ChanBeDu/relevant_section_length · Datasets at Hugging Face

26,523

138,682

6057+55726

Discharge summary

report+addendum

Admission Date: [**2190-3-10**] Discharge Date: [**2190-3-25**] Date of Birth: [**2130-7-8**] Sex: F Service: [**Company 191**] HISTORY OF PRESENT ILLNESS: The patient is a 59 year old Caucasian woman with a past medical history significant for diabetes, chronic arachnoiditis, metastatic thyroid cancer who presents with right lower extremity cellulitis times two days. The patient has had an ulceration on the right lateral ankle and has noticed that it has been worsening in appearance over the last few days with increasing erythema. The patient also complained of nausea. She stated that her temperature at home was 102. She denies any vomiting, constipation or diarrhea. She denies any headaches, chest pain, shortness of breath or abdominal pain. The patient also complains of pain at the dorsum of her right foot and anterior aspect of her lower leg. She denies any trauma. She denies any change in activities. The patient has been on Augmentin 375 mg b.i.d. for one day prior to admission. PAST MEDICAL HISTORY: 1. Metastatic thyroid cancer, status post resection and radiation. 2. Diabetes, Type 2. 3. Hypertension. 4. Chronic arachnoiditis. 5. Chronic back pain. 6. Lower extremity and upper extremity muscle spasms. 7. Anemia. 8. Obstructive sleep apnea. 9. Anxiety. 10. History of colon adenoma. MEDICATIONS ON ADMISSION: 1. Synthroid .175 mg q. day. 2. Catapres .1 mg b.i.d. 3. Catapres patch TTS 3 patch q. week. 4. Glucophage 500 mg b.i.d. 5. Baclofen 20 mg t.i.d. 6. K-Dur 20 mEq q. PM. 7. Quinine 325 mg b.i.d. prn. 8. Coumadin 5 mg alternating with 6 mg each day. 9. Protonix 40 mg q. day. 10. Celexa 40 mg q. day. 11. Vioxx 50 mg q. PM. 12. Amitriptyline 20 mg q.h.s. 13. Zanaflex 1 mg t.i.d. and 2 mg q.h.s. 14. Lisinopril 40 mg b.i.d. 15. Klonopin .5 mg q.h.s. 16. Colace 100 mg t.i.d. 17. Zofran prn. 18. Nubain 10 to 30 mg q. 3-4 hours prn for pain. 19. Humulin sliding scale. 20. Trazodone 150 mg q.h.s. 21. MiraLax 2 capsules prn. ALLERGIES: 1. Compazine causes rash. 2. Methylprednisolone causing gastrointestinal bleed. 3. Pepcid causing mental status changes. 4. Intravenous Nitroglycerin causes mental status changes. PHYSICAL EXAMINATION ON ADMISSION: Vital signs reveal a temperature 99.1, pulse 105, blood pressure 233/97, respiratory rate 20, oxygen saturation 90% on room air. In general the patient was alert and oriented times three in mild discomfort. Head, eyes, ears, nose and throat examination shows pupils equally round and reactive to light. Extraocular muscles intact with moist mucous membranes. There is no lymphadenopathy and no neck tenderness. The lungs are clear to auscultation bilaterally. Cardiovascular, tachycardiac, no murmurs, rubs or gallops. Abdomen, soft, nontender, nondistended with good bowel sounds. There is no organomegaly, no rebound or guarding. Neurological examination shows cranial nerves II through XII intact. The patient has no sensation to light touch below the thighs on both lower extremities, and below the elbows in both upper extremities. She has 4 out of 5 muscle strength in the lower extremities, 4+/5 muscle strength in the upper extremities. Extremity examination, dorsalis pedis and posterior tibial pulses were not palpable bilaterally. On the left heel there is a superficial ulceration on the medial aspect. On the right lower extremity there is a superficial closed ulceration of the second toe. The lateral malleolus had a superficial ulceration with fibrotic center and mild serous drainage. There is no pus or purulence. There is no exposed base. There is no tracking of the wound. There is warmth of the lower extremities. There is a descending cellulitis on the right side to the mid anterior shaft, no calf vein, mild tenderness directly adjacent to the ulceration of the lateral malleolus. LABORATORY DATA: On admission white count was 13.1, hematocrit 35.5, platelets 236. Coagulation screen shows PT of 19.5, INR 2.5. Chem-7 within normal limits except for glucose of 263. The patient's creatinine is 1.0 which is her baseline. Lactate is normal. Magnesium is 1.5, calcium and phosphorus are normal. HOSPITAL COURSE: (By issue) 1. Right lower extremity cellulitis and ulcerations - The patient was admitted to the Podiatry Service on [**3-10**] for the cellulitis of the right lower extremity. On admission she was started on Vancomycin, Levaquin and Flagyl for broad coverage. Blood cultures and wound cultures were taken. Both grew out Escherichia coli. In order to more specifically cover, the patient's antibiotics were changed to Oxacillin and Ceftriaxone. The patient has also had hardware in her right ankle and because of the possibility that this was seated, the patient required surgery. Her Coumadin was discontinued and once her INR had decreased close to baseline, she was taken to the Operating Room for hardware removal. This was done on [**3-18**]. Postoperatively the patient is stable on Oxacillin and Ceftriaxone until two days after the operation. Then due to concern for pneumonia her antibiotic coverage was changed to Zosyn and Vancomycin. She continued this for three days and then was only on Zosyn. Her right lower extremity was in a vacuum-assisted closure dressing and continued to improve, healing by secondary intention. She has been followed by Podiatry. Her left lower extremity ulcer also continued to improve. X-rays showed an old fracture without any changes in the left foot. The patient did not have any further signs of worsening cellulitis or infection of her extremities. 2. Respiratory - On [**3-20**], the patient developed hypoxia with an oxygen saturation of 80% on room air and hypertension with systolic blood pressure in the 190s. She was also complaining of a new productive cough. Chest x-ray done on that day was consistent with congestive heart failure and the patient was given Lasix. There is also question of a right lower lobe infiltrate on the chest x-ray, so Azithromycin was initially added to her regimen of Ceftriaxone and Oxacillin. On the same day, the patient also developed mental status changes which was possibly thought to be related to her hypoxia. At this point, due to concern for pneumonia and respiratory compromise, the patient's antibiotic coverage was changed to Vancomycin and Zosyn and she was transferred to the Intensive Care Unit for closer monitoring. She was never intubated. She was continued on Zosyn and Vancomycin and a sputum culture was obtained. The sputum culture showed [**Female First Name (un) 564**] and did not grow out any bacteria. The patient's respiratory status improved with decrease in oxygen requirements. Once the sputum culture was negative for any bacteria and there was no evidence of Methicillin-resistant Staphylococcus aureus her Vancomycin was discontinued. She was continued on Zosyn for treatment of possible aspiration pneumonia and for her cellulitis. 