ChanBeDu/relevant_section_length · Datasets at Hugging Face

47,305

105,080

36279

Discharge summary

report

Admission Date: [**2158-5-27**] Discharge Date: [**2158-6-13**] Date of Birth: [**2104-3-25**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: 54 yo male s/p unwitnessed fall down 12 stairs. (+) EtOH. Transported to an area hospital where found to have intracranial hemorrhage and was then transferred to [**Hospital1 18**] for further care. Past Medical History: EtOH abuse Seizure history Schizoaffective disorder Family History: Noncontributory Physical Exam: Upon admission: BP: 103/80 70 14 100% Gen: WD/WN, NAD. HEENT: Pupils: brisk 4-2 mm b/l Pupils, mid-position / conjugate Neck: in cervical collar Neuro: Intubated / No eye opening to voice or noxious, PERRL 4-2mm bilaterally, conjugate gaze, trace corneals bilaterally, localizes briskly with LUE, no movement noted to RUE or B/L LE's. PR equivocal bilaterally / no clonus noted. Pertinent Results: [**2158-5-27**] 06:31PM TYPE-ART PO2-163* PCO2-38 PH-7.40 TOTAL CO2-24 BASE XS-0 [**2158-5-27**] 03:39PM LACTATE-0.8 [**2158-5-27**] 03:25PM GLUCOSE-102 UREA N-3* CREAT-0.6 SODIUM-133 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-22 ANION GAP-15 [**2158-5-27**] 03:25PM CALCIUM-7.4* PHOSPHATE-2.4* MAGNESIUM-2.1 [**2158-5-27**] 03:17AM WBC-15.7* RBC-3.94* HGB-11.1* HCT-33.3* MCV-85 MCH-28.2 MCHC-33.3 RDW-15.3 [**2158-5-27**] 01:50AM PLT COUNT-470* [**2158-5-26**] 11:11PM ASA-NEG ETHANOL-265* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**5-27**]: CT Head left SDH measures up to 5 mm thick. left sided SAHs. mild sulcal effacement and mass effect on lt lat ventricle. no midline shift. rt parietal subgaleal hematoma. fxr through squamous portion of rt temporal bone, rt zygomatic arch, likely lateral wall rt maxillary sinus. chronic sinus mucosal dz. . [**5-27**] CT CSpine: No C-spine fx. Multilevel DJD. Compression deformities of T1 and T2 superior end [**Last Name (LF) **], [**First Name3 (LF) **] be chronic. . [**5-28**]: Repeat CT Head: WET READ: no new hemorrhage . [**5-28**]: Repeat CT CSpine: WET READ: Lucency lateral body of dens on right side, ? associated cortical irregularity- only on coronal images. . [**5-30**] Chest AP Lung volumes have improved though there is still moderate atelectasis at both lung bases. Upper lungs clear. Heart size top normal. No appreciable pleural effusion. Brief Hospital Course: He was admitted to the Trauma Service. Neurosurgery, Orthopedic Spine, Plastics and ENT were consulted given his multiple injuries. He underwent CT imaging from head to toe and was then transferred to the Trauma ICU for close monitoring. He remained in the ICU for approx 1 week and was extubated after several days. A Dobbhoff was placed and tube feedings were initiated. His subarachnoid and subdural hemorrhages were managed non operatively; he was loaded with Dilantin and started on a standing dose; the Dilantin will need to continue until he follows up in neurosurgery clinic in 4 weeks. Serial head CT scans were followed and remained stable. Of note due to his high blood alcohol level at time of admission he was activity having delirium tremors requiring benzodiazepines for control. Psychiatry was consulted and made several recommendations pertaining to use of the benzodiazepines. It was felt that he was had high levels of diazepam in his blood further contributing to his delirium and it was recommended that they be stopped and that his clonazepam be restarted at a lower dose than his home dose. He is currently on clonazepam 1 mg [**Hospital1 **] and his Zyprexa was restarted at HS. His mental status improved significantly; he is awake and cooperative with care. He is oriented to himself. His cervical spine dens fracture was also managed non operatively with a hard collar. This will need to be worn for at least 4-6 weeks at which time he will follow up in Spine clinic for repeat CT imaging. Plastics was consulted for the facial fractures and these were also considered non operative. He will follow up in 2 weeks in Plastic Surgery clinic. ENT was also consulted for temporal bone fracture; no operative intervention warranted. he will require an outpatient audiogram after discharge in the next several weeks. Once he was transferred to the nursing unit and as his mental status improved patient inadvertently removed his Dobbhoff. A bedside swallow evaluation was done and he was able to tolerate without signs of aspiration. His diet was upgraded from NPO with tube feedings to a soft diet. Dietary supplements were added as well. He does have a robust appetite. On evening before schedule discharge to rehab he was noted with a fever spike after his central line was removed. A complete fever workup was done which included blood cultures which did come back positive for Gram positive cocci in clusters. He was started on Vancomycin. Infectious Disease was consulted; it was recommended that he undergo repeat imaging of his head and cervical spine and a tagged white cell scan. Results of the tagged white cell scan revealed infectious source as the left knee. He was taken to the operating room for washout, a drain was left in place for a couple of days. His Nafcillin was recommended by ID to continue for another 4 weeks. A PICC line was placed for this purpose. He was evaluated by Physical therapy and is being recommended for rehab after his acute hospital stay. Social work was consulted for coping and EtOH related issues. Medications on Admission: metoprolol 50", trazadone 100 qhs, Zyprexa 20', Doxepin 25', Clonazepam 1"", Zoloft(unsure dose..started 50') Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-10**] hours as needed for pain. 2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 Units Injection TID (3 times a day). 4. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Olanzapine 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 9. Erythromycin Ethylsuccinate 200 mg/5 mL Suspension for Reconstitution Sig: One Hundred (100) MG PO Q6H (every 6 hours). 10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): Check levels weekly and prn based on dose changes. 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for SBP<110/HR <60. 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 15. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) GM Intravenous Q4H (every 4 hours) for 4 weeks. 16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: s/p Fall Subdural hemorrhage Subarachnoid hemorrhage Facial fractures C2 fracture right lateral body MSSA Bacteremia Infected left knee Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: The cervical collar must continue to be worn for at leat [**4-10**] weeks until told to discontinue by Spine Surgery. The Dilantin will need to continue until follow up with Neurosurgery in 4 weeks. Continue the antibiotics for a total of 4 weeks. DO NOT blow your nose or drink through a straw because of your facial fractures. Followup Instructions: Follow up next week in clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP for Dr. [**Last Name (STitle) **], Orthopedics. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow up in 2 weeks with Orthopedic Spine Surgery, call [**Telephone/Fax (1) 3736**] for an appointment. Follow up in 2 weeks with Plastic surgery for your facial fractures; call [**Telephone/Fax (1) 5343**] for an appointment. Follow up in 2 weeks with ENT; an audiogram as an outpatient to assess hearing function is needed. Call [**Telephone/Fax (1) 2349**] for an appointment. Follow up in 4 weeks with Dr. [**Last Name (STitle) 548**], Neurosurgery, call [**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will need a follow up head CT scan for this appointment. Completed by:[**2158-6-21**]

[ "711.06", "801.36", "345.90", "E849.7", "719.01", "291.0", "401.9", "038.11", "295.72", "802.0", "E880.9", "802.4", "873.43", "995.91", "276.1", "805.02", "348.39", "E884.4" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "80.86", "81.91", "96.6", "27.51" ]

icd9pcs

[ [ [] ] ]

7408, 7478

2550, 5623

323, 329

7658, 7738

1096, 2154

8119, 8955

649, 666

5783, 7385

7499, 7637

5649, 5760

7762, 8096

681, 683

275, 285

357, 557

2163, 2527

699, 1077

579, 633

31,507

113,503

53411

Discharge summary

report

Admission Date: [**2103-7-29**] Discharge Date: [**2103-8-2**] Date of Birth: [**2046-3-31**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 949**] Chief Complaint: Hemetemesis Major Surgical or Invasive Procedure: endoscopy s/p banding History of Present Illness: 57F H/O ETOH cirrhosis with known varices admitted [**2103-7-29**] with hematemesis x3 on the prior night. +nausea during the day, then ~9pm she vomited several mouthfuls of bright red blood. She then had an episodes of coffee ground emesis around midnight, thus came to ED. . Per the patient and her husband, she tends to be chronically hyponatremic with a Na ~130 at baseline. She also tends to have a low BP, with SBP 80-90 when in the hospital and 95-110 out of the hospital. . In the ED, her vitals were T 100.6 103 84/56 20 100%2L. she was given 2 L NS, octreotide 50mg IV once, protonix IV once, zofran 4mg iv and ativan 1mg iv. The patient had one more episode of hematemesis in the ED. The patient refused NG lavage. . Per ICU note, on arrival to the floor she was hypotensive with sbps in the 80s. Hepatology saw her and scoped her emergently in the CCU. Upon arrival to the MICU VS= 99.6 92/42 88 16 100%RA. EGD revealed 4 cords of varices without active bleeding. Banding was performed. . She received a total of 2U PRBCs since admission (last [**2103-7-29**] 5am), her HCT improved from 20->27->26->26->24 over 24hrs. She is being called out to the medical floor for further management of presumed GIB, hyponatremia and etoh cirhosis. Past Medical History: - ETOH cirrhosis with known varices - The patient lives in [**State 108**] and was diagnosed with ETOH cirrhosis around 1 year ago. She had an EGD several weeks ago that showed evidence of esophageal varices, was tried on trial of beta blocker, but failed secondary to hypotension. She has had 2 paracenteses in the past and denies history of SBP, though has been on cipro in past per her husband. She is not currently on the transplant list. The patient reports that her last drink was when she found out that she had liver disease. . denies CAD/HTN/DM/PE/DVT/cancer, beleives she had a stroke, though not diagnosed by MD. Social History: Social History: Pt. lives in [**State 108**] and is here visiting her ill mother. [**Name (NI) **] reports drinknig [**1-24**] glasses of wine a night for years, and then for the last 4 years drinking about 3 cocktails a night. She reports not drinking since learning of her diagnosis [**5-30**], per son prior to that was drinking 0.5 bottles wine/day x 5 yrs. Family History: Family history: denies family history of liver disease, DM. Family history of CA. Physical Exam: Vitals: 99.3 84 94/50 24 100%RA Gen: no acute distress HEENT: Clear OP, dry mucous membranes NECK: Supple, No LAD, No JVD CV: RR. NL S1, S2. 3/6 SEM loudest @ apex (first heard here) LUNGS: crackles @ bilateral bases ABD: Soft, distended, mild diffuse TTP, no rebound or gaurding. negative fluid wave. EXT: No edema. 2+ DP pulses BL SKIN: spider hemangeomas, diffuse NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**1-24**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred. faint axterixis PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Admission Labs: WBC-17.1* Hgb-8.6* Hct-25.7* MCV-92 Plt Ct-267 Neuts-66 Bands-5 Lymphs-23 Monos-3 Eos-1 Baso-0 Atyps-2* Metas-0 Myelos-0 Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-1+ Stipple-1+ PT-16.3* PTT-36.2* INR(PT)-1.5* Glucose-94 UreaN-31* Creat-1.2* Na-123* K-5.5* Cl-88* HCO3-27 ALT-33 AST-53* LD(LDH)-255* AlkPhos-99 TotBili-2.0* . Discharge Labs: WBC-6.3 Hgb-8.2* Hct-24.6* MCV-91 MCH-30.6 Plt Ct-148* Glucose-84 UreaN-7 Creat-0.9 Na-133 K-3.3 Cl-100 HCO3-25 Calcium-8.0* Phos-3.2 Mg-1.3* . Studies: [**2103-7-29**] EGD: Findings: Esophagus: Lumen: A medium size hiatal hernia was seen. Protruding Lesions 4 cords of grade II varices were seen in the lower third of the esophagus. The varices were not bleeding. Stomach: Mucosa: Diffuse continuous congestion, erythema, friability and mosaic appearance of the mucosa with contact bleeding were noted in the antrum, stomach body and fundus. These findings are compatible with portal hypertensive gastroapthy. Other procedures: 4 bands were successfully placed in the lower third of the esophagus. Impression: Varices at the lower third of the esophagus Medium hiatal hernia Congestion, erythema, friability and mosaic appearance in the antrum, stomach body and fundus compatible with portal hypertensive gastroapthy (ligation) Otherwise normal EGD to second part of the duodenum [**2103-7-30**] CXR: The cardiomediastinal silhouette is stable. There is increase in distention of the azygos vein which might represent volume overload. There is no evidence of pulmonary edema. The new opacity in the right lower lung most likely consistent with the right middle lobe atelectasis. There is no evidence of pleural effusion. Rib fractures partially healed on the left are again noted. . [**2103-7-30**] RUQ U/S: No portal vein thrombosis. 1. Minimal free fluid noted in the perihepatic space not sufficient for diagnostic or therapeutic paracentesis. . 2. Please note the gallbladder was not visualized. In the absence of history of cholecystectomy, this could reflect a collapsed gallbladder obscured by overlying bowel gas. Otherwise unremarkable abdominal ultrasound. . [**2103-7-31**] Liver U/S with doppler IMPRESSION: 1. 3.9 cm solid right hepatic mass. A multiphasic CT or MRI is recommended for further characterization. 2. Patent hepatic vasculature. 3. Trace of ascites. 4. Splenomegaly. . Brief Hospital Course: 57 year old female with a history of alcoholic cirrhosis with known varices presenting with likely variceal bleed. . 1. Upper GI Bleed: The patient has known esophageal varices. She was initially admitted to the MICU and GI was consulted for bleeding and an EGD was performed. Banding was done by hepatology with no evidence of active bleeding. Her hematocrit dropped from 25.7 to 20.8 between 11am [**7-28**] and 3am [**7-29**]. The patient was transfused 2 units PRBC on the morning of [**7-29**] with an increase in Hct to 27.8 A repeat Hct later in the day on [**7-29**] was 26.2. Hct the morning of [**7-30**] was stable at 26.1. The patient was maintained on protonix IV BID, octreotide gtt, and sucralfate PO. She received ceftriaxone 1g QD X5 days ([**7-29**] - [**8-2**]) for prophylaxis in the setting of a GI bleed. On the evening of [**7-30**] the patient was transferred to the hepatology service. Her hematocrit remained stable and she was switched to PO protonix. On discharge she was adivsed to follow-up with a repeat EGD in 2 weeks time, either with Dr. [**Last Name (STitle) 10285**] in [**Location (un) 86**], or with her gastroenterologist in [**State 108**] with whom she already has an appointment. . 2. EtOH Cirrhosis: The patient's home rifaximin and lactulose were held at presentation as the patient was NPO. There was no evidence of ascites on clinical exam. Ultrasound of the liver showed trace ascites, though not enough to be tapped. Lactulose and rifaximin were restarted on [**7-30**]; lasix and aldactone were initially held and restarted on [**7-31**] as the patient had developed worsening ascities. The ascities decreased somewhat for the remainder of her hospital stay after the diuretics were restarted. LFTs, INR, and Tbili were monitored and decreased from presentation to [**7-30**]. Doppler of the portal vein showed patent hepatic vasculature. . 3. Hyponatremia: The patient had hyponatremia at presentation which was thought to be related to diuretic use as the patient was on lasix QD and aldactone TID at home. This could have also been related to dehydration as patient got several liters of NS in the ED. There was also likely a component of hypotonic/hypervolemic hyponatremia secondary to the patient's known cirrhosis. The sodium increased to 129 on the morning of [**7-30**] and further increased to 133 on the day of discharge. . 4. Leukocytosis: The patient had a WBC of 17 on the day of admission ([**7-29**]). There was no clear source as there were no localizing symptoms, the patient was afebrile and CXR was negative for any acute processes. Blood cultures were negative. Admission urine culture grew out 3000 probable Enterococcus. The WBC decreased to 8 on the morning of [**7-30**]. Ceftriaxone was continued in the setting of the GI bleed. A second urine culture collected on [**8-1**] grew out only skin flora. . 5. Pain: The patient has a high opiate use at home (Percocet) and repeatedly complained of pain during her MICU stay, most often in the area of the esophagus after her EGD. She was put on morphine 2mg IV Q3h PRN and ativan 1-2mg Q4h PRN. She also received trazodone 50mg on the night of [**7-28**] for help with anxiety and sleeping, and was noted by nursing to also take some of her home pills "from her purse" which helped her to sleep. When she was tranferred to the floor, her home medications were held by nursing and she received oxycodone 5mg Q6H PRN and ativan. . 6. Chest pain: The patient reported pain in the area of the esophagus after the EGD procedure. Her EKG was negative and it was felt that the pain was unlikely to be related to an MI given its longevity and initiation around time of EGD. She likely had pain associated with the EGD and anxiety. The patient also likely has a low pain tolerance, but high opiate requirement, given her pain medication usage at home. There was no crepitus on exam. Her pain regimen was continued as per above. CXR on the morning of [**7-30**] showed no evidence of free air. . 7. Depression: Stable during the hospital course, though likely above her baseline given that she was in the city visiting her ill mother before her episodes of hematemesis. Home wellbutrin was held while she was NPO. Wellbutrin was restarted on the afternoon of [**7-30**] when she was taking PO. . 8. FEN: She was kept NPO for her GI bleed 24 hours after EGD and restarted on a liquid diet on [**7-30**]. She was advanced to a regular diet as tolerated. . 9. Prophylaxis: DVT prophylaxis with pneumoboots . 10. CODE: DNR/DNI Medications on Admission: Centrum silver Lasix 40 mg QD Aldactone 100mg TID Wellbutrin 150 mg [**Hospital1 **] Lactulose 45 mL QID Xifaxan 400 mg TID Milk thistle 175 mg QD Restoril 30 mg QHS Dulcolax Oxycodone and ativan prn Q6H Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 1 weeks. Disp:*28 Tablet(s)* Refills:*0* 4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 5. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO QID (4 times a day). Disp:*5400 ML(s)* Refills:*2* 6. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 9. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain for 1 weeks. Disp:*21 Tablet(s)* Refills:*0* 11. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for 5 days. Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: end stage liver disease cirrhosis esophageal varices and upper GI bleed Secondary: Depression Discharge Condition: stable, pain free, hematocrit Discharge Instructions: You had an upper GI bleed to to a bleeding esophageal varices from your liver cirrhosis. These were banded and you should have a repeat endoscopy in a few weeks to evaluate the varices. Please take all medications as directed. Please stop taking your restoril and ativan as it may cause excessive somnolence. Please attend your follow-up appointments. You have an appointment with Dr. [**Last Name (STitle) **] on [**2103-8-15**]. PLease call your doctor if you have any nausea, vomiting, abdominal pain, fevers, bloody vomit, black or tarry stools, bloody stools, or any other concerning symptoms. Followup Instructions: Please call [**Telephone/Fax (1) 463**] if you need to reschedule. Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2103-8-15**] 10:30 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2103-8-15**] 10:30

[ "553.3", "571.2", "285.1", "456.20", "276.1", "303.90", "572.3", "311", "789.59", "537.89", "288.60" ]

icd9cm

[ [ [] ] ]

[ "42.33" ]

icd9pcs

[ [ [] ] ]

12033, 12091

5848, 10419

325, 349

12239, 12271

3426, 3426

12922, 13241

2687, 2755

10674, 12010

12112, 12218

10445, 10651

12295, 12899

3819, 5825

2770, 3407

274, 287

377, 1627

3442, 3803

1649, 2275

2307, 2655

9,702

177,827

21485

Discharge summary

report

Admission Date: [**2138-12-26**] Discharge Date: [**2139-1-2**] Date of Birth: [**2060-8-14**] Sex: M Service: SURGERY Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 2597**] Chief Complaint: Aorto-illiac disease Major Surgical or Invasive Procedure: Open Aorto-bifemoral bypass with [**Female First Name (un) 899**] reimplantation History of Present Illness: Pt is a 78 year old man who presents with thigh claudication who comes to the hospital today for aorto-bifemoral bypass Past Medical History: Aorto-illiac disease CABG HTN Social History: Married, one child, retired electrician No ETOH or Tobacco Family History: Mother with esophageal CA Sister with MI Physical Exam: 98.6 74 16 131/40 96%RA AOx3 NAD RRR CTA Abd: soft, non-tender, no mass ext: warm, well perfused Pertinent Results: [**2138-12-26**] 06:51PM BLOOD WBC-9.8 RBC-3.51* Hgb-10.9*# Hct-32.5* MCV-93 MCH-31.0 MCHC-33.5 RDW-13.1 Plt Ct-624* [**2138-12-26**] 06:51PM BLOOD Plt Ct-624* [**2138-12-26**] 06:51PM BLOOD PT-16.0* PTT-46.2* INR(PT)-1.6 [**2138-12-26**] 06:51PM BLOOD Glucose-164* UreaN-21* Creat-0.5 Na-140 K-4.6 Cl-111* HCO3-26 AnGap-8 [**2138-12-26**] 06:51PM BLOOD Calcium-8.0* Phos-3.3 Mg-1.4* Brief Hospital Course: The patient was left intubated post operation due to some concerns of hypotenstion. This resoled quickly and he was extubated. He was extubated by the AM of POD1. He did well postoperativly. He had epidural anesthesia, which provided good pain control. He was moved to the VICU on POD1. His diet was held until flatus was passed. His INR was revered with Vit K. A bleeding time was done to assess coagulation, which was normal. His swan catheter was changed to cvl on POD 3 due to stable cardiac function. In the OR, a stomach mass was found, so Dr.[**Name (NI) 1482**] service was consulted, he will f/u as an outpt. He was found to have a weak left deltoid, and neurology was consulted. After extensive radiological study, no definate cause for his weakness was found, but it had almost complealty resolved by the time of discharge. Otherwise his diet advanced without incident and he did well from a PT persepective. He was d/c'ed on POD 7 on coumadin to be followed by his PCP. Medications on Admission: Lipitor 40' verapamil 180' altace 5' asa 81mg' mvi lasix 20' doxycycline 100" vit E Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Verapamil HCl 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 5. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 9. Outpatient Lab Work Please Draw PT/INR Three times a week Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: abdominal aortic aneurysm Discharge Condition: Good Discharge Instructions: Notify your MD if you experience increasing pain in the abdomen or back, pain, coldness or discoloration of either of your feet or any other sign that is concering to you. Get yor INR checked three times a week through your PCP Followup Instructions: Call both Dr. [**Last Name (STitle) **] and your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5456**] for follow up. Call Dr.[**Name (NI) 56701**] office as soon as you get home to set up your first blood draw Also, call Dr.[**Name (NI) 1482**] office for follow up regaring stomach mass Completed by:[**2139-1-2**]

[ "272.0", "496", "414.00", "444.0", "441.4", "V45.81", "427.31" ]

icd9cm

[ [ [] ] ]

[ "39.59", "38.93", "39.25" ]

icd9pcs

[ [ [] ] ]

3232, 3290

1269, 2265

306, 389

3359, 3365

861, 1246

3641, 3974

683, 725

2399, 3209

3311, 3338

2291, 2376

3389, 3618

740, 842

246, 268

417, 538

560, 591

607, 667

23,304

129,458

1839+55327

Discharge summary

report+addendum

Admission Date: [**2141-2-8**] Discharge Date: [**2141-2-21**] Service: MEDICINE Allergies: Tomato / Lorazepam Attending:[**First Name3 (LF) 1928**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: None History of Present Illness: 87 year-old man CAD s/p distant MI and 3V CABG, chronic systolic heart failure with EF 30%, h/o Afib not on coumadin, and multiple cancers (metastatic stage 4 colon + bladder cancer), with recent admission for N/V/D, diagnosed with ileus s/p NGT decompression and negative microbiologic workup including sigmoidoscopy to r/o CMV, complicated by HAP on Vanco and Cefepime who now presents from [**Last Name (un) 2299**] house for reported HCT 22 and question of GI bleed. Hct was 25.2 on discharge a few days ago and negative sigmoidoscopy as above. Abd exam unchanged and trace guaiac + per referring physician. In the ED, initial vs were: T 99 HR 96 BP:118/50 RR22 O2Sat:99 on NRB. Patient has now been weaned down on NC. On exam patient had rectal pain, guaiac pos brown stool from below. Noted to have abdominal distension. He underwent CT Abdomen and Pelvis which showed tree in [**Male First Name (un) 239**] opacities in bilateral lungs and bilateral pleural effusions and consolidations consistent with recent HAP, no SBO. Patient was given Flagyl to cover gastrointestinal pathogens. Labs revealed HCT of 23.6. Transfused 1unit pRBCs slowly given EF 30% but also given 1L NS. New worsening renal function on labs and new trop in the context of ARF. BPs in high-90s with tachycardia to low 100s in MAT vs Afib/PVCs so sent to the unit for better monitoring. [**Male First Name (un) **] in case he rules in. VS HR 115, 106/58, 23, 97% 3L NC. Past Medical History: 1. Hypertension. 2. Hyperlipidemia. 3. Congestive heart failure with previous EF 25-30% in [**2137**]. 4. Perioperative atrial fibrillation in [**2136**], not on coumadin now. 5. Basal cell carcinoma. 6. colon cancer dx [**2136**], status post ileocecectomy on [**4-/2137**] with Dr. [**Last Name (STitle) **]. Mets to liver discovered [**2137**] and now status post metastatectomy via hepatectomy in 10/[**2137**]. ? Additional mets discovered [**2139**], s/p cyberknife therapy to liver. 7. Coronary artery disease, status post ST elevation MI in [**2125**] and three-vessel CABG in [**3-/2128**] (LIMA to the LAD, vein graft to the first obtuse marginal and to the right PDA) 8. Acute cholecystitis and cholecystectomy in [**2077**]. 9. Bladder Cancer [**2139**] followed by Dr. [**Last Name (STitle) 261**] 10. S/p left carotid endarterectomy Social History: The patient is a previous mechanical engineer. He smoked occasionally but quit 35 years ago. He denies any alcohol use. Lives alone and is independent. No close relatives in the area. Siblings in [**Location (un) 3156**]. Family History: The patient does not have a significant family history of cancer. Physical Exam: Vitals: T: 97.8 BP:130/70 P:113 R: 18 O2: 97on 4L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP 3cm above clavicle, no LAD Lungs: Wheezes anteriorly with rales at bilateral bases CV: Tachycardic, irregularly irregular, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: No foley Ext: Warm, well perfused, edema bilaterally to shins. Left foot erythematous, warm, slight TTP Pertinent Results: [**2141-2-8**] WBC-6.6 RBC-2.55* Hgb-7.7* Hct-23.6* MCV-93 Plt Ct-272 Neuts-79.6* Lymphs-12.3* Monos-6.3 Eos-1.5 Baso-0.3 PT-14.4* PTT-27.8 INR(PT)-1.3* Glucose-202* UreaN-39* Creat-2.1* Na-139 K-4.5 Cl-100 HCO3-29 AnGap-15 ALT-36 AST-36 CK(CPK)-39* AlkPhos-138* TotBili-0.3 CK-MB-NotDone proBNP-6751* cTropnT-0.04* CK-MB-3 cTropnT-0.03* CK(CPK)-43* Calcium-7.7* Phos-3.5 Mg-2.6 Albumin-2.4* Lactate-2.0 EKG: NSR with frequent PACs, normal axis, Q-wave III, AVF unchanged from prior ECHO [**2141-2-1**]: The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the septum, inferior, and inferolateral walls. The remaining segments contract normally (LVEF = 30-35 %). The estimated cardiac index is normal (>=2.5L/min/m2). 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. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction c/w CAD. Compared with the prior study (images reviewed) of [**2138-9-11**], the findings are similar (heart rate is faster). CXR [**2141-2-8**]: FINDINGS: Single AP upright portable view of the chest was obtained. Bilateral perihilar and bilateral lower lobe opacities are concerning for consolidation due to infectious process or aspiration. Superimposed edema may also be present. Patient is status post median sternotomy and CABG. The aorta is calcified and tortuous. The cardiac silhouette is not enlarged. CT ABDOMEN AND PELVIS [**2141-2-8**]: IMPRESSION: 1. No evidence of bowel obstruction. 2. Bilateral small pleural effusions. Right pleural effusion is stable since the previous study and the left-sided pleural effusion is slightly increased in size. Associated bibasilar atelectasis and consolidation, infectious process or aspiration can not be excluded. 3. Tree-in-[**Male First Name (un) 239**] opacities within the right middle and bilateral lower lobes, likely infectious/inflammatory in nature and could represent aspiration. 4. Stable pulmonary nodules noted at the bases since [**2141-1-23**], but increased in size since [**2140-9-20**]. Given history of colon cancer, findinces are concerning for metastatic disease, progressed since [**2140-9-20**], as stated on the previous study. LEFT LOWER EXTREMITY DOPPLERS [**2141-2-12**]: IMPRESSION: No evidence of left lower extremity DVT. ECHO [**2141-2-15**]: Compared with the prior study (images reviewed) of [**2141-2-1**], no change. CT CHEST [**2141-2-17**] IMPRESSION: 1. Diffuse bronchial wall thickening and peribronchiolar nodular opacities, most prominent in the lower lobes bilaterally, which likely reflect either infectious bronchiolitis or aspiration. 2. New pulmonary nodule in the left upper lobe, and a growing nodule in the right lower lobe. These nodules are concerning for possible metastatic lesions. A three-month followup Chest CT is suggested following appropriate interval antibiotic therapy to assess for interval growth and to also confirm resolution of the above-described airway disease. 3. New small bilateral pleural effusions. 4. Mediastinal lymphadenopathy, increased in size, which may be reactive in the setting of acute infectious or inflammatory process. 5. Hepatic hypodensity surrounding a fiducial marker, which appears larger in size compared to prior study and is incompletely evaluated. Discharge labs: Hct 26.2 Cr 1.9 Brief Hospital Course: 87 year-old man readmitted for evaluation of decreased hematocrit and question of GI bleed. Pt was hypoxic on admission requiring 3 liters of oxygen by nasal cannula. He was found to have enterococcal bacteremia likely [**12-20**] PICC line. PICC line was pulled and a repeat ECHO was performed. No vegetations were seen on the cardiac valves and only one set of blood cultures was positive (for Enterococcus) making infectious endocarditis unlikely. Left lower extremity doppler was negative. The patient was afebrile, without leukocytosis, and finishing up treatment for PNA from prior admission, so hypoxia was thought initially be mostly from acute on chronic systolic heart failure. Pt was admitted with a weight of about 175# and volume overloaded on exam. Gentle diuresis was given with Furosemide given his [**Month/Day (2) 2091**]. He reached a dry weight of 155# when he developed ARF from overdiuresis. Despite the tremendous diuresis, the patient was still requiring 3L O2 which prompted CT Chest to evaluate for other pulmonary pathology. Repeat CT Chest revealed aspiration vs PNA and a new small nodule. Pulmonary consultation was obtained which believes that most of hypoxia likely related to smoldering PNA vs aspiration. Swallow evaluation obtained to evaluate for aspiration. PROBLEM LIST: #. Hypoxia [**12-20**] CHF and PNA. The patient is at his driest weight now at 155#. Recommend completing 7-day course of Zosyn [**Date range (1) 10275**]. Continue Chest PT and incentive spirometry. Pulmonary was consulted and felt this was related to health care associated pneumonia. He will need his oxygen saturation monitored and weaned O2 as tolerated. If no improvement, would need additional pulmonary consultation as outpatient. #. GIB: Pt with occassional red blood in stool. HCT stable. Will defer to PCP or oncology to determine if patient if colonoscopy to evaluate for colon cancer recurrence is indicated. Inpatient colonoscopy not pursued because of stable HCT and also had negative flex sig in [**Month (only) 958**]. His last transfusion was on [**2-8**] and his Hct remained stable at 26-27 during his hospitalization. He was restarted on his ferrous sulfate on discharge. He is already scheduled for follow up with GI as an outpatient. #. Systolic CHF, EF 30-35%: Dry weight 155 lbs. On discharge his weight was 160 lbs. He was restarted on lasix 20mg daily on discharge. His creatitine will need to be closely monitored given that he was over-diuresed. Please check Cr in 2 days to determine interval change. If Cr improving, would increase lasix to 40mg daily (most recent dose). If Cr worsens, would stop lasix and continue to monitor Cr. After Cr check in 2 days, would then check weekly x 2 weeks if Cr back near baseline 1.5. #. ARF on [**Month/Year (2) 2091**]: Baseline Cr 1.5. Bumped to 2.3 after overdiuresis. Lasix 20mg (lower dose) restarted on discharge. Creatinine improved. Pt has occasional urinary retention from BPH. Most post-void residuals are <200cc. #. New nodules in lung and old nodule increased in size---> could be metastatic disease. Repeat CT Chest in 3 months. #. Anemia [**12-20**] chronic GIB: Pt's hematocrit was more or less stable between the range of 26-28. He had occasional red blood in stool. #. Enterococcus bactermia [**12-20**] PICC, PICC removed. Blood cultures from the PICC with enterococcus (low grade). The plan was to complete 14-days of antibiotics (through [**2-21**]) with ampiccilin once susceptibilities were resulted. With the development of PNA and the initiation of treatment for HAP with Zosyn on [**2-17**], ampicillin was discontinued. #. CAD - had elevated troponin to 0.04 on admission but likely related to relative hypotension and [**Name (NI) 2091**]. EKG without significant changes and troponins remained stable. Aspirin was restarted and Hct remained stable. His statin and beta blocker were continued. [**Last Name (un) **] was restarted once his Cr stabilized. #. Gout: In the ICU developed metatarsal erythema and pain. Prednisone 20mg daily x 3 days. LLE Doppler study negative for DVT. #. H/o bladder cancer followed by Dr. [**Last Name (STitle) **] #. H/o colon cancer with mets to liver followed by Dr. [**Last Name (STitle) **]: S/p surgical hepatic resection and then cyberknife therapy for serial hepatic mets from likely colonic primary. Possible new mets to lung as described above. #. Hypertension: Continue Beta-blocker and [**Last Name (un) **] #. Hyperlipidemia: Continue Statin #. DVT Prophylaxis: Pneumoboots #. Code status: DNR/DNI confirmed [**First Name8 (NamePattern2) **] [**Last Name (un) 1188**] house records #. Contacts/HCP: [**Name (NI) 10276**] ([**Telephone/Fax (1) 10277**], [**Doctor First Name **] ([**Telephone/Fax (1) 10278**] (husband and wife, friends of patient). Medications on Admission: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Valsartan 80 mg PO DAILY (Daily). 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 5. Lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Prilosec 20mg daily 7. Duonebs Q6H PRN 8. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough 12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 14. Acetaminophen 1000mg PO Q6H (every 6 hours) as needed for pain. 15. Colace 16. Senna PRN Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for sob/wheeze. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 6. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for sbp < 100. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily): hold for sbp < 100, hr < 60. 9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours). 13. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 14. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for constipation: hold for loose stools. 15. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: PRIMARY DIAGNOSES: - Pneumonia - Acute on chronic systolic heart failure, EF 30-35% - Enterococcal bacteremia associated with PICC - Lower gastrointestinal bleed - Anemia from chronic bleeding and kidney disease - Acute renal failure on stage 3 chronic kidney disease - Urinary retention - Benign prostatic hyperplasia - Lung nodules - Gout SECONDARY DIAGNOSES: - Coronary artery disease - History of bladder cancer - History of metastatic colon cancer - Hypertension - Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Out of Bed with assistance to chair. Discharge Instructions: You were admitted and managed for the following issues: 1. Shortness of breath: Likely from resolving pneumonia and fluid overload from your heart failure. You should complete a short course of antibiotics and get chest physical therapy to help your secretions and phlegm to be loosened up. You will need to continue oxygen and this needs to be weaned as you can tolerate this. 2. Chronic heart failure: Your "dry" weight is approximately 155 pounds. Be sure to have your weight checked daily. If there is a [**2-20**] pound increase from your baseline weight, you should see a medical doctor to have your medication regimen adjusted. Eat low salt foods and restrict fluids to 1500cc. 3. Blood in stools: Only a small amount of blood was seen occasionally in your stools and your blood counts were stable. Speak with your primary doctor about whether or not you would benefit from another endoscopy. 4. Chest CT scan showed a new nodule in your lungs. Given the recent infections, it is unclear if this is related to infection or may represent a metastasis from one of your cancers. A repeat Chest CT is recommended in 3 months to follow up. 5. Enterococcal bacteremia: You had a transient blood infection that was likely a complication from an IV. You will have been fully treated for this infection with 14-days of antibiotics. 6. Gout flare: Treated with 3 days of prednisone 7. Urinary retention: Treated with occasional urinary bladder catheterization as needed. Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2141-3-7**] at 1 PM With: [**Name6 (MD) 81**] [**Name8 (MD) **], 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: SURGICAL SPECIALTIES When: THURSDAY [**2141-2-23**] at 10:00 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: RADIOLOGY When: WEDNESDAY [**2141-4-19**] at 11:30 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Known lastname 1442**],[**Known firstname **] Unit No: [**Numeric Identifier 1443**] Admission Date: [**2141-2-8**] Discharge Date: [**2141-2-21**] Date of Birth: [**2053-10-15**] Sex: M Service: MEDICINE Allergies: Tomato / Lorazepam Attending:[**First Name3 (LF) 1458**] Addendum: Addendum: Hypoxia - PUlmonary consult was called and felt the pneumonia was the likely etiology for his persistent hypoxia. They recommended continuing zosyn for a 7 day course, to be completed on [**2-24**]. They also recommended a speech and swallow eval, which was performed. He had no signs of aspiration and was cleared for regular foods. Brief Hospital Course: Addendum: Hypoxia - PUlmonary consult was called and felt the pneumonia was the likely etiology for his persistent hypoxia. They recommended continuing zosyn for a 7 day course, to be completed on [**2-24**]. They also recommended a speech and swallow eval, which was performed. He had no signs of aspiration and was cleared for regular foods. Discharge Disposition: Extended Care Facility: [**Hospital3 163**] - [**Location (un) 164**] [**Name6 (MD) **] [**Last Name (NamePattern4) 1459**] MD [**MD Number(2) 1460**] Completed by:[**2141-2-21**]

[ "403.90", "428.0", "788.20", "274.01", "280.0", "486", "285.21", "790.7", "V10.51", "585.3", "584.9", "V10.05", "428.23", "518.81", "041.04", "272.4", "999.31", "197.0", "578.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

19150, 19361

18779, 19127

234, 240

15461, 15461

3480, 7242

17186, 18756

2844, 2911

13269, 14835

14952, 15294

12180, 13246

15681, 17163

7258, 7275

2926, 3461

15315, 15440

186, 196

268, 1719

8619, 12154

15476, 15657

1741, 2589

2605, 2828

29,307

175,627

32521

Discharge summary

report

Admission Date: [**2122-2-21**] Discharge Date: [**2122-2-28**] Date of Birth: [**2052-10-30**] Sex: M Service: MEDICINE Allergies: Augmentin Attending:[**First Name3 (LF) 5893**] Chief Complaint: Hypoxia and dyspnea Major Surgical or Invasive Procedure: Intubation History of Present Illness: 69 M h/o COPD, dCHF, on coumadin for h/o afib (per wife, though pt not taking it now) presenting for respiratory distress. Per wife, pt with 2d increasing SOB, non-productive cough, "in bed all day", multiple other family members sick with "flu." . Pt presented to the ED with VS: 97.4 153 134/89 34 83% RA, improved to 96% with NRB, though RR 40s, so pt started on CPAP, with sats 93%, SBP 130s->94, so put back on 4L, with sats 91%. pulmonary exam sounded tight, +wheezing, sinus tach on EKG, CXR showed no CHF, ?PNA in RLL. given solumedrol 125, nebs, levo/vanco for broad coverage. . Pt also with L>R edema, and bilateral LE redness concerning for cellulitis, had similar sx [**10-30**], LENIs negative. unable to lie flat for CTA. ROS negative for F/C/N/V/D, CP, dysuria, constipation. +sick contacts, fatigue. Past Medical History: - COPD (no available PFTs) - on 2L O2 at home, keeps a nebulizer at home and in his taxi - HTN - dCHF (TTE [**10-30**] EF>55%, RV free wall HK, mod aortic dilation) - h/o ?afib. Social History: TOB up to [**2-24**] ppd x 50 years, now <1 ppd. Denies etoh/illicts. Married. 8 children. Taxi driver. Family History: non-contributory Physical Exam: VS: 95.5 145 125/78 39 89%4L GEN: ill appearing, pale, blue ears, speaks in [**12-24**] word sentences, using accessory muscles. HEENT: No JVD. CV: regular, tachy, nl s1, s2, no appreciable m/r/g. PULM: poor airmovement throughout, bilateral +wheeze. ABD: soft, NT, ND, + BS, no HSM. EXT: warm, 2+ dp/radial pulses BL. B LE [**12-24**]+ EDEMA, L>R, +erythema, ?chronic venous changes vs cellulitis. NEURO: alert & oriented x 3. . Pertinent Results: [**2122-2-20**] 11:15PM BLOOD WBC-8.1 RBC-4.41* Hgb-14.0 Hct-42.9 MCV-97 MCH-31.7 MCHC-32.6 RDW-14.5 Plt Ct-171 [**2122-2-27**] 03:27AM BLOOD WBC-7.2 RBC-4.40* Hgb-13.7* Hct-42.3 MCV-96 MCH-31.2 MCHC-32.5 RDW-14.6 Plt Ct-148* [**2122-2-20**] 11:15PM BLOOD Neuts-83.6* Lymphs-9.2* Monos-6.4 Eos-0.7 Baso-0.1 [**2122-2-20**] 11:15PM BLOOD PT-11.7 PTT-26.7 INR(PT)-1.0 [**2122-2-27**] 03:27AM BLOOD PT-11.8 PTT-27.0 INR(PT)-1.0 [**2122-2-20**] 11:15PM BLOOD Glucose-126* UreaN-16 Creat-0.9 Na-145 K-3.5 Cl-97 HCO3-45* AnGap-7* [**2122-2-27**] 03:27AM BLOOD Glucose-78 UreaN-30* Creat-0.8 Na-139 K-4.5 Cl-91* HCO3-46* AnGap-7* [**2122-2-20**] 11:15PM BLOOD CK-MB-7 cTropnT-0.03* proBNP-5511* [**2122-2-22**] 04:00AM BLOOD CK-MB-4 cTropnT-<0.01 [**2122-2-20**] 11:15PM BLOOD Calcium-9.2 Phos-5.0* Mg-2.3 [**2122-2-21**] 12:13AM BLOOD Type-ART pO2-121* pCO2-93* pH-7.29* calTCO2-47* Base XS-14 Intubat-NOT INTUBA [**2122-2-26**] 11:35PM BLOOD Type-ART Temp-36.4 O2 Flow-3 pO2-51* pCO2-91* pH-7.35 calTCO2-52* Base XS-19 Intubat-NOT INTUBA [**2122-2-20**] 11:27PM BLOOD Lactate-1.6 [**2122-2-21**] 03:29AM BLOOD Lactate-1.0 [**2122-2-21**] 05:26AM BLOOD Lactate-0.7 FINDINGS: A single portable image of the chest was obtained and compared to the prior examination dated [**2122-2-20**]. In the interim, an endotracheal tube has been placed that terminates approximately 9 cm above the carina. The image is slightly underpenetrated. There is a new left pleural effusion. In addition, suggestion of a new left retrocardiac opacity is noted, likely secondary to the underlying effusion and atelectasis, difficult to exclude pneumonia. The right hemithorax is relatively clear. IMPRESSION: 1. Endotracheal tube not in ideal position, consider right repositioning. 2. New left retrocardiac opacity, likely secondary to a small-to-moderate size effusion and atelectasis, difficult to exclude pneumonia. EKG: The rhythm is probably sinus tachycardia. Right bundle-branch block. Left anterior fascicular block. Compared to the previous tracing of [**2121-11-3**] there has been a marked increase in rate. Otherwise, no diagnostic interim change. Brief Hospital Course: # hypoxia: Patient intially on 4L NC mainting oxygen saturations of 90%. Over the course of the first few hours of his admission, he showed worsening respiratory distress, with increasing work of breathing. Patinet was intially started on BIPAP for non-invasive ventillatory support. The etiology of his hypoxia/dyspnea was believed to be most likely secondary to a COPD flare. He demonstrated wheezes on chest exam with poor pair movement consistent with an obstructive etiology. Patient with negative LENIS, and given such a low suspicison of PE, CTA was not pursued. He had negative cardiac enzymes x 3, and no evidence of fluid overload on CXR. Patient was intubated on the second day of admission due to increasing hypercapnea and increased work of breathing that was not believed to be sustainable. The patient showed improved ABG on ventilator, with a blood gas that was believed to be consistent with his baseline of CO2 retention. The patient remained intubated for 6 days. During the ce course, he was continued on steroids, freqent nebulizer treatments, and started on levoquin for empiric atypical coverage. Invectious etiology, and more specifically viral cause, was believed to be the inciting factor to his COPD exacerbation. CXR showed no frank infiltrates, sputum Cx showed no growth, and the patient was DFA negative. Patient began to show evidence of fluid overload on exam and CXR, and was diuresed with resolution. The patient showed improvement on physical exam and ease of oxygentation, and was ultimatly extubated. Following extubation the patient showed worsened wheezes and the need for continued BIPAP. When the possibility of re-intubation was addressed, the patient refused. Prednisone was continued with plans for a slow taper. He is being discharged to hospice with BIPAP. on CPAP. Patient hyperventilating w/ anxiety. #Anxiety: Patient notably anxious following extubation, with hypertension, tachycarida, and hyperventilation. These symptoms were somewhat improved on anxietylitics and plan is to discharge patient on morphine and ativan. #cardiac: Again, given shortness of breath and LE edema, some concern of MI at time of admission. The patient had cardiac enzymes negative x three. He was intially started on ASA, which was proptly discontinued. #Diastolic HF: Patient has previously carried the diagnosis. Had LE edema on admission, but not signs of fluid overload on CXR. During the admission, patient showed worsened evidence of fluid overlaod, and was successfully diruesed. The patient will be discharged on a maintence dose of lasix that may require further adjustment. # HTN: The patient has a history of hypertension. He was continued on his home lisinopril/HCTZ, and BP was well controlled. #LE edema/erythema: On admission, the patient was noted to have left lower extremity erythema. Unclear if cellulites vs. changes from venoustasis. The patient had no elevation of WBC or LE edema. He was started on vanc because of concern of it looking worsened in intesnity. With blood cultures negative and low probablity concern of MRSA, the patient was continued on levoquin feeling that it would offer adquate coverage. The patient showed marked improvement with antibiotics and diuresis. #Leg Mass: Patient with fungating black mass on right ankle. Some concern of melanoma, and dermatology was consulted. The differential diagnosis for these lesions includes lymphangiectasia, angiokeratoma, pyogenic granuloma, venous [**Doctor Last Name **] or an atypical kaposi's sarcoma. Bx is needed to rule out KS. The clinical presentation is not consistent with melanoma. Recommened shave biopsy as an outpatient. #Disposition: The patient requested to not be intubated, and given the progressed nature of his end stage COPD, the decision was made with the patient and his family to be discharged to hospice. Medications on Admission: -ipratropium Bromide 0.02 % IH Q6HR -albuterol Sulfate 0.083 % IH Q6HR -lisinopril 10 mg po qdaily -hctz 12.5 mg po qdaily (zestoretic) -prednisone 30mg po qdaily -bactrim 400-80 mg po qdaily -CALCIUM 500+D 500 po qdaily -chantix --- lasix (dose [**Last Name (un) 5487**] per wife, not recorded on pharmacy list) coumadin (not taking) Discharge Medications: 1. BIPAP [**Last Name (un) **]: 4 liters bleed in qHS and PRN comfort: 15 cm H2O IPAP/5 cm H2O EPAP. Disp:*1 BIPAP machine* Refills:*0* 2. Home oxygen [**Last Name (un) **]: Four (4) liters continuous. Disp:*1 home oxygen delivery system* Refills:*0* 3. Albuterol 90 mcg/Actuation Aerosol [**Last Name (un) **]: One (1) nebulizer Inhalation q2-4 hours as needed for shortness of breath or wheezing. Disp:*1 box* Refills:*2* 4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (un) **]: One (1) nebulizer Inhalation every six (6) hours. Disp:*120 aerosol* Refills:*2* 5. Roxanol Concentrate 20 mg/mL Solution [**Last Name (un) **]: [**12-24**] mL PO q2 hour as needed for shortness of breath or wheezing. Disp:*30 mL* Refills:*0* 6. Lorazepam 2 mg/mL Concentrate [**Month/Day (2) **]: One (1) mL PO q 4-6 hours as needed for anxiety or shortness of breath. Disp:*30 mL* Refills:*0* 7. Prednisone 20 mg Tablet [**Month/Day (2) **]: 3 tabs daily x 5 days; 2 tabs daily x 5 days Tablets PO once a day for 10 days: Then resume home dose of 30 mg daily. Disp:*25 Tablet(s)* Refills:*0* 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: [**12-24**] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 9. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 12. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 13. Lisinopril 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital 269**] Hospice Care Discharge Diagnosis: COPD exacerbation Hypertension AVNRT Viral Pneumonia Cellulitis Acute on chronic diastolic heart failure Discharge Condition: Stable on 3L O2 Discharge Instructions: You are being discharged from the hospital after admission for respiratory distress. This was believed to be due to a flare of you underlying, end-stage COPD. In order to help you breath, you required intubation. You were successfully extubated, but still had significant difficulty breathing. After length discussion about goals of care, you decided to pursue comfort measures only, and are now discharged how with hospice care. Followup Instructions: Additional Care provided through hospice services. Contact your PCP to apprise him of your change in care goals.

[ "427.31", "480.9", "428.33", "682.6", "V46.2", "238.2", "491.21", "427.89", "401.9", "428.0", "300.00", "518.81", "V58.61", "V66.7" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10361, 10423

4147, 8039

291, 303

10572, 10590

1985, 4124

11072, 11189

1496, 1515

8424, 10338

10444, 10551

8065, 8401

10614, 11049

1530, 1966

232, 253

331, 1154

1176, 1358

1374, 1480

5,727

188,983

51918

Discharge summary

report

Admission Date: [**2154-2-6**] Discharge Date: [**2154-2-15**] Date of Birth: [**2096-11-3**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 678**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 107485**] is a 57 y/o M with h/o GI Bleed, HTN, CAD, CHF (EF 20%), PAFib, DM2, CRI, HCV, and polysubstance abuse who p/w 4 days SOB and CP. States that he has had progressive dyspnea over the 4 days pta, limiting him to a few steps at a time. Also more leg edema and orthopnea. Reports medical compliance, but questionable dietary compliance; girlfriend buys food with lots of salt. Denies f/c, n/v; had cough productive of clear sputum. Also had CP, substernal, "like someone walking on it," without radiation. Notes last cocaine use several days before admission, last EtOH was 1 day PTA. In the ED, ECG was not ischemic and CXR demonstrated signs of volume overload. His VS were T98 105 206/91 36 84%RA-->100%NRB. Guaiac +. ABG 7.27/51/174. He refused intubation and was placed on BIPAP. He received ASA, Lasix 40mg IV, nitro gtt, dilaudid 1mg, ativan 1mg, benadryl, 10U regular insulin. . In the MICU, he required BIPAP initially but was weaned to 2L NC and eventually to RA. Echo showed no change from prior. On steroids and azithromycin for history of COPD. He was diuresed with 80 IV lasix, putting out 5 liters net in 3 days and 1.6 liters on the day of transfer. He also had altered mental status with a normal head CT, but he was found to have a R occipital mass/hematoma on CT, stable since [**2152**]; the patient refused US of this lesion. He was transfused 1 unit pRBCs when Hct dropped, then refused further blood draws. He was also placed on CIWA scale for EtOH withdrawal. . ROS negative for fever, chills, palpitations, n/v/d, dysuria, other Sx of concern to him. + for CP, SOB, cough. Past Medical History: Past Medical History: Polysubstance abuse - crack cocaine, EtOH, tobacco. Hypertension Type II diabetes mellitus Dyslipidemia CAD s/p MI, MIBI in [**11-18**] showed inf/lat reversible defect CHF EF 20-30% severe global HK. Atrial Fibrillation CRI Anemia h/o GI Bleed- Duodenal AVM's, Angioectasia in the proximal jejunum, Angioectasia in the stomach body, s/p thermal therapy, sigmoid diverticuli Hepatitis C Chronic pancreatitis Affective disorder s/p multiple psychiatric hospitalizations due to SI Depression GERD Gout s/p Arthroscopy with medial meniscectomy [**5-/2149**] Inflatable penile prosthesis [**5-/2148**] Social History: Usually lives in apt with his girlfriend. [**Name (NI) **] used to be an electrician for [**Company 31653**], but has been on disability. Tob: 45 pack-yr EtOH: history of abuse with hospitalizations for delirium [**Company 107492**] and detoxification. last drink one day p.t.a. Illicits: 15 yr h/o Crack cocaine use, last used two days ago. Family History: His father with alcoholism, an uncle who committed suicide by hanging, and a cousin with [**Name2 (NI) 14165**] cell anemia Physical Exam: Vitals: 98.1 BP148-170/71-83 HR109-119 RR20s O2 96%RA Gen: Well-appearing man in NAD, walking around room. HEENT: NC/AT. MMM no erythema/exudate. Poor dentition. JVP elevated to 2 cms below jaw while sitting at 90 degrees. Neck supple w/o LAD. Pulm: Clear to auscultation bilaterally. CV: Tachycardic with regular rhythm, with no murmurs, rubs, or gallops. Abd: Soft, non-tender and non-distended. Bowel sounds are normoactive. Ext: 3+ pitting peripheral edema to knees bilaterally; 2+ dorsalis pedis pulses; no clubbing or cyanosis. Neuro: AAOx3. CNII-XII grossly intact. Pertinent Results: . Labs: [**2-8**] Chem 7: 137 106 36 184 4.5 21 3.4 Ca: 9.0 Mg: 1.9 P: 4.0 Hct 24.3 BNP: [**Numeric Identifier **] . CXR: Cardiomegaly, engorgement of pulm vasculature, pulm edema . TTE [**9-19**]: The left atrium is mildly dilated. The inferior vena cava is dilated (>2.5cm). The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is mildly depressed. Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). Resting regional wall motion abnormalities include with inferior/inferolateral hypokinesis. Right ventricular chamber size and free wall motion are normal. 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 to moderate ([**1-15**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study of [**2153-8-21**], left ventricular function now appears improved. Of note, patient in sinus rhythm for the current study (in aflutter with rapid ventricular response in prior study). . [**11-18**] MIBI 1. Interval development of moderate reversible inferiolateral perfusion defect. 2. Left ventricular enlargement, again slightly worse with stress than rest. 3. Global hypokinesis with ejection fraction of 25%, decreased compared to the prior study, when it was 32%. . [**9-19**] EGD Normal mucosa in the esophagus Few nonbleeding AVMs [**Month/Year (2) **] in the duodenal bulb Erosions in the duodenal bulb . [**5-19**] colonoscopy Angioectasia in the proximal jejunum (thermal therapy) Angioectasia in the stomach body (thermal therapy) Otherwise normal small bowel enteroscopy to mid jejunum . Head US: The region of interest could not be adequately evaluated with ultrasound due to the presence of thick overlying hair in the region. This area could be better evaluated with a MRI examination. . Head CT: 1. No evidence of acute intracranial hemorrhage or mass effect. 2. Hyperdense mass again demonstrated in the right occipital soft tissues, also seen on the study of [**2152-4-29**]. While this appearance is consistent with a hematoma, it would seem most unlikely that a hematoma is still present over the long interval between scans, without expected evolution to lower density material or regression. Correlate for history of recent trauma, and also correlate with direct physical examination. If desired, further evaluation with son[**Name (NI) 867**] or MR study could be considered to exclude other pathology. Brief Hospital Course: A/P: This is a 57 y/o M w/ h/o CHF (EF 20-30%), CAD, h/o gastric AVM with frequent GI bleeds who presented with SOB, likely due to CHF. . #) CHF exacerbation. Refused intubation in ED. Initially received BiPAP in the MICU with stable ABG's which was changed to NC. He tolerated NC overnight with good O2 sats. Was on nitro gtt to afterload reduce and bring down BP that was then titrated off. He was given lasix 80 mg IV for net neg 1L q day. With improvement in respiratory status he was transferred to floor. He was continued on IV lasix. His SOB improved and his lung exam was clear, although he continued to have significant LE edema. He was weaned off oxygen without difficulty. His lasix was changed to PO when he had a bump in Cr that suggested patient had been adequately diuresed. The patient was non-compliant with fluid resriction and diet restriction and was frequently seen getting food and water from the kitchen. BB was initially held due to remote cocaine use and repeated GI bleeds with low Hct, however, pt. developed a-fib with RVR and was started on lopressor for rate control. Given patient's h/o cocaine use and non-compliance he was switched back to diltiazem for rate control in preparation for d/c. Started dilt 90mg qid ACEI was held given ARF. His lasix was held prior to discharge given bump in Cr. This should be titrated for SOB and not LE edema. . #) Afib: Patient has history of atrial fibrillation in the past with cardioversion. During the hospitalization he converted from NSR to a fib with RVR. Initially given BB for rate control without significant effect and then switched to diltiazem with HR in 80s-90s. PCP does not feel pt. is candidate for coumadin and patient refused to be on anticoagulation. EP was consulted for possible cardioversion but they felt he was not a candidate for cardioversion given refusal to take coumadin after procedure. . #) Leukocytosis. Afebrile, no localizing signs of infection. Likely due to steroids. WBC trended down as steroids were tapered. . #) DM2. Patient had very difficult to control blood sugars. Likely secondary to dietary non-compliance and steroids. NPH was increased to 30U qpm and 20U qam. This resulted in some low FS in the morning so he was decreased to 26U and 16U. He often required coverage with sliding scale and his SS had to be increased. . #) Anemia/GI Bleed. Chronic, known AVMs. Serial hct were monitored. There was no evidence of current bleed but Hct trended down to low 20s and the patient received a transfusion for this. He had an appropriate bump in Cr but then proceeded to trend down once again., On the day of discharge he was recommened to have a blood transfusion. The patient refused and stated that he wanted to go home and be with his family. The risks of this decision were explained clearly to him and he wished to sign out AMA. Dr. [**First Name (STitle) 216**], the patient's PCP was aware and made an appointment to see him in 2 days for labwork. While in the hospital he was continued on Iron and Folate as well as PPI [**Hospital1 **]. . #) COPD. Given the patient's significant smoking history it was felt that he may have had an element of COPD exacerbation contributing to his dyspnea. He was given a 5-day course of Azithomycin and placed on a short Prednisone taper. He was also given Nebs prn. . #) Substance abuse. Patient was placed in CIWA scale and showed no evidence of withdrawal so this was discontinued. He was continued on folate/thiamine. He was seen by Addiction nurse and initially refused any formal treatment. He is considering treatment at [**Hospital1 **] house. . #) Occipital soft tissue lesion on CT. Seen on previous head CT from 1 year ago--? hematoma. Attempted US but patient became agitated at US. - will try to repeat U/S in future as patient more cooperative . #) CRI: Cr was at baseline ~3.5-3.9, however it started to trend upwards after aggressive diuresis to a peak of 5.1. Likely in setting of over-diuresis. His lasix was discontinued. Urine lytes showed FeUrea of 26% c/w pre-renal etiology. Has occurred on previous hospitalizations in setting of diuresis and responded to gentle diuresis. Received 1L IVF with no improvement in renal function. ? component of ATN in setting of over-diuresis. Hesitant to give more fluids given tenuous fluid status. Given that the patient has progressive kidney dysfunction, Dr. [**First Name (STitle) 216**] talked at length with him about the possibility of progressing to ESRD at which point he would need diaylsis. Renal was asked to come by and see him, however, he signed out AMA prior to them seeing him. He has an appointment with Dr. [**Last Name (STitle) 4090**] at [**Last Name (un) **] in two weeks. . #) Pancreatic neck lesion: further workup required as an outpatient . #) FEN: Placed on Fluid restriction, Low Na diet. Followed lytes while diuresing. . #) PPX: PPI [**Hospital1 **], SQ Heparin, Access: PIV . #) Code: Full . #) Dispo: Patient left AMA . Medications on Admission: Medication at home: 1. Aspirin 325 mg PO DAILY 2. Ferrous Sulfate 325 PO DAILY 3. Atorvastatin 20 mg PO DAILY 5. Thiamine HCl 100 mg PO DAILY 6. Folic Acid 1 mg PO DAILY 7. Calcitriol 0.25 mcg PO DAILY 8. Calcium Acetate 667 mg PO TID 9. Carvedilol 6.25 mg PO BID 10. Pantoprazole 40 mg PO Q12H 11. Citalopram 40 mg PO once a day. 12. Lasix 80 mg PO once a day. 13. Insulin NPH 20U QAM and 10U QPM. 14. RISS . Meds on Transfer: Aspirin 325 mg PO DAILY Atorvastatin 20 mg PO DAILY HydrALAzine 10 mg IV Q6H Azithromycin 250 mg PO Q24H PredniSONE 60 mg PO DAILY Taper HYDROmorphone (Dilaudid) 1 mg SC Q2H:PRN Haloperidol 2.5 mg PO BID:PRN agitation Insulin SC (per Insulin Flowsheet) DiphenhydrAMINE HCl 25 mg PO Q6H:PRN itching Pantoprazole 40 mg IV Q12H Ferrous Sulfate 325 mg PO DAILY FoLIC Acid 1 mg IV DAILY Thiamine HCl 100 mg IV DAILY Docusate Sodium 100 mg PO BID Senna 1 TAB PO BID:PRN Bisacodyl 10 mg PO DAILY:PRN constipation Sarna Lotion 1 Appl TP QID:PRN itching Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [**Hospital1 **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Six (26) units Subcutaneous every morning. 7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen (16) units Subcutaneous every night. 8. One Touch UltraSoft Lancets Misc Sig: One (1) lancet Miscellaneous twice a day. [**Hospital1 **]:*1 box* Refills:*2* 9. One Touch Ultra Test Strip Sig: One (1) strip Miscellaneous twice a day. [**Hospital1 **]:*100 strips* Refills:*2* 10. DILT-CD 300 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. [**Hospital1 **]:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Congestive heart failure Atrial fibrillation Anemia Cocaine abuse Alcohol abuse Acute renal failure CAD HTN Depression Pancreatic neck lesion Discharge Condition: Pt. left AMA Discharge Instructions: Patient left AMA. He was told that he should stay due to multiple medical issues and he wanted to go home against medical advice. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500ml daily . You were admitted to the hospital for a CHF exacerbation. You were also found to be anemic (low blood counts) and have worsening kidney function. Because of you anemia we recommended that you receive a blood transfusion, but you refused and stated that you wanted to leave the hospital. You stated that you understood the risks of this (bleeding, organ damage, death) and asked to follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 216**] in two days for bloodwork. . Please refrain for drinking alcohol and using cocaine as these drugs are very toxic and causing damage to your body. Followup Instructions: You have an appointment with Dr [**First Name (STitle) **] [**Month (only) **] on [**2154-2-18**] at 12:10pm. You must go to this appointment to have your blood work checked as you may need a blood transfusion. You will have your kidney function checked at this time as well. Phone:[**Telephone/Fax (1) 250**]. . You have an appointment to see a nephrologist Dr. [**Last Name (STitle) 4090**], at [**Last Name (un) **] on [**2154-2-25**] at 3:30pm. Please keep this appointment as your kidney function has been worsening and you will need follow up for this. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]

[ "428.0", "070.70", "305.60", "569.85", "303.90", "305.1", "584.9", "250.00", "280.0", "518.82", "V15.81", "585.9", "427.31", "577.9", "793.0", "491.21" ]

icd9cm

[ [ [] ] ]

[ "93.90", "99.04" ]

icd9pcs

[ [ [] ] ]

13697, 13754

6451, 11444

271, 277

13940, 13955

3712, 5798

14887, 15542

2964, 3090

12469, 13674

13775, 13919

11470, 11880

13979, 14864

3106, 3693

228, 233

305, 1943

5807, 6428

1987, 2587

2603, 2948

11898, 12446

9,960

159,243

1053

Discharge summary

report

Admission Date: [**2181-8-26**] Discharge Date: [**2181-8-29**] Date of Birth: [**2106-9-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: atrial fibrillation and hypotension Major Surgical or Invasive Procedure: Cardioversion for unstable atrial fibrillation PICC placement History of Present Illness: 74 Russian speaking male w/ history of dementia, depression, remote CAD, afib, s/p pacer, now being admitted for increased lethargy, obtundation, fever, atrial fibrillation and hypotension 64/30 and tachypnea 32-34. . On review of the notes from [**Hospital 100**] rehab, patient was lethargic since [**2181-8-18**]. Olanzapine, namenda and depakote stopped. His BP had been 80-90/40-50 and P90s. On day of admission, he spiked fever to 103 w/ AF w/ RVR and more hypotension. His [**Month/Day/Year 802**] was called and the decision was to admit him. . On arrival to the ED, his vital signs were T102.6 P180 BP64/30. Due to unknown code status at the time, cardioversion was attempted twice w/ 50 and 100J but to no avail. He was given 5L NS. He was also started on vanco/levo/flagyl. Later phone call to NH claims that he is DNR/DNI . On arrival to the ICU, phone calls were made to [**Hospital 100**] rehab, PCP([**Doctor First Name **] O/[**Location (un) **]), brother(HCP) and Nice([**Doctor First Name **], who claims to be legal guardian. [**Name (NI) **] Rehab claims that he is DNR/DNI. Brother deferred all decision making to [**Doctor First Name **]. [**Doctor First Name **] claims to be legal guardian and wants to patient to be full code regardless of situation. PCP did not call back at the time of admission. Past Medical History: 1. Atrial fibrillation s/p pacemaker placement, not anticoagulated [**3-1**] med non-adherence and fall risk. EP had apparently evaluated his pacer which was thought to be functional. Rate control was noted to be difficult given pt's agitation and often refusal/non-compliance w/ po agents. 2. Dementia/personolity disorder as above, frequently required chemical/mechanical restraint; has had psych evaluation in past admission. Patient has multiple falls/gait unsteady 3. BPH 4. h/o multiple falls, 1 causing SDH requiring evacuation 5. s/p inguinal hernia repair w/ mesh [**1-30**] 6. CAD w/ evidence of mild reversible defects on emibi in '[**72**]??EF 25-30% per [**Hospital **] rehab note 7. ?CKD baseline 1.2-1.3 8. hypothyroidism Social History: Pt was born and raised in [**Country 532**]. He was married and divorced in a marriage which produced a 37yo son who lives in [**Country 532**]. He worked as an engineer. He emigrated to US in [**2166**]. He is closest with brother, sister-in-law, and [**Name2 (NI) 802**] who live in [**Name (NI) **]. [**Name (NI) **] is a RN who works in home healthcare and has been involved in pt care. DEnies ETOH/smoking. He ambulates w/ walker at baseline. At baseline combative and difficult. Family History: NC Physical Exam: T97.8 P136 BP92/59 R23 98% on 5L Gen- patient is unresponsive to sternal rub, otherwise does not appear to be in distress HEENT- anciteric, minimally reactive to light biilaterally(2-1mm), refuse to let me open eyes, could not open his mouth even with tremendous effort, neck stiff(increased tone throughout), no JVD, no cervical LAD CV- irregular, tachycardic, no r/m/g resp- decreased breath sound on left(anteriorly), no wheezes, no crackles, pursed lips breathing, no accessory muscle use abdomen- no bowel sound, soft, nontender, nondistended, no hepatosplenomegaly EXT- faint distal pulses, no edema neuro- unresponsive to sternal rub, increased tone throughout body, plantar reflexes downgoing, ??myoclonus in lower extremity Pertinent Results: [**2181-8-26**] 02:40PM WBC-10.5# RBC-4.48* HGB-14.3 HCT-41.3 MCV-92 MCH-31.9 MCHC-34.7 RDW-13.6 [**2181-8-26**] 02:40PM NEUTS-82.6* BANDS-0 LYMPHS-11.9* MONOS-5.3 EOS-0.1 BASOS-0.1 [**2181-8-26**] 02:40PM PLT COUNT-182 [**2181-8-26**] 02:40PM PT-14.8* PTT-30.4 INR(PT)-1.3* [**2181-8-26**] 02:40PM CK(CPK)-1012* [**2181-8-26**] 02:40PM CK-MB-4 cTropnT-0.06* [**2181-8-26**] 02:40PM CALCIUM-9.2 PHOSPHATE-4.6* MAGNESIUM-3.0* [**2181-8-26**] 02:40PM CORTISOL-37.1* [**2181-8-26**] 02:40PM GLUCOSE-99 UREA N-72* CREAT-2.3* SODIUM-155* POTASSIUM-4.9 CHLORIDE-117* TOTAL CO2-28 ANION GAP-15 [**2181-8-26**] 03:12PM LACTATE-2.1* [**2181-8-26**] 03:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG [**2181-8-26**] 03:40PM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 [**2181-8-26**] 10:00PM CK(CPK)-626* [**2181-8-26**] 10:00PM CK-MB-4 cTropnT-0.04* [**2181-8-26**] 10:00PM TSH-3.0 [**2181-8-26**] 10:00PM FREE T4-1.0 [**2181-8-26**] 10:00PM CORTISOL-47.1* Labs on discharge (drawn off of PICC while D5 1/2 NS IVFs were running) WBC 4.3 Hgb 9.2 Hct 27.7 Plts 159 Na 136 K 3.1 Cl 107 CO2 23 BUN 24 Cr 0.9 Glu 381 (FS 80) Ca 7.1 Mg 1.7 Phos 2.0 Digoxin 0.6 CXR (portable AP) [**8-26**] - Compared to [**2181-6-16**]. The patient is rotated to the left on this study. Heart is enlarged, allowing for differences in technique, unchanged from the prior study. Right-sided pacer with dual leads unchanged in position and intact. The right lung is clear. There is a left retrocardiac opacity, which may relate to atelectasis, consolidation, or aspiration. No pneumothorax. Visualized osseous structures are normal. EKG [**2181-8-26**] - Atrial fibrillation with a rapid ventricular response @ 162 bpm. Left ventricular hypertrophy. Compared to the previous tracing of [**2181-6-17**] vetricular pacing is no longer recorded and the ventricular response has increased. Brief Hospital Course: 74 M w/ h/o dementia, depression, remote CAD, afib, s/p pacer, now admitted for fatigue, weakness, altered mental status, atrial fibrillation and hypotension. . 1) hypotension: The differential diagnosis included dehydration (pt with hypernatremia, acute renal failure on admission), sepsis (fever,?worsening AF, hypoxia, lactate 2.1, CXR with new L retrocardiac opacity), and ?PE from RA clot(AF). The pt was given 2 L of IVF boluses and was cardioverted for unstable atrial fibrillation with resolution of low BPs. [**Last Name (un) **] stimulation and initiation of broad spectrum antibiotics (vanco/levo/flagyl) was also started on admission. Blood and urine cultures were sent. The urine culture was no growth (final). A urine legionella antigen was negative. Blood cultures were still pending on discharge, however given the fact that the pt did not have leukocytosis, remained AF, and maintained SBPs > 100 during the remaining ICU course, it is not likely that he pt is bacteremic. . 2) PNA: On admission, the pt was hypoxic initially w/ tachypnea, CXR show left retrocardiac opacity. started on broad spectrum antibiotics as above. The sputum culture was contaminated. The pt was discharged on Vancomycin 1 gm q24h and Levofloxacin 500 mg IV q24h to complete a 10 day course for institution acquired PNA (the pt is now on day 4 of 10). . 3) atrial fibrillation s/p pacer: In the ED, the pt was cardioverted for unstable atrial fibrillation with rapid ventricular response with good result. On transfer to the ICU, he was placed on telemetry and the pt was noted to have a HR in the 120-130s with stable BPs and was given Lopressor 5 mg IV with some improvement in rate control. Digoxin was loaded and started on the second hospital day for further rate control. The digoxin level was subtherapeutic at 0.6 2 days after digoxin load; however as pt had not gotten digoxin the day before the test was drawn [**3-1**] renal dosing of digoxin, will continue digoxin 0.125 mg. The pt is not anticoagulated with coumadin [**3-1**] fall risk and aspirin was continued during hospital course. Of note, the pt may be restarted on his usual rate control medication atenolol at [**Hospital 100**] Rehab as he is no longer hypotensive. . 4) hypothryoidism: The pt was continued on synthroid, TFTs within normal limits on admission. . 5) acute on chronic renal disease: The pt's baseline creatinine approximately 1.2-1.3 and on admission Cr elevated to 2.4. Was likely pre-renal in etiology as Cr trended back down to 1.4 after being given IVFs and upon dishcarge was at 0.9. Nephrotoxic medications were avoided. . 6) Dementia: This is progressive per psych and the pt has had a negative metabolic w/u in the past. During the hospital course, the pt was kept on aricept, seroquel, zyprexa prns, and celexa. An EKG was checked and did not have a prolonged QT. Per geriatrics consult, haldol prns were d/c'd. . 7) FEN - The pt's lytes were repleted prn. Maintenance IVF D5 1/2NS @ 75 cc/hr as the pt was not eating on admission [**3-1**] altered mental status. He did have 2 episodes of hypoglycemia (FS 50s) without symptoms during the hospital course that responded to 1 amp of D50 and further D5 1/2NS fluids. The pt continued to not take po throughout hospital course and will need a swallow study to evaluate for intact swallow mechanism to address nutritional needs. . 8) PPx- sc heparin, PPI . 9) access- A PICC line was placed as pt had difficult access. He will need the PICC to complete his IV med course for tx of PNA. . 10) code- full code per legal guardian; however DNR/DNI per transfer papers from [**Hospital 100**] Rehab. . 11) communication- HCP: [**Name (NI) 6869**]/[**Name (NI) 6870**] (brother/sister-in-law) [**Telephone/Fax (1) 6871**]; [**Telephone/Fax (1) 802**] [**Name (NI) 6872**]([**Telephone/Fax (1) 6873**]; [**Telephone/Fax (1) 6874**]). PCP [**First Name4 (NamePattern1) **] [**Name Initial (PRE) 4143**] [**Telephone/Fax (1) 6875**]. On transfer to [**Hospital1 18**], had DNR/DNI paperwork from [**Hospital 100**] Rehab. However, further discussion with his HCP and legal guardian revealed that the pt was not DNR/DNI and is full code. The PCP was [**Name (NI) 653**] during the hospital course. . 12) dispo- transfer back to [**Hospital 100**] Rehab to finish 10 day course of antibiotics for institution acquired PNA (now on day 4 of 10) and to have swallow study performed. Medications on Admission: Aspirin 325 mg QD Atorvastatin 20 QD Atenolol 100 mg [**Hospital1 **](not in [**Hospital 100**] rehab b/c hypotension) Multivitamin seroquel 12.5mg [**Hospital1 **] prn Celexa 20 QD Donepezil 10 mg HS milk of magnesia ativan 1mg [**Hospital1 **] prn synthroid 100mcg qd Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:*240 ML(s)* Refills:*0* 7. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 6 days: Pt needs to complete 10 day course, now on day 4 of 10. Disp:*6 * Refills:*0* 8. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 6 days: Pt needs to complete 10 day course. Now on day 4 of 10. Disp:*6 * Refills:*0* 9. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO BID (2 times a day) as needed for aggitation. Disp:*15 Tablet, Rapid Dissolve(s)* Refills:*0* 11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other day. Disp:*15 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Pneumonia Atrial Fibrillation Acute on Chronic Renal Failure secondary to dehydration Dementia Depression Remote Coronary Artery Disease Hypothyroidism Discharge Condition: Stable. Discharge Instructions: Please take all medications as instructed. Specifically, please finish 10 day course of IV antibiotics (Vancomycin 1g IV q24h and Levofloxacin 500 mg q24h), he is now on day 4 of 10. Please perform bedside swallow study in order to further assess and determine nutritional needs. Followup Instructions: Please follow up with your primary care provider [**Name Initial (PRE) 176**] 1 week. Completed by:[**2181-8-29**]

[ "584.9", "294.10", "331.82", "486", "244.9", "585.9", "276.51", "038.9", "V45.01", "276.0", "427.31", "600.00", "995.92" ]

icd9cm

[ [ [] ] ]

[ "99.62", "38.93" ]

icd9pcs

[ [ [] ] ]

11925, 11991

5819, 10230

351, 414

12187, 12197

3820, 5796

12526, 12643

3048, 3052

10550, 11902

12012, 12166

10256, 10527

12221, 12503

3067, 3801

276, 313

442, 1769

1791, 2530

2546, 3032

75,431

123,581

38674

Discharge summary

report

Admission Date: [**2141-4-19**] Discharge Date: [**2141-4-23**] Date of Birth: [**2083-1-15**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2141-4-19**] Coronary artery bypass graft x3 (left internal mammary artery to left anterior descending artery, saphenous vein grafts to obtuse marginal and left posterior descending artery). History of Present Illness: This 58 year old male recently developed fatigue and had one episode of chest pain. A stress test was abnormal, and he underwent cardiac catheterization which revealed multivessel disease and was referred for surgical evaluation. Past Medical History: hypertension gastroesophageal reflux disease Social History: Lives with: wife and son Occupation: manufacturing supervisor Tobacco: current smoker 42pack years ETOH: occasional Family History: non contributory Physical Exam: Admission: Pulse: 52 Resp: 13 O2 sat: 96%RA B/P Right: 132/68 Weight: 93kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] no edema or varicosities Neuro: Grossly intact x Pulses: Femoral Right: cath site Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit no carotid bruits appreciated Pertinent Results: 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. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [**First Name (STitle) **] was notified in person of the results on Mr.[**Known lastname 67385**] prior to bypass. Post_Bypass: Preserved biventricular systolic function. LVEF 55%. Intact thoracic aorta. Minimal MR [**First Name (Titles) **] [**Last Name (Titles) **]. [**2141-4-22**] 09:15AM BLOOD WBC-14.7* RBC-3.34* Hgb-10.0* Hct-29.4* MCV-88 MCH-30.1 MCHC-34.1 RDW-13.6 Plt Ct-292 [**2141-4-21**] 04:37AM BLOOD WBC-14.0* RBC-3.13* Hgb-9.5* Hct-27.7* MCV-89 MCH-30.5 MCHC-34.4 RDW-13.7 Plt Ct-241 [**2141-4-22**] 09:15AM BLOOD Glucose-154* UreaN-19 Creat-0.7 Na-136 K-4.4 Cl-100 HCO3-27 AnGap-13 [**2141-4-21**] 04:37AM BLOOD Glucose-122* UreaN-22* Creat-0.6 Na-134 K-4.3 Cl-100 HCO3-28 AnGap-10 Brief Hospital Course: He was admitted for same day surgery and underwent coronary artery bypass graft surgery. See the operative report for further details. He received cefazolin for perioperative antibiotics. Post operatively he was transferred to the intensive care unit for management. In the first twenty four hours he was weaned from sedation, awoke neurologically intact and was extubated without complications. On post operative day one he was ready for transfer to the floor. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the Physical Therapy service for assistance with strength and mobility. By the time of discharge on [**4-23**],the patient was ambulating freely, the wounds were clean and healing well and pain was controlled with oral analgesics. He did have a leukocytosis to 20,000 postoperatively, however, no cultures were positive. He had two episodes of brief fever to 101. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: plavix 75 mg daily lisinopril 10 mg daily Toprol 25 mg daily NTG prn zocor 20 mg daily asa 325 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 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:*2* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 4 weeks. Disp:*30 Patch 24 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft Hypertension Gastroesophageal reflux disease Discharge Condition: Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2141-5-22**] at 1:00 Please call to schedule appointments Primary Care: Dr [**Last Name (STitle) **] [**Name (STitle) 17996**] in [**1-21**] weeks ([**Telephone/Fax (1) 6699**]) Cardiologist: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-21**] weeks ([**Telephone/Fax (1) 8725**]) [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2141-4-23**]

[ "414.01", "401.9", "305.1", "288.60", "530.81", "272.4", "780.60" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5341, 5396

3071, 4192

332, 540

5542, 5642

1714, 3048

6182, 6684

1019, 1037

4347, 5318

5417, 5521

4218, 4324

5666, 6159

1052, 1695

281, 294

568, 801

823, 869

885, 1003

79,240

142,189

38171

Discharge summary

report

Admission Date: [**2148-8-30**] Discharge Date: [**2148-9-4**] Date of Birth: [**2085-4-30**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: HCC Major Surgical or Invasive Procedure: [**2148-8-30**] Left hepatic lobectomy for HCC History of Present Illness: Per Dr.[**Name (NI) 1369**] preoperative note as follows: 63-year-old male who underwent a lower extremity bypass several years ago and who had recurrent symptoms of claudication. A CT angiogram was performed to evaluate his aorta and iliac arteries, and a 2.7 cm lesion in the left lobe of the liver was noted incidentally. An MRI on [**2148-5-23**] demonstrated a 2.6 x 3.1 x 2.4 cm lesion in segment 3/4A. On [**2148-6-7**] a CT-guided biopsy of the lesion demonstrated hepatocellular carcinoma in the background of cirrhosis. The patient underwent a preoperative cardiac evaluation. During a myocardial stress test with nuclear imaging on [**2148-6-26**], he was noted to have 0.5 to [**Street Address(2) 4793**] depression in leads V5 and V6. The IV dipyridamole stress test was negative for chest pain and the nuclear imaging demonstrated a large size, moderate intensity, anterior wall, septal wall, apex and inferior wall perfusion abnormality, with mild to moderate improvement on resting images involving the mid septal and basilar inferolateral walls. The left ventricular ejection fraction was 37% post stress and 47% at stress. These were all new since the prior scan in 08/[**2143**]. He underwent cardiac catheterization that demonstrated a right dominant system. The left main was normal. The LAD had a long, 90%, mid stenosis just after a large diagonal branch. The left circumflex demonstrated a 70%, ostial stenosis and there was a large obtuse marginal 2 branch which had 80% stenosis. The right coronary artery contained insignificant disease. He had an ejection fraction of 48%. The patient underwent an uncomplicated coronary artery bypass grafting x2, with a LIMA to the LAD and a saphenous vein to the obtuse marginal 2 that was performed on [**2148-7-15**]. He has had an uneventful recovery and has been cleared for surgical therapy. He is now brought to the operating room after informed consent was obtained for left hepatic lobectomy. He did undergo a follow- up CT scan on [**2148-8-21**] that demonstrated an unchanged size of the 3 cm, biopsy-proven, hepatocellular carcinoma in segments 2/4A. There was an additional, nonspecific, arterial-enhancing, 4 mm lesion of the dome of the liver that is likely focal vascular shunt, but will be assessed at the time of surgery with intraoperative ultrasound. Past Medical History: PMH: CAD, PVD, HTN, DM2, PSH: s/p CABG [**7-18**]; s/p L fem-[**Doctor Last Name **] [**9-/2131**], s/p iliac stenting [**5-15**] Pertinent Results: [**2148-9-4**] 06:50AM BLOOD WBC-9.7 RBC-3.70* Hgb-11.1* Hct-32.6* MCV-88 MCH-29.9 MCHC-34.0 RDW-13.9 Plt Ct-180 [**2148-9-2**] 05:38AM BLOOD PT-11.6 PTT-27.9 INR(PT)-1.0 [**2148-9-4**] 06:50AM BLOOD Glucose-169* UreaN-12 Creat-0.7 Na-136 K-3.8 Cl-101 HCO3-25 AnGap-14 [**2148-9-4**] 06:50AM BLOOD ALT-315* AST-67* AlkPhos-64 TotBili-1.0 Brief Hospital Course: On [**2148-8-30**], he underwent left hepatic lobectomy, cholecystectomy, intraoperative ultrasound surgery. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. IT morphine was used. A JP drain was placed. Please refer to operative note for complete details. Postop, he had a decrease in hct requiring transfusion and T wave inversion in leads V1-V3. Enzymes were trended and remained negative. Metoprolol IV was used. He was transferred to the SICU for management. He was successfully extubated. Vitals remained stable and he was transferred out of the SICU. Postop, he did well. Pain was well controlled with IV dilaudid. This was switched to oxycodone once diet was advanced and tolerated. JP drain had bilious drainage with a bilirubin level of 31.5. The JP remained in place with output that decreased to ~ 80cc/day. The incision was intact without redness or drainage. He did spike a temperature to 101.2 on [**9-1**] for which he was pancultured. Cultures remained negative to date. CXR demonstrated bibasilar atelectasis with linear opacity in the retrocardiac region. He had low grade temps to 100. He was ambulating independently. Foley was removed without incident. His right lower leg incisions were without redness/drainage. Dry gauze dressings were applied. He was discharged to home with his JP drain in place. VNA services were arranged. Medications on Admission: Lisinopril 5, ASA 325, Lopressor 100", Simvastatin 40, Flomax 0.4, Vitamin D2 400", NPH 58u qAM/52 qPM Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 6. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Fifty Eight (58) Subcutaneous once a day. 7. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Fifty Two (52) units Subcutaneous at bedtime. 8. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: HCC Bile leak Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if you experience any of the warning signs listed below empty the drain and record output. bring record of drain outputs to you next appointment with Dr. [**Last Name (STitle) **] [**Name (STitle) **] may shower No driving while taking pain medication. No alcohol No heavy lifting/straining Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2148-9-11**] 9:20 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2148-9-5**]

[ "997.4", "V58.67", "571.5", "155.0", "250.00", "440.20", "576.8", "E879.8", "V45.81", "401.9", "E878.8", "412", "440.4", "414.00" ]

icd9cm

[ [ [] ] ]

[ "51.22", "50.3" ]

icd9pcs

[ [ [] ] ]

5591, 5654

3284, 4705

317, 366

5712, 5712

2922, 3261

6250, 6578

4859, 5568

5675, 5691

4732, 4836

5863, 6227

273, 278

394, 2750

5727, 5839

2772, 2903

32,775

128,184

5368

Discharge summary

report

Admission Date: [**2200-8-27**] Discharge Date: [**2200-10-15**] Date of Birth: [**2168-1-8**] Sex: M Service: SURGERY Allergies: Clindamycin Attending:[**First Name3 (LF) 5547**] Chief Complaint: necrotizing fasciitis Major Surgical or Invasive Procedure: -[**2200-8-28**] radical debridement of soft tissues of R chest wall, abdominal wall, flank, groin; step incisions in abdominal wall fascia & musculature with drainage of peritoneal abscess -[**2200-8-29**] repeat debridement of necrotic soft tissues of R chest, abdominal wall, b/l groins, additional step incisions in abdominal wall fascia & musculature with drainage of peritoneal abscess -[**2200-9-4**] tracheostomy with 8-0 cuffec Portex tube, irrigation & debridement of wounds with further drainage of periappendiceal abscess, placement of 26Fr mushroom-tipped catheter into appendiceal stump within cecum -[**2200-9-17**] IVC filter placement -[**2200-9-26**] vac dressing change under general anesthesia -[**2200-9-30**] vac dressing change under general anesthesia -[**2200-10-2**] preparation of wound bed with debridement & excision of scar, meshed skin graft (16/1000" meshed at 1.5, total surface area 40x55 cm) -[**2200-10-7**] removal of bolster, skin graft, replacement of wound dressing with DuoDerm gel & Xeroform gauze History of Present Illness: 32M with long history of steroid abuse leading to multiple joint replacements, including both hips and both knees. He was an inpatient at [**Hospital6 2910**] for 6 weeks prior to admission for septic left knee joint (cultured for MRSA & [**Female First Name (un) 564**]). He underwent I&D of the joint and developed MRSA and Citrobacter sepsis. ID at NEBH stsarted linezolid, Diflucan, and cipro. He developed fevers, chills, and significant right-sided abdominal and flank pain with extensive erythema and induration of the soft tissues. A CT scan revealed multiple peritoneal, retroperitoneal, intrahepatic, pseudopancreatic, and pelvic cysts. His WBC rose to 40. He was transferred to [**Hospital1 18**] for IR aspiration cytology of cysts and further management. Past Medical History: PMH: -Seronegative arthritis, possibly ankylosing spondylitis, of hips, knees, wrist, on steroids/immunosuppressants since [**2190**](methotrexate, sulfasalazine, Enbrel, Humira, Remicade, prednisone) -anemia of chronic disease -MRSA infection -PUD -anabolic steroid abuse (16 months in early 20s) . PSH: -L TKR [**2-28**] c/b wound dehiscence & septic arthritis in [**3-1**] -R THR [**10-29**] -L THR [**1-25**] -R THR [**4-27**] -L tibial osteotomy -L4-L5 laminectomy [**2193**] (s/p MVA with traumatic disc herniation) Social History: Disabled, lives with mother in [**Name (NI) **], MA. Was a semiprofessional body builder in early 20s with h/o anabolic steroid abuse x 16 months. Tobacco 1 pack/day x 10 years. Denies alcohol use. Family History: noncontributory Physical Exam: On admission: VS: T: 102.4 HR: 120-130 BP: 110s/50s RR: 25 Sat: 96% on 4L CVP ~18 Gen: slightly drowsy, answering all questions appropriately, slightly diaphoretic, somewhat uncomfortable appearing HEENT: NCAT, PERRL, sclera anicteric, OP with bari-cat covering mucosa (pt prepping for CT), dentition appears to be in good repair Neck: obese, JVD unable to be assessed CV: tachy, S1/S2, no m/r/g Pulm: CTA b/l Abd: obese, distended, striae present, skin is erythematous and weeping w/ serous fluid, particularly over RLQ, tender in RLQ & LLQ, BS+ Ext: Anasarca, 3+ LE pitting edema DP pulses are 2+ bilaterally Neuro: A&O x 3, CN II-XII grossly intact, moves all extremities, sensation intact to light touch Skin: plethoric/erythema over face. Erythema over abd/chest/lower extremities, particularly anteriorly. No desquamation. GU: testicular edema . On discharge: VS: T: 97.7 HR: 91 BP 118/78 RR: 18 Sat: 96%RA Gen: NAD, A&O x3 CVS: RRR, nl S1/S2, no m/r/g Pulm: CTA b/l Abd: obese, appropriately tender, skin graft taking well over right abdomen & chest, cecostomy pink/viable in appliance with +stool Ext: b/l skin graft donor sites dry, tender, b/l LE 2+ edema Pertinent Results: On admission: [**2200-8-27**] 11:02PM GLUCOSE-128* UREA N-20 CREAT-0.9 SODIUM-136 POTASSIUM-3.7 CHLORIDE-94* TOTAL CO2-30 ANION GAP-16 [**2200-8-27**] 11:02PM ALBUMIN-2.6* CALCIUM-8.7 PHOSPHATE-3.3 MAGNESIUM-1.8 [**2200-8-27**] 11:02PM ALT(SGPT)-27 AST(SGOT)-57* LD(LDH)-301* ALK PHOS-151* AMYLASE-6 TOT BILI-0.4 [**2200-8-27**] 11:02PM LIPASE-12 [**2200-8-27**] 11:02PM WBC-25.3* RBC-3.10* HGB-9.0* HCT-27.8* MCV-90 MCH-29.0 MCHC-32.3 RDW-17.1* [**2200-8-27**] 11:02PM PLT SMR-NORMAL PLT COUNT-230 [**2200-8-27**] 11:02PM NEUTS-91* BANDS-3 LYMPHS-4* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* [**2200-8-27**] 11:02PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL TEARDROP-OCCASIONAL [**2200-8-27**] 11:02PM PT-14.5* PTT-35.0 INR(PT)-1.3* [**2200-8-27**] 11:02PM SED RATE-82* . CT ABDOMEN W/CONTRAST [**2200-8-28**] 12:45 AM IMPRESSION: 1. Multiple intra-abdominal fluid collections which appear cystic in quality. Though the majority of them are remote from the pancreas, pancreatic pseudocysts remain in the differential. The fluid collection in the right lower quadrant is infiltrating the fascia and associated with significant subcutaneous edema and stranding, concerning for necrotizing infection of the fascia in this locale. 2. Dilated loops of bowel likely due to an ileus. No wall thickening or pneumatosis. 3. Right lower lobe consolidation versus atelectasis. Additional focus of airspace opacity in the right upper lobe is concerning for infection. . SCROTAL US [**2200-8-30**] 5:03 PM IMPRESSION: Relatively symmetric vascular flow within the testes, bilaterally. Marked, diffuse scrotal skin thickening, with no focal collection or gas identified. . CT TORSO W/CONTRAST [**2200-9-3**] 10:30 AM IMPRESSION: 1. Small bilateral pleural effusions with associated atelectasis. 2. No significant change in intraabdominal fluid collections. 3. Extensive debridement of right anterior abdominal wall with associated packing material. . CT GUIDANCE DRAINAGE [**2200-9-5**] 10:23 AM IMPRESSION: Successful CT-guided placement of pigtail catheters in two largest fluid collections in upper abdomen. Samples from both fluid collections sent for culture and stain. . CT GUIDANCE DRAINAGE [**2200-9-8**] 10:27 AM IMPRESSION: 1. Patient status post upsizing of the catheter in a midline subphrenic collection and placement of two additional catheters in left lower quadrant and a perisplenic collections, without complication. 2. Significant interval decrease in the size of the right subphrenic fluid collection. 3. Persistent peripancreatic fat stranding, which may be secondary to pancreatitis. Correlation with laboratory values is recommended. 4. A focal hepatic hypodensity cannot be definitively characterized on this study. However, given its rapid appearance and somewhat tubular configuration, portal vein thrombus should be considered. An abscess would be less likely. 5. Suggestion of expansion and luminal hypodensity in the right common femoral vein. A deep vein thrombus cannot be excluded and ultrasound correlation is recommended. 6. Suspicion for oral contrast tracking along the right lateral abdominal subcutaneous tissues. Although no definite tract is visualized, an enterocutaneous fistula cannot be excluded. . BILAT LOWER EXT VEINS P [**2200-9-8**] 6:01 PM IMPRESSION: Nonocclusive thrombus within the right popliteal vein extending up to the mid right SFV. . CT ABSCESS CATH CHANGE [**2200-9-12**] 11:37 AM IMPRESSION: 1. Patient status post upsizing of a catheter in a subphrenic fluid collection, with removal of 400 cc of fluid. 2. Interval resolution of the perisplenic and left lower quadrant fluid collection, with stable near-complete resolution of the perihepatic collection. 3. Tracking of oral contrast along the cecostomy tube tract, some of which may be intraperitoneal in location. 4. New presumed packing material within the right lower quadrant adjacent to the patient's large subcutaneous defect. . CT ABDOMEN W/O CONTRAST [**2200-9-23**] 12:44 PM IMPRESSION: Compared to prior CT from [**2200-9-12**], the sizable left subphrenic fluid collection has decreased in size and now measures 9.5 x 5.8 cm, previously 10.9 x 9.6 cm. No significant colleciton is identifed in the region of the three additional drains. No new fluid collection. Findings discussed with Dr. [**Last Name (STitle) 1924**]. . On discharge: [**2200-10-10**] 05:59 PM GLUCOSE-169* UREA N-5 CREAT-0.4 SODIUM-140 POTASSIUM-3.9 CHLORIDE-100* TOTAL CO2-36 ANION GAP-8 [**2200-10-10**] 05:59 PM CALCIUM-7.8 PHOSPHATE-4.9 MAGNESIUM-1.8 [**2200-10-10**] 05:59 PM WBC-11.9* RBC-2.92* HGB-8.3* HCT-26.0* MCV-89 MCH-28.4 MCHC-31.9 RDW-15.1* [**2200-10-10**] 05:59 PM PLT COUNT-371 [**2200-10-15**] 4:27 AM PT-20.1* INR(PT)-1.9* Brief Hospital Course: Patient was transferred to [**Hospital1 18**] from [**Hospital6 17390**] on [**2200-8-27**]. He was admitted to the MICU with R abdominal & flank pain with extensive erythema and induration of the soft tissues. ID was consulted. He was started on linezolid, meropenem, and caspofungin. A prednisone taper was planned. He was continued on Lovenox. Overnight, he deteriorated. Surgery was consulted for necrotizing fasciitis. He was taken emergently to the OR for radical debridement with step incisions in the abdominal wall fascia & musculature on [**8-28**]. He remained intubated, sedated, and went to the SICU postoperatively, where he required levophed to maintain his BP. On [**8-29**], he returned to the OR for repeat debridement and additional step incisions. A VAC was placed and required changes q3days. Overnight, he was stable without pressor requirement, but remained intubated and sedated. His cultures grew Citrobacter, which was appropriately covered by meropenem. He remained on linezolid and caspo empirically for C.albicans and GNC in L knee cultures from NEBH. Tube feeds were started on [**8-30**]. Urology was consulted for scrotal edema and retracted penis. Ultrasound demonstrated symmetric blood flow and was negative for evidence of necrotizing fasciitis. On [**9-2**] Ortho was consulted for h/o septic joint. A knee aspirate was performed; the culture was negative. Chronic Pain was consulted and recommended methadone, increased pregabalin and Ativan gtt to wean down fentanyl gtt. A CT torso performed on [**9-3**] did not demonstrate significant change in the intraabdominal fluid collections. On [**9-4**], he went to the OR for tracheostomy, further I&D with drainage of periappendiceal abscess, and placement of cecostomy tube. A swab grew VRE, non albicans [**Female First Name (un) 564**], and S. aureus. A CT torso performed on [**9-5**] failed to demonstrate oral contrast extravasation (i.e. enterocutaneous fistula). Two pigtail drains were placed into his intraabdominal fluid collections with CT-guidance. The fluid drained grew Citrobacter. Ativan gtt was weaned off. Propofol was weaned off the following day. He remained on fentanyl gtt. Trach collar trials were tried daily. On [**9-8**], he underwent CT-guided placement of 2 additional drains as well as upsizing of one previously placed drain. Fluid culture grew Citrobacter, again appropriately covered by meropenem. A nonocclusive thrombus was found in the R popliteal vein-mid R SFV. He was started on heparin gtt. On [**9-9**], a Passy-Muir valve was placed. A PICC was placed on [**9-11**]. On [**9-15**], his antibiotics were changed to tigecycline and caspo. PT was consulted. On [**9-17**], an IVC filter was placed. He was then placed on Lovenox; heparin gtt was stopped. Plastics was consulted and recommended b/l LE STSG. On [**9-23**], a CT abd demonstrated decreased size of the L subphrenic fluid collection and no significant new or 3 drained collection. He was transferred to the floor. On [**10-2**], he went to the OR with Plastics for debridement, scar excision, and meshed skin graft. Regular diet was started on [**10-4**]; he tolerated it well. His last JP drain was d/c'd on [**10-6**]. He returned to the OR with Plastics on [**10-7**] for removal of bolster. His skin graft was viable. The wound VAC was replaced with DuoDerm gel & Xeroform. Coumadin was started on [**10-9**]. His PCA was d/c'd and he was transitioned to PO Dilaudid with IV Dilaudid prn breakthrough pain. Antibiotics were d/c'd on [**10-10**] as per ID recommendations. OT was consulted. On [**10-12**], his cecostomy tube migrated out. Ostomy RNs were consulted and an appliance was afixed. He was decannulated without respiratory difficulty on [**10-14**]. He refused d/c Foley throughout his hospital course secondary to difficulty with physical mobility. He also requires a great deal of encouragement to get out of bed to chair, where he sits for >3 hours/day. His pain is controlled on PO and IV Dilaudid. His PICC line is being left in place as per his request for IV Dilaudid administration. The risk for line infection has been explained to him, and he requests to keep it nevertheless. Medications on Admission: Meds at Home: MSIR, MScontin, prednisone, clonazepam, Percocet, Lasix, omeprazole, Indocin, Lovenox Meds on Transfer: prednisone 15mg qday, epoetin 40,000U qMWF, Lovenox 40mg qday, imipenem 400mg q6h, vanco 500mg [**Hospital1 **], phenergan 12.5mg prn, metoprolol 50mg [**Hospital1 **], zinc sulfate 220mg qday, compazine 10mg [**Hospital1 **], Tylenol prn, pregabalin 50mg TID, MScontin 120mg q8h, MSIR 45mg q3h prn, miconazole powder, hydrocortisone 100mg q8h x 24 hr, Protonix 40mg [**Hospital1 **], TPN Discharge Medications: 1. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 5. Vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble PO TID (3 times a day). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for tachycardia. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day): D/C once INR is [**12-28**]. 12. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day: Please monitor INR and adjust accordingly. 13. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours) as needed. 14. Lorazepam 2 mg/mL Syringe Sig: 0.5-2 mg Injection Q4H (every 4 hours) as needed for anxiety. 15. Hydromorphone 2 mg/mL Syringe Sig: 0.5 mg Injection Q3H (every 3 hours) as needed for breakthrough pain. 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 200 units heparin per unit qday and prn. 17. insulin sliding scale check fingersticks qAC & qHS fingerstick glucose regular insulin dose 0-60 mg/dL [**11-26**] amp D50 61-120 mg/dL 0 Units 121-140 mg/dL 2 Units 141-160 mg/dL 4 Units 161-180 mg/dL 6 Units 181-200 mg/dL 8 Units 201-220 mg/dL 10 Units 221-240 mg/dL 12 Units 241-260 mg/dL 14 Units 261-280 mg/dL 16 Units > 280 mg/dL Notify M.D. 18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five (5) units Subcutaneous once a day: give at breakfast. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: -Necrotizing soft tissue infection of the chest wall, abdominal wall, right flank and right groin, likely secondary to intraperitoneal abscess, s/p multiple debridements, s/p STSG. -Right lower extremity deep venous thrombosis s/p IVC filter. -Prolonged intubation requiring tracheostomy. -Sepsis. Discharge Condition: Afebrile, vital signs stable, tolerating regular diet, skin grafts viable, in place, Foley in place, OOBTC x 3 hours/day, pain controlled with PO & IV Dilaudid. 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 skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please take any new meds as ordered. * Continue to ambulate several times per day. * Continue to eat several, small meals throughout the day. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1927**] Date/Time:[**2200-10-21**] 1:45 Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 5343**] Date/Time:[**2200-10-21**] 4:15 Completed by:[**2200-10-15**]

[ "278.01", "V43.64", "518.5", "995.92", "567.22", "038.9", "540.1", "728.86", "V43.65", "285.9", "453.40" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.7", "93.57", "54.72", "88.51", "31.1", "81.91", "54.3", "96.6", "54.19", "86.22" ]

icd9pcs

[ [ [] ] ]

16084, 16158

8993, 13243

293, 1335

16500, 16663

4139, 4139

17769, 18166

2920, 2937

13801, 16061

16179, 16479

13269, 13370

16687, 17746

2952, 2952

8583, 8970

232, 255

1363, 2141

4153, 8569

2163, 2688

2704, 2904

13388, 13778

7,095

160,672

8294

Discharge summary

report

Admission Date: [**2197-1-24**] Discharge Date: [**2197-1-31**] Date of Birth: [**2123-7-21**] Sex: M Service: MED CHIEF COMPLAINT: Anemia. HISTORY OF PRESENT ILLNESS: A 73-year-old man with the extensive past medical history significant for diabetes, chronic kidney disease, hypertension and peripheral vascular disease presented to the nephrology clinic on [**2197-1-24**] with increasing fatigue and lower extremity edema. Blood work done at that time revealed a hematocrit of 19 in a setting of INR of 6. He was triaged in the emergency room for further work up. On further questioning the patient denies any melena, hematochezia or bleeding of any kind or bruising. Nasogastric lavage done in the emergency room was positive for coffee grounds. He was transfused with 1 units of red blood cells in the emergency room after which he was transferred to the Intensive Care Unit. In the Intensive Care Unit his coagulopathy was reversed with vitamin K and fresh frozen plasma and he was further transfused to a stable hematocrit. Endoscopy done revealed gastritis with lots of blood in the stomach, granularity and nodular lesion in the duodenum which possibly could be the source of his bleeding. He was eventually transferred out to the floor after a stable hematocrit. On the floor he was initiated by dialysis by the renal team. PAST MEDICAL HISTORY: 1. Diabetes mellitus, chronic kidney disease stage 4 complicated by hyperkalemia, volume overload, secondary hypoparathyroidism and anemia. 2. Ulcerative colitis. 3. Right adrenal adenoma. 4. Gout. 5. History of prostate cancer, status post prostatectomy. 6. Remote history of nephrolithiasis. 7. Hypertension, hyperkalemia. 8. Peripheral vascular disease with carotid stenosis, infrarenal abdominal aortic aneurysm, deep venous thrombosis, iron deficiency anemia and adrenal nodule. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Quit smoking at age 73. Retired as a chemical mixer from a leather tannery. No alcohol or illicit drug use. Lives at home with his wife and family. FAMILY HISTORY: Brother had liver cancer. Father and mother had cerebrovascular accidents. Paternal grandfather rectal cancer. PHYSICAL EXAMINATION: On arrival to the floor vital signs: Blood pressure 143/93, heart rate 80, temperature 99.2. Patient appeared in no acute distress. Head and neck examination showed PERRL. Moist mucous membranes. No elevated jugular venous distension. No cervical lymphadenopathy, supraclavicular lymphadenopathy. Heart and lungs normal. Abdomen soft, nontender, nondistended, no palpable masses. Extremities showed absent dorsalis pedis and posterior tibial pulses bilaterally. Right lower extremity revealed bluish discoloration of the toes (patient reports this to be present for the past 3 months). On neurological examination the patient was intact neurologically. Of note in the Intensive Care Unit streaks of blood were noted on the glove with black colored stools on rectal examination with erythema and maceration of the skin around the rectum. PERTINENT LABORATORY DATA, X-RAY AND OTHER TESTS: CBC on admission hematocrit 19.1, on discharge 29.3. On admission white count 16, on discharge 12.3. Platelets at discharge 201. Coagulation panel on admission INR is 6.7, PT 55.1, PTT 46.1. Coagulation panel at discharge was normal. Reticulocyte count 2.2. BUN and creatinine at admission 95 and 11 respectively, at discharge 42 and 7.9 respectively. After the last laboratory on the day of discharge the patient was dialyzed. Liver function tests normal. Troponin 0.11, 0.12, 0.13. Calcium 7.8, phosphorus 3.7, magnesium 1.4, total protein 5.8, albumin 2.8. A1C 6.2. Parathyroid levels 411. Hepatitis panel negative. Lactate normal. Urinalysis revealed 11, 18 RBCs. Blood cultures done negative at discharge. At the time of discharge Helicobacter pylori serology negative. At the time of discharge urine culture contaminated specimen. Specimen obtained during esophagogastroduodenoscopy, biopsy revealed hyperplasia of gastric pit. Refer to MR for details. Chest x-ray on admission revealed no acute cardiopulmonary process. Electrocardiogram revealed sinus rhythm with first degree AV block, right bundle branch block. Unchanged from prior electrocardiograms. PROCEDURES PERFORMED: Esophagogastroduodenoscopy and infusion of dialysis. SUMMARY OF HOSPITAL COURSE: Acute blood loss anemia from upper gastrointestinal bleeding: After the correction of coagulopathy and transfusion of 5 units of packed red blood cells the patient had an esophagogastroduodenoscopy that revealed the above findings and a biopsy was done that revealed the above findings. During the rest of the hospital course his hematocrit remained stable. He was started on pantoprazole to be taken 2 times a day. The patient is scheduled for a repeat upper endoscopy as indicated below. It is suggested that he also get a colonoscopy at that same time. The colonoscopy was scheduled on the same day as the endoscopy. Gastrin levels were sent and are pending at the time of discharge. Will defer to the primary care provider to follow up on the gastrin levels. Coumadin was stopped as the patient had completed about 11 months of anticoagulation therapy for a deep venous thrombosis. He was initiated on aspirin. He was advised to refrain from using non-steroidal anti-inflammatory medications as well as alcohol and caffeine. Chronic kidney disease, stage 5: Dialysis was initiated at this time under the guidance of nephrology. He was started on RenaGel and nephro caps. Epogen will be administered 3x a week during dialysis. Outpatient follow up was arranged by social work for patient to get continued dialysis as indicated below on Tuesdays, Thursday and Saturdays. Peripheral vascular disease: The patient was started on aspirin and then warfarin was stopped. Vascular surgery attending who follows the patient in clinic, Dr. [**Last Name (STitle) **], was attempted to be contact[**Name (NI) **]. However, he was traveling and could not be contact[**Name (NI) **]. The vascular consulting was contact[**Name (NI) **] who recommended that given the chronicity of the problem it is best if the patient follow up with Dr. [**Last Name (STitle) **] for the possibility of an angiogram now that he is on dialysis. Hypertension: He was continued on his medications during the hospitalization after he was out of the Intensive Care Unit. Blood pressure remained stable. Leukocytosis: An infection work up remained negative, likely reactive. Gout: Allopurinol was continued. Type 2 diabetes mellitus: He was continued on glipizide on his home dose with the insulin sliding scale and the A1C was less than 7. Deep venous thrombosis: Warfarin as above was stopped. The patient was placed on aspirin and encouraged ambulation. The patient will require deep venous thrombosis prophylaxis while immobile. For example, if he has further hospitalizations or perioperatively. The patient also has abdominal aortic aneurysm and adrenal nodular as well as carotid stenosis on multiple radiological studies done in our system. These should be followed up as per the discretion of the primary care provider. CONDITION ON DISCHARGE: Stable. Discharged to home. PATIENT DISCHARGE INSTRUCTIONS: The patient was discharged with the following instructions: Please follow with your primary care doctor or return to the hospital if you have fevers, chills, chest pain, dizziness, or any other symptom concerning to you. Make an appointment as instructed below with Dr. [**Last Name (STitle) 6431**] in the next 1 week. You should blood work done at that time for hematocrit. Also discuss with Dr. [**Last Name (STitle) 6431**] about getting another urine test to look for blood as the urine test during the hospitalization reveals some blood. You are scheduled for an upper endoscopy and as a colonoscopy as well. Please contact your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 16615**] for the preparation of the colonoscopy. Please attend the dialysis sessions as instructed. You should not take Coumadin as this may make you bleed for the ulcer. Avoid taking ibuprofen, Motrin, Advil or any such medications without consulting your primary care doctor. You are started on a coated aspirin and please take as instructed. RECOMMENDED FOLLOW UP: 1. Nephrology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**], [**Telephone/Fax (1) 435**] on [**2-1**], [**2196**] at 9 a.m. 2. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 1142**]. Date and time of the appointment [**2197-2-6**] at 9 a.m. 3. Gastrointestinal endoscopy suite room at the [**Hospital1 29402**] on [**2197-2-17**] at 9 a.m. for esophagogastroduodenoscopy and colonoscopy Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**]. Please contact your primary doctor [**First Name (Titles) **] [**Last Name (Titles) 29403**]tion for the preparation for colonoscopy. 4. Dialysis on [**2197-2-2**] at 2:45 p.m. at [**Location (un) 4310**]. 5. Please call Dr. [**Last Name (STitle) **] to make a follow up appointment in the next 1 week for further management of the vascular disease in your legs. MAJOR SURGICAL OR INVASIVE PROCEDURES: Esophagogastroduodenoscopy and infusion of dialysis. DISCHARGE MEDICATIONS: Atorvastatin 5 mg p.o. daily, calcium carbonate 500 mg 2 tablets 3x a day, sevelamer 800 mg tablets 2 tablets 3x a day, nephro caps 1 capsule daily, lansoprazole 40 mg, Senna tablets 2x a day, glipizide 2.5 mg daily, allopurinol 50 mg daily, lidocaine and prilocaine 2.5 - 2.5% cream topically as directed 20 minutes prior to dialysis to the AV graft, metoprolol 25 mg p.o. b.i.d., nifedipine 90 mg sustained release tablets 2 tables to be taken daily, aspirin 325 mg extended coated release tablets once daily. DISCHARGE DIAGNOSES: 1. Acute blood loss anemia. 2. Upper gastrointestinal bleeding. 3. Chronic kidney disease stage 5. 4. Initiation of dialysis. 5. Peripheral vascular disease. 6. Secondary diagnosis: Hypertension, gout, history of deep venous thrombosis. 7. Diabetes mellitus poorly controlled with complications. 8. Abdominal aortic aneurysm. 9. Adrenal nodule. 10. Carotid stenosis. [**Name6 (MD) **] [**Name8 (MD) 21386**], MD [**MD Number(2) 26878**] Dictated By:[**Name8 (MD) 26879**] MEDQUIST36 D: [**2197-1-31**] 19:11:29 T: [**2197-1-31**] 20:08:03 Job#: [**Job Number 29404**]

[ "285.1", "443.9", "227.0", "790.92", "441.4", "288.60", "578.9", "428.30", "428.0", "433.10", "272.4", "V10.46", "585.5", "V12.51", "274.9", "403.91", "276.2", "250.90", "V13.01" ]

icd9cm

[ [ [] ] ]

[ "39.95", "45.16", "99.04", "96.33", "99.07" ]

icd9pcs

[ [ [] ] ]

2111, 2223

9950, 10117

9416, 9929

7301, 8364

8375, 9392

4408, 7214

2246, 4379

154, 163

192, 1359

10138, 10562

1381, 1928

1945, 2094

7239, 7276

7,979

158,966

54288

Discharge summary

report

Admission Date: [**2112-6-19**] Discharge Date: [**2112-7-4**] Date of Birth: [**2069-8-18**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Cephalosporins / Ciprofloxacin Attending:[**First Name3 (LF) 17813**] Chief Complaint: hypothermia, increased seizures Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 42 yo W with h/o with a refractory seizure disorder (on 3 AEDs and w/[**Known lastname 15741**]; followed by Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 16883**] [**Last Name (NamePattern1) 85740**]) following resective and radiation therapy for [**Last Name (NamePattern1) 111222**] in infancy, multiple meningiomas, MR/ID and pan-hypopituitarism with chronic hypothermia, obesity with OSA (no CPAP) presents with hypothermia and increased seizure frequency. The patient has had multiple recent admissions. On [**2112-3-21**], she had [**5-8**] seizures including one grand mal seizure (first grand mal since [**2096**]) after a 4 hour delay in getting her AED medications. While admitted, the patient had at least 2 tonic clonic seizures, which is abnormal for her. She did not have EEG monitoring at that time but was discharged with increased dose of Keppra. On [**3-30**] to [**4-5**] she was admitted for L sided increased weakness and concern for new semiology (sudden laugh, upper extremity and torso tightening, then head down briefly, becoming unresponsive with the event). Zonegram and Lamictal were increased. [**Date range (1) 111225**] readmitted for hypothermia to [**Age over 90 **] F and somnolence. She was treated for PNA, and given stress dose steroids. She continued to have freq tonic seizures including at least 2 GTCs that lasted 2 minutes or less with a typical post-ictal state. Endocrine was consulted and did not feel that hypothermia could be completely attributed to hypopituitarism, but did increase her standing steroids dose. Her baseline seizure frequency until recently had been around five to six per month. Recent Seizures: [**5-29**]-one event with brief eye deviation up and to right, speech arrest and urinary incontinence [**5-31**]- with eye 'rolling', staring, head shaking, body tonic, screaming. Event lasted 20 seconds, postical for 45 seconds. [**6-1**]- at least 4 or 5 brief events with sudden laughing and nonresponsiveness during epilepsy office visit. Staff did not note these as seizures and have witnessed many of these at home. [**6-9**]- 8pm, eyes rolling, face stiff/distorted, head and bilateral extremities shaking, body stiffened, face red, screaming, 40 sec [**6-15**]- 2:25pm, similar to [**6-9**], 1 min 20 sec [**6-18**]- 6:30pm, eyes rolling, generalized stiffening/shaking, 15 sec with 30 sec postictal The patient presents today because caretakers noted her to be hypotherma to 92-[**Age over 90 **] F. She had not had any infectious symptoms such as cough, SOB, rhiorrhea, congestion, sore throat, foul smelling urine, N/V/D. She had been taking prophylactic med (methanamine) to prevent UTI for about 1 month, ending [**6-11**]. Her parents spoke to [**First Name8 (NamePattern2) 16883**] [**Last Name (NamePattern1) 29298**], who recommended ED visit and likely admission given the hypothermia as well as [**3-6**] recent seizures that were either prolonged complex partial or partial with secondary generalization. ROS: per parents No headache, change in speech or comprehension, dysphagia, new focal weakness, fevers, sweats, cough, SOB, N/V/D, abdominal pain, rash. Past Medical History: 1.) Right parietal [**Month/Day (3) 111222**]- age 1.5 yrs, s/p resection and radiation (so baseline left hemiparesis), complicated by hydrocephalus s/p VP shunt 2.) Refractory seizures on multiple AEDs, s/p [**Month/Day (3) 15741**]; about 5 times per month with a variety of manifestations (turns red in the face; brief movements of her eyes, brief moments of non-responsiveness). Swiping the [**Month/Day (3) 15741**] magnet to activate [**Month/Day (3) 15741**]. Last generalized seizure with post-ictal period noted in OMR chart was sometime in [**Month (only) 404**], preceeded by sometime in [**Month (only) **]. Last [**Month (only) 15741**] update in [**11-5**].) Sleep apnea with obese neck; snores/wakes frequently (including for nocturia); does not tolerate CPAP. 4.) Panhypopituitarism (hypogonadism, adrenal insufficiency, hypothyroidism); on glucocorticoid and thyroid replacement, progesterone) 5.) Osteoporosis with unclear h/o knee and shoulder pain 6.) Meningiomas (Right parietal, growing @2cm; RF=XRT@youth) 7.) Developmental Delay / MR [**First Name (Titles) **] [**Last Name (Titles) 111222**] resection 8.) s/p Mohs surgery for a recurrent nodular basal cell cancer on the left occiput; also s/p BCC Tx with Aldara. 9.) h/o urinary incontinence and nocturia, chronic 10.) h/o VPS in RLV, reportedly removed in [**2091**] (but seen on current and prior head imaging, with dilated ventricle) 11.) s/p cholecystectomy in [**2099**] Social History: Patient lives in a group home (Open [**Doctor Last Name 7730**]). Had been bed/wheelchair-bound but was able to walk with 2 person assist on leaving rehab last month, however remains dependent. Parents seem very supportive and knowledgeable; they visit often and take her out on trips. No history of illicits/EtOH/tobacco Family History: Adopted. Unknown family history. Physical Exam: PHYSICAL EXAM ON ADMISSION: VS: T (rectal 92.6F) HR 60-70s BP 85-105/40-60s RR 18 02 98/2L NC GEN: macrocephalic, awake, NAD HEENT: small skin breakdown from prior EEG, no nuchal rigidity, OP clear, MMM CV: RRR, no mr/r/g PULM: CTAB AB: soft, ND/NT, normal BS EXT: no edema NEURO: MSE: Awake but slightly drowsy and falls asleep a few times during examination, easily arousable to voice. Oriented to self, her birthdate but not age, and "hospital." Does not know why she is here, but feels "better." Speech fluent though short phrases only, able to name simple objects and repeat. Comprehension intact for simple commands bilaterally. No obvious neglect, able to name everyone in the room. CN: PERRL 3 to 2mm. R esotropia with disconjugate primary gaze but intact EOM, no nystagmus. Face symmetric. Facial sensation intact to light touch. Palate elevates and tongue protrudes in the midline. MOTOR: increased tone in LUE, with clenched fist position of L hand with contracture. No asterixis or myoclonus. All extremities antigravity with symmetric spontaneous movements and movement to command. SENSATION: intact to light touch throughout DTR: 2 on R [**Hospital1 **], tri, brachio. 2+ brisker on L [**Hospital1 **], tri, brachio. Symmetric 2+ at patellars. Sustained clonus L ankle. L toe upgoing, R toe equivocal. COORDINATION: mildly incoordinated FNF on L, limited by inability to open hand, intact on R GAIT: deferred PHYSICAL EXAM ON DISCHARGE: Now normothermic, otherwise exam unchanged from admission. Awake and alert. Good disposition, answers basic questions, oriented to name, hospital and [**Location (un) 86**]. Follows simple commands. Baseline L spastic hemiparesis. Pertinent Results: [**2112-6-19**] 01:32PM URINE UCG-NEGATIVE [**2112-6-19**] 01:32PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016 [**2112-6-19**] 01:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2112-6-19**] 12:53PM GLUCOSE-84 UREA N-18 CREAT-1.2* SODIUM-139 POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14 [**2112-6-19**] 12:53PM estGFR-Using this [**2112-6-19**] 12:53PM CALCIUM-9.9 PHOSPHATE-3.9 MAGNESIUM-2.4 [**2112-6-19**] 12:53PM TSH-3.0 [**2112-6-19**] 12:53PM WBC-7.6 RBC-4.57# HGB-13.9 HCT-43.6 MCV-95 MCH-30.5 MCHC-32.0 RDW-14.2 [**2112-6-19**] 12:53PM NEUTS-69.0 LYMPHS-23.2 MONOS-4.9 EOS-1.7 BASOS-1.1 [**2112-6-19**] 12:53PM PLT COUNT-187 CXR [**2112-6-19**]: FINDINGS: Low lung volumes persist without focal consolidation. Retrocardiac region is incompletely assessed due to obscuration by battery pack of neural stimulator. Crowding of the vasculature and increased interstitial markings is seemingly unchanged from multiple previous examinations, likely secondary to crowding due to low lung volumes. Cardiac silhouette remains mildly enlarged. IMPRESSION: No acute intrathoracic process. EEG ([**6-20**]): IMPRESSION: This is an abnormal video EEG monitoring study due to one seizure characterized clinically by behavioral arrest and electrographically by electrodecrement and fast activity over the right hemisphere. The remainder of the study showed frequent multifocal left hemispheric epileptiform discharges mainly in the left temporal and central regions as well as occasional right central and temporal epileptiform discharges consistent with multiple active underlying epileptogenic foci. The background activity was diffusely slow with slower frequencies over the right hemisphere suggestive of a diffuse encephalopathy with more severe dysfunction of the right hemisphere. There was higher amplitude over the right central region likely representing breach artifact related to overlying skull defect. [**6-21**]: This is an abnormal video EEG monitoring study due to one seizure characterized clinically by behavioral arrest and electrographically by electrodecrement and fast activity over the right hemisphere. The remainder of the study showed frequent multifocal left hemispheric epileptiform discharges mainly in the left temporal and central regions as well as occasional right central and temporal epileptiform discharges consistent with multiple active underlying epileptogenic foci. The background activity was diffusely slow with slower frequencies over the right hemisphere suggestive of a diffuse encephalopathy with more severe dysfunction of the right hemisphere. There was higher amplitude over the right central region likely representing breach artifact related to overlying skull defect. Brief Hospital Course: 42 yo F with hx of refractory seizure disorder (on 3 AEDs and w/[**Month/Year (2) 15741**]; followed by Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 16883**] [**Last Name (NamePattern1) 85740**]) following resective and radiation therapy for [**Last Name (NamePattern1) 111222**] in infancy, multiple meningiomas, MR/ID and pan-hypopituitarism with chronic hypothermia, obesity with OSA (no CPAP) who presents with hypothermia and increased seizure frequency. Etiology of hypothermia - likely hypothalamic, prophylactic steroids unlikely to help. Has occurred repeatedly over past several months. No infectious etiology or relationship with seizures. Seizures are about daily which is believed to be at baseline, given increased observation while inpatient. ICU and Floor Coure: *NEURO: She was admitted to the neuro ICU and monitored closely overnight. A Bair Hugger was placed and she was slowly rewarmed. She is now maintaining her baseline temperature (usually around 96-98F) without intervention. She was connected to LTM and had no evidence of seizure activity overnight. She was continued on her home AED regimen (Keppra 1000mg [**Hospital1 **], Lamictal 400/350, Zonegran 350mg daily). Continuous video EEG recording captured 2 seizures with brief behavioral arrest, electrographically associated with electrodecrement then fast activity. EEG otherwise showed multifocal epileptiform discharges. The patient had several complex partial-type seizures, usuaully 1-2 per day on average. During the events, the patient would stare off/behavioral arrest, some with right ankle shaking, some with other subtle movements, usually a few seconds long, after which she quickly is back to baseline within seconds. She also had [**1-4**] generalized tonic clonic seizures. She had one just after admission, and one on [**6-4**]. This was about 1 minute of unresponsiveness with bilateral arm stiffening and jerking. Afterwards, she was confused and drowsy for about 30-45 minutes. Her seizure frequency is currently at her baseline. She is unlikely to attain better seizure control with adjustments to her AED regimen, and there will be a balance between side effects/drowsiness and seizure control, so no changes in her seizure medications were made during this hospitalization. Please swipe [**Month/Day (2) 15741**] magnet for any seizure activity. Her parents use this consistently for any noticed seizure. *ENDOCRINE: Endocrine was consulted and her Hydrocortisone was increased to 25 [**Hospital1 **] for the first two days of hospitalization, however this was generally empiric to cover her for potential infection or increased seizures and not meant to specifically improve her temperature stability. The patient was transferred to the floor in good condition ([**6-20**]). She was returned to her home dosing of hydrocortisone 15/5. She was continued on the rest of her home endocrine regiment: levothyroxine 112mcg daily, progestin 100mg. *INFECTIOUS DISEASE: While on the epilepsy service she had a couple other events of elevated temperature. The patient received a full infectious work-up with normal CBC, CXR and UA. Across 4 different infectious work-ups the results were normal (CBC, CRP, ESR, CXR all reassuring). It was determined that her variable temps should be treated empirically with NSAIDs unless there were other clinical signs of infection. A screening WBC, UA and CXR would be reasonable if there was any other clinical concern for infection (O2 demand while awake, change in HR or RR, etc), *PULMONARY: O2 sats were monitored and she was given supplemental O2 as needed (hx of OSA not on CPAP). CXRx4 were normal and unchanged from admission. There were a few nights when her O2 sat would dip into the low 90s, high 80s and she was placed on nasal cannula. Towards the end of the week, prior to discharge she was not requiring O2 at night. *REHAB: The patient was discharged in good condition to a skilled nursing facility closer to her parents. She had previously been living at a group home, however it was decided by the parents that she was not receiving adequate supervision while there. She was seen by PT who felt that rehab may be considered, however [**Hospital 38**] rehab where she has gone on a few occasions did not feel that she was rehabable. She will be discharged to a skilled nursing facility. . TRANSITIONAL CARE ISSUES . Plan for temperature lability: - Please make efforts to keep the patient warm: sunlight, away from AC, with a warm blanket available to place over patient. - Please treat low or high temperatures with ibuprofen 600 mg q6 hours. - If there is concern for infection: change in respirations, O2 sat while awake, HR, etc. consideration should be given for a screening CBC, CXR and UA. If these are normal, her temperature fluctuations should be treated with regular NSAIDs. Please note that the patient can become more somnolent or have slightly increased seizure frequency with abnormal temperatures and this alone may not be indicative of an infection. Plan for seizures: - wipe [**Hospital 15741**] magnet for any seizure - please keep record of all seizures and bring to any neurology/epilepsy appointments - seizure precautions - Ativan prn for any seizure longer than 5 minutes or more than 3 in one hour Medications on Admission: Lamictal 400 mg daily 8am/350 mg at 8pm Keppra 1000 mg [**Hospital1 **] (8am, 8pm) zonisamide 350 mg daily at 8pm ativan 0.5 mg Q HS synthroid 112 mcg daily Cortef 15 mg qAM (8am), 10 mg qPM (4pm) progesterone 100 mg TID tums metamucil, senna, colace vitamin C, D, MVI tylenol prn Discharge Medications: 1. Calcium Carbonate 1000 mg PO BID 2. Multivitamins 1 TAB PO DAILY 3. LeVETiracetam 1000 mg PO BID patient taking own meds 4. Hydrocortisone 5 mg PO QPM at 4 PM 5. LaMOTrigine 400 mg PO DAILY 8am patient taking own meds 6. LaMOTrigine 350 mg PO QHS 8PM 7. Zonisamide 350 mg PO DAILY patient taking own meds 8. Vitamin D 400 UNIT PO DAILY 9. Psyllium Wafer 1 WAF PO DAILY 10. progesterone micronized *NF* 100 mg Oral TID * Patient Taking Own Meds * 11. Levothyroxine Sodium 112 mcg PO DAILY 12. Hydrocortisone 15 mg PO QAM At 8 AM 13. Miconazole Powder 2% 1 Appl TP QID:PRN rash 14. Senna 1 TAB PO BID 15. Lorazepam 0.5 mg PO HS 8pm 16. Ibuprofen 400 mg PO BID 17. Docusate Sodium 100 mg PO BID Discharge Disposition: Extended Care Facility: Neuro-Rehabilitation Center - [**Location (un) 7740**] Discharge Diagnosis: 1. Hypothermia, 2. Hypothalamic dysfunction, 3. Seizures, 4. Pan-hypopituitarism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neuro Exam: Alert, interactive. Baseline left hemiparesis. Discharge Instructions: [**Known firstname **] [**Known lastname **] was admitted to [**Hospital1 18**] with hypothermia and lethargy. She was admitted to the ICU where an extensive infectious work-up was negative. She was rewarmed and transferred to the Epilepsy Service. She was placed back on her home dosing of hydrocortisone. She had a few more episodes of labile temperatures above 99. These were also evaluated for an infectious cause and none was identified. These changes in temperature, in the absence of other clinical symptoms should be considered part of her hypothalmic dysfunction and can be treated empirically with ibuprofen. [**Known firstname **] is being discharged in good condition to a nursing facility closer to home. Plan for temperature lability: - Please make efforts to keep the patient warm: sunlight, away from AC, with a warm blanket available to place over patient. - Please treat low or high temperatures with ibuprofen 600 mg q6 hours. - If there is concern for infection: change in respirations, O2 sat while awake, HR, etc. consideration should be given for a screening CBC, CXR and UA. If these are normal, her temperature fluctuations should be treated with regular NSAIDs. Please note that the patient can become more somnolent or have slightly increased seizure frequency with abnormal temperatures and this alone may not be indicative of an infection. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5340**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2112-7-19**] 1:00 [**Hospital **] CLINIC- [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] WEDNESDAY [**8-3**] 1:45 PM Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 2010**] Date/Time:[**2112-8-8**] 11:00

[ "788.43", "V45.2", "V15.3", "V58.65", "278.00", "V10.83", "253.7", "342.80", "345.41", "378.00", "780.65", "331.4", "327.23", "244.8", "733.00", "783.40", "V12.41", "V49.86", "225.2", "788.91", "255.41" ]

icd9cm

[ [ [] ] ]

[ "89.19" ]

icd9pcs

[ [ [] ] ]

