal ETT Major Surgical or Invasive Procedure: OPCABG x3 [**2116-2-3**] (LIMA to LAD, SVG to RAMUS, SVG to LPDA) History of Present Illness: 78 yo male with recent onset of angina and dyspnea with exertion. He also noted increased fatigue. ETT was abnormal and referred for cath. Past Medical History: HTN elev. chol. CRI secondary hyperparathyrodism anemia osteopenia PVD with carotid disease prostatectomy s/p Ca with XRT Social History: light smoker; quit 20 years ago widowed, lives alone Family History: sister had a CABG in her 50's; mother died CVA at 66 Physical Exam: 5'6" 145# (no preop exam completed by cardiac surgical team as pt. came emergently from cath lab to OR table) Pertinent Results: [**2116-2-9**] 06:15AM BLOOD WBC-7.2 RBC-3.05* Hgb-9.8* Hct-27.4* MCV-90 MCH-32.0 MCHC-35.6* RDW-14.3 Plt Ct-249 [**2116-2-10**] 04:30AM BLOOD PT-17.8* INR(PT)-1.6* [**2116-2-9**] 06:15AM BLOOD Plt Ct-249 [**2116-2-9**] 06:15AM BLOOD Glucose-84 UreaN-34* Creat-1.3* Na-144 K-3.6 Cl-104 HCO3-30 AnGap-14 [**2116-2-9**] 06:15AM BLOOD Mg-2.3 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76335**] (Complete) Done [**2116-2-3**] at 2:50:47 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2037-8-17**] Age (years): 78 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Chest pain. Coronary artery disease. Hypertension. ICD-9 Codes: 786.51, 440.0, 441.2, 424.0 Test Information Date/Time: [**2116-2-3**] at 14:50 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Sinus Level: *3.8 cm <= 3.6 cm Aorta - Ascending: *3.9 cm <= 3.4 cm Aortic Valve - Peak Velocity: *5.0 m/sec <= 2.0 m/sec Findings LEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. Dynamic interatrial septum. Aneurysmal interatrial septum. PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV systolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Normal RV systolic function. AORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Calcified tips of papillary muscles. No MS. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is normal in size. No spontaneous echo contrast 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. The interatrial septum is aneurysmal. A trivial patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with anteroseptal and anteroapical hypokinesis. 4. . Right ventricular chamber size and free wall motion are normal. with normal free wall contractility. 5. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Off-pump, transient regional wall motion changes seen, esp with PDA occlusion. SvO2, CCO stable throughout. ST segment elevation with PDA occlusion, normal post reopening. LVEF= 55%. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2116-2-3**] 16:52 RADIOLOGY Preliminary Report CHEST (PORTABLE AP) [**2116-2-9**] 5:21 PM CHEST (PORTABLE AP) Reason: evaluate effusion [**Hospital 93**] MEDICAL CONDITION: 78 year old man with s/p cabg REASON FOR THIS EXAMINATION: evaluate effusion AP CHEST 5:45 P.M. [**2-9**] HISTORY: Status post CABG. IMPRESSION: AP chest compared to [**2-5**] and [**2-7**]: Bilateral pleural effusion, moderate in volume, left greater than right, has improved since [**2-7**] as previous pulmonary and mediastinal vascular congestion have resolved and borderline cardiomegaly improved. Some opacification at the lung bases, particularly the left is attributable to atelectasis, not appreciably changed. No pneumothorax. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] ?????? Brief Hospital Course: Admitted for cath on [**2-3**] and went to OR emergently on IABP and IV dopamine drip after developing angina during unsuccessful PCI. Dr. [**First Name (STitle) **] performed an off-pump cabg x3 and pt. transferred to the CVICU in fair condition. Amiodarone started for Afib and remained in the unit for volume management. IABP removed by cardiology sevice on POD #1. Required levophed support for a couple of days and extubated on [**2-6**]. Chest tubes removed and transferred to the floor on POD #5.Coumadin started for continuing intermittent a fib. Target INR 2.0-2.5. Cleared for discharge to rehab on POD #7. Pt. is to make all follow up appts. as per discharge instructions. Please contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17918**] (PCP) when pt. is ready to be discharged from rehab .He will be following the INR/coumadin dosing. Medications on Admission: ASA 81 mg daily Lipitor 40 mg daily zetia 10 mg daily diovan 320 mg daily atenolol 12.5 mg daily amlodipine 2.5 mg daily iron 65 mg daily omeprazole 20 mg daily procrit injection every 4-6 weeks SL NTG prn Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for off pump cabg. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 2 days: 400 mg [**Hospital1 **] until [**2-12**]; then 400 mg daily until [**2-19**], then 200 mg daily. 8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 9. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours): hold for K > 4.5. 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO today [**2-10**] only as needed for afib: [**2-10**] only, then daily dosing per rehab provider. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: s/p off pump cabg (OPCABG) postop A fib CAD HTN CRI secondary hyperparathyroidsim carotid artery disease osteopenia anemia prostate cancer s/p radical prostatectomy and XRT GERD intermittent urinary incontinence Discharge Condition: stable Discharge Instructions: no lifting greater than 10 pounds for 10 weeks no driving for one month no lotions, creams, or powders on any incision call for fever greater than 100.5, redness or drainage SHOWER daily and pat incisions dry target INR 2.0-2.5 for A fib- contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17918**] (PCP) [**Telephone/Fax (1) 17919**] when pt. is ready to be discharged. He will be following coumadin dosing/INR. Followup Instructions: see Dr. [**Last Name (STitle) 17918**] in [**1-8**] weeks see Dr. [**Last Name (STitle) 7047**] in [**2-9**] weeks see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2116-2-10**]

[ "411.1", "V10.46", "733.90", "585.9", "276.2", "788.30", "E878.2", "403.90", "998.11", "530.81", "785.51", "414.01", "518.81", "998.2", "433.10", "997.1", "588.81", "427.31", "285.21" ]

icd9cm

[ [ [] ] ]

[ "99.04", "36.12", "88.55", "99.05", "88.53", "36.15", "37.61", "37.22", "99.20", "00.17" ]

icd9pcs

[ [ [] ] ]

9473, 9540

6968, 7842

343, 413

9796, 9805

1016, 4404

10290, 10603

813, 867

8099, 9450

6221, 6251

9561, 9775

7868, 8076

9829, 10267

4453, 6184

882, 997

280, 305

6280, 6945

441, 581

603, 726

742, 797

16,650

176,541

30420

Discharge summary

report

Admission Date: [**2122-2-20**] Discharge Date: [**2122-2-23**] Date of Birth: [**2062-1-10**] Sex: M Service: SURGERY Allergies: Mirtazapine Attending:[**First Name3 (LF) 4691**] Chief Complaint: multiple self inflicted stab wounds Major Surgical or Invasive Procedure: Closure of stab wounds History of Present Illness: Patient was found in a park, non verbal at the scene after self inflicted stab wounds to L chest x 4. Past Medical History: Depression, SI, SA x2 DM2, HTN Social History: Depression, quit/lost job 2 years ago after a divorce, lost health insurance afterwards; multipl suicide attempts Family History: non contributory Physical Exam: HEENT: WNL CV: RRR no MRG CHEST: Wounds closed with interrupted sutures, no hematoma, mild ecchymoses RESP: lungs CTA b/l no RRW ABD: soft, NT, ND, no masses, +BS EXT: no CCE Pertinent Results: [**2122-2-21**] 04:18AM BLOOD WBC-5.4 RBC-3.08* Hgb-8.7* Hct-24.9* MCV-81* MCH-28.2 MCHC-34.7 RDW-15.4 Plt Ct-227 [**2122-2-21**] 04:18AM BLOOD Plt Ct-227 [**2122-2-20**] 04:05PM BLOOD Fibrino-217 [**2122-2-21**] 04:18AM BLOOD Glucose-160* UreaN-10 Creat-0.9 Na-141 K-3.5 Cl-108 HCO3-24 AnGap-13 [**2122-2-20**] 04:05PM BLOOD Amylase-17 [**2122-2-21**] 04:18AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.4 [**2122-2-20**] 04:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: Patient seen in ED where U/S and CT studies confirmed all wounds were superficial to deep structures. Initially 0-silk sutures were placed in chest wounds to control hematoma. On Day 2 these were removed and deep monocryl and superficial nylon sutures were placed. Patient was seen by psychiatry who deemed him section 12 and requiring of psychiatric hospitaliztion. Patient was kept on a 1:1 sitter as a precaution for his own safety until a psychiatric bed could obtained. Please monitor for wound infection. Patient was kept on surgical floor with 1:1 sitter through weekend because of psychiatric team's concern of hematocrit, however HCT was deemed to be stable and on HD4 he was cleared for discharge to psychiatric bed. Medications on Admission: not taking diabetes or HTN control meds in > 2 years Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital1 **] 4 Discharge Diagnosis: multiple left chest stab wounds Discharge Condition: stable medically, needs psychiatric evaluation Discharge Instructions: Return to ER if: - persistent temperature > 101.4 - severe nausea, vomiting or diarrhea - severe chest pain - bleeding or pus from wounds Followup Instructions: Dr. [**Last Name (STitle) **] - call for appointment for 7 days for suture removal.

[ "V62.84", "E956", "875.0", "250.00", "401.9", "311" ]

icd9cm

[ [ [] ] ]

[ "34.71" ]

icd9pcs

[ [ [] ] ]

2584, 2784

1410, 2138

307, 332

2860, 2909

892, 1387

3095, 3182

664, 682

2241, 2561

2805, 2839

2164, 2218

2933, 3072

697, 873

232, 269

360, 463

485, 517

533, 648

81,154

193,294

7820

Discharge summary

report

Admission Date: [**2184-9-15**] Discharge Date: [**2184-10-7**] Date of Birth: [**2115-11-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: Weakness Major Surgical or Invasive Procedure: NA History of Present Illness: Mr. [**Known lastname 28253**] is a very pleasant 68 year old man with past medical history significant for stage III, squamous cell carcinoma of the oropharynx, he is status post radiation with IMRT and six weeks of Erbitux in [**2184-5-31**]. He has a G-tube in place for progressive dysphagia. He now presents with weakness, difficulty ambulating, and dehydration. He reports weakness, but denies, fever, chills, nausea, vomiting, chest pain, oropharyngeal pain, stridro, abdominal pain, focal weakness. ROS otherwise negative. Past Medical History: Hypertension CVA- "small strokes," Exploratory laparatomy about 20 yrs ago for incarcerated hernia Social History: Previous gas station maintenance worker, 40 pack-yr history of smoking and current smoker, drank 2-3 beers a day before the dysphagia started. Family History: Noncontributory. Physical Exam: Vital Signs: Stable General: NAD HEENT: Sclera anicteric, tongue slightly protruding, firm radiation changes anterior/right neck. Gurgling sounds with breathing, but does not appear to bother him. HEART: Regular without murmurs. LUNGS: Clear to auscultation and percussion. ABD: Soft, nondistended, PEG-tube site is clean dry and intact. SKIN: Warm and dry without rashes. EXTREMITIES: Warm. Psych: Alert and oriented with normal affect. Pertinent Results: [**2184-9-15**] 03:00PM GLUCOSE-137* UREA N-13 CREAT-0.5 SODIUM-119* POTASSIUM-3.0* CHLORIDE-71* TOTAL CO2-33* ANION GAP-18 [**2184-9-15**] 03:00PM estGFR-Using this [**2184-9-15**] 03:00PM CALCIUM-9.5 PHOSPHATE-4.0 MAGNESIUM-1.8 [**2184-9-15**] 03:00PM WBC-13.0*# RBC-3.62* HGB-10.3* HCT-29.8* MCV-82 MCH-28.5 MCHC-34.6 RDW-13.8 [**2184-9-15**] 03:00PM NEUTS-89.0* LYMPHS-4.7* MONOS-5.1 EOS-0.8 BASOS-0.3 [**2184-9-15**] 03:00PM PLT COUNT-434 . . . IMAGING . HEAD AND NECK PET-CT [**9-15**]: . RADIOPHARMACEUTICAL DATA: 12.1 mCi F-18 FDG ([**2184-9-15**]); ***************** AMENDED REPORT ***************** . INDICATION:68 year old male with history of stage III squamous cell carcinoma presenting as a right oropharyngeal mass. He is s/p radiation therapy and therapy with cetuximab. . METHODS: Approximately 1 hour after intravenous administration of F-18 fluorodeoxyglucose (FDG), noncontrast CT images were obtained for attenuation correction and for fusion with emission PET images. [The noncontrast CT images are not used to diagnose disease independently of the PET images.] A series of overlapping emission PET images was then obtained. The fasting blood glucose level, measured by glucometer before injection of FDG, was 139 mg/dL. . The area imaged spanned the region from the head to the thighs. Computed tomography (CT) images were co-registered and fused with emission PET images to assist with the anatomic localization of tracer uptake. The determination of the site of tracer uptake seen on PET data can have important implications regarding the significance of that uptake. . INTERPRETATION: Comparison is made to PET/CT of [**2184-4-29**]. . HEAD/NECK: The right oropharyngeal mass extending from the hypophyarynx to the cricoid cartilage seen in the PET/CT dated [**2184-4-29**] is seen again. The FDG-avidity of the mass has decreased since the last scan. The SUVmax today is 7.9 when compared to 16.3 last time. The mass continues to extend past the midline to the left. The craniocaudal extension is still unclear. The left level IIb node seen on the prior study is no longer seen and there is no new nodal involvement. There is low level FDG-avidity of the muscles and soft tissue in the posterior part of the neck and also in the base of the neck which is most likely secondary to radiation therapy (Images 57-62). There is no abnormal FDG-avid focus in the head. . CHEST: There is no FDG-avid mediastinal, hilar or axillary lymphadenopathy. The right upper lobe nodule described in the last PET/CT is stable. There is a new ground glass opacity in the periphery of the right upper lobe and may be secondary to infection, follow up is recommended (Image 73). This is non-FDG-avid. The 2 mm right middle lobe nodule is stable(Image 80). The left lower lobe opacity is seen again and continues to be non-FDG-avid. It currently measures 10.4mm x 11.1mm. . ABDOMEN/PELVIS: There is no abnormal hepatic, splenic or adrenal gland FDG uptake. There is no FDG-avid abdominopelvic lymphadenopathy. There is physiologic tracer accumulation in the gastrointestinal and genitourinary tracts. The focal FDG-avid lesion in the redundant sigmoid colon is not seen today. The FDG-avidity seen in the left scrotum has also resolved.The focal FDG uptake in the right upper quadrant is also not seen today. Contrast is seen in the kidney and the bowel. . MUSCULOSKELETAL:There are non-FDG-avid degenerative changes in the thoracolumbar spine. There is no FDG-avid or destructive bone lesion. The focal FDG-avid lesion described in the iliopsoas tendon anterior to the neck of the left femur has resolved though the hypodense CT correlate is persistent further reinforcing an infective etiology. . Physiologic uptake is seen in the brain, myocardium, salivary glands, GI and GU tracts, liver and spleen. . IMPRESSION: 1. Interval decrease in FDG-avidity of the right oropharyngeal mass. No new FDG-avid lymphadenopathy. The left level II lymph node is not apparent anymore. 2. Stable right upper lobe, right middle lobe nodules. Stable left lower lobe opacity. Resolution of the focal FDG-avidity in the right lower lobe. 3. Resolution of the FDG-avid focus in the sigmoid colon and in the left iliopsoas tendon. . . ECHOCARDIOGRAM [**9-30**] The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis (LVEF = 40%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There is no aortic valve stenosis. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Mild global biventricular systolic dysfunction. Mild mitral regurgitation. . CHEST X-RAY [**10-3**] HISTORY: Throat cancer. Recent tracheostomy. Poor respiratory status. IMPRESSION: AP chest compared to [**10-2**], most recently 4:34 p.m.: Volume loss in the left lower lobe has improved, revealing new consolidation, probably pneumonia. Heart size is normal, pulmonary vasculature is mildly engorged, but there is no pulmonary edema. Tracheostomy tube in standard placement. No mediastinal widening or pneumothorax. . . Brief Hospital Course: [**Hospital Unit Name 153**] course: 68 yo M with PMH of stage III squamous cell throat CA admitted for weakness and dehydration. . He was initially admitted to the oncology floor. However, he was soon transferred from the oncology service to the [**Hospital Ward Name 332**] ICU (combined medical/surgical ICU, with medical team managing Mr. [**Known lastname 28253**]) for hypoxia. . His course, primarily in the ICU, is summarized by issue: . # Hypoxia and respiratory failure, secondary to pneumonia: He was originally admitted to the oncology service and there became hypoxic. When the patient was on the floor, his ABG on 50% FiO2 was 7.51/30/65 when satting 92%. Patient was transferred to ICU on [**9-16**] for hypoxia and respiratory distress. When patient arrived on [**Hospital Unit Name 153**], he was satting at 95-100% on 50% FiO2. This respiratory distress was most likely from right middle lobe PNA seen on CXR, although he did have a high BNP and heart failure may have contributed acutely. He had thick, fluorescent green mucous in oropharynx which was foul smelling, making pseudomonas possible. . MSSA grew out of his sputum on a sample from [**9-18**]. GNRs had been seen on sputum gram stain from this same sample. Broad coverage was continued. . As the admission continued, and other etiologies appeared less likely (i.e., PE, CHF), pneumonia was thought to be the main precipitant of his respiratory failure, in conjunction with patient difficulty in defending his airway because of his distorted throat anatomy; he lacked a gag and had a weak cough. Mr. [**Known lastname 28253**] was initially double covered for pseudomonas with cefepime and cipro, but later the antibiotics were changed to vancomycin, cefepime, flagyl and levofloxacin for coverage of GPCs in sputum; anaerobes from aspiration; and double coverage for pseudomonas. . On the night of [**9-17**], he became more and more tachypneic and was tiring with increasing work of breathing, and ABG showed worsening hypoxia, so we intubated Mr. [**Known lastname 28253**]; this intubation was somewhat difficult per report of anesthesia, with requirement for fiber optic visualization to successfully complete the intubation. His subsequent intubation pre-tracheostomy was done in the OR and difficult anatomy was again visualized. . He was ultimately extubated after some difficulty with cuff leak; after steroids were administered he had a cuff leak and was extubated. He continued to have difficulty with work of breathing due to copious secretions and likely also due to unusual throat anatomy. A mechanical insufflator-exsufflator was used frequently to help with secretions because of his difficulty with coughing; this was helpful but he continued to have significant difficulty with secretions. ENT was consulted and saw thick crusted dry mucus throughout his larynx and coating the area around his vocal cords and trachea. This was removed by ENT via laryngoscopy and he had a brief clinical improvement with an impressive ease of breathing, but within a day, he again had greatly increased work of breathing with upper airway sounds consistent with high degree of secretions which he appeared unable to clear. . After discussion with the patient and his wife, a tracheotomy was performed and trach tube put in place on [**10-2**]. A tortuous and unusual anatomy was appreciated by the ENT service who performed this, assumed to be secondary to his cancer and to radiation and chemotherapy to treat it. His work of breathing immediately decreased significantly. He will require ENT follow-up from Dr. [**Last Name (STitle) 28254**]. . His antibiotic course during the hospitalization for pneumonias was as follows: [**9-16**]: vancomycin and cefepime started for initial coverage of pneumonia. [**9-18**]: levofloxacin and flagyl were started for double coverage of pseudomonas, and increased coverage of anaerobes. [**9-22**]: flagyl was stopped. [**9-24**]: vancomycin and cefepime course completed. [**9-25**]: levofloxacin was completed. [**10-2**]: Cefazolin x3 doses in 24 hours peri-operatively for trach placement, per ENT recommendations. [**10-3**]: With increased sputum, new opacity, leukocytosis and fever, we started vancomycin, cefepime, ciprofloxacin, flagyl. [**10-4**]: Stopped cefepime, flagyl, cipro; vancomycin was continued for GPCs ultimately shown to be MRSA in his sputum. This will be continued after discharge to rehab, as described below. . # Hyponatremia: His sodium was 119 on admission and on repeat. Urine lytes were initially potentially consistent with SIADH. However, with ongoing care and volume repletion, this ultimately resolved after the first few days of his admission and has not been an issue since then. Given the resolution this was unlikely to be related to his oncologic history, and may either have been hypovolemia and renal dysfunction, or transient SIADH associated with his pneumonia. His home hydrochlorothiazide was not restarted. . # Stage III Squamous Cell Throat CA: Mr. [**Known lastname 28253**] is followed as an outpatient, and was seen as an inpatient, by Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **], of [**Hospital1 18**] oncology. He is s/p XRT and cetuximab, last dose [**2184-6-21**]. Surgery has thus far been deferred, consistent with current standards of care for SCC of the throat which at least initially avoids surgery while assessing response to chemotherapy and radiation. He will continue to be followed by Dr. [**First Name (STitle) **]. Follow-up is being arranged with Dr.[**Name (NI) 11574**] office for approximately a month after hospital discharge; this should be kept even if he is still in a rehabilitation facility. Additionally, he needs a PET-CT to be performed before this visit, and again, this must be scheduled even if he is still in a rehabilitation facility. . Swallowing and effective cough remain difficult for Mr. [**Known lastname 28253**]. He has a G-tube in place for feeding. His need for help with secretions decreased somewhat with trach tube but he does continue to need suctioning. . # Chronic systolic heart failure An echocardiogram was performed on [**9-30**], with results above, showing a mild decrease in systolic heart function from prior. He had an elevated BNP on arrival, and likely CHF contributed to his hypoxia which was primarily secondary to pneumonia. Hypertension was treated as below. Daily lisinopril was started. One-time doses of lasix were given at various times to remove volume in order to improve his respiratory status. . # Hypertension: Anti-hypertensives were initially stopped in the setting of his acute illness. He later had hypertension, and was initially treated with hydralazine and then had beta-blocker restarted. In the hospital this was metoprolol for shorter-acting and more flexible dosing, replacing his home atenolol dose. He was also started on lisinopril 5 mg daily. Hydrochlorothiazide, one of his home medications, was not restarted; his blood pressure was in good control in the latter part of his admission. . # H/O CVA: Per notes, he has had a history of 'small strokes'. We did not observe clear residual deficits. We did not observe new deficits. We continued ASA 325mg daily. . # Prophylaxis: Subutaneous heparin . # Access: peripherals; PICC placed on day of discharge. . # Code: Full - OMED team discussed with patient and family. . # Communication: Patient, wife [**Name (NI) 335**] [**Name (NI) 28253**]. Medications on Admission: Atenolol 100 mg QD Hydrochlorothiazide 25 mg QD Aspirin 325 mg Tablet QD Discharge Medications: 1. Aspirin 325 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY (Daily). 2. Ipratropium Bromide 0.02 % Solution [**Name (NI) **]: One (1) Inhalation Q6H (every 6 hours). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Name (NI) **]: One (1) Inhalation Q6H (every 6 hours). 4. Atenolol 50 mg Tablet [**Name (NI) **]: Two (2) Tablet PO QHS (once a day (at bedtime)). 5. Sodium Chloride 0.65 % Aerosol, Spray [**Name (NI) **]: [**1-2**] Sprays Nasal QID (4 times a day) as needed for dry mouth/nose. 6. Phenol 1.4 % Aerosol, Spray [**Month/Day (2) **]: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed for pain. 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Month/Day (2) **]: One (1) treatment Inhalation Q4H (every 4 hours) as needed for SOB, Wheezing. 8. Petrolatum Ointment [**Month/Day (2) **]: One (1) Appl Topical TID (3 times a day) as needed for dry lips. 9. Oxycodone 5 mg/5 mL Solution [**Month/Day (2) **]: Five (5) mg PO Q4H (every 4 hours) as needed for pain . 10. Lisinopril 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 11. Acetaminophen 160 mg/5 mL Solution [**Month/Day (2) **]: 325-650 mg PO Q4H (every 4 hours) as needed for pain. 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 13. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Last Name (STitle) **]: Five (5) ML PO DAILY (Daily). 14. Vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: 1000 (1000) MG Intravenous every twelve (12) hours for 19 doses: Antibiotic treatment to end on [**2184-10-16**]. 15. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: One Hundred (100) mg PO BID (2 times a day) as needed for constipation. 16. Senna 8.8 mg/5 mL Syrup [**Date Range **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 17. Insulin Lispro 100 unit/mL Solution [**Date Range **]: One (1) Subcutaneous ASDIR (AS DIRECTED): Please see attached humalog sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: 1. Pneumonia 2. Respiratory Failure 3. Post-radiation laryngeal anatomical changes Secondary: -Stage III throat cancer -Hypertension Discharge Condition: At the time of discharge patient's tracheostomy had been changed, he was breathing comfortably on trach collar, he had a PICC placed for antibiotic administration, was afebrile with stable vital signs, tolerating his tube feeds at goal and considered medically stable for discharge to pulmonary rehab. Discharge Instructions: You were admitted to the hospital for weakness and dehydration; you were soon diagnosed with pneumonia. You were initially treated with anti-biotics. However, your breathing worsened, you were transferred to the ICU and ultimately intubated to help with your breathing. After further antibiotic treatment your breathing improved and you were able to be successfully extubated. . Even though your infection resolved, you were still having trouble breathing due to the changes in your throat from the cancer and radiation. Again your breathing worsened, so the ENT doctors came to [**Name5 (PTitle) 788**] you and recommended a tracheostomy to help you breath more easily. On [**2184-10-2**] the ENT doctors took [**Name5 (PTitle) **] to the operating room and placed a tracheostomy in your neck; after the procedure your breathing improved considerably. Five days after the trach placement, they changed the tracheostomy to a smaller size, which should help you speak more easily. Speech and swallow came to see you as well, to help you learn how to speak with a valve over the tracheostomy. . Additionally, on [**2184-10-3**] we found that you had a new pneumonia, in the left lower lobe of your lungs. Your sputum culture showed that your infection, was with a type of bacteria called MRSA. As a result you needed to have PICC line (which is a special type of IV) placed to complete 14 days of antibiotic treatment with vancomycin. Your antibiotic course will end on [**2184-10-16**]. At the time of discharge you were able to go to [**Hospital6 **] to help build up your strength before you go home. . Changes made to your medication regimen: 1. Added Vancomycin 1g every 12 hours to finish on [**2184-10-16**] 2. Added Lisinopril 5mg daily to help with your blood pressure 3. Stopped Hydrochlorothiazide 25mg daily because you had some low sodium levels. **Continue to take all other medication as previously prescribed. . Once discharged from rehab, make an appointment with your primary care provider for one week after discharge. Once discharged, please call your doctor or return to the hospital if you have difficulty breathing, fever or chills, have difficulty coughing or controlling your secretions, trouble swallowing, chest pain or any other concerning symptoms. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 1837**] for care of your tracheostomy, your appointment is: MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] Specialty: Otolaryngology Date and time: Friday [**2184-10-22**] at 10:40 AM Location: [**Hospital1 18**] [**Hospital Ward Name 517**] [**Hospital **] Medical Office Building [**Last Name (NamePattern1) 12939**], [**Location (un) 86**], MA Phone number: ([**Telephone/Fax (1) 21740**] . You should also follow up with Dr. [**First Name (STitle) **], your oncologist, your appointment is: MD: Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **] Specialty: Oncology Date and time: Friday [**2184-11-5**] at 11:00 Location: [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital1 28255**] [**Hospital Ward Name 23**] Building [**Location (un) 24**] Phone number: ([**Telephone/Fax (1) 694**] . 2-5 days prior to this appointment, you should get a PET-CT performed. This will be ordered by Dr. [**First Name (STitle) **]. It can be scheduled for convenience of transport by your rehabilitation facility by calling ([**Telephone/Fax (1) 6713**]. . You should also make an appointment to follow up with your Primary Care Provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7790**], after discharge from rehab. Please call the office at [**Telephone/Fax (1) 1579**] to make an appointment. Currently, there is an appointment scheduled as follows, but if he is not be discharged soon, this should be rescheduled: Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2184-10-19**] 8:50 .

[ "V58.66", "428.22", "518.81", "482.42", "799.02", "428.0", "401.9", "149.0", "276.1", "V44.1", "E879.2" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

16619, 16698

6910, 14403

325, 329

16884, 17188

1682, 6886

19520, 21204

1190, 1208

14530, 16596

16719, 16863

14429, 14507

17212, 19497

1223, 1663

277, 287

357, 890

912, 1013

1029, 1174

55,017

137,488

44662+58733

Discharge summary

report+addendum

Admission Date: [**2188-3-27**] Discharge Date: [**2188-4-1**] Date of Birth: [**2127-8-18**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: exertional chest pain Major Surgical or Invasive Procedure: [**2188-3-28**] 1. Coronary bypass grafting x4 with left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to the first obtuse marginal coronary; reverse saphenous vein single graft from aorta to the ramus intermedius coronary artery; reverse saphenous vein graft from the aorta to the first diagonal coronary artery;. 2. Endoscopic left greater saphenous vein harvesting. [**2188-3-27**] Cardiac catheterization and coronary angiography History of Present Illness: 60 year old male with a history of hyperlipidemia who has been experiencing angina for the past two years. He had a + stress test in [**2187-8-2**] and was treated with medications and diet change. Patient continues to experience exertional angina. He states the chest pressure will occur with any type of exertion radiating to his neck. The discomfort will subside within 3 minutes of resting. He was found to have coronary artery disease upon cardiac catheterization. He is now being referred to cardiac surgery for revascularization. Past Medical History: CAD Angina Dyslipidemia Anxiety . Past Surgical History: s/p anal banding s/p Tonsillectomy Social History: Lives with: wife and son Occupation: works for the [**Name (NI) 745**] [**Last Name (NamePattern1) **] Schools Tobacco: negative ETOH: one glass of wine or beer daily Family History: Father had a CABG x6 at the age of 71 Physical Exam: VS: T 98.5 BP 135/83 P 74 RR 18 99 RA wt 89.3 kg GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, no apparent JVD CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2188-4-1**] 04:45AM BLOOD WBC-7.6 RBC-2.79* Hgb-9.3* Hct-25.5* MCV-91 MCH-33.4* MCHC-36.6* RDW-12.4 Plt Ct-186 [**2188-3-31**] 06:10AM BLOOD WBC-10.8 RBC-3.12* Hgb-10.0* Hct-28.4* MCV-91 MCH-31.9 MCHC-35.0 RDW-12.8 Plt Ct-162 [**2188-4-1**] 04:45AM BLOOD Glucose-118* UreaN-12 Creat-0.8 Na-135 K-3.8 Cl-98 HCO3-28 AnGap-13 [**2188-3-31**] 06:10AM BLOOD Glucose-103* UreaN-11 Creat-0.9 Na-135 K-3.7 Cl-97 HCO3-28 AnGap-14 Intra-op TEE [**2188-3-28**] Conclusions PREBYPASS 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. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. POSTBYPASS There is preserved biventricular sustolic function. The study is otherwise unchanged from the prebypass period. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2188-3-28**] 11:59 Brief Hospital Course: The patient was brought to the operating room on [**2188-3-28**] where the patient underwent CABG x 4 with Dr. [**Last Name (STitle) 914**]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: ZELASTINE [ASTELIN] - 137 mcg Aerosol, Spray - 2 sprays intranasally twice daily - No Substitution DILTIAZEM HCL [DILTIA XT] - 240 mg Capsule,Ext Release Degradable - 1 Capsule(s) by mouth daily ISOSORBIDE MONONITRATE [IMDUR] - 30 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth in AM NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s) sublingually q 5 minutes as needed for chest pain ROSUVASTATIN [CRESTOR] - 20 mg Tablet - 1 Tablet(s) by mouth daily . Medications - OTC ASCORBIC ACID - (Prescribed by Other Provider) - 1,000 mg Tablet - two Tablet(s) by mouth dailu ASPIRIN - 81 mg Tablet, Chewable - one Tablet(s) by mouth daily MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by Other Provider) - Tablet - one Tablet(s) by mouth daily OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider) - 1,000 mg Capsule - 1 Capsule(s) by mouth once a day VITAMIN E - (Prescribed by Other Provider) - 400 unit Capsule - one Capsule(s) by mouth daily Discharge Medications: 1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. Disp:*10 Tablet(s)* Refills:*0* 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 7. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 1 weeks. Disp:*14 Tablet Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: CAD Angina Hyperlipidemia Anxiety Past Surgical History: s/p anal banding s/p Tonsillectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema- trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2188-4-22**] 1:00 Cardiologist Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2188-5-2**] 10:40 Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) 2400**],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 133**] in [**5-6**] 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:[**2188-4-1**] Name: [**Known lastname 15128**],[**Known firstname **] M Unit No: [**Numeric Identifier 15129**] Admission Date: [**2188-3-27**] Discharge Date: [**2188-4-1**] Date of Birth: [**2127-8-18**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1543**] Addendum: Medication changes: Percocet changed to Oxycodone as patient c/o "sweats" with Percocet. Albuterol inhaler added. Discharge Medications: 1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 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. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. Disp:*10 Tablet(s)* Refills:*0* 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 6. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 1 weeks. Disp:*14 Tablet Extended Release(s)* Refills:*0* 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation four times a day: 2 puffs QID prn wheezing, SOB. Disp:*qs * Refills:*2* 8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) 102**] [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2188-4-1**]

[ "300.00", "272.4", "414.01", "413.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10350, 10586

3926, 4995

330, 854

7119, 7289

2538, 3903

8077, 9198

1737, 1776

9337, 10327

7004, 7038

5021, 6005

7313, 8054

7061, 7098

1791, 2519

9218, 9314

269, 292

882, 1422

1444, 1478

1553, 1721

64,580

110,362

38760

Discharge summary

report

Admission Date: [**2107-1-2**] Discharge Date: [**2107-1-22**] Date of Birth: [**2081-7-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5893**] Chief Complaint: hyperglycemia Major Surgical or Invasive Procedure: fiberoptic intubation, IR-guided central line placement, IR-guided PICC placement History of Present Illness: Patient is a 25 yo M with PMHx sig. for microcephaly/cerebral palsy and is non-verbal and severely contracted at baseline who presents with lethargy and was found to be in DKA at OSH. Per his mother, he developed a fever to [**Age over 90 **] yesterday. His grandmother, who also cares for him, recently had a cough treated with 5 day course of antibiotics. However, the patient never developed a cough; he may have looked a little more short of breath today. Throughout the day today, he did became increasingly lethargic, though he completed eating his breakfast and lunch without problems. His mother felt that he was not responding as well to her voice, ie smiling or looking at her. His limbs were also more flaccid than at baseline. In addition, she noticed that his eyes were twitching, which has occurred in the past with fevers. They were also bloodshot. His mother noticed that he has been urinating more and drooling less. She denied any vomiting, diarrhea. He has had H1N1 already in [**Month (only) **]. He also had a cough, treated with amoxicillin, in [**Month (only) 1096**]. He usually gets over these episodes rather quickly. . He was taken to [**Hospital3 **], where VS were rectal temp of 100.5, SBP 95, hyperglycemia to 1392, Na 162, and Cr 2.2. He was given CTX there for UTI despite a U/A with neg nitrite, leuk est. He was not given insulin. CT head at OSH reports no acute pathology. . In the ED, vital signs were initially: 97.0, 98, 117/79, 18, 98%. Exam was sig. for slight rhonchi on the right. Labs were sig. for glucose of 1208, Na 170, Cl 128, creatinine 2.6, HCT of 61, lactate 3.1. U/A showed ketones. CXR showed no infiltrate. BCxs, UCx were obtained. He is receiving NS 100 cc/hr. He was not started on insulin gtt. VS on transfer: 99, 117/87, 16, 100% on 2L. Past Medical History: Microcephaly/Cerebral Palsy Kyphosis s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 47817**] rod Social History: Pt lives with his parents. He goes to a day program from 9AM -3PM. His grandmother also cares for him. He is wheelchair bound. He is fed pureed foods and Ensure once a day. Family History: Both parents are healthy. No history of heart disease, DM. Aunt with epilepsy Physical Exam: Temp:97.0 HR:98 BP:117/79 Resp:18 O(2)Sat:98 GEN: The patient is in no distress and appears comfortable. NECK: Supple. No lymphadenopathy in cervical, posterior, or supraclavicular chains noted. HEENT: L pupil 2 mm larger than R, both reactive. Erratic nystagmus. MM dry. CHEST: Lungs are clear without wheeze, rales, or rhonchi. CARDIAC: Regular rhythm; no murmurs, rubs, or gallops. ABDOMEN: Normoactive BS, soft, NT, ND. EXTREMITIES: no peripheral edema, warm. NEUROLOGIC: Alert. Wrists, elbows bilaterally flexed. Increased tone in shoulder joint, less in elbow joint bilaterally. SKIN: There is a maculopapular rash on the back, which the mother states is his usual rash on dependent areas. Erythematous rash on R groin. Pertinent Results: RIGHT UPPER QUADRANT ULTRASOUND [**1-3**]: There is limited assessment, particularly in the midline, due to overlying bowel gas. Where visualized, the liver demonstrates no focal or echotexture architecture abnormality. Main portal vein is patent with normal hepatopetal flow. No intra- or extra-hepatic biliary ductal dilatation is noted, with the common duct measuring 3 mm. The gallbladder is filled with echogenic shadowing stones. No evidence for gallbladder wall thickening or pericholecystic fluid is seen to suggest acute cholecystitis. The patient is nonresponsive, therefore [**Doctor Last Name 515**] sign cannot be assessed. No ascites is seen in the right upper quadrant. IMPRESSION: Cholelithiasis, without findings of acute cholecystitis. CT CHEST/ABD/PELVIS [**1-5**]: 1. Bibasilar areas of consolidation and peribronchovascular ground-glass opacities, probably representing combination of atelectasis with possible aspiration, inflammation, and/or infection. Trace right pleural effusion. 2. Patulous and edematous distal esophagus with circumferential wall thickening and intraluminal fluid, may represent esophagitis, clinical correlation recommended. 3. Nearly diffuse small and large bowel wall thickening and hyperenhancement consistent with enteritis/colitis, such as infectious/inflammatory, less likely ischemic. Appendix not visualized. No bowel obstruction seen. 4. Area of hypoattenuation within the right hepatic lobe has somewhat rounded appearance but has vessels coursing through it, suggestive of perfusion heterogeneity or focal fatty infiltration. CT SINUS [**1-5**]: 1. Diffuse mild mucosal thickening with layering high-density fluid seen throughout the paranasal sinuses. Fungal colonization is not excluded, nor is infection. 2. Area of demineralization along the superior aspect of the medial right maxillary sinus wall. 3. Opacification of the [**Last Name (un) **]- and oropharynx, with ET tube and NG tube in place. 4. Partial opacification of the visualized right mastoid air cells. 5. Marked ventriculomegaly with very thin cerebral cortex, incompletely visualized on the current study. ECHO [**1-10**] The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. CT CHEST/ABDOMEN/PELVIS [**1-12**]: 1. Extensive right lung and left lower lobe consolidations with air bronchograms are new compared to two days prior, with increased left greater than right small pleural effusions. 2. Foley balloon catheter located within the urinary bladder. There is new diffuse anasarca with slight increase in small ascites. No definite findings to account for increased abdominal pressure otherwise. 3. While small bowel loops which are better distended today show no wall thickening, there is apparent persistent wall thickening along the ascending and descending colon, representing non-specific colitis. 4. Patulous esophagus with circumferential wall thickening, again possibly representing esophagitis. Intraluminal fluid extends to the thoracic inlet, increasing risk for aspiration. 5. Rounded peripheral hypodense region in the right hepatic lobe re-demonstrated on non-contrast study, probably representing focal fatty infiltration. CXR [**1-22**]: One supine view. Comparison with the previous study done [**2107-1-21**]. Bilateral interstitial infiltrates consistent with edema persist. Mediastinal structures are unchanged. These are partially obscured by bilateral [**Location (un) 931**] rods. An endotracheal tube, nasogastric tube and PICC line remain in place. All of these are somewhat obscured by orthopedic hardware but appear unchanged. IMPRESSION: Limited study demonstrating persistent bilateral interstitial infiltrates consistent with edema. MICRO: All cultures from admission through [**1-12**] negative, including flu, RSV, urine, stool and sputum. Sputum did grow yeast. [**2107-1-13**] 8:18 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2107-1-15**]** GRAM STAIN (Final [**2107-1-13**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2107-1-15**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM------------- 2 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S [**2107-1-17**] 2:35 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2107-1-17**]): [**9-26**] PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2107-1-19**]): Commensal Respiratory Flora Absent. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE GROWTH. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 86088**] ([**2107-1-15**]). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA | TRIMETHOPRIM/SULFA---- <=1 S FUNGAL CULTURE (Preliminary): YEAST. Test Result Reference Range/Units ASPERGILLUS ANTIGEN 0.2 <0.5 Test ---- Fungitell (tm) Assay for (1,3)-B-D-Glucans Results Reference Ranges ------- ---------------- >500 pg/mL * Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL ADMISSION LABS: [**2107-1-2**] 170 / 128 / 57 --------------< 1208 3.9 / 22 / 2.6 CK: 530 MB: 3 Trop-T: 0.04 Ca: 8.9 Mg: 3.1 P: 3.6 ALT: 86 AP: 321 Tbili: 1.0 Alb: 4.4 AST: 49 LDH: Dbili: TProt: [**Doctor First Name **]: Lip: 474 Osms:434 freeCa:1.26 Lactate:3.1 pH:7.10 (venous) CBC: 5.7 > 17.4 / 61 < 122 N:80.7 L:15.6 M:2.8 E:0.1 Bas:0.7 URINE Prot 25 Glu 1000 Ket 15 OTHER LABS Hgb A1c: 9.7 ENZYMES & BILIRUBIN CK(CPK) [**2107-1-13**] 03:39AM 291 [**2107-1-12**] 06:17AM 297 [**2107-1-11**] 05:30AM 790* [**2107-1-10**] 02:19AM 2699* [**2107-1-9**] 03:59AM 5212* [**2107-1-8**] 01:59PM 8391* [**2107-1-8**] 05:02AM [**Numeric Identifier 86089**]* [**2107-1-7**] 08:59PM [**Numeric Identifier **]* [**2107-1-7**] 01:04PM [**Numeric Identifier 86090**]* [**2107-1-7**] 06:57AM [**Numeric Identifier 26950**]* [**2107-1-7**] 03:31AM [**Numeric Identifier 57835**]* [**2107-1-6**] 08:11PM [**Numeric Identifier **]* [**2107-1-6**] 12:08PM 9652* [**2107-1-6**] 04:17AM 6016* [**2107-1-5**] 06:00AM 1322* [**2107-1-3**] 09:59PM 1169* [**2107-1-3**] 06:30PM 1185* [**2107-1-3**] 02:20PM 1233* [**2107-1-3**] 06:01AM 748* [**2107-1-2**] 09:25PM 530* RENAL & GLUCOSE Creat [**2107-1-19**] 05:02PM 1.0 [**2107-1-18**] 05:23AM 1.2 [**2107-1-17**] 03:48AM 1.3* [**2107-1-16**] 04:20PM 1.5* [**2107-1-15**] 04:00PM 1.7* [**2107-1-14**] 05:57PM 1.8* [**2107-1-13**] 03:39AM 2.1* [**2107-1-12**] 02:09PM 2.4* [**2107-1-11**] 05:30AM 2.5* [**2107-1-8**] 01:59PM 2.4* [**2107-1-7**] 01:04PM 2.7* [**2107-1-7**] 03:31AM 2.6* [**2107-1-6**] 08:11PM 2.4* [**2107-1-5**] 08:44PM 2.0* [**2107-1-5**] 03:58AM 1.6* [**2107-1-3**] 02:20PM 1.2 [**2107-1-2**] 09:25PM 2.6* BLOOD GASES (all venous) pO2 / pCO2 / pH [**2107-1-21**] 01:32PM 52* / 45 / 7.37 [**2107-1-19**] 12:40PM 43* / 50* / 7.42 [**2107-1-17**] 03:47PM 60* / 45 / 7.48* [**2107-1-13**] 01:22AM 42* / 40 / 7.34* [**2107-1-8**] 05:21AM 40* / 28* / 7.33* [**2107-1-5**] 04:09PM 46* / 42 / 7.14* [**2107-1-4**] 11:05PM 39* / 47* / 7.13* [**2107-1-4**] 02:22PM 52* / 53* / 7.11* DISCHARGE LABS: [**2107-1-22**] 145 / 112 / 19 ---------------< 124 3.7 / 21 / 0.8 Ca: 8.0 Mg: 2.0 P: 3.0 6.3 > 9.0 /27.3 < 523 Brief Hospital Course: [**Known firstname **] is a 25 year-old with cerebral palsy who is non-verbal at baseline. He was brought to the hospital by his family for fever, lethargy and concern for dehydration. He was noted to be in diabetic ketoacidosis/hyperosmolar hyperglycemic nonketotic syndrome with profound hyperglycemia. His hopsital course was complicated by aspiration pneumonia and respiratory failure/ARDS requiring mechanical ventilation, septic shock requiring pressor support and renal failure. He also developed a ventilatory associated pneumonia with sputum growing pseudomonas and stenoptrophomonas. He currently has improved significantly in terms of hemodynamics and renal fuction which are both at baseline and his persistant issue has been difficulty assessing readiness for extubation. ACTIVE PROBLEMS: 1. RESPIRATORY FAILURE As above, initially in setting of aspiration with development of ARDS. Improved over time and then subsequently developed ventilator associated pneumonia as above. Now being treated with antibiotics. Intubation was difficult even with use of fiber optics. Extubation has been complicated by difficulty predicting readiness. This is due to a combination of the following: a) 6mm ETT which has non-trivial resistance. He actually appeared to fatigue when kept on pressure support ventilation for more than a couple hours. b) abnormal baseline respiratory mechanics secondary to his body habitus and underdeveloped lungs and also with chronic respiratory acidosis c) difficulty assessing mental status d) concern about need for reintubation. 2. VENTILATOR ASSOCIATED PNEUMONIA He developed new fevers on [**1-12**]. Sputum grew pseudomonas and then stenotrophomonas. Day of transfer, [**2107-1-22**] is day [**7-16**] of meropenem for pseudomonas and day [**3-16**] of bactrim for stenotrophomonas. 3. ELEVATED B-GLUCAN Isolated elevation in beta glucan x 3 with unclear significance. Have been treating with micafungin as has been persistantly febrile. This was changed to voriconazole on [**1-21**]. He should have a repeat beta glucan. 4. DIABETES MELLITUS Now on lantus 15 units and regular insulin sliding scale. When taking meals, should have sliding scale changed to shorter acting. 5. FEVERS Likely secondary to VAP but persisted intermittently even with treatment. Concern also for fungal infection given elevated beta glucan. Central line removed and pan cultured as well. Other possible source is sinus as has evidence of disease on CT. 6. CEREBRAL PALSY Continued baclofen and valium for contractures. 7. ANEMIA This has been stable. Unclear baseline. Initially with gastrocult positive emesis. FOB negative. No evidence of hemolysis. RESOLVED PROBLEMS: 1. SEPTIC SHOCK: Required phenylephrine from [**1-4**] - [**1-10**] with one day also requiring vasopressin. Covered very broadly with antibiotics including antifungals. No culture growth. Likely [**1-4**] ARDS/distributive physiology. 2. ARDS As above, no inciting organism identified. Likely [**1-4**] large aspiration in setting of vomiting. 3. DIABETIC KETOACIDOSIS/Hyperosmolar hyperglycemic nonketotic syndrome Very hyperglycemic and with Hgb A1c 9.7 so more consistent with DMII. Improved on insulin gtt and then transistioned to SQ. Trigger may have been viral URI. 4. HYPERNATREMIA Initially [**1-4**] profound dehydration. Resolution hindered by IVF resusitation. Has improved with enteral free water. 5. ACUTE RENAL FAILURE Became anuric in setting of sepsis. Also with elevated intra-abdominal and bladder pressures which increased the MAPs necessary for renal perfusion. Improved without need for dialysis. 6. ELEVATED CK This elevated after agressive fluid resusitation leading to significant edema including scleral edema and likely resulted from the anatomical limitations on fluid distribution exacerbated by oligura. This improved with improving urine output and resolution of edema. 7. ACCESS Significant diffculty with IV access requiring IO access intilliary and IR guided IJ line and then PICC. Unable to get arterial blood gases. 8. Elevated lipase and transaminases: RUQ US with cholelithiasis but not evidence of cholecystitis. 9. Thrombocytopenia Initially low platelets which improved with resolution of sepsis. 10. LLE edema Asymmetric but multiple ultrasounds negative for DVT Medications on Admission: Fexofenadine 30 mg daily Ranitidine 75 mg [**Hospital1 **] Diazepam 6 mg/4 mg/6 mg Baclofen 5 mg TID Discharge Medications: 1. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-4**] Drops Ophthalmic Q2H (every 2 hours) as needed for eye lubrication. 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 7. Diazepam 2 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Diazepam 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 11. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous once a day. 12. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection four times a day. 13. Meropenem 500 mg IV Q8H 14. Pantoprazole 40 mg IV Q24H 15. Fentanyl Citrate (PF) 100 mcg/2 mL (50 mcg/mL) Syringe Sig: 25-50 mcg Intravenous every four (4) hours as needed for agitation. 16. Voriconazole 200 mg IV Q12H 17. Sulfameth/Trimethoprim 185 mg IV Q8H Day 1 = [**1-19**] 18. 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. 19. Midazolam 0.5-1 mg IV Q4H:PRN discomfort Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Primary: Septic shock, respiratory failure, diabetic ketoacidosis, Hyperosmolar hyperglycemic nonketotic syndrome, diabetes mellitus, ventilator associated pneumonia, acute renal failure Secondary: cerebral palsy Discharge Condition: Mental Status: non-verbal, baseline Level of Consciousness: Alert Activity Status:Bedbound Discharge Instructions: Dear [**Doctor Last Name **], You were admitted with high sugar and dehydration. You got very sick and needed medicine to support your blood pressure and a tube to help you breath. You are doing much better. You are going to [**Hospital1 **] to have the tube removed in a setting where they are more prepared to manage the potential complications in people your size. We will miss you. Followup Instructions: per [**Hospital1 **] has been followed by [**Last Name (un) **] here PCP

[ "737.10", "995.92", "V58.67", "518.81", "782.1", "250.32", "117.9", "578.0", "997.31", "584.9", "276.0", "782.3", "276.52", "728.88", "785.52", "285.9", "041.2", "343.9", "038.9", "742.1", "287.5", "507.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

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18547, 18590

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328, 411

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275, 290

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2388, 2562

20,240

171,057

25267

Discharge summary

report

Admission Date: [**2135-7-5**] Discharge Date: [**2135-8-9**] Date of Birth: [**2078-7-8**] Sex: M Service: MEDICINE Allergies: Dilantin / Keppra / Seroquel Attending:[**First Name3 (LF) 2297**] Chief Complaint: hypoxic respiratory failure, ARDS Major Surgical or Invasive Procedure: Intubation Tracheostomy PEG tube placement History of Present Illness: 56 year old male with a hx of CVA (good functional recovery) admitted on [**6-21**] to [**Hospital **] Hospital with fevers, cough w/ hemoptysis, SOB x 2 and hypoxemia, tachypnea, and elevated WBC. He was intubated shortly after arrival for hypoxemia. Family members were diagnosed with strep throat prior to his admission, and he had some dust exposure while cleaning the roof of his house before admission. CT on [**6-21**] showed diffuse bilateral airspace infiltrate, increased at the bases, no evidence of PE. He has been on >80% FiO2 for the past 2 weeks, currently on 100% FiO2 with a PEEP of 15. Saturations today ([**7-5**]) have been in the mid 80s to low 90s. First bronch complicated by pneumothorax,and was + for pseudomonas. Second bronch complicated by post-bronch desats to mid80s, and showed 9900 WBC 87%p. Recent imaging showed bilateral alveolar interstital infiltrates, slightly improved compaged to [**2135-7-4**]. He was started on gentamycin and cefepime at the outside hospital, on arrival here we have switched him to gent/[**Last Name (un) 2830**]. Of note he also experienced some high fevers starting [**6-29**] (105 F). Past Medical History: CVA [**2128**] seizure disorder Chronic leg pain HTN hyperlipidemia depression COPD eczema CEA in [**2128**] s/p bilateral inguinal hernia repair [**2123**] Social History: Lived at home with family. Works in automotive and motorcycle repair. Quit smoking a few years ago. H/o alcoholism, sober x6yrs. No other drug use. Family History: No h/o seizures, early stroke or MI Physical Exam: General: sedated, does not respond to tactile or auditory stimuli HEENT: Sclera anicteric, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: crackles in b/l anterior lung fields Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge Exam: Vitals: 98.2, 103, 115/79, 22, 96% Trach mask 12L, 50% FIO2 General: occasionally verbal, responds to stimuli, moves four extremities HEENT: Sclera anicteric, PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: clear in b/l anterior lung fields Abdomen: soft, non-distended, bowel sounds present, no hepatosplenomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Results [**2135-7-5**] 09:42PM TYPE-ART PO2-64* PCO2-46* PH-7.35 TOTAL CO2-26 BASE XS-0 [**2135-7-5**] 09:42PM LACTATE-1.1 [**2135-7-5**] 09:42PM O2 SAT-88 [**2135-7-5**] 09:42PM freeCa-1.14 [**2135-7-5**] 08:36PM TYPE-ART TEMP-36.8 PEEP-15 PO2-62* PCO2-49* PH-7.41 TOTAL CO2-32* BASE XS-4 INTUBATED-INTUBATED [**2135-7-5**] 08:06PM TYPE-[**Last Name (un) **] TEMP-37.4 PO2-38* PCO2-62* PH-7.37 TOTAL CO2-37* BASE XS-7 INTUBATED-INTUBATED [**2135-7-5**] 07:56PM GLUCOSE-86 UREA N-74* CREAT-1.0 SODIUM-146* POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-32 ANION GAP-14 [**2135-7-5**] 07:56PM estGFR-Using this [**2135-7-5**] 07:56PM CK(CPK)-10* [**2135-7-5**] 07:56PM CK-MB-1 cTropnT-<0.01 [**2135-7-5**] 07:56PM CALCIUM-10.2 PHOSPHATE-4.1 MAGNESIUM-2.1 [**2135-7-5**] 07:56PM WBC-20.0* RBC-2.71* HGB-8.3* HCT-26.5* MCV-98# MCH-30.7 MCHC-31.3 RDW-15.1 [**2135-7-5**] 07:56PM NEUTS-70 BANDS-8* LYMPHS-10* MONOS-5 EOS-0 BASOS-0 ATYPS-1* METAS-2* MYELOS-4* [**2135-7-5**] 07:56PM HYPOCHROM-3+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL STIPPLED-OCCASIONAL [**2135-7-5**] 07:56PM PLT SMR-HIGH PLT COUNT-532* [**2135-7-5**] 07:56PM PT-13.3* PTT-30.1 INR(PT)-1.2* Discharge Labs: [**2135-8-9**] 04:01AM BLOOD WBC-20.9* RBC-3.05* Hgb-9.3* Hct-27.4* MCV-90 MCH-30.5 MCHC-34.1 RDW-14.5 Plt Ct-425 [**2135-8-8**] 04:15AM BLOOD Neuts-73* Bands-0 Lymphs-13* Monos-8 Eos-3 Baso-1 Atyps-1* Metas-1* Myelos-0 [**2135-8-9**] 04:55AM BLOOD PT-13.5* PTT-39.7* INR(PT)-1.3* [**2135-8-9**] 04:01AM BLOOD Glucose-103* UreaN-27* Creat-0.7 Na-136 K-3.8 Cl-95* HCO3-33* AnGap-12 [**2135-8-9**] 04:01AM BLOOD Calcium-10.6* Phos-4.5 Mg-2.1 [**2135-8-8**] 10:02AM BLOOD Type-ART Temp-38.1 FiO2-50 O2 Flow-15 pO2-75* pCO2-50* pH-7.42 calTCO2-34* Base XS-6 Micro UCx negative Bcx-negative Imaging CXR: ET tube, chest tube, NG tube seen. bilateral parenchymal opacities, left more than right, constant in severity in extent. No pleural effusions. ICU Labs CXR [**7-6**]: Widespread infiltrative pulmonary abnormality is still present, but has improved generally in the right lung and in the left upper lung since [**7-5**]. That component of the abnormality was probably recoverable pulmonary edema. What remains may be the residual of diffuse alveolar damage, in the right lung, and pneumonia in the lingula and left lower lobe. Pleural effusion is minimal, if any. There is no pneumothorax. CXR [**7-7**]: upper lobe could represent fibrotic stage of ARDS given the fact that they are not resolving and where largest abnormalities were present on [**6-21**]. ECHO [**7-8**]: The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. 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 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. Echo [**8-1**] The left 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. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. [**7-11**] bilateral lower extremity dopplers: IMPRESSION: No evidence of a right or left lower extremity DVT. [**7-12**] Abdominal U/S: IMPRESSION: 1. Left-sided nephrolithiasis as described above. 2. Stable right kidney calyceal diverticulum or cyst. 3. Normal caliber of the abdominal aorta. [**7-12**] CT chest w/out contrast: IMPRESSION: Interval decrease in consolidative opacities bilaterally, with likely conversion into fibrotic stage of ARDS or progressed preexisting fibrotic lung disease with patchy ground glass opacities with increased interstitial septal thickening, subpleural reticular and cystic changes with traction bronchiectasis and apical right greater than left honeycombing. No findings to suggest infection. [**7-20**] CT Sinus/mandible/maxillofacial w/out contrast: IMPRESSION: 1. Moderate mucosal thickening of the sphenoid sinuses with secretions. Minimal opacification of the right mastoid air cells. 2. Remote right occipital infarction with ex vacuo dilatation of the right lateral ventricle, better assessed on the head CT of the same date. [**7-20**] CT Head w/out contrast: IMPRESSION: 1. Limited study due to extensive motion artifact. Within this limitation, subtle area of hypodensity in left MCA distribution may be artifactual or reflect left MCA infarction. Correlation with clinical exam is recommended. 2. Remote right occipital infraction with associted ex vacuo dilatation of the right lateral ventricle 3. Prominent sulci and ventricles, significantly progressed since [**2128-10-28**] exam. [**7-20**] CT Torso w/out contrast: IMPRESSION: 1. Mildly distended gallbladder, clinical correlation suggested. 2. No other acute intra-abdominal pathology identified. 3. Mild mediastinal lymphadenopathy again noted. 4. Persistent findings of bibasilar predominant peripheral reticular opacities in the lungs, history of ARDS, without evidence of acute pneumonia. [**7-26**] CT abd/pelvis: IMPRESSION: 1. No acute intra-abdominal or intrapelvic process. Specifically, no acute hematoma detected. 2. Severe bibasilar consolidations and edema, reflective of known history of ARDS. [**7-28**] MRI Head w/ and w/o contrast: IMPRESSION: 1. Pachymeningeal enhancement and bilateral areas of punctate enhancement at the expected locations of perivascular spaces, new since prior exam. The above findings may represent infectious, or inflammatory process, alternatively, central hypotension is a consideration in the setting of recent lumbar puncture. There are no associated areas of restricted diffusion to suggest microabscesses or septic emboli. 2. Encephalomalacia of the right occipital lobe and associated ex vacuo dilatation of the occipital [**Doctor Last Name 534**] of the right lateral ventricle, represents sequelae remote infarction. No evidence of acute infarction. [**2135-8-2**] EEG IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of moderate to severe diffuse background slowing and disorganization. This is suggestive of moderate to severe diffuse cerebral dysfunction which is etiologically non-specific. There are abundant right hemispheric sharp waves that have maximal amplitude at parietal-temporal regions P4, T4. At times, they become pseudo-periodic in prolonged runs. These findings are indicative of a highly potentially epileptogenic area in the right posterior quadrant. However, toward the end of the study, the sharp waves become less frequent and there is improvement in the background activity to [**5-16**] Hz theta. Compared to the prior day's recording, the frequency of the sharp wave has slightly decreased with improvement of background activity. [**2135-8-8**] CXR FINDINGS: In comparison with the study of [**8-7**], there is little overall change. Again, there is prominence of interstitial markings consistent with the patient's known idiopathic pulmonary fibrosis. Vague suggestion of some more coalescent opacifications at the left base, which could possibly represent a developing consolidation in the appropriate clinical setting. Brief Hospital Course: ICU Course 56 yo male with past medical history notable for IPF, HTN, HLD, COPD, CVA [**2128**], transfered from [**Hospital **] Hospital on [**2135-7-6**] for continued management of his hypoxic respiratory failure / ARDS. . # HYPOXIC RESPIRATORY FAILURE: The patient originally presented with respiratory failure, possible secondary to pneumonia, which became ARDS and required intubation using ARDS net protocol and APRV. During his hospital stay he developed positive sputum cultures for Pseudomonas, possibly a ventilator associated infection, or an infection that caused his initial presentation. Chest CT on [**7-12**] revealed improvement in the bibasilar consolidations with a progression of his ARDS into the fibrotic stage. Patient was treated with a course of ciprofloxacin which ended on [**2135-7-20**]. As patient was unable to be weaned from ventilator, tracheostomy was performed on [**2134-7-17**] without complication. Subsequently he developed trach leak requiring an upsizing of the trach. Subseqently he developed increasing oxygen requirements and ventilator support with changes in sputum consistency. He grew MRSA and citrobacter in his sputum and was treated with vancomycin and cipro for 10 days. He was able to be weaned off the ventilator and tolerated trach mask well. He was fitted for a Passy-Muir valve on [**8-5**]. He developed mild pulmonary edema on [**8-6**] and was started on Lasix 20mg IV daily, which was changed to 40mg PO daily at the time of discharge. . # STATUS EPILEPTICUS: He has a known underlying seizure disorder; however, patient had a recurrence of his seizures due to withholding of usual antiseizure medications, and pharmacological clearance of benzodiazepines (received prolonged continuous high dose). He was treated with Versed, Valproate, and Licosamide. EEG showed continued bilateral eleptiform discharges, slowed background, but no frank seizures. Head CT without contrast revealed no new seizure focus area. MRI revealed pachymeningeal enhancement and bilateral areas of punctate enhancement at the expected locations of perivascular spaces, new since prior exam with the changes thought to be secondary lumbar puncture. Versed was tapered once Valproate was therapeutic. Head MRI on [**7-28**] showed no evidence of acute intracranial process. Patient discharged on Valproate 750mg q6, Lacosamide 200 mg [**Hospital1 **] and Neurontin 600 PO TID. He will follow up with his outpatient neurologist and the Neurology service was involved in his care throughout his course. . # ANEMIA: He developed a moderate anemia during this hospitalization, without clinical evidence for active bleeding. This was likely multifactorial due to dilution, acute illness and phlebotomy. However, given recent PEG tube placement, there was concern for retroperitoneal bleed. He was transfused to maintain Hct >24. ABD/PELVIS CT showed no evidence of PEG-related bleeding or retroperitoneal hemorrhage. His HCT remained stable for the remaineder of his course. . # Coag negative Staph Bacteremia (Intravascular Catheter related)- bacteremia thought to be secondary PICC line infection. The PICC was removed and sent for culture, which was negative. Echo showed no vegetations. He was treated with Vancomycin for 10 days as above. . # Leukocytosis: At the time of discharge, pt had a persistent leukocytosis of unclear origin. All blood, urine, CSF cultures were negative at the time of d/c and C diff was negative x2. Sputum culture positive for Staph Aureus was felt to be commensal given his prolonged hospitalizaton, lack of infiltrate on CXR and stable respiratory status. He received a 10d course of Vancomycin for a likey line infection immediately prior to sputum culture result. . # ALTERED MENTAL STATUS: The patient was sedated for mechanical ventilation, and was also likely altered due to his seizure prodrome, post-ictal state, and slow clearance of narcotics. He also has an underlying prior CVA, which contributed to his altered mental status. A head CT without contrast revealed no evidence for new CVA. Lumbar puncture was negative for infection. . # FEVERS: He was repeated cultured and only positive cultures are as above in sputum and blood. CSF was negative for infections. At the time of discahrge, he had been afebrle for several days without localizing s/sx of infection. . # ELECTROLYTE ABNORMALITIES: He developed a hypovolemic hypernatremia during this hospitalization, which was treated with fluid resuscitation and free water boluses as needed. He also had hypokalemia due to nutritional depletion, and was repleted to a goal of 4 daily. . # ACUTE RENAL FAILURE: He developed acute kidney injury, which was attributed in part to aminoglycosides and ATN with a peak Cr of 3.3. His renal function improving slowly with avoidance of nephrotoxic medications. At the time of discharge his Cr was 0.6. . # Diastolic heart failure - He received diuresis at OSH. During [**Hospital Unit Name 153**] course as he was hypotensive, he required fluid boluses. Through the rest of his admission, he was kept in even fluid balance with Lasix 20mg IV daily. He was discharged on Lasix 40mg po qday. . Transitional Issues ======================== -neurology follow up -thoracic surgery follow up [**Last Name (LF) **], [**First Name3 (LF) **] P. MD Medications on Admission: Medications on transfer : versed 1-2mg prn insulin lispro SS lasix 20mg IV Q6hr solumedrol 80mg [**Hospital1 **] protonix 40mg IV BID Ventolin q2hr Gent 400mg IV qday Cefepime 2g IV q12 Fentanyl gtt propofol gtt colace 100mg [**Hospital1 **] miconazole pdr lisinopril 10mg qday zoloft 150mg qday metoprolol 25mg [**Hospital1 **] senna 10mg qday combivent 4puffs q4hrs valproic acid 500mg q8hrs zocor 40mg qday ASA 81mg qday neurontin 900mg TID Heparin SQ5000 q8hrs Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Senna 1 TAB PO DAILY 4. Sertraline 150 mg PO DAILY 5. Valproic Acid 750 mg PO Q6H 6. Gabapentin 600 mg PO TID 7. Amlodipine 10 mg PO DAILY hold for SBP < 100 8. HydrOXYzine 25 mg PO Q6H:PRN itching 9. Lacosamide 200 mg PO BID 10. Lansoprazole *NF* 30 mg ORAL DAILY Reason for Ordering: on NG tube 11. Lidocaine 5% Patch 1 PTCH TD DAILY Apply to lower back. 12. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN rash 13. OxycoDONE Liquid 5 mg PO Q6H:PRN pain 14. Polyethylene Glycol 17 g PO DAILY 15. Acetaminophen 650 mg PO Q6H:PRN pain Please do not exceed 4g total daily 16. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN dry eyes 17. Heparin 5000 UNIT SC TID 18. Furosemide 40 mg PO DAILY hold for SBP<100 19. Atorvastatin 10 mg PO DAILY 20. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB or wheeze 21. Metoprolol Tartrate 25 mg PO BID hold for HR <60, SBP <100 22. Ipratropium Bromide Neb 1 NEB IH Q6H Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Acute Respiratory Failure ARDS Ventilator associated Pneumonia Acute Renal Failure Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. [**Known lastname **]: It was a pleasure taking care of you at [**Hospital1 827**]. You were transferred here from [**Hospital **] Hospital because you had a very bad pneumonia with a bacteria called pseudomonas that required you to have a breathing tube and antibiotics. You were intubated for a long time requiring a tracheostomy tube, which is a tube at the base of your neck for breathing. You were also unable to eat and required a feeding tube through your stomach. Additionally, you had seizures while you were here and we made adjustments to your seizure medicines which you can see on your medication sheet. Also, you developed a second pneumonia which we treated with antibiotics. During your hospital course, you had acute kidney failure, which resolved by the time you were discharged. Followup Instructions: Department: NEUROLOGY When: WEDNESDAY [**2135-8-24**] at 2:30 PM With: DRS. [**Name5 (PTitle) **] & [**Last Name (un) **] [**Telephone/Fax (1) 44**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "03.31", "96.04", "43.11", "96.6", "97.23", "96.72", "31.1", "96.56", "33.24", "38.97", "38.91" ]

icd9pcs

[ [ [] ] ]

17881, 17981

11048, 14797

321, 366

18108, 18108

2862, 4093

19115, 19411

1908, 1946

16879, 17858

18002, 18087

16390, 16856

18285, 19092

4109, 11025

1961, 2404

2420, 2843

247, 283

394, 1545

18123, 18261

1567, 1726

1742, 1892

20,713

177,696

27436

Discharge summary

report

Admission Date: [**2115-3-9**] Discharge Date: [**2115-3-29**] Date of Birth: [**2037-12-4**] Sex: F Service: CARDIOTHORACIC Allergies: Shellfish Attending:[**First Name3 (LF) 1283**] Chief Complaint: slurred speech, mental status changes Major Surgical or Invasive Procedure: [**2115-3-14**] - EGD [**2115-3-20**] - Endovascular repair of thoracic aneurysm with 34 x 15 TAG endograft, aortogram and right proximal external iliac to common femoral artery bypass with 8-mm Dacron graft. History of Present Illness: Ms. [**Known lastname 8320**] is a 77 year old female admitted on [**2115-3-9**] with an approximately 2 day history of mental status changes and slurred speech. The neurology service was consulted, and and MRI showed likely old small lacunar strokes, but no acute changes. It was felt that the mental status changes were due to hypertension. Ms. [**Known lastname 8320**] had run out of Hydrochlorothiazide and had not taken it for likely 1 week. Blood pressure in the emergency department was 226/87. Chest x-ray was suspicious for a dilated thoracic aorta. Chest CTA revealed a 6.6 cm aortic aneurysm of the descending aorta at the level of T10, and a smaller 4.6 cm focal aneurysmal dilation just below this area. She was admitted for further evaluation and management. Past Medical History: Cerebrovascular accident times three Transient ischemic attack Hypertension Social History: 6 pack year history of tobacco use. 2 rum and cokes a day. Lives in [**State 2748**] with her nephew. Family History: Mother with heart problems. [**Name (NI) **] other family history of stroke or blood clots. Physical Exam: Temperature: 96.8 BP: 140/60 HR: 72 RR: 18 O2sat;98% RA General: appears her stated age, pleasant in no acute distress HEENT: atraumatic, anicteric, pupils 2 mm, equal and reactive. Clear oropharynx, dentures Neck: no jugular venous distention, no carotid bruits, no lymphadenopathy CV: S1S2, regular rate and rhythm, no murmurs Lungs: distant breath sounds, otherwise clear, no wheeze, no accessory muscle use Abd: soft, non-tender, non-distended, normoactive bowel sounds, no masses; no flank tenderness Ext: trace edema bilaterally, warm. DP pulses palpable bilaterally. No asterixis. No tenderness over vertbrae. Neuro: cranial nerves [**1-27**] intact, no facial droop, no dysarthria; alert and oriented, no focal deficits. Strength 5/5 in all extremities, equal without pain with passive or active movement on lower extremities bilaterally Pertinent Results: Head CT [**2115-3-9**] No intracranial hemorrhage or mass effect is identified. Left basal ganglia chronic lacunar infarct and cerebellar atrophy. CTA Chest [**2115-3-11**] 6.6 cm focal lesion in the azygoesophageal recess abutting the aorta. Quite possibly a thrombosed saccular aneurysm of the descending aorta at the T10 level. CTA chest [**2115-3-12**] 4.9 cm fusiform aneurysm of the infrarenal aorta. 3.0 x 3.5 cm mass adjacent to the thoracic aorta at the T10 level which could represent a lung or neurogenic tumor or much less likely a duplication cyst or aortic aneurysm. 8 mm nodule at the right lung apex. Followup CT of the chest in three months should be performed to ensure stability. Carotid Ultrasound [**2115-3-12**] Non-hemodynamically significant stenosis of less than 40% was demonstrated in the right internal carotid artery. Hemodynamically significant stenosis of 40-59% was demonstrated in the left internal carotid artery. Video Oropharyngeal Swallow [**2115-3-13**] No evidence of aspiration. For further details, please see the dedicated speech and language pathology report of [**2115-3-13**]. MRI [**2115-3-14**] 2.8 x 3.3 x 3.9 cm right paraaortic mass with features most likely represents a thrombosed pseudoaneurysm or thrombosed saccular aneurysm. The differential diagnosis also includes duplication cyst or pericardial cyst containing proteinaceous material, although these entities are considered much less likely. TEE could be performed for further evaluation to determine whether duplication cyst may be present. 2. Mild ectasia of the descending aorta and multifocal areas of mural plaque consistent with atheromatous disease. [**2115-3-9**] 03:40PM BLOOD WBC-5.1 RBC-4.13* Hgb-12.8 Hct-37.4 MCV-91 MCH-31.1 MCHC-34.4 RDW-13.6 Plt Ct-199 [**2115-3-11**] 06:15AM BLOOD WBC-5.9 RBC-3.98* Hgb-11.7* Hct-35.9* MCV-90 MCH-29.5 MCHC-32.6 RDW-13.7 Plt Ct-223 [**2115-3-20**] 07:41PM BLOOD WBC-12.3*# RBC-3.51* Hgb-10.7* Hct-30.9* MCV-88 MCH-30.5 MCHC-34.7 RDW-13.7 Plt Ct-190 [**2115-3-25**] 03:08AM BLOOD WBC-12.9* RBC-3.58* Hgb-11.1* Hct-30.9* MCV-86 MCH-30.9 MCHC-35.8* RDW-14.7 Plt Ct-199 [**2115-3-26**] 04:30AM BLOOD WBC-10.2 RBC-3.20* Hgb-9.9* Hct-27.9* MCV-87 MCH-30.9 MCHC-35.4* RDW-14.6 Plt Ct-211 [**2115-3-27**] 01:57AM BLOOD WBC-10.5 RBC-3.39* Hgb-10.3* Hct-29.8* MCV-88 MCH-30.4 MCHC-34.6 RDW-14.6 Plt Ct-260 [**2115-3-28**] 05:32AM BLOOD WBC-12.1* RBC-3.83* Hgb-11.6* Hct-34.2* MCV-89 MCH-30.4 MCHC-34.1 RDW-14.5 Plt Ct-330 [**2115-3-9**] 03:40PM BLOOD Neuts-54.7 Bands-0 Lymphs-36.4 Monos-6.7 Eos-1.5 Baso-0.7 [**2115-3-9**] 03:40PM BLOOD PT-11.6 PTT-23.0 INR(PT)-1.0 [**2115-3-27**] 01:57AM BLOOD PT-13.3* PTT-22.0 INR(PT)-1.2* [**2115-3-9**] 03:40PM BLOOD Glucose-94 UreaN-11 Creat-0.9 Na-142 K-4.2 Cl-104 HCO3-28 AnGap-14 [**2115-3-11**] 06:15AM BLOOD Glucose-87 UreaN-13 Creat-1.0 Na-142 K-4.0 Cl-106 HCO3-28 AnGap-12 [**2115-3-25**] 03:08AM BLOOD Glucose-177* UreaN-15 Creat-0.8 Na-141 K-3.8 Cl-100 HCO3-31 AnGap-14 [**2115-3-27**] 01:57AM BLOOD Glucose-94 UreaN-14 Creat-0.8 Na-138 K-3.9 Cl-99 HCO3-29 AnGap-14 [**2115-3-28**] 05:32AM BLOOD Glucose-122* UreaN-20 Creat-1.2* Na-142 K-3.7 Cl-97 HCO3-31 AnGap-18 [**2115-3-22**] 02:51AM BLOOD Lipase-16 [**2115-3-25**] 03:08AM BLOOD Lipase-24 [**2115-3-10**] 07:00AM BLOOD Mg-1.9 Cholest-199 [**2115-3-28**] 05:32AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.4 [**2115-3-22**] 02:51AM BLOOD Albumin-2.9* Calcium-8.4 Phos-4.3 Mg-1.8 MICROBIOLOGY: [**2115-3-10**] Urine Cx: negative [**2115-3-20**] TEE: There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%) There are simple atheroma in the aortic root and ascending aorta. The aortic arch is mildly dilated. There are complex (>4mm) atheroma in the aortic arch. The descending thoracic aorta is moderately dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. At the distal visible extent of the thoracic aorta, a large aneurysmal pouch is identified. There is some flow seen, but a predominant large clot collection. In the sac. The full dimenisons cannot be identified by TEE, but the sac is greater than 4 cm across. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are moderately thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a small pericardial effusion. The pulmonic valve is normal without regurgitation. In the proximal pulmonary artery, an echogenic structure is seen as a luminal irregularity which could represent clot, intimal hyperplasia, or artifact from fluid in the transverse coronary sinus. Suggest clinical correlation. Post Endostenting, the stent is poorly seen. Flow can be seen in branch vessels, possibly intercostals, but no definite flow is seen in the aneurysm. LVEF remains normal. Aortic contours otherwise unchanged. Remaining exam unchanged. Results discussed with surgical team at time of the exam. [**2115-3-14**] Endoscopy Results: Erosive gastritis Duodenitis in the bulb Extrinsic compression in the esophagus Brief Hospital Course: Ms. [**Known lastname 8320**] was admitted for further evaluation and management for mental status changes and hypertension and was found to have a large thoracic/descending aortic aneurysm. On admission, oral blood pressure medications were adjusted for optimal blood pressure control. She was evaluated by the cardiac surgical service. The vascular surgery service was also consulted. She underwent multiple chest CT scans as well as an MRI to characterize her thoracic/descending aortic aneurysm (please see results section for reports). These were compared with MMS reconstruction images of MRI images from an outside institution. Carotid ultrasound was done on [**2115-3-12**] and showed non-hemodynamically significant stenosis of less than 40% was demonstrated in the right internal carotid artery with hemodynamically significant stenosis of 40-59% demonstrated in the left internal carotid artery. As part of her pre-operative work-up, the GI service was consulted for long-standing dysphagia. Oropharyngeal swallowing evaluation showed no evidence of aspiration. Her esophagram was normal. EGD showed erosive gastritis, duodenitis in the bulb with extrinsic compression in the esophagus. It was recommended that she undergo an outpatient esophageal motility study. After pre-operative workup was completed, the patient was taken to the operating room for endovascular repair of her thoracic aortic aneurysm on [**2115-3-20**] (please see the detailed operative note of Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]). She was extubated on post-operative day 1 in the cardiac intensive care unit. She required a nitroglycerin drip for 2 days for blood pressure control and this was eventually weaned off. She received 1 unit of blood on post-op day 2 and her lumbar drain was removed. She was able to tolerate a regular diet and was able to get out of bed to chair. On postoperative day three, Ms. [**Known lastname 8320**] was transferred to the cardiac floor for further recovery. Of note, she had an episode of left lower extremity weakness with concurrent hypotension on the evening of post-op day 2. She had a drop in her hematocrit from 29 to 23 and required 2 units of blood. Repeat imaging revealed a stable (not actively bleeding) left lower quadrant retroperitoneal hematoma. She was transferred back to the intensive care unit for closer monitoring. MRI imaging revealed some lumbar cord edema but no epidural hematoma. Neurology was consulted and recommended conservative management. Her left lower extremity weakness spontaneously resolved. She had some nausea and a KUB revealed a mild ileus and she was placed NPO for a day. Her diet then resumed without complication. She required a nitroglycerin drip for blood pressure control which was weaned off and she was transferred back to the floor on post-operative day 7. She then worked with physical therapy daily to increase her strength and mobility. Oral antihypertensives were optimized for blood pressure control. Ms. [**Known lastname 8320**] continued to make steady progress and was discharged on [**2115-3-28**]. She will follow-up with Dr. [**Last Name (Prefixes) **], Dr. [**Last Name (STitle) **], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Pravachol 40 mg qd ASA 81 mg qd Wellbutrin SR 300 qd Plavix 75 mg qd Norvasc 5 mg qd Hydrochlorothiazide 25 mg Qd MVI 1 tablet qd Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*1* 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 * Refills:*0* 5. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). Disp:*60 Tablet Sustained Release(s)* Refills:*0* 6. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 8. 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* 9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: caregroup Discharge Diagnosis: Thoracic/Abdominal Aortic Aneurysm/Thrombosed pseudoaneurysm or saccular aneurysm Transient encephalopathy NOS Poorly controlled hypertension Discharge Condition: Good Discharge Instructions: Please continue to take all of your medications as instructed. We have started you on a new medication to help control your blood pressure. Please make an appointment with your primary care physician within one week of discharge to follow-up on further testing and establishing a neurologist. Also make appointment with Vascular surgery for follow-up tests. [**Last Name (NamePattern4) 2138**]p Instructions: PCP 2 weeks Cardiologist 2 weeks Dr. [**Last Name (Prefixes) **] 3 weeks Dr. [**Last Name (STitle) **] for follow up of abdominal aneurysm. Completed by:[**2115-5-9**]

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icd9cm

[ [ [] ] ]

[ "99.04", "39.25", "88.72", "00.17", "03.90", "39.73", "45.16", "88.42" ]

icd9pcs

[ [ [] ] ]