3. Congestive heart failure - The patient required Lasix intermittently for mild hypoxia and crackles on lung examination indicative of congestive heart failure. She was also on Zestril 20 mg b.i.d. initially and then titrated up for afterload reduction. Her blood pressure was labile but was controlled with Catapres, Lopressor, and Zestril. 4. Anticoagulation - The patient's Coumadin was discontinued as was previously mentioned in order to be taken to the Operating Room. While off Coumadin the patient was on a heparin drip for her history of deep vein thrombosis and pulmonary embolism. Once it was decided that no further procedures would be done by Podiatry she was restarted on Coumadin. Her heparin drip was continued until her INR would be in the goal range of 2 to 3. 5. Chronic back pain - The patient had chronic back for which she had been on Nubain at home. While in the hospital she was started on a morphine PCA. Initially there was no basal rate, however, the patient was not using the PCA and therefore basal rate was added. Plan was for the patient to have a morphine placed by Neurosurgery once her active acute issues are cleared. This will probably be done after discharge. She was also on Baclofen, Tizanidine and Vioxx for her pain. 6. Hypothyroidism - The patient was continued on Levoxyl. 7. Psyche - The patient was on Celexa and Klonopin. 8. Dysphagia - The patient had a swallowing study previously done in [**Month (only) 1096**], in order to evaluate symptoms of dysphagia. This showed a possible offer for esophageal sphincter dysfunction, no further workup was done at the time. On this admission there is a question of aspiration pneumonia and the patient was re-evaluated by the swallowing service. Again there was no evidence of aspiration but evidence that there was upper esophageal dysfunction. The patient will require a gastroenterology follow up for workup and possible dilatation. For now, she will be on a soft diet with frequent liquids when eating. 9. Anemia - The patient has a history of chronic anemia requiring blood transfusions. While in the hospital she also had periods of time when her hematocrit was below 30. There were no signs of active bleeding. The iron studies showed a mixed picture with decreased iron and TIBC and elevated Ferritin. The patient's iron to TIBC ratio was low suggesting a possible combination of iron deficiency anemia, anemia of chronic disease and possibly anemia related to the patient's hypothyroidism. The patient was given blood transfusions as needed to maintain her hematocrit greater than 30, given her history of congestive heart failure. 10. Diabetes Type 2 - The patient was continued on a sliding scale of insulin. Her Metformin was held when she was not eating. It will be restarted when she is eating more stabilely. CODE STATUS: The patient is full code on admission and discharge. DISCHARGE CONDITION: The patient is in good condition. DISCHARGE STATUS: The patient is to be discharged to an acute rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Aspiration pneumonia. 2. Cellulitis. 3. Hypertension. 4. Congestive heart failure. 5. Obstructive sleep apnea. 6. Chronic anemia. 7. History of deep vein thrombosis and pulmonary embolism. 8. Diabetes Type 2. 9. Chronic back pain. 10. Arachnoiditis. 11. Anxiety disorder. 12. Dysphagia. DISCHARGE MEDICATIONS: Discharge medications will be listed in a discharge summary addendum as they are to be decided at this time. There will be an addendum to this discharge summary at a future date. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By:[**Name8 (MD) 5709**] MEDQUIST36 D: [**2190-3-25**] 09:42 T: [**2190-3-25**] 09:46 JOB#: [**Job Number 23786**] Name: [**Known lastname 4057**], [**Known firstname **] Unit No: [**Numeric Identifier 4058**] Admission Date: [**2190-3-10**] Discharge Date: [**2190-3-26**] Date of Birth: [**2130-7-8**] Sex: F Service: MED ADDENDUM: This is an Addendum for discharge on [**2190-3-26**]. DISCHARGE STATUS: The patient is to be discharged to an extended care facility. CONDITION ON DISCHARGE: Good; the patient was afebrile and tolerating by mouth intake. DISCHARGE DIAGNOSES: 1. Cellulitis. 2. Aspiration pneumonia. 3. Type 2 diabetes mellitus. 4. Arachnoiditis. 5. Chronic back pain. 6. Hypertension. 7. Congestive heart failure. 8. Metastatic thyroid cancer with hypothyroidism. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg by mouth three times per day. 2. Baclofen 20 mg by mouth three times per day. 3. Celexa 40 mg by mouth twice per day. 4. Protonix 40 mg by mouth twice per day. 5. Levoxyl 175 mcg by mouth twice per day. 6. Amitriptyline 25 mg by mouth at hour of sleep. 7. Klonopin 0.5 mg by mouth at hour of sleep. 8. Vioxx 25 mg by mouth once per day. 9. Tizanidine 1 three times per day and 4 mg at hour of sleep. 10. Clonidine patch every Monday. 11. Zosyn 4/0.5 grams q.8h. (for four days after discharge). 12. Coumadin 6 mg by mouth at hour of sleep (dose is to be adjusted to meet an INR goal of 2 to 3). 13. Albuterol nebulizers as needed. 14. Atrovent nebulizers as needed. 15. Lisinopril 30 mg by mouth twice per day. 16. Polyethylene glycol packet one packet q.8h. as needed (for constipation). 17. Dulcolax as needed. 18. Miconazole powder one application three times per day. 19. Lopressor 50 mg by mouth three times per day. 20. Lispro insulin per sliding scale. 21. Trazodone 150 mg by mouth at hour of sleep. 22. Tylenol as needed. 23. Zofran 4 mg q.4h. as needed. 24. Heparin infusion titrated to a partial thromboplastin time goal of 60 to 100. 25. Morphine sulfate patient-controlled analgesia with a 1-mg per hour basal rate and 1 mg every six minutes patient-controlled analgesia rate. DISCHARGE INSTRUCTIONS-FOLLOWUP: 1. The patient is to anticoagulated with a heparin drip until her Coumadin/INR is therapeutic. The INR goal is 2 to 3. 2. Antibiotics: The patient should continue Zosyn through [**3-29**]. 3. The patient should be maintained on a regular insulin sliding scale for diabetes. Once she is on a more stable diet she can be restarted on metformin. 4. Chronic pain management: The patient is to be continued on a morphine patient-controlled analgesia which can be adjusted as needed for optimal pain control. She is to receive a morphine pump by Neurosurgery at some point in the future. 5. Wound care: The patient is to have wet-to-dry dressing changes once per day for her left foot. 6. The patient was instructed to follow up with her primary care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 489**]). 7. The patient was also instructed to follow up with Gastroenterology for further workup of dysphagia. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 166**] Dictated By:[**Doctor Last Name 4059**] MEDQUIST36 D: [**2190-4-11**] 15:28:37 T: [**2190-4-13**] 09:22:17 Job#: [**Job Number 4060**]