16391, 16472

10028, 15338

338, 344

16597, 16597

7168, 10005

18228, 18684

5405, 5441

15669, 16368

16493, 16576

15364, 15646

16832, 18205

5456, 5470

6917, 7149

267, 300

372, 3571

5484, 6889

16612, 16808

3593, 5049

5065, 5389

69,583

130,923

330

Discharge summary

report

Admission Date: [**2196-7-9**] Discharge Date: [**2196-7-28**] Date of Birth: [**2142-9-13**] Sex: F Service: MEDICINE Allergies: Latex / Zanaflex Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: AMS Major Surgical or Invasive Procedure: 1. Intubation [**7-10**] by ICU team 2. LP [**7-11**] by ICU team 3. Tracheostomy [**7-20**] by Interventional Pulmonology (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3072**]) 4. PEG placement [**7-21**] by Gastroenterolgy (Dr. [**Last Name (STitle) **] [**Name (STitle) **]) History of Present Illness: This is a 53 yo WF with a PMHx of advanced [**1-27**] progressive MS, chronic indwelling foley, h/o pe on coumadin who p/f personal care home with AMS . The patient's last admission was [**2196-5-22**] who was admitted for AMS and acute on chronic lethargy. They dx her with toxic metabolic encephalopathy [**1-27**] to UTI and mrsa follicullitis (she had a dermatomal rash). She was treated with vancomycin, she improved was transitioned to orals bactrim and doxycycline and was d/c. . The following history was obtained from an LPN named [**Name (NI) **] [**Name (NI) 3073**] at [**Telephone/Fax (1) 3074**]. She states that since the patient prior admission she never returned to her baseline. The patient seems to have a waxing and wanning mental status. She denies seeing the patient have twitching movements or signs of infection such as recent diarrhea, fever or cough. Temps at [**Hospital1 1501**] ranged from 99.2-99.4. The patient recently history is notable for non-compliance both when she is oriented and when she is not. She refuses UA evalaution and also refuses suprapubic care. It is not clear when the last time her supr-pubic cath was changed. Starting the day of admission, the patient was incoherent, was unable to swallow her pills and was salivating. she was deemed usafe to be at her home and was sent to the ED and [**Hospital1 **]. . The patient arrived to the ED and was intially minimally responsive. Per the ED reports she improved while there from a MS perspective. They did an I and D of the area around her SP cath and it was sent for culture which showed GPC in pairs and GPR. BC and Urine cultures were sent. The patient HCT showed nothing acute and her CXR was wnl. The patient was given levofloxacin and sent to the floor. Past Medical History: 1) Multiple sclerosis (advanced secondary progressive) -followed by Dr. [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **] in neurology clinic -diagnosed at age 23 -largely wheelchair bound, needs assistance with transfer -chronic suprapubic catheter changed once monthly 2) History of pulmonary embolism, on coumadin 3) depression 4) hyponatremia 5) h/o mrsa 6) h/o c. diff colitis 7) h/o intermitent UTI's in the past Social History: Non-smoker, non-drinker. Lives at [**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living in [**Location (un) **]. Divorced. Family History: NC Physical Exam: Admission Physical Exam: VS BP 140/94 P-64 R-18 SaO2-97 RA General: Patient is able to answer yes and no questions but in mostly non verbal except [**12-27**] word statements HEENT: CN 2-12 grossly intact, mmm, pupils equal and minimally responsive to light Endo: no obvious thyroid nodules CV: RRR no rmg Lungs: CTAB no WRR Abdomen: non TTP, active BS, SP cath in place with minimal erythema and milkly residue on inside of tube Extremities/Neuro: UE -some rigidity in bue, 1+ reflexes, 4/5 strength, sensation difficult to access due to limited patient response, [**Last Name (un) 3076**] negative, pulses 2+ and equal LE: -4/5 strength in ble, sensation again difficult to access, babinski down going, no clonus and some rigidity -pulses 2+ and equal Psyc: patient to to have a depressed mood and has a flat affect . Dicharge Physical Exam: Vitals T 99.9 BP 154/79 HR 124 O2 92% on trach mask General: Lying in bed in no acute distress HEENT: Trach collar/mask in place. CV: RRR. No M/R/G LUNGS: Coarse breath sounds bilaterally anteriorly. ABD: PEG in place, with overlying bandage +min sanguious drainage (decreased from yesterday). BS+. Soft. NT/ND EXT: 1+ pitting edema of LE bilaterally, 2+ pitting edema of UE b/l SKIN: Improved macular rash over the LE NEURO: Opens and blinks eyes, sporadically Pertinent Results: Admission labs: [**2196-7-9**] 01:30PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.012 [**2196-7-9**] 01:30PM URINE BLOOD-NEG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-LG [**2196-7-9**] 01:30PM URINE RBC-9* WBC-130* BACTERIA-MANY YEAST-NONE EPI-0 TRANS EPI-1 [**2196-7-9**] 01:30PM URINE MUCOUS-OCC [**2196-7-9**] 12:16PM COMMENTS-GREEN TOP [**2196-7-9**] 12:16PM LACTATE-0.9 [**2196-7-9**] 12:08PM GLUCOSE-137* UREA N-12 CREAT-0.4 SODIUM-122* POTASSIUM-4.4 CHLORIDE-88* TOTAL CO2-27 ANION GAP-11 [**2196-7-9**] 12:08PM estGFR-Using this [**2196-7-9**] 12:08PM WBC-3.3*# RBC-3.07* HGB-9.6* HCT-27.8* MCV-91 MCH-31.2 MCHC-34.4 RDW-18.3* [**2196-7-9**] 12:08PM NEUTS-74.0* LYMPHS-21.5 MONOS-3.6 EOS-0.5 BASOS-0.3 [**2196-7-9**] 12:08PM PLT COUNT-126* [**2196-7-9**] 12:08PM PT-24.4* PTT-34.0 INR(PT)-2.3* Relevant labs: [**7-20**] Skin biopsy: Focal spongiosis, focal follicular neutrophilic parakeratosis, sparse superficial perivascular dermatitis with rare eosinophils, and mild papillary dermal edema. The changes are mild and non-specific. The finding of neutrophilic parakeratosis at a follicular ostium (slide L1-2) is suggestive of seborrheic dermatitis. While the anatomic site is somewhat unusual, a seborrheic dermatitis-like drug eruption is possible. Seborrheic dermatitis may occur more frequently with some medical disorders including epilepsy. PAS stain is negative for fungi. Clinical-pathologic correlation is recommended. Microbiology: [**2196-7-9**] 1:30 pm URINE FROM CATHETER URINE CULTURE (Final [**2196-7-12**]): SERRATIA MARCESCENS. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. 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. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. [**2196-7-9**] 1:00 pm SWAB INCISION OF ABDOMINAL SURFACE. GRAM STAIN (Final [**2196-7-9**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). WOUND CULTURE (Final [**2196-7-13**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. PSEUDOMONAS AERUGINOSA. RARE GROWTH. [**7-9**]: Blood cultures x2 negative [**7-10**]: Legionella urinary antigen negative [**7-11**]: CSF Crypotcoccal antigen negative, fluid culture negative; fungal and viral cultures pending [**2196-7-11**] 7:24 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2196-7-11**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2196-7-13**]): MODERATE GROWTH Commensal Respiratory Flora. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2196-7-12**]): SPECIMEN NOT PROCESSED DUE TO: IMPROPER SPECIMEN COLLECTION. Induced sputum required. PLEASE SUBMIT ANOTHER SPECIMEN. TEST CANCELLED, PATIENT CREDITED. Reported to and read back by DR [**First Name (STitle) 3078**] ([**Numeric Identifier 3079**]) [**2196-7-12**] AT 7:11AM. FUNGAL CULTURE (Preliminary): YEAST. [**7-13**]: C. diff toxin negative [**7-18**]: Skin scrapings KOH negative, fungal culture prelim negative [**7-21**]: Catheter tip culture negative Imaging: CXR [**7-9**]: A single portable chest radiograph is obtained. There has been no significant interval change in comparison to prior study from [**2196-5-18**]. No focal consolidation, effusion, or pneumothorax is seen. The heart and mediastinal contours are unremarkable. No soft tissue or bony abnormalities noted. Biapical pleural thickening is stable. Non-contrast Head CT [**7-9**]: There is no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarct. Hypoattenuation in the subcortical and periventricular white matter is mild and unchanged, likely sequelae of chronic microvascular ischemic disease. The ventricles and sulci are normal in size and symmetric in configuration. There is no shift from normally midline structures. The visualized paranasal sinuses and mastoid air cells are clear with interval resolution of the right sphenoid sinus air-fluid level. No osseous abnormality is identified. MRI Head w/&w/o contrast [**7-14**]: 1. No evidence of acute findings. 2. Stable white matter lesions consistent with patient history of Multiple Sclerosis. 3. Incompletely visualized atrophy of the spinal cord. 4. Opacification of the mastoid air cells. . EEG [**7-10**]: This is an abnormal continuous ICU monitoring study because of initially continuous generalized electrographic seizures consistent with non-convulsive status epilepticus. Over the course of the recording, these frequent seizures subsided with antiseizure medication administration. There was a transition from frequent electrographic seizures to infrequent bifrontal epileptiform discharges at around 22:00 hours. There was no recurrence of electrographic seizures for the remainder of the study duration. Background activity remained slowing, indicative of moderate diffuse cerebral dysfunction, which is etiologically non-specific. EEG [**7-21**]: This is an abnormal continuous ICU monitoring study because of frequent rhythmic bifrontal epileptiform discharges occurring intermittently throughout the recording. The background rhythm was diffusely slow indicative of mild to moderate diffuse cerebral dysfunction. Compared to the prior days recording there were periodic epileptiform discharges which did not evolve into electrographic seizures. EEG [**7-27**]: This is an abnormal continuous ICU EEG monitoring study due to several electrographic seizures in the frontal central region more predominant on the right associated with clinical jerking of the shoulders and occasionally gagging. Also, the background showed a generalized delta slowing consistent with a diffuse encephalopathic process with a non-specific etiology. . Labs on Discharge: [**2196-7-28**] 04:36AM BLOOD WBC-9.5 RBC-2.99* Hgb-9.4* Hct-26.5* MCV-89 MCH-31.5 MCHC-35.5* RDW-16.9* Plt Ct-407 [**2196-7-28**] 04:36AM BLOOD PT-12.8 PTT-27.2 INR(PT)-1.1 [**2196-7-26**] 05:41PM BLOOD Ret Aut-3.6* [**2196-7-28**] 04:36AM BLOOD Glucose-104* UreaN-16 Creat-0.3* Na-144 K-4.1 Cl-102 HCO3-36* AnGap-10 [**2196-7-23**] 03:11AM BLOOD ALT-24 AST-20 LD(LDH)-184 AlkPhos-377* TotBili-0.1 [**2196-7-28**] 04:36AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.7 [**2196-7-23**] 03:11AM BLOOD Albumin-2.8* Calcium-8.0* Phos-1.9* Mg-1.5* [**2196-7-26**] 05:41PM BLOOD Hapto-298* [**2196-7-28**] 04:36AM BLOOD Phenyto-6.8* Valproa-47* Brief Hospital Course: This 53 yo WF with a PMHx of severe MS, MRSA folliculitis, c. diff who p/f [**Hospital1 1501**] with AMS c/w delerium picture who is also found to be hyponatremic (Na-122) with a dirty UA from a PB catheder with labs significant for leukopenia and hypothermia. . In the ED the patient received a dose of levofloxacin, had a negative HCT, got a preliminary laboratory w/u and was sent to the floor. . Upon arrival the patient was able to follow simple commands and would participate in strength testing. She was mostly non verbal only speaking [**12-27**] word phrases that were mostly non sensical. She was unable to relate any history. As a result the patient [**Hospital1 1501**] and medical power of attorney were called. The patient has a fairly highly functioning individual who was verbal and able to ambulate with assistance several monthly ago, according to the medical power of attorney, Mrs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient was then admitted for a similar episode of AMS which was attributed to toxic metabolic encephalopathy at that time. She was then discharged and since that time has never been back to her baseline. According to the nursing home she would have waxing and [**Doctor Last Name 688**] MS and was non compliant with care. . The patient was free water restricted as it was reported that the patient consumed up to 3L of free water a day. She was started on vanco/levoquin for her SIRS. The patient sodiums were monitored overnight and fluids were restarted on her to help correct her hyponatremia. Neurology was consulted and they did not have any additional recomendations at that time. . The second day of admission it was reported that the patient was uncooperative with care and unable to swallow pills. The urology service did come by and changed the patients SPC without significant difficulty. During evalaution she was witnessed having horizontal nystagmus and jaw twitching. A BG was obtained which was wnl and a stat EEG was ordered. The patients repeat Na was 118 and hypotonic infusions that were able to be discontinued were. The patients EEG showed characteristics of status epilepticus and her seizures broke with ativan 1 mg. She was also loaded with 1 g of dilantin. Neurology consults were made aware of the situation and they aggreed with the above management. Their additional recomendations were to conduct an LP, cover empirically with vanco/ceftriaxone and acyclovir and to do a brain MRI when the patient is clinically stable. It was decided that a transfer to the [**Hospital Unit Name 153**] was most appropriate at this time. [**Hospital Unit Name 153**] Course 53 yo female with advanced secondary progressive MS, admitted in status epilepticus, which was likely secondary to a urinary tract infection, c/b hyponatremia and septic shock, who continued to have seizures, with waxing and [**Doctor Last Name 688**] mental status and was, consequently, trach'd and PEG'd at the bedside. Her anti-epileptic treatment was also complicated by a drug rash. # Seizures: Upon presentation to the ICU, the patient was in status epilepticus, which was thought to be secondary to [**Doctor Last Name 3080**] and hyponatremia. LP was performed and returned negative for infectious processes in the CSF. She was intubated for airway protection while in status. She was placed on continuous EEG monitoring, which showed bifrontal epileptiform seizures. Her seizures were treated with levetiracetam, phenytoin, valproic acid and lacosamide, and therapeutic levels of these medications were monitored. Additionally, her [**Doctor Last Name 3080**] and hyponatremia were treated. She was evaluated for cerebral structural lesions with a brain MRI, which showed stable periventricular plaques, consistent with MS. [**First Name (Titles) 3081**] [**Last Name (Titles) 3080**] and hyponatremia resolved with treatment and patient was on 4 epileptics, patient continued to have intermittent seizures. She also had GPEDs on her EEG which is c/w high mortality and very poor prognosis from mental status standpoint. # Urinary tract infection: Urine culture on presentation grew Pseudomonas and Serratia, with an I&D of an abscess at the patient's indwelling suprapubic catheter growing Pseudomonas. It is likely that the infection lowered the patient's seizure threshold. Her UTI was treated with a 14-day course of cefepime, to which both her Pseudomonas and Serratia were sensitive. # Septic shock: Upon arrival to the ICU, the patient was in septic shock, with hypotension, hypothermia, altered mental status, WBC 14 and left-shift, as well as evidence of end-organ dysfunction in a transient transaminitis. Likely source of infection was the urinary tract, as discussed above. However, there was also evidence of possible aspiration on CXR, in the context of ongoing seizures. The patient was empirically treated for HCAP, initially with cefepime, vancomycin and levofloxacin, which was then tailored to cefepime/vanc as levo lowers the seizure threshold, for a total of 8 days. Her initial hypotension and transaminitis resolved with IV fluids. Initial thrombocytopenia, which subsequently resolved, was likely attributable to systemic inflammation as well. The patient's vital signs were and WBC were carefully monitored. # Hyponatremia: On arrival to the ICU, the patient was hyponatremic. This was likely due to SIADH, possibly cerebral salt wasting, and effective intravascular volume depletion due to third-spacing, which were exacerbated by her acute infection. She was treated with free water restriction, normal saline and diuresis for third-spacing and volume overload. Her diuresis was complicated by a metabolic alkalosis, which was corrected with acetozolamide, potassium supplementation and prudent use of furosemide. Acetozolamide was discontnued and patient did not have re-surfacing of hyponatremia. # Mechanical ventilation: Upon arrival to the ICU, the patient was intubated for airway protection, while actively seizing. After a few days, she began to breathe spotaneously on pressure support ventilation; however, due to continued seizures, copious secretions, and waxing and [**Doctor Last Name 688**] mental status, it was predicted that she would require prolonged airway protection. For this reason, Interventional Pulmonology performed a bedside tracheostomy under sedation at the bedside on [**7-20**] and Gastroenterology performed a bedside PEG placement on [**7-21**]. The patient's tracheostomy was complicated by bleeding, as she was anticoagulated on enoxaparin. She eventually transitioned to trach mask, with good oxygen saturation. #Rash: The patient developed a macular rash on her both of her lower extremities, which was initially suspected to be due to a fungal infection; however, KOH stain and fungal cultures returned negative, and the rash was unresponsive to topical antifungal medications. Medication reaction was suspected, since the rash appeared several days after beginning new antiepileptic medications. Biopsy of the rash showed non-specific signs of inflammation. The rash responded well to steroid (fluocinonide 0.01%) ointment. Her LFTs and CBC were trended out of concern for DRESS. # History of PE: The patient was anticoagulated with enoxaparin, which was held as needed for procedures. She developed no signs or symptoms of new thrombosis. # Normocytic Anemia: The patient has a baseline anemia, likely anemia of chronic disease vs. iron deficiency. Her anemia was exacerbated by bleeding after tracheostomy on [**7-20**], but remained stable thereafter. She had several more episodes of oozing from the tracheostomy site as well as from the PEG site. . #Goals of care: Patient had previously made her goal of care wishes very clear to her healthcare proxy and her family and also had it in writing. Her wish was that if she were not functional and alert, she did not want extraordinary measures taken to prolong her life. Primary ICU team and neurology team had involved family meeting with HCP and 2 daughters. It was explained to the family that in the setting of continous seizures and no improvement in mental status despite resolution of what was thought to be instigating them (infection, hyponatremia), long term prognosis for mental status recovery was very poor. Family felt that Ms.[**Known lastname 3082**] would not want to be kept alive like this and decision was to make her CMO and transfer to [**Known lastname **]. . ***Per neurology recommendations immediately prior to discharge, Dilantin can be discontinued and other anti-epileptic medications can be given orally.**** HCP [**Name (NI) **] [**Name (NI) **], cell [**Telephone/Fax (1) 3083**], home [**Telephone/Fax (1) 3084**] Medications on Admission: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. econazole 1 % Cream Sig: One (1) application Topical [**Hospital1 **] (): apply underneath breasts after drying fully. 8. white petrolatum-mineral oil Cream Sig: One (1) Appl Topical DAILY (Daily): to chest and neck. 9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 10. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): Please apply to open erosions on right arm and cover with gauze to protect. Disp:*1 1* Refills:*2* 11. Coumadin 1 mg Tablet Sig: 0.5 Tablet PO once a day: please resume when INR < 3, goal INR [**1-28**]. 12. hydrocortisone 2.5 % Cream Sig: One (1) application Topical twice a day as needed for groin rash. 13. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO at bedtime. 14. tolterodine 4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 15. Enulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO twice a day as needed for constipation. 16. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 10 days. Disp:*20 Capsule(s)* Refills:*0* 17. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 18. gabapentin 100 mg Capsule Sig: [**12-27**] Capsules PO three times a day: 1 tablet qAM, 1 tablet in afternoon, 2 tablets qPM. Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 4. fluocinonide 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): Apply to affected areas. 5. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for fever or pain. 6. morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q4H (every 4 hours) as needed for pain. 7. valproic acid (as sodium salt) 250 mg/5 mL Syrup Sig: 1000 (1000) mg PO Q8H (every 8 hours). 8. ibuprofen 100 mg/5 mL Suspension Sig: Six Hundred (600) mg PO Q6H (every 6 hours) as needed for fever or pain. 9. levetiracetam 500 mg/5 mL Solution Sig: [**2184**] ([**2184**]) mg Intravenous [**Hospital1 **] (2 times a day). 10. lacosamide 200 mg/20 mL Solution Sig: Three Hundred (300) mg Intravenous [**Hospital1 **] (2 times a day). 11. Heparin Flush (10 units/ml) 2 mL IV DAILY AND PRN PER LUMEN per lumen 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 12. fosphenytoin 50 mg PE/mL Solution Sig: One [**Age over 90 **]y Five (125) mg Injection Q8H (every 8 hours). 13. morphine 5 mg/mL Solution Sig: 2-4 mg Injection Q4H (every 4 hours) as needed for pain or respiratory distress. Discharge Disposition: Extended Care Facility: [**Hospital1 656**] House Discharge Diagnosis: Primary Diagnoses: Advanced Secondary Progressive Multiple Sclerosis Multifactorial Encephalopathy Septic Shock Hyponatremia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital for confusion and lethargy, and were sent to the ICU for septic shock most likely due to a severe urinary tract infection. During your stay, you required intubation due to respiratory distress and eventually had a tracheostomy tube and a PEG tube placed. You continued to have frequent seizures despite multiple antiepileptic medications, and your confusion did not improve significantly. After discussion with your health care proxy and family, it was determined that your wishes would be to transition to comfort care, and transfer to a [**Hospital1 **] facility was arranged. Your medications were adjusted with the goal of maximizing comfort and minimizing pain or anxiety. Followup Instructions: You are being discharged to inpatient [**Hospital1 **]. Doctors at the [**Name5 (PTitle) **] facility will manage your ongoing medical care. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2196-7-28**]

[ "V15.81", "285.29", "E947.9", "486", "276.1", "518.84", "682.2", "790.4", "345.90", "V66.7", "287.5", "041.7", "790.92", "348.39", "V46.3", "507.0", "996.79", "276.2", "285.9", "996.64", "276.3", "340", "780.65", "785.52", "416.2", "038.9", "599.0", "693.0", "E849.7", "E879.6", "V58.61", "E879.8", "E944.4", "995.92" ]

icd9cm

[ [ [] ] ]

[ "03.31", "38.91", "59.94", "86.04", "38.97", "43.11", "31.1", "89.19", "33.22", "96.04", "86.11", "96.72" ]

icd9pcs

[ [ [] ] ]

24174, 24226

11850, 20646

287, 587

24395, 24395

4429, 4429

25276, 25585

3081, 3085

22659, 24151

24247, 24374

20672, 22636

24535, 25253

3944, 4410

8357, 11179

244, 249

11199, 11827

615, 2392

4445, 8321

24410, 24511

2414, 2862

2878, 3065

5,278

126,618

4386+4387+4388+4389+55576+55530

Discharge summary

report+report+report+report+addendum+addendum

Admission Date: [**2149-1-24**] Discharge Date: [**2149-1-31**] Date of Birth: [**2100-1-9**] Sex: M Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 49-year-old male who was admitted with a chief complaint of mental status changes and unresponsiveness with admission to the Medical Intensive Care Unit for severe hypernatremia. The patient has a history of developmental delay who was recently admitted between [**2148-12-24**] to [**2149-1-6**]. The patient presents from a nursing home with acute mental status changes. He was found by the nursing home staff to be minimally responsive, diaphoretic, and cyanotic. Vital signs revealed blood pressure was 90/60, heart rate was 113, respiratory rate was 28, oxygen saturation was 95% on room air. His hospital course during his previous admission was notable for mental status changes and decline; where he was previously living at home over the last two months, and he was found by Emergency Medical Service to be surrounded by feces and urine bottles. His baseline (reported by his father) was functional. His supposedly attends [**Location 18898**] dictation summary, but it is unclear what his true baseline is. He was noted to hypernatremic on admission at 159, but remained encephalopathic with an unremarkable magnetic resonance imaging of the head. An electroencephalogram was consistent with toxic metabolic encephalopathy. He was discharged to the nursing home facility for activities of daily living, feedings, and incoherence. He was treated for a urinary tract infection and community-acquired pneumonia. The nursing home reported that he required assistance for feeding and apparently had an altercation with his father who also assists with his feedings. On the three days prior to admission, he had been taking less than 25% of his meals. Upon questioning the patient, the patient was unintelligible. The Emergency Department course was significant for aggressive intravenous hydration with normal saline. The admission blood pressure was 63/39, heart rate was 125; which responded to 4 liters of normal saline to a blood pressure of 121/64 and a heart rate of 96. PAST MEDICAL HISTORY: 1. Juvenile rheumatoid arthritis. 2. Questionable psychiatric disorder of unknown etiology. The patient apparently dropped out of school. MEDICATIONS ON ADMISSION: 1. Thiamine 100 mg p.o. q.d. 2. Haldol 2.5 mg p.o. b.i.d. 3. Nystatin cream as needed. 4. Folate. 5. B12. 6. Protonix. ALLERGIES: His allergies are to ASPIRIN. SOCIAL HISTORY: Nursing home resident. Formerly, he lived with his parents. FAMILY HISTORY: Family history was noncontributory. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed temperature was 99.1, blood pressure was 121/64, heart rate was 96, respiratory rate was 20, oxygen saturation was 98% on 2 liters. He was disheveled and unkempt male lying in bed. He appeared agitated. Head, eyes, ears, nose, and throat examination revealed mucous membranes were dry. Pupils were equal, round, and reactive to light. The skin was dry. Poor skin turgor. Neck revealed no lymphadenopathy. Lungs were clear to auscultation bilaterally and anteriorly with no wheezes. Cardiovascular examination revealed normal first heart sound and second heart sound. A regular rate. No murmurs, rubs, or gallops. The abdomen revealed positive bowel sounds. Soft, nontender, and nondistended. His extremities showed no edema. Cranial nerves II through XII were grossly intact. He moved all extremities. Radial and posterior tibialis pulses were 2+ bilaterally. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission revealed his white blood cell count was 15.9, his hematocrit was 38.7, platelets were 580, and mean cell volume was 98. Differential with 88 neutrophils. His sodium was 171, potassium was 4.6, chloride was 135, bicarbonate was 20, blood urea nitrogen was 105, creatinine was 4.3, and blood glucose was 102. Calcium was 8.7 and phosphate was 2.9. His AST was 29, ALT was 11, CK was 59, amylase was 65, and total bilirubin was 0.4. Albumin was 2.7. RADIOLOGY/IMAGING: His chest x-ray was negative for infiltrate. His electrocardiogram showed a sinus rhythm at a rate of 102, with a normal axis and intervals. No acute ST-T wave changes. HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to the Medical Intensive Care Unit from [**2149-1-24**] to [**2149-1-25**] and then was admitted to the Medicine Service on [**2149-1-25**] through [**2149-1-31**]. 1. RENAL ISSUES: His hypernatremia was corrected with both D-5 half normal saline to initially give him volume which was switched to D-5-W. His last sodium was 142. 2. HYPOTENSION ISSUES: His hypotension which was most likely related to his hypovolemia which responded with aggressive intravenous fluid hydration. He did not require pressors. 3. ACUTE RENAL FAILURE ISSUES: His acute renal failure was most likely secondary to prerenal from hypovolemia. His creatinine returned to baseline and resolved with intravenous hydration. 4. INFECTIOUS DISEASE ISSUES: He had leukocytosis, but was never given any antibiotics since his chest x-ray was normal. His urinalysis did not show any signs of infection. He did have a stage III sacral decubitus ulcer that was treated and seen by the Plastic Service. The patient was to continue dressing changes with Dakin's wet-to-dry dressings b.i.d. and to place miconazole powder to keep the perineal/sacral area dry. If fever does develop, and he develops worsening leukocytosis, he should most likely have a magnetic resonance imaging of the lower spine at some point to rule out an osteomyelitis. 5. ELEVATED INR ISSUES: He had an elevated INR in the setting of poor oral intake. Most likely, he had a vitamin deficiency. He received 10 mg of vitamin K for three days, and his INR returned to [**Location 213**]. 6. ALTERED MENTAL STATUS ISSUES: He was evaluated both by Neurology and by Psychiatry. Neurology felt that this was most likely toxic metabolic, and the patient did improve with the resolution of his hypernatremia. However, he continued to have baseline paranoid hallucinations. Psychiatry was following and initially suggested Haldol 2.5 mg p.o. b.i.d. However, this caused severe somnolence and was held. He has been appropriate and has not required any sitters since the Medical Intensive Care Unit despite not having Haldol. It will most likely need psychiatric followup. We are unsure of his underlying psychiatric condition since his father says he was relatively bright. However, given his social situation of dropping out of college early and living at home with his parents throughout his 40s, this likely represents some type of psychiatric disorder (possible schizophrenia or schizoaffective disorder). 7. NUTRITION ISSUES: His nutritional status has been an issue; especially with his sacral decubitus ulcer, nutritional status is very important. We attempted to have a gastrojejunostomy/percutaneous endoscopic gastrostomy tube insertion on [**2149-1-30**]; however, given the patient's anatomy of a high stomach Interventional Radiology attempt was unsuccessful. Instead, the patient was put in for a peripherally inserted central catheter line on [**2149-1-31**] to start total parenteral nutrition as a supplement to his daily intake. He was to continue encouragement for increased oral intake and Boost supplements, and also to continue multivitamin, thiamine, folate, and zinc supplementation for his sacral decubitus ulcer. 8. DIARRHEA ISSUES: He continued to have diarrhea. Stool culture have been sent off. His Clostridium difficile was negative. However, his stool culture were still pending. Would consider continuing of a low-fiber/low-residue diet until this resolves. He will also need hydration to maintain volume. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. DISCHARGE DISPOSITION: The patient was to be discharged back to rehabilitation for physical therapy, and aid with his activities of daily living, and feedings, and his total parenteral nutrition. DISCHARGE DIAGNOSES: (His discharge diagnoses included) 1. Developmental delay. 2. Possible schizoaffective disorder or schizophrenic disorder. 3. Altered mental status. 4. Hypernatremia. 5. Toxic metabolic syndrome. 6. Acute renal failure. 7. Sacral decubitus ulcers. MEDICATIONS ON DISCHARGE: (His discharge medications included) 1. Miconazole powder 2% q.i.d. as needed (to keep sacrum and perineal area dry). 2. Dakin's 1/4 strength b.i.d. with wet-to-dry dressings to sacral decubitus ulcer. 3. Heparin 5000 units subcutaneously q.12h. 4. Protonix 40 mg p.o. q.d. 5. Cyanocobalamin 50 mcg p.o. q.d. 6. Folate 1 mg p.o. q.d. 7. Thiamine 100 mg p.o. q.d. 8. Zinc sulfate 220 mcg p.o. q.d. (for two weeks). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. He should have logroll precautions q.2h. 2. He needs Boost supplements t.i.d., with a low-residue diet, and total parenteral nutrition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Name8 (MD) 1020**] MEDQUIST36 D: [**2149-1-30**] 17:46 T: [**2149-1-30**] 19:46 JOB#: [**Job Number 18899**] Admission Date: [**2149-1-24**] Discharge Date: [**2149-2-4**] Date of Birth: [**2100-1-9**] Sex: M Service: ADDENDUM: The patient is actualy going to be discharged on [**2149-2-4**]. The patient was kept in the hospital simply, because he needed to be cycled on his total parenteral nutrition before being accepted to rehab. His mental status has improved over the course of hospitalization. He is now more alert and probably is at his baseline confusion. The only new issue is his cardiovascular, Metoprolol 25 mg b.i.d. Was added to his regimen for his tachycardia and can be titrated up. He will also additional need psychiatric follow up while he is at rehab. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Doctor Last Name 18900**] MEDQUIST36 D: [**2149-2-4**] 09:43 T: [**2149-2-4**] 09:53 JOB#: [**Job Number 16513**] Admission Date: [**2149-2-17**] Discharge Date: Date of Birth: [**2100-1-9**] Sex: M Service: ADDENDUM: This addendum will cover the [**Hospital 228**] hospital course from [**2149-2-17**] until [**2149-3-2**]. The remainder of the [**Hospital 228**] hospital course will be dictated by the intern who takes over the patient's care on [**2149-3-3**]. HOSPITAL COURSE: 1. INFECTIOUS DISEASE: The patient has continued to be persistently febrile with leukocytosis. In the recent days, the patient's white blood cell count has been trending downwards. The patient is followed by the Infectious Disease Service and remains on broad spectrum antibiotics, vancomycin and Zosyn. Markers of the inflammation remain high. Markers of inflammation such as ESR, CRP, WBC, and platelets remain high. The differential for the patient's fevers include pneumonia, sacral decubitus ulcer, colitis, Still's disease, and drug fever. On [**2149-2-7**], a CT scan did disclose a fluid collection in the upper medial right thigh. Repeat CT scan was done and attempt was made to drain this area. Drainage was not successful. Repeat ultrasound of the thigh was done to evaluate for fluid collection and none was noted. A right upper quadrant ultrasound was done to rule out a calculus cholecystitis. This study was also negative. Stool samples have been sent off repeatedly for C. difficile, yet these remain negative. All blood cultures to date have also remained negative. The patient does have a history of Still's disease diagnosed at age 13. The patient's father states that the patient was treated with steroids many years ago but has not undergone treatment recently. Still's disease is characterized for fever for more than one week, arthritis, and elevated white blood cell count. Although the patient has many possible sources of infection, this diagnosis should be kept in mind. 2. PSYCHIATRIC: The patient has been followed by Psychiatry during his hospital stay. Initial workup was thought to be consistent with a toxic metabolic syndrome with an underlying psychiatric condition. The differential for his underlying psychiatric condition includes OCD or pervasive developmental disorder such as Asperger's syndrome. The patient has been started on Risperidone 0.5 mg b.i.d. He will require further psychiatric treatment once his medical condition improves. 3. RHEUMATOLOGY: As noted above, the patient carries the diagnosis of Still's disease and has not undergone treatment in the recent past. It is possible that this disease could be contributing to the patient's chronic inflammatory state. 4. NUTRITION: The patient has been maintained on TPN during his hospital stay. The patient also was given a house diet and takes p.o. as tolerated. The patient will require a PEG tube. 5. GASTROINTESTINAL: Recent CT of the abdomen and pelvis disclosed inflammatory changes in the distal sigmoid, upper rectum. The Gastroenterology Service was consulted. Sigmoidoscopy was done which disclosed segmental discontinuous areas of erythema without bleeding. Biopsies were consistent with chronic colitis. Due to concern for inflammatory bowel disease, a small bowel follow through was done which was normal. The patient will undergo colonoscopy to determine the full extent of his colitis and for biopsy of the terminal ileum. 6. SACRAL DECUBITUS ULCER: The patient has a stage III sacral decubitus ulcer. Currently, he undergoes dressing changes and positional changes multiple times per day. The ulcer continues to be soiled. The patient has loose stools. Surgery has been consulted for the possibility of diverting colostomy and this operation is still under discussion. 7. CARDIOLOGY: The patient has been tachycardiac during much of his hospital stay thought to be due to fever and pain. An echocardiogram was done which disclosed a normal ejection fraction, no wall motion abnormalities. 8. PROPHYLAXIS: The patient has been maintained on subcutaneous heparin and PPI access PICC. 9. COMMUNICATION: The patient's father has been involved in the patient's care. 10. CODE STATUS: Full. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) 5092**] MEDQUIST36 D: [**2149-3-2**] 11:43 T: [**2149-3-2**] 13:25 JOB#: [**Job Number 18901**] Admission Date: [**2149-1-24**] Discharge Date: [**2149-3-15**] Date of Birth: [**2100-1-9**] Sex: M Service: This is an addendum covering hospital course from [**2149-3-3**] through [**2149-3-15**]. The workup for the patient's fever continued to be negative. Liver function tests, rheumatoid factor, antinuclear acid antibody, several sets of blood cultures, urine cultures, several chest x-rays, and sputum cultures were checked and were negative. Finally after completing a course of Zosyn and Vancomycin, both antibiotics were discontinued as well as Risperidone with the suspicion that one of these drugs may be causing the fever. Shortly after discontinuation of these three drugs, the patient's fever disappeared and he remained afebrile for about six days at which point he began to have a lowgrade temperature spike again. The patient was repeat pancultured at this time. Urinalysis showed 45 white blood cells in the urine, no yeast, some bacteria and no epithelial cells. Urine culture was pending but the patient was treated empirically with a five day course of Levaquin. Prior to this the patient received 2 courses of Diflucan for positive urinalyses that grew yeast. Urine culture was pending at the time of this dictation. Before the above antibiotics were discontinued, the patient underwent full upper and lower endoscopy which revealed esophageal ulceration, negative for cytomegalovirus and inconclusive for herpes simplex virus by biopsy as well as inactive colitis. The patient was treated with proton pump inhibitors and p-ANCA and ASCA were checked and were pending at the time of discharge. Also while still on antibiotics the patient underwent a computerized tomography scan of the pelvis to look for possible osteomyelitis or fluid collection/abscess underlying the site of his sacral decubitus ulcers. The computerized tomography scan of the pelvis was negative in this regard, however, it did reveal what appeared to be a right subcapital femur fracture. After review of old films, review of new plain films by both Orthopedic Surgery and Musculoskeletal Radiology it was concluded that what was being called a right subcapital femur fracture may actually just be osteophytes. In any event, even if what was seen on imaging did represent a right subcapital femur fracture, review of films revealed that this fracture is old and due to the patient's inability to bear weight, no intervention would be necessary. The patient was kept on total parenteral nutrition with excellent control of his fluid status and electrolytes until [**2149-3-15**] when he was switched to tube feeds. On [**2149-3-14**] the patient underwent open gastrostomy tube placement in the Operating Room after a failed attempt by Gastroenterology to place a gastrostomy tube. The patient has abnormal gastrointestinal anatomy. The reason for the gastrostomy tube was that the patient was noted to tolerate food relatively well with minimal aspiration or no aspiration while awake but since his mental status tends to wax and wane, he is unable to eat when he is weaning, it was thought best to place a gastrostomy tube for tube feeds. At the time of this dictation the patient is afebrile, hemodynamically stable and his mental status appears to be greatly improved. He is interactive and is able to have a coherent, although sometimes nonsensical conversation with the team. It should be noted that his mental status has been waxing and [**Doctor Last Name 688**] and is likely to wax and wane with good days and bad days. When the patient is [**Doctor Last Name 688**], sometimes he will barely open his eyes in response to noxious stimuli or voice. The remainder of this discharge summary will be addended by the next intern on service who will discharge this patient and provide the discharge information such as medications and diagnosis. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Last Name (NamePattern1) 2582**] MEDQUIST36 D: [**2149-3-15**] 12:21 T: [**2149-3-15**] 12:07 JOB#: [**Job Number 18902**] Name: [**Known lastname 2814**], [**Known firstname 168**] S. Unit No: [**Numeric Identifier 2815**] Admission Date: [**2149-1-24**] Discharge Date: Date of Birth: [**2100-1-9**] Sex: M Service: ADDENDUM: Since my last dictation of [**2149-2-4**], the patient did not go to the nursing home and was not accepted because he was on TPN and it would be too expensive for the care facility. He was kept for an evaluation of jejunostomy placement, however, during his stay, the patient spiked a fever, became hypotensive with worsening altered mental status. He was thought to be septic from an unknown source. Blood cultures persistently were negative as were his urine cultures and stool cultures. He was started on Vancomycin, Ceftriaxone and Levofloxacin on [**2149-2-8**], and he was scanned with a CT of the chest and abdomen and pelvis. The CT chest showed several small lymph nodes in the left axilla but consolidation in the posterior segment of the right upper lobe. Adjacent to this in the superior segment of the right upper lobe was a rounded focus of mass like density which could have been related to infection, but follow-up for resolution was recommended to exclude tuberculosis or lung cancer. In the right lower lobe, there was patchy change consistent with aspiration. The left lung was clear. There was a large hiatal hernia. In the abdomen, his pancreas has had fatty infiltrate. The spleen appeared to have been removed. He had an area of active intravenous contrast extravasation that was correlated to a right femoral line placement in the Medical Intensive Care Unit. For this patient's aspiration pneumonia, he was evaluated by speech and swallow and found to have good ability although he has no gag reflex. He was also evaluated by pulmonary for possible bronchoscopy which they declined since the patient's pneumonia was resolving by x-ray on antibiotics. His antibiotic regimen was changed to Vancomycin and Zosyn on [**2149-2-12**]. The patient's white blood cell count has slowly been coming down. His fever curve has also been improving. However, the remaining of focus of his sacral decubitus ulcer as possible source is still high on the differential since he continues to soil this area. General surgery has been consulted to evaluate for diverting colostomy at which time a jejunostomy tube would also be placed. Psychiatry has continued to follow his mental status and it fluctuates. At time, he is very lucid with periods of extreme somnolence with no change in vital signs. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**], M.D. [**MD Number(1) 225**] Dictated By:[**Last Name (NamePattern1) 3087**] MEDQUIST36 D: [**2149-2-15**] 10:07 T: [**2149-2-15**] 10:23 JOB#: [**Job Number 3088**] and [**Numeric Identifier 3089**] Name: [**Known lastname 2814**], [**Known firstname 168**] S. Unit No: [**Numeric Identifier 2815**] Admission Date: [**2149-1-24**] Discharge Date: [**2149-3-18**] Date of Birth: [**2100-1-9**] Sex: M Service: MEDICINE THIS IS A DISCHARGE SUMMARY ADDENDUM As noted in the prior Discharge Summary, the patient continued to remain febrile, hemodynamically stable and his mental status continued to improve until the date of discharge. The patient continued to tolerate tube feeds well through his gastrostomy tube. Of note, the patient had a sputum culture performed on [**2149-3-5**], which grew out Methicillin resistant staphylococcus aureus. Upon discharge, the patient's PIC line will be discontinued. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Rehabilitation. DISCHARGE DIAGNOSIS: 1. Fever of unknown origin. 2. Hypernatremia. 3. Acute renal failure. 4. Toxic metabolic altered mental status. 5. Malnutrition. 6. Sacral decubitus ulcer. 7. Aspiration pneumonia. 8. Esophagitis. 9. Colitis. 10. Developmental delay and paranoia. DISCHARGE MEDICATIONS: 1. Cyanocobalamin 50 mcg p.o. q d. 2. Vitamin C 500 mg p.o. b.i.d. 3. Metoprolol 25 mg p.o. b.i.d. 4. Prevacid 30 mg Slurry p.o. q d or per G tube. 5. Levofloxacin 500 mg p.o. q d until [**2149-3-18**]. 6. Thiamin 100 mg p.o. q d. 7. Folate 1 mg p.o. q d. 8. Tube feed: ProMod with fiber, goal rate of 80 cc per hour. FOLLOW UP: The patient will need to follow up with Dr. [**First Name (STitle) **], his Primary Care Physician, [**Name10 (NameIs) **] needed. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**], M.D. [**MD Number(1) 225**] Dictated By:[**First Name3 (LF) 2816**] MEDQUIST36 D: [**2149-3-17**] 14:27 T: [**2149-3-17**] 14:32 JOB#: [**Job Number 2817**]

[ "276.0", "112.2", "584.9", "707.0", "276.5", "558.9", "507.0", "714.30", "276.2" ]

icd9cm

[ [ [] ] ]

[ "45.25", "99.15", "86.28", "45.16", "38.93", "43.19", "96.6" ]

icd9pcs

[ [ [] ] ]

8004, 8178

22523, 22568

2631, 4333

8200, 8456

22869, 23197

22589, 22846

8483, 8906

2365, 2534

10704, 22501

8939, 10686

23209, 23607

4368, 7914

7929, 7979

169, 2176

2198, 2339

2551, 2613

68,123

160,172

43949

Discharge summary

report

Admission Date: [**2167-5-21**] Discharge Date: [**2167-5-29**] Date of Birth: [**2121-1-4**] Sex: F Service: NEUROLOGY Allergies: Ciprofloxacin / Levofloxacin / Flagyl Attending:[**First Name3 (LF) 11291**] Chief Complaint: fever, AMS Major Surgical or Invasive Procedure: intubation History of Present Illness: Ms. [**Known lastname 805**] is a 46 y/o female with a history of hemorrhagic stroke complicated by brainstem herniation intraoperatively in an attempt to evacuate the bleed, which has caused spasticity and weakness in all extremities, and seizure disorder who initially presented to the hospital after an episode of acting strangely and projectile vomiting. The history was initially obtained by the neurology resident from the patient's mother, where she described bizarre behavior last night, and strange arm movements. Early this morning her mother noted [**Name2 (NI) **] liquid on her face/chin and was found the same substance on the wall, per her mother it appeared to be food so she was concerned that she had projectile vomited. Her mother also described episodes of her looking to the right and not responding overnight that would last for a few minutes and then resolve. After the episode of projectile vomiting her mom called 911. . In the [**Hospital1 18**] ER she was evaluated by the neurology consult team, who felt that her symptoms were consistent with complex partial seizures. She had been tapering off lorazepam over the past few weeks, down to none the morning of admission. Additionally, there was concern from her mother that she had been taking more morphine than had been prescribed. Given the concern for seizure at Stat Net EEG was done in the ER that was read as positive, so she was given 3mg of ativan and 1g of keppra and admitted to the epilepsy service. The neurology consult resident was concerned that she was in complex partial status, and that her sweatiness may also have been due to early infection or opiod withdrawal. . On the neurology floor she was found to be febrile to 102, and continued to seizure requiring ativan. In the setting of her fever she became tachycardic and the neurology team was worried about underlying infection. They attempted an LP but were unsuccessful due to significant fibrous tissue from prior baclofen pump placement. A repeat KUB was done given her complaint of abdominal pain which showed nonspecific bowel gas pattern with a moderate amount of stool. Repeat CXR again showed bibasilar atelectasis vs. infiltrates. Neurology was very concerned that an underlying infection was the cause of her seizures and requested transfer to the MICU. . On arrival to the MICU, VS were 99.7, 116, 151/83, 24, 90% on 5LNC. She continued to seize multiple times per hour and did not have any IV access to give any medications. When not seizing she was very agitated screaming for her mother, and for us to allow her to go home. . Review of systems: unable to obtain as patient is very agitated when awake, or seizing/post ictal Past Medical History: 1. s/p stroke - left parieto-occipital hemorrhagic stroke in [**9-11**], unclear etiology, s/p craniotomy to evacuate hemorrhage, secondary herniation syndrome w subfalcine and transtentorial herniation, bilat Wallerian degeneration syndrome, quadraparesis with increasing spastic paraparesis worse on R, prox upper & both lower extremities, s/p Baclofen pump placement -Evaluated at [**Hospital1 2025**] by Dr [**Last Name (STitle) **] in [**2163**] -ongoing issues with increasing spasticity -[**5-15**] was off Baclofen pump and PO -[**2-15**] on Baclofen PO (no pump), MS Contin, tizanidine -[**7-18**] only on MS Contin for pain management -[**12-19**] on Baclofen PO (no pump), MS Contin & IR PRN 2. hyperhomocysteinemia, mildly elevated, no further w/u planned 3. carries psychiatric diagnoses of OCD & depression with suicidal ideation 4. sickle cell trait 5. Hepatitis C, genotype 3, viral load 799,000 in [**February 2163**], no plans to treat as transaminases normal, f/u planned in [**2165**] 6. microcytic anemia with normal iron studies 7. restrictive lung disease due to weakened resp muscles following stroke 8. GI h/o duodenitis, colitis in [**July 2165**], treated with abx 9. Epilepsy, during [**July 2165**] admission (no clear provoking factor). She has now had about six or so, her mother thinks. [**Name2 (NI) **] have been in the hospital. She has had two at home: She will become agitated and non-sensical, with right gaze deviation, repetitive verbalizations: "help me", "open it", etc. Her mother says that she has had no generalized seizures at home. 10. Question of motor neuron disease (primary lateral sclerosis) raised in prior MRI findings, EMG and nerve conduction studies [**12-15**] provided no evidence for the diagnosis. Social History: Lives alone, but mother looks after her (there most of day and in evening and has a PCA). No smoking (smoked prior to stroke in [**2158**]). No alcohol. Family History: arthritis, walks with cane. Father - unknown. [**Name2 (NI) **]-one with seizures. Physical Exam: ADMISSION PHSYICAL EXAM: Vitals: 99.0 120 170/104 18 98% General Appearance: Lying to right side, slumped, on bed. Covered in sweat. Eyes closed, stuporous. HEENT: NC, OP clear, MMM. Neck: Supple. Lungs: CTA bilaterally. Cardiac: Regular. Normal S1/S2. No M/R/G. Abdominal: Soft, NT, BS+ Extremities: Warm and well-perfused. Neurologic: Mental status: Perseverating on "give me a bump", then "help me" - undirected and could explain. Very stuporous, drifting off to sleep easily after a minute or two. Cranial Nerves: I: Not tested. II: Pupils equally round and reactive to light, 5 to 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: Dysarthric, swallowing secretions. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bulk, could not test strength. XII: Tongue midline. Posture slumped to right. Tone increased - spastic, extensor of legs, flexor of left arm. Power Difficult to assess, but clear flexors only in left arm. Predominant flexors on right, but able to activate extensors. Both legs extensor posture. Reflexes Brisk throughout with upgoing toes bilaterally (toes fan, triple flexion) Sensation No response to vigorous pin throughout. DISCHARGE PHYSICAL EXAM: Vitals: T 98.8, BP 135/89, HR 94, RR 18, 99% on RA GEN: middle aged woman lying in bed in NAD HEENT: OP clear CV: RRR PULM: CTA-B ABD: soft, NT, ND EXT: no edema NEURO EXAM: MS - reported the year as [**2157**], could not name the month. Eventually was able to report the president as [**Last Name (un) 2753**] CN - PERRL 4-->2mm, EOMI with decreased vision in R visual fields MOTOR: mild weakness in bilateral deltoids (4+/5), full strength in bilateral biceps and triceps, [**4-13**] in L finger Ext, 5-/5 in R finger ext, 4+/5 in L [**Month/Day (1) **], full strength in R [**Name (NI) **], pt unable to move legs bilaterally. COORDINATION - no dysmetria on FNF, but difficult to test [**3-12**] weakness GAIT - deferred, pt bedbound at baseline Pertinent Results: ADMISSION LABS: [**2167-5-21**] 07:12AM BLOOD WBC-14.3*# RBC-5.05 Hgb-13.3 Hct-42.2 MCV-84 MCH-26.3* MCHC-31.5 RDW-14.3 Plt Ct-317# [**2167-5-21**] 07:12AM BLOOD Neuts-91.3* Lymphs-6.8* Monos-1.3* Eos-0.1 Baso-0.4 [**2167-5-22**] 12:10AM BLOOD PT-13.3* PTT-62.9* INR(PT)-1.2* [**2167-5-21**] 07:12AM BLOOD Glucose-160* UreaN-13 Creat-0.7 Na-134 K-4.5 Cl-97 HCO3-25 AnGap-17 [**2167-5-21**] 07:12AM BLOOD ALT-29 AST-42* AlkPhos-62 TotBili-0.2 [**2167-5-21**] 07:12AM BLOOD Albumin-4.6 Calcium-9.4 Phos-2.6* Mg-2.0 [**2167-5-21**] 07:36AM BLOOD Lactate-2.6* DISCHARGE LABS: [**2167-5-29**] 04:48AM BLOOD WBC-9.4 RBC-3.92* Hgb-10.5* Hct-32.8* MCV-84 MCH-26.8* MCHC-32.0 RDW-14.8 Plt Ct-339 [**2167-5-29**] 04:48AM BLOOD Glucose-95 UreaN-6 Creat-0.5 Na-141 K-3.5 Cl-103 HCO3-26 AnGap-16 [**2167-5-29**] 04:48AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.8 MICROBIOLOGY: BCx [**2167-5-21**]: no growth UCx [**2167-5-22**]: no growth CSF [**2167-5-22**]: 2+ PMNs with no growth on bacterial culture, viral culture, fungal culture and a negative cryptococcal antigen Sputum Cx [**2167-5-22**]: > 25 PMNs and > 10 epis, with 1+ GNRs, but culture negative for growth BCx [**2167-5-23**]: negative for fungal and mycobacteria CSF [**2167-5-24**]: No PMNs, No microorganisms seen, fluid culture negative and fungal culture negative. Sputum Cx [**2167-5-25**]: [**12-3**] PMNs and < 10 epis, with no microorganisms seen, and no growth. REPORTS: EEG [**2167-5-21**]: IMPRESSION: This telemetry captured 2 pushbutton activations. They occurred early in the record and were 4 seizures similar to those that occurred throughout the night. Overall, there were dozens of seizures and dozens more of briefer (10 seconds) beginnings of rhythmic sharp and fast activity in the left posterior quadrant. Almost all seizures progressed characteristically from the left posterior quadrant to involve most of the hemisphere and sometimes, the right as well. Except for blinking and a bit of head turning, seizures had no clear clinical signs on video. Most seizures lasted under 2 minutes. They were still occurring frequently by the end of the recording at 7:00. ADDENDUM: Prior to this telemetry, the patient had a "stat net" EEG recording in the emergency department from approximately 11:45 until 12:15 that morning. This showed three episodes of the same seizure activity. The first two appeared to have the same sort of electrographic seizure, followed soon by a second one. In all, there were actually five seizures in three episodes over 30 minutes. CT HEAD [**2167-5-21**]: IMPRESSION: 1. Limited study due to motion, however, there is no evidence of gross hemorrhage or acute vascular territorial infarction. 2. Stable appearance of left parieto-occipital encephalomalacia with associated ex vacuo dilatation of the left occipital [**Doctor Last Name 534**] consistent with remote infarction. CXR [**2167-5-21**]: IMPRESSION: Streaky bibasilar opacities which could represent aspiration versus bibasilar atelectasis=. No large confluent consolidation. KUB [**2167-5-21**]: IMPRESSION: Nonspecific, nonobstructed bowel gas pattern. No free air. CXR [**2167-5-22**]: IMPRESSION: Bilateral lower lung opacities are more conspicuous in comparison to prior radiographs from yesterday and in the view of clinical history, concerning for aspiration pneumonia. EEG [**2167-5-22**]: IMPRESSION: This telemetry captured no pushbutton activations. It showed no seizures although it did have some sharp low voltage fast activity in the left posterior temporal region similar to that at the beginning of the frequent seizures from the previous day. Most of the record was markedly suppressed, particularly after mid-afternoon of [**5-22**]. EEG [**2167-5-23**]: IMPRESSION: This telemetry captured no pushbutton activations. The background remained of low voltage throughout the recording, with similar frequencies in all areas, generally indicating medication effect. There were no prominent focal abnormalities, and there was no evidence of even the beginning of electrographic seizures noted on the first day of recording. CXR [**2167-5-23**]: FINDINGS: Comparison is made to prior study from [**2167-5-22**]. The tip of the endotracheal tube and side port are below the gastroesophageal junction. Heart size is upper limits of normal. The endotracheal tube tip is at the level of the clavicular heads, 6 cm above the carina. There is some prominence of the pulmonary vascular markings suggestive of mild pulmonary edema. There is no definite consolidation or large pleural effusions. L-SPINE X-RAY [**2167-5-23**]: FINDINGS: Comparison is made to the prior study from [**2166-12-9**]. There is a pump device seen at the right lower pelvis. The tip of the needle is seen projecting over the T12 vertebral body. Femoral catheter is seen with distal lead tip projecting over the right sacral ala. On the lateral view, there are no compression deformities. There is no abnormal antero- or retrolisthesis. There is facet joint arthropathy of the lower lumbar spine. There is a non-obstructive bowel gas pattern. Feeding tube is seen with the distal tip and side port below the gastroesophageal junction. MR [**Name13 (STitle) 6452**] [**2167-5-23**]: IMPRESSION: 1. Essentially unremarkable examination, with no evidence of rim-enhancing or other fluid collection in the imaged lumbar spine to suggest an infectious process associated with the indwelling baclofen pump device. 2. No pathologic focus of enhancement. 3. No evidence of spondylodiscitis. 4. Only mild disc bulging at the L4-5 and L5-S1 levels, with widely patent spinal canal and neural foramina. MR HEAD [**2167-5-23**]: IMPRESSION: 1. No acute intracranial abnormality; specifically, there is no evidence of an acute ischemic event and no pathologic leptomeningeal or parenchymal focus of enhancement to specifically suggest meningo-encephalitis. 2. Established cystic encephalomalacia with gliosis, mineralization and volume loss involving the left parietooccipital lobe, with associated wallerian degeneration. This is essentially unchanged over the series of studies dating to [**4-/2159**] and may serve as a substrate for seizure. EEG [**2167-5-24**]: IMPRESSION: This telemetry captured no pushbutton activations. The record showed a widespread mixture of faster beta activity and some alpha and theta background. The widespread, similar rhythms suggest medication effect. There were no areas of prominent focal disturbance or any epileptiform features. There were no electrographic seizures. EEG [**2167-5-25**]: IMPRESSION: This telemetry captured no pushbutton activations. It showed several right hemisphere sharp waves but no overly epileptiform discharges and no electrographic seizures. The background rhythm was mildly slow when the patient was most alert. There was also additional slowing on the right side. EEG [**2167-5-26**]: IMPRESSION: This telemetry captured no pushbutton activations. No clearly epileptiform activity or any electrographic seizures were seen in this recording. The background rhythm remained slow and was better seen on the right. This suggests a mild encephalopathy. Background voltages were lower on the left. There was also some independent focal slowing in the right hemisphere. ECHO [**2167-5-28**]: Conclusions The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. 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. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. No valvular vegetations or abscesses appreciated. Normal left ventricular cavity size and wall thickness with preserved global biventricular systolic function. No clinically significant valvular regurgitation or stenosis. Indeterminate pulmonary artery systolic pressure. Compared with the prior study (images reviewed) of [**2163-2-23**], the right ventricle was not previously assessed due to patient position, but was noted to be normal in size and function on the current study. Brief Hospital Course: # SEIZURES: EEG in the ED showed seizures, so the patient received 3 mg lorazepam and 1 g Keppra and was admitted to the epilepsy service. On the Neurology floor, the patient continued to seize (was found to be minimally responsive) and was found to be in non-convulsive status epilepticus. She was found to have a temperature of 102.9 F axillary. Given ongoing seizures and concern for underlying infection, the patient was transferred to the MICU. In the MICU, the patient was intubated and given phosphenytoin, Keppra, and Vimpat, along with a midazolam gtt for refractory seizures. She was started on broad-spectrum antibiotics for possible meningitis. Seizures stopped on [**2167-5-23**] and the patient was weaned off the midazolam drip on [**2167-5-24**]. She was extubated on [**2167-5-25**] and remained without seizures for the rest of her hospital course. She was continued on phenytoin 100 mg PO TID, lancosamide 200 mg IV BID, and Keppra 1500 mg PO BID. . # FEVER/POSSIBLE MENINGITIS: As above, the patient was started on broad-spectrum antibiotics (vancomycin and ceftriaxone) plus acyclovir for possible meninigtis. Lumbar puncture on [**2167-5-22**] showed 210 WBC, however no organisms grew from culture, and HSV PCR was negative. Fluid from the baclofen pump on [**2167-5-24**] showed 15 WBC, but again culture was negative. Due to concern that the baclofen pump was the source of infection, the possibility of explanting the baclofen pump was investigated. However, ID eventually recommended leaving the baclofen pump and discontinuing antibiotics as low level WBC in the pump fluid and negative culture suggested against hardware infection. Cryptococcal antigen, fungal culture, HSV PCR, and Bartonella serologies were negative. TTE was negative for vegetations. Antibiotics were discontinued on [**2167-5-27**] and the patient remained afebrile through the remainder of the hospital course. She will need to be observed at rehab further to ensure that she doesn't spike a fever. . # SPASTICITY: The patient has spasticity in all extremities, legs greater than arms, secondary to hemorrhagic parieto-occipital stroke in [**2158**], s/p baclofen pump placement in [**2159**] by Dr. [**First Name4 (NamePattern1) 54184**] [**Last Name (NamePattern1) 174**] ([**Hospital1 2177**] orthopedics - [**Telephone/Fax (1) 94375**] or pager [**Telephone/Fax (1) 94376**]). The pump was possibly off for several years (from [**2162**] through ?[**2166**]) but, per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27853**] (covering for Dr. [**Last Name (STitle) 174**], cell [**Telephone/Fax (1) 94377**]), the pump was replaced on [**2166-10-28**], and recently the reservoir was refilled on [**2167-5-12**], with plans for another refill on [**2167-7-30**]. Pt has a 20mL pump with a balcofen concentration of 1,000mcg/mL with dosing at 225mcg/day. He mentioned that the first sign of baclofen withdrawal (if the pump malfunctions) is itching without rash and if this happens to use ativan IV and not PO baclofen, and that this is a medical emergency as withdrawal can precipitate seizures. The pump was interrogated here and found to be working. . # CONSTIPATION: The patient has constipation at baseline and had several days without a bowel movement while in the MICU, leading to abdominal pain and some distention. A KUB showed no obstruction. The patient was kept on a bowel regimen and the constipation resolved. . Ms. [**Known lastname 805**] was discharged on [**2167-5-29**] to [**Hospital 38**] Rehab. She has follow-up scheduled with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital1 18**] Neurology, at 3:30 PM on Wednesday, [**6-24**]. PENDING RESULTS: [**2167-5-23**] BCx [**2167-5-24**] CSF from baclofen pump EEG final read [**2167-5-27**] TRANSITIONAL CARE ISSUES: Patient will need to be followed to ensure that she does not have any fevers now that she is off of her vancomycin and ceftriaxone. If she spikes, she should be started on menigitic dose of vancomycin and ceftriaxone and sent to the Emergency Department. Medications on Admission: Per ED reconciliation (CORRECTIONS IN CAPS): hydroxyzine 25 mg Tab Oral 2 Tablet(s) Four times daily, as needed ([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2167-5-21**] 09:08) lorazepam 1 mg Tab Oral THIS IS INCORRECT, 0.5 MG QHS ONLY 1 Tablet(s) Twice Daily ([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2167-5-21**] 09:08) morphine 15 mg Tab Oral (MS CONTIN 15 MG [**Hospital1 **], MS IR 15 MG [**Hospital1 **] PRN) 1 Tablet(s) Twice Daily ([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2167-5-21**] 09:08) ondansetron 4 mg Tab, Rapid Dissolve Oral 1 Tablet, Rapid Dissolve(s) Every 6-8 hrs, as needed ([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2167-5-21**] 09:08) docusate sodium 100 mg Tab Oral 1 Tablet(s) Three times daily ([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2167-5-21**] 09:09) Vitamin D3 1,000 unit Chewable Tab Oral 1 Tablet, Chewable(s) Once Daily ([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2167-5-21**] 09:09) cyclobenzaprine 10 mg Tab Oral 1 Tablet(s) Twice Daily ([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2167-5-21**] 09:10) citalopram 40 mg Tab Oral 1 Tablet(s) Once Daily ([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2167-5-21**] 09:10) FiberCon 625 mg Tab Oral 1 Tablet(s) Once Daily ([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2167-5-21**] 09:10) olanzapine 2.5 mg Tab Oral 0.5 Tablet(s) Twice Daily ([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2167-5-21**] 09:11) alendronate 70 mg Tab Oral 1 Tablet(s) Once Daily ([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2167-5-21**] 09:11) --------------- --------------- --------------- --------------- Active OMR Medication list as of [**2167-5-21**]: Medications - Prescription ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA Aerosol Inhaler - 1-2 puffs inhaled Q4-6HR as needed for SOB ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth once weekly Alendronate must be taken with plain water (tablets [**7-17**] oz; oral solution follow with 2 oz) first thing in the morning and ≥30 minutes before ALTERNATING PRESSURE PAD - - use as directed daily BALOFEN - (Prescribed by Other Provider) - - CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth daily CYCLOBENZAPRINE - 10 mg Tablet - 1 Tablet(s) by mouth twice a day DURO-[**Month/Day (3) **] REACHER 32 IN ALUMINUM OR OTHER SIMILAR REACHER - - please dispense one reacher once ERYTHROMYCIN - 5 mg/gram (0.5 %) Ointment - 1 cm topical 6 times to both eyes FLUOCINOLONE-SHOWER CAP [DERMA-SMOOTHE/FS SCALP OIL] - 0.01 % Oil - apply 1 ounce to scalp daily work into lather and allow to remain on scalp for ~5 minutes. Rinse after. HOSPITAL BED REPAIRS - - use as directed daily as needed for and as needed Dx s/p stroke HYDROCORTISONE - 2.5 % Cream - AAA body twice a day as needed for itch use for 2 weeks HYDROXYZINE HCL - 25 mg Tablet - 2 Tablet(s) by mouth four times per day as needed for for itch INCENTIVE SPIROMETER - - Use daily as instructed KAFO - - B DROP FOOT daily s/p CVA with r quad weakness. needs KAFO or extension to exsiting afo r le. KETOCONAZOLE - 2 % Shampoo - Wash scalp, face, neck daily use for 2 weeks, then 2-3 times per week KETOCONAZOLE - 2 % Cream - Apply to affected areas twice a day LACTULOSE - 10 gram/15 mL Solution - 15 Solution(s) by mouth once a day as needed for constipation stop if diarrhea developed LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth twice a day MORPHINE - 15 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for pain for breakthrough pain only MORPHINE - 15 mg Tablet Extended Release - 1 Tablet(s) by mouth twice a day OLANZAPINE - 2.5 mg Tablet - 1 (One) Tablet(s) by mouth twice a day ONDANSETRON - 4 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth q8hrs as needed for nausea POLYETHYLENE GLYCOL 3350 - 17 gram/dose Powder - 17 grams by mouth eveyr 4 hrs until bowel movement use the lactulose as well RAISED TOILET SEAT - - use as directed daily for lifetime use, dx: s/p stroke Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider: [**Name10 (NameIs) **] house) - 325 mg Tablet - 2 Tablet(s) by mouth every four (4) hours as needed for fever, pain ASPIRIN - (Prescribed by Other Provider) - 650 mg Tablet, Delayed Release (E.C.) - taper Tablet(s) by mouth twice a day Take [**Hospital1 **] [**5-21**] - [**5-27**], then Daily [**5-28**] - [**6-3**], then stop BISACODYL - 10 mg Suppository - 1 Suppository(s) rectally DAILY (Daily) as needed for Constipation CARBAMIDE PEROXIDE - 6.5 % Drops - 1-2 drops in ear daily CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s) by mouth daily DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by mouth tid GLYCERIN (ADULT) - ADULT Suppository - 1 Suppository(s) rectally daily as needed for constipation MULTIVITAMIN-CA-IRON-MINERALS - Tablet - 1 Tablet(s) by mouth daily Discharge Medications: 1. Vitamin D3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. olanzapine 2.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 6. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for fever, pain . 7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 8. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units Injection [**Hospital1 **] (2 times a day). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 11. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 14. lacosamide 200 mg Tablet Sig: One (1) Tablet PO twice a day. 15. morphine 15 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 16. Zofran 4 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 17. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a day. 18. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 19. hydroxyzine HCl 50 mg Tablet Sig: One (1) Tablet PO four times a day as needed for itching. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Seizures Fever Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Ms. [**Known lastname 805**], You were recently admitted to [**Hospital1 18**] for seizures in the setting of an infection. You were treated with antibiotics and your seizures improved. We made the following changes to your medications: 1) We STARTED you on BISACODYL 10mg per rectum as needed for constipation. 2) We STARTED you on IBUPROFEN 400mg every 8 hours as needed for pain or fever. 3) We STARTED you on TYLENOL 650mg every 6 hours as needed for pain or fever. 4) We STARTED you on SUBCUTANEOUS HEPARIN three times a day while you are at rehab to prevent DVTs. 5) We STARTED you on KEPPRA 1500mg twice a day. 6) We STARTED you on PHENYTOIN 100mg three times a day. 7) We STARTED you on SENNA 8.6mg as needed for constipation. 8) We STARTED you on POLYETHYLENE GLYCOL 17 grams per day as needed for constipation. 9) We STARTED you on LACOSAMIDE 200mg twice a day. 10) We CHANGED your DOCUSATE to be twice a day. 11) We CHANGED your MORPHINE to be 7.5mg every 4 hours as needed for pain. 12) We STOPPED your FIBERCON. Please continue to take your other medications as prescribed. If you experience any of the below danger signs, please call your doctor go to your nearest Emergency Department. It was a pleasure taking care of you during this hospitalization. Please observe the following seizure precautions: The following tips will help you to make your home and surroundings as safe as possible during or following a seizure. Some people with epilepsy will not need to make any of these changes. Use this list to balance your safety with the way you want to live your life. Make sure that everyone in your family and in your home knows: - what to expect when you have a seizure - correct seizure first aid - first aid for choking - when it is (and isn't) necessary to call for emergency help Avoid things that are known to increase the risk of a seizure: - forgetting to take medications - not getting enough sleep - drinking a lot of alcohol - using illegal drugs In the kitchen: - As much as possible, cook and use electrical appliances only when someone else is in the house. - Use a microwave if possible. - Use the back burners of the stove. Turn handles of pans toward the back of the stove. - Avoid carrying hot pans; serve hot food and liquids directly from the stove onto plates. - Use pre-cut foods or use a blender or food processor to limit the need for sharp knives. - Wear rubber gloves when handling knives or washing dishes or glasses in the sink. - Use plastic cups, dishes, and containers rather than breakable glass. In the living room: - Avoid open fires. - Avoid trailing wires and clutter on the floor. - Lay a soft, easy-to-clean carpet. - Put safety glass in windows and doors. - Pad sharp corners of tables and other furniture, and buy furniture with rounded corners. - Avoid smoking or lighting fires when you're by yourself. - Try to avoid climbing up on chairs or ladders, especially when alone. - If you wander during seizures, make sure that outside doors are securely locked and put safety gates at the top of steep stairs. In the bedroom: - Choose a wide, low bed. - Avoid top bunks. - Place a soft carpet on the floor. In the bathroom: - Unless you live on your own, tell a family member or [**Name2 (NI) 8317**] before you take a bath or shower. - Hang the bathroom door so it opens outward, so it can be opened if you have a seizure and fall against it. - Don't lock the bathroom door. Hang an "Occupied" sign on the outside handle instead. - Set the water temperature low so you won't be hurt if you have a seizure while the water is running. - Showers are generally safer than baths. Consider using a hand- held shower nozzle. - If taking a bath, keep the water shallow and make sure you turn off the tap before getting in. - Put non-skid strips in the tub. - Avoid using electrical appliances in the bathroom or near water. - Use shatterproof glass for mirrors. At work: - Consider telling your co-workers that you have epilepsy and the correct first aid for seizures. - Climb only as high as you can fall without injuring yourself. - When working around machinery, make sure that safety features are in place, and consider wearing protective clothing. - Try to keep consistent work hours so you don't have to go a long time without sleep. - Try to limit your exposure to flashing lights if this can trigger your seizures. Out and about: - Carry only as many medications with you as you will need, and 2 spare doses. - Wear a medical alert bracelet to let emergency workers and others know that you have epilepsy. - Stand well back from the road when waiting for the bus and away from the platform edge when taking the subway. - If you wander during a seizure, take a friend along. - Don't let fear of a seizure keep you at home. Sports: - Use common sense to decide which sports are reasonable. - Exercise on soft surfaces. - Wear a life vest when you are close to water. - Avoid swimming alone. Make sure someone with you can swim well enough to help you if you need it. - Wear head protection when playing contact sports or when there is a risk of falling. - When riding a bicycle or rollerblading, wear a helmet, knee pads, and elbow pads. Avoid high traffic areas; ride or skate on side roads or bike paths. Driving: - You may not drive in [**State 350**] unless you have been seizure- free for at least 6 months. - Always wear a seatbelt. Parenting: - Childproof your home as much as possible. - If you are nursing a baby, sit on the floor or bed with your back supported so the baby will not fall far if you should lose consciousness. - Feed the baby while he or she is seated in an infant seat. - Dress, change, and sponge bathe the baby on the floor. - Move the baby around in a stroller or small crib. - Keep a young baby in a playpen when you are alone, and a toddler in an indoor play yard, or childproof one room and use safety gates at the doors. - When out of the house, use a bungee-type cord or restraint harness so your child cannot wander away if you have a seizure that affects your awareness. - Explain your seizures to your child when he or she is old enough to understand. Followup Instructions: [**Name (NI) **] has follow-up scheduled with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital1 18**] Neurology, at 3:30 PM on Wednesday, [**6-24**]. Department: [**Hospital3 249**] When: TUESDAY [**2167-6-2**] at 1:45 PM With: [**First Name8 (NamePattern2) 2801**] [**Last Name (NamePattern1) 63708**], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: LIVER CENTER When: TUESDAY [**2167-6-9**] at 3:20 PM With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: OBSTETRICS AND GYNECOLOGY When: WEDNESDAY [**2167-6-24**] at 1:30 PM With: [**Name6 (MD) 94378**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2664**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "438.53", "518.89", "070.54", "518.81", "344.00", "345.3", "784.3", "780.60", "564.09", "728.85", "311", "282.5", "338.29", "438.89" ]

icd9cm

[ [ [] ] ]

[ "03.31", "96.6", "38.93", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

27269, 27366

16013, 19834

310, 322

27425, 27425

7267, 7267

33757, 34923

5014, 5098

25605, 27246

27387, 27404

20143, 25582

27562, 27776

7842, 15990

5113, 5453

27805, 33734

2960, 3041

260, 272

19860, 20117

350, 2941

5635, 6471

7284, 7825

27440, 27538

3063, 4828

4844, 4998

6497, 7248

15,594

116,266

3732

Discharge summary

report

Admission Date: [**2184-2-20**] Discharge Date: [**2184-3-17**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Penicillins / Clindamycin / Tetracycline / Cozaar / Zestril / Coreg / Toprol Xl Attending:[**First Name3 (LF) 7202**] Chief Complaint: abdominal pain, diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: This is a 87 year old man with multiple medical problesm including coronary artery disease status post coronary artery bypass graft, congestive heart failure with ejection fraction of 20-30%, status post pacemaker for sick sinus syndrome, atrial fibrillation on coumadin, chronic lower back pain who was transferred from [**Hospital3 7571**]Hospital to the vascular service with concern for aortic dissection. . The patient reports that he began to develop diarrhea several weeks prior to admission. This diarrhea is only during the day, not related to eating. Per the nurse, the patient's stool is liquid, brown, no bright red blood per rectum. The patient also developed nausea and epigastric pain one week prior to admission. The epigastric pain is sharp, constant, unrelated to eating and without exacerbating or alleviating factors. The patient denies emesis, recent travel, or recent antibiotic use. . The pt presented to [**Location (un) **] emergency department on [**2184-2-15**] for these symptoms, and was noted to have an abdominal aorta aneurysm at the level of the renal artery as well as a short aortic dissection on CT. Repeat CT here revealed a 2 cm aortic dissection at level of renal arteries, with possible chronicity. The patient is transferred to medicine for blood pressure management given patient's systolic blood pressure was up to 198 on day of admission. . On review of systems, patient denies fever, decreased appetite. He complains of worsened sciatica down his right leg. Past Medical History: 1. coronary artery disease 2. pacemaker for sick sinus syndrome, right bundle branch block 3. cardiomyopathy with ejection fraction 20-30% 4. congestive heart failure 5. osteoarthritis 6. severe low back pain 7. gastroespophageal reflux disease 8. orthostatic hypotension 9. atrial fibrillation with cardioversion 10.peripheral neuropathy 11.degenerative joint disease 12.chronic pain 13.pulmonary embolus x2 [**92**].atrial appendage clot 15.depression 16.hypercholesterolemia 17.history of campylobacter PSH: CABG x2 [**66**] / 98, Left subclavian [**Name (NI) **], PTCA [**69**], anterior scalenectomy, lap CCY, b/l carpal tunnel, multiple hernia repair Social History: Lives in a room in a monastery. Drinks one alcoholic beverage every couple of weeks. Quit smoking 30 years ago. No illicit drug use. Family History: NC Physical Exam: Vitals: Tm 99.1 Tc 98.1 P 45-77 BP 118-198/50-85 Sat 95-96%RA General: thin man laying flat in bed, NAD HEENT: PERRL, NCAT, conjunctivae anicteric and noninjected, dry MM, scale and erythema noted in nasolabial folds Neck: no JVD, supple CV: mostly RRR but occasional PVCs per monitor, Grade 2/6 SEM LUSB, PCM palpable in L chest wall, median sternotomy scar well healed Lungs: bibasilar rales, decreased breath sounds, hyperresonant to percussion Abd: soft, NABS, tender to palp in epigastric region without rebound tenderness Extrem: no c/c/e, full dp/pt pulses Neuro: a and ox 3, CNII-XII grossly intact Pertinent Results: [**2178**] cath: COMMENTS: 1. Coronary angiography in this right dominants system revealed severe left main and three vessel CAD. The left main coronary artery was diffusely diseased with a 70% distal stenosis. The LAD was totally occluded proximally. The left circumflex artery had a 70% mid-vessel stenosis and the first obtuse marginal branch was totally occluded. The RCA was occluded immediately distal to its origin. 2. Graft angiography revealed patent SVGs. The SVG to the LAD was widely patent. The skip SVG to the first and second diagonal branchs had moderate luminal irregularities throughout its course. The SVG to the obtuse marginal branch was patent. The SVG to the rPDA was patent and the native posterolateral branch beyond the anastamosis was diffusely diseased. 3. Resting hemodynamic studies revealed normal right and left sided filling pressure. The mean RA pressure was 3 mmHg, teh mean PCWP was 5 mmHg, and the LVEDP was 6 mmHg. The cardiac index was marginally depressed at 2.4 L/min/m2. 4. Left ventriculography revealed global hypokinesis with more severe apical hypokinesis and inferior wall akinesis. The estimated LVEF was 30-35%. FINAL DIAGNOSIS: 1. Severe left main and native three vessel coronary artery disease. 2. Patent SVGs to the LAD, skip diagonals, obtuse marginal and rPDA. 3. Severe systolic ventricular dysfunction. Labs on admission: WBC 7.1 Hct 39.5* MCV 81* Plt Ct 206 Neuts 66.9 Lymphs 23.7 Monos 6.2 Eos 2.5 Baso 0.7 . Glucose 103 UreaN 10 Creat 1.6* Na 141 K 3.5 Cl 104 HCO3 26 AnGap 15 Albumin 4.1 Calcium 9.0 Phos 2.9 Mg 1.8 . ALT 8 AST 20 LD(LDH) 191 47 AlkPhos 59 Amylase 42 Lipase 24 TotBili 0.7 PT 39.1* PTT 38.4* INR(PT) 4.4* . Lactate 1.2 TSH 0.42 Digoxin 0.5* . UA negative . Additional Labs: [**2184-2-27**] 02:40PM CK(CPK) 73 cTropnT <0.01 [**2184-2-27**] 09:00PM CK(CPK) 49 cTropnT <0.01 [**2184-2-28**] 06:40AM CK(CPK) 43 cTropnT <0.01 . [**2184-2-29**] 08:33AM BLOOD Cortsol 27.1* . [**2184-2-27**] 06:49AM URINE Color Yellow Appear Clear Sp [**Last Name (un) **] 1.013 Blood NEG Nitrite NEG Protein NEG Glucose NEG Ketone NEG Bilirub NEG Urobiln NEG pH 5.0 Leuks NEG RBC 0 WBC [**3-28**] Bacteri FEW Yeast NONE Epi 0 CastHy [**3-28**]* Mucous OCC Eos NEGATIVE . [**2184-2-22**] 12:55PM URINE Osmolal 356 UreaN 433 Creat 159 Na 33 . STOOL CULTURE x2: neg C diff: neg OVP x2: negative URINE CULTURE x2: neg BLOOD CULTURE x2: neg . C diff: PENDING OVP x2: PENDING . Studies: . CXR [**2184-2-20**]: 1. Cardiac pacer leads terminate in the right atrium and the right ventricle. 2. Elevated left hemidiaphragm. . CT abdomen [**2-21**]: 1. No evidence of thoracic aortic dissection. 2. Emphysema. 3. A 13 mm vague nodular density in the right middle lobe, which should be evaluated further within three months (as well as a 7 mm nodular density at the left base as well, which can be re-evaluated at he same time). 4. Severe stenosis at the origin of the left renal artery with relative atrophy of the left kidney compared to the right. 5. Short 2cm dissection of the aorta at the level of the renal arteries. Although of uncertain chronicity, the appearance may be chronic. 6. Small abdominal aortic aneurysm. 7. Right common iliac aneurysm. 8. Compression fracture of T12, probably chronic. . EKG [**2184-2-25**]: A-V sequential pacemaker pacemaker rhythm Intervals Axes Rate PR QRS QT/QTc P QRS T 60 0 168 450/450 0 -73 103 . CHEST (PORTABLE AP) [**2184-2-28**]: The portable erect AP radiograph of the chest is reviewed, and compared with the previous study of yesterday. . The patient has prior CABG and median sternotomy. Pacemaker leads remain in place. There is increase in mild congestive heart failure with cardiomegaly with small right pleural effusion. There is increase in bibasilar patchy atelectasis. . Again, note is made of marked tortuosity of the thoracic aorta with calcification. No pneumothorax is identified. [**2184-3-4**] Echo: Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function is difficult to assess but is moderately depressed. Overall left ventricular EF cannot be reliably assessed. 3. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. INDICATION: 87-year-old male with throat pain, equivocal bedside evaluation. Video oropharyngeal swallow. FINDINGS: Note is made of moderate amount of pharyngeal residue after multiple swallowing attempts. Note is made of penetration at thin barium swallow, more with straw than cup sip. No evidence of aspiration is seen. Please also refer to the official report by speech and lung pathologist available on CareWeb. [**2184-3-10**] Echo Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%); the apex appears hypokinetic. Due to suboptimal technical quality, another focal wall motion abnormality cannot be fully excluded. Right ventricular contracrtile function appears normal; there is abnormal septal activation suggestive of intraventricular conduction delay. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The aortic root 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. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2184-3-4**], no major change is evident. [**2184-3-13**] AXR Oral contrast is present within the distal rectosigmoid region, possibly related to contrast administered during a video swallow study of [**2184-3-9**], unless a more recent contrast study has been performed elsewhere in the interval. Again demonstrated are numerous air filled loops of small and bowel, likely related to an ileus. If there is strong clinical suspicion for an obstructive process, additional upright view may be considered for more complete assessment if warranted clinically. CXR [**3-8**]: COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared with the previous study of [**2184-3-6**]. There is continued mild-to-moderate congestive heart failure with cardiomegaly, which is superimposed on patient's underlying severe emphysema. There is increased opacity in the right lower lobe indicating superimposed pneumonia or aspiration. The patient has prior CABG and median sternotomy. Uppermost cerclage wires of the sternum has been broken. Pacemaker leads remain in place. There is continued tortuosity of the thoracic aorta with calcification. No pneumothorax is identified. . CT ABD: IMPRESSION: 1. No evidence of thoracic aortic dissection. 2. Emphysema. 3. A 13 mm vague nodular density in the right middle lobe, which should be evaluated further within three months (as well as a 7 mm nodular density at the left base as well, which can be re-evaluated at the same time). 4. Severe stenosis at the origin of the left renal artery with relative atrophy of the left kidney compared to the right. 5. Short 2cm dissection of the aorta at the level of the renal arteries. Although of uncertain chronicity, the appearance may be chronic. 6. Small abdominal aortic aneurysm. 7. Right common iliac aneurysm. 8. Compression fracture of T12, probably chronic Brief Hospital Course: This 87 yo man with history of CAD s/p CABG, CHF EF 20-30%, s/p PCM for SSS, A fib on coumadin, chronic [**Hospital 16825**] transferred from [**Hospital3 **]hospital [**2184-2-20**] initially to Vascular service with concern for aortic dissection now having hypoxia. The pt presented to [**Location (un) **] ER with diarrhea and cramping and was noted to have an AAA at the level of the renal artery as well as a short aortic dissection on CT. Repeat CT here 2 cm aortic dissection at level of renal arteries, with possible chronicity. Surgery had no plan to intervene on him so pt was transferred to medicine for BP management given pts SBP up to 198. His BP was controlled with hydral and imdur then his BP dropped so these were held. His cardiologist advised conversion from atrial fibrillation. He was electrically cardioverted and treated with Amiodarone and Digoxin. He remained in NSR. . On the night of [**2184-3-2**] a "trigger" was called as he was found to be hypoxic, 78% on 5L NC. ABG 7.39/44/78 on NRB, lactate 1.6. He was treated with Lasix and his hypoxia resolved. Later that evening he was having chest pain, NTG given and BP dropped to 78/p, improved with fluid. Today was sent down for V/Q scan. Upon return from V/Q scan he was hypoxic to the 80s. He was placed on NRB and his sats went to 94%. MICU was called to evaluate him given the need for closer monitoring. . MICU course: For his hypoxia, he was treated for pulmonary edema by diuresis with IV lasix, as well as cont treatment for his CAP. V/q scan was low prob for PE. Started on lasix gtt MICU d #3, placed on vancomycin for nosocomial PNA, pt to recieve 7 more days. Changed to lasix 60 mg IV on [**3-8**]. Pt complained of chest pain on [**3-8**], relieved with 1 SL NTG, became hypoxic with sats 86%, placed on NRB. Increased lasix to 100 mg tid, d/c afterload reduction. Speech and swallow [**Month/Year (2) **] without aspiration, ? silent asp. Began txt for thrush. Narcotics held [**2-26**] low BP. Pt was transferred to [**Hospital Unit Name 196**] service for further CHF mgmt. . Pt has had a long history of ischemic heart disease with h/o cath + CABG. During the [**Hospital 228**] hospital course, he was having several episodes of L sided pleuritic chest pain which was alleviated with a lidocaine patch. There were no ekg changes during the episodes of the chest pain. Several sets of cardiac enzymes were taken during the chest pain episodes and were negative each time. Due to the patient's high risk profile, the patient was resterted on aspirin 325. No further coronary intervention was undertaken during his hospital stay. .. PUMP: BNP 1301 on transfer to [**Hospital Unit Name 196**]. systolic function is low normal (LVEF 50%) by recent echo; the apex appeared hypokinetic. In the MICU, the patient was unresponsive to lasix gtt and standing dose of lasix. Patient was gently diuresed with HCTZ and PO lasix once on the floor with limited efficacy. When BUN/Cr contined to climb, a decision was made to scale back the diuretic dosing. While at rehab, volume status should be At rehab, please hold the captopril dosing for SBP < 90. Pt always runs higher blood pressures on the R arm, since has a h/o subclavian stenosis on the L side. Also, pt tends to run low blood pressures while sitting up although he is asymptomatic. The blood pressure returns up to 100 once the patient is back in bed. . Hypoxia: [**2-26**] CHF and potential nosocomial PNA. Patient has bibasilar infiltrates on CXR. Was treated empirically in the MICU for aspiration pneumonia, completed 7 days of vancoomycin. While on the floor, WBC count was trending down. PNA appears resolving, WBC trending down, pt afebrile. ID consulted and recommended d/c abx. The patient has passed his speech and swallow [**Last Name (LF) **], [**First Name3 (LF) **] aspiration events were less likely. CXR done on [**3-15**] did not show any change from previous while the patient's oxygen dramatically improved. When the patient left the MICU, he was on a high flow O2 mask. While on the floor, he was weaned down to 4L by NC, sating 93-94%. -cont CHF mgmt as above . AF: Pacer, s/p DCCV in past, on amiodarone and anticoagulation. Patient had paced rhythm on his EKG w/o any changes with chest pain epidoses. He was continued on amiodarone. The patient was anti-coagulated with coumadin. During the last few days of his hospitalization, coumadin was held due to elevated INR. While at rehab, the patient's INR should be carefully monitored, checked at least 3 times per week and as needed, and coumadin dosing should be adjusted as necessary. . CRI: patient has had a chronic h/o CRI with baseline Cr 1.6-1.7. His Cr bumped with aggressive IV diuresis, so diuretics were switched to PO and decreased dosing. On discharge, the patient's Cr was 2.2 (close to baseline). It was recommended that the patient follows up with his PCP or his nephrologist for his renal issues. . Abdominal Pain: patient was found to be full of stool on AXR/vs contrast from prior speech/swallow study. Pt given enemas and felt better, responding with lots of stool. More aggressive bowel regimen was started. Abdominal pain was monitored carefully since the patient does have an infrarenal AAA. Should the patient have more severe abdominal or back pain or drop in his Hct, an urgent evaluation for progression of AAA or dissection should be considered. . AAA: patient was originally admitted to the surgical service to evalute his AAA and abdominal aortic disection. After thorough evaluation, he was deemend not a surgical candidate and optimal BP control was recommended. The patient was also started on a statin. While on the medical service, the blood pressure remained well controlled. Surgical service recommends re-imaging CT scan of the abdomen to document the progression or stability of his disease. . Medications on Admission: [**Last Name (un) 1724**]: midodrine 7.5 tid, digoxin 0.125 qod, lasix 40, coumadin 2.5, mevacor 20, prevacid 30, norvasc 2.5, nuerontin 200 "', xanax prn, nitroquick 0.4, oxycontin 20 ", oxycodone 5 prn, colchicine 0.6 . Meds on Transfer: Xanax 0.5 mg po TID prn, amlodipine 2.5 mg po qd, atorvastatin 20 mg po qd, bisacodyl prn, colchicine 0.6 qd, dig 0.125 mg qod, colace, anzemet prn, Lasix 40 mg po qd, nuerontin 200 mg TID, dilaudid prn, hydral 20 mg IV q6 hr, Lansoprazole 30 mg po qd, levothyroxine 88 ug, day, midodrine 7.5 mg po tid, NTG patch, senna, percocet Discharge Medications: 1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 6. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Ten (10) ML Mucous membrane QID (4 times a day) as needed. 8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Amiodarone 200 mg 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. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) inj Subcutaneous ASDIR (AS DIRECTED): please refer to the attached sliding scale. 14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for chronic pain: apply to Left upper chest as needed for chest pain/pressure. 18. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 20. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 22. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 23. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): please hold [**2184-3-17**] and [**2184-3-18**] dosing. 24. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 25. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: Life Care Centers of [**Location (un) **] Discharge Diagnosis: primary diagnosis: 1. chronic type III aortic dissection 2. paroxysmal atrial fibrillation s/p cardioversion 3. epigastric hiatal hernia 4. Congestive heart failure 5. failure to thrive . secondary diagnosis: Discharge Condition: stable, ambulatory, satting 100% on 3L O2 by nasal cannula Discharge Instructions: Please take medications as prescribed. . Please keep follow-up appointments. . If you have acute worsening abdominal or back pain, lightheadedness, fever/chills or any other concerning symptoms please call your primary care physician or return to the emergency room. . Staff: please follow patient's INR. Patient is anti-coagulated with coumadin for afib and SSS. INR level should be [**2-27**]. Patient will need his INR checked daily. Please hold [**3-17**] and [**3-18**] dosing of coumadin. Re-check INR on [**3-19**]. Restart warfarin as needed to keep INR [**2-27**]. . Please check pt's blood pressures. Please do not administer captopril if SBP < 90 . please ambulate the patient and get the patient out of bed as tolerated. Followup Instructions: You must ask your primary care physician to order [**Name Initial (PRE) **] noncontrast cat scan of your chest within 3-6 months to follow-up on a nodule in the right middle lobe of your lung that was incidentally found on your cat scan. . call your PCP [**Name9 (PRE) 16826**],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 16827**] to make a follow up appointment to discuass your heart condition . Please call your primary care physician to arrange [**Name9 (PRE) 702**] in coumadin clinic for managment of your INR and proper dosing of your coumadin. Completed by:[**2184-3-17**]

[ "584.9", "428.0", "553.21", "V58.61", "414.00", "458.0", "263.9", "V45.81", "458.29", "783.7", "427.31", "786.59", "112.0", "428.40", "724.3", "560.1", "276.52", "507.0", "427.32", "441.02", "403.91" ]

icd9cm

[ [ [] ] ]

[ "99.61" ]

icd9pcs

[ [ [] ] ]

19977, 20045

11089, 16968

335, 341

20298, 20359

3369, 4530

21146, 21752

2722, 2726

17590, 19954

20066, 20066

16994, 17216

4547, 4735

20383, 21123

2741, 3350

271, 297

369, 1873

20277, 20277

20085, 20254

4749, 11066

1895, 2555

2571, 2706

17234, 17567

48,898

136,303

42586+58535+58536+58543

Discharge summary

report+addendum+addendum+addendum

Admission Date: [**2111-5-7**] Discharge Date: [**2111-5-12**] Date of Birth: [**2050-6-20**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2111-5-8**] - Endoscopic minimally-invasive coronary artery bypass graft x1 with left internal mammary artery to left anterior descending artery. [**2111-5-7**] - Cardiac Catheterization History of Present Illness: 60M with chronic CAD complicated by myocardial infarction status post bare metal stent to his left anterior descending artery and right coronary artery in [**2098**] who was recently admitted to [**Hospital1 18**] with ill-defined but progrssively worsening substernal chest discomfort, including intermittent symptoms while at rest. He ruled out for myocardial infarction and was started on protonix to treat presumed GERD as a source of his pain. He is now status post cardiac catheterization and is being evaluated for a minimally-invasive CABG. Past Medical History: 1. CARDIAC RISK FACTORS: CAD 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: s/p MI and LAD stenting in [**2098**], elevative PCI of RCA later that year in [**2098**], -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: None Social History: -Tobacco history: None -ETOH: Occasional -Illicit drugs: None Family History: Father: Diet of MI at 54 Grandfather: Died of MI at 65 Grandmother: Died of stroke at 69 Mother: Stroke and MI, still living in her 90s Physical Exam: Pulse: 49SB Resp: 16 SaO2: 100%/RA B/P R: 140/81 L: 134/75 Ht: 73 in Wt: 197 lb General: well appearing in good physical shape Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur II/VI SEM @RUSB Abdomen: Soft, non-distended, non-tender[x] Extremities: Warm, well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: [**2111-5-8**] ECHO The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 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. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [**First Name (STitle) **] was notified in person of the results on MR. [**Known lastname 92036**] before surgical incision. Pre anastomosis, the LVEF 55%. The biventricular systolic function was well preserved (LVEF 55%) post LIMA-LAD off pump anastomosis. Intact thoracic aorta. [**2111-5-7**] Cardiac Catheterization 1. Coronary angiography in this right dominant system demonstrated severe single vessel CAD. The LMCA had mild diffuse disease with distal tapering. The LAD had an 80-90% stenosis at its origin back to the left main with its stent widely patent. The LCx had no significant disease. The RCA was without obstructive disease and its prior stent was widely patent. 2. Limited resting hemodynamics revealed borderline systemic arterial systolic hypertension with an SBP of 130 mmHg. Brief Hospital Course: Mr. [**Known lastname 92036**] was admitted to the [**Hospital1 18**] on [**2111-5-7**] following his cardiac catheterization which revealed complex left anterior descending disease. The cardiac surgical service was consulted for a thoracoscopic left internal mammary artery harvest with off pump single vessel coronary artery bypass grafting. He was worked-up in the usual preoperative manner. On [**2111-5-8**] he was taken to the operating room where he underwent thoracoscopic left internal mammary artery harvest with off pump single vessel coronary artery bypass grafting via a left anterior thoracotomy. Please see operative note for details. He was extubated in the operating room and transferred to the intensive are unit for monitoring. On postoperative day one, he was transferred to the step down unit for further recovery. He worked with physical therapy daily. Lasix was used for gentle diuresis. Beta blockade, a statin and his ace inhibitor were resumed. There were no episodes of postoperative atrial fibrillation. He continued to make steady progress and was discharged home on postoperative day four. Upon discharge, his chest x-ray showed mild bibasilar atelectasis without pneumothorax. His EKG showed normal sinus rhythm. He will follow-up with Dr. [**First Name (STitle) **] in one months time and his appointment has been scheduled. He will schedule appointments with his cardiologist Dr. [**Last Name (STitle) **] and primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 68080**] to be seen in 2 weeks time. Medications on Admission: lipitor 40, lisinopril 5, lopressor 12.5 twice daily, ASA 81 Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 months. Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary artery disease s/p CABGx1 Hyperlipidemia Hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions 2) Please No lotions, cream, powder, or ointments to incisionsuntil they have healed. (8 Weeks). 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart. Call with any fever greater then 101.0 4) You had a left mid anterior thoracotomy and thus have no lifting restrictions. These incisions tend to be painful so please take your pain medication initially as prescribed and then you may supplement a nonsteroidal anti-inflammatory (Alieve or tylenol). You may drive after 1 week as long as you are not driving while using narcotic pain medication. No vigorous exercise or heavy lifting for 6 weeks. 5) You will take plavix for 3 months and then as instructed by your cardiologist. 6) Please take lasix and potassium daily for 5 days then stop. 7) Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Surgeon Dr. [**First Name (STitle) **] on [**2111-6-15**] 1:00PM [**Telephone/Fax (1) 170**] Primary Care Dr. [**Last Name (STitle) 68080**] ([**Telephone/Fax (1) 92142**] in [**2-14**] weeks Cardiologist Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3342**] in [**2-14**] weeks Please call your cardiologist and primary care provider to schedule your follow-up/postoperative visits. Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2111-5-11**] Name: [**Known lastname 14474**],[**Known firstname 1034**] Unit No: [**Numeric Identifier 14475**] Admission Date: [**2111-5-7**] Discharge Date: [**2111-5-12**] Date of Birth: [**2050-6-20**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 265**] Addendum: Just prior to being discharged on [**2111-5-11**], Mr. [**Known lastname **] developed atrial fibrillation. This was treated with intravenous betablockade with good effect. Amiodarone po was initiated. Mr.[**Known lastname 14476**] rhythm converted to NSR. No further episodes of atrial fibrillation occurred. Dr.[**First Name (STitle) **] cleared him for discharge to home on POD# 4. All follow up appointments were advised. Discharge Disposition: Home With Service Facility: [**Location (un) 437**] VNA [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2111-5-12**] Name: [**Known lastname 14474**],[**Known firstname 1034**] Unit No: [**Numeric Identifier 14475**] Admission Date: [**2111-5-7**] Discharge Date: [**2111-5-12**] Date of Birth: [**2050-6-20**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 265**] Addendum: Due to the episode of atrial fibrillation yesterday, medications for discharge were ammended. B-Blocker dosage increased. Amio started. Lisinipril discontinued. Please refer to discharge summary for dosages and frequency. Discharge Disposition: Home With Service Facility: [**Location (un) 437**] VNA [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2111-5-12**] Name: [**Known lastname 14474**],[**Known firstname 1034**] Unit No: [**Numeric Identifier 14475**] Admission Date: [**2111-5-7**] Discharge Date: [**2111-5-12**] Date of Birth: [**2050-6-20**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 265**] Addendum: Discharge Medications: see below Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 months. Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp:*30 Tablet(s)* Refills:*0* 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day for 7 days: then decrease to 2 tabs daily x 7 days, then 1 tab daily for cardiologist to review. Disp:*28 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 437**] VNA [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2111-5-12**]

[ "401.9", "V45.82", "414.01", "518.0", "530.81", "412", "411.1", "272.4", "427.31" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.22", "36.15", "88.72" ]

icd9pcs

[ [ [] ] ]

12302, 12480

3676, 5235

330, 522

6831, 6927

2277, 3653

7992, 9474

1468, 1606

10940, 12279

6745, 6810

5261, 5324

6951, 7969

1621, 2258

1172, 1332

280, 292

550, 1101

1363, 1370

1123, 1152

1386, 1452

54,193

175,115

26807

Discharge summary

report

Admission Date: [**2174-10-19**] Discharge Date: [**2174-10-28**] Date of Birth: [**2095-6-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2763**] Chief Complaint: Weakness, s/p fall, "I was about to die." Major [**First Name3 (LF) 2947**] or Invasive Procedure: CVVHD. History of Present Illness: 79 yo Italian speaking male with h/o cirrhosis [**12-20**] Hep C, who presented with chief complaint of weakness to [**Location (un) 745**] [**Hospital 3678**] Hospital ([**Telephone/Fax (1) 65997**]) after falling in bathtub in the water. Per OSH recs, he said he "didn't feel right" and his "legs were weak" and he lowered himself into the tub. He hit his left shoulder (unclear how if he lowered himself down). Did not hit his head, no LOC. He was unable to pull the cord for help and yelled until a neighbor came to his assistance. Paramedics took him to [**Location (un) 745**] [**Hospital 3678**] hospital ED for evaluation. . At OSH, he underwent a head CT which was normal, and CXR that was concerning for PNA. He was thought to be in heart failure and was given lasix 40mg IV. He received azithromycin 500mg IV x1 and ceftriaxone 1g IV x1. He was also given 1.5L NS. Labs were noteworthy for Na 129, Cr of 1.6, and a troponin of 0.12 (last measured here at 0.01). His SBP ~90, which is his baseline. EKG there demonstrated RBBB. . In the ED at [**Hospital1 18**], initial vs were: T97.9 P96 BP 101/68 R30 O2 sat 97% 2L NC. Labs were notable for troponin of 0.05 and pt received ASA 325mg PO x1, no heparin per discussion with cardiology in ED. RBBB seen on OSH EKG, but was not noted on EKG at [**Hospital1 18**]. His T. bili was noted to be elevated 3.8 (previously 2.2). Pt underwent RUQ US, L shoulder plain film, and diagnostic paracentesis. He was admitted to medicine/liver service for evaluation fo [**Last Name (un) **] and pneumonia. VS on transfer were T 97.9 P95 BP99/57 R32 O2sat 97% RA. . On the floor, pt states he feels "normal." When prompted, he complains of L shoulder pain. No chest pain or abdominal pain. He says his abdominal distention has gone down. When asked about fevers or SOB, he states it depends on "the winds and drafts" coming in and out of the room. Denies DOE. He endorses chronic cough, non-productive, and is unable to describe it more. Sometimes it is so severe he feels like vomiting. No nausea. His last bowel movement looked "normal"- unable to detail further. . His friend who [**Name2 (NI) **] for him ([**Name (NI) **]) is present and states the pt eats little, only fruit and water. [**Doctor Last Name **] is concerned that the patient can no longer live alone and properly take care of himself and he needs more help at home. He states the patient is more confused than his baseline. . Of note, pt was recently admitted [**Date range (1) 65998**] for acute kidney injury for which he was given albumin with an appropriate response. He was also treated for pneumonia/UTI completing 7 day course of levofloxacin [**2174-10-7**]. He was started on diuretics at that time for increased weight gain due to his cirrhosis. . Review of sytems: (+) LLE is chronically "sick because of diabetes" -he has decreased sensation and is unable to walk on it without a walker (-) Denies fever, chills, recent weight loss or gain. Denies headache. Denied chest pain or tightness, palpitations. No dysuria. Denied arthralgias or myalgias. Past Medical History: -PERCUTANEOUS CORONARY INTERVENTIONS: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] in mid-RCA on [**2172-6-5**]. Mid LAD shows 50% long lesion with a 90% discrete 1st diagonal lesion. OM1: 70% long lesion, OM2: 80% ostial lesion, and OM3: 70% ostial lesion --Diabetes mellitus Type II with peripheral neuropathy --peripheral vascular disease --Chronic hepatitis C genotype 2a/2c (untreated) with cirrhosis portal hypertension and splenomegaly. EGD [**12/2172**] revealing esophageal and gastric varices. --Chronic mild anemia and thrombocytopenia (thought secondary to splenic sequestration) --left portal vein thrombosis (seen U/S on [**2174-6-10**]) --left testicular mass versus recurrent hernia ([**3-/2174**]), was supposed to be evaluated by ultrasound --osteoarthritis --varicose veins Social History: Smoke: never EtOH: never Drugs: never Italian-speaking Lives/works: The patient lives alone. He walks with a walker. He is divorced and estranged from his children. His friend [**Name (NI) **] stops by frequently and [**Name (NI) **] for him but is unable to completely care for him. Family History: non-contributory Physical Exam: Physical Exam on admission [**2174-10-19**]: VITALS: T: 96.6 BP: R 91/60 L 98/60 P:86 R:30 O2: 100% RA GENERAL: Alert, oriented, no acute distress, occassionally perseverates on story of how he fell SKIN: nbruise on L shoulder, no jaundice, chronic skin changes in LE b/l, no open lesions, HEENT: Sclera mildly icteric, dry MM, no jaundice under tongue, oropharynx clear Neck: supple, no LAD Lungs: Good inspiratory effort. Faint diffuse crackles bilaterally except at left base. No wheezes or ronchi. CV: Soft heart sounds, regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tense, distended with ascitic fluid, non-tender, small reducible umbilical hernia, non-distended, bowel sounds present, no rebound tenderness or guarding, no hepatomegaly, no caput. Ext: warm, well perfused, 1+ DP pulses, 2+ pitting edema in LE to knees bilaterally, L shoulder with full ROM, no effusion at joint Neuro: no asterixis, CN II-XII intact, 5/5 strength in UE b/l, 5/5 strength in RLE, 4/5 strength in LLE, sensation decreased in LLE compared to RLE. Pertinent Results: OSH labs [**2174-10-19**]: 6.9 >------< 84 31.9 129 94 57 -------------<161 5.5 21 1.6 Cholesterol 90 Lipase 29 Amylase 41 LFTs: AST 110, ALT 32, Alk Phos 220, T bili 4.6, D bili 2.9, Alb 2.6 . CK 105, CKMB 1.0 (nl), Trop 0.12 (0.04-0.78 indeterminant per OSH ranges) . Utox negative [**Hospital1 18**] LABS: Labs on admission [**2174-10-19**]: WBC-7.3 RBC-3.19* Hgb-9.4* Hct-28.6* MCV-90 MCH-29.3 MCHC-32.7 RDW-21.7* Plt Ct-89* Neuts-73* Bands-1 Lymphs-12* Monos-9 Eos-0 Baso-0 Atyps-5* Metas-0 Myelos-0 PT-15.9* PTT-33.1 INR(PT)-1.4* Glucose-156* UreaN-53* Creat-1.5* Na-130* K-5.1 Cl-97 HCO3-25 AnGap-13 ALT-30 AST-90* CK(CPK)-92 AlkPhos-167* TotBili-3.8* Albumin-2.3* Calcium-7.9* Phos-3.5 Mg-2.1 Cardiac enzymes: [**2174-10-19**] 06:45AM BLOOD cTropnT-0.05* [**2174-10-19**] 03:40PM BLOOD cTropnT-0.02* [**2174-10-20**] 06:50AM BLOOD cTropnT-0.02* MICRO: [**2174-10-19**] UCx: no growth [**2174-10-19**] Peritoneal fluid: NGTD [**2174-10-20**] BCx: NGTD IMAGING: [**2174-10-19**] L shoulder xray (AP, neutral, axillary): 1. No acute fractures or dislocation of the left shoulder joint. 2. Moderate degenerative change at acromioclavicular joint and mild glenohumeral degenerative change. [**2174-10-19**] CXR: Low lung volumes persist. Hilar prominence and cephalization of flow suggest pulmonary edema, which may be accentuated due to low lung volumes. The heart remains enlarged and likely somewhat accentuated by the low lung volumes. Previously seen right lung peripheral reticular interstitial opacity is less prominent on the current study. While reticular interstitial opacity in the peripheral right lung is less prominent as compared to the prior exam, subtle peripheral reticular opacities persist bilaterally, which may be secondary to component of chronic interstitial lung disease. _____________ ICU course labs/reports are present in [**Hospital1 1388**] [**Hospital 58922**] Medical Record. Brief Hospital Course: FLOOR COURSE [**Date range (1) 65999**]: 79 yo italian speaking male with h/o cirrhosis [**12-20**] Hep C, CAD s/p fall and with acute renal failure and elevated T bili. . # Fall - appears to be mechanical rather than syncopal as pt denies dizziness or LOC prior to episode. He felt weak, possibly due to poor nutrition or leg weakness from his diabetes. There may have been a component of orthostatis due to aggressive diuresis after last admission. Only injury was to shoulder without fracture or dislocation. CT head at OSH negative. Physical therapy evaluated patient and recommended rehab. . # NSTEMI/Troponin leak/RBBB - RBBB noted on OSH EKG, likely due to rate 118bpm. RBBB not noted on EKG at [**Hospital1 18**]. Pt denies chest pain but has h/o CAD with stenting of RCA in [**2171**]. Troponin mildly elevated, possibly due to renal failure. Received ASA 325mg but no heparin needed per cardiology (discussed in ED). Started aspirin 325mg until troponin trended down, then returned to home dose 81mg. Continued statin, niacin SR. . # Acute kidney injury - Pt with elevated creatinine 1.5 on admission. Cr 0.9-1.1 during last admission but 0.6-0.8 prior. FeUrea suggests pre-renal etiology and per friend, pt has poor intake. [**Month (only) 116**] also be due to hepatorenal syndrome or ATN although no known new insults/meds. ([**2174-9-27**] ECHO with EF >55%). Pt was challenged with albumin 50g x2 and 25gm x1 with improvement in Cr to 1.0. He was given lasix 20mg PO x1 on [**10-22**] with good urine output. Spironolactone was held through hospitalization. . # Hyponatremia - Na improved with albumin + NS suggesting hypervolemic hyponatreima, esp given pt's total body fluid overload. Unlikely due to primary polydipsia as pt has low PO fluid intake per friend. [**Name (NI) **] clear reason for pt to have SIADH. . # Ascites - pt had diagnostic paracentesis in ED, labs suggest transudate c/w known cirrhosis and portal hypertension. No evidence of SBP. Pt is not uncomfortable and abdomen is not tense. No therapeutic tap done on floor prior to [**2174-10-24**]. . # Cirrhosis - pt with known cirrhosis due to Hep C. AST elevated without ALT increase. T bili increased but RUQ US does not show obstruction. RUQ US PRELIM demonstrates persistent thromboses. Per friend, pt is confused but he does not appear encephalopathic. T bili began to trend downwards. INR remained stable 1.3-1.6. He was given lactulose and remained oriented. Nadolol, which he takes for his gastric varices, was stopped [**2174-10-23**] due to frequent episodes of hypotension with SBP 70s. . # Anemia - pt with falling Hct (baseline 26-29). Pt had Hct decrease from 35 to 27 sometime between [**Month (only) 216**] and [**Month (only) **] [**2173**]. He had no evidence of active bleeding on morning of [**2174-10-23**] and was transfused 1 unit blood for Hct ~23 without reaction. . # Infiltrate on admission CXR - Pt completed 7 day levo course for PNA last admission. CXR with improving R opacity (likley prior PNA) and persistent peripheral reticular opacities. He was saturating well. He remained afebrile without leukocytosis. Tachypnea is most likely due to lying flat with ascites. No antibiotics were given during his floor course. . # Living situation - friend concerned about patient's ability to care for himself at home. Pt concerned about cost of Nursing home -SW evaluation for available home services/home health aide . # DM - c/b with peripheral neuropathy. His avandaryl was held and he started on humalog ISS. . # Hypothyroidism - continued levothyroxine # Communication: Patient, friend [**Name (NI) **] . . On [**2174-10-24**], the pt had 2 episodes of BRBPR, complained of epigastric pain. He was hyperkalemic, tachypneic with RR 40s, and the pt was noted to be in respiratory distress. Lactate 10.4 on ABG. He was transferred to MICU [**Location (un) 2452**] for further evaluation and management. ************** In the ICU: HD line placed by renal (Right IJ). Received CVVHD with aggressive regimen to decrease K+. On broad-spectrum antibiotics. Lactate elevated, then improving. Transfused blood nad platelets and FFP as needed. Transplant surgery consulted - signed off, no [**Location (un) **] issues. Hepatology's consultation noted: continue octreotide drip, protonix drip, and transition to CMO. Multiple family updates occurred, with patient's son and daughter and his friend [**Name (NI) **]. A family meeting was held on [**10-28**] with the patient's son and daughter and his friend [**Name (NI) **] and an Italian interpreter and a social worker. Family understood the patient's critical illness and acuity. Goals of care were discussed; patient was determined to be CMO. All at the meeting were in agreement. Social work and ethics consultation service involved in end-of-life care. Comfort measures only: Pressors discontinued on [**10-28**]. Family at bedside. Patient had morphine available for comfort. Patient expired on [**2174-10-28**] in the MICU. Medications on Admission: (per d/c summary [**2174-10-4**], pt unable to recall meds, no changes since discharge per friend): 1. Atorvastatin 10 mg DAILY 2. Niacin SR 500 mg Capsule [**Hospital1 **] 3. Nadolol 40 mg daily 4. Levothyroxine 50 mcg daily 5. Aspirin 81 mg daily 6. Furosemide 20 mg daily - held on admission 7. Spironolactone 50 mg daily - held on admission 8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID: titrate to 3 loose bms daily 9. Avandaryl 4-2 mg daily - change to insulin 10. Levofloxacin - ended [**2174-10-7**] Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: s/p fall ARF Hepatitis C cirrhosis, ascites GI bleed Hypotension Elevated lactate Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2174-11-3**]

[ "456.20", "995.92", "443.9", "276.1", "571.5", "244.9", "789.59", "518.81", "785.59", "V45.82", "038.9", "276.3", "285.1", "357.2", "401.9", "452", "250.60", "428.0", "287.5", "276.2", "570", "584.9", "070.54", "426.4", "414.01", "410.71", "572.3", "276.7" ]

icd9cm

[ [ [] ] ]

[ "38.93", "39.95", "42.33", "54.91", "96.04", "38.95", "38.91", "96.72" ]

icd9pcs

[ [ [] ] ]

13325, 13334

7738, 12725

13459, 13468

5783, 6500

13520, 13646

4649, 4667

13297, 13302

13355, 13438

12751, 13274

13492, 13497

4682, 5764

6517, 7715

277, 385

3212, 3497

413, 3194

3519, 4332

4348, 4633

27,981

104,988

27509

Discharge summary

report

Admission Date: [**2160-11-7**] Discharge Date: [**2160-11-12**] Date of Birth: [**2111-6-10**] Sex: M Service: MEDICINE Allergies: Lasix Attending:[**First Name3 (LF) 2009**] Chief Complaint: Tachycardia, ?GI bleed Major Surgical or Invasive Procedure: Upper Endoscopy10/17/08 History of Present Illness: Per MICU Admit Note 49M h/o EtOH cirrhosis, portal hypertension, esophageal varices c/b GI bleeding s/p banding in '[**58**] and in '[**59**] went to cardiology outpatient clinic today complainig of recurrent syncope, found to be in sinus tachycardia @ 140s and sent to ED for evaluation. Of note, recently admitted for UGIB [**2160-8-29**] - [**2160-8-31**], underwent EGD with evidence of possible [**Doctor First Name 329**] [**Doctor Last Name **] tear but no active bleeding source and no varices. Primary complaint is nausea and vomiting for over 1 year. He may vomit up to 12x per day on occasion, and this has worsened this past week. It can occur any time during the day. Notes that it starts with nausea, then coughing and gagging, then emesis. Subsequenly has had very poor PO intake recently. Denies evidence of black or bright red blood in his emesis; however notes that he has had increasing black stools for 5 days, but no BRBPR, and this has coincided with a slight worsening of his symptoms. Denies h/o diabetes, although reports he was borderline in the past by his PCP. Also reports nearly 12 episodes of syncope over the past 10 months with no clear etiology. Typical scenario is he arises from standing, feels lightheaded, and passes out ("collapses") briefly than awakens feeling fatigued but not confused. Last syncopal episode was this morning walking to the bathroom. Prior to syncope events, other than lightheadedness he denies any prodrome including no chest pain, SOB, palpitations, nausea, vomiting, seizures, confusion, incontinence, tongue biting. Denies any head trauma. A few of the episodes have been witnessed by his mother, who reported no seizure like activity. Had been planned for outpatient neuro and cards evaluation. Also with a history of sinus tachycardia that Hepatology in the absence of clear evidence of volume depletion. In the ED, he was afebrile and normotensive with ECG revealing sinus tach 140s. Exam with mild asterixis (endorses incomplete compliance with lacutlose), nontender abdomen, and G+ melanotic appearing stool in the rectal vault. Hct was 27, near his baseline. He received 2L NS with improvement in his HR to 120s. Hepatology consulted who recommended PPI, octreotide gtt, and cipro for empiric SBP treatment; admit to ICU for EGD today. ROS per above, otherwise negative for jaundice. Does report mild diffuse abominal pain and possibly recent subjective fevers, chills. States last EtOH use 8 months ago. Past Medical History: - ETOH cirrhosis with known portal HTN and hx Grade I-II varices and gastropathy s/p banding - partial portal vein thrombosis [**8-26**] - alcoholic hepatitis - Upper GI bleed from distal esophagitis - Ascites with 2 large volume paracentesis (8 liters each time per patient) in [**Month (only) 216**] and [**2157-9-22**], but no h/o SBP - lower GI bleed from hemorrhoids - iron deficiency anemia - umbilical hernia - depression - HTN - s/p appy Social History: Long history of EtOH abuse. Last alcoholic drink reportedly 8 months ago. Driving licensce suspended due to EtOH related driving. Denies any other ilicit drug use or smoking. Lives with his mother and currently divorced. Formerly worked as an electrician. No tobacco use. Family History: Alcoholism in mother and aunt. Mother with lung cancer (undergoing chemotherapy). Physical Exam: Per MICU Admit Note Afebrile 120 reg 148/86 13 O2sat high 90s on RA General: WDWN, NAD, breathing comfortably on RA HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink Neck: supple, trachea midline, no thyromegaly or masses, no LAD Cardiac: tachycardic, regular, s1s2 normal, no m/r/g, no JVD Pulmonary: CTAB Abdomen: +BS, soft, nontender, nondistended, unable to appreciate ascites or HSM, no spiders or caput Extremities: warm, 2+ DP pulses, no edema Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves all extremities, no asterixis, mild tremulousness Pertinent Results: [**2160-11-7**] 12:30PM WBC-3.1*# RBC-3.25* HGB-8.8* HCT-27.1* MCV-83 MCH-27.0 MCHC-32.4 RDW-20.0* [**2160-11-7**] 12:30PM TSH-2.8 [**2160-11-7**] 12:30PM ALBUMIN-4.1 CALCIUM-9.6 PHOSPHATE-0.5*# MAGNESIUM-1.2* [**2160-11-7**] 12:30PM ALT(SGPT)-45* AST(SGOT)-130* CK(CPK)-63 ALK PHOS-301* TOT BILI-3.3* [**2160-11-7**] 12:30PM GLUCOSE-117* UREA N-6 CREAT-0.8 SODIUM-139 POTASSIUM-3.0* CHLORIDE-97 TOTAL CO2-29 ANION GAP-16 [**2160-11-7**] 06:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-POS mthdone-NEG [**2160-11-7**] 08:15PM HCT-24.0* CXR [**2160-11-7**]: AP CHEST: Lung volumes are low. There is no focal lung consolidation, pleural effusion, or pneumothorax. The cardiomediastinal silhouette is unchanged, and the pulmonary vasculature appears unremarkable. IMPRESSION: No acute cardiopulmonary process. The study and the report were reviewed by the staff radiologist. ECHO [**2160-11-8**]: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60%). There is no left ventricular outflow obstruction at rest or with Valsalva. 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. There is no mitral valve prolapse. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Liver/GB US w/ Doppler [**2160-11-8**]: FINDINGS: Son[**Name (NI) 493**] assessment of the right upper quadrant is significantly limited by patient body habitus and significant bowel gas. The liver is not well seen. Doppler assessment is unable to be performed at this time. The spleen has enlarged measuring 13.4 cm in length. The right kidney measures 11.4 cm, and the left kidney measures 10.9 cm. There is no hydronephrosis, renal stones, or masses. A small amount of intra-abdominal ascites is evident. IMPRESSION: 1. Very limited views of the liver again demonstrate findings compatible with cirrhosis. 2. Splenomegaly. 3. The portal vein cannot be assessed secondary to technical limitations as described above. The patient will return for Doppler assessment once bowel gas has decreased. 4. Mild ascites. [**2160-11-11**] Gastric Emptying Study: INTERPRETATION: Following the oral ingestion of a low-fat egg white meal consisting of 4 oz of egg whites and 120 ml water, the patient was placed supine beneath the gamma camera. Continuous anterior and posterior images of tracer activity in the stomach and bowel were recorded for 45 minutes. Delayed anterior and posterior images were obtained at 2, 3 and 4 hours. Residual tracer activity in the stomach is as follows: At 45 mins 65% of the ingested activity remains in the stomach At 2 hours 56% of the ingested activity remains in the stomach At 3 hours 26% of the ingested activity remains in the stomach At 4 hours 23% of the ingested activity remains in the stomach There is no evidence of gastroesophageal reflex. After prompt emptying during initial 20 minutes, subsequent emptying is gradual. Persistent activity is noted in the gastric fundus with slow redistribution into the gastric antrum. IMPRESSION: Delayed gastric emptying. Brief Hospital Course: A/P: 49M h/o EtOH cirrhosis, GI bleeding s/p variceal banding presents with tachycardia and ?GI bleeding. . # Hematemesis, upper gastrointestinal bleed: Concern for upper GI bleed in patient with cirrhosis and portal hypertension with evidence of [**Doctor First Name 329**] [**Doctor Last Name **] tear on [**2160-8-29**] EGD, however no evidence at that time of gastric or esophageal varices. Other possible sources include PUD (altough on max dose PPI as outpatient) or gastritis/esophagitis. Contribting factor is likely underlying coagulapathy and thrombocytopenia from liver disease. Started on IV PPI [**Hospital1 **] and an Octreotide gtt. Pt received 1 unit packed RBCs on [**11-7**] with a response of his hematocrit from 22.7 to 24.0. EGD was performed [**2160-11-7**] that revealed erythema and congestion in the gastroesophageal junction compatible with [**Doctor First Name 329**] [**Doctor Last Name **] tear, normal mucosa in the stomach and duodenum. Octreotide and Cipro IV were then discontinued. IV Pantoprazole was continued [**Hospital1 **]. Despite initial tachycardia, patient remained hemodynamically stable. On [**2160-11-9**] Nadolol was restarted. The patient was subsequently transferred out of the ICU to the medical floor on [**2160-11-9**]. He was continued on PO Pantoprazole and his hematocrit was montiored and remained stable, with no recurrence of melanotic stools. # Dehydration: Mr. [**Known lastname 37217**] presented with sinus tachycardia, most likely related to intravascular volume depletion due to emesis and poor PO intake and possibly GI bleeding; notably he was IVF responsive in the ED. Although denies EtOH use, per Hepatology there has been concern in past for indiscretion. Also consider infection in patient with h/o ascites and reports of intermittent abdominal pain and subjective fevers. On nadolol as outpatient but no recent dose change to suggest beta-blocker withdrawal. Also consider PE especially given h/o portal thrombosis, however no other pulmonary symptoms or evidence DVT. Nadolol was initially held as above. IVF resuscitation was peformed with NS. Given concern for withdrawal, patient was written for Ativan prn CIWA scale >8. Liver U/S with dopplers per liver service was obtained as a possible infectious or inflammatory source. There was minimal [**Last Name (LF) 67283**], [**First Name3 (LF) **] a diagnostic paracentesis was not peformed. Cipro IV was given initially as above, then discontinued when the etiology was not a variceal bleed. After transfer to the floor, he was monitored on telemetry, and was given a 1 L NS bolus for concern for hypovolemia [**2-23**] decreased PO intake. His heart rate generally remained in the 70s to 80s on the medical floor, and he was not orthostatic on the day of discharge. # Syncope due to orthostatic hypotension: Differential includes vasovagal, orthostatic hypoperfusion, cardiogenic arrythmia, or seizure. Sinus tach supports intravascular volume depletion as likely cause. No prior h/o cardiac disease that would suggest malignant arrythmia and no current chest discomfort. No prior h/o seizure disorder or other CNS disease. ECHO was obtained and did not reveal a new wall motion abnormality or other etiology for his syncope. TSH normal at 1.7. Cardiac enzymes cycled and negative without acute changes on ECG. Hemaglobin A1c normal. Tox screen positive for amphetamine. Patient was seen by electrophysiology, and had an echocardiogram which showed a normal EF of 60%. Pt was borderline orthostatic on [**11-10**] and received 1 L fluid resucitation, but not orthostatic on [**11-11**] or [**11-12**]. Troponins were negative x 3. . # Chronic emesis: GERD was considered as an etiology, although on PPI chronically. EGD did not reveal another potential etiology. Hemoglobin A1c 4.6%. Gastic emptying study [**11-11**] showed delayed gastric emptying, and patient was started on Reglan QID (with meals and at HS) to promote gastric mobility. He was also continued on his high dose PPI. He has scheduled followup with GI on [**2160-12-2**]. . # Cirrhosis: His cirrhosis is due to EtOH, and patient reports 6+ months of sobriety. Continued abstinence was encourged. He is followed by Dr. [**Last Name (STitle) **] of Hepatology. He has a history of large ascites requiring paracentesis; also portal vein thrombosis. Abd ultrasound showed mild ascites. He was started on Cipro for SBP prophylaxsis, and this was stopped after he was transfterred to the floor. His nadalol was decreased from 40 to 20mg. He has follow up scheduled with hepatology. . # Depression: He was contineud on his home citalopram. Medications on Admission: Acamprosate 666 mg PO TID Nadolol 20 mg Tablet po daily Viokase 16 1870 mg PO TID with meals, and take 935 mg prn with snacks Omeprazole 40 mg po BID Folate 1 mg po daily MVI po daily Sucralfate 1 gram po BID Citalopram 20 mg po daily Lactulose 30 ml po tid Lisinopril 5 mg po daily Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): titrate to 3 loose stools per day. 4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*2* 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Acamprosate 333 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO three times a day. 8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Folbalin Plus 2.5-25-2 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear Syncope Sinus Tachycardia Chronic vomiting Delayed Gastric Emptying Secondary: Cirrhosis Discharge Condition: fair, ambulating, tolerating PO Discharge Instructions: You were admitted to the hospital for rapid heart rates, syncope (passing out) and GI bleeding. You had an upper endoscopy that showed an old tear that was likley from vomiting. Your heart rhythm was monitored, and did not show a clear etiology for your rapid heart rate and episodes of passing out. You had an upper endoscopy that showed a small tear that may have been from vomiting, and likley was the source of your bleeding. You had a chest x-ray, EKG, echocardiogram, and abdominal ultrasound that did not show an explanation of your symptoms. . A Gastric Emptying Study showed that your stomach has delayed gastric emptying, meaning that food stays in your stomach longer than average, which may explain why you have had chronic vomiting. You were started on a medication called Reglan to promote gastric emptying. . You are being sent home with a 1 month loop/event recorder to monitor your heart rhythm. Do not drive until you are seen by electrophysiology. . The following changes were made to your medications: Nadalol was decreased to 20 mg per day Lisinopril was stopped Reglan was started for your delayed gastric emptying Viokase was stopped . Take your medications as prescribed. . Follow up as listed below. . Call your doctor or return to the emergency department if you experience any of the following: - Syncope or passing out - Chest pain, shortness of breath, or palpitations - Black or bloody bowel movements - Continued vomiting, with an inability to eat and take liquids - Any other new or concerning symptoms Followup Instructions: See your primary care doctor: DR. [**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Thursday [**11-20**] at 10:15 to discuss the issues raised during this hospitalization. The clinic number is [**Telephone/Fax (1) 36715**]. They requested you call Medical Records at ([**Telephone/Fax (1) 34129**] and arrange to have your records faxed to his office before your visit. . Follow up with Dr. [**First Name8 (NamePattern2) 892**] [**Last Name (NamePattern1) **] in Electrophysiology to discuss your rapid heart rates and episodes of passing out. You have an appointment [**12-25**], at 11:20 AM on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Building. The results of your loop recorder should be available at that time. . Follow up with Gastroenterology (GI) to discuss your delayed gastric emptying. You have an appointment on [**11-25**] at 1:00 PM with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4539**] on the [**Hospital Ward Name 516**] in the [**Hospital Unit Name 1824**] on the [**Location (un) 453**]. . You have a follow up appointment with Dr. [**Last Name (STitle) 34448**] (Hepatology) on [**12-17**] at 3:10 PM at [**Last Name (NamePattern1) **] on the [**Location (un) **].

[ "289.4", "427.89", "530.7", "276.51", "536.8", "572.3", "571.2", "780.2" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

13657, 13663

7763, 12426

290, 316

13876, 13909

4290, 7740

15498, 16777

3599, 3683

12762, 13634

13684, 13855

12452, 12737

13933, 15475

3698, 4271

228, 252

344, 2824

2846, 3294

3310, 3583

65,427

197,665

37785

Discharge summary

report

Admission Date: [**2179-11-17**] Discharge Date: [**2179-11-23**] Date of Birth: [**2095-8-8**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine / Percocet / Oxycontin Attending:[**First Name3 (LF) 1505**] Chief Complaint: exertional fatigue and SOB Major Surgical or Invasive Procedure: [**2179-11-17**] AVR ( 25 mm [**Company 1543**] Mosaic porcine) [**2179-11-17**] mediastinal re-exploration History of Present Illness: 84 year old male with known aortic stenosis, followed with serial echo's over the last 6 years, now with worsening exertional fatigue and shortness of breath. Echo in [**2179-6-4**] showed severe aortic stenosis with [**Location (un) 109**] 0.6cm2 and moderate aortic regurgitation. Asked to evaluate for aortic valve replacement. Past Medical History: Severe Aortic Stenosis Hypertension Hyperlipidemia Gastroesophageal reflux disease Benign prostatic hypertrophy - urinary incontinence Osteoarthritis Bladder stone, on chronic ABX Skin Cancer s/p removal on nose PSH: Appendectomy Umbilical and hernia repair Cataract surgery Social History: Occupation: Retired mail carrier Last Dental Exam: Full dentures Lives with: Wife [**Name (NI) **]: Caucasian Tobacco: Denies ETOH: Rare Family History: Non-contributory Physical Exam: Physical Exam: Vitals - refer to PAT sheet Height: 5'7" Weight: 175 lb General: Well-developed, well-nourished male in no acute distress. Slight urine odor on patient Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur - 3/6 SEM Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] umb/abd. hernia Extremities: Warm [X], well-perfused [X] Edema Varicosities [X] superficial Neuro: Grossly intact, alert and oriented x 3 Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 1+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left: Transmitted murmur Pertinent Results: [**2179-11-17**] 10:06AM HGB-12.5* calcHCT-38 [**2179-11-17**] 10:06AM GLUCOSE-110* LACTATE-0.9 NA+-139 K+-4.3 CL--100 [**2179-11-17**] 01:20PM FIBRINOGE-258 [**2179-11-17**] 01:20PM PT-14.8* PTT-39.6* INR(PT)-1.3* [**2179-11-17**] 01:20PM PLT COUNT-137*# [**2179-11-17**] 01:20PM WBC-9.0 RBC-2.49*# HGB-7.9*# HCT-22.9*# MCV-92 MCH-31.5 MCHC-34.2 RDW-13.8 [**2179-11-17**] 02:38PM UREA N-23* CREAT-1.3* CHLORIDE-110* TOTAL CO2-24 [**2179-11-22**] 01:05AM BLOOD WBC-8.2 RBC-2.98* Hgb-9.3* Hct-27.1* MCV-91 MCH-31.3 MCHC-34.5 RDW-14.0 Plt Ct-246 [**2179-11-22**] 01:05AM BLOOD Plt Ct-246 [**2179-11-21**] 06:14AM BLOOD PT-12.2 PTT-24.2 INR(PT)-1.0 [**2179-11-22**] 01:05AM BLOOD Glucose-112* UreaN-23* Creat-1.3* Na-140 K-4.0 Cl-108 HCO3-25 AnGap-11 Radiology Report CHEST (PORTABLE AP) Study Date of [**2179-11-21**] 5:53 AM [**Hospital 93**] MEDICAL CONDITION: 84 year old man s/p AVR with chest pain and abdominal distension REASON FOR THIS EXAMINATION: ? infiltrate versus ptx versus Final Report SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Chest pain, abdominal distension, status post AVR. Comparison is made with prior study performed a day earlier. Cardiomediastinal contours are unchanged with mild cardiomegaly. There is no pneumothorax. Small right pleural effusion is unchanged. Left lower lobe aeration has improved. There is mild vascular congestion. Calcification in the right mid lung is unchanged. Sternal wires are aligned. DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**] Approved: SUN [**2179-11-21**] 2:06 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 84596**]Portable TTE Age (years): 84 M Hgt (in): 68 BP (mm Hg): 105/48 Wgt (lb): 180 HR (bpm): 63 BSA (m2): 1.96 m2 Indication: Left ventricular function. Myocardial infarction. Pericardial effusion. Tape #: 2009W076-1:11 Machine: Other Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 2.9 cm <= 5.6 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Sinus Level: 1.9 cm <= 3.6 cm Aortic Valve - LVOT diam: 1.6 cm Findings LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. RIGHT VENTRICLE: RV not well seen. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR leaflets move normally. Trace AR. MITRAL VALVE: Mitral valve leaflets not well seen. Trivial MR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions : There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis leaflets appear to move normally. Trace aortic regurgitation is seen. The mitral valve leaflets are not well seen. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: poor technical quality. Left ventricular function is probably normal, a focal wall motion abnormality cannot be fully excluded. The right ventricle is not well seen. Aortic bioprosthesis opens well with trace-mild aortic regurgitation (similar to immediate post-operative TEE). Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2179-11-22**] 09:39 ?????? [**2173**] CareGroup IS. All rights reserved. Brief Hospital Course: Admitted [**11-17**] for Aortic valve replacement surgery with Dr. [**Last Name (STitle) **], please see OR report for details. In summary he had aortic valve replacement with 25mm [**Company 1543**] Mosaic porcine valve. His bypass time was 92 minutes with a crossclamp time of 87 minutes. he tolerated the operation well and was transferred to the cardiac surgery ICU in stable condition. He bleed in the immediate post-op period and was taken back to the operating room for re-exploration. He again returned to the cardiac ICU in stable condition. He awoke neurologically intact was weaned from the ventilator and extubated on the day after surgery. He remained hemodynamically stable and was transferred to the stepdown floor on POD1. On POD3 he had a period of atrial fibrillation and beccame hypotensive. He was transferred back to the cardiac surgery ICU and cardioverted back to sinus rhythm. He stayed in ICU one additional day and then returned to the stepdown floor. Over the next few days his activity gradually increased but it was decided he would benefit from a short stay at rehabilitation. On POD # 6 he was transferred to rehabilitation. He will require a telemetry for monitoring and rehab bed. Medications on Admission: HCTZ 25 mg daily Zocor 20 mg daily Protonix 40 mg daily Flomax 0.4 mg daily Cipro 500mg [**Hospital1 **] Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen 650 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x1 week then 400mg QD x1 wk then 200mg QD. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units SQ Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 **] [**Hospital6 **] in [**Location (un) 701**] Discharge Diagnosis: AS s/p AVR(25mm [**Company 1543**] Mosaic porcine) HTN hyperlipidemia GERD BPH urinary incontinence osteoarthritis bladder calculus skin CA s/p removal on nose Discharge Condition: stable Discharge Instructions: no lotions, creams, powders or ointments on any incision shower daily and pat incision dry no driving for one month and off all narcotics no lfting greater than 10pounds for 10 weeks call for fever greater than 100.5, redness, drainage, or weight gain of 2 pounds in 2 days or 5 pounds in one week Followup Instructions: see Dr. [**Last Name (STitle) **] in [**2-5**] weeks [**Telephone/Fax (1) 6699**] see Dr. [**Last Name (STitle) **] in [**3-9**] weeks see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] please call for all appts. Completed by:[**2179-11-23**]

[ "458.29", "427.31", "997.4", "998.11", "V10.83", "424.1", "560.1", "998.12", "E878.1", "788.39", "427.32", "600.01", "788.20", "E849.7", "401.9", "594.1", "530.81" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21", "99.62", "34.03" ]

icd9pcs

[ [ [] ] ]

8744, 8831

6061, 7277

325, 435

9035, 9044

2075, 2914

9390, 9657

1269, 1288

7433, 8721

2954, 3019

8852, 9014

7303, 7410

9068, 9367

1318, 2056

259, 287

3048, 6038

463, 796

818, 1098

1114, 1253

3,470

138,384

12299

Discharge summary

report

Admission Date: [**2114-6-6**] Discharge Date: [**2114-6-13**] Date of Birth: [**2044-2-19**] Sex: F Service: female with a past medical history significant for hypertension and coronary artery disease, status post myocardial infarction who had multiple bouts of diverticulitis which prompted need for sigmoid colectomy. Center for definitive treatment of her diverticulitis. PAST MEDICAL HISTORY: 1. Hypertension 2. Coronary artery disease, status post myocardial infarction, status post percutaneous transluminal coronary angioplasty 4. Hypothyroidism 5. Hodgkin's disease, status post x-ray therapy PAST SURGICAL HISTORY: 1. Total abdominal hysterectomy/bilateral salpingo-oophorectomy 2. Cholecystectomy 3. Appendectomy 4. Tonsillectomy and adenoidectomy ALLERGIES: CIPRO AND PENICILLIN MEDICATIONS: 1. Flagyl 2. Cardizem 3. Synthroid 4. Aspirin PHYSICAL EXAM: VITAL SIGNS: Afebrile GENERAL: No acute distress HEAD, EARS, EYES, NOSE AND THROAT: She is anicteric. NECK: No lymphadenopathy, no thyromegaly. LUNGS: Clear to auscultation. HEART: Regular rate and rhythm, no murmurs, rubs or gallops. ABDOMEN: Bowel sounds present, soft, nontender EXTREMITIES: No peripheral edema. HOSPITAL COURSE: The patient was admitted to the hospital on [**2114-6-6**] and underwent a laparoscopic assisted converted to open sigmoid colectomy. There were dense adhesions to the left sidewall that prompted the conversion from the laparoscopic approach. After the anastamosis was performed, a small amount of bleeding was noted in the LUQ. With further investigation, this appeared to be related to a small capsular tear from adhesions at the splenic flexure. Despite conservative measures, there was continued bleeding and therefore the decision was made to perform a splenectomy. The patient went to the Intensive Care Unit postoperatively. The patient was maintained on Vancomycin and Flagyl for perioperative antibiotic coverage. On postoperative day 1, the patient was weaned to extubate. On postoperative day 2, the patient continued to remain stable in the Intensive Care Unit. The patient was out of bed ambulating on postoperative day 2. On postoperative day 3, the patient began passing flatus and started on sips. On postoperative day 4, the patient was transferred to the floor in good condition. On postoperative day 5, the patient was advanced to full clears. The patient's central line was removed. The patient's Foley catheter was removed at midnight on postoperative day 5. On postoperative day 6, the patient's JP bulb was removed from the pelvis. The patient's diet was advanced to regular diet and the patient tolerated this well. She was noted to have a wound infection and her wound was opened and she was started on dressing changes. On postoperative day 7, the patient was discharged to a rehabilitation facility in good condition. DISCHARGE MEDICATIONS: 1. Clindamycin 600 mg po tid 2. Tylenol #3 1 to 2 tablets po q4h prn 3. Protonix 40 mg po qd 4. Levothyroxine 125 mcg po qd 5. Lovenox 40 mg subcutaneous q 24 hours 6. Metoprolol 75 mg po bid [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13186**], M.D. [**MD Number(1) 13187**] Dictated By:[**Last Name (NamePattern1) 6067**] MEDQUIST36 D: [**2114-6-13**] 05:48 T: [**2114-6-13**] 06:35 JOB#: [**Job Number 38378**]

[ "562.11", "998.89", "614.6", "V64.4", "682.2", "414.01", "412", "998.11", "998.59" ]

icd9cm

[ [ [] ] ]

[ "45.76", "96.6", "54.59", "54.0", "41.5" ]

icd9pcs

[ [ [] ] ]

2924, 3404

1244, 2901

649, 886

901, 1226

417, 626

71,029

157,269

12692

Discharge summary

report

Admission Date: [**2199-3-13**] Discharge Date: [**2199-3-17**] Date of Birth: [**2137-12-3**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2199-3-13**] Coronary Artery Bypass Graft x 4 (Left internal mammary artery to left anterior descending, Saphenous vein graft to diagonal, Saphenous vein graft to obtuse marginal, Saphenous vein graft to posterior descending artery) History of Present Illness: 61 year old male with one year history of exertional chest pain. Stres test performed suggested inferior wall hypokinesis.Then underwent cardiac cath which showed severe three vessel disease. Past Medical History: Coronary Artery Disease, Hyperlipidemia, Hypertension, Diabetes Mellitus, Gout, Neuropathy, Obesity, Prostate cancer status post prostatectomy, Skull fracture status post repair, Skin cancer, Remote bilateral wrist fracture, Colon polyps, status post herniorrhaphy, status post right arthroscopic knee surgery Social History: Self-employed. Remote tobacco use. Rare ETOH use. Family History: Mother with rheumatic heart disease and valve surgery. Grandfather died from myocardial infarctionat 70. Physical Exam: Vitals: 60 120/64 General: Obese, no acute distress Skin: Unremarkable Neck: Supple, full range of motion Chest: Clear lungs bilaterally Heart: Regular rate and rhythm, no murmur Abdomen: Soft, non-tender, non-distended, +bowel sounds Extremities: Warm, well-perfused, no edema Neuro: Grossly intact, non-focal Pertinent Results: [**2199-3-16**] 07:00AM BLOOD WBC-6.4 RBC-3.11* Hgb-9.2* Hct-26.9* MCV-87 MCH-29.5 MCHC-34.1 RDW-14.1 Plt Ct-131* [**2199-3-16**] 07:00AM BLOOD Glucose-117* UreaN-30* Creat-1.3* Na-139 K-4.3 Cl-102 HCO3-28 AnGap-13 [**2199-3-17**] 06:00AM BLOOD UreaN-27* Creat-1.1 Na-138 K-4.4 [**2199-3-17**] 06:00AM BLOOD Mg-2.2 Brief Hospital Course: Mr. [**Known lastname 39192**] was a same day admit and was brought to the operating room on [**3-13**] 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-operative day one he appeared to be doing well and was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. The physical therapy service was consulted for assistance with post-operative strength and mobility. The patient made good progress and was discharged home on POD 4. By the time of discharge, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. Medications on Admission: Atenolol 50mg daily, Zocor 20mg daily, Aspirin 81mg daily, Allopurinol 300mg daily, Metformin SR 1500mg daily, Exforge daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 6. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Metformin 1,000 mg Tablet,SR,[**Last Name (un) **].Retention,24 hr Sig: One (1) Tablet,SR,[**Last Name (un) **].Retention,24 hr PO once a day: titrate back up to 1500mg/day according to PCP [**Name Initial (PRE) 10700**]. Disp:*30 Tablet,SR,[**Last Name (un) **].Retention,24 hr(s)* Refills:*2* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1 weeks. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO three times a day for 1 weeks. Disp:*21 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary Artery Disease status post Coronary Artery Bypass Graft x 4 Secondary: Hyperlipidemia, Hypertension, Diabetes Mellitus, Gout, Neuropathy, Obesity, Prostate cancer status post prostatectomy, Skull fracture status post repair, Skin cancer, Remote bilateral wrist fracture, Colon polyps, status post herniorrhaphy, status post right arthroscopic knee surgery Discharge Condition: Good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 9751**] in [**2-5**] weeks Dr. [**Last Name (STitle) 8362**] in [**1-4**] weeks Completed by:[**2199-3-17**]

[ "401.9", "V10.83", "V12.72", "V58.67", "272.4", "285.9", "278.00", "357.2", "250.60", "V10.46", "287.5", "411.1", "414.01", "274.9", "V45.77" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4602, 4660

1998, 2872

332, 569

5068, 5074

1659, 1975

5478, 5655

1207, 1313

3047, 4579

4681, 5047

2898, 3024

5098, 5455

1328, 1640

282, 294

597, 791

813, 1124

1140, 1191

18,336

198,442

12453

Discharge summary

report

Admission Date: [**2185-6-20**] Discharge Date: [**2185-6-25**] Date of Birth: [**2124-4-11**] Sex: M Service: Cardiac CHIEF COMPLAINT: 1. Coronary artery disease. HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old male who was recently referred for cardiac testing prior to beginning an exercise program. He did not have any specific complaints of chest tightness, discomfort or shortness of breath. He underwent a catheterization which revealed coronary artery disease. He was admitted for elective coronary artery bypass graft. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes. 2. Hypercholesterolemia. 3. Sleep apnea. 4. Peripheral neuropathy. PAST SURGICAL HISTORY: 1. Tonsillectomy. 2. Sinus surgery. 3. Surgery for detached retina. ALLERGIES: None known. ADMISSION MEDICATIONS: 1. Enteric coated aspirin 81 mg q P.M. 2. Lantus 24 units q P.M. 3. Glucophage 500 mg. 4. .................... 160 mg q A.M. 5. Lipitor 20 mg. 6. Altace 2.5 mg. 7. Rhinocort nasal spray. HOSPITAL COURSE: The patient underwent elective Coronary artery bypass graft times two on [**2185-6-20**] with a LIMA to the LAD, saphenous vein graft to the PDA. He tolerated the procedure well and was transferred to the CICU unit in stable condition. He was extubated the same day of surgery. He was weaned off his Lopressor. He was ready for transfer to the floor on postoperative day two. He was hemodynamically stable thereafter on the floor. He did have a temperature spike on the night of postoperative day two. .................... investigation was sent. They were all negative. He had a normal white count and his urinalysis was negative. He had no signs of at this time of wound infection. His chest x-ray was negative. He continued to have fever spikes at night over the next few days with an unknown source found. The patient did report having low grade temperatures with night sweats all his life. He had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult on [**6-24**] for diabetes management. On postoperative day five he was afebrile and stable. His pain was under control with po analgesics. He was ambulating well. He was ready for discharge home. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg [**Hospital1 **]. 2. Lasix 20 mg q day for one week. 3. KCL 20 milliequivalents q day times one week. 4. Colace 100 mg [**Hospital1 **]. 5. Enteric coated aspirin 325 mg q day. 6. Levofloxacin 500 mg times one week. 7. Lisinopril 2.5 mg q day. 8. Metformin 500 mg q day. 9. Percocet one to two tablets q four to six hours prn. 10. Lipitor 20 mg qid. Follow up with Dr. [**First Name (STitle) **] primary care physician in two weeks and with Dr. [**Last Name (STitle) 70**] in six weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 2209**] MEDQUIST36 D: [**2185-6-30**] 20:46 T: [**2185-7-1**] 11:00 JOB#: [**Job Number 38684**]

[ "362.01", "413.9", "357.2", "250.60", "443.9", "272.0", "250.50", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

