ChanBeDu/relevant_section_length · Datasets at Hugging Face

19,984

100,132

44131+58691

Discharge summary

report+addendum

Admission Date: [**2179-3-5**] Discharge Date: [**2179-3-24**] Date of Birth: [**2105-3-13**] Sex: F Service: MEDICINE Allergies: Benzodiazepines Attending:[**First Name3 (LF) 3984**] Chief Complaint: shortness of breath, red hands and feet Major Surgical or Invasive Procedure: endotracheal intubation, mechanical ventilation, right IJ central line placed, tracheostomy tube placed in OR History of Present Illness: Ms. [**Known lastname 94714**] is a 73yo woman with h/o ALS who presents with 3 weeks of redness in her hands and feet as well as more recent difficulty breathing. The patient had not complained of dyspnea and her husband had noted tachypnea or respiratory distress but per her husband she went to her doctor today, who noted that she was "not breathing well" and sent her to the ER where she was hypoxic in the 80s, responding well to O2 by NC. She was then found to have an ABG of 7.19/126/525/51 and was started on Bipap. She did not tolerate the non-invasive mask ventilation despite sedateion (versed 2mg, and fentanyl 100mg). She experienced a reduction of blood pressure to 66/30, and was subsequently intubated. Per husband, the patient has had ALS for three years. She performs ADLs on her own but has had trouble with speech as well as with keeping her mouth closed at baseline. She has not had any respiratory complaints. She had previously lost 40 pounds but last year was given a Gtube and since then has gained back 14 pounds. [**Name (NI) 1094**] husband states that prior to the last 3 weeks she was in her USOH, and denies any new symptoms including cough, sputum, no sick contacts. She is entirely NPO and has been for about a year. CXR in the ER showed no acute CP process and UA was negative for signs of infection. Per the pt's husband they have never had any sort of conversation regarding code status. The patinet did try bipap in the past but was unable to tolerate it, but her outpatient neurologist has never mentioned intubation or tracheostomy. Mr. [**Known lastname 94714**] states that these are all new thoughts for him and he's not entirely certain what his wife would want at this point. She was transferred to the [**Hospital Unit Name 153**], and she was started on AC 450x16, 100% FiO2, PEEP 5. ABG on this setting was 7.40/57/426/37 and her FiO2 was turned down to 50%. Past Medical History: - ALS diagnosed 3y ago - has Gtube with tube feeds, has difficulty with speech - hypercholesterolemia -?depression Social History: lives at home with husband, has three children two of whom live on the west coast and one of whom lives in [**Location **]. never used tobacco, does not drink alcohol, no other drugs. Works as a writer. At baseline performs ADLs, writes, uses internet to chat with her grandchildren. Family History: father MI age 52, mother deceased at age [**Age over 90 **] Physical Exam: 96.7, 78, 112/64, 16, 100% on AC settings as above Gen: sedated, unresponsive, intubated HEENT: PERRL, NCAT Cor: s1s2, RRR, no r/g/m Pulm: CTAB Abd: soft, NT, ND, +BS, Gtube c/d/i Ext; no c/c/e, bilateral toes with skin changes c/w venous stasis, bilateral fingers with erythematous dry excoriated skin Neuro: babinski upgoing bilaterally, myoclonus BLE, hyperreflexic B patellar, biceps Pertinent Results: on arrival Na 126, CK 273-->115, MB 14-->10, trop <0.01--> <0.01, bicarb 40, UA negative [**2179-3-23**] 02:44AM BLOOD WBC-10.0 RBC-2.88* Hgb-9.4* Hct-27.6* MCV-96 MCH-32.7* MCHC-34.1 RDW-13.5 Plt Ct-316 [**2179-3-23**] 02:44AM BLOOD Neuts-78.7* Bands-0 Lymphs-15.8* Monos-3.6 Eos-1.6 Baso-0.3 [**2179-3-22**] 04:15AM BLOOD PT-11.7 PTT-22.6 INR(PT)-1.0 [**2179-3-23**] 02:44AM BLOOD Glucose-127* UreaN-24* Creat-1.3* Na-145 K-4.5 Cl-107 HCO3-31 AnGap-12 [**2179-3-19**] 05:54AM BLOOD ALT-49* AST-44* LD(LDH)-267* AlkPhos-142* Amylase-41 TotBili-0.3 [**2179-3-19**] 05:54AM BLOOD Lipase-30 [**2179-3-5**] 02:50PM BLOOD CK-MB-14* MB Indx-5.1 cTropnT-<0.01 [**2179-3-5**] 10:15PM BLOOD CK-MB-10 MB Indx-8.7* cTropnT-0.01 [**2179-3-23**] 02:44AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.4 [**2179-3-19**] 05:54AM BLOOD TSH-3.0 [**2179-3-18**] 11:55AM BLOOD Cortsol-23.9* [**2179-3-18**] 12:51PM BLOOD Cortsol-43.3* [**2179-3-18**] 01:48PM BLOOD Cortsol-51.1* [**2179-3-22**] 04:11PM BLOOD Type-ART pO2-136* pCO2-50* pH-7.45 calHCO3-36* Base XS-9 [**2179-3-22**] 04:11PM BLOOD Lactate-1.2 . [**2179-3-12**] 10:57 pm BLOOD CULTURE LT PIV. **FINAL REPORT [**2179-3-18**]** AEROBIC BOTTLE (Final [**2179-3-15**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2179-3-13**] @ 2:35 PM. STAPH AUREUS COAG +. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S ANAEROBIC BOTTLE (Final [**2179-3-18**]): NO GROWTH. . [**2179-3-13**] 12:20 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2179-3-15**]** GRAM STAIN (Final [**2179-3-13**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2179-3-15**]): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S . [**3-15**] ECHO: 1.The left atrium is normal in size. 2.There is mild 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%). 3. Right ventricular chamber size is normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. 6.There is no pericardial effusion. . [**2179-3-5**] EKG: Sinus rhythm. Slight ST segment elevation in leads II, III and aVF which may represent active inferior ischemic process. Followup and clinical correlation are suggested. No previous tracing available for comparison . [**2179-3-12**] EKG: Atrial fibrillation with a rapid ventricular response, rate 160. Non-specific repolarization changes. Compared to the previous tracing of [**2179-3-5**] normal sinus rhythm with abbreviated P-R interval has given way to atrial fibrillation with a rapid ventricular response . [**3-21**] CXR: There continues to be dense opacification in the retrocardiac region consistent with left lower lobe collapse and a small left effusion. There are some patchy areas of increased opacity in the right lower lung and left mid lung that may represent early infiltrate or volume loss. There is no significant change compared to the film from two days ago. The right subclavian line is unchanged. . [**2179-3-22**] Renal US: Mildly echogenic but otherwise normal-appearing kidneys may be secondary to medical renal disease. 1.1 x 0.9 cm echogenic focus in the left kidney may represent a cholesterol deposit versus a nonobstructing kidney stone. Brief Hospital Course: # hypercarbic resp failure: This was felt to be likely ALS induced muscular weakness combined with possible acute PNA given LLL consolidation on CXR. She was intubated for repiratory failure, and treated for a possible pneumonia. She was not able to tolerate weaning off the ventilator, and therefore required tracheostomy for longer term ventilator support. While awaiting trach placement, Ms. [**Known lastname 94714**] also developed a ventilator associated pneumonia. She grew MRSA in her sputum and blood, and was treated with a course of vancomycin. Zosyn was added after 5 days of vancomycin as she had repeated L lung collapse with thick mucous plugging, and we wanted to cover for pneumonia as well. Subsequent surveillance cultures were clean. Zosyn was later switched to Cefepime [**1-7**] worsening renal failure attributed to Zosyn. She completed an 8 day course of antibiotics. Her tracheostomy went well, and she was started on an in/exsufflator as well to aid in clearing her secretions/mucous to prevent recurrent lung colapse. . # A fib: Ms. [**Known lastname 94714**] had several episodes of atrial fibrillation with RVR, all in the setting of L lung collapse. She was initially started on a beta blocker with good response. After having multiple episodes she was started on amiodarone and anticoagulation with heparin. In all cases she converted to sinus rhythm on her own. Shortly after starting heparin, she had an episode of guaiac positive stool, and then a small amount of melena. Her heparin was stopped, and was not restarted as she remained in sinus rhythm, and the concern was that her risk of GI bleeding is higher than her risk of stroke. Her PEG was lavaged, and was OB negative. She will also need a colonoscopy as an outpatient to further evaluate the cause of her melena. She has subtle ST changes on inital EKG, but ruled out for an MI by enzymes. . # hypotension: Ms [**Known lastname 94714**] was hypotensive on intial presentation, responding well to fluid boluses. She had a cortisol stimulation test with normal response. It became clear that she responds to sedation with benzodiazepines with prolonged hypotension (as well as increased delerium and agitation), and therefore these were stopped, and put into her allergy list. After cessation of benzodiazepines, her blood pressure was much more stable, and she did not require bolusing. She never required pressors. . # ALS: It was felt that she likely had progression of her ALS, with diaphragmatic weakness and CO2 retention. Her respiratory mechanics were repeatedly asessed, and showed that she would not be able to come off the vent. Therefore a trach was placed in the OR by thoracic surgery (IP unable to place due to her anatomy). . # hyponatremia: Mrs [**Known lastname 94714**] was hyponatremic on admission. Tis resolved with hydration, indicating that she was likely hypovolemic and total body sodium depleted. She had no further problems with this for the duration of her stay. . #Diarrhea: New on [**2179-3-24**]/ Slight increase in in WBC to 15. Afebrile. No abdominal pain. Has been on course of antibiotics for vent associated PNA. Those antibiotics stopped today. ALso on tube feeds. C. Diff is a possibility given recent abx but it may also be related to tube feeds. On C.Diff is pending. At this point it is reasonable to follow fever curve and stool output. C.Diff lab should be followed up. [**Month (only) 116**] consider empiric treatment of c. diff with flagyl if febrile or diarrhea persists. . #Hypernatremia - Likely releated to low volume. WIll increase free water with tube feeds from 100cc q4hr to 150cc q4h. A chenistry panel should be checked on [**2179-3-26**] to make sure Na remains stable. . # conjunctivitis: Ms. [**Known lastname 94714**] had bilateral conjunctivitis on admission. This resolved with a 7 day course of erythromycin eye cream. . # skin changes: Ms [**Known lastname 94715**] intitial presenting chief complaint was erythema of her hands and feet. Dermatology was consulted, and said that she likely has erythromyalgia. The treatment for this is sarna lotion and aspirin, and improvement does not occur in less than a month. She was treated with sarna and ASA throughout her stay. Additionally she had burns on the inside of both thighs from a hot tea spill at home prior to admission. Per dermatology recs, these areas were treated with antibiotic cream and xeroform dressings, and healed over cleanly without infection. . # FEN: Ms. [**Known lastname 94714**] had a PEG on admission as she has not been able to take PO intake for some time secondary to progression of her ALS. She was continued NPO, with tubefeeds per nutrition. We monitored & repleted her electrolytes lytes. She was kept euvolemic. #Renal Failure: Pt's Creatinine increased during this admission from 0.7 to 1.3. BUN remained around 20 .Urine lytes were consistent with ATN>Reanla failure was attributed to ATN d/2 Zosyn.Although it was chenged to Cefepime, there was no improvement. Renal US showed no obstruction. Pt's creatinitne remained near 1.3.Plan will be to keep pt hydrated , avoid nephrotoxins and follow creatinine as outpatient. . # PPX: Ms. [**Known lastname 94714**] was treated with SC heparin, protonix, and a bowel regimen. She did have some constipation, and her bowel regimen was increased with good results. . # access: She was maintained with PIVs throughout most of her hospitalization. Shortly before discharge a PICC line was placed as she was losing all her peripheral access. . # code status: Per discussion with Ms [**Known lastname 94714**] and her husband she was full code throughout her stay. Medications on Admission: Elavil (stopped a few weeks ago) Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: [**12-7**] PO BID (2 times a day). 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day). 3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 6. Bisacodyl 10 mg Suppository Sig: [**12-7**] Suppositorys Rectal DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 9. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Amiotrophic Lateral Sclerosis Hypercarbic Respiratory Failure Atrial Fibrillation Recurrent Pneumonia-Ventilator Associated Pneumonia Renal Failure Discharge Condition: good , afebrile , no cough , no fever, tracheostomy in good condition. Discharge Instructions: Please continue using exsuflator as needed.PLease come back to ED if you have a new episode of worsening cough, fever and productive sputum. . Pleae take your medications as as prescribed. . You were noted to have diarrhea on the morning prior to discharge, please call [**Hospital1 18**] to check on the results of her c. diff stool culture on [**2179-3-25**], and consider a c. diff study if diarrhea continues. Followup Instructions: PCP: [**Name10 (NameIs) **],[**First Name3 (LF) 2946**] S. [**Telephone/Fax (1) 2936**] . Recent onset of diarrhea. Please call [**Hospital1 18**] microbiology lab at ([**Telephone/Fax (1) 94716**] to follow up results of c. diff toxin assay. . Please check cbc and chem 7 on [**2179-3-26**]. New onset of hypernatremia on [**2179-3-24**]. Free water increased in tube feeds on [**2179-3-24**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2179-3-24**] Name: [**Known lastname 14986**],[**Known firstname 553**] Unit No: [**Numeric Identifier 14987**] Admission Date: [**2179-3-5**] Discharge Date: [**2179-3-24**] Date of Birth: [**2105-3-13**] Sex: F Service: MEDICINE Allergies: Benzodiazepines Attending:[**First Name3 (LF) 1807**] Addendum: Pt was readmitted hours after dischsrge on [**3-24**] /06 because of new episode of rapid atrial fibrillation.In ED her HR was 140 and BP went down to 100 sistolic. She was given IV Diltiazem after which se converted to sinus rhythm. Her BP went down to 90 sistolic . She was sent back to [**Hospital Unit Name 1863**]. Her VS in [**Hospital Unit Name 1863**] 141/73 T 97.7 HR 74 (sinus) SpO2 99% on A/C 400 14 FiO2 50% PEEP 5. PE was unchanges.She had dry mucous membranes. On her labs her initial WBC of [**Numeric Identifier 14988**] went down to [**Numeric Identifier 14989**].Na was 149 Creatinine was 1.3. CxR showed no new evidence of LUL atelectasis. Our impression was that afib was secondary to dehydration. There was no evidence of infection, TSH was 3. Troponins were also (-). We discontinued Cefepime since she had already finished a 7 day course. She was given IV fluids and free water was given through PEG tube. Metoprolol dose was increased from 37.5 [**Hospital1 **] to to 37.5 tid Upon discharge her BP was 139/86 HR 86 Amiodarone was not added d/2 interaction with antipsychotic medications.PLan will be to avoid triggering Afib factors: dehydration , lung collapse. Again , no anticoagulation was offered d/2 hx of GI bleeding with Heparin. The plan will be to Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hospital [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1809**] Completed by:[**2179-3-25**]

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Discharge summary

report

Admission Date: [**2129-9-18**] Discharge Date: [**2129-9-24**] Date of Birth: [**2061-7-24**] Sex: F Service: SURGERY Allergies: Ativan Attending:[**First Name3 (LF) 2777**] Chief Complaint: Lower extremity weakness, found to have acute renal failure and hyperkalemia Major Surgical or Invasive Procedure: None History of Present Illness: 68 year-old female with insulin-dependent diabetes mellitus, extensive peripheral vascular disease well-known to vascular service admitted with lower extremity weakness, found to be in acute renal failure and hyperkalemic. Patient reports lower extremity weakness began 3 days ago, and has gradually increased in intensity. She has not been able to walk, has been wheelchair-bound for past 2 days. Associated with severe lower back pain. Denies pain in her legs. Numbness/tingling in her feet bilaterally at baseline. Denies bowel or bladder incontinence/hesitancy. Reports decided to come to ED today because no one would be home in morning to help her get around the house. . Of note, patient had ARF in [**4-/2128**] with creatinine 5.8, secondary to ATN due to possible hypotension, low PO intake. Also noted to have UTI at that time. Creatinine improved with hydration. This was associated with labile pressors attributed to autonomic dysfunction secondary to diabetes mellitus. . Also of potential significance, patient underwent contrast study to evaluate grafts on [**2129-9-14**]; at that time, her creatinine was 1.4. . In the ED, 98.8 83 118/53 16 100%RA. Laboratory evaluation was significant for hyponatremia (124), hyperkalemia (8.0), and acute renal failure (creatinine 4.8, baseline 1.0-1.1). Initial EKG showed peak T waves and QRS widening, atrial fibrillation. Patient received calcium gluconate 2g IV x1, regular insulin 10 units IV with 1 amp D50, 1 amp bicarbonate, albuterol nebulizer, and Kayexelate 60g PO x1. Repeat EKG showed resolution of peaked T waves, QRS widening. Vascular surgery was consulted and will continue to follow patient; per report, primary concern from vascular standpoint is that left external iliac stent may not be patent given faint pulses (with Doppler). Renal was consulted, although they have not seen the patient. On transfer from ED, 98.2, 72, 127/60s, 16, 99% RA. . On the floor, patient reports feeling well. Lower extremity weakness is improved. Back pain is improved. Denies chest pain, palpitations, shortness of breath. . Review of sytems: (+) Per HPI. Reports lower extremity edema x2-3 weeks (was started on medication for this 2 weeks ago by PCP, ?furosemide). Reports loose stools x2 days, 1 stool per day. (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No dysuria. Denies decreased urine output. Denies arthralgias or myalgias. Past Medical History: Hypertension Dyslipidemia PVD Hypothyroidism Diabetes mellitus, insulin-dependent Peripheral neuropathy Renal calculus Low back pain Carpal tunnel syndrome Shoulder impingement syndrome on the left Ovarian cancer s/p TAH BSO, chemo followed at [**Company 2860**] Staphylococcus cellulitis Fibromatosis Plantar facial herpes zoster . Past Surgical History: (per vascular surgery note) s/p bilateral common iliac artery stent [**8-30**] s/p left superficial femoral artery balloon angioplasty, left external iliac stent and partial common femoral angioplasty [**9-1**] s/p right balloon angioplasty of the distal SFA,stent [**10-2**] s/p angioplasty of left superficial femoral artery, Stenting of left superficial femoral artery, Stenting of left external iliac artery [**5-5**] s/p TAH/BSO Social History: Lives with boyfriend. Former bartender/waittress, retired for 20 years. Quit smoking 15 years ago, smoked 1 PPD for 10 years. Denies alcohol use. Last alcohol drink was [**1-3**]. Denies illicit drug use. Family History: Mother and father with history of alcoholism, sister with esophageal cancer. No family history of renal disease. Physical Exam: On [**Hospital Unit Name 153**] admission: 97.7, 78, 155/55, 16, 93% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: Left basilar crackles; otherwise CTA bilaterally CV: Irregularly irregular; normal S1/S2; II-VI holosystolic murmur best heart at LUSB vs. ?rub Abdomen: Obese; hypoactive bowel sounds; soft, non-tender GU: Foley draining light yellow urine Ext: Radial pulses 1+ and equal bilaterally; unable to palpate right DP, left DP, or left PT pulses; right PT 1+; feet cool to touch; 1+ lower extremity edema to knees bilaterally Neuro: CNII-XII intact; upper and lower extremity strength 5/5 and equal bilaterally; upper extremity asterixis Pertinent Results: LABORATORIES: [**2129-9-18**] 01:05PM BLOOD WBC-9.0 RBC-3.84* Hgb-11.2* Hct-34.4* MCV-90 MCH-29.2 MCHC-32.6 RDW-13.6 Plt Ct-254 [**2129-9-24**] 06:04AM BLOOD WBC-8.4 RBC-3.68* Hgb-11.0* Hct-34.0* MCV-92 MCH-29.9 MCHC-32.4 RDW-13.4 Plt Ct-244 [**2129-9-18**] 01:05PM BLOOD Neuts-71.6* Lymphs-15.6* Monos-11.1* Eos-1.5 Baso-0.2 [**2129-9-18**] 01:05PM BLOOD PT-11.5 PTT-26.9 INR(PT)-1.0 [**2129-9-24**] 06:04AM BLOOD PT-12.6 PTT-27.1 INR(PT)-1.1 [**2129-9-18**] 01:05PM BLOOD Glucose-296* UreaN-118* Creat-4.8*# Na-124* K-8.0* Cl-92* HCO3-17* AnGap-23* [**2129-9-24**] 06:04AM BLOOD Glucose-83 UreaN-19 Creat-1.0 Na-143 K-4.7 Cl-108 HCO3-26 AnGap-14 [**2129-9-18**] 01:05PM BLOOD CK(CPK)-317* [**2129-9-19**] 12:00AM BLOOD CK(CPK)-269* [**2129-9-21**] 06:10AM BLOOD CK(CPK)-95 [**2129-9-21**] 06:18PM BLOOD CK(CPK)-104 [**2129-9-22**] 01:52AM BLOOD CK(CPK)-78 [**2129-9-18**] 01:05PM BLOOD CK-MB-7 cTropnT-0.05* [**2129-9-19**] 12:00AM BLOOD CK-MB-6 cTropnT-0.03* [**2129-9-21**] 06:10AM BLOOD CK-MB-4 cTropnT-<0.01 [**2129-9-21**] 06:18PM BLOOD CK-MB-4 cTropnT-<0.01 [**2129-9-22**] 01:52AM BLOOD CK-MB-4 cTropnT-<0.01 [**2129-9-18**] 05:59PM BLOOD Calcium-9.5 Phos-6.4*# Mg-3.3* [**2129-9-24**] 06:04AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.4 [**2129-9-23**] 04:21AM BLOOD Cholest-210* Triglyc-273* HDL-36 CHOL/HD-5.8 LDLcalc-119 [**2129-9-21**] 06:10AM BLOOD TSH-0.60 ============ [**9-18**] Renal ultrasound: The study is limited due to body habitus. Within these limitations, there is no evidence of hydronephrosis. Both kidneys demonstrate normal echogenicity and good corticomedullary differentiation. No focal masses or lesions identified. No perinephric collections. Left kidney measures 8 cm and the right kidney measures 10 cm. IMPRESSION: Limited by body habitus. Otherwise, unremarkable study without evidence of hydronephrosis. ============ [**9-19**] CXR: Borderline enlargement of the cardiac silhouette has improved since [**24**]/[**2128**]. Lungs are clear. Pulmonary vasculature is mildly engorged, but there is no edema or pleural effusion. ============ [**9-19**] TTE: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and 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) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2128-5-3**], no change. ============ [**9-21**] CXR: As compared to the previous radiograph, there is no relevant change. Unchanged size of the cardiac silhouette, unchanged signs of minimal overhydration. No newly occurred focal parenchymal opacity suggestive of pneumonia, no pneumothorax, no pleural effusions. ============ [**9-22**] LENIS: Right common femoral vein, superficial femoral vein and popliteal veins demonstrate appropriate compressibility and flow with augmentation. The left common femoral vein, superficial femoral vein, and popliteal veins demonstrate appropriate compressibility and flow as well. No overt abnormality seen within the veins of the calves on color images. IMPRESSION: No evidence of lower extremity DVT. Brief Hospital Course: 68 year old female with peripheral vascular disease, insulin dependent diabetes, dyslipidemia admitted with acute renal failure and hyperkalemia. . # Atrial fibrillation with RVR: Atrial fibrillation began spontaneously on [**2129-9-21**] while patient was sleeping. Heart rate went as high as 140-150s without hemodynamic instability (sBP remained >120) or respiratory distress. Patient remained comfortable, only c/o palpitations. Heparin gtt was started at onset of atrial fibrillation. Atrial fibrillation during this hospitalization may have been induced by dehydration/renal failure/electrolyte abnormalities on admission. TTE during this hospital course showed [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 15695**]. Patient remained tachycardic but without symptoms despite metoprolol 100 mg TID and diltiazem drip, so she was transferred to [**Hospital1 1516**] cardiology service for management of Afib. Right before transfer, she spontaneously converted back to normal sinus rhythm. She remained to be in normal sinus rhythm during the stay on [**Hospital1 1516**] service, and was started on coumadin. Hesitant to start amiodarone on a patient with history of hypothyroidism. Hesitant to start digoxin on a patient who had acute renal failure. Patient was discharged with metoprolol XL 50mg daily, and diltiazem ER 120mg daily, and coumadin for goal INR of [**3-1**]. Patient was told to follow up with her cardiologist to discuss the option of anti-arrhythmics in the future. . # Acute renal failure: Patient presented with creatinine of 4.8. Patient had received IV contrast on [**2129-9-14**] hence possibility of contrast-induced nephropathy. There was also concern for pre-renal failure given recent use of furosemide. There was no evidence of hydronephrosis on renal ultrasound. Patient was hydrated with IV fluids. Lisinopril was initially held, and furosemide was discontinued. All medications were renally dosed. Creatinine trended down to her baseline and was 1.0 on discharge. . # Hyperkalemia: Patient presented with a potassium level of 8.1 and significant EKG changes. Patient received calcium carbonate, insulin, bicarbonate and kayexelate in the ED with resolution of EKG changes. Patient was admitted to the ICU for further monitoring and management. Patient was kept on telemetry and received another dose of kayexelate in the ICU before being transferred to the floor on [**2129-9-19**]. Patient's potassium was normal during the rest of her hospital stay. . # Hypertension: Patient's blood pressure were labile during this hospitalization. Her home dose of lisinopril was initially held due to acute renal failure. Her blood presure was controlled with home dose of metoprolol and IV hydralazine and IV metoprolol as needed. After she was transferred to [**Hospital1 1516**] service, she continued to have hypertension (SBP up to 180s), so she was discharged with HCTZ in addition to BB, CCB and ACEI. . # Type II Diabetes mellitus: Patient was continued on home dose of 45 units lantus at bedtime and placed on an insulin sliding scale. Patient's glucose levels were well-controlled on discharge. Patient has severe peripheral neuropathy. Neurontin was continued. . # Peripheral vascular disease: Severe disease with multiple prior interventions, including stenting of common iliac arteries, [**Female First Name (un) 7195**], RSFA, LPA. Cilostazol was initially held due to acute renal failure and restarted on [**2129-9-19**]. Aspirin was continued through out admission. Vascular service was contact[**Name (NI) **], and the decision was made not to have the previously planned angiogram for now as she developed acute renal failure from contrast. Vascular will call patient at home to re-schedule. . # Hypothyroidism: Patient was kept on home dose of levothyroxine. . # Ovarian cancer status post TAH-BSO: Letrozole was initially held at presentation due to acute renal failure. It was restarted later when her renal function returned normal. . Patient was on cardiac healthy diet, and she tolerated POs well. Her contact was [**Name (NI) **] [**Name (NI) 96320**] (boyfriend), ([**Telephone/Fax (1) 96321**]. Her code was full. Medications on Admission: Medications on admission [**2129-9-18**]: CILOSTAZOL 50 mg twice a day FENTANYL 50 mcg/hour Patch 72 hr - 1 every 72 hours GABAPENTIN 300 mg pt takes 3 tablets in the am, 2 tablets at lunch, 3 tablets at dinner and 2 tablets at hs INSULIN GLARGINE 45 units QHS INSULIN LISPRO sliding scale LETROZOLE 2.5 mg daily LEVOTHYROXINE 112 mcg daily LISINOPRIL 40 mg daily METOPROLOL SUCCINATE 50 mg daily SIMVASTATIN 40 mg daily ASPIRIN 325 mg daily . Medications on transfer from floor to ICU [**2129-9-21**]: Fentanyl Patch 50 mcg/hr TP Q72H Insulin Sliding Scale & Fixed Dose Levothyroxine Sodium 112 mcg PO DAILY Simvastatin 40 mg PO DAILY Aspirin 325 mg PO DAILY Docusate Sodium 100 mg PO BID Senna 1 TAB PO BID:PRN Constipation Metoprolol Succinate XL 50 mg PO DAILY Cilostazol *NF* 50 mg Oral twice daily Letrozole *NF* 2.5 mg Oral every other day Acetaminophen 325-650 mg PO Q6H:PRN pain, fever traZODONE 12.5 mg PO HS:PRN insomnia Nystatin Cream 1 Appl TP [**Hospital1 **] Lisinopril 40 mg PO DAILY Gabapentin 600 mg PO Q12H Heparin IV Sliding Scale Ciprofloxacin HCl 500 mg PO Q12H Discharge Medications: 1. Outpatient Lab Work please check PT and INR, and fax the result to Dr. [**Last Name (STitle) 2903**] at ([**Telephone/Fax (1) 67352**]. 2. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cilostazol 50 mg Tablet Sig: One (1) Tablet PO twice daily (). 5. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO Daily (). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please have INR checked on Monday, Dr. [**Last Name (STitle) 2903**] will adjust dose for you accordingly. Disp:*28 Tablet(s)* Refills:*0* 10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 11. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*28 Capsule, Sustained Release(s)* Refills:*2* 12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*28 Tablet(s)* Refills:*2* 13. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 14. Insulin Glargine 100 unit/mL Cartridge Sig: Forty Five (45) unit Subcutaneous at bedtime. 15. Insulin Lispro 100 unit/mL Cartridge Sig: sliding scale Subcutaneous four times a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: - Acute renal failure - Atrial fibrillation with rapid ventricular response Secondary diagnoses: - DMII - Hypertension - Dyslipidemia - Peripheral vascular disease - Peripheral neuropathy - Ovarian cancer s/p TAH BSO, chemo followed at [**Company 2860**] - Hypothyroidism Discharge Condition: Stable, afebrile, ambulating. Discharge Instructions: It was a pleasure to be involved in your care, Ms. [**Known lastname 96322**]. You were hospitalized to [**Hospital1 69**] because of leg weakness. You were found to have acute renal failure, and your potassium was very high. Work up showed that your renal failure and high potassium were likely due to the IV contrast you received on [**2129-9-14**] and that you were dehydrated. You were also found to have a type of arrhythmia called "atrial fibrillation" which was very difficult to control, but you spontaneously converted to normal sinus rhythm later. You need to take coumadin, a blood thinner, to prevent stroke. Your medications have been changed. - coumadin 5mg daily, please have your INR checked on Monday, you primary care doctor, Dr. [**Last Name (STitle) 2903**], [**First Name3 (LF) **] get the result, and will let you how to adjust your coumadin dose accordingly. - diltiazem extended release 120mg once a day - please continue to take your metoprolol succinate 50mg once a day - your simvastatin has been changed to atorvastatin 80mg once a day - you have high blood pressure, so please take hydrochlorothiazide 25mg once a day If you develop chest pain, shortness of breath, palpitations, rapid heart rates, dizziness, leg swelling, leg weakness or any other symptom that concerns you, please call your doctor or come back to the Emergency Department immediately. Followup Instructions: Please follow up with your cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], within two weeks after discharge. Please call [**Telephone/Fax (1) 62**] for appointment. It is important for you to follow up with your cardiologist for your arrhythmia. We spoke with the vascular service, and they plan to give you a break now before they do the previously planned angiogram. The vascular office will call you on Monday to set up an appointment with you. Please follow up with your primary care doctor, Dr. [**Last Name (STitle) 2903**], within two weeks after discharge. Please call [**Telephone/Fax (1) 2205**] for appointment.

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Discharge summary

report+addendum

Admission Date: [**2151-6-29**] [**Month/Day/Year **] Date: [**2151-7-27**] Date of Birth: [**2074-11-28**] Sex: M Service: MEDICINE Allergies: Ancef Attending:[**First Name3 (LF) 2485**] Chief Complaint: Tx from OSH for further management Major Surgical or Invasive Procedure: Interventional Pulmonary adjust/resize of trach Interventional Radiology: Placement of post-pyloric feeding tube History of Present Illness: HPI: This is a 76 YO M initially presented to OSH on [**6-4**] with bilateral cellulitis, lower extremity edema on [**6-11**] was noted to have respiratory distress failing his routine nightly bipap for OSA. At that pt was transferred to CCU for monitoring. . His OSH was as follows - Cellulitis - was treated with unasyn for 11 days then discontinued on [**6-16**]. A LENI on [**6-17**] was negative for DVT. . - Cardiac- His CCU stay was complicated by VT with a code called, which required dopamine pressure. In addition a NSTEMI (peak trop 7.67 on [**6-12**]) occurred treated with aspirin, plavix, and coreg. Apparently heparin was held [**1-28**] to bleeding from the tracheostomy. Then the beta blocker was held secondary to bradycarida. - Respiratory - On transfer to the CCU a "possibly elective tracheostomy at this point" which was performed on [**6-11**]. He was started on CPAP trach mask trials. He was felt to be fluid overloaded and diuresed. A left sided pleural effusion developed and a thoracentesis was performed on [**6-23**], and he was started on cefazolin. Sputum cxs grew out proteus with multiple sensitivies. A lyme cx taken was negative. . - On presentation- the pt is comfortable denies pain, sob, states his (myasthenia [**Last Name (un) 2902**]) MG is longstanding causing difficulty with walking/ and breathing at certain pts. Otherwise no other complaints. Past Medical History: #PMHX DM HTN obesity Myasthenia [**Last Name (un) **] RHF Social History: SOCIAL - per OSH DC summary, married, separated, smoking hx, denies etoh use Family History: Non-contributory Physical Exam: VS T 99.4 p76 bp 118/81 RR 21 Sa91% fsbs 137 AC 750x12 peep 5 fio2 0.4 GEN NAD, obese, comfortable HEENT PERRL, OP clear, neck supple, thick, trach collar CV distant hs, no mrg CHEST coarse bs throughout, no decreased bs ABD normoactive bs, nt/nd, obese, soft, large pannus noted in lower extremity, no ascites EXT : no 2+ pitting edema b/l in lower extremity, warm/erythematous b/l rash in lower extremity calfs, c/w cellulitis, toes also in packing b/l, severe onychomycosis, L hand increased swelling compared with R, o/w PICC in R arm NEURO AAOx3, Pertinent Results: Labs on Admission [**2151-6-29**] 02:35AM BLOOD WBC-7.2 RBC-3.15* Hgb-9.7* Hct-27.7* MCV-88 MCH-30.6 MCHC-34.9 RDW-14.6 Plt Ct-434 [**2151-6-29**] 02:35AM BLOOD Neuts-74.5* Lymphs-11.9* Monos-7.5 Eos-5.7* Baso-0.5 [**2151-6-29**] 02:35AM BLOOD PT-14.2* PTT-24.6 INR(PT)-1.3* [**2151-6-29**] 02:35AM BLOOD Glucose-119* UreaN-35* Creat-1.2 Na-139 K-4.4 Cl-92* HCO3-40* AnGap-11 [**2151-6-29**] 02:35AM BLOOD ALT-7 AST-38 [**2151-6-29**] 02:35AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.3 Iron-20* Cholest-127 [**2151-6-29**] 02:35AM BLOOD calTIBC-196* VitB12-635 Folate-8.3 Ferritn-988* TRF-151* [**2151-6-29**] 02:35AM BLOOD Triglyc-79 HDL-29 CHOL/HD-4.4 LDLcalc-82 LDLmeas-81 [**2151-6-29**] 12:01PM BLOOD Type-ART pO2-98 pCO2-56* pH-7.50* calTCO2-45* Base XS-17 Cardiac Enzymes [**2151-7-10**] 06:03AM BLOOD CK-MB-40* MB Indx-12.8* cTropnT-1.53* [**2151-7-10**] 06:03AM BLOOD CK(CPK)-313* [**2151-7-10**] 12:45PM BLOOD CK-MB-29* MB Indx-11.1* cTropnT-1.74* [**2151-7-10**] 12:45PM BLOOD CK(CPK)-262* [**2151-7-10**] 10:09PM BLOOD CK-MB-17* MB Indx-10.0* cTropnT-1.83* [**2151-7-10**] 10:09PM BLOOD CK(CPK)-170 [**2151-7-11**] 12:00PM BLOOD CK-MB-8 cTropnT-2.70* [**2151-7-11**] 12:00PM BLOOD CK(CPK)-107 [**2151-7-11**] 06:22PM BLOOD CK-MB-NotDone cTropnT-2.89* [**2151-7-11**] 06:22PM BLOOD CK(CPK)-93 [**2151-7-12**] 03:45AM BLOOD CK-MB-6 cTropnT-3.17* [**2151-7-12**] 03:45AM BLOOD CK(CPK)-184* [**2151-7-12**] 10:20PM BLOOD CK-MB-NotDone cTropnT-3.62* [**2151-7-12**] 10:20PM BLOOD CK(CPK)-48 [**2151-7-13**] 03:51AM BLOOD CK-MB-NotDone cTropnT-3.30 [**2151-7-13**] 03:51AM BLOOD ALT-16 AST-28 CK(CPK)-45 AlkPhos-96 TotBili-0.8 Cyclosporine levels [**2151-6-29**] 10:23AM BLOOD Cyclspr-61* [**2151-7-1**] 03:19AM BLOOD Cyclspr-121 [**2151-7-2**] 04:14AM BLOOD Cyclspr-63* [**2151-7-10**] 12:45PM BLOOD Cyclspr-57* Blood gases [**2151-6-29**] 12:01PM BLOOD Type-ART pO2-98 pCO2-56* pH-7.50* calTCO2-45* Base XS-17 [**2151-7-3**] 01:42PM BLOOD Type-ART pO2-88 pCO2-52* pH-7.40 calTCO2-33* Base XS-5 [**2151-7-10**] 06:08AM BLOOD Type-[**Last Name (un) **] pO2-41* pCO2-57* pH-7.32* calTCO2-31* Base XS-0 [**2151-7-10**] 12:46PM BLOOD Type-[**Last Name (un) **] Temp-37.5 pO2-39* pCO2-54* pH-7.34* calTCO2-30 Base XS-1 [**2151-7-12**] 10:42PM BLOOD Type-[**Last Name (un) **] Temp-37.2 Rates-/30 Tidal V-400 PEEP-5 FiO2-50 pO2-43* pCO2-59* pH-7.31* calTCO2-31* Base XS-0 Intubat-INTUBATED Imaging . ECHO [**2151-6-30**] IMPRESSIOn: Poor echo windows. Cannot reliably assess LVEF. Normal RVEF. No pericardial effusion. If clinically indicated a repeat study with echo contrast (Definity) may better characterize LVEF. . Chest Portable [**2151-7-3**] IMPRESSION: Increased layering of left pleural fluid - positional differences could explain. No new focal consolidations. . [**Last Name (un) **]-INTESTINAL TUBE PLACEMENT (W/FLUORO) [**2151-7-9**] IMPRESSION: Successful placement of post-pyloric tube in the third portion of the duodenum. [**2151-7-22**] 04:05AM BLOOD WBC-8.7 RBC-3.22* Hgb-9.6* Hct-28.7* MCV-89 MCH-29.9 MCHC-33.5 RDW-16.6* Plt Ct-292 [**2151-7-20**] 03:23AM BLOOD Neuts-73.7* Lymphs-14.9* Monos-5.3 Eos-5.7* Baso-0.4 [**2151-7-22**] 04:05AM BLOOD PT-15.1* PTT-27.1 INR(PT)-1.4* [**2151-7-22**] 04:05AM BLOOD Glucose-90 UreaN-32* Creat-1.0 Na-144 K-4.5 Cl-107 HCO3-28 AnGap-14 [**2151-7-22**] 04:05AM BLOOD ALT-18 AST-27 AlkPhos-86 TotBili-0.9 [**2151-7-22**] 04:05AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.2 [**2151-7-20**] 05:01PM BLOOD Type-ART FiO2-50 pO2-102 pCO2-58* pH-7.33* calTCO2-32* Base XS-2 Brief Hospital Course: 76 yo male with pmhx significant for morbid obesity, OSA, trach'd p/w cellulitis with course complicated by NSTEMI. . 1. Cellulitis- At outside hospital was started on unasyn, then transitioned to ancef but developed an abx rash, and was changed to vancomycin by arrival to [**Hospital1 18**]. He was noted to have bilateral cellulitis with increased lower extremity swelling and was to finished a 14 day antibiotic course, and monitor for resolving infection. He otherwise was treated symptomatically with aquaphor ointment, and did not spike a fever during his hospital course. He has residual b/l LE erythema that has been stable with no other signs of infection. . 2. HYPOXIA- The patient arrived with a tracheostomy from an OSH, on AC ventilation, when a trach mask trial was attempted, he developed increasing tachypnea, anxiety, and chest pain, which was not cardiac in nature. With a history of MG a NIF was performed which demonstrated low values, but his limited ability for successful trach mask trial, was likely multifactorial, a sputum culture grew swarming proteus and he was started [**Female First Name (un) **] 8 day course of levaquin, he was to have daily NIFs as there are rare exacerbations of MG with levaquin, he remained stable. He otherwise was maintained on duonebs, and fluticasone was added. In addition fluid overload was another potential component of his inability to be weaned from the vent, and he was actively diuresed with 40mg lasix [**Hospital1 **], but his creatinine became elevated to 2.2 from 1.1 baseline likely secondary to overdiuresis as his fena suggestsed a prerenal acute renal failure. He was administered fluid boluses to maintain urine output. Otherwise IP was consulted for a tracheostomy adjustment and felt he was maintaining appropriate oxygenation and ventilation and adjustments were not required. He tolerated weaning to pressure support with MMV at times but during his hospital course developed additional hypoxia associated with a RLL infiltrate, he was continued on levaquin started for a proteus positive sputum culture. A bronchoscopy was performed which did not reveal gross abnormalities, 2 BALs were taken and grew 3+GNRs, speciated as stenotrophomonas. For the remainder of his course the patient remained stable. Based on daily assessment he was placed on trach mask trials or pressure support as tolerated. He tolerated up to 8 hours of 50% trach mask, but became anxious and tachypneic and was restarted on CPAP 8/5 with 40 % FiO2. At [**Hospital1 **] he was satting 94-97 % on CPAP 8/5 and 40 % FiO2. . 3. CV -He was transferred from the outside hospital after having an NSTEMI, not tolerating heparin secondary to bleeding from the tracheostomy site. He was transferred on a betablocker, aspirin, plavix. His lipid profile was checked while inpatient, and hot found to be elevated. He otherwise had an echocardiagram which demonstrated elevated PA pressures of 29, otherwise a suboptimal study without EF calculation, also an moderately dilated aortic root, which was not seen on previous outside hospital echos, he was to follow up as an outpatient for management of his dilatation. He was strted on lisinopril 5 mg PO QD 2 days prior to [**Hospital1 **] which he tolerated well. NSTEMI- He had an episode of supraventricular tachycardia self limiting without associated hypotension. An EKG at that time demonstrated lateral lead ST depressions, with an associated 1mm ST elevation in V1. Cardiac enzymes were cycled and noted to be elevated, likely secondary to demand ischemia. He was started on heparin, a betablocker, aspirin, plavix, and a statin were administered. Cardiology was consulted and recommended continuing medical management. The patient will need to be on plavix for 9-12 months and should follow up with a cardiologist as an outpatient. . 4. DM- The patient's sugars were well controlled on a RISS . 5. HTN- Initially admitted with lopressor, which was held after noting irregularity on ekg, his pressures remained in good range off lopressor. His lopressor was restarted and was titrated up to 37.5 mg [**Hospital1 **] with HRs on 50s-60s. Additionally and ACE-I was added once his creatinine stabilized and his pressures were stable in 120s-130s. 6. Anemia- Normocytic, likely secondary to chronic disease, iron/folate/b12 studies were suggestive of chronic disease, tranfused to a HCT>30 after determination of his NSTEMI. HCT was stable at [**Hospital1 **]. . 7. MG- Stable continued on mestinon, neoral. Discussed with outpatient neurologist, maintained on outpatient regimen, monitored CSA levels for toxicity. He had decreased mental status during his hospital course, and neurology was consulted for evaluation of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 67519**] [**Last Name (un) 2902**] exacerbation. Neurology did not feel that his MG was contributing to his delta MS as much as perhaps ICU delirium. He was continued on his outpatient regimen. HE will need to establish care with a new neurologist. . 8. Anxiety- Maintained on zoloft, and ativan prn . 9. FEN: A post pyloric tube was placed by IR for feeding, but it was d/c'd accident;y x2. AT [**Last Name (un) **] the patient was tolerating softs solids, and therefore the tube was not replaced. . 10. PPX: heparin SC, lansoprazole, bowel regimen . 11. Access: PICC placed at OSH on [**2151-6-17**], cxr confirming placement. A postpyloric feeding tube was placed by fluoroscopy. . 12. Code: Full . 13. Contact: [**Name (NI) **] [**Name2 (NI) **] daughter + HCP [**Telephone/Fax (1) 67520**] (H) [**Telephone/Fax (1) 67521**] (C), [**Telephone/Fax (1) 67522**] (office) . PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**] [**Telephone/Fax (1) 67523**] Neurologist Upender (left practice) [**Telephone/Fax (1) 67524**] Medications on Admission: lopressor 25mg [**Hospital1 **] free h20 150cc q8h ancef 2gm q8h (D6/10) (although DC summary states vanco) benaprotein 2pkt [**Hospital1 **] zoloft 25mg qd alb/atrovent q4hr lotrimin cream to groin [**Hospital1 **] ASA 325 qd aquaphor ointment ble [**Hospital1 **] plavix 75mg qd prevacid 30mg qd mvi 15cc ft qd vit c 500mg [**Hospital1 **] zinc sulfate 220mg qd neoral 75mg [**Hospital1 **] mestinon 180mg tid insulin protocol lasix gtt 20mg/hr lovenox 40 sc qd lidocain patch qd dilaudid 1mg iv q3h prn [**Hospital1 **] Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Pyridostigmine Bromide 60 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours). 11. Insulin Regular Human 100 unit/mL Solution Sig: Three (3) Injection ASDIR (AS DIRECTED): Sliding Scale Per Protocol. 12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 6-12 Puffs Inhalation QID (4 times a day). 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 16. Cyclosporine Modified 100 mg/mL Solution Sig: Seventy Five (75) mg PO Q12H (every 12 hours). 17. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 18. Hydromorphone 0.5-2 mg IV Q3-4H:PRN 19. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 20. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 21. Lorazepam 0.5-1 mg IV HS:PRN Hold for RR <12 22. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 24. 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. [**Hospital1 **] Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] [**Hospital1 **] Diagnosis: Primary Diagnosis 1. NSTEMI 2. Respiratory failure . Secondary Diagnosis Ttpe 2 diabetes HTN obesity Myasthenia [**Last Name (un) **] RHF [**Last Name (un) **] Condition: Hemodynamically stable, HRs 50- 60s, satting 94-97 % on CPAP 8/5 40 % FiO2. [**Last Name (un) **] Instructions: You are being discharged to another care facility where they can take care of your respiratory care. Information about your hospital stay has been communicated to the physician assuming responsibility for your care. Followup Instructions: You should follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab. Name: [**Known lastname 11696**],[**Known firstname **] Unit No: [**Numeric Identifier 11697**] Admission Date: [**2151-6-29**] Discharge Date: [**2151-7-27**] Date of Birth: [**2074-11-28**] Sex: M Service: MEDICINE Allergies: Ancef Attending:[**First Name3 (LF) 1015**] Addendum: Patient pulled out his NG tube. We tried putting in a Dobhoff tube under IR guidance but patient refused. He has already been cleared by Speech and Swallow on [**2151-7-8**] to take soft solids, thin liquids. PO meds may be given as tolerated, but may need to be crushed in purees. If he further requires oral feeds for nutritional supplementation, an NG tube can be placed. . He has been on trach mask for around 12 hours during the day. Otherwise he is on CPAP+PS FiO2 of 0.5, PS of 15, PEEP of 5. . He was coughing up secretions and a sputum sample was sent for culture and sensitivity. Brief Hospital Course: Patient pulled out his NG tube. We tried putting in a Dobhoff tube but patient refused. He has already been cleared by Speech and Swallow on [**2151-7-8**] to take soft solids, thin liquids. PO meds may be given as tolerated, but may need to be crushed in purees. If he further requires oral feeds for nutritional supplementation, an NG tube can be placed. . He has been on trach mask for around 12 hours during the day. Otherwise he is on CPAP+PS FiO2 of 0.5, PS of 15, PEEP of 5. . He was coughing up secretions and a sputum sample was sent for culture and sensitivity. Discharge Disposition: Extended Care Facility: [**Hospital3 2215**] Northeast - [**Hospital1 1947**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1016**] MD [**MD Number(2) 1017**] Completed by:[**2151-7-27**]

[ "427.89", "300.00", "410.71", "428.0", "276.0", "414.01", "682.6", "999.9", "327.23", "584.9", "041.6", "V55.0", "358.00", "250.00", "285.29", "V58.67", "518.81", "V46.11" ]

icd9cm

[ [ [] ] ]

[ "99.04", "96.08", "96.72", "33.24", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

16971, 17208

16375, 16948

315, 429

2666, 6183

15308, 16352

2048, 2066

12077, 12584

2081, 2647

240, 277

14677, 14752

12614, 14647

457, 1856

14780, 15285

1878, 1937

1953, 2032

12,259

123,212

21678

Discharge summary

report

Admission Date: [**2125-10-21**] Discharge Date: [**2125-10-25**] Date of Birth: [**2081-8-6**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5644**] Chief Complaint: Drug overdose- Pt attempted suicide with [**Doctor Last Name 18928**] and Benadryl. Major Surgical or Invasive Procedure: None History of Present Illness: 44 y/o man with recent diagnosis with PMH of drug abuse and anxiety admitted to the [**Hospital Unit Name 153**] after a drug overdose with [**Doctor Last Name 18928**] and benadryl. Pt had a fight with his significant other followed by a witnessed ingestion of 60-80 60 mg [**Doctor Last Name **] tablets and [**12-5**] 50 mg benadryl tablets. Pt was taken to [**Hospital 42508**] Hospital where he was confused and had slurred speech. Per their notes, he became more somulent and was intubated for respiratory protection. Pt also received 50 g charcoal with sorbitol. He was then transferred to [**Hospital1 18**] for toxicology evaluation and admission to the [**Hospital Unit Name 153**]. Past Medical History: 1. Back pain secondary to "disc problems" 2. Accidental overdose as a young man- unknown substance 3. Anxiety 4. Cocaine and heroin abuse Social History: Pt has a girlfriend and children. Rare ETOH. He smokes 3 packs of cigarettes per day. Reports stopped using heroin and cocaine two years ago but had cocaine present on tox screen. Family History: Not applicable. Physical Exam: T- 97.6 BP- 96/64 HR- 75 AC FiO2 .50 with TV of 650 and PEEP of 5 Gen- Sedated on vent but becomes very agitated with any movement. HEENT- NCAT. PERRL. Sedated. Cardiac- RRR. S1S2. No murmers, rubs, gallops. Pulm- Coarse breath sounds throughout. No crackles. Abdomen- Soft. NT. ND. Positive bowel sounds. Extremities- No c/c/e. 2+ DP pulses bilaterally. Neuro- Sedated on vent but becomes agitated with movement. Moving all extremities spontaneously. Unable to assess further on admission. Pertinent Results: [**2125-10-21**] 08:37PM BLOOD Lactate-0.9 [**2125-10-21**] 08:35PM BLOOD WBC-8.5 RBC-3.97* Hgb-11.3* Hct-33.7* MCV-85 MCH-28.5 MCHC-33.6 RDW-13.8 Plt Ct-183 [**2125-10-21**] 08:35PM BLOOD Neuts-61.1 Lymphs-32.1 Monos-4.3 Eos-2.0 Baso-0.4 [**2125-10-21**] 08:35PM BLOOD Plt Ct-183 [**2125-10-21**] 08:35PM BLOOD Glucose-77 UreaN-19 Creat-0.6 Na-135 K-3.7 Cl-104 HCO3-21* AnGap-14 [**2125-10-21**] 08:35PM BLOOD ALT-11 AST-19 LD(LDH)-213 AlkPhos-92 TotBili-0.6 [**2125-10-23**] 04:53AM BLOOD CK-MB-4 cTropnT-<0.01 [**2125-10-23**] 01:50PM BLOOD CK-MB-3 cTropnT-<0.01 [**2125-10-23**] 06:13PM BLOOD CK-MB-3 cTropnT-<0.01 [**2125-10-21**] 08:35PM BLOOD Albumin-3.5 Calcium-8.0* Phos-3.0 Mg-1.8 Iron-121 [**2125-10-21**] 08:35PM BLOOD calTIBC-303 VitB12-482 Folate-10.1 Ferritn-78 TRF-233 [**2125-10-22**] 02:47PM BLOOD ASA-NEG [**2125-10-22**] 04:01AM BLOOD ASA-NEG [**2125-10-21**] 08:35PM BLOOD ASA-6 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2125-10-21**] 08:37PM BLOOD Type-ART pO2-486* pCO2-40 pH-7.35 calHCO3-23 Base XS--3 [**2125-10-21**] 08:35PM URINE bnzodzp-POS barbitr-NEG opiates-POS cocaine-POS amphetm-NEG mthdone-NEG Brief Hospital Course: 1. Respiratory: Pt was intubated at OSH for airway protection [**3-19**] lethargy. He was kept sedated overnight on a propofol drip. The morning after admission, he was awake and agitated, thrashing and trying to get his tube out despite large doses of propofol. We spoke with toxicology who informed us that although he took sustained-release morphine, he was unlikely to worsen from a mental status standpoint if he was awake. Therefore, he was extubated on HD#2 and did well from a pulmonary standpoint with no further issues. 2. Cardiovascular: Mr. [**Known lastname 26699**] was noted to have T wave inversions on tele on the evening of [**10-22**]. An ECG was obtained that showed deep T wave inversions throughout all leads. At that time, pt was CP free without SOB or diaphoresis. He was ruled out for MI with negative cardiac enzymes times three. An echo was obtained which showed a normal EF and good wall motion. There was concern for cerebral T given ECG appearance. CT and MRI of the head were obtained which showed no significant abnormallity. 3. Psych- Psychiatry was consulted in the [**Hospital Unit Name 153**] given the pt's overdose suicide attempt. He was started on valium and clonidine for withdrawal. BEST saw the pt to assist in his placement in an inpatient detox facility. 4. [**Name (NI) 1623**] Pt was tolerating regular diet by the time of transfer to the floor. Electrolytes were repleated PRN. 5. Prophylaxis- SC heparin. Medications on Admission: Xanax [**Doctor Last Name 18928**] (doses unclear) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal QD (once a day). 3. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 7. Clonidine HCl 0.1 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 8. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q3-4H () as needed for ciwa>8. 9. Ondansetron 2-4 mg IV Q6H:PRN nausea 10. Prochlorperazine 10 mg IV Q6H:PRN Discharge Disposition: Extended Care Facility: [**Hospital 1680**] Hospital - [**Location (un) 538**] Discharge Diagnosis: Overdose on opiates Suicide attempt Discharge Condition: Stable Discharge Instructions: During your admission there were some changes noted on your EKG, however your echocardiogram and MRA were normal and cardiac enzymes were negative. However you should follow up with cardiology clinic to have a precautionary stress test. Please call the cardiology clinic at [**Telephone/Fax (1) 62**] to make an appointment. YOu should also follow up with a primary care doctor for general health maintanance. Please call [**Telephone/Fax (1) 250**] to schedule an general health appointment Followup Instructions: Cardiology Clinic for Stress Test call [**Telephone/Fax (1) 62**] to make appointment Please call [**Telephone/Fax (1) 250**] to make a genral health appointment with a primary care doctor at the [**Hospital 191**] clinic

[ "E950.0", "E950.4", "E849.0", "965.09", "298.9", "304.71", "780.79", "292.0", "963.0" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

5555, 5636

3218, 4680

395, 401

5716, 5724

2044, 3195

6267, 6493

1497, 1514

4781, 5532

5657, 5695

4706, 4758

5748, 6244

1529, 2025

272, 357

429, 1123

1145, 1284

1300, 1481

6,676

178,893

9811

Discharge summary

report

Admission Date: [**2146-9-5**] Discharge Date: [**2146-9-13**] Date of Birth: [**2077-6-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3266**] Chief Complaint: CC - transfer from OSH for liver failure [**2-23**] ?amiodarone toxicity Major Surgical or Invasive Procedure: Liver biopsy [**2146-9-6**] Paracentesis [**2146-9-7**] History of Present Illness: HPI - This is a 69 y/o male with a PMH significant for CAD, COPD, PAF, DM who presented to his PCP in [**Name9 (PRE) 205**] with symptoms of decreased appetite, fatigue, and increased abdominal girth over the last six months. There, he was found to have increased ascites, worsening liver function, and increased LE edema. He was sent to [**Location (un) **] for further evaluation. On initial admission to [**Location (un) **], had elevated LFTs with Alk P in 500's, and AST/ALT in 200-300's range. Amiodarone was d/c'd at that point, and Medrol 8 mg [**Hospital1 **] was started. GI followed pt while in-house and CT of abd done showed hyperdense liver that was c/w possible amiodarone toxicity. MRI was c/w ascites and gallstone w/o bile duct dilitation. He had an extensive workup for elevated LFTs, and workup for autoimminue causes, viral causes, and hemachromatosis were all negative. During his admission, the LFTs began to trend down to 140-150 range, 200 range for alk phos. Pt was d/c'd to rehab on high-dose steroids. However, he represented to [**Location (un) **] with abd fullness and SOB [**2-23**] ascites and anasarca. LFTs during the second admission were unchanged with alk phos in the 400 range, with acute renal function worsening (Cr 2.4 -> 3.3). This second admission was also significant for an increase in WBC from 20 to 38, pt remaining afebrile. Upon review of incomplete old records that were obtained, it appears that the patient was started on Amiodarone 200mg [**Hospital1 **] in [**12-24**] following a valve replacement surgery c/b atrial fibrillation. He remained on this dose of amiodarone until it was d/c'd at [**Location (un) **]. ROS - positive for abdominal fullness, decreased appetite, recent diarrhea, and fatigue - negative for any H/A, vision changes, cough, SOB, CP, abd pain, n/v, melena/hematochezia/BRBPR, tremors Past Medical History: PMH - 1. CAD 2. CHF 3. PAF 4. COPD on chronic steroids 5. s/p bioprstetic valve placement at [**Hospital1 336**], complicated by afib, for which he was started on Amiodarone [**12-24**] 6. s/p right CEA 7. DM on insulin 8. diverticulitis s/p partial colectomy 9. CRI Social History: SH - Lives at home with his wife. Used to smoke (30 pack-year history), but has not smoked in 30 years. Occasional EtOH (1 drink/2 weeks) previously, but no EtOH recently. No IVDA. One tatoo on right arm, done about 45 years ago. Family History: FH - Father died of an MI, mother passed at 80. No known family h/o liver diseases. Physical Exam: PE on admission: VS - T 96.3, BP 123/68, HR 78, RR 18, sats 99%/RA General - Fatigued-appearing, pleasant gentleman, AO x 3, NAD HEENT - NC/AT, PERRL, EOMI. No scleral icterus. MM dry, OP wnl Neck - supple, no JVD, no thyromegaly Chest - diffuse, high-pitched expiratory wheezes throughout CV - RRR s1 s2 normal, soft [**2-27**] SM at sternal border Abd - distended, firm but not tense, nontender to palpation; soft BS, alternating dullness and tympany to percussion, no discernable fluid wave; [**Doctor Last Name 515**] sign negative Ext - 2+ pitting edema b/l up to mid-thigh; pulses 2+ b/l Neuro - Pt AO x 3, no asterixis Pertinent Results: CBC [**2146-9-5**] 07:32PM BLOOD WBC-37.2*# RBC-4.95 Hgb-13.9* Hct-42.1 MCV-85 MCH-28.1 MCHC-33.0 RDW-17.5* Plt Ct-161 [**2146-9-6**] 07:10AM BLOOD WBC-38.6* RBC-4.86 Hgb-13.3* Hct-41.5 MCV-85 MCH-27.4 MCHC-32.1 RDW-18.0* Plt Ct-166 [**2146-9-7**] 07:00AM BLOOD WBC-38.9* RBC-4.72 Hgb-12.8* Hct-40.9 MCV-87 MCH-27.2 MCHC-31.4 RDW-17.7* Plt Ct-130* [**2146-9-8**] 06:30AM BLOOD WBC-35.4* RBC-4.07* Hgb-11.0* Hct-35.0* MCV-86 MCH-27.1 MCHC-31.5 RDW-17.9* Plt Ct-83* [**2146-9-8**] 12:25PM BLOOD WBC-35.3* RBC-4.01* Hgb-11.0* Hct-34.0* MCV-85 MCH-27.4 MCHC-32.3 RDW-17.8* Plt Ct-79* DIFF [**2146-9-5**] 07:32PM BLOOD Neuts-97.3* Bands-0 Lymphs-1.7* Monos-0.9* Eos-0 Baso-0 [**2146-9-8**] 06:30AM BLOOD Neuts-96.1* Bands-0 Lymphs-2.2* Monos-1.6* Eos-0.1 Baso-0 COAGS [**2146-9-5**] 07:32PM BLOOD PT-17.2* PTT-34.1 INR(PT)-2.0 [**2146-9-5**] 07:32PM BLOOD Plt Smr-NORMAL Plt Ct-161 [**2146-9-6**] 07:10AM BLOOD Plt Ct-166 [**2146-9-6**] 05:19PM BLOOD PT-15.9* PTT-33.7 INR(PT)-1.7 [**2146-9-7**] 07:00AM BLOOD PT-16.1* PTT-35.0 INR(PT)-1.7 [**2146-9-7**] 07:00AM BLOOD Plt Ct-130* [**2146-9-8**] 06:30AM BLOOD PT-17.2* PTT-38.3* INR(PT)-2.0 [**2146-9-8**] 06:30AM BLOOD Plt Smr-LOW Plt Ct-83* [**2146-9-8**] 12:25PM BLOOD Plt Ct-79* CHEMISTRY [**2146-9-5**] 07:32PM BLOOD Glucose-249* UreaN-118* Creat-3.1*# Na-136 K-4.8 Cl-102 HCO3-19* AnGap-20 [**2146-9-6**] 07:10AM BLOOD Glucose-158* UreaN-121* Creat-3.1* Na-136 K-5.3* Cl-104 HCO3-20* AnGap-17 [**2146-9-6**] 04:50PM BLOOD K-4.9 [**2146-9-7**] 07:00AM BLOOD Glucose-235* UreaN-132* Creat-3.3* Na-136 K-4.8 Cl-103 HCO3-19* AnGap-19 [**2146-9-8**] 06:30AM BLOOD Glucose-142* UreaN-132* Creat-3.4* Na-137 K-4.6 Cl-104 HCO3-18* AnGap-20 [**2146-9-6**] 07:10AM BLOOD ALT-123* AST-84* LD(LDH)-379* AlkPhos-374* TotBili-1.7* [**2146-9-7**] 07:00AM BLOOD ALT-108* AST-75* AlkPhos-345* TotBili-1.5 [**2146-9-8**] 06:30AM BLOOD ALT-83* AST-63* LD(LDH)-281* AlkPhos-291* TotBili-2.1* [**2146-9-5**] 07:32PM BLOOD Albumin-2.3* Calcium-8.6 Phos-5.0* Mg-2.1 [**2146-9-6**] 07:10AM BLOOD Albumin-2.3* Calcium-8.7 Phos-5.3* Mg-2.2 Iron-30* [**2146-9-7**] 07:00AM BLOOD TotProt-4.9* Albumin-2.1* Globuln-2.8 Calcium-8.5 Phos-5.5* Mg-2.1 [**2146-9-8**] 06:30AM BLOOD Albumin-2.7* Calcium-8.3* Phos-5.8* Mg-2.1 [**2146-9-6**] 07:10AM BLOOD calTIBC-100* Ferritn-762* TRF-77* [**2146-9-6**] 07:10AM BLOOD Ammonia-81* [**2146-9-7**] 07:00AM BLOOD Osmolal-336* MISC [**2146-9-7**] 07:00AM BLOOD HCV Ab-NEGATIVE [**2146-9-7**] 07:00AM BLOOD PEP-NO SPECIFI [**2146-9-7**] 07:00AM BLOOD [**Doctor First Name **]-NEGATIVE [**2146-9-7**] 07:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2146-9-5**] 07:32PM BLOOD TSH-2.8 URINE [**2146-9-6**] 01:12AM URINE Osmolal-500 [**2146-9-6**] 11:40PM URINE U-PEP-PND IFE-PND [**2146-9-8**] 04:37PM URINE Osmolal-429 [**2146-9-6**] 01:12AM URINE Hours-RANDOM UreaN-871 Creat-90 Na-137 [**2146-9-8**] 04:37PM URINE Hours-RANDOM UreaN-761 Creat-43 Na-LESS THAN [**2146-9-6**] 01:12AM URINE Eos-NEGATIVE [**2146-9-6**] 01:12AM URINE RBC->50 WBC-[**12-11**]* Bacteri-FEW Yeast-NONE Epi-[**3-26**] TransE-[**3-26**] [**2146-9-6**] 06:44PM URINE RBC-0-2 WBC->50 Bacteri-FEW Yeast-NONE Epi-0 [**2146-9-8**] 04:37PM URINE RBC-0 WBC->50 Bacteri-FEW Yeast-NONE Epi-0 [**2146-9-6**] 06:44PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2146-9-8**] 04:37PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2146-9-6**] 01:12AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2146-9-6**] 06:44PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015 [**2146-9-8**] 04:37PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 PERITONEAL FLUID [**2146-9-7**] 01:58PM ASCITES TotPro-0.8 Albumin-LESS THAN [**2146-9-7**] 01:58PM ASCITES WBC-66* RBC-26* Polys-33* Lymphs-24* Monos-0 Macroph-43* Brief Hospital Course: This is a 69 y/o man with PMH significant for CAD, DM, COPD, a fib, who was on chronic amiodarone since [**12-24**] for rhythm control of a fib, who was transferred to [**Hospital1 18**] from OSH after an extensive workup for liver disease of unknown origin. Workup there was notable for hyperdense liver, ascites; and negative for any autoimmune, viral/infectious, hemachromatosis causes. Pt also here with ARF on CRI. 1. Liver failure/renal failure - Most likely multifactorial, also likely that it was [**2-23**] amiodarone toxicity, based on his prior workup. Workup at OSH for autoimmune and infectious causes for liver failure were all negative. His hepatitis serologies were also negative during this hospital stay. Therapeutic tap on [**2146-8-24**] negative for SBP at the OSH with normal cytology. His paracentesis at this hospital was also negative for SBP. He underwent a transjugular liver biopsy which showed significant amiodarone toxicity with severe fibrosis and incomplete nodule formation. His venous pressure measurements revealed a Hepatic venous pressure gradient of 28mmHg consistent with portal hypertension. It is unclear as to whether the liver biopsy findings were entirely related to amiodarone toxicity or whether the amiodarone toxicty was superimposed on a background of cirrhosis. Risk factors for cirrhosis include diabetes and NASH. He was initially continued on the high-dose steroids that he was transferred here with, but was started to be weaned off as they had no clear benefit. A RUQ u/s with Dopplers showed no liver masses, + ascites, findings c/w cirrhosis and portal hypertension, hepatofugal flow in splenic and portal veins, nl flow in hepatic veins. Given worsening creatinine, he was started on octreotide/midodrine for suspected hepatorenal syndrome, along with albumin. In addition, he developed an Enterococcal UTI for which he was begun on ampicillin [**9-6**]. An NG tube was placed for tube feeds as the patient had poor po intake secondary to decreased appetite. Given his liver failure and probable hepato-renal syndrome, he was evaluated for potential liver transplant by Dr. [**Last Name (STitle) 497**]. Based on the patient's cardiac risk factors/cardiac history and his poor functional status, it was decided that the patient would not be a good liver transplant candidate. On [**2146-9-9**] he became hypotensive and was transferred to the MICU for further management. Following transfer to the MICU, the patient received 2u PRBC, 2u FFP, and Vit K with stabilization of his blood pressure. His renal function/coagulopathy continued to worsen, attributed to hepato-renal syndrome. Following a family meeting on [**9-10**], the decision was made not to pursue dialysis, as the patient is not a liver transplant candidate. Per this family meeting, other medical treatment (octreotide, midodrine, antibiotics, albumin) was decided to be continued, although the patient was made DNR/DNI from a full code on admission. His blood pressures stabilized while in MICU and he was transferred back to the floor as CMO per patient's and family's wishes. He eventually expired on [**2146-9-13**]. Medications on Admission: MEDS (on transfer) protonix 40mg PO QAM flagyl 500mg PO TID (started [**9-5**]) Medrol 8mg PO BID Insulin glargine 15 U qHS Advair 2puffs INH [**Hospital1 **] Combivent 2puffs INH [**Hospital1 **] fosamax 90mg PO qweek Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Completed by:[**2146-9-17**]

[ "V58.67", "789.5", "250.00", "E942.0", "V58.65", "599.0", "584.9", "V42.2", "572.3", "496", "572.4", "427.31", "571.5" ]

icd9cm

[ [ [] ] ]

[ "99.07", "96.6", "54.91", "50.11" ]

icd9pcs

[ [ [] ] ]

11019, 11028

7602, 10750

387, 445

11079, 11117

3644, 7579

2898, 2983

11049, 11058

10776, 10996

2998, 3001

275, 349

473, 2344

3015, 3625

2366, 2635

2651, 2882

22,625

117,153

25999

Discharge summary

report

Admission Date: [**2163-11-3**] Discharge Date: [**2163-11-22**] Date of Birth: [**2091-4-25**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: ICH (transferred from OSH) Right sided weakness Major Surgical or Invasive Procedure: intubation (extubated [**11-7**]) History of Present Illness: 72 yo left handed woman with parkinsonism and labile BP who was in her USOH at a book club meeting on the night of admission, when she went to the BR and felt her right side "gave way" and slid down the wall. Per the husband, she did not lose conciousness. She yelled for help and she was taken to [**Hospital1 9191**]. There, her vitals were (at 2040): 217/121, 74, 16, 98% RA. She was A&Ox3, noted to have headache and dizziness, with right face droop, right arm weakness and slurred speech. Left pupil 2->1, right pupil 3- >1. FS 105. NCHCT was done and she was found to have an intracerebral hemorrhage - 7 slices approx 2x4 cm with lateral ventricle extension. She was given 1 gram of dilantin and lifeflighted here. En route she was given 20mg IV labetolol. Upon arrival, vitals were 98.1, 66, 117/108, 18, 98%RA. She was found to be "verbalizing but not following commands" and was felt she could not protect her airway, thus she was intubated (lido, vec, etom, succ, and versed as needed for sedation). Her BP fell to 97/52, then later rose to 197/92 (very labile). Repeat head CT here shows worse bleed, left sided, on 8 slices, 2x6 cm with extension to the lateral and 3rd ventricles and mass effect on the lateral ventricle without overt shift left to right. Neurosurgery was consulted who did not recommend any intervention at this time. I called the family who confirmed full code status. No preceeding illnesses, very active. Fevers, chills, headaches, weakness, numbness. Naps frequently, not unusual. Past Medical History: Parkinsonism - Followed at [**Hospital1 2025**] Labile BP - no meds, "white coat syndrome" Social History: She lives with her husband, has 2 kids, no tob, etoh, drugs. Clinical social worker, retired. From Southshore. FULL CODE. Family History: There are no hemorrhages, aneurysms, and no cancers in the family. Physical Exam: PE: Vitals: 98.1, 66, 197/92, 19, 98% intubated GEN: elderly thin woman intubated in the ED on stretcher HEENT: NC/AT, anicteric sclera, EET obscuring view NECK: supple, no LAD or bruits CHEST: CTA bilat CV: RRR without mur ABD: soft, NT/ND, +BS, no HSM EXTREM: no edema, warm and well perfused NEURO: MENTAL STATUS: not opening eyes to sternal rub or following commands CRANIAL NERVES: Pupil exam: right 3->2.5, left 2.5->2 EOM exam: + dolls Fundo: could not see disc, but no hemorrhages in the fundus. Corneal reflex: + corneal reflex bilaterally Facial symmetry: obscured by ETT Gag reflex: not done at this time although patient is actively trying to pull ETT with her left hand MOTOR: vigorously moving the left side purposefully, trying to extubate self. Right side is very hypertonic (tone is increased throughout but right>> left) with right arm at her side extensor posturing SENSORY: purposefully withdrawls on the left, extensor postures and triple flexion on the right REFLEXES: a brisk 3 throughout with upgoing toes bilaterally Pertinent Results: [**2163-11-2**] 11:40PM WBC-5.1 RBC-3.94* HGB-13.5 HCT-38.2 MCV-97 MCH-34.3* MCHC-35.4* RDW-12.6 [**2163-11-2**] 11:40PM NEUTS-80.6* LYMPHS-13.8* MONOS-3.7 EOS-1.3 BASOS-0.7 [**2163-11-2**] 11:40PM PLT COUNT-142* [**2163-11-2**] 11:40PM CK(CPK)-106 [**2163-11-2**] 11:40PM CK-MB-3 cTropnT-<0.01 [**2163-11-2**] 11:40PM GLUCOSE-175* UREA N-13 CREAT-0.5 SODIUM-143 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-27 ANION GAP-14 [**2163-11-3**] 12:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2163-11-3**] 12:10AM PT-13.3 PTT-24.8 INR(PT)-1.2 [**2163-11-3**] 04:00AM PLT COUNT-162 [**2163-11-3**] 04:00AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2163-11-3**] 04:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2163-11-3**] 04:00AM TSH-4.3* [**2163-11-3**] 04:00AM TRIGLYCER-89 HDL CHOL-57 CHOL/HDL-2.3 LDL(CALC)-56 [**2163-11-3**] 04:00AM %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE [**2163-11-3**] 04:00AM CALCIUM-8.7 PHOSPHATE-1.9* MAGNESIUM-1.5* CHOLEST-131 [**2163-11-3**] 04:00AM ALT(SGPT)-45* AST(SGOT)-46* CK(CPK)-185* TOT BILI-1.1 [**2163-11-3**] 04:20AM LACTATE-2.5* [**2163-11-3**] 04:20AM TYPE-ART PO2-446* PCO2-30* PH-7.54* TOTAL CO2-26 BASE XS-4 CXR: AP UPRIGHT PORTABLE CHEST X-RAY: The endotracheal tube is seen with the tip at the level of the clavicles. A nasogastric tube descends below the diaphragm with the tip not visualized. The cardiac silhouette is upper limits of normal, with left ventricular prominence. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Both lungs are clear without consolidations or effusions. The surrounding soft tissue and osseous structures demonstrate several right posterior rib fractures. IMPRESSION: No acute cardiopulmonary process. [**11-1**] Head CT NONCONTRAST HEAD CT: There is a large intraparenchymal hemorrhage extending through the white matter of the left insula and the left thalamus, irregularly shaped, but measuring up to 6.0 cm in transverse dimension. Hemorrhage extends into the left lateral ventricle and into the third ventricle superiorly. The degree of hemorrhage has worsened since the study of [**Hospital1 9191**]. The hemorrhage is impressing and narrowing the left lateral ventricle, with mild midline shift to the right. No extra-axial fluid collections are noted. The [**Doctor Last Name 352**]-white differentiation remains preserved. The visualized paranasal sinuses and mastoid air cells are clear. Osseous and soft tissue structures are unremarkable. IMPRESSION: Large intraparenchymal hemorrhage of the white matter of the left frontal lobe and thalamus has increased since the outside hospital study. There is mild midline shift to the right. Head CT [**11-2**]: Increase in the volume of intracerebral hemorrhage, accompanied by slight increase in mass effect, left to right midline shift, and blood within the left lateral ventricle. There is a small amount of hypodensity surrounding the hemorrhage, compatible with an extruded serum. Head CT [**11-3**], [**11-4**]: Similar appearance of large cerebral and intraventricular hemorrhage. No new hemorrhage identified. Head CT [**11-13**]: Interval decrease in hemorrhage within the left frontal/temporal lobes and left thalamus with resolution of the intraventricular blood within the left lateral ventricle. Stable minimal shift of rightward structures. Ventricles are stable in configuration. [**11-15**] Chest/Abd/Pelvis CT - Circumferential bowel wall thickening seen in the cecum. Differential for this includes infection and ischemia. Inflammatory changes are considered less likely. - Micronodule or tree-in-[**Male First Name (un) 239**] type appearance at both lung bases, right greater than left. These may represent early atypical infection. If required, a chest CT could be obtained for further evaluation. - Two large ovarian cysts, the first measuring 4.1 x 4.2 cm, and the second measuring 2.4 x 3.3 cm. The right ovary is not visualized. No free fluid or lymphadenopathy is seen in the pelvis. Given the patient's age, a pelvic ultrasound is recommended for further evaluation. Brief Hospital Course: This is a 72 yo LH woman with h/o labile BP and parkinsonism on a daily baby aspirin who presents from OSH with large left sided intraparenchymal hemorrhage. The bleed is subcortical and extending to the lateral and third ventricle. DDx on the etiology for this hemorrhage includes: hypertensive bleed (esp given location), trauma (less likely by history), AVM/aneurysm, toxic, amyloid (less likely given subcortical location), tumor, sinus thrombosis (also less likely given location, unilateral). Neuro - Untreated hypertension is the most likely etiology of Pt's hemorrhage. Serial head CTs displayed mild worsening in hemorrhage and mass effect with worsening of mental status, requiring intubation. Loaded with Dilantin d/t concern for seizure, but not continued (other factors more likely causing decline in level of alertness). Head CT stable since [**11-3**]. Continued Sinemet. Exam remains notable for intermittent somnolence, at times very difficult to arouse, requiring sternal rub. Pt does not always readily appear to be awake, but will follow commands with eyes closed. Flaccid paralysis in R upper extremity. Plegic R lower extremity worse proximally, withdraws to noxious stim. Increased tone in R lower extremity. Limited speech output, but comprehension intact. CV - Ruled out for MI on admission. Hypertension initially controlled with Nicardipine gtt. Now on regimen of Captopril and Metoprolol. Lipids wnl Chol 131 TG 89 HDL 57 LDL 56. Resp - Extubated on [**11-6**]. Non-specific nodules noted on upper part of [**11-15**] abdominal CT, outpatient chest CT scheduled for follow up. Currently stable on small O2 requirement. FEN/GI - Tolerating tube feeds without difficulty at goal. PEG placed on [**11-17**]. Had increase in LFTs on [**11-15**] (max ALT 291, AST 112) likely d/t Levofloxacin, which was d/c'd, LFTs now improving. No liver pathology identified on [**11-15**] abdominal CT. ID - Treated from [**11-7**] to [**11-12**] with Ciprol for E.coli UTI, changed to Levofloxacin on [**11-12**] in the setting of fever, incr WBC, sputum Cx + MSSA. Levofloxacin d/c'd d/t incr in LFTs. Afebrile with nl WBC at the time of discharge. Nystatin for thrush. Endo - HbA1C 5.6, TSH 4.3 Gyn - L ovarian cysts identified on [**11-15**] pelvis CT, which are unusual for Pt's age. Plan for follow-up pelvic ultrasound after discharge from rehab. Prophylaxis - Heparin SC, bowel regimen, AFOs bilaterally FULL CODE - confirmed with family, husband [**Telephone/Fax (1) 64599**], daughter [**Name (NI) 803**] [**Telephone/Fax (1) 64600**] Discharged to acute rehab on [**2163-11-22**] in stable condition. Medications on Admission: sinemet 25/100 1.5 am, 1.5 pm, 1 qhs vitamins ASA 81 daily Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 2. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 3. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 4. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain, fever. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 9. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): Hold for SBP<120. 10. Insulin Regular Human 100 unit/mL Solution Sig: per scale Injection ASDIR (AS DIRECTED). 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6-8H (every 6 to 8 hours) as needed for titrate to one soft bowel mvmt per day, may hold for loose stools or abdominal pain. 13. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Left intraparenchymal hemorrhage Discharge Condition: Stable. Discharge Instructions: Seek medical attention for somnolence, new weakness, numbness, sudden change in vision or hearing, headache, or for other concerns. Continue all new medications as prescribed. Followup Instructions: Follow up with your primary physician after discharge from rehab. Pelvic ultrasound, RADIOLOGY, [**Hospital Ward Name 23**] Building, [**Location (un) **], [**Telephone/Fax (1) 327**]. Date/Time:[**2163-12-22**] 10:15am. Please go to appt with a full bladder. Chest CT SCAN, RADIOLOGY, [**Hospital Ward Name 23**] Building, [**Location (un) **], [**Telephone/Fax (1) 327**] Date/Time:[**2163-12-22**] 11:30am. Neurology, [**Name6 (MD) **] [**Name8 (MD) **], M.D., [**Hospital Ward Name 23**] Building, [**Location (un) **], [**Telephone/Fax (1) 2574**]. Date/Time:[**2164-1-3**] 2:30 [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2163-11-22**]

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icd9cm

[ [ [] ] ]

[ "43.11", "38.91", "96.72", "96.6" ]

icd9pcs

[ [ [] ] ]

11804, 11901

7653, 10291

364, 399

11978, 11988

3396, 5308

12213, 12924

2231, 2300

10401, 11781

11922, 11957

10317, 10378

12012, 12190

2315, 2621

277, 326

427, 1958

2708, 3377

5317, 7630

2636, 2690

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2089, 2215

29,967

150,734

7550

Discharge summary

report

Admission Date: [**2148-3-15**] Discharge Date: [**2148-3-15**] Date of Birth: [**2071-5-31**] Sex: F Service: EMERGENCY Allergies: Iodine-Iodine Containing / Gadolinium-Containing Agents / Flagyl / Nsaids Attending:[**First Name3 (LF) 2565**] Chief Complaint: Diffuse hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 76-year-old woman with a complicated medical history including NSCLC s/p RULobectomy and diverting colostomy following diverticulosis who is presenting with bleeding. The patient had the biopsy of lymph nodes in her neck yesterday at [**Hospital6 2910**] and then was returned to her LTAC. There it was noted that she was having oozing bleeding from a line site, as well as nausea, vomiting, and abdominal pain. A quick glance at her records suggests that she has had imaging showing diffuse liver metastases. In the ED, initial VS were pain 9, T 97.6, HR 100, BP 109/63, RR 20, 98% on room air. The patient's labs have been consistent with DIC: elevated PT and PTT. Fibrinogen is within normal range, haptoglobin pending. The patient received at leats one unit of FFP, along with vitamin K IV. the Ed reports that she is bleeding from mutiple orifices and is heavily bruised. The patient also received a CT abdomen--current wet read by resident is possible obstruction of stoma (peristomal herniation). Right upper quadrant ultrasound has been completed but not read. The patient also received D50 following a low glucose. The patient has also received vancomycin and Zosyn. She has been mildly tachypneic durign the late part of her ED stay. The Ed was in tocuh with Surgery, who is aware of patient but have not seen patient. Liver was also consulted and recommended RUQ US for examination of common bile duct. . On arrival to the MICU, the patient was oriented to self and "hospital." She denies any pain but was tachypneic. Past Medical History: PMH: CAD, hyperlipidemia, HTN, a-fib, lung CA s/p RULobectomy and cyberknife, PVD with extensive interventions; diverticulitis, GERD, RA, OA, atrial fibrillation on coumadin. PSH: resection for diverticulitis at OSH with colostomy, TAH-BSO, appendectomy, carpal tunnel release, lipoma removal; bilateral groin explorations with graft thrombectomy [**10-27**]; L axillary artery angioplasty and jump graft from L ax-fem to SFA [**9-22**]; mrevision L ax-fem and L-R fem-fem bypass [**4-22**]; L ax-fem-fem bypass [**10-18**]; R CIA-bifemoral bypass [**9-17**]; RLE balloon angioplasty x2 [**2129**]; RULobectomy. Social History: No EtOH. Quit smoking years ago. Family History: Non-contributory. Physical Exam: General: Drowsy, oriented to self and hospital HEENT: Sclera icteric, dried blood in nares, oropharynx clear, EOMI, PERRL Neck: Supple, bruising of neck CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops auscultated Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi to anterior auscultation. Abdomen: Soft, non-tender, bowel sounds present, has two stomata, one in RLQ which is draining bloody fluid into bag and on at umbilicus which is simply covered in gauze. Skin: Ecchymoses on left arm and scattered across neck and extremities Extre: Not able to pick up DPs by Doppler but tibs were found on Doppler, poor capillary refill of left toes Pertinent Results: [**2148-3-15**] 01:15AM URINE WBCCLUMP-FEW MUCOUS-RARE [**2148-3-15**] 01:15AM URINE RBC->182* WBC-138* BACTERIA-MANY YEAST-FEW EPI-4 TRANS EPI-2 [**2148-3-15**] 01:15AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.5 LEUK-LG [**2148-3-15**] 01:15AM URINE COLOR-AMBER APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013 [**2148-3-15**] 01:15AM FIBRINOGE-196 [**2148-3-15**] 01:15AM PT-94.6* PTT-62.5* INR(PT)-9.7* [**2148-3-15**] 01:15AM PLT SMR-VERY LOW PLT COUNT-75*# [**2148-3-15**] 01:15AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ TARGET-1+ BURR-1+ [**2148-3-15**] 01:15AM NEUTS-73* BANDS-0 LYMPHS-18 MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-3* MYELOS-0 NUC RBCS-1* [**2148-3-15**] 01:15AM WBC-13.7*# RBC-3.45* HGB-9.9* HCT-32.1* MCV-93 MCH-28.7 MCHC-30.8* RDW-20.0* [**2148-3-15**] 01:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2148-3-15**] 01:15AM HAPTOGLOB-138 [**2148-3-15**] 01:15AM ALBUMIN-2.8* CALCIUM-7.6* PHOSPHATE-3.2 MAGNESIUM-2.0 [**2148-3-15**] 01:15AM LIPASE-117* [**2148-3-15**] 01:15AM ALT(SGPT)-75* AST(SGOT)-411* LD(LDH)-2530* ALK PHOS-512* TOT BILI-11.8* DIR BILI-8.7* INDIR BIL-3.1 [**2148-3-15**] 01:15AM estGFR-Using this [**2148-3-15**] 01:15AM GLUCOSE-57* UREA N-34* CREAT-2.1*# SODIUM-129* POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-11* ANION GAP-28* [**2148-3-15**] 01:35AM LACTATE-9.9* [**2148-3-15**] 04:35AM PLT SMR-VERY LOW PLT COUNT-76* [**2148-3-15**] 04:35AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL BURR-2+ TEARDROP-OCCASIONAL [**2148-3-15**] 04:35AM WBC-13.6* RBC-2.85* HGB-8.2* HCT-27.5* MCV-96 MCH-28.6 MCHC-29.7* RDW-20.8* [**2148-3-15**] 04:43AM GLUCOSE-207* LACTATE-10.2* [**2148-3-15**] 05:34AM D-DIMER-GREATER TH [**2148-3-15**] 06:13AM O2 SAT-92 [**2148-3-15**] 06:13AM LACTATE-2.7* [**2148-3-15**] 06:13AM TYPE-CENTRAL VE Brief Hospital Course: The patient is a 76-year-old woman with a complicated medical history including NSCLC s/p RULobectomy and diverting colostomy following diverticulosis who is presenting with bleeding. Labs were notable for anemia, thrombocytopenia, elevated pt, ptt, inr. Patient received 10mg iv vitamin k and ffps, with resolution of bleeding. CT a/p in ED showed liver mets, no obstruction to stoma. CXR confirmed known pulmonary nodules/mass. Outpatient oncologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (at [**Hospital1 **]) was contact[**Name (NI) **]. [**Name2 (NI) **] confirmed that patient's prognosis is measured in days to weeks. Health care proxy confirmed that patient does not wish any aggressive measures, and would like her to leave the hospital to focus on quality and comfort. After discussion with patient, HCP, and oncologist decision was made to discharge patient as CMO and stop all unnecessary medications (including aspirin and coumadin given bleed). She was started on medications to focus on comfort including sublingual morphine, ativan, and nebulizers. She was discharged to rehab facility. Medications on Admission: ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 0.5 (One half) Tablet(s) by mouth twice a day ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth daily CILOSTAZOL - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth twice a day FENTANYL - (Prescribed by Other Provider) - 75 mcg/hour Patch 72 hr - q 72 hrs / chnage at 0930 FOLIC ACID-VIT B6-VIT B12 [FOLGARD RX] - (Prescribed by Other Provider) - 1 mg-2.2 mg-25 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE [LASIX] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth as directed every tues/thurs/sat HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 12.5 mg Capsule - 1 Capsule(s) by mouth DAILY (Daily) LEVOTHYROXINE - (Prescribed by Other Provider) - 25 mcg Tablet - 1 Tablet(s) by mouth at bedtime LIDOCAINE [LIDODERM] - (Prescribed by Other Provider) - 5 % (700 mg/patch) Adhesive Patch, Medicated - 11 pm to 11 am / apply to right shoulder MECLIZINE - (Prescribed by Other Provider) - 12.5 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day PREGABALIN [LYRICA] - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day SPIRONOLACTONE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 1.5-2 Tablet(s) by mouth once a day INR goal is [**1-19**] / Have Dr. [**Last Name (STitle) **] your Oncologist to monitor your INR in the usual fashion Takes 4mg Mon/Thurs, 3mg all other days ZOLEDRONIC ACID [ZOMETA] - (Prescribed by Other Provider) - 4 mg/5 mL Solution - annually per Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day PYRIDOXINE - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**12-18**] Inhalation Q6H (every 6 hours) as needed for wheezing. 2. ipratropium bromide 0.02 % Solution Sig: [**12-18**] Inhalation Q6H (every 6 hours) as needed for wheezing. 3. morphine Sig: 2-10 mg Sublingual 3hr as needed for pain, shortness of breath. 4. ativan Sig: 0.5-1 mg Sublingual every four (4) hours as needed for anxiety. 5. bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. 6. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Transdermal every seventy-two (72) hours as needed for secretions. 7. lidoderm Sig: One (1) Transdermal once a day as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 9475**] Care Center - [**Location (un) 3146**] Discharge Diagnosis: Primary: Bleeding Secondary: Metastatic lung cancer Discharge Condition: alert, sleepy, arousable, oriented to self Discharge Instructions: You were admitted to the hospital because of bleeding from removal of the picc line in your arm. We treated you with vitamin K and blood products called ffp's. We spoke with you, your health care proxy and primary oncologist and understand that your wishes are to focus on quality and comfort as opposed to aggressive and invasive procedures. We have made the following changes to your medications: You can stop the following medications: atenolol lipitor cilostazol folic acid, vit b hydrochlorothiazide lyrica synthroid meclizine spironolactone coumadin zoledronic acid aspirin pyridoxine lasix You can continue: fentanyl lidoderm patch We have started the following medications: morphine sublingual for pain ativan sublingual for agitation scopalamine patch prn secretions bisacodyl suppository pr if no bowel movements greater than 72 hours Followup Instructions: None Completed by:[**2148-3-15**]

[ "427.31", "V66.7", "570", "414.01", "401.9", "280.0", "V15.82", "272.4", "287.5", "197.7", "440.20", "V55.3", "530.81", "286.6", "E879.8", "V10.11", "E934.2", "714.0", "287.9", "584.9", "996.74", "786.06", "562.10", "V49.86" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9520, 9606

5421, 6562

355, 362

9702, 9747

3381, 5398

10646, 10682

2643, 2663

8797, 9497

9627, 9681

6588, 8774

9771, 10144

2678, 3362

10173, 10623

296, 317

392, 1940

1962, 2575

2591, 2627

51,145

190,296

40014

Discharge summary

report

Admission Date: [**2135-10-27**] Discharge Date: [**2135-11-9**] Date of Birth: [**2051-9-16**] Sex: M Service: MEDICINE Allergies: Amoxicillin / Morphine Attending:[**First Name3 (LF) 1145**] Chief Complaint: Complete Heart Block Major Surgical or Invasive Procedure: Pacemaker placement Cardiac catheterization with no interventions. History of Present Illness: Mr. [**Known lastname 88012**] is an 84 year old gentleman transferred from [**Hospital 1474**] hospital for evaluation of complete heart block and possible coronary intervention. . Please see Dr.[**Initials (NamePattern4) 28807**] [**Last Name (NamePattern4) 1474**] Hospital admission note dated [**10-24**] for full admitting details. In brief, the patient presented to dialysis on the morning of [**10-24**] with gross hematuria. He makes little to no urine at baseline, but developed intermittent hematuria 4 months ago that was not worked up as he attributed it to aspirin. Aspirin held on admission, Ab CT performed with Nephrology & Urology consults. No consult notes, discharge summary or imaging reports included. . Per an ICU admit note dated [**10-27**], the patient's abdominal CT demonstrated an irregularly shapped bladder wall concerning for neoplasm. Cystoscopy attempted but unsuccessful due to hematuria. He was planned for a biopsy in the OR. Prior to biopsy, the patient developed chest pain in the setting of a 10 point Hct drop with an elevated troponin. Cardiology reportedly cleared the patient for biopsy, but the morning of the procedure (and of transfer to the hospital) he developed 3 pauses of about 25 seconds each, twice requiring CPR (no greater specifics) before generating a 40bpm escape rhythm and was taken to cath for pacing wire placement and left heart cath. . Per the cath report: Diagnostic Cardiologist: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 88013**], MD. [**First Name (Titles) 4084**] [**Last Name (Titles) 88014**], tachycardic. Developed several bouts of abdominal pain/pubic pain, never chest pain. R radial approach, temp pacer placed, Left heart cath performed, no report of findings. Drugs received during cath: Atropine 0.5mg IV x2, Fentanyl, Versed, Zofran, SubQ lidocaine. . Per the patient, he presented to [**Hospital1 1474**] on Sunday for worsening chronic hematuria. He has clear sensorium, but does not adequately remember his hospital course. He does believe he was shocked twice, once awake and once not conscious. He denies ever having chest pain or difficulty breathing. He does describe a sensation of abdominal discomfort prior to his team's cardiac concerns. He also reports intermittent penile discomfort with the three way foley in place as though he cannot urinate. He has no other complaints at this time. . Per the patient's son in law, the patient has had several recent admissions for dyspnea, ? CHF. . Review of systems otherwise negative. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: ESRD on HD, MWF, [**Location (un) 701**]/[**Hospital1 1474**] [**Last Name (un) **] Kidney Center, Dr. [**Last Name (STitle) **] s/p L AV Fistula Anemia of Chronic disease GERD L inguinal hernia ? CHF Social History: Lives with his wife in [**Name (NI) 1474**], independent ADLs. -Tobacco history: quit tobacco in the 60s -ETOH: denies -Illicit drugs: denies Family History: Unable to obtain history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Admission Exam: GENERAL: Eldery thin gentleman. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: L IJ temp pacer in place, no JVP elevation CARDIAC: S1 & S2 regular without murmur. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, mildly/diffusely tender. Large L inguinal hernia, nontender, bowel sounds present. EXTREMITIES: R radial cath wound clean/dry. L AV fistula with palpable thrill. No edema. 2+ DP GU: 3 way foley in place, clear urine with scant clots Pertinent Results: STUDIES: ECHO [**10-29**]: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with focal severe hypokinesis of the inferior wall and inferior septum. The remaining segments contract normally (LVEF = 40-45 %). Right ventricular chamber size is mildly dilated with normal free wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-8**]+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate concentric left ventricular hypertrophy. Mild regional dysfunction c/w CAD. Mild to moderate mitral regurgitation. Mild aortic stenosis. Mild pulmonary hypertension. . CT Ab/Pelvis [**10-29**]: 1. Enhancing mass within the base of the bladder on the left with large amount of clot within the bladder with associated moderate right hydronephrosis and hydroureter. Cannot exclude invasion into the seminal vesicles. Extensive pelvic and retroperitoneal lymphadenopathy. 2. Large left-sided fat and bowel containing inguinal hernia with no evidence of obstruction. 3. Diverticulosis without diverticulitis. . Urine cytology ATYPICAL. Rare atypical urothelial cells, present singly. Squamous cells, anucleate squames, neutrophils and red blood cells. . Carotid studies Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right there is moderate heterogeneous plaque in the ICA and CCA. On the left there is moderate heterogenous plaque in the ICA and CCA. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 106/27, 106/22, 90/26 cm/sec. CCA peak systolic velocity is 109/17 cm/sec. ECA peak systolic velocity is 104 cm/sec. The ICA/CCA ratio is 0.97. These findings are consistent with <40% stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 73/18, 108/22, 92/20cm/ec. CCA peak systolic velocity is 100 cm/sec. ECA peak systolic velocity is 120cm/sec. The ICA/CCA ratio is 1.02. These findings are consistent with <40% stenosis. There is antegrade right vertebral artery flow. There is antegrade left vertebral artery flow. Impression: Right ICA stenosis <40%. Left ICA stenosis <40%. . Admission labs: [**2135-10-27**] 11:48PM GLUCOSE-86 UREA N-49* CREAT-8.7* SODIUM-140 POTASSIUM-5.2* CHLORIDE-98 TOTAL CO2-27 ANION GAP-20 [**2135-10-27**] 11:48PM CK-MB-20* MB INDX-15.4* cTropnT-1.18* [**2135-10-27**] 11:48PM CK(CPK)-130 [**2135-10-27**] 11:48PM WBC-12.6* RBC-4.15* HGB-9.6* HCT-31.0* MCV-75* MCH-23.2* MCHC-31.1 RDW-16.3* [**2135-10-27**] 11:48PM CALCIUM-9.0 PHOSPHATE-8.1* MAGNESIUM-2.2 . Discharge labs: [**2135-11-9**] 06:45AM BLOOD WBC-11.5* RBC-3.76* Hgb-9.1* Hct-29.1* MCV-77* MCH-24.2* MCHC-31.4 RDW-19.4* Plt Ct-148* [**2135-11-9**] 06:45AM BLOOD Glucose-110* UreaN-45* Creat-7.1*# Na-140 K-3.9 Cl-94* HCO3-31 AnGap-19 [**2135-11-8**] 07:25AM BLOOD ALT-15 AST-24 LD(LDH)-191 AlkPhos-88 [**2135-11-2**] 05:42AM BLOOD CK-MB-11* MB Indx-15.3* cTropnT-3.18* [**2135-11-1**] 11:52PM BLOOD CK-MB-10 MB Indx-13.7* cTropnT-2.94* [**2135-11-9**] 06:45AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.0 [**2135-10-31**] 03:54AM BLOOD PSA-450.0* Brief Hospital Course: Mr. [**Known lastname 88012**] is an 84 year old gentleman with CKD on [**Hospital **] transferred from OSH for evaluation of complete heart block after a suspected ACS. The patient was planned for CABG within a week, but was found to have a bladder neoplasm concerning for metastatic disease and intravesicular clot in the setting of longstanding hematuria. # Complete Heart Block: Upon admission, the patient was intermittently in complete heart block, either as an advancement of his trifasicular block, or the result of ischemia. He was temporarily paced and EP placed permanent AICD. Pt developed Pacer induced tachycardia which was corrected by EP via manipulation of the pacer settings. . # CAD: [**Hospital1 1474**] Cath report: 80% LAD: 80% ostial stenosis w/ 80-90% mid segment stenosis, RCA: 99% ostial stenosis with 90% proximal stenosis, LCSX: moderate diffuse disease wtih severe proximal OM stenosis. The patient has a history of CAD and 3 vessel disease with plans to go to CABG within one week, given suspected ACS. However, surgical plans were complicated by a newly found bladder vs prostate tumor and the decision was made to continue medical management. He had continued episodes of angina initially in the setting of hematuria and initiation of therapy for presumed prostate cancer. Statin and ASA continued. He was unable to tolerate long acting nitrate due to hypotension. B-blocker and ACE-I were held initially in the setting of heart block but metoprolol was resumed prior to discharge. Angina was stable without recurrent events in 48 hours prior to discharge. . # Hematuria: The patient has a bladder mass on CT with surrounding lymph nodes suggestive of metastatic disease. Presumably causing hematuria and painful urethral clotting that initially required constant irrigation. Urology and Oncology services were consulted. PSA was 450s. Pt was started on casodex for treatment of possible prostate CA. Lymph node bx was not obtained since pt needed to stay on ASA for his heart condition, and IR did not feel biopsy was safe while on ASA. After discussion with oncology, urology and IR, the plan was to continue casodex for now and follow up with urology and oncology outpatient. The patient's CBI was eventually discontinued and his hematuria resolved. Both urology and oncology agreed that Mr. [**Known lastname 88012**] was not a candidate for cystoscopy and would not seek further direct imaging unless hematuria recurred. Based on the prognosis of this disease, treatment will be Casodex. Pt will follow up with oncology and urology outpatient. . # ESRD: Patient was continued on HD on MWF schedule through the renal service. His sevelamir was increased to 2400mg three times a day . # GERD/dysphagia: The patient had multiple complaints of heartburn, each time resolved with Tums. The patient also complained of a feeling of food getting stuck in a substernal area, followed by a burning sensation, often relieved with belching. The patient reports this sensation has been ongoing for several months. Patient should follow up with PCP for continuing GERD management and further studies (such as barium swallow and gastric emptying). . # L Inguinal hernia: Appeared stable. . # Likely urinary tract infection: Patient to complete seven-day course of ciprofloxacin. Medications on Admission: HOME MEDICATIONS: Unable to obtain home meds . TRANSFER MEDICATIONS: Renvela 1600mg PO TIDAC Zofran 4mg IV x1 Imdur 30mg PO daily Tylenol 650mg PO PRN B Complex daily PRN ASA 81mg PO daily Metoprolol 12.5mg PO BID Protonix 40mg PO Daily Ativan 0.5mg PO Daily Percocet 1-2tabs PO Q4 Listed as new meds: Folate 1mg PO Daily Lisinopril 40mg PO daily Senna Discharge Medications: 1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 tablets* Refills:*2* 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain: Take up to two tablets 5 minutes apart for chest pain or left arm pain. Call Dr. [**Last Name (STitle) 911**] if you take nitroglycerin. Disp:*25 tablets* Refills:*0* 4. Renvela 800 mg Tablet Sig: Three (3) Tablet PO three times a day: take with meals. Disp:*720 Tablet(s)* Refills:*3* 5. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day: with meals. 6. bicalutamide 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. metoprolol succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. Outpatient Lab Work Please check CBC, LFT's on tuesday [**11-15**] with results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 22**] 11. Xanax 0.5 mg Tablet Sig: One (1) Tablet PO three times a week before dialysis. 12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:*2 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Complete heart block Coronary artery disease End-stage renal disease Likely prostate cancer Likely urinary tract infection Gastroesophageal reflux disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You had a very slow heart rate called complete heart block and a pacemaker was inserted that will help your heart rhytm be regular and strong. The blood in your urine was concerning and we found a suspicious mass on the CT scan that may be cancer in your bladder. At the same time, your PSA was very elevated so we started you on Casedex, a medicine that may help to slow prostate cancer. Because you are on aspirin for your heart, the oncologists were very reluctant to perform a biopsy in your bladder and prostate. You will see Dr. [**Last Name (STitle) **] in about a week to further discuss the workup and treatment options. The bleeding in your bladder looks like it has almost stopped, you will also see a urologist in about 3 weeks. Please call Dr. [**Last Name (STitle) 261**] if the bleeding from your penis increases. . We made the following changes in your medicines: 1. Start taking aspirin 81 mg (baby dose) daily to prevent a heart attack 2. Start taking Bicalutamide (Casodex) for possible prostate cancer 3. Start taking simvastatin (Zocor) to prevent the blockages in your heart arteries from worsening. 4. Start taking B complex-vitamin C-folic acid for supplementation for hemodialysis 5. Start taking pantoprazole (protonix) to prevent heartburn. 6. Start taking nitroglycerin as needed for chest pain or jaw pain. You can take up to 2 tablets under your tongue 5 minutes apart. Always sit down when taking. Call Dr. [**Last Name (STitle) 911**] for any chest or jaw pain that does not go away after nitroglycerin. 7. Increase the Revela to 3 tablets before meals. 8. STOP taking Imdur, Lisinopril and folate. Dr. [**Last Name (STitle) 911**] will restart these medicines as needed. 9. Take ciprofloxacin once a day for two more days. . Please get your blood drawn when you see Dr. [**Last Name (un) **] on [**2135-11-15**] Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2135-11-30**] at 3:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**First Name (Titles) **] [**Last Name (Titles) 14316**] [**Name8 (MD) **], 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: SURGICAL SPECIALTIES When: TUESDAY [**2135-12-13**] at 9:00 AM With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 277**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2135-11-17**] at 10:30 AM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD and Dr. [**Last Name (STitle) 59565**] [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Name: [**Doctor Last Name **]-[**Last Name (LF) **],[**First Name3 (LF) **] Z. Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6698**] Phone: [**Telephone/Fax (1) 6699**] Appointment: Tuesday [**2135-11-15**] 11:00am Department: SURGICAL SPECIALTIES When: TUESDAY [**2135-12-13**] at 9:00 AM With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 277**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "39.95", "37.72", "99.25", "37.83" ]

icd9pcs

[ [ [] ] ]

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305, 374

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117,680

31835

Discharge summary

report

Admission Date: [**2111-10-29**] Discharge Date: [**2111-11-5**] Date of Birth: [**2043-12-14**] Sex: F Service: SURGERY Allergies: Heparin Agents Attending:[**First Name3 (LF) 1556**] Chief Complaint: Collapsed at home, bright red blood per rectum after recent hospitalization for upper GI bleed. Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy x 2 - [**10-29**], visible vessels clipped on [**10-30**] Colonoscopy [**11-2**] History of Present Illness: The patient is a 67 year-old female who was admitted to Dr. [**Name (NI) 74681**] service for a GI Bleed [**Date range (1) 74682**]/07 during which she recieved 12 units of PRBCs and was found to have a bleeding ulcers in the antrum & duodenum. She was also started on H Pylori treatment after her assay was reportedly positive elsewhere. She was doing well until the day of readmission when she again started to pass bright red blood per rectum. She had one episode on the morning of admission and felt her knees give out afterward. She was brought by EMS to [**Hospital 1562**] Hospital where her hematocrit was 20. She was transfered from [**Hospital 1562**] Hospital while recieving her first unit of PRBCs. An NG tube was placed prior to transfer and lavage reportedly did not return any blood. The patient denied abdominal pain, nausea/vomiting, chest pain, shortness of breath. Past Medical History: Past Medical History: - Diabetes mellitus - End stage renal disease on hemodiaylsis - hypertension - coronary [**Last Name (un) **] disease - peptic ulcer disease - congestive heart failure - diverticulitis Past surgical history: - appendectomy - cholecystectomy - c-section Social History: No alcohol, tobacco, drugs. Lives with husband in [**Name (NI) 1562**], MA. Family History: not ascertained Physical Exam: (per Dr. [**Last Name (STitle) **] on day of admission) EXAM: HD normal (see nursing note) Alert, NAD, anicteric Op-clear, no evidence epistaxis, NGT clear, non-bloody, non-bilious. CTAB RRR Abdomen-obese, soft, non-tender, non-distended, no mass or hernia. Ext-LUE dialysis graft with pulse/thrill -feet warm, 1+ PT bilaterally -R.groin CVL Pertinent Results: Hematocrit - 21.8 - 30.2 (stable at 31.1 on discharge) Gastrin (drawn on last admission) - 854 [**10-29**] Esophagogastroduodenoscopy - Normal esophagus. Stomach: Multiple superficial non-bleeding ulcers were found in the stomach body, fundus and antrum at various stages of healing. Prior bicapped ulcer was seen in proximal body- no evidence of active or recent bleeding. Visible vessel still noted in ulcer. Additional visible vessel noted in fundus. Nonbleeding. Duodenum: Normal duodenum. [**10-30**] Esophagogastroduodenoscopy - Normal mucosa in the esophagus. Normal mucosa in the duodenum. Blood in the fundus. Ulcer in the fundus. Visible vessel was seen in the fundus without clear surrounding ulcer. A clot was adherent to the vessel and there was stigmata of recent bleeding. Five clips were placed with good hemostasis. No other sources of bleeding were seen. [**2111-11-2**] Colonoscopy - Ulceration, friability and erythema in the terminal ileum (biopsy), Ulceration, friability and erythema in the splenic flexure, at approximately 70 cm compatible with colitis, possibly ischemic (biopsy), Otherwise normal colonoscopy to cecum Pathology: Terminal ileum: Active ileitis with ulceration and granulation tissue; Cecum: Within normal limits; Transverse: Ulceration with granulation tissue; No granulomas, viral inclusions, or dysplasia seen. Urinalysis [**10-29**] - small blood, 100 protein, moderate leukocytes; 0-2 red blood cells, >50 white blood cells, moderate bacteria, [**4-13**] epithelial cells Urine Culture [**10-29**] - >100,000 Klebsiella, sensitive to all antibiotics tested Brief Hospital Course: *) GI bleeding - The patient was admitted to the intensive care unit and underwent an esophagogastroduodenoscopy on hospital day #1 that demonstrated multiple old ulcers, two visible vessels in the stomach but no active bleeding. No interventions were performed. After an episode of hematemesis on hospital day #2, a second esophagogastroduodenoscopy was performed that showed a vessel in a fundal ulcer with stigmata of recent bleeding. This vessel was clipped x 5. While in the emergency department and ICU, the patient received a total of 8 units of packed red blood cells (last on [**10-31**] - hospital day #3), subsequently, her hematocrit was stable. She was transfered out of the intensive care unit to the floor on hospital day #3. She underwent a colonoscopy on hospital day #5 that demonstrated an area of colitis supicious for ischemic colitis; pathology showed nonspecific findings that, according to GI, were most consistent with ischemia. A vascular surgery consult recommended no intervention at this time. Throughout her admission, she was maintained on Protonix 40mg 2x/day and sucralfate. *) Urinary tract infection - the patient was given a 7 day course of Ciprofloxacin for the positive urinalysis on admission, urine culture grew Klebsiella sensitive to all antibiotics tested, including Cipro. Completed 5 days in the hospital, will receive 2 final days as outpatient. *) Hemodialysis - the patient received ultrafiltrate hemodialysis while in the hospital. Given her heparin-induced thrombocytopenia, no heparin was used during dialysis. Used citrate for clotting. *) H. Pylori - Given reported positive H. pylori assay from outside hospital and incomplete course of clarithromycin and amoxicillin from last admission (planned course 2 weeks, actual course 8 or 9 days), the patient was again started on a planned one week course of the same antibiotics. She had one day in the hosptial and is to receive the final 6 days as an outpatient. Medications on Admission: Amoxicillin 250 mg PO daily B Complex-Vitamin C-Folic Acid 1 mg PO daily Calcium Acetate [PhosLo] 667 mg PO daily Clarithromycin 250 mg 2x/day Vytorin 10-40 1 tablet daily Felodipine sustained release 5 mg Tues,[**Last Name (un) **],Sat Lantus 60U qhs Humalog sliding scale Metoprolol 100mg daily Miconazole Nitrate 2 % Powder topically 4x/day Pantoprazole 40mg delayed release every 12 hours Valsartan 160mg daily Discharge Medications: 1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Insulin Glargine 100 unit/mL Solution Sig: Sixty (60) units Subcutaneous once a day. 9. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous qAMACHS. 10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 11. Felodipine 5 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO Tu,Th,[**Last Name (LF) **],[**First Name3 (LF) **]. 12. Clarithromycin 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*13 Tablet(s)* Refills:*0* 13. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours) for 6 days. Disp:*12 Capsule(s)* Refills:*0* 14. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:*2 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Male First Name (un) **] nursing center Discharge Diagnosis: multiple gastric and duodental ulcers, upper GI bleeding, mesenteric ischemia Discharge Condition: stable Discharge Instructions: Please return to emergency room or notify your physician for any of the following: Bleeding from mouth or rectum, dark/black stools, abdominal pain, shortness of breath, dizziness, increasing weakness, [**Male First Name (un) **] over 101.4, nausea and/or vomiting, or any other symptoms that are concerning to you. Continue a soft diet. Followup Instructions: Please follow up with your regular gastroenterologist, cardiologist, nephrologist.

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icd9cm

[ [ [] ] ]

[ "44.43", "99.04", "45.13", "45.25" ]

icd9pcs

[ [ [] ] ]

7755, 7824

3846, 5826

372, 481

7946, 7955

2210, 3823

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30,819

141,037

2014

Discharge summary

report

Admission Date: [**2183-12-14**] Discharge Date: [**2183-12-16**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: found unresponsive Major Surgical or Invasive Procedure: arterial line placed, [**2180-12-14**] central venous line placed, [**2183-12-14**] History of Present Illness: Ms. [**Known lastname 11060**] is an 87 year old woman with history of atrial fibrillation, hypertension, and previous DVT on warfarin who was BIBA after found down. Her family had been unable to reach her for nearly 24 hours when they went to her house and found her unresponsive in the bathroom, barely breathing. She was intubated in the field for "[**Last Name (un) 6055**]-[**Doctor Last Name **]" respirations, and her initial blood pressures were 60/palp. She was given two liters of fluid with improvement in her blood pressures. . On arrival to the ED, her blood pressure was 73/23. She was given two liters of normal saline, and her blood pressures improved to 96/30. Inital vitals: T36.5C, HR 96, BP 96/30, RR 16. A right-sided groin cordis was placed. She received one dose of levofloxacin and clindamycin for community-acquired and aspiration pneumonia coverage. CT head demonstrated an evolving R MCA stroke, and neurology recommended MICU admission (with stroke consult service following). Neurosurgery was consulted in case cerebral edema would require neurosurgical decompression. She received a total of 6L normal saline. Blood cultures were drawn and urine was sent. Past Medical History: - Persistent atrial fibrillation (previously on sotalol, which was ineffective; now on amiodarone) on warfarin - Hypertension - Deep venous thrombosis ([**2175**]) Social History: Lives in [**Location (un) 538**] in senior housing. No tobacco, EtOH, or illicits. Family History: Deferred Physical Exam: VITALS: T99.0F, BP 119/87, HR 92, RR 17, Sat 90% VENT: AC, FiO2 100%, TV 600, Set rate 14, PEEP 5 GENERAL: Minimally responsive but withdraws to noxious stimuli on right side HEENT: Intubated; OP dry; pupils equal and reactive bilaterally NECK: Unable to assess JVP CARD: Tachycardic, normal S1/S2, no m/r/g RESP: Clear to auscultation bilaterally, ? crackles at bases ABD: Obese, non-tender, non-distended, decreased bowel sounds EXT: Edematous in both lower extremities and L>R upper extremities NEURO: Unable to follow commands. Responds to noxious stimuli on right side, minimal shoulder movement to noxious stimuli on left upper extremity; mute Babinski on left, upgoing on right Pertinent Results: ABG: 7.29/31/190/16, lactate 3.0 . Trop-T: 0.39 CK: [**Numeric Identifier **] MB: Pnd . Na 150 K 5.6 Cl 113 HCO3 19 BUN 31 Creat 2.1 Gluc 137 (Anion gap): 18 . Ca: 8.5 Mg: 2.2 P: 5.5 . Serum Tox: ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative Dig: 0.3 . WBC 19.5 N:83.6 L:11.7 M:3.9 E:0.3 Bas:0.5 Hgb 15.7 Hct 47.2 Plt 212 MCV 99 . PT: 18.1 PTT: 25.8 INR: 1.6 . Fibrinogen: 247 . Lactate:5.1 . U/A: Amber, Hazy, SpecGr 1.016, pH 6.5, small bili; moderate leuks, neg nitrates, 100 prot, trace ketons, 0-2 RBC's, 21-50 WBC, Many bacteria, [**6-22**] epis. . STUDIES: . EKG [**12-14**]: atrial fibrillation with normal axis, normal intervals. Lateral T-wave inversions. . CXR [**12-14**]: Low-lying ETT, only 11mm prox to carina; should be partly-withdrawn, several cm. NGT OK. Air space process L lung base, w/sm eff: likely pneumonia. No CHF. . CT Head [**12-14**]: Findings suspicious for large evolving Right MCA infarct w/ loss of grey-white and edema. No hemorrhage. . CT C-spine [**12-14**]: No fx or dislocation. Moderate DJD. . CT Abd/Pelvis [**12-14**]: No acute traumatic injury. NGT terminates in 2nd portion of duodenum. LLL consolidation concering for aspiration. Brief Hospital Course: Ms. [**Known lastname 11060**] is an 87yF found down at home, admitted with respiratory failure, evolving right MCA infarct, acute renal failure, elevated CK, elevated troponin, likely pneumonia, and lactic acidosis. . #) Respiratory Failure. The patient was intubated in the field for respiratory distress. This was felt to be due to a combination of altered mental status and pneumonia (LLL consolidation- presumed aspiration). Treatment was initated with with Unasyn; the patient tolerated the vent well. . #) Hypotension. Felt to be caused by either hypovolemia in setting of dehydration versus infection (elevated lactate on admission). The hypotension was fluid responsive, after which the patient maintained a normal-range blood pressure without pressure requirments. An arterial line was placed for closer BP monitoring; treatment with unasyn to cover CAP/Aspiration + urinary sources . #) MCA Infarct. Both neurology and neurosurgery are following were involved in the patient's care. Thrombolysis was not an option given unclear time course of event (last seen 24 hr prior to presentation). Serial head CTs were obtained and frequent neuro checks were performed. It was felt that patient would likely be left significant neurological deficits s/p her CVA. . #) Acute renal failure. This was thought to be secondary to hypotension (pre-renal etiology) vs. rhabdomyolysis. Pt patient received aggressive IVF initially and her renal function was noted to improve. . #) Hypernatremia. Thought to be due to dehydration/poor oral intake for >24 hours. Was volume repleted but remained free water down. Given the large size of her infarct however, mild hypernatremia was tolerated to try to limit further neurological damage. . #) Elevated CK. Presumed due to rhabdomyolysis from prolonged immobilization. IV fluids were given and the urine alkalinized. The pt's CK level dropped dramatically while renal function improved. . #) Elevated troponin. NSTEMI in setting of hypotension vs. demand ischemia from elevated heart rate vs. troponin leak from skeletal muscle in the setting of rhabdo. Associated ECG changes were considered cerebral versus ischemic T waves. Any anticoagulation and beta blockade was contraindicated given concomitant CVA. . #) A-Fib. The patient anticoagulation was held in the setting of her large and evolving cerebral infarct. Digoxin was continued for rate control. . . #) Dispostion: In light of her poor overall prognosis, on the second hospital day, the goals of care were transitioned to patient comfort; she expired shortly thereafter, on [**2183-12-16**]. Medications on Admission: Coumadin digoxin Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary: right MCA infarct c/b respiratory failure and hypotension Secondary: atrial fibrillation hypertension Discharge Condition: deceased Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

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283, 368

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22990

Discharge summary

report

Admission Date: [**2203-5-14**] Discharge Date: [**2203-5-21**] Date of Birth: [**2134-9-28**] Sex: F Service: MEDICINE Allergies: Dapsone / Cyclosporine / Cefepime / Aztreonam / Azithromycin / Vancomycin Attending:[**First Name3 (LF) 3913**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Cardiac Catheterization Placement of tunneled right internal jugular central venous line History of Present Illness: 68yo woman with h/o NHL s/p SCT in [**2199**] who presented to the ED with acute onset shortness of breath. She describes waking up at 5am on the day of admission because of severe pain from post-herpetic neuralgia in her left face. She then began feeling very short of breath and wheezy for the next 20 minutes. No associated chest pain. No fevers or chills. No nausea or vomiting. She has otherwise been feeling well. She denies any similar symptoms in the past. She has not had any orthopnea or prior episodes of PND. No pleuritic chest pain, no dyspnea on exertion, no LE edema or weight gain. She has been able to mow the lawn and go up a flight of stairs without any difficulty. No recent travel. She does not have a personal or family history of blood clots nor does she have a history of miscarriages. She had tacos last night for dinner. No nausea or vomiting. In the ED, initial VS were: 97.5 192/101 128 24 86% RA. Her oxygen improved to 100% on NRB. She appeared to have increased work of breathing and she had b/l rales on exam; guaiac was negative. BNP was elevated at [**Numeric Identifier 59336**]. The team was concerned about the possibility of PE, but they did not obtain CTA chest because of her advanced kidney disease. The ED team felt that PE was high enough on their differential that they opted to treat with a heparin gtt. They obtained a CT head, which showed some lacunes that were new as compared to [**2199**]. Neurology was consulted to advise whether anticoagulation would be safe. After discussing with oncology, heparin gtt was started. Although the team was concerned about the possibility of heart failure, she was given SL nitroglycerin and ASA but not started on lasix or BP medications. She did receive clindamycin and levofloxacin for concern of a possible RLL infiltrate. She was also given prednisone 60mg x 1 because of the possibility that she might be adrenally insufficient on chronic steroids. Upon arrival to the ICU, she reported feeling comfortable. Her pain was mild and she was not having any difficulty breathing. Past Medical History: - Large Cell Lymphoma: Diagnosed [**2197**], s/p allogeneic SCT in [**6-13**]. Has had multiple regimens of chemotherapy c/b GVHD - Chronic Graft vs Host Disease, mild (cutaneous, liver) - CKD Stage V: Unclear if secondary to chemotherapy, cyclosporin, or GVHD. Had LUE AV fistula placed but found to have occluded left brachiocephalic vessel on fistalugram - Hyponatremia felt to be due to increased fluid intake - s/p Thyroidectomy for thyroid mass, pathology was benign - Herpes zoster c/b post-herpetic neuralgia s/p nerve block Social History: Quit smoking 36 yrs ago. Very occ EtOH use. Married with two daughters. Formerly worked in human resources at a department store. Family History: No fam history of blood clots Her mom deceased age 87 of cerebral hemorrhage. Father deceased age 48 of malignant hypertension. Aunt deceased from breast cancer. Brother [**Name (NI) 59335**] massive MI at the age of 66. Additional brother with hypertension and emphysema Physical Exam: 97.6 129/69 111 18 94% 2L Very pleasant woman in no distress. PERRL, EOMI. Left lid ptosis. CN II-XII intact. OP clear, MMM. Neck supple, no thyroid enlargement, no adenopathy. S1, S2, regular tachycardia, +rub. Lung with good air movement and crackles [**12-12**] of way up b/l. Abd soft and not tender, no palpable mass, no hepatomegaly. Very mild asterixis R>L. Strength 5/5 in UE and LE b/l. No LE edema. DP +2 b/l. Dark discoloration of skin over arms and back. LUE AV fistula with palpable thrill. Pertinent Results: LABORATORY RESULTS ==================== On Admission: WBC-7.2 RBC-3.53* Hgb-11.5* Hct-34.9* MCV-99* RDW-18.0* Plt Ct-226 -- Neuts-74.1* Bands-0 Lymphs-14.2* Monos-8.4 Eos-2.7 Baso-0.7 PT-12.1 PTT-26.2 INR(PT)-1.0 Glucose-114* UreaN-75* Creat-5.2* Na-127* K-4.7 Cl-96 HCO3-12* Calcium-7.8* Phos-6.1*# Mg-2.5 TSH-1.5 On Discharge: WBC-5.8 RBC-3.15* Hgb-9.8* Hct-30.9* MCV-98 RDW-16.8* Plt Ct-169 PT-13.0 PTT-66.9* INR(PT)-1.1 Glucose-84 UreaN-44* Creat-3.9* Na-144 K-4.1 Cl-105 HCO3-29 [**2203-5-20**] 06:42AM BLOOD ALT-13 AST-16 LD(LDH)-184 AlkPhos-63 TotBili-0.2 Calcium-9.1 Phos-2.7 Mg-2.1 MICROBIOLOGY ============= Blood Cultures [**2203-5-14**]: One out of two bottles STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [**2203-5-16**]): GRAM POSITIVE COCCI IN CLUSTERS. Blood Cultures*2 [**2203-5-16**]: No growth Rapid Respiratory Viral Screen [**2203-5-15**]: **FINAL REPORT [**2203-5-17**]** Respiratory Viral Culture (Final [**2203-5-17**]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [**Telephone/Fax (1) 6182**] within 1 week if additional testing is needed. Rapid Respiratory Viral Antigen Test (Final [**2203-5-15**]): Respiratory viral antigens not detected. SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV. HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HCV Ab-NEGATIVE OTHER STUDIES ============== ECG [**2203-5-14**]: Sinus tachycardia with atrial premature beats. Poor R wave progression in leads V1-V3. Cannot rule out old anteroseptal myocardial infarction. Diffuse non-specific ST-T wave abnormalities. Compared to the previous tracing of [**2203-2-15**] there has been interval loss of R wave in leads V2-V3. Chest Radiograph [**2203-5-14**]: CONCLUSION: Added density at the right costophrenic angle is suggestive of an infiltrate. Blunting of the right costophrenic angle is suggestive of a small basal effusion. CT Head W/O Contrast [**2203-5-14**]: CONCLUSION: Periventricular ischemia and scattered lacunar infarcts. No intracranial hemorrhage. CT Chest W/O Contrast [**2203-5-14**]: CONCLUSION: 1. Bibasal effusions along with increased interstitial markings and confluent ground-glass opacities predominantly in the upper lobes. The differential considerations are fluid overload, or CHF. Please correlate clinically. 2. Scattered tiny calcific densities in the left breast may represent fibroadenomas. Mammography is recommended on a non-emergent basis. 3. No mediastinal masses. Transthoracic Echocardiogram [**2203-5-17**]: Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is borderline dilated. Overall left ventricular systolic function is probably mildly depressed (LVEF=~40-45%? %) with basal inferior hypokinesis and possible septal hypokinesis (views are technically suboptimal for assessment of regional wall motion). Diastolic function could not be adquately assessed. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. --Compared with the prior study (images reviewed) of [**2203-1-6**], the left ventricle is now more dilated, left ventricular systolic function is more depressed with new regional wall motion abnormality, the mitral valve chordae appear tethered, mitral regurgitation is now much more prominent. Cardiac Catheterization [**2203-5-18**]: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed single vessel disease. The LMCA was free of critical stenoses. The LAD had a bifurcation lesion with a 50% stenosis in the mid-LAD and 70% stenosis in the D1 branch. The LCx and RCA were widely patent. 2. Resting hemodynamics revealed mildly elevated right heart filling pressures with a mean RA of 11mmHg and severely elevated left heart filling pressures with a mean PCWP of 28mmHg. The cardiac index was preserved at 3.7 l/min/m2. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Severe diastolic ventricular dysfunction. Brief Hospital Course: Ms [**Known lastname 59332**] is a 68yo woman with h/o non-Hodgkin's lymphoma s/p SCT in [**2199**] and stage V CKD who presented with acute dyspnea in the setting of pain, hypertension, and volume overload. # Dyspnea and Hypoxia: She most likely developed flash pulmonary edema from sudden hypertension from the pain in the setting of chronic renal disease. This was supported by CXR and CT chest. She was given Lasix for diuresis. To cover PE (she has had persistent tachycardia), she was started on heparin gtt. This was discontinued as the likelihood of PE was very low given hypoxia and tachycardia resolved with diuresis. She had no evidence of infection or pneumonia. She takes her pentamidine faithfully, so was unlikely to be PCP. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was done during her admission to evaluate for suspected diastolic dysfunction, however showed new inferior basal wall motion abnormality and new moderate to severe mitral regurgitation, see below. # Systolic CHF: New diagnosis, on this admission. [**Last Name (NamePattern4) **] showed EF 40-45%, but likely overestimated given significant new MR. Likely secondary to ischemic event, either from plaque rupture given family history, hyperlipidemia, or vasospasm. The patient had a cardiac catheterization which did not show evidence of occlusive disease. She was started on metoprolol, atorvastatin, and aspirin during her hospital stay. # Sinus Tachycardia: Most likely this was secondary to pain and dyspnea, unlikely to be PE. She was empirically started on a heparin gtt, but stopped when she was no longer hypoxic. TSH was WNL. # CKD stage V: On admission, the patient had mild signs of uremia on exam and labs but denies frank symptoms apart from volume overload. Unfortunately, occlusion of left brachiocephalic makes left AV fistula unusable. Renal was consulted during her hospitalization and did not think she required acute hemodialysis. Transplant surgery was consulted to discuss the possibility of placing another fistula on the right. However, given the new development of CHF, this surgery was placed on hold, and a temporary HD line was placed. Hemodialysis was electively initiated during her hospitalization. She had Hep C and Hep B antibiodies sent. A PPD was placed . All hepatitis serologies were negative and there was no induration to PPD. The patient was discharged to outpatient dialysis. # Graft vs Host Disease: Pt was continued on home prednisone after discussing with oncology. She is also on monthly pentamidine given long term steroids. # Post-herpetic neuralgia: Pt was continued on home pregabalin and nortriptyline for pain control. She will follow up in pain clinic. # Small vessel ischemic disease on Head CT: Neuro was consulted and recommended aspirin, which was started. # h/o thyroidectomy: TSH was WNL. Pt was continued on home dose of levothyroxine. . # Hyponatremia: Chronic, will monitor . # Code: DNR/DNI (confirmed with patient) Medications on Admission: Prednisone 2.5mg daily (for GVHD) Levothyroxine 125mcg daily Nortriptyline 10mg QHS Pregabalin 25mg [**Hospital1 **] Calcium and vitamin D Centrum silver Pentamidine 300mg every month Albuterol inhaler (almost never uses) Discharge Medications: 1. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Cholecalciferol (Vitamin D3) 400 unit Capsule Sig: One (1) Capsule PO twice a day. 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q4H (every 4 hours) as needed for sob, wheezing. 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*2* 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 * Refills:*2* 11. Multivitamin Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Systolic and Diastolic Heart Failure Stage V Chronic Kidney Disease Post Herpetic Neuralgia Secondary Diagnoses: History of allogeneic stem cell transplant for non-Hodgkin's Lymphoma Chronic graft versus host disease Hypothyroidism Discharge Condition: Good, stable on room air, tolerating PO's, euvolemic Discharge Instructions: You were admitted to [**Hospital1 18**] for evaluation of shortness of breath. You were found to have new heart failure and volume overload from your chronic kidney failure. You had a cardiac catheterization which showed evidence of coronary artery disease, but did not explain your heart failure and valve symptoms. You were also stared on hemodialysis while you were inpatient. Medication Changes: START Metoprolol 12.5mg twice a day START Aspirin 81mg daily START Atorvastatin 10mg daily START NEPHROCAPS We discontinued your Calcium Acetate (Phoslo) and Sodium bicarb. Please do not take this medications any more unless asked to do so by your Nephrologist. . Your PPD was negative. . It is important that you see your docotrs for further follow up, as we have arranged for you (see below). . If you experience worsening shortness of breath, chest pain, fevers, chills or any other concerning symptoms please seek medical attention. Followup Instructions: Please set up an appointment to see your PCP Dr [**Last Name (STitle) 29827**] to follow up on your hospitalization. Please keep your previously scheduled appointments: [**2203-5-24**] 01:30p [**Last Name (LF) **],[**First Name3 (LF) 3750**] C. SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] HEMATOLOGY/ONCOLOGY ([**Telephone/Fax (1) 3241**]) [**2203-5-24**] 01:30p [**Last Name (LF) **],[**First Name3 (LF) **] E. SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] HEMATOLOGY/ONCOLOGY ([**Telephone/Fax (1) 3241**]) [**2203-5-27**] 11:10a [**Doctor Last Name **] ONE [**Location (un) **] PLACE ([**Location (un) **], MA), [**Location (un) **] PAIN MANAGEMENT CENTER ([**Telephone/Fax (1) 1652**] [**2203-5-31**] 11:20a [**Doctor Last Name **] [**Hospital6 29**], [**Location (un) **] CC7 CARDIOLOGY (SB)

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icd9cm

[ [ [] ] ]

[ "38.95", "88.56", "37.23", "39.95" ]

icd9pcs

[ [ [] ] ]

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342, 433

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20,804

129,220

45627

Discharge summary

report

Admission Date: [**2168-5-24**] Discharge Date: [**2168-5-28**] Service: MEDICINE Allergies: Penicillins / Levofloxacin Attending:[**First Name3 (LF) 9240**] Chief Complaint: SOB, cough Major Surgical or Invasive Procedure: L midline insertion History of Present Illness: 89 year old male [**Hospital 100**] Rehab resident with history of coronary artery disease, congestive heart failure, OSA, multiple previous pneumonias/bronchitis presents with 4 days shortness of breath and non-productive cough, wheezing. At [**Hospital 100**] rehab providers noted cough, wheezing and shortness of breath x 4 days. Started on ceftriaxone 4 days prior to admission. Previous bronchitis on [**5-9**] treated with azithromycin and nebulizers. Continued on nebs since that time. Also given lasix, multiple doses over past few days for possible chf exacerbation. "Labored breathing" as per notes over this time with oxygen low to mid 90's on 3 liters despite these interventions. Today, also became more lethargic, responding only with small sentences, so decision made to send patient to [**Hospital1 18**] ER. . Patient reports he has been having shortness of breath for years but it has gotten worse in the past four days. Reports choking/coughing after eating food. At baseline most vigorous activity involves transfers to powerized wheelchair. Past Medical History: DDD Pacemaker placed [**7-8**] for second degree AV block Coronary Artery Disease Congestive Heart Failure. [**8-6**] Echo: LVEF>55% Obstructive Sleep Apnea Hypertension gout Lichen Simplex Chronicus, on zyrtec Incisional hernia chronic skin ulcers iron-deficiency anemia h/o DVT s/p prostatectomy s/p appy Ventral hernia Obesity H/o DVT, on coumadin completed 6m course [**2166**] Hypothyroidism Social History: Lives at [**Hospital 100**] Rehab, denies ever smoking Family History: NC Physical Exam: Vitals: 98.3 HR 91, BP 129/59 RR 20 O2 sat 94% on 4L Gen: comforable, speaking in full sentences, gurgle audible HEENT: PERRL, EOMI CV: RRR, nl S1/S2 Chest: Coarse rhonchi diffusely Abd: Soft, nt Ext: No edema Neuro: strength grossly intact x4 Pertinent Results: [**2168-5-24**] 06:31PM GLUCOSE-95 UREA N-32* CREAT-1.4* SODIUM-142 POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-39* ANION GAP-10 [**2168-5-24**] 06:31PM CALCIUM-9.4 PHOSPHATE-3.1 MAGNESIUM-2.4 [**2168-5-24**] 06:31PM WBC-5.3 RBC-4.67 HGB-14.6 HCT-45.8 MCV-98 MCH-31.3 MCHC-31.9 RDW-15.8* [**2168-5-24**] 06:31PM NEUTS-66.2 LYMPHS-24.8 MONOS-3.8 EOS-4.6* BASOS-0.5 [**2168-5-24**] 06:31PM PLT COUNT-213 [**2168-5-24**] 06:31PM PT-13.0 PTT-30.9 INR(PT)-1.1 [**2168-5-24**] 05:00PM CK(CPK)-93 [**2168-5-24**] 05:00PM CK-MB-NotDone cTropnT-<0.01 [**2168-5-24**] 10:51AM TYPE-[**Last Name (un) **] COMMENTS-NOT SPECIF [**2168-5-24**] 10:51AM LACTATE-1.4 [**2168-5-24**] 10:40AM GLUCOSE-123* UREA N-30* CREAT-1.4* SODIUM-144 POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-42* ANION GAP-9 [**2168-5-24**] 10:40AM estGFR-Using this [**2168-5-24**] 10:40AM CK(CPK)-81 [**2168-5-24**] 10:40AM cTropnT-0.03* [**2168-5-24**] 10:40AM CK-MB-NotDone proBNP-885* [**2168-5-24**] 10:40AM CALCIUM-9.1 PHOSPHATE-2.6* MAGNESIUM-2.4 [**2168-5-24**] 10:40AM DIGOXIN-1.4 [**2168-5-24**] 10:40AM WBC-6.3 RBC-4.67# HGB-14.3# HCT-44.8# MCV-96# MCH-30.6# MCHC-31.9 RDW-16.2* [**2168-5-24**] 10:40AM PLT COUNT-229# [**2168-5-24**] 10:40AM PT-12.6 PTT-26.6 INR(PT)-1.1 . pCXR: Limited study demonstrating patchy, multifocal airspace process, superimposed on underlying chronic lung disease, which may represent pneumonia. . CT chest: 1. Worsening of the basal bronchiectasis and bronchial wall thickening, right more than left. Increased bibasal, right more than left, areas of consolidation. These findings might be either due to recurrent aspiration given the patient's hiatal hernia but the existence of bronchomalacia in the right lower lobe might also contribute to this finding being in part atelectasis. 2. Air trapping secondary to bronchomalacia and atelectasis is suspected. 3. Bronchial wall thickening worsened compared to the previous study, involves bronchus intermedius. . TTE: Conclusions: The left atrium is mildly dilated. The estimated right atrial pressure is [**5-12**] mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is dilated. There is mild global right ventricular free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2165-8-16**], the left ventricular walls are thicker. The suboptimal acoustic windows of the current study makes exclusion of a small regional wall motion abnormality difficult (overall left ventricular function appears normal). Brief Hospital Course: 1. Hypoxia: At baseline patient requires 2 L NC O2 prn and is unable to do most physical activity, including walking. Differential includes CHF exacerbation, PNA, PE. At this point clinical suspicion of PE low despite pmh of DVT. Favor diagnosis of bronchiectasis with impaired clearance of secretions and possible repeated aspirations. CT chest without contrast revealed some bibasilar airspace disease and bronchiectasis. Patient is at risk for nosocomial PNA given he lives at [**Location **]. He was treated with vanco/ceftriaxone and azithro initially. He quickly improved in the ICU without further intervention and was transferred to the floor where chest PT was started. His O2 continued to improve at his requirement is at baseline. . 2. CV: He had a TTE which showed slight RV failure, given his risk factors, and per his cardiologist, Dr.[**Name (NI) 9920**], note he was felt to be at CVA risk so coumadin was started for afib. He was started on lovenox until his INR is therapeutic. . 3. Gout: cont allopurinol . 4. Hypothyroid: cont. levothyroxine . 5. FEN: Patient passed swallow evaluation. . 6. Prophylaxis: hep sc, no indication now for bowel proph. . 7. Code: DNR/DNI . 9. Comm: [**Name (NI) **] [**Name (NI) 5749**]: H [**Telephone/Fax (1) 97289**], w: [**Telephone/Fax (2) 97290**] Medications on Admission: Allopurinol 250 mg once daily Calcium/Vit D (Oscal 250 +D) 2 tab before meals Ceftriaxone (got on [**5-23**]) Vit b12 1000 mcg qmo Digoxin .0625 mg QMOWEDFRI Digoxin 0.125 mg QSUNTUESTHURSSAT Fexofenadine 60 mg [**Hospital1 **] Furosemide (got 40 mg on [**5-23**], not standing) Synthroid 75 mcg qd senna 1 tab qd tylenol 650 mg q4 hours prn albuterol q6 hours prn bisacodyl prn guaifenesin/dextromethorphan prn hydrocotrisone 1% cream to buttock area Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Digoxin 125 mcg Tablet Sig: 0.0625 mg PO 3X/WEEK (MO,WE,FR). 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 14. Allopurinol 100 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 15. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous Q12H (every 12 hours): Continue until INR >2, then discontinue and continue coumadin. 16. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime): Please check INR on [**5-29**] or [**5-30**] to adjust coumadin dosage. 17. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO BID (2 times a day). 18. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) g Intravenous Q24H (every 24 hours) for 9 days. 19. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous Q 24H (Every 24 Hours) for 9 days. 20. Heparin Flush 100 unit/mL Kit Sig: Two (2) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Nosocomial Pneumonia Bronchiectasis Atrial Fibrillation Discharge Condition: stable Discharge Instructions: Continue your vancomycin and ceftriaxone for 9 more days, then your midline can be removed. Continue your other medications. Please have your MRSA screen followed up in the next 1-2 days, which was pending at the time of your discharge. You will need your INR checked in the next 1-2 days to adjust your coumadin dose. When your INR is >2 your lovenox can be stopped. Followup Instructions: 1. Please follow up with your PCP in the next 1-2 weeks. Discuss with them possible referral to a pulmonologist for your bronchiectasis. 2. Please have your MRSA screen test followed up at rehab in the next 1-2 days as this was pending. If this is negative you will not need contact isolation. 3. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2168-8-1**] 1:00 4. Please have your INR checked in the next 1-2 days to adjust your coumadin dosage.