[ "197.1", "707.0", "790.7", "507.0", "682.7", "428.0", "428.31", "707.15", "280.0" ]

icd9cm

[ [ [] ] ]

[ "93.56", "99.04", "38.93", "86.22", "78.67" ]

icd9pcs

[ [ [] ] ]

9915, 10039

11364, 11571

10384, 11254

10060, 10360

11597, 13658

1374, 2223

4197, 9893

13671, 14315

177, 1028

2238, 4179

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133,269

36633

Discharge summary

report

Admission Date: [**2182-11-25**] Discharge Date: [**2182-12-8**] Date of Birth: [**2112-11-24**] Sex: F Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 1115**] Chief Complaint: shortness of breath, admit for rigid bronchoscopy Major Surgical or Invasive Procedure: Intubation and mechanical ventilation Bronchoscopy x 2 Atrial line placement PICC line placement History of Present Illness: Mrs. [**Known firstname 2048**] [**Known lastname **] is a 70 yo female with fibrosing mediastinitis and resultant left main occlusion 15 mos s/p metallic L main stent palcement complicated by severe granulaltion tissue at both ends of the stent who presents for rigid bronchoscpoy for debridement on Wed [**11-27**]. Mrs. [**Known lastname **] reports increased SOB x 1 month, low grade fevers and chills in the afternoons, decreased appetite, mild weight loss. Not on home O2. Can walk up 10 steps; has more difficulty walking up stairs lately. Chronic cough productive of brown sputum in AM, yellow in PM, no hemoptysis. She underwent flexible bronchoscopy on the afternoon of admission, and airways were found to be narrowed throughout, L main stent in good position, moderate granulation tissue at proximal end with 80% obstruction and severe granulation at distal end of the stent with only a pinhole opening to the lower and upper segments of the left upper and lower lobes. Also noted were thick purulent secretions. (severe granulation tissue and almost complete occlusion of left upper and lower lobes.) . Review of systems: (+) Per HPI (-) Denies rhinorrhea or congestion, chest pain or tightness, palpitations, nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Past Medical History: - Fibrosing mediastinitis: symptoms of SOB since [**2172**]. s/p lung bx [**2173**], [**2173**] hospital. Positive [**Doctor First Name **] (1:160), RNP (1:[**2172**]), mildly positive RF, elevated ACE level(191), cytoxan [**2173**]-[**2176**]. s/p L main stent placement in [**2181**] - Hypothyroidism (self discontinued levothyroxine) Social History: No tob, no asbestos, No EtOH, no illicits Lives with husband in CT, two children also in CT. Retired, worked for insurance company Family History: Mother-sudden cardiac death at age 64 Sister-Cardiac disease and lupus, death at age 55 Physical Exam: Vitals: T: 98.1 BP: 120/68 P: 121 R: 20 O2: 94 RA General: Alert, oriented, no acute distress, voice hoarse HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, submandibular fullness, JVP not elevated, no LAD Lungs: High pitched inspiratory wheezes, mild expiratory wheezes in proximal airways. Increased expiratory duration CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN III-XII intact, grossly wnl Pertinent Results: Admission labs- [**2182-11-26**] 07:20AM BLOOD WBC-7.2# RBC-4.43 Hgb-11.5* Hct-35.3* MCV-80* MCH-26.0* MCHC-32.6 RDW-13.8 Plt Ct-250 [**2182-11-27**] 06:45AM BLOOD WBC-4.1 RBC-4.18* Hgb-10.8* Hct-32.6* MCV-78* MCH-25.8* MCHC-33.0 RDW-13.6 Plt Ct-224 [**2182-11-26**] 07:20AM BLOOD PT-13.9* PTT-32.4 INR(PT)-1.2* [**2182-11-27**] 06:45AM BLOOD PT-13.4 PTT-31.0 INR(PT)-1.1 [**2182-11-26**] 07:20AM BLOOD Glucose-107* UreaN-9 Creat-0.5 Na-138 K-3.9 Cl-100 HCO3-30 AnGap-12 [**2182-11-27**] 06:45AM BLOOD Glucose-105* UreaN-6 Creat-0.4 Na-137 K-3.7 Cl-101 HCO3-30 AnGap-10 [**2182-11-26**] 07:20AM BLOOD Calcium-8.7 Phos-2.9 [**2182-11-27**] 06:45AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.9 Discharge labs- [**2182-12-7**] 05:12AM BLOOD WBC-4.6 RBC-3.69* Hgb-9.5* Hct-29.4* MCV-80* MCH-25.6* MCHC-32.2 RDW-14.8 Plt Ct-239 [**2182-11-30**] 04:11AM BLOOD Neuts-83.4* Lymphs-9.9* Monos-4.3 Eos-2.1 Baso-0.3 [**2182-12-6**] 05:30AM BLOOD PT-14.4* PTT-29.3 INR(PT)-1.2* [**2182-12-8**] 05:12AM BLOOD Glucose-103* UreaN-10 Creat-0.4 Na-140 K-3.8 Cl-101 HCO3-33* AnGap-10 [**2182-12-8**] 05:12AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9 Pathology [**2182-11-27**] Left mainstem tumor, debridement: 1. Squamous and respiratory epithelium with reactive epithelial atypia, necrosis, fibrosis, acute and chronic inflammation with abscess formation and granulation tissue. 2. Small nodule consistent with Actinomycotic granule. 3. Multiple levels are examined. Echo The left atrium and right atrium are normal in cavity size. The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The 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 stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2181-9-14**], the findings are similar. CT CHEST WITHOUT IV CONTRAST: IMPRESSION: 1. Interval increase in soft tissue material within the left main stem bronchial stent and segmental airways immediately distal to the stent. Marked interval increase in postobstructive consolidation in the left lower lobe. 2. Overall increase in multifocal ground-glass opacities, particularly in the right lower lobe, compatible with chronic infection. 3. Otherwise, stable marked bronchiectasis in the left upper lobe, right middle lobe and lingula. Radiology Report QUANTITATIVE LUNG SCAN Study Date of [**2182-11-26**] Regional analysis of tracer distribution in the lungs shows: RIGHT LUNG: Perfusion/Ventilation Upper Third 18% / 11% Middle Third 29% / 36% Lower Third 38% / 21% LEFT LUNG: Perfusion/Ventilation Upper Third 5% / 10% Middle Third 8% / 15% Lower Third 4% / 7% TOTAL Perfusion/Ventilation Right lung: 84%/68% Left lung: 16%/32% IMPRESSION: Hypoperfusion and hypoventilation of the left lung. [**2182-11-29**] 10:44 am BRONCHOALVEOLAR LAVAGE **FINAL REPORT [**2182-12-4**]** GRAM STAIN (Final [**2182-11-29**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2182-12-4**]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. STAPH AUREUS COAG +. ~5,000 CFU/ML SENSITIVITIES PERFORMED ON REQUEST.. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. SENSITIVITIES REQUESTED BY DR [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ([**Numeric Identifier 59915**]) [**2182-12-2**]. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations Rifampin should not be used alone for therapy. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S Brief Hospital Course: Ms. [**Known lastname **] is a 70 year old woman with inflammatory pulmonary disease who was admitted for observation s/p bronch, c/b intubation and pneumonia. # SOB / fibrosing mediastinitis: Pt had a flex bronch [**11-25**] that showed severe stenosis of L main stent [**3-12**] granulation tissue. V/Q scan [**11-26**] showed hypoperfusion and hypoventilation of L lung, CT chest, bronchial washings with commensal resp flora. Rigid bronch was completed Wed [**11-27**]. Pt remained intubated. Pt was taken back to OR on Fri [**11-29**] for stent removal and further debriding of granulation tissue. Pt was extubated on Sat [**11-30**] after her 2 procedures. She was breathing and satting well initially, but became acutely tachypneic and tachycardic. She had to be re-intubated. She was started on Prednisone 30mg PO daily on [**11-30**], tapered off on [**12-7**]. She was also found to have MRSA in her [**Last Name (LF) **], [**First Name3 (LF) **] the patient was started on Vancomycin on [**2182-12-2**] for a 7 day course. She was extubated successfully on [**2182-12-3**]. She is satting well on RA. PICC was placed for abx. Pt will need f/u with pulm as an outpatient for reevaluation. She is off of her CellCept due to her infection; this will need to be restarted by her outpatient providers. . # Tachycardia: Pulse in 120s on admission, sinus tach with baseline nonspecific ST-T wave changes unchanged from baseline. Tachycardia resolved with fluids. On HD 2 she was noted to have frequent extra beats on morning physical exam. ECG was repeated which showed decreased rate in the 60s with frequent PACs of unclear etiology. On the morning of hospital day 3 cardiac exam was normal. She remained stable. . #PNA: She has a history of spiking a fever post procedures similar to this one. Pt had a fever post procedure. Levaquin and Metronidazole were started initially on [**2182-11-27**] and cultures were sent. Levaquin was changed to Cefepime on [**2182-12-1**] for concern for worsening fevers. Vanc was added on [**2182-12-2**] for GPC in her [**Date Range **], which grew out MRSA for a 7 day course. Cefepime and Flagyl were discontinued on [**2182-12-5**]. Fevers resolved on vancomycin. Vanco levels were borderline low (9.5 and 9.7) therefore doses of vanco were increased to 1250mg and then 1500mg for the last 2 days of treatment respectively. . #Pulmonary edema: There was a question of pulmonary edema at admission. CXRs did not show any convincing evidence, with hilar opacities perhaps related to fibrosing mediastinitis. An echocardiogram showed EF >60%, preserved global systolic function and mild pulmonary artery systolic hypertension. . #Anemia: HCT dropped to 30 from 35 with recent baseline in mid-to-low 30s. Microcytic. Normal coags, platelets and had scant hemoptysis post procedure. Considered likely [**3-12**] chronic disease. Pt was cleared by PT for home and discharged after her abx were complete. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ Outstanding issues: - CellCept will need to be restarted by IP Medications on Admission: - Cellcept [**Pager number **] mg [**Hospital1 **], started 1 month prior to admission - Combivent 18-103 mcg/Actuation Aerosol 1-2 puffs Q4H PRN - Estradiol patch 0.05 2x/week - Tylenol PM prn Discharge Medications: 1. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. estradiol 0.025 mg/24 hr Patch Semiweekly Sig: One (1) Transdermal once a week: use as before. 3. acetaminophen 650 mg/20.3 mL Solution Sig: [**2-9**] PO Q6H (every 6 hours) as needed for pain, fever. 4. multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: fibrosing mediastinitis MRSA post-obstructive pneumonia anemia Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: You were admitted to the hospital due to needing your lung stent removed. You had 2 procedures to debrid the fibrosis of your lung and remove your stent. You required intubation and being on a breathing machine, you are now breathing much better. You also had bacteria found in your lungs, and it was treated with antibiotics. The following changes were made to your medications: - you were started on a multivitamin - your cellcept was stopped, discuss restarting this with your doctor Followup Instructions: Please see your primary care doctor in the next 1-2 weeks. Please call Monday for an appointment to see [**Doctor Last Name **] next week to discuss your cellcept Prior scheduled appointments- Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2183-1-14**] at 11:15 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: WEST PROCEDURAL CENTER When: TUESDAY [**2183-1-14**] at 11:30 AM [**Telephone/Fax (1) 5072**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: WEST PROCEDURAL CENTER When: TUESDAY [**2183-1-14**] at 12:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5072**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Completed by:[**2182-12-8**]