2232, 3051

1036, 2209

824, 1019

705, 801

153, 182

211, 557

579, 682

42,820

127,889

46254

Discharge summary

report

Admission Date: [**2205-9-10**] Discharge Date: [**2205-9-24**] Date of Birth: [**2129-3-14**] Sex: F Service: MEDICINE Allergies: Ampicillin / Ceftin / Bactrim / Zocor / Lopressor / Rezulin Attending:[**Doctor First Name 2080**] Chief Complaint: hip pain Major Surgical or Invasive Procedure: L hip spacer removal, washout, and wound closure History of Present Illness: HPI: This is a 76 year-old Female with a PMH significant for coronary artery disease (4-vessel CABG), critical aortic stenosis with bovine AVR (s/p re-do sternotomy for wound dehiscence with rib plating), s/p carcinoid tumor resection, obstructive sleep apnea (on 2L NC at nighttime), history of deep venous thrombses (IVC filter currently not on anticoagulation), hypertension, hyperlipidemia, insulin-dependent diabetes mellitus, chronic systolic heart failure (LVEF 40%) and anemia of chronic disease who has a complicated surgical history after a left subtrochanteric femur fracture repair in [**2197**] with subsequent opeartive site infection, debridement and irrigation of a left hip abscess with hardware removal and antibiotic spacer placement ([**2205-7-30**]) followed by repeat washout and antibiotic spacer exchange for on-going left septic hip joint ([**2205-8-15**]) now presenting from her rehab facility with persitent hip pain, spacer dislocation and evidence of a larger open wound. . Her infectious history begins when her left prosthetic joint speciated S.lugdenesis in [**2-/2204**] requiring washout with a retention strategy and 6-weeks of IV Vancomycin and Rifampin, followed by 3-months of Rifampin and Doxycycline. . She was subsequently re-admitted on [**2205-7-29**] with on-going left hip pain and underwent debridement and irrigation of a left hip abscess, removal of arthroplasty hardware components, antibiotic spacer placement, with VAC application for wound closure on [**2205-7-30**]. Tissue cultures at that time again noted S.lugdenesis and coagulase negative Staphylooccus. Her post-operative course was complicate by delirium, hypotension and acute renal failure and episodes of coffee-ground hematemesis without decreased hematocrit (treated for H. pylori infection) and she was discharged to rehab on IV Vancomycin for 6-weeks (on [**2205-8-9**]). . Her most recent admission to [**Hospital1 18**] was on [**2205-8-12**], at which time she returned from rehab with a decrease in her hematocrit to 22% and evidence of sanguinous drainage from her left hip. She was reportedly hypotensive to the 80s in the ED, but responsive to IV fluids and 2 units of packed red cells. She underwent an uncomplicated incision and drainage and placement of articulating antibiotic spacer on [**2205-8-15**]. Tissue cultures from her prior debridement had speciated Staphylococcus lugdunensis (similar to her prior hip infection) and her blood cultures from [**2205-8-12**] speciated two species of Staphylococcus epidermidis. Infectious disease was involved and recommended continuing the extended course of Vancomycin IV. She was discharged to rehab on [**2205-8-20**] to continue IV antibiotics. . She is now being directly admitted from clinic given on-going hip pains and evidence of a larger open wound. She was interviewed with her daughter presents. She has been doing 'okay' while at rehab. She has no fevers or chills, ocassional sweats at nighttime. She is tolearting PO intake with nausea, emesis or abdominal pain. She has no headaches or vision changes. She denies chest pain or trouble breathing. No numbness, paresthesias or new weakness in the lower extremities. She denies changes in her bowel habits. Her left hip is painful and has this pain has been escalating while at rehab; she gains some relief from Oxycodone PO. She has been working with PT at rehab, but has not ambulated since her first surgery in late [**2205-6-28**]. . ROS: Denies headaches or vision changes. No cough or upper respiratory symptoms. Denies chest pain, dizziness or lightheadedness; no palpitations. Denies shortness of breath or exertional dyspnea. No nausea or vomiting; denies abdominal pain. No dysuria or hematuria. Denies muscle weakness, myalgias or neurologic complaints. No leg swelling. Denies rashes or lesions. . Past Medical History: 1. Coronary artery disease (4-vessel CABG, [**2190**] - LIMA-LAD, RSVG-RI, OM and PLA of RCA) 2. Critical, symptomatic aortic stenosis with bovine AVR (re-do sternotomy for wound dehiscence with rib plating, [**10/2203**]) 3. Carcinoid tumor of the lung (right middle lobe, s/p resection) 4. Obstructive sleep apnea (oxygen-dependent since lung resection; utilizes 2L nasal cannula O2 only at nighttime; no BiPAP) 5. History of chronic congestive heart failure 6. History of deep venous thrombosus (in [**2176**] twice, s/p IVC filter placement; no chronic anticoagulation since [**2197**]) 7. Hypertension 8. Hyperlipidemia 9. Insulin-dependent diabetes mellitus 10. Restrictive lung disease 11. Carpel tunnel syndrome (bilateral decompressions, [**2179**]) 12. Chronic systolic heart failure (LVEF 40% in [**2205**]) 13. Anemia of chronic disease (baseline HCT 26-31%) . PAST PERTINENT SURGICAL HISTORY: 1. s/p right middle lobe resection, VATS for carcinoid tumor ([**2195-3-20**]) 2. s/p intramedullary rod fixation of left subtrochanteric femur fracture ([**2197-6-3**]) 3. s/p irrigation debridement left hip joint, arthrotomy, exchange bipolar component left hip hemiarthroplasty ([**2204-3-14**]) 4. s/p debridement and irrigation of hip abscess, removal of arthroplasty hardware components, antibiotic spacer placement, VAC application for wound closure ([**2205-7-30**]) 5. s/p debridement irrigation hip hematoma, removal of antibiotic spacer and placement of functional antibiotic spacer and application of surface VAC sponge ([**2205-8-15**]) for left septic hip joint Social History: SOCIAL HX: Patient is originally from [**Country 5881**]. Lives at home with her husband and son in [**Name (NI) 98332**] Plains. Daughter lives in [**Location 86**] and is very involved. Denies tobacco use or alcohol use; no recreational substance use. Patient is now dependent in ADLs and does not ambulate (not since [**2205-6-28**]) given her pain and hip infection issues. . Family History: FAMILY HX: Denies significant family history of cardiovascular disease, early MI, arrhythmia or sudden cardiac death. Father with a history of lung cancer. Physical Exam: ADMISSION PHYSICAL EXAM PHYSICAL EXAM: VITALS: 98.4 116/53 84 18 97% RA GENERAL: Appears in no acute distress. Alert and interactive. Well nourished appearing. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. NECK: supple without lymphadenopathy. JVD [**3-1**] above the clavicle at 90-degrees. Thyroid barely palpable. CVS: Regular rate and rhythm, II/VI holosystolic murmur at RUSB, no rubs or gallops. S1 and S2 normal. RESP: Decreased breath sounds at bases to auscultation bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. Stable inspiratory effort. ABD: soft, non-tender, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses and warm, well-perfused. Right PICC line without erythema or drainage. LEFT HIP: 15-20 cm linear incision cranial to caudal with staples in place superiorly and inferiorly. No surrounding erythema. Mid-incision there appears a 5-6 cm area of open wound with serosanguinous drainage tracking into the fascia. NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs 2+ throughout, strength 5/5 bilaterally, sensation grossly intact. Gait deferred. DISCHARGE PHYSICAL EXAM GENERAL: NAD, awake, alert, wants to go to rehab CV: RRR, S1S2, II/VI holosystolic murmur at RUSB RESP: CTABL, no wheezes or crackles ABD: soft, NTND, +BS EXT: 2+ DP pulses. R PICC line. LEFT HIP: 15-20 cm linear incision cranial to caudal with staples in place superiorly and inferiorly. No surrounding erythema. NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs 2+ throughout, strength 5/5 bilaterally, sensation grossly intact. Gait deferred. Pertinent Results: [**2205-9-10**] 07:26PM BLOOD WBC-7.9 RBC-3.25* Hgb-9.8* Hct-29.7* MCV-92 MCH-30.2 MCHC-33.0 RDW-15.4 Plt Ct-253 [**2205-9-10**] 07:26PM BLOOD Neuts-83.7* Lymphs-10.9* Monos-4.0 Eos-0.9 Baso-0.4 [**2205-9-10**] 07:26PM BLOOD PT-11.9 PTT-29.4 INR(PT)-1.1 [**2205-9-10**] 07:26PM BLOOD Glucose-170* UreaN-32* Creat-0.8 Na-135 K-4.4 Cl-100 HCO3-25 AnGap-14 [**2205-9-10**] 07:26PM BLOOD Calcium-8.4 Phos-3.5 Mg-1.5* [**2205-9-11**] 05:40AM BLOOD Vanco-13.5 Micro [**2205-9-13**] 12:30 pm SWAB Site: HIP LEFT HIP #3. GRAM STAIN (Final [**2205-9-13**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Preliminary): GRAM NEGATIVE ROD(S). RARE GROWTH. ANAEROBIC CULTURE (Preliminary): [**2205-9-11**] 9:00 pm SWAB Site: HIP LEFT HIP SUPERFISCIAL. WOUND CULTURE (Preliminary): SERRATIA MARCESCENS. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 352-7050S [**2205-9-11**]. ESCHERICHIA COLI. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam Susceptibility testing requested by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] #[**Numeric Identifier 98333**] [**2205-9-16**]. ESCHERICHIA COLI. SPARSE GROWTH. SECOND MORPHOLOGY. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam Susceptibility testing requested by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] #[**Numeric Identifier 98333**] [**2205-9-16**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMPICILLIN------------ 16 I 16 I AMPICILLIN/SULBACTAM-- 4 S 4 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S TOBRAMYCIN------------ 2 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S [**2205-9-11**] 9:00 pm TISSUE Site: HIP LEFT HIP #3. **FINAL REPORT [**2205-9-15**]** GRAM STAIN (Final [**2205-9-11**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2205-9-14**]): Reported to and read back by DR. [**Last Name (STitle) **] [**2205-9-12**] 11:11AM. SERRATIA MARCESCENS. SPARSE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ SERRATIA MARCESCENS | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Final [**2205-9-15**]): NO ANAEROBES ISOLATED. DISCHARGE LABS WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 6.2 3.02 9.2 27.3 90 30.5 33.7 14.8 252 Glucose UreaN Creat Na K Cl HCO3 AnGap 122 17 0.7 134 4.2 101 27 10 FINDINGS: Two frontal images of the chest demonstrate a right PICC line in place with the tip overlying the right atrium. The catheter will need to be pulled back 3 cm for appropriate placement. No pneumothorax or other complications are seen. There are slightly smaller lung volumes on this exam than on previous exam which may account for the slight increase in vascular crowding. There is also some decrease in the distinctness of vascular vessels which could be consistent with vascular congestion or low lung volumes. Cardiac silhouette is unremarkable. Again noted is the orthopedic hardware in the mid abdomen overlying the mid abdomen. IMPRESSION: Right PICC line in place with tip overlying the right atrium. Catheter needs to be pulled back 3 cm. Brief Hospital Course: IMPRESSION: 76F with a PMH significant for coronary artery disease (4-vessel CABG), critical aortic stenosis with bovine AVR (s/p re-do sternotomy for wound dehiscence with rib plating), s/p carcinoid tumor resection, obstructive sleep apnea (on 2L NC at nighttime), history of deep venous thromboses (IVC filter currently not on anticoagulation), hypertension, hyperlipidemia, insulin-dependent diabetes mellitus, chronic systolic heart failure (LVEF 40%) and anemia of chronic disease who has a complicated surgical history after a left subtrochanteric femur fracture repair in [**2197**] with subsequent operative site infection, debridement and irrigation of a left hip abscess with hardware removal and antibiotic spacer placement ([**2205-7-30**]) followed by repeat washout and antibiotic spacer exchange for on-going left septic hip joint ([**2205-8-15**]) now presenting from her rehab facility with persistent left-sided hip pain, spacer dislocation and evidence of a larger draining open wound. #Septic Joint/Left Hip Infection- The patient went to the OR on [**2205-9-11**] for an I and D of her left hip, removal of antibiotic spacer, and placement of wound VAC. Her post-op course was complicated by hypotension with BPs 85/50 requiring phenylephrine and transfer to the TICU from [**Date range (3) 98334**]. She was weaned off pressors, hemodynamically stable, and transferred to the medical floors on [**2205-9-12**]. She was taken back to the OR on [**2205-9-13**] for repeat washout and wound VAC placement. Her post-op course was again c/b by hypotension (83/39) not on pressors. She had 750cc blood loss from wound VAC in the PACU and was transfused 3 units PRBC and given IVFs with minimal improvement in pressures. She was transferred to the MICU and transfused 2 additional units PRBCs and all BP meds were held given her hypotension. She was called out of the MICU on [**2205-9-13**]. Her wound VAC was not hooked up to suction, due to a large hematoma and concern for continued bleeding from wound She went back to the OR on [**2205-9-16**] for repeat washout and her post op course was again c/b by hypotension with SBPs in the 70s. In the PACU she had significant bloody VAC output and a Hct drop from 34 to 28. She received pRBC and FFP x1, vitamin K, and was admitted to the TSICU for close monitoring. She had repeated washouts and final closure of her hip wound on [**2205-9-19**]. The patient was continued on her IV Vanc for her previous Staphylococcus lugdunensis infection. He IV Vanc course was completed during this admission. Her wound cultures grew Serratia marcens and E. Coli, for which she was initially treated with Zosyn and subsequently narrowed down to IV ciprofloxacin. There was concern for possible bacteremia given the patient's hypotension, however her blood cultures were negative. She will continue IV ciprofloxacin for 6 weeks ( last day of [**First Name9 (NamePattern2) 621**] [**2205-10-24**]). She is to follow up with ortho and ID in clinic after discharge. Per ID the patient will need weekly CBC, Chem 7, ESR, CRP faxed to their office at #[**Telephone/Fax (1) 24609**]. #Chronic Sacral and right heel decubitus ulcer- The patient was evaluated by the Wound Care Team, and their recs were implemented. The recs are as follows: Wound care: Site: L heel Type: Pressure ulcer Cleansing [**Doctor Last Name 360**]: Saline Dressing: Gauze - dry Change dressing: qd Site: Left heel Description: Necrotic area Care: Moisturize the periwound tissue with Aloe Vesta Moisture barrier Ointment left and right heels. Waffle boots Site: Coccyx Description: Pressure ulcer, unstageable, slough at wound base Care: Irrigate wound w/commercial wound cleanser, pat dry, apply a thin layer of DuoDerm Gel to the wound bed, cover with Mepilex Sacral Foam dressing; Change dressing every 3 days or prn displacement # ISCHEMIC CARDIOMYOPATHY/ CORONARY DISEASE/CHRONIC DIASTOLIC CHF ( LVEF 45% FROM [**2205-7-28**]) -Continue home meds: ASA 81 mg PO, atorvastatin 20 mg PO QHS. Her carvedilol was decreased to 3.125 mg PO BID. These medications were confirmed with her outpatient cardiologist. She was ordered for lisinopril 2.5mg daily while admitted but her blood pressures tended to be on the low side and this was not started. Lasix continued to be held during admission because of low BPs. She did not show signs of volume overload. Of note, if was confirmed that the patient is NOT on Plavix currently. #INSULIN-DEPENDENT DIABETES MELLITUS - the patient achieved optimal glycemic control on 6 units NPH at breakfast and 8 units at dinner with an insulin sliding scale. and is to continue this regimen on discharge. #HISTORY OF DEEP VENOUS THROMBOSIS - The patient has a history of deep venous thromboses in the lower extremities in [**2176**] occurring two times(completed 6-months of Coumadin and had repeat DVT occurrence off anticoagulation). Now she is s/p IVC filter placement with no chronic anticoagulation needs since [**2197**]. Given her high risk for recurrence and immobilization with her hip surgery she was maintained on Heparin 5000mg TID for DVT prophylaxis and this should be continued for 4 weeks following surgery (last date [**2205-10-17**]). # OBSTRUCTIVE SLEEP APNEA, PRIOR LUNG RESECTION - History of obstructive sleep apnea, requiring 2L nasal cannula supplementation at bedtime only (intermittent use). She does not use CPAP at home. She was continued on 2 L Nasal cannula at bedtime # HYPERTENSION - The patient was initially hypotensive after OR, requiring use of pressors. Now, BPs range in the 90-110s/30-50s. Once pressures were stable her Carvedilol 3.125 mg PO BID was restarted. # HYPERLIPIDEMIA - The patient was continued on Atorvastatin 20 mg PO QHS # PEPTIC ULCER DISEASE - The patient underwent eradication therapy after showing positive H. pylori antibodies in the past. She was continued on omeprazole 40mg [**Hospital1 **] TRANSITIONAL ISSUES #FOLLOW UP IN [**Hospital **] CLINIC and [**Hospital **] CLINIC # CONTINUE 6 WEEK COURSE OF IV CIPRO WITH weekly CBC, chem 7 , ESR, CRP faxed to [**Hospital **] clinic at [**Telephone/Fax (1) 24609**] Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY at bedtime 3. Bisacodyl 10 mg PO DAILY:PRN constipation 4. Carvedilol 3.125 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Multivitamins 1 TAB PO DAILY 8. Milk of Magnesia 30 mL PO DAILY 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Senna 1 TAB PO BID 11. Vancomycin 750 mg IV Q 24H 6 weeks until [**2205-9-9**] 12. Heparin 5000 UNIT SC TID 13. Vitamin D 1000 UNIT PO DAILY 14. Omeprazole 40 mg PO BID 15. zinc oxide *NF* 20% Topical [**Hospital1 **] one application topically [**Hospital1 **] 16. Heparin Flush (10 units/ml) 5 mL IV PRN line maintenance 3 mL IV PRN line maintenance; 2 mL IV line flush to PICC line 17. OxycoDONE (Immediate Release) 5 mg PO BID for pain 18. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 2.5-5 mg PO Q4H PRN pain 19. NPH insulin human recomb *NF* 100 unit/mL Subcutaneous daily 4 units SC at breakfast, 4 units SC at dinner time 20. Calcium Carbonate 750 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY at bedtime 3. Carvedilol 3.125 mg PO BID 4. Docusate Sodium 100 mg PO BID 5. Heparin 5000 UNIT SC TID last day [**2205-10-17**] 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 40 mg PO BID 8. Senna 1 TAB PO BID 9. Vitamin D 1000 UNIT PO DAILY 10. Acetaminophen 1000 mg PO Q8H:PRN fever/pain 11. Ciprofloxacin 400 mg IV Q12H last day [**2205-10-24**] 12. NPH 6 Units Breakfast NPH 8 Units Dinner Insulin SC Sliding Scale using HUM Insulin 13. Bisacodyl 10 mg PO DAILY:PRN constipation 14. Milk of Magnesia 30 mL PO DAILY 15. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 2.5-5 mg PO Q4H PRN pain 16. Polyethylene Glycol 17 g PO DAILY:PRN constipation 17. zinc oxide *NF* 20% Topical [**Hospital1 **] one application topically [**Hospital1 **] 18. Calcium Carbonate 750 mg PO BID 19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: Spacer removal, washout, wound closure L hip Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you in the hospital. You were admitted for a left hip infection and you were taken to the operating room for washout and removal of hardware. You will be going to a rehab facility for further physical therapy. -Wound Care: You can get the wound wet/take a shower starting from 3 days post-op. No baths or swimming for at least 4 weeks. Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. No dressing is needed if wound continued to be non-draining. ******WEIGHT-BEARING******* Touchdown weightbearing on Left lower extremity ******MEDICATIONS*********** **You will need to continue ciprofloxacin for one month until [**2205-10-24**] and SC heparin for 4 weeks until your follow up appointment*** - Resume your pre-hospital medications. - You have been given medication for your pain control. Please do not operate heavy machinery or drink alcohol when taking this medication. As your pain improves please decrease the amount of pain medication. This medication can cause constipation, so you should drink 8-8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. -Please speak with your cardiologist regarding a blood pressure medication called lisinopril. We tried to start this medication in the hospital but your blood pressures were on the low side. Followup Instructions: Department: ORTHOPEDICS When: TUESDAY [**2205-10-1**] at 8:25 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2205-10-1**] at 8:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please have your staples removed at your rehabilitation facility at post-operative day 14 ([**2205-10-4**]). Department: INFECTIOUS DISEASE When: MONDAY [**2205-10-7**] at 10:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: ORTHOPEDICS When: TUESDAY [**2205-10-8**] at 2:10 PM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2205-10-8**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "998.12", "285.1", "707.22", "V12.51", "414.01", "338.28", "998.32", "E878.8", "327.23", "V42.2", "250.00", "428.23", "401.9", "V58.67", "V43.64", "707.07", "458.29", "428.0", "707.25", "707.03", "272.4", "998.59", "996.77", "996.66", "041.49", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "84.57", "80.05", "77.69", "80.15", "38.97" ]

icd9pcs

[ [ [] ] ]

21542, 21636

13164, 16465

330, 381

21725, 21725

8192, 8853

23313, 24846

6276, 6433

20513, 21519

21657, 21704

19365, 20490

21908, 22155

6487, 8173

282, 292

9073, 13141

22167, 23290

409, 4257

8963, 9038

21740, 21884

4279, 5863

5879, 6260

5,397

112,979

48428

Discharge summary

report

Admission Date: [**2146-8-10**] Discharge Date: [**2146-8-16**] Date of Birth: [**2093-3-26**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 53 year-old white male with a history of diabetes mellitus insulin dependent with previous admissions for hypoglycemia who presented to the Emergency [**2146-8-10**] with complaints of nausea, vomiting and fatigue for several days. He states because he had decreased appetite and vomiting he had stopped taking his insulin for at least three days. He also complained of polydipsia and polyuria as well as a chest burning sensation. In the Emergency Room he was found to have a blood sugar of 990 as well as a metabolic acidosis (7.1-15-150). The patient received intravenous insulin drip aggressive hydration and was transferred to the MICU. PAST MEDICAL HISTORY: Diabetes times ten years insulin dependent, left foot ulcers, peripheral neuropathy, gastroesophageal reflux disease, status post hernia repair and ETOH abuse. MEDICATIONS ON ADMISSION: Insulin NPH 35 units q.a.m., 25 units q.p.m., insulin regular 15 units q.a.m., 10 units q.p.m. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Lives alone. Smoking one half pack per day. ETOH states six drinks per week plus marijuana use. No intravenous drug use. FAMILY HISTORY: Mother with diabetes mellitus. REVIEW OF SYSTEMS: Denied any hematemesis, melena, bright red blood per rectum, bowel movements have been regular. Denies also fever or chills. PHYSICAL EXAMINATION: Vital signs temperature 95.8. Heart rate 107. Blood pressure 108/47. Mean arterial pressure 67. Oxygen saturation 94% on range of motion air. In general, thin, fatigued. HEENT normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Poor dentition. Dry mucous membranes. Neck was supple. No JVD. Chest slow breathing, clear to auscultation bilaterally. Cardiovascular tachycardia, S1 and S2. No murmurs, rubs or gallops. Abdomen nontender, nondistended, normoactive bowel sounds. Extremities no edema. Scaly skin on the left foot, healing ulcers on the great toe and plantar surface. Charcot deformation. 2+ dorsalis pedis pulses. Neurological alert and oriented times three. Cranial nerves II through XII intact. Motor strength and sensation roughly intact throughout. LABORATORY: White blood cell count 21, hematocrit 44.8, platelets 268. Sodium 120, K 4.3, chloride 73, HCO 38, BUN 64, creatinine 2.2, glucose 990, anion gap 36, ALT 17, AST 26, alkaline phosphatase 118, bili 0.4, amylase 230, lipase 139, calcium 7, magnesium 1.7, phosphorus 1.9. CK 224, CKMB 15, troponin (large), lactate 2.6, acetone large, ETOH negative. Urinalysis greater then 1000 glucose, greater then 80 ketones and no protein, otherwise clear. Chest x-ray no acute pulmonary process. Electrocardiogram was sinus tachycardia at 106 beats per minute, normal axis, wavy baseline, J point elevation in V2 through V6. No significant ST or T wave changes. No Q waves noted. HOSPITAL COURSE: 1. Endocrine: The patient was admitted with diabetic ketoacidosis with metabolic acidosis, a significant anion gap. He was treated with intravenous insulin drip, aggressive hydration and electrolyte repletion. His metabolic acidosis resolved. The patient was controlled on subQ insulin. [**Last Name (un) **] diabetes consulted and throughout the rest of his stay and NPH and regular insulin were titrated to control his blood sugar. The patient also received diabetes education and is scheduled for a follow up appointment with the [**Hospital **] Clinic Dr. [**Last Name (STitle) 12746**] on [**8-24**] at 9:30 a.m. 2. Cardiac: In the MICU the patient ruled in for an myocardial infarction with a CK of 224, CKMB 15 and troponin 0.4. Cardiology was consulted. The patient received oxygen, aspirin and was started on a heparin drip. Cardiac enzymes were cycled. CK and CKMB trended downward, however, the troponin continued to rise. An echocardiogram was done on [**8-10**], which revealed a left ventricular ejection fraction of 20 to 30% with global hypokinesis and akinesis in the inferior wall. His blood pressures varied from 80s to 100s systolic and he was started on Captopril and Lopressor, which were held for blood pressure under 100. A follow up stress test was done, which again revealed hypokinetic motion in the inferior wall, however, the patient was not found to have any perfusion defects and was able to achieve 84% of his heart rate with exercise. He will be discharged with Mavic 1 mg q.d. 3. Gastrointestinal: On admission the patient complained of mid epigastric burning. He was found to have an elevated amylase and lipase, which trended downward during his stay. He tolerated a regular diet without any nausea and vomiting and continued to have regular bowel movements. He did have an abdominal ultrasound done on [**8-11**], which did not show any evidence of cholecystitis, stones, pancreatitis or obstruction. It is possible that his elevation in pancreatic enzymes was secondary to diabetic ketoacidosis. However, epigastric burning persisted and the patient had an upper gastrointestinal done, which was a normal study. He was discharged with Sucralfate 1 gram to take before meals for possible acid reflux. DISPOSITION: The patient will be discharged to home. He has follow up as mentioned with [**Hospital **] Clinic as well as with his primary care physician [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**8-23**] at 4:00 p.m. in the [**Hospital 191**] Clinic. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Diabetic ketoacidosis. 2. Inferior wall myocardial infarction. 3. Acid reflux. DISCHARGE MEDICATIONS: 1. NPH 24 units q.a.m., 15 units q.p.m., regular insulin 12 units q.a.m. and 8 units q.p.m. 2. Mavic 1 mg q.d. 3. Sucralfate 1 gram one hour before meals. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Doctor Last Name 36791**] MEDQUIST36 D: [**2146-8-16**] 13:58 T: [**2146-8-23**] 12:42 JOB#: [**Job Number 101952**]

[ "577.1", "250.13", "414.01", "263.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5645, 5683

1316, 1348

5704, 5790

5814, 6237

1024, 1158

3078, 5623

1517, 3060

1368, 1494

156, 813

836, 997

1175, 1299

12,713

162,518

53095

Discharge summary

report

Admission Date: [**2177-11-17**] Discharge Date: [**2177-12-1**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1654**] Chief Complaint: decline in mental status. Major Surgical or Invasive Procedure: Resection of R cerebellar mass with placement of right intraventricular, occipital drain. Subsequent placement of right anterior ventricular drain. History of Present Illness: 85 yo male with atrial fibrillation on coumadin, CAD, CHF, COPD and a hx of prostate ca who initially presented to [**Hospital3 29818**] on [**2177-11-16**] with mild confusion, increasing SOB over several days, unresponsive to his COPD medications and N, with vomiting. His labs were significant for WBC 23.8 (diff 85N, 5B, 3 %lymph) INR 2.6, K 3.2, elevated creat 1.6 (up from baseline 1.3) and a trop of 0.2, CK 63, MB 2.6. His EKG was notable for a RBBB but did not show any changes to prior. His CXR was notable for RLL patchy infiltrate and LLL consolidation. An ABG showed ph 7.55, pCO2 37, PO2 50. D-Dimer was negative. He was thought to have a CAP with superimposed CHF and possible exacerbation of his COPD. He was given albuterol nebs, lasix, solumedrol, levaquin, morphine. On [**11-17**] he was was found to be increasingly confused and noted to be exhibiting bizarre behavior. A head CT was done and showed 5X2cm R cerebellar hemorrhage with mild mass effect. 2u FFP, vi K, dilantin load and lasix and nitropaste for edema associated with FFP transfusion. He was transferred to [**Hospital1 18**] for further management. Past Medical History: 1 Atrial Fibrillation on coumadin 2 CAD s/p CABG in [**2168**], s/p MI 3 CHF (Last Echo in '[**74**] showed right ventricular cavity enlargement with free wall hypokinesis and severe pulmonary artery systolic hypertension (63mm gradient) consistent with cor pulmonale), mild mitral regurgitation. Low normal left ventricular systolic function. EF 50-55%. 4 mild dementia 5 HTN 6 Emphysema and reactive airway dz on home O2 and nite CPAP (followed by Dr.[**Last Name (STitle) 575**])- FEV1 and vital capacity .85 and 2.4 (45 and 77% of predicted) 7 CRI (baseline 1.3) 8 GERD 9 LGIB [**9-22**]- Last colonoscopy in [**6-18**]: non-bleeding telangiectasias were seen near the ileocecal valve and in the cecum. There were no stigamata of recent bleeding. Diverticulosis of the sigmoid 10 chronic severe bilateral leg pain [**1-22**] spinal stenosis 11 DJD s/p TKR 12 depression Social History: lives w/ his wife; remote tobacco use; no alcohol or illicit drug use. Family History: Non-contributory. Physical Exam: PE: VS: 98.2, HR 78, BP 130/56, RR 27, O2Sat 96 on 2L Gen: NAD, occ non-voluntary movement of R arm HEENT: NG tube in place, arcus senilis, PERRLA, EOMI, mm dry with crusty surface on palate NECK: JVD 14cm, no LAD, LIJ in place, no erythema on insertion site CV: irreg, irregular, no m/r/g Lungs: decerased breath sounds at bases, crackles b/l half way up, no wheezes, or rhonchi Abdmonen: soft, nt, nd, +BS Ext: in Pneumoboots, +DP Neuro: CN II-XII intact, strength 5/5 b/l, hyperactive reflexes b/l, Babinsky +R, ?L, sensitivity grossly intact, hemiballismus of R arm, FFT with action and intention tremor, ametry. Speech slurry but understanding intact. Pertinent Results: [**2177-11-17**] 11:36PM PT-18.3* PTT-34.1 INR(PT)-2.3 [**2177-11-17**] 11:36PM PLT COUNT-235 [**2177-11-17**] 11:36PM WBC-21.4*# RBC-3.39* HGB-10.7* HCT-30.0* MCV-89 MCH-31.5 MCHC-35.6* RDW-14.4 [**2177-11-17**] 11:36PM CALCIUM-9.4 PHOSPHATE-3.8 MAGNESIUM-2.3 [**2177-11-17**] 11:36PM GLUCOSE-195* UREA N-48* CREAT-1.6* SODIUM-131* POTASSIUM-3.9 CHLORIDE-88* TOTAL CO2-29 ANION GAP-18 . Brief Hospital Course: Here, on the [**11-17**], the pt had a right cerebellar craniotomy that revealed a cerebellar hemorrhage as well as a mass in the R cerebellum. He had removal of mass and a placement of a right intraventricular, occipital drain in OR. The pathology revealed a poorly differentiated carcinoma most consistent with small cell carcinoma, concerning for small ca of lung/ neuroendocrine ca or less likely melanoma or lymphoma. He underwent CT of chest/abd/pelvic. That revealed multiple mass lesions within the liver, mediastinum, lung, pelvis, and left inguinal region, concerning for diffuse metastatic disease. One large lesion within the pelvis is contigous with the prostate, possible exophytic prostate lesion or a metastatic focus invading into the prostate. Also, bilateral pleural effusions were seen. The occipital intraventricular drain was removed on the and a right anterior ventricular drain placed on the [**11-18**], b/o a new component of cerebellar hemorrhage involving the vermis. The pt was extubated on the [**11-19**]. CT of the head showed stability of the ICH over the next days. The pt's second drain was removed on the [**11-26**]. The pt also received 5U of PRBC during his operation and 4U of FFPs. He continued to improve in his mental status although to remained with severe dysarthria and dystaxia due to his cerebellar lesion and involvement of other cranial nerves such as the hypoglossus. The pt's prognosis was infaust. Further management of the underlying cancer was discussed with the pt and he refused radiation of chemotherapy and requested comfort care. This was also in accordance to his living will. Palliative care and social work were consulted for a meeting with all teams involved in the pt's care and the family. It was decided to treat the pt with comfort measures only. The pt died on the [**2177-12-1**] at 11.30am. . Medications on Admission: Coumadin 7' Zocor 10' Zoloft 50' Metolazone 2.5' Lasix 40", Protonix 40' KCl 20 mEq qday Nebs with home O2 at 2lNC Ceftriaxone/zithromax started OSH for PNA Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: metastatic cancer of unknown primary Discharge Condition: expired

[ "286.7", "197.7", "197.0", "331.4", "496", "V10.46", "199.1", "198.3", "427.31", "428.0", "431", "403.90", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "01.59", "99.05", "96.72", "96.04", "96.6", "99.04", "99.07", "02.39" ]

icd9pcs

[ [ [] ] ]

5840, 5849

3738, 5604

289, 438

5929, 5939

3316, 3715

2605, 2624

5811, 5817

5870, 5908

5630, 5788

2639, 3297

224, 251

466, 1602

1624, 2500

2516, 2589

40,861

124,739

54994

Discharge summary

report

Admission Date: [**2122-8-30**] Discharge Date: [**2122-9-2**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2736**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 88 F history of severe aortic stenosis (valve area 0.7 in [**2120**]), dHF (takes lasix 40 PO daily at home), dementia, CKD, COPD (baseline 88-91% on RA, uses O2 off and on at home) who presents with dyspnea on exertion at nursing home x 2 days. Per nursing home, pt has been SOB with exertion x 2 days, requiring O2 most of the day whereas previously she was on O2 only at night. They also note she has been feeling more weak lately. She was given extra lasix 20mg PO and nebs at nursing home but continued to have SOB. Had CXR at [**Location (un) 169**] showing no CHF, no infiltrate. Today, pt continued to have some shortness of breath (unchanged from yesterday) requiring same amount of O2. Decision was made to send her to the ED. Per nursing home, patient's baseline weight: 181 Ib and is now 187 Ib which has been increasing. In the ED, initial vitals were 99 73 170/80 18 100% on non rebreather. Pt was then placed on BIPAP and pt looked clinically more comfortable. Labs and imaging significant for BNP 32,000, trop 0.03. CXR showed pulmonary edema. Patient given albuterol neb, ipratropium neb, solumedrol 125mg, azithro 500mg for possible COPD. Also given SL nitro x1, lasix 80mg IV (put out 150 cc UO) and nitro gtt (3.8ml/hr, and BP 120s/90s). Access: two 18 g IVs Vitals on transfer: afebrile, HR 63, RR 28, 138/68, 100% on BIPAP. On arrival to the CCU, pt is comfortable, on BIPAP. After removing bipap, she was found to sat 96% on RA. She states she is confused as to why she is in the hospital and is frusterated that she is here. I spoke to daughter on phone who says her mother has poor baseline status, she needs help with all ADLs, she has SOB with minimal exertion (turning in bed, standing, etc...) and uses oxygen on and off at home. I called nursing home who states that she has been more fatigued the last 2 days, requiring O2 most of the day (as opposed to off and on) and for these reasons they brought her to the ED. They also note her weight is up to 187 Ib from prior 181 Ib. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: unknown, never had a heart attack, no cardiac procedures 3. OTHER PAST MEDICAL HISTORY: Severe aortic stenosis (per [**Hospital3 2568**] records from [**2120**], no accessibly echos in our system)- per daughter, pt has DOE with minimal exertion such as standing, moving in bed to be changed (unclear if from COPD vs dHF vs AS) [**Name (NI) **] Cr 1.6 Anemia of chronic disease DM2 COPD- uses O2 at nursing home occasionally HTN Dementia-moderate, knows her daughters name, [**Name2 (NI) 73869**] know where she lives, needs help with feeding and bathing. TIA Macular degeneration- poor eye site RBBB Social History: She lives in nursing home. Daughter very involved. Used to smoke (most of her life until 20 yrs ago), no ETOH. Needs help dressing, bathing, feeding. Very poor functional status, SOB with rotating in bed. 1 child. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION VS: afebrile, BP 141/56, HR 65 sinus, 96% on RA, Lasix 80mg IV--> UP 400cc GENERAL: comfortable, some accessory muscle use to breath HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, JVP around 9 CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, systolic murmur right sternal border radiating to carotids, apreciate an S2. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, does have accessory muscle use. no wheezes, no crackle. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ pedal edema bilaterally. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: radial 2+ Left: radial 2+ A+O x2: knows year, name, confused as to where she is Pertinent Results: [**2122-8-30**] 03:30PM PLT COUNT-205 [**2122-8-30**] 03:30PM NEUTS-81.5* LYMPHS-11.1* MONOS-6.5 EOS-0.4 BASOS-0.4 [**2122-8-30**] 03:30PM WBC-5.4 RBC-3.96* HGB-11.3* HCT-34.9* MCV-88 MCH-28.6 MCHC-32.4 RDW-14.5 [**2122-8-30**] 03:30PM CK-MB-1 proBNP-[**Numeric Identifier 112294**]* [**2122-8-30**] 03:30PM cTropnT-0.03* [**2122-8-30**] 03:30PM CK(CPK)-84 [**2122-8-30**] 03:30PM estGFR-Using this [**2122-8-30**] 03:30PM GLUCOSE-140* UREA N-38* CREAT-1.9* SODIUM-143 POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-31 ANION GAP-16 [**2122-8-30**] 03:38PM LACTATE-1.1 [**2122-9-2**] 04:40AM BLOOD WBC-7.1 RBC-3.52* Hgb-10.0* Hct-31.2* MCV-89 MCH-28.3 MCHC-31.9 RDW-14.5 Plt Ct-214 [**2122-9-2**] 04:40AM BLOOD Plt Ct-214 [**2122-9-1**] 10:00AM BLOOD PT-10.7 PTT-29.4 INR(PT)-1.0 [**2122-9-2**] 04:40AM BLOOD Glucose-88 UreaN-61* Creat-1.8* Na-149* K-3.4 Cl-104 HCO3-38* AnGap-10 [**2122-9-1**] 10:00AM BLOOD Glucose-88 UreaN-57* Creat-1.9* Na-143 K-3.5 Cl-100 HCO3-33* AnGap-14 [**2122-8-30**] 10:00PM BLOOD CK-MB-2 cTropnT-0.03* [**2122-8-30**] 03:30PM BLOOD CK-MB-1 proBNP-[**Numeric Identifier 112294**]* [**2122-9-2**] 04:40AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.1 [**2122-9-1**] 10:00AM BLOOD VitB12-701 [**2122-9-1**] 10:00AM BLOOD TSH-3.5 [**2122-8-30**] 03:38PM BLOOD Lactate-1.1 **FINAL REPORT [**2122-9-1**]** URINE CULTURE (Final [**2122-9-1**]): NO GROWTH. [**2122-8-30**] 3:30 pm BLOOD CULTURE Blood Culture, Routine (Pending): [**2122-8-30**] 04:15PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.009 [**2122-8-30**] 04:15PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2122-8-30**] 04:15PM URINE RBC-11* WBC-4 Bacteri-NONE Yeast-NONE Epi-<1 [**2122-9-2**] 10:08AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015 [**2122-9-2**] 10:08AM URINE Blood-MOD Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [**2122-9-2**] 10:08AM URINE RBC-16* WBC->182* Bacteri-FEW Yeast-NONE Epi-0 TransE-<1 [**2122-9-2**] 10:08AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015 [**2122-9-2**] 10:08AM URINE Blood-MOD Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [**2122-9-2**] 10:08AM URINE RBC-16* WBC->182* Bacteri-FEW Yeast-NONE Epi-0 TransE-<1 Brief Hospital Course: 88 F with dementia who lives in a nursing home also with history of COPD (on oxygen at home), severe aortic stenosis (valve area 0.7 in [**2120**]), chronic diastolic heart failure who presented with tachypnea, CXR showing mild pulmonary edema, BNP 32,000 consistent with acute on chronic diastolic heart failure. ACUTE ISSUES # PUMP/Acute on chronic diastolic heart failure: CXR with pulmonary edema, 2+ pedal edema and BNP 32,000. Acute diastolic heart failure episode likely secondary to progressive aortic stenosis. Admission weight was 187 Ib, and her baseline weight is 181 Ib. She was initialy given lasix 80mg IV, nitro gtt and BIPAP. She was weaned off nitro gtt and BIPAP and diuresed. Reason for her decompensated heart failure may most likely be due to worsening aortic stenosis because her valve area has gone down since prior imaging (it was .7 in [**2120**] and now is .4). It is also psosible patientn has been eating salty foods however she lives in a nursing home where her diet is usually controlled. Per her daughter she looked like she was back to her baseline the following day after diuresis and her pedal edema went down and she was comfortably breathing on nasal canula. We increased the dose of lasix that she will be taking at home from 40 mg daily to 80 mg. #Severe Aortic Stenosis: Echo here showed ([**2122-8-31**]): The left atrium is mildly elongated. 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%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of mitral regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion without evidence of hemodynamic compromise. IMPRESSION: Critical aortic valve stenosis. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Moderate mitral regurgitation. Pulmonary artery hypertension. Mild aortic regurgitation. There was a discussion with daughter about interventions for severe aortic stenosis. She has moderate dementia and is not a candidate for AVR, nor would she wish to pursue this. A mini-mental status exam score of <20 patients precludes her from enrollment in the Corevalve trial. Her mini-mental was 19. She will be managed symptomatically, per her daughter's wishes. # COPD: Pt with known COPD. No clears signs of COPD exacerbation at this time as no increase in sputum or fevers or wheezing. ED initialy gave her azithromycin and solumdrol for presumed COPD exacerbation. While on the cardiology service, she was given nebs prn and the antibiotics were stopped. #Positive UA: Concern for UTI in setting of foley placement. We started treating her with cefpadoxime and azithromycin for possible pneumonia because of new lesion on cxr (see below) and cefpadoxime will treat E.coli as the most likely culprit for this patient's UTI. #PNA? CXR showing possible new area of suspicion inright lower lobe. Patient was at risk for aspiration and HAP. Her daughter who is her health car proxy, [**Name (NI) **], said (at 13:30 on [**2122-9-2**]) that she wants her mom back at the nursing home and does not want her mom to be in the hospital any longer. She does not want her mother to be treated with IV antibiotics. She understand that this may mean we are treating her with sub-optimal antibiotics. She will be treated for 18 days. Day one is [**2122-9-2**]. # Acute on chronic renal failure: Cr here is 1.9, baseline Cr 1.6. Likely pre-renal in setting of volume overload. CHRONIC ISSUES # DM2: diet controlled at home, blood sugrars in the 130s # HLD: continued home zocor 40mg # Dementia: Continued home galantamine 24mg and memnatine 10 [**Hospital1 **] #Glaucoma: continued Xlantan eye drops 0.005% both eyes qhs #history of TIA: contniued home plavix 75mg TRANSITIONAL ISSES: #follow up urine culure sensitivites and specificies because we may need to change the antibiotic depending on what it grows #Pneumonia: will send her home on cefpadoxime and azithro for 8 days. Day 1 ([**2122-9-2**]) #Severe Aortic stenosis: patient is non-surgical candidate because she has at least moderate dementia and COPD and lives in a nursing home. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from nursing home. 1. Acidophilus Probiotic *NF* (acidophilus-pectin, citrus) 100 million-10 cell-mg Oral [**Hospital1 **] two tabs [**Hospital1 **] 2. Amlodipine 5 mg PO QAM hold for SBP < 100 3. Docusate Sodium 200 mg PO QAM 4. Ferrous Sulfate 325 mg PO QAM 5. Furosemide 40 mg PO QAM 6. galantamine *NF* 24 mg Oral daily 7. Metoprolol Succinate XL 50 mg PO QAM hold for HR < 60, SBP < 100 8. Multivitamins 1 TAB PO DAILY 9. Clopidogrel 75 mg PO DAILY 10. Simvastatin 40 mg PO QHS 11. Tiotropium Bromide 1 CAP IH DAILY hold for HR > 100 12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 13. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 14. MEMAntine *NF* 10 mg Oral [**Hospital1 **] 15. Senna 1 TAB PO BID 16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H hold for HR > 100, if HR > 100 and respiratory difficulty [**Name8 (MD) 138**] MD 17. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze in addition to q6 standing, hold for HR > 100 Discharge Medications: 1. Amlodipine 10 mg PO QAM hold for SBP < 100 2. Clopidogrel 75 mg PO DAILY 3. Docusate Sodium 200 mg PO QAM 4. Ferrous Sulfate 325 mg PO QAM 5. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 6. Furosemide 80 mg PO DAILY PLEASE GIVE IN THE MORNING 7. galantamine *NF* 24 mg Oral daily 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 9. MEMAntine *NF* 10 mg Oral [**Hospital1 **] 10. Multivitamins 1 TAB PO DAILY 11. Senna 1 TAB PO BID 12. Simvastatin 40 mg PO QHS 13. Tiotropium Bromide 1 CAP IH DAILY hold for HR > 100 14. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze in addition to q6 standing, hold for HR > 100 15. Acidophilus Probiotic *NF* (acidophilus-pectin, citrus) 100 million-10 cell-mg Oral [**Hospital1 **] two tabs [**Hospital1 **] 16. HydrALAzine 10 mg PO TID please do not give if SBP<100 or HR < 60 (may potentiate effects of beta blockers) 17. Metoprolol Succinate XL 50 mg PO QAM hold for HR < 60, SBP < 100 18. Azithromycin 500 mg PO Q24H The total course is five days, day 1 = [**2122-9-2**]. Last dose on [**2122-9-6**]. 19. Cefpodoxime Proxetil 400 mg PO Q24H Total course is 8 days, day 1 = [**2122-9-2**]. This will cover both pneumonia and UTI and has been dose adjusted to a CrCl of 21 ml/min. 20. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**] Discharge Diagnosis: Severe Aortic Stenosis Diastolic heart failure COPD Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you at the [**Hospital1 18**]. You were admitted to the [**Hospital1 **] because you were having trouble breathing while at home, and you had gained some weight which was concerning for problems with your heart. We did some studies here and found that you had some worsening of your heart function. We also found that your aortic valve had gotten narrower making it more difficult for you to pump blood to the rest of your body. We used medications to take fluid off of your lungs and it enabled you to breathe more easily. We have changed the following medications We CHANGED the dose of the following medications: 1. Amlodipine 10 mg daily. This was 5 mg daily previously 2. Lasix 80 mg daily. This was 40 mg previously. 3. Metoprolol succinate 50mg daily. This was previously metoprolol tartrate 50mg daily. We had added the following medications: 1. Hydralazine 10mg by mouth three times daily 2. cefpodoxime this will treat your UTI and penumonia 3. azithromycin this will treat your peumonia 4. miralax if you are constipated Please continue taking your metoprolol succinate 50 mg daily in addition to your other medications to treat your diabetes and COPD. We have not changed the dosages in any of those medications. It was a pleasure taking care of you Mrs. [**Known lastname **] Followup Instructions: Wiill follow up at nursing home

[ "272.0", "V46.2", "365.70", "428.33", "584.9", "792.1", "403.90", "285.29", "428.0", "V49.86", "294.20", "496", "365.9", "424.1", "585.1", "V12.54", "250.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13883, 13975

6668, 11449

270, 276

14071, 14071

4305, 5730

15646, 15681

3281, 3396

12560, 13860

13996, 14050

11475, 12537

14253, 15623

3411, 4286

2432, 2489

5765, 6645

211, 232

304, 2324

14086, 14229

2520, 3034

2346, 2412

3050, 3265

61,816

107,605

23522

Discharge summary

report

Admission Date: [**2187-2-4**] Discharge Date: [**2187-3-8**] Date of Birth: [**2136-5-25**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3913**] Chief Complaint: fever, myalgias, bruises Major Surgical or Invasive Procedure: placement of central lines lumbar punctures and intrathecal chemotherapy History of Present Illness: 50-year-old woman with history of hypertension and hyperlipidemia was transferred from [**Hospital6 **] after presenting there with one week of muscle aches, neck tenderness, several bruises, and fever, found to have WBC 233,000, concerning for acute leukemia. Patient was in her usual state of health when about a week ago she started feeling tired, with myalgias, then tender cervical adenopathy. She also developed fevers. Her chronic back pain was also worse. Pt also was reporting heavy menstrual cycles that lasted 1 week one week prior to admission. Upon admission to [**Hospital3 **], she was noted to have an elevated WBC of >200,000, plt: 10 and was transfused and transferred to [**Hospital1 18**] on [**2-4**] for further management. She had a bone marrow biopsy performed the same day that was notable for acute myeloid leukemia with monocytic differentiation. She immediately underwent plasmapheresis and subsequently went into DIC with onset of ARF. Past Medical History: HTN hyperlipidemia depression Social History: Remote history of smoking. No EtOH. Lives with husband. Currently unemployed. Family History: Mother: breast cancer. Maternal grandmother: gastric or colon cancer. Physical Exam: T 101.7, BP 162/102, HR 92, RR 18, 93%RA Gen: middle-aged woman looking anxious but in no acute distress HEENT: EOMI, PERRL, OM moist without lesion Neck: diffuse tender bilateral anterior cervical adenopathy Lungs: CTA bilaterally CV: regular rate, normal rhythm, normal S1/S2 without any m/r/g Abd: soft, nontender, no HSM, BS present Ext: no c/c/e Skin: no ecchymosis Neuro: oriented x 3, mood appropriate Pertinent Results: LABS ON ADMISSION: [**2187-2-4**] 06:30PM WBC 250,000 RBC-2.96* HGB-9.2* HCT-25.9* MCV-88 MCH-31.1 MCHC-35.5* RDW-16.5* [**2187-2-4**] 06:30PM PLT COUNT-77* [**2187-2-4**] 06:30PM PT-15.5* PTT-31.2 INR(PT)-1.4* [**2187-2-4**] 06:30PM FIBRINOGE-179 [**2187-2-4**] 06:30PM GLUCOSE-154* UREA N-9 CREAT-1.0 SODIUM-144 POTASSIUM-3.2* CHLORIDE-105 TOTAL CO2-26 ANION GAP-16 [**2187-2-4**] 06:30PM ALT(SGPT)-55* AST(SGOT)-49* LD(LDH)-1490* ALK PHOS-140* AMYLASE-54 TOT BILI-0.7 [**2187-2-4**] 06:30PM ALBUMIN-3.9 CALCIUM-8.5 PHOSPHATE-1.3* MAGNESIUM-1.9 URIC ACID-6.0* IRON-128 LABS ON DISCHARGE: [**2187-3-8**] 12:00AM BLOOD WBC-1.8* RBC-3.30* Hgb-9.5* Hct-27.0* MCV-82 MCH-28.6 MCHC-35.0 RDW-13.7 Plt Ct-197 [**2187-3-8**] 12:00AM BLOOD Neuts-70 Bands-0 Lymphs-18 Monos-11 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2187-3-8**] 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-2+ Polychr-OCCASIONAL Spheroc-1+ Ovalocy-1+ Schisto-OCCASIONAL [**2187-3-8**] 12:00AM BLOOD Plt Smr-NORMAL Plt Ct-197 [**2187-3-5**] 12:00AM BLOOD Fibrino-448* [**2187-3-8**] 12:00AM BLOOD Gran Ct-1278* [**2187-3-8**] 12:00AM BLOOD Glucose-107* UreaN-15 Creat-0.9 Na-137 K-3.3 Cl-105 HCO3-24 AnGap-11 [**2187-3-8**] 12:00AM BLOOD ALT-58* AST-44* LD(LDH)-258* AlkPhos-128* TotBili-1.0 [**2187-2-17**] 05:07PM BLOOD Lipase-74* [**2187-2-21**] 03:46AM BLOOD CK-MB-3 cTropnT-0.03* [**2187-3-8**] 12:00AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0 UricAcd-2.0* BLOOD COUNTS: [**2187-2-4**] 06:30PM BLOOD WBC-250.0* RBC-2.96* Hgb-9.2* Hct-25.9* MCV-88 MCH-31.1 MCHC-35.5* RDW-16.5* Plt Ct-77* [**2187-2-4**] 11:30PM BLOOD WBC-245.4* RBC-2.89* Hgb-8.8* Hct-25.5* MCV-88 MCH-30.2 MCHC-34.4 RDW-16.4* Plt Ct-72* [**2187-2-5**] 12:56AM BLOOD WBC-124.0* RBC-2.61* Hgb-8.1* Hct-22.9* MCV-88 MCH-31.1 MCHC-35.4* RDW-17.1* Plt Ct-121*# [**2187-2-5**] 01:25AM BLOOD WBC-101.9* RBC-2.47* Hgb-7.3* Hct-21.8* MCV-88 MCH-29.5 MCHC-33.5 RDW-16.9* Plt Ct-96* [**2187-2-5**] 02:22AM BLOOD WBC-59.4* RBC-2.46* Hgb-7.6* Hct-21.5* MCV-87 MCH-30.8 MCHC-35.2* RDW-16.7* Plt Ct-54* [**2187-2-5**] 03:28AM BLOOD WBC-89.2*# RBC-2.66* Hgb-8.2* Hct-22.9* MCV-86 MCH-30.9 MCHC-36.0* RDW-16.9* Plt Ct-33* [**2187-2-5**] 07:53AM BLOOD WBC-121.7* RBC-2.20* Hgb-6.8* Hct-18.5* MCV-84 MCH-31.1 MCHC-36.9* RDW-17.0* Plt Ct-19* [**2187-2-5**] 02:22PM BLOOD WBC-125.2* RBC-2.73* Hgb-8.5* Hct-22.7* MCV-83 MCH-31.1 MCHC-37.3* RDW-16.8* Plt Ct-58*# [**2187-2-5**] 07:15PM BLOOD WBC-107.1* RBC-2.57* Hgb-7.9* Hct-21.1* MCV-82 MCH-30.9 MCHC-37.5* RDW-17.0* Plt Ct-43* [**2187-2-5**] 07:15PM BLOOD WBC-107.1* RBC-2.57* Hgb-7.9* Hct-21.1* MCV-82 MCH-30.9 MCHC-37.5* RDW-17.0* Plt Ct-43* [**2187-2-6**] 01:56AM BLOOD WBC-107.0* RBC-2.56* Hgb-7.9* Hct-21.3* MCV-83 MCH-30.7 MCHC-36.9* RDW-17.3* Plt Ct-25* [**2187-2-6**] 07:52AM BLOOD WBC-76.3* RBC-2.53* Hgb-7.8* Hct-21.2* MCV-84 MCH-30.7 MCHC-36.8* RDW-17.2* Plt Ct-20* [**2187-2-6**] 02:20PM BLOOD WBC-49.2* RBC-2.86* Hgb-8.5* Hct-23.9* MCV-83 MCH-29.6 MCHC-35.5* RDW-16.5* Plt Ct-16* [**2187-2-7**] 01:53AM BLOOD WBC-25.7* RBC-2.85* Hgb-8.4* Hct-24.0* MCV-84 MCH-29.4 MCHC-34.9 RDW-16.3* Plt Ct-27*# [**2187-2-7**] 08:04AM BLOOD WBC-11.0# RBC-2.63* Hgb-8.0* Hct-22.8* MCV-87 MCH-30.5 MCHC-35.3* RDW-16.2* Plt Ct-19* [**2187-2-7**] 10:51PM BLOOD WBC-1.7*# RBC-2.24* Hgb-6.9* Hct-19.5* MCV-87 MCH-31.1 MCHC-35.7* RDW-15.8* Plt Ct-7*# [**2187-2-8**] 08:04AM BLOOD WBC-1.0* RBC-2.88*# Hgb-9.0*# Hct-25.2*# MCV-87 MCH-31.1 MCHC-35.6* RDW-15.0 Plt Ct-17* [**2187-2-9**] 12:00AM BLOOD WBC-0.3*# RBC-2.77* Hgb-8.5* Hct-23.7* MCV-85 MCH-30.6 MCHC-35.9* RDW-15.1 Plt Ct-27* [**2187-2-9**] 11:24AM BLOOD WBC-0.1*# RBC-2.96* Hgb-9.0* Hct-24.8* MCV-84 MCH-30.3 MCHC-36.2* RDW-14.8 Plt Ct-21* [**2187-2-10**] 12:30AM BLOOD WBC-0.1* RBC-2.75* Hgb-8.4* Hct-22.9* MCV-84 MCH-30.5 MCHC-36.5* RDW-14.9 Plt Ct-6*# [**2187-2-10**] 12:46PM BLOOD WBC-0.1* RBC-2.50* Hgb-7.6* Hct-21.1* MCV-85 MCH-30.3 MCHC-35.8* RDW-14.7 Plt Ct-27* [**2187-2-11**] 12:00AM BLOOD WBC-0.1* RBC-2.95* Hgb-8.8* Hct-25.1* MCV-85 MCH-30.0 MCHC-35.3* RDW-14.6 Plt Ct-20* [**2187-2-11**] 12:08PM BLOOD WBC-0.1* RBC-2.59* Hgb-7.8* Hct-22.0* MCV-85 MCH-30.1 MCHC-35.5* RDW-14.6 Plt Ct-19* [**2187-2-12**] 12:00AM BLOOD WBC-0.1* RBC-2.35* Hgb-7.3* Hct-20.0* MCV-85 MCH-30.8 MCHC-36.2* RDW-14.7 Plt Ct-8*# [**2187-2-13**] 12:35AM BLOOD WBC-<0.1* RBC-3.07*# Hgb-9.1* Hct-25.4*# MCV-83 MCH-29.7 MCHC-35.9* RDW-14.7 Plt Ct-12*# [**2187-2-13**] 05:13PM BLOOD WBC-0.1* RBC-2.61* Hgb-7.6* Hct-21.9* MCV-84 MCH-29.0 MCHC-34.5 RDW-14.9 Plt Ct-18* [**2187-2-14**] 04:30AM BLOOD WBC-.1* RBC-2.86* Hgb-8.8* Hct-24.2* MCV-85 MCH-30.7 MCHC-36.3* RDW-14.8 Plt Ct-14* [**2187-2-15**] 12:00AM BLOOD WBC-0.1* RBC-3.09* Hgb-9.3* Hct-25.9* MCV-84 MCH-30.3 MCHC-36.0* RDW-14.7 Plt Ct-26* [**2187-2-19**] 12:10AM BLOOD WBC-0.1* RBC-2.74* Hgb-8.3* Hct-23.2* MCV-85 MCH-30.2 MCHC-35.6* RDW-14.8 Plt Ct-64* [**2187-2-20**] 12:00AM BLOOD WBC-0.1* RBC-3.03* Hgb-9.2* Hct-25.4* MCV-84 MCH-30.3 MCHC-36.2* RDW-14.5 Plt Ct-27*# [**2187-2-20**] 02:03PM BLOOD WBC-0.2*# RBC-2.98* Hgb-9.0* Hct-24.7* MCV-83 MCH-30.2 MCHC-36.5* RDW-14.5 Plt Ct-56* [**2187-2-21**] 03:46AM BLOOD WBC-0.2* RBC-3.36* Hgb-9.8* Hct-28.3* MCV-84 MCH-29.3 MCHC-34.8 RDW-14.5 Plt Ct-43* [**2187-2-22**] 12:00AM BLOOD WBC-0.1* RBC-3.00* Hgb-8.9* Hct-24.9* MCV-83 MCH-29.5 MCHC-35.5* RDW-14.6 Plt Ct-31* [**2187-2-22**] 11:47AM BLOOD WBC-0.2*# RBC-2.66* Hgb-8.0* Hct-22.3* MCV-84 MCH-30.1 MCHC-35.9* RDW-14.0 Plt Ct-17* [**2187-2-23**] 12:00AM BLOOD WBC-0.2* RBC-2.74* Hgb-7.8* Hct-23.2* MCV-85 MCH-28.4 MCHC-33.6 RDW-14.4 Plt Ct-11* [**2187-2-23**] 12:22PM BLOOD WBC-0.1* RBC-2.47* Hgb-7.5* Hct-20.7* MCV-84 MCH-30.5 MCHC-36.4* RDW-14.4 Plt Ct-86* [**2187-2-24**] 12:10AM BLOOD WBC-0.2*# RBC-3.40*# Hgb-9.8*# Hct-28.9*# MCV-85 MCH-28.7 MCHC-33.8 RDW-14.3 Plt Ct-75* [**2187-2-25**] 12:00AM BLOOD WBC-0.1* RBC-2.91* Hgb-8.7* Hct-24.2* MCV-83 MCH-29.8 MCHC-35.8* RDW-14.2 Plt Ct-45* [**2187-2-26**] 12:30AM BLOOD WBC-0.1* RBC-2.79* Hgb-8.2* Hct-23.4* MCV-84 MCH-29.4 MCHC-35.0 RDW-14.1 Plt Ct-22*# [**2187-2-27**] 06:20AM BLOOD WBC-0.2*# RBC-3.30* Hgb-9.8* Hct-27.1* MCV-82 MCH-29.8 MCHC-36.3* RDW-14.0 Plt Ct-7*# [**2187-2-28**] 12:00AM BLOOD WBC-0.3* RBC-3.21* Hgb-9.5* Hct-26.1* MCV-81* MCH-29.5 MCHC-36.3* RDW-13.8 Plt Ct-37* [**2187-2-28**] 10:40AM BLOOD WBC-0.4* RBC-3.22* Hgb-9.5* Hct-26.7* MCV-83 MCH-29.6 MCHC-35.7* RDW-13.7 Plt Ct-40* [**2187-3-1**] 12:00AM BLOOD WBC-0.4* RBC-2.96* Hgb-8.8* Hct-24.5* MCV-83 MCH-29.6 MCHC-35.8* RDW-13.6 Plt Ct-28* [**2187-3-2**] 12:00AM BLOOD WBC-0.5* RBC-2.83* Hgb-8.4* Hct-22.9* MCV-81* MCH-29.6 MCHC-36.7* RDW-13.5 Plt Ct-89*# [**2187-3-3**] 12:15AM BLOOD WBC-0.8*# RBC-3.12* Hgb-9.1* Hct-25.6* MCV-82 MCH-29.2 MCHC-35.6* RDW-13.5 Plt Ct-81* [**2187-3-4**] 12:00AM BLOOD WBC-0.9* RBC-2.93* Hgb-8.7* Hct-24.1* MCV-82 MCH-29.5 MCHC-35.8* RDW-13.7 Plt Ct-79* [**2187-3-5**] 12:00AM BLOOD WBC-1.3* RBC-3.38* Hgb-9.9* Hct-27.6* MCV-82 MCH-29.3 MCHC-35.9* RDW-14.0 Plt Ct-112* [**2187-3-5**] 12:00AM BLOOD WBC-1.5*# RBC-3.38* Hgb-9.7* Hct-27.5* MCV-81* MCH-28.7 MCHC-35.3* RDW-13.9 Plt Ct-149*# [**2187-3-7**] 12:00AM BLOOD WBC-1.4* RBC-3.12* Hgb-9.1* Hct-25.9* MCV-83 MCH-29.1 MCHC-35.1* RDW-13.8 Plt Ct-168 GRANULOCYTE COUNTS (ANC): [**2187-2-9**] 12:00AM BLOOD Gran Ct-24* [**2187-2-10**] 12:30AM BLOOD Gran Ct-0* [**2187-2-11**] 12:00AM BLOOD Gran Ct-0* [**2187-2-12**] 12:00AM BLOOD Gran Ct-0* [**2187-2-19**] 12:10AM BLOOD Gran Ct-0* [**2187-2-22**] 12:00AM BLOOD Gran Ct-0* [**2187-2-22**] 11:47AM BLOOD Gran Ct-30* [**2187-2-24**] 12:10AM BLOOD Gran Ct-0* [**2187-2-25**] 12:00AM BLOOD Gran Ct-15* [**2187-2-26**] 12:30AM BLOOD Gran Ct-0* [**2187-2-27**] 06:20AM BLOOD Gran Ct-82* [**2187-2-28**] 12:00AM BLOOD Gran Ct-176* [**2187-3-1**] 12:00AM BLOOD Gran Ct-264* [**2187-3-2**] 12:00AM BLOOD Gran Ct-420* [**2187-3-3**] 12:15AM BLOOD Gran Ct-517* [**2187-3-4**] 12:00AM BLOOD Gran Ct-612* [**2187-3-5**] 12:00AM BLOOD Gran Ct-858* [**2187-3-5**] 12:00AM BLOOD Gran Ct-1186* [**2187-3-7**] 12:00AM BLOOD Gran Ct-1000* [**2187-3-8**] 12:00AM BLOOD Gran Ct-1278* [**2187-2-9**] 12:00AM BLOOD proBNP-3746* [**2187-2-17**] 12:13PM BLOOD proBNP-1457* [**2187-2-20**] 02:03PM BLOOD CK-MB-3 cTropnT-0.03* [**2187-2-21**] 03:46AM BLOOD CK-MB-3 cTropnT-0.03* Pancreatic: [**2187-2-13**] 12:35AM BLOOD Lipase-135* [**2187-2-14**] 04:30AM BLOOD Lipase-198* [**2187-2-17**] 05:07PM BLOOD Lipase-74* LFTs: [**2187-2-4**] 06:30PM BLOOD ALT-55* AST-49* LD(LDH)-1490* AlkPhos-140* Amylase-54 TotBili-0.7 [**2187-2-5**] 02:22PM BLOOD ALT-83* AST-135* AlkPhos-126* TotBili-4.0* DirBili-2.0* IndBili-2.0 [**2187-2-5**] 07:15PM BLOOD LD(LDH)-3234* TotBili-4.0* [**2187-2-6**] 01:56AM BLOOD LD(LDH)-2721* TotBili-2.4* [**2187-2-6**] 07:52AM BLOOD ALT-65* AST-69* LD(LDH)-2570* AlkPhos-103 TotBili-1.7* [**2187-2-6**] 02:20PM BLOOD LD(LDH)-2209* TotBili-1.5 [**2187-2-6**] 08:07PM BLOOD LD(LDH)-1847* TotBili-1.3 [**2187-2-7**] 10:51PM BLOOD ALT-36 AST-29 LD(LDH)-1059* AlkPhos-63 TotBili-1.1 [**2187-2-8**] 08:04AM BLOOD ALT-33 AST-28 LD(LDH)-958* AlkPhos-65 TotBili-1.1 [**2187-2-9**] 12:00AM BLOOD ALT-29 AST-30 LD(LDH)-866* AlkPhos-69 TotBili-1.1 [**2187-2-11**] 12:00AM BLOOD ALT-27 AST-35 LD(LDH)-714* AlkPhos-83 TotBili-1.3 [**2187-2-13**] 12:35AM BLOOD ALT-43* AST-56* LD(LDH)-625* AlkPhos-91 Amylase-148* TotBili-2.6* [**2187-2-14**] 04:30AM BLOOD ALT-32 AST-28 LD(LDH)-526* AlkPhos-67 Amylase-182* TotBili-1.4 DirBili-0.7* IndBili-0.7 [**2187-2-15**] 12:00AM BLOOD ALT-27 AST-23 LD(LDH)-518* AlkPhos-71 TotBili-1.3 [**2187-2-17**] 12:00AM BLOOD ALT-21 AST-20 LD(LDH)-423* AlkPhos-59 TotBili-1.5 [**2187-2-19**] 12:10AM BLOOD ALT-17 AST-18 LD(LDH)-366* AlkPhos-56 TotBili-1.7* DirBili-0.9* IndBili-0.8 [**2187-2-21**] 03:46AM BLOOD ALT-23 AST-22 LD(LDH)-393* CK(CPK)-48 AlkPhos-74 TotBili-2.7* [**2187-2-26**] 12:30AM BLOOD ALT-29 AST-24 LD(LDH)-279* AlkPhos-111* TotBili-2.2* [**2187-3-3**] 12:15AM BLOOD ALT-34 AST-33 LD(LDH)-232 AlkPhos-120* TotBili-1.4 [**2187-3-4**] 12:00AM BLOOD ALT-39 AST-36 LD(LDH)-245 AlkPhos-115* TotBili-1.0 [**2187-3-5**] 12:00AM BLOOD ALT-36 AST-29 LD(LDH)-243 AlkPhos-118* TotBili-1.1 [**2187-3-5**] 12:00AM BLOOD ALT-40 AST-34 LD(LDH)-247 AlkPhos-127* TotBili-1.2 [**2187-3-7**] 12:00AM BLOOD ALT-57* AST-58* LD(LDH)-250 AlkPhos-119* TotBili-1.0 [**2187-3-8**] 12:00AM BLOOD ALT-58* AST-44* LD(LDH)-258* AlkPhos-128* TotBili-1.0 NHIBITORS & ANTICOAGULANTS Anticardiolipin Antibody IgG 5.4 GPL 0 - 15 0-15 GPL: NEGATIVE;15-20 GPL: INDETERMINATE; >20 GPL: POSITIVE Anticardiolipin Antibody IgM 5.4 MPL 0 - 12.5 MICROBIOLOGY: Initial Cultures [**2187-2-4**] - [**2187-2-18**] were all negative. afebrile for a while spiked --> positive culture: [**2187-2-25**] BLOOD CULTURE Blood Culture, Routine-FINAL {ENTEROCOCCUS FAECIUM}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL INPATIENT surveilance cultures: [**2187-3-4**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2187-3-4**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2187-3-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2187-3-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2187-3-2**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2187-2-28**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2187-2-27**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2187-2-26**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2187-2-26**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2187-2-25**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT IMAGING: ECHOCARDIOGRAMS: [**2187-2-5**]: The left atrium is mildly dilated. 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 ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. [**2187-2-19**]: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated. A patent foramen ovale is present. LVEF >55%. No masses/thrombi/vegetations. There is no VSD. CHEST X-RAYS: [**2-4**]: UPRIGHT PORTABLE CHEST RADIOGRAPH: No priors are available. Other than some left basal linear atelectasis the lungs appear clear and without evidence of pneumothorax, edema, effusions, or lymphadenopathy. Cardiomediastinal silhouette are within normal limits. No osseous abnormalities are noted. [**2-17**]: Heart size, mediastinal width and pulmonary vascularity remain normal. Worsening patchy and linear opacities at both lung bases, favoring atelectasis over infectious pneumonia and accompanied by small pleural effusions. [**3-2**]: One view. Comparison with [**2187-2-28**]. There is minimal streaky density bilaterally consistent with subsegmental atelectasis as before. There is new blunting of the left costophrenic sulcus with hazy increased density in the lower left chest. The heart and mediastinal structures are unremarkable and unchanged. A central venous catheter remains in place. IMPRESSION: Evidence for development of small left effusion. CT AND MRIs: MRI Head ([**2-16**]): 1. No evidence of acute infarct, mass effect, hydrocephalus, or abnormal enhancement. 2. Low signal within the bony structures due to marrow infiltrative process or hypoplasia. CT ABDOMEN W/CONTRAST Study Date of [**2187-2-16**] 5:28 PM 1. Colonic wall thickening/edema more marked along right colon than the left, similar to 3 days ago, but with increased thickening/edema of terminal ileum. Findings are non-specific, more likely infectious or inflammatory, but given new AML, if the patient is undergoing treatment, typhlitis is possible. Otherwise inflammatory bowel disease such as Crohn's could also be considered. Prominent right lower quadrant mesenteric lymph nodes. 2. Increased ascites and third-spacing compared to three days prior. 3. Splenic infarct as first imaged on [**2187-2-13**]. 4. Small bilateral pleural effusions and adjacent atelectasis. Unchanged liver hypodensities, left adrenal nodule, presacral perirectal multilobulated endometriomas. CT ABDOMEN W/CONTRAST Study Date of [**2187-2-22**] 4:46 PM IMPRESSION: 1. Persistent cecal and terminal ileum wall thickening is again seen although slightly improved compared to prior CT.along the most prominent in the right colon, involving the cecum and proximal ascending colon with involvement of the terminal ileum. 2. Persistent but slightly decreased ascites, simple in attenuation. 3. Increased now moderated size pleural effusions with associated lower lobe atelectasis. 5. Persistent wedge-shaped hypodensity in the spleen consistent with an infarct. 6. Stable left adrenal nodule. 7. Stable presacral and perirectal partially cystic lesion previously characterized as endometriomas. BONE MARROW BIOPSIES: Procedure date Tissue received Report Date Diagnosed by [**2187-2-4**] [**2187-2-5**] [**2187-2-7**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 21496**]/ttl Previous biopsies: [**Numeric Identifier 60209**] ATYPICAL MOLE RLQ (ABD), RE-EXC DYSPLASTIC MOLE LLQ [**Numeric Identifier 60210**] ATYPICAL MOLE LLQ (MID) AND RE-EXCISION DYSPLASTIC MOLE [**Numeric Identifier 60211**] GROWTH (LESION) RIGHT FOREARM AND ATYPICAL NEVUS LLQ X 1 [**Numeric Identifier 60212**] FALLOPIAN TUBE/OVARY FS. SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY: DIAGNOSIS: INVOLVEMENT BY ACUTE MYELOID LEUKEMIA WITH MONOCYTIC DIFFERENTIATION, SEE NOTE. Note: Please correlate with cytogenetic findings. Morphologically and immunophenotypically, this is in keeping with acute monoblastic leukemia (FAB subtype M5a). MICROSCOPIC DESCRIPTION Peripheral Blood Smear: The smear is adequate for evaluation. Erythrocytes appear decreased in number and are normochromic with anisopoikilocytosis, including dacryocytes and ovalocytes. The white blood cell count appears markedly increased, and consists predominantly of large cells with moderate amounts of pale blue cytoplasm, including some with granules, round to indented nuclei, [**Doctor Last Name **] open chromatin, and prominent nucleoli. Platelet count appears decreased. Differential count shows 2% neutrophils, 3% lymphocytes, 1% eosinophils, 94% blasts (43% monoblasts, 51% promonocytes). Some contain few granules and some have indented nuclei, morphologically resembling monoblasts and promonocytes. Aspirate Smear: The aspirate material is adequate for evaluation, and consists of several hypercellular spicules consisting primarily of monoblasts and promonocytes with morphology similar to that seen in the peripheral smear. The residual hematopoietic marrow elements are scant. Megakaryocytes are present in decreased numbers; abnormal forms are not seen. Differential shows: 90% Blasts (57% monoblasts, 33% promonocytes), less than 1% Promyelocytes, less than 1% Myelocytes, less than 1% Metamyelocytes, less than 1% Bands/Neutrophils, 2% Plasma cells, 3% Lymphocytes, less than 1% Erythroid. Blasts include monoblasts and promonocytes. Occasional scattered eosinophilic precursors are seen. Clot Section and Biopsy Slides: The biopsy material is adequate for evaluation, and consists of a 1.5 cm core biopsy of trabecular bone. Overall cellularity is estimated to be greater than 90%, and largely consists of large atypical cells morphologically consistent with blasts. Residual hematopoietic elements are scant. Touch prep adds no additional information. Special Stains: Iron stain is adequate for evaluation. Storage iron is normal. No sideroblasts or ringed sideroblasts are seen however these are difficult to assess due to the scant numbers of erythroid precursors present. Flow cytometry studies: show blasts expressing CD4 (dim), HLA-DR, CD33, CD15, CD11c, CD64, CD56, CD71, CD14 (subset). Cytogenetics Report BONE MARROW - CYTOGENETICS Procedure Date of [**2187-2-5**] Specimen Type: BONE MARROW - CYTOGENETICS Lab #: [**Numeric Identifier 60213**] Date and Time Taken: [**2187-2-4**] 8:15 PM Date Processed: [**2187-2-5**] Requesting Physician: [**Name (NI) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Location: INPATIENT Cell culture was established to provide metaphase cells for chromosome analysis. However, no metaphases were available from this specimen, therefore the cytogenetic analysis could not be performed. Please see results of FISH analysis below. -------------------INTERPHASE FISH ANALYSIS, 100-300 CELLS------------------- nuc ish(D8Z2x2),(MLLx2)[100] FISH evaluation for a MLL rearrangement was performed on nuclei with the LSI MLL Dual Color, Break Apart Probe (Vysis) at 11q23 and is interpreted as NORMAL. No rearrangement was observed in 100/100 nuclei, which is within the range of a normal hybridization pattern (up to 1%) established for this probe in our laboratory. A normal MLL FISH finding can result from absence of a MLL rearrangement, from a variant MLL rearrangement, or from an insufficient number of neoplastic cells in the specimen. FISH evaluation for a chromosome 8 aneuploidy was performed with the Vysis CEP 8 DNA Probe (chromosome 8 alpha satellite DNA) at 8p11.1-q11.1 and is interpreted as NORMAL. Two hybridization signals were detected in 95/100 nuclei examined, which is within the normal range (up to 6%) for this probe in our laboratory. A normal chromosome 8 FISH finding can result from absence of trisomy for chromosome 8 or from an insufficient number of neoplastic cells in the specimen. This test was developed and its performance determined by the [**Hospital1 18**] Cytogenetics Laboratory as required by the CLIA '[**65**] regulations. It has not been cleared or approved by the U.S. Food and Drug Administration. This test is used for clinical purposes. D8Z2 at 8p11.1-q11.1 MLL 5' probe at 11q24 MLL 3' probe at 11q24 Cytogenetics Report BONE MARROW - CYTOGENETICS Procedure Date of [**2187-2-20**] Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 60214**],[**Known firstname **] A [**2136-5-25**] 50 Female [**Numeric Identifier 60215**] [**Numeric Identifier 60216**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 21496**], La,[**Doctor Last Name **]/mtd SPECIMEN SUBMITTED: BONE MARROW (1 JAR) Procedure date Tissue received Report Date Diagnosed by [**2187-2-20**] [**2187-2-20**] [**2187-2-22**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 21496**]/dsj?????? Previous biopsies: [**Numeric Identifier 60217**] Immunophenotyping, CSF [**Numeric Identifier 60218**] immunophenotyping - BM [**Numeric Identifier 60219**] BONE MARROW BIOPSY (1 JAR). [**Numeric Identifier 60209**] ATYPICAL MOLE RLQ (ABD), RE-EXC DYSPLASTIC MOLE LLQ (and more) SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY: DIAGNOSIS: Markedly hypocellular marrow (less than 5% cellular), status post chemotherapeutic ablation. MICROSCOPIC DESCRIPTION Peripheral Blood Smear: The smear is adequate. Erythrocytes appear decreased in number, are mildly hypochromic with anisopoikilocytosis including bite cells, echinocytes, acanthocytes, dacrocytes, and microcytes. The white blood cell count appears markedly decreased. Platelet count appears decreased; large forms are not seen. Differential count shows 100% lymphocytes. Aspirate Smear: The aspirate material is adequate and consists of several hypocellular spicules composed of stromal cells, histiocytes, plasma cells, and lymphocytes. Hemosiderin laden macrophages are present. Clot Section and Biopsy Slides: The biopsy material is adequate and consists of a 1.1 cm core of trabecular bone. Overall cellularity is less than 5%, and consists largely of plasma cells and lymphocytes. The remainder is composed of stromal cells, macrophages, and background eosinophilic material consistent with ablative chemotherapy. Marrow clot section is similar to the biopsy. Specimen Type: BONE MARROW - CYTOGENETICS Lab #: [**Numeric Identifier 60220**] Date and Time Taken: [**2187-2-20**] 1:30 PM Date Processed: [**2187-2-20**] Requesting Physician: [**Name (NI) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Location: INPATIENT Cell culture was established to provide metaphase cells for chromosome analysis. Please see results of karyotype below. -------FOCUSED ANALYSIS-------- KARYOTYPE: 46,XX[6] INTERPRETATION: No cytogenetic aberrations were identified in 6 metaphases analyzed from this unstimulated specimen. This normal result does not exclude a neoplastic proliferation. Mosaicism and small chromosome anomalies may not be detectable using the standard methods employed. This study does not represent a full cytogenetic analysis of 20 cells due to poor growth of the specimen in culture. -------INTERPHASE FISH ANALYSIS, 100-300 CELLS--------- nuc ish(ETO,AML1)x2[100] FISH evaluation for an AML1-ETO rearrangement was performed on nuclei with the LSI AML1/ETO Dual Color, Dual Fusion Translocation Probe ([**Doctor Last Name 7594**] Molecular) for ETO at 8q22 and AML1 at 21q22 and is interpreted as NORMAL. No rearrangement was observed in 98/100 nuclei, which is within the normal range (up to 1% dual rearrangement and 3% technical artifact) for this probe in our laboratory. A normal finding can result from absence of an AML1-ETO rearrangement, from a variant AML1-ETO rearrangement, or from an insufficient number of neoplastic cells in the specimen. This test was developed and its performance determined by the [**Hospital1 18**] Cytogenetics Laboratory as required by the CLIA '[**65**] regulations. It has not been cleared or approved by the U.S. Food and Drug Administration. This test is used for clinical purposes. Pathology Examination Procedure date Tissue received Report Date Diagnosed by [**2187-3-6**] [**2187-3-8**] [**2187-3-8**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/aas?????? Previous biopsies: [**Numeric Identifier 60221**] BONE MARROW (1 JAR) [**Numeric Identifier 60215**] BONE MARROW (1 JAR) [**Numeric Identifier 60217**] Immunophenotyping, CSF [**Numeric Identifier 60218**] immunophenotyping - BM (and more) FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: CD4, CD14, CD15, CD19, CD33, CD56, CD45, CD117. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize blast yield. A limited panel is performed to look for residual disease. Approximately 6% of total analyzed events co-express CD4, CD56, CD33, CD14 and CD15. INTERPRETATION The findings are suspicious for increased blasts. However, this small population of blasts cannot be further distinguished, due to lack of unique markers. The differential diagnosis includes residual/blasts relapse of leukemia vs regenerating myeloblasts. CSF: Cytology Report SPINAL FLUID Procedure Date of [**2187-2-23**]: NEGATIVE FOR MALIGNANT CELLS. Cytology Report SPINAL FLUID Procedure Date of [**2187-3-1**]: NEGATIVE FOR MALIGNANT CELLS. Rare mature lymphocytes. Brief Hospital Course: 50-year-old woman with HTN and hyperlipidemia here with hyperleukocytosis with WBC 250,000 with smear suggesting of acute myeloid leukemia. # Acute Monoblastic Leukemia: presented with one week of muscle aches, neck tenderness, several bruises, and fever, found to have WBC 233,000, and bone marow biopsy showing acute monoblastic leukemia (FAB subtype M5a) with monocytic differentiation. Treated with 7+3 regimen (cytarabine and idarubicin) with significant complications of prolonged neutropenic fever, typhlitis, mucositis, all discussed separately. D14 BM Biopsy showed 5% cellularity without blasts. D28 BM biopsy, however, was concerning for increased blasts, but could not be further analyzed due to lack of markers. # CNS Involvement: Concern for CNS involvement of disease partly due to perceived mental status changes although in context of significant pain and medication. LP showed no specific malignant cells but a high monocyte count felt to be concerning for leptomeningeal spread of disease. Started on 10 dose (2/week x 5 week) course of IT MTX and cytarabine. Intrathecal Chemo Doses: [**2-18**] IT Ara C, [**2-23**] IT Cytarabine, [**3-1**] IT Cytarabine, [**3-5**] IT MTX, [**3-8**] IT Cytarabine. # Febrile Neutropenia/VRE Bacteremia: Admitted ([**2-4**]) with fever to 101.7 which rose to 103.2 on day #2 and peaked at 104.9 on [**2-10**]. No source of infection was initially found, and she was empirically treated initially with vancomycin, cefepime and fluconazole but continued to spike. She developed significant typhlitis (discussed below) which was felt to be a possible source of infection, and then blood cultures on [**2-25**] grew out VRE in [**2-15**] bottles. She was treated with a 14 day course of daptomycin which was continued via PICC line at the time of discharge to run through [**2187-3-12**]. Fevers gradually resolved. She was afebrile for 3 days prior to discharge. # Typhlitis (pseudomembranous enterocolitis): Developed severe abdominal pain after becoming neutropenic. CT abdomen/pelvis significant for colonic wall thickening/edema suggestive of typhilitis in the setting of treatment for AML. Developed peritoneal signs on exam including significant rebound tenderness. Surgery consulted however no surgical intervention appropriate. Treated with bowel rest, IVF, TPN, and continued antibiotics, as well as glutamine and antiemetics. Resolved gradually with rising ANC and patient's diet was slowly advanced. She was tolerating regular food without difficulty across the final two days of her hospitalization. # Mucocitis: Patient developed severe Grade III mucositis as she became neutropenic. Treated with Caphosol, Gelclair, acyclovir and morphine PCA. Improved as ANC rose. # Hypertension: Patient with a history of hypertension on atenolol and lisinopril at home. Lisinopril was initially held due to the risk of renal failure during the initial treatement course and atenolol was switched to [**Hospital1 **] metoprolol due to ease of dosing control. She remaind hypertensive across much of her admission with difficulty controlling BPs on a range of medications. She was transferred back to the ICU briefly for hypertensive urgency in the context of severe pain from typhlitis. No evidence of end organ damage by history or exam. BPs improved with increased pain control but she remained hypertensive across most of the remainder of her hospitalization. Her pressures normalized during the final three days of her hospitalization with amlodipine on top of an increased doses of her home beta blocker and her regular home lisinopril. The resolution of her pain, however, was felt to have played the greatest role. # Hyperleukocytosis: Patient presented with one week of muscle aches, neck tenderness, several bruises, and fever, found to have WBC 233,000 concerning for acute leukemia. On admission she underwent leukopheresis and was started on hydroxyurea and allopurinol. Her WBC decreased acutely after leukopheresis but then began to rapidly increase, and then came down with further hydroxyurea. # ARF: Developed ARF on second day of hospitalization with creatinine rising to 2.0 from 1.0 on admission. Gradually resolved with IVF. Remained stable at 0.7-0.9 across last three weeks of hospitalization. # DIC: Developed DIC on second day of hospitalization in settting of AML with leukocytosis. DIC resolved shortly without further complications. # Hypoxic Respiratory Distress: Developed hypoxic respiratory distress [**2-13**] fluid overload in context of significant IVF given for ARF and DIC previous mentioned. No intubation. Resolved with lasix. Small pleural effusion noted on imaging close to discharge. # Hyperbilirubinemia: Brief rise in conjugated bilirubin in the setting of fevers concerning for obstructive process although with normal LFTs. RUQ U/S showed sludge but no evidence of cholelithiasis/cholangitis. Resolved shortly thereafter. # Splenic Infarct: Incidentally found on CT scan, unclear age and etiology. Small PFO on bubble study. Partial coagulopathy workup negative, appropriate for outpatient follow up. # Radiographic Abnormalities for Outpatient Follow-Up: In addition to the splenic infarct CTs and MRIs showed persistent liver hypodensities (previously seen on imaging), a left adrenal nodule, and presacral perirectal multilobulated endometriomas previously seen on MR in [**2185-3-17**]. Medications on Admission: atenolol 25 mg qday lisinopril 10 mg qday bupropion (not compliant) simvastatin Discharge Medications: 1. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours): infuse 400mg daily through [**2187-3-12**]. [**Month/Day/Year **]:*qs Recon Soln(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Month/Day/Year **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* NOTE: this was changed to Omeprazole 20mg after discharge due to lack of insurance coverage for pantoprazole. 3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). [**Month/Day/Year **]:*60 Tablet(s)* Refills:*2* 4. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. [**Month/Day/Year **]:*30 Tablet(s)* Refills:*0* 5. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety, nausea, insomnia. [**Month/Day/Year **]:*40 Tablet(s)* Refills:*1* 6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-13**] Sprays Nasal TID (3 times a day) as needed for dry nose. [**Month/Day (2) **]:*qs * Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Month/Day (2) **]:*60 Capsule(s)* Refills:*2* 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Day (2) **]:*30 Tablet(s)* Refills:*2* 9. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Day (2) **]:*30 Tablet(s)* Refills:*2* 10. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours. [**Month/Day (2) **]:*40 Tablet(s)* Refills:*2* 11. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Five (5) Tablet Sustained Release PO once a day: Take 5 tablets daily through [**2187-3-12**], and then as directed by your physician. [**Name Initial (NameIs) **]:*50 Tablet Sustained Release(s)* Refills:*0* 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: please take only as needed for significant pain. [**Name Initial (NameIs) **]:*25 Tablet(s)* Refills:*0* 13. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2* 14. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2* 15. Hair Prosthetic ICD: 205.00 Dispense #2 Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Acute Myeloid Leukemia Hypertension Typhlitis 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 during your admission at [**Hospital1 69**]. You were admitted for acute myeloid leukemia. You were treated with chemotherapy as well as antibiotics. You developed a few complications during your treatment which included ongoing fevers, typhlitis (an inflammation of the bowel during chemotherapy), mucositis, and high blood pressure. The fevers, typhlitis and mucositis have all now resolved. Your high blood pressures have come down with some new medications. We have changed several of your medications during this admission. Please take your medications exactly as prescribed. Please follow up with your oncologist as directed below. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2187-3-12**] 12:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**] Date/Time:[**2187-3-12**] 12:30

[ "E933.1", "311", "782.4", "276.6", "206.00", "793.99", "528.09", "041.04", "286.6", "272.4", "745.5", "401.9", "288.00", "584.9", "790.7", "518.82", "724.5", "617.9", "799.02", "780.61", "558.9", "322.0", "511.9", "338.29" ]

icd9cm

[ [ [] ] ]

[ "99.72", "41.31", "03.31", "38.93", "99.25", "03.92" ]

icd9pcs

[ [ [] ] ]

35574, 35626

27702, 33104

338, 413

35716, 35716

2088, 2093

36566, 36891

1572, 1643

33234, 35551

35647, 35695

33130, 33211

35864, 36543

1658, 2069

274, 300

2693, 27679

441, 1408

2107, 2674

35731, 35840

1430, 1461

1477, 1556

53,268

191,728

52270

Discharge summary

report

Admission Date: [**2174-2-20**] Discharge Date: [**2174-2-21**] Date of Birth: [**2107-2-24**] Sex: F Service: MEDICINE Allergies: Aspirin / Nsaids Attending:[**First Name3 (LF) 2297**] Chief Complaint: "food stuck in throat" Major Surgical or Invasive Procedure: EGD [**2174-2-21**] History of Present Illness: 66yo woman with h/o esophageal food impactions requiring endoscopies, hypertension, left renal cell cancer s/p left nephrectomy, and asthma p/w esophageal food impaction. Pt was eating chicken at a Chinese restaurant this evening around 5pm when she felt the chicken get stuck in her throat. Since then she has been unable to tolerate any PO intake, including water, and is not tolerating most of her own secretions either. She is able to talk in full sentences, and denies any dyspnea, fevers, chills, or abdominal pain. She denies any heartburn or odynophagia, but endorses occasional dysphagia. She denies any h/o esophageal stricture or ring but states prior impactions were related to spasm and anxiety. . In the ED, initial Vitals: 97 90 158/101 20 100%RA. EKG: SR, NSST-T changes. GI was consulted and recommended 1mg of glucagon to facilitate passage. Glucagon 1mg given without effect and patient admitted to MICU for endoscopy. VS prior to transfer: 89 141/83 18 100%RA . On arrival to the floor, she reports ongoing sensation of food bolus and inability to tolerate secretions. Denies CP or any other symptoms at this time. . ROS: (+) small amount of blood on toilet paper today associated with strained BM. + constipation. Also endorses recent intermittent chest pain over the last 4-5 days associated with cough and rhinorrhea. Granddaughter and multiple family memebers also with cold symptoms. CP not exertional but worse laying flat. She has nto had any since yesterday evening. Denies dysuria, leg swelling, leg pain, palpitations, HA. Past Medical History: Hypertension Left renal cell carcinoma s/p nephrectomy Osteoarthritis pn narcotics contract Asthma ? PUD h/o positive PPD treated with INH. 3 episodes of food impaction requiring EGD in past . PAST SURGICAL HISTORY: s/p breast biopsy 32 years ago, normal s/p cholecystectomy and appendectomy s/p nephrectomy Social History: She smoked until 10 years ago and then quit. Rare alcohol use (last drink 3 months ago), no drug use. She is trying to lose weight and has been exercising more and has effectively lost some weight, although she is still 210 and her BMI is 38.4. Not employed. Raised 6 chldren and 15 grandchildren. Family History: Father had [**Name2 (NI) 499**] cancer at 62, cousins also had [**Name2 (NI) 499**] cancer. Aunt had breast cancers, two was at 70 and 74 and father had diabetes, hypertension, end-stage renal disease and died of an MI at 63, also her brother did have the same diseases. Her mother had a mole, and there was a cousin that had pancreatic cancer. Physical Exam: GEN: pleasant, comfortable, NAD, speaking in full sentences HEENT: PERRL, EOMI, anicteric, MM slightly dry, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules. Poor dentition with multiple loose teeth RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly. CCY and nephrectomy scar well healed. EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. Pertinent Results: [**2174-2-21**] 06:04AM BLOOD WBC-8.2 RBC-4.62 Hgb-12.5 Hct-36.4 MCV-79* MCH-27.0 MCHC-34.3 RDW-13.7 Plt Ct-209 [**2174-2-20**] 10:25PM BLOOD WBC-8.8 RBC-4.86 Hgb-13.2 Hct-38.0 MCV-78* MCH-27.1 MCHC-34.7 RDW-13.5 Plt Ct-219 [**2174-2-21**] 06:04AM BLOOD Neuts-74.1* Lymphs-20.0 Monos-3.5 Eos-1.9 Baso-0.5 [**2174-2-20**] 10:25PM BLOOD Neuts-74.5* Lymphs-19.7 Monos-3.3 Eos-1.9 Baso-0.7 [**2174-2-21**] 06:04AM BLOOD PT-13.5* PTT-26.1 INR(PT)-1.2* [**2174-2-20**] 10:25PM BLOOD PT-13.3 PTT-24.8 INR(PT)-1.1 [**2174-2-21**] 06:04AM BLOOD Glucose-102* UreaN-12 Creat-0.6 Na-141 K-3.2* Cl-101 HCO3-28 AnGap-15 [**2174-2-20**] 10:25PM BLOOD Glucose-90 UreaN-10 Creat-0.8 Na-142 K-3.4 Cl-100 HCO3-28 AnGap-17 [**2174-2-21**] 06:04AM BLOOD CK(CPK)-41 [**2174-2-21**] 06:04AM BLOOD CK-MB-2 cTropnT-<0.01 [**2174-2-21**] 06:04AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.0 Imaging/Studies: CXR: Heart size is normal. Mediastinum is unremarkable. This study neither confirms nor excludes the possibility of non-radiopaque foreign body in the esophagus and if clinically warranted, further correlation with CT or barium swallowing (upper GI study) should be considered. Lungs are clear. There is no pleural effusion or pneumothorax. Multiple osteophytes of the thoracic spine are demonstrated on the lateral projection. EGD: Impression: Food in the lower third of the esophagus (foreign body removal) Erythema and congestion in the lower third of the esophagus Erythema and congestion in the whole examined stomach No esophageal stenosis or stricture Diverticulum in the upper third of the esophagus Otherwise normal EGD to stomach body Recommendations: The findings account for the symptoms, and the residual food bolus in the esophagus is known to be non-obstructing. No esophageal stenosis or stricture noted, so symptoms are likely due to an esophageal dysmotility issue. NPO for now, trial of clear liquid sips in AM. If does not tolerate sips, will need repeat endoscopy in AM. Brief Hospital Course: 66F with HTN, asthma, recurrent food impactions requiring endoscopy now presenting with likely food impaction. . 1. Esophageal food impaction: Pt has h/o recurrent food impactions requiring endoscopy although none in our system. Given inability to control own secretions, she is being admitted to MICU for endoscopy. Differential diagnosis of recurrent food impaction includes mechnical obstruction such as stricture or ring or eosinophilic esophagitis. GI was consulted who performed the EGD on [**2174-2-21**] which showed no stricture or mass, just erythema. After EGD, pt's symptoms improved and per their recs, pt's diet was advanced as tolerated. Pt was then discharged home with outpt GI f/u appt and a esophageal dysmotility study in 2 weeks. . 2. Chest pressure: Has had intermittent chest pain last [**4-19**] days associated with viral symptoms and worse with laying flat. Differential diagnosis includes pericarditis, bronchitis. Unlikely secondary to or [**Location (un) **] related to food impaction and/or recent cough/cold symptoms. CXR without acute infiltrate or e/o perforation and ECG WNL. Pt was ruled our for MI with neg CEs. The chest pressure resolved. . 3. HTN: Pt was continued on home HCTZ . 4. Asthma: Pt was continued on flovent, albuterol prn . 5. BRBPR: Likely secondary to hemorrhoids given symptoms occurred with strained BM in setting of constipation. Hct remained stable requiring no transfusions and pt was hemodynamically stable throughout hospital stay. . 6. Chronic pain: Pt was continued on home percocet . Pt was initially NPO, then advanced diet after EGD. Pt was on Heparin SC for DVT ppx. Pt was full code. Medications on Admission: Albuterol sulfate [ProAir HFA] 90 mcg HFA Aerosol Inhaler [**1-16**] puffs(s) by mouth every four (4) hours as needed for wheezing -not taking Fluticasone [Flovent HFA] 220 mcg Aerosol [**1-16**] inhaled(s) [**Hospital1 **] Hydrochlorothiazide 25 mg Tablet 1 Tablet(s) by mouth daily Oxycodone-acetaminophen [Roxicet] 5 mg-325 mg Tablet 0.5-1 Tablet(s) by mouth every 6 hours as needed for pain Triamcinolone acetonide 0.1 % Cream apply twice a day Senna 8.6 mg Tablet 2 Tablet(s) by mouth at bedtime prn Tums or maalox Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Esophageal dysmotility disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 100627**], It was a pleasure taking care of you here at [**Hospital1 18**]. You were admitted because you had a sensation of fodd being stuck in your throat. You underwent a upper endoscopy that showed no mass or stricture, so your symptoms are likely due to an motility issue. Your diet was then advanced which you tolerated well. You were discharged home with follow-up with the gastroenterology doctors in the [**Name5 (PTitle) **]. No changes were made to your medications. Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2174-3-9**] at 3:30 PM With: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], 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 You also currently have a esophageal dysmotility study ordered for [**3-16**] at 7 am. Department: REHABILITATION SERVICES When: THURSDAY [**2174-2-24**] at 2:50 PM With: [**Name (NI) **] DING, PT, DPT [**Telephone/Fax (1) 2484**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: THURSDAY [**2174-2-24**] at 12:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2174-2-21**]

[ "935.1", "564.00", "V58.69", "401.9", "338.29", "455.8", "V15.82", "493.90", "E849.0", "786.59", "E915", "V10.52", "V45.73", "530.5", "750.4" ]

icd9cm

[ [ [] ] ]

[ "44.13", "98.02" ]

icd9pcs

[ [ [] ] ]

8304, 8310

5514, 7174

300, 322

8386, 8386

3524, 5491

9073, 10133

2573, 2920

7745, 8281

8331, 8365

7200, 7722

8537, 9050

2146, 2240

2935, 3505

238, 262

350, 1908

8401, 8513

1930, 2123

2256, 2557

83,122

188,313

17406

Discharge summary

report

Admission Date: [**2157-6-19**] Discharge Date: [**2157-6-27**] Date of Birth: [**2086-7-14**] Sex: F Service: NEUROSURGERY Allergies: Bactrim Attending:[**First Name3 (LF) 78**] Chief Complaint: Large left acute on chronic SDH, Right subacute-chronic SDH Major Surgical or Invasive Procedure: [**2157-6-21**] bilateral craniotomies for evacuation of SDH History of Present Illness: 70 yo F presents with progressive confusion and gait instability. Pt is confused and unable to contribute to HPI reliably but her friend is able to report a fall back in [**Month (only) 116**] and recent UTIs. OMR reveals a complaint of gait instability for over a month with a visit to her PCP [**Last Name (NamePattern4) **] [**6-6**]. It appears the patient had a syncopal fall with head strike the first week of [**2157-4-19**], diagnosed with a UTI at that time. No Head imaging was performed. Past Medical History: GERD Social History: Lives independently. She does not smoke. Alcohol one drink a day. Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM: O: T: 98.3 HR: 79 BP: 131/50 RR:18 Sat: 99% ra Gen: WD/WN, comfortable, NAD. HEENT: Normocephalic, atraumatic Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: AOx2 to person and place, not to date, cooperative with exam but unable to follow 2 step commands Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Minimal perseveration Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: decreased bulk and normal tone bilaterally. No abnormal movements, tremors. Strength full power [**4-23**] throughout. No pronator drift Appears to have a mild right sided neglect Sensation: Decreased on right upper and lower, fails to discriminate on right, Intact to light touch on left DISCHARGE PHYSICAL EXAM: -CN II-XII grossly intact, trace right nasolabial fold flattening -Strength 5/5 in all 4 extremities, no pronator drift -Sensation full in all 4 extremities Pertinent Results: ADMISSION LABS: -WBC-6.4 RBC-4.16* Hgb-13.3 Hct-39.5 MCV-95 MCH-31.8 MCHC-33.5 RDW-12.5 Plt Ct-364# -Neuts-65.9 Lymphs-26.6 Monos-3.9 Eos-2.9 Baso-0.7 -PT-11.4 PTT-30.8 INR(PT)-1.1 -Glucose-98 UreaN-10 Creat-0.7 Na-142 K-4.1 Cl-108 HCO3-24 AnGap-14 CT HEAD WITHOUT CONTRAST ([**2157-6-19**]): Large left convexity, likely acute-on-chronic large subdural hematoma with hyperdense components in the left frontal, parietal, and occipital locations. Large right frontal likely subacute chronic subdural hematoma. No definite intra-axial hemorrhage. Effacement of left sulci and minimal rightward shift. CXR ([**2157-6-19**]): No acute intrathoracic process. CT HEAD WITHOUT CONTRAST ([**2157-6-21**]): Interval evacuation of bilateral subdural hematomas. A small focus of acute hemorrhage near the right vertex is noted. A residual 16 mm collection persists in the left hemisphere. CT HEAD WITHOUT CONTRAST ([**2157-6-23**]): Post-surgical changes after bilateral subdural hematoma evacuation. Significant interval decrease in size of the left subdural collection, and slight interval decrease in right subdural collection, now with 4 mm leftward shift of normally midline structures. No new hemorrhage Brief Hospital Course: Ms. [**Known lastname **] is a 70 yo F with h/o EtOH abuse and fall with headstrike in [**4-30**] presenting with increasing confusion and gait ataxia, found to bilateral subacute SDH. # BILATERAL SUBACUTE SDH: Likely multifactorial etiology, risk factors include EtOH abuse, age, and fall with headstrike in [**Month (only) 116**] [**2156**], with slow accumulation of blood resulting in progressive neurologic deficits. Patient was admitted to neurosurgery and taken to neurologic ICU for close monitoring. On initial exam, she was AAOx2 with R sided neglect and RLE weakness 4/5. For seizure prophylaxis, she was loaded with dilantin 1gram and started on 100mg TID. She received hydralazine PRN to keep SBP<140. Her neuro exam waxed and waned in ICU likely secondary to delirium superimposed on continued expansion of SDH. On HD#3 patient had bilateral craniotomies to evacuate subdural hematomas. The procedure was uncomplicated and a drain was placed on the right. Post-op she was extubated and transferred to the ICU for observation. By HD #4 (POD #1) her neuro exam had dramatically improved: she was AAOx3, able to follow commands, normal speech and comprehension, full strength in all extremities. Post-op head CT showed pneumocephalus but no hemorrhage; drain was removed. On HD #5 she was transferred to the floor where she remained neurologically stable. She worked with physical therapy who recommended placement in rehab. # SIMPLE PARTIAL SEIZURE: On HD #7 patient had two episodes of simple partial seizures consisting of right facial twitch. Her corrected dilantin level was found to be low at 8.9, so she received a 500mg dilantin bolus and dilantin uptitrated to 150mg PO TID. Her goal Dilantin level is 15-20. Should recheck level in one week on [**2157-7-3**]. # URINARY FREQUENCY: Pt complained of urinary frequency on admission. She was started on empiric Ciprofloxacin while UA and urine cultures were pending. UA was benign and UCx negative, so Cipro was DC'd on [**6-21**]. # GERD: continued home omeprazole ============================== TRANSITION OF CARE: -Please check dilantin level on [**2157-7-3**], goal 15-20 -Needs head staples removed at [**Hospital 18**] [**Hospital 4695**] clinic between [**Date range (1) 48662**] Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Omeprazole 20 mg PO BID 2. Vitamin D Dose is Unknown PO Frequency is Unknown Discharge Medications: 1. Omeprazole 20 mg PO BID 2. Acetaminophen 325-650 mg PO Q6H:PRN Pain or fever > 38.5 3. Vitamin D 0 UNIT PO DAILY 4. Phenytoin Infatab 150 mg PO TID Discharge Disposition: Extended Care Facility: [**Hospital 3137**] Care Center - [**Location (un) 1468**] Discharge Diagnosis: Bilateral subacute SDH Left > right Encephalopathy 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: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? **Your wound was closed with staples. You may wash your hair only after 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. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, do not resume them until cleared by your surgeon. ?????? **You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101.5?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office between [**6-30**] - [**7-4**] for removal of your staples. This appointment can be made with the Nurse Practitioner [**First Name (Titles) **] [**Last Name (Titles) **] [**Name Initial (PRE) 19158**]. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast.

[ "348.30", "788.41", "V15.88", "305.00", "E929.3", "432.1", "530.81", "781.8", "908.9", "345.50", "V13.02" ]

icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

6385, 6470

3720, 5981

330, 393

6565, 6565

2487, 2487

8666, 9306

1055, 1060

6209, 6362

6491, 6544

6007, 6186

6748, 8643

1100, 1264

231, 292

421, 926

1531, 2285

2503, 3697

6580, 6724

948, 955

971, 1039

2310, 2468

42,292

138,503

35830+58038

Discharge summary

report+addendum

Admission Date: [**2162-1-16**] Discharge Date: [**2162-1-19**] Date of Birth: [**2098-4-29**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypoglycemia, Motor Vehicle Accident Major Surgical or Invasive Procedure: None History of Present Illness: 63 M w/ pmh of HTN, heavy alcohol use BIBA s/p MVC w/ ? LOC and airbag deployment. He BS 35 at the scene. . In the ED, initial vs were: T 96.8 P 84 BP 140/70 R 17 O2 sat 96% on RA. Neg trauma w/u. Patient was given an Amp D50 w/ persistently low BS now on D10 ggt. Also w/ asp PNA and given levaquin and flagyl. Most recent vitals, afeb, 136/56, 87, 98% on RA. . BS history: BS: 35 @ scene @ 10:20 rec'd 1 amp D50 BS: 58 @ 11:30 in trauma bay rec'd 1 amp D50 + started on D51/2 NS BS: 49 and 38 (2 different machines) @ 13:05 given 1 amp D50 fluid changed to D10 NS BS: 79 @ 14:10 . On arrival, he endorses some anterior chest wall pain from airbag deployment. He denies sob, n/v, abdominal pain. . 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. Denies melana or blood in stools Past Medical History: DM2 HTN Hyperlipidemia Bilateral corneal implants s/p APPY PVD Heart murmur Social History: [**2-24**] ppd tob (up to 2 ppd at times) since age of 15. 6 beers 3 nights per week. Denies etoh seizures or the shakes. Last DUI was 10 year ago. Lives alone. Gets his medical care through the [**Location (un) **] VA. Family History: Mother died of cancer (unknown type). Father had diabetes. Physical Exam: Admission Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Borderline tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly; ttp over R inferior ribs anteriorly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2162-1-16**] 11:53AM BLOOD WBC-11.5* RBC-3.40* Hgb-11.4* Hct-31.9* MCV-94 MCH-33.6* MCHC-35.8* RDW-17.6* Plt Ct-315 [**2162-1-16**] 06:12PM BLOOD PT-12.2 PTT-32.5 INR(PT)-1.0 [**2162-1-16**] 06:12PM BLOOD Glucose-50* UreaN-11 Creat-0.8 Na-131* K-4.1 Cl-97 HCO3-29 AnGap-9 [**2162-1-16**] 11:53AM BLOOD ALT-19 AST-27 AlkPhos-74 TotBili-0.7 Imaging: All [**2162-1-16**] Trauma CXR: Minimally displaced right-sided rib fractures. Patchy right lower hemithorax consolidations. Head CT: IMPRESSION: No evidence of acute intracranial abnormalities. Spine CT: IMPRESSION: 1. No fracture. 2. Multilevel cervical spondylosis with mild spinal canal stenosis. 3. Grade I retrolisthesis at C3/4. Torso CT: 1. Bilateral lower lobe opacities likely reflect aspiaration. 2. Acute right sixth rib fracture anteriorly in the setting of other more remote healing bilateral rib fractures. . 3. Enteroenteric intussusception in the left mid abdomem, 7 cm in length, without evidence of obstruction. 4. Chronic left renovascular disease with delayed excretion of an atrophic left kidney. Brief Hospital Course: This is a 63 M w/ pmh of DM2 on BIBA to ED after MVC w/ negative trauma w/u but found to be persistently hypoglycemic and on glipizide so admitted to ICU for D10 gtt, blood sugars stable thereafter, and patient saturating well on room air (96%). Started patient on outpatient metformin and instructed to follow up in 1 to 2 weeks with his primary care provider. . # Hypoglycemia: Likely from alcohol consumption in the setting of glipizide and lack of other po intake. He tolerated a regular diet and his blood glucose normalized without IV supplementation. He was transfered to the floor where blood sugars remained stable above 100. Patient was started on Metformin and told to stop his home glipizide given this adverse event. Pt. was instructed to follow up with his primary care provider [**Last Name (NamePattern4) **] 1 to 2 weeks. # Alcohol abuse: No h/o withdrawal, into hospital with an etoh level of 153, given thiamine, folate, MVI, and a banana bag, on CIWA scale. Discharged with thiamine and folate. # Anemia: Unclear baseline or etiology. Denies melana or blood stool. No hematuria. Per patient, has had both upper and lower endoscopy w/o any pathology. Would follow up as an outpatient. # Hyponatremia: Likely due to alcohol use and use of HCTZ. Was discontinued on HCTZ and told to follow up with primary care physician as to restarting. # HTN: On multiple agents as outpatient. Held HCTZ at end of stay as noted above, continued fosinopril, HCTZ, amlodipine, clonidine, metoprolol # DM2: Hgb A1C at 4.9, starting patient on metformin as an outpatient. Medications on Admission: Glipizide 2.5 mg daily HCTZ 25 mg daily Fosinopril 40 mg daily ASA 81 mg daily Omeprazole 20 mg daily Metoprolol 100 mg [**Hospital1 **] Cilostazol 100 mg [**Hospital1 **] Simvastatin 20 mg daily Clonidine 0.2 mcg patch q weekly Amlodipine 5 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fosinopril 40 mg Tablet Sig: One (1) Tablet PO daily (). 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Transdermal once a week. 11. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Hypoglycemia Non Insulin Dependent Diabetes Mellitus Alcohol Use Secondary: Hypertension Hyperlipidemia Peripheral Vascular Disease Discharge Condition: Stable, eating, drinking, voiding, and ambulating without complaints. Discharge Instructions: You were admitted for possible alcohol withdrawal and low blood sugars. Upon arrival, because your sugars were so low, you were given several infusions of glucose and monitored in the intensive care unit. You blood sugars increased, and you were sent to the floor where your blood sugars remained stable. Please set up an appointment with your primary care physician [**Last Name (NamePattern4) **] 1 to 2 weeks -- we attempted to do so but were unsuccessful. We have started you on several new medications: START Metformin 500mg Twice Daily START Thiamine 100mg Once Daily START Folic Acid 1mg Once Daily STOP Hydrochlorothiazide 25mg Once Daily STOP Glipizide 2.5mg Once Daily If you experience any lightheadedness, shortness of breath, nausea, vomiting, diarrhea, constipation, severe chest pain, please contact your primary care provider [**Name Initial (PRE) 2227**]. Followup Instructions: Please schedule an appointment with your primary care provider [**Last Name (NamePattern4) **] 1 to 2 weeks. Completed by:[**2162-1-19**] Name: [**Known lastname 5990**],[**Known firstname **] Unit No: [**Numeric Identifier 13058**] Admission Date: [**2162-1-16**] Discharge Date: [**2162-1-19**] Date of Birth: [**2098-4-29**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 429**] Addendum: Would add to "Anemia" under "Brief Hospital Course" that patient had a negative stool guiaic on the day prior to discharge and that Hct rose from 25 to 27 the day of discharge. Would consider initiating a more thorough anemia workup as an outpatient. Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 430**] MD [**MD Number(2) 431**] Completed by:[**2162-1-19**]

[ "486", "883.0", "530.81", "285.9", "303.01", "440.20", "V42.5", "291.81", "E849.5", "E812.0", "780.09", "427.31", "996.31", "305.1", "250.70", "E879.6", "E849.7", "250.80" ]

icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

8364, 8525

3565, 5153

333, 339

6586, 6658

2450, 2450

7583, 8341

1850, 1910

5455, 6371

6421, 6565

5179, 5432

6682, 7560

1925, 2431

257, 295

1084, 1497

367, 1066

2953, 3542

2466, 2944

1519, 1597

1613, 1834

12,149

103,934

9651

Discharge summary

report

Admission Date: [**2121-8-8**] Discharge Date: [**2121-8-12**] Date of Birth: [**2036-10-16**] Sex: F Service: MEDICINE Allergies: lisinopril / morphine / Oxycodone Attending:[**Last Name (un) 2888**] Chief Complaint: short of breath Major Surgical or Invasive Procedure: aortic valvuloplasty [**8-11**] History of Present Illness: REASON FOR TRANSFER: need for BiPAP HISTORY OF PRESENTING ILLNESS: 84 yo with critical aortic stenosis, diastolic heart failure (EF 65%), CAD admitted to [**Hospital1 18**] for surgical evaluation of AS transferred to CCU due to need for BiPAP. Patient was initially admitted to [**Hospital1 **] [**Location (un) 620**] with respiratory distress, thought to be secondary to flash pulmonary edema. She was initially placed on BIPAP and diuresised with IV lasix. Course at [**Location (un) 620**] was complicated by UTI with administration of CTX. Her creatinine was 2.2 from 2.3 with diuresis. Her heart rate was well controlled, and was continued on her home metoprolol. She was transferred to [**Hospital1 18**] for surgical evaluation for her aortic stenosis and possible balloon aortic valvuloplasty. On arrival to BIDNC discussion involving mgmt of AS ensued and decision was made to precede with ballon angioplasty on [**8-11**]. On [**8-10**] patient triggered twice for tachypnea. Initially patient responded to 20mgIV lasix (received a total of 40mg IV) however again became tachypneic and less responsive so discussion was made to transfer to the CCU for initiation of BiPAP. Prior to transfer patient received additional 20mg IV lasix and ipratrium nebulizer. Vitals on transfer were 130/50 80-90sAF RR: 24-28 98-100 3-4LNC. On arrival to the CCU, patient minimally interactive and patient started on BiPAP. REVIEW OF SYSTEMS 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: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: Critical aortic stenosis Diastolic congestive heart failure (EF 65%) Coronary artery disease s/p MI x 2 Atrial fibrillation 3. OTHER PAST MEDICAL HISTORY: Myelodysplastic syndrome Diabetes mellitus Chronic kidney disease, baseline creatinine 1.7 Peripheral [**Month/Year (2) 1106**] disease Peripheral neuropathy Gout Anemia of chronic disease Bilateral carotid artery stenosis Dementia Peptic ulcer disease Osteoarthritis Depression Anxiety MEDICATIONS: (home) Januvia 100 mg PO daily Gabapentin 100 mg PO daily Mirtazapine 30 mg PO daily Carvedilol 25 mg PO BID Torsemide 60 mg PO daily Docusate 100 mg PO daily Pravastatin 80 mg PO daily Clopidogrel 75 mg PO daily Vitamin B12 500 mg PO daily Omeprazole 20 mg PO daily Allopurinol 200 mg PO daily Warfarin 2 mg daily alternating with 3 mg PO daily Folic acid 1 mg PO daily Trazodone 100 mg PO daily ALLERGIES: Lisinopril (hyperkalemia) Social History: Lives at home. Uses a walker. Quit smoking several years ago. No alcohol or drug abuse. Family History: Non-contributory Physical Exam: VS: T= 97.8 BP=127/57 HR=85 Afib RR=20 O2 sat=100% on Bipap GENERAL: Depressed affect, Bipap on HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 12 cm CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. systolic ejection murmur in RUSB LUNGS: Scan crackles in RLL, rhonchi over left ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ pitting edema in bilateral lower extremities, radial pulses 1+, DP pulses 1+. Patient mildly cool to touch, small area of warmth and erythema over dorsal aspect of L shin SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Procedures: Coronary Angiography, RLHC, Balloon aortic valvuloplasty Indications: Critical aortic stenosis Staff Diagnostic Physician [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Fellow [**Name6 (MD) **] [**Name8 (MD) **], MD Nurse [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6185**], RN Nurse [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6692**], RN Technologist [**Doctor First Name **] Hokinson, RTR Technologist [**First Name8 (NamePattern2) 5335**] [**Last Name (NamePattern1) 5239**], EMT,RCIS Technical Anesthesia: Local Specimens: None Catheter placement via 5 French pulmonary artery catheter Coronary angiography using 5 French JL3.5 JR4, Dual lumen pigtail Blood Oximetry Information Baseline Time Site Hgb(gm/dL) Sat (%) PO2 (mmHg) Content (ml per dl) 10:09 AM PA 7.80 63 6.68 10:16 AM AO 7.80 100 10.61 Cardiac Output Results Phase Fick C.O.(l/min) Fick C.I. (l/min /m2) TD CO (l/min) 3.30 2.11 Hemodynamic Measurements (mmHg) Baseline Site Sys [**Last Name (un) 6043**] End Mean A Wave V Wave HR PCW 30 22 30 65 AO 127 46 78 62 PA 75 34 55 62 ART 100 62 RV 77 16 25 58 RA 23 28 26 58 Baseline Site Sys [**Last Name (un) 6043**] End Mean A Wave V Wave HR LV 154 27 32 62 AO 137 47 81 59 Valve Results Contrast Summary Contrast Total (ml) Omnipaque (300 mg/ml) 35 Radiation Dosage Effective Equivalent Dose Index (mGy) 386 Radiology Summary Total Runs Total Fluoro Time (minutes) 15.7 Findings ESTIMATED blood loss: < 25 cc Hemodynamics (see above): Coronary angiography: right dominant LMCA: Moderate diffuse lumen irregularities up to 50% LAD: Moderate diffuse lumen irregularities up to 50% LCX: Moderate diffuse lumen irregularities up to 50% RCA: Left dominant Interventional details The patient was placed under general anesthesia and the procedure was performed under TEE guidance. The left brachial artery was exposed by surgical technique and coronary arteriography was performed from the left brachial artery. The aortic valve was then crossed with a 0.014 straight wire and a pigtail catheter was placed in the left ventricle for simultaneous pressure recordings. A 0.035 Amplatz SuperStiff guidewire was placed in the left ventricle and a single balloon inflation was performed using a 18 mm Tyshak II balloon. Immediately after balloon deflation, the patient developed marked hypotension. There was no evidence of aortic regurgitation and no evidence of pericardial fluid. CPR was initiated but the left ventricular contractility continued to worsen. The patient expired at 11:11 AM. The family was notified. Assessment & Recommendations 1. Severe aortic stenosis 2. Non obstructive but diffuse coronary artery disease 3. Unsuccessful balloon aortic valvuloplasty resulting in death ______________________________________ Brief Hospital Course: Ms [**Known lastname 32651**] is a 85 y/o F with PMHx of critical aortic stenosis, CAD, DM2, transferred to the CCU for worsening respiratory distress who underwent aortic valvuplasty with procedure complicated by refractory hypotension and asystolic arrest. # PUMP: Patient with known critical AS and transferred to CCU for monitoring of heart failure symptoms prior to valvuloplasty. She was on bipap briefly and then given lasix IV prn for diuresis. Pt was stabilized for 48hrs prior to procedure. She underwent elective valvuloplasty on [**8-12**]. Unfortunately immediately after balloon deflation, the patient developed marked hypotension. Per cath report there was no evidence of aortic regurgitation and no evidence of pericardial fluid. CPR was initiated but the left ventricular contractility continued to worsen. Patient died on [**8-12**]. Family was notified. #Anxiety: Patient had lots of anxiety leading up to procdure and was treated with zyprexa. #LLE Cellulitis. Treated with Vancomycin in house. CHRONIC ISSUES # Afib. Rate controlled in house. Coumadin was held on arrival in plan for procedure. # CAD, Patient with known occlusion of OM1 by CTA and calcifications of widespread coronaries s/p MIx2. In house contineud on home plavix 75mg, pravastatin 80 mg daily # Diabetes mellitus type 2. Maintained on ISS + lantus in house # Peripheral neuropathy. Continued on renally dosed Gabapentin 100 mg q 24 hrs #PUD. Continued on Omeprazole 20 mg daily Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily 2. Gabapentin 100 mg PO DAILY 3. Mirtazapine 30 mg PO HS 4. Carvedilol 25 mg PO BID hold for sbp<95, hr<55 5. Torsemide 60 mg PO DAILY 6. Docusate Sodium 100 mg PO DAILY 7. Pravastatin 80 mg PO DAILY 8. Clopidogrel 75 mg PO DAILY 9. Cyanocobalamin 500 mcg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Allopurinol 200 mg PO DAILY 12. FoLIC Acid 1 mg PO DAILY 13. Warfarin 2 mg PO DAILY16 14. traZODONE 100 mg PO HS:PRN insomnia Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Aortic Stenosis Discharge Condition: Deceased Discharge Instructions: NA Followup Instructions: NA

[ "424.1", "414.01", "427.31", "276.2", "585.9", "300.00", "356.9", "V15.82", "V58.67", "294.20", "272.4", "412", "682.6", "428.0", "584.9", "403.90", "311", "238.75", "428.33", "274.9", "599.0", "250.00", "443.9" ]

icd9cm

[ [ [] ] ]

[ "35.05" ]

icd9pcs

[ [ [] ] ]

9452, 9461

7324, 8804

308, 341

9520, 9530

4355, 7301

9581, 9586

3494, 3512

9425, 9429

9482, 9499

8830, 9402

9554, 9558

3527, 4336

2479, 2604

253, 270

369, 2353

2635, 3373

2397, 2459

3389, 3478

17,072

117,275

5605

Discharge summary

report

Admission Date: [**2142-6-11**] Discharge Date: [**2142-6-16**] Date of Birth: [**2090-7-25**] Sex: M Service: Medicine - [**Hospital1 139**] Firm CHIEF COMPLAINT: Fever and hypotension HISTORY OF PRESENT ILLNESS: This is a 51 year old male with a history of Type 1 diabetes, cerebrovascular disease, status post renal transplant times two, occasional chronic immunosuppression, who currently presents from rehabilitation with one to two days of fever and decreased sensorium. Today his fever was 103.8. The patient also suffered a mechanical fall on [**2142-5-31**] and had a right femur supracondylar fracture and is status post open reduction and internal fixation on [**2142-6-1**]. During this hospital admission he was noted to have a trilinear depression of blood including a white blood cell count of 1.6, decreased hematocrit of 26 and platelets 47 of unclear etiology. They related to the immunosuppression secondary to questionable Allopurinol versus cytomegalovirus and was started on GCSF. The patient was discharged on [**2142-6-7**] to rehabilitation where he was found to be groggy for the past one to two days and spiked a fever. He was then sent to the Emergency Department for further evaluation. PAST MEDICAL HISTORY: 1. Diabetes mellitus Type 1; 2. Renal transplant times two, a living related transplant in [**2128**], and a cadaver renal transplant in [**2136**]; 3. Peripheral vascular disease, status post bilateral toe amputations and right metatarsal amputation in [**2139-2-10**]; 4. Status post right dorsalis pedis bypass in [**2139-2-10**]; 5. Gastroparesis; 6. Benign prostatic hypertrophy, status post transurethral resection of prostate; 7. Gout; 8. Trilinear bone marrow suppression; 9. Right index finger osteomyelitis; 10. History of falls; 11. History of Methicillin-resistant Staphylococcus aureus; 12. Autonomic neuropathy with orthostatic hypotension; 13. Cytomegalovirus colitis in [**2142-3-10**]. MEDICATIONS ON ADMISSION: 1. Protonix 40 mg q. day; 2. Lopressor 12.5 mg b.i.d.; 3. Insulin sliding scale; 4. Lantis 22 units a day; 5. GCSF; 6. Percocet prn; 7. Oxycontin prn; 8. Colace; 9. Tacrolimus 2 mg; 10. Prednisone 10 mg q. day; 11. ProAmatine 2.5 mg q. day; 12. Celexa; 13. Filgastrim 300 mcg subcutaneous per day; 14. Lasix and Zaroxolyn, note should say resume per Renal; 15. ProAmatine 2.5 mg b.i.d.; 16. Neurontin 100 mg b.i.d. and 600 mg q. PM. SOCIAL HISTORY: The patient lives at [**Hospital3 22500**] House in [**Location (un) 3146**]. He is single. He is not sexually active. he denies any history of Neisseria or Chlamydia infection. The previous two years he lived with his mother and father who are passed away. He occasionally drinks alcohol and in the past he used to smoke a pipe. PHYSICAL EXAMINATION: Temperature currently is 103.8, blood pressure 88/42, heartrate 70, oxygen saturations 95% on 3 liters of nasal cannula. In general he appeared chronically ill-appearing, tired. Head, eyes, ears, nose and throat, anicteric sclera, in his right he is blind, his oropharynx was clear. He had moist mucous membranes. Neck examination was supple, he had no lymphadenopathy. Lung examination was clear to auscultation bilaterally, no wheezes, rales or rhonchi. Cardiovascular examination, regular rate, normal rhythm with a II/VI systolic ejection murmur. Abdominal examination, positive bowel sounds, soft, nontender, no hepatosplenomegaly. Rectal examination was obstetrics positive. Extremity examination, trace edema, very tender right knee. He had a well healed incision from his open reduction and internal fixation at the lateral portion of his thigh/knee. There was on induration and no erythema. His knee appeared swollen, erythematous as well as having fluid in the capsule. Neurological examination, he was oriented to place, date and name. LABORATORY DATA: White count 20.8 with 60% neutrophils, 15% bands, 10% lymphocytes, 8% monocytes, 3% meta and 3% myelocytes. Hematocrit was 32.1, MCV 85, platelets 144, PT 13.5, INR 1.2, chem-7 136, 4.4, 99, 22, 83, 2.3 and 143. Chest x-ray showed no infiltrate. Right hip film showed a right-sided distal femur fracture, status post open reduction and internal fixation. His chest x-ray showed slight left ventricular enlargement but otherwise was a negative x-ray. The right upper quadrant ultrasound of the gallbladder showed no pericholecystic fluid. There was no gallbladder wall edema. The common duct appeared normal measuring 0.2 cm, there were no focal liver parenchymal abnormalities. There was no evidence of acute cholecystitis. His computerized tomography scan of the abdomen and pelvis that was done upon admission showed no abnormal fluid collection and no abnormality. HOSPITAL COURSE: 1. Fever with hypotension - It was unclear the origin of his hypotension and fever. It was initially thought that the patient had a septic right-sided joint secondary to high fever and joint tenderness, fluid in the joint, erythema around the joint versus gout. The patient was initially in the Medicine Intensive Care Unit for close observation. His fever defervesced from on admission. He had three sets of blood cultures, all of which were negative at the time of discharge. One set of fungal blood cultures was negative and no microbacteria was isolated from another bottle of blood cultures. His urine culture showed no growth and Helicobacter pylori antibody test was also negative. Infectious Disease was consulted, however, they were not able to pinpoint down the source. Secondary to joint tenderness, a joint tap of his right knee was performed. There was not enough fluid sent for crystals, however, all of the fluid was sent for culture and showed no growth. No polymorphonucleocytes were seen. The patient was started on hospital day #1 on Vancomycin 1 gm q. day which was later increased to Vancomycin 1 gm b.i.d. as well as Levaquin 500 mg q. day. The patient will be maintained on this regimen of antibiotics for one week. A repeat computerized axial tomography scan was performed of his abdomen and pelvis secondary to questionable kidney graft tenderness. However, the repeat computerized axial tomography scan was also negative for any type of abscess or other infectious etiology. The patient was kept on contact precaution secondary to a history of Methicillin-resistant Staphylococcus aureus in his lower extremity ulcers. These ulcers were well healed on admission. The patient's hypotension did resolve with fluids in the Medicine Intensive Care Unit. Since he was transferred out of the Medicine Intensive Care Unit on hospital day #3 he actually had hypertension. Please see cardiovascular section of this dictation. The patient will need to have a follow up appointment with Infectious Disease and again will be continued on Vancomycin 1 gm b.i.d. for another two weeks as well as Levaquin 500 mg q. day for two more weeks. 2. Cardiovascular - The patient had one episode of hypotension in the Medicine Intensive Care Unit which responded to fluids. This was unclear in etiology. At the time the current hypothesis was that the patient was septic, however, given the fact that none of the cultures grew out an organism it was difficult to attribute his hypotension to septicemia. His blood pressure when he was moved on hospital day #3 to the floor ended up being hypertensive. His blood pressure went up to 200/110. The patient was started on Labetolol 12.5 mg p.o. b.i.d. to control his hypertension. The patient also received an echocardiogram on [**6-13**] which showed a greater than 60% ejection fraction and E to A ratio of 0.82 and 1+ aortic regurgitation. There were no other cardiovascular issues. 3. Musculoskeletal - It was thought initially that the patient might have a septic joint versus gout inflammation. The patient had a negative joint fluid tap. He was started on 60 mg of Prednisone p.o. q. day with a taper within one week for coverage of gout. At the time of discharge, the patient's joint pain had decreased significantly but he still has focal joint tenderness. The patient's Allopurinol was held at the time during his hospital stay secondary to his questionable gout flare. 4. Acute renal failure/renal transplant - The patient on hospital day #3 had some focal tenderness over his kidney graft. A computerized tomography scan was obtained which showed no evidence of abscess or inflammation to the graft site. The patient was continued on his Filgastrim 300 mcg subcutaneous q. day as well as his Tacrolimus 2 mg b.i.d. His acute renal failure might have been secondary to his hypotension. His BUN was maximum of 63 and creatinine 1.5. At the time of dictation his BUN was 59 and his creatinine was 1.6. Renal was consulted and we continued to monitor the patient closely. The patient had excellent urine output throughout the hospital course. In fact, on hospital day #5 he had seven liters of urine output. 5. Hematologic - The patient was discontinued on his GCSF. His pancytopenia had resolved. We just continued to follow his blood count. His white count was initially 20 on admission and upon dictation of this discharge summary had decreased down to 17.1. His nadir was 15. There were no other issues. 6. Gastrointestinal bleed? - The patient had black stool and heme positive examination upon admission. His hematocrit was checked every 8 hours for 24 hours. The patient was not actively bleeding. There were no other issues. His hematocrit remained stable. 7. Infectious disease - Please see hypotension/fever section of this dictation for full report, however, all of his blood cultures times three, his urine culture as well as his joint fluid collections were all negative for infection. His white count initially was 20, however, upon discharge was down to 17 at the time of dictation and had nadired down to 15. Infectious Disease was consulted. No etiology for the fever and infection was ever discovered. The patient was maintained on Vancomycin 1 gm b.i.d. as well as Levaquin 500 mg q. day for a total of 14 more days and rehabilitation. DISCHARGE DIAGNOSIS: 1. Fever of unknown etiology 2. Acute attack of gout versus questionable joint inflammation 3. Renal transplant times two 4. Diabetes Type 1 5. Peripheral vascular disease, status post multiple bilateral toe amputations as well as right metatarsal amputation and a right dorsalis pedal bypass. 6. Gastroparesis 7. Benign prostatic hypertrophy status post transurethral resection of prostate 8. Gout 9. Trilinear bone marrow suppression, probable blood loss anemia 10. Right index finger osteomyelitis 11. History of falls 12. History of Methicillin-resistant Staphylococcus aureus in his leg ulcers 13. Autonomic neuropathy with orthostatic hypotension 14. Cytomegalovirus colitis in [**2142-3-10**] DISCHARGE MEDICATIONS: 1. Protonix 40 mg q. day 2. Neurontin 100 mg p.o. b.i.d.; Neurontin 600 mg in the evening 3. Folic acid 1 mg q. day 4. Tacrolimus 2 mg q. day 5. Celexa 20 mg q. day 6. Colace 100 mg b.i.d. 7. Heparin subcutaneous 5000 units b.i.d. 8. Calcium carbonate 500 mg three times a day 9. Aspirin prn 10. Levofloxacin 500 mg q. day times 14 days 11. Vancomycin 1 gm b.i.d. times 14 days 12. Prednisone, he is on a taper, he was tapered from 60 mg and went 60, 50, 40, 30, and 10 mg 13. Oxycodone 5 to 10 mg prn 14. Metoprolol 25 mg b.i.d. 15. Lantis 22 units q. PM as well as insulin sliding scale 16. Patient will be maintained on 10 mg of Prednisone q. day FOLLOW UP PLANS: 1. Will need to follow up with Dr.[**Name (NI) 22501**] in one week. 2. Will need to follow up with his primary care doctor. 3. Will need to follow up with Infectious Diseases in one week. 4. Will be discharged out to rehabilitation. 5. Follow up with renal transplant as needed. 6. Will be discharged out to rehabilitation. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Last Name (NamePattern1) 1892**] MEDQUIST36 D: [**2142-6-15**] 16:47 T: [**2142-6-15**] 18:24 JOB#: [**Job Number 22502**]

[ "458.9", "250.41", "274.0", "578.1", "780.6", "276.8", "280.0", "584.9", "996.81" ]

icd9cm

[ [ [] ] ]

[ "81.91" ]

icd9pcs

[ [ [] ] ]

10923, 12190

10190, 10900

2011, 2452

4799, 10169

2826, 4781

186, 209

238, 1247

1270, 1984

2469, 2803

15,919

193,580

47198

Discharge summary

report

Admission Date: [**2185-7-13**] Discharge Date: [**2185-8-2**] Date of Birth: [**2145-10-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Renal Failure Major Surgical or Invasive Procedure: Right femoral trialysis catheter placement [**2185-7-14**], removed [**2185-7-23**] PICC line placement [**2185-7-21**] Tunneled left IJ line placement in OR on [**2185-7-26**] History of Present Illness: Mr. [**Known lastname 34682**] is a 39 year-old male with h/o Prader-Willi Syndrome, T2DM, HTN, s/p recent trach (for respiratory failure) and [**Doctor First Name 48**] who presents from [**Hospital 100**] Rehab with worsening renal failure requiring hemodialysis. The patient was reportedly in his USOH until 1 week ago when he was noted to develop an elevated Cr. Per his sister, patient was also noted to have a decline in his UO, although no formal documentation of this is available. His Cr and BUN have progressively been increasing (Cr 10 days ago was 1.2 --> 5.5 now; BUN 115; K 5.7). He was transferred to [**Hospital1 18**] for tunneled line placement and hemodialysis. . Upon admission, patient was alert, following simple commands. No evidence of asterixis. Patient had Foley placed at [**Hospital 100**] rehab, but no renal ultrasound to fully r/o post obstructive etiology for [**Doctor First Name 48**]. Per provided nursing notes, no recent contrast agents, NSAIDS, or ACE/[**Last Name (un) **]. Patient had been on Vanco PO for C-diff. Past Medical History: Prader Willi Syndrome Morbid obesity T2DM CRI with baseline creatinine 1.8-2.0 OSA Mental retardation Hypothyroidism Status post tracheostomy and PEG tube placement Social History: Resident at [**Hospital 100**] Rehab. No smoking, ethanol or drug use. Family History: Family history of diabetes. Physical Exam: Physical examination on admission: Vitals: T:97.6 P:NSR @ 64 R: BP:125/77 SaO2:100% on AC500x20x5, FiO2 50%PIP46 with a ABG of: 7.24/51/140 General: Morbidly obese AA male, awake, alert, NAD. Following simple commands HEENT: NC/AT, PERRLA, EOMI without nystagmus, no scleral icterus noted, MMM, JVD unable to appreciate [**3-3**] habitus. Neck: Trach c/d/i. Pulmonary: Distant BS, clear without R/R/W Cardiac: Distant HS, RR, nl. S1,S2 no rub appreciated. Abdomen: Obese, soft, NT/ND, normoactive bowel sounds; limited [**3-3**] habitus. Unable to appreciate any bruits. PEG tube in place. Extremities: No C/C/E bilaterally, 1+, DP and PT pulse. No edema. Skin: No rashes or lesions noted. Neurologic: Alert, non verbal [**3-3**] trach. No asterixis Pertinent Results: Relevant laboratory data on admission: CBC: WBC-11.9* RBC-3.04* HGB-6.8* HCT-23.2* MCV-76* MCH-22.4* MCHC-29.3* RDW-19.3* NEUTS-74* BANDS-1 LYMPHS-11* MONOS-7 EOS-1 BASOS-0 ATYPS-0 METAS-5* MYELOS-1* NUC RBCS-4* PLT SMR-NORMAL PLT COUNT-261 . Chemistry: GLUCOSE-140* UREA N-117* CREAT-5.8*# SODIUM-126* POTASSIUM-5.1 CHLORIDE-92* TOTAL CO2-20* ANION GAP-19 ALT(SGPT)-12 AST(SGOT)-10 LD(LDH)-272* ALK PHOS-516* TOT BILI-0.2 ALBUMIN-2.6* CALCIUM-7.5* PHOSPHATE-9.0*# MAGNESIUM-2.5 . Coagulation: [**2185-7-13**] 08:52PM PT-13.8* PTT-29.4 INR(PT)-1.2* . Urinalysis: [**2185-7-13**] 11:45PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2185-7-13**] 11:45PM URINE OSMOLAL-308 [**2185-7-13**] 11:45PM URINE EOS-NEGATIVE . EKG: NSR 65, RAD1st deg AV delay, poor baseline but no peaked TWs. . Relevant imaging data: [**2185-7-13**] CXR: The study is markedly limited. There is left lower lobe opacity, which may appear slightly increased compared with the previous study. These findings may represent superimposed pneumonia or aspiration. . [**2185-7-14**] Renal U/S: Examination limited due to body habitus and patient's condition. The kidneys are not visualized. . [**2185-7-15**] ECHO: Mild symmetric LVH. Normal cavity size and systolic function (LVEF>55%). The distal third of the left ventricle is not well seen. Due to suboptimal technical quality, a focal WMA cannot be fully excluded. RV chamber size and free wall motion are grossly normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No MVP. PA systolic pressure could not be quantified. There is no pericardial effusion. . [**2185-7-19**] Cystoscopy with retrograde pyelogram: Normal radiographic appearance of the left ureter and renal calices without evidence of hydronephrosis, stricture, or filling defects. Brief Hospital Course: Mr. [**Known lastname 34682**] is a 39 year-old male with morbid obesity, Prader Willi syndrome, T2DM, CRI, status post tracheostomy, transferred from [**Hospital 100**] Rehab for acute on chronic renal failure. His hospital course will be reviewed by problems. . # RENAL FAILURE: As noted above, his creatinine on admission was elevated at 5.8. The etiology of his renal failure was initially unclear, and further work-up was initiated. He did not have an indication for emergent dialysis. Intravenous access was obtained via a trialysis catheter in the right femoral vein on [**2185-7-14**], and large volume resuscitation was administered with crystalloid and RBC transfusion, without improvement in his creatinine. Urine lytes, although initially suggestive of low FeNa, subsequently showed elevated FeUrea >35% not consistent with a pure pre-renal physiology. Renal was involved throughout the [**Hospital 228**] hospital stay. Renal imaging was complicated by the patient's body habitus, and a renal ultrasound could not visualize either kidney given the depth of soft tissue obscuring the windows. MRI or CT was not an option given the patient's habitus and weight. In order to exclude obstruction, urology was consulted, and a cystoscopy with retrograde pyelography was performed, remarkable for normal radiographic appearance of the left ureter and renal calices without evidence of hydronephrosis, stricture, or filling defects. . Given the above work-up, decision was then made to initiate hemodialysis. He had a first session on [**2185-7-20**], then [**7-21**] and [**7-22**]. His right femoral Quinton catheter was removed on [**7-23**] after adequate alternate access was obtained via a left-sided PICC. Attempt to place a tunneled hemodialysis catheter on [**2185-7-28**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 99959**] was unsucessful in the OR. Plans were made to place an AV graft on [**7-30**] however this was again unsuccessful, and patient was taken back to the OR on [**7-31**] where he had a cut down tunneled R Quinton placed. HD was thus initiated on [**7-31**], and then again on [**8-1**]. He remains on Renagel and Calcium acetate for hyperphosphatemia, along with EPO with HD. . # RESPIRATORY FAILURE: Pt chronically trach'd for h/o obesity hypoventilation, multiple episodes of respiratory distress requring vntilator support, with h/o of multiple VAP. The ventilatory parameters were slightly altered. He is currently on PS 22/10, FiO2=0.40. Please continue these parameters at rehab. . # PNEUMONIA: While in the hospital, his WBC was noted to rise. Sputum cultures from [**2185-7-14**] grew Acinetobacter sensitive to Unasyn but resistant to Zosyn, and MRSA. He was placed on Unasyn and Vancomycin on [**7-18**] (day 1), and completed a 14-day course with last doses on [**2185-7-31**]. In addtion, pt is being treated with po vancomycin for concern about c. diff, and should continue to be treated for 14 days s/p [**7-31**] (the last day of his unasyn course), ending on [**2185-8-14**]. . # HYPOTHYROID: Mr. [**Known lastname 34682**] has a known history of hypothyroidism. At the time of admission, his TSH was elevated at 77, with low free T4 0.4. Endocrine was consulted, with recommendation to initiate IV levothyroxine given possible poor gut absorption. He was therefore placed on Levothyroxine 200 mcg daily, with improvement in his TSH to 11 and free T4 to 0.9 on [**2185-7-21**]. Given rapid improvement in his thyroid function tests, it is likely that he has a superimposed component of sick euthyroid. He was transitioned back to Levothyroxine via PEG at 325 mcg daily. Please continue Levothyroxine 325 mcg daily. Please administer SEPARATE from other medications, especially calcium and iron. Please recheck thyroid function tests on [**2185-8-5**] and adjust levothyroxine as necessary. Then please check thyroid function tests again in [**1-31**] weeks to ensure that they remain stable. . # UTI: Pt completed a course of Fluconazole for [**Female First Name (un) 564**] UTI initiated prior to his current admission on [**7-21**] (foley changed on the day of admission). A urine culture from [**7-17**] grew pansensitive Klebsiella, covered by Unasyn, which was treated with a 14d [**Last Name (un) 10128**] ending on [**7-31**]. He has a foley catheter in place. . # History of C. difficile: Pt was admitted on oral Vancomycin. He should remain on oral Vancomycin until 14 days after completion of his above antibiotics, with last doses on [**2185-8-14**]. . # ANEMIA: His hematocrit at the time of admission was 22, with iron studies consistent with anemia of chronic disease/renal failure. He was placed on Epo, which is currently administered at HD. . # Type 2 DM: He was placed on a regular insulin sliding scale in the hospital. Medications on Admission: Synthroid 200 mcg po qd NS 100 q6 flush Diflucan 200 qd until [**7-21**] (for UTI) Vanco 125 mg po qid Renagel 1600 mg po TID Ascorbic Acid 500 mg PO BID, Multivitamin Heparin 5000 SQ TID Nexium 40 mg po qd Lopressor 25 mg po TID Nepro TF 40/hr x 24hours Flomax 0.4 mg po qd Epogen 10K QF Wellbutrin 75 mg po qd Lantus 30U + RISS (LD was [**2185-7-12**]) Lactobacillus 1 Tab G-Tube Discharge Medications: 1. Ascorbic Acid 90 mg/mL Drops Sig: Five (5) ml PO BID (2 times a day). 2. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 4. Bupropion 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Eight (8) Puff Inhalation Q4H (every 4 hours). 7. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): after dialysis. 8. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): continue until [**2185-8-7**]. 9. Insulin Regular Human 100 unit/mL Solution Sig: as directed units Injection ASDIR (AS DIRECTED): per sliding scale. 10. Levothyroxine 300 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): give with 25mcg for total 325mcg. 11. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a day: give with 300mcg for total of 325mcg. 12. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: End Stage Renal Disease on hemodialysis Chronic hypoventilation with tracheosotomy MRSA and zosyn resistant acinetobacter pneumonia [**Female First Name (un) **] UTI c. diff infection DM type 2 chronic anemia Discharge Condition: stable on vent pressure support 22/12 and 40% FiO2 Discharge Instructions: Please call your doctor or return for fevers, chills, sweats, signs of infection, chest pain, shortness of breath, problems with dialysis line or tracheostomy tube. Followup Instructions: 1. schedule f/u with Rehab. 2. please check Thyroid Function Test in 3d ([**8-5**]) and adjust levothyroxine as appropriate. Then please check TFTs again in [**1-31**] weeks to ensure that they are stable. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "482.83", "V09.91", "V45.4", "403.91", "041.3", "008.45", "584.5", "599.0", "278.01", "458.9", "707.09", "112.2", "585.6", "327.23", "276.51", "518.83", "V55.0", "588.89", "707.07", "285.21", "319", "759.81", "244.9" ]

icd9cm

[ [ [] ] ]