12667, 12707

7808, 11152

313, 523

12893, 12900

2548, 7785

1567, 1661

11332, 12644

12728, 12872

11178, 11309

12924, 13283

13334, 13504

1676, 2529

236, 275

551, 1332

1354, 1431

1447, 1551

18,258

199,085

9978+9979

Discharge summary

report+report

Admission Date: [**2180-9-20**] Discharge Date: [**2180-9-26**] Date of Birth: [**2096-3-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 3298**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 84 yo woman with a h/o dementia, DM type II, PVD, multiple resections of toes, metatarsal head resections, prior MRSA, osteomyelitis, recently discharged [**2180-9-19**] (yesterday) after an admission for confusion. This was most likely due to a PICC line infection as patient had coag neg staph bacteremia. Her picc line was dc'd and repeat [**Month/Day/Year **] cultures were negative. A new picc line was placed and she was back to her mental status baseline. Per report, soon after returning to [**Hospital **] health center,she was noted to be tachypneic and was sent to the [**Hospital1 18**] ED. She required oxygen supplementation and reported chest pain. She was given IV lasix x 20mg and foley catheter was placed. Her oxygen was able to be weaned down somewhat. Patient and family were not able to give much further history. She is not more confused than baseline, but is quite sleepy since spending multiple hours in the ED. She had a temp of 100.9 r 30s increased work of breathing. No vomiting, eating well. Has not had diarrhea. Family reports that she has not been choking with eating. ROS otherwise negative per family. Pt unable to give any review of systems due to dementia. Past Medical History: Dementia - per dtr ([**2180-9-12**])- baseline oriented x 2. DMII with neuropathy PVD s/p multiple toe amputations Hypothyroidism Asthma s/p right first metatarsal head resection, right second metatarsal head resection ([**4-/2170**]) s/p CCY ([**4-/2171**]) s/p multiple failed apligrafs, PTA and stentx2 in R superficial femoral artery ([**2179-11-15**]) s/p Left second toe amputation ([**1-/2180**]) h/o MRSA Osteomyelitis currently on parenteral antibiotic therapy Social History: Originally from GA. Moved to [**Location (un) 86**] ~6 years ago. Lives in [**Hospital6 1643**] ([**Telephone/Fax (1) 33307**]. Daughter [**Name (NI) 2013**] and son [**Name (NI) 21693**] (HCP's) live in [**Location (un) 2268**] - [**Telephone/Fax (1) 33395**], cell [**Telephone/Fax (1) 33396**]. Quit smoking +10 years ago, does not drink. Family History: Daughter & Two Sons with DM Physical Exam: On Admission: T 98.7 p 86 bp 172/83 24 bp 172/83 Gen patient in mild resp distress, using abdominal muscles to breathe. Not coughing. Very somnolent, will open eyes to voice and sternal rub, but falls back asleep HEENT o/p clear Neck no [**Doctor First Name **] Chest decreased breath sounds in bases, ? crackles in left base CV RRR Abd soft nontender, mildly distended Ext trace edema in hands bilaterally, feet wrapped in braces, bandages. Neuro somnolent, not able to cooperate with neuro exam On discharge: T 99, BP 158/76, P 93, RR 22, O2 95% on RA Appears comfortable though sleepy but quickly waking up to voice and responding appropriately in short phrases. Not in any respiratory distress or using abdominal msucles to breathe. Lungs without crackles, wheezes, or rubs. No lower extremity edema. Responds appropriately in short phrases, which per daughter is baseline. Pertinent Results: =================== LABORATORY RESULTS =================== On admission: WBC-6.0# RBC-3.13* Hgb-8.2* Hct-26.3* MCV-84 RDW-16.6* Plt Ct-271 --Neuts-83.9* Lymphs-10.7* Monos-3.8 Eos-1.1 Baso-0.5 UreaN-8 Creat-0.8 Na-145 K-3.7 Cl-105 HCO3-34* proBNP-1261* Calcium-8.3* Phos-2.6* Mg-1.8 Lactate-1.1 On Discharge: WBC-3.5* RBC-2.87* Hgb-7.7* Hct-24.2* MCV-84 RDW-16.8* Plt Ct-248 Glucose-61* UreaN-9 Creat-0.6 Na-148* K-3.4 Cl-104 HCO3-39* Calcium-8.3* Phos-3.3 Mg-1.8 Cardiac Enzymes: [**2180-9-20**] 08:13PM [**Month/Day/Year 3143**] CK(CPK)-28* CK-MB-2 cTropnT-0.02* [**2180-9-20**] 02:45AM [**Month/Day/Year 3143**] cTropnT-0.01 [**2180-9-20**] 10:00AM [**Month/Day/Year 3143**] cTropnT-0.05* ============== MICROBIOLOGY ============== [**Month/Day/Year **] culture *2 [**2180-9-20**]: No Growth Urine Culture [**2180-9-20**]: No Growth Stool Culture [**2180-9-21**]: FECAL CULTURE (Final [**2180-9-23**]): NO SALMONELLA OR SHIGELLA FOUND. NO ENTERIC GRAM NEGATIVE RODS FOUND. CAMPYLOBACTER CULTURE (Final [**2180-9-23**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2180-9-22**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2180-9-21**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). ============== OTHER STUDIES ============== ECG [**2180-9-20**]: Sinus rhythm. Compared to the previous tracing ST-T wave changes are [**Last Name (un) 33397**] Chest Radiograph [**2180-9-20**]: IMPRESSION: Low lung volumes with trace bilateral pleural effusions and bibasilar atelectasis; underlying pneumonia cannot be excluded. CT Abdomen and Pelvis W/ Contrast and CTA Chest [**2180-9-20**]: IMPRESSION: 1. No PE or acute aortic syndrome. 2. Moderate right and small left pleural effusions with compressive atelectasis. 3. Rectal wall inflammation compatible with proctitis. 4. No evidence of abscess. . Brief Hospital Course: 84 F with CAD, DM c/b neuropathy, PVD s/p multiple amputations, chronic bilateral foot osteomyelitis on vanco/cefepime/flagyl re-admitted with acute dyspnea within 12 hours of discharge to a rehabilitation facility. CTA was negative for PE, but suggestive of fluid overload and a 2-3L oxygen requirement largely resolved with diuresis. That said, the patient had a recurrence of acute hypoxia/dyspnea during this admission and it seems that these episodes are primarily due to her asthma. Her hospital course is summarized in further detail below. With regards to her reason for re-admission, an acute hypoxic episode, this was initially attributed to decompensated diastolic failure as she was net-positive during her last admission (for picc line infxn) and had evidence of fluid overload on exam (edema, bibasilar crackles) and CXR. This was supported by the resolution of a 2-3 L oxygen requirement and bibasilar crackles with diuresis over approximately five days. CXR showed no evidence of aspiration and speech/swallow evalaution was unremarkable. On [**9-24**], she was noted to become acutely dyspneic and hypoxic to 75% on room air down from 96% earlier that morning. Her exam at that time was notable for a markedly prolonged expiratory phase and the use of accessory muscles, but no wheezing (likely due to very poor air movement). After one albuterol neb, she began to cough and wheeze, after a second neb, her symptoms resolved completely. CXR at that time was notable only for mild fluid overload somewhat improved since admission. She does have a history of asthma, but is unable to relate how often these kinds of episodes have occurred in the past. Her prior regimen consisted only of albuterol prn and it is unclear how often she was receiving this at her facility. The following changes were made to her asthma regimen: She was started on fluticasone inhaler [**Hospital1 **] as well as ipratroprium four times a day. When she first presented, she also complained of chest pressure while short of breath and had a mild troponin elevation to 0.05. CK was flat and there were no EKG changes. She had persistent low-grade fevers (tmax 100.1) during this admission while on broad spectrum antibiotics but cultures returned negative and no etiology was identified. She was continued on standing and SS insulin for DMII and levothyroxine for hypothyroidism. Vancomycin, cefepime and flagyl should be continued until she follows-up with Dr. [**Last Name (STitle) **] in [**Hospital 4898**] clinic (this appointment has not been scheduled but Dr. [**Last Name (STitle) **] is working to arrange it in [**Hospital **] clinic in the week following discharge). Several of her recent CT abdomens have noted persistent proctocolitis which is present on CT from this admission. Per radiology it is unchanged to slightly improved. As she had small amounts of diarrhea, cdiff and O/P were checked and negative. Once her more acute issues resolve and she has completed parenteral antibiotics GI referral for sigmoidoscopy to further evaluate this finding should be considered. She has no notable abdominal pain. Her family confirmed that her mental status was at baseline throughout this admission. She frequently sleeps during the day, but is always arousable to voice. She is oriented to place, but not time. Her speech is fluent, but she is minimally conversant. Transitional Issues: -ID will contact her facility to schedule a follow up visit in [**Hospital 4898**] clinic and monitor her duration of antibiotic therapy. -She will follow up with podiatry and vascular surgery for management of her ulcers and vascular disease -Previous monitoring labs should be resumed for her antibiotics and faxed to the [**Hospital 4898**] clinic. -The patient is persistently anemic. Given fragile renal and volume status electrolytes and CBC should be checked at least -If she has persistent diarrhea after finishing parenteral antibiotics she should be seen in GI for further evaluation of proctolitis Medications on Admission: 1. Vancomycin 1250 mg IV Q 24H Monitor levels closely and dose based on goal peak and trough. 2. CefePIME 2 g IV Q12H 3. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for agitation. 10. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY (Daily). 12. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for Bronchospasm. 18. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 19. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain. 20. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. insulin regular human 100 unit/mL Solution Sig: One (1) Injection three times a day: as per sliding scale. 22. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. Discharge Medications: 1. Vancomycin 1250 mg IV Q 24H 2. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 3. CefePIME 2 g IV Q12H 4. Heparin Flush (10 units/ml) 1 mL IV PRN line flush 5. 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. 6. Ondansetron 4 mg IV Q8H:PRN nausea 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for dyspnea. 8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 10. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for agitation. 15. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY (Daily). 17. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 20. ipratropium bromide 0.02 % Solution Sig: 1-2 puffs Inhalation four times a day. 21. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 23. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty Two (22) units Subcutaneous Q Breakfast: Hold if NPO. 24. NPH insulin human recomb 100 unit/mL Suspension Sig: Fourteen (14) units Subcutaneous with bedtime: hold if not eating 25. insulin lispro 100 unit/mL Solution Sig: 0-12 units Subcutaneous four times a day as needed for hyperglycemia: Give per attached sliding scale. 26. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a day. 27. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) **] Discharge Diagnosis: Acute diastolic heart failure exacerbation Asthma, acute exacerbation Osteomyelitis Peripheral vascular disease Diabetes Mellitus, type 2, uncontrolled Proctocolitis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted with rapid breathing from the nursing home, just one day after discharge from the hospital. This may have been due to having too much fluid on your lungs and your were given a diuretic (fluid pill) to help with this. We suspect that this may have also been related to your asthma so we started you on medicines to help your breathing. You were continued on your course of antibiotics for the non-healing ulcers in your legs. Dr. [**Last Name (STitle) **] will determine how much longer you have to take these when you see her as an outpatient. A full list of your medications is attached and has been provided to the facility where you will be staying. You should be aware that we have added ipratroprium, albuterol, and fluticasone Followup Instructions: Department: PODIATRY When: FRIDAY [**2180-9-29**] at 9:40 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: VASCULAR SURGERY When: FRIDAY [**2180-9-29**] at 11:00 AM With: VASCULAR LAB [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: VASCULAR SURGERY When: FRIDAY [**2180-9-29**] at 11:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Admission Date: [**2180-9-27**] Discharge Date: [**2180-10-7**] Date of Birth: [**2096-3-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 983**] Chief Complaint: worsening SOB Major Surgical or Invasive Procedure: None History of Present Illness: 84 year old woman with asthma and chronic osteomyelitis on vanc/cefepime/flagyl at ALF, just discharged a day prior to admission for SOB suspected secondary to dCHF exacerbation, improved after diuresis and BIPAP for worsening SOB. She had done well overnight and been off oxygen per report but then was found acutely short of breath the following morning with a an SBP in the 190s with HR in 120s, RR 30s and desaturating to oxygen saturations in the 80s. She denied SOB, CP, cough, fever but her speech is quite limited in content due to her severe dementia and she answers she's "pretty good" and that she has no problems to almost all questions. Of note, she has been admitted to [**Hospital1 18**] twice within the last month and has been re-admitted within 24 hours both times. Her first admission in early [**Month (only) **] was for confusion. She was found to have Coag neg Staph bacteremia, attributed to her PICC line. PICC was replaced and [**Month (only) **] cultures were negative at discharge. She re-presented with worsening dyspnea on [**9-20**] and was admitted with presumed CHF exacerbation. She responded well to diuresis with furosemide, though did have an episode of hypoxia after diuresis that was attributed to asthma. She was discharged on bronchodilators and furosemide 20mg PO daily, which was not titrated up from admission dose. No discharge weight documented but per discharge summary was on room air with no crackles or edema on exam. In the ED inital vitals were 155/70 102 44 89% RA. She was placed on BiPAP immediately and RR improved to high 20s, though pt. did look for a time as if she was headed for intubation. EKG showed sinus tachycardia with no ischemic changes. Labs notable for troponin <.01, Hct 28 above recent baseline. CXR showed bilateral pleural effusion, increased vascular congestion c/w fluid overload. Bedside U/S showed no pericardial effusion, Kerley B lines. Exam notable for wheezes. She was given Lasix 20mg IV, Albuterol and Ipratropium nebs, SoluMedrol 125mg. Foley was placed and she had immediate output of 500cc. She was started on a nitro gtt with goal SBP 120 and is being admitted to the ICU due to need for nitro gtt. VS at transfer to ICU 137/58 105 22 99% 2L NC. REVIEW OF SYSTEMS: Pt answers questions about ROS with yes or no though high suspicion of her reliability. She denied essentially all complaints on review of systems including her presenting complaint. Past Medical History: Dementia - per dtr ([**2180-9-12**])- baseline oriented x 2. DMII with neuropathy PVD s/p multiple toe amputations Hypothyroidism Asthma s/p right first metatarsal head resection, right second metatarsal head resection ([**4-/2170**]) s/p CCY ([**4-/2171**]) s/p multiple failed apligrafs, PTA and stentx2 in R superficial femoral artery ([**2179-11-15**]) s/p Left second toe amputation ([**1-/2180**]) h/o MRSA Osteomyelitis currently on parenteral antibiotic therapy Social History: Originally from GA. Lives in [**Hospital6 1643**] ([**Telephone/Fax (1) 33307**] and has been in facilities for >5 years. Daughter [**Name (NI) 2013**] and son [**Name (NI) 21693**] (HCP's) live in [**Location (un) 2268**] - [**Telephone/Fax (1) 33395**], cell [**Telephone/Fax (1) 33396**]. Former smoker since >10 yrs ago. No current alcohol. Family History: Notable for Diabetes mellitus in three of her children. Physical Exam: [**Hospital Unit Name 153**] Admission physical exam: Vitals: T 98.5 BP: 167/69 P: 105 R: 19 O2: 98% 2L NC General: Alert, oriented to person and [**Location (un) 86**], no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Short breaths, Wheezes scattered anteriorly, bibasilar crackles with decreased BS at bases, moderate air entry CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, palp pulses, trace pitting edema b/l to ankle, no clubbing or cyanosis or edema, B/L heel ulcers with clean beds and no purulence or malodor Discharge Exam: VSS GEN: Patient lying comfortably in bed nad a+ox1 HEENT: MMM oropharynx clear NECK: supple no thyromegaly CV: rrr no m/r/g RESP: ctab no w/r/r ABD: soft nt nd bs+ EXTR: no le edema good pedal pulses bilaterally, feet wrapped in boots/gauze. No oozing or bleeding. No TTP DERM: no rashes, ulcers or petechiae neuro: cn 2-12 grossly intact non-focal PSYCH: normal affect and mood Pertinent Results: ==================== LABORATORY RESULTS ==================== On Admission: WBC-3.5* RBC-2.87* Hgb-7.7* Hct-24.2* MCV-84 RDW-16.8* Plt Ct-248 PT-12.9 PTT-21.8* INR(PT)-1.1 Glucose-61* UreaN-9 Creat-0.6 Na-148* K-3.4 Cl-104 HCO3-39* cTropnT-<0.01 proBNP-[**2112**]* ESR-84* Calcium-8.3* Phos-2.7 Mg-1.8 CRP-6.9* Urine: [**Year (4 digits) **]-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD RBC-1 WBC-26* Bacteri-FEW Yeast-NONE Epi-0 TransE-<1 On Discharge: [**2180-10-7**] 07:03AM [**Month/Day/Year 3143**] Glucose-174* UreaN-20 Creat-1.1 Na-143 K-3.6 Cl-105 HCO3-34* AnGap-8 ============== MICROBIOLOGY ============= [**Month/Day/Year **] Cultures *2 [**2180-9-27**]: No Growth to date Urine Culture [**2180-9-27**]: URINE CULTURE (Final [**2180-9-28**]): <10,000 organisms/ml. Urine Culture [**2180-9-30**]: URINE CULTURE (Final [**2180-10-1**]): YEAST. 10,000-100,000 ORGANISMS/ML.. Stool C. diff toxin A and B [**2180-9-30**]: Negative =============== OTHER STUDIES =============== ECG [**2180-9-27**]: Sinus tachycardia. Non-specific ST-T wave changes. Compared to the previous tracing of [**2180-9-24**] the rate has increased. Chest Radiograph [**2180-9-27**]: IMPRESSION: Interstitial pulmonary edema and small-to-moderate bilateral pleural effusions minimally worsened from the prior chest radiograph on [**2180-9-26**]. Chest Radiograph [**2180-9-30**]: IMPRESSION: Since [**2180-9-27**], pulmonary congestion has improved, bilateral mild-to-moderate pleural effusions are unchanged and left lower lung atelectasis has resolved. Brief Hospital Course: This is an 84 F with CAD, DM c/b neuropathy, PVD s/p multiple amputations, chronic bilateral foot osteomyelitis on vanco/cefepime/flagyl and recent admission for dyspnea attributed to CHF who presents with worsening dyspnea due to diastolic CHF exacerbation. # Acute exacerbation of chronic diastolic CHF: The patient presented with elevated BNP, hypoxia, and pulmonary edema on chest radiograph in the context of hypertension with known diastolic CHF strongly pointing to CHF exacerbation as the etiology of her decompensation. On arrival she briefly required BiPAP in the ED when oxygen therapy proved inadequate. With that and furosemide IV she had a considerable amount of diuresis and improved but as systolic [**Year (4 digits) **] pressures, which were felt to partially drive this exacerbation, required nitroglycerin to control she was admitted to the Medical ICU. There she was not diuresed further (amt removed in [**Name (NI) **] unclear though reported around 2L) and actually developed a positive fluid balance over time in the MICU. Nevertheless, her anti-hypertensive regimen was increased and with better control of her BP's she significantly improved and was off oxygen therapy by her transfer to the floor approximately 24-36 hours after admission. On the floor diuresis was continued with IV furosemide and PO torsemide (given concern the patient may have gut wall edema interfering with absorption) and had brisk diuresis of at least one liter a day. Chest radiograph appeared improved. She was started on beta blocker (switched to carvedilol from metoprolol) and ACEi (switched to enalapril from lisinopril). On day of discharge her "dry weight" was 169lbs. Her cr did increase during hospitalization from 0.6 to 1.2 and diuresis was decreased and vanco was adjusted(see below). She continued to have good urine output throughout hospitalization. On day of discharge her cr was stable at 1.1 and her diuretic regimen was adjusted to TORSEMIDE 10MG DAILY. On transfer to [**Doctor First Name 3504**] [**Doctor First Name **], PLEASE CONTINUE TO MONITOR I+O AND DAILY WEIGHTS. SHE WILL NEED CHEM 7 CHECKED THREE TIMES A WEEK FOR ONE WEEK TO FOLLOW HER RENAL FUNCTION AND THEN IF STABLE DECREASE TO TWICE WEEKLY. . # HTN: On presentation she was hypertensive to the 190's and this was thought to be a major factor in her diastolic CHF exacerbation. She was briefly on nitroglycerin drip but this was able to be weaned off relatively quickly after she received a dose of carvedilol and she later received enalapril (daughter was extremely resistant to restarting lisinopril). With these medications her [**Doctor First Name **] pressure was dramatically better controlled and she was discharged on COREG 12.5 [**Hospital1 **] AND ENALAPRIL 40MG DAILY. # Osteomyelitis of heels: Wounds appeared stable and without signs of acute infection. [**Hospital1 **] cultures were negative. She had low grade fevers but these have been persistent and may be related to drug. She was continued on her vancomycin, cefepime, and metronidazole. Prior to discharge her vanco trough was 25 and her dose was adjusted to 1g q24hours. PLEASE CHECK A VANCO TROUGH ON [**10-9**] PRIOR TO HER DOSE AND ADJUST THE VANCO DOSE FOR A GOAL OF 15-20. SHE NEEDS TO CONTINUE IV CEFEPIME, METRONIDAZOLE AND VANCOMYCIN UNTIL HER APPOINTMENT ON [**10-17**] IN [**Hospital **] CLINIC WHEN HIS CONTINUED THERAPY WILL BE EVALUATED. # Anemia: Pt has a chronic anemia with Hct in mid 20's. Likely etiologies include her chronic osteo and anemia of chronic inflammation though near constant hospitalization and phlebotomy likely playing a role as well. Stools also found to be guiac positive during last hospitalization but brown likely due to her proctolitis seen on imaging. Nevertheless, this would be low grade bleeding and patient's Hct actually improved during this hospitalization likely due to reducing degree of dilution during diuresis. Her hct was stable at 26 on [**10-3**] and no signs of bleeding were noted. Medications on Admission: -Vancomycin 1250 mg IV Q 24H -MetRONIDAZOLE (FLagyl) 500 mg IV Q8H -CefePIME 2 g IV Q12H -Ondansetron 4 mg IV Q8H:PRN nausea -albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for dyspnea -bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. -acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. -lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY. -lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). -docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). -risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for agitation. -levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). -lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY. -metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID. -multivitamin Tablet Sig: One (1) Tablet PO DAILY -heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). -ipratropium bromide 0.02 % Solution Sig: 1-2 puffs Inhalation four times a day. -furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). -fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). -NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty Two (22) units Subcutaneous Q Breakfast: Hold if NPO. -NPH insulin human recomb 100 unit/mL Suspension Sig: Fourteen (14) units Subcutaneous with bedtime: hold if not eating -insulin lispro 100 unit/mL Solution Sig: 0-12 units Subcutaneous four times a day as needed for hyperglycemia: Give per attached sliding scale. -ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a day. -simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**1-2**] nebs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. ipratropium bromide 0.02 % Solution Sig: [**1-2**] neb Inhalation Q6H (every 6 hours). 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. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: do not exceed 3000 mg acetaminophen per day. 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hrs on and 12 hrs off. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 8. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for agitation. 9. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY (Daily). 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 13. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 16. enalapril maleate 20 mg Tablet Sig: Two (2) Tablet PO once a day. 17. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 18. CefePIME 2 g IV Q12H 19. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 20. NPH insulin human recomb 100 unit/mL Suspension Sig: 14-22 units Subcutaneous twice a day: Take 22 units in the AM prior to breakfast and 14 units prior to dinner; hold if not eating. 21. torsemide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 22. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours). 23. Outpatient Lab Work Please draw Chem 7 three times weekly for one week and if creatinine stable can decrease to twice weekly. Please also draw vancomycin trough on [**10-9**] prior to daily dose and adjust vancomycin for goal trough of 15-20. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: Primary Diagnosis: Acute on chronic diastolic CHF Hypertension Secondary Diagnoses: Diabetes Mellitus type 2 Peripheral Vascular Disease Osteomyelitis Hypothyroidism Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted with shortness of breath that was probably due to fluid overload in your lungs. You were treated to remove excess fluid and better control your [**Location (un) **] pressure and you got much better. You are being discharged to continue to recover. Your medications have been changed. Please take all medications as prescribed. Followup Instructions: 1) You will follow up with the doctors in the facility where you go to monitor your breathing and other issues. 2) Department: INFECTIOUS DISEASE When: TUESDAY [**2180-10-17**] at 10:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

30957, 31111

22573, 26604

16318, 16324

31322, 31322

20942, 21003

31871, 32297

19672, 19729

28627, 30934

31132, 31132

26630, 28604

31499, 31848

19798, 20517

31217, 31301

20533, 20923

21442, 22550

8969, 9580

18612, 18798

3856, 5533

16265, 16280

16352, 18592

31151, 31196

21017, 21428

31337, 31475

18820, 19292

19308, 19656

17,628

128,559

53739

Discharge summary

report

Admission Date: [**2179-12-20**] Discharge Date: [**2179-12-31**] Date of Birth: [**2103-10-29**] Sex: M Service: [**Location (un) **] HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 110313**] is a 76 year old Caucasian male with a history of asbestosis and restrictive lung disease who was recently admitted to this hospital from [**12-7**] through [**12-14**] for right lung decortication and pleurectomy. He is now representing with complaints of increased shortness of breath since his prior discharge. During the previous hospitalization, his hospital course was complicated by exacerbation of his congestive heart failure requiring Natrecor. The patient also had two brief episodes of hypotension and syncope. In addition, the patient was discontinued home with a Foley catheter due to the fact that when the Foley catheter was removed prior to discharge the patient was unable to urinate. The patient was to have the Foley catheter removed by the [**Hospital6 407**] services at his home, however, before that has happened the patient is returning to the hospital today. With regards to his current symptoms, the patient states that right after returning home, however, before that as it happened the patient is returning to the hospital today. With regards to his current symptoms, the patient states that right after returning home from his prior discharge he started to develop gradually increasing shortness of breath and weakness. In particular, the symptoms have worsened over the last 48 hours. He also complains of decreased appetite and decreased p.o. intake. He also states that he had intermittent chest pain in a band like fashion across the chest which is worse with activity, however, he states that it is not pleuritic chest pain. He denies any cough, fevers or chills. He denies any nausea, vomiting, diarrhea or abdominal pain. The patient states he has chronic lower extremity edema and has not noticed any change in that in the recent days. With regards to his shortness of breath, the patient specifically notes that it is significantly worse when he is sitting up and therefore has spent most of the previous day lying supine. PAST MEDICAL HISTORY: 1. Asbestosis and restrictive lung disease: The patient is status post recent right lung decortication and pleurectomy. 2. Dilated cardiomyopathy: The patient's ejection fraction is measured at 35%. 3. History of supraventricular tachycardia. 4. Pericarditis. 5. Fatty liver. 6. Alcoholic hepatitis. 7. Status post cholecystectomy. 8. Status post tonsillectomy. 9. History of positive PPD. MEDICATIONS ON ADMISSION: Digoxin .125 mg q. day; Aspirin 325 mg q. day; Protonix 40 mg q. day; Colace 100 mg b.i.d.; Dulcolax prn; Ambien prn; Percocet prn; Flomax .4 q. day; Lasix 40 mg b.i.d.; Diovan 160 mg q. day; Ciprofloxacin for a five day course. In addition, the patient was previously taking Coreg 6.25 mg b.i.d., however, this discharge he had been off of Coreg as it was not included in his discharge medications although he is not certain why. ALLERGIES: 1. Penicillin causes a rash; 2. Shellfish causes anaphylaxis. SOCIAL HISTORY: The patient has no recent alcohol abuse history and denies any tobacco use. PHYSICAL EXAMINATION ON ADMISSION: Temperature 97, pulse 92, blood pressure 132/96, respiratory rate 18, oxygen saturation 100% on 3 liters. In general, the patient is alert and oriented but appears tired and chronically ill. Head, eyes, ears, nose and throat examination: Pupils are equally round and reactive to light. The sclera are anicteric and not injected. The oropharynx is clear with slightly dry mucus membranes. Neck examination: There is no jugulovenous distension or carotid bruit. Lung examination: The patient has bibasilar crackles with decreased breath sounds at the left base, upper fields have better air movement and no crackles. There are no wheezes throughout the lung fields. Cardiovascular examination: There is a regular rate and rhythm with normal S1 and S2. No murmurs or rubs. Abdominal examination: Soft, nontender, nondistended. The liver edge is 3 cm below the costal margin, positive bowel sounds. Extremity examination: There is 3+ pitting edema of bilateral lower extremities. The feet are warm to the touch with 2+ dorsalis pedis pulses. There is no calf tenderness. Neurological examination: Though the patient is limited by his shortness of breath, he has a grossly intact neurological examination. LABORATORY DATA: On admission laboratory data revealed complete blood count showing a normal white count of 8.0, with a decreased hematocrit of 30.4, platelets 295. Chem-7 is significant for a sodium of 128. Digoxin level was .6, TSH was within normal limits. Urinalysis was within normal limits. Chest x-ray shows left pleural effusion which was unchanged. It also shows right and left mid lungs on opacities. There is no evidence of congestive heart failure. Electrocardiogram, low voltage limb leads, normal axis, normal intervals and T wave flattening isolated to V2. No ST or other T wave changes. HOSPITAL COURSE: 1. Shortness of breath - The patient was clearly exhibiting ....................<as he had significant increase in shortness of breath while upright and could not tolerate this for more than a few seconds. The most likely causes of his shortness of breath are his congestive heart failure, pneumonia, pleural effusion, and myocardial infarction. The patient was ruled out for an myocardial infarction by cardiac enzymes. It was thought that initially his most likely etiology was congestive heart failure exacerbation. Therefore he was diuresed with Lasix. The day after admission he showed significant improvement in his symptoms, however, subsequently he began to gradually worsen. At this point it was felt that the symptoms were not only due to congestive heart failure, a computerized axial tomography scan was obtained which showed a loculated effusion in the right lung and a loculated smaller effusion in the left lung as well as a questionable right upper lobe ground-glass opacity. As the patient was worsening and there was this opacity seen on the x-ray there was a concern that there might be a pneumonia contributing to the patient's symptoms. Therefore, he was started on Levaquin initially for the treatment of community acquired pneumonia. When his symptoms again worsened, he was also started on Vancomycin given that he had recently been in the hospital and could have a Methicillin-resistant Staphylococcus aureus infection. It was felt that the patient's symptoms most likely were due to his significant pleural effusion, especially on the right side. Therefore he was scheduled for a pigtail catheter to be placed in the right pleural effusion for drainage. This was done by Radiology. When this catheter was placed, there was a sanguinous drainage initially and that subsequently became serosanguinous. After the patient's pigtail catheter placement due to the bloody drainage he was having, he was transferred to the Medicine Intensive Care Unit for closer monitoring. He had an uncomplicated Medicine Intensive Care Unit course where he received blood product transfusions both for clotting and for maintenance of his hematocrit. He did well in the Medicine Intensive Care Unit and after the placement of the pigtail catheter had a significant improvement in symptoms. He is able to sit forward with minimal shortness of breath. Several days after the initial pigtail catheter placement and an inferior infusion, the patient went back to Radiology for a thoracentesis of the right anterior loculated infusion. After this drainage, the patient did report mild symptomatic improvement though not as significant as after the previous drainage. Prior to discharge, the patient's pigtail catheter continued to produce approximately 300 cc of serosanguinous output per 24 hours. The plan was to maintain the catheter in place until the drainage tapered off. 2. Pneumonia - Though there is no definite evidence of pneumonia, given the patient's continuous respiratory status, it was felt that he would benefit from treatment. So, he was started on Levaquin and Vancomycin as stated above. He would continue on both of these for a total of 14 days. 3. Wound infection - Several days into the hospital admission it was noted that the patient's surgical wound from his prior admission on the right posterior torso was producing exudate as well as a foul odor. Thoracic Surgery debrided this wound. There was also material sent off for culture which grew out Methicillin-resistant Staphylococcus aureus bacteria. As the patient was already started on Vancomycin, this was continued for the treatment of his wound infection. At no point did the patient present signs of advancing infection such as bacteremia or sepsis. 4. Congestive heart failure - Although the patient was initially treated for his congestive heart failure with more aggressive diuresis with Lasix, it is unlikely that he had any significant congestive heart failure exacerbation. He was continued on Digoxin and Lasix initially. He was also restarted on his Coreg at a lower dose of 3.125 mg b.i.d. After several days the Lasix was discontinued as the patient had limited p.o. intake and did not require any diuresis. He was maintained on a 2 gm sodium diet and fluid restriction. 5. Hematology - The patient had an elevated INR prior to his pigtail catheter placement. He required transfusion of fresh frozen plasma in order to perform the procedure. He had also previously been on Aspirin due to his heart disease. This was held several days prior to the procedure and was restarted due to continued serosanguinous drainage from his pigtail catheter. 6. Fluids, electrolytes and nutrition - The patient was hyponatremic on admission, however, this was a chronic condition for him, likely secondary to congestive heart failure. His sodium level remained stable throughout the hospital admission and no further workup or treatment was initiated for this. 7. Code status - The patient was Do-Not-Resuscitate, Do-Not-Intubate on admission and on discharge. DISCHARGE STATUS: The patient is to be discharged to a pulmonary rehabilitation facility. DISCHARGE CONDITION: The patient is in good condition, he is afebrile, hemodynamically stable and tolerating p.o. and able to tolerate light activity with assistance. DISCHARGE MEDICATIONS: 1. Coreg 3.125 mg b.i.d. 2. Levaquin 500 mg q. 24 hours to be continued for a total course of 14 days. 3. Protonix 40 mg q. day. 4. Digoxin .125 mg q. day. 5. Vancomycin 1 gm intravenously q. 12 hours to be continued for a total of 14 days. 6. Ambien 5 to 10 mg p.o. q.h.s. prn 7. Colace 100 mg p.o. b.i.d. 8. Dulcolax 10 mg p.o. q. day prn FOLLOW UP INSTRUCTIONS: The patient will be followed up at his Pulmonary Rehabilitation. He will also follow up with his primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] and with Cardiothoracic Surgery and Dr. [**Last Name (STitle) 175**]. This discharge summary will be addended in a future dictation. [**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**] Dictated By:[**Name8 (MD) 5709**] MEDQUIST36 D: [**2179-12-31**] 08:18 T: [**2179-12-31**] 08:30 JOB#: [**Job Number 110314**]

[ "998.59", "428.0", "486", "501", "428.33", "511.9", "518.0", "425.4", "276.1" ]

icd9cm

[ [ [] ] ]

[ "99.07", "86.28", "99.04", "34.04", "38.93", "34.91" ]

icd9pcs

[ [ [] ] ]

10334, 10481

10504, 11472

2644, 3154

5135, 10312

185, 2193

3284, 5117

2215, 2617

3171, 3269

11,526

148,870

31036

Discharge summary

report

Admission Date: [**2122-7-30**] Discharge Date: [**2122-8-4**] Date of Birth: [**2057-12-2**] Sex: F Service: PLASTIC Allergies: Tape Attending:[**First Name3 (LF) 7733**] Chief Complaint: L dorsal wrist/hand defect from previous partial flap failure. Major Surgical or Invasive Procedure: 1. Free microvascular right radial forearm flap to dorsal aspect of left hand (microvascular). 2. Plastic closure right forearm. 3. Splint immobilization right and left forearms. 4. Split-thickness skin graft left forearm. History of Present Illness: [**Known firstname 40658**] is a familiar patient to our hand service. She, several months ago, had a subtotal incomplete amputation followed by revascularization of the entire wrist and hand, as well as open reduction of a very complex disarticulation injury. She recently had coverage of exposed plate on the dorsal aspect of the hand with a reversed dorsal interosseous tissue flap. A portion of this did not survive, namely the distal portion, and she comes back today for coverage of residual area of exposed plate and carpal bones. A free flap from the opposite forearm with primary closure of the opposite forearm was chosen. The recipient vessels were the radial artery in the mid forearm. Several days ago an angiogram had documented the patency. Past Medical History: DM II, HTN, Hypercholesterolemia Social History: Lives alone near [**Last Name (un) 17679**]. Works two jobs - factory in evening, housecleaning in daytime. Never smoked. Does not drink, no drug use. Family History: Non-contributory Physical Exam: On Discharge Alert and Oriented RRR no murmurs Lungs clear to auscultation R forearm incision intact and without erythema. Steri strips in place. L doral wrist with STSG in place without evidence of necrosis. Splint in proper position. Brief Hospital Course: Taken to the OR for free flap and STSG to L dorsal wrist. Tolerated the procedure well, was extubated and transferred to the floor without incident. Dopplers were strong throughout the hospital course. Drain was removed on [**8-2**]. Was maintained on abx. [**8-3**] R hand dressing taken down. L hand dressing down and changed. Skin graft is taking well. OOB walking without assistance. [**8-4**] was discharged from the hospital ambulating, tolerating diet, and pain controlled. Medications on Admission: Glyburide, norvasc, lipitor, advair Discharge Medications: 1. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 10 days. Disp:*40 Capsule(s)* Refills:*0* 2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 56860**] nursing care Discharge Diagnosis: L wrist/hand defect from previous partial flap failure Discharge Condition: stable Discharge Instructions: Please return to the hospital if you experience fevers greater then 101.4, chills, or other signs of infection. Also return to the hospital if you experience chest pain, shortness of breath, redness, swelling, or purulent discharge from the incision site. Return if you experience worsening pain or any other concerning symptoms. Certain pain medications may have side effects such as drowsiness. Do not operate heavy machinery while on these medications. Certain pain medications such as percocet or codeine can cause constipation. If needed you can take a stool softner such as Colace (one capsule) or gentle laxative (such as Milk of Magnesia) once per day. Restart taking all your regular medications once you arrive at home. . Please resume previous medications as prior to your surgery. Please take pain medications and stool softener as prescribed. . Please follow-up as directed. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 5385**] in one week [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 7738**]

[ "250.00", "401.9", "998.83", "278.00", "E878.8", "E849.8" ]

icd9cm

[ [ [] ] ]

[ "86.70", "86.69" ]

icd9pcs

[ [ [] ] ]

2691, 2755

1883, 2370

326, 558

2854, 2863

3800, 3986

1589, 1607

2457, 2668

2776, 2833

2396, 2434

2887, 3777

1622, 1860

224, 288

586, 1344

1366, 1401

1417, 1573

76,782

101,278

50450

Discharge summary

report

Admission Date: [**2104-8-9**] Discharge Date: [**2104-8-20**] Date of Birth: [**2035-1-17**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Sulfonamides Attending:[**First Name3 (LF) 3016**] Chief Complaint: right upper extremity weakness, dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 69 yo F with DM, COPD, metastatic breast CA s/p cycle 1 of adriamycin/cytoxan [**5-29**] awaiting 2nd cycle who was recently seen in [**Hospital **] clinic and noted to have persistent RUE weakness. MRI C spine showed mets to C5-C7 causing moderate compression of cord. She was admitted on [**8-9**] for spine eval and treatment. She was started on steroids. Pt triggered on [**8-10**] afternoon for hypotension, low UOP, and hypoxia. Pt refused interventions. Started on broad abx and reportedly stabilized. . Tonight she was noted to be hypoxic to 85% on 6L. She was "difficult to arouse." O2 sats improved with NRB. VBG showed 7.44/47/47 w lactate 1.0. Review of prior admit suggested that she became altered almost nightly until rx with BiPAP which successfully treated her sx. This was tried on the floor but patient became hypoxic and did not tolerate mask. She is admitted to ICU for w/u and rx with BiPAP. . Currently, she reports that she wants to be left alone. She denies any CP, SOB, abd pain. . Of note, she was hypoxic during her previous admission in [**Month (only) 116**]/[**Month (only) **]. At that point, the etiology was unclear. It was thought [**2-23**] lymphangitic spread of tumor. Also considered PE (although CTA neg) and tamponade (although echo not c/w hd sig tamponade). Also considered fluid overload and she seemed to improve somewhat with diuresis. It was ultimately thought that sleep apnea was large contributor. She was treated w BiPap nightly with significant improvement in mental status. Past Medical History: 1. Diabetes. followed at [**Last Name (un) **] Diabetes Center. Her last hemoglobin A1c was 6.0 in 05/[**2104**]. 2. Hypercholesterolemia/?hypertension 3. Schizoaffective disorder. The patient is followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] and is on Clozaril with q 1 month CBCs 4. COPD/Asthma. The patient is maintained on Advair and albuterol for this. She does state that she uses her albuterol approximately one time per day. Her last pulmonary function tests were in [**2096**]. 5. h/o Falls 6. Back pain 7. ? Severe sleep apnea: as documented above and per recent d/c summary. Improved with BiPAP in the unit last month. . Breast Ca history: - dx [**2104-6-9**] w dyspnea, hypoxia, falls w right breast mass - [**6-17**]: cytoxan, adriamycin, neupogen, emend, steroids Social History: Has been residing at [**Hospital 100**] Rehab since her last hospitalization. Health Care proxy is [**Name (NI) **] [**Name (NI) **]. She does not smoke but notes that her mother smoked heavily.(HCP [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 105120**]). Family History: The patient's grandmother had coronary artery disease. Her parent's died of cervical cancer and stroke. Physical Exam: VS: 96.8 HR 97 94/43 20 100% NRB and 94% on 60% FiO2 Manual BP 126/60 w pulsus of [**6-29**] Gen: sleepy but arousable. Neuro: AAO to person, place, situation, time. Does fall asleep mid-sentence. localizes to voice, withdraws/localizes to pain. - cn: PERRLA, EOMI although limited by lack of cooperativity. face symmetric. - motor: 3/5 strength RUEx, [**5-26**] LUEx. lower ex limited by effort although at least [**3-26**] bilat. - toes equiv bilat. 1+ ankle and knee bilat Heent; Dry MM, JVP flat Cards: RRR no MGR Lungs: no rales, CTAB Abd: obese, mildly tender diffusely. No rebound or guarding Ext: edema throughout Pertinent Results: EKG [**8-10**]: NSR NA NI, TW flattening V5-V6. no apprec right heart strain other than small Q in III. . 140 102 12 ---------------< 178 3.8 31 0.5 . WBC: 11 - stable HCT: 27 - stable PLT: 526 - stable PT: 16.0 PTT: 34.3 INR: 1.4 . VBG: 7.44/47/47 lactate 1 . ABG on arrival to unit: [**Unit Number **].39/53/114/33 . CXR: my read: linear atelectasis right mid lung but no evidence of PNA. Stable widening of mediastinum. . MRI Brain prelim: Multiple intracranial metastases, many of which are leptomeningeal. Right frontal epidural metastasis. Multiple bone metastases. . [**8-9**] MRI C-spine w/o contrast: (PRELIM): Metastatic disease involving C5-C7 vertebral bodies with vertebral collapse and retropulsion and epidural component causing moderate compression on the cord. . TTE [**8-11**]: Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to increased stroke volume due to aortic regurgitation. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Small, hyperdynamic left ventricle with normal regional systolic function. Trivial pericardial effusion without tamponade. Compared with the prior study (images reviewed) of [**2104-6-17**], the pericardial effusion is smaller. The other findings are similar. [**2104-8-9**] 12:50PM GLUCOSE-234* UREA N-11 CREAT-0.6 SODIUM-140 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-31 ANION GAP-11 [**2104-8-9**] 12:50PM estGFR-Using this [**2104-8-9**] 12:50PM ALT(SGPT)-14 AST(SGOT)-26 LD(LDH)-285* ALK PHOS-186* TOT BILI-0.3 [**2104-8-9**] 12:50PM WBC-9.3 RBC-3.44* HGB-8.9* HCT-28.9* MCV-84 MCH-25.8* MCHC-30.7* RDW-22.7* [**2104-8-9**] 12:50PM NEUTS-82.6* LYMPHS-6.9* MONOS-6.0 EOS-4.1* BASOS-0.4 [**2104-8-9**] 12:50PM PLT COUNT-623* [**2104-8-9**] 12:50PM PT-15.4* PTT-32.1 INR(PT)-1.4* Brief Hospital Course: # Metastatic breast cancer: with C5-7 cord compression, right upper extremity weakness improving on steroids. Also found to have brain metastases and the patient has been treated with Decadron. After extensive discussion with Ms. [**Known lastname 5655**], her HCP and her outpatient psychiatrist, further chemotherapy or radiation was refused. She was determined to have capacity to make this decision and understands the risk of paralysis without treatment. She will be discharged to maximize functional status and control symptoms. . # Resp failure/hypoxia: intermittent and likely related to obstructive sleep apnea. Ms [**Known lastname 5655**] refused all interventions, including BiPAP/CPAP and occassionally oxygen. She was treated with an 8 day course of antibiotics for health care associated pneumonia with improvement in her pulmonary status. She was maintained on nebulizer treatments and was on 4L O2 nasal canula at discharge. # Altered ms: underlying psychiatric illness with intermittent hypoxia related to obstructive sleep apnea and brain metastases. She waxed and waned through the hospitalization, but was at our observed baseline at discharge. Her outpatient dose of clozapine was continued initially however the patient had periods of agitation during her admission and the clozapine was held. Her agitation was treated with ativan and zydis as needed. The clozapine was not restarted on discharge. # Hypotension: The patients home dose of lisinopril was held second to her hypotension on admission. Her blood pressure remained in the 130/60-70s so the lisinopril was not restarted. She may need to be monitored for hypertension and be re-evaluated by her primary physician when lisinopril can be restarted safely. # ID: For her cough with productive sputum, the patient completed a course of vancomycin and zosyn. Her cough improved and she remained afebrile for the duration of her admission. At discharge she was complaining of dysuria and frequency, but was unable to provide a urine sample. She will be empirically treated with a 7 day course of ciprofloxacin (history of pan-sensitive e.coli in the past) # DM: Outpatient doses of NPH were continued including a sliding scale insulin as needed. #Seizure: the day prior to discharge, she had new onset complex partial seizure manifested as left lateral eye gaze with blinking and incontinence. The seizure activity was stopped with 2mg IV ativan. She was started on Keppra 500 mg [**Hospital1 **] without any recurrence of seizure activity. Medications on Admission: Albuterol IH q 4-6 hours prn aspirin 81 mg daily Clozapine 125mg qAM, 100mg qPM SC heparin advair 250-50 [**Hospital1 **] ibuprofen 600 mg tid lisinopril 10 mg daily ondansetron 4mg q8 prn oxycodone 5 mg q4 hours prn pioglitazone 45 mg daily spiriva 1 puff daily acetaminophen prn bisacodyl prn docusate sodium [**Hospital1 **] NPH 75 units q AM, 34 units in PM omeprazole 20 mg daily vitamin D 800mg daily vancomycin 1g IV q 12 metronidazole 500 PO TID Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: [**1-23**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 2. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: [**1-23**] Adhesive Patch, Medicateds Topical DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**1-23**] Inhalation Q4H (every 4 hours). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 13. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every [**4-27**] hours as needed for pain. 14. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO once a day. 15. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for constipation. 16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Seventy Five (75) Units Subcutaneous qAM. 17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty Five (35) Units Subcutaneous qPM. 18. Cipro 250 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Metastatic breast cancer-brain, bone C5-C7 spinal cord compression [**Hospital 77965**] Healthcare associated pneumonia Diabetes mellitus Hypertension Schizoaffective disorder with paranoia Discharge Condition: Stable, refusing further intervention for metastatic breast cancer and spinal cord compression. Goals of care are symptom control and maximization of function. Discharge Instructions: You were admitted with arm weakness and were found to have breast cancer spread to your bones and brain. You were treated with steroids, but declined further chemotherapy or radiation therapy. You will be discharged to a rehabilitation facility to help maximize your function and control your symptoms. You understand the potential for paralysis with untreated spinal cord compression. . Please call your doctor or return to the ED if you develop chest pain, shortness of breath, inability to tolerate your medications or any other concerning symptom. Followup Instructions: Please follow up with your doctors at the [**Hospital3 **] facility. [**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11028, 11094

6247, 8778

336, 342

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3825, 6224

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34848

Discharge summary

report

Admission Date: [**2130-8-12**] Discharge Date: [**2130-8-18**] Date of Birth: [**2063-7-5**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 30**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Intubation for respiratory failure Bronchoscopy Ultrasound guided thoracentesis History of Present Illness: Ms. [**Known lastname 30207**] is a 67 yo woman with COPD, SCLC (s/p chemo/XRT), who presented [**8-12**] to OSH with SOB that awoke her from sleep. She was treated for CHF exacerbation with nitro gtt and diuresis, despite no known history of heart disease. EKG at OSH notable for T-wave inversions v2-v4, II, avF which later normalized. She was also noted to have a leukocytosis with WBC 15k and 5% bands. She was transferred to [**Hospital1 18**] MICU. . On arrival to [**Hospital1 18**] ED, BP=117/64, HR=110, RR=22, sat recorded as 98%. Pt transported on BIPAP 10/5. Nitro drip initially continued and pt given first doses of ceftriaxone, azithro, and levaquin. Pt's pressures dropped to SBP~60-70s, still mentating. Nitro drip was discontinued. Soon after this, pt reportedly requested intubation for increased work of breathing. Pt intubated with versed boluses for sedation and sent for CTA prior to arrival to floor. CTA notable for no PE, RLL consolidation, extensive emphysematous changes, possible empyema. She was admitted to the MICU. . In the MICU, she underwent broncoscopy with removal of RLL mucous plug. Respiratory function improved considerably and she was extubated promptly. Ceftriaxone, vanc, and clinda were given initially. However, vanc and clinda were discontinued the morning of [**8-15**] as this was felt to be more likely community-acquired PNA. Currently breathing well on RA. The conclusion of the MICU team was that her recent respiratory failure was primarily of an infectious rather than CHF etiology. She has continued to be intermitently low-grade febrile. . Mental status has also been an issue. At baseline she has dementia with 24- hour home care. In the MICU she has been intermittently agitated getting xanax .25 mg q6h PRN with good effect. Additionally, IP was consulted to evaluate if stent placement would be beneficial; they advised against any such intervention. . On acceptance to the medicine service, the patient denies shortness of breath, cough, chest pain, or hemoptysis. She further denies abdominal pain, diarrhea/constipation, blood in bowel movements, pain with urination, or other complaints. Past Medical History: 1. SCCa of the lung, "limited stage", diagnosed [**6-2**] -- s/p platinum/etoposide chemo + XRT (RLL, hilum, mediastinum) at [**Hospital1 18**], completed course on [**2129-12-15**]/ -- followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27542**] with serial CTs -- refused prophylactic cranial radiation therapy 2. COPD - no PFT testing 3. Previous PNA requiring intubation [**2-3**] 4. Dementia: neagtive w/u during last hospitalization in [**2-3**] 5. Hypertension Social History: Lives alone with 24hr nursing care. Has been in and out of rehab last several months. +tobacco use (1 ppd x24 years). quit in [**Month (only) 116**] [**2129**] when she was diagnosed with SCLC. Denies EtOH or illicit drug use recently. Attorney/HCP is [**Name (NI) **] [**Name (NI) 52403**] [**Telephone/Fax (1) 79789**]. No immediate family; neighbors check on her frequently and are acting as next of [**Doctor First Name **]. Neighbours [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17926**] [**Telephone/Fax (1) 79794**] [**Doctor Last Name **]: [**Telephone/Fax (1) 79795**] House: [**Telephone/Fax (1) 79796**]. Discussion with [**Doctor First Name **] - states that she has not been safe at home, leaving gas on, fidgeting with circuit breakers. Family History: no history of cancer in the family. Physical Exam: Discharge exam: General: Alert, oriented x1, no acute distress. Patient appears very thin. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased breath sounds and dullness to percussion Right lung base; otherwise clear. negative egophony. 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 neuro: CNII-XII intact, strength and sensation grossly intact. Brief Hospital Course: This is a 67 F with a history of SCLC and previous PNA presneting with a large (complex appearing) RLL consolidation, leukocytosis w/ left shift, and respiratory distress requiring intubation, all of which suggest a significant RLL pneumonia. . Hospital course by issue: . # PNEUMONIA: Large RLL consolidation, white count, and increasing O2 requirement all c/w PNA. Not displaying septic physiology currently although UOP on admission was the lower end of normal. Surprising that she did not present sooner given magnitude of PNA. On Ceftriaxone, Clindamycin, and Vancomycin for possible cavitary pneuomonia. Low UOP was likely [**2-27**] to infection and third spacing. She was given IVF with goal UOP > 30cc/hr. A bronchoscopy was also done on [**2130-8-13**] to look for endobronchial lesions. No obvious abnormality, besides a large mucous plug was found. Sputum was sent for gram stain and cytology. The night of [**2130-8-13**] the patient had a temperature spike of 101F. Blood, urine, sputum, and stool cultures were resent, none of which came back positive. She also underwent a thoracentesis on [**2130-8-17**] for drainage of a right sided pleural effusion that was suspicious for empyema. Drainage showed no frank pus, likely a complicated parapneumonic effusion. Air seen on CT prior had decreased, this was thought to be a bronchopleural fistula that has since sealed. She shall need a follow up CT scan. Pt was switched to levofloxacin 750mg to finish a 10 day course. . MS changes - patient had waxing and [**Doctor Last Name 688**] mental status initially, now stable, although still has baseline dementia. . # ARF: Cr initially at 1.5 from baseline of 1.0. Likely intravascular depletion in the setting of third spacing from significant infection. Has since improved back to baseline during hospital course. . # Anemia: Pt found to have hct down as low as 23. During hospital course, has stabilized to 28. Iron studies sent consistent with anemia of chronic inflammation. . # SCLC: to follow up with Dr. [**Last Name (STitle) **] in [**Hospital1 **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23509**] . #Rash: Pt developed a urticarial rash on back and legs just prior to discharge that was itchy. This was believed to be a contact dermatitis, and she was given [**Name (NI) 6398**] lotion for symptomatic relief. . # Communication: Patient + HCP/ATTORNEY [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 79797**] . # Dispo: To [**Doctor Last Name **] green nursing home. However, the patient has safety issues at home and will need social work to help work with HCP to determine best future course. Medications on Admission: lisinopril 2.5 mg daily alprazolam 0.25mg q6h PRN furosemide 20mg daily paxil 10mg daily metoprolol 12.5 mg [**Hospital1 **] MVI Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q4H (every 4 hours). 2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: Five (5) ML PO BID (2 times a day) as needed for Constipation. 7. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for agitation. 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 12. [**Hospital1 6398**] Anti-Itch 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for itching. 13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 14. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Discharge Disposition: Extended Care Facility: [**Doctor Last Name **] Green Nursing & Rehab Center - [**Hospital1 **] Discharge Diagnosis: Primary: Pneumonia Secondary: Small Cell Lung Caner Dementia Discharge Condition: Hemodynamically stable, back at baseline O2 requirement. Discharge Instructions: You were admitted to [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Hospital with Pneumonia. Pneumonia is an infection of your lungs that can be caused by bacteria, viruses or other organisms. In your case, your infection was very serious in that it required a breathing tube to be put down your throat to help you breath. You were also given antibiotics to fight the infection, one of which is called levofloxacin. You are being discharged with this antibiotic, and you should take this medication for it's full prescribed course. . Because of your pneumonia, you also had a collection of fluid next to your lung. This was drained while you were here at the hospital. You should follow this up with your primary care provider or your oncologist, either Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 23509**] . Also, when you were first admitted to the hospital, you were extremely confused. This has improved somewhat, however we are very concerned for your continued safety once you leave the hospital because of your propensity to become confused. It is important that you continue to stay in a skilled nursing facility where there are people that can help you 24 hours a day. . Finally, while you were in the hospital, you developed a rash that was itchy and was likely due to an allergy to something that your skin touched. We gave you [**Last Name (STitle) 6398**] lotion to help with the itching. If this worsens a great deal or you begin to have difficulty breathing, please contact your primary care doctor or go to the nearest emergency department. . Please take all medications as directed. . If you begin to have trouble breathing, have chest pain or start having fevers greater than 101.4, please contact your primary care provider or go to the nearest emergency department. Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in radiation oncology. You have an appointment with him at [**Hospital1 **] on [**2130-9-11**] at 9am. Also, please make a follow up appointment with your oncologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23509**]. You should have a CT scan in the next several months to follow up on your pleural effusion. You can set this up with Dr. [**Last Name (STitle) 23509**], his contact information is below. [**Last Name (NamePattern1) **] [**Location (un) 669**], [**Numeric Identifier 79798**] ([**Telephone/Fax (1) 79799**] Completed by:[**2130-8-18**]

[ "496", "584.9", "162.8", "782.1", "518.81", "486", "285.9" ]

icd9cm

[ [ [] ] ]

[ "33.23", "96.04", "34.91", "96.71" ]

icd9pcs

[ [ [] ] ]

8865, 8963

4578, 7277

309, 391

9069, 9128

11045, 11720

3895, 3932

7456, 8842

8984, 9048

7303, 7433

9152, 11022

3947, 3947

3964, 4555

250, 271

419, 2573

2595, 3091

3107, 3879

76,801

184,425

38327

Discharge summary

report

Admission Date: [**2139-3-30**] Discharge Date: [**2139-4-14**] Date of Birth: [**2095-12-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Thoracentesis with pigtail catheter insertion - Right [**2139-3-31**], Left [**2130-4-1**] Left thoracotomy Bronchoscopy with tumor debulking, recanalization of airway PICC placement History of Present Illness: Ms. [**Known lastname 1661**] is a 43 y/o female with a h/o advanced NSCLC dx [**2138-8-14**] s/p chemotherapy x 6 cycles, who was originally admitted to an OSH on [**2139-3-21**] due to severe nausea and vomiting. Regarding prior cancer history, she is s/p 6 cycles of chemotherapy with [**Doctor Last Name **]-alimta-erbiltix. Repeat CT scan [**2139-3-11**] showed progression despite this therapy, thus she started Taxotere on [**2139-3-18**]. Following this she developed severe N/V and was unable to keep any fluid down. On [**3-21**] when she presented to the OSH, with these symptoms and shortness of breath. She was found to have pericardial effusion with tamponade physiology. A pericardial drain was placed [**3-21**]. On [**2139-3-24**] she underwent bronchoscopy with limited left anterior thoracotomy with creation of a pericardial window. Bronchoscopy revealed a intraluminal lesion in her right main bronchus with almost complete obstruction. She was uneventfully extubated post-operatively [**3-24**] and transferred back to the medical floor [**2139-3-25**]. As she continued to have shortness of breath and high oxygen requirement, she was transferred back to the ICU on [**2139-3-30**]. She was then transferred to the ICU at [**Hospital1 18**] with plan for IP evaluation and possible stenting the following morning. ABG at 0648 [**2139-3-30**] on 15L O2, 7.43/43/63. VS on transfer 112/59, 117, 37, 99, 95/NRB. Upon arrival to [**Hospital1 18**], patient able to speak in [**3-19**] word sentences but overtly tachypnic with minimal exertion. Relays history as above. Continues to have pain along lower left breast after thoracotomy. Also intermittently feels like 'having a panic attack' with increased shortness of breath and rapid breathing. She is generally able to 'calm herself' through these episodes and is unsure what causes them. She denies any constipation. She was previosly able to go to commode up to 3 days prior but then SOB has inhibited her. She had a Foley placed today when getting on the bedpan became too much work. Sometimes talking can also be painful along her ribs. She last ate this morning. Past Medical History: NSCLC: Dx [**2137**] s/p chemotherapy x 6 cycles with [**Doctor Last Name **]-alimta-erbiltix; with disease progression [**2139-3-11**]; started Taxotere [**2139-3-18**] x 1 Pericardial effusion with tamponade [**2139-3-21**] Social History: Previously worked in [**Last Name (un) **] management prior to cancer diagnosis. Lives with significant other, [**Name (NI) **], for last 10 years. Three children (23 - son, 18 - son, 13 - daughter) and is very close with mother, [**Name (NI) 2155**] [**Name (NI) 85401**]. - Tobacco: None - etOH: None - Illicits: None Family History: Mother with history of breast cancer. Sister with noncancerous cysts removed. One aunt with unknown cancer. Physical Exam: Admission Physical Exam VS: 97.2, 117, 104/73, 35 and 100/NRB GEN: Appears calm at rest but HEENT: NCAT, NRB in place, mouth breathing CV: Tachycardia, regular, without murmur PULM: Course breath sound with more bronchial breath sounds on right; thoracotomy incision with dressing clean, dry, intact and no erythema or exudate ABD: Mildly distended, nontender with minimal bowel sounds LIMBS: WWP without edema SKIN: With some eccymoses on abdomen, no erthyema around PIVs NEURO: A&O x 3 . Pertinent Results: Admission labs: [**2139-3-30**] 09:45PM BLOOD WBC-6.8 RBC-3.33* Hgb-10.1* Hct-29.2* MCV-88 MCH-30.4 MCHC-34.7 RDW-15.6* Plt Ct-329 [**2139-3-30**] 09:45PM BLOOD Neuts-46* Bands-2 Lymphs-19 Monos-28* Eos-3 Baso-2 Atyps-0 Metas-0 Myelos-0 [**2139-3-30**] 09:45PM BLOOD PT-14.0* PTT-31.4 INR(PT)-1.2* [**2139-3-30**] 09:45PM BLOOD Glucose-83 UreaN-10 Creat-0.7 Na-140 K-4.4 Cl-102 HCO3-25 AnGap-17 [**2139-3-30**] 09:45PM BLOOD ALT-34 AST-33 AlkPhos-124* [**2139-3-30**] 09:45PM BLOOD Albumin-2.4* Calcium-8.3* Phos-3.8 Mg-1.7 . CXR [**2139-3-30**]: Homogeneous opacity of the right hemithorax with mild rightward mediastinal and tracheal shift , with abrupt cutoff of the right main bronchus is concerning for right hilar mass lesion with collapse of the right lung. Recommended a CT chest with contrast for further evaluation. . Pleural Fluid: ATYPICAL. Two highly atypical cells in a background of mesothelial cells, histiocytes, lymphocytes, and neutrophils. . CT chest with contrast [**2139-3-31**]: 1)large right hilar mass which infiltrates the collapsed right middle and lower lobes and obstructs the right main stem bronchus just beyond its takeoff. contiguous with extensive mediastinal lymphadenopathy 2) large right and moderate left pleural effusion and large pericardial effusion. . ECHO: The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a moderate sized pericardial effusion. An apical pericardial adhesion cannot be excluded. No right ventricular diastolic collapse is seen. Brief RA invaginaiton is seen (evidence of elevated intrapericardial pressure without overt tamponade present). . TEE: TEE done s/p pericardial window to assess for adequacy of drainage. The left atrium is normal in size. Left ventricular wall thicknesses are normal. Regional left ventricular wall motion is normal. with mild global free wall hypokinesis. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. The pericardium appears thickened. There are pericardial calcifications. There are no echocardiographic signs of tamponade. All findings discussed with surgeons at the time of the exam. . Pericardial Fluid: POSITIVE FOR MALIGNANT CELLS, consistent with adenocarcinoma. , EKG: Sinus tachycardia. Left atrial abnormality. Low limb lead voltage. T wave inversion in leads I and aVL, leads V2-V6 with ST-T wave flattening in leads II, III and aVF. These findings may represent anterolateral ischemic process. No previous tracing available for comparison. Followup and clinical correlation are suggested. QTc430 . Bilateral LENI: No evidence of deep venous thrombosis within the lower extremities bilaterally . Portable TTE (Focused views) Done [**2139-4-12**] at 6:03:31 PM The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). The estimated cardiac index is high (>4.0L/min/m2). Right ventricular chamber size and free wall motion are normal. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Well seated aortic valve bioprosthesis with higher than expected transaortic gradient which may be due to hyperdynamic left ventricular function. No prior studies for comparison. Brief Hospital Course: 43 y.o. Female patient w/ metastatic NSCLC s/p 6 cycles of [**Doctor Last Name **]-alimta-erbiltix, taxotere with disease progression transferred from OSH w/ pericardial/pleural effusion, RML/RLL collapse [**12-16**] tumour burden s/p rigid bronch with debridement, several pericardial windows/drain placement, pleuredesis. Transferred from CT surgery to OMED for XRT with goal for possible stenting of RML, RLL bronchus. ##. NSCLC/pericardial effusion: Pt has undergone 6 cycles of [**Doctor Last Name **]-alimta-erbiltix, now on taxotere but with continued disease progression. Found to have an intraluminal lesion in her right main bronchus with almost complete obstruction of the RML and RLL for which she underwent rigid bronchoscopy with some tumor debridement and recanualization. Patient also received XRT with original plan to shrink tumor enough to allow possible stenting by IP. However, patient had recurrent pericardial effusion due to malignancy. This effusion was originally drained at her OSH prior to transfer, once tranferred she underwent left and sub-xiphoid pericardial windows placed with cardiac surgery. Despite this intervention, the patient's respiratory status worsened, repeat TTE showed persistent posterior loculated effusion with persistent tamponade physiology. Transferred to the CCU for further evaluation and management on [**4-12**]. She was evaluated by cardiac and thoracic surgery as well as interventional cardiology. After lengthy discussion it was determined that the only way to approach the effusion was with open sternotomy. The patient and her family declined this intervention and indicated that they would like to focus on comfort care. Ms [**Known lastname 1661**] is still interested in pursuing palliative XRT as well as potentially any palliative chemotherapy such as erlotinib that may be available to her. Patient and family request transfer back to [**Hospital2 **] [**Hospital3 6783**] to be closer to home. #. SOB/hypoxia - likely multifactorial. Patient has pericardial effusion, pleural effusion, and obstructive lung malignancy. Effusions around lungs and heart were already drained with pericardial window x2 and chest tube, however with reaccumulation of fluids. Patient made decision to be comfort care only and declined [**Doctor First Name **] further drainage of pleural effusions. IV fluids were intermittently bolused as needed to keep preload elevated. Pt was continued on NRB 02 mask for comfort and support. #. Leukocytosis/UTI - pt has had a stably high WBC count in the 27-29's, but no signs of sepsis. Possibly due to stress reaction from pleurodesis or surgery. Also has a Proteus and Klebsiella UTI for which she was treated with ciprofloxacin for a 7 day course. #. Depression - pt was continued on celexa #. AF with RVR. The patient went into rapid atrial fibrillation with RVR on [**4-12**] with rates to 170s. BP remained in high 90-100s. Returned to sinus rhythm with carotid sinus massage. Digoxin was initially loaded, but his was discontinued due to patient's preference for comfort care and maintenance of sinus rhythm. She has otherwise been in sinus tach to low 100s. Pt and her family confirm that she is DNR/DNI and would like to focus on comfort measures, they are however still interested in learning about palliative treatment options such as chemotherapy/XRT. Medications on Admission: - Folic acid 1 mg po daily - Advair 250/50 inhalation [**Hospital1 **] - Celexa 40 mg daily - Compazine 10 mg po Q6H PRN nausea - Magnesium oxdie 400 mg po daily - Zofran 8 mg po BID with chemotherapy - Reglan 10 mg po BID PRN nausea Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for wheezing. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temp/pain. 11. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 14. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**11-15**] Tablet, Rapid Dissolves PO PRE-XRT (). 15. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Discharge Disposition: Extended Care Discharge Diagnosis: Primary: Pleural effusion of malignancy (NSCLC), right main stem bronchus obstruction and right middle/lower lung lobe collapse from perihilar malignancy, cardiac tamponade/pericardial effusion of malignancy . Secondary: Depression. . You have follow up appointments scheduled below. 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 shortness of breath, after having been found to have significant fluid in the sac surrounding your heart. You also had significant fluid in your lungs, both felt due to your lung cancer. The tumor in your right lung is large enough that it was blocking your bronchi (larger airways), and causing your right middle/lower lobes to collapse. You had a number of drains and chest tubes placed to remove the fluid around your heart and in your lungs. You also underwent bronchoscopy to decrease the size of your tumor. You will be started on oral chemotherapy to help with your symptoms. ******* . It is important that you continue to take your medications as directed. Please see below for the changes we made to your medications during this admission. . 1. Stop folic acid 2. Stop magnesium oxide 3. Stop Reglan 4. Start Lorazepam 0.5-1mg every 6 hours as needed for pain 5. Start Percocet 1-2 tabs every 4 horus as needed for pain. Do not take more than 4g of tylenol in one day 6. Start Benzonatate 100mg po TID 7. Docusate, senna, bisacodyl as needed for constipation 8. Ipratropium nebs every 6 hours as needed for shortness of breath 9. Albuterol nebs every 2 hours as needed for pain Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] Date/Time:[**2139-5-7**] 10:30 Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) 4322**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2139-5-7**] 10:30

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icd9cm

[ [ [] ] ]

[ "32.01", "38.93", "37.12", "34.91", "33.24", "92.29" ]

icd9pcs

[ [ [] ] ]

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8496, 11873

334, 519

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Discharge summary

report+report

Unit No: [**Numeric Identifier 106961**] Admission Date: [**2180-5-12**] Discharge Date: [**2180-5-16**] Date of Birth: [**2100-2-3**] Sex: F Service: [**Last Name (un) **] ADMISSION DIAGNOSIS: Status post motor vehicle collision. DISCHARGE DIAGNOSIS: 1. Status post motor vehicle collision. 2. Left temporal subarachnoid and intraparenchymal hemorrhage, stable. 3. T1 tear drop fracture. 4. T2 burst fracture. 5. Hypertension. 6. Coronary artery disease. 7. Gastroesophageal reflux disease. 8. Blood loss anemia. HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old woman who initially presented to the emergency department having been brought in by EMS following a motor vehicle collision. The patient was a restrained driver and accidentally ran her car into her neighbor's house. There was significant damage to the car and house. The patient did not recall the events. It is unclear whether or not she lost consciousness before or after the event. PAST MEDICAL HISTORY: 1. Question of diabetes mellitus. 2. Depression. 3. Coronary artery disease. 4. Status post cardiac catheterization with stent placement. 5. Hypertension. 6. GERD. 7. Hypercholesterolemia. ALLERGIES: The patient has a significant IV contrast allergy which causes anaphylaxis. MEDICATIONS ON ADMISSION: 1. Plavix 75 mg daily. 2. Avapro 75 mg daily. 3. Toprol 25 mg daily. 4. Lipitor 20 mg daily. 5. Nexium 40 mg daily. 6. Lexapro 20 mg daily. 7. Digoxin 0.25 mg daily. 8. Magnesium Oxide 400 mg daily. 9. Multivitamin daily. 10. Cilium 1 tsp daily. 11. Imdur 30 mg daily. 12. Zetia 10 mg daily. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Unknown. PHYSICAL EXAMINATION: Vital signs: On admission temperature was 100.4 degrees F, pulse 103, blood pressure 156/68, respiratory rate 24, oxygen saturation 100% on face mask. The patient had an initial GCS of 14HEENT: Pupils equal, round and reactive to light. Normocephalic. There was a small ecchymosis in the right temporal region. TMs clear bilaterally. Neck: Midline and with a cervical collar. Chest: Clear to auscultation bilaterally. There was some mild sternal chest tenderness to palpitation. Regular, rate, and rhythm without murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended. There was some very mild gastric tenderness. FAST exam was negative. Rectal: Exam demonstrated normal tone and guaiac negative. Pelvis: Stable. Back: Examination was nontender and without deformity. Extremities: Warm and well perfused with no obvious injury. Neurologic: Although the patient had a GCS of 14, she was alert and oriented to person only. RADIOLOGY STUDIES: On admission chest x-ray was negative. Pelvis x-ray was negative. CT of the head demonstrated a small left subarachnoid, as well as very small left temporal intraparenchymal hemorrhage. CT scan of the cervical spine demonstrated T1 tear drop fracture, as well as a T2 burst fracture. CT of the chest, abdomen, and pelvis were all done without IV contrast and showed no gross abnormalities. HOSPITAL COURSE: The patient was admitted to the trauma intensive care unit for q.1 hour neurochecks and was followed closely by the neurosurgical service who also was the consult service for the spine. The patient had a repeat head CT scan done within 12 hours which demonstrated essentially no change of her intracranial bleed. The patient's mental status improved rapidly after being admitted. She was initially maintained with a goal systolic blood pressure of less than 150 which was easily done on Esmolol drip, as well as with IV beta-blockade. The patient, after restarting her home medications, had difficulty in maintaining a blood pressure below 150. MR of the cervical spine demonstrated no ligamentous injury, the patient was essentially pain free and also cleared clinically from having to wear the cervical collar. The neurosurgical service, which was consulting for spine surgery, felt that her T1 and T2 fractures were stable in nature, and that no additional braces or precautions were necessary. As also part of initial evaluation, given her cardiac history, the patient had an EKG that demonstrated approximately [**Street Address(2) 4793**] depressions from leads V4 through V6. Over the first 24 hours, the patient was ruled out for MI. Over the subsequent days, the patient had an uneventful ICU course. She was discontinued from invasive monitoring and continued to do well. She did have some difficulty with pulmonary toilet and had some coarse secretions. She also had a very mild oxygen requirement via face tent and nasal cannula. She was left in the ICU for aggressive chest physical therapy, as well as pulmonary toilet. Ultimately, on the day of discharge, she was tolerating a regular diet, had adequate pain control on p.o. pain medications, with no focal or neurologic findings. She had a GCS of 15 and was alert and oriented times three. The patient had by physical therapy and cleared for discharge with continued physical therapy requirements working with gait training, strengthening, as well as transfers. Syncopal work-up during her hospital stay included an echocardiogram which showed a normal ejection fraction of greater than 55%, but 2+ mitral regurgitation. No other structural abnormalities were seen. Carotid duplex bilaterally demonstrated no significant carotid stenosis. The patient was maintained on continuous telemetry throughout her stay and demonstrated no unusual arrhythmias which may have contributed to her syncopal episode. DISPOSITION: To rehabilitation facility. DIET: 1800 calorie diabetic diet, also low fat, supplemented with Ensure, Boost, or diabetic equivalent t.i.d.. DISCHARGE MEDICATIONS: 1. Tylenol 650 mg p.o. q.4 hours p.r.n. 2. Lexapro 20 mg daily. 3. Protonix 40 mg daily. 4. Toprol XL 25 mg daily. 5. Lipitor 20 mg daily. 6. Imdur 30 mg daily. 7. Percocet [**1-30**] tab p.o. q.6 hours p.r.n. 8. Avapro 75 mg daily. 9. Digoxin 0.25 mg daily. 10. Heparin 5000 units subcue t.i.d. 11. Magnesium oxide 400 mg daily. 12. Insulin sliding scale. DISCHARGE INSTRUCTIONS: 1. The patient should follow-up with the trauma clinic, as well as with Dr. [**Last Name (STitle) 66048**] of the neurosurgery service in two weeks. 2. Encourage chest physical therapy, as well as pulmonary toilet to maintain excellent oxygen saturations. 3. The patient should continue to work with physical therapy in order to strengthen her gait mobility and balance. 4. If the patient has any focal neurologic findings, she should come back to the emergency department immediately and have a immediate neurologic work-up, including a head CT scan. [**Doctor Last Name **] A. MD [**Last Name (Titles) **] Dictated By:[**Last Name (NamePattern1) 23688**] MEDQUIST36 D: [**2180-5-16**] 10:34:16 T: [**2180-5-16**] 11:07:28 Job#: [**Job Number 106962**] Unit No: [**Numeric Identifier 106961**] Admission Date: [**2180-5-12**] Discharge Date: [**2180-5-16**] Date of Birth: [**2100-2-3**] Sex: F Service: [**Last Name (un) **] ADMISSION DIAGNOSIS: Status post motor vehicle collision. DISCHARGE DIAGNOSIS: Status post motor vehicle collision. Left temporal intraparenchymal hemorrhage. Left temporal subarachnoid hemorrhage. T1 teardrop fracture. T2 burst fracture. Blood loss anemia. HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old woman who parked her car inside of her neighbor's house. The patient had positive LOC and did not recall all of the events. She arrived to the Trauma Bay hemodynamically stable and with a GCS of 15. PAST MEDICAL HISTORY: Question of diabetes. Depression. Coronary artery disease. Status post cardiac stenting. PAST SURGICAL HISTORY: Unremarkable. MEDICATIONS AT HOME: 1. Plavix 75 mg daily. 2. Avapro 75 mg daily. 3. Toprol 25 mg daily. 4. Lipitor 20 mg daily. 5. Nexium 40 mg daily. 6. Lexapro 20 mg daily. 7. Digoxin 0.25 mg daily. 8. Magnesium oxide 400 mg daily. 9. Multivitamin one tablet daily. 10. Silium 1 tsp daily. 11. Imdur 30 mg daily. 12. Zetia 10 mg daily. ALLERGIES: Iodine and codeine. PHYSICAL EXAMINATION ON ADMISSION: The patient had a GCS of 15 and was hemodynamically stable. Vital signs included temperature of 104 degrees, tachycardiac heart rate of 103, blood pressure 156/65, 100% on nonrebreather facemask. The patient's primary survey was negative. She, on physical examination, had only a right temporal ecchymosis and pain on palpation to her sternum and epigastric area. RADIOLOGY ON ADMISSION: Chest x-ray was negative with no pneumothorax, no fracture, and a normal mediastinum. Pelvis x- ray demonstrated no fracture and no dislocation. CT of the head demonstrated a left subarachnoid bleed as well as a small left temporal intraparenchymal hemorrhage. There was no midline shift and no effacement of the ventricles. CT of the C-spine was ultimately negative. CT of the chest, abdomen and pelvis was negative. HOSPITAL COURSE: The patient was admitted to the trauma surgical ICU for neuro checks and close monitoring. She had an A-line placed for blood pressure monitoring. Goal blood pressure was less than 150 and was achieved with esmolol drip. The patient had no change in her neurologic exam and a repeat head CT scan demonstrated no change in her intracranial bleed. The patient was also evaluated by the neurosurgical service for her spine fractures and these were deemed to be stable. She had an MR of her cervical spine which also confirmed that there was no ligamentous injury. The patient remained in the ICU for aggressive pulmonary toilet and had no other complications during her stay. Ultimately, the patient was discharged to home tolerating a regular diet, and adequate pain control on p.o. pain medications and ambulating with the help of physical and occupational therapy. The patient had no neurologic findings. The patient did also have a syncopal workup which included an echocardiogram demonstrating 55% ejection fraction as well as 2+ mitral regurgitation, but no other structural abnormalities. The patient had a carotid ultrasound duplex which revealed no significant carotid stenoses. The patient also had continuous cardiac telemetry during her hospital stay which revealed no unusual arrhythmias which might be responsible for her syncopal episode. DISCHARGE CONDITION: Stable. DISPOSITION: To rehab facility. MEDICATIONS ON DISCHARGE: 1. Tylenol p.r.n. 2. Lexapro 20 mg daily. 3. Protonix 40 mg daily. 4. Toprol 25 mg daily. 5. Lipitor 20 mg daily. 6. Imdur 30 mg daily. 7. Percocet 5/325 mg 1-2 tablets q.6h. p.r.n. 8. Avapro 75 mg daily. 9. Digoxin 0.25 mg daily. 10. Heparin subcutaneously 5000 units t.i.d. 11. Magnesium oxide 400 mg daily. DISCHARGE INSTRUCTIONS: The patient is to be discharged to rehabilitation. Chest PT and pulmonary toilet should be encouraged. The patient should follow up with the trauma clinic and neurosurgical service (Dr. [**Last Name (STitle) 739**] in 2 weeks time. The patient should have both her pulmonary status as well as her neurologic status closely monitored. If there are any focal findings or changes in her neurologic exam, she should return to the emergency department and have stat head CT among other diagnostic workup. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 106963**] Dictated By:[**Last Name (NamePattern1) 23688**] MEDQUIST36 D: [**2180-5-16**] 19:21:45 T: [**2180-5-16**] 19:57:15 Job#: [**Job Number 106964**]

[ "401.9", "852.06", "805.2", "414.00", "530.81", "E823.0", "280.0", "853.06", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "38.91" ]

icd9pcs

[ [ [] ] ]

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7185, 7370

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47663

Discharge summary

report

Admission Date: [**2102-6-5**] Discharge Date: [**2102-6-17**] Service: MEDICINE Allergies: Quinidine Attending:[**First Name3 (LF) 905**] Chief Complaint: Fall Major Surgical or Invasive Procedure: Left hemi arthroplasty, removal of internal medullary nail from femur which was placed 5 months ago History of Present Illness: Mr. [**Known lastname 19434**] is a 89 year old male with CAD, CHF, COPD, Afib, CRI, L femur fracture [**1-11**]; presents following fall with pain in L hip. He was at a golf course today, standing and watching when he said he slipped and/or his leg gave out from under him, causing him to fall. He immediately felt pain in his left hip. Denies LOC, denies hitting head or neck. Was feeling fine earlier in the day. Fall witnessed by others. He fractured his L midshaft femur in [**1-11**] with nail placement. . Pt has extensive history of CAD with CHF and CRI. CABG in [**2074**]'s; last cath [**2085**]. Believes he has not had an MI since CABG but prior have "5 or 6". Ambulates around his house and the length of a few houses, but does not do stairs at home. Also with h/o COPD and says O2 sats are in the low 90's at best when checked. Past Medical History: # CAD, history of inferior and apical wall MI, s/p CABG [**2074**], Cath [**2085**]: 3VD, SVG's to the OM1 and LAD are widely patent; Occluded SVG to the PDA # CHF, last ECHO EF <30% [**2101-6-4**] at Dr.[**Name (NI) 5765**] office # Atrial fibrillation s/p DCCV in [**2089**] on amio since [**2090**] # Atrial flutter secondary to quinidine, s/p ablation [**2090**] # Severe tricuspid regurgitation w/ moderate PHTN # Pleural fibrosis s/p pleurectomy [**2077**] # COPD, PFTs [**2099**]: FEV1 60% FVC 71% FEV1/FVC1 119% # Peripheral vascular disease # CRI: baseline creatinine 2.0 # Hypothyroidism [**1-6**] amiodarone # Psoriasis # Distal abdominal aorta anuerysm # Basal and squamous cell carcinomas Social History: Patient lives with wife in [**Name (NI) **]. He is a former furniture and carpet salesman. He used to be in the army and was an instructor for the airforce. He has a 138 pack year history, quit in [**2074**] prior to CABG. Ocassional glass of wine socially. Family History: Father-MI Physical Exam: PE and vitals on admission V: 97.1 140/70 85 20 94% 4L NC Gen: very pleasant, lying in bed in NAD HEENT: NC/AT. EOM: full range of motion. Tonsils are non-erythematous. Neck: soft, no lymphadenopathy. CV: nl S1/S2. with 2/6 systolic murmur throughout precordium Pulm: no crackles appreciated. Diffuse wheezes and rhonchi throughout Abd: soft and non-tender, ND, +BS Ext: Both UE and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] to palpation. LLE- Able to wiggle toes and has full sensation to light touch. bilateral 1+ edema, L>R. R anterior thigh with dressings [**1-6**] recent "skin cancer removal" Neuro: A&Ox3 . Vitals and exam on discharge: 97.3 110/60 91 20 93% on 2L 240/incontinent Exam mostly unchanged. See following. CVS: irregularly irregular Pulm: scattered rhonchi with diffuse wheezes, good air movement Abd: soft, NTND, +bs Ext: upper and lower extremities warm, dressings on LLE c/d/i, no erythema or warmth. dressing on RLE c/d/i. bilateral +1 edema Pertinent Results: [**2102-6-5**] 02:50PM GLUCOSE-102 UREA N-45* CREAT-2.3* SODIUM-147* POTASSIUM-5.3* CHLORIDE-109* TOTAL CO2-29 ANION GAP-14 [**2102-6-5**] 02:50PM CALCIUM-8.7 PHOSPHATE-4.2 MAGNESIUM-2.7* [**2102-6-5**] 02:50PM WBC-6.3 RBC-4.10* HGB-12.2* HCT-38.8* MCV-95 MCH-29.6 MCHC-31.3 RDW-15.2 [**2102-6-5**] 02:50PM NEUTS-71.2* LYMPHS-22.4 MONOS-3.8 EOS-1.8 BASOS-0.8 [**2102-6-5**] 02:50PM PLT COUNT-162 [**2102-6-5**] 02:50PM PT-24.5* PTT-35.8* INR(PT)-2.5* . L hip/pelvis XRay: There is an intramedullary rod in the left femur with a single proximal screw. There is also varus angulation and deformity seen of the femoral head and neck and due to difficulty in positioning patient, this area is not fully evaluated; however, there is likely a fracture involving the femoral neck on the left side. Dystrophic calcifications are identified. There are degenerative changes and joint calcifications involving the right hip. Degenerative changes of the lower lumbar spine are identified. . L femur Xray: 1. As seen earlier today, there is an acute fracture of the left femoral neck. 2. The spiral fracture of the left femoral shaft is evaluated, and there is no change in fracture fragment position or hardware appearance compared to [**2102-4-20**]. There remains some angulation of the mid aspect of the more proximal to distal interlocking screws. . ECHO [**2102-6-12**] The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Low normal left ventricular systolic function without definite regional dysfunction. Mild mitral regurgitation. Pulmonary artery systolic hypertension. . CT HEAD done on [**2102-6-14**] for acute delirium There is no intracranial hemorrhage, shift of normally midline structures, or evidence of acute major vascular territorial infarct. [**Doctor Last Name **]-white matter differentiation is preserved. Surrounding osseous structures are unremarkable. The imaged portions of the paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No intracranial hemorrhage. . CXR ([**2102-6-16**]): PA and lateral views of the chest are obtained. Midline sternotomy wires are again noted. There is volume loss in the right lung, with apical pleural thickening. Linear atelectasis versus scar is noted in the right mid lung. Retrocardiac atelectasis is noted, which appears slightly increased from prior study. The heart is enlarged. There is no pneumothorax. Brief Hospital Course: # Hip fracture: pt had removal of previous hardware and plating/hemiarthroplasty - involved procedure. He has been evaluated by PT and progressed to functional mobility. . #Hypotension: after surgery pt had some episodes of hypotension, likely secondary to blood loss during surgery and agressive diuresis. We held his diuretic, gave his blood transfusions and his blood pressures have been stable in the 90's systolic. . #CHF: ECHO revealed LVEF 50% His lungs always sounded wet on auscultation. His BP dropped after surgery due to aggressive diuresis and blood loss. His lasix has been held, with no evidence of worsening CHF on chest x-ray ([**2102-6-16**]). He is maintaining his sats on 2L. He is very sensitive to the lasix as he drops his pressure. His rate was better controlled after starting the Amiodarone. This also helped his blood pressure. . # CAD: extensive history but stable during this hospitalization. Continued ASA, beta blocker, statin. . # COPD: former smoker, on inhalers at home without home O2 currently. Has been 80's to low 90's here. We continued his nebulizer treatments and albuterol while in the hospital. We titrated his O2 as needed, with a goal of O2 sat 90-93%. He has been maintaining this O2 on 2L nasal cannula. . #Afib: Afib has been stable over this hospitalization. Pt has a hx of being difficult to convert. His rate has been well controlled on amiodarone and metoprolol. . # Agitation, delirium: Initially a problem in the immediate post-surgical period, at which time it was controlled with pain management and Haloperidol PRN. Behavior however improved drastically and patient is very cooperative and pleasant without any intervention. . # Blood Loss: Baseline Hct near 28. He has some bleeding in the postoperative period from his surgical wound. He got blood transfusion. His HCT was stable for more than a week prior to discharge. Surgical wound was well healed and no blood is seen on bandage. . #Hypothyroidism: We continued the pt on his synthroid. . #Prophylaxis: He has been maintained on 30 lovenox daily (secondary to his kidney function) and was recently restarted on his home dose of Coumadin. His INR has been responding. Will need to stop lovenox after INR between [**1-7**]. His INR needs to be monitored closely due to the interaction with Amiodarone. Medications on Admission: 1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-6**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 11. Atrovent 0.02 % Solution Sig: [**12-6**] puffa Inhalation every six (6) hours as needed for shortness of breath or wheezing. 12. Aerochamber Inhaler Sig: One (1) Miscellaneous use with inhalers. 13. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-6**] Sprays Nasal TID (3 times a day) as needed. 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Morphine Sulfate 1-2 mg IV Q4H:PRN 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q24H (every 24 hours): Please stop when INR reaches 2 to 3. . 16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12 () as needed for pain. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for insomnia. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Left femoral neck fracture Secondary: Anemia, atrial fibrillation, Hypotension, chronic obstructive pulmonary disease, chronic renal insufficiency, peripheral vascular disease Discharge Condition: Stable Discharge Instructions: Please take all your medications and follow up with your appointments. Please do not hesitate to go to the emergency room or call your doctor if you have any worsening shortness of breath, nausea, vomiting, leg pain, dizziness or any other concerns. . Please monitor your INR every other day until it is between 2 and 3. Please stop Lovenox as soon as INR reaches 2. Please continue to take your coumadin and check your INR two times a week. Your coumadin may need to be adjusted because you are on Amiodarone. . Please check electrolytes frequently. If potassium is above 5.0 please give 30 mg of Kayexalate. . We have stopped your lasix for low blood pressures and renal failure while on the lasix. Please evaluate patient before re-starting lasix. Followup Instructions: Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2102-6-22**] 8:10 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2102-6-22**] 8:30 . Provider: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2102-9-28**] 9:00 . Please make an appointment to see your primary care physician [**Last Name (NamePattern4) **] [**6-13**] days from the day of discharge from the hospital. . Please make an appointment to follow up with Dr. [**Last Name (STitle) 1005**] in orthopedics in two weeks. Please call to make the appointment. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "244.9", "E885.9", "285.1", "707.9", "397.0", "458.29", "427.31", "496", "428.0", "416.8", "V12.59", "414.01", "V54.89", "293.0", "820.8", "790.92", "414.02", "V15.82", "440.23", "E849.4", "515", "696.1", "V10.83", "585.9", "412", "998.11" ]

icd9cm

[ [ [] ] ]

[ "81.52", "78.55", "99.04", "78.65" ]

icd9pcs

[ [ [] ] ]

11290, 11356

6432, 8758

220, 322

11576, 11585

3259, 6409

12389, 13215

2220, 2231

9753, 11267

11377, 11555

8784, 9730

11609, 12366

2246, 2889

176, 182

350, 1202

2908, 3240

1224, 1928

1944, 2204

41,290

106,402

30501+57699

Discharge summary

report+addendum

Admission Date: [**2175-1-11**] Discharge Date: [**2175-1-20**] Date of Birth: [**2132-1-28**] Sex: F Service: SURGERY Allergies: Amoxicillin / Erythromycin Base / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 301**] Chief Complaint: Patient presented with abdominal pain at [**Hospital6 1597**], CT scan revealed free air. Patient was transferred to [**Hospital1 18**]. Major Surgical or Invasive Procedure: Status Post Marginal ulcer repair History of Present Illness: This patient is a 42 year old female who complains of ABD PAIN. Went to [**Hospital3 **] ED this am for abd pain ,has free air to abd per CT at bypass site.rec,d Fentanyl 50 per amb enroute. Had Flagyl IV Appears uncomfortable MY HPI: transfer from [**Hospital3 2568**]. Presnted there w/ diffuse abdominal pain that started this AM. At OSH, CT demonstrated free air. Pt is s/p gastric bypass in [**2171**] here by Dr. [**Last Name (STitle) **]. Per OSH CT, increased air at anastamosis, suggestive of perforation. Received abx, IVF, analgesia at OSH. En route & at OSH had decreased SBP to 60, now improved w/ IVF. Past Medical History: Hypertension, dyslipidemia, asthma, and obstructive sleep apnea on CPAP. Social History: She denies any alcohol, drug or tobacco abuse. She states she quit smoking three weeks ago. Family History: Non-contributory Physical Exam: Temp:97.5 HR:88 BP:98/65 Resp:20 O(2)Sat:98 normal Constitutional: uncomfortable Head / Eyes: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact ENT / Neck: Oropharynx within normal limits Chest/Resp: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds GI / Abdominal: Soft, Nondistended, diffusely tender, + rebound, + guarding GU/Flank: No costovertebral angle tenderness Musc/Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Neuro: Speech fluent Psych: Normal mood, Normal mentation Pertinent Results: [**2175-1-11**] 12:25PM BLOOD WBC-19.7*# RBC-5.07 Hgb-9.7*# Hct-33.7* MCV-67*# MCH-19.1*# MCHC-28.6*# RDW-17.3* Plt Ct-452*# [**2175-1-13**] 12:23PM BLOOD WBC-12.3* RBC-3.82* Hgb-7.4* Hct-25.2* MCV-66* MCH-19.4* MCHC-29.5* RDW-17.5* Plt Ct-381 [**2175-1-18**] 06:10AM BLOOD WBC-5.1 RBC-4.24 Hgb-8.2* Hct-27.7* MCV-65* MCH-19.2* MCHC-29.4* RDW-18.4* Plt Ct-355 [**2175-1-11**] 12:25PM BLOOD Plt Smr-HIGH Plt Ct-452*# [**2175-1-13**] 02:07AM BLOOD PT-13.5* PTT-26.1 INR(PT)-1.2* [**2175-1-18**] 06:10AM BLOOD Plt Ct-355 [**2175-1-11**] 12:25PM BLOOD Glucose-76 UreaN-18 Creat-0.8 Na-141 K-4.6 Cl-108 HCO3-21* AnGap-17 [**2175-1-13**] 02:07AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-140 K-4.1 Cl-107 HCO3-26 AnGap-11 [**2175-1-16**] 06:20AM BLOOD Glucose-99 UreaN-4* Creat-0.6 Na-138 K-4.0 Cl-103 HCO3-29 AnGap-10 [**2175-1-11**] 12:25PM BLOOD Lipase-35 [**2175-1-14**] 03:34AM BLOOD Lipase-12 [**2175-1-11**] 12:39PM BLOOD Lactate-3.0* [**2175-1-11**] 05:01PM BLOOD Calcium-8.0* Phos-3.6 Mg-1.5* [**2175-1-14**] 01:43PM BLOOD Calcium-8.3* Phos-2.6* Mg-1.8 [**2175-1-18**] 06:10AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.1 Brief Hospital Course: Patient transferred from [**Hospital3 **] with abdominal pain and free air noted on CT scan. Patient went to the operating room where a Closure of marginal ulcer,Omental patch, Gastrostomy and Takedown of gastroenteric fistula was performed. Initially postop patient was monitored very closely in the intensive care unit. Pain control was difficult to achieve with use of ketamine. On postoperative day 3 patient was transferred to the floor. PPI and antibiotics were continued intravenously and patient's labs were closely monitored. On postoperative day 5 patient was started on a bariatric diet. R arm cellulitis was noted and patient started on warm packs and vancomycin. On postoperative day 6 R arm celluilitis improved and patient progressed to a bariatric stage 3 diet. We will discharge her to home today with oral protonix, keflex for cellulitis and follow up with Dr. [**Last Name (STitle) **] in one week. Medications on Admission: lisinopril 10 QD, symbicort Discharge Medications: 1. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day: Please take for one week. Disp:*28 Capsule(s)* Refills:*0* 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:*300 ML(s)* Refills:*0* 4. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day. Disp:*500 ml* Refills:*0* 5. Multivitamin Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Perforated marginal ulcer Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items [**9-22**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 49**] in one week at [**Hospital Ward Name **] [**Hospital Ward Name 23**] building [**Location (un) 470**]. Please call [**Telephone/Fax (1) 2723**] to make an appointment. Completed by:[**2175-1-20**] Name: [**Known lastname 571**],[**Known firstname 634**] Unit No: [**Numeric Identifier 12080**] Admission Date: [**2175-1-11**] Discharge Date: [**2175-1-20**] Date of Birth: [**2132-1-28**] Sex: F Service: SURGERY Allergies: Amoxicillin / Erythromycin Base / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 559**] Addendum: Jp drain discontinued and staples removed from midline incision. VNA set up to monitor: R arm cellulitis G-tube Midline incision Compliance with kelfex Compliance with no smoking Ensure appointment with Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) 1239**] [**Last Name (NamePattern1) **] NP Discharge Disposition: Home With Service Facility: [**Hospital 136**] Homecare [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 560**] MD [**MD Number(1) 561**] Completed by:[**2175-1-20**]