[ "285.9", "458.9", "482.42", "276.2", "996.59", "518.81", "714.81", "E878.2", "519.3", "244.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "96.71", "33.91", "33.24", "38.91", "33.78", "32.01", "38.97", "96.05" ]

icd9pcs

[ [ [] ] ]

11821, 11827

8025, 11148

321, 420

11934, 12056

3101, 8002

12629, 13812

2377, 2467

11393, 11798

11848, 11913

11174, 11370

12117, 12606

2482, 3082

1589, 1828

232, 283

448, 1570

12071, 12093

1872, 2211

2227, 2361

55,357

178,220

327

Discharge summary

report

Admission Date: [**2196-8-16**] Discharge Date: [**2196-8-18**] Date of Birth: [**2160-7-23**] Sex: F Service: MEDICINE Allergies: Bactrim / Vioxx / Penicillins / Cellcept / Ceftriaxone / Ferrlecit Attending:[**First Name3 (LF) 2817**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: peritoneal dialysis History of Present Illness: Ms. [**Known lastname **] is a 36 year old female with a history of SLE, lupus nephritis, ESRD on PD who presented to the ER with two days of chest pain and worsening shortness of breath. At home she had been having pain. She had been having pain during her PD sessions at home, and was having difficulty tolerating the PD sessions, so she stopped doing her home PD sessions Sunday evening. Over the next few days, she started having more shortness of breath, was experiencing chest heaviness, orthopnea and PND. Her shortness of breath worsened over, and she presented to the ER today for further evaluation. She denies any cough, nasal congestion, fever/chills, night sweats, n/v/d. Does have her baseline abdominal pain and has felt worsening "abdominal heaviness" since missing her PD sessions. . In the ED, initial vs were: T-98.2 P-124 BP-133/92 R-24 O2 sat-98%. On arrival she was tachypneic to the 20's, complaining of chest heaviness and also tachycardic. She had a CXR that showed bilateral pleural effusions, pulmonary vascular congestion, an EKG that showed sinus tachycardia with TWI in I, AVL. An echocardiogram was done that was mostly unchanged from prior, showing an LVEF of 40% with severe 3+ MR. [**First Name (Titles) 6**] [**Last Name (Titles) **] showed 7.47/34/179, troponin of 0.09, CK of 135, MB of 3, BNP>[**Numeric Identifier **], K+ was 5.3, serum tox was positive for tricyclics, otherwise negative. She was given 60mg IV lasix as she still makes urine, SL nitro x 2, and levofloxacin to cover for CAP. . On the floor, her initial VS were: T-96.5, HR-133, BP-128/97, RR-38, 100% on NRB. She continues to complain of shortness of breath, despite stable oxygen saturations. She also continues to complain of abdominal pain/heaviness, and generally feels overwhelmed with her illness and doing the PD at home, has also not been having as regular of bowel movements at home recently. Also of note, she was recently on a prednisone taper for a lupus flare, where she experiences vague symptoms, including SOB, arthritis, abdominal heaviness. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough. Denies palpitations. Denies nausea, vomiting, diarrhea. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: # Lupus rash # Herpes Simplex I - [**12-1**], white lesions on the tongue and buccal mucosa # Axillary Adenopathy - [**10-1**], biopsied -> reactive lymph node # Osteopenia - [**7-1**], L spine Tscore -2.40, Fem neck -1.91, Tot Hip -1.41 # Hypercholesterolemia - [**7-31**] # Lung abscess - [**7-31**] # Pulmonary emboli (PE) - [**5-31**] # Angioedema vs Anasarca - [**5-31**], associated with 2 grand mal seizures, required intubation for massive facial/laryngeal swelling # Pleural Effusions - s/p pleurodesis in [**6-10**] nephrotic syndrome # Lupus nephritis / Nephrotic syndrome - [**4-30**], renal bx showed focal proliferative class III # GERD / Gastric ulcer - [**2-1**], seen on barium swallow # Recurrent pneumonia - [**2185**], possibly from aspirations, most recent [**2191-10-1**] # Antiphospholipid antibody syndrome (APS) - [**2184**], requiring anticoagulation to INR of 2 to 3 # Breast Masses - [**8-/2182**], bilateral, largest right upper outer quadrant 4/3 cm # Thrombotic thrombocytopenic purpura (TTP) - [**10/2182**], s/p plasmapheresis # Inflammatory eye mass - [**11/2180**], s/p excision of mass, [**2-2**] lupus # Gonorrhea - [**7-/2180**], disseminated gonococcus # Abnormal pap smear - [**2180**], subsequent paps x 2 normal # Systemic lupus erythematosus (SLE) - [**2179**], followed by Dr. [**Last Name (STitle) **] # Raynaud's syndrome # Stroke - hemiparalysis # Asthma - no problems for several years Social History: Married with three children, born in [**2184**], [**2185**], and [**2188**]. Lives in [**Hospital1 8**]. Went to [**University/College 3036**]. Worked as an accountant until health declined in early [**2187**]. No tobacco, ethanol or drug use. Family History: No collagen vascular disorders. Maternal grandmother died of pancreatic cancer last year. No other cancers in the family. No FH heart disease. Her parents are alive and she has 3 healthy children. Physical Exam: VS: Tmax: 37.3 ??????C (99.1 ??????F) Tcurrent: 36.7 ??????C (98.1 ??????F) HR: 121 (118 - 133) bpm BP: 136/94(104) {128/94(103) - 165/106(120)} mmHg RR: 18 (17 - 38) insp/min SpO2: 100% Heart rhythm: ST (Sinus Tachycardia) General Appearance: Thin, Anxious Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, dry MM Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), Tachycardic Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t) Crackles : , Bronchial: right base , Diminished: bases ) Abdominal: Soft, Distended, Tender: diffusely Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Musculoskeletal: No(t) Unable to stand Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): person, place, time , Movement: Not assessed, Tone: Not assessed Pertinent Results: [**2196-8-16**] 02:15PM WBC-7.2# RBC-2.53* HGB-7.8* HCT-22.4* MCV-89 MCH-30.9 MCHC-34.9 RDW-15.0 [**2196-8-16**] 02:15PM NEUTS-73.1* LYMPHS-19.2 MONOS-3.7 EOS-3.7 BASOS-0.3 [**2196-8-16**] 02:15PM PLT COUNT-248 [**2196-8-16**] 02:15PM PT-42.8* PTT-26.2 INR(PT)-4.5* [**2196-8-16**] 02:15PM RET AUT-1.2 [**2196-8-16**] 02:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-POS [**2196-8-16**] 02:15PM HAPTOGLOB-191 [**2196-8-16**] 02:15PM TOT PROT-5.1* [**2196-8-16**] 02:15PM CK-MB-3 proBNP-GREATER TH [**2196-8-16**] 02:15PM cTropnT-0.09* [**2196-8-16**] 02:15PM ALT(SGPT)-5 AST(SGOT)-8 LD(LDH)-337* CK(CPK)-135 ALK PHOS-50 TOT BILI-0.1 [**2196-8-16**] 02:15PM GLUCOSE-99 UREA N-55* CREAT-14.2*# SODIUM-136 POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-24 ANION GAP-18 [**2196-8-16**] 02:34PM LACTATE-0.9 K+-5.3 [**2196-8-16**] 02:34PM TYPE-ART PO2-179* PCO2-34* PH-7.47* TOTAL CO2-25 BASE XS-2 INTUBATED-NOT INTUBA COMMENTS-GREEN TOP [**2196-8-16**] 09:05PM FIBRINOGE-632*# ---------------- [**2196-8-16**] TTE: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate global left ventricular hypokinesis (LVEF = 40 