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icd9cm

[ [ [] ] ]

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icd9pcs

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47172

Discharge summary

report

Admission Date: [**2117-10-4**] Discharge Date: [**2117-10-6**] Date of Birth: [**2044-4-5**] Sex: F Service: CARDIAC MEDICINE HISTORY OF THE PRESENT ILLNESS: The patient is a 73-year-old female with a history of coronary artery disease, noninsulin-dependent diabetes mellitus, and a baseline left bundle branch block who was in her usual state of health until one day prior to admission when she noticed an episode of chest tightness which she described as [**4-16**] which lasted approximately ten minutes. Sublingual nitroglycerin helped relieve the pain. She had a second episode later that day and took sublingual nitroglycerin with relief. She also had a third episode later that evening with associated diaphoresis and nausea. The pain was not fully relieved with nitroglycerin. She woke up feeling short of breath that evening. On the morning of admission, she had two additional episodes of chest pain associated with nausea and diaphoresis. She states that in the Emergency Room she had [**9-16**] chest tightness. At that time, she had been placed on aspirin, beta blocker, heparin, and nitro without significant relief. She also was started on Aggrenox and the chest pain improved to [**3-17**] chest tightness. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post catheterization in [**1-8**] with diffuse LAD disease. The patient had a normal P mibi in [**10-8**]. 2. History of left bundle branch block. 3. History of noninsulin-dependent diabetes mellitus. 4. Hypertension. 5. Anemia secondary to MGUS. 6. Status post left carotid endarterectomy. 7. History of zoster. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. q.d. 2. Atenolol 50 mg p.o. q.d. 3. Lasix 80 mg p.o. q.d. 4. Mavik 16 mg p.o. q.d. 5. Metformin 500 mg p.o. b.i.d. 6. Norvasc 10 mg p.o. q.d. 7. Iron 325 mg p.o. q.d. SOCIAL HISTORY: The patient quit smoking approximately 25 years ago. She denied alcohol use. She lives alone. She served as a waitress for 52 years. PHYSICAL EXAMINATION ON ADMISSION: In general, the patient was comfortable in no acute distress. HEENT examination revealed that the oropharynx was clear with moist mucous membranes. Neck: JVP went to the level of approximately 10 cm. The neck was supple. Chest: Rales at both bases were noted. Heart: Regular rate and rhythm with normal S1, S2 with no appreciable murmurs. Abdomen: Soft, nontender, nondistended, Guaiac negative in the Emergency Department. Extremities: Trace pedal edema with 1+ DP pulses. LABORATORIES ON ADMISSION: White count 6.5, hematocrit 28.8, platelets 253,000. Chem-7 on admission revealed a sodium of 135, potassium 5.0, BUN 37, creatinine 1.4, glucose 145, magnesium 2.2. PT 12.5, INR 1.1, PTT 30.2. The EKG was normal sinus rhythm with left bundle branch block. Chest x-ray was notable for mild CHF. HOSPITAL COURSE: The patient is a 73-year-old with known coronary artery disease, left bundle branch block, presenting with chest pain. The patient's presentation was concerning for acute coronary syndrome and her admission EKG had an old left bundle branch block with no significant change from a prior EKG. The patient was treated for acute coronary syndrome with aspirin, nitro drip, heparin drip, as well as Aggrastat. She had cardiac enzymes cycled which had negative CK and troponin. The patient was ruled out for myocardial infarction with enzymes. She went to Cardiac Cath where right heart catheterization revealed hemodynamics with a right atrium pressure of 15, pulmonary artery pressure of 62/28 with a mean of 43, and pulmonary capillary wedge pressure of 19. A wave 29 with V of 22. The patient's cardiac output by Fick was 5.09 liters per minute. Given the patient's renal labs at that point revealing a creatinine of approximately 1.6 and the patient's hematocrit was 28.7, it was decided to admit the patient to the CCU briefly for blood transfusion, hydration, and acetylcysteine treatment. The patient received a total of 2 units of packed red blood cells during this admission. Her hematocrit on admission was 28.8 and had increased to 32.2 after 2 units of the packed red blood cells. After the patient's prehydration and blood transfusion, she underwent cardiac catheterization. The cardiac catheterization showed three vessel coronary artery disease. The LMCA had a distal 40% stenosis which involved the origins of the LAD and LCX, LAD had moderate disease throughout which was more severe in the middle with a maximal stenosis of 50-60%. The circumflex had a 50% stenosis. The catheterization was also notable for moderate diastolic biventricular dysfunction as well as severe pulmonary hypertension. After the catheterization, the patient was transferred back to the Cardiac Medicine Floor where she had an echocardiogram which showed the left atrium to be mildly dilated with mild metric LV hypertrophy. There was mild LV systolic dysfunction with mild hypokinesis of the anterior septum. The RV was normal size with normal free wall motion. Regarding the patient's catheterization, it was felt that the patient should continue her current medical management and in addition Imdur 30 mg p.o. q.d. was added to her regimen. DISCHARGE CONDITION: Good. DISCHARGE STATUS: The patient is to be discharged to home. DISCHARGE DIAGNOSIS: 1. Status post cardiac catheterization and history of coronary artery disease. 2. History of noninsulin-dependent diabetes mellitus. 3. History of anemia. DISCHARGE MEDICATIONS: 1. Mavik 16 mg p.o. q.d. 2. Imdur 30 mg p.o. q.d. 3. Lasix 80 mg p.o. q.d. 4. Protonix 40 mg p.o. q.d. 5. Iron 325 mg p.o. t.i.d. 6. Metoprolol 50 mg p.o. q.d. 7. Aspirin 325 mg p.o. q.d. 8. Sublingual nitroglycerin p.r.n. 9. Norvasc 10 mg p.o. q.d. 10. Metformin 500 mg p.o. b.i.d. FOLLOW-UP: The patient is to follow-up with her cardiologist, Dr. [**First Name (STitle) 437**], in two weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**MD Number(1) 5226**] Dictated By:[**Last Name (NamePattern4) 17418**] MEDQUIST36 D: [**2117-10-6**] 14:28 T: [**2117-10-6**] 19:14 JOB#: [**Job Number 99940**]

[ "593.9", "411.1", "414.01", "250.00", "429.9", "401.9", "416.8", "285.9" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.23" ]

icd9pcs

[ [ [] ] ]

5303, 5371

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5392, 5551

1710, 1908

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2612, 2912

1273, 1684

1925, 2083

46,553

122,944

53333

Discharge summary

report

Admission Date: [**2183-10-14**] Discharge Date: [**2183-11-5**] Date of Birth: [**2103-4-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3021**] Chief Complaint: Jaundice. Major Surgical or Invasive Procedure: 1. ERCP 2. IR guided Percutaneous Catheter (PTC) to biliary ducts 3. IR guided Metal stenting of biliary ducts via PTC 4. IR placement of venting gastric tube and jejunal tube History of Present Illness: Ms [**Name13 (STitle) 109733**] is a 82 year old woman who was diagnosed with stage I (T4N0M0) poorly differentiated adenocarcinoma of the colon in [**2181**]. She underwent resection followed by adjuvant chemotherapy including 5FU-LCV given at Cape Code Hospital Cancer under the direction of Dr [**Last Name (STitle) **] [**Name (STitle) 7049**]. Subsequently she has been follewed by CT scans. CT scan of chest/abdomen/pelvis in [**12-16**] showed severe emphysema and a left upper lobe pulmonary nodule. Repeat Ct scans in [**7-17**] revealed a large abdominal mass in the head of the pancreas measuring 4.4x5.6 cm. PET scan in [**8-16**] showed abnormal uptake in both the lung nodule and abdominal mass.A biopsy was attempted via EUS but pathology c/w necrosis and glandular cells only. Patient was scheduled for a CT guided biopsy for next week, however, she was seen today at the clinic clinic by Dr [**Last Name (STitle) **] and found to be jaundiced with lab work significant for a T.Bil of 7. Patient reports that she has noticed icteric sclerae for the past few days as well as nausea and lack of appetite for 1 week. She also notes weight loss of [**5-12**] pounds over the past week. She denies emesis, abdominal pain or any other pain. Past Medical History: 1. Colon cancer-[**11/2182**] T4N0M0 (0/23 lymph nodes) see HPI 2. HTN- diagnosed approximately a year ago. Has not been taking BP meds over the past 5 days. Social History: Married and lives with husband. Independent in all ADLs. Has two children. Son lives on West coast and has traveled to [**Location (un) 86**] during the current hospitalization, daughter lives in [**Name (NI) 1727**]. Remote heavy tobacco use, etoh-glass of wine per day. Family History: Sister deceased of [**Name (NI) 4278**] lymphoma approximately 40 years ago, daughter diagnosed with Breast cancer at age 42. No h/o colon cancer in the family. Physical Exam: ADMISSION EXAM: General;Pleasant, no signs of acute distress HEENT:mildly icteric sclerae, mucus membranes moist and without any lesions. Lymph nodes; No cervical, supraclavicular or axillary LAD Neck: supple, no thyromegaly, no JVD. Lungs: Clear to ausculation bilaterally with good air movement. CV:S1S2, normal rate and rythm, no murmurs, gallops or rubs Abdomen: Surgical scars well healed, normal bowel sounds, soft and no tenderenss or gaurding, no masses palpated and no HSM. Neuro: Right eye mild ptosis( chronic), all other cranial nerves intact, normal muscle strength. Non focal exam. Ext: no edema Skin: + jaundice Pertinent Results: [**2183-10-14**] 08:51AM UREA N-19 CREAT-0.8 SODIUM-135 POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13 [**2183-10-14**] 08:51AM estGFR-Using this [**2183-10-14**] 08:51AM ALT(SGPT)-353* AST(SGOT)-302* ALK PHOS-1177* TOT BILI-8.7* DIR BILI-7.0* INDIR BIL-1.7 [**2183-10-14**] 08:51AM TOT PROT-6.7 [**2183-10-14**] 08:51AM CEA-8.2* [**2183-10-14**] 08:51AM WBC-8.5 RBC-3.93* HGB-12.1 HCT-38.2 MCV-97 MCH-30.9 MCHC-31.8 RDW-14.5 [**2183-10-14**] 08:51AM NEUTS-63.1 LYMPHS-27.0 MONOS-6.4 EOS-2.6 BASOS-0.9 [**2183-10-14**] 08:51AM PLT COUNT-461* [**2183-10-14**] CT CHEST/ABD/PELVIS: 1. Interval increase in size of porta hepatis mass which is now causing compression of the common bile duct and new severe intrahepatic bile duct dilation. The mass is also newly cavitary and communicating with the duodenum. 2. New main portal vein tumor or bland thrombus. 3. Unchanged right lower quadrant colonic anastomosis with no evidence of soft tissue recurrence at the anastomotic site. 4. Unchanged 10 x 6 mm left upper lobe pulmonary nodule which may represent a primary lung malignancy, or metastasis. [**2183-10-15**] ERCP: FINDINGS: One fluoroscopic spot view from ERCP was submitted for review. This image showss degenerative changes of the thoracolumbar spine and a calcified abdominal aorta. In the periphery of the film, opacified loops of bowel are seen. There is atelectasis of the lung bases. Per ERCP note, a large infiltrating mass was discovered in the wall of the duodenum and the ampulla could not be reached for evaluation of the biliary tree. IMPRESSION: Single fluoroscopic spot image showing degenerative changes of the thoracolumbar spine, residual oral contrast, and atelectatic lung bases. Further ERCP images were not completed due to obstruction by a duodenal mass. . [**2183-10-15**]: Duodenal mass, biopsy: Poorly differentiated carcinoma most consistent with colonic primary site, see note. . Note: Immunostains for CDX-2 (diffuse) and cytokeratin 20 (focal) are positive within the tumor, while immunostains for cytokeratin 7 and TTF-1 are negative. No normal duodenal mucosa is present for evaluation. . [**2183-10-19**] Chest CTA:FINDINGS: Comparison to a prior CT torso dated [**2183-10-14**] and initial CT from another institution dated [**2182-4-19**]. Atherosclerotic calcification of the aortic arch and its branches, coronary arteries, and calcification of the aortic annulus are moderately severe, stable since [**2183-10-14**]. The heart size is normal. There is no pericardial effusion. Bilateral pleural effusions that have developed since [**2183-10-14**] are small. The airways are patent to the subsegmental level. There is no evidence of pulmonary embolism, nor is there evidence of right heart strain. The pulmonary artery diameter is within normal limits. There is no pathologic enlargement of the mediastinal, axillary, or supraclavicular lymph nodes. The thyroid gland is normal in size. Centrilobular emphysema is severe. The airways are patent to the subsegmental level. Bronchial secretions in the left lower lobe are moderate in volume (3:54). The left upper lobe 10 x 6 mm solid lesion has enlarged since initial imaging dated [**2182-4-19**], but is stable since [**2183-8-4**]. There are no new pulmonary nodules or consolidation. Compression fractures of T8 and T11, extensive bridging osteophytosis and kyphosis at the level of T8 are unchanged since a CT dated [**2183-1-1**]. The study is not tailored for evaluation of the upper abdomen, only to confirm a large porta hepatis low-attenuation lesion, new left-sided biliary pigtail catheter without pneumobilia, new small volume ascites in the left subphrenic space (400B, image 33), uniformly thickened adrenal glands stable since [**2183-10-14**], stable left renal pelvis dilatation and a mild sliding hiatus hernia. IMPRESSION: 1. No evidence of pulmonary embolism. 2. New ascites and small bilateral pleural effusions. 3. Stable left upper lobe nodule since [**2183-8-4**] represent either a primary lung neoplasm or metastasis. 4. Severe centrilobular emphysema. . [**2183-10-20**] Abdominal Series: ABDOMINAL RADIOGRAPH, SUPINE AND LEFT LATERAL DECUBITUS VIEWS: On the decubitus views, there is no evidence of free air to suggest perforation. Metallic biliary stent is visualized along the right lateral margin of the lumbar vertebral bodies. A transhepatic biliary catheter is visualized extending through the biliary stent with the tip seen in the region of small bowel overlying the midline. Residual contrast material is seen within the gallbladder and distal colon. There is nonspecific small bowel gas pattern without evidence of obstruction. The bilateral visualized lung fields are without gross infiltrate. IMPRESSION: 1. No evidence of free air to suggest perforation on the lateral decubitus films. 2. Visualization of a metallic CBD stent with a biliary catheter seen extending through the stent into the small. 3. Residual contrast is seen within the distal colon, and there is nonspecific small bowel gas pattern without evidence of obstruction. [**2183-10-21**] Head CT without contrast: FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or infarction. The ventricles and sulci are moderately enlarged, consistent with age-appropriate atrophy. There is no shift of normally midline structures. The bones are unremarkable. The right maxillary sinus is not pneumatized and may be sequelae of inflammation from childhood. The remainder of the paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No evidence of acute intracranial abnormalities including infarction or hemorrhage. . [**2183-10-21**] Portable Chest: AP chest compared to [**10-21**] and chest CTA [**2183-10-19**]: Emphysema is severe. Small right pleural effusion unchanged. No good evidence for pneumonia or pulmonary edema. Apparent 1-cm wide nodule projecting over the base of the right lung is not present on the chest CTA three days ago, and is presumably artifactual. Heart size normal. No pneumothorax. . [**2183-10-25**] Portable Abdomen: There is no evidence of bowel obstruction. Air-filled loops of contrast are seen within the colon from prior barium study. There is no free air. Stent projects in the right abdomen. Degenerative changes are in the lumbar spine. . [**2183-10-26**] Portable CXR for NGT Placement: NG tube tip is out of view below the diaphragm. Cardiomediastinal contours are normal. The lungs are hyperinflated consistent with emphysema. Aside from minimal atelectasis in the left base, the lungs are otherwise clear.There is no evident pneumothorax or pleural effusion. . [**2183-10-26**] Portable Abdomen: Comparison is made with prior study performed five hours earlier. A new NG tube tip is in the stomach. There are no interval changes. . [**2183-10-29**] GJ tube placement: PROCEDURE AND FINDINGS: An informed written consent was obtained after explaining the procedure, benefits, alternatives and risks involved. Patient was brought to the angiography suite and placed supine on the imaging table. The upper abdomen was prepped and draped in the usual sterile fashion. A preprocedural huddle and timeout was performed as per [**Hospital1 18**] protocol. The stomach was insufflated with air through the indwelling nasogastric tube. Under fluoroscopy, the outline of stomach and colon were noted. Left margin of the liver was marked under ultrasound guidance. Then under fluoroscopic guidance, three T-fastener buttons were sequentially deployed in a triangular fashion, elevating the stomach to the anterior abdominal wall. A small skin incision was made between the T-fasteners and a 19-gauge needle was introduced into the stomach under fluoroscopic guidance. The position of the needle was confirmed with small contrast injection, and a 0.035 [**Doctor Last Name **] wire was placed through the needle. The needle was then removed and soft tissue tract dilated. An 8-French Bright-Tip sheath was placed over the guidewire and the guidewire removed. Using a combination of 5-French Kumpe catheter and 0.035 angled Glidewire, the catheter was successfully advanced past the pylorus and the duodenal mass, into the proximal jejunum. The guide wire was removed and small amount of contrast injected to confirm the position. Then a 0.035 Amplatz wire was placed and the catheter as well as the Bright-Tip sheath were removed. The tract was further dilated with the telescopic soft tissue dilator and a peel-away sheath was placed. Through the peel-away sheath a 16 French MIC gastrojejunostomy catheter was placed and advanced into the proximal jejunum. The peel-away sheath was removed and the retainingballoon was inflated with 7 cc of saline mixed with small amount of contrast. The catheter was secured in place by sliding the plastic disc on the outside. Contrast injection through the catheter confirmed satisfactory placement and position with the tip of the jejunal port distal to the ligament of Treitz. The catheter was flushed and capped. Sterile dressing and a Flexi-Trak device was applied. Patient tolerated the procedure well and there were no immediate complications. IMPRESSION: Successful ultrasound and fluoroscopically guided placement of a 16-French MIC gastrojejunostomy tube with the tip of the jejunostomy port terminating distal to the ligament of Treitz. The gastrostomy port to be connected to low-wall suction overnight and the catheter can be used tomorrow morning for feeding purposes. The catheter needs to be changed every three months and a followup arrangement will be made. . [**2183-10-31**] Portable abdomen: Preliminary Report !! WET READ !! multiple dilated loops of small bowel concerning for SBO. no free air. bibasilar atlectesis. CT could be used to further evaluate [**2183-11-4**]: T bili 0.9, AST/ALT 22/28, ALP 194. [**2183-11-5**]: WBC 12.2, Hb 10.8, HCT 36.8, PLT 501, Na 143, K 4.9, Cl 105, CO2 35, BUN 18, creat 0.5, glucose 99, Ca 8.5. Brief Hospital Course: # Metastatic colon adenocarcinoma: Abdominal mass and pulmonary nodule are both PET avid and were concerning for either a second primary or metastatic colon adenocarcinoma, with evidence of tumor in liver, peripancreatic, probably posterior LN, and portal vein. Prior EGD-biopsy of the mass was inconclusive performed at a outside hospital. Repeat biopsy of the abdominal mass was done at time of ERCP on [**2183-10-14**] and results returned [**2183-10-15**] showed poorly differentiated carcinoma most consistent with colonic primary site. The patient was seen by a surgical team (Dr. [**Last Name (STitle) **] who reviewed the case [**2183-10-16**] with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] and indicated that palliative surgery at this time was not advisable. After a family meeting with Dr. [**Last Name (STitle) **], it was decided to pursue rehabilitative placement and consider palliative chemotherapy if the patient's functional status improved. However, she developed recurrent small bowel obstructions, for which she is a non-operative candidate. She agrees to inpatient hospice care if she fails to improve soon. # Obstructive jaundice: Pt underwent an attempted ERCP [**2183-10-14**] for decompression but cannulation of the ampulla was unseccessgul due to tumor mass. On [**2183-10-15**] she underwent percutaneous catheter decompression via Interventional Radiology team and tolerated both procedures without immediate complication and with lab evidence of decompression. IR metal stenting of the biliary tree was performed trhought the percutaneous catheter under sedation and local anesthesia on [**2183-10-20**]. The patient experienced significant post procedure pain thought secondary to the lengthy tumor that was cannulated for stent placement. Her pain was treated with narcotic analgesia. Perforation was ruled out with abdominal plain films. The drain and stent resolve the obstruction. # COPD with Hypoxemia and Hypercarbia: The patient developed a new oxygen requirement shortly after her initital percutaneous biliary catheter was placed. A CTA was negative for PE, but showed marked emphysema. She was maintained on 2 liters NC oxygen over the subsequent days. On the day following placement of her metal biliary stent on [**2183-10-20**], the patient became acutely more confused with an increasing oxygen requirement. A head CT without contrast was negative for an acute process. ABG showed marked hypercarbia. THe patient was tranferred for 1 day to the ICU for management for hypoxia and hypercapnea. Her hypoxia was likely due COPD, narcotics, and volume overload from IVF and resolved with IV Lasix. Signs of mild delirium waxed and waned. She was transferred out of the ICU on [**2183-10-22**] satting in the low 90's on room air (her baseline, given her COPD). She had another episode of hypercapneic respiratory failure [**2183-11-4**], which resolved with naloxone. Narcotic analgesia and benzodiazepines were entirely stopped. # Upper GI bleeding: The patient passed a large melenic, guaiac + stool on [**2183-10-23**] with a drop in her hematocrit for which she was transfused 1 unit PRBSs on [**2183-10-24**]. The patient's prophylactic heparin was discontinued at this time. The etiology was felt to be her known necrosing duodenal tumor mass and discussions with the GI consult service and her covering primary oncologist felt that there was no role for endoscopic intervention. Radiation oncology consult was obtained to consider several fractions of radiation to the duodenal tumor mass in an effort to slow her blood loss. After consideration of the risks and benefits, the patient and her family decided to forgo radiation. She continued to be intermittanting guaiac positive, most recently on [**2183-10-31**] after started tube feeding. # Small bowel obstruction: On [**2183-10-25**] the patient developed acute nausea and vomiting. Plain film of the abdomen revealed multiple air fluid levels consistant with a small bowel obstruction and thought to be secondary to the patient's known tumor mass. A nasogastric tube was placed for decompression with good relief of the patient's symptoms. On [**2183-10-29**] a venting gastrojejunostomy tube was placed without complication and the patient's nasogastric tube was removed the following day. Tube feeding through the J tube was begun at a rate of 20cc per hour at 1/2 strength on [**2183-10-30**]. Late on the evening of [**2183-10-31**], the patient developed abdominal distension and right upper quadrant pain, a repeat abdominal film again showed multiple air fluid levels consistant with small bowel obstruction despite little output from when the patient's venting G tube was placed to suction. Surgery informed the patient that she is not an operative candidate. Her symptoms improved, but repeat KUB showed worsening SBO. Tube feeds remain off and the patient and family have opted against TPN, but instead they would like her to continue with IV fluids. # Hypotension/tachycardia/acute renal failure: On [**2183-10-26**] the patient became hypotensive, tachycardic, and less responsive with an elevated BUN/creatanine of 30/1.2. A foley catheter was placed and the patient responded to gentle IV hydration at 75cc/hr with return to her baseline mental status in 24 hours and normalizing of her BUN/creatanine to 13/0.5 over ensuing days. Her fluid status has been difficult to manage given her poor nutrition, small bowel obstruction with nasogastric drainage, and propensity for congestive heart failure prior to her intensive care unit transfer. # HTN: The patient had not been taking BP meds for the week prior to admission and was normotensive, so BP meds were held. # Code status: After the most recent episode of respiratory failure, she and her family agree to DNR/DNI. She understands her disease is terminal and she is very sick with many life-threatening conditions and a high chance of never improving. She is still hoping for rehab, but understands that palliative care is appropriate if she does not improve soon. Medications on Admission: fexofenadine 180 mg daily-has not been taking last five days and asymptomatic lisinopril-hydrochlorthiazide 20-25- has not been taking last 5 days. prochlorperazine - took on edose this am. Discharge Medications: 1. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: One (1) mL Injection Q12H (every 12 hours). 2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) Solution PO QID (4 times a day) as needed for pain. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 6. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed for nausea. 7. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day) as needed for Nausea. 8. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 10. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for constipation. 11. Cepacol 4.5 mg Lozenge Sig: One (1) Mucous membrane every eight (8) hours as needed for sore throat. 12. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: 75mL/hr Intravenous continuous: With D5W = D5NS. Continue unless other nutrition (tube feeds or PO) is started or short of breath or hypoxic. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: 1. Obstructive jaundice. 2. Metastatic Colon CA to biliary tree, portal vein, liver, and lung. 3. COPD and respiratory failure. 4. Upper GI bleeding. 5. Small bowel obstruction. 6. Acute Renal Failure. 7. Malnutrition. Discharge Condition: Mental Status: Confused - sometimes. Activity Status: Bedbound. Level of Consciousness: Lethargic but arousable. Discharge Instructions: You were admitted with jaundice caused by bile duct obstruction from tumor to the abdomen. Biopsy of the tumor revealed recurrent metastatic colon cancer. This is also involving the lung. To relieve the bile duct obstruction, you underwent percutaneous catheter drainage of the biliary tree, after unsuccessful ERCP attempt. The surgeons reviewed your case and felt that introduction of metal stents via the percutaneous catheter was the best initial method to maintain patency of the blocked biliary ducts. This was done and has worked successfully. However, you developed a small bowel obstruction. A feeding tube was placed, but we have not been able to use it because of the obstruction. Nutrition has been limited to only intravenous fluids. You also had two episodes of respiratory failure due to a combination of narcotic pain medicine overlying poor respiratory condition from emphysema. Bleeding from your upper gastrointestinal tract thought to be due to the tumor invading your duodenum and requiring blood transfusion. Acute renal failure and unresponsiveness in the setting of the small bowel obstruction due to hypovolemic shock was treated with fluids by IV. Followup Instructions: Dr. [**Last Name (STitle) **] after rehab.

[ "560.9", "401.9", "197.7", "518.81", "348.30", "584.9", "576.2", "578.1", "285.1", "V10.09", "197.8" ]

icd9cm

[ [ [] ] ]

[ "45.16", "87.51", "51.98", "44.32" ]

icd9pcs

[ [ [] ] ]

20861, 20932

13105, 19209

326, 504

21195, 21195

3099, 13082

22541, 22587

2273, 2436

19449, 20838

20953, 21174

19235, 19426

21334, 22518

2451, 3080

277, 288

532, 1785

21210, 21310

1807, 1967

1983, 2257

28,075

197,751

46656

Discharge summary

report

Admission Date: [**2196-3-11**] Discharge Date: [**2196-4-26**] Date of Birth: [**2118-9-27**] Sex: F Service: CARDIOTHORACIC Allergies: Percocet / Darvocet-N 50 Attending:[**First Name3 (LF) 165**] Chief Complaint: SOB/recurrent ascites Major Surgical or Invasive Procedure: [**2196-3-14**] redo sternotomy/TVR(33mm St. [**Male First Name (un) 923**] porcine)/aortic exploration [**2196-3-29**] Left VATS [**2196-4-1**] trach/open G- tube placement [**2196-4-15**] tunneled HD catheter placement History of Present Illness: 77 yo female with extensive PMH including CABG in [**2192**]. Originally seen in [**12-15**] when she had right heart failure/ascites and was admitted to hospital directly from clinic with Dr. [**Last Name (STitle) 1290**]. Had a lead extraction at that time with Dr. [**Last Name (STitle) 914**] with hope that TR would resolve if lead was removed. Echo [**2-13**] still showed severe TR. Seen again on [**2-29**] with Dr. [**First Name (STitle) **] with last paracentesis done approx. 2 weeks ago prior to PAT. Had treatment for vertigo earlier in [**Month (only) 958**]. Admitted now for pre-op workup. Past Medical History: Tricuspid Regurgitation Anemia HTN Hyperlipidemia CAD s/p NSTEMI [**2190**] CABG x3 [**3-12**] PTCA x2 A fib Sick Sinus Syndrome s/p pacer [**2-11**] Lead extraction [**12-15**] Neuropathy Diverticulits Glaucoma PVD s/p Fem. Art stent [**2193**] ?COPD Gout CKD (Baseline 1.7) GERD Social History: Retired. 30 pack-year hx of tobacco, quit 15 years ago. Rare social EtOH, no illicits. Lives with her daughter Family History: Mother's Sister died of MI at age 52. Physical Exam: 127 # 57.7 kg 96.8 HR 71 RR 18 156/48 ( by exam [**2-29**]): generally SOB PERLA, EOMI, anicteric, OP unremarkable neck supple, + JVD CTA right; basilar rales on left RRR 3/6 murmur heard best at RUSB severely distended abdomen extrems warm, well-perfused, 1+ LLE edema, well-healed LLE EVH site no varicosities noted nonfocal neuro exam 2+ bil. fems 1+ bil. DPs NP bil. PTs murmur radiates to both carotids; ?left Physical Exam prior to Discharge vs: 98.4/97, 85 ap, 93/41, rr-22 GENERAL: WITHDRAWN,NO-MIN. LEFT SIDED MOVEMENT Lungs: CTA CVS: RRR ABD:soft, +BS, ABD inc. C/D/I, + drainage around PEG site EXT: warm, 0 C/C/E Pertinent Results: RADIOLOGY Final Report CT CHEST W/O CONTRAST [**2196-3-28**] 8:20 PM CT CHEST W/O CONTRAST Reason: ? effusion and ? loculated LUL vs infiltrates with low grade [**Hospital 93**] MEDICAL CONDITION: 77 year old woman with s/p tvr REASON FOR THIS EXAMINATION: ? effusion and ? loculated LUL vs infiltrates with low grade fevers CONTRAINDICATIONS for IV CONTRAST: Renal failure PROCEDURE: CT chest without contrast on [**2196-3-28**]. COMPARISON: [**2196-3-15**] and multiple previous chest radiographs in between. TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to the subdiaphragmatic area without contrast. Thinner slice 5 mm and 1.25 mm images were reconstructed in the axial plane at different window algorithms. Sagittal/coronal reformatted images were also obtained for further evaluation. HISTORY: 77-year-old woman with status post TVR questionable loculated left upper lobe collection versus infiltrate. FINDINGS: An endotracheal tube ends 4.5 cm from the carina, a feeding tube terminates in the stomach, a left transsubclavian PICC line in the left subclavian vein, and a single lead from a left pacemaker in the right atrium close to the tricuspid valve. Four previous chest drainage catheters approaching from the right subxiphoid location have been removed. Expansion of the left lung has improved with a decrease in the basal component of left pleural effusion/hemothorax. However, along the left lateral costal surface is a persistent high attenuation pleural or extrapleural collection now containing air as well as fluid. Another relatively high-density (50 [**Doctor Last Name **]) collection centered in the anterior mediastinum where the chest tubes previously coursed has enlarged, now 9cm across and at the site of previous chest tube entry is a smaller (3cm) loculated hematoma (2:48). Right pleural effusion is smaller, and atelectasis has improved minimally. The aerated portions of both lungs are unremarkable. Although this study is a non-contrast examination yet, there is an aortic dissection denoted inward displacement of the intimal calcification extending from the aortic arch into the descending thoracic and abdominal aorta. Transverse diameter of the descending aorta, 2.5 cm, (2:54) is unchanged from the prior examination. The bony structures do not show any lesions suspicious for malignancy and/or infection. The limited evaluation of the abdomen shows a decreased ascites. IMPRESSION: 1. Enlarging retrosternal/mediastinal hematoma. Stable to slightly increased, loculated left pleural or extrapleural collection; new gaseous contents presumably due to chest tube manipulation. 2. Decreased left basal pleural effusion and/or hemothorax and right basal pleural effusion with better re-expansion of the left lung than the right. 3. Chronic thoraco-abdominal aortic dissection. 4. Decreased abdominal ascites. 5. Transsubclavian left PICC line ends in the left subclavian vein. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 11004**] [**Name (STitle) 11005**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: WED [**2196-3-30**] 1:33 PM CT HEAD W/O CONTRAST [**2196-3-18**] 2:35 PM CT HEAD W/O CONTRAST Reason: assess for cva/bleed [**Hospital 93**] MEDICAL CONDITION: 77 year old woman s/p tvr REASON FOR THIS EXAMINATION: assess for cva/bleed CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Status post TVR with change in mental status. Please evaluate for stroke or hemorrhage. COMPARISON: Non-contrast head CT of [**2196-3-15**]. FINDINGS: There has been interval development of hypodensity in the right cerebral hemisphere involving primarily the right parietal lobe and right occipital lobe extending to the cortex. These findings are consistent with a subacute embolic infarction. There is no evidence of hemorrhage, mass effect, shift of normally midline structures, or hydrocephalus. Periventricular white matter hypodensity is consistent with chronic microvascular ischemic changes. The surrounding osseous structures are unremarkable. The imaged paranasal sinuses are well aerated. IMPRESSION: Evolving subacute infarction in the right cerebral hemisphere, which given its distribution is most likely secondary to embolus. At the time of dictation, these findings were discussed with the cardiovascular team caring for the patient. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5998**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**] Approved: FRI [**2196-3-18**] 10:56 PM Conclusions PRE-BYPASS: 1. The left atrium is markedly dilated. No thrombus is seen in the left atrial appendage. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. 4. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. 7. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. The septal leaflet is restricted and does not coapt with the anterior leaflet. The tricuspid regurgitation jet is eccentric and may be underestimated. There is mild pulmonary artery systolic hypertension. 8.There is a trivial/physiologic pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions. 1. There is a dissection flap seen in the distal aortic arch. There is a large false lumen with minimal flow. 2. A tricuspid prosthetic valve is seen, well seated, leaflets open well. The mean tricuspid valve gradient is 6 mmof Hg. 3. RV function is severely depressed. LV function is unchanged. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD, Interpreting physician [**Last Name (NamePattern4) **] [**2196-3-30**] 15:26 Brief Hospital Course: Admitted [**3-11**] for pre-op workup. Seen by hepatology service for eval. of ascites and US tap done on [**3-13**]. Underwent Tricuspid valve replacement surgery with Dr. [**First Name (STitle) **] on [**3-14**] and Type B aortic dissection found on opening (please refer to operative note). Transferred to the CVICU in fair condition on milrinone, levophed, epinephrine, vasopressin, and propofol drips. Left chest tube placed for effusion as well as a new arterial line on POD #1. Bronchoscopy also done POD #1 with clot noted in left mainstem bronchus. Seen by liver team with shock liver most likely and paracentesis performed. Dialysis access placed [**3-15**]. Keppra started for ? seizures after neuro consult. Renal consult done. Head CT done with mutiple infarcts noted. Posterior-lateral MI noted by EKG. EP team interrogated pacer. HIT negative. All sedation stopped for full neuro evaluation. Pacing wires removed POD #4. Repeat head CT done after she failed to awaken. This showed a right occipital/parietal embolic infarcts. Pressors slowly weaned off. Sub Q heparin started on POD #7 for prophylaxis. Lines changed on POD #9 with tips sent for culture due to rising WBC and fever.A fib treated with amiodarone. Diuresis continued as well as transfusions intermittently. New HD catheter placed.Flagyl started empirically while C diff testing done. ID consult also done.Left VATS done by thoracic surgery on [**3-29**] with 2 new chest tubes placed.Aspergillus noted in empyema.Voriconazole started.Cipro started for UTI on POD #15. New triple lumen subclavian line placed POD #16. FFP given [**3-30**] for INR 1.9 as well as vitamin K in preparation for trach/PEG. Trach and open G-tube done [**4-1**]. Continued to require neosynephrine for support and intermittent HD as needed. U/S guided right thoracentesis done for approx. 900 cc on [**4-7**]. Weaned to trach collar on [**4-7**]. She had asystole on [**4-8**] while attempts were made to place a Passy-Muir valve, with probable mucous plugging. CPR was performed for 4-5 min with ACLS protocol. She then resumed a BP and generated a pulse after suctioning. Left apical chest tube removed per thoracic on [**4-9**]. Basilar tube remained in place for continuing output. Persistent leukocytosis prevented her from getting a tunneled catheter needed for continued HD. Carotid US done [**4-12**] did not show any significant stenoses. Midodrine started. WBC remained elevated with serratia PNA and cefepime continued. Tunneled HD catheter placed with interventional radiology on [**4-15**] (POD #32) The remainder of her hospital course was essentially uneventful. Hemodialysis continued for her ischemic ATN, renal following. ID followed with recommendations for ABX due to Apergillous in the left pleural clot, and leukocytosis. Midodrine was optimized and the Neo was ultimately weaned to off. [**4-21**] Thoracic evaluated the PEG site and changed PEG to a foley cath, tube feeds continue at goal. [**4-22**] After Hemodialysis was completed Mrs [**Known lastname 99058**] was felt to be stable and ready to transfer to rehab for further increase in strength and activity, as well as ventilator weaning. Cleared for discharge to rehab on POD #44. Please note all followup appts. needed for pt. Weekly labs needed are noted in the discharge instructions with results to be called/faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (Infect.Dis). Medications on Admission: tricor 72.5 mg daily pravachol 40 mg daily ASA 325 mg daily lasix 40 mg daily lopressor 25 mg TID nifedipine 60 mg daily MVI daily prilosec 20 mg daily trental 400 mg [**Hospital1 **] allopurinol 300 mg daily spironolactone 25 mg [**Hospital1 **] timolol 0.25% one gtt OU [**Hospital1 **] latanoprost 0.005% one gtt right eye QHS procrit weekly Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 3. Pravastatin 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime). 4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**12-9**] Drops Ophthalmic PRN (as needed). 5. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 6. Miconazole Nitrate 2 % Powder [**Month/Day (2) **]: One (1) Appl Topical TID (3 times a day). 7. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1) Injection [**Hospital1 **] (2 times a day). 8. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 6-8 Puffs Inhalation Q4H (every 4 hours) as needed. 9. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff Inhalation Q4H (every 4 hours). 10. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1) Injection ASDIR (AS DIRECTED). 11. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at bedtime) as needed for glaucoma. 12. Timolol Maleate 0.25 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day) as needed for glaucoma. 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 14. Levetiracetam 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QAM (once a day (in the morning)). 15. Levetiracetam 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QPM (once a day (in the evening)). 16. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily). 17. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID (4 times a day). 18. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 19. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension [**Last Name (STitle) **]: One (1) PO TID (3 times a day). 20. Magnesium Sulfate 2 gm / 50 ml SW IV PRN mg <2.0 21. Calcium Gluconate 2 gm / 100 ml D5W IV PRN Free Cal <1.12 to run over 1 hr. 22. Dextrose 50% 12.5 gm IV PRN glucose < 60 Recheck glucose q 30 minutes until glucose > 100 23. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 24. Heparin Flush (5000 Units/mL) 4000-[**Numeric Identifier 2249**] UNIT IV 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. 25. Vancomycin 500 mg IV HD PROTOCOL until [**5-1**] 26. Voriconazole 200 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q12H (every 12 hours). 27. Midodrine 5 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO QID (4 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Tricuspid Regurgitation s/p redo sternotomy/TVR/aortic exploration Anemia HTN Hyperlipidemia CAD s/p NSTEMI [**2190**] CABG x3 [**3-12**] PTCA x2 A fib Sick Sinus Syndrome s/p pacer [**2-11**] Lead extraction [**12-15**] Neuropathy Diverticulits Glaucoma PVD s/p Fem. Art stent [**2193**] ?COPD Gout CKD (Baseline 1.7) GERD acute renal failure CVA MI PNA Discharge Condition: stable Discharge Instructions: call for fever greater than 100.5, redness or new drainage no lotions, creams or powders on any incision no lifting greater than 10 pounds for another month LABS weekly: CBC, LFTs, Beta-D glucan, galactomanins to be called to: Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 457**] Infectious Disease Alternatively, fax # [**Telephone/Fax (1) 432**] Followup Instructions: see Dr. [**Last Name (STitle) **] in [**12-9**] weeks after discharge from rehab see Dr. [**Last Name (STitle) **] in [**1-10**] weeks after discharge from rehab see Dr. [**First Name (STitle) **] in 4 weeks after discharge from rehab [**Telephone/Fax (1) 170**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2196-4-26**]

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icd9cm

[ [ [] ] ]

[ "38.04", "54.91", "38.95", "39.61", "34.91", "31.1", "35.27", "43.19", "39.95", "34.52", "96.05", "88.72", "96.6" ]

icd9pcs

[ [ [] ] ]

15683, 15765

8875, 12322

312, 535

16164, 16173

2336, 2498

16614, 16999

1620, 1660

12717, 15660

5684, 5710

15786, 16143

12348, 12694

16197, 16591

1675, 2317

251, 274

5739, 8852

563, 1170

1192, 1475

1491, 1604

31,810

172,623

9092

Discharge summary

report

Admission Date: [**2110-7-23**] Discharge Date: [**2110-7-26**] Date of Birth: [**2071-9-18**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 1990**] Chief Complaint: please note: this is CC for ICU care (patient surgical admission does not appear to have been documented) failed extubation s/p ERCP Major Surgical or Invasive Procedure: ERCP History of Present Illness: This is a 38yo morbidly obese female with a past medical history of asthma, sarcoidosis, hypertension and a question of diastolic dysfunction causing congestive heart failure who was admitted to the [**Hospital Unit Name 153**] emergently following an ERCP that required an unplanned intubation. . On [**7-22**], patient presented to the ED with RUQ pain, nausea and vomiting. A RUQ U/S showed cholelithiasis without evidence of cholecystitis. Patient was noted to have a mild transaminitis and was admitted to the general surgery service for observation. General surgery note from [**7-24**] states that plan for patient was D/C if LFTs trending down v. ERCP if trending up. All liver function labs from [**7-24**] trending down, however, patient transferred East for ERCP. Patient also planned for cholecystectomy following completion of ERCP in [**11-20**] days. . This afternoon, the patient was transferred East for ERCP. She received ~1.5 L fluids peri-procedure and was ~3L positive yesterday. Initially conscious sedation was attempted, however, patient's sats dropped to the mid-80s when adequate sedation was attained. There was a concern that the patient may have aspirated during the procedure. It was noted that she had abundant frothy white secretions as well. Per report, she was difficult to sedate requiring 2mg midazolam, 120mg succ, 250mcg fentanyl, and ~1g propofol. Per anesthesia, she was given nebs thru her tube during the procedure. A biliary sphincterotomy was performed with minimal sludge noted. Pt received one dose of ampicillin with procedure. Past Medical History: Sarcoidosis Asthma Hypertension H/O CHF [**12-21**] diastolic dysfunction in setting of HTN EF > 60% Social History: She works at [**Hospital1 18**] in the department of medicine. She lives at home with her husband and three children. She denied use of tobacco, alcohol, or illicit drugs. Family History: Notable for mother with hypertension. No known history of neurologic disease. Physical Exam: General - intubated, sedated, in NAD. Cards - RRR, nl s1/s2, no murmurs Pulm - intubated, anterior ausultation, clear on limited exam Abdomen - obese, hypoactive bowel sounds, soft, non-distended Extremities - WWP, 2+ radial pulses, no c/c/e Pertinent Results: [**2110-7-23**] 01:20AM BLOOD WBC-6.1 RBC-4.89 Hgb-13.0 Hct-39.5 MCV-81* MCH-26.6* MCHC-32.9 RDW-14.1 Plt Ct-294 [**2110-7-23**] 01:20AM BLOOD Neuts-78.8* Lymphs-16.9* Monos-3.6 Eos-0.5 Baso-0.2 [**2110-7-23**] 01:20AM BLOOD Plt Ct-294 [**2110-7-24**] 06:45AM BLOOD PT-13.6* PTT-29.8 INR(PT)-1.2* [**2110-7-23**] 01:20AM BLOOD Glucose-120* UreaN-7 Creat-0.7 Na-140 K-3.4 Cl-106 HCO3-25 AnGap-12 [**2110-7-23**] 01:20AM BLOOD ALT-323* AST-137* AlkPhos-175* TotBili-0.7 [**2110-7-26**] 05:50AM BLOOD ALT-84* AST-15 LD(LDH)-138 AlkPhos-114 Amylase-33 TotBili-0.7 [**2110-7-23**] 01:20AM BLOOD Lipase-31 [**2110-7-23**] 06:40AM BLOOD Lipase-123* [**2110-7-26**] 05:50AM BLOOD Lipase-16 [**2110-7-23**] 06:40AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.9 [**2110-7-25**] 05:18AM BLOOD TSH-2.1 [**2110-7-23**] 01:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2110-7-24**] 11:41PM BLOOD Type-ART Temp-37.0 Rates-/15 Tidal V-500 PEEP-5 FiO2-40 pO2-109* pCO2-63* pH-7.28* calTCO2-31* Base XS-0 -ASSIST/CON Intubat-INTUBATED [**2110-7-24**] 11:41PM BLOOD Lactate-1.2 [**2110-7-23**] 02:45AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-SM Urobiln-0.2 pH-6.5 Leuks-NEG [**2110-7-23**] 02:45AM URINE RBC-[**1-22**]* WBC-[**4-29**]* Bacteri-MANY Yeast-NONE Epi-[**10-9**] RUQ ultrasound - Cholelithiasis without evidence of cholecystitis. EKG - Sinus bradycardia with sinus arrhythmia. Normal ECG except for rate Since previous tracing of [**2109-10-4**], heart rate slower chest x-ray - ET tube is in standard position projecting 3.8 cm above the carina Brief Hospital Course: * note - this d.c summary represents care on the pulmonary and then general medical services. For information on her hospital course prior to her transfer to the ICU, please contact Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**]. 38F with asthma, sarcoidosis and obesity who required intubation during ERCP and was transferred to the ICU for failed extubation. History of hospitalization from time of admission to the ICU stay is unclear, as there is no written surgical history and patient was admitted initially to the surgical service. . ERCP was done including sphincterotomy after baloon extraction of sludge, no stones. . Respiratory Failure - Patient was admitted to the unit after ERCP as she was difficult to sedate with desats during a ERCP requiring intubation. Concern that patient may have aspirated during the procedure vs volume overload as patient has been several liters positive over last 24-48 hours and has uncertain history of CHF [**12-21**] diastolic dysfunction. Could also be due to fact that patient required a large amount of sedation to overcome gag reflex. Patient was weaned from AC to PS overnight and then sedation was weaned and patient was extubated without complication and did not experience recurrent respiratory difficulties throughout the hospiatlization. . Transaminitis - LFTs on ICU admission were elevated, began to trend down, patient is s/p ERCP with sphincterotomy [**7-24**]. Pt was on general surgery service, attending [**First Name8 (NamePattern2) **] [**Name8 (MD) 468**], MD. Was planned for cholecystectomy in next 1-3 days following ERCP. As per general surgery plan to discharge from ICU to medical team and then would follow up with plan for cholecystectomy in the future. unclear what final plan was as patient was discharged from hospitalist service. On arrival to the Hospitalist service, the patient was noted to be afebrile, tolerating regular diet, denying abdominal pain, and transaminitis was resolving on serum assays. Pt. was sent home after conferring with surgery who recommended outpatient follow up for evaluation for lap chole in the future. Medications on Admission: Keflex Pseudoephedrine Loratadine Pulmicort 2 puffs [**Hospital1 **] Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 doses. Disp:*2 Tablet(s)* Refills:*0* Pseudoephedrine Loratadine Pulmicort Discharge Disposition: Home Discharge Diagnosis: symptomatic cholelithiasis s/p sphincterotomy c/b respiratory failure requiring intubation Discharge Condition: stable, afebrile, ambulatory, tolerating regular diet, no complaints, moving bowel and bladder without diffculties. Discharge Instructions: Do not take any aspirin or ibuprofen for a week. Return to the [**Hospital1 18**] emergency department for: bleeding in the bowel movements, abdominal pain, nausea, vomiting, fever. Followup Instructions: With Dr. [**Last Name (STitle) 31379**] in 3 weeks - call for appointment: ([**Telephone/Fax (1) 27734**].

[ "428.32", "574.20", "599.0", "401.9", "518.81", "135", "E878.8", "428.0", "493.90", "278.00" ]

icd9cm

[ [ [] ] ]

[ "96.04", "51.85", "96.71" ]

icd9pcs

[ [ [] ] ]

6751, 6757

4317, 6450

401, 407

6892, 7010

2697, 4294

7241, 7351

2341, 2420

6569, 6728

6778, 6871

6476, 6546

7034, 7218

2435, 2678

229, 363

435, 2011

2033, 2135

2151, 2325

48,830

185,833

13114

Discharge summary

report

Admission Date: [**2144-6-22**] Discharge Date: [**2144-6-29**] Date of Birth: [**2070-10-16**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea/Diminished exercise tolerance Major Surgical or Invasive Procedure: [**2144-6-22**] Coronary artery bypass graft x 4 Left internal mammary artery grafted to left anterior descending artery/ saphenous vein grafted to ramus intermedius/ PLV History of Present Illness: This is a 73 year old male who has noted gradual decline in exercise tolerance in the setting of hypertension, hyperlipidemia and bradycardia. He complains of dyspnea with moderate exertion and first nted these symptoms with playing tennis. His dyspnea improves with rest. He denies chest pain, palpitations, lightheadedness, syncope, orthopnea, PND and pedal edema. He continues to exercise on a regular basis. A stress echo was performed which was normal however a cardiac CT scan showed his calcium score to be very high at 3962. He was subsequently sent for a cardiac catheterization which revealed severe three vessel disease. Given the severity of his disease, he was referred for surgical management. Past Medical History: Hypertensin Dyslipidemia First Degree AV Block with Bradycardia Prostate Cancer Prostatectomy Spine Surgery Hernia Repair Right rotator cuff repair Bilateral Inguinal hernia repair Deviated Septum Repair Social History: Race: Caucasian Last Dental Exam: Every 6 months0 Lives with: Wife Contact: Phone # Occupation: Retired, engineering/construction Cigarettes: Denies ETOH: Social Illicit drug use: Denies Family History: Mother sudden death at age 53. Father died at age 89. Has 3 brothers, 2 sisters - one sibling diagnosed with CAD. Physical Exam: Vital Signs sheet entries for [**2144-6-3**]: BP: (L) 130/78. (R) 134/80 Heart Rate: 70. Resp. Rate: 16. Pain Score: 0. O2 Saturation%: 99. Height: 65" Weight: 163 General: WDWN in NAD Skin: Warm, Dry and intact. HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Teeth in good repair. Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR, No M/R/G Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds +[X] Extremities: Warm [X], well-perfused [X] No edema Varicosities: Rith thigh and lower leg with superficial varicosities. Left leg appears suitable. Neuro: Grossly intact [X] Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [**Name (NI) 167**]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit None Pertinent Results: [**2144-6-22**] Echo: PRE_BYPASS The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. 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 root is mildly dilated at the sinus level. There are complex (>4mm) atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST-BYPASS The patient is AV paced. There is normal biventricular systolic function. The mitral regurgitation was initially somewhat worse after separation from bypass (mild to moderate) but decreased back to mild later on. The rest of valvular function was unchanged. The thoracic aorta was intact after decannulation. [**2144-6-29**] 04:57AM BLOOD WBC-12.5* RBC-3.80* Hgb-11.0* Hct-33.5* MCV-88 MCH-28.8 MCHC-32.7 RDW-13.4 Plt Ct-272 [**2144-6-22**] 02:12PM BLOOD WBC-13.6*# RBC-3.50*# Hgb-10.0*# Hct-30.6*# MCV-87 MCH-28.7 MCHC-32.9 RDW-12.9 Plt Ct-148* [**2144-6-29**] 04:57AM BLOOD PT-12.3 INR(PT)-1.1 [**2144-6-22**] 02:12PM BLOOD PT-16.9* PTT-27.0 INR(PT)-1.6* [**2144-6-29**] 04:57AM BLOOD Glucose-93 UreaN-21* Creat-1.0 Na-138 K-4.1 Cl-104 HCO3-27 AnGap-11 [**2144-6-22**] 03:30PM BLOOD UreaN-17 Creat-0.8 Na-143 K-3.5 Cl-110* HCO3-23 AnGap-14 [**2144-6-24**] 04:29AM BLOOD ALT-13 AST-46* LD(LDH)-226 AlkPhos-79 Amylase-51 TotBili-0.6 Brief Hospital Course: Mr. [**Known lastname 40046**] was a same day admit and brought directly to the operating room where he underwent a coronary artery bypass graft x 4 (Left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the posterior left ventricular branch, ramus intermedius, diagonal branch) with Dr.[**Last Name (STitle) **]. Please see operative note 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, Statin, aspirin, and diuresis was initiated. Post-operatively he developed an ileus, which resolved with an aggresive bowel regimen. POD#1 He was transferred to the surgical step down floor for further monitoring. His chest tubes and wires were removed. Physical therapy was consulted for evaluation of strength and mobility. Mr.[**Known lastname 40046**] had failure to void x 2. The foley catheter was reinserted and urology was consulted. He had some postoperative hypoxia that improved with diuresis and increased ambulation. POD#6 he had a brief episode of postoperative atrial fibrillation that resolved with beta-blocker and electrolyte replacement. No further episodes occurred. By post-operative day #7 he was ready for discharge to home with a leg bag and VNA services. Appropriate follow-up appointments were advised. Medications on Admission: Norvasc 5mg daily Aspirin 81mg daily Renexa 500mg twice daily Lipitor 80mg daily Fish Oil 1000mg twice daily MVI Glucosamine Aleve 220mg QHS Discharge Medications: 1. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*80 Tablet(s)* Refills:*2* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. 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* 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*60 Capsule, Ext Release 24 hr(s)* Refills:*2* 9. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 11. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day for 10 days. Disp:*10 Capsule, Extended Release(s)* Refills:*0* 12. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Corornary artery disease s/p Coronary artery bypass graft x 4 Past medical history: Hypertensin Dyslipidemia First Degree AV Block with Bradycardia Prostate Cancer Prostatectomy Spine Surgery Hernia Repair Right rotator cuff repair Bilateral Inguinal hernia repair Deviated Septum Repair 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 trace 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) **] [**2144-8-5**] at 1:00p Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2912**] [**2144-7-16**] at 1:45 Wound Check [**2144-7-7**] at 10:30a Please follow up with Urology for urinary retention Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 3100**] in [**4-23**] 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:[**2144-6-29**]

[ "414.01", "560.1", "427.31", "427.89", "272.4", "458.29", "287.49", "401.9", "285.9", "788.29", "V10.46" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7850, 7905

4733, 6169

349, 521

8236, 8468

2673, 4710

9391, 10056

1726, 1841

6360, 7827

7926, 7988

6195, 6337

8492, 9368

1856, 2654

272, 311

549, 1258

8010, 8215

1501, 1710

72,545

123,167

8390+55938+55939

Discharge summary

report+addendum+addendum

Admission Date: [**2176-8-22**] Discharge Date: [**2176-9-6**] Service: VSU CHIEF COMPLAINT: Left hallux infection and left foot pain. HISTORY OF PRESENT ILLNESS: This is an 82 year-old gentleman who presented to our emergency room with a left hallux infection. The patient was sent to us by his podiatrist to be admitted to the vascular surgery for evaluation. The patient's toe changes are secondary to nail clipping which resulted in gangrenous changes which have progressed over the last two to three months. PAST MEDICAL HISTORY: Illnesses include type 2 diabetes with retinopathy, nephropathy and neuropathy. History of hypertension. History of paroxysmal atrial fibrillation. History of congestive heart failure with ejection fraction of 45%. History of coronary artery disease, status post coronary artery bypass graft in [**2169**]. History of chronic renal insufficiency. History of cataracts. History of glaucoma. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Include Lipitor 10 mg q.d., lisinopril/hydrochlorothiazide 20/25 tablet q.d., aspirin 325 mg q.d., Avandia 4 mg q.d., Glucophage 500 mg b.i.d., Lasix 20 mg q Monday and Friday, Toprol XL 25 mg q.d., Procardia XL 30 mg q.d., insulin 70-30 units 25 units q.A.M. and 10 units q dinner. PAST SURGICAL HISTORY: Cholecystectomy. SOCIAL HISTORY: Patient is married, is Russian speaking. Denies alcohol or smoking. PHYSICAL EXAMINATION: Vital signs: 97.5, 60, 20, blood pressure 114/50, O2 saturation 98% on room air. General appearance: An elderly male in no acute distress. Head, eyes, ears, nose and throat examination is unremarkable. Lungs are clear to auscultation bilaterally. Heart is a regular rate and rhythm without rub, rub or gallop. Abdominal examination is unremarkable. Extremity examination shows warm extremities with two dry gangrenous lesions on the left hallux without erythema or drainage. Neurologic examination is intact, nonfocal, oriented x3. Pulse examination shows palpable femorals bilaterally, Dopplerable popliteal artery pulses bilaterally. The dorsalis pedis on the left is monophasic with a biphasic posterior tibial signal. On the right the dorsalis pedis and posterior tibial are monophasic signals only. HOSPITAL COURSE: The patient was initially evaluated in the emergency room. His white count was 9.2, hematocrit 35.3, BUN 46, creatinine 1.4. Chest x-ray was obtained which was negative for congestive heart failure and pneumonia. Electrocardiogram was a sinus rhythm bradycardic. No wound culture was obtained at the time of the patient's assessment in the emergency room but urine cultures and blood cultures were obtained which finalized at no growth. The vascular service was consulted and the patient was admitted to the vascular service for continued care. Patient underwent pulmonary vascular resistances of the left extremity which showed forefoot pressures of 7 mm. He then underwent an arteriogram on [**2176-8-22**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] which demonstrated the abdominal aorta was patent with single renal arteries which were patent and duplicate and patent renal arteries on the left. The right lower extremity had a patent common iliac, internal and external iliac arteries. The left lower extremity showed patent common iliac internal and external arteries. There was a patent common femoral, profunda and superficial femoral artery. There was mild distal disease in the superficial femoral artery. The popliteal was patent. Anterior tibial occludes proximally. The posterior tibial occludes in mid calf. The perineal has proximal stenosis but runs off to the ankle and reconstitutes a plantar in the foot. The patient tolerated the arteriogram. His post BUN and creatinine remained stable. He was given a bicarb Mucomyst protocol pre- and post angiogram. Cardiology was consulted regarding the patient's perioperative risk assessment for anticipated left leg revascularization. An echocardiogram was obtained which showed left atrium normal size. The right atrium was moderately dilated. Left ventricular wall thickness was normal. The ventricular cavity size was normal. The overall left ventricular systolic function is mildly depressed. There were resting regional wall motion abnormalities including inferolateral hypokinesis with distal septal, distal inferior and apical akinesis. The right ventricle chamber size was normal and systolic function was normal. The mitral valve leaflet was a mild thickness with 1+ mitral regurgitation. There was mild pulmonary systolic hypertension. Compared with previous echocardiogram done [**2174-6-1**] there was no change. Patient's calculated ejection fraction was 40 to 45%. The patient underwent a stress test. The initial portion of stress showed no anginal symptoms or ischemic electrocardiographic changes. The resting and stress perfusion images demonstrated moderate reversible perfusion defect in the anterior wall and apex that is more prominent when compared to [**2174-11-21**]. Gated imaging revealed normal wall motion and the calculated ejection fraction is 49%. Cardiology assessed the patient as intermediate clinical risk markers for surgery. They felt that there was no further cardiac evaluation indicated at this time. Recommendations were to continue current medical management. The patient's diabetic management was under the care of the [**Last Name (un) **] Service during his hospitalization. He was able to be maintained on his pre-admission insulin dosing with minimal correction. The patient underwent on [**2176-8-29**] a left popliteal to peroneal bypass with nonreversed saphenous vein graft angioscopy. Patient tolerated the procedure well and was transferred to the post anesthesia care unit in stable condition. The patient had a monophasic dorsalis pedis and a biphasic posterior tibial and a warm foot post procedure. Patient continued to do well and was transferred to the Vascular Intensive Care Unit for continued monitoring and care. Postoperative day #1 there were no overnight events. The patient remained on bed rest and ambulation was begun on postoperative day #2. He was continued on perioperative antibiotics of Vancomycin, Levofloxacin and Flagyl. Postoperative enzymes were negative. Patient's heart rate was well controlled on Toprol XL 25 mg and nifedipine CR 30 mg. Postoperative day #2 the patient had an episode of rapid atrial fibrillation. The patient's Toprol was increased and his diltiazem was also increased for a goal heart rate of 60s to 70s and his beta blockade and calcium channel blocker would need to be adjusted for blood pressure greater than 110 to 120. Patient was placed on drip and rate adjusted for rate control and blood pressure control. Postoperative day 3 patient converted to normal sinus rhythm and he was converted to oral agents. Patient remained in sinus rhythm during the rest of this hospitalization. Physical therapy worked with the patient and felt that he would be best serviced by a short term rehabilitation stay before being discharged to home. On postoperative day 5 the patient's Foley was discontinued. Anticoagulation was begun via D line. Pulmonary vascular resistances were obtained. Study demonstrated metatarsal pressures on the left of 7 mm and on the right 4 mm. The remaining hospital course was unremarkable and the patient was discharged to rehabilitation in stable condition. Patient will follow up with Dr. [**Last Name (STitle) 1391**] in two weeks time and a decision will be made at that time regarding left first toe amputation. The patient should also follow up with his cardiologist, Dr. [**First Name (STitle) **], and continue on his Coumadin. His INR should be monitored on a daily basis until the patient is in a steady therapeutic state of goal INR of 2.0 to 3.0. Adjust Coumadin dosing accordingly. The patient will be also discharged on diltiazem 240 mg q.d. He may ambulate essential distances, full weight bearing with an Ace wrap from knee to foot when ambulating. He will keep his foot elevated when not ambulating. DISCHARGE MEDICATIONS: Lisinopril 20 mg q.d., Alrestatin 10 mg q.d., Lasix 20 mg q Monday and Friday, _____________ [**2176-9-4**] 1 mg daily, metformin 500 mg b.i.d., acetaminophen tablets 325 1 to 2 q 4 to 6 hours p.r.n., oxycodone/acetaminophen 5/325 tablets 1 to 2 q 4 to 6 hours p.r.n., Dorcolamide/timolol 2/0.5% eye drops 1 o.d., Lopressor 50 mg sustained release q.d., aspirin 81 mg .q.d., fluconazole nitrate powder to affected areas t.i.d., warfarin 5 mg q.d., adjust dosing for goal INR of 2.0 to 3.0, Colace 100 mg b.i.d., Dulcolax tablets 2 p.r.n., insulin 70-30, 25 units q breakfast and 10 units at supper. DISCHARGE DIAGNOSES: 1. Left hallux dry gangrene with infection secondary to arterial insufficiency. 2. Postoperative blood loss anemia, transfused. 3. Postoperative paroxysmal atrial fibrillation, controlled. 4. Type 2 diabetes with triopathy. 5. History of hypertension. 6. History of paroxysmal atrial fibrillation. 7. History of coronary artery disease with congestive heart failure, status post coronary artery bypass grafts in [**2169**]. 8. Status post echocardiogram with positive ischemic changes and an ejection fraction to 40 to 45%. 9. Chronic renal insufficiency. 10. History of cataracts. 11. History of glaucoma. 12. Status post diagnostic arteriogram and left run off on [**2176-8-25**]. 13. Status post left popliteal peroneal bypass with nonreversed greater saphenous vein, angioscopy with valve lysis on [**2176-8-29**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2176-9-5**] 14:09:14 T: [**2176-9-5**] 16:19:06 Job#: [**Job Number 29628**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 5177**] Admission Date: [**2176-8-22**] Discharge Date: [**2176-9-9**] Date of Birth: [**2094-7-25**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 231**] Addendum: [**Date range (1) 5178**] patient experienced low urinary output which did not respond to fluid bolus. renal functiion stable creatinine. Bladder scan showed 500cc , patatient than voided spontaneously with a post void residual of 60cc. foley was placed. patient was began on flomax 0.4mgmHS a void trial was done today with success. patient shoulkd folowup on an outpatient basis for urological and proatate evaluation to assess his urinary retention. patient also had postoperative episode of PAF which converted to NSR. Recommendations were to consider anticoagulation. patient will be d/c on ASA. He should followup with Dr. [**Last Name (STitle) **] re anticoagulation for his PAF. Discharge Disposition: Extended Care Facility: [**Last Name (un) 3008**] house [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2176-9-9**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 5177**] Admission Date: [**2176-8-22**] Discharge Date: [**2176-9-9**] Date of Birth: [**2094-7-25**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 231**] Addendum: [**2176-9-9**] patient reassessed by PT and cleared to be d/c to home. With home saftey pt evaluation. Discharge Disposition: Extended Care Facility: [**Last Name (un) 3008**] house [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2176-9-9**]

[ "428.0", "285.1", "788.20", "250.60", "V45.81", "250.50", "401.9", "357.2", "440.24", "427.31", "250.40", "583.81", "362.01" ]

icd9cm

[ [ [] ] ]

[ "88.42", "39.29", "99.04", "88.48" ]

icd9pcs

[ [ [] ] ]

11690, 11904

8748, 10944

8127, 8727

1008, 1292

2266, 8103

1316, 1334

1443, 2248

106, 149

178, 529

552, 981

1351, 1420

18,461

144,312

22571

Discharge summary

report

Admission Date: [**2181-1-22**] Discharge Date: [**2181-2-7**] Date of Birth: [**2105-12-29**] Sex: M Service: MEDICINE Allergies: oxycodone-acetaminophen / hydrocodone-acetaminophen Attending:[**First Name3 (LF) 2145**] Chief Complaint: Diarrhea and bowel perforation Major Surgical or Invasive Procedure: [**2181-1-22**] Central venous Line placed in right internal jugular vein [**2181-1-28**] PICC line placed [**2181-2-1**] Transesophageal echocardiography performed [**2181-2-2**] PICC line placed History of Present Illness: Mr. [**Known firstname **] [**Known lastname **] is a 75 year old man with history of Crohn's s/p small bowel resections x 3, s/p ileocectomy, h/o post-colonoscopy jejunal diverticular perforation s/p small bowel resection [**2174**], perianal fistula, diverticulitis, colon polyps, and h/o GI bleeding who presented on [**2181-1-22**] to an OSH from home with increased diarrhea and concern for dehydation. Of note, he has three recent hospital admission for GI symptoms ranging from diarrhea to constipation. Per the patient he believes his change in pain medications and bowel regimens were responsible for these admission. At the OSH, a CT abdomen/pelvis was performed demonstrating a contained bowel perforation. He was transferred [**Hospital1 18**] on [**2181-1-23**] and admitted to the surgical service for further management. He was treated conservatively with bowel rest, cipro IV and flagyl IV. Patient remained hemodynamically stable without concerning physical exam. Surgical team decided patient did not warrant surgical intervention at this time and could be conservatively managed. Patient was started on a clear diet which the patient did not accept as he did not want to contribute to his continuous diarrhea. TPN was ordered given patient's report of recent weightloss and inability to tolerate pos. Patient was then transferred to the medical service for further management. . At the time of transfer, the patient's only concern is the extreme pain in his bilateraly hips. He reports having chronic pain that is managed by long acting morphine 15 mg up to 4 times per day and a fentanyl patch 75 mcg. He reports he has not received any pain medications today. This pain is the same character as his chronic hip pain just much more severe as he is lying on his side/hip because of the diarrhea. He is concerned to start his home regimen as he fears it may cause his diarrhea to completely stop and make his perforation worse. The patient denies abdominal pain, nausea or vomiting. He has no blood in his stool. He has no current fevers or chills. He does report an episode of chills yesterday and intermittent episodes of chills and diaphoresis over the last 10 days at home. He describes continuous diarrhea throughout the day today that is nonbloody and causing anal and scrotal pain. Past Medical History: 1) Crohn's disease s/p SB rections x3 managed on chronic prednisone, azathioprine, mesalamine 2) Perianal fistula 3) Diverticulitis 4) Colon polyp 5) Bowel perforation secondary to colonscopy 6) GI bleed on coumadin [**2-/2180**] 7) Afib rate controlled and on coumadin 8) h/o DVT RUE [**2175**] 9) HTN 10) CRI unknown baseline creatinine 11) h/o PNA 12) Avascular necrosis of bilateral hips R > L 13) Chronic back pain 14) Gout 15) h/o MRSA and VRE 16) s/p appendectomy Social History: Patient is retired, widowed with five children and living with his second wife. [**Name (NI) **] ambulates with the assistance of a walker at home. His wife [**Name (NI) **] assists him with most ADLs prior to coming to the hospital. He denies use of tobacco, alcohol, illicit drugs, or herbal medications. Family History: Denies family history of IBD. Physical Exam: VS T 98.4 120/66 78 20 98% RA. General: Alert, oriented x3, uncomfortable, restless HEENT: Sclera anicteric, MMM, R eye strabismus Neck: supple, JVP not elevated, no LAD, R IJ CVL in place Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, nontender, + bs, no masses, no rebound, no guarding, no CVA or suprapubic tenderness, + anal pain and skin break down from chronic diarrhea Ext: R dorsal surface of foot swollen, erythematous, and warm 2+ distal pulses in all four extremities Pertinent Results: MICRO: . STOOL STUDIES: [**2181-1-24**] C. diff toxin negative [**2181-1-24**] Ova & Parasites negative [**2181-1-25**] C. diff toxin negative [**2181-1-25**] Ova & Parasites negative [**2181-1-25**] Stool culture negative [**2181-1-26**] Ova & Parasites negative [**2181-1-30**]: C. diff toxin negative . BLOOD CULTURES: [**2181-1-26**] STAPH AUREUS COAG +. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S . [**2181-1-27**] MSSA (sensitivities as above) [**2181-1-28**] MSSA (sensitivities as above) [**2181-1-29**] No growth to date [**2181-1-30**] No growth to date [**2181-1-31**] No growth to date [**2181-2-1**] No growth to date [**2181-2-2**] No growth to date . [**2181-1-26**] CVL catheter tip: MSSA (sensitivities as above) . [**2181-1-28**] Urine cx: No growth . IMAGING: . [**2181-1-23**] outside film CT read: Free air along the ascending colon and at the greater omentum anterior to a wall thickened distal ileum bowel loop (3, 52; 201, 69), consistent with bowel perforation, likely in the setting of active Crohn's flare. . [**2181-1-23**] CXR: In comparison with study of [**2174-9-2**], there is little change and no evidence of acute cardiopulmonary disease. No evidence of free intraperitoneal gas, though this may well not represent a true upright image. If perforation is a serious clinical concern, CT could be considered for further evaluation. . [**2181-1-26**] CT Abdomen/Pelvis w/o contrast: 1. In this patient with history of Crohn's disease, and recent microperforation, there is no significant interval change in the amount of free intraperitoneal air. No intra-abdominal abscesses or fluid collections are seen. 2. Interval improvement in the bibasilar tree-in-[**Male First Name (un) 239**] opacities, likely related to infection or aspiration. New trace pleural effusions. 3. Cholelithiasis, without evidence of acute cholecystitis. 4. AVN of bilateral femoral head. . [**2181-1-29**] CXR PA and Lateral: As compared to the previous radiograph from [**2181-1-29**], the PICC line is in unchanged position. At the right lung base, the pre-described opacities are more subtle than on the previous image. As noted in the previous report, they could correspond to early pneumonia or a small amount of intrafissural fluid. No new opacities are seen in the lung parenchyma. The left lung is unremarkable. . [**2181-1-29**] Neck Ultrasound: 1. Heterogeneous hypoechoic track in the right neck, corresponding with the location of the recent central line removal, likely represents fluid and/or clot within this tract. 2. Nonocclusive thrombus seen within the right internal jugular vein. . [**2181-1-29**] CT neck with contrast: 1. Heterogeneous hypoechoic track in the right neck, corresponding with the location of the recent central line removal, likely represents fluid and/or clot within this tract. 2. Nonocclusive thrombus seen within the right internal jugular vein. . [**2181-1-31**] Transthoracic Echo: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. No echocardiographic evidence of endocarditis. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Normal global biventricular systolic function. . [**2181-2-1**] Transesophageal Echo: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). with normal free wall contractility. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No echocardiographic signs of endocarditis. Normal global biventricular systolic function. Mild tricuspid regurgitation. No other significant valvular regurgitation seen. . Brief Hospital Course: 75 year old man with a history of afib, Crohn's, and avascular necrosis who is transferred to [**Hospital1 18**] after imaging suggestive of bowel perforation. [**Hospital **] medical management of bowel perforation was complicated by CVL-associated infection with MSSA bacteremia and septic thrombus. . 1) MSSA Bacteremia: Secondary to CVL-associated infection. Last fever on [**2181-1-28**]. Last positive blood culture [**2181-1-28**]. Patient started on Vancomycin on and switched to Nafcillin on [**2181-1-29**] based on culture results. Patient's TEE and TTE were negative for evidence of endocarditis. New PICC line placed on [**2181-2-2**] after > 72 hours of negative blood cultures. Given patient's concurrent nonocclusive thrombus his antibiotic course will be extended to four weeks (last dose on [**2181-2-27**]). Patient will follow up with the [**Hospital1 18**] Infectious disease clinic on [**2181-3-1**]. Patient should continue to have weekly CBC, BUN/Cr and LFTs monitored while on naficillin and the results faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions regarding outpatient antibiotics should be directed to the clinic is closed. . . 2) Nonocclusive Thrombus: Located in right IJ at site of prior CVL. Given patient's concurrent MSSA bacteremia, thrombus is presumed septic. CT scan and ultrasound show no evidence of surrounding abscess or involvement of carotid artery. Patient was started on coumadin and bridged with a heparin gtt. He will continue Nafcillin regimen as above. . 3) Bowel microperforation: Patient with no history of acute abdomen or indication for surgical intervention on presentation. Patient was medically managed with cipro/flagyl x 14 days (last dose on [**2181-2-4**]). His abdominal exam remained benign throughout his admission. . 4) Diarrhea: Patient presents with watery, nonbloody diarrhea of several days. Quantity of stools declined during his admission but watery consistency persists. Stool studies negative for infection (C. diff, ova & parasites, and negative cultures). Aggressive treatment of possible Crohn's flare (with steroids or immune modulators) was avoided given patient's recent bowel perforation and systemic infection. He was continued on home regimen of prednisone 5 mg and azathioprine 50 mg daily. His mesalamine was initially held on admission but ultimately restarted at a higher dose. Just prior to discharge patient was started on a trial of cholestyramine as this would help treat bile salt wasting if it is contibuting to his diarrhea. If patient's stools remain watery over the next 48 hours his dose may be increased. If no improvement is seen within 2 days of increasing his dose of cholestyramine his diarrhea is likely not due to bile salt wasting and the cholestyramine can be discontinued. Patient requested use of a Flexiseal fecal containment system for comfort. Flexiseal was kept in place during the majority of his admission to prevent skin break down and treat skin irritation. Patient is to continue current medical regimen and follow up with [**Hospital 18**] [**Hospital **] clinic within two weeks of discharge. . Given patient's decreased mobility and increased narcotic use, close attention should be paid to the frequency and quantity of patient's bowel movements as constipation may contribute to poor appetite or complicate patient's recent bowel perforation. Patient and family are rightfully very anxious about the management of his pain and the affect it may have on his bowels. . 5) Malnutrition: Patient describes 20 lbs weight loss in 2 months with increased diarrhea and poor po intake. He was started on TPN during his admission. Initially, patient's bowel microperforation was managed with bowel rest and antibiotics. Given his persistent benign abdominal exam and clinical stability he was instructed to start a regular diet. Due to patient's loose stools, high pill burden, hip pain he continued to have poor po intake. Strongly recommend that patient continue to followed closely by a nutritional team after discharge to optimize patient's diet as he is able to increase his po intake. The nutrition team cautioned patient that tube feeds may be warranted if no improvement in his caloric intake is seen. . 5) Avascular necrosis of bilateral hips: Patient with severe bilateral hip pain R > L that is exacerbated by his immobility during this admission. His pain was extremely difficult to manage during his admission as his pain requirements varied widely from day to day. On transfer to the medicine service he was restarted on his home fentanyl patch 75 mcg q72h which was titrate up to 100 mcg q72h, and started on standing acetaminophen 1 g TID, lidocaine 5% patch to right hip daily. He required additional dilaudid IV which ranged from 1 mg q4h prn to 1.5 mg q3h standing. He was ultimately transitioned to a dilaudid PCA to help determine his narcotic requirements. Patient will likely require PCA adjustments when his physical activity increases. . Patient's greatest concern during his admission was his pain regimen and his bowel regimen as he believes his recent GI issues (constipation, diarrhea, and bowel perforation) were due to an imbalance in his pain medications and bowel regimen. He also would frequently decline physical therapy due to fear of pain which only worsened his already impressive deconditioned state. He was counseled that there are medications available to help manage his pain and that his recovery is dependent on his participation. He was also counseled that his narcotic regimen may continue to change with increased activity at rehabilitation and that his health care providers at rehab would be able to adjust his current pain regimen to accommodate to his pain levels. . 6) Atrial fibrillation: Patient has required no rate control for afib throughout hospitalization. He remained on heparing gtt and coumadin for anticoagulation. Patient's INR was not consistently above 2.0 during his admission on coumadin 4 mg daily. His coumadin dose was increased to 5 mg daily on day of discharge. Patient should continue heparin drip until INR is consistently > 2.0 for > 24 hours. Recommend increased monitoring of INR after discharge as his diet and antibiotic regimen will be changing. Patient's goal INR remains [**2-22**] as he has atrial fibrillation, history of RUE DVT ([**2175**]), and new diagnosis of R IJ thrombus. . 7) CRI: Patient with unclear baseline. Creatinine 2.6 on presentation with decrease to as low as 1.2 during his admission. Creatinine 1.3 on day of discharge. . 8) GOUT: Patient presented with mild right ankle and dorsal foot erythema and edema consistent with prior gout. This exam remained stable throughout admission. However, on [**2181-2-5**] patient reported some mild right wrist swelling and signficant pain. Overnight he had a fever and the following morning his right wrist was considerably more swollen, erythematous, and tender to palpation. His exam was consistent with gout. He was started on prednisone 30 mg po on [**2181-2-6**]. He received an additional 30 mg po on [**2181-2-7**]. Recommend tapering prednisone to 20 mg daily on discharge and tapering the patient down to home dose of 5 mg po daily over the next two weeks as his gout symptoms allow. Caution should be taken with excessive prednisone use as prednisone make abdominal exams less reliable. . NUTRITON: Patient encouraged to eat regular diet; continue TPN pending ability to maintain adequate caloric intake by mouth. Strongly recommend close monitoring by Nutrition services. . IV ACCESS: 1 PIV, PICC placed [**2181-2-2**] by IR . EMERGENCY CONTACT: [**Name (NI) **] (wife)[**Telephone/Fax (1) 58550**]; and [**Doctor Last Name **](son)[**Telephone/Fax (1) 58551**] . CODE STATUS: DNR/DNI . DISPO: Rehab Medications on Admission: Pentasa 1000mg daily mag Oxide 3 tabs daily Azathioprine 50mg daily Paxil 20mg daily Prednisone 5mg daily Dulcolax 10mg daily Coumadin 3mg daily Lopressor 12.5 mg daily Discharge Medications: 1. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical every eight (8) hours as needed for rectal irritation. 3. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): Please taper prednisone dose back to home dose of 5 mg daily over the next two weeks as gout flare allows. Tablet(s) 4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. mesalamine 250 mg Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO QID (4 times a day). 8. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 9. hydromorphone (PF) 4 mg/mL Solution Sig: SEE PCA dosing below. Injection ASDIR (AS DIRECTED): Patient currently on dilaudid 0.10 mg/hr basal rate with boluses of 0.1 q6min with a lock out of 6 minutes and total 1.10 mg/hr. 10. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 11. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day): This medication may be titrated up. If no affect on diarrhea in 2 days can be discontinued completely. Do not give this medication with other oral medications as it will decrease their absorption. 12. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gram Intravenous Q4H (every 4 hours). gram 13. heparin flush (porcine) in NS 100 unit/mL Kit Sig: sliding scale heparin Intravenous continuous: Please continue heparin drip with goal PTT 60-100 until INR is > 2.0 for over 24 hours. 14. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Eight (8) mg Injection Q8H (every 8 hours) as needed for nausea. 15. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: Bowel perforation Crohn's disease Diarrhea Avascular necrosis of bilateral hips Atrial fibrillation Gout: Right wrist and R foot MSSA Bacteremia Septic thrombus Anemia of chronic disease Acute renal failure Malnutrition Discharge Condition: Afebrile, hemodynamically stable, alert and oriented to person, place and day of the week. Dependent for all ambulation and transfers. Discharge Instructions: You were transferred to [**Hospital1 69**] after you were found to have a perforation of your colon on CT imaging at an outside hospital. On presentation you were found to have no clinical indications for surgical repair. You were medically managed with antibiotics. You tolerated the antibiotics well and completed a 14 day course of antibiotics (ciprofloxacin and flagyl) on [**2181-2-4**]. Your diarrhea persisted throughout your admission. The frequency of diarrhea improved with treatment of your bowel perforation but the consistency remained unchanged. The stool studies showed no evidence of infection as the cause of your diarrhea. Your diarrhea may be due to your bowel perforation, your Crohn's disease, or your malnutrition. You were continued on your home Crohn's medications including low dose prednisone and imuran. These medication could not be increased as they could cause your bowel perforation and infections to get worse. Your mesalamine dose was able to be increased. Your malnutrition was treated with TPN. Your diet was advanced and you were encouraged to eat frequently throughout the day. You should continue to use TPN until you have reliable oral intake. You should be followed closely by a dietician after your discharge. . Your hospital admission was complicated by an infection and blood clot from your IV. The IV allowed bacteria to enter your blood and grow. The infection is being treated with IV antibiotics and the blood clot is being treated with IV heparin until your coumadin could reach appropriate levels. It is very important that you continue to take your coumadin to prevent the blood clot from expanding and to prevent future clots. You will need to continue to have your INR monitored closely while your antibiotics and diet are changing. You will continue your IV antibiotics for your blood infection until [**2181-2-27**]. You will need to follow up with the infectious disease clinic to ensure that your infection has completely resolved. . A great challenge during your admission was your pain control. You experienced severe hip pain that was likely worsened by your immobility. You required widely varying amounts of IV pain medications to keep your pain controlled. The amount of pain medications that you will need in the future is likely going to change as you increase your activity and work with physical therapy to get stonger. Your physician at your rehab will be able to adjust these medications to make sure that your pain is controlled. . The following changes were made to your home medications: 1) STOP metoprolol 2) STOP Doculax 3) START Nafcillin IV 2 gram every 4 hours for MSSA bacteremia. Last dose on [**2181-2-27**]. 4) START Acetaminophen 1 gram by mouth three times a day for pain control. 5) START Lidocaine 5% patch apply to right hip daily for pain control 6) START Dilaudid PCA 7) START Cholestyramine (for bile acid sequestration as a trial to slow diarrhea) 4 grams po bid. 7) INCREASE Mesalamine 1000 mg by mouth four times a day for diarrhea. 8) INCREASE Coumadin to 5 mg daily 9) INCREASE Fentanyl patch to 100 mcg patch q72 hours 10) INCREASE Prednisone to 20 mg daily and taper as gout allows over the next week to your home prednisone dose of 5 mg daily. . Please continue to take all other medications as previously directed. . It is very important that you continue to have your INR and electrolytes monitored closely after discharge. You will also need to follow up with a gastroenterologist and the infectious disease specialists as listed below. Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: FRIDAY [**2181-2-16**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21795**], 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 . Department: INFECTIOUS DISEASE When: THURSDAY [**2181-3-1**] at 9:50 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], 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: RHEUMATOLOGY When: THURSDAY [**2181-3-8**] at 10:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

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24999

Discharge summary

report

Admission Date: [**2173-9-24**] Discharge Date: [**2173-10-2**] Date of Birth: [**2151-6-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: headache, neck pain, chills Major Surgical or Invasive Procedure: Lumbar puncture x 2 History of Present Illness: Mr. [**Known lastname **] is a 22y/o M from [**Country 11150**] who presented to an OSH today with a 10 day history of persistent headache, neck pain, fevers, chills, nausea, vomiting, phonophobia, and generalized fatigue and malaise. The patient first noticed these symptoms ten days PTA with the insidious onset of headache and lethargy. The symptoms were initially accompanied by nausea and vomiting. The patient states that the symptoms went largely unchanged for most of the remainder of the time PTA, until roughly one day ago the nausea and vomiting went away and the headache began to get worse, accompanied by severe neck stiffness and pain with hip flexion. The patient began to notice that loud noises made his head hurt worse, and that moving his eyes exacerbated his pain. Throughout this period he continued to have fevers with shaking chills and sweats. He endorses decreased PO intake. He denies CP/SOB, dysuria, flank pain, cough, rash, itching, focal weakness, difficulty swallowing, numbness, tingling, abdominal pain, diarrhea, constipation, change in stool color or consistency. He denies sick contacts. [**Name (NI) **] is unaware of PPD status or of having received BCG vaccine. He is currently a medical student in [**Country 9362**] and was scheduled to return there on [**10-2**]. On arrival to the ED in the OSH, the patient was given a LP and was started on Ceftriaxone 2g IV Q12h. The LP showed 357 WBC in tube #4 with 3 RBC, protein of 356, glucose of 39, and diff of 49 PMN, 50 lymphs, initial gram stain negative. Pt was noted to be in urinary retention, foley was inserted with 1.5L drainage, foley left in. Because the OSH had no available negative pressure rooms, the patient was transferred to [**Hospital1 18**] with direct admission to 12R. Past Medical History: Asthma Social History: The patient lives in [**Country 11150**], where he is a medical student. He has been visiting the USA over the past 2 months, and had spent most of the trip in [**State 531**] City. The patient denies sick contacts, environmental exposures, or unusual PO intake. The patient has not travelled outside the NY area while in the US. The patient has had no sexual contacts. [**Name (NI) **] with friends while in NY. The patient does not use EtOH, tobacco, or illicits. His family lives in [**Country 11150**]. Family History: Noncontributory Physical Exam: VS: Tmax 102 | Tcurrent 101.1 | 116 | 28 | 98% RA . GEN: WDWN male in moderate distress, lying quietly in bed with covers pulled up, shivering. Answers questions appropriately, but frequently with delay. NEURO: Oriented to person, place, time, and situation. CN II-XII intact. Tenderness with evaluation of extraocular muscles. Moves all extremities spontaneously. Motor exam with [**6-3**] symmetric strength to flexion and extension in all major muscle groups. Sensory exam intact to light touch throughout. Gait not evaluated [**3-3**] pain. HEENT: PERRLA, EOMI, OP clear, MM dry. No palatal petichiae or tonsillar exudate. Anicteric sclerae. NECK: supple, no supraclavicular or cervical LAD. Exquisite tenderness to palpation in dorsal cervical midline. +Kernig sign. +Brudzinski sign. +pain with neck flexion. CHEST: CTA B COR: tachy, regular rhythm. Normal S1, S2. No M/R/G appreciated. ABD: soft, NT, ND, bowel sounds present. No masses or HSM. EXT: no edema. W/WP. Peripheral pulses intact and symmetric. SKIN: no rashes, no petichiae, palms and soles specifically evaluated. Pertinent Results: [**2173-9-24**] 08:59PM BLOOD WBC-15.4* RBC-5.38 Hgb-14.6 Hct-40.5 MCV-75* MCH-27.1 MCHC-36.0* RDW-11.9 Plt Ct-385 [**2173-9-24**] 08:59PM BLOOD Neuts-87.5* Lymphs-8.0* Monos-3.6 Eos-0 Baso-0.8 [**2173-9-24**] 08:59PM BLOOD PT-12.6 PTT-24.8 INR(PT)-1.1 [**2173-9-24**] 08:59PM BLOOD Fibrino-563* [**2173-9-24**] 08:59PM BLOOD ALT-17 AST-15 LD(LDH)-177 AlkPhos-74 TotBili-0.8 [**2173-9-24**] 08:59PM BLOOD Calcium-9.1 Phos-2.5* Mg-2.1 [**2173-9-24**] 08:59PM BLOOD Hapto-367* . CSF Results: LP #1: From OSH - CSF culture - no growth, Fungal cultures - preliminary no growth, AFB cultures pending Serologies - Lyme negative, Enterovirus negative . LP #2 [**9-25**]: Tube 1: WBC 273, RBC, polys 14, lymphs 84 mono 2 Tube 4: WBC 304, RBC 10, polys 18, lymphs 78, mono 4 protein 442 Glucose 13 . LP #3 [**9-28**]: Tube 1: WBC 408, RBC 1, polys 10, lymphs 90, mono 0 Tube 4: WBC 394, RBC 9, polys 10, lymphs 89, mono 1 protein 208 Glucose 32 . TB PCR pending x2 VDRL pending HSV [**1-31**] - negative . Blood Serology: Erlichia Antibody - pending Strongyloides Antibody - pending RPR - non reactive Lyme - negative . Microbiology: Urine culture [**9-24**] - no growth (final) Urine culture [**9-27**] - no growth (final) Blood cultures 8/26 - no growth (final) Blood cultures 8/27 - no growth to date Blood cultures 8/29 - no growth to date Blood cultures 8/30 - no growth to date . CSF [**9-25**]: gram stain negative, fluid culture negative, fungal cultures prelim negative, AFB culture pending, AFB smear negative, viral cultures pending, cryptococcal Ag negative . CSF [**9-28**]: gram stain negative; cultures negative todate, fungal culture pending, AFB pending Stool cultures - C. Diff negative, O&P pending, marcoscopic - no worms . Imaging: CXR [**9-24**]: No acute cardiopulmonary disease. _______________________________ CT HEAD [**9-25**]: IMPRESSION: No evidence of acute intra- or extra-axial hemorrhage, mass effect. No evidence of enhancing lesions, or meningeal enhancement. ______________________________ KUB [**9-25**]: The bowel gas pattern is nonspecific and nonobstructive with no evidence for free air, pneumatosis or ascites. ____________________________ MRI Head [**9-26**]: There is normal signal intensity throughout the brain parenchyma. The ventricles, sulci, and cisterns are unremarkable. There is no slow diffusion, susceptibility artifact, or areas of abnormal enhancement. Surrounding soft tissues are unremarkable. There is an isolated punctate focus of elevated T2/FLAIR signal in the periventricular white matter of the left parietal lobe, likely of little clinical significance. IMPRESSION: No evidence of acute infarction, an infectious process, or an enhancing mass lesion. ____________________________ MRI Lumbar Spine [**9-27**]: Vertebral body height, alignment, and signal intensity are normal. There is no paraspinal or epidural soft tissue enhancing masses. There is no spinal canal stenosis or neural foraminal stenosis. There is diffuse, marked leptomeningeal enhancement of the conus medullaris and the cauda equina nerve rootlets. No definite enhancing leptomeningeal nodules are appreciated. IMPRESSION: Leptomeningeal enhancement of the conus medullaris and cauda equina. This finding can be seen in diffuse meningeal infection as provided by history. Other differential diagnostic consideration would include metastatic disease. _________________________ MRI Thoracic Spine [**9-27**]: The study is technically limited due to extreme patient motion and is suboptimal for adequate evaluation of the thoracic spine. There is some suggestion of abnormal spinal cord enhancement along its surface, but this is difficult to fully characterize given the poor resolution due to motion degradation and the lack of axial images. Also, there is some suggestion of increased abnormal STIR signal intensity from the T6-T9 levels in the left paraspinal musculature with mild corresponding enhancement, but this evaluation too is limited due to lack of axial images or adequate resolution. Of note, vertebral body height and alignment appears normal. No definite paraspinal fluid collection is seen. IMPRESSION: Technically limited and suboptimal study for adequate evaluation of the thoracic spine. Possible abnormalities as described above need repeat imaging for adequate interpretation. ________________________ EKG [**9-28**]: Regular narrow complex tachycardia - may be sinus tachycardia but consider also atrial flutter with 2:1 response Modest nonspecific ST-T wave changes No previous tracing for comparison _______________________ ECHO [**9-29**]: 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 leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. _______________________ CT OF THE ABDOMEN [**9-29**]: The imaged portions of the lung bases are clear with no opacities, effusions, or nodules identified. The liver appears normal with no focal lesions identified. The gallbladder, pancreas, and spleen all appear normal. The adrenals are normal. The kidneys enhance and excrete normally. There is no mesenteric lymphadenopathy. There is no retroperitoneal lymphadenopathy. There is no free fluid in the abdomen. The small bowel appears unremarkable. _____________________ CT OF THE PELVIS WITH CONTRAST [**9-29**]: The appendix is abnormally thick with a diameter up to 7.6 mm. In addition, the wall of the appendix abnormally enhances. However, there is no sign of any periappendiceal fat stranding or fluid. This may be consistent with a very early appendicitis. Though this may not correlate with the clinical history, careful clinical observation is recommended. The terminal ileum and cecum are unremarkable, which suggests no tuberculosis involvement. The large bowel is otherwise unremarkable. The distal ureters and bladder appear normal. A Foley tube and rectal tube are noted. There is no free fluid in the pelvis or lymphadenopathy. BONE WINDOWS: The osseous structures are unremarkable. IMPRESSION: Possible early appendicitis, careful clinical observation is recommended. No radiographic evidence of tuberculosis involvement in the abdomen. _____________________ Repeat CT Abdomen and Pelvis [**9-30**]: normal contrast filling the apendix, no acute change. ______________________ LENIs: no DVTs in lower extremities, bilaterally Brief Hospital Course: Mr. [**Known lastname **] is a 22 man, native of [**Country 11150**], with no significant PMHx admitted with meningitis/encephalitis presumed to be Tuberculous meningitis. . The patient was initially admitted to the regular medical floor, vital sings were Tmax 102; Tc 98.8; P 62; RR 18; BP 94/56. Patient was continued on Ceftriaxone for bacterial meningitis. Patient then developed photophobia overnight and became increasingly lethargic, with waxing/[**Doctor Last Name 688**] mental status. Also, patient was noted to have new abdominal tenderness not noted on previous exams. Infectious Disease was consulted who recommended repeating the LP to obtain further specimen for TB PCR and other exams; they also recommended starting patient on Acyclovir pending HSV results and antibiotic coverage for suspected TB meningitis in conjunction with steroids. The patient was started on INH, pyrazinamide, pyridoxine, Rifampin, Ethambutol and Dexamethasone. . Given the patient's worsening mental status including increasing lethargy and new-onset photophobia without focal CNIII deficits, patient was transferred to the [**Hospital Ward Name 332**] ICU for further management. He was kept on respiratory precautions and with negative pressure isolation. . 1. Meningitis/Fever - Patient's history, physical exam, and LP results from the OSH and repeated at [**Hospital1 18**] were concerning for bacterial meningitis with very high opening pressures, although the time course was somewhat more prolonged than would be expected for a bacterial process. Gram staining was negative, but showed a relative preponderance of lymphocytes with high protein levels making a viral process or TB higher on the differential diagnosis. Initially, the patient was maintained on bacterial coverage with Ceftriaxone and Vancomycin which was added to cover resistant pneumococcus. Mr. [**Known lastname **] continued to have photophobia with waxing/[**Doctor Last Name 688**] mental status although his WBC steadily trended downwards. He continued to show signs of increased intracranial pressure with CN VI palsy bilaterally, ?CN IV palsy and sluggish pupils. The patient continued to have headache, back pain and positive Kernig's sign. He was continued on treatment for TB meningitis with steroids. Ceftriaxone and Vancomycin were discontinued once CSF cultures from the OSH came back negative. Acyclovir was later discontinued as CSF HSV 1 and 2 came back negative. Repeat LP was performed as per ID recommendations which again showed a lymphocytic predominance with decreasing levels of protein and increasing glucose. With continued treatment the patient's mental status began to steadily improve. He became more alert and oriented and was able to respond quickly and appropriately to questioning. He continued to have a left sided CN VI palsy on lateral gave but his pupils were more reactive. Pt continued to have periods of severe headache, back pain and leg pain throughout his admission, treated with acetaminophen, oxycodone and IV morphine as needed. Droplet precautions and negative pressure isolation was discontinued as the patient has no signs or symptoms or active TB. MRI of the head was also performed which did not reveal any evidence of TB or other abnormalities. Patient had 1 value of temp of 101.1 during the last day of hospitalization. No source of infection was immediately apparent, so, since patient is at an increased risk for DVT (due to LE paraplegia), bilateral LENIs were ordered and were negative for DVT bilaterally. DDx for the fevers included atelectasis and incentive spirometer was placed at patient's bedside. 2. Lower Extremity Weakness - On admission to the ICU, the patient was acutely ill and remained in bed with altered mental status. With improving mental status the patient was found to have b/l lower extremity weakness. On admission, however, the patient had full strength bilaterally. Lower extremity strength was 2-3/5, upper extremity strength 5/5 b/l. In addition he had b/l up going toes, b/l clonus. Sensations remained intact throughout. There was at no time any saddle anesthesia or incontinence although the patient did have one episode of severe diarrhea as a result of aggressive bowel regimen for constipation. MRI of the thoracic and lumbar spine revealed leptomeningeal enhancement of the conus medullaris and cauda equina in the setting of diffuse meningeal irritation. There was question of a paraspinal soft tissue enhancement poorly seen on MR of the thoracic spine. These findings supported meningeal irritation of the cord as a cause for this patient's lower extremities weakness, with a combination of upper and lower motor neuron findings due to involvement of the conus medullaris. Neurology was consulted who suggested continued treatment of the underlying infection and continued steroids. CT of the abdomen/pelvis did not reveal any involvement of the paraspinal musculature or soft tissues. Patient received 6 days of steroids, patient should be given his last day of 6mg IV Dex q 6 today. ([**2173-10-2**]). Please refer to the enclosed taper of steroid doses to treat the patient appropriately. 3. Abdominal Pain - Initially the patient had one episode of abdominal pain with nausea/vomiting and decreased appetite. His abdomen remained soft, mildly tender, with no rebound or guarding. Abdominal x-ray did not reveal any free air or obstruction. LFTs were within normal limits. This resolved and the patient continued to have good PO intake without abdominal pain. On [**9-28**] the patient again began to complain of abdominal pain, diffuse in nature, constant and sharp in nature, rated [**9-8**]. He did not have an acute abdomen on physical examination. This was thought to be due to constipation as the patient had not had a bowel movement for several days. The patient was treated with an aggressive bowel regimen including PR lactulose which caused the patient to have a large quantity of loose stool. After this the patient continued to have an appetite with good PO intake but continued to complain of diffuse abdominal pain. A CT of the abdomen and pelvis was performed with oral and IV contrast which showed a filling defect in the appendix with a thickened wall suggestive of appendicitis. Surgery consult was placed who recommended repeat imaging of the abdomen due to the suboptimal quality of the first study which did not show filling of the cecum. The patient remained without an acute abdomen throughout, WBC count was steadily decreasing, fever curve decreasing. The suspicion for TB enteritis or lymphadenopathy causing appendiceal obstruction remained. Repeat CT abdomen/pelvis however showed a normal filling appendix, appendicitis was ruled out and surgery team signed off. 4. Urinary retention- At OSH, pt was found to have urinary retention, requiring a foley. Pt was tried on voiding trial here and failed, thus necessitating putting foley back in. Likely related to conus syndrome as above. Voiding trial was attempted once more, but the patient began to experience severe abdominal pain several hours after the foley was removed. Patient complained of inability to pass urine, the foley was placed back in and 750cc of urine came out while abdominal pain resolved. 5. Tachycardia - The patient was in sinus tachycardia beginning [**9-27**] which persisted and reached a maximum HR of 160s. This was thought to be due to his underlying infection with persistent low grade fevers. The patient was anxious and having at times severe headaches, back ache and leg pain. The patient responded appropriately to several fluid boluses of NS which caused his HR to come down to the 60s. Baseline fluids were maintained with intermitted NS boluses as needed. The patient continued to match his urine input and output and was able to tolerate aggressive fluids without any problems. In addition, he was treated with Ativan for anxiety, Percocet and Morphine for pain which also seemed to slow his heart rate. Notably, the patient's heart rate decreased during sleep and increased during the daytime, likely as a result of anxiety. On the last day, foley was clamped, patient had urge to void, so foley was d/c'ed. However, patient has a h/o of urinary retention while being in in the hospital, so he should be evaluated for urine output frequently. 6. Cerebral salt wasting: Initially the patient was thought to have SIADH with low serum sodium levels likely due to his underlying CNS infection. A trial of fluid restriction however failed to normalize the patient's sodium level. 24h urinary sodium secretion was above normal suggesting cerebral salt wasting as the cause for his low sodium. The patient was treated with NS at 150 cc/hr with one day of salt tablets with normalization of his sodium. Patient sodium normalized (135) being the last [**Location (un) 1131**], while taking in POs. 7. F/E/N: Maintained on a regular diet, NPO during the time he was suspected of having appendicitis. Serum electrolytes were monitored carefully. As mentioned above, serum sodium levels decreased to a low of 129 but increased to normal limits with normal saline and salt tabs. 8.Prophylaxis: Heparin SC, pneumo boots due to high risk of DVT with LE weakness. PPI, RISS due to steroids, PO intake. 9. Contact: [**Name (NI) **] and [**Name2 (NI) 62780**] [**Name (NI) **] (H)[**Telephone/Fax (1) 62781**], (C)[**0-0-**]. [**Hospital3 13313**]: [**Telephone/Fax (1) 62782**], Micro lab [**Telephone/Fax (1) 62783**]. Medications on Admission: None Discharge Medications: 1. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 2. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours). Disp:*qs Capsule(s)* Refills:*2* 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Ethambutol 400 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 6. Pyrazinamide 500 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Pyridoxine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed. 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety. 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 14. Morphine 2 mg/mL Syringe Sig: [**1-31**] Injection Q4H (every 4 hours) as needed. 15. Dexamethasone Taper 6 mg IV q6 hours - [**Date range (1) 62784**] 4.5 mg IV q6 hours- [**Date range (3) 62785**] 3 mg IV q6 hours- [**Date range (1) 62786**] 1.5 mg IV q6 hours- [**Date range (3) 62787**] 4 mg po (can divide doses) qday-[**Date range (3) 62788**] 3 mg po (can divide doses) qday-[**Date range (1) 62789**] 2 mg po (can divide doses) qday-[**Date range (1) 62790**] 1 mg po (can divide doses) qday-[**Date range (3) 62791**] OFF 16. Regular Insulin Sliding Scale Breakfast Dinner 0-150 0 0 151-200 2 units 2 units 201-250 4 units 4 units 251-300 6 units 6 units 301-350 8 units 8 units 351-400 10 units 10 units >401- [**Name8 (MD) **] MD Discharge Disposition: Extended Care Facility: [**Hospital3 13313**] Discharge Diagnosis: Primary diagnosis: Meningitis most likely tuberculous Lower extremity weakness Abdominal pain NOS Discharge Condition: stable, afebrile, improved, regaining strength Discharge Instructions: -please continue all treatments as directed -please have PT work with the patient, especially strengthening exercises -please follow up all the CSF culture data. please call [**Hospital1 18**] at [**Telephone/Fax (1) 4645**] to finfd out any additional results from microbiology lab. Main number for [**Hospital1 **] is [**Telephone/Fax (1) 2756**] -please continue all treatments as directed -please have PT work with the patient, especially strengthening exercises -please follow up all the CSF culture data. please call [**Hospital1 18**] at [**Telephone/Fax (1) 4645**] to finfd out any additional results from microbiology lab. Main number for [**Hospital1 **] is [**Telephone/Fax (1) 2756**] -please involve Neurology and Infectious Disease specialists at your facility to care for the patient -Medication (including dexamethasone taper) per instructions Followup Instructions: -Will need to call [**Hospital1 **] to follow up on CSF and culture data. -other as per discharge summary Completed by:[**2173-10-2**]

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icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

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47747

Discharge summary

report

Admission Date: [**2178-7-2**] Discharge Date: [**2178-7-7**] Date of Birth: [**2121-12-23**] Sex: M Service: MEDICINE Allergies: Ibuprofen Attending:[**First Name3 (LF) 2186**] Chief Complaint: Initial: Hypotension & Agitation (Transferred from ICU) Major Surgical or Invasive Procedure: Hemodialysis Catheter Replacement Peripherally Inserted Central Catheter History of Present Illness: 56-year-old man with history of DM1, ESRD on HD 3x/week, HTN, CAD, afib/flutter s/p ablation, who presented with hypotension from dialysis today. For the past week, per patient and wife, the patient has had chills and worsening of his chronic cough at home. No temperature was taken. The cough has been productive. He has also been confused intermittently, weaker with two falls at home with no LOC or head trauma, and has had poor appetite. Per the wife, the patient's agitation is similar to his chronic anger. Patient denies that he has been intermittently confused at home. . On the day of admission at dialysis, he was found to be hypotensive to 80s/40s and was agitated, though oriented x 3, with temperature of 100.3. Was brought to the ED, where vitals were T 101, BP 89/43, HR 115, RR 12, 98%RA. CXR and EKG were unremarkable. He received vancomycin 1g, ceftriaxone 1g, acetaminophen, haloperidol 5 mg IV X 2, lorazepam 2mg IV, about 2L NS and a norepinephrine gtt was started. . On review of systems, patient denies any headache, visual changes, lightheadedness, chest pain, dyspnea, abdominal pain, diarrhea, constipation, dysuria. Past Medical History: ESRD on HD(T,Th,Sat) HTN DM CAD sp MI [**64**]' a fib/flutter s/p ablation in [**2173**] AV fistula in R arm - s/p clot in fistula and thrombectomy diverticulosis on colonoscopy [**2174**] frequent eloping from hospital and leaving AMA Social History: Pt lives at home with wife and 2 sons. [**Name (NI) 1403**] part time [**Street Address(1) 100812**] Bank. 50pack yr h/o tobacco use, quit in [**2160**]. Very distant marijuana use, no other drugs, no etoh. Family History: noncontributory Physical Exam: PHYSICAL EXAMINATION: VITALS GEN: Obese, middle-aged man sitting in a chair, comfortable and talkative. Remembers providers name easily. HEENT: Wearing glasses. Sclera anicteric, conjunctivae clear, OP moist and without lesion CV: Regular. Distant sounds. CHEST: Clear. No crackles, wheezes or rhonchi. ABD: Soft, obese, NT, ND, no HSM EXT: No c/c/e SKIN: No rash NEURO: Oriented x 3, CNs II-XII groslly intact, 5/5 strength bilaterally Pertinent Results: [**2178-7-2**] 01:15PM GLUCOSE-169* UREA N-52* CREAT-12.2*# SODIUM-139 POTASSIUM-5.5* CHLORIDE-98 TOTAL CO2-22 ANION GAP-25* [**2178-7-2**] 09:31PM WBC-10.3 RBC-3.55* HGB-10.2* HCT-32.8* MCV-93 MCH-28.8 MCHC-31.1 RDW-15.7* NEUTS-73.6* LYMPHS-16.1* MONOS-8.3 EOS-1.6 BASOS-0.4 Blood Cultures 6/19, [**7-3**], [**7-4**]: Positive for Entercoccus faecalis [**Date range (1) 35547**] Pending Brief Hospital Course: ICU course: Blood cultures grew GPC in [**6-19**] bottles and he was treated broadly with antibiotics. Aggressive IVF were given and he was weaned off pressors. His dialysis line was exchanged and as he improved, he was called out to the medical floor. 1. Entercoccus faecalis bacteremia: 6 out of 6 bottles grew out GPC with enterococcus noted. Ampicillin 1g IV q12H x2weeks & Gentamicin 140mg IV QHD x4weeks started. No vegetations were noted on TTE though the status was suboptimal. Patiend denied TEE. Daily surveillance cultures were taken and positive through [**7-4**], pending thereafter. Patient became unsatisfied with the duration of his stay and insisted that he felt fine enough to leave. He cited external social and financial factors as his main motivation. He agreed to return to the ER if he felt ill again. He agreed to follow-up with Gentamicin during HD. Coverage was switched to Vancomycin 1g IV QHD x6weeks. 2. Delerium / Weakness: Resolved with initiation of antibiotics; likely from bacteremia. 3. ESRD: Received Hemodialysis QMWF during stay. Tunneled catheter placed for dialysis. Patient agreed to continue outpatient dialysis after leaving AMA. 4. Diabetes: The patient was maintained on his home dose of insulin 70/30 45 units [**Hospital1 **] with ISS for extra coverage. Medications on Admission: Calcium Acetate [PhosLo] 667 mg Capsule 3 Capsule(s) by mouth three times a day (Prescribed by Other Provider) Folic Acid 1 mg Tablet 1 Tablet(s) by mouth once a day (Prescribed by Other Provider) [**2178-1-28**] Lisinopril 5 mg Tablet 1 Tablet(s) by mouth once a day (Prescribed by Other Provider) [**2178-1-28**] Metoprolol Succinate 50mg PO BID Aspirin 325 mg Tablet 1 Tablet(s) by mouth once a day (Prescribed by Other Provider) [**2178-1-28**] Insulin NPH & Regular Human [Humulin 70/30] 100 unit/mL (70-30) Suspension 45 units twice a day (Prescribed by Other Provider) Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: 0.5 Subcutaneous twice a day. 8. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous at dialysis for 6 weeks: Total of six weeks. Day 1 = [**2178-7-4**]. 9. Gentamicin Sulfate (PF) 80 mg/8 mL Solution Sig: 1.5 Intravenous at dialysis for 6 weeks: 140mg total. To be given at dialysis. Day 1 = [**2178-7-4**]. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Enterococcal Bacteremia (blood stream infection) 2. Unconfirmed Endocarditis Secondary: 1. End Stage Renal Disease 2. Insulin Dependent Diabetes 3. Hypertension Discharge Condition: Stable. Discharge Instructions: You presented to the hospital with changes in mental status, hypotension, and fever. You were found to have an blood infection and were started on antibiotics and given fluids. Pictures were taken of your heart through the front of your chest to see if your heart valves had been infected through the blood. These pictures were not very clear and so a procedure to take pictures from the back of the heart through the esophagus was ordered. You chose not to have this procedure done and instead agreed to treat you as if the pictures had shown that you were infected. You were given a new peripherally inserted central catheter (PICC) to give you your antibiotics for the blood stream infection and possible heart valve infection. While you were here, you were also continued on your dialysis regimen for your chronic renal failure. Please come back to the hospital if you have any new fevers; chills; signs of infection around the area of your placed lines such as redness, swelling or pain; chest pain, shortness of breath or any other symptoms that are concerning to you. Followup Instructions: Please follow-up with your primary care physician.

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icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "88.72" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2156-12-8**] Discharge Date: [**2156-12-20**] Date of Birth: [**2094-3-28**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: ETOH Cirrhosis and HCC now s/p orthotopic liver transplant Major Surgical or Invasive Procedure: [**2156-12-8**]: Orthotopic liver transplant [**2156-12-17**]: ERCP History of Present Illness: 62 y.o. male with ETOH cirrhosis/HCC with diuretic-resistant ascites despite placement of a TIPS shunt and resultant significant hydrocele and possible inguinal hernia. He is requiring paracentesis approximately every 7 to 10 days. Last tap 2 weeks ago and was scheduled for a tap today at [**Hospital1 3325**]. Past Medical History: 1. Alcohol-related cirrhosis status post TIPS placement [**2154-10-8**] requiring dilatation [**2154-10-15**] 2. Upper GI bleeding in [**2152**]. Patient was treated at an outside hospital and it is unclear whether his upper GI bleed was secondary to esophageal varices or peptic ulcer disease. 3. Coronary artery disease status post angioplasty in the [**2129**]. 4. Diabetes mellitus type 2 diagnosed in [**2152**]. Hemoglobin A1c [**2154-10-4**] was 6.3 5. Umbilical hernia status post repair [**2154-11-3**] 6. Right knee surgery 7. Depression 8. HCC, growth [**Last Name (un) 64259**] 2.5x2.5cm confirmed on [**2156-9-8**] at the dome of the liver 9. Recurrent recent paracentesis due to refractory ascites Social History: Married with two adult sons. Formerly worked as a vice president of a trucking company. Drank from the age of 20 until [**2154-9-19**]. He never smoked. Denies IV drug use. Family History: Father and brother died of MI at the age of 52. His mother and sister have diabetes. Physical Exam: 98.3 59 123/72 20 99%RA 5'8", wt 104.8kg A&O x3, nervous, wife present anicteric sclerae, mmm, pharynx wnl, upper dentures Neck: no LAD, no TM, 2+ bilat carotids without bruits Luns: clear Cor: RRR, no murmur Abd: Large/ascites/tense, ventral hernia obvious with head to chin tuck, NT Back: R flank lipoma, no cvat tenderness GU: large Right hydrocele Vasc: 1+ femoral pulses, no bruits Ext: trace ankle edema, 2+ DPs, no cyanosis Neuro: A&O x3, no asterixis/flap, toes down Bilat. strength 5/5 bilaterally & equal, skin: [**Location (un) **] erythema Pertinent Results: On Admission: [**2156-12-8**] WBC-5.3 RBC-3.27* Hgb-10.5* Hct-29.8* MCV-91 MCH-32.1* MCHC-35.3* RDW-14.4 Plt Ct-156 PT-13.6* PTT-31.7 INR(PT)-1.2* Fibrino-486* Glucose-153* UreaN-21* Creat-1.7* Na-135 K-4.1 Cl-102 HCO3-24 AnGap-13 ALT-25 AST-43* AlkPhos-127* Amylase-50 TotBili-1.6* Lipase-44 On Discharge [**2156-12-20**] WBC-7.7 RBC-2.74* Hgb-8.4* Hct-24.3* MCV-89 MCH-30.9 MCHC-34.7 RDW-17.3* Plt Ct-182 Fibrino-271 Glucose-111* UreaN-28* Creat-1.8* Na-134 K-4.5 Cl-104 HCO3-22 AnGap-13 ALT-55* AST-22 AlkPhos-171* Amylase-84 TotBili-0.8 Lipase-114* Albumin-2.4* Calcium-7.6* Phos-2.9 Mg-1.9 Iron Studies: [**2156-12-19**] Brief Hospital Course: 62 y/o male with Hepatitis C virus cirrhosis and hepatocellular carcinoma is admitted for Orthotopic (piggyback) donor after cardiac death (DCD) liver transplant, portal vein-portal vein anastomosis, branch patch (recipient) to celiac patch (donor), common bile duct to common bile duct anastomosis (no T tube) with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please see the operative note for surgical details. In addition it should be noted that this is a DCD donor who also was HTLV1 and HTLV2 serologically positive. Prior to surgery this was discussed in detail with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] in infectious disease and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] in hepatology. It was determined that the risk of continued progression of his hepatocellular carcinoma and risk of complications and death from his end-stage liver disease was greater than the risk of transmission and the development of disease related to the HTLV1 and HTLV2 positivity. This was discussed with Mr. and Mrs. [**Known lastname 64260**] in great detail and informed consent was given. At the time of exploration the patient had approximately 12 liters of ascites that was cloudy and appeared chylous. It did not smell or appear grossly infected. There was no fibrin in the peritoneal cavity and no inflammation suggestive of peritonitis. The fluid was sent for Gram stain which returned 1+ polys. Cultures were sent which were returned as no growth.He was given vancomycin and Zosyn in addition to his preoperative Unasyn and in addition received routine induction immunosuppression. He had a small cirrhotic liver with normal anatomy. There was a tumor in theright lobe of the liver, but no evidence of any extrahepatic spread. The donor liver had a replaced left hepatic artery. Patient was transferred to the SICU following surgery. He was extubated on POD 2, and subsequently transferred the same day. Seen by [**Last Name (un) **] for blood glucose management. He was managing glucose at home prior to surgery with diet but will be discharged home on Lantus and a humalog sliding scale. Patient and wife received teaching and meds/syringes/supplies were ordered. On POD 6 the patient suffered a hypotensive episode with tachycardia that appeared to be AFib on telemetry. He denied chest pain, SOB or palpitations. He received a NS bolus for BP of 80/P. Cardiology was consulted. Enzymes were cycled (normal, metoprolol was continued. An Echo was performed showing an EF of 35%. In addition findings included comparison with the prior study (images reviewed) of [**2155-4-16**], showing the regional left ventricular systolic dysfunction is new and c/w interim ischemia/infarction (mid-LAD distribution). No anticoagulation ws recommended, Metoprolol was increased to 25 [**Hospital1 **]. On POD 4 the medial drain started with more output and a drain bili was sent with a result of 7.7. A CT was done showing no drainable collections. After the patient fall he had an U/S of the liver done to evaluate blood flow which was normal. This output was followed for several days, and output was replaced with albumin for each liter of output. When no relief of drainage, patient was sent for an ERCP on [**12-17**] (POD 9) Cholangiogram showed leak of contrast at the anastomotic site of the [**Last Name (un) 28791**] and native bile duct and a 9cm by 10F Cotton [**Doctor Last Name **] biliary stent was placed successfully across the anastomotic leak site. Patient did have post ERCP pancreatitis, which was treated with continued clears for an additional day. By POD 11 he was tolerating regular diet and the amylase and lipase normalized. On POD 12 (day of discharge) the final drain was removed and suture placed. He will go home with VNA for help with medications and blood sugar management as this is a new therapy for him. Medications on Admission: Celexa 40', Furosemide 80', Spironolactone 25', Flomax 0.4', Oxycodone 5'hs, Lactulose PRN, Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day for 3 days: Follow Prednisone Taper per transplant clinic guidelines. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Continue as long as taking pain medication and as needed. Disp:*60 Capsule(s)* Refills:*2* 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 13. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime: Then continue sliding scale Humalog. 14. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day. 15. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a day: Total 2.5 mg [**Hospital1 **]. Discharge Disposition: Home With Service Facility: [**Location (un) 6138**] Home Care Services Discharge Diagnosis: ETOH cirrhosis and HCC now s/p liver transplant Discharge Condition: Good Discharge Instructions: Call the transplant office at [**Telephone/Fax (1) 673**] if you experience any of the following symptoms: fever > 101, chills, nausea, vomiting, diarrhea, inability to eat, or inability to take or keep down medications. Monitor for pain over the incision site or liver, yellowing of the skin or eyes, an increase in abdominal girth. Monitor incision for redness, drainage or bleeding. Do not drive if you are taking narcotics. Take your medications exactly as directed. No heavy lifting You may shower, pat incision dry Have labs drawn every Monday and Thursday and have them faxed to [**Telephone/Fax (1) 697**]. CBC, Chem 10, AST, ALT, Alk Phos, Albumin, T Bili and trough Prograf Level Followup Instructions: Please call [**Telephone/Fax (1) 673**] for appointment with Dr [**Last Name (STitle) **] on Wednesday [**12-22**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2156-12-20**]

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icd9cm

[ [ [] ] ]

[ "99.06", "51.87", "99.04", "50.59", "00.93", "99.07" ]

icd9pcs

[ [ [] ] ]

8725, 8799

3092, 7011

373, 443

8891, 8898

2439, 2439

9637, 9911

1757, 1845

7154, 8702

8820, 8870

7037, 7131

8922, 9614

1860, 2420

275, 335

471, 785

2453, 3069

807, 1546

1562, 1741

26,595

189,778

49053

Discharge summary

report

Admission Date: [**2119-7-2**] Discharge Date: [**2119-7-8**] Date of Birth: [**2070-4-24**] Sex: F Service: ADMITTING DIAGNOSIS: 1. Abdominal pain-rule out gastrointestinal bleed 2. Dehydration/hypotension 3. Acute renal failure 4. Acute blood loss anemia 5. Depression 6. Status post gastric bypass 7. Status post liposuction/breast reduction 8. Status post endometrial biopsy 9. History of iron deficiency anemia 10. Status post cholecystectomy [**26**]. Status post appendectomy DISCHARGE DIAGNOSIS: 1. Abdominal pain - Not otherwise specified 2. Myocardial infarction - As per cardiac enzymes 3. Abdominal pain-rule out gastrointestinal bleed 4. Dehydration/hypotension 5. Acute renal failure 6. Acute blood loss anemia 7. Depression 8. Status post gastric bypass 9. Status post liposuction/breast reduction 10. Status post endometrial biopsy 11. History of iron deficiency anemia 12. Status post cholecystectomy [**28**]. Status post appendectomy HISTORY OF PRESENT ILLNESS: The patient is a 40 year old female who underwent a gastric bypass in [**2114**] who also had a history of diverticulosis and iron deficiency anemia who had had episodes of abdominal pain since [**2118-12-28**]. Now the reason for this visit was brought about by the patient being found in bed by her daughter on the morning of admission with increased lethargy and decreased level of alertness. The initial history was taken by the patient's daughter who said that the patient has been having diarrhea for several days and had had several episodes of hematemesis over the past week. There was note that one episode of diarrhea may have been reddish brown, questionable for blood. Otherwise the patient has not had any fevers, chills or cough or other chest pain. Notably in the past she had the abdominal pain evaluated by an abdominal computerized tomography scan which was unremarkable for any sort of fluid or contrast in the stomach, evidencing suture breakdown and no etiology was found. It was felt that she may have had some sort of dumping syndrome. She did undergo colonoscopy in the past for evaluation of this pain which showed diverticulosis but no other pathologic findings. Further details of the history could not be obtained secondary to the patient's condition. When she presented in the Emergency Department her temperature was 98.2, blood pressure was 70/30 with a pulse of 80, respiratory rate of 12. She was sating 100% on room air and was somewhat lethargic and initially given Narcan to assess whether this was secondary to narcotics but there was no change in the patient's mental status. Otherwise she was given intravenous hydration with 1 liter of lactated ringer's and 4 liters of normal saline with blood pressure remaining in the 70s systolic. Therefore she was started on a Dopamine drip while in the Emergency Department. While in the Emergency Department she had a maroon colored stool at which time surgery was consulted for evaluation of this patient. PHYSICAL EXAMINATION: On initial examination, blood pressure was 99/50, pulse 89, respiratory rate 20. She was sating 95% on the 100% nonrebreather. She was a tired and ill-appearing Caucasian female in no respiratory distress. Sclera were anicteric. Her mucous membranes were moist. The oropharynx had no erythema or exudate. Her pupils were 3 mm and reactive to 2 mm bilaterally. Her neck was supple without any lymphadenopathy or jugulovenous distension. She had crackles from the mid fields to the bases bilaterally. There was no wheeze. The heart was regular rate and rhythm with a normal S1 and S2, no murmur was noted. Her abdomen was slightly distended. It was severely tender to minimal palpation and there was some involuntary guarding. Her bowel sounds were hyperactive but otherwise her abdomen was noted as rigid. Her extremities had no edema. They were somewhat cool to palpation but there was no cyanosis. Her dorsalis pedis and posterior tibial pulses were [**12-31**]. LABORATORY DATA: At the time of admission her laboratory data showed a potassium of 6.6 which was later checked at 4.3. Her sodium was 142, chloride and carbon dioxide 99 and 26, her BUN was 21 with a creatinine of 2.5 and glucose of 145. Her calcium, magnesium, phosphorus were 7.2, 1.8 and 8.1 with an albumin of 3.1. Her white count was 13.3 with a hematocrit of 47.2 and platelet count of 350. She had 85% neutrophils and 5% bands. Her serum was positive for benzodiazepines and her urine was positive for benzodiazepines and opiates. Otherwise, there were no other drugs or toxic agents found. Her chest x-ray showed a linear opacity with some atelectasis but no other evidence of pulmonary edema. In terms of her coagulation studies PT was 14.3 and INR was 1.4 with a PTT of 28.0. Her electrocardiogram showed normal sinus rhythm with normal axis. There were nonpathological Q waves in II, III and AVF. There was some T wave inversion in III and AVF and some T wave inversion in V1 through 4 and ST segment depression II and III. HOSPITAL COURSE: On the patient's initial assessment it is felt that the patient had several problems, the first was hypotension secondary to what was most likely volume depletion for which the patient was on the Dopamine drip. Her abdominal pain was concerning for the possibility of bowel ischemia and there was a question that she might also be having some sort of cardiac ischemic event. It was felt that the patient may have been slightly hypoxic secondary to volume overload as her oxygen saturation went down after being given the intravenous fluids. The patient was admitted and surgery as noted was consulted. From the surgical perspective it was felt that this patient was again dehydrated with acute renal failure secondary to this and possible myocardial infarction. Evaluation of the computerized tomography scan of the abdomen showed diffusely thickened small bowel with no free fluid or free air and no dilated loops, so it was felt that this possibly could have been some sort of ischemic event. The patient's lactate was normal and at the time of admission the patient's lactate was 1.8 which was within normal limits. Notably in terms of her cardiac enzymes, the initial cardiac enzymes showed CKMB of 38 with an MB index of 1.2 and troponin of 0.23. It was felt the patient needed intensive care monitoring and would possibly need laparotomy. Dictated By:[**Last Name (NamePattern1) 13262**] MEDQUIST36 D: [**2119-8-27**] 18:50 T: [**2119-8-27**] 19:05 JOB#: [**Job Number 102941**]

[ "410.71", "557.0", "296.7", "276.5", "V45.3", "584.9", "280.9", "250.00" ]

icd9cm

[ [ [] ] ]

[ "45.13", "96.04", "38.93", "96.71", "38.91", "89.64" ]

icd9pcs

[ [ [] ] ]

534, 993

5093, 6596

3046, 5075

1022, 3023

150, 513

21,795

194,390

13822

Discharge summary

report

Admission Date: [**2177-1-12**] Discharge Date: [**2177-1-17**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11597**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **]-year-old woman with h/o CAD s/p CABG, AF, [**11-25**]+ AR, 2+ MR, 3+ TR, moderate systolic pulm HTN, EF 40% transferred from [**Location (un) **] for acute asthmatic bronchitis and CHF. At baseline, patient is ambulatory, no on oxygen and able to do most o f her ADLs. Patient present to OSH with nonproductive cough, SOB and subjective fevers on [**2177-1-8**]. CXR was negative for pneumonia. EKG showed SVT and ST-T wave abnormalities. BNP was 1357, TSH WNL. Urine was negative for legionella and strep pneumonia antigen. She was admitted and placed on telemetry, and ruled out for MI by cardiac enzymes. She had a episode of respiratory distress on [**1-9**] that resolved with IV lasix. CXR on [**1-9**] showed bibasilar opacities that may represent pneumonia. She was pla ced on Cefuroxime 750 mg IV Q8 for acute asthmatic bronchitis. CT chest on [**1-9**] with marked cardiomegaly with both chamber enlargement and findings suggestive of RHF, no PE or DVT, and bilateral pleural effusions R> L, as well as a large hypodensity in the liver. Cardiology was consulted and and echo was performed, with the result not available at time of transfer. She was placed on Albuterol and Atrovent which was switched to xopenex and atrovent given tachycardia [**12-26**] to albuterol. [**1-11**], she was again found to be in respiratory distress which resolved with 40 mg IV lasix. Pulmonary was consulted, and xopenex was d/c'ed and the patient was started on prednisone. BP fell after lasix, but returned to [**Location 213**] after a 250-300cc fluid bolus. Transferred to [**Hospital1 18**] for [**Hospital 41518**] medical management. Past Medical History: Presumed Alzheimer's Dementia Valvular heart disease CAD s/p CABG Multiple thoracic compression fractures AF - diagnosed in [**1-26**] hospitalization in [**1-26**] with bibasilar pna co mplicated with ARF a nd hypernatr emia and AF RCC s/p Nephrectomy Hypothyroidism Social History: Patient lives in apartment that is attached to daughter's home. No EtOH or tobacco Family History: FH of CAD Physical Exam: (admission exam) T 98.6 BP 93-116/40-56 91 RR 20-24 99% on 4L Gen: elderly woman lying in bed in NAD Neck: no cervical LAD, JVP hard to assess given TR CV: irregularly irregular, no murmurs Lungs: bilateral expiratory crackles, Left sided inspiratory crackles, rhonchi throughout Abd: BS+, soft, diffuse tenderness, most in LLQ, nondistended, no organomegaly Ext: no edema Neuro: A&O, CN2-12 intact, no focal deficits Pertinent Results: RADIOLOGY: ========== CXR [**1-12**]: Heart size is within normal limits. There is tortuosity of the thoracic aorta. There are possible small bilateral pleural effusions and bibasilar atelectases but correlate clinically and reevaluate on followup PA and lateral chest films. No pulmonary edema or CHF. Status post CABG. . KUB [**1-12**]: No definite intestinal obstruction or other diagnostic abnormalities . CT Abd [**1-14**]: 1. Large retroperitoneal hematoma on the left extending from the kidney down to the pelvis, centered around the left psoas muscle, pushing the kidney anteriorly. Fat planes are seen between hematoma and aortic aneurysm. These findings likely represent spontaneous retroperitoneal hemorrhage. Given history of right nephrectomy, if patient had history of renal cell carcinoma, an underlying tumor could also be the source of hematoma. 2. [**Hospital1 **]-lobulated intrathoracic aortic aneurysm. Associated heavily calcified and ectatic aorta. 3. Bilateral small-to-moderate pleural effusions with associated atelectasis. 4. Status post right nephrectomy. 5. Nonspecific focal area of increased attenuation within the left kidney. 6. Calcifications are seen within the liver, spleen, kidney, and mesentery consistent with history of granulomatous disease CTA Chest from [**Hospital3 934**] on [**1-9**] Impression: marked cardiomegaly with multichamber enlargement and findings suggestive of right heart failure. No evidence of pulmonary embolus or DVT. Large area of hypodensity in the right lobe of the liver, ? technical. Recommend abdominal CT with delayed images to rule out liver mass. Proximal abdominal aortic 4.5 cm aneurysm which can also be evaluated with abdominal CT. Bilateral pleural effusion, right greater than left. [**2177-1-12**] 07:42PM BLOOD WBC-7.6# RBC-3.90* Hgb-11.4* Hct-33.9* MCV-87 MCH-29.2 MCHC-33.5 RDW-14.7 Plt Ct-200 [**2177-1-13**] 05:20AM BLOOD WBC-7.4 RBC-3.04* Hgb-9.1* Hct-26.2* MCV-86 MCH-29.8 MCHC-34.6 RDW-14.8 Plt Ct-174 [**2177-1-13**] 11:15AM BLOOD Hct-26.1* [**2177-1-13**] 06:23PM BLOOD WBC-6.6 RBC-3.87*# Hgb-11.4*# Hct-33.1*# MCV-86 MCH-29.5 MCHC-34.4 RDW-14.5 Plt Ct-179 [**2177-1-14**] 01:21AM BLOOD Hct-32.6* [**2177-1-14**] 06:05AM BLOOD WBC-6.3 RBC-3.73* Hgb-11.2* Hct-30.9* MCV-83 MCH-30.0 MCHC-36.3* RDW-14.9 Plt Ct-209 [**2177-1-14**] 04:46PM BLOOD Hct-33.4* [**2177-1-15**] 09:15PM BLOOD Hct-32.5* [**2177-1-17**] 05:13AM BLOOD WBC-10.5 RBC-3.85* Hgb-11.6* Hct-33.4* MCV-87 MCH-30.0 MCHC-34.6 RDW-15.0 Plt Ct-264 [**2177-1-12**] 07:42PM BLOOD PT-12.3 PTT-79.7* INR(PT)-1.1 [**2177-1-12**] 07:42PM BLOOD Plt Smr-NORMAL Plt Ct-200 [**2177-1-13**] 05:20AM BLOOD Plt Ct-174 [**2177-1-13**] 06:23PM BLOOD PT-10.6 PTT-30.2 INR(PT)-0.9 [**2177-1-13**] 06:23PM BLOOD Plt Ct-179 [**2177-1-14**] 06:05AM BLOOD PT-11.6 PTT-27.5 INR(PT)-1.0 [**2177-1-14**] 06:05AM BLOOD Plt Ct-209 [**2177-1-15**] 04:35AM BLOOD PT-11.5 PTT-25.6 INR(PT)-1.0 [**2177-1-15**] 04:35AM BLOOD Plt Ct-193 [**2177-1-16**] 05:18AM BLOOD PT-12.2 PTT-27.2 INR(PT)-1.0 [**2177-1-16**] 05:18AM BLOOD Plt Ct-208 [**2177-1-17**] 05:13AM BLOOD Plt Ct-264 [**2177-1-13**] 06:23PM BLOOD Fibrino-304 [**2177-1-12**] 07:42PM BLOOD Glucose-153* UreaN-30* Creat-1.0 Na-143 K-4.8 Cl-107 HCO3-27 AnGap-14 [**2177-1-13**] 05:20AM BLOOD Glucose-114* UreaN-34* Creat-1.0 Na-142 K-4.6 Cl-107 HCO3-27 AnGap-13 [**2177-1-13**] 06:23PM BLOOD Glucose-140* UreaN-33* Creat-1.0 Na-141 K-5.0 Cl-104 HCO3-21* AnGap-21* [**2177-1-15**] 04:35AM BLOOD Glucose-89 UreaN-33* Creat-1.0 Na-143 K-4.1 Cl-107 HCO3-27 AnGap-13 [**2177-1-17**] 05:13AM BLOOD Glucose-92 UreaN-30* Creat-0.9 Na-141 K-4.2 Cl-105 HCO3-26 AnGap-14 [**2177-1-15**] 04:35AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.3 [**2177-1-16**] 05:18AM BLOOD Calcium-8.7 Phos-2.1* Mg-2.1 [**2177-1-17**] 05:13AM BLOOD Calcium-9.3 Phos-2.1* Mg-2.2 [**2177-1-13**] 05:20AM BLOOD calTIBC-190* Hapto-182 Ferritn-399* TRF-146* [**2177-1-12**] 07:42PM BLOOD TSH-1.3 Brief Hospital Course: Patient was admitted on [**1-12**] and was continued on atrovent and prednisone for asthma exacerbation. Continued on ceftriaxone initially for tx CAP->then changed to Levofloxacin, finishing a full 7 day course of antibiotics started at the OSH. Further diuresis held due to intravascular depletion, though a BNP was found to be 13,000 and an admission CXR showed small bilateral pleural effusions. On admission, she did have a PTT of 77, though no report of being on heparin, and complained of LLQ tenderness of palpation. Her LLQ tenderness was attributed to constipation as she stated she had not had a BM for a day, and she was ordered a bowel regimen. . Respiratory status stabilized, however on [**1-14**] at noon, trigger called for hct drop from 34 to 26. Hct dropped from 40 on admission to OSH --> 36 on transfer --> 33 on admission here --> 26. Subsequently stablized at 26. Found to be trace guaiac positive. Also complaining of LLQ quadrant and lower back pain. ASA and plavix was stopped. She had also been placed on SQ heparin on admission for DVT prophylaxis and this was stopped. Abd CT was ordered to evaluate for diverticulitis and RP bleed, and found large RP bleed. Vascular surgery consulted given finding of thoracic aortic aneurysn on abd CT for ? ruptured aneurysm. However thoracics felt that ruptured aneurysm unlikely. Appears to be separate process as on CT [**1-13**] there is a plane of fat between the aorta and the bleed. Decision made to manage medically. Additionally, vascular surgery stated that the aneurysm was not amenable to repair, and that rupture of the aneurysm would be catastrophic, but that nothing could be done if that were to happen. This was communicated to the family ([**First Name8 (NamePattern2) **] [**Name (NI) 23306**] HCP). Patient was given 2 Units pRBC's in addition to 2 unit platelets (given recent ASA, plavix). Hematocrit bumped appropriately after 2 units from 26->33. Monitored in ICU overnight. Hematocrit stable although slowly down-trending from 33-30. Blood pressure stable in 110's w/ HR controlled in 80's. . Given clinical stability, called out to medicine floor on [**1-15**]. Hematocrit remained stable between 30-33, and was 33.4 at time of discharge. She was restarted on her ASA 162 mg QD, but her plavix will be held indefinitely per recommendations from surgery. She did have a desaturation from 97% on 4L to 89% on [**1-16**], likely [**12-26**] fluid overload from transfusions, but improved quickly to baseline after 20 mg IV lasix. A Chest X-ray showed no evidence of pneumonia or CHF, but continued to show small bilateral pleural effusions. A copy of the report from her CTA of the chest at the OSH was obtained, and also showed no evidence of pneumonia and small bilateral pleural effusions. In discussion with son, patient was always slightly short of breath with minimal exercise [**12-26**] to her severe valvular disease. Gentle diuresis was continued and eventually returned to her home dose of 10 mg QOD. She was placed on 2.5 mg lisinopril qd to decrease afterload for her CHF. Her steroids were also gradually tapered, and she will finish her taper over the next 5 days. At time of discharge, she had an oxygen saturation of 94% on RA. PT was consulted and felt that patient would benefit from 24 hour services at home and PT services. However, the family felt that this was infeasible at this time because of other illness in the family. The patient was screened for rehab at [**Hospital1 **], where the patient's daughter is, and accepted. Medications on Admission: Outpatient medications: asp irin 162 mg PO QD ate nolol 25 mg a day Detrol-LA 2 mg QD Lasix 20 mg QOD Plavix 75 mg a day Protonix 40 mg QD Synthroid 25 mcg QD fosamax 70 mg Qweek Tums TID Vitamin B12 110-0.5 QD Vitamin D 400 U QD Discharge Medications: 1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every Saturday). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Disp:*1 month supply* Refills:*2* 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day): do not administer within 2 hours of levothyroxine. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for diarrhea. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days: 20 mg for 2 days, then decrease to 10 mg for 2 days, then decrease to 5 mg for 2 days, then stop. Tablet(s) 13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: after finishing 20 mg for 2 days. 14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: after finishing 10 mg for 2 days. 15. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 16. Aspirin 162 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 17. Detrol LA 2 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. 18. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 19. Vitamin A 8,000 unit Capsule Sig: One (1) Capsule PO once a day. 20. Vitamin B-12 250 mcg Tablet Sig: One (1) Tablet PO twice a day. 21. Lasix 20 mg Tablet Sig: [**11-25**] tablet Tablet PO every other day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Retroperitoneal hemorrhage Asthmatic bronchitis Congestive Heart Failure Discharge Condition: fair Discharge Instructions: 1. Please take all medications as prescribed. 2. Please keep all follow-up appointments. 3. Please seek medication attention if you develop worsened left lower quadrant abdominal pain, lightheadedness, chest pain, worsened shortness of breath, nausea, vomiting, diarrhea, constipation or have any other concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 5647**], M.D. Date/Time:[**2177-4-3**] 10:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2177-6-10**] 11:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) 5647**], M.D. Date/Time:[**2177-1-23**] 11:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2177-2-13**] 1:45 PM Completed by:[**2177-1-17**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12732, 12804