[ "534.50", "537.4", "996.62", "327.23", "401.9", "568.89", "493.90", "567.9", "E878.2", "V45.86", "272.4", "682.3" ]

icd9cm

[ [ [] ] ]

[ "43.19", "44.63", "44.41" ]

icd9pcs

[ [ [] ] ]

7915, 8128

3486, 4411

450, 486

5120, 5120

2351, 3463

6833, 7892

1359, 1377

4489, 4969

5071, 5099

4437, 4466

5265, 6464

1393, 2332

274, 412

6476, 6810

515, 1135

5134, 5241

1157, 1232

1248, 1343

13,864

151,219

49306

Discharge summary

report

Admission Date: [**2182-7-13**] Discharge Date: [**2182-7-17**] Service: MEDICINE Allergies: Procainamide / Bactrim Attending:[**First Name3 (LF) 358**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 89 yo with CAD, s/p CABG, CHF, EF 15%, who presents from the nursing home with shortness of breath. The patient reports that today before eating she suddenly had a very violent, non productive cough and shortness of breath associated with some dry heaves. She does not recall any chest pain, nausea or vomiting in the context. She denies any fluid or food intake before the event. She also denies fevers, chills or night sweats. . ROS: otherwise negative for abdominal pain, diarrhea, constipation, f/c/ns, weight loss, dysuria, changes in the color of the urine or stool. . In the ED the patient was placed on BIPAP and was given Vancomycin, Levofloxacin and Flagyl for PNA. A CXR was done and was read as below. Nitro was started for BP control. Aspirin was given. The patient showed rapid improvement and was able to be titrated of the BipAP to 4L Nc. Past Medical History: 1. Coronary artery disease; s/p coronary artery bypass graft x2 2. Congestive heart failure with EF 15%, severe global left ventricular hypokinesis with septal dyskinesis and relative sparing of the basal lateral and inferolateral walls. 3+ MR 3. Status post biventricular pacemaker in [**8-28**]. 4. Paroxysmal atrial fibrillation. 5. Hypertension. 6. Hyperlipidemia. 7. Diverticular disease, status post colectomy. 8. History of mesenteric emboli. 9. Restless leg syndrome. 10.Arthritis. 11.History of Ativan abuse. Social History: ETOH: none Tobacco: remote history Living situation: [**Hospital **] nursing home, ambulatory with wheelchair, relatively independent in ADLs; Family: 2 sons, 1 alive in [**State 1727**] Family History: non-contributory Physical Exam: Physical exam: Afebrile, vital signs stable with blood pressure 110-120/60-70 Gen: NAD, elderly but alert and conversive HEENT: NC/AT, surgical pupils, dry mm NECK: no LAD, no JVD, no carotid bruit COR: distant heart sounds, regular rhythm, 2/6 systolic murmur PULM: clear ABD: + bowel sounds, soft, nd, nt, midline scar Skin: warm extremities, no rash, surgical vein grafing scars bilaterally EXT: 2+ DP, no edema/c/c, no CVA tenderness Neuro: 5/5 strength in upper extremities , following commands, PERRLA, reflexes 2+ b/l Pertinent Results: [**2182-7-13**] 12:25PM WBC-14.9* RBC-5.03# HGB-15.5# HCT-46.6# MCV-93 MCH-30.9 MCHC-33.3 RDW-14.2 [**2182-7-13**] 12:25PM GLUCOSE-292* UREA N-25* CREAT-0.9 SODIUM-140 POTASSIUM-5.5* CHLORIDE-104 TOTAL CO2-25 ANION GAP-17 [**2182-7-13**] 12:42PM LACTATE-3.3* [**2182-7-13**] 01:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2182-7-13**] 01:45PM URINE RBC-0 WBC-0 BACTERIA-0 YEAST-NONE EPI-0 . CXR: Right lung airspace opacity most consistent with pneumonia, with possible developing left perihilar airspace opacity, and mild superimposed congestive heart failure. . EKG: [**Month/Day/Year **] paced, HR 69, poor baseline [**2182-7-17**] 06:55AM BLOOD WBC-7.1 RBC-4.11* Hgb-12.9 Hct-37.4 MCV-91 MCH-31.5 MCHC-34.5 RDW-13.9 Plt Ct-195 [**2182-7-17**] 06:55AM BLOOD Glucose-79 UreaN-19 Creat-0.7 Na-142 K-4.0 Cl-106 HCO3-31 AnGap-9 Brief Hospital Course: # Acute on chronic systolic heart failure exacerbation vs atypical pneumonia: initially diagnosed with health care acquired pneumonia and placed on vancomycin, ciprofloxacin and flagyl. However, she improved rapidly with blood pressure control and mild diuresis, and gives no history of fever, cough or sputum production. The clinical scenario makes me lean towards flash pulmonary edema in the setting of hypertensive emergency, with acute on chronic systolic heart failure exacerbation. On discharge, her lungs were clear and she required no supplemental oxygen for the last 48 hours of her stay. Her home heart failure meds were restarted, including oral Lasix, carvedilol, and isosorbide (short acting mononitrate instead of SA form previously given). An ace inhibitor was started, as she had not been on one previously, in the setting of heart failure with decreased EF. I contact[**Name (NI) **] the nursing home to discuss any recorded personal history of reactions to ACE inhibitors, and there were none. Additionally, given the possibility of atypical pneumonia causing/contributing to her presentation, she will finish a 5 day course of ciprofloxacin. Vancomycin and flagyl were discontinued shortly after transfer out of the ICU, and she remained afebrile with stable/normal WBC. # HTN -- see above, blood pressure well controlled on discharge. Was on nitro gtt on admit, weaned to home medications without difficulty. # PAF: continue on Amiodarone. Pt [**Name (NI) **] paced, device check previously scheduled in [**Month (only) **]. . # CAD: continue on carvedilol and aspirin, ROMI'd by enzymes. No change in EKG. . # Hyperglycemia: likely in the setting of acute illness, normoglycemic prior to discharge. HgA1c <6%. . # Restless leg syndrome: continued on Ropinirole . # Depression: continued on mirtazipine . Contact: [**Name (NI) **] [**Name (NI) **] [**Name (NI) 103319**] [**Telephone/Fax (1) 103320**] Medications on Admission: ALLERGIES: Procainamide > Lupus, thrombocytopenia and Bactrim > rash . Medications: Amiodarone 200 mg PO DAILY Furosemide 20 mg PO DAILY Aspirin 81 mg PO DAILY Start: In am Isosorbide Mononitrate 30 mg PO DAILY Carvedilol 12.5 mg PO BID Duoneb neb Q6H:PRN wheeze Acetaminophen Prilosec 20mg QD Trazodone 50mg QD Mirtazapine 22.5mg Bisacodyl 10mg supp prn Percocet prn Ropinirole HCl 0.5 mg PO QHS Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for afib. 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for restless leg syndrome. 7. Mirtazapine 15 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. 9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Multivitamin & Mineral Formula Tablet Sig: One (1) Tablet PO once a day. 14. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 15. Isosorbide Mononitrate 20 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Outpatient Lab Work basic chemistry panel in [**9-8**] days to evaluate creatinine and potassium after initiation of ACE inhibitor. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: 1. acute on chronic systolic CHF exacerbation 2. possible atypical pneumonia Discharge Condition: stable, on room air, with stable blood pressures in the 110-120 systolic range for greater than 24 hours. Discharge Instructions: You were hospitalized for respiratory distress. It was due to an acute on chronic systolic congestive heard failure (with flash pulmonary edema), which resolved with blood pressure control and diuresis. It may have also been related to a pneumonia, so we ask that you finish the antibiotics given. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Fluid Restriction: less than two liters each day. Please call your physician or return to the hospital with any concerns or questions, particularly fever greater than 101, shortness of breath, chest pain, or cough/sputum production. Followup Instructions: You should be seen by Dr. [**Last Name (STitle) 103321**] within one week of return to [**Location (un) 582**]. Your creatinine and potassium should be checking in the next 10-14 days because you have started an ace inhibitor. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2182-7-31**] 1:00

[ "424.0", "428.23", "272.4", "V45.81", "427.31", "428.0", "486", "333.94", "401.9", "V45.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7282, 7359

3411, 5347

249, 256

7480, 7588

2481, 3388

8270, 8610

1903, 1921

5795, 7259

7380, 7459

5373, 5772

7612, 8247

1951, 2462

190, 211

284, 1141

1163, 1682

1698, 1887

71,131

110,493

47401

Discharge summary

report

Admission Date: [**2163-3-21**] Discharge Date: [**2163-3-25**] Date of Birth: [**2101-9-22**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Right leg pain Major Surgical or Invasive Procedure: [**2163-3-21**] Coronary artery bypass graft x 3 (left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending artery) History of Present Illness: 61 yo man with hypertension, hyperlipidemia and a known bicuspid aortic valve who went to see his PCP [**1-12**] with symptoms of right calf pain, expressing his concerns for DVT. A routine EKG showed ST elevations that were thought to be an ischemic process versus left ventricular hypertrophy versus left axis deviation. He was sent to the ER for further evaluation. Troponins were positive to .21. However, the presence of EKG Q-waves were thought to suggest that this was a remote event. An echo demonstrated new anterior lateral hypokinesis, compared to previous studies, overall LV systolic function was decreased (LVEF 45%) and demonstrated new wall motion abnormalities. A cardiac catheterization revealed three vessel coronary artery disease. He has now been referred for surgery. Past Medical History: - Anteroseptal myocardial infarction in [**2162-12-13**] - Dyslipidemia - Hypertension - Bicuspid aortic valve - DVT right leg [**2153**] - Sciatica - Ischemic cardiomyopathy (LVEF 45%) - Obesity - Tobacco and ETOH abuse - Right lower extremity DVT - ?Soft palate lesion Past Surgical History: - s/p Testicular repair Social History: Race: Caucasian Last Dental Exam: 1 yr ago Lives with: Partner in [**Name2 (NI) 3494**] Occupation: Works as a bus driver for Holiday Inn, MSM. Tobacco: 0.5-1ppd x 35 years. -quit [**2163-3-6**]- on Chantix ETOH: 6 drinks/day Family History: Father died at 48 from lung cancer/MI Physical Exam: Pulse: 90 Resp: 16 O2 sat: 100% B/P Right: 125/86 Left: 127/78 Height: 5'8" Weight: 198lbs General: Well-developed male in no acute distress Skin: Warm[X] Dry [X] intact [X] dry, erythematous bilateral infra-mammary eruption HEENT: NCAT[X] PERRLA [X] EOMI [X] anicteric sclera, OP benign, no lesion seen Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur 2/6 SEM Abdomen: Obese, Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema none Varicosities: None [X] Neuro: Grossly intact [X], MAE, [**6-16**] strengths, non-focal exam Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Pertinent Results: [**2163-3-21**] Echo: 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. A patent foramen ovale is present. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is mildly depressed (LVEF=45 %). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic valve is bicuspid. There is mild aortic valve stenosis (valve area 1.8cm2) with Cardiac output 4.0L/min.. Mild to moderate ([**2-13**]+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**Known firstname **] [**Known lastname 100303**]. POST-BYPASS: Preserved RV systolic function. LVEF 45%. The mid anterior and anteroseptal walls are hypokinetic compared to pre CABG. Surgeon informed of these findings. With epinephrin only 0.02 mcg/kg/min they improved signficantly later on. Intact thoracic aorta. Same valvular findings as before. All wall motions similar to prebypass after chest closure. Brief Hospital Course: Mr. [**Known lastname 100303**] was a same day admit after undergoing pre-operative work-up as an outpatient. On [**2163-3-21**] he was brought to the operating room where he underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later this day he was weaned from sedation, awoke neurologically intact and extubated. Beta-blockers and diuretics were started and he was gently diuresed towards his pre-op weight. On post-op day one he was transferred to the step-down floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. He continued to make good progress while working with physical therapy for strength and mobility. On post-op day four he was discharged home with VNA services and the appropriate medications and follow-up appointments. Medications on Admission: Aspirin 325 mg p.o. daily Plavix 75 mg p.o. daily, Metoprolol 50 mg p.o. b.i.d. Lisinopril 10 mg p.o. daily simvastatin 80 mg p.o. daily Chantix Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*2* 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). Disp:*90 Tablet(s)* Refills:*2* 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO BID (2 times a day) for 7 days. Disp:*14 Tablet, ER Particles/Crystals(s)* Refills:*0* 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: this is [**2-13**] of your home dose. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft Past medical history: - Anteroseptal myocardial infarction in [**2162-12-13**] - Dyslipidemia - Hypertension - Bicuspid aortic valve - DVT right leg [**2153**] - Sciatica - Ischemic cardiomyopathy (LVEF 45%) - Obesity - Tobacco and ETOH abuse - Right lower extremity DVT - ?Soft palate lesion Past Surgical History: - s/p Testicular repair 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: trace upper and lower extremity 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: Please come to [**Hospital Ward Name 121**] 6 next Thursday, [**3-31**] at 10AM for wound check. You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] on [**4-14**] at 1:15PM [**Telephone/Fax (1) 170**] Cardiologist: Dr. [**Last Name (STitle) **] on [**4-26**] at 2PM Please call to schedule appointments with your Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**5-17**] 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:[**2163-3-25**]

[ "272.0", "414.01", "411.1", "412", "V85.30", "V15.82", "278.00", "496", "724.3", "746.4", "414.8" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6485, 6543

4136, 5050

293, 497

6984, 7228

2787, 4113

8151, 8799

1918, 1957

5245, 6462

6564, 6621

5076, 5222

7252, 8128

6938, 6963

1972, 2768

239, 255

525, 1317

6643, 6915

1675, 1902

3,513

186,086

16861

Discharge summary

report

Admission Date: [**2204-8-5**] Discharge Date: [**2204-8-16**] Date of Birth: [**2129-7-30**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: transfer from OSH for sepsis and [**Last Name (un) **] plus CRI Major Surgical or Invasive Procedure: central line placement History of Present Illness: Pt is a 75F with a PMHx significant for severe PVD, CAD, DM, and CKD who presented to [**Hospital1 **]-[**Location (un) 620**] on [**8-3**] after being found down unresponsive at home. She was found to be hypoglycemic to 29 with hypotension and bradycardia. Her hypotension and confusion improved with hydration. She had a positive UA which eventually grew klebsiella, treated initially with levofloxacin. She had a leukocytosis to 18 and a creatinine of 6 up from presumed prior baseline of ~2. On morning of transfer, pt had blood cultures result 3/3 bottles positive for GAS, her antibiotics were switched to vancomycin which was then changed to ceftriaxone. Her blood pressure dropped to the 60s. She was given a bolus of bicarb and transfered to their ICU. After an additional bolus of 500cc she was started on levophed. She was anuric throughout the day. She had a midline placed on right side. She received 80mg IV solumedrol this morning in the setting of low BPs and rare eos in urine. . On arrival to the MICU pt was awake but drowsy. She was receiving levophed throughout her transfer. Arrival VS: 96.3 68 102/26 22 97% 2L NC on 0.04mcg/kg/min levophed. On ROS, pt denies pain, lightheadedness, headache, neck pain, sore throat, recent illness or sick contacts, cough, shortness of breath, chest discomfort, heartburn, abd pain, n/v, diarrhea, constipation, dysuria. Is a poor historian regarding how long she has had a rash on her legs. States she has not felt ill and she was brought to the hospital because her daughter came home and found her sleeping. Does complain of feeling very thirsty. . On arrival to the MICU, pressors were continued, pt given bolus of D5bicarb and antibiotics. A surgical consult was called to evaluate the patient for possible necrotizing fasciitis. She had L subclavial line placed. Past Medical History: CAD, s/p CABG in [**2197**] (LIMA to LAD, SVG to OM1, OM2 and RCA with graft stenting in [**2198**] Systolic CHF, EF 45-50% from [**9-/2202**] CKD (reported baseline 1.5-2 although last level was 3 in [**2-27**]) HTN HL DM2 GERD Melanoma Peripheral vascular disease Iron deficiency anemia, on procrit. Social History: Lives at home, son and daughter visit nearly daily. Son fills her pill box, she doesn't know meds. Ambulates independently, leaning on furniture. Non-smoker, quit 40 years ago. Denies ETOH. Family History: Family History: Non-contributory Physical Exam: Vitals: T:96.3 BP:102/26 P:68 R:22 O2: 97% 2L General: Oriented x 3, appears drowsy with marked speech latency. Answers questions appropriately. Irritable. HEENT: Sclera anicteric, MM very dry Neck: Neck veins flat. Lungs: Clear to auscultation bilaterally, difficult exam due to pt cooperation. Slight bibasilar crackles. CV: Median sternotomy scar. RRR. 2/6 systolic murmur heard best at LLSB. Abdomen: Soft, minimally tender to palpation in epigastrium. + BS. No rebound or guarding. No HSM or masses palpable. Obese. Ext: Cool. Radial arteries difficult to palpate. R hand edematous and pale. Bilateral lower extremities pale and cool. 1+ monophasic DP pulses bilaterally. Absent TP pulses. Multiple areas of skin sloughing, tender to palpation. No crepitous. Neuro: Oriented x 3 with latent speech. Cranial nerves intact. Moving extremities. Pertinent Results: [**2204-8-5**] 03:33PM PT-16.4* PTT-37.9* INR(PT)-1.5* [**2204-8-5**] 03:33PM PLT COUNT-208 [**2204-8-5**] 03:33PM NEUTS-96.2* LYMPHS-2.7* MONOS-1.0* EOS-0.1 BASOS-0.1 [**2204-8-5**] 03:33PM WBC-16.7* RBC-4.05* HGB-11.2* HCT-33.2* MCV-82 MCH-27.6 MCHC-33.7 RDW-16.8* [**2204-8-5**] 03:33PM ALBUMIN-2.3* CALCIUM-6.6* PHOSPHATE-9.2*# MAGNESIUM-2.2 [**2204-8-5**] 03:33PM ALT(SGPT)-85* AST(SGOT)-197* LD(LDH)-421* CK(CPK)-410* ALK PHOS-108 TOT BILI-0.2 [**2204-8-5**] 03:33PM estGFR-Using this [**2204-8-5**] 03:33PM GLUCOSE-142* UREA N-116* CREAT-6.1*# SODIUM-140 POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-13* ANION GAP-24* [**2204-8-5**] 04:31PM O2 SAT-79 [**2204-8-5**] 04:31PM LACTATE-1.4 [**2204-8-5**] 04:31PM TYPE-MIX TEMP-35.7 PO2-50* PCO2-30* PH-7.17* TOTAL CO2-12* BASE XS--16 INTUBATED-NOT INTUBA [**2204-8-5**] 09:34PM URINE MUCOUS-RARE [**2204-8-5**] 09:34PM URINE HYALINE-5* [**2204-8-5**] 09:34PM URINE RBC-11* WBC-82* BACTERIA-MOD YEAST-NONE EPI-0 [**2204-8-5**] 09:34PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [**2204-8-5**] 09:34PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011 [**2204-8-5**] 10:06PM O2 SAT-73 [**2204-8-5**] 10:06PM LACTATE-1.3 [**2204-8-5**] 10:06PM TYPE-MIX TEMP-35.6 PO2-45* PCO2-31* PH-7.22* TOTAL CO2-13* BASE XS--13 INTUBATED-NOT INTUBA Brief Hospital Course: MICU course: Pt arrived in MICU with GAS septicemia, UTI, ARF, and LE wounds. Started on Clinda and unasyn for UTI and GAS septicemia. IVF rehydration for ARF, which after 3 days of trending up, reached a [**Location (un) **] of 6.9, and since has trended down, now at 6.5. Gen Surgery, vascular surgery and wound care were consulted for LE wounds. In light of ARF, vascular surgery deferred angio study of known PAD until renal function returned, although they feel that the LE wounds will not fully heal without revascularization. Wound care recommendations were formulated and followed. ID was consulted regarding both LE wounds and documented infections. Dermatology was consulted regarding LE wounds, and recomended PTH for ?calciphylaxis, remaining unclear if they plan to biopsy wound. Patient has been markedly uncomfortable throughout MICU stay, complaining of pain and unwillingness to participate in her care, including taking PO therapies. Son closely involved in her care, and after long discussions, has agreed to make her DNR/DNI and not allow an NG tube for tube feeds. Course on the floor: Pt was transitioned to CMO per conversations with family and patient who expressed her wish to not have any further interventions. Pt was made comfortable with morphine boluses and fentanyl patches (pt prefered to not be touched). Palliative care was involved. Antibiotics and IV fluids were discontinued. Labs were not checked and heparin sc was dicontinued. All non-comfort oriented medicines were also discontinued. Pt appeared comfortable c frequent visits from son until she passed away. Medications on Admission: Toprol 100mg daily Lisinopril 80?mg daily Isosorbide mononitrate 30mg daily Amlodipine 10mg daily Clopidogrel 75mg daily Aspirin 325mg daily Furosemide 80mg daily Pantoprazole 40mg daily Ezetimibe 10mg daily Glucotrol 5mg daily Atorvastatin 40mg daily epogen injections from transfer: Prilosec 20 mg [**Hospital1 **] Plavix 75 mg daily aspirin 325 daily NovoLog sliding scale IV fluids D5W with 3 amps of sodium bicarb PhosLo 667 mg TIDAC ceftriaxone 1 gram daily Levophed titrating to blood pressure Zofran 4 mg q. 6 hours p.r.n. Tylenol 650 q. 6 hours p.r.n. Discharge Disposition: Expired Discharge Diagnosis: Discharge Condition: Discharge Instructions: Followup Instructions: Completed by:[**2204-8-20**]

[ "780.96", "785.52", "707.03", "311", "038.0", "348.30", "584.9", "443.9", "V45.81", "250.00", "428.20", "286.9", "585.9", "276.2", "995.92", "403.90", "695.89", "414.00", "707.14", "707.22", "428.0", "682.6", "110.4", "599.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7381, 7390

5155, 6769

378, 402

7436, 7436

3742, 5132

7488, 7516

2832, 2850

7413, 7413

6795, 7358

7462, 7462

2865, 3723

275, 340

430, 2267

2289, 2592

2608, 2799

20,296

180,867

21300

Discharge summary

report

Admission Date: [**2133-4-27**] Discharge Date: [**2133-5-5**] Date of Birth: [**2068-2-16**] Sex: M Service: VSU CHIEF COMPLAINT: Right foot arterial insufficiency with ischemic rest pain and nonhealing ulceration. HISTORY OF PRESENT ILLNESS: This 65-year-old male with a known peripheral vascular disease who underwent a right femoral AK-[**Doctor Last Name **] with PTFE on [**2132-4-17**]. The patient underwent a thrombolysis angioplasty of the graft on [**2132-11-14**]. Patient now returns with increasing rest pain, foot coolness for the past 2 weeks. Patient also has developed an ulcer on the right heel that has been present since [**2132-11-19**]. At that time, the patient's right foot was edematous, but warm with little pain. However, since that time, the patient has developed increasing pain and coolness of the right foot, which has become more acute over the last 2 weeks. Patient now is admitted for further evaluation and treatment. PAST MEDICAL HISTORY: Hypertension, peripheral vascular disease. PAST SURGICAL HISTORY: As in HPI and a cholecystectomy in the remote past. ALLERGIES: He has no known drug allergies. MEDICATIONS ON ADMISSION: Include Lopressor 25 mg t.i.d., Coumadin 2 mg daily, and aspirin 81 mg daily. REVIEW OF SYSTEMS: Patient denies headaches, visual changes, chest pain, shortness of breath, nausea, vomiting, diarrhea, dysuria, hematuria, constipation. PHYSICAL EXAM: Vital signs: Temperature 99.6, heart rate 96, respiratory rate 16, 97% oxygen saturation on room air, blood pressure 132/88. General appearance: Alert and oriented male x3. Neurologically: Grossly intact. HEENT exam: Neck is supple with no lymphadenopathy. Cardiac exam is a regular rate and rhythm with a normal S1 and 2. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended. Extremity exam shows a right foot with 2+ edema, cool to palpation, and tender. The right heel ulcer is 1 x 1 cm size, dry with eschar, which is shallow. Pulse exam shows palpable femorals bilaterally. On the right, the popliteal is absent. There are no pedal pulses by Doppler or by palpation on the left. The left popliteal is palpable with a palpable DP and a triphasic left PT. HOSPITAL COURSE: Patient was admitted to the vascular service. IV heparinization was begun with a goal PTT for 60- 80. The patient was begun on IV hydration. Routine preangio labs were obtained. Patient underwent a diagnostic arteriogram with the department of interventional radiology on [**2133-4-27**]. The study demonstrated no significant aortoiliac disease. There was abrupt occlusion of the right common femoral artery with reconstitution of some of the branches of the profunda. There was a short reconstitute posterior tibial or peroneal artery midcalf, but with no name or collateral vessels distal in the calf and foot. Results of the study were reviewed. The patient postangio did well. He was prepared for surgery and underwent on [**2133-4-29**], vascular vein mapping for assessment of conduit material, a right femoral thrombectomy with intraoperative arteriogram. Intraoperative findings found a clot in the PFA, in the PTFE graft. There was no below-knee popliteal runoff. No collaterals. There is stenosis of the proximal profunda femoris. Patient was transferred to the PACU with a triphasic common femoral and profunda femoral signal post thrombectomy. Postoperative day 1, patient's T. max was 101.5-100.9. Patient had sinus tachycardia requiring Lopressor for rate control. The right extremity was cool below mid leg. The right groin dressing was clean, dry, and intact. There was no Dopplerable signals in the right foot. IV heparin was continued. Total CKs were done serially. Initial CK was 1669, initially postoperatively; on postop day 1 is [**2152**]. White count was 14.7, hematocrit 31.8. BUN 10, creatinine 0.6. Magnesium and phosphorus were repleted along with a K. Patient's Nipride was weaned, and patient was transferred to the VICU for continued monitoring and care. Postoperative day 2, the patient's T. max was 99.7. White count was 15.8, hematocrit 30.6. PTT was 72. BUN 11, creatinine 0.6. Patient remained NPO, IV hydration, IV Lopressor for blood pressure control, Dilaudid for pain. Patient returned to the OR on [**2133-4-30**] and underwent a right above-knee amputation. He tolerated the procedure well. There was viable muscle and tissue with brisk bleeding at the amputation edges. Patient was transferred to the PACU extubated and stable. Postoperatively, he was hypertensive with systolic blood pressure at 170 requiring nitroglycerin and Nipride drips for systolic blood pressure control. His postoperative hematocrit was 26.1. Patient required a transfusion. Postoperative days 2 and 1, the patient required diuresis with Lasix. T. max was 101.4-98.4. Posttransfusion hematocrit was 27.2. White count continued to rise at 16.5. Total CK was 2055. Patient's diet was advanced as tolerated, and he was delined and transferred to the regular nursing floor on telemetry. Patient was evaluated by physical therapy on [**2133-5-3**]. Patient will require rehab stay prior to being discharged to home. Postoperative day 3, patient was 99.5. He diuresed 2.5 liters. The amputation site dressing was removed. It was intact. There were no ischemic edges. Postoperative day 4, rehab screening was instituted. Pain was under good control, tolerating his POs. Stump site was clean, dry, and intact. At time of discharge to rehab, patient was stable. DISCHARGE MEDICATIONS: Protonix 40 mg daily, metoprolol 50 mg t.i.d., acetaminophen 325 mg tablets [**12-21**] q.4-6h. p.r.n., oxycodone/acetaminophen 5/325 pills [**12-21**] q.4-6h. as needed, hydromorphone 2 mg tablets q.2h. p.r.n. for breakthrough pain. DISCHARGE DIAGNOSES: 1. Arterial insufficiency with right leg and foot pain and right heel ulceration nonhealing. 2. Failed thrombectomy. 3. Postoperative blood loss anemia corrected. 4. Postoperative volume overload diuresed. 5. Systolic hypertension controlled. PROCEDURES: Arteriogram of the right leg with a runoff [**2133-4-27**], a right femoral thrombectomy with intraoperative arteriogram on [**2133-4-29**], and a right AK amputation on [**2133-4-30**]. DISCHARGE INSTRUCTIONS: Patient may ambulate nonweightbearing on the effected extremity. No stump shrinkers. The skin clips remain in place until the patient is seen in followup by Dr. [**Last Name (STitle) 1391**]. He will determine when sutures should be removed. Patient should be seen by Dr. [**Last Name (STitle) 1391**] in [**1-22**] weeks and should call for an appointment at [**Telephone/Fax (1) 1393**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2133-5-5**] 10:31:12 T: [**2133-5-5**] 11:08:30 Job#: [**Job Number 56333**]

[ "996.74", "250.00", "440.24", "285.1", "998.11", "440.32", "427.89", "276.5", "997.1", "444.22", "E878.5", "276.6", "276.8", "401.9", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "88.48", "84.17", "39.49" ]

icd9pcs

[ [ [] ] ]

5820, 6269

5564, 5799

1195, 1274

2259, 5540

6294, 6954

1070, 1168

1448, 2241

1294, 1432

153, 239

268, 979

1002, 1046

3,488

140,358

11230

Discharge summary

report

Admission Date: [**2197-5-13**] Discharge Date: [**2197-5-26**] Service: MED Allergies: Aspirin Attending:[**First Name3 (LF) 2641**] Chief Complaint: central cord syndrome and CHF Major Surgical or Invasive Procedure: none, blood transfusion and fresh frozen plasma transfusion History of Present Illness: 85 yo F admitted to Nsurg [**2197-5-13**] with C6-7 central cord syndrome and small epidural hematoma s/p fall at home with ETOH level > 200. Head CT negative at OSH. On solumedrol gtt in T-SICU, now off all steroids. Pt. also noted to have thrombocytopenia, [**Month/Day/Year 5348**] 60-90K, and CRI with [**Month/Day/Year 5348**] around 2.5. On [**2197-5-17**], pt. transfused 2 units PRBCs, 2 units FFP and 2 pk platelets [**12-26**] hct-33, plt-70, INR-1.4. Became SOB, given 40 IV lasix, O2 with good response. Past Medical History: 1.)ETOH abuse 2.)Anemia [**12-26**] bleeding polyps in '[**93**], has been transfusion dependant 3.)Detatched L retina 4.)Cataract R eye 5.)hemicolectomy in '[**83**] Social History: recently widowed x 3 mo., lives in split family house with son and dtr. [**Name (NI) **] [**Name2 (NI) **]. Heavy ETOH. Family History: n/c Physical Exam: V- 98.3, 120-150/70-90, RR: 20-30, HR-90, 97% on 3.5L gen: elderly female, sitting up in bed with hard collar on, eating dinner with 2 daughters [**Name (NI) 4459**]: [**Name (NI) 5674**], dilated L pupil (chronic) neck: hard collar in place CV: RRR, no m/g/r pulm: bibasilar crackles [**11-26**] way up b/l, no ronchi, mild wheezes abd: s/nt/nd, NABS extr: trace edema b/l, Radial, DP pulses 2+ bilaterally neuro: A+Ox3, appropriate affect, arm strength, DTRs, and sensation equal bilaterally Pertinent Results: [**2197-5-13**] 02:00AM WBC-5.3 RBC-2.61* HGB-8.3* HCT-25.1* MCV-96 MCH-31.7 MCHC-32.9 RDW-19.9* [**2197-5-13**] 02:00AM PLT SMR-LOW PLT COUNT-93* [**2197-5-13**] 02:00AM PT-14.1* PTT-25.9 INR(PT)-1.3 [**2197-5-13**] 10:10AM PT-14.2* PTT-25.1 INR(PT)-1.3 [**2197-5-13**] 02:00AM CK-MB-23* MB INDX-3.4 cTropnT-0.05* Brief Hospital Course: Neuro: Ms. [**Known lastname 36081**] came in with a central cord syndrome after a fall at home. She was placed on a solumedrol now off all steroids. She was placed in a hard cervical collar and must keep it on for 12 wks with 2 wk f/u with Dr. [**First Name (STitle) **] (flex/ext. films at that time). She was transfused with fresh frozen plasma and given vitamin K to keep her INR around 1.3. It remained stable during her hospitalization around 1.3-1.5. Her platelets remained above 50, usually between 60-70, so no interventions were necessary from that standpoint. Heme: Ms. [**Known lastname 36081**] continued to be pancytopenic during her stay. She was transfused with PRBCs and FFP during her stay per neurosurgery recommendations as above. Per her PCP, [**Name10 (NameIs) 5348**] WBC is 3 with about 120 platelets. She has received multiple transfusions and often gets fluid overloaded. It was thought that the pancytopenia may be due to alcohol use but MDS could not be omitted as an etiology without a bone marrow biopsy. This procedure may be done during outpatient followup since it would change prognosis. The patient was maintained on thiamine and folate as well. She left with rising white and platelet counts. Pulm: Ms. [**Known lastname 36081**] developed the onset of a cough productive of sputum during her course as well as dyspnea with falling oxygen saturations and a chest x ray with right sided opacities. She improved with chest PT, a 10 day course of levofloxacin and flagyl, and 2 L of O2 by nasal cannula. She was thought to have developed an aspiration pneumonia or a pneumonitis since she failed her speech and swallow evaluation. The patient was placed on aspiration precautions and a nectar thickened diet. Her physical exam has improved, now with fewer crackles at the bases. CV: Following transfusions, Ms. [**Known lastname 36081**] developed CHF with a troponin leak and some EKG changes such as inverted t waves in leads V3 + V4, consistent with ischemia. She could not be give heparin or aspirin with PMH of HIT and with spinal cord compression from hematoma. Before these events, she had an echo which showed an EF of 40-45%. She's been rate controlled with beta blockade and had bp control with lisinopril. She was diaresed with lasix to improve her active CHF but then developed hypernatremia. Following infusion of D5W, her hypernatremia resolved. Once stabilized from the heme/neuro standpoint she will be a candidate for catheterization so stress and echo may be indicated as follow up. Renal: Ms. [**Known lastname 36081**] has acute renal failure with a [**Known lastname 5348**] around 2 per PCP. [**Name10 (NameIs) **] discharge, her creatinine was improving at 1.4. GI: I spoke with Dr.[**Last Name (STitle) 5217**] who stated that Ms. [**Name14 (STitle) 36082**] is a chronic GI bleeder who has undergone multiple endocscopies and colonoscopies to repair several angiodysplasias. He agreed with current management. Medications on Admission: prevacid 15 toprol xl 50 accupril 20 lasix 20 aldactone 25 thyroid med Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day). 7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for CP. 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Please take for 2 more days with the final day on [**5-28**]. 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days: Please take for 2 more days with the final day on [**5-28**]. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO QD (once a day) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: central cord sydrome CHF pancytopenia chronic renal failure Discharge Condition: good Discharge Instructions: Be sure to eat a nectar thickened diet. No thin liquids. Please have another speach and swallow evaluation once your collar is removed. Watch closely for leg swelling, shortness of breath, or chest pain. Once patient eats and drinks more, she will need to be restarted on her 20 mg. PO of lasix per day if her electrolytes are stable. Please check a chem 7 in 5 days since she has been hypernatremic. Your INR and platelets should be checked in 5 days. The INR should be less than 1.3 and the platelets should be greater than 50. Followup Instructions: Please call [**Telephone/Fax (1) 36083**] to follow up with Dr. [**Last Name (STitle) 5217**] in 2 weeks. (I was unable to reach his office to make this appointment for you.) He may want to schedule you for a stress test and echocardiogram since you had some ischemic looking EKG changes. Please call Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 88**] to schedule a follow up visit within 2 weeks. He will need flexion and extension films prior to your visit and this is to be scheduled by his office. Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2539**] in the [**Hospital **] clinic on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building on [**6-27**] at 3pm. His phone number is [**Telephone/Fax (1) 36084**]

[ "507.0", "276.0", "585", "305.00", "852.40", "287.5", "952.05", "428.0", "584.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

6526, 6596

2082, 5057

240, 302

6700, 6706

1733, 2059

7284, 8067

1198, 1203

5178, 6503

6617, 6679

5083, 5155

6730, 7261

1218, 1714

171, 202

330, 852

874, 1043

1059, 1182

5,289

194,762

46367

Discharge summary

report

Admission Date: [**2110-10-10**] Discharge Date: [**2110-12-12**] Service: VASC [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: The patient was an 84 year old gentleman with multiple past medical problems including paroxysmal atrial fibrillation, history of sinus node dysfunction status post dual chamber pacemaker placement in [**2108-8-22**], history of long term hypertension, well known history of abdominal aortic aneurysm which was documented that had grown from 5.5 centimeters in [**2109-8-22**] to 7.2 mg on [**2110-9-17**]. The patient at that time had previously declined elective surgery and when he was noticed to have this increasing size in his abdominal aortic aneurysm, he continued to decline elective abdominal aortic aneurysm repair. He also had a history of hypertrophic cardiomyopathy with a compromised ejection fraction of 40%. He had a history of a left upper extremity deep vein thrombosis, history of gastroesophageal reflux disease, history of degenerative joint disease. The patient is status post left hip arthroplasty, history of left ventricular hypertrophy, history of mild aortic regurgitation with moderate mitral regurgitation and finally a history of hemorrhoidectomy in the distant past. With his multiple medical problems, he presented to his primary care physician on the evening of [**10-10**] for weakness and general malaise. He was found to have a systolic blood pressure in the 70s and also a complaint of having episodes of melana. He was transferred emergently to the Emergency Department where upon arrival he was found to be hypertensive and tachycardic. Due his known history of the 7.2 centimeters abdominal aortic aneurysm, an emergent ultrasound was obtained and it documented an intact aneurysm. Upon obtaining good intravenous access and resuscitating him with intravenous fluids and packed red blood cells, a CT scan was obtained and demonstrated a primary aortic enteric fistula. While in the Emergency Room, the patient began bleeding red blood from nose, mouth as well as continued to have episodes of massive melena. He was intubated for airway protection and the seriousness and acuity of his condition was discussed with the distant relatives present at that time Prior to his intubation, Mr. [**Known lastname 98538**] discussed going to surgery with Dr. [**Last Name (STitle) **]. At that point, he wanted surgical intervention. An emergent Vascular Surgery consultation was obtained and the family was explained about the great risk and high mortality of this kind of procedure, but despite this, they knew that the patient wished to have surgery on those conditions and he was scheduled to undergo an emergent surgical repair. On [**2110-10-10**], the patient was taken to the Operating Room where he underwent a resection of the 7.2 centimeter infrarenal aortic aneurysm that required a temporary supra-celiac cross clamp of about 30 minutes and a 40 minute infrarenal aortic cross clamp as well as a replacement of the aorta with a 20 millimeter Dacron tube graft. Subsequently the sac of the aneurysm was debrided and an omental pedicle coverage of the graft was performed. An intraoperative consultation was obtained with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] from the Blue Surgical Team who performed a duodenal fistula resection, duodenotomy closure with an omental flap placement. Due to the aggressive resuscitation and the patient's instability, the abdomen was left open but covered with a sterile drape with drains as well as a pack. The patient was transferred to the Intensive Care Unit for continued monitoring and full support. He was started on broad empiric antibiotic coverage. Two days later, the patient improved moderately from a hemodynamic standpoint and it was decided that it was a reasonable time to attempt a primary closure. The plan was also to remove the pack within the abdominal cavity and the patient was taken back to the Operating Room with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] from the Blue Team a second time. He tolerated the procedure well. It was impossible to close him primarily and subsequently he was transferred once again to the Trauma Intensive Care Unit for close monitoring and support. His postoperative course was long and complicated. He eventually grew Enterococcus klebsiella, Bacteroides fragilis as well as other organisms from the intraoperative cultures. He was started on Levofloxacin, AmBisome, Zosyn as well as Vancomycin with the guidance and input of Infectious Disease. All along this time, he was supported with intravenous fluids and vasopressors and he was started on total parenteral nutrition. Over the course of the next couple of weeks, he became progressively icteric and he was noted to have an elevated bilirubin. It was thought at that time that he might have had cholestasis since multiple ultrasounds did not reveal any signs of cholecystitis. He was scheduled to undergo an endoscopic retrograde cholangiopancreatography at the beginning of [**Month (only) 359**] and this study did not reveal any potential blockage or obstruction. He was found to have a moderate diffuse dilation of the common bile duct with some sludge, measuring about 12 millimeters and this is why he had a stent placed successfully in the common bile duct. Subsequently this stent was removed but in spite of this his bilirubin never returned to [**Location 213**] values and remained elevated. His Intensive Care Unit course was subsequently complicated by prolonged intubation, ultimately requiring a tracheostomy that was performed by Dr. [**First Name (STitle) **] [**Name (STitle) **] from Interventional Pulmonology on [**2110-11-12**]. The patient tolerated this procedure well and this tracheostomy allowed the surgical Intensive Care Unit staff to perform much better pulmonary toilet. By the beginning of [**Month (only) **], he was tolerating trials of trach mask with on and off episodes of hypotension. He was intermittently on and off pressors to treat this hypotension during this time . He was started on enteral tube feeding as well as kept on total parenteral nutrition, closing monitoring transferrin levels as well as liver function tests. During the entire month of [**Month (only) **], the patient appeared to wax and wane but ultimately became progressively sicker and deteriorated. His liver function tests never improved and progressively his renal function worsened. He developed bilateral pulmonary infiltrates and he was growing Pseudomonas from his sputum. The family was approached and informed repeated times about the seriousness of his condition and the likely poor prognosis of his postoperative course. Despite this, the patient's family wished to continue full support and keep him in the Trauma Surgical Intensive Care Unit. He continued to decline and progressively became sicker and more pressor dependent to keep adequate hemodynamics. Upon meeting with the Surgical Intensive Care Unit staff and in agreement with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the vascular attending on record, it was decided that cardiopulmonary resuscitation would not be indicated on this patient, but he will be kept on the pressor support as well as ventilatory support as the patient's family wished. By the evening of [**2110-12-11**], he was more acidotic and minimally responsive with low blood pressure requiring a full ventilatory support to barely keep his saturations above the 90s. By the next day, on [**2110-12-12**], in the morning, he was hypotensive, hypothermic, despite our support with Dopamine, Levophed, and full ventilatory support. By mid afternoon, the patient's monitor alarm went off and he was noted to be asystolic. The Primary Team was called to evaluate the patient and upon confirming the absence of corneal reflexes, tracheal reflex as well as a lack of spontaneous breathing or heart rate, nor any response to painful stimuli he was pronounced dead at 03:35 pm on [**2110-12-12**]. The patient's family was notified as well as the covering staff physician for the Vascular Surgical Service. The patient's family declined a postmortem examination and upon making arrangements, the patient was transferred to the morgue of the [**Hospital1 69**] Hospital. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. 2914 Dictated By:[**Last Name (NamePattern4) 26544**] MEDQUIST36 D: [**2110-12-12**] 19:13 T: [**2110-12-12**] 21:24 JOB#: [**Job Number 98541**]

[ "584.9", "997.1", "427.31", "415.11", "441.4", "577.0", "997.5", "518.5", "998.59" ]

icd9cm

[ [ [] ] ]

[ "46.79", "38.91", "96.6", "51.87", "00.14", "38.44", "31.1", "33.23", "39.59", "38.93", "54.62", "96.72", "54.74", "99.15" ]

icd9pcs

[ [ [] ] ]

150, 8657

63,252

181,004

1350

Discharge summary

report

Admission Date: [**2132-9-9**] Discharge Date: [**2132-9-12**] Date of Birth: [**2093-5-15**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Ragweed Attending:[**Doctor First Name 5911**] Chief Complaint: - fibroids, adnexal mass, presenting for surgery Major Surgical or Invasive Procedure: - diagnostic laparoscopy - exploratory laparotomy - supra-cervical hysterectomy - right salpingo-oophorectomy - lysis of adhesions - cystoscopy - right ureteral stent placement and removal History of Present Illness: 39-year-old, G2, P 0-0-2-0, premenopausal Caucasian female with hypertension, hypothyroidism, anxiety and menorrhagia related to her symptomatic recurrent fibroids with surgical history significant for 2 prior abdominal myomectomies. She presents complaining of worsening fibroid related symptoms, specifically with menorrhagia. Menorrhagia labs were drawn and were essentially negative except mildly elevated prolactin which was repeated and noted to be within normal limits when fasting. Preoperative endometrial biopsy was benign. PUS ([**2132-6-27**]) at OSH, multifibroid uterus 12.2 cm, largest fundal 7.4 cm, left 5.2 cm fibroid, 5 cm right ovary with 4.6 cm complex cyst. Normal left ovary. No hydronephrosis. Different treatment options were discussed and the patient opted to proceed with surgical management with a diagnostic laparoscopy for possible total laparoscopic hysterectomy and RSO but understood that there was a likely risk of conversion to a laparotomy given her prior abdominal history and pelvic exam suggesting an enlarged 14 to 16 size fibroid uterus. Past Medical History: - hypertension - hypothyroidism - anxiety - myomectomy x 2 Social History: - non-contributory Family History: - non-contributory Physical Exam: Physical Examination: Pleasant overweight female in no acute distress. BP is 140/82, weight 216.5 pounds, height 5 feet 5 inches. HEENT: Normocephalic, atraumatic. Neck: Supple, full range of motion, no thyromegaly, no nodules. Back: No CVA tenderness. Lungs: Clear to auscultation bilaterally. CV: Regular rate and rhythm. Abdomen: Centrally obese, soft, nontender, nondistended, positive bowel sounds. No rebound or guarding. Well-healed low transverse suprapubic scar. Extremities: No clubbing, cyanosis, or edema. Pelvic: There is grossly normal external female genitalia. On bimanual exam, uterus ~[**11-23**] wks size, the cervix is deviated very posteriorly and there are multiple palpable subserosal fibroids on the anterior lower uterine segment and fundus, compressing the bladder. They are tender to deep palpation. No palpable adnexal masses; however, the exam is quite limited due to the patient's body habitus. On speculum exam, the cervix again is tilted quite posteriorly from the anterior fibroids and quite high, the vaginal vault also tight. Pertinent Results: [**2132-9-12**] WBC-13.4 Hgb-8.8 Hct-26.6 Plt Ct-305 [**2132-9-10**] WBC-14.7 Hgb-10.8 Hct-30.7 Plt Ct-278 [**2132-9-9**] WBC-18.2 Hgb-12.7 Hct-37.2 Plt Ct-349 . [**2132-9-12**] Glucose-112 UreaN-5 Creat-0.7 Na-138 K-3.8 Cl-104 HCO3-27 AnGap-11 [**2132-9-9**] Glucose-155 UreaN-8 Creat-0.6 Na-140 K-3.8 Cl-106 HCO3-24 AnGap-14 . [**2132-9-9**] 08:34PM BLOOD Type-ART Rates-14/0 Tidal V-500 PEEP-5 FiO2-50 pO2-153 pCO2-46 pH-7.35 calTCO2-26 Base XS-0 -ASSIST/CON Intubat-INTUBATED [**2132-9-9**] 04:55PM BLOOD Type-ART pO2-212 pCO2-41 pH-7.39 calTCO2-26 Base XS-0 Intubat-INTUBATED [**2132-9-9**] 03:46PM BLOOD Type-MIX PEEP-0 FiO2-59 pO2-48 pCO2-29 pH-7.36 calTCO2-17 Base XS--7 Intubat-INTUBATED . [**2132-9-9**] 04:55PM Hgb-11.6 calcHCT-35 [**2132-9-9**] 03:46PM Hgb-8.4 calcHCT-25 O2 Sat-84 COHgb-1.4 MetHgb-0.5 Brief Hospital Course: 1. Fibroids, menorrhagia, complex R ovarian mass On diagnostic laparoscopy, extensive adhesions were noted, and the decision was made to convert the procedure to an exploratory laparotomy. Due to these extensive adhesions, as well as several cervical/parametrial fibroids, the case was prolonged and a significant blood loss sustained. She was transfused 2 units of PRBC intra-operatively. A right ureteral stent was placed and subsequently removed. Of note, a Urology consult was obtained intra-operatively to confirm the right ureteral & baldder dissection. Post-operatively she was taken to the ICU for closer monitoring. Please see operative report for full details. . ICU course: She was monitored in the ICU overnight and remained intubated post-operatively for conservative measures, per the anesthesia team's recommendataions. Her BP remained stable and she did not require pressors during the surgery or post-op. She responded appropriately to the transfusion of blood, and her pulmonary status remained stable. On the morning of POD#1 she was extubated without difficulty, and later that evening was transferred to the floor. . The remainder of her hospital course was uncomplicated; Hct stabilized around 26 and she was transitioned successfully to oral pain medication and her diet advanced. She remained afebrile and had stable vital signs, and was discharged home in good condition on POD#3. . 2. Hypertension Home medication initially held due to significant blood loss during surgery. After transfer out of the ICU and with stable blood pressures on the floor, home medication was re-started. . 3. Hypothyroidism Was not an issue during this hospitalization; home medication was continued. . 4. Anxiety Was not an issue during this hospitalization; home medication was continued. Medications on Admission: - atenolol - levothyroxine - Celexa Discharge Medications: 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:40 Tablet(s) Refills:2 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed for pain. Disp:30 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Iron 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Disp:30 Capsule, Sustained Release(s) Refills:2 5. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours: total Tylenol dose not to exceed 4000mg per day (Percocet also has Tylenol). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: - fibroids - menorrhagia - complex right ovarian cyst Discharge Condition: - good Discharge Instructions: - no heavy lifting (greater than 10lbs) for 6 weeks - nothing in the vagina (sex, tampons, douching) for 6 weeks - do not drive while using narcotic pain medication - call your doctor for the following: - bleeding or discharge/pus from your incision - redness around your incision - if your incision re-opens - heavy bleeding - severe pain - fevers, chills, nausea, vomiting - any other concerns Followup Instructions: Provider: [**Name6 (MD) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 8246**] Date/Time:[**2132-10-20**] 10:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 5913**]

[ "596.8", "620.2", "560.81", "300.00", "518.81", "401.9", "218.1", "285.1", "244.9", "218.0", "218.2", "626.2", "V64.41" ]

icd9cm

[ [ [] ] ]

[ "99.04", "68.39", "65.49", "54.59", "57.32" ]

icd9pcs

[ [ [] ] ]

6324, 6330

3745, 5542

330, 521

6428, 6437

2904, 3722

6895, 7113

1765, 1785

5628, 6301

6351, 6407

5568, 5605

6461, 6872

1800, 1800

1823, 2885

242, 292

549, 1631

1653, 1713

1729, 1749

65,267

129,095

52907

Discharge summary

report

Admission Date: [**2108-8-26**] Discharge Date: [**2108-8-28**] Date of Birth: [**2046-8-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2042**] Chief Complaint: cholangitis Major Surgical or Invasive Procedure: Right jugular line [**First Name3 (LF) **] History of Present Illness: Mr. [**Known lastname **] is a 61 year-old male with hx of metastatic colon cancer in remission, COPD, and recurrent biliary obstruction who presented to the ED with a day of abdominal pain and fevers. He states he started feeling unwell last night with 3 hours of chest/abdominal pain and subjective fevers. This morning he took tylenol with some response, but then around 2 pm he developed fevers, rigors, and worsening abdominal/chest pain. He described his abdominal pain diffuse and sharp. He admitted to some nausea, but denied vomiting. He then took another tylenol and also a dose of ciprofloxacin. . Of note he has had over twenty ERCPs in the past for recurrent biliary stent blockages. He states this is the sickest he has ever felt prior to [**Known lastname **]. . In the ED, initial vs were: T 99.8 P 103 BP 92/66 R 16 O2 sat 96%. Patient was given zosyn, 5 L NS, and started on a levophed drip due to hypotension. On exam he had RUQ tenderness and was guaiac negative. During his ED course he put out 700 cc in his foley. . Currently he denies abdominal pain, nausea, chest pain, or shortness of breath. . Review of systems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies, chest pressure, palpitations, or weakness. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Colon Cancer metastatic to liver s/p left colectomy, s/p left liver lobe segmentectomy, s/p chemotherapy; currently in remission. - Recurrent biliary obstruction due to 5-FU. Per recent PCP note, the patient reports that he has ERCPs every 3-6 months to remove biliary sludge. - COPD - Schizophrenia - GERD - Macular degeneration - right temporal adnexal carinoma s/p removal and skin graft repair by derm - s/p Appendectomy - s/p Cholecystectomy Social History: He lives alone. He is on disability. Quit smoking and drinking in [**2100**]. Family History: His mother died of colon cancer. Physical Exam: Vitals: T: 97.6 BP: 100/60 P: 77 R: 19 O2: 95% on RA CVP 8 General: Alert and oriented. Speech is somewhat slow, but he is appropriate. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Breathing comfortably. Crackles present bilaterally at the bases. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Well-healed midline scar presnt. + hyperactive bowel sounds. Soft, nondistended. Slight tenderness to palpation in the RUQ. No reboung or guarding. GU: foley with light yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: Na 138 K 3.5 Cl 103 BUN 13 Cr 1.1 Glu 116 Ca 8.7 Mg 1.7 Phos 1.2 trop <0.01 . ALT 142 AST 165 AP 351 Tbili 2.6 Alb 4.2 Lip 26 . WBC 9.8 Hct 37.7 Plt 129 N 93.3% L 3.1% M 2.3% . PT 12.8 PTT 20.4 INR 1.1 Lactate 2.6 . Micro: UA negative for leuk or nitr BCx x 2 - pending . Images: CXR: IMPRESSION: Status post placement of a right-sided IJ terminating within the upper SVC. There is no pneumothorax. . EKG: normal sinus rhythm, nl axis, with no STE or STD. . [**Year (4 digits) **] - [**2108-8-27**] - IMPRESSION: Previously placed metal stents were noted on fluoroscopy in the CHD and CBD. Evidence of a previous sphincterotomy was noted in the major papilla A single periampullary diverticulum with small opening was found at the major papilla. Cannulation of the biliary duct was performed with a balloon catheter using a free-hand technique Multiple filling defects were noted in the biliary tree within the metal stents. Large amount of stone and sludge debris was removed with a balloon catheter after multiple sweeps of the metal stents. Occlusion cholangiogram revealed further fixed filling defect at the proximal edge of the metal stents and the R hepatic duct/hilum area, likely hyperplastic overgrowth of tissue related to the metal stents. A 5cm by 10FR Double pigtail plastic biliary stent was placed successfully with the proximal edge in the Left hepatic duct. Contrast and bile drainage was noted after placement of the pigtail stent Recommendations: Continue with IV antibiotics Pt may resume diet Pt will be transferred back to [**Hospital Unit Name 153**] under the care of the ICU team [**Hospital Unit Name **] in 4 months to re-evaluate biliary tree, remove stent and clean debris Brief Hospital Course: 61 year-old male with hx of metastatic colon cancer in remission, COPD, and recurrent biliary obstruction who presented to the ED with a day of abdominal pain and fevers concerning for cholangitis. . # Cholangitis and septic shock: The patient has metal biliary stents in place which tend to have an occlusion every [**3-1**] months. His LFTs were mildly elevated. The patient's hypotension was most likely due to his cholangitis. He required fluid resusitation, pressors, antibiotics and bowel rest. He was stabilized and able to undergo [**Month/Day (3) **] on [**2108-8-27**]. He had a successful [**Date Range **] drainage of stone and sludge debris from the stents in the common bile duct and the patient also had a pigtail catheter placed in the left hepatic duct. His hypotension resolved after [**Date Range **] and he was able to be transferred to the floor. He will need to finish a 10 day course of antibiotics (Ciprofloxacin and Flagyl) as an outpatient. It was recommended that he continue taking Ursodiol. . # Chest pain: The patient had an episode of chest pain which was felt to be most likely pain referred from his abdomen. His cardiac enzymes were negative and he did not have any EKG changes. . # The following medical issues remained stable during this hospitalization: Thrombcytopenia, COPD, Schizophrenia, GERD and Constipation. Medications on Admission: Albuterol 90 mcg inhaler 2 puffs qid prn Alprazolam 0.25-0.5 mg po daily prn anxiety Advair 500 mcg-50 mcg inh daily Gabapentin 800 mg [**Hospital1 **], 1200 mg po qhs Misoprostol for constipation Miralax Propranolol 30 mg po bid Ranitidine 150 mg po bid Risperidone 1.5 mg po qafternoon and 3 mg qhs Ursodiol 300 mg po tid Ziprasidone 40 mg po bid Melatonin Discharge Medications: 1. Misoprostol Oral 2. Atrovent 0.03 % Spray, Non-Aerosol Nasal 3. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Risperidone 3 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Risperidone 0.5 mg Tablet Sig: Three (3) Tablet PO QAFTERNOON (). 9. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 10. Ziprasidone HCl 40 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 7 days. Disp:*14 Tablet(s)* Refills:*0* 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 7 days. Disp:*21 Tablet(s)* Refills:*0* 13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. 14. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO every [**6-5**] hours as needed for anxiety. 15. Ipratropium Bromide 0.03 % Spray, Non-Aerosol Sig: [**12-31**] sprays Nasal three times a day as needed for runny nose. 16. Propranolol 10 mg Tablet Sig: Three (3) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses # cholangitis Secondary Diagnoses # chest pain - noncardiac etiology # thrombocytopenia # COPD # Schizophrenia # Gerd # hyphosphotemia, hypocalcemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with an infection from your gallbaldder like the infections that you have had before. You were treated with strong IV antibiotics. Because your blood pressure was very low you needed to stay in the intensive care unit. You had an [**Month/Day (2) **] procedure that removed gall stones and sludge from your gallbladder. Your blood pressure came back to normal with IV medication, antibiotics and fluids and you stayed overnight on the regular hospital floor. You did not eat or drink anything until you had your [**Month/Day (2) **]. After your procedure you drank just clear liquids. You've done well and now you can go back to a normal diet. Your antibiotics will change from IV to medicines that you should take by mouth for 7 days. Do not stop taking the anitbiotics when you feel better, it is important that you finish all the pills completely. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28258**], MD Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2108-10-9**] 2:00 Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2108-12-13**] 8:00 Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2108-12-13**] 8:00

[ "V10.05", "275.3", "295.90", "576.1", "V87.41", "275.41", "530.81", "496", "574.51", "786.59", "287.5" ]

icd9cm

[ [ [] ] ]

[ "51.87", "38.93", "51.88" ]

icd9pcs

[ [ [] ] ]

8065, 8071

4884, 6245

327, 372

8283, 8283

3120, 3120

9326, 9715

2416, 2450

6655, 8042

8092, 8262

6271, 6632

8433, 9303

2465, 3101

1551, 1831

276, 289

400, 1532

3136, 4861

8298, 8409

1853, 2303

2319, 2400

76,390

196,855

42237

Discharge summary

report

Admission Date: [**2110-10-18**] Discharge Date: [**2110-11-5**] Date of Birth: [**2030-10-19**] Sex: F Service: NEUROLOGY Allergies: lisinopril Attending:[**First Name3 (LF) 2569**] Chief Complaint: Transferred from OSH, intubated and sedated Major Surgical or Invasive Procedure: Endotracheal Intubation History of Present Illness: The pt is a 79 y/o woman with a prior hx of HTN, DM, hypothyroidism who comes in as an OSH transfer intubated with left thalamic IPH. She was stated to be in her normal state of health until about 3 weeks ago when after a friends death she was noted to have bouts of confusion and a glossy look. She has been evaluated at [**Hospital **] hospital for this several times including an inpatient admission for several days. I have no official reports from Beverely as of yet but per her daughter she states that they were working her up for "inflammation" possibly of the thalamus (unknown which side) They completed about 3 MRI's some of them with contrast and an LP was the next thing to be done. Unfortunately they were unable to provide much more medical history with regards to this. What family did notice was that she was confused at times, would answer questions inappropriately at times and had a glossy look at times. There were no abnormal movements noted. Today she stayed in bed past her usual time and when she got up she was noted to be very lethargic. The daughter also noted that she was more confused. Having had her atenolol recently changed she thought it was low blood sugar but her neighbor measure her bP noting SBP in the 140's and a normal blood sugar level. In the later afternoon she was given liquids and vomited it up. She also had fecal incontinence. Ambulance was called and she was taken to an OSH ED. There she was lethargic was intubated for airway protection using fentanyl, Etomidate, vec and suc's. She had a CT scan and unfortunately we do not have today's images but the read stated a left thalamic bleed with early vasogenic edema measuring 2cm with IV extension. At the times of exam she was intubated and on sedation. Past Medical History: Hypothyroidism HTN GOUT DM HLD Social History: Lives on her own. Family History: No hx of early strokes. Physical Exam: Physical Examination on Admission Vitals: T:98 P: 70 R: 16 BP:140/78 SaO2:100 General: Intubated sedated HEENT: NC/AT, MMM, Neck: Supple, No nuchal rigidity Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2 Abdomen: soft. Extremities: No C/C/E bilaterally. Skin: no rashes or lesions noted. Neurologic: Sedated/ Intubated. Pupils pinpoint but reactive. Conjugate gaze. + Dolls, + Gag, + Corneal stronger on the left, + grimace to pain. Left UE withdraws, Right extends, Triple flex at the lower extremities. Reflexes not appreciated in upper or lower ext. Right toe mute left upgoing. Tone increased in LE's. DISCHARGE PHYSICAL EXAM: Vital signs: Tm 100.1, Tc 98.9, BP 123/36, HR 63, RR 12, 97%on CPAP GEN: awake elderly woman lying in bed, NAD HEENT: OP clear, MM dry CV: RRR PULM: mild crackles at the bases ABD: soft, NT, ND EXT: trace peripheral edema . Neurological Exam: MS - awake, able to follow simple commands, knew she was in a hospital, thought it was [**Hospital **] Hospital, knew it was [**Month (only) **] but thought it was [**2011**]. CN - decreased upgaze on the R eye, PERRL 2.5->2, face symetrical, facial sensation intact, hearing intact bilat MOTOR - Delt Tric Bic WristExt FExt Grip R 5 5 5 5 5- 5 L 5- 4+ 5 4 5- 5 antigravity in legs bilaterally. SENSORY - intact to light touch throughout COORDINATION - FNF intact bilaterally, but pt has difficulty lifting LUE GAIT - deferred Pertinent Results: Labs on Admission: [**2110-10-18**] 09:25PM BLOOD WBC-7.2 RBC-4.27 Hgb-13.9 Hct-38.7 MCV-91 MCH-32.5* MCHC-35.8* RDW-13.4 Plt Ct-203 [**2110-10-18**] 09:25PM BLOOD Neuts-77.0* Lymphs-17.6* Monos-4.3 Eos-0.7 Baso-0.4 [**2110-10-18**] 09:25PM BLOOD PT-12.2 PTT-22.8 INR(PT)-1.0 [**2110-10-18**] 09:00PM BLOOD Glucose-144* UreaN-21* Creat-0.9 Na-143 K-4.7 Cl-103 HCO3-28 AnGap-17 [**2110-10-24**] 02:10AM BLOOD ALT-33 AST-40 LD(LDH)-273* CK(CPK)-510* AlkPhos-81 TotBili-0.3 [**2110-10-24**] 02:10AM BLOOD CK-MB-4 cTropnT-<0.01 proBNP-767* [**2110-10-19**] 02:11AM BLOOD Calcium-8.3* Phos-4.0 Mg-1.9 Cholest-140 [**2110-10-19**] 02:11AM BLOOD %HbA1c-6.8* eAG-148* [**2110-10-19**] 02:11AM BLOOD Triglyc-587* HDL-39 CHOL/HD-3.6 LDLmeas-63 [**2110-10-19**] 02:11AM BLOOD TSH-1.9 [**2110-10-19**] 02:11AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2110-10-18**] 09:00PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [**2110-10-18**] 09:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011 [**2110-10-18**] 09:00PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 TransE-<1 LABS ON DISCHARGE: [**2110-11-5**] 06:04AM BLOOD WBC-10.3 RBC-3.75* Hgb-11.5* Hct-34.8* MCV-93 MCH-30.6 MCHC-33.0 RDW-14.8 Plt Ct-489* [**2110-11-5**] 06:04AM BLOOD PT-26.1* PTT-35.2* INR(PT)-2.5* [**2110-11-5**] 06:04AM BLOOD Glucose-141* UreaN-33* Creat-1.3* Na-148* K-3.6 Cl-103 HCO3-34* AnGap-15 [**2110-11-5**] 06:04AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.2 Microbiology: Blood cultures x 2, [**2110-10-21**]: Negative Sputum culture, [**2110-10-25**]: Coag positive staph BAL culture, [**2110-10-25**]: Oxacillin sensitive staph aureus Urine cultures, [**2110-10-25**]: Negative Blood cultures x 2, 9/[**Telephone/Fax (1) 91561**]: Negative MRSA Screen: [**2110-10-27**]: Negative Echo: The left atrium is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 75%). with depressed free wall contractility. 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. There is no pericardial effusion. MRA/MRI/MRV: Stable foci of hemorrhage in the left thalamus and right frontoparietal lobe. Abnormal signal in the right thalamus has progressed since the MRI from [**2110-10-4**]. There is poor visualization of the straight sinus and the internal cerebral veins. These findings are concerning for cerebral [**Last Name (un) **]-occlusive disease. CTV: Occlusion of the straight sinus and distal vein of [**Male First Name (un) 2096**]. Unchanged bilateral thalamic edema with left thalamic hemorrhage with intraventricular extension, and right posterior parietal deep white matter hemorrhage likely secondary to venous sinus thrombosis. Nonocclusive thrombus in the superior sagittal sinus. CT Torso: Focal saccular aneurysmal dilatation of the mid descending thoracic aorta measuring 3.2 x 2.3 x 6.0 cm. Hematoma within the superior aspect of the aneurysm sac. Endotracheal tube tip at the level of the carina pointing towards the right mainstem bronchus. Hypoattenuating lesion in the caudate lobe, likely a simple cyst but with mixed attenuation values likely due to its small size. Cholelithiasis without evidence of acute cholecystitis. CXR [**2110-11-4**]: FINDINGS: As compared to the previous radiograph, there is no relevant change. No evidence of pneumonia. Borderline size of the cardiac silhouette with tortuosity of the thoracic aorta. No pulmonary edema. No pneumothorax. Brief Hospital Course: Ms. [**Known lastname 91562**] was admitted to the ICU approximately 12 days prior following being transferred from an OSH, intubated for "lethargy". Prior to this event, her family describes a course of 3 weeks during which she would have intermittent periods of confusion and a "glossy look". She was admitted to an OSH briefly on [**9-15**] for five days when a series of tests were performed to identify the source of her AMS. During this stay, her mental status improved. They identified an area of thalamic "inflammation" for which she was finally discharged and was being worked up as an outpatient. She received two more CT scans and at least one more MRI and family reports that she was about to get an LP soon. During this period, she would intermittently have periods of confusion. On the day of her admission, she was noted to be extremely lethargic. She had an episode of vomitting and fecal incontinence, and subsequently EMS was called. - She was seen and staffed by our stroke attending [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**] who on his exam, was able to identify skew deviation and small pupils. On NCHCT scan, she was noted to have two intraparenchymal hemorrhages (see below) which have since remained stable. - She continued to remain intubated for few more days. She received an MRV and CTV which revealed evidence of cerebral venous thrombosis for which she was initiated on IV heparin therapy (see images below). - She was extubated on [**2110-10-24**] and did well during the course of the day. She was transferred to the SDU later that evening, and initially did well. Later, she had an episode of hypoxia and tachypnea that did not respond to positive pressure ventilation. She was transferred to the intensive care unit, reintubated. A repeat head CT at the time, showed no change in his IPH. - The cause for reintubation is thought to be [**3-19**] volume overload. She was noted to be net five liters positive over the course of her stay, as a consequence of IV fluids, free water boluses to treat hypernatremia, etc. She was diuresed and has remained net negative over the past several days. - Following her reintubation, she did receive IV diuresis aggressively, but this was briefly held secondary to an episode of hypotension that occurred over the weekend which was transient and responded quickly to a bolus of fluids. - She self extubated on the night of [**2110-10-28**] and had since not required reintubation. She remains mildly tachypneic at baseline (25-30) and mildly hypoxic (92-94%) on humidified tent. - A BAL performed on [**2110-10-25**] subsequently grew out Coag positive Staph Aureus and moraxella catarrhalis. She was initially started on vancomycin/tobra/cefepime, which have subsequently been narrowed to nafcillin and ciprofloxacin for the same. - Her daughter has been at her bedside for much of her stay. They have been counseled about her extensive rehab course, and are open to various options. The search for rehab was initiated, please contact [**Name (NI) 803**] [**Name (NI) **] for more information ([**Numeric Identifier 91563**]). - The etiology of her thrombosis is not clear. A hypercoagulability panel has been deferred for the outpatient setting; she will remain anticoagulated for at least 6 months. She did receive a CT torso which did not reveal any source of malignancy. She did however have an aneurysm discovered on that scan which was not intervened on. Vascular surgery were consulted and will follow the aneurysm as an outpatient. - She was transferred to the floor on [**2110-10-31**] and remained stable. She was kept on Nafcillin+Cipro for her ventilator aquired pneumonia, and completed her course on [**11-3**]. Her fluid status was kept at net negative and she was diuresed with 40 mg Lasix due to fluid overload and pulmonary edema. She remains mildly tachypneic at baseline (25-30) and mildly hypoxic (92-94%) on humidified tent, and is kept on CPAP. Her pressures were controlled with PRN hydralazine for systolic pressures above 160. - Her Cr increased to 1.8 after she was given an extra 40mg IV lasix on [**11-3**]. This improved once her PO lasix was held and PO intake was encouraged. PENDING LABS: Blood Cultures x2 [**2110-11-3**] Urine Culture [**2110-11-3**] TRANSITIONAL CARE ISSUES: Patient will need her INR monitored to ensure that it remains between [**3-20**]. She will also need her creatinine monitored to ensure that it continues to trend down with increased oral intake. She will need her volume status monitored to ensure that she does not get fluid overloaded, and to determine if she needs lasix. Medications on Admission: Metformin 1g/500mg Atenolol 50 [**Hospital1 **] Levothyroxine 0.1 mcg LAntoprastol gtt Allopurinol Bactrim DS [**Hospital1 **] Discharge Medications: 1. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for pruritis. 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever/pain. 3. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 4. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. 11. 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: [**Hospital6 **] Discharge Diagnosis: Primary: cerebral hemorrhage, cerebral venous thrombus Secondary: diabetes, hypertension, hyperlipidemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. NEURO EXAM: somnolent, but arousable, mild L-sided weakness. Discharge Instructions: Dear Ms. [**Known lastname 91562**], You were seen in the hospital for a bleed in your brain that was caused by a blood clot in one of the veins of your head. You were put on a blood thinner and your neurological status improved. Your course was complicated by a ventilator associated pneumonia, which you were treated for with antibiotics. We made the following changes to your medications: 1) We STOPPED your METRFORMIN. You can restart this medication once your renal function fully stabilizes. 2) We DECREASED your ATENOLOL to 25mg twice a day. 3) We STOPPED your LANTOPRASTOL. 4) We STOPPED your ALLOPURINOL. You should restart this medication once your renal function fully stabilizes. 5) We STOPPED your BACTRIM. 6) We STARTED you on SARNA lotion three times a day as needed for itchy rash. 7) We STARTED you on TYLENOL 650mg every 6 hours as needed for pain or fever. 8) We STARTED you on DOCUSATE 100mg twice a day. 9) We STARTED you on FISH OIL 1,000mg twice a day. 10) We STARTED you on SIMVASTATIN 40mg once a day. 11) We STARTED you on FAMOTIDINE 20mg once a day. 12) We STARTED you METHYLPHENIDATE 2.5 mg twice a day. 13) We STARTED you on WARFARIN 3mg once a day. This dose should be adjusted to keep your INR between [**3-20**]. 14) We STARTED you on a HEPARIN FLUSH as needed for your PICC line. Once you have your PICC line out, you don't need this medication. Please continue to take your other medications as previously prescribed. If you experience any of the below listed Danger Signs, please contact your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Followup Instructions: Please call your PCP to get [**Name Initial (PRE) **] referral prior to attending the stroke follow-up. Also, please call [**Telephone/Fax (1) 10676**] to update your registration information prior to your stroke follow-up appointment. Department: NEUROLOGY When: MONDAY [**2111-1-5**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You also have a follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26770**] in vascular sugery on [**4-8**] at 9:45am, located at [**Hospital Unit Name 91564**]. If you need to cancel or change this appointment, please call ([**Telephone/Fax (1) 4852**] [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "348.89", "244.9", "428.0", "599.0", "272.4", "437.6", "250.00", "276.0", "401.9", "428.31", "E879.8", "458.29", "997.31", "041.11", "441.2", "431", "348.5", "041.85", "274.9" ]

icd9cm

[ [ [] ] ]

[ "33.23", "96.6", "96.72", "33.24" ]

icd9pcs

[ [ [] ] ]

13297, 13340

7503, 11801

318, 343

13489, 13489

3785, 3790

15399, 16320

2238, 2263

12333, 13274

13361, 13468

12181, 12310

13731, 14097

2278, 2899

14126, 15376

3167, 3766

235, 280

11827, 12155

4976, 7480

371, 2131

3804, 4957

13504, 13707

2153, 2186

2202, 2222

2924, 3148

17,226

128,705

15664+15737

Discharge summary

report+report

Admission Date: [**2138-12-1**] Discharge Date: [**2138-12-24**] Date of Birth: [**2070-11-29**] Sex: M Service: GOLD SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old male with a history of myocardial infarction, coronary artery bypass graft x 4, coronary artery disease, who presented with bright red blood per rectum in the Emergency Department, pale, diaphoretic, with blood pressure of 60s in the field. The patient received three units of packed red blood cells while in the Emergency Department, and had continued bleeding, intermittently dropping his blood pressure. The patient stated that he had no previous episodes of rectal bleeding, had a normal colonoscopy three years prior, and was not on any anticoagulants except for aspirin. The patient had hematuria intermittently for one month, and had a recent workup which had found him to have a bladder tumor. He planned to have it removed at [**Hospital6 1129**] in the near future. PAST MEDICAL HISTORY: Coronary artery disease status post coronary artery bypass graft, status post AICD, asymptomatic. Patient also with hyperthyroidism, scheduled for surgery, and the patient is status post cholecystectomy. MEDICATIONS: Amiodarone, atenolol, aspirin, Ativan. ALLERGIES: Include codeine, morphine, penicillin and contrast dye. HOSPITAL COURSE: The patient, as above, received three units of packed red blood cells while in the Emergency Department, plus nine liters of intravenous fluid. The patient was admitted to the Medical Intensive Care Unit, where he received two more liters of intravenous fluid and two more units of packed red blood cells. The patient continued to have systolic blood pressures in the 90s, and was afebrile. Initial hematocrit was noted to be 31.6, and a repeat hematocrit was noted to be 19.6. The patient was transfused four more units of packed red blood cells, and sent to angiography for localization of bleeding and possible embolization. The patient continued to bleed, and had about 15 units of gross blood in the angiography suite and was brought to the operating room emergently. The patient underwent a left colectomy secondary to a massive gastrointestinal bleed noted in the colon. The procedure was complicated by massive coagulopathy. During the procedure, the patient underwent a bradycardic episode and arrested. The patient was resuscitated per protocol. The patient was transferred to the Surgical Intensive Care Unit in critical condition with only skin closure. The patient was placed on levofloxacin and Flagyl. The patient had an electrocardiogram which showed decreased ST depressions in V2 and V4 on postoperative day one, and the patient began ruling in for a myocardial infarction. An echocardiogram showed an ejection fraction of 35%, and hypokinetic areas and poor right ventricle function. The patient was taken back to the operating room for extended right hemicolectomy with an ileostomy. He was started on imipenem and thought to be stable, with no active bleeding. The patient's ST depressions improved on electrocardiogram, but the patient had ruled in for a myocardial infarction by enzymes. The patient had placement of bilateral chest tubes for presumed effusions, with significant output from both. On postoperative day seven and six, the patient spiked a fever to 102 and 103, and was pancultured, which grew out budding [**Female First Name (un) **] albicans. The patient had enterococcus in the blood. The patient underwent an ultrasound-guided tap of a fluid collection and was started on amphotericin, vancomycin and continued on imipenem. The patient was extubated on postoperative day 15 and 14, and was transferred from the Surgical Intensive Care Unit to the floor on postoperative 17 and 16. The patient was afebrile. Vital signs were stable. The patient was continued on tube feeds. Imipenem and vancomycin were discontinued. The patient underwent a swallow study and was still felt to be at high risk for aspiration. The patient underwent a second study for swallowing on postoperative day 19 and 20, where he was found to have overt aspiration risk. On postoperative day 21 and 20, the patient underwent a video swallowing study which showed that the patient was still at aspiration risk. The patient's amphotericin was discontinued, and the patient was screened for rehabilitation facility placement. The patient was felt to be ready for discharge to a rehabilitation facility. CONDITION AT DISCHARGE: Stable DISCHARGE STATUS: To rehabilitation facility DISCHARGE DIAGNOSIS: 1. Status post transverse colectomy, right colectomy 2. Postoperative myocardial infarction The patient is to follow up with Dr. [**Last Name (STitle) **], and also to have continuing swallowing studies until oral intake can be restarted. [**Name6 (MD) 19851**] [**Name8 (MD) 19852**], M.D. [**MD Number(1) 19853**] Dictated By:[**Name8 (MD) 5915**] MEDQUIST36 D: [**2138-12-24**] 23:44 T: [**2138-12-25**] 00:26 JOB#: [**Job Number **] Admission Date: [**2138-12-1**] Discharge Date: [**2138-12-25**] Date of Birth: [**2070-11-29**] Sex: M Service: REASON FOR ADMISSION: Lower gastrointestinal bleed. HOSPITAL COURSE: This is a 68-year-old gentleman who has had lower gastrointestinal bleed now which was unrelenting and initially admitted to the Medicine service. Angiogram was attempted and patient was unable to be embolized. He subsequently underwent an emergent partial colectomy for presumed left colon bleed and required damage control procedure by Dr. [**Last Name (STitle) 42928**] with an abbreviated laparotomy stapling off the right colon and moving the left colon due to ongoing coagulopathy and intraoperative near cardiac arrest. The patient had an open abdomen in the Intensive Care Unit required significant amount of pressors until he remains stable after receiving numerous blood products. Two days postoperatively, he developed worsening signs of sepsis and taken back to the operating room for exploration, where he was found to have an ischemic right colon and this was removed and ileostomy was performed. The patient's abdominal fascia was then reapproximated and skin was left open. His postoperative Intensive Care Unit course was significant for development of a fungal infection resistant to [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] requiring amphotericin treatment and also ventilator-associated pneumonia. He eventually resolved this and was transferred to the floor. While on the floor, he continued to make slow, but steady recovery and eventually was having bowel function and tolerating enteral feeds. His antibiotics were stopped and he remained afebrile, and was transferred to rehabilitation tolerating po off antibiotics, and is on his usual home medications. DR [**Last Name (STitle) 19852**] [**Name (STitle) 19851**] 02.916 Dictated By:[**Name8 (MD) 45325**] MEDQUIST36 D: [**2139-1-19**] 13:54 T: [**2139-1-23**] 07:16 JOB#: [**Job Number 45326**]

[ "V45.81", "562.13", "410.91", "557.0", "242.90", "997.1", "998.59", "414.01", "427.89" ]

icd9cm

[ [ [] ] ]

[ "45.73", "99.15", "96.6", "46.21", "96.72", "34.04", "45.71", "88.47" ]

icd9pcs

[ [ [] ] ]

4597, 5261

5279, 7117

4521, 4576

176, 985

1008, 1336

54,241

179,292

40669

Discharge summary

report

Admission Date: [**2124-12-6**] Discharge Date: [**2124-12-7**] Date of Birth: [**2061-11-20**] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base Attending:[**First Name3 (LF) 1515**] Chief Complaint: post-cardiac catheterization right femoral access site groin hematoma Major Surgical or Invasive Procedure: [**2124-12-6**] - Cardiac catheterization History of Present Illness: 63 y/o F with bicuspid aortic valve (recent echo showed valve area 0.8) who is undergoing workup for planned upcomming AVR as well as aortic root replacement for 4.5cm aneurysm who presented to [**Hospital1 18**] cath lab today for elective pre-op cath. Cath revealed clean coronaries but post-cath course complicated with right groin hematoma after pulling sheath as well as 20 min vaso-vagal episode requiring 0.5mg atropine and dopamine drip. . [**Hospital1 18**] cath lab: Initialy tried radial approach and gave heparin. Unsuccessful so switched to right femoral. Cath revealed clean coronaries. Post cath, sheath was pulled and hematoma developed in R groin. Pt also vaso-vagaled post cath and BP 50s, HR 40s, given atropine 0.5mg x1, 1 L IVF, dopamine. Plan is to admit to CCU for monitoring overnight. . On arrival to the floor, patient denied any active complaints. She reports chronic mild chest pressure and shortness of breath with exertion. No orthopnea or PND. No heart palpitations. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough. She denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes (diet-controlled), +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: NONE - PERCUTANEOUS CORONARY INTERVENTIONS: NONE - PACING/ICD: NONE 3. OTHER PAST MEDICAL HISTORY: - Aortic stenosis - rheumatic fever (age 7) - scarlet fever (age 7) - Hypertension - hypercholesterolemia - hypothyroidism - rt foot fracture (s/p ORIF) - s/p appendectomy - s/p ovarian cyst removal - osteoporosis - arthritis rt hand Social History: She is a widow, living alone. Looking for part-time work. She used to manage medical records for [**Hospital1 1501**]. Does not exercise. She is a widow, living alone. Sister lives nearby. Tobacco: quit [**2097**] ETOH: [**2-25**] wine/wk. Family History: Both parents died early of alcohol abuse. Brother died of esophageal cancer. She has two sisters living. Paternal uncle with sudden cardiac death in his 40's. Physical Exam: PHYSICAL EXAMINATION (on admission): VS: T=96.5 BP=95/49 HR=93 RR=17 O2 sat=98%2LNC GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD noted. CARDIAC: Harsh crescendo-decrescendo 2/6 systolic murmur heard throughout. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. Femoral cath site intact with no evidence of active bleeding. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 1+ Left: DP 1+ Pertinent Results: [**2124-12-6**] 10:30AM BLOOD WBC-4.9 RBC-3.67* Hgb-11.5* Hct-33.4* MCV-91 MCH-31.4 MCHC-34.5 RDW-12.2 Plt Ct-232 . [**2124-12-6**] 10:30AM BLOOD PT-10.8 PTT-32.4 INR(PT)-1.0 . [**2124-12-6**] 05:15PM BLOOD WBC-6.7 RBC-3.66* Hgb-11.2* Hct-34.2* MCV-93 MCH- 30.6 MCHC-32.8 RDW-12.1 Plt Ct-222 . [**2124-12-6**] 09:21PM BLOOD WBC-9.1 RBC-3.43* Hgb-10.9* Hct-31.3* MCV-91 MCH-31.7 MCHC-34.7 RDW-12.1 Plt Ct-240 . [**2124-12-6**] 10:30AM BLOOD Ret Aut-1.1* . [**2124-12-6**] 10:30AM BLOOD Glucose-128* UreaN-25* Creat-0.5 Na-139 K-4.0 Cl-106 HCO3-25 AnGap-12 . [**2124-12-6**] 10:30AM BLOOD ALT-32 AST-28 AlkPhos-48 Amylase-77 TotBili-0.3 . [**2124-12-6**] 03:08PM BLOOD Cholest-133 . [**2124-12-6**] 10:30AM BLOOD %HbA1c-5.8 eAG-120 . [**2124-12-6**] 03:08PM BLOOD Triglyc-43 HDL-56 CHOL/HD-2.4 LDLcalc-68 . MICROBIOLOGIC DATA: [**2124-12-6**] Urine culture - negative [**2124-12-6**] Staph aureus screening - pending . IMAGING STUDIES: [**2124-12-6**] CARDIAC CATH - Selective coronary angiography of this right-dominant system demonstrated no angiographically apparent flow-limiting disease. The LMCA, LAD, LCx and RCA had no significant stenoses. The RCA had the catheter deeply engaged with pleating but no fixed stenoses, it could not be selectively engaged without deep seating and damping. Limited resting hemodynamics revealed normal systemic arterial pressures. ortography revealed a dilated thoracic aorta. No angiographically apparent flow-limiting coronary artery disease. Normal systemic arterial pressures. Dilated thoracic aorta. . [**2124-12-7**] VASCULAR ULTRASOUND OF RIGHT GROIN - Color Doppler and spectral analysis of the vasculature of the right groin was performed. Normal arterial and venous waveforms were seen in the CFA and CFV, wihtout evidence of pseudoaneurysm. The common femoral and greater saphenous veins were compressible, and no filling defect was noted by Grey scale imaging. No focal fluid collection in the region of visible hematoma was observed. . [**2124-12-7**] CXR (PA AND LATERAL) - pending final read per radiology. Brief Hospital Course: 63F with a PMH significant for acute rheumatic fever in childhood, with known severe bicuspid aortic valve stenosis ([**Location (un) 109**] of 0.7 cm2) and aortic root dilation, now pre-op for AVR-Bental procedure on [**2125-1-2**], who came to [**Hospital1 18**] today for an elective pre-op left heart catheterization. The procedure was attempted radially but was technically not possible, so right femoral access was obtained. The patient was heparinized during the case due to this initial radial attempt. The femoral sheath was pulled and an appropriate ACT with good hemostasis was noted, but then the patient felt a popping sensation and developed hypotension and a new groin hematoma. She appeared to be having a vagal response, and was given Atropine and IVF with improvement. She was started on Dopamine gtt for hypotension, but this could not be completely weaned off. The patient was then transferred to the CCU for close monitoring. . # HYPOTENSION - Patient likely developed a vasovagal episode in the settiong of groin hematoma and compression at the time of her cardiac catheterization procedure. She received Atropine and IVF resuscitation with some repsonse, but then required initiation of Dopamine gtt which was subsequently weaned the morning following her procedure. Her anti-hypertensive medications were held in this setting. Her hematocrit was stable on serial evaluation (range 31-34%) without evidence of further bleeding on exam. We continued to monitor her hemodynamics serially and provided low-dose fluid boluses as needed. Her blood pressure was still mildly low in the 90-100 mmHg systolic range following Dopamine discontinuation and we held her Lisinopril and HCTZ at discharge. . # BICUSPID AORTIC VALVE, AORTIC ROOT DILATATION, AORTIC STENOSIS - Patient presents with valve area of 0.7 cm2. She denies dyspnea, syncope, lightheadedness, or pedal edema on this admission. Of note, her aortic aneurysm was found to be 4.5-cm. She is scheduled for upcoming AVR and aortic root replacement (Bentall procedure) with Cardiac Surgery in [**2124-12-24**]. She will continue her pre-op surgical evaluation prior to her procedure with Dr. [**Last Name (STitle) 914**] in [**Month (only) 404**]. . # GROIN HEMATOMA - In the cardiac catheterization lab, patient was noted to develop right femoral access site groin hematoma following sheath pull with subsequent vagal episode. Her hematoma was clinically monitored and appeared stable overnight. She had a stable hematocrit with no further evidence of bleeding. We maintained an active type and screen with peripheral IV access at all times. . # HYPOTHYROIDISM - We continued her home dosing of Levothyroxine 112 mcg PO daily. . # HYPERLIPIDEMIA - We continued her home dosing of Ezetimibe 10 mg PO daily and Simvastatin 40 mg PO daily. . TRANSITION OF CARE ISSUES: 1. Stopped Lisinopril and HCTZ at discharge because of low blood pressure. She will check BP the day after discharge and call Dr. [**Last Name (STitle) **] with the results. 2. Scheduled follow-up with Dr. [**Last Name (STitle) **] (her primary care physician) after discharge. 3. At the time of discharge, a chest X-ray and Staph aureus swab screening were pending. Medications on Admission: EZETIMIBE-SIMVASTATIN [VYTORIN 10-40] 10 mg/40 mg Tablet daily GENTAMICIN - 0.1 % Cream - apply twice daily HYDROCHLOROTHIAZIDE 25 mg daily KETOCONAZOLE - 2 % Cream - apply to rash daily LEVOTHYROXINE 112 mcg daily LISINOPRIL 40 mg daily TRIAMCINOLONE ACETONIDE 0.1 % Cream - apply to ears and neck daily for 7 to 10 days TYLENOL EXTRA STRENGTH 1000 mg [**Hospital1 **] CALCIUM CITRATE-VITAMIN D3 [CALCIUM CITRATE + D] Dosage uncertain. Discharge Medications: 1. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. 2. gentamicin 0.1 % Cream Sig: One (1) application Topical twice a day. 3. ketoconazole 2 % Cream Sig: One (1) application Topical once a day as needed for rash. 4. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for pain. 6. calcium citrate-vitamin D3 Oral Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Post-cardiac catheterization right femoral access site groin hematoma . Secondary Diagnoses: 1. Hypertension 2. Hyperlipidemia 3. Diabetes mellitus, type 2 4. Severe aortic stenosis 5. Bicuspid aortic valve 6. History of acute rheumatic fever 7. Aortic root dilatation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], . It was a pleasure taking care of you during yuor admission. You were admitted to the Coronary Care Unit (CCU) at [**Hospital1 771**] after you underwent elective cardiac catheterization prior to your planned valve surgery in [**Month (only) 404**] of [**2124**]. Following the procedure, you developed a small right groin hematoma (evidence of bleeding) and were closely monitored overnight in the CCU. You briefly required IV medication to support your low blood pressure. This medication was stopped and your blood pressure was stable but still slightly low. Your bleeding remained stable and your hematocrit (blooc count) was stable prior to discharge. Because your blood pressure was low, we have stopped your home antihypertensives, lisinopril and hydrochlorothiazide. As was discussed prior to discharge, please measure your blood pressure at any local pharmacy and call Dr. [**Last Name (STitle) **] with the results. Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include: dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit, or have a bowel movement. * You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. * Your pain is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any other concerning symptoms. . CHANGES IN YOUR MEDICATIONS: . * Upon admission, we ADDED: NONE . * The following medications were DISCONTINUED on admission and you should NOT resume: -Lisinopril 40mg daily -Hydrochlorothiazide (HCTZ) 25mg daily . * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: Department: [**Hospital **] MEDICAL GROUP When: THURSDAY [**2124-12-14**] at 9:00 AM With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2400**] [**Telephone/Fax (1) 133**] Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**] Campus: OFF CAMPUS Best Parking: On Street Parking Please call Dr. [**Last Name (STitle) **] tomorrow, [**2124-12-8**], with your blood pressure as he had discussed with you.