[ "96.72", "39.95", "38.99", "57.32", "38.93", "38.94", "38.95", "96.6", "87.74", "59.8", "99.04" ]

icd9pcs

[ [ [] ] ]

11268, 11334

4720, 9549

336, 514

11587, 11640

2707, 2732

11853, 12199

1890, 1919

9981, 11245

11355, 11566

9575, 9958

11664, 11830

1934, 1955

283, 298

542, 1597

2746, 4697

1619, 1785

1801, 1874

31,301

169,336

21255

Discharge summary

report

Admission Date: [**2138-2-13**] Discharge Date: [**2138-2-25**] Date of Birth: [**2056-6-15**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 618**] Chief Complaint: L sided weakness Major Surgical or Invasive Procedure: IV TPA/angiogram History of Present Illness: HPI: 81 year old right handed woman hx atrial fibrillation (not on Coumadin), bilateral CEA, HTN, who presented on [**2138-2-13**] with left hemiparesis. She was last known normal at 2:15pm on [**2138-2-13**]. She and her husband had just returned home from a restaurant. Her husband left the room for a few minutes. When he returned at 2:30pm, she was slumped over in her chair. She was slurring her words and had weakness of her left arm and leg. There was no evidence of trauma. The husband called EMS. Per EMS, she had two episodes each lasting one minute of rhythmic, high amplitude jerking of the right arm. She did not follow instructions during these episodes. No eye deviation, tongue biting, or incontinence during these episodes. Patient was taken to the [**Hospital1 18**] ED. Stroke code was called at 3:50pm. Stroke fellow was at bedside at 3:55pm. Her NIHSS was 16. NIH SS: 1a. Level of Consciousness: 0 1b. LOC questions: 0 1c. LOC commands:0 2. Best gaze:1 3. Visual: 1 (left hemianopia vs extinction) 4. Facial palsy: 2 5a. Motor arm, left: 3 5b. Motor arm, right:0 6a. Motor leg, left: 3 6b. Motor leg, right: 0 7. Limb ataxia: 0 8. Sensory: 2 9. Best language: 1 ( missed one transition word during repetition testing) 10. Dysarthria: 1 11. Extinction and inattention: 2 (left visual neglect and left sensory neglect) Patient was taken to CT head which showed dense right MCA sign. No hypodensity appreciated on the right. No loss of [**Doctor Last Name 352**]-white differentiation. CTA brain showed intraluminal thrombus of the proximal right M1 artery and the bifurcation of the right ICA. CT perfusion showed decreased blood volume in the right ACA and increased MTT in the right ACA. After Head CT, patient was given 6.1mg of TPA. She received an infusion of 50mg iv TPA in the ED. She got an additional 10.4mg of iv TPA in the Angio suite. Once patient returned to the ED from the CT scanner, she desaturated. Patient was emergently intubated. Her BP transiently increased to 200 systolic. Once she was given Propofol, her SBP returned to 140-160's. She was taken to the angio suite at 5:30pm. Conventional angiogram showed revascularization of the proximal right MCA. No thrombus was visible. No intra-arterial TPA or MERCI device was utilized. During the procedure, she was given norephinephrine prn and nitroglycerin prn. It was noted that she had a right femoral hematoma at the site of the catheter insertion. The catheter sheath was left in place. Patient was given frequent groin checks. She also had a small amount of bleeding from her external ear canals bilaterally. Patient was admitted to the SICU. STAT Head CT was obtained at 7:50pm. There was no intracranial bleeding. Past Medical History: -Afib dx 1 month ago-declined coumadin because of frequent blood draws -HTN (not well controlled per daughter) -CABG stent x5 (20 y ago) -CAD patient had 3 stents placed. One stent was placed in [**2132**] and another stent was placed in [**2135**] -breast mass diagnosed in [**2137-7-10**] [**2137-8-10**]- breast cancer was resected (lumpectomy) with negative, clear margins No chemo or radiation -Bilateral CEA Social History: Married, has 2 daughters Family History: Had daughter who died of brain aneurysm Physical Exam: VS: BP 167/73 P 70 R 18 02 99% Gen: WD/WN Heent: supple neck, no carotid bruits, bilateral CEA scars, no lymphadenopathy Chest: sternotomy scar, ecchymosis over the upper sternum, lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi Heart: irregularly irregular, no murmurs, Abd: soft, non-distended, non-tender, no mass, decreased bowel sounds Ext: no cyanosis, clubbing, or edema Skin: no erythema Neuro: MS: alert, able to answer month and age, able to repeat with one mistake (missed transition word), follows simple commands, decreased fluency, eyes open spontaneously CN: incomplete left homonymous hemianopsia, pupils equal, round, and reactive, extraocular movements intact, dense left lower facial droop Motor: flaccid left arm and leg, normal tone of right arm and leg left arm and leg did not move spontaneously right arm was 5/5 Strength, right leg was at least [**1-14**] Strength Sensory: did not admit to feeling noxious applied to the left arm or leg did admit to noxious applied to right arm or leg withdrew to noxious with the left arm and leg Reflex: T BR B K A toes Left 0 0 0 0 0 mute Right 0 0 0 0 0 mute Coord: unable to assess Gait: unable to assess Pertinent Results: [**2138-2-13**] 09:00PM %HbA1c-6.1* [**2138-2-13**] 09:13PM TYPE-ART PO2-124* PCO2-35 PH-7.41 TOTAL CO2-23 BASE XS--1 [**2138-2-13**] 09:13PM LACTATE-1.4 [**2138-2-13**] 09:00PM GLUCOSE-138* UREA N-26* CREAT-0.8 SODIUM-139 POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-22 ANION GAP-11 [**2138-2-13**] 09:00PM ALT(SGPT)-17 AST(SGOT)-25 LD(LDH)-188 CK(CPK)-160* ALK PHOS-62 TOT BILI-0.5 [**2138-2-13**] 09:00PM CK-MB-5 cTropnT-<0.01 [**2138-2-13**] 09:00PM %HbA1c-6.1* [**2138-2-13**] 09:00PM HOMOCYSTN-9.7 [**2138-2-13**] 09:00PM TSH-1.6 [**2138-2-13**] 09:00PM WBC-9.4 RBC-2.72*# HGB-8.9* HCT-25.8*# MCV-95 MCH-32.8* MCHC-34.5 RDW-13.5 [**2138-2-13**] 09:00PM PT-13.3 PTT-26.9 INR(PT)-1.1 [**2138-2-13**] 09:00PM SED RATE-22* [**2138-2-13**] 04:00PM GLUCOSE-92 UREA N-28* CREAT-1.0 SODIUM-141 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13 [**2138-2-13**] 04:00PM cTropnT-<0.01 [**2138-2-13**] 04:00PM WBC-8.8 RBC-3.64* HGB-11.7* HCT-35.1* MCV-96 MCH-32.3* MCHC-33.5 RDW-13.3 [**2138-2-13**] 04:00PM PT-12.5 PTT-22.2 INR(PT)-1.1 [**2-13**]: Head: CT/CTA/CTP: 1. Thrombus in the right internal carotid artery at the bifurcation of the MCA and ACA, and involving the M1 segment of the right MCA and A1 segment of the right ACA. Both MCA and ACA demonstrate more distal filling. 2. Evidence of ischemia in the distribution of the right anterior cerebral artery. [**2-13**]: CTH: (After TPA) No evidence of hemorrhage after TPA intravenous infusion. [**2-14**]: CTH: prelim: no significant hemorrhage/infarction noted on CTH [**2-13**]: CXR: 1. The endotracheal tube lies too close to the carina and can be moved up 2 cm. 2. Moderate CHF. [**2-14**]: TTE: The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild aortic regurgitation. Moderate mitral regurgitation. Mild pulmonary hypertertension. MRA head: [**2-15**]: 1. Areas of narrowing in both middle cerebral arteries could be due to occlusive atherosclerotic disease or due to emboli. 2. Probable partial occlusion of the A2 segment of the left anterior cerebral artery. 3. Atherosclerotic disease in the posterior circulation as described above. MRI brain:: [**2-15**]: 1. Acute left frontal lobe infarct. 2. Small right middle cerebral artery infarcts in the basal ganglia and right posterior temporal regions. 3. The left-sided infarct has lower ADC value than the right-sided infarct and could be of more recent origin than the right-sided infarcts. CT abd/pelvis: [**2-15**]: 1. Right proximal anterior thigh subcutaneous hematoma. No retroperitoneal hematoma identified. 2. Small bilateral pleural effusions with bibasilar atelectasis. 3. L5 spondylolysis. Grade I L4 on L5 anterolisthesis. 4. Mild pulmonary edema with small bilateral pleural effusions. [**2-15**]: R groin u/s: Limited exam shows right groin hematoma with internal flow demonstrating arterial waveforms suggestive of pseudoaneurysm, less likely AV fistula. Repeat ultrasound or contrast- enhanced CT is recommended for further evaluation. Brief Hospital Course: Neuro: pt received IV tPA with CT/CTA findings. pt was brought to the angio suite where RMCA appears to have been recanalized, so no IA TPA was given. pt with some bleeding from her ear canals bilaterally - repeat CT without evidence of bleeding. repeat CT at 24 hrs (after TPA) demonstrated: no significant bleeding. no evidence of infarction. Pt with improving strength of L side UE and LE. However, noted on [**2-14**] to be moving L>R but moving all 4 extremities spontaneously. Pt after extubation continued to be quite sedated. Upon am of [**2-15**], pt noted to be moving her L side spontaneously with minimal spontaneous movement of her RUE. no movement of her RLE. MRI revealed bilatreal ACA infarcts with some R MCA territory infarctions. MRA revealed clot in LACA with both ACAs deriving from her R sided intracerebral circulation. the patient continued not to speak, was abullic, and had decreased spontaneous movement of both sides with plegia of RLE. Heme: pt with significant groin hematoma - improved by HD2. However, HCT continued to decline and hematoma noted to be greater in size. CT abdomen/pelvis revealed R thigh hematoma. R groin U/S revealed 2x2cm of pseudoaneurysm. pt was transfused 3 units of pRBCs stable serial hematocrit thereafter. Pseudoaneurysm was injected with thrombin by interventional radiology on [**2138-2-17**]. Resp: pt remained intubated until HD 2 when she was extubated without incident in am. CXR demonstrating pulmonary edema - given 20 mg lasix X 2 with pRBC transfusion. CV: telemetry revealed A Fib throughout stay in ICU. BPs well controlled without medications during stay. CE X 2 negative. Echo revealed: no thrombus. however, with dropping HCT, CE increased and troponing rising to 1.[**Street Address(2) 56254**] depressions in V2-V6. cardiology consulted and recommended maximizing statin and starting asa which was done. repeat echo revealed: Endo: normal TSH, A1c 6.1 COURSE ON [**Hospital1 **]: remained abulic, R hemiparesis mildly improved, started on Heparin drip for PEG tube which was inserted on [**2-24**]. There was some bleeding during the procedure but her Hematocrit has remained stable. Her R thigh size has been stable and her peripheral pulses are being monitored by Doppler. Cardiology recommended could add Lisinopril if needed for BP control. Completed course of Cipro for UTI. Medications on Admission: Cozaar 100mg qd atenolol 50 mg [**Hospital1 **] Adalat 30 mg qday Lipitor 40 mg qd Plavix 75 mg qday Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Insulin Regular Human 100 unit/mL Solution Sig: scale scale Injection ASDIR (AS DIRECTED). 4. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed: max 4 g daily. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: 0.5 Tablet PO Q 8H (Every 8 Hours). 7. 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: R MCA and L ACA stroke s/p iv TPA Discharge Condition: abulic, R hemiparesis mildly improved, does not follow commands Discharge Instructions: You have had a stroke. You required a Percutaneous Gastrostomy tube for feeding. You should resume amticoagulation 48 hrs after the surgery for your atrial fibrillation. Followup Instructions: [**Hospital 56255**] CLINIC: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 162**], MD Date/Time: Tuesday [**2138-4-1**] 10:00 Phone:[**Telephone/Fax (1) 2574**] Please call the above number prior to appointment to update your hospital registration information. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2138-2-25**]

[ "599.0", "388.69", "E849.7", "428.0", "368.46", "433.11", "V10.3", "V45.89", "427.31", "E879.8", "442.3", "401.9", "434.01", "414.01", "414.02", "342.00", "784.5", "V45.82", "997.2", "351.8", "784.3", "787.20" ]

icd9cm

[ [ [] ] ]

[ "43.11", "96.6", "99.10", "99.29", "96.71", "96.04", "88.91", "87.03", "93.90", "88.41" ]

icd9pcs

[ [ [] ] ]

11973, 12070

8808, 11186

312, 330

12147, 12212

4976, 8785

12431, 12823

3605, 3647

11338, 11950

12091, 12126

11212, 11315

12236, 12408

3662, 4957

256, 274

358, 3092

3114, 3546

3562, 3589

27,175

146,914

33302

Discharge summary

report

Admission Date: [**2116-4-5**] Discharge Date: [**2116-4-24**] Date of Birth: [**2058-1-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: lethargy, altered MS, hyperglycemia Major Surgical or Invasive Procedure: Percutaneous tracheostomy [**2116-4-13**] Intubation/mechanical intubation Central Line placement Lumbar Puncture History of Present Illness: 58 yo M w/ brittle DMI c/b neuropathy, narcotics abuse, past etoh abuse, CRI, HTN, bipolar, p/w lethargy, confusion at home and became unresponsive in the ED. Admitted to the MICU for respitory failure (now intubated), hypotension, hyperglycemia. Per pts. partner he has been disoriented with intermittent hallucinations, nonsensical speech, difficulty ambulating and poor po intake for the past several days. He has also had uri symptoms and a dry cough for 1 week. His partner was a sick contact (URI w/ cough). He was brought in to [**Hospital1 18**] by his partner. . In the ED: T 97.5 HR 73 BP 109/62 RR 16 SPO2 98% FS 443 Initial labs were significant for a K of 6.1 with peaked T waves on ECG. He was given calcium, insulin, and IVF (total 6L of NS). A CXR showed dilated loops of bowel on initial read, therefore, an OGT placement was attempted. During this procedure the pt. desaturated to 86% on RA, this in combination with the pts. poor MS resulted in the patient being intubated (w/ etomidate/rocuronium) for airway protection and hypoxia. A CT scan of the abdomen showed no acute pathology but did reveal bibasilar lung consolidation (L>R). He was given levoflox 500 iv x1 and zosyn 4.5gm iv x 1. A head CT was significant for a Left parietal 1 cm lesion (per partner this is old). Also pts. UA was + bacteria and nitrates. Additionally, in the [**Name (NI) **], pts. BP transiently dropped to 85/53 and he was started on a levophed GTT. Past Medical History: IDDM CRI Chronic Fatigue Gout bipolar disorder GERD ETOH abuse (sober x 6 years) narcotics abuse multiple TIA's HTN known brain lesion (yearly MRI) Social History: 1 PPD x 40 years. No etoh in last six years. No recreational drugs. Lives with GF, on disability. Family History: 15 brothers/sisters, 5 of whom died of brain tumors Physical Exam: VS: Temp:95.1 BP: 108/62 HR:67 RR:16 O2sat 100% on AC 550/18 peep 5 Fi02 100% GEN: intubated, responsive to pain (off sedation) HEENT: PERRL anicteric,intubated, poor dentition NECK: No JVD, right IJ in place RESP: clear anteriorly CV: RR, distant heart sounds, no murmurs ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: 1+ ankle edema bilat. 2+DP on right and 1+ DP on left SKIN: no rashes/no jaundice Pertinent Results: HEMATOLOGY [**2116-4-5**] 05:30PM BLOOD WBC-10.4 RBC-3.84* Hgb-11.4* Hct-33.4* MCV-87 MCH-29.6 MCHC-34.0 RDW-17.0* Plt Ct-234 [**2116-4-6**] 12:56AM BLOOD WBC-7.6 RBC-3.27* Hgb-9.5* Hct-29.0* MCV-89 MCH-29.1 MCHC-32.8 RDW-16.3* Plt Ct-191 [**2116-4-16**] 03:02AM BLOOD WBC-17.0* RBC-2.80* Hgb-8.1* Hct-24.2* MCV-86 MCH-28.8 MCHC-33.4 RDW-18.3* Plt Ct-477* [**2116-4-17**] 03:47AM BLOOD WBC-16.4* RBC-2.57* Hgb-7.5* Hct-22.5* MCV-88 MCH-29.2 MCHC-33.4 RDW-18.3* Plt Ct-510* [**2116-4-5**] 05:30PM BLOOD Neuts-67 Bands-7* Lymphs-17* Monos-8 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 COAGULATION [**2116-4-6**] 12:56AM BLOOD PT-12.6 PTT-38.5* INR(PT)-1.1 CHEMISTRY [**2116-4-5**] 05:30PM BLOOD Glucose-491* UreaN-55* Creat-4.6* Na-132* K-6.3* Cl-104 HCO3-12* AnGap-22* [**2116-4-5**] 07:51PM BLOOD Glucose-377* UreaN-52* Creat-3.8* Na-137 K-4.6 Cl-113* HCO3-13* AnGap-16 [**2116-4-17**] 03:47AM BLOOD Glucose-207* UreaN-37* Creat-2.4* Na-152* Cl-122* HCO3-20* LFTS [**2116-4-5**] 07:51PM BLOOD ALT-13 AST-14 LD(LDH)-131 AlkPhos-146* TotBili-0.2 [**2116-4-8**] 05:34AM BLOOD ALT-18 AST-18 LD(LDH)-189 AlkPhos-128* TotBili-0.5 [**2116-4-11**] 03:02AM BLOOD ALT-29 AST-23 LD(LDH)-205 AlkPhos-268* TotBili-1.0 CA/MG/PHOS [**2116-4-5**] 05:30PM BLOOD Calcium-9.1 Phos-6.4* Mg-1.7 [**2116-4-7**] 05:53AM BLOOD Albumin-2.6* Calcium-8.1* Phos-4.2 Mg-1.9 [**2116-4-8**] 05:34AM BLOOD Albumin-2.6* Calcium-7.8* Phos-4.6* Mg-1.7 VITAMIN [**2116-4-11**] 03:02AM BLOOD VitB12-[**2105**]* [**2116-4-12**] 02:49AM BLOOD calTIBC-113* VitB12-GREATER TH Folate-16.0 Ferritn-1062* TRF-87* [**2116-4-13**] 03:23AM BLOOD VitB12-1742* AMMONIA [**2116-4-5**] 07:51PM BLOOD Ammonia-8* THYROID [**2116-4-12**] 02:49AM BLOOD TSH-1.4 [**2116-4-12**] 02:49AM BLOOD Free T4-0.65* IMMUNE [**2116-4-7**] 05:53AM BLOOD IgG-663* TOXICOLOGY [**2116-4-5**] 05:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Barbitr-NEG Tricycl-POS BLOOD GAS [**2116-4-5**] 09:06PM BLOOD Type-ART Rates-/14 PEEP-5 FiO2-100 pO2-295* pCO2-43 pH-7.13* calTCO2-15* Base XS--14 AADO2-395 REQ O2-68 -ASSIST/CON Intubat-INTUBATED [**2116-4-6**] 02:24AM BLOOD Type-ART pO2-183* pCO2-38 pH-7.18* calTCO2-15* Base XS--13 [**2116-4-17**] 05:22AM BLOOD Comment-GREEN TOP [**2116-4-5**] 05:35PM BLOOD Lactate-1.9 K-6.4* CSF ANALYSIS WBC RBC Polys Lymphs Monos [**2116-4-8**] 05:20PM 11 1* 02 87 13 TUBE#4 CHEMISTRY TotProt Glucose LD(LDH) [**2116-4-8**] 05:20PM 20 108 21 CULTURE NEGATIVE HSV NEGATIVE NEGATIVE FOR MALIGNANT CELLS URINE: CULTURE GROUP B STREP SPUTUM: COAG AUREUS MSSA FLU: POSITIVE B RPR: NR STOOL: NEGATIVE FOR C. DIFF HEAD CT2/24/08 1. No evidence of acute intracranial hemorrhage. 2. Left parietal ovoid lesion with questionable punctate central calcification. Recommend MRI with gadolinium for better evaluation. No appreciable surrounding edema. No mass effect. CT ABD/PELVIS 1. No evidence of bowel obstruction. 2. Air and stool-filled colon. 3. Bibasilar consolidations, left significantly greater than right, likely representing aspiration or other pneumonia. 4. Nonspecific periportal edema. Possible etiologies include acute intravenous hydration, hypoalbuminemia, or hepatitis or other liver disease, or HIV-related disease. MRI/MRA OF HEAD There is an area of susceptibility artifact in the left periatrial region with a central portion of high signal on T2 images consistent with a cavernoma. There is no mass effect, midline shift or hydrocephalus seen. No acute infarct is identified. There is fluid seen in bilateral mastoid air cells. IMPRESSION: No evidence of acute infarct. Cavernoma left periatrial region of the parietal lobe. Brief Hospital Course: RESPIRATORY FAILURE / INFLUENZA B / MSSA PNEUMONIA Mr. [**Known lastname 15655**] was brought to the ED for altered mental status, and became unresponsive while in the emergency department, primarily for airway protection. He exhibited sepsis physiology with hypotension, and was treated started on levophed initially. CT of the abdomen revealed consolidation at the lung bases. Trials to wean the vent toward extubation were difficult with decreased oxygenation. DFA revealed that the patient was INFLUENZA B positive. Culture of sputum was positive for methicillin sensitive staph aureus, and this was felt to be high likelihood for staph superinfection. Because of his respiratory failure, he was covered broadly with vancomycin and zosyn for a ten day course. Because of his protracted vent course, he underwent tracheostomy placement on [**2116-4-13**]. Post-tracheostomy, his respiratory status improved and he had stable O2 saturation. On [**2116-4-21**] his trach fell out and he was transferred to the MICU for further management, but he continued to have stable respiratory status post-trach and was transferred back to the floor. By discharge, his O2 saturation was 100% on room air. . ALTERED MENTAL STATUS The patient had a history of confusion and of dropping objects per his family/partner just prior to admission. Tox screen on admission was negative in urine, and positive for TCA in serum. When sedation was weaned, he became hemodynamically agitated but mainly unresponsive with disconjugate gaze. MRI/MRA showed no acute infarct. EEG showed diffuse slowing consistent with toxic/metabolic encephalopathy. Neurology was consulted and followed the patient while in house through the work-up. The patient had no gross thyroid function abnormality. An RPR was negative. Ultimately, he was weaned off of his sedation of versed and fentanyl in a very slow manner, and over 2-3 days became arousable and eventually conversant. By discharge, he was oriented to name, not place and date but was able to carry out simple conversations. Mini mental status score was 17 at discharge. . RECALCITRANT HYPERTENSION As sedation was weaned for extubation, the patient's blood pressure rose to 190-200 / 70s-80s consistently. He was treated with a mixture of labetolol gtt, hydralazine IV/PO, and isordil. He was started on captopril given stable though lower renal function/eGFR and this was titrated upwards. He additionally was continued on PO labetolol, hydralazine, and isosorbide mononitrate. His captopril was switched to lisinopril, and labetolol to metoprolol by discharge. . ASPIRATION On suctioning of the trach, it was discovered that the patient had been aspirating tube feeds and also crushed fragments of pills. A post-pyloric Dobhoff was placed with success, but was eventually lost. RN trial of PO pills at the bedside was successful. . ACUTE ON CHRONIC KIDNEY FAILURE/DISEASE The patient's creatinine on admission was 4.6, eventually declining over the course of hospital stay to 1.9. This was felt to be consistent with an acute kidney injury picture. . DIARRHEA The patient briefly exhibited large stool volumes, and c.diff associated diarrhea/colitis was considered given hospital and antibiotic exposure. A toxin was eventually positive. He was started on treatment with a 14-day course of metronidazole to be finished on [**2116-4-30**]. . DIABETES: his FS was mostly high in the 200s-300s during most of the hospital stay but decreased by discharge. He was discharged with glargine 8 units at hs and a sliding scale. His insulin regimen would likely need to be adjusted at rehab for better glucose control. . NUTRITION The patient was not immediately PEG'd given possibility of awakening after sedation was weaned off. He was supported with tube feeds for a short time then was able to tolerate liquid diet. He was discharged with soft solids and thin liquids. . CODE STATUS/DISPOSITION The patient was a full code. Medications on Admission: Allopurinol 300mg 2 per day Aolchicine 0.6mg PO daily Atenolol 100mg PO daily Lisinopril 20mg PO daily Protonix 40mg PO daily Oxycontin 40mg q8h Oxycodone 30mg PRN Soma/Carisiprodol 350mg tablets Lipram 4500 cap rxmeal Humalog 75/25 SS Levemir Flex Pen ?units Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) unit Injection TID (3 times a day). 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lidocaine (PF) 1 % (10 mg/mL) Solution Sig: Three (3) ML Injection Q2H (every 2 hours) as needed for Cough. 5. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 6. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days: Until [**2116-4-30**]. 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever > 101.0. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 11. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: see comment Subcutaneous four times a day: Pre-meal FS 100-150: 2 unit; 151-200: 3 units; 201-250: 6 units; 251-300: 9 units; 301-350: 12 units. Bedtime FS 200-250: 3 units; 251-300: 6 units; 301-350: 9 units. 12. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 13. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO TID (3 times a day). 15. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) unit Subcutaneous at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital Discharge Diagnosis: Primary diagnoses: influenza, MSSA infection, Clostrodium difficile colitis Secondary diagnoses: insulin-dependent diabetes mellitus, chronic kidney disease, chronic fatigue, gout, bipolar disorder, GERD, alcohol abuse, narcotics abuse, multiple TIA's, hypertension, known brain lesion (yearly MRI) Discharge Condition: stable Discharge Instructions: You presented to [**Hospital1 18**] with unresponsiveness and respiratory failure. You were found to have a lung infection. You were intubated and later underwent a tracheostomy. The tracheostomy tube later fell out but your respiratory status continued to improve greatly. You also had an infection of your colon called C. diff colitis and were started on metronidazole to be finished on [**2116-4-30**]. Please take all your medications and go to your follow-up appointment as instructed below. If you develop recurrent respiratory difficulty, fevers, chills, abdominal pain, diarrhea, or any other concerning symptom, please call your physician or go to the nearest Emergency Room. Followup Instructions: * Dr. [**Last Name (STitle) 1057**], [**Telephone/Fax (1) 77309**]: 11:15 am, [**2116-5-18**].

[ "274.9", "487.0", "518.81", "403.90", "357.2", "349.82", "584.9", "008.45", "250.63", "482.41", "585.9", "276.2" ]

icd9cm

[ [ [] ] ]

[ "33.23", "03.31", "96.6", "31.1", "38.93", "96.04", "96.72" ]

icd9pcs

[ [ [] ] ]

12304, 12378

6435, 10379

349, 465

12722, 12731

2755, 6412

13466, 13564

2249, 2302

10690, 12281

12399, 12476

10405, 10667

12755, 13443

2317, 2736

12497, 12701

274, 311

493, 1947

1969, 2118

2134, 2233

30,172

134,737

33535

Discharge summary

report

Admission Date: [**2106-5-28**] Discharge Date: [**2106-6-1**] Date of Birth: [**2077-12-17**] Sex: M Service: SURGERY Allergies: Ampicillin Attending:[**First Name3 (LF) 4691**] Chief Complaint: MVC with major blunt chest trauma Major Surgical or Invasive Procedure: I&D, ORIF right BBFFx w/ ECU Repair [**5-28**] Flex bronch, EGD History of Present Illness: Pt is 28 yo m admitted [**2106-5-28**] s/p MVC transported via Med flight. Pt was the driver involved in high speed MVC in which his car reportedly hit and went under tractor trailer which resulted in prolonged extrication and then medflighted to [**Hospital1 18**]. Past Medical History: Crohn's Asthma Social History: Works as a mechanical engineer No substance abuse Family History: nc Physical Exam: Temp (F): 99.0 Heart Rate: 89 Blood Pressure: 177/93 Resp Rate: 15 O2 Sat(%): 98 Room Air/O2: 15L non rebreather GENERAL non-rebreather in place HEENT trachea midline, subcutaneous emphysema along chest wall and neck midline RESPIRATORY bilateral wheeze CARDIOVASCULAR RRR GI Soft NABS ND Pertinent Results: [**5-28**] CXR IMPRESSION: Osseous fractures involving the middle third of the bilateral clavicles, bilateral upper ribs, and right scapula. Subcutaneous emphysema involving the soft tissues of the neck and upper chest. Persistent pneumomediastinum. No pneumothorax is identified. [**5-28**] Hand FINDINGS: The forearm is obscured by an overlying cast. There are displaced fractures involving the distal radius and ulna with one bone width volar displacement and medial angulation of the over-riding distal fragments. There is surrounding soft tissue swelling. There are no radiopaque foreign bodies. There are no other fractures in the visualized wrist, fingers and elbow. There are no degenerative changes. IMPRESSION: Distal radius and ulna shaft fractures as described. [**5-28**] CT Torso IMPRESSION: 1. Significant pneumomediastinum with posterior tracheal laceration just above the carina. 2. Bilateral upper lung contusions, right greater than left. 3. Bilateral upper rib fractures, clavicle fractures, right scapular fracture with extensive chest wall emphysema extending into the neck soft tissues as well as along nerve roots into the central spinal canal. 4. No evidence of traumatic injury to the abdomen or pelvis. [**5-28**] CTH IMPRESSION: 1. No evidence of intracranial hemorrhage or skull fracture. 2. Soft tissue gas as described likely extension from subcutaneous emphysema and pneumomediastinum in the chest. Please refer to report from CT torso for further detail. [**5-28**] CT CSPINE IMPRESSION: 1. Chip fracture involving the right C6 transverse process (stable). No fracture line extension into the transverse foramen. Remainder of the cervical spine is intact with normal alignment. 2. Extensive soft tissue gas in the chest wall, neck soft tissues. 3. Pneumomediastinum with air dissecting into the retropharynx and parapharyngeal space. 4. Bilateral rib fractures, right first, left first and second. Bilateral clavicular fractures. 5. Air outlining the thecal sac which appears to extend in along the nerve roots. [**5-29**] UGI Limited exam due to patient's discomfort.There is a small area of persistent opacification adjacent to the esophagus, which may be artefactual however a small self-contained leak cannot be excluded. Findings discussed with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] shortly on the day of the study. Brief Hospital Course: The patient was admitted to Trauma surgery from the emergency department directly to the Trauma ICU. . Injuries were found to be: 1) Bilateral clavicle fx and Right scapular fracture 2) Open radial/ulnar fx- s/p I&D, ORIF right BBFFx w/ ECU Repair [**5-28**] 3) Chip fracture involving the right C6 transverse process (stable). 4) R>L Pulmonary contusions 5) Bilateral rib fx: No intervention was done for the rib fractures 6) Pneumomediastinum 7) Evulsed R 4th digit tip - Plastics followed and adaptec placed 8) ? Right upper molar fracture . ** Regarding the multiple bony fractures: Orthopedics has been following along. The team took him to the OR after stabilization of the chest injury to perform incision and drainage and open reduction internal fixation of the open radial/ulnar fractures with ECU repair. The patient tolerated the procedure well with no complications. Expectant management was done on the remainder of the fractures with the patient only requiring pain control. Physical therapy and occupational therapy were consulted on the patient to assess home vs rehab needs and both services felt the patient was capable and able enough to return home, requiring only home OT ** Regarding the pneumomediastinum: The patient had developed evidence of pneumomediastinum, as evidence by CAT scan and chest x-ray. After discussion with the patient and the ICU team and Thoracic Surgery, it was decided the patient would be best served by a flexible bronchoscopy and esophagogastroduodenoscopy, to determine if there was any evidence of tracheal or esophageal injury. The following day, an UGI was performed to rule out esophageal injury and was reportedly negative. The patient's diet was advanced, and he tolerated advancement of his diet without any complications. The crepitus is resolving. ** Regarding the evulsed R 4th digit tip: Plastic Surgery has been following and placed adaptec and did not feel any surgical correction was necessary. Outpatient follow up with Plastics in Hand Clinic was recommended. ** Regarding the possible right upper molar fracture: a panorex was taken to evaluate for fractures. The read was not performed at the time of discharge, so the patient was discharged with the copy of the panorex and instruction to follow up with an Oral surgeon or dentist as an outpatient The patient was intubated in the TICU s/p bronchoscopy to evaluate for tracheal injury s/p blunt trauma. None were found and the patient was extubated without issues. Ortho operated on the patient in the OR as above. On [**5-30**] the patient was transfered out of the ICU in stable condition and had pain controlled on PCA. The patient had an uncomplicated remainder of his hospital course. Upon discharge, the patient was afebrile with all vitals stable, tolerating po feeds, ambulating independently, and with pain controlled on po pain medication. Medications on Admission: Albuterol prn Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Outpatient Occupational Therapy Please assist with Activities of Daily Living 4. Albuterol Inhalation Discharge Disposition: Home Discharge Diagnosis: 1) Bilateral clavicle fx and right scapular fx 2) Open radial/ulnar fx 3) Chip fracture involving the right C6 transverse process (stable). 4) R>L Pulmonary contusions 5) Bilateral rib fx 6) Evulsed R 4th digit tip 7) ? Right upper molar fx Discharge Condition: Fair Discharge Instructions: Please call your surgeon or come to the Emergency Department if you experience any of the following: - Fever >101.5 or chills - Worsening nausea or vomiting - Inability to tolerate food or water - Increasing redness or drainage from your wound - Any pus from your wound - Anything else of concern Right upper extremity is non weight bearing (no splint needed) You will need outpatient Occupational Therapy. You will be given a script for treatment. You will be given a CD of your dental xrays so you can follow up with your dentist to evaluate if you fractured your right upper molar. You will need to schedule a follow up appointment to further evaluate this. You will follow up with Orthopedic surgery to manage your fractures and your right arm. You will follow up with Plastics regarding your ring finger. You will follow up with Trauma surgery regarding your overall injuries and pulmonary contusions. Followup Instructions: Please call [**Location (un) **] office ([**Telephone/Fax (1) 1228**]) to follow up with Orthopedic Surgery next week. Please call The Hand Clinic ([**Telephone/Fax (1) 1228**]) to schedule a follow up appointment with Plastic Surgery next week. Please call Dr.[**Name (NI) 12389**] Clinic ([**Telephone/Fax (1) 6429**]) to schedule a 2 week follow up with Trauma Surgery Please make a follow up appointment with an Oral Surgeon or Dentist in the next week

[ "883.0", "805.06", "958.7", "811.00", "810.00", "881.20", "813.54", "807.03", "861.21", "E812.0" ]

icd9cm

[ [ [] ] ]

[ "83.64", "79.32", "33.23", "45.13", "79.62", "38.91" ]

icd9pcs

[ [ [] ] ]

6869, 6875

3548, 6436

304, 370

7160, 7167

1133, 3525

8130, 8594

787, 791

6500, 6846

6896, 7139

6462, 6477

7191, 8107

806, 1114

231, 266

398, 666

688, 704

720, 771

55,247

119,508

34908

Discharge summary

report

Admission Date: [**2133-8-4**] Discharge Date: [**2133-8-6**] Date of Birth: [**2069-7-25**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5084**] Chief Complaint: neck pain status post syncopal fall Major Surgical or Invasive Procedure: None History of Present Illness: This is a 64 year old man on Aspirin 325 mg and Pradaxa for a cardiac stent with history of lung/prostate cancer, syncope, and frequent falls who was in his bathroom today when he experiences a syncopal fall. He states that he had diarrhea, stood up and became lightheaded and then had a loss of consciousness. He wife was at home and heard him fall and came to him immediately. The fall itself was unwitnessed so it is uncertain if there was a head strike. The patient denies headache, numbness, tingling, weakness vision, or hearing deficit. He states that he has neck pain with range of motion especially chin to chest and has pain on the back of his right neck and right shoulder. His family states that while in the ED here he lost consciousness again for approximately 20 secs when he sat up in bed. He sat up on the stretcher began sweating, became nauseous, was seen to have rolled his eyes back in his head and was unresponsive. His wife states that he has a n adrenal insufficiency and is prone to dehydration. Past Medical History: lung and prostate CA Recent Hyperkalemia I with Stent placement (on ASA 325 and Pradaxa) adrenal insufficiency Hypertension Hypercholesteremia syncope frequent falls Social History: live at home with wife Family History: non contributory Physical Exam: PHYSICAL EXAM: O: T: 97 BP:113/ 70 HR:18 R:18 O2Sats:100% Gen: comfortable, NAD. HEENT: A traumatic Pupils: EOMs: intact Neck:painful range of motion on chin to chest, + pain on palpation right neck and right scapula Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-14**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to 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 [**4-18**] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements On the day of discharge: Alert and oriented x 3. Pupilary irregularity again noted in right eye, otherwise non focal exam. Pertinent Results: NCHCT [**2133-8-4**] Left parietal focal hyperdensity measures 15 x 12 mm, similar in size to 8:27 Preliminary Reporta.m. This appearance is nonspecific and the differential includes a Preliminary Reporthyperdense metastatic lesion, although focal hemorrhage is not excluded given reported recent fall. A possible second area of hyperdensity in region of Preliminary Reportleft cingulate gyrus is likely due to similar process, although small Preliminary Reportsubarachnoid blood is not excluded. MR is recommended for further evaluation. MRI with/without contrast Brain [**2133-8-4**] One and possibly two metastatic lesions in the brain without significant perilesional edema. MRI without contrast Neck [**2133-8-4**] Motion artifact degrades the quality and decreases the sensitivity of this study. There is abnormal increased signal within the posterior paraspinal soft tissues, including the interspinous ligaments, concerning for ligamentous injury/sprain with edema. The alignment appears maintained. The bone marrow signal is unremarkable. The vertebral body heights are grossly preserved. There is mild disc space narrowing at C5-C6 and C6-C7. At C2-C3, there is a small central disc bulge without significant spinal canal narrowing. The neural foramina are preserved. At C3-C4, there is a posterior disc bulge asymmetric to the left resulting in mild spinal canal narrowing. There is mild right and moderate left neural foraminal narrowing due to uncovertebral and facet joint osteophytes. At C4-C5, there are posterior intervertebral osteophytes without significant spinal canal narrowing. There are moderate to severe bilateral neural foramina due to uncovertebral and facet joint osteophytes. At C5-C6, there is a left paracentral disc bulge and intervertebral osteophyte deforming the anterior cord, resulting in moderate-to-severe spinal canal narrowing at this level. The left neural foramen is also narrowed due to a combination of uncovertebral and posterior osteophytes. At C6-C7, there are intervertebral posterior osteophytes and a disc bulge deforming the anterior cord. There is also bilateral mild-to-moderate neural foraminal narrowing due to the disc bulge extending into both neural foramina. At C7-T1, there is no significant spinal canal or neural foraminal narrowing. The prevertebral soft tissues, while difficult to evaluate due to motion, are grossly unremarkable. IMPRESSION: 1. Within the limitations of this study, likely interspinous ligamentous injury/sprain with edema as described. 2. Moderate-to-severe spinal canal narrowing at C5-C6. 3. Multilevel spondylosis of the cervical spine as described Echocardiogram [**2133-8-5**] No structural cardiac cause of syncope identified. Poor technical quality due to patient's body habitus. Left ventricular function is probably normal, a focal wall motion abnormality cannot be fully excluded. Moderate mitral regurgitation. Mild dilatation of the aortic root and ascending aorta. Carotid Ultra sound: Preliminary report of your ultrasound does not show any stenosis or occlusion of your carotid arteries. Brief Hospital Course: This is a 64 year old man on Aspirin 325 mg and Pradaxa with history of coronary artery disease with stenting, prostate cancer metastatic to bone and adrenals, syncope, and frequent falls who was in his bathroom today when he experiences a syncopal fall. The patient had a Head CT that was consistent with left parietal hemorhage vs mass. The patient was seen by the neurosurgery service in the emergency room. At that time, the patient denied headache, numbness, tingling,weakness vision, or hearing deficit. A MRI of the brain with and without contrast was ordered and showed "One and possibly two metastatic lesions in the brain without significant perilesional edema and a large mass in the right masticator space, possibly representing metastatic disease. Keppra was initiated 500 mg IV. He stated that he has neck pain with range of motion especially chin to chest and has pain on the back of his right neck and right shoulder. A CT of the neck at [**Hospital 79882**] Hospital was negative for fracture. Given the patients painful range of motion and recent fall a MRI of the cervical spine was ordered to rule out ligamentous injury. The test was consistent wit abnormal increased signal within the posterior paraspinal soft tissues, including the interspinous ligaments, concerning for ligamentous injury/sprain with edema. His family stated that while in the Emergency Department here he lost consciousness again for approximately 20 secs when he sat up in bed. At that time he sat up on the stretcher began sweating, became nauseous, was seen to have rolled his eyes back in his head and was unresponsive. His wife states that he has adrenal insufficiency and is prone to dehydration. The patient was given two 500 cc normal saline bolus and a syncope work up was ordered which included EKG, craotid ultrasound, echocardiogram and cardiac enzymes. Electrolytes including magnesium, clacium and phosphate were low and were repleated. The patient was admitted to the ICU for monitoring On [**8-5**] the patient had an echocardiogram which only showed moderate MR with an EF of 55%. His carotid ultrasounds showed no stenois. His orthostatics were checked and showed no BP lability. Dr. [**Last Name (STitle) 35885**] recommended whole brain XRT and made a refferral to a radiation specialist at [**Hospital3 **] per the patient's request. Dr. [**Last Name (STitle) **] recommended a CT torso and an EEG which were both performed. Results of these are reported in the report sections of this summary. He remained neurologically intact and was transfered to the floor and was discharged home on [**8-6**]. Medications on Admission: lopressor 75 mg po BID Calcitrol 0.50 mg po BID prednisone 5 mg po qd for adrenal insufficiency zocor 80 mg po q hs pradaxa 150 mg [**Hospital1 **] sensapar 15 mg po bid zytiga 1 gram po qd- cancer tx asprin 325 mg po qd florinef 0.2 mg po qam glucosamine 1 tab po bid vitamin D 1 gram [**Hospital1 **] lopressor 75 po bid calcitrol 0.50 po bid prednisone 5 mg po qd simvastatin 40 mg po qd Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain do not exceed 4 grams in 24 hours 2. Aspirin 325 mg PO DAILY 3. Calcitriol 0.5 mcg PO BID 4. Cinacalcet 15 mg PO BID 5. Dabigatran Etexilate 150 mg PO BID 6. Famotidine 20 mg PO BID 7. Fludrocortisone Acetate 0.2 mg PO DAILY 8. Methocarbamol 500 mg PO TID:PRN muscle spasm hold for lethargy RX *methocarbamol 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*60 Tablet Refills:*1 9. Metoprolol Tartrate 75 mg PO BID 10. PredniSONE 5 mg PO DAILY for adrenal insufficency 11. Simvastatin 40 mg PO DAILY 12. Zytiga *NF* (abiraterone) 1 gram Oral qd may take home medication * Patient Taking Own Meds * 13. LeVETiracetam 500 mg PO BID RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: metastatic brain lesions Orthostatic hypotension Falls NOS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital after a loss of consciousness and fall. An MRI of your brain revealed what appears to be metastatic lesions in the brain. You also had tests to evaluated the cause of your loss of consciousness. Your echocardiogram showed only moderate mitral regurgitation and your carotid dopplers did not reveal any stenosis. You should continue your follow up with your Cardiologist and Endocrinologist for further evaluation of your falls and sudden losses of conciousness. We noted some ligimentous injury on the MRI of your Cervical spine, we have recommended that you should continue to wear your cervical collar. Followup Instructions: You will be contact[**Name (NI) **] by [**Hospital3 **] radiation oncology for radiation planning. You Have th following appointment in our system: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2133-8-20**] 10:30 Completed by:[**2133-8-6**]

[ "401.9", "V45.82", "424.0", "288.60", "723.0", "255.41", "V10.46", "E888.9", "V10.11", "198.3", "847.0", "275.3", "272.4", "V15.88", "198.7", "780.2", "414.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10110, 10116

6246, 8875

342, 349

10219, 10219

3111, 6223

11027, 11362

1655, 1673

9317, 10087

10137, 10198

8901, 9294

10370, 11004

1703, 1962

267, 304

377, 1409

2234, 3092

10234, 10346

1431, 1599

1615, 1639

5,244

150,966

45145

Discharge summary

report

Admission Date: [**2186-9-20**] Discharge Date: [**2186-9-25**] Service: SURGERY Allergies: Ipratropium Attending:[**First Name3 (LF) 6346**] Chief Complaint: Nursing home patient presenting with abdominal pain, vomiting X2, lethargic, non-verbal. Major Surgical or Invasive Procedure: [**2186-9-20**]: Percutaneous cholecystostomy tube placement by ultrasound guidance for cholecystitis. [**2186-9-20**]: 2 units of fresh frozen plasma (FFP) [**2186-9-20**]: Right internal jugular central venous catheter placed History of Present Illness: [**Age over 90 **] year-old male admitted from [**Hospital **] Nursing Home presenting with abdominal pain and mental status changes, reportedly vomiting once. He was found to be lethargic, with a glucose of 400, non-responsive to a fluid bolus of 1.5L, became non-verbal, with elevated LFT's, [**Hospital1 18**]. In the ED, CT and U/S was found to show cholecystitis (enlarged gallbladder with stones). Admitted to surgical ICU for monitoring, as patient was unstable as above and would not tolerate an operation. Past Medical History: 1. CRI- baseline creatinine 1.2-1.4 2. CAD- h/o AMI [**2175**] s/p PCI to LAD 3. CHF- TTE [**2183**] with EF 25% including apical akinesis, 1+ MR, 2+ TR, moderate PA systolic HTN 4. HTN 5. Dementia/Depression 6. Osteoporosis 7. Type 2 diabetes mellitus Social History: Lives in nursing home Has two caregivers who are very involved (listed in communication section). Heavy tobacco use in past, but quit ~20 years ago, no EtOH. Wife lives in area and has with her own caregiver [**First Name (Titles) **] [**Last Name (Titles) **] live in other states; [**State **] & and other is uninvolved Family History: non-contributory Physical Exam: Height: 5' 11'' Weight: 70kg VS: 100 PR, 108, 124/89, 29, Sat 93% Gen: lethargic, responds to name HEENT: PERRLA, EOMI CV: Tachy, normal S1 S2, II/VI RESP: tachypnic, clear to auscultation ABD: bowel sounds present, soft, tenderness to right upper quadrant Ext: no edema, warm Skin: intact Pertinent Results: Admission Labs -------------- [**2186-9-20**] 09:06AM GLUCOSE-149* UREA N-47* CREAT-1.5* SODIUM-143 POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-23 ANION GAP-13 [**2186-9-20**] 09:06AM ALT(SGPT)-138* AST(SGOT)-41* LD(LDH)-169 ALK PHOS-94 AMYLASE-22 TOT BILI-0.8 [**2186-9-20**] 09:06AM CALCIUM-7.9* PHOSPHATE-3.1 MAGNESIUM-2.2 [**2186-9-20**] 07:05AM PT-14.4* PTT-28.7 INR(PT)-1.3* [**2186-9-20**] 04:00AM GLUCOSE-143* UREA N-51* CREAT-1.7* SODIUM-142 POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16 [**2186-9-20**] 04:00AM CALCIUM-8.3* PHOSPHATE-3.6 MAGNESIUM-2.3 [**2186-9-20**] 04:00AM WBC-14.4* RBC-4.03* HGB-12.9* HCT-36.6* MCV-91 MCH-32.2* MCHC-35.4* RDW-14.9 [**2186-9-20**] 04:00AM PLT COUNT-194 [**2186-9-19**] 07:44PM LACTATE-2.4* [**2186-9-19**] 07:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-TR KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG [**2186-9-19**] 07:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2186-9-19**] 05:50PM ALT(SGPT)-311* AST(SGOT)-108* CK(CPK)-29* ALK PHOS-129* AMYLASE-27 TOT BILI-1.1 [**2186-9-19**] 05:50PM cTropnT-0.07* [**2186-9-19**] 05:50PM CK-MB-4 [**2186-9-19**] 05:50PM ALBUMIN-3.3* [**2186-9-19**] 05:50PM LACTATE-3.0* [**2186-9-19**] 05:50PM WBC-22.5*# RBC-4.79# HGB-15.3# HCT-43.4# MCV-91 MCH-32.0 MCHC-35.4* RDW-15.0 [**2186-9-19**] 05:50PM NEUTS-90.3* BANDS-0 LYMPHS-6.7* MONOS-2.8 EOS-0.1 BASOS-0.2 [**2186-9-19**] 05:50PM PT-17.6* PTT-31.0 INR(PT)-1.6* . [**2186-9-19**] 8:15 PM ~LIVER OR GALLBLADDER US Reason: ELEVATED LFTS IMPRESSION: Findings suggestive of acute cholecystitis. Please correlate with physical exam. . [**2186-9-19**] 5:49 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Indication:elevated LFT's, leukocytosis, diffuse abd pain, foul stool IMPRESSION: 1. Distended gallbladder with pericholecystic inflammatory stranding and perihepatic free fluid are suggestive of cholecystitis. Please refer to right upper quadrant ultrasound performed the same day for further details. 2. Bibasilar opacities likely represent atelectasis, but infection cannot be excluded. 3. 3.4 cm infrarenal aortic aneurysm. 4. Innumerable renal cysts with atrophied kidneys. . [**2186-9-19**] 5:44 PM ~CHEST (PORTABLE AP) Reason: eval free air, acute process IMPRESSION: 1. No evidence of pneumoperitoneum. Please correlate with subsequently performed CT scan of the abdomen/pelvis as well as right upper quadrant ultrasound. 2. Left lung base increased opacity, possibly on the basis of left lower lobe atelectasis versus pneumonia. 3. Right basilar atelectasis. . [**2186-9-19**] 5:27:32 PM ~ Cardiology Report ECG Sinus tachycardia. Occasional atrial ectopy. Left axis deviation with left anterior fascicular block. Left ventricular hypertrophy. Prior anteroseptal myocardial infarction. Compared to tracing of [**2186-4-3**] the heart rate is faster. Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**] Intervals Axes Rate 104, PR 156, QRS 144, QT/QTc 346/406.57, P 10, QRS -49, T 106 . [**2186-9-20**] 9:39 AM ~ GB DRAINAGE,INTRO PERC TRANHEP; GUIDANCE PERC TRANS BIL Reason: cholecystitis . PROCEDURE: After explaining potential risks and benefits of the procedure to the patient's wife by telephone, verbal consent was obtained. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2026**] served as witness. Patient identity was confirmed by name and date of birth. A qualified nurse was present to administer 50 mg of fentanyl over a 30-minute period with appropriate monitoring. The right upper abdomen was prepared and draped in the usual sterile fashion. 1% lidocaine buffered with bicarbonate was injected into the skin and subcutaneous tissues for local anesthesia. Thereafter, utilizing ultrasound guidance, an 8-French pigtail catheter was inserted directly into the gallbladder. There was a free return of bile. The gallbladder was decompressed with suction (approximately 300 cc.) and specimens were sent for culture and Gram stain. The catheter was then connected to the bag to drain dependently. The patient tolerated the procedure and no immediate complications were observed. Dr. [**First Name (STitle) **] was present for all essential portions of the procedure. IMPRESSION: 1. Patient status post percutaneous cholecystostomy tube placement by ultrasound guidance. . [**2186-9-20**] 3:30 AM ~CHEST PORT. LINE PLACEMENT IMPRESSION: 1. Right internal jugular line without evidence of pneumothorax. The orientation of the distal tip suggests possible placement within the ostium of the azygos vein. 2. Small left pleural effusion. 3. Left lower lobe collapse. . Brief Hospital Course: HD1: Presented to ER, Pt admitted to SICU for observation and percutaneous cholecystostomy drainage. Overnight patient recieved 2 units of FFP, remained afebrile and hemodynamically stable with a decreasing white count. HD2: Perc chole drain placed without incident, creatinine improving from 2.1->1.5, ICU course notable for improved mental status; patient advanced to clears without incident. patient's mental status much improved and ready to transfer to floor. Patient's family had visited for support without incident. HD3-6: Patient did well on the floor. mental status improved to that of baseline - was repsonding appropriately and able to thave conversations. he was tolerating a regular diet and had worked some with physical therapy - sitting in a chair, etc... Patient did have one episode of increased respirations which after appropriate workup and treatment was determined to be fluid overload and responded well to lasix. he was ready to be discharged on HD4 but there were no beds, so patient remained in house until HD6 at which he was discharged back to his facility with his perc chole drain with instructions to f/u in about 3 weeks with dr [**First Name (STitle) **] in clinic. Medications on Admission: Caltrate 600mg Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: cholecystitis Discharge Condition: good Discharge Instructions: please seek medical attention if you experience fever > 101.5, severe nausea, vomitting, pain, change in mental status. perc chole drain stays in until follow up. If it comes out, please call Dr[**Name (NI) 11471**] office ([**Telephone/Fax (1) 6347**] immediately and/or come to the emergency room. Followup Instructions: Please call Dr[**Name (NI) 11471**] office for an appointment in [**3-11**] weeks ([**Telephone/Fax (1) 6347**] Completed by:[**2186-9-25**]

[ "585.9", "575.10", "530.81", "428.0", "403.90", "294.8", "250.00", "428.20" ]

icd9cm

[ [ [] ] ]

[ "38.93", "51.01" ]

icd9pcs

[ [ [] ] ]

8014, 8084

6744, 7949

307, 537

8142, 8149

2062, 6721

8499, 8642

1719, 1737

8105, 8121

7975, 7991

8173, 8476

1752, 2043

179, 269

565, 1085

1107, 1363

1379, 1703

52,878

181,656

41963

Discharge summary

report

Admission Date: [**2169-10-10**] Discharge Date: [**2169-11-8**] Date of Birth: [**2116-11-24**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3853**] Chief Complaint: "Altered mental status." Major Surgical or Invasive Procedure: Lumbar puncture gastric tube placement History of Present Illness: Mr. [**Known lastname 87162**] is a 52 y/o male with bipolar d/o well controlled on lithium who presented to [**Hospital3 **] Hospital following 3 days of fever, cough and nausea. Noted to have AMS, garbled speech and was ataxic. Denied toxic ingestions, substances of abuse. Complained of diarrhea over 1 week. Labs notable for acute renal failure, hyponatremia (126), metabolic acidosis and plt count of 40. A head CT was negative, CXR revealed a possible LLL PNA, and CT abd/pelvis was remarable for perinephric stranding and a thickened GB wall. Lithium level was WNL. Transferred to [**Hospital1 18**] for further management. . On arrival to the ED here, the patient's vitals were 98.1 98 105/72 20 94% RA. An ECG showed NSR. Laboratory studies were remarkable for hyponatermia, ARF, WBC 2.9 with 18% bands, plt count of 40. A lumbar puncture was done with ptn 31 and glucose 74 (serum glucose 116). Tox screen (-). The patient was given 2g ceftriaxone, 1g vanco, 500mg azithro for ? pneumonia, coverage for meningitis/encephalitis. No acyclovir given CSF results. While in the ED, the patient spiked a fever to 101.1F. Pressure droped to 85 systolic, 105-115's after 2L IVF in our ED, getting a 3rd on transfer. BP currently 91/55. Had Profuse, watery, greenish, profuse, guaiac positive diarrhea. Sent for CDiff and Culture. Given concern for TTP, a smear was reviewed that showed bandemia but no schistocytes or other evidence of TTP/HUS. Concern for sepsis and admitted to the ICU. . On arrival to the ICU the patient's vitals were 97.9 90 96/76 16 95%. Described some back pain but not other complaints at this time Past Medical History: Bipolar disorder -New this admission Nephrogenic diabetes insipitus [**12-21**] to lithium Persistent dysphagia and dysarthria [**12-21**] to delayed lithium toxicity and ? cerebellar syndrome Social History: Lives alone and is independent. Works part-time at Stop & Shop. Brother [**Name (NI) **] is his gaurdian. Smokes 1.5ppd. No EtoH or other drug use. Recieves most medical care at the [**Hospital1 1474**] VA. Family History: NC Physical Exam: Admission Vitals - 97.9 90 96/76 16 95% General - Lying in bed in NAD HEENT - PERRLA, anicteric, MM dry, Op clear Neck - Supple, no JVD CV - Tachycardic, S1 and S2 no m/r/g Lung - Decreased breath sounds with mild rhonci in LLL. Otherwise good air entry b/l Abdomen - Soft, NT/ND, BSx4, no organomegally Ext- No gross deformity or edema. Bunions on feet. Dry skin. Neuro - Awake and alert. Oriented x3. Slurred speech. No focal neuro deficits. Moving all extremities. Discharge 99.6 109/75 86 18 96 RA I/O24-6135/4000 pain: none GEN: AAOX3 in NAD HEENT: CN 2-12 grossly intact, MM dry, edentulous but wearing dentures NECK: no lad CV: RRR, no RMG RESP: CTAB, no WRR ABD: abdomen flat, active BS, no TTP, no HSM, g tube in place in epigastrum, cdi and non tender EXTR: WWP, 5/5 strength, sensation, pulses intact and equal DERM: no obvious rashes Neuro: CN intact, strength, sensation wnl, speech somewhat garbled but able to understand PSYCH: mood and affect wnl Pertinent Results: Radiology CT abdomen at OSH from [**10-10**] LUNG BASES: The imaged lung bases are clear aside from mild dependent atelectasis. ABDOMEN: The non-contrast appearance of the liver, spleen, gallbladder, pancreas, and both adrenal glands is normal. There is no hydronephrosis or kidney stones. Bilateral perinephric stranding is nonspecific. The abdominal aorta is normal in course and caliber. No retroperitoneal or mesenteric lymphadenopathy is seen. No free air or free fluid is seen. The stomach and duodenum appear normal. PELVIS: Loops of small bowel demonstrate no signs of ileus or obstruction. The appendix is normal. There is no apparent thickening of the colon and no signs of diverticulosis. No free pelvic fluid. Urinary bladder is distended appearing normal. No inguinal or pelvic lymphadenopathy. BONES: No worrisome bony lesions are seen. IMPRESSION: 1. Nonspecific perinephric stranding. Please correlate for possible infection. 2. No signs of colitis or bowel obstruction. CT head [**10-10**] There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. [**Doctor Last Name **]-white matter differentiation is preserved. Ventricles are normal in size and configuration. Imaged paranasal sinuses are clear. Mastoid air cells are opacified on the left. Left middle ear cavity, right middle ear cavity and right mastoid air cells are well aerated. The bony calvarium is intact. Minimal mucosal thickening is noted along the paranasal sinuses. IMPRESSION: Opacification of the left mastoid air cells. No evidence of acute infarction or hemorrhage. Consider MRI to further assess as needed. CXR [**10-11**] A small right subhilar region of heterogeneous opacity obscures the hemidiaphragmatic contour. Dilation of the azygos vein and left atrium, in addition to mild pulmonary vascular congestion, is new. The lungs are otherwise clear. There is no pneumothorax or pleural effusion. IMPRESSION: 1. Persistent subhilar right lower lobe pneumonia. 2. Elevated venous pressure consistent with hypervolemia. MR HEAD W/O CONTRAST Study Date of [**2169-10-15**] IMPRESSION: 1. No obvious focus of slow diffusion to suggest an acute infarct. 2. Increased signal intensity in the mastoid air cells, from fluid/mucosal thickening, left more than right. 3. Nonspecific FLAIR hyperintense foci in the cerebral white matter- etiology uncertain. Followup can be considered as no prior studies are available with post-contrast images if necessary after clinical and lab correlation. CHEST (PA & LAT) Study Date of [**2169-10-18**] IMPRESSION: Resolved right subhilar lower lobe pneumonia. VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2169-10-25**] VIDEO OROPHARYNGEAL SWALLOW: Video oropharyngeal swallow study was performed in conjunction with the speech and swallow team. Multiple consistencies of barium were administered. There is aspiration with thin liquids. There is aspiration with nectar-thickened liquids, but somewhat less than with the thin liquids. There is a swallow delay and residuals within the vallecula. IMPRESSION: Aspiration with thin and nectar-thickened liquids. For complete report, please see speech and swallow note in OMR. Admission labs [**2169-10-10**] 04:30PM BLOOD WBC-2.9* RBC-4.28* Hgb-12.6* Hct-37.1* MCV-87 MCH-29.5 MCHC-34.1 RDW-12.9 Plt Ct-40* [**2169-10-10**] 04:30PM BLOOD Neuts-65 Bands-18* Lymphs-8* Monos-9 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2169-10-10**] 04:30PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2169-10-10**] 04:30PM BLOOD Glucose-116* UreaN-42* Creat-2.4* Na-131* K-3.7 Cl-102 HCO3-16* AnGap-17 [**2169-10-10**] 04:30PM BLOOD ALT-32 AST-63* LD(LDH)-348* AlkPhos-56 TotBili-0.3 [**2169-10-10**] 04:30PM BLOOD Albumin-3.2* UricAcd-11.2* [**2169-10-11**] 05:20AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.5 [**2169-10-10**] 04:30PM BLOOD Hapto-374* [**2169-10-10**] 04:30PM BLOOD ASA-5.0 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2169-10-10**] 04:49PM BLOOD Glucose-109* Lactate-0.8 Na-133 K-3.8 Cl-106 calHCO3-17* Brief Hospital Course: Mr. [**Known lastname 87162**] is a 52 y/o M with biploar presenting with sepsis, pancytopenia, [**Last Name (un) **], PNA, diarrhea, AMS. Also has nephrogenic DI [**12-21**] lithium toxicity. CXR suggestive of PNA. Anaplasma PCR also positive. Anaplasma likely major cause of his presentation. . ## Anaplasmosis: Mr. [**Known lastname 87162**] was found to have positive PCR for Anaplasma at [**Hospital3 **] hospital, which was complicated by skin rash characterized by classic target lesions on his arms, leukopenia, and thrombocytopenia. Given that he was septic on initial presentation with altered mental status, fever, tachycardia, and leukocytosis, he was admitted to the ICU and treated initially with broad-spectrum antibiotics due to concern for pneumonia, which were later discontinued once he was confirmed to have Anaplasmosis. He also had a lumbar puncture, which was unremarkable. He improved with Doxycycline and was subsequently transferred out of the ICU. He completed a 10-day course of Doxycycline ending on [**2169-10-21**]. Lyme and Babesia studies were also negative. Acute anaplasma serologies were negative and ID felt there would be limited utility to repeat them. A repeat lyme serology was also checked and this was negative. . ## Nephrogenic diabetes insipidus: Patient has nephrogenic diabetes insipidus due to Lithium use. He was interestingly hyponatremic on presentation, but this was likely due to diarrhea and hypovolemia with inadequate solute intake. When his access to free water was restricted, he maintained substantial urine output and quickly developed hypernatremia, which required D5W to correct. Nephrology guided management with normalization of his sodium once he was able to match his urine output with oral water intake. His Lithium has therefore been discontinued. On discharge his sodium was 145 and the patient is on free water flushes at 450 Q2Hours through his feeding pump. The patients 24 hour urine output has been around 4 L for several days. The patient should follow up with renal the first week of [**Month (only) 404**]. ## Acute on chronic renal failure: Baseline Cr is 1.4, but his admission Cr was 2.4, which is likely due to Lithium toxicity, as well as his acute Anaplasma infection and resulting hypovolemia in the setting of sepsis with pre-renal injury. As stated above, his Lithium has been held due to likely diabetes insipidus and possible cerebellar degeneration (see below). New baseline appears to be between 2.2 and 2.4 and on the day of discharge his creatinine was 2.4. ## Thrombocytopenia, leukopenia: These were thought to be due to Anaplasmosis and resolved with treatment ## Dysarthria: Developed new dysarthria during this admission, which persistent after his infection was treated and his sodium normalized. Neurology was consulted and recommended MRI of the brain to out a stroke. This was done and was negative for a stroke. Neurology reviewed this and felt there was evidence of cerebellar degeneration. He has normal speech at baseline per family report. PT and speech therapy were also consulted. Neurology did not feel that his MRI indicated any specific pathological process. Neurology nad psychiatry both felt that the dysarthria is probably due to lithium toxicity and resultant cerebellar degeneration and may take a long time (months to years) to resolve, if at all. Although early disseminated lyme disease (with cns involvement) and a demyelinating process were considered, these were felt to be very unlikely per neurology given negative initial lyme serologies, and normal CSF on LP, and an examination inconsistent with these syndromes. Repeat Lyme serologies (convalescent serologies) were ordered given that he may have been co-infected with Lyme diesease with negative initial serologies, 21 days after the initial assay and was negative. ## Bipolar disorder: Lithium has been held due to its toxicity. He will continue on Prolixin for now. Psychiatry recommended continued followup with outpatient psychiatry providers, but no need to acutely start another mood stabilizer because he was calm and not manic during the hospitalization. Seroquel was added to his guardianship documentation. Cogentin was also added during this hospitalization. #Generalized/Weakness and ataxia: Able to walk independently and work in grocery at baseline, but here he was somewhat unsteady and used a walker to ambulate. PT recommended that he was supervision level. His family was unable to provide 24/7 care so the patient was referred for placement at a [**Hospital1 1501**]. ##Dysphagia: The patient also developed trouble eating while in house and speech and swallow evalauted the patient. They found that he was aspirating and unsafe to eat or drink. After discussion with his guardian and brother [**Name (NI) **], as well as with him, elected to place a G tube. This was performed by interventional radiology on [**2169-11-1**]. The patient has been on isosource 1.5 at 55 cc/hr continous. This will likely be easier while the patient is requring free water flushes at 450 Q2hours. If this requirement changes TF can be cycled or bolused. Bolus recomendations are 2 cans of isosource TID via g-tube. Cycle feeding recomendations are start at a rate of 50 ml/hr and increase rate by 20 ml/h to goal of isosource 1.5 at 110 ml/h for 12 hours (1800-0600). . Transitional Issues: -f/u with neurology clinic ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**], after discharge from the Cooledge House) -f/u with outpatient psychiatry (your usual provider) -f/u with speech language pathology for repeat swallowing evaluation in [**12-22**] weeks weeks the Cooledge House Medications on Admission: Lithium, dosage unknown Fluphenazine 10mg PO qHS Discharge Medications: 1. fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for fungal rash. 3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 4. benztropine 1 mg 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 once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] Discharge Diagnosis: Anaplasmosis infection with sepsis and cytopenias Nephrogenic diabetes insipidus due to Lithium use with resultant Hypernatremia Dysarthria, Dysphagia, and Ataxia Deconditioning Acute on chronic renal failure Discharge Condition: Mental Status: Clear and coherent, but dysarthric, so difficult to understand Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker) and stand-by to contact-guard assistance Discharge Instructions: You were admitted to the Intensive Care Unit for treatment of an infection called Anaplasmosis, which is a bacterial infection transmitted by a tick bite. You improved with appropriate antibiotic therapy. Your Lithium was stopped because it was harming your kidneys and possibly may have led to degeneration of the cerebellum (part of the brain that controls speech, movement coordination, and is involved in swallowing coordination. However, you still had trouble with your speech, so you had an MRI, which did not indicate any specific problems with the exception of possibly some cerebellar atrophy per our neurology colleagues who evaluated you here in the hospital. You will need to continue to work on getting your speech back to normal which may take a while (months or years). You are advised to use a walker to ambulate. You were also found to have difficulty swallowing to the extent that you cannot eat or drink safely as we discussed. Given this, we elected in discussion with you and [**Doctor Last Name **] and [**Doctor Last Name **] to place a gastric feeding tube (Gtube) to protect you from aspirating large amounts of food or drink into your lung which could cause pneumonia and or respiratory failure. You will be sent to a rehabilitation facility on tube feeds and free water flushes. These should be continued until you follow up with renal physicians. You also need to be evaluated by speech and swallow in 2 weeks to see if you are safe to take things by mouth. MEDICATION CHANGES: - STOP taking Lithium Take all other medications as prescribed (see below) Followup Instructions: f/u with neurology clinic ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**], after discharge from the Cooledge House) f/u with outpatient psychiatry (your usual provider) f/u with speech language pathology for repeat swallowing evaluation in [**12-22**] weeks weeks the Cooledge House

[ "588.1", "333.1", "E939.8", "112.0", "295.62", "082.49", "781.3", "296.80", "305.1", "787.91", "787.20", "585.3", "995.92", "276.0", "349.82", "276.52", "038.8", "486", "334.2", "276.2", "584.9", "784.51", "284.19", "276.1", "783.5" ]

icd9cm

[ [ [] ] ]

[ "03.31", "96.6", "43.11" ]

icd9pcs

[ [ [] ] ]

14078, 14125

7667, 13050

331, 372

14378, 14378

3495, 7644

16250, 16577

2490, 2495

13499, 14055

14146, 14357

13426, 13476

14636, 16130

2510, 3476

13071, 13400

16150, 16227

267, 293

400, 2032

14393, 14612

2054, 2249

2265, 2474

22,797

125,010

44159

Discharge summary

report

Admission Date: [**2193-8-15**] Discharge Date: [**2193-8-28**] Date of Birth: [**2143-7-23**] Sex: F Service: MEDICINE Allergies: Morphine / Codeine / Sulfonamides / Compazine / Iodine; Iodine Containing / Ceftriaxone Attending:[**First Name3 (LF) 689**] Chief Complaint: Found down Major Surgical or Invasive Procedure: Right IJ central venous catheter PICC History of Present Illness: HPI: 50 yr old female with hx of MS, chronic [**First Name3 (LF) 45862**] catheter and hx of multiple UTIs who was found down by her superintendant. EMS was called after she would not answer her door and she was found down, lethargic, not answering questions, tachycardic to 160s and very hot to the touch. Fingerstick was 76 and she was given D50. In the ED, HR was 160 and she was given 2L of NS. She was also given ceftriaxone and vancomycin. She was then noted to have agonal breathing with periods of apnea and she was intubated. Following infusion of the flagyl and ceftriaxone, pt was noted to have a new diffuse, erythematous rash on her entire body. She was given benedryl, dexamethasone and pepcid and the rash improved dramatically. In MICU, she was treated with vancomycin and meropenem. UCx with ngtd. Was extubated on [**8-17**]. Has remained hemodynamically stable and afebrile. Currently is reporting some cough and shortness of breath, but denies f/c/ns, cp, n/v, abd pain. States she is much weaker than her baseline. Past Medical History: Past Medical History: 1) Secondary progressive MS dx [**2168**] 2) MRSA cellulitis 3) [**Year (4 digits) 45862**] catheter for incontinence 4) h/o multiple UTIS: Pseudomonas, Klebsiella/Morganella, (resistant to gatifloxacin) and MRSA 5) s/p viral meningitis [**4-/2188**] 6) ORIF right ankle fracture 7) Non-healing pressure ulcer R heel Social History: Lives at home with VNA services, two visits daily for help getting dressed and bathed; former nurse; divorced with 2 children; has 2 estranged brothers; Remote EtOH use; 15 pack year smoking history quit 10 years ago, no IVDU Family History: 2 paternal aunts with MS. [**Name13 (STitle) **] mother also had MS and died one year ago. Physical Exam: Exam: temp 104 rectal, BP 122/71, HR 160 --> 117, O2 100% on AC 500/14/5/100%; CVP 2 --> 7 Gen: intubated, sedated HEENT: PERRL, MM dry Neck: right IJ in place; no JVD noted CV: regular but with freq ectopy; no murmurs Chest: rhonchi noted on left ant lung field; clear post fields; no wheezing Abd: +BS, soft, nondistended; [**Name13 (STitle) 45862**] foley in place with some purulent draininage Ext: 2+ edema bilaterally; warm; 1+ DP; bilateral heel ulcers Neuro: moves all ext; legs contracted; nl tone in upper ext; 1+ DTRs, [**Name (NI) 11849**] toes bilaterally . CXR: severe throacic scoliosis . EKG: NSR at 106, nl axis; prolonged QTc, nl PR; EKG goes into ventricle bigeminy; ? TWI in V5-V6 Pertinent Results: [**2193-8-15**] 02:52PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016 [**2193-8-15**] 02:52PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-250 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2193-8-15**] 02:52PM URINE RBC-[**4-6**]* WBC->50 BACTERIA-MOD YEAST-MOD EPI-0-2 [**2193-8-15**] 02:52PM WBC-11.4*# RBC-5.31 HGB-13.2 HCT-40.6 MCV-77* MCH-24.8* MCHC-32.5 RDW-14.2 [**2193-8-15**] 02:52PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2193-8-15**] 02:52PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2193-8-15**] 02:52PM cTropnT-<0.01 [**2193-8-15**] 02:52PM CK-MB-3 [**2193-8-15**] 02:52PM GLUCOSE-174* UREA N-4* CREAT-0.5 SODIUM-135 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-17* ANION GAP-20 [**2193-8-15**] 02:59PM LACTATE-1.5 [**2193-8-15**] 11:51PM CEREBROSPINAL FLUID (CSF) PROTEIN-56* GLUCOSE-72 Ucx = 10-100k yeast, no bacterial growth Bcx = no growth CSF = no growth CXR: severe throacic scoliosis . EKG: NSR at 106, nl axis; prolonged QTc, nl PR; EKG goes into ventricle bigeminy; ? TWI in V5-V6 DISCHARGE LABS: [**2193-8-26**] 05:30AM BLOOD WBC-6.5 RBC-4.44 Hgb-10.7* Hct-34.2* MCV-77* MCH-24.1* MCHC-31.3 RDW-14.9 Plt Ct-477* [**2193-8-26**] 05:30AM BLOOD Plt Ct-477* [**2193-8-26**] 05:30AM BLOOD Glucose-84 UreaN-11 Creat-0.4 Na-145 K-4.3 Cl-107 HCO3-29 AnGap-13 Brief Hospital Course: A/P: 50F with hx of MS, chronic UTIs who presents with lethargy and fever presumably [**3-6**] to a recurrent UTI. Was also intubated following an episode of "agonal" breathing, possibly related to anaphylactic reaction to ceftriaxone. 1. Fever/UTI: Pt with grossly positive UA and with hx of several UTIs including pseudomonas, MRSA, Klebsiella. No pneumonia seen on CXR. Heel ulcers do not appear infected. LP/CSF negative for meningitis. Patient was treated broadly for her UTI with 14d of vancomycin and meropenem. Her urine culture never grew an organism except for 10-100k yeast, which was not treated. Blood cultures were negative. She remained afebrile and without leukocytosis. A bladder scan was repeated to look for a stone which could be causing her frequent UTIs, however, this was negative. She was to follow up with Dr. [**Last Name (STitle) 9125**] for management of her [**Last Name (STitle) 45862**] cath and whether to resume tobramycin irrigation. 2. Microcytic anemia Patient was noted to have guaiac positive stools but her HCT remained stable at 30. She should have an out-pt colonoscopy. 3. Respiratory failure She was intubated [**3-6**] agonal breathing and extubated [**8-17**] without incident. She occasionally reports some sob but does not appear to be in any distress, no increased work of breathing. Encourage IS use. 4. Allergic reaction Had respiratory distress and rash, which appears to be related to ceftriaxone, however, pt received ceftaz in recent past without incident(completed course [**8-1**]). 5. Tachycardia/Bigeminy: Pt admitted with HR in the 160s which came down to 110s with fluid; cardiac enzymes negative, no events on tele. resolved 6. MS: Patient's weakness was worse than baseline [**3-6**] recent illness. She was seen by PT/OT who recommended rehab, which she refused. She was continued on her out-patient dose of baclofen and neurontin. 7. Contact: [**Name (NI) **] [**Name (NI) 32245**] [**Telephone/Fax (1) 94762**] (son) 8. Full code Medications on Admission: Home Meds: * Albuterol psn * Baclofen 20 mg Tablet qid * Escitalopram Oxalate 10 mg qd * Docusate Sodium 100 mg [**Hospital1 **] * Oxybutynin Chloride 15qam, 10mg qpm * Alendronate 70 mg qFRI * Ranitidine HCl 150 mg [**Hospital1 **] * Fluconazole 200mg qd * Vit D3 * Modafinil 200 mg qam, 100mg qpm * Gabapentin 200mg qid * MVI qd * Dulcolax prn * Percocet prn * Glatiramer 20 mcg SC * ? Tobramycin 80 mg in 100 ml normal saline via foley, clamp foley for 45 mintues then drain. Twice a week. - ceftaz completed on [**8-1**] - vancomycin completed [**8-1**] 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. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Modafinil 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 9. Ibuprofen 400 mg Tablet Sig: 1-1.5 Tablets PO Q8H (every 8 hours) as needed. 10. Anzemet 50 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp:*5 Tablet(s)* Refills:*3* Discharge Disposition: Home With Service Facility: Multicultural VNA Discharge Diagnosis: Anaphylatic shock Urinary tract infection Iron deficiency anemia Hypertension Vocal cord paralysis Multiple sclerosis Discharge Condition: Stable, afebrile Discharge Instructions: Please take all medications as previoulsy prescribed. If you experience recurrent fever >101 please call Dr. [**Last Name (STitle) 2903**] or return to the ER. Followup Instructions: 1) Please call Dr. [**Last Name (STitle) 9125**], your urologist, to schedule follow up of your [**Last Name (STitle) 45862**] catheter tube. He can be reached at [**Telephone/Fax (1) 6445**] 2) Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] (ENT) [**Telephone/Fax (1) 94763**] to schedule an appointment for a repeat evaluation of your vocal cords. 3) Please call Dr. [**Last Name (STitle) 2903**] to schedule a follow-up appointment. Tel. [**Telephone/Fax (1) 2936**]

[ "995.0", "996.64", "785.52", "995.92", "401.9", "518.81", "693.0", "424.0", "038.9", "340", "280.9", "276.2", "599.0", "707.07", "E930.5", "478.30" ]

icd9cm

[ [ [] ] ]

[ "96.04", "03.31", "96.71", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

7864, 7912

4349, 6360

358, 397

8074, 8092

2926, 4054

8301, 8815

2097, 2189

6968, 7841

7933, 8053

6386, 6945

8116, 8278

4070, 4326

2204, 2907

308, 320

425, 1475

1519, 1837

1853, 2081

63,290

107,060

5412

Discharge summary

report

Admission Date: [**2198-1-26**] Discharge Date: [**2198-3-5**] Date of Birth: [**2138-11-8**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: Neutropenic fever, diffuse large B-cell lymphoma. Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 59 year-old man with a history of diffuse large B-cell lymphoma s/p IVAC D11 who presents with fever, nausea and vomiting of 1 day duration. He was feeling overall well until this morning when he developed a fever of 102. He vomited twice (bilious, non-bloody). Denies abdominal pain or diarrhea. Denies cough, sore throat, rhinorrhea or headache. Denies sick contacts though was concerned his milk was old. Denies shortness of breath or chest pain. Denies rashes. Does report increased urinary frequency but no dysuria. Yesterday he went to his outpatient oncology appointment, received 1 unit platelets with no complications and felt well enough to walk home. . In the ED, initial vitals were T 100.3, BP 112/89, HR 94, RR 18, 100% NRB. During ED course Tmax 102.7. He was noted to be in AFib at a rate of 135-160 which improved without intervention. O2 sat 98-100% 2L. BP dropped to 76 and he was given 5L NS and started on levophed. He received vancomycin and cefepime before being transferred to the ICU. On arrival to the ICU patient was actively rigoring. . Patient recently admitted [**Date range (3) 21959**] and treated with IVAC chemotherapy x 5 days which was complicated by neutropenia, thrombocytopenia, dizziness and diarrhea. Hospital stay was also complicated by Atrial Fibrillation treated with metoprolol and digoxin. Patient also has history of pulmonary embolism ([**10-15**] admission) felt to be secondary to right atrial catheter-associated thrombus complicated by likely TIA/amaurosis fugax. Patient was treated with fondaparinux but this was then stopped last admission due to thrombocytopenia. . ROS: The patient denies melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: ONCOLOGIC HISTORY: Mr. [**Known lastname **] initially presented in early [**6-/2197**] with fever, weight loss, and muscle and joint aches. He was diagnosed with PMR and started on prednisone with improvement in his symptoms. During the preceding six months, he reported a history of the generalized body pain as well as fatigue, weakness, and poor appetite. He also reported periodic fevers, drenching night sweats, and a 25-pound weight loss also over the same six months. Marked improvement of both his musculoskeletal and constitutional symptoms after prednisone treatment. He then presented to the emergency room on [**2197-7-17**] with palpitations and dizziness and was found to be in atrial fibrillation. He has had a history of PAF in the past. He was febrile to 101.6 with a heart rate of 126. CT scan of the chest, abdomen, and pelvis on showed multiple low-attenuation lesions within the liver, spleen, and kidneys with characteristics felt atypical for lymphoma. A follow-up MRI of the abdomen showed hypovascular masses in both kidneys and spleen of various sizes consistent with lymphoma. Mr. [**Known lastname **] then underwent bone marrow aspirate and biopsy on [**2197-7-26**], which showed extensive necrosis with focal involvement by a high-grade B-cell lymphoma, diffuse large B-cell type. FISH translocation was notable for c-Myc and Bcl-2 indicating a "double hit" lymphoma characterized by a Burkitt's-like lymphoma. . Mr. [**Known lastname **] has overall tolerated his chemotherapy relatively well. He has continued on his Fondaparinux daily when on [**2197-11-16**], he noted sudden onset sudden of a dark cover in the lower half of the visual field in his right eye, which lasted [**10-20**] minutes, then self-resolved. He presented to the emergency room for evaluation. TEE revealed thrombus at the tip of his right atrial catheter, with no PFO. Ophthalmology work up was negative and the episode was attributed to TIA with recommendation to continue fondaparinux. He was discharged on [**2197-11-18**] with no further episodes. . TREATMENT HISTORY: 1. Initiated treatment with [**Hospital1 **] chemotherapy on [**2197-7-29**] with two doses of Rituxan on [**2197-8-2**] and [**2197-8-3**]. Follow up CT imaging on [**2197-8-5**] showed stable lymphomatous lesions in the kidney, spleen, and abdominal nodes. 2. Rituxan 500 mg given on [**2197-8-10**] with a fever that evening and admission for neutropenia. During admission, noted for atrial fibrillation with RVR and was started on digoxin at 0.125 mg daily along with metoprolol 200 mg daily. 3. Readmitted on [**2197-8-18**] for his second cycle of [**Hospital1 **] chemotherapy, which was delayed for two days due to hypotension and cough. A CT of the chest showed bilateral lower lobe opacities, right greater than left, concerning for infection and he was treated with a course of Levaquin. 4. On [**2197-8-30**], received Rituxan at 375 mg/m2. 5. Follow up PET scan on [**2194-9-6**] showed no evidence for lymphoma but was notable for multiple peripheral base pulmonary opacities with rims of soft tissue density and relative central lucencies most of which were new. He underwent CT of the chest for further evaluation, which showed multiple filling defects within the segmental and subsegmental branches of the right lower lobe arteries compatible with pulmonary emboli. 6. Admitted on [**2197-9-7**] for initiation of anticoagulation with fondaparinux and began third cycle of treatment with [**Hospital1 **] on [**2197-9-8**](dose level 2) 7. Received Rituxan 375 mg/m2 on [**2197-9-25**]. 8. Admitted on [**2197-9-29**] for fourth cycle of treatment with [**Hospital1 **](dose level 3). 9. Received Rituxan 375 mg/m2 on [**2197-10-17**]. 10. Admitted on [**2197-10-20**] for fifth cycle of treatment with [**Hospital1 **](dose level 3 with Adriamycin at dose level 2. Received Rituxan on [**2197-11-7**]. 11. Admitted on [**2197-11-23**] for high-dose cyclophosphamide. 12. Admitted on [**2198-1-15**] for IVAC (originally admitted for high-dose MTX, but PET scan showed progressive disease). . OTHER MEDICAL HISTORY: 1. Diffuse large B-cell lymphoma, Burkitt's like with c-Myc and Bcl-2 positivity s/p [**Hospital1 **] x 5 cycles and multiple rituxan infusions. He has had recurrent disease within 2 - 3 months of his last treatment. Patient recently admitted [**Date range (3) 21959**] for CNS prophylaxis with high-dose MTX for his aggressive lymphoma. However, PET scan prior to admission was concerning for rapidly progressive disease and CT torso on admission agreed with these findings and his LDH continued to rise. He was therefore started on IVAC chemotherapy x5 days and discharged on neupogen. 2. PAF diagnosed in [**2180**] with now chronic atrial fibrillation in the past several months. He had no history of treatment with anti-arrhythmia or anticoagulation prior to his admission in [**8-/2197**], currently receiving treatment with metoprolol and digoxin. 3. Pulmonary embolism, currently receiving treatment with fondaparinux. 4. Polymyalgia rheumatica diagnosed in [**2197**] and managed by Dr. [**Last Name (STitle) **], although further treatment on hold while getting treatment for lymphoma and unclear if his symptoms were related to lymphoma and not PMR. 5. Remote history of syphilis, gonorrhea, and genital herpes in [**2160**]. 6. Tonsillectomy and adenoidectomy in the [**2137**]. 7. Myopia. 8. Recent probable TIA with from thrombus on right atrial catheter tip Social History: Mr. [**Known lastname **] is married and lives in [**Location **]. He previously worked as a software engineer, but now works without pay from home contributing to open source software projects. He gas two adult children but has minimal contact with them. He is a nonsmoker, drinks alcohol on occasion, and denies any history of illicit drugs. Family History: Father had an MI in his 70s and his paternal grandfather had an MI in his 40s. His mother is status post aortic valve replacement. His younger brother had probable schizophrenia and died from suicide at age 18. There is no family history of cancer. Physical Exam: ADMISSION EXAM: Vitals: T: 98.8 BP: 100/53 HR: 64 RR: 18 O2Sat: 94% 2L GEN: Pale, thin, no acute distress. HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear, pale conjunctiva NECK: No JVD, COR: Irregular rate, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, ND, +BS, mild tenderness on LLQ and RUQ but described as "tightness" and not overt abdominal pain, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. Moves all 4 extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. . DISCHARGE EXAM: GEN: Cachectic, NAD CV: RRR, nl s1 and s2, no m/r/g Chest: CTAB ABD: Soft, NTND, +BS Pertinent Results: ADMISSION LABS: [**2198-1-25**] 12:20PM BLOOD WBC-<0.1* RBC-3.32* Hgb-10.0* Hct-29.0* MCV-87 MCH-30.2 MCHC-34.5 RDW-14.8 Plt Ct-13*# [**2198-1-26**] 01:30PM BLOOD WBC-0.1* RBC-3.17* Hgb-9.5* Hct-26.4* MCV-83 MCH-29.8 MCHC-35.8* RDW-14.9 Plt Ct-21* [**2198-1-25**] 12:20PM BLOOD Neuts-53 Bands-0 Lymphs-40 Monos-0 Eos-7* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2198-1-26**] 01:30PM BLOOD Neuts-0* Bands-0 Lymphs-100* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2198-1-26**] 01:30PM BLOOD PT-14.5* PTT-29.5 INR(PT)-1.3* [**2198-1-26**] 01:30PM BLOOD Glucose-134* UreaN-19 Creat-1.0 Na-134 K-3.6 Cl-104 HCO3-20* AnGap-14 [**2198-1-25**] 12:20PM BLOOD Albumin-4.2 Calcium-8.9 [**2198-1-25**] 12:20PM BLOOD ALT-15 AST-19 LD(LDH)-161 AlkPhos-94 TotBili-0.5 [**2198-1-26**] 01:30PM BLOOD Digoxin-0.7* [**2198-1-26**] 01:38PM BLOOD Lactate-1.9 . PERTINENT LABS: [**2198-2-9**], [**2198-1-29**] Aspergillus Galactommanan Ag: negative [**2198-2-9**], [**2198-1-28**] B-Glucan: negative . DISCHARGE LABS: [**2198-3-5**] 05:47AM BLOOD WBC-6.1 RBC-3.01* Hgb-8.4* Hct-25.9* MCV-86 MCH-27.9 MCHC-32.5 RDW-17.8* Plt Ct-201 [**2198-3-5**] 05:47AM BLOOD Neuts-61.1 Lymphs-28.4 Monos-9.4 Eos-0.8 Baso-0.2 [**2198-3-5**] 05:47AM BLOOD PT-15.0* PTT-40.3* INR(PT)-1.3* [**2198-3-5**] 05:47AM BLOOD Glucose-99 UreaN-21* Creat-1.1 Na-141 K-4.2 Cl-107 HCO3-27 AnGap-11 [**2198-3-5**] 05:47AM BLOOD ALT-55* AST-49* LD(LDH)-209 AlkPhos-81 TotBili-0.2 [**2198-3-5**] 05:47AM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.2 Mg-2.0 ................................................................ MICROBIOLOGY: [**2198-2-12**] BAL: no growth [**2198-2-12**] Lung tissue: no bacterial, fungal, AFB, or mycobacterial growth **All blood, urine, and stool cultures were negative** ................................................................ PATHOLOGY: [**2198-2-12**] Right 6th rib biopsy: Unremarkable bone, cartilage and soft tissue . [**2198-2-12**] Right lower lobe biopsy: Acute and organizing pneumonia with abscess formation. No fungal organisms identified on GMS and PAS stains. . [**2198-2-12**] Lymph node biopsy right, level 12: No carcinoma identified in three examined lymph nodes. ................................................................ IMAGING: [**2197-1-27**] CXR: As compared to the previous radiograph, there is a newly appeared right basal and perihilar opacity with subtle air bronchograms, in continuation with the inferior hilar structures. In the setting of neutropenia and fever, a newly appeared pneumonia must be suspected. . [**2198-1-29**] CT Chest w/ con: 1. Right lower lobe pneumonia. 2. Small-to-moderate bilateral pleural effusions. 3. Mesenteric edema and ascites may reflect third spacing. . [**2198-2-3**] CXR: AP chest compared to chest radiograph since [**1-28**], and a chest CT scan [**1-29**]. Sequence of radiographic findings to suggest pneumonia present on [**1-28**] worsened in the right lower lobe on [**1-29**] and then the patient subsequently developed pulmonary edema. Since [**1-31**] nearly all of these abnormalities have resolved. Small bilateral pleural effusions remain. . [**2198-2-8**] CT Chest/Abd/Pelvis w/ con: Large area of consolidation within the right lower lobe now has a new area of cavitation. This could represent progression of known pneumonic consolidation or be representative of fungal disease. Clinical correlation recommended. No lymphomatous involvement noted. . [**2198-2-13**]: CXR: Moderate right pneumothorax has changed in distribution, with a change in posture from supine to erect, now visible in the upper hemithorax. Two right pleural tubes are also in place. There is substantial atelectasis at the base of the postoperative right lung and perihilar consolidation which could be atelectasis. Obviously follow up will be careful for possibility of postoperative pneumonia. Left lung is clear. Heart size is normal. A right subclavian infusion port ends in the right atrium. Brief Hospital Course: 59M with Burkitt's-like DLBCL s/p R-[**Hospital1 **], high-dose cytoxan, and recent IVAC for progressive disease, initially admitted to the ICU for febrile neutropenia, found to have pneumonia. . # Neutropenic Fever: The patient presented on [**1-26**] with neutropenic fever to 102 and nausea/vomiting. He became hypoxic requiring oxygen, and hypotensive requiring Levophed, and was admitted to the [**Hospital Unit Name 153**]. He had diarrhea, so the source was thought to be GI. He was empirically treated with vanc/cefepime/flagyl. Urine and stool cultures (including multiple C.diff's), and urine Legionella antigen were negative. CXR and CT showed RML/RLL pneumonia (management of pneumonia is discussed below) and micafungin was added. He was eventually weaned off pressors and had improved oxygenation. The micafungin was d/c'd and he was transferred to the floor on [**1-31**]. All blood cultures were negative. G-CSF was continued post-chemo and his counts improved markedly, so it was stopped on [**2-1**]. . # Pneumonia: Patient was found to have a RML/RLL pneumonia on CXR, confirmed by CT chest. He was initially treated broadly with vanc/cefepime/flagyl/micafungin, which was later tapered to vanc/cefepime. He improved clinically, though continued to have intermittent low-grade fevers and productive cough. There was concern for aspiration so he underwent a video-assisted swallowing study which did not reveal any aspiration, though he was switched to thin liquids and soft solids with aspiration precautions. A repeat CT chest on [**2-8**] showed new cavitary lesion within the pneumonia. Pulmonary was consulted but felt that they would be unable to reach the area via bronchoscopy. Antibiotics were switched to vanc/zosyn for better anaerobic coverage out of concern for aspiration pneumonia. At this point the patient was due for another round of chemotherapy, which could not be initiated in the setting of active pneumonia. Therefore, CT surgery was consulted to evaluate for possible lobectomy. Dr. [**First Name (STitle) **] took the patient to the operating room on [**2-12**] where he underwent right thoracotomy and right lower lobectomy with buttressing of bronchial staple line with intercostal muscle, and bronchoscopy with BAL. The patient remained in the ICU POD 1, to monitor atrial fibrillation. He had afib with RVR POD 1, which stopped after metoprolol 7.5mg IV was given. The anterior chest tube was removed on [**2-14**], and he was transferred to the floor. The last chest tube was discontinued on [**2-16**]. Post-op course was complicated by a hydropneumothorax which required placement of a pigtail catheter on [**2-22**] which was later removed. . # Increased stool output: Unclear etiology, but all of his stool studies negative, including numerous C. diff toxins. Symptomatic control with Imodium QID PRN. The diarrhea eventually resolved. . # DLBCL: Burkitt's-type lymphoma, previously on R-[**Hospital1 **], high-dose cytoxan, and IVAC with continued anemia and thrombocytopenia s/p chemo. He was transfused with goal Plt>10, Hct>24. He was continued on acyclovir and Bactrim for viral and PCP [**Name Initial (PRE) 1102**]. Rituxan was given on [**2198-2-11**], but complicated by a reaction [**2-8**] of the way through the dose, and the dose was not restarted. He was given another dose of Rituxan on [**2198-3-4**]. He is scheduled for a follow-up PET scan on [**2198-3-12**]. . # Atrial fibrillation: His HR was poorly controlled despite uptitrating the digoxin and metoprolol. Cardiology was consulted and a TEE with cardioversion was performed on [**2198-2-28**]. Digoxin was stopped. He was started on amiodarone 40mg TID for 1 week, then 400mg [**Hospital1 **] for 1 week, then 400mg daily. He was continued on anticoagulation with Fondaparinux. His metroprolol succinate was decreased to 100 mg daily from 200 mg daily. He will follow-up with Dr. [**Last Name (STitle) **] from cardiology. Medications on Admission: 1. G-CSF (Neupogen) 300mcg SC daily 2. Levofloxacin 500mg PO daily 3. Acyclovir 400mg PO Q8H 4. Sulfamethoxazole-trimethoprim 800-160mg PO MWF 5. Digoxin 125mcg PO DAILY 6. Metoprolol succinate 100mg PO HS 7. Fondaparinux 7.5mg/0.6mL Syringe SC daily, on hold since [**2198-1-25**] 8. Oxycodone 5-10mg PO Q4H prn pain 9. Calcium carbonate 200 mg (500 mg) PO TID 10. Cholecalciferol (vitamin D3) 400 unit PO DAILY 11. Famotidine 20mg PO Q12H 12. MVI one Tablet PO DAILY 13. Ondansetron 4mg PO TID prn Discharge Medications: 1. acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 2. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO MWF ([**Month/Day/Year 766**]-Wednesday-Friday). 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 5. multivitamin Tablet Sig: One (1) Tablet PO once a day. 6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO see below: take 400 mg three times per day until [**2198-3-6**], then two times per day until [**2198-3-13**], then once per day after that. Disp:*60 Tablet(s)* Refills:*2* 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO three times a day. 9. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO at bedtime. 10. Guaifenesin-DM NR 10-100 mg/5 mL Liquid Sig: Five (5) mL PO twice a day as needed for cough for 5 days. Disp:*1 bottle* Refills:*0* 11. fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous once a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - Pneumonia - Atrial fibrillation . Secondary diagnosis: - Diffuse large B-cell lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking part in your care at the [**Hospital1 771**]. You were initially admitted to the intensive care unit after becoming quite ill after your recent chemotherapy treatment. You were found to have a pneumonia which was treated with antibiotics and the surgeons then removed part of your infected right lung. We also converted your heart back to a normal rhythm and started medication for this. . The following changes were made to your medications: -STOP digoxin. -DECREASE metoprolol succinate. -START amiodarone. . For your incisions: Call Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 2348**] if these become red, swollen, or drain. Keep chest tube sites covered with gauze and bandages, changing daily, until healed. . You may shower but do not tub bath for 6 weeks. Followup Instructions: Department: Radiology - PET scan When: [**Telephone/Fax (1) 766**] [**2198-3-12**] at 1:45 p.m. Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: [**Hospital3 **] [**2198-3-26**] at 11:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15675**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: CARDIAC SERVICES When: WEDNESDAY [**2198-4-4**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "293.0", "284.1", "E933.1", "511.89", "427.31", "538", "276.69", "998.11", "729.5", "513.0", "200.20", "789.59", "512.1", "V49.83", "507.0", "584.9", "416.2", "E878.6", "725" ]

icd9cm

[ [ [] ] ]

[ "32.49", "33.24", "88.72", "34.04", "99.28", "99.61" ]

icd9pcs

[ [ [] ] ]

18789, 18795

13119, 17074

361, 367

18947, 18947

9162, 9162

19953, 20736

8163, 8414

17624, 18766

18816, 18816

17100, 17601

19098, 19930

10156, 13096

8429, 9041

9057, 9143

272, 323

395, 2275

18892, 18926

9178, 10000

18835, 18871

18962, 19074

10016, 10140

2297, 7786

7802, 8147

48,750

177,598

42594

Discharge summary

report

Admission Date: [**2107-7-29**] Discharge Date: [**2107-8-17**] Date of Birth: [**2049-10-7**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1363**] Chief Complaint: cough, dyspnea Major Surgical or Invasive Procedure: 1. Bronchoscopy 2. G tube placement 3. Vocal cord injection History of Present Illness: Mr. [**Known lastname 13014**] is a 57-year-old man with a history of metastatic EGFR positive NSCLC with mets to brain, kidney, liver, on Erlotinib, with recent discharge for pneumonia, who presents with worsening SOB, cough productive of greenish sputum, low-grade fever, and fatigue. Per report, he has also had poor po intake for the past 2 days. He completed course of meropenem yesterday ([**7-28**]) for PNA. No F/C/sweats/CP/N/V. Sent from rehab for WBC 24 today. He has had normal bowel movements, no diarrhea. He is unable to cough up any sputum. In ED, initial vitals were: pain 5 T 97.7 HR 89 BP 98/67 RR 18 98%. Exam was significant for cachectic appearing male, with lungs clear with good air entry and dry cough. Labs were significant for WBC to 24 with 90% PMN's. CXR showed LUL consolidation largely unchanged. Lactate reassuring at 1.5. Increasing parenchymal opacification with volume loss on left, cavitation, which may be associated with increased extent of infection. Blood cultures were sent. He was given 1g IV Vancomycin x1 in addition to nebs. Pt given tylenol as well for chronic back pain. Final vitals prior to transfer were 99.1 ??????F (37.3 ??????C), Pulse: 94, RR: 14, BP: 100/56, O2Sat: 97. Review of Systems: (+) Per HPI + wt loss, (-) Denies fever, chills, night sweats. Denies blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, lower extremity edema. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: NSCLC, s/p LUL resection and chemo/XRT, with metastatic disease to brain diagnosed in [**3-21**] s/p XRT and steroid treatment stg radiation-esophagitis Malnutrition previously receiving TPN at home via PICC stopped [**4-21**] h/o pilonidal cyst . PAST ONCOLOGIC HISTORY: - [**9-/2106**]: developed a cough, progressed to voice hoarseness 11/[**2106**]. - [**11-20**]: CT showed left upper lung mass and left-sided lymphadenopathy - [**2106-12-24**]: PET scan showed a large left upper lung spiculated mass measuring 4.2 x 3 cm with an SUV of 24.2 and a left hilar conglomerate of lymph nodes with an SUV of 9.3 - [**2106-12-30**]: flexible bronchoscopy with EBUS. Brushings from this bronchoscopy were positive for adenocarcinoma lesion. Lymph node stations 4L, 7 and 11L were positive. The tumor stained positive for CK7 and TTF-1 and negative for P63 and CK5/6. - [**2106-12-31**]: Head MRI negative - [**2107-1-17**]: started Cisplatin 50 mg/m2 days 1, 8, 29, 35 with Etoposide 50 mg/m2 given on days 1 through 5 and 29 through 33, with concomitant XRT. - [**2107-2-14**]: Cycle 2 Cisplatin/Etoposide - [**2107-3-7**]: Completed XRT - [**Date range (1) 92150**]: Admitted with twitching, loss of control of left arm, found to have seizures; MRI showed multiple supratentorial sites of metastatic disease as well as 2 cerebellar lesions. - [**2107-3-17**]: started whole brain radiation - [**2107-3-28**]: PET scan with multiple sites of metastatic disease in [**Month/Day/Year 500**] and muscle. - EGFR positive. - [**2107-4-28**]: Started Erlotinib Social History: Currently residing at rehab, Windgate in [**Location (un) 620**]. He has a sister nearby who is very involved in his care. Non smoker, no alcohol. Lived in the home of a physician with MS, whom he has helped with daily activities up until recently. He recently stopped working doing home repair. Non smoker, no alcohol. Family History: His mother had breast cancer at the age of 54, which was treated and then recurred and died at age 60. His father had [**Name2 (NI) 500**] cancer in his 70s and also had several types of skin cancer, possibly melanoma. He has two sisters who are with him today and one brother without any history of malignancy. He is not married and lives alone. He has no children. Physical Exam: Admission: Vitals - T: 98.5 BP: 98/65 HR: 93 RR: 24 02 sat: 96% RA GENERAL: cachectic, mildly tachypnic, speaks slowly HEENT: + facial wasting, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, dry MM, nontender supple neck, no LAD, no JVD CARDIAC: Reg, S1/S2, no murmurs, gallops, or rubs LUNG: decreased BS diffusely, particular on left ABDOMEN: thin, nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities , no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, slow speech but oriented and appropriate SKIN: warm and well perfused, no excoriations or lesions, no rashes Discharge: Vitals - Tc-98.1, Tm- 98.9, HR 60-90s, BP 90-110s/60-70s, RR 16-21, 95-97% RA I/O: 1664 (PO) +1006 (TF)/ 800 GENERAL: cachectic, slow speech with hoarse voice, in NAD HEENT: + facial wasting, dry mucous membranes without evidence of mucositis or thrush CARDIAC: Reg, S1/S2, no murmurs, gallops, or rubs LUNG: L sided rales heard best at base, clear on the right ABDOMEN: thin, nondistended, +BS, nontender, G tube in place with overlying dressing, pink macular rash around dressing EXTREMITIES: moving all extremities, no edema NEURO: 5/5 strength in UE with exception of decreased L grip strength, which is improving SKIN: macular acneiform rash on face, neck, and shoulders Pertinent Results: Admission: [**2107-7-29**] 03:25PM WBC-24.4*# RBC-3.49* HGB-9.7* HCT-29.4* MCV-84 MCH-27.9 MCHC-33.1 RDW-15.1 [**2107-7-29**] 03:25PM NEUTS-90.7* LYMPHS-2.3* MONOS-3.5 EOS-3.5 BASOS-0.1 [**2107-7-29**] 03:25PM PLT COUNT-455* [**2107-7-29**] 03:25PM GLUCOSE-78 UREA N-33* CREAT-0.7 SODIUM-136 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-25 ANION GAP-13 [**2107-7-29**] 03:39PM LACTATE-1.5 [**2107-7-29**] 03:25PM cTropnT-<0.01 Imaging: CXR [**2107-7-29**]: Persistent extensive left upper lobe consolidation including a large cavitary component. Although a left-sided pleural effusion is probably reduced, there is increasing parenchymal opacification with volume loss at the left base, which may be associated with increased extent of infection. Clinical correlation is suggested. CT Chest [**2107-7-30**]: While there has been improvement in left-sided moderate pleural effusion, there are now confluent opacities at the left lower lobe suggestive of progression of multifocal pneumonia in this region. Otherwise, there is stable appearance of consolidation involving the left upper lobe, left lower lobe, and lingula with little change in the appearance of left upper lobe cavitary lesion. CT Abdomen/Pelvis [**2107-8-3**]: 1. Advancement of disease, marked by increased size of a hepatic lesion and an increase in the lytic components of known osseous disease. No new metastatic foci identified. 2. Significant fecal load. 3. Likely unchanged metastatic disease to the kidneys, comparison is difficult given contrast timing. 4. Left lower lobe consolidation with volume loss consistent with known pneumonia. Microbiology: ASPERGILLUS GALACTOMANNAN ANTIGEN (Bronchoalveolar Lavage) Test Result Reference Range/Units ASPERGILLUS ANTIGEN 1.2 H <0.5 Blood cultures [**2107-7-29**]: Negative CXR [**2107-8-11**]: worsening LLL PNA Discharge Labs: [**2107-8-17**] 04:03AM BLOOD WBC-17.4* RBC-3.14* Hgb-8.6* Hct-26.3* MCV-84 MCH-27.5 MCHC-32.8 RDW-16.9* Plt Ct-352 [**2107-8-17**] 04:03AM BLOOD Glucose-121* UreaN-19 Creat-0.7 Na-136 K-4.3 Cl-103 HCO3-27 AnGap-10 [**2107-8-17**] 04:03AM BLOOD Calcium-8.1* Phos-2.4* Mg-2.1 Brief Hospital Course: Mr. [**Known lastname 13014**] is a 57-year-old man with a history of metastatic EGFR positive NSCLC with mets to brain, kidney, liver, on Erlotinib, with recent discharge for pneumonia, who presents with worsening SOB, cough productive of greenish sputum, and significant leukocytosis secondary to complicated LLL PNA. # Complicated PNA: Pt had complicated course during last admission with continued LUL cavity. Patient presented with a new LLL consolidation on CT despite recently completing treatment course of meropenem. CT read as LLL PNA and continued LUL cavity. Aspiration event was likely given his vocal cord dysfunction. He was started on vancomycin and meropenem per ID recs. He was evaluated by pulmonary and a bronchoscopy was performed on [**8-1**] which showed a large amount of secretions but no obstruction. BAL was aspergillus ag positive and grew yeast, but serum aspergillus ag and beta glucan were negative. Pt started on voriconazole on [**8-4**]. Vanc d/c'ed and pt maintained on [**Last Name (un) **]/Vori. Pt with supplemental O2 requirements [**8-11**] and CXR noted to have increase in LLL PNA. [**Last Name (un) **] and Vanc restarted. Vori continued. [**Last Name (un) **] changed to Zosyn [**8-12**]. Will stop IV antibiotics on discharge. # [**Month/Day (4) 9036**] care: Pall care consult initiated at request of pt's sister, [**Name (NI) 66110**]. Pt expressed wishes to focuse on [**Name (NI) **] and stop IV antibiotics. Family meeting with Dr. [**Last Name (STitle) 3274**] [**8-16**]. Pt to be discharged to residential hospice. Pt desires to continue tube feeds. Spoke with him regarding voriconazole by G tube and he wanted to continue for time being. # Cachexia/malnutrition: Patient continued to have poor PO intake for multiple reasons. He has difficulty and pain with swallowing with known vocal cord dysfunction, pain in his back that makes it uncomfortable for him to sit up and eat, and overall poor appetite. CT abdomen showed possible progression of cancer which may indicated decreased response to tarceva. Attempted dobhoff placement but pt did not tolerate well. Patient underwent G-tube placement and vocal cord injection on [**8-9**] after being cleared and consented by anesthesia. Tube feeds were started [**8-10**], pt tolerated tube feeds well at goal and wishes to continue tube feeds in hospice center. # Anemia: Hct remained chronically low in low 20s. He was transfused 2 units PRBCs on [**2107-8-9**] prior to going to OR for Hct of 20. There were no signs of frank bleeding and Hct remained stable. Pt received 3u pRBCs [**8-9**]. H/H remained stable after transfusion. # Left vocal cord paralysis: Noted on last admission. He underwent vocal cord injection with Dr. [**Last Name (STitle) 85784**] [**Name (STitle) **] on [**8-9**]. The patient was transferred to the ICU overnight s/p L vocal cord injection with poor abduction of R cord and concern for possible airway obstruction secondary to b/l medialization of the cords. The patient did well overnight and was given 10 mg IV decadron. He was then transferred to the oncology team. Pt unable to get repeat L sided vocal cord injection for 4-6wks per ENT team. With hospice in place, will not f/u with ENT as OP unless he chooses to set it up with goal of quality of life. Chronic issues: # Dysphagia/Odynophagia: Likely secondary to radiation therapy and tumor. He was able to tolerate soft solids; po medications were changed to IV whenever possible. However, given long-standing dysphagia that pt reported was worsening, GI was curbsided regarding possibility of upper endoscopy. Pt ended up getting G tube as opposed to PEG so endoscopy was not pursued to evaluate esophagus for cause of odynophagia. We will not pursue further workup in setting of hospice care. # NSCLC, EGFR positive: mets to brain, kidney, liver, on Erlotinib. Repeat CT abdomen/pelvis showed advancement of disease in liver and lytic components. He was continued on erlotinib for his lung cancer and keppra for seizure prophylaxis. Palliative care was consulted per request from pt's sister, [**Name (NI) 66110**]. Pt opted for [**Name (NI) **] measures with residential hospice. Will go off erlotinib at time of discharge since progression while on med and focus on [**Name (NI) **]. # Back Pain: Chronic. Likely due to axial metastatic lesions. He was continued on liquid oxycodone and a fentanyl patch was added. # Coccyx ulcer: Wound consult was initiated and recommendations for wound care were followed by nursing. # GERD: He was continued on ranitidine. Transitions of Care: 1. Code Status: DNR/DNI 2. Contact: Sister [**Name (NI) 66110**] 3. Discharge to residential hospice. Medications on Admission: Discharge Medications: 1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): at 1700. 2. clindamycin phosphate 1 % Gel Sig: as directed Topical once a day: apply to infected area once daily. 3. erlotinib 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. levetiracetam 500 mg/5 mL (5 mL) Solution Sig: Ten (10) ml PO twice a day. 5. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for pain. 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous Q6H (every 6 hours) for 8 days: last day = [**2107-7-27**]. 8. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Four Hundred (400) mg PO DAILY (Daily). Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain, fever please contact HO if giving for fever RX *acetaminophen 650 mg/20.3 mL 650 mg by G tube every 6 hours Disp #*1 Liter Refills:*0 2. Ranitidine (Liquid) 150 mg PO DAILY RX *ranitidine HCl 15 mg/mL 150 mg by G tube daily Disp #*1 Liter Refills:*0 3. LeVETiracetam Oral Solution 1000 mg PO BID RX *Keppra 1,000 mg 1 tablet by G tube twice daily Disp #*60 Tablet Refills:*0 4. Megestrol Acetate 400 mg PO DAILY:PRN low appetite RX *Megace Oral 400 mg/10 mL (40 mg/mL) 400mg Suspension(s) by G tube daily Disp #*1 Liter Refills:*0 5. Benzonatate 100 mg PO TID:PRN cough RX *benzonatate 100 mg 1 capsule(s) by mouth three times daily Disp #*90 Capsule Refills:*0 6. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation RX *Diocto 50 mg/5 mL 100 mg by G tube twice daily Disp #*1 Liter Refills:*0 7. Fentanyl Patch 25 mcg/hr TP Q72H RX *fentanyl 25 mcg/hour 25mcg/hr patch every 72 hours Disp #*10 Transdermal Patch Refills:*0 8. Nystatin Oral Suspension 5 mL PO QID:PRN thrush RX *nystatin 100,000 unit/mL 5 mL by mouth four times daily Disp #*100 Milliliter Refills:*0 9. Polyethylene Glycol 17 g PO DAILY hold for loose stools RX *ClearLax 17 gram/dose 17 g(s) by G tube daily Disp #*30 Packet Refills:*0 10. Senna 1 TAB PO BID hold for diarrhea RX *senna 8.8 mg/5 mL 5 mL by G tube twice daily Disp #*100 Milliliter Refills:*0 11. Voriconazole 200 mg PO Q12H RX *Vfend 200 mg 1 tablet(s) by G tube every 12 hours Disp #*60 Tablet Refills:*0 12. Hospice eval Please screen and admit to hospice. 13. Morphine Sulfate (Concentrated Oral Soln) 5-10 mg PO Q2H:PRN pain RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 5-10 mg(s) by G tube every 2 hours Disp #*30 Milliliter Refills:*0 14. Lorazepam 0.5 mg SL Q2H:PRN anxiety RX *Ativan 0.5 mg 1 tablet(s) by G tube every 2 hours Disp #*100 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: [**Hospital 13054**] Hospice Discharge Diagnosis: Primary: -Pneumonia -Severe Malnutrition -Vocal cord paralysis Secondary: -Metastatic EGFR positive NSCLC Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 13014**], It was a pleasure taking care of you during this admission. You were hospitalized for a recurrent pneumonia and treated with antibiotics. You were also not eating well, so a tube was placed in you stomach to help supplement you with nutrition. You also received a vocal cord injection for your vocal cord paralysis. Some changes have been made to your medications. Please see the attached list. You have decided to focus on [**Last Name (LF) **], [**First Name3 (LF) **] you will be transferred to a residential hospice center. We will stop your IV antibiotics. Followup Instructions: You will follow-up with the hospice physicians. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**] Completed by:[**2107-8-17**]

[ "478.33", "276.0", "197.7", "117.3", "530.81", "285.9", "707.22", "261", "198.5", "784.59", "198.0", "707.03", "198.3", "507.0", "V10.11", "484.6" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.29", "31.42", "33.24", "43.19", "99.25", "31.0" ]

icd9pcs

[ [ [] ] ]

15528, 15583

8161, 11468

307, 369

15734, 15734

5931, 7846

16543, 16715

4115, 4488

13646, 15505

15604, 15713

12889, 12889

15917, 16520

7862, 8138

4503, 5912

1646, 2176

253, 269

398, 1627

15749, 15893

12760, 12863

11484, 12739

2198, 3758

3774, 4098

79,564

108,525

3403

Discharge summary

report

Admission Date: [**2161-4-22**] Discharge Date: [**2161-4-25**] Date of Birth: [**2105-11-8**] Sex: F Service: NEUROSURGERY Allergies: Taxol Attending:[**First Name3 (LF) 1854**] Chief Complaint: Brain mass, in need of shunt procedure Major Surgical or Invasive Procedure: 3rd ventriculostomy History of Present Illness: 55F with a history of metastatic breast cancer, who has right and left cerebellar brain metastases. Her oncological problem started in [**2146**] when a right breast mass was discovered on mammogram. She had lumpectomy and T2, N0, and M0 invasive carcinoma was found. She received chest irradiation with CMF (cyclophosphamide, methotrexate, and 5-FU), adjuvant chemotherapy, followed by tamoxifen. In [**2149**], she had recurrence with chest irradiation followed by tamoxifen. She stopped tamoxifen in [**2151**]. In [**2156**], she developed recurrent disease in the left breast. Metastatic work up revealed metastases in lungs and bone. She received Adriamycin and cyclophosphamide for 4 cycles, together with one dose of taxol from which she developed an anaphylactic reaction. She then completed whole brain cranial irradiation on [**2160-8-6**]. She was admitted to neurosurgery for 3rd ventriculostomy so that she could undergo radiation treatment in her brain for metastases. Past Medical History: See above, plus: hypertension and sarcoidosis. Past Surgical History: She had breast surgeries, a right lumpectomy in [**2146**] and a left lumpectomy in [**2149**]. She had a lung biopsy in [**2156**]. Social History: She does not smoke cigarettes or drink alcohol. Has a fiance. Family History: Mother died of breast cancer. An aunt from the maternal side has breast cancer but it is under control. Her father is healthy. She has 2 uncles, one died of smoking-related lung cancer while another is alive with non-smoking-related cancer. There are other members of her family with diabetes. Physical Exam: On discharge: She is awake, alert, and oriented times 3. Her language is fluent with good comprehension, naming, and repetition. Her recent recall is good. Cranial Nerve Examination: Her pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full. Visual fields are full to confrontation. Her face is symmetric. Facial sensation is intact bilaterally. Her hearing is intact bilaterally. Her tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: She does not have a drift. Her muscle strengths are [**6-15**] at all muscle groups. Her muscle tone is normal. Her reflexes are 2- and symmetric bilaterally. Her ankle jerks are absent. Her toes are downgoing. Sensory examination is intact to touch. Coordination examination does not reveal dysmetria. Her gait is normal. She does not have a Romberg. Head: incision CD&I with vertical mattress sutures in place, no bleeding present CV: RRR, no murmurs Chest: CTAB Abd: S/ND/NT +BS Ext: wwp Pertinent Results: [**2161-4-25**] 07:20AM BLOOD WBC-4.1 RBC-2.98* Hgb-10.9* Hct-32.2* MCV-108* MCH-36.5* MCHC-33.8 RDW-14.4 Plt Ct-198 [**2161-4-25**] 07:20AM BLOOD PT-12.6 PTT-38.3* INR(PT)-1.1 [**2161-4-25**] 07:20AM BLOOD Plt Ct-198 [**2161-4-24**] 11:00AM BLOOD FacVIII-72 [**2161-4-23**] 05:12AM BLOOD Glucose-109* UreaN-6 Creat-0.8 Na-142 K-3.8 Cl-108 HCO3-27 AnGap-11 [**2161-4-25**] 07:20AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.1 [**2161-4-23**] 05:12AM BLOOD Calcium-9.4 Phos-3.1 Mg-2.1 [**2161-4-23**] 05:12AM BLOOD Glucose-109* UreaN-6 Creat-0.8 Na-142 K-3.8 Cl-108 HCO3-27 AnGap-11 Brief Hospital Course: Pt was admitted to neurosurgical service for scheduled procedure. She underwent a head CT for stereotactic planning on the day of admission. She then was taken to the operating room and underwent ventriculoscopy. She tolerated this procedure with no complications. (for full details of procedure, see dictated operative report.) Hospital course by system: Neuro: the patient tolerated the surgery well with no resulting neurological deficits. She was monitored in the PACU overnight with hourly neuro checks and then transferred to the floor POD1. On the day of discharge she was completely neurologically intact (see exam above). CV: no issues, pt remained hemodynamically stable throughout hospitalization Pulmonary: no issues, pt received incentive spirometry post-op and lungs were CTA GI: no issues, tolerating full diet on day of discharge GU: no issues, pt making adequate urine without foley on day of discharge ID: The pt received perioperative antibiotics and post operative vanc/gent for 3 doses each. on the day of discharge she was afebrile with no elevated white count. HEME: Prior to the procedure she received 2000U of Factor 8 per recommendations of hematology due to her Factor 8 deficiency. She received 2000U 12hours later and a third dose 12 hours after the second dose. her followup factor 8 level was 72 postoperatively which was therapeutic. Of note, she did have some slight oozing from the incision site, this was corrected easily by over-suturing the incision. On the day of discharge her HCT had decreased slightly to 33, but was hemodynamically stable with no bleeding from the wound. she had followup with heme planned. Oncology: pt had plans for followup with radiation oncology and brain tumor clinic provided to her. on the day of discharge the pt was hemodynamically stable and good with pain controlled, afebrile with plans for followup. Medications on Admission: Tykerb Diovan Iron Vit B6 Discharge Medications: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: DO NOT DRIVE OR DRINK ALCOHOL WITH THIS MEDICATION. TAKE A STOOL SOFTENER WITH THIS MEDICATION. Disp:*60 Tablet(s)* Refills:*0* 4. Tykerb 250 mg Tablet Oral 5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Breast cancer with metastasis to brain Discharge Condition: Stable and good Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: You will follow-up with Radiation/oncology Dr. [**Last Name (STitle) 3929**] for cyberknife planning on Monday [**2161-4-27**] at 9am on [**Hospital Ward Name 23**] 5. Call [**Telephone/Fax (1) 15755**] for confirmation. . You have a Brain [**Hospital 341**] Clinic appointment with Provider: [**Name10 (NameIs) 640**] [**Name8 (MD) 15756**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2161-5-11**] 3:00. This is on the [**Location (un) 858**] of the [**Hospital Ward Name 23**] Building on the [**Hospital Ward Name 516**]. . PLEASE RETURN TO THE OFFICE IN 10 DAYS FOR REMOVAL OF YOUR STAPLES/SUTURES. Please call [**Telephone/Fax (1) **] to arrange. . ALSO PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS from today . You should also follow-up with hematology. Please call their office to make an appointment with [**First Name11 (Name Pattern1) 916**] [**Last Name (NamePattern4) **], MD [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 15757**] [**Last Name (NamePattern1) **],MD. Please call their office to make an appointment: ([**Telephone/Fax (1) 11576**]

[ "197.0", "331.4", "599.0", "135", "V10.3", "286.0", "198.3", "198.5", "401.9" ]

icd9cm

[ [ [] ] ]

[ "02.2" ]

icd9pcs

[ [ [] ] ]

6184, 6190

3673, 4007

309, 331

6273, 6291

3078, 3650

7677, 8844

1680, 1980

5637, 6161

6211, 6252

5587, 5614

6315, 7654

4034, 5561

1448, 1584

1995, 1995

2009, 3059

231, 271

359, 1354

1376, 1424

1600, 1664

47,035

161,860

5388

Discharge summary

report

Admission Date: [**2146-2-3**] Discharge Date: [**2146-2-5**] Date of Birth: [**2071-10-9**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 594**] Chief Complaint: Hypercarbic Respiratory Failure Major Surgical or Invasive Procedure: None History of Present Illness: This is a 74 yo F with PMH significant for DM2, hypothyroid, restrictive lung disease, OSA, HTN, HL who presented to [**Hospital 882**] Hospital on [**1-25**] due to hypoglycemia and increased respiratory distress. During the few days prior to that admission, the patient c/o increased fatigue, lethargy, and somnolence. At that time, VNA nurse noticed her FBS to be in the 50-60s. The patient also had some watery diarrhea up to 3xs per day. The patient also had recently uptitrated her home O2 to 3L from 2L due to desats into the 70s. . At [**Hospital1 882**], the patient had a CXR that showed increased density at both lung bases and a right sided pleural fluid. Large pulm vessels. A TTE showed normal LV thickness, EF 60%, no regional wall motion abnormalities, septal flattening c/w RV increased pressure. Est PA pressure is 40mmHg. During the hospitalization, the patient was kept on BiPap for CO2 in the 90-100, then weaned. The patient completed a course of Levaquin for CAP. The patient was initially diuresed, but developed [**Last Name (un) **] and this was stopped. The patient also was diagnosed with C diff and started on Flagyl 500mg TID. . On arrival to the MICU, the patient is wearing BiPap. She denies difficulty breathing or subjective dyspnea. She looks comfortable. Past Medical History: Appendectomy DM2 Hyperlipidemia HTN Cholecystectomy Hernia Repair H/o melanoma TAH/BSO Carpal tunnel OA Vitamin D deficiency Hypothyroid Restrictive lung disease [**2-10**] obesity Social History: Lives with husband, at rehab Family History: Noncontributory Physical Exam: ADMISSION EXAM Vitals: T: 96.1 BP: 137/60 P: 79 R: O2: 100% Bipap 20/7 General: On Bipap, answering questions appropriately, laying with eyes closed, lethargic HEENT: dry MM Neck: obese CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: good breath sounds BL, scattered rhonchi at bases Abdomen: soft, NT, obese, +BS, fecal tube with liquid stool, no rebound/guarding GU: foley Ext: warm, well perfused, 3+ edema of all extremeties, non-warm firm erythema of BL lower extremeties c/w vhronic venous stasis, does not look cellulitic Skin: cherry hemangiomas and sebarrheic keratosis Neuro: nonfocal Discharge exam Tcurrent: 36.6 ??????C (97.8 ??????F) HR: 83 BP: 116/49(63) RR: 22 SpO2: 97% General: laying with eyes closed, drowsy HEENT: dry MM, EOMI Neck: obese CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: good breath sounds BL, scattered rhonchi at bases Abdomen: soft, NT, obese, +BS, fecal tube with liquid stool, no rebound/guarding GU: foley Ext: warm, well perfused, 3+ edema of all extremities, non-warm firm erythema of BL lower extremities c/w chronic venous stasis, does not look cellulitic Skin: cherry hemangiomas and sebarrheic keratosis Neuro: CNIII-XII intact, moving all extremities spontaneously, normal DTRs Pertinent Results: Admission labs [**2146-2-3**] 12:50AM BLOOD WBC-7.1 RBC-3.86* Hgb-9.1* Hct-32.1* MCV-83# MCH-23.6* MCHC-28.3* RDW-17.8* Plt Ct-121*# [**2146-2-3**] 12:50AM BLOOD Neuts-81.5* Lymphs-10.7* Monos-4.7 Eos-3.0 Baso-0.2 [**2146-2-3**] 12:50AM BLOOD PT-13.4* PTT-33.3 INR(PT)-1.2* [**2146-2-3**] 12:50AM BLOOD Glucose-110* UreaN-52* Creat-1.2* Na-146* K-4.2 Cl-103 HCO3-37* AnGap-10 [**2146-2-3**] 12:50AM BLOOD Calcium-9.6 Phos-2.9 Mg-1.9 [**2146-2-3**] 12:29AM BLOOD Type-ART O2 Flow-6 pO2-104 pCO2-89* pH-7.31* calTCO2-47* Base XS-13 Intubat-NOT INTUBA Comment-BIPAP 20/7 [**2146-2-3**] 12:29AM BLOOD Lactate-0.9 [**2146-2-3**] 05:58PM BLOOD freeCa-1.34* Discharge labs [**2146-2-5**] 02:15AM BLOOD WBC-7.0 RBC-3.90* Hgb-9.1* Hct-32.1* MCV-82 MCH-23.4* MCHC-28.4* RDW-17.5* Plt Ct-174 [**2146-2-5**] 02:15AM BLOOD Glucose-113* UreaN-42* Creat-0.8 Na-150* K-4.1 Cl-104 HCO3-46* AnGap-4* CXR: IMPRESSION: 1. Enlarged cardiac silhouette with moderate pulmonary edema and bilateral pleural effusions, right greater than left, are suggestive of congestive heart failure. 2. Bibasilar atelectatic changes. However, findings may be related to aspiration. Brief Hospital Course: This is a 74 yo F with morbid obesity and recent hospitalization for PNA who was transfered here from rehab with somnolence [**2-10**] hypercarbia and a PCO2 114. . 1. Hypercarbic Respiratory Failure: Secondary to obesity, untreated OSA, and possibly obesity/hypoventilation syndrome. The patient has had multiple presentations similar to this. She uses O2 at home, but no positive pressure ventilation. The patient presented with a PCo2 of 114. She was placed on BiPap 20/7 with improved ventilation. However, the patient remained lethargic. Repeat gas showed a PCO2 of 97. Her baseline is 80-90. Her saturations remained 90-100% even off non-invasive ventilation. The patient will need BiPap to wear as an outpatient during naps and at night. Otherwise, she may benefit from a trach in the future. In addition, she was started on methylphenidate to improve drive to breath. She can continue on supplemental O2 as needed with goal O2 sat >90%, < 95%. Without BiPAP, she will continue to present with this same constellation of symptoms. . 2. C diff colitis: The patient had a recent diagnosis of C diff colitis at [**Hospital 882**] Hospital. She is being treated with PO Flagyl 500mg Q8hrs. The patient will complete a 14 day course of treatment. Flexiseal to be used ongoing. . 3. Recent PNA: On her last hospitalization, the patient had BL conoslidations and was treated with a 7 day course of levaquin. The patient had no fever or leukocytosis here, so no antibiotics were started. . 4. Pulmonary Artery Hypertension: OSH TTE showed PA pressures > 40. This is likely [**2-10**] obesity/OSA. The patient was gently diuresed and treated with biPap. . 5. Psych: On celexa, buspar. She intermittently was shouting incoherently in the MICU, and responded well to zyprexa 5mg PO PRN. . 6. HL: On Tricor as outpatient. Here on gemfibrazole. Discharged on home medication. . 7. DM2: SSI here. On Humulin at home. . 8. Leg pain: chronic issues, likely secondary to chronic peripheral edema. Her pain was treated with tylenol and she received gentle diuresis. . 9. HTN: initially diovan and diltiazem held on admisison to ICU, discharged on diovan, but diltiazem held for time being as want to add back 1 at a time. Can be restarted as needed in outpatient setting. ============================= Transitional issues # SHE NEEDS BiPAP WHENEVER SLEEPING, AT NIGHT OR DURING THE DAY # If agitated, she responds well to zyprexa 5-10mg PO x1 # Restart home diltiazem as needed Medications on Admission: Buspirone 5mg [**Hospital1 **] Aspirin 81mg Celexa 20mg Qday Colace 100mg [**Hospital1 **] Lovenox 40mg Qday Fenofibrate 145mg Qday Levothyroxine 50mcg Qday Flagyl 500mg TID Seraquel 25mg QHS PRN Discharge Medications: 1. BiPAP settings Mask Ventilation: Nasal CPAP w/PSV (BIPAP) Inspiratory pressure: 20 cm/h2o Expiratory pressure: 10 cm/h2o Supp O2: 4 L/min titrate to O2 sat 92% goal Should wear BiPAP whenever sleeping, including during naps during the day. 2. buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 6. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day. 7. fenofibrate 150 mg Capsule Sig: One (1) Capsule PO once a day. 8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. methylphenidate 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 10. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. 11. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day. 13. oxybutynin chloride 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 14. Humalog 100 unit/mL Solution Sig: Per sliding scale . Subcutaneous . 15. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: hypercarbic respiratory failure Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted because at rehab because you were found to be sleepy. This is due to high carbon dioxide in the blood, which is due to obesity and obstructive sleep apnea. We treated you by keeping you on BiPAP (a pressurized face mask) at night and during all naps. Also, we started you on a new medication (Methylphenidate). These two actions will help you to stay as awake as possible. Now, your carbon dioxide level has dome down and you are back to your baseline (per your husband). You are being discharged back to rehab. . We made the following changes to your medicatuions: -START Methylphenidate -HOLD diltiazem you were previously on, likely to restart soon Followup Instructions: Please follow up as planned with your Primary care doctor.