6819, 10377

283, 289

12921, 12928

2859, 6796

13300, 13826

2395, 2406

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12825, 12900

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12952, 13277

2421, 2840

10427, 10635

224, 245

317, 1988

2010, 2279

2295, 2379

79,575

127,630

29860

Discharge summary

report

Admission Date: [**2194-9-18**] Discharge Date: [**2194-10-5**] Date of Birth: [**2160-1-13**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Compazine Attending:[**First Name3 (LF) 800**] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: 1. Liver biopsy 2. Intubation with mechanical ventilation 3. Flexible sigmoidoscopy History of Present Illness: Ms [**Known lastname 71411**] is a 34 y.o. F with Crohn's disease on Imuran and Pentasa, who started having fever, headache, myalgias, rhinorrhea, and sore throat on [**2194-9-1**]. Prior to this, she had travelled to [**Country 6607**] 12 days earlier. Was in some rural areas. She came to the [**Hospital1 **] ER 1 week prior to her admission in early [**Month (only) **] for feeling unwell. She was sent home. Her symptoms worsened and she went to her PCP's office, who by report, tested her for influenzae, which was positive. She was not put on Tamiflu given her symptoms were > 48 hours. Symptoms worsened and she presented again to the [**Hospital1 **]-N ED on [**9-13**]. . The patient was admitted to [**Hospital1 **]-N ICU and was found to be influenzae and mycoplasma positive. She was started on tamiflu for 5 days. Pt also found to have Mycoplasma IgM positive on [**2194-9-17**], which was thought to be cause of her hepatitis as well. CTA chest was completed also which revealed bilateral lobe consolidation concerning for pna, small bilateral pleural effusions, small pericardial effusion, and splenomegaly. She was treated for secondary bacterial pneumonia as [**Doctor Last Name **]. Initially on ceftriaxone and doxycycline, then changed to vanco and zosyn after continued to be febrile 101. When mycoplasma was returned positive, zosyn changed to levaquin and doxy was stopped. Continued to be tachypneic with shallow breathing. . During her time at [**Hospital1 **]-N, the patient had transaminitis. Initially, thought to be obstructive process. HIDA revealed severe liver dysfunction. MRCP showed hepatosplenomegaly with concerns of early portal hypertension. INR 1.6 on discharge. She was seen by surgery and gastroenterology. Thought that hepatitis was due to mycoplasma. She was also noted to be pancytopenic --> heme was consulted and no evidence of hemolysis. Thought to be BM suppression secondary to infection with thrombocytopenia for splenomegaly. . She was transferred to [**Hospital1 18**] for further workup. Currently, the patient feels that she has a painful, dry throat. She is asking for ice chips. She has worsened diffuse abdominal pain different from a Crohn's falre. If she moves or hiccups, the abdominal pain is worse. She notes gaining wt recently but cannot tell me how much -- possibly 10 lbs while at [**Location (un) 620**]. . ROS: Endorses weakness, mild fevers, nasal congestion, nonproductive cough, chest pain, increased SOB that has worsened at [**Location (un) **]. Denies melena, hematochezia, dysuria, hematuria, rhinorrhea, ankle swelling. Past Medical History: Crohn's disease low sex drive on low dose testosterone depression osteopenia spontaneous abortion x 1 Social History: Lives at home with her family. Recently had a son who goes to daycare. Independent of ADLs. Denies tobacco, alcohol, illicit drug use. Family History: Noncontributory Physical Exam: Admission physical exam Vitals - T: 98.5 BP: 121/68 HR: 112 RR: 25 02 sat: 96% 4 L NC GENERAL: ill appearing young female, tachpnic HEENT: slightly icteric sclera, OP - no exudate, no erythema, no cervical LAD CARDIAC: tachycardic, no m/r/g LUNG: decreased BS at bases bilaterally, no w/r/r ABDOMEN: distended, diffusely tender to palpation but no rebound or guarding, no HSM palpated but could not palpate due to likely ascites, + fluid wave, + shifting dullness EXT: no c/c/e, asterixis with arms outstretched NEURO: A&O x 3 (name, [**Location (un) 86**], [**2194**], president [**Last Name (un) 2753**]) DERM: no rashes, no petechiae, no eccymoses, slight jaundice Pertinent Results: Laboratories: [**2194-9-18**] 07:47PM BLOOD WBC-10.2# RBC-2.88*# Hgb-8.7*# Hct-27.7*# MCV-96 MCH-30.2 MCHC-31.4 RDW-17.4* Plt Ct-197 [**2194-9-18**] 07:47PM BLOOD Neuts-57 Bands-23* Lymphs-10* Monos-3 Eos-0 Baso-0 Atyps-5* Metas-2* Myelos-0 NRBC-3* [**2194-9-18**] 07:47PM BLOOD PT-17.7* PTT-68.7* INR(PT)-1.6* [**2194-9-18**] 07:47PM BLOOD ALT-309* AST-1623* LD(LDH)-2046* AlkPhos-196* Amylase-69 TotBili-7.7* DirBili-6.0* IndBili-1.7 Lipase-52 Albumin-1.9* [**2194-9-18**] 07:47PM BLOOD Glucose-38* UreaN-21* Creat-0.8 Na-133 K-5.0 Cl-102 HCO3-18* AnGap-18 Calcium-7.3* Phos-2.6*# Mg-3.0* [**2194-9-18**] 07:47PM BLOOD Iron-103 calTIBC-100* Hapto-<20* Ferritn-GREATER TH TRF-77* [**2194-9-24**] 02:46AM BLOOD Triglyc-752* [**2194-9-18**] 10:41PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**Doctor First Name **] antibody-NEGATIVE Smooth muscle antibody-NEGATIVE tTG-IgA-32* HCV Ab-NEGATIVE HERPES 6 DNA PCR--negative ADENOVIRUS PCR-negative CERULOPLASMIN-normal range HEPATITIS E ANTIBODY (IGM)-negative HEPATITIS E ANTIBODY (IGG)-negative HERPES SIMPLEX (HSV) 1, IGG-Test--negative HERPES SIMPLEX (HSV) 2, IGG-Test--negative ALPHA-1-ANTITRYPSIN-331 H [**2194-10-1**] 05:15AM BLOOD IgG-1423 IgA-265 IgM-680* [**2194-9-19**] 02:06AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CMV IgG ANTIBODY (Final [**2194-9-19**]): POSITIVE FOR CMV IgG ANTIBODY BY EIA. 18 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final [**2194-9-19**]): POSITIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: SUGGESTIVE OF RECENT/ACTIVE INFECTION. A positive IgG result generally indicates past exposure. Infection with CMV once contracted remains latent and may reactivate when immunity is compromised. Interpret IgM result with caution; liver disease, autoimmune and lymphoproliferative diseases may cause false positive results. IgM antibody may persist for 6 months or longer after primary infection and may reappear during reactivation. Greatly elevated serum protein with IgG levels >[**2185**] mg/dl may cause interference with CMV IgM results. Submit follow-up serum in [**2-4**] weeks. [**2194-9-19**] Blood CMV viral load 38,200 copies/mL Imaging: CT abd/pelvis ([**9-19**]): IMPRESSION: 1. Thickening and irregularity of the entire terminal ileum with fistula formation consistent with Crohn's disease. Interval resolution of abdominal phlegmon with minimal scarring and no definite mesenteritis. 2. Abdominal ascites. 3. Bilateral pleural effusions with atelectasis. 4. Moderate pericardial effusion. 5. Thickening of the right colon likely secondary to hepatitis and third spacing. 6. Hepatosteatosis and hepatomegaly. Liver biopsy: [**2194-9-19**]: Liver, transjugular needle biopsy: 1. Moderate diffuse lobular mixed inflammation composed of lymphocytes and neutrophils. 2. Cellular changes consistent with cytomegalovirus effect. 3. Severe mixed steatosis without associated intracytoplasmic hyalin. 4. Focal balloon cell degeneration is seen. 5. Scattered cell show immunoreactivity for cytomegalovirus. 6. No immunoreactivity is seen for HSV [**1-3**]. 7. Trichrome and iron stains are pending, and will be reported in an addendum. Note: The findings of severe steatosis, balloon cell degeneration, and lobular mixed inflammation raises the possibility of a pre-existing with toxic metabolic injury with superimposed CMV infection. RUQ ultrasound ([**9-26**]): IMPRESSION: Small amount of ascites localized to inferior aspect of right lower quadrant and left lower quadrant. Abdominal U/S with doppler ([**10-1**]): IMPRESSION: 1. Hepatosplenomegaly with echogenic liver. Echogenic liver may be related to diffuse fatty infiltration or other forms of liver disease. 2. Appropriate directional flow of hepatic arteries, hepatic veins, and portal veins. 3. Diffuse gallbladder wall edema, similar to the CT from [**2194-9-19**]. The gallbladder is only moderately distended, and may be secondary to hepatitis. Sigmoid colon biopsy ([**10-1**]): DIAGNOSIS: Colon, sigmoid, mucosal biopsy: No diagnostic abnormalities recognized. Small bowel followthrough ([**10-3**]): IMPRESSION: 1. Terminal Ileum with nodular lymphoid hyperplasia. 2. Multiple fistulae between the cecum and terminal ileum, with involvement of the appendix. 3. Nonobstructive mid-ileal stricture. Brief Hospital Course: Summary: 34 YO F w/ longstanding Crohn's disease on Imuran, w/ fevers and respiratory distress x 2weeks, fulminant liver failure, influenza A and mycoplasma IgM +. Cytomegalovirus hepatitis: While in the MICU, the patient developed fulminant hepatic failure and was subsequently transferred to the surgical ICU and placed on the transplant list. The patient was noted to be briefly encephalopathic and started on lactulose. On biopsy, the patient was confirmed to have a CMV hepatitis and started on gancyclovir. Tests for hepatitis A/B/E, [**Doctor First Name **], HSV, ferritin, ceruloplasmin, adenovirus, varicella were within normal limits. The anti-smooth muscle antibody was high. The patient was placed on Ursodiol for hyperbilirubinemia. Her INR was elevated, so she was given vitamin K. On the gancyclovir treatment, the patient's liver enzymes steadily improved, however, they started to rise towards the end of her admission. There was concern that the gancyclovir was possibly hepatotoxic and she was therefore changed to valgancyclovir for an induction period of one week post-discharge followed by a maintenence period. On the valgancyclovir, her liver enzymes improved and will be followed as an outpatient. Since she had liver damage, her home wellbutrin and testosterone will be held on dischare until her followup GI appointment. Crohn's disease: The patient has a history of Crohn's disease and had known fistulas in the terminal ileum. Her Imuran was stopped, since its use predisposed her to CMV infection. The patient continued to have abdominal pain with diarrhea. The abdominal pain was controlled with dilaudid. There was concern that her diarrhea was related to CMV colitis, however a simoidoscopy with biopsy showed no concerning infection. A small bowel followthrough was done to see if her Crohn's was flaring. The followthrough was normal and showed known fistulas. The patient continued treatment with mesalamine and was not discharged on an immunomodulator. She will have outpatient followup to decide further treatment. Respiratory distress: The patient was transferred with respiratory distress. She was found to have bilateral pleural effusions and infiltrates. She was influenza A positive (records not available) and finished a course of Tamiflu. She was also found to have Mycoplasma IgM, however, infectious disease thought it might have been a false positive. Despite ID concerns, the patient was given a 5 day course of azithromycin. She needed to be intubated for her respiratory distress and had an uncomplicated extubation. Normocytic anemia: The patient developed a normocytic anemia and was found to have guiaic positive stool. She was transfused 4 units of blood. There was concern for a transfusion related reaction (fever), so the patient was given leuko-reduced transfusions. A pathology consult thought a transfusion reaction was unlikely saying "although the patient experienced oxygen desaturation, had a low arterial PO2, and developed crackles at the time of the transfusion, it is difficult to separate these from the findings from the symptoms she is experiencing due to her underlying condition. The lack of diffuse infiltrates on CXR and the lack of hypotension temporally associated with the transfusion make transfusion-related acute lung injury (TRALI) unlikely. In addition, an anaphylactic reaction is unlikely because she did not experience other systemic manifestations of such a reaction, such as erythema, urticaria, hypotension, flushing, or GI symptoms. It was unclear whether bronchospasm was directly associated with the transfusion. However, it is known that bronchospasm was suspected many hours after the transfusion, making it more likely that it was due to her underlying lung infection than the transfusion. Finally, as the patient has been experiencing fevers throughout her hospitalization, and given that leukoreduction significantly decreases the incidence of febrile non-hemolytic transfusion reactions, the patient's fever is most likely due to her underlying illness and not the transfusion." Upon transfer to the medical floors, the patient had a stable hematocrit without signs of bleeding. Papilledema: The patient developed papilledema in the setting of fulminant liver failure and intubation. Neurology evaluated the patient and thought "The patient is at risk for cerebral edema due to liver failure, poor synthetic function, and difficulty holding fluid in the vascular space. She is hypocoagulable and at risk for bleeeding due to her poor synthetic function; however, she is simultaneously hypercoagulable and at increased risk for thrombosis due to her history of Crohn's disease and prior spontaneous abortion. She is also at risk for meningitis and encephalitis due to her prior infection and unknown cause of her liver failure." An MRV of the head ruled out sinus thrombosis and a head CT was normal. Hyponatremia: The patient developed hyponatremia, most likely due to SIADH. She was fluid restricted to 1500 cc/day and it resolved. Nutrition: The patient was placed on TPN while in the SICU because she was intubated and had poor PO intake greater than 7 days. Her alkaline phosphatase was likely high secondary to TPN use. On transfer to the floors, the patient was able to take POs, so TPN was discontinued. Upon its discontinuation, the alkaline phosphatase level trended towards normal values. Medications on Admission: Medications at home: --Wellbutrin 150 mg --Imuran 150 mg --Pentasa 500 mg --Testosterone . Med on transfer: Nexium 40, Vancomycin 1'', Levaquin 750, Folic acid, iron 325'', Pentasa 500'', Wellbutrin 150'', Tamiflu'' Discharge Medications: 1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 2. Mesalamine 500 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO four times a day. Disp:*240 Capsule, Sustained Release(s)* Refills:*2* 3. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take 2 pills twice a day until [**10-11**]. On [**10-12**], you should take 2 pills once a day for 2 months (last day [**12-12**]). Disp:*148 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: 1. CMV hepatitis 2. Crohn's disease 3. Respiratory distress . Secondary: 1. Influenza A 2. Mycoplasma pneumonia Discharge Condition: Stable. Patient ambulating, on room air Discharge Instructions: You came to the hospital after being transferred for shortness of breath. You were treated for your mycoplasma pneumonia. You developed liver failure which made you confused. You required intubation to help you breathe. A biopsy showed that you had CMV, a virus, infecting your liver. Therapy with Gancyclovir was started and you started to improve. You were originally listed on the liver transplant list, but your name was removed. Your infections were most likely due to Imuran for your Crohn's so it was stopped during this illness. You liver tests improved. . You also developed diarrhea and abdominal pain. It might have been related to your Crohn's flare. A flexible sigmoidoscopy was perfomed and it looked grossly normal, biopsies were normal. You also had a barium swallow which showed stable fistulas. Your blood and stool cultures have been all negative. . Your medications have been changed. You should take your medications as instructed. You should not start any of your old medications until your appointment with Dr. [**Last Name (STitle) 3708**]. . You have a followup appointment with Dr. [**Last Name (STitle) 3708**], a GI specialist. He knows about you and will follow your laboratories. . You should come back to the hospital if you have fevers or chills, shortness of breath, become confused, or have worsening diarrhea or abdominal pain. . Use a mask and be sure to do frequent handwashing when interacting with a sick child. Followup Instructions: Appointment #1 MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3708**] Specialty: Gastroenterology Date and time: Thursday, [**10-9**] at 10:20am Location: [**Hospital1 **], [**Hospital Ward Name 516**], [**Hospital Ward Name 452**]/Rose 1 Phone number: [**Telephone/Fax (1) 463**] . Appointment #2 MD: Dr [**Last Name (STitle) 16151**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6624**] Specialty: Primary Care Date and time: Friday [**10-10**] at 10:30am Location: [**Location (un) **], [**Apartment Address(1) 6850**], [**Location (un) 71412**] ,[**Numeric Identifier **] Phone number: [**Telephone/Fax (1) 3329**] Special instructions if applicable: . You will also have an appointment to followup with the infectious disease doctor. You should call Dr. [**First Name (STitle) **] for an appointment, [**Telephone/Fax (1) 6732**]. It can be in the morning of [**10-20**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

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icd9cm

[ [ [] ] ]

[ "96.72", "38.91", "96.04", "99.15", "33.24", "45.25", "50.11", "38.93" ]

icd9pcs

[ [ [] ] ]

14741, 14799

8531, 13940

313, 399

14963, 15005

4040, 8508

16504, 17549

3320, 3337

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14820, 14942

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3352, 4021

253, 275

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3168, 3304

49,998

198,445

39731

Discharge summary

report

Admission Date: [**2171-9-24**] Discharge Date: [**2171-9-30**] Date of Birth: [**2093-12-14**] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2724**] Chief Complaint: increased lethargy and unsteadiness Major Surgical or Invasive Procedure: Right craniotomy with evacuation SDH History of Present Illness: 77 yo woman with a PMHx significant for DM2, HTN, and hyperlipidemia presents with increasing weakness over past 2 weeks, lethargy and unsteadiness (per family). Pt is s/p Right SDH evacuation via burr hole on [**2171-9-11**].She has had 2 episodes of incontinence which she attributes to not ambulating fast enough. Pt presented to her PCP today who sent her to the emergency room for CT scan. CT scan revealed re-accumulation of SDH (chronic) and she was transferred to [**Hospital1 18**]. Pt denies h/a, vision changes,N/V. Past Medical History: PMHx: Type II Diabetes HTN HL Social History: Patient lives in [**Location 8242**] w/ her husband who worked as a mechanic. She is from [**Location (un) **] [**Country 2559**] and speaks only italian but has been living in the country for the past 44 years. Non-smoker, no EtOH Family History: Mother and Father both were healthy into their late 80s. 4 children - 1 deceased (not medical cause) 3 other children healthy Physical Exam: PHYSICAL EXAM: O: T:99.2 BP: 137/62 HR:78 R 16 O2Sats 98% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs intact Neck: Supple. Abd: Soft, NT Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place only. Language: Speech with good comprehension of simple questions (language barrier). Speaking with family appropriately. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-17**] throughout. No pronator drift Sensation: Intact to light touch Exam upon discharge: xxxxx Pertinent Results: CT (head) - reviewed from OSH. Chronic right SDH, increasing in size and MLS compared to previous scan. Brief Hospital Course: Pt was admitted to the ICU for close monitoring. She was brought to the OR [**9-25**] where under general anesthesia she underwent craniotomy with evacuation of SDH. Post-op she was extubated and returned to ICU for close monitoring. She was less lethargic and neurologically intact with the exception of poor date identification though this is reportedly her baseline by the family. Post op CT showed good resolution of SDH collection. On POD#1 she had some hypotension to systolic of 80's and her hematocrit was 26. She received fluid bolus and 2u PRBC transfusion. Her HCT on repeat testing increased to 29.6 and she had no further episodes of hypotension. She was transfered to the floor in stable condition on POD#2. A repeat CBC on this day showed stable HCT at 29.7. Upon exam she was non focal and AOx3. She was seen by physical therapy and occupational therapy and plan was for discharge to a rehab facility vs home pending her progress. The physical therapy team saw her again on [**9-29**] and cleared her for discharge home with family support on [**9-30**]. Medications on Admission: Glyburide 5 mg Amitriptylene 10 mg Januvia 100 mg Metformin 1000 mg Lisinopril 5 mg Simvistatin Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 2. lisinopril 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. sitagliptin 100 mg Tablet Sig: One (1) Tablet PO daily (). 6. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 2436**] Home Care Discharge Diagnosis: Right subdural hematoma hypotension acute blood loss anemia with transfusion Discharge Condition: AOx3. Activity as tolerated. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? 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 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. Followup Instructions: Please have your staples removed the week of [**10-7**]. Call to schedule this appt. You will also need appt in 4 weeks with Head CT. Please call [**Telephone/Fax (1) 2992**] to arrange. Completed by:[**2171-9-30**]

[ "285.1", "432.1", "250.00", "272.4", "458.29", "401.9" ]

icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

4462, 4523

2636, 3715

333, 372

4644, 4675

2506, 2613

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1247, 1374

3861, 4439

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258, 295

400, 928

1840, 2459

1606, 1824

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2480, 2487

65,779

138,640

48529

Discharge summary

report

Admission Date: [**2161-5-27**] Discharge Date: [**2161-6-2**] Date of Birth: [**2100-7-22**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1481**] Chief Complaint: Gastroesophageal reflux disease Major Surgical or Invasive Procedure: [**2161-5-27**] Laparoscopic Nissen fundoplication History of Present Illness: Mr. [**Known lastname **] is a 60-year-old man who has had a long history of gastroesophageal reflux symptoms with heartburn and regurgitation. He has also had some episodes of nocturnal coughing and pneumonia. He is admitted this hospitilization for management after laparoscopic Nissen fundoplication. Past Medical History: - Colon polyps. [**Known lastname **] [**2157**] adenoma. Colon [**4-24**] adenomas, diverticulosis. -Extensive diverticulosis - h/o diarrheal illness: C. diff, [**Country 4825**] stain negative. Small bowel x-ray negative. [**Country **] no evidence for microscopic colitis, TI normal [**4-24**]. - GERD-diagnosed in [**2153**]. - Barrets [**4-24**] - Duodenal ulcer remote - HP treatment - Pancreatic Cysts-Pancreatic tail lesion on [**2-22**] on CAT scan. MRCP-1 cm dense cyst with a dense wall [**4-24**] - EUS. - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Tear - CVA in [**2151**] - Mitral valve fibroelastoma - HTN - HL - lumbar radiculopathy - migraines - allergies - left inguinal hernia - hepatitis A Social History: Smoking/Tobacco: Currently 1ppd, 40 pack-year smoking history EtOH: Occasional Illicits: None Lives with wife & son Family History: Father - died of colon cancer, no other GI cancers in the family or any chronic intestinal diseases Physical Exam: Vitals:Temp 98.2, HR 64, BP 144/76, RR 18, 95% Room air CV:RRR Resp: CTAB Abd: soft, mod distended, incisions c/d/i, steristrips in place Ext: No LE edema Pertinent Results: [**2161-6-2**] 06:45AM BLOOD WBC-7.1 RBC-5.08 Hgb-13.7* Hct-42.5 MCV-84 MCH-27.0 MCHC-32.3 RDW-15.2 Plt Ct-387 [**2161-6-2**] 06:45AM BLOOD Glucose-96 UreaN-21* Creat-0.9 Na-140 K-4.9 Cl-103 HCO3-24 AnGap-18 [**2161-6-1**] 06:25AM BLOOD Glucose-98 UreaN-23* Creat-1.1 Na-138 K-4.7 Cl-102 HCO3-26 AnGap-15 [**2161-5-31**] 01:07AM BLOOD Glucose-115* UreaN-18 Creat-1.6* Na-138 K-4.6 Cl-101 HCO3-28 AnGap-14 Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**2161-5-27**] for laparoscopic Nissen fundoplication. He tolerated this procedure well and had an uneventful stay in the PACU. He was moved to the floor later that evening By systems his hospital course was such: Neuro: Initially his pain was controlled with a morphine PCA and Toradol. He was transitioned to PO medication and Toradol on POD1. His Dilaudid PCA was discontinued. Due to an elevation in creatinine, his Toradol was discontinued on POD4. Cardiovascular: His rhythm was occasionally sinus bradycardia following his procedure. His blood pressure medications were held for low HR and low-normal BP on POD1 and POD2. On POD3 he had an episode of atrial fibrillation with rapid ventricular response responsive to 5 mg IV Lopressor one time. This was accompanied with worsening shortness of breath. An EKG was performed which did not show any signs of ischemia or cardiac process. Chest xray showed worsening interstitial edema. He was transferred to the ICU. Cardiac enzymes were cycled and negative X3. He had no recurrence of atrial fibrillation but continued to have sinus bradycardia occasionally, which is his baseline preoperatively. Respiratory: In the postoperative period, Mr. [**Known lastname **] had persistent oxygen requirement and SOB. On POD1 he had persistent desaturations during ambulation. This resolved initially with nebulizer treatments. On POD1 however, he had continued desaturations with ambulation. He received Lasix one time for what was suspected to be postoperative effusions. On POD3 he had coinciding atrial fibrillation with rapid ventricular response. He was transferred to the ICU where he received nebulizers and lasix for diuresis. After a 24 hours stay in the ICU, he was weaned off oxygen to room air and transferred to the floor. There, he still had shortness of breath, but it was significantly. He was able to ambulate without O2 requirement and do stairs with physical therapy. Gastrointestinal: Postoperatively, he was NPO the night after his Nissen fundoplication. On POD1 he was advanced to sips and then clears, which he tolerated well. On POD2 he was advanced to regular diet with Nissen precautions which he tolerated well. Genitourinary. Mr. [**Known lastname **] had a Foley catheter in the postoperative period. It was discontinued on POD1. He voided appropriately thereafter. On POD4, he had an elevation in his creatinine suspected to be secondary to Lasix. His nephrotoxic medications were discontinued. His creatinine improved the following day (from 1.6 to 1.1). Consults: Mr. [**Known lastname **] was seen by physical therapy on [**2161-6-2**]. They ambulated with him and had him do stair work. He had no desaturations and was able to move comfortably. He was recommended to home without services. He was discharged to home on [**2161-6-2**]. Medications on Admission: Atorvastatin 20', Baclofen 10''', Dexlansoprazole 60'', Dicyclomine 10'', folic acid 1', Lisinopril 10', Metoclopramide 5 before lunch and HS, Mirtazapine 7.5 qHS, Ranitidine 150'', Sertraline 100', Verapamil 120', ASA 325', Loperimide PRN Discharge Medications: 1. Acetaminophen 650 mg PO Q6H pain RX *acetaminophen 650 mg q 6 hours Disp #*40 Tablet Refills:*0 2. Atorvastatin 20 mg PO DAILY 3. Baclofen 10 mg PO TID 4. DiCYCLOmine 10 mg PO BID 5. Docusate Sodium 100 mg PO BID RX *Colace 100 mg twice a day Disp #*60 Tablet Refills:*0 6. FoLIC Acid 1 mg PO DAILY 7. Lisinopril 10 mg PO DAILY 8. Metoclopramide 5 mg PO BID give 1 before lunch, 1 before bedtime 9. Mirtazapine 7.5 mg PO HS 10. Nicotine Patch 14 mg TD DAILY 11. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain RX *oxycodone 5 mg q 4 hours Disp #*40 Tablet Refills:*0 12. Ranitidine 150 mg PO BID 13. Sertraline 100 mg PO DAILY 14. Verapamil 120 mg PO DAILY 15. dexlansoprazole *NF* 60 mg Oral [**Hospital1 **] 16. Aspirin 325 mg PO DAILY Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Gastroesophageal reflux Postoperative hypoxemia, responding to diuretics Atrial fibrillation with rapid ventricular response Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], You were admitted to the west 3 surgery service for laparoscopic Nissen fundoplication for your reflux. This means that your stomach is wrapped around its upper edge to prevent reflux. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or operate heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until cleared by your surgeon. *You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. *You are [**Female First Name (un) **] regular diet but continue to eat non-sharp food. No bread please. Followup Instructions: Please call Dr.[**Name (NI) 1482**] office to schedule an appointment in [**1-16**] weeks. Office number is [**Telephone/Fax (1) 2981**]. Completed by:[**2161-6-2**]

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icd9cm

[ [ [] ] ]

[ "44.67", "53.71" ]

icd9pcs

[ [ [] ] ]

6287, 6336

2352, 5222

334, 387

6504, 6504

1923, 2329

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5513, 6264

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263, 296

415, 722

6519, 6631

744, 1480

1496, 1614

58,616

169,050

49307

Discharge summary

report

Admission Date: [**2127-7-23**] Discharge Date: [**2127-7-29**] Date of Birth: [**2042-9-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: s/p Cath with pulmonary edema Major Surgical or Invasive Procedure: 1)Diagnostic Cardiac Catheterization 2)Cardiac Catheterization s/p Left Circumflex and Left Main Coronary Stenting and Right Coronary Angioplasty History of Present Illness: 84 yo M w/ Cerebral palsy, mild MR, seizure d/o, sCHF, recent echo showed worsening MR, mod pulm HTN, and biventricular dysfunction. Patient had catheterization today showing diffuse CAD with elevated PCWP and pulmonary edema. History obtained from patient, group home manager, and medical records. Patient has some occasional shortness of breath that does not appear to be associated with exertion. Also has occasional cough with mild sputum production. Denies orthopnea, PND, recent chest pain. Group home manager agrees with patient's history. Patient denies diarrhea or constipation, nausea or vomiting, or changes in weight. Patient was seen in [**Month (only) **] by Dr. [**Last Name (STitle) **] for evaluation of c/o exertional chest pain and was treated medically. Patient was also admitted for chest pain in [**2-5**] when ruled out for MI. ECHO done on [**2127-6-26**] showed Severe biventricular hypokinesis c/w diffuse process (multivessel CAD, toxin, metabolic, etc.). Moderate pulmonary artery systolic hypertension. Mild-moderate mitral regurgitation. It showed worsening function in comparison to ECHO in [**11-6**]. Cardiac perfusion imaging done in [**11-6**] showed no new or reversible perfusion defects. Stable fixed perfusion defects involving distal anterior, apex and septum and worsening hypokinesis and left ventricular cavity dilatation. LVEF=28%. In cath, CO was 4.17 with CI of 2.69. PA sat of 60%, PCWP of 40 with RA pressure of 15. LAD was occluded, LMCA 60% ostial occlusion and 80% mid. LCX 80% mid and RCA occluded. Patient was given Lasix 40mg IV and admitted to the CCU for aggressive diuresis. Past Medical History: 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none . OTHER PMH: - Right eye cataract - bilateral carotid stenosis ([**2126-8-1**] U/S : right 60-69% stenosis, on the left a 40-59% stenosis) - Seizure disorder (resistant to keppra) - Legally blind in left eye. - Gastroesophageal reflux disease. - Osteoarthritis. - Mild MR secondary to Cerebral Palsy - Prostate cancer, with radiation proctitis secondary to XRT - Status post left wrist fusion. - Status post CVA with residual left sided hemiparesis. - Hearing loss Social History: The patient lives in a group home. He denies any history of tobacco or alcohol. No h/o illicit drug use. He states his niece is invloved with his care and lives nearby; visits him at his group home often. -Tobacco history:none Family History: No family history of arrhythmia, cardiomyopathies, or sudden cardiac death; but he states his brother has "heart disease" and high cholesterol. Physical Exam: VS: T= 96.4 BP=100/54 HR=51 RR=15 O2 sat= 97% 2L NC GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm while supine CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. Distant heart sounds. LUNGS: Resp were unlabored, no accessory muscle use. Decreased breath sounds, particularly at bases. Diffuse crackles. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Non tender right groin. No evidence of hematoma SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: 1+ DP Left: 1+ DP Pertinent Results: Cardiac Cath Study Date of [**2127-7-23**] COMMENTS: 1. Selective coronary angiography in this right-dominant systems demonstrated severe three vessel coronary artery disease. The LMCA had a 60% ostial stenosis and an 80% mid-segment stenosis. The LAD was occluded. The LCx had an 80% mid-segment stenosis. The RCA was also occluded. 2. Resting hemodynamics revealed elevated right-sided filling pressures with an RVEDP of 11 mmHg. There was severe pulmonary arterial hypertension with a PA systolic pressure of 88 mmHg; however, this must be interpreted in the context and severe left-sided volume overload with a mean baseline PCWP of 40 mmHg. There is mild systemic systolic arterial hypertension with an SBP of 139 mmHg. FINAL DIAGNOSIS: 1. Severe three vessel coronary artery disease. 2. Severe left sided volume overload. 3. Severe pulmonary hypertension. 4. Mild systemic systolic arterial hypertension. 5. Admitted to CCU for diuresis and surgical consultation. Cardiac Cath Study Date of [**2127-7-28**] COMMENTS: US guided access of B/l femoral arteries and right femoral vein Transseptal puncture and LHC. LA with marked V waves. Tandem heart initiated with hemodynamic support. Coronary Angiogram: LMCA: 60% ostial and 80% mid LAD: Occluded LCX: 80% mid RCA: occluded mid Successful PTCA/Stenting of LMCA with PROMUS 3.0 X 23 mm DES at 20 atms Successful PTCA/stenting of mid LCX with PROMUS 3.0 X 15 [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 103322**] of prox/mid RCA with 2.0 X 40 mm Apex Rx balloon at 4-8 atms. 30-40% residual with diffuse disease and small dissection with normal flow. Tandem heart support was removed at end of procedure. hemodynamically stable. FINAL DIAGNOSIS: 1. Successful drug eluting stenting of LMCA and LCx arteries using Tandem Heart support. CHEST (PORTABLE AP) Study Date of [**2127-7-24**] 8:08 AM IMPRESSION: 1. Small bilateral pleural effusions, right greater than left. 2. Bibasilar opacities may represent atelectasis, pleural fluid or pneumonia, if clinically appropriate. 3. Mild cardiomegaly, unchanged. 4. Large hiatal hernia, unchanged. The study and the report were reviewed by the staff radiologist. CAROTID SERIES COMPLETE Study Date of [**2127-7-24**] 10:13 AM . There is antegrade right vertebral artery flow. There is antegrade left vertebral artery flow. Impression: Right ICA stenosis 60/69%. Left ICA stenosis 60-69% . [**2127-7-23**] 02:55PM BLOOD WBC-5.0 RBC-3.42* Hgb-11.1* Hct-33.9* MCV-99* MCH-32.4* MCHC-32.7 RDW-14.8 Plt Ct-202 [**2127-7-29**] 06:15AM BLOOD WBC-8.3 RBC-3.38* Hgb-10.9* Hct-32.5* MCV-96 MCH-32.1* MCHC-33.4 RDW-15.6* Plt Ct-190 [**2127-7-23**] 05:10PM BLOOD Neuts-70.8* Lymphs-20.7 Monos-5.5 Eos-2.6 Baso-0.4 [**2127-7-23**] 02:55PM BLOOD PT-16.1* PTT-32.0 INR(PT)-1.4* [**2127-7-29**] 06:15AM BLOOD PT-17.7* PTT-31.3 INR(PT)-1.6* [**2127-7-23**] 02:55PM BLOOD Glucose-102* UreaN-31* Creat-1.1 Na-137 K-4.4 Cl-102 HCO3-24 AnGap-15 [**2127-7-24**] 04:40AM BLOOD Glucose-103* UreaN-37* Creat-1.7* Na-139 K-4.5 Cl-104 HCO3-26 AnGap-14 [**2127-7-24**] 05:18PM BLOOD Creat-1.6* Na-139 K-4.0 Cl-103 [**2127-7-26**] 08:05AM BLOOD Glucose-98 UreaN-36* Creat-1.2 Na-139 K-4.0 Cl-104 HCO3-27 AnGap-12 [**2127-7-28**] 06:15AM BLOOD Glucose-98 UreaN-34* Creat-1.1 Na-138 K-3.6 Cl-107 HCO3-23 AnGap-12 [**2127-7-29**] 06:15AM BLOOD Glucose-113* UreaN-31* Creat-1.2 Na-141 K-3.7 Cl-109* HCO3-23 AnGap-13 [**2127-7-24**] 04:40AM BLOOD ALT-12 AST-23 LD(LDH)-263* AlkPhos-81 TotBili-0.3 [**2127-7-24**] 04:40AM BLOOD %HbA1c-5.4 eAG-108 Brief Hospital Course: Mr. [**Known lastname 1024**] is a 84 year old male with Cerebral palsy, mild MR, seizure d/o, systolic CHF, with recent echocardiogram showing worsening Mitral Regurg, mod pulm HTN, and biventricular dysfunction. Patient had catheterization today showing diffuse CAD with elevated PCWP and pulmonary edema. # Systolic Heart Failure: Patient has low EF and elevated PCWP. Patient denied symptoms; however, his exam was positive for diffuse crackles with decreased breath sounds at bases and elevated JVP. He had adequate oxygen saturations on 2L NC, and his BP was stable. He was fluid overloaded on exam and the overall goal was to diurese. He responded well to Lasix 40mg IV. His blood pressure decreased to low-normotensive and his creatinine was 1.2. Low doses of furosemide were adequate to diurese. The patient's outpatient provider should consider starting a beta-blocker pending normal heart rate and blood pressure in the future as the patient has systolic congestive heart failure with a low ejection fraction. . #CAD: Cath showed 3 vessel disease with likely ischemic cardiomyopathy. Last echo showed EF between 20-25%. Patient denies symptoms this admission, but noted years of anginal symptoms in the past. He has been considered for an ICD in the past but deferred given comorbidities and lack of heart failure symptoms at that time. However, since then, has worsened EF and development of sx from HF; could benefit from CRT given widened QRS. Seen by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] who does not believe he is a candidate for surgery. He underwent PCI on [**7-28**] and had successful drug eluting stenting of LMCA and LCx arteries using Tandem Heart support. Also there was balloon angioplasty of the RCA. He will be discharged on dual antiplatelet therapy with clopidogrel and aspirin for his drug eluting stents. . #Acute on Chronic Kidney Failure: Patient presented at baseline creatinine, but had jump to 1.7 from 1.1. Most likely etiology was prerenal secondary to fluid overloaded state and poor CO. Other possibilties included contrast nephropathy, however the bump in creatinine was too soon after the cath to be attributed to the dye. FeUrea is 29%, suggestive of prerenal azotemia. He had a creatinine of 1.2 at time of discharge. . #Seizure disorder: Unknown when last had a seizure. Reportedly refractory to Keppra. In house he was on phenobarbital without incident. . #Osteoarthritis: no current complaints of joint pain. NSAIDs were not given in the setting of aspirin use and need for anitplatelet agents in this patient with new drug eluting stents. Tylenol prn was used for pain control. . Medications on Admission: Ca Carbonate 500mg PO BID MVI daily Phenobarbital 60mg PO daily Omeprazole 20mg PO BID Diovan 40mg PO daily ASA 325 po daily Lipitor 10mg PO daily terazosin 2mg PO daily Lasix 20mg [**11-30**] tab PO daily debrox 6.5% 4 drops each ear 2X weekly Triacinolone cream 0.1mg to back of neck, arms, and lower legs [**Hospital1 **] Oxaprozin 20mg [**11-30**] tab PO daily Ferrous Sulfate 325mg PO daily Tylenol w/ codeine 30mg [**11-30**] tab q6hrs prn pain Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnosis: Coronary Artery Disease Acute on Chronic Renal Failure Systolic Congestive Heart Failure, Chronic Secondary Diagnosis: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Mr. [**Known lastname 1024**], Thank you for letting [**Hospital1 18**] participate in your care. You were admitted to us after an ultrasound evaluation of your heart showed decreased function, in addition to your symptoms of shortness of breath. A diagnostic cardiac catheterization allowed us to evaluate the coronary arteries and showed you had several blockages in your vessels that were causing your symptoms and decreased your heart function. We performed a therapeutic catheteriation procedure placing several stents in your left and right coronary arteries to relieve the blockages. This also required us to hook you up to a heart pump during the procedure that helped circulate your blood during the procedure. All the main blockages were relieved, with no complications. Please follow up with your primary cardiologist and primary care physician within two weeks of discharge. Call your primary care physician or go the the ER if you experience severe chest pain, shortness of breath, bleeding or pain in your groin incision sites, or any other concerning symptom. Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. PFO precautions. These are the medication changes made: 1) Please stop your ibuprofen, 2) we decreased your diovan (valsartan)to 40mg by mouth daily Followup Instructions: We recommend that you follow up with your cardiologist and Primary Care Physician after discharge. These are your already scheduled appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2127-10-7**] 10:00 Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2127-11-20**] 3:00 Provider: [**Name10 (NameIs) 161**] [**Name8 (MD) 6476**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2128-6-10**] 2:30 Completed by:[**2127-8-1**]

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icd9cm

[ [ [] ] ]

[ "00.66", "88.56", "36.07", "00.42", "00.46", "37.68", "37.23" ]

icd9pcs

[ [ [] ] ]

10761, 10819

7601, 10260

343, 491

11015, 11015

4025, 4760

12480, 13117

3051, 3196

10840, 10840

10286, 10738

5750, 7578

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274, 305

519, 2156

10979, 10994

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11030, 11099

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2807, 3035

25,251

188,623

8314

Discharge summary

report

Admission Date: [**2174-11-6**] Discharge Date: [**2174-12-9**] Date of Birth: [**2096-8-27**] Sex: M Service: MEDICINE Allergies: Penicillins / Morphine / Codeine / Cefazolin Attending:[**First Name3 (LF) 759**] Chief Complaint: falls, bacteremia Major Surgical or Invasive Procedure: Esophagastroduodenoscopy Cardioversion Intubation IR guided drainage of abcess PICC placement History of Present Illness: This is a 78 year old male with type II diabetes, severe peripheral [**First Name3 (LF) 1106**] disease, coronary artery disease s/p CABG and atrial fibrillation on coumadin who presents to the emergency room after two falls at home. The first fall occurred on [**2174-11-3**] at home when he fell in his kitchen. He hit is right shoulder and presented to the emergency room where he had a right clavicle xray which showed no fracture of dislocation and was discharged home with pain medications. The patient has very limited mobility at baseline and uses a wheelchair. He requires the use of his arms to help get out of bed and into his wheelchair and also for balance. He has had significant pain his his right arm since his fall and this has made getting around his house increasingly difficult. On [**2174-11-4**] he was trying to take a shower and had a plastic bag on his right foot to protect his foot ulcers. He tried to get out of the shower and he slipped on the plastic bag and fell on his right hip. Because his arm was hurt as well he was unable to get himself back to a seated position and lay on the ground for an hour before a friend found him and called 911. EMS came to his home but he did not want to come back to the hospital so they placed him in his bed. He reports that they placed him facing in the wrong position and he was unable to get out of bed or reach his pills so he has not been taking his pills now for 48 hours. He was so disabled that he ultimately called EMS again so that he could be brought to the emergency room. . In the ED, initial vs were: T: 99 P: 108 BP: 131/81 R: 16 O2 sat 99% on RA. He had a CXR which showed mild [**Date Range 1106**] prominence but no focal infiltrates. He had an xray of his right hip which was negative for fracture and a non-contrast head CT which showed no evidence of hemorrhage. Patient was given one liter of normal saline, zofran 4 mg IV x 1 and vancomycin 1000 mg IV x 1 out of concern for possible right shoulder cellulitis. He is admitted to the floor for further management. . On the floor he continues to have significant right shoulder pain. He has mild right hip pain but is able to move his right leg. He denies fevers, chills, lightheadedness, dizziness, chest pain or shortness of breath. He did have nausea earlier in the day but this has resolved. He denies abdominal pain, constipation, diarrhea, melena, hematochezia, dysuria or hematuria. He has minimal sensation in his feet bilaterally but denies foot pain. All other review of systems is negative in detail. Past Medical History: 1. CAD (s/p CABG, [**1-14**]) 2. CHF (EF 17% on pMIBI from [**3-17**]) 3. DM (diet controlled, HgA1c 6.2 on no agents) 4. PVD s/p R AK popliteal to post tibial artery bypass in [**3-14**], percutaneous intervention [**3-16**] s/p PTSG L [**7-14**] s/p plasty & stent of R SFA, plasty of PT [**2173-2-16**] 5. Afib/flutter on chronic anticoagulation 6. htxn 7. hyperlipidemia Social History: He lives by himself and does all of his own activities of daily living. He quit smoking in [**5-/2174**] but has a heavy smoking history. He uses a walker and a wheelchair to assist with ambulation. He does not currently drink alcohol or use illicit drugs. Family History: He has one brother with diabetes and one sister with stomach cancer. His mother had diabetes. His father died at age 79 of unclear reasons. He has four daughters and one son who are healthy. Physical Exam: On admission: Vitals: T: 100.0 BP: 154/96 P: 103 R: 20 O2: 99% on RA FS: 99 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Scarce inspiratory crackles at the bases, no wheezes, or ronchi CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops, well healed CABG scar Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: Warm, severe peripheral [**Year (4 digits) 1106**] disease, multiple toe amputations, small ulcer near nailbed on right second toe with dried blood, 2 x 2 cm healing ulcer on medial plantar right foot, dopplerable distal pulses bilaterally, decreased sensation in lower extremities throughout. Right shoulder with mild erythema and pain over palpation of the right clavical. Although he has 5/5 strength in the right upper extremity he is severely limited by pain, particularly with arm flexion. The right hip has pain over palpation near the right trochanteric bursa. There is no gross bruising. No significant pain with flexion or extension of the right leg. . On discharge: VSS, lungs clear, RRR, full movement in legs to anti-gravity. SC pain, errythema resolved. Foley in place. Exam otherwise unchanged Pertinent Results: LABS On Admission . [**2174-11-5**] 10:43PM BLOOD WBC-12.8* RBC-4.79 Hgb-12.9* Hct-38.4* MCV-80*# MCH-27.0 MCHC-33.7 RDW-15.8* Plt Ct-219 [**2174-11-5**] 10:43PM BLOOD Neuts-90.2* Lymphs-5.9* Monos-3.7 Eos-0 Baso-0.1 [**2174-11-5**] 10:43PM BLOOD PT-24.0* PTT-33.6 INR(PT)-2.3* [**2174-11-5**] 10:43PM BLOOD Glucose-84 UreaN-50* Creat-1.4* Na-134 K-4.0 Cl-100 HCO3-21* AnGap-17 [**2174-11-5**] 10:43PM BLOOD ALT-26 AST-56* CK(CPK)-786* AlkPhos-117 TotBili-0.4 [**2174-11-5**] 10:43PM BLOOD cTropnT-0.04* [**2174-11-6**] 08:10AM BLOOD CK-MB-9 cTropnT-0.04* [**2174-11-6**] 05:05PM BLOOD CK-MB-9 cTropnT-0.04* [**2174-11-6**] 08:10AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.1. On discharge: . [**2174-12-5**] 05:27AM BLOOD WBC-6.8 RBC-3.34* Hgb-9.3* Hct-28.0* MCV-84 MCH-27.8 MCHC-33.2 RDW-17.8* Plt Ct-171 [**2174-12-5**] 05:27AM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-136 K-3.9 Cl-98 HCO3-35* AnGap-7* [**2174-12-5**] 05:27AM BLOOD Calcium-7.9* Phos-3.6 Mg-1.9 . Other relevant labs: . [**2174-11-13**] 05:16AM Hct-22.1 . [**2174-11-29**] 04:34AM BLOOD ESR-44* [**2174-11-14**] 05:26AM BLOOD ESR-30* [**2174-11-10**] 05:59AM BLOOD ESR-72* [**2174-11-10**] 05:59AM BLOOD calTIBC-190 Ferritn-252 TRF-146* [**2174-11-29**] 04:34AM BLOOD CRP-9.3* [**2174-11-14**] 05:26AM BLOOD CRP-67.3* [**2174-11-10**] 05:59AM BLOOD CRP-215.1* . MICROBIOLOGY . [**11-6**] STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.5 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S . [**11-6**] WOUND CULTURE (Final [**2174-11-9**]): STAPH AUREUS COAG +. MODERATE GROWTH OF TWO COLONIAL MORPHOLOGIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S . [**11-7**] JOINT FLUID STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 1 S TRIMETHOPRIM/SULFA---- <=0.5 S . [**10-14**] HELICOBACTER PYLORI ANTIBODY TEST (Final [**2174-11-16**]): EQUIVOCAL BY EIA. . IMAGING [**11-5**] HIP XR IMPRESSION: No fracture or dislocation with degenerative changes at the hips bilaterally and extensive atherosclerotic disease with right femoral stents. . CXR Progression of mild pulmonary edema and redemonstration of large cardiomegaly. . [**11-6**] CT HEAD 1. No acute intracranial hemorrhage or acute fracture 2. Mild paranasal sinus disease. . CT UPPER EXT 1. Low attenuation collection about the right sternoclavicular joint, which is superiorly and anteriorly subluxed with surrounding soft tissue and muscular edema. Amorphous calcifications in both sternoclavicular joints. While infection must be excluded, these findings may be secondary to trauma in the setting of pre-existing CPPD arthropathy. 2. Circumferential thickening of the right pleura in the setting of prior asbestos exposure. If there is no recent outside chest CT, this should be further evaluated with a dedicated chest CT. . FOOT XRAY 1) New shallow concavity at the base of the fifth metatarsal. However, no aggressive features identified. Please see comment. . [**11-8**] ECHO Mild spontaneous echo contrast is seen in the body of the left atrium. No thrombus is seen in the left atrial appendage. There is mild regional left ventricular systolic dysfunction with inferior and inferolateral hypokinesis (EF 40-45%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are moderately thickened with focal calcification of the right coronary cusp. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are structurally normal. 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. IMPRESSION: No definitive evidence of valvular vegetation. Focal thickening of the right aortic cusp that appears unchanged from prior study [**2174-3-14**]. . [**11-9**] CXR As compared to the previous examination from [**2174-11-5**], a PICC line has been inserted over the right upper extremity. The tip of the line projects over the right atrium, the line should be retracted by 3 to 4 cm. There is no evidence of pneumothorax or other complication. Otherwise, the radiographic appearance is unchanged. . [**11-10**] MRI SPINE Though the evaluation for spine infection is quite limited in the absence of gadolinium and further, by the significant motion degradation of image quality, 1. Findings are quite concerning for a septic right L4-5 facet joint with right paraspinal abscess and possible developing discitis. It is possible that there is a small epidural fluid collection at L4-5, as detailed above, though this is not conclusive. 2. Severe multilevel spinal canal narrowing and cauda equina compression. 3. Moderately severe multilevel bilateral foraminal narrowing. . XR PELVIS 1. Moderate to severe lumbar spine and SI joint degenerative changes. 2. Diffuse calcified atherosclerotic disease with left femoral [**Month/Year (2) 1106**] stents; otherwise no radiopaque foreign bodies. . L-SPINE 1. Moderate to severe lumbar spine and SI joint degenerative changes. 2. Diffuse calcified atherosclerotic disease with left femoral [**Month/Year (2) 1106**] stents; otherwise no radiopaque foreign bodies. . [**11-11**] KUB Small bowel loops and large bowel loops are distended. The small bowel loops measure up to 5.5 cm. This is consistent with ileus. Moderate-to-severe degenerative changes are in the lumbar spine. . [**11-17**] CXR Cardiomegaly persists. Low lung volumes limit assessment. Left basilar and retrocardiac opacification is consistent with atelectasis although a pneumonitis from aspiration or infection can certainly be superimposed. Peribrochial cuffing, cephalization, and a small left pleural effusion suggest continue volume overload/congestion. No pneumothorax. Bilateral calcified pleural plaques. Median sternotomy wires are again seen. . [**11-18**] VIDEO SWALLOW Normal video oropharyngeal swallow exam without evidence of penetration or aspiration. . MRI SPINE There is continued suspicion for question of septic arthritis of the right facet joint at L4-5 level with a small epidural and paraspinal fluid collection. Examination is limited by motion. Gadolinium-enhanced repeat study possibly under anesthesia is recommended to get better evaluation of the abnormality. Multilevel degenerative changes are again noted. Findings were discussed with Dr. [**First Name (STitle) **] [**Name (STitle) **] at the time of interpretation of this study on [**2174-11-19**] at 12:30 p.m. . [**11-21**] ECHO The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferior and anterolateral walls. The remaining segments are mildly hypokinetic. Overal LVEF is moderately reduced (LVEF 35-40 %). No masses or thrombi are seen in the left ventricle (but apical images are suboptimal image quality). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2174-3-14**], the regional left ventricular systolic dysfuntion is more extensive c/w interim ischemia. . MRI L-SPINE 1. Suspicious finding on the recent non-enhanced examinations is demonstrated to represent a 2.5 cm (CC) relatively thick rim-enhancing fluid collection, centered at the L5 level, dorsal to and significantly compressing the thecal sac. In this clinical context, this very likely represents an epidural abscess. There may be a right ventral epidural component, as well. 2. At least two small rim-enhancing fluid collections the right paraspinal muscles, likely representing small focal abscesses, which may relate to septic arthritis of the right L4-L5 facet joint; however, this process is not definitely demonstrated on the present examination. 3. Pathologic T2-hyperintensity within the L3-4 through L5-S1 discs, without definitive discal enhancement or endplate destruction; this may be degenerative in nature. 4. No other site of organized collection identified within the lumbar spine. 5. Extensive multilevel, multifactorial degenerative changes with severe spinal canal stenosis at the L2-3 through L4-5 levels. . PORT LINE PLACEMENT As compared to the previous radiograph, the patient has been intubated. The tip of the tube projects 5 cm above the carina. New central venous access line over the left subclavian vein. The tip of the line projects over the superior SVC. Unchanged sternal wires, unchanged moderate cardiomegaly with mild overhydration. No evidence of pneumothorax. . CXR . In comparison with the study of earlier in this date, there has been placement of a nasogastric tube, that extends well into the stomach. Poor definition of the hemidiaphragms raises the possibility of developing pleural effusion and basilar atelectasis bilaterally. . [**11-22**] CXR In comparison with the study of [**11-21**], the monitoring and support devices remain in place. Enlargement of the cardiac silhouette persists with evidence of [**Date Range 1106**] congestion. Poor definition of the hemidiaphragms is consistent with bibasilar atelectasis and effusion. . [**11-23**] In comparison with the study of [**11-22**], the monitoring and support devices remain in place. Substantial enlargement of the cardiac silhouette persists with some evidence of [**Date Range 1106**] congestion. The hemidiaphragms are somewhat more sharply seen on this study. Persistent low lung volumes. . CT HEAD 1. No evidence of acute hemorrhage or acute [**Date Range 1106**] territorial infarction. . [**11-24**] CXR As compared to the previous radiograph, the patient has been extubated and the nasogastric tube has been removed. The lung volumes have minimally decreased. There is unchanged moderate cardiomegaly, the radiographic signs suggesting overhydration have slightly increased. Also, a potentially pre-existing right pleural effusion is better visible than on the previous image. Otherwise, no relevant change. . [**11-27**] The cardiomegaly is moderate, unchanged. The sternotomy wires are unchanged. The patient is in mild pulmonary edema, that is also unchanged since the prior study, accompanied by bilateral pleural effusions, moderate. There are no new focal consolidations, but bilateral basal retrocardiac atelectasis is unchanged. There is no evidence of pneumothorax. . KUB There is a significantly dilated air filled stomach. There are multiple air filled and dilated small bowel loops (luminal diameter up to 3.5 cm) and large bowel loops (luminal diameter up to 6.5 cm). There is no evidence of air fluid levels or free air. . [**11-28**] CXR In comparison with the study of [**11-27**], there has been a substantial increase in bilateral pulmonary opacifications in this patient with enlargement of the cardiac silhouette and evidence of midline sternal wires. The radiographic findings could reflect severe pulmonary edema, widespread pneumonia, or even ARDS. . [**11-29**] ABD Ileus has resolved. There is no bowel obstruction. . CXR Marked improvement of previously existing pulmonary edema. No pneumothorax. . [**11-30**] CT SPINE Severe multilevel disc degenerative changes throughout the lumbar spine as described in detail above. The previously identified epidural collection at L5 level is not visualized in this examination, correlation with MRI is recommended, since CT is not able to provide the same anatomical detail in the thecal sac. PATHOLOGY [**11-17**] GASTRIC BIOPSY: Antral and fundic mucosa, no diagnostic abnormalities recognized. No bacillary forms consistent with H. pylori identified on [**Doctor Last Name 6311**] stain. . EEG [**11-22**] This telemetry captured no pushbutton activations. Routine sampling showed a mild to moderately slow and disorganized background consisting of mixed theta frequencies. Occasionally, this occurred in a burst suppression type pattern. This is suggestive of a moderate to severe encephalopathy which may be secondary to medications. No focal or lateralized abnormalities were noted and no epileptiform features were seen. . [**11-23**] This telemetry captured no pushbutton activations. Routine sampling showed a mild to moderately slow and disorganized background with occasional periods of burst suppression. This is consistent with a moderate to severe encephalopathy and may have been related to medications. No focal abnormalities were noted and no epileptiform features were seen. Brief Hospital Course: Mr [**Known lastname 29275**] is a 78 yo gentleman who initally presented for a fall, however was found to be bacteremic with a seeded SC joint infection. His hospital course was initially complicated by an UGI bleed leading to ICU admission, then later complicated by vfib arrest in MRI scanner while undergoing imaging for back pain concerning for epidural abcess, leading to CCU admission. He underwent cooling protocol and was discharged from the CCU in stable condition. He was found to have an epidural abcess, however given his high surgical risk, we proceeded with medical management. He continued to improve on the floor with no further complications. . #) Bacteremia: Pt presented with fever and elevated WBC and was found to have MSSA in his blood. He was started on cefazolin (pt with PCN allergy) per ID recs. His cultures cleared after the first positive set and his SC joint infection improved clinically. The source of his bacteremia was unclear, however the most likely source was his lower extremity ulcers vs possible indolent [**Known lastname **] infection from prior [**Known lastname 1106**] surgery. He was seen by podiatry and [**Known lastname 1106**] who were not concerned for osteomyelitis or active infection of the foot. There were no valvular vegetations on TEE, therefore little concern for endocarditis. He did have evidence of infection of his sternoclavicular joint and an aspiration was positive for MSSA, and this was thought to be resulting from his bacteremia rather than a primary infection in the context of a fall. CT [**Doctor First Name **]/ortho were consulted but felt that he was not a good surgical candidate for debridment of the joint given his hx of CABG. He will complete an 8 week course of Cefazolin 2g IV q8 (day1=[**2174-11-8**]) and should follow-up with ID on discharage and should also obtain weekly safety labs (CBC/diff, BUN, Cr, LFTs, ESR, CRP) while on antibiotics (next set of labs due [**12-10**]). . # s/p cardiac arrest: During MRI scan for assessment of back pain patient went into cardiac arrest. Unclear whether he was in ventricular tachycardia/fibrillation vs. PEA. He was intubated and coded for 40 minutes, intermittently regaining pulses during the code. NSR was finally achieved after amiodarone and defibrillation. However, the patient remained hypotensive and was started on pressors, sedation, and Arctic Sun cooling protocol in the CCU. EEG and head CT were unremarkable. TTE was initially concerning for new wall motion abnormalities suggesting an ischemic etiology, but EKG showed no evidence of ACS and CE remained flat. It is therefore thought that the patient may have had PEA [**2-14**] anesthesia for MRI scan. After completion of the cooling protocol, the patient was successfully weaned off the ventilator and extubated without difficulty. He regained consciousness and appered to be back to his neurologic baseline. He stayed in NSR with only a few episodes of afib with aberrancy while on tele on the floor. The patient will need to follow up with EP on discharge for further assessment and evaluation. . #) Epidural Abcess: Pt reported back pain with point tenderness and neurosurgery was consulted out of concern for epidural abcess. MRI was performed and was concerning for epidural abscess as well as R paraspinal muscle abcesses by MRI, however the study was inadequate. Pt underwent MRI under anesthesia in attempt to obtain a better study, however arrested in MRI scanner. Given these circumstances, it was decided that further intervention, including imaging or surgery requiring anesthesia, would be deferred. IR guided drainage of the fluid collection was attempted but minimal fluid was obtained and no organisms were isolated in the aspirate. He was treated with IV abx and monitored for neurological change. Given his baseline disabiliy and ongoing issues with incontinence, we monitored for decrease in lower extremity strength (anti-gravity at baseline) and saddle parasthesia, and pt remained clinically stable. His pain also improved and on discharge was controlled with tylenol. Neurosurgery plans for f/u with MRI lumbar spine after completion of abx course, for which pt will be hospitalized given his inability to tolerate MRI without sedation and high risk for complications with anesthesia. Would also recommend monitoring neurologic status while at rehab, contacting neurosurgery urgently if change in neuro exam. . # chronic atrial fibrillation: His coumadin was initially held on admission due to supratherapeutic INR and then [**2-14**] GI bleed. After defibrillation, the patient was noted to be in normal sinus rhythm. He remained in sinus rhythm throughout his time in the intensive care unit and medical floor. It was felt that although anticoagulation is often still used up to four weeks s/p conversion to NSR from AF, in the setting of his recent GI bleed, anticoagulation should be held. He will be discharged on aspirin, consider restarting coumadin after colonoscopy. . #) Coffee-ground emesis: The patient had increasing emesis throughout his admission, first occurring subsequent to meals. On [**11-12**] he had 4-5 episodes of vomiting and then developed coffee ground emesis requiring MICU transfer. He remained hemodynamically stable, but required 7 units of blood over a 24 hour period to maintain a Hct>25. EGD showed a single, clean base, 2.5cm x3cm non-bleeding ulcer with blood clot in the antrum. The clot was flushed away, epi injected at ulcer edge, cauterized area covered with blood. His hematocrit subsequently stabilized and he had no further coffee ground emesis at the time of his transfer back to the floor, however his Hct was seen to slowly drift downwards and he received another unit of blood before discharge to the floor. He was treated for h pylori infection with flagyl, clarithromycin and IV PPI given equivicol H pylori ab screening test. Plan was for colonoscopy as well but this was deferred [**2-14**] cardiac arrest. In the cardiac ICU, Clarithromycin was switched to tetracycline as it was felt that the medication was prolonging the patient's QTc. He had no further episodes of hematemasis while on the floor and crit remained stable. EGD and colonoscopy were deferred in the hospital given his instability, however he is scheduled for EG/colonoscopy on discharge and will also be discharged on a PPI. . #) Hypertension: Pt had periods of normal BP but tended to have higher BPs in the AM. His Metoprolol and lisinopril were titrated to BP control prior to discharge, pressures in 120s-130s on discharge however may need further titration as an outpatient for optimal control. He was also re-started on lasix prior to discharge given his hx of volume overload as an inpatient, however at a decreased dose given that he had poor PO intake and increased bicarb while in the hospital. . #) Acute Renal Failure: Elevated creatinine on admission. Pre-renal and thought to be due to dehydration in the context of poor mobility/poor access to fluids. He was re-hydrated and his kidney function improved and remained normal throughout the admission. Lasix and lisinopril were initially held, but restarted due to hypertension and volume overload. . #) Ileus: pt with abd distension and decreased BMs on return from the cardiac intensive care unit. KUB showed no acute obstruction. Pt improved with uptitration of his bowel regimen, which will be continued on discharge. . #) s/p falls: The patient had two mechanical falls in the setting of living alone and having little sensation and poor mobility in his lower extremities. His sore right shoulder likely also contributed to his second fall, also may have been disoriented [**2-14**] bacteremia. There was evidence of chronic degenerative changes but no acute process. He was seen by PT/OT as an inpatient. He will be discharged to outpatient rehab and will require PT/OT/social work f/u. . #) Type 2 diabetes: Diet controlled, last HbA1c was 5.7%. Has had minimal insulin requirements as an inpatient, however QID blood glucose was initially continued due to poor nutrition and hypoglycemia. Fingersticks were dc'd 2 days prior to discharge as sugars normalized with increasing PO intake. . #) Peripheral [**Month/Day (2) **] Disease: s/p multiple surgeries, currently with ulcer on medial plantar right foot followed by podiatry and [**Month/Day (2) 1106**]. Foot xray not concerning for aggresive osteo at this time. He was treated with wound care per podiatry recs and continued on aspirin for his PVD. . #) Chronic Systolic Heart Failure: Pt had some evidence of volume overload on CXR and by exam throughout the admission. He was treated with IV/PO lasix and metoprolol. PO lasix dose decreased on discharge given pts poor PO intake and increased bicarb, however may need to be up-titrated as an outpatient. Additionally, when adequate dose for BP/HR control is achieved, would consider switching to Toprol XL for cardioprotection in the context of sCHF. . #) Nutrition: Pt with poor PO intake therefore NG tube was placed when the patient returned from the cardiac intensive care unit. Placement required IR guidance given his hx of prior nose surgeries. He pulled the tube before reaching goal tube feeds and it was not replaced given that his PO intake was increasing. He was cleared for ground solids and small pills with applesauce by speech and swallow, who also stated that he could be advanced to solid diet as tolerated. . #) Urinary retention: Pt failed last voiding trial prior to discharge, therefore foley was re-placed and pt discharged to rehab with foley in place. He was continued on tamsulosin on DC. Would recommend voiding trial in rehab. . #) ? Mesothelioma: Pleural thickening (in the setting of prior asbestos exposure) noted on [**2174-11-6**] Chest CT, concerning for mesothelioma. Bilateral calcified pleural plaques consistent with possible asbestosis on CXR [**2174-11-17**]. Pt is scheduled to f/u with thoracic surgery on discharge. . #) Hyperlipidemia: His home statin was continued . #) Anemia: Initially concerning for iron deficiency therfore was started on ferrous gluconate. Worsened with GI bleed but improved after transfusions and stabilized. Iron supplementation was held on discharge given his history of consitipation. . #) Depression: Home celexa was continued. Medications on Admission: Brimonidine 0.15 % 1 drop in right eye Q8H Citalopram 20 mg daily Ergocalciferol 50,000 units weekly Famotidine 20 mg daily Furosemide 40 mg 1-2 tablets daily Lisinopril 5 mg daily Metoprolol Tartrate 25 mg [**Hospital1 **] Nitroglycerin 0.4 mg SL PRN Oxycodone-Acetaminophen 5 mg-325 mg 1-2 tabs PRN Simvastatin 20 mg daily Warfarin 7.5 mg daily Aspirin 81 mg daily Bisacodyl 5 mg 1-2 tablets [**Hospital1 **]:PRN Cyanocobalamin 1,000 mcg daily Colace TID:PRN Discharge Medications: 1. Brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic Q8H (every 8 hours). 2. Citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [**Hospital1 **]: One (1) Capsule PO once a week. 4. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO TID (3 times a day). 7. Nitroglycerin 0.4 mg Tablet, Sublingual [**Hospital1 **]: One (1) Sublingual once as needed for chest pain. 8. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QHS (once a day (at bedtime)). 9. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 12. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Hospital1 **]: One (1) Injection Q8H (every 8 hours) as needed for nausea. 14. Cyanocobalamin 1,000 mcg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 15. Simethicone 80 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO four times a day as needed for gas. 16. Cefazolin 10 gram Recon Soln [**Hospital1 **]: One (1) Recon Soln Injection Q8H (every 8 hours): Please continue for 8 week course (day 1=[**2174-11-8**]). 17. Docusate Sodium 100 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 18. Outpatient Lab Work Please obtain weekly CBC/diff, BUN, Cr, LFTs, ESR, CRP, please send to infectious disease clinic, attn: [**Doctor First Name 1423**] [**Doctor Last Name **] ([**Telephone/Fax (1) 1419**]). First set should be drawn on [**12-10**]. 19. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 20. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Not to exceed 4 g/day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: - Bacteremia - Sternal/spinal MSSA osteomyelitis - Antral ulcer with bleeding - Acute blood loss anemia - Acute renal failure - Cardiac arrest Secondary: - Right pleural thickening NOS - CAD s/p CABG (LIMA-LAD, SVG-PDA, and SVG-OM) - Chronic systolic heart failure (40%) - Atrial fibrillation - Small secundum ASD/PFO - Left retinal artery occlusion - Peripheral [**Hospital1 1106**] disease - s/p bilateral hallux amputations - Chronic right foot ulceration - Hypertension - Anemia of chronic disease - Diabetes mellitus type II Discharge Condition: stable but frail Discharge Instructions: You were admitted for falls and you were found to have bacteria in your blood, therefore you were treated with intravenous antibiotics. While in the hospital, you developed an upper gastrointestinal bleed and were seen by gastroenterology who examined your stomach with a camera and found ulcers. These were cauterized and injected to prevent any further bleeding. Additionally, while in the hospital, you had back pain and were found to have an abcess in your spine. While getting imaging of this abcess, your heart went into an abnormal rhythm and you were transferred to the cardiac intensive care unit. In the intensive care unit, you were stabilized and eventually returned to the medicine floor, where we decided to delay further imaging or surgery of your spine given the high risk of intervention. Therefore, we continued to manage your condition with IV antibiotics. You remained stable however had decreased oral intake and urinary retention, therefore you were seen by nutrition and had a foley catheter placed. . Please take your medications as prescribed and follow-up with your physicians as outlined below. The following changes have been made to your medications: -you will need to take IV cefazolin (day 1=[**2174-11-8**] for a total of 6 weeks -please take pantoprazole 40 mg by mouth every day . Please return to the hospital if you have fevers, chills, shortness of breath, chest pain, increasing weakness in your legs, or any other symptoms that are concerning to you. Followup Instructions: Please follow up with infectious disease regarding your bacteremia: . Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] BLOOD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2174-12-12**] 11:00 . You will need safety labs including CBC/diff, BUN, Cr, LFTs, ESR, CRP on [**12-10**], and every week thereafter while on abx. . Please follow up with gastroenterology in regards to your GI bleed: . Dr. [**First Name8 (NamePattern2) 1586**] [**Name (STitle) 2161**] Specialty: Gastroenterology Date and time: Wednesday, [**12-28**] at 11:00am Location: [**Location (un) **], [**Hospital Ward Name 1950**] Bldg [**Location (un) **], [**Location (un) 86**], MA Phone number: [**Telephone/Fax (1) 463**] . Please follow up with cardiology in regards to your cardiac arrest: . Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Date and time: Friday, [**12-30**] at 10:20am Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) **], [**Location (un) 86**], MA Phone number: [**Telephone/Fax (1) 62**] . Also, please follow up with thoracic surgery in regards to the pleural thickening that was found on your CT: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**] Date/Time:[**2174-12-22**] 10:00 . Please keep the following previously scheduled appointment: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2174-12-28**] 8:40 . You will also need to be readmitted to the hospital in 6 weeks for follow-up imaging of your spine given your epidural abces.

[ "041.86", "427.41", "E938.4", "560.1", "788.20", "507.0", "790.92", "V58.61", "707.14", "427.5", "272.4", "711.01", "995.92", "531.40", "324.1", "428.0", "276.0", "730.08", "038.11", "501", "584.9", "401.9", "E934.2", "715.31", "728.88", "428.23", "707.13", "250.00", "427.32", "410.01", "041.11", "440.23", "427.31", "E885.9", "163.9", "285.1", "V45.81", "311", "707.15" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.62", "81.91", "88.72", "96.71", "96.04", "45.16", "38.91", "03.09", "44.43", "86.22", "99.60" ]

icd9pcs

[ [ [] ] ]

32455, 32534

19235, 29617

322, 418

33118, 33137

5232, 5900

34682, 36330

3688, 3880

30129, 32432

32555, 33097

29643, 30106

33161, 34659

3895, 3895

5914, 19212

265, 284

446, 2999

3909, 5063

3021, 3397

3413, 3672

82,150

158,564

44074

Discharge summary

report

Admission Date: [**2190-3-10**] Discharge Date: [**2190-3-19**] Date of Birth: [**2112-1-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: A-line History of Present Illness: 74 y/o M with multiple medical problems including hx of [**Name (NI) 94612**], CVAs, CAD, afib on coumadin and chronic aspriation presents from rehab with fevers and lethargy from nursing home. He has dementia and cognitive deficits at baseline from his CVAs. He was hypoxic to 48% on RA at the nursing home. He arrived and was on NRB and had O2 sats in high 90s and was very tachypneic. He was complaining of SOB but no other history could be obtained. In the ED, initial vs were T 99.9, P 100, BP 91/52, R 32 O2 sat 100% on 15 NRB. He had difficult access. The ED team tried R fem and accessed the artery twice, then R IJ. They were able to place a CVL in the L groin. His oxygentation worsened and he was intubated. His code status could not be confirmed. In the ED labs show elevated trop to 1.63; ekg with lateral ST depressions, so cardiology was consulted. They thought it was likely demand ischemia in the setting of sepsis and did not recommend starting heparin. He also had a hct of 21 down from baseline around 30 and was transfused two units of PRBCs. His SBP dropped to the 80s after intubation and a levofed gtt was started. He also received 1 gm vanco, 4.5 gm zosyn, and an [**Name (NI) **] 600 mg PR. He was trace guiac positive on rectal exam. On the floor, the patient is intubated and sedated. No history could be obtained. ROS was negative except for that in HPI per report. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: #. Ogilvies Syndrome- Has frequent admissions for abdominal distention, with dilated colon on imaging, which resolves with rectal tube decompression. #. Chronic aspiration (Per PCP) #. CVA complicated by expressive aphagia, dysphagia #. Coronary artery disease, s/p CABG in [**2154**], mild systolic regional hypokinesis with EF 55% #. HTN #. Hyperlipidemia #. GERD #. History of pancreatitis #. Type 2 diabetes c/b gastroparesis #. Anemia h/o intermittent heme+ stools #. Atrial fibrillation on coumadin Social History: Living at [**Hospital3 1186**] nursing home since stroke in [**2183**], wife passed away 5 years ago, no tobacco or ETOH use. Family History: NC Physical Exam: VS: 116/66, T 100, HR 102, RR 40. GENERAL APPEARANCE: lying in bed, tachypneic, pale, opening eyes slowly to voice, but somnolent. HEAD drooling mucous out from his mouth. HEART: regular rhythm, normal S1S2, no murmurs, tachycardic. LUNGS: significantly labored, rhonchi throughout. ABDOMEN: NABS, soft, NT, mildly distended. SKIN: diaphoretic, cool skin. EXTREMITIES: 2+ edema on the RUE, 1+ edema on the RLE. On discharge: Vitals: 97.3 124/74 96 29 96 on 2L General: pt is alert, minimally verbal, NAD HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not assessible, Lungs: rhonchorous, good airmovement CV: RRR. Nl S1 and S2. Abdomen: soft, ABS. slightly distended from edema. nontender GU: foley in place. yellow urine in foley bag. Ext: edema of foot. otherwise anasarca significantly improved. L PICC Pertinent Results: LABS ON ADMISSION: [**2190-3-10**] 05:15PM BLOOD WBC-10.1 RBC-2.17*# Hgb-6.5*# Hct-21.3*# MCV-98# MCH-30.0 MCHC-30.7* RDW-18.3* Plt Ct-165 [**2190-3-10**] 05:15PM BLOOD Neuts-88.2* Lymphs-6.5* Monos-4.2 Eos-0.8 Baso-0.3 [**2190-3-10**] 05:15PM BLOOD PT-25.1* PTT-48.9* INR(PT)-2.4* [**2190-3-10**] 05:15PM BLOOD Plt Ct-165 [**2190-3-10**] 05:15PM BLOOD Glucose-186* UreaN-73* Creat-1.2 Na-152* K-4.4 Cl-120* HCO3-26 AnGap-10 [**2190-3-10**] 05:15PM BLOOD ALT-31 AST-60* CK(CPK)-378* AlkPhos-91 TotBili-0.3 [**2190-3-11**] 03:24AM BLOOD ALT-32 AST-60* LD(LDH)-380* AlkPhos-74 TotBili-0.6 DirBili-0.3 IndBili-0.3 [**2190-3-10**] 05:15PM BLOOD CK-MB-29* MB Indx-7.7* [**2190-3-10**] 05:15PM BLOOD cTropnT-1.63* [**2190-3-10**] 05:15PM BLOOD Albumin-2.6* Calcium-8.1* Phos-3.6 Mg-2.9* [**2190-3-10**] 05:31PM BLOOD pH-7.36 Comment-RUN ON GRE [**2190-3-10**] 06:15PM BLOOD Type-ART Rates-/14 PEEP-5 pO2-307* pCO2-43 pH-7.37 calTCO2-26 Base XS-0 -ASSIST/CON Intubat-INTUBATED [**2190-3-10**] 05:31PM BLOOD freeCa-1.11* [**2190-3-10**] 05:31PM BLOOD Glucose-190* Lactate-2.3* Na-152* K-4.4 Cl-118* calHCO3-23 On dishcarge: [**2190-3-19**] 12:02PM BLOOD WBC-13.3* RBC-3.18* Hgb-9.8* Hct-30.4* MCV-95 MCH-30.8 MCHC-32.3 RDW-17.2* Plt Ct-227# [**2190-3-14**] 02:18AM BLOOD Neuts-84.7* Lymphs-8.5* Monos-5.1 Eos-1.7 Baso-0.1 [**2190-3-19**] 12:02PM BLOOD PT-26.5* PTT-44.3* INR(PT)-2.6* [**2190-3-19**] 12:02PM BLOOD Glucose-61* UreaN-60* Creat-1.3* Na-147* K-4.2 Cl-116* HCO3-15* AnGap-20 CXR: [**2190-3-10**] IMPRESSION: Pulmonary vascular congestion, cardiomegaly and probable pleural effusions, consistent with cardiac decompensation. . CT Head: [**2190-3-10**] 1. No intracranial hemorrhage. 2. Chronic small vessel ischemic change. 3. Paranasal sinus fluid, may related to intubation. 4. Persistent complete opacification of the left mastoid air cells. . CT Chest/Abd/Pelvis: [**2190-3-10**] 1. Moderate bilateral pleural effusions with interstitial edema and mild cardiomegaly, consistent with cardiac decompensation. 2. Greater than expected perihilar consolidation in the left lung, concerning for sequela of aspiration, or infectious consolidation. 3. No acute abnormalities in the abdomen or pelvis. 4. Diffuse anasarca. 5. Atherosclerotic disease. 6. Improved distension of sigmoid colon without volvulus or obstruction. . The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with akinesis of the mid- and distal septum, as well as apex (mid-LAD distribution). The remaining segments contract normally (LVEF = 40-45%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Mild mitral regurgitation. RUE U/S: NO DVT Brief Hospital Course: 74 y/o M with multiple medical problems including hx of [**Name (NI) 94612**], CVAs, CAD, afib on coumadin and chronic aspriation presented on [**3-10**] with pneumonia. He was found to be hypoxic to 48% RA at his nursing home. He was intubated and femoral line placed in the ED due to respiratory distress, at that time code status could not be confirmed. He had an NSTEMI with troponin peak at 1.8 (thought to be due to demand). He was intubated and required pressors briefly in the setting of intubation. He was extubated on [**3-11**] with no pressor requirement. He was also noted to have a drop in his Hct for unclear reasons and was transfused 4 units of blood while in the ICU. He was transferred to the floor where antibiotics were changed to Vanco, Cefepime, and Flagyl (to cover for aspiration as patient was still febrile on HAP coverage). Patient had much difficulty with his own secretions. On [**3-17**], he developed rapid breathing, gurgling, secretions. Sats dropped to the 70s on 3L NS. Started on an NRB. Found to have SBP in the 190s. He was again tranferred to the ICU, was febrile to 100.6, tachypneic, diaphoretic. ABG was 7.25/49/122 at that time. He underwent aggressive diuresis which improved his oxygenation and returned him to near euvolemia. He was transferred out of the ICU on 2L O2 requirement. On the floor he was found to be in his usual state of health + oxygen requirement. Despite the fact that patient is very ill at baseline and at high risk of becoming more ill, he is presently doing well, euvolemic, on antibiotics, with access. Hct is stable, INR therapeutic. Mental status waxes and wanes at baseline. Pt opens eyes and speaks occassionally. To Do at Rehab: PICC Line care - daily flush, weekly dressing changes Decubitous ulcer - q3 day dressing changes, clean with saline and cover with dry gauze. q2hour shifting in bed to improve healing and prevent worsening wound care. Frequent suctioning Chest physical therapy Legs should be placed in soft supportive boots to reduce pressure ulcers Tube feeding through G tube NPO # Communication: has two daughters and son; [**Doctor Last Name **] is HCP, work no: [**Telephone/Fax (1) 94613**]. Email: [**Company 94611**]. [**Doctor First Name **], daughter [**Telephone/Fax (1) 94614**]. Medications on Admission: (per OMR discharge summary): # Aspirin 81 mg daily # Lisinopril 20 mg daily # Lansoprazole 30 mg daily # Lasix 20 mg daily # Metoprolol Tartrate 25 mg [**Hospital1 **] # Isosorbide Dinitrate 10 mg TID # Mirtazapine 30 mg qHS # Warfarin 1 mg daily # Simvastatin 40 mg daily # Insulin Regular Sliding Scale # Multivitamins 1 tab daily # Cholecalciferol (Vitamin D3) 400 unit daily # Prednisolone Acetate 1 % Drops [**Hospital1 **] to R eye # Bacitracin 500 unit/g Ointment to eyes daily # Nitroglycerin 0.3 mg Tablet, Sublingual PRN Discharge Medications: 1. Aspirin 81 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 2. Lisinopril 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day: Please do not give if systolic blood pressure less than 120. 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 4. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily): Do not give if systolic blood pressure less than 100. 5. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day): do not give if heart rate less than 60, or systolic blood pressure less than 90. 6. Isosorbide Dinitrate 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a day: do not give if systolic blood pressure less than 100. 7. Mirtazapine 15 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at bedtime). 8. Coumadin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 9. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 10. Multivitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 11. Vitamin D 400 unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 12. Prednisolone Acetate 1 % Drops, Suspension [**Last Name (STitle) **]: 1-2 drops Ophthalmic twice a day: right eye. 13. Bacitracin 500 unit/g Ointment [**Last Name (STitle) **]: One (1) application Ophthalmic twice a day. 14. Nitroglycerin 0.3 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1) Sublingual ASDIR as needed for chest pain. 15. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8 hours): Last day is [**2190-3-23**]. 16. Vancomycin 750 mg Recon Soln [**Month/Day/Year **]: Seven [**Age over 90 1230**]y (750) mg Intravenous every twelve (12) hours: last day [**3-21**]. 17. CefePIME 2 g IV Q24H 18. Cefepime 2 gram Recon Soln [**Month/Year (2) **]: Two (2) gm Intravenous every twenty-four(24) hours: last day [**3-21**]. 19. PICC Line single lumen PICC placed on [**3-18**] in LUE 20. 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. 21. 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. 22. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Month/Year (2) **]: per sliding scale Subcutaneous QACHS. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: primary: health care associated pneumonia aspiration pneumonia volume overload, and acute on chronic systolic heart failure NSTEMI atrial fibrillation Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Lethargic but arousable Activity Status: Bedbound on 2L oxygen Discharge Instructions: Mr [**Known lastname 42086**] - It was a pleasure to care for you during your hospitalization. You were admitted for a severe pneumonia for which you were treated. You were also received alot of fluids causing swelling of your body which has now improved. During your hospitalization you had a small heart attack. You continue to do poorly because of difficulty in controlling your secretions, however this is not anticipated to improve. Medications changed: Increased Lansoprazole 60mg daily Increased Simvastatin 80mg daily No other medications were changed. It is important that your family act in your best interests to make sure you are well cared for and that your comfort is considered. How to best do this will be an ongoing discussion. Followup Instructions: Please follow up with the health care providers at your nursing home. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2190-3-19**]

[ "410.71", "038.9", "276.2", "285.9", "507.0", "V44.1", "511.9", "438.11", "V45.81", "290.40", "276.0", "V58.61", "518.81", "536.3", "584.9", "707.23", "272.4", "401.9", "437.0", "787.20", "438.82", "530.81", "428.23", "250.60", "995.92", "707.03", "428.0", "427.31", "785.52" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "96.71", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

12458, 12531

7043, 9341

321, 329

12726, 12726

3781, 3786

13651, 13846

2910, 2914

9923, 12435

12552, 12705

9367, 9900

12875, 13628

2929, 3341

3355, 3762

1774, 2221

274, 283

357, 1755

5423, 7020

3800, 5414

12741, 12851

2243, 2750

2766, 2894

7,681

166,189

17126

Discharge summary

report

Admission Date: [**2166-5-30**] Discharge Date: [**2166-6-6**] Date of Birth: [**2117-1-14**] Sex: M Service: [**Location (un) 259**] [**Hospital1 **] HISTORY OF PRESENT ILLNESS: This is a 49-year-old gentleman with hepatitis B, alcohol-induced cirrhosis with multiple admissions for melanotic stools and upper GI bleed, who is most recently admitted to [**Hospital1 188**] from [**12-19**] to [**12-23**], and is here now presenting with hypertension, anemia, and hematemesis. The patient was admitted to the Intensive Care Unit on [**2166-5-30**] after experiencing an episode of hematemesis and becoming faint. The patient was transferred to [**Hospital1 346**] Intensive Care Unit hypertensive requiring emergent TIPS procedure on the [**5-31**]. The patient initially had been admitted to [**Hospital1 346**] in late [**Month (only) 404**] for melenic stools and at that time the patient was hemodynamically stable, therefore TIPS was deferred. Patient in the Intensive Care Unit was stable post TIPS procedure. His hematocrit was at 35, and he was denying chest pain, shortness of breath, nausea, vomiting, melena, bright red blood per rectum. He did note some weakness and fatigue and mild abdominal pain. The patient was stable for transfer to the floor on [**6-1**]. PAST MEDICAL HISTORY: 1. Hepatitis C type 1A diagnosed in [**2159**], status post PEG-Interferon treatment with ribavirin in [**2165-11-27**]. 2. Erosive gastritis, duodenitis diagnosed on EGD in [**2165-7-28**] at [**Hospital3 3834**]. 3. Diabetes mellitus type 2. 4. Lumbar disk herniation. 5. History of hematemesis, melenic stools in [**2166-7-28**]. MEDICATIONS UPON TRANSFER TO THE GENERAL MEDICINE SERVICE: 1. Levaquin 500 mg po q day. 2. Protonix 40 mg po q day. 3. NPH 4 units in the am and regular insulin-sliding scale. 4. Lactulose 30 cc titrate [**1-28**] bowel movements. 5. Multivitamin. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAM UPON TRANSFER: Vital signs: Temperature max 98.7, blood pressure 114/58, heart rate 88/109, currently 96, respiratory rate 20, and 97% on room air. Generally, the patient is well-nourished, mildly jaundiced, protuberant abdomen in no acute distress. HEENT: No lymphadenopathy, anicteric sclerae. Scant petechiae in the oropharynx. Neck: No jugular venous distention, no lymphadenopathy. Cardiovascular exam: Regular rate, no murmurs, rubs, or gallops. Pulmonary: Faint bibasilar crackles, no wheezes, and otherwise clear. Abdomen is distended, positive fluid shift, no pain, palpable liver edge. Extremities: No clubbing, cyanosis, or edema, no palmar erythema, no spider telangiectasia. LABORATORY STUDIES UPON TRANSFER: Complete blood count: white blood cell count 6.9, hematocrit 35.6, MCV 88, platelets 64. PT 15.5, PTT 38.6 INR 1.6. Sodium 135, potassium 3.5, chloride 103, bicarbonate 26, BUN 5, creatinine 0.6, glucose 113, calcium 7.3, magnesium 1.3, phosphorus 4.1. ALT 98, AST 133, LDH 221. Alkaline phosphatase 124. Total bilirubin 2.5. HOSPITAL COURSE LISTED BY PROBLEM: 1. Upper GI bleed/status post TIPS: The patient was transferred to the general floor after having a TIPS procedure on the 5th. He came to the floor on the 6th. His hematocrit was stable at 35. An ultrasound was performed on the [**8-3**], and was read as having a patent TIPS with no ascites. The patient began to spike temperatures on the [**8-4**], temperature max 103.3, during which the patient has been treated for SBP prophylaxis with Levaquin 500 mg po q day. A CT scan of the abdomen was performed at that time to assess for any fluid collection near the site of the TIPS, perhaps an abscess, or a hematoma. The CT scan impression read no abscess, small amount of ascites with pericholecystic fluid. There was a perfusion defect noted in the right hepatic lobe consistent with an infarction. The patient continued to spike temperatures throughout the remainder of his hospital course receiving Tylenol prn and blood and urine cultures were sent with each spiking temperature with no growth to date upon discharge. Interventional Radiology as well as the Liver Service discussed the possibility of revising the TIPS in the setting of fevers and elevated liver function tests. I was thought that the patient's fevers were attributed to this focal area of ischemia within the liver and that by following the liver function tests, we would be able to monitor this. Interventional Radiology consulted us on this decision, and we were advised to follow the liver function tests including total bilirubin and INR as indicated for worsening liver function, which would warrant a TIPS revision. The patient's overall clinical presentation had not changed dramatically, however, he was complaining of referred shoulder pain as well as hiccups during the last two days of hospitalization. The patient was treated with Thorazine prn for hiccups, and received one time doses of oxycodone for the shoulder pain. Patient's LFTs were followed twice daily and began to trend down. His bilirubin was as high as 5.3 on the [**8-4**]. It slowly began to trend down, but was elevated again on the [**8-5**] at 5. By day of discharge, his bilirubin had come down to 2.6. Alkaline phosphatase was as high as 219 on the [**8-4**], and had trended down to 190 upon discharge. Both AST and ALT additionally had trended down upon discharge. The patient remained febrile throughout the remainder of his hospital course, however, there was no obvious source of infection based on CT scan of the abdomen, ultrasound, and chest x-ray performed on the [**8-3**]. Again his fevers were attributed to the focal area within the liver. 2. History of lower gastrointestinal bleed: Patient's hematocrit was stable status post TIPS ranging from 32 to 33 throughout much of his hospital course. However, on the day of discharge, [**2166-6-6**], his hematocrit had dropped from 33 to 28.6. The patient's guaiac status was negative on that day, and throughout most of his course he had remained negative with only a few trace guaiac positive [**Location (un) 1131**] stools. A repeat hematocrit was drawn later on that morning and was 30.3. 3. Diabetes mellitus type 2: Patient's blood sugars varied from 150 to 250 throughout most of his hospital course. He is maintained on an insulin-sliding scale with 4 units of NPH in the morning. The patient currently does not have a regimen that he takes at home, and was instructed to followup with his PCP for [**Name Initial (PRE) **] diabetic treatment. CONDITION ON DISCHARGE: On the day of discharge, the patient was febrile. However, his clinical presentation had not changed. He was adamant about leaving the hospital and had even threatened to leave against medical advice. We were able to convince him to stay so that we can follow his hematocrits closely. After his hematocrit had gone up from 28 to 30, we decided that the patient was stable for discharge. DISCHARGE DIAGNOSIS: Upper gastrointestinal bleed status post TIPS. DISCHARGE MEDICATIONS: 1. Lactulose 30 cc tid titrate to [**1-28**] bowel movements. 2. Thorazine 10-25 mg po tid as needed for hiccups. 3. Oxycodone 10 mg po q4-6h prn as needed for shoulder pain, a total of only 10 tablets were dispensed. 4. Protonix 40 mg po q day. 5. Tylenol 325 mg po q4-6h prn. FOLLOW-UP INSTRUCTIONS: Upon discharge, the patient was instructed to followup with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 7307**] at the Liver Clinic at [**Last Name (NamePattern1) 439**] on Monday, [**6-9**]. Additionally, the patient was instructed to followup with his PCP regarding diabetes management. [**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**] Dictated By:[**Last Name (NamePattern1) 1600**] MEDQUIST36 D: [**2166-6-8**] 23:19 T: [**2166-6-9**] 05:19 JOB#: [**Job Number 48096**]

[ "578.1", "070.32", "789.5", "287.5", "456.8", "285.1", "070.54", "573.4", "571.2" ]

icd9cm

[ [ [] ] ]

[ "39.1" ]

icd9pcs

[ [ [] ] ]

7086, 7365

7015, 7063

201, 1305

7390, 7986

1327, 6577

6602, 6994

19,383

185,333

26295

Discharge summary

report

Admission Date: [**2124-12-30**] Discharge Date: [**2125-1-16**] Date of Birth: [**2107-2-15**] Sex: F Service: ORTHOPAEDICS Allergies: Amoxicillin Attending:[**First Name3 (LF) 16613**] Chief Complaint: Multitrauma MVA Major Surgical or Invasive Procedure: [**2124-12-30**] 1. Right tibial intramedullary nail. 2. Left tibia intramedullary nail and irrigation and debridement. 3. Left femur intramedullary nail. 4. Right metatarsal closed reduction and percutaneous pinning x2. 5. Left wrist application plaster splint. [**2125-1-2**] Inferior vena cava venogram with placement of retrievable inferior vena cava filter. [**2125-1-3**] 1. Complete fasciotomy, right leg 2. Complete fasciotomy, left leg [**2125-1-6**] 1. Closure fasciotomy, right leg 2. Closure facsiotomy, left leg History of Present Illness: 17 yo restrained driver, auto v auto, prolonged extrication, + LOC, L femur fx, open L tib-fib fx, closed R tib-fib, L distal radius fx, R foot fx/dislocation Past Medical History: Denies Social History: high schoool senior Lives at home with parents Family History: NA Physical Exam: Gen-Alert/oriented, NAD VS-afebrile/VSS CV-RRR Lungs-CTA bilat Abd-soft NT/ND Ext-LUE: cast in place, +EPL/FPL/APL +Radial pulse LLE:Incision clean/dry/intact without evi RLE: Pertinent Results: [**2124-12-30**] 03:55AM WBC-14.2* RBC-3.11* HGB-8.8* HCT-24.3* MCV-78* MCH-28.2 MCHC-36.1* RDW-12.9 [**2124-12-30**] 04:16AM GLUCOSE-123* LACTATE-2.5* NA+-139 K+-3.1* CL--106 TCO2-24 Brief Hospital Course: Patient was admitted to [**Hospital1 18**] ICU on [**2124-12-30**]. Patient was taken to the OR on [**2124-12-30**] for treatment of multiple fractures. Patient had debridement of left open tibia fracture. IM nails of left femur, left tibia and right tibia. Patient also has closed reduction of Right metatarsal fractures and casting of left distal radius fracture. Patient had IVC filter placed on [**2125-1-2**]. On [**2125-1-3**] patient was complaining of increased pain in lower legs. Patient was taken back to the OR on [**2125-1-3**] for fasciectomies of bilateral lower legs. Surgery went without complications. Post-op Patient did have some low O2 sat on [**2125-1-2**] CXR was done and found to be slightly fluid overloaded. IVF were held patient was placed on O2. Pulmonary was consulted and left recs to repeat CXR and cont with O2. Over the next few days O2 sats had improved. Pain remained controlled. Patient was taken back to surgery on [**2125-1-6**] for closure of fasciectomies. Again surgery went without complications. Patient returned to the OR on [**2125-1-11**] for ORIF of right metatarsal fractures. Patient continued to progress appropriately with physical therapy. Pain remained controlled. Patient did complain of pain with urination on [**2125-1-14**]. UA was done and was found to have UTI. Bactrim was started x 3days. On day of discharge patient was afebrile/vital signs stable, incisions were clean/dry/intact. Patient was discharged in stable condition. Medications on Admission: Denies Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Left femur fracture Left tibia fracture Left non-displaced distal radius fracture Right tibia fracture Right metatrasal fracture Compartment synd bilat lower extremity Discharge Condition: stable Discharge Instructions: Please cont with weight bearing as toleratd left leg. Non-weight bearing right leg. Lovenox for anti-coagulation. Oral pain medication as needed. Please keep incision clean/dry. Please call/return if any fevers, increased discharge from incision or trouble breathing. Physical Therapy: Activity: WBAT LLE, NWB RLE, NWB LUE -aggressive physical therapy -ROM as tolerated bilateral knees -ROM as tolerated bilateral ankle Treatments Frequency: Dry sterile dressing once daily. When incision is dry, may leave open to air. Please remove sutures in legs on [**2125-1-19**]. Please do not soak or scrub incision. Followup Instructions: Follow-up with Dr.[**Last Name (STitle) 1005**] 2weeks after discharge Follow-up with Dr.[**Last Name (STitle) 7376**] 2weeks after discharge, please call for appt. [**Telephone/Fax (1) 1228**] [**Name6 (MD) 13978**] [**Name8 (MD) **] MD [**MD Number(2) 16614**] Completed by:[**2125-1-16**]

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icd9cm

[ [ [] ] ]

[ "96.71", "86.22", "79.35", "79.36", "83.65", "99.04", "79.37", "79.17", "38.7", "83.19", "79.66", "93.54" ]

icd9pcs

[ [ [] ] ]

3381, 3428

1548, 3038

294, 823

3640, 3649

1336, 1525

4308, 4631

1121, 1125

3095, 3358

3449, 3619

3064, 3072

3673, 3941

1140, 1317

3959, 4094

4116, 4285

239, 256

851, 1011

1033, 1041

1057, 1105

30,815

170,372

32531

Discharge summary

report

Admission Date: [**2147-11-1**] Discharge Date: [**2147-11-7**] Service: MEDICINE Allergies: Codeine / Lipitor Attending:[**First Name3 (LF) 7881**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: This is an 85-year-old nun with a history of hypertension, hyperlipidemia, diabetes, and CAD, s/p CABG x 3 and stents in [**1-/2146**] and 10/[**2146**]. She was admitted to [**Hospital1 **] on [**2147-10-29**] with complaints of chest pain. Pt reports CP never really resolved after last stent; unable to ambulate to bathroom without pain and SOB. CP does not occur at rest; always associated with SOB, denies N/V, lightheadedness, diaphoresis. Baseline orthopnea, sleeps in chair; reports LE edema that is improved from baseline. Denies palpitations. At OSHh she ruled in for a NSTEMI with a peak troponin of 0.95. She underwent cardiac catheterization yesterday and was found to have a lesion in the SVG from the diag to the OM-1. Her EF was reported as 25-30%. Last night at OSH s/p cath; pt has persistant chest pain. She was transferred to [**Hospital1 18**] for interventional cath. Cath was done; PCI to graft ostium with BMS, 2 BMS to mid-graft lesions. Past Medical History: CAD, s/p CABG x 3, s/p PCI in [**1-/2146**] and [**9-/2147**] . PMH: Hypertension Hyperlipidemia Diabetes Anemia spinal stenosis Appendectomy tonsillectomy previous h/o quiac + stools none at present; had EGD and c-scope wnl . Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension Social History: Pt is a nun, lives in retirement convent MA, retired. Denies smoking,ETOH or drugs. Family History: Sister had MI at 82, brother with MI in 60s, mother died of MI at 72, dad with CAd died at 84. Physical [**Year (4 digits) **]: VS - afebrile, 161/81, 68 18 98%2L Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 8 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 3/6 SEM mid-peaking, clearly heard S2, no radiation to carotids. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Clear anteriorly. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. Groin: sheath in place on left, small hematoma on right, dressing c/d/i. Pertinent Results: [**11-1**] Cardiac Cath: 1. Selective venous conduit angiography demonstrated a diffusely diseased SVG graft to the obtuse marginal with a jump segment to the diagonal. The ostial portion of the graft demonstrated a 60% lesion. The graft also had a 90% lesion just proximal to the anastomosis site on the obtuse marginal along with a 70% lesion just proximal to the anastomosis site on the diagonal. 2. LV ventriculography was deferred. 3. Limited resting hemodynamics demonstrated severe central hypertension (180/72 mm Hg). 4. Successful direct stenting of the ostium of the SVG-OM-Diag with an Ultra (4.5x13mm) bare metal stent. Final angiography demonstrated no angiographically apparent dissection, 10% residual stenosis and TIMI III flow throughout (See PTCA comments). 5. Successful direct stenting of the distal SVG-OM graft with a Vision (4x12mm) bare metal stent. Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout (See PTCA comments). 6. Successful direct stenting of the SVG jump graft to the diagonal with a Vision (4x12mm) bare metal stent. Final angiographyc demonstrated no angiographically apparent dissection, 20% residual stenosis and TIMI III flow throughout (See PTCA comments). FINAL DIAGNOSIS: 1. One (1) venous conduit (SVG) disease. 2. Successful direct stenting of the SVG-OM-Diag with three bare metal stents. [**2147-11-4**] CXR: Worsening pulmonary edema. Portable semi-upright chest radiograph is compared to the prior study. There is cardiomegaly. There is tortuosity of the aorta, which appears to be somewhat ectatic as well. There is a patchy opacity at the right lung base, which has diminished in size since the prior study. The remainder of the lungs are clear. There does not appear to be failure at this time. CT abd/pelvis [**11-2**]: 1. Left groin subcutaneous hematoma, without evidence of retroperitoneal hemorrhage. 2. Retained renal contrast is compatible with acute tubular necrosis. 3. Cholelithiasis. 4. Colonic diverticulosis, without additional findings to suggest diverticulitis. Brief Hospital Course: #. CAD-Patient was initally admitted from OSH for interventional cath. On [**11-1**] she underwent PCI which demonstrated a diffusely diseased SVG graft to the obtuse marginal with a jump segment to the diagonal. The ostial portion of the graft demonstrated a 60% lesion. The graft also had a 90% lesion just proximal to the anastomosis site on the obtuse marginal along with a 70% lesion just proximal to the anastomosis site on the diagonal. She underwent successful direct stenting of the SVG-OM-Diag with three bare metal stents which showed TIMI III flow after. The patient was continued on her home aspirin, plavix, [**Last Name (un) **], nitrate and beta blocker. She received both pre and post-cath hydration as well as mucomist. The patient had a brief episode of hypotension on hospital day #2 which resolved on its own. She received 500cc fluids with improvement in her BP. An EKG was done which showed some deeper TWI in V2-V6. A CT abdomen was done which did not show any evidence of RP Bleed. On hospital day #3, the patient had a rapidly expanding hematoma which was evacuated by vascular surgery and an corrected pseudoaneurysm (see details below). HCT was stable, nadir 18 but stable in the low 30s after surgical evacuation / repair. Patients cardiac enzymes were also trended post-cath. First set showed CK 73 (-->77). Troponin was 0.21. Troponin peak at 0.37, CK peak at 77. Patient was subsequently stable from a cardiac standpoint and sent home on her home asa, plavix, [**Last Name (un) **] and beta blocker. Nitrate was discontinued. . #.Systolic heart failure: Pt has CHF with EF 30%. A an ECHO was done after her hematoma and hypotensive episode to make sure there was no evidence of pericardial effusion or new ischemia. ECHO showed Mild symmetric left ventricular hypertrophy with moderate global/regional systolic dysfunction. Mild calcific aortic stenosis. Pts Lasix was held briefly during hypotensive episode but restarted once her BP stabilized. She was also continued on her [**Last Name (un) **] and BB. . #Acute Renal Failure-Pt had a Cr 1.1 at the OSH and was found to be 1.4 post-cath. The CT abdomen on [**11-2**] demonstrated contrast in her kidneys and collecting ducts consistent with ATN. Her meds were renally dose and all nephrotoxins were avoided. Her creatinine subsequently improved throughout her hospitalization and remained stable. . 2) Bradycardia: Patient stayed in NSR with a rate in the 60s. She did have an episode of bradycardia reported by surgeons which was thought to be a vagal episode (given concurrent report that SBPs were elevated). There were no further episodes of bradycardia throughout the rest of her course. She was monitored on tele with no events. . 4) Valve: Has a murmur on [**Month/Year (2) **] and ECHO notable for mild AS ([**Location (un) 109**] 1.2-1.9cm2). Peak gradient of 29mmHg, velocity of 2.7m/s. Also has 1+ MR [**First Name (Titles) **] [**Last Name (Titles) **]. Currently do not appear to be affecting pt's hemodynamics. No active issues during hospitaliztion. . #) HYPOTENSION/HYPERTENSION: Pt had episode of hypotension in the OR likely due to large volume of acute blood loss. She received a total of 6uprbcs both intra- and post-operatively with good result. Her BP subsequently remained stable. Meds were intially held but as her BP remained stable, her Carvedilol, Valsartan and Lasix restarted. Her Imdur was held upon discharge. . #) HEMATOMA: On post-cath check initially, pt found to have a small hematoma which intially resolved by holding pressure and her Hct was stable. However the following day the patient was standing up and noted a "[**Doctor Last Name **]" sound. She was found to have a rapidly expanding hematoma in her left groin. She subsequently went to the OR where her Hct was found to be 18. She underwent a left groin exploration, repair of the L CFA and placement of a JP drain. The clot was evacuated and a discrete tear was identified in her L CFA. This was sutured with good results. Intraop, she was given 4u pRBC, 1.5L of NS and 800mL LR. She had EBL of 1L and made only 20cc of UOP. She began the OR with SBPs as high as 190 and a HR of 110; however, by the end of the procedure her SBPs were in the 100s-110s and her HR was in the 60s. She required the initiation of neosynephrine for unclear reasons. She remained intubated due to instability of her VS with weaning of the vent. She recovered to the CCU and was successfully extubated that evening. She was weaned of the neosynephrine and her BP meds were all initially held. She subsequently required an additional 2Uprbcs in the CCU to keep her HCT>30. Her hematoma/tear was repaired with good result. She was followed by vascular surgery and the JP drain was removed. She will need to follow up with Dr [**Last Name (STitle) 1391**] in vascular surgery on [**11-15**]. . #) DIABETES: HgbA1C was 7.0% on admission. She was monitored with an insulin sliding scale and her glyburide was held. She was restarted on glyburide prior to discharge. . #) ANEMIA: Pts Hct dropped secondary to her hematoma. She received a total of 6Units prbcs and had a goal for Hct>30. Her Hct remained stable after these tranfusions. . . Medications on Admission: Plavix 75 mg 1 tab daily Diovan 160 mg 1 tab [**Hospital1 **] Folic Acid 1 mg 1 tab daily Lasix 80 mg 1 tab daily MVI 1 tab daily Imdur 60 mg 1 tab daily Coreg CR 12.5 1 tab daily Protonix 40 mg 1 tab daily Colace 100 mg [**Hospital1 **] Glyburide 10 mg [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day. 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 10. Colesevelam 625 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual prn chest pain as needed for pain. Disp:*30 1* Refills:*0* Discharge Disposition: Home With Service Facility: Care Solutions, Inc Discharge Diagnosis: CAD s/p CABG and s/p cath with stenting to SVG graft CHF; Systolic with EF 30% HTN Hyperlipidemia Diabetes Mellitus Spinal stenosis Discharge Condition: improved Discharge Instructions: You were admitted to the hospital wtih chest pain. You underwent a cardiac catheterization which showed some occlusion in the grafts done from your previous CABG. Stents were placed at the site to open up the blockage. YOu had some bleeding at the site in your left groin. You went to the operating room to repair an aneurysm found in one of the left femoral arteries. You subsequently did well. You were continued on your home medications except isosorbide which you do not need anymore. In addition, we added colesevelam for cholesterol. . If you have worsening chest pain, shortness of breath, nausea, vomiting, lightheadedness, or any other concerning symptoms, please call your doctor or return to the ED. . PLease follow up as below. Followup Instructions: Please call your cardiologist and make a follow up appt in 1 week Please call your PCP and make [**Name Initial (PRE) **] follow up appointment in the next 2-3 weeks. Please follow up with Dr. [**Last Name (STitle) 1391**] from vascular surgery at the [**Hospital1 18**] on Wednesday [**11-15**] at 9:45AM. [**Telephone/Fax (1) 1393**]

[ "584.5", "272.4", "250.00", "998.12", "285.1", "410.71", "414.01", "428.0", "458.29", "724.02", "401.9", "428.22", "414.02", "998.11" ]

icd9cm

[ [ [] ] ]

[ "39.31", "88.57", "00.40", "88.56", "36.06", "00.66", "00.47" ]

icd9pcs

[ [ [] ] ]

11236, 11286

4660, 9883

236, 261

11462, 11473

2508, 3791

12265, 12605

1683, 2489

10205, 11213

11307, 11441

9909, 10182

3808, 4637

11497, 12242

186, 198

289, 1253

1275, 1566

1582, 1667

71,364

175,502

38264

Discharge summary

report

Admission Date: [**2185-7-5**] Discharge Date: [**2185-7-16**] Date of Birth: [**2127-11-2**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 949**] Chief Complaint: Hyponatremia. Major Surgical or Invasive Procedure: PICC line placement (removed by patient). Right internal jugular vein hemodialysis line placement (removed by ICU team). History of Present Illness: 57 yo male with history of ESLD [**3-2**] HCV cirrhosis, c/b portal hypertension with resistant ascites, hepatic encephalopathy, and recurrent hyponatremia with multiple recent admissions for refractory hyponatremia and volume overload. On [**6-15**], he was admitted with hyponatremia at which point tolvaptan was increased from 30mg to 60mg and diuretics were held. Diuretics were reinstituted prior to discharge on [**6-18**] once sodium was 125. On [**6-24**], he was readmitted for weight and hyponatremia. Tolvapatan was continued but diuretics were held during admission and at discharge. He was most recently discharged on [**2185-7-2**] after an admission for volume overload where he was found to have diastolic heart failure as a contributing factor. He was started on torsemide given its equal parenteral bioavailability as the patient is known to not follow his sodium restriction at home. The patient had routine labs drawn and was found to be hyponatremic to 125. The patient states that he was contact[**Name (NI) **] by [**Name (NI) 1022**] [**Name (NI) **] and told to come into the clinic, however the patient instead called 911 and went to the [**Hospital3 **] emergency room where he apparently had a sodium of 105. His sodium on recheck here was 127. He is alert and oriented but incorrect in many of his facts during interview. In the ED, he was found to have acute kidney injury with creatinine of 1.4, so he was given a single dose of albumin and sent to the floor. ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -HCV (genotype 1) cirrhosis complicated by hyponatremia, ascites, and hepatic encephalopathy -obesity -hypertension -Insulin-dependent diabetes -CVA with no residual deficits -dyslipidemia -neuropathy -osteoarthritis of the knees -spinal stenosis w/ disk herniation and disc fragments in the canal resulting in permanent diability and foot drop -right lower extremity nerve impingement. -PAD -h/o hypomagnesemia -COPD -anxiety -h/o kidney stones -Past heavy ETOH use, quit [**2177**] -s/p right wrist tendon repair after a plate-glass injury [**2154**] Social History: Lives at home with his children and wife who is his primary caretaker. Relationship with wife is contentious given his noncompliance to fluid or sodium restriction. History of cocaine and marijuana use as well as previous heavy drinking (prior to [**2177**]). He still smokes half a pack per day, which is less than previously. On disability for spinal stenosis and chronic back pain. Family History: Positive for HTN and CAD as well as CVAs. No family history of liver disease. Physical Exam: Upon admission: VS: 96 142/81 102 20 98% on RA GENERAL: Well-appearing man in NAD, comfortable, appropriate. HEENT: MMM, scleral icterus, mild conjunctival pallor. NECK: Supple, no cervical LAD. HEART: RRR, soft S1, systolic murmur radiating to carotids. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Protuberent abdomen, flank dullness. Unable to assess HSM. EXTREMITIES: WWP, 1+ bilateral LE edema, 2+ peripheral pulses. SKIN: No rashes or lesions. NEURO: Awake, A&Ox3, CNs II-XII intact, muscle grossly intact Pertinent Results: LABS UPON ADMISSION: [**2185-7-5**] 03:30PM BLOOD WBC-7.6# RBC-2.88* Hgb-9.3* Hct-27.2* MCV-95 MCH-32.4* MCHC-34.2 RDW-20.7* Plt Ct-117*# [**2185-7-5**] 03:30PM BLOOD Neuts-76.2* Lymphs-14.3* Monos-6.1 Eos-2.9 Baso-0.5 [**2185-7-5**] 03:30PM BLOOD PT-23.3* PTT-46.4* INR(PT)-2.2* [**2185-7-5**] 03:30PM BLOOD Glucose-110* UreaN-21* Creat-1.4* Na-127* K-4.1 Cl-88* HCO3-23 AnGap-20 [**2185-7-5**] 03:30PM BLOOD AST-120* AlkPhos-125 TotBili-10.4* [**2185-7-5**] 03:30PM BLOOD Albumin-3.2* [**2185-7-6**] 05:35AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.3 [**2185-7-6**] 05:35AM BLOOD Osmolal-262* [**2185-7-5**] 03:30PM BLOOD AFP-2.4 [**2185-7-5**] 03:30PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2185-7-5**] 04:08PM BLOOD Glucose-107* Lactate-5.1* Na-125* K-4.0 Cl-86* calHCO3-25 [**2185-7-5**] 04:08PM BLOOD Hgb-9.1* calcHCT-27 [**2185-7-5**] 04:08PM BLOOD freeCa-1.00* LABS PRIOR TO DISCHARGE: MICRO: [**2185-7-12**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2185-7-12**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2185-7-11**] URINE URINE CULTURE-FINAL [**2185-7-11**] MRSA SCREEN MRSA SCREEN-PENDING [**2185-7-11**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2185-7-10**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2185-7-5**] IMMUNOLOGY HCV VIRAL LOAD-FINAL [**2185-7-5**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2185-7-5**] BLOOD CULTURE Blood Culture, Routine-FINAL IMAGING: [**2185-7-5**] RUQ ultrasound: 1. Limited evaluation of the left lobe of the liver. Cirrhosis with mild splenomegaly and small volume ascites. 2. Patent portal venous system. 3. Cholelithiasis. [**2185-7-5**] CXR: There is mild enlargement of the cardiac silhouette which is unchanged. There has been no interval change in the appearance of mild indistinctness of the pulmonary vascular markings suggestive of minimal pulmonary vascular congestion. No focal consolidation, pleural effusion or pneumothorax is present. The mediastinal and hilar contours are stable. Mild degenerative changes are present in the thoracic spine. Brief Hospital Course: 57 yo male with hep C cirrhosis presented with hyponatremia, mild confusion, and acute kidney injury, after very recent hospitalization during which he was started on torsemide for mild diastolic heart failure. #Goals of care: During this admission it was clear on multiple occasions that Mr. [**Known lastname 85273**] was not compliant with our treatment recommendations. He was seen by nursing and other staff members to go to the kitchen and bathroom and drink large amounts of water, in regular violation of the free water restriction of 1800 mL/day. In addition, he admitted to lying about his urine output by adding sink water to the urinal container. Lastly, he removed his PICC line at a time when he was being treated with a continuous furosemide infusion for volume overload. He said that the PICC line "fell out when he was scratching his arm." Given all of these concerns about compliance, and a long history of such problems, the decision was made to remove Mr. [**Known lastname 85273**] from the liver transplant list. A family meeting was held in which immediate family members, including wife and his two daughters, were present. At the meeting, we discussed transitioning Mr. [**Known lastname 85273**] to comfort-directed care and making arrangements for hospice care, either at home or at an inpatient facility. At the time when these arrangements were being made, Mr. [**Known lastname 85273**] insisted on leaving the hospital to go home. He was warned that we did not feel he was medically ready to go home; he was at the time still being treated with continuous furosemide infusion. However, he was insistent on leaving the hospital against medical advise. He was transitioned over to torsemide 30 mg once daily. His tolvaptan was held. (His hyponatremia is more likely the result of non-compliance with free water restriction, and it is unlikely that tolvaptan will benefit him as long as he is unable to comply with dietary recommendations). Spironolactone was also held. Simvastatin is likely of little benefit for primary prevention given his overall poor prognosis with end-stage liver disease (MELD 28-29), and this medicine was also held. The patient will go home with plans for visiting nursing and transition to home hospice. #Acute renal failure: Creatinine mildly increased from prior. This was likely a result of decreased effective circulating volume due to poor oncotic pressure despite total body volume overload. He was recently started on torsemide during his last admission and discharged on torsemide and spironolactone. Upon admission, diuretics were held. Lower dose torsemide was restarted once his creatinine normalized. #Volume overload: Likely a combination of mild diastolic heart failure and cirrhosis in a patient who is non-compliant with sodium restriction. Albumin is low at 3.2. A low salt diet was ordered, although patient was noncompliant with this recommendation. Diuretics were initially held and then resumed given the degree of his volume overload. A TSH was normal. MICU Course: Mr. [**Known lastname 85273**] was transferred to the MICU on [**2185-7-11**] for a higher level of nursing attention and for initiaion of CVVH. Ultrafiltration was started for volume overload via a right IJ HD line. Tolvaptan was discontinued. He did not tolerate ultrafiltration due to agitation, despite haldol 5mg iv. A lasix gtt was initiated. He had transient hypotension in the setting of initiating ultrafiltration, requiring levophed briefly. Nephrology was following and the decision was made to continue the lasix drip. Patient diuresed well with the lasix drip over 48 hours, net negative 4-5 L. He was also temporarily placed on low dose dopamine for diuresis, which was discontinued.. Encephalopathy started to clear with liquid lactulose. Transferred to [**Hospital Ward Name **] 10. Lasix drip discontinued due to staffing concerns. Patient given Lasix 40mg IV x1. Subsequently, he triggered as he became asymptomatically hypotensive to 80/40 with SOB requiring 2L nasal cannula. He was given two doses of albumin 25g and his blood pressures improved. Patient was ultimately discharged on torsemide 30 mg once daily. #Hyponatremia: The patient's hyponatremia was at baseline prior to admission. However, his fluid status continues to be difficult to manage and his diuretic regimen may need further optimization. He was continued on tolvaptan 60mg daily with an 1800cc fluid restriction. Tolvaptan was held at time of discharge due to changing goals of care. #Hyperbilirubinemia: Currently the patient has no signs of a portal vein thrombosis or SBP that would cause the patient's liver disease to decompensate. RUQ ultrasound was unrevealing, and tbili trended back to baseline. HCV VL much lower than last check. AFP lower than prior. No fevers or white count, with all cultures negative to date. #Hepatic encephalopathy: Most likely secondary to noncompliance with lactulose. Lactulose was uptitrated and rifaximin was continued. # Elevated lactate: possibly due to impaired clearance of lactate by liver, however this is higher than normal for the patient. This may be a result of intravscular depletion from diuretics. Medications on Admission: clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day doxepin 25 mg Capsule Sig: One (1) Capsule PO HS ergocalciferol (vitamin D2) 50,000 unit PO 1X/WEEK (WE). insulin glargine 100 unit/mL Solution Sig: Twenty Nine (29) units SC qhs ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-30**] inh qid lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day ondansetron 4 mg Tablet, Rapid Dissolve Sig: One Q8H as needed for nausea. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) prn pain pantoprazole 40 mg Tablet, Delayed Release po q24h rifaximin 550 mg Tablet Sig: One (1) Tablet PO DAILY simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY tolvaptan 30 mg Tablet Sig: Two (2) Tablet PO DAILY ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID ferrous sulfate 300 mg (60 mg iron) PO DAILY (Daily). magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO tid multivitamin Tablet Sig: One (1) Tablet PO DAILY simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, qid prn gas pain. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical tid prn pruritis hydroxyzine HCl 25 mg Tablet Sig: 1-2 Tablets PO QHS prn pruritis. torsemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 2. doxepin 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (WE). 4. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-30**] Puffs Inhalation Q6H (every 6 hours) as needed for dyspnea. 5. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas. 13. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed for itching. 14. lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO every four (4) hours as needed for encephalopathy. 15. insulin glargine 100 unit/mL Cartridge Sig: Twenty Nine (29) units Subcutaneous at bedtime. 16. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 17. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for dry skin. 18. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 19. torsemide 20 mg Tablet Sig: 1.5 Tablets PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital3 **]Hospice Discharge Diagnosis: Primary Diagnoses: Hyponatremia, Acute kidney injury secondary to hypovolemia Secondary Diagnoses: Cirrhosis seconday to hepatitis C and EtOH Insulin-dependent diabetes, Obesity, Hypertension, Dyslipidemia, Chronic obstructive pulmonary disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Weight at discharge: Discharge Instructions: You were admitted to the hospital for evaluation of some abnormal laboratory tests: 1. Low sodium levels. 2. Acute kidney injury. During the admission, your diuretic medicines, torsemide and spironolactone, were stopped. You were treated with a medicine similar to torsemide but given intravenously, and your symptoms improved. We would like you to continue to take torsemide. The dose will be 30 mg daily. We asked that you stay in the hospital so that you could continue intravenous medicines to help remove fluid from the body. However, you have insisted on returning home. Please know that you are leaving the hospital against our medical advice, since we believe that you would benefit from further medical treatment while in the hospital. We spoke to you at length about following our diet recommendations. The diet recommendations are: 1. Maintaining a low-sodium diet (<2 grams total daily). 2. Limiting fluid intake to less than 1500 cc/day. The following changes have been made to your medication regimen: HOLD simvastatin HOLD tolvaptan HOLD spironolactone Followup Instructions: Please attend the following appointments: Department: TRANSPLANT CENTER When: WEDNESDAY [**2185-7-20**] at 11:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: WEDNESDAY [**2185-7-20**] at 12:30 PM [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: MEDICAL SPECIALTIES When: TUESDAY [**2185-8-2**] at 3:00 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2185-7-18**]

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

14321, 14375

5942, 11159

280, 403

14665, 14665

3828, 3835

15937, 16838

3173, 3252

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2770, 3157

20,485

175,359

30777

Discharge summary

report

Admission Date: [**2183-5-8**] Discharge Date: [**2183-5-20**] Date of Birth: [**2105-11-21**] Sex: F Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 9240**] Chief Complaint: Transfer from OSH for GI bleed, stroke and PE Major Surgical or Invasive Procedure: transesophageal echocardiogram History of Present Illness: This is a 77 year old woman with seizure disorder and unclear h/o CAD, and unclear h/o CVA who presented to OSH on [**5-1**] with painless BRBPR x 1 week. Gastroenterology w/u there thought the bleed could be from NSAIDs which she takes for back pain and aspirin. However, EGD and colonoscopy did not reveal a source of bleed. She was admitted with a hemaglobin of 8.5 and recieved 2 units of PRBC and stabilized to a hemaglobin of 9.7 before transfer to [**Hospital1 18**]. . Her course at OSH was complicated by neurologic findings. On [**5-2**], she was noticed to have a left facial droop and expressive aphasia. MRI of the head showed a small acute infarct in the left peritrigonal redion. Neurology was consulted and did not think the small area of infarct in that area could explain her word finding difficulties and thought his could be more from enchephalopathy rather than an aphasic disorder. . On [**5-2**], she also desaturated to 60% and cardiac enzymes were cycled. They were elevated and cardiology consult was called. EKG was "unintepretable due to LBBB" and an echo as done. Echo showed normal LV function but significant RV strain and RV overload with pulm htn. V/Q scan is high probability for large burden of bilateral PE's involving the segmental and subsegmental areas. . Given her GIB of unknown source and large burden of PE, anticogulation was an issue and she was transferred to [**Hospital1 18**] for further care. . Currently, she has expressive aphasia which makes taking her history difficult. She currently complaints of RUQ/R Rib pain. At OSH, she had unremarkable RUQ and KUB. . She denies chest pain or shortness of breath. . At OSH, vitals before transfer: 9736, 136/81, 80, 16, 92% on 4LNC. Past Medical History: 1. Remote CAD, unclear details, had angioplasty 2. Remote CVA event, unclear details 3. h/o PE's 4. Seizure disorder 5. Hypothyroid 6. Hypercholesterolemia 7. CRI (unknown baseline cr) 8. s/p Zenker's diverticulum 9. Degenerative joint disease 10. Multiple UTIs Social History: no tobacco, 2 vodka&waters/day, lives alone, only child, son and daughter Family History: non contributory Physical Exam: per Dr. [**First Name8 (NamePattern2) 15989**] [**Name (STitle) **]: VITALS: 98.0, 164/94, 90, 20, 94%-2LNC GEN: A+Ox3, NAD, expressive aphasia HEENT: PERRLA, EOMI, MMM, OP clear NECK: no JVD CV: RRR, 2/6 SEM at LUSB, no gallop or rub PULM: CTAB, no w/r/r, coarse ABD: soft, NT, ND, +BS EXT: no c/e/c NEURO: Left eyelid lower than right. No clear facial droop. CN [**1-27**] otherwise intact. Strenth [**4-19**] all extremities. Sensation grossly intact. F to N intact. Her expressive aphasia on admission was notable for some word finding difficulties. She seemed to comprehend well. Pertinent Results: 137 92 28 -------------< 86 3.9 34 1.5 CK: 61 MB: Notdone Trop-T: 0.18 Ca: 9.6 Mg: 1.3 P: 4.0 . 10.5 3.9 >----< 245 33.2 PT: 11.6 PTT: 34.1 INR: 1.0 . Trends: WBC 3.9, 5.7, 5.3, 5.1, 6.4 Hct: 33, 32, 29, 27, 27, Platelet 245, 231, 216, 192, 200 Creatinine 1.5 - 1.5 - 1.4 - 2.7 Trop: 0.18 - 0.16 HbA1c-5.9 Cholest-127, Triglyc-123 HDL-59 CHOL/HD-2.2 LDLcalc-43 Valproa-46 - 56 Urine lytes: FeNA<0.1% on [**5-11**] . Micro: Urine: coag neg staph x1 urine: neg x1 blood cx; ngtd . At OSH: # VQ scan shows high probability of PE with evidence of multiple segmental and subsegmental defects throughout both lungs with the largest being posterior in the right lower lobe as well as superiory in the left upper lobe. # MRI brain: Acute small infarct in the left peritrigonal region and also small vessel changes # Echo: NL LV function. Right ventricular pressure overload with mildly reduced RV function and severe pulm htn. . Radiology: [**5-9**]: CT A Chest: 1. Atherosclerotic aorta without evidence of dissection or aneurysmal dilatation. 2. Findings consistent with mild volume overload. 3. Prominent mediastinal lymph nodes and single enlarged paratracheal node are likely reactive. However, follow-up chest CT is recommended following resolution of acute symptoms to exclude the possibility of neoplasm. 4. Small pericardial effusion. 5. Axial hiatal hernia. 6. Diverticulosis without diverticulitis. . [**5-9**] CT Chest abd pelvis without IV contrast: 1. Diffuse ground-glass opacities, which are nonspecific and likely represent pulmonary edema and less likely infection. 2. Moderate-sized pericardial effusion. 3. Large hiatus hernia and intrathoracic location of the stomach. 4. Pleural plaques indicating prior asbestos exposure. . [**5-9**]: Echo: The left atrium is elongated. The estimated right atrial pressure is 11-15mmHg. There is moderate symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is normal (LVEF>55%), without regional wall motion abnormalities. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. 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 a small posterior pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Small pericardial effusion. Moderate LVH with preserved global and regional biventricular systolic function. Diastolic dysfunction with evidence of elevated right and left-sided filling pressures. Moderate pulmonary hypertension. . DVT scan neg . Renal U/S [**5-11**]: no hydro Brief Hospital Course: 77 year old female with GIB from unknown source, large PE burden and acute stroke at OSH. She was on the floor for one night then became hypotensive. Transferred to the MICU on [**5-9**]. received 2L IVF. Noted to have differences in right and leg arm BPs. CTA was ordered which showed no dissection. She was stabilized and returned to the floor on [**5-10**]. Remainder of hospital course by problem: . # GI Bleed: Possibly from her outpatient aspirin and NSAID use. She had been using NSAIDS for her back pain since [**Month (only) 956**]. EGD at OSH: hiatal hernia, no bleed. Colonoscopy at OSH: diverticulosis, no obvious source of bleed. We placed 2 large [**Last Name (un) **] IVs and monitored her Hct closely. It trended down with IVF in the setting of hypotension but stabilized. We treated with a PPI. The Hct remained stable over the hospital course. . # PE: At OSH: VQ scan shows high probability of PE with evidence of multiple segmental and subsegmental defects. She was stable on 3-4L NC. We treated with heparin gtt and started coumadin. She had a therapeutic INR on coumadin dose of 5 mg QHS. She will need her INR checked every week and adjust the coumadin dose accordingly. . # CVA: OSH MRI showed small acute infarct in left peritrigonal region of less than 1cm. Neuro was consulted. Given the small area of the infarct, we anticoagulated as above. She initially was quite aphasic with a left eyelid droop. These symptoms improved substantially during her stay. She was able to speak coherently and act appropriately. She was alert and oriented x3, able to move all extremities, and interact appropriately. The carotid US showed L sided subclavian steal. Neuro was made aware of this. This issue will need to be addressed at her coming neuro appointment. She will follow up with Dr [**Last Name (STitle) 72861**] in neuro clinic at the [**Hospital1 **]. . # ARF: The patient came in with creatinine of 1.5 (it had been up to 1.9 at OSH). On [**5-11**] it increased to 2.7 rather acutely and she became anuric. This was 48 hours after the administration of IV contrast. Renal was consulted Her FeNa was 0.1% c/w contrast nephropathy. Renal ultrasounds did not show hydronephrosis. She was anuric initially. did not respod to IVF. was started on diuril and lasix. the anuria resolved and she diuresed profusely even after stopping the lasix. the Cr trended down and was 2.3. . # SEIZURE DISORDER: unclear etiology for h/o seizures. At OSH valproic acid level was low and she was reloaded. Initially she was on valproic acid here but was found to have a subtherapeutic level. hence we discontinued the valproic acid. she will follow up with neurology here and a decision about restarting it can be made at that time. . # CAD: She has remote and vague history of CAD from OSH notes. At OSH, she has elevated enzymes and per cardiology consult note: EKG was uninterpretable due to LBBB. Her enzymes were elevated probably due to RV strain from PE's rather than from an ischemic event. The CE trended downward at our hospital and she was CP free. she was started on as[irin 81 mg and was continued on simvastatin. . # CODE: Full code (from OSH record) Medications on Admission: upon transfer # Allopurinol 300 mg PO DAILY # Furosemide 40 mg PO DAILY # Levothyroxine Sodium 100 mcg PO DAILY # Depakote 250 mg PO BID # Pantoprazole 40 mg PO Q24H # Simvastatin 40 mg PO DAILY # Multivitamins 1 CAP PO DAILY # Cyanocobalamin 100 mcg PO DAILY # Albuterol 0.083% Neb Soln 1 NEB IH Q6H # Ipratropium Bromide Neb 1 NEB IH Q6H # Ondansetron 8 mg IV Q8H:PRN Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID:PRN. 11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 14. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 15. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO q4-6h: prn as needed for back pain. 19. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 20. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO QD:PRN as needed for back pain. Discharge Disposition: Extended Care Facility: [**Hospital3 12564**] Health Network Discharge Diagnosis: CVA GI bleed pulmonary embolism non-ST elevation myocardial infarction patent foramen ovale Discharge Condition: stable Discharge Instructions: Take all medications as directed. Do not stop or change your medications without first speaking to your physician. Follow up as oulined below. If you experience any shortness of breath, chest pain, weakness, dizziness, pain in abdomen, nausea, vomitting, diarrhea, difficulty in urination or any other concerning symptoms call the doctor on call or go to the emergency room. Followup Instructions: Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2183-6-10**] 2:00 Please make a follow up appointment within 2 weeks of discharge with your primary care provider Dr [**Last Name (STitle) 72862**] ([**Telephone/Fax (1) 72863**]) Please remove the Foley catheter within 10 days of the rehab stay. Please check INR every 7 days and adjust the coumadin dose accordingly. Completed by:[**2183-5-20**]

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icd9cm

[ [ [] ] ]

[ "38.93", "88.72" ]

icd9pcs

[ [ [] ] ]

11496, 11559

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315, 348

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11728, 12107

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230, 277

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51978

Discharge summary

report

Admission Date: [**2117-11-7**] Discharge Date: [**2117-11-19**] Date of Birth: [**2072-8-27**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 4659**] Chief Complaint: 45 F pedestrian struck by car with left frontal SDH, b/l SAH and grade 1 splenic lac Major Surgical or Invasive Procedure: Bolt placement [**2116-11-7**] Exploratory laparotomy [**2117-11-8**] Percutaneous tracheostomy [**2117-11-12**] PEG [**2117-11-15**] History of Present Illness: This is an unfortunate 45 yo lady who was struck by a car while walking and suffered a traumatic brain injury with L frontal SDH, b/l SAH and grade 1 splenic laceration. She was admitted to the ACS service with neurosurgery and orthopedics consultation. Past Medical History: PMH: vertigo, HTN, untreated, GSW to neck [**2097**] Social History: Married, one child in good health. Family History: NC Physical Exam: Gen: does not open eyes to command, does not follow commands but will spontaneously move all extremities. CVS: RRR Pulm: CTAB. Trach in place Abd: soft, NT/ND, PEG in place Ext: b/l LE ecchimoses, improving. B/l LE edema. Pertinent Results: [**2117-11-7**] 04:45PM BLOOD WBC-16.0* RBC-3.37* Hgb-10.1* Hct-29.4* MCV-87 MCH-29.9 MCHC-34.3 RDW-12.9 Plt Ct-314 [**2117-11-7**] 08:25PM BLOOD WBC-14.6* RBC-3.07* Hgb-9.3* Hct-26.6* MCV-87 MCH-30.3 MCHC-35.0 RDW-13.2 Plt Ct-266 [**2117-11-7**] 11:48PM BLOOD Hct-31.8* [**2117-11-8**] 02:11AM BLOOD WBC-9.0 RBC-3.71* Hgb-11.4* Hct-32.0* MCV-86 MCH-30.6 MCHC-35.5* RDW-13.8 Plt Ct-200 [**2117-11-8**] 05:12AM BLOOD Hct-31.0* [**2117-11-8**] 02:07PM BLOOD Hct-28.4* [**2117-11-8**] 05:00PM BLOOD Hct-27.6* [**2117-11-8**] 10:47PM BLOOD WBC-5.6 RBC-2.86* Hgb-8.7* Hct-24.4* MCV-85 MCH-30.2 MCHC-35.5* RDW-14.1 Plt Ct-130* [**2117-11-9**] 04:36AM BLOOD WBC-8.8# RBC-3.01* Hgb-8.9* Hct-25.6* MCV-85 MCH-29.6 MCHC-34.8 RDW-14.1 Plt Ct-127* [**2117-11-9**] 01:53PM BLOOD WBC-10.0 RBC-2.80* Hgb-8.5* Hct-24.1* MCV-86 MCH-30.4 MCHC-35.4* RDW-14.2 Plt Ct-144* [**2117-11-10**] 12:33AM BLOOD WBC-7.4 RBC-2.37* Hgb-7.1* Hct-21.0* MCV-89 MCH-30.2 MCHC-34.1 RDW-14.1 Plt Ct-146* [**2117-11-10**] 09:43AM BLOOD Hct-25.2* [**2117-11-10**] 08:18PM BLOOD Hct-26.1* [**2117-11-11**] 01:31AM BLOOD WBC-8.8 RBC-2.98*# Hgb-9.2*# Hct-25.8* MCV-87 MCH-30.9 MCHC-35.7* RDW-15.1 Plt Ct-133* [**2117-11-11**] 03:17PM BLOOD WBC-8.7 RBC-2.84* Hgb-8.6* Hct-24.7* MCV-87 MCH-30.5 MCHC-35.0 RDW-15.0 Plt Ct-138* [**2117-11-11**] 03:17PM BLOOD WBC-8.7 RBC-2.84* Hgb-8.6* Hct-24.7* MCV-87 MCH-30.5 MCHC-35.0 RDW-15.0 Plt Ct-138* [**2117-11-12**] 01:52AM BLOOD WBC-8.1 RBC-2.84* Hgb-8.7* Hct-24.6* MCV-87 MCH-30.5 MCHC-35.2* RDW-15.3 Plt Ct-163 [**2117-11-13**] 01:40AM BLOOD WBC-8.2 RBC-2.62* Hgb-8.3* Hct-23.4* MCV-89 MCH-31.8 MCHC-35.6* RDW-14.9 Plt Ct-194 [**2117-11-14**] 01:09AM BLOOD WBC-9.1 RBC-2.93* Hgb-9.0* Hct-25.7* MCV-88 MCH-30.6 MCHC-34.9 RDW-15.7* Plt Ct-188 [**2117-11-15**] 02:16AM BLOOD WBC-11.7* RBC-3.03* Hgb-9.2* Hct-26.4* MCV-87 MCH-30.4 MCHC-35.0 RDW-15.9* Plt Ct-237 [**2117-11-16**] 02:01AM BLOOD WBC-12.2* RBC-2.86* Hgb-8.8* Hct-25.8* MCV-90 MCH-30.7 MCHC-34.1 RDW-15.6* Plt Ct-281 [**2117-11-17**] 01:28AM BLOOD WBC-14.1* RBC-3.10* Hgb-9.2* Hct-28.7* MCV-93 MCH-29.8 MCHC-32.2 RDW-15.7* Plt Ct-402 [**2117-11-18**] 03:06AM BLOOD WBC-12.2* RBC-3.24* Hgb-9.5* Hct-29.3* MCV-90 MCH-29.4 MCHC-32.6 RDW-16.1* Plt Ct-357 [**2117-11-19**] 01:17AM BLOOD WBC-10.6 RBC-3.32* Hgb-10.1* Hct-31.5* MCV-95 MCH-30.5 MCHC-32.1 RDW-15.7* Plt Ct-561*# [**2117-11-7**] 04:45PM BLOOD Plt Ct-314 [**2117-11-7**] 04:45PM BLOOD PT-13.5* PTT-23.0 INR(PT)-1.2* [**2117-11-7**] 08:25PM BLOOD PT-13.6* PTT-22.3 INR(PT)-1.2* [**2117-11-7**] 08:25PM BLOOD Plt Ct-266 [**2117-11-8**] 02:11AM BLOOD PT-12.8 PTT-21.7* INR(PT)-1.1 [**2117-11-8**] 02:11AM BLOOD Plt Ct-200 [**2117-11-8**] 10:47PM BLOOD Plt Ct-130* [**2117-11-9**] 04:36AM BLOOD Plt Ct-127* [**2117-11-9**] 01:53PM BLOOD Plt Ct-144* [**2117-11-10**] 12:33AM BLOOD Plt Ct-146* [**2117-11-11**] 01:31AM BLOOD Plt Ct-133* [**2117-11-11**] 03:17PM BLOOD Plt Ct-138* [**2117-11-12**] 01:52AM BLOOD PT-12.3 PTT-22.4 INR(PT)-1.0 [**2117-11-12**] 01:52AM BLOOD Plt Ct-163 [**2117-11-12**] 01:42PM BLOOD PT-12.6 PTT-23.6 INR(PT)-1.1 [**2117-11-13**] 01:40AM BLOOD Plt Ct-194 [**2117-11-14**] 01:09AM BLOOD Plt Ct-188 [**2117-11-15**] 02:16AM BLOOD Plt Ct-237 [**2117-11-16**] 02:01AM BLOOD Plt Ct-281 [**2117-11-17**] 01:28AM BLOOD Plt Ct-402 [**2117-11-18**] 03:06AM BLOOD Plt Ct-357 [**2117-11-19**] 01:17AM BLOOD Plt Ct-561*# [**2117-11-7**] 04:45PM BLOOD UreaN-19 Creat-0.7 [**2117-11-7**] 08:25PM BLOOD Glucose-180* UreaN-16 Creat-0.8 Na-145 K-3.7 Cl-117* HCO3-18* AnGap-14 [**2117-11-8**] 02:11AM BLOOD Glucose-155* UreaN-13 Creat-0.6 Na-149* K-4.6 Cl-125* HCO3-16* AnGap-13 [**2117-11-8**] 05:00PM BLOOD Glucose-175* UreaN-12 Creat-0.5 Na-151* K-3.4 Cl-124* HCO3-19* AnGap-11 [**2117-11-8**] 10:47PM BLOOD Glucose-154* UreaN-11 Creat-0.6 Na-150* K-3.5 Cl-123* HCO3-20* AnGap-11 [**2117-11-9**] 04:36AM BLOOD Glucose-163* UreaN-11 Creat-0.6 Na-150* K-3.7 Cl-123* HCO3-21* AnGap-10 [**2117-11-9**] 01:53PM BLOOD Glucose-147* UreaN-10 Creat-0.6 Na-148* K-3.9 Cl-119* HCO3-23 AnGap-10 [**2117-11-10**] 12:33AM BLOOD Glucose-130* UreaN-11 Creat-0.7 Na-150* K-4.0 Cl-119* HCO3-25 AnGap-10 [**2117-11-10**] 02:34PM BLOOD Glucose-141* UreaN-12 Creat-0.5 Na-149* K-3.7 Cl-118* HCO3-25 AnGap-10 [**2117-11-11**] 01:31AM BLOOD Glucose-132* UreaN-15 Creat-0.5 Na-149* K-3.9 Cl-117* HCO3-29 AnGap-7* [**2117-11-11**] 03:17PM BLOOD Glucose-148* UreaN-15 Creat-0.4 Na-149* K-3.5 Cl-113* HCO3-28 AnGap-12 [**2117-11-12**] 01:52AM BLOOD Glucose-140* UreaN-16 Creat-0.5 Na-149* K-3.4 Cl-112* HCO3-29 AnGap-11 [**2117-11-12**] 01:42PM BLOOD Glucose-119* UreaN-17 Creat-0.4 Na-146* K-3.5 Cl-113* HCO3-28 AnGap-9 [**2117-11-13**] 01:40AM BLOOD Glucose-124* UreaN-16 Creat-0.4 Na-145 K-3.6 Cl-113* HCO3-25 AnGap-11 [**2117-11-14**] 01:09AM BLOOD Glucose-141* UreaN-17 Creat-0.4 Na-139 K-3.8 Cl-105 HCO3-26 AnGap-12 [**2117-11-14**] 03:08PM BLOOD Glucose-152* UreaN-16 Creat-0.4 Na-135 K-3.6 Cl-100 HCO3-26 AnGap-13 [**2117-11-15**] 02:16AM BLOOD Glucose-124* UreaN-16 Creat-0.3* Na-135 K-4.0 Cl-102 HCO3-25 AnGap-12 [**2117-11-16**] 02:01AM BLOOD Glucose-109* UreaN-11 Creat-0.4 Na-135 K-3.6 Cl-99 HCO3-26 AnGap-14 [**2117-11-17**] 01:28AM BLOOD Glucose-141* UreaN-12 Creat-0.4 Na-146* K-4.0 Cl-108 HCO3-31 AnGap-11 [**2117-11-18**] 03:06AM BLOOD Glucose-151* UreaN-17 Creat-0.4 Na-148* K-4.3 Cl-107 HCO3-32 AnGap-13 [**2117-11-19**] 01:17AM BLOOD Glucose-155* UreaN-19 Creat-0.4 Na-145 K-4.4 Cl-107 HCO3-27 AnGap-15 [**2117-11-15**] 06:14AM BLOOD Type-ART pO2-117* pCO2-29* pH-7.51* calTCO2-24 Base XS-1 [**2117-11-15**] 09:19AM BLOOD Type-ART pO2-118* pCO2-35 pH-7.46* calTCO2-26 Base XS-2 [**2117-11-16**] 02:31AM BLOOD Type-ART pO2-124* pCO2-34* pH-7.48* calTCO2-26 Base XS-3 Brief Hospital Course: Mrs [**Known lastname **] was admitted on [**2117-11-7**] after suffering a collision vs car when walking on the street. She was intubated on the field and transported to our ED. Here a CT of her head was performed and showed: -subarachnoid hemorrhage along the cerebral vertex, small left -vertex subdural hematoma -small left parasagittal cortical contusion A CT torso was performed as well and demonstrated: 1. Grade 1 splenic laceration, with a small to moderate volume hemoperitoneum. 2. Non-displaced right first rib fracture. 3. Acute left mid clavicular fracture. 4. Equivocal nondisplaced left transverse process tip fractures at L4 and L5. The patient was transferred to the TSICU for further management Neurologic: A bolt was placed by Neurosurgery on HD1 for ICP monitoring, she intermittently would have increased ICPs into the mid 30s. Her mental status was very minimal during her stay. She did not wake up, she had only spontaneous movements of the lower extremities, with no purposeful movements, and didn't follow commands. Bolt was ultimately removed on [**2117-11-12**]. Continuous EEG monitoring was started for suspected epileptic activity. Initially this was unrevealing, however, on [**2117-11-15**] there was concern for possible seizure activity, so Dilantin level was increased to 250 TID from 100 TID. The HOB was kept at 30 degrees and the SBP >110 to increase CPP. Intermittent mannitol was needed for increased ICPs, and the patient responded appropriately. MRI was obtained that confirmed the presence of diffuse axonal injury. Her Dilantin was stopped on HD10 and she was started on Keppra to be continued upon discharge. Cardiovascular: The patient was tachycardic and hypertensive upon arrival and IV metoprolol was titrated. The patient remained hemodynamically stable during her stay. She was maintained on a stable regimen of lopressor and labetolol without any issues. On HD12 Diltiazem was started for better pain control. Pulmonary: She was intubated when arrived to the [**Hospital1 18**] ED. Ventilator weaning was difficult because of increased ICP and a decision was made to perform a tracheostomy on HD6. The patient was on the ventilator via the trach on minimal pressure support settings and was finally weaned off the ventilator on HD 10 Gastrointestinal / Abdomen: The patient suffered from a grade 1 splenic laceration with hemoperitoneum. On HD1 because of persistent tachycardia as well as lactic acidemia and failure to improve clinically she was taken urgently to the operating room for exploration. The abdomen was washed out and no active bleeding was seen at that time. Please see full operative note for details. Postoperatively, serial HCTs were checked and were stable. Ultimately due to persistent poor neurologic status, a PEG tube was placed on [**2117-11-15**] for nutrition. Prior to this, the patient was receiving tube feeds via an OGT. Tube feeds are currently at goal. MSK: The patient had a left clavicle fracture with dislocated left shoulder reduced by orthopedics. The left clavicle fracture was managed conservatively by orthopedics. No surgical intervention was needed. Nutrition: The patient was kept NPO on IVF upon arrival to the TSICU. Tube feeds were started on HD3. On [**11-15**] a PEG was placed to provide longer term enteral access. Renal: A foley was placed upon arrival to monitor UOP. The patient's urine output remained adequate during her stay. Electrolytes were monitored routinely and repleted as necessary. Hematology: Hct was trended. She received 2U of PRBC upo arrival. 2U PRBC were given on POD4 because her Hct was slowly trending down: from 25 to 21. She responded to this transfusion appropriately and since that time did not require any further transfusions and her HCT remained stable. Endocrine: The patient was on a RISS and fingesticks were checked q6h Infectious Disease: Ancef was started after bolt placement and was subsequently discontinued on [**2117-11-12**] when the bolt was removed. The patient was started on ceftriaxone for MSSA pneumonia on HD10. Urine culture is growing Enterococcus and sensitivities are pending at the time of discharge. Prophylaxis: - DVT: boots, SQH was started when HCT stable and approved by neurosurgery - Stress ulcer: famotidine Medications on Admission: vertigo patch-[**Last Name (un) 5487**] Discharge Medications: 1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 2. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 3. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) un Injection TID (3 times a day). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for oral thrush. 10. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. insulin regular human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 13. diltiazem HCl 30 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). 14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 15. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 16. labetalol 5 mg/mL Solution Sig: 10-20 mg Intravenous Q6H (every 6 hours) as needed for SBP >160. 17. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) g Intravenous Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: 45F pedestrian struck 1. L frontal SDH, b/l SAH, diffuse axonal injury 2. Grade 1 splenic lac 3. s/p trach and PEG 4. MSSA PNA 5. L clavicle Fx 6. R 1st rib Fx Discharge Condition: Stable, not awake, spontaneous movements, but does not follow commands Discharge Instructions: Please call if you develop worsening pain, nausea, vomiting, fevers, chills, chest pain, SOB, or any other concerns that you may have. You will be discharged on multiple medications, please take all of these as prescribed. You will be sent to rehab with a tracheostomy tube to help with your breathing and a feeding tube to provide nutrition. These will be mainatined by your healthcare providers at rehab. Followup Instructions: Please f/u in [**Hospital 2536**] clinic in two weeks. Please call to make an appointment. ([**Telephone/Fax (1) 2537**] Please follow-up in [**Hospital 9696**] clinic in 2 weeks at [**Hospital3 **] Hospital [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Center, [**Location (un) 551**]. Please call [**Telephone/Fax (1) 1228**] for an appointment Follow up in 4 weeks with Non Contrast Head CT to see Dr [**Last Name (STitle) **] in the [**Hospital 4695**] Clinic. An appointment can be made by calling [**Telephone/Fax (1) 2992**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**] Completed by:[**2117-11-19**]