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icd9cm

[ [ [] ] ]

[ "37.22", "88.42", "88.56" ]

icd9pcs

[ [ [] ] ]

9795, 9801

5642, 8852

363, 407

10136, 10136

3559, 4476

12509, 12975

2611, 2771

9339, 9772

9822, 9916

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254, 325

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8,735

100,361

15493

Discharge summary

report

Admission Date: [**2145-5-7**] Discharge Date: [**2145-5-20**] Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1390**] Chief Complaint: 89 year old female presenting with nausea, vomiting, diarrhea and abdominal pain. Major Surgical or Invasive Procedure: [**5-13**] Lysis of adhesions and enterotomy x2. History of Present Illness: [**Age over 90 **]F s/p multiple abdominal operations including incisional hernia repair x3 with a known recurrent ventral hernia, who presents with a 1-day history of abdominal pain, nausea/vomiting. Pt has been followed by Dr. [**Last Name (STitle) **] for her hernia with non-operative management given her prior lack of obstructive symptoms. Approximately 3 months ago, patient began having intermittent episodes of nonbloody diarrhea associated with mild cramping. On [**5-6**], she experienced increasing abdominal pain, initially in a band-like distribution across her upper abdomen and later over her large hernia. The pain is intermittent and associated with a bloating and firmness of her hernia during severe epioShe had 2 episodes of nonbloody, nonbilious emesis with associated subjective fevers/chills. Last bowel movement was [**5-6**] and was loose; last flatus [**5-6**] early evening. She presented to the ED for evaluation, and a surgical consult was requested. Past Medical History: HTN Hepatitis CHF s/p CCY ('[**12**]) Incarcerated hernia s/p abd surgery Fibroid s/p TAH Social History: Russian-speaking. Lives in [**Location 86**] alone. Moved to US 2 years ago. Family History: (-) Tobacco/EtOH/IVDA Physical Exam: On Admission: Vitals: 97.8 112 131/99 16 97% GEN: NAD. Alert, oriented x 3. HEENT: No scleral icterus. Mucous membranes mildly dry. CV: RRR PULM: Unlabored breathing ABD: Very large ventral hernia with significant loss of domain. Soft but very distended with mild tenderness to palpation. No R/G. RECTAL: Normal tone. No masses. No gross blood. Heme-occult negative. EXT: Warm trace pitting edema of LLE. No calf tenderness, warmth, or pain with passive ankle flexion. On Discharge: Vitals: T 98.8, HR 88, 140/64, RR 14, 98% on 2 liters NC Neuro: AAO x 3. No pain. No acute distress. Strength 4/5 in all distal extremities, [**1-25**] in proximal extremities. CV: S1 S2, no m/r/g. Pulm: Clear in upper lobes bilaterally, diminished in bases bilaterally. GI: Positive BS. Obese, softly distended. Slightly tender over areas of prior herniations. Mid-line incision closed with surgical staples, CDI. No exudate or signs of infection. GU: Voiding. Incontinent at times. Extrem: Warm with 2 - 3+ edema.UEs cool. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. Pulses 2+ in all extremities. Pertinent Results: [**2145-5-7**] 05:05PM BLOOD WBC-3.9* RBC-5.00 Hgb-13.6 Hct-41.7 MCV-83 MCH-27.2 MCHC-32.6 RDW-18.3* Plt Ct-245 [**2145-5-7**] 03:55AM BLOOD WBC-4.6 RBC-5.32 Hgb-14.6 Hct-44.3 MCV-83# MCH-27.5 MCHC-33.0 RDW-18.3* Plt Ct-241 [**2145-5-7**] 05:05PM BLOOD Glucose-125* UreaN-16 Creat-0.7 Na-136 K-3.9 Cl-101 HCO3-25 AnGap-14 [**2145-5-7**] 03:55AM BLOOD Glucose-158* UreaN-18 Creat-0.8 Na-132* K-6.4* Cl-98 HCO3-21* AnGap-19 [**2145-5-7**] 05:05PM BLOOD Calcium-8.6 Phos-3.2 Mg-2.2 [**2145-5-7**] 05:59PM BLOOD Lactate-1.4 [**2145-5-7**] 04:07AM BLOOD Lactate-1.8 K-3.6 [**2145-5-7**] 03:55AM NEUTS-71.5* LYMPHS-20.9 MONOS-6.5 EOS-0.6 BASOS-0.5 [**2145-5-7**] 03:55AM ALBUMIN-3.6 [**2145-5-19**] 10:35AM BLOOD CK-MB-1 cTropnT-<0.01 [**2145-5-20**] 05:25AM BLOOD WBC-6.0 RBC-3.63* Hgb-9.7* Hct-30.3* MCV-84 MCH-26.7* MCHC-31.9 RDW-18.4* Plt Ct-175 [**2145-5-20**] 05:25AM BLOOD Plt Ct-175 [**2145-5-20**] 05:25AM BLOOD Glucose-125* UreaN-10 Creat-0.3* Na-135 K-3.4 Cl-97 HCO3-28 AnGap-13 [**2145-5-20**] 05:25AM BLOOD Calcium-7.3* Phos-1.3* Mg-1.8 [**2145-5-7**]: CT abdomen/pelvis Large, [**Hospital1 **]-lobed ventral hernia contains multiple small bowel loops. There is evidence of incarceration, with mesenteric kinking and multiple areas of abrupt narrowing at the entry and exit points of the hernia. Loops within and proximal to the hernia are dilated up to 5-6 cm, with air-fluid levels. Several regions of circumferential wall thickening, mucosal hyperemia, and surrounding fluid raise concern for ischemia. There is no pneumatosis, pneumoperitoneum, or portal/mesenteric venous gas. [**2145-5-8**] KUB: Within this limitation, dilated small bowel loops in the left lower quadrant are noted, likely representing the dilated obstructive loop of bowel present in prior study. NG tube tip is in the stomach. [**2145-5-18**] ECG: Sinus rhythm. Left axis deviation with possible left anterior fascicular block. Borderline voltage criteria for left ventricular hypertrophy. Modest ST-T wave changes that are non-specific. Compared to the previous tracing of [**2145-5-14**] ventricular premature contraction is absent. Otherwise, no other significant diagnostic change [**2145-5-19**] CXR (AP): Mild pulmonary edema with small to moderate bilateral pleural effusions. Brief Hospital Course: Ms. [**Known lastname 44910**] was admitted to the Acute Care Surgery service on [**2145-5-7**] for management of her abdominal pain secondary to a small bowel obstruction/incarcerated ventral hernia. Given the large size of her [**Hospital1 **]-lobed ventral hernia, in addition to Ms. [**Known lastname 44911**] poor surgical candidacy, she was treated conservatively via bowel rest, IVF, and nasogastric decompression via NGT. Her labs, most notably, her lactate and WBC were trended throughout her hospital stay and were noted to be within normal limits. Ms. [**Known lastname 44910**] gradually responded well to this treatment, and was noted to be much less distended and tender to palpation by HD#2. She self-dc'ed her NGT overnight on HD#2 without worsening of her symptoms. On HD#3, her abdominal exam remained improving, and she was given a bowel regimen to which she responded well. On [**5-11**], the patient was advanced to clears but did not tolerate that well and was again made NPO. Because of concern for increasing abdominal pain and worsening SBO, the patient was taken to the OR for an exploratory laparotomy, lysis of adhesions, and small bowel resection with primary anastomosis. See operative note for details. Her skin and subcutaneous tissue were closed. She was transferred to the TSICU post-op. ICU course: Neuro: The patient remained sedated while intubated. Once sedation was weaned, she responded appropriately in terms of mental status. Her pain was controlled. CV/Pulm: Her cardiovascular status was stable and she was continued on b-blockers while in the ICU. She has a history of congestive heart failure and her volume status was monitored closely. She was edematous and diuresed with lasix [**Hospital1 **]. Her IVFs were discontinued as well in order to improve her edema, and instead albumin was given. She remained intubated post-op and was able to be weaned and extubated on [**5-15**]. GI: Post-op, she had an NGT in place and was NPO. Her NGT was removed on [**5-16**] and she was advanced to sips on [**5-17**]. Her abdominal wound was covered with dry sterile dressing and an abdominal binder was kept on at all times. Her incision remained c/d/i. GU: She had a foley in place. She had intermitent episodes of low UOP and was bolused gently as needed, with goal of 15-20 cc/hr of urine. Heme: Her hematocrit remained stable throughout her ICU course ID: she was given clotrimazole cream for a fungal infection Prophy: She received subcutaneous heparin for DVT prophylaxis. She was also continued on a H2 blocker. Dispo: she was stable and ready for transfer to the floor on [**2145-5-17**]. Once transferred to the surgical floor, Mrs.[**Known lastname 44912**] course by system is as follows: Neuro: She's been oriented x 3 including the reason for her admission. Her pain has been treated with tramadol and oxycodone PRN. She has intermittent minor pain as expected post-operatively. Cardio: Beta blockers have been continued. She has been hemodynamically stable with adequate rate control (70 - 90s). Generalized edema 2 - 3+ persists. Continue furosemide treatment as discussed below. The patient did describe chest pain (as translated by her daughter) and shortness of breath on [**5-19**]. An ECG was obtained and showed no acute changes when compared to prior tracings this admission. Troponin levels were drawn and were found to be flat. She has not described further chest pain after its spontaneous resolution. Pulm: A chest x-ray taken on [**5-18**] showed likely bilateral pleural effusions. She remains on supplemental oxygen via nasal cannula. She has described feeling short of breath at times. Albuterol and atrovent nebulizer treatments have been administered with good results. Furosemide therapy is continued. With a fluid balance goal of 1 - 2 liters negative per day, her dose was increased on [**5-19**] to 20mg PO BID. Our recommendation is to continue this dosing for approximately five days and then decrease the dose back to her previous home dose of 20mg PO daily. Of course, further clinical exams are warranted to determine effectiveness and titration of diuretic therapy. GI: Mrs.[**Known lastname 44912**] abdominal incision has been well-approximated with no signs of infection. There have been no issues of constipation or diarrhea. She is tolerating a mechanical soft, regular diet. GU: Daily fluid balances have been closely monitored due to Mrs.[**Known lastname 44912**] history of congestive heart failure and current (likely) bilateral pleural effusions. She has diuresed well from daily Lasix. Her foley catheter was discontinued on [**5-19**]. She has since voided without issue, although frequently incontinent. Lines: A right brachial PICC line was in place for prior IV therapy. The line was discontinued on [**5-19**]. Endocrine: Although Mrs. [**Known lastname 44910**] is noted to have a history of diabetes, her pre-prandial blood glucose levels have been well controlled. In general, she has not required an exogenous insulin secondary to hyperglycemia while recouperating post-operatively. Per prior medical records, she not taking any oral diabetic agents. At this time, Mrs. [**Known lastname 44910**] is hemodynamically stable and ready to be transferred to rehab. Medications on Admission: -Iodoquinol HCl 1% topical cream to affected area [**Hospital1 **] -Furosemide 20mg daily -Metronidazole 1% topical gel to affected area [**Hospital1 **] -Metoprolol tartrate (unknown dose) -Glyburide (unknown dose) Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheeze 2. Clotrimazole Cream 1 Appl TP [**Hospital1 **] fungal skin infection apply to affected area of skin 3. Furosemide 20 mg PO BID 4. Metoprolol Tartrate 12.5 mg PO BID Hold for sbp<110 or HR<60 5. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain RX *tramadol 50 mg 0.5-1 Tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*1 6. Acetaminophen 325 mg PO Q6H:PRN pain Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital because of a small bowel obstruction. You were treated with bowel rest, IVF, and nasogastric decompression via an NGT. You responded well to this treatment and did not require surgical intervention to correct your small bowel obstruction. You may continue with your regular diet. You should continue with your home medications. You should continue to wear your abdominal binder at home while walking around for comfort. You should seek immediate medical attention if you develop abdominal pain, nausea/vomiting, inability to take in food/water, or any other symptoms which are concerning to you. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: TUESDAY [**2145-6-8**] at 2:00 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2145-5-20**]

[ "428.32", "788.5", "401.9", "427.89", "250.00", "552.21", "560.9", "428.0", "117.9" ]

icd9cm

[ [ [] ] ]

[ "54.59", "96.04", "96.71", "38.97", "45.62" ]

icd9pcs

[ [ [] ] ]

11099, 11165

5071, 10379

299, 350

11233, 11233

2768, 5048

12158, 12502

1587, 1610

10649, 11076

11186, 11212

10405, 10626

11409, 12135

1625, 1625

2117, 2749

178, 261

378, 1362

1640, 2102

11248, 11385

1384, 1476

1492, 1571

66,093

100,888

38469

Discharge summary

report

Admission Date: [**2175-5-24**] Discharge Date: [**2175-5-25**] Date of Birth: [**2108-5-20**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Cordis line placement, endotracheal intubation History of Present Illness: 66 YOM with CAD on high dose ASA, locally advanced pancreatic cancer s/p gastrojejunostomy (c/b colon perforation s/p right colectomy & ileostomy), hx GI bleed from GJ anastamotic site [**7-/2174**], at which time EGD with extensive clipping failed to achieve hemostatsis and eventually underwent successful GDA embolization, but rebled in [**2174-11-19**] (BRBPOstomy) with negative ileoscopy, and EGD/enteroscopy showing oozing from GJ anastomosis but no active bleeding and no intervention, as well as ulcer at the ampulla associated with migrated biliary stent who presents now with reportedly hematemesis and BRBPO earlier today without associated symptoms. Of note, was recently admitted with obstructive jaundice, ERCP [**2175-3-19**] showed biliary stent protruding from the ampulla but no blood or ulceration described. En route to [**Hospital1 18**] became transiently hypotensive (details unknown) and diverted to [**Hospital1 **] [**Location (un) 620**]. Hct there 29 (stable from [**2175-5-19**]), given IVF, protonix and morphine, and xfered to [**Hospital1 18**]. On arrival here BP 102/44, HR 66. Ostomy output was heme positive but without gross blood, NGL showed coffee grds that did not clear with 500cc lavage. While in ED became unresponsive and hypotensive to 50's - intubated for airway protection and started on pressors. Given IVF but no blood yet. Labs here show hct 26, plts 180 (were 46 on [**2175-5-19**]), lactate 3.3, nl BUN/cr. Received 4u pRBCs in ICU, initially stable with BP 122/36, HR 100 on minimal levo in ED. PPI ordered but not yet initiated. Surgical team involved in ED but not felt to be a surgical candidate given unresectable cancer. Evaluated pt as he was arriving in ICU. Initially SBP 90s, HR 130s sinus tach. Shortly after arrival to ICU pt became hypotensive to 60s systolic and tachy to 130s on 2 pressors -> converted to VT -> shocked x 1, 3 pressors started at max dose. Copious BRB per OG tube (600cc in past 20 mns per ED transport). Past Medical History: - hypertension - hyperlipidemia - CAD s/p MI [**4-/2174**] s/p DES, also s/p CABG x5 [**6-/2173**] - carotid stenosis (70% left carotid) - pancreatic head adenocarcinoma s/p staging lap [**3-/2174**], s/p gastrojejunostomy, open CCY, open wedge liver Bx, pancreatic Bx [**2174-7-5**] - colon perforation s/p ex-lap, right colectomy, ileostomy, mucous fistula [**2174-7-15**] ONCOLOGIC HISTORY: - Mr. [**Known lastname 30113**] developed weight loss back in [**2172**]. He had undergone a quadruple bypass at that time and noticed he lost approximately 45-50 pounds despite eating well. - He developed painless jaundice first noted in 04/[**2173**]. He underwent an ERCP with stent placement by Dr. [**First Name (STitle) 39335**] and Dr. [**Last Name (STitle) **] subsequently performed endoscopic ultrasound. - He underwent a CT angiography at [**Hospital1 1170**] on [**2174-6-15**] and was felt that his disease was generally resectable. He went on to undergo a staging laparoscopy with laparoscopic liver biopsies performed on [**2174-4-15**]. - He underwent a side-to-side gastrojejunostomy, open cholecystectomy, open wedge liver biopsy and multiple open pancreatic biopsies on [**2174-7-5**] at which time the tumor was found to be unresectable. - His recovery was complicated by a ruptured colon for which he underwent emergency right hemicolectomy and ileostomy, debridement and reclosure of right subcostal excision on [**2174-7-15**]. - He was seen again on [**2174-8-3**] for a mesenteric bleed. - Has been on Gemcitabine Social History: Married with 3 kids. Quit smoking and alcohol (former heavy EtOH). Family History: No known FH of pancreatic cancer. Physical Exam: No admission physical exam given critical status and code situation. Discharge exam: Expired. Pertinent Results: [**2175-5-24**] 09:20PM BLOOD WBC-11.3*# RBC-2.28* Hgb-8.6* Hct-25.5* MCV-112* MCH-37.6* MCHC-33.6 RDW-20.5* Plt Ct-180# [**2175-5-24**] 09:20PM BLOOD Neuts-78.4* Lymphs-15.3* Monos-5.1 Eos-0.2 Baso-1.0 [**2175-5-24**] 09:20PM BLOOD PT-11.9 PTT-26.9 INR(PT)-1.0 [**2175-5-24**] 09:20PM BLOOD Glucose-136* UreaN-10 Creat-0.6 Na-133 K-5.8* Cl-105 HCO3-23 AnGap-11 [**2175-5-24**] 10:52PM BLOOD Type-CENTRAL VE Tidal V-450 PEEP-5 FiO2-100 pO2-114* pCO2-45 pH-7.16* calTCO2-17* Base XS--12 AADO2-567 REQ O2-92 Intubat-INTUBATED [**2175-5-24**] 10:52PM BLOOD Glucose-155* Lactate-6.0* Na-131* K-5.4* Cl-110 [**2175-5-24**] 10:52PM BLOOD Hgb-12.0* calcHCT-36 [**2175-5-24**] 10:52PM BLOOD freeCa-0.92* CXR: Initial images demonstrate the endotracheal tube to be 7.5 cm above the carina, although later images after adjustment showed to be 6 cm above the carina. An endogastric tube courses inferiorly and into the stomach. The right-sided Port-A-Cath tip sits in the superior right atrium. A right central venous catheter tip sits in the right brachiocephalic vein. Clips and coil material are seen in the right upper quadrant. Additionally, a stent like structure is seen in the left upper quadrant. The cardiomediastinal and hilar contours are normal. The lungs are clear. There is no large pleural effusion or pneumothorax. IMPRESSION: 1. Lines and tubes as described above. 2. No acute cardiopulmonary process. Brief Hospital Course: 67M with metastatic pancreatic cancer who presented with small volume hematemesis, subsequently became hemodynamically unstable and expired upon transfer to the MICU. . Hematemesis: The patient was NG Lavaged in the ED with bright red blood after 500cc lavage. He subsequently dropped his BP to the 60s systolic and was intubated in the ED, Cordis was placed for access, Levophed was started He was transfused 4 units PRBCs in the ED. GI and surgery were consulted. GI initially planned to perform EGD upon transfer to the ICU. Surgery felt he was not a surgical candidate and suggested getting IR involved for possible embolization. He was transferred to the MICU on Levophed and Dopamine. He had 600cc bright red blood output during transfer from the ED to the MICU. Massive transfusion protocol was initiated and PRBC, PLT, FFP transfusion was started with calcium supplementation. The patient went into monomorphic VT soon after transfer to the MICU and returned to a sinus rhythm after 1 shock. The NG tube subsequently stopped functioning and he began to extravasate bright red blood per mouth. Rapid transfusion protocol was continued while the family was contact[**Name (NI) **]. Ultimately, he went into PEA and then asystolic arrest and the family did not wish to pursue continued aggressive measures. He expired at 0100 on [**2175-5-25**]. Immediate cause of death was cardiopulmonary arrest, chief cause of death was pancreatic cancer, other cause of death was acute blood loss. Significant time was spent with the family and they seemed satisfied with care provided. Medications on Admission: Active Medication list as of [**2175-5-23**]: LISINOPRIL - (Prescribed by Other Provider) - 2.5 mg Tablet - 1 (One) Tablet(s) by mouth once a day LORAZEPAM [ATIVAN] - 0.5 mg Tablet - [**11-20**] Tablet(s) by mouth 30 minutes prior to your CyberKnife treatment. METOPROLOL SUCCINATE [TOPROL XL] - (Prescribed by Other Provider) - 25 mg Tablet Extended Release 24 hr - 1 (One) Tablet(s) by mouth once a day OLANZAPINE [ZYPREXA] - 2.5 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for hiccups OXYCODONE - 5 mg Tablet - [**11-20**] Tablet(s) by mouth q4-6h as needed for pain PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for nausea ASPIRIN - (OTC) - 325 mg Tablet - 1 (One) Tablet(s) by mouth once a day DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by mouth twice a day as needed for constipation Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: 1. Cardiopulmonary arrest 2. Acute blood loss 3. Pancreatic cancer 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

[ [ [] ] ]

[ "99.62", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

8297, 8306

5653, 7234

323, 371

8416, 8425

4217, 5630

8477, 8619

4051, 4087

8269, 8274

8327, 8395

7260, 8246

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4188, 4198

272, 285

399, 2392

2414, 3951

3967, 4035

45,420

168,666

41438

Discharge summary

report

Admission Date: [**2175-3-6**] Discharge Date: [**2175-3-12**] Date of Birth: [**2123-3-12**] Sex: F Service: NEUROSURGERY Allergies: Voltaren Attending:[**First Name3 (LF) 3227**] Chief Complaint: sudden onset left sided weakness Major Surgical or Invasive Procedure: [**2175-3-7**]: Right craniotomy and washout of Brain Abcess History of Present Illness: 51 year old female with sudden onset left sided weakness starting earlier this evening. The patient began complaining of headaches approximately 5 days ago and was seen by her PCP who diagnosed her with a sinus infection and started her on Augmentin. After starting augmentin she had two episodes where she states her "eyes were flitting" and had a few episodes of memory loss. She was subsequently seen by her ENT who noticed a slight L facial droop. She presented to an outside ED after her episode of total Left hemiplegia this evening and was found to have a Right frontal lesion with surrounding edema on CT head. Her hemiplegia has since resolved somewhat. She notes her tongue "feels heavy" and is having difficulty articulating words, she denies numbness. She complains of nausea/no vomiting. Past Medical History: Hypertension Social History: married, denies smoking, occasional alcohol Family History: non contributory Physical Exam: O: T: BP: 137/63 HR: 94 R 18 O2Sats 97% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3->2mm bilat EOMs decreased left gaze Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. Slight dysarthria. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Left facial droop. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-18**] throughout right, [**4-18**] throughout left. Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing right, upgoing left Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin On the day of discharge: oriented to person, place and time.left facial droop, left pronator drift, left upper extremity- deltoid/biceps/trceps full strength. left interossei /grip 0/5. wrist flexors [**2-18**] and wrist ext [**3-18**]. Pertinent Results: CTH [**2175-3-6**]:(outside) R frontal mass with surrounding edema MRI with and without gado [**2175-3-7**]: 1. A 3.6-cm mass is present within the posterior right frontal lobe which demonstrates a smooth peripheral rim of enhancement and central slow diffusion, characteristic of a large abscess. The diffusion findings and thin enhancement pattern suggest that the mass is unlikely to represent GBM or metastasis. Surrounding edema is present which is effacing the overlying sulci and resulting in 4 mm of right to left shift of midline structures. The basal cisterns are patent. No other abscesses are identified. 2. The right petrous apex is pneumatized and opacified. The mastoid air cells and the paranasal sinuses are clear. CT head [**2175-3-7**]: right frontal lobe lesion status post right craniotomy with unchanged extent of vasogenic edema and mild leftward shift of the midline structures. Transthoracic Echocardiogram [**2175-3-8**]: Normal study. No valvular pathology or pathologic flow identified. CHEST PORT. LINE PLACEMENT Study Date of [**2175-3-10**] 8:37 AM Right PICC tip is in the lower SVC/cavoatrial junction. Cardiomediastinal contours are normal. The lungs are clear. There is no pneumothorax or pleural effusion. 2-25-11TEETH (PANOREX FOR DENT- official read pending CT SINUS W/ CONTRAST Study Date of [**2175-3-10**] 4:30 PM FINDINGS: Aside from minimal frontal sinus and bilateral ethmoidal air cell mucosal thickening, the paranasal sinuses and mastoid air cells are well aerated. The bony nasal septum deviates to the right and a small bony spur is seen. [**Doctor Last Name **] bullosa is noted on the left. The anterior clinoid processes are not pneumatized. The lamina papyracea and cribriform plates are intact bilaterally. The sphenoid sinus septum is midline. The area of the previously identified abscess is not included on the present study. IMPRESSION: Minimal frontal sinus and bilateral ethmoidal air cell thickening. Otherwise, the paranasal sinuses and mastoid air cells are clear. CHEST (PA & LAT) Study Date of [**2175-3-12**] 10:14 AM official read pending UA [**2175-3-12**]- NEGATIVE blood cultures from [**2175-3-7**]- pending Brief Hospital Course: The patient was urgently taken to the OR for drainage of a suspected abscess. Intraoperatively, purulent fluid were drainged and sent for microbiology analysis. Postoperatively infectious Disease was consulted and she was started on Vancomycin, Ceftraixone, Ampicillin and Flagyl. Prior to that blood and urine cultures were sent. She was extubated the following morning on [**3-8**]. The patient remained neurologicaly stable througout her hospitalization. As part of an infectious workup an HIV test was obtained. Transthoracic echocardiogram was negative for vegetation. On [**3-10**] HIV test resulted as negative. She was seen by ID and her ampicillin and vancomycin were discontinued. PICC Line was placed. PT and OT were consulted for assistance with discharge planning. On [**2175-3-11**], the patient requested to be discharged home as it is her birthday. Infectious Disease had made final reccomendations and was fine with the patient being discharged home. The patient was discharged on MetRONIDAZOLE (FLagyl) 500 mg PO/NG TID and CeftriaXONE 2 gm IV Q12. It was recomennded that she continue these antibotics until [**2175-4-28**]. The patient was cleared to go home with 24 hour supervision by her family and will have PT and OT at home. Medications on Admission: metoprolol, Augmentin (since [**3-1**]) Discharge Medications: 1. Outpatient Lab Work CBC with differential, chem 10 panel, liver function tests.Please have these labs drawn weekly and sent to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**], MD at [**Telephone/Fax (1) 1419**] 2. Outpatient Lab Work dilantin level laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q12H (every 12 hours). Disp:*24 * Refills:*2* 5. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. Disp:*24 ML(s)* Refills:*0* 6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): until [**2175-4-28**]. Disp:*90 Tablet(s)* Refills:*2* 7. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*30 Tablet(s)* Refills:*0* 10. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain: contains tylenol do not exceed 4 grams of tylenol with in 24 hours will cause liver failure. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 8300**] VNA Discharge Diagnosis: Brain Abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin,Plavix (clopidogrel), or Aspirin, prior to your injury, do not resume until cleared by your surgeon. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. your family has agreed to provide 24 hour supervision of you to ensure your safety at home. You will need weekly labs drawn as recommended by infectious disease. a CBC with differential, a chemistry panel, and Liver function tests. Please have this faxed to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**], MD at [**Telephone/Fax (1) 1419**] CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**7-23**] days(from your date of surgery) for removal of your sutures and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need an MRI of the brain with gadolinium contrast. ?????? You have the following Infectious Disease Follow Up APPTS: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2175-3-27**] 10:30 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2175-4-28**] 10:00 ?????? You will need weekly labs drawn as recommended by infectious disease. a CBC with differential, a chemistry panel, and Liver function tests. Please have this faxed to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**], MD at [**Telephone/Fax (1) 1419**] Completed by:[**2175-3-12**]

[ "781.94", "414.01", "324.0", "784.51", "041.6", "041.09", "401.9", "342.92", "780.39" ]

icd9cm

[ [ [] ] ]

[ "01.24", "38.97" ]

icd9pcs

[ [ [] ] ]

8088, 8147

5104, 6367

305, 368

8205, 8205

2889, 5081

10547, 11770

1318, 1336

6458, 8065

8168, 8184

6393, 6435

8313, 10524

1351, 1614

233, 267

396, 1205

1849, 2870

8220, 8289

1227, 1241

1257, 1302

20,278

122,268

27868

Discharge summary

report

Admission Date: [**2153-5-19**] Discharge Date: [**2153-5-22**] Date of Birth: [**2099-11-12**] Sex: F Service: MEDICINE Allergies: Aspirin / Morphine Sulfate Attending:[**First Name3 (LF) 2078**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: HPI: 53 y.o. F hx asthma, sinusitis p/w episode of SSCP onset while watching TV, mid-sternal heavyness, non-radiating, no SOB, initially felt gasy and pain improved with belching, then had some worsening chest pain associated with SOB, diaphoresis. Called EMS, pain relieved after one NTG. Pain last approx 45 minutes total. The pain had complained of similar type of pain approximately one month ago, had been scheduled for stress test. In ED at OSH, given 300mg plavix, nitro paste. Transferred to [**Hospital1 18**] for further care. Past Medical History: asthma - exacerbation less than monthly, uses flovent, singulair, occasionally flovent for rescue and regularly prior to exercise, no hx of intubations. Worse in spring Carpal tunnel release Social History: married, lives with husband, son, his girlfriend, etc, 25 pack yr smoking quit 7 yrs ago, no etoh, or drugs. Family History: no early CAD, mother with some vague hx of cardiac problems, no MI Physical Exam: PE: Temp 97.8, BP 129/71, HR 57, RR 20, O2sat 98% on RA Gen: comfortably, lying in bed, NAD HEENT: anicteric, OP clear, no JVD Resp: occ wheezes, no crackles CV: RRR, I/VI SEM at LUSB, no gallop Abd: soft, NT, ND, no HSM Extr: no edema, 2+ pulses Pertinent Results: [**2153-5-22**] 10:40AM BLOOD WBC-6.2 RBC-3.74* Hgb-11.9* Hct-34.1* MCV-91 MCH-32.0 MCHC-35.1* RDW-12.8 Plt Ct-253 [**2153-5-21**] 07:00AM BLOOD WBC-10.5 RBC-3.74* Hgb-12.0 Hct-34.4* MCV-92 MCH-32.2* MCHC-35.0 RDW-13.0 Plt Ct-224 [**2153-5-21**] 12:26AM BLOOD Hct-32.1* [**2153-5-20**] 07:05AM BLOOD WBC-9.4 RBC-4.18* Hgb-13.5 Hct-38.3 MCV-92 MCH-32.3* MCHC-35.2* RDW-12.9 Plt Ct-246 [**2153-5-19**] 07:30PM BLOOD WBC-10.9 RBC-4.29 Hgb-13.5 Hct-39.3 MCV-92 MCH-31.5 MCHC-34.4 RDW-12.8 Plt Ct-265 [**2153-5-22**] 10:40AM BLOOD Plt Ct-253 [**2153-5-21**] 07:00AM BLOOD PTT-68.5* [**2153-5-21**] 12:26AM BLOOD PT-13.3* PTT-90.0* INR(PT)-1.2* [**2153-5-20**] 05:07PM BLOOD PT-13.6* PTT-101.4* INR(PT)-1.2* [**2153-5-22**] 10:40AM BLOOD Glucose-89 UreaN-9 Creat-0.8 Na-139 K-3.8 Cl-105 HCO3-28 AnGap-10 [**2153-5-19**] 07:30PM BLOOD Glucose-108* UreaN-11 Creat-0.8 Na-140 K-3.7 Cl-102 HCO3-25 AnGap-17 [**2153-5-22**] 10:40AM BLOOD CK(CPK)-51. Selectove coronary angiography of this left dominant system demonstrated no significant CAD. The LMCA and LAD were without angiographic evidence of CAD. The LCX was diminutive and non-dominant. The RCA was a large dominant vessel without angiographic evidence of CAD. 2. Limited resting hemodynamics demonstrated mildly elevated left sided filling pressures with LVEDP=16 mmHg. 3. Left ventriculography was limited by ectopy but systolic function appeared normal with an ejection fraction visually estimated to be 60%. FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Mild diastolic ventricular dysfunction. 3. Normal left ventricular systolic function. 2 [**2153-5-21**] 07:00AM BLOOD CK(CPK)-56 [**2153-5-21**] 12:26AM BLOOD CK(CPK)-52 [**2153-5-20**] 07:05AM BLOOD CK(CPK)-59 [**2153-5-19**] 07:30PM BLOOD CK(CPK)-60 [**2153-5-21**] 07:00AM BLOOD CK-MB-NotDone cTropnT-0.01 [**2153-5-21**] 12:26AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2153-5-20**] 05:07PM BLOOD CK-MB-NotDone cTropnT-<0.01 Brief Hospital Course: Admitted to [**Hospital Unit Name 196**] for cardiac catheterization after chest pain. Transferred to CCU for aspirin desensitization. CCU course: 1. Aspirin desensitization: She was monitored in the CCU during the desensitization protocal. She was premedicated with benadryl and solumedrol. She received 10 increasing doses of aspirin over 90 minutes. She tolerated the procedure well without any asthmatic symptoms. . 2. Chest pain: She was initially maintained heparin, integrillin, plavix, and lipitor. She also received 325 of aspirin at the end of the desensitization protocal. After the desensitization, she had recurrent chest pain that was identical to her previous chest pain. Her EKG still had slight ST elevations in V4-V6. Her cardiac enzymes remained flat. She received 2 SL nitroglycerin, 1 mg morphine, and 1 mg ativan. She dropped her pressure to 80 systolic and received a 500cc fluid bolus. She was started on a nitro drip with resolution of her chest pain. Given that her EKG changes were borderline and given that her enzymes remained flat, her pain was thought not to be cardiac. Therefore, her heparin and integrillin was stopped. She was maintained on nitro drip as that controlled her pain. Plan for catherization on Tuesday. [**Hospital1 **]: Transferred to [**Hospital1 **] on [**5-21**] without complications. No chest pain, shortness of breath or complaints [**Date range (1) 18468**]. Cardiac catheterization on [**5-22**] revealed normal coronary arteries. Tolerating PO. Hemostasis obtained. Medications on Admission: FLovent, albuterol MDI, singular, MVI Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Resume home medications Discharge Disposition: Home Discharge Diagnosis: Normal coronary arteries Discharge Condition: Good Discharge Instructions: Take all medications as prescribed. CALL Your doctor or go to the ER IF: You have a temperature over 100.5. Your pain is happening more often or is getting worse even though you are taking your medicines. You have new or worsening swelling in your feet or ankles. You think your medicine is causing problems such as a rash, itching, or swelling. You have questions or concerns about your illness or medicine. SEEK CARE IMMEDIATELY IF: Call 9-1-1 or 0 for an ambulance right away if you have any of the following symptoms. Never try to drive yourself to the hospital if you have signs of a serious health problem. Your chest discomfort does not go away after resting and taking your chest pain medicine as directed. You have new or worsening chest pain, tightness, or discomfort that lasts longer than 15 to 20 minutes. You have chest discomfort and feel lightheaded, dizzy, weak, or faint. You have chest discomfort and suddenly start sweating for no reason that you know of. You have nausea or vomiting with your chest discomfort. You have new or worsening trouble breathing. You lose feeling or movement in your face, arms, or legs, or suddenly feel weak. You suddenly have trouble thinking clearly, seeing, or speaking. You cough or vomit blood. Followup Instructions: Follow up in [**7-2**] days with your Cardiologist Dr. [**Last Name (STitle) 26191**]

[ "493.90", "786.59" ]

icd9cm

[ [ [] ] ]

[ "99.12", "37.22", "88.55", "88.53" ]

icd9pcs

[ [ [] ] ]

5427, 5433

3565, 5110

299, 325

5502, 5509

1603, 3062

6809, 6898

1252, 1321

5198, 5404

5454, 5481

5136, 5175

3079, 3542

5533, 6786

1336, 1584

249, 261

353, 894

916, 1110

1126, 1236

11,795

134,094

7598

Discharge summary

report

Admission Date: [**2173-2-2**] Discharge Date: [**2173-3-29**] Date of Birth: [**2106-5-8**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: Diffuse Abdominal Pain Major Surgical or Invasive Procedure: 1. Pancreatic necrosectomy with wide drainage. 2. Gastrostomy tube placement. 3. Feeding jejunostomy tube placement. 4. Cholecystostomy tube placement History of Present Illness: This is a 66 year old male with the onset of epigastric abdominal pain [**2173-1-25**]. He was admitted to [**Hospital3 8544**] with pancreatitis complicated by oliguria (ATN). A CT revealed acute pancreatitis and large gallstones with possible cholecystitis and the patient was relatively stable. At the OSH, he developed respiratory distress and delirium on [**2173-1-28**] and was started on Bipap. He was eventually intubated on [**2173-1-31**]. Due to the prolonged ileus, he was started on TPN. He was then transferred to [**Hospital1 18**]. This progressed to infected pancreatitic necrosis. The pain radiated to his back and the patient had never described similar episodes in the past. Past Medical History: HTN, HLD, s/p prostatectomy and hernia repair Social History: Lives with wife. 2 beers/day Family History: N/C Physical Exam: VS: 99.5, 95, 125/70, 24, 99% Gen: Intubated, sedated CV: RRR Pulm: coarse bilaterally at bases Abd: soft, distended, NT (patient sedated) Ext: no C/C/E Pertinent Results: CT ABDOMEN W/CONTRAST [**2173-2-7**] 2:07 PM IMPRESSION: Compared to the outside study of [**2173-2-1**], there has been progression of the inflammatory changes surrounding the pancreas, consistent with the patient's history of necrotizing pancreatitis. There is near total necrosis of the pancreatic head with necrotic relative low attenuation material in this region. No well-defined drainable fluid collections are present at this time. . CT ABD W&W/O C [**2173-2-13**] 5:22 PM IMPRESSION: 1. No evidence of pulmonary embolism. 2. No significant changes in the peripancreatic inflammatory changes due to necrotizing pancreatitis. 3. Diverticulosis. . CT ABD W&W/O C [**2173-2-21**] 8:29 AM IMPRESSION: 1. Progression of necrotizing pancreatitis with significant interval increase in peripancreatic fluid. 8.3 x 6 cm rounded collection impressing on the greater curvature of the stomach is starting to form a more discrete wall. Additional similar rounded collections along the duodenum. 2. Cholelithiasis without evidence of cholecystitis. 3. Consolidation at the right base which could represent atelectasis or less likely aspiration. The appearance is not significantly changed from prior exam. 4. Sigmoid diverticulosis without evidence of diverticulitis. . CT ABDOMEN W/O CONTRAST [**2173-2-24**] 1:41 PM IMPRESSION: 1. Persistent right basilar opacity with air bronchograms, which may represent atelectasis, although pneumonia cannot be excluded. 2. New perihepatic fluid collection, perhaps a new pseudocyst, but otherwise the overall contour of multiple fluid collections associated with the partially necrotic pancreas do not appear significantly changed. 3. Increased ascites. . CT ABD W&W/O C [**2173-3-10**] 12:51 PM IMPRESSION: 1. Status post pancreatitis debridement with significant reduction of the fluid collection in the pancreatic bed. No evidence of pancreatic hemorrhage is seen. 2. Nonenhancing areas within the pancreatic head and body are consistent with pancreatic necrosis with no complication including gas collection. 3. Severe attenuation of proximal portion of a splenic vein and superior mesenteric vein. Thrombosis cannot be excluded in these vessels. No pseudoaneurysm is found although this study is not CT angiogram. 4. Status post cholecystostomy, jejunostomy, gastrostomy and two drainage tubes placement within the pancreatic bed. 5. Atelectasis of the right lower lobe. . CTA ABD W&W/O C & RECONS [**2173-3-12**] 1:02 PM IMPRESSION: 1. Status post necrotizing pancreatitis with debridement and cholecystostomy, jejunostomy, gastrostomy, and placement of drainage catheter within the pancreatic bed. 2. Moderate degree of attenuation of proximal portion of splenic vein and superior mesenteric vein is unchanged. No thrombosis is noted. No pseudoaneurysm is seen. 3. Unchanged nonenhancing areas within the pancreatic head and the body consistent with pancreatic necrosis with no complication including gas collection. 4. Atelectatic changes of the right lower lobe. . MRA BRAIN W/O CONTRAST [**2173-3-17**] 8:45 AM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST IMPRESSION: 1. No acute intracranial pathology, including no sign of intracranial mass or bleed. 2. Unremarkable MRA of the circle of [**Location (un) 431**] and unremarkable MRA of the vertebral and carotid arteries. . CTA ABD W&W/O C & RECONS [**2173-3-23**] 10:32 AM IMPRESSION: 1. Essentially stable appearance of multiple intra-abdominal fluid collections in this patient with necrotizing pancreatitis. 2. Unchanged focal attenuation of proximal splenic vein, which is patent. No evidence of pseudoaneurysm. 3. Essentially unchanged appearance to pancreas, with non-enhancing regions consistent with pancreatic necrosis. 4. Right lower lobe atelectasis. 5. Markedly distended urinary bladder. . Brief Hospital Course: He presented to the ICU and was manaaged conservatively. He remained intubated and was on Meropenum empirically. Prior to going to the OR on [**2173-2-24**], he was weaned from the ventilator and transferred to the floor on two separate occasions. Each transfer to the floor, he developed respiratory distress and was sent back to the ICU and eventually was reintubated. Transfered to floor [**2-12**] and readmitted [**2-13**] with hypotension, respiratory distress, oliguria, and intubated on Levophed. Again, he was transferred to the floor on [**2173-2-19**] and then returned to ICU on [**2173-2-20**]. FEN: He went to IR for a Dobhoff tube placement on [**2173-2-3**] and was started on trophic tube feedings. He showed improvement and was reporting +flatus and +BM. The NGT was D/C'd. His TF were advanced slowly to goal and the TPN was stopped on [**2-8**]. GI: He was NPO. He vomitted a large amount of bile emesis. He require repositioning of the Dobhoff. He also had a NGT in place. Once he had +flatus and +BM, the NGT was D/C'd. CV: He was on Lopressor to control for tachycardia and hypertension. GU: He was responding to IV lasix with brisk urine output. Post-operatively he was continued on Lasix for diuresis. He had a foley in place and had good urine output. Pulm: He was intubated. Post pyloric tube was placed on [**2-3**]. He required Lasix for crackles and had good response. He was started on Levoquin on [**2-21**] for possible pneumonia When he was transferred back to the ICU on [**2173-2-20**], he had a slow decline. He had a temperature to 102.3, he appeared more somulent, he was having frequent PVC's, he was expectorating thick, green secretions, his BUN and Cr were on the rise. He was becoming septic and had +blood cultures. It was becoming more concerning that surgery may be unavoidable. He went to the OR on [**2173-2-24**] for a: 1. Pancreatic necrosectomy with wide drainage. 2. Gastrostomy tube placement. 3. Feeding jejunostomy tube placement. 4. Cholecystostomy tube placement. He had a prolonged ICU course and was intubated for 2 weeks. He slowly improved with much ICU care. ABD: Post-operatively he had a G-tube, J-tube, Cholecystostomy tube, and 2 JP drains. In the OR, he had 1200 IVF, 3 RBC, 2 FFP, EBL 50, 1500 murky fluid and 1500 ascites. He had a large midline incision that was being packed with wet to dry dressing. The wound was brownish and had thick, tan drainage. Granulation tissue began to show and the wound was VAC'd on [**2173-3-16**]. He continued to have much drainage from the wound. The Cholecystostomy tube was changed from being clamped to gravity drainage due to concerns that he had enzymes leaking through the wound. His skin around the incision looked red. The VAC was removed and dressing changes were performed TID. He received Vancomycin for 10 days for wound erythema, which improved. On [**3-23**], a surveillance CT showed: 1. Essentially stable appearance of multiple intra-abdominal fluid collections in this patient with necrotizing pancreatitis. 2. Unchanged focal attenuation of proximal splenic vein, which is patent. No evidence of pseudoaneurysm. 3. Essentially unchanged appearance to pancreas, with non-enhancing regions consistent with pancreatic necrosis. Resp: He had a pro-longed intubation and was eventaully weaned to extubation on [**2173-3-8**]. He continued to need good pulmonary toilet and chest PT. GI: His G-tube was to gravity initially and then eventually capped. J-tube feedings were started and slowly advanced to goal. The Cholecystostomy tube was to gravity and draining a moderate volume of biliuos fluid. This was left to gravity while his abdominal incision continued to heal. He was followed by Speech and Swallow who recommended clear fluids with supervision. He was noted to aspirate on [**2173-3-19**] when attempting fluids. Speech and Swallow again saw the patient and he had improved and was cleared for clear fluids with supervision. He was having daily loose stool. He was ordered for Immodium and banana flakes. His stool eventually was becoming more formed. Cards: Cards consulted because they noted transient ST depression on tele (strips not available for review), 12 EKG done is not substantially changed from EKG from [**2165**]. Patient never c/o CP. Recs: Perhaps there are trasient ischemia when the pt is under extreme stress. He had an ECHO which was negative. [**Last Name (un) **]: He was followed by [**Last Name (un) **] for continued blood glucose management. . Neuro: He was A+O x 1. He often spoke in nonsensical sentences. He slowly improved and became more alert, awake and conversant. He had right sided weakness, but pattern is difficult to clarify given limited cooperation and pain. He may have proximal>distal right UE weakness and mildly right leg weakness. Isolated right deltoid weakness could reflect axillary nerve injury, but weakness may be more diffuse in right arm and leg. Etiology of encephalopathy also is unclear. Mild uremia could be a contributing factor. Normal LFTs, He may have slight right sided visual neglect (though not certain on exam). Head CT negative from [**2173-3-8**] (except fluid in mastoid air cells), but an MRI brain should be obtained when possible to rule out a left hemisphere lesion. A MRI on [**3-16**] showed: no pathology, no masses or bleeding, and unremarkable MRA of the circle of [**Location (un) 431**] and unremarkable MRA of the vertebral and carotid arteries. He slowly continued to clear mentally and become more alert and oriented. Activity: He was having orthostatic symptoms when PT was attempting to transfer him to the chair. He was dizzy, weak, confused and was having 20-30 mmHg systolic drop with change of position. His Lopressor was decreased and as his strength improved, he was able to tolerate more activity. He will need continued PT. ID:Finished abx course Meropenem([**Date range (1) 27725**]) fluconazole ([**Date range (1) 27726**]) Zosyn ([**Date range (1) 2820**]), Vancomycin ([**Date range (1) 27727**]). Ampicillin ([**2-28**]-), fluconazole ([**2-25**]-?, [**Date range (1) 27726**]) [Levoflox ([**2178-3-4**], [**2096-2-21**]), Meropenem([**Date range (1) 27725**], [**Date range (1) 15078**]), Vancomycin ([**Date range (1) 27727**], [**Date range (1) 27728**], [**Date range (1) 27729**]), Zosyn ([**Date range (1) 2820**])]; {[**3-1**] MRSA (+) at nares} . Imaging: [**3-17**] MR [**Name13 (STitle) 430**]: No acute intracranial pathology, including no sign of intracranial mass or bleed. 2. Unremarkable MRA of the circle of [**Location (un) 431**] and unremarkable MRA of the vertebral and carotid arteries. [**3-12**] CT Abd: No thrombosis, No pseudoaneurysm. Unchanged nonenhancing areas within the pancreatic head and the body consistent with pancreatic necrosis. [**3-10**]: CT abdomen: Significaant reduction in peripancreatic fluid collections. Pancreatic necrosis, no gas. Attenuation in splenic vein, thrombosis cannot be ruled out. [**3-8**]: CT head: no pathology/stroke [**3-5**]: b/l UE U/S- superficial thrombus in R basilic vein [**3-1**] CXR: bilateral effusions and bibasilar air space opacities. [**2-24**] CT abd: R basilar opacity, new peri-hepatic fluid collection, unchanged pancreatic necrosis, ascites [**2-24**] RUQ US: cholelithiasis, no cholecystitis, 15 mm CBD, cholesterol polyp [**2-15**] LENI:wnl, echo- wnl, EF > 55; [**2-7**] CT Abd: evolving pancreatic head necrosis [**2173-2-1**]: Head CT - no bleeding or mass effect [**2173-2-1**]: Abd. CT - evolution of pancreatitis w/ markedly diminshed perfusion c/w pancreatitic necrosis [**2163-1-29**]: U/S - 1.3 cm stone in neck of gallbladder assoc. w/ thickening of the wall of GB w/ small pericholecystic fluid [**2173-1-25**]: Abd. CT - cholelithiasis, pancreatitis. . Micro: [**3-9**] C diff neg [**3-4**]: Cdiff (-); [**3-3**]: C.diff (-) x 2, [**3-2**]: swab: enterococcus, fluid: enterococcus; [**3-1**]: C.diff (-), BCx:(-), SCx:(-), Tip:(-); [**2-24**]: swab GB: Enterococcus Amp sensitive. peritoneal swab #1- NG, #2- E-coccus, pancreas #1- E-coccus, #2 e-coccus; [**2-22**]: UCx yeast Medications on Admission: Tx Meds: insulin, imipenem 500 Q6, protonix, lopressor 5 Q4, tylenol, fentanyl PRN Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed. 3. Amylase-Lipase-Protease 468 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 4. Loperamide 1 mg/5 mL Liquid Sig: Two (2) PO TID (3 times a day) as needed. 5. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 6. Acetaminophen 160 mg/5 mL Solution Sig: Two (2) PO Q4H (every 4 hours) as needed. 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO HS (at bedtime) as needed. 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 13. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty (20) Units Subcutaneous twice a day. 15. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection four times a day: See Sliding Scale. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: 1. Fulminant pancreatitis. 2. Necrotizing pancreatitis. 3. Multiple system organ failure, progressing 4. Cholelithiasis. 5. Respiratory failure resulting in prolonged intubation 6. Post-op Delerium/Confusion 7. Post-op Urinary Retention 8. Right arm proximal weakness post surgery 9. Mild oral phase deficit Discharge Condition: Good Discharge Instructions: * Increasing pain * Fever (>101.5 F) * Persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain . Please resume all of your regular medications and take any new meds as ordered. . Ambulate several times per day. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 468**] in 3 weeks. Call ([**Telephone/Fax (1) 27730**] to schedule an appointment. Completed by:[**2173-3-29**]

[ "729.89", "584.5", "327.23", "574.00", "577.0", "577.2", "995.92", "401.9", "286.7", "038.0", "785.52", "272.4", "348.30", "250.00", "511.9", "518.81", "789.5", "278.00", "788.20" ]

icd9cm

[ [ [] ] ]

[ "51.03", "43.19", "38.93", "93.90", "99.04", "96.6", "52.22", "00.17", "96.04", "46.39", "96.72", "99.07", "38.91", "99.15" ]

icd9pcs

[ [ [] ] ]

14993, 15065

5383, 12385

334, 491

15421, 15427

1541, 5360

15729, 15890

1347, 1352

13644, 14970

15086, 15400

13537, 13621

15451, 15706

1367, 1522

272, 296

519, 1216

12394, 13511

1238, 1285

1301, 1331

402

167,615

8205

Discharge summary

report

Admission Date: [**2156-11-11**] Discharge Date: [**2156-11-18**] Date of Birth: [**2105-9-26**] Sex: F Service: MEDICINE Allergies: Penicillins / Tetracyclines / Plaquenil / Chloroquine / Sulfonamides / Floxin / Heparin Agents Attending:[**First Name3 (LF) 2009**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Transesophageal [**First Name3 (LF) **] PICC line placement History of Present Illness: The pt is a 51-year-old woman with SLE and severe PAH diagnosed in [**2154-12-20**] with excellent response to Flolan, recently admitted and discharged on day PTA for right heart cardiac cath performed for progressive hypoxemia with increased need for supplemental oxygen despite an improved [**Year (4 digits) 461**] and six-minute walk test distanceand renal biopsy for proteinuria, transferred from [**Hospital3 **] Hospital with hypotension SBPs 60s-70s. Patient discharged from [**Hospital1 18**] [**11-10**], awoke this am around noon with confusion, lethargy, dizziness with standing. On arrival to [**Hospital3 **] ED BP 73/48,HR 103, RR18 95% 4L, T98.2. Prior to transfer BP 85/53, 100% RA. Only OSH Lab Data WBC 4.2 HCT 30, PLT 133. CXR low lung volumes with no acute process. PIV x 2 placed, received 4L NS and Linezolid x 1 and transferred to [**Hospital1 18**] MICU. Upon arrival pt's vitals 100.7 HR 106 BP 95/57 RR19 74-99% O2 sats. She reports she has had dizziness, low BPs and overall malaise x 2-3 days. Also reports subjective fevers, no chills, and tenderness at line site x 1 week but no purulent drainage or erythema. She has had line x 1 year and reports prior h/o similar presentations with line sepsis. Has minimal pain at left flank site of biopsy, no pain in right groin where had cath. Only other complaint is chronic headache and recurrence of chronic bilateral shoulder pain x 2 days. Recent medictaion changes include addition of Lisinopril 1 week prior and holding of Coumadin for procedure (renal biopsy) planned to be restarted [**11-13**]. Denies change in chronic dyspnea or LE edema, denies cough, chest pain, LE pain, dysuria, hematuria, melena, hematochezia, numbness/weakness. Past Medical History: -systemic lupus erythematosus with history of pleuritis, glomerulonephritis ([**2144**]) -Diabetes mellitus type 2 -pulmonary arterial hypertension on Flolan -atrial septal defect of the secundum type (versus a stretched PFO) -obstructive sleep apnea on home oxygen -anticardiolipin antibody (although disputed in recent heme-onc notes, recent tests negative) -type 1 heparin induced thrombocytopenia (ALTHOUGH QUESTIONABLE PER HEME/ONC) -obesity -restrictive pulmonary disease -migraines -history of sinusitis -fibromyalgia. -history of a miscarriage PSH s/p cholecystectomy, s/p hysterectomy Social History: She has not ever worked outside the home. She lives in [**Hospital3 **]. She has no tobacco or alcohol use. She has four children. Family History: Her father died of colon cancer at age 73. Her mother is healthy as are her brother and sisters. Physical Exam: Vitals - T 100.7 HR 106 BP 95/57 RR 19 O2sat 74-99% GENERAL: Patient sitting back in bed with nasal cannula oxygen, NAD, speaking in full sentences. Cushingoid appearance HEENT: Dry MM. NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Thick. Unable to appreciate JVD. CV: Tachy. Prominent split S2. No thrills, lifts. No S3 or S4. Chest: Crackles in bases L>R. No wheezes or rhonchi. Right chest tunneled Hickmans with mild tenderness just superior to line. No purulence or drainage. Minimal erythema. Abd: Obese. Hypoactive bs. Somewhat distended, soft, NT. No HSM or tenderness. No CVA tnederness. No palpable hematoma over left Ext: Trace edema. No clubbing or cyanosis. R groin dsg C/D/I. No femoral bruits or thrills. Skin: Thinning, ecchymoses RLE, UE BL, erythema over anterior chest and back Neuro: CN 2-12 intact. AAO x 3 Pertinent Results: IMAGING: CXR: Azygos distention reflects increased intravascular fluid volume. Pulmonary circulation is borderline engorged but there is no edema. Mild cardiomegaly stable. No pleural effusion or pneumothorax. Right subclavian line tip projects over the mid SVC. No pneumothorax Chest CT: IMPRESSIONS: 1. Main pulmonary artery enlargement is little changed compared to [**2154**], and is consistent with the history of pulmonary hypertension. Cardiac enlargement, with prominence of the right ventricle, is unchanged. 2. No evidence of interstitial lung disease or other new intrathoracic process is seen to account for increasing oxygen requirement. 3. Small pericardial effusion may be related to the patient's underlying lupus. 4. Mild small airway obstruction. 5. Allowing for differences in technique, sub-4 mm right lower lobe nodule is not changed from [**2154**]. Without strong risk factor for intrathoracic malignancy, no further followup is recommended [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] guidelines. TTE: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2156-9-6**], the estimated pulmonary artery systolic pressure is slightly higher. TEE: The left atrium is mildly dilated. The right atrium is moderately dilated. There is a small secundum atrial septal defect with mild bidirectional shunting across the interatrial septum at rest. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 45 cm from the incisors. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The pulmonic valve leaflets are thickened. No masses or vegetations are seen on the aortic, mitral, triucuspid and pulmonary valves The tricuspid valve leaflets are mildly thickened. The main pulmonary artery is dilated. There is no pericardial effusion. IMPRESSION: No valvular vegetations seen. Small secondum ASD with bidirectional shunt (small). Dilated main pulmonary artery. Mild-to-moderate tricuspid regurgitation. Globally hypokinetic RV. Renal U/S: no evidence of hematoma or abscess s/p biopsy Head CT: IMPRESSION: No evidence of acute intracranial hemorrhage or mass effect. Lucent area seen within the right frontal bone, most likely a venous [**Doctor Last Name **]; however, please correlate clinically with history of prior surgery or history of underlying malignancy. MRI may be obtained for the latter. STUDIES Cardiac Catheterization [**11-9**] FINAL DIAGNOSIS: 1. Severe pulmonary arterial hypertension despite supplemental oxygen and Flolan infusion. 2. Mild right ventricular diastolic dysfunction. 3. Normal left-sided filling pressures as reflected in the PCW. CT CHEST [**11-10**] 1. Main pulmonary artery enlargement is little changed compared to [**2154**], and is consistent with the history of pulmonary hypertension. Cardiac enlargement, with prominence of the right ventricle, is unchanged. 2. No evidence of interstitial lung disease or other new intrathoracic process is seen to account for increasing oxygen requirement. 3. Small pericardial effusion may be related to the patient's underlying lupus. 4. Mild small airway obstruction. 5. Allowing for differences in technique, sub-4 mm right lower lobe nodule is not changed from [**2154**]. Without strong risk factor for intrathoracic malignancy, no further followup is recommended [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] guidelines. [**2156-9-6**] Echo The left atrium is normal in size. The right atrial pressure is indeterminate. 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 moderately dilated with moderate global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. There is mild to moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2155-5-23**], the RV has decreased in size (less dilated) and the estimated PA systolic pressure has decreased. ABG: 7.35/42/87 CRP: 26.7 ESR: > 100 Cre: 0.9 on admission, 0.8 on discharge Hct stable in high 20s to low 30s CKs flat, Trop 0.02 on admission. Brief Hospital Course: # Sepsis: Likely in setting Hickman line infection, which patient has had in the past ([**2155-5-20**]). Patient was initially septic on admission, meeting SIRS criteria for fever, tachycardia, elevated WBC, and positive blood cultures. No evidence of endocarditis on TTE or TEE. No evidence of PNA or UTI. No evidence of septic hematoma from recent procedures (renal biopsy or right heart cath). She was initially treated with fluid boluses, daptomycin and levofloxacin, and became hemodynamically stable without requiring pressors. Vancomycin sensitive Strep viridans and CNS were subsequently noted to be growing on OSH cultures. ID was consulted for antibiotics management and recommended a rule out for endocarditis and removal of the Hickman catheter for culture and removal of infection nidus. However, per Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **], the decision was made that the Hickman line was to be kept in place for her continuous flolan, due to the difficulty and the danger to her general health of discontinuing the infusion. She will receive 4 weeks of Vancomycin as an outpatient through the PICC line taht was placed. Surveillence cultures were noted to have microccoccus spp, subsequent cultures neg. She will need repeat blood cultures if febrile as outpatient. She will have blood cultures, CBC, LFTs, BUN and Cre, and Vancomycin trough checked weekly as an outpatient while on Vancomycin. #Pulmonary hypertension: Recent cardiac cath demonstrated severe pulm HTN despite Flolan. Flolan was continued. Lasix was held [**2-21**] low BPs and can be reinitiated as an outpatient. Supplemental oxygen was continued to maintain O2 sats >93%. She was restarted on her coumadin prior to discharge for prevention of chronic pulmonary emboli that may have contributed to her pulm HTN. # Lupus nephritis: Patient has lupus nephritis with recent worsening of proteinuria, most recently Protein/creatinine ratio 8, improved from 15-16 [**9-27**]. Her renal biopsy showed an IgG immune deposition, diabetic nephropathy, and lupus nephritis. No treatment regimen was recommended at this time per nephrology consult given her other medical issues. Lisinopril was inititally administered, but she was unable to tolerate it and had issues with hypotension and AMS (see below.) She will follow up with them as an outpatient and has been scheduled into Dr. [**Name (NI) 12492**] clinic. #AMS: Likely initiated by hypotension. Patient trigged for hypotension 10-12 hours after being administered Lisinopril with SBPs into the 70s. She was noted to be somnolent. No hypoglycemia was noted. Pt Did not take more than her usual vicodin and tylenol #3, but out of concern for narcotics overdose, Narcan was administered. Akathisia-like movements were then noted after narcan administration, which were relieved with benadryl and benztropine. Pt reports similar event one week ago at home in setting of low blood pressure with AMS and loss of memory of events. Her Lisinopril and Lasix were subsequently held and her SBPs were maintained > 100. Her mental status was at baseline on discharge. Patient should have another Head CT in [**3-25**] months. # DM: oral hypoglycemics were held and she was controlled on ISS while hospitalized # Depression/Anxiety: Pt on multiple meds at home. Originally there was some concern for serotonin syndrome given multiple medications and received Linezolid at OSH however her hypotension resolved after the linezolid was discontinued and the other antiobiotics were started. Continued Cymbalta, amitriptyline, holding Wellbutrin #Migraines: Continued Amitrityline Medications on Admission: MEDICATIONS: Tylenol with Codeine allopurinol 100 mg once a day amitriptyline 200 mg q.h.s. Wellbutrin 150 mg twice a day Premarin 0.625 mg once a day Cymbalta 60 mg once a day Flolan 15 ng/kg/minute continuous IV Vitamin D Fexofenadine furosemide 40 mg twice daily gabapentin 1600 mg twice a day Vicodin prn lisinopril metformin nystatin prednisone 10 mg once a day. 4 mg of warfarin (held x 1 week) Ambien Fluconazole 150 mg qMWF Lorazepam 0.5 mg q four hours prn anxiety. Supplemental oxygen, 4L x approx. 14 hours per day Discharge Medications: 1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 3. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Amitriptyline 50 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 400 mg Capsule Sig: Four (4) Capsule PO QHS (once a day (at bedtime)) as needed. 7. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 9. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Epoprostenol 0.5 mg Recon Soln Sig: One (1) Recon Soln Intravenous INFUSION (continuous infusion). 12. Fluconazole 150 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 13. Insulin Lispro 100 unit/mL Solution Sig: variable units Subcutaneous ASDIR (AS DIRECTED): per sliding scale. 14. Vancomycin 1,000 mg Recon Soln Sig: 1250 (1250) mg Intravenous twice a day for 4 weeks: start date [**2156-11-15**] end date [**2156-12-10**]. Disp:*48 doses* Refills:*0* 15. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 16. Outpatient Lab Work Please check weekly CBC with differential, chem 7, and liver function tests. Results should be faxed to [**Telephone/Fax (1) 432**]. 17. Normal saline flushes Sig: 5-10 cc ASDIR for 30 days: Please use pre and post dose. No heparin given allergy to heparin agents. . Disp:*150 flushes* Refills:*0* Discharge Disposition: Home With Service Facility: Accredo IV Home Infusion Discharge Diagnosis: Sepsis likely from Hickman catheter infection Discharge Condition: The patient was afebrile and hemodynamically stable prior to discharge. Discharge Instructions: 1) You were admitted to the hospital with low blood pressure. This was from an infection of the catheter in your chest. You were given antibiotics for this infection. You should continue these antibiotics for the full course described below. You will need to take your antibiotics (Vancomycin) for four weeks, starting from [**2156-11-15**] until [**2156-12-10**]. You had a semipermanent line called a PICC line placed for this reason. 2) The following changes were made to your medications: Your lasix was stopped due to low blood pressure. Your lisinopril was stopped due to low blood pressure. 3) Please keep all of your followup appointments 4) Please call your doctor or come back to the hospital if you experience light-headedness, dizziness, chest pain, shortness of breath, rash, itchiness, fevers, abdominal pain, nausea, vomiting, pain with urination, diarrhea, leg swelling, or any other concerning symptoms. . 5) You should have a repeat head CT in [**3-25**] months for further evaluation of findings noted on your imaging studies from this hospitalization. Followup Instructions: Please call for a follow up appointment with your PCP [**Last Name (LF) 29169**],[**Name9 (PRE) 29166**] [**Name Initial (PRE) **]. at [**Telephone/Fax (1) 27854**] in 2 weeks. Please follow up with your pulmonologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within 1-2 weeks after discharge. Please discuss restarting your Lisinopril and Lasix with her at this time. Please follow up with renal as an outpatient for treatment of your nephritis. You are scheduled to see Dr. [**Last Name (STitle) **] on [**2157-3-15**] at 3:00 pm. The phone number for the renal clinic is 61-[**Telephone/Fax (1) **] in case you need to schedule. You will be contact[**Name (NI) **] by the renal clinic if an earlier availability opens up, per Dr. [**Last Name (STitle) **]. Other appointments: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2156-11-19**] 1:00 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2156-11-23**] 2:30 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2156-11-23**] 2:30 Completed by:[**2156-11-18**]

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icd9cm

[ [ [] ] ]

[ "38.93", "88.72" ]

icd9pcs

[ [ [] ] ]

15653, 15708

9736, 13366

369, 431

15798, 15872

3985, 7163

16996, 18252

2967, 3065

13943, 15630

15729, 15777

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3080, 3966

318, 331

459, 2182

7172, 7523

2204, 2802

2818, 2951

12,140

183,207

5087+55637

Discharge summary

report+addendum

Admission Date: [**2144-5-29**] Discharge Date: [**2144-6-2**] Date of Birth: [**2074-1-31**] Sex: M Service: [**Last Name (un) 7081**] ADMISSION DIAGNOSES: History of small cell lung cancer - status post chemotherapy and radiation therapy. Pulmonary nodule. Peptic ulcer disease. Hypercholesterolemia. Gastroesophageal reflux disease. Chronic obstructive pulmonary disease/emphysema. Status post mediastinoscopy. DISCHARGE DIAGNOSES: Status post right video-assisted thoracoscopy. Status post bronchoscopy. Status post right upper lobe wedge resection. Hypotension. History of small cell lung cancer - status post chemotherapy and radiation therapy. Pulmonary nodule. Peptic ulcer disease. Hypercholesterolemia. Gastroesophageal reflux disease. Chronic obstructive pulmonary disease/emphysema. Status post mediastinoscopy. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 70-year-old male who was diagnosed with small cell lung cancer in [**2135**], and at that time was found to have disease in the lymph nodes which was deemed to be inoperable. He therefore underwent chemotherapy and radiation therapy, with his last treatment in [**2137**]. He had been doing well since then but was found to have a pulmonary nodule in late [**2143-9-21**] on follow-up imaging. His repeat computer tomography at that time suggested possible enlargement of the nodule. He therefore presented for resection of the nodule in order to determine its etiology. PHYSICAL EXAMINATION ON ADMISSION: He was afebrile at 97.8 degrees Fahrenheit, his pulse was 113, his blood pressure was 146/85, and he was otherwise saturating 97 percent on room air. He was in no acute distress. He had no scleral icterus. He had no cervical adenopathy. The carotids were 2 plus. The lungs were clear to auscultation and percussion bilaterally; although the breath sounds were distant. He had no crackles or wheezes. Heart was otherwise regular and without rubs. The abdomen was soft. There was no evidence of hepatosplenomegaly or ascites. He had no inguinal adenopathy, and otherwise no peripheral edema. PREOPERATIVE LABORATORY DATA ON ADMISSION: His preoperative hematocrit was 44.5. SUMMARY OF HOSPITAL COURSE: The patient was admitted on [**2144-5-29**] and on that day underwent a right video-assisted thoracic surgery with wedge resection without note of intraoperative complications or excessive blood loss. It was noted that he was somewhat hypotensive intraoperatively, but this was felt by the Anesthesia Department to be secondary to his anesthesia. He was not extubated in the Operating Room secondary to a slow recovery time from anesthesia. The patient was taken to the Post Anesthesia Care Unit intubated. While in the Post Anesthesia Care Unit, the patient became somewhat more alert and oriented, and it was felt at that time that he was safe extubation. Shortly after he was extubated, the patient became acutely tachycardic and somewhat hypotensive with a mean arterial pressure in the 50s and with a decreasing oxygen saturation. Therefore, he was re-intubated and an echocardiogram was performed in the Post Anesthesia Care Unit to rule out any sort of cardiac dysfunction. This showed an ejection fraction of greater than 50 percent. No significant valvular disease, and no evidence of a hyperdynamic stated indicating that there was poor filling. His hematocrit was otherwise stable, and his chest tube output was normal. It was felt that the hypotension was again secondary to anesthesia. The patient was started on a Neo-Synephrine drip for pressor support. Later that night, he was transferred to the Cardiac Surgery Recovery Unit for more intensive monitoring. He was extubated on postoperative day one and did fine weaning from oxygen throughout the rest of his hospitalization. Notably, on postoperative day two he did have collapse of his right lower lobe on chest x-ray; but with aggressive chest physical therapy, coughing, and deep breathing exercises he was re- expanded. He did not need any sort of bronchoscopy. Otherwise, in terms of his Intensive Care Unit stay, his Intensive Care Unit stay was prolonged secondary for a need for blood pressure support on Neo-Synephrine which was weaned, and the Neo-Synephrine was discontinued on postoperative day three. He did remain slightly tachycardic, but this was felt to be close to his baseline; as per his preoperative numbers. Otherwise, the patient was eating well. His chest tubes came out on postoperative day two, and he had no evidence of a significant pneumothorax, and his chest x-ray otherwise looked fine. DISCHARGE CONDITION/DISPOSITION: It was felt that by postoperative day four - as the patient was up and ambulating, had excellent pain control with oral pain medications, and was taking adequate oral intake, and was otherwise saturating well with a minimal oxygen requirement - that he could be discharged home in good condition. He was discharged to home with his prior hematocrit prior to discharge being 33. Otherwise, his blood urea nitrogen and creatinine were 25 and 1. His pathology was still pending at the time of discharge. MEDICATIONS ON DISCHARGE: 1. Percocet one to two tablets by mouth q.4-6h. as needed (for pain). 2. Tylenol 325 mg by mouth q.6h. as needed (when not taking Percocet). 3. Ibuprofen 600 mg by mouth q.6h. (for seven days). Otherwise, he was told he could continue his aspirin per day, a multivitamin, and Pepcid. He was advised not to take aspirin while taking ibuprofen. DISCHARGE INSTRUCTIONS: The patient was instructed to follow up with his oncologist and his primary care physician within the next 10 to 14 days. He was to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 175**] in one week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 7082**] Dictated By:[**Doctor Last Name 3763**] MEDQUIST36 D: [**2144-6-2**] 08:19:41 T: [**2144-6-2**] 08:48:03 Job#: [**Job Number 20931**] Name: [**Known lastname **], [**Known firstname 126**] Unit No: [**Numeric Identifier 3495**] Admission Date: [**2144-5-29**] Discharge Date: Date of Birth: [**2074-1-31**] Sex: M Service: [**Last Name (un) 3496**] Since the prior dictation, the [**Hospital 1325**] hospital course was prolonged secondary to episodes of tachycardia during ambulation. His rate reached as high as 170 in a sinus tachycardia, but there was no evidence of hypotension or hemodynamic instability during these episodes. There seemed to be no clear etiology to this as the patient's volume status was appropriate. He did not have an abnormally low hematocrit and it did not seem to be secondary to any sort of medication related problem. We did touch base with his primary care physician who was also aware of persistent baseline tachycardia, although it had never been as high as 170. It is felt that this was just secondary to the patient's mild deconditioning and recent inactivity. We started him on low-dose beta blocker (metoprolol 12.5 mg p.o. b.i.d.) to aid in rate control. His pressures remained stable while on this regimen. Therefore, by [**2144-6-4**] (postoperative day six) as his rate was in the 90s, blood pressure was in the 110s over 70s and saturation was 99 percent on one liter, it was felt that he could be discharged to a rehabilitation facility in fair condition for further physical therapy. The patient was to follow-up with his primary care physician within one week and also with Dr. [**Last Name (STitle) 1719**] within four days ([**2144-6-8**]) for recheck of his status. Otherwise, the patient's physical condition had not changed since the prior dictation and his only changes in medication were the addition of metoprolol 12.5 mg p.o. b.i.d. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3497**] Dictated By:[**Doctor Last Name 3498**] MEDQUIST36 D: [**2144-6-4**] 09:13:07 T: [**2144-6-4**] 09:24:36 Job#: [**Job Number 3499**]

[ "496", "997.3", "458.29", "518.0", "530.81", "V10.11", "V16.1", "162.3", "272.0" ]

icd9cm

[ [ [] ] ]

[ "32.29", "96.71", "96.04", "33.23" ]

icd9pcs

[ [ [] ] ]