[ "276.0", "008.45", "278.03", "272.4", "278.01", "401.9", "338.29", "782.3", "244.9", "416.8", "294.8", "250.00", "327.23", "518.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8485, 8551

4428, 6898

321, 327

8627, 8627

3257, 4405

9508, 9570

1915, 1932

7145, 8462

8572, 8606

6924, 7122

8807, 9485

1947, 3238

250, 283

355, 1648

8642, 8783

1670, 1853

1869, 1899

3,135

186,628

27757

Discharge summary

report

Admission Date: [**2168-6-29**] Discharge Date: [**2168-7-4**] Date of Birth: [**2118-7-25**] Sex: M Service: CARDIOTHORACIC Allergies: Lisinopril Attending:[**Known firstname 922**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2168-6-30**] - Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to RCA, SVG to Ramus to OM) History of Present Illness: 49 y/o male with chest pain and +ETT. Referred for cardiac cath and found to have 3 vessel disease. Thus referred for surgical intervention. Past Medical History: Hypertension, Hypercholesterolemia, Peripheral Vascular Disease s/p Left Fem/Fem Bypass and right femoral endarterectomy, Arthritis Social History: Lives with wife. [**Name (NI) 1403**] at grocery store. Tobacco: 1ppd for 25 yrs. ETOH: Socially Family History: Father MI at age 57 s/p CABG x 2. Sister s/p CABG [**2164**]. Physical Exam: VS: 65 18 96/53 113/58 5'[**72**]" 217# General: WD/WN male in NAD Skin: Unremarkable, -lesions HEENT: EOMI, PERRL, OP benign Neck: Supple, FROM, -JVD, -carotid bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -edema/varicosities Neuro: MAE, Non-focal, A&O x 3 Pertinent Results: Cath [**6-29**]: Three vessel coronary artery disease. Severe systolic ventricular dysfunction. Mild diastolic ventricular dysfunction. Echo [**6-29**]: There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is low normal (LVEF 50-55%). Resting regional wall motion abnormalities include inferior and inferoseptal hypokinesis. There is focal hypokinesis of the apical free wall of the right ventricle. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation seen. The estimated pulmonary artery systolic pressure is normal. CXR [**7-4**]: [**2168-6-29**] 11:10AM BLOOD WBC-6.9 RBC-4.06* Hgb-13.0* Hct-36.0* MCV-89 MCH-31.9 MCHC-36.0* RDW-13.3 Plt Ct-185 [**2168-7-1**] 02:24AM BLOOD WBC-9.4 RBC-3.43* Hgb-11.3* Hct-30.2* MCV-88 MCH-33.0* MCHC-37.5* RDW-14.0 Plt Ct-182 [**2168-7-3**] 05:03AM BLOOD WBC-10.0 RBC-2.70* Hgb-8.5* Hct-23.9* MCV-89 MCH-31.7 MCHC-35.7* RDW-13.7 Plt Ct-149* [**2168-6-29**] 11:10AM BLOOD PT-12.1 PTT-27.7 INR(PT)-1.0 [**2168-7-2**] 03:10AM BLOOD PT-12.7 PTT-25.7 INR(PT)-1.1 [**2168-6-29**] 11:10AM BLOOD Glucose-138* UreaN-30* Creat-0.9 Na-133 K-4.2 Cl-100 HCO3-23 AnGap-14 [**2168-7-3**] 05:03AM BLOOD Glucose-117* UreaN-16 Creat-0.8 Na-136 K-4.3 Cl-100 HCO3-29 AnGap-11 [**2168-6-29**] 11:10AM BLOOD ALT-41* AST-23 AlkPhos-84 Amylase-45 TotBili-0.8 [**2168-6-29**] 04:22PM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.036* [**2168-6-29**] 04:22PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 10840**] [**Last Name (Titles) 1834**] a cardiac catheterization which revealed 3 vessel disease. After pre-operative testing and surgical consent, he was brought to the operating room on [**2168-6-30**] where he [**Date Range 1834**] a coronary artery bypass grafting to four vessels. Please see operative report for surgical details. He tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. He did require several units of platelets and packed rede blood cells secondary to bleeding and increased chest tube output. Early post-op day one he was weaned from sedation, awoke neurologically intact and was extubated. Beta blockerade, a statin, aspirin and diuretics were started. He was gently diuresed towards his pre-op weight. On post-op day two he was transferred to the telemetry floor for further care. His chest tubes were removed on post-op day two and epicardial pacing wires on post-op day three without complication. His HCT did trend down slightly after surgery, but he was asymptomatic and not transfused. He was started on Iron and Vitamin C. Physical therapy followed him during entire post-op course for assistance with his strength and mobility. He continued to improve with stable labs and vitals signs and was transferred home on postoperative day four with VNA services and the appropriate follow-up appointments. Medications on Admission: Benicar 20mg qd, Vytorin 10/40mg qd, Aspirin 325mg qd, Bisoprolol 5mg qd, Plavix 75mg qd (last dose 6/21) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*1* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 8. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*1* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks. Disp:*56 Capsule, Sustained Release(s)* Refills:*0* 11. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily) for 2 weeks: Use 14mg Patch for 2 weeks, followed by 7mg Patch for 2 weeks. Disp:*14 Patch 24HR(s)* Refills:*0* 12. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Transdermal once a day for 2 weeks: Use 14mg Patch for 2 weeks, followed by 7mg Patch for 2 weeks. Disp:*14 * Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 PMH: Hypertension, Hypercholesterolemia, Peripheral Vascular Disease s/p Left Fem/Fem Bypass and right femoral endarterectomy, Arthritis Discharge Condition: Good Discharge Instructions: Can take shower. Wash incisions with water and gentle soap. Gently pat dry. Do not take bath or swim. Do not apply lotions, creams, ointments or powders to incisions. Do not drive for 1 month. Do not lift greater than 10 pounds for 2 months. Followup Instructions: Dr. [**Last Name (STitle) 13178**] in 4 weeks Dr. [**Last Name (STitle) 1295**] in [**2-12**] weeks Dr. [**Last Name (STitle) **] in [**1-11**] weeks Completed by:[**2168-7-28**]

[ "443.9", "401.9", "414.01", "413.9", "272.4", "V17.3" ]

icd9cm

[ [ [] ] ]

[ "36.13", "88.49", "39.61", "88.53", "88.48", "99.05", "37.22", "36.15", "99.04", "88.56" ]

icd9pcs

[ [ [] ] ]

6165, 6227

2936, 4369

285, 383

6468, 6474

1240, 2913

6764, 6944

838, 901

4525, 6142

6248, 6447

4395, 4502

6498, 6741

916, 1221

235, 247

411, 553

575, 708

724, 822

18,273

169,217

17630

Discharge summary

report

Admission Date: [**2189-6-8**] Discharge Date: [**2189-6-12**] Service: MEDICINE Allergies: Keflex Attending:[**First Name3 (LF) 2297**] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: lumbar puncture [**6-8**] History of Present Illness: 83 y/o M who was in his usual active state until one week prior to presentation when he experienced a headache, lightheadedness, stiff neck, subjective fever and chills. He stayed in bed for much of the week until convinced to go to [**Hospital1 18**]-[**Location (un) 620**]. At arrival his vitals wer: T=101.3, HR=100, BP=106/52, RR=24, O2sat=96% 2L. WBC=13, bands 46%? lactic acid=2.0, BUN/Cr= 44/2.0, HCO3= 20. Pt was started on levofloxacin. On the 17th the Pt experienced hypotension (SBPs=70s) and was placed on neosynephrine and given IVF. Doxycyclin, gentamicin, and vancomycin were also started on the 17th. Of note his albumin is 1.9, total protein 4.8. On [**2189-6-7**] he had an ABG of pH=7.34, pO2=103, pCO2=38 at 8pm then pH=7.29, pO2=65, pCO2=42 at 1 am. Pt was intubated just prior to transfer to [**Hospital1 18**] out of concern for respiratory failure. . Pt did handle a dead cat (used a shovel to remove it, did not touch directly) days before his symptoms appeared. He is noted to have had a clinic visit to [**Location (un) 620**] for a "tick bite" on [**2189-6-4**], no further information available at this time. No sick contacts. Traveled to South America in [**2188-11-22**]. Past Medical History: DM2 hypercholesterolemia arthritis TURP for BPH [**2164**], [**2166**] pulmonary fibrosis x 15 yrs, Dx by PFTs/CXR as per daughter, no [**Name (NI) **] (PCP unaware of Dx) VZV (zoster) on head last year Social History: worked in garment industry with cashmere (polluted lives with wife, no ETOH, distant tobacco Family History: --father died at 85 of Alzheimers --mother died at 109 ? --sister 91 Alzheimers Physical Exam: PE: T=98.9, BP=90/56, HR=80-104, RR=18, O2sat high 90s on Vt=640, FiO2 60%, PEEP=5, pH=7.38, PCO2=34, pO2=308 GEN: intubated, mildly sedated, arousable HEENT: injected conjuntiva, mm dry, no elevated JVP CV: rrr, no m/r/g PULMO: rhonchi b/l anteriorly ABD: soft, distended, no obvious tenderness EXT: warm, 2+ DP/PT, trace edema b/l Brief Hospital Course: A/P: 83 y/o M w/ fever, chills, headache, hypotension 1. Intubation: pt presented intubated. ABG at OSH showed hypoxia. Unclear primary lung disease. Pt without symptoms at baseline or with illness. Pt was hyperventilating to blow off CO2 due to primary acidosis. This likely led to increased work of breathing and concern for intubation. Pt was extubated [**6-9**] after hemodynamically stabilized and weaned down to 4L O2 nasal cannula. Pt had expiratory wheezing after extubation, most likely due to mild pulmonary edema from volume resuscitation. This has resolved with diuresis (20mg IV Lasix qd x 2 days). 2. Hypotension: likely secondary to sepsis, although unclear source. Hemodynamically stabilized with levophed drip, which was weaned off [**6-9**]. Since then, pt's blood pressure has been stable. 3. Elevated WBCs: consistent with infectious etiology in association with fever. Trended up despite multiple antibiotics, plateaued at ~16. Received vanco, doxy, gent. CXR with ? of PNA (portable image), diffuse interstitial markings consistent with pulmonary fibrosis. LP clear, no evidence of meningitis. Urine cultures and blood cultures show no [**Last Name (un) 4904**]. [**6-8**] sputum culture shows 1+ GPC and grew sparse oropharyngeal flora. Per ID consult, continuing doxycycline until leptospirosis lab results come back. Negative for ehrlichia. HSV titers pending. 4. Mental Status: symptoms of headache, stiff neck, fever are consistent with meningitis. His change in mental status following these symtoms may indicate a menigoencephalitis. Pt was apparently delirious in OSH. --CT head, LP negative --after extubation, pt's mental status appears to have returned to normal 5. Renal Failure: Cr=2.O at [**Location (un) 620**], now 1.5, likely pre-renal as BUN/Cr ratio < 20 and improvement with IVF. Cr plateaued at 1.5-1.6 6. Metabolic Acidosis: possibly secondary to early renal failure. Resolved with fluid resuscitation. Since extubation, pt's respiratory status has improved to near baseline and pt is on regular diet and ambulating. Medications on Admission: --asa --MVI --glucosamine 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 10 days. 5. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Healthcare - [**Location (un) 620**] Discharge Diagnosis: Primary: sepsis Secondary: Type 2 diabetes, hypercholesterolemia, arthritis, pulmonary fibrosis Discharge Condition: stable, good Discharge Instructions: seek medical attention if having fevers, chills, low blood pressure, confusion Followup Instructions: PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 8477**]. Please follow-up within [**11-23**] weeks following discharge from rehabilitation facility

[ "515", "038.9", "276.2", "250.00", "716.90", "584.9", "518.81", "272.0", "995.92" ]

icd9cm

[ [ [] ] ]

[ "96.71", "03.31" ]

icd9pcs

[ [ [] ] ]

5075, 5159

2302, 3707

233, 260

5299, 5313

5440, 5634

1847, 1929

4465, 5052

5180, 5278

4415, 4442

5337, 5417

1944, 2279

174, 195

288, 1493

3723, 4389

1515, 1720

1736, 1831

10,444

182,552

30106

Discharge summary

report

Admission Date: [**2139-2-14**] Discharge Date: [**2139-2-24**] Date of Birth: [**2098-6-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Fever/chills, abdominal pain Major Surgical or Invasive Procedure: Intubation Swan Catheter placement R IJ placement R thoracentesis PICC placement History of Present Illness: 40 M with PMH of [**Doctor Last Name 11332**] mal seizures was in his USOH until Thursday afternoon when he had shaking chills at work. He went home and felt unwell so went to bed early. He awoke later in the evening with back and abdominal pain and some mild SOB. This persisted so he went to the ER at [**Location (un) **] [**2139-2-13**]. Denies fevers, cough, upper respiratory symptoms, recent dental procedures ( last one 2 months ago), recent travel. . At OSH, Vs T 96.1, HR 112, BP 115/63 RR 20, Sat 100% RA. CT abdomen was done that showed periaortic lymphadenopathy??, Given that his d dimmer was elevated a CTA was ordered, CT with contrast to further evaluated lymph nodes and started on therapeutic dosage of Lovenox. Given that U/A was positive 1+ bacteria [**10-3**] WBC, + nitrates, leukocytes and stearase Levaquin was started. Hem onc consult was planed. . Repeated CT showed bilateral pleural effusions, ascites, no evidence of PE, lung findings ? septic emboli. Given evidence of ascites, an u/s guided paracentesis was done 3/207 4:45 pm. Culture from Ascitic fluid also growing Group A strep.. At around 1:40 am on [**2139-2-14**], he became hypotensive, IV fluids given, the patient started on Levophed and transfered to the ICU. Vancomycin was added when [**2-15**] blood cultures were postitive with Gram + cocci. Bedside Echo was performed (not recorded) and reportedly showed a vegatation on the posterior leaflet of the Mitral valve, along with MR. . Given deterioration of clinica status, the patient was transferred to [**Hospital1 18**] CCU for further management. Past Medical History: [**Doctor Last Name 11332**] mal seizures dx at age 17 Social History: No IVDA, 2 glasses of wine/night. Denies smoking. He is college librarian, and lives with his wife and 4y/o son. Family History: NO Family history of heart disease or premature death. Physical Exam: T 99.3 BP: 103/69, Hr 127 RR 23 General: patient in moderate distress, speaking full sentences well nourished, oriented to person, place and time. HEENT: Pupils and reactive to light, conjuctiva pink, no JVD. Lungs: Decrease breath sounds bibasilar, dullness to percussion. + crackles 1/3 up Cardiovascular: PMI 5th intercostal space. RRR, tachycardic, s1-s2 normal, no murmurs appreciated. No additional heart sounds. Abdomen: BS+, distended, diffuse tenderness to palpation, worse on left lower quadrant Guiac negative Extremities: cold, grey color, no evidence of splinter hemorrhages, janeaway lesions on palms or soles,no osler nodes on skin. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: OSH: Admit [**2139-2-13**] WBC 9.6 HCT 41.8 Plat 158 Chem 7: 130 96 21 ------------> 2.9 26 1.5 AST 33, ALT 24 Bili Total 1.3 * ESR 2 [**2139-2-14**] WBC 6.5 HCT 44.3 Plat 51 131 106 37 -------------> 6.1 20 2.0 AST 175 ALT 103 Alk phosph 18 Ck 749 CKMB 21.6 Index 2.9 Trop I <0.04 . [**2139-2-14**] 02:33PM FIBRINOGE-357 D-DIMER->[**Numeric Identifier 961**]* [**2139-2-14**] 02:33PM PT-16.3* PTT-55.6* INR(PT)-1.5* [**2139-2-14**] 02:33PM PLT SMR-VERY LOW PLT COUNT-46* [**2139-2-14**] 02:33PM NEUTS-17* BANDS-52* LYMPHS-0 MONOS-3 EOS-0 BASOS-0 ATYPS-2* METAS-17* MYELOS-9* [**2139-2-14**] 02:33PM WBC-6.6 RBC-4.61 HGB-15.8 HCT-45.6 MCV-99* MCH-34.2* MCHC-34.6 RDW-13.7 [**2139-2-14**] 02:33PM TSH-1.7 [**2139-2-14**] 02:33PM ALBUMIN-2.8* CALCIUM-6.2* PHOSPHATE-3.0 MAGNESIUM-1.7 [**2139-2-14**] 02:33PM CK-MB-39* MB INDX-2.6 cTropnT-<0.01 [**2139-2-14**] 02:33PM LIPASE-14 [**2139-2-14**] 02:33PM ALT(SGPT)-140* AST(SGOT)-209* LD(LDH)-478* CK(CPK)-1497* ALK PHOS-37* AMYLASE-83 TOT BILI-0.9 [**2139-2-14**] 02:33PM GLUCOSE-77 UREA N-27* CREAT-1.0 SODIUM-133 POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-17* ANION GAP-15 [**2139-2-14**] 04:01PM URINE RBC-[**11-3**]* WBC-[**5-24**]* BACTERIA-MOD YEAST-NONE EPI-0-2 [**2139-2-14**] 04:01PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2139-2-14**] 04:01PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.027 [**2139-2-14**] 04:04PM freeCa-0.95* [**2139-2-14**] 04:04PM LACTATE-2.1* [**2139-2-14**] 04:04PM TYPE-ART RATES-/27 O2 FLOW-4 PO2-70* PCO2-23* PH-7.37 TOTAL CO2-14* BASE XS--9 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**] [**2139-2-14**] 08:41PM O2 SAT-73 [**2139-2-14**] 08:41PM TYPE-[**Last Name (un) **] TEMP-37.2 . [**2139-2-14**] pCXR: Cardiac size is not enlarged. Bilateral pleural effusions are present, larger on the right than the left. Underlying infiltrates at both bases cannot be excluded . [**2139-2-14**] ECG: Sinus tachycardia. Low QRS voltages in limb leads. rsr' in leads V1-V2 . [**2139-2-14**] RIGHT UPPER QUADRANT ULTRASOUND: The main portal vein is patent with flow in an appropriate direction. The hepatic veins are patent with appropriately direction of flow. Within the liver, there is a small cyst in the right lobe, measuring up to 9 mm in diameter, as well as two small echogenic structures in the right lobe, the larger measuring 1.3 cm in diameter. There is no intra- or extra-hepatic biliary ductal dilation. The gallbladder is not seen. There is no hydronephrosis. A small amount of perinephric fluid is seen around the right kidney. There is a trace amount of ascites fluid seen in the right lower quadrant and left lower quadrant. A pleural effusion, as well as suggestion of collapse versus consolidation in the right lower lobe is seen. IMPRESSION: 1. Patent portal vein. 2. Small echogenic foci in the liver. Given the history, although these are likely hemangiomas, small abscesses could have a similar appearance and close follow up is recommended. 3. Small amount of ascites. 4. Right-sided pleural effusion and likely right lower lobe collapse or consolidation . [**2139-2-15**] CT abd/pelvis w/contrast: 1. Bilateral pleural effusion and adjacent bibasilar atelectasis. Focal opacity within the lingula, which is concerning for pneumonia. 2. Hypodensity within the right lobe of the liver, likely representing a cyst as seen on ultrasound from [**2139-2-14**]. Hemangioma within the right caudate lobe. Numerous low-density lesions within the liver, in the setting of endocarditis and low attenuating [**Last Name (LF) 71770**], [**First Name3 (LF) **] represent microabscesses, most commonly fungal, however tuberculosis cannot be entirely excluded. 3. Low-density retroperitoneal lymph node as described above, which may be seen in the setting of tuberculosis and atypical mycobacterial infections,seminoma, metastatic squamous cell, Whipple's disease. 4. Small to moderate ascites. 5. Small pericardial effusion . [**2139-2-16**] Trans-esophageal echocardiogram: Conclusions: The left atrium is normal in size. No mass/thrombus is seen in the left atrium or left atrial appendage. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). 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. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are myxomatous. The posterior leaflet (P2) has a focal thickening at a primary chordal insertion (0.7 cm) which may repesent chordal involvment in myxomatous disease or a cessile vegetation. Trivial mitral regurgitation is seen. . IMPRESSION: Possible mitral valve endocarditis. No significant mitral regurgitation. No intra-cardiac abcess. . [**2139-2-19**] CT chest/abdomen/pelvis with Contrast: 1. Moderate-sized bilateral pleural effusions unchanged. Diffuse bilateral nodular opacities are seen within the lungs; given history of endocarditis this finding is concerning for septic emboli. 2. The cecum demonstrates mild bowel wall thickening concerning for an infectious or inflammatory process. 3. Low-density retroperitoneal lymph node as described above is unchanged from [**2139-2-15**]. . Brief Hospital Course: - Mr. [**Known lastname 71771**] was admitted with a presumed diagnosis of endocarditis and on transfer had already grown Gp A Strep from ascitic fluid drawn at the OSH. He was initially started on Vanc/PCN but was switched to PCN/Clinda per ID recs. He will complete a 6-week course of IV PCN, however, as his mitral valve was not completely normal and thus endocarditis could not totally be excluded. - He was tachycardic and hypotensive on arrival so he was given > 6 L of IVF in boluses to maintain his pressure and was transiently on phenylephrine. - He had a TEE which did not show endocarditis and his syndrome was most consistent with Group A Strep Toxic Shock Syndrome as he had hypotension, acute renal failure (resolved with fluids), elevated LFTs, acute lung injury and DIC. He received 2 platelet transfusions for plt count of 10 but his platlet count was normal on discharge. His coags had already begun to normalize at the time of transfer. Also, a RIJ was placed w/ Swan for venous access and hemodynamic monitoring. - He was tachypneic on arrival but initially maintained his sats on a non-rebreather but was intubated on HOD2 for increased work of breathing. He was extubated after approximatly 48 hrs and went home with O2 sats in the high 90s on room air. He did have a diagnostic and therapeutic thoracentesis of his R Lung at which time we took off 1.2 L. The fluid was consistent with exudate but did not grow any bacteria. - He was delirious after extubation, which was thought to be from overwhelming infection and sedating medications received during intubation. His mental status was back to baseline on discharge. - There was concern for ischemia to his R great toe. When he first presented, his extremities were cool. As his hypotension resolved, he developed an erythematous rash on bilateral feet which developed into an ecchymotic looking R great toe. This was thought to be [**1-16**] microvascular infarcts. He was evaluated by Vasc [**Doctor First Name **] who determined that there was no indication for surgical intervention. ASA was started once plt count had resolved. - He was continued on his home anti-seizure meds. - He was discharged to home on IV PCN with outpatient PCP and ID [**Name9 (PRE) 702**]. Medications on Admission: Divalproex Sodium 500 mg PO TID Carbamazepine 200 mg PO BID Discharge Medications: 1. Penicillin G Pot in Dextrose 3,000,000 unit/50 mL Piggyback Sig: One (1) dose Intravenous Q4H (every 4 hours) for 32 days: through [**2139-3-28**]. Disp:*192 dose* Refills:*0* 2. PICC Flush Heparin 100 Units/ml 5 mL SASH Disp One week supply 3. PICC Flush Normal Saline 5 mL SASH Disp: One week supply 4. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Outpatient Lab Work Please check CBC, BUN, Creatinine, AST, ALT, Alk Phos, Tbili, qWeekly and fax result to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] at [**Telephone/Fax (1) 1419**]. Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: Primary: 1. Sepsis with Group A strep/ Toxic shock syndrome 2. Hypotension 2. Pleural effusion Discharge Condition: Hemodynamically stable. Ambulatory independently Discharge Instructions: You were admitted to the hospital with sepsis (infection in your blood causing low blood pressure and inflammation). There was also concern that you may have some infection in one of the valves in your heart (although this was not clearly seen by echocardiogram). You will be discharged on IV antibiotics (Penicillin) to complete a 6 week course. It is important that you are followed by both a primary physician and Dr. [**Last Name (STitle) 9404**] from Infectious Diseases. You should discuss the need for prophylactic antibiotics prior to dental proceedures with Dr. [**Last Name (STitle) 9404**]. . Take all medications as prescribed. . You will need weekly blood draws to check on your blood counts and liver tests. These will be sent to Dr. [**Last Name (STitle) 9404**] in Infectious Diseases . Call your doctor or return to the hospital if you have fever greater than 101 degrees, severe back or abdominal pain, worsening shortness of breath, dizziness, or any other symptom that concerns you. Followup Instructions: Please follow up with Infectious Diseases as below: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2139-3-17**] 9:00 * Please follow up with your new primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] phone ([**Telephone/Fax (1) 71772**]), at [**Hospital1 **] as previously scheduled ([**2139-3-3**] at 2:20pm). Contact information for Dr. [**First Name (STitle) **] as below: [**Hospital1 **] [**Location (un) 71773**] [**Location (un) 15749**], [**Numeric Identifier 43858**]

[ "040.82", "286.6", "511.9", "570", "789.5", "995.92", "038.0", "293.0", "518.81", "584.9", "785.52", "345.00", "276.1", "567.29", "421.0", "041.01", "599.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.93", "96.6", "34.91", "00.17", "96.04", "89.64", "88.72", "99.05" ]

icd9pcs

[ [ [] ] ]

11901, 11962

8724, 10985

344, 427

12101, 12152

3149, 8701

13209, 13822

2284, 2340

11095, 11878

11983, 12080

11011, 11072

12176, 13186

2355, 3130

276, 306

455, 2058

2080, 2136

2152, 2268

8,896

164,203

52069

Discharge summary

report

Admission Date: [**2182-9-27**] Discharge Date: [**2182-10-5**] Date of Birth: [**2107-1-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7651**] Chief Complaint: Dyspnea Acute on chronic systolic and diastolic heart failure. Major Surgical or Invasive Procedure: Endoscopy Percutaneous GallBladder Drainage Bronchoscopy History of Present Illness: Mr. [**Known lastname 63208**] is a 75M with known severe CAD s/p CABG in [**2167**], systolic and diastolic CHF (EF 30%), and PVD, s/p recent complicated admission from [**Date range (1) 107779**]/07 for NSTEMI, who re-presented to the ED on the evening of [**9-26**] complaining of shortness of breath. He states that since his recent discharge on [**9-16**] until yesterday, he has been in his USOH, which features stable dyspnea on exertion, 3-pillow orthopnea, lower extremity claudication, and chronic angina which responds to SL nitrates. He reports that yesterday afternoon he was out shopping with his son when he experienced bilateral leg and hip pain, as well as his typical chest pain. No radiation, no assoc SOB, n/v, diaphoresis. He took two SL nitros with resolution of the pain. His lower extremity symptoms resolved with rest. . Later that evening he was watching TV and went to bed feeling at his baseline, which is "[**2-16**] shortness of breath." However, during the night he awoke with acute onset shortness of breath rated an [**2185-7-19**]. He sat up in bed and put the fan on, which helped only minimally. He called his son, who lives upstairs, and the son came and called EMS. He denies feeling any fevers or chills, with no new cough. He denies chest pain, hand/arm pain, nausea, or lightheadedness associated with the shortness of breath. His chronic lower extremity edema has worsened of late. He denies medication non-compliance or any type of dietary indiscretion, stating that he has eaten mostly cereal and salmon since discharge. He did have some ice cream the evening that his symptoms developed. . In ED, had a CXR read as pulonary edema vs. infiltrate. Received 40mg IV lasix, to which he put out 500cc urine. Albuterol nebs administered with minimal effect. Got Levoflox 750 IV x1 per ED protocol. BiPAP was attempted, but pt refused. Nitroglycerin gtt then started. Initially admitted to MICU team, where he noted to be in obvious respiratory distress, with accessory muscle use, tachypneic to high 30s. Received 120mg IV lasix, IV morphine 2mg with good effect. He then received 5mg metolazone with 180mg IV Lasix, again with minimal output. He was then transferred to the CCU team for his primarily cardiac issues. . In his prior hospital course he ruled in for NSTEMI and had multiple caths and interventions where he was found to have severe native and graft disease. After his third cath of the admission, he developed chest pain, hypertension, and repsiratory distress, for which he was transferred to the CCU. There, he was aggressively diuresed with significant improvement in his respiratory status. Additionally, he was febrile and found to have staph aureus bacteremia, for which he completed a course of antibiotics. Finally, his CCU stay was complicated by the development of complete heart block with bradycardia, for which pacer placement was planned, but not performed pending resolution of bacteremia with negative surveillence blood cultures. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He does endorse exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for chronic exertional chest pain relived by SL nitrates, chronic dyspnea on exertion, 3-pillow orthopnea, and chronic LE edema. No palpitations, syncope or presyncope. . Past Medical History: NSTEMI [**2180**] (cath, no intervention) CHF (systolic and [**Last Name (LF) 107778**], [**First Name3 (LF) **] 30%%) peripheral [**First Name3 (LF) 1106**] disease diabetes ([**4-15**] A1c 6.3) hypertension hypercholesterolemia grade II internal hemrohrroids colonic diverticulosis GERD hypoxic respiratory failure secondary to pneumonia and CHF. Chronic renal insufficiency baseline 1.5 - 2.0 PVD with B fem to distal bypass Cardiac: CABG x 3 in [**2167**] (LIMA-LAD, SVG-OM, SVG-PDA) with only LIMA-LAD patent multiple PCI's: [**11/2176**]: ostial LIMA_LAD stent with re-stenosis and brachytherapy [**5-/2177**] [**2180-4-6**]: Taxus in the RPDA. [**2180-5-2**]: rotational atherectomy of the RCA - r stents in RCA plus stnent rPDA. [**2179**]- rothational atherectomy LMCA into LCX s/p Cypher stent, and stent to LCX. Also + Cypher stet to RCA Last Cath [**2181-6-8**] baloon coronary PLB + stent to subclavian artery. [**2180**]: Cath w/ 3VD w/o intervenable stenosis in setting of NSTEMI -CHF 2.[**2179**] EF 40-50% inf wall hypokinesis mild to moderate AR MR [**Name13 (STitle) **] w/ RVR, not anticoagulated due to GI bleed Social History: Social history is significant for the absence of current tobacco use. He quit smoking 2 years ago after 60+ pack years. He was a heavy drinker in the past but quit EtOH 2 yrs ago. He lives alone but his son lives upstairs. Family History: Noncontributory. No family history of sudden cardiac death or early coronary artery disease. Physical Exam: VS: T 97.8, BP 129/50, HR 97, RR 18, O2 92% on 5LNC and NRB Gen: obese elderly AA male in mild repiratory distress; Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of [**9-20**] cm. CV: PMI located in 5th intercostal space, midclavicular line. Quiet precordium. RR, normal S1, S2. No S4 or S3 appreciated. Chest: Well healed sternotomy scar. No chest wall deformities, scoliosis or kyphosis. Resp were frequent with accessory muscle use. Coarse breath sounds throughout, with inspiratory and expiratory crackles bilaterally [**2-10**] way up. + end expiraotry wheezing. Abd: Obese, soft, NT/ND, No HSM or tenderness. Ext: 3+ bilateral pitting edema L>R to knees. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; 2+ radial; DP, PT dopplerable Left: Carotid 2+ without bruit; 2+ radial; DP, PT dopplerable Pertinent Results: Bronchial washing: NEGATIVE FOR MALIGNANT CELLS. Pulmonary macrophages, bronchial epithelial cells, squamous cells and lymphocytes. . [**9-26**] Admission Chest AP: There has been interval development of diffuse perihilar reticular opacities and a few scattered Kerley B lines within the right base along with predominantly alveolar opacities within the lower lung fields (right greater than left). The apices remain clear and heart size remains enlarged with unchanged slightly tortuous intrathoracic aorta. No evidence of pneumothorax or large pleural effusions. . [**9-26**] EKG demonstrated SR @ 97, RBBB, LAFB; prolonged PR; unchanged from [**9-15**] . 2D-ECHOCARDIOGRAM performed on [**9-27**] demonstrated: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with focal hypokinesis of the basal to mid inferior wall, mid inferior wall, anterolateral wall and apex [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] There is a mild resting left ventricular outflow tract obstruction. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.9 cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2182-9-9**], regional left ventricular dysfunction is similar. Severity of mitral regurgitation has increased. Calculated aortic valve area is consistent with mild stenosis (underestimation of LVOT gradient on prior echo may have caused overestimation of severity of aortic stenosis). The other findings are similar. . PORTABLE RENAL ULTRASOUND . CLINICAL INDICATION: 75-year-old male with coronary artery disease status post CABG and chronic renal disease with poorly controlled hypertension. . The kidneys are relatively symmetrical in size measuring 9.4 cm in length on the right and 10.2 cm on the left. There is a slightly greater than 3 cm simple cyst in the lateral upper pole of the right kidney. There appears to be a nonobstructive stone towards the upper pole. This measures approximately 9 mm in diameter. There is no hydronephrosis, perinephric fluid collection or solid mass seen in the right kidney. . The left kidney is similar in size measuring 10.2 cm in length and also has a small 2 cm simple cyst in the upper pole laterally. No stones, masses or signs of hydronephrosis are seen on the left side. The bladder is empty via a Foley catheter and cannot be assessed. . CONCLUSION: No evidence of renal obstruction with symmetrical-sized kidneys. A small nonobstructive stone is seen in the right kidney as described. . Abdominal XRAY: TWO SUPINE VIEWS. The lower pelvis is not included. The bowel gas pattern is unremarkable. There is a large amount of fecal material in the right colon. Soft tissues are normal in appearance. There are degenerative arthritic changes in the spine. No significant intra-abdominal calcifications are seen. . IMPRESSION: Limited study demonstrating no evidence of obstruction. . Chest CT without contrast: IMPRESSION: 1. Resolving right lower lobe and superior segment right upper lobe pneumonia with layering small pleural effusion. 2. Enlarged gallbladder with gallbladder wall edema seen on the inferiormost images is concerning for acute cholecystitis. Clinical correlation is recommended. . Gallbladder Ultrasound: IMPRESSION: 1. Distended, sludge-filled gallbladder with wall edema, suspicious for acute cholecystitis in the appropriate clinical setting. . CT Abdomen/Pelvis: IMPRESSION: 1. Interval placement of percutaneous cholecystostomy, the catheter is dislodged and now terminates in the hepatic parenchyma. 2. Interval resolution of bilateral pleural effusions. 3. Interval resolution of left rectus muscle hematoma. . Chest XRAY [**2182-9-30**] IMPRESSION: Resolving right lower lobe pneumonia. . Brief Hospital Course: 75M with extensive CAD, acute on chronic systolic and diastolic CHF, now presenting with acute onset of respiratory distress. . # Respiratory distress - The patient's clinical status was most likely consistent with acute on chronic exacerbation of his systolic and diastolic CHF. The patient was aggressively diuresed with marked improvement in his clinical symptoms. Although the patient had what appeared to be an infiltrate in his right lower lobe, he did not have fever or leukocytosis to suggest a pneumonia. The patient did have hemoptysis, but it seemed that it was in the setting of resolving a previous pulmonary infection and supratherapeutic PTT. An echocardiogram was done which showed a depressed EF of 30% which was consistent with the patient's history and physical findings. At discharge, the patient's dyspnea was resolved, and he was able to amublate with the assistance of PT with minimal dyspnea. He will be discharged to a rehabilitation facility for further physical therapy to improve his status to his pre-hospitalization baseline. . # Hemoptysis: The patient had hemoptysis during this admission. Pulmonary was consulted to further evaluate the hemoptysis and the infiltrate which was seen on CXR and CT chest. A bronchoscopy with BAL showed what appeared to be resolving pulmonary infection which was most likely the cause of the hemoptysis. The cytology was negative for malignant cells. The vasculitic serologies remained negative at discharge. The patient no longer had hemoptysis at the time of his discharge. . # Acalculous Cholecystitis: The patient developed severe abdominal pain, predominantly in his right upper quadrant with rebound and guarding. A CT chest showed a markedly enlarged gallbladder with wall edema most likely consistent with acalculous cholecystitis. A percutaneous drain was placed with good drainage of bile/sludge. General surgery was consulted and they felt that this drain needed to be placed for a total of 6 weeks. The patient's initial drain became dislodged requiring placement of a new drain prior to discharge. The patient's abdominal pain markedly improved prior to discharge after the drain placement. He will need followup in surgery clinic in approximately 5-6 weeks to have the drain evaluated and removed. . # CAD/angina - The patient has known severe CAD s/p recent DES to oLIMA; He had an episode of CP the day prior to admission, but remained chest pain free throughout the rest of his admission. His EKG remained unchanged and his biomarkers were negative. The patient will continue on his aspirin, plavix, statin, and nitrates at his home dose with followup with his PCP and cardiologist (Dr.[**Name (NI) **] for further management. . # Rhythm - The patient has a history of paroxysmal atrial fibrillation and a phase 4 block that was evaluated on a prior admission. The patient was to have a pacemaker placed, but he was admitted at this time prior to his appointment in [**Hospital **] clinic. The patient is scheduled to see Dr. [**Last Name (STitle) **] on [**2182-10-9**] for pacemaker evaluation given his phase 4 block and pauses on telemetry during his prior admission. The patient also has a history of paroxysmal atrial fibrillation. He was on [**Date Range **] until [**3-/2177**] when he was admitted for a massive GIB requiring multiple transfusions. Since that time, the patient has been off of his anticoagulation and has had only rate control. A colonscopy performed after the GIB ([**2177**]) did not show any large bleeding lesions. Also, an EGD was performed during this admission based on recommendations of the GI service. The patient's EGD showed mild erythema in the fundus but no lesions to explain his occult blood positive stool. The patient will need further workup with colonoscopy as an outpatient to evaluate for source of bleed. At this admission, it was felt the patient would benefit from anticoagulation given his medical history, depressed EF, hypertension, diabetes, and CAD. Although he would benefit from anticoagulation, at this time it was not started because he still needs a colonscopy per GI to rule out causes of lower GIB, and he still has a percutaneous gallbladder drain for 5 more weeks. Also, he will likely have a pacemaker placed by the EP service as well within the next few weeks. Once this workup is complete, he will need to be started on [**Year (4 digits) **] with a goal INR of [**1-12**]. . # Hypertension - The patient's blood pressure was well controlled during this hospitalization. He was initially on a nitroglycerin drip, but it was stopped early on in his hospitalization. He will continue with his home dose of antihypertensive medications. . # Acute kidney injury on CKD - The patient's baseline creatinine 1.5-1.7, and it elevated to 2.8. With diuresis, his creatinine improved at discharge and approached near his baseline. A renal ultrasound did not show evidence of post renal obstruction. The patient will followup with his PCP regarding his [**Name9 (PRE) 2091**]. . # Diabetes - The patient was initially hyperglycemic to ~300 and with small AG on labs. Antihyperglycemics were initially held on admission, but with insulin his AG closed. He was maintained on insulin sliding scale and his glipizide was held. He will be discharged on his prior home dose of glipizide and will need adjustments made by his PCP based on his home glucose control . # h/o bacteremia - The patient was s/p abx course, and remained afebrile throughout this hospitalization. His surveillance cultures were negative. . # Moderate AS: The patient has moderate aortic stenosis with valve area 1.0-1.2 cm2. This was unchanged from prior echos. Medications on Admission: 1. Aspirin, Buffered 325 mg PO DAILY 2. Glipizide 5 mg PO once a day. 4. Diltiazem HCl 60 mg PO QID 5. Isosorbide Dinitrate 60 mg PO TID 6. Amlodipine 5 mg PO DAILY 7. Nitroglycerin 0.4 mg Sublingual PRN 8. Simvastatin 80 mg PO once a day 9. Pantoprazole 40 mg PO once a day 10. Clopidogrel 75 mg PO once a day 11. Fluticasone 50 mcg 2 puffs twice a day Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Isosorbide Dinitrate 30 mg Tablet Sig: Two (2) Tablet PO three times a day. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Fluticasone 50 mcg/Actuation Disk with Device Sig: Two (2) puffs Inhalation twice a day. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for headache. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. 13. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 14. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis: Acute on Chronic systolic and diastolic heart failure Secondary Diagnosis: Hemoptysis Acalculous cholecystitis Diabetes Guaiac positive stools Peripheral Arterial Disease Coronary Artery Disease Hypercholesterolemia Chronic Kidney Disease Paroxysmal Atrial Fibrillation Discharge Condition: Good; afebrile, no shortness of breath Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet You were admitted for worsening shortness of breath and coughing up blood. You were found to have worsening heart failure as well as a pneumonia in your lung causing blood in your sputum. A bronchospcopy was performed which showed resolving infection in your lung. You also had an ECHOcardiogram which showed that you do have heart failure which was also the likely cause of you worsening shortness of breath. During your hospitalization, you devloped abdominal pain and a CT scan showed a large gallbladder filled with bile/sludge that was not draining properly. You had a drain placed in your gallbladder with good drainage and you will need to keep that drain in for 6 weeks. Also during your hospitalization, you were found to have blood in your stools. You had an endoscopy which showed very mild irritation of your stomach, but no overt source of bleeding. You will need an outpatient colonscopy scheduled with the gastroenterology clinic. You will also need to followup with the electrophysiology clinic regarding pacemaker placement for your irregular heart rhythm. Please take all medications as prescribed. Please go to all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or your cardiologist: chest pain, shortness of breath, worsening abdominal pain, diarrhea, vomiting, or nausea. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2182-10-9**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2182-10-25**] 8:20 Please call the [**Hospital **] clinic at ([**Telephone/Fax (1) 2233**] to make an appointment within the next 2 weeks and also to schedule a colonoscopy Please call the surgery clinic at ([**Telephone/Fax (1) 95902**] to make an appointment in 5 weeks to have your gallbladder drain removed

[ "424.1", "427.31", "786.3", "575.10", "414.00", "440.21", "250.00", "V15.81", "413.9", "272.0", "584.9", "428.0", "585.9", "428.43", "410.72", "V15.82", "403.90", "578.1", "996.59", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "33.24", "51.01", "45.13", "51.02" ]

icd9pcs

[ [ [] ] ]

18086, 18165

10861, 16566

378, 437

18498, 18539

6567, 10838

20052, 20654

5451, 5545

16971, 18063

18186, 18186

16592, 16948

18563, 20029

5560, 6548

276, 340

465, 4036

18280, 18477

18205, 18259

4058, 5194

5210, 5435

29,972

155,807

45918

Discharge summary

report

Admission Date: [**2174-10-2**] Discharge Date: [**2174-10-8**] Date of Birth: [**2103-12-17**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Vioxx / Celebrex / Lasix Attending:[**First Name3 (LF) 3561**] Chief Complaint: Mental status changes, ARF Major Surgical or Invasive Procedure: R-IJ Placed Fiberoptic nasal intubation History of Present Illness: 70F h/o COPD, OSA on BiPAP at night, HTN, DM2, morbid obesity, chronic pain who presents from NH after being found to be lethargic, confused and unable to ambulate, with 'tongue hanging out of mouth'. Of note pt recently seen in the pain clinic and started taking Morphine 2 days ago. . ED COURSE: Initial VS T 97.7 HR 60 BP 90/50 RR 20 SaO2 99%RA then desated to 86%RA, placed on NRB O2 improved to 100%. FS 105. on 50% ventimask. Pt was hypoxic on RA placed on NRB. U/A positive and serum tox negative. CXR without clear. She was given ceftriaxone 2gm for UTI, solumedrol and pepcid for "enlarged tongue", narcan 0.2mg x2, 0.4mg narcan x1 with minimal response in mental. 1.7L IVFs infused with improvement of lactate to 0.2. Pt was hypotensive and started on peripheral dopa with improvement in SBP to 120s. Initial labs notable for ARF Cr 5.6, K 6.7, phos 8.8. She received Bicarb 1amp, Insulin 10Units, and 1amp D50 for hyperacute TW. She was placed on BiPAP for 1hr in ED for initial ABG 7.19 pCO2 83 pO2 247. She was admitted to MICU for closer monitoring. . Past Medical History: -morbid obesity -hypertension -diabetes - diet controlled -osteoarthritis -obstructive sleep apnea on Bipap at home -COPD -gout -depression -hypothyroidism -GERD Social History: Social History: Lives temporarily at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Lost housing at [**Known firstname 553**] [**Last Name (NamePattern1) 7143**] in [**2174-4-14**]. 30-40 ppd smoking history. No EtOH, IVDU, or illicit drugs. Patient is not sexually active. Does not excercise, but is very careful about what she eats. Family History: Mother with HTN Physical Exam: T 96.6 HR 66 BP 141/65 (on dopa 5) RR 12 SaO2 99% on 15L, FiO2 30% ventimask General: Obese, somnolent, arousable intermittently HEENT: pinpoint PERRL, anicteric sclera, nasal trumpet and ventimask, tongue protruding from mouth, crusted tongue surface very dry MM CV: Reg Nml S1, S2, no M/R/G RESP: Distant BS, poor air movement, no crackles or wheeze appreciated anteriorly Abdomen: soft, obese, ND, +BS, tender to palpation LLQ, Umbilical area no rebound/no guarding Extremities: warm, trace bilateral edema, dopplerable pulses Neuro: Somnolent, arousable to voice, follows simple commands, moves all extremities, involuntary twitching of extremeties. Pertinent Results: MICRO: [**2174-10-3**] 9:34 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2174-10-3**]): <10 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2174-10-5**]): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. Please contact the Microbiology Laboratory ([**8-/2473**]) immediately if sensitivity to clindamycin is required on this patient's isolate. 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. Trimethoprim/Sulfa sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- S VANCOMYCIN------------ <=1 S ACID FAST SMEAR (Final [**2174-10-4**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): . [**2174-10-2**] 6:26 pm URINE Site: CATHETER **FINAL REPORT [**2174-10-4**]** URINE CULTURE (Final [**2174-10-4**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: A/P: 70F h/o COPD, OSA, HTN, DM2 who presents from NH after being found lethargic with MS changes and ARF . # Hypotension: No fever, leukocytosis, and elevated cardiac enzymes in setting of ARF make cardiogenic process less likely without ischemic changes on EKG. Etiology most likely urosepsis with +UA and recently similar admission requiring ICU for Urosepsis and unresponsiveness. Hypovolemic shock also possibility given extremely dry MM and ARF. She was initially covered broadly with Abx vanco/zosyn, also h/o GPC on blood culture (coag neg staph, coming from NH). She was kept on a 5 day course of Vanco for MRSA in sputum, no infiltrate on CXR. She was switched to ceftriaxone and completed 5 days for an E coli UTI and switched to cefpodoxime po for a total 7 day course of abx for the UTI. She never required pressors and BP responded well to IVF boluses. She became Hypertensive when sedation was weaned off. . # Altered mental status: Likely toxic-metabolic due to infection, hypercarbia, and narcotic use with underlying COPD (baseline pCO2 low 50s, HCO3 30). Pt responded to narcan but only transiently. Pt also switched to morphine which is renally cleared now with ARF. She was treated with Abx as above, she was intubated for airway protection and hypercarbia. She was extubated on [**10-5**] and her MS status cleared. She was kept on oxycodone only for pain control and neurontin and escalation of other narcotics were avoided. She was kept on BiPAP o/n with plan to cont Bipap at any signs of lethargy. Her TSH was normal. . #. Respiratory: Pt desated in ED with O2 sat 86%RA. However, pt very lethargic with depressed MS, most likely from obtundation in setting of hypercarbia, narcotics and infection as above. No evidence of pulm edema on CXR. COPD [FEV1 82% predicted [**8-16**]]. She was briefly intubaated with fiberoptic nasal intubation given morbid obesity. She was successfully extubated [**10-5**] with BiPAP o/n [**11-18**] for settings. She remained on RA while she was extabated with O2 sats 88-92%goal given COPD. Her advair was resumed. # Acute renal failure: Baseline 1.0 now with ARF, unclear etiology, NSAID related vs. hypotension/ATN, vs. rhabdo. Her CK was never elevated significantly, she responded very well to IVF with correction of Renal failure with fluids alone. Her diuretic was subsequently resumed. Umyoglobin was negative. Her ACE-I was also resumed. . # HTN: PT was significantly hypertensive with BP 180-210 range requiring nitro gtt for [**2-15**] while she was NPO post extubation. Her lisinopril was resumed at 40mg daily, her BB was titrated up to 100mg TID and Norvasc was added [**10-6**] and increased to 10mg on [**10-7**]. . # DM2: HISS. Monitor FS. Her orag hypoglycemics to be resumed while on floor or outpatient . #. CODE: FULL Medications on Admission: Meds (per NH records): -MS Contin 45mg [**Hospital1 **] -Advair Diskis 250/50 [**Hospital1 **] -Combivent -Lisinopril 20mg daily -Atenolol 25mg daily -Levoxyl 50mcg daily -Paxil 20mg daily -Wellbutrin 100mg TID -Gabapentin 300mg TID -Allopurinol 100mg daily -Edecrine 100mg daily -ASA 325mg daily -Colace/senna/dulcolax -Folic Acid 1mg daily -Ambien 10mg HS Discharge Medications: 1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 3. Ipratropium Bromide 0.02 % Solution Sig: [**2-15**] Inhalation Q6H (every 6 hours) as needed. 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Ethacrynic Acid 25 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every [**5-20**] hours as needed for PRN PAIN for 1 doses. Tablet(s) Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Discharge Diagnosis: Primary: mrsa bronchitis ecoli uti Secondary: htn morbid obesity niddm oa osa copd gout depression hypothyroidism gerd Discharge Condition: Good. Good. Discharge Instructions: You were admitted to the hospital because you were found to be lethargic and unresponsive. In the hospital you were diagnosed with bronchitis and a urinary tract infection. You were treated with a full course of antibiotics for both of these infections. Please take all of your other medications according to your usual schedule as described below. Please return to your pcp or to the Emergency Department if you have any fevers, burning when you urinate, chest pain, shortness of breath, or any concerns. Followup Instructions: Please make an appointment with your primary care doctor within the next two weeks. Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2174-10-25**] 3:00 Provider: [**Name10 (NameIs) 13368**] [**Last Name (NamePattern4) 13369**], MD Phone:[**Telephone/Fax (1) 1091**] Date/Time:[**2174-11-1**] 1:40

[ "780.09", "250.00", "327.23", "584.9", "491.22", "244.9", "041.11", "041.4", "530.81", "E937.9", "401.9", "311", "599.0", "278.01", "V09.0" ]

icd9cm

[ [ [] ] ]

[ "93.90", "96.04" ]

icd9pcs

[ [ [] ] ]

9858, 9954

5409, 6342

328, 369

10118, 10133

2748, 4409

10689, 11066

2042, 2059

8619, 9835

9975, 10097

8237, 8596

10157, 10666

2074, 2729

4438, 5386

262, 290

397, 1464

6357, 8211

1486, 1649

1681, 2026

23,249

116,775

49575+59214

Discharge summary

report+addendum

Admission Date: [**2131-9-11**] Discharge Date: [**2131-9-19**] Date of Birth: [**2052-1-28**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 134**] Chief Complaint: Chest Pain<h3>[**Known lastname 103687**],[**Known firstname 103688**] J. [**Numeric Identifier 103689**] . Major Surgical or Invasive Procedure: Cardiac cath with drug eluting stent placed in the proximal LAD History of Present Illness: Pt was eating dinner this evening, then developed SSCP, no radiation, lasted about 1hr. + diaphoresis, no palpitations, no n/v, no dizziness, no lightheadedness. Thinking it was indigestion, pt took 2 tylenol, alka-seltzer and peptobismol. When this produced no relief, famiy took pt to OSH, chest pain improved on the way to OSH. At OSH, given ASA, NTG w/improvement of sx. EKG changes persisted (STE's in V2-V4) and pt was xferred to [**Hospital1 18**] for cath. Pt was given a bolus of integrillin, bivalirudin, but no heparin, given h/o HIT. He was given a total of 180cc's of optiray dye. Social History: lives with wife at daughter in law's house. Pt has smoked 2ppd x 65yrs. now smokes 1ppd. No EtOH Family History: brother died of CAD in his 80's Physical Exam: PE: Vitals: T96.8 HR 72 BP 127/67 RR 14 O2sat 97% on 4L NC . Gen: elderly male, in bed, NAD HEENT: OP clear, no lesions, PERRLA, EOMI, flat JVP. no carotid bruits Pulm: barrel chested. diffuse wheezes throughout. no rales/rhonchi CV: distant heart sounds. S1, S2 RRR. no M,R,G Abd: +BS. soft, NT, ND, no HSM Groin: arterial and venous sheaths in R groin. slight ooze. no bruits Ext: warm, dry, no lesions. + onychomycosis Neuro: A&Ox3. hard of hearing. Pertinent Results: Cath results: . HD: PAP 52/22/36 PCWP 28 CI: 2.39 PA sat 60% Art Sat 91% . R dominant system LMCA: no obstructive dz LAD: TO proximally LCx: Minimal Dz RCA: Minimal Dz, RCA large dominant vessel giving collaterals to LAD . Cypher stent was placed in LAd and patient experienced crushing SSCP during deployment which resolved shortly thereafter-->given nitro, SSCP resolved-->TIMI 3 flow. . Brief Hospital Course: a/p: 79 yo male, HTN, ESRD on HD, COPD, extensive smokeing hx presented w/SSCP, c/w STEMI, taken to cath at [**Hospital1 18**] where totally occluded prox LAD lesion was stented with DES, now chest pain free, recovering in the CCU/step down unit. . 1. CAD: As above pt is s/p STEMI, s/p cardiac cath with stenting of his LAD. Following his cardiac catheterization, the pt??????s cardiac enzymes trended down. He was briefly placed on a nitro drip for ? of cardiac chest pain vs. indigestion, but was quickly weaned off the drip and remained chest pain free for the remainder of his hospitalization. He was placed on aspirin, plavix, lopressor, and a statin post-stenting and continued on these medications throughout his hospitalization. The pt was also placede on coumadin for anti-coagulation. . 2. Pump: Post MI the pt??????s echo showed overall left ventricular systolic function depression with akinesis of the antero-septum, anterior wall and apex. The remaining segements of his LV appeared hypokinetic (basal lateral wall moves best). No masses or thrombi were seen in the left ventricle. The pt was placed on lisinopril for afterload reduction as well as being continued on his HD. . 3. Rhythm: Pt was monitored on telemetry throughout his hospitalization. Post MI the pt remained largely in NSR with occasional PVCs. However, post-MI he was noted to have LAFB and RBBB. It was unclear whether this was his baseline or the result of his MI. The pt did have an episode of Afib with RVR. The pt was loaded with amiodarone. Initially he was planned to receive amio 800 mg qd X1 week with a taper in the usual fashion (400 qd X 1 wk, then 200 qd X1 week). However, given that this was an isolated episode and that the pt is no longer experiencing Afib with RVR the pt??????s amiodarone will be decreased to 200 mg, to be worked up further by his out-pt cardiologist. 4. h/o HTN: As above, the pt??????s blood pressure was well-controlled on lopressor 100 mg [**Hospital1 **]. . 5. COPD: The pt was initially wheezing on exam. The pt was started on his out-pt alb/atrovent nebs. Serially CXRs were followed and demonstrated stable b/l pleural effusions. Following the administration of his nebs he has been asymptomatic. . 6. ESRD on HD: The pt received dialysis on Tu/Th/Sat. His meds were renally dosed. 7. Physical limitations: The pt has had continued difficulty with transfers out of bed unless assisted. PT has recommended [**Hospital 31940**] rehab. The pt has also had continued musculoskeletal ??????related right shoulder pain. The pt should receive continued PT for this issue as well. . 8. Cold L hand: The pt has been noted to have a transiently cold and numb left hand. Angiography has revealed diminished flow in his AV graft. Transplant team saw pt and feel that pt??????s hand is viable and is stable.Per their recs, his sx are likely [**1-3**] to fluid shifts related to HD??????this is a typical manifestation of A-V grafts. However, pt needs out-pt follow-up in one week for further evaluation. 9. ? facial droop??????The pt??????s nursing staff was initially concerned that the pt had a left facial droop. However, full neurologic exam and head CT were normal. .. 9. FEN??????the pt was placed on a cardiac healthy/low NA diet during hosp 10. ppx??????The pt was on ppi, bowel regimen, and coumadin during hospi. 11. Code: full code. This status was discussed with patient and family. 12. Dispo: The pt is to be d/c??????d to [**Doctor First Name 391**] Bay for [**Hospital 64052**] rehabilitation. Physical therapy saw the pt and recommended continued PT given his poor transfer/ambulatory status. Medications on Admission: 1. Flomax 0.4mg daily 2. Trazodone 50mg qhs 3. Atenolol 50mg daily 4. Norvasc 10mg daily 5. Avodart 0.5mg qd 6. Clonidine 0.2mg [**Hospital1 **] 7. Xalatan 1 gtt qhs 8. Hydralazine 100mg daily 9. Protonix 40mg daily 10. Tylenol prn 11. Nicotine patch 14 mg daily for two weeks, then 7mg daily x 2wks, then d/c Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed. 12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days: On [**2131-9-19**] pt was on day 4 of a seven day course. 15. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. 17. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. 18. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay - [**Hospital1 392**] Discharge Diagnosis: STEMI Discharge Condition: Stable Discharge Instructions: Pt or ECF should contact pt's primary care physician or [**Name9 (PRE) **] if pt: --experinces chest pain or shortness of breath --gains more than 5 lbs in one week --experiences persistent numbess in his left hand --has any change in mental status above his baseline Followup Instructions: Pt should follow up with: Appointments: --With his PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 28436**] ([**Telephone/Fax (1) 103690**] on [**2131-9-28**] at 3:15 pm. Duringt this visit he will be seeing both Dr. [**Last Name (STitle) 28436**] as well as attending the coumadin clinic. --Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] ([**Telephone/Fax (1) 24747**], Cardiology [**2131-9-24**] at 10:45 in [**Hospital1 **]. --Transplant Center at [**Hospital1 18**] ([**Telephone/Fax (1) 3618**] will contact pt with appointment for the next week. If they do not call within three days of discharge, please contact them at the above number for an appointment. Name: [**Known lastname 16909**],[**Known firstname 11669**] J. Unit No: [**Numeric Identifier 16910**] Admission Date: [**2131-9-11**] Discharge Date: [**2131-9-19**] Date of Birth: [**2052-1-28**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 6568**] Addendum: Anti-coagulation: Mr. [**Known lastname **] was started on argatroban for anti-coagulation. He was bridged to coumadin by protoccol. His discharge INR was 3.2. Discharge Disposition: Extended Care Facility: [**Doctor First Name 1726**] Bay - [**Hospital1 3983**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3518**] MD [**MD Number(1) 3519**] Completed by:[**2131-9-20**]

[ "403.91", "305.1", "599.0", "410.11", "V17.3", "428.20", "V45.1", "496", "585.6", "426.52", "041.4", "427.31", "719.41", "428.0", "V58.61", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.95", "37.21", "00.45", "00.40", "00.66", "36.07", "88.56" ]

icd9pcs

[ [ [] ] ]

9524, 9763

2144, 5784

385, 451

7910, 7919

1729, 2121

8237, 9501

1206, 1240

6145, 7757

7881, 7889

5810, 6122

7943, 8214

1255, 1710

235, 347

479, 1074

1090, 1190

6,871

181,108

5443+5444

Discharge summary

report+report

Admission Date: [**2119-2-28**] Discharge Date: [**2119-3-17**] Date of Birth: [**2062-5-15**] Sex: M Service: CHIEF COMPLAINT: Back pain, retroperitoneal mass on CT. HISTORY OF PRESENT ILLNESS: The patient is a hospital transfer to our emergency room who is a diabetic with peripheral vascular disease, hypertension, and hypercholesterolemia who one week ago developed moderate to severe lower back pain. The patient denied any sprain, trauma, falls or lifting. The back pain was without radiation, numbness, weakness, nausea or vomiting. The patient denied dysuria or hematuria. The patient was seen at a local hospital where abdominal CT was obtained that showed a retroperitoneal mass. The patient was given Bactrim and discharged. The patient requested evaluation at [**Hospital1 346**]. PAST MEDICAL HISTORY: Diabetes mellitus type 2 x 15 years, hypertension, hypercholesterolemia, peripheral vascular disease, chronic renal insufficiency with baseline creatinine of 2.2, history of SVT status post surgery, history of hemorrhoids. PAST SURGICAL HISTORY: Orthopedic surgery for leg fracture and toe amputations. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: Zocor 20 mg q.d.; Zestril 10 mg q.d.; OxyContin for pain; Advil for pain; and insulin. SOCIAL HISTORY: The patient is married and lives with his wife. [**Name (NI) **] has occasional alcohol use, occasional cigar use. He is a retired bricklayer. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.1, blood pressure 186/94, pulse rate 84, respiratory rate 14, oxygen saturation 97% on room air. GENERAL: He was a morbidly obese white male in no acute distress. HEENT: Examination was unremarkable. NECK: Supple with no lymphadenopathy. CARDIAC: Regular rate and rhythm with normal S1 and S2. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Obese, soft and nontender, nondistended, with bowel sounds present. BACK: No costovertebral angle tenderness or muscle spasm. RECTAL: Normal tone, no masses, guaiac positive. EXTREMITIES: There was 3+ edema with chronic venous stasis changes with right foot Charcot foot changes. Femoral pulses were palpable bilaterally. Popliteal pulses were palpable bilaterally. Pedal pulses were nonpalpable. NEUROLOGICAL: Examination was unremarkable. LABORATORY DATA: White count 14.3, hematocrit 31.6, platelet count 272,000, neutrophils 75, bands 2, lymphocytes 15. PT/INR and PTT were normal. BUN 41, creatinine 2.2, K 8.0, recheck 6.2. Outside CT scan showed a 7 x 5 x 4 x 4 mass at the level of L2. HOSPITAL COURSE: A repeat CT of the abdomen was obtained which demonstrated contained leak in the abdominal aorta, 3 cm distal to the right renal artery, positive node enlargement. Multiple blood and urine cultures were obtained which were all no growth and negative ABF staining, negative fungal staining, negative to date but not finalized ABF and fungal cultures. The patient was transferred to the surgical intensive care unit for continued monitoring and care. He had a Foley catheter placed by the urology service. He was placed with two large-bore 18-gauge needles nitroglycerin to maintain his systolic blood pressure at less than 130, n.p.o., intravenous hydration, serial hematocrits. Mucomyst was begun. Dr. [**Last Name (STitle) 22063**] was consulted by consulted by Dr. [**Last Name (STitle) 1391**] to consider placing a stent graft in the aortic pseudoaneurysm secondary to tumor invasion. The patient underwent endovascular aortic stent placement on [**2119-2-28**]. He remained intubated and was stable and was transferred to the surgical intensive care unit for continued care. Serial hematocrits were obtained. He was transfused two units of packed red blood cells. Post-transfusion hematocrit was 28. The patient's examination remained unremarkable and he continued to require Nipride drip and beta blockade to maintain a systolic blood pressure of less than or equal to 130. He was weaned to extubate. On postoperative day two the patient required aggressive diuresis for volume overload secondary to third spacing. The patient was extubated without difficulty. His post-transfusion hematocrit was 33.7, BUN 37, creatinine 3.5, K 4.0. Abdominal examination remained unchanged and pulse examination remained unchanged. His hematocrit remained stable. The patient was transferred to the vascular intensive care unit for continued monitoring and care. A renal consultation was requested because of continuing elevation in his creatinine. They felt the etiology of the creatinine bump was secondary to acute tubular necrosis which was caused by a combination of contrast-induced hypotension. On [**2119-3-3**] the patient returned to CT scan and underwent a CT needle biopsy and aspiration. Tissue and fluid were sent for culture. The culture results demonstrated 1+ PMNs, ABF stain was negative, so far the culture has shown no growth, and the ABF is not finalized but no growth. With these results the patient was placed on vancomycin, levofloxacin and Flagyl. His medications were renal dosed. The patient required intravenous hydration for low urinary output per renal. Infectious disease was consulted to determine length of therapy and antibiotic agents that should be utilized for this patient's care. Recommendations were to continue current antibiotic therapy and adjust according to culture results. The patient returned to CT on [**2119-3-6**] for further specimens for culture. He tolerated the procedure without complications. His acute renal failure slowly resolved. His peak creatinine was 4.0. He returned to baseline of 1.8. General surgery continued to follow the patient awaiting further anticipation of intra-abdominal surgery. Podiatric surgery saw the patient for left foot callus protection. The patient's antihypertensives required redosing with improvement in his renal function. Ace inhibitor was restarted, Zestril 20 mg q.d. on [**2119-3-8**]. Discussion ensued regarding intra-abdominal intervention with axillofemoral bypass graft. Cardiology consultation was requested for perioperative risk assessment. Echocardiogram demonstrated left atrial dilatation mild, right atrial dilatation mild, left ventricular and right ventricular dilatation with global hypokinesis, pulmonary hypertension. Valves were without stenosis or regurgitation. Ejection fraction was calculated at 20%. Although the patient's Persantine MIBI was negative for ischemic changes, but because of the low ejection fraction and global hypokinesis, cardiac catheterization was recommended. The patient underwent cardiac catheterization on [**2119-3-4**] which demonstrated multivessel disease, right coronary artery 40-50% stenosis, main trunk 20% stenosis, left anterior descending coronary artery 20% stenosis, main circumflex coronary artery 30% stenosis. The patient did not require any cardiac intervention or surgery; continue on medical therapy. After rediscussion and reconsideration it was decided that the patient would be at a very high risk for open procedure and that for the present time we would continue conservative treatment with long-term antibiotics, monitor the patient and then determine if any other surgical intervention is required. The following day post catheterization the patient had an episode of vague anterior chest discomfort described as a heaviness/burning. EKG was obtained which showed ST depressions in V4, 5 and 6. The patient was transferred to a monitoring unit to rule out myocardial infarction. His CPKs and troponin levels were flat. His EKG returned to baseline. General surgery was consulted on [**2119-3-8**] to do an open biopsy. The patient underwent exploratory laparotomy, retroperitoneal dissection, phlegmon drainage and biopsy on [**2119-3-10**]. He tolerated the procedure well and was transferred to the postanesthesia care unit in stable condition. Postoperatively the patient did well. The patient's culture from the operating room on the 31st grew out Gram positive cocci. The patient was continued on vancomycin. The patient will require a total of eight weeks of antibiotics. Physical therapy and occupational therapy did evaluate the patient for potential rehabilitation. The right PICC line initially was felt not to be positioned correctly. After reevaluation it was felt that it was in the correct position and did not require any adjustment. The patient's hematocrit was noted to be 27. Recommendations of cardiology to maintain his hematocrit greater than 30 included transfusion. This will be discussed with the attending and decision made before patient discharge, with a repeat hematocrit if transfused. At the time of discharge the patient was afebrile. His wounds were clean, dry and intact. DISCHARGE INSTRUCTIONS: Recommendations were to continue antibiotics for a total of eight weeks, starting from [**2119-3-16**]. He would require abdominal and pelvic CT with intravenous contrast at two weeks post discharge and four weeks post discharge. This request will be called to Dr.[**Name (NI) 22064**] office and arranged for the patient. The patient should have, per infectious disease, weekly complete blood counts, SMA-7's and vancomycin troughs. We will clarify with the infectious disease service whether he will require serial ESRs to be done on an outpatient basis. The laboratory findings should be called to the infectious disease clinic. The infectious disease clinic number is [**Telephone/Fax (1) 457**]. FOLLOW UP: A follow-up appointment in two weeks with Dr. [**Last Name (STitle) 22063**] and Dr. [**Last Name (STitle) 1774**], which is Thursday clinics or Dr. [**Last Name (STitle) **], which is Friday clinics, should be arranged along with his abdominal CT. Arrangements should be made for the patient to be seen on follow up by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] of the renal service at the same time he has his initial follow-up visit with Dr. [**Last Name (STitle) 22063**] and the infectious disease service. DISCHARGE MEDICATIONS: 1. Dulcolax tablets 5-10 mg q.d. p.r.n. 2. Aspirin 81 mg q.d. 3. Vancomycin 1,000 mg intravenous q. 24 hours with trough levels q. week. 4. Levofloxacin 500 mg intravenous q. 24 hours. 5. Flagyl 500 mg intravenous q. 8 hours. 6. Zantac 150 mg b.i.d. 7. Metoprolol 50 mg b.i.d., hold for systolic blood pressure of less than 110, heart rate less than 55. 8. Lisinopril 10 mg q.d. 9. Percocet tablets [**2-9**] q. 4-6 hours p.r.n. for pain. 10. Epogen 6,000 units subcutaneous q. Sunday and Wednesday. 11. Heparin subcutaneous 5,000 units q. 8 hours. SURGICAL PATHOLOGY: The periaortic lymph node was reactive with fragments of fibrinous connective tissue with marked chronic and active inflammation and focal abscess formation. The retrocaval phlegmon showed fibrinous and fibroadipose tissue with abscess formation, reactive lymph nodes. There was no malignancy identified in either specimen. DISCHARGE DIAGNOSES: 1. Retroperitoneal mass, i.e. abscess status post exploratory laparotomy, retroperitoneal approach. 2. Abdominal aortic aneurysm, status post aortic endovascular stenting. 3. Chronic renal insufficiency with episode of acute tubular necrosis, resolved. 4. Coronary artery disease with ejection fraction of 20% status post cardiac catheterization, mild triple vessel disease. 5. Left foot deformity, stable. 6. Hypertension, controlled. 7. PICC line placement for long-term antibiotics. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2119-3-17**] 11:28 T: [**2119-3-17**] 11:40 JOB#: [**Job Number 22065**] Admission Date: [**2119-2-28**] Discharge Date: [**2119-3-17**] Date of Birth: [**2062-5-15**] Sex: M Service: ADDENDUM/DISCHARGE INSTRUCTIONS: PICC line care as per institutional protocol. Left foot dressing, DSD qd. Monitor CBC, SMA-7, Vanco trough weekly. Call results to Dr.[**Name (NI) 22066**] office and Infectious Disease Clinic number. Monitor ESR and CRP at two weeks and four weeks postdischarge, and call those to Infectious Disease. Antibiotics will be continued for a total of eight weeks starting from the date [**2119-3-16**]. Please call and arrange for abdominal/pelvic CT with contrast IV at two weeks and at four weeks. Correlate these with follow-ups with Dr. [**Last Name (STitle) **]. Give the patient Mucomyst 20%, 600 mg, 2 doses prior to planned CT and two doses after planned CT dates. Monitor glucose by fingersticks before meals and at bedtime. FOLLOW-UP VISITS: Dr. [**Last Name (STitle) **] at two weeks and at four weeks with abdominal/pelvic CT with IV contrast. Please call ([**Telephone/Fax (1) 22067**] for arrangements for the procedure and follow-up visit. The patient should also be seen by the Infectious Disease Clinic, Dr. [**Last Name (STitle) 1774**], or Dr. [**Last Name (STitle) **], and their number is ([**Telephone/Fax (1) 22068**]. The patient also should be seen by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] of Nephrology Department with the initial visit postdischarge; his number is ([**Telephone/Fax (1) 817**]. DISCHARGE DIAGNOSES: 1) Abdominal aortic aneurysm, status post endovascular stenting on [**2119-2-28**]. 2) Retroperitoneal mass/abscess, status post CT needle aspiration on [**3-4**] and [**2119-3-6**]. 3) Open laparotomy retroperitoneal approach with biopsy on 11/31. 4) Coronary artery disease with an ejection fraction of 30% with global hypokinesis and negative stress test. Status post cardiac catheterization on [**2119-3-14**]. 5) Chronic renal insufficiency with acute tubular necrosis corrected secondary to contrast induced, resolved. 6) Chronic anemia, stable. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. 2914 Dictated By:[**MD Number(3) 22069**] MEDQUIST36 D: [**2119-3-17**] 12:48 T: [**2119-3-17**] 13:02 JOB#: [**Job Number 22070**]

[ "401.9", "443.9", "272.0", "584.5", "567.2", "414.01", "250.00", "441.3", "285.9" ]

icd9cm

[ [ [] ] ]

[ "54.24", "54.0", "39.71", "37.22", "88.55", "38.93", "40.29" ]

icd9pcs

[ [ [] ] ]

13354, 14156

10132, 11029

2601, 8832

11979, 13332

1094, 1308

9576, 10109

1493, 2583

149, 189

218, 823

846, 1070

1325, 1470

76,261

116,501

8519

Discharge summary

report

Admission Date: [**2148-9-6**] Discharge Date: [**2148-9-17**] Date of Birth: [**2072-2-26**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2569**] Chief Complaint: Code stroke: found by wife in the morning to be unresponsive, non-communicative and to have left sided weakness. Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a 76 yo M with history of pAfib on coumadin, CHF (EF 10-15%), Prostate CA, stroke, who presents with acute onset left sided weakness, drowsiness and inability to speak. Over the past several weeks, he had been experiencing increased SOB and difficulty climbing stairs. He has been followed by his cardiologist who had scheduled a cardiac cath for this morning. In that setting he had been holding his coumadin since Monday and was not taking other anticoagulation or antiplatelets. This morning his wife woke him up around 5am to come in for the catheterization and found him unresponsive. He was also apparently not moving his left side. She tried to waken him up but he would not open his eyes. He did not interact purposefully at that time and apparently could not communicate. EMS was called and he was brought to the ED at which time code stroke was called. His NIHSS was calculated to be 15, he underwent CT/CTA/CTP which revealed extensive clot from R ICA above the bifurcation to the R MCA with area of hypodensity. Given the time course of the time of last known well >8hrs, tPA was not given; interventional thrombectomy/lysis was considered and extensively discussed but given the time course and the unfavorable risk/benefit assessment ultimately was not pursued. While awaiting assessment in the ED, the patient's respiratory status became tenuous with shallow breathing. He was responsive only to vigorous sternal rub. He was therefore intubated and sedated for airway protection. ROS was not possible in this setting. Past Medical History: 1. CAD status post MI in [**2136-3-24**], [**2136-8-24**], [**2137**]. He has known 3VD. He is status post PTCA of the left circ and OM1 in 4/00. He is status post PTCA stent of the ramus in 5/00. In [**8-/2136**] he had restent of the ramus and stent in the proximal LAD. In 11/00 he had PTCA of the left circ. His last stress was in [**11/2136**]. He exercised four minutes, 48% exercise capacity, no anginal symptoms, no EKG changes. He had a fixed defect in the anterior septal region. 2. History of obstructive jaundice status post ERCP in [**Month (only) 547**] [**2135**] with sphincterotomy and extraction of common bile duct stone. 3. Hypertension. 4. Hypercholesterolemia. 5. Depression. 6. Paroxysmal atrial fibrillation. 7. CVA: ischemic left middle cerebral artery territory infarct in his posterior frontal lobe with subsequent right hemiparesis. Suspected cardioembolic source. On long-term Coumadin. 8. Systolic HF, last EF 25% on TTE [**12-27**]. 9. Prostate CA [**45**]. Right inguinal hernia repair Social History: Came here from [**Country 532**] in [**2132**]. Russian speaking only. He lives with his wife. [**Name (NI) **] does not smoke tobacco or drink alcohol. Denies illicit drugs. Family History: Coronary artery disease Physical Exam: Physical Exam: On admission: Vitals: T: afebrile P: 92 R: 20 BP: 150/100 SaO2: 97% General: responsive only to sternal rub, eyes closed, able to follow simple commands, HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: irregular, S1S2S3 systolic murmur, Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: (If applicable) NIH Stroke Scale score was 14: 1a. Level of Consciousness: 2 1b. LOC Question: 2 1c. LOC Commands: 2 2. Best gaze: 1 3. Visual fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 2 5b. Motor arm, right: 0 6a. Motor leg, left: 1 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 3 10. Dysarthria: 0 11. Extinction and Neglect: 1 -Mental Status: Drowsy, eyes closed, responds only to vigorous sternal rub. ? neglect of left side. No spontaneous speech, -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: Forced conjugate deviation towards the right that can be overcome with VOR VII: No clear facial droop, facial musculature symmetric when grimacing VIII: VOR intact IX, X:+ gag -Motor: Normal bulk, decreased tone in the left upper extremity No adventitious movements, such as tremor, noted. No asterixis noted. Level of arousal limited accurate assessment of motor strength but appeared to have full strength in the right upper and lower extremities. Left upper extremity demonstrated [**2-26**] at the deltoid and flaccid paralysis distal to the deltoid. Left lower extremity was at least [**2-26**] in all muscle groups, tone was not decreased, no external rotation, -Sensory: withdrawal to noxious in all extremities -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 mute R 2 2 2 2 mute Plantar response was extensor bilaterally. -Coordination/Gait: defered Physical Exam on Discharge: expired Pertinent Results: [**2148-9-9**] 04:05AM BLOOD WBC-6.9 RBC-4.18* Hgb-12.5* Hct-37.3* MCV-89 MCH-30.0 MCHC-33.6 RDW-14.2 Plt Ct-160 [**2148-9-7**] 02:12AM BLOOD WBC-7.8 RBC-4.26* Hgb-12.9* Hct-38.6* MCV-91 MCH-30.2 MCHC-33.3 RDW-14.2 Plt Ct-163 [**2148-9-6**] 03:00PM BLOOD WBC-6.3 RBC-4.23* Hgb-12.8* Hct-38.0* MCV-90 MCH-30.3 MCHC-33.8 RDW-14.4 Plt Ct-178# [**2148-9-6**] 05:40AM BLOOD WBC-6.7 RBC-4.02* Hgb-12.4* Hct-36.3* MCV-90 MCH-30.8 MCHC-34.1 RDW-14.6 Plt Ct-365 [**2148-9-5**] 08:24AM BLOOD WBC-5.4 RBC-4.36* Hgb-13.2* Hct-40.5 MCV-93 MCH-30.3 MCHC-32.7 RDW-14.7 Plt Ct-185 [**2148-9-9**] 04:05AM BLOOD Plt Ct-160 [**2148-9-8**] 02:03AM BLOOD PT-13.0* PTT-35.0 INR(PT)-1.2* [**2148-9-7**] 02:12AM BLOOD PT-13.1* PTT-32.2 INR(PT)-1.2* [**2148-9-5**] 08:24AM BLOOD PT-15.2* INR(PT)-1.4* [**2148-9-6**] 05:40AM BLOOD Fibrino-350 [**2148-9-9**] 04:05AM BLOOD Glucose-145* UreaN-20 Creat-0.6 Na-143 K-3.5 Cl-107 HCO3-28 AnGap-12 [**2148-9-8**] 02:03AM BLOOD Glucose-104* UreaN-15 Creat-0.6 Na-141 K-3.5 Cl-106 HCO3-26 AnGap-13 [**2148-9-7**] 02:12AM BLOOD ALT-19 AST-33 AlkPhos-79 [**2148-9-9**] 04:05AM BLOOD Calcium-8.7 Phos-2.2* Mg-1.9 [**2148-9-7**] 02:12AM BLOOD CK-MB-6 cTropnT-0.03* [**2148-9-6**] 05:40AM BLOOD cTropnT-<0.01 [**2148-9-7**] 02:12AM BLOOD Triglyc-60 HDL-43 CHOL/HD-3.2 LDLcalc-83 [**2148-9-6**] 05:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2148-9-6**] 05:54AM BLOOD Glucose-153* Lactate-3.3* Na-138 K-7.3* Cl-107 calHCO3-16* [**2148-9-6**] 05:54AM BLOOD Hgb-13.3* calcHCT-40 O2 Sat-94 COHgb-5 MetHgb-0.3 HEAD AND NECK CTA [**9-6**] Thrombus within the right intracranial ICA extending over the supraclinoid ICA and bifurcation with thrombus in the right M1 segment of the middle cerebral artery. The right ICA is not opacified through the petrous segment, but this may reflect decreased flow due to the distal thrombus rather than thrombosis of this segment of the vessel as there is no hyperdense thrombus visualized in this segment of the artery. Corresponding decreased cerebral blood flow and blood volume in the right middle cerebral artery distribution. There is distal collateral flow. Origin of the thrombus may be from extensive soft plaque in the proximal cervical internal carotid artery. Occluded right vertebral artery from its origin through the V4 segment, where it is distally reconstituted. No intracranial hemorrhage. HEAD AND NECK MRI [**9-6**] FINDINGS: There is slow diffusion within the entire right middle cerebral artery territory, compatible with acute/subacute ischemia. Hyperintense signal is seen within the right internal carotid artery extending from the distal cervical portion through the bifurcation and also in the middle cerebral artery on the right, which may reflect combination of slow flow and/or thrombus. There is no hemorrhage. Elsewhere, there is confluent and punctate FLAIR signal hyperintensity in periventricular and subcortical white matter bilaterally, which likely reflect sequela of moderate microvascular disease. The visualized portions of the paranasal sinuses, mastoids, and orbits are unremarkable. Fluid is noted within the nasopharynx. IMPRESSION: 1. Acute infarct involving nearly the entire right middle cerebral artery territory. 2. Thrombus and/or slow flow within the right internal carotid artery extending from the distal cervical portion through the bifurcation of the internal carotid artery and into the right middle cerebral artery. 3. No intracranial hemorrhage. TTE [**9-11**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.1 cm <= 4.0 cm Left Atrium - Four Chamber Length: *7.7 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.4 m/s Right Atrium - Four Chamber Length: *7.2 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 15% to 20% >= 55% Left Ventricle - Stroke Volume: 35 ml/beat Left Ventricle - Cardiac Output: 3.22 L/min Left Ventricle - Cardiac Index: *1.67 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': *0.02 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.02 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *50 < 15 Aorta - Sinus Level: 2.8 cm <= 3.6 cm Aorta - Ascending: *3.9 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 10 Aortic Valve - LVOT diam: 2.1 cm Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - E Wave deceleration time: *101 ms 140-250 ms TR Gradient (+ RA = PASP): *45 to 48 mm Hg <= 25 mm Hg Pulmonic Valve - Peak Velocity: 0.7 m/sec <= 1.5 m/sec Findings This study was compared to the prior study of [**2147-6-5**]. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. No ASD or PFO by 2D, color Doppler or saline contrast with maneuvers. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Severe regional LV systolic dysfunction. No LV mass/thrombus. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. Mild thickening of mitral valve chordae. Mild (1+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: Trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of agitated normal saline at rest. Patient was unable to cooperate with maneuvers. Echo contrast was administered by the clinical nurse. [**First Name (Titles) 2325**] [**Last Name (Titles) **] effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is markedly dilated. The right atrium is markedly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is severe global and regional left ventricular systolic dysfunction with akinesis to dyskinesis of the basal to mid inferior wall and apex, and global hypokinesis in the remaining segments (EF 15-20%). No masses or thrombi are seen in the left ventricle. Mild right ventricular systolic dysfunction. The ascending aorta is mildly dilated. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: No left ventricular thrombus. No PFO or ASD by resting saline injection. Severe regional left ventricular systolic dysfunction. Mild mitral regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2148-8-1**], the findings are similar. CT Head [**9-7**]: FINDINGS: The patient's head is turned to the right at approximately 45 degrees, making evaluation slightly difficult. There is cytotoxic edema in essentially the entire territory of the right middle cerebral artery, representing evolution of the known thromboembolic infarction. There is no evidence of hemorrhagic transformation. The right lateral ventricle is partially effaced. The third ventricle is minimally shifted to the left, without significant compression. The left lateral ventricle is stable in size. There is no uncal herniation and no cerebellar tonsillar herniation. There is persistent hyperdensity in the distal right internal carotid artery and proximal right middle cerebral artery, corresponding to the known embolus. Calcifications are again noted in bilateral intracranial vertebral arteries, as well as cavernous and supraclinoid portions of bilateral internal carotid arteries. Hypodensities are again noted in the white matter of the left cerebral hemisphere, likely corresponding to sequela of chronic small vessel ischemic disease. The imaged paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: 1. Continued expected evolution of the acute infarction in the right middle cerebral artery territory, with only mild mass effect at this time. No hemorrhagic transformation. 2. Persistent embolic occlusion of the distal right internal carotid artery and proximal right middle cerebral artery. 3. No intracranial hemorrhage. Brief Hospital Course: The pt is a 76 yo M with history of pAfib on Coumadin, off Coumadin for 5 days as he was planned to undergo cardiac catheterization because of recent worsening of his cardiac function and CHF (EF 10-15%) who was transported to the hospital after his wife found him lethargic, non-communicative and with left side weakness. He was found on CTA and CT perfusion to have thromboembolic occlusion of [**Country **]-RMCA c/b ischemia in the RMCA distribution. His limited neurological exam demonstrated R hemiparesis (arm>leg), left sided neglect and forced eye deviation towards the right. The patient was not given tPA because of the time course; he was last seen well at 10 or 11 PM and was found at 5 AM. The patient was intubated in ED for airway protection and transferred to the ICU. After extubation transferred to the floor [**9-8**]. On [**9-12**], pt was again transferred to ICU based on initiation of heparin gtt for acute limb ischemia, concern about hemorrhagic conversion of large CVA, new HAP, advanced CHF. Given poor prognosis, patient was transitioned to comfort measures only. 1. Ischemic stroke: An MRI was performed and confirmed acute infarct in the entire right MCA territory and large thrombus in the right carotid extending from the distal cervical portion, through the bifurcation of the internal carotid and into the right MCA. Given the size of stroke and risk of bleeding he was not started on heparin drip or anticoagulation for AFib. Stroke risk factors: A1c (5.2), lipid profile (TChol 138, LDL 83, HDL 43, TG 60). CMO as above. 2. Cardiovascular: hx of CHF: In ICU, cardiology service got involved and recommended preventing volume overload, started betablocker drip for heart rate control and will perform TTE. On floor, initiated CHF/AFib regimen of metoprolol 25 mg PO q6h and lisinopril 5 mg daily. On [**9-12**], pt was found to have a cold, mottled, pulseless left leg. Vascular surgery consulted urgently. Stat CTA LE was obtained, pt started on heparin gtt. Found to have aortoiliac thrombus. Would need amputation of leg, however, not operative candidate given cardiac. If no surgery, would progress to ischemic necrosis of the leg and sepsis. Given poor prognosis, transitioned to CMO as above. 3. Pulmonary: The patient was extubated successfully. However, on floor was noted to be tachypneic with [**Last Name (un) 6055**] [**Doctor Last Name **] respirations. On [**9-11**], received 20 mg furosemide IV in light of tachypnea, crackles, JVD, congestion on CXR. On [**9-12**], continued to be tachpneic, with worsening CXR infiltrates and new leukocytosis, was started on antibiotic therapy for HAP. Discontinued once transitioned to CMO. 4. GI: failed speech/swallow. NG tube placed, and was receiving nutrition. Scheduled for PEG placement. Medications on Admission: Medications - Prescription - pt was only taking warfarin. WARFARIN - (Prescribed by Other Provider) - warfarin 5 mg tablet one tablet(s) by mouth once a day or as directed last dose Monday [**2148-9-2**] ATENOLOL - (Not Taking as Prescribed) - atenolol 25 mg tablet one Tablet(s) by mouth once a day LISINOPRIL - (Not Taking as Prescribed) - lisinopril 5 mg tablet one Tablet(s) by mouth once a day ASPIRIN; 81 MG po DAILY Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: ischemic stroke left aortoiliac thrombus Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2148-9-17**]

[ "272.4", "401.9", "444.09", "486", "428.0", "427.31", "V58.61", "428.23", "V49.86", "V10.46", "434.01", "444.81", "414.01", "438.20", "V45.82", "348.5" ]

icd9cm

[ [ [] ] ]

[ "38.97", "38.08", "38.93", "83.14" ]

icd9pcs

[ [ [] ] ]

17901, 17910

14599, 17393

417, 423

17994, 18003

5459, 11624

18059, 18208

3251, 3276

17869, 17878

17931, 17973

17419, 17846

18027, 18036

4398, 5403

11673, 14576

3306, 3306

5431, 5440

265, 379

451, 2000

3321, 4257

4272, 4381

2022, 3041

3057, 3235

30,126

117,043

33017

Discharge summary

report

Admission Date: [**2156-11-18**] Discharge Date: [**2156-11-24**] Date of Birth: [**2090-3-31**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 5790**] Chief Complaint: Stage IV lung cancer, malignant pleural effusion and shortness of breath Major Surgical or Invasive Procedure: Pleurex catheter placement, open thoracotomy, evacuation of pleural effusion, placement of Pleurex catheter. History of Present Illness: Mrs. [**Known lastname 44696**] is a 66 year old female with Stage IV, NSCLC and history of recurrent malignant pleural effusion who was transfered for [**Hospital1 18**] for plamcent of a pleurex catheter. She was last tapped on [**2156-11-14**]. At that time 800cc of fluid were removed. Three days later she returned to [**Hospital 1562**] Hospital with continued dyspnea nd was found to have a recurrent right pleural effusion. She was transferred to [**Hospital1 18**]. On arrival she was tachypnic, hypoxic with increased work of breathing and was found to have non-occlusive segment and sub-segmental left lower lobe pulmonary emboli and near complete collapse of the righ lung by a large pleural effusion. Past Medical History: Stage IV non-small cell lung CA Mitral valve prolapse. Social History: non-contributory Family History: non-contributory Pertinent Results: [**2156-11-18**] 04:52PM PT-14.6* PTT-80.7* INR(PT)-1.3* [**2156-11-18**] 01:18AM TYPE-ART PO2-67* PCO2-41 PH-7.43 TOTAL CO2-28 BASE XS-2 [**2156-11-18**] 12:52AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2156-11-18**] 12:52AM PLT SMR-NORMAL PLT COUNT-440 [**2156-11-18**] 12:52AM PT-12.5 PTT-27.4 INR(PT)-1.1 [**2156-11-24**] 01:56AM BLOOD WBC-9.4 RBC-2.85* Hgb-9.2* Hct-27.6* MCV-97 MCH-32.2* MCHC-33.2 RDW-16.8* Plt Ct-459* [**2156-11-18**] 12:52AM BLOOD Neuts-78* Bands-0 Lymphs-13* Monos-8 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2156-11-24**] 01:56AM BLOOD Plt Ct-459* [**2156-11-18**] 12:52AM BLOOD PT-12.5 PTT-27.4 INR(PT)-1.1 [**2156-11-24**] 01:56AM BLOOD Glucose-118* UreaN-19 Creat-0.9 Na-140 K-3.8 Cl-109* HCO3-26 AnGap-9 [**2156-11-19**] 12:39AM BLOOD Glucose-156* UreaN-11 Creat-0.6 Na-127* K-4.8 Cl-93* HCO3-24 AnGap-15 [**2156-11-24**] 01:56AM BLOOD Calcium-7.7* Phos-2.6* Mg-1.9 [**2156-11-24**] 02:12AM BLOOD Type-ART Temp-37.1 Rates-/26 Tidal V-383 PEEP-5 pO2-138* pCO2-36 pH-7.48* calTCO2-28 Base XS-4 Intubat-INTUBATED [**2156-11-18**] 01:18AM BLOOD Type-ART pO2-67* pCO2-41 pH-7.43 calTCO2-28 Base XS-2RADIOLOGY Final Report CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2156-11-18**] 3:03 AM CTA CHEST W&W/O C&RECONS, NON- Reason: r/o pulmonary embolism; image lung for endobronchial disease Field of view: 36 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 66 year old woman with stage IV NSCLC with progressive skeletal and pulmonary metastatic disease and continuing malignant effusions txferred from OSH for acute on chronic desaturation s/p thoracentesis on [**11-14**] with 800cc removed. REASON FOR THIS EXAMINATION: r/o pulmonary embolism; image lung for endobronchial disease CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 66-year-old woman with non-small-cell lung cancer and progressive metastatic disease with malignant effusion and acute desaturation status post thoracentesis; evaluate for pulmonary embolism. COMPARISONS: None. TECHNIQUE: MDCT images of the chest were obtained both without and with 90 cc of non-ionic intravenous Optiray contrast. Multiplanar reformations were essential to interpretation. The study was optimized for evaluation of the pulmonary arteries rather than the mediastinal structures. CHEST: There are non-occlusive filling defects within left lower lobe segmental and subsegmental pulmonary arterial branches (3, 43). The central pulmonary arteries are patent. Thoracic aorta has a normal caliber, without evidence of intramural hematoma or dissection. There is a fat attenuation focus in the left thyroid lobe. The right lung is almost entirely collapsed by a very large simple right pleural effusion causing mediastinal shift. The compressed lung parenchyma demonstrates areas of relative [**Name (NI) 20534**]. There is a focus of simple fluid in the left upper lobe, which appears fissural. There are numerous pulmonary nodules within the left lung, measuring up to 25 x 19 mm (3, 77). A small simple appearing left pleural effusion is also noted. Pathologically enlarged right axillary lymph nodes measure up to 20 x 11 mm. A left hilar node measures 18 x 15 mm. The right hilum is suboptimally evaluated but increased soft tissue in this region is suspicious for lymphadenopathy. A lower pretracheal lymph node measures 17 x 16 mm. A subcarinal node measures 28 x 18 mm. There is no pericardial effusion. OSSEOUS STRUCTURES: There are sclerotic metastases at multiple sites, without associated pathologic fracture. The approximate T10 body is completely sclerotic, as is the left T7 pedicle and transverse process and the majority of the sternum and the right scapular tip. Multiple additional smaller sclerotic foci are noted. IMPRESSION: 1. Non-occlusive segmental and sub-segmental left lower lobe pulmonary emboli. 2. Near complete collapse of the right lung by a large pleural effusion. [**Name (NI) **] of portions of the compressed lung may be secondary to pneumonia. 3. Pulmonary nodules, thoracic adenopathy and numerous osseous lesions are compatible with diffuse metastatic disease. Bone scan correlation may be considered. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 7805**] [**Name (STitle) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: [**Doctor First Name **] [**2156-11-18**] 8:27 PM RADIOLOGY Final Report BILAT UP EXT VEINS US [**2156-11-18**] 2:33 PM BILAT UP EXT VEINS US Reason: source of PE [**Hospital 93**] MEDICAL CONDITION: 66 year old woman with stage 4 nsclc REASON FOR THIS EXAMINATION: source of PE INDICATION: 66-year-old woman with a stage IV non-small cell lung cancer, please evaluate for the source of pulmonary embolism. TECHNIQUE AND FINDINGS: Grayscale, color flow, and Doppler images of both upper extremities were obtained. Both jugular veins, subclavian veins, axillary veins, brachial veins, and basilic and cephalic veins demonstrates normal compressibility, respiratory variation in venous flow and venous augmentation. IMPRESSION: No evidence of DVT in both upper extremities. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Name (STitle) **] DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: [**Doctor First Name **] [**2156-11-18**] 5:18 PM Brief Hospital Course: Patient was transferred to the [**Hospital1 18**] for further management. CT scan of the chest revealed non-occlusive segmental and sub-segmental left lower lobe pulmonary emboli, near complete collapse of the right lung by a large pleural effusion, [**Hospital1 20534**] of portions of the compressed lung may be secondary to pneumonia, pulmonary nodules, thoracic adenopathy and numerous osseous lesions are compatible with diffuse metastatic disease. Interventional pulmonary service was consulted for placement of Pleurex catheter. She tolerated the procedure well but subsequently to placement, catheter became occluded. She was started on heparin gtt for her PEs. Overnight she developed relative oliguria and hypotension. She was taken to the operating room on [**11-18**] and underwent VATS with evacuation of 2.6 liters of effusion fluid and placement of Pleurex catheter. She was transferred back to ICU.Over the next several days she did well and was extubated. However, she experienced several episodes of respiratory distress followed by bradycardia and brief asistoly that was reversed with mask ventilation. On [**11-22**] she once again became bradycardic and required intubation. Extensive discussions were held with the family about the patients poor prognosis. The family made the decision to extubate the patient and make her comfortable and not initiate any other heroic measures aimed at prolonging her life. She was extubated on [**11-24**] and passed away shortly after. Medications on Admission: colace, digoxin, protonix, zofran, Discharge Medications: NONE Discharge Disposition: Expired Discharge Diagnosis: Stage IV lung CA Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None Completed by:[**2156-11-25**]

[ "518.0", "V66.7", "424.0", "518.5", "427.5", "276.2", "427.89", "198.5", "788.5", "415.19", "162.9", "197.2" ]

icd9cm

[ [ [] ] ]

[ "99.04", "96.04", "38.93", "34.06", "96.71", "34.04" ]

icd9pcs

[ [ [] ] ]

8521, 8530

6910, 8407

362, 472

8590, 8600

1386, 2803

8653, 8689

1349, 1367

8492, 8498

6023, 6060

8551, 8569

8433, 8469

8624, 8630

250, 324

6089, 6887

500, 1216

1238, 1299

1315, 1333

69,271

164,867

33315

Discharge summary

report

Admission Date: [**2112-6-27**] Discharge Date: [**2112-7-3**] Date of Birth: [**2040-10-16**] Sex: F Service: MEDICINE Allergies: Codeine / OxyContin / Ativan Attending:[**First Name3 (LF) 5893**] Chief Complaint: Chief Complaint: Shortness of Breath Reason for MICU transfer: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 71-year-old woman with a past medical history of known metastatic breast cancer and a known chronic pleural effusion (has bilateral drains, gets drained QOD). Over past two weeks she has had increased drainage. She presented to [**Hospital3 **] hospital with worsening shortness of breath. Sat initially 75%. She was scheduled for pleuredesis here in the future. Pt states increasing SOB and increased drain output x 2 weeks, but acutely worse this week, with the output from the R-sided drain appearing more bloody. No fevers, chills, diarrhea, vomiting, abd pain. Does note LE edema bilaterally, as well as productive cough for the past week. Denies recent sick contacts. She is undergoing chemo for breast CA (last session Wednesday). In the ED, initial VS were: 98, 116/54, 97% 15L NRB. CXR initially with loculated effusions. CT of chest with worsened pleural effusion. ?distal PE on CTA. Satting 95% on NRB. On arrival to the MICU, says that her breathing feels better but still feels SOB. Denies any CP, HA, abdom pain, leg pain. Review of systems: Per HPI Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes - , Dyslipidemia - , Hypertension - 2. OTHER PAST MEDICAL HISTORY: Bilateral stage I lobular carcinoma (see below) goiter, which is being followed Basal cell cancer ten years ago . PSH: Tonsillectomy at age 14 and a cholecystectomy at age 25, rotator cuff surgery at 64 and knee surgery at age 55. . ONCOLOGIC HISTORY: 1. [**5-/2108**]: Multiple suspicious areas on breast MRI. Bilateral breast biopsy demonstrated invasive lobular carcinoma. 2. [**6-/2108**]: Underwent bilateral mastectomy for what appeared to be multifocal disease in both breasts and had negative sentinel lymph node biopsy. The right breast had a lesion staged as T1b and was grade II, ER positive, PR negative, HER-2 negative, grade II. The left breast lesion was T1C M0, ER/PR positive, HER-2/neu negative without lymphovascular invasion and grade II. BRCA [**2-15**] testing negative. 3. [**7-/2108**]: Oncotype DX assay revealed a recurrence score of 21, which was in the intermediate risk group. The patient declined enrollment in the TAILORx trial because she did not want chemotherapy. Started on Arimidex. The last bone mineral density scan in [**7-/2108**] revealed osteopenia at the left femoral neck Social History: Lives with husband. [**Name (NI) **] 4 kids. Occupation retired school teacher. Smoking history 20 pack-year smoking hx; quit 33 years ago. Alcohol denies. Family History: A brother who was diagnosed with breast cancer at age 59, metastatic disease at age 60. She has a sister who was diagnosed with breast cancer at age 49 and died at age 51 from metastatic disease. She has another sister recently diagnosed with breast cancer in [**2109**]. Genetic testing for BRCA 1 or 2 mutations was performed and was negative. Physical Exam: Admission Physical Exam: Vitals: T 98.1 HR 95 BP 107/44 RR 27 O2 93% NRB General: Alert, oriented, no acute distress, can speak in full sentences HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Pulsus measured at about [**7-21**]. Lungs: Clear to auscultation b/l in upper lung fields; decreased air movement halfway up lung fields, dullness to percussion, bronchial breath sounds, rubs, and coarse ronchi in b/l lower lung fields. Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding. B/l chest tube sites with clean dressings. GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge exam - expired Pertinent Results: ADMISSION LABS: [**2112-6-26**] 11:15PM BLOOD WBC-7.2 RBC-3.59* Hgb-10.6* Hct-34.1* MCV-95 MCH-29.7 MCHC-31.1 RDW-18.3* Plt Ct-410 [**2112-6-26**] 11:15PM BLOOD Neuts-78.9* Lymphs-18.0 Monos-2.2 Eos-0.5 Baso-0.4 [**2112-6-26**] 11:15PM BLOOD PT-11.5 PTT-27.3 INR(PT)-1.1 [**2112-6-26**] 11:15PM BLOOD Glucose-96 UreaN-14 Creat-0.9 Na-133 K-4.8 Cl-100 HCO3-22 AnGap-16 [**2112-6-26**] 11:15PM BLOOD proBNP-1349* [**2112-6-26**] 11:15PM BLOOD cTropnT-<0.01 [**2112-6-27**] 05:05AM BLOOD CK-MB-1 cTropnT-<0.01 [**2112-6-26**] 11:15PM BLOOD Calcium-8.4 Phos-4.0 Mg-2.0 [**2112-6-26**] 11:36PM BLOOD Lactate-1.5 DISCHARGE LABS: [**2112-6-30**] 04:23AM BLOOD WBC-10.4 RBC-3.60* Hgb-10.9* Hct-33.5* MCV-93 MCH-30.2 MCHC-32.5 RDW-17.6* Plt Ct-486* [**2112-6-30**] 04:23AM BLOOD PT-13.5* PTT-25.6 INR(PT)-1.3* [**2112-6-30**] 02:53PM BLOOD Glucose-154* UreaN-22* Creat-1.1 Na-125* K-5.0 Cl-95* HCO3-19* AnGap-16 [**2112-6-30**] 04:23AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.8 MICRO: -BCx - NGTD -Sputum - yeast and commensal respiratory flora -Pleural fluid - no growth IMAGING: -CXR (admission, [**2112-6-26**]): Increased moderate loculated right and small dependent left pleural effusions with accompanying mild pulmonary edema. Infectious process in the right lobe would be difficult to exclude. -CXR (most recent, [**2112-7-1**]): Compared to the most recent radiograph from [**2112-6-30**], moderate right apical pneumothorax accompanying passive collapse of underlying lung has minimally increased whereas minimal right basal pneumothorax is smaller. Bilateral, diffuse, pulmonary edema is constant. Left Port-A-catheter tip is in low SVC. A singel chest tube is presenting in right lung base. Left lung base opacity improved over last 24 hours is mostly atelectasis. -TTE ([**2112-6-27**]): The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Tricuspid regurgitation is present but cannot be quantified. There is mild pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. -CTA chest ([**2112-6-27**]): 1. Interval increase in large loculated right and small dependent left pleural effusions with resultant increase in consolidation in the right lung, most of which is likely compressive atelectasis. 2. Bilateral left greater than right ground-glass opacity with septal thickening is most likely pulmonary edema, though in this patient on chemotherapy accompanying atypical infection would be difficult to exclude. Progression of metastatic disease is felt less likely given the time course. 3. Tiny left apical subsegmental pulmonary embolus of questionable clinical significance. 4. Stable mediastinal and hilar metastatic disease -LENIs ([**2112-6-27**]): No evidence of DVT in bilateral lower extremities. Brief Hospital Course: Ms. [**Known lastname 77320**] is a 71-year-old woman with h/o metastatic breast cancer and known chronic pleural effusion (has bilateral Pleurex catheters, gets drained QOD), who p/w 2 weeks of worsening SOB and hypoxia. She had persistent hypoxia and a trapped right lung, for which further intervention could not be undertaken. During this hospitalization, she made a transition to defer further aggressive treatment or diagnostics and was transitioned to comfort measures. She was initially admitted to the ICU, however after her decision to focus on comfort was transferred to the floor on a morphine drip. She passed away soon after her transition to the floor in the presence of her husband and family. ACTIVE ISSUES: # SOB and Hypoxia: This was likely due to an increase in her malignant effusions, as well as trapped right lung. She does have notable h/o recurrent bilateral malignant pleural effusions with bilateral pleurx catheters - s/p right sided Pleurx on [**2112-4-11**] and left sided PleurX on [**2112-4-20**]. Interventional pulmonary (IP) was consulted and recommended 2 doses tPA to the R catheter. The improved fluid drainage after the loculations were broken up, however the right lung remained trapped and did not reexpand after fluid removal. She was also found to have a PNA (had new GGO's on CT chest), and was treated with vanc, cefepime and azithro which was subsequently changes to levofloxacin. Per IP, there was no further intervention possible for her trapped lung, as well as PTX and loculations. # Goals of care and symptom control: Given her metastatic disease and trapped right lung refractory to medical interventions, the decision was made to pursue comfort-focused care after a family meeting. Efforts were made to transition the patient to hospice, but she worsened clinically prior to transfer and care was transitioned to comfort. She was placed on a morphine gtt on [**2112-7-3**]. CHRONIC/INACTIVE ISSUES: # Metastatic breast CA: At admission, pt on weekly taxol 80mg/m2 C3D12. We continued morphine as needed for pain. Given her goals of care as discussed above, anastrozole was discontinued prior to discharge. # RUE DVT: Diagnosed in early [**2112**] during hospital admission in setting of recent PICC line; plan was for lifelong anticoagulation. Lovenox was discontinued in the setting of comfort focused care. # Afib/flutter: occurred during pericardial window. Amiodarone was discontinued prior to discharge as this may have been contributing to her nausea. Medications on Admission: Medications - Prescription AMIODARONE - 200 mg Tablet - 1 (One) Tablet(s) by mouth Once daily ANASTROZOLE - 1 mg Tablet - 1 Tablet(s) by mouth daily ENOXAPARIN - 60 mg/0.6 mL Syringe - injection subcutaneously twice a day (every twelve hours) LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply at 8pm Up to twice daily Patch may remain in place for up to 12 hours. Remove at 8am. MORPHINE - 15 mg Tablet Extended Release - 1 Tablet(s) by mouth Every 12 hours ONDANSETRON HCL - 4 mg Tablet - 1 (One) Tablet(s) by mouth every eight (8) hours as needed for nausea OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth Every 6 hours PANTOPRAZOLE [PROTONIX] - 20 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day as needed for may repeat once - No Substitution SERTRALINE - 25 mg Tablet - 1 Tablet(s) by mouth daily Medications - OTC DOCUSATE SODIUM - (OTC) - 100 mg Capsule - Capsule(s) by mouth Twice daily GLUCOSAMINE &CHONDROIT-MV-MIN3 - (Prescribed by Other Provider; OTC) - Dosage uncertain MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain POLYETHYLENE GLYCOL 3350 - (OTC) - 17 gram/dose Powder - by mouth Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis Loculated pleural effusion with trapped lung Pneumothorax Bacterial pneumonia Secondary Diagnosis Metastatic breast cancer Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired Completed by:[**2112-7-4**]

[ "V66.7", "V49.86", "276.1", "427.31", "V12.51", "V10.3", "518.82", "427.32", "240.9", "486", "512.89", "V10.83", "511.81" ]

icd9cm

[ [ [] ] ]

[ "34.91", "99.10" ]

icd9pcs

[ [ [] ] ]

11157, 11166

7385, 8098

362, 368

11352, 11369

4122, 4122

11433, 11478

2908, 3256

11117, 11134

11187, 11331

9939, 11094

11393, 11410

4746, 7362

3296, 4103

1456, 1466

267, 324

8114, 9330

396, 1437

9348, 9913

4138, 4730

1589, 2718

2734, 2892

65,390

161,586

35966

Discharge summary

report

Admission Date: [**2199-1-3**] Discharge Date: [**2199-2-6**] Date of Birth: [**2131-8-19**] Sex: F Service: MEDICINE Allergies: Heparin Agents / Aspirin / Albuterol Attending:[**First Name3 (LF) 2181**] Chief Complaint: Transferred from [**Hospital 4199**] Hospital for suspected T9-10 vertebral osteomyelitis Major Surgical or Invasive Procedure: 1. Partial vertebrectomy at T7-T8. 2. Fusion T7-T8. 3. Incicison and drainage with debridement 4. Posterior T3-T12 fusion. 5. Incision and drainage of epidural abscess. 6. Bone graft. 7. Tracheostomy 8. Thoractomy and chest tube placement and removal 9. Percutaneous endoscopic gastrotomy tube placement History of Present Illness: Patient is a 67 year old Spanish-speaking female with h/o ESRD on HD, CAD, h/o HIT, DM, s/p L BKA, and prior line infections who is being transfered for possible vertebral osteomyelitis. She was originally admitted to [**Hospital 4199**] Hospital from [**Date range (1) 81661**] for abdominal pain and mental status changes. She had an abdominal CT negative for intraabdominal pathology but it showed vertebral osteomyelitis. Follow-up MRI showed T9-T10 osteomyelitis without evidence of cord compression on [**12-18**]. On comparison with prior images from [**11-12**], per report, it appears that vertebral changes were present but not recognized at the time. Blood cultures grew enterococcus faecalis and she was treated with vancomycin on dialysis days for a 14 day course to end [**1-3**]. She had her HD catheter pulled [**12-23**]. Surveillance cultures have shown NGTD. She had a negative PPD and 3 negative AFB smears. She had an attempted bone biopsy by IR but no bone was recovered. She was transferred "for further evaluation of the osteomyelitis for possible fungal or tuberculoid etiologies, if no improvement with the vancomycin." Bone biopsy was done on [**12-27**] with inefficient yield for diagnosis. She was readmitted on [**1-1**] for recurrent abdominal pain. She is dialyzed T, Th, Sat and had a partial session on [**1-3**]. She has a left arm fistula that was used at the OSH for dialysis but then clotted. A second abdominal catheter was placed on [**12-25**] for further access but per the dc summary, "it is felt that this fistula should be left for further maturation." Per signout, "current HD access via right subclavian line, has immature AVF in LUE." On floor, she continues to complain of severe RUQ pain, worse with movement and worse in the supine position. She states it radiates around her back on both sides when it gets severe. She states she's had it for two weeks, although the dc summary from the OSH states several months. Also complains of pain radiating down her right leg of [**2-6**] weeks. On further questioning, she also endorsed lower extremity weakness for 4 days-1 week. Denies fevers, chills, chest pain, shortness of breath, nausea, or vomiting. Had not had a bowel movement for several days at OSH, previously had diarrhea. Does not urinate. Past Medical History: Hypertension End Stage Renal Disease on dialysis T, TH, Sat, last session for 2 hours on [**2199-1-3**] Peripheral Vascular Diseas, s/p left Below the Knee Amputation Type 2 Diabetes Mellitus, insulin-dependent Coronary Artery Disease s/p Myocardial Infarction in [**Male First Name (un) 1056**] 10 years ago, BMS placement in [**2197**] Anemia H/o Heparin-Induced Thrombocytopenia treated with argatroban and h/o Deep vein Thrombosis (associated with line placement) in [**9-12**], treated with coumadin x 1 month Hypercholesterolemia Obesity Dibabetic Neuropathy in legs H/o cholecystectomy [**2196**] H/o appendectomy Hypercalcemia Groin line sepsis with stenotrophomonas in [**9-12**], MRSA line infection [**9-9**] R knee osteoarthritis Left arm fistula [**9-/2198**], right arm fistula now occluded Social History: Social history is significant for the absence of current tobacco use, quit smoking in [**2194**]. There is no history of alcohol abuse. Lives at home with her husband, daughter, son and [**Name2 (NI) 802**]. She is originally form [**Male First Name (un) 1056**]. She does not speak English. Family History: There is no family history of sudden death. Mother died of an MI at 56 YO. Dad had a cardiovascular disease and died at [**Age over 90 **] YO of "old age". One sister with HTN, one sister and one brother healthy. [**Name2 (NI) **] history of cancer in the family. Physical Exam: VITALS: T 97.6 HR 86 141/41 20 100% on 40% trach mask GENERAL - elderly obese female, alert, responsive, makes eye contact. Does not respond to questions or commands, but interacts. HEENT - PERRL, EOMI, MMM NECK - supple, tracheostomy in place LUNGS - Decreased breath sounds at bases bilaterally, air movement R > L. Coarse rales more on left. HEART - Regular rate and rhythm with 2/6 systolic murmur. ABDOMEN - obese, + BS, soft, non-tender to palpation. PEG tube in place. EXTREMITIES - Edematous bilaterally, [**1-5**]+. 1+ pedal pulses in right foot, has left BKA. NEURO: no sensation or movement of lower extremities. Moves upper extremities bilaterally and spontaneously, moves head, mouths words (trach in place). Clearly alert and responsive, but does not repsond to commands, will occasionally respond to questions. Spanish-speaking only. SKIN - multiple wounds, post-surgical and pressure wounds, as detailed below. Trach: continues to have increase drainage peritube G-tube: left ABD with moderate thick drainage from site, no peritubular skin breakdown Right axilla: 2 open sites, 1 x 1 cm yellow/red 50% each, wound bed, 0.5 cm x 0.5 cm pink wound bed, wound edges are irregular, no drainage, no s/s of infection, other noted healed sites in this area, undetermined etiology of wounds-possible friction Right ABD: 2 ulcers now closed Right lateral thigh: 2 unstageable pressure ulcers 1 x 3 cm yellow/black wound bed beginning to slough 7.5 x 1.5 cm necrotic black firm tissue beginning to slough at proximal end and separate from wound edges. There is a moderate amount of yellow serous drainage. There is no periwound erythema, edema, induration or fluctuance. Right lower leg just above ankle: intact darkly pigmented tissue circumferentially in two linear configurations, ? etiology no acute for s/s of infection Left lateral chest tube site: closed Left forearm/wrist: 0.5 x 1 cm dry yellow eschared site Midline back vertebral incision: intact with steristrips in place Left thoracotomy incision: not approximated, 1 x 15 cm with necrotic yellow black tissue in the wound bed, small amount of yellow drainage with no odor, wound edges defined, no surrounding erythema, edema, or fluctuance Inferior to left thoracotomy incision: 4 x 4.5 cm partial thickness ulcer with 100% red wound bed improved maybe related to tape injury, wound edges are irregular, no s/s of infection Left lateral back: 2.5 x 1 cm unstageable pressure ulcer with 50% yellow/50% pink wound bed, irregular wound edges, no surrounding s/s of infection Left trochanter: 3 x 3.5 cm unstageable pressure ulcer, 100% yellow fibrinous tissue, irregular wound edges, scant drainage with no odor, periwound tissue intact with no induration, edema, or fluctuance Intergluteal tissue: unchanged parital thickness ulcer with 100% red wound bed and irregular wound edges most likely related to moisture, appears to be healing Perianal: anterior anus 1.5 x 0.2 cm, Stage II pressure ulcer most likely from pressure of the FMS tubing. Pertinent Results: Admission Labs: [**2199-1-3**] 07:55PM WBC-9.2 RBC-3.09* HGB-9.0* HCT-29.4* MCV-95 MCH-29.1 MCHC-30.6* RDW-16.6* [**2199-1-3**] 07:55PM PLT COUNT-171 [**2199-1-3**] 07:55PM GLUCOSE-125* UREA N-41* CREAT-5.2* SODIUM-137 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-26 ANION GAP-14 [**2199-1-3**] 07:55PM CALCIUM-10.1 PHOSPHATE-5.0* MAGNESIUM-2.3 [**2199-1-3**] 07:55PM ALT(SGPT)-9 AST(SGOT)-12 ALK PHOS-112 AMYLASE-18 TOT BILI-0.3 [**2199-1-3**] 07:55PM LIPASE-14 . Studies: . MR CERVICAL, THORACIC AND LUMBAR SPINE WITHOUT AND WITH CONTRAST [**2199-1-4**] . HISTORY: End-stage renal disease and known T9-10 vertebral osteomyelitis, now with progressive lower extremity weakness and incontinence. . Sagittal imaging was performed with long TR, long TE fast spin echo, short TR, short TE spin echo, and STIR imaging. Axial imaging was performed with short TR, short TE spin echo and long TR, long TE spin echo technique. Due to the patient's renal failure (EGFR of 8) informed consent was obtained before administration of 20 cc of ProHance intravenous contrast. Subsequently, sagittal and axial short TR, short TE imaging was repeated. Comparison to an outside MR of the thoracic spine of [**2198-12-18**]. . FINDINGS: Again seen is evidence of discitis and osteomyelitis centered at T8-9. There is now a large, irregular, fluid collection at the former location of the intervertebral disc. There is extensive enhancement around the periphery of this abnormality. This enhancing fluid collection extends through the anterior cortex of the vertebral bodies and is contiguous with a small amount of intraspinal epidural abnormal enhancement. These findings suggest intraspinal extension of infection with an epidural phlegmon. There is extensive paraspinal soft tissue abnormality extending from T6 to T10. This contains two focal non-enhancing areas that represent abscess collections surrounded by extensive paraspinal phlegmon. All of these changes appear to have progressed since the study of [**12-18**]. Also seen are small bilateral pleural effusions. These appear somewhat smaller than on the study of [**12-18**]. . The epidural material appears to encroach on the anterior aspect of the spinal cord and may cause some degree of cord compression. This is not well evaluated on this examination. . Incidentally noted is anterior subluxation of L4 on L5 on a degenerative basis. . CONCLUSION: Discitis and osteomyelitis with a large abscess within the vertebral column with extension anteriorly to the paravertebral space and posteriorly with at least a small intraspinal epidural phlegmon. The images are severely degraded by motion artifact. However, there appears to be edema . TRANS-THORACIC ECHOCARDIOGRAM, performed [**2199-1-28**] . The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is mild aortic valve stenosis (valve area 1.5cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2199-1-9**], the severity of aortic stenosis is higher, though may be related to improved definitiion of the aortic velocity rather than a true change. . HEAD CT, [**2199-1-29**] . IMPRESSION: Periventricular white matter and basal ganglia hypodensities likely represent chronic microvascular disease. However, given the lack of comparison studies, acute encephalopathy cannot be ruled out. . NECK CT, [**2199-1-29**] . IMPRESSION: 1. Status post T-spine fusion, with bilateral pleural effusions. 2. Paranasal sinus disease. . PORTABLE CHEST X-RAY, [**2199-2-1**] (most recent study) . IMPRESSION: . 1) Marked volume loss in the left lower lobe, possibly from mucous impaction or obstructing lesion given persistence of atelectasis. 2) Large amount of at least partially loculated fluid in the left lung. . CT T-SPINE, [**2199-1-9**] . IMPRESSION: Status post T8-T11 fusion with intervertebral body cage. Marked destruction of the T9 and T10 vertebral bodies and to a lesser disc extent T8 and T11 reflect known osteomyelitis/discitis and partial vertebrectomy. . [**2199-2-1**] 06:11AM BLOOD WBC-12.5* RBC-2.76* Hgb-8.3* Hct-26.5* MCV-96 MCH-30.1 MCHC-31.3 RDW-16.4* Plt Ct-271 [**2199-1-30**] 07:32AM BLOOD WBC-9.8 RBC-2.16*# Hgb-6.5*# Hct-21.3*# MCV-97 MCH-30.1 MCHC-31.2 RDW-16.0* Plt Ct-199 [**2199-1-28**] 06:30AM BLOOD WBC-11.5* RBC-2.38* Hgb-7.0* Hct-23.3* MCV-98 MCH-29.5 MCHC-30.2* RDW-16.0* Plt Ct-194 [**2199-1-26**] 02:53AM BLOOD WBC-14.9* RBC-2.48* Hgb-7.2* Hct-24.0* MCV-97 MCH-29.3 MCHC-30.2* RDW-15.7* Plt Ct-145* [**2199-1-21**] 02:30PM BLOOD WBC-24.7* RBC-2.81* Hgb-8.3* Hct-26.9* MCV-96 MCH-29.6 MCHC-31.0 RDW-16.1* Plt Ct-137* [**2199-1-17**] 01:55AM BLOOD WBC-12.9* RBC-2.91* Hgb-8.8* Hct-27.1* MCV-93 MCH-30.2 MCHC-32.4 RDW-16.6* Plt Ct-120* [**2199-1-14**] 02:50AM BLOOD WBC-14.8* RBC-3.46* Hgb-10.7* Hct-30.8* MCV-89 MCH-30.9 MCHC-34.7 RDW-16.1* Plt Ct-126* [**2199-1-6**] 03:05AM BLOOD WBC-20.1* RBC-3.83* Hgb-11.3* Hct-34.8* MCV-91 MCH-29.6 MCHC-32.6 RDW-16.8* Plt Ct-141* [**2199-1-5**] 07:57PM BLOOD WBC-15.7*# RBC-3.26* Hgb-9.9* Hct-30.0* MCV-92 MCH-30.2 MCHC-32.8 RDW-16.2* Plt Ct-151 Brief Hospital Course: Patient is a 67 year old Spanish-speaking female with h/o ESRD on HD, CAD, h/o HIT, DM, s/p L BKA, and prior line infections who was transferred for vertebral osteomyelitis and epidural abscess now status post incidion and drainage of abscess with posterior fusion from T3-T12 with residual paraplegia. . The patient was transfered to the SICU on the Orthopaedic Spine service on [**2199-1-13**] for management of her osteomyelitis and epidural abscess. Due to the unresolved paraplegia an IVC filter was placed by the General Surgery service for DVT prophylaxis given her history of heparin-induced thrombocytopenia. After her thoracotomy for her vertebrectomy she was noticed to require additional respiratory support and a chest x-ray was obtained. An apical pneumothorax was identified and a chest tube was placed. While in the SICU a PEG and trach were placed due to inablility to wean off of the ventilator. Pt had septic physiology requiring three pressors for blood pressure support. She developed a pneumonia and was placed on the antibiotics. Her symptoms improved, however she developed a new atrial fibrillation of unknown etiology. She was started on amiodarone and diltiazem with subsequent conversion to sinus where she remained. . On [**1-26**] the patient was transfered back to the medical service for continuing management of her multiple medical issues. The evening following the transfer her family members noted that she had seemed less responsive over the course of the day. On initial exam she would make eye contact but was not responding to commands or answering questions. She was moving her arms spontaneously. Her oxygen saturation was 100%, and an ABG drawn at that time showed no evidence of hypercarbia. The following morning she spiked a fever to 101 degrees, at which point she was pan-cultured, and a chest x-ray showed worsening consolidation, especially in the left lung. Her antibiotic coverage was broadened, and her mental status gradually improved over the next several days. She still remained intermittently responsive to commands, but she would respond to family members, and she began to move her upper extremities spontaneously. . #. Vertebral osteomyelitis: She presented with known vertebral osteomyelitis and after having completed a 2 week course of Vancomycin. She continued to complain of RUQ abdominal pain thought to be radicular in nature. She also endorsed some lower extremity weakness on admission and possible decreased sensation. She had an episode of stool incontinence overnight the night of admission and an MRI was obtained that showed a large abscess at T8-T9 within the vertebral column with extension anteriorly to paravertebral space and posterially with small epidural phlegmon. There also appeared to be edema in spinal cord at the level of the abscess. She was taken to the OR on [**2199-1-5**] and was treated initially with vancomycin and ampicillin. Patient had incision and drainage of her epidural abscess, multiple thoractomies and posterior fusion from T3-T12. After growing VRE from blood on [**1-27**]. Pt was started on linezolid and cefepime. Flagyl was eventually added out of concern for sinusitis. Last day of cefepime [**2-6**]. Please see full details under "Fevers" section. . #. ESRD on HD: She receives dialysis T, Th, Sat and had a partial session on [**1-3**]. There were no signs of uremia on admission. She was dialyzed twice after undergoing MRI with contrast in order to prevent NSF. . #. CAD: She had no symptoms on admission of CAD. Plavix was stopped in preparation for a possible procedure. She was continued on metoprolol, Lipitor, and has an allergy to ASA. . #. Heparin-induced thrombocytopenia (HIT): She has a h/o HIT with recent UE DVT due to line placement in [**9-12**]. Heparin products were avoided during this admission. She has a midline that CANNOT be flushed with heparin. . # Fevers: The infectious disease service had been following before transfer to the medicine service, and they continued to follow the patient after developing new fevers on [**1-27**]. At that point she had two catheters in her left internal jugular vein - one triple lumen catheter, and one HD catheter. Cultures were drawn from both catheters as well as peripherally. Both of these catheters were removed, and a temporary HD line was placed with a VIP port for non-HD access. Cultures drawn from the earlier left IJ lines eventually grew out vancomycin resistant enterococcus, which prompted the ID team to recommend Linezolid for the bactermia and cefepime for hospital-acquired pneumonia for antibiotic coverage. She improved on this regimen over the next several days, remaining afebrile, with improved mental status. She was transferred to the MICU for 2 days due to nursing concerns and staffing issues, but then returned to the medical floor. During this time she also developed increased secretions around the trach, which were thought to possibly represent sinusitis (which was also noted on head CT) so she was started on Flagyl as well for anaerobic coverage. She continued to improve, with clearance of further culture data, and within a week she was stabilized and considered ready for transfer to LTAC for continued care and rehab. . The infectious disease team recommended the following treatment plan for discharge: 1. Cefepime for HAP, discontinued at discharge, on [**2199-2-6**] 2. Linezolid and Flagyl, to be continued until [**2199-2-12**] 3. Ampicillin, to be resumed on [**2199-2-12**] when stopping linezolid and flagyl, and continued until [**2199-3-2**] . Until completion of ampicillin treatment, weekly labs should be drawn (ESR, CRP, LFT's, CBC with diff) and faxed to the infectious disease clinic at [**Telephone/Fax (1) 1419**]. . # Altered mental status: On transfer to the medical service, as noted above, she was altered and minimally responsive, not moving her arms. Her neuro exam was limited due to her lack of alertness, but she was also not moving her upper extremties, and not withdrawing to pain. With concern for possible spread of epidural abscess and/or anoxic brain injury, a CT head/neck was obtained. This was a non-contrast CT, given her recent gadolinium exposure, tenuous respiratory status, and inability to lie still. We could not give CT contrast due to lack of peripheral venous access (this was attempted multiple times without success). However, her mental status improved significantly with antibiotics, and she regained movement in her arms as the infection cleared. . # Respiratory status The patient was noted to have a large left-sided pleural effusion on CXR in addition to the new pneumonia. It was decided that with all of her comorbidities and recent complications, that draining the effusion would be too high-risk. Her respiratory status remained stable after antibiotic treatment, with decrease in secretions, stable respiratory rate. Her trach remains in place for now, to be removed in the future if tolerated. Pt has a large left-sided pleural effusion that has been stable. . # ESRD on hemodialysis: The patient remained on a Tuesday, Thursday, Saturday dialysis schedule. On Tuesday, [**2-5**] the HD catheter was not functioning properly at dialysis, so TPA was left in the line overnight, and HD was performed on Wednesday, [**2-6**] without incident. The plan per the renal team was to resume her previous Tuesday/Thursday/Saturday schedule after transfer to outside facility. She was continued on her preadmission renal medications. Left upper extremity AV fistual clotted. . # Atrial fibrillation: Shortly before transfer to the medicine service the patient was noted to be in atrial fibrillation. She was started on amiodarone and diltiazem, with good control, and returned to sinus rhythm. The amiodarone was discontinued, and she was maintained with good heart rate control on diltiazem at time of discharge. She was also started on coumadin for anticoagulation. It was decided to leave the IVC filter in place, given risks of removal and lack of mobility in her future course. The coumadin dose was increased to 5 mg per day 2 days before discharged, given subtherapeutic INR. This dose may require further adjustment pending INR trend. . # Type II Diabetes Mellitus: Patient receives long-acting insulin qam in addition to sliding scale qid. . # Vascular access: Patient has a left upper extremity AV fistula that was used for dialysis at the outside hospital but clotted prior to transfer. As noted above, access was difficult throughout her hospital course, and she had multiple temporary lines placed, avoiding tunneled line placement due to active bacteremia. However, a tunneled left IJ dialysis line was placed by IR on [**Last Name (LF) 2974**], [**2-1**], along with a R-sided midline for use in continued antibiotic treatment. Heparing flushes SHOULD NOT be used. . # Pain control: It is not clear exactly how much pain the patient has been having, as she is not able to articulate how much or where her pain is. However, she does become noticeably calmer and more comfortable with analgesia. On discharge she was on a regimen of oxycodone 5 mg per PEG tube Q 4 hours, with good effect. . # Nutrition: The patient was kept on tube feeds at a goal rate of 25 cc/hour. She occasionally had residuals on routine checks, but mostly her tube feeds have been running without incident. Her abdomen has consistently remained soft and non-tender. . # Wound care: The patient has surgical wounds, as well as several pressure wounds on her back and legs. The wound care service was very involved with her care, and provided recommendations for continued wound care. Please see the Page 1 for the specific recommendations. . # Anemia - The patient's hematocrit remained low throughout the hospitalization, requiring transfusions. Likely combination of ESRD, anemia of inflammation, combined with operative blood loss. Her hematocrit at time of discharge was stable. . # Goals of care: The patient initially was DNR/DNI on admission, but this was reversed before her surgical procedure. After lengthy discussions with the family, her code status was returned to DNR/DNI after transfer back to the medicine service. We explained that the patient will likely require intensive services indefinitely, and that she will probably never return to her previous level of function. Palliative care was also consulted, and they explained that there are also comfort measures available should the patient and her family be interested in them in the future. The family's current plan is to transfer to a long term acute care facility for further rehab and treatment. . The patient was discharged to LTAC on [**2199-2-6**]. Medications on Admission: Amlodipine 10mg po daily Cimetidine 20mg po daily Florastor 250mg po daily Folic Acid 1mg po daily Insulin 32 units SC at bedtime plus RISS Isosorbide Dinitrate 20mg po TID Lipitor 20mg po daily Lisinopril 5mg po daily Toprol XL 200mg po daily Nephrocaps 1mg po daily Percocet 5/325 1 tab po q4h prn for pain Renagel 800mg po TID Sensipar 90mg po daily Vancomycin 1gm IV with dialysis, last dose [**2199-1-3**] Gabapentin 100mg po daily *Stopped Plavix 75mg po daily for possible procedure Discharge Medications: 1. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 4. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 3-5 MLs Miscellaneous Q6H (every 6 hours) as needed for Thick secretion. 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 11. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day) as needed for constipation. 12. Insulin Regular Human 100 unit/mL Solution Sig: see attached insulin scale units Injection per attached regimen: Please give insulin regimen as instructed on attached scale. Disp:*qs * Refills:*2* 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 14. Metoclopramide 5 mg/mL Solution Sig: Five (5) mg Injection Q6H (every 6 hours). 15. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred (600) mg Intravenous Q12H (every 12 hours): to be continued until [**2199-2-12**]. 16. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours): to be continued until [**2199-2-12**]. On dialysis days, please give AFTER dialysis. 17. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO every [**4-9**] hours as needed for pain: please hold for sedation, RR < 10. 18. Ampicillin Sodium 1 gram Recon Soln Sig: Two (2) grams Intravenous every twelve (12) hours: Please give from [**2-12**] to [**3-2**]. On dialysis days, please dose AFTER dialysis. Disp:*qs * Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital1 81662**] Med Ctr. Discharge Diagnosis: 1. Thoracic osteomyelitis T9-10 with epidural abscess 2. Atrial fibrillation 3. Pneumonia 4. Apical pneumothorax 5. End stage renal disease 6. Post-operative fevers 7. Post-op acute blood loss anemia 8. Diabetes 9. Paraplegia 10. Heparin-induced thrombocytopenia Discharge Condition: Alert, responsive, mouths words but does not consistently respond to questions or commands. Moves both arms, but paraplegic. Discharge Instructions: You have undergone the following operation: ANTERIOR/POSTERIOR Thoracic debridement and fusion with instrumentation Please engage in physical therapy as the patient can tolerate You should take your antibiotics as prescribed for the full course of treatment. You will need to take Linezolid and Flagyl until [**2-12**], then stop those antibiotics and start ampicillin, from [**2-12**] through [**3-2**] (completing an 8 week course in total). While taking antibiotics, you should have labs drawn once a week, including ESR, CRP, LFT's, and CBC with diff. These results should be faxed to the infectious disease clinic office at [**Hospital1 18**] - the fax number is [**Telephone/Fax (1) 1419**]. You should also continue your previous dialysis schedule, on Tuesdays, Thursdays, and Saturdays, as coordinated by the renal service. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 363**] in his clinic in 2 weeks. Call [**Telephone/Fax (1) **] for an appointment. You should also followup with the infectious disease clinic before you finish your course of antibiotics on [**3-2**]. You can call [**Telephone/Fax (1) 457**] to schedule an appointment.