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icd9cm

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28915

Discharge summary

report

Admission Date: [**2197-8-28**] Discharge Date: [**2197-9-11**] Date of Birth: [**2126-10-12**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: [**2197-8-28**] Exploratory Lap [**2197-8-29**] Closure of Abdominal wound History of Present Illness: 70 year old female involved in a motor vehicle crash; intubated at scene because of mental status changes; also was found to be in shock with a distended abdomen. She had both a positive FAST and DPL and was taken to the operating room directly from the trauma bay for exploratory. Past Medical History: Hypertension GERD Bilateral knee replacements with post-op GI bleed Family History: Nonconttibutory Physical Exam: Tm/c: 100.2/100.2 HR: 97 BP: 160/80 RR: 18 O2sat: 97%RA Gen: AAOx3, NAD, TLSO on HEENT: Left eye: EOMI, PERRL; Right eye: ptosis, CN IV and VI intact With TLSO off and patient lying flat in bed: CV: RRR, no murmurs Lungs: CTAB Abd: NA BS present, soft, NT, ND, steri-strips intact, distal wound opened, packed, bandaged - clean and intact Extr: venodynes, no C/C/E Pertinent Results: IMAGING . CT PELVIS W/CONTRAST [**2197-8-28**] 6:16 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST IMPRESSION: 1. Free air within the anterior mediastinum, and air anterior to the epicardium, of indeterminate etiology. 2. Edema within the lungs. 3. Small right pleural effusion. 4. Post-surgical changes of the abdomen, with an open abdominal wound and stomach, small and large bowel protruding through the wound defect. Free air and free fluid in the abdomen. Per the operative note, there was a tear at the root of the mesentery with vascular injury. 5. Multiple fractures, including the T11 vertebral body with retropulsion of fragments into the central spinal canal. The acuity of this finding is uncertain, as there are no priors for comparison. There is a fracture of some transverse processes of the lumbar spine, and a fracture of the right posterior eleventh rib. 6. Enhancement of the small bowel mucosa suggesting shock. . . CT C-SPINE W/O CONTRAST [**2197-8-28**] 6:16 PM CT C-SPINE W/O CONTRAST IMPRESSION: 1. No evidence of cervical spine fracture. 2. Grade I anterolisthesis of C3 on C4. 3. Edema at the lung apices. . . CT HEAD W/O CONTRAST [**2197-8-28**] 6:15 PM INDICATION: Status post MVC. Intubated. There are no prior studies for comparison. NONCONTRAST HEAD CT SCAN: There is a very small amount of subdural blood along the falx cerebri on the left side near the vertex (series 2 images 22 through 27). No other definite areas of hemorrhage are appreciated. The ventricles and cisterns are normal. The density values of the brain parenchyma are normal, with preservation of the [**Doctor Last Name 352**]-white matter differentiation. There are widened bifrontal extra-axial spaces, which may be related to involutional change. There is a small amount of fluid layering posteriorly within each maxillary sinus. There is partial opacification of the ethmoid air cells. The mastoid air cells are clear. Osseous and soft tissue structures are unremarkable. IMPRESSION: Small subdural hematoma along the left side of the falx cerebri. No shift of the normally midline structures. The finding was discussed with Dr. [**Last Name (STitle) 69770**] at the conclusion of the exam. . . TRAUMA #2 (AP CXR & PELVIS PORT) [**2197-8-28**] 6:08 PM INDICATION: Trauma. CHEST: Trauma supine chest and pelvis reviewed. There is diffuse opacification of both lungs. The left diaphragmatic border is obscured. The pleura are grossly clear without large effusions or pneumothoraces. No displaced rib fractures are identified. The patient is intubated with the ET tube located 1.5 cm above the carina. NG tube is present in the stomach. The heart and mediastinal contours are within normal limits given the supine projection. IMPRESSION: Diffuse opacification of both lungs likely secondary to pulmonary edema versus contusion. ET tube 1.5 cm above the carina, some withdrawal may provide more optimal position is possible. PELVIS: No displaced pelvic fractures are identified. Evaluation of the proximal femur is limited secondary to rotation. There is lumbar scoliosis with convexity to the left with associated osteophytes and degenerative changes. Bowel gas is unremarkable. IMPRESSION: No gross injury. . . CT HEAD W/O CONTRAST [**2197-8-29**] 10:57 AM INDICATION: Evaluation for interval change in a 70-year-old lady, status post motor vehicle accident. Assessment for intracranial hemorrhage. TECHNIQUE: Axial images of CT of the head. COMPARISON: [**2197-8-28**]. FINDINGS: There is left subdural hematoma on the free edge of falx that is unchanged in comparison to prior study. There is no new acute extra- or intraaxial hemorrhage. There is no major or minor territorial infarct. There is no mass effect or shift of normal midline structures. There is no fracture line or soft tissue density abnormality identified. There is normal soft tissue density of the brain parenchyma. There are widened stable bifrontal extra-axial spaces which are related to atrophic changes . There are air fluid levels within the maxillary sinuses and sphenoid sinuses that are unchanged in comparison to prior study. Mastoid air cells are clear. IMPRESSION: Unchanged small left subdural hematoma along the falx. No new change. . . CHEST (PORTABLE AP) [**2197-8-30**] 4:54 AM INDICATION: Status post MVC and exploratory laparotomy. Evaluate for interval change. FINDINGS: Compared with [**2197-8-28**], lines and tubes are unchanged in position. There has been considerable partial interval clearing of the diffuse patchy pulmonary densities, with mild residual atelectasis at the left base. . . CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2197-8-31**] 9:16 AM INDICATION: Trauma, evaluate for facial fractures. COMPARISON: Head CT, [**2197-8-29**]. TECHNIQUE: MDCT-acquired contiguous axial images of the facial bones were obtained without intravenous contrast. Three-dimensional reconstructed images were obtained. CT OF THE FACIAL BONES WITHOUT INTRAVENOUS CONTRAST: No facial fracture is identified. Mild-to-moderate mucosal thickening is seen involving all of the paranasal sinuses, with air-fluid levels demonstrated in the maxillary, sphenoid, and ethmoid sinuses. All of these findings are likely secondary to patient's intubated state. Tiny hyperdensity within a right sphenoid sinus air cell likely represents a minute osteoma. Visualized portions of the mastoid air cells are clear. Surrounding soft tissue structures appear unremarkable. There is extensive atherosclerotic calcification of the cavernous portion of both internal carotid arteries. At C2-3 and C3-4, facet degenerative changes are present, more pronounced on the right leading to mild-to-moderate neural foraminal narrowing. An endotracheal tube and nasogastric tube are partially imaged within the airway and esophagus respectively. IMPRESSION: 1. No facial fracture identified. 2. Air-fluid levels within the paranasal sinuses consistent with the patient's intubated state. . . CHEST (PORTABLE AP) [**2197-9-1**] 9:19 PM CLINICAL INDICATION: Evaluate lung integrity. TECHNIQUE: AP semierect portable examination is compared with prior examination dated [**2197-8-30**]. FINDINGS: A left-sided chest tube is visualized with side port projecting over the subcutaneous soft tissues outside of the hemithorax. Recommend advancement. Left-sided subclavian line terminates in the proximal SVC. NG tube projects over the body of the stomach. Cardiomediastinal silhouette is within normal limits. There is increased left lower lung hazy opacity. Right-sided pleural effusion again seen. Small left apical pneumothorax again appreciated. New surgical staples seen over the upper abdomen. IMPRESSION: 1. Recommend advancement of left-sided chest tube with side port seen projecting outside of the left hemithorax. 2. Interval increase in left lower lung hazy opacification. . . CHEST (PORTABLE AP); CHEST, SINGLE VIEW ON [**9-2**] at 2100. REASON FOR THIS EXAMINATION: s/p removal chest tube HISTORY: Left chest tube to waterseal, status post removal of chest tube. FINDINGS: There has been interval removal of the left chest tube. There is a small left pneumothorax that is similar in size to that seen on the film from the prior day. There continue to be bibasilar opacities and patchy areas of volume loss. . . CHEST (PORTABLE AP) [**2197-9-2**] 5:16 AM REASON FOR THIS EXAMINATION: eval for interval change CLINICAL INDICATION: 50-year-old woman status post MVC, evaluate for chest tube placement. IMPRESSION: Interval advancement of left-sided chest tube, small residual left apical pneumothorax. Interval increase in bibasilar opacities. . . CTA NECK W&W/OC & RECONS; CTA HEAD W&W/O C & RECONS [**2197-9-6**] 6:19 PM REASON FOR THIS EXAMINATION: ? aneurysm in carotid system in setting of CNIII palsy CLINICAL INFORMATION: Cranial nerve III palsy, question carotid aneurysm. NON-CONTRAST HEAD CT Exam shows near complete resolution of the left parafalcine subdural hematoma posteriorly seen on prior study of [**2197-8-29**]. The low-density extra-axial fluid collections over the frontal aspects of both hemispheres are again noted and unchanged. Ventricular dimension is unchanged. IMPRESSION: Some resorption of the left parafalcine subdural hematoma. No other new findings. CT ANGIOGRAM OF THE CERVICAL VESSELS WITH MULTIPLANAR REFORMATTED IMAGES AND 3-DIMENSIONAL RECONSTRUCTED IMAGES IMPRESSION: No evidence of significant internal carotid artery stenosis. See above comment regarding the appearance of C4-5 on the left. CT ANGIOGRAM OF THE INTRACRANIAL CIRCULATION There is no evidence of aneurysm or flow abnormality. The cavernous portions are always difficult to assess on CT angiography for technical reasons. If there remains a clinical question regarding a small aneurysm in either cavernous portion, formal catheter angiography may be considered for further evaluation. IMPRESSION: No definite evidence of aneurysm. See above comment regarding the appearance of the cavernous portions of the internal carotid arteries. . . ABDOMEN (SUPINE ONLY) [**2197-9-6**] 3:18 PM REASON FOR THIS EXAMINATION: r/o obstruction or other processes INDICATION: 70-year-old woman status post motor vehicle accident, status post exploratory laparotomy, now with increasing nausea and vomiting. Rule out obstruction. COMPARISON: Abdominal radiograph [**2197-8-29**]. FINDINGS: There is unremarkable bowel gas pattern. There is air in the rectum. Multiple surgical clips are projecting over the midline. Interval removal of the nasogastric tube. Fractures of 11th posterior, ninth lateral ribs. Levoconvex scoliosis, centered at L3-L4. IMPRESSION: No evidence of obstruction. . . PROCEDURES . OPERATIVE REPORT [**Last Name (LF) **],[**First Name3 (LF) **] J. Name: [**Known lastname **],[**Known firstname **] T Unit No: [**Numeric Identifier 69771**] Service: MED Date: [**2197-8-28**] Date of Birth: [**2139-12-26**] Sex: F Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], MD 2211 INDICATIONS: This woman has been in a motor vehicle accident. She was found to be in shock and her abdomen was distended. I should mention that 1 of her pupils was also wide. PROCEDURE: She was taken to the operating room and placed in a supine position, given a general anesthetic. The abdomen was prepped and draped using Betadine. A vertical incision was made taking it down to the level of the fascia. The fascia was opened. The abdomen was opened and the following findings were noted. Considerable bleeding was noted within the abdomen. There was a large rent in the mesentery of the small bowel that extended into the right lower quadrant. There was bleeding from vessels at the root of the mesentery and we managed to control the bleeding with several sutures of 3-0 silk and 2-0 silk up through the mesentery. The patient, at this point, was extremely hypothermic and we needed to get control of this and we had transected the bowel both on the ileum and also on the ascending colon. We removed the intestine by clamping with [**Doctor Last Name 1356**] clamps and then ligating with 2-0 silk sutures. Once this was done, we carried out a very fast anastomosis using the linear cutting stapler and a TA stapler across the remaining part. The anastomotic line was inverted using interrupted 3-0 silk sutures. At this point, after making sure that we controlled the blood vessel in the mesentery with the silk sutures, we decided to leave the mesenteric defect open. I should mention that we carried out a look at the spleen. The spleen was not bleeding. There was an adhesion to the lower end of the spleen which was divided. The liver was similarly not bleeding. We did not open the lesser sac. We placed a [**Location (un) 5701**] bag in place and then used warm saline to irrigate. We then closed the abdomen using 0 Prolene suture in continuous fashion to the skin and thus the abdomen was left open, the [**Location (un) 5701**] bag being used to hold the abdominal contents in place. Two [**Location (un) 1661**]-[**Location (un) 1662**] drains were left in place and a superficial dressing was placed. There were 2 liters of blood within the abdomen. This was suctioned out with the autotransfusor and got the bloodback from the cell [**Doctor Last Name 10105**]. ESTIMATED BLOOD LOSS: 500 cc. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**] . . OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Motor vehicle crash resulting in open abdomen mesenteric vein avulsion. POSTOPERATIVE DIAGNOSIS: Motor vehicle crash resulting in open abdomen mesenteric vein avulsion. PROCEDURE: 1. Closure of mesenteric defect. 2. Closure of abdomen. INDICATIONS FOR SURGERY: The patient is a 70-year-old female who sustained a motor vehicle crash that required an exploratory laparotomy the day prior. She was noted to have a mesenteric avulsion with profuse bleeding from the venous system. These were suture ligated, and hemostasis was achieved; however, the abdomen was left open due to the necessity for a second look to assess the viability of the bowel, thus the patient was taken back to the operating room for closure. PROCEDURE IN DETAIL: The patient was brought to the operating room in stable condition. She was already intubated in the intensive care unit prior to presentation to the operating room. The abdomen was prepped and draped with sterile Betadine. The previously-placed [**Location (un) 5701**] bag was removed from the circumferential surrounding skin, and the abdomen was explored. There was noted to be adequate hemostasis at the mesenteric rent. The bowel seemed adequately viable. Four laparotomy pads were removed from the abdomen which had been placed as packing the day before. The mesenteric defect was then closed with interrupted 3-0 silk sutures at the previously performed ileocolostomy anastomosis. An NG tube was placed with adequate positioning in the stomach. The wound was then closed with looped #1 PDS sutures. It was noted to come together nicely without undue tension. The peak inspiratory pressures on the ventilator did not increase substantially at all during this procedure. The subcutaneous tissue was then copiously irrigated, and the skin was closed with skin staples. The patient was transferred back to the ICU in stable condition. All sponge and needle counts were correct at the end of the case x 2. The patient did undergo an abdominal x-ray, as the previous sponge count had not been counted. There was no evidence of any retained instruments or sponge counts in the abdomen. Dr. [**Last Name (STitle) **] was present and scrubbed during the entire procedure. [**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 67332**] . . URINE [**2197-9-8**] URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML - FURTHER IDENTIFICATION TO FOLLOW LABS: [**2197-8-28**] 06:17PM FIBRINOGEN-146* [**2197-8-28**] 06:17PM PT-14.2* PTT-31.8 INR(PT)-1.3* [**2197-8-28**] 06:17PM PLT COUNT-143* [**2197-8-28**] 06:17PM WBC-12.9* RBC-2.88* HGB-9.8* HCT-27.0* MCV-94 MCH-34.1* MCHC-36.3* RDW-12.9 [**2197-8-28**] 06:17PM UREA N-18 CREAT-1.1 [**2197-8-28**] 06:24PM freeCa-0.99* [**2197-8-28**] 06:17PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2197-8-28**] 06:24PM HGB-10.3* calcHCT-31 O2 SAT-82 CARBOXYHB-1.6 MET HGB-0.1 [**2197-8-28**] 06:24PM GLUCOSE-173* LACTATE-3.2* NA+-132* K+-3.3* CL--105 TCO2-23 [**2197-8-28**] 07:32PM HGB-8.6* calcHCT-26 [**2197-8-28**] 09:11PM OSMOLAL-286 [**2197-8-28**] 09:11PM CALCIUM-6.4* PHOSPHATE-3.5 MAGNESIUM-1.2* [**2197-8-28**] 09:11PM CK-MB-45* MB INDX-3.1 cTropnT-0.20* [**2197-8-28**] 09:11PM ALT(SGPT)-25 AST(SGOT)-49* CK(CPK)-1455* ALK PHOS-29* TOT BILI-0.4 [**2197-8-28**] 09:11PM GLUCOSE-209* UREA N-15 CREAT-0.7 SODIUM-133 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-20* ANION GAP-12 [**2197-8-29**]: Glucose 205*, Urea Nitrogen 15, Creatinine 0.8, Sodium 133, Potassium 3.1*, Chloride 105, Bicarbonate 21*, Anion Gap 10, Creatine Kinase (CK)3864*, Creatine Kinase, MB Isoenzyme 118*, CK-MB Index 3.1 % 0 - 6 Calcium, Total 6.8* Phosphate 2.5* Magnesium 2.2 Creatine Kinase (CK) 4314* Creatine Kinase, MB Isoenzyme 99 CK-MB Index 2.3 % [**2197-9-1**]: Phenytoin 9.4* ug/mL [**2197-9-5**]: White Blood Cells 10.8 Red Blood Cells 3.29* Hemoglobin 10.3* Hematocrit 30.4* % MCV 92 fL 82 - 98 MCH 31.4 pg 27 - 32 MCHC 34.0 % 31 - 35 RDW 15.0 % 10.5 - 15.5 Platelet Count 172 K/uL 150 - 440 [**2197-9-8**]: Glucose 119* Urea Nitrogen 13 Creatinine 0.6 Sodium 133 Potassium 3.4 Chloride 100 Bicarbonate 25 Anion Gap 11 Calcium, Total 7.9* Phosphate 3.2 Magnesium 1.9 Hemoglobin A1c 6.1* % Urine Color Yellow, Urine Appearance Clear Specific Gravity 1.005 DIPSTICK URINALYSIS Blood SM, Nitrite NEG, Protein NEG, Glucose NEG, Ketone NEG, Bilirubin NEG, Urobilinogen NEG, pH 7.0, Leukocytes SM MICROSCOPIC URINE EXAMINATION RBC [**2-26**]*, WBC [**11-13**]*, Bacteria MANY, Yeast NONE, Epithelial Cells <1, Transitional Epithelial Cells 0-2 Brief Hospital Course: She was admitted to the trauma service; because of a positive DPL and FAST exams she was immediately taken to the operating room for exploratory laparotomy (see Pertinent results). . Neurosurgery was consulted because of the subdural hematoma; this injury was nonoperative; serial head CT scans were performed and were stable; neurologically she has remained intact. She was fitted for a TLSO brace because of her L1 transverse process fracture. This will need to be worn at all times while out of bed; while in bed if not worn she will need to be log rolled. She will follow up with Dr. [**Last Name (STitle) 548**] in 6 weeks for repeat imaging. . Ophthalmology was consulted for ptosis of her right eye following the crash; ?post traumatic CN III palsy; this was nonoperative. She underwent CTA of her head and neck, no acute processes were identified (see Pertinent results). . Her finger sticks were somewhat elevated throughout her hospital stay 200's; she was placed on a sliding scale. There was no documented history of Diabetes. She also experienced vertigo during this admission; she was started on Meclizine which improved the dizziness that she was experiencing. Physical therapy worked with patient to assess for BPPV; the vertigo was not reproducible with maneuvers. . She also experienced 2 days of nausea and vomiting; KUB did not reveal any obstruction. She was placed on Reglan which was eventually stopped; the Meclizine seemed to improve these symptoms. It was later discovered that she had a UTI and that she has had frequent UTI's in the past and was planning on having bladder suspension surgery in the future prior to her admission. This could be the reason for her elevated finger sticks. Ciprofloxacin for 10 days was started. . She tolerated a regular diet and her staples were removed and steri-strips with benzoin were applied prior to her discharge to her rehabilitation facility. Medications on Admission: HCTZ 25' Toprol XL 100' Accupril 20' Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal twice a day as needed for constipation. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection four times a day as needed for based on fingersticks per sliding scale. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP <110. 6. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP <110. 7. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic [**Hospital1 **] (2 times a day): Apply OD. 8. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for UTI for 10 days. 12. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO DAILY (Daily) for 5 days. 13. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily): hold for HR <60 and/or SBP <110. 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: s/p Motor vehicle crash Left subdural hematoma Right 11th rib fracture L1 transverse body fracture Post traumatic CN III palsy Discharge Condition: Stable Discharge Instructions: Please take your medications as directed. Please always have your brace on unless you are lying flat in bed. Please ask for assistance in putting on your brace. Please call for your follow-up appointments as detailed. Please call/return to [**Hospital1 18**] if you have persistent pain, fever, nausea/vomit, bleeding/drainage from your wound, dizziness and/or difficulty breathing. Followup Instructions: Follow-up with plastic surgery clinic the Friday after discharge. Call [**Telephone/Fax (1) 5343**] to schedule the appointment. Follow up with Opthamology Resident Clinic in 1 week, call [**Telephone/Fax (1) 253**] for an appointment. Follow-up with Dr. [**Last Name (STitle) 548**], Neurosurgery in 5 weeks; call [**Telephone/Fax (1) 1669**] to schedule the appointment. Inform the office that you will also need A/P & Lateral Thoracic/Lumbar spine films for this appointment. Please follow-up with Trauma clinic, please call [**Telephone/Fax (1) 6429**] Completed by:[**2197-9-11**]

[ "902.87", "362.11", "873.44", "E823.0", "860.0", "806.25", "805.4", "401.9", "863.89", "958.4", "518.5", "378.51", "873.61", "599.0", "530.81", "374.30", "V43.65", "807.01", "852.22", "873.43" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.06", "96.6", "38.93", "45.73", "23.19", "54.25", "99.05", "38.87", "96.72", "99.07", "54.75", "34.04", "00.17", "27.59", "86.59" ]

icd9pcs

[ [ [] ] ]

21982, 22062

18480, 20396

304, 381

22233, 22242

1221, 8164

22677, 23268

799, 816

20485, 21959

22083, 22212

20422, 20460

22266, 22654

831, 1202

241, 266

10358, 16149

16181, 18457

409, 692

714, 783

24,611

126,874

43956

Discharge summary

report

Admission Date: [**2136-5-20**] Discharge Date: [**2136-6-6**] Date of Birth: [**2078-6-7**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Tracheostomy Open Gastrostomy Tube Placement History of Present Illness: 57F p/w sudden onset of abdominal pain since 8AM DOA. Pain described as epigastric with radiation to the back. Worse with lying back. Improved when sitting up. +Nausea, +Diaphoresis, +Diarrhea Past Medical History: HTN Hypercholesterolemia Social History: No EtOH No Tobacco Family History: Non-contrib Physical Exam: 96.2 69 157/22 16 97% GEN: A&Ox3 CV: RRR S1/S2 LUNGS: CTA B/L ABD: Soft, ttp epigastrum, no rebound, no guarding EXT: no edema NEURO: grossly intact Pertinent Results: [**2136-5-20**] 05:47PM LACTATE-2.5* [**2136-5-20**] 05:30PM GLUCOSE-175* UREA N-14 CREAT-0.9 SODIUM-141 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-22 ANION GAP-18 [**2136-5-20**] 05:30PM estGFR-Using this [**2136-5-20**] 05:30PM ALT(SGPT)-38 AST(SGOT)-25 LD(LDH)-193 CK(CPK)-54 ALK PHOS-67 AMYLASE-856* TOT BILI-0.4 [**2136-5-20**] 05:30PM LIPASE-1839* [**2136-5-20**] 05:30PM cTropnT-<0.01 [**2136-5-20**] 05:30PM CK-MB-NotDone [**2136-5-20**] 05:30PM PHOSPHATE-3.8 [**2136-5-20**] 05:30PM URINE HOURS-RANDOM [**2136-5-20**] 05:30PM URINE UCG-NEGATIVE [**2136-5-20**] 05:30PM WBC-10.1 RBC-4.99 HGB-16.4* HCT-44.6 MCV-90 MCH-32.8* MCHC-36.7* RDW-15.0 [**2136-5-20**] 05:30PM NEUTS-91.0* BANDS-0 LYMPHS-5.9* MONOS-2.9 EOS-0.1 BASOS-0.1 [**2136-5-20**] 05:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2136-5-20**] 05:30PM PLT SMR-NORMAL PLT COUNT-233 [**2136-5-20**] 05:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.035 [**2136-5-20**] 05:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2136-5-20**] 05:30PM URINE RBC-[**2-20**]* WBC-0 BACTERIA-RARE YEAST-NONE EPI-0-2 Brief Hospital Course: Patient was admitted from the [**Hospital1 18**] ED department directly to the TICU. Patient began fluid resuscitation, antibiotic coverage, and pain control. She began to experience respiratory difficulty with increased O2 requirements and was electively intubated in the TICU. On HD 13 the patient went to the OR for open trach placement as well as open G-J tube placement without complication. Please see operative report for details. She continued her resuscitation in the TICU post-operatively and continued to improve. Patient was started on tube feeds through her jejunostomy and tolerated them well. On HD14 she had her trach-collar removed and was in no respiratory distress. She was transferred to the floor in stable condition and was discharged to rehab in stable condition with follow-up with Dr. [**Last Name (STitle) **] in [**1-21**] weeks. Medications on Admission: Lisinopril Lipitor Erythromycin Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Topical 1-5X/DAY (). 3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 4. Insulin Regular Human Injection 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety. 8. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: [**12-20**] tab PO Q4-6H (every 4 to 6 hours) as needed. 10. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed. 11. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed. 12. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) cc PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Pancreatitis Discharge Condition: Stable Discharge Instructions: Please call physician or return to ED if any of the following occur: 1. Fever >101.5 2. Intractable nausea/vomiting 3. Increased pain 4. Redness/Swelling/Discharge from wound 5. Any other concerning symptoms Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in [**1-21**] weeks. Call [**Telephone/Fax (1) 6439**] for appointment. Completed by:[**2136-6-6**]

[ "518.81", "272.0", "720.2", "401.9", "584.9", "577.0", "486", "511.9", "427.31", "112.2", "789.5" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.72", "44.39", "38.93", "38.91", "33.24", "31.1", "96.6" ]

icd9pcs

[ [ [] ] ]

4094, 4174

2164, 3030

327, 374

4231, 4240

901, 2141

4496, 4651

700, 713

3112, 4071

4195, 4210

3056, 3089

4264, 4473

728, 882

273, 289

402, 600

622, 648

664, 684

12,941

134,987

8091

Discharge summary

report

Admission Date: [**2131-5-14**] Discharge Date: [**2131-5-17**] Date of Birth: [**2064-3-12**] Sex: F Service: CT [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: This is a 67 year old female with a history of recurrent idiopathic pericardial effusion over the course of the past 10 years who was referred to Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] for discussion of surgical options for treatment. Patient is followed on an ongoing basis by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of the [**Location (un) 86**] Heart Group. Over this time patient has undergone several pericardial drainage procedures which repeatedly demonstrate benign reactive mesothelial cells with no evidence of malignancy. Patient's effusion, which was generally described as moderate to large, was noted in [**2131-1-10**] to have enlarged to the point of causing collapse of the right ventricular free wall. At that time patient underwent repeat pericardial centesis which again demonstrated clear fluid without evidence of carcinoma. Patient subsequently was noted to reaccumulate this effusion and was subsequently referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] for discussion of potential surgical options for treatment of her recurrent effusion. Patient was thereafter further referred to Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] for discussion of the same and was subsequently scheduled for a thoracoscopically assisted pericardial window procedure on [**2131-5-14**]. PAST MEDICAL HISTORY: Recurrent pericardial effusion. Osteoporosis. Gastroesophageal reflux disease. Hypothyroidism. OUTPATIENT MEDICATIONS: Levoxyl, Travatan eyedrops, Carafate, Caltrate, multivitamin. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is retired and lives with her sister and brother in [**Name (NI) 583**], [**State 350**]. HOSPITAL COURSE: On [**2131-5-14**], the patient underwent a thoracoscopically assisted pericardial window procedure. The patient tolerated the procedure well and required 1.4 liters of fluid intraoperatively. Patient had an estimated urine output of approximately 300 cc during the procedure. Patient had minimal estimated blood loss. Patient was successfully extubated and thereafter transferred to the PACU for further evaluation and management. Postoperatively patient was noted to be afebrile and stable with bilateral breath sounds noted and lung sounds that were clear to auscultation bilaterally. A left sided chest tube was noted to be in place with no evidence of leak and was attached to low continuous wall suction with minimal serosanguineous drainage. Patient's postoperative hematocrit was noted to be 37.1. The patient was subsequently cleared for transfer to the floor and was admitted to the cardiothoracic service under the direction of Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**]. Postoperatively patient's clinical course was uneventful. On postoperative day one the chest tube was removed without complications following a successful trial on water seal. On postoperative day two patient was noted to be afebrile and stable. Her dressing was noted to be clean, dry and intact and she had bilateral breath sounds with clear lung sounds bilaterally. Patient was noted to be independently ambulatory and was noted to be productive of adequate amounts of urine. Patient was tolerating a full regular diet and demonstrated adequate pain control via oral pain medications. Patient was subsequently cleared for discharge to home with instructions for followup on postoperative day two, [**2131-5-17**]. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is to be discharged to home with instructions for followup. DISCHARGE MEDICATIONS: 1. Percocet one to two tabs p.o. q.four to six hours p.r.n. for pain. 2. Levothyroxine 88 mcg p.o. q.d. 3. Sucralfate one tab p.o. q.i.d. 4. Colace 100 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: The patient is advised to maintain her chest tube dressing in place for 48 hours following discharge, after which point it may be removed. Patient may shower, but should pat dry her incisions afterward. No bathing or swimming until further notice. Patient may resume a regular diet. Patient was advised to limit physical activities, no heavy exertion. No driving while taking prescription pain medications. Patient is to follow up with her PCP within one to two weeks following discharge. Patient is to follow up with Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] within 10 to 14 days following discharge for repeat wound evaluation. Patient is to call to schedule her appointments. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**] Dictated By:[**Last Name (NamePattern1) 28881**] MEDQUIST36 D: [**2131-5-17**] 17:17 T: [**2131-5-17**] 18:57 JOB#: [**Job Number 28882**]

[ "423.8", "733.00", "530.81", "244.9" ]

icd9cm

[ [ [] ] ]

[ "37.12", "39.62" ]

icd9pcs

[ [ [] ] ]

3900, 4072

2003, 3751

4097, 5101

1764, 1865

186, 1619

1642, 1739

1882, 1985

3776, 3877

28,205

122,801

20610+20611

Discharge summary

report+report

Admission Date: [**2143-5-17**] Discharge Date: [**2143-5-20**] Date of Birth: [**2069-9-7**] Sex: M Service: OTOLARYNGOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 7729**] Chief Complaint: Melanoma of the right cheek Major Surgical or Invasive Procedure: Resection of melanoma right cheek, superficial parotidectomy, cervical facial flap reconstruction [**2143-5-17**] History of Present Illness: Mr. [**Known lastname **] is a 73-year-old man, who was noted on routine skin examination to have a changing mole on his right cheek. The lesion was approximately 3 centimeters in diameter, slightly raised, with variegation in color. It did not bleed or itch. He underwent a punch biopsy on [**2-12**] with pathology reportedly showing an at least 1.87 mm thick melanoma with evidence of mitosis. He has no prior history of melanoma or other skin cancers. He does note a pruritic lesion on his right ankle that has been present for an uncertain time period. He denies subcutaneous nodules, swollen glands, cough, dyspnea, abdominal complaints or anything that might be suggestive of more widespread disease. Past Medical History: CAD s/p MI [**54**] years ago, CHF, A-fib, s/p AVR [**2138**] on coumadin, hypothyroid, AAA Social History: He is married with 3 children, ages 38, 36 and 35. He has not drunk alcohol in 30 years and has not smoked for 25 years. He used to be in the construction business and more recently worked for the skating rink at [**University/College 55089**]. He is currently retired. Family History: There is no family history of melanoma. He has a brother, who died of lung cancer. Physical Exam: Gen: Well, NAD, Alert and Oriented CV: Irreg/Irreg, mechanical st.Jude's valve audible RESP: CTAB ABD: Soft, NT, ND HEENT: Surgical incision rigth face/neck c/d/i with running nylon suture. JP drains removed with drain sites C/D/I. Minimal peri-incisional erythema Pertinent Results: pathology pending at time of discharge Brief Hospital Course: 73yo M presented to [**Hospital1 18**] on [**2143-5-17**] for resection of melanoma from the right cheek, superficial parotidectomy and rotational flap reconstruction. The pt tolerated all procedures without complication, for details please see operative note. Patient received periop antibiotic prophylaxis. Lovenox was started on POD#1 as a bridge to Coumadin. Diet was advanced as tolerated. On POD#2 pt experienced mild chest tightness. An EKG was unchanged and cardiac enzymes were negative x3. A CXR revealed diffuse bibasilar atelectasis and the pt was rhonchorus upon auscultation. Pt was treated with nebulizer treatments and pulmonary toilet. One JP drain was removed on POD2 and the second JP drain was removed on POD #3. Patient is being discharged: afebrile, tolerating regular diet without nausea/vomiting, pain well controlled on oral medication, voiding, incision clean, dry and intact, and ambulating well. Currently and on POD 3, pt and staff agree pt is ready for discharge home w/ f/u w/ Dr. [**Last Name (STitle) 1837**] in [**12-26**] weeks. Medications on Admission: Amiodarone 200', Amlodipine 10', Lasix 80', Neuronton 300 QID, Irbesartan 150", Synthroid 0.075', Pravastatin 80', Spiriva INH, Coumadin 2.5, Verapamil ER 90 [**Hospital1 **], Lovenox Discharge Disposition: Home Discharge Diagnosis: Melanoma Discharge Condition: Good Discharge Instructions: Resume all home medications. Seek immediate medical attention for fever >101.5, chills, increased redness, swelling, bleeding or discharge from incision, chest pain, shortness of breath, difficulty breathing, severe headache, increasing neurological deficit, or anything else that is troubling you. No strenuous exercise or heavy lifting until follow up appointment, at least. Do not drive or drink alcohol while taking narcotic pain medications. Call your surgeon to make follow up appointment. Followup Instructions: Call the office of Dr.[**Last Name (STitle) 1837**] at ([**Telephone/Fax (1) 26719**] to schedule a follow-up appointment Completed by:[**2143-5-20**] Admission Date: [**2143-5-21**] Discharge Date: [**2143-5-25**] Date of Birth: [**2069-9-7**] Sex: M Service: OTOLARYNGOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 7729**] Chief Complaint: Right face hematoma Major Surgical or Invasive Procedure: Incision and drainage of right face hematoma [**2143-5-21**] History of Present Illness: The patient is a 73-year-old male who approximately 5 days prior to returning to the operating room, underwent a right superficial parotidectomy and excision of a malignant melanoma involving the skin. He did well postoperatively. Due to an artificial heart valve and atrial fibrillation, his anticoagulation was restarted. Unfortunately, over the past 24 hours, he has developed an expanding hematoma. He presents today for evacuation. Past Medical History: CAD s/p MI [**54**] years ago, CHF, A-fib, s/p AVR [**2138**] on coumadin, hypothyroid, AAA Social History: He is married with 3 children, ages 38, 36 and 35. He has not drunk alcohol in 30 years and has not smoked for 25 years. He used to be in the construction business and more recently worked for the skating rink at [**University/College 55089**]. He is currently retired. Family History: There is no family history of melanoma. He has a brother, who died of lung cancer. Physical Exam: On day of discharge Vitals 96.5 96.0 60 102/60 18 93/RA NAD, A x O x 3 PERRLA, EOMI, Anicteric CN II-XII grossly intact WOUND site C/D/I with no hematoma, erythema, or drainage. Suture line stable. RRR with appreciable valve click, no r/g CTA B, no r/r/c ABD Soft, NT/ND, NABS EXT Warm and well perfused Pertinent Results: [**2143-5-21**] 08:58PM HCT-28.6* [**2143-5-21**] 04:40PM TYPE-ART PO2-262* PCO2-36 PH-7.48* TOTAL CO2-28 BASE XS-4 [**2143-5-21**] 04:40PM LACTATE-1.1 [**2143-5-21**] 04:40PM freeCa-0.99* [**2143-5-21**] 04:32PM GLUCOSE-124* UREA N-15 CREAT-1.2 SODIUM-139 POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-27 ANION GAP-9 [**2143-5-21**] 04:32PM CALCIUM-7.7* PHOSPHATE-1.9* MAGNESIUM-1.7 [**2143-5-21**] 04:32PM WBC-10.1# RBC-2.93*# HGB-8.1*# HCT-24.2*# MCV-83 MCH-27.5 MCHC-33.2# RDW-14.4 Brief Hospital Course: [**2143-5-21**] Patient presented to ED per HPI above and was taken to the OR for I/D of right face hematoma. The patient tolerated this procedure well, was extubated in the OR, and transferred to the PACU for recovery. From the PACU he spent the night in the SICU for wound site monitoring. His post-op check was unremarkable. He was kept NPO and given IV hydration. . [**2143-5-22**] There were no overnight events. He was transferred to CC6 floor status for recovery. The patient was OOB to the chair twice and tolerated it well. He was given a clear liquid diet which he tolerated well and advanced to a regular diet. He was given all PO medications as at home. His drain output was noted to be serosanguinous. . [**2143-5-23**] There were no overnight events. The patient was OOB to [**Doctor Last Name **] multiple times. He was started on a therapeutic heparin drip. There was noted to be no increase in incision site drainage, swelling, or other bleeding. His foley was removed and he voided within 6 hours. . [**2143-5-24**] There were no overnight advents. His JP drains were D/C'd as well as his Ancef. The wound site was stable, with no swelling or increased drainage. He was up ambulating in the [**Doctor Last Name **] multiple times and "feeling well". . [**2143-5-25**] There were no overnight events. At the time of discharge he was afebrile, tolerating a regular diet, and ambulating without assistance. He had no complaints of pain, SOB, CP, F/C/N/D/HA. He was discharged on therapeutic Lovenox shots [**Hospital1 **] and instructed to follow up with his PCP as soon as possible for anticoagulation with Coumadin. Medications on Admission: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) dose Subcutaneous Q12H (every 12 hours) for 10 days. Disp:*20 dose* Refills:*2* 10. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 12. Outpatient Lab Work INR Checks and Coumadin monitoring per PCP. Discharge Disposition: Home Discharge Diagnosis: s/p hematoma I&D following resection of R face melanoma AFIB Mechanical Aortic Valve Recurrent melanoma to R face Discharge Condition: Stable, to home Discharge Instructions: Please report to the ER immediately for fever > 101F, increasing pain from your wound site, persistent nausea/vomiting, shortness of breath, chest pain, or increasing swelling, redness, or obvious signs of infection from your wound site. . Take your medications exactly as prescribed. Take your stool softener as long as you are taking narcotic pain medication. . Follow up with your primary care physician PCP as soon as possible following your discharge for coordinating your Coumadin therapy. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 1837**] in [**12-26**] weeks following your discharge. Please call his office to schedule an appointment. . Please follow up with your cardiologist for restarting your Coumdain therapy. See him as soon as possible following your discharge.

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icd9cm

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40608

Discharge summary

report

Admission Date: [**2150-3-28**] Discharge Date: [**2150-4-2**] Date of Birth: [**2070-7-7**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: SAH Major Surgical or Invasive Procedure: [**2150-3-28**]: R EVD placement [**2150-3-28**]: Cerebral angiogram with coiling History of Present Illness: Mrs. [**Known lastname 88864**] is a 79 yo Right handed woman who presents with new onset SAH. Per her husband, the patient had a similar event, possibly as young as 17 when an operation was performed "on the back of her head." This a.m., she informed her husband that she was abruptly feeling warm and soon thereafter became diaphoretic. After this, she was noted to have some mild weakness of her left arm and to become progressively more somnolent. Here at the [**Hospital1 18**] ED, she was noted to have vertical nystagmus at rest. She seemed to be lethargic, with some commands on the right, but not the left, side. she was obtunded with agonal breathing so she was intubated for airway protection and sedated with propofol. She became hypertensive to the 210s systolic, so IV nicardipine gtt was started along with nimodipine A stat head CT showed diffuse SAH ([**Doctor Last Name **] III). Past Medical History: 1. HTN on ACE and thiazide 2. HL on statin 3. Aneurysmal SAH at 17y/o with "5wks in a coma" but "now it's calcified" and no subsequent Neuro f/u as far as the husband knows 4. other PMH unknown, but husband says no other health problems, and no Neurologic deficits prior to today Social History: Married, lived in a retirement community with husband; reportedly independent in ADLs. + ETOH while watching TV, patient reports about 3+ wine glasses of scotch. Family History: Unknown Physical Exam: On admission: PHYSICAL EXAM: Hunt and [**Doctor Last Name 9381**]: 3 [**Doctor Last Name **]: 3 Gen: Intubated and sedated. HEENT: NCAT, MMM Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. Neuro: (prior to angio) Eyes open to noxious. No commands. Pupils equal and reactive (4 to 2mm). Discs sharp. EOM appear full. Face symmetric. Both arms appear purposeful and anti-gravity. Legs purposeful as well. Discharge: Expired Pertinent Results: Head CT [**2150-3-28**]: HEAD CT: There is diffuse subarachnoid hemorrhage predominantly in the posterior fossa also in the suprasellar cistern and extending predominantly to the right sylvian fissure and interhemispheric fissure as well as convexity sulci. There is mild ventriculomegaly seen. There is a rim calcification identified in the prepontine interpeduncular region, which could represent calcified aneurysm. Head CTA [**2150-3-28**]: CT angiography of the head demonstrates a calcified and thrombosed aneurysm at the basilar artery with possible filling of the small portion of the aneurysm and its medial portion. Additionally, there appears to be a small aneurysm at the tip of the basilar artery, which may be distinct aneurysm, measuring approximately 3 mm. Neck CTA [**2150-3-28**]: Negative for vascular anomalies. Head CT [**2150-3-28**]: IMPRESSION: Left frontal approach EVD ends in the left frontal [**Doctor Last Name 534**]. Minimal amount of intraventricular hemorrhage. No hydrocephalus. Extensive SAH. Head CT [**2150-4-1**]: IMPRESSION: Status post coiling of right basilar tip aneurysm and left frontal ventriculostomy catheter insertion. Slight reduction in the size of lateral and third ventricles and stable appearance of the dilated temporal horns. Redistribution of hemorrhage in the lateral ventricles and third ventricle. Extensive subarachnoid hemorrhage, predominantly right-sided, and no evidence of a new hemorrhage in the brain parenchyma. Head CT/CTA [**2150-4-1**]: The parenchymal hemorrhage and edema, surrounding the left frontal approach shunt catheter, has increased now measuring approx 2.6 x 1.9 cm, previously 1.5 x 1.2 cm. The tip of the EVD is unchanged. Mild increase in the blood in both lateral ventricles, with minimal increase in the ventricular size. Blood also seen within third and fourth ventricles. CTA read- pending re-cons, but pre-lim negative for further aneurysms. Brief Hospital Course: 79F who presented with a extensive, diffused SAH. Patient underwent an emergent EVD placement into the left frontal [**Doctor Last Name 534**]. A CTA was suggestive of possible small aneurysms at the basilar tip (around a previously thrombosed aneurysm) and possibly at the R PCA. A four vessel angio revealed one aneurysm at the basilar tip which was secured with two coils on [**3-28**]. She was admitted to the Neuro ICU for close monitoring. On [**3-29**], patient was noted to be confused, CIWA scale ordered, pt received Ativan x2 for agitation. On [**3-30**], her HCT dropped to 25.9 thus to maintain consistent cerebral perfusion she was transfused 2 units. Post transfusion HCT was 32.7. Moreover, her drain was increased to 20 cm H20. She continued to remain stable. She was able to tolerate oral food thus speech and swallow was deferred. On [**3-31**], her HCT remained stable. [**Date range (1) 88865**]: patient was found to be more lethargic in the morning after recieving 5mg of Valium for what apeared to be withdrawl symptoms. A non contrast head CT was ordered which showed a new left ventricular hemorrhage, we initiated TPA flushes thru her ventriculostomy with little effect. She became more lethargic and tachypneic in the evening and was intubated for respiratory distress. Her EVD continued to clot off and discussion was had with the family regarding the need for a new EVD to placed on the left side. Her respiratory status remained poor and there was concern for sepsis. A family meeting was held to discuss goals of care on [**4-2**] and the family decided to make her CMO and not go foward with a new EVD. The was made CMO and expired. Medications on Admission: 1. Quinapril 2. HCTZ 3. atorvastatin << No anticoagulants or anti-platelet agents, confirmed with husband >> Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Subarachnoid hemorrhage Basilar tip aneurysm Left 6th cranial nerve palsy Anemia Altered Mental Status Fever Respiratory Failure Intraventricular hemorrhage Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2150-4-7**]

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icd9cm

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308, 392

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28303

Discharge summary

report

Admission Date: [**2102-8-21**] Discharge Date: [**2102-8-30**] Date of Birth: [**2027-1-20**] Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1232**] Chief Complaint: BLADDER CANCER Major Surgical or Invasive Procedure: PROCEDURES: Extensive lysis of adhesions, radical cystoprostatectomy with ileal conduit urinary diversion including a hand-sewn anastomosis, repair of incisional hernia. History of Present Illness: 75M H/O high-grade poor;y-differentiated muscle invasive bladder CA, s/p failed attempt at bladder sparing management with BCG, and partial Cx, now for radical Cx Past Medical History: PMH: Bladder Ca, s/p BCG, XRT, and surgery Past medical history is significant for hypertension and glaucoma and negative for myocardial infarction, angina, diabetes, colitis, stroke, ulcer, lung disease, thyroid disease, hepatitis, gout, and sciatica. Past surgical history includes history of invasive rectal cancer treated with surgery and radiation therapy in [**2074**]. He also has undergone an appendectomy, tonsillectomy, and vasectomy. Right inguinal herniorrhaphy Rectal Ca, s/p surgery and XRT in [**2074**] HTN Glaucoma PSH: TURBT's, partial Cx [**2098**] LAR Appy T&A Vasectomy Social History: He has a minimal smoking history with the use of a pipe and rare cigarette smoking as a young adult. He drinks 3-4 cups of caffeinated product per day, and there is no family history of GU cancer. He currently has decreased erectile quality and no colon symptoms. There is no history of peripheral edema. Family History: no family history of GU cancer Physical Exam: DISCHARGE EXAM: WdWn Male, NAD, AVSS Cooperative, pleasant, good spirits Abdomen soft, appropriately tender incision site c/d/i. Drain site c/d/i Ostomy w/pink stoma and ureteral stents visible scrotal edema improved, no ecchymosis, uncircumcised lower extremities w/trace edema to mid-anterior tibia. Bilateral calves w/out tenderness to deep palpation and no callor/erythema. Pertinent Results: [**2102-8-30**] 05:50AM BLOOD WBC-9.7 RBC-3.68* Hgb-10.9* Hct-32.9* MCV-89 MCH-29.6 MCHC-33.1 RDW-14.4 Plt Ct-263 [**2102-8-27**] 07:29AM BLOOD WBC-8.5 RBC-3.49* Hgb-10.5* Hct-30.8* MCV-88 MCH-30.0 MCHC-33.9 RDW-14.6 Plt Ct-207 [**2102-8-26**] 08:05AM BLOOD WBC-9.6 RBC-3.54* Hgb-10.7* Hct-31.1* MCV-88 MCH-30.1 MCHC-34.2 RDW-14.9 Plt Ct-196 [**2102-8-30**] 05:50AM BLOOD Plt Ct-263 [**2102-8-30**] 05:50AM BLOOD PT-17.1* INR(PT)-1.5* [**2102-8-29**] 07:24AM BLOOD PT-15.8* PTT-24.4 INR(PT)-1.4* [**2102-8-30**] 05:50AM BLOOD Creat-0.9 Na-141 K-3.6 Cl-106 HCO3-29 AnGap-10 [**2102-8-29**] 07:24AM BLOOD Glucose-99 UreaN-16 Creat-0.9 Na-142 K-3.7 Cl-107 HCO3-28 AnGap-11 [**2102-8-28**] 06:00AM BLOOD Glucose-90 UreaN-16 Creat-0.8 Na-145 K-3.8 Cl-110* HCO3-26 AnGap-13 [**2102-8-29**] 07:24AM BLOOD Calcium-8.1* Mg-1.8 [**2102-8-28**] 06:00AM BLOOD Calcium-7.8* Mg-1.9 Final Report INDICATION: 75-year-old male with hypoxia, tachycardia and dyspnea on exertion. Evaluate for pulmonary embolism. Also with remote history of bladder cancer status post resection. EXAMINATION: CTA of the chest with and without intravenous contrast. COMPARISONS: Comparison is made to CT of the torso from [**2102-8-11**] and [**2099-12-31**]. IMPRESSION: 1. Acute isolated sugsegmental pulmonary embolism in left lower lobe. 2. New moderate left and small right simple layering pleural effusions. Brief Hospital Course: Mr. [**Known lastname 68716**] was admitted to the Urology service after undergoing the above procedures with Dr. [**Last Name (STitle) **]. Please see the dictated operative note for details. Patient received perioperative intravenous antibiotic prophylaxis and deep vein thrombosis/pulmonary embolis prophylaxis with coumadin. The post-operative course was significant for a delayed extubation (which occurred POD1 in the ICU) and pulmonary embolism noted on CT scan but not precipitated by any specific change in vital signs. With the eventual passage of flatus, Mr. [**Last Name (Titles) 68717**] diet was advanced and he was transitioned from IV pain medication to oral pain medications. The ostomy nurse saw the patient for ostomy teaching. At the time of discharge the [**Last Name (Titles) **] was healing well with no evidence of erythema, swelling, or purulent drainage. His drain was removed and his scrotal edema, which was monitored daily, was markedly improved. The ostomy was perfused and patent and the ureteral stents were visible protruding through a pink stoma. Mr. [**Name13 (STitle) 60816**] has several post-operative follow up appointments and was discharged home with visiting nurse services to further assist his transition home with ostomy care and continue his [**Name13 (STitle) **] care and INR monitoring. Medications on Admission: Current medications include Diovan, hydrochlorothiazide, Caduet, aspirin, and selenium. Discharge Medications: 1. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a day for 2 days: Please START taking the medication on the day prior to your scheduled follow up appointment. Disp:*6 Capsule(s)* Refills:*0* 2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. potassium citrate 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 8. Caduet 5-10 mg Tablet Sig: One (1) Tablet PO once a day. 9. psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a day): Use as necessary and as directed for bulking stool. 10. valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Outpatient Lab Work COUMADIN (Warfarin) usage requires monitoring with routine lab work. Please have your VNA nurse monitor your INR levels and adjust dose as required per your Urologist. 12. Outpatient Lab Work -Please take the coumadin daily at the same time. You will make arrangements through your PCP for routine INR monitoring and coumadin dosing. Please call and discuss this with your PCP when you get home today 13. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0* 14. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: please take the same time each day at 4pm. Disp:*90 Tablet(s)* Refills:*2* 15. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: PREOPERATIVE DIAGNOSES: Bladder cancer, incisional hernia, duplicated left collecting system. POSTOPERATIVE DIAGNOSES: Bladder cancer, incisional hernia, duplicated left collecting system. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Please also refer to the handout of instructions provided to you by your Urologist -Please also refer to the instructions provided to you by the Ostomy nurse specialist that details the required care and management of your Urostomy -You will be sent home with [**Hospital6 407**] (VNA) services to facilitate your transition to home care of your urostomy and YOUR COUMADIN DOSING AND MONITORING. -Please take the coumadin daily at the same time. You will make arrangements through your PCP for routine INR monitoring and coumadin dosing. Please call and discuss this with your PCP when you get home today. -Toprol XL is also a NEW medication that you will take in addition to your other medications. -Resume your pre-admission/home medications except as noted. Always call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor -If you have been prescribed IBUPROFEN, please note that you may take this in addition to the prescribed NARCOTIC pain medications and/or tylenol. FIRST, alternate Tylenol (acetaminophen) and Ibuprofen for pain control. -REPLACE the Tylenol with the prescribed narcotic if the narcotic is combined with Tylenol (examples include brand names Vicodin, Percocet, Tylenol #3 w/ codeine and their generic equivalents). ALWAYS discuss your medications (especially when using narcotics or new medications) use with the pharmacist when you first retrieve your prescription if you have any questions. Use the narcotic pain medication for break-through pain that is >4 on the pain scale. -The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 4 grams (from ALL sources) PER DAY and remember that the prescribed narcotic pain medication may also contain Tylenol (acetaminophen) so this needs to be considered when monitoring your daily dose and maximum. -If you are taking Ibuprofen (Brand names include Advil, Motrin) this should always be taken 2ith food. If you develop stomach pain or note black stool, stop the Ibuprofen. -Please do NOT drive, operate dangerous machinery, or consume alcohol while taking narcotic pain medications. -Do not drive and until you are cleared to resume such activities by your PCP or urologist -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -Please also refer to the educational handout on post-operative instructions provided by Dr.[**Doctor Last Name **] office. -Please also refer to the instructions on FOLEY CATHETER CARE and leg bag use. -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -If you had a drain removed from your abdomen, bandage strips called ??????steristrips?????? have been applied to close the [**Doctor Last Name **]. Allow the bandage strips to fall off on their own over time but please REMOVE the gauze dressing on Sunday. You may get the steristrips wet. -Resume ALL of your pre-admission medications, except HOLD aspirin unless otherwise advised -You will return to Dr.[**Doctor Last Name **] office for staple removal in one week, the staples do not need to be covered however protect staples from catching on clothing or bed sheets -Take antibiotic as directed for two days STARTING THE DAY PRIOR to your scheduled follow-up appointment with Dr. [**Last Name (STitle) **]. DO NOT START taking the medication until the day prior to your scheduled Foley catheter removal and voiding trial. -resume regular home diet and remember to drink plenty of fluids to keep hydrated and to prevent constipation Followup Instructions: -Follow up in approximately ONE week for [**Last Name (STitle) **] check and ureteral stent removal. DO NOT have anyone else other than your Surgeon remove your ureteral stents for any reason. Call Dr[**Doctor Last Name **] office today to schedule/confirm your follow-up appointment AND if you have any questions. You will be discharged home with VNA services for urostomy care and coumadin dosing/INR monitoring. -Please take the coumadin daily at the same time. You will make arrangements through your PCP for routine INR monitoring and coumadin dosing. Please call and discuss this with your PCP when you get home today Your current pre-arranged appointments are listed here: Provider: [**Name Initial (NameIs) **]/OSTOMY NURSE Phone:[**Telephone/Fax (1) 13760**] Date/Time:[**2102-9-14**] 1:30 Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2102-9-14**] 1:30 Completed by:[**2102-8-30**]

[ "276.2", "E878.6", "753.4", "518.5", "568.0", "591", "365.9", "998.11", "188.9", "415.11", "V10.06", "285.1", "401.9", "553.21" ]

icd9cm

[ [ [] ] ]

[ "54.59", "56.51", "53.51", "40.3", "57.71" ]

icd9pcs

[ [ [] ] ]

6841, 6902

3497, 4837

318, 491

7138, 7138

2090, 3474

11003, 11996

1645, 1677

4975, 6818

6923, 7117

4863, 4952

7289, 10980

1692, 1692

1708, 2071

264, 280

519, 683

7153, 7265

705, 1303

1319, 1629

54,762

171,051

37655+58163

Discharge summary

report+addendum

Admission Date: [**2147-12-20**] Discharge Date: [**2147-12-27**] Date of Birth: [**2101-7-28**] Sex: M Service: CARDIOTHORACIC Allergies: Bee Pollen Attending:[**First Name3 (LF) 4679**] Chief Complaint: esophageal cancer Major Surgical or Invasive Procedure: [**2147-12-20**] 1. [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy. 2. Laparoscopic jejunostomy. 3. Therapeutic bronchoscopy. 4. Esophagogastroduodenoscopy. 5. Buttressing of intrathoracic anastomosis with thymic fat pad. History of Present Illness: 46M with long segment Barrett's esophagus and biopsies this year that indicated intramucosal adenocarcinoma. A PET scan on [**2147-11-8**] showed no distant FDG uptake but mild FDG avidity in the distal esophagus with a small area of nodularity. It was decided that endoscopic ablation would not be the appropriate treatment. Given the patient's young age and excellent health he is being admitted for [**Date Range 12351**]-[**Doctor Last Name **] minimal invasive esophagectomy. Past Medical History: GERD, hypertension, seasonal allergies, and obstructive sleep apnea, Barrett's esophagus dx in [**2142**] Social History: He works as a computer engineer. Married. No tobacco. Socially drinks alcohol. Family History: non-contributory Physical Exam: VS: T 100.6, HR 95 SR, BP 114/76, RR 20, O2 Sats 95% RA Physical Exam: General: pt in hospital bed, pleasant, A and O x 4 without deficit, in NAD Lungs: clear bilaterally t/o to auscultation. Chest: VATS sites right lateral chest healing without redness purulence nor drainage. Chest tube site covered with dry gauze dsg. JP site with scant SS drg. Abd: soft, NT, ND, intact J tube without redness, purulence,nor drg. Ext: warm, no edema. pulses intact t/o. Pertinent Results: [**2147-12-25**] Esophagus study: no evidence of leak or holdup [**2147-12-23**] Chest & Abdominal CT IMPRESSION: 1. Status post esophagectomy with gastric pull-through has the expected appearance. No definite evidence of leak. 2. Ground-grass opacity of the right upper and lower lobes is likely post-operative edmea and hypoinflation atelectasis, although aspiration and developing infection cannot be excluded. 3. Abnormal low density of the left hepatic lobe is likely post-operative edema ad the portal and hepatic veins and proximal left hepatic artery appear patent, but evolving ischemia can not be excluded. CXR: [**2147-12-25**] The right-sided chest tube has been removed. The nasogastric tube has also been removed. On the right, there is a millimetric focal pleural air inclusion limited to the very apex. No evidence of tension. Resolving bilateral basal atelectasis. Unchanged size of the cardiac silhouette. [**2147-12-22**] 1. Status post esophagectomy with neoesophagus along the right mediastinum and mediastinal drain. 2. Bibasilar plate-like atelectasis without evidence of effusions or fluid overload. [**2147-12-26**] WBC-15.6* RBC-4.14* Hgb-11.3* Hct-34.1 Plt Ct-245 [**2147-12-25**] WBC-14.8* RBC-4.11* Hgb-11.7* Hct-34.1 Plt Ct-234 [**2147-12-22**] WBC-16.5* RBC-4.11* Hgb-11.7* Hct-34.8 Plt Ct-160 [**2147-12-21**] WBC-13.0* RBC-4.23* Hgb-12.4* Hct-36.0 Plt Ct-174 [**2147-12-20**] WBC-15.6*# RBC-4.29* Hgb-12.1*# Hct-36.5 Plt Ct-172 [**2147-12-26**] Glucose-129* UreaN-18 Creat-0.8 Na-140 K-4.5 Cl-104 HCO3-29 [**2147-12-25**] Glucose-114* UreaN-20 Creat-0.8 Na-143 K-3.9 Cl-108 HCO3-26 [**2147-12-21**] Glucose-128* UreaN-17 Creat-0.9 Na-139 K-3.8 Cl-105 HCO3-28 [**2147-12-20**] Glucose-147* UreaN-20 Creat-1.1 Na-141 K-4.5 Cl-107 HCO3-24 [**2147-12-26**] ALT-501* AST-202* AlkPhos-166* TotBili-0.6 [**2147-12-25**] ALT-607* AST-191* LD(LDH)-384* AlkPhos-137* TotBili-0.7 DirBili-0.2 IndBili-0.5 [**2147-12-23**] ALT-910* AST-291* AlkPhos-84 TotBili-0.9 DirBili-0.3 IndBili-0.6 [**2147-12-26**] Calcium-8.5 Phos-3.2 Mg-1.9 Cultures: [**2147-12-22**] Urine, BC x2, Sputum: no growth Brief Hospital Course: Mr. [**Known lastname **] was admitted for [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy. Laparoscopic jejunostomy. Therapeutic bronchoscopy, Esophagogastroduodenoscopy. Buttressing of intrathoracic anastomosis with thymic fat pad. He was transferred to the TSICU intubated and was extubated on POD1. Respiratory: Aggressive pulmonary toilet, nebs were continued. Over the course of his hospitalization his oxygen was titrated off. Cardiac: he remained hemodynamically stable. HR 70-80 SR GI: PPI continued prophylactic. NGT remained until POD3 Nutrition: J-tube feeds: Replete tube feeds were started on POD1 and slowly titrated to Goal 100 Ml/hr on POD Esophagus study was performed on [**12-25**] which showed no anastomic leak. He was started on a full liquid diet. ID: On POD2 he spiked fevers to 101. he was pan cultured with no growth. His WBC was mildly elevated. Abdominal CT done [**12-23**] performed and negative for anastomic leak. But Abnormal low density of the left hepatic lobe is likely post-operative edema ad the portal and hepatic veins and proximal left hepatic artery appear patent, but evolving ischemia can not be excluded. LFT's were trended, and came down over time. He had no further fevers. Pain: Epidural managed by the acute pain service with good control was removed on POD5. He converted to J-tube pain meds with good control. GU: POD5 the foley was removed and he voided without difficulty Tubes/Drains: were removed on POD5. The chest tube site required a U suture for moderate drainage which will be removed during his f/u visit. Disposition: He was discharged home on POD7 with Tube feeds, VNA and will follow-up with Dr. [**First Name (STitle) **] as an outpatient. Medications on Admission: Fluticasone daily,l metropolol 25 mg daily, omeprazole 40 mg [**Hospital1 **] Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:*400 ML(s)* Refills:*0* 2. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO every twelve (12) hours. Disp:*60 Tablet(s)* Refills:*2* 3. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day. Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 4. Replete Full Strength Goal Rate 100 mL/hr Cycle 1500-0900 Flush 100 mL before and after tube feeds Discharge Disposition: Home With Service Facility: Diversified VNA and hospice Discharge Diagnosis: Esophageal cancer Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Difficulty or painful swallowing. Diarrhea -Incision develops drainage -Chest tube site, JP site cover with a bandaid until healed -Nothing in Feeding tube unless it is in liquid form. -Call immediately if J-tube falls out or suture comes loose Followup Instructions: Follow-up with Dr. [**First Name (STitle) **] [**0-0-**] Date/Time:[**2148-1-9**] 10:00am on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]. Chest tube Suture removal when seen by Dr. [**First Name (STitle) **] Chest X-Ray 45 minutes before your appoinment on the [**Location (un) 861**] Radiology Department Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6955**] [**Telephone/Fax (1) 33146**] Completed by:[**2147-12-27**] Name: [**Known lastname **],[**Known firstname 126**] Unit No: [**Numeric Identifier 13412**] Admission Date: [**2147-12-20**] Discharge Date: [**2147-12-27**] Date of Birth: [**2101-7-28**] Sex: M Service: CARDIOTHORACIC Allergies: Bee Pollen Attending:[**First Name3 (LF) 1999**] Addendum: Due to insurance requiring prior authorization, the patient PPI was switched to omeprazole 40 mg po daily, as approved by Dr. [**First Name (STitle) **] for pt to swallow. Discharge Disposition: Home With Service Facility: Diversified VNA and hospice [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 2001**] Completed by:[**2147-12-27**]

[ "530.85", "327.23", "553.3", "573.8", "780.62", "150.5", "401.9", "276.2", "530.81", "338.12" ]

icd9cm

[ [ [] ] ]

[ "42.52", "45.13", "33.23", "03.90", "46.32", "96.6", "42.41" ]

icd9pcs

[ [ [] ] ]

8208, 8424

3963, 5719

297, 554

6575, 6575

1820, 3940

7154, 8185

1308, 1326

5847, 6432

6534, 6554

5745, 5824

6720, 7131

1412, 1801

240, 259

582, 1064

6589, 6696

1086, 1194

1210, 1292

63,116

128,038

52139

Discharge summary

report

Admission Date: [**2100-12-11**] Discharge Date: [**2100-12-24**] Date of Birth: [**2045-6-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8388**] Chief Complaint: Chief Complaint: anasarca, need for start of HD Reason for MICU admission: hypoxemia and tachycardia Major Surgical or Invasive Procedure: [**12-21**], [**12-22**], [**12-23**]- hemodialysis Paracenteses x3 Initation of CVVH and Hemodialysis. Tunnelled dialysis catheter placed. PICC line placement History of Present Illness: 55 year old man with Afib, dilated cardiomyopathy, alcoholic cirrhosis, COPD, ESRD; presenting to ED w/ anasarca not responsive to Lasix. He has noted increased shortness of breath, pedal edema, orthopnea, and cough x 3 days. Has gained 13 pounds at rehab over the last week. Increased diuresis was attempted at rehab (80 mg IV lasix TID). He was seen by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**] at his rehab, decision to admit for initiation of HD (?CVVHD vs. daily HD). Will need a line for HD. Other ROS at rehab notable for several days of lower extremity redness concerning for cellulitis (not recently on antibiotics) and dropping hematocrits with guiaiac positive stools (in setting of supratherapeutic on coumadin) necessitating 2 units PRBCs over the last two days. . In the ED, initial vs were: T98.9 76 115/82 20 98% on 6L. HRs mostly in 120s. BPs in low 100s. Tried and then refused bipap and facemask. 90% on 6L. Patient was given vanc, zosyn, 80 mg lasix plus zaroxlyn 5 mg. . In the MICU, patient sleepy but arousable. Denies pain complaints. Does endorse cough, nonproductive of sputum. Endorses that he is DNR/DNI but does not provide further history. . Review of systems: (+) Per HPI (-) Denies fever, chills, headache, blurry vision, shortness of breath, chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. Past Medical History: - CKD - baseline unclear ?in [**3-23**].5 range - Afib usually on coumadin. - COPD on 2-4L O2 at rehab - EtOH cirrhosis. History of hepatic encephalopathy. Had transjugular liver biopsy at [**Hospital1 112**] on [**11-23**]. - Congestive heart failure - R heart failure with TR (?due to pericardial disease) - recurrent LE cellulitis; recently on a course of IV vancomycin through [**2100-11-17**]. Had a hematoma evacuated on [**2100-11-21**]. - HTN - Morbid obesity - Lymphedema of lower extremities - h/o idiopathic constrictive pericarditis s/p pericardial stripping in [**2083**] - Psoriasis - History of MRSA cellulitis Social History: Currently living at [**Hospital 100**] Rehab. On disability. Past smoker and EtOH abuse of unclear duration. Family History: noncontributory Physical Exam: ADMISSION EXAM: General: Lethargic but arousable. When awoken, appropriate and oriented x3, but falls asleep easily (mid-conversation). Mildly tachypneic with pursed lip breathing at times. HEENT: PERRL, R subconjunctival hemorrhage with much more mild erythema of L sclera as well. EOMI. MM slightly dry. Neck: supple, JVD elevated at least to ear at 30 degrees with prominent neck vein distension. Lungs: Poor effort. Clear to auscultation on right, diminished breath sounds on left. CV: Irregularly irregular, S1 + S2 with loud P2, [**2-26**] SM at LLSB, +RV heave. Abdomen: slightly tense, non-tender, prominent distension with peripheral dullness, bowel sounds present, no rebound tenderness or guarding. Abdominal wall edema also present. Ext: L arm with 3+ edema, R arm with minimal edema. PICC site benign appearing. Lower extremities with 4+ edema; anterior shins covered with thick yellow scaly skin; generalized venous stasis changes. L anterior shin with large ulceration, no bleeding or purulent drainage. DISCHARGE VS: T 97.6 HR 89 BP 103/ 52 RR 18 SaO2 100% 3L NC Pertinent Results: WBC 7.8 N82.2 L8.1 M5.2 E4.0 B0.5 Hct 28.0 MCV 90 Plts 223 PT 17.2 PTT 33.4 INR 1.6 138 98 113 4.9 30 3.8 Ca 9.2 Mg 2.7 Phos 6.4 ALT 10 AST 19 LDH 157 CK 23 AlkP 97 Tbili 0.8 Tprot 7.6 Alb 3.3 Globuln 4.3 Trop 0.11 BNP [**Numeric Identifier 38477**] Dig 0.3 ABG 7.25/76/84/35 lactate 1.3 UA large blood 741 RBC's, neg nitrite, large LE, >1000 WBC's many bacteria, 100 protein, neg ketones and glucose BCx negative x2 [**12-11**] URINE CULTURE (Final [**2100-12-13**]): ENTEROBACTER CLOACAE. >100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Influenza A and B negative by DFA Peritoneal fluid pending Ascites WBC 235 Poly 61 L1 Mono 11 Macroph 27 RBC 205 Tprot 3.7 Glucose 130 LDH 120 Alb 1.7 [**12-10**] EKG Tracing is suspicious for reversal of left arm and left leg electrodes. Atrial fibrillation, average ventricular rate 120, with right bundle-branch block (possibly rate-related) with secondary repolarization abnormalities in most leads, but primary repolarization abnormalities in leads II and V6. Low limb lead voltage. Poor anterior R wave progression, question normal variant versus prior anterior wall myocardial infarction. Compared to the previous tracing of [**2083-12-13**] atrial fibrillation with a rapid ventricular response has replaced sinus rhythm and right bundle-branch block is more pronounced. Low limb lead voltage and poor R wave progression are new. Differential includes pericardial effusion, worsened pulmonary process, and ischemia. Clinical correlation is suggested. [**12-11**] EKG Atrial fibrillation with a rapid ventricular response. Right bundle-branch block. Non-specific ST-T wave changes. Low voltage in the limb leads. Compared to the previous tracing there is no significant change. [**12-11**] Echo IMPRESSION: Marked right ventricular cavity enlargement with free wall hypokinesis. Moderate pulmonary artery systolic hypertension. Moderate to severe tricuspid regurgitation. Mild-moderate mitral regurgitation. [**12-11**] CXR A bedside upright radiograph of the chest in the frontal projection was obtained with the patient slightly rotated. Note is made of cardiomegaly. In addition, there is diffuse engorgement of the pulmonary vasculature. Left basal atelectasis is also noted. A right pleural effusion is small. Multiple sternotomy wires are visualized, one of which is fractured. IMPRESSION: Cardiomegaly and pulmonary vascular engorgement . [**12-11**] UE u/s No evidence of deep venous thrombosis in the left upper extremity. [**12-11**] BLE u/s Limited study secondary to patient discomfort and marked lower extremity edema. The calf veins were not interrogated secondary to overlying dressings. No DVT in the bilateral lower extremities. Non-compressibility of the right common femoral vein and superficial femoral vein is attributed to marked lower extremity edema. [**12-13**] CXR FINDINGS: As compared to the previous examination, there is no relevant change. Perihilar haziness and increase in diameter of the pulmonary vasculature suggests mild-to-moderate pulmonary edema. In addition, a preexisting left-sided consolidation in the basal lateral parts of the thorax could suggest a combination of pleural effusion and subsequent atelectasis. The fact that this opacity is completely unchanged since [**2100-12-11**] makes pneumonia rather unlikely. The presence of a small right-sided pleural effusion cannot be excluded. The cardiac silhouette appears to be mildly enlarged. There is no evidence of newly occurred focal parenchymal opacities. The sternal wires are in unchanged alignment, the most caudal wire is ruptured. Unchanged clips projecting over the upper parts of the mediastinum. [**12-21**] Duplex Doppler U/S 1. Coarsened nodular liver architecture consistent with cirrhosis. 2. Normal hepatic doppler evaluation with no evidence of Budd-Chiari as clinically questioned. Pulsatility and variability in the portal venous waveform which may be seen with right heart failure or tricuspid regurgitation. 3. Splenomegaly and ascites consistent with portal hypertension. 4. Bilateral echogenic kidneys attributed to medical renal disease. 5. Cholelithiasis without evidence of cholecystitis. 6. Small right pleural effusion. [**12-22**] HD Line-Placement of a 15.5 French x 23 cm temporary hemodialysis catheter via right internal jugular access with the tip in the right atrium. The catheter is ready to use. Labs on day of discharge: WBC 8.2 Hb 8.6 Hct 28.7 Plt 168 Cr 4.0 AST, ALT, TBili, AlkPhos - within normal limits Brief Hospital Course: 55 year old man with history of Afib, cardiomyopathy, presenting with anasarca and shortness of breath with plan for initiation of hemodialysis; encephalopathy which has improved with transition from goals of care from CMO to DNR/DNI but HD okay per patient wishes. # Acute on chronic respiratory acidosis. Unclear baseline - to what degree acidemia is due to acute hypoventilation vs. worsening of metabolic acidosis. For respiratory component, was getting morphine on floor - likely leading to hypoventilation. Otherwise, acute component may be due to COPD vs. altered mental status. Unclear if Co2 retention also contributing to mental status. Last ABG on [**12-21**] showed pH 7.27. # Respiratory distress/hypoxemia. Multifactorial with major contribution of volume overload/pulmonary edema plus left sided consolidation (which may be asymmetric edema vs. pneumonia/infectious consolidation; also may be layering effusion). Also may have component of COPD flare/reactive airways, though no current wheezing on exam. Has cor pulmonale and PA HTN. Also with some restrictive component with large abdomen/ascites. ABG with elevated pCO2. Refusing intubation and BiPap. Pt was started on Lasix gtt with goal negative as much as bp could tolerate but did not have great UOP response. Pt got HD line placed and started on CVVH and then HD. Had paracenteses (approx 20 L removed total over 3 paracenteses). Nebs prn for wheezing. After fluid removal, was breathing much more comfortably. # Anasarca. Patient with RV failure, cirrhosis, worsening renal failure. Volume removed with CVVH and HD as above. # Tachycardia/Afib. Seems to be somewhat difficult to rate control at baseline (limited by BP) but notes suggest slightly worse lateley. [**Month (only) 116**] be related to intravascular shifts with attempts at diuresis/inability to mobilize third space fluids, or related to current pulmonary disease. Pt half loaded with Dig 0.5 mg x1 and continued on PO metoprolol QID as much as BP tolerated. Coumadin was held given procedures and pt was given FFP for invasive procedures. Tachycardia was an issue, so diltiazem given to control heart rate without dropping blood pressure. This was rather effective. Metoprolol was d/c and diltiazem initiated for rate control with less effect on blood pressure. He was d/c on digoxin and diltiazem. # UTI. Ciprofloxacin x 7 day course - completed. # Acute renal failure. Baseline prior to one month ago unknown, but has been in the 3s for at least the last few weeks. Nature of chronic insufficiency unclear. Volume overloaded; pt got CVVH and HD as above. # Altered mental status. Differential includes hypercarbia, hepatic encephalopathy, uremia, infection. Pt started on Lactulose, Rifaxamin (had some refusal to take these meds, but then became more compliant). Mental status improved. # Congestive heart failure. Documented RV failure with normal LV. Has signs of chronic RV failure on exam, such as volume overload. Diuresed/CVVH as above. Continued on BB and digoxin as above. Started diltiazem. # Cirrhosis. Documented as EtOH related. Also consider some element of RV failure resulting in questionable cardiac ascites. Pt received 6L large volume paracentesis, then 8L and then 8L. # Anemia. Episodes of guiaic pos stool and Hct drops, leading to transfusion at rehab. HCt stable here. Coumadin was held as above. # Leg edema/rash. Question: hyperkeratosis from lymphedema. Unclear how much infection is playing a role. Large ulcer with good granulation tissue, no evidence of surrounding infection. Wound care followed and offered recommendations. (in discharge orders) Medications on Admission: - Lasix 80 mg IV Q8H - Digoxin 0.125 mg Q48hours - Rifaximin 400 mg TID - Lactulose 30 grams (45 ml) QID - Metoprolol 12.5 mg QID - Sevelamer 1200 mg TID - Albuterol 2 puffs Q2H prn wheeze - Advair 100/50 [**Hospital1 **] - Spiriva once daily - Omeprazole 40 mg [**Hospital1 **] - Vitamin D 1000 units daily - Multivitamin daily - Zofran 2mg Q8H prn nausea - Miconazole powder [**Hospital1 **] - Dulcolax 10 mg PR prn - polysaccharide iron 150 mg daily - Aranesp 60 mcg weekly on Fridays Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]: One (1) Cap Inhalation DAILY (Daily). 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. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Tunneled Access Line (e.g. Hickman), heparin dependent: Flush with 10 mL Normal saline followed by Heparin as above daily and PRN per lumen. 5. Ondansetron 4 mg IV Q8H:PRN nausea 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 8. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 9. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 10. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO QOD (). 11. Rifaximin 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a day). 12. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Forty Five (45) ML PO QID (4 times a day). 13. Sevelamer HCl 400 mg Tablet [**Hospital1 **]: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob, wheeze. 15. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 16. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 17. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) flush Injection PRN (as needed) as needed for line flush. 18. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 19. Midodrine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a day). 20. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [**Last Name (STitle) **]: 15-30 MLs PO QID (4 times a day) as needed for indigestion. 21. Diltiazem HCl 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a day). 22. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 23. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 24. Ammonium Lactate 12 % Lotion [**Hospital1 **]: One (1) Appl Topical ASDIR (AS DIRECTED). 25. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000) units Injection DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: PRIMARY: anasarca, renal failure, hepatic encephalopathy SECONDARY: alcoholic cirrhosis, dilated cardiomyopathy Discharge Condition: Afebrile. Vital signs stable. Does not ambulate well at baseline d/t lymphedema Discharge Instructions: You were admitted to the hospital with shortness of breath and swelling. For the volume overload that you had from fluid, you were started on dialysis and followed closely by the renal team. You also had fluid taken off from your abdomen on 3 occasions (paracentesis). At rehab, you had had blood in your stool, but then, while hospitalized, that bleeding issue resolved. . You had low blood pressures, but with pressor support you were able to leave the MICU and be stable on the floor without pressor support. . Wound care team followed you closely for the skin changes on your legs which are felt due to lymphadema and will improve now that you are getting dialysis. . Your medications have not changed. Please continue to take your medications as listed. Call your doctor or 911 if you experience crushing chest pain, difficulty breathing, intractable nausea or vomiting, fevers/chills, blood in your urine stool or vomit or any other concerning medical problem. Followup Instructions: please follow-up with Dr. [**Last Name (STitle) 36055**] your primary care doctor at your earliest convenience. Call [**Telephone/Fax (1) 89609**] to set up an appointment. Completed by:[**2100-12-26**]

[ "427.31", "276.2", "V58.61", "285.9", "599.0", "789.59", "372.72", "572.2", "518.83", "585.6", "278.01", "428.0", "305.00", "571.2", "584.9", "425.4", "707.19", "V12.04", "428.22", "403.91" ]

icd9cm

[ [ [] ] ]

[ "38.91", "39.95", "54.91", "38.93", "38.95" ]

icd9pcs

[ [ [] ] ]

16454, 16520

9417, 13052

418, 580

16676, 16758

3943, 9394

17774, 17979

2811, 2828

13590, 16431

16541, 16655

13078, 13567

16782, 17751

2843, 3924

1827, 2019

294, 380

608, 1808

2041, 2669

2685, 2795

19,912

116,004

44552

Discharge summary

report

Admission Date: [**2168-11-28**] Discharge Date: [**2168-12-2**] Date of Birth: [**2092-3-27**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: This is a 76 year-old female with coronary artery disease status post coronary artery bypass graft in [**2153**] and multiple percutaneous interventions who was brought to the Emergency Department after a witnessed cardiac arrest. The patient was in the mall and had a witness cardiac arrest. There was bystander CPR at two minutes and after eight minutes an AED arrived and the patient was shocked. CPR continued for five to six minutes and then EMS arrived. Initial rhythm was complete heart block and the patient was treated with epinephrine. This led to ventricular tachycardia and the patient was shocked leading to a rhythm of ventricular fibrillation, which converted to sinus rhythm after two further shocks. Electrocardiogram showed inferior ST elevations and lateral ST depressions. The patient was intubated and brought to the Emergency Department. In the Emergency Department she was treated with heparin and Integrilin, but this was discontinued due to coffee ground emesis. A chest x-ray showed a right pneumothorax and a chest tube was placed. The patient became hypotensive and Dobutamine and Levophed were started for blood pressure support. The patient was transferred to the Coronary Care Unit and the pressors were weaned off with fluid boluses. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. Coronary artery disease status post coronary artery bypass graft in [**2153**], multiple PCIs and a redo coronary artery bypass graft in [**2163**]. 4. Bladder prolapse. PHYSICAL EXAMINATION ON ADMISSION: Pulse 100 to 120. Blood pressure 60 to 80/40 to 60. Oxygen saturation 86 to 90% on the ventilator. Her heart was regular with no murmurs. There were rhonchorous breath sounds bilaterally. The abdomen was benign and there was no edema. HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit status post cardiac arrest and resuscitation. The main concern of the family from the time of admission was the patient's wishes regarding end of life care and previous discussions suggesting that she wished not to be intubated or resuscitated. After extensive discussions with the family it was determined to give the patient 48 hours to determine, which direction her neurologic status would go. The neurology consult team followed throughout the hospitalization and while she initially showed some positive signs by [**12-1**] it appeared that the patient was not going to make a rapid recovery back to her baseline functional status as she would have wished. Additionally the patient's respiratory status was compromised both by right pneumothorax secondary to rib fracture sustained during CPR as well as probable aspiration pneumonia. On [**12-2**] another meeting with the patient's two sons and daughter was held. They believed firmly that it would be their mother's wishes to withdraw care as she never wished to have her life sustained with heroic measures. Therefore in the afternoon of [**12-2**] the patient's mechanical ventilation was discontinued and she quickly had a respiratory arrest. The patient was pronounced dead at 2:40 p.m. The family declines postmortem examination. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Last Name (NamePattern1) 15468**] MEDQUIST36 D: [**2168-12-2**] 03:09 T: [**2168-12-7**] 07:08 JOB#: [**Job Number 95435**]

[ "518.81", "958.7", "348.1", "507.0", "428.0", "599.0", "512.1", "578.0", "427.41" ]

icd9cm

[ [ [] ] ]

[ "88.72", "99.20", "34.04", "38.91", "96.71" ]

icd9pcs

[ [ [] ] ]

1969, 3605

162, 1439

1711, 1951

1461, 1696

6,291

148,120

29982

Discharge summary

report

Admission Date: [**2138-5-30**] Discharge Date: [**2138-6-8**] Date of Birth: [**2069-11-19**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:[**Known firstname 3561**] Chief Complaint: Fever and Hypotension Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 68 year old man with a past medical history significant for diffuse large B-cell lymphoma, status post two cycles of R-CHOP, who originally presented to [**Hospital1 18**] from rehab with fever, chills, and malaise the day prior to admission. He had been feeling relatively well over days prior to admission. He denied any nausea, vomiting, diarrhea, or recent fever, but endorses slight tenderness and redness over the PICC insertion site. Concerned due to his previous medical history, his rehabilitation facility sent the patient to the [**Hospital1 18**]. . On presentation to the ED, patient was noted to have a temperature of 101.7, heart rate of 115, blood pressure of 72/38, RR of 16, and oxygen saturation of 96%. He received cefepime 2gm IV, vancomycin 1 gm IV, and Tylenol. His PICC line was removed and sent for culture. Due to concern for hypotension and sepsis, he was transferred to the ICU. . In the ICU, he was given IVFs to which his blood pressures responded and have been stable in the 90s systolic (his baseline). Blood cultures from admission grew [**4-2**] pansensitive staph aureus as well as [**2-2**] hafnia alvei which was sensitive to ceftriaxone, thus he was started on nafcillin and ceftriaxone. Source was thought to be his PICC line which, as above, was removed on admission. Cellulitis of the sking surrounding the PICC was also noted. Additionally, while in the ICU, he was found to have a DVT right basilic vein extending to axillary vein; for this he was started on heparin gtt with plan to transition to coumadin. Prior to his admission, he was being treated for C. diff with PO vanco. He has had persistent diarrhea while here, C. diff was sent and was negative x3. He has, however, been continued on his PO vanco. . ROS: Significant weight change from his baseline 175 to his current 139 over the past year. He attributes this to poor appetite [**1-31**] alcohol abuse. Negative for chest pain, SOB Past Medical History: 1. Prostate cancer status post TURP and radiation per patient 2. [**Doctor Last Name 933**] disease treated with PTU/levoxyl 3. Hypertension 4. Hyperlipidemia 5. Alcohol abuse (last used 2 months ago) 6. Status subarachnoid hemorrhage and subdural hematoma following an alcohol-related fall in [**4-5**]. 7. Diffuse Large B-cell lymphoma, diagnosed [**2138-4-29**], now receiving chemotherapy. 8. C. difficile colitis 9. VRE 10. Hyponatremia (SIADH) . Onc History: Pt initially presented to [**Hospital3 46817**] in early [**Month (only) 547**] with cachexia, pour appetite, and right hydronephrosis secondary to a testicular mass and retroperitoneal lymphadenopathy. A biopsy showed diffuse large B-cell lymphoma and he received two cycles of Rituxan-CHOP on [**2138-4-18**] and [**2138-5-15**]. Social History: Currently lives at rehabilitation center/nursing home. Prior to [**5-5**] lived alone in [**Hospital3 4298**]. Separated from his wife. [**Name (NI) **] a son who lives in [**Name (NI) 531**] and a daughter who lives in [**Location (un) 10054**]. Tobacco: 1.5 ppd X 50 years. Alcohol: Used to drink [**12-31**] bottle of wine and four bottles of beer daily but stopped 2 months ago. Denies illicit drugs. Family History: Brother with question of sudden cardiac death, second brother with diabetes and coronary artery disease who died at age 57, third brother with history of cerebrovascular accident. Physical Exam: Vital signs: T 98.6, HR 121, BP 108/36, RR 28, 97% on RA General: Cachectic. In no apparent distress. HEENT: Anicteric sclera. No oropharyngeal lesions. Poor dentition. Slightly dry mucous membranes. Neck: Supple. No JVD. No cervical lymphadenopathy. Heart: Tachycardic. Normal S1 and S2. No murmurs, rubs, or gallops appreciated. Lungs: Clear to auscultation bilaterally. No crackles. Abdomen: Soft. Hypoactive bowel sounds. Nontender throughout. No rebound or guarding. Extremities: Warm and well perfused. 2+ radial pulses. No peripheral edema appreciated. Pertinent Results: [**2138-5-30**] 09:10PM PLT COUNT-392# [**2138-5-30**] 09:10PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL BURR-OCCASIONAL [**2138-5-30**] 09:10PM NEUTS-77* BANDS-0 LYMPHS-15* MONOS-5 EOS-0 BASOS-0 ATYPS-3* METAS-0 MYELOS-0 [**2138-5-30**] 09:10PM WBC-1.5* RBC-3.43* HGB-10.9* HCT-30.7* MCV-90 MCH-31.7 MCHC-35.5* RDW-17.9* [**2138-5-30**] 09:10PM LIPASE-14 [**2138-5-30**] 09:10PM ALT(SGPT)-13 AST(SGOT)-12 ALK PHOS-68 TOT BILI-0.6 [**2138-5-30**] 09:10PM GLUCOSE-106* UREA N-10 CREAT-0.7 SODIUM-129* POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-24 ANION GAP-16 [**2138-5-30**] 09:16PM LACTATE-1.4 [**2138-5-30**] 09:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2138-5-30**] 09:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 . pCXR [**2138-5-30**]: Single AP upright portable chest radiograph is reviewed and compared to [**2138-5-14**]. Heart size is normal. Mediastinal and hilar contours are unremarkable. Pulmonary vasculature is not enlarged. There is no focal consolidation. There is no significant amount of pleural fluid. There is no pneumothorax . R upper ext u/s [**2138-6-1**]: Occlusive thrombus in the right basilic vein extending into the axillary vein. . TTE [**2138-5-30**]: 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%). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2138-2-27**], there is no significant change. . TEE [**2138-6-4**]: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. A catheter is seen in the right atrium coming in contact intermittently with the triscuspid valve. No mobile elements are seen attached to the catheter. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch and descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No vegetations are seen on the aortic valve. An eccentric jet of probable mild aortic regurgitation is seen; however, given the eccentric nature of this flow, cannot exclude the possibility of a small aortic leaflet perforation. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**12-31**]+) mitral regurgitation is seen. There is no pericardial effusion. . Left upper ext u/s [**2138-6-5**]: No evidence of DVT in the left upper extremity. . Micro: [**2138-5-30**], blood cultures 4/4 bottles: STAPH AUREUS COAG +. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. PENICILLIN SENSITIVITY AVAILABLE ON REQUEST. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S . [**2138-5-30**], blood cultures 2/4 bottles: HAFNIA ALVEI. FINAL SENSITIVITIES. Trimethoprim/Sulfa sensitivity testing available on request. STAPH AUREUS COAG +. SENSITIVITIES PERFORMED ON CULTURE # 231-0361L [**2138-5-30**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ HAFNIA ALVEI | AMPICILLIN------------ <=2 R AMPICILLIN/SULBACTAM-- <=2 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S . PICC cath tip [**2138-5-30**]: STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- S . Urine cx [**2138-5-30**]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . [**2138-5-31**], blood cultures: 1/4 bottles with Staph Aureus (sensitivies same as blood cx from [**2138-5-30**]) . Blood cultures [**2138-6-1**], [**2138-6-3**], [**2139-6-8**]: NGTD . Stool: negative for Cdiff x 3, negative for O&P, stool culture negative Brief Hospital Course: 68 year old man with diffuse B cell lymphoma status post two cycles of R-CHOP who presented with fever and hypotension in the setting of infected PICC line. He also was noted to have an upper extremity DVT associated with the line. . 1) Sepsis/Infected PICC/upper DVT: He received IVFs in the ICU and did not require pressers. His PICC line was removed; blood cultures and PICC catheter tip grew MSSA and Hafnia Alvei. He was given Nafcillin and Ceftriaxone. R upper extremitiy u/s revealed a DVT of the right basilic vein extending into the axillary vein (this is where the old PICC had been). He was placed on a heparin drip. Trans-thoracic and trans-esophageal echos were done; neither revealed a vegetation but the TEE showed an eccentric jet of aortic regurgitaion which could not be ruled out as a manifestation of endocarditis. ID was consulted, and felt he should be treated for endocarditis. The Ceftriaxone should be given for a 2-week course (Hafnia Alvei is not a common cause of endocarditis), and Nafcillin should be given for 6 weeks (as MSSA commonly causes endocarditis). He will f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Infectious diseases on [**7-14**] at 9:30am. He will need weakly labs while on ABX, including CBC w/diff, chemistry panel, LFTs. These can be faxed to [**Hospital **] clinic (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) at fax # [**Telephone/Fax (1) 432**]. . 2) RUE DVT: At site of former PICC, U/S showed occlusive thrombus in the right basilic vein extending into the axillary vein. He was on a heparin drip for 1 week. Heparin was d/c'd and no further anticoaggulation started for the following reasons: The DVT was associated with a line that was removed, and the patient has a h/o subdural & subarachnoid hemorrhage 3 months ago. . 3) Diarrhea: The patient had recent C. diff infection for which he was on PO vanco. He continued to have loose stools. C. diff toxin was sent and was negative x4 during this admission. Toxin B sent. - cont. PO vanco - f/u C. diff toxin B . 4) Diffuse large B cell lymphoma: Received two cycles of R-CHOP previously. Chemotherapy started in [**2138-3-30**]. He was on allopurinol for tumor lysis and neupogen for cell count enhancement. Neupogen was d/c'd in the ICU when counts rose. Due to the infection and possible endocarditis, his CHOP chemotherapy will be held, but he was given 1 dose of Rituximab while inpatient. He will f/u with his outpatient Oncologist, Dr. [**Last Name (STitle) 410**] one week after discharge. . 5) [**Doctor Last Name 933**] Disease: Followed by endocrine as an outpatient. The patient was continued on levothyroxine dose of 25mcg daily. He should f/u with his endocrinologist, Dr. [**First Name (STitle) **] as previously scheduled. . 6) Hyponatremia: During previous hospitalization, patient was noted to have low sodium level, thought to be secondary to SIADH. He received fluid resuscitation in the ICU initially. After his sepsis physiology resolved, he was placed on a free H2O restriction of 1500 ml. His sodium was stable in the low 130s. . 7) FEN: Regular diet. Continued on multivitamins, thiamine, folic acid. . . 8) Prophylaxis: Was given heparin gtt for DVT as above, then ambulating. Also given PPI and bowel regimen. . Code: FULL. Medications on Admission: -hexavitamin PO qd -folic acid 1mg qd -thiamine 100 mg qd -protonix 40mg qd -clotrimazole 1% topical q12hr -levothyroxine 25 mcg qd -nystatin 5cc PO q6hr swish and swallow -triamcinolone 1% cream TP qd -lovenox 40 mg SC qd -allopurinol 200 qd -tylenol 325mg PO q6hr PRN pain -megestrol 40 mg qd prn -lactulose 30 cc q6hr PRN -colace 100 PO q12hr PRN -zofran 4mg PO q8hr PRN -dilaudid 4mg PO q4hr PRN -calcium carbonate 1250 PO q12 -epogen 12,000 units SC qT,Th, Sa -magnesium oxide 400 mg PO bid -filgastrim 480 mcg q24 hr Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. CeftriaXONE 1 gm IV Q24H 6. Nafcillin 2 gm IV Q4H 7. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. 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. 11. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 13. Multivitamin,Tx-Minerals Tablet Sig: One (1) Cap PO DAILY (Daily). 14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: N.E. [**Hospital **] Hospital Discharge Diagnosis: 1. Sepsis secondary to infected PICC line and bacteremia 2. Right upper extremitiy DVT related to old PICC line 2. Endocarditis 3. Lymphoma Discharge Condition: Afebrile, stable Discharge Instructions: Please take your medications as prescribed. You will not be taking blood thinners. Continue to take Ceftriaxone for 1 more week (last full day is [**2138-6-15**]). Continue to take Nafcillin for 5 more weeks (last day is [**2138-7-12**]). . You will need weakly labs while on antibiotics, including CBC w/differential, chemistry panel, LFTs. These can be faxed to [**Hospital **] clinic (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) at fax # [**Telephone/Fax (1) 432**] . Call your doctor if you have fever, chills or any other symptom that concerns you. Followup Instructions: - Please see Dr. [**Last Name (STitle) 410**]/Dr. [**First Name (STitle) **] on [**2138-6-16**] at 11AM. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD: [**Telephone/Fax (1) 3241**] Date/Time:[**2138-6-16**] 11:00 - You are scheduled to follow up with the Infectious Diseases team, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], as below. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2138-7-14**] 9:30 - You are scheduled to see your endocrinologist, Dr. [**First Name (STitle) **]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1802**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2138-6-20**] 11:00 Completed by:[**2138-6-9**]

[ "253.6", "996.74", "008.45", "202.85", "996.62", "458.9", "995.91", "038.11", "401.9", "272.4", "041.11", "285.22", "421.0", "682.3", "453.8", "288.00", "244.9", "E879.8", "780.6" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.25", "88.72" ]

icd9pcs

[ [ [] ] ]

15383, 15439

9900, 13258

295, 317

15623, 15642

4331, 9877

16275, 17117

3553, 3734

13831, 15360

15460, 15602

13284, 13808

15666, 16252

3749, 4312

234, 257

345, 2292

2314, 3114

3130, 3537

11,633

124,787

14665

Discharge summary

report

Admission Date: [**2139-7-3**] Discharge Date: [**2139-7-14**] Date of Birth: [**2077-9-9**] Sex: F Service: Surgery, Blue Team HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old white woman with a history of coronary artery disease, status post coronary artery bypass graft, multiple sclerosis, and hypercholesterolemia who presents with lethargy and purulent discharge from her vagina. The patient was brought by her husband to the Emergency Room at [**Hospital6 33**] because of the lethargy and drainage. She was evaluated at the [**Hospital6 33**] at which time there was a high suspicion for necrotizing fasciitis in her right lower lobe. The patient was subsequently transferred to the [**Hospital1 69**] for further management. The patient's husband reports that the patient headache a dilatation and curettage one month ago, and for the last 10 days the patient has had poor oral intake and worsening lethargy. At [**Hospital6 33**] the patient was resuscitated with intravenous fluids and given vancomycin, ceftazidime, and clindamycin. The patient was then transferred to the [**Hospital1 1444**] for further care. PAST MEDICAL HISTORY: (The patient's past medical history is significant for) 1. Multiple sclerosis. 2. Coronary artery disease. 3. Hypercholesterolemia. PAST SURGICAL HISTORY: Past surgical history is significant for coronary artery bypass graft. SOCIAL HISTORY: Her social history is unknown. MEDICATIONS ON ADMISSION: Her home medications were Pravachol and digoxin. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: On presentation the patient's temperature was 97.2, pulse of 84, blood pressure of 103/41, respiratory rate of 20, and 100%; the patient was intubated. On examination, the patient was intubated and sedated. She supposedly was alert and oriented times two prior to her intubation. Her mucous membranes were noted to be dry. Her pupils were equally reactive to light, and conjunctivae were noted to be clear. Tympanic membranes were also clean and intact. She did not have any jugular venous distention on examination. Her lungs were clear to auscultation bilaterally. Her heart was regular in rate and rhythm. Her abdomen was soft, tender in the lower quadrants with no evidence of guarding or palpable mass. Her rectal examination was guaiac-positive. No palpable masses were noted. On pelvic examination, the patient was noted to have a purulent discharge from her vagina. No mass was palpated. Her right thigh was noted to be indurated with crepitus noted. The patient was noted to have palpable dorsalis pedis pulses and posterior tibialis pulses on presentation. Also noted was that her first great toe bilaterally was noted to be bluish discoloration. PERTINENT LABORATORY DATA ON PRESENTATION: On presentation, her white blood cell count was 14.6, her hematocrit was 32.8, and her platelets were 125. Her sodium was 136, potassium of 4.8, chloride of 113, bicarbonate of 12, blood urea nitrogen of 99, creatinine of 3, blood glucose of 77. She was noted to have 10 bands on admission. Her urinalysis was noted to have moderate blood, 3 to 5 red blood cells on microbiology. Her blood gas was 7.19/32/72/13 and a base deficit of 14. Her PT was 15. Her PTT was 38.1. Her INR was 1.6. RADIOLOGY/IMAGING: She had a chest x-ray which was within normal limits. No evidence of congestive heart failure. No evidence of effusion. No evidence of cardiomegaly. A CT of her abdomen was noted to have free fluid in her pelvis. No evidence of free air in the peritoneal cavity, and there was a thickened portion in her right colon. There was also noted to be some air in the psoas muscle and the gluteal muscle as well as her thigh. HOSPITAL COURSE: This is a 61-year-old woman transferred from an outside hospital and noted to have purulent discharge from her vagina and likely necrotizing fasciitis in her right thigh. The patient presented intubated, and on presentation the patient was quickly further resuscitated with a total of 11 liters of crystalloid. A PA catheter as well as an arterial line were placed, and the patient was placed on high-dose penicillin, gentamicin, and clindamycin. A pressure PA catheter was not placed. A central venous catheter was placed, and the patient was quickly transferred to the Intensive Care Unit for further management. Later in the same day (on [**2139-7-3**]), the patient was taken to the operating room and underwent an exploratory laparotomy, appendectomy, Hartmann and sigmoid colostomy, and opening of her right thigh including fasciotomy. Intraoperatively, it was noted that the patient had a perforated sigmoid in the posterior aspect of her sigmoid colon. The patient was also noted to have a necrotic appendix that was perforated. The patient was also noted to have focal peritonitis, and there was some purulence found in her fascia in her right thigh. Postoperatively, the patient was transferred to the Intensive Care Unit. A PA catheter was then placed, and the patient was placed on intravenous antibiotics which included high-dose penicillin, clindamycin, and meropenem. The patient also had to be placed on a dopamine drip and Levophed to maintain her blood pressure. On [**7-5**], the patient's condition continued to deteriorate requiring the addition of epinephrine to maintain vascular and her blood pressure. Also noted was that the patient's cardiac enzymes, and her MB fractions, as well as her troponin were noted to be significantly elevated. At that time, an echocardiogram was obtained as well as an electrocardiogram which all showed that the patient had recently suffered an acute myocardial infarction. Despite these measures, the patient continued to be septic, and her platelets began to drop initially slowly then quickly dropped below 50, then below 40. The patient also became more and more acidotic requiring ampules of bicarbonate as well as a bicarbonate drip. The patient's renal function also deteriorated, and she became oliguric. Subsequently, the patient was taken back to the operating room and underwent a exploration of her right thigh in addition to a counter incision made in the lateral aspect of her right thigh opening extra pockets of pus and abscess. After this area was cleaned and irrigated copiously, the patient was then returned back to the Surgical Intensive Care Unit in critical condition. The next day, the Renal Service was consulted for her oliguria and her persistent acidosis. At that point, a Quinton catheter in the patient's left femoral vein, and she began continuous venovenous hemofiltration (or CVVH). Over the next three to four days, the patient's clinical condition actually improved requiring less dosage of her vasopressors. The patient's acidosis was also slowing improving. Her urine output also improved slightly. The patient was then started on total parenteral nutrition, and she was also started very slowly on tube feeds. She initially did not tolerate her tube feeds due to the fact that her feeding tube was not passed post pylorically. However, after leaving the feeding tube in her stomach the patient spontaneously passed the feeding tube post pylorically and was able to tolerate some of the tube feeds that were given to her at a rate of 40 cc an hour. The whole time, the patient was receiving total parenteral nutrition, and her clinical condition appeared to improve slightly. Nevertheless, however, her platelet count continued to drop so that by [**7-6**], the patient's platelet count had dropped to 28. After multiple transfusions of platelets, the patient had likely developed anti-platelet antibody and was able to continually drop her platelets despite multiple transfusions. At this point, it was decided to not transfuse her anymore unless the platelets were washed, but unfortunately the blood bank did not have washed platelets to give to the patient. However, despite her platelets dropping to as low as 11, the patient's hematocrit remained relatively stable and did not require large amounts of blood transfusions. Nevertheless, the patient's clinical condition remained relatively stable. Her base pressors were reduced only to dopamine renally dosed. This lasted for a few days until [**7-12**] when the patient suddenly developed an episode of bradycardia and almost asystole. Although, the patient's heart rate spontaneously returned to her baseline, her blood pressure remained low requiring increasing her dopamine drip from an initial renal dose to up to 10, even as high as 15. On [**7-13**], the patient's clinical picture continued to deteriorate. She became more and more acidotic. Her blood pressure became more labile, dropping spontaneously to the 80s and requiring increases in her pressors. Her dopamine went up to 15. Despite that, the patient's blood pressure still spontaneously dropped to the 80s. Moreover, her acidosis got worse. Her lactate had increased up to 10, and her base deficit had increased to greater than 12. Despite having the patient on continuous venovenous hemofiltration, her acidosis did not improve. Meanwhile, her platelets continued to drop to as low as 9 on [**7-13**]. There was also evidence of some bleeding. Her conjunctivae, at that point, were noted to be completely red showing evidence of bleed. Moreover, she was noted to have a large ecchymotic area in her left flank, showing a possible retroperitoneal bleed as well. At this point, a Swan-Ganz catheter was refloated, giving the patient platelets as well as fresh frozen plasma. The fresh frozen plasma was given since the patient suddenly had become coagulopathic and her PT went up to as high as 26 with an INR going up a high as 5. After refloating the Swan-Ganz catheter, the patient was noted to have adequate platelets, however, she became progressively oliguric. Despite continuous venovenous hemofiltration, she became more and more acidotic. At this point, the patient's family was notified of her poor prognosis. On [**7-14**], the family spoke with the attending (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**]) and relayed their wishes to perhaps withdraw care in this patient. On [**7-14**], it was also noted that the patient's pupils had now become fixed and dilated, with a very slow and sluggish in her left pupil, indicating that the patient most likely may bled to her head, herniating her brain on the right. At this point, a Neurology consultation was obtained. Neurology attending (Dr. [**Last Name (STitle) 1693**] evaluated the patient, and it was determined that the patient very likely had herniated her brain with very minimal brain stem activity. The only function left was mostly secondary to reflex. At that point, a family meeting was held consisting of Dr. [**Last Name (STitle) 957**], Dr. [**Last Name (STitle) 1693**] (the neurologist), as well as family members (which included the patient's daughter as well as the patient's husband and other family members). This family meeting was held on [**7-14**], and the discussion regarding the patient's prognosis was made. At this point, the family wished to make the patient comfort measures only given the patient's very poor prognosis. Subsequently, on [**7-14**], at 2:30 p.m., the patient's family decided at that point to withdraw care and her vasopressors were then discontinued, and the patient expired quickly thereafter. Inquiry was made to the family regarding a postmortem; however, the patient's family refused a postmortem. The patient's family was present when the patient expired. Dr. [**Last Name (STitle) 957**] was well aware. CONDITION AT DISCHARGE: The patient expired. DISCHARGE STATUS: The patient expired. DISCHARGE DIAGNOSES: 1. Necrotizing fasciitis. 2. Perforated sigmoid colon. 3. Perforated appendix. 4. Sepsis/sepsis shock. 5. Multiorgan failure which included kidney failure and possibly liver failure as well. The patient's coagulation system also failed. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**] Dictated By:[**Name8 (MD) 20292**] MEDQUIST36 D: [**2139-7-14**] 17:49 T: [**2139-7-18**] 01:18 JOB#: [**Job Number 43182**]

[ "566", "584.9", "728.86", "340", "540.0", "038.9", "557.0", "569.83", "567.2" ]

icd9cm

[ [ [] ] ]

[ "96.04", "83.21", "45.95", "48.69", "47.09", "48.81", "83.09", "83.02", "54.0" ]

icd9pcs

[ [ [] ] ]

11841, 12315

1487, 3789

3807, 11742

1339, 1411

11757, 11820

174, 1156

1179, 1315

1428, 1460

10,906

152,809

50850+50851+59291

Discharge summary

report+report+addendum

Admission Date: [**2118-11-9**] Discharge Date: [**2118-11-16**] Date of Birth: [**2052-8-26**] Sex: M Service: CCU CHIEF COMPLAINT: Hyperkalemia. HISTORY OF PRESENT ILLNESS: This is a 66 year-old Russian, but English speaking male with a past medical history of known coronary artery disease and chronic renal insufficiency with a creatinine between 2 and 2.5 recently admitted on [**2118-11-9**] for asymptomatic hyperkalemia after increase in outpatient diuretic regimen. The patient had been discharged from [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 216**] without Lasix, which was restarted in the interim. Approximately one week he was seen by his primary care physician and Lasix was discontinued and his normal Aldactone dose was changed from one half pill to three pills q.d. On the day of admission the patient was seen again by primary care physician with laboratories showing potassium 7.4. At this time he was advised to go to the Emergency Department. Electrocardiogram showed minimally peaked T waves, left axis deviation, sinus bradycardia. However, he was asymptomatic throughout. In the Emergency Department he received 30 grams of Kayexalate, Lactulose, calcium and bicarb. He was admitted to Far Six where he received additional doses of Kayexalate and Lactulose with good results on potassium. On [**2118-11-10**] he [**Year (4 digits) 1834**] 4 liter large volume paracentesis for intractable ascites with supplemental albumin. This was repeated on [**2118-11-11**] when 3.5 liters of fluid was removed. Of note, Mr. [**Known lastname 105732**] had only moderate abdominal distention, which was much improved after paracentesis. He was without complaints or shortness of breath or other discomfort. He was transferred to the Coronary Care Unit for right heart catheterization and aggressive diuresis with pressure management. Of note, the patient's history is notable for a creatinine bump to 3 with Lasix and potassium increases with Aldactone. PAST MEDICAL HISTORY: 1. Coronary artery disease status post inferior myocardial infarction in 4/99 status post coronary artery bypass graft in 4/99 with saphenous vein graft to the left internal mammary coronary artery, diagonal with sequential graft to the obtuse marginal, and finally to the posterior descending coronary artery. Coronary artery bypass graft was complicated by cardiogenic shock requiring intra-aortic balloon pump. Postoperative course complicated by sepsis requiring bilateral below the knee amputations. He also suffers from stump infections with Pseudomonas and MRSA. 2. Hyperthyroid. 3. Chronic renal insufficiency. 4. Upper GI bleed. 5. Gout. 6. Congestive heart failure, EF of 20%. 7. Heparin induced thrombocytopenia. 8. Severe mitral regurgitation. 9. History of severe ascites, which known to be HBV and HCV negative. This is likely secondary to severe right heart failure. MEDICATIONS ON ADMISSION: 1. Allopurinol 200 mg po q.d. 2. Aldactone. 3. Levoxyl 175 micrograms po q.d. 4. Isordil 10 mg po t.i.d. 5. Zoloft 100 mg po q day. 6. Digoxin 0.125 mg po qd. 7. Hydralazine 25 mg po q.i.d. MEDICATIONS ON TRANSFER: Include all the previous medications in addition to Lasix 40 mg po q.d. and Tylenol prn. ALLERGIES: Keflex and heparin induce thrombocytopenia. SOCIAL HISTORY: Negative for tobacco or alcohol. He is a Russian immigrant. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature 98.4. Blood pressure 110/72. Pulse 72. Respiratory rate 20. Sating 95% on room air. In general, this is a moderately obese Caucasian male with a protruding abdomen lying in bed and in no acute distress. HEENT JVP is approximately 20 cm. Cardiovascular is just a quiet 3 out 6 systolic murmur best heard at the apex. Lungs anterior examination is clear. Abdomen normoactive bowel sounds, nontender, distended with fluid. Extremities clean, dry and intact, below the knee amputations bilaterally. No swelling. LABORATORIES ON TRANSFER TO THE CORONARY CARE UNIT: Chem 7 with a sodium 140, potassium 5.1, chloride 113, bicarb 18, BUN 39, creatinine 2.4, blood sugar 86, albumin 3.6, calcium 8.1, phosphate 3.7, magnesium 2.1, digoxin 0.7. Potassium on admission noted to decrease from 7.4 to 7.1 to 6 to 5.8 to 5.1 times three consecutive times. Electrocardiogram on [**11-9**] showed evidence for old inferior myocardial infarction with Qs in leads 3 and AVF. There is also evidence for first degree heart block and poor R wave progression. Repeat electrocardiogram on [**2118-11-10**] showed first degree heart block with occasional sinus nodal block with junctional escape. Echocardiogram from [**7-/2117**] showed mildly dilated left atrium, markedly dilated right atrium, left ventricular systolic function markedly decreased. There is dyskinesia in the basal anteroseptal, mid anteroseptal, basal and mid inferoseptal regions. There is also akinesis of the basal inferior, mid inferior, basal and mid inferolateral and inferior apices area. There is also evidence for 1+ aortic regurgitation, 4+ mitral regurgitation and 4+ tricuspid regurgitation. EF at that time was noted to be 20%. HOSPITAL COURSE: Mr. [**Known lastname 105732**] was transferred from the Kurlind Service to the Coronary Care Unit on [**2118-11-11**]. 1. FEN: As stated above, Mr. [**Known lastname 105732**] received aggressive treatment for asymptomatic hyperkalemia without electrocardiogram changes. Potassium since that time has been stable approximately 4.7 to 4.8. This has been followed carefully. He has received low potassium and low sodium diet without problems. 2. Cardiovascular/coronary artery disease: Mr. [**Known lastname 105732**] was not on aspirin prior to transfer despite his history of coronary artery disease. He was placed on aspirin on [**2118-11-11**] without problems. Pumps, Mr. [**Known lastname 105732**] was known to have an EF of 20% with ischemic cardiomyopathy. These symptoms are mostly right sided consisting entirely of ascites and no lower extremity edema. Liver function tests were checked on transfer to look for evidence of passive congestion. Alkaline phosphatase was noted to be elevated at 208, otherwise liver function tests within normal limits. Mr. [**Known lastname 105732**] [**Last Name (Titles) 1834**] right heart catheterization in the Coronary Care Unit showing a wedge of approximately 17 to 20, SVR of [**2057**], cardiac output around 3 with cardiac index around 2.1. CVP was known to be elevated secondary to tricuspid regurgitation. Hydralazine and Isordil were held initially and he was placed on Dobutamine for better renal perfusion. On the first night he received 40 mg of intravenous Lasix with approximately 2 liters diuresis. In the intervening days he was diuresed well with Metolazone and prn Lasix with approximately 2 liter diuresis for the next three days. On [**2118-11-13**] he was placed back on Hydralazine 25 mg po q.i.d. His cardiac output was noted to decrease from 5 to 4 and his Hydralazine was increased to 50 mg po q.i.d. The next day he received Isordil 10 mg po t.i.d. and tolerated this very well. On [**2118-11-14**], right heart catheterization was removed without further problems. Of note, wedge pressure was unable to be evaluated on [**11-13**] and 19 secondary to severe mitral regurgitation. 3. Renal: As stated above, Mr. [**Known lastname 105732**] has had trouble with diuresis in the past secondary to creatinine elevation and hyperkalemia as side effects of diuretic therapy. Renal was consulted who thought that ultrafiltration/dialysis was not an option at this time. They felt that the trade off between elevating creatinine and fluid reduction was unnecessary at this time. He was diuresed well with Lasix and Metolazone. Creatinine on [**2118-11-13**] was 2.5 up from 2.4. On [**2118-11-14**] his BUN had bumped from 45 to 55 showing some evidence for intravascular depletion. Finally on [**2118-11-15**] creatinine was shown to be 2.6. At that time dry weight was noted to be 162.6 pounds with prostheses in place. 4. Gastrointestinal: As stated above Mr. [**Known lastname 105732**] received two large volume paracenteses first on [**11-10**] and then again on [**2118-11-11**]. He continued to have a distended belly and ultrasound was used to evaluate left over fluid. Of note, there was no fluid in the right lower quadrant or left lower quadrant. There was still a mild to moderate degree of fluid in the right upper quadrant next to the liver. It was decided at that time not to remove any further fluid for fear of injury to the liver. 5. Pulmonary: On the day of transfer Mr. [**Known lastname 105732**] [**Last Name (Titles) 1834**] chest x-ray showing small right pleural effusion and possible evidence of consolidation in that area. However, because he was asymptomatic and afebrile no further treatment was undergone. 6. Rheumatology: Mr. [**Known lastname 105732**] has a history of gout. Allopurinol was continued. 7. Endocrine: TSH at admission was 2.0. He was continued on his normal dose of Levoxyl without problems. 8. Prophylaxis: Mr. [**Known lastname 105732**] was started on Protonix secondary to heparin induced thrombocytopenia. He was not a candidate for heparin. Secondary to his bilateral below the knee amputations he was not a candidate for pneumoboots. DISPOSITION: Mr. [**Known lastname 105732**] was full code. He will be discharged home without further services. He was seen by physical therapy who thought that he was at baseline. DISCHARGE MEDICATIONS: 1. Allopurinol 200 mg po q.d. 2. Digoxin 0.125 mg po q.d. 3. Levoxyl 0.175 mg po q.d. 4. Zoloft 100 mg po q.d. 5. Hydralazine 50 mg po q.i.d. 6. Isordil 10 mg po t.i.d. 7. Lasix 20 mg po q.d. 8. Metolazone 2.5 mg po q.d. FOLLOW UP: He will follow up with Dr. [**Last Name (STitle) **] his cardiologist at a later time. Of note, Mr. [**Known lastname 105732**] had three episodes of asymptomatic nonsustained ventricular tachycardia including a 6 beat, 10 beat and 11 beat run. EP will be consulted at a later time. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Name8 (MD) 8073**] MEDQUIST36 D: [**2118-11-15**] 10:54 T: [**2118-11-18**] 09:47 JOB#: [**Job Number 105733**] Admission Date: [**2118-11-9**] Discharge Date: [**2118-11-16**] Date of Birth: [**2052-8-26**] Sex: M Service: CCU CHIEF COMPLAINT: Admission for hyperkalemia and transferred to the Coronary Care Unit for fluid overload. HISTORY OF PRESENT ILLNESS: This is a 66-year-old Russian male with a past medical history for known coronary artery disease and chronic renal insufficiency with a creatinine between 2 and 2.5, recently admitted for [**11-9**] for asymptomatic hyperkalemia after increase in Aldactone as an outpatient. The patient had been admitted to the hospital in [**Month (only) 216**] on Lasix but had creatinine bumps and therefore was discharged without Lasix. During the interim time he was restarted on Lasix, potassium, and spironolactone. Approximately one week prior to admission he was seen by his primary care physician who discontinued Lasix and increased Aldactone from one-half pill to three pills. On the day of admission he was seen by his primary care physician with laboratories showing potassium of 7.4, but was asymptomatic. At the time he decided to go to the Emergency Department. Electrocardiogram showed minimally peaked T waves, left axis deviation, and sinus bradycardia. He was given 30 g of Kayexalate, lactulose, calcium, and bicarbonate in the Emergency Department. In the intervening day, he received additional doses of Kayexalate and lactulose times three with potassium decreasing to 5.1. On [**2118-11-10**], he [**Year (4 digits) 1834**] 4-liter large volume paracentesis with supplemental albumin. On the day of transfer (on [**11-11**]) another 3.5 liters of fluid was removed. Mr. [**Known lastname 105732**] has a history of severe ascites which tested hepatitis B and hepatitis C negative. It was thought to be secondary to severe right heart failure. He was without complaints of shortness of breath or other discomforts. Prior to large-volume paracentesis he did have some mild abdominal distention which is much improved. He is being transferred to the Coronary Care Unit for right heart catheterization and aggressive diuresis and blood pressure management. Of note, the patient's history is significant for creatinine bumps to 3 with diuresis with Lasix and increased potassium with Aldactone. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post inferior myocardial infarction in [**2116-3-26**]. Status post coronary artery bypass graft in [**2116-3-26**] with saphenous vein graft to left internal mammary artery, saphenous vein graft to diagonal with sequential graft to the first obtuse marginal, and saphenous vein graft to the posterior descending artery. Operation was complicated by cardiogenic shock requiring intra-aortic balloon pump. Postoperative course complicated by sepsis requiring bilateral below-knee amputations. He suffered stump infections with pseudomonas and methicillin-resistant Staphylococcus aureus. 2. Hypothyroidism. 3. Chronic renal insufficiency with creatinine between 2 and 2.5. 4. Upper gastrointestinal bleed. 5. Gout. 6. Congestive heart failure with an ejection fraction of 20%. 7. Heparin-induced thrombocytopenia. 8. Severe mitral regurgitation. 9. History of ascites. MEDICATIONS ON ADMISSION: 1. Allopurinol 200 mg p.o. q.d. 2. Aldactone. 3. Levoxyl 175 mcg p.o. q.d. 4. Isordil 10 mg p.o. t.i.d. 5. Zoloft 100 mg p.o. q.d. 6. Digoxin 0.125 mg p.o. q.d. 7. Hydralazine 25 mg p.o. q.i.d. MEDICATIONS ON TRANSFER: Medications on transfer to the Coronary Care Unit included all of the above in addition to Lasix 40 mg p.o. b.i.d. and Tylenol p.r.n. ALLERGIES: Allergy to KEFLEX and HEPARIN (heparin-induced thrombocytopenia). SOCIAL HISTORY: The patient denies tobacco or alcohol use. His is a Russian immigrant. FAMILY HISTORY: Family history is noncontributory. PHYSICAL EXAMINATION ON PRESENTATION: On admission temperature was 98.4, blood pressure 110/72, pulse 72, respiratory rate 20, satting 95% on room air. In general, he was a moderately obese male with protruding abdomen, lying in bed, in no acute distress. HEENT revealed jugular venous distention elevated beyond the angle of the jaw of approximately 20 cm. Cardiovascular revealed there was a [**3-1**] quiet systolic murmur at the apex. Lungs on anterior examination were clear to auscultation. The abdomen had normal active bowel sounds, nontender, distended with fluid. No masses. Extremities were clean, dry, and intact. Bilateral below-knee amputations, no swelling. LABORATORY DATA ON PRESENTATION: Laboratories on transfer, Chem-7 showed the following: Sodium 140, potassium 5.1, chloride 113, bicarbonate 18, BUN 39, creatinine 2.4, sugar 86. Albumin 2.6, calcium 8.1, phosphate 3.7, magnesium 2.1. Digoxin level of 0.7. Of note, potassium had decreased from 7.4 to 7.1 to 6 to 5.8 to 5.1 times three consecutive times. RADIOLOGY/IMAGING: Electrocardiogram on [**11-9**] showed evidence for old inferior myocardial infarction with Q waves in leads III and aVF; first-degree heart block, poor R wave progression. On [**11-10**], there was evidence for first-degree heart block with occasional sinus nodal block with a junctional escape. Echocardiogram from [**2117-7-27**] showed mildly dilated left atrium, markedly dilated right atrium, left ventricular systolic function markedly decreased with dyskinesis of the basal anteroseptal, middle anteroseptal, and basal and middle inferoseptal regions. There was also akinesis of the basal inferior, middle inferior, basal and middle inferolateral, and inferoapical regions. There was also evidence for 1+ aortic regurgitation, 4+ mitral regurgitation, and 4+ tricuspid regurgitation. Ejection fraction at that time was 20%. HOSPITAL COURSE: 1. FLUIDS/ELECTROLYTES/NUTRITION: As stated above, Mr. [**Known lastname 105734**] potassium elevation was likely secondary to Aldactone. In the future he should no longer receive Aldactone or ACE inhibitors, much less any medication that would elevate potassium, as Mr. [**Known lastname 105732**] seems particularly sensitive to these medications. He was placed on a low-sodium/low-potassium diet. 2. CARDIOVASCULAR: (a) Coronary artery disease: Mr. [**Known lastname 105732**] has a history of coronary artery disease but was not on aspirin on admission. He was placed on aspirin. (b) Pump: Mr. [**Known lastname 105732**] had an ejection fraction of 20% and ischemic cardiomyopathy. He has signs of right-sided failure without symptoms except for his tense ascites. Liver function tests were checked for possible passive congestion but were within normal limits. They were only significant for alkaline phosphatase of around 200. On transfer to the Coronary Care Unit, he [**Known lastname 1834**] right internal jugular introduction with Swan placement soon after. Initial Swan numbers were the following: INCOMPLETE DICTATION [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Name8 (MD) 8073**] MEDQUIST36 D: [**2118-11-15**] 10:37 T: [**2118-11-18**] 09:34 JOB#: [**Job Number 105735**] Name: [**Known lastname 17208**],[**Known firstname 17209**] Unit No: [**Unit Number 17210**] Admission Date: [**2118-11-9**] Discharge Date: [**2118-11-18**] Date of Birth: [**2052-8-26**] Sex: M Service: CCU ADDENDUM: On the previous day of discharge, [**2118-11-15**], Mr. [**Known lastname **] felt not back to baseline and requested one day further of hospitalization. The following day, his rhythm which had previously been first degree heart block with occasional junctional escape rhythm, changed to paroxysmal atrial tachycardia with variable block. He was asymptomatic. Ventricular response rate ranged from 40 while sleeping to 70s-80s. Serial electrocardiograms were taken. The following day Mr. [**Known lastname **] had converted to the previous first degree heart block with occasional junctional escape rhythm; however, that day, creatinine was found to be 3.3, BUN 83, with dry weight at goal of 163 pounds with prosthetic legs. He was kept one day further for monitoring. Repeat creatinine at that time was 3.0 with BUN 85. On the day of discharge, [**2118-11-18**], AM BUN was 80 with creatinine of 3.2. He was feeling well. The previous day at 04:00 PM he had converted back into the paroxysmal atrial tachycardia with a variable block, sometimes [**12-28**], sometimes [**12-29**]. Amiodarone was started on the first day of this rhythm, on [**2118-11-16**] with the following load: 400 mg po tid times five days which will then be changed to 400 mg po bid times two weeks, which will then be changed to 400 mg po q day. When BUN and creatinine started to indicate overdiuresis, further diuretics were held. He will be discharged on the following diuretic regimen: Lasix 20 mg po q day. Metolazone will be held until seen by Dr. [**Last Name (STitle) 1426**] in one week. Of note, Digoxin was also discontinued on [**2118-11-16**] secondary to possible Digoxin toxicity, especially with these passive pneumonic rhythms of first degree heart block, junctional escape rhythm, and paroxysmal atrial tachycardia with variable block. DISCHARGE MEDICATIONS: 1) Levoxyl 0.175 mg po q day, 2) Zoloft 100 mg po q day, 3) allopurinol 200 mg po q day, 4) Lasix 20 mg po q day, 5) aspirin 325 mg po q day, 6) Hydralazine 25 mg po qid, 7) Isordil 10 mg po tid, 8) amiodarone 400 mg po tid for an additional three days, 400 mg po bid times two weeks, and then change to 400 mg po q day. Of note, Mr. [**Known lastname **] will follow up with Nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 17211**] in one week. Cardiology Clinic will contact Mr. [**Known lastname **] with the exact time and date. He has been instructed to check his daily weights with a goal of 163 pounds. He was also outfitted with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor for further monitoring during the load of amiodarone and also the most recent arrhythmias. Electrophysiology study for non-sustained ventricular tachycardia will be done at a later time. Furthermore, nasal swabs and perirectal swabs were sent to help change Mr. [**Known lastname **] to non-MRSA precautions; however, nasal and rectal swabs showed continual methicillin - resistant Staphylococcus aureus carriage. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1729**], M.D. [**MD Number(1) 6268**] Dictated By:[**Name8 (MD) 1037**] MEDQUIST36 D: [**2118-11-18**] 13:20 T: [**2118-11-21**] 10:36 JOB#: [**Job Number 17212**]

[ "584.9", "428.0", "412", "414.01", "424.0", "789.5", "427.89", "276.7", "244.9" ]

icd9cm

[ [ [] ] ]

[ "54.91" ]

icd9pcs

[ [ [] ] ]

14281, 16219

19769, 21187

13732, 13934

16237, 19745

9925, 10614

10632, 10722

10751, 12768

3504, 5239

13960, 14174

12790, 13706

14191, 14263

28,595

136,967

2837

Discharge summary

report

Admission Date: [**2165-8-4**] Discharge Date: [**2165-8-17**] Date of Birth: [**2107-10-29**] Sex: M Service: MEDICINE Allergies: Bactrim / Dapsone Attending:[**First Name3 (LF) 1674**] Chief Complaint: suicide attempt Major Surgical or Invasive Procedure: intubation biopsy of skin lesion History of Present Illness: 57 y.o. male with history of HIV/AIDS, CD4 of 270, no record of viral load, who was found down and unresponsive at home by his roommate, next to an empty pill bottle. Patient had reportedly contact[**Name (NI) **] his health care proxy recently via e-mail saying that he "wasn't going to be around anymore" and expressing a desire to give up the keys to his locker. Of note, patient was hospitalized in [**2162-9-27**] for a suicide attempt with 8 pills of Trazodone, 4 pills of Compazine, and 20+ pills of Wellbutrin in addition to [**1-27**] bottle of wine. At this time he was diagnosed with major depression and discharged to follow-up with therapy. Upon arrival to the ED, vitals were T - 100.6, HR - 112, BP - 143/91, RR - 13, O2 - 100%. He was awake, but had slurred speech and no gag reflex. He was thus intubated for protection of his airway. Tox screen revealed elevated salicylate, acetaminophen and tricyclic antidepressant levels. ABG also showed anion gap metabolic acidosis. He was given NAC, charcoal and Naloxone. CXR was remarkable for successful placement of ETT and ?infiltrates for which he received Pentamidine for possible PCP given his HIV status. He also received Levoquin/Vancomycin for UA suggestive of UTI. CT head showed no gross abnormalities. Patient was admitted to the [**Hospital Unit Name 153**] for further management. Past Medical History: PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES, OR OTHER NEUROLOGIC ILLNESS): - HIV + Dx'd [**2153**], when had PCP x 2; had been compliant with HAART until 3 months ago when self d/c'd (CD4 90, VL 130K [**2164-1-31**]) - h/o diverticulitis - h/o pna x 2 (? PCP) - s/p CCY - s/p Appy - h/o shingles - h/o colonic polyps - depression - bronchiectasis Social History: Pt states that he drinks socially ("about 4 glasses of wine a month") and denies recent or remote drug use (except "I took a puff of marijuana in [**2129**]"). Pt has remote tobacco Hx (quit [**2137**], 15 year hx). He was in the military (Navy) from [**2127**]-72 active duty, reserves [**2130**]-75 (Hospital Corpsman, 2nd class), honorable d/c. He was a member of the [**Hospital1 13820**] Order from [**2135**]-80 and currently identifies as Catholic. No legal difficulties. Pt was in long- term relationship w/ partner for nine years, which ended in [**2156**] after both men were dx'd HIV+ in [**2153**]. No partner currently. In [**2161**], pt worked as a paralegal in a high-tech company, then on disability for breakdown. Now on SS. Family History: brother with MI in 50s FAMILY PSYCHIATRIC HISTORY: Pt denies family psychiatric hx. Stepfather with alcohol dependence. Physical Exam: Vitals: T- 98.4, BP - 131/85, HR - 109, RR - 14, O2 - 100% AC - 600/14/.[**3-30**] General: Sedated, intubated, but responding to painful stimuli HEENT: NC/AT; pupils equally round, slowly reactive to light; slightly dry mucus membranes Neck: Supple, nl LAD Chest/CV: S1, S2 nl, no m/r/g appreciated Lungs: CTAB, anteriorly Abd: Soft, non-distended with decreased bowel sounds, no organomegaly Ext: No c/c/e Skin: No lesions Pertinent Results: Admit Labs: [**2165-8-4**] 05:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-NEG [**2165-8-4**] 05:00PM PLT COUNT-204 [**2165-8-4**] 05:00PM NEUTS-77.0* LYMPHS-19.4 MONOS-2.8 EOS-0.2 BASOS-0.6 [**2165-8-4**] 05:00PM WBC-7.6 RBC-4.64 HGB-16.2 HCT-45.3 MCV-98 MCH-34.9* MCHC-35.8* RDW-13.9 [**2165-8-4**] 05:00PM ASA-9 ETHANOL-NEG ACETMNPHN-16.4 bnzodzpn-NEG barbitrt-NEG tricyclic-POS [**2165-8-4**] 05:00PM OSMOLAL-291 [**2165-8-4**] 05:00PM ALBUMIN-4.3 CALCIUM-8.5 PHOSPHATE-6.2*# MAGNESIUM-2.1 [**2165-8-4**] 05:00PM CK-MB-7 [**2165-8-4**] 05:00PM LIPASE-35 [**2165-8-4**] 05:00PM ALT(SGPT)-82* AST(SGOT)-76* CK(CPK)-1575* ALK PHOS-72 AMYLASE-226* TOT BILI-0.4 [**2165-8-4**] 05:00PM GLUCOSE-118* UREA N-29* CREAT-2.7*# SODIUM-135 POTASSIUM-5.1 CHLORIDE-100 TOTAL CO2-15* ANION GAP-25* [**2165-8-4**] 05:40PM LACTATE-1.9 [**2165-8-4**] 11:47PM ASA-11 Other Labs: [**2165-8-13**] 06:40AM BLOOD WBC-4.0 Lymph-32 Abs [**Last Name (un) **]-1280 CD3%-93 Abs CD3-1190 CD4%-9 Abs CD4-116* CD8%-77 Abs CD8-990* CD4/CD8-0.1* [**2165-8-4**] 05:00PM BLOOD ASA-9 Ethanol-NEG Acetmnp-16.4 Bnzodzp-NEG Barbitr-NEG Tricycl-POS [**2165-8-4**] 05:40PM BLOOD Type-ART Rates-14/ Tidal V-500 PEEP-5 FiO2-100 pO2-279* pCO2-38 pH-7.29* calTCO2-19* Base XS--7 AADO2-416 REQ O2-70 -ASSIST/CON Intubat-INTUBATED Comment-LACTATE AD [**2165-8-5**] 07:25AM BLOOD pO2-109* pCO2-34* pH-7.36 calTCO2-20* Base XS--5 [**2165-8-8**] 06:00AM BLOOD LD(LDH)-300* CK(CPK)-4066* [**2165-8-5**] 11:17PM URINE Eos-NEGATIVE [**2165-8-5**] 03:07PM URINE Osmolal-429 Micro Data: Blood Cx ([**8-6**]) - No growth x 4 sets Urine Cx ([**8-6**]) - negative Sputum ([**8-6**]) - >25 polys. Heavy growth oral flora Tissue ([**8-8**]) - Negative gram stain/culture Urine ([**8-9**]) - negative Blood ([**8-9**]) - negative Sputum ([**8-9**], [**8-10**], [**8-12**]) - DFA for PCP negative Stool ([**8-12**]) - C. Diff negative. O&P negative. Crypto/Giardia negative Stool ([**8-13**]) - O&P negative Stool ([**8-14**]) - O&P pending Blood ([**8-14**]) - NGTD (final pending) Stool ([**8-15**]) - C. Diff negative Stool ([**8-16**]) - C. Diff pending Pathology: Skin, right hip ([**8-8**]): Subepidermal blistering disorder with marked epidermal necrosis and focal necrosis of eccrine units, consistent with pressure induced blister (coma blister). (See note). Note: The lack of a more prominent inflammatory component speaks against infection. No viral changes are observed. Initial and level sections examined. This case was discussed with Dr. [**First Name (STitle) **] on [**2165-8-12**]. Studies: CT of chest on [**8-9**]: 1. Multifocal bronchopneumonia, involving posterior segment of right upper lobe and superior segment of right lower lobe to greater degree than the lung bases. Distribution and rapid onset favors an aspiration pneumonia. 2. Probable fatty infiltration of the liver. 3. Small dependent pleural effusions and very small pericardial effusion. CHEST (PORTABLE AP) [**2165-8-7**] 7:17 AM Comparison is made with the prior study performed a day earlier. Cardiac size is normal. Persistent and possibly increase in left lower lobe atelectasis. Right lower lobe atelectasis has improved. Faint illdefined opacity in the right upper lobe is more conspicuous in the current examination. There are no sizable pleural effusions or pneumothorax. IMPRESSION: Right upper lobe illdefined opacities consistent with infectious process given the clinical history. CHEST (PORTABLE AP) [**2165-8-4**] 5:24 PM FINDINGS: Single bedside AP examination labeled "supine at 17:25" is compared with two views dated [**2164-2-20**]. The tip of the ET tube lies some 2.9 cm proximal to the carina and an NG tube extends below the diaphragm with side- hole likely in the gastric fundus and tip beyond the film. The lung volumes are relatively low with patchy bibasilar minor atelectasis, but no focal consolidation. The cardiomediastinal silhouette and pulmonary vessels are likely within normal limits, with no supine evidence of pleural effusion. The patient is apparently status post cholecystectomy. C diff toxin negative x 3 Brief Hospital Course: 1) Fevers/Pneumonia Patient developed persistent fevers over the first 24 hour period of admission. He was extubated on HD#2 but developed an increasing cough and sputum production. Sputum sample on HD#3 showed 3+ gpc and 2+ gnrs which subsequently grew out only respiratory flora. Urine sample showed large blood and RBCs. The patient was initially placed on levofloxacin and flagyl for presumed aspiration pneumonitis vs. pneumonia and coverage for potential urinary sources. However, on [**8-9**] the patient had persistent temperature spikes with a productive cough and was changed over to vancomycin and zosyn for possible hospital acquired PNA given his previous intubation. A CT scan was obtained which showed multifocal bronchopneumonia, involving posterior segment of right upper lobe and the superior segment of the right lower lobe. Repeat sputum samples were obtained as well as sputum for pneumocystis. Although specimens were somewhat suboptimal for the sputum cx, the DFA for PCP was negative [**Name Initial (PRE) **] 3 samples. The patient improved clinically and was changed to Augmentin on [**8-13**]. Three days prior to transfer patient had an isolated temp of 100.6. Other than persistent cough, his only other complaint was soft stools. Stool for C. Diff was negative for 3 samples. 2) Overdose Patient's tox screen was significant for salicylates, acetaminophen and tricyclic antidepressants. He is now s/p NAC, charcoal lavage and Naloxone. He was seen by psychiatry on morning of admission who recommend inpatient psychiatric hospitalization once medically stable. Patient was placed under section 12 and could not leave the hospital. He was watched by a sitter. He remained cooperative throughout the remainder of his hospitalization. 3) Acute Renal Failure This occurred in the setting of hypovolemia and likely rhabdomyolysis. Patient was found to have an elevated CK with normal MB and trp that was felt to be secondary to being found down as well as his brief paralytic exposure with intubation. His renal function improved with IVF and his creatinine returned to baseline. His CK continued to trend down and was 406 on last check. 4) HIV/AIDS CD4 was 270, HAART regimen stopped by patient for over two weeks prior to the suicide attempt. Patient had been on a salvage regimen prior to discharge in discussion with the [**Hospital 778**] Clinic. His regimen included MK0518 1 tab [**Hospital1 **], TMC25 2tabs [**Hospital1 **], Truvada 1 tab qd and Norvir 1 tab [**Hospital1 **]. These were held of admission until the patient's proxy could bring the experimental drugs (non-formulary) into the hospital. However, in discussions with the ID consult team, it was decided to defer on restarting HAART until the patient is seen as an outpatient. He was restarted on PCP prophylaxis with Atovaquone. He wasn't placed back on Bactrim due to concern for a possible allergic reaction (he had previously been desensitized to this, but several weeks had elapsed since his last dose). Medications on Admission: Medications (per OMR in [**1-/2164**]): Ambien 5 mg TABS PO QHS Lorazepam 0.5 mg tab PO QD Wellbutrin SR 150 mg PO QD Flovent 110 2 puffs [**Hospital1 **] Atazanavir 300 mg PO QD Norvir 100 mg QD Combivir 1 tab PO BID Viread 300 mg 1 tab PO QD Atovaquone 750 mg PO BID Azithromycin 1200 mg PO QTuesday. Discharge Medications: 1. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-27**] Sprays Nasal QID (4 times a day) as needed. 2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 4. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO DAILY (Daily). 5. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days: Last dose on [**8-18**]. 6. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for cough. Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4, [**Hospital Ward Name **] [**Hospital1 18**] Discharge Diagnosis: Primary: Suicide attempt with ingestion Aspiration pneumonia Acute renal failure Secondary: HIV/AIDS (h/o PCP) Depression s/p cholecystectomy s/p appendectomy h/o diverticulitis Discharge Condition: Temp - 98.9. Vitals otherwise stable. Discharge Instructions: You are being discharged to a psychiatric facility for further care after your suicide attempt. You will need to follow up with your PCP regarding restarting your HAART regimen. You are being treated for aspiration pneumonia. While in the hospital you were given Vancomycin and Zosyn and were changed to Augmentin on [**8-13**]. You should complete a full 14-day course of this medication (last dose on [**8-18**]). Followup Instructions: You will need to follow up with your psychiatrist upon discharge from the pyschiatric facility. You will also need to follow up with [**First Name4 (NamePattern1) 3788**] [**Last Name (NamePattern1) 13821**], NP or Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2392**] from the [**Hospital 778**] Health Center ([**Telephone/Fax (1) 2393**]), 1 week after discharge from the psychiatric facility. You will need to have the sutures removed from your right hip biopsy site in [**8-21**]. This can be arranged with the dermatology clinic ([**Telephone/Fax (1) 1971**]) or if still at [**Hospital1 18**] by paging the on call dermatology resident. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2165-8-17**]

[ "728.88", "965.4", "969.1", "V12.72", "E950.0", "311", "707.03", "042", "980.0", "969.0", "276.52", "E950.3", "709.8", "507.0", "787.91", "276.2", "584.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "86.11" ]

icd9pcs

[ [ [] ] ]

11747, 11838

7724, 10770

294, 329

12060, 12101

3462, 4413

12569, 13391

2879, 3001

11124, 11724

11859, 12039

10796, 11101

12125, 12546

3016, 3443

239, 256

357, 1715

1737, 2104

2120, 2863

4424, 7701

31,705

122,950

10572

Discharge summary

report

Admission Date: [**2159-7-22**] Discharge Date: [**2159-7-23**] Service: MEDICINE Allergies: Penicillins / Ivp Dye, Iodine Containing Attending:[**First Name3 (LF) 99**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: ERCP History of Present Illness: 84 y/o male with MMP including CAD s/p 2VCABG, T2DM, HTN, and hyperlipidemia now with new pancreatic mass along with biliary obstruction. He was scheduled to have a pancreatic biopsy and ERCP with stent placement on [**2159-7-23**] at [**Hospital1 18**]. However, the pt's family brought him to the ED with concern for a change in his mental status. He was recently admitted at the NEBH from [**2159-7-14**] to [**2159-7-17**] with several weeks of abdominal pain, N/V, poor PO intake, and wt loss and was found to have a large pancreatic mass along with lesions in his liver and lungs suspicious for metastatic disease. After discussion with the ERCP team, he was admitted to the MICU for ERCP and stent placement. . ED Vitals: T 99 HR 99 BP 140/43 RR 16 99%RA. In the ED, he was given Zofran for nausea. He was also given levo/flagyl for concern for an abdominal source of infection. . ROS: Positive for recent wt loss, N/V, poor PO intake, and abdominal pain. No CP or SOB. No orthopnea, PND, or LE edema. Past Medical History: - HTN - CRI (Creat 1.7) - PVD - diabetes - SFA stenosis- claudication - Hypercholest - AS - Anemia - CHF class III. - COPD Social History: SH: Former heavy smoker (>60pyh). lives at home with wife. retired [**Name2 (NI) **]. Family History: nc Physical Exam: per admitting resident T 98.2 HR 115 BP 123/56 RR 30 98%RA General: 84M in NAD. HEENT: NC/AT. MM dry. OP clear. Neck: No JVD. CV: S1, S2 with Grade III/VI systolic ejection murmur. No r/g. Pulm: CTAB without any wheezes or crackles. Abd: Soft, diffusely tender, distended, normoactive BS. Ext: Trace pitting edema B/L. Neuro: A/O x 3 with prompting. Skin: Diffuse jaundice. . Pertinent Results: [**2159-7-22**] 01:01PM PT-19.2* PTT-38.0* INR(PT)-1.8* [**2159-7-22**] 11:40AM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.013 [**2159-7-22**] 11:40AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-1 PH-6.5 LEUK-NEG [**2159-7-22**] 11:40AM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2 TRANS EPI-0-2 [**2159-7-22**] 11:40AM URINE HYALINE-0-2 [**2159-7-22**] 04:50AM URINE HOURS-RANDOM [**2159-7-22**] 04:50AM URINE GR HOLD-HOLD [**2159-7-22**] 04:50AM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.013 [**2159-7-22**] 04:50AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-1 PH-6.5 LEUK-NEG [**2159-7-22**] 04:50AM URINE RBC-1 WBC-[**1-29**] BACTERIA-MOD YEAST-NONE EPI-1 RENAL EPI-[**1-29**] [**2159-7-22**] 04:50AM URINE GRANULAR-0-2 HYALINE-0-2 [**2159-7-22**] 03:30AM GLUCOSE-265* UREA N-66* CREAT-1.8* SODIUM-135 POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-22 ANION GAP-18 [**2159-7-22**] 03:30AM estGFR-Using this [**2159-7-22**] 03:30AM ALT(SGPT)-223* AST(SGOT)-311* ALK PHOS-1037* AMYLASE-33 TOT BILI-18.7* DIR BILI-15.8* INDIR BIL-2.9 [**2159-7-22**] 03:30AM LIPASE-56 [**2159-7-22**] 03:30AM TOT PROT-6.1* ALBUMIN-3.1* GLOBULIN-3.0 CALCIUM-9.2 PHOSPHATE-3.8 MAGNESIUM-2.3 [**2159-7-22**] 03:30AM AMMONIA-57* [**2159-7-22**] 03:30AM WBC-23.9*# RBC-3.52* HGB-11.4* HCT-33.0* MCV-94 MCH-32.5* MCHC-34.6 RDW-17.7* [**2159-7-22**] 03:30AM NEUTS-91.2* LYMPHS-4.4* MONOS-3.9 EOS-0.4 BASOS-0.1 [**2159-7-22**] 03:30AM PLT COUNT-273 Brief Hospital Course: Patient underwent ERCP with stenting for biliary obstruction due to pancreatic mass with liver and lung lesions, most likely reflecting metastases of pancreatic neoplasm. Biopsy was not obtained. On day after ERCP patient developed intermittent ventricular tachycardia with hypotension. An emergent femoral line was placed for access. Patient was started on pressors for hypotension, he was mentating and complaining of pain which was treated with IV morphine. Family was called and came to the hospital for meeting. Patient clearly stated that he did not wish to be shocked or intubated. Supportive therapy was continued. On [**2159-7-23**] at 1.45 PM he went into asystole. Per patient's and family wish no resuscitation was attempted and the patient expired. Family declined post-mortem exam. Medications on Admission: Metoprolol 25 mg PO BID Glipizide 5 mg PO daily Terazosin 5 mg PO QHS Lasix 40 mg PO daily Lisinopril 5 mg PO daily Lovastatin 40 mg PO daily Tegretol 100 mg PO BID Metformin 500 mg PO BID Zantac 150 mg PO daily Prilosec 20 mg PO daily Vicodin 5/500 PRN 1 TAB daily Nasonex 2 sprays IN [**Hospital1 **] Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: cardiac arrest pancreatic tumor Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a Completed by:[**2159-7-24**]

[ "428.0", "272.4", "250.00", "225.2", "576.2", "496", "197.7", "424.1", "197.0", "157.0", "427.1", "585.9", "584.9", "443.9", "403.90", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "51.87", "00.17", "38.93" ]

icd9pcs

[ [ [] ] ]

4765, 4774

3587, 4384

268, 274

4849, 4858

1993, 3564

4910, 4944

1578, 1582

4737, 4742

4795, 4828

4410, 4714

4882, 4887

1597, 1974

207, 230

302, 1312

1334, 1458

1474, 1562

64,652

162,378

35333

Discharge summary

report

Admission Date: [**2123-3-3**] Discharge Date: [**2123-3-10**] Date of Birth: [**2044-2-7**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: ICH Major Surgical or Invasive Procedure: Intubation History of Present Illness: 79 year old woman with PMH significant for hypertension and hypothyroidism found down in her apartment and transferred from [**First Name8 (NamePattern2) **] [**Hospital **] [**Hospital 80560**] Hosp with a left frontal intraparenchymal hemorrhage. This note is based on NRsurg note (pt is unresponsive now and no family member is available). On Saturday morning, she called her son and left 10 messages in a row about the same topic. On Sunday, she talked to her other son, and said she had difficulty remembering how to make a cup of tea. She was last heard "normal" on the telephone on Sunday or Monday. Today, her son called her mother but she did not answer. Her other son went to the patient's house and could hear her yelling that she had fallen and was on the floor. The son called the fire department to open the door. She was found on the floor between the kitchen and the bedroom, and was taken to an OSH. It is unclear how long she was down. Baseline: The patient lives alone. She has had progressively decline over the past year, and has not been bathing or taking care of her hair. Her son shops for her food. Over the past week, her family has been trying to get her in an [**Hospital3 **]. She has previously turned away VNA services. At [**Location (un) **] [**Location (un) 1459**], her neurological exam was "alert and oriented x2, 5/5 strength in all 4 extremities, motor function is equal and symmetric." Blood pressure was 142/80 on admission. She was given NS 1000 mL IV and Fosphenytoin 1 gm IV x1, and transferred to [**Hospital1 18**]. Labs showed Cr 0.7, Na 130, ALT 39, AST 102, alk phos 147, TSH 3.74, TropT 0.02. Head CT showed moderate sized left frontal intraparenchymal hemorrhage, no midline shift or herniation. CT C-spine showed no fractures or dislocations of the cervical spine, mild cervical spondylosis without spinal canal stenosis. At the [**Hospital1 18**], the C-collar was replaced. She was given Tylenol 1 gm PR x1. Once at [**Hospital1 18**], she received a labetalol drip (bp 220/ 102) and SaO2 92% 2L. She then required EET (with etomidate and pancuromium) and was placed on propofol (got a bolus of 40) and became hypotensive: SBP 50s. Sherequired ressucitation with 1.5 l NS. Her exam worsened and she became more unresponsive (as compared to Neurosurg note). I ordered a CT CNS STAT that took 2 hours to get done given her low SBP. She remained with a normal temperature all this time. Past Medical History: Hypertension Hypothyroidism dementia Social History: smoked at least 1 ppd for the past 60+ years. Denies EtOH use. Family History: Her daughter died of non-[**Name (NI) 29512**] lymphoma, her son has hypertension. Physical Exam: VS: temp 99.8, bp 220/ 102, HR 92, RR 28, SaO2 92% 2L. required EET (with etomidate and pancuromium). Gen: Lying in bed, unresponsive. HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: Soft, nontender, non-distended. No masses or megalies. Percussion within normal limits. +BS. Ext: no edema, no DVT data. Pulses ++ and symmetric. Bruised arms. Neurologic examination: off midazolam drip for 15 minutes No meningismus. No photophobia. MS: Responsive to painful stimuli. CN: Brain stem reflexes : Corneals - bl. Pupils 2 to 1 bl and symmetrically. Dolls eyes -. No gaze deviation. No bobbing or Robbing. No nystagmus. Gag +. Motor: She withdraws to pain in 4 limbs. Pertinent Results: [**2123-3-10**] 06:11AM BLOOD WBC-12.0* RBC-3.49* Hgb-11.2* Hct-31.8* MCV-91 MCH-32.2* MCHC-35.3* RDW-14.0 Plt Ct-464* [**2123-3-2**] 05:10PM BLOOD WBC-16.8* RBC-4.06* Hgb-13.1 Hct-36.8 MCV-91 MCH-32.3* MCHC-35.6* RDW-13.9 Plt Ct-480* [**2123-3-2**] 05:10PM BLOOD Neuts-88.0* Lymphs-6.7* Monos-4.8 Eos-0.2 Baso-0.2 [**2123-3-2**] 05:10PM BLOOD PT-13.1 PTT-28.9 INR(PT)-1.1 [**2123-3-10**] 06:11AM BLOOD Glucose-100 UreaN-8 Creat-0.5 Na-134 K-3.3 Cl-94* HCO3-26 AnGap-17 [**2123-3-2**] 05:10PM BLOOD Glucose-150* UreaN-16 Creat-0.8 Na-130* K-4.0 Cl-90* HCO3-29 AnGap-15 [**2123-3-3**] 07:40AM BLOOD ALT-38 AST-99* LD(LDH)-431* CK(CPK)-2115* AlkPhos-112 TotBili-0.4 [**2123-3-3**] 06:56AM BLOOD ALT-37 AST-101* LD(LDH)-417* CK(CPK)-2209* AlkPhos-116 TotBili-0.6 [**2123-3-3**] 07:40AM BLOOD CK-MB-19* MB Indx-0.9 cTropnT-<0.01 [**2123-3-3**] 06:56AM BLOOD CK-MB-21* MB Indx-1.0 cTropnT-<0.01 [**2123-3-2**] 05:10PM BLOOD CK-MB-40* MB Indx-1.5 cTropnT-<0.01 [**2123-3-10**] 06:11AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.6 [**2123-3-9**] 07:12AM BLOOD Calcium-8.7 Phos-2.3* Mg-1.6 [**2123-3-8**] 05:55AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0 [**2123-3-7**] 02:28AM BLOOD Calcium-8.4 Phos-2.3* Mg-1.9 [**2123-3-6**] 03:04AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.9 [**2123-3-3**] 07:40AM BLOOD Albumin-3.3* Calcium-8.0* Phos-2.8 Mg-1.7 Cholest-185 [**2123-3-2**] 05:10PM BLOOD Calcium-9.2 Phos-4.2 Mg-1.9 CT brain on [**2122-3-1**]: IMPRESSION: 1. Moderate-sized left frontal lobe hemorrhagic contusion with minimal surrounding edema. No significant shift of midline structures or evidence of intracranial herniation detected. 2. Small right frontal subcutaneous hematoma without underlying fracture. 3. Chronic small vessel ischemic changes within the periventricular white matter. Old lacunar infarctions in the right basal ganglia and left thalamus. [**2123-3-3**] 06:56AM BLOOD Triglyc-95 HDL-92 CHOL/HD-2.1 LDLcalc-79 [**2123-3-3**] 07:40AM BLOOD TSH-9.2* [**2123-3-4**] 01:42AM BLOOD Free T4-0.89* [**2123-3-5**] 03:40AM BLOOD Phenyto-16.9 [**2123-3-3**] 12:32PM BLOOD Phenyto-30.6* [**2123-3-10**] 08:17AM BLOOD Type-ART pO2-208* pCO2-39 pH-7.43 calTCO2-27 Base XS-2 Comment-RECIEVED W [**2123-3-3**] 02:50AM BLOOD Rates-/16 Tidal V-889 FiO2-100 pO2-336* pCO2-43 pH-7.39 calTCO2-27 Base XS-1 AADO2-331 REQ O2-61 -ASSIST/CON Intubat-INTUBATED [**2123-3-4**] 10:05PM BLOOD Lactate-0.7 K-3.2* [**2123-3-4**] 10:05PM BLOOD freeCa-1.14 Brief Hospital Course: Pt was admitted to the Neuro-ICU for management of her lobar hemorrhage. She had serial CT scans which did not show significant progression. With her prior history of dementia and location of hemorrhage it was thoutght to likely be secondary to amyloid angiopathy. Her ICU course was complicated by difficulty with extubation. Once extubated and stable she was transferred to the neurology floor. On the floor she was initially stable but soon developed respiratory distress and delerium. Chest XR and CT were significant for extensive left lobe colapse and infiltrate. After discussion with family it was decided to not escalate care and she was made comfort measures only. Palliative care was consulted to aide in making her comfortable and decreasing aggitation. She was started on a morphine infusion with PRN haldol. She tolerated this well and expired without significant distress. Medications on Admission: ASA 81 mg daily Levoxyl Atenolol Enalapril Cardizem MVI Discharge Medications: . Discharge Disposition: Expired Discharge Diagnosis: Cerebral hemorrhage dementia pneumonia Discharge Condition: Expired Discharge Instructions: . Followup Instructions: .