465, 865

5221, 5573

5598, 8129

2250, 5195

179, 443

894, 1522

2182, 2221

61,474

184,660

41606

Discharge summary

report

Admission Date: [**2191-8-26**] Discharge Date: [**2191-8-31**] Date of Birth: [**2124-8-18**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1115**] Chief Complaint: hyperbilirubinemia Major Surgical or Invasive Procedure: ERCP with stent placement on [**8-27**] History of Present Illness: Mr. [**Known lastname 90447**] is a 67 year old man with a history of CAD and anemia who reports one month ago he developed jaundice that lasted for two days. He reports going to his PCP and having [**Name Initial (PRE) **] CT of the abdomen which he reports was normal. He reports being told that he should stop his simvastatin in case that was contributing to his presentation. The jaundice apparently went away until two days ago when it reappeared. He also noticed his urine became tea colored. Last night he had the sudden onset of right upper quadrant pain that was sharp in nature. He felt that this was a gas pain that he could not relieve. He notes that this abdominal pain is different from his chronic abdominal/RUQ pain that he has had for two years. He takes oxycontin approximately every other day on average for the last two years. He is not sure what diagnosis he was told as to why he has persistent RUQ pain. . Because of the RUQ pain and jaundice, he presented to [**Hospital3 17184**] this morning. He had a temperature to 101.7, a WBC of 18.6, T bili of 26.2 and CT scan showing a CBD to 11mm with distal tapering and bile duct walls with mild inhancement possibly relating to biliary stasis versus infection/inflammation. He was given 12mg morphine, 1mg dilaudid, 3.375 zosyn and 4mg zofran at OSH and trasnferred to [**Hospital1 18**] for ? ERCP. Of note, on review his EKG showed ST elevation in aVR and depressions in V2-V6. . In the ED here he had a right upper quadrant ultrasound which showed mild CBD dilation to 9mm without intrahepatic ductal dilation. There was no cholelithiasis and a normal appearing gallbladder. His hematocrit was significant for a drop from 32 at the OSH to 23 at the ED here. This was repeated in the ED and was stable. He was also guiac negative. Surgery consulted and recommended antibiotics for cholangitis and ERCP. His EKG no longer had ST elevation. His troponin was 0.08 prior to transfer. He was given a dose of aspirin, Zosyn, and 2 L of IVF. VS on transfer were: 98.3, 114/54, 81, 16, 98% on RA. . On arrival to the ICU a troponin was added to his PM labs. It was significant for 0.34. Cardiology was consulted and ERCP also saw the patient. . Review of systems: (+) Per HPI (-) Denies fevers at home, chills, night sweats, changes in appetite. Denies headache or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, changes in stool color or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. He denies any history of angina. . Past Medical History: Coronary Artery Disease - 3 vessel disease Hemolytic anemia Hyperlipidemia Social History: - Tobacco: Smoked fifty years ago. Does not remember how much he smoked. - Alcohol: Denies current alcohol use. Reports previous social use. - Illicits: Denies. Family History: Mother - had diabetes. Died from a cerebral hemorrhage. Father - died from an MI at age 65. Brother - three years older with diabetes. Physical Exam: Physical Exam on Admission: Vitals: T: 99.4 BP: 124/60 P: 83 R: 16 O2: 99 % on 2L General: Alert, oriented, no acute distress, mildly jaundice HEENT: MMM Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales CV: Regular rate, no murmurs Abdomen: soft, obese, bowel sounds present, no rebound tenderness or guarding, slight tenderness to palpation in RUQ with deep palpation GU: no foley Ext: warm, well perfused, 1+ DP pulses, no edema . Physical Exam on Discharge: VSS General: AAOx3, in NAD, jaundiced HEENT: Sceral icterus, Moist mucous membranes, Neck: No JVP elevation Lungs: CTAB, no wheezes or rhonchi CV: RRR, no murmurs Abdomen: Soft, mildly tender to deep palpation in one spot in RUQ underneath his ribs just medial to miclavicular line. Nondistended, no guarding or rebound. Negative [**Doctor Last Name **] sign Extremities: Warm, well perfused, 2+DP pulses bilaterally, no edema Pertinent Results: Labs on Admission: [**2191-8-26**] 09:20AM WBC-20.8* RBC-2.59* HGB-9.0* HCT-23.4* MCV-90 MCH-34.6* MCHC-38.4* RDW-19.1* [**2191-8-26**] 09:20AM NEUTS-92.0* LYMPHS-4.6* MONOS-3.0 EOS-0.2 BASOS-0.1 [**2191-8-26**] 09:20AM PHOSPHATE-2.3* MAGNESIUM-2.0 [**2191-8-26**] 09:20AM CK-MB-14* MB INDX-2.4 [**2191-8-26**] 09:20AM cTropnT-0.08* [**2191-8-26**] 09:20AM LIPASE-20 [**2191-8-26**] 09:20AM ALT(SGPT)-178* AST(SGOT)-134* CK(CPK)-590* ALK PHOS-85 TOT BILI-25.0* DIR BILI-18.4* INDIR BIL-6.6 [**2191-8-26**] 09:20AM GLUCOSE-144* UREA N-21* CREAT-1.2 SODIUM-142 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-24 ANION GAP-13 [**2191-8-26**] 11:21AM PT-16.7* PTT-27.0 INR(PT)-1.5* [**2191-8-26**] 12:30PM WBC-16.7* RBC-2.53* HGB-8.6* HCT-23.4* MCV-93 MCH-33.9* MCHC-36.6* RDW-17.7* [**2191-8-26**] 03:40PM HAPTOGLOB-<5* [**2191-8-26**] 03:40PM CK-MB-37* MB INDX-6.6* cTropnT-0.34* [**2191-8-26**] 03:40PM LD(LDH)-361* CK(CPK)-562* [**2191-8-26**] 09:02PM URINE COLOR-[**Location (un) **] APPEAR-Hazy SP [**Last Name (un) 155**]-1.032 [**2191-8-26**] 09:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-2* PH-5.5 LEUK-NEG [**2191-8-26**] 09:02PM URINE RBC-2 WBC-4 BACTERIA-FEW YEAST-NONE EPI-0 [**2191-8-26**] 11:18PM CK-MB-34* MB INDX-7.9* cTropnT-0.89* [**2191-8-26**] 11:18PM CK(CPK)-432* Labs on Discharge: [**2191-8-31**] 08:55AM BLOOD WBC-12.5* RBC-3.52* Hgb-11.2* Hct-30.5* MCV-87 MCH-31.7 MCHC-36.5* RDW-17.9* Plt Ct-215 [**2191-8-31**] 08:55AM BLOOD Glucose-96 UreaN-18 Creat-1.1 Na-138 K-4.3 Cl-105 HCO3-26 AnGap-11 [**2191-8-31**] 08:55AM BLOOD ALT-80* AST-71* AlkPhos-125 TotBili-15.0* [**2191-8-31**] 08:55AM BLOOD Calcium-9.4 Phos-3.0 Mg-2.4 [**2191-8-31**] 03:14PM BLOOD [**Doctor First Name **]-NEGATIVE [**2191-8-30**] 06:25AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE [**2191-8-29**] 06:35AM BLOOD HCV Ab-NEGATIVE [**2191-8-27**] 06:00AM BLOOD Triglyc-228* HDL-4 CHOL/HD-18.5 LDLcalc-24 Pending Labs: [**2191-8-31**] 03:14PM BLOOD ALPHA-1-ANTITRYPSIN-PND [**2191-8-31**] 08:55AM BLOOD HEREDITARY HEMOCHROMATOSIS MUTATION ANALYSIS-PND [**2191-8-30**] 06:25AM BLOOD HEPATITIS C VIRAL RNA, GENOTYPE-PND [**2191-8-30**] 06:25AM BLOOD LIVER FIBROSIS PANEL-PND . Micro: [**2191-8-29**] 06:35AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE Blood cx [**8-26**]:pnd Urine cx [**8-26**]: no growth . Cardiac Cath [**7-/2190**] Left main 50 % lesion, LAD 50%, circumflex 50%, right 99% . [**8-26**] 1.[**Street Address(2) 1755**] elevation in aVR ST depressions in I, II, V2, V3, V4, V5, V6 T wave inversions in V3-V6, avL . [**8-26**] [**Company 90448**] wave inversions in III, q wave ST depression of 1 mm in V3-V6 . Imaging: RUQ US [**8-26**]: 1. CBD prominence to 9 mm without intrahepatic ductal dilatation, cholelithiasis, or evidence of cholecystitis. 2. Splenomegaly to 16 cm. 3. Echogenic liver compatible with fatty infiltration. Other forms of liver disease including advanced hepatic fibrosis/cirrhosis cannot be excluded on this study. . ERCP [**8-27**]: Impression: 1. A single moderately sized periampullary diverticulum was found at the major papilla. 2. Cannulation was very difficult given the peri-ampullary diverticulum. 3. A 7 cm x 5 FR single pigtail pancreatic stent was placed to facilitate cannulation. 4. Cannulation of the biliary duct was then successful and deep with a sphincterotome after a guidewire was placed. 5. Contrast medium was injected resulting in complete opacification. 6. A mild diffuse dilation was seen at the common bile duct which measured 10 mm. 7. There was no evidence of filling defects. 8. Given recent NSTEMI and need for heparin, a sphincterotomy was not performed. 9. A 9cm by 10FR plastic biliary stent was placed successfully. 10. Once procedure was complete, the pancreatic duct stent was removed using a snare. 11. Differential for clinical picture includes small stone or stricture not seen on fluoroscopy vs. intrinsic liver disease. Recommendations: 1. NPO overnight with aggressive IV hydration as tolerated given recent cardiac issues. 2. Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call ([**Pager number 8437**]) 3. Continue to trend LFTs. 4. If bilirubin does not decrease in 2 days, would consider hepatology consult to consider intrinsic liver disease. 5. Repeat ERCP in 8 weeks for stent removal or exchange. Brief Hospital Course: Mr. [**Known lastname **] is a 67 year old man who presented with signs and symptoms concerning for ascending cholangitis and EKG findings and elevated troponins consistent with NSTEMI. #Ascending cholangiti: Patient has a history of hemolytic anemia with a previous hyperbilirubinemia total bili to 18, however it was indirect. On admission he had a direct hyperbilirubinemia, and signs and symptoms of ascending cholangitis. While his blood cultures never grew out any organisms, and his ERCP showed no exact obstruction he had a stent placed and his bilirubin originally improved, then increased then then steadily decreased down to 15.1 on discharge. He defervesed and his wbc also decreased throughout his admission. He was originally treated with zosyn which was switched to ciprofloxacin [**Hospital1 **] per ERCP to complete a 14 day course. At the time of discharge he reports having minimal if any RUQ pain, tolerating PO, and noticed a decrease in the darkness of his urine. His stent will need to be removed after 8 weeks by ERCP. Of note: Per anesthesia, the patient vomited when given sedation. They performed laryngoscopy and noted green-yellow vocal cords, concerning for aspiration, so they proceded with intubation and sedation. Suctioning returned no material, which lessened their concern for an aspiration event. #Hyperbilirubinemia: Hepatology was consulted during his stay given his unclear etiology of the direct hyperbilirubinemia / jaundice as it did not improve as expected with treatment of cholangitis. Multiple lab studies were sent off, and are pending at the time of discharge. They chose not to perform a liver biopsy since his bilirubin was continuing to decrease, and he will have follow-up with Hepatology as an outpatient. #NSTEMI / CAD : On admission, the patient was found to have elevated cardiac biomarkers. An EKG from the OSH showed ST elevation in aVR and reciprocal depressions in I, II, and V2-V6. There were also T-wave inversions in V3-V6, avL. On presentation to this facility these had partially resolved, with ST depression of 1mm in V3-V6, and T wave inversions in III. During his admission, the patient complained of no chest pain and had no recent history of chest pain or dyspnea on exertion. His troponin peaked at 0.89 on [**8-26**] and then began to drop. Cardiology was consulted during this admission and recommended medical management with heparin and asa, they chose not to performed a cardiac catheterization as he was asymptomatic. Statin should be initiated as an outpatient once liver issues improve. Close outpatient cardiology follow up was arranged. . Anemia: Patient reports a history of anemia for several years and is followed by hematology. The exact cause of his chronic anemia is unclear. [**Name2 (NI) **] reports his baseline hematocrit is in the mid 20's, but he is not sure. His hematocrit dropped from 32 to 23 after receiving fluids, but he did not respond appropriately to transfusion of 3 units PRBCs (5 point increase to 28). He was guaiac negative and had no signs of bleeding. During his stay he received a total 3 units PRBCs. A Coombs test was sent to investigate the cause of his anemia, and his outpatient Hematologist contact[**Name (NI) **]. Transitional Issues: Labs: -Liver Fibrosis blood work- PENDING -HCV viral RNA- PENDING -AMA-PENDING -[**Last Name (un) 15412**]-PENDING -Blood cultures ([**8-26**] and [**8-27**])PENDING Appointments: -Appointments scheduled with PCP, [**Name10 (NameIs) 2085**], hematologist. -Appointments made at [**Hospital1 18**] with hepatology. new hepatologist (liver doctor). -ERCP will contact patient to schedule removal of the sent (8wks after placement) -Once his LFTs are resolved, he should ideally be restarted on statin Medications added: -Plavix 75mg po daily, per cardiology. -Ciprofloxacin [**Hospital1 **] until [**2191-9-8**] to treat cholangitis Medications changed: -Metoprolol was decreased to 12.5 TID, from patients 25mg po BID, because he was having low BPs with his home dose. This should be readdressed at this follow-up appointments -Asa increased from 81mg-->325mg per cardiology Medications on Admission: Metoprolol 25 mg [**Hospital1 **] Aspirin 81 mg Oxycontin- once every few days. Reports 40 mg for chronic RUQ pain. Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*0* 3. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 8 days. Disp:*17 Tablet(s)* Refills:*0* 4. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. OxyContin Oral Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Acute Cholangitis, NSTEMI, Hemolytic Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 90447**], It was a pleasure taking care of you during your hospitalization. You were admitted because of abominal pain and jaundice concerning for cholangitis, an infection of your bile system. You had a procedure called an ERCP on [**8-26**] that did not show frank evidence of infection or biliary stones - a stent was placed to help the bile drain. Your liver enzymes were also elevated and you were seen by the liver doctors. We sent tests to look for liver disease, some of which are still pending and will be followed up by the liver doctors. . It was also noted that you had EKG changes and your blood tests showed elevated cardiace enzymes, indicating a small heart attack. You were treated conservatively with a blood thinning medication called heparin and followed by the cardiologists. They decided that you did not require a cardiac catheterization or further treatment during this hospitalization. . You will need to follow up with your PCP, [**Name10 (NameIs) **], and the Liver doctors in the [**Name5 (PTitle) **] term for close follow up. -You will need to have the stent taken out by your ERCP doctors, their team will get in touch with you about this appointment . Medication changes: We added the following medications: 1.Plavix 75 mg by mouth once a day 2.Ciprofloxacin 500mg by mouth twice a day until [**2191-9-8**] . Medication changes: 1. Please increase your dose of aspirin from 81mg (baby aspirin) to full strength 325mg by mouth once a day 2. Please stop taking your simvistatin until your liver problems resolve and you are instructed to restart it. 3. Please DECREASE your dose of metoprolol from 1 tablet (25mg) by mouth twice a day to [**1-2**] tablet by mouth 3 times a day. . Medications to continue: -oxycontin as needed Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] J. Location: [**Hospital **] MEDICAL Specialty: INTERNAL MEDICINE Address: [**Last Name (un) 59485**], N [**University/College **],[**Numeric Identifier 21478**] Phone: [**Telephone/Fax (1) 9674**] Appointment: TUESDAY [**9-6**] AT 1PM Department: LIVER CENTER When: THURSDAY [**2191-9-8**] at 3:00 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**Last Name (LF) **], [**Name8 (MD) **] MD Location: [**Hospital **] MEDICAL Specialty: CARDIOLOGY Address: [**Last Name (un) 59485**], N [**University/College **],[**Numeric Identifier 21478**] Phone: [**Telephone/Fax (1) 9674**] Appointment: [**9-16**] AT 2PM Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Location: [**Hospital **] MEDICAL Specialty: HEMATOLOGY/ONCOLOGY Address: [**Last Name (un) 59485**], N [**University/College **],[**Numeric Identifier 21478**] Phone: [**Telephone/Fax (1) 90449**] Appointment: FRIDAY [**9-23**] AT 10AM The ERCP office will get in touch with you about setting up an appointment to remove the stent that they placed (likely around 8 weeks after it was placed on [**2191-8-26**])

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icd9cm

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icd9pcs

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20751

Discharge summary

report

Admission Date: [**2128-1-7**] Discharge Date: [**2128-1-13**] Date of Birth: [**2068-2-16**] Sex: M Service: VSU CHIEF COMPLAINT: Right calf claudication. HISTORY OF PRESENT ILLNESS: This is a 59-year-old gentleman who has had right leg symptoms for years. The pain is noted to be in both legs. He has had a left lower extremity bypass graft in [**Location (un) 5450**], [**Location (un) 3844**] in [**2120**]. He is here now after being evaluated for right leg SFA tibial disease for elective revascularization by Dr. [**Last Name (STitle) 1391**]. REVIEW OF SYSTEMS: Positive for mild nausea over the last 3 weeks. No fever or chills. ALLERGIES: Penicillin, ibuprofen, Skelaxin, Flagyl, morphine, Zestril, lecithin, zolpidem. MEDICATIONS ON ADMISSION: Lopid 1200 mg daily, atenolol 100 mg daily, clonidine 0.4 mg daily, Plavix 75 mg daily, aspirin 81 mg daily, Actos 45 mg daily, Lasix 20 mg daily, Vytorin [**10-9**] daily, Lantus insulin, Zyprexa, mirtazapine and Combivent p.r.n. ILLNESSES: Include peripheral vascular disease, history of chronic pancreatitis with pancreatic mass status post resection with splenectomy, history of alcohol abuse--former, history of depression, history of hypercholesteremia, history of coronary artery disease status post myocardial infarction x2 in [**2125-8-22**] associated with congestive heart failure, ejection fraction 25%, status post left main trunk stenting in [**2125-8-22**], history of MRSA pneumonia-- treated, history of C. diff--treated, history of GERD, history of carotid artery disease status post left carotid endarterectomy. PHYSICAL EXAMINATION: Vital signs: 99, 66, 18, blood pressure 140/80, O2 sat 96% on room air, fingerstick glucose 149 on admission. General appearance is a gentleman in no acute distress but anxious. Lungs are clear to auscultation. Heart is a regular rate and rhythm but faint on auscultation secondary to increased AP diameter. Abdominal exam was unremarkable. Pulse exam shows that the left DP is dopplerable. The PT is absent. On the right, the DP and PT are absent both by palpation and Doppler. ADMITTING LABS: White count was 12.3, hematocrit 39.7, platelets 472, INR 0.9, BUN 23, creatinine 2.6. Urinalysis was negative. EKG showed a normal sinus rhythm with normal axis, with ventricular couplets and first degree AV block. Chest x-ray was without failure. HOSPITAL COURSE: The patient was admitted to the vascular service in preparation for elective surgery. The patient was quite anxious and confused overnight secondary to administration of Ativan after discussing it with the wife and husband. The patient is very sensitive to Ativan and hallucinates. Ativan was discontinued with improvement in the patient's sensorium. The patient has a history of alcohol use in the past but has not been active with alcohol over the last 25 years. The patient was given a nicotine patch for his history of tobacco dependence. The patient proceeded to surgery on [**2128-1-8**]. He underwent an in situ saphenous vein graft to the right femoral artery to anterior tibial bypass. He tolerated the procedure well. He was transferred to the PACU in stable condition. He remained hemodynamically stable, and his postop chest x-ray was without pneumothorax. The patient continued to do well. His EKG was without changes. His CK-MBs were unremarkable. His troponins were 0.02. The patient does have chronic renal insufficiency. His hematocrit was 27. He was given 1 unit of packed red blood cells. He was transferred to the regular VICU for continued monitoring and care. Postoperative day 1, there were no overnight events. The patient was delined. The diet was advanced as tolerated. He was maintained on bedrest and stayed in the VICU. Postoperative day 2, he continued to tolerate his P.O.'s, low- grade temperature of 100.6 to 98.6, hematocrit was 25.2. Hematology was consulted. They felt that this was an iron deficiency anemia and recommended iron repletion, which he was placed on iron tablets 325 one to two tablets daily. The patient diuresed 1 liter self-diuresis. He was evaluated by physical therapy on postoperative day #3. His vancomycin was discontinued. His Dilaudid was increased for improvement in his analgesic control. Physical therapy felt that the patient could be discharged to home with continued PT at home and home safety evaluation. The patient was discharged to home in stable condition on [**2128-1-13**]. DISCHARGE DIAGNOSES: 1. Right leg claudication, status post right femoral- anterior tibial in situ saphenous vein graft. 2. Preoperative delirium secondary to Ativan, resolved. 3. Anxiety secondary to tobacco dependence, resolved. 4. Postoperative blood loss anemia--transfused. 5. Chronic iron deficiency anemia, started on iron. DISCHARGE INSTRUCTIONS: The patient may ambulate essential distances. He should keep his right leg elevated when sitting in a chair. He may shower but no tub baths. No driving until seen in follow-up. He should continue the nitro patches for smoking cessation, and he has been instructed and warned about smoking and wearing a patch. This could be fatal. He understands this. He should call our office in 2 weeks time for follow-up appointment. If the skin clip areas develop redness, drainage or swelling, or he develops a fever greater than 101.5, he should notify Dr.[**Name (NI) 1392**] office. DISCHARGE MEDICATIONS: Nicotine 14 mg/24h patch daily, gabapentin 800 mg t.i.d., gemfibrozil 600 mg b.i.d., clonidine 0.1 mg tablets at bedtime, Plavix 75 mg daily, pioglitazone 45 mg daily, Lasix 40 mg daily, mirtazapine 15 mg at bedtime, Colace 100 mg b.i.d., Vytorin 10/40 mg tablets 1 daily, olanzapine 2.5 mg at bedtime p.r.n., glargine 10 U/D, Humalog insulin before meals as directed, atenolol 100 mg daily, hydromorphone 2 mg tablets [**12-23**] q.2-4h. p.r.n. for pain, iron 325 mg tablets daily. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2128-1-13**] 09:54:22 T: [**2128-1-13**] 11:16:36 Job#: [**Job Number 55372**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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174,189

50653

Discharge summary

report

Admission Date: [**2124-6-5**] Discharge Date: [**2124-6-13**] Date of Birth: [**2045-1-21**] Sex: M Service: MEDICINE Allergies: Bactrim / Sulfa (Sulfonamide Antibiotics) / Hayfever / Levaquin Attending:[**First Name3 (LF) 30**] Chief Complaint: Right leg swelling and pain Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 79M with a history of ESRD on HD (ANCA-related GN) and DM with recent admission for fever without clear source who presented to the ED with worsening right lower extremity erythema and pain. The patient underwent biopsy a lesion on the dorsum of his right foot in [**2124-4-11**], with residual ulcer formation. Pathology revealed necrotizing vasculitis. The patient reports significant increase in pain and erythema over the dorsal surface of his foot over the last few days since recent discharge. On the day of admission, he visited his podiatrist, who debrided the ulcer. He denies fever, chills, nausea, and vomiting. Of note, the patient had a recent hospitalization from [**Date range (1) **] after presenting with fever and weakness. He was noted to have a mild leukocytosis on admission, but otherwise unremarkable labwork and imaging studies, including a film of his right foot. At the time, his right foot ulcer appeared clean and without drainage, swelling or erythema. After 72 hours of negative blood cultures, his antibiotics (vancomycin) were stopped. Podiatry did not feel that the ulcer site was infected, and recommended f/u with vascular. Initial VS in the ED: 98.7 88 164/79 17 100% RA. On examination, there was a small 0.5 x 0.5 cm ulcer with fibrinous exudate, erythema and warmth over the entire shin, creeping up to just below the patella. Patient was given IV vancomycin 1 g X 1. CXR revealed interval increase in pulmonary edema and a stable L-sided loculated effusion. He was taken to HD directly from the emergency room. On the floor, the patient reports mild shortness of breath. He states his R foot is painful, but redness improved. 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 nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - ANCA vasculitis - ESRD on HD from ANCA-positive glomerulonephritis dx [**2112**], on HD through left arm graft, MWF - Gout - Depression - HTN - Hyperlipidemia - Glaucoma - Diverticulosis - h/o Septic thrombophlebitis - h/o Cellulitis of the right upper extremity - h/o Gastrointestinal bleed secondary to NSAID use - h/o Diverticulitis - s/p Left inguinal hernia repair - LVH - Mitral regurgitation - Pulmonary HTN - chronic anemia - DM2 - asthma - Wegener's granulomatosis Social History: Speaks fluent Spanish and is quite proficient in English. Retired butcher. Lives with wife and oldest daughter. [**Name (NI) **] smoking history. Denies any current alcohol use, or heavy use in the past. No illicit drug use. Family History: Mother with diabetes, kidney disease, CAD. 3 brothers with heart disease, one has had MI. Sister with diabetes. No family history of cancer. Physical Exam: ADMISSION Physical Exam: Vitals: T: 97.8 BP: 156/62 P: 80 R: 18 O2: 98%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes or rhonchi CV: Regular rate and rhythm, normal S1 + S2, 3/6 SEM throughout, no rubs or gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: RLE erythematous from the foot to shin, tender, warm, right foot with dressing in place. No improvement of erythema as demarcated by pen on [**6-5**]. 2+ pitting edema to shin b/l DISCHARGE Physical Exam: Gen: Awake, alert, NAD Heart: RRR, 3/6 systolic murmur Lungs: CTAB Abd: +BS, soft, NT/ND Ext: WWP, no edema. did not see pt on admission, but redness, swelling, warmth not present. ~1.5cm ulcer on right dorsal foot, clean base, no surrounding erythema, no exudate. Pertinent Results: ADMITSSION LABS: [**2124-6-5**] 11:35AM GLUCOSE-106* UREA N-89* CREAT-7.9*# SODIUM-133 POTASSIUM-6.5* CHLORIDE-95* TOTAL CO2-20* ANION GAP-25* [**2124-6-5**] 11:35AM WBC-27.0*# RBC-3.42* HGB-9.9* HCT-32.1* MCV-94 MCH-29.0 MCHC-30.9* RDW-20.0* [**2124-6-5**] 11:35AM PLT SMR-NORMAL PLT COUNT-230 [**2124-6-5**] 11:35AM NEUTS-87* BANDS-7* LYMPHS-3* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2124-6-5**] 11:49AM LACTATE-1.6 DISCHARGE LABS: [**2124-6-13**] 07:40AM BLOOD WBC-7.7 RBC-3.38* Hgb-10.0* Hct-31.2* MCV-92 MCH-29.5 MCHC-32.0 RDW-19.1* Plt Ct-248 [**2124-6-13**] 07:40AM BLOOD Glucose-77 UreaN-36* Creat-4.7*# Na-130* K-4.2 Cl-93* HCO3-26 AnGap-15 [**2124-6-5**] CHEST XRAY: IMPRESSION: Pulmonary edema, bilateral effusions, large and loculated on the left appearing stable, and small right effusion appearing slightly diminished from prior. [**2124-6-5**] R FOOT FILM IMPRESSION: 1. Soft tissue swelling and dorsal ulceration along the mid foot overlapping the cuneiforms. No definite radiographic evidence for acute osteomyelitis. 2. Irregularity involving the base of the fifth proximal phalanx which is stable since the prior study and may represent a subacute fracture. Brief Hospital Course: The patient is a 79M with a history of ESRD on HD (ANCA-related GN) and DM with recent admission for fever without clear source who presented to the ED with worsening RLE cellulitis, improving on IV Vanc and Ceftazidime. Acute issues: # RLE cellulitis and bacteremia: The patient's clinical findings and leukocytosis to 27.0 with bandemia were most suggestive of a soft tissue infection though there was no evidence of systemic toxicity in the form of fevers. Blood cultures grew out pan-sensitive Serratia while would culture from his right foot ulcer grew out both Pseudomonas aeruginosa and Serratia. The patient was treated with Vancomycin and Zosyn for his cellulitis as well as Tylenol for pain; the patient's cellulitis improved significantly with antibiotics and the patient was able to ambulate with assistance. The patient's leukocytosis improved to 9.2 on [**6-9**]. The patient was transitioned to vancomycin and ceftazidime to be administered at future hemodialysis sessions (unable to receive PO Ciprofloxacin given his Levaquin allergy). #Hematochezia: The patient had 8 episodes of BRBPR during this hospitalization. Given the intermittent nature of these episodes, they were may have been due to hemorrhoids although the patient has a history of severe diverticulosis and AVMs. On hospital day 3, the patient experienced further episodes of BRBPR overnight without hypotension or tachycardia. The BRBPR continued into the following day with an episode associated with some dizziness and pre-syncope. NT lavage was attempted, but unable to draw back fluid. He received 2L NS and 2 units pRBCs and was transferred to the ICU for close monitoring. In the ICU, his Hct remained stable at 30 after 2 units prbcs. He did not have any further BRBPR and remained hemodynamically stable throughout. Pt was then transferred to the floor where he passed a large blood clot and received an additional 1 unit red cells. He remained hemodynamically stable and his Hct was stable x >36hrs prior to discharge. GI followed through his discharge. # ESRD on HD: MWF HD schdule. Patient was significantly volume overloaded at admission, but improved with HD. He was placed on strict free water restriction after gaining 6.2 kg body weight on [**6-9**] after his last HD session on [**6-7**]. The patient was continued on his home Nephrocaps and Sevelamer. # Dyspnea: Patient was initially dyspneic at admission due to volume overload in the setting of his ESRD. CXR on [**6-6**] showed significant improvement of his initial pulmonary edema as did his clinical exam. Patient did not report any problems regarding his breathing at discharge. #. p-ANCA Vasculitis: The patient's vasculitis appeared to be cutaneous involvement of Wegener's (small + medium necrotizing vasculitis) per Derm note from 5/[**2123**]. The patient was continued on his home Prednisone 30 mg daily. #. HTN: The patient's hypertension improved on HD. He was continued on his home Labetalol (on non-HD days), Nifedipine, and Valsartan. #. DM2: Patient's DM2 not an active issue. The patient was not on insulin or oral agents at home, but his blood sugars were monitored closely and maintained on an insulin sliding scale given his infection and prednisone use. Per the patient's PCP, [**Name10 (NameIs) **] patient was previously hyperglycemic in the setting of infection and prednisone. Chronic issues: #. Asthma: Stable. The patient was continued on his home Advair and Albuterol/Ipratropium. #. Depression: Stable. The patient was continued on his home Paroxetine. Transitional issues: # IV abx: needed for 14 day total course (started on Ceftaz and Vanco [**6-9**]) # foot ulcer: to see Podiatry w/in 1 week of D/c Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 4. Cyanocobalamin 1000 mcg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 7. Hydrocodone-Acetaminophen (5mg-500mg [**12-13**] TAB PO Q8H:PRN pain 8. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB 9. Labetalol 200 mg PO BID 10. Nephrocaps 1 CAP PO DAILY 11. NIFEdipine CR 30 mg PO DAILY 12. Omeprazole 40 mg PO BID 13. Paroxetine 20 mg PO DAILY 14. PredniSONE 30 mg PO DAILY 15. sevelamer CARBONATE 1600 mg PO TID W/MEALS 16. Simvastatin 20 mg PO DAILY 17. Valsartan 80 mg PO DAILY 18. Loratadine *NF* 10 mg Oral daily Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Serratia bacteremia Polymicrobial cellulitis (Serratia marcescens and Pseudomonas aeruginosa) Discharge Condition: Stable

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icd9cm

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Discharge summary

report

Admission Date: [**2189-4-7**] Discharge Date: [**2189-4-23**] Date of Birth: [**2150-11-25**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Hypotension and Melena Major Surgical or Invasive Procedure: Splenic artery embolization History of Present Illness: 38 y/o M referred from OSH for evaluation of melena and unknown gastric lesion. His symptoms started 3 days prior to admission, when he noted feeling lightheaded with doing regular daily activities. He also noted elevated glucose in 400's. He thinks he began noticing black stools later that evening, which he describes as "coffee-ground" stools. The following day he layed in bed all day, noting increasing orthostasis and continued black BM's. He also noted associated DOE and SOB with even minimal activity. He denies any abdominal pain, but notes mild feelings of nausea with no vomiting. On further ROS he notes some subjective fevers/chills and mild nonproductive [**First Name3 (LF) **], but his wife did not note a fever at home. He notes decreased PO intake and decreased urine output as well. . He presented to his PCP with these [**Name9 (PRE) 19382**] who noted at Hct of 35 but pale appears with a BUN/Cr of 92/2.6 and SBP 80's-90's with HR ~100. He was referred to the ED where he was felt to be severely volume depleted and given several liters of NS and 3U PRBC's overnight. AM Hct was 27.4, and follow-up BUN/Cr improved to 63/1.4. In addition his SBP improved to 110-120 range. AM EGD done by Dr [**Last Name (STitle) 3265**] was notable for a gastric lesion of unclear etiology c/w bleeding leoimyoma vs varix. By report pt had an abdominal u/s notable for a normal portal circulation with a slightly enlarged spleen. He was placed on [**Hospital1 **] PPI and somatostatin. After d/w Dr [**Last Name (STitle) **] he was referred to [**Hospital1 18**] for further evaluation. . On arrival pt states that he feels much improved compared to arrival to OSH. He denies current LH but notes mild thirst. On further history he states that he normally takes Tylenol PM to sleep, but ran out Tylenol PM about 1 week prior to his symptoms. He started taking 2 of Motrin at night in an attempt to help him sleep, which he does not usually take. Past Medical History: 1. Diabetes Mellitus (previously Type 2 diagnosed several weeks before developing severe pancreatitis, insulin depended but no h/o DKA) 2. H/O Pancreatitis in [**2183**], requiring a 4 week hospitalization and s/p cholecystectomy Social History: Pt works in a senior position for a plastics company; he notes a long h/o exposure to chemicals. He has smoked ~1ppd x 3-4 years, was able to quit for 3-4 weeks but then restarted. He notes occasional Etoh use, notes 2 beers a night the past few nights which is unusual for him. Denies h/o IVDA. Lives with his wife and 3 daughters. Family History: Father: DM Mother: HTN Sister: died of cervical cancer Another Sister: thyroid cancer Physical Exam: VS: T=99.3, BP=113/54, HR=81, RR=14, O2=97% on RA GEN: Pt resting comfortably in NAD HEENT: nonicteric, mucosa moist, no LAD CHEST: CTA bilaterally CV: RRR, no murmers ABD: soft, obese, NT, ND, prior CCY scar; rectal exam w/o hemorrhoid, with guiac positive black stools EXT: no LE edema NEURO: AAO x 3, CN's intact, grossly nonfocal Pertinent Results: [**2189-4-7**] 09:56PM WBC-4.3 RBC-3.39* HGB-11.0* HCT-29.1* MCV-86 MCH-32.4* MCHC-37.7* RDW-14.8 [**2189-4-7**] 09:56PM PLT SMR-VERY LOW PLT COUNT-64* [**2189-4-7**] 08:25PM GLUCOSE-83 UREA N-45* CREAT-1.3* SODIUM-143 POTASSIUM-4.5 CHLORIDE-110* TOTAL CO2-26 ANION GAP-12 [**2189-4-7**] 08:25PM ALT(SGPT)-30 AST(SGOT)-68* LD(LDH)-201 ALK PHOS-44 AMYLASE-25 TOT BILI-1.1 [**2189-4-7**] 08:25PM LIPASE-13 [**2189-4-7**] 08:25PM ALBUMIN-3.3* CALCIUM-8.0* PHOSPHATE-3.4 MAGNESIUM-1.2* [**2189-4-7**] 08:25PM PT-14.2* PTT-20.5* INR(PT)-1.3* ECG: Sinus bradycardia with borderline 1st degree A-V block Lateral T wave changes are nonspecific Intervals Axes Rate PR QRS QT/QTc P QRS T 42 214 82 448/386.86 39 48 24 CXR: Right costophrenic angle is not included within the film view. The heart size is normal. No mediastinal or hilar enlargement is present. Lungs are clear. No pneumothorax or pleural effusion is seen. IMPRESSION: Normal chest x-ray. CT abdomen: 1. Occlusion of the splenic vein and a focal area of the superior mesenteric vein leading to venous shunting and significant formation of splenic and gastric varices. The main portal vein and hepatic veins appear patent. No esophageal varices are identified. 2. Splenomegaly. 3. 6.8-cm cystic structure with peripheral calcification in the region of the pancreas which may represent a pseudocyst, although a focal mass cannot be entirely excluded. 4. Hypoattenuating lesions within the apex of the left kidney which are too small to characterize likely reflecting simple cysts. Nonobstructing punctate calculus is also identified within the left kidney. 5. Fused left SI joint. LENI: Normal compressibility, augmentation, respiratory variation, where appropriate within the deep veins of the left upper extremity. Particularly, the left internal jugular vein, subclavian vein, axillary vein are patent. There is no evidence of subclavian vein thrombosis. Venogram: 1) Portal venogram demonstrating high-grade stenosis of the superior/proximal superior mesenteric vein (SMV), with a pressure gradient of 17 mm Hg across the stenosis. 2) Multiple large varices; one bypassing the tight stenosis from the inferior portion of the SMV to the main portal vein, the remainder draining the extensive gastric variceal system in the left upper quadrant. 3) Nonvisualization of the splenic vein and inferior mesenteric vein. 4) After discussion with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1924**], a decision was made again stenting or other intervention at this time, and the 23 cm-long, 5-French [**Last Name (un) 2493**]-Tip sheath was left in place with its distal tip in the main portal vein and attached externally to heparinized saline pressure bag. IR guided stent placement: Successful placement of 14 x 40 mm SMART stent dilated to 12 mm, spanning from the inferior portion of the main portal vein to the superior portion of the SMV. Post-stent venogram demonstrated good flow throughout the stent and no residual venous pressure gradient. Abdominal ultrasound: The portal vein is patent with hepatopetal flow. The SMV stent cannot be directly visualized secondary to significant bowel gas. However, the SMV is visualized proximal to the stent and flow is patent. Since flow is demonstrated proximal and distal to the site of the stent, we infer the stent itself to be patent. IMPRESSION: Inferred patency of SMV stent though not directly visualized. Brief Hospital Course: A/P: 38 y/o M referred from OSH with recent h/o orthostatis, resoloving ARF, and unclear gastric lesion c/w varix or tumor. . 1. Gastric lesion/melena - Endoscopy revealed multiple isolated gastric varices. As it is unusual to develop isolated gastric varices, splenic vein throbosis must be more closely evaluated in a patient with a known h/o cirrhosis or portal hypertension. After speaking with Dr [**Last Name (STitle) 50933**] from GI, an abdominal CT was performed on the evening of admission to evaluate for splenic vein throbosis as this would be a superior study to abd u/s. The Abdominal CT was read as positive for splenic vein thrombosis with gastric varices as well as splenomegaly. In addition, the abd CT also found from AVM in the chest as well concerning for a subclavian stenosis/thrombosis. 3 peripheral IVs (18, 20, 20 gauges) were placed in the pt. The pt was started on supportive management with IVF's, serial Hct's, [**Hospital1 **] PPI, and somatostatin therapy. As he continued to have BRBPR, PRBCs and FFP were transfused. GI recommended surgical evaluation for possible splenectomy as there is no GI intervention that would resolve the underlying issue. A swan ganz catheter was floated from the femoral vein to measure the pressures in the portal system to determine if the patient had portal hypertension as well. It showed a gradient of 6 from the hepatic vein to the wedge, which is not consistent with hypertension. Surgery was reluctant to intervene as the operative mortality is high (up to 10%) for splenectomy in a patient with multiple collaterals in the mesentary and omentum. Instead, a venography was performed which showed a high grade stenosis in the SMV. At this point, it was thought that relieving this obstruction could be the definitive therapy for the gastric varices. IR placed a stent in the SMV. The patient was not initially anticoagulated as he continued to have blood in his BMs. . 2. DM - With the patient's history it is difficult to tell if he is a type II or if became type I after the onset of severe pancreatitis. Glucose management became difficult given his NPO status and somatostatin use. He was placed on a sliding scale with lantus 30units QAM (55units QAM and Actos (Pioglitazone) at home). This was too high as the patient became hypoglycemic with FS in the 50's since he was NPO. He was instead given D50 and the lantus was stopped. 3. ARF - Given his h/o hypotension at the OSH and poor PO intake and decreased urine output, his ARF appears to be pre-renal in nature. His Cr appears to have significantly improved with IVF's and PRBC's. His elevated BUN is likely related to his UGIB. Given his DM and recent ARF, he was prehydrated him with bicarb and Mucomyst prior to IV contrast for his abd CT and for his IR procedures. . 4. HYPOTENSION - Now resolved, appears to be related to UGIB and vokume depletion. Given his c/o subjective fevers/chills and nonproductive [**Last Name (LF) **], [**First Name3 (LF) **] check CXR, UA, and BC's to look for evidence of infection as well. ABOVE IS THE BRIEF HOSPITAL INTERNAL MEDICAL NOTE. BELOW IS THE SURGICAL BRIEF HOSPITAL NOTE. Upon Consult, the patient Hct was observed for a few days. A decision was made to embolize the splenic artery, allow the spleen to be infarcted, and have the patient come back to for surgery a few weeks later to remove the spleen as well as an exploratory laparotomy to further evaluate the region around the splenic vein thrombosis. At time of discharged, the patient had been stable for several days without having to require a transfusion. He was discharged in stable condition with specific instructions for post-hospital care, as well as, follow-up. Medications on Admission: ALLERGIES: NKDA . MEDICATIONS AT ADMISSION: 1. Ibuprofen prn, 2 tabs at night 2. Lantus 55U QAM 3. Humalog ISS 4. Actos 15mg QD 5. Zetroretic (? antihypertensive) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: Please do not take while taking percocet. Disp:*40 Tablet(s)* Refills:*0* 2. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Pioglitazone 15 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*14 Tablet(s)* Refills:*0* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Bleeding gastric varices Superior mesenteric vein thrombosis Diabetes Mellitus Gout Discharge Condition: Good Discharge Instructions: Please call or return if you have fever >101, feel lightheaded, persitent nausea or vomiting, bloody vomiting, have bloody diarrhea or stools, abdominal pain, fatigue, chest pain, shortness of breath, bleeding or drainage around wounds, severe pain, or anything else that causes you concern. Please Ice and rest your left knee, if it get inflammed or pain worsens please call Rheumatology for an appointment - ([**Telephone/Fax (1) 25330**] Please return next week for scheduled surgery. Please restart your preadmission medications except for your blood pressure medications Followup Instructions: Please follow up for your vision with the outpatient ophthalmology clinic at [**Telephone/Fax (1) 66556**]. Please come in next Thursday ([**4-30**]) for your surgery - Dr. [**Name (NI) 60612**] office will call you with the time ([**Telephone/Fax (1) 2363**] Completed by:[**2189-5-1**]

[ "289.51", "287.4", "578.1", "456.8", "584.9", "305.1", "557.0", "274.0", "458.9", "250.80", "403.91", "289.59", "577.2", "285.1", "377.02", "368.8", "459.2" ]

icd9cm

[ [ [] ] ]

[ "45.13", "39.79", "89.64", "99.15", "39.50", "99.07", "88.64", "39.90", "99.04", "00.45", "00.40", "38.93", "88.49", "81.91" ]

icd9pcs

[ [ [] ] ]

11603, 11609

6919, 10634

336, 366

11737, 11744

3440, 6896

12369, 12659

2983, 3070

10853, 11580

11630, 11716

10660, 10830

11768, 12346

3085, 3421

274, 298

397, 2358

2380, 2613

2632, 2967

60,969

148,373

42205

Discharge summary

report

Admission Date: [**2118-8-19**] Discharge Date: [**2118-8-29**] Date of Birth: [**2041-9-23**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pressure Major Surgical or Invasive Procedure: [**2118-8-22**] 1. Coronary bypass grafting x 2 with left internal mammary artery to the left anterior descending coronary artery; reverse saphenous vein single graft from aorta to distal right coronary artery. 2. Full left-sided Maze procedure with a combination of Atricure bipolar system and the CryoCath with resection of left atrial appendage. History of Present Illness: 76 yo female with hx PAF and CHF who is status post 2 previous electrical cardioversions presented [**8-14**] to OSH with chest presssure under bilateral breasts. She had an echo performed [**2117-4-22**] which showed concentric LVH with EF 47% [**Location (un) 109**] 1.8 cm 1+ AI, 1+ TR. Last cardioversion was done [**2117-9-22**]. She presented to OSH on Sun with chest pressure which developed at rest. She had not taken Lasix for 4 days prior to presentation. She was found to be in RAF in the ED, was started on Diltiazem gtt and Lasix 80 IV BID. She was cath'd [**8-18**] and found to be have 3 vessel CAD. Transferred to [**Hospital1 18**] for CABG/MAZE. Past Medical History: Atrial fibrillation Hypertension Hyperlipidemia Obesity History of cellulitis bilateral lower extremities last year Social History: Race: Caucasian Last Dental Exam: 2 years ago, per patient she was told she needs tooth extracted from upper left Lives with: Husband, [**Name (NI) **] Contact: [**Name (NI) **] Occupation: Retired lobbyist for the [**Location (un) 3844**] Police Association Cigarettes: Smoked no [] yes [x] last cigarette 14 years old Other Tobacco use: ETOH: < 1 drink/week [] [**2-7**] drinks/week [x] >8 drinks/week [] Illicit drug use - none Family History: No premature coronary artery disease Father MI < 55 [] Died in 70's MI Mother < 65 [] Died in 70's from Rheumatic fever Physical Exam: T 98.5 Pulse: 93 AF Resp:18 O2 sat:2L 94% B/P Right: 108/79 Left: Height:5'5" Weight: 297# General: AA) x 3 in NAD Skin: Dry [] intact [] Chronic lower extremity changes bilaterally HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Distant breath sounds Heart: RRR [] Irregular [x] Murmur [II/VI SEM] Distant heart sounds Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Obese Extremities: Warm [x], well-perfused [x] Edema trace LE edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:1+ Left:1+ DP Right:1+ Left:1+ PT [**Name (NI) 167**]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right:none Left:none Pertinent Results: [**2118-8-19**] Vein Mapping: The right greater saphenous vein is patent throughout with the caliber of 0.33 to 0.46 in the thigh and 0.30 to 0.37 in the calf. The left greater saphenous vein is also patent with a caliber ranging from 0.34 to 0.54 in the thigh and 0.26 to 0.31 in the calf. [**2118-8-19**] Carotid U/S: 1. No significant carotid artery stenosis bilaterally. 2. Mild atherosclerotic plaques in the carotid bulbs and internal carotid arteries bilaterally. [**2118-8-22**] Echo: PRE-BYPASS: Moderate to severe spontaneous echo contrast is seen in the body of the left atrium. Moderate to severe spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). A left atrial appendage thrombus cannot be excluded. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is mild regional left ventricular systolic dysfunction with basal and mid inferoseptal and inferior wall hypokinesis. Overall left ventricular systolic function is moderately depressed (LVEF= 35-45 %). The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Trivial mitral regurgitation is seen. There is a small pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results at time of surgery. POST-BYPASS: The patient is on an epinephrine infusion. The patient is now A-paced. Inferoseptal and inferior wall hypokinesis is still present, though slightly improved from pre-bypass exam. Estimated EF is 45%. Right ventricular function is unchanged. Mild aortic regurgitation is seen. Mild aortic stenosis is unchanged. Trivial mitral regurgitation is seen. The ascending aorta, aortic arch, and descending thoracic aorta are intact. [**2118-8-29**] 08:50AM BLOOD WBC-12.0* RBC-3.66* Hgb-10.1* Hct-30.9* MCV-84 MCH-27.5 MCHC-32.5 RDW-16.0* Plt Ct-310 [**2118-8-19**] 05:17PM BLOOD WBC-9.6 RBC-4.99 Hgb-13.5 Hct-40.1 MCV-80* MCH-27.1 MCHC-33.7 RDW-15.0 Plt Ct-294 [**2118-8-29**] 08:50AM BLOOD PT-22.5* INR(PT)-2.1* [**2118-8-29**] 08:50AM BLOOD UreaN-36* Creat-0.9 Na-139 K-4.5 Cl-99 [**2118-8-19**] 05:17PM BLOOD Glucose-133* UreaN-35* Creat-1.2* Na-139 K-4.0 Cl-92* HCO3-40* AnGap-11 [**2118-8-25**] 01:51AM BLOOD ALT-10 AST-36 AlkPhos-66 TotBili-3.1* Brief Hospital Course: Mrs. [**Known lastname **] was transferred to [**Hospital1 18**] for surgical evaluation. Upon admission she received medical management and underwent pre-operative work-up. She was brought to the operating room on [**8-22**] where she underwent a coronary artery bypass graft x 2 with left internal mammary artery to the left anterior descending coronary artery; reverse saphenous vein single graft from aorta to distal right coronary artery/ Full left-sided Maze procedure with a combination of Atricure bipolar system and the CryoCath with resection of left atrial appendage.CARDIOPULMONARY BYPASS TIME: 115 minutes. CROSS-CLAMP TIME: 95 minutes. Please see operative report for further surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. She arrived intubated, on propofol, levo, epi and was a-paced over SB 40's for optimal cardiac function. Sedation was weaned,she was found to be neurologically intact and extubated without incident that postop night. Pressors were slow to wean off as she was acidotic, requiring blood, and epi was discontinued. Dobutamine was added for continued hemodynamic support. Betablocker was initially held due to hypotension and bradycardia. Once pressors and inotropy were weaned off by POD#4 Coreg and Digoxin were started. Amiodarone was initiated for MAZE and post-op rapid a-fib. Mrs[**Last Name (un) 91505**] heart rate and hypotension improved. An Ace was added but she became hypotensive and was discontinued. She continued to progress and on [**8-26**] she transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. Anticoagulation was initiated for postoperative AFib/MAZE. Gynecology was consulted due to persistent vaginal discharge. She had initially been consulted by gyn preop and a dose of Diflucan was given, however the micro resulted in nonfungal organisms. She was placed on Metronidazole po x 7 days per gynecology. The remainder of her hospital course was essentially uneventful. She was cleared for discharge to [**Hospital3 **] in [**Hospital1 3597**] on POD# 7. All follow up appointments were advised. Medications on Admission: Calcium 1500 mg po daily Coumadin 4 mg alternating with 5 mg (Tues, Friday only) Lasix 40 po daily - skips occassionally Lisinopril 20 mg daily Metoprolol 12.5 mg [**Hospital1 **] Zocor 20 mg daily Discharge Medications: 1. potassium chloride 10 mEq [**Hospital1 8426**] Extended Release Sig: Two (2) [**Hospital1 8426**] Extended Release PO BID (2 times a day). 2. amiodarone 200 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO TID (3 times a day) for 3 days: then decrease to 200mg [**Hospital1 **] x 1 week then 200mg po daily until seen by cardiologist. 3. warfarin 1 mg [**Hospital1 8426**] Sig: as directed [**Hospital1 8426**] PO DAILY (Daily) as needed for AFib. 4. calcium carbonate 200 mg calcium (500 mg) [**Hospital1 8426**], Chewable Sig: One (1) [**Hospital1 8426**], Chewable PO DAILY (Daily). 5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for groin and skin folds. 6. senna 8.6 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a day). 7. simvastatin 10 mg [**Hospital1 8426**] Sig: Two (2) [**Hospital1 8426**] PO DAILY (Daily). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. ranitidine HCl 150 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily). 10. aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1) [**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily). 11. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): per sliding scale. 12. digoxin 250 mcg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO once a day. 13. carvedilol 6.25 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a day). 14. metronidazole 500 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a day) for 7 days. 15. furosemide 40 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a day). 16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing. 17. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 19. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 20. warfarin 1 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] once a day: INR goal >2 for AF/MAZE/LAA ligation. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x 2 Atrial fibrillation s/p MAZE procedure Past medical history: Hypertension Hyperlipidemia Obesity History of cellulitis bilateral lower extremities last year Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema +1 bilaterally 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) 914**] on [**2118-10-4**] at 1pm Cardiologist: Dr.[**Name (NI) 68097**] office will call to arrange appointment Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 1492**] in [**4-5**] 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:[**2118-8-29**]

[ "623.5", "707.22", "788.5", "272.4", "V70.7", "401.9", "V85.42", "278.00", "V58.61", "511.9", "427.31", "428.0", "V43.65", "707.09", "458.29", "285.9", "411.1", "695.89", "788.29", "599.0", "041.85", "276.2", "428.20", "414.01" ]

icd9cm

[ [ [] ] ]

[ "37.36", "36.15", "36.11", "39.61" ]

icd9pcs

[ [ [] ] ]

10610, 10657

5770, 7970

324, 674

10918, 11159

2887, 5747

12082, 12586

1971, 2093

8218, 10587

10678, 10778

7996, 8195

11183, 12059

2108, 2868

270, 286

702, 1367

10800, 10897

1522, 1955

14,492

124,519

29474

Discharge summary

report

Admission Date: [**2164-12-22**] Discharge Date: [**2165-3-21**] Date of Birth: [**2138-4-14**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3705**] Chief Complaint: ED admit to [**Hospital Unit Name 153**] for status epilepticus Major Surgical or Invasive Procedure: A-line placement Endotrachial tube placement NG tube placement History of Present Illness: 26yo woman with polysubstance abuse who is transferred from [**Hospital **] Hospital for status epilepticus, admitted to the [**Hospital Unit Name 153**] intubated for further evaluation. As patient is unable to answer questions on admission, history obtained by prior records and discussion with family. Per pt's sister's, pt was in USOH, without complaining of fevers, chills, headaches, or other symptoms. Of note they report that she has been having cocaine induced "seizures" over the past year but never sought medical attention. Pt was with her father on day of admission to OSH, when he reports that he heard a noise, and found her on the floor of the bathroom shaking, with blood tinged "foam" in her mouth. Cocaine and heroin were found at the site, with the needle still present. The shaking activity continued intermittently. EMS arrived after about 20 minutes at which time she was intubated for airway protection. She was brought to OSH and received ativan 6mg, was loaded on fosphenytoin 1gram and PB 500mg. Her pupils were fixed and dilated. She was febrile (103) and her tox screen was positive for benzo, cocaine, methadone and cannabis. To obtain a head CT, she received vecuronium as she was apparently still seizing. Head CT was read as normal. She was on pressors for a short time for hypotension. . [**Hospital1 18**] ED course: She was med-flighted; VS on arrival 102.3, HR 200s, 100/40, intubated. Tylenol, vanco, CTX given; started on versed gtt. NS bolus 1.25 liters; acyclovir 600mg IV x 1. . [**Hospital Unit Name 153**] course: LP obtained without meningitis. Pt was followed by the neurology team who initially felt that her seizures were due to substance toxicity, however, after review of EEG, felt that there may be an aspect of epileptiform changes. She was initially on broad spectrum antibiotics, but after CSF showed no meningitis and all other cultures remained negative, these were discontinued. Of note, cxr on [**12-24**] was consistent with an aspiration pneumonia vs. pneumonitis. She was never febrile after this, and wbc count remained normal, and so antibiotics were not re-started. . Her hemodynamics stabilized and the patient was transferred to the floor for further management. Past Medical History: - one febrile childhood seizure (age 2; chickenpox) - seizures after shooting cocaine (during the past year) - hep C for few years - s/p C-section 4wks ago; baby was addicted - three pregnancies Social History: + heroin, intravenous cocaine, smoking, oxycontin Recent time spent in jail for one week, released [**2164-12-18**] (unclear which charges--mostly drug related and shoplifitng) Three children with three fathers [**Name (NI) 32007**] 4 weeks ago Currently without a home; stays at others' places or on the street Family History: Family History: - nephew with seizures - no sudden death - both parents with etoh abuse Physical Exam: VITALS: T102.3 HR144 BP116/81 RR15 sO295 GEN: intubated, feels warm, sedated HEENT: mmm; PERRL, mildly injected, unable to assess oropharynx NECK: in hard collar, trachea midline, no LAD LUNGS: Coarse breath sounds bilaterally, no wheezes HEART: Regular rate and rhythm, normal S1 and physiologically split S2, no murmur or rub ABDOMEN: normal bowel sounds, soft, nontender, nondistended; scar of C-section looks clean; some vaginal bleeding EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema; no petechial rash or vesicular rash MENTAL STATUS: intubated; currently not on any sedatives (but s/p ativan, fosphenytoin, PB and vecuronium-this was given 1.5 hr prior to this exam). Not responding to voice or noxious. CRANIAL NERVES: II: no blink to threat. PERL 2.5-->2 mm. . Disc margins sharp, no pappilledema. III, IV, VI: No dolls. No rooving eye movements. Eyes midline, no skew. V: No corneals or response to nasal tickle VII: Face symmetrical VIII: - IX: no gag XII: - [**Doctor First Name 81**]: - MOTOR SYSTEM: Normal bulk. Tone flaccid. No adventitious movements, no tremor, no clonus. No spontaneous movements and no response to noxious. SENSORY SYSTEM: No response to noxious REFLEXES: Absent DTS's Toes: mute bilaterally. COORDINATION: deferred GAIT: deferred Pertinent Results: [**2164-12-22**] 04:11PM GLUCOSE-87 UREA N-8 CREAT-0.7 SODIUM-141 POTASSIUM-3.2* CHLORIDE-118* TOTAL CO2-15* ANION GAP-11 [**2164-12-22**] 04:11PM CK(CPK)-8901* [**2164-12-22**] 04:11PM CALCIUM-7.4* PHOSPHATE-3.1 MAGNESIUM-1.7 [**2164-12-22**] 04:11PM WBC-9.4 RBC-4.09* HGB-12.1 HCT-34.0* MCV-83 MCH-29.6 MCHC-35.5* RDW-13.3 [**2164-12-22**] 04:11PM PLT COUNT-223 [**2164-12-22**] 12:13PM FDP-40-80 [**2164-12-22**] 11:25AM WBC-11.8* RBC-4.36 HGB-12.9 HCT-37.0 MCV-85 MCH-29.5 MCHC-34.8 RDW-13.3 [**2164-12-22**] 11:25AM PLT COUNT-265 [**2164-12-22**] 07:12AM GLUCOSE-102 UREA N-12 CREAT-0.8 SODIUM-145 POTASSIUM-3.4 CHLORIDE-120* TOTAL CO2-15* ANION GAP-13 [**2164-12-22**] 07:12AM ALT(SGPT)-47* AST(SGOT)-109* LD(LDH)-544* CK(CPK)-5311* ALK PHOS-51 AMYLASE-403* TOT BILI-0.2 [**2164-12-22**] 07:12AM LIPASE-74* [**2164-12-22**] 07:12AM CK-MB-75* MB INDX-1.4 cTropnT-<0.01 [**2164-12-22**] 07:12AM ALBUMIN-3.4 CALCIUM-6.4* PHOSPHATE-2.0*# MAGNESIUM-2.2 [**2164-12-22**] 07:12AM PT-15.4* PTT-31.9 INR(PT)-1.4* [**2164-12-22**] 07:12AM FIBRINOGE-202 D-DIMER-4206* [**2164-12-22**] 05:28AM TYPE-ART TEMP-37.3 RATES-20/2 TIDAL VOL-500 PEEP-5 O2-60 PO2-138* PCO2-27* PH-7.31* TOTAL CO2-14* BASE XS--11 -ASSIST/CON INTUBATED-INTUBATED [**2164-12-22**] 02:45AM CEREBROSPINAL FLUID (CSF) PROTEIN-43 GLUCOSE-112 [**2164-12-22**] 02:45AM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-0 POLYS-0 LYMPHS-82 MONOS-18 [**2164-12-21**] 11:40PM PHENOBARB-8.9* PHENYTOIN-17.4 [**2164-12-21**] 11:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-POS tricyclic-NEG [**2164-12-21**] 11:40PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG cocaine-POS amphetmn-NEG mthdone-POS [**2164-12-21**] 11:40PM WBC-12.9* RBC-4.52 HGB-13.5 HCT-38.5 MCV-85 MCH-29.9 MCHC-35.0 RDW-13.3 [**2164-12-21**] 11:40PM NEUTS-77.3* LYMPHS-17.7* MONOS-3.3 EOS-1.4 BASOS-0.4 [**2164-12-21**] 11:40PM PLT COUNT-387 . [**2164-12-22**] CXR: ET tube 4cm above carina. No clear infiltrate or effusion. . [**2164-12-22**] CT Head: No evidence for hemorrhage, mass effect, or acute ischemic changes. Please note that MRI is more sensitive in the detection of acute ischemia. Bilateral air fluid levels in the maxillary sinuses may be secondary to intubation, however, could also represent acute sinusitis . [**2164-12-22**] CT Cspine: No fracture or dislocation . [**2164-12-22**] CT Chest, Abd, Pelvis: (wet read) 1. Probable aspiration left upper lung lobe vs consolidation; 2. mildly dilated fluid filled loops of small and large bowel throughout abd/pelvis; 3. peri-portal vein edema which can be a CT sign of liver disease; 4. Enlarged uterus c/w post-partum hx; 5. Cholelithiasis without evidence for cholecystitis. . [**12-22**] EEG IMPRESSION: This is an abnormal EEG. The first abnormality of bilateral central sharps is consistent with cortical irritability in these regions. Abnormality number two of a posterior low voltage activity may suggest a subcortical reason in the posterior regions bilaterally. Further evaluation with imaging and clinical correlation would be suggested. The generally slowed background and suppressed background would be suggestive of medication effect. If clinical suspicion for seizures remains, intermittent EEGs or bedside telemetry would be suggested. . [**12-24**] CXR IMPRESSION: AP chest compared to [**12-21**] through 26: Mild vascular congestion and small regions of peribronchial opacification have developed at the lung bases since [**12-23**] and may represent volume overload and early pneumonia, respectively. Heart is normal size. Pleural effusion, if any, is on the right and minimal. No pneumothorax. ET tube tip at the thoracic inlet. Nasogastric tube looped in the stomach. . [**12-27**] EEG IMPRESSION: Minimally abnormal EEG due to the occasional generalized slowing in wakefulness. This suggests a disturbance in midline structures but is not specific with regard to etiologies. Some might even be due to drowsiness, possibly in turn the sign of a mild encephalopathy. Nevertheless, the background rhythm reached normal frequencies at times, and there were no areas of focal slowing or any epileptiform features. . [**12-31**] CT head FINDINGS: There is no intracranial hemorrhage, hydrocephalus, or acute territorial infarction. There is no mass effect or shift of the normally midline structures. The visualized orbits, paranasal sinuses, and osseous structures are unremarkable. IMPRESSION: Normal non-contrast head CT. . [**12-31**] CXR The heart is normal in size. The mediastinal and hilar contours are normal. The pulmonary vascularity is normal. The lungs appear clear. There are no pleural effusions. The soft tissues and osseous structures are unremarkable aside from mild thoracic scoliosis. IMPRESSION: No evidence of pulmonary infiltrates. . [**12-31**] Upper arm U/S FINDINGS: In the left upper arm medially, there is a subcutaneous collection measuring 1.3 x 0.7 x 1.2 cm with well-defined margins, without vascularity, but with echogenic debris within it. In the mid upper arm, there is a 1.1 x 1.5 x 0.7 cm thick-walled noncompressible collection without vascularity. IMPRESSION: Two subcutaneous nodules as described above, which confirm the palpatory findings. . [**1-2**] Video Swallow FINDINGS: Barium of varying consistencies was administered to the patient under fluoroscopic guidance in conjunction with the speech pathologist. There was no evidence of aspiration with any consistency barium. The exam was otherwise unremarkable. Please refer to the speech and swallow pathologist report for full details and recommendations. IMPRESSION: No evidence of aspiration. . Brief Hospital Course: Ms. [**Known lastname 70746**] is a 26 female with history of polysubstance abuse who has suffered anoxic brain injury on account of drug-induced seizures. Pateint required ICU stay and prolonged hospital stay for management of social issues. . [**Hospital Unit Name 13533**]: Her Status Eiplipticus stopped after dilantin load. She was continued on dilatin per neurology as she was thought to be prone to seizures from childhood febrile seizure. Her mental status remained depressed, with slurred speech, thought to be from expected prolonged post-ictal state [**3-1**] status. Social work was also consulted for polysubstance abuse. Her transaminitis was thought to be [**3-1**] massive drug use, and trended down with IV fluids. Hepatits labs pending. Patient was extubated without event and her new baseline functional status is likely secondary to anoxic brain injury sustained during seizures. . # Thrombocytosis: Resolved. Likely due to a systemic inflammatory response from prolonged seizure. Could also have been due to inflammation from hypoxic encephalopathy. . # Hypoxic encephalopathy: Improvement from admission, although patient has suffered anoxic brain injury thus limiting her ADLs. She has been seen by Speech Pathology and has had improvement in ability to speak. Patient also evaluated by Neuropsychology and will require outpatient behavior neurology evaluation as per her Discharge Plan. Patient seen by OT in house and patient has progressed. She will require intensive OT as an outpatient. She was also seen by Speech Therapy and also improved in her ability to articulate simple words. . # Seizures: Now resolved. Most likely secondary to cocaine use, given pt's history of cocaine-induced seizures. No further seizures since admission. EEG showed central irritable focus (thus ? predisposed to seizure) and MRI/MRA head normal. Patient to follow-up with behavioral neurology as an outpatient. . # Psychosocial: Difficult family dynamics, although father has been made offical guardian. She will be returning home with her brother and sister-in-law. . # Transaminitis: Resolved. Likely secondary to hypotension in setting of status epilepticus superimposed on underlying HepB sAb and cAb positive. [**Last Name (un) **] negative. Hepatic function remained normal throughout the remainder of the hospital course. . # Polysubstance abuse: Strong history of abuse involving cocaine/heroin/cannibis. Patient did not experience withdrawal symptoms while on the floor. . # Possible suicide attempt prior to admission: Psychiatry evaluated patient and believe that she is not at current risk for suicidal gestures given her poor functional status and greatly diminished executive function. . . Her hospital course on the floor was a prolonged stay that was propagated by the social and insurance situation surrounding her discharge. During the stay that was in excess of 80 days was remarkable for improvement in both her speech and able to interact with others. She was medically stable and at one time was treated with an anti-fungal for vaginal pruritus. Labs were not drawn towards the end of her hospital stay and there were no concerns that was she not medically stable. . After discussion with the patient and the medical staff, all were in agreement that [**Known firstname 27414**] [**Known lastname 70746**] was a suitable candidate for discharge. Medications on Admission: Methadone 120mg [**Name (NI) 244**] (unclear, don't know who prescribed this or if getting it from a friend) Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 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. Outpatient Occupational Therapy Patient with anoxic brain injury who will require intensive Occupational Therapy. 5. Outpatient Speech/Swallowing Therapy Patient with anoxic brain injury who will require intensive Speech Therapy. Discharge Disposition: Home Discharge Diagnosis: Status epilepticus Thrombocytosis Hypoxic Encephalopathy Aspiration pneumonitis Rhabdomyolysis Polysubstance Abuse Transaminitis Discharge Condition: Hemodynamically stable. Ambulatory with assist. Discharge Instructions: Please take all medications as instructed. There were several changes made to your current medications regimen. . If you experience any fever, nausea, vomiting, lightheadedness, chest pain, shortness of breath, or any other concerning symptoms please seek medical attention immediately. Followup Instructions: Please make a follow-up appointment with a primary care doctor within the next 2 weeks. . Please make appointment with behavior neurology 2 weeks after you have been discharged. Ask for Dr. [**Last Name (STitle) **] [**Name (STitle) **] who saw you when you were at the hospital. His number is [**Telephone/Fax (1) 1690**]. Tell secretary that Dr. [**Last Name (STitle) **] saw you when you were at the hospital. . You will also need Occupational Therapy and Speech Therapy. Completed by:[**2165-3-26**]

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icd9cm

[ [ [] ] ]

[ "03.31", "38.91", "96.71" ]

icd9pcs

[ [ [] ] ]

14465, 14471

10358, 13755

380, 445

14644, 14694

4676, 6692

15030, 15539

3291, 3364

13914, 14442

14492, 14623

13781, 13891

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3930, 4100

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109,308

18516

Discharge summary

report

Admission Date: [**2197-9-3**] Discharge Date: [**2197-9-12**] Service: FENARD ICU HISTORY OF PRESENT ILLNESS: Eighty-year-old male admitted [**9-3**] for nausea, vomiting, and diarrhea. Apparently had been on Augmentin in the past for foot infection. Upon arrival to the ED found to be hypotensive, but responding to IV fluids. Started on Vancomycin, levofloxacin, and Flagyl. Admitted to the floor, where he had a relatively uncomplicated course for the first few days. Stool came back positive for Clostridium difficile and he was treated for that. On [**9-9**] p.m., patient became acutely confused and had declining mental status. Gas drawn at the time revealed a pH of 7.17 believed to be related to metabolic acidosis. Also found to be hypotensive at the same time. He was intubated for continued respiratory acidosis. Was started on Dopamine and transferred to the Intensive Care Unit. PAST MEDICAL HISTORY: 1. CAD status post CABG. 2. Ischemic cardiomyopathy with an EF of 20-30% with severe MR. 3. Dual lead pacemaker. 4. Chronic renal failure. 5. Right hip repair in [**Month (only) 216**] of this year. 6. Left cataract surgery. MEDICATIONS UPON TRANSFER: 1. Levofloxacin 250 p.o. q.d. 2. Vancomycin 500 mg q 4 hours. 3. Zofran. 4. Bumex 2 p.o. b.i.d. 5. Senna. 6. Colace. 7. Atrovent. 8. Albuterol. 9. Digoxin 0.25 Monday and Friday. 10. Metoprolol. 11. Flagyl 500 p.o. t.i.d. 12. Trazodone. 13. Zocor. 14. Flomax. 15. Enalapril 10 mg p.o. q.d. 16. Neurontin 300 mg p.o. q.d. 17. Lopressor 12.5 mg p.o. b.i.d. PHYSICAL EXAM UPON ARRIVAL TO THE ICU: Weight 57 kg. Temperature 98. Blood pressure 120/40. Heart rate of 80. General: Sedated and intubated. Fair air movement with crackles throughout. Unable to appreciate JVD. S1, S2, [**1-19**] holosystolic murmur. Abdomen is soft, nontender, and nondistended, normoactive bowel sounds. Extremities reveal profound anasarca. LABORATORIES ON ADMISSION: Significant for a white count of 11.2, hemoglobin 31, platelets 150, creatinine of 2.8. BRIEF HOSPITAL COURSE: Patient is admitted to the Intensive Care Unit in the context of hypotension, metabolic acidosis. This was believed to be due to an overwhelming infection and he was volume resuscitated. However, continuing volume resuscitation, probably led to worsening of his congestive heart failure. His creatinine continued to rise leading to a value of 3.0. He was eventually extubated, and was able to maintain decent oxygenation. On the night of [**9-11**], the patient developed new episodes of hypotension. At the same time, his sputum was growing Staphylococcus aureus. He was on broad-spectrum antibiotics throughout hospital stay including Vancomycin, ceftazidime, levofloxacin, and Flagyl. Patient initially responded to dopamine, but as the day progressed and particularly [**9-12**], he had continuous episodes of hypotension not responding to IV fluids. He was started on dopamine as well as norepinephrine with very minimal effect. At this point, he suffered an asystolic arrest, and despite resuscitative efforts, he expired around 10 a.m. on [**9-12**]. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981 Dictated By:[**Name8 (MD) 5094**] MEDQUIST36 D: [**2197-9-12**] 13:43 T: [**2197-9-13**] 09:13 JOB#: [**Job Number 50889**]

[ "424.0", "428.0", "276.4", "707.0", "428.23", "038.9", "276.5", "008.45", "410.71" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "86.22", "96.04" ]

icd9pcs

[ [ [] ] ]

2058, 3342

122, 914

1945, 2034

936, 1930

63,053

176,922

5843

Discharge summary

report

Admission Date: [**2145-12-7**] Discharge Date: [**2145-12-13**] Date of Birth: [**2081-11-5**] Sex: M Service: SURGERY Allergies: Demerol / Haloperidol / Ativan Attending:[**First Name3 (LF) 668**] Chief Complaint: HCV/HCC here for liver transplant Major Surgical or Invasive Procedure: [**2145-12-7**] liver transplant [**2145-12-10**] L ear helix biopsy History of Present Illness: 64 y/o male who presented for liver transplant evaluation and was accepeted and listed. Approximately 20 years ago, he was noted to have an elevated SGOT during a life insurance physical and was diagnosed with Hepatitis C. Only recently has the patient become more symptomatic with fatigue and pruritus. No chest pain or difficulty breathing are noted. The patient reports feeling fatigued. The patient denies any recent fever or chills, no nausea or vomiting. Intermittent diarrhea (on lactulose) Patient continues to have c/o pruritus and has very profound quadricep cramps that make him jump out of bed. The patient currently sees his psychiatrist about every two months and attends AA meetings on a regular basis. Last food was cheese and crackers at 10AM . Past Medical History: - Bipolar disorder: Diagnosed in [**2129**], past suicide attempt in the 70s during a manic phase or s/t to drug and alcohol abuse. Had been stable on Wellbutrin and Lithium since [**29**] and 93 respectively, except for during a trial of IFN therapy in [**2138**] where hospitalization was required. - HCV: Genotype unknown. Liver biopsy in [**9-/2144**] showed stage 4 cirrhosis and small well-differentiated hepatocellular carcinoma. Found to have grade 1 esophageal varices on EGD in 4/[**2143**]. Developed hepatic encephalopathy in [**2142**] requiring hospitalization at [**Hospital1 2025**], started on lactulose with good effect. Past treatments include peg interferon and ribavirin in [**2139**]. These meds were discontinued due to suicidal ideation. - HCC: Recently noted 1.4 cm enhancing lesion on liver imaging, proved to be small, well-differentialed HCC on bx in [**9-26**]. - Hypothyroidism. On levothyroxine as an outpatient. -[**2145-12-7**] liver transplant Social History: He lives [**Location (un) **] w/ wife, who is a nurse. [**First Name (Titles) **] [**Last Name (Titles) 23165**] beverage for 30 years. No tobacco use ever. Family History: Patient recalls no history of neurologic or autoimmune diseases. Physical Exam: VS: 98.2, 75, 133/79, 18, 100% RA General: appears tired but engages easily in converastion HEENT: no scleral icterus, MMM, Card: RRR, II/VI systolic murmur Lungs: CTA bilaterally Abd: protuberant but soft, cannot feel liver edge, no hernia, + BS Extr: 1+ pitting edema lower extremities, 2+ DPs Skin: multiple excoriations, most notable over abdomen and back of neck. No areas appear infected or actively bleeding Neuro: No asterixis, A+Ox3 . Pertinent Results: [**2145-12-13**] 05:50AM BLOOD WBC-5.6 RBC-3.47* Hgb-11.0* Hct-33.9* MCV-98 MCH-31.6 MCHC-32.3 RDW-15.1 Plt Ct-88* [**2145-12-10**] 05:03AM BLOOD PT-11.4 PTT-40.7* INR(PT)-0.9 [**2145-12-13**] 05:50AM BLOOD Glucose-107* UreaN-47* Creat-1.0 Na-137 K-5.4* Cl-105 HCO3-30 AnGap-7* [**2145-12-13**] 05:50AM BLOOD ALT-221* AST-68* AlkPhos-114 TotBili-0.4 [**2145-12-13**] 05:50AM BLOOD Calcium-7.2* Phos-1.6* Mg-2.2 [**2145-12-13**] 05:50AM BLOOD tacroFK-9.0 Brief Hospital Course: On [**2145-12-7**], he underwent cadaveric liver transplant. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please refer to operative note for complete details. Induction immunosuppression was administered. Bile was produced after vascular and biliary anastomoses. Two drains were placed. He was transferred to the SICU postop for care and was extubated without complication. He experienced severe restless leg syndrome. Psychiatry was consulted with recommendation to use seroquel (home medication). Seroquel was resumed with improvement each day. His home dose of Wellbutrin was resumed. LFTs trended back down and postop day 1 liver duplex was normal. He remained hemodynamically stable and was transferred out of the SICU. Diet was advanced and tolerated. His incision had some erythema that was non-blanching and not warm. This was felt to be bruising. He inadvertently pulled out one of the JP drains without complication. The 2nd JP was removed several days later. Both were non-bilious. Immunosuppression consisted of cellcept which was well tolerated, steroids were tapered. He did require intermittent insulin per sliding scale. NPH was added as well. Prograf was started on postop day 1. Dose was adjusted to 3mg [**Hospital1 **] for trough level which stabilized at 9.0. PT evaluated and recommended a rolling walker and home PT. VNA services were arranged. Of note, he was noted to have a chronic non-healing lesion on his left ear. Dermatology was consulted. A shave biopsy was done to rule out squamous cell. Sutures were to remain in place for two weeks. The plan was for the sutures to be removed at f/u appointment on [**12-23**] in the [**Hospital 1326**] clinic. A dermatology follow up appointment was to be scheduled with Dr. [**First Name (STitle) **] as an outpatient. He was doing well, vitals were stable and was tolerating a regular diet at time of discharge. Medications on Admission: Buproprion 150 SR daily, Cholestyramine 4 gm 1 packet [**Hospital1 **], Clotrimazole 10 mg troche 5x daily, Clotrimazole cream [**Hospital1 **], Folic acid 1 mg daily, Lasix 20 mg daily/PRN swelling, Hydroxyzine 25 mg TID PRN itch, Lactulose 10 gm/15 ml 3 TBSP 3-5x daily PRN , Levothyroxine 75 mg (dose increase 2 weeks ago) Protonix 40 mg daily, Compazine 10 mg PRN nausea, Qutiapine 50 mg 1/2-1 tab PRN hs insomnia, Spironolactone 200 mg daily, Sucralfate 1 gm QID, Provigil 100 mg daily, Ursodiol 600 mg daily, Vit D2 400 unit capsule 2 caps daily, Glucosamine/chondroitin 250/200 mg [**Hospital1 **], Mag Oxide 500 mg [**Hospital1 **], MVI daily, Thiamine 100 mg daily Discharge Medications: 1. Lasix 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day for 5 days: Last day of lasix [**12-18**]. Disp:*5 Tablet(s)* Refills:*0* 2. Fluconazole 200 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q24H (every 24 hours). 3. Prednisone 5 mg Tablet [**Month/Year (2) **]: Four (4) Tablet PO DAILY (Daily). 4. Colace 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO twice a day. 5. Levothyroxine 75 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Quetiapine 25 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed for agitation/insomnia. 8. Quetiapine 25 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO BID (2 times a day) as needed for agitation. 9. Valganciclovir 450 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY (Daily). 10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 11. Mycophenolate Mofetil 500 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO BID (2 times a day). 12. Bupropion HCl 150 mg Tablet Sustained Release [**Month/Year (2) **]: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 13. Oxycodone 5 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 14. Clotrimazole 1 % Cream [**Month/Year (2) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 15. Tacrolimus 1 mg Capsule [**Hospital1 **]: Three (3) Capsule PO Q12H (every 12 hours). 16. NPH Insulin Human Recomb 100 unit/mL Suspension [**Hospital1 **]: Ten (10) units Subcutaneous once a day. 17. NPH Insulin Human Recomb 100 unit/mL Suspension [**Hospital1 **]: Ten (10) units Subcutaneous at bedtime. 18. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: follow sliding scale Injection four times a day. Disp:*1 bottle* Refills:*2* 19. One Touch Ultra System Kit Kit [**Hospital1 **]: One (1) Miscellaneous four times a day. Disp:*1 kit* Refills:*1* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: HCC/HCV now s/p orthotopic liver transplant L superior helix: 0.5 x 0.5cm hemorrhaghic crusted erosion ? squamous cell carcinoma vs less likely traumatically nonhealing lesion. s/p Punch biopsy: Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid ( rollimg walker) Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, diarrhea, increased abdominal pain, increased drainage from the incision or old drain sites yellowing of skin or eyes or any other concerning symptoms. Monitor the abdominal incisions for drainage or bleeding. You may keep them covered if there is drainage but it is safe to leave them open to air. You may Clean biopsy site with soap, water, then pad dry every day for 2 weeks. Cover with a thin layer of vaseline and perform dressing change every day for 2 weeks. Followup Instructions: Left ear suture removal [**12-23**] at Transplant Office follow up appointment Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2145-12-30**] 2:00 Dermatology follow up appointment with Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 1971**])-you will receive a call with an appointment for a full body exam. Dr. [**First Name (STitle) **] will call you with biopsy results. Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2145-12-23**] 8:00 Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2145-12-30**] 10:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2308**], MD Phone:[**Telephone/Fax (1) 3965**] Date/Time:[**2145-12-14**] 11:30 Completed by:[**2145-12-13**]

[ "173.2", "296.80", "155.0", "244.9", "293.0", "070.70", "571.5" ]

icd9cm

[ [ [] ] ]

[ "00.93", "50.59", "18.12" ]

icd9pcs

[ [ [] ] ]

8210, 8267

3405, 5337

324, 395

8506, 8506

2927, 3382

9355, 10278

2379, 2446

6062, 8187

8288, 8485

5363, 6039

8763, 9332

2461, 2908

251, 286

423, 1187

8599, 8739

1209, 2188

2204, 2363

79,998

151,758

35148

Discharge summary

report

Admission Date: [**2101-11-7**] Discharge Date: [**2101-12-14**] Date of Birth: [**2030-2-14**] Sex: F Service: MEDICINE Allergies: Anesthesia Tray Attending:[**First Name3 (LF) 348**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Thoracentesis bilaterally History of Present Illness: 71yo female with a past medical history of Type 2 Diabetes Mellitus, Ankylosing Spondylitis, HTN, h/o DVT, and recent admission with new onset bilateral lower extremity paralysis s/p fall was admitted from her rehab with worsened shortness of breath. . Patient was at rehab after prolonged hospital stay (see details below). Per report from rehab, patient has had persistent shortness of breath since admission to rehab, and over the last 2-3 days, patient was found to have increasing shortness of breath with tachypnea. She was administered 40mg IV lasix x 1 with 1L urine output and was then sent to [**Hospital1 18**] for further evaluation. . Of note, patient recently had a prolonged hospital stay from [**2101-10-19**] - [**2101-11-4**] after a fall at home. After her fall, she gradually developed lower extremity paralysis and was transferred to [**Hospital1 18**] for further evaluation. MRI demonstrated T11-T12 cord compression and she was taken for T8-L2 posterior spinal fusion with T11 laminectomy. Her post-operative course was complicated by the following: - atrial fibrillation with tachycardia with adequate control with metoprolol - bilateral pleural effusions - This was thought related to severe atelectasis and was treated with aggressive chest PT. - h/o DVT - patient has a history of DVT and had an IVC filter placed. Coumadin was restarted upon discharge. - C. diff - diagnosed wtih C.diff and started on flagyl - UTI - Enterococcus UTI and started on amoxicillin - Acute Renal Failure - Creatinine peaked to 1.9 during previous admission . Upon arrival in the ED, vital signs were temp 95.1, HR 90s, BP 93/76, RR 30s, and Pulse ox 100% 4L. Labs were notable for creatinine of 1.2 (baseline 1-1.2), potassium 5.7, troponin elevated to .08, and BNP elevated to 8506. INR was therapeutic to 2.3. ECG was notable for atrial fibrillation with no acute ST changes. CXR was also remarkable for left pleural effusion that has increased in size and a moderate right sided pleural effusion as well. She was administered kayexalate and aspirin 325mg PO x 1. . Upon arrival to the floor, patient reports feeling generally well with improvement in her shortness of breath. Denies cough. Patient is a somewhat poor historian. Past Medical History: Diabetes: insulin-dependent HTN Hyperlipidemia glaucoma Morbid obesity ankylosing spondylitis dx by chiropracter baseline urinary incontinence Social History: - Home: admitted from rehab but was previously living at home with her daughter [**Name (NI) **]; previously was able to complete all ADLs independently - Occupation: not working - EtOH: Denies - Drugs: Denies - Tobacco: Denies Family History: N/C Physical Exam: T 96.9 / BP 114/62 / HR 100 / RR 22 / Pulse ox 99% RA Gen: morbidly obese, fatigued appearing female, no acute distress HEENT: Clear OP, MMM NECK: Supple, No LAD, unable to assess JVD given body habitus CV: tachycardic and irregular, no murmurs / rubs / gallops LUNGS: difficult to assess given body habitus; decreased breath sounds throughout the left side with decreased breath sounds on right lung field to at least 2/3rd up ABD: Morbidly obese, Soft, NT, ND. NL BS. Scattered skin tears with no erythema, tenderness, or drainage EXT: 4+ pitting edema bilaterally SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 0/5 strength in lower extremities bilaterally with 5/5 upper extremity strength bilaterally PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2101-11-18**] echo the right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. 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. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [**2101-11-7**] CXR 1. Complete opacification of the left hemithorax suggesting large pleural effusion and/or atelectasis. Stable layering right pleural effusion. 2. Interval removal of PICC line. [**2101-12-9**] CXR Increasing large left-sided pleural effusion could be secondary to change in position of left upper quadrant pigtail catheter [**2101-12-13**] CXR In comparison with study of [**12-12**], there is removal of the left chest tube. The degree of opacification at the left base is unchanged. No acute focal pneumonia has developed in the interval. Complete blunting of the right costophrenic angle. Some opacification persists in the left retrocardiac region as well. [**2101-12-9**] ECG Atrial fibrillation with ventricular premature beats. Inferior and lateral ST-T wave changes are non-specific. Compared to the previous tracing of [**2101-12-7**] poor R wave progression is not seen on the current tracing and there are more ventricular premature beats. . [**2101-11-7**] 04:00PM BLOOD WBC-8.8 RBC-2.78* Hgb-8.3* Hct-25.8* MCV-93 MCH-30.0 MCHC-32.4 RDW-16.5* Plt Ct-348 [**2101-11-14**] 05:00AM BLOOD WBC-6.6 RBC-2.41* Hgb-6.9* Hct-22.2* MCV-92 MCH-28.7 MCHC-31.2 RDW-16.2* Plt Ct-331 [**2101-11-15**] 04:47AM BLOOD WBC-7.5 RBC-2.78* Hgb-8.1* Hct-25.5* MCV-92 MCH-29.1 MCHC-31.7 RDW-15.5 Plt Ct-362 [**2101-12-13**] 05:36AM BLOOD WBC-7.6 RBC-2.98* Hgb-8.5* Hct-26.4* MCV-88 MCH-28.6 MCHC-32.4 RDW-14.7 Plt Ct-363 [**2101-11-7**] 04:00PM BLOOD PT-23.8* PTT-36.2* INR(PT)-2.3* [**2101-11-8**] 07:15AM BLOOD PT-33.2* PTT-150* INR(PT)-3.5* [**2101-12-13**] 05:36AM BLOOD PT-17.5* PTT-29.9 INR(PT)-1.6* [**2101-12-13**] 05:36AM BLOOD Glucose-76 UreaN-45* Creat-1.0 Na-136 K-4.8 Cl-99 HCO3-33* AnGap-9 [**2101-11-7**] 04:00PM BLOOD Glucose-238* UreaN-39* Creat-1.2* Na-132* K-5.7* Cl-96 HCO3-29 AnGap-13 [**2101-11-24**] 06:35AM BLOOD Glucose-83 UreaN-31* Creat-1.0 Na-137 K-5.4* Cl-98 HCO3-34* AnGap-10 [**2101-11-24**] 03:45PM BLOOD K-6.5* [**2101-11-24**] 11:25PM BLOOD K-5.5* [**2101-11-25**] 05:35AM BLOOD Glucose-102 UreaN-34* Creat-1.1 Na-141 K-4.8 Cl-101 HCO3-35* AnGap-10 [**2101-11-25**] 03:55PM BLOOD K-5.3* [**2101-11-17**] 05:39AM BLOOD ALT-9 AST-22 LD(LDH)-214 AlkPhos-105 [**2101-11-7**] 04:00PM BLOOD ALT-10 AST-21 CK(CPK)-41 AlkPhos-131* TotBili-0.4 [**2101-11-7**] 04:00PM BLOOD Lipase-43 [**2101-11-7**] 04:00PM BLOOD CK-MB-NotDone proBNP-8506* [**2101-11-7**] 04:00PM BLOOD cTropnT-0.08* [**2101-11-7**] 11:40PM BLOOD CK-MB-NotDone cTropnT-0.10* [**2101-11-8**] 07:15AM BLOOD CK-MB-NotDone cTropnT-0.09* [**2101-12-11**] 05:50AM BLOOD proBNP-5791* [**2101-11-7**] 04:00PM BLOOD Albumin-2.7* Calcium-8.6 Phos-3.8 Mg-2.0 [**2101-12-1**] 06:15AM BLOOD Albumin-2.4* Calcium-8.4 Phos-2.8 Mg-2.0 [**2101-12-12**] 05:00AM BLOOD Albumin-2.4* Calcium-8.3* Phos-3.3 Mg-2.0 [**2101-11-30**] 05:53AM BLOOD calTIBC-177* Ferritn-506* TRF-136* [**2101-11-10**] 06:15AM BLOOD %HbA1c-6.3* [**2101-11-10**] 08:47AM BLOOD Type-ART pO2-36* pCO2-58* pH-7.42 calTCO2-39* Base XS-10 [**2101-12-12**] 01:05AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2101-12-9**] 12:14PM PLEURAL WBC-2250* RBC-5500* Polys-61* Lymphs-29* Monos-6* Eos-4* [**2101-12-9**] 12:14PM PLEURAL TotProt-2.6 Glucose-145 LD(LDH)-186 Albumin-1.4 [**2101-12-4**] 11:32AM PLEURAL TotProt-1.9 Glucose-164 LD(LDH)-174 [**2101-11-12**] 01:08PM PLEURAL TotProt-1.4 Glucose-87 LD(LDH)-141 [**2101-11-11**] 04:11PM PLEURAL TotProt-1.6 Glucose-176 LD(LDH)-120 Amylase-24 [**2101-11-13**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI} [**2101-12-9**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL {STAPH AUREUS COAG +}; ANAEROBIC CULTURE-FINAL INPATIENT [**2101-12-12**] URINE URINE CULTURE-PRELIMINARY {ENTEROCOCCUS SP.} INPATIENT Brief Hospital Course: 71F with bilateral lower extremity paralysis s/p fall, anklyosing spondylitis, Type 2 Diabetes Mellitus, atrial fibrillation, and h/o DVT p/w three days of worsening dyspnea. # Dyspnea: Patient was intermittently dyspneic after admission but generally was not hypoxic. The etiology of her dyspnea was thought to be mixed, with her large bilateral pleural effusions, pulmonary edema secondary to hypoalbuminemia, obesity, and mucous plugging all contributing. She was therefore transferred to the MICU where pigtail catheters were placed in the pleural space bilaterally and drained significant amounts of fluid. Her respiratory status improved afterward. The pleural fluid was a transudate by Light's criteria and the gram stain and culture were negative. A right subclavian line was also placed in the MICU because IV access was difficult to attain. She was transferred back to the medical floor on [**11-15**] and continued to do well from a respiratory perspective. She had episodes of dyspnea with exertion when being moved in bed but consistently kept an oxygen saturation >90% and was never tachypneic. She was aggressively diuresed because of anasarca, likely secondary to hypoalbuminemia and IVF administration during her prior admission while on the surgical service, and was negaative three to five liters each day for the first five days after being transferred to the floor. AutoDiuresis continued and the patient's anasarca improved, she was then started on lasix to maintain negative fluid balance. Her chest tubes were eventually placed to waterseal, with the right being removed first. She continued to reaccumulate fluid in the left pleural space when the tube became clogged multiple times and her L CT was changed after CT chest showed that it was adherent to the pericardium. The new CT drained a large amount of fluid immediately and then the drainage decreased significantly, the tube was pulled three days later and the fluid did not reaccumlate. For several days preceeding day of d/c she was had no difficulty breathing and stated that her lungs felt clear. # Anasarca: The patient was severely volume overloaded, likely secondary to hypoalbuminemia and IVF administration during her prior admission while on the surgical service, and was diuresed aggressively with marked improvement, as described above. The nutrition service was consulted and made [**Month/Year (2) 7219**] about dietary supplementation. She was given boost supplements with each meal but her albumin only slowly began to improve, likely that she was losing a large amount of protein through her CT. Pt. was negative approximately 40 L (forty liters) for length of stay. # Lower extremity paralysis: Patient was recently discharged after being admitted for LE paralysis which occured in the setting of a traumatic fall, spinal compression fractures, and an epidural hematoma. During her prior hospitalization, she underwent T8-L2 posterior spinal fusion w/ T11 laminectomy and decompression of her hematoma. She was discharged to a rehab center with intensive PT and OT, and these services were continued after readmission. She also was managed with other prophylactic treatments for her SCI, including repositioning in bed q2h to decrease her risk of bed sores and intermittent straight cathing to decrease her risk of UTI (compared to the risk associated with an indwelling catheter). However, an indwelling bladder catheter was ultimately placed because the patient was being aggressively diuresed for anasacara. She was treated for one E.coli UTI and then had a foley change for enterococcus colonization. She initially had a spinal wound dehiscence which ortho spine commented on and did not think was a new surgical issue though it was initially draining large amounts of serosanguinous fluid. The wound dehisence mostly sealed over the course of this admission. # Lower extremity DVT: Patient was diagnosed with a DVT a few months prior to admission and was admitted on warfarin. However, warfarin was held in anticipation of a thoracentesis. Because she has an IVC filter in place (placed during her prior hospitalization because anticoagulation was contraindicated in the setting of an epidural hematoma), she was not initially bridged with heparin when her INR fell below 2 because she was awaiting chest tube placement. After chest tubes were placed bilaterally, a heparin gtt was started and continued until her INR was greater than 2. # Type 2 Diabetes Mellitus: Patient was maintained on an ISS and had a HbA1C<7%. # UTI: The patient had a urine culture that grew E. coli sensitive to bactrim, gentamicin, and zosyn. She was initially managed with bactrim but developed hyperkalemia. Because her renal function was normal, a transtubular potassium gradient was calculated and found to be 4.3%, consistent with hypoaldosteronism. The bactrim was discontinued and the patient's potassium levels subsequently normalized after 48 hours. Zosyn was started and the patient completed a 10 day course of antibiotics for complicated UTI. She was discharged without the foley, but with [**Month/Year (2) 7219**] for q4h timed voids (straight caths) because of the decreased risk of UTI associated with this method, when compared to indwelling catheters. # C diff: Patient had diarrhea and positive c diff toxin during her prior hospitalization and was continued on flagyl. Her two week course was completed on [**2101-11-13**] but then restarted shortly afteward because of recurrence of loose stools. Flagyl was continued for two weeks after the patient's last antibiotic dose for for UTI. She again developed loose stools the day before d/c and a c.diff was pending at the time of d/c [**Hospital **] rehab will need to follow up on this result and treat her if positive. # Atrial Fibrillation: Patient has a CHADS score of 2 and aspirin will be adequate for long-term thromboembolic ppx, though she may be anticoagulated with warfarin indefinitely considering that her DVT was likely idiopathic in etiology. Her metoprolol was uptitrated to 100mg [**Hospital1 **] because she continued to have HR around 100, and she was also monitored on telemetry. # Hypertension: Stable, patient was continued on metoprolol. Lisinopril was d/c'd to give BP room for lasix and metoprolol. She should be restarted on this once she is euvolemic. #Hyperlipidemia: Patient was continued on tricor. #Decubital ulcers: The wound nurse [**First Name (Titles) **] [**Last Name (Titles) 7219**] on wound care and the plastic surgery team was also consulted to debride a gluteal ulcer. With good wound care her sacral ulcers decreased in size over the course of her hospitalization. # CODE: FULL CODE # COMM: [**Name (NI) **], [**Name (NI) **] [**Known lastname **] [**Telephone/Fax (1) 80237**], [**Telephone/Fax (1) 80238**] Medications on Admission: HOME MEDICATIONS: 1.Albuterol 2.Amoxicillin 250mg PO bid ([**2106-11-4**]) (was discharged on 500 [**Hospital1 **]) 3.ASA 325mg PO daily 4.Bisacodyl 10mg PO daily prn 5.Docusate 100mg PO bid 6.Fenofibrate 145mg PO daily 7.Metoprolol 25mg PO tid 8.Flagyl 500mg PO tid ([**Date range (1) 13497**]) 9.Miconazole powder 10.MVI 11.Pravastatin 40mg PO daily 12.Senna 13.Coumadin 2mg PO daily 14.Lovenox 15.Silver Sulfadiazine cream daily 16.Tylenol prn 17.Insulin sliding scale . MEDICATIONS ON TRANSFER: Metoprolol Tartrate 25 mg PO TID MetRONIDAZOLE (FLagyl) 500 mg PO Q8H last day [**11-18**] Miconazole Powder 2% 1 Appl TP QID:PRN Acetaminophen 325-650 mg PO Q6H:PRN Multivitamins W/minerals 1 TAB PO DAILY Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Neutra-Phos 1 PKT PO TID Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN Pravastatin 40 mg PO DAILY Aspirin 325 mg PO DAILY Senna 1 TAB PO BID:PRN Ascorbic Acid 500 mg PO DAILY Sertraline 25 mg PO DAILY Bisacodyl 10 mg PR HS:PRN Silver Sulfadiazine 1% Cream 1 Appl TP DAILY Collagenase Ointment 1 Appl TP DAILY Gluteals: Apply Santyl (enzymatic debrider), massage into wound edges and wound bed. Docusate Sodium 100 mg PO BID Sodium Chloride Nasal [**12-29**] SPRY NU QID:PRN Fenofibrate *NF* 145 mg Oral daily Heparin IV Sliding Scale Sulfameth/Trimethoprim DS 1 TAB PO BID Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose Vancomycin 1000 mg IV Q 12H Levofloxacin 750 mg PO Q24H Vitamin A 30,000 UNIT PO DAILY Lorazepam 0.5-1 mg PO Q4H:PRN anxiety Zinc Sulfate 220 mg PO DAILY Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 6. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 8. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 10. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 11. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 13. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 14. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-29**] Sprays Nasal QID (4 times a day) as needed. 15. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily). 16. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush CVL, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 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. Outpatient [**Name (NI) **] Work PT, PTT, INR. twice weekly. Start [**2101-12-15**] Please fax to NP or MD on staff for titration of warfarin dose 20. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 21. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain: do not exceed 4g/day. 22. Insulin Glargine 100 unit/mL Solution Sig: Sixty (60) units Subcutaneous at bedtime. 23. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day: Hold for HR<60 or SBP<95. 24. Insulin Lispro 100 unit/mL Cartridge Sig: Per sliding scale Per sliding scale Subcutaneous four times a day. 25. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day for 10 days: Hold for SBP <95, give metoprolol first and then recheck BP before giving. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Primary: Pleural effusion Spinal Cord Injury Secondary: Deep Vein Thrombosis Atrial Fibrillation Morbid Obesity Hypertension Hypercholesterolemia Diabetes Mellitus Type II Discharge Condition: Good Discharge Instructions: You were admitted with shortness of breath. We transferred you to the intensive care unit because you were having difficulty breathing. After removing some of the fluid from your lungs, though, your breathing improved. On the medical floor, we also treated you for swelling related to excess fluid, a urinary tract infection, and the clots you developed in your legs several months ago. You had fluid on your lungs and so we used tubes to drain this fluid. The fluid kept comming back on the left side until several days ago when we pulled out the tube there. We also gave you lasix to help you urinate the fluid out. We stopped your antibiotics because you completed the course. We increased your metoprolol because your heart was beating too fast. We stopped your lovenox because your blood was thinned with the coumadin. Please take all of your medications as prescribed. Please keep all of your follow-up appointments. Please call your doctor or return to the hospital if you experience fevers, chills, sweats, chest pain, shortness of breath or anything else of concern. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**12-29**] weeks after discharge: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 65542**] ORTHOPEDICS: Please follow up with Dr. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] at two weeks from the date of discharge. [**Telephone/Fax (1) 3736**] Provider ORTHO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3736**] Completed by:[**2101-12-14**]