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2196-7-29**], the heart rate is now higher and LVEF is slightly lower. . [**2196-8-17**] CXR (PA and Lat): FINDINGS: In comparison with the study of [**8-16**], there are bilateral pleural effusions with compressive atelectasis and engorgement of pulmonary vessels, consistent with the clinical impression of volume overload. The possibility of supervening pneumonia cannot be definitely excluded and would have to be made on clinical grounds. Brief Hospital Course: #) Volume Overload/Shortness of Breath: in the setting of missing PD sessions, likely due to volume overload, especially in the context of the findings on CXR, and echo. Also possible is PNA. We consulted the renal team and continued Ms. [**Known lastname **] on PD while in the ICU on an aggressive schedule to remove extra fluid. She was started on empiric treatment for CAP with levofloxacin. While she was afebrile on the floor and had a normal WBC, she had a fever in the ED and it was decided to continue empiric treatment of possible CAP as an outpatient for a total of 5 days (last dose to be [**2196-8-20**]) of 750 mg levofloxacin daily. . #) High INR: Pt has h/o PEs and has anti-phospholipid Ab syndrome with no evidence of bleed. It peaked at 6.0 and rather than give Vitamin K, we decided to let it drift back down by holding coumadin. The INR was 3.6 on the day of discharge, and she is followed by the coumadin clinic at [**Company 191**]. We have contact[**Name (NI) **] the [**Name (NI) 191**] clinic for her f/u. As their recs, she should take 3.75 mg tonight, and 5 mg starting tomorrow ([**8-19**]) until she hears back from the [**Hospital3 **]. She will need to F/U by getting an INR check on [**Hospital3 766**], [**8-22**], which will need to be faxed to [**Company 191**] coumadin clinic. . #) ESRD on PD: As per renal, we continued her PD in house, and she will be returning to her regular home regimen as an outpatient. We have continued her senna and colace as an outpatient to help with constipation, and have tried miralax while in house. She also came in with a positive amitryptiline when she arrived to [**Hospital1 18**] and her dose was held. We rechecked a level and it is still pending. We told pt not to take any more of this medication until this result came back and she followed up with her PCP. . #) Tachycardia: Pt has been in sinus tach since arriving on the floor. TSH nl. Has baseline tachy, possibly [**2-2**] anemia. Pt would decline blood products. Given her low EF on echo, it was decided to start labetalol 100 mg POBID for her which has helped bring both her BP and heart rate down. . #) Anemia: patient with recent HCT of around 25, however in the end of [**Month (only) 116**] HCT was around 30, drop thought to be due to hemolysis. Hemolysis labs were rechecked which were negative. Her Hct was stable for us around 25. We kept an active T/S, and the plan is to continue her darbepoetin Q2 weeks. . #) Hypertension: we continued her home medications, and given her EF of 40% with 3+ MR, and her persistent hypertension, we continued her home dose of lisinopril, amlodipine, and added labetalol 100 mg POBID. . #) Depressed EF (40%) on TTE, with 3+ MR. - Continue labetalol. - Arrange for cardiology f/u with Dr. [**Last Name (STitle) 171**] next week. . #) SLE: Continued her home plaquenil Medications on Admission: 1. Amlodipine 5 mg DAILY 2. Calcitriol 0.25 mcg DAILY 3. Cyclobenzaprine 10 mg HS as needed for pain. 4. Darbepoetin Alfa In Polysorbat 60 mcg/0.3 mL Syringe q 2 weeks. 5. Hydroxychloroquine 200 mg: Two (2) Tablet PO EVERY OTHER DAY 6. Hydroxychloroquine 200 mg: One (1) Tablet PO EVERY OTHER DAY 7. Lisinopril 40mg DAILY 8. Ranitidine HCl 150 mg twice a day. 9. Prednisone 20 mg Tablet Sig: see below Tablet PO DAILY (Daily): [**Date range (1) 3045**]: 3 tabs daily, [**Date range (1) 3046**]: 2 tabs daily, [**Date range (1) 3047**]: 1 tab daily, [**Date range (1) 3048**]: [**1-2**] tab daily. Disp:*25 Tablet(s)* Refills:*0* 10. Sevelamer Carbonate 800 mg TID W/MEALS 11. Coumadin 10 mg M, W, F, Sun. 12. Coumadin 7.5 mg T, Th, Sat. Discharge Medications: 1. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Cyclobenzaprine 10 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for pain, muscle spasm. 9. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 6X/WEEK (MO,TU,WE,TH,FR,SA). 10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. 11. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 12. Hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY (Every Other Day). 13. Coumadin 2.5 mg Tablet Sig: 1.5-2 Tablets PO once a day: Please take one and a half pills (3.75 mg) on [**8-18**], and two pills starting [**8-19**] until you hear back from the [**Hospital 3052**]. Disp:*30 Tablet(s)* Refills:*2* 14. Outpatient Lab Work Please have INR checked and fax to [**Hospital 191**] [**Hospital3 **]: ([**Telephone/Fax (1) 3053**] Discharge Disposition: Home Discharge Diagnosis: Volume overload/shortness of breath Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 69**] because you were short of breath from having too much fluid on after suboptimal peritoneal dialysis sessions for a few days. While you were here, we were able to aggressively use peritoneal dialysis to take off fluid to make you more comfortable. Your blood pressure and heart rate were also high, and we have started a new medication for you to help with this problem. PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS: 1) Please START taking labetalol 100 mg by mouth two times a day 2) Today ([**8-18**]), please take 3.75 mg of coumadin. 3) For the next two days (Friday, [**8-19**] and Saturday, [**8-20**]), please take 5 mg of coumadin. 4) Go back to your regular dose of coumadin on [**8-21**] (Sunday). 5) Do not take your amitriptyline. We have drawn a level and if it comes back normal you can continue taking it. Your PCP can let you know when this level comes back or you can call to find out if you can start taking this medication again. PLEASE CONTINUE THE FOLLOWING FOR YOUR PERITONEAL DIALYSIS 1) 5 cycles of 1500 milliliter fill, 1.5% dextrose alternating with 2.5% dextrose; 1 day dwell of 1.5% dextrose with 1500 milliliter fill. 2) PLEASE CALL [**Doctor First Name 3040**] at [**Location (un) **] peritoneal dialysis center. Followup Instructions: INR CHECK Please go for a blood draw to check your INR on [**Location (un) 766**], [**8-22**], and have the results faxed to the [**Hospital 18**] [**Hospital3 **] [**Hospital 197**] Clinic ([**Telephone/Fax (1) 3053**]. CARDIOLOGY [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2196-8-24**] 2:40 RHEUMATOLOGY [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2196-9-22**] 1:00 [**First Name8 (NamePattern2) 3049**] [**Last Name (NamePattern1) 3050**], MD Phone:[**Telephone/Fax (1) 3051**] Date/Time:[**2196-10-5**] 11:15 Completed by:[**2196-9-13**]