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7396, 7405

6365, 7263

326, 338

7487, 7496

3919, 6342

7546, 7550

2974, 3059

7370, 7373

7426, 7466

7289, 7347

7520, 7523

3074, 3573

283, 288

366, 2817

3597, 3900

2839, 2877

2893, 2958

52,172

182,987

45447

Discharge summary

report

Admission Date: [**2106-11-25**] Discharge Date: [**2106-12-5**] Date of Birth: [**2037-6-2**] Sex: F Service: MEDICINE Allergies: Effexor / cefepime Attending:[**First Name3 (LF) 4358**] Chief Complaint: Neck pain, SOB Major Surgical or Invasive Procedure: none History of Present Illness: 69F h/o HTN, hypothyroidism, tracheobronchomalacia s/p surgery [**1-/2106**], COPD on 4L home O2, OSA on VPAP, prior admission for PNA with and ICU stay, who p/w 3d of pain in back of head, unsteady gait, and cough. Pt states that her symptoms began 3-4 days ago with pain in the back of her head, more significant on the R side. It starts at the back of the head, near the occiput, and travels up the scalp to the forehead. This pain is intermittent, shooting sharp pain that happens every 5-10 min and has been increasing in frequency. She has tried ibuprofen for the pain but with no relif. She denies any associated dizziness, lightheadedness, or blurry vision. She has also been having a productive cough of thick, yellow sputum, along with increasing oxygen requirement. She notes that she has oxygen at home, but usually only uses it in the car (at 4L) but recently has been having to use it during the day as well. Her wife, who is at her bedside, has noticed that the pt has had an unsteady gait for the past few days in which the pt will stumble after walking a few steps and she states she has to catch the pt to prevent her from falling. In ED VS were 98.6 86 122/68 16 95% 4L. Labs significant for WBC 18.7 with left shift. CXR demonstrated large LUL consolidation, widening of mediastinum [**3-3**] lymphadenopathy. Given levaquin 750mg IV x1. VS on transfer T 102.1, HR 88, BP 115/59, rr 22 - 26, SpO2 95% on 4LO2 NC. On the floor, T 101.7, BP 124/60. She appeared comfortable and was accompanied by her wife who was at her bedside. Her wife noted that she felt she had an upper respiratory tract infection about 4-5 days prior. She was experiencing the shooting pains at the back of her head during the interview, but she stated it didn't prevent her from doing her daily activities. She endorsed an intentional 70lb weight loss in the past 16 mos. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Hypertension Hypothyroid Restless Leg Syndrome COPD TBM Depression Elevated cholesterol Osteoarthritis GERD Obstructive sleep apnea Past surgical history: Bilateral Knee replacements Oophorectomy on left Tonsillectomy Rotator cuff repair Social History: Lives with wife. [**Name (NI) **] works for the census bureau collecting data in hospitals. No current tobacco use, smoked 3PPD, quite 25 years ago. No history of drug use. She is a recovering alcoholic, sober since [**2082**]. The patient's weekly exercise regimen consists of exercising three times per week for 1 hour. Family History: Father: Hypothyroidism, early onset Alzheimer's disease, died at 65. Mother: died of CVA at age 85. Physical Exam: ADMISSION PHYSICAL EXAM VS: T 100.1, BP 120/60, P 90, R 32, O2 93 4L GA: AOx3, NAD, Calm and appropriate HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. Cards: RRR S1/S2 heard. S3 auscultated. no murmurs/gallops/rubs. Pulm: Decreased breath sounds L>R, but no rales/wheezes/rhonchi Abd: soft, NT, ND, +BS. Extremities: wwp, no edema. Radials, DPs, PTs 2+. Skin: Dry and intact Pertinent Results: ADMISSION LABS [**2106-11-25**] 01:50PM BLOOD WBC-18.7*# RBC-4.16* Hgb-12.7 Hct-38.5 MCV-93 MCH-30.7 MCHC-33.1 RDW-12.9 Plt Ct-256 [**2106-11-25**] 01:50PM BLOOD Neuts-92.5* Lymphs-3.8* Monos-2.8 Eos-0.8 Baso-0 [**2106-11-25**] 01:50PM BLOOD Glucose-115* UreaN-15 Creat-1.0 Na-134 K-3.5 Cl-93* HCO3-26 AnGap-19 [**2106-11-26**] 05:55AM BLOOD ALT-28 AST-34 AlkPhos-106* TotBili-0.4 [**2106-11-25**] 01:50PM BLOOD Calcium-8.5 Phos-2.8 Mg-2.3 [**2106-11-26**] 12:06PM BLOOD Type-ART pO2-78* pCO2-32* pH-7.50* calTCO2-26 Base XS-1 MICROBIOLOGY [**2106-11-25**] Blood Culture x2: [**2106-11-26**] Blood Culture x2: [**2106-11-25**] Legionella Urinary Antigen (Final [**2106-11-26**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. [**2106-11-26**] URINE CULTURE (Final [**2106-11-27**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [**2106-11-26**] MRSA Screen: Positive [**2106-11-27**] Influenza DFA: Negative [**2106-11-29**] and [**2106-12-2**] Sputum cultures: Contaminated by oral flora [**2106-12-2**] Urine culture: Pending at time of d/c, no growth to date [**2106-12-2**] Blood culture: Pending at time of d/c, no growth to date IMAGING [**2106-11-25**] ECG: Normal sinus rhythm. Left atrial enlargement. Incomplete right bundle-branch block. Compared to the previous tracing of [**2105-12-17**] ventricular bigeminy no longer exists. [**2106-11-25**] CHEST (PA & LAT): There is widening of the mediastinum, particularly the right lower paratracheal region, compatible with lymphadenopathy, as demonstrated on the recent chest CTs from [**2106-10-19**] and [**2106-4-5**]. There is a new consolidative opacity in the left upper lobe compatible with pneumonia. Lungs are hyperinflated with lucency and relative attenuation of pulmonary vascular markings in the upper lobes compatible with underlying emphysema. No pleural effusion or pneumothorax is present. There are mild degenerative changes of the thoracic spine. Right-sided rib deformities are unchanged. [**2106-11-25**] CT HEAD W/O CONTRAST: There is no evidence of acute hemorrhage, large acute territorial infarction, or large masses. There are bilateral subcortical and periventricular white matter hypodensities in keeping with chronic small vessel ischemic changes. Ventricles and sulci are normal in size and configuration. Mucosal thickening is seen in all the paranasal sinuses, most severe in the left frontal and right sphenoid sinus, with sparing of the right frontal sinus, which is . Mastoid air cells are well pneumatized. [**2106-11-26**] CHEST (PORTABLE AP): Lung volumes are lower today than yesterday and there is mild vascular congestion but not florid pulmonary edema. Lower lung volumes exaggerate the size of the already large area of consolidation in the left upper lobe, but the overall impression is that it has grown. There is no appreciable left pleural effusion. Mediastinal fullness suggests central lymph node enlargement, not surprising in the face of a large area of pneumonia. Heart size is top normal. No pneumothorax. Patient has had right chest surgery, entailing posterior upper rib fractures, which are not completely fused. [**2106-11-26**] CT CHEST W/O CONTRAST: There is dense consolidation with air bronchograms centered predominantly within the lingula with extension into the apicoposterior segment of the superior lobe. Scattered additional predominantly peripheral interstitial abnormalities were present on the prior examination and likely represent fibrosis. There is severe upper lobe predominant emphysema. A 3-mm left apical pulmonary nodule is unchanged (3:7), as is a 4-mm left lower lobe pulmonary nodule (3:27) dating back to [**2105-11-17**], establishing one-year stability. There is mild bilateral dependent atelectasis. There are coronary artery and aortic calcifications. No pericardial effusion is seen. A left hilar node measures 2.0 cm in short axis, a right paratracheal node 1.5 cm in short axis, and a prevascular node 1.6 cm in short axis, all increased in size from [**2106-10-27**] CT. Other smaller reactive nodes are noted throughout the mediastinum. [**2106-11-28**] CHEST X-RAY: IMPRESSION: Compared to the film from two days prior, there has been some interval partial clearing of the dense left-sided infiltrate, which although still present, has slightly more aerated lung within it. Right upper rib fractures are again seen secondary to prior surgery. There continues to be mild vascular congestion. [**2106-12-1**] CHEST X-RAY: FINDINGS: In comparison with the study of [**11-30**], there is little overall change in the appearance of the heart and lungs. Extensive bilateral opacifications are unchanged. No evidence of pleural effusion or vascular congestion [**2106-12-3**] KUB: 1. Normal gas pattern without evidence of obstruction or ileus. 2. No free air. 3. Compression fracture of L5. [**2106-12-3**] CXR: Pneumonia in the axillary region of the left lung continues to clear. Change in patient positioning is probably responsible for greater prominence to the prevascular mediastinum crossing the upper portion of the right hilus. The heart is normal size. Emphysema is severe, and the pulmonary fibrosis is likely at the lung periphery. There are no findings to suggest new pneumonia. DISCHARGE LABS: [**2106-12-5**] 06:02AM BLOOD WBC-15.6* RBC-4.44 Hgb-13.6 Hct-40.6 MCV-91 MCH-30.6 MCHC-33.4 RDW-13.2 Plt Ct-587* [**2106-12-5**] 06:02AM BLOOD Plt Ct-587* [**2106-12-5**] 06:02AM BLOOD Glucose-89 UreaN-23* Creat-1.0 Na-141 K-4.0 Cl-104 HCO3-28 AnGap-13 [**2106-12-5**] 06:02AM BLOOD Calcium-8.8 Phos-4.4 Mg-2.2 Brief Hospital Course: 69F h/o HTN, hypothyroidism, tracheobronchomalacia s/p surgery [**1-/2106**], COPD on 4L home O2, OSA on VPAP, prior admission for PNA with and ICU stay, who p/w 3d of pain in back of head, unsteady gait, LUL PNA. # [**Name (NI) 96987**] Pneumonia - Pt's high fever, cough, leukocytosis, chest x-ray all consistent with pneumonia. She was initially treated with levofloxacin 750mg PO daily but on the second hospital day, pt triggered for fever to 103.2 and hypoxia. She was transfered to the ICU on a non-rebreather mask with oxygen saturation sat 94%. Her antibiotics were broadened to include vancomycin and cefepime upon transfer. While in the MICU, her cefepime was discontinued due to adverse reaction (rash). She was continued on vancomycin. Levaquin and tobramycin were added for double gram-negative coverage. Her symptoms and radiographic findings improved significantly with this regimen that she finished on [**12-3**]. # Leukocytosis: Despite improvement on the above antibiotic regimen for pneumonia, she developed a leukocytosis which peaked at 20 without clear cause. CXR and KUB as well as laboratory studies were unrevealing. C diff infection was considered but patient did not stool and no sample was collected. Given her overall clinic improvement with a lack of and pain or diarrhea and improving leukocytosis further testing was deferred. Surveillance cultures remained no growth to date at the time of discharge. # COPD/tracheobronchiomalacia - Pt was continued on her home advair, zafirlukast, sprivia, proair, with albuterol nebs q6 standing, q2prn. # Neck/Head pain - Etiology unclear. Could be occipital neuralgia given the transient, intermittent, sharp shooting nature of the pain. Pain was refractory to tylenol, increased dose of gabapentin, lidocaine patch and soft collar brace. # OSA - VPAP per home settings. # Hypothyroidism - Continued levothyroxine at home dose # GERD - Continued home omeprazole # Dyslipidemia - Continued pravastatin # Hypertension - Continued triamterene-HCTZ . transitional: - follow up final blood and urine cultures. Medications on Admission: CABERGOLINE 0.5 mg QOD for RLS FLUTICASONE Proprionate 50mcg: 2 sprays each nostril [**Hospital1 **] ADVAIR (inhaler) 250/50: 1 puff [**Hospital1 **] GABAPENTIN 600mg qAM, 900 mg qHS LEVOTHYROXINE 137 mcg daily OMEPRAZOLE Delayed-Release 40mg [**Hospital1 **] PRAVASTATIN 40 mg qHS SERTRALINE 100 mg twice a day TOLTERODINE 4 mg once a day TRIAMTERENE-HYDROCHLOROTHIAZID - 37.5-25 mg once a day ZAFIRLUKAST 20mg [**Hospital1 **] ASCORBIC ACID 500mg once daily Calcium/Mg/Zn 333/133/5mg [**Hospital1 **] FERROUS SULFATE 65 mg [**Hospital1 **] Centrum Silver for Women Vitamin E 400 IU qd DHA (fishoil/omega3oil) 250mg daily IC Albuterol 90 mcg inhaler 1-2 puffs Iprat-Albuterol (via nebulizer) 1 0.5-3.0 mg ampule up to QID Discharge Medications: 1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. zafirlukast 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO QHS (once a day (at bedtime)). 5. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 6. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. sertraline 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 9. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day) as needed. 11. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) cap Inhalation QID PRN as needed for shortness of breath or wheezing. 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 13. cabergoline 0.5 mg Tablet Sig: One (1) Tablet PO QOD: RLS. 14. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) puff Nasal once a day: in each nostril. 15. tolterodine 4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 1514**] Health Care Center - [**Location (un) 1514**] Discharge Diagnosis: Bacterial Lobar Pneumonia secondary dx: OSA pulmonary hypertension pulmonary fibrosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname 96986**], It was a pleasure taking care of you. You were admitted to the hospital for pneumonia. Because you have underlying lung disease, you became very ill and temporarily required ICU level care. You were treated with IV antibiotics and your condition improved. You are currently stable and we now believe that you are safe to leave the hospital for rehab. . Please continue taking all of your home medications. . Followup Instructions: Department: MEDICAL SPECIALTIES When: MONDAY [**2107-1-3**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RHEUMATOLOGY When: THURSDAY [**2107-2-17**] at 12:30 PM With: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

13671, 13763

9314, 11405

294, 301

13895, 13895

3648, 8961

14521, 15165

3131, 3233

12180, 13648

13784, 13874

11431, 12157

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2219, 2512

240, 256

329, 2200

13910, 14022

2534, 2666

2789, 3115

30,257

170,637

46545+58924

Discharge summary

report+addendum

Admission Date: [**2107-9-1**] Discharge Date: [**2107-9-16**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 800**] Chief Complaint: transfer from [**Hospital1 18**] [**Location (un) 620**] with concern for aortic thrombus Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] yo F w/ MMP who initially presented to [**Hospital1 4086**] w/ CP, SOB and back pain. She had a leukocytosis (wbc of 19.8) and a +UA. She was started on levofloxacin and ruled out for an MI. A VQ scan was done which showed low prob for a PE. A CT angio was significant for an intramural hematoma of the ascending aorta from the aortic valve to the origin of the innominate artery. Additionally, the thoracic aorta was ectatic w/ multifocal calcification, noncalcified plague, focal mural thrombus was present in 2 locations in the descending thoracic aorta. Also noted was a small-mod L pleural effusion w/ atelectasis bilaterally at the bases. She was transferred to [**Hospital1 18**] for further care. She was admitted to the vascular service due to the aortic thrombi. It was determined that the thrombi are asymptomatic and that surgery is not currently indicated. Abx (levo [**8-31**] or 24?->ceftrioxone->cipro stopped [**9-5**]) were continued for the UTI. While at [**Hospital1 **], she developed new afib/rvr was loaded with amiodarone + amio gtt (loaded with 2g) and transitioned to po amio. Again pt had AF/RVR started on dilt drip transitioned to dilt po. She has continued to have SOB. An echo done on [**9-2**] was significant for [**2-9**]+MR, 4+TR, RV dilatation and depressed free wall contractility and a preserved EF. Patient transferred to medicine for furthur evaluation. Past Medical History: Emphysema. Interstitial lung disease Hiatal hernia with GERD Hypertension Diabetes Exertional dyspnea colostemy (diverticulosis) breast ca Social History: The patient lives at [**Location 98845**] house. Patient alone and is self-sufficient. She quit smoking 25 years ago and smoked ~ 20 yrs. She denies etoh and drug use Family History: Father had [**Name2 (NI) 499**] ca, mother lived to 85 Physical Exam: VS: 98.5, 128/60, 78, RR 18 02 sat 96% on 2L Gen: elderly F, NAD HEENT: MMM, nasal cannula in place. no JVD CV: irreg. irreg, no murmur Lungs: decreased BS at the bases, exp. wheezes bilaterally Abd: NT/ND, normoactive BS Ext: no edema, WWP Pertinent Results: [**2107-9-1**] 10:11PM BLOOD WBC-17.2*# RBC-3.26* Hgb-9.6* Hct-28.0*# MCV-86 MCH-29.4 MCHC-34.3 RDW-13.2 Plt Ct-353 [**2107-9-1**] 10:11PM BLOOD Neuts-84.5* Lymphs-7.9* Monos-7.5 Eos-0.1 Baso-0 [**2107-9-1**] 10:11PM BLOOD PT-13.5* PTT-27.7 INR(PT)-1.2* [**2107-9-1**] 10:11PM BLOOD Glucose-146* UreaN-33* Creat-1.1 Na-130* K-4.7 Cl-98 HCO3-19* AnGap-18 [**2107-9-1**] 10:11PM BLOOD ALT-31 AST-30 AlkPhos-144* Amylase-30 TotBili-1.0 [**2107-9-1**] 10:11PM BLOOD cTropnT-0.04* [**2107-9-6**] 06:47AM BLOOD proBNP-4549* [**2107-9-1**] 10:11PM BLOOD Albumin-3.2* Calcium-8.3* Phos-4.3 Mg-2.1 [**2107-9-1**] 10:28PM BLOOD Type-ART pO2-64* pCO2-37 pH-7.35 calTCO2-21 Base XS--4 [**2107-9-2**] 03:21AM BLOOD Lactate-2.3* . Echo [**2107-9-2**]: The left atrium is elongated. The right atrium is moderately dilated. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). The right ventricular cavity is dilated with depressed free wall contractility. The ascending aorta is moderately dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**2-9**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. . CXR [**2107-9-5**]: 1) Cardiomegaly and mild interstitial edema. 2) Left greater than right pleural effusion with underlying collapse and/or consolidation. 3) Compared with [**2107-9-3**], the CHF findings appear more pronounced.The bibasilar opacities are unchanged. . CXR [**9-6**] In comparison with the study of [**9-4**], the degree of left pleural effusion has somewhat decreased. Cardiomegaly with some elevation of pulmonary venous pressure persists. Relative [**Name (NI) 95365**] raises the possibility of pericardial effusion or underlying cardiomyopathy. Prominence of central pulmonary vessels suggests some pulmonary hypertension. No acute focal pneumonia. . CXR [**9-7**] - Since yesterday, cardiomegaly is stable and vascular congestion cleared. Left moderate pleural effusion slightly enlarged and right small-to- moderate pleural effusion is unchanged. Possibly enlarged pulmonary arteries are unchanged. The aorta is tortuous. Lungs are otherwise clear. There is no other change since yesterday. . UE ultrasound [**9-7**] - Clot in right cephalic vein with no extension of clot into other vessels. . Ct chest with contrast: 1. Acute dissection of the ascending aorta associated with acute progressing intramural hematoma. Dissection does not extend to the aortic valve and ends before the origin of great vessels. 2. Increase thrombus in the descending aorta. Severely atheromatous and dilated aorta. 3. Bilateral nonhemorrhagic pleural effusions with associated atelectasis, most prominent on the right. 4. Enlarged pulmonary artery suggesting pulmonary hypertension. 5. Severe cardiomegaly. 6. Large hiatal hernia and dilatation of the esophagus. 7. Calcified mediastinal lymph nodes. Brief Hospital Course: [**Age over 90 **] yo F w/ mmp incld DMII, htn, emphysema, ILD, now with aortic thrombus/dissection which is progressiving, new a.fib w/RVR, leukocytosis, previous UTI (treated w/ cipro), pleural effusions, worsening tricuspid regurg, now CMO. . # Comfort measure only After many discussions with family, patient made comfort measures only after exploring that only way that patient will get better is with extensive and very risky surgery that family and patient does not want. Pain and palliative care was called to help with pain management. In addition, the geriatrics team has been very helpful. Telemetry was discontinued. In additon, discontinued overnight vital signs as well as subcutaneous heparin and aspirin. Patient was started on pain medication first with liquid morphine, however there was concern by the family that this was making the patient too confused, so changed to oxycontin. Suspect that patient not acutely delirious, and that confusion likely a combination of underlying medical problem as well as medication. In addition, started patient on zyprexa daily and PRN. Pt's beta-blocker was continued as rate control will likely help with symptoms. We stopped checking new labs, and vitals were taken only with concern for acute worsening. Patient was started on aggressive bowel regimen because on oral narcotics, was also disimpacted one time. . # Atrial fibrillation/Aortic dissection Atrial fibrillation was new on this admission, patient has a history of palpitations but no known hx of afib. Here patient noted to have afib w/ RVR to the 120s. Pt was initially rate controlled with amiodarone and diltiazem and then these medications were discontinued and Metoprolol was started. Metoprolol was uptitrated as tolerated by HR and BP for rate control. Currently on 37.5 mg PO QID. As per the CT scan, aortic dissection appears to be progressing, and there is obviously large risk of rupture at any time. However, patient and family do not want surgery. As above, patient made comfort measures only. Checked TSH on admission which was normal, so unlikely that playing any role in new onset of atrial fibrillation . # SOB: Patient has had consistent shortness of breath throughout admission. Patient recieved intermittent Lasix IV for vascular congestion. Patient also started on Advair for underlying lung disease. Nebs were changed to levalbuterol as per cardiology suggestion as tends to make less tachycardic than albuterol. Continued ipratropium nebs in addition. SOB likely from pleural effusions, underlying lung disease and worsening pulmonary htn. Patient has been on 2L O2 and has been intermittently tachypneic with excellent o2 sats. . # leukocytosis: Patient initially had a leukocytosis and apparently a dirty UA at [**Location (un) 620**]. Patient was treated on transfer with levoflox then ceftrioxone then ciprofloxacin. urine culture from [**9-2**] was negative. Patient remained afebrile and WBC declined, however did not normalize completely. Decision was made for no furthur lab draws. . # Blood pressre: Patient has a history of hypertension. Patient has not had elevated blood pressure in house. Was treated with beta-blocker as above. . # worsening TR: Patient has worsening tricuspid regurgitation, now 4+ on [**2107-9-2**] echo (previous echo in [**2101**]). Worsenging TR likely secondary to pulmonary disease. Treatment for pulmonary disease as above. # h/o breast ca: No new treatment pursued at this time. . # Diabetes: In house, held glyburide, originally kept on sliding scale, however with decision to make patient CMO discontinued insulin sliding scale as patient not with markedly elevated glucose and trying to minimize patient discomfort. . # pain control/sleep: Pain was one of patient's major issues. Pt felt constantly uncomfortable, stating that she could not get into a comfortable place. Patient was started on tylenol RTC, low dose ibuprofen RTC, alidocaine patch, heating pads as needed. Originally on liquid morphine, family had some concern that patient wasn't mentating as well so changed over to oxycontin. . # Sleep Patient with sleep cycle disturbances while in house. As per geriatrics consult, started Remeron 7.5 mg PO q hs to help with sleep, appetite. . # code status: DNR/DNI verified with daughter and family Medications on Admission: Medications on transfer: tylenol 1000mg po q8hrs aspirin 81mg po qdaily bisacodyl 10mg prn diltiazem 60mg qid colace 100mg po qdaily furosemide 40mg [**Hospital1 **] glyburide 5mg po qdaily heparin sq [**Hospital1 **] RISS atrovent q6 prn milk of mag prn omeprazole 40 qdaily KCL 20meq po bid . Home meds: atenolol 50mg qaily glyburide 5mg daily evista 60mg qdaily asa 325mg qdaily prilosec nifedipine cr 60mg qdaily Discharge Disposition: Home With Service Facility: Hospice of the Good [**Doctor Last Name 9995**] Discharge Diagnosis: 1) progressive aortic dissection, pleural effusions, atrial fibrillation with rapid RVR 2) Emphysema, Interstitial lung disease, Hiatal hernia with GERD, Hypertension, Diabetes, Exertional dyspnea, colostomy (diverticulosis), breast ca Discharge Condition: awake, comfortable, in no acute distress Discharge Instructions: You were admitted to the hospital here after transfer from [**Hospital1 18**] [**Location (un) 620**]. You were found to have a large progressive aortic dissection. The option of surgery was discussed, however you and your family felt this was not what you wanted. In addition, you went into new onset of a rapid heart rate (atrial fibrillation) and were found to have new pleural effusions. There were long discussions with you and your family about goals of care, and it was decided that the goal was to minimize needle sticks and medication administration and to keep you as comfortable as possible. You were started on agents to control your heart rate, and aggressive pain control. You should continue to take all of your medications as prescribed below. All of these medications are oral. We would reccomend that when and if you can no longer take oral medications that you switch the PO morphine over to the concentrated version, where much less volume can be administered for pain control. The goal is to maximize comfort. Followup Instructions: As per your extended care facility [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2107-9-15**] Name: [**Known lastname **],[**Known firstname 2045**] Unit No: [**Numeric Identifier 15811**] Admission Date: [**2107-9-1**] Discharge Date: [**2107-9-16**] Date of Birth: [**2012-9-5**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 877**] Addendum: Patient was to be discharged to hospice today which is why discharge summary was complete. On morning of planned discharge, patient was awake, alert, oriented to person, placed but not date or year. Patient was eating and stated that she was uncomfortable. At 9 am, rounded again with team, patient was still awake and alert. Around 11:30 am, attending saw patient, patient noted to have agonal respirations. Patient was only responsive to sternal rub and would grasp hands. The family was called to come to the hospital and the ambulance was cancelled. Decision to go to hospice was put on hold. Primary team reevaluated patient around noon. patient was non-responsive, cool and clammy. Pt did not blink to threat or respond to sternal rub. No radial pulses appreciated. Heart sounds were distant. BP was doppler only. Pulses now only faint in carotid and femoral. Family arrived quickly, however on arrival, patient had expired. Called to prononce patient. listened to heart for 2 minutes without beat. Listened to lungs for 1 minute there was no spontanous breathing activity. No carotid or femoral pulses appreciated. Patient pronounced dead at 12:55 pm on [**2107-9-16**]. Family was at the bedside. Offerred family an autopsy and they declined. Discharge Disposition: Home With Service Facility: Hospice of the Good [**Doctor Last Name 5548**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 878**] MD, [**MD Number(3) 879**] Completed by:[**2107-9-16**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

14063, 14297

5966, 10282

307, 314

11108, 11151

2455, 5943

12237, 14040

2122, 2178

10849, 11087

10308, 10308

11175, 12214

2193, 2436

178, 269

342, 1757

10333, 10727

1779, 1920

1936, 2106

25,717

101,820

22940

Discharge summary

report

Admission Date: [**2161-2-21**] Discharge Date: [**2161-2-21**] Date of Birth: [**2095-7-1**] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 106**] Chief Complaint: Septic Shock Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: Pt is a 65 y/o female unknown to [**Hospital1 18**], who was referred for cardiac cathetrization. She has a hx of CVA and bowel perforation 5 months ago s/p colostomy, and has not recovered well from this surgery and is cared for by her husband. She was noted to have N/V 2 days ago, and was told to increase her PO fluids. Temp at home was 99. She improved somwehat, but was noted by her husband to have decreased ostomy output. The evening prior to admission she begam clammy, vomited, and was unresponsive. EMS was called and she was difficult to intubate in the field. She was taken to [**Hospital3 **], and there was suspicion for STE MI by EKG. Also coffee ground emesis but stable Hct. She was hypotensive and placed on pressors, and referred to [**Hospital1 18**] for cardiac cath. Cardiac cath did not reveal significant coronary lesions, but some mild global dysfunction. Given her clinical picture this was likely c/w sepsis. Past Medical History: CVA in '[**53**] w/ L-sided hemiparesis [**8-/2160**] had bowel perforation w/ colostomy Osteoporosis Social History: Cared for at home by her husband Family History: Mother w/ hx of CVA, Father w/ CAD Physical Exam: T=91 BP=96/65 HR=110 O2=95% GEN=Intubated LUNGS=normal BS's bilaterally CARDIAC=difficult secondary to BS's ABD=tense, no bowel sounds EXT=no edema, cold extremities, cyanotic toes/fingers NEURO=pupils fixed and dilated, absent corneal reflexes, absent gag reflex; positive doll's eye per surgery Pertinent Results: [**2161-2-21**] 09:53AM GLUCOSE-190* UREA N-32* CREAT-1.4* SODIUM-140 POTASSIUM-2.0* CHLORIDE-113* TOTAL CO2-12* ANION GAP-17 [**2161-2-21**] 07:40AM GLUCOSE-128* LACTATE-8.1* K+-1.8* [**2161-2-21**] 09:53AM WBC-0.4* RBC-3.77* HGB-11.9* HCT-37.5 MCV-100* MCH-31.5 MCHC-31.6 RDW-14.4 [**2161-2-21**] 10:18AM TYPE-ART PO2-69* PCO2-36 PH-7.03* TOTAL CO2-10* BASE XS--21 Brief Hospital Course: She was transferred to the CCU, where she was found to be hypothermic, has an elevated Lactate, and was hypotensive requiring 4 pressors and fluids wide-open. Her neuro exam revealed loss corneal and gag reflexes. Surgery was consulted about possible abdominal process at the etiology of her septic shock, but surgery felt that given her unstable picture and neurological impairements that surgery was not indicated. Her husband and son were notified, and it was felt that the patient's wishes were not to have aggressive measures. After discussion with the family and medical team, it was decided to withdraw care. Pressors were stopped, her ventilation was weaned down, and she was given Morphine for comfort. At 13:30 she was noted to have absent heart sounds, pulse, and was without spontaneous respirations or brainstem reflexes. She was pronounced dead at 13:30 by the medical resident Dr. [**Last Name (STitle) **]. The attending, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], was notified. The family requested an autopsy. Discharge Disposition: Expired Discharge Diagnosis: Likely Septic Shock Discharge Condition: Deceased Completed by:[**2161-2-21**]

[ "276.8", "401.9", "428.21", "V44.3", "038.9", "438.20", "995.92", "V12.59", "518.81", "557.0", "785.52", "276.2" ]

icd9cm

[ [ [] ] ]

[ "88.42", "37.23", "88.53", "00.17", "88.56", "96.71" ]

icd9pcs

[ [ [] ] ]

3338, 3347

2258, 3315

307, 332

3410, 3449

1859, 2235

1491, 1527

3368, 3389

1542, 1840

255, 269

360, 1299

1321, 1425

1441, 1475

27,953

104,446

4704

Discharge summary

report

Admission Date: [**2143-12-27**] Discharge Date: [**2144-1-3**] Date of Birth: [**2069-9-2**] Sex: M Service: MEDICINE Allergies: Aspirin / lisinopril / Nifedipine / Cephalexin / Nafcillin Attending:[**First Name3 (LF) 2782**] Chief Complaint: Abnormal labs Major Surgical or Invasive Procedure: None History of Present Illness: This is a 74-year-old gentleman with a pmhx. significant for dCHF, afib on coumadin, CKD, MSSA/GBS bacteremia, and was recently discharged on [**2143-12-19**] for compression fracture of T11 vertebrea and afib with RVR who presents to the ED at the request of his nurse practioner for elevated potassium. Mr. [**Known lastname 19829**] had been evaluated in the infectious disease clinic on [**12-25**] and had routine labs drawn, at which time his potassium was found to be 5.7. He was told to go to the ED that night for evaluation, but decided to come in the next day. Patient denies any particular complaints but does complain of fatigue. No headache, fevers, chills, nausea, vomiting, diarrhea, or other concerning signs or symptoms. . In the ED, initial vitals were: 97.3 120 105/72 22 100% RA. Labs were significant for a creatinine of 3.3 up from a baseline of 1.5 and a potassium of 6.1. Patient complained of wheezing and chest congestion and received a dose of levaquin for presumed HCAP. He also received nebs, 15grams of kayexalate and 250cc of fluid. Mr. [**Known lastname 19829**] was transferred to the MICU for further evaluation and work-up. Past Medical History: --S. aureus/G-strep bacteremia: Unknown source although left maxillary dental abscess suspected. Was on IV nafcillin until [**2143-12-16**], followed in [**Hospital **] [**Hospital 4898**] clinic. --Retroperitoneal Hemmorhage [**2143-6-7**] in the setting of INR of 8 --Diastolic CHF --HTN --Asthma --Atrial fibrillation, on warfarin. s/p multiple cardioversions, last TEE-guided cardioversion on [**2143-11-5**] --Atopic dermatitis --Hypercholesterolemia --CKD (creatine from 1.4-2.3 in the last 2 months) --s/p UGI bleed in [**2130**] from two gastric ulcers, H. pylori neg --hx of colonic adenomas on colonoscopy in [**2133**] --s/p appendectomy --Normocytic anemia- recent BM bx on [**5-24**] which showed mild erythroid dyspoiesis suggesting the possibility of an early evolving MDS. Cytogenetics and FISH for MDS were negative. --Herpes Zoster on upper back in [**2143-5-8**] --Gout Social History: Originally from [**Country 19828**]; came to US in the [**2091**]. Married, lives with his wife. Three adult daughters. [**Name (NI) 1403**] as a physicist for radiation oncology at [**Hospital1 112**]/[**Company 2860**]. Previously employed by [**Hospital1 18**]. Denies tobacco or illicit drug use. Occasional EtOH - 1 drink several times per week. Family History: Mother died of complications of childbirth. Father died in his 90s from complications of an aortic aneurysm. Brother died of cancer of unknown primary. Son died 10 years ago by drowning during a caving expedition. Three daughters are alive and well. Multiple family members have eczema. Physical Exam: VS: 96.6, 83, 109/70, 16 GENERAL: No acute distress, wheezy HEENT: EOMI, very dry mucous membranes NECK: Supple, no cervical LAD LUNGS: Moderate air movement bilaterally, expiratory upper airway wheezes HEART: Irregularly irregular, no MRG ABDOMEN: Obese, soft, NT, ND, no organomegaly, no rebounding or guarding EXTREMITIES: 2+ edema bilaterally, peripheral pulses intact SKIN: Diffuse blanching erythema over entire body NEURO: Alert and oriented x3 PSYCH: Calm, appropriate affect Pertinent Results: [**2143-12-27**] 10:18PM GLUCOSE-108* UREA N-90* CREAT-3.3* SODIUM-144 POTASSIUM-5.8* CHLORIDE-110* TOTAL CO2-22 ANION GAP-18 [**2143-12-27**] 10:18PM CALCIUM-8.4 PHOSPHATE-8.2*# MAGNESIUM-2.4 [**2143-12-27**] 10:18PM WBC-7.4 RBC-2.48* HGB-8.2* HCT-25.6* MCV-103* MCH-33.3* MCHC-32.2 RDW-16.7* [**2143-12-27**] 10:18PM NEUTS-78.6* LYMPHS-10.9* MONOS-8.5 EOS-1.5 BASOS-0.5 [**2143-12-27**] 10:18PM PLT COUNT-409 [**2143-12-27**] 10:18PM PT-30.4* PTT-42.4* INR(PT)-2.9* [**2143-12-27**] 06:17PM PO2-47* PCO2-52* PH-7.22* TOTAL CO2-22 BASE XS--6 COMMENTS-GREEN [**2143-12-27**] 06:17PM LACTATE-1.7 K+-6.1* [**2143-12-27**] 04:30PM GLUCOSE-131* UREA N-88* CREAT-3.3*# SODIUM-141 POTASSIUM-7.6* CHLORIDE-108 TOTAL CO2-20* ANION GAP-21* [**2143-12-27**] 04:30PM CK(CPK)-81 [**2143-12-27**] 04:30PM cTropnT-0.08* [**2143-12-27**] 04:30PM CK-MB-5 proBNP-4982* [**2143-12-27**] 04:30PM WBC-10.4 RBC-2.81* HGB-9.3* HCT-29.0* MCV-103* MCH-33.3* MCHC-32.2 RDW-16.7* [**2143-12-27**] 04:30PM NEUTS-80.3* LYMPHS-9.0* MONOS-8.4 EOS-1.5 BASOS-0.8 [**2143-12-27**] 04:30PM PLT COUNT-532* . TEE Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is moderate bileaflet mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**12-9**]+) mitral regurgitation is seen. There is no pericardial effusion. . IMPRESSION: Mitral and aortic leaflets are thickened but no discrete vegetation is identified. No abscess seen. . TTE: MPRESSION: Aortic leaflet thickened with mild aortic regurgitation but no discrete vegetation. Moderate mitral regurgitation with thickened leaflets but without discrete vegetation. Pulmonary artery hypertension. Minimal aortic valve stenosis. Dilated thoracic aorta. . MRI TSpine/LSpine: IMPRESSION: 1. No osteomyelitis, discitis or epidural abscess. 2. Interval subacute T11 compression fracture without retropulsion. 3. Interval progression of the known L1 compression fracture, but without retropulsion. 4. Low lumbar degenerative changes, without spinal stenosis. . [**2143-12-27**] Chest PA and lateral radiograph demonstrates unremarkable mediastinal and hilar contours. Stable mild cardiomegaly evident. Increased opacity overlying the right diaphragm on background of right lower lung atelectasis, may indicate pneumonia. No pleural effusion or pneumothorax evident. Stable L1 and T12 compression fractures. Stable degenerative changes of the right shoulder. IMPRESSION: Increased opacity of right lower lung may reflect worsening atelectasis, though in proper clinical setting, pneumonia is a possibility. No pleural effusion evident. . Culture data (organism and susceptibilities): STAPHYLOCOCCUS EPIDERMIDIS | STAPHYLOCOCCUSEPIDERMIDIS | | CLINDAMYCIN----------- =>8 R =>8 R DAPTOMYCIN------------ S S ERYTHROMYCIN---------- =>8 R =>8 R GENTAMICIN------------ 4 S 4 S LEVOFLOXACIN---------- =>8 R =>8 R LINEZOLID------------- 1 S 2 S OXACILLIN------------- =>4 R =>4 R RIFAMPIN-------------- =>32 R =>32 R TETRACYCLINE---------- =>16 R =>16 R VANCOMYCIN------------ 2 S 2 S Brief Hospital Course: BRIEF HOSPITAL COURSE: This is a 74-year-old gentleman with a pmhx significant for recent MSSA and group G strep bactremia, dCHF, asthma, and afib on coumadin who was admitted after routine lab tests showed an elevated potassium. He was found to be bacteremic on admission. A work-up for the source was inconclusive. He was discharged with a PICC line for likely 6 weeks of vancomycin therapy. . ACTIVE ISSUES: # POSITIVE BLOOD CULTURES: Blood cultures from [**12-27**] to [**12-29**] grew methicillin resistant staph. epidermis. Source search included evaluation for valvular vegetations included TTE and TEE which were unrevealing. Given history of compression fractures an MRI T and L spine showed no source. A RUQ ultrasound was obtained in setting of right upper extremity edema and pain on palpation of the axilla revealed evidence of a non occlusive clot. In setting of atopic dermatitis, multiple skin lesions and recent knee injury with slow healing wound, skin source entertained. A picc line was placed and 4-6 weeks of vancomycin will be continued at discharge dose of 750mg [**Hospital1 **]. . # ACUTE RENAL FAILURE: Patient with creatinine of 3.3 up from a baseline of 1.5. On admission, patient was 89 kg, down from 94.9kg on [**2143-12-16**]. He appeared hypovolemic with increased thirst, and BUN/creatinine ratio is >20. Urine lytes demonstrated FeUrea < 34 (25) consistent with pre-renal etiology. After administration of IVF, renal function improved with discharge creatinine 1.1. AIN possibly contributed given recent treatment with Nafcillin. Urine eosinophils were positive. Valsartan and lasix were initially held. Valsartan was restarted prior to discharge and lasix was restarted at a lower dose 40mg. . # HYPERKALEMIA: Likely in the setting of dehydration, renal failure, and valsartan. With fluids and kayexalate, patient's potassium trended down. . # SHORTNESS OF BREATH: Differential includes asthma exacerbation vs. pneumonia vs. bronchitis vs. volume overload. Mr. [**Known lastname 19829**] was given a prednisone burst ( 5 days of 40mg prednisone) with significant improvement in his symptoms. His Advair was increased to 500/50 and he was started on Singulair. . INACTIVE ISSUES: # AFIB WITH RVR: Metoprolol, diltiazem and coumadin were continued during admission. . # HTN: Metoprolol and dlitiazem was continued. . # ATOPIC DERMATITIS: Hydroxyzine and clobetasol were continued during admission. . TRANSITIONAL ISSUES: - PCP [**Last Name (NamePattern4) 702**]: basic metabolic panel - OPAT follow-up: Vancomycin trough at discharge was 22 - Code Status: Full Medications on Admission: fluticasone-salmeterol 250-50 mcg/dose Disk - 1 puff [**Hospital1 **] hydroxyzine HCl 25 mg qhs simvastatin 40 mg daily clobetasol 0.05 % Ointment [**Hospital1 **] valsartan 80 mg daily ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler every 6-7 hours prn cholecalciferol 400 unit daily multivitamin Tablet daily metoprolol succinate 200 mg daily albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler q4h prn Lasix 60 mg Tablet daily warfarin 5 mg Tablet daily for 7 days dilt 120mg ER daily oxycodone-acetaminophen 5-325 mg Tablet q6h prn pain Discharge Medications: 1. vancomycin 750 mg Recon Soln Sig: One (1) Intravenous twice a day for 6 weeks. Disp:*qs * Refills:*0* 2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 6. valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO once a day. 9. multivitamin Tablet Sig: One (1) Tablet PO once a day. 10. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every four (4) hours. 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 14. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 15. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Home With Service Facility: Primary home care specialists Discharge Diagnosis: Acute on chronic kidney injury Bacteriemia Atrial fibrillation Congestive heart failure Asthma Atopic dermatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you. You came because of high potassium. Your potassium was high because your kidneys were not functioning as they usually do. We gave you fluid and held diuretics for few days and your kidney function came back to the baseline. While you were in the hospital we found a bacteria in your blood. Therefore we had to give you intravenous antibiotics that you have to continue at home for 6 weeks. We have done the following changes to your medication: TAKE VANCOMYCIN 750 mg intarvenously through the PICC line twice a day. Home service will come to help you. CHANGE furosemide 60 mg daily to furosemide 40 mg daily Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2144-1-7**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: [**Hospital3 249**] When: TUESDAY [**2144-1-7**] at 2:20 PM With: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**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: INFECTIOUS DISEASE When: WEDNESDAY [**2144-1-22**] at 10:30 AM With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], 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

[ [ [] ] ]

[ "88.72", "38.93" ]

icd9pcs

[ [ [] ] ]

11857, 11917

7260, 7634

332, 338

12074, 12074

3644, 7214

12988, 13961

2832, 3120

10455, 11834

11938, 12053

9877, 10432

12225, 12965

3135, 3625

9710, 9851

279, 294

7649, 9450

366, 1536

9467, 9689

12089, 12201

1558, 2448

2464, 2816

78,017

140,897

42790

Discharge summary

report

Admission Date: [**2178-12-4**] Discharge Date: [**2178-12-5**] Date of Birth: [**2124-11-11**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: Shortness of breath, hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: This is a very pleasant 54 yo female w/ pmh significant for L breast CA-invasive ductal cancer in [**2169**], s/p lumpectomy with chemo followed by taxol and radiation tx, hx of 45 pack years of smoking, COPD, Polycythemia and recent dx of stage IV lung Ca (adenocarcinoma) who comes in today for hypoxia and increase in SOB. Pt states that she has been using home O2-2L with sats in at 88-90% for the last month since her dx of lung CA a few weeks ago. On Wed she went to see her new PCP, [**Name10 (NameIs) **] [**Last Name (STitle) 92442**] [**Name (STitle) 92443**], due to change insurance coverage, who obtained a CXR at [**Hospital1 18**] [**Location (un) 620**] which showed RML infiltrate and she was started on moxifloxin. She denies having any fever or chills at the time and her cough seems to be improving on tessalon pearls and guaifenasine-codeine. Her SOB has been stable at home for the last several days until today when she was off the oxygen for ~ 2hours while travelling to see her doctor. She also walked around at [**Company 12679**] prior to her appointment. She then had increase in SOB "difficult catching her breath". On arrival to her PCP office her O2 sat was 78% on RA. She was started on Oxygen and sent to [**Hospital1 **] [**Location (un) 620**] ED. On arrival to [**Hospital1 **] [**Location (un) 620**] her vitals were: 98.5 HR: 104 BP: 132/68 Resp: 18 O(2)Sat: 88 2 L Low. Her labs at the time were notable for WBC 8.4/Hgb 16.4/Hct 50.6/ MCV 98.2/ Plats of 257, no diff. BUN of 7/creat of 0.4. Her D.dimer of 0.8 (normal range of 0-0.49), so she had a CTA earlier in the day which showed no PE but a lung tumor pressing on right bronchial and pulmonary artery (prelim report). She was then transfer to our ED for admission to oncology. Pt has an appointment with Dr. [**Last Name (STitle) **] next week (new patient eval). On arrival to our ED her vitals were: 97.2 99 124/69 20 92% 4L. As per note she was in no appearent distress. Her O2 sats remained in the low 90s on 4L N/C. She was given nebs and started on vanco and zosyn for the pna previously seem on cxray on [**12-2**]. She was then admitted to the ICU due to her O2 requirement and for further monitoring. On transfer her vitals were: 97.8ta. HR: 104. BP: 122/68. O2: 91% 4lnc. RR 20. She appears well and breathing without any difficulty. She is accompanied by her 2 children. ROS: As per HPI, she denies any fever, chills, no wt loss (wt gain in the last few months), baseline fatigue for the last few months. Baseline SOB on home O2 at 2L N/c, + non-productive cough which is improving over the last few days with meds. No chest pain, no LE edema. Decrease in appetite, no abd pain, no n/v, no change in her bowel movements. + abd lumps that she initially noticed in [**Month (only) **]. No bloody stools/no melena. No dysuria, no hematuria, no freq. No muscle pain. No HA, no dizziness, no visual or hearing changes, no gait disturbance. Past Medical History: ONCOLOGY HISTORY: -[**2169**] She was noted to have a 1.5-2.0 cm area of nodularity in the left breast on examination. A core biopsy was nondiagnostic. [**2170-4-28**] she had an excisional biopsy performed. This showed a 0.9 cm moderately differentiated invasive ductal cancer. There was DCIS comprising about 5% of the mass. There was LCIS present. There was no LVI. The cancer was noted to be ER positive, PR positive and HER 2/neu negative. There was as positive margin. -[**5-2**] she underwent a left breast reexcision and sentinel LN mapping procedure. This showed invasive ductal cancer, moderately differentiated in several foci around the biopsy cavity. The largest foci measured 1.5 cm. There was DCIS as well but the margins were negative for both invasive and in-situ cancer. There was LCIS present. A single sentinel LN was identified and this was positive for a metastases measuring 4 mm. -[**6-1**] She had a completion axillary dissection which showed that 12 additional axillary LN were negative. - [**Date range (1) 92444**] she received chemotherapy with "dose dense" CA for 4 cycles followed by 4 cycles of taxol. -[**Date range (1) 92445**] she received breast irradiation under the direction of Dr [**Last Name (STitle) **]. -[**Date range (1) 92446**] She was treated with tamoxifen -[**Date range (1) 92447**] she completed a 5 year course of aromasin -[**Date range (3) 92448**] She was admitted to the [**Hospital6 **] for bilobar pneumonia and hypoxia. Her initial O2 sat was 77% on RA. She was given antibiotics and nebulizers. She had a Chest CT on [**2178-1-9**] which showed no evidence of pulmonary embolus. There were enlarged mediastinal and hilar lymph nodes with bronchial cutoff and RML collapse and partial LLL collapse, as well as bilateral adrenal masses and ?left hepatic lobe lesion. An MRI of the abdomen on [**2178-1-13**] showed bilateral adrenal adenoma and focal fatty infiltration of the medial segment of the left lobe of the liver adjacent to the falciform ligament. -[**2178-1-30**] She had a repeat chest CT at [**Location (un) 2274**]: IMPRESSION: Significant improved aeration throughout all lung zones. Residual atelectasis or small infiltrates right middle and both lower lobes. No evidence of pathologically enlarged mediastinal or hilar lymphadenopathy. Enlarged bilateral adrenal lesions. -[**2178-11-5**] seen by Dr [**First Name (STitle) 1356**] and reported having noticed 3 firm masses in the subcutaneous tissue of the abdomen-one to the left of the umbilicus measured 4 x 3 cm, one in the epigastrium measured 1 x 2 cm and one in the later mid abdominal wall measured 1 x 0.5 cm -[**2178-11-6**] seen by Dr [**Last Name (STitle) 92449**] who biopsied the mass in the epigastrium. This showed metastatic adenocarcinoma. The cancer was positive for CK7, EMA and CEA and negative for ER, mammoglobin, CK 20, CD 10, S100, TTF-1, vimentin, RCC, PAX 8 andp63. In discussion with the pathologist-she noted that up to 22% of lung cancers may be negative for TTF-1. Differential dx was either lung or breast cancer by morphology -[**2178-11-13**] CT scan of the head was negative. Chest CT showed extensive mediastinal and right hilar adenopathy. There was compression of the right sided bronchi with atelectasis of the RML. Abdomen/pelvic CT showed no liver metastases. Prior CT scans showed a 2.4 cm right adrenal nodule and this was without change. However the left adrenal nodule is now significantly larger and more heterogenous appearing measuring 3.7 x 2.0 cm suggesting superimposed metastatic disease. There are several SQ nodules: there is a 3.1 cm cavity containing an air-fluid level a the site of the biopsy (this area was included in the chest CT from [**2-7**] and was new). There is a 8 mm nodule int he left lateral anterior SQ fat also new. Inferiorly there are additional nodules-largest in the left paraumbilical measuring 3.1 cm. Another nodule is seen lateral to the left acetabulum measuring 1.7 cm, there is a right paramedian nodule posterior to the gluteus maximus measuring 1.8. There are no bone lesions seen. OTHER MEDICAL HX: COPD (Chronic Obstructive Pulmonary Disease) POLYCYTHEMIA COLONIC ADENOMA TOBACCO DEPENDENCE Social History: She is widowed. She is currently unemployeed. she lives by herself and her 2 children live close by. She has 2 grandchildren who she usually watches over. Smoked 1.5 ppd x 30 years. She drinks socially. Family History: Mother: breast cancer on her early 60s and die at age of 66 yo with complications r/t breast cancer. (Pt had genetic testing and had no evidence of either the BRCA 1 and 2 germline mutations) Sister: brain CA uncertain what time, died in her 50s 2 children who are healthy Physical Exam: VITALS: 127/61, 87, 91-92% ON 4L GEN: well appearing female sitting in bed in NAD HEENT: PERRLA, EOM intact, sclera non-icteric, conjunctiva non-injected, no cervical LAD, neck supple, OP clear Lungs: CTA on L, dimished BS through on R posterior/anterior with inspiratory wheezing medially on anterior cw. No increase in WOB CV: RRR, normal S1/S2, no murmurs ABD: soft, NT/ND, + BS, multiple palpable indurated nodules-largest on umbilicus (~ 4cm in diameter w/ erythema), multiple smaller ones on LLQ SKIN: as noted above with multiple indurated nodules on abd in addition to right shoulder area. No rashes noted EXT: no edema, no cyanosis, + pulses Neuro: A+Ox3, CN II- XII intact, symmetrical strength on bil UE/LE [**4-3**], intact sensation Pertinent Results: [**Location (un) 620**] from [**2176-12-4**]: WBC 8.4/Hgb 16.4/Hct 50.6/ MCV 98.2/ Plats of 257, no diff. BUN of 7/creat of 0.4. Her D.dimer of 0.8 (normal range of 0-0.49) IMAGING: CXRAY FROM [**Location (un) 620**]: Chest x-ray shows a right hilar mass with a heat a right lower lobe or lateral subsegment of the right middle lobe infiltrate CTA on [**2178-12-4**]: as per note- no PE, but a lung tumor pressing on right bronchial and pulmonary artery (prelim) CT of head and Torso on [**2178-11-13**] (as per Atrius report)- Copy of the CD attached to chart, needs to be uploaded in our system). CT scan of the head was negative. Chest CT showed extensive mediastinal and right hilar adenopathy. There was compression of the right sided bronchi with atelectasis of the RML. Abdomen/pelvic CT showed no liver metastases. Prior CT scans showed a 2.4 cm right adrenal nodule and this was without change. However the left adrenal nodule is now significantly larger and more heterogenous appearing measuring 3.7 x 2.0 cm suggesting superimposed metastatic disease. There are several SQ nodules: there is a 3.1 cm cavity containing an air-fluid level a the site of the biopsy (this area was included in the chest CT from [**2-7**] and was new). There is a 8 mm nodule int he left lateral anterior SQ fat also new. Inferiorly there are additional nodules-largest in the left paraumbilical measuring 3.1 cm. Another nodule is seen lateral to the left acetabulum measuring 1.7 cm, there is a right paramedian nodule posterior to the gluteus maximus measuring 1.8. There are no bone lesions seen. . Chem 10 138 100 7 109 3.7 29 0.6 Ca: 8.7 Mg: 2.1 P: 3.8 . Alb: 3.8 . CBC 93 6.8 > 15.3 < 260 44.6 N:76.3 L:13.3 M:8.2 E:2.0 Bas:0.2 . PT: 11.9 PTT: 33.4 INR: 1.1 . BCx X2 [**2178-12-4**] NGTD Brief Hospital Course: 54 yo female w/ pmh significant for L breast CA-invasive ductal cancer in [**2169**], s/p lumpectomy with chemo followed by taxol and radiation tx, hx of 45 pack years of smoking, COPD, Polycythemia and recent dx of metastatic adenocarcinoma likely stage IV lung Ca who comes in today for hypoxia and increase in SOB. # Hypoxia/SOB: These symptoms today were in the setting of not using oxygen for 2 hours, otherwise pt states that her cough was improving and she denies having any fevers. So this is less like to be due to pneumonia, although it is possible that she could develop a post-obstructive pneumonia given her anatomy and tumor burden. Her OSH CTA was reviewed by the Pulmonary attending and felt more consistent with tumor burden causing lung collapse and compression. CTA from the OSH, preliminarily, remains negative for pulmonary emboli. The patient also has baseline COPD which likely worsened her condition today. She remained stable in-house on her home O2 requirement of 2L nasal cannula. She was continued on her home Advair diskus and provided symptomatic relief with tessalon perrles and codeine-guaifenescin PRN. On review of the CTA, it was felt that the patient would likely not benefit from stenting and thus Interventional Pulmonary were not called in-house. The patient and her new primary outpatient oncology team can consider this as an option long-term. As the patient was very stable and Heme/Onc did not have any acute recommendations of work-up in-house over the weekend, the patient was discharged home with oxygen. She has adequate oxygen supplementation at home, was able to walk >200 feet in the medical ICU without issues and has good family support (who will check in on her frequently each day). As the patient responded well symptomatically to low-dose ativan, she was given a prescription for this upon discharge, to help with anxiety and air hunger. . # Metastatic adenocarcinoma: This was found on biopsy of abdominal skin nodule, and is thought to be due to lung cancer. She has significant smoking history and breast cancer history, although as per Atrius oncologist, the metastasis is unlikely to be due to breast cancer. The patient also has mets to her left adrenal gland w/ mediastinal/hilar adenopathy, multiple skin nodules and large lung mass. As aforementioned, in discussions with Heme/Onc regarding treatment options, they did not feel anything would be acutely offered or worked-up further in-house. Review of the CTA did not suggest that stenting would be particularly helpful although further discussion with the patient between Heme/Onc and IP is warranted. The patient will establish care with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] next week. # Polycythemia: Patient with hx of polycythemia likely related to long term COPD and hypoxia Medications on Admission: - home oxygen therapy 2liter nasal prongs - Folic Acid 1 mg Oral Tablet take one a day - Cyanocobalamin, Vitamin B-12, (VITAMIN B-12) 1,000 mcg/mL Injection Solution please give 1000 microgram IM x1 - Benzonatate (TESSALON PERLE) 100 mg Oral Capsule take one po tid - Codeine-Guaifenesin (GUAIFENESIN AC) 10-100 mg/5 mL Oral Liquid take one teaspoon every 6 hr prn cough - Fluticasone 50 mcg/Actuation Nasal Spray, Suspension Use 2 sprays in each nostril once daily - Fluticasone-Salmeterol (ADVAIR DISKUS) 100-50 mcg/dose Inhalation Disk with Device Use 1 inhalation twice daily and rinse your mouth thoroughly afterward - Albuterol Sulfate (PROAIR HFA) 90 mcg/Actuation Inhalation HFA - Aerosol Inhaler Take 1-2 puffs every 4 to 6 hours as needed - Ipratropium-Albuterol (DUONEB) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation Solution for Nebulization 3cc via neb [**Hospital1 **] x 2 wks as needed for copd flare - CITRACAL TABLET 950MG PO (CALCIUM CITRATE) as directed Discharge Medications: 1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. 3. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 4. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) inhalation Inhalation twice a day. 5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) sprays Nasal once a day. 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: Three (3) cc via neb Inhalation twice a day: x2 weeks as needed for COPD flare. 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Metastatic lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to the hospital for shortness of breath and low oxygen saturations. We believe this is due to the effects of your lung cancer, rather than from an infection or clot in your lungs. You should continue using your inhalers and oxygen to help you breathe better at home. It is important from now on that you always bring your oxygen with you, even if you are only running errands, in order to help prevent low oxygen levels in the future. No changes were made to your medications. It was a pleasure to take care of you at [**Hospital1 827**]! Followup Instructions: Please keep your upcoming appointment with Dr. [**Last Name (STitle) **]: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2178-12-10**] at 10:30 AM With: [**Name6 (MD) **] [**Name8 (MD) 831**], 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: THURSDAY [**2178-12-10**] at 10:30 AM With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "198.2", "305.1", "238.4", "785.6", "198.7", "V10.3", "162.2", "V46.2", "518.0", "496" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15442, 15448

10691, 13525

341, 348

15515, 15515

8856, 10668

16285, 16964

7797, 8073

14545, 15419

15469, 15494

13551, 14522

15666, 16262

8088, 8837

273, 303

376, 3323

15530, 15642

3345, 7560

7576, 7781

30,850

140,248

31169

Discharge summary

report

Admission Date: [**2124-10-18**] Discharge Date: [**2124-10-27**] Date of Birth: [**2062-10-3**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: Metastic Sarcoma left chest Major Surgical or Invasive Procedure: Left extrapleural pneumonectomy, flexible bronchoscopy, thoracic duct ligation, diaphragmatic repair, pericardiectomy with mesh placement, left 6th rib excision Social History: Smoked for 20 y, but quit 30 y ago. Rare drinks alcohol, denies history of illicit drug use. He is a retired commercial fisherman, married, with 2 children and 2 grandchildren. Family History: Notable for coronary artery disease but no history of malignancy. Physical Exam: General: 62 y.o. male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple, no lymphadenopathy Card: normal S1,S2 regular, rate & rhythm, no murmur/gallop or rub Resp: decreased breath sounds on right otherwise clear. Left very diminished breath sounds throughout lung field GI: bowel sounds positive, abdomen soft non-tender/non-distended Extr: warm no edema Wound: left thoracotomy site clean, dry intact with steri-strips Neuro: non-focal Pertinent Results: [**2124-10-18**]: GLUCOSE-168* UREA N-17 CR-1.0 SOD-140 POT-4.0 CHL-106 CO2-24 [**2124-10-18**]: WBC-14.9 RBC-4.32 HGB-13.5 HCT-37.0, PLTS: 308 [**2124-10-23**]: CT abdomen w/contrast No definite evidence of bowel ischemia. Please note this condition may be present with a normal CT examination and needs to be correlated with clinical suspicion. Normal appendix . Colonic diverticulosis. 2. Postoperative changes from recent left pneumonectomy with moderate amount of simple fluid and air within the left hemithorax along with adjacent subcutaneous edema and emphysema. Mild amount of residual pneumomediastinum. 3. Incompletely characterized right adrenal nodule. Can be better evaluated with dedicated MRI or CT adrenal protocol. 4. Radioactive seeds along the posterior right pelvis with adjacent small hypoattenuating, likely cystic lesions. 5. 5-6mm nonspecific RML nodule. Can be followed up in [**7-25**] months given patients history of malignancy. CXR: [**2124-10-27**] Expected changes of left hydropneumothorax following pneumonectomy. Brief Hospital Course: pt was admitted on [**2124-10-18**] for extrapleural pneumonectomy, flexible bronchoscopy, thoracic duct ligation, diaphragmatic hernia repair, pericardectomy with mesh replacement, left 6th rib excision. An epidural was placed at the time of surgery. Pt was extubated in the OR and transferred to the SICU for ongoing monitoring of cardiopulmonary status. Pt briefly required neo gtt for hypotension- given volume resusitation with hespan and neo was weaned off. cardiac enzymes were cycled and were neg. On POD#3 pt was transferred from the icu to the floor for ongoing post op care. On POD#4 pt noted to be in afib treated w/ IV dilt- required pressor support for IV dilt and therefor was transferred back to the ICU for hemodyamnic moniotring and support. Pt also had persistant left arm weakness since he awoke from surgey. neuro was consulted and pt was thought to have a plexopathy possibly d/t OR positioning. PT/OT was consulted and treated the patient thru-out his hosp stay w/ gradual and staedy improvement in his symptoms. POD#5 pt was in NSR after diuresis and was maintained on dilt gtt and lopressor w/ stable BP. He was again transferred fromt he ICU to the floor. Later on POD#5, he developed abd pain and distention. An abd CT was unremarkable for acute process. Pt was placed on an aggessive bowel regimen w/ results and relief of his symptoms. On POD#[**7-20**] he was [**Last Name (un) 1815**] full liq diet and was pogressing well w/ PT/OT. On POD#8 dilt gtt was weaned off and pt was again back in afib which was successfilly treated w/ increased lopressor. Pain was well controlled on po percocet, motrin and his pre-hosp fent patch was resumed. he was d/c'd to home on POD#9 w/ [**Name (NI) 269**], PT/OT services. Medications on Admission: Fentanyl patch, Motrin, and Neurontin for chronic right hip pain. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO tid. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* 4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*1* 5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO QID (4 times a day). Disp:*180 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 805**] [**Last Name (NamePattern1) **] Care Discharge Diagnosis: Mestatic Sarcoma left chest [**7-20**] left base lung lesion cytologic evaluation [**2-20**] External Beam XRT to Left chest Grade III/III left buttocks myxofibrosarcoma Discharge Condition: Good Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if experience: -Fever > 101 or chills -Increased Shortness of breath, cough or sputum production -Chest pain Incision site: steri-strips remove in [**11-26**] days. if start to come off remove. You may shower No swimming or bathing for 6 weeks No driving while taking narcotics: take stool softners with narcotics Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] on Thursday 9:30am [**2124-11-2**] at the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center on the [**Location (un) **]. Report to the [**Location (un) **] radiology department for a chest x-ray 45 minutes before your appointment. Follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] Completed by:[**2124-11-14**]

[ "197.0", "197.1", "V10.89", "716.96", "458.29", "198.89", "427.31", "997.09", "353.0", "197.2" ]

icd9cm

[ [ [] ] ]

[ "32.5", "40.64", "03.90", "34.84", "33.22", "37.31" ]

icd9pcs

[ [ [] ] ]

4797, 4935

2379, 4123

351, 513

5149, 5156

1300, 2356

5589, 6005

726, 794

4240, 4774

4956, 5128

4149, 4217

5180, 5566

809, 1281

284, 313

529, 710

7,840

190,442

30843

Discharge summary

report

Admission Date: [**2149-6-26**] Discharge Date: [**2149-7-7**] Service: CARDIOTHORACIC Allergies: Demerol Attending:[**First Name3 (LF) 1505**] Chief Complaint: SOB and weakness Major Surgical or Invasive Procedure: s/p AVR(23mm CE pericardial valve) [**2149-6-26**] History of Present Illness: This 90WM has a known history of severe AS/AR had increasing SOB and was cathed. He was pretreated with mucomyst and bicarbonate for renal protection. Past Medical History: Aortic stenosis, severe Aortic regurgitation, moderately severe CHF (EF 70%) CRI (baseline Cre 2.5) s/p left nephrectomy ([**2136**]) BPH Urinary incontinence Anemia (baseline Hct 34) Depression Social History: Retired construction worker. Married 71 years. Has 1 son and daughter. Former cigar smoker for 'many years' (quit 35 years ago). [**2-4**] glass wine daily Family History: Father with CAD and CHF. Physical Exam: Elderly [**Male First Name (un) 4746**] in NAD AVSS HEENT: NC/AT, PERLA, EOMI Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+=bilat w/ rad. murmur Lungs: Clear to A+P CV: RRR without R/G, II/VI blowing SEM Abd: +BS, soft, nontender without masses or hepatosplenomegaly Ext: without C/C/E, pulses: 2+ fem and radials bilat., 1+ DP and PT bilat. Neuro: nonfocal Pertinent Results: [**2149-7-5**] 07:20AM BLOOD WBC-7.6 RBC-3.14* Hgb-9.3* Hct-29.0* MCV-92 MCH-29.7 MCHC-32.2 RDW-14.0 Plt Ct-323 [**2149-6-29**] 03:08AM BLOOD PT-13.6* PTT-39.2* INR(PT)-1.2* [**2149-7-5**] 07:20AM BLOOD Glucose-103 UreaN-85* Creat-2.0* Na-140 K-4.3 Cl-103 HCO3-29 AnGap-12 Date: [**2149-7-7**] Signed by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 72986**] on [**2149-7-7**] Affiliation: [**Hospital1 18**] Cosigned by [**Name (NI) 2620**] [**Last Name (NamePattern1) 2621**], [**Name (NI) 65847**] on [**2149-7-7**] REPEAT BEDSIDE SWALLOWING EVALUATION: HISTORY: We returned to evaluate this [**Age over 90 **] y/o male with known severe AS/AR referred on [**2149-6-26**] for a cath and pre-op eval for AVR. Pt is s/p AVR off pump c/b V tach, shocked x 2 on [**6-26**], extubated [**6-27**]. Pt was started on clear liquids but had overt coughing after thin liquids. It appears he was tolerating nectar thick liquids and pureed solids, but we were consulted to evaluate for oral and pharyngeal dysphagia while the pt was in the ICU. PMH includes CHF, CRI, urinary incontinence, anemia, depression, s/p left nephrectomy [**2136**], L shoulder surgery, tonsillectomy He was seen on [**2149-7-1**] but had overt signs of aspiration after ice chips, thin liquids and nectar thick liquids. He had a weak cough and also had difficulty fully clearing his secretions. It was recommended he remain NPO and an NG tube was placed. He was transferred to the floor and a repeat bedside swallowing evaluation was performed on [**2149-7-3**]. The pt continued to have intermittent signs of aspiration at the bedside, but it appeared that he may be able to tolerate a modified diet with compensatory strategies, so further evaluation via a video swallowing evaluation was recommended. A video swallowing evaluation was performed the same day and findings revealed a mild oral and pharyngeal dysphagia characterized by reduced oral control, mild swallow delay, reduced laryngeal elevation / absent epiglottic deflection and reduced bolus propulsion. It was recommended that the pt receive primary nutrition via the NG tube and receive trials of nectar thick liquid and puree consistency solids with 1:1 supervision, alternate between bites and sips, and take repeat swallows after each bite or sip. The pt was seen for swallowing therapy on [**2149-7-4**] and tolerated the consistencies presented and understood the compensatory strategies. We returned today to evaluate the pt's use of compensatory strategies, to see if he is tolerating his diet, and to see if he could be advanced to a less restricted diet. His RN reported that he has been eating well and has not shown overt signs of aspiration with nectar thick liquids and puree consistency solids. EVALUATION: The examination was performed while the patient was seated upright in the chair on [**Hospital Ward Name 121**] 220. Cognition, language, speech, voice: The pt was awake, oriented x3 and able to follow all basic commands. His language was fluent, his speech was not dysarthric and his vocal quality was WFL with mildly reduced volume. Teeth: Remaining in fair condition. Secretions: WFL ORAL MOTOR EXAM: The pt presented with symmetrical facial appearance and adequate labial and buccal tone. Tongue protrusion was at midline and both strength and ROM were within normal limits. Palatal elevation was symmetrical, +gag. SWALLOWING ASSESSMENT: The evaluation was performed with the pt's breakfast tray and included ice chips, thin liquid (tsp, cup), nectar thick liquid (cup), puree ([**3-8**] oz) and cracker. Oral transit was timely and no residue remained in the oral cavity. Laryngeal elevation was timely but mildly reduced to palpation. The pt coughed immediately after 3 trials of thin liquid by cup and consecutive bites of pudding by tsp (resulting in greater residue). There were no other overt signs of aspiration for any other consistencies, including other puree boluses presented. SUMMARY / IMPRESSION: The pt showed overt signs of aspiration after half of trials of thin liquid by cup and all trials of pudding consistency by tsp. There were no other overt signs of aspiration for any other consistencies, including other puree consistency boluses. The pt demonstrated the compensatory strategies and was able to alternate between bites of solids and sips of liquid with verbal cues. Therefore, we recommend that the pt continue to take a modified diet of nectar thick liquids and can be advanced to soft consistency solids with 1:1 supervision for help with feeding and cues for strategies. Pills can be crushed in puree. If the pt has any difficulty tolerating this diet, please re-consult and we will return to re-evaluate the pt. This swallowing pattern correlates to a Dysphagia Outcome Severity Scale (DOSS) rating of 3, moderate dysphagia with supervision, strategies and 2 or more diet consistencies restricted. RECOMMENDATIONS: 1. The pt can continue with a modified diet of nectar thick liquids and be advanced to soft consistency solids with the following precautions: a) 1:1 supervision b) Single sips of nectar thick liquids only by cup c) Alternate between EVERY bite and sip. d) Cue the pt to take an extra swallow after each sip of liquid. 2. Pills can be crushed with puree. 3. Please re-consult if the pt has any difficulty tolerating this diet. 4. Follow up with speech and language therapy is recommended for the pt at rehab. These recommendations were shared with the patient, nurse and medical team. ____________________________________ [**Doctor First Name 20695**] [**Doctor First Name **], M.A., Speech Pathology Graduate Intern Pager #[**Numeric Identifier 72987**] ____________________________________ [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.S., CCC-SLP Pager #[**Numeric Identifier 2622**] RADIOLOGY Preliminary Report CHEST (PA & LAT) [**2149-7-6**] 9:38 AM CHEST (PA & LAT) Reason: r/o inf, eff [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old man with severe AS REASON FOR THIS EXAMINATION: r/o inf, eff HISTORY: Aortic stenosis. PA and lateral radiographs of the chest demonstrate the patient to be status post median sternotomy. Cardiomediastinal contours are [**Age over 90 1506**] compared to [**2149-7-4**]. There has been marked interval improvement in the previously seen bilateral pleural effusions. There may be a persistent small left-sided pleural effusion. Trachea is midline. Surgical clips project over the left upper quadrant. No consolidation. There is bibasilar atelectasis. A prosthetic aortic valve is again noted. IMPRESSION: Improved bilateral pleural effusions with persistent, small, left-sided effusion. Bibasilar atelectasis. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**] Cardiology Report ECHO Study Date of [**2149-6-26**] *** Report not finalized *** PRELIMINARY REPORT PATIENT/TEST INFORMATION: Indication: Intra-op TEE for AVR Height: (in) 61 Weight (lb): 130 BSA (m2): 1.57 m2 BP (mm Hg): 125/49 HR (bpm): 52 Status: Inpatient Date/Time: [**2149-6-26**] at 08:43 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW210-0:0 Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *5.9 cm (nl <= 4.0 cm) Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.5 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 4.4 cm Left Ventricle - Fractional Shortening: *0.20 (nl >= 0.29) Left Ventricle - Ejection Fraction: 35% (nl >=55%) Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm) Aorta - Ascending: *4.0 cm (nl <= 3.4 cm) Aorta - Arch: *3.1 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: *2.9 cm (nl <= 2.5 cm) Aortic Valve - Peak Gradient: 75 mm Hg Aortic Valve - Mean Gradient: 55 mm Hg Aortic Valve - LVOT Diam: 1.8 cm Aortic Valve - Valve Area: *0.4 cm2 (nl >= 3.0 cm2) INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. Mild spontaneous echo contrast in the body of the LA. Mild spontaneous echo contrast in the LAA. Depressed LAA emptying velocity (<0.2m/s) Cannot exclude LAA thrombus. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity size. Moderately depressed LVEF. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Moderately dilated ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Mildly dilated descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Moderate (2+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Severe mitral annular calcification. No MS. Mild to moderate ([**2-4**]+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions: PRE-BYPASS: 1. The left atrium is moderately dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. 2. Mild 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. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is moderately depressed. 4. There is mild global right ventricular free wall hypokinesis. 5. The ascending aorta is moderately dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. 6. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Moderate (2+) aortic regurgitation is seen. 7. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. Mild to moderate ([**2-4**]+) mitral regurgitation is seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. 1. A well-seated bioprosthetic valve is seen in the aortic position with normal leaflet motion. A trace central AI jet is seen. A mild perivalvular leak is also seen near the mitral aspect of the bioprosthesis. 2. MR [**First Name (Titles) **] [**Last Name (Titles) 1506**]. 3. Biventricular function is improved. 4. Aorta is intact 5. Other findings are [**Last Name (Titles) 1506**] Brief Hospital Course: The patient underwent cardiac cath on [**6-13**] which revealed: [**Location (un) 109**] of 0.5 cm2, 20% [**First Name9 (NamePattern2) **] [**Last Name (un) 2435**]., 20% LAD [**Last Name (un) 2435**], 20% LVX lesion, and 20% RCA lesion. He had an echo which showed severe AS/AI, heavy MAC, LVH, and an EF of 70%. Dr. [**Last Name (STitle) **] was consulted and [**6-26**] the pt. had an AVR(23mm CE pericardial valve). The cross clamp time was 65 mins., total bypass time was 86 mins. He tolerated the procedure well and was transferred to the CSRU on Neo and Propofol in stable condition. He was extubated on POD#2 and had his CTs d/c'd. His creatinine increased slightly to 2.6. His epicardial pacing wires were d/c'd on POD#5. He became mildly confused which eventually resolved. He also had difficulty swallowing and was temporarily tube fed and eventually passed his swallowing study. He was transferred to the floor on POD#5. He also had a flare of gout in his R 1st finger PIP which was treated with indocin. He continued to progress and was discharged to rehab in stable condition on POD#11. Medications on Admission: ASA 81 mg PO daily Lopressor 25 mg PO BID Microzide 12.5 mg PO daily Proscar 5 mg PO daily Lasix 80 mg PO daily Prozac 10 mg PO daily Oxytrol 3.9 mg/24 hour patch 2x/wk Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet 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: One (1) PO BID (2 times a day). 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 8. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 9. Lactulose 10 g/15 mL Solution Sig: Thirty (30) ML PO TID/PRN. 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: Aortic stenosis CRI-s/p L nephrectomy BPH anemia depression Discharge Condition: Good. Discharge Instructions: Follow medications on dsicahrge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office for temp>101.5, sternal drainage. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 68100**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 4783**] for 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2149-7-7**]

[ "428.0", "274.9", "276.0", "787.2", "285.9", "593.9", "600.00", "311", "424.1", "V45.73" ]

icd9cm

[ [ [] ] ]

[ "89.60", "39.61", "96.6", "35.21" ]

icd9pcs

[ [ [] ] ]

14871, 14941

12712, 13826

237, 290

15045, 15053

1317, 7285

15380, 15627

877, 903

14045, 14848

7322, 7369

14962, 15024

13852, 14022

15077, 15357

8299, 12689

918, 1298

181, 199

7398, 8273

318, 470

492, 688

704, 861

15,526

144,559

26589

Discharge summary

report

Admission Date: [**2183-9-30**] Discharge Date: [**2183-10-23**] Date of Birth: [**2118-10-15**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Adominal pain, necrotizing pancreatitis Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Drainage of retroperitoneal abscess and lesser sac. 3. Debridement of necrotic pancreatic tissue. 4. Open cholecystectomy. 5. Combined gastrojejunostomy feeding tube. History of Present Illness: This 64-year-old gentleman was transferred to [**Hospital1 18**] 1 day prior to this operation for [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 36688**] Hospital. While there, he was found to have a deteriorating course after 13 days of treatment for acute gallstone pancreatitis. He had been treated with steroids for presumed COPD exacerbation and also was placed on anticoagulation with Coumadin for atrial fibrillation. There is concern for pancreatic abscess and he was transferred to our care. We performed a CAT scan that did infact delineate gas in the pancreatic bed. With these findings, we reversed his anticoagulation and took him to the operating room the following day for a pancreatic debridement and abscess drainage. Past Medical History: PMH: HTN DM Dyslipidemia Nephrolithiasis Presumed OSA Presumed obesity, hypoventilation syndrome COPD Atrial Fibrillation Pertinent Results: On discharge: WBC 10.6, 25.5 Hct Brief Hospital Course: Went to OR as described above. Turbid fluid was found in subhepatic space. Large retroperitoneal abscess, pancreatic abscess. 3 drains placed in lesser sac and open cholecystectomy performed. Imipenem begun at OSH was continued post-op, fluconazole was added was added [**10-2**]. [**11-26**] blood culture bottles positive for klebsiella sensitive to imipenem. Same grew from peritoneal fluid. On [**9-30**] he went into afib s/p unsuccessful DCCV. He was converted to NSR with amiodorone. Asymptomatic, ruled out for MI. Afib thought to be secondary to fever, infection. Cardiology consulted and recommended continuing with beta blocker only. Remained rate controlled but in afib over next 2 weeks. Imipenem course (14days post-op) was completed and antibiotics were stopped on [**10-15**]. Calorie counts revealed that he was taking very little oral calories and nutrition helped with J-tube feed recommendations. Patient's blood glucose levels remained within control, he was afebrile, and he began getting out of bed with PT to a chair. Staples on the abdominal incision were removed. Rehab screening began, however several days after the antibiotics were stopped he spiked one night to 102. Wound was partially opened for examination given the fevers and Chest x-ray, UA were negative, and the CVL was removed (no growth on the line tip culture). Flagyl was started empirically for diarrhea (despite negative c difficile studies), and vancomycin was addded when he continued to have low grade fevers over the next 2 days. Blood cultures were negative, however a culture from the JP fluid grew several gram negatives, including klebsiella. Infectious disease service was re-consulted and recommended continuing with zosyn only (and for 4 weeks probably). A picc line was placed in IR for this purpose. Patient also began to have rapid afib with the febrile episodes, cariology again consulted and he was controlled with PO lopressor and PO diltiazem. They did not feel that he was a good candidate for DC cardioversion at this time. By [**10-19**] patient was afebrile, pain well-controlled, getting out of bed daily and heart rate within normal parameters. He is being discharged to rehab with follow-up planned and weekly labs. Please continue with twice daily wet to dry dressing changes on the open parts of the abdominal incisions. The 2 [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains will also need to be kept to suction and emptied every shift. They are draining remains of necrotic pancreas and normally have a greyish color. Discharge Medications: 1. Piperacillin-Tazobactam 4.5 g Recon Soln [**Last Name (NamePattern1) **]: One (1) Recon Soln Intravenous Q8H (every 8 hours). Recon Soln(s) 2. Acetaminophen 325 mg Tablet [**Last Name (NamePattern1) **]: Two (2) Tablet PO Q4H (every 4 hours) as needed. 3. Artificial Tear Ointment 0.1-0.1 % Ointment [**Last Name (NamePattern1) **]: One (1) Appl Ophthalmic PRN (as needed). 4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Last Name (NamePattern1) **]: [**11-24**] Drops Ophthalmic PRN (as needed). 5. Nystatin 100,000 unit/mL Suspension [**Month/Day (2) **]: Five (5) ML PO QID (4 times a day) as needed. 6. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1) Injection TID (3 times a day). 7. Dolasetron 12.5 mg/0.625 mL Solution [**Month/Day (2) **]: One (1) Intravenous Q8H (every 8 hours) as needed for nausea. 8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Day (2) **]: One (1) ML Intravenous DAILY (Daily) as needed. 9. Metoprolol Tartrate 50 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO BID (2 times a day). 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR [**Month/Day (2) **]: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 11. Furosemide 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3 times a day). 12. Diltiazem HCl 120 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3 times a day). 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 14. Zolpidem 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 15. Potassium Chloride 20 mEq Packet [**Last Name (STitle) **]: One (1) Packet PO DAILY (Daily). 16. Captopril 12.5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO TID (3 times a day). 17. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 18. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30) ML PO Q6H (every 6 hours) as needed. 19. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 20. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. 21. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours). 22. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours). 23. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 24. Insulin NPH Human Recomb 100 unit/mL Cartridge [**Last Name (STitle) **]: 40 units Subcutaneous twice a day: with breakfast and dinner. 25. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: prn units Subcutaneous PRN: PER ISS PROTOCOL AT REHAB. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: 1. Pancreatic abscess. 2. Pancreatic necrosis. 3. Gallstone pancreatitis. Discharge Condition: Stable Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. Be sure to take your complete course of antibiotics. You may take showers (no baths) after your dressings have been removed from your wounds. Followup Instructions: Please follow-up Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4340**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2183-11-25**] 10:00 Please also follow-up with Dr. [**Last Name (STitle) **] in 3 weeks. Please call ahead of time to schedule an appointment. THanks. Completed by:[**2183-10-22**]

[ "427.31", "V58.65", "584.9", "496", "401.9", "V58.61", "707.05", "567.38", "428.0", "327.23", "995.92", "250.00", "787.91", "278.01", "577.0", "574.41", "518.81", "038.49" ]

icd9cm

[ [ [] ] ]

[ "96.6", "44.32", "96.72", "38.93", "99.29", "96.04", "99.62", "52.22", "51.22", "88.72", "99.69" ]

icd9pcs

[ [ [] ] ]

7044, 7124

1557, 4131

355, 554

7242, 7251

1500, 1500

8075, 8409

4154, 7021

7145, 7221

7275, 8052

1514, 1534

276, 317

582, 1335

1357, 1481

25,207

128,583

3572

Discharge summary

report

Admission Date: [**2114-8-20**] Discharge Date: [**2114-9-4**] Date of Birth: [**2047-1-30**] Sex: M Service: [**Location (un) 259**] MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old man with a past medical history significant for coronary artery disease, Wegener's granulomatosis and myelodysplasia (please see past medical history below) who presented with chest pain over the prior three days, as well as fevers and chills. Regarding fevers, the patient has a history of Wegener's granulomatosis with treatment with prednisone (still on 5 mg q day) and Cytoxan (discontinued in [**2113-12-18**]) and several admissions for fever and neutropenia in the past. On presentation for this admission, the patient reported having had low grade temperatures and odynophagia for approximately three days prior to admission, as well as mild cough and fatigue. He was started on levofloxacin two days prior to admission without significant improvement in symptoms. Then, on the morning of admission, he reported having fevers to 104??????, as well as shaking chills, for which he presented to the [**Hospital6 256**] Emergency Department. There, he received a dose of vancomycin, gentamicin, ceftazidime and Flagyl in the Emergency Department. While in the Emergency Department, the patient's systolic blood pressure dropped to the 80s and this was accompanied by lightheadedness and left sided chest pain. The patient's blood pressure improved with hydration. Regarding the patient's chest pain, the patient has an extensive history of coronary artery disease and is followed for this by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (see below for more detail). The patient reported substernal chest pain with swallowing that he was felt was dissimilar to past anginal pain. The pain did not radiate, was not associated with dyspnea, palpitations, nausea or vomiting. However, in the Emergency Department, in the setting of hypertension, the patient's reported onset of his left sided chest tightness that was indeed similar to his prior anginal pain. An electrocardiogram in the Emergency Department showed ST depressions in V2 through V5, as well as T-wave inversions in leads 1, AVL and V1 through V6. The patient was given aspirin and sublingual nitroglycerin with improvement in his left sided chest pain from 6 out of 10 in severity to 1 out of 10 in severity in the Emergency Department. His pain resolved by the time he arrived in the Medical Intensive Care Unit. Electrocardiogram findings also resolved with repeat electrocardiogram taken in the Intensive Care Unit. PAST MEDICAL HISTORY: 1. Coronary artery disease A. Status post multiple interventions: Coronary artery bypass graft in [**2105**] with left internal mammary artery to the LAD, saphenous vein graft to the PL and saphenous vein graft to the PDA. B. Multiple catheter procedures: Stent x2 to the left circumflex, stent to the LAD, distal to the left internal mammary artery touchdown. Most recent catheter procedure: [**2114-6-4**], normal hemodynamics. Angiography significant for occlusion of the LAD mid segment with a patent left internal mammary artery and a patent distal LAD stent. Old RCA occlusion. Saphenous vein graft to the PL was found to be widely patent. Saphenous vein graft to the PDA was found to have 70% mid vessel stenosis. The patient underwent stenting of the saphenous vein graft to the PDA with 0% residual stenosis. C. Last echocardiogram prior to current admission (performed [**2114-1-29**]): The study was of relatively poor quality and revealed a left ventricular ejection fraction of 35% to 40%. Mild concentric left ventricular hypertrophy was seen with moderate depression of LV systolic function. Dyskinesis of the basal inferior and mid inferior segments was noted, as was hypokinesis of the basal inferolateral and mid inferolateral portions. Right ventricular size and function was normal. The patient was found to have moderate mitral regurgitation. 2. Wegener's granulomatosis was initially diagnosed as RA, later felt to be Wegener's in [**2111**]. The patient had been treated with prednisone and Cytoxan. Cytoxan was started in [**2113-10-18**] and discontinued in [**2113-12-18**]. 3. Myelodysplasia, receives transfusions every one to two weeks. 4. Hypertension 5. Hyperlipidemia OUTPATIENT MEDICATIONS: 1. Epogen 40,000 units q week 2. Carafate 1 gm q day 3. Captopril 25 mg t.i.d. 4. Prednisone 5 mg q.d. 5. Amiodarone 200 mg q.d. 6. Lopressor 100 mg t.i.d. 7. Lasix 40 mg prn 8. Vitamin E ALLERGIES: No known drug allergies. REPORTS GASTROINTESTINAL UPSET WITH CODEINE. SOCIAL HISTORY: The patient is married and lives at home with his wife. [**Name (NI) **] smoked one pack per day x20 years, quit about 17 years ago. The patient reports alcohol use of approximately one to two drinks per week. FAMILY HISTORY: The patient's brother has coronary artery disease. The patient's mother was diagnosed with [**Name (NI) 2481**] disease. LABORATORY DATA ON PRESENTATION: A CBC revealed a white count of 1.0 with the following differential: 40 segs, 4 bands, 50 lymphocytes, 6 monocytes. Granulocyte count was 590. The patient's hemoglobin was 12.5 and his hematocrit was 36.2. His platelet count was 43. A chem-7 revealed sodium of 137, potassium of 4.0, chloride of 99, bicarbonate of 22. BUN of 32 and creatinine of 1.2 with a glucose of 118. The patient's initial CK was 33 with a troponin of 3. Subsequent CKs were 82 and then 67. Subsequent troponins were 2.7 and 6.4. The patient's last ANCA prior to this current admission was 1.3. A urinalysis revealed no red blood cells, no white blood cells, no bacteria and no epithelials. IMAGING: An AP and lateral chest x-ray obtained on [**8-20**] revealed heart size stable. Pulmonary vasculature was within normal limits. Bibasilar interstitial coarse reticular opacities were seen. These were stable compared with prior studies. No acute processes were appreciated. Electrocardiogram in the Emergency Department: Sinus tachycardia at 100 beats per minute, axis 0, intervals normal with T-wave inversions in leads 1, AVL, V2 through V6. ST depressions were seen in leads V2 through V5. An old Q wave was seen in lead 3. Compared with prior study from [**2114-6-30**], T-wave inversions and ST depressions are new. Electrocardiogram in the MICU: Sinus tachycardia at 100 beats per minute, axis 0, intervals normal. Resolution as above, no change compared with prior electrocardiogram from [**2114-6-30**]. OTHER LABS AND IMAGING OF NOTE FOR THIS CURRENT ADMISSION: Transthoracic echocardiogram: As will be discussed below, the patient received a TTE on [**2114-8-24**] for evaluation of his heart function following non Q-wave myocardial infarction as well as for evaluation of possible endocarditis in the setting of fevers and neutropenia. This echocardiogram was felt to be of adequate quality (versus poor quality of above noted echocardiogram). There was no evidence of endocarditis found; left ventricular ejection fraction was estimated at 55%. Left ventricular hypertrophy was noted. Wall motion abnormalities were noted as hypokinesis at the basal inferoseptal and mid inferoseptal portions. Right ventricular function and wall thickness were normal; 3+ mitral regurgitation was noted. Esophagogastroduodenoscopy: As will also be noted below, the patient underwent esophagogastroduodenoscopy on or about [**8-24**] for evaluation of possible esophagitis, again in the setting of neutropenia and fevers, as well as a history of odynophagia. The esophagogastroduodenoscopy was negative for esophagitis. CT scan of the sinuses, [**2114-8-27**], revealed no evidence of acute sinus disease. BRIEF HOSPITAL COURSE: The patient was initially admitted to the Medical Intensive Care Unit on [**2114-8-20**] with neutropenia, fevers, odynophagia and hypotension. As noted above, during a hypotensive episode, the patient developed chest pain. What follows is a brief hospital course by problem list: 1. CARDIAC: The patient ruled in for a non Q-wave myocardial infarction by troponin levels. He was continued on captopril, Lopressor and Aspirin; subsequently, the aspirin was discontinued for very low platelet levels. In terms of the patient's rate and rhythm status, the patient has a history of AT and NST; initially his amiodarone was discontinued upon admission for the possible risk of bone marrow suppression. However, following cardiology consult, his amiodarone was restarted on [**2114-8-23**]. Cardiology felt that the overall chronology of the patient's onset of neutropenia was not compatible with his starting amiodarone and that furthermore, his history of atrial tachycardia and NST warranted restarting amiodarone. The patient's overall post myocardial infarction cardiac function was assessed with the transthoracic echocardiogram. Results from the [**8-24**] study are noted above. The patient's hemodynamic status was stabilized over the first day or so of his admission, such that he was no longer hypertensive, nor did he exhibit any chest pain or electrocardiogram changes following his above mentioned course. Thus, on [**2114-8-22**], he was called out of the MICU to the medicine floor. 2. INFECTIOUS DISEASE: Shortly after transfer from the MICU to the medicine floor on [**2114-8-22**], the patient spiked temperature to 103.4?????? and exhibited rigors and chills. The infectious disease service was consulted and an exhaustive work up for the fever source ensued. The patient initially received the above mentioned antibiotics in the Emergency Department. His subsequent antibiotic regimen was tailored over the course of his hospitalization. The patient received a course of ceftazidime, as well as a 14 day course of acyclovir. The latter was prescribed for HSV like lesions that appeared shortly after admission on the patient's upper lip and which subsequently subsided completely following the administration of acyclovir. As noted above, the patient underwent a transthoracic echocardiogram for evaluation of endocarditis; this study was negative for endocarditis. The patient also underwent esophagogastroduodenoscopy for evaluation of possible esophagitis in the setting of neutropenia and odynophagia; this study was likewise negative. Furthermore, cultures were taken of the patient's blood, urine and stools. These were negative, as was a buffy coat test for HSV. The patient continued to have intermittent fevers with a T-max on [**8-25**] of 102.0??????; subsequently, his temperature curve dwindled such that his T-max on [**8-27**] was 100.0??????. Thereafter, the patient remained afebrile for a time until, on [**8-30**], he was noted to have a temperature of 100.9??????. At this point, as with the remainder of the patient's hospitalization, no clear source for a fever was found, however it was felt on [**8-30**] that his resurgence of temperature was most likely due to possible cellulitis and/or intravenous site infection. Thus, the patient was restarted on ceftazidime and started on vancomycin. Subsequent blood cultures were negative and the ceftazidime was discontinued. However, the patient continued intravenous vancomycin through the remainder of his hospitalization for treatment of the possible intravenous site infection. The patient's right forearm intravenous site exhibited some tenderness, erythema and a palpable cord. These signs and symptoms slowly diminished over the ensuing days up to the patient's discharge from the hospital. From this point on, the patient did not exhibit frank fever spikes and his intravenous sites as noted above slowly improved. The patient, as will be noted below, was discharged home on four doses of p.o. Linezolid to finish covering what had been covered by the intravenous vancomycin. 3. HEMATOLOGY: The hem/onc service was consulted and followed the patient for issues pertaining to his history of myelodysplasia. The patient was transfused several units of packed red blood cells over the course of his hospitalization; this was fully consistent with his periodic requirement for red blood cell transfusion related to the above noted condition. The patient's platelets remained low throughout his hospitalization and for this reason he was not given aspirin. In terms of the patient's neutropenia, much discussion was held as to whether or not the patient should be given G-CSF in an attempt to improve his white count. However, because the patient had a history of having blast cells in his smears, the risk of possible conversion to AML was felt too high to warrant use of G-CSF at that time. 4. RHEUMATOLOGIC ISSUES: The rheumatology service was consulted for evaluation of the patient's Wegener's granulomatosis. They advised continued use of prednisone 5 mg p.o. q.d. and thus the prednisone was continued. 5. FLUIDS, ELECTROLYTES AND NUTRITION: The patient's electrolytes remained stable overall throughout his course. The patient suffered a brief bout of odynophagia early in his admission; however, his ability to take adequate p.o. nutrition was not significantly hampered and he maintained a healthy appetite throughout his hospitalization. It should be noted that the patient did have several bouts of diarrhea for which he was found to be Clostridium difficile negative on a number of tests. His diarrhea eventually subsided and as noted above he continued to have good p.o. intake with no nausea or vomiting. The patient also ambulated well throughout his ambulation. DISCHARGE CONDITION: As noted above, the patient's overall course improved over his hospitalization. On the day of discharge, his vital signs were stable and he was afebrile with a temperature of 98.1??????. His intravenous cellulitis revealed some continued palpable cords with decreased erythema and tenderness. The patient very much wished to go home after his protracted hospital stay and following much discussion with the various consult services and primary team it was felt that the patient was indeed healthy enough to go home, so long as he had adequate and intense follow up in the near future. DISCHARGE DIAGNOSES: 1. Neutropenia 2. Coronary artery disease, status post non Q-wave myocardial infarction 3. Wegener's granulomatosis 4. Myelodysplasia DISCHARGE MEDICATIONS: For the most part, the patient was discharged home on the above noted outpatient medication regimen. Changes included the fact that his aspirin had been discontinued due to his low platelet count. Also, he was prescribed four doses of p.o. Linezolid to finish the course of intravenous vancomycin he had received. The patient had received five days of vancomycin at the time of discharge. Also, the patient was restarted on his amiodarone 200 mg q day; this was begun on [**2114-8-23**]. FOLLOW UP: The patient is to follow up with [**Hospital3 328**] on [**2114-9-5**]. The patient is also to follow up with the hem/onc service, specifically Dr. [**Last Name (STitle) 410**] within one week of discharge. Also, the patient is to follow up with his attending physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Location (un) 1683**] in approximately two weeks following discharge. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8873**] [**Name8 (MD) **], M.D. [**MD Number(1) 8874**] Dictated By:[**Last Name (NamePattern1) 1550**] MEDQUIST36 D: [**2114-9-5**] 07:29 T: [**2114-9-5**] 07:41 JOB#: [**Job Number 16298**]

[ "410.71", "284.8", "238.7", "414.01", "V45.82", "446.4", "999.2", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

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4956, 7819

14293, 14432

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14960, 15688

4428, 4709

193, 2648

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4726, 4939

18,982

190,811

3191

Discharge summary

report

Admission Date: [**2138-6-23**] Discharge Date: [**2138-7-2**] Date of Birth: [**2069-8-5**] Sex: F Service: SURGERY Allergies: Captopril / Neurontin / Shellfish / Nsaids / Promethazine Attending:[**First Name3 (LF) 301**] Chief Complaint: Epigastric Pain Right upper quadrant pain Nausea & vomiting Major Surgical or Invasive Procedure: Exploratory Laparotomy, repair of incarcerated ventral hernia History of Present Illness: Ms [**Known lastname **] is a 68 year old ill appearing female with multiple medical problems who presented to the emergency department with complaints of right upper quadrant pain for a few hours. She reported epigastric pain x 1 month, pain worsening with food, as well as complaints of nausea & vomiting. Past Medical History: Past Medical History: 1. CVA x2 - Frontal with minimal residual LLE and right facial weakness. 2. DM, w/ diabetic gastroparesis 3. PE s/p IVC filter [**2135**] 4. HTN 5. Mild CHF, LVEF 50% 3/06. 6. Hypercholesterolemia 7. COPD - Multiple hospitalizations for flares including in [**1-/2131**], [**4-/2131**], [**3-/2131**], [**11/2133**], [**11-14**], [**8-15**] Baseline peak flow of 250 190. Uses 2L O2 at night. 8. Asthma 9. Trochanteric bursitis - [**5-/2136**] 10. Recurrent C diff colitis - [**2135**] 11. Functional obstruction necessitating laparotomy in [**2135**]- Complicated by long healing course and abdominal hematoma. 12. Question of seizures - Pt found to have hyperammonemia from valproate. 13. Lipomatous mass extending into the chest- [**6-/2134**] 14. Chronic lumbar back pain, s/p lumbar laminectomy- [**2128**] 15. DJD of knees 16. Depression 17. Severe GERD, s/p treatment for H pylori 18. MRSA PNA 19. h/o hypomagnesemia Social History: Mrs [**Known lastname **] was born in [**State 3908**]. She worked for many years as a waitress. She has lived in an assisted facility for the last several years. She has four children, who are supportive and live nearby. Former 30+ pack-year smoker, quit 5 years ago. Former EtOH use. No illicit drug use. Family History: HTN in relatives, malignancy including pancreas, larynx. Diabetes and asthma. Physical Exam: HR 112 T: 100.1 BP: 155/102 RR: 35 Spo2: 100% General: uncomfortable Head/eyes: anicteric, EOMI, PERRLA ENT/Neck: no JVD Chest/Respiratory: Clear to auscultation bilaterally, diffuse wheezes, coarse breath sounds Cardiovascular: tachycardic GI: abdomen: large hernia GU: No CVAT Musculoskeletal: DP pulses palpable, no edema Skin: diaphoretic Neuro: Alert& oriented x 3 Pertinent Results: [**2138-6-22**] 09:10PM BLOOD Glucose-133* UreaN-37* Creat-2.6* Na-141 K-4.1 Cl-94* HCO3-28 AnGap-23* [**2138-6-22**] 09:10PM BLOOD ALT-34 AST-28 CK(CPK)-106 AlkPhos-70 Amylase-233* TotBili-0.2 [**2138-6-22**] 09:10PM BLOOD Albumin-5.2* [**2138-6-22**] 09:10PM BLOOD WBC-13.6* RBC-4.06* Hgb-11.9* Hct-36.2 MCV-89 MCH-29.2 MCHC-32.7 RDW-18.7* Plt Ct-374 [**2138-6-25**] 02:38AM BLOOD WBC-10.4 RBC-2.97* Hgb-9.6*# Hct-26.6* MCV-89 MCH-32.1* MCHC-36.0* RDW-18.3* Plt Ct-225 [**2138-6-26**] 01:25PM BLOOD Glucose-135* UreaN-38* Creat-1.5* Na-150* K-3.8 Cl-109* HCO3-32 AnGap-13 [**2138-6-26**] 09:30PM BLOOD ALT-45* AST-37 LD(LDH)-591* AlkPhos-46 TotBili-0.4 [**2138-7-1**] 06:35AM BLOOD Glucose-PND UreaN-PND Creat-1.8* Na-137 K-4.3 Cl-99 HCO3-28 AnGap-14 [**2138-6-30**] 05:00AM BLOOD WBC-10.3 RBC-3.17* Hgb-9.4* Hct-28.3* MCV-90 MCH-29.7 MCHC-33.2 RDW-17.1* Plt Ct-362 . KUB [**2138-6-22**] IMPRESSION: Non-specific bowel gas pattern, better assessed on subsequent CT examination. . CT abdomen/pelvis [**2138-6-23**] IMPRESSION: 1. Small bowel obstruction with distal transition point at the level of the patient's known mid abdominal right ventral hernia. 2. A single, complex cystic lesion in the right renal lower pole was better seen on prior contrast study and again warrants further evaluation with MRI. 3. Stable 11 x 8 mm cytic lesion within the pancreatic uncinate process. Further evaluation with MRI is recommended. 5. IVC filter in place in the infrarenal IVC. 6. Stable, non-complex right adductor muscle intramuscular hematoma. . CXR PA/Lat [**2138-6-22**] IMPRESSION: No acute cardiopulmonary process. . CXR [**2138-6-25**] FINDINGS: Compared with [**2138-6-23**], no significant change or acute process is seen. No overt CHF or infiltrates. Brief Hospital Course: Ms [**Known lastname **] was seen in the emergency department on [**2138-6-23**]. On examination she was determined to have a high grade small bowel obstruction associated with incarcerated ventral hernia. CT of the abdomen and pelvis confirmed small bowel obstruction. She was taken to the OR emergently for exploratory laparotomy and repair of incarcerated hernia. She tolerated the procedure well, see op report for details. She was extubated and taken to the SICU for further recovery. She remained in SICU until POD#5. She was then transferred to [**Hospital Ward Name 121**] 9. . Respiratory: After extubation she remained on NC oxygen at 3L. She was weaned to O2 @ 1L, which she also wears at home as needed. Breath sounds remained coarse throughout. She recieved chest PT and nebulizer treatments daily. CXR revealed on evidence of consolidation or atelectasis. . Cardiovascular: Hypertensive post-op. Required Lopressor & Hydralazine IV and orally in ICU and [**Hospital Ward Name 121**] 9. Weaned to home meds at time of discharge. . Neuro: Developed confusion in intensive care unit POD#[**5-15**]. Neuro consult obtained. IV narcotics were discontinued. She was treated for a sodium level of 150. Her mental status improved when sodium normalized to 145. Family members indicated she had experienced confusion on previous admissions. She returned to [**Location 213**] baseline mental status at time of discharge. . GU/Renal: Foley catheter post-op. Aggressively diuresed post-op in the SICU with Lasix. Creatinine frequently remained elevated above 1.5. Foley was later discontinued and she voided without difficulty. Renal service was consulted regarding chronic lasix use, low urine output, and elevated creatinine. It was advised that she remain off of lasix at discharge, to be resumed at a later time in outpatient follow up. Her creatinine of 1.8 was considered within an expected range for her since her onset of chronic renal insufficiency. Saline boluses were stopped, and she remained euvolemic. She was discharged with a follow up appointment with the renal clinic. . GI/Abdomen: Remained soft with midline abdominal incision intact with staples. POD#7 developed bloody ooze on distal portion of incision. Sutures added between staples and surgicell packing placed with fair effect. Oozing stopped, surgicell removed prior to discharge. . Nutrition: remained NPO in early post-op period. Diet was advanced without difficulty, tolerated a diabetic diet at time of discharge. . Musculoskeletal: Physical therapy consulted for evaluation, strengthening and conditioning. Continued to progress well and was able to ambulate 100 feet on room air with a walker at time of discharge. . Ms [**Known lastname **] was discharged home on POD# in stable condition with all appropriate follow up appointments & prescriptions. Medications on Admission: Advair 250/50 1 puff [**Hospital1 **] Albuterol neb q 4 hours prn Aspirin 81 mg po qd Lipitor 20 mg po qd Norvasc 10 mg po qd Colace 100mg po bid Desiprimine 2 tablets 10mg po qhs Diltiazem 60 mg 1 capsule [**Hospital1 **] Lasix 40 mg po qd glipizide 10 mg po qd MS Contin 15 mg po qd MS Contin 30 mg po qd Prednisone 20 mg po qd REglan 10 mg po qid Senna 1 tab po bid Tripleptal 300 mg po bid Discharge Medications: Resume home meds except Lasix. DO NOT RESUME LASIX, until instructed to do so by your doctors. 2. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: S/P Exploratory Laparotomy, repair of incarcerated ventral hernia Discharge Condition: stable Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. Activity: No heavy lifting of items [**11-24**] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. You will be given pain medication which may make you drowsy. No driving while taking pain medicine. Followup Instructions: You have an appointment with [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 3100**],MD [**First Name (Titles) **] [**Last Name (Titles) 191**] on [**2138-7-15**] at 9:10, [**Telephone/Fax (1) 250**] for follow up from your hospitalization. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD Phone:[**Telephone/Fax (1) 250**] on Date/Time:[**2138-8-19**] 12:30 . Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2138-9-9**] 8:25 . You have an appointment on Tuesday [**7-22**] @ 8:00 am with Dr. [**Last Name (STitle) 4883**], a nephrologist. [**Telephone/Fax (1) 60**]. . Friday [**7-18**], with Dr. [**Last Name (STitle) **] @ 3:45 in [**Hospital Ward Name 23**] building [**Location (un) **], surgical specialties. [**Telephone/Fax (1) 2723**]. Completed by:[**2138-7-2**]

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icd9cm

[ [ [] ] ]

[ "38.93", "54.59", "53.61" ]

icd9pcs

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374, 438

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46878

Discharge summary

report

Admission Date: [**2200-10-27**] Discharge Date: [**2200-10-29**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7333**] Chief Complaint: heart block Major Surgical or Invasive Procedure: [**10-28**] [**Company 1543**] pacemaker placement, by [**Doctor Last Name 13177**] for [**Doctor Last Name **] History of Present Illness: [**Age over 90 **] y/o male with PMH PVD, CAD (sees cardiologist at other hospital but no documented CABG or cath) recurrent falls (2 falls in 2 weeks), who initialyl presented to [**Hospital3 **] hospital for workup. [**Hospital3 417**] felt this was likely a TIA and sent pt home. Pt then followed up with PCP who put on Holter (last tuesday [**10-21**] for 24 hrs). At 7:55pm during the Holter recording, pt had syncope which corresponds to Holter recording of 3rd degree heart block in [**4-10**] sec pauses- had 5-7 episodes, per patient. Since wednesday, there have been 2 other episodes where he sits down and gets dizzy/foggy. Holter was recently read and pt told to come to ED. In ED, found to be in 1st degree heart block with LBBB. Initial vitals were 98.5, 71, 143/58, 18, 98%. Denied any chest pain. Trop negative. Cardiology was consulted in the ED and pt was transfered to the CCU for close monitoring. Access- 2 peripherals and vitals on transfer afebrile, HR 65, RR 18, 98% RA, BP 150/56. . In the CCU, pt denies any chest pain or shortness of breath. Vitals BP 181/43, HR 76, 95% on RA, afebrile, NSR. . Pt denies chset pain, no SOB, no fevers, no chills, no abd pain, does report chronic back pain, remainder of ROS negative. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension (unclear, not documenteD) 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: renal stones CAD-no known MI (covering cardiologist will fax cards records here tomorrow AM) PVD cataracts s/p surgery Hiatal hernia. Questionable history of hypertension. The patient was on metoprolol 25 mg b.i.d. given to him either his previous primary M.D. or cardiologist. History of multiple falls. Chronic lower back pain as well as neck pain and some hip discomfort. Mild dementia Failure to thrive prostate surgery? Social History: he lives by himself and his healthcare proxy is his nephew and [**Name2 (NI) 802**]. He lived by himself until 4 months ago, now in [**Hospital 4382**] facility. He is independent with ADLs. At baseline, he ambulates with a walker. No ETOH, no tobacco. Went to [**Hospital1 **] poly tech, graduated in [**2119**]. Was an engineer. Family History: Significant for cancer and heart disease, which run in the family. Physical Exam: ADmission Exam: VS: BP 181/43, HR 76, 95% on RA, afebrile, NSR 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 JVP of 8cm. CARDIAC: RRR, [**12-11**] diastolic murmur, 3rd heart sound LUNGS: no crackles, rhonchi, rhales 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+ Left: Carotid 2+ Femoral 2+ Pertinent Results: [**2200-10-27**] cTropnT-<0.01 [**2200-10-29**] WBC-9.4 Hgb-11.2* Hct-32.4* MCV-99* Plt Ct-276 [**10-29**] CXR, IMPRESSION: 1. Pacemaker leads in the expected position of the right atrium and right ventricle 2. Unchanged possible right thyroid enlargement causing tracheal deviation. Consider ultrasound for further evaluation. Brief Hospital Course: [**Age over 90 **] M with history of CAD (although nothing recorded in OMR) and recent falls admitted for documented high degree heart block on holter monitor. . # RHYTHM: Pt with pauses on Holter concerning for underlying heart block, likely explaining patients recurrent falls. Patient had dual-chamber pacemaker placed [**10-28**]. At time of discharge, CXR confirmed appropriate lead placement. Implant site without erythema, drainage, hematoma, infection. Will receive 3-day (total) course of post-op antibiotics. . # HTN: Was hypertensive up to the 180s on initial presentation. Controlled with captorpil. . # CAD: OMR reports CAD but pt and family deny. Continued his home regimen of ASA 81. . # Back Pain: Tylenol 1,000 TID standing, per home regimen . # CRI: Cr 1.3, consistent with Cr from 1/[**2199**]. HAs been in the 1.2-1.4 range since [**2198**], likely a chronic picture from HTN. Medications on Admission: Tylenol 500mg TID Vit D2 50,000 U once a month multivitamin ASA 81 Lidocaine patch- apply to lower back Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. cephalexin 250 mg Capsule Sig: One (1) Capsule PO four times a day for 3 days. Disp:*12 Capsule(s)* Refills:*0* 3. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day: apply to lower back. 4. acetaminophen 500 mg Capsule Sig: One (1) Capsule PO three times a day. 5. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 6. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Excella Home Care Discharge Diagnosis: Complete Heart Block Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You had complete heart block and needed a pacemaker to help fix the conduction system of your heart. You will need to take antibiotics for 2 days to prevent an infection at the pacer site. No lifting more than 5 pounds for 6 weeks with your left arm, do not reach your left arm over your head for 6 weeks. Please wear the sling at night for one week only. . Medication changes: 1. Start taking Cephalexin, an antibiotic for 3 days to prevent infection at the pacer site. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2200-11-5**] at 9:30 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Name:[**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 10541**],MD Location: [**Hospital1 **] HEALTHCARE - [**Location (un) 8720**] Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY,[**Apartment Address(1) 8722**], [**Location 8723**],[**Numeric Identifier 8724**] Phone: [**Telephone/Fax (1) 8725**] The office has been contact[**Name (NI) **] for an appointment for next week. You will be called at home with a follow up within the next week. If you dont hear in two business days, please call the above number . Department: CARDIAC SERVICES When: [**12-29**] at 3:00pm With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

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Discharge summary

report+addendum

Admission Date: [**2132-12-4**] Discharge Date: [**2132-12-9**] Date of Birth: [**2077-5-30**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5018**] Chief Complaint: L-sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: [**Known firstname **] [**Known lastname 92613**] is a 55 year-old RHM who presented by ambulance to [**Hospital1 18**] emergency room after he had sudden onset of left sided numbness and then weakness. He states that he had just come home from work at CVS where he is a manager and had been sitting down and watch television (NCIS). At 12:45 am he noticed a sudden numbness of his left hand that felt like pins and needles. He was able to open and close the hand and became frightened and stood up. When he got up he noticed that he was having difficulty standing on his left foot and that it had a numb feeling as well. He shouted out for help from his brother who he lives with and he called 911. On arrival to the the hospital a code stroke was called and he scored a 2 on the NIHSS for left sided sensory deficits and tactile extinction on the left. Blood glucose was 368. A CT was performed, but revealed a hemorrhage so tPA was not given. According to the patient he was hospitalized in [**2131-12-29**] when he said that he had been feeling "off". He was found to have significant diabetes and CHF and had been started on insulin, antihypertensives, lasix and warfarin but has not taken any of the medications since [**Month (only) 404**] as he says that he cannot afford the copay. He was recently transitioned to a part-time employee at CVS and lost his medication benefit. He says that he wakes up almost every hour during the night to urinate, and has been extremely tired, but otherwise reports no recent changes in his health. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. No bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Hypertension - noncompliant w/ meds type II DM diagnosed in [**2131-12-29**] - noncompliant and supposed to be on insulin ? of atrial fibrillation (started on warfarin - but says he's never heard this diagnosis) CHF (unknown EF) Social History: Works as a manager at the CVS in [**Hospital1 **]. Lives w/ his brother. Divorced. Non-[**Hospital1 1818**]. Occassional beer drinker (not significant amount) Family History: Father - DM, HTN Mother - healthy, [**Name2 (NI) 1818**] 2 daughters - healthy Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98 110 BP initially 230/128 R 14 SpO2 95% ra General: Awake, cooperative, NAD. obese HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: CTABL Cardiac: elevated JVp at 7 cm, RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: significant pedal edema, pulses palpated Skin: psoriatic rash over right lower leg. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [**2-28**] at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Mildly diminished pinprick sensation on the left face. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: dimished pinprick and temperature sensation on the left hemibody w/ no agraphesthesia. Right side intact. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 1 1 1 1 0 R 1 1 1 1 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: deferred DISCHARGE EXAM: Vitals: T 98 BP 149/83 HR 60 RR 18 O2 96% RA General: Awake, cooperative, NAD. obese HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: CTABL Cardiac: elevated JVp at 7 cm, RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: significant pedal edema, pulses palpated Skin: psoriatic rash over right lower leg. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [**2-28**] at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: dimished pinprick and temperature sensation on the left hemibody w/ no agraphesthesia. Right side intact. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 1 1 1 1 0 R 1 1 1 1 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: ambulates steadily with walker Pertinent Results: ADMISSION LABS: [**2132-12-4**] 01:48AM BLOOD WBC-9.4 RBC-5.44 Hgb-16.1 Hct-45.6 MCV-84 MCH-29.6 MCHC-35.3* RDW-13.4 Plt Ct-187 [**2132-12-4**] 01:48AM BLOOD PT-11.3 PTT-30.1 INR(PT)-1.0 [**2132-12-4**] 07:37AM BLOOD Glucose-265* UreaN-26* Creat-1.9* Na-139 K-3.9 Cl-98 HCO3-33* AnGap-12 [**2132-12-4**] 07:37AM BLOOD ALT-20 AST-20 LD(LDH)-283* CK(CPK)-92 AlkPhos-96 TotBili-0.4 [**2132-12-4**] 07:37AM BLOOD CK-MB-5 cTropnT-0.02* [**2132-12-4**] 07:37AM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.3 Mg-2.1 Cholest-252* [**2132-12-4**] 07:37AM BLOOD %HbA1c-10.4* eAG-252* [**2132-12-4**] 07:37AM BLOOD Triglyc-263* HDL-38 CHOL/HD-6.6 LDLcalc-161* [**2132-12-4**] 01:48AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2132-12-4**] 02:03AM BLOOD Glucose-335* Lactate-2.4* Na-136 K-3.9 Cl-95* calHCO3-27 DISHCARGE LABS: [**2132-12-8**] 05:30AM BLOOD WBC-9.3 RBC-4.94 Hgb-15.0 Hct-42.1 MCV-85 MCH-30.3 MCHC-35.6* RDW-13.4 Plt Ct-185 [**2132-12-8**] 05:30AM BLOOD Glucose-128* UreaN-35* Creat-1.9* Na-139 K-3.9 Cl-99 HCO3-32 AnGap-12 [**2132-12-8**] 05:30AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.2 IMAGING: ECHO [**2132-12-4**]: Conclusions No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is moderate symmetric left ventricular hypertrophy. 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 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. Physiologic mitral regurgitation is seen (within normal limits). There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: No cardiac source of embolism seen. Normal global and regional biventricular systolic function. Negative bubble study. Moderate symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. No significant valvular abnormality seen. Mildly dilated ascending aorta. CT HEAD [**2132-12-5**]: IMPRESSION: Right basal ganglia hemorrhage. No significant mass effect or midline shift or herniation. The small acute hematoma mentioned above is the region of right thalamus and internal capsule rather than in the basal ganglia. No significant surrounding edema or mass effect. Correlate clinically to decide on the need for further workup for underlying lesion. CXR [**2132-12-5**]: IMPRESSION: Limited exam. Mild pulmonary vascular congestion. MRA [**2132-12-5**]: IMPRESSION: 1. Evolution of the right thalamic hemorrhage. 2. No evidence of acute infarct. 3. Changes of chronic small-vessel ischemic disease. 4. No evidence of stenosis, occlusion or arteriovenous malformation, as described. 5. There is a small infundibulum at the origin of the right posterior communicating artery. CXR [**2132-12-5**]: Cardiomegaly is severe. Widening of the upper mediastinum could be due to mediastinal fat deposition and vascular engorgement. Pulmonary vasculature is normal, and there is no edema or appreciable pleural effusion. No pneumothorax. Brief Hospital Course: [**Known firstname **] [**Known lastname 92613**] is a 55 year-old RHM who presented with sudden onset of left sided numbness and then weakness in the setting of uncontrolled hypertension, diabetes and CHF. . # NEURO: On arrival his NIHSS was 2 and initial CT image revealed a 1cm right thalamic hemorrhage. His examiantion showed left sided sensory loss to pinprick/proprioception but no cortical signs (no agraphesthesia). He also had subtle weakness on the left arm>leg. He was transfered to the ICU for HTN control with plan to be placed on a nicardipine gtt, but was noted to have SBP 172 without nicardipine gtt. His BPs were then better controlled on an oral regimen (see below), and he was able to be transferred out of the ICU. There he remained very stable, with well controlled blood pressures (although his BP meds had to be adjusted to obtain goal SBP's - see below). . # CVS: In order to control pt's BP's, we started him on 20mg lasix for his CHF and BP control. We started him on lisinopril, which was uptitrated to 40mg QD. We started him on lasix 20mg QD and metoprolol which was uptitrated to 75mg Q6H. We started pt on simvastatin. . # Renal: Unclear Cr baseline, possibly elevated given risk factors but then throughout admission was downtrending in the setting of diuresis. Therefore, pt was likely volume overloaded. His Cr will need to be monitored in the future though to ensure it continues to decrease, . # Resp: significant sleep apnea and CXR showing mild volume overload. He was started on lasix as above with improvement in his apnea. Continue auto CPAP for now, pt will need sleep study after discharge. . # Endo: - A1c was 10.4 and LDL was 161, [**First Name8 (NamePattern2) **] [**Last Name (un) **] was consulted and recommended changing his NPH to lantus, which we did. He was also put on an ISS while here. #Code Status: full TRANSITIONAL CARE ISSUES: Patient was on warfarin prior to [**Month (only) 404**] (when he stopped taking his meds) for possible atrial fibrillation. Given his recent intracerbral hemorrhage he was not put on anticoagulation while here, but this issue will need to be addressed at his neurology follow-up appointment. His telemetry did not demonstrate any evidence of atrial fibrillation while here. Pt will also need sleep study performed - our sleep department will be in contact to set this up. Please continue auto CPAP during rehab. Medications on Admission: non-compliant w/ all meds but thinks he was on: lisinopril warfarin insulin furosemide Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 6. lisinopril 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for skin redness. 9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 10. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: per insulin sliding scale. 11. Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital3 4339**] Discharge Diagnosis: Right thalamic hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). NEURO EXAM: very mild L-sided weakness Discharge Instructions: Dear Mr [**Known lastname 92613**], You were seen in the hospital for left sided weakness. We determined that you had a bleed in your brain. We started you on the following medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 6. lisinopril 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for skin redness. 9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 10. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: per insulin sliding scale. 11. Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. 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: You have an appointment with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Friday Decemebr 23rd at 3pm. His office is located at [**Street Address(2) 72550**] # 151 in [**Hospital1 **], MA. If you have any questions about this appointment you can call him at [**Telephone/Fax (1) 30445**]. Please call [**Telephone/Fax (1) 10676**] to update your demographic information prior to coming to your neurology follow-up appointment. Department: NEUROLOGY When: TUESDAY [**2133-1-27**] at 2:00 PM With: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD [**Telephone/Fax (1) 657**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Name: [**Known lastname 14449**],[**Known firstname **] Unit No: [**Numeric Identifier 14450**] Admission Date: [**2132-12-4**] Discharge Date: [**2132-12-9**] Date of Birth: [**2077-5-30**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1886**] Addendum: Mr. [**Known lastname **] had evidence of acute on chronic diastolic heart failure during his admission for which he was started on Lasix 20mg daily. Discharge Disposition: Extended Care Facility: [**Hospital3 490**] [**Name6 (MD) **] [**Last Name (NamePattern4) 1887**] MD, [**MD Number(3) 1888**] Completed by:[**2133-1-27**]