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icd9cm

[ [ [] ] ]

[ "99.04", "34.09", "99.07", "38.93" ]

icd9pcs

[ [ [] ] ]

19353, 19453

8385, 15232

284, 312

19670, 19677

3844, 8362

20811, 21484

3010, 3015

16834, 19330

19474, 19649

15258, 15258

19701, 20788

3030, 3825

15276, 15733

237, 246

340, 2581

15758, 16811

2603, 2748

2764, 2994

80,015

101,451

51015

Discharge summary

report

Admission Date: [**2159-10-16**] Discharge Date: [**2159-10-23**] Date of Birth: [**2100-4-12**] Sex: M Service: MEDICINE Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) / Tetanus / Tuberculin,Purif.Prot.Deriv. / metoprolol Attending:[**First Name3 (LF) 13256**] Chief Complaint: bloody emesis and BRBPR Major Surgical or Invasive Procedure: EGD on [**2159-10-16**] and [**2159-10-20**] History of Present Illness: Pt is a 59yo M with bright red bloody emesis and BRBPR. The pt is s/p variceal banding on [**10-5**] with 5 bands for an acute variceal bleed with BRBPR and epigastric pain. At that time the pt was noted to have a hematocrit of 31.1, and he was observed at [**Hospital3 **] until [**10-15**]. Subsequently the pt did well and was advanced to PO solids, and he was planned to be discharged today, but then had "black" diarrhea all day and was vomiting "dark brown" material x1 around lunch, as well as diaphoresis and right anterior abdominal wall tenderness, without radiation. The pt was re-evaluated by the MDs there and they determined that the pt would be a poor candidate for a repeat EGD, and the pt was transferred here to [**Hospital1 18**] for evaluation and presumptively for a TIPS procedure. At [**Hospital1 **] today the pt's hematocrit continued to fall and he was transfused 4 units of pRBC, and then transfered here. . On arrival to the MICU the pt was complaining of abdominal pain, had an SBP of the 90's, HR 120's. Story c/w outside records. Past Medical History: - EtOH abuse - EtOH cirrhosis - Variceal bleeds - Erosive esophagitis and gastic varicies - CVA and left hemiplegia - IDDM - Schizophrenia - Anemia - Hypothyroidism - Obesity - HTN - HL - Migranes - COPD Social History: Patient lives in a nursing home. He denies recent alcohol use and says it was "in the past", he denies smoking or other drugs. He is originally from [**Country 7192**] and has children in [**Country **]. He has a sister in [**Location (un) 538**]. He does not have a HCP. Family History: Non-contributory. Physical Exam: Physical Exam on Admission: T: 98.9 BP:92/45 P:116 R:16 O2: 99 General: Alert, oriented to person, place, time, event, talking in fluent sentences. HEENT: Sclera anicteric, MMM, oropharynx clear 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: Obese, tender to palpation over right anterior abdominal wall, no body wall ecchymoses, no tenderness to percussion, no rebound, no guarding, no organomegaly appreciated though physical exam is severely limited. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Dried blood between legs. Physical Exam on Discharge: O: 99.3, 97.6, 144/67, 87, 20, 99%RA HEENT: MMM, dentures in place Neck- unable to assess JVP due to habitus Cardiac: RRR, 2/6 systolic murmur in LUSB, no gallops or rubs appreciated Lungs: Clear to auscultation bilaterally. Abdomen: Obese, soft, nontender, unable to palpate liver or spleen tip. No capute medusae. No appreciable shifting dullness. Extremities: 2+ edema bilaterally 2+ pulses. Skin- no palmar erythema. Multiple actinic keratoses on the back. Pertinent Results: Labs upon admission: . [**2159-10-16**] 01:50AM BLOOD WBC-11.0 RBC-3.92* Hgb-12.0* Hct-33.7* MCV-86 MCH-30.6 MCHC-35.6* RDW-14.9 Plt Ct-241 [**2159-10-16**] 01:50AM BLOOD Neuts-86.8* Lymphs-9.7* Monos-2.7 Eos-0.5 Baso-0.3 [**2159-10-16**] 01:50AM BLOOD PT-15.8* PTT-26.2 INR(PT)-1.4* [**2159-10-16**] 01:50AM BLOOD Glucose-237* UreaN-12 Creat-1.0 Na-140 K-4.4 Cl-106 HCO3-28 AnGap-10 [**2159-10-16**] 01:50AM BLOOD ALT-95* AST-140* LD(LDH)-377* AlkPhos-77 TotBili-0.8 [**2159-10-16**] 01:50AM BLOOD Lipase-44 [**2159-10-16**] 01:50AM BLOOD Albumin-2.9* Calcium-7.7* Phos-3.3 Mg-1.8 [**2159-10-16**] 11:11PM BLOOD freeCa-1.03* . Labs upon discharge: . [**2159-10-23**] 05:45AM BLOOD WBC-1.4* RBC-2.85* Hgb-8.8* Hct-26.6* MCV-93 MCH-30.7 MCHC-33.1 RDW-15.8* Plt Ct-226 [**2159-10-23**] 05:45AM BLOOD PT-15.4* PTT-29.4 INR(PT)-1.3* [**2159-10-23**] 05:45AM BLOOD Glucose-162* UreaN-5* Creat-0.7 Na-139 K-3.6 Cl-104 HCO3-24 AnGap-15 [**2159-10-23**] 05:45AM BLOOD ALT-116* AST-24 AlkPhos-81 TotBili-0.6 [**2159-10-23**] 05:45AM BLOOD Calcium-7.7* Phos-2.5* Mg-2.0 . Imaging: Echo [**2159-10-17**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Left ventricular systolic function is hyperdynamic (EF>75%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . [**2159-10-17**]: Abd US: IMPRESSION: 1. Limited study. Findings consistent with hepatic cirrhosis with patent hepatic vasculature. 2. Small amount of ascites. 3. Splenomegaly. 4. No evidence of gallstones or cholecystitis. . [**2159-10-19**]: CXR: FINDINGS: There are mild bilateral lower lobe opacities likely atelectasis. Minimal pulmonary vascular congestion is seen. Widening of the mediastinum is attributed to the tortuous course of thoracic aorta. The heart size is normal. Pleural effusion if any is minimal on the right side. No opacities concerning for pneumonia. . Blood cultures: [**10-16**], [**10-17**], [**10-19**]: NGTD Urine culture: [**2159-10-16**]: negative . EGD [**2159-10-16**]: . Esophagus: Protruding Lesions 5 cords of grade III-IV varices were seen in the lower third of the esophagus. The varices were not bleeding. Excavated Lesions Two ulcers ranging in size from 5 mm to 5 mm were found in the lower third of the esophagus. One had stigmata of recent bleeding. Both ulcers seemed to be post-banding ulcers. . Stomach: Mucosa: Normal mucosa was noted. Duodenum: Mucosa: Normal mucosa was noted. Impression: Varices at the lower third of the esophagus Ulcers in the lower third of the esophagus Normal mucosa in the stomach Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum Recommendations: Continue PPI and Octreotide infusion. Add Carafate as well. If he should bleed again, he will need TIPS procedure. Further management per Liver team. Additional notes: The attending was present for the entire procedure. The patient's home medication list is appended to this report. FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology . EGD [**2159-10-20**]: . Esophagus: Protruding Lesions 2 cords of grade II varices were seen starting at 36 cm from the incisors in the lower third of the esophagus. 2 bands were successfully placed. 1 band was placed below the ulcer. Excavated Lesions A single oozing 6 mm ulcer was found in the on the previously banded esophageal varix. Stomach: Contents: Red blood was seen in the whole stomach. Other No gastric varices were seen. Duodenum: Normal duodenum. Other findings: Bile in duodenum. Impression: Varices at the lower third of the esophagus (ligation) Ulcer in the on the previously banded esophageal varix Blood in the whole stomach No gastric varices were seen. Bile in duodenum. Otherwise normal EGD to second part of the duodenum Recommendations: serial hct, transfuse if hct<24 or active bleeding Cont' Octreotide gtt, PPI gtt, ceftriaxone 1 g daily, lactulose, carafate 1 g QID No NG tube placement Additional notes: The procedure was performed by the attending physician and fellow FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology . Brief Hospital Course: 59 yo male with history of alcoholic cirrhosis and variceal bleeding s/p recent banding on [**10-5**], presented with recurrent variceal bleeding. . #. Variceal bleeding: He was initially admitted to the MICU on [**2159-10-16**] with hypotension and tachycardia believed to be secondary to a variceal bleed. He was intubated initially for airway protection prior to EGD. Endoscopy showed 5 cords of grade III-IV nonbleeding varices in the lower third of the esophagus, and two post-banding ulcers, with one having stigmata of recent bleeding, no interventions were performed at that time. He received 2 units of pRBC. He was transferred to the floor on [**2159-10-17**]. He was doing well with no additional melena or hematochezia until [**10-20**] when he developed hematochezia and had a 7 point HCT drop. He was transferred to the MICU where he underwent repeat EGD which showed 2 cords of grade 2 varices in the lower [**1-22**] of the esophages and an oozing ulcer on the previously banded esophageal varix. He received an additional 2units PRBC. He was monitored on the floor after his octreotide and PPI drips were stopped and he had no further episodes. He was not started on a beta-blocker due to concern for worsening of his reactive airway disease and a history of possible beta-blocker allergy. His protonix drip was changed to protonix 40mg PO BID. He will follow up with the hepatology departement in the next 1-2 weeks for likely re-scope. If he rebleeds, then consideration for a TIPS may be warranted. . #Hepatitis- patient developed shock liver in the setting of his GI bleed with his LFTs increasing into the AST and ALT of 700s and were downtrending and resolving at the time of discharge. . #. Abdominal Pain: Pt's abdominal pain is atypical for a variceal bleed, which generally are painless. The pt presented intially to the OSH on [**10-5**] with abdominal pain as well. On the CT performed then the pt was seen to have a duodenitis. The clinical relevance of this is not certain. US was performed, which did not show signficant ascites. . # Fever: unclear etiology. SBP was considered, though he did not have any obvious ascites to tap. Regardless, he was treated empirically with a course of Ceftriaxone 2g daily with transition to cipro 500mg [**Hospital1 **] on discharge. He should complete a total of 10 days of antibiotics to be completed [**2159-10-26**]. He remained afebrile on discharge with negative cultures to date. . # [**Name (NI) **] Pt noted to develop leukopenia with a total WBC=1.4 on discharge. The origin of this was unclear. It was thought that this could have been in the setting of his ceftriaxone course and thus this was changed to cipro as above. However, he was continuing to nadir on discharge. It is also possible that his risperidone could have been contributing. We recommend a follow up CBC within a week after discharge. His outpatient providers to should address whether to continue his risperidone. . # SOB- patient had several episodes of shortness of breath while in house. It was likely multifactorial from his known reactive airway disease, significant anemia in the setting of UGIB, volume overload, and possible transient hepatopulmonary syndrome in the setting of his shock liver. He was continued on nebs, and his diuresis was adjusted to lasix 40mg daily and spironolactone 50mg daily. On discharge his SOB had markedly improved. . #. IDDM: Pt was maintained on a regimen of lantus 20U QHS and Humalog SS. Note that his lantus regimen was much less aggressive in-house than at home. This is likely due to eating a different diet in-house. Thus, we increased his lantus to 36U QHS on discharge to account for this, but this is still less than his home dose. Note that re-uptitration of his insulin may be warranted if glucose control is not adequate. . #. Volume overload: Pt noted to become more volume overloaded while in house. It appears he is on lasix 40mg daily at home, but this was held in the setting of his bleeding. We restarted this along with spironolactone 50mg daily on discharge. . #. Schizophrenia: Not an active issue. Continued home risperidone, though this may be further addressed by outpatient providers given the possibility of this medication contributing to his leukopenia . #. Hypothyroidism: Not an active issue. Continued home levothyroxine. . #. HL: Not an active issue. Initially held simvastatin [**2-21**] [**Last Name (LF) 105984**], [**First Name3 (LF) **] be restarted in the future after resolution of LFTs . # Follow-up/Transitional -CBC should be followed up within the next week to ensure resolution of leukopenia -[**Month (only) 116**] consider changing risperidone in setting of leukopenia -Final blood cultures still pending on discharge -Whether to restart statin should be addressed as outpatient Medications on Admission: Advair 250/50 1 puff [**Hospital1 **] Cepacol 1 tab q4hrs prn cough Docusate 100mg tab - 2 tabs qhs Ferrous sulf 325 1 tab [**Hospital1 **] Folic acid 1mg qday Furosemide 40 mg po qday vicodin 1 tab [**Hospital1 **] Latanoprost 0.005% 1 drop L eye qhs levothyroxine 225mcg qday Lisinopril 5mg po qhs KCl ER 10meq cap qday prilosec otc 20mg po qday risperidone 1.5mg po qhs Simvastatin 10 mg po qhs albuterol 0.083# i unit q4h ibuprofen 600mg po qhs prn for pain lactulose 30ml TID prn for constipation proair hfa 2 puffs q4hrs prn SOB/wheeze humalog 20 U qam, 20 U qlunch 40U qdinner Lantus 74U qam lantus 36U qpm bisacodyl prn fleet enema prn milk of mag prn Discharge Medications: 1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): in left eye. 2. risperidone 3 mg Tablet Sig: One "half" tablet Tablet PO at bedtime: 1.5mg . 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. levothyroxine 25 mcg Capsule Sig: One (1) Capsule PO once a day: Take in addition to 200mcg dose. Total dose of 225mcg. 7. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): please only give so patient has 3 bowel movements per day. 9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*6 Tablet(s)* Refills:*0* 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation twice a day. 14. Cepacol Sore Throat 15-3.6 mg Lozenge Sig: One (1) Mucous membrane every four (4) hours as needed for sore throat. 15. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 16. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Inhalation 18. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 19. Lantus 100 unit/mL Solution Sig: Thirty Six (36) Units Subcutaneous qPM. 20. Humalog 100 unit/mL Solution Sig: see below Subcutaneous see below: 20 Units given with breakfast 20 Units given with lunch 40 units given with dinner. 21. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a day: total dose of 225mcg. 22. Outpatient Lab Work Please draw CBC and Complete Metabolic panel during the week of [**2159-10-29**]. Discharge Disposition: Extended Care Facility: [**Hospital 10246**] Extended Care Center - [**Location (un) 2268**] Discharge Diagnosis: Primary: Variceal bleed, Alcoholic cirrhosis, shock liver, shortness of breath Secondary: Diabetes Mellitus Type II, Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you while you were here at [**Hospital1 18**]. You were admitted to our hospital from another hospital for concern that you were having bleeding in your stomach and esophagus. You had had two bleeds at that hospital. When you arrived here you were in the intensive care unit (where we looked inside your esophagus and stomach) to see if there was bleeding and did not see any, so there was nothing done at that time. You were then on the regular hospital [**Hospital1 **] floor. We kept you on some medicines to prevent you from bleeding and watched you over the next few days. You developed some bright red blood in your stools and you were transfered to the intensive care unit to be monitored and had another endoscopy(look inside the esophagus and stomach) and they saw an ulcer that was bleeding ontop of one of the varices (blood vessels that had previously bled). They put a couple of bands on this to stop the bleeding and gave you a blood transfusion and you were feeling better and had no more bleeding. You will need to stay on the pantoprazole twice a day for now, as well as need to have another endoscopy to have the varices taken care of. You also had a fever when you arrived to our hospital, and we are not exactly sure where the infection is coming from. Because you can get infections with having these type of bleeds we put you on IV antibiotics at first and then switched this to a pill antibiotic called bactrim which you will need to finish the course of when you leave. Your white blood cell count (indicating body's response to infection) got very low while you were on the IV antibiotic and we think this caused it to drop too much. We stopped that medicine, but this will need to be followed-up by your primary care doctor to make sure it gets back up into the normal range. For your diabetes- your blood sugars were well controlled on a much lower dose of insulin (20U at bedtime) than you receive at home. So we will ask you to stop your morning dose of Lantus when you return home. You should have your blood sugars closely monitored while you are at home, and adjustments can be made further. You developed some worsening swelling of your legs during your stay, most likely due to all of the blood transfusion that we were giving you. We are adding another medication call spironolactone to your medication list to help you get more fluid off of you. It will also be important that you stick to a low sodium diet. Transitional Issues: Pending labs: None Medications started: 1. Ciprofloxacin 500mg tab by mouth twice a day (to finish course on [**2159-10-26**]) 2. Spironolactone 50mg tab by mouth once a day 3. Pantoprazole 40 mg by mouth twice a day 4. Sulcrafate (for the stomach) Medications changed: 1. Lantus- please stop MORNING dose of lantus, and continue to check blood sugars before each meal Medications stopped: 1. Omeprazole (taking another form of it) 2. Simvastatin (because liver function not back to normal) 3. Ibuprofen- this is an NSAID and these should not be taken given history of bleeding ulcer on the esophageal varix Follow-up- 1.You will need to have your varices (blood vessels that are exposed) in your esophagus, banded again and you will need to schedule this appointment (see below) 2.Your blood sugars should be monitored closely and medication changes should be made based on these numbers when you are eating your home diet 3.Your primary care doctor will need to recheck your liver function tests and determine if you should be restarted on your simvastatin if they feel it will be beneficial. Followup Instructions: Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Liver Clinic follow up- Unfortunately we were unable to schedule this appointment for you prior to discharge. You will need to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the Liver Clinic at [**Hospital1 18**] within 10-14 days, to have another endoscopy with (banding and obliteration of your varices). To make this appointment please call [**Telephone/Fax (1) 105985**]

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Discharge summary

report

Admission Date: [**2130-1-24**] Discharge Date: [**2130-1-29**] Date of Birth: [**2072-3-22**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2159**] Chief Complaint: DKA Major Surgical or Invasive Procedure: None. History of Present Illness: 57yo woman with h/o DM2, pain syndrome, psychiatric history presented to ED initially with complaints of fever, chills, rhinorrhea, productive cough, and pleuritic chest pain since [**2130-1-12**]. No prior DVT/PE, no hemoptysis, no [**Doctor First Name **] or bed rest w/in past month, no leg swelling, no long trips, no active CA. No TB risk factors. . Initial eval in ED was notable for the following: Initial vitals were 100.3, 150, 148/82, 24, and 97% on room air. She subsequently spiked a temp to 101.2. She was found to be in DKA with bicarb of 7 and anion gap of 29. Urine pos for ketones. WBC of 22.6. Chest film demonstrated new right lateral infrahilar patchy opacity, and UA suggested urinary infection. CT abdomen done and demonstrated LLL consolidation, possible bowel wall thickening, no free air. Otherwise, she had no anginal symptoms, and her EKG was within normal limits and unchanged. Initial set of cardiac enzymes negative. She was given IVF wide open, and started on insulin gtt. Electrolytes were repleted. She was started on broad spectrum empiric abx with vancomycin, ceftriaxone, and flagyl. She was given 4L in total of NS. . Transferred to MICU for DKA, placed on insulin drip, electroytes monitored, blood sugars trended down. Transferred to medicine floor once stabilized. Past Medical History: DM2 Back pain Depressive sx Anxiety sx somatization features dyslipidemia Social History: The patient was born and raised in El [**Country 19118**] and moved to the U.S. 18 years ago. She has a GED. She works full time for the past 11 years as a mail clerk. She has three children. She lives with two sons, ages 29 and 27 and also most recently with her ex-boyfriend of 14 years. She denies owning a gun. She denies history of abuse. Family History: NC Physical Exam: VS: 99.6, 82, 120/70, 24, 97% RA Gen a&o x3, nad HEENT moist mucous membranes, no thrush Neck supple CV regular tachycardia, no m/r/g Resp decreased breath sounds, crackles bilaterally, no wheezes/rales Abd soft, nt, nd, nabs Ext no c/c/e Neuro non-focal Pertinent Results: [**2130-1-24**] 02:35PM BLOOD WBC-22.6*# RBC-4.65 Hgb-14.5 Hct-45.0 MCV-97 MCH-31.1 MCHC-32.2 RDW-13.4 Plt Ct-377 [**2130-1-24**] 02:35PM BLOOD Neuts-81* Bands-4 Lymphs-5* Monos-10 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2130-1-27**] 07:18AM BLOOD Plt Ct-414 [**2130-1-28**] 07:50AM BLOOD PT-12.6 PTT-26.1 INR(PT)-1.1 [**2130-1-24**] 02:29PM BLOOD D-Dimer-1601* [**2130-1-24**] 01:10PM BLOOD Glucose-364* UreaN-11 Creat-0.8 Na-131* K-4.8 Cl-95* HCO3-7* AnGap-34* [**2130-1-24**] 01:10PM BLOOD ALT-22 AST-14 CK(CPK)-27 AlkPhos-170* Amylase-21 TotBili-0.5 [**2130-1-24**] 01:10PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2130-1-24**] 09:49PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2130-1-25**] 06:29AM BLOOD CK-MB-2 cTropnT-<0.01 [**2130-1-24**] 01:10PM BLOOD Albumin-4.0 Calcium-9.9 Phos-2.6* Mg-1.8 [**2130-1-24**] 07:54PM BLOOD Type-[**Last Name (un) **] pO2-33* pCO2-40 pH-7.13* calTCO2-14* Base XS--16 Comment-GREEN TOP [**2130-1-24**] 01:23PM BLOOD Glucose-345* Lactate-2.8* K-5.0 . CT ABDOMEN W/CONTRAST [**2130-1-24**] 6:34 PM 1. Left lower lobe dense consolidation with air bronchograms, incompletely imaged but concerning for underlying pneumonia. 2. Short segment of proximal jejunum demonstrating moderate wall thickening of uncertain clinical significance. Although findings may represent focal peristalsis, further characterization with a small bowel follow-through is recommended on a nonemergent basis once acute presentation has resolved to rule out underlying inflammatory bowel disease. 3. 1 cm left adnexal calcification of unclear etiology. 4. Sigmoid diverticula without evidence of diverticulitis. . CHEST (PA & LAT) [**2130-1-24**] 3:04 PM New infrahilar patchy opacities concerning for pneumonia. . ECG Study Date of [**2130-1-24**] 1:41:38 PM Sinus tachycardia Short P-R interval Low lead voltage Normal ECG except for rate Since previous tracing, heart rate faster, anterior T waves improved Brief Hospital Course: 57yo woman with insulin requiring type II diabetes presents with respiratory syndrome/pneumonia and found to be in DKA, stabilized in MICU, now transferred to floor. . # DKA As demonstrated by hyperglycemia, marked increased anion gap acidosis and ketosis. Suspect that she has advanced insulin deficiency as well as insulin resistance given her history and her current presentation in DKA. Most likely precipitant is acute infectious process; there is evidence of both PNA and UTI on initial evaluation. Abdominal CT (-) for acute intraabdominal process. Non-ischemic EKG, normal cardiac enzymes. Initially treated with very broad spectrum Abx with vanco/ceftriaxone/flagyl, switched to levaquin. Anion gap closed yesterday, but continued insulin gtt b/c of persistently high serum glucose, turned off prior to floor transfer and switched to standing insulin with SSI. Hyperkalemia and acidosis corrected. Urine and blood cultures no growth. Held metformin given risk of lactic acidosis, restarted on discharge. [**Last Name (un) **] consulted, cut down AM lantus to 50. Arranged f/u with [**Last Name (un) **] nurse educator for insulin coverage on sick days. . # Pneumonia CT chest revealed increased opacity noted lateral to the hila bilaterally as well as superior to the left hila concerning for worsening multifocal pneumonia. Initial leukocytosis now resolved. Levoquin 10 day course. Symptomatic treatment with guaifencin, nebs. . # Depression Continued fluoxetine. . # Dyslipidemia Continued lipitor. . # Back pain Held sedating meds. Cleared by PT for home. . # Dispo DC'd to home once blood sugars stable on diabetic medication regimen. As recommended by radiology, she should have non-emergent follow up evaluation of jejunal thickening (SBFT) and left adnexal cyst. Medications on Admission: Atorvastatin 20 mg qHS FLUOXETINE 10 mg LANTUS 20units HS METFORMIN 500 mg [**Hospital1 **] PROTONIX 40MG qD FLEXERIL 10 mg TID prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. 2. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*12 Tablet(s)* Refills:*0* 3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five (5) ML PO Q6H (every 6 hours) as needed. 7. Insulin Glargine 100 unit/mL Solution Sig: 50 units Subcutaneous in AM. Disp:*2 bottles* Refills:*2* 8. Humalog 100 unit/mL Cartridge Sig: One (1) per sliding scale Subcutaneous Before each meal and prior to bedtime. : Please adjust dose based on your sliding. . Disp:*qs qs* Refills:*2* 9. Lancets Misc Sig: One (1) lancet Miscellaneous for blood sugar measurement. Disp:*qs lancets* Refills:*2* 10. One Touch Ultra Test Strip Sig: One (1) strip Miscellaneous four times a day: Use acording to sliding scale. . Disp:*qs qs* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Diabetes ketoacidosis Community-acquired pneumonia SECONDARY DIAGNOSES: DM2 Back pain Depressive sx Anxiety sx Somatization features Dyslipidemia Discharge Condition: Stable. Discharge Instructions: Please take all medications, including insulin, as prescribed. You should take 50 units of glargine insulin (lantus) every morning. You should take the humalog insuling according to the sliding scale provided to you. Call your PCP or return to the ED if you experience shortness of breath, chest pain, nausea, vomiting, diarrhea. Followup Instructions: Please see your PCP [**Name Initial (PRE) 176**] 1 week for further medical management, call number below for an appointment: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 250**] You have an appointment with the diabetes nurse educator on [**2130-1-30**] at the [**Hospital **] Clinic, [**Location (un) **] at 10:30am. You will be taught how to do insulin coverage when you get sick.

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icd9cm

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icd9pcs

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2429, 4345

8159, 8574

2135, 2139

6331, 7530

7580, 7651

6175, 6308

7803, 8136

2154, 2410

7672, 7748

276, 281

355, 1661

1683, 1758

1774, 2119

12,586

128,300

10715

Discharge summary

report

Admission Date: [**2182-4-10**] Discharge Date: [**2182-5-3**] Date of Birth: [**2118-2-18**] Sex: F Service: CHIEF COMPLAINT: Transferred from outside hospital, congestive heart failure exacerbation. HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 35080**] is a 64-year-old woman with coronary artery disease, mitral valve stenosis with recent admission to [**Hospital1 69**] for congestive heart failure, coronary artery disease, requiring mitral valve replacement, however, was deemed not a surgical candidate who underwent an attempted valvuloplasty at [**Hospital6 1129**]. Her postoperative course is complicated by failure to extubate, hypotension requiring pressors, Heparin induced thrombocytopenia, atrial fibrillation requiring amiodarone. Was transferred to rehabilitation facility on [**4-6**]. Patient was recovering until [**4-9**] when she developed increased dyspnea. Chest x-ray there demonstrated large left and small right effusion. Patient was then transferred to [**Hospital6 3426**], where she was intubated for respiratory distress, and noted to have a heart rate in the 120s, rhythm atrial fibrillation. At [**Hospital3 **], the patient received digoxin for rate control, noted to have a temperature of 106 with blood cultures drawn. Had a limited echocardiogram which demonstrated preserved LV/RV function without effusion from which time per patient's family request, the patient was transferred. PAST MEDICAL HISTORY: 1. Coronary artery disease, 50% mid right coronary artery, 100% mid left anterior descending artery, 90% D1, 80% distal circ. 2. Mitral valve stenosis, valve area of 0.7 cm with history of valvuloplasty x2. 3. Mitral regurgitation. 4. 2+ aortic stenosis, mild congestive heart failure, ejection fraction 51%. 5. Kyphoscoliosis with severe restrictive lung disease. 6. Breast cancer status post radical left mastectomy in [**2153**] with treatment with chemotherapy and radiation. 7. History of alcohol abuse, although no use in the past 20 years. 8. Status post tonsillectomy. 9. C section x2 and gout. MEDICATIONS AT REHABILITATION CENTER: 1. Nitropaste. 2. Coumadin. 3. Aspirin. 4. Amiodarone. 5. Xanax. 6. Lopressor. 7. Multivitamin. 8. Allopurinol. 9. Pepcid. MEDICATIONS ON TRANSFER: 1. Neo 5.2. 2. Vitamin K. 3. Digoxin 0.125 mg IV q day. 4. Zantac 50. 5. Ativan 1 mg IV prn. SOCIAL HISTORY: Patient worked as an attorney. She is now retired and lives alone. She has no tobacco use, distant alcohol abuse. FAMILY HISTORY: No early coronary disease. ALLERGIES: Heparin causing thrombocytopenia, and pork, and clams. Tolerates IV contrast. REVIEW OF SYSTEMS: Not available. PHYSICAL EXAMINATION: Temperature 101.6, blood pressure 77-85/40-58, heart rate 86-91, respirations 20, and 100%. General: Middle-aged woman intubated, slightly agitated, alert. HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Noted with G tube in place. Neck is supple, obese. Cardiovascular: Distant holosystolic murmur at apex and intermittently audible diastolic murmur at upper sternal border. Pulmonary: Coarse breath sounds, positive rhonchi anteriorly. Abdomen: Mild distention, normoactive bowel sounds, soft, nontender, nondistended, positive hernia. Extremities: No edema; thready dorsalis pedis and posterior tibialis; bilaterally warm. Neurologic: Alert and not following commands. Skin: Positive erythema and scaling. LABORATORIES ON ADMISSION: White count 12.7. Differential: 86 neutrophils, 7 lymphocytes, 5 monocytes, 1 eosinophil. Hematocrit 30.5, platelets 508. Sodium 138, potassium 4.5, chloride 99, bicarb 26, BUN 17, creatinine 0.8, glucose 74, calcium 7.3, magnesium 1.4, phosphorus 3.2. LFTs within normal limits. Urinalysis: Large blood, 30 protein, trace ketones, and small bile, moderate leukocyte esterase. HOSPITAL COURSE: Dr [**Last Name (STitle) **] was attending of record on evening of initMs. Schitial intense evaluation. On [**2182-4-11**], CCU attending of record was Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Mrs [**Known lastname 35080**] was monitored in the admission evening in the Coronary Care Unit and underwent evaluation of her congestive heart failure and mitral stenosis. Her mitral stenosis was evaluated by emergency echo was found to be severe, despite prior effort at percutaneous valvuloplasty at [**Hospital1 2025**]. Here, formal surgical consultation was obtained and again she was determined to not be a candidate for surgery given her history of radiation treatment in the chest, her anatomic abnormalities with a kyphoscoliosis, and generalized deconditioning, and sepsis. She underwent evaluation for any other improvement in cardiac hemodynamics including cardiac catheterization with shuntogram which demonstrated trivial left to right shunting from a perforated atrial septum. Her aortic stenosis was deemed mild. It was determined she would unlikely benefit from further intervention. She was maintained on Neo-Synephrine for hypotension with eventual switch to Levophed. She was eventually poorly responsive though to Neo-Synephrine. Eventually, her Levophed was gently weaned off with stable blood pressures by [**2182-4-25**]. She maintained normal sinus rhythm throughout hospitalization, was maintained on amiodarone. 2. Pulmonary: The patient required full ventilatory support through [**2182-4-25**]. She was persistently febrile with initial sputum samples demonstrating MSSA pneumonia. She was maintained on Vancomycin throughout hospitalization as well as Zosyn. On [**4-25**], she was essentially able to be successfully extubated, however, continued to require significant levels of Morphine for tachypnea. Infectious Disease: Patient with persistent fevers and hypotension of unclear etiology. Patient was cultured repeatedly. She underwent tap of bilateral pleural effusions which demonstrated transudative fluid only. She had no skin breakdown. Liver function tests remained stable with modest elevations in her total bilirubin which were self limited. She had no evidence of skin breakdown. The patient underwent significant diuresis initially. She was made negative approximately 5-6 liters. However, she developed severe contraction, alkalosis at this level of diuresis without significant improvement in her hemodynamics or pulmonary function. Then gently allowed to equilibrate and further treatment of her congestive heart failure included therapeutic drainage of her bilateral pleural effusions. Eventually, patient's metabolic alkalosis corrected sufficiently for extubation. Neurologic: Patient was initially, alert and appropriate and following commands, however, on approximately [**4-20**], she began developing tremors. Patient's Versed and Reglan were discontinued at this time as they were felt to be possible contributors. She no longer was able to appropriately follow commands even after extubation. All sedation was weaned. She continued to have intermittent tremors. The patient declined further evaluation with head CT scan and neurologic examination given overall poor prognosis. On [**4-25**] at time of extubation, patient's family made the decision to continue her care at comfort measures only given her poor long-term prognosis. She was continued only on Morphine drip. Her medications at this time with discontinuation of any further congestive heart failure management and antibiotics. On [**2182-5-2**], she deceased peacefully with the family at her bedside. CAUSE OF DEATH: 1. Sepsis. 2. Congestive heart failure. 3. Mitral stenosis, severe. DR.[**Last Name (STitle) **],[**First Name3 (LF) 420**] 11-628 Dictated By:[**Last Name (NamePattern1) 7485**] MEDQUIST36 D: [**2182-5-3**] 14:58 T: [**2182-5-7**] 08:24 JOB#: [**Job Number 35081**]

[ "482.41", "785.59", "255.4", "427.31", "398.91", "038.8", "276.4", "396.0", "511.9" ]

icd9cm

[ [ [] ] ]

[ "34.91", "96.6", "96.72", "37.21", "38.93", "00.13", "88.72" ]

icd9pcs

[ [ [] ] ]

2511, 2631

3879, 7876

2690, 3463

2651, 2667

144, 219

248, 1453

3478, 3861

2266, 2360

1475, 2241

2377, 2494

13,837

177,997

10871

Discharge summary

report

Admission Date: [**2162-4-22**] Discharge Date: [**2162-4-25**] Date of Birth: [**2086-7-12**] Sex: F Service: MEDICINE Allergies: Colchicine / Atorvastatin / Cinacalcet Attending:[**First Name3 (LF) 99**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 75 yoF w/ ESRD on HD (T, Th, Sat) who is a nursing home resident presenting to the ER with shortness of breath. She became SOB early a.m. in addition to a cough, denies chest pain or other associated symptoms. Her SOB occured while supine, she was awake and felt acutely short of breath, she sat up and her breathing improved slightly but still felt short of breath so she let her nurse know and was sent to the hospital. She complains of 1 week of cough, no F/C, no hemoptysis, cough is non productive. No medication non compliance or dietary indescretion per patient. At baseline for the past few weeks (s/p admission/discharge for line infection) she has been working w/ physical thearpy and has dyspnea with PT, walks around room w/ assistance and walker. No angina. . She states her baseline weight is about 150 or so however, she currently weighs 124.5 lbs. She is unaware about any weight loss and feels as though she weighs the same as usual. . She has no chest pain or anginal symptoms. . In EMS she rec'd 3 sprays of NTG, and was started on BiPAP in the ambulance. . In the ER initial VS were: T 98.4 HR 96 BP 200/108 O2 sat 100% on CPAP. She was started on a nitrogtt, renal was consulted for dialysis, she was continued on BiPAP (started in EMS). VS prior to transfer to the floor were: HR 79 BP 197/77 RR 15 O2 sat: 97% on 4L. Past Medical History: Diabetes Dyslipidemia Hypertension - Complicated proximal humerus fracture ([**6-/2161**]): followed by orthopedics, currently advised to avoid L arm weight bearing - Stroke, per family 2, one about 4-5 years prior and one >20 yrs ago family is unsure of deficit - Post polypectomy bleed admitted on [**4-24**] for BRBPR - ESRD on HD: Tues, Thurs, Sat at [**Location (un) **]. - CHF: ECHO [**2162-3-25**]: EF 30-40%. LVH (moderate, and diastolic dysfunction) - Hypertension - Type 2 DM: diagnosed >40 years ago, complicated by ESRD, controlled on insulin - Sarcoidosis with ocular involvement: seen every 3 months for eye exam - not biopsy proven - Gout: last flair [**10-18**]; usually occurs in R toes - Knee surgery s/p fall - Obstructive sleep apnea: [**2161-8-12**] sleep study shows moderate obstructive sleep apnea consisting mainly of hypopneas that produced substantial drops in oxygen saturation. Social History: No smoking history. History of rare ethanol intake. No illicit drugs. Currently resides at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] after L arm fracture, usually lives with her daughter. Ambulatory with cane at baseline. Family History: Hypertension, Diabetes mellitus type 2. Physical Exam: Vitals - T: 98.0 BP: 211/94 HR: 81 RR: 27 02 sat: 100% on 4L GENERAL: NAD, AOx3 HEENT: MMM, OP clear, JVP 10cm, distended EJ CARDIAC: RRR, 3/6 SEM at the USB, high pitched and mid-peaking, good carotid upstroke and no radiation, [**3-20**] HSM at the apex- soft. LUNG: poor respiratory effort, rales [**2-13**] way up bilaterally, no wheezes ABDOMEN: soft, NT, ND, no masses or orgnaomegaly EXT: WWP, no c/c/e NEURO: Grossly normal, AOx3 SKIN: no rashes . Pertinent Results: ================== ADMISSION LABS ================== . [**2162-4-22**] 08:25AM BLOOD WBC-7.0 RBC-3.25* Hgb-9.9* Hct-32.7* MCV-101* MCH-30.5 MCHC-30.3* RDW-17.2* Plt Ct-194 [**2162-4-22**] 08:25AM BLOOD Neuts-52 Bands-0 Lymphs-12* Monos-3 Eos-33* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2162-4-22**] 08:25AM BLOOD PT-13.5* PTT-26.8 INR(PT)-1.2* [**2162-4-22**] 08:25AM BLOOD Glucose-198* UreaN-35* Creat-5.0* Na-138 K-5.1 Cl-99 HCO3-29 AnGap-15 [**2162-4-22**] 08:25AM BLOOD CK(CPK)-29 [**2162-4-22**] 08:25AM BLOOD CK-MB-NotDone cTropnT-0.12* proBNP-[**Numeric Identifier 35404**]* [**2162-4-22**] 08:25AM BLOOD Calcium-10.2 Phos-5.0*# Mg-2.6 [**2162-4-22**] 08:31AM BLOOD Lactate-1.3 . ============== RADIOLOGY ============== . CHEST, AP: The examination is suboptimal due to underpenetration, patient motion, and low lung volumes. The lungs are clear without consolidation or edema. There is mild crowding of vascular markings. Note is made of tracheal wall calcifications. There are no pleural effusions or pneumothorax. There is unchanged moderate cardiomegaly. The aorta is slightly tortuous. A right dual-lumen central venous catheter is again seen with tip in the mid right atrium. IMPRESSION: No acute cardiopulmonary process. . EKG: IVCD, slightly worse STE in AVR and STD in II. LAE. . ECHO: 2/110/10: EF 30-40%, global hypokinesis. Mild LVH w/ wall thickness of 1.4, symmetric. RV normal. indeterminate PASP. Severe MAC, 1+MR. Mild AS. . CXR [**2162-4-22**]: moderate CHF, bilateral pleural effusions (small), no focal infiltrate, Tunneled Right sided HD catheter in RA. Brief Hospital Course: 75 yoF w/ a h/o HTN, DM, ESRD on HD (T,T,Sa) presents with acute onset SOB. SOB/Hypoxia: The patient had acute onset shortness of breath. EF is 30-40 and also has moderate LVH She improved with positive pressure and a nitro gtt. She is very hypertensive and the likely cause is fluid overload. Etiology of heart failure is presumed to be hypertensive heart disease however the patient has never had a cardiac cath, and her hypokinesis is global. She ruled out for an MI. SOB markedly improved with dialysis and ultrafiltration. The patient was dialyzed on Thursday, underwent UF for 2L on Friday and dialyzed again on Saturday with another 2 L removed. Her new dry weight is 53 kg. She was sating 100% while supine on room air prior to discharge. She should continue irbesartan (switched to losartan while at the [**Hospital1 18**] for formulary reasons) and carvedilol 12.5mg po bid upon discharge. After Eospinophilia: Has had this in the past without clear explanation. Has had negative stool O&P, in addition has had a normal cortisol in the past and there has been a thought of possible sarcoid but this has not been further evaluated. Stool O&P was negative. She should follow up with an allergist. Dr. [**First Name8 (NamePattern2) 2602**] [**Name (STitle) 2603**] ([**Telephone/Fax (1) 14583**] Medications on Admission: B Complex-Vitamin C-Folic Acid 1 mg po daily Allopurinol 100 mg po qod Carvedilol 12.5 mg po bid Docusate Sodium 100 mg po bid Irbesartan 150 mg Tablet po bid Lactulose 15mL [**Hospital1 **] on MWF Ranitidine HCl 75mg po bid Sevelamer Carbonate 1600 mg po tid Simvastatin 80mg daily Senna 8.6 mg Tablet 2 tablets tid Aspirin 81 mg po daily NPH 12 units qam Regular insulin sliding scale Plavix 75 mg po daily Discharge Medications: 1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as directed sliding scale Subcutaneous four times a day: Regular insulin sliding scale and NPH 12 units qam. 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at bedtime) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Primary Diagnosis: Pulmonary Edema, acute on chronic CHF Hypertensive Emergency Discharge Condition: stable, sating 100% on room air Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. You were admitted for pulmonary edema (fluid in your lungs) which was treated with fluid removal during dialysis. Please return to the hospital if you have any further shortness of breath, chest pain, or any other symptoms that concern you. No changes were made to your medications. Followup Instructions: Please follow up with your PCP [**Name9 (PRE) **],[**First Name3 (LF) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 608**] within 2 weeks of your discharge. Please follow up with Dr. [**First Name8 (NamePattern2) 2602**] [**Name (STitle) 2603**] ([**Telephone/Fax (1) 14583**] upon 4 weeks of your discharge. Completed by:[**2162-4-25**]

[ "285.21", "135", "288.3", "274.9", "428.0", "404.93", "250.40", "272.4", "428.33", "V45.11", "426.3", "327.23", "585.6", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "39.95", "93.90" ]

icd9pcs

[ [ [] ] ]

7764, 7837

5054, 6369

305, 311

7961, 7995

3446, 5031

8418, 8765

2913, 2954

6829, 7741

7858, 7858

6395, 6806

8019, 8395

2969, 3427

258, 267

339, 1698

7877, 7940

1720, 2629

2645, 2897

78,920

177,455

53805

Discharge summary

report

Admission Date: [**2194-4-9**] Discharge Date: [**2194-4-18**] Date of Birth: [**2131-5-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2782**] Chief Complaint: alcohol withdrawal, delirium tremens Major Surgical or Invasive Procedure: endotracheal intubation [**2194-4-10**] History of Present Illness: Pt is a 62 yo male with a h/o etoh abuse transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for etoh withdrawal and question of intraventricular hemorrhage. Pt was found down with a right forehead abrasion and reported at the OSH that he tripped and fell on pavement. He denies any loss of consciousness. Head and C-spine at the OSH were concerning for possible intraventricular hemmorhage. He was hypertensive, tachycardic and hyperpertensive and there was concern for alcohol withdrawal and he was given 1 mg of ativan at the OSH before transfer. His potassium was also found to be 2.9 and he was given 40 mEq K in his IVF. . On arrival to [**Hospital1 18**], his initial VS were 150, RR: 22, BP: 152/93, O2Sat: 97 on 2 L NC. He was tremulous and agitated requiring 5 people to place him in restraints. In the ED he was given 28 mg of IV lorazepam within the first 30 minutes. He received a total of 36 mg iv lorazepam. His OSH head showed focal rounded area of hyperdenisity within temporal [**Doctor Last Name 534**] of L lateral ventricle, may represent acute IV hemorrhage.Neurosurgery evaluated the pt and recommended loading with dilantin 750 mg iv x1. He also received IVF with thiamine and folic acid. Repeat K here was 3.6. Prior to transfer his, BP dropped to 50/57 and his dilantin infusion was slowed. His VS prior to transfer were: 98 ??????F, P: 67, RR: 15, BP: 89/58, O2 Sat 100% on 2 L NC. . On arrival to the ICU, patient was tremulous, unable to assess for pain. Past Medical History: EtOH dependence, h/o withdrawal Hypertension GERD HCV Social History: Per patient, has a house and lives with a girlfriend (has not been able to contact her). Reports having a daughter. Drinks 18 [**Name2 (NI) 17963**]/day, +tobacco. Family History: noncontributory Physical Exam: On admission: Vitals: T: 96.9 BP: 133/82 P: 95 R: 10 O2: 98% 2L NC General: tremulous on arrival and mumbled speech then obtunded HEENT: large contusion over right forehead, Sclera anicteric, dry MM, oropharynx clear Neck: c- collar in place Lungs: Clear to auscultation over anterior chest 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 NEURO: Pupils 3 mm ->1 mm bilaterally, equally reactive, initially moving all extremites with tremor, then with rest, withdraws to pain equally in all extremities . Pertinent Results: ADMISSION LABS: [**2194-4-9**] 03:45AM BLOOD WBC-6.1 RBC-3.67* Hgb-12.3* Hct-36.8* MCV-100* MCH-33.6* MCHC-33.4 RDW-12.2 Plt Ct-109* [**2194-4-9**] 03:45AM BLOOD Neuts-78.9* Lymphs-11.9* Monos-8.3 Eos-0.2 Baso-0.7 [**2194-4-9**] 03:45AM BLOOD PT-12.2 PTT-27.3 INR(PT)-1.1 [**2194-4-9**] 03:45AM BLOOD Glucose-139* UreaN-7 Creat-0.8 Na-136 K-3.6 Cl-100 HCO3-22 AnGap-18 [**2194-4-9**] 03:45AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.4* TOXICOLOGY: [**2194-4-9**] 03:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG DISCHARGE LABS: MICROBIOLOGY: MRSA SCREEN: NEGATIVE IMAGING: [**2194-4-9**] CXR: Compared to the previous radiograph, there is a subtle right medial and basal opacity, consistent with aspiration in the appropriate clinical setting. Otherwise, unchanged normal chest radiograph with normal size of the cardiac silhouette. The observation was made at 10:08 a.m. on [**2194-4-9**] and the findings were communicated at the same time to the referring physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and the findings were discussed over the telephone. [**2194-4-10**] CXR: AP single view of the chest has been obtained with patient in semi-upright position. Comparison is made with the next previous similar study of [**2193-4-8**]. On previous examination identified right lower parenchymal density partially overshadowed by the heart contours and apparently located in the right lower lobe posterior segment has cleared up. No new pulmonary abnormalities are identified and no pulmonary vascular congestion is found. Similar as on the preceding examination of [**4-9**], there is a rounded mass overlying the contour of the ascending arch. This abnormality has not changed significantly since yesterday. Comparison with a supine chest examination transferred from [**Hospital3 26615**] Hospital, this mass is new. Unfortunately, the transferred image is not identified by date. [**2194-4-10**] CXR: Patient with alcohol withdrawal and concern for aortic dissection, intubated for sedation for CT. Comparison is made with prior study performed five hours earlier. ET tube tip is in standard position, 4.2 cm above the carina. There are lower lung volumes with increasing bibasilar opacities. There is no evident pneumothorax. Cardiomediastinal silhouette is unchanged. [**2194-4-10**] CTA CHEST: 1. No acute aortic pathology. No CT abnormality to account for the radiographic abnormality described on chest radiographs [**2194-4-10**]. 2. Bibasilar atelectasis with volume loss in the lower lobes bilaterally. Supervening aspiration cannot be excluded. No pneumonia. Secretions in the left main stem bronchus. 3. 4-mm right middle lobe nodule. If the patient has no risk factors for malignancy, no followup is needed. If the patient has risk factors for malignancy, followup with dedicated chest CT in one year is recommended if there is no prior imaging documenting stability. 4. Fatty liver. [**2194-4-12**] CT HEAD: IMPRESSION: Study is somewhat limited by motion; within this limitation, no acute abnormality is seen. ATTENDING NOTE: Study limited. Outside CT shows blood near left temporal [**Doctor Last Name 534**] which is not apparent on current study. The scalp hematoma is decreased. . [**2194-4-17**] CT HEAD: IMPRESSION: No acute intracranial hemorrhage or mass effect. Previously seen left temporal [**Doctor Last Name 534**] blood products are no longer present. Brief Hospital Course: HOSPITAL COURSE: Patient is a 62 yo male with history of alcohol abuse who was brought to OSH after fall and found to be in ETOH withdrawal at OSH with question of intraventricular hemorrhage and transferred to [**Hospital1 18**] for further eval who required 36 mg iv lorazepam in the ED for signs of ETOH withdrawal, intubated for CTA given concern for question of aortic dissection and for increasing agitation. Patient was kept on propofol and IV ativan prn while intubated. He was started on standing ativan for agitation and extubated successfully on [**4-13**]. . # Alcohol withdrawal/Delirium Tremens: Patient had evidence of delirium tremens and severe alcohol withdrawal in the ED with tachycardia to 150s, BP to 153/93, agitation and question of hallucinations. He received 36 mg iv lorazepam in ED. Patient was first maintained on IV ativan prn on CIWA, however, he required increasing doses of IV ativan, up to 16 mg at a time. He was intubated and placed on propofol gtt with prn ativan for increasing agitation, and for the need for CTA of chest (as below) given question of aortic dissection. His agitation and ativan requirement decreased over time and he was started on standing PO ativan and extubated successfully. He was started and continued on thiamine, folate and MVI daily. His Mg and K were repleted aggressively throughout the hospital stay. He required intermittent doses of IV haldol for acute agitation. Pt remained stable and was transferred to the floor [**2194-4-15**]. . # Intraventricular hemorrhage vs contusion s/p fall: Patient presenting to outside ED with evidence of trauma given his large R forehead hematoma and lacerations on extremities. CT head was done at OSH and showed possibility of intraventricular hemorrhage and transferred to [**Hospital1 18**] for neurosurgery eval. Patient seen in ED by neurosurgery who reviewed the imaging, which showed a hypodensity in R temporal [**Doctor Last Name 534**]. C-spine was cleared by CT and by exam. It was thought to be due to artifact and no hemorrhage seen. He had no edema on head CT from OSH. Neurosurgery recommended Dilantin 100 mg q8hrs x7 days for prophylaxis. Patient had an episode of oversedation and unresponsive, and given change on neuro exam on [**4-12**], repeat head CT was obtained without acute abnormality. Had f/u head CT on [**4-17**], which continues to show no evidence of acute abnormaility or bleed. . # Question of aortic dissection: Patient has a new finding on CXR of potential aortic dissection. Given discordant blood pressure of 150/90 right arm and 130/85 left arm, and as patient was unable to relate clear history given his agitation, he was intubated and CTA of chest was obtained. The imaging did not show aortic dissection. . # History of GERD: Pt has hx of GERD per OSH, on pantoprazole daily per OSH record. He was continued on pantoprazole in house. . # Social: patient reports living in a house with a girlfriend, and also reports a daughter. Unable to contact any of these people, social work was consulted to assist with locating family members and to assist with his alcohol dependence. Daughter was able to be located, is amenable to becoming health care proxy. #Conjunctivitis: erythema, injection, and exudate on R eye present on [**4-18**]. Rx for erythromycin drops started Medications on Admission: none known Discharge Medications: 1. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) Ophthalmic QID (4 times a day). Disp:*1 tube* Refills:*0* 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**]/[**Hospital1 8**] VNA Discharge Diagnosis: Primary Diagnosis: Alcohol withdrawal Acute delirium HCV Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted with a fall while intoxicated. You were sent here as there was concern that you had bleeding in your brain. Your follow-up head imaging showed resolution of bleeding in your brain. You were briefly on precautionary (prophylactic) anti-seizure medication. You were seen by the S/W regarding your alcohol abuse history, and you were provided with information regarding resources for alcohol abuse treatment. You Should not be driving. Medication changes: STARTED Thiamine and Folate Started Erythromycin eye ointment Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] Location: [**Hospital1 **] [**Location (un) **] Address: [**Doctor Last Name **], [**Location (un) **],[**Numeric Identifier 89216**] Phone: [**Telephone/Fax (1) 84402**] Appt: [**4-24**] at 9:15am

[ "401.9", "793.19", "E939.4", "070.54", "781.3", "920", "372.30", "E888.9", "303.91", "291.0", "292.81", "530.81" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

10148, 10219

6430, 6430

340, 381

10319, 10319

2964, 2964

10988, 11242

2202, 2219

9813, 10125

10240, 10240

9778, 9790

6447, 9752

10426, 10882

3519, 5936

2234, 2234

10902, 10965

264, 302

409, 1928

6249, 6407

2980, 3502

10259, 10298

2248, 2945

10334, 10402

1950, 2005

2021, 2186

14,427

167,648

23965

Discharge summary

report

Admission Date: [**2183-6-10**] Discharge Date: [**2183-6-15**] Date of Birth: [**2125-1-11**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: motor cycle crash rib pain, elbow pain Major Surgical or Invasive Procedure: none History of Present Illness: Pt is 58 yr-old gentleman adm on trauma service from OSH s/p motorcycle crash in which pt was trying to avoid hitting a coyote & dropped cycle at approx 45mph. Pt was wearing helmet, -LOC, -tox screen. Transferred from OSH c/o R rib and R elbow pain. Past Medical History: Coronary Artery Disease, Hypertension, Hyperlipidemia, Diabetes Mellitus Type II, GERD, Hiatal Hernia, Hypothyroidism, Chronic back pain, History of Kidney Stones, s/p Rotator Cuff Surgery, s/p Polypectomy, s/p Tonsillectomy Social History: 90 pack year history of tobacco, quit [**2173**]. Admits to rare ETOH. Currently lives with his wife and works for [**Name (NI) 22957**]. Family History: Denies premature CAD. Physical Exam: P75, BP 170/80, RR22, 90% mask GEN: on backboard, NAD HEENT: NCAT, airway clear, TMs clear, PERRL PULM: Good BS B/L, no chest crepitus, mild ? paradoxical movement of R chest CV: RRR, strong pulses b/l in U/LE ABD: S/NT/ND Ext: no gross deformities, pain w/ palp over R elbow pelvis stable, back no stepoffs/deformity, tenderness over t3/t4 chin abrasion, R elbow abrasion rectal: good tone,no blood,Guiac NEG Pertinent Results: [**2183-6-10**] 02:23AM WBC-18.8* RBC-4.74 HGB-15.4 HCT-41.4 MCV-87 MCH-32.4* MCHC-37.0* RDW-14.5 [**2183-6-10**] 02:23AM PT-13.8* PTT-22.5 INR(PT)-1.2* [**2183-6-10**] 02:23AM PLT COUNT-286 [**2183-6-10**] 02:23AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2183-6-10**] 02:23AM BLOOD Amylase-64 [**2183-6-10**] 02:40AM BLOOD Glucose-143* Lactate-1.0 Na-139 K-4.2 Cl-107 calHCO3-25 CHEST (PORTABLE AP) [**2183-6-10**] 4:31 PM Status post CABG. Heart size is borderline for technique. Discoid atelectases are present at the left lung base. Minimal blunting left costophrenic angle. No pneumothorax. Compared with previous film of same date, there has been marked improvement with significant resolution of the bilateral pulmonary opacities noted on the prior study. CT C-SPINE W/O CONTRAST [**2183-6-10**] 2:28 AM No cervical spinal fractures. Mild anterior spondylolisthesis of C4 and C5 with degenerative changes of the facet joints. Densities in the visualized lung apices CT T/L-SPINE W/O CONTRAST [**2183-6-10**] 2:32 AM 1. No fractures or malalignment of the thoracolumbar spine. 2. Acute rib fractures of the right posterior fourth through eighth ribs. 3. Extensive consolidation and ground-glass densities of the visualized lungs as well as interlobular septal thickening and a small right pleural effusion. Brief Hospital Course: Pt arrived in ED in NAD, but c/o R rib/flank pain and R elbow pain. Pt. was afebrile and P75, BP 170/80, RR 90% on mask ventilation. Pt was imaged and found to have post rib fx #[**3-9**], no elbow fx despite pain, and likely underlying pulm contusions. The pt was admitted to TSICU for pain management and pulmonary toilet, then transferred to the floor for continued care on HD 2. The patient remained on appropriate GI/DVT prophylaxis throughout his hospital course. Hospital course by system is described below: Neuro: Pt remained A/O x4 throughout. His pain was controlled initially with Dilauded PCA changed to morphine PCA later on HD 1, then transitioned to PO pain meds of tylenol and oxycodone on HD4. CV: Pt remained normocardic/tensive throughout hospital stay on home Rx of Quinapril, Coreg and Lipitor. EKG on admission ws NSR, 1st deg. AV block, age indeterminate ant/inf MI, and no PVCs compared to previous EKG. Pulm; pt was initially hypoxic likely secondary to injury. With pain control and aggressive pulmonary toilet CXR and chest CT revealed interval improvement that corresponded to clinical improvement of pt's oxygenation/ventilation. Good pain control was maintained to maximize respiratory effort. GI/FEN: Pt. was initially NPO, then NPO secondary to nausea which responded to Rx and his diet was advanced appropriately as this resolved. Fluids/electrolytes were maintained and he had no issues regarding this. Heme/ID: Pt remained afebrile, and no Abx tx given while in hospital. GU/Renal: Pt. received foley catheter which was d/c'd on HD4, no UTI and good UOP throughout. Ext: R elbow showed no fx on XR. Abrasions were cleaned and dressed appropriately. Medications on Admission: Metformin 1000", Plavix 75', Levothyroxine 88mcg', ASA 81', Relafen 750", Fluticasone 50mcg, Quinapril 10' MVI, lipitor 40', Albuterol, Prilosec 20', Coreg 25", lasix 80', insulin regimen: (pt is [**Name (NI) **] pt.) Glargine 29 gpm, Humalog 26 at every meal. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a day. 10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Status post motorcycle crash Rib fractures: Right posterior #[**3-9**] pulmonary contusion Discharge Condition: good Discharge Instructions: You were transferred to [**Hospital1 18**] due to injuries incurred from your motorcycle crash. You were treated by the trauma surgery team. Your injuries were fractures to your ribs #[**3-9**] on your right side. You were admitted to the intensive care unit to closely monitor your pain control and lung fuunction given your rib fractures. Please resume all medications that you were taking before this hospital admission. Follow the discharge instructions and please arrange follow up as described below. If you experience increasing pain not controlled with your medication, difficulty breathing, severe cough, fever, pain with breathing, HA or any other symptoms that worry you please seek medical attention. Followup Instructions: Please follow up with the trauma surgery clinic in [**12-3**] weeks. Call [**Telephone/Fax (1) 6429**] to make an appointment.

[ "E816.2", "250.00", "807.05", "724.5", "V45.81", "530.81", "244.9", "401.9", "V58.67", "V13.01", "414.00", "861.21", "V15.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5834, 5840

2916, 4604

353, 360

5975, 5982

1528, 2893

6745, 6877

1060, 1083

4916, 5811

5861, 5954

4630, 4893

6006, 6722

1098, 1509

275, 315

388, 640

662, 888

904, 1044

60,762

122,926

4282

Discharge summary

report

Admission Date: [**2135-6-30**] Discharge Date: [**2135-9-18**] Date of Birth: [**2097-2-6**] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Amoxicillin / Omeprazole Attending:[**First Name3 (LF) 8487**] Chief Complaint: Neutropenic fever / epigastric pain Major Surgical or Invasive Procedure: Bone marrow biopsy. PICC line removal. Tunneled line placement. Bone marrow biopsy. History of Present Illness: 38 y/o female with history of ALL, diagnosed [**9-23**], status post complete remission induced by five cycles of chemotherapy but with recent relapse by bone marrow biopsy [**2135-6-13**] status post admission for reinduction chemotherapy [**Date range (1) 18555**] who presented to the ED from home with epigastric pain and fevers. . Her admission was prompted first by a call to the [**Date range (1) 3242**] floor at approx 9pm on [**6-29**] with concerns that she was not feeling well. She noted epigastric pain for approximately three days associated with diarrhea and nausea. She was directed to call the [**Month/Year (2) 3242**] fellow on call, and when she mentioned fever to 100.2 associated with chills and rigors, she was directed to the ED for evaluation. . In the ED her vitals with T 99.1 orally, HR 109, BP 128/87, RR 16, and satting 100% on RA. She received 2gm cefepime, IV dilaudid, and was pan-cultured. CXR was without evidence for pneumonia. She was guiac negative. No CT scan was performed. . On review of systems, she denies cough, shortness of breath, or diaphoresis. Her diarrhea has resolved, but her abdominal pain continues. She notes it has been occurring since tuesday, is worse with eating, and is constant all day and evening. Past Medical History: PAST ONCOLOGIC HISTORY: # Her ALL was diagnosed in [**9-23**], [**Location (un) 5622**] chromosome negative. She underwent 4 cycles of part A and part B hyperCVAD and 1 cycle of maintenance therapy. As above, she had a recent relapse of her disease by bone marrow biopsy on [**2135-6-13**] and had re-induction chemotherapy on [**6-17**] with plans to undergo matched un-related allogeneic stem cell transplantation if a donor becomes available. Her treatment course has been complicated by -F+N, low back pain, C diff, -surgical debridement and extraction of a tooth on [**2135-2-11**] due to dentoalveolar abscess to bone -vaginal Herpes outbreak while in hospital [**Date range (1) 18555**]. . OTHER PAST MEDICAL HISTORY: # DMII # HTN # s/p tonsillectomy # s/p cholecystectomy # s/p tooth #12 flap, fistulectomy and debridement [**2134-12-26**] # s/p upper left tooth extraction on [**2135-2-11**] # vaginal herpes Social History: Lives alone in [**Location (un) 669**]. Originally from [**Country 3515**]. Previously worked as a financial aid officer in a bank. No EtOH, no tobacco. Family History: ? sickle cell train in sister. + for HTN in parents and for DM in both sets of grandparents. Physical Exam: On admission VS: 99.5 99 16 120/88 97%RA GEN: Well appearing, in no acute distress HEENT: moist mucus membranes, no oral ulcers. Some subtle whitening CV: RRR s1, s2, no M/G/R RESP: CTA bilaterally ABD: soft - most tender to palpation in mid epigastrum. no rebound or guarding EXT: no ulcers, no edema, no foot lesions, good sensation Pertinent Results: LABS AT ADMISSION: . [**2135-6-30**] 06:03AM GLUCOSE-174* UREA N-11 CREAT-0.6 SODIUM-140 POTASSIUM-3.7 CHLORIDE-109* TOTAL CO2-25 ANION GAP-10 [**2135-6-30**] 06:03AM ALT(SGPT)-57* AST(SGOT)-49* LD(LDH)-223 ALK PHOS-72 AMYLASE-41 TOT BILI-0.5 [**2135-6-30**] 06:03AM LIPASE-27 [**2135-6-30**] 06:03AM ALBUMIN-4.0 CALCIUM-8.3* PHOSPHATE-3.8 MAGNESIUM-1.8 [**2135-6-30**] 06:03AM WBC-0.1* RBC-3.01* HGB-9.0* HCT-26.0* MCV-86 MCH-30.0 MCHC-34.7 RDW-13.4 [**2135-6-30**] 06:03AM NEUTS-30* BANDS-0 LYMPHS-45* MONOS-5 EOS-10* BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-10* [**2135-6-30**] 06:03AM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-2+ TEARDROP-2+ [**2135-6-30**] 06:03AM PLT SMR-LOW PLT COUNT-34* [**2135-6-30**] 06:03AM PT-14.5* PTT-31.5 INR(PT)-1.3* [**2135-6-30**] 03:00AM COMMENTS-GREEN TOP [**2135-6-30**] 03:00AM LACTATE-0.7 [**2135-6-30**] 02:40AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2135-6-30**] 02:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2135-6-29**] 12:00PM GLUCOSE-239* UREA N-12 CREAT-0.7 SODIUM-141 POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13 [**2135-6-29**] 12:00PM WBC-0.1*# RBC-3.16* HGB-9.7* HCT-27.0* MCV-85 MCH-30.6 MCHC-35.8* RDW-13.6 [**2135-6-29**] 12:00PM NEUTS-18.2* BANDS-3.0 LYMPHS-51.5* MONOS-15.2* EOS-12.1* BASOS-0 [**2135-6-29**] 12:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ TEARDROP-1+ [**2135-6-29**] 12:00PM PLT SMR-VERY LOW PLT COUNT-37* [**2135-6-29**] 12:00PM GRAN CT-27* .. MICROBIOLOGY: [**6-30**]: [**11-19**] blood cultures positive for coag neg staphylococcus. .. STUDIES . CT CHEST ([**2135-7-13**]): New bilateral pleural effusions are very tiny. Dependent ground-glass opacity in both bases clears in inspiration and prone imaging and are due to air trapping. One 9 x 7 mm bulla in right lower lobe is unchanged (4A:106). Lungs are otherwise clear. There is no lymph node enlargement using CT criteria. There is no pericardial effusion. Airways are patent to the subsegmental level. This study was not tailored for subdiaphragmatic evaluation except to note clips in the upper abdomen. Bones are normal. IMPRESSION: 1. New very tiny bilateral pleural effusions. 2. Otherwise, normal exam. No findings of infection. . RUQ ULTRASOUND ([**2135-7-7**]): The liver is diffusely echogenic. No focal liver lesions are identified. There is no intrahepatic biliary ductal dilation. The CBD is likely nondilated, though could not be specifically identified. Portal venous flow is hepatopetal. The kidneys are normal without hydronephrosis. The aorta is normal caliber. The spleen and pancreas are normal. IMPRESSION: Echogenic liver most likely fatty infiltration. More severe forms of liver disease such as cirrhosis and fibrosis cannot be excluded on the basis of this examination. . PELVIC ULTRASOUND ([**2135-7-7**]): IMPRESSION: 1. Heterogeneous 9 mm enodmetrium with possible focal endometrial lesion. Follow up or son[**Name (NI) 18556**] could be performed if desired, for further evaluation of the endometrium. 2. 9 mm right adnexal cyst which today has the appearance of a paraovarian cyst. 4. Enlarging fibroids (largest 2.8 cm). . LUE ULTRASOUND [**7-6**]: No evidence of DVT involving the left upper extremity. . BONE MARROW BIOPSY [**7-6**]: DIAGNOSIS: Relapsed B-acute lymphoblastic leukemia. The biopsy material is adequate for evaluation. The bone marrow cellularity is 80-90%. Bony trabecula are focally thickened. There is an interstitial infiltrate of immature cells consistent with blasts occurring in sheets occupying 90% of marrow cellularity. In the remaining hematopoiesis, the M:E ratio estimate is decreased. Erythroid precursors are decreased and exhibit maturation. Myeloid elements are markedly decreased and exhibit maturation. Megakaryocytes are decreased. Abnormal forms are not seen. Focal loose clustering is noted. Compared to a previous M08-407, S08-[**Numeric Identifier 18557**], the current biopsy shows greater cellularity comprised mostly of blasts with similar morphology to those seen on the prior biopsy. . TTE [**7-19**]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . Bone marrow biopsy [**8-1**]: The biopsy material is adequate for evaluation and reveals a markedly hypercellular bone marrow (90% cellularity). There is an interstitial infiltrate of immature cells consistent with blasts occupying 90% of marrow cellularity. By immunohistochemistry, the blasts are not immunoreactive for CD4 or CD68 (histiocytes staining). Brief Hospital Course: In summary, this is a 38 year-old woman with [**Location (un) 5622**] chromosome negative ALL, previously on chemo-therapy status post induced remission with relapse of disease on bone marrow biopsy [**2135-6-13**] status post reinduction chemotherapy as inpatient [**Date range (1) 18555**] presenting with abdominal pain, fever and neutropenia. # Acute Lymphoblastic Leukemia: Because the infectious work-up was negative, we decided to perform bone marrow biopsy to assess for ALL disease recurrence. The path report is provided above; it showed 80% blasts. Reinduction chemotherapy with hyperCVAD part B was started (D+1 was [**2135-7-12**]). There were no complications during the chemotherapy. She was kept on allopurinol and sodium bicarbonate IV hydration to prevent methotrexate-related renal toxicity. She was started on filgrastim. The decision was made by her outpatient oncologist to pursue an allogenic bone marrow transplant, so screening for bone marrow transplantation was undertaken she had a TTE, PFTs and an HIV test. ID also evaluated her as part of the pre-transplant workup. Unfortunately she started to have recurrent fevers as described above and her bone marrow biopsy on [**8-1**] showed relapse so it was decided to treat her with clofarabine to attempt to induce remission so she could undergo a transplant in the near future. # Neutropenic fever: Granulocyte count was 18 on night of admission. As above, patient received one 2 mg dose of IV cefepime in the ED. When she arrived on the floor there was no clear source of infection; CXR and urine culture were negative and physical exam was remarkable only for mild epigastric tenderness. Blood cultures were drawn; one of four samples grew gram positive cocci so she was started on IV vancomycin. Speciation returned as coagulase negative staph; vanco was stopped but her coverage was later broadened to cefepime and caspofungin due to her persistent fevers and low white counts. Her PICC line was removed and cultured. This was negative. Blood cultures remained negative on broad spectrum antibiotics but she continued to spike fevers overnight. No infectious source was identified. She was restarted on IV vancomycin for continued fevers and also developed diarrhea and was found to be C. diff positive and so was started on po flagyl. She stopped having fevers for a while, however they began again on [**7-26**]. A CT of her chest showed no active disease, a CT of her sinuses showed no sinusitis, cultures were all negative and it was thought that the fevers were due to her ALL so a bone marrow biopsy was done on [**8-1**] which showed a packed marrow. She continued to have fevers while being treated with clofarabine, however her fevers resolved a few days after her course of clofarabine was completed. Approximately two weeks after clofarabine completion on [**8-16**], with an ANC of 0, the patient again developed fevers. Her PICC was pulled. Chest and abdominal CT did not show any source. Blood cultures grew vancomycin-resistant enterococcus. Linezolid was initially started but switched to daptomycin out of concern for linezolid-induced bone marrow suppression. # Tachypnea: The patient was noted to be increasingly tachypneic in the context of VRE bacteremia. CT chest was consistent with volume overload, and she was tentatively diuresed given pericardial effusion (below). On [**8-18**], her tachypnea was worsening, and she was transferred to the ICU for further management. # Acute Pancreatitis: A few days after completing clofarabine she developed persistent abdominal pain. She had had a MRI to evaluate a possible new nodule seen on abdominal US, however the MRI showed no liver pathology except for iron deposition. An abdominal CT showed pancreatitis so she was made NPO and given aggressive IV hydration and dilaudid for pain control. TPN was started for nutrition. Flagyl was stopped as this could exacerbate pancreatitis. After 6 days when she was still experiencing significant pain, abdominal CT was done to evaluate for complications, and it was negative for abscess or necrosis. # C.diff infection: The patient developed diarrhea and was found to be C.diff positive on [**7-18**]. She was started on po flagyl and her diarrhea resolved. She was continued on flagyl as she remained neutropenic on broad spectrum antibiotics. She was switched to po vancomycin when she developed pancreatitis. # Vaginal Bleeding: On HD 2, she started her menses. She had received an injection of medroxyprogesterone acetate in clinic 2 months prior to admission(this is a q3 month injection), but this was ineffective. When her bleeding and fevers continued, GYN was consulted for recs regarding additional progesterone therapy and work-up for gynecologic cause of fevers and abdominal / suprapubic pain. Pelvic exam was negative for cervical motion tenderness. Pelvic U/S showed possible endometrial polyp versus intrauterine clot, two uterine fibroids, and stable right hydrosalpinx versus ovarian cyst. There was no pathology to account for her fevers. Progesterone/estrogen injections as well as GnRH analogues were deferred due to the thromboembolic risks and the low liklihood of any benefit to be had from either therapy in the setting of recent progesterone therapy. Her platelets and red cells were repleted as needed; platelets were transfused to keep levels greater than 30 to minimize menstrual blood loss. Her menstrual bleeding continued until GYN returned for a reevaluation and recommended using a low-dose estradiol patch. After wearing the patch for 2 weeks with an increase in the dose, her menstrual bleeding stopped and she was taken off the estradiol patch. Several days later, she again started bleeding. Gynecology again saw the patient and restarted an estradiol patch. # Initial epigastric pain: Differential diagnosis for abdominal pain at presentation included peptic ulcer disease, pancreatitis, or gastritis (viral or chemical). She had been on protonix, but still may have developed gastric ulcerations or mucosal lesions secondary to steroids (per chemo), viral ulcers, or infection. We continued her pantoprazole and treated her pain with PO dilaudid. H. pylori serology and RUQ ultrasound were negative. We could not perform upper endoscopy due to her thrombocytopenia. Further work-up could be pursued as outpatient when her cell counts recover; however, her epigastric pain resolved during the hospital course. # Genital Herpes: Shortly before presentation, she was diagnosed with vaginal herpes for which she was being treated with acyclovir. This was continued for the duration of the hospitalization. # Hypertension: The patient was initally on her outpatient metoprolol dose, however she had elevated pressures while hospitalized and so had her metoprolol increased to 50 mg daily and 5 mg of amlodipine added. Her BP medications were held during her pancreatitis as she was NPO. She was hypertensive in this setting and was treated with hydralazine and metoprolol IV. # Diabetes: We held her glimepiride and started her on a humalog insulin sliding scale for tighter glucose control. Her home glargine was decreased from 20U to 18U qPM as she had a few episode of midnighttime hypoglycemia. Her lantus was decreased during her episode of pancreatitis as she was on TPN. Insulin in the TPN was titrated upward, with adequate control of hyperglycemia. # Pericardial effusion: TTE showed pericardial effusion with diastolic collapse of the right ventricle consistent with tamponade physiology. Cardiology saw the patient and advised volume resuscitation. This recommendation was balanced with her respiratory distress and anasarca in response to aggressive fluids. ____________________________________________________________ [**Hospital Unit Name **] course [**2135-8-18**]- [**2135-9-18**] The pt was transferred to the [**Hospital Ward Name 332**] ICU [**2135-8-18**] for persistent febrile neutropenia and sepsis. In the [**Hospital Unit Name 153**], she had a long course with recurrent fevers and infections. Infectious disease and the [**Hospital Unit Name 3242**] team were both involved extensively. Nephrology was also involved as the pt was put on CVVH for renal failure. She needed extensive blood and platelet transfusions for persistent anemia and thrombocytopenis. She was intubated for several weeks due to respiratory failure. She did recieve tube feedings and TPN for nutritional support. She was eventually made DNR/DNI on [**9-15**] and, despite use of multiple pressors, succumbed to septic infection on [**2135-9-18**]. Medications on Admission: Metoprolol 37.5mg po qday Acyclovir 400mg po Q 8 hours Glimepiride 2mg po BID Lantus/Humalog sliding scale Discharge Medications: Pt expired on [**2135-9-18**]. Discharge Disposition: Expired Discharge Diagnosis: Pt expired. Discharge Condition: . Discharge Instructions: . Followup Instructions: . Completed by:[**2137-1-17**]

[ "423.9", "250.00", "263.9", "284.1", "995.92", "401.9", "780.61", "518.81", "008.45", "584.9", "204.00", "288.00", "427.5", "E933.1", "486", "V09.80", "280.0", "285.9", "577.0", "623.8", "038.0", "287.5" ]

icd9cm

[ [ [] ] ]

[ "99.15", "39.95", "38.95", "38.93", "96.04", "96.72", "86.05", "00.14", "41.31", "99.25", "88.72", "96.6" ]

icd9pcs

[ [ [] ] ]