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41905

Discharge summary

report

Admission Date: [**2112-11-11**] Discharge Date: [**2112-11-23**] Date of Birth: [**2042-7-28**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4891**] Chief Complaint: Headache, nausea and vomiting, after a fall Major Surgical or Invasive Procedure: [**2112-11-13**]: right mini craniotomy and left burr hole and evacuation of subdural hematomas History of Present Illness: 70 right-handed male with essential thrombocytosis on aspirin, Hypertension, hyperlipidemia presents with headache, nausea and vomiting and neurosurgery was involved once the patient was found to have bilateral sub-dural hematomas. Patient was in his normal state of health until around 1.5 prior to admission when he filling water in his hot water tank at home and was kneeling down and stood up and his the top of his head on a copper pipe. He felt "stunned" but had no LOC. Then had a vertex headache since which latterly was also bifrontal but was mild and intermittent. Since Wednesday, his symptoms worsened with more severe headache, nausea and vomiting. He also had some light-headedness when sitting or standing and felt "funny". Patient went to see PCP and had [**Name Initial (PRE) **] CT today at OSH whch showed bilateral subdural hematomas and was transfered to [**Hospital1 18**] for evaluation. Denies any gait difficulties. Still has a headache [**4-14**] and received IV morphne at OSH. Currently feels foggy but is alert and oriented and speech per family is slightly slurred and not quite as cognitively with it as usual. HOSPITAL COURSE: The patient was initially on the neurosurgical and neurology services, and later transitioned to the medical service, as well as the medical ICU and the cadiology service over the course of his admission. ON INITIAL TRANSFER TO INTERNAL MEDICINE SERVICE 70 year old man with known HTN/hyperlipidemia, essential thrombocytosis on Anagrelide (phospholipase A2 inhibitor - platelet reducing [**Doctor Last Name 360**]), who presented on [**2112-11-11**] with headache and nausea and vomiting, ad was found to have bilateral Sub-dural hematomas, left greater than right, with some rightward shift of midline structures by approximately 5mm, for which he underwent R burr hole evacuation and L mini craniotomy and evacuation, membrane lysis, adhesiolysis. He has also been started on Dilantin for seizure prophylaxis. He was reportedly extubated in TICU and doing well postoperatively. However, subsequently developed increasing agitation and delirium and required Haldol and transient restraints. At this point in his course, he was noted to have desaturations and vital signs revealing that he was 100% around MN Tuesday am then nadirs to 84-91% on RA in the early am Tuesday. This was improved to 93% on 4L and 95% on 5L. He has been getting more tachycardic to a peak of 115 bpm recorded, and hypertense to the 140-160's. In response to this, this am he was given 10 IV Lasix, an Ipratropium neb, and has been getting IV Metoprolol. Out of concern for PE, the pt was sent for CTA, and Medicine was consulted and transfer initiated. There was reportedly a plan for an echo. Pt was interviewed prior to the CTA and denied SOB, CP, pain anywhere, and was without any complaints. However, his daughter and wife at the bedside stated that his mental baseline at hat point was far from his baseline. He appeared very dyspneic. They also state that his neck appeared grossly swollen compared to baseline. Vitals at that time: 99.4, 169/88, 22, 94% 4L NC. ROS as above, otherwise negative. The patient subsequently required a short stay in the medical ICU for treatment of hypoxia, tachycardia and delrium. MEDICINE INTERVAL COURSE FROM MICU This is a 70 year old man with essential thrombocytosis, now s/p bilateral craniotomy/burr holes for SDH on [**11-13**] who developed hypoxia, tachycardia, HTN on the floor and found to have severe bilateral pulmonary infiltrates concerning for aspiration vs pulmonary hemorrhage. He was sent to MICU for hypoxia, and has since stabilized. Duing his ICU stay, the patient was placed on Labetalol contiuous drip overnight 0.5 mg/hr overnight then stopped at 8am and transitioned to PO Labetalol, and uptitrated to 200 [**Hospital1 **]. Also continued Lisinopril. He was given Lasix diuresis (40 IV at MN and 20 IV at 3a) and is net 2L negative. Through the night his blood pressure has improved from hypertensive but now down to 100-120's, and pulse improved from 100's to 70-80's. O2 has been weaned down from facemask to now just a few L of NC. Per MICU nurse, he was noted to desat to 90% on RA but improved back to mid-high 90% on 3L NC. He had swallow study which he passed. Cardiac echo was performed. Vitals by call out: 100.4 at 3a, 98.4 p81 107/55. On interview, he was without complaint and says his breathing is much better, that before he was unable to take deep breaths but that this is better. No CP, nausea, abd pain, tingling/numbness, focal neuro deficits. Otherwise no complaints, ROS negative. On exam, overall he looks 180 degrees better, his dyspnea is better, juguluar pulsations noted at angle of mandiblelungs are surprisingly very clear, RRR with slower rate and crescendo-descrescendo AS type murmur heard, abdomen soft NT ND benign, no BLE edema, and extremities are warm and well perfused. Mental status is alert and calm, conversant, appropriate. Labs showed a declining Hct but improved WBC count and plts from prior. Chemistry panel shows improved Na, HCO3; however BUN/Cr ratio are slightly worse. He had developed a mild elevation in Troponin while CK and MB are negative; most recent EKG shows improved rate. BCx and UCx are still pending. CXR has no read yet, to me it appears very minimally improved but still with a very impressive L > R infiltrates. Due to persistent tachycardia while on the medica service, with the evenua development of relative hypotension,the patient was transferred to the cardiology service for ongoig management of her heart rate and blood pressure. Once these were stabiliwd, the patient was again transferred to hemedical service. MEDICINE INTERVAL EVENTS ON TRANSFER FROM CARDIOLOGY The patient was transferred back from the Cardiology service after stabilization of persistent SVT's, despite multiple nodal agents and 200 TID Amiodarone. He responded to an increased Amiodarone dose to 400 TID with plan to continue at this dose for a week then decrease to 400 daily until f/u with Elelectrophysology team after discharge. He was also continued Labetalol 200 [**Hospital1 **] and added Metoprololol 25 qid, continued Lisinopril as well. On my review of his vitals and telemetry, his blood pressure and pulse are dramatically improved and pulses are in the 60's even with ambulation with