[ "327.23", "584.9", "428.33", "250.40", "V15.81", "782.0", "431", "428.0", "585.9", "403.90" ]

icd9cm

[ [ [] ] ]

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icd9pcs

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43735

Discharge summary

report

Admission Date: [**2129-5-20**] Discharge Date: [**2129-5-26**] Date of Birth: [**2054-2-23**] Sex: F Service: ORTHOPAEDICS Allergies: Codeine / Lactose Attending:[**First Name3 (LF) 3190**] Chief Complaint: Back and leg pain Major Surgical or Invasive Procedure: Posterior decompression, fusion, instrumentation L3-S1 and laminectomy L3 ([**5-23**]) and partial vertebrectomy of L3, L4, and L5, fusion L3 to S1, anterior spacers x3, and autograft, bone morphogenic protein and allograft on [**2129-5-20**] History of Present Illness: Ms. [**Known lastname 30119**] has undergone a previous lumbar fusion and continue to experience back pain. It appears as though she has developed a pseudarthrosis. She has elected to proceed with revision surgical intervention. Past Medical History: PMH: CAD w/MI ([**2108**]), PVD, HTN, HPL, DM (borderline), chronic back pain, migraines, hemochromatosis, right knee OA PSH: R ext iliac stent, R SFA angioplasty, L ext iliac stent, CABG x1, spinal fusion x2, R TKA Social History: Denies tobacco Family History: N/C Physical Exam: A&O X 3; NAD RRR CTA B Abd soft NT/ND BUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes symmetric at biceps, triceps and brachioradialis BLE- good strength at hip flexion/extension, knee flexion/extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes symmetric at quads and Achilles + axial back pain Pertinent Results: [**2129-5-25**] 04:10PM BLOOD WBC-5.8 RBC-3.14* Hgb-10.0* Hct-28.1* MCV-90 MCH-31.7 MCHC-35.4* RDW-15.6* Plt Ct-174 [**2129-5-25**] 01:54AM BLOOD WBC-5.7 RBC-3.04* Hgb-9.6* Hct-26.8* MCV-88 MCH-31.4 MCHC-35.7* RDW-15.7* Plt Ct-164 [**2129-5-24**] 03:17AM BLOOD WBC-5.1 RBC-2.94* Hgb-9.4* Hct-26.5* MCV-90 MCH-31.9 MCHC-35.4* RDW-15.3 Plt Ct-148* [**2129-5-22**] 08:00AM BLOOD WBC-7.6 RBC-3.36* Hgb-10.4* Hct-30.6* MCV-91 MCH-30.9 MCHC-33.9 RDW-13.7 Plt Ct-141* [**2129-5-25**] 01:54AM BLOOD Glucose-150* UreaN-9 Creat-0.4 Na-142 K-3.4 Cl-104 HCO3-29 AnGap-12 [**2129-5-24**] 03:17AM BLOOD Glucose-123* UreaN-11 Creat-0.5 Na-145 K-3.3 Cl-108 HCO3-27 AnGap-13 [**2129-5-23**] 01:40PM BLOOD Glucose-151* UreaN-11 Creat-0.5 Na-142 K-3.6 Cl-106 HCO3-26 AnGap-14 [**2129-5-22**] 08:00AM BLOOD Glucose-90 UreaN-8 Creat-0.5 Na-139 K-3.5 Cl-100 HCO3-28 AnGap-15 [**2129-5-25**] 01:54AM BLOOD Calcium-7.7* Phos-1.7* Mg-1.6 [**2129-5-23**] 01:40PM BLOOD Calcium-7.5* Phos-2.7 Mg-1.7 Brief Hospital Course: Ms. [**Known lastname 30119**] was admitted to the [**Hospital1 18**] Spine Surgery Service on [**2129-5-20**] and taken to the Operating Room for a L3-S1 interbody fusion through an anterior approach. Please refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a PCA. Prior to the staged second procedure she developed atrial fibrillation and had an episode of hypoxemia. Both resolved with chemical intervention and she was not placed on anticoagulation. On HD#2 ([**2129-5-21**]) she returned to the operating room for a scheduled L3-Sq decompression with PSIF as part of a staged 2-part procedure. Please refer to the dictated operative note for further details. The second surgery was also without complication and the patient was transferred to the SICU for observation. Postoperative HCT was low and she was transfused blood with good effect. A bupivicaine epidural pain catheter placed at the time of the posterior surgery remained in place until postop day one from the second procedure. She was kept NPO until bowel function returned then diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#2 from the second procedure. She was fitted with a lumbar warm-n-form brace for comfort. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: famotidine amlodipine lasix synthroid pravastatin venlafaxine metoprolol Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 50 mcg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 6. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets 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). Discharge Disposition: Extended Care Facility: [**Hospital3 1122**] Center - [**Hospital1 3597**] Discharge Diagnosis: Lumbar spondylosis and spondylolisthesis and pseudarthrosis Atrial fibrillation Acute post op blood loss anemia Discharge Condition: Good Discharge Instructions: You have undergone the following operation: ANTERIOR/POSTERIOR Lumbar Decompression With Fusion Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a brace. This brace is to be worn for comfort when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity: Out of bed w/ assist LSO for ambulation; may be out of bed to chair without. Treatments Frequency: Please continue to inspect the incision for infection. Followup Instructions: With Dr. [**Last Name (STitle) 363**] in 2 weeks Completed by:[**2129-5-26**]

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icd9cm

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28748

Discharge summary

report

Admission Date: [**2107-9-2**] Discharge Date: [**2107-9-16**] Date of Birth: [**2027-11-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2932**] Chief Complaint: leg weakness Major Surgical or Invasive Procedure: None History of Present Illness: 79 year old male male with h/o inoperable 6 cm AAA, severe AS (0.9 cm), alcoholic cirrhosis, stable liver lesion x 3 years, who was in his USOH until 3 months ago, when he developed progressively worsening upper back and bilateral shoulder pain. He went to see his PCP, [**Name10 (NameIs) **] he was noted to have a 10 lb unintentional weight loss over one year, but ROS otherwise negative. Labs checked at that time were normal, except for an elevated AFP of 450. An abdominal u/s demonstrated a stable liver lesion of three years (never biopsied at patient's wishes) and a new bladder lesion. He was treated with multiple, different regimens for his back pain, including Motrin, Xanaflex, Toradol, and most recently oxycodone without relief. On day of admission, the patient's granddaughter, who is a RN, called the patient's PCP reporting that he fell yesterday from a standing position onto right side, and was now unable to get up from the couch and unable to urinate. At home, he was also noted to be hypotensive to 60/palp by his granddaughter. [**Name (NI) **] PCP's advice, the patient was then taken to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He had a lumbar spine MRI which was reportedly normal. In the OSH ED, 800 cc of urine was drained by a foley. His BNP was elevated to 1600, troponin of 0.3 with no ischemic changes noted on his EKG. His creatinine was also noted to be elevated to 2.1 from a baseline of 1.0. The patient was also noted to be hypoxic at 86%/2LNC with an ABG of 7.42/24/50. He was subsequently placed on 15 L of O2, with a SaO2 of 91%. CXR was consistent with pneumonia and congestive heart failure. At the OSH, he received 250 mg Levoflox x 1, Lasix 20 mg IV x 2, and lovenox SC for elevated troponin prior to transfer to [**Hospital1 18**] ICU for further management. Past Medical History: 1. 6 cm AAA - inoperable 2. severe AS (0.9 cm) 3. alcoholic cirrhosis 4. h/o liver lesion x 3 yrs 5. new bladder lesion 6. elevated AFP 7. Right CEA [**2104**] 8. Active EtOH use Social History: He lives at home alone in a [**Location (un) 1773**] apt, able to ambulate at baseline up the stairs and 30-50 yards without dyspnea. Former 20 ppy history, quit 20 years ago. Still drinks [**2-7**] pint per day per family (pt denies), last drink likely 2 days PTA. Family History: Noncontributory Physical Exam: Vital Signs on admission VS: T 100, BP 115/56, HR 83, RR 24, SaO2 96%/70% FM General: Pleasant, fatigued-appearing, diaphoretic male in slight distress, AO x3. HEENT: NC/AT, PERRL, EOMI. MMM, OP clear. Neck: supple, elevated JVP of 9 cm, FROM Chest: few right basilar rales, otherwise CTA-B CV: RRR, s1 s2 normal, [**3-14**] SM at LSB without radiation Abd: soft, distended, NT, NABS. Dullness to percussion at flanks, no discernable fluid wave. Normal rectal tone, no saddle anesthesia. Ext: no c/c/e, cool extremities with dp 1+ b/l Skin: large area of ecchymoses over the right hip extending over the right flank Neuro: AO x 3, CN II-XII grossly intact. Markedly diminished sensation over the LE extending from feet to b/l groins to PP/LT. Normal sensation to LT/PP over UE and trunk. Motor strength 5/5 in UE b/l; 4/5 strength in distal LE with 1/5 strength in proximal LE, R>L. +fasiculations and extensor spasms of b/l LE. Upgoing babinski's b/l. DTR's 2+ throughout. Gait not tested. Pertinent Results: Laboratory Studies on Admission [**2107-9-2**] WBC-9.1 RBC-4.77 HGB-13.2 HCT-38.1 MCV-80 RDW-19.8 PLT COUNT-110 NEUTS-86.3 LYMPHS-7.8 MONOS-4.6 EOS-0.5 BASOS-0.7 ALT(SGPT)-28 AST(SGOT)-106 LD(LDH)-428* CK(CPK)-1211* ALK PHOS-119* AMYLASE-98 TOT BILI-2.0 LIPASE-70* ALBUMIN-3.4 CALCIUM-9.6 PHOSPHATE-4.5 MAGNESIUM-1.7 GLUCOSE-90 UREA N-44 CREAT-1.7 SODIUM-140 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-20 ANION GAP-21 Radiology: [**9-5**] CXR: slightly improved RLL opacity, new patchy opacity L base [**9-4**] CT L-spine: markedly demineralized lumbar spine, extensive degenerative changes with spinal stenosis T12-L1, 6 cm AAA [**8-26**] MRI L spine: multiple bony lesions T3, T4, T5, T7, T8-12. T4 infiltrated with mild pathologic compression and retropulsion. T4 moderate spinal stenosis and spinal cord compression [**9-3**] MRI C-spine: probable metastatic compression T4 OSH: [**8-22**] Abd u/s: 2.1 cm x 2.3 cm hyperdense lesion in right posterior lobe of liver, unchanged from [**12/2103**], likely hemangioma. +Splenomegaly and ascites, GB sludge and probable cholelithiasis. 1.7 x 2.3 cm polypoid soft tissue mass in the base of the urinary bladder. Infraabdominal AAA 5.9 x 6.5 cm, increased since prior CT scan. [**9-2**] - CT chest/abd/pelvis without contrast: small left, moderate right pleural effusion. Moderate RLL infiltrate abd atelectasis. COPD with upper lobe with "honeycombing." Nodular liver, spleen is enlarged, esophageal and periumbilical varices, and small amount of ascites. Small calcified hepatic granuloma. +gallstones. Several tiny non-obstructing left kidney stones, indwelling foley with a collapsed urinary bladder. 5.7 x 6.0 cm infra-abdominal AAA. Brief Hospital Course: 79 y/o male with AAA, EtOH cirrhosis, critical AS, p/w LE paresis found to have cord compression at T4 due to metastatic cancer (multiple spinal, liver, bladder) of unknown primary 1. Spinal cord compression: Spine MRIs showed T4 infiltrated with associated compression fracture and cord compression. Multiple other lesions noted throughout thoracic vertebra T2-T8. The patient was started on IV decadron. Given worsening lower extremity functioning, the patient was transferred to the [**Hospital Ward Name **] medical service for urgent radiation. He had minimal if any improvement with radiation. Neurosurgery evaluated him for possible surgery, but felt he was not a good operative candidate given critical aortic stenosis and 6 cm AAA. 2. Metastatic cancer to spine (unknown primary). Given known liver lesion and markedly elevated AFP (865), hepatocellular carcinoma was suspected. Other possibilities include bladder cancer (given bladder mass), although urine cytology showed only degenerated epithelial cells. SPEP showed a small monoclonal band (most polyclonal) and UPEP was negative. PSA was within normal limits. Initially, a full metastatic work-up (chest CT, bone scan) was planned with possible IR-guided biopsy (spine vs liver). However, given underlying medical problems (critical AS), poor prognosis (multiple metastases), worsening medical status (worsening transaminitis, thrombocytopenia, possible DIC, CHF in setting of severe AS, demand ischemia), the patient was felt to be unlikely to tolerate both invasive diagnostic testing and chemotherapy. A family meeting was held, and the decision was made to pursue comfort-oriented care with a plan to transition to hospice. The patient's mental status gradually declined, and he passed away on [**2107-9-16**]. Medications on Admission: MEDS (at home) - 1. ASA 81 mg qd 2. Lisinopril 20 mg qd 3. Atenolol 25 mg qd 4. Protonix 40 mg qd 5. Lovastatin 20 mg qod Discharge Disposition: Expired Discharge Diagnosis: Primary: spinal cord compression Secondary: metastatic cancer of unknown primary, aortic stenosis, abdominal aortic aneurysm, aspiration pneumonia. Discharge Condition: Deceased [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**] Completed by:[**2107-9-16**]

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icd9cm

[ [ [] ] ]

[ "92.29" ]

icd9pcs

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276, 290

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Discharge summary

report

Admission Date: [**2110-6-20**] Discharge Date: [**2110-7-9**] Date of Birth: [**2057-2-26**] Sex: M Service: MEDICINE Allergies: Penicillins / Motrin / Retrovir / Lipitor / Tricor Attending:[**First Name3 (LF) 1973**] Chief Complaint: loss of consciousness Major Surgical or Invasive Procedure: stereotactic brain biopsy right frontal craniotomy with resection of mass bronchoscopy with tumor debulking History of Present Illness: Mr [**Known lastname 2816**] is a 53-year-old man with a past medical history significant for HIV, Hep C, metastatic squamous cell lung ca with mets to the brain who was transferred from an outside hospital with a seizure. The patient only recalls that his blood sugars were elevated on the night before admission, that he got up to go to the bathroom around 1 am, and remembers waking up around 8 am in the bathtub covered with stool. He denies confusion, but reports some left sided numbness that has persisted but improved slightly. Head CT at the [**Hospital 78319**] hospital showed a large mass in the right frontoparietal area 2.5 cm in diameter with vasogenic edema. Past Medical History: Past onc history (per Dr.[**Name (NI) 6767**] initial outpatient note [**2110-6-9**]): Mr. [**Known lastname 2816**] developed hemoptysis in [**2110-3-1**]. A chest X-ray and chest CT showed a tumor in his R lung. He underwent a bronchoscopy at an OSH, which was complicated by hemorrhage. He was transferred to [**Hospital1 1170**] on [**2110-5-7**] to have the broncoscopic biopsy with bronchial stent placement. Pathology showed poorly differentiated squamous cell carcinoma with ulceration, necrosis and lymphovascular invasion. Subsequent PET/CT showed the lung tumor together with brain metastases. He was taken to [**Hospital1 9191**], where he had a gadolinium-enhanced head MRI, showing brain metastasis. He was started on dexamethasone for this. The patient was referred by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] (neuro-onc at [**Hospital1 18**]) for management of his brain mets. He presented to Dr.[**Name (NI) 6767**] office on [**2110-6-9**]. He had a nonproductive cough but denied fever, chills, nightsweat,headache, nausea, vomiting, seizure, imbalance, urinary incontinence, or fall. He was sent to the ED for further management and admitted to the Interventional Pulmonary service. A bronch on [**6-10**] showed that the stent had migrated proximally. The stent was replaced, and the patient is being transferred to the Oncology service for further management of his oncologic issues. COPD, HIV, GERD, Latent Tuberculosis, Depression S/p Right total knee replacement, Bipolar Disorder Social History: Lives alone: 30 year smoking history quit a few weeks ago. Has a girlfriend and health aid. Denies ETOH.Prior history of IV drug abuse 10+ years ago Family History: non-contributory Physical Exam: PE VS T 97.1 hr 61 bp 127/76 96% 3L gen awake, alert, pleasant heent op clear, mmm, perrl, no papilledema or retinal hemorrhaging on fundoscopic exam neck supple, no jvp, no lad cv nls1s2 pulm inspiratory and expiratory wheezing gi abd soft, obese, nontender, no bruits ext 1+ le edema skin warm, red ms [**First Name (Titles) **] [**Last Name (Titles) **] tenderness neuro ms oriented to person place, grossly to time (day saturday, year [**2009**]), cn ii-xii intact, motor [**5-5**] upper&lower extremity r=l, nl light touch, dtrs symmetric, plantar response flexion Pertinent Results: Admission labs: [**2110-6-21**] 06:15AM BLOOD Glucose-169* UreaN-13 Creat-0.5 Na-135 K-4.1 Cl-97 HCO3-30 AnGap-12 [**2110-6-21**] 06:15AM BLOOD WBC-9.8 RBC-4.27* Hgb-12.1* Hct-36.5* MCV-85 MCH-28.4 MCHC-33.3 RDW-14.2 Plt Ct-241 [**2110-6-22**] 08:00AM BLOOD ALT-42* AST-17 AlkPhos-137* TotBili-0.3 Discharge Labs: [**2110-7-9**] WBC-7.9 RBC-3.07* Hgb-8.4* Hct-24.8* MCV-81 RDW-16.8* Plt Ct-243 [**2110-7-9**] BLOOD Glucose-140* UreaN-19 Creat-0.6 Na-135 K-3.9 Cl-95* HCO3-28 [**2110-7-5**] BLOOD ALT-149* AST-83* AlkPhos-237* TotBili-0.4 [**2110-7-7**] BLOOD Phos-5.0* Mg-1.9 Imaging: [**2110-6-21**]. PA/LATERAL CXR: A large central right upper lobe mass is again demonstrated with associated right hilar and paratracheal lymphadenopathy. Linear opacities projecting distal to the mass may represent a component of minor post-obstructive atelectasis or localized lymphangitic spread of tumor. Heart size is normal. No pleural effusions or acute skeletal abnormalities are identified. IMPRESSION: Large central right upper lobe neoplastic mass with associated right paratracheal and right hilar lymphadenopathy. These findings have previously been evaluated by CT of the chest, and correlation with that study recommended for more complete assessment. [**2110-6-21**]. Non-contrast head CT. Images are degraded by motion artefact. There is a 2.5 x 2.6 cm right parasagittal frontal lobe mass with central areas of low attenuation and extensive adjacent vasogenic edema unchanged since recent MR study. There is no significant mass effect or shift of normally midline structures. There are no other masses or lesions. There is no intra- or extra-axial hemorrhage. The ventricles and sulci are normal in size and configuration. The [**Doctor Last Name 352**] and white matter differentiation is well preserved. Osseous structures are unremarkable. IMPRESSION: Unchanged right frontal parasagittal mass with surrounding vasogenic edema, without significant mass effect or shift of midline structures. No hemorrhage. [**2110-6-24**]. Triplanar post-Gadolinium spin echo T1-weighted images and axial post-Gadolinium MP-RAGE of the head were obtained. Again seen is an enhancing mass involving the right frontal lobe with central area of apparent cavitation. The mass measures approximately 2.7 x 2.7 x 3.1 cm in its traverse, AP, and craniocaudal dimensions. This appears to have minimally increased in size since the prior study from [**2110-6-11**]. Again seen is a large area of surrounding edema with sulcal effacement. There is also depression of the right lateral ventricle and minimal right to left shift of the normally midline structures. No new enhancing lesions are identified. Overlying right frontal burr hole is again seen. IMPRESSION: Large right frontal mass with surrounding edema again visualized. The mass may have minimally increased in size compared to [**2110-6-11**]. [**2110-7-3**] MDCT-acquired contiguous axial images of the head were obtained without IV contrast. The patient is status post right frontal craniotomy. There is some adjacent soft tissue swelling. There is no new intracranial hemorrhage. There is again marked vasogenic edema. There appears to be minimally increased subfalcine herniation with 14 mm midline shift compared to 13 on prior, although this may be due to technique and slice selection. There is persistent edema and mass effect on the lateral ventricle as well as sulcal effacement, which overall is otherwise similar. There is trace residual pneumocephalus. The subcutaneous emphysema is similar. The mastoid processes are not well pneumatized but are unchanged. The mucosal thickening in the left mastoid is similar. IMPRESSION: Persistent right frontal vasogenic edema with subfalcine herniation and minimally increased midline shift, which may be due to technique. No new intracranial hemorrhage. [**2110-7-7**] TRANSTHORACIC ECHOCARDIOGRAPHY: 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%) Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild aortic leaflet thickening without discrete vegetation or valvular regurgitation. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Brief Hospital Course: Mr [**Known lastname 2816**] is a 53-year-old man with a past medical history significant for HIV, Hep C, metastatic squamous cell lung ca with mets to the brain who was transferred from an outside hospital with a seizure. The patient only recalls that his blood sugars were elevated on the night before admission, that he got up to go to the bathroom around 1 am, and remembers waking up around 8 am in the bathtub covered with stool. He denies confusion, but reports some left sided numbness that has persisted but improved slightly. Head CT at the [**Hospital 78319**] hospital showed a large mass in the right frontoparietal area 2.5 cm in diameter with vasogenic edema. 1. Loss Of Consciousness: The patient was admitted with loss of consciousness and left sided numbness. It is unclear whether the event was syncopal or seizure related, though the latter is thought to be more likely given his brain metastases. Because of this, he was continued on dexamethasone. He was started on anti-epileptic medications (initially dilantin, which was discontinued and keppra started in its place per neurologic consultation). 2. Brain Metastases: The patient has a known brain metastasis. He was evaluated by the neurosurgical service on this admission, and underwent a steriotactic brain biopsy of a right frontal parasagittal mass on [**6-23**], which showed a poorly differentiated metastatic carcinoma on pathologic evaluation. He then underwent craniotomy and resection of the same mass on [**6-25**]. His post-operative course was complicated by development of stroke symptoms: Left facial droop and hemiplegia on [**6-29**]. CT revealed worsening right frontal vasogenic edema with new foci of parenchymal and possible subarachnoid hemorrhage and 13-mm leftward subfalcine herniation. He was started on mannitol and increased doses of dexamethasone. He underwent repeat head CT on [**2110-7-2**] demonstrating no new bleeds and mild improvement in edema. On discharge, the patient had evidence of increasing strength on his left side (ability to lift left leg against gravity and mild resistance; and ability to move L hand mildly against gravity; unable to lift forearm or shoulder). He will complete a taper of the dexamethasone following discharge, and should be maintained on a dosage of 2mg twice daily following the taper. He is also to see the radiation oncologist Dr. [**First Name8 (NamePattern2) 4580**] [**Last Name (NamePattern1) 66047**]. Of note, the patient complains of intermittent headache, which is relieved with dilaudid. 3. Non-small cell lung cancer metastatic to brain, adrenal glands: The patient has stage IV non-small cell lung cancer with metastases to the brain and adrenals. He has undergone stenting and of the right mainstem bronchus, which is invaded/enveloped by his R lung mass. He will pursue additional oncologic treatment near his home in [**Location (un) 5503**]. He is scheduled to see Dr. [**First Name8 (NamePattern2) 4580**] [**Last Name (NamePattern1) 66047**] (radiation oncologist) on Thursday [**7-17**] regarding radiation therapy. 4. Hyponatremia: He developed hyponatremia following his brain resection. The hyponatremia was thought to be due to cerebral salt wasting as well as SIADH from his lung cancer. He was treated with a hypertonic saline, fluid restriction, and lasix. On discharge, his sodium had normalized to 135 on continued fluid restriction, salt tabs, and lasix. He was encouraged to continue these measures at home and to have his sodium checked by his PCP. 5. Fever: The patient experienced fevers post-operatively. His infectious workup was notable for coagulase negative staph in two out of two blood cultures on [**2110-7-3**]. Follow-up cultures were negative. TTE was w/o evidence of endocarditis. His positive blood cultures were attributed to contamination from his skin. He defervesced without intervention. 6. Steroid-induced diabetes: The patient was kept on glyburide and SSI. He is being discharged on glyburide alone. 7. HIV/AIDS: The patient is on HAART (CD4 150, HIV-1 < 50 copies/ml [**2110-6-14**]). He was continued on HAART and bactrim prophylaxis for PCP. 8. COPD: asymptomatic during hospital stay. Continued on inhalers. 9. CODE STATUS: DNR/DNI -- this was discussed during conversations between the patient and the palliative medicine service. See below for exerpt regarding the patients wishes and psychosocial concerns from a note by palliative medicine physician, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]: "a) His priority right now is to spend as much time as possible with his family, especially with his partner of more than a decade [**Name (NI) **]. He is hoping he can return home after this hospitalization. We discussed that he is to have another re-evaluation with PT today or tomorrow; he is focused on doing PT at home and prefers not to go to rehab. He states that his partner [**Name (NI) **] ([**Name2 (NI) **]) is experienced in caring for him and is in fact employed to care for him (I did not catch the name of agency -- [**Doctor Last Name 6382**]... something). b) He is interested in pursuing tx options that his physicians feel can help reduce tumor burden and palliate his disease, such as XRT. He is open to talking about transitioning to hospice care in the future and in fact says [**Doctor First Name **] has been in contact with [**Name (NI) 6136**] [**Name (NI) 269**] (his current agency) because they also do hospice care. He would like her to get as much support as possible in the home; we discussed some of the various services they offer including RN visits, personal care assistants, SW. c) He mentioned to me that he has told his prior doctors here that [**Name5 (PTitle) **] is not interested in being intubated again or being on mechanical ventilation. He initially said that "CPR would be OK, but no breathing tubes." However, as we discussed further what his priorities are, it became clear that he wants any remaining time to be spent alert, comfortable, and interactive with his loved ones, not intubated or unconscious in the ICU. Given this goal, he was able to articulate that if he were gravely ill, he would want to be "let go naturally." He wishes to be DNR/DNI and I have conveyed this to his medical team. We did not specifically discuss intubation for planned procedures, but having a DNR/DNI code status does not prevent him from undergoing future intubation for planned procedures that could possibly benefit him clinically (such as bronchoscopy). d) He seems to be doing a good amount of reflecting on his life; he shared about overcoming his very abusive childhood (mother actively abused him and at one point he was hospitalized because she gave him a soda can spiked with house cleaner; mother was abused by father and "she took it out on me because we had the same name"); he states that he was a "really bad person in his young days", did a lot of awful things. He initially says that maybe his cancer is punishment for his prior life, but then recants and says he doesn't really believe he is being punished -- "life is just being unfair"; He shared that he's happy he has done well with his dx of HIV/AIDS, which he acquired from IVDU; shared with pride that he has done a lot of HIV teaching in high school, is glad he has done something constructive with the hard events in his life. We came back to this point several times as he was reflecting on life." Medications on Admission: combivent, clonidine bactrim, dexamethasone,atripla, glyburide, ambien, zetia, lexapro, oxcarbazepine, oxycontin, percocet, spireva Discharge Medications: 1. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 2. Combivent 18-103 mcg/Actuation Aerosol Inhalation every six (6) hours. 3. Famotidine 20 mg Tablet PO twice a day: For stomach acid. 4. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY 6. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID To prevent seizures. Disp:*120 Tablet(s)* Refills:*2* 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Laxative. Disp:*60 Tablet(s)* Refills:*2* 9. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*200 Tablet(s)* Refills:*0* 11. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO QID (4 times a day): isp:*240 Tablet(s)* Refills:*2* 12. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed: For nausea. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*0* 13. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) Disp:*120 Tablet(s)* Refills:*2* 15. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Tapering Dose: Every 4hours x 2day; Every 6hr x 2 day; Every 8hr x 2day; Every 12hr x 2day. Then go to 2mg twice a day. Disp:*30 Tablet(s)* Refills:*2* 16. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours: To start after taper of 4mg done. Disp:*120 Tablet(s)* Refills:*2* 17. Colace 100 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours as needed for constipation: Stool softener. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 6138**] Home Care Services Discharge Diagnosis: Primary: Stage IV lung cancer with metastases lung cancer to brain Status post craniotomy and tumor resection Syndrome of inappropriate anti-diuretic hormone Secondary: HIV Hepatitis C COPD Hypercholesterolemia h/o Latent Tuberculosis Depression s/p total right knee replacement type II diabetes mellitus Discharge Condition: Ambulating with assist, improving left sided weakness, off of oxygen, alert & oriented x3 Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake fiber as pain medicine (narcotics) can cause constipation. You can also use stool softener or laxative. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? You have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered CALL YOUR SURGEON/DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: You have an appointment to see [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] You have an appointment scheduled with Dr. [**First Name8 (NamePattern2) 4580**] [**Last Name (NamePattern1) 66047**] (radiation oncologist) on Thursday [**2110-7-17**] at 9am. He is affiliated with [**Hospital3 23439**]. His office is on [**Location (un) 78320**]., [**Location 21487**], MA. If you have questions, please call [**Telephone/Fax (1) 78321**].

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icd9cm

[ [ [] ] ]

[ "01.59", "32.28", "33.23", "38.93" ]

icd9pcs

[ [ [] ] ]

18019, 18093

8433, 15924

332, 442

18443, 18535

3593, 3593

19846, 20357

2969, 2987

16106, 17996

18114, 18422

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271, 294

470, 1146

3610, 3893

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2802, 2953

42,402

173,138

2580

Discharge summary

report

Admission Date: [**2157-4-27**] Discharge Date: [**2157-5-1**] Date of Birth: [**2103-6-22**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1515**] Chief Complaint: Chest Pain and Fever Major Surgical or Invasive Procedure: Pericardiocentesis with drain placement History of Present Illness: 53 year-old female with RA on MTX and plaquenil, positive PPD s/p treatment presented to [**Hospital 191**] clinic [**2157-4-27**] with 3-4 days persistent fevers (101.4 at home), left-sided/central pleuritic type chest pain worse with deep breaths. She denies cough, sorethroat, SOB. She did have chills, fever. Three days prior to presentation, she had diffuse bodyaches which have since resolved. She reports similar symptoms, including lack of cough, with pneumonia approximately one year ago. She denies recent sick contacts. Chest pain was markedly worse today, leading her to present to PCP's office. . In [**Hospital 191**] clinic today, vitals T100, P110, BP118/60, and 100% RA. She was noted to have a tender precordium and friction rub on exam. She was sent to the emergency department for further evaluation. . In the ED, T99.6 (Tm 101.4), P116, BP111/61, RR18, 98% RA. On exam, she was noted to have JVD to 12-13cm. Pulsus was [**8-25**]. Laboratory data was significant for creatinine 1.1 (baseline 0.7-0.8), hematocrit 31.5 (baseline 36-39), WBC 8.9 without left shift, and normal coags. Blood culture was sent. EKG was significant for sinus tachycardia (rate 112) without electrical alternans. CXR was without obvious consolidation or effusion. CTA was negative for pulmonary embolism, consolidation, or pleural effusion; a moderate pericardial effusion, new since [**5-23**], was seen. Patient received acetaminophen 1 gram PO, 500cc IVF bolus, Toradol, and aspirin. Cardiology fellow was consulted; bedside TTE showed preserved LVEF (>55%), normal RV free wall motion, mild aortic regurgitation, and moderate-sized circumferential pericardial effusion with invagination of the RA and LA but no RV diastolic inversion. Given hemodynamic stability, patient, was admitted to CCU for pericardiocentesis in the morning. On transfer from the ED, BP90/62, P100, RR22-24, 98% RA. . On arrival to the CCU, patient reports feeling well. Over course of today has develop nonproductive cough. Currently without dyspnea. Chest pain with deep respiration, otherwise comfortable. Denies lightheadedness, chest pain. Past Medical History: CARDIAC RISK FACTORS: Diabetes(-), Dyslipidemia(-), Hypertension(-) CARDIAC HISTORY: None OTHER PAST MEDICAL HISTORY: RA (diagnosed [**2152**]; diffuse bodyaches and pain particularly in MCP joints; negative RF, mildly positive anti-CCP antibody) Positive PPD s/p INH therapy (9 month course, completed [**9-16**]) Osteoporosis Social History: Post-doc. Health services research at [**Location (un) **] VA. Lives with husband. Denies tobacco use, now or in the past. Reports rare alcohol use. Denies illicit drug use. Family History: [**Name (NI) 2320**] - Mother, father, sister [**Name (NI) **] cancer - Mother (nonsmoker) MI - Father (age 70) Physical Exam: On admission - BP99/61, P98, T98.0. HR16, 97%RA General - Resting comfortably in bed, no acute distress HEENT - Sclera anicteric, MMM, oropharynx clear Neck - JVD to angle of mandible at ~30 degrees; positive hepatojugular reflex; increased JVP with deep respiration Pulm - CTA bilaterally; no wheezes, rales, or rhonchi CV - Decreased breath sounds; tachycardic; normal S1/S2; no murmurs; no appreciable pericardial rub; ?rub with inspiratory variation; pulsus 10 Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended Ext - Warm, well perfused, radial and DP pulses 2+; no edema Pertinent Results: STUDIES of RELEVANCE in CHRONOLOGICAL ORDER: [**2157-4-27**] CT A Chest 1. New moderate pericardial effusion, not present in [**2156-5-16**]. Recommend clinical correlation for signs of tamponade, though none detected on CT. Echocardiography is recommended. 2. No evidence for pulmonary embolus or acute aortic process. ECHO [**2157-4-27**]: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a moderate sized pericardial effusion. There is a moderate sized circumferential pericardial effusion, with invagination of the RA and LA but no RV diastolic inversion. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. IMPRESSION: Moderate circumferential pericardial effusion with signs of early tamponade physiology. [**2157-4-28**] ECHO (s/p pericardiocentesis): Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. A catheter is seen in the pericardial space. There are no echocardiographic signs of tamponade. IMPRESSION: Tiny residual effusion post tap. No evidence of tamponade physiology. ECG [**2157-4-27**]: Sinus tachycardia, rate 109. Non-specific T wave changes. RSR' pattern in leads VI-V2. Possible left atrial abnormality. Compared to the previous tracing of [**2156-11-19**], except for the increase in rate and the decrease in T wave voltage throughout the tracing, no other diagnostic interval change. These changes are non-specific and may be due to a metabolic change o to [**2157-4-28**] Cardiac Cath 1. Resting hemodynamics demonstrated equalization of RA, RV, PA diastolic, and mean PCWP pressures consistent with cardiac tamponade, with preserved cardiac output of 5.0 (cardiac index of 3.0). 2. Pericardiocentesis demonstrated an opening pericardial pressure of 12 mmHg, which dropped to 0 after removal of ~ 150 ccs of bloody fluid. 3. Post-procedure echocardiogram confirmed only very small residual effusion. FINAL DIAGNOSIS: 1. Pericardial effusion with tamponade physiology. LABORATORY RESULTS of RELEVANCE in CHRONOLOGICAL ORDER [**2157-4-27**] 09:45PM PT-13.0 PTT-26.2 INR(PT)-1.1 [**2157-4-27**] 07:14PM COMMENTS-GREEN [**2157-4-27**] 07:14PM LACTATE-1.0 [**2157-4-27**] 07:00PM GLUCOSE-107* UREA N-20 CREAT-1.1 SODIUM-136 POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-25 ANION GAP-17 [**2157-4-27**] 07:00PM estGFR-Using this [**2157-4-27**] 07:00PM CK(CPK)-75 [**2157-4-27**] 07:00PM cTropnT-<0.01 [**2157-4-27**] 07:00PM CK-MB-NotDone [**2157-4-27**] 07:00PM ALBUMIN-4.2 [**2157-4-27**] 07:00PM TSH-2.1 [**2157-4-27**] 07:00PM CRP-126.7* [**2157-4-27**] 07:00PM CRP-126.7* [**2157-4-27**] 07:00PM WBC-8.9# RBC-3.51* HGB-10.6* HCT-31.5* MCV-90 MCH-30.2 MCHC-33.6 RDW-12.9 [**2157-4-27**] 07:00PM PLT COUNT-408 [**2157-4-27**] 07:00PM SED RATE-103* Brief Hospital Course: This is a 53 year-old female with h/o RA on MTX and plaquenil, positive PPD s/p treatment, who presented to [**Hospital 191**] clinic [**2157-4-27**] with 3-4 days persistent fevers (101.4 at home) and left-sided/central pleuritic type chest pain worse with deep breaths. She wsa found to have a pericardial effusion that required pericardiocentesis and drain placement. Her hospital course is summarized in brief below: . #. Pericardial effusion: Likely acute in development. Symptoms started 3 days prior to presentation. Evidence of early tamponade physiology with moderate new effusion - has JVD, tachycardia, some evidence of invagination of LA,RA and repiratory variation in mitral valve inflow. However, still hemodynamically stable with no evidence of RV dysfunction, blood pressure currently at baseline, no pulsus or evidence of failure. Patient underwent pericardiocentesis in the cath lab. 250 cc of serosanguinous fluid removed. TotProt: 5.2. Glucose: 57. LD(LDH): 1303. Amylase: 48. Albumin: 3.1. WBC: 2556. Hct,Fl: 4. Meets exudate criteria by glucose less than 60 and Protein greater than 3. Low glucose in pericardial fluid likely indicated RA related effusion. Repeat TTE showed minimal residual effusion. Preliminary fluid cultures on pericardial fluid showed with GPC in clusters that turned out to be Coagulase negative staph. An ID consult was requested that felt effusion was unlikely to be due to infection. Patient has prior history of tb that was treated witn INH. The only way to truly rule this out would be a pericardial biopsy that shoudl be performed if effusion recurs. This was felt to be likely a contaminant given lack of leukocytosis and overall clinical presentation. She received 1 gram of vancomycin while speciation finalized. Pericardial drain with no output was d/cd on HD #3. Started on indocin with good response in terms of pain prior to dischage. Patient will follow up as outpatient with Rheumatology for further auto-immune management and with cardiology for follow up TTE. . #. Anemia: Hematocrit 31.5 and wsa 28.1 to 31.5 during hosptial stay. Within past 6 months, ranging between 36-39. No evidence of bleeding or reason for hemolysis. Iron studies consistent with AOCD, but patient was noted to have guaiac postiive stool. colonoscopy in [**2152**] showed grade II internal hemorrhoids. . #. Rheumatoid arthritis: Patient denies flares of disease. Disease has been stable since diagnosis in [**2149**]. A rheumatology consult was obatined. Since above pericardial effusion was felt to be secondary to RA, methotrexate was increased to 17.5 mg weekly and started on prednisone 20 mg daily until follow up with outpatient Rheumatology. . #. Osteoporosis: Continued calcium, vitamin D per home regimen . #. Chronic pain: Continued gabapentin, amitryptiline per home regimen . CONTACT: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12997**], ([**Telephone/Fax (1) 13047**] (h), ([**Telephone/Fax (1) 13048**] (c) Medications on Admission: HOME MEDICATIONS: Plaquenil 400mg PO daily Methotrexate 12.5mg PO QSaturday Neurontin 400mg PO QHS Amitryptiline 10mg PO QHS Folic acid Calcium + vitamin D Omega 3 Naltrexone 2.5mg PO QHS MEDS on TRANSFER to CCU: IV access: Peripheral line Order date: [**4-28**] @ 0009 8. Heparin Flush *NF* 10 unit/mL Pericardial drain q4H:PRN per pericardial drain protocol Order date: [**4-28**] @ [**2149**] 2. Acetaminophen 325 mg PO Q6H:PRN fever, pain Order date: [**4-28**] @ 0009 9. Hydroxychloroquine Sulfate 400 mg PO DAILY Order date: [**4-28**] @ 0119 3. Amitriptyline 10 mg PO HS Order date: [**4-28**] @ 0119 10. Indomethacin 50 mg PO TID Order date: [**4-28**] @ 0009 4. Calcium Carbonate 500 mg PO TID Order date: [**4-28**] @ 0119 11. Morphine Sulfate 2-4 mg IV Q4H:PRN pain hold for sedation, rr less than 8 Order date: [**4-28**] @ 1523 5. Docusate Sodium 100 mg PO BID:PRN Constipation Order date: [**4-28**] @ 0119 12. Senna 1 TAB PO BID:PRN Constipation Order date: [**4-28**] @ 0119 6. FoLIC Acid 1 mg PO DAILY Order date: [**4-28**] @ 0119 13. 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. Order date: [**4-28**] @ 0009 7. Gabapentin 400 mg PO DAILY Order date: [**4-28**] @ 0119 14. Vitamin D 800 UNIT PO DAILY Order date: [**4-28**] @ 0119 Discharge Medications: 1. Indomethacin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*0* 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 3. Hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 11. Methotrexate (Anti-Rheumatic) 2.5 mg Tablets, Dose Pack Sig: Seven (7) Tablets, Dose Pack PO once a week. Disp:*28 Tablets, Dose Pack(s)* Refills:*6* 12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day: Please continue taking at 20 mg daily until instructed by Dr. [**Last Name (STitle) **] to taper dose. Disp:*30 Tablet(s)* Refills:*0* 13. Morphine 15 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain: Do not drive or drink alcohol with this medication. Stop taking if you develop constipation, confusion or fatigue. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Tamponade SECONDARY: Rheumatoid Arthritis Discharge Condition: stable, afebrile Discharge Instructions: You were admitted for pericardial effusion. You required pericardiocentesis with placement of a drain to drain the fluid around your heart. You tolerated the procedure very well. Although you required ICU-level care and monitoring, you were stable and were released to the floor in good condition. You will require follow-up as recommended below (please note that you have outstanding labs that will need to be followed-up by your PCP, [**Name10 (NameIs) 3**] indication in the discharge summary). Please take all of your medications as prescribed. . Please return to the ED for CP, SOB, nause, vomiting, abdominal pain, body aches, fevers, chills, rigors, bloody stool, buringin on urination, light headedness or dizziness, changes in vision, or any other symptom that concerns you. Followup Instructions: 1) Please follow-up with your cardiologist Dr. [**Last Name (STitle) **]. You can call his office on monday at ([**Telephone/Fax (1) 2037**] to schedule a follow up in the next 7-14 days. Please be sure to ask about when to schedule your follow up echocardiogram. 2) Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**First Name8 (NamePattern2) 1243**] [**Name8 (MD) **], M.D. on [**2157-5-13**] at 2:00 pm. 3) Please call your Rheumatologist Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD at [**Telephone/Fax (1) 2226**] to schedule an appointment in the next 7 days. 4) Please call the Infectious disease clinic at [**Telephone/Fax (1) 457**] to make an appointment in the next 2 to 4 weeks. Completed by:[**2157-5-2**]

[ "338.29", "423.3", "727.00", "733.00", "285.29", "391.0", "795.5", "584.5" ]

icd9cm

[ [ [] ] ]

[ "37.0", "37.21" ]

icd9pcs

[ [ [] ] ]

13000, 13006

7151, 10132

335, 377

13101, 13120

3828, 6260

13952, 14749

3085, 3199

11513, 12977

13027, 13080

10158, 10158

6277, 7128

13144, 13929

3214, 3809

10176, 11490

275, 297

405, 2526

2666, 2878

2894, 3069

61,434

157,903

18794

Discharge summary

report

Admission Date: [**2159-10-30**] Discharge Date: [**2159-11-2**] Date of Birth: [**2113-8-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: weakness, s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: 46 yo M PMH uncontrolled [**Doctor First Name 2320**], HTN, cirrhosis and obesity who presented from home with bilateral lower extremity weakness. Pt reports that LE weakness has been ongoing x 1 day. He has been able to ambulate and get out of bed though. He reports falling down 10 last night resulting in head strike and brief LOC. This was an unwitnessed fall. In addition, he reports feeling febrile yesterday with some chills. Had 2 episodes of vomiting. No diarrhea or abd pain. No dysuria. Mild substernal CP yesterday lasting 5 hrs that resolved. No SOB. He reports that over the last few days bloos sugars have been well controlled in the 180's-190's. He reports compliance with his insulin regimen. . n the ED, initial VS: 98.9 117 90/38 18 100%. He was described as Somnolent. K was 7.4 with peaked T waves on EKG, given Ca, 10 units IV insulin (followed by 10 units/hr insulin gtt). K improved to 4.9. Given 3L IVF. Starting 4th L with some K. Noted to be in new renal failure. CT head/cspine okay. CXR okay. Current VS: 97.8 116 97/51 20 99RA. Access 2 18g PIV. . In the ICU, he reported feeling well other than some discomfort in his lower extremities. Past Medical History: DM II (A1c [**10-3**] 11%)c/b neuropathy Obesity HTN Hyperlipidemia History of polysubstance abuse Cirrhosis Bipolar disorder Anxiety Low back pain Social History: - Lives alone. Independent - Tobacco: Smokes [**11-25**] ppd - Alcohol: none - Illicits: none Family History: Father, brother and sister with [**Name (NI) 2320**] Physical Exam: Physical Exam on Admission: Vitals: T:98.3 BP:102/41 P:114 R:14 O2:96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, PERRL, EOMI, visual fields intact to confrontation, OP clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place draining clear urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AOx3, CN II-XII grossly intact, 5/5 strength in all 4 ext, diminshed sensation in feet Pertinent Results: Labs on Admission: [**2159-10-30**] 03:35AM WBC-16.4* RBC-4.23* HGB-12.5* HCT-38.1* MCV-90 MCH-29.6 MCHC-33.0 RDW-13.6 [**2159-10-30**] 03:35AM LIPASE-67* [**2159-10-30**] 03:35AM ALT(SGPT)-60* AST(SGOT)-38 ALK PHOS-71 TOT BILI-0.2 [**2159-10-30**] 03:35AM GLUCOSE-602* UREA N-51* CREAT-4.9*# SODIUM-126* POTASSIUM-7.4* CHLORIDE-92* TOTAL CO2-23 ANION GAP-18 [**2159-10-30**] 05:50AM URINE RBC-[**5-3**]* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 RENAL EPI-0-2 [**2159-10-30**] 05:50AM CK-MB-9 cTropnT-0.02* [**2159-10-30**] 05:50AM CK(CPK)-850* . On Discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 8.1 4.68 13.4* 40.4 86 28.5 33.0 13.8 235 Glucose UreaN Creat Na K Cl HCO3 AnGap 152 18 1.2 134 4.6 98 30 11 CK: 242 Serum tox: negative Urine: [**2159-11-1**] 14:49 Yellow Clear 1.017 Source: CVS [**2159-10-30**] 10:15 Straw Clear 1.023 Source: Catheter [**2159-10-30**] 05:50 Straw Clear 1.024 DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks [**2159-11-1**] 14:49 TR NEG NEG 1000 NEG NEG NEG 7.0 NEG Source: CVS [**2159-10-30**] 10:15 LG NEG 25 1000 NEG NEG NEG 5.0 NEG Source: Catheter [**2159-10-30**] 05:50 LG NEG TR 1000 NEG NEG NEG 5.0 NEG MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE RenalEp [**2159-11-1**] 14:49 0-2 0-2 RARE NONE 0-2 Source: CVS [**2159-10-30**] 10:15 [**1-26**]* 0-2 OCC NONE 0-2 Source: Catheter [**2159-10-30**] 05:50 [**5-3**]* 0-2 NONE NONE 0-2 0-2 Imaging: [**10-30**] CT Head: No evidence of acute intracranial traumatic injury. [**10-30**] CT C-spine: No acute cervical fracture or malalignment. 12/7 L-spine xray: No acute lumbar or pelvic injury. [**10-30**] Renal U/S: Normal renal son[**Name (NI) **] [**10-31**] Hip x-ray: Negative for fracture, dislocation Brief Hospital Course: 46 yo M PMH uncontrolled [**Month/Day (4) 2320**], HTN, cirrhosis and obesity who presented from home with bilateral lower extremity weakness with fall down 10 steps. Initially admitted to MICU for 1 day for hyperglycemia and ARF, transferred for floor for continued mgmt. # Hyperosmolar Hyperglycemic State: Pt presented with BS of 600, serum osm of 324 though no anion gap. [**Month (only) 116**] have been precipitated by inadequate insulin regimen. No clear infectious etiology. Pt reported compliance with his current insulin regimen. BS normalized with IVF hydration. He was seen by [**Last Name (un) **] who suggested adding pre-prandial humalog 13 units (B-L-D) and altering SS. He was continued on glargine 60 units [**Hospital1 **]. Humalog sliding scale adjusted to start at 13units with meals. Sugars at time of discharge stable. Patient to follow-up with [**Last Name (un) **] week after discharge. Of note, patients lisinopril was held at time of discharge due to persistently elevated potassium. (K at discharge 4.8) Plan to follow-up with PCP as well as [**Last Name (un) **] prior to restarting medication. . # Acute Renal Failure: Creatinine on admission elevated to 4.9. Most likely related to pre-renal azotemia in setting of osmotic diuresis from hyperglycemia though given degree of renal failure and LOS fluid balance of 1-2L would not have expected this degree of renal failure. Also possible there was some obstruction (such as BPH) though renal u/s was negative. Cr normal at time of DC. Patient passed voiding trial with nl urine output. . # Hematuria. UA + for large blood, negative for infection. Hematuria thought secondary to fall. UA at with trace blood at time of discharge. UA should be obtained as outpatient and worked up if still present. . # Vomiting/Subjective Fevers: Pt reported 2 episodes of vomiting the day prior to admission. He had no further symptoms while hospitalized. Symptoms may represent viral illness. Pt was afebrile. No e/o PNA on CXR. UA not suggestive of UTI. ECG not suggestive of MI and CEs neg. At time of discharge, WBC wnl and patient afebrile without localizing complaints. . # LE Weakness: Acute weakness largely due to HHS as well as history of chronic low back pain. Improved during hospitalization. Pt seen by PT who suggested outpatient PT. X-ray of hip negative for fracture or dislocation. Discharged with cane and walker. LBP controlled with Tylenol 500mg Q6 (<2gm in setting of liver dysfunction) and tizinadine 4mg qhs. . # Unwitnessed Fall: Per pt's story sounds mechanical rather than a syncopal episode. Likely related to the LE weakness he was experiencing. Patient will be discharged with plan for outpatient physical therapy to optimize strength and mobility. . # Neuropathic Pain. Patient with increasing neuropathic pain secondary to progressive uncontrolled [**Last Name (un) 2320**]. Patient restarted on low dose Neurontin TID as well as Amitryptyline at night. Pharmacy consulted re the interaction between amitryptyline and prescription anti-depressants. Per pharmacy low dose amitryptyline in 46yo male safe with low clinical probability of adverse effects. Patient will need to be monitored for signs of TCA toxicity as an outpatient. . # Cirrhosis. LFTs stable in house with no signs of active decompensation or encephalapathy. . # Depression/Anxiety. Patient continued on home regimen of Duloxetine and Clonezapam. Medications on Admission: Vitamin E 400 Unit Lisinopril 40 Mg Lantus 60 units QAM and 60 units QPM Humalog 100/ml SS Cymbalta 60 Mg Clonazepam 1 Mg TID Discharge Medications: 1. insulin glargine 100 unit/mL Solution Sig: Sixty (60) u Subcutaneous twice a day. 2. insulin lispro 100 unit/mL Solution Sig: per sliding scale u Subcutaneous breakfast, lunch, dinner, bedtime: per sliding scale. Please dispense 1 10mL vial. Disp:*1 vial* Refills:*1* 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 7. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 8. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 10. Insulin Syringe 1 mL 28 x [**11-25**] Syringe Sig: One (1) syringe Miscellaneous four times a day: 100 syringes. Disp:*1 box* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Hyperglycemic hyperosmolar state, Acute Renal Failure Diabetes complicated by peripheral neuropathy . Secondary: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted with very high blood sugar and admitted to the intensive care unit. Your blood sugar was likely elevated because you were not taking enough insulin. You were seen by the diabetes specialists who recommended changes to your insulin regimen. You also had some kidney damage that resolved prior to your discharge. . You fell on your hip in the day prior to admission. X-ray was negative for fracture. You pain was treated with over the counter pain medication and should continue to improve with time. You will continue to work with physical therapy as an outpatient and at time of discharge you were given a cane and crutches to help with stability. . Regarding the burning sensation you have in your hands and feet. A new medication was started at night, Amitriptyline, to help alleviates these pains. . CHANGES TO YOUR MEDICATIONS: HOLD your LISINPRIL until you see your PCP. [**Name10 (NameIs) **] [**Name11 (NameIs) 51462**] 25mg. Take one 25mg tablet at night. If you find you are becoming more sleepy or experiencing excessive dry mouth, urinary retention, stop taking this medication. DECREASE dose of GABAPENTIN to 100mg tablets three times a day. . YOUR NEW INSULIN REGIMEN Glargine 60units in morning and 60units at night Humalog 13 units prior to breakfast, lunch and dinner Sliding scale: when sugars are between 80-150; administer 13units of humalog; 151 - 200: 15units 201-250: 17units 251-300: 19units 301-350: 21units 351-400: 23units . Followup Instructions: Primary Care Appt with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31**] You have an appt on [**11-30**]; however you should call for an earlier appt when you return home. [**Last Name (NamePattern1) 14305**] [**Telephone/Fax (1) 9251**] - continue to hold your lisinopril until you see Dr. [**Last Name (STitle) 31**]. . [**Last Name (un) **] DIABETES FOLLOW-UP: Monday [**11-5**] @ 2pm Completed by:[**2159-11-5**]

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Discharge summary

report

Admission Date: [**2109-3-31**] Discharge Date: [**2109-4-5**] Date of Birth: [**2026-11-6**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: STEMI Major Surgical or Invasive Procedure: cath History of Present Illness: 84F h/o MI in [**2086**] and CVA [**2099**], on Coumadin FOR AFIB, denies CABG or stents, c/o 1 hr of chest tightness, nausea, diaphoresis, onset while at rest watching TV. Followed by Mark [**Doctor Last Name **] at [**Location (un) **]. In ED had inferior STEMI with 2>3 STE in inferior leads. She got ASA and a Heparin bolus. INR was >3 so no gtt started. She was not given plavix prior to procedure. She was taken to the cath lab where she was found to have 90-100% mid RCA occlusion. The wire was delpoyed across the lesion but due to her INR of >3 and fragile appearing [**Last Name (un) 12599**] she was not felt to be a canditate for stenting. She underwent baloon angioplasty. . Following proceure, As radial T band was being remove she vagaled and had SBP drop to 50's with HR in the 150's. Was given 1-2 mg of atropine, started on dopamine. Systolics rose to the 80's. She was then given 10mg IV diltiazem followed by 15mg IV metoprolol with control of her HR to the 130's and SBP to 100's. She arrives ont he floor on 10 of dopa. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: CAD 2. CARDIAC HISTORY: - CABG: - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - Knwon MI in [**2088**] - CVA - Afib on coumadin - Social History: - Tobacco history: Quit smokign 21 years ago - ETOH: occasional glass of wine - Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: 120 97/70 RR18 02 SAT 100% 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 JVP elevation 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. . Exam at discharge: Vitals T 98.4 BP 125-156/76-86 HR 85-100RR 18 O2 94RA I/O: Tele: AF, rate 90's-low 100's no VEA Weight: 58.3(58.6) . General Appearance: NAD, sitting in chair Head, Ears, Nose, Throat: Normocephalic Cardiovascular: irregularly irregular (S1: Normal), JVP 12cm H2O, no murmurs, rubs or gallops Respiratory / Chest: CTAB Abdominal: Soft, Non-tender Extremities: right LE with 1+, LLE nl. Neurologic: Oriented to self, [**Hospital1 18**], Month, year, good attention Pertinent Results: ADMISSION LABS: [**2109-3-31**] 06:15PM BLOOD WBC-6.6 RBC-3.59* Hgb-12.1 Hct-36.5 MCV-102* MCH-33.8* MCHC-33.3 RDW-12.6 Plt Ct-219 [**2109-3-31**] 07:00PM BLOOD PT-40.4* PTT->150 INR(PT)-4.0* [**2109-3-31**] 07:00PM BLOOD Glucose-113* UreaN-17 Creat-1.0 Na-144 K-3.0* Cl-105 HCO3-26 AnGap-16 [**2109-3-31**] 06:15PM BLOOD cTropnT-<0.01 [**2109-4-1**] 12:54AM BLOOD CK-MB-88* MB Indx-12.0* cTropnT-3.54* [**2109-4-1**] 05:11AM BLOOD CK-MB-87* MB Indx-11.0* cTropnT-3.65* [**2109-4-1**] 12:54AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.5* [**2109-3-31**] 07:00PM BLOOD %HbA1c-5.9 eAG-123 [**2109-3-31**] 07:00PM BLOOD Triglyc-81 HDL-52 CHOL/HD-2.3 LDLcalc-52 [**2109-3-31**] 06:22PM BLOOD Glucose-109* Lactate-2.3* Na-141 K-3.3 Cl-102 calHCO3-28 PERTINENT INTERVAL LABS: [**2109-3-31**] 07:00PM BLOOD WBC-7.0 RBC-3.35* Hgb-11.0* Hct-33.1* MCV-99* MCH-32.9* MCHC-33.3 RDW-12.7 Plt Ct-194 [**2109-4-1**] 12:54AM BLOOD Hct-32.2* Plt Ct-199 [**2109-4-1**] 05:11AM BLOOD WBC-7.5 RBC-3.35* Hgb-10.9* Hct-33.4* MCV-100* MCH-32.5* MCHC-32.6 RDW-12.8 Plt Ct-203 [**2109-4-2**] 01:31AM BLOOD WBC-8.5 RBC-3.13* Hgb-10.4* Hct-31.0* MCV-99* MCH-33.3* MCHC-33.6 RDW-12.9 Plt Ct-182 [**2109-4-3**] 06:29AM BLOOD WBC-6.4 RBC-3.12* Hgb-10.2* Hct-31.6* MCV-101* MCH-32.7* MCHC-32.3 RDW-13.4 Plt Ct-179 [**2109-3-31**] 07:00PM BLOOD PT-40.4* PTT->150 INR(PT)-4.0* [**2109-4-1**] 05:11AM BLOOD PT-29.3* PTT-41.3* INR(PT)-2.8* [**2109-4-2**] 12:31PM BLOOD PT-38.9* INR(PT)-3.8* [**2109-4-3**] 06:29AM BLOOD PT-29.0* PTT-38.1* INR(PT)-2.8* [**2109-3-31**] 07:00PM BLOOD Glucose-113* UreaN-17 Creat-1.0 Na-144 K-3.0* Cl-105 HCO3-26 AnGap-16 [**2109-4-1**] 05:11AM BLOOD Glucose-131* UreaN-18 Creat-1.1 Na-140 K-4.1 Cl-103 HCO3-26 AnGap-15 [**2109-4-2**] 01:31AM BLOOD Glucose-118* UreaN-22* Creat-1.2* Na-141 K-3.6 Cl-104 HCO3-22 AnGap-19 [**2109-4-3**] 06:29AM BLOOD Glucose-78 UreaN-21* Creat-1.0 Na-142 K-3.5 Cl-107 HCO3-25 AnGap-14 [**2109-4-1**] 12:54AM BLOOD CK(CPK)-734* [**2109-4-1**] 05:11AM BLOOD CK(CPK)-788* [**2109-4-1**] 01:22PM BLOOD CK(CPK)-633* [**2109-4-2**] 01:31AM BLOOD CK(CPK)-603* [**2109-4-3**] 06:29AM BLOOD ALT-41* AST-67* AlkPhos-41 TotBili-0.7 [**2109-3-31**] 06:15PM BLOOD Lipase-59 [**2109-3-31**] 06:15PM BLOOD cTropnT-<0.01 [**2109-4-1**] 12:54AM BLOOD CK-MB-88* MB Indx-12.0* cTropnT-3.54* [**2109-4-1**] 05:11AM BLOOD CK-MB-87* MB Indx-11.0* cTropnT-3.65* [**2109-4-1**] 01:22PM BLOOD CK-MB-48* MB Indx-7.6* cTropnT-2.35* [**2109-4-2**] 01:31AM BLOOD CK-MB-25* MB Indx-4.1 cTropnT-1.88* [**2109-4-1**] 12:54AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.5* [**2109-4-2**] 01:31AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.8 [**2109-4-3**] 06:29AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.1 [**2109-3-31**] 07:00PM BLOOD %HbA1c-5.9 eAG-123 [**2109-3-31**] 07:00PM BLOOD Triglyc-81 HDL-52 CHOL/HD-2.3 LDLcalc-52 STUDIES: ECG ([**3-31**]): Sinus rhythm. Right bundle-branch block. Inferior ST segment elevation consistent with an acute inferior myocardial infarction and probable lateral extension with slight ST segment elevation in leads V5-V6. There is reciprocal ST segment depression in leads I, aVL and V1-V2. No previous tracing available for comparison. Cardiac Cath ([**3-31**]): COMMENTS: 1) Selective coronary angiography of this right-dominant system demonstrated one-vessel coronary artery disease. The LMCA, LAD, and LCx had minimal disease but were free of angiographically-apparent flow-limiting stenoses. The mid-RCA was subtotally occluded. 2) After the mid-RCA angioplasty, she began complaining of nausea and dizziness and was noted to have a noninvasive sBP in the high 50s. The transducer was connected to the right radial arterial sheath sidearm, with blunted pressure recordings. Noninvasive readings were consistently below sBP 70. She was given 2 mg atropine for presumed vagal reaction, and started on IV fluids and dopamine, up to 20 mcg/kg/min. A right common femoral arterial sheath was placed in preparation for possible IABP placement. However, her sBPs were then noted to be in the 80s-90s. At that time, her heart rates were in the 140s-150s (transiently as high as 200) and appeared to be atrial fibrillation; she was then given 15mg IV metoprolol with resulting heart rates in the 120s and stable sBPs in the 100s. The RCFA sheath was manually pulled and a TR band was applied to the RRA site. She was transported to the CCU in stable condition. ADDENDUM: PCI COMMENTS: Initial angiography revealed a subtotally occluded RCA. We planned to treat this using PTCA. A 6 Fr JR5 guiding catheter provided reasonable support throughout the procedure. Chronic Warfarin therapy with known INR of 3.2 48 hours prior. A Prowater wire was successfully advanced across the target lesion and positioned in the distal vessel. An Apex 2.0 x 8 mm balloon was used to pre-dilate the occlusion, restoring flow to the vessel. Attempts were made to deliver a Mini-Vision 2.0 x 12 mm and then a 2.0 x 8 mm stent, however we were unable to advance these across the lesion. Final angiography showed TIMI 3 flow within the vessel and no apparent dissection. It was elected to stop with conventional balloon angioplasty given her elevated INR. Post angioplasty hemodynamic course as documented above. Hemostasis achieved at right radial arterial access site using TR band. FINAL DIAGNOSIS: 1. One vessel coronary artery disease status post primary balloon angioplasty of the mid-RCA stenosis. 2. Vagal reaction and hypotension requiring pressors and fluids. . ECG ([**2109-3-31**]): rate 84, Baseline artifact makes P wave morphology difficult. This could be sinus rhythm with premature atrial contractions and ventricular premature beats versus atrial fibrillation with ventricular premature beats. Right bundle-branch block. Inferior and lateral ST segment elevation consistent with an acute inferior myocardial infarction. Compared to tracing #1 baseline artifact is more pronounced. . ECG [**2109-3-31**]: rate 133. Probable atrial fibrillation with a rapid ventricular response and baseline artifact. Right bundle-branch block. Left anterior fascicular block. Q waves in leads III and aVF consistent with an inferior myocardial infarction which is probably acute. Compared to tracing #2 the inferior and lateral ST segment elevation is less pronouced. Q waves are more apparent in leads III and aVF. TRACING #3 . ECG [**2109-3-31**]: rate 126. Possible atrial flutter with variable block. Right bundle-branch block with left anterior fascicular block. Slight ST segment elevation in leads III and aVF with Q waves suggesting evolution of an inferior myocardial infarction. Premature ventricular contraction is also present. Lateral ST-T wave changes consistent with ongoing ischemia. Compared to tracing #3 atrial flutter may be present. The ventricular premature beat is new. . ECG [**2109-3-31**]: rate 123. Probable atrial fibrillation with a rapid ventricular response. Right bundle-branch block with left anterior fascicular block. Inferior myocardial infarction which is evolving. ST-T wave changes suggest ongoing ischemia. Compared to tracing #5 the ventricular rate is slower. . ECG [**2109-4-1**]: rate 86. Atrial flutter at an atrial rate of about 300 with variable block. Right bundle-branch block with left anterior fascicular block. Inferior myocardial infarction with inferior T wave inversions suggesting an evolving inferior myocardial infarction. Non-specific T wave flattening in leads V4-V6. Compared to tracing #6 the ventricular rate is slower. The ST segment depression in leads V1-V2 is less pronounced. . ECHO [**2109-4-1**]: The left atrium is elongated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferior septum, inferior and inferolateral walls. The remaining segments contract normally (LVEF = 35 %). The right ventricular cavity is mildly dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-26**]+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with moderate regional systolic dysfunction c/w CAD. Severe tricuspid regurgitation. Pulmonary artery hypertension. Mild-moderate mitral regurgitation. Labs on Discharge: [**2109-4-5**] 06:55AM BLOOD WBC-6.3 RBC-3.12* Hgb-10.2* Hct-31.4* MCV-101* MCH-32.6* MCHC-32.4 RDW-13.6 Plt Ct-198 [**2109-4-5**] 06:55AM BLOOD PT-26.2* INR(PT)-2.5* [**2109-4-5**] 06:55AM BLOOD UreaN-19 Creat-0.9 Na-144 K-3.8 Cl-108 HCO3-30 AnGap-10 [**2109-4-4**] 06:56AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.9 Brief Hospital Course: Brief Clinical Summary: Ms. [**Known lastname **] is an 82 year old woman with history of CAD, Afib on coumadin and CVA who presented with inferior STEMI secondary to RCA occlusion now s/p percutaneous balloon angioplasty with immediate post procedural course complicated by hypotension and tachycardia initially requiring pressors, hospitalization complicated by delirium. Issues: # Inferior STEMI: Because patient presented with supratherapeutic INR, decision was made not to commit patient to plavix with PCI, so she underwent POBA of the RCA. She was chest pain free with resolution of ST changes after intervention. She was initially hypotensive and bradycardic on presentation, requiring dopamine for support which was soon weaned off. She also received a dose of atropine on the night of presentation, after which she became more delirious. She was continued on aspirin, beta blocker. Atorvastatin dose was increased to 80mg daily. Lisinopril 2.5mg was started prior to discharge. TTE showed EF of 35%, symmetric LVH with moderate regional systolic dysfunction, severe TR, moderate mitral regurgitation, and RV failure. Hemoglobin A1c was 5.9% consistent with prediabetes. Lipid panel showed HDL 54, LDL 47 and trigl 108. The patient has been arranged with cardiac follow-up. # Acute Systolic Dysfunction: EF 35% on ECHO. No signs of CHF during her hospital stay. Her discharge weight is 128 pounds. She will require daiy weights with the consideration of starting a diuretic if her weight increases or she shows signs of CHF. An ECHO should be scheduled in [**3-1**] weeks to assess LV function. # Delirium: ICU course was complicated by significant delirium which quickly resolved on the floor. She was given several doses of olanzapine and quetiapine in the ICU in efforts to restore her sleep-wake cycle. # Afib with RVR: She remained in atrial fibrillation throughout hospitalization. CHADS score is 4. Presented with supratherapeutic INR, so warfarin was initially held, then restarted prior to discharge. She was continued on metoprolol. # Hypertension Home antihypertensives were initially held in the setting of hypotension. When hemodynamically stable, she was restarted on metoprolol in setting of atrial fibrillation, and she was started on low dose lisinopril. Her metoprolol was increased to 150 of succinate once per day. Home HCTZ was discontinued. # Code Status was FULL CODE during this hospitalization # Husband: [**Name (NI) **] [**Name (NI) **]: [**Telephone/Fax (1) 18277**]. Transitional Issues: 1. cardiology f/u 2. uptitrate lisinopril as tolerated 3. uptitrate metoprolol as tolerated Medications on Admission: Warfarin 3.75-7mg Calcium 600 D HCTZ 25 mg QD Lipitor 10mg QD Immodium PRN Maalox 2 tsp QHS Metoprolol 50mg QD MVI Probiotics Tylenol 500mg [**Hospital1 **] PRN - Discharge Medications: 1. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. [**Hospital1 **]:*45 Tablet Extended Release 24 hr(s)* Refills:*0* 2. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO once a day: please adjust dose as instructed by your doctor. [**Last Name (Titles) **]:*90 Tablet(s)* Refills:*2* 3. Calcium 500 + D Oral 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2* 5. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2* 7. immodium Sig: One (1) once a day as needed for diarrhea. 8. Maalox RS Oral 9. multivitamin Tablet Sig: One (1) Tablet PO once a day. 10. probiotics Sig: One (1) once a day. 11. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for pain. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at [**Location (un) 620**] Discharge Diagnosis: ST Elevation Myocardial Infarction Delirium Hypertension Tachycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to the hospital because you had a heart attack. We started you on new medications to help protect your heart. You had some delirium (confusion) in the hospital, which is now improved. The following changes were made to your medications: - STOP Hydrochlorothiazide - DECREASE Warfarin to 3mg daily and adjust your dose as instructed by your doctor - INCREASE Lipitor to 80mg daily to lower your cholesterol - START Aspirin 325mg daily to prevent blood clots - INCREASE Metoprolol Succinate to 150mg daily to slow your heart rate - START lisinopril 2.5mg daily It was a pleasure taking care of you, we wish you all the best! Followup Instructions: Name: MARK [**Name Initial (MD) **] [**Name8 (MD) **],MD Location: [**Hospital3 **] CARDIOLOGISTS When: Tuesday [**4-9**] at 1pm Address: [**2109**], [**Location (un) **],[**Numeric Identifier 8934**] Phone: [**Telephone/Fax (1) 18278**] Completed by:[**2109-4-5**]

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icd9cm

[ [ [] ] ]

[ "00.66", "88.53", "88.56", "37.22", "00.40" ]

icd9pcs

[ [ [] ] ]

16904, 16981

12971, 15492

281, 287

17094, 17094

3497, 3497

17944, 18212

2245, 2360

15819, 16881

17002, 17073

15632, 15796

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12637, 12948

315, 1894

3513, 8765

17109, 17221

2057, 2112

1916, 1945

2128, 2229

47,297

165,671

30823

Discharge summary

report

Admission Date: [**2194-12-22**] Discharge Date: [**2194-12-26**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 425**] Chief Complaint: Complete Heart Block Major Surgical or Invasive Procedure: [**Company 1543**] Sensia ROD 01: dual chamber History of Present Illness: [**Age over 90 **]M with PMH HTN CKD and possible recent pneumonia (dx [**12-14**]) presented to [**Hospital1 18**] [**Location (un) 620**] with altered mental status. Tele revealed CHB with HR 25-40, SBP 150-190 mmHg. No reversible etiology thus far (no nodal agents, no metabolic abnormalities, no ischemic EKG changes). Transfer for consideration of temp wire/PPM. Family initially declined, but now want PPM. Only home medication is Lisinopril 10. No cardiac hx. He has been afebrile, UA was negative and Bcx are pending. No CXR was done. . On arrival to the CCU he was noted to be in 2nd degree heart block with 2:1 conduction. His temp is 95.1 BP 131/50, RR18 100% on 4L. He is A&Ox1 but pleasant. He is unable to provide further history. . He denies CP, SOB, cough, diarrhea constipation, urinary symptoms though he is not a reliable historian. . Of note he presented to [**Location (un) **] [**12-14**] for weakness and s/p fall. EKG at that time showed sinus bradycardia wih PR prolongation. A CXR showed a RLL opacity which was treated as a presumed PNA with a course of azithromycin and ceftin which he would have just finished 1-2 days ago. Fianl read from CXR was atelectasis and not consolidation. During this admission he required a 1:1 sitter for delirium. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - CKD Baseline Cre (1.4-1.7) - Remote colon CA - Elevated PSA (11.1 on [**2-17**]) Social History: - Tobacco history: None - ETOH: None - Illicit drugs: None Lives with Wife who is his HCP. Ambulates with walker Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: NAD. Oriented x0. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVD not appreciated. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Bradycardic, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ . DISCHARGE PHYSICAL EXAM: VS T 96.6 HR: 86-94 BP: 130-165/73-98 RR: 18 02 sat: 99% RA GENERAL: [**Age over 90 **] yo male sitting in chair in no acute distress HEENT: PERRLA, mucous membranes moist, no lymphadenopathy, JVP non elevated CHEST: LS clear throughout, no wheezes, no rales, no rhonchi CV:RRR, NL S1S2, no murmurs rubs or gallops ABD: soft, non-tender, non-distended, BS normoactive EXT: Warm and dry, 2+ DP/PT, no pedal edema NEURO: Alert, oriented to person only, answers questions appropriately, pt poorly compliant with neurological exam. SKIN: no rash, no open sores PSYCH: Pt alert to person only Pertinent Results: ADMISSION EXAM: [**2194-12-22**] 03:46AM GLUCOSE-116* UREA N-36* CREAT-1.4* SODIUM-142 POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-22 ANION GAP-15 [**2194-12-22**] 03:46AM ALT(SGPT)-36 AST(SGOT)-35 CK(CPK)-54 ALK PHOS-47 TOT BILI-1.5 [**2194-12-22**] 03:46AM CALCIUM-8.8 PHOSPHATE-2.9 MAGNESIUM-2.1 [**2194-12-22**] 03:46AM WBC-5.4 RBC-3.89* HGB-12.4* HCT-36.2* MCV-93 MCH-31.9 MCHC-34.3 RDW-12.5 [**2194-12-22**] 03:46AM NEUTS-70.8* LYMPHS-19.8 MONOS-5.9 EOS-3.0 BASOS-0.5 [**2194-12-22**] 03:46AM PT-13.6* PTT-26.6 INR(PT)-1.2* [**2194-12-22**] 03:46AM PLT COUNT-120* . PERTINENT LABS: [**2194-12-22**] 03:46AM BLOOD CK-MB-3 cTropnT-<0.01 [**2194-12-23**] 05:34AM BLOOD CK-MB-8 cTropnT-0.11* [**2194-12-23**] 05:34AM BLOOD VitB12-434 Folate-GREATER TH [**2194-12-23**] 05:34AM BLOOD TSH-2.5 [**2194-12-24**] 03:04PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG RAPID PLASMA REAGIN TEST (Final [**2194-12-25**]): NONREACTIVE. . DISCHARGE LABS: [**2194-12-26**] 07:10AM BLOOD WBC-8.7 RBC-3.49* Hgb-11.0* Hct-32.1* MCV-92 MCH-31.4 MCHC-34.1 RDW-12.8 Plt Ct-117* [**2194-12-26**] 07:10AM BLOOD Plt Ct-117* [**2194-12-26**] 07:10AM BLOOD Glucose-113* UreaN-49* Creat-1.5* Na-146* K-4.0 Cl-113* HCO3-27 AnGap-10 . MICRO/PATH: . MRSA Screening: Negative CDiff Antigen [**12-23**]: Negative RPR [**12-24**]: Negative . IMAGING/STUDIES: . EKG: [**2194-12-13**] One hundred percent ventricular paced rhythm. Compared to the previous tracing of [**2194-12-22**] the patient has gone from 2:1 A-V block with ventricular rate of 40 to one hundred percent A-V pacing, rate 66. . CXR [**2194-12-23**] FINDINGS: The patient received a new dual-lead left pectoral pacemaker lead with one of the leads terminating into the right ventricle and other lead into the right atrium. On the lateral view, though the tip of the ventricular lead is seen clearly, atrial lead tip is seen as a faint opacaity at the level where the ventricular pacemaker lead takes anterior curve. There is no pneumothorax. Bilateral lungs are clear. There are no lung opacities of concern for pneumonia/pulmonary edema. Posterior costophrenic angles are blunted, likely small effusions. Heart size is top normal. Aorta is generally large but there is no focal aneurysmal dilatation. The visualized part of the abdomen is remarkable for air filled and mild dilation of the bowel loops. . Obliques views are recommended to further confirm the location of atrial lead which was less distinct on lateral view. Radiograph of the abdomen is recommended for further evaluation of mildly dilated bowel loops. . CXR [**2194-12-23**] FINDINGS: An oblique view also of the lateral clearly shows both the atrial and ventricular catheter heading anteriorly in the appropriate position. . Dilatation of gas-filled loops of bowel persists. If there is clinical concern for severe adynamic ileus or mechanical obstruction, an abdominal series or even CT could be obtained. Brief Hospital Course: [**Age over 90 **]M with HTN, CKD, and new AMS likely from dementia/delrium and new high grade AV Block now s/p pacemaker placement. . ACTIVE ISSUES: . # High grade AV block: Initially presented in high grade AV block with 2:1 and 3:1 conduction. He underwent uncomplicated pacemaker placement. EKG demonstrated 100% capture and CXR demonstrated good lead placement. He should follow up in device clinic in one week after discharge. He will also need PCP [**Name9 (PRE) 702**] in the next week or two. . #Delerium: Mr. [**Name (NI) 72959**] has a history of several months of cognitive decline which was felt to most likely be from microvascular vs. Alzheimers dementia. His hospitalization has been complicated by acute delirium requiring antipsychotic medications and soft restraints. Work up this hospitalization included a negative CXR, UA, RPR, Normal TSH, Folate/B12. He is curently on low dose Seroquel which seems to have helped his agitation but may be contributing to his urinary retention. Please attempt to d/c Seroquel and follow mental status. . #Acute Kidney Injury on CKD: Mr. [**Name (NI) 72960**] creatinine rose briefly to a peak of 2.1 which was believed to be from poor PO intake. He was given IVF and his lisinopril was held with improvement of his creatinine back to 1.4 on the day of discharge. . #Acute Urinary Retention: Mr. [**Name (NI) 72959**] developed acute urinary retension 3 days into his hospitalization thought to be related to anti-cholinergic side effects of atypical antipsychotics he recieved including seroquel. He had a foley placed with a plan for a temporary 5 day course. He was also started on tamsulosin. We anticipate his foley can be d/c'd in 5 days time but he may need formal follow-up for urinary retension as an outpatient. . CHRONIC ISSUES: . #HTN: Lisinopril was held on admission because he was hypotensive in the setting of heart block. After his procedure his lisinporil was restarted after being held briefly for [**Last Name (un) **] as above. . #Elevated PSA: Last PSA >11 1/[**2193**]. Does not want treatment or biopsy of potential prostate CA but metastatic disease could be a consideration if LFT abnormalities do not resolve. Rectal exam evealed an irregularly shaped and enlarged prostate. Unclear if this is contributing to his urinary retention although the medications are more likely the cause. . #Anemia: Mild chronic anemia. Stable . #Thrombocytopenia: Mild chronic thrombocytopenia. Stable . TRANSITIONAL ISSUES: # Foley/Urinary Retention: Patient developed urinary retention thought to be related a few doses of seroquel in house. He was started on tamsulosin and a temporary foley was placed with a plan to remove after 5 days. . #Pacemaker follow up: He should follw up with device clinic in one week. . #Dementia: Mr [**Name (NI) 72959**] may benefit from a formal evaluation of his dementia, as well as possible long term care placement after rehab. Medications on Admission: Lisinopril 10 mg daily Discharge Medications: 1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: Please increase to 10 mg if creatinine stable. . 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. quetiapine 25 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime). 4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO at bedtime. 5. Outpatient Lab Work Please check Chem-7 and CBC on Monday [**2194-12-29**] Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at [**Location (un) 620**] Discharge Diagnosis: Delirium Second degree heart block s/p pacemaker Hypertension 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 to the hospital with a block in the conduction system of your heart and required a pacemaker. This was placed on [**12-22**] and it is functioning well. You can remove the dressing on [**12-27**] and take a shower, do not remove the tape over the incision area. You cannot lift more than 5 pounds or lift your left arm over your head for 6 weeks. If you have any discomfort at the incision site, you can take Tylenol for the pain. While you were hospitalized, you developed a severe confusion called delerium. You needed some new medicines to help you stay calm and the gerontology team evaluated you. . We made the following changes to your medicines: 1.START taking Tamsulosin to help you urinate 2. START taking Seroquel to help you stay calm at night 3. DECREASE Lisinopril to 5 mg daily 4. START a multivitamin. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2194-12-30**] at 4:00PM With: DEVICE CLINIC ([**Telephone/Fax (1) 4105**]) Building: [**Hospital1 **] Hospital, [**Location (un) 620**] Best Parking: outside lot Department: CARDIAC SERVICES When:Tuesday [**2-3**] 3pm With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Building: [**Hospital1 **] Hospital, [**Location (un) 620**] Best Parking: outside lot Completed by:[**2194-12-26**]

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icd9cm

[ [ [] ] ]

[ "37.83", "37.72" ]

icd9pcs

[ [ [] ] ]

9782, 9859

6332, 6467

273, 322

9965, 9965

3328, 3908

11002, 11463

2081, 2099

9335, 9759

9880, 9944

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1754, 1815

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9980, 10118

3924, 4321

1846, 1933

8127, 8798

1668, 1734

1949, 2065

2720, 3309

70,267

188,882

3699

Discharge summary

report

Admission Date: [**2198-12-3**] Discharge Date: [**2198-12-26**] Date of Birth: [**2159-8-28**] Sex: F Service: MEDICINE Allergies: Penicillins / Amoxicillin / clindamycin / clavulanic acid / Aztreonam / Sulbactam / tazobactam / Cephalosporins Attending:[**First Name3 (LF) 7055**] Chief Complaint: cardiac arrest Major Surgical or Invasive Procedure: pulmonary intubation Central line placement History of Present Illness: 39 yo female history of HTN, IDDM, NiCMY with EF 45%, nonobstructive CAD, and ESRD s/p HD today heard to release a large yelp with an agonal breath and subsequently found to be unresponsive and pulseless. There are no strips from HD. CPR was initiated for three minutes until AED was applied and advised shock with return of spontaneous circulation, a perfusing rhythm, and 100% sat. EMS reports that she was responsive only to painful stimuli, with a GCS of 6. EKG at that time was reported as NSR 70-80 withuot ectopy and antiarrythmic deferred. In the ED, she was found to have gurgling breath sounds, poor tone, was not coherent and appeared to be "out of it" so she was intubated with atomidate and vecuronium. She was started on 150mg IV amio bolus with drip at 1mg/minute. She was sedated with propofol. She was hypertensive at 170's/100's, with multiple runs of PVC's including 10 run beats of VT. Her ectopy decreased with amio. After head CT and guaiac were negative, a cooling protocol was initiated with goal temp of 33. A full strength rectal aspirin was administered. Blood gas upon admission was 7.43/49/108/34. En route to the CCU, 2mg of Ativan were given for questionable tongue twitching representing seizure activity. . Of note, recently seen at [**Hospital1 2177**] for febrile viral illness for which she was given doses of vanco, levo, and flagyl. Her potassium at that time was listed as 4.1. EKG at that time was noted to be NSR at 75, with multiple PVC's and no acute ST-T changes. . In the CCU, she is unable to complete a review of systems or voice her complaints as she is intubated. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: Nonobstructive CAD with 30% mid RCA stenosis, 30% PLB stenosis in [**2192**]. In [**2-6**], LAD, Lcx with minor irregularities - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: -NiCMY, LVEF 45% -ESRD due to IDDM and HTN, on HD MWF via RUE AVG since [**2195**] -HTN, difficult to control -IDDM -Pulmonary HTN (PASP above 50 mmHg on echo [**5-/2198**], at least partially due to OSA -HL -Obesity -Hypothyroidism -GERD -Epilepsy -Recent viral infection on levaquin -Chronic back pain -Anxiety and Depression Social History: -ASA 81 -lisinopril 40 [**Hospital1 **] -labetalol 500 [**Hospital1 **] -clonidine 0.6 [**Hospital1 **] -hydral 100 tid -amlodipine 10 daily -isosorbide mononitrate 30 daily -keppra 500 [**Hospital1 **] -keppra 500 at 2pm mwf -ferrous sulfate 325 tid -synthroid 150 [**Hospital1 **] -phoslo 667 two caps [**Hospital1 **] -calcitriol 0.5 daily -simvastatin 40 daily -colace 100 [**Hospital1 **] -metoclopramide 5 prn prior to meals -lorazepam 1 daily for mood -tramadol 50-100 [**Hospital1 **] prn pain -omeprazole 40 [**Hospital1 **] -levemir 2 units qAM -humalog 2U small, 3U medium, 4U large Family History: Unknown. Physical Exam: ADMISSION PHYSICAL EXAM: VS: GENERAL: Intubated and sedated with low tone. Vent: AC TV 450 RR 12 FiO2 60% PEEP 5. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, JVP elevated. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. +S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Central bilateral breath sounds. ABDOMEN: +BS, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: wwp, no c/c/e. SKIN: Thick woody skin with multiple excoriations. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ . DISCHARGE PHYSICAL EXAM: VS: Tmax/Tcurrent: 98.7/98.5 HR 59-74 RR: 18-20, BP: 122-154/50-94 O2 sat: 100% RA. . I/O over 24 hours: 960/1.6 out in HD 8H 400/anuric . FS: 33/21/66/184 . GENERAL: sleepy but easily arousable. HEENT: MM moist, no JVD. CHEST: CTABL but poor aeration/poor effort. no wheezes, no rales, no rhonchi auscultated. L ICD site dressing c/d/i but tender to palpation surrounding, no erythema or fluctuance. CV: irreg irreg, no murmurs. ABD: soft, non-tender, non-distended, BS normoactive. EXT: wwp, no edema. DPs, PTs 1+. Large hematoma proximal to fistula, somewhat mobile and tender, improved from last week and shrinking in size. Fistula itself is also large with positive thrill. NEURO: Somnolent, awakens to voice and speaks clearly but minimally. Oriented x 3. Follows commands. SKIN: no rash PSYCH: no agitation or anxiety Pertinent Results: ADMISSION LABS: . [**2198-12-3**] 07:45PM BLOOD WBC-5.4 RBC-3.11* Hgb-10.4* Hct-31.2* MCV-100* MCH-33.3* MCHC-33.1 RDW-16.4* Plt Ct-219 [**2198-12-3**] 07:45PM BLOOD PT-13.4 PTT-29.7 INR(PT)-1.1 [**2198-12-3**] 07:45PM BLOOD Fibrino-409* [**2198-12-3**] 11:51PM BLOOD Glucose-205* UreaN-11 Creat-3.8* Na-139 K-2.7* Cl-94* HCO3-30 AnGap-18 [**2198-12-3**] 11:51PM BLOOD ALT-6 AST-27 CK(CPK)-102 AlkPhos-153* TotBili-1.0 [**2198-12-3**] 07:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2198-12-3**] 07:48PM BLOOD pO2-108* pCO2-49* pH-7.43 calTCO2-34* Base XS-6 Comment-GREEN TOP [**2198-12-3**] 07:48PM BLOOD Glucose-147* Lactate-3.3* Na-139 K-3.8 Cl-93* . PERTINENT LABS: . [**2198-12-3**] 07:45PM BLOOD cTropnT-0.09* [**2198-12-3**] 07:45PM BLOOD CK-MB-1 [**2198-12-3**] 11:51PM BLOOD CK-MB-1 cTropnT-0.09* [**2198-12-4**] 05:59AM BLOOD CK-MB-1 cTropnT-0.09* [**2198-12-3**] 07:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2198-12-4**] 05:59AM BLOOD TSH-3.0 [**2198-12-4**] 10:38AM BLOOD HIV Ab-NEGATIVE . DISCHARGE LABS: [**2198-12-24**] 06:43AM BLOOD WBC-6.1 RBC-2.63* Hgb-8.4* Hct-25.8* MCV-98 MCH-31.9 MCHC-32.6 RDW-15.0 Plt Ct-214 [**2198-12-24**] 06:43AM BLOOD Glucose-81 UreaN-82* Creat-7.8*# Na-125* K-6.8* Cl-88* HCO3-24 AnGap-20 [**2198-12-24**] 06:43AM BLOOD Calcium-9.3 Phos-4.7* Mg-2.1 . MICRO/PATH: . Blood Cultures x 2 [**12-3**]: No Growth MRSA SCREEN (Final [**2198-12-6**]): No MRSA isolated. MRSA SCREEN (Final [**2198-12-16**]): No MRSA isolated. . IMAGING/STUDIES: . CXR [**12-3**]: IMPRESSION: Endotracheal and nasogastric tubes in position. Bilateral pleural effusions with overlying atelectasis. Left base opacity may represent combination of atelectasis and pleural effusion, although underlying consolidation cannot be entirely excluded. . CT Head [**12-3**]: IMPRESSION: No evidence of acute intracranial process. . TTE [**12-4**]: . CXR Portable [**12-4**]: IMPRESSION: 1. Tip of left IJL abuts wall of the upper SVC. 2. Worsening mild to moderate congestive heart failure. . EEG [**12-5**]: IMPRESSION: This is an abnormal continuous ICU EEG study since the background was disorganized and slightly slow consistent with a mild diffuse encephalopathy of non-specific etiology. Superimposed frontally predominant delta activity was seen with stimulation during bedside care and likely represents a pattern of arousal. No epileptiform discharges or electrographic seizures were recorded. This EEG show a significant improvement compared to previous day's recording as background frequency is faster at 7.5 Hz (compared to 5 Hz on the previous day) and some normal sleep morphologies were also noted. . Chest Portable [**12-5**]: There is new almost complete collapse of the left lower lobe. There is no pneumothorax. Small right and moderate left pleural effusions are unchanged. Cardiomediastinum is shifted towards the left side. Left IJ catheter tip is in the upper to mid SVC. . EEG [**12-6**]: IMPRESSION: This is an abnormal extended routine EEG study. Background was markedly attenuated and slow with admixed faster frontal rhythms that were interrupted by brief periods of marked suppression. These findings are indicative of an underlying moderate encephalopathy most likely related to the effect of sedative medications. The background was reactive in response to physical stimulation. No epileptiform discharges or electrographic seizures were present. . CXR Portable [**12-7**]: IMPRESSION: 1. Endotracheal tube appropriately retracted to 5 cm above the carina. 2. Resolution of pulmonary edema. 3. Stable moderate left greater than right bilateral pleural effusions. 4. Stable mild cardiomegaly. . CXR Portable [**12-8**]: . The feeding tube, left IJ catheter and endotracheal tube are unchanged in position. There is persistent cardiomegaly. There is unchanged left retrocardiac opacity. There are no signs for overt pulmonary edema. There is a small right-sided pleural effusion as well. Overall, these findings are stable. . CXR Portable [**12-9**]: The endotracheal tube, feeding tube, and right IJ central venous catheter are stable in position. There is again seen cardiomegaly and left retrocardiac opacity, which is unchanged. There are no pneumothoraces or signs for overt pulmonary edema. A small right-sided pleural effusion is also present. . Video Oropharyngeal Swallow [**12-13**]: VIDEO OROPHARYNGEAL SWALLOW: A video oropharyngeal swallow study was performed in conjunction with the speech and swallow team. Multiple consistencies of barium were administered. The patient could not fully cooperate due to mental status, although limited swallows of nectar and honey-thickened liquids showed no obvious aspiration. Please see speech and swallow note in OMR for complete details. . Arterial Duplex Extremity Exam [**12-14**]: FINDINGS: Focal exam in the area of trauma was performed. There is a large area of flow interpose between the arterial and venous anastomosis. This most likely represents an aneurysmal dilatation arising off the draining vein rather than any disruption of the anastomosis. There is persistent flow with expected waveforms throughout the draining vein up through to the subclavian vein. Findings were transmitted to the referring physician at the time of initial performance of this scan. . CXR PA/LAT [**12-21**]: IMPRESSION: PA and lateral chest compared to [**12-5**] through 13: Small left pleural effusion has decreased substantially since [**12-9**]. Small right pleural effusion or more likely right pleural scarring, unchanged. New transvenous right ventricular pacer defibrillator lead in standard placement. Moderate cardiomegaly, unchanged. No pulmonary or mediastinal vascular engorgement. No pneumothorax or mediastinal widening. Lungs are grossly clear. Brief Hospital Course: 39 yo female with history of HTN, IDDM, NiCMY, nonobstructing CAD, and ESRD on HD admitted after cardiac arrest with cooling protocol found to be hypokalemic with chronic prolonged qtc and polymorphic VT now extubated and s/p placement of single chamber ICD. . ACTIVE DIAGNOSES: . # Cardiac arrest s/p ICD placement: Pt had VT to Vfib arrest at dialysis center assessed as being the result of baseline prolonged QT interval (chronic per old EKG's obtained from [**Hospital1 2177**]) in the setting of electrolyte shifts during dialysis, most notably hypokalemia. Our thinking was that hypokalemia predisposed her to early after depolarizations with R on T phenomena making her more likely to have a degenerating rhythm due to her long QT. She had a long and eventful hospital course including undergoing arctic sun cooling and re-warming, successful extubation following prior failed attempt (she required re-intubation due to mucous plugging), and gradual recovery of her baseline mental status. She required frequent work with PT and speech and swallow to resume PO intake. She was dialyzed in-house by the renal team who recommended she be dialyzed using a high K bath in the future to maintain her K around 5. Additionally, EP was consulted and after a significant amount of consideration and deliberation it was determined that she would benefit from a single chamber ICD which was placed despite concerns regarding her multiple comorbidities. She had evidence of significant ectopy on telemetry throughout her hospitalization including frequent PVC's and occasional runs of NSVT. She was discharged to rehab for continued recovery of her physical function. ICD dressing was removed on [**12-25**] and steri strips should stay in place until after her ICD check on [**2198-12-27**]. . # ESRD ON HD: Stable. She was maintained on her MWF dialysis schedule with high K buffer with goal K of 5. She did not have any significant arrythmias during dialysis but during one session she rolled onto the dialysis needle and punctured her graft. Doppler study was obtained which demonstrated her graft was intact and vascular surgery evaluated and stated it was okay for further dialysis. She has a large resolving hematoma proximal to the fistula. . # Poor PO Intake/Severe Physical Deconditioning: Pt worked with speech and swallow almost daily to enhance her ability to take in nutrition by mouth. She was also seen by the nutrition service as it was felt she would be aided in her physical recovery with improved nutritional status. She was discharged to a rehab facility to aid in recovery of her physical functional status. . CHRONIC DIAGNOSES: . # Insulin dependent diabetes mellitus: Stable. She was managed in-house on a combination of long acting and humalog sliding scale. She is very sensitive to insulin and has had episodes of hypoglycemia. . # HTN: Stable. On admission she had an unconventional antihypertensive regimen including significant doses of clonidine and hydralazine. She was gradually tapered off her regimen and it was replaced with carvedilol and lisinopril. . # CAD: History of nonobstructive CAD but without ischemic changes on EKG's and without positive cardiac enzymes. She was treated with aspirin and atorvastatin as well as her blood pressure regimen above. . # Chronic Diastolic Congestive Heart Failure: History of non-ischemic cardiomyopathy with EF 45%. Her TSH was wnl??????s and her HIV negative. She was treated with a heart failure regimen including carvedilol and lisinopril. . # Hypothyroidism: Her TSH was wnl's on admission. Her home synthroid was held as her history of hypothyroidism was questionable and it was unclear if it played any role in her cardiac excitability and subsequent cardiac arrest. Following her recovery, her TSH was checked once again and was found to be 3.0 and she was re-started on her home synthroid. . # Chronic back pain: Pt with hx of chronic low back pain on narcotics as a home med but was oftentimes very somnolent, especially when taking these medications so they were discontinued. She infrequently complained of pain which was treated conservatively with tylenol and ibuprofen. . # Questionable History of Epilepsy: Pt with questionable history of epilepsy on keppra as a home medication. She underwent EEG testing for >24 hours without any epileptiform discharges and there was concern that prior episodes of syncope (cardiogenic or otherwise) had been misinterpreted as epilepsy. Her keppra was held given her initially cloudy mental status and she did not have any seizure-like activity during her lengthy admission. Keppra was restarted at discharge but pt should see a neurologist in follow up to assess if this medication is truly needed. . # Anxiety: Pt described significant anxiety related to her medical condition and trivial things such as fear of the dark. She was seen by the psychiatry team who recommended small standing doses of ativan (a home med) which was attempted but oftentimes left her somnolent and difficult to evaluate. These medications were held and her mental status improved significantly. . TRANSITIONAL ISSUES: . #She will need close supervision during dialysis and will need a high K bath to maintain K at goal of 5. . #She will need device clinic follow-up for her new single chamber ICD. Given her severe diabetes and ESRD, she is at increased risk of complications related to her device including pocket infections and should be monitored carefully. . #She will need to AVOID QT PROLONGING MEDICATIONS as these can cause a life-threatening arrythmia to occur in her given her underlying prolonged QT interval . #She will need significant rehabilitation as she is severely deconditioned . #She will need close follow up with her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 16694**]e her many social and medical issues. Attempts were made to attempt that process by carefully clarifying her home medications, elements of her medical history which seemed questionable, and addressing her polypharmacy by eliminating unnecessary medications. . #She will likely need an outpatient social worker to help her cope with her multiple medical issues Medications on Admission: confirmed with her pharmacy and PCP [**Name9 (PRE) **] [**Name9 (PRE) 16695**] 50 qhs -nitrostat 0.4 mg -ambien 10 mg hs, -amlodipine 10 daily -ASA 81 daily -lisinopril 40 [**Hospital1 **] -labetalol 400 [**Hospital1 **] -clonidine 0.3 [**Hospital1 **] -hydral 100 tid -isosorbide mononitrate 30 daily -keppra 500 [**Hospital1 **] -keppra 500 at 2pm mwf -ferrous sulfate 325 tid -synthroid 150 daily -phoslo 667 two caps [**Hospital1 **] -calcitriol 0.5 daily -simvastatin 40 daily -colace 100 [**Hospital1 **] -lorazepam 1 daily for mood -albuterol neb .083% QID prn -epogen in HD Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily): HOld SBP < 100. 3. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for SBP>180: hold for SBP <100. 4. calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily): taper appropriately. 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Limit to 3 grams daily. 8. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. carvedilol 12.5 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day): hold for SBP <90 and HR <55. 10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Place on abdomen on days of dialysis. 11. Levemir 100 unit/mL Solution Sig: Four (4) units Subcutaneous at bedtime. 12. Humalog 100 unit/mL Solution Sig: [**3-2**] U Subcutaneous as instructed: As instructed per sliding scale. 13. ferrous sulfate 324 mg (65 mg iron) Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 15. levothyroxine 150 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 16. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO EVERY MONDAY, WEDNESDAY AND FRIDAY AFTER DIALYSIS (). 18. ferrous sulfate 324 mg (65 mg iron) Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital **] Rehabilitation & [**Hospital **] Care Center - [**Location 1268**] Discharge Diagnosis: Ventricular Fibrillation arrest End stage renal disease on hemodialysis Diabetes mellitus type 2 on insulin Hypertension Non ischemic cardiomyopathy: EF 45% Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure to care for you at [**Hospital1 18**]. Your heart stopped because of a dangerous heart rhythm called ventricular fibrillation. You were brought to [**Hospital1 18**] and your body temperature was cooled to help your heart recover. You have recovered well and we have placed an internal defibrillator that will shock you if your heart has the dangerous rhythm again. You will need to take antibiotics for a few days to prevent and infection at the site and return every 6 months to get the defibrillator checked. . We made the following changes to your medicines: - STOP: labetolol, clonidine, amlodipine, isosorbide mononitrate, keppra, iron, simvastatin, phoslo, metoclopramide, lorazepam, tramadol and omeprazole. - DECREASE: lisinopril, hydralazine - START atorvastatin, carvedilol, nephrocaps, nicotine patch, sevelamer, tylenol, ibuprofen, lidocaine patch, ipratrium nebulizer, famotidine, bismuth. - CONTINUE: synthroid, insulin, aspirin, calcitriol, colace Followup Instructions: Electrophysiology: Department: CARDIAC SERVICES When: TUESDAY [**2199-1-8**] at 9:40 AM With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "37.94", "38.91", "39.95", "96.04", "96.71", "38.97", "96.6" ]

icd9pcs

[ [ [] ] ]

19717, 19826

10962, 11223

388, 434

20027, 20027

5111, 5111

21218, 21538

3391, 3401

17778, 19694

19847, 20006

17171, 17755

20212, 21195

6206, 10939

3441, 4240

2197, 2404

16086, 17145

334, 350

462, 2088

5127, 5802

20042, 20188

5818, 6190

2435, 2764

11241, 16065

2110, 2176

2780, 3375

4265, 5092

10,000

187,813

28868

Discharge summary

report

Admission Date: [**2186-8-10**] Discharge Date: [**2186-8-31**] Date of Birth: [**2136-12-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: transferred from OSH with hepatic failure and acute renal failure for further evaluation and management Major Surgical or Invasive Procedure: large volume paracentesis; placement and removal of R femoral hemodialysis catheter; placement and removal of PICC line; placement of tunnelled RIJ hemodialysis catheter History of Present Illness: 49M with decompensated EtOH cirrhosis with ascites and esophageal varices, admitted to OSH on [**7-29**] with increased abdominal girth, lower extermity edema. . OSH course: Had a paracentesis on [**7-29**] (-) for SBP (WBC79, 33%PMNs). Also had a 6.5L paracentesis on [**8-7**] that was (-) for SBP (59WBC, 13%PMNs, g.stain/cx (-)). Pt spiked on [**8-8**] & was pan-cultured. Started on Zosyn/Cipro on [**8-8**]. Blood cx on [**8-9**] was + for E.coli. Cipro was d/c'ed on [**8-9**]. Zosyn cont'd. On admission, had Cr 2.2 (baseline 1.4) that remained stable until [**8-8**], when jumped to 3.2 and then 4.2 on [**8-9**] and 5.4 on [**8-10**]. Did not respond to fluid challenge/IV albumin/lasix. Was started on octreotide/midodrine on [**8-9**]. Transferred to [**Hospital1 18**] for possible transplant evaluation. Past Medical History: - alcohol induced cirrhosis with ascites and grade III esophageal varices - type 2 diabetes mellitus for the past 3 and half years Social History: Pt is citizen of [**Country 7192**] . Former tob, <1ppd, stopped 15 yrs ago; former alcholic-none since [**Holiday **] [**2185**], formerly "heavy" in his 20s-30s, then one sixpack/week until [**2185**]. Family History: Noncontributory. No liver disease. Physical Exam: VS: Tc 99.0 BP124/70 HR89 RR20 O2sat: 94%2L GEN: pleasant, comfortable, NAD HEENT: Mildly icteric, MM dry, op without lesions NECK: No JVD RESP: CTAB. Slight crackles at bases, R>L CV: RR, S1 and S2 wnl, no m/r/g ABD: Distended, tympanitic to percussion. +shifting dullness. Bandage at RLQ from paracentesis. No HSM appreciated. No rebound/guarding or TTP. EXT: 2+ edema bilat. SKIN: jaundice. no spiders visualized. NEURO: AAOx3. Moves all ext spont Pertinent Results: [**2186-8-11**] 05:20AM BLOOD WBC-9.1 RBC-2.86* Hgb-9.7* Hct-27.4* MCV-96 MCH-33.9* MCHC-35.4* RDW-16.1* Plt Ct-65* [**2186-8-11**] 05:20AM BLOOD Neuts-86.0* Bands-0 Lymphs-8.4* Monos-3.1 Eos-2.0 Baso-0.5 [**2186-8-11**] 05:20AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL [**2186-8-11**] 05:20AM BLOOD PT-19.8* PTT-40.7* INR(PT)-1.9* [**2186-8-11**] 05:20AM BLOOD Glucose-98 UreaN-81* Creat-6.2* Na-135 K-4.0 Cl-104 HCO3-14* AnGap-21* [**2186-8-11**] 05:20AM BLOOD ALT-11 AST-25 LD(LDH)-199 AlkPhos-46 Amylase-60 TotBili-2.5* [**2186-8-11**] 05:20AM BLOOD Lipase-115* [**2186-8-11**] 05:20AM BLOOD Albumin-2.8* Calcium-7.4* Phos-6.4* Mg-2.4 [**2186-8-11**] 11:06AM BLOOD Type-ART Temp-36.7 pO2-75* pCO2-25* pH-7.35 calTCO2-14* Base XS--9 Intubat-NOT INTUBA [**2186-8-11**] 05:20AM BLOOD C3-41* C4-11 [**2186-8-14**] 03:40PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE [**2186-8-14**] 03:40PM BLOOD HCV Ab-NEGATIVE . STUDIES REPORTED FROM OSH: MICRO: [**8-2**], [**8-8**] urine cx (-) [**8-7**] Ascites: g.stain (-), cx (-) [**8-7**] blood cx (+) E.coli (pansens except resist to Cipro) [**8-8**] blood cx (+) E.coli [**8-9**] sputum cx oropharyngeal flora . TTE [**8-10**]: prelim EF 60%, RV mildly dilated. Mild PR, severe TR, mild-mod MR, [**Hospital1 **]-atrial enlargement. . RUQ U/S [**8-8**]: Main portal vein appears to be dilated with decreased venous flow and mild echogenic densities suggesting possible non occlusive thrombus vs proximal obstruction vs multiple varices. Hepatic veins and arteries, splenic vein and artery, and IVC appear to be patent and have appropriate flow directions. . RENAL U/S [**7-31**]: No hydronephoris or renal calculi. Both kidneys nml in echotexture; 10.9cm each. Enlarged spleen to 15cm noted. . STUDIES AT [**Hospital1 18**]: CHEST (PA & LAT) [**2186-8-27**] 12:44 PM REASON FOR THIS EXAMINATION: eval pna HISTORY: [**Hospital **] hospital acquired pneumonia in patient in renal failure on dialysis. CHEST, SINGLE AP VIEW. There is relatively [**Name2 (NI) 15410**] patchy opacity in the right upper and both mid zones, in the setting of low inspiratory volumes. Compared with [**2186-8-24**], there has been some interval improvement in the degree of confluence in the right upper zone infiltrate. No new infiltrate is identified. No pleural effusions are seen. The right IJ central line tip overlies the right atrium, unchanged. ECG Study Date of [**2186-8-14**] 10:08:02 AM Baseline artifact. Sinus bradycardia. Low QRS voltage. Prolonged QTc interval. Findings are non-specific but clinical correlation is suggested. No previous tracing available for comparison. [**2186-8-31**] 05:30AM BLOOD WBC-4.8 RBC-2.79* Hgb-9.4* Hct-27.2* MCV-98 MCH-33.9* MCHC-34.7 RDW-19.9* Plt Ct-38* [**2186-8-31**] 05:30AM BLOOD PT-17.2* PTT-37.0* INR(PT)-1.6* Brief Hospital Course: 49yo M with EtOH cirrhosis with ascites and esophageal varices transferred from [**Hospital 794**] hospital with acute renal failure and E. Coli bacteremia. . # Renal: Likely etiology of decompensation just before the time of transfer from [**Doctor First Name 794**]/RI to [**Hospital1 18**] was ATN in the setting of sepsis, large volume paracentesis, and hypotension around [**Date range (1) 69658**]. Although there may have been a component of HRS, HRS would not explain the sudden deterioration. Additionally, possible underlying IGA nephropathy but doubtful this was significant contributor to sudden decompensation. Negative renal u/s on [**7-31**], repeat [**8-11**] with no hydronephrosis. Urine electrolytes, osm, urine sediment c/w atn on [**8-11**], repeat urinalysis while receiving dialysis showed unclear picture with urine sodium in the 20 range and a bland sediment. SInce the patient remained anuric on octreotide/midodrine and albumin, these were stopped; if his kidney function improves, there may be benefit to restarting these for HRS. The patient was dialysed initially on a three-times weekly schedule but then required almost daily hemodialysis for volume overload after receiving multiple transfusions of blood products to correct coagulopathy and bleeding after line placements. Since [**8-27**], he has been maintained on a Monday-Wednesday-Friday dialysis schedule. A tunnelled RIJ catheter was placed with fluoroscopic guidance on [**8-29**] for long term dialysis access. . # Liver: Cirrhosis Pt with cirrhosis from etoh history c/b grade III esophageal varices and ascites. There has been no evidence of SBP. Currently HD stable. U/S showed possible non occlusive thrombus in the portal vein of uncertain clinical significance. There has been no apparent encephalopathy on a regimen of lactulose prn, so there has been no need for rifaximin. Given his tenuous volume status, nadolol for variceal prophylaxis has been held, but we would like to restart beta blockade if his blood pressure will tolerate it. His ascites has become tense; if this becomes uncomfortable for him, he may need another large volume paracentesis, but would proceed with caution given his bleeding tendency. . # Pancreatitis: On [**8-13**], patient reported epigastric pain and his amylase and lipase were slightly elevated; this resolved over the next two-three days and his diet was advanced back to regular/renal food without complication. . # ID: 1) E.coli bacteremia Pt with e.coli bacteremia likely from urinary source--(+) U/A at OSH but no urine culture available. Negative paracentesis at that time. The E coli was sensitive to all antibiotics except fluoroquinolones; he received a total of 21 days of antibiotics with subsequent negative surveillance blood cultures. 2)productive cough/pneumonia by CXR On transfer he was found to have a cough and CXR showed RUL consolidation. Two days later he became very hypoxic in the setting of receiving both zolpidem and hydromorphone and required a brief stay in the ICU with non-invasive ventilatory support and close monitoring of his respiratory status. He was treated for hospital acquired pneumonia with vancomycin x10days and zosyn x10days; he defervesced and CXR showed some improvement of RUL consolidation, although he still requires 2-3L oxygen. 3)sbp ppx--had been on cipro, but no clear indication, as did not have sbp in past and has recently had FQ-resistant E coli bacteremia, so no further Abx ppx. . # Heme - 1)Anemia: initial w/u neg for fe deficiency, thyroid dx, b12 and folate normal. Likely renal dx with low epo; so epoetin has been added, 4000 units at dialysis. After placement of a femoral HD catheter and again after its removal as well as with placement of a brachial PICC line and subsequent placement of a RIJ HD catheter, patient had significant oozing/bleeding requiring numerous plt, FFP, cryo transfusions and vit K, estrogen, amicar (see below). Hct currently stable at 28. 2) Thrombocytopenia: likely [**2-9**] cirrhosis/hypersplenism. Given ddAVP and platelets before procedures but still had significant bleeding complications after every access placement. 3) Coagulopathy: has required FFP, cryo, and platelets/ddavp to acheive hemostasis after PICC line ([**8-19**]) and after femoral line removal ([**8-21**]) and after RIJ placememnt ([**8-23**]). Hematology recommended vit k po x3 days (through [**8-25**]), also conjugated estrogen iv x5 days total (through [**8-27**]). Received cryoprecipitate as needed to keep fibrinogen above 100 while there was bleeding. Since bled despite above interventions, gave aminocaproic acid on [**8-26**]; no apparent thrombotic complications. . # Asymmetric RUE swelling - may simply represent brachiocephalic insufficiency [**2-9**] large bore indwelling catheter in RIJ vs DVT. Anticoagulation contraindicated given extensive bleeding due to coagulopathy. . #Endocrine:DM history, although reportedly no longer needing insulin as outpatient, likely from liver failure. FSG have been 120-200 while taking po diet--minimal insulin requirement, so will monitor blood glucose with am chem 7, no SSI needed at this time. . # FEN: - low sodium/low K/low phos diet with consistent carbs - fluid restriction to 1200cc/day . # PPX: PPI, lactulose prn . # Dispo: Full Code; patient's poor prognosis has been discussed at length with him and with his family. Unfortunately, given his immigration status, he cannot be considered for liver transplantation at [**Hospital1 18**]. Medications on Admission: OUTPATIENT MEDS: Lasix 40 [**Hospital1 **] Aldactone 50 Nadolol 40 Cipro 750 qweek . MEDS ON TRANSFER: Zosyn 2.25g q8 Octreotide 100mcg q8 IV Albumin 25% 25g [**Hospital1 **] Lactulose 20 tid Midodrine 7.5mg q8 Protonix 40' Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 2. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 3. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation Q6H (every 6 hours). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed: do not exceed 2gm/day. 6. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane Q2H (every 2 hours) as needed. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QIDACHS (4 times a day (before meals and at bedtime)). 8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital 52455**] Hospital Discharge Diagnosis: cirrhosis c/w grade III esophageal varices and ascites; acute renal failure requiring ongoing hemodialysis; E coli bacteremia and hospital acquired pneumonia, both resolved; anemia of chronic inflammation; thrombocytopenia; coagulopathy secondary to liver disease; type 2 diabetes mellitus not currently requiring insulin Discharge Condition: stable--tolerating po diet and meds, pain free, requiring hemodialysis for ATN, requiring 1-2 L/min O2 by nasal cannula due to recent pneumonia (completed 10 days of vanc and zosyn on [**8-29**]) Discharge Instructions: See discharge summary. Followup Instructions: hospitalization for the near-term; supportive care of liver disease (not a transplant candidate due to immigration status): may need therapeutic thoracentesis if tense ascites becomes uncomfortable to patient; consider trial of hepatorenal treatment (ie octreotide/midodrine) if return of renal function; hemodialysis for now--see discharge summary for details. . If immigration status changes, call the liver center for transplant evaluation: DR [**First Name (STitle) **] [**Doctor Last Name **] [**Telephone/Fax (1) 2422**]

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icd9cm

[ [ [] ] ]

[ "54.91", "38.95", "99.06", "99.04", "99.05", "39.98", "38.93", "97.49", "99.07", "39.95" ]

icd9pcs

[ [ [] ] ]

11921, 11977

5208, 10722

419, 590

12342, 12539

2350, 4201

12610, 13141

1828, 1864

10996, 11898

11998, 12321

10748, 10833

12563, 12587

1879, 2331

276, 381

4230, 5185

618, 1437

1459, 1591

1607, 1812

10851, 10973

10,214

190,549

50414

Discharge summary

report

Admission Date: [**2164-7-19**] Discharge Date: [**2164-7-25**] Date of Birth: [**2089-8-11**] Sex: M Service: CSU HISTORY: The patient is a direct admission to the operating room for coronary artery bypass grafting. He underwent cardiac catheterization at [**Hospital1 **] [**First Name (Titles) **] [**2164-6-12**]. His chief complaint was shortness of breath and cold sweats along with not feeling well and mild dyspnea, which were new symptoms. He had a positive exercise tolerance test and was referred for cardiac catheterization. His catheterization showed an EF of 50 percent with left main 30 percent, LAD 100 percent mid and 50 percent proximal lesions, circumflex 100 percent, ostia 30 percent proximal lesion with a 70 percent PDA proximal lesion. PAST MEDICAL HISTORY: Hypertension. Hyperlipidemia. Colostomy after colon resection due to colon cancer. ALLERGIES: The patient states no known drug allergies. MEDICATIONS ON ADMISSION: 1. Atenolol 25 q.d. 2. Norvasc 10 q.d. 3. Zocor 20 q.d. 4. Plavix 75 q.d. SOCIAL HISTORY: Lives in [**Hospital1 3494**] with his wife. [**Name (NI) **] is very independent and active. Denies alcohol use. Denies tobacco use. FAMILY HISTORY: No significant family history. PHYSICAL EXAMINATION: Height 5'7". Weight 197 pounds. Vital signs: Afebrile. Heart rate 63, sinus rhythm, blood pressure 143/69, respiratory rate 16, and O2 saturation 94 percent on room air. General: Lying flat in bed in no acute distress. Neurologic: Alert and oriented times three, nonfocal examination. Cranial nerves are grossly intact. Neck is supple. No lymphadenopathy and no bruits. Respiratory: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, S1, S2, with no murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Colostomy with a pink stoma. Extremities are warm and well perfused with no edema or varicosities. Pulses: Radial 2 plus bilaterally. Dorsalis pedis 2 plus bilaterally. Posterior tibial 2 plus bilaterally. Femoral 1 plus bilaterally. LABORATORY DATA: White count 6.4, hematocrit 43.3, platelets 170. PT 15.5, PTT 34.3, INR 1.5. Sodium 136, potassium 4.1, chloride 104, CO2 23, BUN 14, creatinine 0.9, and glucose 210. ALT 19, AST 14.8, alkaline phosphatase 70, amylase 74, total bilirubin 0.6, albumin 3.7. Urinalysis was negative. EKG: Sinus bradycardia with left anterior fascicular block. Nonspecific ST changes. CHEST X-RAY: Small rounded opacity noted in the left lung base likely representing a nipple shadow. HOSPITAL COURSE: As stated previously, the patient was a direct admission to the operating room, where he underwent coronary artery bypass grafting x4. Please see the OR report for full details. In summary, the patient had a CABG x4 with a free LIMA to the LAD, saphenous vein graft to diag, saphenous vein graft to OM, and saphenous vein graft to the PDA. His bypass time was 101 minutes with a cross-clamp time of 63 minutes. He tolerated the operation well. Was transferred from the operating room to the Cardiothoracic Intensive Care Unit. Patient did well in the immediate postoperative period. His anesthesia was reversed. His sedation was discontinued and he was successfully weaned from the ventilator and extubated. He remained hemodynamically stable throughout the day of his surgery requiring a Neo-Synephrine infusion to maintain an adequate blood pressure. On postoperative day one, patient continued to do well. He remained hemodynamically stable. His Neo-Synephrine drip was weaned to off. His chest tubes were removed. Diuresis was begun and he stayed in the Cardiothoracic Intensive Care Unit because he was on Neo-Synephrine drip during part of the day. On postoperative day two, the patient continued to remain hemodynamically stable. His diuretics were increased. Central lines were discontinued, and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Once on the floor, the patient had an uneventful hospital course. His activity level was gradually advanced with the assistance of the nursing staff and physical therapy. He was noted to have several short bursts of SVT for which his beta blockade was increased. On postoperative day six, it was decided that the patient was stable and ready to be discharged to home. At the time of this dictation, patient's physical exam is as follows: Vital signs: Temperature 98.8, heart rate 77, sinus rhythm, blood pressure 113/75, respiratory rate 20, and O2 saturation 94 percent on room air. Weight preoperatively 95 kg. At discharge, 92.2 kg. Laboratory data: Hematocrit 25.9, sodium 136, potassium 4.5, chloride 99, CO2 28, BUN 22, creatinine 1.1, glucose 127. Physical exam: Neurologically: Alert and oriented times three. Moves all extremities, follows commands. Nonfocal exam. Respiratory: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, S1, S2. Sternum is stable. Incision with Steri- Strips open to air clean and dry. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Colostomy with pink stoma. Extremities are warm and well perfused with 1 plus edema. Right saphenous vein graft site with Steri-Strips open to air, clean and dry. CONDITION ON DISCHARGE: Good. DISPOSITION: He is to be discharged to home with visiting nurses. DISCHARGE DIAGNOSES: Coronary artery disease status post coronary artery bypass grafting x4 with a free left internal mammary artery to the left anterior descending artery, saphenous vein graft to diagonal, saphenous vein graft to obtuse margin, saphenous vein graft to posterior descending artery. Hypertension. Hypercholesterolemia. Colon cancer status post colectomy with colostomy. Diabetes mellitus type 2. FOLLOW-UP INSTRUCTIONS: The patient is to have followup in the [**Hospital 409**] Clinic in two weeks. Follow up with Dr. [**Last Name (STitle) 105058**] in [**12-20**] weeks. Follow up with Dr. [**Last Name (STitle) **] in four weeks. DISCHARGE MEDICATIONS: 1. OxyContin 5/325 1-2 tablets q.4h. prn. 2. Lasix 20 mg q.d. for two weeks. 3. Aspirin 325 q.d. 4. Metoprolol 50 mg b.i.d. 5. Potassium chloride 20 mEq q.d. for two weeks. 6. Simvastatin 20 mg q.d. 7. Niferex 150 mg q.d. x1 month. DISCHARGE INSTRUCTIONS: Additionally, the patient is to check his fingerstick blood sugars t.i.d. with results being reported to his primary care provider. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2164-7-25**] 18:25:59 T: [**2164-7-26**] 04:22:44 Job#: [**Job Number **]

[ "272.0", "414.01", "411.1", "250.00", "V10.05", "401.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

1227, 1259

5459, 5855

6118, 6352

979, 1055

2619, 4799

6377, 6745

4815, 5337

1282, 2601

5880, 6095

810, 953

1072, 1210

5362, 5437

28,265

102,725

19625

Discharge summary

report

Admission Date: [**2131-2-8**] Discharge Date: [**2131-2-15**] Date of Birth: [**2077-10-30**] Sex: F Service: CARDIOTHORACIC Allergies: Amitriptyline / Latex / adhesive tape / adhesive bandage Attending:[**First Name3 (LF) 165**] Chief Complaint: Shortness of breath and fatigue Major Surgical or Invasive Procedure: [**2131-2-8**] Redo mitral valve replacement with a size 27-mm St. [**Male First Name (un) 923**] mechanical valve History of Present Illness: Ms. [**Known lastname **] is a 53 year old female with a history of mitral valve disease and heart failure 2 years and 3 months after resection of a large left atrial myxoma and mitral valve repair with annuloplasty ring. Since the time of her surgery, she has continued to have very limited exercise tolerance and gets short of breath with routine activities such as climbing stairs, grocery shopping etc. She has not had orthopnea or PND and has not had any acute episodes of severe dyspnea since beginning medical therapy with furosemide and lisinopril. Her last echo in [**Month (only) 596**] showed moderate to severe mitral regurgitation. She is very dissatisfied with her current quality of life and is depressed. She has thus been referred for evaluation for a redo mitral valve replacement. Past Medical History: Mitral regurgitation s/p Mitral valve repair/Resection of atrial myxoma.rep. ASD [**9-10**] Hidranitis suppurativa (feet/left inframammary/bil. groins) Prediabetes Benign pelvic mass (removed) Glaucoma Hypertension Hyperlipidemia Palpitations Depression/Anxiety Osteoarthritis neck Remote B foot fractures Past Surgical History: s/p Laproscopic BSO [**5-13**] s/p Vaginal delivery x 2, one complicated by stillbirth s/p Right Shoulder arthroscopy s/p Lumpectomy for benign breast mass s/p L thigh mass removal Social History: Race: Caucasian Last Dental Exam:one yr ago Lives with: Husband Occupation: [**Name2 (NI) 1139**]: Smokes [**1-18**] cigarettes per day since age 18, denies drug use. ETOH: 2 drinks per week Family History: No cardiac relevant history Physical Exam: Pulse:67 Resp:18 O2 sat: 100% B/P Right 136/69: Left: Height:5' 3 [**2-4**] " Weight: 154# General:NAD; well-appearing Skin: Warm[] Dry [x] intact [x]right instep/bil. groins/left inframammary fold with small ingrown areas and tiny red spots; no obvious infection present HEENT: NCAT[x] PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable Neck: Supple [x] Full ROM []no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur- 2/6 SEM heard loudest at apex Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no HSM/CVA tenderness; healed scars Extremities: Warm [x], well-perfused [x] Edema -none Varicosities: None [x] Neuro: Grossly intact; MAE [**6-7**] strengths; nonfocal exam Pulses: Femoral Right: 1+ Left:2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: 2+ Left:2+ Pertinent Results: [**2131-2-8**] Intraop Echo: Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. A mitral valve annuloplasty ring is present. Moderate to severe (3+) mitral regurgitation is seen.The jet is transvalvular,etiology from a coaptation defect bettween the anterior and residual remnant of the posterior mitral valve replacement. Post Bypass: Patient is now s/p 27 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Mechanical Mitral valve replacement on a Norepinephrine drip at 0.06 mcg/kg/min. The cardiac output is 5.2lpm. The mechanical mitral valve is well seated with appropriate washing jets observed.There are no paravalvular leaks observed. The mean gradient across the Mitral valve is 4mmHg. The ventricular function is preserved with an EF>55%. There are no visible aortic dissection flaps observed. . [**2131-2-14**] Discharge Chest x-ray: The tiny right apical pneumothorax is decreased and the miniscule left apical pneumothorax is unchanged. Small bilateral pleural effusions are unchanged. Opacification of the right middle lobe has increased. Linear left basilar atelectasis is unchanged. Moderate cardiomegaly is unchanged and has a normal post-operative appearance. A prosthetic mitral valve is seen. . [**2131-2-14**] WBC-6.0 RBC-3.48* Hgb-10.8* Hct-30.9* MCV-89 MCH-31.1 MCHC-35.0 RDW-16.0* Plt Ct-331 [**2131-2-13**] WBC-5.6 RBC-3.21*# Hgb-9.8*# Hct-28.3*# MCV-88 MCH-30.5 MCHC-34.5 RDW-16.7* Plt Ct-273 [**2131-2-12**] WBC-6.0 RBC-2.35* Hgb-7.6* Hct-21.5* MCV-91 MCH-32.2* MCHC-35.2* RDW-14.4 Plt Ct-221 [**2131-2-11**] WBC-8.6 RBC-2.54* Hgb-8.1* Hct-23.0* MCV-91 MCH-31.7 MCHC-35.1* RDW-14.6 Plt Ct-203 [**2131-2-10**] WBC-10.9 RBC-2.78* Hgb-8.8* Hct-25.5* MCV-92 MCH-31.5 MCHC-34.4 RDW-15.2 Plt Ct-191 [**2131-2-15**] PT-27.5* INR(PT)-2.7* [**2131-2-14**] PT-24.8* PTT-37.0* INR(PT)-2.4* [**2131-2-13**] PT-23.1* INR(PT)-2.2* [**2131-2-12**] PT-33.6* PTT-41.4* INR(PT)-3.4* [**2131-2-11**] PT-17.5* INR(PT)-1.6* [**2131-2-14**] Glucose-133* UreaN-8 Creat-0.5 Na-138 K-4.0 Cl-103 HCO3-28 [**2131-2-13**] Glucose-101* UreaN-11 Creat-0.5 Na-139 K-3.9 Cl-103 HCO3-29 [**2131-2-12**] Glucose-131* UreaN-11 Creat-0.6 Na-137 K-3.7 Cl-100 HCO3-32 [**2131-2-11**] Glucose-103* UreaN-7 Creat-0.4 Na-134 K-4.0 Cl-99 HCO3-30 [**2131-2-10**] Glucose-105* UreaN-6 Creat-0.5 Na-135 K-4.2 Cl-103 HCO3-29 Brief Hospital Course: Mrs. [**Known lastname **] was a same day admit and on [**2131-2-8**] was brought directly to the operating room where she [**Date Range 1834**] a redo-sternotomy, and mitral valve replacement. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring. Within 24 hours she was weaned from sedation, awoke neurologically intact and was extubated without incident. On post-op day one, beta-blockers and diuretics were started. On post-op day two she was transferred to the step-down floor for further care and recovery. Chest tubes and epicardial pacing wires were removed without complication. Coumadin was started with a Heparin bridge until patient's INR was therapeutic. Given the mechanical mitral valve, Coumadin was dosed daily and titrated for a goal INR between 3.0 - 3.5. She experienced a postoperative delirium which improved with several days of Haldol. By discharge, her mental status improved significantly. Over several days, she otherwise continued to make clinical improvements with diuresis. She remained in a normal sinus rhythm as beta blockade was advanced as tolerated. She was cleared for discharge to home on postoperative day seven. Prior to discharge, outpatient Coumadin followup was arranged with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Hospital6 733**]. Medications on Admission: AMOXICILLIN - 500 mg Tablet - 4 Tablet(s) by mouth 1 hour before dental procedure FUROSEMIDE [LASIX] - 20 mg Tablet - 1 Tablet(s) by mouth once a day LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth daily LORAZEPAM - 1 mg Tablet - 1 (one) Tablet(s) by mouth at bedtime [**Month (only) 116**] take additional [**2-4**] tablet twice during the day prn anxiety METOPROLOL TARTRATE - (Dose adjustment - no new Rx) - 50 mg Tablet - 0.5 (One half) Tablet(s) by mouth twice a day PAROXETINE HCL - 20 mg Tablet - 1 Tablet(s) by mouth once a day TRAVOPROST (BENZALKONIUM) [TRAVATAN] - (Prescribed by Other Provider: [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]) - 0.004 % Drops - 1 gtts bilateral eyes as directed by optho TRAZODONE - 50 mg Tablet - 1 [**2-4**] Tablet(s) by mouth at bedtime call with any worsening of symptoms. ACETAMINOPHEN - (OTC) - 500 mg Tablet - [**2-4**] Tablet(s) by mouth once a day as needed for pain ASPIRIN - (OTC) - 81 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) MULTIVITAMIN [ONE DAILY MULTIVITAMIN Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*70 Tablet(s)* Refills:*0* 5. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). Disp:*qs qs* Refills:*0* 7. Travatan Z 0.004 % Drops Sig: One (1) gtt Ophthalmic at bedtime: 1 gtt in each eye . Disp:*qs qs* Refills:*0* 8. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO twice a day. Disp:*180 Tablet(s)* Refills:*2* 9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Take for INR between 3.0 and 3.5. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] homecare Discharge Diagnosis: Mitral regurgitation s/p Redo-sternotomy Mitral valve replacement Hypertension Hyperlipidemia Depression/Anxiety Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Tylenol and Dilaudid Incisions: Sternal - healing well, no erythema or drainage Trace Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] 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. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] at [**2131-3-5**] 1:30 Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 62**] Date/Time:[**2131-3-12**] 3:40 Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] [**Telephone/Fax (1) 1144**] Date/Time:[**2131-4-13**] 2:00 **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication Mechanical mitral valve Goal INR 3.0 - 3.5 First draw [**2131-2-16**] Results to [**Company 191**] Anticoagulation phone [**Telephone/Fax (1) 2173**] fax [**Telephone/Fax (1) 3534**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2131-2-15**]

[ "996.02", "705.83", "V58.61", "424.0", "E878.1", "401.9", "429.5", "293.0", "300.4" ]

icd9cm

[ [ [] ] ]

[ "35.24", "39.61" ]

icd9pcs

[ [ [] ] ]

9425, 9480

5766, 7150

354, 470

9637, 9819

3010, 5743

10742, 11683

2056, 2085

8251, 9402

9501, 9616

7176, 8228

9843, 10719

1650, 1832

2100, 2991

283, 316

498, 1299

1321, 1627

1848, 2040

30,911

138,155

44824

Discharge summary

report

Admission Date: [**2124-3-8**] Discharge Date: [**2124-3-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: The pt. is a [**Age over 90 **] year-old male with a PMH of CAD, moderate AS, and COPD admitted with acute onset dyspnea. The patient has a history of multiple hospitalizations for acute heart failure felt related to anemia, transient ischemia leading to acute-on-chronic [**Age over 90 7216**] dysfunction and pulmonary edema. He has been followed in cardiology clinic and has declined further attempts at revascularization. He was recently admitted from [**Date range (1) 62048**] with acute CHF and was diureses, discharged home on increase dose of lasix (20mg daily). He was again admitted from [**Date range (1) 29263**] for dyspnea and lasix was increased further to 20mg [**Hospital1 **]. . The patient presented to the ED with complaints of sudden onset dyspnea over the past 1 hour prior to presentation. He denied chest pain, denied palpatations. No fever/chills. +[**4-16**] word dyspnea. +b/l lower extremity edema. He reported recent increase in rhinorrhea. Initial vitals: T 97.5, HR 96, BP 102/60, RR 28, O2 100% on neb. He was given levaquin 750mg IV and solumedrol 125mg IV as well as combivent neb. O2 sat found to be 100% on 4L following neb and pt reported improvement in dyspnea. He was then given lasix 20mg IV with subequent decrease in BP to 89/39. Given ASA 325mg. BP improved to 99/53 without intervention. ECG unchanged from prior. BNP elevated to 7291. Response to lasix not recorded. He is now being admitted to the CCU for further management, concern for brief episode of hypotension. . Past Medical History: 1. Coronary Artery Disease - [**2122-11-16**] - s/p BMS to OM2, D1, Left circumflex in [**2122-11-16**] for unstable angina and TWI in V2-4 - [**2123-5-24**] - NSTEMI s/p cardiac cath and balloon angioplasty 2. Congestive Heart Failure - Systolic and [**Month/Day/Year **] Failure - most recent echo on [**2123-9-3**] with EF 40% 3. Valvular Disease - Moderate Aortic Stenosis - mild-moderate aortic regurgitation - mild-moderate mitral regurgitation 4. Hypertension 5. Chronic GI Bleeds 6. Colon Cancer s/p right hemicolectomy 7. Gout 8. Degenerative joint disease 9. History of Chronic Pyelonephritis 10. s/p bladder stone removal 11. COPD 12. s/p appendectomy in [**2048**] Social History: Immigrated from [**Country 532**]. He has been widowed for 8 years and lives alone in [**Location (un) **]. He has children in the area who are helpful. An aid comes to clean the apt and bathe him. His son lives nearby. Occupation: general surgeon in [**Location (un) 4551**]. He retired at age 63 due to his hand tremor. EtOH: 1 glass of wine or alcoholic drink /week. Tobacco: none Family History: Non contributory Physical Exam: VS - Afebrile, BP 95/50, HR 59, RR 25, O2 98% 2L Gen: WDWN elderly male in NAD, appears younger than stated age. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP elevated to earlobe CV: RR, 3/6 systolic murmur LUSB raditaing to carotids. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles to halfway B/L. Speaking in full sentences. Abd: Soft, NTND. No HSM or tenderness. Ext: 2 pitting edema B/L. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Admission labs: [**2124-3-8**] 03:15PM BLOOD WBC-6.1# RBC-3.75* Hgb-9.2* Hct-29.9* MCV-80* MCH-24.6* MCHC-30.9* RDW-19.1* Plt Ct-183 [**2124-3-9**] 06:17AM BLOOD PT-16.0* PTT-32.0 INR(PT)-1.4* [**2124-3-8**] 03:15PM BLOOD Glucose-100 UreaN-32* Creat-1.2 Na-139 K-4.1 Cl-100 HCO3-32 AnGap-11 [**2124-3-9**] 06:17AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1 . Discharge labs: [**2124-3-11**] 07:28AM BLOOD WBC-6.5 RBC-3.51* Hgb-8.8* Hct-28.0* MCV-80* MCH-25.0* MCHC-31.3 RDW-19.0* Plt Ct-155 [**2124-3-11**] 07:28AM BLOOD PT-15.1* PTT-35.7* INR(PT)-1.3* [**2124-3-11**] 07:28AM BLOOD Glucose-107* UreaN-33* Creat-1.0 Na-144 K-4.4 Cl-105 HCO3-32 AnGap-11 [**2124-3-11**] 07:28AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.2 . Cardiac biomarkers: [**2124-3-8**] 03:15PM BLOOD proBNP-7291* [**2124-3-8**] 03:15PM BLOOD cTropnT-0.03* CK(CPK)-39 [**2124-3-8**] 10:33PM BLOOD cTropnT-0.02* CK(CPK)-31* [**2124-3-9**] 06:17AM BLOOD cTropnT-<0.01 CK(CPK)-56 . CHEST (PORTABLE AP) Study Date of [**2124-3-8**] 2:44 PM There is a new infiltrate at the right lung base. In addition there is prominence of the pulmonary vasculature and enlargement of the cardiac silhouette consistent with congestive heart failure which has increased compared to prior. There is probable background interstitial lung disease. Cystic degenerative change of the left humeral head is noted as before. No soft tissue abnormality is detected. IMPRESSION: 1. Findings consistent with congestive heart failure. 2. Possible infiltrate in the right lung base. 3. Probable underlying interstitial lung disease. Brief Hospital Course: [**Age over 90 **] year-old male with a PMH of CAD, moderate AS, and COPD admitted with acute onset dyspnea. He has had multiple recent admission for SOB. This admission seems to be related to bronchospasm. Improved with bronchodilators. BNP is well below baseline of recent admissions. There is concern that he is having transient ischemic events leading to worsening [**Age over 90 7216**] dysfunction which is exacerbating his symptoms. Ultimately he was both diuresed and treated with bronchodilators and inhaled steroids and anticholinergics. He was discharged clinically doing well with close follow up. Pt refused rehab and was discharged home. . #. Dyspnea - The patient presents with acute onset dyspnea, similar to prior admissions. His description seems consistent with bronchospasm and he improved with a combination of bronchodilators, inhaled anticholinergics, inhaled steroids, and diuresis. His symptoms are complicated by CHF given evidence of volume overload on exam and CXR. BNP elevated though decreased from prior. The patient has no evidence of CE elevation or new ischemic ECG changes. He likely has episodes of transient ischemia leading to acute-on-chronic [**Age over 90 7216**] dysfunction and pulmonary edema as described prior. He was discharged on Spiriva, albuterol, and his home diuretic regimen. . #. Coronary Artery Disease - s/p BMS to OM2, D1, Left circumflex in [**2122-11-16**] for unstable angina - pt has declined further attempts at revascularization. No current acute ischemic changes on ECG. Troponins negative x3 sets. Continued ASA, metoprolol, and statin at home doses. . #. Moderate Aortic Stenosis - careful diuresis given increased preload dependence. Continued BB and ACE-I as above, on ACE I as outpatient. . # Gout: On allopurinol. Started cholchicine at home dose for exacerbation s/p diuresis. . #. COPD - scheduled for outpatient PFTs. Started patient on spiriva with albuterol PRN with improvement of symptoms (see above). . #. Chronic GI Bleeds ?????? Stable. Pt has had GIB in past on Plavix. HCT stable this admission. On PPI. Medications on Admission: Allopurinol 100 mg Daily Aspirin 81 mg Daily Atorvastatin 80 mg HS Colchicine 0.6 mg [**Hospital1 **] Docusate Sodium 100 mg [**Hospital1 **] Furosemide 20 mg [**Hospital1 **] Ipratropium Bromide 0.02 % Solution q6hrs Lisinopril 2.5 mg Daily Metoprolol Succinate 25 mg Daily Mom[**Name (NI) 6474**] 50 mcg/Actuation 2 puff Nasal [**Hospital1 **] Nitroglycerin 0.3 mg SL PRN Pantoprazole 40 mg Daily Polysaccharide Iron Complex 150 mg Daily Tamsulosin 0.4 mg HS Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 12. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Mom[**Name (NI) 6474**] 50 mcg/Actuation Spray, Non-Aerosol Sig: Two (2) spray Nasal twice a day. 15. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*2* 16. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as needed: do not take more than 2 in a row. call your doctor for chest pain that does not resolve. Discharge Disposition: Home With Service Facility: Family Care Extended Discharge Diagnosis: Primary: CHF, COPD . Secondary: Aortic stenosis, GI bleeding, gout Discharge Condition: At baseline, on room air, stable vital signs. Discharge Instructions: You were admitted for shortness of breath. We gave your breathing medications and IV medications to get rid of extra fluid. You felt better. . Please continue to take your medications as ordered. We made the following changes: 1. Please take tiotropium bromide (Spiriva) inhalation twice a day 2. Please take albuterol inhalation as needed for shortness of breath up to every 6 hours 3. Please take vitamin C with your iron pills 4. Please stop taking your atrovent nebulizer. The Spiriva will work in its place. . Please follow up with Dr. [**Last Name (STitle) 171**] on this hospitalization. . If you experience chest pain you can take nitroglycerin as you have in the past, but do not take this more than twice because of your aortic stenosis. If you are short of breath, please take albuterol. If these fail, you should call your doctor or return to the emergency room. You should also call your doctor or come to the emergency room if you experience palpitations, passing out, difficulty speaking or walking, diarrhea, vomiting, or other concerning symptoms. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2124-3-15**] 10:00 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2124-3-15**] 1:00 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2124-3-15**] 1:00 Completed by:[**2124-3-15**]

[ "274.9", "578.9", "496", "428.0", "428.43", "V10.05" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9462, 9513

5233, 7320

280, 287

9624, 9672

3655, 3655

10786, 11222

2953, 2971

7832, 9439

9534, 9603

7346, 7809

9696, 10763

4021, 5210

2986, 3636

221, 242

315, 1834

3671, 4005

1856, 2535

2551, 2937

73,087

190,805

41280

Discharge summary

report

Unit No: [**Numeric Identifier 89886**] Admission Date: [**2116-6-22**] Discharge Date: [**2116-6-26**] Date of Birth: [**2061-12-15**] Sex: M Service: OME HISTORY OF PRESENT ILLNESS: This patient is a 54-year-old male with metastatic renal cell carcinoma, admitted today to begin cycle 2 week 2 high-dose IL-2 therapy. His oncologic history began in [**2112-1-14**]. He presented with microscopic hematuria with workup revealing a right renal mass. He underwent right radical nephrectomy on [**2112-4-18**] revealing an 11.5 cm renal cell carcinoma, firm and grade 2. He had a recurrence on the skin of his left face in [**2112-12-16**], which on excisional biopsy showed clear cell neoplasm most consistent with metastatic renal cell carcinoma. He underwent re-excision to obtain clean margins. He was followed with surveillance imaging and on CT on [**2116-1-14**], torso revealed liver lesions consistent with metastatic disease. He was referred here for discussion of high-dose IL- 2 therapy. He passed eligibility testing and began cycle 1 week 1 high-dose IL-2 on [**2116-3-9**] receiving 13 of 14 doses week 1 and 10 of 14 doses week 2. Follow-up CTs revealed disease regression in the hepatic and right adrenal mets, and he was admitted for cycle 2 week 1 of therapy on [**2116-6-8**]. During the week he received 11 of 14 doses with course complicated by toxic encephalopathy requiring an additional day of hospitalization. He has now recovered and is ready for week 2 of therapy. PAST MEDICAL HISTORY: Metastatic kidney cancer as above, hypertension, anxiety, depression, hypothyroidism after IL-2. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Married, lives with his wife, two children and son-in-law, works for an electronics company. Denies tobacco, alcohol and drug use. Speaks primarily Portuguese. MEDICATIONS: Lisinopril 10 mg p.o. daily on hold, mirtazapine 50 mg p.o. daily, multivitamin 1 tablet daily, Colace 100 mg daily, levothyroxine 75 mcg p.o. daily. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Well-appearing male in no acute distress. Performance status 1. VITAL SIGNS: 97.2, 67, 16, 136/98. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Moist oral mucosa without lesions. NECK: Supple. Lymph nodes in cervical, supraclavicular or bilateral axillary lymphadenopathy. HEART: Regular rate and rhythm, S1, S2. CHEST: Clear bilaterally. ABDOMEN: Soft, nontender. EXTREMITIES: No edema. SKIN: Intact. NEURO EXAM: Nonfocal. ADMISSION LABS: WBC 16.1, hemoglobin 12.3, hematocrit 35.5, platelet count 318,000, INR 1.2, BUN 16, creatinine 1.4, sodium 135, potassium 4.1, chloride 99, CO2 28, glucose 82, ALT 9, AST 19, CK 28, total bili 0.5, albumin 4.3, calcium 9.3, phosphorus 2.8, magnesium 2.2. HOSPITAL COURSE: This patient was admitted and went through interventional radiology for central line placement prior to therapy. His admission weight was 74 kg and he received interleukin-2 600,000 international units per kilo equalling 44.6 million units IV q. 8 hours x 14 potential doses. During this week he received 5 of 14 doses with therapy stopped early due to development of shock attributed to capillary leak syndrome from IL-2 therapy. He was initially hypotensive on treatment day #2 without response to fluid boluses and was subsequently placed on dopamine 6 mcg per kilogram per minute with Neo-Synephrine added secondary to persistent hypotension. He went to maximum dose dopamine and Neo-Synephrine, and was eventually weaned off Neo-synephrine followed by dopamine of the following day. He was placed on continuous blood pressure bedside and central telemetry monitoring. No cardiac arrhythmias were noted. IL-2 therapy was held until he was weaned from pressors and he was given his fifth dose of interleukin-2 on Wednesday at 4:00 p.m. He subsequently developed significant hypotension unresponsive to maximum dose Neo-Synephrine and dopamine, requiring the addition of Levophed, and was transferred to the ICU for further hemodynamic monitoring. Once in the ICU he was stabilized. Source of shock was felt to be hypovolemia related to capillary leak from IL-2 therapy. He returned to 11 Riceman on [**2116-6-25**] and further IL-2 was discontinued given the severity of side effects noted. Other side effects during this week included nausea and vomiting improved with antiemetic therapy; rigors improved with Demerol and significant fatigue. During this week he developed acute renal failure with a peak creatinine of 3.5 with associated oliguria and metabolic acidosis improved with bicarbonate replacement intravenously. Electrolytes were monitored and repleted per protocol. Strict urine output, serial creatinine bicarbonate levels were monitored. IV fluids were maintained given acute renal failure in the setting of hypotension. During this week he had no transaminitis, hyperbilirubinemia, myocarditis, coagulopathy or thrombocytopenia noted. He was anemic without need for packed red blood cell transfusion. By [**2116-6-26**] he had recovered from side effects to allow for discharge to home. CONDITION ON DISCHARGE: Alert, oriented, ambulatory. DISCHARGE STATUS: To home with his daughter. DISCHARGE DIAGNOSES: Metastatic renal cell carcinoma status post cycle 2 week 2 high-dose IL-2 therapy complicated by shock and acute renal failure. DISCHARGE MEDICATIONS: Sarna lotion topically q.i.d. p.r.n. pruritus, cephalexin 500 mg b.i.d. times 5 days, diphenhydramine 25 to 50 mg q.i.d. p.r.n. pruritus, Lomotil 2 to 2 tabs q.i.d. p.r.n. loose stools, Lasix 20 mg p.o. daily times 5 days, levothyroxine 75 mcg p.o. daily, lorazepam 0.5 to 1 mg t.i.d. p.r.n. nausea, vomiting, mirtazapine 15 mg at bedtime, Compazine 10 mg p.o. q.i.d. p.r.n. nausea/vomiting, ranitidine 150 mg b.i.d. p.r.n. indigestion, Eucerin cream topically. The patient will restart lisinopril 10 mg p.o. daily. FOLLOW-UP PLANS: This patient will return to clinic in 4 weeks after CT scans to assess disease response. I have reviewed the dictation summary as dictated by [**First Name8 (NamePattern2) 622**] [**Last Name (NamePattern1) 17265**]. I agree with the hospital course and disposition as noted. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 66804**] Dictated By:[**Last Name (NamePattern1) 18853**] MEDQUIST36 D: [**2116-6-26**] 16:49:14 T: [**2116-6-27**] 10:18:39 Job#: [**Job Number 89887**] cc:[**Numeric Identifier 89888**]

[ "197.7", "300.4", "276.2", "V58.12", "244.9", "584.9", "785.50", "401.9", "458.29", "198.7", "V10.52" ]

icd9cm

[ [ [] ] ]

[ "00.15", "38.93" ]

icd9pcs

[ [ [] ] ]

2028, 2046

5262, 5391

5415, 5933

2815, 5138

2069, 2523

5951, 6535

188, 1507

2540, 2797

1530, 1666

1683, 2011

5163, 5240

45,219

187,810

16220

Discharge summary

report

Admission Date: [**2151-10-7**] Discharge Date: [**2151-10-11**] Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 9853**] Chief Complaint: Fever and altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] [**Hospital **] nursing home resident w/ a h/o Diastolic CHF presents with fatigue, altered mental status, cough, SOB, and tachypnea. (DNR/DNI) . He was recently discharged from the [**Hospital1 18**] on [**2151-9-4**], he had been admitted with diarrhea. He had been doing relatively well with the exception of decreased mobility and weight gain ("dry weight" around 125 lbs and now 156lbs). Over the past 1 week his daughter had noticed a new cough, sounds "junky" but he was unable to bring anything up. This cough has been worsening and his mental status has also been worsening. Over the past 48 hour the patient has been responsive to verbal stimuli but would not speak much. He was more withdrawn and was not eating. Normally he is AOx3 and able to hold a normal conversation per his dtr, he is able to feed himself but needs help with bathing. He lives in a hospice care facility as of the past 2 weeks given his multiple recent hospitalizations and his decline in functional capacity. In addition to his cough his daughter has noticed a shortness of breath x 2 weeks. It is at rest as well as worsened with exertion (even standing up). No diarrhea recently, occ constipation. No n/v. No urinary symptoms or dysuria. No chest pain. No new rashes. Slowly worsening lower ext edema. No fevers or chills noted at home. . In the ED, the patient was noted to be initially febrile and with his presentation of cough and SOB he was given vanc / cefepime for noscomial pneumonia given his nursing home / hospice residence. He was noted to be AOx0-1. His initial vitals were: 101.9 HR 108 170/90 RR 32 96% on 3L NC. He was guiac negative. CXR with bilateraly pleural effusions. He was noted to have abd distention and a foley was placed, 1 liter of urine was relieved and his abd distention improved. Given 500cc NS in the ER. Past Medical History: Diastolic Congestive Heart Failure, EF > 55% in [**2151**] Chronic Renal Failure (baseline Cr 1.5 in [**5-20**], but lately has been worse 2.5-3.0 cryoglobuminemia type 2 and poss MPGN-sees Dr. [**Last Name (STitle) 4883**] [**MD Number(4) 46282**] over body ([**5-20**])-treated with Valtrex and prednisone Moderate C4-C5 spinal stenosis DJD of spine BPH, prostate surgery 30years ago Hypertension anemia, likely of CKD Biliary sludge s/p ERCP [**8-20**] Social History: smoked, but quit in his 40s, minimal EtOH intake with dinner; was former bricklayer. Was very functional until [**5-20**], then hospitalizaitons and progressive decline in functional status. Enrolled in hospice [**9-20**], but family do not want to continue. Family History: nc Physical Exam: Vitals: T: 98.3 BP: 144/70 HR: 96 RR: 16 O2Sat: 100% on NRB GEN: NAD, AOx0 HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: JVP 11cm, no cervical lymphadenopathy, trachea midline COR: RRR, [**2-17**] HSM at LLSB without radiation, soft heart sounds PULM: Lungs w/ scattered ronchi and decreased breath sounds at the bases, no wheezes or rales ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: 3+ pitting pedal edema to lower thighs bilat symmetrical NEURO: Alert, responds to verbal stimuli, follows commands and moving all 4 extremities. PERRL, EOMI. Pertinent Results: Resp gram stain: >25PMNs, GPC clusters/pairs, GPR rods Cx oropharyngeal flora, staph aures coag pos (MSSA) Blood Cx [**10-7**] and [**10-8**] NTD. Abdominal x-ray [**10-7**]: IMPRESSION: Question mildly dilated loops of small bowel in the left mid abdomen. Consider CT scan for more sensitive evaluation for obstruction. CXR [**10-7**]: large b/l pleural effusion c hazy opacities over mid/lower lung fields c/w Atx vs mass effect vs PNA CXR [**10-9**]: unchanged b/l pleural effusions. minimal decrease bibasilar bronchograms. Brief Hospital Course: [**Age over 90 **] year old male with progressive CKD, diastolic heart failure, BPH with LUTS, multiple recent hospitalizations with decrease in functional capacity, now living in hospice facility, admitted with 2weeks of SOB, 1 week of NP[**MD Number(3) **]/rhonchi, fevers, depressed MS. Febrile in ER, hypoxic, required NRB, CXR with b/l effusions and possible PNA, admitted to MICU [**10-7**]. Per family, pt was getting around the clock morphine/ativan and was kept sedated at nursing home so likely aspirated. He was started on Vanc/Zosyn, mental status improved greatly by the next day and transfered to the floor [**10-8**] on face mask. Sputum culture grew MSSA so his abx were changed to augmentin for total 7day course. By next day, he was remarkably better, weaned off O2, tolerating PO, A&Ox3, getting up to chair. He was also volume overloaded and was started on IV Lasix. He was persistently net positive so his Lasix was titrated up to 100mg IV bid and Zaroxolyn was added. This may be continued as necessary in order to achieve additional diuresis as necessary and then may be switched to a PO regimen. He had a Foley catheter that was removed on the day of discharge and he voided; however, if he should be monitored for urinary retention and a Foley should be replaced as necessary. His Toprol XL was stopped on admission, and he was started on metoprolol at low dose on the floor. This may also be titrated back up to his pre-hospitalization dose of 100mg daily as tolerated. Palliative care was consulted to discuss goals of care with the family. They have decided that he would want a higher level of care than he was receiving at his hospice facility and that simple treatable conditions should be addressed as appropriate. Lab draws and vital signs should be kept to a minimum as able, and if he were to experience a sudden decompensation, goals of care would shift to comfort and a hospice discussion could then be re-initiated. Medications on Admission: Lasix 80mg po bid Toprol XL 100mg po daily Amlodipine 5 mg po daily Cyanocobalamin 1000 mcg po daily Discharge Medications: 1. Furosemide 10 mg/mL Solution Sig: One Hundred (100) mg Injection [**Hospital1 **] (2 times a day). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 4. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. 5. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 6. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. 8. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Allevyn Dressing 3 X 3 Bandage Sig: One (1) bandage Topical once a day. 11. Aloe Vesta 2-n-1 Protective Ointment Sig: One (1) application Topical once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Aspiration Pneumonia Acute on Chronic Diastolic heart failure acute urinary retention Altered mental status Deconditioning Chronic kidney disease Discharge Condition: Stable Discharge Instructions: You were admitted for pneumonia and treated with antibiotics. You were also admitted with worsening of your heart failure and treated with IV diuretics to remove fluids. You had some urinary retention when you first arrived. We have removed your foley but please let your doctor know if you have any trouble voiding. If you have worsening difficulty breathing, fevers, chills, chest pain, or any other concerning symptoms, seek medical attention immediately. Followup Instructions: You will be followed by the doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab. Follow up with Dr. [**Last Name (STitle) 58**] [**Telephone/Fax (1) 3329**] if you are discharged from rehab.