17409, 17418

8546, 17197

344, 429

17473, 17476

3322, 8523

17526, 17558

2849, 2944

17354, 17386

17439, 17452

17223, 17331

17500, 17503

2959, 3303

269, 306

457, 1720

2469, 2663

2679, 2833

29,795

186,488

34710

Discharge summary

report

Admission Date: [**2142-7-19**] Discharge Date: [**2142-7-23**] Date of Birth: [**2080-9-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 134**] Chief Complaint: Chest pain, Shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 61 yo male transferred from [**Hospital1 6687**] with chest pain and concern for STEMI, found to have depressed EF but no intervenable acute coronary dz, transferred to CCU from cath lab with hypotension. Per report, pt had normal day on [**7-18**], lifted weights in AM hours - felt fine but admitted to sweating 'much more than usual.' After lifiting, had 10 minutes of chest discomfort, not assoc with breathing, then went away. Had stable day, no acute issues, lied on beach and ate 'pounds' of licorice, then went out with friends, drank 2 bottled Heinekens, went to bed. Awoke semi-acutely in AM on day of presentation with shortness of breath. At [**Hospital1 18**], EKG notable for mild st-elevations in I, II, ?STEMI vs. pericarditis, pt clinically SOB, taken to cath lab. Cath showed no acute coronary stenoses, bedside echo showed global hypokinesis, apex>base, rvedp 12, pcwp 22, CI 1.6. On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. Past Medical History: PMH: 1. obsessive compulsive disorder 2. cocaine abuse history (heavy 97-99, intermittemntly currently) 3. glaucoma Cardiac Risk Factors: (-) Diabetes, Dyslipidemia, Hypertension CURRENT MEDICATIONS: 1. Klonopin prn ALLERGIES: seasonal allergies Social History: Significant for the absence of current tobacco use. +EtOH hx of '[**3-28**]' drinks per week, mostly beer, with red wine. Pt married, has three high school/college aged children. Pt former emergency room physician in [**Name9 (PRE) 760**], 'retired' a >5 yrs ago, moved with family to [**Hospital1 6687**]. Now currently works construction intermittently, sometimes moonlights in ER. Reports cocaine abuse issue in 97-99, then has used intermittently. On initial history today, reported cocaine use 10-14 days ago, ~'1 gram.' Then on repeat questioning, reported significant use the day prior to admission. Pt also sexually active with multiple female partners over past 2 years, last tested >1yr ago, was (-). Has never had STD. Family History: There is no family history of premature coronary artery disease or sudden death. Father died at age 59 with "hypertensive cardiomyopathy," reportedly had 'clean cath a month before' passing. Mother has no hx of coronary disease, alive, with dementia. Physical Exam: VS: T 98.6, BP 96/55 on dopa, HR 94, RR 14, 2L 98% Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP at jaw angle at 20 degrees elevation in bed. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. No friction rub. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: EKG on admission notable for mild st-elevations in I, II with concern for STEMI vs. pericarditis. A subsequent EKG showed ST segment elevations in leads I, aVL and V5-V6 which were consistent with acute lateral myocardial ischemic process. An EKG with right-sided chest leads demonstrated no evidence of right ventricular transmural ischemia. The final EKG done on [**7-19**] showed persistent ST segment elevation in leads I and aVL. The ST segment elevation previously recorded in leads V5-V6 had resolved. EKG on [**7-20**] demonstrated prominent T wave inversions in leads V4-V6 with biphasic T waves in leads V2-V3 and T wave inversions in the inferior leads suggestive of anterior and inferior ischemia. Compared to the previous tracing of [**2142-7-19**] the anterior T wave abnormalities are new. . ETT performed on [**2142-7-19**] demonstrated - The left atrium is normal in size. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis (LVEF = 15-20 %). Right ventricular chamber size is normal with mild global free wall hypokinesis. The number of aortic valve leaflets cannot be determined. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. . Echo on [**2142-7-21**]- Compared with the prior study of [**2142-7-19**] showed left and right ventricular systolic function are markedly improved. The left atrium is mildly elongated. There is mild regional left ventricular systolic dysfunction with very mild hypokinesis of the distal septum and anterior walls. The remaining segments contract normally and overall systolic function is preserved (LVEF = 55-60 %). The estimated CI is normal (>=2.5L/min/m2). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size is normal with focal hypokinesis of the apical free wall. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . CARDIAC CATH performed on [**7-19**] demonstrated: Coronary angiography of this right dominant system revealed nonobstructive coronary artery disease. The LMCA and LCx were without angiographically evident flow limiting stenosis. The LAD had a 40% lesion after D1. The RCA had a 30% mid vessel lesion. Resting hemodynamics revealed elevated right and left sided filling pressures with RVEDP of 12 mm Hg and mean PCWP 22 Hg. PASP was elevated at 42 mm Hg. Systemic arterial pressure was low at 70-80 mm Hg with MAP 46 mm Hg. Cardiac index was depressed at 1.64 mm Hg. . HEMODYNAMICS: elevated pcwp 20, CI 1.6 . LABORATORY DATA: CXR [**7-20**]: FINDINGS: The cardiac silhouette remains at the upper limits of normal. No convincing evidence of vascular congestion. However, there is some increasing prominence of the azygos vein region, raising the possibility of some right-sided heart failure. . [**2142-7-20**] 04:15AM BLOOD CK(CPK)-215* [**2142-7-19**] 12:36PM BLOOD CK(CPK)-359* [**2142-7-20**] 04:15AM BLOOD CK-MB-11* MB Indx-5.1 [**2142-7-19**] 12:36PM BLOOD CK-MB-33* MB Indx-9.2* [**2142-7-19**] 04:25AM BLOOD cTropnT-1.05* [**2142-7-19**] 04:25AM BLOOD CK-MB-49* MB Indx-9.7* proBNP-3913* . [**2142-7-19**] URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-POS amphetm-NEG mthdone-NEG [**2142-7-19**] ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . [**2142-7-19**] WBC-19.5* RBC-5.17 Hgb-15.5 Hct-44.2 MCV-86 MCH-29.9 MCHC-35.0 RDW-13.2 Plt Ct-344 [**2142-7-22**] WBC-6.0 RBC-4.23* Hgb-12.6* Hct-36.8* MCV-87MCH-29.7 MCHC-34.1 RDW-13.1 Plt Ct-205 . [**2142-7-19**] PT-13.7* PTT-28.3 INR(PT)-1.2* [**2142-7-22**] PT-12.5 PTT-22.7 INR(PT)-1.1 . [**2142-7-19**] Calcium-8.8 Phos-3.7 Mg-1.9 [**2142-7-22**] Glucose-89 UreaN-15 Creat-1.1 Na-139 K-3.9 Cl-102 HCO3-29 AnGap-12 . [**2142-7-19**] ALT-22 AST-67* CK(CPK)-503* AlkPhos-80 TotBili-0.9 [**2142-7-19**] TotProt-7.4 Albumin-4.7 Globuln-2.7 [**2142-7-19**] Ferritn-127 . [**2142-7-19**] TSH-5.9* [**2142-7-19**] T4-5.2 . [**2142-7-19**] 05:38AM BLOOD Type-ART pO2-60* pCO2-44 pH-7.29* calTCO2-22 Brief Hospital Course: This is a 61 yo male presenting with shortness of breath and found to have clinical heart failure without underlying coronary artery disease in the setting of intermittent cocaine abuse. During evaluation at an OSH, there was concern for an STEMI and the patient was transferred to the [**Hospital1 18**] cath lab. He was found to have no identifiable coronary disease, but he did have compromised systolic function with depressed EF and increased pcwp. The patient was transferred to the CCU with hypotension requiring pressors which have since been weaned off. The patient was re-echoed and his systolic function improved (LVEF 55-50%) with only very mild hypokinesis of the distal septum and anterior walls. Transient systolic dysfunction and subsequent hypotension was likely secondary to recent cocaine abuse by the patient. . CAD/Ischemia: The patient did not have a prior history of CAD. Cardiac cath showed no acute stenoses. During hospitalization, the patient was started on Lisinopril 2.5mg daily to prevent cardiac remodeling. Pt was also put on Aspirin 81mg daily for secondary cardioprotective effects. . Pump: Cardiac cath revealed a compromised EF (LVEF 15-20%) with a PCWP of 20. He was given IV Lasix in the cath lab to help improve systolic function. CXR on admission showed signs of 'mild CHF.' He demonstrated cardiogenic failure with a compromised CI at 1.4, and did not meet criteria for Impella support. Initial ECHO showed akinesis in ant septum, ant free wall and apex, hypokinesis in inferior septum and inferior wall, normal basal aspects, LVEF 20-30%, and no effusions or valvular problems. The patient required a Dopamine drip to maintain cardiac output, and was eventually weaned once CI and SVR improved. A repeat ECHO on [**7-21**] showed LVEF improved to 55-60%, CI normal (>2.5), mild regional LV systolic dysfunction with mild hypokinesis of distal septum/anterior walls. Clinical heart failure is likely secondary to cocaine abuse. Additional workup yielded RPR -, T4 nml. Lyme serology and HIV testing pending. . Rhythm - No baseline EKG was available for comparison. However, pt's rhythm was sinus for duration of hospitalization. . Valves - Valves were normal on ECHO. . Hypotension - This was likely due to pump failure as described above, and has since improved. . Respiratory failure - On admission, pt had 2L O2 requirements with CXR findings of mild CHF and no identifiable signs of infiltrate or other pathology. Respiratory compromise was likely secondary to pulmonary edema. During hospitalization, oxygenation rapidly improved and pt was satting well on room air at discharge. . Renal failure - Baseline Cr was elevated upon admission to 1.4. Pt had received contrast during cath. The slight rise in creatinine was likely due to poor perfusion. Cr levels have since normalized. . Etoh/cocaine - The pt's actual intake amount of EtOH and cocaine is unclear but his urine tox screen came back positive. AST was mildly elevated at 67, ALT normal at 22, and bili 0.9. In previous discussions regarding substance abuse problems, the pt was not interested to talk to anyone during this stay. He has a psychiatrist who he sees as an outpatient about these issues. Social work was consulted and gave the patient referrals for substance abuse options on [**Hospital1 6687**] but the patient prefers to do one on one counseling with his psychiatrist. . Psych- On the day of discharge the primary team was called by his wife who reported the patient was expressing suicidal ideation. When Dr. [**Known lastname 79570**] was asked about this he denied suicidal ideation and reported he and his wife had one of their typical arguments and he stated "maybe it would have been better for you if I had died" which his wife misinterpreted as suicidal ideation. Psych was consulted and reported he had no acute psychiatric contraindication to discharge. Close follow up was set up with his psychiatrist Dr. [**Last Name (STitle) **]. Psych also recommended that Dr. [**Known lastname 79570**] discuss restarting Zoloft with his psychiatrist. . Glaucoma- The patient continued his home medications: Latanoprost and Timolol. . FEN - The patient was maintained on a cardiac diet. Electrolytes were repleted as necessary, and the patient was diuresed intermittently with Lasix to maintain euvolemia. . Code - Pt is FULL CODE. Medications on Admission: Klonopin PRN Lumigan 0.03 % Drops Sig: One (1) Ophthalmic at bedtime. Istalol 0.5 % Drops, Once Daily Sig: One (1) Ophthalmic qAM. Discharge Medications: 1. Lumigan 0.03 % Drops opthalmic once daily at bedtime. 2. Istalol 0.5 % Drops opthalmic Once daily qAM. 3. Aspirin 81 mg PO DAILY. 4. Klonopin Oral (resume home dosing) 5. Lisinopril 2.5 mg PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Non-ischemic cardiomyopathy secondary to cocaine 2. Substance abuse Secondary: 1. Glaucoma Discharge Condition: Good Discharge Instructions: You were admitted to [**Hospital1 18**] for chest pain with compromised systolic heart function. The etiology of the dysfunction is unclear, but is likely related to your drug abuse. The following new medications have been started: -Lisinopril 2.5mg daily for heart and blood pressure -Aspirin 81mg daily for secondary cardiovascular protection . You were evaluated by inpatient psychiatry and they have suggested that you may benefit from restarting the Zoloft. Please discuss this with your psychiatrist at your next follow up appointment. If you develop cheset pain, jaw pain, or chest pressure with pain radiating into arm, or if you have any concerns about your medical condition, please call 911 or present to the nearest ED. . It is also recommended that you have a lipid panel blood test collected and have results faxed to your PCP. [**Name10 (NameIs) **] is important to assess your need for a cholesterol-lowering drug. Followup Instructions: Please make an appointment to follow-up with: 1. Cardiology: You have a follow up appointment with Dr. [**Last Name (STitle) 3302**] on Wednesday [**8-8**] at 1pm. [**Hospital Ward Name 23**] Building, [**Location (un) 436**]. Call [**Telephone/Fax (1) 62**] with any questions. 2. PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]: Tuesday [**7-31**] at 1:30pm. [**Street Address(2) 79571**], [**Hospital1 6687**]. [**Telephone/Fax (1) 38070**]. Please call [**Telephone/Fax (1) 66939**] to register prior to this appointment. 3. Psychiatrist: Dr. [**Last Name (STitle) **]: Wednesday [**7-25**] at 3pm in ER. This apppointment is only to touch base. Please schedule a routine appointment (call [**Telephone/Fax (1) 79572**]) for Monday [**7-30**]. Completed by:[**2142-8-15**]

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icd9cm

[ [ [] ] ]

[ "37.23", "89.64", "88.72", "88.56" ]

icd9pcs

[ [ [] ] ]

13321, 13327

8544, 12664

345, 371

13475, 13482

4037, 8521

14464, 15307

2873, 3127

13089, 13298

13348, 13454

12933, 13066

13506, 14441

3142, 4018

12682, 12907

274, 307

2053, 2102

399, 1825

1847, 2032

2118, 2857

9,332

115,051

8953

Discharge summary

report

Admission Date: [**2159-9-16**] Discharge Date: [**2159-9-21**] HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old gentleman, oxygen dependent from COPD who was admitted twice last month at [**Hospital3 27946**] for pneumonia, discharged two days prior to admission on Cipro for pneumonia and presents states he has not improved and his status is worsening. Shortness of breath, tachypnea, no fevers, no chills, no cough, positive dark sputum positive weight loss about 30 lbs over the last year, positive exposure to asbestos, positive tobacco and pipe exposure 25 years ago, quit. In the Emergency Room respiratory rate of 32 with 80% oxygen saturation on room air, 90's on a 50% face mask. Given 80 mg gm times one. PAST MEDICAL HISTORY: Two recent admissions to [**Hospital3 31084**] for pneumonia. COPD vs asbestosis on home O2 two liters. Coronary artery disease status post small MI years ago, hypertension, questionable atrial fibrillation, benign prostatic hypertrophy status post TURP years ago and blindness due to macular degeneration. MEDICATIONS: Current medications include Lanoxin .25 mg po Monday, Wednesday, Friday, Saturday, Lanoxin 0.125 mg po Sunday, Tuesday, Thursday, Flovent 4 puffs [**Hospital1 **], Serevent 2 puffs [**Hospital1 **], Protonix 40 mg po q day, Levaquin 500 mg po q day times 21 days, Diltiazem 60 mg po q 6 hours, Humibid DM one po bid, Flomax 0.4 mg po q day, Captopril 12.5 mg po tid, Albuterol 2 puffs each qid, Atrovent 2 puffs qid, Prednisone taper, 20 mg q day times two, then will go to 10 mg q day times two, then to 5 mg q day times two, to 2 mg q day times two, to 1 mg q day times two. Also receiving prn Haldol 0.5 mg po prn q h.s. ALLERGIES: Ativan. He just does not tolerate it well. PHYSICAL EXAMINATION: On admission, generally he was tachypneic, ill appearing, in no apparent distress. He was febrile with a temperature of 102.4, heart rate 110-130 in atrial fibrillation. Blood pressure 110-140/42-81. Mucus membranes were dry. He has a right surgical pupil, left was 2 mm and reactive, no JVD, irregularly irregular heart rate, no murmurs, diffuse rhonchi, decreased breath sounds in the left upper lobe, no wheezes. Abdomen soft, nontender, non distended, positive bowel sounds. Extremities, no edema with ecchymoses. Neuro, alert and oriented to hospital and name, not date. Able to move all extremities. LABORATORY DATA: White count 30.9. Chest x-ray, left upper lobe infiltrate, no CHF. EKG showed atrial fibrillation. HOSPITAL COURSE: The patient first stayed in the unit for a day and a half, treated for his pneumonia, had a CT scan. The CT results, without contrast, he had diffuse emphysema, severe, with bullous changes in the left space, patchy ground glass in consolidation involving the right lower lobe, the left upper lobe, the left lower lobe and the lingula. He had lymphadenopathy in the mediastinum and no plaque or effusion. Chest x-ray at this time showed two left infiltrates with hyperinflated lung fields with bronchiectasis, pneumonia overlying COPD. Throughout his stay after day 2 transferred to a regular floor, continued to improve, his white count went to 14.9, still with a left shift, was being treated on Levaquin and Vancomycin. His heart was being treated with Diltiazem and Digoxin. Saturations continued to improve where he got up to 50% face mask and now is satting well on a 4 liter nasal cannula. Pulmonary evaluated patient and plan was continued to treat pneumonia and decided Vancomycin was unnecessary at that time because there is no evidence for MRSA. Outside cultures grew Pseudomonas and patient continued to be covered by Levaquin and improved. Before discharge patient had a swallow study which showed minor aspiration with thick barium and a little bit more risky aspiration with thin barium. Speech and swallow recommended to keep the patient on thick nectar liquids and to use the chin tuck position in swallowing. The patient will be discharged to rehab and we expect his pulmonary status to improve from this pneumonia although he does have severe COPD. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Much improved. Will be going to rehab. DISCHARGE DIAGNOSIS: 1. Pneumonia. 2. Chronic obstructive pulmonary disease. 3. Coronary artery disease. 4. Hypertension. 5. MAT. 6. Benign prostatic hypertrophy. 7. Blindness. 8. Hard of hearing. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) 9018**] MEDQUIST36 D: [**2159-9-21**] 09:01 T: [**2159-9-21**] 09:36 JOB#: [**Job Number 31085**]

[ "427.31", "501", "492.8", "412", "414.00", "507.0", "401.9", "482.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4240, 4692

2547, 4127

1794, 2529

104, 741

764, 1771

4152, 4219

3,386

122,289

10151

Discharge summary

report

Admission Date: [**2137-5-2**] Discharge Date: [**2137-5-13**] Date of Birth: [**2072-5-17**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 9240**] Chief Complaint: urosepsis Major Surgical or Invasive Procedure: [**Hospital Unit Name 153**] stay [**Date range (3) 33895**] 2 pRBCs on [**2137-5-4**] Right IJ on [**2137-5-2**] History of Present Illness: 64 yo female NH patient with chronic, indwelling foley, mental retardation, recurrent osteomyelitis of thoracic spine s/p fusion [**2136**], recurrent UTIs (recent adm [**2-27**] for urosepsis), DM, HTN, presents from nursing home with nausea and vomiting. Pt is unable to give reliable history. . Per NH transfer records, pt had non-bloody, yellow greenish n/v x 1 on day of admission. No relief with compazine. Following by vomiting x 2. Noted to be febrile to 101.2 and tachycardic to 120 with normal BP and o2 sat. Of note, pt recently had positive Cdiff on [**4-29**], repeat on [**5-1**] was indeterminate. Last large BM on [**4-29**]. . In the ED, initial vitals were 103.9, p120, BP 75/46, rr18, 100% 2L. Pt was given vanco 1gm, Levofloxacin 750mg IV, Flagyl 500mg IV. For ? hyperkalemia (K 6.7 at 8:30pm) was given kayexalate, D50, Insulin 10U - with repeat K of 4.0 at 10:30pm. Pt was given 3L of NS with inc in BP to 99 systolic. Prior to tx to [**Name (NI) 153**], pt's BP dropped to 80s prompting initiation of Levophed. Received addl 1L for total 4L. Past Medical History: - h/o Osteomyelitis T6-T8 with cord compression: s/p T6-7 corpectomy with T5-8 strut graft/fusion on [**2136-10-19**], s/p T3-L3 fusion w/bone graft on [**2136-11-2**], on long-term nafcillin - h/o MSSA epidural abscesses from L4-brain: s/p multiple drainages during prior admissions - h/o ATN requiring HD, now with CRI (recent baseline 1.2-1.4) - anemia likley [**2-22**] ACD, on epo (recent baseline hct 26-28) - h/o upper GIB (no recent scopes in OMR) - COPD - h/o transudative pleural effusion - h/o sepsis - h/o drug resistant acinetobacter from sputum cx (sensitive to tobramycin) - h/o VRE UTI - h/o resp failure: s/p trach and PEG [**2136-11-9**], continues to require vent at rehab - persistent diarrhea (C.diff negative) - Mental retardation - DVT [**1-/2130**] - NIDDM - Obesity - Sciatica - Hypertension - Hypercholesterolemia - Anxiety - Psoriasis - Paroxysmal A. fib - cholelithiasis - hypothyroidism Social History: Lives in a NH. Guardian is [**Name (NI) 402**] [**Name (NI) 33801**] [**Telephone/Fax (1) 33802**]. Family History: Pt unable to provide Physical Exam: VS: 99.9, 135/98, 102, 28, 100 on 4L Gen: lying in bed in NAD, alert and oriented to person and hospital, but refused to answer most other questions HEENT: PEERL, EOMI, OP clear but dry Lung: poor respitory effort, CTAB anteriorly CV: tachy, nl S1 and S2 Abd: soft and obese, occasional moaning to palpation (not reliable exam as pt not consistent during the exam), +BS Ext: no edmea, palpable pulses Skin: multiple pressure ulcers in bottock and back Neuro: A&O to person and place (not name of the hosptial); baseline dementia, refused to answer and follow commandes with rest of the questions Pertinent Results: [**2137-5-2**] 08:30PM BLOOD WBC-25.7*# RBC-3.84*# Hgb-12.7# Hct-37.7# MCV-98# MCH-33.1* MCHC-33.7 RDW-16.2* Plt Ct-292 [**2137-5-2**] 08:30PM BLOOD Neuts-78* Bands-11* Lymphs-3* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2137-5-3**] 03:50AM BLOOD PT-15.9* PTT-34.2 INR(PT)-1.4* [**2137-5-2**] 08:30PM BLOOD Glucose-167* UreaN-84* Creat-3.6*# Na-134 K-6.7* Cl-96 HCO3-21* AnGap-24* [**2137-5-2**] 08:30PM BLOOD Calcium-10.6* Phos-3.4 Mg-2.7* [**2137-5-4**] 01:30PM BLOOD calTIBC-77* VitB12-GREATER TH Folate-19.3 Hapto-261* Ferritn-GREATER TH TRF-59* [**2137-5-3**] 03:50AM BLOOD TSH-0.16* [**2137-5-3**] 03:50AM BLOOD Free T4-0.92* [**2137-5-4**] 12:38PM BLOOD Cortsol-18.2 [**2137-5-4**] 12:39PM BLOOD Cortsol-29.3* [**2137-5-4**] 01:30PM BLOOD Cortsol-31.3* [**2137-5-3**] 03:50AM BLOOD ALT-4 AST-12 LD(LDH)-128 CK(CPK)-40 AlkPhos-69 Amylase-18 TotBili-0.2 Brief Hospital Course: 64 yo female NH patient with chronic, indwelling foley, mental retardation, recurrent osteomyelitis of thoracic spine s/p fusion [**2136**], recurrent UTIs (recent adm [**2-27**] for urosepsis), DM, HTN, presents from nursing home with nausea and vomiting found to be in urosepsis and reported C diff colitis. . # Sepsis- urinary source - pt has indwelling foley catheter and history of recurrent UTI; UA on admission has [**12-10**] WBC, many bacteria, mod leuk, positive nitrites; she has a ho of UTI w/ VRE and enterobacter and successfully treated with daptomycin and imepenem; She was started on IV dapto and merepenem, added cipro for double coverage of gram negatives initially; Blood cx and urine cx grew proteus species sensitive to merepenem; Dapto was discontinued. She was initially started on levophed and IVF bolus to maintain CVP 8 and MAP 60, and she was started on vasopressin on [**2137-5-4**] and weaned off the levophed on the same day, and vasopressin was discontinued 24hrs after that. Pt. was unable to tolerate PICC placement, and given that pt. has only 3 days left of meropenem it was decided to finish this course, then remove her CVL at [**Hospital1 1501**]. . # likely C diff colitis - reported C diff positive on [**2137-4-29**], not on treatment, multiple C diff ho; with elevated WBC of 25 on admission; she presented w/ N/V (emesis guiac negative); abd exam unreliable; reported last BM [**4-29**]; KUB very poor quality; CXR no free air; She was started on PO flagyl; C diff was negative x 2, although her WBC came down nicely with PO flagyl, will continue for 14 day course. . # lactic acidosis - pt is Diabetic, initial UA showed no ketones, no glucose; blood lactate level elevated likely in the setting of sepsis; attempted ABG, but pt consistantly refused and became agitated overnight, VBG showed 7.27/48/52/23 and lactate trending down w/ fluids and abx treatment overnight; continue treatment of her infections as above; her acidosis improved. . # hypotension - likely from her sepsis, intially on IVF bolus and levophed titration to keep MAP 60 and CVP8 which was weaned off; continue treatment of her infection as above; hold bblocker initially, which was restarte at low dose 12.5mg PO bid for PAF control. Sent to [**Hospital1 1501**] on her regular toprol dose as hypotension resolved. . # DM - continued her lantus and SSI, FS QID . # PAF - pt has known history of afib on bblocker for rate control, no on anticoagulation given ho of SDH; She was initailly NSR, and given her hypotension, her bblocker was intially held; had two episodes of AFib w/ RVR on [**2137-5-4**] controlled with IV lopressor 5mg x 1, or IV dilt 10mg x 1; once her hypotension resolved, she was restarted on low dose bblocker. . # ARF - Cr on admission 3.6 up from baseline 0.9 -1.0; likely prerenal in the setting of dehydration; continue IVFs, and Cr gradually improved. . # hypothyroidism - continue synthroid home dose; last free T4 0.4 in [**10-26**]; recheck TSH in the am low; free T4 0.92 # multiple skin ulcers - continue routine wound care and wound cx sent; wound care consulted . # Anemia - baseline Hct 26-28, initial Hct on admission was 37, most likely in the setting of hemoconcentration in the setting of dehydration; now Hct back to baseline this am after fluid resuscitation; received 2 units of pRBCs on [**2137-5-4**] for a hct drop to 22; checked iron panel and B12; Fe supplement was d/c'ed on [**2137-5-5**] and continued Vit B12, epo treatment. . FEN: intially NPO give N/V and IVF bolus and maintenance; gradually started Diabetasource at 70cc/hr continuously through PEJ, can tolerates po fluids. Loves diet ginger ale with ice. . PPX: PPI, hep SC tid . CODE STATUS: Full code. Medications on Admission: Senna MVI Dicloxacillin 500mg tid Fragmin 5000u sc qd Seroquel 12.5mg [**Hospital1 **] Buspar 10mg [**Hospital1 **] toprol XL 25mg qd Ultram 50mg qid prn pain Lantus 6U qd Synthroid 200mg qd Iron 325mg qd Aranesp 60mcg qweek B12 1000mg qmo Vit c 500mg [**Hospital1 **] Neurontin 200mg tid Protonix 40mg [**Hospital1 **] Insulin SS Discharge Medications: 1. Ascorbic Acid 90 mg/mL Drops [**Hospital1 **]: Five Hundred (500) mg PO BID (2 times a day). 2. Gabapentin 250 mg/5 mL Solution [**Hospital1 **]: Three Hundred (300) mg PO Q48H (every 48 hours). 3. Quetiapine 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a day). 4. Levothyroxine 100 mcg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5,000 units Injection TID (3 times a day). 6. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: 325-650 mg PO Q4-6H (every 4 to 6 hours) as needed. 7. Buspirone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 8. Epoetin Alfa 2,000 unit/mL Solution [**Hospital1 **]: 2,000 units Injection QMOWEFR (Monday -Wednesday-Friday). 9. Metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day) for 3 days. Disp:*9 Tablet(s)* Refills:*0* 10. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO DAILY (Daily). 11. Papain-Urea 830,000-10 unit/g-% Ointment [**Hospital1 **]: One (1) Appl Topical DAILY (Daily). 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 13. Toprol XL 25 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO once a day. 14. Metoclopramide 5 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) mg PO QIDACHS (4 times a day (before meals and at bedtime)). 15. Meropenem 500 mg Recon Soln [**Last Name (STitle) **]: Five Hundred (500) mg Intravenous Q12H (every 12 hours) for 3 days. 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: One (1) ML Intravenous DAILY (Daily) as needed: for CVL. 17. Lantus 100 unit/mL Solution [**Last Name (STitle) **]: Six (6) units Subcutaneous once a day. 18. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: sliding scale sliding scale Subcutaneous four times a day. 19. Iron (Ferrous Sulfate) 325 (65) mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 20. Vitamin B-12 1,000 mcg/mL Solution [**Last Name (STitle) **]: One (1) injection Injection once a month. Discharge Disposition: Extended Care Facility: East [**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **] Discharge Diagnosis: Sepsis Due to Urinary Tract Infection Diarrhea Acute Renal Failure Discharge Condition: stable Discharge Instructions: Please continue your medications as listed below. Please follow up with your PCP [**Last Name (NamePattern4) **] [**2-24**] weeks. Followup Instructions: 1. Please follow up with your PCP [**Last Name (NamePattern4) **] [**2-24**] weeks.

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icd9cm

[ [ [] ] ]

[ "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

10470, 10572

4111, 7845

281, 396

10683, 10692

3220, 4088

10871, 10958

2565, 2588

8227, 10447

10593, 10662

7871, 8204

10716, 10848

2603, 3201

232, 243

424, 1491

1513, 2431

2447, 2549

2,090

172,739

53416

Discharge summary

report

Admission Date: [**2137-10-7**] Discharge Date: [**2137-11-11**] Date of Birth: [**2061-4-8**] Sex: M Service: CARDIOTHORACIC Allergies: Amiodarone / Monosodium Glutamate Attending:[**First Name3 (LF) 922**] Chief Complaint: Asymptomatic ascending aortic aneurysm Major Surgical or Invasive Procedure: [**2137-10-7**] - Redo Sternotomy, Replacement of ascending aorta and total arch. tracheostomy [**2137-10-18**] gastrojejunostomy [**2137-10-22**] History of Present Illness: This 76 year old white male [**Month/Day/Year 1834**] repair of a Type A aortic dissection and coronary artery bypass in [**2-6**]. The aorta was noted to be dissected to both iliacs at that time and he subsequently had coil embolization of left internal iliac aneurysm [**7-10**]. Recent CTA shows increase in ascending aortic diameter to 6.3 cm. He was referred for surgical evaluation. Past Medical History: Peripheral vascular disease ascending aortic aneurysm Type A aortic dissection Hypertension Congestive heart failure Atrial fibrillation s/p ablation [**7-11**] Tachybrady syndrome s/p pacemaker Ventral Hernia Cholelithiasis Diverticulosis Benign Prostatic Hypertrophy Spinal stenosis s/p Replacement of Ascending aorta (26mm Gelweave graft)/resuspension of Aortic Valve /Coronary Artery Bypass Graft x1 (SVG to PDA)[**2-6**] s/p Coil embolization of left internal iliac [**7-10**] s/p Tonsillectomy s/p left trigger finger release hyperlipidemia Social History: He is married with three grown children. He does not smoke and drinks occasionally. He is an art representative for the [**Hospital1 **] Market. His wife is [**Name (NI) 17**] and she can be reached at cell [**Telephone/Fax (1) 109864**] or at work [**Telephone/Fax (1) 109865**]. Family History: noncontributory Physical Exam: Admission: Pulse: Resp: O2 sat: B/P Right: 132/76 Left: 128/80 Height: 5'[**39**]" Weight: 203 lbs General: Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] ventral hernia Extremities: Warm [X], well-perfused [X] Edema Varicosities: None [X] left thigh saph. vein harvest site incision well-healed Neuro: Grossly intact [X],nonfocal exam, MAE [**5-7**] strengths Pulses: Femoral Right/Left: 2+ DP Right/Left: 2+ PT [**Name (NI) 167**]/Left: 2+ Radial Right/Left: 2+ Carotid Bruit Right/Left: none Pertinent Results: [**2137-11-6**] Head CT There is no evidence of hemorrhage, edema, mass or mass effect. There is no evidence of acute vascular territorial infarct. The previously seen hypoattenuating focus within the left frontal lobe is again demonstrated, most likely representing partial volume-averaging effect.The ventricles and sulci are normal in caliber and configuration, unchanged in size in comparison to prior studies. No fracture identified. [**2137-10-25**] Chest CT without contrast There is complete resolution of the pre-existing left pneumothorax with complete reexpansion of the left lung. In the mediastinum, the aortic graft continues to be barely visualized. The parts of the superior pericardial recess that bulge into the aortopulmonary window are of unchanged dimensions. Also unchanged are the diffuse calcifications of the aortic valve and the coronary arteries. The pre-described retrosternal fluid collection is of unchanged apical basal extent, however, its overall thickness has minimally decreased. In unchanged manner, the fluid collection does not contain gas and shows as far as an assessment without contrast is possible. Unchanged moderate cardiomegaly. Minimal increase of the pre-existing bilateral pleural effusions. Newly occurred bilateral dependent areas of atelectasis with air bronchograms. The symmetry and the bilateral nature of the changes favor atelectasis over pneumonia. Newly appeared are minimal uncharacteristic peribronchial nodular opacities in the right lower lung that are too small to represent substantial infectious changes that could cause the clinical symptoms of the patient. Unchanged suspicion of bronchomalacia. 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. A mobile density is seen in the descending aorta consistent with an intimal flap/aortic dissection with likely thrombus. The aortic valve leaflets (3) are mildly thickened. 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. Trivial mitral regurgitation is seen. No masses or vegetations are seen on the pulmonic valve, but cannot be fully excluded due to suboptimal image quality. There is no pericardial effusion. [**2137-10-21**] Echo: IMPRESSION: No evidence of endocarditis. Normal [**Hospital1 **]-ventricular function. Mild aortic regurgitation. Extensive descending aortic dissection with thrombus in the false lumen. Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2137-11-11**] 04:00AM 6.0 3.34* 10.1* 31.2* 93 30.2 32.4 17.0* 224 Source: Line-PICC BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2137-11-11**] 04:00AM 224 Source: Line-PICC [**2137-11-11**] 04:00AM 15.4* 26.8 1.3* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2137-11-11**] 04:00AM 95 42* 1.1 145 4.2 109* 27 13 Source: Line-PICC ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2137-11-3**] 03:15AM 65* 44* 265* 88 18 0.6 OTHER ENZYMES & BILIRUBINS Lipase [**2137-11-6**] 03:15AM 179* CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2137-11-11**] 04:00AM 8.7 3.5 2.3 NEUROPSYCHIATRIC Phenoba Phenyto Valproa Phenyfr %Phenyf [**2137-11-10**] 11:24PM 12.2 [**2137-11-10**] 09:07AM ART 37.1 CPAP 40 86 33* 7.49* 26 Brief Hospital Course: Mr. [**Known lastname 656**] was admitted to the [**Hospital1 18**] on [**2137-10-7**] for surgical management of his ascending aortic aneurysm. He was taken to the operating room where he [**Date Range 1834**] a redo sternotomy with replacement of his ascending aorta and arch. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. He remained intubated and sedated following surgery. Left shoulder and right thigh twitching was noted and a neurology consult was obtained. A head CT was performed which was negative. Repeat scan 2 days later also negative. He continued to have seizure activity and was started on dilantin, Keppra, and ultimately phenobarbital over more than a week with continued frequent seizures whenever Propofol was off. Propofol was turned off to continue to evaluate his neurological status with continued neurology evaluations and continuous EEG monitoring. He had persistent fevers with no source for many days. Eventually he developed a LLL pneumonia with enterococcus in his sputum and positive blood cultures. Ampicillin and gentamicin were started and he defervesced. He eventually was off Propofol without seizures (although still unresponsive) and the phenobarbital was weaned by levels. He re spiked fevers and cultures of sputum on [**10-19**] grew Serratia for which a two week course of Cipro and Vancomycin were given. Lines were changed multiple times during these times. Of note, the patient has a right IJ thrombosis discovered during a line placement. Neurology continued to follow the patient with multiple EEG's performed to evaluate seizure activity. He was weaned off of dilantin, briefly taken off phenobarbital and then restarted on a standing dose. He was weaned down on Keppra with improving mental status but EEG performed on [**2137-11-10**] showed increased seizure activity. His Keppra was increased to 750 mg nightly and he was kept on his maintenance phenobarbital dose per neurology recommendations. CT of the head on [**10-22**] showed hypodensity of the right frontal lobe. Repeat head CT on [**2137-11-6**] showed no acute process. The patient's mental status improved gradually and he was following simple commands, answering questions and moving all extremities at the time of discharge. Per neurology, the patient is to maintain his standing doses of phenobarbital and Keppra and follow up with neurology after discharge from rehab. Multiple discussions were had with his wife and family throughout the course. The patient developed atrial fibrillation during his hospital course and was started on Lopressor for rate control. He was on and off Neo-Synephrine intermittently. He was anticoagulated with Coumadin for afib (which was briefly held due to hematuria). At the time of discharge, he had restarted Coumadin and INR was slowly increasing. He was no longer in atrial fibrillation but being paced with his intrinsic permanent pacemaker at a rate in the 60's alternating with sinus rhythm in the 70's. He was on a maintenance dose of beta blockers. The patient was slowly weaned on the ventilator and on [**10-18**] he [**Month/Year (2) 1834**] a percutaneous tracheostomy at the bedside. See operative note for full details. He was treated for a full two week course for enterococcus pneumonia. He was thought to be colonized with serratia and required no further antibiotic treatment. He did have a left sided chest tube placed for effusion. CXR on [**2137-11-9**] showed small left effusion, left basilar atelectasis. He was tolerating CPAP with a pressure support of 10, becoming tachypneic with lower pressure support trials. CXR on [**2137-11-11**] showed small left effusion and left basilar atelectasis. He was restarted on a 7 day course of Lasix for the effusion. Mr. [**Known lastname 656**] [**Last Name (Titles) 1834**] a minilaparotomy and transgastric jejunal tube placement on [**2137-10-22**]. See operative report for full details. He was tolerating tube feeds at goal. Stools were being guiaced and were negative. The patient had hypernatremia and increased BUN throughout his hospital course. He was thought to be intravascularly dry and Lasix was discontinued. He was given free water and sodium returned to a normal range. Creatinine peaked at 1.9 but was back to baseline (1.1) at the time of discharge. He did have hematuria after foley trauma while on Coumadin. He was seen by urology and started on continuous bladder irrigation. His urine became clear and foley was pulled [**2137-11-9**]. He failed to void and foley was reinserted later that night with small old blood clots evacuated. He was able to be easily manually irrigated and urine was clear at discharge. Per urology recommendations, the patient was started on Flomax and he is to have a repeat voiding trial in 2 weeks. No further urology follow up is needed unless hematuria recurs. Interventional pulmonology was consulted for a question of bronchomalacia after a bronchoscopy. They determined he needed no intervention at this time. Mr [**Known lastname 656**] received multiple units of red blood cells throughout his hospital course. He had iron studies done which showed normal iron levels, low TIBC and low transferrin levels. It was determined that the patient has anemia of chronic disease. He was restarted on Coumadin on [**11-9**] and had a goal INR [**2-5**] for atrial fibrillation and right internal jugular thrombosis. Length of anticoagulation to be determined by the patient's cardiologist and neurologist. At the time of discharge, Mr. [**Known lastname 656**] was afebrile, white blood count was normal, he was being [**Doctor Last Name 2598**] lifted into a chair and tolerating the settings of CPAP 40% PEEP 5 PS 12. His mental status continued to improve. It was felt that he was safe for transfer to a rehabilitation facility at this time. Medications on Admission: Norvasc 5', Lipitor 20', Lasix 20', Lopressor 150", KCl 20', Flomax 0.4', ASA 81', Colace 200', MVI, Multag 400', Lorazepam 0.5', Naproxen prn Discharge Medications: 1. Acetaminophen 650 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: 10 ml PO BID (2 times a day). 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 5. Dronedarone Oral 6. Ranitidine HCl 15 mg/mL Syrup Sig: 10 ml PO DAILY (Daily). 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-4**] Drops Ophthalmic Q6H (every 6 hours). 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**6-12**] Puffs Inhalation Q6H (every 6 hours). 10. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Phenobarbital 20 mg/5 mL Elixir Sig: 7.5 ml PO TID (3 times a day). 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 15. Levetiracetam 100 mg/mL Solution Sig: Five (5) ML PO QAM (once a day (in the morning)). 16. Levetiracetam 100 mg/mL Solution Sig: 7.5 ML PO QPM (once a day (in the evening)). 17. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 18. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Dose for Goal INR 0f [**2-5**]. 19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 20. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO twice a day for 7 days. 21. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Dilated ascending aorta s/p replacement of ascending aorta and arch postoperative seizures Peripheral vascular disease s/p Type A aortic dissection Hypertension Congestive heart failure Atrial fibrillation s/p ablation [**7-11**] Tachybrady syndrome s/p pacemaker Ventral Hernia Cholelithiasis Diverticulosis Benign Prostatic Hypertrophy Spinal stenosis s/p Replacement of Ascending aorta (26mm Gelweave graft)/resuspension of Aortic Valve /Coronary Artery Bypass Graft x1 (SVG to PDA) [**2-6**] s/p Coil embolization of left internal iliac [**7-10**] s/p Tonsillectomy s/p left trigger finger release s/p tracheostomy s/p gastrojejunostomy Discharge Condition: good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. Please contact you [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**] with all wound issues. 2) Report any fever greater then 100.5 3) Flush double lumen PICC with 10 cc NS q shift 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) Wash incision daily with soap and water. No lotions, creams or powders to incision until it has healed (6 weeks). 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month. 7) Check lytes, BUN/Cre, Hct, coags daily until stable - Goal INR [**2-5**] 7) Call with any questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**] Dr. [**Last Name (STitle) 1728**] in [**2-5**] weeks. [**Telephone/Fax (1) 14148**] Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-5**] weeks. Dr [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**] [**Telephone/Fax (1) 1694**] after discharge from rehab Please call for appointments. Scheduled appointments: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2137-12-3**] 10:00 Provider: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**] Date/Time:[**2138-3-7**] 10:00 Completed by:[**2137-11-11**]

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icd9cm

[ [ [] ] ]

[ "38.93", "44.39", "38.45", "31.1", "34.04", "39.61", "33.23", "33.24", "96.72", "96.6" ]

icd9pcs

[ [ [] ] ]

14158, 14224

6170, 12090

338, 487

14909, 14916

2565, 6147

15647, 16400

1794, 1811

12283, 14135

14245, 14888

12116, 12260

14940, 15624

1826, 2546

260, 300

515, 906

928, 1476

1492, 1778

65,904

108,623

4488

Discharge summary

report

Admission Date: [**2158-5-10**] Discharge Date: [**2158-5-11**] Date of Birth: [**2075-12-6**] Sex: F Service: MEDICINE Allergies: Zithromax / Sorbitol Attending:[**First Name3 (LF) 2297**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 82yo female with a history of COPD was admitted from the ED with dyspnea. . She was seen on [**2158-5-5**] with her outpatient pulmonologist Dr. [**Last Name (STitle) 575**] at which time she complained of persistently increased shortness of breath. Her O2 requirement increased from 2L to 3L O2 and was started on prednisone 5mg daily. Then one day prior to this admission, she developed increased shortness of breath, persistent cough with changed sputum production. Associated symptoms include chills, light-headedness, and decreased appetite. On the morning of admission, she was evaluated by her home health aide who recommended that she go to the hospital. She then presented to [**Hospital6 33**]. CXR demonstrated chronic lung disease with RLL disease suggestive of pneumonia. While in the OSH ED, she received levofloxacin, lorazepam, solumedrol, and she was started on BiPap. Since she receives her medical care from [**Hospital1 18**] primarily, she was transferred to [**Hospital1 18**]. . Upon arrival to the [**Hospital1 18**] ED, temp 99.5, HR 90, BP 107/52, RR 21, and pulse ox 90% RA. She received ceftriaxone 1 g IV x1, vancomycin 1g IV x 1, ativan 1mg IV x 1, aspirin 300mg PR x 1. Past Medical History: Past Medical History: -CAD, h/o IMI '[**40**]; dobutamine stress ECHO ([**5-11**]) without ischemia -COPD followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**]; FEV1 0.51 (30% predicted) on last PFTs. -GERD -history of gallstones -biliary colic - ulcerative colitis followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] states recently treated with enemas 2-3 months ago. -depression/anxiety -osteoporosis w/thoracic compression fx -Abd ventral hernia. Stable. -Chronic back pain, currently seen at pain center -hypothyroidism Social History: She is widowed. She lives by herself in [**Location (un) 470**] walk-up apt. Supportive children. No ETOH or tobacco. Family History: n/c Physical Exam: Gen: cachectic, fatigued appearing HEENT: Clear OP, dry mucous membranes NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: poor effort, crackles at right lower bases, poor air movement throughout ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. frequently needs redirection to answer questions. CN 2-12 grossly intact. Preserved sensation throughout. [**4-11**] strength throughout. [**12-9**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred Pertinent Results: OSH LABS: [**2158-5-10**] WBC 26.8 / Hct 35.3 / Plt 280 N 17 / Bands 34 / L 3 / M 3 / Meta 19 / Myelocytes 24 Na 131 / K 3.5 / Cl 83 / CO2 41 / BUN 18 / Cr .5 / BG 82 Ca 8.8 / TP 6.8 / Alb 3.7 / Alk Phos 66 TB .6 / AST 37 / ALT 32 CK 174 / MB 9.8 / Trop T . 1 BNP [**Numeric Identifier 19197**] . [**Hospital1 18**] LABS: [**2158-5-10**] - 7:35pm Na 130 / K 4.7 / Cl 85 / CO2 35 / BUN 19 / Cr .6 / BG 51 Ck 184 / MB 8 / Trop T . 07 Ca 8.1 / Mg 1.5 / Phos 3.1 ALT 34 / AST 64 / Alk Phos 54 / TB .7 / Alb 3.5 / Lipase 11 WBC 20.4 / Hct 35 / Plt 248 N 33 / Bands 60 / L 3 / E 0 / M 1 INR 1.5 / PTT 31.1 . OSH STUDIES: - [**2158-5-10**] CXR - per report - chronic lung disease with right lung disease suggestive of superimposed pneumonia . STUDIES: - ECG [**2158-5-10**] - sinus rhythm with occasional PBCs, normal axis, ~100bpm, no acute ST change - Echo [**6-14**] - EF 45-50% - normal LA; mild LV systolic dysfunction with inferior / inferolateral hypokinesis; mild global free wall HK; Significant pulmonic regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: She was admitted with hypoxia, hypercarbia, and found to have pneumonia on CXR superimposed on COPD. She did not tolerate BiPap and was maintained on high flow mask. She was continued on broad spectrum antibiotics and unfortunately continued to desaturate and further decompensate on high flow mask. She developed bradycardia and asystolic cardiac arrest and died within 5 minutes. She was DNR/DNI as confirmed with the patient. Medications on Admission: HOME MEDICATIONS: 1. Amlodipine 5mg PO daily 2. Aspirin 81mg PO daily 3. Tylenol / Codeine 30/300mg qid prn 4. Spiriva 18mcg inh daily 5. Synthroid 125mcg PO daily 6. Simvastatin 5mg daily 7. Pantoprazole 40mg daily 8. Lorazepam .5mg PO tid prn 9. Lasix 10mg PO daily 10. Advair discus inh [**Hospital1 **] 11. Albuterol 90mcg 1-2 puffs qid prn SOB 12. Lidoderm 5% [**Hospital1 **] 13. Mirapex .125mg qhs prn restless legs 14. Nitrostat .3mg SL NG 15. Hydrocortisone enemas prn 16. Colace 100mg qhs 17. Metamucil PO daily 18. MVI daily 19. Gas-X Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Pneumonia COPD Exacerbation Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

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icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

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5029, 5038

3969, 4400

289, 295

5109, 5118

2880, 3946

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57,172

161,086

8909

Discharge summary

report

Admission Date: [**2117-5-27**] Discharge Date: [**2117-6-1**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2880**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo M w/ CAD (s/p most recent PCI in [**3-/2116**] w/ DES in proximal LAD and stent in RCA), and ischemic cardiomyopathy with an EF of 40% on TTE ([**12-12**]) who was directly admitted from Dr.[**Name (NI) 8664**] clinic with woresening shortness of breath. Pt reports that he has been feeling more short of breath over the past few months and that it is gradually getting worse. He reports he is now dyspneic tying his shoes. He notes peripheral edema off and on. His meds were increased last week he was taking 40mg lasix [**Hospital1 **] and then this week 20mg lasix [**Hospital1 **]. He reports that his weight has been stable this week and not previously. He does not know his dry weight. He reports chest pain 1 week ago that he took nitro for and it resolved in 5 min with no associated symptoms and was when he was at rest. He denies any other episodes. He denies syncope, and history of focal neurological symptoms. He had a 2U pRBC transfusion mid [**Month (only) 958**] for his dyspnea. He lives alone and has been eating a lot of canned soups and microwave meals recently. He deneis fever, chills, or cough. He does report early satiety but no changes in his bowel movements and now N/V, fevers or chills. He denies any recent prolonged travel, or leg pains/unilateral swelling. His weight on [**5-20**] was 165 lbs. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: DM2 Macular degeneration, left eye Osteoarthritis Squamous cell skin lesions, [**11/2105**] Colon cancer s/p colon resection and splenectomy [**2081**] BPH AAA Social History: He has been married for 63 years. He is a retired newspaper printer. Remote history of smoking 20pack years. No alcohol. His wife recently passed away. has a son who is an ophtamologist in CT. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Physical Exam: VS:97.5, 94/66, 91, 26, 98RA GENERAL: Pleasant elderly man in NAD, but unable to speak in full sentences due to tachypnea. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: JVD CARDIAC: RRR, [**3-8**] systloci murmur at the LUSB, S3 present loudest at the LLSB. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN:Bruises on extremities. Trace edema in the ankles bilaterally. No edema in the gluteal region or lower back. PULSES: 2+DP/PT pulses bilaterally Discharge Physical Exam: VS: 98.1, 108/69, 74 (70-110) , 18 96%RA wt 66.1kg (down from General: AAOx3, NAD, lying comfortably in bed flat HEENT: elevated JVP Lungs: Scattered crackles at the bases bilaterally Caridac: Regular rate, multiple ectopic beats. [**3-8**] crescendo murmur at the LUSB. Abd: Soft, nontender, nondistended Extremities: Trace edema in the ankles bilaterally, 2+ pulses, warm and well perfused Pulses: 2+DP/PT bilaterally Pertinent Results: Admission Labs: [**2117-5-27**] 03:40PM BLOOD WBC-7.5 RBC-3.84* Hgb-9.2* Hct-32.4* MCV-84 MCH-23.9* MCHC-28.4* RDW-22.3* Plt Ct-373 [**2117-5-27**] 03:40PM BLOOD Neuts-63 Bands-0 Lymphs-21 Monos-14* Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2117-5-27**] 03:40PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+ Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Target-2+ Burr-OCCASIONAL Acantho-OCCASIONAL [**2117-5-27**] 03:40PM BLOOD PT-13.1* PTT-29.5 INR(PT)-1.2* [**2117-5-27**] 03:40PM BLOOD Glucose-140* UreaN-33* Creat-1.3* Na-140 K-5.4* Cl-104 HCO3-26 AnGap-15 [**2117-5-27**] 03:40PM BLOOD CK-MB-3 cTropnT-0.04* [**2117-5-27**] 11:20PM BLOOD CK-MB-3 cTropnT-0.04* [**2117-5-27**] 03:40PM BLOOD CK(CPK)-49 [**2117-5-27**] 03:40PM BLOOD Calcium-9.4 Phos-4.2 Mg-2.5 Urine Labs: [**2117-5-31**] 11:13AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011 [**2117-5-31**] 11:13AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2117-5-31**] 11:13AM URINE RBC-41* WBC-9* Bacteri-FEW Yeast-NONE Epi-0 [**2117-5-31**] 11:13AM URINE CastHy-84* [**2117-5-31**] 11:13AM URINE Mucous-RARE Discharge Labs: [**2117-6-1**] 06:00AM BLOOD WBC-8.3 RBC-3.84* Hgb-9.0* Hct-32.4* MCV-84 MCH-23.4* MCHC-27.8* RDW-22.2* Plt Ct-328 [**2117-5-31**] 06:06AM BLOOD PT-15.2* PTT-36.3 INR(PT)-1.4* [**2117-6-1**] 06:00AM BLOOD Glucose-152* UreaN-43* Creat-1.2 Na-138 K-3.9 Cl-100 HCO3-29 AnGap-13 TTE [**2117-5-28**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild (non-obstructive) focal hypertrophy of the basal septum. There is moderate regional left ventricular systolic dysfunction with akinesis of the mid- and distal anterior septum and severe hypokinesis of the basal inferior wall (multivessel CAD). There is mild hypokinesis of the remaining segments (LVEF = 35%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Moderate regional left ventricular systolic dysfunction. Moderate calcific aortic stenosis. Mild aortic regurgitation. Compared with the prior study (images reviewed) of [**2116-12-9**], LV function is slightly worse. The other findings are similar. CXR [**2117-5-27**]: IMPRESSION: 1. Small new bilateral pleural effusions. 2. Enlarged cardiac silhouette. Recommend further evaluation with echocardiogram to evaluate for pericardial effusion Microbiology: [**2117-5-31**]: URINE CULTURE NEGATIVE Brief Hospital Course: [**Age over 90 **] yo M w/ significant CAD s/p PCI, ischemic cardiomyopathy (last EF 40% in [**12-12**]), hx of colon cancer s/p resection, DM II and hx of HTN who presented with dyspnea due to decompensated heart failure that improved with diuresis of 5kg. . # Acute on chronic systolic heart failure: patient was volume overloaded on exam on admission with tachypnea to the point of not being able to speak more than a couple of words in a row. He was directly admitted from his cardiologists office for IV diuresis. He was started on a IV lasix drip for diuresis at a very low rate, however his BPs was dropping to 70s systolically (asymptomatically) so he was transferred to the CCU for monitoring during diuresis. He had a repeat TTE to evaluate his aortic stenosis and EF. The likely source of his decompensation is a combination of his high sodium diet and his multiple PACs on his EKG/telemetry. His discharge weight was 66.1kg.At discharge patient is speaking in full sentences without problems and lungs just have scattered crackles at the bases, and trace peripheral edema to the ankles bilaterally. He was counseled in low sodium diets, he showed some resistance to doing this and it is unclear if he was truely ready to change this diet. His family was also counseled on these dietary issues. -Medication changes: 1. Furosemide increased from 20mg po once a day to 40mg po twice a day 2. His Lisinopril was held due to low blood pressures (sBP of 80-90s). This can be restarted as an outpatient pending his blood pressure follow-up 3. He is not on a beta blocker currently which can be discussed as an outpatient given his multiple PACs, and he had a couple of runs of NSVT (8beats) and his HR generally runs 90s-110. This was not started due to his lower blood pressure. 4. Patient will require close monitoring of his weights and respiratory status, he will have cardiac telemonitoring set up to assist with this . #CAD s/p DES in LAD, and RCA- last LHC was [**3-/2116**] with restenting of LAD due to restenosis of the stent. He had negative troponin x 2, and his EKG showed no acute changes. He was continued on his home plavix, full dose aspirin, and statin. #. Acute Renal Failure: Cr 1.3 from baseline of 0.9 which resolved with diuresis. . #Diabetes- his last A1c was 7.1. His oral medications were converted to sliding scale while inpatient and he was restarted on his home medications at the time of discharge. . Your discharge weight is: 145 lbs Transitional Issues: Pending labs: None Medications started: None Medications changed: 1. Furosemide (lasix) increased from 20mg by mouth once a day to 40mg by mouth twice a day Medications stopped: 1. Lisinopril (blood pressure medication being held because your blood pressure was on the lower side). Discuss with Dr. [**Last Name (STitle) **] about restarting this as an outpatient once your blood pressures are checked again. Follow-up needed for: 1. Patient weight 2. Blood pressure- your blood pressure has been on the low side so we held your lisinopril. You should also discuss with your doctor if you should be on a medication called a beta blocker. Medications on Admission: clopidogrel [Plavix] 75 mg Tablet furosemide 20 mg Tablet 1 Tablet(s) by mouth every day sob, taper as directed [**2117-4-14**] glipizide 2.5 mg Tablet (hold while inpatient) lisinopril 2.5 mg Tablet metformin 850 mg Tablet (hold while inpatient) nitroglycerin 0.4 mg Tablet, Sublingual prn polyethylene glycol 3350 17 gram/dose Powder prn constipation simvastatin 20 mg Tablet po qday aspirin 325 mg Tablet MVI sennosides-docusate sodium 8.6 mg-50 mg Tablet -2 tabs prn constipation 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. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: do not take more than 4g in 24 hours. 8. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 9. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual prn as needed for chest pain. 11. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. Discharge Disposition: Home With Service Facility: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12448**] Home Care Discharge Diagnosis: Primary: Acute on chronic systolic heart failure Secondary: Type II Diabetes Mellitus Coronary Artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 30968**], It was a pleasure caring for you here at [**Hospital1 18**]. You were admitted from your cadiologist's office because you were very short of breath and had gained weight recently due to having extra fluid in your legs and in your lungs. It was felt that you would need IV lasix in order to get some of the fluid off. You were likely retaining more fluid due to eating foods that are high in salt (like ramen). While we took off fluid your blood pressures were on the low side so you were in the intensive care unit to be monitored for a short period, before coming back to the regular floor. We took of 11 lbs of fluid. It will be very important to eat less sodium in your diet and to weigh yourself daily. Your discharge weight is: 145 lbs Transitional Issues: Pending labs: None Medications started: None Medications changed: 1. Furosemide (lasix) increased from 20mg by mouth once a day to 40mg by mouth twice a day Medications stopped: 1. Lisinopril (blood pressure medication being held because your blood pressure was on the lower side). Discuss with Dr. [**Last Name (STitle) **] about restarting this as an outpatient once your blood pressures are checked again. Follow-up needed for: 1. Patient weight 2. Blood pressure- your blood pressure has been on the low side so we held your lisinopril. You should also discuss with your doctor if you should be on a medication called a beta blocker. -Please weigh yourself daily and if you gain more than 3lbs [**Name6 (MD) 138**] your MD -Follow a low sodium diet Followup Instructions: Department: [**Hospital1 18**] [**Location (un) 2352**] When: TUESDAY [**2117-6-8**] at 2:10 PM With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIAC SERVICES When: THURSDAY [**2117-6-10**] at 2:40 PM With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital1 18**] [**Location (un) 2352**] When: THURSDAY [**2117-6-17**] at 2:10 PM With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: ORTHOPEDICS When: WEDNESDAY [**2117-8-25**] at 11:25 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11282, 11425

6595, 7906

258, 264

11578, 11578

3626, 3626

13345, 14806

2224, 2339

10269, 11259

11446, 11557

9760, 10246

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292, 1642

3642, 4761

11593, 11736

1836, 1997

1664, 1727

2013, 2208

3185, 3607

64,830

185,071

53520

Discharge summary

report

Admission Date: [**2173-7-21**] Discharge Date: [**2173-8-25**] Date of Birth: [**2109-10-31**] Sex: M Service: SURGERY Allergies: Amoxicillin / adhesive tape / Tegaderm Attending:[**First Name3 (LF) 695**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: [**2173-7-21**]: [**Month/Day/Year **] with sphincterotomy, stent placement History of Present Illness: Mr. [**Known lastname 11679**] had undergone a right hepatic lobectomy on [**2173-6-18**] and had been recovering well: he was discharged with a JP drain in place as it was producing greater than 50-70cc per day of fairly bilious output. He presented for [**Date Range **] on [**2173-7-21**] to evaluate for possible biliary leak and received both sphincterotomy and stent placement in the main duct; contrast extravasation was noted at the level of the intrahepatics without clear localization of the leak. Pre-procedure the patient was noted per report to have a blood pressure in the 80's systolic, though he was mentating well. Peri-procedurally, he became hypotensive to the 60's systolic without evidence of hemodynamic instability. He was resuscitated with upwards of 5L of crystalloid and was placed on Neosynephrine and transferred to the SICU for further monitoring. Past Medical History: PMH: Metastatic colon cancer s/p chemotherapy, HLD, HTN, CAD s/p MI (RCA stent [**2163**], PCI [**12-2**]), COPD, Psoriasis PSH: Right colectomy ([**1-30**]), R. hepatic lobectomy ([**2173-6-18**]) Social History: 35 years smoking, current smoker; occasional alcohol. Denied illicit drug use. No history of IV drug use, marijuana use, blood transfusions, tattoos or piercing. Married; and has two children. Retired [**Hospital1 1559**] Airport limosine driver. Family History: Mother: died at age 73 of metastatic breast cancer. Father: died at age 70 of liver cancer. His maternal grandmother died of unknown causes. His maternal grandfather died of lung cancer. His paternal grandparents died of unknown causes. Physical Exam: Vital Signs: Temp: 98.0 Pulse:65 BP:95/51 RR:17 O2 SAT:97% room air Gen:WD/WN Neuro/Psych: Oriented x3, Affect Normal, NAD, Cooperative with exam. Neck: No masses, Trachea midline, Thyroid normal size, non- tender, no masses or nodules, No right carotid bruit, No left carotid bruit, Supple. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy . Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Soft, Not distended, Not tender to palpation, No masses, guarding or rebound, No hepatosplenomegaly, No hernia, No AAA, Bowel sounds present. Rectal: Normal tone, No gross blood, Guaiac Negative. Extremities: No popliteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes Pertinent Results: Diagnostics: [**2173-7-21**]: ECG: Sinus bradycardia. Prior inferior myocardial infarction. Q-T interval prolongation. Non-specific inferior ST-T wave changes. Compared to the previous tracing of [**2173-6-24**] the rate has slowed, the Q-T interval is prolonged. Clinical correlation is suggested. [**2173-7-21**]: CXR: Small right pleural effusion unchanged since [**7-14**], right infrahilar consolidation increased, most likely atelectasis. Lungs are otherwise clear. No appreciable left pleural effusion. Heart size normal. No free subdiaphragmatic gas. Right upper quadrant drain and biliary catheter in place, not fully evaluated by this examination. [**2173-7-22**]: TTE: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. LV systolic function appears depressed (ejection fraction 40 percent) secondary to severe hypokinesis with focal akinesis of the inferior septum, inferior free wall, and posterior wall. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [**2173-7-25**]: TTE: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular dysfunction with severe hypokinesis of the basal inferolateral wall and akinesis in the remainder of the LV (LVEF = 10%). A left ventricular mass/thrombus is not seen but cannot be fully excluded. The right ventricular cavity is dilated with hyperkinesis of the basal free wall but mid-to-distal wall severe hypokinesis to akinesis (with slight contraction of RV apex). The aortic valve is not well seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial to very small pericardial effusion. There are no echocardiographic signs of tamponade. [**2173-7-25**]: CT abdomen-pelvis: New large right and moderate left pleural effusions. Diffuse reticular opacities in the left lung and right middle lobe, which likely represent infection and less likely asymmetric edema. Pulmonary nodules, many of which are obscured by pleural effusions. Recommend continued followup once acute disease resolves. Status post right hepatic lobectomy with surgical drain and a CBD stent in place. Status post colectomy. Extensive vascular disease with a small infrarenal aortic ectasia/aneurysm. Anasarca. Within the right lower quadrant, located anterior to the right psoas muscle abutting the IVC anterolaterally, is a reniform collection of fluid measuring approximately 4.7 x 9.8 x 3.1 cm (transverse x CC x AP), which could represent a seroma, biloma, or fluid collection. There is no pelvic side wall or inguinal lymphadenopathy by size criteria. [**2173-7-30**]: CT abdomen-pelvis: Fluid collections seen anterior to the right psoas is ascitic in nature. Marked volume overload marked by bilateral pleural effusions, slightly increased on the left since prior, moderate ascites and anasarca. Brief Hospital Course: In brief, Mr. [**Known lastname 11679**] was admitted to the SICU post [**Known lastname **] for hypotension. He was entirely asymptomatic from his hypotension (except UOP was pressure dependent and his Cr did trend up) yet required levophed to maintain his SBP in the 90s (and maintain adequate urine output). He was started on midodrine PO and slowly weaned from the levophed. An echocardiogram demonstrated an EF of 40% but no apparent acute changes. He was eventually weaned from the levophed entirely, hemodynamically stable (on midodrine) and transferred to the floor on HD2. Unfortunately, later that evening, he became hypoxic to an SaO2 of the 80% with tachypnea to the 30s and tachycardia to the 140s. CXR demonstrated new pulmonary edema versus consolidation and he was transferred back to the ICU for further monitoring and resuscitation where he was intubated shortly after transfer for persistent tachypnea and excessive work of breathing. He became hypotensive and required triple pressor therapy to ensure adequate hemodynamics. An echocardiogram demonstrated a new EF of 10% and there were mild but unimpressive troponin rise (cardiology felt was all demand ischemia and the depressed cardiac function was directly related to an inflammatory state....sepsis). A CT scan did not show any acute intraabdominal process (fluid related to ongoing bile drainage present) but did show impressive bilateral ground glass reticular appearance to the lung. He was started on broad spectrum antibiotics to treat the presumed source (pneumonia) and a few days later sputum culture/BAL demonstrated [**Female First Name (un) **] and he was started on fungal coverage with micafungin. He improved rapidly thereafter. There were some changes to his pressor regimen (levophed, vasopressin, dobutamine initially, then transitioned to levo-vaso-milrinone) before he was ultimately able to be successfully weaned. The vent was in the process of being weaned when it he self dc'd it on HD 9 and, to everyone's surprise, did well from a respiratory standpoint, remaining extubated. He was transferred to the floor on HD 14, hemodynamically stable and remained as such for the remainder of his hospital stay (a repeat echocardiogram on HD 18 demonstrated a return to baseline cardiac function with an EF of 45%), which was characterized by optimizing his nutritional status and aggressive physical therapy to build back his strength from his extended stay in the ICU. Pertinent details of his hospital course, by systems: Neurologic: No acute issues on discharge. He was AAOx3 and appropriate. Immediately post-extubation in the ICU, he did demonstrate some temporary confusion and agitation. He was treated to good effect with zyprexa and when he was transferred out of the ICU, he was continued on this medication (zyprexa 2.5 mg daily). Cardiovascular: As described above -- initially hypotensive but with an overall normal/baseline echocardiogram (EF 40%). Upon readmission to the ICU in sepsis, his EF on repeat echo was 10%. He had a swan-ganz catheter placed to assist assessment of his cardiac status. He was on multiple pressors which were eventually weaned when he was adequately treated for his sepsis. His cardiac function returned to baseline, with a repeat echo on [**2173-8-9**] demonstrating a normal EF of 40-45%. He remained hemodynamically stable throughout the remainder of his hospital stay. He was continued on metoprolol 12.5 mg [**Hospital1 **], lisinopril 5 mg daily and aspirin 81 mg. The lisinopril was discontinued prior to discharge as SBP was generally 90-100 Respiratory: Intubated, as above. Treated for severe pneumonia, as above (and see ID section). He remained stable from this perspective post-extubation. No acute issues thereafter. He completed his course of antibiotics (see ID). GI: He was NPO initially, briefly on TPN before a post-pyloric dobhoff was placed on [**2173-7-30**] when tube feeds were started and slowly ramped up to his goal feeding rate. His diet was advanced as well after extubation but he was unable to maintain adequate caloric intake (lack of appetite) prompting continuation of tube feeds and evantually transitioning them to cycled feeds with weaning rate to accomodate for increased caloric intake during the day. on discharge his rate was 45 cc /hour cycled over 12 hours at night GU: Initially had a normal Cr (0.7 on admission), this slowly trended upwards to a peak of 3.2 on [**7-24**] before declining slowly back to his baseline on [**2173-7-30**]. His urine output was adequate and there were no active issues on discharge. ID: Initially started on vanc and zosyn for broad spectrum empiric coverage. He grew enterobacter cloacae (meropenem sensitive) and yeast on a [**7-26**] BAL. He was started on and then completed a two-week course of meropenem and micafungin. He grew coag negative staph on a [**8-6**] blood culture (presumed to be from his central line); the CVL was dc'd and he completed a 5 day course of vancomycin per the recommendations of the ID team. He was afebrile with a normal white blood cell count throughout the tail end of his hospitalization and was discharged without acute ID issues. Medications on Admission: clonazepam 1 [**Month/Year (2) 5910**], diphenoxylate atropine 5/0.5''' PRN diarrhea, lisinopril 10', lovastatin 80', metoprolol tartrate 50'', prochlorperazine 10 q8H, trazodone 50 [**Last Name (LF) 5910**], [**First Name3 (LF) **] 81' Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Lovastatin *NF* 80 mg ORAL DAILY Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 3. OLANZapine (Disintegrating Tablet) 2.5 mg PO DAILY RX *olanzapine 2.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 4. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN diarrhea 5. Tube Feed Order Tubefeeding: Isosource 1.5 Cal Full strength; Goal rate: 45 ml/hr Cycle start: [**2161**] Cycle end: 0800 Flush w/ 30 ml water q6h and when disconnecting tube not in use during day ICD-9: 263.0 6. Metoprolol Tartrate 12.5 mg PO BID Hold for SBP < 100 or HR < 60 RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*15 Tablet Refills:*3 Discharge Disposition: Home With Service Facility: [**Hospital1 **] District Nursing Association Discharge Diagnosis: bile leak bacteremia sepsis pneumonia decompensated CHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if you have any of the following: temperature of 101 or greater, chills, nausea, vomiting, jaundice, abdominal pain, malfunction of feeding tube, increased JP drain output, or output stops, JP insertion site appears red or has drainage, diarrhea or constipation -continue cycled tube feeds as ordered. Flush drain with 50cc of water every 6 hours and after any feeding disconnect. -keep a food diary -empty and record all JP drain output. Bring record of drainage to next appointment with Dr. [**Last Name (STitle) **] [**Name (STitle) 110015**] JP drain dressing daily (dry dressing) Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Infusion Resource will supply tube feeds [**Hospital1 **] VNA has been arranged Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2173-9-1**] 09:00 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2173-9-1**] 09:40 Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2173-9-16**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2173-8-25**]

[ "518.81", "486", "V10.05", "785.59", "412", "428.0", "584.5", "112.4", "305.1", "995.92", "997.49", "999.32", "038.9", "V10.07", "459.81", "V45.82", "287.5", "E879.8", "425.4", "696.1" ]

icd9cm

[ [ [] ] ]

[ "96.72", "51.87", "33.24", "96.04", "99.15", "51.85", "96.6" ]

icd9pcs

[ [ [] ] ]

12554, 12630

6227, 11455

310, 387

12730, 12730

2872, 6204

13730, 14290

1797, 2038

11743, 12531

12651, 12709

11481, 11720

12881, 13707

2053, 2853

259, 272

415, 1293

12745, 12857

1315, 1516

1532, 1781

27,100

166,427

8109

Discharge summary

report

Admission Date: [**2153-7-10**] Discharge Date: [**2153-7-13**] Date of Birth: [**2119-10-6**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: CODE STROKE Major Surgical or Invasive Procedure: Intravenous tPA Left Common Carotid Artery stent Left Middle Cerebral Artery clot retrieval with Penumbra device Transesophageal Echocardiogram History of Present Illness: 33yo man with AML s/p allogeneic transplant c/b GVHD presents with decreased responsiveness, difficulty speaking, and right hemiparesis at IVIG today. On awakening this morning, he took his clonazepam and oxycodone and felt that he should not drive to IVIG, so his mother took him there. There he was interacting, speaking normally. His mother saw him last well at 2:10pm. She went to a doctor's appointment and when she returned to IVIG, he was sleeping. When the doctors tried to [**Name5 (PTitle) **] him up at the end of IVIG, he was difficult to arouse. They examined him and noted speech difficulties, right hemiparesis, and an upgoing right toe. He was sent by EMS to the ED. In the ED, CODE STROKE was called at 4:23. Neurology was at the bedside as he was moved from the guerney. FS 102. NIHSS was 20 for questions, commands, gaze, fields, facial palsy, hemiparesis, sensory deficit, aphasia, dysarthria, and neglect (see below). Past Medical History: Acute Myeloid Leukemia, type M1 See above Mucositis Graft-versus host disease Deep vein thrombosis, left upper extremity GERD anxiety Recurrent C diff infection Recent influenza A ([**2153-2-6**]) [**Hospital 28915**] Medical History: AML Type I - [**2151-8-19**] - allogeneic transplant from unralated donor conditioned with cytoxan and TBI - Course complicated by Grade II GVHD GI tract [**9-/2151**] treated with prednisone - resolved. - [**10/2151**] -- lower extremity weakness and fatigue. After work up felt that symptoms were related to cyclosporin toxicity. -- prednisone was started and cyclosporin adjusted. - [**1-/2152**] Abdominal pain, diarrhea. Admitted to hospital and treated with higher dose of steroids. Colonoscopy showed GVHD. - Oral mucositis treated - prednisone decreased and began phototherapy at [**Hospital1 112**]. - Began Photophoresis [**2152-11-20**]. - s/p 4 weeks Rituxan on [**2153-2-8**] with initial improvement of GVHD. He also developed Influenza A and he was treated with Tamiflu and levaquin. then flare of GVHD and he received another rituxan cycle which was completed at early [**Month (only) **]. - Currently he receives Rituxan once a month alternating with IVIG. Social History: He used to be a lead singer for the band LFO. He has two brothers. Not married. He lives on his own. Contact info: brother [**Name (NI) **] [**Telephone/Fax (1) 28916**] (C). Mother is [**Name (NI) 2013**]. Family History: Grandmother's brother-leukemia, Grandfather (paternal) colon cancer, Grandmother (maternal) RCC. Maternal grandfather-prostate cancer and HTN. Physical Exam: Genl: sitting up in bed, trying to communicate HEENT: NCAT, dry MM CV: RRR, nl S1, S2, no m/r/g Chest: CTA anteriorly Abd: BS+, nontender Ext: warm and dry, right arm down by side, right leg externally rotated NIHSS: 1a. LOC: 0 1b. q's: 1 1c. commands: 1 2. gaze: 1 3. fields: 1 4. facial palsy: 2 5. motor arm: 4, 0 6. motor leg: 4, 0 7. ataxia: 0 (unable to test) 8. sensory: 1 9. language: 2 10. dysarthria: 2 11. neglect: 1 Neurologic examination: MS: Awake, alert, attempting to communicate, speech very dysarthric, seems to be fluent with significant word finding difficulty. Comprehension poor, though able to follow some simple commands. Does not seem to know that he has right hemiparesis. Right sided neglect. CN: Pupils equal, reactive. EOM full to left, with left gaze preference, pass midline on right, exotropia on upgaze. Left facial palsy with some movement. Motor: Antigravity on left. Initially, dense hemiparesis in right arm and leg; prior to IV tPA was able to move leg antigravity. Sensory: Inconsistent response to noxious on right, intact on left. DTRs: hyperreflexic on right; right toe upgoing, left toe downgoing Coord: unable to test Pertinent Results: Na:140 K:4.4 Cl:104 TCO2:26 Glu:85 140 107 20 -----------< 97 4.8 24 1.2 CK: 21 MB: Pnd Mg: 1.9 P: 3.8 14.1 > 38.5 < 301 N:78.0 L:12.1 M:9.1 E:0.7 Bas:0.1 PT: 12.2 PTT: 29.2 INR: 1.0 ALT: 51 AP: 226 Tbili: 0.7 Alb: 3.8 AST: 36 LDH: 245 Other labs: [**2153-7-13**] 06:30AM BLOOD WBC-14.6* RBC-3.37* Hgb-11.1* Hct-32.9* MCV-97 MCH-32.9* MCHC-33.8 RDW-14.3 Plt Ct-306 [**2153-7-13**] 06:30AM BLOOD AT III-PND [**2153-7-13**] 06:30AM BLOOD ACA IgG-PND ACA IgM-PND [**2153-7-13**] 06:30AM BLOOD Lupus-PND [**2153-7-11**] 03:03AM BLOOD %HbA1c-5.6 [**2153-7-11**] 03:03AM BLOOD Triglyc-150* HDL-37 CHOL/HD-5.3 LDLcalc-128 [**2153-7-13**] 06:30AM BLOOD Homocys-PND [**2153-7-13**] 06:30AM BLOOD PROTHROMBIN MUTATION ANALYSIS-PND [**2153-7-13**] 06:30AM BLOOD FACTOR V LEIDEN-PND CMV viral load [**2153-7-10**]: negative Urine culture [**2153-7-10**]: negative Imaging: CT/CTA: CT HEAD: There is subtle loss of the left insular ribbon. No dense MCA is noted. Otherwise, there is no evidence of acute intracranial hemorrhage, edema, shift of normally midline structures, loss of the basal cisterns, or hydrocephalus. The soft tissues and orbits are unremarkable. No fracture or bony destruction is seen in the calvarium. Mucosal thickening is seen along the floor of the maxillary sinuses. Otherwise, the remainder of the paranasal sinuses are well aerated. There is mild opacification of the mastoid air cells, more so on the right. CT PERFUSION: A small region of acute infarct is seen in the left parietal lobe, with associated delayed transit time and decreased blood volume and blood flow. There is a larger area of surrounding ischemia, with delayed transit time but without corresponding decrease in blood volume. CTA HEAD AND NECK: A nearly occluding thrombus is seen in the left common carotid artery, which measures up to 6 mm in diameter and approximately 2.2 cm in craniocaudal dimension. In addition, there is abrupt termination of the contrast column in the mid M1 segment of the left MCA, consistent with occlusion. Collateral blood flow is noted supplying the left MCA distribution. The remainder of the carotid and vertebral arteries and their major branches appear patent. No evidence of aneurysm formation is seen. The V1 segment of the vertebral arteries, particularly on the left, are obscured by beam- hardening artifact from contrast in nearby venous structures. No lymph node enlargement is seen meeting CT size criteria for adenopathy. The thyroid gland appears homogeneous. No masses are seen in the visualized lung apices. No region of bony destruction is seen within the osseous structures. IMPRESSION: 1. Small area of acute infarct in the left MCA distribution with larger surrounding area of ischemia. No hemorrhage or midline shift. 2. Nearly occlusive thrombus in left common carotid artery. Occlusion in mid M1 segment of left MCA. Angiogram [**2153-7-10**]: FINDINGS: Right common carotid artery arteriogram demonstrates normal filling of the right common carotid artery and its branches. The right internal carotid artery fills well along the cervical, petrous, cavernous and supraclinoid portion. The anterior cerebral artery and the middle cerebral artery are seen well. However, there is no cross flow into the left hemisphere through an anterior communicating artery. Injection of the left vertebral artery arteriogram shows normal filling of the left vertebral artery and its branches. Two large right picas are seen. There is no reflux into the right vertebral artery. The superior cerebellar artery is duplicated on the right side. The posterior cerebral arteries fill well, however, there is some ___ collateral seen through the cortical branches of the left PCA, however, this is very poor and the PCOM is seen to be rather small. Left common carotid artery arteriogram shows large amount of thrombus in the common carotid artery 1 cm proximal to the bifurcation and the area of thrombus extends for 30 mm and creates a significant stenosis of the left common carotid artery. The left common carotid artery arteriogram status post stenting shows occlusion of the left M1 by thrombus. The left A1 is patent. Left common carotid artery arteriogram status post mechanical thrombolysis shows recanalization of the left middle cerebral artery with both superior and inferior division completely open. Right common femoral artery arteriogram shows patent right common femoral artery and with no evidence of stenosis. CT HEAD [**2153-7-11**]: Most of the hyperdense material in the left MCA territory has resolved with small amount of hyperdense material remaining in the insular region, likely due to contrast enhancement of infarct. No definite new focus of hemorrhage or new large vascular territorial infarct seen. MRI HEAD [**2153-7-11**]: Region of acute infarct is re-demonstrated along the left lenticular nucleus. However, compared to the CT perfusion of [**2153-7-10**], the region of acute infarct appears to be more extensive, now involving the left caudate nucleus, the left insular cortex, as well as punctate foci along the centrum semiovale and small regions of cortex in the left frontal, parietal and temporal lobes. In addition, regions of residual hyperdensity that was seen along the left centrum semiovale and extending inferiorly into the left insular region that was seen on the CT head of [**2153-7-11**] after washout of contrast enhancement, there are corresponding regions of susceptibility signal dropout, consistent with hemorrhage. There is no shift of normally midline structures, no evidence of hydrocephalus or effacement of the basal cisterns. While mildly irregular, normal vascular flow voids are seen along the left MCA territory as well as along the other major intracranial arteries. The soft tissues and osseous structures are unremarkable. Minimal mucosal thickening is noted in the maxillary sinuses and in the ethmoid air cells. Fluid is also noted in the mastoid air cells, particularly on the right, which is unchanged from the most recent prior head CT. IMPRESSION: 1. Comparison between MR head and prior CT perfusion is difficult, however, there appears to be more extensive infarcts today compared to the CT perfusion of [**2153-7-10**]. Blood products are noted along the left centrum semiovale and the left insular region. There is mild mass effect on the left lateral ventricle, without midline shift. Flow void in the left MCA is demonstrated. TTE [**2153-7-11**]: The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2151-12-9**], no change. TEE [**2153-7-12**]: 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 or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 45 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: No echocardiographic evidence of atrial septal defect or left atrial thrombus. Normal biventricular function. No significant valvular disease. Brief Hospital Course: Mr. [**Known lastname 4469**] was taken from the ED after receiving IV tPA to the angiography suite for intra-arterial intervention. He had a stent placed to open the high-grade thrombotic stenosis of the Left Common Carotid. The clot in the Left MCA was then retrieved using the Penumbra device. He was then admitted to the Neuro ICU for close monitoring. A head CT following the intervention had a hyperintensity suggestive of a hemorrhage versus contrast extravasation. As this had largely disappeared on the follow-up CT 12 hours later, this was attributed to the latter, and he was started on aspirin 325 daily and Plavix 75 daily. His blood pressure was kept under 160 systolic, although he remained largely in the 110s without medical intervention. Both TTE and TEE were negative for PFO or ASD. A hypercoagulability work-up was sent and pending at time of discharge. He was kept on Insulin sliding scale and Tylenol prn temp > 100.4. LDL was 128 and HDL 37; statins are relatively contraindicated in conjunction with cyclosporin, and it is felt that his lipid panel may be addressed by diet and exercise at this point. He was also later started on fish oils (omega 3 fatty acids). Hb A1c was 5.7. The oncology service was also involved in the patient's care. He was soon resumed on cellcept and a reduced dose of cyclosporin (50 mg [**Hospital1 **], rather than 75 mg [**Hospital1 **]) while in house; he was continued on his other medications as scheduled. He received a stress dose of steroids in the ICU, and was tapered to 15 mg q am and 10 mg q pm at the direction of oncology. He was directed to continue this dosing of prednisone until an appointment with oncology four days after discharge. Oncology seemed to agree with Neurology that future sessions of IVIg posed too great a risk of recurrent stroke, given his event this week. MRI did confirm an acute stroke of the left striatum and external capsule, with some involvement of the left insular cortex. His exam was remarkably good, however, given his initial presentation. He regained full strength in his extremities, though had a persistent right facial droop. He had mild anomia, dyscalculia, agraphia, finger agnosia, and left-right confusion. He was transferred to the floor after 36 hours in the ICU, wher his condition remained stable. He was given full clearance by both physical and speech/swallow therapy services and was discharged in stable condition on [**2153-7-13**]. Medications on Admission: acyclovir 400mg [**Hospital1 **] clonazepam 1mg qhs cyclosporine 75mg [**Hospital1 **] dexamethasone - 0.5 mg/5 mL Elixir - 5ml's swish and spit by mouth twice a day as needed for mouth dryness fluconazole 5 mls by mouth daily folic acid 1 mg Tablet daily ativan 0.5 -1mg every six(6)hours prn cellcept [**Pager number **] mg twice a day MYLANTA/LIDOCAINE 2%/BENADRYL ELIXIR - - Mix in 1:1:1 solution. 5cc's swish and spit four times a day as needed for mouth pain oxycodone 5 mg every four (4) hours as needed for pain oxycontin 10 mg twice a day prednisone 30mg by mouth once a day Taper as directed protonix 40mg daily protopic - 0.1 % Ointment - Apply to affected areas twice a day bactrim 200 mg-40 mg/5 mL Suspension - 20 Suspension(s) by mouth 3X/WEEK (MO,WE,FR) ursodiol 300 mg q am and 600mg q pm Allergies: not known drug allergies Discharge Medications: 1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*2* 4. Dexamethasone 0.5 mg/5 mL Elixir Sig: Five (5) ml PO once a day as needed for swish/spit for mouth dryness. 5. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): please give in suspension form, 40mg/ml x 5 ml daily. . 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for anxiety. 8. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. MYLANTA/LIDOCAINE 2%/BENADRYL ELIXIR Mix in 1:1:1 solution. 5cc's swish and spit four times a day as needed for mouth pain 10. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 12. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 13. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO Q AM (). 14. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO Q PM (). 15. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 17. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 18. Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension Sig: Twenty (20) ML PO 3 X PER WEEK, MWF (). 19. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). Disp:*21 Tablet(s)* Refills:*0* 20. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Left lateral lenticulostriate stroke secondary to left common carotid artery and left middle cerebral artery occlusions Discharge Condition: Stable, mild right facial weakness with mild dysarthria, full strength throughout Discharge Instructions: Please take your medications as prescribed and follow up with your appintments as scheduled. You have had a stroke. If you experience any new, worsening, or concerning symptoms (including trouble with speech/language, vision loss, weakness, numbness/tingling), please call your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] at [**Telephone/Fax (1) 682**], your neurologist Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 7394**] (or the [**Hospital1 18**] on-call neurologist at [**Telephone/Fax (1) 28917**]), or head to the nearest emergency room as soon as possible. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2153-7-17**] 11:00 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2153-7-26**] 11:00 Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 9816**], RN Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2153-7-26**] 11:00 Neurology Follow-Up: Date/Time:[**2153-9-18**] 1 pm Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone: ([**Telephone/Fax (1) 7394**] [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

[ "433.11", "E849.8", "453.8", "996.85", "434.01", "528.00", "205.00", "518.81", "300.00", "E878.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "99.10", "00.63", "00.61", "88.72", "00.41", "00.46", "88.41", "96.71" ]

icd9pcs

[ [ [] ] ]