[ "414.01", "584.9", "V45.11", "250.60", "403.91", "486", "344.1", "730.28", "995.92", "585.6", "427.31", "357.2", "348.30", "511.9", "512.1", "285.1", "V46.11", "038.0", "V45.82", "324.1", "996.73", "041.04", "785.52", "599.0" ]

icd9cm

[ [ [] ] ]

[ "03.09", "39.95", "84.51", "81.62", "81.04", "84.52", "31.1", "81.05", "38.95", "96.6", "43.11", "81.64", "38.93", "38.7", "77.89", "34.09", "96.72", "96.04", "99.10", "00.14" ]

icd9pcs

[ [ [] ] ]

26745, 26802

13223, 19021

385, 690

27109, 27237

7534, 7534

28123, 28447

4192, 4458

24512, 26722

26823, 27088

23998, 24489

27261, 28100

4473, 7515

256, 347

22719, 23972

718, 3039

7550, 13200

19036, 22707

3061, 3867

3883, 4176

45,038

141,418

41326

Discharge summary

report

Admission Date: [**2177-6-13**] Discharge Date: [**2177-6-15**] Date of Birth: [**2155-10-30**] Sex: F Service: MEDICINE Allergies: Meropenem / Vancomycin / morphine / Iron / Ursodiol / peanuts / wheat / Gluten / Soy / dairy products / pregabalin / pork products Attending:[**First Name3 (LF) 10293**] Chief Complaint: Abdominal pain, LUE pain/swelling Major Surgical or Invasive Procedure: None History of Present Illness: 21 year old woman with eosinophilic esophagitis, chronic pancreatitis, on TPN and now with end-stage liver disease, cutaneous mastocytosis, Crohn's disease, GERD, legal blindness s/p anoxic brain injury who presents with worsening abdominal pain and LUE numbness/tingling, swelling. . The patient has chronic abdominal pain (daily, constant) but states that over the last two days, the pain has worsened from baseline [**2176-4-22**] to [**2176-7-25**]. The pain is sharp and has caused her to be nauseated, no vomiting. The patient feels she has become more jaundiced in the interim also. She has chronic loose stools which has not worsened recently, denies dysuria, recent travel, exotic foods, sick contacts. The patient felt her ascites and lower extremity had worsened yesterday but resolved with her normal spironolactone for diuresis. She states she has had hematemesis in the past but not recently, known varices but no variceal bleed, encephalopathy last year (admitted to [**Hospital1 2025**]) and has never had SBP, paracentesis for ascites. She also denies fevers/chills, shortness of breath, confusion, lethargy. The patient underwent EGD on Tuesday with her pediatric GI doctor, who stated there were varices, none actively bleeding or requiring banding. The patient's mother is unsure of the grades of these varices. . With regards to her left upper extremity, the patient noticed "pins and needles" sensation for a week now. Per her mother, she often gets this sensation when she needs a transfusion of platelets. The patient had received 8 units platelets and 1 unit pRBC prior to the EGD, however, given her known bleeding diathesis. The patient state that her LUE became throbbing, with intense pain and became more swollen around her wrist. This made it difficult for her to grasp anything or grip tightly with that hand. She has not tried anything for this pain, has two Fentanyl patches for her abdominal pain. Of note, the patient had a IV placed in the upper part of her left hand last week. . Of note, the etiology of the patient's liver disease remains unclear although is felt possibly due to cholestasis from TPN. She was evaluated at [**Hospital1 2025**] for liver transplant but denied secondary to her low body mass index. Reportedly [**Hospital1 2025**] has also declined transitioning her care from the pediatric GI to adult GI/hepatology care. She was seen in Liver Clinic at [**Hospital1 18**] in [**2177-3-18**] for a second opinion and full work-up revealed weakly positive [**Last Name (un) 15412**] (1:20), elevated IgG >1900, normal ceruloplasmin, elevated alpha-1 antitrypsin. Her first liver biopsy [**9-/2174**] showed portal fibrosis, ceroid laden macrophages, ductular reaction. Repeat biopsy [**5-/2176**] demonstrated cholestatic liver with bridging fibrosis, ductular reaction and again ceroid laden macrophages. . In the ED, initial VS were: pain [**9-27**], T99.2, HR140, BP130/76, RR100% on RA. The patient has a TPN port in place. Labs were notable for mildly elevated LFTs, TBili 12.3, INR 1.4, lipase 142 and mild leukocytosis to 12.8 without bands. Blood and urine cultures were sent. CT head was normal. RUQ ultrasound with doppler showed small amount of ascites (perihepatic, loculated) and patent vasculature. Guaiac negative with ?small fissure near gluteal cleft. She received Zofran X1 and Fentanyl X2. . On arrival to the MICU, VS were: T99.8, HR111, BP118/68, RR16, O2sat 98% on RA. The patient was resting in bed, appearing chronically ill and somewhat uncomfortable. Mother at bedside. . ROS: Ongoing symptoms of dysphagia, abdominal pain (constant, especially with PO meds), fatigue. Also reports ongoing tendency to bleed, especially of gums/lips, unclear precipitant recently. Otherwise, denies fevers/chills, cough, wheeze, dysuria, Past Medical History: 1. Eosinophilic esophagitis. 2. Chronic pancreatitis diagnosed in [**2172**], with normal ERCP in [**2172**]. 3. TPN dependence since [**77**]/[**2172**]. 4. Cutaneous mastocytosis. 5. Crohn's disease, previously treated with 6-MP, methotrexate, and Humira. 6. GERD diagnosed on barium swallow. 7. Pancytopenia status post bone marrow biopsy and FISH demonstrating hypocellular marrow. 8. Left-sided ovarian cyst. 9. Chronic bleeding disorder of unknown etiology for which the patient requires Amicar 10. Legally blind s/p anoxic brain injury from ?stroke, code when anaphylaxis to Iron infusion ([**Hospital1 2025**]) . Past Surgical History 1. Cholecystectomy in [**2172**]. 2. Appendectomy in [**2172**]. 3. Splenectomy in [**10/2175**] for pancytopenia. 4. Celiac sympathectomy in [**2173**]. 5. Side-to-side feeding jejunostomy in [**2175**]. 6. Left-sided ovarian cyst removal in [**2171**]. 7. ERCP x2 in [**2172**]. Social History: Lives at home with her mother. Denies alcohol, tobacco or illicit drugs. Resides in [**Location (un) 3320**], MA. Mother is primary means of support. Aunt also supportive. The patient at baseline goes out, shops, does yoga and has a fair appetite despite multiple serious drug allergies. Family History: No family history of liver disease or liver cancer. Family history notable for coronary disease and breast, colon cancers. Physical Exam: Admission Exam: VS: Temp: 99.8 BP: 127/76 HR: 140 -->120 RR: 18 O2sat 99% on RA GEN: Pleasant, mildly uncomfortable, NAD, chronically ill-appearing, jaundiced HEENT: PERRL, EOMI, icteric sclera, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy RESP: CTA b/l with good air movement throughout, no wheezing/rhonchi/rales CV: Tachycardic, regular rhythm, S1 and S2 wnl, no murmurs/gallops/rubs ABD: Nondistended, surgical incision sites c/d/i - well healed, soft, TTP in R/LUQ, no masses EXT: No cyanosis/ecchymosis; palpable edema in dorsal region of left wrist without skin changes/erythema, purulence, skin breakdown - mild TTP. No palpable axillary cords. SKIN: Jaundiced, no rashes/lesions, warm NEURO: AAOx3. Cn II-XII intact. Strength and sensation grossly intact throughout. RECTAL: Reportedly guaiac neg from below (in ED), no hemorrhoids, small palpable anal fissue (deep, 12 o'clock below gluteal cleft) Pertinent Results: Admission Labs: [**2177-6-13**] 06:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2177-6-13**] 06:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-0.2 PH-6.5 LEUK-TR [**2177-6-13**] 06:15AM URINE RBC-<1 WBC-3 BACTERIA-NONE YEAST-NONE EPI-<1 TRANS EPI-<1 [**2177-6-13**] 06:10AM LACTATE-0.7 [**2177-6-13**] 06:00AM GLUCOSE-85 UREA N-8 CREAT-0.4 SODIUM-137 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-12 [**2177-6-13**] 06:00AM ALT(SGPT)-135* AST(SGOT)-183* ALK PHOS-240* TOT BILI-12.3* [**2177-6-13**] 06:00AM LIPASE-142* [**2177-6-13**] 06:00AM ALBUMIN-3.2* CALCIUM-8.7 PHOSPHATE-3.4 MAGNESIUM-1.9 [**2177-6-13**] 06:00AM WBC-12.8* RBC-3.34* HGB-9.1* HCT-29.9* MCV-90 MCH-27.2 MCHC-30.4* RDW-15.8* [**2177-6-13**] 06:00AM NEUTS-67 BANDS-0 LYMPHS-13* MONOS-9 EOS-9* BASOS-1 ATYPS-1* METAS-0 MYELOS-0 . Discharge Labs: [**2177-6-14**] 06:11AM BLOOD WBC-11.6* RBC-3.17* Hgb-8.9* Hct-29.0* MCV-91 MCH-28.1 MCHC-30.7* RDW-16.0* Plt Ct-417 [**2177-6-14**] 06:11AM BLOOD Neuts-44* Bands-0 Lymphs-34 Monos-13* Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-1* [**2177-6-14**] 06:11AM BLOOD PT-17.5* PTT-38.2* INR(PT)-1.6* [**2177-6-14**] 06:11AM BLOOD Glucose-102* UreaN-11 Creat-0.4 Na-137 K-4.3 Cl-103 HCO3-27 AnGap-11 [**2177-6-14**] 06:11AM BLOOD ALT-125* AST-160* AlkPhos-218* TotBili-11.0* . EKG: Sinus tachycardia, HR 134, normal axis, normal intervals, QTc 419, no ST elevations or T wave inversions. . Imaging: CT head without contrast: No acute intracranial process. If there is continued concern for embolic event, further evaluation with MRI is recommended. . RUQ ultrasound: 1. No intrahepatic biliary dilation. The common bile duct was not seen. 2. Small amount of perihepatic ascites which demonstrates a loculated appearance near the inferior tip of the liver. Superimposed infection or hematoma cannot be excluded. 3. Patent main portal vein. . L Wrist X-Ray: There is no acute fracture. The alignment is maintained. There is generalized demineralization. There is no aggressive bone lesion or periostitis. . L UE ultrasound: 1. No DVT in the left arm. 2. No fluid collection is seen at the left wrist. . . Brief Hospital Course: The patient is a 21 year-old woman with eosinophilic esophagitis, chronic pancreatitis, on TPN and now with end-stage liver disease, cutaneous mastocytosis, Crohn's disease, GERD, legal blindness s/p anoxic brain injury who presents with worsening abdominal pain and LUE numbness/swelling. . # Left wrist/hand pain: Focal area of swelling on dorsum of the wrist with limited range of motion secondary to pain. No history of recent trauma, though she did have recent PIV placed in area of swelling. X-ray negative for fracture, but demonstrated generalized demineralization. LUE duplex without evidence of DVT. Patient was evaluated by Plastic surgery service, who felt that patient's symptoms were secondary to extensor tendinitis vs. arthritic process. Her wrist was placed in a splint, and she was instructed to follow-up in Hand Clinic on [**2177-6-24**]. The patient's pain was initially controlled with Fentanyl 25-50 mcg PRN in the ICU. On the floor, the patient refused all narcotic medications other than demerol. After explaining the risks of this medication, she was given 15.5 mg X 2 with good control of pain. Lidocaine patch was placed over wrist. . # Abdominal pain: Patient with baseline chronic abdominal pain for which she uses fentanyl pathc. TBili stable from [**2177-5-27**] in OMR, mildly elevated from [**2177-3-4**] OSH labs (TBili 10.3 then). RUQ ultrasound without new thrombi or worsening ascites. The patient's pain was controlled with fentanyl in the ICU, and later demerol on the floor (after speaking with pain service). At discharge, he abdominal pain was well controlled. . # End-stage liver disease: Presumably from cholestasis of TPN, although eosinophilic infiltration may be contributing. Has been complicated by encephalopathy and varices in the past, no variceal bleeding or significant ascites/SBP. MELD on admission was 20. Long term goal involves weaning off TPN with transition to full PO diet. Without this transition, patient is not a good transplant candidate. . # Eosinophilic esophagitis: Stable. Continued TPN (with Carnitine, Vitamin K, Pepcid). . # Chronic bleeding disorder: Etiology unclear. Continued Amikar 1000mg four times daily. . # Chronic pancreatitis: Diagnosed in [**2172**], normal ERCP then. On chronic TPN for this, with associated liver complications. Continued Zofran 8mg IV TID and Creon. . # Cutaneous mastocytosis: Stable. Continued Singulair 20mg qHS and Advair (therapeutic exchange) for home Symbicort. . # Crohn's disease: Currently stable, although with chronically loose stools. Continued Pentasa 2500mg [**Hospital1 **] and Carafate 1 gram TID. . # GERD: Stable. Continued Nexium IV and Pepcid in TPN. . Medications on Admission: * Nexium 40mg [**Hospital1 **] * Zofran 8mg TID * Fentanyl patch 100 mcg X2, changed daily, alternating days * Pentasa 2500mg [**Hospital1 **] * Singulair 20mg qHS * Amicar 1000mg over 1 hour QID * Zenpep DR 15,000 TID * Spironolactone 100mg daily * Carafate 1gm.10mL TID * Symbicort 160mcg 1 puff daily * Desmopressin 1.5mg/mL 1 spray PRN bleeding * Albuterol 90 mcg PRN * TPN over 14 hours, Pepcid 40mg, Vitamin K 10mg, vitamins, Carnitine 1 gram included) Discharge Medications: 1. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal EVERY OTHER DAY (Every Other Day): alternating days. 2. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal EVERY OTHER DAY (Every Other Day): alternating days. 3. Pentasa 500 mg Capsule, Extended Release Sig: Five (5) Capsule, Extended Release PO twice a day. 4. Singulair 10 mg Tablet Sig: Two (2) Tablet PO at bedtime. 5. aminocaproic acid 250 mg/mL Solution Sig: 1000 (1000) mg Intravenous QID (4 times a day) for ASDIR doses: Take as directed by your hematologist. 6. Zenpep 15,000-51,000 -82,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO three times a day. 7. Nexium IV 40 mg Recon Soln Sig: One (1) infusion Intravenous twice a day. 8. ondansetron HCl 2 mg/mL Solution Sig: Eight (8) mg Intravenous every eight (8) hours as needed for nausea. 9. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a day. 10. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation once a day. 12. desmopressin Nasal 13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for sob/wheeze. 14. TPN Per outpatient instructions 15. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for wrist pain. Disp:*10 Adhesive Patch, Medicated(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Centrus Home Care Discharge Diagnosis: Primary Diagnosis: - Extensor tendonitis, left wrist - End-Stage Liver Disease - Chronic Pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 89962**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with abdominal pain and swelling in your wrist. The swelling in your wrist was evaluated by the plastic surgeons. Thry believe your symptoms are likely due to inflammation of some tendons in your wrist. You will follow-up with them in a few weeks time. . MEDICATION CHANGES: START: Lidocaine patch to wrist as needed for pain 12hrs on 12hrs off. . Please continue all your medications as they have been prescribed. Should you experience any symptoms that concern you after leaving the hospital, please call you doctor or return to the emergency room. Followup Instructions: Please follow-up in Hand Clinic on Tuesday, [**6-24**]. Please call ([**Telephone/Fax (1) 32269**] after [**Hospital1 107**] Day to confirm your time. . Please arrange your follow-up appointment with Dr. [**Last Name (STitle) 497**] by calling his office after [**Hospital1 107**] Day. . Department: TRANSPLANT SOCIAL WORK When: WEDNESDAY [**2177-6-18**] at 11:00 AM With: TRANSPLANT SOCIAL WORKER [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2177-7-16**] at 4:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], 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: MEDICAL SPECIALTIES When: WEDNESDAY [**2177-7-23**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "555.9", "571.6", "727.05", "530.13", "577.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13594, 13642

8871, 11553

427, 433

13788, 13788

6648, 6648

14646, 15895

5550, 5676

12063, 13571

13663, 13663

11579, 12040

13939, 14326

7557, 8848

5691, 6629

14346, 14623

354, 389

461, 4264

6664, 7541

13682, 13767

13803, 13915

4286, 5228

5244, 5534

40,213

143,496

28690

Discharge summary

report

Admission Date: [**2125-5-1**] Discharge Date: [**2125-5-7**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2009**] Chief Complaint: Altered mental status, weakness, incontinence Major Surgical or Invasive Procedure: None History of Present Illness: This is a [**Age over 90 **] year old woman with past medical history of aortic stenosis, mitral regurgitation, and chronic cough who presented with weakness, stool incontinence, confusion, and questionable respiratory symptoms. On the morning of admission the patient apparently had diarrhea in her bed and was unable to recognize a regular visitor. Apparently, these were both acute developments as she is rarely confused and does not have incontinence at baseline. She was also having some increased secretions and cough per her daughter (the patient minimizes this). No fevers or chills, chest pain, shortness of breath, lower extremity edema, orthopnea, or PND per the patient's report in retrospect. When her daughter came to see her later in the day on the day of admission she noted she was quite weak and unable to walk without assistance, which is not her baseline, though she does note her mother has been weaker and less mobile recently secondary to her spinal stenosis. Upon noting he decreased ability to ambulate her daughter became quite concerned and the patient was brought to the [**Hospital3 **] Emergency Department for further evaluation. In the [**Hospital1 18**] Emergency Department VS: 98.7, 116/70, HR 102, RR 16, 100% 2L NC. Her chest radiograph was without pneumonia and UA was without signs of infection. Given the patient's confusion remained unchanged she was admitted to medicine after receiving a liter of IV fluids. On the floor, the patient denied any major complaints and seemed much closer to her baseline mental status. Past Medical History: - Hypertension - Osteoporosis - Aortic Stenosis / mitral regurgitation - Chronic cough - Spinal stenosis - Left breast hamartoma - History of falls Social History: Former teacher of languages and quite active at baseline. Independent for ADL's and ambulates with walker. No smoking since the [**2065**]'s. No alcohol. Family History: Non-contributory Physical Exam: On Admission: VS: 98.6 BP 139/86 HR 86 RR 20 94% RA GENERAL: Well appearing elderly woman, appears much younger than stated age, in no distress. Hard of hearing. HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD. CARDIAC: RR. Normal S1, S2. II/VI systolic crescendo murmur at RUSB LUNGS: Mild rhonchi throughout, clears with cough ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: 2+ pitting edema of lower extremities, 2+ dorsalis pedis/ posterior tibial pulses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**12-29**]+ reflexes, equal BL. Gait assessment deferred Pertinent Results: LABORATORY RESULTS ===================== On Presentation: WBC-7.7 RBC-4.12* Hgb-12.5 Hct-36.0 MCV-87 RDW-14.2 Plt Ct-212 ---Neuts-69.9 Lymphs-23.6 Monos-5.9 Eos-0.2 Baso-0.3 Glucose-116* UreaN-34* Creat-1.3* Na-136 K-3.1* Cl-95* HCO3-32 On Discharge WBC-7.0 RBC-3.98* Hgb-11.9* Hct-35.3* MCV-89 RDW-14.0 Plt Ct-217 Glucose-101 UreaN-15 Creat-0.7 Na-140 K-3.8 Cl-102 HCO3-27 Cardiac Enzymes: [**2125-5-1**] 04:55AM CK(CPK)-224* CK-MB-7 cTropnT-0.02* [**2125-5-1**] 10:59AM CK(CPK)-250* CK-MB-7 cTropnT-0.25* [**2125-5-1**] 05:26PM CK(CPK)-269* CK-MB-10 MB Indx-3.7 cTropnT-0.52* [**2125-5-1**] 10:56PM CK(CPK)-285* CK-MB-12* MB Indx-4.2 cTropnT-0.33* [**2125-5-2**] 03:45AM CK(CPK)-273* cTropnT-0.29* Urinalysis: Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004 Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RBC-5* WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 Microbiology ============= Blood Cultures *4 are NGTD Legionella urinary antigen negative Urine culture *2 finalized as negative for growth. OTHER RESULTS ============== Chest Radiograph [**2125-4-30**]: IMPRESSION: No pneumonia. ECG [**2125-5-1**]: Sinus rhythm. Consider prior anterior myocardial infarction. Compared to the previous tracing of [**2124-8-23**] atrial ectopy is no longer recorded. There is diffuse non-specific ST-T wave flattening with a decrease in the limb lead voltage. Otherwise, no diagnostic interim change. CXR [**2125-5-1**]: FINDINGS: In comparison with the study of [**4-30**], there is continued enlargement of the cardiac silhouette. Ectasia of the aorta persists. Generalized prominence of interstitial markings could reflect elevated pulmonary venous pressure, chronic lung disease, or both. No acute focal pneumonia. Echocardiogram [**2125-5-1**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The ascending aorta is mildly dilated. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2123-2-2**], no major change is evident. ECG [**2125-5-2**]: Normal sinus rhythm. Deep T wave inversions in the inferolateral leads. Left ventricular hypertrophy. Compared to the previous tracing sinus tachycardia has resolved. T wave inversions are more marked. R wave progression is improved. Chest Radiograph [**2125-5-3**]: IMPRESSION: Bibasilar airspace opacities which may be attributed to atelectasis versus aspiration pneumonia in the proper clinical setting. Clinical correlation is recommended. Brief Hospital Course: [**Age over 90 **] year old woman with history of hypertension, moderate aortic stenosis, and mitral regurgitation presenting with cough, increased secretions, weakness, and stool incontinence presumed due to viral syndrome with course complicated by pulmonary edema and respiratory distress requiring ICU stay. 1)Viral bronchitis: The patient denied dyspnea on presentation and numerous attempts were made to seek out a frank pulmonary bacterial infection given accounts of cough and then respiratory decompensation. Chest radiograph was never read as consistent with pneumonia until possibly on [**2125-5-3**] but by that point patient had been afebrile and improving and there was no reason to suspect aspiration or infection. It is possible the patient had a viral bronchitis precipitating her initial symptoms but this is nearly impossible to prove. 2)Acute vs Acute on Chronic Diastolic Heart Failure: On the morning of [**2125-5-1**] the patient developed fairly acute shortness of breath consistent with flash pulmonary edema. The exact etiology of this acute decompensation of presumed diastolic failure is unknown. This did occur in the context of rising cardiac enyzmes but as inter NSTEMI echo was within normal limits it seems unlikely that area infarcted was large enough to cause significant pump dysfunction. It seems more likely that the fluid the patient had received overnight and and element of hypertension in the context of AS precipitated acute volume overload in the LV and pulmonary edema. The patient responded well to diuresis with furosemide and creatinine remained stable. She was euvolemic on the floor and prior to discharge was restarted on her home triamterene with no signs of fluid overload. Her diltiazem dose was increased to 240mg PO daily. Echocardiogram obtained during enzyme elevation showed preserved, normal EF. 3) NSTEMI/CAD: Cardiology was alerted during enzyme rise, but as the patient was elderly and has other comorbidities as well as the fact this occurred in the context of tachycardia and likely represented demand infarction they chose to pursue medical management. Enzymes peaked quickly and resolved with minimal overall rise (troponin peak 0.52, CK 285). The patient never had chest pain and echocardiogram during enzyme elevation (probably after actual infarction event) revealed stable cardiac ejection. The patient was continued on her statin and aspirin throughout hospitalization. Prior to discharge her calcium channel blocker was increased in dose. 4)Confusion: Exact etiology of the patient's confusion remains unclear. On the day of presentation it does seem she was dehydrated and the intial presumption that dehydration from a viral infection and diarrhea caused delirium is not unreasonable. This confusion persisted throughout first few hospital days with repeated disruptions including flash pulmonary edema followed by unit transfer and probable ICU psychosis on [**2125-5-3**]. Whereas previous episodes had been associated with simple confusion on [**2125-5-3**] the patient became quite agitated and combative requiring 1.5 mg haloperidol IV and then 5 mg olanzapine in order to control her behavior. These multiple incidents of interim confusion and agitation/delirium in the hospital were most likely multifactorial and related to toxic-metabolic insults as well as confusing environment. After receiving the haloperidol/olanzapine the patient reported sleeping well and thereafter she never had severe delirium and her family believed she was near her mental status baseline. Her mental status wax and wanes between A & O x3 versus A & O x1. 5)Hypertension: The patient was marginally hypotensive in the ED so her home calcium channel blocker and diuretic were held. These were restarted without incident prior to discharge and her calcium channel blocker was increased in dose. 6)Osteoporosis: She was continued on calcium and vitamin D throughout her hospitalization. 7)PPx: She received SC heparin for DVT prophylaxis. No GI prophylaxis was indicated. The patient tolerated a full diet prior to discharge. Due to deconditioning she was discharged to rehabilitation for intensive PT and strengthening. She was DNR but not DNI per discussion with her primary cardiologist. Medications on Admission: - Diltiazem 180mg daily - Aspirin 81mg daily - Simvastatin 20mg daily - Triamterene 50mg daily - Calcium daily (unknown dose) - Vitamin C (unknown dose) - Vitamin E (unknown dose) - Multivitamin daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Triamterene 50 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Vitamin E 200 unit Tablet Sig: One (1) Tablet PO once a day. 7. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 8. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnoses: Acute vs Acute on Chronic Diastolic Heart Failure Non-ST elevation myocardial infarction Viral syndrome Deconditioning Secondary Diagnoses Atrial Stenosis Mitral Regurgitation Hypertension Osteoporosis Discharge Condition: Good, stable oxygen saturation on room air, afebrile. Mental status can range from A & O x1 to A & O x3. Discharge Instructions: You were admitted to the hospital because you seemed weaker than usual and your daughter and others were concerned about your confusion and increased cough. It is unclear what precipitated this though we suspect you may have had a viral infection that caused lung and GI symptoms and may have led you to get a bit dehydrated. Unfortunately, as you were receiving fluids your heart became unable to handle it and you had fluid back up in your lungs. This made you very short of breath so you had to go to the intensive care unit. This was also a large stress on your heart that caused some damage to the heart muscle. This is what is called a heart attack. You received medicines to help get rid of fluid and these helped improve your breathing. You also had an echocardiogram to assess how your heart was pumping after the damage to the heart muscle cells and this showed your heart as a whole was working as well as it had been previously. . We did numerous tests to look for the cause of your pulmonary symptoms but our imaging studies never showed a pneumonia. Probably, you had a viral infection that caused your increased cough and sputum. . Finally, you were noted to be very weak in the hospital. Therefore, you are being discharged to a rehabilitation facility to help regain your strength before going home. . Your diltiazem was increased in dose to 240mg daily. Your medications have otherwise not been changed. Please continue to take all your other medications as previously prescribed. . Please call your doctor or come in to your local ED if you have chest pain, shortness of breath, fevers, chills, night sweats, severe abdominal pain, or any other concerning changes in your health. Followup Instructions: Please call to set up an appointment to see Dr [**Last Name (STitle) 5351**] 1-2 weeks after being discharged from the rehabilitation facility. Her office can be reached at [**Telephone/Fax (1) 608**]. . Please keep your previously scheduled appointment with Dr. [**Last Name (STitle) 911**] on [**2125-9-27**] at 1:40 PM. His office can be reached at [**Telephone/Fax (1) 62**]. Completed by:[**2125-5-7**]

[ "401.9", "466.0", "276.8", "348.30", "079.99", "428.33", "786.2", "724.00", "410.71", "424.1", "428.0", "733.00", "276.51", "424.0", "759.6" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11445, 11511

6240, 10520

306, 313

11777, 11885

2978, 3354

13642, 14054

2271, 2289

10771, 11422

11532, 11756

10546, 10748

11909, 13619

2304, 2304

3371, 6217

221, 268

341, 1911

2318, 2959

1933, 2082

2098, 2255

61,920

122,908

8191+55920

Discharge summary

report+addendum

Admission Date: [**2137-3-19**] Discharge Date: [**2137-3-28**] Date of Birth: [**2058-12-10**] Sex: M Service: CARDIOTHORACIC Allergies: Keflex Attending:[**First Name3 (LF) 165**] Chief Complaint: exertional chest pain Major Surgical or Invasive Procedure: [**2137-3-19**]:Emergency coronary artery bypass graft times 3, left internal mammary artery to left anterior ascending artery and saphenous vein grafts to ramus and obtuse marginal arteries. History of Present Illness: 78 year old male with two week history of exertional chest pain. He was seen by PCP who prescribed nitroglycerin and referred him to a cardiologist. He continued to develop substernal chest pain with short walks and awakes him at night time. He was walking and took nitroglycerin that resolved the pain for 15 minutes and then it returned and took an additonal nitroglycerin and aspirin, then called EMS. He was transferred to [**Hospital6 **] emergency room, ruled out at [**Hospital6 **] and underwent cardiac catheterization that revealed significant coronary artery disease, IABP was placed and he was transferred for surgical evaluation. Past Medical History: Myelodysplastic Syndrome (on weekly Procrit inj) Palpitations x 7 yrs Hypothyroidism Prostate Cancer [**2131**] s/p XRT Tongue Ca [**2124**] s/p chemo/XRT GERD Social History: Occupation: retired construction foreman Tobacco: quit 30 years ago ETOH: [**12-23**] glass of wine nightly Family History: Family History: Mother died of bladder cancer Father died of "heart dz" at 69yo Physical Exam: Physical Exam Pulse: Resp: O2 sat: B/P Right: Left: Height: Weight: General: no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] anterior Heart: RRR [x] Irregular [] Murmur none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], Edema none Neuro: Alert and oriented x3 moves all extremities - on bedrest with IABP Pulses: Femoral Right: IABP Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: bruit Left: no bruit Pertinent Results: Admission Labs: [**2137-3-22**] 10:00AM BLOOD Hct-27.3*# [**2137-3-22**] 03:22AM BLOOD WBC-5.3 RBC-2.26* Hgb-7.6* Hct-21.4* MCV-95 MCH-33.4* MCHC-35.3* RDW-24.6* Plt Ct-120* [**2137-3-19**] 06:18PM BLOOD WBC-5.1 RBC-3.11*# Hgb-10.8* Hct-31.6* MCV-101* MCH-34.7* MCHC-34.2 RDW-25.2* Plt Ct-302 [**2137-3-20**] 12:52AM BLOOD PT-13.9* PTT-37.1* INR(PT)-1.2* [**2137-3-19**] 06:18PM BLOOD PT-12.3 PTT-62.0* INR(PT)-1.0 [**2137-3-22**] 03:22AM BLOOD Glucose-118* UreaN-21* Creat-1.0 Na-137 K-4.0 Cl-104 HCO3-29 AnGap-8 [**2137-3-19**] 06:18PM BLOOD Glucose-109* UreaN-15 Creat-0.9 Na-144 K-3.9 Cl-107 HCO3-26 AnGap-15 Discharge Labs: [**2137-3-27**] 08:35AM BLOOD WBC-7.4 RBC-3.59* Hgb-11.5* Hct-34.7* MCV-97 MCH-32.0 MCHC-33.0 RDW-21.6* Plt Ct-401# [**2137-3-27**] 08:35AM BLOOD Plt Ct-401# [**2137-3-27**] 08:35AM BLOOD PT-12.7 INR(PT)-1.1 [**2137-3-27**] 08:35AM BLOOD Glucose-146* UreaN-24* Creat-1.1 Na-140 K-4.4 Cl-100 HCO3-31 AnGap-13 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Diastolic Dimension: 5.4 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% to 50% >= 55% Aorta - Ascending: 3.1 cm <= 3.4 cm Findings LEFT ATRIUM: Normal LA size. No spontaneous echo contrast is seen in the LAA. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Top normal/borderline dilated LV cavity size. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is normal in size. No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. LVEF = 40%. 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic arch. The IABP tip is visible 2 cm below the LSCA. 6. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusion of phenylephrine. A-pacing for slow sinus rhythm. Improved left ventricular systolic function post cpb. LVEF is now 60%. There is improved inferior wall motion. MR remains 1+. AI remains 1+. The aortic contour is normal post decannulation. The IABP remains in good position. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2137-3-19**] 22:40 Radiology Report CHEST (PA & LAT) Study Date of [**2137-3-27**] 4:56 PM Preliminary Report Small left pleural effusion, decreased in size c/w [**3-25**]. s/p CABG. Lungs clear, no ptx. DR. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**] Wet read entered: WED [**2137-3-27**] 6:00 PM Brief Hospital Course: Transferred in from outside hospital with intra aortic balloon pump taken emergently to the operating room and underwent coronary artery bypass graft surgery. See operative report for further details. He was transferred to the intensive care unit for post operative management. In the first twenty four hours his intra aortic balloon pump was weaned and removed. Then he was weaned from sedation, awoke neurologically intact, and was extubated without complications. He was transfused for post operative anemia. He remained in the intensive care unit for hypotension that required neosynephrine, which was weaned off on post operative day three. Physical therapy worked with him on strength and mobility. He was transferred to the floor on post operative day four. He continued to progress but had persisent pleural effusion that was tapped [**3-25**] with no complications. He then had rapid atrial fibrillation the am [**3-26**] that was treated with beta blockers and amiodarone following which he converted to sinus rhythm. the remainder of his post-operative course was uneventful. His was discharged on POD9, he is to follow up with Dr [**First Name (STitle) **] on Monday [**2137-4-15**] 1:30 Medications on Admission: atenolol 25mg daily prilosec 20mg daily synthroid 50mcg daily NTG prn Procrit inj weekly Ibuprofen prn->arthritis Discharge Medications: 1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 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. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 6. epoetin alfa 4,000 unit/mL Solution Sig: 4000 (4000) units Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*30 4000 units/ML* Refills:*1* 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x4 days then 400mg QD x1 week then 200mg QD. Disp:*60 Tablet(s)* Refills:*1* 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass grafting [**2137-3-19**] postop A Fib Secondary: Myelodysplastic Syndrome (on weekly Procrit inj) Palpitations x 7 yrs Hypothyroidism Prostate Cancer [**2131**] s/p XRT Tongue Ca [**2124**] s/p chemo/XRT GERD Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema-none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon:Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:Monday [**2137-4-15**] 1:30 Cardiologist:Dr. [**Hospital1 29116**] Medical will call you with appointment should be scheduled for 3 weeks from discharge Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) 29117**] [**Telephone/Fax (2) 17465**]in 1-2 weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2137-3-28**] Name: [**Known lastname 5090**],[**Known firstname **] Unit No: [**Numeric Identifier 5091**] Admission Date: [**2137-3-19**] Discharge Date: [**2137-3-28**] Date of Birth: [**2058-12-10**] Sex: M Service: CARDIOTHORACIC Allergies: Keflex Attending:[**First Name3 (LF) 265**] Addendum: This patient was discharged with Metoprolol 25 mg TID Previous d/c summmary states both 25 mg TID and 50mg TID Discharge Disposition: Home With Service Facility: [**Location (un) 1082**] VNA [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2137-3-28**]

[ "427.31", "414.01", "V10.46", "511.9", "458.9", "238.75", "V10.01", "997.1", "E849.7", "244.9", "285.9", "E878.2", "530.81" ]

icd9cm

[ [ [] ] ]

[ "39.61", "34.91", "36.15", "36.12" ]

icd9pcs

[ [ [] ] ]

12003, 12182

6718, 7930

296, 490

9759, 9981

2291, 2291

10822, 11980

1509, 1575

8095, 9372

9475, 9738

7956, 8072

10005, 10799

2920, 4744

4787, 6695

1590, 2272

234, 258

518, 1167

2307, 2904

1189, 1351

1367, 1477

16,439

143,493

29119

Discharge summary

report

Admission Date: [**2150-10-21**] Discharge Date: [**2150-11-2**] Date of Birth: [**2092-3-31**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: Slurred speech and left sided weakness Major Surgical or Invasive Procedure: Intraarterial tPA administration Intubation and mechanical ventilation Bronchoscopy History of Present Illness: The pt is a 58 year-old right-handed woman with a history of esophageal cancer who presented with acute onset slurred speech and left sided weakness. The pt was unable to offer a detailed history at the time of my encounter. Therefore, the following history is per EMS and the pt's daughter. Per the pt's daughter, she was just discharged from [**Name (NI) 5871**] Hospital at about 4pm on the day of admission. She had been admitted there since past Thursday for a "rectal infection" and dehydration. Her daughter brought her home and she was initially doing well. At about 1820, per the daughter, she started "mumbling" but seemed to be aware of her surroundings and the fact that she was mumbling. She was seen to have a left facial droop and was not moving her left side. 911 was immediately called and she was brought to [**Hospital1 18**] ED. Code stroke was called at [**2050**] and Neurology was immediately at bedside. NIHSS as follows: 1a. LOC: alert, responsive (0) 1b. LOC questions: knew age and name of month (0) 1c. LOC commands: closed eyes and gripped with right hand (0) 2. Best gaze: Right gaze preference (1) 3. Visual: Complete left hemianopia (did not blink to threat) (2) 4. Facial Palsy: Total paralysis of left lower face (2) 5a. Left arm: No movement (4) 5b. Right arm: no drift (0) 6a. Left leg: Will only move toes, will not lift leg off of bed (?) 6b. Right leg: Will only move toes, will not lift leg off of bed (?) 7. Limb ataxia: absent (on right, unable to test left) (0) 8. Sensory: no sensory loss bilaterally (0) 9. Language: No aphasia (0) 10. Dysarthria: Severe (2) 11. Extinction/inattention: Neglects left side of space (2) Total NIHSS: 13, but pt did not move either leg, so may in fact be higher The pt was unable to offer a review of systems. Past Medical History: -diabetes mellitus -esophageal cancer, status post radiation and chemotherapy. Also had feeding tube until about three weeks ago. -asthma -depression -history of DVT, had been on warfarin until last week per daughter Social History: Pt lives alone in [**Location (un) 1468**] and very much wants to go home. She is willing to go to rehab prior to return home. As pt and I were discussing this, screener from [**Hospital1 **] walked into the room and spoke with pt about rehab. Pt being screened by various facilities. Pt feeling that doctors [**Name5 (PTitle) **]'t understand her strong wish to get home. She is becoming frustrated with long length of stay. Pt has a son and a daughter who live relatively close by but were not in to visit at the time of this conversation. Pt is coping well but her patience is wearing thin. Rehab screens may help things move along for d/c. Will meet with family when they are in to visit with pt. Family History: NC Physical Exam: On admission: NIHSS as follows: 1a. LOC: alert, responsive (0) 1b. LOC questions: knew age and name of month (0) 1c. LOC commands: closed eyes and gripped with right hand (0) 2. Best gaze: Right gaze preference (1) 3. Visual: Complete left hemianopia (did not blink to threat) (2) 4. Facial Palsy: Total paralysis of left lower face (2) 5a. Left arm: No movement (4) 5b. Right arm: no drift (0) 6a. Left leg: Will only move toes, will not lift leg off of bed (?) 6b. Right leg: Will only move toes, will not lift leg off of bed (?) 7. Limb ataxia: absent (on right, unable to test left) (0) 8. Sensory: no sensory loss bilaterally (0) 9. Language: No aphasia (0) 10. Dysarthria: Severe (2) 11. Extinction/inattention: Neglects left side of space (2) Vitals: T: 99F P: 112 R: 16 BP: 135/80 SaO2: 92%RA (up to 97% on FM) General: Lying in bed with eyes open HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: No carotid bruits appreciated. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: Weeping edema of the lower extremities bilaterally Skin: no rashes noted. Neurologic: -Mental Status: Alert. Mildly inattentive to examiner's questions. Language is very difficult to understand due to significant dysarthria. She neglects the left half of space. -Cranial Nerves: Olfaction not tested. PERRL 3 to 2mm and brisk. VFF to confrontation. Right gaze preference. Facial sensation intact to pinprick. Left facial droop in an UMN pattern. Tongue protrudes in midline. -Motor: Normal bulk throughout. Flaccid hemiplegia on the left. No adventitious movements noted. -Sensory: No deficits noxious stimuli throughout. No extinction to DSS. -Coordination: No dysmetria to FNF on R, cannot test L due to weakness. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 0 0 0 0 0 R 1 1 1 1 0 Plantar response was flexor bilaterally. -Gait: Deferred. Pertinent Results: 16> 10.6 <89 31.1 PT: 16.7 PTT: 25.8 INR: 1.5 Fibrinogen: 354 Na:140 K:3.7 Cl:124 TCO2:18 Glu:143 BUN 25 Creat 1.1 Serum and urine tox negative Radiologic Data: CT head: There is no evidence hemorrhage. There appears to be slight loss of insular ribbon on the right, but no obscuration of the basal ganglia on that side. I cannot appreciate a dense artery sign. The ventricles, cisterns, and sulci appear normal. CT angio of the COW & neck: possible tapering of the R MCA just prior to the bifurcation. Heterogeneous area in the right lobe of the thyroid, 7 mm. Recommend further evaluation of the thyroid via ultrasound. EKG [**10-21**]: Sinus rhythm. Old inferior myocardial infarction. Low voltage in the precordial leads. Possible previous anteroseptal myocardial infarction. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 95 124 86 [**Telephone/Fax (2) 70094**] 2 -4 Head CT [**10-22**]: The exam is somewhat limited by motion. Again seen is a rounded focus of hyperdensity in the right basal ganglia consistent with hemorrhage. There is increasing surrounding hypodensity and impression on the right lateral ventricle. There is no hydrocephalus or shift of normally midline structures. Fluid is again noted in the sphenoid sinuses. Osseous structures are unremarkable. IMPRESSION: Stable rounded focus of right basal ganglia hemorrhage. Increasing surrounding hypodensity and mass effect on the right lateral ventricle may represent edema related to the hemorrhage or evolving right MCA infarct. NOTE ADDED AT ATTENDING REVIEW: Although there is considerable motion artifact, there is evolution of the large right MCA infarction since the earlier study of [**2150-10-22**]. There is no evidence of new hemorrhage, but the infarction is largely obscured by artifact, small to moderate amounts of bleeding cannot be excluded [**10-22**] ECHO: 1. The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. 2. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). 3. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. [**10-23**] Abd CT: 1. No evidence of retroperitoneal hematoma. 2. Bilateral pleural effusions and atelectasis. 3. Ascites. 4. Probable small nonobstructive right renal calculi. [**10-23**] MRI/MRA brain: 1. Large right middle cerebral artery infarction with sharp cut-off of the right MCA at its bifurcation. Smaller infarcts in the left parietooccipital watershed region and the left cerebellar hemisphere. The infarctions are of acute/early subacute nature and are likely secondary to a thromboembolic phenomenon. 2. Small hemorrhagic component of the right MCA infarct. 3. Very slow flow in the left vertebral artery. [**10-24**] LUE US: 1) No DVT visualized. 2) Flattening of the left proximal subclavian venous waveform is a nonspecific finding; if there remains high suspicion for venous thrombosis, a CT venogram could be considered to exclude central thrombus. [**10-26**] RUE US: Small linear nonocclusive clot in the left axillary vein. [**10-26**] Head CT: In the interval, there has been an evolution of large MCA infarct, including increasing swelling and edema and compression of the right lateral ventricle. Site of hemorrhagic component of the infarct described on the previous MR has not changed in appearance since the prior study. There are no new sites of hemorrhage identified. There is no hydrocephalus or shift of normally midline structures. Again noted is a fluid in the sphenoid sinus. Osseous structures are unremarkable. IMPRESSION: Evolution of the large right MCA infarction since [**10-22**], including increase in edema and compression of the right lateral ventricle. No evidence of new hemorrhage. [**10-28**] PCXR: Atelectasis is progressed from the left lower lobe and lingula and there to entire left lung, producing severe leftward mediastinal shift, obscuring the entire cardiac contour, accompanied with a complete opacification of the left bronchial tree distal to the main bronchus due to retained secretions. A new focal opacity at the periphery of the right mid lung could be a small amount of pleural fluid in the fissure but should be followed to exclude a new lesion in the one, which would suggest infection or infarction. There is no layering right pleural effusion or any pneumothorax. [**10-29**] PCXR: The left lung has re-expanded with minimal left lower lobe atelectasis persisting. There is blunting of bilateral costophrenic angles consistent with pleural effusions. Hazy opacity is noted anteriorly in the right upper lobe and involving the right lower lobe as well. There is mild volume overload. The aorta is tortuous. The cardiac silhouette is at the upper limits of normal, accounting for patient and technical factors. There is an indwelling right upper extremity PICC line with the distal tip approximately 5 cm proximal to the cavoatrial junction. IMPRESSION: Interval expansion of the left lung post-bronchial washout. There is remnant left lower lobe atelectasis. There is also hazy opacity in the right perihilar and lower lungs as described above which may be confluent edema, aspiration, or multifocal pneumonia. Indwelling PICC line as above. [**11-2**] Head CT: Unchanged per wet read by radiology. Also, reviewed with Stroke attending, showing resolving right basal ganglia hemorrhage. Brief Hospital Course: The pt is a 58 year-old woman with a history of deep vein thromboses and esophageal cancer who presented with acute onset dysarthria, left hemianopia, left facial droop, flaccid hemiplegia on the left (at least in the arm), and left hemineglect. These abnormalities pointed to a lesion of the right frontal, parietal and possibly temporal lobes. Given acute onset, this was thought to most likely represent a stroke in the distribution of the right MCA. Her risk factors for stroke included malignancy, diabetes mellitus, and possible radiation to the neck area which may cause acceleration of arterial atherosclerosis of large arteries. The presence of thrombocytopenia was a contraindication to IV tPA. After lengthy discussion with the pt's son, the decision was made to take the pt to angio for IA tPA which showed After this procedure, she was admitted to the NeuroICU for further care. NEURO: Repeat CT scan 24 hours after event showed an area of bleed in the right basal ganglia. Aspirin and anti-coagulation was held. MRI and MRA brain [**10-23**] showed right middle cerebral, but also left parietooccipital region and left cerebellar infarcts. Carotid ultrasound not necessary as she had a neck CTA showed a kink in the right cervical ICA without evidence of stenosis or occlusion. Bilateral vertebral arteries were also normal in caliber and patent including the origins. Patient was resumed on Aggrenox on [**10-28**] without complication and then on [**11-2**] was swtiched to Lovenox. At time of discharge, head CT was stable without new bleed and showing resolving right basal ganglia hemorrhage. Given stable head CT, patient may start Lovenox as above. CV: Surface cardiac ECHO on [**10-22**] showed an EF>65% and no PFO, ASD, thrombus. Blood pressure control with IV labatelol prn SBP > 180mmHg (goal SBP 140-180mmHg). Chol 130 and LDL 71. LFTs were within normal limits and patient was started on atorvastatin 10mg QD. HEME: Patient had a history of FV Leiden heterozygote, history of esophageal cancer, history of DVT bilateral upper extremities and labile INRs while on coumadin secondary to nutritional status and poor compliance. Hematology/Oncology were consulted regarding appropriate anticoagulation in this setting and recommended Lovenox given malignancy. Given initial basal ganglia bleed, aspirin and warfarin were held. Aggrenox was started on [**10-28**] given stable serial head CTs. HIT antibody was sent and was negative. Of note, patient was transiently thrombocytopenic which was thought to be idiopathic thrombocytopenic purpura and started on prednisone 20mg QD. She will require a slow taper off steroids. Patient should continue on Aggrenox until [**11-6**]. She should then start Lovenox as long term form of anti-coagulation. PULM: Patient was reintubated for respiratory distress on [**10-21**] extubated [**10-25**]. [**10-27**] CXR showed collapsed left lung. Pulmonology was consulted and she was started on standing albuterol/atrovent nebs q6H, chest PT TID and CPAP @8mm Hg overnight keeping sats>92%. A bronchoscopy was performed on [**10-28**] showing complete collapse of left lung/pna. A cleanout was performed and BAL fluid was gram stain neg and culture showed oropharyngeal fluid. Empiric antibiotics were discontinued after 72 hours of negative culture growth. Serial chest x-ray were performed which showed reinflation of the left lung. ID: Patient had a history of coagulase negative staph "sepsis" @OSH on ciprofloxacin since prior to the admission to [**Hospital1 18**]. Ciprofloxacin was discontinued on [**10-27**] since PICC line was pulled and surveillance cultures from [**10-22**] and [**10-24**] had only one bottle positive for coag neg staph which was likely contamination. Curbsided ID who concurred with this decision. Patient was started on vanco [**10-27**] for possible left-sided pneumonia however it was discontinued after negative growth on bronchial fluid culture. ONC: Spoke with Dr. [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 25442**] ([**Telephone/Fax (1) 70095**] outpatient oncologist who reported that esophageal cancer status post chemotherapy and radiation therapy, NO SURGERY. Last chest CT was in [**8-12**] which showed no lymphadenopathy and [**9-11**] visit notes noted patient to be in remission. GU: Creatinine ranged from 1.1 to 1.4. Good urine output. END: Will need f/u imaging of thyroid glands given nodule seen on CTA of neck. HbA1c 7.2. FS QID and Regular insulin sliding scale. FEN: Speech and swallow recommended ground solids, thin liquids, crush meds in purees, asp precaut, 1:1 assist, alternate sips/bites. Patient refused NGT/PEG. PPX: wound care, PPI, BM meds, pneumoboots CODE: DNR/DNI COMMUNICATION: HCP [**Name (NI) **] [**Name (NI) **] [**Known lastname 70096**] Work [**Numeric Identifier 70097**] or [**Telephone/Fax (1) 70098**]; Daughter [**Name (NI) 3742**] [**Telephone/Fax (1) 70098**], [**Name2 (NI) **]/oncologist at [**Hospital3 1443**]: [**Location (un) **], but he is moving and will be unreachable Resident at LMH: [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 25442**] ([**Telephone/Fax (1) 70095**] PCP: [**Name10 (NameIs) **] [**Name11 (NameIs) **] [**Telephone/Fax (1) 27093**] Medications on Admission: -ritalin 5mg po qam -prednisone 10mg po daily -bactrim DS 1tab po bid (?) -magnesium oxide 1tab po tid -remeron 15mg po qhs -tums 500mg 1 tab po qacs Discharge Medications: 1. Acetaminophen 650 mg Suppository [**Telephone/Fax (1) **]: One (1) Suppository Rectal Q4-6H (every 4 to 6 hours) as needed for fever or pain. 2. Insulin Regular Human 100 unit/mL Solution [**Telephone/Fax (1) **]: PER SLIDING SCALE UNITS Injection ASDIR (AS DIRECTED). 3. Atorvastatin 10 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). 4. Miconazole Nitrate 2 % Powder [**Telephone/Fax (1) **]: One (1) Appl Topical QID (4 times a day). 5. Prednisone 20 mg Tablet [**Telephone/Fax (1) **]: 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. Docusate Sodium 60 mg/15 mL Syrup [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day). 8. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. Fentanyl 25 mcg/hr Patch 72HR [**Last Name (STitle) **]: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 10. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Neb Inhalation Q6H (every 6 hours). 11. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) Neb Inhalation Q6H (every 6 hours). 12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]: One (1) Adhesive Patch, Medicated Topical QD (): Please apply 1 patch to area for 12 hours then remove. [**Month (only) 116**] apply a patch every 24 hours. Do not apply to open skin lesion. 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month (only) **]: Two (2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. . 14. Aspirin 81 mg Tablet [**Month (only) **]: One (1) Tablet PO once a day. 15. Dipyridamole 50 mg Tablet [**Month (only) **]: Four (4) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary diagnosis: Right middle cerebral artery stroke with small hemorrhage Reinflated collapsed left lung status post bronchoscopy Secondary diagnosis: H/o deep vein thrombosis on warfarin (h/o noncompliance) Esophageal cancer, status post radiation and chemotherapy Diabetes mellitus H/o feeding tube (approx three weeks ago) Asthma Depression Discharge Condition: Neurologically stable. Left-sided weakness leg>arm. Slight left neglect. Oriented x3 person, place and year. Discharge Instructions: Please take medications as prescribed. You have been started on Aggrenox (ASA81/Dipyridamole) which should be DISCONTINUED on [**2150-11-6**]. Lovenox 100mg SC Q12H should be started on [**2150-11-6**] and continued as anti-coagulation. Please check head CT if neurologic exam or mental status changes. Please keep your follow-up appointments. If you have any worsening weakness, fevers/chills, severe headache, change in mental status or any other worrying symptoms, please call your primary care physician or return to the emergency room. Followup Instructions: PROVIDER: [**First Name8 (NamePattern2) 4267**] [**Name11 (NameIs) **], MD PHONE: [**Telephone/Fax (1) 657**] DATE/TIME: [**2150-12-9**] 1:00PM PROVIDER: [**Name10 (NameIs) **] [**Name11 (NameIs) 27092**], MD PHONE: [**Telephone/Fax (1) 27093**] DATE/TIME: [**2150-12-3**] 1:30PM [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2150-11-2**]

[ "276.2", "784.5", "V10.03", "250.00", "368.46", "311", "V12.51", "342.00", "722.52", "434.91", "493.90", "518.82", "518.0", "289.81", "707.03", "401.9", "287.5" ]

icd9cm

[ [ [] ] ]

[ "99.10", "38.93", "33.24", "96.72", "96.07", "38.91", "96.6", "99.04", "96.04" ]

icd9pcs

[ [ [] ] ]

18516, 18586

11046, 16339

356, 442

18978, 19089

5337, 5509

19683, 20110

3252, 3256

16539, 18493

18607, 18607

16365, 16516

19113, 19660

4706, 5318

3271, 3271

278, 318

470, 2270

5518, 8719

18762, 18957

10896, 11023

18626, 18741

3286, 4511

4526, 4689

2292, 2511

2527, 3236

24,295

139,432

29616+57648

Discharge summary

report+addendum

Admission Date: [**2152-12-17**] Discharge Date: [**2153-1-2**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: Found down Major Surgical or Invasive Procedure: G-PEG placement History of Present Illness: This is an 89yo man with PMH significant for HTN, MDS, and gastric ulcers, who was transferred from an OSH for ICH after being found down. He was last well on the [**Name (NI) 2974**] PTA. His neighbors and son had not heard from him by [**Name (NI) 1017**], [**First Name3 (LF) **] the neighbors went into his apartment and found him on the ground. He said he tripped and fell. He was brought to an OSH. There, he was reportedly alert and oriented when he presented. His blood pressure was 217/89 on arrival at 3:44pm. He was able to tell his neighbor that he fell when he was just about to start cooking (and, in fact, he was found with a burner on). He was taken for head CT, which showed a large intraparenchymal bleed with biventricular extension. While returning from the CT, he had interval worsening of mental status and stopped speaking. He was intubated, despite what appears to be fairly clear notes documenting that he was DNR in accordance with prior wishes expressed to his family. He was loaded with dilantin (and given etomidate and succ for the intubation). He was transferred to [**Hospital1 18**] for neurosurgical evaluation. He was seen by neurosurgery, who did not feel he was a surgical candidate. His son, living in [**Name (NI) 6257**], was called and expressed that the patient would have wished to be made comfortable, but that he would preferably be kept alive until the son was able to come from [**Name (NI) 6257**]. Past Medical History: HTN MDS gastric ulcers Social History: Lives alone at his home. At baseline he was functioning independently. Son in [**Name2 (NI) 6257**]. Son is [**Name (NI) **] [**Name (NI) 70991**] Jr, phone number in [**Country 6257**] is 351-[**Medical Record Number 70992**]-67 (can be called through dialing assistance). Son staying with friends in [**Name (NI) 86**] area: [**Doctor First Name **] and [**Name (NI) **] [**Last Name (NamePattern1) 43417**]. Can be reached at [**Initials (NamePattern4) 70993**] [**Last Name (NamePattern4) 70994**]# [**Telephone/Fax (1) 70995**] or at their home [**Telephone/Fax (1) 70996**]. Can also reach via [**Doctor First Name 70997**] office [**Telephone/Fax (1) 70998**]. Family History: Not contributory. Physical Exam: VS: T 101.4, HR 79, BP 152/62 on arrival, then 123/50 (briefly fell to SBP of 80s, requiring some IVF to return to 110s-130s), RR 16, SaO2 100%/ventilator Genl: intubated, not yet sedated HEENT: ETT in place, NGT in place CV: RRR, nl S1, S2 Chest: CTA w/ vented breath sounds Abd: soft, NTND Ext: warm & dry, lacerations on R leg Neurologic examination: Mental status: grimaces and withdraws to stim, does not open eyes or follow any commands (not on sedation) Cranial nerves: pupils equal and reactive, 2->1mm bilaterally, no corneal reflex but significant film in eyes, no clear facial asymmetry but ETT in place, +gag. Motor: withdraws RUE, RLE > LUE > LLE to stimulus Sensory: withdraws to noxious in all extremities DTRs: trace throughout, R toe down, L toe equivocal Pertinent Results: ABG 7.27/44/416/26 lactate 1.5 serum and urine tox negative U/A - +blood, few bact, 0 WBC Chem: Na 140, K 3.8, Cl 103, CO2 25, BUN 42, Cr 1.4, gluc 179, Ca 8.4, Mg 2.5, P 5.7 CK 1899 (from [**2110**] at OSH), MB 14, trop 0.06 ALT 38, AST 81, AP 65, [**Doctor First Name **] 190, lip 16, TB 0.7, alb 3.8 WBC 13.6, Hct 36.1, plts 55 PTT 26.2, INR 1.2 Head CT from OSH: Approx 3cmx3cmx4cm ICH in anterior internal capsule on R, extending to the L and into the ventricles bilaterally. +tight L basilar cistern and ?beginning of tentorial herniation. Head CT ([**12-16**]): Intraparenchymal hemorrhage centered in the right caudate nucleus head, possibly hypertensive in etiology. Hemorrhage extends into both lateral ventricles. The septum pellucidum is displaced 11 mm leftward. CXR from OSH: +cardiomegaly, no clear PNA CXR (admission): ETT in place, lungs clear ECG (admission): Baseline artifact. Sinus rhythm. Atrial premature complexes. Modest nonspecific low amplitude lateral T wave changes. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 85 168 94 [**Telephone/Fax (2) 70999**] 45 C-, T-, L-spine CT: 1. No acute cervical/thoracic/lumbar spine fracture or malalignment. 2. Degenerative changes of the lower cervical spine, greatest at C5/6, Lumbar spines. 3. Atherosclerotic calcifications of the carotid arteries. . [**12-27**] LENI: Age-indeterminate nonocclusive thrombus in the mid to distal right superficial femoral vein. . Chest CT :IMPRESSION: 1. No areas of consolidation to suggest pneumonia. 2. Asymmetrical enlargement of left vocal cord, for which further evaluation with direct visualization is recommended as communicated by telephone to Dr. [**Last Name (STitle) **] on [**2152-12-27**]. 3. Small left and trace right pleural effusion with adjacent dependent areas of atelectasis. 4. Distension of intrathoracic esophagus concerning for esophageal dysmotility. 5. Tracheobronchomalacia. Once the patient's condition has been stabilized, this could be more fully assessed with a dedicated CT trachea study if warranted clinically. 6. Coronary artery calcifications. 7. 4 cm right renal lesion, probably a cyst, but difficult to fully characterize. Ultrasound may be helpful, if warranted clinically. Brief Hospital Course: This is an 89yo man with large IPH and IVH s/p fall, transferred intubated from OSH. On admission, his exam showed a L hemiparesis. The following issues were addressed during his hospitalization: 1. Right basal ganglia hemorrhage: His history, examination and Head CT findings suggest hypertensive basal ganglia hemorrhage as his pathogenesis. His hemorrhage has been stable over the course of his hospitalization, confirmed by serial neurological examinations and serial head CTs. The latest CT on [**12-23**] showed slight decrease in the size of hemorrhage and midline shift. Neurosurgery was consulted and no surgical intervention was indicated. No hydrocephalus developed, though there was an intraventricular extent of hemorrhage. Upon admission the patient was administered Mannitol 25mg iv q6h and SBP was controlled <160mmHg and MAP<130mmHg. He was successfully extubated on [**2152-12-18**] and transferred out of the neuro ICU. His neurological examination showed progressive wakefullnes and attention. His examination showed some expressive language abilities. He was able to follow simple commands. Motor function showed bilateral antigravity movement. Right side showed full strength and purposeful movement. His c-spine was cleared with repeated C-spine CT (no fractures) and examination. . 2. Respiratory status: The patient arrived to [**Hospital1 18**] intubated. He was successfully extubated on [**2152-12-18**]. After extubation, he gradually developed stridor, upper airway congestion and increased work of breathing. He was transferred to the medicine service. A chest CT showed supraglottic asymetric (L>R) edema and tracheobronchomalacia. ENT was consulted and laryngoscopy was performed, showing mild upper airway edema which was attributed to trauma from intubation. The patient received a total of 3 courses ([**12-23**], [**12-25**], [**12-27**]) of Decadron x3 doses and racemic-epinephrine nebulizer prn were given x 1. This was discontinued secondary to hypertension. He was given humidified air, aggressive pulmonary suctioning, Scopolamine patch to assist in reduction of secretions, mouth care, and atrovent and albuterol nebulizers with some improvement. Repeat laryngoscopy by ENT showed resolving edema. With the initiation of the above mentioned measures, the patient's respiratory status improved significantly. . 3. HTN: The patient's BP was managed based upon the neurology intracranial hemorrhage protocol (MAP<130, SBP<160). Metoprolol was titrated up to 50 tid, Lisinopril to 5 mg daily, Hydralazine was titrated up to 20mg Q6hrs. . 4. Persistent low grade fever: The patient had low-grade fevers for approximately one week. The ddx included infection of unknown source or post intracranial hemorrhage. On [**12-21**] he developed 101F fever and found to have UTI (UCx +for pan-[**Last Name (un) 36**] Klebsiella oxytoca). This was initially treated with Levofloxacin then switched to Ceftriaxone due to copious nasal secretions and suspicioun of sinusitis. Due to worsening in respiratory status Flagyl was added on [**12-24**]. On [**12-25**] the patient spiked to 104F (around time of platelet transfusion) with a leukocytosis. Vanco was added and ID was consulted. Per their recs, all antibiotics were discontinued. His leukocytosis was thought to be secondary to the steroids. The patient defervesced off all antibiotics. His blood cultures grew out contaminants (1/12 bottles with cornybacterium). The patient was afebrile for >48 hrs prior to discharge. . 5. Heme: The patient has a history of MDS and has had occasional thrombocytopenia over the hospital stay. The patient was periodically transfused to avoid oozing that occured from [**Last Name (un) **]/oral suctioning. The patient did not need any transfusions during the last five days of hospitalization. . 6. DVT: The patient was found to have a R SFV non-occlusive clot that appeared chronic in appearance. An IVC filter was not placed as IR did not think it was indicated giving the chonic look of the clot and a low probability of embolus. Given his MDS with low plts and recent ICH, anticoagulation therapy was not initiated. . 7. ARF: The patient went into ARF with a bump in cr from 1.0 to 1.4. This improved with IVF and was therefore presumed to be due to pre-renal azotemia. The high ACEI dosage was also felt to be contributory. This medication was titrated down with improvement of his renal function back to baseline. . 8. Hypernatremia: The patient was found to be hypernatremic on several occassions. This was likely [**12-22**] to inadequate free water administration. Therefore, he was given free water boluses with improving sodium levels. Upon discharge his Na was still slightly elevated at 147 but trending to nl (145 at [**Hospital1 18**] lab) with the free H20 via his GJ tube. . 9. Nutrition: The patient failed swallowing evaluation and was thought to be at high risk for aspiration. After discussion with his health care proxy (son), a [**Name (NI) **] tube was placed. He was given Replete with fiber which was increased to 80 mg/hr with 150cc H20 Q4 hrs. . 10. UTI: The patient was found to have a UTI with urine that grew out klebsiella. He was treated with levofloxacin x 7days. . 11. Code status: DNR/DNI Medications on Admission: Unknown. Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Name (NI) **]: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever. 2. Albuterol Sulfate 0.083 % Solution [**Name (NI) **]: 1-2 puffs Inhalation Q4-6H (every 4 to 6 hours) as needed for wheezing. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Name (NI) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Docusate Sodium 100 mg Capsule [**Name (NI) **]: One (1) Capsule PO BID (2 times a day). 5. Furosemide 20 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY (Daily). 6. Hydralazine 10 mg Tablet [**Name (NI) **]: Two (2) Tablet PO Q6H (every 6 hours). 7. Ipratropium Bromide 0.02 % Solution [**Name (NI) **]: One (1) neb Inhalation Q6H (every 6 hours). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 9. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 11. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID (4 times a day) as needed for thrush. 12. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Twenty (20) units Subcutaneous at bedtime. 13. Humalog insuling sliding scale Please refer to attached humalog insulin sliding scale Discharge Disposition: Extended Care Facility: [**Hospital **] rehab Discharge Diagnosis: Primary: ICH ARF LE DVT UTI (klebsiella) supraglottic edema secondary to intubation trauma . Secondary: HTN MDS gatric ulcers Discharge Condition: Stable. Discharge Instructions: Please return to the ER or call you PCP if you experience increasing SOB, worsening sputum production, change in MS, or any other symptoms that concern you. Followup Instructions: Please follow up with your PCP upon discharge from the rehabilitation facility. Completed by:[**2153-1-1**] Name: [**Known lastname 11971**],[**Known firstname **] Unit No: [**Numeric Identifier 11972**] Admission Date: [**2152-12-17**] Discharge Date: [**2153-1-2**] Date of Birth: [**2064-6-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1455**] Addendum: Mr. [**Known lastname **] was kept one additional day for a follow up CT head and EEG per neurology request for change in MS over a the period of one weeks time. His head CT showed resolving areas of hemorrhage without any evidence of rebleed. An EEG was obtained on the day of discharge. The results will be faxed to the rehab facility once they are in. The patient remained afebrile and without leukocytosis for >5 days prior to discharge. Blood cultures have all been negative. The patient will be discharged to a rehab facility today after his EEG. He has an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in neurology after discharge. Per neurology the patient's SBP should be kept between 130-160 and his platelets kept above 100k. Head CT: 1. Evolution of blood products in the area of the right caudate head. No new areas of hemorrhage. 2. Interval partial opacification of the mastoid air cells. . WBC 6, HCT 26, pl 133, BUN 26, Cr 0.9, Na 142 Discharge Disposition: Extended Care Facility: [**Hospital **] rehab [**Name6 (MD) **] [**Last Name (NamePattern4) 1456**] MD [**MD Number(2) 1457**] Completed by:[**2153-1-2**]

[ "453.41", "478.6", "519.19", "599.0", "251.8", "431", "E932.0", "507.0", "401.9", "238.75", "584.9", "531.90", "276.0", "287.5" ]

icd9cm

[ [ [] ] ]

[ "96.71", "44.32", "96.6", "99.05", "96.04" ]

icd9pcs

[ [ [] ] ]

14344, 14530

5661, 10912

273, 290

12614, 12624

3343, 5638

12829, 14105

2515, 2534

10971, 12373

12465, 12593

10938, 10948

12648, 12806

2549, 2880

223, 235

318, 1766

3027, 3324

14114, 14321

2919, 3011

2904, 2904

1788, 1813

1829, 2499

45,425

134,219

35118

Discharge summary

report

Admission Date: [**2191-10-5**] Discharge Date: [**2191-10-20**] Date of Birth: [**2112-8-25**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3913**] Chief Complaint: 2 week history of anorexia, intermittent nausea and severe fatigue, decreased urine output. Major Surgical or Invasive Procedure: Bone Marroy Biopsy CVVH Transjugular liver biopsy Right jugular HD line re-placement PICC line placement (left) History of Present Illness: 79 F with multiple myeloma who was transerred from an outside hospital for management of renal failure in the setting of gammaglobuinopathy. . She originally developed monoclonal gammopathy of undetermined significance in [**2182**] which developed into multiple myeloma in 12/[**2189**]. She was treated with Zolendronic acid, thalidomide (50 mg) and decadron, and has been maintained on decadron (40 mg) weekly. Her dose of Thalidomide and Dexamethosone were decreased by half in [**Month (only) 116**] for neuropathy in the setting of good counts (IgG 1,229 on [**2191-5-9**]). She has been off thalidomide since [**Month (only) **]. . She presented to [**First Name8 (NamePattern2) **] [**Hospital **] Hospital on [**2191-9-30**] with 2 week history of anorexia, intermittent nausea and severe fatigue, decreased urine output. Her symptoms started after returning from a trip to Europe on [**9-6**]. She also reports abdominal bloating/discomfort, pale/loose stools. She was unable to drink water due to nausea. She has continued to take her medications including diuretics and lisinopril. . Her labs on admission to [**Hospital **] Hospital showed a BUN of 57, Cr 6.8, Uric acid of 18, TP 13.8, Alb 1.9. IgG level 7,550, IgA 15, IgM 8. CT scan demonstarted several lytic lesions with sclerotic borders in pelvix and spine. CO2 at admission 18, down to 14 on [**2191-10-1**]. She was sent to [**Hospital1 18**] for further management. . On admission, she feelt "wiped", had a mild headach, dry cough, occasional nausea, neuropathy. She denies pain, shortness of breath, vomiting. Stool today was normal in color. She also compains of left eye inflammation and discharge, "pink eye". Past Medical History: MGUS: 10 years IgG ~[**2182**] Multiple myeloma in [**11-20**] with IgG 2,610, free kappa light chain in urine, lytic lesion in calvarium and some in long bones. BmBx demonstrated 5% plasmacytosis. Treated with monthly Zolendraonic acid and daily Thalidomide 50 mg (history of mild renal insufficiency), and Dexamethasone 40 mg weekly. IgG 1,229 on [**2191-5-9**]. Thalidomide held due to neuropathy but continued dexamethasone. [**7-22**] IgG 1,500, [**2191-9-7**] IgG 2,681. Diabetes mellitus with baseline renal insufficiency Hypertension s/p Hysterectomy Peripheral neuropathy Metal plate in foot Social History: She is a very active woman, who works as a painter and was leading a tour in Europe 1 month ago. She lives alone in [**Location (un) 28318**], MA and leases part of her house to various tenants. She denies any alcohol or tobacco history as well as any other drugs. Her daughter lives in [**Name (NI) 3914**] and is her HCP. Family History: Father had stroke at age [**Age over 90 **] Mother with CAD Physical Exam: On Admission: VS: T 97.1, HR 103, BP 138/67, RR 22, Sat 95%/RA GEN: NAD, lying comfortably, SKIN: Mild jaundice, small spider angiomas HEENT: Scleral icterius, small discharge from left eye, mimimal conjuntival injection, PERRL (5->3 mm), O/P clear, MMM, LN: No cervical LAD CV: RRR, 2/6 systolic murmur lodest at LUSB, nl S1, S2, no JVD P: CTAB no w/r/r, coughs with deep inspiration ABD: Soft, non-tender, non-distended, decreased bowel sounds, echymosis at area of heparin injections EXT: WWP, no c/c/e, 2+ DP pulses NEURO: A&Ox3, CN 2-12 intact, normal bulk and tone, 5/5 strength in upper and lower extremities, normal sensation except reports tingling in feet, trace asterixis Pertinent Results: On Admission: [**2191-10-5**] 04:10PM WBC-6.6 RBC-3.35* HGB-10.3* HCT-29.0* MCV-87 MCH-30.8 MCHC-35.6* RDW-13.9 [**2191-10-5**] 04:10PM NEUTS-73.1* LYMPHS-20.3 MONOS-5.7 EOS-0.6 BASOS-0.4 [**2191-10-5**] 04:10PM PLT COUNT-151 [**2191-10-5**] 04:10PM GLUCOSE-107* UREA N-10 CREAT-2.1* SODIUM-127* POTASSIUM-3.6 CHLORIDE-94* TOTAL CO2-26 ANION GAP-11 [**2191-10-5**] 04:10PM ALT(SGPT)-64* AST(SGOT)-90* LD(LDH)-392* ALK PHOS-192* TOT BILI-5.2* [**2191-10-5**] 04:10PM TOT PROT-11.8* ALBUMIN-1.4* GLOBULIN-10.4* CALCIUM-6.7* PHOSPHATE-3.5 MAGNESIUM-1.5* [**2191-10-5**] 04:10PM OSMOLAL-278 [**2191-10-5**] 04:10PM PT-17.9* PTT-150* INR(PT)-1.6* [**2191-10-5**] 04:10PM FIBRINOGE-136* [**2191-10-5**] 02:34PM URINE HOURS-RANDOM UREA N-98 CREAT-60 SODIUM-77 POTASSIUM-62 CHLORIDE-49 TOT PROT-553 URIC ACID-8.8 PROT/CREA-9.2* [**2191-10-5**] 02:34PM URINE U-PEP-TWO ABNORM IFE-MONOCLONAL OSMOLAL-315 [**2191-10-5**] 02:34PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.010 [**2191-10-5**] 02:34PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011 [**2191-10-5**] 02:34PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-8.5* LEUK-LG [**2191-10-5**] 02:34PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-8.0 LEUK-LG [**2191-10-5**] 02:34PM URINE RBC-236* WBC-72* BACTERIA-FEW YEAST-NONE EPI-0 [**2191-10-5**] 02:34PM URINE RBC-213* WBC-93* BACTERIA-FEW YEAST-NONE EPI-0 [**2191-10-5**] 02:34PM URINE HYALINE-5* [**2191-10-5**] 02:34PM URINE HYALINE-2* [**2191-10-5**] 02:34PM URINE WBCCLUMP-FEW MUCOUS-RARE [**2191-10-5**] 02:34PM URINE WBCCLUMP-MANY MUCOUS-RARE [**2191-10-5**] 02:34PM URINE EOS-NEGATIVE [**2191-10-5**] 09:25AM AMMONIA-21 Brief Hospital Course: 79 female with multiple myeloma, Hep C, presents with 2 weeks nausea and found to be in renal failure, liver failure concerning for amyloidosis, RCC, other etiologies. . ICU COURSE - She was admitted to the ICU for CVVH in the setting of a mixed respiratory and metabolic alkalosis and an arterial pH of 7.57. Her pH improved on CVVH to 7.41. She received plasmaphoresis twice in the unit and serum Ig levels fell from 7.2 to 3.6 gm/dL. She was started on treatment with cytoxan and dexamethasone and was called out. . MULTIPLE MYELOMA - Patient was started on cytoxan (1.2 g/m2)and prednisone (total of 80mg) on [**10-7**]. Patient received plasmapheresis in order to protect her kidney. Her IgG on admission was 7208 and trended down with pheresis and stayed down after stopping it on [**10-13**]. Patient received 2 more doses of prednisone 20mg this past week. She will need to come back Monday for follow up appointment and we will starte Velcade. The most likely treatment, after speaking with her outpatient Hematoncologist will be prednisone/melphalan/velcade. . RENAL FAILURE - Patient had myeloma kidney with possible RTA associated with myeloma. Patient required CVVH and then Hemodialysis. last session was [**10-13**]. Patient recovered her renal function and now has been on creatinine of 1.3. Fluid was an issue in multiple occassions, but patient responded to lasix 40mg IV. . LIVER DYSFUNCTION / LIVER MASSES - Patient with HCV serology positive at OSH, but negative here and negative viral load. Most likely was a false positive due to high IgG. Patient had negative work up including autoimmune, viral, Wilson's and hemochromatosis. Ultrasound showed multiple masses, that were corroborated by MRI. Patient had transjugular liver biospy on [**10-14**], which showed infiltration of Myeloma to the liver. Patient received prednisone 20mg IV 2 doses for this and LFTs improved. Bilirubin trended down from 5.2 to 3.3, but today was 4.2. It is thought to be due to the wean off the prednisone dose as well as nafcillin (see below). We will follow the LFTs this upcomming Monday. . COAGULOPATHY - Patient had low platelets, high INR and low fibrinogen on admition, which were thought to be due to liver dysfunction. As the liver function improved with chemotherapy coagulopathy improved as well. Patient discharged with normal INR, PLT and PTT without any evidence of bleeding and stable HCT. . TRIPLE ACID-BASE DISORDER - Thought due to fluid overload and renal failure. Improved with chemotherapy and as renal and liver function improved. MSSA bacteremia may have worsened the disorder. Patient with stable CO2 at ~20. . HYPONATREMIA - Patient admitted with hyponatremia thought due to nausea and decreased PO intake with diuretics at OSH. Resolved. . EYE INFLAMMATION - "Pink eye" by her report but responded to optic antihistamines at outside hospital. Was started on erythromycin drops and improved. Today was the last day of treatment and aptient is asymptomatic. . HYPERTENSION - Triamterene/Hydrochlorothiazide 37.5/25 mg at home. Were stopped during hospitalization. Can re-start if needed as outpatient. . DIABETES - Regular insulin sliding scale. . DIET: Regular Diet Medications on Admission: On Tansfer from OSH: Triamterene/Hydrochlorothiazide 37.5/25 mg Lisinopril 5 mg daily Protonix Zometa Decadron 20 mg weekly Aspirin 162 mg daily At Home: - Triamterene/Hydrochlorothiazide 37.5/25 mg PO daily - Lisinopril 5 mg PO daily - Protonix - Zometa - Decadron 20 mg weekly - Aspirin 162 mg daily Discharge Medications: 1. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Naphazoline-Pheniramine 0.025-0.3 % Drops Sig: One (1) Drop Ophthalmic QID (4 times a day) as needed for eye irritation. 4. Insulin Per Sliding Scale (attached sheet) 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-15**] Sprays Nasal QID (4 times a day) as needed. 7. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gram Intravenous Q6H (every 6 hours) for 10 days. 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 10. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis Multiple Myeloma with liver infiltration Acute Renal Failure Secondary Diagnosis Diabetes mellitus with baseline renal insufficiency (baseline 1.2) Hypertension s/p Hysterectomy Peripheral neuropathy Metal plate in foot Discharge Condition: Stable, breathing comfortably on room air, walking, eating, with baseline kidney function. Discharge Instructions: You were seen at the [**Hospital1 18**] for multiple myeloma with acute renal failure and multiple liver masses. You require CVVH and hemodialysis to manage your fluid, acids and electrolytes. You also required plasmapheresis to help protect your kidneys. Luckily, your renal function recovered. You had USG, and MRI of your liver, which showed multiple masses and were inconclusive, so we had to perform a transjugular liver biopsy (through the neck), which showed infiltration of the myeloma to your liver. For your myeloma you received cytoxan and prednisone upon admision. You will need chemotherapy as outpatient.

[ "584.9", "572.2", "570", "276.8", "250.40", "287.5", "E933.1", "372.03", "276.1", "273.1", "357.6", "585.9", "403.90", "276.3", "599.0", "203.00" ]

icd9cm

[ [ [] ] ]

[ "99.71", "38.93", "99.04", "50.11", "39.95", "99.25", "99.05", "41.31", "99.07" ]

icd9pcs

[ [ [] ] ]

10336, 10415

5842, 9041

408, 521

10698, 10791

4029, 4029

3229, 3290

9394, 10313

10436, 10677

9067, 9371

10815, 11437

3305, 3305

277, 370

549, 2248

4043, 5819

2270, 2872

2888, 3213

22,176

131,977

48268

Discharge summary

report

Admission Date: [**2186-4-8**] Discharge Date: [**2186-4-14**] Date of Birth: [**2140-4-12**] Sex: F Service: ADMITTING DIAGNOSES: 1. Colonic obstruction with toxic megacolon. 2. Pneumatosis coli. 3. Metastatic breast cancer. 4. History of congestive heart failure. 5. Anemia. 6. Hypothyroidism. 7. Status post craniotomy for resection of metastatic disease. 8. Status post stereotactic radiosurgery. 9. Status post left Chamberlain procedure. 10.Status post lumpectomy. DISCHARGE DIAGNOSES: 1. Colonic obstruction with toxic megacolon--status post total abdominal colectomy with end-ileostomy and sigmoid colon mucous fistula and omentectomy. 2. Pneumatosis coli. 3. Metastatic breast cancer. 4. History of congestive heart failure. 5. Anemia. 6. Hypothyroidism. 7. Status post craniotomy for resection of metastatic disease. 8. Status post stereotactic radiosurgery. 9. Status post left Chamberlain procedure. 10.Status post lumpectomy. ADMISSION HISTORY AND PHYSICAL: Ms. [**Known lastname 101686**] is a 45-year-old woman who has had metastatic breast cancer notably to the lung, bone, brain, endometrium, and the liver who was recently diagnosed with pelvic disease in [**2186-1-9**], after a biopsy secondary to vaginal bleeding. She has been on Xeloda since [**92**]/[**2185**]. She presented with persistent complaints for approximately 2 weeks of feeling bloated and obstipated with some crampy abdominal pain. She had also had some bilious nausea and vomiting. As her symptoms worsened, she sought medical attention several times, and finally was evaluated in the ED for an acute change in the pain. INITIAL EXAMINATION: 99.3, pulse 81, blood pressure 115/66, respiratory rate 12, satting 98% on room air. She did not appear to be in any distress. She was not jaundice, and her sclerae were anicteric. She did not have any palpable cervical adenopathy. Her lungs were clear. Heart was regular. Abdomen was distended. It was tense. It was notably tender on the right to percussion with some guarding. Rectal exam did not have any stool in the vault, but otherwise no masses palpable. ADMISSION LABS: White count 7.1, hematocrit 31.3. BUN and creatinine were 20 and 1.3 with a K of 3.0 notably. LFTs - ALT and AST 8 and 30, alk phos 80, total bili 0.5. Calcium 8.5. The patient had a CT of the abdomen in order to further assess the etiology of the obstruction and was found to have distal large bowel obstruction from pelvic metastases with secondary ischemic infarction of the ascending colon, as per pneumatosis coli. She also had some right-sided hydronephrosis and hydroureter from the distal obstruction, and several metastatic liver lesions were noted. There were sclerotic metastases to the bone present. HOSPITAL COURSE: The patient was admitted and after extensive discussion with the hematology and oncology services, it was felt that the patient was in need of an exploratory laparotomy and likely colectomy in order for relief of this obstruction. Therefore, the patient was taken to the operating room on [**2186-4-8**] and underwent a total abdominal colectomy with end-ileostomy, sigmoid colon mucous fistula, and omentectomy. There was no note of intraoperative complication or excessive blood loss. The patient tolerated the procedure well. She remained intubated and spent the night in the Intensive Care Unit for respiratory support and management of fluid status. On postoperative day #1, the patient was extubated without note of difficulty. Her hematocrit was otherwise stable. She was, therefore, transferred to the floor by postoperative day #2. On postoperative day #2, the patient was notably somewhat tachycardic, actually since postoperative day #1, with pulse ranging between 100 and the high-120s. This was evaluated, and as the patient's hematocrit was stable, and she was maintaining good O2 sats, it was felt this was secondary to a combination of dehydration and pain. Therefore, she was aggressively rehydrated with lactated Ringer's, and pain control was achieved postoperatively with the use of PCA. By postoperative day #3, it was apparent that the patient's pain was a combination of acute and chronic pain. It was felt that the pain management service should be involved and; therefore, they were consulted to manage the patient's acute on chronic pain. In terms of their recommendations, they suggested getting her back to her oral medications as fast as possible, but in the meanwhile that methadone PCA would be the best choice for her. She was started on this. She did not really respond to the methadone PCA and required some dilaudid intermittently, but by postoperative day #4, she was showing evidence of bowel activity and, therefore, was started on her PO pain medications along with some additional Vioxx which actually did control her pain. Otherwise, the patient's postoperative course was relatively uneventful. Her tachycardia resolved, although she did remain with the pulse between 80s-90s by the time of her discharge. She always maintained stable pressures, and only had a low-grade temp of 101.6 which was thought to be secondary to atelectasis. We did want to schedule an MRI as an inpatient to evaluate for the extent for bony metastatic disease, as there may have been some possible way to intervene if it was, in fact, spinal in origin, but the patient said she was not comfortable with sitting through an MRI during the hospitalization and; therefore, it was felt that this could be done as an outpatient as per her wishes. Otherwise, it was noted that the patient did well. She was given physical therapy, and given instructions regarding a stoma. It was felt that by postoperative day #6, this patient was on a regular diet which she was tolerating without any difficulty, and that she had excellent pain control with PO medications, and was ambulating to the best of her ability, that she could be discharged to home in fair condition. The acute pain management service recommendations were followed up for her pain. Otherwise, at the time of discharge the patient's hematocrit was 27.3. Her BUN and creatinine had improved to 13 and 1.0, and her K was 3.6. DISCHARGE MEDICATIONS: 1. Methadone 15 mg po bid. 2. Oxycodone 5 mg po q 4-6 h prn pain. 3. Vioxx 50 mg po qd. She was told she could resume her home medications which included: 4. Xeloda 1 [**Hospital1 **]. 5. Lasix prn. 6. Ambien 10 mg po qd. 7. Coreg 12.5 mg po qd. 8. Levoxyl 50 mcg po qd. 9. Mavik 1 mg po qd. She was advised that she should follow-up with her primary care physician for any adjustments in these medications. [**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**] Dictated By:[**Last Name (NamePattern1) 13262**] MEDQUIST36 D: [**2186-4-14**] 11:18 T: [**2186-4-14**] 11:28 JOB#: [**Job Number 101687**] cc:[**Last Name (NamePattern1) 101688**]

[ "197.6", "198.5", "428.0", "591", "197.5", "197.7", "560.89", "276.5", "197.0" ]

icd9cm

[ [ [] ] ]

[ "46.21", "46.13", "54.4", "45.8" ]

icd9pcs

[ [ [] ] ]

513, 2131

6229, 6929

2785, 6206

2148, 2767

71,879

106,786

10475

Discharge summary

report

Admission Date: [**2178-9-8**] Discharge Date: [**2178-9-15**] Service: ORTHOPAEDICS Allergies: Oxycontin Attending:[**First Name3 (LF) 11415**] Chief Complaint: Right hip fracture Major Surgical or Invasive Procedure: ORIF right hip. History of Present Illness: 86 F w/ Alzheimer's dementia s/p fall from chair onto R hip w/ pain/deformity. No syncope or LOC. Past Medical History: 1. Aortic aneurysm - details unclear, per daughter pt was told she had no surgical options 2. Alzheimer's Dementia - lives in dementia unit/ALF. At baseline does not always know place/time and prone to agitation in a new environment 3. Osteoporosis 4. Hx of multiple fractures 5. Hx of falls 6. Hx of recurrent UTIs 7. ?Hx of Crohn's disease 8. Hypothyroidism 9. HTN 10. Depression 11. Hx of K antigen in blood - should get K antigen neg blood transfusion if needed Social History: lives in dementia unit, an ALF, at [**Last Name (un) **]. Walks w walker at baseline. No significant smoking, alcohol, drug use Family History: Noncontributory Physical Exam: Upon Discharge: AVSS NAD AAO x 3 NCAT RRR, S1S2 CTAB Soft, NTND RLE - wound c/d/i. Soft compartments. NVI. SILT. palpable DP pulse. Pertinent Results: [**2178-9-7**] 10:55PM BLOOD WBC-10.7# RBC-3.43* Hgb-10.9* Hct-32.5* MCV-95 MCH-31.6 MCHC-33.4 RDW-14.5 Plt Ct-273 [**2178-9-8**] 06:40AM BLOOD WBC-8.2 RBC-3.04* Hgb-9.5* Hct-28.7* MCV-94 MCH-31.3 MCHC-33.2 RDW-14.1 Plt Ct-303 [**2178-9-8**] 05:05PM BLOOD WBC-14.6*# RBC-2.95* Hgb-9.2* Hct-27.1* MCV-92 MCH-31.3 MCHC-34.0 RDW-15.4 Plt Ct-327 [**2178-9-9**] 01:14AM BLOOD WBC-9.7 RBC-3.07* Hgb-9.5* Hct-27.6* MCV-90 MCH-30.8 MCHC-34.3 RDW-16.8* Plt Ct-223 [**2178-9-9**] 06:15AM BLOOD Hct-30.7* [**2178-9-10**] 06:45AM BLOOD WBC-7.6 RBC-2.69* Hgb-8.4* Hct-24.0* MCV-89 MCH-31.3 MCHC-35.1* RDW-16.2* Plt Ct-180 [**2178-9-10**] 11:50PM BLOOD WBC-9.7 RBC-3.42*# Hgb-10.4* Hct-30.0* MCV-88 MCH-30.6 MCHC-34.8 RDW-16.1* Plt Ct-173 [**2178-9-11**] 06:50AM BLOOD WBC-9.6 RBC-3.31* Hgb-10.2* Hct-29.2* MCV-88 MCH-30.8 MCHC-35.0 RDW-16.4* Plt Ct-185 [**2178-9-11**] 09:00AM BLOOD WBC-9.5 RBC-3.35* Hgb-10.5* Hct-29.6* MCV-88 MCH-31.2 MCHC-35.3* RDW-16.5* Plt Ct-193 [**2178-9-12**] 06:40AM BLOOD WBC-8.4 RBC-3.08* Hgb-9.5* Hct-27.5* MCV-89 MCH-30.8 MCHC-34.5 RDW-16.6* Plt Ct-227 [**2178-9-12**] 09:35PM BLOOD Hct-27.9* [**2178-9-13**] 10:45AM BLOOD Hct-29.0* [**2178-9-14**] 09:25PM BLOOD Hct-31.9* [**2178-9-15**] 06:25AM BLOOD WBC-8.0 RBC-3.45* Hgb-10.6* Hct-31.2* MCV-90 MCH-30.7 MCHC-34.0 RDW-16.6* Plt Ct-284 [**2178-9-7**] 10:55PM BLOOD PT-13.0 PTT-24.9 INR(PT)-1.1 [**2178-9-10**] 06:45AM BLOOD PT-12.6 PTT-26.4 INR(PT)-1.1 [**2178-9-11**] 09:00AM BLOOD PT-12.1 PTT-26.5 INR(PT)-1.0 [**2178-9-7**] 10:55PM BLOOD Glucose-125* UreaN-20 Creat-0.9 Na-137 K-4.8 Cl-104 HCO3-25 AnGap-13 [**2178-9-8**] 06:40AM BLOOD Glucose-131* UreaN-19 Creat-0.7 Na-136 K-4.9 Cl-104 HCO3-24 AnGap-13 [**2178-9-8**] 05:05PM BLOOD Glucose-161* UreaN-18 Creat-0.7 Na-133 K-4.5 Cl-102 HCO3-22 AnGap-14 [**2178-9-9**] 01:14AM BLOOD Glucose-171* UreaN-19 Creat-0.9 Na-133 K-4.1 Cl-104 HCO3-21* AnGap-12 [**2178-9-10**] 06:45AM BLOOD Glucose-118* UreaN-15 Creat-0.6 Na-131* K-4.1 Cl-103 HCO3-23 AnGap-9 [**2178-9-10**] 11:50PM BLOOD Glucose-90 UreaN-17 Creat-0.7 Na-133 K-4.0 Cl-102 HCO3-25 AnGap-10 [**2178-9-11**] 06:50AM BLOOD Glucose-102 UreaN-18 Creat-0.7 Na-134 K-3.9 Cl-102 HCO3-23 AnGap-13 [**2178-9-11**] 09:00AM BLOOD Glucose-134* UreaN-17 Creat-0.8 Na-134 K-3.9 Cl-103 HCO3-22 AnGap-13 [**2178-9-12**] 06:40AM BLOOD Glucose-100 UreaN-17 Creat-0.6 Na-139 K-4.1 Cl-107 HCO3-24 AnGap-12 [**2178-9-15**] 06:25AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND K-PND Cl-PND HCO3-PND [**2178-9-8**] 05:05PM BLOOD CK-MB-3 cTropnT-<0.01 [**2178-9-9**] 01:14AM BLOOD CK-MB-6 cTropnT-<0.01 [**2178-9-8**] 05:05PM BLOOD Calcium-8.8 Phos-3.7 Mg-1.7 [**2178-9-10**] 06:45AM BLOOD Calcium-7.9* Phos-1.9* Mg-1.9 [**2178-9-10**] 11:50PM BLOOD Calcium-7.9* Phos-2.6* Mg-2.0 [**2178-9-11**] 06:50AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.9 [**2178-9-11**] 09:00AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9 [**2178-9-12**] 06:40AM BLOOD Calcium-7.6* Phos-2.0* Mg-2.2 Xrays of R hip [**9-8**]: IMPRESSION: 1. Comminuted, displaced right femoral intertrochanteric fracture. No dislocation. 2. Osteoarthritis of bilateral hips. CXR: IMPRESSION: 1. Mild cardiomegaly, with mild CHF. 2. Slight cortical step-off and irregularity of the right humeral neck. Correlate with site of symptoms, and if clinically indicated, dedicated right shoulder radiographs can be obtained to exclude an acute fracture. TTE: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Diastolic function could not be assessed because of aortic regurgitation. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is markedly dilated. No dissection flap is seen (best excluded by [**Last Name (LF) **], [**First Name3 (LF) **] MR/CT). The aortic valve leaflets (3) are thickened but with good leaflet excursion. There is no aortic valve stenosis. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Moderate to severe aortic regurgitation. Markedly dilated ascending aorta. CT Head: IMPRESSION: No acute intracranial process. CT Chest: IMPRESSION: 1. Limited study with no evidence of pneumonia. Mild changes of both lung bases may represent atelectasis versus mild chronic interstitial changes due to CHF. 2. Stable cardiomegaly. Based on the radiographic appearance, pulmonary edema seen on [**9-7**] has resolved today. 3. Ascending aortic aneurysm, unchanged. 4. Interval increase in diameter of aberrant right subclavian artery, with resultant proximal dilatation of the esophagus. Brief Hospital Course: Mrs. [**Known lastname 34586**] was seen in the ED and found to have a right subtrochanteric femur fracture. She undwerwent ORIF on [**2178-9-8**]. She tolerated the procedure well, but had an epidose of SVT intra-op that was quickly controlled with an esmolol drip. She was sent to the ICU overnight for observation. She then transferred to the general floor in stable condition the next day. Post op anemia: She was transfused a total of 6 units of prbcs post op for acute blood loss anemia. On discharge, her blood volume was stable. Hypoxia: On POD 2 she desaturated down into the 70s. A CT of her chest showed atelectasis and was otherwise benign. She improved with supplemental oxygen and remained stable thereafter. Her foley came out POD 4. Her pain was well controlled with IV and then PO pain meds. She tolerated a regular diet throughout her stay She was seen and evaluated by PT. She is being discharged today in stable condition with her staples still in place. Medications on Admission: Synthroid 25', ASA 81', Omeprazole 20', Wellbutrin 75'', Donepezil 10qhs, Vit D, Fosamax 70qfriday, Mirtazapine 15qhs Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection Subcutaneous DAILY (Daily) for 4 weeks. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for crackles/wheezing. 13. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for crackles/wheezes. 17. Insulin Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-50 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice 51-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 2 Units 2 Units 2 Units 2 Units 201-250 mg/dL 4 Units 4 Units 4 Units 4 Units 251-300 mg/dL 6 Units 6 Units 6 Units 6 Units 301-350 mg/dL 8 Units 8 Units 8 Units 8 Units 351-400 mg/dL 10 Units 10 Units 10 Units 10 Units Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Right hip fracture Discharge Condition: Stable, improved. Discharge Instructions: WBAT on your leg. continue to ambulate daily and work with PT as planned. Continue to take your blood thinning medication as planned. Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. Physical Therapy: WBAT Treatments Frequency: Reinforce dressing as needed for drainage Lovenox 40mg SC q24 hrs x 4 weeks Followup Instructions: Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in 2 weeks. Call [**Telephone/Fax (1) 1228**] to make that appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**] Completed by:[**2178-9-15**]

[ "997.1", "427.89", "820.22", "441.4", "311", "285.1", "331.0", "276.1", "E884.2", "E878.8", "799.02", "V15.51", "V15.88", "401.9", "294.10", "244.9" ]

icd9cm

[ [ [] ] ]

[ "79.15" ]

icd9pcs

[ [ [] ] ]

9542, 9614

6433, 7417

240, 258

9677, 9697

1223, 5893

10663, 10988

1038, 1055

7585, 9519

9635, 9656

7443, 7562

9721, 10517

1070, 1070

10535, 10540

10562, 10640

182, 202

1087, 1204

286, 386

5902, 6410

408, 876

892, 1022

25,638

114,953

20924

Discharge summary

report

Admission Date: [**2159-3-22**] Discharge Date: [**2159-3-28**] Date of Birth: [**2080-7-26**] Sex: M Service: NSU HISTORY OF PRESENT ILLNESS: Patient is a 78-year-old male with a past medical history of seizure disorder, found by family at the bottom of the stairs unconscious with seizure activity. Patient failed field intubation and was made an oral airway, bagged with an O2 saturation of 98 percent. Patient was transferred to [**Hospital6 2561**], where he was intubated and stabilized. Head CT demonstrated bilateral subarachnoid hemorrhage and subdural hematoma. Patient was transferred to [**Hospital1 69**] Emergency Department as a hemodynamically stable patient. PAST MEDICAL HISTORY: 1. COPD. 2. Seizure disorder. 3. Bladder cancer in [**2153**] status post urostomy. 4. Status post femoral bypass. ALLERGIES: None. MEDICATIONS: 1. Dilantin. 2. Lamictal. 3. Aspirin. Upon admittance to [**Hospital3 **] Medical Center, physical exam showed systolic blood pressure of 218/106, O2 saturation was 99 percent. Respiratory rate was 20. Heart had a regular, rate, and rhythm, S1, S2 present, no murmurs, rubs, or gallops. His abdomen was soft, nontender, nondistended. Bowel sounds times four. His lungs were clear bilaterally, and his extremities had no clubbing, cyanosis, or edema. HEENT: Right eye bruise with swelling. No other lacerations or battle signs. Neurological exam: Patient opens eyes to voice, moves arms to command, squeezed left hand to command. Pupils were 4 to 3 mm reactive bilaterally. Does not blink to visual threat. No facial asymmetry. Positive corneal and gag reflex. His motor activity: He moves upper extremities to antigravity. No lower extremity movement. Sensory: Withdraws to pain in the left lower extremity only. Reflex: Trace. Left lower extremity reflex with muscle, mute toes bilaterally. ASSESSMENT AND PLAN: He is a 78-year-old man with a fall secondary to seizure now with bilateral subdural hematomas and subarachnoid hemorrhage without midline shift. Assessment and plan for this patient at this time was to keep his systolic blood pressure between 100 and 140, hourly neurologic checks. He was given mannitol 50 grams q.4h. Check q.4h. serum sodium and osmolality. He was given Dilantin 500 mg times one. Recheck Dilantin one hour after bolus. Hyperventilated with goal pCO2 between 32 and 35. He was administered Solu-Medrol per Spine protocol. MRI of the spine per trauma protocol with possible MRI of the brain. A stat noncontrast head CT was ordered for four hours. He was given 10 bags of platelets. Held all aspirin and he was at full code at this point. On [**2159-3-23**], the patient's vital signs were a temperature of 98.8, pulse was 63 and 114, his blood pressure was 100/54, and his respiratory rate was between 22 and 25. He was ventilated, and his O2 saturation was 98 to 100 percent. He was on propofol 50 mcg/kg/minute. At this time, the patient was localizing the pain in the upper extremities only. His pupils were 3 to 2 mm bilaterally. Slight left outward eye deviation. Toes mute. No movement in the lower extremities. No reflex. The assessment and plan at this time: He was under sedation. Plegic in the lower extremities. We wanted to keep his blood pressure between 100 and 140. Hourly neurologic checks. PCO2 between 33 and 35. Keep him euvolemic. Serum osmolality q.4h. If less than 320, given him mannitol. Continue Solu-Medrol times 24 hours, subQ Heparin tonight, serial hematocrits. On [**2159-3-27**], he spiked a fever at 102.8. His systolic blood pressure was 110-146/51-66. His heart rate was between 73 and 129. His respiratory rate was between 24 and 37. His pupils were trace reactive to ambient light. He was moving his upper extremities spontaneously. No lower extremity movement at this time. His assessment and plan: Neurologically no change. Replaced TC from oral A line. He was to have a full fever workup, chest x-rays, correct the sodium with free water, and the plan was to talk to the family at this time. On [**2159-3-28**], on Neurosurgery, his temperature was 101.7. His pulse was between 88 and 101. Respiratory rate was between 21 and 36. He was intubated and saturating between 93 and 99 percent. His eyes were closed. He localized to pain on the left. Right arm flexed posture versus localized. Pupils 3 mm reactive to ambient light. Paraplegia of the legs. Assessment and plan: CT of the head shows evolving subarachnoid hematoma with contusions. There is minimal mass effect. Awaiting family discussion regarding CMO status. The goal is to keep his blood pressure below 140. Later on [**2159-3-28**], attending in the Trauma ICU spoke with the family and explained the developments in his case. They told me that the patient had often expressed a strong desire not to be kept alive if he would be physically impaired. They asked that the patient be removed from mechanical ventilation and made comfort measures only. In light of his grim prognosis, I agree that this is a reasonable course. At 10 p.m., the patient was pronounced dead by Trauma attending physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at 10 p.m. He was without spontaneous respirations, no heart activity on telemetry. Exam confirms no breath sounds, heart sounds. Pupils were fixed and dilated. No brain stem functions. DR.[**First Name (STitle) **],[**First Name3 (LF) 125**] 14-118 Dictated By:[**Known firstname 55659**] MEDQUIST36 D: [**2159-3-28**] 23:11:14 T: [**2159-3-30**] 06:51:35 Job#: [**Job Number 55660**]

[ "496", "E849.0", "952.05", "V10.51", "851.85", "E880.9", "V44.6", "780.39", "482.41" ]

icd9cm

[ [ [] ] ]

[ "99.05", "96.72", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

1428, 5654

165, 702

724, 1408

83,014

150,856

14314

Discharge summary

report

Admission Date: [**2179-3-4**] Discharge Date: [**2179-3-6**] Date of Birth: [**2128-11-22**] Sex: F Service: MEDICINE Allergies: Latex Attending:[**First Name3 (LF) 425**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 50 yo F s/p MI at age 38 p/w chest pressure, with radiation to the left arm and throat, that began at 7 p.m. this evening. The patient was seating, [**Location (un) 1131**] a dinner menu when the pain began. She had associated lightheadedness and coldness but not nausea, vomiting, or diaphoresis. The patient returned home, where she took ASA 325 mg x 2 plus NTG SL x 1, with some relief. At around 8 p.m., she presented to the ED at [**Hospital3 **]. At [**Hospital3 **], initial vital signs were T 97.5 P 59 RR 16 BP 92/73 Sat 98%. She was treated with NTG SL x 3 followed by nitro drip, Plavix 300 mg PO, and heparin gtt. The patient was transferred to [**Hospital1 18**] for emergent cardiac catheterization. Coronary angiography demonstrated long diffuse stenosis of the RCA from the acute margin to the distal PL branch, with appearance consistent with spontaneous dissection. During the catheterization, the patient received fentanyl 12.5 mcg, heparin gtt at 700 units/hr, nitroglycerin 200 mcg, and Versed 0.5 mg IV. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, cough, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Of note, the patient had similar symptoms 12 years ago, at which time she reportedly had ischemic EKG changes but underwent cardiac catheterization that showed clean coronaries. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: as above -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: -osteoarthritis -s/p endometrial ablation [**2176**] Social History: Married. Has two sons, aged 18 and 19. -Tobacco history: Former smoker. Smoked from age 17 to age 38. Initially smoked 1 pack/day, but was smoking 1.5 packs/week just before she quit. -ETOH: 4-5 drinks/week -Illicit drugs: None. Specifically denies cocaine. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Positive family history of stroke. Physical Exam: (Per Admitting Resident) VS: T=98.4 BP=110/71 HR=78 RR=15 O2 sat=97%/RA GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL. No xanthalesma. NECK: Supple. JVP not elevated. CARDIAC: RRR. Normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Normal bowel sounds. Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: A+Ox3. CN II-XII intact. PULSES: Right: Radial 2+ DP 2+ PT 2+ Left: Radial 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs [**2179-3-5**] 02:30AM BLOOD WBC-8.6 RBC-5.33 Hgb-11.8* Hct-36.8 MCV-69* MCH-22.1* MCHC-32.0 RDW-14.1 Plt Ct-255 [**2179-3-5**] 07:54AM BLOOD PT-12.9 PTT-39.0* INR(PT)-1.1 [**2179-3-5**] 02:30AM BLOOD Glucose-123* UreaN-10 Creat-0.6 Na-136 K-4.1 Cl-100 HCO3-28 AnGap-12 [**2179-3-5**] 02:30AM BLOOD Calcium-9.6 Phos-4.3 Mg-1.9 Cholest-185 [**2179-3-5**] 02:30AM BLOOD %HbA1c-5.2 eAG-103 [**2179-3-5**] 02:30AM BLOOD Triglyc-57 HDL-88 CHOL/HD-2.1 LDLcalc-86 Discharge Labs [**2179-3-6**] 07:15AM BLOOD WBC-6.3 RBC-4.87 Hgb-11.1* Hct-34.0* MCV-70* MCH-22.8* MCHC-32.6 RDW-14.4 Plt Ct-217 [**2179-3-6**] 07:15AM BLOOD PT-12.9 PTT-111.0* INR(PT)-1.1 [**2179-3-6**] 07:15AM BLOOD Glucose-97 UreaN-8 Creat-0.5 Na-138 K-3.9 Cl-103 HCO3-29 AnGap-10 [**2179-3-6**] 07:15AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0 Cardiac Biomarkers [**2179-3-5**] 02:30AM BLOOD CK(CPK)-127 [**2179-3-5**] 02:30AM BLOOD CK-MB-15* MB Indx-11.8* cTropnT-0.05* Cardiac Catheterization (PRELIMINARY REPORT): 1. Selective coronary angiography in this right dominant system demonstrated single vessel disease. The LMCA had no angiographically apparent CAD. The LAD had mild irregularities. The LCx had a 10% proximal stenosis. The RCA had a long, diffuse stenosis from the acute marginal to the distal PL branch with a possible high take-off of the PDA; an appearance consistent with spontaneous dissection. 2. Left ventriculography revealed no significant mitral regurgitation. The ejection fraction was calculated to be 55% with inferoapical hypokinesis. FINAL DIAGNOSIS: 1. Probably spontaneous dissection of distal RCA. 2. Hypokinetic inferoapical segment. Echocardiogram: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 10-15mmHg. There is mild regional left ventricular systolic dysfunction with focal apical inferior hypokinesis. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Mild regional (apical inferior) hypokinesis with overall normal left ventricular systolic function. Brief Hospital Course: 50 yo F with h/o vasospastic MI in the setting of clean coronaries presents with NSTEMI from spontaneous RCA dissection. # Spontaneous RCA Dissection - The patient presented with chest pain and was found to have ACS. Cardiac catheterization showed spontaneous RCA dissection. No intervention was performed at that time. The patient was started on full dose aspirin, plavix, and heparin gtt. Beta blocker was initially held due to sinus bradycardia. Echo was performed on the day following admission and showed mild apical inferior hypokinesis with overall normal left ventricular systolic function. She was continued on the heparin drip for 36 hours. She remained free of chest pain during her inpatient course. At the time of discharge, she was started on a beta blocker and high-dose statin. Prior to discharge, she was also started on a calcium channel blocker. # Anxiety - The patient was continued on her paroxetine. Medications on Admission: Paroxetine Flurbiprofen ASA 81 mg daily (stopped used 2-3 weeks ago becaus she ran out) Vitamin C 500 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily): Pills may be cut in half. However, pills should NOT be cruched or chewed. Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Flurbiprofen Oral Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Right Coronary Artery Dissection Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You presented to the emergency department with chest discomfort. You were transferred to [**Hospital1 18**] for cardiac catheterization, during which you were found to have a dissection in one of the blood vessels supplying your heart. You were placed on a heparin drip to thin your blood for 36 hours. You are also being started some oral blood thinners which you will continue to take at discharge. CHANGES TO YOUR MEDICATIONS: - INCREASE Aspirin to 325 mg daily - START Plavix 75 mg daily - Discuss with your cardiologist how long you should take this medication. - START Atorvastatin 80 mg daily - START Metoprolol Succinate 12.5 mg daily - START Amlodipine 5 mg daily It was a pleasure taking part in your medical care. Followup Instructions: Cardiology: [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 1557**], MD Phone: ([**Telephone/Fax (1) 42482**] Date/time: [**3-24**] at 3:45pm. Dr. [**First Name (STitle) 1557**] also wants to perform a stress test on you within 1 week of discharge. You should call his office on Monday to schedule this. Primary care: [**First Name8 (NamePattern2) 6480**] [**Last Name (NamePattern1) 6402**], MD Phone: ([**Telephone/Fax (1) 42483**] Please keep any scheduled appts.

[ "414.12", "410.71", "300.00" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.56", "88.53" ]

icd9pcs

[ [ [] ] ]

7593, 7599

5722, 6657

275, 300

7694, 7694

3278, 4816

8596, 9086

2537, 2659

6819, 7570

7620, 7673

6683, 6796

4833, 5699

7842, 8247

2674, 3259

2094, 2161

8276, 8573

225, 237

328, 1986

7709, 7818

2192, 2246

2008, 2074

2262, 2521

10,721

193,038

6491

Discharge summary

report

Admission Date: [**2193-3-7**] Discharge Date: [**2193-3-21**] Date of Birth: [**2155-12-25**] Sex: M Service: MEDICINE Allergies: Compazine Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Palpitations, Chest Pressure Major Surgical or Invasive Procedure: Atrial Flutter Ablation Hemodialysis History of Present Illness: Briefly, this is a 37 YOM with history of ESRD [**1-17**] hypertension vs. glomerulonephritis on dialysis M/W/F s/p 2 failed kidney transplants, hyperparathyroidism, severe pHTN presenting with one week of racing heart. . He says this is associated with non-radiating left sided chest pressure and shortness of breath (no particular trigger, but occasionally worse with lying down). He felt this was likely due to fluid overload but did not improve with dialysis. He has also had nasusea and vomitting which has been a chronic problem for him but worsened over the past week with associated diarrhea. He has been eating and drinking well and does not feel dehydrated. In fact, he feels a bit fluid overloaded, especially in his face. He has also had ongoing body aches. Of note, he is not taking any of his medications, including labetolol and nifedipine. . He gets dialysis at [**Location (un) **] M/W/F in [**Location (un) **]. He says yesterday's session removed 3.3L of fluid. He also has a history of hyperparathyroidism for which he was at a scheudled appointment with his surgeon on day of admission. His surgeon noted tachycardia and referred him to the ED. . Of note, he had a CT of his chest two days prior to admission to evaluate his systemic vascular flow. This showed unchanged adenopathy and right axillary edema and extensive venous collateralization in the chest wall which was also unchanged. . CT also showed heavy atherosclerotic coronary calcification, Aortic valvular calcification which could be hemodynamically significant, and unchanged Moderate-to-severe global cardiomegaly unchanged. . In the ED, VS were 98.1 128 139/86 18 99% ra. . EKG showed aflutter with rate of 129, LAD, and LAFB. Trop was 0.43 but within past baselines. . He received 1L IVF, and dilt boluses which did not alter his heart rate. He also received metoprolol 15mg IV. He was given zofran and reglan given for vomiting . He was initially admitted to medicine. Echo this morning demonstrated normal EF but very dilated RV with free wall hypokinesis as well as abnormal systolic septal motion/position consistent with right ventricular pressure overload. There is severe pulmonary artery systolic hypertension. . Hospital course has been complicated with hypoglycemic episodes that coincide with hypotension (down to 80s) and elevated lactate. He also gets an acutely rigid abdomen when he is hypoglycemic and hypotensive. Pt has been transferred to the MICU twice for these episodes. He's been treated with D5W @ 50/hr and briefly covered with broad spectrum antibiotics (vanc/zosyn). . On [**3-7**], he had HD with significant fluid removal (3 L removed). He was uneventful all day until 5pm, pt had episode of BP 80s, and bradycardia to 30s. His troponins remained stable although he had some TWIs. He ws given D5W IVF and sugars improved to high 80s. Lactate noted to be 6->11 x 3 despite IVFs (received total 1.5L). He also spiked a Temp to 100.8. . A CT scan [**3-10**] showed cecal wall thickening and occlusion of his [**Female First Name (un) 899**]. Thus, there was a thought that he gets transient mesenteric ischemia when he is hypotensive. He was evaluated by transplant surgery and vascular surgery for possible mesenteric ischemia, however, they do not think that this is the case because there is retrograde flow through the [**Female First Name (un) 899**] suggesting great collateral supply to this territory. Also, the [**Female First Name (un) 899**] does not supply the cecum which was the only part of the bowel that looked inflammed/ischemic. Thus, he has been covered empirically with vanc/zosyn for possible septic etiology given no better explanation. His cultures have been negative and he remained hemodynamically stable. His lactate and hypoglycemia improved. Past Medical History: 1. ESRD on HD for at least ten years, felt to be due to longstanding hypertension vs glomerulonephritis - HD at [**Location (un) **] [**Location (un) **], T/Th/Sat, followed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] - s/p two failed kidney transplants, most recently in [**4-/2188**] 2. HTN, longstanding, poorly controlled 3. Chronic abdominal pain, s/p workup in [**3-/2190**] including normal US, EGD with esophagitis and several large duodenal ulcers. 4. Hypercholesterolemia 5. Anemia 6. GIB, likely hemorrhoidal Social History: Lives with brother, denies smoking, ETOH. Some marijuana use. Family History: Grandmother and mother with possible history of diabetes. Sister with ESRD, possibly due to HTN. Physical Exam: ADMISSION EXAM: VS: T=97.4 BP=102/71 HR=78 RR=24 O2 sat=100% 2L 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 at the ear, distented external jugular w/ signficiant pulsitations on the left side CARDIAC: PMI very laterally displaced with bounding contractions. Tachycardic, normal S1, S2.3/6 systolic apical murmur with 2/6 murmur of TR. No thrills. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. decreased Breath sounds on the right with crackels at the mid back and base on the left side no egophony ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE EXAM: Gen: AOx3, NAD, some agitation due to frustration with long hospital stay Neck: Chronically stenotic EJ Heart: RRR, [**2-19**] holosystolic murmur at LLSB and apex with radiation to the axilla, RV heave improved, R sided S3 resolved Lungs: CTAB Abd: soft, NT, ND Ext: 1+ edema BL Pertinent Results: ADMISSION LABS: [**2193-3-7**] 04:35PM BLOOD WBC-4.6 RBC-5.28# Hgb-14.2# Hct-46.6# MCV-88# MCH-26.8* MCHC-30.4* RDW-19.1* Plt Ct-111* [**2193-3-8**] 09:00AM BLOOD PT-13.4* PTT-34.0 INR(PT)-1.2* [**2193-3-7**] 04:35PM BLOOD Glucose-94 UreaN-38* Creat-7.9*# Na-140 K-4.5 Cl-96 HCO3-28 AnGap-21* [**2193-3-8**] 09:00AM BLOOD ALT-27 AST-24 CK(CPK)-254 AlkPhos-282* TotBili-1.3 [**2193-3-7**] 04:35PM BLOOD cTropnT-0.43* [**2193-3-7**] 04:35PM BLOOD Calcium-8.7 Phos-6.1*# Mg-2.1 [**2193-3-7**] 04:35PM BLOOD TSH-3.4 [**2193-3-8**] 09:00AM BLOOD WBC-5.2 RBC-5.42 Hgb-13.9* Hct-48.1 MCV-89 MCH-25.6* MCHC-28.8* RDW-18.9* Plt Ct-106* [**2193-3-9**] 07:16AM BLOOD WBC-3.8* RBC-5.42 Hgb-13.8* Hct-48.3 MCV-89 MCH-25.4* MCHC-28.5* RDW-18.8* Plt Ct-104* [**2193-3-10**] 05:00PM BLOOD WBC-5.8# RBC-5.40 Hgb-14.3 Hct-49.3 MCV-91 MCH-26.6* MCHC-29.1* RDW-18.4* Plt Ct-124* [**2193-3-11**] 03:39AM BLOOD WBC-4.4 RBC-5.00 Hgb-12.6* Hct-44.3 MCV-89 MCH-25.3* MCHC-28.5* RDW-18.4* Plt Ct-120* [**2193-3-11**] 06:29AM BLOOD Hct-41.0 [**2193-3-7**] 04:35PM BLOOD Neuts-67.4 Lymphs-21.3 Monos-6.9 Eos-4.0 Baso-0.4 [**2193-3-11**] 03:39AM BLOOD Neuts-67.3 Lymphs-21.5 Monos-7.9 Eos-2.7 Baso-0.5 [**2193-3-8**] 09:00AM BLOOD PT-13.4* PTT-34.0 INR(PT)-1.2* [**2193-3-8**] 09:00AM BLOOD Plt Ct-106* [**2193-3-9**] 07:16AM BLOOD Plt Ct-104* [**2193-3-9**] 05:00PM BLOOD PT-17.6* PTT->150 INR(PT)-1.7* [**2193-3-10**] 01:50AM BLOOD PT-16.0* PTT-150* INR(PT)-1.5* [**2193-3-10**] 01:15PM BLOOD PTT-150* [**2193-3-10**] 05:00PM BLOOD Plt Ct-124* [**2193-3-10**] 05:15PM BLOOD PT-17.3* PTT-45.3* INR(PT)-1.6* [**2193-3-11**] 03:39AM BLOOD Plt Ct-120* [**2193-3-11**] 06:29AM BLOOD PT-16.9* PTT-43.5* INR(PT)-1.6* [**2193-3-11**] 04:06PM BLOOD PT-15.8* PTT-49.7* INR(PT)-1.5* [**2193-3-8**] 09:00AM BLOOD Glucose-95 UreaN-45* Creat-8.6* Na-140 K-4.8 Cl-97 HCO3-27 AnGap-21* [**2193-3-9**] 07:16AM BLOOD Glucose-85 UreaN-27* Creat-6.1*# Na-137 K-7.1* Cl-95* HCO3-26 AnGap-23* [**2193-3-10**] 07:20AM BLOOD Glucose-69* UreaN-40* Creat-7.4*# Na-137 K-6.1* Cl-95* HCO3-18* AnGap-30* [**2193-3-10**] 10:26AM BLOOD Na-137 K-5.3* Cl-93* HCO3-17* AnGap-32* [**2193-3-11**] 12:16AM BLOOD Na-136 K-4.8 Cl-96 [**2193-3-11**] 03:39AM BLOOD Glucose-75 UreaN-45* Creat-8.3* Na-138 K-4.7 Cl-97 HCO3-18* AnGap-28* [**2193-3-11**] 06:29AM BLOOD Na-136 K-4.5 Cl-97 [**2193-3-11**] 02:00PM BLOOD Glucose-106* UreaN-22* Creat-5.5*# Na-136 K-3.8 Cl-96 HCO3-24 AnGap-20 [**2193-3-7**] 11:48PM BLOOD CK(CPK)-203 [**2193-3-9**] 03:35PM BLOOD CK(CPK)-406* [**2193-3-10**] 05:00PM BLOOD ALT-23 AST-19 LD(LDH)-353* CK(CPK)-353* AlkPhos-283* TotBili-1.6* [**2193-3-11**] 03:39AM BLOOD ALT-20 AST-17 LD(LDH)-320* CK(CPK)-331* AlkPhos-270* TotBili-1.5 [**2193-3-8**] 09:00AM BLOOD Calcium-7.8* Phos-7.1* Mg-2.3 [**2193-3-9**] 07:16AM BLOOD Calcium-7.5* Phos-5.5*# Mg-2.3 [**2193-3-10**] 07:20AM BLOOD Calcium-7.1* Phos-5.4* Mg-2.4 [**2193-3-10**] 10:26AM BLOOD Albumin-3.5 [**2193-3-10**] 05:00PM BLOOD Albumin-3.3* Calcium-6.7* Phos-5.3* Mg-2.3 [**2193-3-11**] 03:39AM BLOOD Calcium-6.8* Phos-5.8* Mg-2.2 [**2193-3-11**] 02:00PM BLOOD Calcium-7.1* Phos-3.3# Mg-2.1 [**2193-3-10**] 05:53PM BLOOD Type-[**Last Name (un) **] pO2-243* pCO2-25* pH-7.40 calTCO2-16* Base XS--6 Comment-GREEN TOP [**2193-3-10**] 09:34PM BLOOD Type-ART pO2-142* pCO2-22* pH-7.45 calTCO2-16* Base XS--5 [**2193-3-11**] 04:11PM BLOOD Type-[**Last Name (un) **] Temp-36.6 Comment-GREEN TOP [**2193-3-10**] 05:06PM BLOOD Type-[**Last Name (un) **] pO2-247* pCO2-25* pH-7.36 calTCO2-15* Base XS--9 Comment-GREEN TOP [**2193-3-10**] 05:06PM BLOOD Lactate-9.9* [**2193-3-10**] 05:53PM BLOOD Lactate-8.7* [**2193-3-10**] 09:34PM BLOOD Lactate-8.0* Na-133 K-6.0* Cl-98 calHCO3-15* [**2193-3-11**] 12:38AM BLOOD Lactate-5.9* [**2193-3-11**] 03:54AM BLOOD Lactate-3.5* [**2193-3-11**] 06:41AM BLOOD Lactate-3.6* [**2193-3-11**] 10:19AM BLOOD Lactate-2.4* [**2193-3-11**] 04:11PM BLOOD Lactate-3.7* [**2193-3-10**] 09:34PM BLOOD O2 Sat-97 COHgb-1.8 MetHgb-0.2 CXR: There is significant cardiomegaly noted. Prominent pulmonary hila are noted and there is some subcarinal splaying. Generalized pulmonary plethora is noted, although this is not as prominent as on the prior study. A few nonspecific interstitial lines are seen at the right lung base, again not as significant as on the prior study. . ECHO: The left atrium is moderately dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is small echodensity on the atrial side of the basal posterior basal leaflet/mitral annulus (cine loop #48). It may represent a small separated calcification or a vegetation (likely healed). A thrombus is possible, but less likely. Moderate to severe (3+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Severe pulmonary hypertension. Dilated and markedly hypokinetic right ventricle with evidence of pressure/volume overload and moderate to severe functional tricuspid regurgitation. Symmetric left ventricular hypertrophy with normal global and regional systolic function. Moderate to severe mitral regurgitation. A small mobile mass on the posterior mitral annulus/basal mitral leaflet, as described above. No clear atrial-level shunt seen, but unable to exclude a small PFO because of inadequate saline contrast opacification of the cardiac structures. . Compared with the prior study (images reviewed) of [**2192-4-16**], pericardial effusion is no longer seen. There is a suggestion of similar echodensity on the prior study, though images are less clear. Findings discussed with Dr. [**First Name8 (NamePattern2) 24906**] [**Last Name (NamePattern1) **] at 1420 hours on the day of the study. ===================== CHEST (PORTABLE AP) Study Date of [**2193-3-9**] 1:40 PM REASON FOR EXAMINATION: Evaluation of the patient with shortness of breath and tachypnea. Portable AP radiograph of the chest was reviewed in comparison to [**2193-3-7**]. Severe cardiomegaly and bilateral enlargement of the pulmonary arteries is redemonstrated, unchanged. Hilar and mediastinal lymphadenopathy is better assessed on chest CT. Cardiomegaly including enlargement of left and right atria is present. No appreciable pleural effusion or pneumothorax is seen. Lungs are clear. ============================= CHEST (PORTABLE AP) Study Date of [**2193-3-10**] 6:02 PM FINDINGS: In comparison with study of [**3-9**], there is again substantial enlargement of the cardiac silhouette without definite vascular congestion, raising the possibility of cardiomyopathy or pericardial effusion. Hilar prominence consistent with lymphadenopathy is better seen on chest CT. There is suggestion of some increasing opacification at the right base, though without obliteration of the right heart border or hemidiaphragm. This could be a technical artifact, though in the appropriate clinical setting, a developing right lower lung consolidation could be considered. ============================= CT HEAD W/O CONTRAST Study Date of [**2193-3-10**] 9:57 PM IMPRESSION: 1. No evidence of intracranial abnormalities. If clinical suspicion for an acute infarction is high, MRI is the recommended study of choice. 2. Renal osteodystrophy changes are again noted. =================================== CTA ABD/PELVIS W&W/O C & RECONS Study Date of [**2193-3-10**] 10:44 PM 0 IMPRESSION: 1. New small right pleural effusion with adjacent opacity, likely atelectasis, but infection cannot be excluded. 2. Celiac and SMA and associated branches are patent. The origin of the [**Female First Name (un) 899**] is thrombosed with retrograde filling. 3. Stenosis at the origin of the celiac artery with poststenotic dilation may be due to a crossing arcuate ligament given lack of atherosclerotic calcifications. 4. New small perihepatic and pelvic free fluid, diffuse body wall edema, cardiac enlargement with reflux of contrast into the IVC, likely due to volume overload. 5. Mild cecal wall thickening, likely due to underdistension and surrounding fluid but an ischemic or infectious colitis cannot be excluded. 6. Decreased opacification of the distal SMV. In the absence of bowel wall thickening to suggest bowel ischemia, this likely represents flow artifact rather than venous thrombsis. If symptoms persist, repeat imaging could be considered. ============================= [**3-11**] KUB: IMPRESSION: Nonspecific bowel gas pattern with mild prominence of the transverse colon and splenic flexure may suggest colonic ileus. No free air or pneumatosis. ============================= US of Defunct AV fistula: IMPRESSION: 1. Occluded feeding brachial artery with aneurysmal dilatation. 2. Occluded AV fistula, patent draining basilic vein. ============================== [**3-19**] TTE: 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. Right atrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is low normal (LVEF 50-55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is dilated with depressed free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 35 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. There is a 4 x 7 mm mobile echodensity seen on the atrial side of the P2 scallop of the posterior leaflet of the mitral valve which may represent a mass, thrombus associated with MAC, or vegetation. Severe (4+) mitral regurgitation is seen with reversal of flow in the left atrial appendage and pulmonary veins. Moderate to severe [3+] tricuspid regurgitation is seen. There is no pericardial effusion. IMPRESSION: No SEC or thrombus in the LA/LAA/RA/RAA. Small mobile mass seen on the posterior leaflet of the mitral valve, as described above. Severe mitral regurgitation. Moderate to severe tricuspid regurgitation. =================== DISCHARGE LABS [**2193-3-21**] 06:30AM BLOOD WBC-8.0 RBC-4.88 Hgb-12.5* Hct-43.2 MCV-88 MCH-25.6* MCHC-29.0* RDW-18.7* Plt Ct-72* [**2193-3-21**] 06:30AM BLOOD PT-62.0* PTT-48.4* INR(PT)-6.2* [**2193-3-21**] 06:30AM BLOOD Glucose-119* UreaN-25* Creat-5.8* Na-139 K-4.4 Cl-99 HCO3-26 AnGap-18 [**2193-3-21**] 06:30AM BLOOD Calcium-7.5* Phos-3.5 Mg-2.4 [**2193-3-19**] 06:25AM BLOOD TSH-14* [**2193-3-19**] 06:25AM BLOOD T4-4.1* T3-54* calcTBG-0.86 TUptake-1.16 T4Index-4.8 Free T4-0.96 [**2193-3-15**] 04:00AM BLOOD Cortsol-22.7* [**2193-3-20**] 10:55AM BLOOD Lactate-3.5* Brief Hospital Course: ASSESSMENT AND PLAN: 37-year-old male with history of ESRD on dialysis M/W/F s/p 2 failed kidney transplants presenting with tachycardia and Dyspnea, found to be in aflutter with new echo findings of dilated RV and right sided heart failure. Patient was later transferred to the MICU for a lactic acidosis in the setting of hypoglycemia. He was transfered back to medicine but then back to the ICU for a repeat episode of lactic acidosis and hypoglycemia, which improved after fluid removal with HD. The patient underwent successful aflutter ablation. . 1. A. flutter: Patient found to be in a supraventricular tachycardia consistant with atrial flutter while at outpatient surgical evaluation. He was sent to the emergency department where his heart rate did not respond to IV dilitizem or PO metoprolol. The patient had adenosine here which did not break the rhythm. Finally, vagal maneuvers elucidated 2:1 aflutter and the patient underwent a successful ablation with restoration of sinus rhythm. The patient will remain on coumadin for 1 month after the ablation. . 2. Right Heart Failure: Patient's most recent ECHO demonstrates right ventricular enlargement and hypokinesis with severe functional TR and significant pulmonary hypertension. Compared to the study a year prior the right sided failure has worsened. This is all consistant with the right heart cath results from [**4-26**] showing elevated left sided pressures, significant pulmonary HTN and resultant right sided failure. The patient was diuresed with UF/HD with improved exercise tolerance dyspnea, however, has now dropped his blood pressure with fluid removal. During his lactic acidosis episodes, the patient was resuscitated with multiple liters of fluid, which put him into worsened R heart failure with louder TR, a RV heave, and right sided S3. The patient underwent 3 consecutive sessions of HD/UF with improvement of his symptoms and decrease of his hepatic congestion. The patient tolerated this with his BP. He was discharged on metoprolol, lisinopril, and aspirin. . 3. Lactic acidosis: The patient developed multiple episodes of lactic acidosis, mostly asymptomatic except for some compensatory tachypnea. The patient was admitted to the ICU for workup, where he underwent imaging of his abdomen, was started empirically on broad spectrum ABX, and fluid resuscitated. The patient was found to have some chronic stenosis of the [**Female First Name (un) 899**], but this was not causing intraabdominal pathology and the patient had adequate collaterals. No infectious etiology was discovered and the patient's BP remained stable. Likely, these episodes were due to type B lactic acidosis and not due to a true hypoperfusion state. The patient had elevated LFTs consistent with hepatic congestion. The patient also had hypoglycemia during these episodes, which possibly triggered his lactate production. After improvement in his liver function and fluid status, the patient did not have further episodes of lactic acidosis. . 4. Hypoglycemia: Endocrine was consulted regarding this hypoglycemia. A insulin level, C peptide, beta hydroxybutyrate level were checked and did not elucidate a pathophysiology. Proinsulin is still pending. Likely, the patient received IV insulin due to hyperkalemia and with his poor renal clearance, had protracted hypoglycemia. The patient also had poor gluconeogenesis due to liver congestion. He will follow-up with his PCP. . 5. Mitral Regurgitation/Tricuspid Regurg: patient admitted with ECHO demonstrating severe MR, pulmonary hypertension, right ventricular dilation and hypokenesis. patient also noted to have severe TR on ECHO. The chronically elevated pressures from MR were felt to be causing atrial enarlgement and increasing his propensity for aflutter. Patient was referred to cardiac surgery for possible mitral valve replacement and tricuspid annular repair. He should follow-up with them after maximal medical optimization of his heart failure. . 6. CKD: Patient with ESRD from FSGS and is status post two failed cardaveric transplants. Was continued on home MWF dialysis sessions while inpatient. . 7. Hyperparathyroidism: Per report was at his surgeon's office today for preop eval. Nothing in our system referring to this so likely a new diagnosis. Calcium here was low and PTH was extremely elevated. Likely a component of renal osteodystrophy and tertiary hyperparathyroidism. Patient will continue to follow-up with renal and endocrine surgery. . TRANSITIONAL ISSUES: - patient will need to have endocrine surgery appointment rescheduled - patient is a full code - F/u proinsulin - Patient is being followed by [**Company 191**] coumadin clinic - Cardiac surgery f/u as dictated by his outpatient cardiologist Medications on Admission: Phoslo 667 2 capsules TID Sensipar 60mg daily labetolol 200mg [**Hospital1 **] nifedipine 60mg xr daily omeprazole 40mg daily Tums 2 tabs TID Modafinil 10mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Capsule(s)* Refills:*2* 3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 caps* Refills:*2* 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Coumadin 1 mg Tablet Sig: 1-5 Tablets PO once a day: Dose will be determined by the [**Hospital 197**] Clinic. Disp:*90 Tablet(s)* Refills:*2* 8. Outpatient Lab Work Please have INR drawn at dialysis on Friday [**3-22**]. Please have results faxed to [**Hospital 191**] [**Hospital **] clinic at [**Telephone/Fax (1) 3534**]. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: -Atrial flutter -right heart failure -end stage renal disease -hypoglycemia -lactic acidosis SECONDARY: -hyperparathyroidism 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 while you were in the hosptial. You came in with a fast heart rate called atrial flutter. We performed a procedure that put you back in normal rhythm. After the procedure, you will need to stay on a blood thinner called coumadin for at least a month. This medication will need its levels monitored by the [**Hospital 191**] [**Hospital **] clinic. They will be in touch with you and let you know how much coumadin to take. You were also found to have very significant failure of the right side of your heart. We took fluid off with dialysis, but we were limited somewhat by your low blood pressure. You will be discharged on a couple of new medications listed below. While in the hospital you an episode of low blood sugar and some electrolyte abnormalities. We performed a head CAT scan which was negative for an acute bleed. We also treated your electrolyte abnormalities with fluids. We performed a CAT scan of your abdomen and pelvis which showed one of the arteries in your mesentery (which feeds the intestines) was blocked but our transplant surgeons did not feel you needed a surgery at this time. As for your low blood sugar, we gave you sugar to correct this and since then your blood sugars have been stable. The following changes have been made to your medications: - START Aspirin 81mg - START Metoprolol 50mg once a day - Start Lisinopril 5mg once a day - Start Coumadin as directed by the [**Hospital3 **], for now hold it given your INR is elevated until otherwise directed. - Continue Phoslo, omeprazole, and nephrocaps as directed -STOP labetalol -STOP nefedipine -STOP Modafinil Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2193-3-27**] at 9:30 AM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: FRIDAY [**2193-4-5**] at 2:35 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 24905**], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "411.89", "585.6", "276.7", "588.81", "276.2", "287.5", "251.2", "573.0", "397.0", "338.29", "272.0", "428.0", "427.32", "416.8", "285.21", "428.33", "558.9", "557.1", "789.07", "424.0", "403.11" ]

icd9cm

[ [ [] ] ]

[ "37.27", "37.28", "37.34", "39.95" ]

icd9pcs

[ [ [] ] ]

23897, 23903

17820, 22309

307, 346

24082, 24082

6295, 6295

25898, 26575

4823, 4921

22786, 23874

23924, 24061

22599, 22763

24233, 25875

4936, 5979

5995, 6276

22330, 22573

239, 269

374, 4162

6311, 17797

24097, 24209

4184, 4727

4743, 4807

74,793

181,257

38932

Discharge summary

report

Admission Date: [**2136-3-20**] Discharge Date: [**2136-3-24**] Date of Birth: [**2059-12-23**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest tightness Major Surgical or Invasive Procedure: Coronary artery bypass graft x4 (left internal mammary artery > left anterior descending, saphenous vein graft > diagonal, saphenous vein graft > obtuse marginal, saphenous vein graft > posterior descending artery) [**2136-3-20**] History of Present Illness: 76 year old gentleman has a history of chest tightness associated with shortness of breath that occurred this winter while he was shoveling. He also reports having dyspnea when he walks quickly. He denies any symptoms occurring at rest. He subsequently had a stress test with myoview on [**2136-2-21**]. He exercised for 4 minutes 31 seconds. Positive for EKG changes. Nuclear imaging revealed a large, severe predominantly reversible defect towards the apex and fixed towards the base, septal and inferior walls. Anterior wall hypokinesis. EF 47%. Presents today for cardiac cath which revealed 3 V CAD. Cardiac surgery consulted for CABG evaluation. Past Medical History: Hypertension Glaucoma Ureter stone removal Social History: Lives with: Girlfriend Occupation:Retired Tobacco: remote hx (quit 40 years ago) ETOH:1 glass of wine with dinner daily Family History: father died during [**Name (NI) 3106**], mother died at age 77. Sister with CHD, CHF, died 1 year ago Physical Exam: Pulse: 72 Resp:14 O2 sat:96% RA B/P Right: 113/68 Left: Height: 5'9" Weight: 205# General:AAO x 3 in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:2+ - no hematoma Left:2+ DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right:none Left:none Pertinent Results: Pre Bypass: Left ventricular wall thicknesses are normal. There is mild regional left ventricular systolic dysfunction with Basal inferior, mid anterior and anteroseptal and apical septal dyskinesis. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. The aortic valve area calcluates to 1.95 cm2 by the continuty equation, suggesting borderline mild aortic stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post Bypass: Patient is AV paced. Preseved biventricular function. Septum appears dyskentic, c/w pacing. Wall motion is otherwise unchanged. Aortic contours intact. Remaing exam is unchanged. All findings discussed with surgeons at the time of the exam. [**2136-3-24**] 05:30AM BLOOD WBC-7.3 RBC-2.74* Hgb-8.2* Hct-23.9* MCV-87 MCH-30.0 MCHC-34.3 RDW-13.5 Plt Ct-155 [**2136-3-23**] 05:25AM BLOOD Hct-25.2* [**2136-3-24**] 05:30AM BLOOD Glucose-84 UreaN-34* Creat-0.8 Na-136 K-4.1 Cl-100 HCO3-30 AnGap-10 Brief Hospital Course: Admitted same day to surgery and underwent coronary artery bypass graft surgery. See operative report for further details. He recieved cefazolin for perioperative antibiotics. Post operatively he was transferred to the intensive care unit for post operative management. In the first twenty four hours he was weaned from sedation, awoke neurologically intact, and was extubated without complications. He continued to progress and on post operative day one was transferred to the floor for the remainder of his care. Physical therapy worked with him on strength and mobility. He continued to progress and was ready for discharge to home on post operative day 4. All follow up appointments were advised. Medications on Admission: Toprol XL 25 mg daily Travoprost 0.004% 1 gtt OS q HS ASA 81 mg daily Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary artery disease s/p CABG Hypertension Glaucoma ureter stone Discharge Condition: Alert and oriented x3 Ambulating sternal pain managed with percocet Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2136-4-26**] 1:15 Please call to schedule appointments Primary Care Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 86377**] in [**1-7**] weeks [**Telephone/Fax (1) 86378**] Cardiologist Dr [**Last Name (STitle) 5686**] [**Telephone/Fax (1) 62**] in [**1-7**] weeks Completed by:[**2136-3-24**]

[ "401.9", "414.01", "426.11", "411.1", "997.1", "365.9", "458.29" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4398, 4456

3567, 4277

338, 571

4568, 4638

2261, 3544

5178, 5584

1475, 1578

4477, 4547

4303, 4375

4662, 5155

1593, 2242

283, 300

599, 1254

1276, 1321

1337, 1459

30,671

177,470

29057

Discharge summary

report

Admission Date: [**2112-11-10**] Discharge Date: [**2112-11-24**] Date of Birth: [**2080-7-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7651**] Chief Complaint: Dyspnea Chest pain Major Surgical or Invasive Procedure: 1. Thoracentesis [**11-14**] 2. Pericardiocentesis [**11-16**] 3. VATS, Chest Tube, Pericardial Window dilation, [**11-17**] History of Present Illness: This is a 32 y.o. male with history of aortic valve replacement for strep. viridans endocarditis that was complicated by aortic insufficiency who presents with progressive dyspnea. Patient has experienced exertional dypsnea since [**2112-11-7**]. Prior to this, patient had been able to walk several walks without any difficulty in breathing. Since [**11-7**], he becomes dypsneic after walking 1 block on level ground. He has never had dyspnea before and denies any cough or pleuritic chest pain. Patient reports 4 pillow orthopnea. He denies any lower exremity oedema. He reports reproducible chest pain that is at baseline from his sternotomy incision, which is relieved with ibuprofen. He also reports back pain when bending down to pick something up. . In the ED, bedside echocardiogram was obtained and demonstrated large pericardial effusion, without any tamponade physiology. Chest x-ray revealed large chest x-ray. Although patient was dyspneic, he did not have any hemodynamic instability or significant pulsus paradoxus. He was admitted to CCU for hemodynamic monitoring. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for dyspnea and chest pain as above. No history of ankle edema, palpitations, syncope or presyncope. Past Medical History: Bicuspid aortic valve Aortic regurgitation Anemia AV Endocardiitis (Strept Veridans) Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T:99.1 , BP:137/80 , HR:100 , RR:14 , O2 96% on RA, Pulsus of 5mmHg Gen: WDWN Spanish speaking male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 6cm, negative Kussmaul's sign. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Diminished breath sounds and dullness to percussion at right base. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; 2+ DP Pertinent Results: EKG demonstrated Sinus rhythm at 66 bpm with decreased relative voltage compared with prior dated [**6-/2112**], at which time patient had met criteria for LVH. Secondary TWI from LVH, but otherwise no new ST-T wave changes. 2D-ECHOCARDIOGRAM performed on [**11-10**] demonstrated: Borderline dilation of LV cavity, normal LV systolic function (EF 55%), normally-functioning mechanical aortic valve prosthesis, [**1-26**]+ MR, large circumferential pericardial effusion, no echographic evidence of tamponade. Cx-ray on [**11-10**]: A large right pleural effusion associated with compressive atelectasis, cardiomegaly. [**2112-11-10**] 12:30PM GLUCOSE-84 UREA N-17 CREAT-0.8 SODIUM-140 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-27 ANION GAP-11 [**2112-11-10**] 12:30PM WBC-3.9* RBC-4.50* HGB-12.5* HCT-38.1* MCV-85 MCH-27.8 MCHC-32.9 RDW-17.4* [**2112-11-10**] 12:30PM PLT COUNT-224 [**2112-11-10**] 12:30PM NEUTS-67.3 LYMPHS-24.4 MONOS-5.9 EOS-2.1 BASOS-0.4 [**2112-11-10**] 12:30PM PT-29.8* PTT-31.6 INR(PT)-3.1* Brief Hospital Course: ASSESSMENT AND PLAN, AS REVIEWED AND DISCUSSED IN MULTIDISCIPLINARY ROUNDS . ## Pericardiocentesis: Patient admitted to CCU w/ cocern for impending tamponade. Was monitored in CCU and deemed to be stable for floor after an appropriate period of time. Coumadin was held and heparin gtt started for anticoagulation when patient's INR near 2.5. Pericardiocentesis drain placed in Cath Lab on [**11-16**]. Post-drainage showed near complete resolution of the effusion. Patient was then taken to OR by thoracics for VATS (out of concern for hemothorax), chest tube placement, and pericardial window. OR course notable for open pericardial window (as noted in prior operative reports) that was further dilated in OR. 2L of fluid removed that was sanguinous and clotted prior to being able to check Hct - suggesting significant blood component. Patient with small pneumothorax s/p procedure, and w/ air leak. Chest tube left in place until [**2112-11-21**] when deemed safe to remove. . ## Pleural effusion - Large right-sided pleural effusion. Once patient's INR subtherapeutic, patient underwent diagnostic and therapeutic thoracentesis on [**11-14**] removing 1L of sanguinous fluid from the R-pleural space. Hct of fluid 13% consistent with prior bleeding. LDH and protein consistent with exudative process as well. After pericardiocentesis as above, patient had some improvement in pleural effusions indicating communication between the pleural and pericardial space. Given concern for lung entrapment with bloody effusions, definitive drainage of pleural space was performed in OR w/ VATS and chest tube placement as above. Ultimately upwards of 3L of fluid was removed from the R-lung. F/u imaging showed near complete resolution of the patient's effusions. Patient remained comfortable on room air throughout his hospitalization. . ## Valves - 25mm mechanical aortic valve prosthesis - On admission, patient's coumadin held. Heparin gtt started when INR near 2.0. CT surgery recommended the patient to be on ASA and coumadin on discharge due to added benefit of preventing thrombosis in mechanical valves with minimal increase in risk of significant GI bleeding. Patient was restarted on coumadin prior to discharge. Target INR [**2-27**] with aortic mechanical valve. Will be followed in coumadin clinic. . ## Remainder of the patient's hospitalization was uneventful. Medications on Admission: 1. ASA 81g daily 2. Ibuprofen 400mg daily 3. Warfarin 6mg qHS Discharge Medications: 1. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 7. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: - Post-pericardotomy Syndrome with pericardial and pleural effusion Secondary Diagnosis: - Mechanical Aortic Valve (INR 1.5-2.0) Discharge Condition: Good. Chest tube removed, patient comfortable on room air w/o increased work of breathing. Discharge Instructions: You were admitted to the hospital for evaluation of increasing shortness of breath. Tests done on admission indicated that you had an accumulation of fluid around your heart and in your lungs. This fluid is likely the result of an infrequent complication of your prior aortic valve surgery and is known as post-pericardotomy syndrome. While in the hospital you had this fluid removed by first a bedside thoracentesis to drain some fluid from your lung. Second, a pericardiocentesis was performed to drain fluid from around your heart. Lastly, to ensure that all the fluid was removed effectively a chest tube was placed in the OR and any remaining fluid was removed from the lung and around the heart. Please follow-up with your Cardiologist Dr.[**Doctor Last Name 3733**] as below and follow-up with your PCP as directed below. Should you experience any sudden shortness of breath, chest pain, increasing difficulty with breathing, or any other symptom concerning to you please contact your doctor, or return to the Emergency Department as soon as possible. Followup Instructions: [**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2112-12-6**] 2:40 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2112-12-21**] 3:30 [**Hospital 197**] Clinic- [**2112-11-25**] to have INR checked Goal INR 1.5-2.0

[ "V43.3", "429.4", "423.0", "420.90", "511.8", "285.29", "V58.61", "998.11" ]

icd9cm

[ [ [] ] ]

[ "37.21", "37.0", "34.91", "34.09", "34.52", "88.55" ]

icd9pcs

[ [ [] ] ]

7639, 7696

4372, 6767

336, 466

7890, 7984

3324, 4349

9098, 9468

2321, 2403

6882, 7616

7717, 7717

6793, 6859

8008, 9075

2418, 3305

278, 298

494, 2071

7827, 7869

7737, 7805

2093, 2180

2196, 2305

24,797

101,025

21147

Discharge summary

report

Admission Date: [**2164-3-25**] Discharge Date: [**2164-3-28**] Date of Birth: [**2108-3-28**] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 55 year old male with a past medical history significant for end-stage renal disease on hemodialysis, Hepatitis C, and Hepatitis B, hypertension, poly-substance abuse found down, on admission here with a finger stick of 68. The patient was unable to provide any history on presentation. The patient was unintelligible and flailing limbs in the Emergency Department. Temperature was 100.2 F., and more than 103.0 F. rectally in the Emergency Department with systolic blood pressure of 200 and with heart rate in the 120s. The patient's labs were notable for a creatinine of 6.2; no urine output when Foley catheter was placed. He had arterial blood gas of 7.51, 44, 74. A lumbar puncture was performed, showing 6 white blood cells with 93% neutrophils and 31 red blood cells; no organisms on Gram Stain. The patient received ceftriaxone 2 grams, Vancomycin 1 gram and a total of 6 mg of Ativan and 5 mg of Haldol, Tylenol and the patient was admitted to [**Hospital Unit Name 153**] secondary to unstable oxygen saturation. PAST MEDICAL HISTORY: Obtained from [**Hospital6 **]. 1. End-stage renal disease on hemodialysis. 2. Chronic anemia, secondary to renal disease. Baseline hematocrit of 28 to 32. 3. Chronic thrombocytopenia, baseline platelets between 70 to 80. 4. Hypertension. 5. Hepatitis B and C. 6. Myocardial infarction at age 21. 7. Peripheral vascular disease. 8. Abdominal aortic aneurysm 3.9 cm measured in [**2163-3-24**]. 9. Status post appendectomy. 10. Cholelithiasis. OUTPATIENT MEDICATIONS: 1. Nephrocaps one capsule p.o. q. day. 2. Pantoprazole 40 mg p.o. q. day. 3. Sevelamer 400 mg p.o. three times a day. 4. Amlodipine 10 mg p.o. q. day. 5. Docusate 100 mg p.o. twice a day. 6. Percocet p.r.n. PHYSICAL EXAMINATION: On admission, temperature 98.4 F.; blood pressure 134/75; heart rate ranging between 91 to 126; respiratory rate 18; O2 saturation 92% on room air. The patient was a confused, cachectic, combative male. Pupils about 3 mm. There is a question of being unreactive. Unable to assess oral cavity. Neck is difficult to examination with a question of stiffness. Lungs clear to auscultation bilaterally. Heart: Regular rate, S1, S2, no murmur. Belly is soft, nontender, nondistended; positive bowel sounds. Has several old scars. Rectal examination is guaiac positive. Extremities have left fistula with thrill and bruit and has a right surgical incision oozing serosanguinous fluid and indurated. Neurologic examination was difficult as the patient was uncooperative, somnolent, but easily aroused, agitated, nonverbal, moving all four extremities. Strength intact; three plus reflexes throughout. No clonus. Toes were downward. LABORATORY: On admission, pertinent labs included white blood cell count 11.1, hematocrit 32.4, platelets 95, MCV of 103. Chem-10 was sodium of 139, potassium 4.7, chloride 92; bicarbonate 25, BUN 11, creatinine 6.2, glucose 100, anion gap of 22, INR of 1.1. CK 107, troponin 0.03. Serum toxicology was negative. The patient had an EKG showing sinus tachycardia at 122; normal axis and intervals. Has left ventricular hypertrophy by voltage, one to two mm ST depression in V4 through V6 and II. No Qs. Chest x-ray was clear but has motion artifacts. MRI of the head on [**3-25**], showing chronic microvascular infarction; no acute infarction. CT scan of the head on [**3-24**], was negative for hemorrhage. His white matter change was consistent with microvascular angiopathy. The patient had an echocardiogram done on [**3-27**] showing there is a mild symmetric left ventricular hypertrophy and overall left ventricular systolic function is normal. Left ventricular ejection fraction greater than 55%. Mild aortic regurgitation and trivial mitral regurgitation. No evidence of endocarditis seen. HOSPITAL COURSE: 1. ALTERED MENTAL STATUS: Differential diagnosis including syncope, seizures, stroke, HSV encephalitis, alcohol withdrawal or illicit drug use. The patient improved back to his baseline after staying in the Intensive Care Unit for two days and then was transferred to the floor. Both CT scan and MRI of the head showing old infarction; no acute hemorrhage or infarction. Given his history of poly-substance abuse, this could be from the drug use, although the serum toxicology was negative. The lumbar puncture was negative for bacterial culture and viral culture and later returned also negative. The patient was originally started on Acyclovir due to suspicion of possible HSV infection, encephalitis and was discharged after viral culture returned to be negative. 2. RULE OUT MYOCARDIAL INFARCTION: The patient has [**Street Address(2) 4793**] depression V4 through V6 and II, but has three sets of stable CK and troponin. The echocardiogram showed normal left ventricular function with only one plus AR and trivial mitral regurgitation; otherwise unremarkable. 3. GUAIAC POSITIVE STOOL: The patient had a hematocrit drop slightly below 25 from a baseline of 28. Was transfused with one unit of packed red blood cells. We recommend outpatient endoscopy and colonoscopy. Given that the patient is a regular [**Hospital6 **] patient, it would be more beneficial for him to go to the [**Hospital6 **] system so the record will stay there. 4. END-STAGE RENAL DISEASE ON HEMODIALYSIS: He has received hemodialysis on Monday and Wednesday during his hospital stay. 5. THROMBOCYTOPENIA OF UNKNOWN CAUSE: This has been a chronic problem for the patient. At discharge, platelet level is 78. 6. ANEMIA: The patient has chronic anemia secondary to end-stage renal disease. Iron studies are consistent with anemia of chronic disease. Has normal folate and B12 levels. Will just continue monitoring and transfuse if less than 25. 7. HYPERTENSION: The patient's blood pressure was on the higher end and only on Amlodipine 10 mg p.o. q. day. Will recommend him to add another [**Doctor Last Name 360**]. His primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 56081**], was notified by his nurse in the [**Location (un) 56082**] Center. The patient had a high blood pressure while in the hospital and recommend monitoring and adding another [**Doctor Last Name 360**] for better control of his blood pressure. DISCHARGE DIAGNOSES: 1. Syncope. 2. End-stage renal disease on hemodialysis. 3. Hypertension. 4. Peripheral vascular disease. 5. Abdominal aortic aneurysm. 6. Poly-substance abuse. 7. Hepatitis B and C. DISCHARGE STATUS: To home. CONDITION AT DISCHARGE: Vitals stable, ambulating, eating. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. q. day. 2. Sevelamer 400 mg p.o. three times a day. 3. B complex. 4. Vitamin C. 5. Folic acid 1 mg p.o. q. day. 6. Amlodipine 10 mg p.o. q. day. 7. Docusate 100 mg p.o. twice a day. DISCHARGE INSTRUCTIONS: 1. The patient should call his primary doctor, Dr. [**Last Name (STitle) 56081**], for follow-up within the week. 2. He should also follow-up with hemodialysis center as he is routinely scheduled and the next one is this Friday. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Name8 (MD) 18513**] MEDQUIST36 D: [**2164-3-28**] 16:07 T: [**2164-3-29**] 19:12 JOB#: [**Job Number 56083**]

[ "799.4", "070.32", "780.2", "285.9", "403.91", "287.5", "441.4", "070.54" ]

icd9cm

[ [ [] ] ]

[ "39.95", "03.31", "99.04" ]

icd9pcs

[ [ [] ] ]

6500, 6729

6804, 7017

4017, 4030

7041, 7526

1709, 1923

1946, 4000

6745, 6781

166, 1207

4046, 6479

1231, 1685

66,483

178,107

36038

Discharge summary

report

Admission Date: [**2190-12-29**] Discharge Date: [**2191-1-3**] Date of Birth: [**2114-6-28**] Sex: M Service: MEDICINE Allergies: Naprosyn Attending:[**Doctor First Name 1402**] Chief Complaint: Transfer for urgent cardiac catheterization Major Surgical or Invasive Procedure: Cardiac catheterization Central venous line placement (subclavian) History of Present Illness: Mr. [**Known lastname **] is a 76 year-old man with a history of DM, HTN, HL but no known CAD, who initially presented to an OSH with shortness of breath on [**12-27**] who is now being transferred with a STEMI. Per the OSH records (no history could be obtained from the patient as he is intubated): Presented on [**12-27**] with two weeks of cough and dyspnea. Seen by his PCP and was given tylenol with codeine. On the day of admission, had worsened SOB and cough with white sputum. No fevers. Also with chest pain, reportedly from coughing. Noted to have ARF (SCr of 1.5 on admit) with a lactate of 1.6. CK and troponin were negative. BNP was 386. CXR showed RLL PNA and he was treated with levaquin. On HD#2, at 7pm, noted by to be SOB and wheezing. O2 sat <80% and placed on NRB after which time he became unresponsive with reported right eye gaze and questionable weakness of the RUE. An ABG was done and showed 7.03/106/297 (on NRB) and he was intubated. Soon after, BP 220/113 with a HR of 114. Labs later returned with a CK of 186, MB 10.2, trop T 0.495. ECG showed sinus tach. Aspirin then increased to 325 and atorvastatin 80 given. A head CT was ordered before heparin was administered. At 4:30am on day of transfer patient was hypotensive with ECG showing ?STEMI. Neosynephrine was started. He is transferred to [**Hospital1 18**] for urgent cardiac catheterization, on Neo, insulin, and heparin gtts. Cardiac catheterization at [**Hospital1 18**] showed: Two vessel coronary artery disease. Diastolic dysfunction with severely elevated filling pressures. Stenting of mid LAD with two overlapping BMS. Past Medical History: 1. CARDIAC RISK FACTORS: (+) Diabetes (+) Dyslipidemia (+) Hypertension 2. CARDIAC HISTORY: -CABG: None. -PCI: None. -PACING/ICD: None. 3. OTHER PAST MEDICAL HISTORY: - Diverticulosis - History of colon polyps - Osteoarthritis Social History: Lives at home alone. Quit smoking 15 years ago, prior to that smoked [**1-13**] ppd x18 years. Denied EtOH and illicit drug use. Family History: Non contributory Physical Exam: GENERAL: Intubated and sedated. HEENT: NCAT. Sclera anicteric. Pupils constricted. NECK: Difficult to assess JVP with central line in place. CARDIAC: RRR, nl S1-S2, no MRG LUNGS: Vented resp were unlabored. Diffuse wheezes anteriorly. ABDOMEN: +BS, soft/NT/ND. EXTREMITIES: WWP, No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ DPs bilaterally. Pertinent Results: Laboraotyr studies: [**2190-12-29**] 07:51AM BLOOD WBC-10.5 RBC-3.43* Hgb-11.0* Hct-31.6* MCV-92 MCH-32.0 MCHC-34.9 RDW-13.2 Plt Ct-217 [**2190-12-30**] 04:21AM BLOOD WBC-14.5* RBC-3.31* Hgb-10.5* Hct-30.0* MCV-91 MCH-31.9 MCHC-35.1* RDW-13.3 Plt Ct-194 [**2191-1-2**] 06:21AM BLOOD WBC-9.4 RBC-3.33* Hgb-10.3* Hct-29.8* MCV-90 MCH-31.1 MCHC-34.7 RDW-13.3 Plt Ct-186 [**2190-12-29**] 07:51AM BLOOD Neuts-87.8* Lymphs-10.4* Monos-1.2* Eos-0.6 Baso-0 [**2190-12-29**] 07:51AM BLOOD PT-15.1* PTT-68.6* INR(PT)-1.3* [**2191-1-2**] 06:21AM BLOOD PT-21.7* PTT-150* INR(PT)-2.1* [**2190-12-29**] 07:51AM BLOOD Glucose-174* UreaN-29* Creat-1.4* Na-139 K-4.5 Cl-106 HCO3-23 AnGap-15 [**2191-1-2**] 06:21AM BLOOD Glucose-112* UreaN-27* Creat-1.1 Na-142 K-3.6 Cl-102 HCO3-30 AnGap-14 [**2190-12-29**] 11:10AM BLOOD CK(CPK)-262* [**2190-12-29**] 03:00PM BLOOD CK(CPK)-511* [**2190-12-29**] 10:01PM BLOOD CK(CPK)-714* [**2190-12-30**] 04:21AM BLOOD CK(CPK)-644* [**2190-12-29**] 11:10AM BLOOD CK-MB-19* MB Indx-7.3 cTropnT-0.36* [**2190-12-29**] 03:00PM BLOOD CK-MB-50* MB Indx-9.8* cTropnT-0.64* [**2190-12-29**] 10:01PM BLOOD CK-MB-80* MB Indx-11.2* cTropnT-1.24* [**2190-12-30**] 04:21AM BLOOD CK-MB-71* MB Indx-11.0* cTropnT-2.02* [**2190-12-29**] 11:10AM BLOOD Calcium-7.8* Phos-2.8 Mg-2.2 Cholest-246* [**2190-12-29**] 07:51AM BLOOD Albumin-3.6 [**2191-1-2**] 06:21AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.1 [**2190-12-29**] 07:51AM BLOOD VitB12-352 [**2190-12-29**] 07:51AM BLOOD %HbA1c-6.2* [**2190-12-29**] 11:10AM BLOOD Triglyc-113 HDL-45 CHOL/HD-5.5 LDLcalc-178* [**2190-12-29**] 09:55AM BLOOD Type-ART pO2-113* pCO2-56* pH-7.28* calTCO2-27 Base XS--1 [**2190-12-31**] 02:10PM BLOOD Type-ART pO2-100 pCO2-46* pH-7.43 calTCO2-32* Base XS-4 [**2190-12-30**] 03:12PM BLOOD Type-ART Temp-37.3 Rates-/15 PEEP-5 FiO2-40 pO2-105 pCO2-53* pH-7.31* calTCO2-28 Base XS-0 Intubat-INTUBATED [**2190-12-30**] 05:52AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.022 [**2190-12-30**] 05:52AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2190-12-30**] 05:52AM URINE RBC-10* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [**2190-12-30**] 05:52AM URINE CastGr-4* CastHy-28* Microbiology: [**2191-1-1**] SWAB RESPIRATORY CULTURE-Pending; GRAM STAIN-No organisms; FUNGAL CULTURE-Pending [**2191-1-1**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2191-1-1**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-Pending [**2191-1-1**] BLOOD CULTURE Blood Culture - Pending [**2191-1-1**] CATHETER TIP-IV Pending [**2191-1-1**] ASPIRATE Nasal Sinus GRAM STAIN- GRAM STAIN (Final [**2191-1-1**]): 2+ (1-5 per 1000X FIELD): SQUAMOUS EPITHELIAL CELLS. 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. Respiratory culture and fungal cultures - Pending. [**2190-12-30**] CATHETER TIP-IV WOUND CULTURE-negative [**2190-12-30**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY {ASPERGILLUS SPECIES}, sparse growth; oropharyngeal flora [**2190-12-30**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2190-12-30**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2190-12-30**] URINE URINE CULTURE-Negative [**2190-12-29**] MRSA SCREEN MRSA SCREEN-negative [**2190-12-29**] CATHETER TIP-IV Negative Imaging/Studies: ECG 12.17: Artifact is present. Sinus rhythm. There are tiny R waves in the anterior leads consistent with possible prior anterior infarction. There is ST segment elevation in the lateral and anterolateral leads with ST segment depression in the inferior leads consistent with acute myocardial infarction. Clinical correlation is suggested. C. Catheterization [**12-29**]: FINAL DIAGNOSIS: 1. STEMI. 2. Two vessel coronary artery disease. 3. Diastolic dysfunction with severely elevated filling pressures. 4. Successful stenting of the mid LAD with two overlapping BMS. CXR 12.17: IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Heterogeneous peribronchial infiltration in the lower lungs, right greater than left could be due to asymmetric edema, but alternatively, given the presence of partially calcified pleural thickening along the right lower costal margin could be due to overlying pleural abnormality. Upper lungs are clear, and free of either vascular congestion or edema. There is no layering pleural effusion. Heart size is normal. ET tube in standard placement, an ascending pulmonary floatation catheter tip projects over the left pulmonary artery at the origin of the descending portion, nasogastric tube passes into the stomach and out of view and a right subclavian line can be traced as far as the low right atrium. No pneumothorax. ECG [**12-30**]: Sinus rhythm. ST segment elevation in the anterior and anterolateral leads with terminal T wave inversion and more modest ST-T wave changes in the remaining leads consistent with evolving myocardial infarction. Compared to the previous tracing evidence of evolution is now present. Clinical correlation is suggested. ECHO [**12-31**]: The left atrium is elongated. A small secundum atrial septal defect is present. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Small secundum ASD. CXR [**12-31**]: FRONTAL CHEST RADIOGRAPH: The endotracheal tube and Swan-Ganz catheter have been removed. A left subclavian central venous line tip terminates in distal SVC. There is no pneumothorax. The cardiomediastinal silhouette is stable. Bibasilar opacities likely represent atelectasis and are unchanged. CTA head/neck: 1. No evidence of acute infarct, vessel cutoff or intracranial hemorrhage. Final read pending reformats. 2. Left maxillary opacification and mass effect mass causes dehiscence of the medial wall. Consideration includes inverting papilloma but squamous cell cancer or infectious process cannot be excluded. Appearance is unchanged from [**Location (un) 620**] study performed [**2190-12-29**]. Chest CT: Preliminary - No focal consolidation to suggest aspergillus pneumonia. Brief Hospital Course: 76M with HTN, DM, HL, but no known CAD, presented to OSH w/ PNA and ARF, now transferred to [**Hospital1 18**] CCU w/ STEMI. S/p BMS x2 to mid-LAD 90% stenosis. 1. CAD. Pt w/ STEMI, admitted to CCU on [**12-29**] s/p BMS x2 to mid-LAD for 90% stenosis. On cath, Fick CO 6.73, CI 3.20. Anatomy also w/ proximally occluded RCA w/ robust collaterals. ECG pos cath showing STe in V2-V6 w/ biphasi Tw in same leads. His CKs peaked at 714, MB 11.2 on [**12-29**] and troponin at 2.02 on [**12-30**]. On [**12-29**] patient was started on ASA 325, Plavix 75 and high dose statin. Patient was also started on lopressor 12.5 TID. Patient was continued on this regimen until [**12-30**] when he was extubated. He was started on captopril 12.5mg TID for elevated BPs and MI on [**12-31**]. After extubation, patient denied CP or shortness of breath. Throughout this time he was continued on heparin gtt for anterior wall MI and was transitioned to coumadin. He was trasferred to the floor on [**1-1**]. He remained symptom free through hospital stay to discharge. At time of discharge his medications included Metoprolol XL 50 mg QD and Lisinopril 10. The patient was started on coumadin for prophylaxis of possible thrombus formation after MI. His INR was therapeutic at 2.6 on discharge. 2. Pneumonia. Noted on CXR from OSH w/ RLL infiltrate, and started on Levofloxacin at OSH, [**12-27**] for CAP. He was continued on this regimen while intubated. Patient remained afebrile throughout CCU stay. As respiratory status and oxygenation improved and pt was extubated, repeat CXR showed bibasilar opacities consistent w/ atelectasis. Sputum Cx did not grow organisms w/ exception of Aspergillus species. Patient will complete a 7day course of levofloxacin the day after discharge. 3. Aspergillus positive sputum Cx & Left maxillary sinus opacification with dehiscence of medial sinus wall. Significance of Aspergillus on sputum culture was unclear. Pt. is diabetic and received solumedrol at OSH and one dose of prednisone for COPD exacerbation while at [**Hospital1 18**], but is not frankly immunocompromised. CT chest was obtained that did not show changes consistent w/ infiltrative aspergillus. Sinus cultures were negative/pending at time of discharge. ID was consulted who did not feel that the findings were consistent w/ invasive aspergillosis. CT at OSH and CTA at [**Hospital1 18**] showed opacification found in L maxillary sinus with mass effect mass and dehiscence of the medial sinus wall. This was felt to be unlikely an infectious process, but was felt to be more likely a neoplastic one by ID. ENT was consulted and felt the process was not related to the respiratory failure/COPD exacerbation. A Cx sample was obtained. Patient was recommended to follow up w/ ENT as an outpatient for further workup. 4. Hypercarbic respiratory failure. Pt. was intubated at OSH for CO2 >100 on ABG, treated w/ duonebs, levofloxacin and solumedrol IV for COPD exacerbation. PCO2 was 56 on admission and pt was found to have diffuse wheezes on exam. He was started on Ipratropium and Xopenex nebs stadning and prn. Levofloxacin was continued. He received one dose of 20 mg IV lasix. Respiratory status improved w/ ABG of 105/53/7.31/28 and patient was successfully extubated on [**12-30**]. He remained somewhat somnolent post extubation, ABG PCO2 was 46, however this improved significantly by [**12-31**] w/ pt being A&O x3, communicating clearly. By day of discharge he was sating well in the mid 90's on RA. He contineud to be treated with xopenex tid and atroven q6h for COPD flare. 5. Left facial droop and hemiparesis. On day of extubation patient was noted to have a left facial droop, LE hyperreflexia, upgoing left toe and LLE LUE weakness, however patient was somnolent and could not cooperate w/ a full motor exam. Given OSH report of R gaze deviation and these findings, CVA or ICH was suspected. Heparin gtt was temporarily held. CTA of heach and neck did not show flow limiting lesions, ICH or lesions consistent w/ CVA. Carotid U/S showed 60-69% R ICA stenosis, 40-59% L ICA stensosis. Pt's symptoms and exam improved on [**1-1**], w/ slight L nasolabial fold flattening remaining on exam. It was felt that this may have been a TIA or possible localized symptoms that may occur in patient's w/ encephalopathy. Anticoagulation was restarted and patient was arranged for OP Neurology follow up. 6. Congestive heart failure, diastolic, acute. Pt. w/o symptoms of HF on exam or hx, however w/ slight suggestion of HF on initial XR. He received one dose of lasix 20mg prior to extubation. Echo showed LVEF > 55% and mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Pt was continued on metoprolol and started on ACEI for HTN. At time of discharge his medications included Metoprolol XL 50 mg QD and Lisinopril 10. 7. Acute renal failure. Creatinine on arrival to OSH elevated to 1.5, no baseline was available. This improved to 1.1 by [**1-2**]. U/A was consistent w/ pre-renal etiology, however possible CKD given hx of HTN and DM. No proteinuria on UA. Patient was started on ACEI during admission (see above) for HTN and renal protection. On discharge his ARF had resolved and his Cr had decreased to 1.0. 8. Diabetes. On PO Metformin at home, was on insulin gtt at OSH ICU. While hospitalized, his home Metformin was held. Patient was started on Lantus and RISS for tight blood sugar control. Fasting BG ranged between 124 - 188, but [**1-2**] improved to 112 on Lantus 15u and RISS. He was discharged back on his home metformin. 9. Depression. Pt was continued on home Celexa. Medications on Admission: Aspirin 81mg daily Lisinopril 10mg daily Simvastatin 80mg daily Metformin 500mg daily Citalopram 40mg daily Tylenol PRN Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 4. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) 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. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 1 days. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 11. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation TID (3 times a day). 12. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for cough. 13. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Primary- ST elevation myocardial infarction Respiratory failure Pneumonia Transient ischemic attack Secondary- Hypertension Diabetes Hyperlipidemia Discharge Condition: Hemodynamically stable, afebrile Discharge Instructions: You were admitted to [**Hospital1 18**] as a transfer from [**Hospital3 **] for a heart attack and respiratory failure (You were intubated). While at [**Hospital1 18**] you underwent a cardiac catheterization with placments of stents to open flow in the blood vessels of your heart. You were also treated with medications for your heart attack. You were also treated for pneumonia and Chronic Obstructive Pulmonary Disease exacerbation with antibiotics and medications to help you breathe better. With this regimen, you heart condition and your breathing improved significantly. You were started on multiple new medications and you should continue to take these as you leave the hospital. Please see below for detailed list of new medications. After you were extubation, it was noticed that you had weakness which quickly resolved. Neurology evaluated you and did not feel that you had a stroke, however this may have been a transient ischemic attack (a mini-stroke). You will need to follow up with neurology. In addition, you were also found to have changes in your left sinus that may be concerning for a mass. You were evaluated by infectious disease and head and neck specialists who felt that you should follow up for this mass as an outpatient with your ENT doctor. Changes to your medications: 1. You were started on plavix 75 mg daily. It is very important that you take this medication every day and do not miss a dose. 2. You were started on coumadin 5 mg daily. You will need to have blood work checked to ensure that you anticoagulation is at an appropriate level. 3. You were started on pantoprazole 40 mg daily to decrease the risk of stomach bleeding on anticoagulation. 4. You were started on Toprol XL 50 mg daily. 5. You were started on xopenex nebs three times daily and atrovent nebs every 6 hours to treat your COPD exacerbation. 6. You will need to take one more day of levofloxacin to finish treatment for the pneumonia. Otherwise continue your outpatient medications as prescribed. Should you experience any fevers, chills, weight loss, nightsweats, chest pain, shortness of breath, cough, swelling in your legs, dizziness, visual changes, weakness, difficulty walking or any other symptoms concerning to you, please call your primary care physician or go to the nearest emergency room. Followup Instructions: Please follow up with your Primary care doctor, Dr. [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 19980**]). An appointment was made for you on [**1-10**] at 11:40 am. Please follow up with ENT within the next 1-2 months for workup for the sinus mass which was found on CT. It is very important that you see your ENT doctor for this. An appointment was made for you to follow up with neurology ([**Telephone/Fax (1) 2574**]) on [**2-7**] at 1 pm. His office is located in the [**Hospital Ward Name 23**] Building on the [**Location (un) **]. If you cannot keep any of the above appointments, please call to reschedule.