[ "293.0", "788.20", "600.01", "428.0", "285.21", "273.2", "428.33", "482.41", "403.10", "507.0", "585.9", "723.0", "584.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7323, 7389

4116, 6075

249, 255

7579, 7588

3559, 4093

8096, 8308

2929, 2933

6227, 7300

7410, 7558

6101, 6204

7612, 8073

2948, 3540

177, 211

283, 2156

2178, 2636

2652, 2913

9,016

192,252

11090+56166

Discharge summary

report+addendum

Admission Date: [**2177-9-8**] Discharge Date: Date of Birth: [**2103-10-19**] Sex: M Service: CHIEF COMPLAINT: Rectal cancer. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 35803**] was recommended to Dr. [**Last Name (STitle) 3314**] for evaluation of a rectal cancer. This rectal cancer was stage II by ultrasound demonstrating carcinoma of the rectum starting at the cutaneous junction extending up 4 cm to 5 cm going into the muscularis propria. Prior to surgery, the patient was seen by the stoma therapist and two sites had been marked for possible colostomy. The patient was scheduled for an operation on [**9-8**] for direct admission to the hospital. PAST MEDICAL HISTORY: (The patient's past medical history includes a history of) 1. Coronary artery disease, status post coronary artery bypass graft and followed by percutaneous transluminal coronary angioplasty. The patient has no following symptoms since this procedure. 2. Gout. 3. Degenerative joint disease. 4. Peripheral vascular disease. 5. Hypertension. 6. Severe burns on both arms, when the patient was 18 months old requiring multiple skin grafts and amputation of his right fifth digit. 7. Status post cerebrovascular accident. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Zestril 10 mg p.o. q.d., allopurinol 300 mg p.o. q.d., magnesium oxide 400 mg p.o. q.d. PHYSICAL EXAMINATION ON ADMISSION: On physical examination, the patient was in no apparent distress. His chest was clear. Heart was regular rate and rhythm. Neurologically, he had poor hand mobility but otherwise normal neurologic function. LABORATORY DATA ON ADMISSION: Notable examination values were a hematocrit of 46.5. A BUN of 31, a creatinine of 1.3. RADIOLOGY/IMAGING: Electrocardiogram demonstrated T wave flattening in II, III, and V6; but no other gross ST changes. HOSPITAL COURSE: On [**9-8**] the patient was operated on for rectal cancer and underwent an abdominal perineal resection under general anesthesia and tracheal intubation by Dr. [**Last Name (STitle) 3314**] and Dr. [**Last Name (STitle) **]. 7 liters of fluid of lactated Ringer's intraoperatively with 630 cc of urine output with 500 cc of estimated blood loss. The patient had 20 cm of rectum sigmoid colon removed and had an ostomy raised. He was stable to the Postanesthesia Care Unit; however, the patient had difficulty with extubation and was transferred to the Intensive Care Unit where he stayed overnight with ventilator settings of pressure support of 5, PEEP of 5, FIO2 of 60, and arterial blood gas of 7.35/36/161/21/-4. The patient was successfully extubated in the morning following surgery with one notable laboratory value of creatinine of 1.7 with adequate, but borderline renal output, most likely secondary to hypovolemia. Otherwise, the patient was stable, and the patient was successfully extubated and transferred to the floor where the patient was changed to maintenance intravenous fluids, and his Pleurovac connected to his drains was continued on suction. The remainder of his hospital course was uneventful. His patient-controlled analgesia was discontinued, and the patient began to tolerate a clear diet, and eventually advanced to a regular diet. He was seen by Physical Therapy and was out of bed and ambulating. The Pleurovac was discontinued, and his drain output decreased and were pulled. On postoperative day six, the patient complained of diffuse right-sided chest pain with no other associated symptoms. An electrocardiogram was done and was negative for any acute changes. The patient was changed to his home medications. His intravenous fluids were discontinued, and the patient was advanced finally to full liquids, and he had formal ostomy teaching. DISCHARGE DISPOSITION: The patient's anticipated day of discharge was pending. CONDITION AT DISCHARGE: His condition on discharge was stable. MEDICATIONS ON DISCHARGE: 1. Allopurinol 300 mg p.o. q.d. 2. Zestril 10 mg p.o. q.d. 3. Magnesium oxide 400 mg p.o. q.d. DISCHARGE DIAGNOSES: Status post abdominal perineal resection secondary to rectal cancer. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5014**], M.D. [**MD Number(1) 35804**] Dictated By:[**Name8 (MD) 522**] MEDQUIST36 D: [**2177-9-16**] 10:12 T: [**2177-9-18**] 07:20 JOB#: [**Job Number 35805**] Name: [**Known lastname 6203**], [**Known firstname 6204**] Unit No: [**Numeric Identifier 6205**] Admission Date: [**2177-9-8**] Discharge Date: [**2177-9-19**] Date of Birth: [**2103-10-19**] Sex: M Service: ADDENDUM: Following the last dictation, Mr. [**Known lastname **] was tolerating a regular diet but had decreased amounts of stool output over a day while tolerating a regular diet. The patient was made n.p.o. A KUB was taken demonstrating a picture most consistent with postoperative ileus with a mildly dilated small loops of bowel preceding the ileostomy, and a large amount of stool on this morning (which is [**2177-9-19**]). The patient was seen by Dr. [**Last Name (STitle) 6206**]. His belly was soft, and he was passing large amounts of air, and it was felt that the patient's condition was stable, and he could be discharged home. Date of discharge is [**2177-9-19**]. DISCHARGE DIAGNOSES: Status post abdominal peritoneal resection. MEDICATIONS ON DISCHARGE: Ostomy supplies and Percocet one to two tablets p.o. q.3-4h. p.r.n. for pain. [**First Name11 (Name Pattern1) 2636**] [**Last Name (NamePattern4) 6207**], M.D. [**MD Number(1) 6208**] Dictated By:[**Name8 (MD) 4745**] MEDQUIST36 D: [**2177-9-19**] 07:46 T: [**2177-9-24**] 09:42 JOB#: [**Job Number 6209**]

[ "276.5", "427.60", "E878.3", "599.7", "997.4", "154.1", "211.3", "780.09", "560.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "48.5", "96.04" ]

icd9pcs

[ [ [] ] ]

3812, 3879

5369, 5414

5441, 5786

1302, 1412

1898, 3788

3894, 3934

128, 144

173, 686

1668, 1879

709, 1275

65,481

141,781

44198

Discharge summary

report

Admission Date: [**2101-2-23**] Discharge Date: [**2101-2-24**] Date of Birth: [**2057-11-8**] Sex: F Service: MEDICINE Allergies: Penicillins / Amoxicillin / E-Mycin / Latex / Ondansetron / Vancomycin / Levofloxacin / Zofran / Phenergan / Dilaudid / Ceftriaxone / Sulfamethoxazole/Trimethoprim / Voriconazole / Fluconazole / Caspofungin / Doxycycline / Propranolol / Neurontin / Azithromycin / Xopenex Hfa / Optiray 300 / Ketorolac Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: fluconazole desensitization Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. [**Known lastname 94828**] is a 43 year old female with CVID, extensive allergy history, atonic colon s/p resection, and recurrent vaginal yeast infections previously admitted for both Caspofungin & Fluconazole desensitization, presenting again for Fluconazole desensitization. . Of note, the patient has had phlebitic reactions previously to catheters left in place for IVs. She will need daily IV's placed to receive her Fluconazole infusions. . Currently, the patient is without complaints. She presents from home without concerns. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Common Variable Immunodeficiency, on monthly IVIG Esophageal dysmotility/Autonomic neuropathy ? Behcet's disease Colonic inertia s/p subtotal colectomy at [**Hospital3 14659**], [**2093**] Atrophic vaginitis with recurrent yeast infections Sleep disorder characterized by non-REM narcolepsy, restless leg syndrome, and periodic leg movements Social History: No tobacco, alcohol and illict drugs. Family History: Non-contributory Physical Exam: General: Alert, oriented, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, scaphoid, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: thin, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2101-2-24**] 04:52AM BLOOD WBC-4.1 RBC-4.22 Hgb-13.6 Hct-38.9 MCV-92 MCH-32.3* MCHC-35.1* RDW-11.5 Plt Ct-249 [**2101-2-24**] 04:52AM BLOOD Neuts-49.3* Lymphs-43.2* Monos-6.0 Eos-1.0 Baso-0.5 [**2101-2-24**] 04:52AM BLOOD Glucose-87 UreaN-15 Creat-0.8 Na-136 K-4.0 Cl-103 HCO3-24 AnGap-13 [**2101-2-24**] 04:52AM BLOOD Calcium-9.6 Phos-4.5 Mg-2.1 Brief Hospital Course: 43F with CVID, extensive allergy history, and recurrent vaginal yeast infections here for Fluconazole desensitization. # Fluconazole desensitization: Patient with recurrent yeast infections, requiring anti-fungal therapy. Patient previously received Caspofungin and Fluconazole desensitization to treat her yeast infections, now here for repeat Fluconazole desensitization. Her target dose is IV Fluconazole 800mg daily, to be infused at 80 cc/hour for 5 hours. Desensitization was performed per protocol. She was pre-treated with diphenhydramine 25 mg and IV famotidine 20 mg. She then was treated with a steadily increasing concentration of IV fluconazole, until she was at her goal dose. She experienced no rash, no wheezing and no evidence of allergic reaction. She had a mild cough, and was given benadryl PO. # Esophageal dysmotility: Patient was treated with her home dose of nexium. # Sleep disorder: Patient was treated with her home dose of Concerta 36mg PO qAM. # Common variable immunodeficiency: Patient will continue her monthly IVIG infusions as an outpatient. Medications on Admission: Nexium 40mg PO BID Concerta 36mg PO qAM Ativan 0.5mg PO BID:PRN Discharge Medications: 1. Esomeprazole Magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 2. Concerta 36 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO daily (). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once () as needed for anxiety. 6. Epinephrine 0.3 mg/0.3 mL Pen Injector Sig: One (1) Pen Injector Intramuscular ONCE (Once) as needed for allergic reaction for 1 doses: Use as needed for anaphylaxis. Discharge Disposition: Home Discharge Diagnosis: Fluconazole Desensitization Common Variable Immunodeficiency Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted for desensitization of fluconazole. You were treated with antihistamines, followed by slowly increasing doses of fluconazole. You experienced some cough, but otherwise haad no symptoms of allergic reaction. One hour after your fluconazole infusion completed, you were discharged. Please begin outpatient fluconazole infusions as previously arranged. No other changes have been made in your medications. Followup Instructions: Please follow up with the following appoitnments: Provider: [**Name10 (NameIs) 1248**],BED SEVEN [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2101-2-25**] 8:15 Provider: [**Name Initial (NameIs) 455**] 1-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2101-2-26**] 8:00 Provider: [**Name Initial (NameIs) 455**] 1-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2101-2-27**] 8:00 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "279.03", "V14.8", "V07.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4775, 4781

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2010, 2028

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530, 559

1192, 1572

631, 1174

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1954, 1994

18,622

117,826

10050

Discharge summary

report

Admission Date: [**2159-10-8**] Discharge Date: [**2159-10-13**] Date of Birth: [**2123-5-20**] Sex: M Service: CARDIOTHORACIC Allergies: Morphine / Prochlorperazine / Droperidol / Decadron Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: recurrent thoracic germ cell tumor Major Surgical or Invasive Procedure: Revision of thoracotomy, resection of 1st and 2nd ribs, partial clavicular resection History of Present Illness: Pt is a 36 year old man who in [**2154**] was diagnosed with a left mediastinal nonseminomatous germ cell tumor. He had chemotherapy as well as stem cell transplantation followed by a left thoractomy with total left pneumonectomy and resection of the tumor. He did well until [**2159-5-18**] when he presented to his PCP's office with L shoulder pain. A chest CT was performed at that time which demonstrated a mass consistent with recurrence of his tumor. He underwent further chemotherapy as well as radiation therapy and presents for elective resection of his recurrence. Past Medical History: L mediastinal germ cell tumor, as above s/p gastrostomy tube placement Social History: Divorced, no tobacco currently but former 0.5-1ppd smoker x 5 years Moderate EtOH Family History: DM, HTN, no h/o cancer Physical Exam: Gen: NAD HEENT: EOMI, nares patent, oropharynx without erythema/exudate Neck: no masses CV: RRR, no m/r/g Lung: CTA B, no wheezes/crackles. Large thoractomy incision with staple in place, no active oozing or erythema. Abd: soft, NT/ND, Gtube in place Ext: no edema, WWP Neuro: aao x 4, appropriate Pertinent Results: [**2159-10-8**] 09:50AM BLOOD WBC-5.7 RBC-3.19* Hgb-11.1* Hct-31.0* MCV-97 MCH-34.9* MCHC-35.9* RDW-14.7 Plt Ct-228 [**2159-10-8**] 09:50AM BLOOD PT-12.6 PTT-31.2 INR(PT)-1.1 [**2159-10-8**] 09:50AM BLOOD Plt Ct-228 [**2159-10-8**] 03:15PM BLOOD Glucose-95 Creat-1.0 Na-140 K-3.8 Cl-107 HCO3-25 AnGap-12 [**2159-10-8**] 03:15PM BLOOD Calcium-8.0* Phos-2.9 Mg-1.5* [**2159-10-8**] 07:53AM BLOOD Type-ART pO2-436* pCO2-36 pH-7.45 calHCO3-26 Base XS-2 Intubat-INTUBATED Vent-CONTROLLED [**2159-10-8**] 07:53AM BLOOD Glucose-129* Na-141 K-4.0 Brief Hospital Course: Pt was admitted and underwent an uncomplicated sternotomy with 1st and 2nd rib excision and partial left clavicular excision. He was transferred to the ICU intubated and stable. He was given a fentanyl epidural with adequate control of his pain although his epidural dose was adjusted for better titration of his pain. On POD #2 he was extubated successfully. His epidural was discontinued for a fentanyl PCA with satisfactory control of his pain. At that time, it was noted that the patient was hoarse. An ENT consult was obtained who evaluated the patient for possible vocal cord paralysis. A left paralyzed vocal cord was noted. Both a bedside swallow and a video swallow demonstrated no aspiration but weak swallowing function and he was cleared for a regular diet. His diet was advanced to clear liquids and transferred tot he floor. His L pleural [**Doctor Last Name **] drain was clamped and repeat CXR demonstrated no significant change. On POD #3, a CXR demonstrated no signficant change and his L pleural [**Doctor Last Name **] drain was discontinued. He was advanced to a regular diet which he tolerated well. He was able to ambulate well and his pain was well-controlled with PO pain medication. He was discharged home on POD#5 in stable condition. Medications on Admission: testosterone MVI advil prn Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three times a day for 2 weeks. Disp:*42 Tablet(s)* Refills:*0* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks. Disp:*28 Capsule(s)* Refills:*0* 4. Oxygen-Air Delivery Systems Device Sig: Two (2) Liters Miscell. Continuous O2 therapy: Wean to keep oxygen saturation >90%. Disp:*1 Tank* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Health Services Discharge Diagnosis: Recurrent germ cell tumor of the anterior chest wall Discharge Condition: Stable Discharge Instructions: Please call Dr.[**Name (NI) 1816**] office or return to the hospital if you experience chills or fever greater than 101.5 degrees F. Please return if you notice excessive swelling, redness or tenderness of your wounds, or if they begin to drain pus. Continue your deep breathing exercises at home. You may shower when you go home. Avoid tub bathing/swimming until follow-up visit. Wash wounds with soapy water, pat dry. Apply neosporin ointment to wounds as needed. Followup Instructions: Provider: [**Name10 (NameIs) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 170**] Call to schedule appointment. Appointment should be in [**8-31**] days. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 674**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5808**] Call to schedule appointment Provider: [**Name10 (NameIs) 39**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 41**] Appointment should be in [**5-27**] days. Call to schedule appointment.

[ "478.31", "V10.89", "197.2", "V42.82", "V44.1", "198.89", "197.1" ]

icd9cm

[ [ [] ] ]

[ "37.33", "34.4" ]

icd9pcs

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4093, 4168

2182, 3445

362, 449

4264, 4272

1619, 2159

4786, 5327

1262, 1286

3522, 4070

4189, 4243

3471, 3499

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1301, 1600

288, 324

477, 1053

1075, 1147

1163, 1246

54,623

170,000

39402+58289

Discharge summary

report+addendum

Admission Date: [**2143-8-29**] Discharge Date: [**2143-9-12**] Date of Birth: [**2093-2-3**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: Productive cough, fever, shortness of breath, tranferred from an outside hospital with a visual field deficit. Major Surgical or Invasive Procedure: Transesophageal echocardiography. (otherwise, medical management: heparin gtt, then warfarin anticoagulation for cardioembolic stroke; started CCB for rate-control (afib); started ACEi and thiazide for HTN; s/p IV antibiotics for multifocal PNA) History of Present Illness: Mr. [**Known lastname 87103**] is a 50-year-old right-handed who presented to an outside hospital with fever, productive cough, shortness of breath, transferred to [**Hospital1 18**] after developing a visual field deficit. *** Mr. [**Known lastname 87103**] was last well on Saturday night. He works in a bar and was serving on for a large party. He had some beer and later snorted some cocaine. He stayed out, getting home at about 6 a.m. and sleeping through until 2 p.m. when he was due to return to work. He worked for about four hours before drinking two beers and returning home. By the end of that shift he was feeling unwell, with some chest congestion. He also felt fatigued. Nonetheless, he slept well, waking at about 8:30 a.m. on [**Known lastname 766**] morning (the timing of events varying slightly while taking the history). He stood, felt light-headed and fell, with brief loss of consciousness, but he recalls striking his head on a table and his neck flexing or extending (in which direction he cannot say). He did not suffer any superficial injury. He got back into bed. By this time he was feeling even sicker, now with some cough that became productive over the course of that day. He also gradually developed a pounding headache with severe pain that was in time with heart beats. He felt quite unwell, had become febrile with chills and was fatigued. He ate nothing and drank some water and CoolAid, but noted that his urine was becoming darker. He slept very little that night. On Tuesday he felt even less well, with continuing headache, fever, chills, and productive cough. Again he slept poorly. On Wednesday he and he and his girlfriend, who lives with him, decided that he should go to the hospital. She drove him there. In the OSH, atrial fibrillation with a rapid rate was noted and diltiazem infusion started. Neurologic examination was not performed in the OSH ED. He was noted to be diaphoretic, unable to get out of bed, not eating, confused, but denied headache and chest pain. Vital signs were 98.1 degrees, heart rate of 145, repiratory rate of 24, blood pressure of 179 systolic. Right eye blurring was noted. Oxygen saturation was 93%. Laboratory data was significant for creatinine of 1.5, normal CK and CK-MB, slightly elevated troponin I at 0.07. Bilirubin was also mildly elevated. CT head was performed. He was transferred to [**Hospital1 18**] for further management. In [**Hospital1 18**] ED, right field cut restricted to the right eye was recorded. CTA chest was performed and the patient was given cetriaxone and levoquin, hydralazine given blood pressure of 175/123, aspirin and diltiazem. Urinanalysis was significant for proteinuria, toxicology was positive for opiates and cocaine. *** He reports headache, tremulousness, sweats, fatigue, cough productive of sputum, shortness of breath. On Neurologic review of systems, patient denies any history of seizures or unexplained loss of consciousness (other than syncope above), vertigo or dizziness, diplopia, difficulty hearing, tinnitus, difficulty with speech or swallowing, weakness, difficulty moving, abnormal movements, numbness, tingling, tremor, problems with gait, balance or coordination, difficulty with sphincter control or sexual function, difficulty with thinking or memory, problems sleeping (except as above) or excessive sleepiness, depressive symptoms. Past Medical History: - No significant - Patient denied hypertension, hypercholesterolemia, prior arrhythmia Social History: De facto relationship with girlfriend, have lived together for 18 years. Works in bar, part-time for the last two years. Worked as an appliance salesman prior to that time. Completed eighth grade in school. Rare cocaine use - once in 'long-time' on Saturday. Does not smoke. Regular drinking - claims two or so most days. Speaks English - this is his first language. Family History: No family history of stroke. Physical Exam: T 98.1 F ; HR 95 BPM ; BP 164/117 (on arrival in ICU), now 149/71 mmHg ; RR 19 BPM ; O2Sat 94% (NC 3L) ; Pain 0/10 General Observations and Appearance Reasonable self care, looks stated age. Diaphoretic. Fine tremor. Restless. General Physical Exam Head - Size appears within normal limits, symmetric, no exostoses nor tenderness. No injuries. Eyes - No exophthalmos, normal [**Doctor First Name 2281**], round pupils, normal sclera. ENT/OP - MM slightly dry and tongue surface normally papillated. Tongue of normal size/muscle bulk. Neck - No bruits, pulses normal, no LAD, supple, normal appearance, thyroid normal. Chest/Thorax/Breasts - CTA, RR, good air entry, no dysmorphic features. No consolidation by vocal fremitus. Cardiovascular - Irregular, normal PMI, normal s1 s2, no M/R/G. Peripheral pulses normal. Abdomen - No scars, stigmata of liver disease, soft, non-tender, no masses nor organomegaly. Spine - Normal curvatures, non-tender, no dimpling or unusual hair growth. Extremities - No deformities, nor contractures. No clubbing, cyanosis nor edema. No arthropathy. Normal digits. No palmar erythema. Skin - Neither greasy nor dry, no spider angiomas, no tattoos, scars other markings. Hair and Nails - Normal appearances. Male pattern baldness with normal hairline. Mental Status Alert and slightly hyper-aroused given setting. Oriented to person and time, but not hospital. Comprehension intact for simple and complex instruction, including across midline. Naming was intact for colors and high frequency objects. Anomia for low frequency objects. Repetition intact. Neglected right side of stroke scale pictures. Writing with spelling errors and phrases, but [**Location (un) 1131**] not intact - could spell some words from stroke card, but with many errors and could not read (~ alexia without agraphia with preserved colors). [**Doctor Last Name 1841**] forward, normal, could not perform in reverse. Registered four words with one trial and recalled none, even with prompting. Occasional paraphasic errors (phonemic) and perseveration on words. Affect was not observed as full-range, mood euthymic. Thought process logical, content appropriate. Judgement not tested. Insight retained. Cranial Nerves Patient reports baseline olfaction. Field deficit, right homonymous hemianopia on confrontation, then on careful inspection with hat pin: Split in middle of macula and exact right visual fields. Acuity not tested. Pupillary reaction to light and accommodation intact (2 mm to 1.5 mm), including consensual reactions. Eye movements were full without observed deviation of either eye nor report of diplopia. No neutral position nor end-gaze nystagmus. Pursuit movements were smooth. Jaw opening was symmetric and facial sensation intact to light touch. Facial expressions were of reduced strength symmetrically at eyes and with decreased excursion on right side at mouth, with nasolabial fold flattening. Hearing was grossly intact. Soft palate symmetric at rest and with elevation. Apparently normal salivation and swallowing. No dysphonia. Shoulder shrug and head turning strong, full range and with symmetry within normal limits. Tongue bulk and movements normal and symmetric. No dysarthria. Tone Slightly increase in right arm and both legs. Normal axial/postural tone without negative myoclonus (asterixis). No spasticity. Power and Muscle Bulk ( left ; right ) Normal bulk throughout the upper and lower extremities Deltoid ( 5 ; 5 ) Triceps ( 5 ; 5 ) Biceps ( 5 ; 5 ) Wrist and finger extensors ( 5 ; 5 ) Finger flexion ( 5 ; 5 ) Finger (fifth) abduction ( 5 ; 5 ) Hip flexors ( 5 ; 5 ) Quadriceps femoris ( 5 ; 5 ) Biceps femoris ( 5 ; 5 ) Plantar flexors ( 5 ; 5 ) Tibialis anterior ( 5 ; 5 ) Toe extensors ( 5 ; 5 ) Reflexes ( left ; right ) Biceps ( ++ ; ++ ) Triceps ( ++ ; ++ ) Brachioradialis ( ++ ; ++ ) Quadriceps ( ++ ; ++ ) Plantar flexors ( ++ ; ++ ) Plantar responses ( down ; down ) Routing reflex, grasp, snout and palmar-mental reflexes not tested. Clonus not present in plantar flexors. Coordination, Fine Motor Control and Patterned Movements Hand roll and rapid sequential finger apposition normal. Finger to nose normal with eyes closed. Sensation Light touch intact and symmetric on medial and lateral surface of upper and lower limbs. Anterior surface of trunk intact. Gait and Station Not tested given lines and drains, pneumoboots. Other Signs No pronator drift. No extinction on double simultaneous stimulation of the hands or legs. Exam today significant for some spastic increase in tone on right, hyporeflexia on right. Some improvement of macula vision loss. Able to write, but [**Location (un) 1131**] still difficult. Pertinent Results: -------------- BRAIN IMAGING: -------------- *OSH* NCHCT [**2143-8-28**] (prior to xfer to [**Hospital1 18**]) There is a large area of [**Doctor Last Name 352**] and white matter hypodensity involving the left temporal, parietal, and occipital lobes with assiciated sulcal effacement. Findings are compatible with cytotoxic edema in the setting of a left PCA territory acute infarction. Within this area of infarction are areas of intermediate density with a gyral pattern, could represent spared parenchyma. There is no definite evidence of hemorrhage. Periventricular white matter hypodensity is noted compatible with chronic microvascular ischemic disease. There is slight prominence of the ventricles and the sulci, compatible with mild atrophy. There is minimal rightward shift of midline at the septum pellucidum of 2 mm. There is no evidence for herniation. BONE WINDOWS: Osseous structures are intact. There is mild mucosal thickening of the right and left maxillary sinuses and right and left sphenoid sinuses. The globes and orbits appear intact. IMPRESSION: Large left PCA territory acute infarction. Please correlate with MRI. MRI/MRA [**2143-8-29**] Extensive left PCA territory infarction with internal areas of hemorrhage is redemonstrated, similar in distribution as compared to [**2143-8-28**] head CT. A thin peripheral rim of cytotoxic edema causes mild effacement of the occipital [**Doctor Last Name 534**] and exerts mass effect on the body of the left lateral ventricle. A 2-mm rightward midline shift is similar as compared to two days prior. Suprasellar and basilar cisterns are patent. In addition, there are new foci of restricted diffusion within the left thalamus (24, 14) and right occipital lobe (24, 14 and 24, 16), concerning for new foci of microinfarct due to embolic disease. There are confluent and discrete FLAIR and T2 signal hyperintensities within the periventricular and subcortical white matter, consistent with small vessel ischemic disease. There is mucosal thickening involving maxillary, ethmoid, sphenoid and frontal sinuses. Fluid level is noted in the right maxillary sinus, suggestive of an element of acute disease. Globes and soft tissues appear unremarkable. MRA BRAIN AND NECK: The intracranial internal carotid arteries, anterior cerebral arteries, middle cerebral arteries, posterior cerebral arteries, vertebral and basilar arteries appear patent without flow-limiting stenosis, aneurysm greater than 3 mm, or dissection. There is slight asymmetry of segmental left PCA as compared to the contralateral site, which may be further assessed by CTA if clinically indicated. Cervical portions of carotid and vertebral arteries appear patent and normal in caliber. Proximal vessel origins are poorly visualized due to motion and artifacts. IMPRESSION: 1. Large left PCA territory infarct with hemorrhagic conversion and mild effacement of occipital [**Doctor Last Name 534**] of lateral ventricle as well as a stable 2-mm rightward midline shift. No evidence of transtentorial or tonsillar herniation. 2. Additional foci of acute microinfarct of left thalamus and right occipital lobes are suggestive of central embolic disease. 3. Moderate-to-severe small vessel ischemic disease. 4. Patent anterior and posterior circulation vasculature. Slight asymmetry of the left PCA segmental branches as compared to the right. CTA may be considered for further assessment if clinically relevant. 5. Patent cervical vertebral and carotid arteries. Poor visualization of vessel origins due to motion artifacts. 6. Mild to moderate paranasal sinus disease, with right maxillary fluid level, suggesting an element of acute disease. NCHCT [**2143-8-31**] A large area of hypodensity in the left occipital, parietal and temporal lobes with sulcal effacement is again noted and consistent with known PCA infarct. Serpiginous areas of hyperdensity corresponding to hemorrhagic conversion are not significantly changed compared to the prior studies. There is persistent 2 mm rightward shift of the normally midline structures and effacement of the occipital [**Doctor Last Name 534**] of the left lateral ventricle. No evidence of uncal or transtentorial herniation. Mild periventricular white matter hypodensity is compatible with chronic small vessel ischemic disease. Ventricles and sulci are otherwise slightly prominent consistent with mild age-appropriate involutional change. Globes and lenses are intact. There is mild mucosal thickening in the bilateral ethmoid air cells and right maxillary sinus. The remainder of visualized paranasal sinuses and mastoid air cells are well aerated. No osseous abnormality is identified. IMPRESSION: 1. No significant change in known left PCA infarct with hemorrhagic conversion. No evidence of new or worsening hemorrhage compared to prior MR [**First Name (Titles) **] [**Last Name (Titles) **], allowing for differences in technique. No new hemorrhage or infarct. 2. Bilateral ethmoid and right maxillary sinus disease. -------------- CHEST IMAGING: -------------- CT-angiogram of the chest on [**2143-8-29**] There is no pulmonary embolism. The pulmonary artery is normal in caliber. There are coronary artery vascular calcifications. The aorta and great vessels appear normal. There is no pericardial fluid. There are diffuse multifocal bilateral air space opacities. There are moderate bilateral pleural effusions. There are several reactive hilar, mediastinal and pre-vascular lymph nodes. There is no axillary lymphadenopathy. Lobes of the thyroid appear normal. The airways appear patent to the subsegmental levels bilaterally. There is pleural septal thickening. Limited evaluation of the upper abdomen appears normal. BONE WINDOWS: There are no suspicious-appearing sclerotic or lytic lesions. IMPRESSION: 1. Diffuse multifocal air space opacities with moderate bilateral pleural effusions concerning for pneumonia. 2. No pulmonary embolism. 3. Pulmonary edema. CT-angiogram of chest on [**2143-9-3**] FINDINGS: Comparison to CTA of [**2143-8-29**]. There is no evidence of pulmonary embolism. Bilateral pleural effusions and associated compressive atelectasis are moderately severe. The lungs are homogeneously ground-glass in appearance with concomitant left upper lobe consolidation in a bronchocentric distribution (4:9). Comparison to the prior study indicates interval resolution of the majority of bronchocentric nodules with persistence of those in the left upper lobe, marked interval progression in size of the pleural effusion, There has been interval resolution of smooth septal thickening in the apices indicating resolution of interstitial pulmonary edema. The left atrium is moderately enlarged and the left atrial appendage thrombus is unchanged since [**2143-8-29**]. There is no pericardial effusion. Reflux of contrast into the hepatic veins suggests triscuspid regurgitation. The airways are patent to the subsegmental level. Anterior bowing of the posterior membrane of the upper trachea suggests image acquisition during the expiratory phase. Right paratracheal, left peribronchial and subcarinal adenopathy is moderately severe, the largest node in the subcarinal station measures 15 mm (4:28), stable since [**2143-8-29**]. Thoracolumbar osteophytosis is moderately severe. IMPRESSION: Worsening bilateral pleural effusions. Overall improvement in the bronchocentric pulmonary nodules/opacities shown on the CTA of [**2143-8-29**] with persistent diffuse ground-glass opacity and left upper lobe focal consolidation. The appearance suggests a resolving pneumonitis, possibly inhalational, resolving bronchopneumonia or pulmonary hemorrhage are also possible. This much less likely to represent cryptogenic organizing pneumonia as it has improved in such a short interval. ----------------- ECHOCARDIOGRAPHY: ----------------- TTE [**2143-8-29**] Mild 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 definite thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 32 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: Thrombus identified in the left atrial appendage. There is dense spontaneous echo contrast in the body and appendage of the left atrium. The left atrial ejection velocity is very low (<10cm/s). TTE [**2143-9-3**] The left atrium is markedly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis (LVEF = 45-50 %). Right ventricular chamber size is normal with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace 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 mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2143-8-29**], the biventricular systolic function is slightly worse. Brief Hospital Course: [**Known firstname **] [**Known lastname 87103**] is a 50 y/o RHM with no PMH who was transferred to our hospital in atrial fibrillation and hypertensive with a multifocal pneumonia and a large LEFT PCA-territory stroke following recent inhalation of cocaine. His workup revealed multiple interrelated problems, including a multifocal pneumonia with moderate bilateral effusions on CTA-chest (no PE), atrial fibrillation with left atrial thrombus on TEE, hypertension, and most importantly, a LEFT-sided PCA territory stroke involving a large extent of the LEFT occipital lobe and inferior-posterior temporal lobe. His large LEFT PCA-territory stroke is certainly the cause of his visual deficits and his language and memory problems. This stroke was most likely cardioembolic in origin, given the atrial fibrillation with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**] discovered in our ICU. On heparin his hematologic system had significant difficulty maintaining a consistent therapeutic PTT (goal was 50-70 due to hemorrhagic conversion; note: abnormally low factor Xa level was measured after doses ranging from 1600-2200 were needed with day-by-day large swings from 30s to 80s). Likewise, his INR as well has been slow to come up on PO warfarin (now 1.6 after up-titration to a dose of 12.5mg on [**9-11**]). There is likely an underlying coagulopathy. Initially, he was monitored in our ICU, where hemorrhagic conversion was seen on MRI and a [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**] was discovered on bedside TEE. Heparin was started along with a low dose of PO warfarin 2.5mg for several days with no response, then up-titrated with INR no higher than 1.6 after several days of uptitration through 5-7.5-10-12.5mg daily on the floor. Heparin was stopped 3d prior to discharge on Dr.[**Name (NI) 35878**] advice, and the patient will be sent out with an INR below our initial goal range of 2.0-2.5, partly due to the patient's insistence on leaving the hospital. This was discussed at length with Dr. [**Last Name (STitle) **], stroke attending on service as of [**2143-9-12**]. He was started on aspirin 81mg, which he will take until his INR is fully therapeutic. He will have his blood drawn every two days at [**Hospital1 18**]-[**Location (un) **] near his home, beginning Friday [**9-13**] (day after discharge), and Dr. [**First Name (STitle) **] (Neurology chief resident on the stroke service) will monitor the results and call him with recommendations. He will then be managed by Dr. [**Last Name (STitle) **] in [**Company 191**]/[**Hospital **] clinic beginning [**Hospital 766**] [**9-16**]. Regarding his pneumonia, his pulmonary symptoms improved initially in the ICU on IV ceftriaxone monotherapy; he was never febrile and never developed a leukocytosis. Culture data were unrevealing, but were sent after abx were initiated, so therapy was never tailored to a specific organism. However, on [**9-3**] after two days on the floor (d4 of CTX), he began to decompensate with RR in the 30s and worsening hypoxia. Given his low factor Xa level (likely hypercoagulable state) and a D-dimer in the [**2133**], anther CTA-chest was ordered, but again did not reveal any significant PEs. His MF-PNA was still present and bilateral effusions were larger at that time. Bedside TTE showed decreased EF to 45-55%. We broadened his antibiotic coverage to IV vancomycin and cefepime, and diuresed him with 20mg furosemide two times over the next two days (he had JVD to the jaw at the time, no [**Location (un) **], and he improved rapidly over the next several days. Vancomycin was peeled off after 4d and cefepime was stopped after 8d. Also developed intermittent hyperphosphatemia to [**5-9**] of unclear origin. This occurred despite relatively normal GFR (Cr 1.0 with phos 5.8) and no hypocalcemia (Ca 9.2 with low albumin) and should be followed up, likely insignificant. Medications on Admission: no home meds Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) as needed for hypertension. Disp:*90 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily) as needed for stroke ppx: Dr. [**Last Name (STitle) **] will d/c this medication once your INR is therapeutic on warfarin/Coumadin. Disp:*30 Tablet, Chewable(s)* Refills:*0* 3. Warfarin 10 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Take a TOTAL DAILY DOSE of 12.5mg (ONE 10mg tablet plus ONE 2.5mg tablet);MUST have INR monitored by Dr. [**Last Name (STitle) **]. Disp:*10 Tablet(s)* Refills:*0* 4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anti-coagulation (stroke prevention in a patient with atrial fibrillation and left atrial thrombus): Take a TOTAL DAILY DOSE of 12.5mg (ONE 10mg tablet plus ONE 2.5mg tablet);MUST have INR monitored by Dr. [**Last Name (STitle) **]. Disp:*10 Tablet(s)* Refills:*0* 5. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for atrial fibrillation / tachycardia. Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: 1. Left PCA stroke, large, with hemorrhagic conversion. 2. Right homonymous hemianopsia and anomia. Secondary: 1. Atrial fibrillation and left atrial thrombus. 2. Hypertension. 3. Multifocal pneumonia atop what is likely cocaine-induced pneumonitis. 4. Labile personality, possibly [**2-5**] difficulties with language and memory. Discharge Condition: Right-homonymous hemianopsia. Word-finding difficulties, mild anomia. Discharge Instructions: You came to our hospital with a large stroke in the back-left part of your brain. Your blood pressure was very high, your heart was in an abnormal fast rhythm called atrial fibrillation which led to clot formation within your heart, which is likely the reason for your stroke, which caused your visual symptoms and headache. The area of brain damaged by the stroke (due to blood clots floating from your heart into your brain) also had some bleeding after the initial stroke. IMPORTANT: You need to take two CRITICAL medications to prevent another stroke from occurring. These two medications are WARFARIN (aka Coumadin) and aspirin. For the warfarin (also called Coumadin), you will take 12.5mg per day starting now -- this is ONE 10mg tablet plus ONE 2.5mg tablet once per afternoon for a total of 12.5mg. DO NOT SKIP DOSES or take any extra. ***If blood tests are not performed regularly to monitor the effect of this medication, it can become dangerous instead of preventative, so it is extremely important that you follow up on the blood draws for INR monitoring (EVERY TWO DAYS for now) and ALWAYS follow our instructions if there are any dose-changes. You can have your blood drawn either here or at our [**Hospital1 18**]-[**Location (un) **] location (1000 [**Location (un) **], [**Location (un) 453**] laboratory). You must come here to visit Dr. [**Last Name (STitle) **] in clinic starting this Friday in the [**Hospital Ward Name 23**] building (see below). We will manage the warfarin/Coumadin monitoring and dosing with him. For the aspirin, you will take one "baby aspirin" 81mg tablet per day until your INR is above 2.0. Once your INR is 2.0, stop taking the aspirin. Dr. [**First Name (STitle) **] will call to advise you about this. In addition to the blood thinner (warfarin/Coumadin), you need to take THREE medications to control your heart rate and blood pressure so that you can function without further heart problems and to reduce your high risk of more strokes or heart attack in the future. These are called diltiazem (to control your fast heart rate because of atrial fibrillation), lisinopril (for blood pressure), and hydrochlorothiazide (for blood pressure); you will take each of these once every day in the morning. You also had a severe, multifocal pneumonia when you arrived. This may have been the result of a severe lung injury called pneumonitis from the cocaine you ingested, and then you had a subsequent superinfection with bacteria in your injured lungs. We never learned which bacterial species were causing the infection (mild antibiotics were given before cultures were taken), but you got substantially better after an eight-day treatment course with IV antibiotics (four days of IV Vancomycin and eight days of IV Cefepime). You do not need to take additional antibiotic medications for your infection, which appears to have resolved. Dr. [**Last Name (STitle) **] will re-evaluate your lungs when you visit him in clinic. Followup Instructions: 1. Internal Medicine (to monitor your blood-thinner levels, treat your high blood pressure, treat your atrial fibrillation, and monitor your heart and lung function): [**Last Name (LF) **], [**9-16**] at 3:00pm (please arrive 15-30min early) with Dr. [**Last Name (STitle) 91**] at the [**Hospital1 18**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **], South Suite ([**Hospital Ward Name 23**] Clinical Center is on the [**Hospital Ward Name **], on the NorthEast corner of the intersection of [**Location (un) **] & [**Hospital1 **].) 2. Stroke Neurology with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (the attending stroke physician stroke neurologist who saw you first in the ICU and hospital floor when you came to [**Hospital1 18**]): TUESDAY, [**10-29**] at 3:30pm at [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **], Neurology suite. ([**Hospital Ward Name 23**] Clinical Center is at the NorthEast corner of [**Location (un) **] [**Hospital1 39240**].) [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2143-9-12**] Name: [**Known lastname 13799**],[**Known firstname 116**] Unit No: [**Numeric Identifier 13800**] Admission Date: [**2143-8-29**] Discharge Date: [**2143-9-12**] Date of Birth: [**2093-2-3**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 608**] Addendum: Please note the addition of hydrochlorothiazide to the patient's discharge medication list. Medications on Admission: none Discharge Medications: **PLEASE NOTE THE ADDITION OF HCTZ (25mg daily), which was not listed above. 1. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) as needed for hypertension. Disp:*90 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily) as needed for stroke ppx: Dr. [**Last Name (STitle) **] will d/c this medication once your INR is therapeutic on warfarin/Coumadin. Disp:*30 Tablet, Chewable(s)* Refills:*0* 3. Warfarin 10 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Take a TOTAL DAILY DOSE of 12.5mg (ONE 10mg tablet plus ONE 2.5mg tablet);MUST have INR monitored by Dr. [**Last Name (STitle) **]. Disp:*10 Tablet(s)* Refills:*0* 4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anti-coagulation (stroke prevention in a patient with atrial fibrillation and left atrial thrombus): Take a TOTAL DAILY DOSE of 12.5mg (ONE 10mg tablet plus ONE 2.5mg tablet);MUST have INR monitored by Dr. [**Last Name (STitle) **]. Disp:*10 Tablet(s)* Refills:*0* 5. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for atrial fibrillation / tachycardia. Disp:*120 Tablet(s)* Refills:*2* 6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day: for high blood pressure. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**] Completed by:[**2143-9-12**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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275, 387

701, 4084

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4211, 4579

20,610

116,364

52551

Discharge summary

report

Admission Date: [**2135-4-6**] Discharge Date: [**2135-4-11**] Date of Birth: [**2090-2-1**] Sex: F Service: GYN REASON FOR ADMISSION: The patient was admitted postoperatively from a total abdominal hysterectomy. ADMISSION DIAGNOSIS: 1. Status post total abdominal hysterectomy. 2. Status post postoperative hemorrhage, reexploration, and religation of the right uterine artery. 3. Postoperative anemia. DISCHARGE DIAGNOSES: 1. Status post total abdominal hysterectomy. 2. Status post postoperative hemorrhage, reexploration, and religation of the right uterine artery. 3. Postoperative anemia. DISCHARGE MEDICATIONS: 1. Iron. 2. Colace. 3. Percocet. 4. Motrin. HISTORY OF HOSPITALIZATION: The patient was admitted status post total abdominal hysterectomy secondary to uterine fibroids. Please see admission operative note for full details. She is a 45-year-old gravida 2, para 2 with a history of large fibroid uterus and menometrorrhagia. Her fibroid uterus was approximately 20 cm in size. PAST MEDICAL HISTORY: C section x2. She has no medical history. PHYSICAL EXAMINATION: Physical exam is within normal limits. With noting her fibroid uterus, decision was made to proceed with a total abdominal hysterectomy. At the time, this was felt to be uncomplicated, however, when the patient was transferred to the floor, she was dizzy and nauseated. Her blood pressure is found to be 54/palp and the heart rate was in the 100s, the sat was 95%. She was evaluated at that time, placed on Trendelenburg, and given IV bolus until her blood pressures resolved to the 80s-90s/30s-40s. A second drop in blood pressure was noted 67/38. A STAT hematocrit was sent, and a MICU consult was initiated. She had been putting out 200-400 cc urine in each hour, however, the concern was for bleeding, and she was noted to be slightly distended. Decision was made to proceed to the operating room. She was type and crossed for 4 units, and she proceeded to the operating room. The laparotomy revealed bleeding at the right uterine artery pedicle which was ligated. Please see full operative report for details of that procedure. She received 2 units of blood intraoperatively as well as 2 units postoperatively. She was transferred to the MICU postoperatively for immediate postoperative care as she was extubated 8:30 or 9 pm. She was maintained overnight in the MICU. Was found to be hemodynamically stable, and transferred to the floor the following morning. At that time, her hematocrit was noted to be 34.4 and her laboratory values were within normal limits. She was advanced within her diet. Her calcium was noted to be low at 7.1 and was repleted. She was hemodynamically stable with adequate urine output. Her blood pressure was stable. She was maintained on STD prophylaxis, and she was transferred on postoperative day one from the MICU to the floor. At that time, the beginnings of her routine postoperative care were initiated. Her diet was advanced over the following few days, and she was able to tolerate a regular diet. She was noted to be tachycardic on postoperative day one on the late afternoon with a heart rate in the 120s. The chest x-ray was obtained, and she was found to have a small left pleural effusion. Chem-10 was obtained and all electrolytes were noted to be within normal limits. The following day she was monitored, the question of pain medications arose with regard to her tachycardia. She also noted had chest discomfort and CTA was ordered the following day which was read as negative with small bilateral pleural effusions and patient was not thought to have a pulmonary embolus. She was maintained on the next four days. Her diet was advanced. Her pain control improved. Her tachycardia resolved, and she underwent routine postoperative care. On [**4-9**], two days prior to discharge, she was notably vomiting and had nausea overnight, however, this was self limited, resolved on its own, and on postoperative day five, [**2135-4-11**], she was greatly improved. She was tolerating regular diet, voiding spontaneously without a Foley catheter. Her tachycardia had stabilized at 90s-100s, and she was discharged home in stable condition on postoperative day five to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. [**First Name11 (Name Pattern1) 412**] [**Last Name (NamePattern4) 108522**], M.D. [**MD Number(1) 108523**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2135-4-13**] 21:56 T: [**2135-4-18**] 06:58 JOB#: [**Job Number 108524**]

[ "998.11", "285.1", "218.2", "275.41", "E878.8", "218.1" ]

icd9cm

[ [ [] ] ]

[ "54.12", "68.4" ]

icd9pcs

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445, 616

639, 1020

1110, 4611

253, 424

1043, 1087

3,868

116,382

44091

Discharge summary

report

Admission Date: [**2125-5-3**] Discharge Date: [**2125-6-6**] Date of Birth: [**2060-7-29**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1283**] Chief Complaint: Left leg ulcers Major Surgical or Invasive Procedure: s/p Aorto-Innominate artery bypass/aorto-> L common carotid bypass [**2125-5-22**] s/p L carotid->L subclavian bypass(8 mm PTFE)/Thoracic aortic stent graft [**5-23**] History of Present Illness: This 64BF has a history of PVD and foot ulcers and was admitted from Dr.[**Name (NI) 7257**] office for VAC placement and possible angiograms. Past Medical History: -- DM2 -- chronic foot ulcers/PVD -- HTN -- OA -- obesity -- asthma -- leg pain/neuropathy -- depression -- anemia -- h/o MRSA bacteremia [**11-18**], also septic arthritis treated at [**Hospital3 **] . Right thalamic hemorrhage resulting in a gait disorder and incontinence of urine, followed by Dr. [**Last Name (STitle) **]. Old CVAs. Neuropathy, peripheral. Anxiety and panic disorder. Status post total abdominal hysterectomy. Hypercholesterolemia. Social History: The patient lives with her daughter [**Name (NI) 2048**] and her three kids since being d/c'ed from a nursing home last [**Month (only) 205**]. Has seven children, many grandchildren. Smokes [**1-16**] to 1 pack per day. Family History: Brother died of an MI in his 30's, she denies diabetes mellitus in the family. Cancer in parents (mother died in 40s, father in 80s), at least two siblings, but unsure what kind. Physical Exam: Discharge General NAD Vitals 98.8, 118/58, 92 SR, 20 RR, 98% RA, 124.2 kg Neuro A/O x3 MAE R=L strength, generalized weakness Pulm CTA but diminished bilat bases no rhochi/wheezes Card RRR no murmur/rub/gallop Abd Soft nontender nondistended obese + BS BM [**6-5**] Ext warm pulses with doppler no edema IV access midline Rt AC Inc Sternal healing no erythema no drainage staples intact - plan for removal [**6-14**] Left subclavian incision healing no erythema no drainage staples intact - plan for removal [**6-14**] Right groin incision - no drainage or erythema covered with DSD staples intact plan for removal [**6-14**] Left ankle ulcer tissue pink healing no drainage - VAC dc'd and wet - dry dressing [**Hospital1 **], area 6cm L x 1.5 cm W x .25 cm D Left calf circular open area that is pink healing no drainage dry dressing Skin care eval [**5-28**] S/P surgery, she developed a drug rash and has dry desquamation overall body. There are several open blistered sites on her left forearm and one open site on her right forearm. All unroofed blisters are partial thickness ulcers with pink wound beds. There is minimal drainage from the sites. The wound edges are irregular. The periwound tissue has blistered skin and dry exfoliation. There are no s/s of infection. Goals of wound care: resolved skin issues Recommendations: Pressure relief per pressure ulcer guidelines Support surface: BariMaxx II with ETS Turn and reposition every 1-2 hours and prn Heels off bed surface at all times Multipodis Splints to B/L LE's If OOB, limit sit time to one hour at a time and sit on a pressure relief cushion, 4"Foam. Elevate LE's while sitting. Commercial wound cleanser or normal saline to irrigate/cleanse all open wounds. Pat the tissue dry with dry gauze. Apply Aquaphor Ointment to the intact dry skin upper and lower extremities, torso [**Hospital1 **] Apply Adaptic (nonadherent dsg) to the open ulcers (unroofed blisters) Cover with dry gauze Secure with netting, no tape on skin. Change dressing daily. Support nutrition and hydration. [**5-31**] SWALLOWING ASSESSMENT: PO assessment was conducted with ice chips, water and nectar thick liquid via tsp, cup and straw sip, custard, applesauce and whole & crushed meds in applesauce and one bite of ground up [**Location (un) **] crackers in custard. Swallows were slow / delayed. Laryngeal elevation felt adequate to palpation. There was no cough, no throat clear and no change in voice quality after eating or drinking. However, the pt. consistently said that she felt like coughing after drinking water. She said she did not feel like coughing after drinking nectar thick liquids. We were unable to obtain a reliable O2 saturation despite trying on her finger, toe or ear. She seemed to swallow ground and pureed solids but did best when she alternated between bites and sips. She could not swallow the whole pill w/nectar or in applesauce. So, we crushed the pill in custard and swallowed it with a sip of nectar to follow. SUMMARY / IMPRESSION: [**Known firstname **] [**Known lastname 1661**] may be aspirating thin liquids because she says she feel like coughing consistently after drinking water. However, she appears safe to drink nectar thick liquids and to eat pureed or ground solids if she alternates between bites and sips. She could not swallow a whole pill today with nectar thick [**Location (un) 2452**] juice or whole in applesauce, but she swallowed her pill crushed in custard w/a sip of nectar to follow. This swallowing pattern correlates to a Dysphagia Outcome Severity Scale (DOSS) rating of Level 4, Mild to moderate dysphagia with 2 consistnecy restrictions and intermittent supervision/cueing. This dysphagia is likely due to her old strokes. RECOMMENDATIONS: 1. Diet of ground solids and Nectar thick liquids with Pills crushed in puree 2. Supervision w/meals Alternate between bites and sips 3. If there are further concerns about aspiration on this diet, we would be happy to perform a FEES evaluation. She would not be a candidate for a Videoswallow because she is too large to fit into the fluoroscope. These recommendations were shared with the patient, nurse and medical team. ____________________________________ [**First Name4 (NamePattern1) 1154**] [**Last Name (NamePattern1) 19916**] [**Doctor Last Name 3748**], M.S., CCC-SLP Pager # [**Numeric Identifier 22568**] Pertinent Results: [**2125-6-5**] 07:23AM BLOOD WBC-10.7 RBC-2.71* Hgb-8.0* Hct-23.9* MCV-88 MCH-29.5 MCHC-33.4 RDW-16.5* Plt Ct-311 [**2125-5-6**] 06:10AM BLOOD Neuts-95.5* Bands-0 Lymphs-1.9* Monos-1.3* Eos-1.0 Baso-0.4 [**2125-5-3**] 07:30PM BLOOD WBC-5.5 RBC-4.54 Hgb-12.1 Hct-37.2 MCV-82 MCH-26.7* MCHC-32.5 RDW-14.9 Plt Ct-158 [**2125-5-3**] 07:30PM BLOOD Neuts-65.6 Lymphs-26.2 Monos-4.7 Eos-3.2 Baso-0.3 [**2125-6-6**] 05:38AM BLOOD PT-16.4* INR(PT)-1.5* [**2125-6-5**] 07:23AM BLOOD Plt Ct-311 [**2125-5-3**] 07:30PM BLOOD Plt Ct-158 [**2125-5-3**] 07:30PM BLOOD PT-11.4 PTT-26.1 INR(PT)-1.0 [**2125-5-30**] 03:03AM BLOOD ESR-65* [**2125-6-6**] 10:41AM BLOOD Glucose-156* UreaN-25* Creat-1.1 Na-140 K-3.7 Cl-109* HCO3-22 AnGap-13 [**2125-5-3**] 07:30PM BLOOD Glucose-130* UreaN-23* Creat-1.1 Na-142 K-3.8 Cl-107 HCO3-24 AnGap-15 [**2125-5-22**] 11:20PM BLOOD CK(CPK)-188* [**2125-5-18**] 04:45AM BLOOD ALT-40 AST-39 LD(LDH)-310* AlkPhos-136* Amylase-52 TotBili-0.3 [**2125-5-18**] 04:45AM BLOOD Lipase-44 [**2125-5-22**] 11:20PM BLOOD CK-MB-4 cTropnT-0.02* [**2125-6-6**] 10:41AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.3 [**2125-5-3**] 07:30PM BLOOD Calcium-9.1 Phos-3.0 Mg-2.3 RADIOLOGY Final Report CHEST (PA & LAT) [**2125-6-5**] 8:42 AM CHEST (PA & LAT) Reason: evaluate effusion [**Hospital 93**] MEDICAL CONDITION: 64 year old woman with R innom. aneurysm REASON FOR THIS EXAMINATION: evaluate effusion PORTABLE UPRIGHT CHEST, 8:52 A.M., [**6-5**]. INDICATION: Followup effusion. FINDINGS: Compared with 5/16 and with [**2125-5-29**], haziness at the right lung base is consistent with the right pleural effusion seen on CT of [**6-2**] and does not appear grossly changed. The left hemidiaphragm is elevated compared with the pre-op study consistent the left lower lobe collapse on CT. The superimposed left pleural effusion appears perhaps slightly smaller. The known right innominate artery aneurysm and recent aortic stent graft are again noted. No overt CHF. IMPRESSION: Overall, no definite/obvious significant interval changes appreciated. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: TUE [**2125-6-5**] 12:00 PM RADIOLOGY Final Report CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2125-6-2**] 1:16 PM CTA CHEST W&W/O C&RECONS, NON- Reason: r/o leak [**Hospital 93**] MEDICAL CONDITION: 64 year old woman with s/p aortic reconstruction REASON FOR THIS EXAMINATION: r/o leak CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 64-year-old woman post aortic reconstruction, evaluate for leak. TECHNIQUE: Multidetector contiguous axial images of the neck and chest were obtained following the administration of intravenous contrast. Delayed images of the neck through the chest were obtained. Non-contrast study of the chest was also obtained. FINDINGS: Compared to prior study of [**2125-5-4**], there has been repair of the aneurysmal dilatation of the innominate artery. Stent graft is seen extending from the distal portion of the ascending thoracic aorta through the arch and through the proximal portion of the descending thoracic aorta. No leak is identified. Injection of contrast was performed via the left arm, and there are a large amount of collaterals seen extending along the posterior chest wall to the azygos and hemiazygos veins which enter the right atrium via the IVC. The SVC, and proximal left subclavian vein are thrombosed in the interval. There are no filling defects in the pulmonary arterial vasculature. No pulmonary embolism is identified. At the site of surgical clips in the left upper neck, there is a large hematoma measuring 3.6 x 6.8 cm. Lung windows demonstrate atelectasis of the left lower lobe, moderate and to a lesser degree on the right. Small bilateral pleural effusions are present. Few images through the upper abdomen demonstrate a simple cyst arising from the upper pole of the left kidney measuring 5.5 cm in diameter. A calcified granuloma is seen in the spleen. Findings were discussed with Dr. [**Last Name (STitle) **]. Bridges on [**2125-6-2**]. IMPRESSION: 1. No leak post aortic reconstruction. 2. No pulmonary embolism. 3. Left neck hematoma as described above. 4. Interval development of thrombosis of the superior vena cava and proximal left subclavian vein. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**] Approved: SUN [**2125-6-3**] 11:13 AM Cardiology Report ECG Study Date of [**2125-5-24**] 9:25:12 AM Sinus tachycardia with diffuse low voltage. Q waves in leads III and aVF consistent with prior inferior myocardial infarction. Compared to the previous tracing of [**2125-5-22**] no diagnostic change. Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **] Intervals Axes Rate PR QRS QT/QTc P QRS T 102 130 80 294/352.85 48 -10 75 Cardiology Report ECHO Study Date of [**2125-5-23**] PATIENT/TEST INFORMATION: Indication: Intra-op TEE for Aortic stenting Status: Inpatient Date/Time: [**2125-5-23**] at 11:04 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW07-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**] INTERPRETATION: Findings: LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally effusion. Conclusions: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD on [**2125-5-24**] 07:08. [**Location (un) **] PHYSICIAN: Brief Hospital Course: Admitted [**5-3**] to vascular service for left leg venous stasis ulcers which was infected, she was sterted on IV antibiotics and VAC placed [**5-4**]. She was worked up for mass that was compressing trachea that revealed innominate artery aneurysm. Cardiac surgery was consulted and she underwent preoperative workup. She underwent recontruction and bypass of aneurysm in two phase on [**5-22**] and [**5-23**], see operative report for further details. She was transferred to the CSRU and requiring pressors for blood pressure management. She awoke neurologically intact and over the next few days was weaned off pressors and diuresised. She extubated on [**5-28**] without complications and continued to progress. She remained in the CSRU for respiratory and blood pressure monitoring. She had swallowing evaluation due to concerns for aspiration that she did well and was cleared for nectar thickended. She was started on anticoagulation for thrombosis Rt subclavian. She continued to do well and was transferred to [**Hospital Ward Name **] 2 on [**6-4**] for continued treatment. She continued to work with physical therapy and was ready for discharge to rehab. Medications on Admission: Remeron 30 mg PO daily Lopressor 50 mg PO BID Mevacor 20 mg PO daily MVI Vicodin PRN Plavix 75 mg PO daily Celexa 10 mg PO daily Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Gluconate 300 mg 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 8. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. 12. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): UNTIL INR 2.0. 13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 14. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 15. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical QID (4 times a day) as needed. 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: each port of midline daily and as needed. 17. insulin sliding scale Insulin SC (per Insulin Flowsheet) Sliding Scale Fingerstick QACHSInsulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog 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 61-100 mg/dL 0 Units 0 Units 0 Units 0 Units 101-130 mg/dL 2 Units 2 Units 2 Units 0 Units 131-150 mg/dL 4 Units 4 Units 4 Units 0 Units 151-180 mg/dL 6 Units 6 Units 6 Units 2 Units 181-210 mg/dL 8 Units 8 Units 8 Units 4 Units 211-240 mg/dL 10 Units 10 Units 10 Units 6 Units Ordered by [**Last Name (LF) **],[**First Name3 (LF) 2114**] M, APN Beeper#: [**Numeric Identifier 72690**] on [**6-4**] @ 2112 Acknowledged by RN on [**6-4**] @ 2140 by [**Last Name (LF) **],[**Name8 (MD) 674**], RN Processed by pharmacy on [**6-4**] @ 2118 by [**Last Name (LF) **],[**First Name3 (LF) **] Order #:[**Numeric Identifier 94654**] 18. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1 doses: for [**6-6**] only, then MD to order daily dose. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Innominate artery aneurysm PVD HTN NIDDM Depression Iron deficiency anemia CRI s/p breast ca s/p CVA ^chol. vascular dementia Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 10 weeks. Shower daily, let water flow over wounds, pat dry with a towel. Call our office for temp.>101.5, sternal drainage. Do not use creams, lotions, or powders on wounds. Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) **] for 2 weeks. (vasc. foot surgeon)[**Telephone/Fax (1) 2395**] Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.[**Telephone/Fax (1) 170**] Make an appointment with Dr. [**Last Name (STitle) 8499**] after discharge from rehab [**Telephone/Fax (1) 7976**] Completed by:[**2125-6-6**]

[ "305.1", "280.9", "287.5", "459.81", "519.19", "518.5", "437.0", "585.9", "442.81", "682.6", "250.00", "707.14", "599.0", "401.9", "V10.3", "290.40", "707.13" ]

icd9cm

[ [ [] ] ]

[ "93.59", "39.52", "99.05", "88.72", "96.6", "99.04", "39.22", "96.72", "38.93", "39.73" ]

icd9pcs

[ [ [] ] ]

16828, 16901

12850, 14029

292, 462

17071, 17079

5968, 7243

17480, 17841

1366, 1547

14209, 16805

8338, 8387

16922, 17050

14055, 14186

17103, 17457

11080, 12789

1562, 2850

237, 254

8416, 11054

2862, 5949

490, 634

12827, 12827

656, 1112

1128, 1350

4,042

189,510

24180

Discharge summary

report

Admission Date: [**2133-3-10**] Discharge Date: [**2133-3-22**] Date of Birth: [**2077-12-6**] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: The patient is a 55 year old woman with a history of diabetes, hypertension, hypercholesterolemia, who had presented to the office of Dr. [**Last Name (STitle) **]. [**Last Name (Prefixes) **] after a positive exercise stress test. She had undergone a cardiac catheterization which demonstrated three vessel coronary artery disease and, more specifically, a high grade stenosis of the mid LAD, high grade stenosis of the left circumflex, and complete occlusion of the RCA. When she presented to the office, she did have some dyspnea on exertion, but no worsening chest pain, and review of systems was negative. PAST MEDICAL HISTORY: Significant for diabetes mellitus, hypertension, hypercholesterolemia, history of a breast mass. PAST SURGICAL HISTORY: She had a breast biopsy. MEDICATIONS ON ADMISSION: Metformin 500 mg p.o. b.i.d., glyburide 5 mg p.o. b.i.d., Hyzaar 12.5/50 daily, Lipitor 10 mg daily, atenolol 50 mg daily, aspirin 325 mg daily, famotidine 10 mg daily, alprazolam 0.5 mg b.i.d. p.r.n. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient was a forty pack-year smoker; quit three years ago. She rarely drinks EtOH. Lives with her spouse and works as a contract auditor. FAMILY HISTORY: Her mother had coronary artery disease history. PHYSICAL EXAMINATION: She is 5'7", weighs 240 pounds. Healthy appearing. No acute distress. Neck was within normal limits. Chest was clear to auscultation bilaterally. Heart was regular rate and rhythm. Abdomen was obese, soft, nontender. Extremities were warm. Two plus distal pulses bilaterally. LABORATORY DATA: Her preoperative labs included a CBC with white count of 7.8, hematocrit of 37.8, platelets 313. Sodium 141, potassium 5.1, BUN 22, creatinine 1.2, glucose 157. She had a chest x-ray preoperatively which showed no acute infiltrate or congestive heart failure. The cardiac catheterization which was done at [**Hospital3 1280**] on [**2133-1-6**] demonstrates three vessel coronary artery disease with a right dominant circulation, high grade stenosis of the mid-LAD, proximal segment of the larger left circumflex, and 100 percent occlusion of the proximal RCA. There is preserved left ventricular function. HOSPITAL COURSE: On the day of admission, the patient went to the operating room, where she underwent a coronary artery bypass graft x 3 (LIMA to LAD, SVG to RCA, SVG to OM). The patient tolerated the procedure well, and postoperatively was taken intubated to the cardiothoracic intensive care unit on standard medications. Her early postoperative course was significant for atrial fibrillation/atrial flutter with normal blood pressure. She was started on amiodarone and beta blockade to help her rate control. Otherwise, she was extubated and transferred to the floor by postoperative day number three. At this point, on the floor she remained hemodynamically stable, and telemetry demonstrated that she would have paroxysmal atrial fibrillation with no effect on hemodynamic status. Cardiology was consulted, and assisted in management of this patient. She was maintained on beta blockade, and the decision was made to anticoagulate her, due to her frequent episodes of atrial fibrillation followed by sinus rhythm. She was started on heparin, and this was continued until her INR was therapeutic on her Coumadin. She otherwise did well. Reached a level five clearance with the physical therapists, was diuresed to her preoperative weight, and now that she is therapeutic on her Coumadin, is stable to go home, with followup with Dr. [**Last Name (STitle) **]. [**Last Name (Prefixes) **], Dr. [**Last Name (STitle) 1159**] and Dr. [**First Name (STitle) **] as appropriate. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post CABG x 3. 2. Postoperative atrial fibrillation. 3. Diabetes. 4. Hypertension. 5. Hypercholesterolemia. 6. Gastroesophageal reflux disorder. 7. Sciatica. MEDICATIONS ON DISCHARGE: Potassium chloride 20 mEq one tab p.o. daily for seven days. Colace 100 mg p.o. b.i.d. as needed. Famotidine 20 mg p.o. b.i.d. Aspirin 81 mg p.o. daily. Atorvastatin 10 mg p.o. daily. Glyburide 5 mg p.o. b.i.d. Metformin 500 mg p.o. b.i.d. Ferrous gluconate 300 mg p.o. daily. Ascorbic acid 500 mg p.o. b.i.d. MVI p.o. daily. Lasix 20 mg p.o. daily for seven days. Metoclopramide 10 mg p.o. q 6 as needed. Dilaudid 2 mg tablets, [**12-28**] p.o. q 4 hours p.r.n. Losartan 12.5 mg p.o. daily. Atenolol 50 mg p.o. daily. Coumadin 7.5 mg p.o. for her first night home. She will have VNA services, who will draw her INR labs, and this will be sent to Dr. [**First Name (STitle) **] as instructed in her discharge page one. DISPOSITION: Stable to discharge to home. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) 8958**] MEDQUIST36 D: [**2133-3-22**] 12:41:41 T: [**2133-3-22**] 13:44:00 Job#: [**Job Number 57045**]

[ "997.1", "272.0", "414.01", "724.3", "401.9", "530.81", "250.00", "427.31" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

1398, 1447

3893, 4087

4114, 5135

978, 1218

2400, 3872

925, 951

1470, 2382

166, 780

803, 901

1235, 1381

74,817

142,201

9166

Discharge summary

report

Admission Date: [**2179-6-23**] Discharge Date: [**2179-6-25**] Date of Birth: [**2131-10-15**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors / Azathioprine Attending:[**Doctor First Name 2080**] Chief Complaint: Anemia Major Surgical or Invasive Procedure: None History of Present Illness: This is a 47-year-old man with a history of dermatomyositis who is currently on steroids, MTX, recently recieved rituximab ([**Month (only) 958**]), and who recently underwent 1 week of treatment for H. pylori, who was found on routine labs to have a hct of 14 (prior: 33 two months prior). He was not having any symptoms but was called by his rheumatologist and told to go to the ED last night. He did not want to go last night and so presented to the ED in the morning. He reports chronic body weakness 2/2 his myositis but denies any worsening fatigue. He denies any recent chest pain, DOE, or SOB. . Of note he reported one episode of dark brown stool one week prior, but since has had lighter brown stools. He denies any BRBPR, N/V, abd pain. He does report chronic fevers at home, states he felt warm coming to the ER but this was not unusual for him. He denies any recent cough, URI or dysuria. His rheumatologist added on hemolysis labs, LDH was elevated but the hapto was > 100. . In the ED, initial vs were:4 103 94 [**Telephone/Fax (1) 31524**] 18 100. Labs were notable for lactate of 2.1, hb of 4 and hct of 14. An INR was 1.3. A CXR showed ?LLL consolidation. An ECG was normal and unchanged from prior. GI was consulted in the ED and recommended admit to ICU and NG lavage, but ED did not feel NG lavage needed to be done. Patient was given 1L fluid, 1U PRBC and ordered for another PRBC. His vitals at the time of transfer were 99.6, 76, 97/55 14 100% RA. In the ED, rectal exam notable for +BRB, with brown stool, guaiac +. . On the floor, the patient feels well. He denies any current N/V, abd pain, diarrhea, melena, BRBPR, fatigue, SOB, dizziness or CP. . Review of sytems: (+) Per HPI (-) Denies, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: -dermatomyositis on sc MTX 25/wk, Medrol taper, and s/p IVIG x6 and Rituxan x2 -H. Pylori positive - 1 week of tripple thereapy. -Elevated BP without Dx of HTN -atypical chest pain Social History: tobacco: denies alcohol: denies drugs: denies Lives [**Location (un) 6409**]. Divorced. Works as a computer systems engineer. Family History: (As per d/c summary on [**2177-10-31**]) Mother - HTN Father - [**Name (NI) **] [**Name2 (NI) **] - siblings with HTN Physical Exam: Vitals: T: 99.4 BP: 114/75 P: 77 R: 14 O2: 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, no JVD, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Rectal: External hemorrhoids Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. +2 pitting edema of b/l LE Pertinent Results: [**2179-6-23**] 10:11PM PH-7.45 [**2179-6-23**] 10:11PM LACTATE-0.9 [**2179-6-23**] 10:11PM freeCa-1.01* [**2179-6-23**] 09:12PM HCT-25.5*# [**2179-6-23**] 09:12PM PLT COUNT-376 [**2179-6-23**] 01:45PM HCT-18.9*# [**2179-6-23**] 09:31AM LACTATE-2.1* [**2179-6-23**] 08:19AM COMMENTS-GREEN TOP [**2179-6-23**] 08:19AM K+-3.8 [**2179-6-23**] 08:19AM HGB-4.7* calcHCT-14 [**2179-6-23**] 08:10AM GLUCOSE-100 UREA N-12 CREAT-0.6 SODIUM-134 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-24 ANION GAP-12 [**2179-6-23**] 08:10AM LD(LDH)-546* TOT BILI-0.4 [**2179-6-23**] 08:10AM HAPTOGLOB-134 [**2179-6-23**] 08:10AM WBC-5.0 RBC-1.95* HGB-4.3* HCT-14.9* MCV-76* MCH-21.9* MCHC-28.7* RDW-16.6* [**2179-6-23**] 08:10AM NEUTS-73* BANDS-0 LYMPHS-13* MONOS-11 EOS-2 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2179-6-23**] 08:10AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL [**2179-6-23**] 08:10AM PLT SMR-NORMAL PLT COUNT-469* [**2179-6-23**] 08:10AM PT-14.5* PTT-34.1 INR(PT)-1.3* [**2179-6-23**] 08:10AM FIBRINOGE-332 [**2179-6-23**] 08:10AM RET MAN-3.2* [**2179-6-22**] 03:42PM WBC-5.9 RBC-1.99* HGB-4.3* HCT-15.7* MCV-79* MCH-21.5* MCHC-27.3* RDW-16.7* [**2179-6-22**] 03:42PM NEUTS-74.6* LYMPHS-11.4* MONOS-8.3 EOS-3.8 BASOS-0.1 [**2179-6-22**] 03:42PM PLT COUNT-473* [**2179-6-22**] 03:42PM RET MAN-1.5 . CXR [**6-23**]: Frontal and lateral views of the chest were obtained. Patchy left lower lobe opacity is worrisome for pneumonia given patient's history of fever. The right lung is clear. There is no pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are unchanged. No pulmonary edema is seen. IMPRESSION: Left lower lobe consolidation, worrisome for pneumonia. . Discharge Labs: [**2179-6-25**] 12:27PM BLOOD WBC-7.2 RBC-3.43* Hgb-8.7* Hct-28.3* MCV-83 MCH-25.2* MCHC-30.5* RDW-17.4* Plt Ct-416 [**2179-6-25**] 12:27PM BLOOD Glucose-107* UreaN-10 Creat-0.5 Na-137 K-4.0 Cl-104 HCO3-26 AnGap-11 [**2179-6-23**] 08:10AM BLOOD Hapto-134 Brief Hospital Course: This is a 47-year-old gentleman on MTX, Rituxan, and IVIG who presents with acute on subacute anemia discovered on routine labs. # ANEMIA, multifactorial: Unclear etiology, but likely the result of marrow-toxic drugs patient has been receiving for dermatomyositis (methotrexate, bactrim, omeprazole, and rituxan) in the setting of baseline anemia, versus iron deficiency anemia and occult GI bleed. Rituxan can definitely cause a pure anemia; unclear if the other medications cause pure anemias or mixed cytopenias. Hemolysis labs were normal, ruling out a destructive etiology of anemia. Finally, patient could be losing blood, but again, no clear source. He does have gastritis and an external hemmorhoid, but unlikely to cause such a large drop in hct. Patient was initially transfused 5 units of PRBCs with appropriate bump in hct. GI was consulted who recommended EGD/colonoscopy, though not urgently as Hct stablilized. Bactrim, MTX, and rituxan were discontinued. Mr. [**Known lastname 1968**] was started on [**Hospital1 **] pantoprazole and 2 large bore IVs were placed. Heme/onc was consulted. Bone marrow bx was performed on [**6-25**] showing red cell precursors and low iron. He was started on iron supplementation. He will follow up with Heme for further care. - additionally, an EGD/colonoscopy was scheduled for [**7-1**] with Dr. [**Last Name (STitle) 2161**]. He will continue his PPI as well. . # Dermatomyositis: Chronic condition (symptoms started in [**10-6**]; Flair in [**2-7**] started on high dose steroid, given two doses of rituxan, and continued on MTX), no evidence of acute flair at this time. Patient is on steroids and MTX sc every week. In the ICU, Mr. [**Known lastname 1968**] was continued on steroids. His MTX and bactrim were held, and he was put on atovaquone for PCP [**Name Initial (PRE) 1102**]. Rheumatology was consulted. They recommended tapering his methyprednisolone to 8mg daily alternating with 4mg daily. He will follow up closely with them. . Community acquired pneumonia: Cough with positive chest xray. Was given Levofloxacin 750mg daily for 5 days. . # Gastritis/H. Pylori: Patient completed 1 week of triple therapy for his H.Pylori. His discontinued the medications because he thought they made him feel "dizzy." Can consider retreating in the future once anemia stable. Medications on Admission: CLOBETASOL - 0.05 % Cream - apply daily to affected area for 2 weeks use once a day to affected area, not exceeding 2 weeks in one month, 60 grams, one refill. LEUCOVORIN CALCIUM - 5 mg Tablet weekly 12h after MTX, stop daily oral folic acid METHOTREXATE NA (PRESERV FREE) - 25 mg/mL Solution - 1 ml intramuscular injection weekly stop oral MTX METHYLPREDNISOLONE - 8 mg Tablet - 1 Tablet(s) by mouth daily SULFAMETHOXAZOLE-TRIMETHOPRIM - 800 mg-160 mg Tablet - 1 Tablet(s) by mouth TIW Take Mo/Wed/Fri CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 WITH VITAMIN D3] - 600 mg (1,500 mg)-400 unit Tablet, Chewable - 1 Tablet(s) by mouth daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 2. Methylprednisolone 4 mg Tablet Sig: 1-2 Tablets PO as directed: Please alternate 4mg with 8mg daily, as part of your taper. Disp:*60 Tablet(s)* Refills:*0* 3. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) MG PO DAILY (Daily). Disp:*500 ML* Refills:*0* 4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:*4 Tablet(s)* Refills:*0* 7. Outpatient Lab Work CBC. please fax results to: Fax: [**Telephone/Fax (1) 4004**] Discharge Disposition: Home Discharge Diagnosis: Anemia, multifactorial Iron deficiency Community acquired pneumonia Dermatomyositis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 1968**], . It was a pleasure taking care of you. You came to the hospital because of a drop in your hematocrit. We gave you blood transfusions and your hematocrit came up. We think that your low blood counts are because of multiple causes, including medications and iron deficiency, as well as perhaps slow GI bleeding. You were also diagnosed with a pneumonia and will be given an antibiotic. You will be following up with hematology and rheumatology. You will also need to undergo an endoscopy and colonoscopy described below. . Please have your blood counts re-checked within 1 week. . The following changes were made to your medications: 1. Methotrexate stopped 2. Rituxan stopped 3. Methoprednisolone decreased to 8mg daily alternating with 4mg daily 4. Bactrim stopped 5. Atovaquone 1500mg daily started 6. Levofloxacin 750mg daily for 4 days 7. Omeprazole 20mg twice daily 8. Ferrous sulfate 325mg twice daily started for iron supplementation Please take all of your medications as prescribed. Please keep all of your follow-up appointments. . Return to the hospital if you develop lightheadedness, dizzines, blood in your stools, chest pain, shortness of breath, pain with urination, cough, nausea, vomiting, diarrhea, fevers, or any other concerning signs or symptoms. Followup Instructions: Please see below for your endoscopy and colonoscopy. You will receive a letter with instructions for this, including how to prepare. Please avoid any aspirin or NSAID medications until then. Please arrive at 9:30 on the [**Hospital Ward Name **] [**Hospital Ward Name 1950**] [**Location (un) **]. Please call [**Telephone/Fax (1) 463**] with any questions. Department: ENDO SUITES When: THURSDAY [**2179-7-1**] at 10:30 AM . Department: DIGESTIVE DISEASE CENTER When: THURSDAY [**2179-7-1**] at 10:30 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage . [**2179-7-16**] 01:00p [**Last Name (LF) **],[**First Name3 (LF) 1730**] A., [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 13005**] SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] HEMATOLOGY/ONCOLOGY-SC . Dr. [**Last Name (STitle) **] will call you to schedule an appointment with rheumatology

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icd9cm

[ [ [] ] ]

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34912

Discharge summary

report

Admission Date: [**2104-8-25**] Discharge Date: [**2104-9-18**] Date of Birth: [**2063-7-4**] Sex: M Service: MEDICINE Allergies: Cefazolin Attending:[**First Name3 (LF) 2745**] Chief Complaint: transferred from OSH - headache and new onset seizure. Major Surgical or Invasive Procedure: [**2104-8-28**] OR for steriotactic biopsy with pathology in OR showing high grade glioma however final path sig. for toxoplasmosis History of Present Illness: 41 y.o male from [**Country 651**] who presented to [**Hospital **] Hospital on [**8-25**] with a a progressive HA over a few weeks and new onset of seizure and found to have on CT a large left intracranial mass . He was loaded with Cerebryx and given Decadron 10 mg IV x1 and transferred to [**Hospital1 18**] for further care. On arrival patient was thought to be disoriented, confused even with cantonese interpreter. He had a repeat CT showing a large mass in the left basal ganglia with vasogenic edema, mass effect and 7 mm rightward shift of septum on head CT and MRI with Irregular rim-enhancing mass centered within the left thalamus with inferior extension into the brainstem. . On [**8-28**] he underwent a stereotactic brain biopsy with prelim results showing malignant glioma. On further review pathology showed toxoplasma gondii with staining + for Ab and parasites seen in tissue. . ID was consulted and pt was placed on Pyrimethamine, Sulfadiazine and folinic acid for toxoplasmosis treatment. He was continued on Phenytoin for seizure prophylaxis. . On [**8-31**] he complained of itchy scalp and forhead and on [**9-2**] developed raised vessicles on right forehead with eyelid swelling. DFA + for VZV and he was started on Acyclovir. Ophthamology was consulted and detected no ocular involvement from zoster or toxoplasmosis; pt was started on prophylactic erythromycin otic. Over time, pt developed some R upper eyelid erythema and edema. Cefazolin was started for concern of an overlying cellulitis. On [**9-2**] he spiked a fever to 102.9 with rigors and tachycardia and passed 40cc-50cc BRBPR. Blood, urine cultures and CXR were all negative. Pt's fever lifted the next day, his tachycardia after 3 days. GI was consulted for blood - colonoscopy significant only for hemorrhoids, no evidence of CMV colitis or other infections / masses. On [**9-5**], pt was transferred to the floor. He was noted to have intermittent bouts of hiccups, thought to be secondary to his brain lesion and increasing liver enzymes. Hepatitis serologies returned positive for Hepatitis B surface antigen, core antibody with a viral load over 3 million. On [**9-6**], pt developed [**Location (un) **] erythematous rash over chest, arms and legs. Thought to be a drug rash, cefazolin was stopped (eyelid erythema / edema had resolved) and pt was switched from phenytoin to keppra. Over 3-4 days, rash diminished. From [**9-6**] to [**9-10**], pt continued on medication, improved neurologically, started asking more questions, eating, ambulating well. On [**9-11**] - pt spiked a fever, U/A was leukocyte and nitrite positive. Pt started on Cipro for suspected UTI. Urine cultures grew E.Coli sensitive to cipro. Blood cultures pending. Foley d/c'ed. Pt responded well to antibiotics and continued to improve. Past Medical History: CAD: " small invasive procedure on his heart with placement of a piece of metal to keep blood flowing to his heart". procedure included minor incision in his groin indicating cardiac cath. His was taking medication for this up until recently and was stopped per cardiologist as not indicated anymore MI: possible minor heart attack last year Unknown speech / language disorder, communicates more by writing. Social History: Cantonese speaking, born in [**Country 651**]. Lives by himself, fully independent, disabled secondary to "speech" impairment. Per Brother, HIV positive, multiple sexual partners in past (unclear men, women or both), has not used contraception or STD prophylaxis. No IVDU, no previous blood transfusions Family History: Mother with uterine Ca. Physical Exam: Physical Exam: Vitals: 99.6 104/79 100 18 99%on RA. General: Thin Cantonese man, sitting quietly in chair, in NAD. HEENT: 2cm biopsy scar over left frontal skull. Crusting vesicular lesion over R side opthalmic trigeminal area - no vesicles or open areas. Slight droop to R eyelid, no swelling or erythema. PERRL 3mm a 2mm, white sclera. No oropharyngeal thrush. Moist mucous membranes. Neck: supple Lungs: Clear to auscultation bilaterally no rales, wheezes or rhonchi CV: tachycardic to 100, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, nontender, nondistended, bowel sounds present, no rebound tenderness or guarding. Ext: Warm, well perfused, 2+ pulses bilaterally. no peripheral edema Neuro: Alert, following commands, answering questions appropriately, stuttering unchanged. CN II-XII in tact. Strength [**4-7**] in flexors and extensors for L arm, [**3-8**] in flexors and extensors of R arm. Plantar flexion [**4-7**] bilaterally, [**3-8**] dorsiflexion on right [**4-7**] on left, [**4-7**] leg extension / flexion bilaterally. Slightly decreased pronator drift on R side. Gait not tested this AM Skin: No rash. Pertinent Results: IMAGING [**2104-8-26**] MRI head w/wo contrast - Irregular rim-enhancing mass centered within the left thalamus with inferior extension into the brainstem. The imaging characteristics including inferior extension favor a glioblastoma multiforme. Less likely in the differential are metastasis, lymphoma and PNET. Of note, it has been shown that slow diffusion within the enhancing portion of a glioblastoma multiforme, as in this case, is associated with an aggressive behavior. . [**2104-9-2**] - CXR - No signs of acute cardiopulmonary process . [**2104-9-5**] - Bilat LE US - No evidence of bilateral lower extremity deep venous thrombus . [**2104-9-15**] - ABDOMINAL US - LIVER, GALLBLADDER - The liver is normal in echotexture. No focal lesion is identified. There is no intra- or extra-hepatic biliary dilatation. The common bile duct measures 3 mm. The gallbladder is not distended. A small amount of sludge is noted within the gallbladder. There is no pericholecystic fluid or wall edema. The spleen measures 12.2 cm in length and is unremarkable. The main portal vein is patent with appropriate direction of flow. . [**2104-9-16**] CT HEAD w/o contrast - 1. New high density, presumably blood in part of the wall of the lesion. This change is most likely treatment related. 2. Decrease in edema, midline shift, and distortion of the third and lateral ventricles. . . CULTURES [**2104-9-2**] - Skin Scraping - Positive VZV [**2104-9-5**] - HIV antibody positive - CD4 154 [**2104-9-7**] - CMV IgG ANTIBODY (Final [**2104-9-9**]): POSITIVE FOR CMV IgG ANTIBODY BY EIA. 292 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. . CMV IgM ANTIBODY (Final [**2104-9-9**]): NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. [**2104-9-7**] - HBV Viral Load (Final [**2104-9-11**]): Greater than 38,000,000 IU/ml. HCV VIRAL LOAD (Final [**2104-9-9**]): HCV-RNA NOT DETECTED. [**2104-9-11**] - Urine - Positive for EColi - AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R [**2104-9-11**] - Blood cultures x 2 : no growth. [**2104-9-15**] - Stool cultures, no C.diff, no salmonella, shigella, or campylobacter, no O&P, no giardia, no cryptosporidium. LABS: [**2104-8-25**] 02:30PM BLOOD WBC-4.5 RBC-4.85 Hgb-11.2* Hct-34.5* MCV-71* MCH-23.1* MCHC-32.5 RDW-14.4 Plt Ct-207 [**2104-8-29**] 06:45AM BLOOD WBC-6.4 RBC-5.36 Hgb-12.3* Hct-37.8* MCV-70* MCH-22.9* MCHC-32.5 RDW-16.1* Plt Ct-185 [**2104-9-5**] 12:50PM BLOOD WBC-4.8 RBC-4.68 Hgb-11.1* Hct-33.5* MCV-72* MCH-23.8* MCHC-33.2 RDW-15.6* Plt Ct-135* [**2104-9-8**] 12:50PM BLOOD WBC-3.5* RBC-4.90 Hgb-11.4* Hct-34.7* MCV-71* MCH-23.2* MCHC-32.8 RDW-15.9* Plt Ct-164 [**2104-9-13**] 06:40AM BLOOD WBC-2.9* RBC-4.20* Hgb-10.1* Hct-29.9* MCV-71* MCH-24.1* MCHC-33.8 RDW-16.1* Plt Ct-244 [**2104-8-25**] 02:30PM BLOOD Neuts-69.2 Lymphs-27.8 Monos-2.3 Eos-0.5 Baso-0.2 [**2104-8-25**] 02:30PM BLOOD PT-13.9* PTT-33.8 INR(PT)-1.2* [**2104-9-5**] 10:40AM BLOOD WBC-5.8 Lymph-34 Abs [**Last Name (un) **]-[**2067**] CD3%-86 Abs CD3-1689 CD4%-8 Abs CD4-154* CD8%-77 Abs CD8-1523* CD4/CD8-0.1* [**2104-8-25**] 02:30PM BLOOD UreaN-11 Creat-0.7 Na-129* K-3.6 Cl-96 HCO3-25 AnGap-12 [**2104-9-1**] 06:15AM BLOOD Glucose-116* UreaN-11 Creat-0.6 Na-129* K-4.1 Cl-95* HCO3-25 AnGap-13 [**2104-9-5**] 12:50PM BLOOD UreaN-6 Creat-0.7 [**2104-9-7**] 09:25AM BLOOD Glucose-98 UreaN-6 Creat-0.6 Na-132* K-3.5 Cl-102 HCO3-23 AnGap-11 [**2104-9-10**] 07:35AM BLOOD Glucose-103 UreaN-3* Creat-0.6 Na-138 K-3.3 Cl-105 HCO3-27 AnGap-9 [**2104-9-13**] 06:40AM BLOOD Glucose-84 UreaN-4* Creat-0.7 Na-138 K-3.6 Cl-104 HCO3-26 AnGap-12 [**2104-9-5**] 05:48AM BLOOD ALT-48* AST-24 LD(LDH)-239 AlkPhos-95 Amylase-93 TotBili-0.2 [**2104-9-8**] 12:50PM BLOOD ALT-90* AST-60* AlkPhos-179* TotBili-0.3 [**2104-9-9**] 12:55PM BLOOD ALT-137* AST-90* AlkPhos-228* TotBili-0.3 [**2104-9-10**] 07:35AM BLOOD ALT-99* AST-46* AlkPhos-200* TotBili-0.3 [**2104-9-11**] 07:50AM BLOOD ALT-69* AST-21 LD(LDH)-169 AlkPhos-196* TotBili-0.5 [**2104-9-13**] 06:40AM BLOOD ALT-42* AST-19 AlkPhos-181* TotBili-0.3 [**2104-8-26**] 04:00AM BLOOD Calcium-8.3* Phos-4.1 Mg-2.1 [**2104-9-10**] 07:35AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.0 [**2104-9-6**] 09:00AM BLOOD calTIBC-160* Ferritn->[**2095**] TRF-123* [**2104-9-8**] 12:50PM BLOOD HCV Ab-NEGATIVE [**2104-9-11**] 10:13AM URINE Blood-MOD Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2104-9-11**] 10:13AM URINE RBC-[**5-13**]* WBC-[**10-23**]* Bacteri-MOD Yeast-NONE Epi-0 Brief Hospital Course: Patient was admitted with new onset seizures with workup revealing a left thalamic lesions. CT torso on [**2104-8-26**] revealed no malignancy and MRI with contrast finding's consistent with Glioblastoma Multiforme. The patient went to the operating [**Last Name (un) **] on [**2104-8-28**] for a left steriotactic biopsy with initial pathology revealing a high grade glioma. Patient was noted to have vomited twice after large meals on [**2104-8-29**]. Patient continued to demonstrate a right pronator drift on exam. He was found to have vesicular rash on R side of face and culture confirmed Herpes Zoster. The final pathology from his brain biopsy was positive for toxoplasmosis and ID was consulted. He started on a appropriate therapy. Opthomology was also consulted regarding shigles on face due risk of corneal erosion - they found no evidence of VZV or toxoplasmosis involvement. Per pt family he has a past history of multiple sex partners who had known HIV. On [**9-5**] he had intermittent episodes of tachycardia and slight hypotension resolved with fluids. He then had BRBPR and GI was consulted, this was determined by colonoscopy to be due to internal hemorrhoids with no signs of colitis. He was then transferred to the Medicine service for management of multiple medical problems. On the medical floor, pt neurologic condition continued to improve. He was able to follow commands, answer basic questions. He was advanced to regular diet. His floor course was complicated by 2-3 days of diarrhea (C. diff negative, culture negative) which spontaneously resolved and a catheter associated UTI, which was treated with 5 days of Cipro. His symptoms on the floor included pain around his VZV rash and chronic bilateral vision blurriness, which he stated he had had for months before and did not prevent him from seeing / [**Location (un) 1131**]. . TOXOPLASMOSIS - L thalamic lesion frozen section initially consistent with glioblastoma multiforme, however, final path demonstrated toxoplasmosis. Pt started on Pyrimethamine, Sulfadiazene and Folinic Acid treatment. Pt showed no signs of mass effect or herniation. His neuro exam improved over time; he was more alert, oriented, answering questions appropriately and trying to communicate with staff. His RUE weakness, R pronator drift and RLE dorsiflexion weakness remained. He stated his vision remained slightly blurry bilaterally, but was not associated with vision loss, pain or other changes during his hosptial stay. A follow up CT on treatment day 12 showed decrease edema and mass effect, with some blood thought to be secondary to treatment. He remained confused throughout his stay and was unable to describe why he was in the hospital. Discharge treatment includes: . - Pyrimethamine 75 mg po daily - Sulfadiazene 1-1.5grams po q 6 hours - Folinic acid 10-20 mg po daily . UTI: Pt developed catheter related E. Coli UTI towards the end of his hospital course, which was treated with Cipro x 5 days. No fever since starting treatment. Other investigations for infectious causes, including CXR and blood cultures, were negative. . GI BLEED: Prior episode of 40cc-50cc BRBPR with tachycardia. Hct remained stable. Per GI, Colonoscopy positive for hemorroids, no colitis or other pathology seen. They could not rule out UGIB including PUD. . ANEMIA: Appears to have iron overload (90% transferritin saturation) with very high ferritin. Per hemoglobin electrophoresis, pt has studies consistent with beta thalassemia trait - which is likely contributing to his anemia. Also contributing could be his active HIV / Hepatitis B, inflammatory process, and to a lesser extent, minor intermittent hemorrhoid bleeding. . TRIGEMINAL NERVE VZV INFECTION: Rash over R face confirmed zoster infection. Crusting, healing with Acyclovir. Initial concern for cellulitis due to some edema, erythema over R upper eyelid, however, this seem to resolve spontaneously over time. Ophthamology determined no ocular involvement as of [**2104-9-5**]. Per ID, we will continue Acyclovir to complete 14 days of treatment as well as erythromycin optic. We recommend Acetominophen and oxycodone to alleviated facial pain associated with zoster, given side effect profile of Gabapentin. . ORAL THRUSH: Oral thrush disappeared with daily nystatin. Pt complained of no dysphagia and was taking PO well at discharge. Nystatin d/c'ed at discharge. . HIV: HIV antibody positive with CD4 abs 154. Pt started on Atovaquone for PCP [**Name Initial (PRE) 1102**]. ID recommends waiting to start HIV therapy, pending additional lab tests. He should have his CD4 count rechecked as an outpatient as his wbc decreased during admission with treatment of his infection. He may require additional prophylaxis based on his repeat counts. . RASH: Pt developed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], erythematous rash covering chest, extremities; blanching, no mucosal involvement. Thought to be secondary to cephalosporin - which was being given for presumed cellulitis over zoster infection. Cefazolin stopped and rash dissapated over 3-4 days. In addition, given unknown etiology of rash, Phenytoin was changed to keppra. . HEPATITIS: Hep B surface antigen and core antibody positive, with negative surface antibody and high viral load, indicating active chronic hepatitis B. Hep C antibody negative. Pt had transient increses in liver enzymes, which were stable / trending down at discharge. It was thought that hepititis could be exacerbating anemia. Pt was screened for HCC and had low AFP and no masses seen on ultrasound. . SEIZURE: Questionable seizure activity on admission, no seizure activity throughout hospitalization. Switched to keppra from phenytoin , due to chance of phenytoin drug rash. Pt maintained on Keppra 1000mg [**Hospital1 **]. Will f/u with neurosurgery in 1 month for repeat CT and re-evaluation. This should be scheduled as an outpatient. He should continue Keppra until his follow up. . Medications on Admission: None. Discharge Medications: 1. Pyrimethamine 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 2. Sulfadiazine 500 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). Disp:*360 Tablet(s)* Refills:*2* 3. Leucovorin Calcium 5 mg Tablet Sig: Four (4) Tablet PO Q 24H (Every 24 Hours). Disp:*120 Tablet(s)* Refills:*2* 4. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) teaspoons (10ml) PO DAILY (Daily). Disp:*1 bottle* Refills:*2* 5. Erythromycin 5 mg/g Ointment Sig: 0.5 Ophthalmic [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*2* 6. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO 5X/D () for 2 days. Disp:*10 Tablet(s)* Refills:*0* 7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Tablet(s) 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice 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 face pain. Disp:*30 Tablet(s)* Refills:*0* 12. Outpatient Lab Work Please fax the following laboratory studies weekly to the [**Hospital **] clinic at [**Hospital1 18**] - fax [**Telephone/Fax (1) 432**] attn Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] 1 CBC (WBC, PLT, HCT, HGB) 2 LFTs (AST, ALT, ALK, TBILI) Discharge Disposition: Extended Care Facility: Shaugnessy - [**Hospital 656**] rehabilitation hospital network Discharge Diagnosis: Primary: AIDS CD4 154 Hepatitis B Toxoplasmosis brain lesion Trigeminal Varicella Zoster B thalassemia trait Secondary: Oral Thrush E-Coli UTI Anemia Internal Hemorrhoids Discharge Condition: vital signs stable, taking PO well, ambulating without assistance. Discharge Instructions: You were transferred to [**Hospital1 18**] from [**Hospital **] Hospital with a headache and possible new onset seizure after imaging showed a large mass in your brain. . A biopsy of the mass was done, and, originally, it was thought that this mass was a type of brain cancer, glioblastoma multiforme. . However, on further evaluation, it was discovered that the mass was from an infection, known as toxoplasmosis. Around the same time, you also developed a rash on your face, known as trigeminal varicella zoster, and white plaques in your mouth, known as thrush. We did many tests and discovered the following: - you have HIV / AIDS with a CD4 count of 154 - you have active Hepatitis B - you do not have Hepatitis C - you have anemia We gave many medications to treat your toxoplasmosis brain lesion, your trigeminal zoster and your oral thrush. In addition, we gave medicines to prevent other opportunistic infections associated with HIV (Atovaquone for PCP), and medications to prevent possible seizures (Keppra). We did not yet start medications to treat HIV. You are being discharged to a rehabilitation facility to continue your recovery. It is extremely important that you follow up with all doctors [**Name5 (PTitle) 2176**] to manage your illness. It is also very important that you take all medications prescribed to you; this is the only way to prevent further infections. New Medications: Pyimethamine Sulfadiazine Leucovorin Atovaquone Erythromycin Eye Ointment Acyclovir Levetiracetam Acetaminophen as needed for pain Omeprazole Please take all medications Please keep all follow up appointments. You have an appointment at the Infectious Disease Clinic on [**2104-10-13**] at: Division of Infectious Disease Department of Medicine [**Hospital1 69**] [**Hospital **] Medical Office Building, Suite GB [**Last Name (NamePattern1) 439**] [**Location (un) 86**] , [**Telephone/Fax (1) 79895**] Please call beforehand to confirm your appointment Please call neurosurgery at [**Telephone/Fax (1) 79896**] to schedule an appointment and follow up CT in 1 month (mid [**Month (only) **]) Please have your rehab facility fax the following laboratory studies weekly to the [**Hospital **] clinic at [**Hospital1 18**] - fax [**Telephone/Fax (1) 432**] attn Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] 1 CBC 2 LFT's Please return to the hospital or seek further medical care if you have fever, chills, increasing headache, trouble with vision or swallowing, cough, trouble breathing, chest or abdominal pain, dizziness, weakness, or anything else that concerns you. Followup Instructions: Please follow up with your infectious disease physician at the time and location below: You have an appointment at the Infectious Disease Clinic on [**2104-10-13**] at - Division of Infectious Disease Department of Medicine [**Hospital1 69**] [**Hospital **] Medical Office Building, Suite GB [**Last Name (NamePattern1) 439**] [**Location (un) 86**] , [**Telephone/Fax (1) 79895**] Please call beforehand to confirm your appointment. Please have your rehab facility fax the following laboratory studies weekly to the [**Hospital **] clinic at [**Hospital1 18**] - fax [**Telephone/Fax (1) 432**] attn Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] 1 CBC 2 LFT's Please call neurosurgery at [**Telephone/Fax (1) 79896**] to schedule an appointment and follow up CT in 1 month (mid [**Month (only) **])

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icd9cm

[ [ [] ] ]

[ "45.23", "01.13" ]

icd9pcs

[ [ [] ] ]

17707, 17797

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34053

Discharge summary

report

Admission Date: [**2177-4-28**] Discharge Date: [**2177-5-3**] Date of Birth: [**2096-12-18**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Subdural hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: 80 y/o female transferred with a right sided subdural hematoma. Apparently Ms [**Name13 (STitle) 78596**] lives with her daughter and has baseline dementia she was put to bed around 1100pm and found at elevator around 5:00 am face down in her apartment building. Past Medical History: CHF, Diabetes (Insulin dependent), GERD, Hyperlipidemia, Hypertension ? Dementia Social History: Lives with daughter, non [**Name2 (NI) 1818**] no alcohol Family History: Unavailable Physical Exam: T: BP:140/55 HR:63 R 17 O2Sats 100% Gen: In process of being intubated snoring respirations had received Ativan, Benadryl and Haldol at outside facility or during transfer. HEENT: Pupils: 2.0-1.5 EOMs unable to assess Neck: Not in collar Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Snoring ? seizing ER is in preparation of intubating patient Pupils 2.0-1.5 Localized briskly with upper extremeties moving spontaneously Withdrew legs briskly Pertinent Results: CT: [**4-28**]: IMPRESSION: 1. Acute right cerebral subdural hematoma. Unchanged leftward 3 mm subfalcine herniation. Small left frontal acute subdural hematoma. 2. Large subgaleal hematoma overlying the right frontal bone. [**5-1**]: IMPRESSION: 1. No significant change in the moderate-sized right and small left subdural hematoma, with stable minimal subfalcine herniation. 2. No evidence of major vascular territorial infarction. Brief Hospital Course: Patient was admitted on [**4-28**] from OSH after having been found face down on the floor at her apartment building. She had a CT scan showing a right sided subdural hematoma approx 1.5cm at largest width the majority is 1.0cm with approx 5mm of shift though sulci with only mild effacement. She was then admitted to the ICU for q1h neurochecks and ongoing evaluation of her subdural bleed. She was successfully weaned to extubation on [**4-30**] and subsequently transferred to the neurosurgery step down unit. On [**5-1**], she had worsened mental status and was emergently sent for a CT scan to evaluate for new hemorrhage vs stroke. CT was stable for bleeding, and negative for new infarct. She had worsening renal failure with Cr 3.5 (2.0 on arrival). Yesterday she demonstrated mixed metabolic/respiratory acidosis with pH 7.24 and was subsequently intubated and now on ventilator. She continues to have an anion gap metabolic acidosis. We continue to suspect that most of her exam is secondary to metabolic encephalopathy given that it is non focal. Neurology was consulted for evaluation of a possible seizure condition that may be causing the episodes in the absence of new bleeding or infarct. EEG was ordered and showed no clinical or electrographic seizures. Low amplitude mixed frequency generalized slowing along with bursts of superimposed slowing and brief periods of suppression were observed. This is most consistent with a severe encephalopathy and deep midline dysfunction. On [**5-2**] a family meeting was held and the gravity of the situation was adddressed with the family that a meaningful recovery would not be likely. The family decided to make her CMO and she passed away on [**5-3**]. Medications on Admission: Glucosamine 500mg PO QD, Aspirin 81mg PO, Lasix 40mg QD, ToprolXL 100mg, Synthroid 50mcg QD, Naproxen 500mg, Zocor 20mg, Prilosec 20mg PO Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Subdural Hematoma Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[**2177-7-9**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2134-7-15**] Discharge Date: [**2134-7-20**] Date of Birth: [**2074-1-11**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Ciprofloxacin / Levofloxacin / Percocet / Simvastatin Attending:[**First Name3 (LF) 2279**] Chief Complaint: Dizziness Major Surgical or Invasive Procedure: Upper Endoscopy with injection and clipping History of Present Illness: This patient is a 60 yo F with a past medical history of DMII, CAD s/p CABGx4, Carotid stenosis s/p L CEA, PVD, SFA angioplasty in [**Month (only) 116**], hypertension who presented with 2 days of fatigue and weakness with difficult to control hyperglycemia. She presented to her PCP out of concern for her blood glucose levels and was found to be orthostatics. She denies syncope over the past few days but does endorse pre-syncopal sx of "blackness." She denies diarrhea/nausea/vomiting as well as chest pain or palpitations. . In the ED, she was anemic to 22 from 35, NG lavage with coffee grounds and admitted to ICU for upper GI bleed. In the ICU, patient transfused 3 units blood on [**7-15**]. Plavix, aspirin and anti-hypertensives held, patient started on pantoprazole gtt. EGD showed clot/visible vessel in antrum, injected and clipped x 2, also esophagitis. Of note, the patient has a history of PUD which improved with ranitidine but has never had previous GI bleed. She denies alcohol use but has been taking Tramadol for 1 week for tooth pain. . Patient's HCT remained stable in ICU(27 to 28 to 26.7). She was transitioned to [**Hospital1 **] PPI and transferred Past Medical History: Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension . Cardiac History: CABG, in [**2133**] anatomy as follows: CABG x4 (LIMA to LAD, SVG to OM, SVG to DIAG, SVG to PDA)/MV repair (26 mm [**Company 1543**] ring) . Other Past History: -Coronary artery disease status post CABG in [**2133**] c/b sternal osteomyelitis -Diabetes complicated by retinopathy and neuropathy. Followed by [**Last Name (un) **]. She is on [**First Name8 (NamePattern2) **] [**Last Name (un) **] for known proteinuria. A1C down from 9.5 to 7.2% -Dyslipidemia--LDL 97 and HDL 40 -Hypertension -Diastolic and systolic heart failure (LVEF on [**2133-5-7**] of 40%) -Peripheral [**Date Range 1106**] disease -Carotid stenosis s/p left CEA -Obesity -Chronic kidney disease with baseline Cr 1.2-1.4 -h/o tobacco abuse -Anxiety Social History: 40pkyr tobacco history quit several weeks ago. Denies any illicit drug use. Rare EtOH use. Lives with boyfriend. Family History: Majority of family members have various forms of heart disease including heart attacks, HTN, and arrythmias requiring pacemakers. There is no family history of premature coronary artery disease or sudden death. Physical Exam: Exam upon transfer to the floor: Vitals: T: 97.7 (tmax 97.7) HR 94 BP: 147/78 RR: 18 99% on RA (note that vitals were taken before Metoprolol and Amplodipine were re-started.) General: Alert, oriented, no acute distress Neck: supple, unable to assess JVD given to large neck Lungs: Clear to auscultation bilaterally, no crackles CV: Regular rate and rhythm, normal S1 + S2 Abdomen: obese, soft, non-tender, non-distended, hypoactive bowel sounds present, no rebound tenderness or guarding Ext: warm, well perfused, 2+ pulses, no lower extremity edema Pertinent Results: [**2134-7-15**] 04:45PM BLOOD WBC-11.9* RBC-2.49*# Hgb-7.7*# Hct-22.2*# MCV-89 MCH-30.7 MCHC-34.5 RDW-15.1 Plt Ct-250 [**2134-7-16**] 04:56AM BLOOD WBC-10.7 RBC-3.22* Hgb-9.4* Hct-27.1* MCV-84 MCH-29.3 MCHC-34.8 RDW-15.8* Plt Ct-225 [**2134-7-17**] 07:30AM BLOOD WBC-12.4* RBC-3.41* Hgb-10.0* Hct-30.5* MCV-90 MCH-29.2 MCHC-32.6 RDW-17.0* Plt Ct-227 [**2134-7-16**] 04:56AM BLOOD Neuts-77.3* Lymphs-16.1* Monos-4.3 Eos-2.0 Baso-0.4 [**2134-7-15**] 04:45PM BLOOD PT-12.2 PTT-25.6 INR(PT)-1.0 [**2134-7-15**] 04:45PM BLOOD Glucose-219* UreaN-126* Creat-2.3* Na-131* K-5.2* Cl-92* HCO3-26 AnGap-18 [**2134-7-16**] 04:56AM BLOOD Glucose-239* UreaN-106* Creat-1.6* Na-138 K-4.3 Cl-104 HCO3-23 AnGap-15 [**2134-7-17**] 07:30AM BLOOD Glucose-266* UreaN-61* Creat-1.3* Na-147* K-4.8 Cl-114* HCO3-23 AnGap-15 [**2134-7-15**] 04:45PM BLOOD cTropnT-0.01 [**2134-7-15**] 09:36PM BLOOD CK-MB-2 cTropnT-<0.01 [**2134-7-20**] 06:20AM BLOOD WBC-9.1 RBC-3.38* Hgb-10.3* Hct-30.0* MCV-89 MCH-30.4 MCHC-34.3 RDW-17.3* Plt Ct-244 [**2134-7-20**] 06:20AM BLOOD Glucose-166* UreaN-23* Creat-1.3* Na-140 K-4.1 Cl-106 HCO3-28 AnGap-10 [**2134-7-18**] 09:18PM BLOOD CK-MB-3 cTropnT-<0.01 [**2134-7-18**] 07:11AM BLOOD CK-MB-3 cTropnT-<0.01 [**2134-7-15**] 09:36PM BLOOD CK-MB-2 cTropnT-<0.01 [**2134-7-15**] 04:45PM BLOOD cTropnT-0.01 [**2134-7-15**] 04:45PM BLOOD CK-MB-2 [**2134-7-20**] 06:20AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.1 EGD [**2134-7-16**]: Impression: Medium hiatal hernia Erythema in the esophagus compatible with esophagitis Blood in the whole stomach A red localized clot with likely vessel was seen in the antrum. The mucosa was heaped up around this adherent clot but no discrete ulceration was seen. The lesion was not actively bleeding at the time of endoscopy. in the stomach (injection, endoclip) Normal mucosa in the duodenum Otherwise normal EGD to second part of the duodenum Brief Hospital Course: Ms. [**Known lastname 23081**] is a 60 yo F with a past history of CAD s/p CABG, PVD s/p recent SFA stent, Carotid steonsis s/p CEA, DM, CKD, CHF presented with weakness, dizziness and was found to be anemic with HCT 22 from baseline 35. She was found to have a clotted vessel in antrum on EGD which was subsequently injected and clipped. This bleeding vessel likely due to PUD in the setting of antiplatelet medications (Plavix and ASA.) . # Anemia: Secondary to acute blood loss. Upper GI source was identified on EGD (ulcer vs. dulefoy's lesion, wasn't clear) and clipped. Patient was given 3 units PRBCs and IV PPI. Hematocrits increased throughout hospitalization. Discharge hematocrit was 30. Plavix and aspirin, and hypertensives were initially held given blood loss and relative hypotension. At time of Metoprolol, Lasix, and Spironolactone as well as Aspirin were restarted at home doses. Upon discharge, the patient was hemodynamically stable with SBP in 120s and HR ranging 80s-90s. The MICU team discussed holding Plavix with her cardiologist who agreed to this, but Ms. [**Known lastname 23081**] has been instructed to followup on whether to continue to hold Plavix as well when to restart her other antihypertensive medications (losartan and amlodipine) with her PCP and Cardiology. Patient started on [**Hospital1 **] PPI and will need an outpatient colonoscopy with repeat egd in [**4-27**] weeks with biopsies for H. Pylori. . # Acute on chronic renal failure: initial Cr 2.3 that improved to 1.3. This was likely pre-renal in the setting of poor forward flow and hypovolemia from GI bleed. . # Asymptomatic but culture + UTI: Patient has a history of pan-sensitive Klebsiella UTIs with sulfa/cipro/levo allergy. We did not want to give nitrofurantoin with renal failure and so began treatment with Ceftriazone (1 day) which was switched to Cefpodoxime for a 6 day course (day 1 [**2134-7-17**]). . # Diabetes Type 2: Before admission, the patient reported difficult to control blood glucose levels at home over the past 2 days. She was initially placed on reduced insulin regime with SS and then increased to home insulin once eating/drinking. BS continued to be high- given HgA1C 12.4 [**2134-6-4**], we increased Lantus to 23 U for discharge. We recommend that this patient be followed by a NP[**MD Number(3) 18184**] PCP's office for close diabetic F/U. . # HTN: Patient is normally treated for hypertension with Metoprolol, Amlodipine, Lasix, Spironolactone and Losartan. These meds were initially held on admission and Metoprolol, Lasix, Spironolactone were restarted. She needs to followup with her cardiologist and PCP [**Last Name (NamePattern4) **]: when to restart Losartan and Amlodipine. The patient has CHF, with EF40% remained euvolemic/hypovolemic throughout admission. . # Chest Pain: She did complain of mild chest pressure once during admission, but ruled out for MI with two sets of negative cardiac enzymes, serial EKGs were unchanged, pain resolved spontaneously. Medications on Admission: Amlodipine 10 mg daily Amitriptyline 10 mg hs Citralopram 40 mg daily Plavix 75 mg daily Furosemide 80 mg po BID Gabapentin 300 mg daily Aspart SS Lantus 18 U qhs Losartan 100 mg daily Metoprolol Tartrate 100 mg [**Hospital1 **] Pravastatin 40 mg daily Spironolactone 12.5 mg daily Trazodone 150 mg qhs Aspirin 325 mg daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed for insomnia. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lantus 100 unit/mL Cartridge Sig: 23 U Subcutaneous at bedtime. Disp:*1 month supply* Refills:*2* 12. Insulin Aspart 100 unit/mL Cartridge Sig: Sliding Scale Subcutaneous please take as directed per sliding scale: Please take as directed per sliding scale. 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed causing anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital because you felt dizzy and we found that you had very low blood levels (low hematocrit.) By placing a tube into your stomach, we were able to determine that you were bleeding from your stomach. We gave you 4 units of blood and stopped many of your home medications. You had an endoscopy procedure which showed a vessel that was most likely the cause of bleeding. The GI doctors were [**Name5 (PTitle) 460**] to clip this vessel to stop it from bleeding. . After this procedure, we watched your blood levels (hematocrit) and saw that they improved over time. We also watched your kidney function. When you arrived, your creatinine was higher than normal, which indicated kidney problems, most likely due to your low blood levels. Your kidney also improved after you received blood. . Your bleeding vessel could have been due to an ulcer which then exposed a blood vessel; ulcers can be made worse by NSAIDs (ibuprofen, motrin, alleve) and alcohol so you should avoid these things as well as follow up with your primary care doctor. It could also just be a blood vessel very close to the stomach's surface. Blood vessels are more likely to bleed in patients who take anti-platelet medications. You take Aspirin and Plavix. We discussed with your cardiologist and recommend that you stop taking the Plavix when you go home. You can continue taking the aspirin. Your cardiologist can followup with this plan. . Because low blood volume causes low blood pressure, we stopped your antihypertensive medications while you were in the hospital. When you go home, you take your metoprolol, lasix and Spironolactone. When you see your primary care doctor, they can decide whether or not to start Losartan and amlodipine again. . You reported that you had difficult controlling your blood sugar before coming to the hospital. This was probably because you were sick and had lost blood. However, while you were in the hospital, your blood sugar remained high, and we noticed that your last HgA1C in [**Month (only) 116**] was 12.4. For this reason, we increased your Lantus to 23 units qhs. We will recommend that you follow up your diabetes monthly with a nurse practitioner at your PCP's office to make sure that your glucose levels are under control. . Finally, we treated you for a urinary tract infection while you were in the hospital. You did not have any symptoms but you did have bacteria in your urine. At home you will continue the antibiotics: Cefpodoxime for two more days. . In summary: We changed the following medications 1. You should stop taking Plavix. 2. You should stop taking Losartan, Amlodipine. Please talk to your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 9533**] this medicine. . We added the following medications: 1. Cefpodoxime for 2 more days 2. Protonix (this is an acid suppressing medicine) twice daily. . Finally, you should continue caring for your heart failure, you should weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: 1. Immediate Primary Care Followup: We would like you to have an appointment with a primary care doctor this week. Please call [**Hospital6 733**] at [**Telephone/Fax (1) 250**] on Friday morning and ask for an appointment that day. Please tell them that you were just in the hospital and must come in this week. You can see any [**Name6 (MD) **] [**First Name (Titles) **] [**MD Number(3) 97729**]. 2. Please call Gastroenterology at [**Telephone/Fax (1) 463**]. You should make an apppointment in 6 weeks to followup with a GI doctor. You also need to schedule a colonoscopy and another endoscopy with them that will be done with biopsies. 3. You have an appointment on Thursday [**8-26**] at 1PM with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for a repeat endoscopy. Please call [**Telephone/Fax (1) 463**] for directions on where to go. . 4. Department: [**Hospital3 249**] When: TUESDAY [**2134-8-10**] at 1:45 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16202**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . 5. Department: CARDIAC SERVICES When: MONDAY [**2134-8-30**] at 1:20 PM With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage **We are working on getting you seen at an earlier date with Dr. [**Last Name (STitle) **]. Their office will contact you with an update. If you do not hear from them, please call their office.** [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]

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icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

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76,683

137,196

36179

Discharge summary

report

Admission Date: [**2103-3-29**] Discharge Date: [**2103-4-10**] Date of Birth: [**2034-10-4**] Sex: F Service: SURGERY Allergies: Penicillins / Keflex / Tagamet Hb / Morphine / Pontocaine / Xylocaine / Gentamicin / Gantrisin / Macrodantin / Erythromycin Base / Hydrocodone / Toprol Xl / Tetracycline / Metoprolol Tartrate Attending:[**First Name3 (LF) 5547**] Chief Complaint: Gastric Stump Cancer Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Subtotal gastrectomy with retrocolic Roux-en-Y gastrojejunostomy. 3. Feeding jejunostomy tube placement. History of Present Illness: 68 yoF well known to our service who arrives pre-op for admission and pre-op medication for planned completion gastrectomy and jejunostomy. Recently she has experienced intermittent abdominal pain and left sided rib pain, that does not interfere with her normal daily activitis, but does cause her mild SOB during exaccerbations. Past Medical History: 1. Steroid-dependent chronic obstructive pulmonary disease. She is currently only able to walk several steps before developing shortness of breath. She walks with the aid of a cane. She presented to the office visit today in a wheelchair. 2. Common variable immunodeficiency. She is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Location (un) 511**] allergy, asthma, and immunology and will require intravenous gamma globulin prior to surgery. 3. Polymyalgia rheumatica. 4. Hypothyroidism. 5. Aortic regurgitation. 6. Mitral valve prolapse. 7. Type 2 diabetes mellitus. 8. Hyperlipidemia. 9. Monoclonal gammopathy. 10. Recurrent urinary tract infections. 11. Peptic ulcer disease status post partial gastrectomy with Billroth II anastomosis in the [**2063**] status post an additional gastric and intestinal resection the following year. Past Surgical History: 1. Status post open appendectomy, [**2053**]. 2. Status post TAH/BSO, [**2069**]. 3. Status post left hemithyroidectomy, [**2091**]. 4. Status post right hemicolectomy, [**2095**]. 5. Status post open cholecystectomy in the [**2063**], perhaps at the time of one of her gastric procedures. 6. Status post left femoral hernia repair. Allergies: including metoprolol, Macrodantin, nitrofurantoin, sulfa, amlodipine, fluticasone, tetracycline, hydrocodone, penicillin, codeine, cimetidine, morphine, Keflex, cefaclor, Novocain, Pontocaine, and Xylocaine. Social History: Social History: The patient is widowed and lives alone in [**Location (un) 8072**], [**Location (un) 3844**], though one of her daughters is currently staying with her. She has six living children. She has not made them aware of her cancer diagnosis and does not want me to reveal this diagnosis until she is ready. She currently is smoking half a pack of cigarettes daily and has done so for more than 20 years. She does not regularly drink alcohol. Family History: Family history is remarkable for a mother with lung cancer. She has a daughter with fibromyalgia and another daughter with osteoarthritis and yet another daughter with lupus. There is no family history of gastric cancer. Physical Exam: At discharge: V.S 98.2, 92, 124/58 Gen: a and o x3, NAD CV: RRR, no MRG RESP:decreased breath sounds thoughout ABD:+BS, ND, NT, soft, scars c/w prior surgery. J-Tube intact with d/s/d. Incision ota with steri strips Ext: no CCE Pertinent Results: [**2103-4-6**] 06:05AM BLOOD WBC-10.6 RBC-4.86 Hgb-11.7* Hct-36.1 MCV-74* MCH-24.0* MCHC-32.3 RDW-16.1* Plt Ct-390 [**2103-4-6**] 06:05AM BLOOD Plt Ct-390 [**2103-4-6**] 06:05AM BLOOD Glucose-109* UreaN-21* Creat-0.5 Na-140 K-4.6 Cl-103 HCO3-28 AnGap-14 [**2103-4-6**] 06:05AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.3 [**2103-4-6**] 06:05AM BLOOD TSH-7.9* [**2103-4-6**] 06:05AM BLOOD T4-4.5* [**2103-4-4**] 08:48PM BLOOD Type-ART Temp-35.6 pO2-62* pCO2-33* pH-7.56* calTCO2-30 Base XS-7 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2103-3-30**] 12:12PM BLOOD Glucose-158* Lactate-0.7 Na-136 K-4.0 Cl-98* [**2103-3-30**] 12:12PM BLOOD Hgb-10.8* calcHCT-32 O2 Sat-95 [**2103-3-31**] 02:37AM BLOOD freeCa-1.09* [**2103-4-5**] 09:14AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 [**2103-4-5**] 09:14AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2103-4-5**] 09:14AM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0 [**2103-4-5**] 09:14AM URINE AmorphX-RARE [**2103-4-5**] 09:14AM URINE Mucous-RARE . MRSA SCREEN (Final [**2103-4-1**]): No MRSA isolated. . MR HEAD W & W/O CONTRAST [**2103-4-6**] No significant abnormalities on MRI of the brain with and without gadolinium. No acute infarcts, abnormal enhancement, or significant subcortical white matter ischemic disease is noted . URINE CULTURE (Final [**2103-3-31**]): NO GROWTH. . SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING [**2103-4-6**] No radiopaque foreign body . CHEST (PORTABLE AP) [**2103-4-2**] Interval withdrawal of endotracheal tube. NG tube is present with tip projecting over the gastric fundus. Surgical clips overlying the mid upper abdomen are again noted. The cardiomediastinal silhouette is unchanged. There is no pneumothorax or large pleural effusion. The pulmonary vasculature is unchanged. Interval improvement in right cardiophrenic opacity. . Pathology Examination subtotal gastrectomy DIAGNOSIS: Stomach, subtotal gastrectomy: 1. Gastric segment with invasive adenocarcinoma, diffuse type, with focal signet ring cell morphology, arising in a background of chemical gastropathy with glandular dysplasia; see synoptic report. 2. Duodenum with no carcinoma seen. Brief Hospital Course: The patient was admitted for completion gastrectomy and jejunostomy. Given her significant comorbidities and exceedingly high perioperative risk for morbidity and mortality, Dr. [**Last Name (STitle) 1924**] advised perhaps neoadjuvant treatment with chemotherapy followed by surgery if she remained without evidence of metastatic disease and tolerated the therapy. However, Ms. [**Known lastname **] refused to consider this approach in favor of up-front surgery. She understood the significant risks of the surgery and consented to proceed. She was pre-op'd and consented. She was given one unit of IVIG one hour prior to surgery. . The patient was admitted to Trama/surgical ICU for close assessment. On [**3-30**] she her acidosis improved and she was extubated. She was than transferred to [**Hospital Ward Name **] 5. . She was started on supervised sips advanced to regular diet and tube feeds via J-tube were started and advanced to goal rate. She tolerated both well. When she reached goal rate her TF was cycled over 14 hours. The patient's foley was removed and she voided with out any issues. . The patient appeared to be confused, not able to remember name of her daughter. Neurology was consulted and an MRI was done. MRI was with in normal limits. All of the patient's home medications were restarted. The patient's mental status returned to baseline. UA was negative. . Chest physical therapy was done q 4hrs., physical therapy and occupational therapy were consulted and recommended that the patient go to rehab. . The patient's staples were removed and steri strips were applied. The patient will follow up with Dr. [**Last Name (STitle) 1924**] in [**12-22**] weeks and her PCP in one week or as needed. Medications on Admission: acyclovir 200', albuterol, alprazolam 0.5''', B12 monthly, Vit D, ESTRADIOL 0.05mg/24 hour twice weekly, advair, folic acid, lasix 40', janiva 50', xopenx''', synthroid 112', montelukast 10', nystatin, prednisone 10'', lyrica 150'', compazine 10' prn, ROSIGLITAZONE [AVANDIA] 4'', SPIRIVA daily, TIZANIDINE, ALUM-MAG HYDROXIDE-SIMETH [MYLANTA], B COMPLEX VITAMINS [VITAMIN B COMPLEX], COENZYME Q10, CYANOCOBALAMIN [VITAMIN B-12], DIPHENHYDRAMINE HCL [BENADRYL] 25'', ENSURE, LACTASE [LACTRASE] 250 with food Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Date Range **]: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/Wheeze. 2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device [**Date Range **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]: One (1) Capsule, w/Inhalation Device Inhalation Daily (). 4. Prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 5. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 7. Estradiol Transdermal Patch 0.05 mg/24 hr Patch Weekly [**Last Name (STitle) **]: One (1) Transdermal tuesday, saturday (): 1patch on tuesday and 1 patch on saturday . 8. Rosiglitazone 2 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day). 9. Prochlorperazine Maleate 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Montelukast 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 11. Hydrocortisone Valerate 0.2 % Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 12. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 13. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Hospital1 **]: One (1) Inhalation TID (3 times a day). 14. Alprazolam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 15. Levothyroxine 112 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 16. Pregabalin 75 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 17. Acyclovir 200 mg/5 mL Suspension [**Hospital1 **]: One (1) PO DAILY (Daily). 18. Meperidine 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 19. insulin Insulin SC Fixed Dose Orders Q12H NPH 10 Units . Insulin SC Sliding Scale Q6H Humalog Glucose Insulin Dose 0-60 mg/dL [**12-22**] amp D50 61-120 mg/dL 0 Units 121-140 mg/dL 3 Units 141-160 mg/dL 6 Units 161-180 mg/dL 9 Units 181-200 mg/dL 12 Units 201-220 mg/dL 15 Units 221-240 mg/dL 18 Units 241-260 mg/dL 21 Units 261-280 mg/dL 24 Units 281-300 mg/dL 27 Units 301-320 mg/dL 30 Units > 320 mg/dL 33 Units Discharge Disposition: Extended Care Facility: [**Hospital3 2857**] - Maplewood - [**Location (un) 32944**] Discharge Diagnosis: Primary: gastric stump cancer Severe COPD Post-op mental status changes . Secondary: COPD, Common variable immunodeficiency, Polymyalgia rheumatica, Hypothyroidism, AR, MVP, DM2, hyperlipidemia, Monoclonal gammopathy, recurrent UTIs, PUD PSH: B2 in [**2063**]'s for PUD, open appendectomy ('[**53**]), TAH/BSO ('[**69**]), Left hemithyroidectomy ('[**91**]) [with completion R thyroidectomy], Right hemicolectomy ('[**95**]), open cholecystectomy ('70s), Left femoral hernia repair. Discharge Condition: Stable. Tolerating tube feed and regular diet. Pain well controlled with oral medications. 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. . Tube feeds: Nutren Pulmonary Full strength -Please cycle your tube feeds for 14 hrs over night. -Start time is 6pm and end time is 8am -Tube feed rate is 80cc/hr . Followup Instructions: 1. Please call Dr.[**Name (NI) 12822**] office, [**Telephone/Fax (1) 7508**], to make a follow up appointment in [**12-22**] weeks. 2. Please call your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) 275**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 79522**], to make a follow up appointment in one week or as needed. Completed by:[**2103-4-10**]