18040, 18046

12701, 15168

328, 473

18210, 18294

4270, 4519

19023, 19772

2920, 3065

16064, 18017

18067, 18189

15194, 16041

18318, 19000

3080, 3510

276, 290

501, 1444

5162, 12678

3534, 4251

1466, 2678

2694, 2904

4531, 5153

22,617

139,974

47980

Discharge summary

report

Admission Date: [**2114-5-5**] Discharge Date: [**2114-6-21**] Date of Birth: [**2050-1-28**] Sex: M Service: PLASTIC Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 5883**] Chief Complaint: Right lower extremity necrotizing fasciitis Major Surgical or Invasive Procedure: Right lower extremity incision, debridement and four compartment fasciotomy foley catheter placement central venous line placement endotracheal tube placement hemodialysis catheter placement orogastric and Dobbhoff tube placement History of Present Illness: Patient is a 64-year-old, obese, diabetic male with CAD presented with a 1-day history of right calf pain. This was preceded by prodromal syndrome and a possible right leg injury. He presented to his PCP with severe leg pain on [**5-4**]. A right-LENI study was negative for any DVT, so he was sent home with tylenol 3. The pain was unremitting so he went to [**Hospital1 56809**] on [**5-5**] after midnight with severe right leg pain and some small bullae. He was evaluated by the surgical team there who noted the bullae had progressed quite rapidly. He was also found to have severe RLE cellulitis, hypotension and ARF. He was then transferred to [**Hospital1 18**] for further care. Past Medical History: PMH: DM2, HTN, gout, CAD, h/o angina, h/o MI [**2098**] PSH: angioplasty [**2099**](?) Social History: works as a machinest Family History: NC Physical Exam: PE on admit: 101.3 104 90/40 20 100% on 100%O2 Sedated, intubated RRR CTAB Abd soft, NT, ND Ext warm, RLE with weeping bullae, +1 edema, no fluctulence Pulses dopplerable DP B/L Pertinent Results: [**2114-5-5**] 09:23PM TYPE-ART PO2-121* PCO2-33* PH-7.26* TOTAL CO2-15* BASE XS--11 [**2114-5-5**] 09:23PM LACTATE-5.5* [**2114-5-5**] 09:23PM freeCa-1.14 [**2114-5-5**] 09:22PM O2 SAT-58 [**2114-5-5**] 09:18PM GLUCOSE-58* UREA N-62* CREAT-3.9* SODIUM-136 POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-13* ANION GAP-23* [**2114-5-5**] 09:18PM CK(CPK)-694* [**2114-5-5**] 09:18PM CK-MB-30* MB INDX-4.3 cTropnT-2.07* [**2114-5-5**] 09:18PM ALBUMIN-2.7* CALCIUM-7.9* PHOSPHATE-5.9* MAGNESIUM-1.6 [**2114-5-5**] 09:18PM WBC-14.0* RBC-3.88* HGB-12.7* HCT-35.8* MCV-92 MCH-32.6* MCHC-35.4* RDW-14.2 [**2114-5-5**] 09:18PM PLT COUNT-186 [**2114-5-5**] 09:18PM PT-14.8* PTT-36.7* INR(PT)-1.3* [**2114-5-5**] 09:18PM FIBRINOGE-557* [**2114-5-5**] 08:25PM LACTATE-4.6* [**2114-5-5**] 08:25PM O2 SAT-56 [**2114-5-5**] 07:15PM TYPE-ART PO2-76* PCO2-41 PH-7.23* TOTAL CO2-18* BASE XS--9 [**2114-5-5**] 07:15PM LACTATE-4.5* [**2114-5-5**] 07:02PM GLUCOSE-59* UREA N-61* CREAT-3.8* SODIUM-137 POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-15* ANION GAP-21* [**2114-5-5**] 07:02PM CK(CPK)-701* [**2114-5-5**] 07:02PM CK-MB-34* MB INDX-4.9 cTropnT-1.83* [**2114-5-5**] 07:02PM WBC-10.6 RBC-4.00* HGB-12.9* HCT-37.1* MCV-93 MCH-32.3* MCHC-34.8 RDW-14.2 [**2114-5-5**] 05:10PM TYPE-ART RATES-/12 TIDAL VOL-850 O2-100 PO2-107* PCO2-43 PH-7.21* TOTAL CO2-18* BASE XS--10 AADO2-588 REQ O2-93 INTUBATED-INTUBATED VENT-CONTROLLED [**2114-5-5**] 03:42PM LACTATE-3.4* [**2114-5-5**] 02:22PM TYPE-MIX PO2-55* PCO2-54* PH-7.13* TOTAL CO2-19* BASE XS--11 COMMENTS-MIXED [**Last Name (un) **] [**2114-5-5**] 02:13PM GLUCOSE-127* UREA N-58* CREAT-3.5* SODIUM-138 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-17* ANION GAP-22* [**2114-5-5**] 02:13PM ALT(SGPT)-73* AST(SGOT)-100* LD(LDH)-258* CK(CPK)-500* ALK PHOS-39 AMYLASE-36 TOT BILI-0.9 [**2114-5-5**] 02:13PM VANCO-8.0* [**2114-5-5**] 02:13PM PT-14.6* PTT-33.9 INR(PT)-1.3* [**2114-5-7**] 06:31AM BLOOD freeCa-1.10* [**2114-5-8**] 12:25PM BLOOD freeCa-1.15 [**2114-5-11**] 04:06PM BLOOD freeCa-1.12 [**2114-5-12**] 08:23PM BLOOD freeCa-1.07* [**2114-5-18**] 09:39AM BLOOD freeCa-1.20 [**2114-5-10**] 08:17PM BLOOD Hgb-9.2* calcHCT-28 O2 Sat-69 [**2114-5-11**] 02:32AM BLOOD Hgb-8.4* calcHCT-25 O2 Sat-71 [**2114-5-11**] 08:01AM BLOOD Hgb-6.5* calcHCT-20 O2 Sat-74 [**2114-5-11**] 05:15PM BLOOD Hgb-8.3* calcHCT-25 O2 Sat-76 [**2114-5-12**] 12:55AM BLOOD Hgb-9.0* calcHCT-27 O2 Sat-74 [**2114-5-12**] 04:11AM BLOOD Hgb-10.0* calcHCT-30 O2 Sat-76 [**2114-5-12**] 08:45AM BLOOD Hgb-9.2* calcHCT-28 O2 Sat-71 [**2114-5-6**] 05:14AM BLOOD Glucose-220* Lactate-5.8* K-5.3 [**2114-5-7**] 07:09PM BLOOD Glucose-102 K-5.0 [**2114-5-10**] 08:10PM BLOOD Glucose-132* K-4.5 [**2114-5-12**] 12:56AM BLOOD Glucose-119* Na-134* K-4.2 Cl-106 [**2114-5-13**] 12:10PM BLOOD Glucose-199* K-3.5 [**2114-5-16**] 11:36AM BLOOD Glucose-115* Lactate-1.2 K-3.8 [**2114-5-17**] 02:49AM BLOOD Glucose-96 [**2114-5-18**] 09:39AM BLOOD Lactate-1.4 [**2114-5-5**] 05:10PM BLOOD Type-ART Rates-/12 Tidal V-850 FiO2-100 pO2-107* pCO2-43 pH-7.21* calHCO3-18* Base XS--10 AADO2-588 REQ O2-93 Intubat-INTUBATED Vent-CONTROLLED [**2114-5-5**] 09:23PM BLOOD Type-ART pO2-121* pCO2-33* pH-7.26* calHCO3-15* Base XS--11 [**2114-5-6**] 05:14AM BLOOD Type-ART pO2-67* pCO2-42 pH-7.26* calHCO3-20* Base XS--7 [**2114-5-6**] 09:38AM BLOOD Type-ART pO2-126* pCO2-36 pH-7.30* calHCO3-18* Base XS--7 [**2114-5-6**] 06:01PM BLOOD Type-ART pO2-150* pCO2-33* pH-7.34* calHCO3-19* Base XS--6 [**2114-5-7**] 06:29AM BLOOD Type-ART pO2-74* pCO2-34* pH-7.28* calHCO3-17* Base XS--9 [**2114-5-8**] 02:20AM BLOOD Type-ART pO2-139* pCO2-27* pH-7.35 calHCO3-16* Base XS--8 [**2114-5-8**] 03:33AM BLOOD Type-MIX pO2-31* pCO2-33* pH-7.32* calHCO3-18* Base XS--9 [**2114-5-8**] 08:37AM BLOOD Type-ART PEEP-10 pO2-143* pCO2-25* pH-7.39 calHCO3-16* Base XS--7 Intubat-INTUBATED [**2114-5-8**] 08:27PM BLOOD Type-ART Temp-36.5 pO2-138* pCO2-40 pH-7.27* calHCO3-19* Base XS--7 Intubat-INTUBATED [**2114-5-9**] 08:18AM BLOOD Type-ART pO2-140* pCO2-43 pH-7.23* calHCO3-19* Base XS--9 [**2114-5-9**] 07:14PM BLOOD Type-ART pO2-123* pCO2-43 pH-7.22* calHCO3-19* Base XS--9 [**2114-5-10**] 12:39PM BLOOD Type-ART pO2-103 pCO2-41 pH-7.27* calHCO3-20* Base XS--7 [**2114-5-10**] 02:33PM BLOOD Type-ART pO2-107* pCO2-41 pH-7.29* calHCO3-21 Base XS--6 [**2114-5-11**] 04:06PM BLOOD Type-ART pO2-110* pCO2-40 pH-7.31* calHCO3-21 Base XS--5 [**2114-5-14**] 03:11AM BLOOD Type-ART pO2-140* pCO2-36 pH-7.43 calHCO3-25 Base XS-0 [**2114-5-16**] 03:54PM BLOOD Type-ART pO2-85 pCO2-44 pH-7.50* calHCO3-36* Base XS-9 [**2114-5-17**] 02:49AM BLOOD Type-ART pO2-119* pCO2-45 pH-7.49* calHCO3-35* Base XS-10 [**2114-5-18**] 09:39AM BLOOD Type-ART pO2-78* pCO2-36 pH-7.47* calHCO3-27 Base XS-2 [**2114-5-14**] 01:38AM BLOOD Vanco-6.6* [**2114-5-15**] 06:51PM BLOOD Vanco-11.6* [**2114-5-16**] 03:10AM BLOOD Vanco-9.9* [**2114-5-6**] 01:00AM BLOOD Cortsol-57.8* [**2114-5-6**] 02:00AM BLOOD Cortsol-62.2* [**2114-5-6**] 09:25AM BLOOD TSH-1.7 [**2114-5-14**] 01:38AM BLOOD calTIBC-186* TRF-143* [**2114-5-17**] 03:24PM BLOOD Calcium-7.7* Phos-3.2 Mg-1.9 [**2114-5-22**] 09:06AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.4* [**2114-5-27**] 06:15AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.5* [**2114-5-28**] 05:55AM BLOOD Calcium-8.4 Phos-4.2 Mg-1.7 [**2114-5-5**] 07:02PM BLOOD CK-MB-34* MB Indx-4.9 cTropnT-1.83* [**2114-5-5**] 09:18PM BLOOD CK-MB-30* MB Indx-4.3 cTropnT-2.07* [**2114-5-6**] 10:00PM BLOOD CK-MB-26* MB Indx-3.0 cTropnT-2.68* [**2114-5-7**] 01:33PM BLOOD CK-MB-15* MB Indx-2.1 cTropnT-2.19* [**2114-5-8**] 06:19AM BLOOD CK-MB-9 cTropnT-1.54* [**2114-5-18**] 03:06AM BLOOD CK-MB-1 cTropnT-0.39* [**2114-5-18**] 08:43AM BLOOD CK-MB-NotDone cTropnT-0.34* [**2114-5-18**] 04:10PM BLOOD CK-MB-NotDone cTropnT-0.32* [**2114-5-19**] 03:06AM BLOOD CK-MB-NotDone cTropnT-0.26* [**2114-5-8**] 06:19AM BLOOD Lipase-17 [**2114-5-9**] 04:12AM BLOOD Lipase-24 [**2114-5-9**] 08:20PM BLOOD Lipase-39 [**2114-5-10**] 03:26AM BLOOD Lipase-44 [**2114-5-12**] 04:00AM BLOOD Lipase-70* [**2114-5-17**] 02:36AM BLOOD Lipase-111* [**2114-5-6**] 09:25AM BLOOD ALT-1175* AST-1391* AlkPhos-46 Amylase-69 TotBili-0.8 [**2114-5-7**] 02:00AM BLOOD ALT-2509* AST-2894* AlkPhos-77 Amylase-58 TotBili-1.2 [**2114-5-7**] 01:33PM BLOOD ALT-2533* AST-2575* CK(CPK)-706* AlkPhos-123* Amylase-42 TotBili-1.1 [**2114-5-8**] 06:19AM BLOOD ALT-1759* AST-1308* CK(CPK)-313* AlkPhos-148* Amylase-24 TotBili-1.4 [**2114-5-9**] 12:17AM BLOOD ALT-1319* AST-795* AlkPhos-179* TotBili-1.9* [**2114-5-9**] 12:50PM BLOOD ALT-966* AST-534* AlkPhos-187* Amylase-21 TotBili-2.2* [**2114-5-10**] 03:26AM BLOOD ALT-794* AST-384* AlkPhos-183* Amylase-25 TotBili-2.9* [**2114-5-12**] 04:00AM BLOOD ALT-482* AST-180* AlkPhos-204* Amylase-29 TotBili-4.3* [**2114-5-13**] 01:48AM BLOOD ALT-362* AST-130* Amylase-45 TotBili-4.3* [**2114-5-17**] 02:36AM BLOOD ALT-120* AST-58* LD(LDH)-218 AlkPhos-201* Amylase-40 TotBili-1.9* [**2114-5-18**] 03:06AM BLOOD CK(CPK)-22* [**2114-5-18**] 04:10PM BLOOD CK(CPK)-28* [**2114-5-19**] 03:06AM BLOOD CK(CPK)-31* [**2114-5-26**] 05:45AM BLOOD ALT-43* AST-24 AlkPhos-113 TotBili-0.8 [**2114-5-13**] 01:48AM BLOOD Glucose-187* UreaN-35* Creat-1.9* Na-138 K-3.6 Cl-104 HCO3-22 AnGap-16 [**2114-5-6**] 01:45PM BLOOD Glucose-144* UreaN-70* Creat-4.4* Na-133 K-4.9 Cl-103 HCO3-16* AnGap-19 [**2114-5-7**] 01:33PM BLOOD Glucose-113* UreaN-84* Creat-5.1* Na-129* K-5.3* Cl-100 HCO3-14* AnGap-20 [**2114-5-7**] 10:00PM BLOOD Glucose-119* UreaN-73* Creat-4.3* Na-130* K-4.8 Cl-103 HCO3-13* AnGap-19 [**2114-5-9**] 08:01AM BLOOD Glucose-102 UreaN-54* Creat-3.0* Na-131* K-4.6 Cl-105 HCO3-17* AnGap-14 [**2114-5-13**] 01:48AM BLOOD Glucose-187* UreaN-35* Creat-1.9* Na-138 K-3.6 Cl-104 HCO3-22 AnGap-16 [**2114-5-17**] 04:53PM BLOOD Glucose-93 UreaN-37* Creat-1.5* Na-143 K-4.2 Cl-109* HCO3-28 AnGap-10 [**2114-5-18**] 03:06AM BLOOD Glucose-206* UreaN-37* Creat-1.4* Na-143 K-4.0 Cl-112* HCO3-25 AnGap-10 [**2114-5-21**] 06:10AM BLOOD Glucose-91 UreaN-33* Creat-1.2 Na-148* K-4.0 Cl-118* HCO3-23 AnGap-11 [**2114-5-27**] 06:15AM BLOOD Glucose-77 UreaN-14 Creat-1.1 Na-136 K-4.0 Cl-102 HCO3-26 AnGap-12 [**2114-5-28**] 05:55AM BLOOD Glucose-68* UreaN-15 Creat-1.1 Na-138 K-3.8 Cl-102 HCO3-27 AnGap-13 [**2114-6-7**] 05:30AM BLOOD Glucose-62* UreaN-7 Creat-0.7 Na-136 K-4.0 Cl-106 HCO3-25 AnGap-9 [**2114-6-10**] 05:56AM BLOOD Glucose-137* UreaN-5* Creat-0.7 Na-134 K-4.1 Cl-103 HCO3-24 AnGap-11 [**2114-5-5**] 07:02PM BLOOD Fibrino-592* [**2114-5-7**] 07:00PM BLOOD Fibrino-328 [**2114-5-9**] 11:00PM BLOOD Fibrino-298 [**2114-5-5**] 02:13PM BLOOD PT-14.6* PTT-33.9 INR(PT)-1.3* [**2114-5-7**] 06:02AM BLOOD PT-19.6* PTT-67.8* INR(PT)-1.9* [**2114-5-8**] 08:01PM BLOOD PT-17.2* PTT-52.2* INR(PT)-1.6* [**2114-5-11**] 01:47AM BLOOD PT-13.7* PTT-28.6 INR(PT)-1.2* [**2114-5-17**] 02:36AM BLOOD PT-13.0 PTT-31.0 INR(PT)-1.1 [**2114-5-18**] 03:06AM BLOOD Plt Ct-442* [**2114-5-19**] 03:06AM BLOOD Plt Ct-452* [**2114-5-25**] 05:20AM BLOOD Plt Ct-403 [**2114-5-26**] 05:45AM BLOOD Plt Ct-404 [**2114-6-6**] 05:10AM BLOOD PT-13.9* PTT-40.1* INR(PT)-1.2* [**2114-6-6**] 05:10AM BLOOD Plt Ct-375 [**2114-6-7**] 05:30AM BLOOD Plt Ct-350 [**2114-6-10**] 05:56AM BLOOD Plt Ct-308 [**2114-5-5**] 02:13PM BLOOD Neuts-36* Bands-13* Lymphs-21 Monos-11 Eos-0 Baso-0 Atyps-0 Metas-14* Myelos-3* Promyel-2* [**2114-5-26**] 05:45AM BLOOD Neuts-70.0 Lymphs-23.2 Monos-5.4 Eos-1.1 Baso-0.4 [**2114-5-5**] 02:13PM BLOOD WBC-10.9 RBC-4.13* Hgb-13.2* Hct-38.7* MCV-94 MCH-32.0 MCHC-34.2 RDW-14.0 Plt Ct-177 [**2114-5-6**] 01:45PM BLOOD WBC-14.9* RBC-3.38* Hgb-10.8* Hct-31.2* MCV-92 MCH-31.8 MCHC-34.5 RDW-14.0 Plt Ct-143* [**2114-5-7**] 07:00PM BLOOD WBC-20.1* RBC-2.07* Hgb-6.7* Hct-18.9* MCV-91 MCH-32.2* MCHC-35.3* RDW-14.2 Plt Ct-126* [**2114-5-7**] 10:00PM BLOOD WBC-23.7* RBC-2.95*# Hgb-9.3*# Hct-26.0*# MCV-88 MCH-31.3 MCHC-35.5* RDW-14.7 Plt Ct-104* [**2114-5-8**] 04:02PM BLOOD WBC-24.3* RBC-3.20* Hgb-9.9* Hct-27.3* MCV-85 MCH-30.8 MCHC-36.2* RDW-15.4 Plt Ct-83* [**2114-5-9**] 04:12AM BLOOD WBC-31.1* RBC-3.00* Hgb-9.3* Hct-25.8* MCV-86 MCH-31.1 MCHC-36.1* RDW-15.8* Plt Ct-76* [**2114-5-10**] 03:26AM BLOOD WBC-40.5* RBC-3.11* Hgb-9.7* Hct-26.7* MCV-86 MCH-31.2 MCHC-36.2* RDW-15.7* Plt Ct-81* [**2114-5-11**] 01:47AM BLOOD WBC-41.7* RBC-2.84* Hgb-9.0* Hct-24.9* MCV-88 MCH-31.5 MCHC-36.0* RDW-15.9* Plt Ct-70* [**2114-5-15**] 02:46AM BLOOD WBC-14.2* RBC-2.85* Hgb-8.6* Hct-25.2* MCV-88 MCH-30.2 MCHC-34.2 RDW-16.7* Plt Ct-272 [**2114-5-18**] 03:06AM BLOOD WBC-10.1 RBC-2.53* Hgb-7.7* Hct-23.6* MCV-94 MCH-30.3 MCHC-32.4 RDW-15.8* Plt Ct-442* [**2114-5-27**] 06:15AM BLOOD WBC-6.1 RBC-2.82* Hgb-8.4* Hct-25.0* MCV-89 MCH-29.8 MCHC-33.6 RDW-15.6* Plt Ct-407 [**2114-6-7**] 05:30AM BLOOD WBC-10.3 RBC-2.55* Hgb-7.7* Hct-21.9* MCV-86 MCH-30.1 MCHC-34.9 RDW-16.1* Plt Ct-350 [**2114-6-10**] 05:56AM BLOOD WBC-9.0 RBC-2.74* Hgb-7.7* Hct-23.1* MCV-85 MCH-28.3 MCHC-33.4 RDW-16.4* Plt Ct-308 Brief Hospital Course: Mr. [**Known lastname 6330**] was admitted to Dr. [**Last Name (STitle) 17477**] service at [**Hospital1 18**] on [**2114-5-5**] following his transfer from an outside hospital. Upon arrival to [**Hospital1 18**], the patient was septic, requiring multiple pressors with elevated bandemia and elevated troponin level, acidemic with an elevated lactic acid level and with a right calf that had multiple bullae with desquamation circumferentially; there was no evidence of systemic emboli. His diagnosis was consistent with necrotizing fasciitis and so was taken to the OR immediately and underwent a debridement of the right lower extremity with a four compartment fasciotomy. For details of the procedure, see operative dictation. He was then transferred to the SICU in septic shock with multi-organ failure (e.g. acute renal failure, hepatic failure). He was kept intubated, maintained on 3 pressors (vasopressin/levophed/neo) to maintain his blood pressure and started on vanco/zosyn/clinda. The following day, he underwent further debridement after the team noted further developing bullae on the dorsum of his right foot. Again, for details of the procedure, see operative dictation. He was then started on CVVHD on [**5-6**] for ARF. IV-Ig was then started and continued for 3 days; zigris was [**Last Name (un) **] given and continued for 5 days (both protocolized). He spent the next several days on triple pressors, CVVHD, and on full ventilatory support. Over the next few days, he slowly improved. On [**2114-5-9**], PODs 3 & 4, tube feeds were begun and advanced to goal over the next day. On [**5-11**], PODs 5&6, he was hemodynamically stable and weaned off of all pressors. On [**5-12**], his renal function improved to the point that CVVHD was no longer needed and therefore stopped. On [**5-13**], repeat blood cultures were obtained as cultures from the 27th grew Gram (+) cocci in pairs from 1 out of 2 bottles and was considered a contaminant. Although wound cultures from [**2033-5-4**] were all positive for group A beta-strep there was no further evidence of bacteremia (i.e. blood cultures showed no growth). Therefore, under the recommendation of the Infectious Disease team, the vancomycin and clindamycin was discontinued on [**2114-5-14**]. On [**2114-5-16**], The patient's respiratory status was deemed stable and much improved and he was therefore extubated without issue. However, on [**2114-5-17**], the patient had a 20 beat run of VTach which was considered benign by Cardiology. Clear liquids were started, lopressor was increased as the patient was slowly becoming hypertensive, ASA was started, and a bedside Echo requested, showed an EF of 40% with some inferolateral wall hypokinesia. The patient was then deemed stable enough to be moved out of the ICU to the floor. Over the next few days, the patient comntinued to improved and his diet was advanced to a regular diet on [**2114-5-22**]. He was then deemed to be without any further genral surgical issues and was then transferred to the Plastic Surgery service. The pt progressed well and demonstrated unrestrained ROM of his affected area, passed his speech and swallow study and was evaluated by PT and OT who recommended rehab placement on discharge. Pt underwent successful debridment and vac change in the OR on [**2114-5-25**] and [**2114-5-29**], see op note for details. On [**2114-6-1**] the pt went to the OR for another wound debriedment and for skin grafting of the upper [**3-17**] of his lower right leg wound. Please see op note for detail of surgery. Pt continued with PT and OT. On [**2114-6-4**] the pt was found to be unresponsive and diaphoretic in bed and his blood glucose was found to be 20. The pt was given glucagon and 1 amp of D50 IV. The pt. soon became conversant and A&Ox3 and repeat BG as 247. At that time a left subclavian CVL was placed at the bedside for emergent IV access using sterile procedure. Post placement CXR showed no PTX and the tip of the CVL in the SVC. Pt was continued on Q1 hr finger sticks and placed on D5NS and [**Last Name (un) **] was consulted who recommended changing pt to Lantus and restarting metformin. On [**2114-6-6**] yhe pt was taken to the OR for a STSG of the right ankle and had a vac dressing change -- see OP note for details. On [**2114-6-7**] the pt had his CVL pulled and a PICC was placed. The pt was started on Flagyl at this time and was tested for a suspicion of c-diff. The pt had 3 assays performed for c-diff and all were negative, and therefore flagyl was d/c'd. On [**2114-6-13**] the pt. returned to the OR for a vac removal and for limited debridment of the right leg -- see OP note for details. The pt subsequently received dressing changes daily and was made full WB LLE and NWB RLE. PT re-evaluated pt and recommended rehab. OT also was consulted for PT to place a RLE splint. [**2114-6-16**] the pt had foley removed but failed to void in timely fashion, and therefore foley was reinserted and drained 700cc urine. Voiding trial attempted again on [**2114-6-18**], failed again and therefore foley catheter was replaced. Pt will have further voiding trial and management in future and is currently ready for discharge to rehab. Medications on Admission: Glimepiride 2mg QDaily Metformin 1000mg [**Hospital1 **] Probenecid 1mg [**Hospital1 **] HCTZ 25mg QDaily Nadolol Celebrex 200mg QDaily Avandia 4mg [**Hospital1 **] Crestor 10mg QDaily Lisinopril 5mg QAM Humulin ?dose (per daughter) Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6 PRN (). 3. Epoetin Alfa 3,000 unit/mL Solution Sig: Two (2) Injection QMOWEFR (Monday -Wednesday-Friday). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 10. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 11. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 13. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 16. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 18. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hospital - [**Location (un) 701**] Discharge Diagnosis: Right lower extremity necrotizing fasciitis and four compartment fasciotomy Group A Strep. Bacteremia septic shock liver failure acute renal failure adult respiratory distress syndrome Discharge Condition: good Discharge Instructions: You have been treated for a very rapidly advancing infection of your right lower leg. You were in the ICU and intubated for many days as well as have undergoing multiple surgeries and skin grafting for your right lower leg. You are felt well enough to be discharged to rehab to futher work on your mobility of your right lower leg and for continued necessary wound care. Please continue with physical therepy and occupational therepy as needed. Return to the ER or see your doctor if: -you have persistant fevers/shakes/chills, continued pus-like drainage from your wound, any signs of infection around your wound, any numbness or tingling in your right lower leg or any other worsening of your current condition. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 6633**] in [**1-15**] weeks. Please call [**Telephone/Fax (1) 2998**] for an appointment.

[ "995.92", "570", "785.52", "V58.67", "682.6", "785.4", "250.30", "785.51", "038.0", "584.5", "728.86", "V45.82", "401.9", "278.00", "041.01", "518.5" ]

icd9cm

[ [ [] ] ]

[ "99.04", "96.6", "83.13", "86.69", "86.22", "99.14", "96.72", "00.17", "89.64", "83.45", "00.14", "93.59", "00.11", "83.09", "38.93", "39.95", "33.24" ]

icd9pcs

[ [ [] ] ]

19743, 19821

12593, 17828

328, 559

20050, 20057

1663, 12570

20821, 20963

1444, 1448

18111, 19720

19842, 20029

17854, 18088

20082, 20798

1463, 1644

245, 290

587, 1280

1302, 1390

1406, 1428

20,651

119,666

20186

Discharge summary

report

Admission Date: [**2191-11-8**] Discharge Date: [**2191-11-16**] Date of Birth: [**2135-3-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3913**] Chief Complaint: Progressive dyspnea on exertion X 2 wks Major Surgical or Invasive Procedure: Pericardiocentesis and Balloon pericardiotomy History of Present Illness: Mr. [**Name14 (STitle) 36733**] is a 56yo man with a history of IgG Multiple Myeloma. This was first diagnosed in [**11-18**] when pain between his shoulders prompted a chest x ray demonstrating a posterior chest wall mass. CT demonstrated a large mass in the right posterior mediastinum and hemithorax destroying the transverse processes of T3, T4, and hte ribs at that level. CT guided biopsy of this right posterior chest wall lesion was consistent with plasmacytoma. This was CD-134 positive, adn positive for monclonal kappa and cytoplasmic immunoglobulin. Bone marrow biopsy was significatn for plasma cells involvement, 41% of the marrow cellularity. Skeletal survey showed no additional lytic lesions. His IgG was 8703, SPEP with abnormal band representing 58%, and a beta-2-microglobulin or 3.4. He was treated in [**2190-12-3**] with steroids and XRT, and the IgG level decreased to 5041. Then, chemotherapy was postponed for a lo0bar pnemonia, treated with IV antibiotics. He then ([**2191-1-24**]) started Doxil, vincristine, and decadron. After the first cycle, he developed difficulty with balance/coordination. He was diagnosed with polyneuralgia and started on folate and B12. MRI at that time demonstrated only prominent sulci. An LP was negative, and he was also HSV negative. Then he completed his second cycle of DVD, but had increasing size of a neck mass and incerased size of rib mass. He was then started on Cytoxan with pulsed Decadron and XRT to the neck. Then, he was switched to Velcade, with response of IgG decreased to 789, and SPEP with only 4% of total protein. He underwent stem cell mobilization with cytoxan, and then autologous transplant with melphalan conditioning on [**2191-7-28**]. On [**11-8**], he presented to clinic with shortness of breath, a pulsus of 15, and a chest xray significant for a large mediastinal mass. His room air saturation was 90%. His [**11-8**] echocardiogram demonstrated circumferential pericardial effusion (2.6cm anterior to RV) with evidence of right ventricular and atrial diastolic collapse consistent with tamponade physiology. Catheterization [**11-9**] demonstrated tamponade physiology with increased and equalized diastolic pressures of RA, PCWP, and pericardial pressures. 600cc of bloody fluid was removed by pericardiocentesis, and balloon pericardiotomy was performed. Past Medical History: 1.Plasma cell myeloma IgD myeloma diagnosed in 12/[**2189**]. MRI of the thoracic mass with bony involvement of T3 through T5 with right posterior ribs and lesion into the spinal canal. Prevertebral mass size of 5.6 x 8.0 x 9.0 at the posterior aspect of the trachea. He is status post three radiation therapy cycles in 12/[**2189**]. He underwent bone marrow biopsy, which demonstrated plasma cell myeloma, with chromosome 13 deletion. He was started on DVD chemotherapy in 02/[**2190**]. 2. Recurrent zoster. 3. History of tobacco abuse. 4. History of viral encephalitis in 12/[**2177**]. 5. Depression. 6. SIADH with hyponatremia. 7. Hypertension. 8. Anemia. 9. Odynophagia. 10.Steroid induced diabetes. 11.History of pneumonia in 02/[**2190**]. 12.History of general herpes. 13.Mild restrictive lung disease. PFTs: [**2191-6-14**] Act Pre %Pred FVC 4.19 5.16 75 FEV1 3.02 3.93 77 FEV1/FVC 72 70 103 Social History: Lives on Cape w/ wife who is [**Name Initial (MD) **] former RN. 3 children from previous marriage. Tobacco >1PPD X >20 yrs, quit [**2187**]. Former ETOH abuse, now occ. ETOH. NO IVDU Family History: DM, HTN (brother at 58yo), Father deceased [**1-17**] CHF. Physical Exam: 97.9, 106, 18, 140/80 *No pulsus paradoxus gen: alert/oriented, no acute distress. heent: no oropharyngeal erythema/lesions, PERRLA, EOMI CV: tachycardic, regular rhythm, S1, S2; no m/r/g no JVD pericardial drain site clean with dressing in place (drain pulled) resp: decreased breath sounds and dullness to percussion in left lung base; otherwise clear to auscultation abd: soft, nontender, nondistended + bowel sounds extr: 1+ pitting edema bilaterally to calves Pertinent Results: ADMIT LABS: [**2191-11-8**] 03:10PM BLOOD WBC-6.0 RBC-3.47* Hgb-11.9* Hct-35.5* MCV-102* MCH-34.4* MCHC-33.6 RDW-14.8 Plt Ct-193 [**2191-11-8**] 03:10PM BLOOD Neuts-68.4 Bands-0 Lymphs-25.6 Monos-5.3 Eos-0.4 Baso-0.2 [**2191-11-8**] 09:07PM BLOOD PT-14.0* PTT-24.9 INR(PT)-1.2 [**2191-11-8**] 03:10PM BLOOD Plt Ct-193 [**2191-11-8**] 03:10PM BLOOD Glucose-144* UreaN-17 Creat-1.0 Na-144 K-3.9 Cl-105 HCO3-28 AnGap-15 [**2191-11-8**] 03:10PM BLOOD ALT-33 AST-35 LD(LDH)-226 AlkPhos-230* TotBili-0.7 DirBili-0.3 IndBili-0.4 [**2191-11-8**] 03:10PM BLOOD TotProt-7.1 Albumin-3.9 Globuln-3.2 Calcium-9.6 Phos-3.5 Mg-2.2 UricAcd-6.9 [**2191-11-8**] 03:10PM BLOOD PEP-PND IgG-1195 IgA-PND IgM-PND [**2191-11-8**] CT chest: IMPRESSION: 1) Large anterior mediastinal mass, which given patient's history is most likely a lymphoma. 2) Moderately large pericardial effusion. 3) 2.4 x 4.0 cm mass displacing the cervical esophagus anteriorly. 4) A few images of the lower cervical spine show some irregularity in the region of the epidural space this could be secondary to artifact. However if the patient has symptoms, an MR is recommended. 5) Moderate left pleural effusion and small right pleural effusion. [**2191-11-11**] CT chest: IMPRESSION 1. Status-post balloon pericardiotomy with marked decrease in pericardial effusion. A small amount of air is seen within the pericardium. 2. Slightly increased bilateral pleural effusion, left greater than right. 3. Redemonstration of extensive mediastinal and hilar lymphadenopathy associated with left pleural atelectasis, unchanged within the very short interval of three days. [**2191-11-15**] CT chest: FINDINGS: The size of the dominant mediastinal mass and the other mediastinal adenopathy is unchanged over the short interval compared to the prior study. Unchanged also is pericardial and pleural effusion. The appearance of the lungs is stable. Please refer to the prior report for detailed description of the pertinent findings. IMPRESSION: Stable. TTE: -[**11-8**]:Overall left and right ventricular systolic function is normal. There is a large circumferential pericardial effusion (2.6cm anterior to the right ventricle) with evidence for right ventricular and right atrial diastolic collapse, consistent with impaired fillling/tamponade physiology. -[**11-9**]: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small (~0.7cm) pericardial effusion anterior to the right atrium and right ventricle.. A catheter is seen in the pericardial space. -[**11-11**]: 1. The left ventricular cavity size is normal. 2. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. -[**11-15**]: The left ventricular cavity size is normal. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (tape reviewed) of [**2191-11-11**], the pericardial effusion appears similar to slightly larger. [**11-10**]: SPECIMEN RECEIVED: PERICARDIAL FLUID DIAGNOSIS: NEGATIVE FOR MALIGNANT CELLS. Brief Hospital Course: 56yo man with history of IgG multiple myeloma. #Pericardial Effusion/Tamponade: The patient was admitted for shortness of breath. He was found to have a pericardial effusion and tamponade physiology on echo. He was treated in the CCU with pericardiocentesis with ~ 600cc bloody fluid obtained. A balloon pericardiotomy was performed as well. Cytology from the pericardial fluid was negative for malignant cells. A repeat TTE on the [**11-10**] demonstrated small amount of residual pericardialfluid, but no tamponade physiology. Once stable, he was transferred to the BMT unit. His pulsus was monitored and was between [**7-26**] daily. He was also monitored on telemetry with no events while on the floor. #Anterior Mediastinal Mass: He was treated with a five day course of Solumedrol 125mg IV qD, and there was no interval change in the size of the mass by repeat CT. CT surgery and interventional pulmonary were consulted and the decision was made to biopsy the lesion by bronchoscopy. The benefits and risks of the procedure was discussed with the patient. We also discussed that although it was possible that the mass was relapsed myeloma, it was unusual that it occurred within 4 months of the transplant. Another primary malignancy, including lymphoma was also in the differential. The patient reported that he understood that we didn't fully know what we were treating and still did not want the procedure. #Multiple Myeloma: The patient received 5 days of methylprednisolone with no change in the size of the mass. He then decided that he did not want further diagnostic procedures and would f/u as an outpatient for Velcade. #Shortness of Breath/Hypoxia: The patient had a small pleural effusion on admission, which increased in size over the first few hospital days. By the second or third day on the floor, he was intermittently requiring 2L oxygen by nasal cannula to have oxygen saturation of 95-96% and his pleural effusion was larger on both cxr and CT. The interventional pulmonologists had suggested tapping the effusion for symptomatic relief, but the patient refused any further invasive procedures. The day before discharge, a pulse ox was measured while the pt was ambulating which was 93% on room air. He denied feeling short of breath. By discharge, his oxygen saturation was 96-97% on room air and 94-95% with ambulating. He has home oxygen in case he is symptomatic, but was advised to immediately call the heme-onc office if this occurred. #F/U: The patient will follow up for velcade within the week. Medications on Admission: Lopressor 50 mg PO BID Oxycontin 40 mg PO BID Oxycodone PRN breakthrough pain Ativan PRN anxiety Fanvir 400 mg PO TID Pentadamine neb q mo last tx [**2191-9-19**] compazine 10 mg PO BID Colace Senekot Discharge Medications: 1. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 2. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 3. OxyContin 20 mg Tablet Sustained Release 12HR Sig: Three (3) Tablet Sustained Release 12HR PO twice a day. Disp:*120 Tablet Sustained Release 12HR(s)* Refills:*0* 4. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Colace 100 mg Capsule Sig: Two (2) Capsule PO twice a day. Disp:*120 Capsule(s)* Refills:*2* 6. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 7. Compazine 10 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for nausea. Disp:*40 Tablet(s)* Refills:*0* 8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 9. Clotrimazole 10 mg Troche Sig: One (1) Mucous membrane five times a day. Disp:*500 mg* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Multiple Myeloma, pericardial effusion (s/p cardiac tamponade) Secondary: Hypertension, Steroid induced hyperglycemia Discharge Condition: stable Discharge Instructions: Please take all medications as prescribed. If you experience chest pain, shortness of breath, palpitations, or increased heart rate, you should return to the emergency department. Followup Instructions: Please come back to the oncology clinic on Friday [**2191-11-18**] for your first dose of Velcade.

[ "511.9", "285.9", "V42.82", "423.9" ]

icd9cm

[ [ [] ] ]

[ "37.12", "37.0", "37.21" ]

icd9pcs

[ [ [] ] ]

11631, 11637

7817, 10357

356, 404

11809, 11817

4651, 7794

12047, 12149

4069, 4129

10609, 11608

11658, 11788

10383, 10586

11841, 12024

4144, 4632

277, 318

437, 2826

2848, 3849

3865, 4053

3,392

183,362

16774

Discharge summary

report

Admission Date: [**2172-4-2**] Discharge Date: [**2172-4-30**] Date of Birth: [**2134-12-19**] Sex: F Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: A 37-year-old female who presented on the [**3-3**] with end-stage liver disease secondary to hepatitis C who presents waking up in bed and finding a significant amount of blood on her tee shirt from a bleeding point on a healing midline abdominal incision. The patient's bleeding was stopped in the Emergency Room. The patient was admitted previously for uncontrolled bleeding status post an exploratory laparotomy in [**2171-12-22**] secondary to a small bowel obstruction. The patient at that time was without any other complaints and was being followed as an outpatient with frequent routine labs. The patient's base _______had risen from 2 in the last month to 3.4 prior to admission so the patient was admitted for observation and management. PAST MEDICAL HISTORY: Significant for end-stage liver disease, esophageal cancer, non-Hodgkin's lymphoma, small bowel obstruction status post exploratory laparotomy and lysis of adhesions, status post lumpectomy, Clostridium difficile in [**2171-12-22**], right lower extremity trauma from motor vehicle accident as a child, chronic lower extremity cellulitis and poor dentition. ALLERGIES: The patient reports no known drug allergies. MEDICATIONS ON ADMISSION: 1. Ursodiol 300 t.i.d. 2. Chloride 300 mEq q. day. 3. Lasix 40 mg q. day. 4. Spironolactone 50 mg q. day. 5. Protonix 40 mg p.o. q. day. 6. Mycelex 10 mg t.i.d. 7. Nadolol 20 mg q. day. 8. Lactulose two teaspoons q. day t.i.d. 9. Ketaconazole cream. 10. Colace 200 b.i.d. 11. Multivitamin. PHYSICAL EXAMINATION ON ADMISSION: No acute distress. No asterixis. Head and neck examination significant for icterus. Cardiovascular: Regular rate and rhythm. Lungs clear to auscultation bilaterally. Abdomen was soft. She had a non-tender healed midline incision with four areas of ulceration. No purulence. Slight staining onto gauze at second area of ulceration. No hematoma. The patient had a small area of tenderness in the right lower quadrant. Extremities were without lower extremity edema and no lesions. Right below-knee skin graft was patent. LABORATORY ON ADMISSION: The patient's laboratories on admission were a white count 9.1, hematocrit 30.4, hematocrit 57, platelet count 57,000. Chem-7 with 131/3.3/97/23/16/0.8 and 129. ALT 14, AST 40, alk phos 112, total bilirubin 6.9, albumin of 2.6, and amylase of 58. The patient's INR was 3.4. HOSPITAL COURSE: On hospital day five it was discovered the patient was MRSA bacteremic. Infectious Disease was consulted to evaluate patient. Decided to wait for cultures. The patient was continued to be worked up by Infectious Disease, getting a bone scan and _______ to evaluate for possible sources of infection. Her vancomycin level was titrated. She was transferred to the Medical Intensive Care Unit on the [**1-12**] for close monitoring, of PA catheter and for acute renal impairment with a creatinine that went from 0.8 to 3.4. The patient's renal function improved over a period of time returning to a baseline of 1.8. The patient was transferred to the floor and prepped for an orthotopic liver transplant. On hospital day 17 the patient was being pre-op'd for orthotopic liver transplant and was given the appropriate preoperative medications. On hospital day 17 and postoperative day one, the patient did not receive her liver secondary to development of a large clot intraoperatively. As such, the patient was taken out of the Operating Room and failed to receive her transplant. The patient went back to the unit for close monitoring immediately postoperatively and was then transferred to the floor. The patient was finally transferred to the floor on the [**12-25**] hospital day 23. On the floor patient had a fairly unremarkable course. On hospital day 29 patient was to be discharged to an extended care facility where she will receive physical therapy and await a potential new liver for transplant. DISCHARGE MEDICATIONS: 1. Ketaconazole cream. 2. Acetaminophen 325 mg two tabs p.o. q. 4-6h. p.r.n. 3. Morphine sulfate 2 mg/mL syringe one to two injections q. 4h. 4. Miconazole powder. 5. Ciprofloxacin 250 mg tabs p.o. b.i.d. 6. Protonix 40 mg one tab p.o. b.i.d. 7. Insulin sliding scale. 8. Fluconazole 200 mg IV q. 24h. 9. Furosemide 60 mg IV q. 12h. 10. Zofran 2-4 mg IV q. 6h. p.r.n. 11. Multivitamin. DISCHARGE DIAGNOSES: Liver cirrhosis. Hepatitis C. Esophageal cancer. FOLLOW UP: Patient will follow up in the Liver [**Hospital 1326**] Clinic with Dr. [**First Name (STitle) **] the week following discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Doctor Last Name 13307**] MEDQUIST36 D: [**2172-4-30**] 11:35:13 T: [**2172-4-30**] 12:58:40 Job#: [**Job Number 47385**]

[ "790.7", "280.0", "202.80", "415.11", "286.7", "789.5", "571.5", "070.54", "998.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "99.04", "99.05", "54.59", "38.91", "38.7", "96.72", "89.61", "99.07", "89.62", "54.91", "88.72", "89.64", "99.06" ]

icd9pcs

[ [ [] ] ]

4558, 4610

4135, 4536

1403, 1726

2595, 4112

4622, 5012

183, 937

2299, 2577

960, 1377

29,872

177,175

28270

Discharge summary

report

Admission Date: [**2143-7-28**] Discharge Date: [**2143-8-9**] Service: MEDICINE Allergies: Heparin Agents / Bee Pollens Attending:[**First Name3 (LF) 17865**] Chief Complaint: Hypoxia, hypotension Major Surgical or Invasive Procedure: arterial line l radial artery l IJ CVL attempt l femoral line placement and removal intubation extubation History of Present Illness: Ms. [**Known lastname **] is a [**Age over 90 **] year old female with hx of HIT leading to bilateral AKAs, ESRD ([**2-11**] HIT) on HD, was recently brought in by son for [**Name2 (NI) 15780**] to 87-91% on [**7-23**] L pleural effusion was noted on CXR and pt was given a 7 day course of Levaquin 250 mg and Albuterol Nebs. She returns today after son noted hypoxia again at home. States she was very lethargic yesterday after dialysis which she has at home. She was tachy to the 120s and son gave her metoprolol but brought her in after she coughed up a large amount of phlegm. He states she has been more confused - baseline knows her name and where she is, but not date. . Of note, 2 of her daughters came down with similar symptoms with fevers and sputum production within the past week and were prescribed avelox. . In the ED, initial vs were: 102.4 rectal, 119, 79/50, 20, 99 on 2L. Patient was given vanc/zosyn, started on levafed for hypotension as low as 60s/40s and received 3.5 L IVF in ED. CT abd/pelvis without acute intraabdominal pathology. She was transfered to the MICU for further management. . Review of sytems obtained from son: (+) Per HPI (-) Denies night sweats, recent weight loss or gain (other than targeted with dialysis. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied 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. Past Medical History: - HIT resulting in thrombosis in LE s/p L AKA [**2142-1-25**], R AKA on [**2142-4-18**] PVD - R fem-DP bypass w/ saphenous graft [**2141-9-26**] - unable to revascularize toes - CAD, s/p MI last fall (NSTEMI related to HIT?) - ESRD, dialysis dependent since [**7-/2141**] - h/o anemia, renal - osteodystrophy, MWF schedule - GERD, on protonix - Hypothyroidism, on levothyroxine - Baseline Tachycardia to 110s - mild global LV dysfunction on echo [**1-/2142**] (EF 45-50%) - Rapid A fib (post-op [**4-17**]) s/p electric cardioversion Social History: Lives with his son in [**Name (NI) 10022**] MA who is her primary caregiver. She does not smoke, drink alcohol or do drugs. She has not traveled outside MA. Family History: Noncontributory Physical Exam: On arrival to MICU: Vitals: T: 96.8 BP: 129/46 P: 109 R: 32 O2: 100% on 3L General: somnolent but arousable to noxious stimuli, oriented x0, no acute distress [**Name (NI) 4459**]: Sclera anicteric, MMM Neck: supple, JVP flat, no LAD Lungs: bibasilar crackles. CV: Irregularly irregular, [**1-15**] murmur at LSB. No rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: Upper extremities without palpable pulses, R IJ tunnelled dialysis catheter, L femoral line. Bilateral lower extremity AKA Pertinent Results: [**2143-7-27**] 06:20PM WBC-9.6 RBC-4.06* HGB-11.9* HCT-43.6 MCV-107* MCH-29.3 MCHC-27.3* RDW-17.2* [**2143-7-27**] 06:20PM NEUTS-76.5* LYMPHS-15.8* MONOS-7.0 EOS-0.4 BASOS-0.3 [**2143-7-27**] 06:20PM PLT COUNT-322 . [**2143-7-27**] 06:20PM PT-41.7* PTT-34.9 INR(PT)-4.4* . [**2143-7-27**] 06:20PM GLUCOSE-102 UREA N-27* CREAT-3.4* SODIUM-147* POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-29 ANION GAP-16 . [**2143-7-28**] 02:32AM CALCIUM-8.2* PHOSPHATE-4.3# MAGNESIUM-2.1 . CXR: IMPRESSION: Persistent left basilar opacity likely reflective of effusion and atelectasis/pneumonia. A small right pleural effusion. Markedly limited exam. . CT abd Pelvis: ***Wet Read*** Bilateral pleural effusions, not significantly changed. Very small perihepatic fluid. Small amount of free pelvic fluid, slightly increased since prior study of 8/[**2142**]. otherwise, no significant change. . EKG: A-fib rate 115, nl axis, ST depressions in I, aVL and V4-V6 with TWI in V4-6 all from prior ECG. . [**2143-8-9**] 04:26AM BLOOD WBC-11.0 RBC-2.66* Hgb-7.6* Hct-27.0* MCV-102* MCH-28.7 MCHC-28.2* RDW-16.6* Plt Ct-212 [**2143-8-8**] 05:16AM BLOOD WBC-13.7* RBC-2.66* Hgb-7.7* Hct-27.5* MCV-104* MCH-28.9 MCHC-27.9* RDW-16.3* Plt Ct-178 [**2143-7-27**] 06:20PM BLOOD WBC-9.6 RBC-4.06* Hgb-11.9* Hct-43.6 MCV-107* MCH-29.3 MCHC-27.3* RDW-17.2* Plt Ct-322 [**2143-8-9**] 04:26AM BLOOD PT-29.3* PTT-71.8* INR(PT)-2.9* [**2143-7-27**] 06:20PM BLOOD PT-41.7* PTT-34.9 INR(PT)-4.4* [**2143-7-29**] 02:30PM BLOOD PT-88.6* PTT-46.8* INR(PT)-10.8* [**2143-8-9**] 04:26AM BLOOD Glucose-194* UreaN-11 Creat-1.0 Na-134 K-4.7 Cl-100 HCO3-23 AnGap-16 [**2143-8-8**] 11:33AM BLOOD Glucose-212* Na-133 K-4.6 Cl-100 HCO3-24 AnGap-14 [**2143-7-27**] 06:20PM BLOOD Glucose-102 UreaN-27* Creat-3.4* Na-147* K-3.9 Cl-106 HCO3-29 AnGap-16 [**2143-7-27**] 06:20PM BLOOD cTropnT-0.20* [**2143-7-28**] 02:32AM BLOOD CK-MB-3 cTropnT-0.17* [**2143-7-28**] 09:30AM BLOOD CK-MB-NotDone cTropnT-0.14* [**2143-7-29**] 02:30PM BLOOD D-Dimer-824* [**2143-8-1**] 10:53AM BLOOD Cortsol-19.1 [**2143-8-1**] 12:34PM BLOOD Cortsol-40.0* [**2143-7-28**] 02:32AM BLOOD TSH-3.9 . Echo: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis (LVEF = 20 %). The estimated cardiac index is depressed (<2.0L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. There is moderate thickening of the mitral valve chordae. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Severe aortic stenosis. Severe global left ventricular systolic function. Mildly dilated right ventricle with global hypokinesis. Depressed cardiac index. Brief Hospital Course: Ms. [**Known lastname **] is a [**Age over 90 **] yo woman with hx of HIT, ESRD on HD, s/p b/l AKA presents with respiratory failure secondary to ?pneumonia, complicated by heart failure and inability to wean off pressors or ventilator. Due to the lack of response to treatment, patient was made comfort measures only on [**8-9**] and terminally extubated. . Respiratory failure. Patient was treated intiially with 8 days of vanco/cefepime for Pneumonia. DFA for flu negative. There was difficulty weaning from ventillator in spite of aggressive fluid removal with CVVH and treatment of pneumonia. Pt was terminally extubated on [**8-9**] and expired about 20 minutes later. . Shock. Patient presented with what was thought to be septic shock due to pneumonia. She was treated with 8 days of vanco/cefepime for VAP, however, it was difficult to wean her levophed dose. She subsequently developed a rising leukocyosis thought to be secondary to a line infection which was positive for enterococcus. She was treated with lenozolid for this. Finally, she was felt to have an element of cardiogenic shock given her echo showed severe aortic stenosis which per cardiology was not seconary to sclerosis of the valve but rather due to impaired filling in the setting of CAD and A. fib with RVR. Her hemodynamics never normalized and she required ongoing titration of her pressors, both levophed and vasopressin. Three days prior to death, her a-line dysfunctioned and we (as well as anesthesia) were unable to place another one. We did not have a reliable blood pressure [**Location (un) 1131**] the last two days of hospitalization. . Enteroccus line infection. Tip of femoral line positive for enteroccus. Line was removed on [**8-3**] and plan was to treat until [**8-12**], pt expired prior to completion of treatment. . Heart failure/functional AS. Patient's most recent echo which was performed during her hospital stay showed severe AS, but per cardiology, likely functional due to CAD and poor filling times in setting of tachycardia. She was loaded with digoxin for rate control. She underwent CVVH for volume removal. As above, she never stabalized hemodynamically. . HIT. HIT was diagnosed in [**12/2141**] and complicated by thrombus in bilateral lower extremities requiring amputations. She was initially supertherapeutic, likely in setting of abx and coumadin interaction. Her couamdin was held and FFP was given for an OG placement and attempted CVL placement. She was placed on agratroban when INR was below 2, and coumadin was held for the rest of the hospitalization. . ESRD on HD. She was started on CVVH for volume removal during her ICU stay. It was continued throughout expect for a few days in the middle when we thought her tachycardia may have been to volume depletion. It was restarted, later. . Anemia. Her anemia was felt to be due to chronic disease, blood loss from blood draws and procedures, and guiaic positive stools. Her Hct remained stable. . CAD. Patient had NSTEMI in [**2142**]. An echo was performed during her hospital stay and showed an EF of 20% on most recent echo. Beta-blockers were held due to her need for pressors. Aspirin was held as she was on argatroban drip. She was continued on a statin. She would benefit from revascularization, but she is likely not a candidate for CABG. . Hypothyroid. She was continued on levothyroxine during her hospital stay. Her TSH was checked and was normal during her ICU stay. . Communication: [**Name (NI) **] son [**Name (NI) **] [**Name (NI) **] (dentist) - [**Telephone/Fax (1) 68653**] . Goals of care. Family meeting was held on [**2143-8-8**] to discuss of goals of care. Family recognizes that patient would not want to be trached and in a chronic vent facility. It was explained to the family that patient required too much ventillator support to be extubated. The family agreed to patient DNR with a plan of withdrawal of care when the family was gathered. On [**8-9**], she was extubated with her family in the room. She expired about 20 minutes later. Time of death 10:40am. Medications on Admission: Aspirin 81 mg DAILY Metoprolol Tartrate 12.5 mg PRN for HR > 120 Toprol XL 25 mg daily Warfarin 1 mg as directed Daily Atorvastatin 20 mg DAILY Pantoprazole 40 mg DAILY Levothyroxine 75 mcg DAILY Lidocaine-Prilocaine 2.5-2.5 % Cream [**Hospital1 **] prn pain. Camphor-Menthol 0.5-0.5 % QID prn itching. Folic Acid 1 mg DAILY Cyanocobalamin 500 mcg DAILY Vitamin B1 and B12 daily Sevelamer HCl 800 mg TID W/MEALS Midodrine 2.5 mg PRN prior to dialysis NTG SL prn chest pain Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmomary Arrest Respiratory Failure Acute on Chronic Systolic Heart Failure End stage renal disease Pneumonia Enterococcus Line Infection Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2143-8-9**]

[ "996.62", "V49.76", "414.01", "785.52", "790.92", "V58.61", "995.92", "486", "585.6", "412", "038.9", "440.20", "518.81", "041.04", "E934.2", "785.51", "427.31", "428.0", "530.81", "285.21", "244.9", "424.1", "V09.80", "276.2", "428.23" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93", "96.72", "96.6", "96.04" ]

icd9pcs

[ [ [] ] ]

11188, 11197

6528, 10633

257, 364

11385, 11394

3286, 6505

11450, 11487

2645, 2662

11156, 11165

11218, 11364

10659, 11133

11418, 11427

2677, 3267

197, 219

392, 1897

1919, 2454

2470, 2629

50,257

145,622

7922

Discharge summary

report

Admission Date: [**2169-4-27**] Discharge Date: [**2169-5-5**] Date of Birth: [**2116-9-26**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4679**] Chief Complaint: SOB Major Surgical or Invasive Procedure: [**2169-4-28**] Right chest tube thoracostomy [**2169-4-30**] Right video-assisted thoracoscopic surgery and decortication of lung. History of Present Illness: 52M ho testicular CA, Ulcerative colitis, recently admitted to the OSH ICU for necrotizing pna x 5 days, did not require intubation but was on non-rebreather, who was discharged 2 days ago and since then has been having worsening dyspnea, malaise, SOB, fever 101.8. Pt initialy reported to [**Hospital6 **] ED and then transfered to [**Hospital1 18**] ED. . In detail, pt reports 1 mo he had emesis and felt feverish, sluggish, malaise. The following week he had chest pain down his right side that reminded him of his prior stone in the common bile duct in [**2166**]. He saw a Gi doctor who considered biliary colic. Following day he felt worse and had fever and reported to OSH hospital where he was diagnosied with a pneumonia and treated initialy with clinda and then switched to 4 days of zosyn and vanco. Received total of 5 days of levoflox. CTA was negative for PE but did reveal necrotizing pna in RUL, pna in RLL and LLL, right sided effusion (this is all per wife who is RN). He was put on non-rebreather to maintain sats in 90s. He was discharged 2 days ago and felt a little better. Today he felt worse, recurrent pleuritic CP, fevers and reported to OSH. . While at [**Hospital3 **] ED he was given zofran for some nausea and then sent to [**Hospital1 18**] ED. . In the ED, initial VS were: 90% RA, 139/83, RR 30, 91 HR, T 98.4 Triggered for requiring 6L NC for sat in low 90s, RR 30s. Access 18g Given morphine, albuterol neb, ipratropium neb, zofran, zosyn 4.5g and plans to give Vanco. Given 1 L NS. Blood cx drawns. Labs: lactate 0.9, WBC 14, HCT 40, PLT 599. CXR:RML and RLL opacity and effusion Transfer vitals: 94% on 6L NC, 132/71, RR 22, HR 87, T 98.4 Pt transfered to MICU for resp distress in setting of pneumonia. . On arrival to the MICU, pt is comfortable but diapharetic. Denies any dyspnea or cough. ROS positive for 16 Ib weight loss since pna, night sweats for a few weeks, no cough whatsoever. Has intermitten diarrhea from UC but has been having more episodes in setting of antibiotics lately. Some blood in stool. Past Medical History: Common bile duct stone sp ERCP with stone removal [**2166**] ?biliary colic- getting outpatietn workup Sciatica- gabapentin and tizanidine HTN Ulcerative COlitis- mesalamine prn Testicular CA Renal cysts Several lumbar spine surgeries complciated with E coli infection Social History: 35+ smoking history, quit years ago, no drugs. He does not smoke, drink, or use any drugs. He is married. He has two children. He continues to work at Stop & Shop. Family History: Positive for cerebral aneurysm in his father as well as lung cancer in his mother. Physical Exam: Vitals: T:99.6, HR 80, BP 133/69, 96% on 4L General: Alert, oriented, diapharetic but 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: crackles in bases bilaterally, decreased breath sounds in right lower base 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: a+o X3 Pertinent Results: Admission Labs: [**2169-4-27**] 09:20PM BLOOD WBC-14.6* RBC-4.72 Hgb-13.5* Hct-40.2 MCV-85 MCH-28.6 MCHC-33.6 RDW-13.0 Plt Ct-599*# [**2169-4-27**] 09:20PM BLOOD Neuts-77* Bands-1 Lymphs-8* Monos-4 Eos-8* Baso-0 Atyps-0 Metas-2* Myelos-0 [**2169-4-28**] 03:55AM BLOOD PT-14.5* PTT-28.4 INR(PT)-1.4* [**2169-4-27**] 09:20PM BLOOD Glucose-119* UreaN-25* Creat-1.2 Na-140 K-4.3 Cl-104 HCO3-27 AnGap-13 [**2169-4-28**] 03:55AM BLOOD ALT-53* AST-35 LD(LDH)-204 CK(CPK)-34* AlkPhos-121 Amylase-22 TotBili-0.3 [**2169-4-28**] 03:55AM BLOOD CK-MB-1 cTropnT-<0.01 [**2169-4-28**] 04:46PM BLOOD CK-MB-1 cTropnT-<0.01 [**2169-4-27**] 09:20PM BLOOD Calcium-9.3 Phos-4.3 Mg-2.1 [**2169-4-28**] 03:55AM BLOOD calTIBC-177* Ferritn-858* TRF-136* [**2169-4-28**] 03:55AM BLOOD HIV Ab-NEGATIVE [**2169-4-30**] 12:14PM BLOOD pO2-81* pCO2-48* pH-7.41 calTCO2-31* Base XS-4 CXR ([**2169-4-27**]): Moderate cardiomegaly, new since [**2166**], with large right and small left pleural effusions, central vascular congestion, and mild interstitial edema, concerning for cardiac decompensation. . TTE ([**2169-4-28**]): The left atrium is mildly dilated. 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). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild-moderate pulmonary artery hypertension. There is a small to moderate sized pericardial effusion anterior to the right atrium (#37). The effusion appears loculated - ?pericardial cyst. IMPRESSION: Small/moderate loculated anterior pericardial effusion c/w ? pericardial cyst. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Dilated ascending aorta. Pulmonary artery hypertension. . CTA Chest ([**2169-4-28**]): 1. No pulmonary embolism or aortic pathology identified. 2. Large right loculated simple appearing pleural effusion without areas of rim enhancement or complex density to suggest superimposed infectious process. Significant amount of adjacent pulmonary parenchymal collapse is identified in all right lobes particularly the right lower lobe. 3. Hypodensity in the lateral aspect of the collapsed right lobe likely due to pneumonia. 4. Evidence of right heart strain with enlarged right ventricle and straightening of the interventricular septum. . [**2169-4-30**] 11:42 am PLEURAL FLUID RIGHT PLEURAL FLUID. GRAM STAIN (Final [**2169-4-30**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2169-5-3**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2169-4-30**] 11:50 am ABSCESS RIGHT PLEURAL ABSCESS. GRAM STAIN (Final [**2169-4-30**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2169-5-3**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2169-4-30**] 12:15 pm TISSUE PLEURAL TISSUE RIGHT LUNG(INTRA PLEURAL). GRAM STAIN (Final [**2169-4-30**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2169-5-3**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Brief Hospital Course: 52 M with HTN and UC who was recently admitted to [**Hospital3 **] ICU with necrotizing pneumonia, presented again with persistent SOB, fevers and a para pneumonic effusion. . # Pneumonia with Para pneumonic Effusion Started on vancomycin, cefepime and levofloxacin the MICU. CT scan showed a para pneumonic effusion on the lower right lobe. Drained 1.7L by paracentesis while in the MICU, with fluid showing an exudative pathology. Chest tube remained in place and on suction. On [**4-30**] he underwent a right VATS decortication and tolerated the procedure well. He returned to the PACU in stable condition and maintained stable hemodynamics. He has 3 chest tubes in place for drainage. His pain medications required many adjustments but he was able to cough and deep breath and use his incentive spirometer effectively. His port sites were dry and healing well and his oxygen was weaned off easily. The Infectious Disease service also followed him during his stay and antibiotics were switched to vancomycin, ceftriaxone and Flagyl for empiric coverage. He remained afebrile with a WBC down to 12K. His intraop cultures remained negative except for a pleural tissue culture which grew rare gram positive rods. The ID team reviewed the cultures but felt that it was most likely a contaminent. They recommended completing a 3 week course of Flagyl and Levaquin and they will follow him in their out patient clinic in a few weeks. After an uneventful recovery he was discharged to home on [**2169-5-5**] and will follow up in the Thoracic Clinic in 2 weeks. Medications on Admission: CITALOPRAM - 20 mg Tablet - 1 Tablet(s) by mouth daily GABAPENTIN - 800 mg Tablet - 1 [**2-13**] Tablet(s) by mouth three times a day HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a day IBUPROFEN - 800 mg Tablet - 1 Tablet(s) by mouth three times a day standing MESALAMINE [CANASA] - 1,000 mg Suppository - 1 Suppository(s) rectally at bedtime PRN DIARRHEA (last taken 1 mo ago) OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth QAM TIZANIDINE - 4 mg Tablet - 2 Tablet(s) by mouth three times a day as needed for muscle spasm Medications - OTC MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours). 3. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. tramadol 50 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for constipation. 11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. Disp:*1 inhaler* Refills:*0* 12. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): thru [**2169-5-21**]. Disp:*16 Tablet(s)* Refills:*0* 13. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): thru [**2169-5-21**]. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Empyema. 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 for lung surgery and you've recovered well. You are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * Your chest tube dressing may be removed in 48 hours. If it starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. * You will continue to need pain medication once you are home but you can wean it over a few weeks as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol 650 mg every 6 hours in between your narcotic. If your doctor allows you may also take Ibuprofen to help relieve the pain. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk 4-5 times a day and gradually increase your activity as you can tolerate. Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, chest pain or any other symptoms that concern you. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2169-5-18**] at 3:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please report 30 minutes prior to your appointment to the Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinicla Center for a chest xray. Department: INFECTIOUS DISEASE When: TUESDAY [**2169-5-23**] at 11:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: MONDAY [**2169-10-9**] at 8:10 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2169-5-5**]

[ "311", "510.9", "556.9", "507.0", "416.8", "401.9", "V70.7", "724.3", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "34.04", "34.52" ]

icd9pcs

[ [ [] ] ]

11127, 11133

7593, 9161

313, 448

11186, 11186

3671, 3671

12874, 14063

3021, 3105

9855, 11104

11154, 11165

9187, 9832

11337, 12851

3120, 3652

7548, 7570

270, 275

476, 2529

3688, 6728

7500, 7515

11201, 11313

2551, 2821

2837, 3005

9,480

103,395

14988

Discharge summary

report

Admission Date: [**2133-8-28**] Discharge Date: [**2133-9-3**] Date of Birth: [**2069-1-21**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: This is a 64 year-old [**Location 43876**] male with no significant past medical history who now presents with seven hours of constant crushing substernal chest pain. The patient reports having less severe substernal chest pain one day prior to admission while at work, nonradiating in nature with no associated symptoms, and relieved by ten minutes of rest. He denies any prior history of such pain and attributed it to indigestion. Then around 8:00 a.m. on the day of admission the patient developed substernal crushing chest pain while at work associated with shortness of breath and nausea. Because the pain failed to resolve he electively went to [**Hospital3 417**] Hospital and was found to have ST elevations in 2, 3, AVF, V2-V6 with large Q waves in the precordial leads. He was immediately started on aspirin, nitroglycerin, morphine, Integrilin and Lopressor and transferred to [**Hospital1 69**] for emergent cardiac catheterization. MEDICATIONS ON ADMISSION: None. ALLERGIES: No known drug allergies. FAMILY HISTORY: Brother died of an myocardial infarction at the age of 35. Cousin died of myocardial infarction in his 60s. Father with prostate cancer. No history of diabetes or strokes in the family. SOCIAL HISTORY: Three and a half pack year tobacco history. The patient quit three years ago. The patient drinks about two to three beers per day. He denies any recreational drug use. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION: Temperature 97.9. Blood pressure 105/62. Pulse 78. Respirations 12. Sating 99% on room air. In general, he is a well developed, well nourished [**Location 43876**] male who appeared fatigued, but was in no acute distress. Pupils are equal, round and reactive to light. Extraocular movements intact. Oropharynx was clear with mucous membranes are moist. His neck was supple with no appreciable JVD, carotid bruits, thyromegaly or lymphadenopathy. Lungs are clear to auscultation bilaterally. Cardiac examination revealed regular rate and rhythm with no murmurs, rubs or gallops. His point of maximal impulse was not displaced and there was no heave present. His adomen was soft, nontender, nondistended with normal bowel sounds and no hepatosplenomegaly. Extremities were without any clubbing, cyanosis or edema or calf tenderness. He had 2+ distal pulses throughout. Neurological examination was nonfocal and symmetric. LABORATORIES ON ADMISSION: Significant for a hematocrit of 37.5, white count 4.2, creatinine 0.6, INR 1.2, CKs peaked at [**2122**], MBs peaked at 484 with a peak index of 24.3 and troponins were greater then 50. AST 233, with the rest of his liver function tests normal. Triglycerides 87, HDL 82, LDL 190. Cardiac catheterization left ventricular ejection fraction less then 45%, large area of anteroapical and inferoapical akinesis with hypokinesis at basal segments, left anterior descending coronary artery with 40% proximal and 100% mid stenosis, left circumflex with 80% proximal lesion, 80% stenosis in upper branch of large obtuse marginal one, right coronary artery with 60% origin and 80% distal region just before posterior descending coronary artery. HOSPITAL COURSE: A balloon was placed in the patient's mid left anterior descending coronary artery without complications during his cardiac catheterization. He was started on an Integrilin drip along with aspirin, low dose Metoprolol and Lipitor. He was started on an intravenous heparin drip six hours after his femoral sheath was taken out. Because the patient continued to have chest pain even after his cardiac catheterization he was placed on a nitroglycerin drip for symptomatic relief. A repeat electrocardiogram showed no new changes. The patient's blood pressure and heart rate remained stable off all pressors. He was monitored closely on tele watching for any conduction abnormalities after his large anterior myocardial infarction. His electrolytes were checked on a regular basis and were repleted as needed. His sats remained excellent on 2 liters of nasal cannula. He was placed on a cardiac/diabetic diet and given adequate post catheterization intravenous fluid hydration. His hematocrit remained stable post catheterization and his groin site showed no signs or symptoms of a hematoma. He remained afebrile throughout his hospital stay with no leukocytosis. His creatinine remained stable throughout his hospital stay with no signs of dye induced nephropathy. On hospital day number two the patient developed acute mental status changes consistent with delirium. A head CT was obtained, which was negative for any infarction or bleed. Sed rate, TSH, vitamin B-12, folate, RPR and serum tox screens were all negative. Psychiatry was consulted and the patient's increased agitation/delirium was felt to be a result of alcohol withdraw. He was placed on a CIWA scale with prn Valium. Neurology was also consulted and a head MRI was obtained, which came back negative for any acute process. The patient's mental status returned to baseline within the course of the next three days with the help of prn Valium. DISCHARGE DIAGNOSES: 1. Severe three vessel coronary artery disease status post large anterolateral and inferior myocardial infarction. 2. Depressed left ventricular systolic function with an EF of less then 45% and several wall motion abnormalities. 3. Delirium secondary to alcohol withdraw. 4. Hypercholesterolemia. DISCHARGE MEDICATIONS: Aspirin 325 q.d., Lipitor 10 mg q.d., Atenolol 25 mg q.d., Lisinopril 10 mg q.d., folic acid q.d., Thiamine q.d., multivitamin q.d., Protonix 40 mg q.d. DI[**Last Name (STitle) 408**]E STATUS: The patient was discharged to home in stable condition. He is to see Dr. [**Last Name (Prefixes) **] (cardiothoracic surgeon) on Thursday [**9-10**] at 10:30 a.m. in his office to further discuss imminent coronary artery bypass graft, which will be performed within the next two weeks. The patient is to continue on his cardiac medications (aspirin, statin, beta blocker and ace inhibitor). He has been advised to avoid all alcohol at least until his cardiac surgery. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. Dictated By:[**Last Name (NamePattern4) 1198**] MEDQUIST36 D: [**2133-10-22**] 16:27 T: [**2133-10-27**] 10:24 JOB#: [**Job Number 10064**]

[ "410.71", "414.01", "E878.8", "401.9", "305.00", "424.0", "780.09", "998.12", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "36.01", "88.56", "99.20", "37.23", "88.53" ]

icd9pcs

[ [ [] ] ]

1201, 1391

5303, 5606

5630, 6550

1139, 1184

3357, 5282

1637, 2584

1599, 1614

160, 1112

2599, 3339

1408, 1579

45,910

153,970

54735

Discharge summary

report

Admission Date: [**2197-10-25**] Discharge Date: [**2197-11-2**] Date of Birth: [**2129-5-28**] Sex: M Service: MEDICINE Allergies: Ultram / IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 8263**] Chief Complaint: paraparesis Major Surgical or Invasive Procedure: fusion Laminectomy Lumbar T9-S1 with instrumentation and allograft History of Present Illness: 68 year old male with a PMH significant for polio (residual right lower extremity weakness and atropy), DMII (not on medications), HTN, diastolic HF with a preserved EF, CAD (described on CT) with angina symptoms relieved by SL nitro, who presented for evaluation for paraparesis since [**Month (only) **] of this year. He was found to have severe central stenosis from T9-S1 and extensive spondylosis on recent MRI. He underwent fusion Laminectomy Lumbar T9-S1 with instrumentation and allograft and was admitted to TSIUC for post operative care. He was successfully extubated without issue on [**10-26**], but developed a new O2 requirement of 4L NC which he does not have at home. He was tachycardic and hypertensive with SBPs to the 160s systolic, and HR ranging 90s-110s. . He has also had 2 episodes of CP with negative enzymes, relieved by SL nitro and no changes in his EKG. To his recollection he has never had a heart attack, he has never had a stent placed, and never had a cardiac catheterization. . Currently patients complains of productive cough. He is a chonic smoker and at baseline coughs every day however his cough has become more productive with clear/yellow sputum which he attributes to having stopped smoking since admission. He reports having chest pain only during coughing. Denies any pleuritic chest pain. Denies any significant shortness of breath. Reports sleeping on two pillows at home but denies any PND. He has had one episode CHF many years ago. He was recently started on lasix for worsening peripheral edema. . On review of systems he reports feeling very bloated. He's passing gas, and has had 1BM since admission, but is very uncomfortable. Reports pain is somewhat controlled on IV dilauded. He has not noticed any changes in his lower extremity weakness of numbness since surgery. Past Medical History: Diastolic Heart Failure with preserved EF - recently started on Lasix by his PCP. [**Name Initial (NameIs) **] [**10-16**] with LVH and preserved EF. Hypertension c/b LVH CAD c/b angina, unknown history of MI, caths Type 2 DM BPH Polio H/O measels, mumps, whooping cough Hemorrhoids Cervical laminectomy and fusion Ulnar nerve decompression Social History: He's from [**Hospital1 189**]. He has residual weakness on the right side from Polio and has been unable to ambulate on the left secondary to pain and spinal disease for which he was operated on this admission. He is a 1ppd smoker since age 12. He drinks 6-8 drinks per week. He denies any IVDU. He drinks socially, denies any drug use. Family History: Heart disease, diabetes, and arthritis. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.4 147/63 97 96% 1L Ins/Outs: [**Telephone/Fax (3) 111913**]/850 Gen: sitting upright in chair apears somewhat uncomfortabe, awake, oriented and appropriate. HEENT: EOMI, PERRL, MMM, OP clear Neck: JVD ~12, no LAD CV: RRR, nl s1, s2, no murmurs, no rubs or gallops. Resp: Decreased breath sounds in the lung bases with few crackles. No wheezes. GI: soft, distended, tympanitic, no HSM, no guarding, +BS Ext: 2+ pedal edema on the right, with trace over the shins bilaterally Neuro: CNII- CNXII intact, Decreased motor strenght in bilateral legs. Decreased sensation to light touch in bilateral legs. Psych: A&OX3, appropriate DISCHARGE PHYSICAL EXAM: VS: 99.2 132/60-174/69 90-101 20 96% RA FBG 135-162 (6H total) -150cc/24hr Gen: sitting in bed HEENT: sclera anicteric, MMM, OP clear Neck: JVD unable to be assessed, no LAD CV: RRR, nl s1, s2, no murmurs, no rubs or gallops. Resp: Decreased breath sounds in the lung bases L>R. Rhonchi which clears up after cough. Bibasilar crackles and few scattered wheezes. GI: soft, less distended, uncomfortable with palpation, tympanitic, no HSM, no guarding, +BS Ext: Somewhat cool extremities, faint PT pulses. 1+ edema. Neuro: Alsert and oriented. CNII-CNXII intact, Decreased motor strenght in bilateral legs. Decreased sensation to light touch in bilateral legs. Psych: A&OX3, appropriate Pertinent Results: Pertinent Labs: [**2197-10-26**] 03:41AM BLOOD WBC-8.7 RBC-3.73*# Hgb-10.5*# Hct-32.2*# MCV-86 MCH-28.2 MCHC-32.6 RDW-14.7 Plt Ct-217 [**2197-10-27**] 01:11AM BLOOD WBC-11.4* RBC-3.42* Hgb-9.5* Hct-29.6* MCV-87 MCH-27.9 MCHC-32.2 RDW-14.7 Plt Ct-228 [**2197-10-27**] 03:40PM BLOOD WBC-9.9 RBC-3.65* Hgb-10.3* Hct-31.9* MCV-87 MCH-28.1 MCHC-32.3 RDW-14.3 Plt Ct-226 [**2197-10-25**] 03:17PM BLOOD PT-12.5 PTT-31.8 INR(PT)-1.2* [**2197-10-26**] 03:41AM BLOOD Glucose-146* UreaN-9 Creat-0.3* Na-143 K-3.2* Cl-106 HCO3-31 AnGap-9 [**2197-10-27**] 01:11AM BLOOD Glucose-157* UreaN-10 Creat-0.4* Na-139 K-3.3 Cl-103 HCO3-27 AnGap-12 [**2197-10-27**] 08:00PM BLOOD CK-MB-5 cTropnT-<0.01 [**2197-10-28**] 01:30AM BLOOD CK-MB-4 cTropnT-<0.01 [**2197-10-29**] 06:11AM BLOOD cTropnT-<0.01 proBNP-419* [**2197-10-29**] 10:35AM BLOOD cTropnT-<0.01 [**2197-10-27**] 08:00PM BLOOD CK(CPK)-1037* [**2197-10-26**] 03:41AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.8 [**2197-10-25**] 02:26PM BLOOD Type-ART pO2-269* pCO2-48* pH-7.36 calTCO2-28 Base XS-1 [**2197-10-25**] 04:49PM BLOOD Type-ART pO2-258* pCO2-48* pH-7.37 calTCO2-29 Base XS-2 [**2197-10-30**] 11:31AM BLOOD Type-[**Last Name (un) **] pO2-40* pCO2-57* pH-7.41 calTCO2-37* Base XS-8 Comment-GREEN TOP [**2197-10-30**] 11:31AM BLOOD Lactate-1.1 . SPUTUM Gram Stain and Culture: Pending . CXR: [**2197-10-25**] FINDINGS: Frontal view of the chest was obtained. The patient has been extubated with removal of OG tube. Right IJ sheath terminates in the proximal SVC. Cervical fusion devices and thoracolumbar fusion device is incompletely imaged. Heart size and cardiomediastinal contours are stable. Widespread bilateral heterogeneous opacities are compatible with mild pulmonary edema. Right upper lobe atelectasis is improved. Left lung atelectasis is stable. No pneumothorax. . IMPRESSION: Interval extubation. Mild pulmonary edema, similar to prior. Improved right upper lobe atelectasis and stable left atelectasis. . CXR: [**2197-10-29**] Moderate cardiomegaly and pulmonary vascular congestion are essentially unchanged since [**10-27**] but there is greater opacification in the left lower chest including more consolidation in the left lower lobe either atelectasis or pneumonia and increasing small-to-moderate left pleural effusion. No pneumothorax. T- and L-Spine Film [**2197-10-31**] 1. Status post anterior and posterior cervical fusion. Surgical hardware appears intact. 2. Multilevel degenerative disc disease throughout the thoracolumbar spine, status post posterior spinal fusion of the lower thoracolumbar spine. Surgical hardware appears intact. 3. Diffuse bone demineralization with no evidence for compression fracture. 4. Mild degenerative joint disease of the hips. Spine CT [**2197-11-1**] 1. No evidence of fracture or malalignment. 2. Moderate-to-severe degenerative changes as described above. 3. Breached screw through the superior endplate above the intervertebral disc of T9. Brief Hospital Course: 68 year old male history of polio, DMII, HTN, diastolic CHF, CAD (described on CT) with angina symptoms, who underwent T9-S1 decompression and fusion transfered to medicine for evalaution of chest pain, tachycardia and new O2 requirement. . ACUTE: # Hypoxemia: This episode requiring persistent O2 requirement in the post-surgical period was felt to be multifactorial. Patient has extensive history of smoking and CT chest prior to admission showed interstitial and empysematous changes suggesting possible COPD. CXR, in combination with new cough, was consistent with pneumonia. DDx also included acute on chronic diastolic heart failure exacerbation given elaveted JVP, peripheral edema, few crackles on lung exam and finding of interstial edema on CXR. Based on prior chest CT, there were no findings suggestive of maligancy. Finally given immobilazation with recent surgery and being tachycardic with new O2 requirement, PE also in the differential. However, patient has an IV dye allergy that is described as serious and sounds like anaphylaxis therefore CT imaging was deferred. Given his condition at the time of transfer, pleural effusion on x-ray, and restricted lung volumes, a V/Q scan was likely be of little utility. Additionally, he was not tachycardic and his [**Doctor Last Name **] score was 1.5 making PE less likely. As such, the patient was treated with standing duonebs, vancomycin/cefepime, and IV lasix. Given that his MRSA screen was negative, he was then transitioned to levofloxacin for a total course of 7 days (last day [**2197-10-26**]). He was discharged without requirement for oxygen. Additionally, he was provided duonebs prn. He was also discharge on his home lasix dose. . # Chest pain: There was evidence of CAD on CT, as well as several coronary risk factors (HTN, HLD, DM, smoking history). His pain was relieved with nitro. However chest pain happens only with coughing suggesting upper respiratory tract inflammation. There were no ischemic changes on EKG and troponins were negative. He was continued on aspirin, lipitor and losartan and remained chest pain free throughout admission. . # Spinal decompression and fusion: Patient underwent T9-S1 decompression and fusion. He had no change in his motor function during his hospital stay with persistent left > right sided lower extremity weakness. He was initially on IV pain meds and was transitioned to PO dilaudid on discharge. He will be discharged to rehab for intensive physical therapy. . CHRONIC: # Hypertension: Continued on home losartan and amlodopine. . # DM2: Diet controlled at home presumably. Covered by ISS in house and started on metformin 500 daily on discharge. . # BPH: Continued on home finasteride and tamsulon during admission. . TRANSITIONAL: # follow-up with Dr. [**Last Name (STitle) 363**] in ortho on [**11-9**] at 10 am # titrate metformin for diabetes control # CT demonstrated breached screw through the superior endplate above the intervertebral disc of T9. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientPharmacy. 1. Aspirin 81 mg PO DAILY 2. Furosemide 40 mg PO DAILY 3. Atorvastatin 10 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY 5. meloxicam *NF* 7.5 mg Oral Daily 6. Finasteride 5 mg PO DAILY 7. Amlodipine 5 mg PO DAILY 8. Tamsulosin 0.4 mg PO DAILY Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Atorvastatin 10 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY 5. Tamsulosin 0.4 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Furosemide 40 mg PO DAILY 8. meloxicam *NF* 7.5 mg ORAL DAILY 9. Nitroglycerin SL 0.4 mg SL PRN chest pain 10. Senna 1 TAB PO BID 11. Levofloxacin 750 mg PO DAILY Duration: 4 Doses 12. Docusate Sodium 100 mg PO BID 13. Bisacodyl 10 mg PR HS:PRN constipation 14. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H pain RX *hydromorphone [Dilaudid] 2 mg [**2-6**] tablet(s) by mouth q3hrs Disp #*480 Tablet Refills:*0 15. Polyethylene Glycol 17 g PO DAILY 16. MetFORMIN (Glucophage) 500 mg PO DAILY RX *metformin 500 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 17. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, sob 18. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob, wheeze Discharge Disposition: Extended Care Facility: Radius [**Hospital 36748**] HealthCare Center - [**Hospital1 189**] Discharge Diagnosis: 1. Spinal stenosis 2. COPD Exacerbation 3. Hospital Acquired Pnemonia 4. Acute on chronic diastolic CHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname 111914**], it was a pleasure taking care of you during your hospitalization at [**Hospital1 18**]. You had been experiencing worsening lower leg weakness and numbness therefore you were admitted for elective spine surgery which went well. After your surgery you continued to require oxygen most likely from variety of reason, including chronic lung disease from smoking, fluids in your lung as well as pneumonia. You were treated with antibiotics, nebulizer treatments and given lasix to help get rid of extra fluid fom your body. Your symptoms continued to improve on antibiotics and with continued lasix. You were discharge without a need for oxygen. You should continue all of your previous medications. Additionally, you are being discharged with a prescription for levofloxacin to treat your pneumonia, dilaudid to treat your pain, metformin to help control your diabetes, and additional medications to help you move your bowels. Followup Instructions: Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 **], Orthopedics Address: [**Location (un) **], [**Location (un) 8661**] 2 [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3573**] Appt: [**11-9**] at 10am

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icd9cm

[ [ [] ] ]

[ "81.64", "81.05", "03.90", "77.79" ]

icd9pcs

[ [ [] ] ]

11716, 11810

7427, 10426

323, 391

11958, 11958

4446, 4446

13086, 13427

2993, 3034

10829, 11693

11831, 11937

10452, 10806

12093, 13063

3074, 3712

272, 285

419, 2253

11973, 12069

4462, 7404

2275, 2618

2634, 2977

3737, 4427

64,530

177,565

39579

Discharge summary

report

Admission Date: [**2123-9-21**] Discharge Date: [**2123-9-25**] Date of Birth: [**2061-3-14**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: right adrenal pheochromocytoma Major Surgical or Invasive Procedure: right adrenalectomy [**9-21**] History of Present Illness: HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old woman who is now well known to me. She originally presented a month or two back to the hospital with a small-bowel obstruction which was managed nonoperatively. During her hospitalization, however, we noted an adrenal mass and began workup for possible functional endocrine tumor. This turned out to be positive. After seeing the patient in clinic two weeks ago, I referred her for endocrinology followup to confirm the diagnosis of a pheochromocytoma. This is now felt to be firmly confirmed. We have now switched the patient's medications from a calcium channel blocker to a combination of alpha blockade and beta blockade. This will allow the exact management in the perioperative period. The patient is, otherwise, asymptomatic today, and she comes for her definitive procedure. Past Medical History: Past Medical History: HTN, HL, GERD Past Surgical History: c-sections Social History: Lives at home with husband, retired. Denies tobacco, social EtOH, no drugs. Family History: Mother with melanoma, no history of ovarian, breast, or endocrine cancers Physical Exam: Physical Examination: completed [**2123-8-26**]: Vitals: Supine: BP 123/74, P 80; Sitting: BP 122/78, P 84; Standing: BP 119/76, P 92; Weight 155, Height 62" General: Well appearing, no apparent distress HEENT: PERRL, EOMI, MMM, no lid lag, proptosis, OP without lesions Neck: No lymphadenopathy, no thyromegaly Heart: Regular rhythm, tachy/normal rate, II/VI flow murmur. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, +BS, no masses palpable. Extremities: WWP, no edema, 2+ pulses. Neuro: Normal strength, no tremor. DTR normal. Skin: No lesions, unremarkable Pertinent Results: [**2123-9-24**] 06:10AM BLOOD WBC-4.5 RBC-3.37* Hgb-9.3* Hct-27.9* MCV-83 MCH-27.6 MCHC-33.4 RDW-14.5 Plt Ct-247 [**2123-9-23**] 06:10AM BLOOD WBC-5.7 RBC-3.47* Hgb-9.5* Hct-28.5* MCV-82 MCH-27.3 MCHC-33.2 RDW-14.6 Plt Ct-256 [**2123-9-22**] 01:45AM BLOOD WBC-6.3 RBC-3.44* Hgb-9.5* Hct-27.3* MCV-79* MCH-27.6 MCHC-34.8 RDW-14.4 Plt Ct-271 [**2123-9-21**] 08:36PM BLOOD WBC-8.3# RBC-3.63* Hgb-10.2* Hct-28.9* MCV-80* MCH-28.0 MCHC-35.2* RDW-14.4 Plt Ct-296 [**2123-9-24**] 06:10AM BLOOD Plt Ct-247 [**2123-9-23**] 06:10AM BLOOD Plt Ct-256 [**2123-9-22**] 01:45AM BLOOD Plt Ct-271 [**2123-9-24**] 06:10AM BLOOD Glucose-88 UreaN-7 Creat-0.6 Na-136 K-3.9 Cl-100 HCO3-30 AnGap-10 [**2123-9-23**] 06:10AM BLOOD Glucose-87 UreaN-8 Creat-0.6 Na-133 K-3.8 Cl-99 HCO3-30 AnGap-8 [**2123-9-22**] 01:45AM BLOOD Glucose-122* UreaN-11 Creat-0.6 Na-138 K-3.9 Cl-104 HCO3-25 AnGap-13 [**2123-9-24**] 06:10AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.8 [**2123-9-23**] 06:10AM BLOOD Calcium-8.2* Phos-2.0* Mg-1.8 [**2123-9-22**] 01:45AM BLOOD Cortsol-41.7* [**2123-9-21**] 09:09PM BLOOD freeCa-1.20 [**2123-9-21**]: IMPRESSION: AP chest compared to [**2123-7-26**]: With the chin down, tip of the endotracheal tube is at the thoracic inlet, no less than 5.5 cm from the carina, 2 cm above optimal placement. Left lower lobe atelectasis is mild, probably explains small left pleural effusion. Right lung clear. Heart size normal. No pneumothorax. Right jugular line ends in the mid SVC and nasogastric tube in the stomach [**2123-9-22**] 6:16 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2123-9-24**]** MRSA SCREEN (Final [**2123-9-24**]): No MRSA isolated. Brief Hospital Course: 62 year old female who on hospitalization for small bowel obstruction noted to have an adrenal mass. Further work-up was done and she was reported to have a right pheochromocytoma. Prior to her surgery, her blood pressure was controlled with alpha and beta blockers. She was taken to the operating room on [**9-21**] where she had a right adrenalectomy. She had an epidural catheter placed for post-op pain management. She had a 'rocky' operative course, and required pressors for hemodynamic support after removal of the pheo. She had an 800cc blood loss. Post-operatively, she was monitored in the intensive care unit and required levophed for hypotension for about 12 hours. Once her vital signs stablized she was extubated. She was seen by the Acute Pain service on [**9-21**] and her pain regimen was initiated via the epidural catheter. She was started on a regular diet. She was transferred to the Acute Care floor on [**9-22**]. Her vital signs have been stable and she has not required any anti-hypertensive agents at all. She is afebrile and tolerating a regular diet. She has been ambulating in the [**Doctor Last Name **]. She has not moved her bowels. Her epidural is scheduled for removal this afternoon followed by removal of her foley. She is preparing for discharge home. She will need follow-up in 10 days for staple removal and a follow-up appointment with Dr. [**Last Name (STitle) **]. Medications on Admission: [**Last Name (un) 1724**]: amlodipine 10', wellbutrin, doxazosin 2', labetalol 100', lisinopril 20', simvastatin 20', Ca/vitD, vitD3, omeprazole 20 Discharge Medications: 1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for Post surgical pain. Disp:*30 Tablet(s)* Refills:*0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day: hold for diarrhea. Discharge Disposition: Home Discharge Diagnosis: right adrenal mass w/u for pheochromocytoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You are being discharged from the hospital after you were admitted for an adrenal mass (a 'pheochromocytoma'). You had removal of the mass and are ready for discharge. You will be discharged with the following instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items [**9-3**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please follow up with the Acute Care Service for removal of staples in 10 days. You can schedule this appointment by [**Last Name (un) **] #[**Telephone/Fax (1) 600**]. You can also schedule a follow-up appointment with Dr. [**Last Name (STitle) **] after [**Holiday 1451**]. Again, you can schedule this appointment by calling #[**Telephone/Fax (1) 600**]

[ "458.29", "227.0", "530.81", "272.4", "E878.6", "401.9", "759.6" ]

icd9cm

[ [ [] ] ]

[ "03.90", "07.22", "50.12" ]

icd9pcs

[ [ [] ] ]

5816, 5822

3883, 5304

345, 378

5910, 5910

2171, 3858

7589, 7952

1463, 1538

5502, 5793

5843, 5889

5330, 5479

6061, 7219

1341, 1353

1553, 1553

1575, 2152

275, 307

7231, 7566

435, 1257

5925, 6037

1302, 1317

1369, 1447