PT. Telemetry shows normal sinus rhythm with alarms for occasional frequent ectopy and bigeminy/trigeminy as before but overall much less ectopy and runs of SVT's. He looks dramatically improved and PT is now recommending possible d/c home. Hematologically, his platelets continue to rise and per H/O recs he was started on ASA 325 after confirmation by NeuroSurgey that this was resonable from their perspective. His Anagrelide was also increased to 1g [**Hospital1 **]. He is also on subQ Heparin for DVT prophylaxis. His WBC count is still elevated, but he has had no fevers, and cultures were negative. He is not acting infected by my evaluation, and I suspect that the elevated WBC count may be part of the hematological process that is driving his platelets up, but cannot be sure. His Vanc/Zosyn that was on empirically last week was stopped and was not restarted, and his condition has not worsened since then, and again no fevers. Oxygenation has not been any furhter issue. He is stable on room air, and his CXR is improved but still with infiltrates that I still suspect are aspiration event and not edema or PNA. Past Medical History: PMHx: - Bilateral subdural hematomas with midline shift, admitted to NSurg for bilateral mini-craniotomies and burr holes in [**11/2112**]; course complicated by hypoxia (thought to be aspiration + flash edema), difficult to control supraventricular tachycardia (started on Amiodarone, Labetalol, and Metoprolol), severe hypertension, and thrombocytosis - Essential thrombocytosis on Anagrelide for past 20 yrs and Aspirin, per family he failed Hydroxyurea. Has a Hematologist in the VA system, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 90983**] [**Telephone/Fax (1) 90984**] or [**Telephone/Fax (1) 90985**]. Denies episodes of hemorrhage in the past - HTN - HLD - Bilateral cataract ops - Fractured left 3 ribs c/b pneumthroax following fall 3 years ago Social History: Lives with wife, works for restaurant, independent with ADL's. Prior 1.5 ppd smoker, quit 3 yrs ago. 2 glasses of wine per night, no illicits. Has daughter [**Name (NI) **] home [**Telephone/Fax (1) 90986**], cell [**Telephone/Fax (1) 90987**] Family History: Mother - bladder ca Father - died of PE Sibs - 3 brothers with ca - pancreatic, lung ca and brain ca Physical Exam: O: T: not documented BP: 170/80 HR: 77 R 17 O2Sats 97% RA Gen: C/O mild HA HEENT: Pupils: anisociria likely [**3-9**] cataract ops (left small and irregular) Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. Normal S1/S2 withourt murmurs. Regular with ectopics Abd: Soft, NT, BS+. [**Doctor Last Name **] de [**Doctor Last Name 2031**] spots on abdomen Extrem: Warm and well-perfused. DPs full and palpable bilaterally. Small wound on forefoot on right <1cm ? old cut Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Seems slightly less cognitively able with difficulties in relaying history. Orientation: Oriented to person, place, and date but thought it was [**11-13**] as opposed to [**11-11**]. Recall: 0/3 objects at 3 minutes 1 with prompting. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Attention reduced unable to [**First Name8 (NamePattern2) **] [**Doctor Last Name 1841**] backwards. Cranial Nerves: I: Not tested II: Pupils irregular and reactive to light right 3-2mm left irregular likely [**3-9**] cataract op 1-1.5mm. Visual fields are full to confrontation. III, IV, VI: Extraocular movements with jerky pursuits and somewhat broken saccades but without nystagmus. V, VII: Facial strength full save difficulty keeping left eye closed with reduced power and sensation intact and otherwise symmetric facies. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Limb exam: Normal tone throughout. Motor: Full power throughout in UE and LE. Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 3 1 Left 2+ 2+ 2+ 3 1 Plantar reflexes flexor on the right and extensor on the left. Cerebellar: No finger/nose or heel-shin ataxia. RAMs were normal. . PHYSICAL EXAM ON TRANSFER TO INTERNAL MEDICINE 101.0 101.0 149/76 (113-175) HR low 100's (78-115) 20 95% on 4L Younger than stated age M who appears dyspneic but can speak short sentences laying in bed, mildly agitated and moving around in bed, then dozes off, wife and daughter at bedside. He appears flushed, warm, and very fatigued. Head has bilateral scalp incisions with staples in place, the wounds appear OK, nonpurulent, non erythematous EOMI, no scleral icterus noted, mouth extremely dry appearing. External jugular pulsations noted just a few cm above the clavicle, while internal jugulars more difficult to assess. R basilar paninspiratory light crackle otherwise rest of lung is clear no wheezes RRR with very frequent PAC and early to mid peaking systolic murmur through precordium, bilateral radials easily palpable, no heaves Abd obese soft NT ND, benign No BLE edema. Extrems are warm to touch, no mottling. CN 2-12 grossly intact, he is moving around in the bed and moving all extremities spontaneously. Not oriented to place or time, some answers are appropriate but others are not appropriate at all. Recognizes his wife and daughter and can maintain minimal conversation. . PHYSICAL EXAM ON DISCHARGE: AFebrile at least a week Systolics 120-140's with pulses 50-60's even with walking Satting high 90's on RA even with ambulation Appearing much improved, clear, coherent, in good spirits. Lungs CTAB except light crackles at bases persistent through admission RRR no tachycardia but with occasional pauses Abd soft NT ND No BLE edema, extremities warm no mottling, has L 4th and 5th digit amputations Scalp shaved with clean, healing bilateral incisions, staples removed Pertinent Results: ADMISSION LABS: [**2112-11-11**] 06:50PM BLOOD WBC-13.7* RBC-3.38* Hgb-10.9* Hct-32.5* MCV-96 MCH-32.4* MCHC-33.7 RDW-12.3 Plt Ct-510* [**2112-11-12**] 05:25AM BLOOD WBC-13.6* RBC-3.60* Hgb-11.4* Hct-34.8* MCV-97 MCH-31.6 MCHC-32.8 RDW-12.3 Plt Ct-549* [**2112-11-13**] 07:00AM BLOOD WBC-14.5* RBC-3.47* Hgb-11.3* Hct-33.6* MCV-97 MCH-32.5* MCHC-33.6 RDW-12.7 Plt Ct-465* [**2112-11-11**] 06:50PM BLOOD Neuts-82* Bands-0 Lymphs-10* Monos-7 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2112-11-11**] 06:50PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-NORMAL [**2112-11-12**] 05:25AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL [**2112-11-15**] 03:40PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL [**2112-11-11**] 06:50PM BLOOD PT-13.7* PTT-23.1 INR(PT)-1.2* [**2112-11-12**] 05:25AM BLOOD PT-13.3 PTT-27.1 INR(PT)-1.1 [**2112-11-11**] 06:50PM BLOOD Glucose-135* UreaN-21* Creat-1.0 Na-130* K-5.3* Cl-96 HCO3-21* AnGap-18 [**2112-11-12**] 05:25AM BLOOD Glucose-112* UreaN-21* Creat-1.0 Na-131* K-4.6 Cl-95* HCO3-24 AnGap-17 [**2112-11-13**] 01:45PM BLOOD Glucose-130* UreaN-18 Creat-1.0 