[ "311", "V15.82", "401.9", "272.4", "410.91", "501", "435.9", "584.9", "428.0", "428.31", "414.01", "486", "784.2", "250.00", "518.81" ]

icd9cm

[ [ [] ] ]

[ "00.40", "38.93", "00.66", "37.23", "96.71", "00.46", "36.06", "88.56" ]

icd9pcs

[ [ [] ] ]

16564, 16641

9516, 15224

314, 382

16833, 16867

2872, 6631

19248, 19921

2445, 2463

15394, 16541

16662, 16812

15250, 15371

6648, 9493

16891, 18175

2478, 2853

2146, 2191

18204, 19225

231, 276

410, 2031

2222, 2283

2053, 2126

2299, 2429

19,851

140,626

44318+58701

Discharge summary

report+addendum

Admission Date: [**2125-12-24**] Discharge Date: [**2126-1-14**] Date of Birth: [**2061-2-21**] Sex: M Service: MEDICINE Allergies: Motrin / Codeine / Nortriptyline Attending:[**First Name3 (LF) 1162**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: intubation History of Present Illness: 64 yo M w/ HIV, ESRD on HD, Hep C, Dm II and other multiple medical problems p/w SOB. Patient normally gets HD on TThSat. He stated on admission that on the Saturday prior to this admit he felt not enough fluid was removed at his last dialysis. Also over the weekend he had increased salt intake. On the AM of admission he started feeling SOB and was found to be satting low 80s on RA. He was sent to the ED where he was put on NRB and then on cpap. His saturation improved to 97%. His CXR showed fluid overload. Renal was consulted and he was sent to the [**Hospital Unit Name 153**] for further care and management. . On ROS he denies CP, dizziness, palpitations, abd pain, N/V/D. Past Medical History: 1) HIV: diagnosed in [**2106**], followed by Dr. [**Last Name (STitle) 1057**] at [**Hospital1 18**]; [**4-15**] VL <50; CD4 614 in [**8-/2125**] 2) Diabetes Mellitus, type 2, since ~[**2106**] with neuropathy, charcot foot, nephropathy, and ? mild retinopathy. 2) Chronic renal failure on Hemodialysis and graft infections, thrombus: dx approx. [**2115**]. Started HD in 2/[**2118**]. On HD on tues, thurs, sat at [**Doctor Last Name **] hospital. Dialysis unit - ([**Telephone/Fax (1) 17592**] / Nephrologist - Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -([**Telephone/Fax (1) 94994**] 3) [**Female First Name (un) 564**] esophagitis 4) Hepatitis C: genotype IB-> last viral load [**8-/2124**] 175,000 5) Congestive heart failure: last EF 50-55%, known ASD 6) Necrotizing Fasciitis: [**2112-10-17**]- [**2113**]: multiple surgeries and circumcision during hospitalization. 7) hypertension 8) Hypercholesterolemia 9) LE Diabetic ulcers 10) Herpes zoster of the left mandibular distribution of the trigeminal nerve. [**2115**] 11) R suprapatellar abscess: [**2115**]. 12) IVDU (heroin and cocaine) [**2079**]-[**2102**], none since [**2102**] 13) Obesity 15) GI Bleed: [**2117**]. OB positive stool. No frank blood. Negative scopes. 16) Anemia: [**2117**]. Started Epogen. 18) Colonic Polyps 19) Gastritis with large hiatal hernia. 20) Lipodystrophy 21) Charcot foot: dx in [**9-13**]. 22) Colonic AVM: seen on [**3-9**] colonoscopy on the ileocecal valve. Treated with thermal therapy. At that time was also offerred hormonal therapy, but this was deferred. 23) positive AFB in sputum: [**2119-11-17**]. MYCOBACTERIUM GORDONAE. No abnormalities on CT chest in [**2121**]. 24) MRSA- grew out from culture from L ant chest wound 25) venous access problems as noted above Social History: previously lived alone. Hx of tobacco abuse (quit 20 yrs ago), hx of alcohol abuse (quit >20 yrs ago), hx of heroin and cocaine abuse (quit >20 yrs ago) Family History: non-contributory Physical Exam: 97 86 133/66 22 100/NRB GEN: mildly SOB HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, difficult to assess jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: b/l crackles and rhonchi CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: 1+ edema, warm, good pulses. s/o chr venous stasis and neuropathy SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. decreased senasation to touch and pain in b/l LE. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps Pertinent Results: [**2125-12-24**] 08:43PM CK(CPK)-45 [**2125-12-24**] 08:43PM CK-MB-3 cTropnT-0.09* [**2125-12-24**] 04:34PM GLUCOSE-77 UREA N-31* CREAT-6.1*# SODIUM-138 POTASSIUM-5.5* CHLORIDE-97 TOTAL CO2-31 ANION GAP-16 [**2125-12-24**] 04:34PM CALCIUM-9.7 PHOSPHATE-6.4*# MAGNESIUM-2.0 [**2125-12-24**] 04:34PM WBC-7.0 RBC-2.60* HGB-7.9* HCT-24.7* MCV-95 MCH-30.2 MCHC-31.9 RDW-21.5* [**2125-12-24**] 04:34PM NEUTS-81.4* LYMPHS-11.0* MONOS-4.1 EOS-3.0 BASOS-0.4 [**2125-12-24**] 04:34PM PLT COUNT-233 [**2125-12-24**] 04:34PM PT-24.2* PTT-37.7* INR(PT)-2.4* CXR: AP upright portable chest radiograph is obtained. There is persistent cardiomegaly with pulmonary vascular congestion Brief Hospital Course: A/P: 64 yo M w/ HIV, ESRD on HD, DM p/w SOB. 1: SOB-Patient underwent hemodialysis on [**12-25**] with removal of 4L fluid. At that time he had oxygen saturations of 98% on NRB. The following morning on [**12-26**] the patient appeared lethargic, with worsening bilateral infiltrates on CXR and low PO2 on ABG while on NRB. He was initially placed on BiPAP but still appeared fatigued, and unable to support his own breathing. He was therefore emergently intubated. While intubated, he was hemodialyzed with removal of another 4L of fluid. He was extubated the evening of [**12-26**] and had adequate oxygen saturations on 4l NC. He did not develop further dyspnea after extubation and was transferred to the floor. On [**12-28**] the patient had a third session of dialysis after which he had no further supplemental oxygen requirement. He had no evidence of infection during this hospitalization and his lungs were clear to ausculatation at the time of discharge. . 2. Mental Status: Patient was found to be lethargic in setting of hypoxia on morning of [**12-26**]. he was emergently intubated, and extubated that same evening. His mental status has returned to baseline, as he is alert and oriented X3 since extubation. . 3. ESRD: cont HD as per schedule, as above. His next HD should be [**12-30**]. 4. HIV/Hep C: continued outpatient regimen. 5. HTN: cont valsartan, atenolol and norvasc 6. DM: The patient was found to be hypoglycemic while taking adequate po once transferred to the floor. His AM NPH was decreased to 17 units sc qAM and his BG was in the 100s on this regimen. He should continue on his RISS. 7. h/o line thrombosis: cont coumadin Medications on Admission: ALBUTEROL 17 GM--Two puffs four times a day ATENOLOL 25MG--One every day ATIVAN 0.5 mg--one tablet(s) by mouth once COUMADIN 4MG--[**Name6 (MD) **] dialysis md [**Last Name (Titles) **] 160 mg--one tablet(s) by mouth daily HUMULIN N 100U/ML--30 u sq every morning INDINAVIR SULFATE 400 MG--Take 2 tabs by mouth, with ritonavir, twice a day LAMIVUDINE 150 MG--Take after hemodialysis Methadone 10 mg--2 tablet(s) by mouth twice a day for pain. may take additional tablet once a day for breakthrough. NEPHROCAPS 1--Take one tablet by mouth every day NEURONTIN 300 mg--one capsule(s) by mouth twice a day NORVASC 10MG--Take one by mouth every day Power Wheelchair --use for better mobility daily QUININE SULFATE 200MG--One every day as needed for cramps RITONAVIR 100MG--Take one tablet, with indinavir, twice a day ROXICET 5 MG/325 MG--One by mouth q 4-6 hrs as needed for pain, max 5 per day; #140/28 day supply STAVUDINE 20MG--Take one tablet every day, and after hemodialysis on dialysis days Discharge Medications: 1. Indinavir 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 2. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO PLEASE GIVE AFTER HD (). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Methadone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Stavudine 20 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 11. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 15. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for cramps. 16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 17. Insulin Please see attached Insulin regimen, FS 4 times daily NPH 17 units sc QAM with breakfast, then regular insulin sliding scale Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: hypoxia ESRD on HD HIV HTN DM Discharge Condition: stable, 98%RA Discharge Instructions: You were admitted with fluid overload that responded to dialysis however you were briefly placed on a respirator to protect your airway. You will be discharged on the same medications that you arrived on. You will continue HD on your regular days. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1085**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2126-1-2**] 10:00 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2126-1-9**] 9:30 Name: [**Known lastname **],[**Known firstname 133**] W Unit No: [**Numeric Identifier 15030**] Admission Date: [**2125-12-24**] Discharge Date: [**2126-1-14**] Date of Birth: [**2061-2-21**] Sex: M Service: EMERGENCY Allergies: Motrin / Codeine / Nortriptyline Attending:[**First Name3 (LF) 11940**] Addendum: The patient was ready for transfer back to rehab when he was noted to be lethargic. A BG was checked which was 53. The patient was given a glass of OJ and began responding appropriately. His NPH was changed for the next morning to 5units SC. His discharge was postponed. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 419**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 164**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11942**] MD [**MD Number(2) 11943**] Completed by:[**2125-12-30**]

[ "403.91", "250.60", "553.3", "V09.0", "535.51", "V58.67", "V45.1", "996.62", "357.2", "285.21", "250.40", "518.81", "070.54", "272.0", "707.12", "041.11", "428.0", "585.6", "V58.61", "285.1", "V08", "428.33", "327.23" ]

icd9cm

[ [ [] ] ]

[ "96.71", "45.13", "39.95", "96.04" ]

icd9pcs

[ [ [] ] ]

10130, 10443

4463, 5440

314, 327

8855, 8871

3753, 4440

9169, 10107

3078, 3096

7178, 8604

8802, 8834

6160, 7155

8895, 9146

3111, 3734

255, 276

355, 1040

5455, 6134

1062, 2890

2906, 3062

7,855

136,169

51305+59333

Discharge summary

report+addendum

Admission Date: [**2163-2-19**] Discharge Date: [**2163-2-25**] Date of Birth: [**2106-7-3**] Sex: F Service: HEPATOBILIARY SURGERY HISTORY OF PRESENT ILLNESS: This is a 56-year old female with a history of osteogenesis imperfecta who presented to [**Hospital3 25148**] Center in [**Location (un) 3844**] early in the morning of [**2-19**] after the acute onset of right upper quadrant epigastric pain. The evening prior ([**2-18**]), the pain began as a vague tightening that wax and waned but became more frequent and progressively worsened. The patient presented to [**Hospital3 33594**] Center. There the patient had a workup which included a right upper quadrant ultrasound which was read as cholelithiasis with slight gallbladder wall thickening. The patient was to the Operating Room where a laparoscopic cholecystectomy was attempted. Upon exploration, the gallbladder appeared within normal limits, but there appeared to be a contained thrombus within the gallbladder fossa. The patient was closed, and hematocrit and liver function tests were rechecked. She was found to have a decreased hematocrit and elevated liver function tests. The patient was transferred to [**Hospital1 188**] Surgical Intensive Care Unit under the care of Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] for further workup, evaluation, and treatment. PAST MEDICAL HISTORY: Includes osteogenesis imperfecta/nonspecific connective tissue disorder. MEDICATIONS ON ADMISSION: Include calcium supplements. ALLERGIES: None. PERTINENT LABORATORY DATA: The patient's laboratories from [**Hospital1 **] included a hematocrit of 43.4. Hematocrit later on in the afternoon around 2:00 p.m. included a hematocrit of 32. Her LFTs elevated from 184 her ALT and 152 AST to 1176 ALT and 807 AST. Her amylase went from 99 to 169. Her total bilirubin went from 1.1 to 2.4. Her INR on the 2:00 p.m. afternoon laboratories at [**Hospital1 **] was an INR of 0.9. RADIOLOGIC STUDIES: A CT scan at that time illustrated large hepatitic cysts in left medial segment extending to the gallbladder fossa. HOSPITAL COURSE: The patient had serial hematocrit's evaluated here during her admission and was taken to the Operating Room for persistent pain and slowly drifting hematocrit. Please see the Operative Note on [**2-21**] for further information by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Postoperatively, the patient was in the Intensive Care Unit and had an incident of some low urine output and got a little bit of fluid. She was monitored and found to be stable. On the evening of [**2-22**], the patient was transferred to the floor and found to be stable. She did, however, have a temperature spike over the evening of [**2-23**]. Her central venous line was discontinued, and her tip was sent for culture. She was hep-locked. Her Foley was discontinued on [**2-25**]. She was started on some clears and was doing well. Otherwise, she advanced to a regular diet without any complaints. Her culture is pending at this time, but she has remained afebrile during the remainder of the admission. Please also note that this patient had received 2 units of blood. The first unit was on [**2-20**] as well as the second unit on [**2-20**]. A third unit was given on [**2-21**]. Medications on discharge will include Percocet as needed, Colace, and Compazine p.o. DISCHARGE DISPOSITION: Her LFTs had started to drift down, and the patient was tolerating a regular diet, and had no difficulties. CONDITION ON DISCHARGE: Discharged on [**2-25**] in good condition. MEDICATIONS ON DISCHARGE: Percocet, Colace, and Compazine p.o., as well as Protonix p.o. DISCHARGE FOLLOWUP: She is to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in approximately one to two weeks. She is to call if she has any questions. DISCHARGE DIAGNOSES: 1. Status post open cholecystectomy, status post exploratory laparotomy, and status post evacuation of hematoma on [**2163-2-21**]. 2. Hypotension. 3. Hypovolemic requiring fluid boluses. 4. Postoperative fever. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **] Dictated By:[**Doctor Last Name 22186**] MEDQUIST36 D: [**2163-2-25**] 14:47:14 T: [**2163-2-25**] 15:18:43 Job#: [**Job Number 106428**] Name: [**Known lastname 17347**], [**Known firstname **] Unit No: [**Numeric Identifier 17348**] Admission Date: [**2163-2-19**] Discharge Date: [**2163-2-25**] Date of Birth: [**2106-7-3**] Sex: Service:HEPATOBILIARY SURGERY SERVICE DISCHARGE DIAGNOSES: 1. Ruptured gallbladder. 2. Chronic cholecystitis. 3. Acute blood loss anemia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5622**] Dictated By:[**Doctor Last Name 17349**] MEDQUIST36 D: [**2163-6-29**] 07:41:43 T: [**2163-6-29**] 08:59:53 Job#: [**Job Number 17350**]

[ "285.1", "575.11", "573.8", "756.51", "575.4", "780.6", "276.5", "998.89", "458.8" ]

icd9cm

[ [ [] ] ]

[ "99.04", "39.98", "50.61", "38.93", "51.22", "50.0" ]

icd9pcs

[ [ [] ] ]

3496, 3605

4747, 5088

3702, 3766

1546, 2164

2182, 3472

3787, 3960

182, 1422

1445, 1519

3630, 3675

19,312

112,324

28832

Discharge summary

report

Admission Date: [**2187-7-23**] Discharge Date: [**2187-7-26**] Date of Birth: [**2128-7-12**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Aortic Dissection Major Surgical or Invasive Procedure: None History of Present Illness: 59 year old left handed man with h/o ascending aortic dissection (repaired in [**2182**] at [**Hospital1 2177**]), HTN and CAD s/p CABG p/w aortic dissection. The patient reported falling on [**7-21**], two days prior to presentation. He thinks he tripped on a brick and did not have difficulty getting up afterwards. That night he woke up having found that he wet his bed without tongue or extremity soreness. He does not usually wet his bed. Then on [**7-23**] @6am he was trying to get out of bed for breakfast when he fell towards the right hitting a birdcage and then eventually landed on the floor. No LOC or head trauma. He reportedly had difficulty getting back up and required help from his wife. [**Name (NI) **] figured out that his difficulty picking himself up was due to weakness in his right arm and leg. Weakness lasted approximately 30 minutes so that by the time his wife brought him to the [**Name (NI) **] at an OSH, his symptoms were gone and head CT normal. Workup at OSH, revealed an aortic dissection starting between the left carotid and left sublclavian then extending to the left common iliac artery. Patient was subsequently transferred from OSH to [**Hospital1 18**] on esmolol for further managment of type A+B aortic dissection and recent h/o TIA. Past Medical History: Aortic Aneurysm repair in [**2182**] CABG Hypertension Hyperlipidemia ?TIA Hernia repair Social History: Grew up in [**State 9512**]. Lives in [**Location 686**] but often stays with a friend who lives in [**Name (NI) 8**]. He is married wife [**Telephone/Fax (1) 69605**]. He is on disability for his ht problems. Used to work loading and unloading trucks. No tobacco, 40 oz of beer/day usually on the weekends and +cocaine use, last used [**7-23**]. Family History: Non-contributory Physical Exam: PE: 97.3 106/57 68 15 100RA sitting up in bed, NAD, pleasant NCAT, anicteric sclerae, mmm, OP clear neck supple, no carotid bruits nl S1 S2, RRR, scar from midline sternotomy incision CTAB no wheeze ABD soft +BS nontender ext nonedematous Pertinent Results: [**2187-7-23**] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG [**2187-7-23**] 06:45PM GLUCOSE-83 UREA N-11 CREAT-1.0 SODIUM-140 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-31 ANION GAP-10 [**2187-7-23**] 06:45PM cTropnT-<0.01 [**2187-7-25**] Carotid Duplex Ultrasound Duplex and color Doppler demonstrate no appreciable plaque or wall thickening involving either carotid system. The peak systolic velocities bilaterally are normal as are the ICA/CCA ratios. There is normal antegrade flow involving both vertebral arteries. [**2187-7-25**] MRA of Head Unremarkable MRA of the circle of [**Location (un) 431**] given the limitations of the exam. A preliminary report was entered into the computer by Dr. [**First Name (STitle) **] at 5:25 p.m. [**2187-7-24**] MRA chest 1. Type B aortic dissection, straddling the takeoff of the left subclavian artery, but not extending into any of the great vessels of the arch. 2. Dissection extends into the left common iliac artery. 3. Right renal artery arises from the false lumen; left renal artery as well as the celiac axis, SMA, and [**Female First Name (un) 899**] arise from the true lumen. 4. Circumaortic renal vein. Brief Hospital Course: Mr. [**Known lastname 14477**] was admitted to the [**Hospital1 18**] on [**2187-7-23**] for evaluation of his aortic dissection. He was admitted to the cardiac surgical intensive care unit and continued on an esmolol drip. The vascular surgery service was consulted for assistance in his care. A chest MRA was performed which revealed a Type B aortic dissection, straddling the takeoff of the left subclavian artery, but not extending into any of the great vessels of the arch extending into the left common iliac. The right renal artery arises from the false lumen and the left renal artery as well as the celiac axis, SMA, and [**Female First Name (un) 899**] arise from the true lumen. When compared to previous films, it was believed that these findings were consistent with an old dissection. As he had some right sided weakness, the neurology service was consulted. A carotid duplex ultrasound was obtained which revealed normal bilateral internal carotid arteries. A brain MRI was also obtained which revealed an unremarkable MRA of the circle of [**Location (un) 431**]. No evidence of stroke was found and Mr. [**Known lastname 69606**] strength and mobility remained stable. Aspirin threapy was recommended. On [**2187-7-25**], Mr. [**Known lastname 14477**] was transferred to the step down unit. His blood pressure was aggressively controlled. He continued to make steady progress and was discharged home on [**2187-7-26**]. He will follow-up with his cardiologist and primary care physician as an outpatient. Medications on Admission: Doxazosin Nifedipine Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 3. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:*30 Tablet Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Type B aortic dissection s/p Ascending Aorta replacement [**2182**] Discharge Condition: Good. Discharge Instructions: Monitor blood pressure. Followup Instructions: Dr. [**First Name (STitle) **] in 3 months with CT Scan. Please call for scheduling: [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) **] (Neurology) as soon as possible for additional testing [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2187-8-3**]

[ "401.9", "V12.59", "305.60", "414.00", "V45.81", "441.03" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5974, 6032

3703, 5227

338, 345

6144, 6152

2446, 3680

6224, 6543

2146, 2164

5298, 5951

6053, 6123

5253, 5275

6176, 6201

2179, 2427

281, 300

373, 1653

1675, 1765

1781, 2130

22,157

198,698

21113

Discharge summary

report

Admission Date: [**2153-5-18**] Discharge Date: [**2153-5-22**] Date of Birth: [**2075-1-3**] Sex: M Service: MED CHIEF COMPLAINT: Right arm pain, chest pain, hypotension. HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old man with a history of mild dementia, severe chronic obstructive pulmonary disease, nursing home resident, status post crush injury to his right arm twenty years ago for which he underwent a right brachial bypass surgery, who was noted to have a cold, painful right upper extremity on [**2153-5-19**] at the nursing home. At this time, he was also with some complaint of chest pain. The patient was treated with aspirin, morphine and Lovenox. He presented to the [**Hospital6 1760**] Emergency Department where he was seen by Vascular Surgery who recommended starting him on heparin for questionable arterial clot and vascular insufficiency. The patient was also seen by the Cardiology service in the Emergency Department who did a bed side echocardiogram, which showed no definite thrombus in his left atrium. In the Emergency Room, his vital signs were as follows: Temperature 98.4, heart rate 90, blood pressure 98/palp, 96 percent on two liters nasal cannula. His [**Known lastname **] blood cell count was 16.3. The patient was transferred to the Medical Intensive Care Unit on [**2153-5-19**] for a labile blood pressure. PAST MEDICAL HISTORY: Coronary artery disease, status post myocardial infarction two years ago. Chronic obstructive pulmonary disease on home O2 requirement, dementia, bilateral bolus pemphigoid, history of seizures, bilateral THR, status post right arm bypass of brachial artery twenty years ago. HOME MEDICATIONS: 1. Imdur 30 mg q d. 2. Prednisone 7.5 mg q d. 3. Theophylline 200 mg q d. 4. Vitamin B-12. 5. Multivitamin. 6. Lovastatin 20 mg q d. 7. Tetracycline 600 mg b.i.d. 8. Ativan 0.5 mg t.i.d. SOCIAL HISTORY: The patient lives in [**Location (un) 18437**]. He has a son and daughter who are both involved in his medical care. PHYSICAL EXAMINATION: Temperature 98.6, heart rate 119, blood pressure 120/70, respiratory rate 20, O2 saturation 95 percent on four liters nasal cannula. HEENT: Poor dentition. Pupils equal, round and reactive to light. Extraocular movements intact. Chest: Bilateral diffuse rhonchi. Moving air well. Cardiovascular: Distant cardiac sounds. Normal S1, S2, tachycardiac but with regular rhythm. Abdomen: Soft, nontender, nondistended, no pulsatile masses. Extremities: Multiple erosions on his lower extremities, nonpalpable pulses throughout. His right arm was blue in color with pale, [**Known lastname **] fingertips. No pulse was Dopplerable. A pulse was Dopplerable at his right axilla. His left arm was oozing serosanguinous fluid. It was red in color. HOSPITAL COURSE: The patient was transferred to the Medical Intensive Care Unit on [**2153-5-19**] for persistent hypotension on the floor. The cause of his hypotension was unknown and because the patient did have an elevated [**Known lastname **] blood cell count, he was treated with empiric antibiotics; vancomycin, levofloxacin and Flagyl. The goal was to keep his mean arterial pressures greater than 60. He received 250 cc intravenous fluid boluses to help accomplish this. He was also started on Neo-Synephrine. With this, his pressures improved. His urine output remained somewhat stable at approximately 25 cc per hour. He was seen by Vascular Surgery. The patient underwent an angiogram through the left femoral artery, which revealed that his twenty year old bypass graft on his right arm was completely occluded. The patient's arm remained cool and cold and mildly tender. His pain was controlled well with morphine. The heparin drip was continued. Because the patient had likely ischemia greater than twenty-four hours, the chances of him recovering function of his right hand was minimal, thus, a surgical procedure to reestablish flow was not indicated. The options included amputation and/or pain control as the patient's overall function was deteriorating. The patient became volume overloaded during this hospital course with the normal saline boluses in the setting of underlying congestive heart failure. He was seen by the Palliative Care team and at the time of discharge, the consensus of the Medical Intensive Care Unit team was to discharge the patient back to [**Location (un) 18437**] where he was to receive palliative care. CONDITION ON DISCHARGE: Poor. DISCHARGE STATUS: To [**Location (un) 18437**]. DISCHARGE DIAGNOSES: Coronary artery disease. Chronic obstructive pulmonary disease. Right arm ischemia secondary to graft occlusion. Dementia. DISCHARGE MEDICATIONS: 1. Morphine elixir 2.5 mg sublingual q four hours. 2. Morphine elixir 2.5 mg q two hours p.r.n. acute pain. 3. Ativan 0.5-1.0 mg sublingual q 2-4 hours p.r.n. agitation. 4. Tylenol 650 mg p.r.n. fever. 5. Dulcolax suppository p.r.n. 6. Scopolamine 1.5 mg transdermal patch q 72 hours p.r.n. secretions. Antibiotic therapy was discontinued as there was no clear indication of infection. [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 2019**] Dictated By:[**Doctor Last Name 2020**] MEDQUIST36 D: [**2153-5-22**] 14:39:45 T: [**2153-5-22**] 15:27:24 Job#: [**Job Number 56025**]

[ "294.8", "428.0", "496", "287.5", "E878.2", "996.74", "414.01", "276.0", "584.9" ]

icd9cm

[ [ [] ] ]

[ "88.49", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

4549, 4676

4699, 5317

2807, 4445

1700, 1889

2047, 2789

153, 195

224, 1382

1405, 1682

1906, 2024

4470, 4527

16,381

186,899

26521

Discharge summary

report

Admission Date: [**2141-2-8**] Discharge Date: [**2141-2-11**] Date of Birth: [**2097-3-18**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 297**] Chief Complaint: Unresponsiveness, hypothermia Major Surgical or Invasive Procedure: None History of Present Illness: Briefly, this is a 43 year-old homeless, spanish speaking male who was found unresponsive in a park without evidence of trauma. In the emergency department, he was found to be hypothermic to 88.8. He was warmed with a bare hugger and warmed normal saline infusion. He was hypotensive to 80s systolic and responded to dopamine. He also had a witnessed seizure in the emergency department. Head CT and lumbar puncture were negative. Past Medical History: None. Social History: He is homeless and lives in a shelter. He drinks 2-3 beers per day. Family History: Non-contibutory Physical Exam: Vitals: Temperature:99.0 Pulse:92 Blood Pressure:139/75 Respiratory Rate:13 Oxygen Saturation:98% on room air General: Alert and oriented in no acute distress HEENT: Pupils equal and reactive, extraoccular movements intact without nystagmus, moist mucouse membranes. Cardiac: Regular rate and rhythm without murmurs, rubs, or gallops. Pulmonary: Clear to auscultation bilaterally. Abdomen: Normoactive bowel sounds, soft, nontender, nondistended. Extremities: 2+ dorsalis pedis pulses, no cyanosis, no edema, thickened dry skin on feet, thickened nails. Neurologic: Cranial nerves II-XII grossly intact, finger to nose intact, strength 5/5 deltoids, biceps, triceps, hip flexors, hip extensors, quadriceps, hamstrings, dorsiflexion, plantar flexion bilaterally, sensation intact to light touch bilaterally. Pertinent Results: Hematology: WBC-4.2 HGB-12.3 HCT-36.1 PLT COUNT-102 NEUTS-64.2 LYMPHS-31.5 MONOS-2.5 EOS-1.6 BASOS-0.1 . Chemistries: SODIUM-142 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-23 UREA N-14 CREAT-0.7 GLUCOSE-111 CALCIUM-8.3 PHOSPHATE-5.8 MAGNESIUM-1.8 . LFTs: ALT(SGPT)-46 AST(SGOT)-139 ALK PHOS-59 AMYLASE-73 TOT BILI-0.2 LIPASE-80 . Coagulation: PT-12.2 PTT-30.8 INR(PT)-1.0 . PHENYTOIN-<0.6 . Admission toxicology screen: Negative except for EtOH. . Imaging: Head CT: No mass lesions or bleed Chest X-ray: Bilateral opacities consistent with pulmonary edema, possibly non-cardiogenic edema in the setting of recent seizure. . Microbiology: Blood and urine cultures ([**2-8**]): No growth CSF: No microorganisms on gram stain, culture with no growth. Brief Hospital Course: This is a 43 year-old male admitted after being found unresponsive, hypothermic, and hypotensive presumably secondary to alcohol intoxication. . 1. Alcohol intoxication: His unresponsiveness was likely secondary to alcohol intoxication. He states that he only drinks 2-3 beers, but this is unclear. His hypotension and hypothermia have resolved. By hospital day 2, he had no evidence of alcohol withdrawal. Within the last 24 hours of hospitalization, he did not require any Valium by CIWA scale. . 2. Seizure: In the ED, he had a witnessed seizure, it is unclear the etiology although it could have been precipitated by hypothermia and/or alcohol withdrawal. He states that he has not had history of previous seizure. Head CT was negative and LP was negative for bacterial infection. He was started on acyclovir empirically, but this was stopped once his mental status improved. He had no further episodes of seizure. HSV PCR is still pending at the time of this dictation. Given his clinical stability he was called out to the medical floor. . 3. Elevate CK: This elevation is likely secondary to rhabdomyelis from being found down. His CK trended down with IV hydration. . 4. Anemia: His anemia is likely secondary to chronic alcohol use. His hematocrit is stable with no evidence of active bleed. He was maintained on iron supplementation while in house. . 5. FEN: Regular diet once his mental status recovered. . 6. Access: Peripheral IV. . 7. Dispo: On the morning of hospital day 3, he told a co-worker that he was going to his mother's house. Shortly thereafter, he was not found in the hospital. He did not return to the hospital that day. He was medically stable and was competent to make medical decisions at the time that he eloped. Medications on Admission: None. Discharge Medications: None Discharge Disposition: Home Facility: Patient eloped. Discharge Diagnosis: Alcohol withdrawal Seizure Discharge Condition: He had no evidence of alcohol withdrawal the morning the he eloped Discharge Instructions: NA as patient left without being discharged. Followup Instructions: NA as patient left without being discharged Completed by:[**2141-2-11**]

[ "291.81", "991.6", "285.9", "728.88", "305.01", "V60.0", "780.39", "E901.0" ]

icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

4400, 4433

2553, 4314

324, 330

4503, 4571

1786, 2237

4664, 4738

927, 944

4371, 4377

4454, 4482

4340, 4348

4595, 4641

959, 1767

255, 286

358, 796

2246, 2530

818, 825

841, 911

3,217

199,064

10948

Discharge summary

report

Admission Date: [**2129-7-27**] Discharge Date: [**2129-8-2**] Date of Birth: [**2048-1-13**] Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 398**] Chief Complaint: s/p left hip fxr repair with failure to extubate. Major Surgical or Invasive Procedure: intubation and extubation History of Present Illness: 81-year-old female, with a history of COPD on home O2, severe MS, PAF, PVD, who sent to [**Hospital1 18**] from [**Location (un) 620**] on [**7-27**]. She initially presented to [**Hospital1 18**]-[**Location (un) 620**] [**2129-7-22**] with cough. She was admitted and treated for a COPD exacerbation with a steroid taper and ceftriaxone and Z-Pak for empiric coverage of acute bronchitis. She was also noted to have renal failure thought secondary to dehydration. From the DC summ, she was also felt to be volume overloaded later in the stay. She was evaluated with an echo which showed high filling pressures, mild MS [**First Name (Titles) **] [**Last Name (Titles) **] of 50%. Cardiology recommend restarting her Lasix on [**7-26**] at 20mg/day (had been on 120) and her Cr decreased with this. Plan was to titrate up her Lasix dose as her Cr would tolerate. Her HCTZ was restarted on [**7-26**] as well. . On [**7-27**], she was scheduled to be transfered to rehab and had a mechanical fall at [**Location (un) 620**]. Xrays showed left complex acetabular fracture. Decision was made to transfer to [**Hospital1 18**] for a surgical repair. Dr. [**Last Name (STitle) 2637**] accepted the patient, however upon arrival to the floor, it was felt that the complexity of the patient necisitated a transfer to the medicine team. . Treated on medicine until [**7-29**] when taken to OR. Post-op, unable to extubate patient secondary to respiratory distress so sent to MICU for furhter care. Past Medical History: 1. h/o upper GIB to [**6-20**]. Barrett's esophagus vs. mild esophagitis. 2. COPD on home O2 3. h/o left pleural effusion 4. DM 5. CKD (Cr ~1.1) 6. Gout 7. h/o TRALI to FFP in [**2128-10-15**] 8. Lung cancer status post right lower lobe resection without chemo in 10/[**2123**]. 9. Diastolic congestive heart failure with MS and MR, EF 60% 10. Hypertension 11. Paroxysmal atrial fibrillation had been on coumadin until UGI in [**6-25**]. High grade AV block s/p DDD pacemaker implantation in [**Month (only) **] [**2128**] 13. Hypercholesterolemia 14. TIA in [**2129-5-15**] 15. PVD, s/p angioplasty and s/p left common femoral endarterectomy and patch angioplasty and stenting of her external and common iliac arteries. Also right external iliac artery stent, endarterectomy of the EIA, CFA, PFA with bovine patch angioplasty and iliac and femoral angiography in [**3-22**]. Social History: Denies any alcohol use. Quit tobacco 5 years ago; previously smoked [**2-15**] PPD. No IV drug use. Family History: She denies any family history of clotting problems. [**Name (NI) **] mother had cancer but she doesn't recall what kind. Physical Exam: Exam: Afebrile BP 90/40 (off pressors) P68 Gen: Intubated. Moving all fours. Responds to commands. Lungs: good breath sounds. No wheeze CV: RR, distant. [**3-22**] HSM at apex. Abd:soft, NT,ND LE:no edema Left hip: Incision in groin/abdomen. C/d/i. No obvious hip trauma. Pertinent Results: [**2129-7-27**] 08:00PM BLOOD WBC-15.7*# RBC-2.97* Hgb-8.5* Hct-24.9* MCV-84 MCH-28.7 MCHC-34.2 RDW-17.4* Plt Ct-356 [**2129-8-2**] 04:27AM BLOOD WBC-17.6* RBC-2.97* Hgb-9.2* Hct-26.1* MCV-88 MCH-30.9 MCHC-35.3* RDW-17.4* Plt Ct-175 [**2129-8-1**] 04:11AM BLOOD PT-11.4 INR(PT)-1.0 [**2129-7-27**] 08:00PM BLOOD Glucose-223* UreaN-100* Creat-2.5* Na-134 K-5.2* Cl-97 HCO3-26 AnGap-16 [**2129-7-30**] 09:05PM BLOOD UreaN-109* Creat-3.3* K-5.5* [**2129-8-2**] 04:27AM BLOOD Glucose-252* UreaN-86* Creat-1.6* Na-137 K-4.2 Cl-106 HCO3-24 AnGap-11 [**2129-8-2**] 08:08AM BLOOD HEPARIN DEPENDENT ANTIBODIES-PENDING . Imaging: CT LLE [**7-27**]: 1. Complex, comminuted fracture of left acetabulum involving anterior and posterior columns and acetabular roof. Comminuted complex fracture of left iliac [**Doctor First Name 362**] extending into the left sacroiliac joint. Complex fracture of left inferior pubic ramus. 2. Associated hematoma at fracture site and extending into retroperitoneal space superiorly, the pelvic sidewall medially, and involving adjacent iliopsoas and gluteus musculature. 3. Focal low density structure adjacent to the left femoral artery. Consider correlation with ultrasound to exclude the possibility of pseudoaneurysm or hematoma. . RENAL U/S [**7-28**]: Limited study. No hydronephrosis. Bilateral non-obstructing renal stones. . P-mibi [**7-29**]: The image quality is good. Left ventricular cavity size is normal. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 74%. . LENI [**7-31**]: No evidence of DVT involving the left lower extremity . PICC placement [**7-31**]: 40 cm right brachial vein [**Last Name (un) **] catheter terminating in the SVC. The catheter is ready for use. Brief Hospital Course: A/P: 81 yof with MMP s/p hip fracture repair, failed exutbation in PACU. . 1. Respiratory failure: Pulling TV of 1000+ on [**6-18**]. RSBI 25. ABG 7.33/40/140. Suspect failure to extuabte post-op was anesthesia related. She does not appear fluid overloaded on exam. Nothing concerning for PNA. Was extubated successfully the night of [**7-29**]. Her COPD exacerbation was successfully treated with steroids, nebulizer treatments, and 1 week of CTX. Her wheezing greatly improved and she was transitioned to prednisone 20mg daily at time of discharge. She should continue this for 2 more days, then decrease to prednisone 10mg daily for three days. Her Advair, Spiriva and nebs should be continued. . 2. Hip fracture: s/p acetabular fracture repaire through groin. Ortho took her to the OR on [**7-29**] and performed a left acetabular ORIF. She was given 1 week of post-op antibiotics empirically. She was initially on Lovenox once daily for DVT ppx given her hip fx, but this was converted to fondaparinux 2.5mg SC qD given concern for HIT (see below). This should be continued until her HIT Ab returns negative, and then may be transitioned back to Hep SC tid. She is to f/u with orthopedics in 2 weeks after discharge. Her dressings are to be changed as needed as these have been draining serous discharge from her wound. On day of discharge, orthopedics evaluated the would who felt there was no infxn present. She is to be touch-down weight baring on her Left leg until cleared by orthopedics to advance. . 3. Decreasing Plts There was a concern for HIT given drop in plts >50% in 4 days from 360->140. Her Lovenox SC qD was switched to Fondaparinux 2.5mg SC qD and a HIT Antibody was sent out. This was pending at day of discharge and should be followed up. If this returns negative, she may be re-challenged with Hep SC tid and her platelets should be closely monitored. . 4. DM: She was on an aggressive Insulin sliding scale given FS in teh 300s while on the steroids for her COPD exacerbation. Given her elevated BS, she was started on NPH 7 units qAM and 4 units qhs along with her Humalog SS tid with meals. Please follow up on her BS and adjust her scale accordingly as she is tapering off of the steroids over the next week. . 4. ARF: Developed anuria in the first 24 hours post-op. Likely ATN given extensive intra-op blood loss of 2L. Cr peaked at 3.3 on [**7-31**] and slowly trended back down to 1.6 on day of discharge. Her nephrotoxic meds were held and all other meds were renally dosed. Please continue to monitor her Creatinine daily or every other day until her creatinine returns to baseline (1.1-1.2). . 5. CHF: Currently appears euvolemic. Will hold her Lasix for now until ARF resolves. Please restart Lasix 40mg once daily once her creatinine returns to normal. . 6. Rhythm: History of afib; currently vpaced. Off coumadin prior to admission. No plans to restart now given fall risk and dementia. . 7. COPD flare: Initially diagnosed with COPD flare at [**Hospital1 **]; started on ABx, steroids. No evidence of bacterial PNA. Continue Abx x1 week. On Prednisone 20mg daily x2 more days, then 10mg daily x3 days. Cont spiriva, advair, nebs. . 8. HTN: Initially held BP meds given ARF, post-op blood loss. Now hypertensives to 200s and restarted home dose of lopressor 25mg [**Hospital1 **] and diltiazem 360 qD. Her HCTZ 25mg daily was held and should be restarted once her creatinine returns to normal. . 9. Gout: Cont renally dosed allopurinol of 100mg every other day. . 10. Nutrition: Renal, cardiac, diabeteic diet. Passed a formal speech and swallow eval that did not show evidence of aspiration. . DISPO - Pt was discharged to rehab with ortho f/u in 2 weeks. Pls f/u on HIT Ab; no heparin products are to be given until that is found to be negative. Pls f/u on her creatinine daily until it returns to baseline. PICC may be removed once blood draws are no longer required. Medications on Admission: Lipitor 40 mg p.o. at bedtime Lasix 120 mg p.o. q. day allopurinol 300 mg p.o. q. day metoprolol 25 mg p.o. b.i.d. aspirin 325 mg p.o. daily gabapentin 600 mg p.o. t.i.d. trazodone 50 mg p.o. at bedtime p.r.n. glipizide 2.5 mg p.o. b.i.d HCTZ 25 mg p.o. daily Cardizem CD 360 mg p.o. daily omeprazole 20 mg p.o. daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 8. DILT-CD 180 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO once a day. 9. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) injection Subcutaneous DAILY (Daily). 10. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 days: From [**Date range (1) 22730**]. 12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: Start from [**Date range (1) 35547**]. 13. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 14. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 15. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 16. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 1 days. 17. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. 18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as directed below units Subcutaneous twice a day: Please give 7 (seven) units of NPH in the morning; 4 (four) units in the evening. . 19. Insulin Lispro (Human) 100 unit/mL Solution Sig: as per sliding scale attached. units Subcutaneous three times a day. Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Healthcare - [**Location (un) 620**] Discharge Diagnosis: COPD flare Acute renal failure secondary to ATN Hip fracture s/p ORIF Thrombocytopenia due to suspected HIT Discharge Condition: Medically stable for discharge to rehab. Discharge Instructions: Please follow daily creatinine given recent acute renal failure along with electrolytes. Please taper steroids given for COPD flare. Has been on prednisone 20 mg PO x 2 days. [**Month (only) 116**] taper to 10 mg prednisone on [**2129-8-3**] for three days and then discontinue. Please restart HCTZ 25mg daily once her ARF resolves back to baseline Creatinine of 1.1-1.2. Do NOT given heparin products or heparin flushes until her Heparin depdendant Antibodies return negative (pending on discharge) as she has suspected HIT. Followup Instructions: Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1005**] at ([**Telephone/Fax (1) 2007**] to schedule a follow up appointment in 2 weeks. Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 17753**] after your discharge from rehab. Completed by:[**2129-8-2**]

[ "584.5", "340", "443.9", "E885.9", "997.5", "272.0", "808.0", "V10.11", "491.21", "V45.01", "274.9", "287.4", "428.32", "427.31" ]

icd9cm

[ [ [] ] ]

[ "79.39" ]

icd9pcs

[ [ [] ] ]

11557, 11641

5221, 9157

324, 351

11793, 11836

3337, 5198

12413, 12784

2906, 3028

9526, 11534

11662, 11772

9183, 9503

11860, 12390

3044, 3318

235, 286

379, 1872

1894, 2772

2788, 2890

22,206

197,358

11255

Discharge summary

report

Admission Date: [**2118-8-8**] Discharge Date: [**2118-8-11**] Date of Birth: [**2041-4-17**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old female with past medical history of coronary artery disease, status post CABG in [**9-/2116**], hypertension, hypercholesterolemia, who is status post episode of left hand, left face, and left upper extremity weakness in [**2118-5-22**]. Workup at that time included a MRI/significant for 70% right internal carotid artery stenosis. Doppler ultrasound examination in [**2118-5-22**] revealed also a 60-70% right internal carotid artery stenosis as well as a 40% left internal carotid artery stenosis. Catheterization showed the right internal coronary artery with calcified 70% lesion at the bifurcation with the right external carotid artery. In the Catheterization Laboratory, the patient's right internal coronary artery lesion was predilated with a .......... balloon, and then stented with an 8.0 x 30 mm precise stent. Final residual was 30% with normal flow. During balloon inflation, the patient had an episode of bradycardia and required atropine x1 dose. Status post procedure, patient was examined by the attending Cardiology and the attending cardiologist felt to be neurologically intact. Upon arrival to the Coronary Care Unit, she denied any headaches, visual changes, numbness, weakness, altered sensation, chest pain, shortness of breath, palpitations, nausea, vomiting. She denied any leg or back pain at the catheterization site. She was transferred to the CCU for further hemodynamic monitoring. PAST MEDICAL HISTORY: 1. Coronary artery disease status post CABG in [**9-21**], with LIMA to LAD, saphenous vein graft to RCA/PDA, saphenous vein graft to OM-1. 2. Hypertension. 3. Hypercholesterolemia. 4. Osteoarthritis of the left knee. 5. Sciatica. 6. History of diverticulitis. 7. Small bowel obstruction with colectomy in [**2103**]. 8. Total abdominal hysterectomy. ALLERGIES: The patient reports allergies to Robitussin resulting in rash, and Vioxx resulting in shortness of breath. MEDICATIONS PRIOR TO ADMISSION: 1. Aspirin 325 mg p.o. q.d. 2. Lipitor 10 mg p.o. q.d. 3. Lopressor 25 mg p.o. q.d. 4. Zantac 150 mg p.o. q.d. 5. Celebrex 200 mg p.o. q.d. 6. Accupril 20 mg p.o. q.d. 7. Plavix 75 mg p.o. q.d. 8. Vitamin E. 9. Calcium supplementation. 10. Multivitamin. SOCIAL HISTORY: Patient is widowed. She is retired. She has two children in the area. She denies any tobacco, alcohol, and drug use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAM UPON ADMISSION: Vital signs showed a temperature of 96.4, blood pressure 152/60, heart rate 58, respiratory rate 18, oxygen saturation 97% on room air. General appearance: Well-developed, well-nourished female, sleeping comfortably in no acute distress. HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular eye movements intact without nystagmus. Oral mucosa moist. Oropharynx is clear. Neck: Supple. Carotid pulse 1+ bilaterally. No carotid bruits auscultated, no evidence of lymphadenopathy, no jugular venous distention. Lungs: Clear to auscultation bilaterally, no rhonchi, rales, wheezes. Cardiovascular: Regular, rate, and rhythm. S1, S2 heart sounds auscultated. No murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended. No hepatosplenomegaly. Positive normoactive bowel sounds. Groin: Bandage on right catheterization site clean, dry, and intact. No serosanguinous discharge. No evidence of bruit or hematoma formation. Femoral pulses 1+ bilaterally. Extremities: 1+ bilateral nonpitting edema, 1+ dorsalis pedis pulses bilaterally. Feet warm, dry. PERTINENT LABORATORIES ETC: Complete blood count on admission showed WBC 4.2, hematocrit 27.9, platelet count 166. Coagulation profile showed a PT of 13.4, PTT 58.4, INR 1.2. Serum chemistries showed a sodium of 133, potassium 4.3, chloride 104, bicarbonate 23, BUN 31, creatinine 1.2, glucose 126, calcium 8.5, phosphorus 3.2, magnesium 2.0, albumin 3.3. EKG showed sinus bradycardia with sinus arrhythmia at a rate of 45 beats per minute. Normal axis. Borderline P-R interval. Low voltage noted throughout the precordium. With poor R-wave progression. Evidence of a Q wave noted in lead III with T-wave inversion. New T-wave inversion compared with previous EKG in 10/[**2115**]. BRIEF SUMMARY OF HOSPITAL COURSE: 1. Coronary artery disease: Patient's history of coronary artery disease status post CABG in [**9-/2116**], now status post right internal carotid artery stenosis. She is continued on her outpatient doses of aspirin, Plavix, Lipitor. As she had evidence of low systolic blood pressure status post carotid artery stenting, initially all of her outpatient antihypertensive medications were held. However, it was noted later on the evening of admission that patient was unable to maintain a systolic blood pressure greater than 100. She reported taking her antihypertensive medications in the a.m. prior to her stenting procedure, despite preoperative information not to do so. She was bolused with fluid aggressively, however, this did not result in significant maintenance of systolic blood pressure greater than 100. Therefore, she was started on Neophed at a rate of 0.1 mcg/kg/minute. This was titrated up to keep her systolic blood pressure greater than 120. Additionally, p.m. laboratories revealed that patient's hematocrit was 27.3. Therefore, she was transfused 1 unit of packed red blood cells on the evening of [**2118-8-8**]. She tolerated this well. On the evening on [**2118-8-9**], the patient was weaned off Neophed. Blood pressure at that time was stable with systolic rates of 120s to 130s. She tolerated this without any difficulty. Patient was maintained off all of her outpatient antihypertensives throughout this hospital course. She was instructed not to reinstate any of these medications until seeing Dr. [**First Name (STitle) **] in followup after discharge. 2. Status post right internal carotid artery stent: Patient was admitted to the CCU from the Catheterization Laboratory status post right internal carotid artery stenting. She tolerated this procedure well. After arrival, she was followed by the Neurology Consult Service. She had neuro checks every two hours for the first six hours of her admission, then neuro checks were spaced out to every six hours. Immediately after the stenting procedure, she was evaluated by Neurology attending physician, [**Name10 (NameIs) 1023**] felt her to be neurologically intact. Initially, the plan was the patient to be discharged to home on the morning after stenting procedure, [**2118-8-9**]. However, during evaluation that morning, the patient appeared to be confused and mildly disoriented. She also had episodes of being agitated at times, requiring posey vest placement, and medication with Ativan. As it was questionable whether the patient was delirious secondary to new environment or anesthetics or pain medicines used status post stenting procedure versus whether she had suffered an acute neurological event, Neurology consultation was obtained. Neurology input was consistent with an examination indicative of delirium or altered mental status. The patient had no focal neurological findings. As she had a recent Foley catheter in place, Neurology recommended that we check a urinalysis and urine culture. They also recommended continuation of aspirin and Plavix. Patient's urine was sent for analysis and culture, and was negative. Patient was also evaluated by the Psychiatry service. During their exam, she continued to be mildly confused and disoriented, but not acutely agitated. Their impression was also one of resolving delirium. Per Psychiatry recommendation, the patient's family was encouraged to stay at her bedside as much as possible for frequent reorientation. When family was not available, the patient had a sitter again for frequent reorientation and to monitor her for agitation and confusion. On the morning of [**2118-8-11**], patient was re-evaluated. She appeared to be much less confused and disoriented. She was actually alert and oriented to person, place, and time. She was completely intact on neurological examination. After discussion with Psychiatry followup and attending, Dr. [**First Name (STitle) **], decision was made to discharge the patient to home under the care of her sister, [**Name (NI) **], along with home nursing services. CONDITION ON DISCHARGE: Fair. Mentation improved. Patient is alert and oriented. No evidence of neurological insult or compromise. Hematocrit and blood pressure values were stable. Patient was ambulating independently. DISCHARGE STATUS: The patient was discharged to home with services. DISCHARGE DIAGNOSES: 1. Cerebral atherosclerosis. 2. Hyperlipidemia, mixed. 3. Hypertension, essential, benign. 4. History of transient ischemic attack. 5. Status post carotid stenosis, angioplasty, and stent placement. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Plavix 75 mg p.o. q.d. 3. Lipitor 10 mg p.o. q.d. 4. Multivitamins one capsule p.o. q.d. 5. Celebrex 200 mg p.o. b.i.d. 6. Ranitidine 150 mg p.o. q.d. FOLLOW-UP PLANS: Patient was to followup with Dr. [**First Name (STitle) **] on the day after discharge at the [**Hospital1 188**] [**Hospital Ward Name 517**], [**Hospital Unit Name 723**], [**Location (un) **] for a blood pressure check. She was instructed not to take any of her blood pressure medications prior to admission, including Lopressor and Accupril, until she saw Dr. [**First Name (STitle) **] for her followup blood pressure check. Additionally, she had a later follow-up appointment scheduled with Dr. [**First Name (STitle) **] on [**2118-11-15**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**Last Name (NamePattern1) 257**] MEDQUIST36 D: [**2118-9-8**] 14:56 T: [**2118-9-12**] 08:08 JOB#: [**Job Number 36151**] cc:[**Last Name (NamePattern4) 36152**]

[ "413.9", "401.9", "433.10", "V45.81", "272.4" ]

icd9cm

[ [ [] ] ]

[ "39.90", "39.50", "88.41" ]

icd9pcs

[ [ [] ] ]

2552, 2586

8879, 9079

9102, 9285

4465, 8562

2142, 2397

9303, 10170

160, 1616

2601, 4437

1638, 2110

2414, 2535

8587, 8858

44,083

131,048

36118

Discharge summary

report

Admission Date: [**2112-5-22**] Discharge Date: [**2112-5-25**] Date of Birth: [**2057-11-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: DOE Major Surgical or Invasive Procedure: Thoracentesis Pericardial Drain placment and removal Cardiac Cath History of Present Illness: Mr. [**Known lastname 81936**] is a 54 yo M h/o esophageal ca (dx [**11-22**], s/p 1 cycle of 5-FU and cisplatin and 6 wks XRT) who is status post esophagectomy on [**2112-5-4**] who was discharged home post-op on [**2112-5-11**] and developed progressive DOE over the next week and half prompting him to present to the ED on [**2112-5-22**]. Notably, patient was seen in thoracic surgery clinic on [**2112-5-19**] at which time he was noted to have a moderate sized left pleural effusion. Patient notes that he experienced dyspnea mainly when climbing stairs and ambulating around his house. He did not have shortness of breath of rest but did experience orthopnea. Prior to presentation he did not have any chest pain. He denies any recent fevers, chills, coughing, sore throat or nasal congestion. . On [**2112-5-22**] patient was admitted to the thoracic surgery service where he underwentleft thoracentesis yielding 1200 cc of dark serous fluid. Patient's shortness of breath continued despite this intervention so CTA chest was performed that demonstrated a large pericardial effusion. Similarly, a TTE on [**5-22**] showed moderate to large circumferential pericardial effusion with early tamponade. Overnight patient remained hemodynamically stable. He underwent c. cath today that demonstrated right heart filling pressures with a mean RA of 12mmHg and near equalization of diastolic pressures consistent with early tamponade physiology. A pigtail cath was placed that drained 400cc serosangous fluid. Repeat ECHO demonstrated RA pressure of 5 mmHg. . On arrival to the CCU, patient feels that shortness of breath is much improved. He denies any groin pain or pain in the region of his pericardial drain. . ROS: (+)50 lb wt loss since [**11-22**]. . . He denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - Esophageal cancer, locally advanced: s/p 1 cycle 5-FU and cisplatin [**1-25**], cycle 2 held [**1-18**] thrombocytopenia, s/p radiation [**2112-1-18**] to [**2112-2-22**]. s/p esophagectomy [**2112-5-4**]. Social History: -Tobacco history:none -ETOH: no ETOH for 7 months, previously drank 4-6 beers several nights a week. -Illicit drugs: None Previously worked as an autobody mechanic. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T= 98.7 BP=148/89 HR=100 RR=20 O2 sat=97% RA GENERAL: Well appearing Caucasian male, Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, JVP not elevated 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: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. BACK: surgical scar at T6 appears well healed ABDOMEN: Surgical scars well healed. Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS =============== [**2112-5-22**] 10:17AM BLOOD WBC-6.7 RBC-3.75* Hgb-9.3* Hct-29.2* MCV-78* MCH-24.9* MCHC-32.0 RDW-14.5 Plt Ct-189 [**2112-5-22**] 10:32AM BLOOD PT-14.7* PTT-26.7 INR(PT)-1.3* [**2112-5-22**] 10:17AM BLOOD Glucose-109* UreaN-15 Creat-0.8 Na-143 K-3.8 Cl-106 HCO3-25 AnGap-16 [**2112-5-23**] 06:50AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.4 Mg-1.7 Iron-17* [**2112-5-23**] 06:50AM BLOOD calTIBC-286 Ferritn-101 TRF-220 [**2112-5-22**] 11:57AM PLEURAL WBC-575* RBC-7525* Polys-35* Lymphs-10* Monos-16* Eos-1* Meso-26* Macro-12* [**2112-5-22**] 11:57AM PLEURAL TotProt-4.3 Glucose-114 LD(LDH)-160 [**2112-5-23**] 10:40AM OTHER BODY FLUID WBC-2389* Hct,Fl-2.5* Polys-48* Lymphs-32* Monos-0 Macro-20* [**2112-5-23**] 10:40AM OTHER BODY FLUID TotProt-4.8 Glucose-91 LD(LDH)-818 Amylase-32 Albumin-3.0 ======= MICRO: ======= [**2112-5-22**] 11:57 am PLEURAL FLUID GRAM STAIN (Final [**2112-5-22**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [**2112-5-23**] 10:40 am FLUID,OTHER PERICARDIAL . GRAM STAIN (Final [**2112-5-23**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): [**2112-5-23**] 10:40 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERICARDIAL FLUID. Fluid Culture in Bottles (Preliminary): NO GROWTH. ========== CYTOLOGY ========== Pleural Fluid [**2112-5-22**]: NEGATIVE FOR MALIGNANT CELLS. Pericardial Fluid [**2112-5-23**]: NEGATIVE FOR MALIGNANT CELLS. ========= IMAGING ========= ECHO: [**5-22**] The right atrial pressure is indeterminate. 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 are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is a moderate sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. IMPRESSION: Moderate to large circumferential pericardial effusion with early tamponade. ECHO [**5-23**] PRE- PERICARDIOCENTESIS Overall left ventricular systolic function is normal (LVEF>55%). There is a moderate sized pericardial effusion. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. POST- INTERVENTION There is a trivial pericardial effusion. There are no echocardiographic signs of tamponade. ECHO [**5-24**] Limited study. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The tricuspid valve leaflets are mildly thickened. There is a small circumferential pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2112-5-23**], the pericardial effusion is smaller and no right ventricular diastolic collapse is present (when compared to pre-pericardiocentesis images). CTA [**5-22**] IMPRESSION: 1. Large pericardial effusion increased significantly from [**4-8**], [**2111**]. Measures simple fluid attenuation. Minimal compressive effect on the right ventricle. Echocardiography recommended for further evaluation. 2. Small bilateral pleural effusions, loculated on the right and associated with the compressive atelectasis/collapse of the left lower lobe. 3. No evidence of pulmonary embolus or dissection. 4. Expected post-surgical appearance of the mediastinum consistent with esophagectomy and gastric pull-through. 5. Probable Paget's disease of the posterior 5th and 10th right ribs, unchanged. C.Cath: [**2112-5-23**] COMMENTS: 1. Resting hemodynamics revealed mildly elevated right heart filling pressures with a mean RA of 12mmHg. There was near equalization of diastolic pressures of diastolic pressures consistent with early tamponade physiology. The cardiac index was preserved at 3.3 l/min/m2. 2. With ultrasound guidance a pigtail catheter was successfully placed in the pericardial space and 400cc of serosangous fluid was removed. 3. The mean RA pressure fell to 5mmHg and a repeat echocardiogram demonstrated near complete resolution of the effusion. FINAL DIAGNOSIS: 1. Successful removal of 400cc of pericardial fluid. Brief Hospital Course: This is a 54 year old male with locally advanced esophageal cancer s/p chemo and radiation and more recently s/p esophagectomy who presents with progressive shortness of breath and found to have pericardial effusion and left sided pleural effusion which were drained resulting in improvement of symptoms. # Pericardial Effusion: On [**2112-5-22**] patient was admitted to the thoracic surgery service where he underwentleft thoracentesis yielding 1200 cc of dark serous fluid. Patient's shortness of breath continued despite this intervention so CTA chest was performed that demonstrated a large pericardial effusion. Similarly, a TTE on [**5-22**] showed moderate to large circumferential pericardial effusion with early tamponade. Overnight patient remained hemodynamically stable. He underwent c. cath on [**2112-5-23**] that demonstrated right heart filling pressures with a mean RA of 12mmHg and near equalization of diastolic pressures consistent with early tamponade physiology. A pigtail cath was placed that drained 400cc serosangous fluid. It was an exudate by light's critea. Repeat ECHO demonstrated RA pressure of 5 mmHg. Most likely etiologies include reactive effusion secondary to recent esophagectomy vs radiation induced effusion. Infectious etiology less likely given no history of fevers and no elevation of white count. The drain put out an additional 270cc and no further drainage since evening. The drain was removed on [**2112-5-24**] and the patient's respiratory status improved. Pericardial fluid cytology demonstrated no malignant cells and cultures were preliminarily negative at time of discharge. Would suggest pt have a repeat ECHO in [**3-21**] weeks. He has follow up scheduled with Dr. [**First Name (STitle) **], his thoracic surgeon. # Pleural Effusion: The patient had complaints of DOE. Prior CXR showed enlarging moderate left pleural effusion and small right effusion. On [**2112-5-22**] patient was admitted to the thoracic surgery service where he underwent left thoracentesis yielding 1200 cc of dark serous fluid and an exudate. The cultures were prelim no growth and cytology was negative for malignant cells. # PUMP: ECHO from [**5-22**] demonstrated EF 60-70%. Patient remained euvolemic. His atenolol was initially restarted but was stopped at time of discharge given his pressure were running in the low normal range (SBP's high 90's to low 100's). Patient should follow up with his PCP in one week for BP check to determine if this medication should be restarted. . # CORONARIES: No h/o CAD. He was continued on home dose of ASA. Atenolol stopped at time of discharge as explained under PUMP. . # RHYTHM: Remained in sinus rhythm with rates in the 70's-80's as monitored on telemetry. . # Esophageal CA: Patient is s/p chemo, radiation and esophagectomy. Plan for further treatment per primary oncology team as an outpatient. . # Hypotensive Episode: A few hours following pericardial drain removal patient noted to become diaphoretic and have transient episode of hypotension to 84/51. Notably, patient had just finished his dinner. Blood pressure came back up to a normotensive range right away without any intervention. Likely this represented a vaso vagal episode. Notably, he did not have any further episodes overnight or up until discharge. # HTN: Initially patient's atenolol 50mg daily was continued, however, given that his SBP's were running in the high 90's to low 100's consistently for 24 hours prior to discharge (while on the atenolol) we decided to have him stop the atenolol and follow up with his PCP within the next week for a blood pressure check. # Microcytic Anemia: Iron studies indicated an Fe of 17 with normal ferritin and TIBC. Possible this could be 2/2 blood loss from recent surgery. Would suggest outpatient anemia work-up including age appropriate screening. Patient was a FULL code during this admission. Medications on Admission: Atenolol 50 mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Pleural Effusion Pericardial Effusion Secondary: Esophageal cancer HTN Discharge Condition: stable, ambulating, normotensive, O2 sat >92% room air Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because you were having shortness of breath. We determined you had fluid in your left lung that was removed. Additionally, there was fluid found around your heart and a drain was placed. The fluid was removed and you tolerated the procedure. You can continue taking over the counter tylenol as needed for pain. You were also found to be anemic and started on iron supplement. We suggest that you discuss this anemia with your oncologist or primary care physician. NEW MEDICATIONS: START Ferrous Sulfate 325mg twice a day MEDICATION CHANGES: STOP Atenolol- you should have your blood pressure rechecked when you see your PCP and he can decide whether or not you need this restarted. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: Provider: [**Known firstname **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**] Date/Time:[**2112-5-31**] 10:30 You should schedule an appointment to see your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within the next week. His phone number is [**Telephone/Fax (1) 17753**]. Completed by:[**2112-5-25**]

[ "V10.03", "511.9", "423.9", "401.9", "285.9" ]

icd9cm

[ [ [] ] ]

[ "34.91", "37.21", "37.0" ]

icd9pcs

[ [ [] ] ]

13498, 13547

9283, 13185

319, 387

13672, 13729

4261, 5286

14788, 15146

3265, 3380

13257, 13475

13568, 13651

13211, 13234

9205, 9260

13753, 14389

3395, 4242

2752, 2825

5810, 9188

14409, 14765

276, 281

415, 2672

5779, 5779

2856, 3066

2694, 2732

3082, 3249

5743, 5743

42,468

132,751

1572

Discharge summary

report

Admission Date: [**2112-6-4**] Discharge Date: [**2112-6-9**] Date of Birth: [**2049-8-17**] Sex: F Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 9152**] Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: Ms [**Known lastname 9147**] is a 62 year-old female with a history of alcohol abuse, falls leading to subdural and subarachnoid hemorrhages with resultant L partial motor seizure who now presents with headache, agitation, and transfer from an outside hospital for another SAH / IPH hemorrhage. Per reports she was complaining of headache this morning. Nursing came in at the rehab center and noticed her to be very confused, somnolent and noncooperative. There was a man who the family has not met and is a reported boyfriend of the patient in the room. Nursing was concerned he had given her some [**Known lastname 4982**]. She was taken to an OSH where she was given narcan without response and a NCHCT demonstrated a new IPH. She was then transferred to [**Hospital1 18**] for further management. Of note her CXR demonstrated some vascular peritracheal prominence and UA demonstrated a new UTI. Ms. [**Known lastname 9149**] initial trouble began [**2111-7-26**] when she fell down some stairs leading to a basilar skull fracture and R subdural hematoma. She underwent a craniotomy for evacuation of the hemorrhage and R temporal lobectomy. On POD #5 she developed L arm and face twitching lasting 5-10 minutes. She had been on prophylactic Dilantin and initially Keppra was added to her regimen for seizure control. Because of side effects, this was changed to Dilantin and Depakote. After a prolonged hospitalization and rehabilation, she was eventually discharged to home on [**2112-3-11**] where she was living independently for several weeks with daily assistance from her daughter who lives nearby. She was admitted to the neurosurgery service [**Date range (1) 9150**] after she had another fall from standing. She was found to have a new right frontal subarachnoid hemorrhage and was observed and evaluated for possible syncope. Her dilantin level was toxic at 23.9 and this medication was then discontinued. It is unclear from the records if she was supposed to restart at discharge or continuing holding the dilantin. There was no mention of gait unsteadiness in the documentation, but dilantin toxicity may have been contributing to her falls at that time. in Mid [**Month (only) 547**] while at rehab noticed that her left arm, face and leg were shaking. This persisted during the ambulance ride to [**Hospital **] [**Hospital 1459**] Hospital and was not stopped until 1mg of ativan was administered somewhere around 30minutes after symptoms began. Ms. [**Known lastname **] was admitted to the epilepsy service after she had a breakthrough seizure at her rehab facility. It was discovered that her dilantin had been discontinued prior to her recent discharge from the neurosurgery service and on admission her dilantin level was subtherapeutic at 7.2 and her depakote was also subtherapeutic at 28. She was found to have a urinary tract infection. Her seizure was likely a result both the infection and her low dilantin level. Because of her recent falls, it was decided that dilantin might be contributing to her instability, so this medication was not restarted. She was instead loaded with IV keppra and then started on oral maintenance keppra. She was given an extra dose of depakote during the hospital and the level at discharge was therapeutic at 57. She had no further seizures during the hospitalization and an routine EEG showed no epileptiform events. Her UTI was treated with ceftriaxone. She initially has some significant confusion thought to be post-ictal but this improved over the several days following her seizure. She was evaluated by PT and OT who recommended rehab for further treatment of her gait and balance difficulties. At discharge, her neurological exam was remarkable for some tangential thinking and mild gait instability requiring a walker. Per cousin she was admitted to [**Hospital6 **] over the [**Hospital1 **] day holiday to the psychiatric facility for attacking a nurse. It is unclear how they adjusted her meds. However, on review of her current meds she seems to be off of keppra and on scheduled Chlorpromazine. Patient was too uncooperative, and refused to answer any questions. However, on speaking with her cousins they deny recent fever or chills. No night sweats. She has had recent weight loss and refusal to eat. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. She also has been refusing to void recently. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: -Hypertension -R Radial Nerve Compression -Fibroids -Right Craniotomy and SDH Evaluation ([**2111-8-26**]) -Alcohol Abuse Social History: Had been living alone, but recently was in rehabilitation after having been discharged from inpatient psychiatric facility. Long history of alcohol abuse in the past, but none since discharge from rehab. No drugs/tobacco. One daughter. Family History: unknown secondary to adoption Physical Exam: Vitals: T:97.6 P:81 R: 16 BP:168/98 SaO2:98% General:minimally cooperative with examination, sleeping becomes agitated when answering questions. refused to open eyes. but spontaneously opened later in exam. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities: warm and well perfused Skin: no rashes or lesions noted. Neurologic: -Mental Status: Confused. she knew her name stated she was in a hospital "stated she did not give a Sh*t " to the rest of my questions refusing to answer and told me to go away. Her cousins were at bedside, she did not state there names and stated she did not care about them. Speech was clear and nondysarthric. Did not follow commands. -Cranial Nerves: I: Olfaction not tested. II: Unable to assess visual field secondary to patient cooperation. III, IV, VI: was able to look to the left and right following the examiner. V: Facial sensation could not be tested VII: No facial droop, facial musculature symmetric and strong VIII: Hearing intact to voice -Motor: Moves all extremities spontaneously (R>L). However, had good withdraw brisk in all 4 extremities to noxious. -DTRs: upper extremities she kept pushing me away and could not test. [**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach L 2 0 R 2 0 Plantar response were mute bilaterally. -Coordination: no ataxic movements observed Pertinent Results: [**2112-6-4**] 05:50PM URINE RBC-23* WBC->182* BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-1 [**2112-6-4**] 05:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG [**2112-6-4**] 05:50PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.015 [**2112-6-4**] 05:50PM PT-12.7 PTT-27.6 INR(PT)-1.1 [**2112-6-4**] 05:50PM PLT COUNT-182 [**2112-6-4**] 05:50PM NEUTS-84.0* LYMPHS-9.9* MONOS-5.4 EOS-0.2 BASOS-0.5 [**2112-6-4**] 05:50PM WBC-6.1 RBC-3.37* HGB-11.4* HCT-32.8* MCV-98 MCH-34.0* MCHC-34.8 RDW-12.5 [**2112-6-4**] 05:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2112-6-4**] 05:50PM PHENYTOIN-<0.6* VALPROATE-113* [**2112-6-4**] 05:50PM ALBUMIN-4.0 [**2112-6-4**] 05:50PM CK-MB-2 cTropnT-<0.01 [**2112-6-4**] 05:50PM cTropnT-<0.01 [**2112-6-4**] 05:50PM CK(CPK)-20* [**2112-6-4**] 07:34PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG Brief Hospital Course: Neurology: Ms. [**Known lastname **] was admitted after a fall that was concerning for having been secondary to a seizure. While it was unclear whether or not she fell because of that, she was started on Keppra. She had no seizures while she was here. A routine EEG revealed epileptiform discharges from the right parietal region. She had no seizures during her admission. Her intraparenchymal hemorrhage is likely secondary to a fall. Two follow-up HCTs were negative. She is currently at her neurological baseline. ID: Ms. [**Known lastname **] was found to have a urinary tract infection with proteus mirabilis on admission and is s/p three days of IV ceftriaxone. A repeat UA was negative. It may be that her concurrent infection may have caused her to be encephalopathic and fall. CV: Initially, Ms. [**Known lastname 9149**] blood pressure [**Known lastname 4982**] were held. However, during her admission her SBPs increased to the 150s-160s. Her metoprolol was restarted as well as her keppra. Psych: Ms. [**Known lastname **] had some agitation initially. However, she was able to be managed with thorazine 25mg TID. She did not have any behavioral outbursts afterwards for the remainder of her admission. [**Known lastname **] on Admission: Amlodipine 10 mg PO daily Colace 200 mg daily Vitamin B 12 250 mg PO daily Laculose 20 mL daily Synthroid 75 mg PO daily depakote 1000 mg [**Hospital1 **] Metoprolol 50 mg PO BID Chlorpromazine 50 mg PO TID Acetaminophen 650 mg PO daily Bisacodyl - Rectal chlorpromazine 25 mg PO TID PRN Milk of Magnesia FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by mouth Qday THIAMINE HCL - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth qday Discharge [**Hospital1 **]: 1. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY (Daily). 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. chlorpromazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. chlorpromazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation. 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 11. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO BID (2 times a day). 12. valproic acid 250 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 13. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. tramadol 50 mg Tablet Sig: One (1) Tablet PO X1 (ONE TIME) for 1 doses. Discharge Disposition: Extended Care Facility: [**Location (un) 1459**] Care and Rehabilitation Center Discharge Diagnosis: intraparenchymal hemorrhage; subdural hemorrhage. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted because of a fall. You were found to have a left frontal intraparenchymal hemorrhage and a right subdural hemorrhage that were likely secondary to your fall. We were concerned that your fall may have been due to a seizure. You had an EEG that showed no seizure, but did show epileptiform discharges coming from the right parietal region. Because of this, you were started on a medication called Keppra for your seizure. It is important that these [**Location (un) 4982**] be taken everyday for seizure control. You also had a urinary tract infection which may have made you unsteady and precipitated your fall. Followup Instructions: Please call to schedule f/u with Dr. [**First Name (STitle) **] by calling [**Telephone/Fax (1) 3294**] within the next 2-4 weeks. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9153**]

[ "905.0", "E929.3", "305.00", "599.0", "218.9", "345.50", "853.06", "401.9", "E888.9", "852.20", "293.0", "V12.54", "041.6", "V15.88", "V11.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11238, 11320

7950, 9207

276, 283

11414, 11414

6931, 7927

12255, 12481

5307, 5338

11341, 11393

11597, 12232

6229, 6912

5353, 5869

232, 238

311, 4889

9221, 11215

11429, 11573

4911, 5034

5050, 5291

29,104

198,939

33147

Discharge summary

report

Admission Date: [**2136-2-18**] Discharge Date: [**2136-2-27**] Date of Birth: [**2054-5-12**] Sex: F Service: CARDIOTHORACIC Allergies: Zyban / Wellbutrin Attending:[**First Name3 (LF) 281**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: pleurex catheter placement History of Present Illness: 81F NSCLC dx'd [**12-20**], s/p Rt talc pleurodesis on [**2136-1-3**] for malig pleural effusion, s/p Rt pleurocentesis on [**2-13**] - now presents with increasing dyspnea, CXR with Rt stable pleural effusion. Patient denies chest pain, fevers, chills, nausea or vomiting. Past Medical History: Polymyalgia rheumatica, pleural effusion, lung nodule, htn, ^chol, osteoporosis Social History: The pt quit smoking four years ago. Prior to this, she smoked 1 ppd for approximately 64 years. She does not drink EtOH. She lives independently at home. Family History: The patient is not aware of any medical conditions running in her family. Physical Exam: VS- AVSS Gen- NAD, AxOx3 heart- RRR lungs- diminished BS on the left abd- BS+, soft, NT/ND Pertinent Results: [**2136-2-18**] 05:30PM WBC-10.4 RBC-4.12* HGB-11.0* HCT-35.8* MCV-87 MCH-26.6* MCHC-30.6* RDW-13.8 [**2136-2-18**] 05:30PM GLUCOSE-150* UREA N-19 CREAT-1.0 SODIUM-133 POTASSIUM-5.2* CHLORIDE-94* TOTAL CO2-29 ANION GAP-15 Brief Hospital Course: Patient was admitted for shortness of breath. She underwent a CT chest to assess a large right sided pleural effusion as she had previously undergone talc pleurodiesis. The CT showed b/l segmental and subsegmental pulmonary emboli. She was immediately heparinized. Interventional pulmonology took her for a pleur-ex catheter on [**2-20**] to drain her pleural effusion. Her heparin was held for the procedure. She was restarted on lovenox after the procedure for continued anticoagulation. . PPD#1 pt c/o dizziness upon awakening. SBP 70's. HR 90's. Given IVF bolus w/o response. Pleurex catheter drained for 500cc frank blood. Stat HCT and typed and crossmatched for 2UPRBC. Pt transferred to the ICU for ongoing management. HCT 27, then 25-transfused. BP stabilized. Pleural drainage decreased. LE US revealed right DVT. ECHO w/o tamponade physiology. Dr. [**Last Name (STitle) **] had discussion w/ pt and family and Dr. [**Last Name (STitle) 3274**] and pt made DNR/DNI- given risk of re-bleed, IVC filter was placed. . The patient was continued on comfort care only. A morphine PCA was started for pain control. She was given albuterol nebs and lasix IV as needed but only for comfort at her request. This was continued until she expired on [**2136-2-27**]. Medications on Admission: Valsartan 80, Atenolol 50, HCTZ 50, Triamterene 50, Nortryptilene 10 Discharge Medications: none Discharge Disposition: Home with Service Discharge Diagnosis: NSCLC dx'd [**12-20**], s/p Rt talc pleurodesis on [**2136-1-3**] for malig pleural effusion, s/p Rt pleurocentesis on [**2-13**] - now with increasing dyspnea, CXR with Rt stable pleural effusion. PMH: Polymyalgia rheumatica, COPD, HTN, hypercholesterolemia, osteoporosis, breast CA s/p lumpectomy and XRT, s/p hysterectomy recurrent pulmonary effusion pulmonary embolism. death Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**] Completed by:[**2136-2-27**]

[ "285.22", "725", "496", "401.9", "162.8", "V10.3", "276.52", "584.9", "453.41", "285.1", "415.19", "197.2", "272.4" ]

icd9cm

[ [ [] ] ]

[ "34.04", "38.7", "34.91", "99.04" ]

icd9pcs

[ [ [] ] ]

2802, 2821

1381, 2653

304, 333

3247, 3257

1130, 1358

3310, 3436

928, 1004

2773, 2779

2842, 3226

2679, 2750

3281, 3287

1019, 1111

245, 266

361, 637

659, 740

756, 912

17,586

103,252

51974

Discharge summary

report

Admission Date: [**2177-8-30**] Discharge Date: [**2177-9-1**] Service: CARDIOTHORACIC Allergies: Indapamide / Atenolol Attending:[**Known firstname 922**] Chief Complaint: 84M s/p aorto-inomminate bypass with endocascular stents of the aortic arch/CABGx1 who was at rehab and had a VT arrest. Major Surgical or Invasive Procedure: none History of Present Illness: This 84WM is well know to our service. He is s/p aorto-inomminate bypass with endovascular stenting of the aortic arch and descending aorta/CABG x 1 (SVG->PDA) on [**2177-6-24**]. He had a prolonged post op course and was eventually [**Date Range 107589**] and had a gastrostomy tube. He was initially transferred to rehab on [**8-4**], but was readmitted with a pleural effusion. He had a chest tube and was again discharged on [**8-22**]. He had a VT arrest at rehab and was transferred to an outside hospital ER where he had ACLS protocol with defibrillation. He had PO2 of 29 at the outside ER. The O2 was brought up above 100 and he was transferred to the CSRU in critical condition. Past Medical History: HTN Depression Syncope Vocal hoarseness with L vocal cord paralysis s/p sinus surgery s/p CABGx1, aortic stenting tracheostomy respiratory failure gastrostomy tube Social History: Lives alone Cigs: 20 pk yr hx, quit 35 yrs. ago. ETOH: none Family History: unremarkable Physical Exam: [**First Name5 (NamePattern1) 4746**] [**Last Name (NamePattern1) 107589**] on vent. VS: T:95.8 BP: 123/66 P: 67 O2 sat 100% on TV 450 IMV 18 PEEP 10 HEENT: NC/AT, pupils fixed and dilated 4-5mm, non-reactive, oropharynx benign Lungs: Clear to A+P CV: RRR without R/G/M, nl s1, s2 Abd: soft, nontender, g tube in place Ext: no C/C/E Neuro: non responsive to verbal or painful stimuli, myoclonic movements Pertinent Results: [**2177-8-31**] 05:03AM BLOOD WBC-15.8* RBC-2.94* Hgb-8.7* Hct-25.9* MCV-88 MCH-29.5 MCHC-33.4 RDW-15.4 Plt Ct-317 [**2177-8-31**] 05:03AM BLOOD Glucose-114* UreaN-36* Creat-1.2 Na-137 K-3.6 Cl-98 HCO3-29 AnGap-14 RADIOLOGY Final Report CTA CHEST W&W/O C &RECONS [**2177-8-30**] 11:21 PM CTA CHEST W&W/O C &RECONS Reason: ? PE Field of view: 36 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 84 year old man s/p CABGx1(SVG-PDA)/aoroto-inominate bypass,endovascular stents of the aortic arch and descending aorta, today - VT arrest in NH REASON FOR THIS EXAMINATION: ? PE CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 84-year-old man status post CABG x1 with aortoinnominate bypass endovascular stent of aortic arch and descending aorta. Today with V-tach arrest. Evaluate for pulmonary embolism. COMPARISON: [**2177-8-14**] CTA chest. TECHNIQUE: MDCT-acquired axial images of the chest were obtained without and with IV contrast per non-gated chest pain protocol. Multiplanar reformations were obtained. CT CHEST WITHOUT AND WITH IV CONTRAST: There has been interval decrease in size of the large right-sided pleural effusion, which now is moderate in size. Diffuse bilateral ground-glass opacities are seen throughout the lungs, likely representing pulmonary edema. There has been interval development of opacity within the left lower lobe, which could represent aspiration pneumonia or atelectasis. The heart is enlarged. A saccular aneurysm is again noted along the aortic arch. An aortic stent is seen along the aortic arch. There is lack of IV contrast within the aorta secondary to bolus timing. There are extensive coronary and aortic calcifications. The patient is status post median sternotomy. CTA CHEST: There is no evidence of filling defects within the pulmonary arterial vasculature. No evidence of pulmonary embolism. As mentioned above, the aorta is unopacified secondary to bolus timing. A stent is seen extending along the aortic arch. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Diffuse bilateral opacities similar to prior study likely represent pulmonary edema. 3. Interval improvement of right-sided pleural effusion, now moderate in size. 4. Interval worsening of left lower lobe consolidation, representing either pneumonia, aspiration or atelectasis. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**] DR. [**First Name (STitle) 15744**] N. [**Doctor Last Name 1447**] Approved: SUN [**2177-8-31**] 3:36 PM Brief Hospital Course: The patient was admitted to the CSRU. Due to unstable hemodynamics and ventricular dysrhythmias, he was maintained on Dopamine and Lidocaine drips. He urgently underwent chest CTA to rule out pulmonary embolus and a head CT to rule out stroke. The head CT found no evidence of infarction or hemorrhage, and he ruled out for PE by CT angiogram. The CTA was however notable for interval worsening of a left lower lobe consolidation, representing either pneumonia, aspiration or atelectasis. Given his VF arrest and likely oxygen deprivation, he continued to experienced generalized myoclonus. The neurology service was consulted for further evaluation and EEG was performed. The EEG showed generalized discharges and very little, if any normal background was seen. Given his anoxic brain injury and grim prognosis, the family decided to withdraw support. Patient expired on [**9-1**] @[**2187**] with the family at bedside. Family declined autopsy. Discharge Medications: Not applicable Discharge Disposition: Expired Facility: [**Hospital1 18**] Discharge Diagnosis: Anoxic brain injury after VT arrest, Seizures Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[**2177-9-17**]

[ "401.9", "311", "410.91", "V45.81", "348.1", "427.41", "389.9", "V44.0", "345.3" ]

icd9cm

[ [ [] ] ]

[ "96.71", "00.17" ]

icd9pcs

[ [ [] ] ]

5420, 5459

4408, 5358

353, 359

5548, 5557

1821, 2190

5610, 5645

1364, 1378

5381, 5397

2227, 2372

5480, 5527

5581, 5587

1393, 1802

193, 315

2401, 4385

387, 1083

1105, 1270

1286, 1348

25,163

129,634

6994

Discharge summary

report

Admission Date: [**2153-3-8**] Discharge Date: [**2153-3-9**] Service: Cardiothoracic Intensive Care Unit CHIEF COMPLAINT: Status post right carotid stent. HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old female with a history of coronary artery disease with normal left ventricular function and catheterization in [**2148**] with an left anterior descending artery occlusion and collateral filling. On an [**2151-8-26**] exercise tolerance test for chest discomfort the patient exercised for 10 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol and noted ST depressions anteriorly and inferolaterally. Imaging with moderate apical reversible defect in a left anterior descending artery distribution and reversible unchanged septal defect. A carotid ultrasound study in [**2152-8-25**] showed an 80% to 99% right-sided plaque and a 40% plaque on the left. A repeat carotid series on [**2153-2-20**] showed a mild increase in stenosis and peak velocity increase at 334/117. The patient denies any syncope, visual changes, or change in mental status. While the patient has remained asymptomatic, her increase in carotid ultrasound over the last year prompted a discussion regarding revascularization of her carotid artery. Given the patient's age and cardiovascular comorbidities, and the patient's availability to the CREST trial, the decision was made for placement of a right carotid artery stent for revascularization in the Catheterization Laboratory. One stent was deployed in the right coronary artery distal to her tubular 80% lesion with a final residual 10% with normal flow. While in the Catheterization Laboratory the patient remained hemodynamically stable. Her systolic blood pressures ranged from 112 to 150 and her heart rate from 59 to 90. Her oxygen saturations were 97% to 100% on room air. Nitroglycerin and Levophed drips were initiated to titrate her systolic blood pressure to a goal of 120 to 160. The patient was brought to the Cardiothoracic Intensive Care Unit for monitoring and blood pressure control. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Hypercholesterolemia. 4. Hypothyroidism. 5. Insomnia. 6. Arthritis. 7. Status post hysterectomy. MEDICATIONS ON ADMISSION: (Home medications included) 1. Aspirin 325 mg by mouth twice per day (for the CREST trial). 2. Lipitor 10 mg by mouth once per day. 3. Lisinopril 2.5 mg by mouth once per day. 4. Plavix 75 mg by mouth once per day. 5. Levoxyl 0.05 mg by mouth once per day. 6. Folate 1 mg by mouth once per day. ALLERGIES: Allergies include SULFA and PENICILLIN. SOCIAL HISTORY: The patient is married. She does not smoke or drink alcohol. FAMILY HISTORY: Family history was negative for myocardial infarction or a cardiac history. PHYSICAL EXAMINATION ON PRESENTATION: The patient's temperature was 95.8 degrees Fahrenheit, her blood pressure was 143/62, her heart rate was 68, and her oxygen saturation was 99% on room air. Her respiratory rate was 15. In general, in no acute distress. The patient was alert and oriented times three. Head, eyes, ears, nose, and throat examination revealed pale conjunctivae. The pupils were equally round and reactive to light. There was poor dentition. There was no lymphadenopathy noted. Pulmonary examination revealed the lungs were clear to auscultation bilaterally. Cardiovascular examination revealed first heart sounds and second heart sounds. No murmurs, rubs, or gallops. Abdominal examination revealed hypoactive bowel sounds. The abdomen was soft and nontender. Extremity examination revealed no clubbing, cyanosis, or edema. There were equal dorsalis pedis pulses bilaterally. Neurologic examination was nonfocal. PERTINENT RADIOLOGY/IMAGING: An electrocardiogram showed a sinus rhythm at 60 as well as normal axis and intervals. No left ventricular hypertrophy was noted. There were no ST depressions or elevations were noted. PERTINENT LABORATORY VALUES ON PRESENTATION: Her white blood cell count was 7, her hematocrit was 37.4, and her platelets were 119. Coagulations revealed her INR was 1.1. Her total cholesterol was 172 and her low-density lipoprotein was 79. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient is an 80-year-old female with multiple medical problems, status post right internal carotid artery stent on [**3-8**] as part of the CREST protocol. The patient was admitted to the Coronary Care Unit on a Neo-Synephrine drip to keep her systolic blood pressures in the 120 to 160 range. The patient's arterial sheath was removed by a Cardiology fellow. The patient had no change in her neurologic examination overnight or a change in vision, strength, sensation, or cranial nerves. The patient maintained a blood pressure of 118 to 140/38 to 48 (as per guidelines of the CREST protocol). 1. CARDIOVASCULAR ISSUES: The patient was continued on her aspirin twice per day (per the CREST protocol) and then will be changed to once per day as well as Plavix 75 mg by mouth once per day and atorvastatin pump. Neo-Synephrine was discontinued. The patient maintained a blood pressure goal of 120 to 160. The patient's home blood pressure medications were held. 2. ENDOCRINE ISSUES: The patient was maintained on her home dose of levothyroxine. 3. PROPHYLAXIS ISSUES: The patient was maintained on a cardiac low-cholesterol diet. The patient was maintained on subcutaneous heparin and docusate for prophylaxis. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to see Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] on the Monday following discharge and to hold all her blood pressure medications until that time but to continue her aspirin twice per day as well as Plavix. DISCHARGE DISPOSITION/CONDITION: The patient was ambulated and out of bed and was discharged home with close followup. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**Last Name (NamePattern1) 5713**] MEDQUIST36 D: [**2153-3-9**] 12:18 T: [**2153-3-10**] 10:10 JOB#: [**Job Number 26203**]

[ "414.01", "458.29", "433.10", "244.9", "401.9", "272.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2755, 4262

2303, 2658

5564, 6230

4297, 5530

134, 168

197, 2101

2123, 2276

2674, 2737

1,578

101,061

3407

Discharge summary

report

Admission Date: [**2139-5-18**] Discharge Date: [**2139-6-1**] Date of Birth: [**2060-11-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 358**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 78 yo Russian speaking F with h/o pulmonary HTN, CHF, OSA on home O2 who initially admitted on [**2139-5-18**] from home with vomiting, loss of appetite x 1 month. Diarrhea x 1 week. Per ED notes, pt also c/o RLQ/RUQ pain; rates pain as [**8-26**] lasting several days. Pt is also chronically on home O2 2-3L NC for OSA, CHF and pulmonary hypertension. . ED COURESE: VS afebrile, HR 62, BP 144/85, RR 20, 95% RA. Exam notable for RUQ/RLQ tenderness to palp, guaic neg. Given zofran 8 mg IV x 1 with improvement in sxs. CT showed no new changes. Ready for d/c but then nauseous. No abx in ED. Given 10 mg compazine as well. . Admitted to medicine for diarrhea. On arrival, hx obtained from interpreter. Pt c/o of right > left abd pain for unclear duration of time, also with nausea/vomiting; diarrhea 3-4 days ago but none since. No chest pain/pressure, SOB, cough. No GU sxs. Poor appetite for several weeks. On floor pt found to be hypoxic on O2 4LNC O2 sats 85%, CXR c/w pulm edema, she was given 40mg IV x 2, nebs, and put out 1.5L UOP, she was also put on a NRB with improvement in O2 Sats to 95%. However, patient kept trying to pull off her NRB mask leading to [**Last Name (LF) 15780**], [**First Name3 (LF) **] was transferred to the [**Hospital Unit Name 153**] for more intensive care and monitoring. Past Medical History: 1.Atrial septal defect repair [**6-17**] complicated by sinus arrest with PPM placement. 2. CHF 3. AF s/p cardioversion x 2 (on amiodarone) 4. HTN 5. GERD 6. TAH/BSO ('[**33**]) for fibroids 7. ?CVA 8. Pulm HTN 9. CRI (baseline 1.5) 10. OSA on home O2 (2-3L NC) 11. s/p APPY, s/p CCY ('[**33**]) 12. Gallstone pancreatitis s/p ERCP, sphincterotomy 13. Elevated alk phos secondary to amiodarone (All above per hospital records) Social History: Lives alone in senior living housing, has daughter in law who brings her groceries, has VNA once a week. No tob, EtOH, IVDU Family History: NC Physical Exam: ON ADMIT VS: T 98.1, 91-95% on NRB, HR 60-74, 116/48, RR 22-26 Gen: Russian speaking woman, lying in bed comfortable, not using accessory muscles, breathing comfortably on NRB HEENT: PERRL, + periorbital edema, JVP hard to assess [**12-19**] thick neck CV: RRR, nl s1/s2 LUNGS: pronounced crackles bilaterally 1/2way up lungs, R>L ABD: obese, soft, +BS, + discomfort with palp, no rebound/guarding, EXT: no LE pitting edema Pertinent Results: ECHO BUBBLE STUDY -negative for shunt CR: Brief Hospital Course: resp failure -rx'd multifact -chf, pulm htn, pna CHF -diastolic ef 75% -diuresed lasix gtt, til cr bumped PULM HTN - no shunt on bubble study, pulm to see for any other recs ?PNA -RLL opacity, zosyn started, though no wbc count, may stop since cr bumped AFIB -paced, not on anticoag due to h/o hemorrhagic stroke, CKD -1.8-2ish, now up 2.4 after lasix gtt, holding, good uop CHEST PAIN -cm's negative x5, always resolves with gi cocktail DISP -> rehab, usually goes home, then fails, ?placement ______________________________________bt/[**5-28**]/ 1) N/V/D -- likely viral gastroenteritis, resolved with supportive care. Unfortunately, iatrogenic CHF exacerbation after aggressive fluid resucitation. See the following course. 2)Respiratory Distress: Transferred to the [**Hospital Unit Name 153**] from the floor for acute worsingin hypoxia. Acute pulmonary edema s/p fluid hydration for viral gastroenteritis in baseline severe pulmonary HTN (worse on ECHO from [**5-21**], 75 to 90 mm Hg), +/- worsening pulm HTN, +/- PNEUMONIA. Improved over several days with diuresis and BIPAP use. Transferred back to 11 [**Hospital Ward Name 1827**] when she became stable on nasal canula. Slowly weaned to baseline home oxygen requirement of 4 liters. Additionally treated with Zosyn for concern of hospital acquired pneumonia, but unconvincing clinical picture without fever or elevated WBC. Zosyn was discontinued 24 hours prior to discharge without event. The pulmonary team consulted regarding her pulmonary hypertension, and recommended avoiding afterload reduction and possible future evaluation for OSA. Pt refused BiPAP repeatedly and an evaluation was deferred until she may be more compliant with the treatment. 3)CHF EXACERBATION [**Hospital 15781**] transfer to the ICU, was diuresed with a lasix gtt with improvement in symptoms. 02 sats 91-95% on 6L, up from her 4Lbaseline. -spent several days in the unit getting diuresed. Lasix was held for about three days as patient creatine increased. her respiratory status remained stable, bubble study was negative for shunt. Ultimately patient was transferred back to the floor, with pulmonary consult for consideration of interventions or other treatments for her severe pulm HTN. . . -creatine stabilized, home dose lasix was restarted without event. . . 4)CKD: baseline cr 1.8 ~2.1, peaked at 2.4 after diuresis. diuresis was held, patient continued to have good urine output. cr returned to baseline, was 1.7 on discharge. . 5)ATRIAL FIBRILLATION -rate controlled in 60s. metoprolol and amiodarone was continued per her home dosing. The ICU team inquired about her [**Hospital **] status, and after discussion with PCP, [**Name10 (NameIs) **] it was deemed [**Name10 (NameIs) **] is contraindicated due to her past history of hemorrhagic stroke. . 7)Hypothyroidism: levothyroxine continued. Medications on Admission: Meds: (per old d/c summary) home oxygen 2-3L amiodarone 200 mg qd lasix 40 mg qam/20 mg qpm paroxetine 10 mg qd ASA 81 mg qd atorvastatin vit toprol XL 25 mg qd levothyroxine 75 mcg qd PPI oxycodone 5 mg prn Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q 1400 (). Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: hypoxia chf exacervation pulmonary hyptertension pneumonia Discharge Condition: stable, on home oxygen of 4 Lpm nasal canula Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 liters Followup Instructions: Please follow up with your primary physician within two weeks, and appointment

[ "585.9", "428.0", "008.8", "403.90", "518.84", "327.23", "427.31", "486", "244.9", "530.81", "428.33", "416.8", "V45.01", "584.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7208, 7278

2817, 5681

329, 335

7381, 7427

2751, 2794

7603, 7684

2287, 2291

5941, 7185

7299, 7360

5707, 5918

7451, 7580

2306, 2732

275, 291

363, 1677

1699, 2129

2145, 2271

27,318

111,791

51496

Discharge summary

report

Admission Date: [**2162-11-18**] Discharge Date: [**2162-12-29**] Date of Birth: [**2113-5-30**] Sex: M Service: MEDICINE Allergies: Penicillins / Dicloxacillin Attending:[**First Name3 (LF) 678**] Chief Complaint: Pt unable to give [**12-25**] to history of MR. [**Name13 (STitle) **] was sent here for eval after group home felt that his behavior was off. Major Surgical or Invasive Procedure: Endotracheal Intubation PICC line placement History of Present Illness: [**Known firstname **] [**Known lastname 106770**] is a 49-year-old gentleman with severe mental retardation (non-verbal at baseline, deaf/blind since birth), epilepsy, bilateral anopthalmia, initially admitted for subdural hematoma (stable, no intervention performed) who was transferred from the floor with sudden onset of respiratory distress, desaturation to mid 80s on 6L NC. He had recently been noted to have a LUE DVT on [**2162-11-27**] associated with a PICC line which was subsequently pulled. No anticoaggulation given for this given the recent subdural hematoma for which he was admitted and the relatively low risk of PE with upper ext DVTs. The team was concerned for possible PE vs a new aspiration pneumonitis or pneumonia. Of note, he completed a 10 day course of levo/flagyl for aspiration pna on [**2162-11-29**] and had a G tube placed for TFs on [**2162-11-25**] given his chronic aspiration. Blood cultures positive for coag neg staph on [**2162-11-18**] and [**2162-11-23**] were felt likely to be contaminants given the fact that they were different species. . He had initially presented to the Emergency Department on [**2162-11-18**] s/p unwitnessed fall at Group Home. He was found to have acute right-sided subdural hematoma with minimal mass effect, and unchanged ventriculomegaly. He was given 1g Dilantin load and admitted to the Neurosurgical ICU. Repeat Head CT 5-hours later showed no change, and no intervention was planned. Patient was transferred to the MICU initially for hypernatremia up to 174 and ARF which resolved with IVFs and free H20. His WBC started to rise and he was started on Vancomycin for L knee cellulitis. Arthrocentesis of the knee was neg for septic joint. He had a PICC line placed and was transferred to the floor. . Past Medical History: 1. Severe mental retardation 2. Epilepsy 3. Hx DVT s/p IVC filter placement 4. Porcelain gallbladder 5. Bowel/bladder incontinence 6. Nephrogenic DI 7. History of GI bleeding 8. Hx Decubitus ulcers Social History: Parents both deceased, siblings uninvolved; lives in a group home, current guardian is at [**Telephone/Fax (1) 106771**], or [**Telephone/Fax (1) **]. Family History: mother- DM, ALS father- mental health issues developmental delay in several family members Charcot [**Name2 (NI) 106772**] Tooth in several family members Physical Exam: PHYSICAL EXAM ON ADMISSION O: T:97 BP: 100/60 HR:70 R 18 O2Sats 93% ra Gen: Moans, uncooperative, with contracted all four extremities HEENT: anophthalmia Extrem: Warm. Neuro: Mental status: Arousable, moans, uncooperative with exam. VIII: Hearing appears intact, moves to voice Motor: Moves all four extremities, appears to have full strength, emaciated Sensation: unable to assess, moves extremities to light touch Reflexes: not detectable Toes downgoing bilaterally . PHYSICAL EXAM ON TRANSFER TO MICU VS: T 97.9; BP 125/104; HR 103; RR 24; O2 85% NRB, up to 98% NRB GEN: Chronically ill-appearing, grunting intermittently, aggitated, moving all extremities SKIN: Multiple ecchymoses over face, bilateral knees, R shoulder, R arm, L elbow HEENT: Anopthalmic on R. Edentulous. MM dry. No JVD. No carotid bruits. LUNGS: decr bs b/l, but otherwise clear CV: S1S2 RRR. No appreciable MRG ABD: + BS, soft, NT/ND. EXT: no peripheral edema. Palpable DP pulses NEU: Extremely limited exam due to mental state. Anophthalmic. Does not respond to voice. Does not follow commands. Moves limbs spontaneously. Pertinent Results: ** PICC LINE PLACMENT SCH [**2162-12-14**]: Uncomplicated ultrasound and fluoroscopically guided single lumen PICC line placement via the right basilic venous approach. Final internal length is 37 cm, with the tip positioned in SVC. The line is ready to use . ** CXR [**2162-12-3**]: Bibasilar improvement of atelectasis . ** US EXTREMITY NONVASCULAR LEFT [**2162-11-29**]: Status post removal of venous catheter with persistent echogenic thrombus which is not propagated on limited examination . ** UNILAT UP EXT VEINS US [**2162-11-26**]: Acute thrombus in the left subclavian, axillary and brachial veins surrounding the patient's PICC line. . ** CT torso [**2162-11-25**]: 1. Gastrostomy tube within the body of the stomach, which is not in an intrathoracic position. 2. Bilateral lower lobe airspace opacity most suggestive of aspiration although pneumonia cannot be excluded. 3. Porcelain gallbladder. This is a risk factor for gallbladder carcinoma. 4. Shriveled, malpositioned, calcified, and scarred right kidney consistent with chronic process. 5. Stool-filled distended rectum without evidence of proximal bowel dilation. . ** Head CT [**11-19**]: Acute or subacute right-sided subdural hemorrhage, measuring 1.1 cm in greatest diameter, with minimal mass effect and no evidence of midline shift. Unchanged ventriculomegaly. Again normal pressure hydrocephalus is a consideration in the proper clinical setting. . ** CT C-Spine: No definite evidence of fracture or malalignment. Ossific fragments associated with the C5 spinous processes are likely chronic/degenerative, however, correlation with detailed physical examination is recommended. . ** R SHOULDER AND L ELBOW XR: Extremely limited views of the right shoulder and left elbow. No gross evidence of fracture or dislocation. . ** L Knee XR: No evidence of acute fracture or dislocation. No joint effusion. . ** Pelvis AP: IMPRESSION: No evidence of fracture. . ** Repeat Head CT: Moderate-sized acute/subacute right subdural hemorrhage, unchanged compared to five hours prior. Brief Hospital Course: 49M h/o severe mental retardation, epilepsy, anophthalmia, and nephrogenic DI presenting following a fall found to have a right sided subdural hematoma, profound hypernatremia, and knee cellulitis. . SUBDURAL HEMATOMA: The patient had an unwitnessed fall at his group home. He was found to have an acute right subdural hematoma without evidence of midline shift. He was loaded with dilantin. He was evaluted by the neurosurgical service who recommended serial head CT which showed no change in the hematoma. Surgical intervention was deferred unless acute worsening with herniation was found. The patient will follow-up with the neurosurgeons with a repeat head CT in 2 weeks of discharge. . HYPERNATREMIA: This was felt most likely relate to significant dehydration worsened by his history of nephrogenic DI. He was able to concentrate his urine to Uosm>600. His serum sodium was corrected with initially isotonic fluids then with free water via his NG tube. The follow-up head CT did not show significant cerebral edema after sodium correction. He will need to continue to have appropriate amounts of free water per PEG to keep an appropriate Sodium. . Knee cellulitis: This was felt to be likely related to a prior fall that was secondarily infected. Orthopedics was consulted for evaluation of a potentially septic joint however a joint aspirate showed minimal fluid w/o evidence of infection. He was treated with vancomycin for 14 days. This problem was fully resolved at time of discharge. . ACUTE on Chronic RENAL FAILURE (stage 3, GFR 40): This was felt to be pre-renal in nature. He was volume expanded as above and his urine output improved appropriately. His Cr had returned to baseline at time of discharge. . Hypoxia: The patient had two events of significant hypoxia during his hospital stay. Upon arrival to MICU on [**2162-11-30**], the patient was aggitated and a good O2 sat could not be obtained b/c a good pleth was not seen. He was given haldol 3mg IV, became less aggitated, and his O2 sat came up to 98% on NRB. CXR revealed low lung volumes and evidence of large amount of stool in intestines. CT torso from [**11-25**] reviewed revealing collapse of lower lung lobes b/l as well as distended rectum. There was concern that his distended abdomen was making his respiratory status worse and he was disimpacted (large amount of stool removed). His resp status stabilized 98-100% on NRB. . On [**12-3**], the patient acutely decompensated, with PO2 on ABG at 49. He was intubated after discussion with pcp/guardian and brought to the MICU for aggressive suctioning. After a short intubated course he was extubated. Repeated discussions with his PCP led to [**Name Initial (PRE) **] decision to make him truly DNI/DNR. He was extubated uneventfully and discharged to the floor. By the time of discharge he was saturating 94% on 1L NC. . MRSA/PROTEUS MIRABILIS PNEUMONIA: Upon transfer to the floor, Mr. [**Known lastname 106770**] had a bump in his WBC. Blood, urine, and sputum cultures were sent. Respiratory cultures were positive for MRSA and Proteus mirabilis. The patient was started on vancomycin and aztreonam. A PICC line was placed. He finished a 14 day course of each prior to discharge. . EPILEPSY: The patient's home dose of depakote and phenytoin was increased given a subtherapeutic level. The patient had no notable seizure episodes while in-house. Levels should be followed weekly after discharge. . ELEVATED PTT and thrombocytopenia: The patient has had an elevated PTT in OMR dating back to [**2161-2-21**] of unclear etiology. Also his platelets were just below his prior low baseline. There was no evidence of active consumption. Factor VIII and IX levels were normal. The thrombocytopenia was likely a chronic process either from a primary marrow process or less likely a medication effect (such as depakote) as his platelets were near his baseline his medications were not changed. Thrombocytopenia resolved by the time of discharge. . C-SPINE Osseus changes: The patient was found to have ossific fragments near C5 without cord compromise. Ortho-spine was consulted and recommended a soft-collar for comfort. Fall: As the patient suffered a fall at his group home, his case managers and social workers from the group home and MA [**Name (NI) 71399**] were contact[**Name (NI) **] and will investigate the events. PPX: Patient maintained on a regimen of Colace, Senna, Dulcolax with good results. PPI was used throughout hospitalization. Pneumoboots were used for DVT prophylaxis; holding heparin in setting of subdural hematoma and ? coagulopathy. Calcium Carbonate and Vitamin D for bone health. . FEN: the patient was admitted with a weight of ~95 lbs which was down from 133 in [**2162-3-23**]. PEG tube was placed and TF modified with input from the nutrition service. . Medications on Admission: MEDICATIONS AT GROUP HOME 1. Depakote 500mg PO BID 2. Calcium Carbinate 600mg PO qd 3. Colace 100mg PO BID 4. Saline eye wash 5. Lactulose 30mL qd 6. Ativan 0.6 mg PO q2h:PRN 7. Prilosec 20mg PO qd 8. Seroquel 100mg PO qd 9. Vitamin D 400mg PO qd 10. Dulcolax 10mg PR: PRN 11. Fosamax 1 tablet by mouth weekly . ALLERGIES: PCN, Dicloxacillin Discharge Medications: 1. Balanced Salt Soln Non-[**Doctor First Name **] #3 Solution [**Doctor First Name **]: One (1) ML Ophthalmic QID (4 times a day). 2. Insulin Regular Human 100 unit/mL Solution [**Doctor First Name **]: One (1) Injection ASDIR (AS DIRECTED). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Doctor First Name **]: One (1) Tablet PO DAILY (Daily). 4. Therapeutic Multivitamin Liquid [**Doctor First Name **]: One (1) Cap PO DAILY (Daily). 5. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension [**Doctor First Name **]: One (1) PO DAILY (Daily). 6. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet [**Doctor First Name **]: One (1) Powder in Packet PO DAILY (Daily). 7. Lactulose 10 gram/15 mL Syrup [**Doctor First Name **]: Thirty (30) ML PO TID (3 times a day): hold for >2BM/day. 8. Haloperidol 1 mg Tablet [**Doctor First Name **]: One (1) Tablet PO TID (3 times a day) as needed for aggitation. 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 10. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal DAILY (Daily). 11. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: Six (6) Tablet PO QHS (once a day (at bedtime)). 12. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID (4 times a day) as needed. 13. Valproic Acid 250 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO Q8H (every 8 hours). 14. Phenytoin 50 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2) Tablet, Chewable PO BID (2 times a day). 15. Outpatient Lab Work Please check phenytoin and valproic acid levels 16. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 17. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]: One (1) NEB Inhalation Q6H (every 6 hours). 18. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) NEB IH Inhalation Q6H (every 6 hours). 19. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet [**Last Name (STitle) **]: One (1) Powder in Packet PO DAILY (Daily). 20. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Twenty (20) mL PO BID (2 times a day). 21. Diazepam 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4 hours). 22. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1) gram Intravenous Q 24H (Every 24 Hours) for 9 days. 23. Aztreonam 1 gram Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln Injection Q12H (every 12 hours) for 12 days. 24. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID (4 times a day) as needed for 12 days: please give via oral swab. 25. Outpatient Lab Work Please obtain vancomycin trough level on [**2161-12-19**], goal [**9-12**] 26. Outpatient Lab Work Please check phenytoin (goal 10.0-20.0) and valproate (goal 50-100) levels weekly Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Nursing and Rehab Discharge Diagnosis: PRIMARY: right subdural hematoma pneumonia left subclavian deep venous thrombus Hypoxia Cellulitis (resolved) Poor Nutrition SECONDARY: epilepsy severe mental retardation bowel/bladder incontinence anophthalmia/blindness congenital deafness Discharge Condition: NEUROLOGICALLY STABLE Discharge Instructions: DISCHARGE INSTRUCTIONS FOR HEAD INJURY ?????? Take your pain medicine as prescribed ?????? 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 CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Fever greater than or equal to 101?????? F . You had a pneumnia. You finished an antibiotics course for 2 weeks. . You also had a fungal infection inside your mouth and was treated for it. . Please take medications as directed. . Please keep your follow-up appointments. Followup Instructions: Patient will be discharged to [**Hospital **] [**Hospital **] Nursing and Rehab. . YOU HAVE AN APPOINTMENT WITH DR. [**Last Name (STitle) **], [**Telephone/Fax (1) **], ON [**2163-1-13**] 2:00 PM. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST PRIOR TO THAT WHICH WAS SCHEDULED ON [**2163-1-13**] 1:30 PM, [**Telephone/Fax (1) 327**]. . Follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**], [**Telephone/Fax (1) 250**], as needed, after transfer back to group home. . [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**] Completed by:[**2162-12-29**]

[ "999.2", "518.81", "584.9", "112.0", "482.41", "318.1", "453.8", "588.1", "787.20", "V45.78", "276.0", "V18.0", "E884.4", "261", "507.0", "285.21", "585.9", "V09.0", "389.7", "852.20", "682.6", "790.92", "287.5", "482.83", "345.90", "458.29" ]

icd9cm

[ [ [] ] ]

[ "43.11", "96.71", "96.04", "38.93", "33.23", "96.6" ]

icd9pcs

[ [ [] ] ]

14282, 14358

6061, 10912

433, 479

14644, 14668

3988, 5931

15657, 16351

2693, 2850

11304, 14259

14379, 14623

10938, 11281

14692, 15634

2865, 3043

250, 395

507, 2286

5940, 6038

3058, 3969

2308, 2508

2524, 2677

9,900

166,180

16710+16711

Discharge summary

report+report

Admission Date: [**2150-12-7**] Discharge Date: [**2150-12-19**] Date of Birth: [**2079-1-15**] Sex: F Service: Vascular Service CHIEF COMPLAINT: Bilateral toe dry gangrene. HISTORY OF PRESENT ILLNESS: History of present illness was obtained from the patient who was a reliable historian. This is a 72 year old white female with known diabetes Type 2, history of congestive heart failure secondary to aortic valvular disease, status post aortic valve replacement in [**2146**] presents with a long history of leg claudication, bilateral calf and in the last six months has become debilitated and is unable to walk even very short distances. Onset of dry gangrene to the right first toe, present times one year with new changes on the left first toe in the last several months. The patient was hospitalized at St. [**Hospital 107**] Hospital for intravenous antibiotics and current vascular evaluation. She underwent an magnetic resonance imaging scan at that time. She is now referred here to Dr. [**Last Name (STitle) 1391**] for consideration for bypass surgery. REVIEW OF SYSTEMS: Negative for fever, chills, sweats, nausea and vomiting, negative for myocardial infarction, chest pain, paroxysmal nocturnal dyspnea or orthopnea. She does have a history of arrhythmia, questionable atrial fibrillation, being treated with Amiodarone, history of bicuspid aortic valvular disease, status post replacement with St. [**Male First Name (un) 923**], history of dyspnea on exertion, history of rest pain which is intermittent. She has generalized deep vein thrombosis. She denies cerebrovascular accident, transient ischemic attack, seizures or syncope. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Metformin 500 mg b.i.d., Glyburide 10 mg b.i.d., Lisinopril 20 mg q.d., Amiodarone 200 mg q.d., Lasix 80 mg q.d., Centrum multivitamin tablets daily, Folic acid 1 mg q.d., Klor-Con 10 mEq q.d., Zocor 5 mg q.d., Warfarin 5 mg q. day except for Saturday which is 2.5. Other medications include Cephalexin 100 mg q.i.d. which was begun on [**2150-12-4**] for a total of seven days, Oxycodone with APAP 5/325 tablets one q. 1/2 hour before toe treatment, Celebrex 200 mg daily prn, Zyprexa 5 mg at h.s. prn. PAST HISTORY: The patient had an echocardiogram done on [**2150-10-14**] which demonstrated significant ventricular concentric hypertrophy with mild inferobasal hypokinesis and normal systolic function, prosthetic aortic valve not well visualized. Mean gradient was 23 mm of mercury, peak gradient was 40 mm of mercury with a trace aortic insufficiency, calcified mitral annulus, mild to moderate mitral regurgitation and normal tricuspid valve with mild tricuspid regurgitation of the right ventricle. Systolic pressure was 26. Left to right atrial pressure, left atrial enlargement. The patient also underwent on [**2150-10-23**] Adenosine stress which showed overall left ventricular function calculated at 49%. There was some diminished ejection fraction that was in the lower anterior region but overall ventricular ejection fraction was calculated to be 89%. There appears to be normal left ventricular wall thickening, the study is somewhat technically limited, the patient could not handle to raise her hands. There is a question of small irreversibility in the apical anterior region. This could represent small reversible ischemia. The illnesses include Type 2 diabetes times ten years and history of congestive failure times two compensated, last episode was one year prior to admission. Previous surgical history includes aortic valve in [**2146**] done at [**Hospital 4415**]. SOCIAL HISTORY: The patient is widowed, lives with daughter and is a former 10 pack year smoker. She denies alcohol use and has been wheelchair bound for the last year. PHYSICAL EXAMINATION: Vital signs, stable. Afebrile. Temperature 115/50, pulse 86, respirations 12. The patient is drowsy but arouses easily. Head, eyes, ears, nose and throat examination was unremarkable. Pulse examination shows diminished carotid pulses bilaterally without bruits. Brachial and radial pulses are palpable bilaterally. Femoral pulse on the right is diminished but palpable. The left is intact. The popliteals are absent bilaterally. The right dorsalis pedis is doppler signal, absent posterior tibial. The left dorsalis pedis and posterior tibial are doppler signals. There are no femoral bruits. Chest examination shows regular rate and rhythm with a I/VI systolic ejection murmur at the base, not radiating. Chest is clear to auscultation. Abdomen is obese with bowel sounds present times four. There are no bruits, masses or organomegaly. Rectal examination shows good tone. There are no masses. She is guaiac negative. Extremities, bilateral lower extremity swelling with erythema, there are degenerative joint changes of the hands and knees. The right first, third and fourth toe are with dry gangrene. The left first toe is with dry gangrene. The left third, fourth and fifth toes are with abrasions on the dorsal surface with 1 to 2+ edema bilaterally. There is erythema from the ankles to below the knees bilaterally. Neurological examination is unremarkable. HOSPITAL COURSE: The patient was admitted to the Vascular Service under the care of Dr. [**Last Name (STitle) 1391**]. She was placed on bedrest with bathroom privileges. Antibiotics of Levofloxacin, Kefzol and Flagyl were begun. [**Hospital1 **] was requested to see the patient. Liver function tests were obtained which were unremarkable. Her Metformin was held perioperatively and she was placed on a regular insulin sliding scale. For congestive failure, she was asymptomatic. Intravenous heparinization was begun for a goal INR of 50 to 70. Coumadin was held. Cardiology was requested to see the patient in regards to questionable reversible ischemic changes on her stress test. Cardiology evaluated the echocardiogram and stress test and felt the patient is at a high risk for surgery, therefore no other intervention was required, and low dose beta blocker, Amiodarone during the perioperative period, hold Coumadin and allow her to reverse normally, intravenous heparin when INR is less than 2.0. Congestive failure-wise, chest x-ray was unremarkable. The patient was compensated. Complete blood count, white count was 7.1, hematocrit 28.7, BUN 31, creatinine 2.2, potassium 4.0. Chest x-ray shows left lower base with atelectasis versus scarring. The patient was preopped for surgery. The patient underwent on [**2150-12-10**] a right femoral pedal bypass with insitu saphenous vein and tolerated the procedure well. She tried one unit of packed red blood cells intraoperatively. She was transferred to the Post Anesthesia Care Unit in stable condition. Immediate postoperatively she was hemodynamically stable, afebrile, and postoperative hematocrit was 29.9, INR 1.9, PTT 91.8, BUN 28, creatinine 1.8, potassium 4.6. The patient remained mildly agitated and remaining examination was unremarkable. The right foot showed a palpable pedal pulse and was warm. The patient continued to do well and was transferred to the Vascular Intensive Care Unit for continued monitoring and care. Electrocardiogram was obtained for diminished cardiac index which was unchanged and serial creatinine kinases were negative. Over night blood gases were 7.28/58/77/28/0, on post extubation 7.32/54/66/29/0. Hematocrit remained stable at 31.9. Heparin was continued and Coumadin was reinstituted. Temperature maximum on postoperative day #2 was 38.4, defervesced to 37.8. Hemodynamically she remained stable. Her hematocrit was 29.2, BUN 38, creatinine 2.2. Her heparin was continued, coumadinization was continued with serial monitoring of both the PTT and INR. Physical therapy was requested to see the patient and assist the patient for discharge planning. Her p.o. fluids were increased. Lasix was restarted and [**Hospital1 **] continued to manage her diabetic insulin requirements. Psychiatry was requested to see the patient because of persistent agitation. They felt this was multifocal related to her surgery and recommended Haldol 2.5 mg b.i.d. with prn 2.5 to 5 mg q. 4 to 6 hours. The heparin was discontinued on [**4-14**], INR was 3.4. Serial INRs are continued to be monitored and coumadinization was continued. The wound continued to be clean, dry and intact with palpable right dorsalis pedis pulse. Her delirium required several more days before she was back to baseline. She was discharged anticoagulated in stable condition to rehabilitation for continued physical therapy. DISCHARGE MEDICATIONS: Haldol 2.5 mg b.i.d. Acetaminophen 325 to 650 mg q. 4-6 hours prn Insulin sliding scale and six insulin dosings, please see enclosed flow sheet Enalapril 5 mg q.d. Metoprolol 25 mg b.i.d. Lasix 80 mg q.d. Protonix 40 mg q.d. Amiodarone 200 mg q.d. DISCHARGE DIAGNOSIS: 1. Bilateral toe gangrene secondary to tibial vessel disease, status post right femoral-pedal bypass graft. 2. Postoperative delirium improved with Haldol. 3. Diabetes, insulin dependent, controlled. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2150-12-17**] 18:18 T: [**2150-12-17**] 18:36 JOB#: [**Job Number **] Admission Date: [**2150-12-7**] Discharge Date: [**2150-12-28**] Date of Birth: [**2079-1-15**] Sex: F Service: ADDENDUM TO INITIAL DISCHARGE SUMMARY The [**Hospital 228**] hospital discharge was deferred secondary to continued waxing and [**Doctor Last Name 688**] of her mental status and continued Haldol wean. Coumadin was held secondary to elevated INR which was related to antibiotics the patient was on. This was reinstituted once her INR was not super-therapeutic. The patient continued to improve and her Haldol wean continued as of [**2150-12-22**] and physical therapy pre-screened the patient for potential rehabilitation. Her Zyprexa and Zoloft were continued to be held and until the patient was back to baseline. On [**2150-12-24**] the resident was called to the patient's beside at 2:50 AM for desaturation with an O2 sat on room air of 80% and 96% on face mask. Arterial blood gases were obtained which is 7.28, 88, 70, 43 and 10. The patient was then placed on a non-rebreather mask without improvement in her blood gases. The decision was made to intubate the patient. The patient was intubated by Anesthesia and transferred to the MICU for continued monitoring and care. The patient's oxygenation improved once intubated. The patient was extubated on [**2150-12-26**]. She continued to do well and over the next 24 hours was transferred to the VICU for continued monitoring and care. She continued to be followed by [**Female First Name (un) 3408**] during her hospitalization who managed her diabetic needs. Her diet was advanced after she was extubated. She is tolerating this well. Her antibiotics were discontinued at [**2150-12-28**]. Her Telemetry was discontinued. Rehabilitation screening was begun and patient was transferred to the regular nursing floor. Psychiatry continued to follow the patient and the patient was off Haldol since [**2149-12-24**] and the recommendations were to restart the Zyprexa once the concerns for sedation were decreased and the delirium totally resolved. Case management continued to follow the patient and with the family have had long discussions regarding ultimate discharge planning. She continued to be followed by [**Female First Name (un) 3408**] who required to adjust her insulin sliding scale needs. Physical therapy felt that she would require rehabilitation to be able to ambulate independently. MEDICATIONS ON DISCHARGE: 1. Metoprolol 25 mg twice a day. 2. Lasix 40 mg q day. 3. Warfarin 2.5 mg q day. 4. Protonix 40 mg q 24 hours. 5. Albuterol nebs q 6 hours while awake. 6. Apromiom Bromate nebulizer q 6 hours while awake. 7. Amiodarone 200 mg q day. 8. Enalapril 5 mg q day. 9. Insulin sliding scale and fixed insulin doses as follows. Fixed dosing is NPH insulin 14 units at breakfast q day. Regular insulin sliding scale is q.i.d., breakfast, lunch, dinner and at bedtime. Glucose less than 150 no insulin, 151 to 200 three units, 201 to 250 six units, 251 to 300 9 units, 301 to 350 12 units, 351 to 400 15 units, greater than 400 18 units. DISCHARGE DIAGNOSIS ADDENDUM: 1. Respiratory failure secondary to sedation, status post intubation, extubation. Resolved delirium secondary to metabolic and analgesic resolved. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2150-12-28**] 19:15 T: [**2150-12-28**] 21:20 JOB#: [**Job Number 47283**]

[ "250.01", "440.24", "V45.81", "518.81", "V43.3", "414.01", "401.9", "293.9" ]

icd9cm

[ [ [] ] ]

[ "39.29", "96.04", "38.22", "96.71" ]

icd9pcs

[ [ [] ] ]