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icd9cm

[ [ [] ] ]

[ "45.91", "96.6", "43.7", "54.59", "46.39", "99.14" ]

icd9pcs

[ [ [] ] ]

10527, 10614

5722, 7447

472, 613

11142, 11235

3454, 5699

12929, 13285

2965, 3190

8006, 10504

10635, 11121

7473, 7983

11259, 12401

12416, 12906

1914, 2475

3205, 3205

3219, 3435

412, 434

641, 974

996, 1891

2508, 2949

74,409

135,008

13901

Discharge summary

report

Admission Date: [**2192-1-2**] Discharge Date: [**2192-1-5**] Date of Birth: [**2113-9-28**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 8404**] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: None. History of Present Illness: 78 yo man with history of recurring prostate Ca, Paget's dz, and newly diagnosed sarcoma of the left hip metastatic to lung discovered [**10/2191**] admitted to [**Hospital Unit Name 153**] for respiratory distress this am. The pt was diagnosed with L hip sarcoma after presenting with L hip pain and found on MRI to have L femoral mass atypical for prostate ca, and underwent CT guided Bx, showing soft tissue sarcoma in the bone. Staging CT at that time showed numerous pulmonary mets. Pt was admitted [**Date range (1) 29694**] for cycle 1 of palliative Doxorubicin, and PSA was recently seen to be increasing and so restarted on hormonal therapy. He went home and was feeling weak, but otherwise OK. Then for the past 1-1.5 wks has been having a dry cough, progressively limiting his ability to sleep. Initially worse with talking or sitting up, now it gets worse with reclining. No fevers, chills or sweats outside of the hot flashes he's been having from the hormonal Tx. Early in the am of [**1-2**] had significant SOB, called the on-call [**Hospital1 18**] Onc and was referred to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. CXR there reportedly showed white out of left lung and was requiring 100% NRB to oxygenate, and desatted to 92% on 4L NC when weaning was attempted. He was transferred to [**Hospital1 18**] where initial vitals were: 96.8 98 123/70 20 99%15L. His labs showed hypoNa to 127 with hypoCl, neutropenia (WBC count 1.4 down from 16.3 on [**2191-12-21**]), anemia to Hct 29.7 (has been trending down). He had CTA which ruled out PE but showed progressed innumerable bilateral pulmonary lesions, and increase in small L pleural effusion and new small R effusion. CT head was done in case pt needed anticoagulation which was negative. They were unable to wean him off the rebreather. He received Vancomycin and Cefepime. Vitals before admission: 98 125/60 24 100%NRB. He has a port and 20g R hand. Currently, ROS as above, also with decreased energy since chemo L leg pain (currently non-wt bearing, has been workign with PT), decreased PO intake, a couple aspiration events in the past several days, nausea with the chemo, and incontinence at baseline. His SOB has improved with the oxygen. ROS negative for for f/c/ns, h/a's, HEENT problems, CP/palps, vomit/diarrhea, dysuria, skin or joint problems. Past Medical History: - peripheral vascular disease with right leg claudication. - hypercholesterolemia. - hypertension. - Paget's disease, diagnosed in [**2185**]. - Vasectomy, [**2151**]. - Appendicectomy, [**2145**]. - Prostate adenocarcinoma, stage T2c, [**Doctor Last Name **] score 3+4=7, [**8-4**] cores, involving up to 50% of the cores, dx [**5-/2183**], s/p external beam radiation and androgen suppression therapy, completed [**1-/2184**], now with biochemical recurrence on leuprolide, followed by by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] [**Name (STitle) **]. - Metastatic sarcoma of left thigh bone to lung, dx 10/[**2191**]. Social History: He is of Irish descent and he lives locally in [**Hospital1 **] with one of his seven daughters. [**Name (NI) **] also has two sons. [**Name (NI) **] particular child is designated the HCP. [**Name (NI) **] is a retired civil engineer who worked on the [**Location (un) 41649**] and [**Location (un) 6692**] Airport. He is a former smoker having quit many years ago with 3ppd for 20 years history. He rarely drinks wine. No drugs. Family History: He has a brother with skin cancers. His mother died from lung cancer. His father had a CVA and dementia. Physical Exam: 97.8 104 126/62 23 99% on 15L NRB Thin elderly gentleman in no distress with NRB on, doesn't appear in respiratory distress, able to give history in full sentences EOMI, no scleral icterus Mouth dry appearing R chest port appears non infected, well placed Bibasilar to midway up lung fields with light pan-inspiratory dry sounding crackles and fair to good air movement RRR with early harsh whooshing systolic murmur at sternal borders, at LLSB S2 is obscured but audible in other fields, bilateral 2+ radial pulses Abd soft NT ND, BS+ No BLE edema, extremities are warm and well perfused, not mottled CN2-12 intact, moving all extremities with no focal deficits noted Pertinent Results: Labs at Admission: [**2192-1-2**] 06:30AM BLOOD WBC-1.4*# RBC-3.97* Hgb-10.4* Hct-29.7* MCV-75* MCH-26.2* MCHC-35.1* RDW-15.5 Plt Ct-376 [**2192-1-2**] 06:30AM BLOOD Neuts-16* Bands-0 Lymphs-36 Monos-37* Eos-2 Baso-5* Atyps-1* Metas-1* Myelos-2* [**2192-1-2**] 06:30AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-2+ Polychr-1+ [**2192-1-2**] 06:30AM BLOOD PT-13.9* PTT-32.7 INR(PT)-1.2* [**2192-1-2**] 06:30AM BLOOD Ret Aut-4.6* [**2192-1-2**] 06:30AM BLOOD Glucose-127* UreaN-11 Creat-0.6 Na-127* K-4.0 Cl-90* HCO3-29 AnGap-12 [**2192-1-2**] 06:30AM BLOOD ALT-10 AST-14 LD(LDH)-150 AlkPhos-30* TotBili-0.4 [**2192-1-2**] 06:30AM BLOOD Lipase-16 [**2192-1-2**] 06:30AM BLOOD cTropnT-<0.01 [**2192-1-2**] 06:30AM BLOOD Albumin-3.0* Calcium-8.8 Phos-4.3 Mg-1.8 Iron-18* [**2192-1-2**] 06:30AM BLOOD calTIBC-182* Ferritn-1509* TRF-140* [**2192-1-2**] 06:30AM BLOOD Osmolal-265* Urine Studies: [**2192-1-2**] 06:45AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018 [**2192-1-2**] 06:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2192-1-2**] 06:45AM URINE Hours-RANDOM UreaN-632 Creat-122 Na-54 K-55 Cl-66 [**2192-1-2**] 06:45AM URINE Osmolal-518 Brief Hospital Course: In summary a 78-year-old man with history of recurring prostate Ca, Paget's dz, and newly diagnosed sarcoma of the left hip metastatic to lung discovered [**10/2191**] admitted to [**Hospital Unit Name 153**] for respiratory distress. # Hypoxia: Presented with hypoxia. Corrected to mid 90's with NRB suggestive of V/Q mismatch. Thought to be due to rapid progression of innumerable pulmonary metastases from previous CT chest just 2 weeks ago. Given neutropenia, treated like febrile neutropenia as well with Vancomycin and Cefepime. His hypoxia slowly got worse. In conjunction with pt's Oncologist and family, pt was made CMO given poor response to chemo and very aggressive nature of his malignancy. He passed away peacefully in the evening of [**2192-1-4**]. Medications on Admission: - amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). - enalapril maleate 10 mg Tablet Sig: Two (2) Tablet PO daily - hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). - simvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). - aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). - cholecalciferol (vitamin D3) 400 unit Tablet Sig: Five (5) Tablet PO DAILY (Daily). Discharge Medications: N/a Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Deceased Discharge Instructions: N/a Followup Instructions: N/a [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**] Completed by:[**2192-1-4**]

[ "185", "276.50", "288.03", "171.3", "731.0", "197.0", "E933.1", "253.6", "511.9", "518.81", "780.61" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7247, 7256

5986, 6754

323, 330

7307, 7317

4712, 5963

7369, 7494

3896, 4003

7219, 7224

7277, 7286

6780, 7196

7341, 7346

4018, 4693

263, 285

358, 2723

2745, 3431

3447, 3880

52,547

137,101

35858

Discharge summary

report

Admission Date: [**2117-7-23**] Discharge Date: [**2117-9-18**] Date of Birth: [**2042-3-13**] Sex: F Service: SURGERY Allergies: Cefepime Attending:[**First Name3 (LF) 695**] Chief Complaint: indigestion, unintentional weight loss, epigastric pain, fatigue, overall failure to thrive Major Surgical or Invasive Procedure: [**2117-7-26**]: Upper GI [**2117-8-6**]: Gastrojejunostomy and feeding jejunostomy. [**2117-8-11**]: biliary catheter exchange [**2117-8-17**]: paracentesis [**2117-8-19**]: Upper GI [**2117-8-20**]: paracentesis [**2117-8-26**]: Aspiration of liver abscess [**2117-8-30**]: paracentesis [**2117-9-2**]: Tube cholangiogram with exchange [**2117-9-3**]: paracentesis [**2117-9-7**]: paracentesis [**2117-9-10**]: paracentesis [**2117-9-16**]: paracentesis [**2117-9-16**]: attempted port a cath placement right [**2117-9-17**]: dual lumen port a cath placed left (in R atrium) History of Present Illness: Pt is a 75 y/o F s/p left hepatic lobectomy ([**11-3**]), CBD excision and Roux en Y HJ for cholangiocarcinoma c/b liver infarction and abscess s/p drainage who returns now with constant mid-epigastric pain (which she describes as reflux), 5lb weight loss over the past week, fatigue. Pt was recently was admitted ([**Date range (1) 5356**]) for drainage at Pigtail catheter insertion site and decreased [**Date range (1) 19843**] output. She also complained of indigestion, weight loss and dehydrated. On [**7-14**], Dr. [**Last Name (STitle) 19420**] performed a cholangiogram which demonstrated a bile leak at the junction of right anterior hepatic ducts and right posterior hepatic ducts into a large abscess cavity. A percutaneous transhepatic biliary drainage procedure was performed, accessing the leaking right posterior hepatic duct with placement of a [**Last Name (STitle) 19843**] through this duct with its tip located in the abscess cavity. No leakage was seen at the indwelling stent which was previously placed across the right anterior hepatic duct to the hepaticojejunostomy anastomosis. The indwelling pigtail catheter in the abscess collection was left in place, connected to a bulb for drainage. Post procedure, she received iv cefepime, but developed flushing. Cefepime was discontinued. A dose of vancomycin was administered without event. She remained afebrile. Vital signs were stable. The PTC and new pigtail catheter were capped over night after the cholangiogram. On [**7-16**], the transhepatic [**Month/Year (2) 19843**] in the collection was opened and aspirated yielding a 100cc. On [**7-17**], she remained afebrile. The PTC was capped. The abscess [**Month/Year (2) 19843**] to JP drained 200cc of dark bile. The transhepatic abscess catheter drained a total of 170cc for 24 hours. LFTs improved. [**Month/Year (2) **] sites remained dry and without redness. She was started on protonix [**Hospital1 **] during prior admission c/o of indigestion with much improvement. However since discharge pt complains of poor PO intake and worsening refulx which is continuous and not improved or worsened with food. Pt denies fever chills, dizziness, shortness of breath, dizziness, falls,cp/abd pain/diarrhea/constipation/dysuria. Past Medical History: PMH: HTN, high cholesterol, hypothyroid, DM II PSH: Cleft palate surgery as child, tonsillectomy, left hepatic lobectomy, CBD excision and RNY hepatojej for cholangiocarcinoma [**11-3**] [**2117-5-19**] cholangiogram with exchange of PTC [**2117-5-26**] exchange of PTC [**2117-7-5**] exchange of PTC with stent placement [**2117-7-15**] new [**Month/Day/Year 19843**] placed thru biliary duct into collection Social History: Recently retired RN. Married with 6 children (oldest son died [**1-31**]). Husband is not well.One child lives in FL, others liver near her Family History: N/C Physical Exam: General: pleasant, nad HEENT:PERRL, EOEMI, sclerae anicteric OP: MMM, no ulcers/lesions/thrush, upper and lower dentures Neck: supple, no LAD, no thyromegaly Cardiovascular: RRR, normal S1, S2, no M/G/R Respiratory: CTA bilat w/o wheezes/rhonchi/rales Gastrointestinal: +bs, soft, distended, 3 R. catheters - no surrounding erythema/drainage, well bandaged, healing L. upper abd wound, L. J. tube without surrounding erythema/drainage. Musculoskeletal: moving all extremities Ext: Warm and well perfused, no edema. Skin: no rashes, no jaundice Neurological: aaox3, cn 2-12 Psychiatric: non-anxious, normal affect Pertinent Results: [**2117-7-23**] 04:10PM PT-13.1 PTT-23.9 INR(PT)-1.1 [**2117-7-23**] 04:10PM PLT COUNT-276 [**2117-7-23**] 04:10PM WBC-9.1 RBC-3.80* HGB-11.2* HCT-34.1* MCV-90 MCH-29.4 MCHC-32.8 RDW-13.7 [**2117-7-23**] 04:10PM ALBUMIN-3.6 CALCIUM-9.3 PHOSPHATE-3.3 MAGNESIUM-2.3 [**2117-7-23**] 04:10PM ALT(SGPT)-37 AST(SGOT)-40 ALK PHOS-390* TOT BILI-0.8 [**2117-7-23**] 04:10PM GLUCOSE-135* UREA N-21* CREAT-0.9 SODIUM-135 POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-28 ANION GAP-14 [**2117-7-23**] 05:10PM OTHER BODY FLUID TOT BILI-35.5 Brief Hospital Course: Pt is a 75 y/o F s/p left hepatic lobectomy ([**11-3**]), CBD excision and Roux en Y HJ for cholangiocarcinoma c/b liver infarction and abscess s/p drainage who returned to our hospital with with constant mid-epigastric pain (which she describes as reflux), 5lb weight loss over the past week prior to admission and, fatigue. Prior to this admission, patient was admitted ([**Date range (1) 5356**]) for drainage at Pigtail catheter insertion site and decreased [**Date range (1) 19843**] output. She also complained of indigestion, weight loss and dehydrated. On [**7-14**], Dr. [**Last Name (STitle) 19420**] performed a cholangiogram which demonstrated a bile leak at the junction of right anterior hepatic ducts and right posterior hepatic ducts into a large abscess cavity. A percutaneous transhepatic biliary drainage procedure was performed, accessing the leaking right posterior hepatic duct with placement of a [**Last Name (STitle) 19843**] through this duct with its tip located in the abscess cavity. No leakage was seen at the indwelling stent which was previously placed across the right anterior hepatic duct to the hepaticojejunostomy anastomosis. The indwelling pigtail catheter in the abscess collection was left in place, connected to a bulb for drainage. Post procedure, she received iv cefepime, but developed flushing. Cefepime was discontinued. A dose of vancomycin was administered without event. She remained afebrile. Vital signs were stable. The PTC and new pigtail catheter were capped over night after the cholangiogram. On [**7-16**], the transhepatic [**Month/Year (2) 19843**] in the collection was opened and aspirated yielding a 100cc. On [**7-17**], she remained afebrile. The PTC was capped. The abscess [**Month/Year (2) 19843**] to JP drained 200cc of dark bile. The transhepatic abscess catheter drained a total of 170cc for 24 hours. LFTs improved. [**Month/Year (2) **] sites remained dry and without redness. During prior admission patient c/o of indigestion which improved markedly. However since discharge pt complains of poor PO intake and worsening refulx which is continuous and not improved or worsened with food. Inital work-up with a constract abdominal CT showed two sites of new focal biliary dilatation in the right lobe, including increased regional enhancement, raising concern for superimposed cholangitis. However, for the most part, there has been only slight increased in overall biliary ductal prominence in most areas. There was moderate distention of the stomach with decompressed duodenum and small bowel. No definite obstructing mass was identified however there was a persistent fluid collection anterior to the remaining right hepatic lobe. Superior migration of biliary stent F/U KUB [**2117-7-26**] to evaluate CT findings showed Persistent narrowing in the second portion of the duodenum possibly related to scarring or extrinsic mural infiltration by tumor. Follow-up CT was consistent with gastric outlet obstruction. Endoscopy was unable to identify or access the duodenum. The patient underwent TPN and NG decompression and repeat endoscopy, and the outlet to the stomach could still not be identified. It was unclear whether this is ulcer, inflammatory, or recurrent tumor. The patient is, therefore, brought to the operating room for gastrojejunostomy and feeding jejunostomy. The patient received 2500 mL of crystalloid, 2 units of packed red cells and made 175 mL of urine EBL was approx 500ml. She remained inpatient to monitor her tube feeds, continue TPN, and to manage her acites with diuresis. She continued to have repeat paracenteses with peritoneal fluid cultures that were negative on [**8-17**]. She also continued to have exchanges of her various abscess cavity catheters on [**8-18**]. On [**8-20**], her paracentesis fluid grew out 1+ PMN's and she was started on a 7 day course of levofloxacin. On [**8-26**], she underwent CT guided drainage of one of her R. liver lobe abscesses with 6 ml of purulent red/brown drainage with resultant growth of VRE and E. coli. She had been initiated on meropenem and vancomycin on [**8-25**] that was then changed to meropenem and linezolid on [**8-31**]. [**Month/Day (4) **] at the time showed Na: 132 K: 4.1 Cl: 101 HCO3: 25 BUN: 17 Cr: 0.7 Gluc: 123 Ca: 7.4 Mag: 2.1 Phos: 3.0 AST/ALT: 23/36 Alk phos: 217 WBC: 11.2 HCT: 27.7 Plt: 22. [**8-30**] peritoneal fluid: 2825 WBC, 2450 RBC, 71 polys, 12 L, 11M, 2 mesothelial, 2 macro. Patient was taken to IR for numerous IR guided paracentesis with sevaral liters of fluid taken off at each tap. All fluid was appropriatly replaced with albumin. Abcess fluid cultures from [**2117-7-29**] grew ESCHERICHIA COLI MODERATE GROWTH. and SPARSE PSEUDOMONAS AERUGINOSA growth. Follow-up CT [**2117-9-10**] showed a fluid collection at the anterior margin of the hepatic lobe resection site decreased in size compared to [**2117-8-4**] with two pigtail drains in place. A 2.6 x 2.0 cm collection at the inferior posterior aspect of the right hepatic lobe is decreased in size status post placement of pigtail catheter [**Year (4 digits) 19843**]. Patient was maintained on TPN and wound care was asked to provide reccomendations regarding skin care. Peritoneal fluid was followed fow WBC and RBC. WBC count dropped precipitously to 283 on [**2117-9-16**] from 2365 on [**2117-9-3**]. On [**9-3**] patient was initiated on meropenem and daptomycin. Her discharge plan per Dr. [**Last Name (STitle) 724**] was to keep her on linezolid 600mg po bid (for the VRE in the abscess), and Meropenem 500 mg IV q 6 hours for the various gram negatives and B fragilis in the abscesses;the micafungin was switched to fluconazole 400 mg orally daily for presumptive yeast. There was no set duration of antibiotics at this time, this will depend on how Ms. [**Known lastname **] does clinically. At discharge patient was to please follow-up for weekly CBC's once or twice weekly as needed by Hepatobiliary; Medications on Admission: Discharge Medications: 1. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Medications: 1. Meropenem 500 mg Recon Soln Sig: One (1) Intravenous three times a day for 1 months. Disp:*90 doses* Refills:*0* 2. Outpatient Lab Work Please draw CBC with diff, Chem 7, Mg, Phos, Calcium, LFTs, Fax results to [**Telephone/Fax (1) 18738**] [**First Name9 (NamePattern2) 5035**] [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **] and [**Telephone/Fax (1) 697**] [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**] 3. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Carvedilol 6.25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Amylase-Lipase-Protease 60,000-12,000- 38,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID (3 times a day). Disp:*90 Cap(s)* Refills:*2* 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 11. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 13. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:*60 Tablet(s)* Refills:*2* 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 16. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*28 Tablet(s)* Refills:*0* 17. glucometer Please dispense 1 glucometer. One time only Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Cholangiocarcinoma gastric outlet obstruction malnutrition liver abscess ascites SBP Discharge Condition: Stable/Fair Discharge Instructions: Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea vomiting, issues with implanted port, inability to tolerate PO medication regimen, inability to tolerate TPN, increased drainage around tubes, changes in the nature of the drainage or other problems or concerns [**Name (NI) **] care ( aspiration) once daily empty and record all drains and send record with patient to clinic visits New [**Name (NI) 19843**] sponges to all [**Name (NI) 19843**] sites daily and as need port a cath accessed: port care Have thyroid function tests checked in [**Month (only) **] for increased levothyroxine dose Followup Instructions: [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**] will be calling with appointment time for Dr [**Last Name (STitle) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] from infectious disease TPN management is through [**Location (un) 511**] Home therapies and Dr [**Last Name (STitle) 519**] [**Name (STitle) **] q Monday to be faxed to Dr [**Last Name (STitle) 519**] ([**Telephone/Fax (1) 18738**]) [**Telephone/Fax (1) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]

[ "996.79", "244.9", "V10.09", "272.4", "338.29", "E878.2", "537.0", "572.0", "530.19", "263.9", "789.59", "576.8", "E879.8", "250.00", "567.23", "997.4", "401.9", "782.3" ]

icd9cm

[ [ [] ] ]

[ "96.6", "50.91", "51.98", "87.54", "45.16", "46.39", "54.91", "97.05", "38.93", "86.07", "44.39", "99.15", "45.13" ]

icd9pcs

[ [ [] ] ]

13826, 13885

5043, 11017

360, 939

14014, 14028

4489, 5020

14728, 15334

3835, 3840

11769, 13803

13906, 13993

11043, 11043

14052, 14705

3855, 4470

228, 322

967, 3227

3249, 3661

3677, 3819

26,963

199,222

31910

Discharge summary

report

Admission Date: [**2192-10-25**] Discharge Date: [**2192-11-2**] Date of Birth: [**2135-6-16**] Sex: M Service: CARDIOTHORACIC Allergies: Tricor / Lipitor Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest Discomfort Major Surgical or Invasive Procedure: [**2192-10-29**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA) History of Present Illness: 57 y/o male with known CAD who has had multiple stents to his LAD who has been doing well until several weeks ago when he has developed chest discomfort. Had a stress test on [**2192-10-16**] which showed ischemia and an EF of 50%. Then he developed chest pain on [**10-24**] and presented to the ED. Underwent cath at OSH which revealed severe three vessel disease. Transferred to [**Hospital1 18**] for surgical revascularization. Past Medical History: Coronary Artery Disease s/p Multiple PCI/Stents, Hypertension, Hyperlipidemia, Diabetes Mellitus w/ Peripheral Neuropathy, s/p Tonsillectomy, s/p Hernia repair x 2, s/p Appendectomy, s/p left shoulder repair, Retinopathy Social History: Works as an accountant. Lives with wife. Occasional ETOH. Denies tobacco use. Family History: Non-contributory Physical Exam: VS: 55 110/67 16 Neuro: A&O x 3, MAE HEENT: EOMI, PERRL Neck: Supple, FROM -JVD Lungs: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS, well-healed midline scar Ext: Warm, well-perfused, -c/c/e Pertinent Results: [**10-29**] Echo: PRE-CPB The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. POST-CPB Normal biventricular systolic function. Thoracic aorta appears intact. [**10-31**] CXR: The patient was extubated in the meantime interval with removing of the Swan- Ganz catheter and NG tube. The mediastinal drains and left chest tube are in unchanged position. The cardiomediastinal silhouette is stable. The lungs are clear with markedly improved areas of basal atelectasis. Small apical right pneumothorax and tiny left pneumothorax are new. Anterior retrosternal air seen on lateral view is either in the anterior pleural space or in anterior mediastinum. Bilateral pleural effusion is small, unchanged . Multiple coronal stents are noted. [**2192-10-25**] 11:15PM BLOOD WBC-7.3 RBC-3.89* Hgb-12.3* Hct-34.5* MCV-89 MCH-31.6 MCHC-35.6* RDW-13.5 Plt Ct-252 [**2192-11-1**] 09:40AM BLOOD WBC-9.4 RBC-2.88* Hgb-8.9* Hct-25.6* MCV-89 MCH-31.0 MCHC-34.9 RDW-14.3 Plt Ct-220 [**2192-10-25**] 11:15PM BLOOD PT-12.4 PTT-23.9 INR(PT)-1.1 [**2192-10-30**] 02:30AM BLOOD PT-13.3* PTT-24.3 INR(PT)-1.2* [**2192-10-25**] 11:15PM BLOOD Glucose-183* UreaN-20 Creat-1.6* Na-142 K-4.5 Cl-106 HCO3-29 AnGap-12 [**2192-11-1**] 09:40AM BLOOD Glucose-208* UreaN-24* Creat-1.7* Na-138 K-4.0 Cl-102 HCO3-27 AnGap-13 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname **] was transferred to [**Hospital1 18**] for bypass surgery. He underwent all preoperative testing prior to surgery. He received medical management as we awaited several days for Plavix washout. On [**10-29**] he was brought to the operating room where he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics. He was gently diuresed towards his pre-op weight. Later on this day he was transferred to the SDU for further management. He was transfused several units of blood for low HCT. Chest tubes were removed on post-op day two. Epicardial pacing wires were removed on post-op day three. He remained in a normal sinus rhythm and continued to make clinical improvements with diuresis. Routine chest x-ray was notable for small stable bilateral pneumothoraces. The remainder of his hospital course was uneventful. On post-op day four he appeared to be doing well and was discharged home with VNA services and the appropriate follow-up appointments. Discharge vitals: BP 110-140/60, HR 58-68, with 99% saturations on room air. Medications on Admission: Plavix 75mg qd, Aspirin qd, Zocor 20mg qd, Lasix 20mg 3x/wk, Neurontin 600mg [**Hospital1 **], Glipizide, Isosorbide Mononitrate 60mg qd, Byetta Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:*120 Capsule(s)* Refills:*1* 7. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 8. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 11. Byetta 10 mcg/0.04 mL Pen Injector Sig: 1.2 units Subcutaneous twice a day. Disp:*3 pen* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital6 486**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Postoperative Pneumothoraces(small, stable) PMH: Hypertension, Hyperlipidemia, Diabetes Mellitus w/ Peripheral Neuropathy, s/p Multiple PCI/Stents, s/p Tonsillectomy, s/p Hernia repair x 2, s/p Appendectomy, s/p left shoulder repair, Retinopathy Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds ion one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 67247**] in [**3-10**] weeks Completed by:[**2192-11-2**]

[ "362.01", "357.2", "250.50", "V45.82", "401.9", "250.60", "424.0", "272.4", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.15", "36.13", "99.04", "39.61", "99.05" ]

icd9pcs

[ [ [] ] ]

6216, 6266

3287, 4653

301, 402

6616, 6622

1471, 3264

6922, 7048

1219, 1237

4848, 6193

6287, 6595

4679, 4825

6646, 6899

1252, 1452

245, 263

430, 864

886, 1108

1124, 1203

44,486

178,101

13892

Discharge summary

report

Admission Date: [**2137-4-29**] Discharge Date: [**2137-5-5**] Date of Birth: [**2061-10-28**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Codeine / Diazepam / Benzodiazepines / Iodine Attending:[**First Name3 (LF) 443**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Pericardiocentesis, Right heart catheterization History of Present Illness: This is a 75 yof with hx of CAD s/p cardiac cath with RCA stent in [**2-/2136**], HTN, Hyperlipidemia, GERD, Afib, diastolic dysfunction, pericardial effusion, pulmonary HTN who presented to [**Hospital3 **] after 7 days of increasing SOB, 3lb weight gain. Upon review of [**Hospital1 **] records it appears pt was treated for CHF exacerbation, an Echo was performed which showed significant pulmonary HTN in the 90s, preserved EF and moderate sized effusion in the posterior aspect, small anterior pericardial effusion. During her admission she was also noted to be anemic with a Hct of 25 from a previously established Hct of 32 and was transfused 2u PRBCs. Following her Echo findings of an effusion as well as pulmonary HTN pt was transferred to [**Hospital1 18**] for right cardiac catheterization and evaluation for possible pericardial effusion. Pt denies any current chest palpitations, pain, pre-syncope symptoms. She does endorse some shortness of breath which is worse than when she was at home but the same as it was in [**Hospital1 2519**]. She endorses a cough with productive white/grey sputum. She endorses diarrhea which she has had for months, usually watery. She denies any n/v/f/c, abdominal pain, focal numbness and tingling. Past Medical History: Hypertension Hyperlipidemia Atrial fibrillation S/P TIA Depression Bilateral cataract surgery Angina Pneumonia/ Bronchitis GERD Anemia Arthritis Irritable bowel syndrome Chronically elevated WBC for past 8 years s/p TAH/BSO - also reports history of R "ovary explosion" as a young adult Hx cholecystectomy and appendectomy Cardiac Risk Factors: Hyperlipidemia, Hypertension Percutaneous coronary intervention - reports previous cath, unsure of date and location Social History: Social history is significant for the absence of current tobacco use. Hx of tobacco last use [**2103**] - 2-3 packs/day X 15yrs. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Pt is a widow, lives in [**Location 5110**]. Has 6 children and 17 grandchildren Physical Exam: VS: T=97.8, BP=141/64, HR=90, RR=22, O2 sat=93-96% on 3l GENERAL: Obses Caucasian Elderly Female in tripod position tachypneic on 3 l NC saturating well. HEENT: EOMI, MMM NECK: JVP significantly elevated CARDIAC: S1, S2, ?pericardial rub, tachycardic to 110 irregularly, irregular. Pulsus Paradoxus 8. LUNGS: Crackles noted b/l mid thorax down. ABDOMEN: Soft, obese, NT, ND. No HSM or tenderness. EXTREMITIES: 2+ mixed edema to the knees b/l. Pertinent Results: IMAGING of RELEVANCE: [**2137-4-29**] ECHO The left atrium is markedly dilated. The right atrium is markedly dilated. Left ventricular cavity size is normal. Left ventricular wall thicknesses are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a large pericardial effusion. The effusion appears circumferential, but is largest (> 3cm) posterior to the left ventricle. There is approximately 1 cm of fluid anterior to the right ventricle. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2136-3-2**], the pericardial effusion is larger. The severity of tricuspid regurgitation is increased. Estimated pulmonary artery pressures are higher. The right ventricular cavity size appears enlarged with global hypokinesis. The ventricular rate is faster. . [**5-1**]/ECHO Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There is a moderate sized, echo dense inferior and inferolateraly pericardial effusion without evidence for hemodynamic compromise. Compared with the prior study (images reviewed) of [**2137-4-30**], the pericardial effusion is now larger and echo dense suggestive of thrombus/clot. In retrospect, a smaller echo dense pericardial effusion may have been present on the prior study, but if so, the effusion is larger and much more apparent on the current study. Clinical correlation and serial evaluation is suggested. ------------------ LABS of RELEVANCE: . [**2137-5-5**] 04:55AM BLOOD WBC-21.8* RBC-3.19* Hgb-9.2* Hct-28.2* MCV-88 MCH-28.8 MCHC-32.6 RDW-18.3* Plt Ct-389 [**2137-5-4**] 05:08AM BLOOD WBC-22.5* RBC-3.24* Hgb-9.1* Hct-28.2* MCV-87 MCH-28.2 MCHC-32.3 RDW-18.2* Plt Ct-421 [**2137-5-3**] 05:40AM BLOOD WBC-22.5* RBC-3.09* Hgb-8.7* Hct-26.9* MCV-87 MCH-28.2 MCHC-32.5 RDW-18.9* Plt Ct-397 [**2137-5-2**] 05:15AM BLOOD WBC-28.4* RBC-3.36* Hgb-9.4* Hct-29.5* MCV-88 MCH-28.1 MCHC-32.0 RDW-18.3* Plt Ct-457* [**2137-5-1**] 05:00AM BLOOD WBC-23.1* RBC-3.18* Hgb-9.1* Hct-27.3* MCV-86 MCH-28.6 MCHC-33.3 RDW-18.8* Plt Ct-462* [**2137-4-30**] 06:40AM BLOOD WBC-24.7* RBC-3.15* Hgb-9.0* Hct-26.9* MCV-85 MCH-28.5 MCHC-33.4 RDW-18.7* Plt Ct-472* [**2137-4-29**] 07:17PM BLOOD WBC-21.8* RBC-3.20*# Hgb-9.0*# Hct-27.3*# MCV-85 MCH-28.1 MCHC-33.0 RDW-18.6* Plt Ct-503* [**2137-5-2**] 05:15AM BLOOD Neuts-94* Bands-3 Lymphs-2* Monos-0 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2137-5-1**] 05:00AM BLOOD Neuts-94* Bands-0 Lymphs-3* Monos-1* Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2137-5-5**] 04:55AM BLOOD PT-19.4* PTT-33.4 INR(PT)-1.8* [**2137-5-4**] 01:30PM BLOOD PT-19.9* PTT-32.8 INR(PT)-1.9* [**2137-5-2**] 05:15AM BLOOD PT-17.3* PTT-32.0 INR(PT)-1.6* [**2137-5-1**] 05:00AM BLOOD PT-16.1* PTT-31.9 INR(PT)-1.4* [**2137-5-5**] 04:55AM BLOOD Glucose-132* UreaN-53* Creat-1.1 Na-142 K-4.9 Cl-98 HCO3-33* AnGap-16 [**2137-5-4**] 05:08AM BLOOD Glucose-107* UreaN-55* Creat-1.2* Na-142 K-4.7 Cl-101 HCO3-32 AnGap-14 [**2137-5-3**] 05:40AM BLOOD Glucose-104 UreaN-57* Creat-1.1 Na-141 K-3.6 Cl-97 HCO3-31 AnGap-17 [**2137-5-2**] 05:15AM BLOOD Glucose-132* UreaN-60* Creat-1.3* Na-140 K-4.1 Cl-97 HCO3-30 AnGap-17 [**2137-5-1**] 03:44PM BLOOD UreaN-62* Creat-1.4* Na-138 K-4.1 Cl-96 HCO3-30 AnGap-16 [**2137-5-1**] 05:00AM BLOOD Glucose-247* UreaN-62* Creat-1.3* Na-131* K-4.1 Cl-92* HCO3-27 AnGap-16 [**2137-4-30**] 06:40AM BLOOD Glucose-123* UreaN-67* Creat-1.4* Na-132* K-5.1 Cl-94* HCO3-25 AnGap-18 [**2137-4-30**] 06:40AM BLOOD LD(LDH)-703* CK(CPK)-28 [**2137-4-29**] 07:17PM BLOOD CK(CPK)-27 [**2137-4-30**] 06:40AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2137-4-29**] 07:17PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2137-5-5**] 04:55AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8 [**2137-5-4**] 05:08AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9 [**2137-5-1**] 03:44PM BLOOD calTIBC-194* Ferritn-717* TRF-149* [**2137-5-2**] 02:38PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017 [**2137-4-29**] 08:26PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2137-5-2**] 02:38PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2137-4-29**] 08:26PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2137-5-2**] 02:38PM URINE RBC-0-2 WBC->50 Bacteri-FEW Yeast-NONE Epi-0-2 PERICARDIAL EFFUSION: [**2137-4-30**] 04:30PM OTHER BODY FLUID WBC-1000* Hct,Fl-<2.0 Polys-84* Lymphs-5* Monos-10* Eos-1* [**2137-4-30**] 04:30PM OTHER BODY FLUID TotProt-6.0 Glucose-100 LD(LDH)-642 Amylase-21 Albumin-2.8 Brief Hospital Course: # CORONARIES: Pt noted to have mild Troponin leak of 0.02-0.04 in the setting of poor renal perfusion. Pt has CAD with h.o. stent to the RCA. Do not suspect current ichemia given lack of ST changes during hospitalization. Pt was continued on home regimen of Metoprolol, Atorvastatin, ASA # PUMP: During admission pt was noted to be hypervolemic on examination with diffuse crackles on pulmonary auscultation, mixed 2+ edema in b/l lower extremities. Pt was started on a Furosemide gtt for diuresis and then transitioned to a PO regimen of Furosemide 80mg [**Hospital1 **]. Pt was instructed to weigh herself every morning and call her Cardiologist if she noted any difference of more than 2 lbs. # RHYTHM: During hospitalization pt was noted to be in A. fibrillation initially with rapid ventricular response of 120-130. On day of transfer pt was noted to have SOB with a rate in the 140s after which she received IV Metoprolol 5mg Tartrate with response of heart rate within 100-120. Pt was changed to Metoprolol 100mg Taretrate TID, a heart rate of 100-120 was tolerated given the presence of hypoxia, pulmonary HTN, pericardial effusion. Pt was restarted on her Coumadin prior to discharge. # Pericardial Effusion: Pt was noted to have 2 pericardial effusions, moderate size in the posterior aspect, small effusion in the anterior portion. Pt underwent pericardiocentesis that was noted to show 800cc serosanguinous fluid. Analysis of fluid showed WBC 1000 but negative on fluid culture, anaerobic culture, AFB smear. Gram stain also nowed no microorganisms and 2+ Polymorphonuclear leukocytes. Cytology was also negative, an autoimmune panel of [**Doctor First Name **], double stranded DNA were still pending at time of discharge but unlikely to be positive given her lack of symptoms in the past. Following pericardiocentesis pt was noted to have an echodensity collection thought to be clot formation. Re-examination with repeat Echos showed no changes thus indicating no unstable bleed into the pericardium. Suspect that the collection has always been present but hidden from prior Echos because of the pericardial fluid superimposed around it. - Recommend pt undergo repeat Echo in 1 week to again reassess pericardium, specifically possibility of constrictive pericarditis. # Psych: During hospitalization pt was noted to be intermittently confused primarily with delusions of being tied up or mistreated. Psychiatry were consulted and determined pt may have been having delirium super imposed on mild dementia. Per Psych recommendations pt was started on Seroquel at bedtime. Alprazolam was discontinued due it's increased risk of Delirium. Prior to discharge pt agreed to Psychiatry follow up as an outpatient, Psychiatry touched base with pt's PCP regarding this issue. # Pulmonary HTN: Pt has a history of Pulmonary HTN per transfer summary, it appears she was started on oxygen last [**Month (only) 359**] for it but has never been worked up. She last saw a Pulmonologist several years ago for her asthma. Her reason for transfer was due to her noted pulmonary pressures in the 90s-100s on Echo, right heart cath was performed to determine whether etiology is cardiac versus Pulmonary. Her right heart cath pressures are notable for a high mean pressure, higher PA diastolic pressure when compared to the wedge (which is elevated by itself). From her right heart cath results it is likely that there is a cardiac component superimposed on a pulmonary one given the elevated Wedge with an even greater PA diastolic pressure. I clinically suspect that there are two processes going on - acute and chronic. Her diastolic dysfunction and fluid overload state are likely the acute causes of her pulmonary HTN. I do believe though that she does have a chronic underlying pulmonary HTN that is due to a pulmonary process. Pt has OSA and is intermittently non-adherent to it which is likely a component, pt also has a smoking history and may have a COPD component too (no PFTs available). Pt also has a history notable for numerous pneumonias as a child and adult, it is possible that with recurrent infection that may be some pulmonary fibrosis which may be working in addition to the aforementioned OSA and COPD. Autoimmune conditions such as Rh. Arthritis, Lupus may also cause pulmonary HTN particularly given her pericardial effusion, pleural effusion. She does not though have any prior history of autoimmune symptoms and it would be atypical for her first presentation to be at this age. Chronic PEs is another diagnosis to consider however prior to this transfer she had been on Coumadin for her A. fib. Unfortunately further studies such as PFTs, high-res Chest CT are not helpful given her current hypervolemic status. Discussed this with family who preferred a pulmonary physician in [**Hospital3 **]. - Recommend pt set up Pulmonary appointment for Pulmonary HTN work up - pt discharged onb home regimen of 2l NS to be worn at all times - encouraged pt to continue her CPAP at home # Leukocytosis: Pt has history of leukocytosis from her myelodysplastic syndrome. On review of her records from [**Hospital1 2519**] it appears her WBC trended up and then down from 16.1->25.3 over several days and then trended down to 23.3 prior to transfer. Her WBC has been trending up during this hospitalization from 21.8->24.7->23.1->28.4->22.5->22.5->21.8. Likely due to her MDS as she did not show any signs of infection during admission. # OSA: Continued pt in hospital on CPAP. Recommended she continue it as an outpatient. # Myeloproliferative d/o: Pt has JAK-2 mutation with a history of leukocytosis. Pt was previously on hydroxyurea when she was noted to be in polycythemia [**Doctor First Name **]. Following a decrease in her Hct she was then transitioned briefly to Procrit. No [**First Name9 (NamePattern2) **] [**Doctor First Name **] or anemia noted during hospitalization. # HTN: Pt was continued on Amlodipine and Metoprolol. # GERD: Pt was continued on Omeprazole and Maalox PRN. # Depression: Pt was conrinued on her home regimen of Fluoxetine daily. Medications on Admission: Calcium/Vit D [**Hospital1 **] Folic Acid 1 Toprol 100 [**Hospital1 **] Norvasc 5 Mag Oxide 400 [**Hospital1 **] Iron 325 [**Hospital1 **] Imdur 120 qam Lisinopril 40 daily ASA 81 Omeprazole 20 [**Hospital1 **] Oxcarbazepine 150 [**Hospital1 **] Prozac 40 Bumex 3 Colchicine 0.6 Calcitonin INH Coumadin 5 qhs Lipitor 80 Flonase nasal Lidoderm prn Vicodin prn tylenol prn Nitro prn xanax prn Discharge Medications: 1. Oxygen Prescription Pt will need Oxygen at all times on 2lpm 2. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule 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. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal QHS (once a day (at bedtime)). Disp:*1 bottle* Refills:*2* 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day: Please take at 8am. Disp:*30 Tablet(s)* Refills:*2* 11. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 12. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation four times a day. Disp:*1 inhaler* Refills:*2* 14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day: Please take at 1600. Disp:*30 Tablet(s)* Refills:*2* 15. Outpatient Lab Work Please have your blood drawn on [**2137-5-7**]. Please have your blood collected to check your PTT, PT, INR. Please have the results faxed ATTN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] Fax number: ([**Telephone/Fax (1) 41630**]. 16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary: Pericardial Effusion, Pulmonary Hypertension, Delirium, CHF exacerbation, A. Fib, delirium Secondary: Mild dementia, Hypertensionm Hyperlipidemia, Myelodysplastic syndrome Discharge Condition: Stable, afebrile on 2l oxygen Discharge Instructions: You were transferred to this hospital for evaluation of your difficulty breathing, heart failure as well as a fluid collection around your heart. Whilst in the hospital you underwent a pericardiocentesis to drain the fluid around your heart, we also started you on a medication to get rid of the excess fluid from your heart failure. Prior to your discharge you were back down to your baseline oxygen requirement of 2 litres, you also were able to walk with physical therapy who recommended you go home with physical therapy. We made several changes to your medications. We started you on 8 new medications: 1. Please take Furosemide 80mg in the morning at 8am 2. Please take Furosemide 80mg in the afternoon at 4pm 3. Please take Questiapine 12.5mg at bedtime 4. Please take Aspirin 325mg once a day 5. Please take Fluticasone 1 nasal spray in each nostril at bedtime 6. Please take 325mg Ferrous Sulfate once a day 7. Please take Ipratropium Inhaler 2 puffs four times a day 8. Please take Coumadin 2mg at bedtime. We changed 2 of your medications: 1. Please take Prilosec 40mg once a day instead of 20mg twice a day. 2. Please take Metoprolol Tartrate 100mg three times a day instead of twice a day. We stopped 5 of your old medications: 1. Please stop taking Bumex 3mg daily 2. Please stop taking Norvasc 5mg daily 3. Please stop taking Digoxin 0.25mg daily 4. Please stop taking Imdur 180mg daily 5. Please stop taking Lisinopril 40mg daily We made no changes to the following medications: 1. Nitroglycerin spray 2. Fluoxetine 40mg daily 3. Atorvastatin 80mg at bedtime 4. Trileptal 150mg twice a day 5. Folic Acid 1mg daily 6. Colchicine 0.6mg daily Please weigh yourself every day at the same time of day in the same outfit. If you gain >2lbs please call your Cardiologist. If you experience any further chest pain, difficulty breathing please return to the ED. Followup Instructions: You have an appointment with your Cardiologist Dr. [**Last Name (STitle) 10543**] on [**2137-5-7**] at 2:45pm. You will need a Transthoracic echo in a weeks time to evaluate the collection in the lining of the heart, this should be set up through Dr.[**Name (NI) 41631**] office. You will also need your blood checked as you were restarted on Coumadin. Please have your blood drawn on [**2137-5-7**] and have the results faxed over to Dr.[**Name (NI) 41631**] office. His fax number is ([**Telephone/Fax (1) 41630**]. Please make an appointment to see a Pulmonary doctor [**First Name (Titles) **] [**Last Name (Titles) 2519**] in the next two weeks for your pulmonary hypertension. Please make an appointment to see Dr. [**First Name (STitle) **] within the next week. Please make an appointment to see a psychiatrist within the next two weeks. Please call [**Telephone/Fax (1) 1387**] for an appointment. Please make an appointment to see your neurologist Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 40860**] to see if you still need to be on Oxcarbazepine.

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icd9cm

[ [ [] ] ]

[ "37.21", "37.0" ]

icd9pcs

[ [ [] ] ]

16768, 16819

8347, 14436

348, 398

17044, 17076

3009, 8324

19000, 20090

2366, 2530

14879, 16745

16840, 17023

14462, 14856

17100, 18977

2545, 2990

289, 310

426, 1677

1699, 2165

2181, 2350

23,267

174,028

30608

Discharge summary

report

Admission Date: [**2164-5-8**] Discharge Date: [**2164-6-5**] Date of Birth: [**2117-12-21**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: [**5-8**] Splenectomy [**5-19**] Open tracheostomy; open g-tube placment [**5-25**] ORIF right tib/fib fracture [**5-30**] Tracheosotmy decannulation @ bedside [**5-12**] Treatment of fracture/dislocation of T3-4 and T4-5. Posterior decompression with laminectomy, medial facetectomy at T2-3, T3-4, T4-5. Posterior arthrodesis, T2 to T6. Instrumented segmental posterior T2 to T6 with rod screw hook construct. Left iliac crest bone graft. Application of morcellized allograft. History of Present Illness: 44 yo male s/p high speed [**Male First Name (un) **] motor vehicle crash, unrestrained driver who complained of severe abdominal pain/chest pain at scene. Approx 1 hour extrication with + LOC, +EtOH. He was med flighted to [**Hospital1 18**] and attempt at intubation by med flight crew failed due to blood in air way. LMA was placed during flight. He was intubated via fiber optics upon arrival in the operating room. We are consulted for Past Medical History: HTN Depression EtOH abuse Social History: Married +EtOH Family History: Noncontributory Physical Exam: PE: 97.3 93 133/87 17 100% [**Name (NI) 5442**] Pt intubated/sedated Unable to assess extra-ocular muscle movement at this time. Significant edema of bilateral conjuctiva. No crepitus of orbital walls. No septal hematoma Pertinent Results: [**2164-5-8**] 04:34PM GLUCOSE-97 UREA N-11 CREAT-0.8 SODIUM-142 POTASSIUM-4.6 CHLORIDE-112* TOTAL CO2-21* ANION GAP-14 [**2164-5-8**] 04:34PM CALCIUM-7.8* MAGNESIUM-1.5* [**2164-5-8**] 04:34PM WBC-12.8* RBC-3.15* HGB-10.0* HCT-29.3* MCV-93 MCH-31.8 MCHC-34.2 RDW-14.6 [**2164-5-8**] 04:34PM PLT COUNT-255 [**2164-5-8**] 03:37PM TYPE-ART RATES-/16 TIDAL VOL-700 O2-50 PO2-114* PCO2-48* PH-7.27* TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED [**Month/Day/Year **]-CONTROLLED [**2164-5-8**] 12:47PM ASA-NEG ETHANOL-152* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST IMPRESSION: 1. Grade 3 splenic injury, with large perisplenic hematoma, with possible areas of vascular disruption in the splenic hilum, and foci of active contrast extravasation. Small amount of blood also extends around the liver. 2. Perisplenic hematoma approaches and slightly displaces the left hemidiaphragm, and sagittal images suggest possible discontinuity in the left hemidiaphragm. Diaphragmatic injury and/or rupture cannot be excluded. 3. Multiple bilateral rib fractures, multifocal areas of pulmonary contusion, and blood in the pleural spaces bilaterally. 4. Markedly comminuted right acetabular fracture, and posteriorly displaced right femoral head. 5. Possible fracture of the posterior aspect of the T4 vertebral body. When the patient is clinically stabilized, MRI or thin-slice CT is recommended for further evaluation. Above findings were discussed with the surgical team at the time of study interpretation on [**2164-5-8**], and wet [**Location (un) 1131**] was placed in the ED dashboard conveying the above findings at 1400 hours on [**2164-5-8**]. CT T-SPINE W/O CONTRAST IMPRESSION: 1. Acute small avulsion fracture of anterior-inferior endplate of T4 as well as bilateral fractures of the T5 pedicles at their junction with the vertebral body. 2. In conjunction with a recent MRI examination, there is involvement of all three spinal columns making this an unstable injury and neurosurgical/ orthopedic spine consult is recommended as discussed with caring trauma team physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 33863**] on date of exam at approximately 3 p.m. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**], orthopedic attending physician, [**Name10 (NameIs) **] the case with us by telephone at 4PM. 3. Unchanged appearance to bilateral multiple rib fractures and bilateral pleural effusions and adjacent compression atelectasis. ADDENDUM : There is apparent overdistention of endotracheal tube balloon cuff on scout image. Discussed this observation with Dr. [**Last Name (STitle) **] at approximately 6:49 p.m. on date of exam. CHEST (PORTABLE AP) FINDINGS: Comparison is made to previous study from [**2164-5-19**]. There is unchanged cardiomegaly. Spinal fixation hardware is identified and unchanged. There is a left retrocardiac opacity with obscuration of the left hemidiaphragm. This may be secondary to pleural fluid, atelectasis, or developing infiltrate. There are no signs for overt pulmonary edema. The right lung is clear. Brief Hospital Course: He was admitted to the Trauma Service. Orthopedics, and Orthopedic Spine Surgery were immediately consulted because of his injuries. He was taken to the operating room for an exploratory laparotomy and splenectomy. Orthopedics also performed a closed reduction, right hip dislocation with traction pin placement and splinting and closed reduction of right distal tibia fracture at that time. He would later be taken back to the operating room by Orthopedics for Open reduction internal fixation right posterior column and transverse acetabular fracture. On [**5-12**] he was taken back to the operating room by Orthopedic Spine Surgery for treatment of fracture/dislocation of T3-4 and T4-5 posterior decompression with laminectomy, medial facetectomy at T2-3, T3-4, T4-5, posterior arthrodesis, T2 to T6, instrumented segmental posterior T2 to T6 with rod screw hook construct, left iliac crest bone graft and application of morcellized allograft. Plastic Surgery was also consulted because of facial fractures noted on CT imaging; these injuries were deemed nonoperative. No further interventions regarding this was recommended. He remained in the Trauma ICU, vented and sedated. A decision was made on [**5-19**] to perform an open tracheostomy and open gastrostomy tube placement. He was eventually weaned from ventilator and sedation and was transferred to the floor in the next few days. A right femoral percutaneous Bard G2 type inferior vena cava filter was also placed because of risk for DVT and PE given his multiple orthopedic injuries. Once awake Psychiatry was consulted given history of depression and concerns for if this auto crash was an attempt to harm himself. He was placed on 1:1 sitters and it was recommended that he go to an inpatient psychiatric facility once medically cleared. Both patient and his wife were in agreement to this. His tracheostomy was removed on [**5-30**] and he is managing his secretions and maintaining adequate oxygen saturations. Physical, Occupational and Speech therapy were all consulted. He made significant gains with the therapies. He is to remain non weight bearing on his right leg; he passed the swallowing evaluation. He is no longer receiving tube feedings and is tolerating a regular diet. Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Enoxaparin 30 mg/0.3 mL Syringe Sig: 0.3 ML's Subcutaneous Q12H (every 12 hours). 7. Metoprolol Tartrate 50 mg Tablet Sig: 1 [**11-29**] Tablet PO TID (3 times a day). 8. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 9. Oxycodone 5 mg Tablet Sig: 3-4 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain: hold for RR <12. 10. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 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. Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4 Discharge Diagnosis: s/p Motor vehicle crash Liver laceration Splenic laceration Right acetabular fracture Right tibia/fibula fracture T4 fracture Discharge Condition: Stable Discharge Instructions: DO NOT bear any weight on your right leg. Followup Instructions: Follow up in Trauma Clinic with Dr. [**Last Name (STitle) **], in 2 weeks, call [**Telephone/Fax (1) 6439**] for an appointment. Follow up with Dr. [**Last Name (STitle) **] in [**Hospital 5498**] Clinic in 2 weeks, call [**Telephone/Fax (1) 1228**] for an appointment. Follow up with Dr. [**Last Name (STitle) 1352**], Orthopedic Spine Surgery, in 2 weeks, call [**Telephone/Fax (1) 1228**] for an appointment. Completed by:[**2164-6-5**]

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icd9cm

[ [ [] ] ]

[ "31.1", "79.75", "97.88", "79.35", "43.19", "21.71", "79.36", "81.63", "99.04", "41.5", "77.79", "81.05", "79.06", "00.33", "96.6", "38.7" ]

icd9pcs

[ [ [] ] ]

8216, 8261

4848, 7108

337, 820

8431, 8440

1664, 4825

8530, 8974

1390, 1407

7131, 8193

8282, 8410

8464, 8507

1422, 1645

274, 299

848, 1294

1316, 1343

1359, 1374

18,160

171,429

25952

Discharge summary

report

Admission Date: [**2166-2-6**] Discharge Date: [**2166-2-12**] Date of Birth: [**2091-4-13**] Sex: F Service: NEUROSURGERY Allergies: Ace Inhibitors / Atenolol / Verapamil / Levaquin Attending:[**First Name3 (LF) 1835**] Chief Complaint: Consulted for 74 F who was tx from OSH intubated reported subdural bleed and lown pupil. It was ascertained that she fell in her bathroom at about 5AM - went to OSH at 9AM where she had increased solemnance, decreased movement, and left sided facial weakness over the course of an hour and was intubated. She was intubated, HD stable, and transfered to [**Hospital1 18**]. Major Surgical or Invasive Procedure: Right sided craniotomy History of Present Illness: Ms [**Known lastname 41841**] is a 74-year-old female who was brought to the [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] Emergency Room from an outside facility. She apparently sustained a fall this morning at around 5 a.m. in her bathroom. The patient did initially well, however deteriorated over the course of a couple of hours. When she presented to the outside hospital, she was initially doing reasonably well with a GCS of 14 and mild-sided headaches and underwent a CT scan. During CAT scanning, the patient decompensated and needed urgent intubation. The CAT scan was completed and revealed a large right-sided subdural acute hematoma with approximately 2-cm thickness and a significant midline shift. The patient was therefore originally transported by med-flight to the [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **]. Upon arrival, the patient was paralyzed and had no neurological exam secondary to paralytics on board. The outside hospital CT was reviewed. Mannitol was given emergently and the OR was notified. The CAT scan was repeated showing a stable subdural hematoma as mentioned above. The patient was taken stat to the OR for right-sided craniectomy for decompression. Past Medical History: DM II HTN Hyperlipidemia PSH: Laminectomy All: ACE inhib Atenolol Verapamil Levofloxacin [**Last Name (un) 1724**]: [**Doctor First Name **] Iron Diovan Metformin Glyburide Aggrenox Social History: Married with grown children Family History: Unknown Physical Exam: On admission: PE: 96.2 48 118/43 14 100% NAD intubated R pupil 6mm, unresponsive small chin abrasion RRR CTAB soft NT/ND no back abrasions or step off GCS 3, intubated and sedated Pertinent Results: [**2166-2-12**] 08:34AM BLOOD WBC-5.1 RBC-3.77* Hgb-11.4* Hct-34.2* MCV-91 MCH-30.3 MCHC-33.4 RDW-15.6* Plt Ct-87* [**2166-2-12**] 02:12AM BLOOD WBC-6.6 RBC-4.02* Hgb-12.3 Hct-34.5* MCV-86 MCH-30.5 MCHC-35.5* RDW-15.6* Plt Ct-83* [**2166-2-11**] 12:01PM BLOOD WBC-4.9 RBC-3.73* Hgb-11.1* Hct-32.2* MCV-86 MCH-29.7 MCHC-34.4 RDW-15.8* Plt Ct-73* [**2166-2-11**] 01:02AM BLOOD WBC-4.2 RBC-3.71* Hgb-11.4* Hct-32.2* MCV-87 MCH-30.8 MCHC-35.5* RDW-15.7* Plt Ct-71* [**2166-2-10**] 03:46PM BLOOD WBC-6.1 RBC-3.76*# Hgb-11.4*# Hct-32.7*# MCV-87 MCH-30.2 MCHC-34.8 RDW-15.5 Plt Ct-57* [**2166-2-10**] 05:20AM BLOOD WBC-6.7 RBC-2.65* Hgb-8.0* Hct-24.1* MCV-91 MCH-30.3 MCHC-33.3 RDW-15.2 Plt Ct-97* [**2166-2-12**] 08:34AM BLOOD Plt Ct-87* [**2166-2-12**] 08:34AM BLOOD PT-22.4* PTT-34.1 INR(PT)-2.2* [**2166-2-12**] 02:12AM BLOOD Plt Ct-83* [**2166-2-12**] 02:12AM BLOOD PT-19.6* PTT-30.9 INR(PT)-1.9* [**2166-2-11**] 12:01PM BLOOD Plt Ct-73* [**2166-2-11**] 12:01PM BLOOD PT-20.5* PTT-32.6 INR(PT)-2.0* [**2166-2-10**] 12:04AM BLOOD PT-21.8* PTT-41.5* INR(PT)-2.1* [**2166-2-10**] 05:20AM BLOOD PT-22.7* PTT-38.4* INR(PT)-2.2* [**2166-2-9**] 12:21AM BLOOD PT-15.0* PTT-46.0* INR(PT)-1.3* [**2166-2-12**] 08:34AM BLOOD Glucose-168* UreaN-96* Creat-2.5* Na-145 K-6.1* Cl-107 HCO3-20* AnGap-24* [**2166-2-12**] 02:12AM BLOOD Glucose-83 UreaN-89* Creat-2.0* Na-148* K-3.7 Cl-111* HCO3-24 AnGap-17 [**2166-2-11**] 12:01PM BLOOD Glucose-131* UreaN-82* Creat-2.1* Na-147* K-3.8 Cl-113* HCO3-21* AnGap-17 [**2166-2-11**] 01:02AM BLOOD Glucose-81 UreaN-72* Creat-2.0* Na-146* K-3.8 Cl-115* HCO3-20* AnGap-15 [**2166-2-10**] 03:46PM BLOOD Glucose-161* UreaN-71* Creat-1.9* Na-144 K-4.4 Cl-114* HCO3-17* AnGap-17 [**2166-2-10**] 05:20AM BLOOD Glucose-136* UreaN-63* Creat-1.8* Na-145 K-4.8 Cl-118* HCO3-16* AnGap-16 [**2166-2-10**] 12:04AM BLOOD Glucose-117* UreaN-62* Creat-1.8* Na-146* K-4.7 Cl-117* HCO3-17* AnGap-17 [**2166-2-11**] 12:01PM BLOOD ALT-3409* AST-6176* LD(LDH)-2091* AlkPhos-112 Amylase-116* TotBili-2.1* [**2166-2-11**] 01:02AM BLOOD ALT-4350* AST-[**Numeric Identifier 64522**]* LD(LDH)-5745* AlkPhos-107 Amylase-133* TotBili-2.0* [**2166-2-10**] 03:46PM BLOOD CK-MB-3 cTropnT-0.18* [**2166-2-9**] 03:04PM BLOOD CK-MB-4 cTropnT-0.14* [**2166-2-9**] 08:53AM BLOOD CK-MB-5 cTropnT-0.12* [**2166-2-12**] 08:34AM BLOOD Calcium-8.1* Phos-7.5*# Mg-2.3 [**2166-2-12**] 02:12AM BLOOD Calcium-8.6 Phos-5.3* Mg-2.1 [**2166-2-11**] 12:01PM BLOOD Albumin-2.3* Calcium-7.8* Phos-4.6* Mg-2.1 [**2166-2-11**] 09:10AM BLOOD Calcium-8.2* Mg-2.0 [**2166-2-11**] 01:02AM BLOOD Osmolal-327* [**2166-2-10**] 03:46PM BLOOD Osmolal-330* [**2166-2-10**] 12:04AM BLOOD Phenyto-11.6 Brief Hospital Course: Ms [**Known lastname 64523**] family consented to an emergent Right-sided frontotemporal parietal craniotomy for decompression, evacuation of hematoma, small duraplasty. Post operatively she was brought to the Trauma ICU. On postoperative neuroexam showed PERRLA [**3-23**], following commands in feet, post operative head CT showed Status post evacuation of a right subdural hematoma, with decreased right to left subfalcine herniation and uncal herniation. Persistent subdural hemorrhage as well as effacement of the right cerebral sulci. Pneumocephalus. She was started on Dilantin post operatively, usual prophylatic antibiotics and tube feeds. Her T/L/S spine showed no fractures. On her first post operative day she with drew all extremties to pain. Her creatinine noted to increase from 1.4 to 1.7 On Post op day 2 she had an MRI of her head which showed Status post evacuation of subdural hematoma with pneumocephalus and air-fluid level on the right subdural space with maximum width of 12 mm. Mild mass effect on the right lateral ventricle without midline shift. Small area of signal abnormality in the left thalamus could be due to an infarct of undetermined age. No evidence of hydrocephalus. An attempt at weaning ventilator was stopped due to metabolic acidosis and mixed respiratory alkalosis. On Post op day 3 she was noted to be in rapid AF started on Lopressor, amiordarone (eventually refractory) and eventually a Cardiazem drip. She was noted to be fluid overloaded at this time she completed a rule out MI protocol. Her exam was noted to only withdraw her lower extremeties. A repeat head CT showed: 1. Status post evacuation of subdural hematoma with decreasing pneumocephalus and stable size of right subdural collection. Stable subarachnoid blood and mass effect. 2. Focal area of left thalamic hypodensity likely representing a lacunar infarct. She had fevers and lower extrmeties were negative for DVT. A chest XRay showed atalectasis her liver enzymes were extremely high ALT 4401, AST [**Numeric Identifier **] a ultrasound of the liver on [**2-10**] showed patent portal and hepatic veins. On Post Op Day 4 [**2-10**]- She had multiple vent changes requiring increased peep to raise PO2 greater than 70. Chest XRay continued to show atelectasis. Her neuroexam showed withdraws left upper extremity to pain. Increase toe response to stimulus. INR increased to 2.3 related to liver enzymes for which she received PRBCs, she continued fevers of unknown origin. She began to have decreased urine output and creatinine up to 1.9. She had Hepatology consult who felt her transmitis was related to Budd Chiari, Drug toxin and shock liver. Abd ultrasound was done as mentioned above and a hepatitis panel. On Post Op Day 5 [**2-11**] Ms [**Known lastname 64523**] labs continued to worsen BUN of 72 and creatinine of 2.0 lactate of 2.2, plt of 71 and INR 2.0. She had no eye opening, no movement to painful stimuli a repeat head CT: No appreciable interval change in postoperative fluid collection. No change in mass effect. Liver enzymes improved. Renal consulted to see the patient. They recommended checking a variety of labs, DCing Lasix, Ethcynic acid,and Metologone and starting Epogen. On Post Op Day 6 [**2-12**] Ms [**Known lastname 41841**] continued to have rapid AFib on Cardizem drip, fevers, periods of hypotension and hypoxia. Blood gas showed 7.50/34/73 with tachypnea. Neurologically she had roving eye movements in lateral gaze and no motor repsonse, grimaces to noxious stimuli no gag but has + corneals and cough. An emergent plan was made to obtain a CTA of the chest to rule out PE, MRI of head/neck along with evoked potentials. Before these tests could be completed Ms [**Known lastname 41841**] became hemodynamically unstable her pupils were noted to fixed and dilated, she became hypotensive and bradycardic. Her family was notified emergently they asked the patient not to be coded she passed away to 0855. Medications on Admission: Glyburide, Aggrenox, [**Last Name (LF) **], [**First Name3 (LF) **], FE, Diovan, Glucophage and calcium Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Subdural Hematoma, CAD,Diabetes,hypertension, hyperlipidemia,anemia and chronic renal insufficinecy Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: None Completed by:[**2166-2-12**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "99.07", "01.39", "96.6", "01.24", "99.05", "02.12" ]

icd9pcs

[ [ [] ] ]

9359, 9368

5188, 8154

687, 712

9512, 9522

2505, 5165

9574, 9610

2280, 2289

9330, 9336

9389, 9491

9202, 9307

9546, 9551

2304, 2304

273, 649

740, 2011

8163, 9176

2318, 2486

2033, 2219

2235, 2264

49,558

177,601

5066

Discharge summary

report

Admission Date: [**2129-7-8**] Discharge Date: [**2129-8-4**] Date of Birth: [**2073-11-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1253**] Chief Complaint: shortness of breath, fever, respiratory failure Major Surgical or Invasive Procedure: Intubation aline placement IJ line placement x 2 Bronchoscopy Esophageal balloon placement History of Present Illness: This is a 55 yo M with h/o HTN who initially presented to an OSH 2 days ago complaining of fevers, SOB and now is being transferred in the setting of respiratory failure. History is obtained from OSH records and pt's family. Per OSH d/c summary, pt was being conservatively treated for URI sxs 5 days prior to presentation to OSH with ? unknown abx, cefclor, promethazine, and codeine but did not feel better and thus was admitted to [**Hospital3 **] on [**7-6**]. At the time, he was reportedly complaining of subjective fevers, chills, rigros, sore throat, shortness of breath, and cough without hemoptysis. No diarrhea, abd pain, n/v, myalgias. . On presentation to OSH, febrile to 104.3, O2 sat 91% on RA --> 96% 4L NC, RR 18. WBC 4.7 with 86.3% neutrophils, plts 106K, Na 128, Cr 1.2, HCO3 29. CXR revealed multi-focal PNA (L>R). Flu swab negative. Sputum cx, urine legionella, HIV still pending. He was placed on respiratory isolation for r/o TB for unclear reasons other than his history of being from [**Country 3587**]. He was treated with IV vancomycin, ceftriaxone, azithromycin and bactrim (added on [**7-8**]). However, on am of transfer, pt noted to desat from 97% on 2-3L NC to 77%, requiring NRB. Pt also noted to be tachypneic with RR in 30s, febrile to 101-102 in spite of tylenol. ABG 7.44/35/71/24 on NRB. CXR revealed nearly complete white out of left lung. . Upon arrival to the [**Hospital Unit Name 153**], the pt is intubated and not responsive to sternal rub. Past Medical History: HTN Hypercholesterolemia Social History: Works as school bus driver. Married and lives at home with wife. [**Name (NI) **] EtOH, illicits, IVDA, tobacco per OSH d/c summary. Moved to USA from [**Country 3587**] 20 years ago. No other known recent TB risk factors. Family History: No family contacts with known tuberculosis. Otherwise non-contributory Physical Exam: 98.1 149/91 92 20 97RA Glucose 148 GEN: appears weak, but comfortable, non-toxic. NAD. HEENT: clear OP, mmm NECK: No LAD. CV: RRR, no MRG, +2 pulses CHEST: CTA B, good AE. ABD: +BS, soft, NT/ND EXT: No edema, well perfused Neuro: CN2-12 grossly intact, no focal defecits. MSK: profound generalized weakness, slowly improving daily. Unable to feed self, able to sit forward in chair, but unable to sit up in bed from lying position. Strength 3/5 diffusely. Pertinent Results: LABS ON ADMISSION: [**2129-7-8**] 03:32PM BLOOD WBC-3.5* RBC-3.76* Hgb-11.5* Hct-32.8* MCV-87 MCH-30.6 MCHC-35.1* RDW-13.3 Plt Ct-119* [**2129-7-8**] 03:32PM BLOOD Neuts-79* Bands-10* Lymphs-9* Monos-1* Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2129-7-8**] 03:32PM BLOOD PT-13.8* PTT-36.9* INR(PT)-1.2* [**2129-7-8**] 03:32PM BLOOD WBC-3.5* Lymph-10* Abs [**Last Name (un) **]-350 CD3%-43 Abs CD3-150* CD4%-34 Abs CD4-120* CD8%-10 Abs CD8-33* CD4/CD8-3.62* [**2129-7-8**] 03:32PM BLOOD Glucose-204* UreaN-13 Creat-0.8 Na-131* K-4.8 Cl-100 HCO3-25 AnGap-11 [**2129-7-8**] 03:32PM BLOOD ALT-76* AST-201* LD(LDH)-1794* CK(CPK)-5948* AlkPhos-51 Amylase-74 TotBili-0.3 [**2129-7-8**] 03:32PM BLOOD Lipase-64* [**2129-7-8**] 03:32PM BLOOD Albumin-2.8* Calcium-6.8* Phos-2.7 Mg-2.3 . Micro: [**7-22**] BAL: GNRs PCP- [**Name10 (NameIs) 5963**] HIV [**2-4**]- negative, HIV viral load negative Cryptococcal Ag- negative Toxo Ab- negative C. Diff- negative CMV Ab and viral load- negative Legionella negative Beta glucan and galactomannan- negative Viral resp culture- negative Echinococcus Antibody Igg- negative Mycoplasma- negative HSV [**2-4**]- IgG + for HSV1, IgM - neg EHRLICHIA- negative Histoplasmosis- pnd Entamoeba- pnd Hanta virus- neg LEPTOSPIRA- pnd LCM- pnd Q-fever- negative . Reports- . echo- 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 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 regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion . CT torso IMPRESSION: 1. Extensive multifocal pulmonary consolidations with areas of ground-glass opacity, together suggestive of extensive infection. 2. Hepatic hypodensity as above, most likely a cyst. 3. Large amount of fluid seen throughout the colon, with further characterization not possible on this non-contrast study . LENI IMPRESSION: No DVT of either lower extremity . CXR [**8-1**]: IMPRESSION: 1. NG tube tip in stomach. 2. Multifocal pneumonia with slight improvement in left upper lobe aeration. . Abd US: IMPRESSION: 1. Gallbladder sludge with no evidence of cholecystitis. 2. Left hepatic cyst unchanged from that described on CT done on the same day. . CT CAP: IMPRESSION: 1. Extensive multifocal pulmonary consolidations with areas of ground-glass opacity, together suggestive of extensive infection. 2. Hepatic hypodensity as above, most likely a cyst. 3. Large amount of fluid seen throughout the colon, with further characterization not possible on this non-contrast study. . Discharge labs: [**2129-8-3**] 06:00AM BLOOD WBC-9.3 RBC-3.55* Hgb-10.8* Hct-32.9* MCV-93 MCH-30.5 MCHC-32.9 RDW-15.5 Plt Ct-329 [**2129-8-3**] 06:00AM BLOOD Neuts-63.9 Lymphs-22.6 Monos-6.2 Eos-6.7* Baso-0.6 [**2129-7-8**] 03:32PM BLOOD WBC-3.5* Lymph-10* Abs [**Last Name (un) **]-350 CD3%-43 Abs CD3-150* CD4%-34 Abs CD4-120* CD8%-10 Abs CD8-33* CD4/CD8-3.62* [**2129-8-3**] 06:00AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-136 K-3.8 Cl-101 HCO3-24 AnGap-15 [**2129-7-29**] 04:05AM BLOOD ALT-61* AST-30 AlkPhos-84 TotBili-0.6 [**2129-8-1**] 06:15AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0 [**2129-7-18**] 10:45AM BLOOD ANCA-NEGATIVE B [**2129-7-18**] 10:45AM BLOOD [**Doctor First Name **]-NEGATIVE [**2129-7-14**] 04:07AM BLOOD HIV Ab-NEGATIVE Brief Hospital Course: 55 M w HTN, who originally presented to OSH w fever/SOB, and was subsequently transferred to [**Hospital1 18**] in hypoxic respiratory failure in the setting of multi-focal PNA. . # Acute Hypoxic Respiratory Failure: Pt required intubation before transfer to [**Hospital Unit Name 153**]. He had prolonged fevers without identifable cause. Required high PEEP requirement while on Vanc/Zosyn/Levo. He had a multifocal PNA on CXR and required proning to increase oxygenation. He had a low CD4 count despite negative HIV test at [**Hospital1 **] and OSH. There was concern also for PCP and he was also treated with steriods and bactrim. Bactrim was later stopped and then later restarted. Steriods were stopped and then restarted and later tapered. Differential included CAP vs interstitial inflammatory process (acute interstial pna, acute eosionphilic pna) vs vasculitis. Vasculitis less likely with no hemorrhage on bronch on [**7-22**], and negative [**Doctor First Name **], ANCA, and anti-GBM. Infectious work-up showed: HIV 1 and 2 negative, PCP negative, [**Name9 (PRE) 20890**] and glucactomanna negative, Legionella antigen negative, viral culture negative, blood cultures negative, toxo negative, CMV negative, ehrlichia negative, mycoplasma negative. Urine culture yeast only. Neg Hep C/B. Met Hb normal. Had a dose of caspo on [**7-16**], was discontinued following discussion with ID. Echinococcus, LCM, hanta virus, and Entamoeba negative. Due to high levels of PEEP initally BAL and bronch were not able to be completed until [**7-22**]. Cx from BAL grew a small amount of yeast and was negative for PCP and virus; AFB was negative as well. ID closely followed the patient. He was treated with vancomycin, Zosyn, Levo. Also had Azithro, flagyl (stopped with negative c. diff), Bactrim, Doxycycline, and Micafungin. During [**Last Name (un) 10128**] also had ET complication of a partial extuabation with cuff above vocal cords, then was corrected. 2 days later had rupture of balloon and ET tube exchanged. Xray with findings of pneumomediastinum, thoracics evaluated pt, otherwise stable and though to be secondary to high PEEP. Patient was gradually weaned off the vent over the course of the next couple days and was extubated on [**7-26**] without complication. On [**7-26**], antibiotics were discontinued. Pt was transferred to the floor stable, on room air, and on tube feeds due to failed swallow study on [**7-28**]. On the floor, patient remained afebrile with stable pulmonary status. He was continued on a slow prednisone taper, as it is unclear if steroids in the ICU were responsible for some of his improvement in the ICU. On [**8-4**] his prednisone was decreased from 10 mg to 7.5 mg, with plans to decrease dose by 2.5 mg every 5 days until off. # Hypertension: Has hx of htn at baseline. Intially BP meds held. Later in course BP was elevated. He was give sedation as needed and treated with PRN hydral and metoprolol. BP was labile, and was increased as sedation was weaned. Pt required propofol, versed, and fentanyl to prevent agitation. . Pt was started on metoprolol and later low dose lisinopril was added for improved BP control. Please follow up on his blood pressure and titrate medications as necessary. Please note that his blood pressure may improve as his prednisone dose decreases. Please check lytes, BUN/Cr in 5 days to ensure tolerating lisinopril. . # ARF: Developed acute renal failure but had adequate UOP. FeNa consistent with pre-renal, however was third spacing. Given blood as neede. Renally dosed meds. . Renal failure improved, and normalized by the time of discharge. . # Hypernatremia: Developed hypovolemia hyponatremia. Improved with free water boluses as needed. . # Constipation/Diarrhea: Initially had consiptiaon, then later had diarrhea after PO contrast and bowel meds. C. diff negative x 3. Diarrhea later improved. Had a flexiseal placed. Abd CT without obstruction of evidence of acute process. Diarrhea resolved. . # Diabetes: Had elevated blood sugars elevated, that were more elevated with steriod treatments. Was placed on SSI intiailly then changed to insulin gtt. On the floor, he was treated with SQ insulin, but did not reliably require insulin. Please follow glucose levels, and consider starting metformin if remains elevated. . # Elevated LDH, CK: Had what appeared to be rhabomyolisis. CK to [**Numeric Identifier 7923**]. Given IVF and monitored UO. CK improved. . # Hyperkalemia: With renal failure and rhabo had developed elevated K to >6. No EKG changes. Was treated with kayexalate and insulin. Improved once BMs started. Resolved by time of discharge. . # Anemia: unclear cause, but likely marrow suppression due to acute illness. Hemolysis labs negative. . # Pancytopenia: Initially thrombocytopenic at OSH but has progressively developed leukopenia and anemia. Low CD4, but with negative HIV testing. Unclear cause. Cell counts improved. . # Weakness: pt was noted to have profound generalized weakness, initially unable to sit up in bed, feed self, or lift arm above shoulder. Pt worked with PT with gradual but signif improvement. The profound weakness is thought to be due to an ICU myopathy from prolonged intubation/sedation. Pt will be discharged to [**Hospital1 **] for inpatient rehab. Medications on Admission: HOME MEDICATIONS: Atenolol 25 mg daily Cefaclor 250 mg po tid Promethazine [**2-4**] tsp qid . MEDICATIONS ON TRANSFER: Vancomycin 1 gm IV q12h (last dose [**7-8**] 1200) Ceftriaxone 1 gm IV q24h (last dose 6/4 1400) Azithromycin 250 mg IV q24h (last dose 6/4 1800) Bactrim 350 mg IV q6h (last dose [**7-8**] 1000) Albuterol neb q1h prn Albuterol neb q6h prn Ipratropium neb q6h prn Lidocaine SL NTG 0.4 mg prn Maalox 30 ml q2-4h prn Milk of magnesia 10 ml daily prn Docusate 100 mg [**Hospital1 **] prn Atenolol 25 mg daily Tylenol 1gm q6h prn Benzonatate 100 mg tid prn Pantopraozle 40 mg daily Hydrocone syrup 5 ml q4h prn Propofol 150 mg IV X 1, vecuronium 10 mg IV X 1, ativan 4 mg IV X 1 and then 2 mg IV X 1 with intubation Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 3. Prednisone 5 mg Tablet Sig: as dir Tablet PO once a day: 7.5 mg po q day x 4 days, then 5 mg po q day x 5 days, then 2.5 mg po q day x 5 days, then d/c. 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please check lytes, BUN/Cr in 5 days. Note: started on [**8-3**]. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or fever. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: # Acute respiratory failure/Multifocal pneumonia; unclear etiology (presumed infectious) # ARDS # ICU myopathy/profound weakness # Hypertension # Anemia Discharge Condition: stable Discharge Instructions: You were admitted for an acute respiratory failure that required prolonged intubation. Extensive laboratory workup was performed, but no definative diagnosis was able to be made, however we suspect that this was due to an infectious etiology. You were treated with antibiotics, and are now only being treated with a slow taper of prednisone. After your ICU stay, you were profoundly weak, and will require inpatient rehab to help you regain your strength. Followup Instructions: Recommend a slow prednisone taper for his respiratory failure of unclear etiology. Pt's prednisone was decreased from 10mg to 7.5 on [**8-3**], and recommend decreasing by 2.5 mg every 5 days until off. . Pt was started on Lisinopril on [**8-3**] for hypertension. Please note that this may improve once off of prednisone. Please follow up lytes/bun/cr in 5 days to ensure tolerating well. Titrate prn. . Pt will need aggressive PT. Patient is highly motivated. . Recommend monitoring patient off of insulin, and if persistently hyperglycemic, consider starting metformin. . He should follow up with his primary care physician in approx 2 weeks.

[ "E849.7", "799.02", "272.0", "276.1", "486", "787.20", "576.8", "276.2", "573.8", "518.81", "E879.8", "996.59", "284.1", "728.88", "584.9", "401.9", "458.9", "285.9", "787.91", "250.80" ]

icd9cm

[ [ [] ] ]

[ "33.24", "00.14", "96.04", "96.72", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

13171, 13244

6508, 11809

361, 453

13441, 13450

2841, 2846

13956, 14607

2273, 2345

12590, 13148

13265, 13420

11835, 11835

13474, 13933

5759, 6485

2360, 2822

11853, 11930

274, 323

481, 1968

2860, 5742

11955, 12567

1990, 2017

2033, 2257

14,330

162,631

533+534

Discharge summary

report+report

Admission Date: [**2113-4-18**] Discharge Date: [**2113-5-2**] Service: MEDICAL/VASCULAR CHIEF COMPLAINT: Left foot cellulitis. HISTORY OF PRESENT ILLNESS: This is an 83 year-old male with extensive past medical history sent from dialysis for evaluation and treatment who has been unable to walk or the past eight months. He de orthopnea, paroxysmal nocturnal dyspnea, fevers or chills, nausea or vomiting. PAST MEDICAL HISTORY: End stage renal disease on hemodialysis, hypertension, MSSA sepsis treated, chronic atrial fibrillation, history of peptic ulcer disease, history of abdominal aortic aneurysm, history of benign prostatic hypertrophy, history of cerebrovascular accident, history of peripheral vascular disease, history of gastrointestinal bleed, history of prostate carcinoma. Left lower lobe pneumonia in [**2112-5-4**]. History of gastritis and esophagitis. History of right inguinal hernia without repair. PAST SURGICAL HISTORY: Hemorrhoidectomy remote, amputation of right first toe remote, left TMA in [**2110-5-5**]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Levofloxacin 250 mg po q 48 hours. 2. Flagyl 500 t.i.d. 3. Colace. 4. Senna tabs. 5. Protonix. 6. Zolpidem 5 mg q.d. 7. Sevelamer 800 mg t.i.d. 8. Nephrocaps one q.d. 9. Amiodarone 200 mg po q.d. 10. Coumadin 1 mg q.d. ADMISSION LABORATORIES: CBC with a white blood cell count of 6.9, poly 72, lymphocytes 18, hematocrit 33, platelets 255, BUN 9, creatinine 3.4, K 3.5. Echocardiogram done in [**Month (only) 956**] showed normal ejection fraction with mitral regurgitation and aortic regurgitation noted. The patient was begun on Vanco, Levo and Flagyl antibiotics. Coumadin was continued. Protonix was continued and vascular was consulted regarding management. Vascular examination showed a pleasant male in no acute distress. HEENT examination was unremarkable. carotids were without bruits. Heart was a regular rate and rhythm. The lungs were diminished at the right base and abdominal examination had a palpable aortic aneurysm. The foot examination showed a left foot cold with ischemic appearing black ulceration on the left medial heel and ankle with no erythema, fluctuance or drainage. The pulse examination showed palpable femorals on the right, dopplerable on the left. Popliteal was dopplerable on the right, absent on the left. The dorsalis pedis pulses were absent bilaterally. The patient PT was dopplerable on the right and absent on the left. The foot x-ray showed no evidence of osteomyelitis. Arteriogram on [**2113-3-30**] showed a abdominal aortic aneurysm with a left common iliac aneurysm with plaque. The distal superficial femoral artery, popliteal and BK [**Doctor Last Name **] diseased, the single vessel run off via the peroneal was reconstituted to the dorsalis pedis pulse. There was no posterior tibial pulse. Recommendations were to hold his Coumadin, normalize his INR, begin heparinization for goal PTT between 40 and 60, obtain MRI/MRA of the left leg and the aorta to evaluate the aorta and in flow disease, consider cardiac workup with echocardiogram and PMIBI, continue antibiotics broad spectrum, follow culture results and tailor as necessary. Multipodus splint to the right foot to prevent heel ulcerations. Echocardiogram was obtained, which demonstrated symmetric left ventricular hypertrophy. This was a suboptimal technical quality study, so focal wall motion could not be excluded. The overall ventricular function EF was greater then 55%. There was a mild aortic stenosis and mitral leaflets appeared thickened, but they were unable to adequately assess the mitral regurgitation. There was mild pulmonary hypertension. Compared to previous study on [**2113-1-18**] there is probably a similar aortic gradient that is slightly higher. The patient underwent a PMIBI. There were no anginal or ischemic changes, but the patient did have premature ventricular contractions and premature atrial contractions. His nuclear portion showed an abnormal study with severe fixed defect involving the basilar portion of the inferior wall. The ejection fraction was calculated at 54% and on visual inspection it is in the range of 65 to 70. Medical attending evaluated the patient and a moderate cardiac risk for surgery. The patient had a CTA of the abdomen and pelvis to determine abdominal aortic aneurysm. Findings demonstrated intrarenal abdominal aortic aneurysm of 4.9 by 5.2 cm. There is an aneurysm of the right proximal common iliac artery, which measures 4.1 by 2.9 cm. There is an aneurysm of the left common iliac, which measures 1.7 by 2.5 cm. There is an aneurysm in the proximal right internal iliac artery, which measures 1.4 to 2.0. There is dense vascular calcification and multiple venous collaterals seen along the anterior subcutaneous tissues of the abdomen with collateral flow to the right common femoral vein. There is moderate stenosis of the right external iliac artery. The celiac superior mesenteric arteries are patent. There is dense calcification involving the ostium of the left renal artery and dense calcifications at the origin of the right renal artery. There are extensive venous intercostal collaterals along the anterior abdominal wall. These findings are consistent with severe vena cava occlusion. The right inguinal hernia contains small bowel. There is no evidence of obstruction. Incidentally there was gallstones in the gallbladder. Bilateral adrenal enlargement may represent adrenal hyperplasia. Diverticulosis without evidence of diverticulitis. The patient underwent an abdominal aortic angio with left leg run off. There showed significant infrarenal aortic atherosclerotic changes with aneurysmal dilatation extending to the common iliac. There is diffuse atherosclerotic ulcerative plaque of the bilateral external and internal iliac arteries. There is severe disease of the left superficial femoral artery, which occluded at the adductor canal. The left PFA is occluded and above and below knee popliteal arteries are occluded. There is reconstruction of a diffusely diseased attenuated peroneal, which reconstitutes the dorsalis pedis. After careful review of the arteriogram and CTA a long discussion with the patient's daughter and the patient was determined being as a high risk and his comorbidities and recommendations were a left below the knee amputation. The patient consented to that and underwent on [**2113-4-27**] a left below the knee amputation. He tolerated the procedure well and he was transferred to the PAC in stable condition. He remained hemodynamically stable. He was transferred to the VICU for continued monitoring and care. Initial dressing was removed on postoperative day number two. The wound was clean, dry and intact. The skin edges were intact with no ecchymosis and no drainage. Physical therapy and occupational therapy began to work with the patient. renal continued to follow the patient for hemodialysis needs. Percocet caused the patient to be confused so he was started on Tylenol #3. Renal recommended that the patient only receive narcotics a single dose q 24 hours supplement the patient's break through pain with extra strength Tylenol tablets two q 4 to 6 hours prn for pain. The remaining hospitalization was unremarkable. The patient was discharged to rehab. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg po q.d. 2. Nephrocaps one q.d. 3. Sevelamer 800 mg t.i.d. 4. Protonix 40 mg po q.d. 5. Acetaminophen 325 to 650 mg po q 4 to 6 hours prn for pain. 6. Colace 100 mg b.i.d. 7. Senna tablets one b.i.d. 8. Metoprolol 25 mg b.i.d. hold for systolic blood pressure less then 100, heart rate less then 60. 9. Albuterol Ipratropium multi dose inhaler one to two puffs q 6 hours. 10. Coumadin 1 mg q.h.s. DISCHARGE DIAGNOSES: 1. Severe peripheral vascular disease with left leg ischemia status post below the knee amputation. 2. End stage renal disease on hemodialysis. 3. PMIBI with fixed inferior basilar wall defect, ejection fraction greater then 55%. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2113-5-1**] 10:13 T: [**2113-5-1**] 10:23 JOB#: [**Job Number 4418**] Admission Date: [**2113-5-2**] Discharge Date: [**2113-5-5**] Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is an 84-year-old man with multiple medical problems including end-stage renal disease on hemodialysis, previous hypertension, atrial fibrillation, peptic ulcer disease, recently status post left below the knee amputation from [**4-27**] and discharged from [**Hospital1 **] on [**5-1**], and was transferred to rehab. He returned to us on [**5-1**] because of increased shortness of breath and hypoxia, and was slightly obtunded. The patient had dialysis on [**5-1**] and he was initially sating 96% on 2 liters. In the Emergency Department, he was given a dose of ceftriaxone and Levaquin for a pneumonia and left pleural effusion that was drained 800 cc of fluid. Postthoracentesis, his saturations went up to 96-97%. He did have a small pneumothorax as a complication of this procedure. However, then his oxygen saturations fluctuated in the low 90s. His blood pressure transiently dropped to systolic blood pressure 75, which responded to fluid boluses. In the Emergency Department, it was discussed with Renal, there was no need to dialyze at that time. He was evaluated by Surgery for his left below the knee amputation which appeared to be healing well as per Surgery. PAST MEDICAL HISTORY: 1. End-stage renal disease on hemodialysis, Tuesdays, Thursdays, Saturdays. 2. Hypertension. 3. Atrial fibrillation. 4. Peptic ulcer disease. 5. Abdominal aortic aneurysm which is 4.3 cm in [**2108**]. 6. Benign prostatic hypertrophy with prostate cancer. 7. Cerebrovascular accident. 8. Peripheral vascular disease. 9. Left below the knee amputation. 10. History of MSSA line sepsis. 11. Gastritis. 12. Esophagitis. 13. Right inguinal hernia. 14. Gastrointestinal bleed in [**2111-6-5**]. 15. Chronic lower back pain. 16. Previous admissions for persistent left lower lobe retrocardiac pneumonia. CT scan in the past had shown a mass. The patient on a previous admission had refused bronchoscopy, therefore the question of whether this postobstructive pneumonia was never worked up. MEDICATIONS ON ADMISSION: 1. Amiodarone 200 mg q day. 2. Nephrocaps one cap q day. 3. Renagel of 800 mg tid. 4. Protonix 40 mg q day. 5. Colace 100 mg [**Hospital1 **]. 6. Coumadin 1 mg q day. 7. Lopressor 25 mg [**Hospital1 **]. 8. Senna. SOCIAL HISTORY: He is a two pack per day smoker for 65 years, occasional alcohol use. He is a retired iron worker and lives alone. EXAMINATION ON ADMISSION: His temperature was 99.2, blood pressure 102/45, heart rate 83, respiratory rate 18, and sating at 91% on 4 liters. In general, he was awake. His HEENT: Pupils are equal and reactive, but were about 1 mm bilaterally. Extraocular movements are intact. Dry mucous membranes. Chest: He had decreased breath sounds on the left with coarse breath sounds on the right. Cardiac: Regular, rate, and rhythm with a systolic murmur, distant heart sounds. Abdomen: Positive bowel sounds. Soft, nontender, nondistended. Extremities: Left below the knee amputation, tender stump bandage, right leg showed no edema with poor toenail care. Neurologic: Mental status: He was awake and talks. Alert to person and [**Hospital1 **], and was speaking nonsense at times. LABORATORIES ON ADMISSION: Sodium of 140, potassium 5.9, chloride 104, bicarb 21, BUN 38, creatinine 6.5, glucose 72, nonhemolyzed specimen. His white count was 9.4, hematocrit of 33.5, platelets of 200, 83% neutrophils, 13% lymphocytes. His INR was 1.5 with a PT of 14.8 and a PTT of 24.6. CK of 4,006, CK MB of 17, MBI was 0.4 and troponin of 1. His pleural fluid showed protein 2.3, glucose 92, LDH 84, albumin of 1.3. His blood cultures were drawn. Electrocardiogram showed a junctional rhythm with questionable ST depressions in V3 through V6, but appears older consistent with electrocardiogram on [**2113-4-19**]. Regular rate at 86 with some low voltages. Chest x-ray showed progression of a left pleural effusion, with partial layering and the right pleural effusion appeared to be stable. The patient was initially admitted to the MICU from [**5-1**] to [**5-3**]. 1. Pulmonary: The patient presented with shortness of breath and hypoxia. Chest x-ray showed a large left pleural effusion which was much increased from his previous chest x-ray. His left effusion was tapped in the Emergency Room. His sats have been maintaining in the low 90s on a nonrebreather, given that the probability of a pneumonia and intermittent hypertension. Blood cultures were sent. This was thought to be sepsis from a pneumonia. He was started on ceftriaxone and Levaquin. His antibiotics were then changed to ceftazidime and was continued on Vancomycin, since he had previously been on this for colonization by MRSA in his toes. Eventually his sputum cultures did grow out Staph coag positive species, and his ceftazidime was then switched over to levofloxacin and Flagyl po on [**2113-5-4**]. The possibility of pulmonary embolus was considered given his hypotension, his acute respiratory decompensation and increased left pleural effusion, however, the patient has since refused CTA. Patient's saturations over the course of the hospitalization has remained approximately 94-95% on the Medical floor when he was transferred on [**2113-5-4**]. 2. Cardiovascular: The patient has a history of atrial fibrillation, hypertension, and abdominal aortic aneurysm. Given his new hypotension, his blood pressure medications were held (his beta blocker was held). He was continued on amiodarone and was kept in regular rhythm. His anticoagulation he had been subtherapeutic as per records on his last admission, and had not been anticoagulated. He was refusing Heparin drip as well because he was refusing blood draws, and understood the risks and benefits of not being on Heparin and was restarted on Coumadin in hospital. His blood pressure has remained in the 85-100 range, tolerating ................ greater than 55. His last issue was his elevated CK MB and troponin. His elevated CK was thought to be secondary to his below the knee amputation since his MB index was low thought to be secondary to his renal failure. His enzymes were cycled and remained stable. His CK continued to fall. 3. Renal: Patient with end-stage renal disease on hemodialysis. He continued on hemodialysis on Tuesdays, Thursdays, and Saturdays. He had some degree of rhabdomyolysis, and the Renal team did not feel that there was any urgent need for dialysis initially. He was continued on Nephrocaps and Renagel. 4. GI: Given his history of peptic ulcer disease and gastrointestinal bleed, he was given Protonix. His hematocrit had remained stable throughout hospitalization, and his vascular surgery had been following him for his left below the knee amputation. He is stable from that standpoint and has been having dressing changes as needed. He has a multipodas boot on the right foot that should be continued given his tenderness on the right heel. His code status was changed in the hospital from full code from DNR/DNI. The patient has been refusing blood draws and understands the risks of refusing both the CTA of the chest and refusing blood draws. DISCHARGE DIAGNOSES: 1. Left lower lobe pneumonia. 2. Left pleural effusion status post thoracentesis with small pneumothorax. 3. Hypotension. 4. Sepsis. 5. Paroxysmal atrial fibrillation. 6. End-stage renal disease. MEDICATIONS AT DISCHARGE: 1. Amiodarone 200 mg po q day. 2. Aspirin 325 mg po q day. 3. Combivent 1-2 puffs q6h. 4. Renagel 800 mg po tid. 5. Nephrocaps one cap po q day. 6. Vancomycin dosed when Vancomycin level is less than 15 at hemodialysis. 7. Levofloxacin 250 mg po q48h starting on [**2115-5-7**]. 8. Flagyl 500 mg po tid to stop on [**5-14**]. 9. Coumadin 1 mg po q hs to be titrated for a goal of [**2-6**] INR. 10. Protonix 40 mg po q day. 11. Senna one tablet po bid prn. 12. Colace 100 mg po bid. 13. Folic acid 1 mg po q day. TREATMENTS: He is to continue on hemodialysis on Tuesdays, Thursdays, Saturdays and to be monitored for his INR on Coumadin. He is to have dressing changes to the left below the knee amputation, and to keep the left leg straight. He is to followup with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], and he should also have multipodas boot to the right foot while in bed, sheepskin, and Physical Therapy for his left below the knee amputation. He is to be discharged to [**Hospital3 4419**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Name8 (MD) 1020**] MEDQUIST36 D: [**2113-5-5**] 08:31 T: [**2113-5-5**] 08:35 JOB#: [**Job Number 4420**]

[ "511.9", "728.89", "038.9", "V49.75", "512.1", "486", "403.91", "185", "427.31" ]

icd9cm

[ [ [] ] ]

[ "39.95", "34.91" ]

icd9pcs

[ [ [] ] ]

15655, 15864

7417, 7845

10522, 10737

967, 1097

15878, 17191

119, 142

8496, 9687

11693, 15634

11565, 11678

9709, 10496

10754, 10883

31,187

146,146

33656

Discharge summary

report

Admission Date: [**2113-2-14**] Discharge Date: [**2113-2-24**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: Shortness of breath and chest pain Major Surgical or Invasive Procedure: Colonoscopy EGD cardiac catheterization with no intervention History of Present Illness: EVENTS / HISTORY OF PRESENTING ILLNESS: The history is obtained from the limited notes obtained from [**Hospital1 **] as the patient is intubated and son not available. Per notes, poor historian but developed intermittent CP and extreme sleepiness x 4 days. She was brought in by a neighbor who sees her everyday and stated she was sleeping more often than normal and complaining of the intermittent pain, and had to be convinced to come in. Also related SOB x 1 day and right leg pain. In the OSH ED the patient was unable to rate her chest pain or locate it, and she complained most of upper epigastric pain. No nausea, diaphoresis. + lightheadedness. ED physcician spoke with son who stated his mother had complained of increasing bowel movements that were darker in color recently. . In ED at [**Hospital3 1280**], vitals 99, 111/59, 73% RA. Placed on face mask and O2 sat increased to 89% on 15L. EKG demonstrated ST depressions II, III, aVF, V3-V6, ST elevation in avR, V1, all new when compared to prior on [**2112-12-13**]. Aspirin 324mg given and heparin started. Guaiac negative. HCT was 21 and heparin was stopped transiently but restarted prior to transfer. She was transfused 2 units PRBCs. CXR showed CHF and given 20mg IV lasix. She continued to be hypoxic on a face mask and due to worsening SOB, she received 15 mg etomidate and 100 mg succinylcholine and was intubated for hypoxic respiratory failure and started on propofol. . She initially came throught the ED at [**Hospital1 18**] but was taken emergently to the cath lab where she was found to have 30% ostial stenosis in left main, no significant disease in LAD, 30% mid and distal LCx, 60-70% stenosis prox and mid RCA, and 90% in PDA. No intervention performed d/t anemia and desire to avoid anticoagulation. . On review of symptoms per [**Hospital1 **] note, she denied fever, chills, sore throat, emesis, abdominal pain, diarrhea, melena, hematochezia (different story from son). No hematuria, dysuria, frequency, urgency, back pain, rashes, headache. Past Medical History: PAST MEDICAL HISTORY: # Deaf, communicates well & reads lips well # HTN # H/O TIA # COPD (emphysema) - on albuterol # Hysterectomy # Appendectomy Social History: Cardiac Risk Factors: Hypertension, tobacco Family History: NC Physical Exam: PHYSICAL EXAMINATION: VS: T 98.4, BP 138/60, HR 98, RR 21, O2 100% on AC 450/14/5/0.5 Gen: Elderly female intubated, comfortable, opens eyes intermittently. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with no JVP. CV: PMI located in 5th intercostal space, midclavicular line. RRR, nml S1 and S2, III/VI SEM best heard in LUSB Chest: Mild crackles at bilateral bases. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. No hematomas bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; DP dopplerable Left: Carotid 2+ without bruit; Femoral 2+ without bruit; DP dopplerable Pertinent Results: [**2113-2-14**] 08:50PM WBC-14.2* RBC-3.36* HGB-7.6* HCT-25.5* MCV-76* MCH-22.6* MCHC-29.8* RDW-16.9* PLT COUNT-348 [**2113-2-14**] 07:43PM GLUCOSE-108* UREA N-14 CREAT-0.7 SODIUM-141 POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-27 ANION GAP-13 [**2113-2-14**] 07:43PM ALT(SGPT)-14 AST(SGOT)-45* LD(LDH)-587* CK(CPK)-107 ALK PHOS-57 AMYLASE-36 TOT BILI-0.5 [**2113-2-14**] 07:43PM CK-MB-5 cTropnT-0.06* [**2113-2-14**] 07:43PM ALBUMIN-3.5 CALCIUM-7.9* PHOSPHATE-4.5 MAGNESIUM-2.0 IRON-35 [**2113-2-14**] 08:50PM PT-12.5 PTT-46.7* INR(PT)-1.1 [**2113-2-14**] 07:43PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-1+ OVALOCYT-1+ TARGET-OCCASIONAL SCHISTOCY-1+ BURR-1+ PENCIL-OCCASIONAL ACANTHOCY-OCCASIONAL ------------------ Cardiac cath [**2-14**] COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated single vessel coronary artery disease. The LMCA has a 30% ostial stenosis. The LAD had no obstructive CAD. The LCX has a 40% stenosis at the mid and distal LCx. The RCA has a 60-70% mid stenosis with a 90% stenosis at the mid PDA. 2. Limited resting hemodynamic measurement demonstrated normal systemic arterial pressure of 126/58 mmHg. 3. No intervention was performed at this time due to the patients underlying active pneumonia and anemia with Hct 21%. -------------------- TTE [**2-15**] The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with basal to mid infero-lateral hypokinesis. No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). At least mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild functional mitral stenosis (mean gradient 4mmHg) due to mitral annular calcification. Mild to moderate ([**12-7**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is a trivial/physiologic pericardial effusion. ------------------ carotid u/s [**2-17**] FINDINGS: Minimal heterogeneous left-sided calcific plaque involving the carotid bulb and extending into the internal carotid artery. The peak systolic velocities, however, are normal bilaterally. The ICA to CCA ratios are also unremarkable. There is antegrade flow involving both vertebral arteries. IMPRESSION: No significant ICA or CCA stenosis involving either the left or right carotid systems. non contrast ct chest [**2-21**] CT CHEST WITHOUT IV CONTRAST: There are mild to moderate atherosclerotic calcifications of the aortic arch and descending aorta. Minimal calcification is seen within a normal caliber ascending aorta medially (2:25). The aortic valve is moderately calcified, as is the mitral annulus and coronary arteries. Scattered mediastinal lymph nodes do not meet CT criteria for enlargement. There are small bilateral pleural effusions. 3- mm pulmonary nodules are seen within the right upper lobe (3:13) and right middle lobe lateral segment (3:30). There is a small area of focal bronchiectasis in the right upper lobe (3:13) which may represent prior infection. While not tailored for infradiaphragmatic evaluation, there is a large partially rim- calcified cyst within segment [**Doctor First Name 690**] of the liver measuring 46 x 40 mm. A small hypodensity within the segment II of the liver likely represents a cyst. There is a small hiatal hernia, as well as small calcified splenic granulomas. There are no suspicious lytic or sclerotic lesions. IMPRESSION: 1. Moderately calcified aortic valve and coronary arteries. 2. Subcentimeter pulmonary nodules. [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] criteria, if there is no history of smoking or significant risk factors for lung cancer, no further followup is needed. Otherwise, followup with a dedicated chest CT in 12 months is recommended. Brief Hospital Course: # CAD/Ischemia EKG changes and symptoms likely due to subendocardial ischemia in the setting of poor oxygenation d/t severe anemia and critical AS with no evidence of acute thrombus/STEMI or significant left main disease requiring CABG. Cardiac catheterization demonstrated mild diffuse disease with 90% stenosis in PDA, no stent placed d/t anemia and wish to avoid plavix without known source of bleed. Patient received 4 units of PRBC in the first 48hrs and subsequently maintained HCT >30. ECG changes resolved once patient's HCT was stabilized. EGD on [**1-25**] showed AVM in second part of duodenum that was cauterized. Plan for CABG during surgery on [**3-3**]. . # Pump Echocardiogram on [**2-15**] found severe AS with Left Ventricle - Ejection Fraction: 50% to 55%, Aortic Valve - Valve Area: *0.6 cm2, Aortic Valve - Peak Gradient: *97 mm Hg, 1+ MR, and 1+AR. EF. Intially presented with clinical signs of failure and pulmonary congestion on chest xray and was diuresed and started on Metoprolol, Aspirin, Atorvastatin. Cardiovascular surgery recommeded aortic valve replacement which is scheduled for [**3-3**]. She underwent pre operative clearance for her surgery by anesthesia prior to her discharge. She will have CABG with possible MVR given 2+ MR. . # Respiratory failure Presented with SOB in setting of anemia, crtical AS/heart failure, and COPD and was intubated with extubation the following day, patient has underlying COPD. Underwent PFT's as preop workup and was discharged with no oxygen requirement. . # Microcytic Anemia Presented with Hct of 21, received 4 units PRBCs and started on iron supplement then stabalized at Hct >30. EGD on [**1-25**] showed AVM in second part of duodenum that was cauterized. Patient did not require any transfusions for >1 week prior to discharge. GI recommendation to wait 1 week prior to surgery which will require 40,000-50,000 units of heparin. Surgery planned on [**3-3**]. . Medications on Admission: Simvastatin 10mg Atenolol 25mg Nifedipine sustained release 30mg Albuterol 90mcg IH Ferrex 150 plus Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day. Disp:*120 sprays* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Severe aortic stenosis Hypertension Microcytic anemia GI bleed COPD Deaf Discharge Condition: Stable Discharge Instructions: You were found to have severe aortic stenosis during this hospitalization. Your anemia was found to be due a bleeding site in part of your small intestine. You have been cleared to undergo surgery on [**3-3**] at that time they will replace your valve and you will undergo a bypass surgery. You will be given specific instructions from the cardiac surgery team as to how to prepare for your surgery and what time to show up. Please return to the ER if you hvae any chest pain, shortness of breath or any palpitations. Followup Instructions: Call your doctor ([**Doctor Last Name **],LINYUN [**Telephone/Fax (1) 12295**]) in the next few months for follow up. Follow directions regarding when to show up for your surgery on [**2113-3-3**]

[ "280.0", "428.31", "537.83", "428.0", "455.3", "424.1", "414.8", "305.1", "518.81", "389.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.24", "88.56", "37.22", "44.43" ]

icd9pcs

[ [ [] ] ]

10670, 10729

7809, 9763

297, 360

10846, 10855

3493, 7786

11422, 11623

2667, 2671

9913, 10647

10750, 10825

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10879, 11399

2686, 2686

2708, 3474

223, 259

388, 2420

2464, 2590

2606, 2651

75,435

136,056

26498

Discharge summary

report

Admission Date: [**2190-2-7**] Discharge Date: [**2190-3-3**] Date of Birth: [**2122-4-16**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 7651**] Chief Complaint: Chest pain, nausea, vomiting Major Surgical or Invasive Procedure: Chest tube placement IR guided drainage of lung empyema Intubation IJ line for hemodialysis Intra-aortic balloon pump placement History of Present Illness: Patient is a 67 y/o with PMH of CAD s/p MI [**8-/2189**], h/o UGIB, DM, hyperlipidemia, AS and CHF (EF 25%) who presented to OSH today with nausea and vomiting as well as chest pain. Per the patient's wife the patient was very tired today, with decreased appetite and poor energy. He took oxycodone for L rib fracture pain and immediately began vomiting. He continued to feel tired and seemed "out of it" to his wife who then brought him into the [**Name (NI) **]. Of note, the patient was recently admitted to [**Hospital3 **] on [**2-3**] after a fall on [**1-31**] which he slipped on ice. He sustained L-sided 7th-9th rib fractures. He has had ongoing L-sided CP since he was discharged yesterday. In OSH ED initial VS were T 99.4, HR 110, BP 86/62, RR 24, 94% RA. Pt reportedly looked lethargic and pale. Initial labs revealed Trop 17.93, CK 1756 and MB 225. EKG showed sinus tach, LVH, and worsened ST depressions in V4-V6. He was given zofran 4mg IV x 1, dilaudid 1mg IV x 2, and ASA 325mg PO x 1. After discussion with covering cardiologist he was also started on hep gtt and given lopressor 2.5mg IV x 1. CTA was performed which showed known rib fractures and L pleural effusion, neg. for PE. Given elevated CE he was transferred to CCU for further management. On arrival to the CCU the patient was sleepy but alert. He complained of intermittent chest pain, however he was unable to qualify whether this was different than his rib fx. pain. Pt was continued on Heparin gtt 1000u/hr. He was maintained on 100% NRB satting in high-90s. Labs were sent, and were notable for a bump in Cr (1.9 at OSH->2.5). On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism. He reports a history of bleeding on heparin (colonic AVM source requiring 17 units blood). He denies recent fevers, chills or rigors. The patient denies any melena, rectal bleeding, or transient neurologic deficits. No change in weight, bowel habit or urinary symptoms. No arthralgias, myalgias, headache or rash. All other review of systems negative. Cardiac review of systems is notable for + chest pain. Patient has dyspnea on significant exertion, however denies paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. Hypertension 2. Coronary Artery Disease s/p MI [**2188**], medically managed, no stent. 3 vessel disease on cardiac catheterization in [**8-31**]. 3. Type 2 Diabetes Mellitus complicated by peripheral neuropathy and gastroparesis 4. Hyperlipidemia 5. Aortic stenosis, valve area 0.9cm2 6. Dilated cardiomyopathy, EF 25% 7. h/o GIB [**1-25**] AVM in distal duodenum 8. Anemia, on Procrit and iron injections 9. h/o epistaxis on Plavix 10. h/o R hip fracture 11. Peripheral Vascular Disease 12. L 7-9th rib fx Social History: - Home: Lives with his wife - Occupation: retired forensic engineer. Works in stable with horses. - Tobacco: Denies - EtOH: rare Family History: Unknown, adopted. Possible h/o DM. Physical Exam: VS- 98.0 107 93/58 28 100%NRB GENERAL: Appears uncomfortable, sleepy but arousable HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink. NECK: Supple with JVP at jaw line. CARDIAC: Tachy, regular, normal S1, S2. No m/r/g audible. LUNGS: No chest wall deformities, scoliosis or kyphosis. + tachypnea, no accessory muscle use. CTA anteriorly. ABDOMEN: Soft, mildly distended. NT. No HSM appreciated. + BS EXTREMITIES: cool. multiple small excirations on b/l LE. No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: moving all extremities, oriented to person and time Pertinent Results: Admission Labs [**2190-2-7**] WBC 11.3 / Hct 29.3 / Plt 183 N 87 / L 7 / M 6 / E 0 / B 0 INR 1.4 / PTT 40.5 Na 133 / K 4.9 / Cl 91 / CO2 29 / BUN 46 / Cr 2.5 / BG 325 Alb 3.9 / Ca 8.9 / Phos 5.9 ALT 30 / AST 237 / LDH 618 / Alk Phos 70 / TB .5 CK 2843 / MB 262 / Trop T 3.88 Iron 14 TChol 113 / HDL 36 / LDL calc 56 [**2190-3-3**]: Na 137, K 3.7 (repleted), Cl 101, Bicarb 28, BUN 40, Creat 2.7. Hct 25.2, wbc 5.0, INR 1.4. [**Hospital3 **] Cr peak 4/0 [**2-7**] and [**2-8**] Cardiac Markers CK-MB MB Indx cTropnT [**2190-2-23**] 07:06AM 6 4.18*1 CHEMS ADDED 8:58AM [**2190-2-16**] 04:06AM 2 5.90*2 Source: Line-aline [**2190-2-9**] 08:43AM 17* 1.5 13.50*1 [**2190-2-7**] 09:15AM 149* 5.4 7.31*1 Source: Line-A line [**2190-2-7**] 12:15AM 262* 9.2* 3.88*3 ALT AST (LDH) (CPK) AP [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] DBili IBili [**2190-2-21**] 05:34AM 45* 33 295* 54 0.9 [**2190-2-18**] 04:02AM 69* 21 63 1.1 [**2190-2-17**] 03:59AM 94* 24 337* 68 1.8* 1.2* 0.6 [**2190-2-12**] 04:09AM 683 185 663* 213* 4.1* 3.5* 0.6 [**2190-2-9**] 08:43AM [**2197**] 1480* 1543* 1151* 68 1.0 [**2190-2-8**] 04:58AM 2737*4183* 5796* 70 [**2190-2-7**] 09:15AM 37 272* 2777* 61 [**2190-2-7**] 12:15AM 30 237* 618* 2843* Discharge Labs 137 101 40 61 AGap=12 3.7 28 2.7 Ca: 8.0 Mg: 2.1 P: 4.8 WBC 5.0 HGB 8.4 PLT 145 HCT 25.2 MCV 90 PT: 15.9 PTT: 28.1 INR: 1.4 CARDIAC CATHETERIZATION - [**2190-2-7**] 1. Selective coronary angiography of this right-dominant system revealed multi-vessel coronary artery disease. The LMCA was without significant stenoses. The LAD had a 60% mid-vessel stenosis. D1 had a 70% stenosis. The LCX and Ramus each had 70% stenoses. A small OM branch was occluded and a second OM had a 70% stenosis. The RCA was occluded proximally with left-to-right collaterals. 2. Limited resting hemodynamics demonstrated markedly elevated biventricular filling pressures, with an RVEDP of 20mmHg and a mean PCWP of 36 mmHg (before lasix given). The mixed venous 02 saturation was 48, giving a cardiac output of 4.0 and a cardiac index of 1.8, indicating cardiogenic shock prior to placement of the IABP. The aortic valve gradient was 22, yielding a valve area of 0.9, indicating moderate-to-severe AS. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate aortic stenosis. 3. Cardiogenic shock. ECHOCARDIOGRAM - [**2190-2-7**] Focused study by on call fellow. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe global left ventricular hypokinesis (LVEF = 15 %). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. The aortic valve leaflets are moderately thickened. Significant aortic stenosis is present (not quantified). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Tricuspid regurgitation is present but cannot be quantified. There is no pericardial effusion. CT ABD/PELVIS - [**2190-2-14**] 1. Moderate left pleural effusion with subjacent atelectasis. 2. No evidence for intra-abdominal abscess or acute intra-abdominal pathology. 3. Very mild edema in subcutaneous tissues of bilateral thighs. No loculated fluid collections are identified. 4. Displaced fractures of the left seventh, eighth, and ninth ribs, which appear to be acute. 5. Nonobstructive subcentimeter bilateral renal calculi. No hydronephrosis. [**2190-2-19**] RUQ US INDICATION: 57-year-old man with enlarged gallbladder on bedside ultrasound, normal LFTs, and normal clinical exam, evaluate for cholecystitis. FINDINGS: A limited portable ultrasound was done in the ICU. Transverse and sagittal images of the gallbladder demonstrate some sludge within the gallbladder but it is not overly distended and there is no gallbladder wall thickening or pericholecystic fluid identified. No gallstones are seen. IMPRESSION: Sludge within the gallbladder but no signs of cholecystitis ECHO [**2190-2-22**] Akinetic, infarcted inferior and inferolateral segments with severe hypokinesis of all other segments. Dilated and hypokinetic right ventricle. Aortic stenosis that is probably moderate to severe. Moderate to severe mitral regurgitation. CT CHEST - [**2190-2-25**] 1. Interval decrease in multiple loculated hydropneumothorices within the left pleural cavity. 2. Interval resolution of the right upper lobe collapse. 3. New septal thickening attributed to hydrostatic edema. 4. Unchanged displaced fracture of left seventh, eighth and ninth ribs. 5. Improving bilateral pleural effusions. [**2190-3-2**] CXR FINDINGS: In comparison with the study of [**3-1**], there is little overall change. Again there are patchy areas of increased opacification on the left that could reflect pneumonia. Left chest tube remains in place, and there is no pneumothorax. The right lung is essentially clear, given the lower level the lung volumes. Micro data PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Other [**2-15**] [**Numeric Identifier 65463**]* [**Numeric Identifier 65464**]* 0 0 0 01 [**2-14**] [**Numeric Identifier 65465**]* [**Numeric Identifier 890**]* 0 0 0 02 RIJ tip/blood cx SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ 2 S Pleural Fluid STAPH AUREUS COAG + | ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Brief Hospital Course: 67 yo male with a history of coronary artery disease s/p MI, diabetes mellitus, hyperlipidemia, and recent fall with rib fractures was admitted with nausea and vomiting, found to have myocardial ischemia. His hospital course was complicated by multifactorial shock, empyema formation, community acquired pneumonia, acute renal failure, and heart failure. 1. Myocardial Infarction Upon admission to the hospital, patient was found to have ST depressions in V4 through V6 with markedly elevated CK to a peak of 2843 with MB 618 and Troponin T peaked to 13.88. He was taken emergently to catheterization where he was found to have 3 vessel disease, aortic stenosis (valve area of .9), and cardiogenic shock. He had an intra-aortic balloon pump placed for improved blood pressures and coronary perfusion. He also required multiple vasopressors during his stay in the cardiac intensive care unit. His blood pressure slowly improved, and he was then restarted on his cardiac regimen of an aspirin, beta blocker, ACEI, and statin. He will need to follow-up with his primary cardiologist within 1-2 weeks of his discharge from the hospital. 2. Shock Patient was in shock during this hospitalization. Etiology was thought initially due to cardiogenic shock in the setting of his acute myocardial infarction. His blood pressure improved; however, he was then thought to be septic due to bacteremia. He was initially maintained with an intra-aortic balloon pump, levophed, and dopamine. His blood pressure improved with medical management of his heart disease and bacteremia. His liver function tests and creatinine were transiently elevated in the setting of his hypotension but improved throughout hospital course. 3. Sepsis Patient was found to have MSSA bacteremia with an associated MSSA empyema. With the help of infectious disease, he was ultimately treated with 3 week course of nafcillin to be completed on [**2190-3-12**]. He also had line associated coag negative staph bacteremia (1/4 bottles) and was treated with 7 day course of vancomcyin to be completed on [**2190-3-4**]. Repeat blood cultures were negative ad line was discontinued. Please see empyema discussion below. 4. Pneumonia Patient had an initial sputum culture which was positive for moraxella catarrhalis. He was treated with a course of levofloxacin with improvement in his symptoms. 5. Empyema During his hospitalization, patient developed recurrent fevers. Repeat chest CT imaging demonstrated development of a complicated left sided effusion. He underwent a thoracentesis by thoracic surgery and his effusion was consistent with an empyema. Cultures were positive for MSSA for which he was treated wtih nafcillin. He initially was maintained with a pleurex catheter. He self discontinued the pleurex catheter and his chest tube was slowly withdrawn by thoracic surgery. The empyema drain is still in place and daily CXR were done to monitor progress. He has an appt with a thoracic surgeon in 1 week with a CXR before the appt to evaluate the tube and possibly remove it. His nafcillin course is to be completed on [**2190-3-12**]. 6. Bacteremia During his hospitalization, patient developed recurrent fevers. Blood cultures and a catheter tip culture returned positive with MSSA. He was treated with a 7 day course of vancomycin which was to be completed on [**2190-3-4**]. Weekly labs need to be faxed to Dr. [**First Name (STitle) **], the ID fellow. 7. Respiratory Failure Patient was initially intubated within 24 hours of admission to the hospital due to desaturations presumed related to his shock. He underwent bronchoscopy on [**2190-2-18**] which did not demonstrate a clear cause of his respiratory failure. His respiratory status improved with diuresis, treatment of his underlying infection, and treatment of his cardiac disease. He had oxygen saturations in low-mid 90s on room air at time of discharge 8. Acute Kidney Injury Patient initially presented with marked acute kidney injury with a creatinine that peaked at 4 during his admission. Given his shock, fluid overload, and respiratory failure, patient was started on CVVH for a short time during his admission for aggressive fluid removal. His creatinine slowly improved back to approximately 2.7 - 2.9. Etiology of his renal failure was thought likely related to shock, infection, sepsis, and bacteremia. 9. Type 2 Diabetes Mellitus Patient was converted from multiple outpatient oral medications to insulin with an insulin sliding scale. His blood sugars were maintained on adequate control with fingerstick ranging from 100-200 on his sliding scale and long-acting basal insulin. Upon discharge, he was recommended to either transition back to his oral agents or consider starting insulin as an outpatient regimen and conducting insulin teaching. 10. Anemia Etiology appears most likely related to chronic inflammation, chronic renal insufficiency, sepsis, and multiple blood draws. Patient's baseline hematocrit appears to be in the low 30s with a previous hematocrit of 31.6 in [**2186**]. He is maintained on erythropoeitin and iron as an outpatient. His hematocrit has remained stable between 26-30 during the last 5 days of his admission. 11. Hyperlipidemia Patient was on vytorin as an outpatient. He was started on simvastatin during this admission. His liver function tests were abnormal during his admission, although this was thought likely related to his shock liver. His liver function tests were improved after starting simvastatin. 12. Peripheral Neuropathy He was continue on his gabapentin during his admission. Lyrica was also restarted during this admission as well as cymbalta. 13. Hypernatremia Patient did have complications of hypernatremia during this admission with a peak sodium of 150. He received free water to replete his free water deficit. Upon discharge, his sodium was 139. 14. Acute Systolic Heart Failure Patient was found to have a markedly reduced EF of [**10-7**]% thought likely related to ischemic heart disease. As patient's blood pressure improved, he was restarted on beta blocker, ACEI, and a decreased dose of lasix. We would recommend that his lasix be increased if he develops any signs of fluid overload. 15. Aortic Stenosis Patient was found to have a moderate aortic stenosis with a valve area of [**12-24**].2cm2. 16. Delirium Patient had brief episodes of delirium thought related to prolonged hospitalization and ICU course, medications related to benzodiazepines and opiates. His symptoms improved quickly with frequent reorientation and avoiding further sedating or altering medications. Upon discharge, he was oriented x 3. ACCESS: L PICC in place FULL CODE CONTACT: Wife [**Name (NI) 37953**] [**Name (NI) 65466**] [**Telephone/Fax (1) 65467**] (H), [**Telephone/Fax (1) 65468**] (C) Medications on Admission: Lasix 40mg [**Hospital1 **]-tid Glipizide 20mg [**Hospital1 **] Gabapentin 400mg, 3 in am, 3 in midday, 3 in pm, 1 at bedtime Metformin 1000mg [**Hospital1 **] Lyrica 50mg daily Prandin 2mg, 3 in am, 2 in midday, 2 in evening Carvedilol 3.125mg [**Hospital1 **] Nexium 40mg [**Hospital1 **] Cymbalta 60mg dialy Vytorin [**9-/2161**] daily Trazodone 50mg qhs prn (not taking) Januvia 100mg daily Provigil 200mg daily Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. Aspirin 325 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): Please hold for bowel movements > 2. Thanks. . 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-25**] Sprays Nasal QID (4 times a day) as needed. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**12-25**] Inhalation Q4H (every 4 hours) as needed. 11. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 4 days: Please continue through [**2190-3-4**]. . 12. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1) Intravenous Q4H (every 4 hours): Please continue through [**2190-3-12**]. . 13. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 14. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 15. Pregabalin 50 mg Capsule Sig: One (1) Capsule PO once a day. 16. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO daily (). 17. 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. 18. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 20. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. 22. Nafcillin 2 gram Piggyback Sig: One (1) dose Intravenous every four (4) hours for 9 days: last day [**2190-3-12**]. 23. Insulin Glargine 100 unit/mL Solution Sig: Seventeen (17) units Subcutaneous at bedtime. 24. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 1 days: Last day [**2190-3-4**]. 25. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Empyema 2. Acute Renal Failure 3. Myocardial Infarction 4. Acute on Chronic Systolic Heart Failure 5. Aortic Stenosis SECONDARY DIAGNOSIS: 1. Anemia Discharge Condition: Stable. Patient is tolerating oral intake and is alert and oriented x 3. Discharge Instructions: You were admitted to the hospital with chest pain. This was thought likely related to a heart attack, lung infection related to your recent falls and rib fractures, and rib fractures. For your heart attack, we started you on several new medications. For your infection, you are being treated with antibiotics. Your hospital course was also complicated by a severe blood infection for which you were treated with antibiotics. We made the following changes to your medications: - vancomycin - this is a medication to treat your infection. This should be stopped on [**2190-3-4**] - nafcillin - this is an antibiotic to treat your lung infection and this should be continued until [**2190-3-12**]. - insulin - this is a medication to treat your diabetes. While you are at rehab, they should be checking your blood sugars and will restart you on your home diabetes regimen of metformin, prandin, and januvia. - provigil - we have discontinued this medication -your ACE inhibitor was stopped because of acute renal failure, it should be restarted once your kidneys improve. . Please return to the hospital if you have any fevers, shaking chills, night sweats, worsening or changing shortness of breath, chest pain, lower extremity swelling, nausea, vomiting, diarrhea, or abdominal pain. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 Liters/day Followup Instructions: Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] within 2 weeks of discharge from rehab. Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: ([**Telephone/Fax (1) 18658**] Date/Time: Monday [**3-8**] at 2:15pm. Thoracic surgery: Dr.[**Last Name (STitle) **] Phone: [**Telephone/Fax (1) 65469**] Please follow-up your thoracic surgery team at your appointment scheduled on Tuesday [**3-9**] at 1:00 pm in [**Hospital1 **] [**Location (un) 859**] Chest Disease Center . Infectious disease: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: ([**Telephone/Fax (1) 6732**] Date/Time: [**4-2**] at 11am. [**Hospital Ward Name 517**] [**Last Name (NamePattern1) **], basement of [**Hospital Unit Name **].

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icd9cm

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4458

Discharge summary

report

Admission Date: [**2112-1-28**] Discharge Date: [**2112-2-3**] Date of Birth: [**2063-4-30**] Sex: M Service: NEUROSURGERY Allergies: Vicodin Attending:[**First Name3 (LF) 78**] Chief Complaint: CC:[**CC Contact Info 19114**] Major Surgical or Invasive Procedure: NONE INVASIVE EPLEY MANEUVER History of Present Illness: HPI: 48M fell while walking down stairs. Does not recall slipping but does recall trying to reach for railing but "my arm would not move." Struck the back of his head. Had severe dizziness after fall and was unable to stand up. Denies nausea, vomiting, chest pain, SOB, neck pain, back pain, or any other injuries. Patient had a history of an LP for bad headaches 12 years ago that showed xanthochromia. Workup by neurosurgery including angiogram never showed source or aneurysm. Grandfather died of aneurysm at age 82. Past Medical History: HIV ?????? well controlled, no history of Ois HepC - prior history of treatment trial, not tolerant of medications IDDM ?????? x 33 years, on insulin pump. A1C 5.6% Diabetic Nephropathy ?????? has proteinuria, on ACE Social History: Lives with wife and children. Wife very supportive. Family History: NC Physical Exam: PHYSICAL EXAM: O: T: 97.1 BP: 134/68 HR:84 R 20 99% RA O2Sats Gen: comfortable, NAD. HEENT: Pupils: 5 to 2 Bilaterally EOMI 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. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-25**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B Pa Right 2+ 2+ Left 2+ 2+ Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin On discharge - pt with non focal neuro exam / pain well controlled. Pertinent Results: RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2112-2-1**] 5:41 PM CT HEAD W/O CONTRAST; CT ORBITS, SELLA & IAC W/ & W/ Reason: Please do bilateral temporal bone head ct to rule out fractu [**Hospital 93**] MEDICAL CONDITION: 48 year old man with SAH/SDH, vertigo. REASON FOR THIS EXAMINATION: Please do bilateral temporal bone head ct to rule out fracture as well as ? SAH/SDH size, thanks. CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 48-year-old male with subarachnoid hemorrhage/subdural hemorrhage, now with vertigo. Concern for change in size of hemorrhage or fracture. COMPARISON: CTA head, [**2112-1-31**] and [**2112-1-30**]; cerebral angiogram, [**2112-1-29**]; MRA brain, [**2112-1-29**]; and non-contrast head, CT [**2112-1-28**]. TECHNIQUE: Non-contrast CT of the head and temporal bones. FINDINGS: Again demonstrated is the small subdural hematoma along the superior sagittal sinus near the vertex which is not appreciably changed. Suspected subdural hematoma of the inferior left frontal lobe is not well visualized on today's examination. No new sites of intracranial hemorrhage are identified. There is no shift of normally midline structures. The ventricular system is stable in size and configuration. There is no evidence of acute major vascular territorial infarction. There is mild mucosal thickening of the ethmoid sinus and moderate right maxillary sinus mucosal thickening. Opacification of several bilateral mastoid air cells is noted with small fluid levels in a few of the air cells. The middle ear cavities are clear. There is no evidence of temporal bone fracture. No gross abnormality of the bilateral ossicles or middle ear structures are identified. Minimal calcifications of the carotid siphons are noted. IMPRESSION: 1. No significant change in small subdural hematoma near the vertex along the superior sagittal sinus. 2. Suspected small subdural hematoma of the inferior frontal lobe, not well appreciated on today's examination. 3. Opacification of a small number of mastoid air cells, left greater than right. 4. No evidence of fracture. 5. Paranasal sinus mucosal thickening as described. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: TUE [**2112-2-2**] 8:34 AM RADIOLOGY Final Report CT ORBITS, SELLA & IAC W/ & W/O CONTRAST [**2112-2-1**] 5:41 PM CT HEAD W/O CONTRAST; CT ORBITS, SELLA & IAC W/ & W/ Reason: Please do bilateral temporal bone head ct to rule out fractu [**Hospital 93**] MEDICAL CONDITION: 48 year old man with SAH/SDH, vertigo. REASON FOR THIS EXAMINATION: Please do bilateral temporal bone head ct to rule out fracture as well as ? SAH/SDH size, thanks. CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 48-year-old male with subarachnoid hemorrhage/subdural hemorrhage, now with vertigo. Concern for change in size of hemorrhage or fracture. COMPARISON: CTA head, [**2112-1-31**] and [**2112-1-30**]; cerebral angiogram, [**2112-1-29**]; MRA brain, [**2112-1-29**]; and non-contrast head, CT [**2112-1-28**]. TECHNIQUE: Non-contrast CT of the head and temporal bones. FINDINGS: Again demonstrated is the small subdural hematoma along the superior sagittal sinus near the vertex which is not appreciably changed. Suspected subdural hematoma of the inferior left frontal lobe is not well visualized on today's examination. No new sites of intracranial hemorrhage are identified. There is no shift of normally midline structures. The ventricular system is stable in size and configuration. There is no evidence of acute major vascular territorial infarction. There is mild mucosal thickening of the ethmoid sinus and moderate right maxillary sinus mucosal thickening. Opacification of several bilateral mastoid air cells is noted with small fluid levels in a few of the air cells. The middle ear cavities are clear. There is no evidence of temporal bone fracture. No gross abnormality of the bilateral ossicles or middle ear structures are identified. Minimal calcifications of the carotid siphons are noted. IMPRESSION: 1. No significant change in small subdural hematoma near the vertex along the superior sagittal sinus. 2. Suspected small subdural hematoma of the inferior frontal lobe, not well appreciated on today's examination. 3. Opacification of a small number of mastoid air cells, left greater than right. 4. No evidence of fracture. 5. Paranasal sinus mucosal thickening as described. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: TUE [**2112-2-2**] 8:34 AM RADIOLOGY Final Report MRA BRAIN W/O CONTRAST [**2112-1-29**] 9:50 AM MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST Reason: Please evaluate for aneurysm or other vascular malformation. Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 48 year old man with SAH - likely nontraumatic. REASON FOR THIS EXAMINATION: Please evaluate for aneurysm or other vascular malformation. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 48-year-old with subarachnoid hemorrhage. Please evaluate for aneurysm or vascular malformation. There are no prior MRAs available for comparison. Comparison is made with the CT head from [**2112-1-28**]. TECHNIQUE: Three-dimensional time-of-flight MR arteriography was performed with rotational reconstructions. FINDINGS: There is a large PCA on the right, likely a normal variant. There is a small, triangular 1.5-mm protrusion at the probable origin of the left ophthalmic artery, close to the area of recent hemorrhage. However the ophthalmic artery itself is not seen and thus this cannot definitively be called an infundibulum. There is a large PCA which is likely a normal anatomic variant. The remaining intracranial, vertebral and internal carotid arteries and their major branches appear normal. There is no evidence of stenosis, occlusion or aneurysm formation. IMPRESSION: There is a small protrusion at the expected origin of the left ophthalmic artery, which does not meet all the criteria for an infundibulum, as the origin of the ophthalmic artery is not seen. As a result recommend CTA or cerebral angiography for further evaluation of the opthalmic artery. There is a large PCA which is likely a normal variant. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) 19115**] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**] Approved: SAT [**2112-1-30**] 9:36 PM RADIOLOGY Final Report MRA NECK W&W/O CONTRAST [**2112-1-29**] 9:50 AM MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST Reason: Please evaluate for aneurysm or other vascular malformation. Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 48 year old man with SAH - likely nontraumatic. REASON FOR THIS EXAMINATION: Please evaluate for aneurysm or other vascular malformation. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 48-year-old with subarachnoid hemorrhage. Please evaluate for aneurysm or vascular malformation. There are no prior MRAs available for comparison. Comparison is made with the CT head from [**2112-1-28**]. TECHNIQUE: Three-dimensional time-of-flight MR arteriography was performed with rotational reconstructions. FINDINGS: There is a large PCA on the right, likely a normal variant. There is a small, triangular 1.5-mm protrusion at the probable origin of the left ophthalmic artery, close to the area of recent hemorrhage. However the ophthalmic artery itself is not seen and thus this cannot definitively be called an infundibulum. There is a large PCA which is likely a normal anatomic variant. The remaining intracranial, vertebral and internal carotid arteries and their major branches appear normal. There is no evidence of stenosis, occlusion or aneurysm formation. IMPRESSION: There is a small protrusion at the expected origin of the left ophthalmic artery, which does not meet all the criteria for an infundibulum, as the origin of the ophthalmic artery is not seen. As a result recommend CTA or cerebral angiography for further evaluation of the opthalmic artery. There is a large PCA which is likely a normal variant. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) 19115**] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**] Approved: SAT [**2112-1-30**] 9:36 PM Cardiology Report ECG Study Date of [**2112-1-28**] 5:50:54 PM Normal sinus rhythm. Normal tracing. Mild baseline artifact. No significant change compared with tracing [**2102-8-17**]. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S. Intervals Axes Rate PR QRS QT/QTc P QRS T 65 162 90 400/408 56 27 51 ([**Numeric Identifier 19116**]) RADIOLOGY Preliminary Report CAROT/CEREB [**Hospital1 **] [**2112-1-29**] 3:44 PM CAROT/CEREB [**Hospital1 **] Reason: r/o aneurysm Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 48 year old man with SAH REASON FOR THIS EXAMINATION: r/o aneurysm HISTORY: 48-year-old male patient with subarachnoid hemorrhage to rule out aneurysm. TECHNIQUE: Informed consent was obtained from the patient after explaining the risks, indication and alternative management. Risks explained included stroke, loss of vision and speech, temporary or permanent with possible treatment with stent and coils if needed. The patient was brought to the interventional neuroradiology theater and placed on the biplane table in the supine position. Both groins were prepped and draped in the usual sterile fashion. A patient timeout was performed by two patient identifiers. Access to the right common femoral artery was obtained using a 19-gauge single wall needle, under local anesthesia using 1% lidocaine mixed with sodium bicarbonate and with aseptic precautions. Through the needle, a 0.35 [**Last Name (un) 7648**] wire was introduced and the needle taken out. Over the wire, a 5 French vascular sheath was placed and connected to saline infusion (mixed with heparin 500 units in 500 cc of saline) with a continuous drip. Through the sheath, a 4 French Berenstein catheter was introduced and connected to continuous saline infusion (with heparin mixture: 1000 units of heparin in 1000 cc of saline). The following vessels were selectively catheterized and arteriograms were performed from these locations. After review of films the catheter and the sheath were withdrawn and pressure was applied on the groin until hemostasis was obtained. The procedure was uneventful and the patient tolerated the procedure well without complications. The patient was sent to the floor with orders. The following blood vessels were selectively catheterized and arteriograms were obtained in the AP and lateral projections. 1. Right internal carotid artery. 2. Left internal carotid artery. 3. Right common carotid artery. 4. Left common carotid artery. 5. Right vertebral artery. 6. Left vertebral artery. The left posterior communicating artery appears prominent. The left vertebral artery is seen supplying the anterior spinal artery. There is no evidence of any aneurysms, AV fistulas, AV formations, stenosis or occlusions. IMPRESSION: Cerebral angiogram of the above-mentioned vessels demonstrated no evidence of any aneurysm, vascular malformation, stenosis or occlusion. The attending, Dr. [**Last Name (STitle) **] was scrubbed and present for the entire procedure. DR. [**First Name8 (NamePattern2) 19117**] [**Name (STitle) **] DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] PreliminaryApproved: TUE [**2112-2-2**] 2:29 PM Brief Hospital Course: Pt was admitted to the hospital to the ICU for observation and close monitoring after slip and fall resulted in Subarachnoid hemorrhage and subdural hematoma. Pt underwent Angiogram which was negative for aneurysm. He was started on Nimodipine. Stroke consult was obtained for intial syncope workup. He was placed on meclizine for continued complaints of vertigo. He was transferred to a regular floor and evaluated by the ENT team for the c/o vertigo. They performed Epley Maneuver from which the pt has relief of symptoms. They diagnosed him with benign positional vertigo. He was seen by PT and deemed safe for discharge with a home safety eval. His dilantin and nimodipine were stopped as he has never had a sz during this stay nor is his SAH thought to be aneurysmal. he was d/c'd to home without pain medication per his request. Follow up and instructions were discussed. Medications on Admission: Medications prior to admission: Atripla Crestor Lipitor Lisinopril Insulin ASA - last dose was one week ago - stopped it because he has a planned surgery for hernia repair soon. Discharge Medications: 1. ATRIPLA Oral 2. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: benign positional vertigo subarachnoid hemorrhage Discharge Condition: STABLE Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit - YOUR DILANTIN WAS STOPPED, YOU DID NOT HAVE A SEIZURE. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F AVOID SUDDEN MOVEMENTS OF YOUR HEAD - THIS WILL POSSIBLY REVERSE THE POSITIVE OUTCOME THAT YOU'VE HAD WITH THE EPLEY MANEUVER. IF YOU HAVE QUESTIONS REGARDING WHEN THIS ACTIVITY RESTRICTION IS COMPLETE = PLEASE CALL THE OTOLARYGOLOGY DEPARTMENT FOR DR. [**First Name (STitle) 3880**]. Followup Instructions: Dr. [**First Name (STitle) **] / Otoloaryngology as needed [**Telephone/Fax (1) **] Follow up with your primary care physician within the next 2 weeks You DO need to follow up in the Neurosurgery Department with Dr. [**Known firstname **]. PLEASE CALL THE OFFICE FOR AN APPOINTMENT TO BE SEEN IN 4 WEEKS WITH A CAT SCAN OF THE BRAIN TO EVALUATE FOR YOUR SUBDURAL COLLECTIONS. TAKE YOUR [**Hospital **]HOSPITAL MEDICATION AS PREVIOUSLY PRECRIBED AS PER YOUR REQUEST YOU ARE NOT BEING SENT HOME WITH A PRESCRIPTION FOR NARCOTIC/ PAIN CONTROL. YOU HAVE THE FOLLOWING APPOINTMENTS ALREADY IN THE SYSTEM THEY ARE LISTED BELOW FOR YOUR REMINDER Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6400**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2112-3-24**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2112-4-26**] 4:00 Completed by:[**2112-2-3**]

[ "250.01", "851.82", "V08", "386.11", "070.70", "E880.9", "430", "401.9", "272.4" ]

icd9cm

[ [ [] ] ]

[ "88.41", "38.91" ]

icd9pcs

[ [ [] ] ]

16120, 16178

14637, 15525

300, 331

16272, 16281

2574, 2769

18011, 18983

1214, 1218

15754, 16097

11936, 11961

16199, 16251

15551, 15551

16305, 17988

1248, 1490

15583, 15731

230, 262

11990, 14614

359, 888

1678, 2555

1505, 1662

910, 1128

1144, 1198