8681, 8930

8951, 11838

11864, 12992

1748, 3656

5255, 8658

3852, 5237

1114, 1721

168, 197

226, 1094

3673, 3829

22,543

146,274

11085

Discharge summary

report

Admission Date: [**2135-12-22**] Discharge Date: [**2135-12-26**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 759**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None. History of Present Illness: 82M w/STIV NSCLC last admitted [**Date range (2) 35795**] for effusion; during that admission, pleuroscopy and talc pleurodesis were performed. [**10-17**], he required repeat thoracentesis. Today, he reported to the ED w/3 days of severe pleuritic, non-radiating substernal CP, SOB, and L leg pain. He has not eaten for three days b/c of feeling ill, but not nauseous. On CTA, he was found to have PEs in the RUL, RLL and R pleural effusion. In the ED, heparin gtt started and pt was admitted to MICU. Troponin elevated and TTE w/global decrease in function compared to prior. ROS negative for fever, chills, nausea, vomitting, diarrhea, BRBPR, melena, HA, muscular weakness, other sx of concern to him. Past Medical History: -Stage IV NSCLC w/ L malignant pleural effusion -CAD s/p stent LAD [**3-/2132**] -CHF (EF 30-40% [**2135-12-22**]) -RCC s/p left nephrectomy [**2113**] -Renal artery stenosis -CRI-baseline Cr 1.5 -Left CEA -HTN -DM II -hypercholesterolemia Gout Pulmonary hypertension. Social History: lives w/ wife in [**Name (NI) **], MA retired shipyard worker--asbestos exposure. greater 50ppy smoking hx- quitx30 yrs. Family History: mother died [**Name2 (NI) 35796**] age82 father died [**Name2 (NI) 35796**] age 81 Physical Exam: VS: T98.3 HR99 134/73 23 97%3L GEN: NAD HEENT: MMM & clear OP NECK: No LAD in ant/post cervical, submental, pre-aurical, axillary chains LUNGS: Coarse BS RUL HEART: RRR, nl S1, S2, no m/r/g ABD: Soft, nt, nd, +BS EXTR: WWP X 4 w/palpable cord LLE; negative [**Last Name (un) 5813**] bil NEURO: CN2-12 intact, 5/5 strength throughout Pertinent Results: [**2135-12-22**] 11:20AM WBC-14.5* RBC-4.36* HGB-12.2* HCT-36.2* MCV-83 MCH-28.0 MCHC-33.8 RDW-15.7* [**2135-12-22**] 11:20AM NEUTS-82.9* LYMPHS-8.7* MONOS-4.8 EOS-3.4 BASOS-0.3 [**2135-12-22**] 11:20AM cTropnT-0.28* [**2135-12-22**] 11:20AM GLUCOSE-150* UREA N-30* CREAT-1.3* SODIUM-141 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-26 ANION GAP-17 [**2135-12-22**] 11:44AM LACTATE-1.5 [**2135-12-22**] 08:30PM cTropnT-0.23* . ECG: ST @ 105/min w/1st degree HB (PR 188) and lateral ST depression increased since prior . CTA: acute pulmonary emboli in the pulmonary arteries to the right upper and right lower lobes. unchanged lung mets in the left lower lobe, right upper lobes. new right pleural effusion. . TTE: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is moderately depressed (ejection fraction 30-40 percent) secondary to hypokinesis of the inferior septum, inferior free wall, posterior wall, and lateral wall. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated athe sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2135-12-12**], the left ventricular ejection fraction appears somewhat further reduced with more extensive regional wall motion abnormalities (but the ejction fraction may have been overestimated on the prior report). . LENIS b/l: No evidence of deep vein thrombosis. Brief Hospital Course: 82M w/ CHF, CAD, HTN, DM, stage IV NSCLC admitted to MICU with RUL, RLL [**Hospital 35797**] transferred to medicine on heparin gtt, started on coumadin and levo/flagyl for post-obstructive PNA. . 1. PE- Found to have large PEs in RUL and RLL. LENIS were negative. Predisposing factor is metastatic lung CA. This patient has multiple poor prognostic factors for this PE, including initially elevated troponin, decreased cardiac function on TTE compared to ten days prior, and strain on ECG. However, he gradually improved and was transferred from the MICU to the medicine floor while being heparinized with a continuous drip. Patient remained stable on 2L oxygen after transfer. Coumadin 5 mg qHS was started on [**12-24**] with an INR goal of 2.0 to 3.0. Patient was switched to lovenox on [**12-25**] in order to bridge him until his INR is in the therapeutic range. Heparin drip was discontinued. INR was 1.2 on day of discharge. Patient was given a prescription for one week supply of Lovenox which should be sufficient to reach therapeutic goal on Coumadin. He has a close followup appointment with his PCP in order to check the INR after discharge. . 2. Pleural Effusion- CTA showed thick rind around the left pleural surface, most likely representing malignant pleural disease. In addition, a new small right pleural effusion was detected. While PE can cause effusion, most likely re-accumulation secondary to malignancy. Pain over old pleurodesis site was controlled with IV and PO narcotics. Patient was discharged on Tylenol and PO Dilaudid PRN pain which optimally suppressed his symptoms. He has a followup with oncology as an outpatient on [**12-29**]. . 3. Postobstructive Pneumonia: LLL opacity found on chest CT. Given productive cough, it was considered to represent a postobstructive pneumonia. Patient was started on Levo/flagyl for at total course of 14 days. His abx were initiated on [**12-25**]. He should continue both abx as an outpatient for an additional 12 days. Blood cutures from [**12-22**] were pending upon discharge. Sputum cultures could not be obtained. . 4. NSCLC- Stage IV. Given current situation, not a candidate for therapy. Patient has a followup appointment with oncology. . 5. CAD- s/p stent LAD 04/[**2131**]. CEs were initially elevated in the MICU but were trending down consistently from 0.28 - 0.23 - 0.19 - 0.07. Elevations most likely reflected CRI and cardiac strain in setting of PE rather than active ischemia. In addition, patient was already on a heparin drip as part of his PE management. Patient was restarted on short-acting BB on [**12-24**] (with equivalent dose of his long-acting outpatient BB). ASA was continued throughout his hospital stay. . 6. Microcytic anemia- Baseline 30-36. Remained stable throughout hospital course. Low iron, high ferritin and low TIBC were in line with ACD. . 7. CHF- Worsening function (EF 30-40%) likely secondary to PE. Should improve once PEs are resolving. Patient was continued on his ISDN. He was also restarted on his BB, Lasix, and CCB once one the medicine floor. Prior discharge he was also started on a low dose of an ACEI. His CCB can be increased to his initial outpatient dose after discharge. The ACEI should be titrated up as needed. . 8. HTN- Normotensive on transfer. Antihypertensives were initially held in the ICU given the large PEs. Patient was stepwise restarted on his BB, Lasix, and a lower dose of his CCB. See also above. . 9. CRI- Baseline Cr 1.2 to 2.5. Cr remained around baseline throughout this hospital stay. . 10. DMII- Diet controlled at home. Patient was on RISS. . 11. FEN- House diet, repleted lytes PRN. . 12. PPx- Initially heparin drip, then Lovenox/Coumadin. . 13. Code- Discussed poor prognosis in the context of metastatic cancer and large PEs. Patient wanted to remain full code. Social work was consulted. Medications on Admission: Lasix 20mg QD KCl 20 mEq QD Isordil 20mg tid Toprol XL 25mg QD ASA Allopurinol lovastatin 20mg QD neurontin 300mg tid norvasc 5mg QD Discharge Medications: 1. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain, fever. Disp:*60 Tablet(s)* Refills:*2* 4. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime: Your INR should be checked two days after discharge. Your coumadin dose should be adjusted accrodingly. Disp:*60 Tablet(s)* Refills:*2* 7. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 12 days: Started [**12-25**]. . Disp:*12 Tablet(s)* Refills:*0* 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 12 days: Started [**12-25**]. Disp:*36 Tablet(s)* Refills:*0* 11. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous Q12H (every 12 hours) for 7 days: Continue until your INR is therapeutic (2.0 to 3.0) for 48 hours. Disp:*14 mg* Refills:*1* 12. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day. 13. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times a day. 14. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Increase dose slowly according to your PCP's recommendations. Disp:*30 Tablet(s)* Refills:*2* 15. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain for 14 days. Disp:*60 Tablet(s)* Refills:*0* 17. Lovenox 100 mg/mL Solution Sig: Ninety (90) mg Subcutaneous twice a day for 1 days. Disp:*2 syringe* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary Diagnosis: 1. Pulmonary embolism 2. Systolic CHF 3. Post-obstructive pneumonia 4. CAD 5. NSCLC . Secondary Diagnosis: 1. Hypertension 2. CRI 3. Type II diabetes 4. Gout Discharge Condition: Afebrile. Hemodynamically stable. Ambulating. Tolerating PO. Discharge Instructions: Please call your primary doctor or return to the ED with fever, chills, chest pain, shortness of breath, nausea/vomiting, spontaneous bleeding or any other concerning symptoms. You have been started on antibiotics (Levofloxacin and Metronidazole) for pneumonia. Please take for a total of 14 days as directed on your prescriptions. . Please take all your medications as directed. You have been started on Lisinopril for your heart. You have also been started on Lovenox to be taken for one week, in addition to coumadin to be taken long-term. Your INR should be checked two days after discharge and your coumadin dose should be adjusted according to an INR goal of 2.0 to 3.0. You INR can either be checked by the coumadin clinic at Dr.[**Name (NI) 35798**] office or by the VNA services and have the results faxed to Dr.[**Name (NI) 35798**] office ([**Telephone/Fax (1) 35799**]). For the first 1-2 weeks, your INR should be checked twice a week. . Please keep you follow up appointments as below. Followup Instructions: Please follow up with your primary care doctor ([**Last Name (LF) **],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 17663**]) within the next week. . You have an appointment in the [**Hospital 197**] Clinic of Dr.[**Name (NI) 35798**] office on Thursday, [**2135-12-29**] at 8:30a.m. Please call his office if you are unable to keep this appointment. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**] Date/Time:[**2135-12-29**] 2:30 Provider: [**Name10 (NameIs) 10341**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[**2135-12-29**] 2:30

[ "V45.82", "250.00", "274.9", "486", "285.22", "162.9", "428.22", "585.9", "197.2", "428.0", "415.19", "414.01", "403.91" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9725, 9776

3769, 7620

233, 240

9998, 10061

1876, 3746

11114, 11724

1422, 1506

7804, 9702

9797, 9797

7646, 7781

10085, 11091

1521, 1857

190, 195

268, 974

9924, 9977

9816, 9903

996, 1267

1283, 1406

67,209

190,561

19283

Discharge summary

report

Admission Date: [**2189-12-20**] Discharge Date: [**2189-12-29**] Date of Birth: [**2112-2-5**] Sex: M Service: MEDICINE Allergies: Dicloxacillin Attending:[**First Name3 (LF) 2387**] Chief Complaint: New A-fib with RVR Major Surgical or Invasive Procedure: electrical cardioversion History of Present Illness: 77 yo M with dCHF (Grade II), severe AS (0.8-1.0cm2), HTN, HL, diet controlled DM, PVD s/p Left axillary bifemoral bypass [**2189-8-28**] and s/p left fem-pt bypass w/ ISSV [**2184**] presents with a-fib /w RVR. The patient was last admitted on [**9-10**] here at [**Hospital1 18**] for infected left groin s/p axillary [**Hospital1 **]-femoral bypass. He underwent debridement and closure with vac. His wound grew MSSA and was to complete 6 months of treatment with Dicloxacillin. He was doing well until he reported DOE, improving with rest, one week prior. He was admitted to [**Hospital3 1443**] Hospital on [**2192-12-14**] for his DOE and found to be in ARF and hyperkalemic with a creatinine of 3 per report. The ARF was thought to be a delayed reaction to Dicloxaxcillin, which was d/c and he was started on prednisone, presumably for AIN. He was also found to be anemic and was transfused 4U pRBC. The patient's symtpoms improved and was discharged home. The patient reports feeling palpiations on Friday evening that resolved on its own. He denied any prior history of palpitations or chest pain. This morning around 8am the patient was again SOB, felt palpitations and left sided chest tightness, [**5-17**], no radiation. His SOB did not improve with rest as previously and presented to the [**Hospital1 18**]. In the ED, initial vitals were 97.6 55 105/56 22 100%RA. Upon further evaluation of the ED staff he was found to be in a-fib w/ RVR with rates 110-140's (no prior history). Given his history of severe AS they did not want to push IV nodal agents and was started on an esmolol gtt. He was also given 0.25mg IV Digoxin. His labs were remarkable for Trop 0.33, CK 295, MB: 19, MBI: 6.4. Creatinine 2.1, Bicarb 16, Na; 130, Glucose: 381, WBC: 14.8, UA positive, but [**11-27**] epi, lactate 1.4. CXR did not show pulmonary edema or consolidation. The patient was started on a heparin gtt with a 2000U bolus (guaiac negative). The patient had already taken ASA 325mg at home and was not loaded for plavix given patient high likelihood to need surgery given severe AS and severe PVD. He was also given 1.25L IVF. [**Month/Year (2) **] surgery was consulted in the ED. He also had LENI prior to arrive to the CCU that showed no DVT and a right thigh hematoma 5.5x2.8 cm. In the CCU the patient denied CP, SOB and only minimal palpitations. He did not feel light-headed or dizzy. Patient SBP declined to SBP 80's with rates in the 120's. Pt was asx and given 500cc IVF bolus and additional digoxin 0.25mg x1. His esmolol was d/c and BP improved to SBP 95 (MAPS 70's). Anesthesia was called in anticipation of cardioversion. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Diet Controlled Diabetes Dyslipidemia Hypertension 2. CARDIAC HISTORY: dCHF (Grade II) Severe Aortic Valve Stenosis (valve area 0.8-1.0cm2, mean gradient 58mmHg) 3. OTHER PAST MEDICAL HISTORY: PVD Left axillary bifemoral bypass [**2189-8-28**] s/p left fem-pt bypass w/ ISSV [**2184**] Abdominal Aortic Aneurysm [**2168**] h/o Cataracts h/o bladder ca Social History: Pt is a pharmacist and lives with his wife -[**Name (NI) 1139**] history: quit 6months ago 1/2ppd x40yrs -ETOH: rare -Illicit drugs: denied Family History: Father MI at 80 Mother with brain tumor No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T=97.4 BP=95/58 HR=112 RR=9 O2 sat=100% 2L 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 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. tachy, irregularly irregular, normal S1, S2. III/VI SEM with radiation to the carotids no /r/g. Delayed carotid upstrokes. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/ +1. erythema/warmth over the left foot; well healed surgical scar over b/l groin. fluid collection over the right anterior thigh SKIN: stasis dermatitis, skin breakdown over the left buttock, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP dopplerable PT doppler Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP dopplerable PT doppler Pertinent Results: On admission: [**2189-12-20**] 01:00PM PT-11.4 PTT-24.0 INR(PT)-0.9 [**2189-12-20**] 01:00PM PLT SMR-LOW PLT COUNT-114* [**2189-12-20**] 01:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL TEARDROP-OCCASIONAL [**2189-12-20**] 01:00PM NEUTS-93* BANDS-0 LYMPHS-2* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2189-12-20**] 01:00PM WBC-14.8*# RBC-3.32* HGB-9.9* HCT-29.8* MCV-90 MCH-29.9 MCHC-33.3 RDW-17.3* [**2189-12-20**] 01:00PM calTIBC-257* HAPTOGLOB-166 FERRITIN-576* TRF-198* [**2189-12-20**] 01:00PM ALBUMIN-3.7 CALCIUM-9.5 PHOSPHATE-4.4 MAGNESIUM-2.0 IRON-16* [**2189-12-20**] 01:00PM ALT(SGPT)-42* AST(SGOT)-47* LD(LDH)-323* CK(CPK)-295* ALK PHOS-64 TOT BILI-0.4 [**2189-12-20**] 01:00PM GLUCOSE-381* UREA N-74* CREAT-2.1*# SODIUM-130* POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-16* ANION GAP-18 [**2189-12-20**] 03:30PM URINE GRANULAR-0-2 COARSE GRANULAR CASTS [**2189-12-20**] 03:30PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE EPI-[**11-27**] [**2189-12-20**] 03:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2189-12-20**] 05:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2189-12-20**] 09:06PM TSH-1.2 [**2189-12-20**] 09:06PM calTIBC-202* HAPTOGLOB-154 FERRITIN-458* TRF-155* [**2189-12-20**] 09:06PM ALBUMIN-2.9* IRON-14* [**2189-12-20**] 01:00PM CK-MB-19* MB INDX-6.4* cTropnT-0.33* proBNP-4305* [**2189-12-20**] 09:06PM CK-MB-70* MB INDX-11.2* cTropnT-3.87* [**2189-12-21**] 05:27AM BLOOD CK-MB-46* MB Indx-10.8* cTropnT-7.01* [**2189-12-22**] 04:56AM BLOOD CK-MB-12* MB Indx-9.1* Imaging: [**2189-12-20**]: EKG Atrial fibrillation with a rapid ventricular response. Right bundle-branch block. Right axis deviation. Non-specific ST-T wave changes. Compared to the previous tracing atrial fibrillation is new. [**2189-12-20**]: CXR The patient is slightly rotated to the left. The lungs appear clear bilaterally with no areas of focal consolidation. Minimal left basilar atelectasis is noted. There is no pneumothorax or pleural effusion. Though the heart size appears slightly larger than on the prior study, the patient is slightly rotated and lung volumes are lower than on the prior study. The aorta remains tortuous with calcification but stable. There are no overt signs of fluid overload. Tubing is noted overlying the epigastrium, most likely external to the patient. Degenerative changes of the thoracic spine are noted, not well evaluated. IMPRESSION: No acute intrathoracic process. [**2099-12-19**]: Doppler lower extremity 1. No evidence of bilateral lower extremity DVT. 2. Likely right thigh hematoma as described above. [**2189-12-21**]: Echo The left atrium is elongated. The right atrium is moderately dilated. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Regional function is grossly normal ? Focal hypokinesis of basal inferior wall (clip [**Clip Number (Radiology) **]). Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-9**]+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2189-8-27**], the estimated pulmonary artery systolic pressure is now lower. The severity of aortic stenosis is similar. [**2189-12-21**]: Renal U/S 1. No hydronephrosis. Simple bilateral renal cysts and tiny non-obstructing crystals seen within the kidneys bilaterally. 2. No evidence of renal artery stenosis. 3. Thick-walled urinary bladder containing echogenic material, which may represent debris. These findings may be related to the presence of a Foley catheter. Microbiology: urine cx [**2189-12-20**]: > 100,000 CFU E.coli sensitivities: AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R blood cx [**2189-12-20**]: 2 of 2 sets GRAM NEGATIVE ROD(S) | AMIKACIN-------------- S AMPICILLIN------------ R CEFTAZIDIME----------- S CEFTRIAXONE----------- S CIPROFLOXACIN--------- S GENTAMICIN------------ S MEROPENEM------------- S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ S blood cx: [**12-21**]- [**12-24**]: negative Brief Hospital Course: 77 yo M with dCHF (Grade II), severe AS (0.8-1.0cm2), HTN, HL, diet controlled DM, PVD s/p left axillary bifemoral bypass [**2189-8-28**] complicated by MSSA graft infection, presents with new onset atrial fibrillation with rapid ventricular response. 1. Atrial Fibrillation: presented with new onset atrial fibrillation with rapid ventricular response. Etiology most likely provoked from systemic infection (see below). Given patient's severe aortic stenosis, nodal agents were relatively contraindicated and rate was difficult to control despite an esmalol drip and loading dose of digoxin. As a result of symptomatic hypotension, patient was semi-emergently cardioverted with anesthetia at bedside and converted back to normal sinus rhythm. Rate controlled with reduced rate of home metoprolol once hypotension had resolved. Patient was started on coumadin with heparin bridge for CHADS score of 3. However, because patient had rapidly expanding hematomas and symptomatic anemia requiring multiple transfusions, anticoagulation was reversed. Patient monitored on telemetry throughout hospital stay and remained in normal sinus rhythm throughout. 2. Sepsis secondary to UTI: Upon admission, patient was found to have [**2-11**] blood cultures and urine culture positive for pansensitive e.coli. Also exhibited septic physiology with leukocytosis to 14.8, fever, hypotension and rapid heart rate. Hypotension resolved after d/c cardioversion and resuscitation with IV fluids. Patient initially started on meropenem for broad spectrum gram negative coverage, which was narrowed down to cefazolin when blood culture sensitivities returned. CT abdoman and lower extremities with no evidence of abscess or fluid collection on multiple PVD grafts. Patient defervesced, leukocytosis resolved and blood cx became negative after [**12-20**]. Patient will need long term antibiotics for prior MSSA graft infection. He will follow up with infectious disease clinic as an outpatient. 3. Coronaries: Reported episode of chest discomfort with palpitations prior to admission in the setting of atrial fibrillation with rapid ventricular response. Although repeat EKGs showed old RBBB and new right axis deviation. Cardiac enzymes elevated with peak CK of 623 and troponin of 7.01. Patient maintained on heparin drip and aspirin with b-blocker and ACEI added when blood pressure could tolerate. Conservative management was choosen as patient was septic and would likely require surgical intervention for aortic stenosis in the near future. Persantine MIBI showed mild to moderate fixed inferior wall defect, slightly worsened when compared to the prior study. Patient remained chest pain free for the remainder of hospital stay. 4. Acute on chronic anemia: Patient presented with a hematocrit of 29.8 that fell to 22.9 the day after admission. Although patient's baseline hematocrit was unknown, he likely had chronic anemia associated with renal insufficiency. Etiology of acute blood loss thought to be related to multiple hematomas in right upper arm and left gluteus muscle in the setting of recent trauma from mechanical fall and new anticoagulation for atrial fibrillation. Right upper extremity hematoma was near picc site, but doppler revealed patency of brachiocephalic vein with no evidence of hematoma obstructing insertion site. Additionally, patient may have coagulopathy as severe AS has been associated with acquired [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Disease. Hemolysis labs were normal, CT abdoman/ pelvis with no evidence retroperitoneal bleed, and no evidence of GI blood loss. Patient remained hemodynamically stable throughout hospital stay. Anticoagulation was reversed with 2 U FFP and vitamin K 5mg x 3. Received in total 6 U pRBC and Hematocrit stabilized around 25. He will require repeat check in hematocrit to ensure no further anemia 2 days following hospitalization. 5. Aortic Stenosis: Patient has history of severe stenosis without symptoms of syncope, chest pain, or shortness of breath. Repeat echo showed valve area of 0.8cm2 and peak gradient 64mmHg. Valve replacement was not pursued as patient was septic. No further intervention was pursued. 6. PUMP: Grade II dCHF. Upon presentation, the patient appearred hypovolemic on exam, so lasix was held and patient received several fluid boluses of 500cc to treat hypotension. Of note, cardiac output is preload dependent given severe AS. Through the duration of hospital stay, the patient was weighed daily and I/O were strictly followed with goal even fluid balance. Maintained on bblocker, ACEI with no requirement for diuretic. 7. ARF: Presented with creatinine of 2.1 from baseline Cr of 0.8-1.0. Presumptively diagnosed with allergic interstitial nephritis at outside hospital based on rash with dicloxacillin use and peripheral eosinophilia and started presumptively of high dose steriods. Prednisone was stopped upon admission at [**Hospital1 18**] given severe systemic infection and uncertainty of prior diagnosis. Kidney function improved spontaneously throughout hospital stay and on discharge was 1.2. 8. PVD s/p multiple grafts: History of prior MSSA graft infection s/p debridement. CT abdoman and lower extremity showed no evidence of new/ acute abscess. [**Hospital1 **] surgery saw patient and believed that there was no need for acute surgical intervention. As above, patient was placed on longterm therapy with cefazolin with instructions to follow up with infectious disease as an outpatient. 9. Left lower extremity fracture: evaluated by x-ray, appears chronic distal fibular fracture although could be superimposed acute mallealar fracture. Evaluated by podiatry who favored conservative management with air cast x 4-6 weeks with nonweight bearing status. Pain controlled in hospital by percocet. 10. Diabetes: Diet controlled, but on admission glc 300's. Likely combination of stress and initiation of steriods. Maintained on sliding scale insulin and over hospital course insulin requirements decreased significantly. 11. Urinary Retention: Upon admission, patient had a foley catheter inserted for more accurate monitoring of urine output especially in acute management of hypotension. Tamulosin and finasteride were also briefly stopped. Upon stabilization of patient, BPH medications were resumed and attempted removal of catheter. Patient was unable to void and required multiple intermittent catheterizations. Foley was reinserted and patient scheduled for voiding trial with outpatient urologist in 1 week. Medications on Admission: Dicloxacillin 500mg q6 (stopped) Prednisone 30mg [**Hospital1 **] (started on [**12-17**]) Aspirin 325mg daily Amlodipine 10mg daily Lasix 40mg daily Lisinopril 40mg daily Metoprolol Succinate 100mg SR daily Simvastatin 80mg daily Niacin 1000mg SR daily Flomax 0.4mg daily Finasteride 5mg daily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 3. Niacin 500 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. 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. 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for ankle pain. 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. CefazoLIN 2 g IV Q12H 13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 14. Outpatient Lab Work Please collect weekly CBC with differential, LFT, BMP while on cefazolin. All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] 15. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Outpatient Lab Work please check Hct, PT/ INR, PTT 2 days following discharge on [**1-1**] Discharge Disposition: Extended Care Facility: Life Care Center at [**Location (un) 2199**] Discharge Diagnosis: Primary Diagnosis: Non ST elevation Myocardial Infarction Atrial fibrillation s/p cardioversion E-coli Urinary Tract Infection E-coli Bacteremia Left malleolus Fracture with chronic left foot changes acute urinary retention Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: Mr. [**Known lastname **], You had an infection in your urine and your blood. This will need to be treated with antibiotics for 4 weeks. You also had acute renal failure but this is also improving now. You were bleeding into your arm and your buttocks, so you became very anemic and required multiple blood transfusions. You will need to have your blood checked frequently at rehabilitation. You had an irregular heart beat called atrial fibrillation. We were able to shock you out of that rhythm and you are now in a regular rhythm. Your risk of a stroke is higher now that you have had atrial fibrillation and you were initially placed on coumadin, a blood thinner, to help prevent the risk of blood clots. However, because your blood counts kept dropping we stopped the blood thinner coumadin. Finally, you were found to have a chronic fracture in your left lower extremity. You will need to wear a special boot on this leg for 4-6 weeks and avoid placing weight on the ankle until you see the orthopedic physicians. . Medication changes: 1. Stop taking Lasix 2. Start Cefazolin 2gms twice daily to treat the blood infection 3. Stop taking amlodipine 4. Decrease the Metoprolol to 25 mg daily 5. Decrease lisinopril to 2.5 mg daily 6. Take percocet 5mg every 6 hours as needed for ankle pain Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: [**Name8 (MD) **]: Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2190-3-8**] 11:20 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2190-3-8**] 10:30 . Cardiology: [**First Name8 (NamePattern2) 5987**] [**Last Name (NamePattern1) 3236**] Phone: [**Telephone/Fax (1) 11554**] Date/Time: Tuesday [**1-26**] at 2:15pm. . Primary Care: [**Last Name (LF) **],[**First Name3 (LF) **] P Phone: [**Telephone/Fax (1) 52528**] Date/time: Please call for an appt after you get out of rehabiliation. . Infectious Disease: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 16976**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2190-1-11**] 9:00 am [**Hospital **] Medical Building, [**Location (un) 448**], [**Doctor First Name **], [**Location (un) 86**]. . Podiatry: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 52529**] Please call the office at [**Telephone/Fax (1) 52530**] to schedule an appointment in the next 2-3 weeks. . Renal: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 6984**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Date/Time: [**2190-2-16**] 01:00 pm Location: [**Hospital Ward Name **] CENTER, [**Location (un) **] Phone: [**Telephone/Fax (1) 721**] . Urology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27414**] Please follow up at 9:45am on [**2190-1-4**] for a voiding trial so you can get your foley catheter remover. Phone:([**Telephone/Fax (1) 52531**]

[ "428.32", "585.9", "427.31", "276.1", "790.92", "458.8", "600.01", "440.23", "E929.3", "276.52", "V58.65", "V15.82", "272.4", "599.0", "410.71", "250.00", "995.92", "276.2", "428.0", "E934.2", "923.03", "038.42", "403.90", "682.7", "424.1", "788.29", "824.8", "285.1", "V10.51", "285.21", "707.15", "924.00", "584.9" ]

icd9cm

[ [ [] ] ]

[ "99.62", "38.93", "86.22", "93.53" ]

icd9pcs

[ [ [] ] ]

18930, 19001

10431, 17026

295, 321

19269, 19269

5336, 5336

20886, 22486

4048, 4209

17371, 18907

19022, 19022

17052, 17348

19439, 20467

4224, 5317

3592, 3683

20487, 20863

236, 257

349, 3474

19041, 19248

5351, 10408

19283, 19415

3714, 3875

3496, 3572

3891, 4032

30,473

167,100

32128

Discharge summary

report

Admission Date: [**2109-11-13**] Discharge Date: [**2109-11-14**] Date of Birth: [**2062-7-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Peritoneal dialysis catheter revision History of Present Illness: 47M h/o ESRD on PD, HTN, diastolic CHF p/w respiratory distress after elective PD catheter revision. Pt had low flow via PD catheter during last few days prior to admit and therefore went to [**Hospital1 18**] for catheter revision. Procedure completed without complications, but pt developed respiratory distress after extubation. Pre-OP VS T 98.4, HR63, RR18, BP 146/67, 98%RA; was found to be breathing slowly post-op as anaesthesia had not been fully reversed. Additionally, BP increased transiently to 190/90; O2sat 89% on RA. BiPAP 5/8 was placed with rapid increase in O2sats to 100%. Received nebs given wheeze on clinical exam. Pt received only 350cc IVF during procedure, furosemide 20mg IV was given post-procedure and 150cc UOP were recorded. CXR showed mild flash pulmonary edema. . MICU evaluation requested due to respiratory distress. On evaluation, VS were stable with normalized BP, O2 sats 100% on BiPAP. Renal attg also consulted by surgery team and overnight monitoring in MICU was requested with possible peritoneal dialysis. Furosemide 200 mg IV administered per renal recs and pt was transferred to MICU. Past Medical History: # ESRD on PD # HTN # Diastolic CHF Social History: # Tobacco: Never # Alcohol: Rare # Personal: Lives with three children at home. Divorced. Family History: Noncontributory Physical Exam: VS (in PACU): T Afebrile, BP 126/80, HR 55, RR 24, O2sat 100% on BiPAP 5/8 GEN: Uncomfortable [**1-25**] BiPAP mask, but NAD HEENT: PERRL, EOMI, anicteric, BiPAP mask in place NECK: No JVD elevation, supple RESP: Coarse BS throughout with crackles up to mid-way b/l CV: RR, S1/S2 WNL, no m/r/g ABD: Soft, ND, +BS, tender over PD catheter site EXT: No c/c/e, warm, good pulses SKIN: No rashes/no jaundice NEURO: A&Ox3, moving all extremities Pertinent Results: Admission labs: . [**2109-11-13**] 09:07PM WBC-8.3 RBC-3.72* HGB-10.3* HCT-32.7* MCV-88 MCH-27.7 MCHC-31.5 RDW-15.4 [**2109-11-13**] 09:07PM GLUCOSE-103 UREA N-86* CREAT-16.9* SODIUM-144 POTASSIUM-5.7* CHLORIDE-109* TOTAL CO2-16* ANION GAP-25* [**2109-11-13**] 09:07PM ALBUMIN-3.4 CALCIUM-7.9* PHOSPHATE-8.1* MAGNESIUM-3.3* . EKG: Sinus bradycardia at 54, normal axis, normal intervals, no acute ST changes, minimally peaked T waves in V2, V3. . Imaging: . CXR: Diffuse opacifications of both lungs. No clear infiltrate. Significant cardiomegaly. Brief Hospital Course: 47M h/o ESRD on PD, HTN, diastolic CHF p/w respiratory distress after elective PD catheter revision. . # Respiratory distress: Pt initially admitted for peritoneal catheter revision, but BP to 190/90 after extubation post-procedure with acute SOB and desat to 80s. Administered BiPAP and furosemide 200mg IV with MICU transfer. CXR showed likely pulmonary vascular congestion in setting of known diastolic heart failure. Peritoneal dialysis was started overnight given limited response to furosemide IV, but suboptimal PD as pt was recently post-op. Weaned off BiPAP upon MICU arrival, and trial off O2 in a.m. revealed 93% O2sats on RA at rest. Chlorothiazide 500 mg IV subsequently administered, followed by furosemide 200mg IV. Ambulatory O2sat later 93-97% with no SOB. Pt d/c'd on furosemide 200mg PO BID with instructions to f/u in renal clinic the next day. . # ESRD/PD revision: Pt producing urine, PD catheter operating. Pt continued on calcitriol, PhosLo, per home regimen; d/c'd on Kayexalate 15mg daily with instructions to f/u in renal clinic the next day. Also issued script for oxycodone 5mg [**Hospital1 **] PRN pain x 2 days. . # Hyperkalemia [**1-25**] ESRD: K = 5.7 in PACU with EKG demonstrating only minimal peaked T waves in V2, V3; pt on standing Kayexelate as outpatient. D/c'd with Kayexelate 15mg daily. ACE-I and amiloride held to avoid exacerbating hyperkalemia. . # Sinus bradycardia: Pt transiently bradycardic, resolved during MICU admission. Pt continued on home regimen of beta blocker with holding parameters. . # HTN: Brief episode of hypertension to 190/90 after extubation likely contributing to respiratory distress. Normotensive on MICU evaluation and discharge. Pt continued on home regimen of beta blocker and Ca channel blocker, with ACE-I held given hyperkalemia. . # Full code Medications on Admission: # Furosemide 80 mg [**Hospital1 **] # Lisinopril 40 mg daily # Amlodipine 10 mg daily # Amiloride 5 mg daily # Calcitriol 0.5 mcg PO M/W/F # Sodium polystyrene sulfonate 15 g daily # Calcium acetate 667 mg tabs, 2tabs TID # Metoprolol succinate 150 mg daily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Sodium Polystyrene Sulfonate 15 g/60 mL Suspension Sig: Sixty (60) mL PO once a day. Disp:*1800 mL* Refills:*0* 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO M/W/F (). 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Furosemide 80 mg Tablet Sig: 2.5 Tablets PO twice a day. Disp:*50 Tablet(s)* Refills:*0* 9. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO twice a day as needed for pain for 2 days. Disp:*4 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: 1) Peritoneal catheter revision 2) Respiratory distress likely secondary to pulmonary edema 3) End stage renal disease . Secondary: 4) Hypertension 5) Diastolic heart failure Discharge Condition: Ambulatory oxygen saturation 93-97% Discharge Instructions: You were admitted to the hospital to readjust your peritoneal catheter. After the surgery, you had a high blood pressure which caused you to become short of breath due to excess fluid in your lungs. At first you were treated with a special mask to help with your breathing, but then this was stopped and you received supplemental oxygen. . When you leave the hospital you will need to take some additional mediations: 1) Lasix 200mg by mouth twice daily 2) Kayexalate 15grams daily (to help control your potassium level) . ***You should not take your lisinopril until you talk to your kidney doctor.*** . Also, you must follow-up in renal clinic with Dr. [**Last Name (STitle) 7473**] or the available physician tomorrow, [**Name9 (PRE) 2974**] [**11-15**]. . In addition, you need to follow-up with Dr. [**Last Name (STitle) **] on Monday, [**11-25**]. Please call tel. [**Telephone/Fax (1) 673**] to make and confirm your appointment with him. Followup Instructions: Please follow-up on Friday, [**11-15**], with Dr. [**Last Name (STitle) 7473**] or the available physician in the renal clinic. . You should follow-up with your primary care physician within one to two weeks after discharge from the hospital. . Also, you need to follow up with Dr. [**Last Name (STitle) **] on Monday, [**11-25**]. You need to call him at tel. [**Telephone/Fax (1) 673**] to make and confirm your appointment. Completed by:[**2109-11-14**]

[ "585.6", "403.91", "276.7", "427.89", "428.0", "428.32", "285.21", "996.56" ]

icd9cm

[ [ [] ] ]

[ "54.98", "54.93" ]

icd9pcs

[ [ [] ] ]

5810, 5816

2798, 4634

337, 377

6044, 6082

2221, 2221

7079, 7539

1727, 1744

4943, 5787

5837, 6023

4660, 4920

6106, 7056

1759, 2202

277, 299

405, 1545

2237, 2775

1567, 1604

1620, 1711

23,699

172,876

48911

Discharge summary

report

Admission Date: [**2142-8-21**] Discharge Date: [**2142-8-29**] Date of Birth: [**2090-3-28**] Sex: F Service: [**Hospital1 139**] HISTORY OF PRESENT ILLNESS: This was a 52-year-old female with a past medical history of pneumonia, chronic obstructive pulmonary disease, and a history of tuberculosis exposure with a negative PPD on [**2142-8-19**], who presented to her primary care physician for [**Name9 (PRE) 102715**] symptoms. She was treated as an outpatient with levofloxacin; however, her symptoms continued to worsen. On [**2142-8-18**], the patient went to an outside hospital with an oxygen requirement and a white blood cell count of 13.8. The patient was admitted and started on ceftriaxone, azithromycin, as well as levofloxacin and doxycycline. At the outside hospital, the patient had a bronchoscopy performed which showed no masses, negative bronchoalveolar lavage for acid fast bacilli, Chlamydia, Legionella. The patient was subsequently intubated for an oxygen requirement and transferred to [**Hospital1 190**] for a lung biopsy. The patient was taken to the Medical Intensive Care Unit during her stay there on [**2142-8-21**] to [**2142-8-28**]. On admission, the patient was thought to have a community-acquired pneumonia which caused the oxygen requirement but also the possibility of an interstitial process. The patient was started on ceftriaxone, azithromycin, and Levaquin for probable community-acquired pneumonia. A CT scan was performed which showed evidence of an infectious process bilaterally and some pulmonary edema. On [**2142-8-22**], the Cardiothoracic Surgery Service was consulted to perform a lung biopsy. The right middle lobe was biopsied which showed adult respiratory distress syndrome in the exudative phase. The patient continued to improve and was extubated on [**2142-8-23**]. At that time, her oxygen requirement was three liters for 97 percent oxygenation. An echocardiogram was performed which showed an ejection fraction of 65 percent in an otherwise normal heart. The [**Hospital 228**] medical Intensive Care Unit stay was complicated by agitation and confusion after her extubation. Psychiatry was consulted, and the patient was found to have a history of drug abuse and alcohol abuse. There was concern that she may have gone through withdrawal, and also this could be delirium secondary to sedation. The patient was monitored in the Intensive Care Unit for several days. Her symptoms improved. She required less oxygenation. The patient was transferred to the [**Last Name (un) 102716**] B Service on [**2142-8-28**]. At that time, the patient stated that she was feeling good with an occasional cough and clear sputum. The patient had an occasional diarrhea, but at the time of transfer, she denied any fevers, chills, nausea, vomiting, chest pain, shortness of breath, dysuria or abdominal pain. PAST MEDICAL HISTORY: Her past medical history is significant for hypertension, depression, gastroesophageal reflux disease, history of pancreatitis, chronic pain, chronic obstructive pulmonary disease, history of tuberculosis exposure with a negative PPD on [**2142-8-19**]. PHYSICAL EXAMINATION: On transfer, her temperature was 97.3, blood pressure 98/62, pulse 85, respiratory rate 20, oxygen saturation 94 percent in room air. In general, the patient was ambulating, in no acute distress, pleasant, talking in complete sentences. HEENT: Pupils are equal, round, and reactive to light and accommodation. Neck examination revealed no jugular venous distention, no lymphadenopathy. Cardiovascular exam revealed a regular rate and rhythm, no murmurs, rubs or gallops. Pulmonary exam revealed crackles at the bases bilaterally. He had no wheezing and no rhonchi. His abdomen was nontender and nondistended with positive bowel sounds. Extremity exam revealed good pulses in all four extremities. Neurological exam revealed he was alert and oriented times three. Cranial nerves II through XII were intact. LABORATORY DATA: On transfer, her white count was 19.0, hematocrit 32.3. CT of the head showed no acute intracranial hemorrhage or mass effect. HOSPITAL COURSE: The patient was monitored on the Medicine Service. The patient had improving mental status without any episodes of confusion or agitation. The patient remained afebrile on the floor and had oxygen saturation of 98 percent in room air prior to her discharge. The patient was continued on ceftriaxone and azithromycin for her resolving community-acquired pneumonia. The patient was reevaluated by Psychiatry, and she was deemed to be fit to go home and follow-up with an outpatient psychiatrist. CONDITION AT DISCHARGE: Good. No shortness of breath, fever, or chills. DISCHARGE STATUS: To home. DISCHARGE MEDICATIONS: 1. Multivitamin. 2. Thiamine 100 mg q.day. 3. Folic acid 1 mg p.o. q.day. 4. Nicotine patch 20 mg/24 hours once a day. 5. Atenolol 75 mg p.o. q.day. 6. Pantoprazole 40 mg p.o. q.day. 7. Azithromycin 250 mg p.o. q.day. 8. Amlodipine 2.5 mg p.o. q.day. 9. Venlafaxine 37.5 mg p.o. q.day. 10. Prednisone taper. 11. .................... 400 mg p.o. q.day for seven days. DISCHARGE INSTRUCTIONS: The patient was asked to follow-up with case manager, [**Doctor Last Name **], to arrange an outpatient drug rehabilitation program. She was also asked to see her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 77614**], to make an appointment within the next week. DISCHARGE DIAGNOSIS: 1. Adult respiratory distress syndrome, exudative. 2. Pneumonia. 3. Mental status change with alcohol and drug abuse. 4. History of depression. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2142-9-24**] 18:54 T: [**2142-9-24**] 21:05 JOB#: [**Job Number 102717**]

[ "304.10", "787.91", "496", "512.1", "401.9", "518.82", "293.0", "486", "515" ]

icd9cm

[ [ [] ] ]

[ "96.71", "33.28", "38.91" ]

icd9pcs

[ [ [] ] ]

4812, 5189

5534, 5944

4186, 4695

5214, 5513

3204, 4168

4710, 4789

181, 2903

2926, 3181

61,605

102,612

43532

Discharge summary

report

Admission Date: [**2120-6-12**] Discharge Date: [**2120-6-21**] Date of Birth: [**2043-10-16**] Sex: F Service: MEDICINE Allergies: Demerol / Vicodin / amiodarone / Ace Inhibitors Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: asymptomatic AFib/RVR Major Surgical or Invasive Procedure: Internal defibrillator placement History of Present Illness: 76y/o lady with DM2, AFib on Warfarin s/p DCCV [**2116**] and also 2 weeks ago, h/o rheumatic fever s/p mechanical AVR and MVR in [**2098**], systolic CHF (EF=20-25%), interstitial lung disease on home O2 (question of amio toxicity), and h/o strep endocarditis who was referred to the ED from her PCP's office due to AFib/RVR, and is admitted to the CCU due to difficulty controlling her HR in the ED. . Of note, she was recently admitted [**Date range (1) 69954**] from her PCP's office due to AFib/RVR in the setting of UTI and volume depletion from uptitrated diuretics. At that time, she was given Diltiazem IV in the ED, dropped her BP, and was admitted to the CCU. She was successfully cardioverted [**5-30**] and was in NSR at the time of discharge. Her Lasix dose was decreased, her Lisinopril was stopped due to hypotension, and she was started on Cefpodoxime for UTI. . She has been doing well overall since discharge. Denies any chest pain, worsened shortness of breath, lightheadedness, leg swelling. 2 nights ago she felt the sudden onset of palpitations; she took her pulse which was 160 so she figured she might be back in AFib but she hoped it would only be temporary. A few times since then, she repeated the pulse and it was ~130. Today she was at her post-discharge PCP [**Name9 (PRE) 702**] and was found to be in AFib/RVR so she was referred to the ED. . In the ED, initial VS were: T 98, HR 151, BP 108/67, RR 20, POx 100% 3L NC. EKG confirmed AFib/RVR, no changes concerning for ischemia. Labs were notable for Cr 1.8 (this is the lowest it has been in years), and therapeutic INR at 2.7. She was given 500cc normal saline over 45 minutes with no change in HR, but she and developed mild crackles at the lung bases without dyspnea or decrease in O2 sat. She was then given Diltiazem 10mg IV x1 with HR still 140's but BP dropped to 80/50. She was Digoxin loaded with 0.5mg IV. She was started on a Diltiazem gtt and was admitted to the CCU due to trouble controlling her HR. VS prior to transfer were: HR 130-150, BP 108/70, RR 12, POx 100% 2L NC. . On arrival to the CCU, she feels well. No chest pain, no palpitations. She is at her baseline level of shortness of breath (feels dyspneic even when walking a few feet). . REVIEW OF SYSTEMS Pertinent for mild cough that is non-productive. Also, mild left ankle edema, though better today. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. . . Past Medical History: 1. CARDIAC RISK FACTORS: (+)DM, (+)HTN, (+)HLD 2. CARDIAC HISTORY: Afib s/p cardioversion in [**2116**], mechanical MVR and AVR in [**2098**] -h/o strep endocarditis in [**2115**] s/p 6 weeks of vanc/PCN -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: -psoriasis -interstitial lung pathology per PFTs in [**3-21**]; felt to possibly be [**3-14**] amiodarone toxicity. -gallbladder removal -hernia repair -s/p TIA in [**2115**] -DMII -Gout -Hypothyroidism Social History: Pt lives in [**Location 29789**] with her daughter and son. She has 5 children, 10 grandchildren, and 1 greatgrandchild. -Tobacco history: Former, quit 23 yr prior, smoked 1 ppd for 'many years' -ETOH: Denies -Illicit drugs: Denies Family History: Father - died of MI at age 42 Mother - 2 MI, died of PE. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 97.7, HR 117, BP 113/64, RR 18, POx 97% 3L NC GENERAL: Obese lady in NAD. Oriented x3. Mood, affect appropriate. HEENT: Moon facies. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Obese, no JVD. CARDIAC: Loud/mechanical clicks audible, irregularly irregular and tachycardic. No murmur. LUNGS: Mild bibasilar crackles. ABDOMEN: Obese but nondistended, no masses. EXTREMITIES: Mild left ankle/foot edema. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ DISCHARGE PHYSICAL EXAM: VS: T 98.8/98.6 HR 69-70 SR BP 100-142/56-72 RR 18-20 O2 96-99% 3L NC GENERAL: Obese lady in NAD. Oriented x3. Mood, affect appropriate. HEENT: Moon facies. NECK: Obese, JVD at 16cm CARDIAC: Loud/mechanical clicks audible, RRR. Incision: Left chest ICD incision, dressing c/d/i, no bleeding/ small atable hematoma/ mild ecchymosis. 2+ radial and ulnar pulses, + CSM left hand LUNGS: Decreased crackles BB. ABDOMEN: Obese but nondistended, no masses. EXTREMITIES: [**2-12**]+ bilat edema to knee PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: Labs on Admission: [**2120-6-12**] 03:50PM BLOOD WBC-9.7# RBC-3.97* Hgb-12.9 Hct-42.3 MCV-107* MCH-32.6* MCHC-30.6* RDW-15.6* Plt Ct-152 [**2120-6-17**] 06:52AM BLOOD WBC-5.9 RBC-3.59* Hgb-11.6* Hct-37.3 MCV-104* MCH-32.2* MCHC-31.0 RDW-15.3 Plt Ct-136* [**2120-6-12**] 03:50PM BLOOD PT-27.7* PTT-34.0 INR(PT)-2.7* [**2120-6-12**] 03:50PM BLOOD Glucose-171* UreaN-33* Creat-1.8* Na-141 K-4.9 Cl-104 HCO3-25 AnGap-17 [**2120-6-13**] 03:03AM BLOOD ALT-41* AST-61* [**2120-6-13**] 03:03AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.7 . Imaging: . Chest x-ray [**6-12**] FINDINGS: Single AP upright portable view of the chest was obtained. The patient is status post median sternotomy. The cardiac silhouette remains moderate-to-severely enlarged. The aorta is calcified. There is mild pulmonary vascular congestion. Hazy opacity projecting over the left costophrenic angle may relate to overlying soft tissue, although a pleural effusion cannot be excluded. Small right pleural effusion is also difficult to exclude. IMPRESSION: Persistent moderate-to-severe enlargement of the cardiac silhouette. Difficult to exclude small bilateral pleural effusions. Pulmonary vascular congestion. . Renal US/Artery Doppler: 1. Bilateral renal cysts, as described above. 2. The left kidney is decreased in size. Left arterial waveforms demonstrate blunted systolic upstroke, suggestive of renal artery stenosis. . Chest x-ray [**6-19**]: FINDINGS: There is a biventricular pacemaker in the left chest wall with leads in the right atrium, right ventricle, and a third lead through the coronary sinus. There is no pneumothorax. Left retrocardiac and right basilar opacities are likely atelectasis. There is mild improvement in pulmonary edema. Cardiomediastinal silhouette is unchanged. There is no focal consolidation or pleural effusions. IMPRESSION: 1. Biventricular pacemaker/AICD with leads in appropriate positioning. 2. Improved pulmonary edema. . Labs on D/c: [**2120-6-21**] 07:00AM BLOOD WBC-8.4 RBC-3.60* Hgb-11.7* Hct-37.3 MCV-104* MCH-32.5* MCHC-31.4 RDW-15.6* Plt Ct-137* [**2120-6-21**] 07:00AM BLOOD PT-20.7* INR(PT)-2.0* [**2120-6-21**] 07:00AM BLOOD UreaN-38* Creat-1.5* Na-146* K-4.5 Cl-102 HCO3-38* AnGap-11 [**2120-6-21**] 07:00AM BLOOD Mg-2.4 Brief Hospital Course: BRIEF CLINICAL SUMMARY: Ms. [**Known lastname **] is a 76y/o lady with DM2, AFib on Warfarin s/p DCCV [**2116**] and also 2 weeks ago, h/o rheumatic fever s/p mechanical AVR and MVR in [**2098**] on warfarin, systolic CHF (EF=20-25%), and interstitial lung disease on home O2 (question of amio toxicity) who presents with recurrent AFib/RVR. She had a BiV ICD placed and was started on dofetilide prior to discharge, without complication. ISSUES: #. AFib with RVR: Patient had successful AC cardioversion on [**2120-6-12**] from atrial fibrillation to sinus rhythm. The patient then went back into atrial fibrillation, and dofetilide was started, with conversion to sinus rhythm on [**2120-6-14**]. She then had sinus bradycardia (likely from left atrial focus, not actually sinus) with QT >500ms and offset pauses >3 seconds. She had a BiV ICD placed on [**2120-6-18**], with future consideration for AVJ ablation if Afib persists and is difficult to control. The patient did have LUQ/flank discomfort post-procedurally which may have been secondary to intermittent phrenic nerve pacing, and the LV lead output was adjusted. The patient was restarted on dofetilide 125mcg [**Hospital1 **], and QTc remained stable on serial ECGs. The patient was also discharged on po Carvedilol 12.5mg [**Hospital1 **] and warfarin 5 mg M/Th and 2.5mg all other days. INR on day of discharge 2.0. Goal INR for home is 2.5-3.5. #. Chronic systolic CHF: Recent TTE showed EF 20-25% with TR and mod PHTN. The patient's ACE-inhibitor was stopped, as was very likely to be contributing to renal issues. The patient received PRN diuresis with lasix in addition to home torsemide when appeared volume up. The patient was discharged to home on torsemide 20mg qd and carvedilol 12.5mg [**Hospital1 **]. #. CKD: Cr 1.5 on day of discharge, much better than ??????baseline??????. Has left sided renal artery stenosis on renal ultrasound. While in the hospital, avoided nephrotoxins, renally dose meds (e.g. Allopurinol). We discontinued ACE-inhibitor and renal function substantially improved, making us believe that the lisinopril was likely contributing to renal dysfunction. #. h/o rheumatic fever s/p mechanical AVR and MVR: stable. Valves well seated on last TTE. INR therapeutic at admission. Warfarin was held, and heparin drip started in anticipation of ICD implantation and continued while INR<2.5. Warfarin restarted after implantation, and INR increased to 2.0 by day of discharge. She was discharged on warfarin 5 mg M/Th and 2.5mg all other days at home, which is usual home dose, without lovenox bridge. INR goal of 2.5-3.5 for mechanical mitral valve. #. Interstitial lung disease: stable. At home she uses 3-5L NC for interstitial lung disease thought to be from amiodarone toxicity. We continued supplemental home O2 in the hospital, and continued steroids. Discharged home on prednisone 15mg qd, with continued slow taper to be directed by outpatient practitioners. #. Diabetes: stable. Steroids likely the cause of high blood sugars, not DM-2. the patient was maintained on a diabetic diet. hyperglycemia was treated with Humalog sliding scale while in the hospital. #. Gout: stable. continued Allopurinol (renally dosed) #. Hypothyroidism: stable. continued Levothyroxine TRANSITIONS OF CARE: - Ace-inhibitor likely contributing contributing to renal failure. Would strongly recommend against restarting an ACE-inhibitor. - monitor renal function intermittently as outpatient in setting of dofetilide use - INR monitoring for mechanical AVR/MVR Medications on Admission: carvedilol 12.5 mg [**Hospital1 **] furosemide 40 mg daily warfarin 5 mg MO,TH and 2.5 mg other days prednisone 15 mg daily levothyroxine 25 mcg daily citalopram 20 mg daily allopurinol 300mg daily fluticasone 50 mcg/actuation Spray: 1 spray [**Hospital1 **] folic acid 1 mg daily ferrous sulfate 300 mg (60 mg iron) daily multivitamin w/minerals daily . Discharge Medications: 1. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. warfarin 5 mg Tablet Sig: One (1) Tablet PO MONDAY AND THURSDAYS (). 4. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO TUES, WED, FRI, SAT, SUN (). 5. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 14. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 15. dofetilide 125 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*2* 16. Outpatient Lab Work Please check INR, Chem 7 on Monday [**6-24**] with results to Dr. [**Last Name (STitle) **] at Phone: [**Telephone/Fax (1) 68055**] Fax: [**Telephone/Fax (1) 93673**] ICD 9: 427.31 Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Atrial fibrillation Chronic Systolic congestive heart failure Chronic Kidney disease Hypertension Intersticial Lung disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure caring for you at [**Hospital1 18**]. Your atrial fibrillation was beating very fast and we tried to give you medicine to slow the rhythm but this led to a dangerously slow heart rate. A pacemaker was placed and now you are tolerating the medicine well. You will go home on dofetalide to control your heart rate. No lifting more than 5 pounds with your left arm or lifting your left arm over your head for the next 6 weeks. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . We made the following changes to your medicines: 1. START taking dofetalide to slow your heart rate 2. Decrease allopurinol to 100 mg daily 3. Stop taking furosemide, take torsemide instead to get rid of extra fluid 4. START taking fluticasone inhaler to help improve your lung function Followup Instructions: Department: CARDIAC SERVICES When: THURSDAY [**2120-6-27**] at 9:00 AM With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) 68054**],[**First Name3 (LF) **] Location: HEALTHWORKS Address: [**Street Address(2) 93672**], [**Location (un) **],[**Numeric Identifier 9310**] Phone: [**Telephone/Fax (1) 68055**] Appointment: Wednesday [**2120-6-26**] 3:00pm Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD Address: [**Hospital1 **], [**Location (un) **],[**Numeric Identifier 6425**] Phone: [**Telephone/Fax (1) 6937**] *Please call your cardiologist to book a follow up appointment for your hospitalization. You need to be seen within 1 month of discharge.

[ "696.1", "397.0", "V12.54", "244.9", "496", "V15.82", "V17.3", "E879.8", "427.81", "V46.2", "428.22", "999.2", "428.0", "515", "427.31", "440.1", "403.90", "451.82", "249.00", "998.12", "585.9", "274.9", "V43.3", "416.8", "V58.61", "V13.02", "E878.1" ]

icd9cm

[ [ [] ] ]

[ "99.61", "99.69", "00.51", "99.29" ]

icd9pcs

[ [ [] ] ]

13002, 13061

7579, 10861

339, 374

13229, 13229

5300, 5305

14298, 15231

4083, 4141

11541, 12979

13082, 13208

11162, 11518

13412, 14275

4181, 4714

3371, 3583

278, 301

402, 3281

5319, 7556

13244, 13388

10882, 11136

3614, 3818

3303, 3350

3834, 4067

4739, 5281

27,606

145,985

34617

Discharge summary

report

Admission Date: [**2132-8-27**] Discharge Date: [**2132-9-3**] Date of Birth: [**2083-1-29**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Not herself lately Major Surgical or Invasive Procedure: 1. Right-sided craniotomy for resection. 2. Intraoperative image guidance. 3. Microscopic dissection. 4. Duraplasty. History of Present Illness: 49F sent from OSH with h/o schizoeffective disorder and depression lives at a halfway house was sent to OSH for evaluation. Has become more lethargic with slurred speech progressing over the past week. Claims she has been frequently losing balance however denies falls. Having feelings of worthlessness and feeling of despair. Pt is unaware of if she has been taking her medications and unsure of illicit drug use. She is a heavy smoker and lives in a halfway house she has a case manager from the Department of Mental Health Past Medical History: Schizoaffective disorder Depression GERD Arthritis Mammogram Colonoscopy Social History: Lives at halfway house, 48pack yr smoker, denies ETOH or illicit drug use Family History: non-contributory Physical Exam: T: 98.7 BP:124/54 HR:74 RR:20 O2Sats:95 Gen: Comfortable lying in the bed in NAD. HEENT: Pupils:PERRL 2.5-2 EOMs intact Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: unable to recall [**3-17**] objects at 5 minutes Language: Speech slurred with flight of thoughts. Naming intact. No Dysarthria, no paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2.5mm to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-19**] throughout. No pronator drift however has bilat asterixis. Sensation: Intact to light touch Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: normal on finger-nose-finger Pertinent Results: [**2132-8-27**] 04:31PM WBC-8.5 RBC-3.72* HGB-11.8* HCT-36.8 MCV-99* MCH-31.7 MCHC-32.1 RDW-13.4 [**2132-8-27**] 06:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-7.0 LEUK-SM [**2132-8-27**] 04:31PM PLT COUNT-234 [**2132-8-27**] 04:31PM GLUCOSE-89 UREA N-34* CREAT-1.3* SODIUM-141 POTASSIUM-4.6 CHLORIDE-110* TOTAL CO2-22 ANION GAP-14 [**2132-8-27**] 06:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG Brief Hospital Course: She was admitted from the outside hospital for slurred speech and lethargy, received q1H neuro checks, and underwent a head CT which showed: Well circumscribed, hyperdense, homogeneously enhancing mass centered within the atria of the right lateral ventricle. Findings are most compatible with an intraventricular meningioma. Mild associated edema, without midline shift or hydrocephalus. She also had an MRI showing 3 x 4 cm mass arising from the choroid plexus atrium of the right lateral ventricle. Most likely representing an intraventricular meningioma. Given these findings, she was consented the following day for surgery to remove the mass to take place on [**2132-8-29**]. She was loaded with dilantin and decadron was initiated. She was also started on thiamine, folate, b12. A CTA was perfromed to see if there was vascular supply to the mass, which showed: No large, direct arterial supply or large, direct venous drainage seen to the mass. The following morning, she went to the OR for a craniotomy and resection with an MR wand study beforehand, showing a stable mass in the atrium of the right ventricle. Post-operatively, she was brought to the S-ICU and monitored. She was watched closely with frequent neuro checks, and a post-op CT showed no bleeding or mass effect, with the tumor resected. However on POD#1, she was noted to be agitated, and found to have an increase in Left facial droop as well as left arm weakness. Neurology was consulted at this point, and an MRI showed probable acute infarct in the right posterior lenticulostriate territory adjacent to the ventricle, as well as postoperative changes with resection of mass without residual nodular enhancement. No hydrocephalus or midline shift. Pt seemed to improve slighlty, and was followed by the neuro stoke consult service. ASA was held for concerns of post-op bleeding. The following day, she was deemed stable enough to be transferred to the floor. A psych consult was obtained for persistent agitation and exacerbation of her schizoaffective disorder, who recommended a 1:1 sitter, and re-adjusted her psych meds, including adding seroquel and prn haldol. A speech and swallow study was also performed, and she was cleared for PO ground solids and pureed food and thin liquids. On [**9-2**], her sutures were removed. She was screened for an acute psych rehab where she could receive PT, and was accepted at Radius Specialty care. She was discharged in stable condition, and will follow-up with dr. [**Last Name (STitle) **] in 4 weeks time. She is sent to rehab on a steroid taper. Medications on Admission: Ativan .5mg''', Clozaril 700mg',Depakote 1000mg", Seroquel 100mg', Seroquel 150mg qhs, Protonix 40mg', Miralax 17G'''' Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Tablet, Delayed Release (E.C.)(s) 2. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO QID (4 times a day). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Clozapine 100 mg Tablet Sig: Seven (7) Tablet PO HS (at bedtime). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) unit/mL Injection TID (3 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 14. Valproate Sodium 750 mg IV BID 15. Valproate Sodium 500 mg IV DAILY Please give between 750 mg doses so pt receives medication tid. 16. Haloperidol 1-2 mg IV Q3-4H:PRN agitation 17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain. 18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for groin folds. Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital Discharge Diagnosis: Right-sided intraventricular tumor Schizoaffective disorder Discharge Condition: Stable Discharge Instructions: General Instructions ?????? Have a healthcare assistant 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. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Follow-Up Appointment Instructions ?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ?????? You will not need an MRI of the brain with/ or without gadolinium contrast. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 4 weeks Completed by:[**2132-9-3**]

[ "434.91", "274.9", "997.02", "311", "530.81", "293.0", "295.74", "225.0", "305.1", "721.3", "784.3" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

7362, 7436

3068, 5647

337, 456

7540, 7548

2546, 3045

9314, 9407

1216, 1234

5816, 7339

7457, 7519

5673, 5793

7572, 9291

1249, 1435

279, 299

484, 1012

1731, 2527

1450, 1715

1034, 1108

1124, 1200

16,852

181,674

28764

Discharge summary

report

Admission Date: [**2148-7-16**] Discharge Date: [**2148-7-20**] Date of Birth: [**2083-6-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: 65M with increasing DOE Major Surgical or Invasive Procedure: Aortic valve replacement(23mm CE Pericardial tissue valve) [**2148-7-16**] History of Present Illness: This 65M has had increasing DOE for the past 8 months. An echo on [**2148-6-27**] revealed: 60% LVEF, [**First Name8 (NamePattern2) **] [**Location (un) 109**] on 0.8cm2, pk. grad. of 97mmHg, 2+AI, and 1+MR. A cardiac cath on [**7-3**] showed clean coronaries. He was admitted for elective AVR. Past Medical History: Aortic stenosis Migraines ^chol. BPH, s/p prostate surgery s/p appy Social History: Unemployed janitor, lives with wife. Cigs: none ETOH: none Family History: unremarkable Physical Exam: WDWNHM in NAD AVSS HEENT: NC/AT, PERLA, EOMI, oropharynx benign Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids with radiating murmur bilat. Lungs: Clear to A+P CV: RRR w/ III/IV SEM Abd: +BS, soft, nontender, without masses or tenderness Ext: without C/C/E, pulses 2+= bilat. throughout. Neuro: nonfocal Pertinent Results: [**2148-7-20**] 05:17AM BLOOD WBC-9.5 RBC-3.11* Hgb-9.4* Hct-27.2* MCV-87 MCH-30.3 MCHC-34.7 RDW-12.9 Plt Ct-211# [**2148-7-20**] 05:17AM BLOOD Glucose-106* UreaN-16 Creat-0.8 Na-139 K-3.9 Cl-102 HCO3-29 AnGap-12 RADIOLOGY Final Report CHEST (PA & LAT) [**2148-7-18**] 2:10 PM CHEST (PA & LAT) Reason: pleural effusions [**Hospital 93**] MEDICAL CONDITION: 65 year old man with REASON FOR THIS EXAMINATION: pleural effusions INDICATION: Assessment for pleural effusions. TECHNIQUE: PA and lateral view of the chest. COMPARISON: Comparison available from [**7-17**]. FINDINGS: Mildly enlarged heart is stable. Mediastinum and hilar contours are widened and stable. There is a small stable left pleural effusion. The remainder of the lungs is clear. IMPRESSION: Stable left pleural effusion. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Name (STitle) **] DR. [**First Name (STitle) 29814**] [**Name (STitle) 65954**] [**Doctor Last Name **] Cardiology Report ECHO Study Date of [**2148-7-16**] PATIENT/TEST INFORMATION: Indication: Aortic valve disease. Shortness of breath. Intra-op TEE for AVR Height: (in) 65 Weight (lb): 130 BSA (m2): 1.65 m2 BP (mm Hg): 144/65 HR (bpm): 64 Status: Inpatient Date/Time: [**2148-7-16**] at 09:19 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW4-: Test Location: Anesthesia West OR cardiac Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**] MEASUREMENTS: Left Atrium - Long Axis Dimension: *5.9 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *6.9 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 5.0 cm (nl <= 5.0 cm) Left Ventricle - Inferolateral Thickness: *1.5 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.0 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.0 cm Left Ventricle - Fractional Shortening: *0.25 (nl >= 0.29) Left Ventricle - Ejection Fraction: 55% (nl >=55%) Aorta - Valve Level: 2.4 cm (nl <= 3.6 cm) Aorta - Ascending: *3.6 cm (nl <= 3.4 cm) Aorta - Arch: 2.2 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: 2.4 cm (nl <= 2.5 cm) Aortic Valve - Peak Velocity: *4.0 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 66 mm Hg Aortic Valve - Mean Gradient: 49 mm Hg Aortic Valve - LVOT Peak Vel: 1.28 m/sec Aortic Valve - LVOT VTI: 36 Aortic Valve - LVOT Diam: 1.8 cm Aortic Valve - Valve Area: *0.8 cm2 (nl >= 3.0 cm2) Aortic Valve - Pressure Half Time: 352 ms Mitral Valve - Mean Gradient: 3 mm Hg Mitral Valve - Pressure Half Time: 90 ms Mitral Valve - MVA (P [**12-11**] T): 2.4 cm2 Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A Ratio: 0.89 INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Moderate symmetric LVH. Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Focal calcifications in aortic root. Mildly dilated ascending aorta. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: ?# aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS. Moderate (2+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Mild thickening of mitral valve chordae. No MS. The MR vena contracta is <0.3cm. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Resting bradycardic for the patient. Conclusions: PRE-BYPASS: 1.The left atrium is markedly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4.The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5.The number of aortic valve leaflets cannot be determined (possible bicuspid). The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7.There is no pericardial effusion. POST BYPASS: Pt was initially AV paced and then in Sinus rhythm. Pt is receiving an infusion of phenylephrine. 1. A bioprosthetic valve is seen in the Aortic position. All three leaflets move well and the valve appears well seated. Peak velocity across the aortic valve is 1.7 m/s, with a mean gradient of 10 mm of Hg. Flow is detected in the Left main coronary artery. 2. Aorta intact post decannulation. 3. Bi ventricular systolic function is preserved. 4.Trace mitral regurgitation is present. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2148-7-16**] 12:44. Brief Hospital Course: The patient was admitted on [**2148-7-16**] and underwent AVR with 23mm CE pericardial valve. Cross clamp time was 68 mins., and total bypass time was 97 mins. He tolerated the procedure well and was transferred to the CSRU on Neo and Propofol. He was extubated on the post op night and was transferred to the flor on POD#1. His chest tubes were d/c'd on POD#1 and pacing wires were d/c'd on POD#3. He continued to progress and was discharged to home on POD#4 in stable condition. Medications on Admission: None. Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). Disp:*120 Capsule, Sustained Release(s)* Refills:*2* 2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. 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* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Aortic valve repair Discharge Condition: Satisfactory Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no driving for 1 month no lifting > 10# for 10 weeks Followup Instructions: Followup in 4 weeks Completed by:[**2148-7-22**]

[ "424.1", "458.29", "346.90", "E849.7", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

9073, 9122

7489, 7976

345, 422

9186, 9201

1303, 1632

9397, 9448

932, 946

8032, 9050

1669, 1690

9143, 9165

8002, 8009

9225, 9374

2390, 7466

961, 1284

282, 307

1719, 2364

450, 749

771, 840

856, 916

65,326

160,955

23114

Discharge summary

report

Admission Date: [**2175-3-31**] Discharge Date: [**2175-4-5**] Date of Birth: [**2101-3-7**] Sex: M Service: MEDICINE Allergies: Penicillins / furosemide Attending:[**Attending Info 11308**] Chief Complaint: Cycle #1 ICE for relapsed DLBCL. Major Surgical or Invasive Procedure: PICC line placement and removal History of Present Illness: Mr. [**Known lastname **] is a 74yo man with CAD/CHF, DM, HTN, CKD, COPD, and relapsed DLBCL admitted for cycle #1 ICE salvage. He received rituximab [**2175-3-21**]. Previously he was treated with 6 cycles of R-CHOP finishing 1/[**2174**]. Several months later, he relapsed in the same site (temples) with nodules. He was then placed on clindamycin, but more nodules appeared. He then had a biopsy which confirmed relapse, so presents today to start salvage chemotherapy. He was recently taken off atenolol because of bradycardia. A recent stress test and echo was suggestive for inferior wall ischemia, yet his cardiologist has cleared him to proceed with chemo. . ROS: He denies fatigue, F/C/S, wght loss, N/V, headache, dizziness, visual changes, hearing changes, chest pain, dyspnea, cough, abdominal pain, back pain, diarrhea, constipation, hematochezia, melena, hematuria, other urinary symptoms, paresthesias, or rash. All other ROS were negative. Past Medical History: Relapsed DLBCL, s/p 6 cycles R-CHOP finishing 1/[**2174**]. DM. CAD. Cardiomyopathy/EtOH. HTN. CHF/EF 10-20%. COPD. Hypertension. Hyperlipidemia. Osteoarthritis. Cataracts. BPH. Social History: History of tobacco use and alcohol abuse - quit both > 10 years ago, no illicit drug use. Came to the U.S. from [**Male First Name (un) 1056**] 40 years ago. Worked as manual laborer. Lives with wife, has a large and supportive family. He has 5 children. Family History: He denies cancer of any type in family. Mother had heart problems. Father had asthma. Physical Exam: Admission Physical Examination: VS: T 98.3F, BP 155/82, HR 62, RR 18, O2 sat 97% RA, Ins/Outs, wght 184.7 lbs, ht 62in. GEN: A&O, NAD. HEENT: Sclerae non-icteric, EOM intact, o/p clear, MMM. Neck: Supple, no thyromegaly, no JVD. Lymph nodes: No cervical, supraclavicular, axillary, or inguinal LAD. CV: S1S2, RRR, no MRG. RESP: Good air movement bilaterally, no rhonchi or wheezing. BACK: ABD: Soft, protuberant, non-tender, no HSM. EXTR: No edema or calf tenderness. DERM: No rash. Neuro: Strength 5/5, sensation normal to touch, non-focal. PSYCH: Appropriate and calm. Pertinent Results: ADMISSION LABS: [**2175-3-31**] 01:10PM BLOOD WBC-7.5 RBC-4.47* Hgb-13.5* Hct-41.4 MCV-93 MCH-30.3 MCHC-32.7 RDW-14.7 Plt Ct-207 [**2175-3-31**] 01:10PM BLOOD Neuts-61.0 Lymphs-27.3 Monos-6.9 Eos-4.0 Baso-0.7 [**2175-3-31**] 01:10PM BLOOD UreaN-27* Creat-1.8* Na-138 K-4.7 Cl-102 HCO3-25 AnGap-16 [**2175-3-31**] 01:10PM BLOOD Calcium-9.8 Phos-3.6 Mg-2.205/04/12 01:10PM BLOOD ALT-15 AST-23 LD(LDH)-204 AlkPhos-65 TotBili-0.4 . [**2175-3-9**] PET: IMPRESSION: New FDG avid left cervical adenopathy, concerning for lymphoma. Findings in the left ribs likely representing fibrous dysplasia. . [**2175-3-29**] ECHO: IMPRESSION: Poor functional exercise capacity. Echocardiographic images suggestive of INFERIOR WALL ISCHEMIA. Normal heart rate and blood pressure response to exercise. . [**2175-3-29**] STRESS TEST: IMPRESSION: No anginal type symptoms or ischemic EKG changes at a high cardiac demand and poor functional capacity. Intermittent junctional rhythm/ sick sinus syndrome during recovery. Resting systolic hypertension. Echo report sent separately. . Labs on Admission: [**2175-4-4**] 05:12AM BLOOD WBC-20.2*# RBC-3.92* Hgb-11.7* Hct-35.9* MCV-92 MCH-29.8 MCHC-32.6 RDW-14.6 Plt Ct-138* [**2175-4-4**] 05:12AM BLOOD Neuts-93.5* Lymphs-4.0* Monos-0.3* Eos-1.9 Baso-0.2 [**2175-4-3**] 05:11AM BLOOD PT-11.2 PTT-22.2* INR(PT)-1.0 [**2175-4-4**] 05:12AM BLOOD Gran Ct-[**Numeric Identifier **]* [**2175-4-4**] 05:12AM BLOOD Glucose-138* UreaN-21* Creat-1.4* Na-138 K-4.0 Cl-102 HCO3-28 AnGap-12 Brief Hospital Course: 74M with previously noted SSS and relapsed DLBCL undergoing active chemotherapy with ICE on the oncology service, who was incidentally noted to have asymptomatic sinus bradycardia to the 20s with occassional sinus pauses, as well as afib and SVT. . # Sick sinus syndrome: On [**2175-4-1**], the pt had asymptomatic sinus brady to 30s (pauses up to 2.2s). Then on [**2175-4-2**] (~7AM), he developed sinus brady to ~20 bpm, asymptomatic with sBPs >130s. Later in the morning (~11AM), after being given IV lasix, he developed SVT (appears to be AF with occasional sinus beats) with a ventricular rate in the 140s. This was controlled somewhat with 2.5mg IV metoprolol with HR in the 120s. At ~3PM, he developed SVT to 240s for 1-2 minutes; remained asymptomatic with high or normal sBPs throughout. Was given low-dose BB. Had already broken into SVT in 120s. Then he developed sinus rhythm in 30s-40s with frequent up to 3 sec pauses. During transport to the [**Hospital Ward Name 517**] CCU, the pt had several runs of VT up to 20beats. Was evaluated by EP. Patient did not have pacemaker placed in the setting of immunosuppression. In house, patient tolerated a beta blocker well and was discharged on metoprolol XL. He will follow up with cardiology as outpatient. . # Relapsed DLBCL: Planning for 2 cycles of ICE followed by autoBMT. Cardiology previously cleared pt to start chemotherapy despite echo and stress test findings. Started on neupogen. Started cycle #1 ICE: Ifosfamide 1500mg/m2 Days 1/2/3 (dose reduced 25% for CKD), mesna 500mg/m2 q3hr x4 doses Days 1/2/3, carboplatin AUC5 Day 1, and etoposide 75mg/m2 Days 1/2/3 (dose reduced 25% for CKD). Patient was monitored daily for tumor lysis syndrome. Continued acyclovir and bactrim for ppx. Was discharged on neupogen. Will f/u with heme/onc as outpatient. . # Leukocytosis: WBC on [**4-4**] was 20, thought [**12-29**] neupogen. No fevers or obvious sign of infection. . # CAD: Tolerated low dose metoprolol. Continued home lisinopril, aspirin, hctz. . #Allergic reaction: While on Onc floor, pt developed an acute allergic reaction with hives accompanied by afib with RVR and HTN, thought to be [**12-29**] po lasix. Was treated with benadryl, famotidine, steroids. . #Acute Diastolic Dysfunction: Appeared euvolemic at present. Re-started HCTZ. . CHRONIC ISSUES: . # CKD: Chemo dose-reduced accordingly. Trended Cr . # COPD: noted in previous notes; . # Hyperlipidemia: Continue outpatient atorvastatin. . # DM: Held glipizide and acarbose in house. Covered with insulin sliding scale. . # BPH: Continue outpatient doxazosin. . # Pain: None currently. Coverwith Acetaminophen, oxycodone PRN. . TRANSITIONS OF CARE: -will f/u with cardiology -will f/u with heme/onc -will continue neupogen for 2 weeks -started metoprolol XL 25mg PO qd -will go home with event monitor Medications on Admission: ACARBOSE 50 mg PO TID ATENOLOL 50 mg PO once a day ATORVASTATIN [LIPITOR] 20 mg PO once a day CLINDAMYCIN HCL 600mg PO q8HR DOXAZOSIN 4 mg PO once a day GLIPIZIDE 10 mg Extended Rel 24 hr PO once a day HYDROCHLOROTHIAZIDE 25 mg PO once a day LISINOPRIL 20 mg PO once a day OMEPRAZOLE 40 mg PO daily ONDANSETRON 8 mg Rapid Dissolve PO q8HR PRN nausea OXYCODONE-ACETAMINOPHEN [ROXICET] 5mg-500mg PO q6HR PRN postoperative pain ASPIRIN 325 mg PO once a day Discharge Medications: 1. filgrastim 480 mcg/1.6 mL Solution Sig: One (1) injection Injection Q24H (every 24 hours) for 2 weeks: please continue until your heme-oncologist instructs you to stop. Disp:*14 injection* Refills:*0* 2. doxazosin 4 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. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO at bedtime. 6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. acarbose 50 mg Tablet Sig: One (1) Tablet PO three times a day. 8. pioglitazone 45 mg Tablet Sig: One (1) Tablet PO once a day. 9. terazosin 5 mg Capsule Sig: One (1) Capsule PO at bedtime. 10. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 11. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 14. Lantus 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous at bedtime. Discharge Disposition: Home With Service Facility: Multicultural VNA Discharge Diagnosis: Sick Sinus Syndrome Diffuse large B cell lymphoma Diabetes Mellitus type 2 Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: I was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for chemotherapy and some slow and fast heart rates were note on the monitor. You were followed closely and metoprolol was started to slow your heart rate. You will have an event monitor on when you go home to follow your rhythm. Please follow instructions for use. You will need to give yourself neupogen injections daily for the next 2 weeks. . We made the following changes to your medicines: 1. START taking Neupogen injections daily to raise your white blood cell counts. 2. STOP taking ibuprofen, Atenolol, Clindamycin, and lipitor 3. DECREASE the aspirin to 81 mg daily 4. START taking Acyclovir and Bactrim for prevention of infection, take these medications until Dr. [**Last Name (STitle) 3759**] says you can stop 5. START Metoprolol (Toprol) 25mg daily for heart rate control Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2175-4-6**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/BMT When: THURSDAY [**2175-4-6**] at 9:00 AM With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: BMT CHAIRS & ROOMS When: THURSDAY [**2175-4-6**] at 9:30 AM . Name: [**Last Name (LF) 14919**],[**First Name3 (LF) **] E. Address: [**Apartment Address(1) 14920**], [**Location (un) **],[**Numeric Identifier 6809**] Phone: [**Telephone/Fax (1) 14918**] *You need to follow up with your primary care provider for hospitalization within 1 week of discharge. Please walk into your doctors to be [**Name5 (PTitle) 12314**] anytime between 8am-4pm Monday-Friday. Department: CARDIAC SERVICES When: THURSDAY [**2175-4-27**] at 3:20 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) 163**] MD [**MD Number(2) 11313**] Completed by:[**2175-4-7**]

[ "414.01", "427.1", "715.90", "288.60", "600.00", "995.27", "V58.11", "427.81", "428.0", "E944.4", "427.31", "250.00", "708.0", "202.80", "403.90", "272.4", "585.9", "E934.8", "428.32", "496" ]

icd9cm

[ [ [] ] ]

[ "38.97", "99.25" ]

icd9pcs

[ [ [] ] ]

8654, 8702

4055, 6376

315, 349

8849, 8849

2530, 2530

9889, 11428

1835, 1924

7405, 8631

8723, 8828

6927, 7382

9000, 9866

1939, 1949

1971, 2511

243, 277

377, 1342

2546, 3595

3610, 4032

8864, 8976

6747, 6901

6392, 6726

1364, 1543

1559, 1819

10,421

175,088

28373

Discharge summary

report

Admission Date: [**2151-2-28**] Discharge Date: [**2151-3-20**] Date of Birth: [**2078-10-7**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4111**] Chief Complaint: Enterocutaneous Fistulae Major Surgical or Invasive Procedure: Exploratory Lapartomy Lysis of Adhesions Takedown of enterocutaneous fistulae G-tube exchange small bowel resection with anastomosis History of Present Illness: 72M with h/o sigmoid colectomy in [**2147**] for diverticulitis. He underwent an exploratory laparotomy x 2 in [**5-/2150**] for SBO complicated by multiple enterotomies that were combined and converted to a proximal end-jejunostomy further complicated by an enterocutaneous fistula. Presents for enterocutaneous fistula repair and takedown of ostomy. Past Medical History: PMH: COPD Prostate Cancer Meningitis as child Diverticulitis PSH: Appendectomy [**2108**] Left Inguinal Hernia Repair [**2142**] Radical Prostatectomy [**2141**] Sigmoid Colectomy [**2147**] Ex-Lap, LOA, end ileostomy with GJ tube placement [**2-12**] SBO [**5-16**] Social History: Married with 3 children, ETOH 10 years ago, 25 ppy Tobacco 15 years ago. Retired federal government. Family History: Non-contributory Physical Exam: Admission Physical Exam [**2151-2-28**] 99.5 94 132/90 18 93%RA NAD NCAT, PERRL, EOMI, CNII-XII grossly intact neck supple, no cervical lymphadenopathy lungs clear heart RRR Abd soft, NT, ND, BS+, end ileostomy, GJ tube present Ext: 1+ ankle edema, no cyanosis or clubbing Pertinent Results: Admission Labs [**2151-2-28**] 06:00PM BLOOD WBC-9.3 RBC-3.03* Hgb-9.5* Hct-29.1* MCV-96 MCH-31.4 MCHC-32.6 RDW-14.2 Plt Ct-452* [**2151-2-28**] 06:00PM BLOOD PT-11.9 PTT-26.1 INR(PT)-1.0 [**2151-2-28**] 06:00PM BLOOD Glucose-82 UreaN-21* Creat-0.8 Na-141 K-3.0* Cl-102 HCO3-30 AnGap-12 [**2151-2-28**] 06:00PM BLOOD ALT-16 AST-17 AlkPhos-82 Amylase-65 TotBili-0.3 DirBili-0.1 IndBili-0.2 [**2151-2-28**] 06:00PM BLOOD Albumin-3.2* Calcium-8.9 Phos-2.5*# Mg-2.0 Iron-36* [**2151-2-28**] 06:00PM BLOOD calTIBC-302 Ferritn-91 TRF-232 [**2151-2-28**] 01:44PM BLOOD Type-ART Temp-38.1 pO2-74* pCO2-44 pH-7.44 calTCO2-31* Base XS-4 Intubat-NOT INTUBA Comment-ROOM AIR Discharge Labs OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Enterocutaneous fistula. POSTOPERATIVE DIAGNOSIS: Difficult abdomen enterocutaneous fistula. Multiple adhesions and multiple enterocutaneous fistulas. INDICATIONS FOR SURGERY: I heard from a hospital in [**State **] in which he had undergone surgery for intestinal obstruction. Apparently the procedure was extraordinarily difficult and after a number of hours there were multiple enterotomies which could not be dealt with. At least 3 loops of bowel, according to my findings today, were brought out through an incision and the incision was closed thus giving him loss of domain and incisional hernia. At that point the operation was terminated and he was later referred to me with a wide open central abdominal wound with multiple loops of bowel on the surface and an abdominal fistula. The nutritionalist assisted the patient including 3 days preparation in which he had a quick burst of around-the-clock enteral nutrition to increase his transferrin to 231 from the situation in which he previously had a transferrin down around 110. He had lost about 30 of 40 pounds. The following procedure was carried out. PROCEDURE IN DETAIL: Under satisfactory general anesthesia the patient was placed supine and prepped and draped in the usual manner. Before draping the incision, the old gastrostomy tube was removed and a new fresh sterile gastrostomy tube was calibrated at the appropriate level and sewn in with some FiberWire. We began the operation by extending the incision cephalad and inferiorly and it was a relatively small incision through which it would have been difficult to do the operation. As it turned out we used the entire length of the midline incision in the abdomen. We began the incision superiorly entering the abdomen above the liver without making any enterotomies and without making any holes in the liver. The bowel, as one would expect, was intimately associated with the abdomen. We isolated the small bowel loops after very strenuous dissection and very difficult with the bowels. The bowel really matted to each other. We were able to get him back to having one afferent limb and one efferent limb which we then placed [**Doctor Last Name **] Kochers and then resected the bowel. The mesentery, which was a single mesentery across these loops, had approximately 15 inches to 18 inches of bowel attached to it, but he had ample bowel remaining so that nutrition __________. with 4-0 and 2-0 silk, mostly 2-0, until we had gotten the loops of small bowel, 1 proximal and 1 distal, immediately adjacent to each other. There was a slight difference in caliber because the top part of the anastomosis had had some food passed through it in the past and the distal had not had any food for approximately about 10 months and so there was complete diversion. As a matter of fact in the colon, there was some stool balls in the right colon and they had probably been there for 10 months. We had tried to enematize them prior to the operation without success. After this we carried out a two-layer silk, 4-0 silk anastomosis in end-to-end and had ligated the mesentery and sutured the mesentery before we had put these 2 loops of bowel together. The blood supply was excellent and we were very happy with the anastomosis. The fistula which has a lot of skin attached had also been resected prior to doing this and this was satisfactory as well. It then became time to mobilize the abdominal wall widely to repair his incisional hernia which was brought about by the previous operation carried out elsewhere. This was done with immobilization of the entire area and was extensive enough to require #19 [**Doctor Last Name 406**] drains in the subcutaneous area. Gloves, gowns and drapes were then changed. The wound was closed in layers with #1 Prolene in running fashion on the fascia, 3-0 Vicryl as the subcutaneous closure. This was difficult in the area below the umbilicus but this was successfully carried out with interrupted vertical mattress of 3-0 nylon. The superior portion was closed with 4-0 Monocryl and 3-0 Vicryl. Estimated blood loss was 150 cc. The patient tolerated the procedure well. Two sponge counts, needle counts and instrument counts were reported as correct by the nurse in charge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 26005**] Dictated By:[**Last Name (NamePattern1) 63863**] Brief Hospital Course: [**Known firstname **] [**Known lastname **] was admitted to [**Hospital1 18**] on [**2151-2-28**] under the care of Dr. [**Last Name (STitle) 957**]. TPN was continued. Preoperative labs showed TRF 135; Albumin 3.3; Baseline pCO2 44. Preoperatively Hibiclens washes were provided and he was given a prep of Neomycin/Erythromycin. He was taken to the operating room on [**3-4**] where he underwent an exploratory laparotomy; lysis of adhesions; gastrostomy tube change; enterocutaneous fistula resection; primary anastomosis; w/ repair of incisional hernia. He tolerated the procedure well and was taken to the ICU postoperatively for closer monitoring. Pain was controlled via epidural and PCA. At POD 1 he was afebrile and with good urine output. Hct was 26. He was transferred to the floor. At POD 3 he received 1 unit PRBCs for a Hct of 24.0. The narcotic component of the epidural as discontinued. We continued to await bowel function. At POD 4 Reglan was started. He was afebrile and ambulating. At POD 6 he was febrile to 101.5. The epidural was removed. CXR showed LLL PNA. He was (+) flatus. He was tolerating clear liquids. The incision site, particularly around the G-tube, had a moderate amount of erythema/purulent drainage. Vancomycin/Cefepime/Flagyl were started for empiric coverage. Blood/Urine cultures were negative for growth. Incisional drainage was (+) for yeast; enterococcus; MRSA. Fluconazole was added. At POD 10 he continued to have an elevated WBC count at 17.2. Incisional cellulitis and drainage was resolving. Repeat CXR showed continued LLL PNA and right middle lobe opacities. At POD 11 he was tolerating a regular diet. WBC count was 16.6. Chest CT was completed which showed small bilateral effusions and severe emphysema. At POD 12 he was somnolent. ABG was obtained which showed pCO2 of 69; PH 7.35; PO2 80. Albuterol/Atrovent were provided with good response. Narcotics were discontinued. TPN was discontinued. At POD 14 he was afebrile and with good bowel function. WBC count was 11.8. Repeat ABG showed PCO2 at 50. Megace and zinc were started for poor appetite. Calorie counts showed 29g protein; 998 kcal. At POD 16, pt discharged to home with services. At this point, pt is tolerating a regular diet and PO intakes have significantly improved since he was first discontinued from TPN. He will continue to take IV Vancomycin and PO Cipro, Flagyl and Fluconazole at home for additional 1 wk. Medications on Admission: Diltiazem 120mg qd Atrovent 4 puffs QID Albuterol 2 puffs q3h prn Temazepam 30mg qhs prn Ativan 0.5mg [**Hospital1 **] prn Paroxetine 20mg qd Protonix 40 Oxycodone 10mg q12h Darvocet q4H prn Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Enterocutaneous Fistulae Emphysema Post-op pneumonia Post-op anemia Post-op wound infection Discharge Condition: Good Discharge Instructions: Please return or contact for: * Fever (>101 F) or chills * Abdominal Pain * Nausea or Vomiting * Increased Shortness of breath or chest pain * Redness or drainage from incision site * Increased swelling or redness of extremities * Inability to pass gas or stool * Any other concerns Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 957**] in 2 weeks. Please call for an appointment Completed by:[**2151-3-22**]

[ "V10.46", "997.3", "285.1", "492.8", "486", "V55.1", "998.59", "569.81", "682.2", "553.21", "261" ]

icd9cm

[ [ [] ] ]

[ "53.51", "46.74", "45.62", "99.04", "97.02", "99.15" ]

icd9pcs

[ [ [] ] ]

9466, 9518

6768, 9224

339, 473

9653, 9660

1614, 6745

9991, 10121

1282, 1300

9539, 9632

9250, 9443

9684, 9968

1315, 1595

275, 301

501, 856

878, 1147

1163, 1266

12,775

160,395

28080

Discharge summary

report

Admission Date: [**2121-12-20**] Discharge Date: [**2122-1-6**] Date of Birth: [**2057-6-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: Found down Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: 64 yo F hx DM II (on lantus and lispro) presented after being found unresponsive by landlord in [**Hospital3 **] facility. She was last seen 2 days PTA. She was found lying in prone position, covered in feces. Pt brought in by EMS who found the patient to be hypothermic and hypoglycemic to 10, given 2 amps of D50. Her Temp in ED was 29.9 degrees C, and she was started on a warming blanket as well as warming fluids. The patient was initiatilly in atrial fibrilattion with occasional PVCs, initially hypotensive to 70's/palp, although after initial bolus HR was 79 and BP 165/117. Pt was placed in c-collar, intubated for airway protection. Head and c-spine CTs were performed and negative. Pt was noted to become hypertensive to 220's and given nitro paste. Pt's last BS in ED was 318, placed on D5 1/2 NS. Past Medical History: DM II, insulin dependent on lantus 40 Units qAM and lispro sliding scale, HgbA1C 5.2 on [**2121-11-21**] (improved from 15 in the past) HTN Leg pain (EMG suggestive of demyelinating process), seen by neuro [**10-22**], who recommended LP. Comedone nodule below xiphoid process Social History: lives at [**Hospital3 **] facility, divorced, no children. quit smoking 20 yrs ago, quit EtOH 23 yrs ago, no IVDU. Family History: father died at 46 from complication of DM mother died at 86, hx HTN brother with ESRD [**3-20**] HTN, s/p renal tx, died from ICH Physical Exam: Vitals: Temp 96.1, HR 103, BP 114/100, O2 sat: 100% on AC Gen: elderly female, intubated, sedated, unresponsive, hair with feces remnants HEENT: R eye with surroundin ecchymosis, ET tube in place, loose teeth and poor dentition Resp: CTA b/l with good BS, no crackles or wheezes CV: RRR nl s1, s2, II/VI SEM at LUSB, + carotid bruit on R Abd: soft, NT, ND, no HSM, + BS Extr: areas of ecchymoses with some skin excoriation on anterior dependent portions, no edema, 2+ distal pulses Neuro: moves all extremities spontaneously, PERRL, eyes move laterally spontaneously in rhythmic fashion. Pertinent Results: [**2121-12-20**] 02:15PM PT-14.9* PTT-29.6 INR(PT)-1.3* [**2121-12-20**] 02:15PM PLT SMR-NORMAL PLT COUNT-253 [**2121-12-20**] 02:15PM WBC-25.4* RBC-4.15* HGB-12.7 HCT-36.9 MCV-89 MCH-30.7 MCHC-34.5 RDW-13.5 [**2121-12-20**] 02:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2121-12-20**] 02:15PM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-2.1 [**2121-12-20**] 02:15PM CK-MB-104* MB INDX-1.3 [**2121-12-20**] 02:15PM CK-MB-104* MB INDX-1.3 [**2121-12-20**] 02:15PM CK(CPK)-7910* AMYLASE-62 [**2121-12-20**] 02:15PM UREA N-21* CREAT-0.6 [**2121-12-20**] 02:26PM freeCa-1.04* [**2121-12-20**] 02:26PM HGB-12.2 calcHCT-37 O2 SAT-58 CARBOXYHB-2 MET HGB-0 [**2121-12-20**] 02:26PM GLUCOSE-119* LACTATE-3.6* NA+-147 K+-4.3 CL--108 TCO2-28 [**2121-12-20**] 02:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2121-12-20**] 05:50PM PROLACTIN-18 TSH-2.3 [**2121-12-20**] 05:50PM FREE T4-0.87* [**2121-12-20**] 05:50PM GLUCOSE-175* UREA N-19 CREAT-0.5 SODIUM-147* POTASSIUM-2.6* CHLORIDE-113* TOTAL CO2-20* ANION GAP-17 [**2121-12-20**] 05:57PM HGB-13.7 calcHCT-41 [**2121-12-20**] 08:33PM PTH-167* [**2121-12-20**] 08:50PM PT-15.3* PTT-28.7 INR(PT)-1.4* [**2121-12-20**] 08:50PM PLT SMR-NORMAL PLT COUNT-265 [**2121-12-27**] 03:04AM BLOOD WBC-12.8* RBC-2.83* Hgb-8.6* Hct-25.8* MCV-91 MCH-30.4 MCHC-33.3 RDW-13.3 Plt Ct-348 [**2121-12-24**] 01:52AM BLOOD Neuts-75.7* Lymphs-17.7* Monos-3.6 Eos-2.9 Baso-0.1 [**2121-12-27**] 03:04AM BLOOD PT-11.2 PTT-22.3 INR(PT)-0.9 [**2121-12-27**] 03:04AM BLOOD Glucose-90 UreaN-20 Creat-1.3* Na-141 K-4.3 Cl-109* HCO3-24 AnGap-12 [**2121-12-20**] 02:15PM BLOOD CK(CPK)-7910* Amylase-62 [**2121-12-20**] 08:50PM BLOOD ALT-34 AST-102* LD(LDH)-774* CK(CPK)-6902* AlkPhos-230* [**2121-12-21**] 05:10AM BLOOD ALT-29 AST-87* LD(LDH)-546* AlkPhos-176* TotBili-1.4 [**2121-12-22**] 05:05AM BLOOD CK(CPK)-2617* [**2121-12-23**] 03:48AM BLOOD CK(CPK)-1129* [**2121-12-27**] 03:04AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.2 [**2121-12-20**] 08:50PM BLOOD VitB12-464 Folate-GREATER TH [**2121-12-21**] 04:07PM BLOOD Ammonia-20 [**2121-12-25**] 05:43AM BLOOD Type-ART pO2-139* pCO2-36 pH-7.46* calTCO2-26 Base XS-2 [**2121-12-22**] 01:14PM BLOOD Glucose-84 Lactate-2.0 K-3.4* . CT head IMPRESSION: No evidence of acute intracranial hemorrhage. . Abd u/s: IMPRESSION: 1. Patent hepatic vasculature. 2. Cholelithiasis without evidence of acute cholecystitis. 3. Echogenic renal cortex. This may be seen in the setting of medical-renal disease. . MRI/MRA brain: IMPRESSION: 1. Unusual appearance, including relatively acute infarcts in the inferior right cerebellar hemisphere and left frontal cortex and subcortical white matter. Their dispersed location and apparent slight difference in age, as well as the relatively normal cranial MRA, raise the possibility of embolic events from a central (i.e., cardiac or aortic) source. 2. No evidence of hemorrhage. 3. Less marked and discrete decreased diffusion in the left posterior parietooccipital cortex, without correlate on the other sequences, which may represent transient diffusion abnormality related to the given history of status epilepticus (though such process often demonstrates enhancment). 4. No mass or pathologic focus of enhancement. 5. Extensive acute-on-chronic inflammatory change in the sphenoid sinus. 6. Unremarkable cranial MRA, with no flow-limiting stenosis. Brief Hospital Course: Patient was admitted to the MICU with altered mental status and hypoglycemia (in field), hypothermia after being found down. . Persistent coma- Patient initially presented with both hypothermia and hypoglycemia and was obtunded. The patient was found to have seizures on the second day of hospitalization on EEG and was treated with ativan and dilantin. The seizures resolved per exam, but the patient remained obtunded. Further eval by neurology revealed no obvious reversible causes of the patient's diminished mental status. LP and MRI were performed. LP showed no signs of infection and MRI showed small infarcts. Per neurology there were no obvious reversible causes and with the progression to decerebrate posturing the prognosis was poor. For this reason after extensive discussion with the HCP [**First Name5 (NamePattern1) **] [**Name (NI) 68299**]) the decision was made to extubate without reintubation. . Hypothermia - pt initially hypothermic to 30 degrees C. No clear environmental factors to explain such degree of hypothermia as pt was indoors. Decreased heat production from hypoglycemia or other endocrine abnormalities a possibility. No clear endocrine caouse was found. This was not a persistent issue in the MICU. Pt was started on empiric abx. . Hypoglycemia - pt with extremely low BS on presentation. She is normally on lantus and lispro SS. Causes for profound hypoglycemia were likely a combination of being found down as well as prolonged action of lantus. C-peptide was low supporting this theory. . VAP- Patient found to be febrile with high WBC as well as increase in pulmonary secretions, the patient was kept on vancomycin. The patient defervesced on abx and was kept on abx until the patient was placed on CMO. . Rhabdomyolysis - likely related to pt being being down for extended time. Renal function was normal and was aggressively rehydrated. CKs were trended and decreased. Patient's creatinine slightly increased, but remained stable. . Patient was extubated on [**12-30**] and did well. She was placed on comfort measures only. Pain was controlled with concentrated morphine elixir and respiratory distress was controlled with sublingual lorazepam. She expired on [**1-6**]. Medications on Admission: Lantus 40 Units qAM, lispro SS lisinopril 2.5mg PO daily ASA 325 mg daily Thiamine 100mg daily Folate 1 mg daily Neurontin 300mg TID Tramadol 100mg QID Discharge Disposition: Extended Care Discharge Diagnosis: hypoglycemia Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

[ "357.2", "E888.9", "V58.67", "434.11", "518.84", "427.31", "250.30", "728.88", "584.9", "921.0", "250.60", "345.3" ]

icd9cm

[ [ [] ] ]

[ "03.31", "38.91", "96.04", "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

8322, 8337

5893, 8119

325, 350

8394, 8404

2395, 5870

8461, 8593

1639, 1771

8358, 8373

8145, 8299

8428, 8438

1786, 2376

275, 287

378, 1190

1212, 1491

1507, 1623

28,730

143,621

31104

Discharge summary

report

Admission Date: [**2125-6-6**] Discharge Date: [**2125-6-16**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: transfer from OSH for GIB in setting of ERCP today Major Surgical or Invasive Procedure: None during this admission History of Present Illness: [**Age over 90 **]year old gentleman with a history of metastatic prostate cancer, HTN, a fib (not anticoagulated), CCY who presented to [**Hospital **] hospital [**5-30**] s/p being found on his floor by his girlfriend with jaundice and elevated LFTs. He had imaging that showed no liver masses, dilation of the bile duct s/p CCY, no large pancreatic mass. He was transfered on [**6-5**] to [**Hospital1 18**] for ERCP. . ERCP demonstrated an ampullary mass which was stented open with 2 metal stents. No sphincterotomy was performed. Biopsies were taken, but it was suspect for a second primary malignancy. After the ERCP the GI fellow was called for a small amount of dark brown/green stool, but it was felt that it was not likely guiaic positive and patient was transferred back to [**Location (un) **] about 6pm. . At [**Location (un) **] he had stools that were melanotic and tinged with red blood. He had transient hypotension to systolics in the 80s that responded to a 500cc NS bolus. His VS prior to transfer back to [**Hospital1 18**] were SBPs in the 120's and HR in the 80's. His Hcts were 40 on admission to [**Location (un) **] on [**5-30**] in am of [**6-5**] post-procedure on [**6-5**]. Past Medical History: Prostate cancer with mets to spine (seen again on CT at [**Location (un) **]) HTN afib (not anticoagulated) CCY-Laproscopic in [**2122**] bilateral hernia repair bilateral cataract surgery Social History: Widower twice over, now dating a 60yo. Lives at home and independent in ADLs, still drives. distant history of tobacco ~20pk-yrs, social EtOH but not for many years. Family History: One brother is 86 and healthy, the other passed at [**Age over 90 **]yo. Physical Exam: General: elderly man in NAD VS: F HR 85 BP 114/77 RR 29 o2Sat 99% Neuro: AAOx3, obeys commands, 5/5 strength throughout HEENT: PERRL, EOMI, icteric sclera, top dentures in, bottom out, OP clear Neck: supple, no LAD, RIJ in place Chest: CTAB, BS better heard on right than left side Cardiac: [**Last Name (un) **] [**Last Name (un) 3526**], no m/r/g ABD: +BS, NTND, no guarding or rebound, surgical scars from laporscopic CCY Ext: warm, 2+ pulses Skin: jaundice, right hip with 4cm in diameter pressure ulcer, with good granulation tissue, multiple other abrasions on right side (knees, shoulders) Pertinent Results: [**2125-6-6**] 09:16PM HCT-30.2* [**2125-6-6**] 01:54PM HCT-29.9* [**2125-6-6**] 11:00AM WBC-12.0* RBC-2.96* HGB-9.7* HCT-28.8* MCV-97 MCH-32.9* MCHC-33.9 RDW-15.8* [**2125-6-6**] 11:00AM PLT COUNT-263 [**2125-6-6**] 05:55AM GLUCOSE-123* UREA N-34* CREAT-0.6 SODIUM-138 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-25 ANION GAP-9 [**2125-6-6**] 05:55AM ALT(SGPT)-57* AST(SGOT)-58* LD(LDH)-159 CK(CPK)-48 ALK PHOS-467* TOT BILI-2.7* [**2125-6-6**] 05:55AM ALBUMIN-2.2* CALCIUM-7.4* PHOSPHATE-3.2 MAGNESIUM-2.4 [**2125-6-6**] 05:55AM WBC-10.7 RBC-2.88* HGB-9.6* HCT-29.0* MCV-101* MCH-33.3* MCHC-33.1 RDW-15.4 [**2125-6-6**] 05:55AM NEUTS-65 BANDS-1 LYMPHS-17* MONOS-13* EOS-1 BASOS-0 ATYPS-0 METAS-2* MYELOS-1* NUC RBCS-1* [**2125-6-6**] 05:55AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL STIPPLED-OCCASIONAL [**2125-6-6**] 05:55AM PLT SMR-NORMAL PLT COUNT-282 [**2125-6-6**] 02:08AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2125-6-6**] 02:08AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2125-6-6**] 12:44AM GLUCOSE-139* UREA N-34* CREAT-0.6 SODIUM-137 POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-25 ANION GAP-9 [**2125-6-6**] 12:44AM estGFR-Using this [**2125-6-6**] 12:44AM ALT(SGPT)-61* AST(SGOT)-63* LD(LDH)-163 CK(CPK)-51 ALK PHOS-463* TOT BILI-2.9* [**2125-6-6**] 12:44AM ALBUMIN-2.2* PHOSPHATE-1.7* MAGNESIUM-2.4 [**2125-6-6**] 12:44AM WBC-12.5* RBC-2.70* HGB-9.1* HCT-27.8* MCV-103* MCH-33.6* MCHC-32.6 RDW-14.9 [**2125-6-6**] 12:44AM PLT COUNT-272 [**2125-6-6**] 12:44AM PT-13.3* PTT-33.4 INR(PT)-1.2* Brief Hospital Course: Hospital course # GI Bleed: Patient presented with significant GIB in setting of ERCP with intervention, likely bleeding from site of intervention vs oozing from the ampullary mass, which has become apparent once the patient was rehydrated. Pt was transfused 2U PRBCs, started on [**Hospital1 **] IV PPI, with close follow up by ERCP team. Patient was no longer having melenic stools. Patient was started on IV fluids for rehydration after patient had bouts of diarrhea secondary to C. diff, and his hematocrit slowly trended to 24. Stools remained guiac positive although were grossly normal light brown color suggesting the slow decrease in Hct was secondary to ongoing oozing from the mass with a component of hemodilution from IVF. Per prior discussions with ERCP team, no further endoscopies should be pursued at this time unless patient becomes hemodynamically unstable. Patient remained hemodynamically stable. He received 1u PRBC transfusion. He is being transferred to [**Hospital1 1501**] with plan to follow up CBC in 1 week. # Ampullary Mass/Obstruction/Jaundice: Patient is status post placement of 2 stents. Pathology biopsy revealed poorly differentiated carcinoma with some endocrine features on routine microscopy. Immunostains are being performed and will be reported in an addendum. CTA abdomen revealed abdominal lymphadenopathy centered around the porta hepatis concerning for metastatic spreads from patient's known ampullary cancer. Patient has a follow up appointment scheduled with heme onc [**6-18**] to address prognosis and treatment strategies. # Bacteremia: Clostridium perfringens bacteremia at [**Location (un) **] with concern over complications such as ascending cholangitis characterized by Charcot's triad (fever, jaundice, and abdominal pain) or [**Last Name (un) **] pentad (confusion and hypotension). Patient received a 10 day course of Unasyn with surveillance blood cultures all negative. LFT's trended down appropriately. # Leukocytosis: Patient continued having leukocytosis despite covering for C. Perfringens, initially believed to be caused by pneumonia. However, patient's WBC continued increasing, with no bandemia. C. diff came back positive and patient was started on Flagyl. Patient remained afebrile and hemodynamically stable throughout. # AAA: An infrarenal AAA measuring up to 3.3cm with associated periaortic triangular density suspicious for contained aortic wall rupture was incidentally discovered on CTA abdomen. Vascular surgery was consulted, and felt that medical management was most appropriate at this patient given the patient's comorbidities. # Back pain: Patient has had chronic back pain, with no neurological deficits. MRI was done to r/o cord compression vs epidural abscess and was normal. Patient's pain was well controlled with Ultram 50mg po TID. # HTN: Outpatient Toprol was initially held in the setting of GIB, but patient's BP gradually increased and he was restarted on Metoprolol 35 mg po BID. Patient tolerated it well. # Atherosclerosis: Ectasia and tortuosity of the abdominal aorta with atherosclerosis and possible ulcerated plaque were also noted on CTA abdomen. Patient's lipids were WNL. Patient was started on Statin. # Respiratory distress: Patient was triggered for decreased respiratory rate and low oxygen saturations. Repeated sputum cultures were sent but the sample was contaminated. Patient was having some cough and was started on Levofloxacin with coverage later expanded to Vancomycin. CTA was done to rule out pneumonia versus PE given poor oxygen saturation despite antibiotics and revealed no abnormalities. Levofloxacin and vancomycin were discontinued after 5 day course. Blood cultures were negative. Patient had low grade fevers to 100.4 and leukocytosis. C. diff cultures were positive and patient was started on Flagyl. # Afib: patient not anticoagulated, rate controlled with Toprol XL at home. Patient did not have episodes of RVR during this hospitalization. # INR: Was slightly elevated in setting of infection/malnutrition/liver congestion. Patient received 3-day course of Vitamin K starting on [**6-6**]. His INR had normalized. # Prostate Cancer: s/p radiation treatment at DF-peripheral site, metastatic to bones, no active issues, stable. # FEN: IVF boluses as needed for hypotension, electrolyte repletion, NPO initially, now on low salt diet. # PPX: IV PPI, pneumoboots # Code: DNR/DNI confirmed with patient # communication: with patient and HCP [**Name (NI) **] [**Name (NI) 52**] (brother) at [**Telephone/Fax (1) 73429**] or [**Name (NI) **] [**Name (NI) 52**] (nephew) at [**Telephone/Fax (1) 73430**]. Medications on Admission: Toprol XL 50mg QD MVI Asa 81mg 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. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl Topical DAILY (Daily). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for back pain. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for back and leg pain: NTE > 4g in 24h. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for leg and back pain. 9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 14 days. 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: charwell house Discharge Diagnosis: 1. GI bleed 2. Ampullary mass 3. Abdominal Aortic Aneurysm 4. C. difficile colitis 5. hyperlipidemia 6. Hypertension 7. Atrial fibrilation 8. Coronary artery disease 9. Metastatic prostate cancer 10. C. perfringens bacteremia Discharge Condition: Stable Discharge Instructions: You have been treated at [**Hospital1 69**] for acute GI bleed. If you are experiencing chest pain, shortness of breath, loss of consiousness call 911. If you are experiencing bloody or black stools, fevers > 100.4, dizziness, inability to tolerate food, inability to walk, severe pain, or any other concerning symptoms, please call your primary care physician or go to the emergency department. Please continue taking your medications as prescribed. You will be transferred to a rehab center where you will continue working with physical and occupational therapists. Followup Instructions: Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2125-6-18**] 10:30 Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2125-6-18**] 10:30 Call your primary care physician to set up a follow up appointment [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

[ "998.11", "401.9", "790.7", "707.04", "440.0", "008.45", "198.5", "441.4", "576.1", "156.2", "V10.46", "E878.8", "427.31" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

10478, 10520

4396, 9050

311, 340

10790, 10799

2696, 4373

11420, 11912

1989, 2063

9132, 10455

10541, 10769

9076, 9109

10823, 11397

2078, 2677

221, 273

368, 1576

1598, 1790

1806, 1973

5,601

186,235

13204

Discharge summary

report

Admission Date: [**2161-8-31**] Discharge Date: [**2161-9-3**] Date of Birth: [**2131-12-23**] Sex: F Service: [**Hospital1 **] Medicine HISTORY OF PRESENT ILLNESS: The patient is a 29 year-old female with a history of chronic pancreatitis (status post cholecystectomy [**2161-4-13**]) who was transferred to the [**Hospital1 1444**] from [**Hospital 40262**] Hospital for fulminant hepatic failure. The patient was in her usual state of health on the day prior to admission to the outside hospital and it is unclear of the exact events that led to her hospital admission on [**2161-8-31**]. Per her friends, the patient's stepmother became concerned on the morning of [**2161-8-31**], because the patient was speaking with slurred speech and talking about "impossible matters" on the telephone. The patient's friend went to the patient's house at 9:30 a.m. and found her usually well kept friend in disarray and disoriented. Per the friend, the patient was experiencing both auditory and visual hallucinations. She was reportedly belligerent with grossly yellow skin, markedly dilated pupils and a very dry mouth. The patient reportedly had diffuse bilious emesis (more then five) with specks of blood. She had decreased appetite and two episodes of nonbloody diarrhea. Per the friend, the patient reported that she was unsure what medications she had taken. Another friend spoke with the patient the prior evening and reported that the patient told her she was in significant pain and was going to take some medication. According to the friend there were multiple pill bottles in the home. Both the patient and her friend report there is no history of suicidal ideation and intentional overdose is unlikely. The patient denies flushing, fever, constipation, seizure, tachycardia, or urinary retention. She denies toxic ingestions including antihistamines, tricyclic antidepressants, elicit drugs or herbal medications. She has never experienced hallucinations before. She does not have a history of depression and denies current symptoms of depression. She has never been diagnosed with a psychiatric disease or admitted to a psychiatric hospital. There is no family history of psychiatric disease. Of note, the patient's personal life has been increasingly stressful of late, secondary to an episode of domestic physical abuse on [**2161-8-24**]. The patient has left the relationship and reports that she is currently safe. She denies abdominal trauma. Upon presentation of these symptoms the patient was admitted to [**Hospital 40262**] Hospital on [**2161-8-31**] where she was found to have an ALT of 14,810 and AST of 13,400 (from [**4-11**] and [**3-4**] respectively). She was transferred to the [**Hospital1 346**] MICU for further workup. At the time of transfer the patient's mental status had returned to baseline. Upon further questioning the patient reports that she has had persistent epigastric abdominal pain since [**2161-3-13**] when she was diagnosed with pancreatitis secondary to pancreatic divisum. She reports an alcohol binge two nights prior to this admission. She was transferred to [**Hospital1 190**] where endoscopic retrograde cholangiopancreatography showed no pancreatic divisum and she returned to [**Hospital 40262**] Hospital for a total six week hospital stay. Upon discharge from that hospital admission she describes her abdominal pain as 3 out of 10, which has become progressively worse over the course of the last five months. She was readmitted to [**Hospital 40262**] Hospital in [**2161-7-13**] for pancreatitis, but left against medical advise due to child care issues. The patient explains that the abdominal pain progressed to 9 out of 10 by the week prior to admission. She describes the pain as a constant "stabbing," light contractions," stretching in a band like fashion across her epigastrium and radiating to her back. The pain is worse after eating. She denies nausea, vomiting, fevers or chills, diarrhea or change in bowel habits. She has not had any recent changes in her weight or energy level. The patient denies bruises or increased menstrual flow. She denies any recent changes in her medications. She reports that she has taken approximately four to six regular strength Tylenols per day of the last five months for her abdominal pain and Flexeril approximately three times a week. She also take an over the counter weight loss aid "Metabolife" (Ephedra). Her only other medication is Protonix 40 mg q.d. She has never received a blood transfusion. She was in a monogamous relationship times three years and does not use protection. She does not know her HIV status. There is no history of liver disease in her family. She has had no recent travels. Of note, the patient reported history has been inconsistent across interviewers. REVIEW OF SYSTEMS: The patient reports she has had a cough for approximately one week. She denies headache, changes in her vision, shortness of breath, chest pain, arthralgias, dysuria or hematuria. PAST MEDICAL HISTORY: G2 P2 status post tubal ligation, cholecystectomy, chronic pancreatitis. MEDICATIONS: Tylenol, Flexeril, Protonix, Metabolife. ALLERGIES: No known drug allergies. Food allergy to walnuts. SOCIAL HISTORY: The patient is a single mother of two daughters (ages 6 and 2). She lives in [**Hospital3 **]. Her mother lives in [**Name (NI) 108**], but frequently stays at a cottage in [**State 1727**]. She works as an assistant manager at [**Company 40263**] Video. Her children are being cared for by friends and family during this hospital admission. The patient is a victim of domestic violence. She has recently ([**2161-8-24**]) ended a long term relationship due to physical abuse. She is interested in seeking help. She has a very supportive relationships with her friends below, medical proxy [**Name (NI) **] [**Name (NI) 11461**] telephone [**Telephone/Fax (1) 40264**], cell phone [**Telephone/Fax (1) 40265**] and [**Doctor First Name 4489**] Soars. Tobacco use three quarters of a pack per day times eighteen years. Alcohol none. Intravenous drug use none. FAMILY HISTORY: No liver disease, questionable lupus, diabetes mellitus. PHYSICAL EXAMINATION: General, obese female with flat affect, lying in bed in no acute distress. Vital signs, maximum temperature 99.3, current temperature 99.3. Blood pressure 104/68. Pulse 66. Respiratory rate 18. Oxygen saturation 98% on room air. Finger stick blood glucose 148. HEENT atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Anicteric. Mucous membranes are moist. Oropharynx pink without lesions. Neck supple. No lymphadenopathy. No jugulovenous distention. No carotid or thyroid bruits. Cardiovascular regular rate and rhythm. S1 and S2. No extra heart sounds, rubs or murmurs. Carotid upstroke brisk. Radial pulse 2+ bilaterally. Dorsalis pedis pulses 1+ bilaterally. Chest bibasilar rales. Good air movement. Abdomen decreased bowel sounds. No caput medusa. No fluid waves. Tenderness to percussion in right upper quadrant. Tenderness to light palpation across upper quadrants and over epigastrium. Liver percussed to approximately 6 cm. [**Doctor Last Name 7282**] resonant to percussion. Negative colon's sign. Negative [**Doctor Last Name 27210**] sign. Extremities no clubbing. 1+ edema in lower extremities bilaterally. Skin, warm, dry, no bruising or petechia. No jaundice. No spider angiomata. Neurological alert and oriented times three. Cranial nerves II through XII are intact. No nystagmus. No asterixics. No focal neurological deficits. Deep tendon reflexes 2+ and symmetric throughout. Toes down going. Distal sensation intact. 5 out of 5 strength throughout. LABORATORY: CBC white blood cell count 8.4, hematocrit 43.7, platelets 201. Chem 10 sodium 137, potassium 3.2, chloride 102, bicarbonate 21, BUN 16, creatinine 1.0, glucose 69, calcium 8.6, magnesium 1.8, phosphate 1.5. ALT 9152, AST 5025, LDH 2310, alkaline phosphatase 210, total bilirubin 2.8, lipase 149, PT 20.9, PTT 31.5. Hepatitis B surface antigen and viral load negative. Hepatitis A antibody negative. Toxoplasma, CMV, EBV serologies negative. Antimitochondrial antibody negative. Anti smooth muscle antibody negative. Ceruloplasmin 20, serum copper 845. Triglycerides 83, cholesterol 100. Iron studies within normal limits. Hepatitis C virus PCR pending. STUDIES: Abdominal plain films, no obstruction. No free air. Right upper quadrant ultrasound, no evidence of focal liver anomalies or bile duct dilatation. Flow within portal vessels normal. HOSPITAL COURSE: 1. Gastrointestinal: A: Fulminant liver failure. The patient arrived in acute liver failure with transaminases of ALT 14,810 and AST 13,400. She received aggressive hydration, a fetal cystine q 4 times two days, potassium and phosphate repletion and bowel rest. Her transaminases began to trend down by hospital day one (9152, 5025 respectively) and throughout her hospital course to 2433 and 224 respectively on hospital day four. Coagulation studies improved after administration of vitamin K. She was able to tolerate full po by hospital day three and was discharged home with instructions to return for a follow up appointment with Dr. [**First Name (STitle) **] within two weeks of discharge to review the results of the tests pending at her discharge. The rapid elevation and resolution of the patient's transaminases suggested toxin induced or ischemic cause over autoimmune, genetic or viral causes of her fulminant hepatic failure. Toxicology screens have been negative and the patient denies tox ingestion of high quantities of Tylenol, Flexeril, Ephedra or any other medications or drugs. However, the patient arrived in the hospital a confused mental state and has given a variable history of medication usage. Toxicology screens for Tylenol and alcohol were negative at the outside hospital from which she was transferred, but more extensive toxicology screens were done outside of the time of useful sensitivity. The patient was advised to avoid use of Ephedra, Tylenol and Flexeril in the future in the event that these medications precipitated her liver dysfunction. Right upper quadrant ultrasound showed no evidence of thrombus in the main portal vein, left or right portal veins or inferior vena cava and normal blood flow. As suspected viral serologies and autoimmune studies were negative (HCV/PCR) pending. The patient's HIV status is unknown. B: Chronic pancreatitis. The patient has a history of chronic pancreatitis of unknown etiology. Her amylase remained within normal limits throughout this hospital admission, though her lipase values were chronically elevated (149 to 198). She reports no history of alcohol abuse and although she has been reported to have pancreatic divisum in the past, her most recent endoscopic retrograde cholangiopancreatography ([**2161-3-13**]) reports normal anatomy. She has undergone a cholecystectomy in the past with no resolution of her chronic abdominal pain or elevated pancreatic enzymes. She was placed on bowel rest during this hospital admission and given aggressive fluid rehydration. Her abdominal pain resolved from 9 out of 10 to 1 out of 10 by hospital day three and she was tolerating full po. She was discharged on hospital day four and advised to follow up with Dr. [**First Name (STitle) **] within two weeks after discharge for more extensive reevaluation of her chronic pancreatitis as an outpatient and possible repeat endoscopic retrograde cholangiopancreatography. C: Chronically dark stool, the patient was guaiac negative throughout this admission. Her hematocrit was stable. Her iron studies were within normal limits. An abdominal x-ray was normal. The patient was advised to follow up with her primary care physician if she notices any change in texture or color of her stool. 2. Renal: The patient was given aggressive fluid hydration on admission and for the first few days of her hospital course to protect her against the possible developments of hepatorenal syndrome. 3. Endocrine: In the setting of liver failure, patient's blood glucoses were followed closely to rule out disturbances with normal glucose metabolism. Her finger stick blood glucoses were found to be elevated on hospital days one and two. When the patient's D5 normal saline, finger stick blood glucoses were normal. 4. Psychological: The patient has a history of long term and recent domestic violence. She has no history of depression. She denies overdose. She has left the hospital against medical advise previously due to the lack of alternative child care options. Psychiatry consulted on the patient during this hospital admission and recommended that there was no psychiatric contraindication to discharging the patient. Social services helped to plan safe transfer of the patient to alternative housing from the hospital on the day of discharge and help the patient identify resources to help her cope with her current situation safely. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSIS: Fulminant hepatic failure, resolving. DISCHARGE MEDICATIONS/INSTRUCTIONS: Nexium 40 mg po q.d. The patient was advised to avoid the use of Tylenol, Ephedra and Flexeril. She is to follow up with Dr. [**First Name (STitle) **] within two weeks of discharge to discuss the results of tests that were pending at the time of her discharge and further evaluate her chronic pancreatitis as an outpatient. [**Name6 (MD) **] [**Name8 (MD) **], M.D. Dictated By:[**Doctor Last Name 40266**] MEDQUIST36 D: [**2161-9-8**] 12:05 T: [**2161-9-15**] 06:35 JOB#: [**Job Number 40267**]

[ "E980.5", "977.9", "570", "572.2", "577.1", "286.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6181, 6239

13221, 13844

8718, 13168

6262, 8700

4878, 5060

184, 4858

5083, 5277

5294, 6164

13193, 13200

15,455

152,443

13563

Discharge summary

report

Admission Date: [**2145-4-24**] Discharge Date: [**2145-5-4**] Date of Birth: [**2068-2-5**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: none History of Present Illness: 77 yo female transferred from OSH for further eval of respiratory failure. The patient was admitted to OSH on [**4-18**] with acute shortness of breath. She was found to have RLL PNA on CXR and intubated in the ED for hypercarbic respiratory failure. Her initial ABG on AC FiO2 1.0 was 7.19/80/405. She was treated empirically with ceftriazone, azithromycin for CAP and Solumedrol for COPD exacerbation. Initial ECG was notable for TWI throughout the precordium and CK and troponin peaked on HD 2 at 205, 1.21. An echo was notable for EF 65% with concentric LVH. The patient was (+) 4.5 L, F/U CXR were suggestive of b/l effusions and her BNP peaked at 3120 so she was diuresed with lasix 40 PO bid. Sputum cx notable for [**Female First Name (un) **] albicans so fluconazole was started on [**4-23**]. On AC, her hypoxia and hypercarbia improved but she was difficult to wean [**12-23**] to decreased mental status despite a negative head CT. She was transferred to [**Hospital1 18**] with "anoxic brain injury" and attempts to wean. . Past Medical History: 1. COPD, FEV1 28%, FEV1/FVC - 53% 2. Type 2 DM 3. HTN 4. Hyperlipidemia 5. PVD 6. Lung Cancer s/p LUL lobectomy 7. Breast Cancer s/p R mastectomy 8. gastritis 9. glaucoma 10. anemia 11. ?CAD but recent stress mibi negative in [**3-25**] Social History: unknown Family History: unknown Physical Exam: on transfer to floor temp 96.7, BP 134/71, 94, 24, 96% on 3L NC Gen: AO x 3, somwhat fearfull, sitting up in bed. finishing neb HEENT: PERRL, EOMI, MMM, OP clear Neck: no JVD appreciable due to large size, bandage of central line site CV: RRR, no g/m/r Chest: crackles at both bases but on left [**11-23**] of the way up, unchanged from this am, moderate air movement. Abd: obese, +BS, soft, NTND Ext: 1+ pitting edema of bilateral hands; no leg edema, 2+ DP Pertinent Results: [**2145-4-28**] 05:01AM BLOOD WBC-6.0 RBC-3.71* Hgb-9.8* Hct-30.2* MCV-82 MCH-26.3* MCHC-32.3 RDW-15.8* Plt Ct-171 [**2145-4-28**] 05:01AM BLOOD Neuts-77.1* Lymphs-18.7 Monos-3.6 Eos-0.5 Baso-0.1 [**2145-4-28**] 05:01AM BLOOD Plt Ct-171 [**2145-4-28**] 05:01AM BLOOD PT-13.2 PTT-24.6 INR(PT)-1.2 [**2145-4-28**] 05:01AM BLOOD Glucose-195* UreaN-21* Creat-0.7 Na-145 K-4.1 Cl-106 HCO3-31* AnGap-12 [**2145-4-28**] 05:01AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.1 [**2145-4-25**] 05:25AM BLOOD calTIBC-283 VitB12-372 Folate-20.0 Ferritn-98 TRF-218 . HIT antibody: negative . ** CXR: Findings suggest probable failure with bilateral effusions and post-surgical changes in the left hemithorax. Underlying pneumonia cannot be excluded at the left base. . ** ECHO: 1. The left atrium is mildly dilated. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. LV systolic function appears depressed. Overall left ventricular systolic function cannot be reliably assessed. Distal septal hypokinesis is present. 3. The aortic valve leaflets are mildly thickened. 4. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is moderate thickening of the mitral valve chordae. Mild (1+) mitral regurgitation is seen. . ** RUE U/S: No evidence for deep vein thrombosis in the right upper extremity veins. . ** PERSANTINE MIBI [**2145-4-30**] 1. No wall perfusion defects. 2. Ejection fraction 59% . ** VENOUS DUP EXT UNI (MAP/DVT) [**2145-4-30**] 1:42 PM No evidence of DVT, left lower extremity. Brief Hospital Course: . . [**Hospital 40963**] HOSPITAL COURSE . On arrival to [**Hospital1 18**], the pt was sedated on propofol. She was weaned off the propofol and began to wake up. She completed her course of antibiotics for a ? of LLL pneumonia. There was a question of whether an acute MI caused the patient's respiratory failure on the day of her presentation to the outside hospital. Her cardiac enzymes were followed and they trended down. A heparin drip was not started as it was thought that the pt was outside the appropriate window. The patient improved dramatically on antibiotics and a steroid taper and she was extubated ten days after she was intubated. The patient's BP was difficult to control once the propofol was weaned off and she was restarted on all of her home medications and titrated up to keep SBP < 140. On HD #11, she was doing well on nasal cannula and transferred to the floor. . At midnight on HD #12, patient was noted to go into acute respiratory distress. She had very poor air movement and was hypoxic to 83%. She was not thought to be wet at that time. She was started on continuous nebs, 100% face mask, given Lasix 40 IV with good output (although she had been 1L neg for the day), and given a dose of morphine. She initially was asking for re-intubation but was able to settle out and her O2 sats returned to the 90s. CXR obtained and looked unchanged. EKG with persistent Q waves in lateral leads and continued poor R wave progression. No new changes. ABG was 7.23/81/142. . Cardiology was consulted and looked at prior EKGs. Of note patient had a recent normal P MIBI, but this may be a false negative if patient has L Main disease. Cardiology recommended cycling enzymes and placing on nitro gtt. . The patient was then transferred back to the floor with a plan to have a pMIBI for rule out ischemia. MIBI was performed the following day, and was found to be negative for perfusion defects. . . . BRIEF SUMMARY OF ISSUES ADDRESSED DURING THIS ADMISSION . 1. RESPIRATORY FAILURE - Patient was treated for LLL PNA and COPD exacerbation at OSH. She completed 10 day course of ceftriaxone on [**4-28**] and received a course of azithro at the OSH. She was continued on nebs and NC Oxygen throughout her admission. Diuresis was continued with lasix 20 mg PO daily. . 2. NSTEMI/Troponin @ OSH - Troponin here has been < 0.10. The patient had slight EKG changes during acute hypoxia this hospitalization (pseudonormalization of T waves in V4-6), and positive troponin leak (but always < 0.1). EKG is now unchanged from previous and stress MIBI done was negative for ischemia. She was continued on a betablocker, aspirin, ACE, and statin. . 3. COPD - She was eventually changed to her outpatient regimen of Combivent, Fluticasone, and Salmeterol inhalers. She was also continued on a slow steroid taper at the time of discharge. . 4. ALTERED MS: The patient was transiently confused during this admission. Now this has completely resolved. The etiology was thought to be secondary to sedating medications and narcotics. These medications should be avoided in the future. . 5. DIABETES - She was continued on fixed dose of NPH with an insulin sliding scale. Her metformin was held. The NPH dose was titrated up to 36 units QAM, and 32 units QPM. This increased requirement is likely due to steroid treatment and should be titrated down when appropriate. . 8. ANEMIA - The patient was anemic on this admission. Iron studies, B12, and folate were all within normal limits. There were no active signs of bleeding. Her baseline hematocrit is unknown. She may need EGD/colonoscopy as an outpatient for work up of anemia. . 9. RIGHT UPPER EXT EDEMA: A RUE ultrasound was done which did not show evidence of DVT. Likely due to infiltrated IV. Now completely resolved. . 10. CONCERN FOR HIT: The patient had a slight drop in her platelets on this admission. Since HIT was suspected, heparin was discontinued and a HIT antibody was sent. This HIT ab came back negative. . Medications on Admission: -Metformin 500 [**Hospital1 **], Zocor, Dilt 240, atenolol 50, lasix 40 daily, serevent, flovent, combivent, zoloft, pilocarpine eye gtt, fluormethalone eye gtt, Novolin 26 Units qAM/22 Units qPM (transfer) -insulin gtt 2u/h, asa, atenolol 50 [**Hospital1 **], lasix 40 [**Hospital1 **], zocor 20, diflucan 150 ([**4-23**]), ceftriaxone ([**4-18**]), azithro ([**4-18**]), metformin 500 [**Hospital1 **], combivent, Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Pilocarpine HCl 0.5 % Drops Sig: One (1) Drop Ophthalmic Q6H (every 6 hours). 5. Fluorometholone 0.1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 9. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 12. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-22**] Puffs Inhalation Q6H (every 6 hours). 13. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 14. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 15. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 16. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 36 units Subcutaneous QAM. 20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty Two (32) units Subcutaneous QHS. 21. Prednisone 10 mg Tablet Sig: As directed Tablet PO DAILY (Daily) for 4 weeks: 30 mg PO QD x 1 week; then 20 mg PO QD x 1 week; then 10 mg PO QD x 1 week; then 5 mg PO QD x 1 week. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: 1) Pneumonia 2) Respiratory Failure 3) COPD 4) HTN Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the ER if you experience fever, chills, chest pain, or difficulty breathing. Please take your medications as prescribed and follow up as scheduled below. Followup Instructions: Please follow up with your PCP (Dr. [**Last Name (STitle) **]) on [**5-20**] at 8:40 AM.

[ "162.9", "535.50", "486", "287.5", "491.21", "285.9", "E937.9", "293.0", "112.4", "999.9", "250.00", "707.05", "428.30", "518.81", "410.71", "V58.65" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10207, 10279

3810, 7824

333, 340

10374, 10382

2213, 3787

10622, 10714

1708, 1717

8291, 10184

10300, 10353

7850, 8268

10406, 10599

1732, 2194

274, 295

368, 1407

1429, 1667

1683, 1692

1,552

170,777

48649

Discharge summary

report

Admission Date: [**2195-1-30**] Discharge Date: [**2195-2-3**] Date of Birth: [**2144-11-2**] Sex: F Service: MEDICINE/[**Location (un) 259**] HISTORY OF PRESENT ILLNESS: The patient is a 52 year-old female with a history of depression and suicidal ideation who presents status post TCA and Trazodone overdose. The patient presented to the Emergency Department per ambulance. The patient was obtunded upon arrival, therefore a history was obtained through the patient's daughter and sister. [**Name (NI) **] their report the patient had increased depression over the past several weeks due to difficulties with boyfriend and had been increasing her dose of Elavil and Trazodone over the past week. On the day of admission the patient was noted to be increasingly lethargic. The EMTs were called by the sister as the patient became more somnolent. The patient did admit to doubling/tripling her daily dose of Elavil and Trazodone. The pills were counted by EMT in the Emergency Department and about 20 Trazodone and 7 Elavil were not accounted for. The patient's sister states that the patient had been wishing that she were "no longer around" but did not describe any plans for suicide. REVIEW OF SYSTEMS: Negative for recent illness, fevers or chills, nausea, vomiting, cough, chest pain, shortness of breath. In the Emergency Department the patient was noted to be apneic and therefore was intubated for airway protection, but became very agitated during nasogastric tube placement requiring 10 mg of Versed and Vecuronium. One dose of activated charcoal was given and the patient was started on alkalinized intravenous fluids. Electrocardiogram showed no QRS widening, but an old R wave of 5 mm in AVR was seen. PAST MEDICAL HISTORY: Hypertension, obesity, obstructive sleep apnea, peptic ulcer disease, status post upper gastrointestinal bleed, hypercholesterolemia, chronic back and hip pain, status post left arthroscopy, depression with prior psychiatric admission to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for suicidal ideation in [**2194-8-9**] and question of suicide attempt in [**2162**] by OD. History of past substance abuse, cocaine for which the patient denies use in the last year. Status post eye trauma with metal foreign body in eye. Status post cholecystectomy and ETT MIBI in [**2191**] with normal EF and no wall motion abnormalities. ALLERGIES: Penicillin causes rash. MEDICATIONS: Trazodone 50 mg po q.h.s., Elavil 150 mg po q.d., Celexa 20 mg po q.d., Zestril, Prilosec 20 mg po q.d. and Neurontin 300 mg po t.i.d. and Percocet. SOCIAL HISTORY: The patient drinks up to one pint of hard alcohol at a time and smokes a half a pack per day. No intravenous drug abuse or other drug. She lives with her sister in [**Location (un) 686**]. She patient is unemployed. PHYSICAL EXAMINATION: Temperature 97.4. Heart rate 105. Blood pressure 162/95. Respiratory rate 14. Oxygen sat 100%. Weight 131 kilograms. General, intubated and sedated. HEENT normocephalic, atraumatic. Pupils are equal, round and reactive to light and accommodation going from 3 mm to 2 mm bilaterally and symmetric. Anicteric sclera. Neck supple. No lymphadenopathy. Cardiovascular distant heart sounds. Normal S1 and S2. No murmurs, rubs or gallops. Lungs rhoncerous bilaterally. Abdomen soft, nontender, nondistended. Obese. Normal bowel sounds. Extremities no clubbing, cyanosis or edema. Skin no rashes. LABORATORY: White blood cell count 12.4, hematocrit 35.2, platelets 246. Diff 72% neutrophils, 23% lymphocytes and 2 monocytes. Coags normal. Chemistry 142 sodium, 4.0 K, 104 chloride, 26 bicarb, 11 BUN, 1.1 creatinine and glucose 94. AST 20, ALT 23, alkaline phosphatase 186 with chronic elevation times years. T bili .2. Amylase 42, lipase 14, serum osms 294, measured osms 281. Calcium 8.1, magnesium 1.7, albumin 3.8. Arterial blood gas on IMV 700 times 12, 100% FIO2 with 7.33/52/443. Serum tox positive TCA. Urine tox positive benzos. Urinalysis specific gravity 1.020, pH 5.0, nitrate negative, red blood cell and white blood cell negative. Chest x-ray question of upper zone redistribution with good placement of endotracheal tube. No infiltrates. Electrocardiogram normal sinus rhythm, left axis deviation, terminal R wave around 5 mm in AVR (this is also on prior electrocardiogram from [**Month (only) 404**]). QT corrected .43 seconds, QRS .96 seconds. No ST or T wave changes and overall no change from [**2194-12-9**] studies. IMPRESSION: The patient is a 52 year-old female with a history of depression and prior suicidal ideation status post tricyclic antidepressant and Trazodone overdose who was transferred to the MICU secondary to intubation and for cardiac monitoring. HOSPITAL COURSE: The patient in the MICU did well without any evidence of arrhythmia on telemetry or electrocardiogram changes. The patient was maintained on intravenous fluids with bicarbonate in order to maintain alkalinization. The patient was successfully extubated on the [**12-31**]. She was seen by psychiatry who felt that the patient was likely a still a suicide risk, therefore she was placed on a one to one sitter. Additionally, the patient had a white blood cell count, which rose to 18 status post intubation and a chest x-ray which showed diffuse patchy opacities. In the MICU she was started on Clindamycin, but this was discontinued after one day since most likely this was secondary to a pneumonitis rather then pneumonia. The patient remained afebrile during her hospital stay. White blood cell decreased to 12.7 on the day of discharge. Oxygen saturation is excellent at 97% on room air. It is believed that this is most likely secondary to pneumonitis. If symptoms were to develop and the patient were to become febrile or symptoms were to exacerbate the patient would be started on po Levo and Flagyl. The patient was seen by psychiatry who felt that she required inpatient psychiatric hospitalization. She will be sent to a psychiatric [**Hospital1 **], since she is now medically cleared for transfer. Electrocardiogram without any significant changes from [**2194-12-28**] with a QRS interval less then .[**Street Address(2) 102327**] or T wave changes and normal sinus rhythm. The patient had been on telemetry monitoring times several days without any evidence of arrhythmia. The white blood cell count was decreased significantly from 18 to 15.4, 13.2 and 12.7 with only one day of antibiotics. Likely the increase in the white blood cell count was secondary to stress response and it is believed that the patient's opacities on chest x-ray are secondary to pneumonitis. The patient has been afebrile since admission. The patient is alert and oriented times three with an intact neurological examination. The patient's vital signs are within normal limits. DISCHARGE DIAGNOSIS: 1. TCA and Trazodone overdose. 2. Depression with question of suicide attempt. 3. Hypertension. 4. Obesity. 5. Peptic ulcer disease status post upper gastrointestinal bleed. 6. Obstructive sleep apnea. 7. Hypercholesterolemia. 8. Chronic back and hip pain status post left arthroscopy. 9. History of prior substance abuse (cocaine). 10. Status post cholecystectomy. 11. ETT MIBI from [**2191**], normal EF and no wall motion abnormalities. DISCHARGE MEDICATIONS: Zestril 40 mg po q.d., Protonix 40 mg po q.d., Lipitor 10 mg po q.d., Albuterol MDI two puffs q.i.d. prn, Colace 100 mg po b.i.d., Tylenol 650 mg po q 4 to 6 hours prn, Motrin 400 mg po q 6 hours prn and Neurontin 300 mg po t.i.d. The patient will be followed up by Dr. [**Last Name (STitle) **] at [**Hospital1 **]. She should follow up in the next two weeks. At that time an outpatient sleep apnea workup should be considered along with further workup of her chronically elevated alkaline phosphatase and a repeat chest x-ray should be done at about four to six weeks following discharge. The patient's hypertension should also be reassessed and a beta blocker may be considered at that time. Diet, low salt. DISCHARGE CONDITION: Stable. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6756**], M.D. [**MD Number(1) 6757**] Dictated By:[**Name8 (MD) 15885**] MEDQUIST36 D: [**2195-2-3**] 10:54 T: [**2195-2-3**] 11:01 JOB#: [**Job Number **]

[ "786.03", "E950.3", "780.09", "507.0", "311", "278.00", "969.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

8142, 8412

7403, 8120

6927, 7379

4819, 6906

2887, 4801

1238, 1751

193, 1218

1774, 2627

2644, 2864