Na-131* K-3.6 Cl-104 HCO3-19* AnGap-12 [**2112-11-11**] 06:50PM BLOOD ALT-23 AST-40 AlkPhos-59 TotBili-0.3 [**2112-11-12**] 05:25AM BLOOD ALT-21 AST-28 AlkPhos-60 TotBili-0.3 [**2112-11-14**] 12:00AM BLOOD CK-MB-4 cTropnT-<0.01 [**2112-11-14**] 04:21AM BLOOD CK-MB-4 cTropnT-<0.01 [**2112-11-14**] 11:00AM BLOOD CK-MB-4 cTropnT-<0.01 [**2112-11-11**] 06:50PM BLOOD Albumin-4.8 [**2112-11-12**] 05:25AM BLOOD Albumin-5.0 Calcium-9.9 Phos-3.2 Mg-2.1 [**2112-11-13**] 01:45PM BLOOD Calcium-7.2* Phos-2.4* Mg-1.7 [**2112-11-13**] 01:45PM BLOOD Phenyto-6.0* [**2112-11-14**] 04:21AM BLOOD Phenyto-5.1* [**2112-11-15**] 04:08PM BLOOD Type-ART pO2-64* pCO2-26* pH-7.47* calTCO2-19* Base XS--2 [**2112-11-15**] 04:08PM BLOOD Lactate-1.1 [**2112-11-15**] 04:08PM BLOOD O2 Sat-92 [**2112-11-16**] 12:18AM BLOOD freeCa-1.10 . DISCHARGE LABS [**2112-11-23**] 06:20AM BLOOD WBC-14.3* RBC-2.59* Hgb-8.2* Hct-26.0* MCV-101* MCH-31.7 MCHC-31.5 RDW-12.6 Plt Ct-1294* [**2112-11-22**] 06:15AM BLOOD WBC-14.6* RBC-2.83* Hgb-8.7* Hct-28.6* MCV-101* MCH-30.8 MCHC-30.5* RDW-12.7 Plt Ct-1547* [**2112-11-21**] 06:50AM BLOOD WBC-16.0* RBC-2.75* Hgb-8.7* Hct-27.3* MCV-99* MCH-31.5 MCHC-31.7 RDW-12.5 Plt Ct-1523* [**2112-11-20**] 07:28AM BLOOD WBC-16.0* RBC-2.74* Hgb-8.8* Hct-26.3* MCV-96 MCH-32.2* MCHC-33.7 RDW-12.5 Plt Ct-1476* [**2112-11-19**] 05:47PM BLOOD WBC-15.8* RBC-2.80* Hgb-9.0* Hct-27.7* MCV-99* MCH-32.0 MCHC-32.4 RDW-12.3 Plt Ct-1613* [**2112-11-23**] 06:20AM BLOOD Neuts-73* Bands-1 Lymphs-18 Monos-5 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2112-11-22**] 06:15AM BLOOD Neuts-73* Bands-0 Lymphs-9* Monos-9 Eos-6* Baso-1 Atyps-2* Metas-0 Myelos-0 [**2112-11-23**] 06:20AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-OCCASIONAL Burr-OCCASIONAL [**2112-11-22**] 06:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-1+ [**2112-11-16**] 05:32AM BLOOD PT-15.0* PTT-29.1 INR(PT)-1.3* [**2112-11-16**] 04:45AM BLOOD PT-15.0* PTT-29.6 INR(PT)-1.3* [**2112-11-22**] 06:15AM BLOOD Glucose-77 UreaN-9 Creat-0.9 Na-138 K-4.5 Cl-103 HCO3-25 AnGap-15 [**2112-11-21**] 06:50AM BLOOD Glucose-81 UreaN-13 Creat-0.9 Na-137 K-4.0 Cl-102 HCO3-24 AnGap-15 [**2112-11-20**] 07:28AM BLOOD Glucose-69* UreaN-16 Creat-1.0 Na-135 K-4.3 Cl-101 HCO3-23 AnGap-15 [**2112-11-19**] 05:47PM BLOOD Glucose-95 UreaN-12 Creat-0.9 Na-137 K-3.9 Cl-100 HCO3-24 AnGap-17 [**2112-11-19**] 06:52AM BLOOD Glucose-83 UreaN-12 Creat-0.9 Na-136 K-4.5 Cl-101 HCO3-22 AnGap-18 [**2112-11-16**] 04:45AM BLOOD ALT-23 AST-25 LD(LDH)-185 CK(CPK)-145 AlkPhos-74 Amylase-39 TotBili-0.4 [**2112-11-19**] 05:47PM BLOOD CK-MB-3 cTropnT-<0.01 [**2112-11-17**] 07:05AM BLOOD CK-MB-3 cTropnT-<0.01 [**2112-11-16**] 07:40PM BLOOD CK-MB-3 cTropnT-0.01 [**2112-11-22**] 06:15AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.1 [**2112-11-21**] 06:50AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.8 [**2112-11-20**] 07:28AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.9 [**2112-11-17**] 07:05AM BLOOD Albumin-3.5 Calcium-8.4 Phos-2.8 Mg-2.3 [**2112-11-18**] 07:20AM BLOOD TSH-1.9 [**2112-11-21**] 06:50AM BLOOD Phenyto-12.0 [**2112-11-18**] 07:20AM BLOOD Phenyto-14.2 [**2112-11-17**] 07:05AM BLOOD Phenyto-6.0* [**2112-11-16**] 12:18AM BLOOD Type-ART Temp-37.4 pO2-68* pCO2-24* pH-7.45 calTCO2-17* Base XS--4 Intubat-NOT INTUBA [**2112-11-15**] 04:08PM BLOOD Type-ART pO2-64* pCO2-26* pH-7.47* calTCO2-19* Base XS--2 [**2112-11-16**] 12:18AM BLOOD Lactate-1.0 [**2112-11-15**] 04:08PM BLOOD Lactate-1.1 [**2112-11-15**] 04:08PM BLOOD O2 Sat-92 . MICROBIOLOGY: Blood cultures negative [**2112-11-15**] and urine culture negative [**2112-11-15**] . URINALYSIS [**2112-11-23**] 09:29AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007 [**2112-11-23**] 09:29AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2112-11-23**] 09:29AM URINE RBC-1 WBC-5 Bacteri-FEW Yeast-NONE Epi-<1 TransE-<1 [**2112-11-23**] 09:29AM URINE CastHy-1* [**2112-11-20**] 04:27PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012 [**2112-11-20**] 04:27PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2112-11-20**] 04:27PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [**2112-11-20**] 04:27PM URINE CastHy-6* [**2112-11-15**] 10:47PM URINE Hours-RANDOM UreaN-306 Creat-28 Na-104 K-22 Cl-119 [**2112-11-15**] 10:47PM URINE Osmolal-394 . RADIOLOGY: [**11-11**] CXR- IMPRESSION: No acute intrathoracic process. . [**11-12**] CT Head- IMPRESSION: Allowing for differences in technique, there is a mild interval increase in the left hemispheric subdural hematoma. Stable rightward shift of midline structures to approximately 5 mm. Stable small right hemispheric subdural hematoma. . [**11-13**] CT Head- IMPRESSION: 1. Expected postoperative pneumocephalus in the bifrontal regions secondary to interval evacuation of bilateral subdural hematomas. 2. Persistent hypodense subdural hematomas slightly smaller bilaterally with no significant midline shift. . [**11-14**] CT Head- IMPRESSION: Status post burr hole and craniotomy for bilateral subdural hemorrhage evacuation, with decreased degree of pneumocephalus and extent of the hemorrhages. Left parafalcine tiny dense subdural hemorrhage is decreasing from the prior study. . [**11-15**] CTA chest IMPRESSION: 1. There are no filling defects in the main and lobar pulmonary arteries to suggest pulmonary embolism. However, evaluation of the segmental and subsegmental branches was suboptimal due to inadequate opacification. 2. Bilateral ground-glass opacities in the perihilar, bilateral upper lobes, and superior segment of the right lower lobe are likely due to hemorrhage; aspiration has similar radiologic appearance. This pattern does not favor interstitial lung disease. 3. likely right pericardial cyst. 4. Mild-to-moderate right more than left simple pleural effusion with atelectasis of adjacent lung. 4. Multiple borderline-sized mediastinal lymph nodes. . [**11-15**] CXR IMPRESSION: AP chest compared to [**11-11**]: Widespread new interstitial pulmonary abnormality, increase in heart size and mediastinal vascular engorgement are findings of pulmonary edema due to cardiac decompensation. There is particularly pronounced abnormality in the right upper and paraspinal lower lungs; it could be asymmetric pulmonary edema or another process such as large scale pneumonia, aspiration or hemorrhage. Pleural effusion is small if any. No pneumothorax. Asymmetric edema, if that is the diagnosis, was explained by emphysema seen on the chest CTA performed earlier today. . [**2112-11-16**]: echo The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Left ventricular systolic function is hyperdynamic (EF>75%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric LVH with hyperdynamic systolic function. Mild mitral regurgitation. Calcified aortic leaflets without frank stenosis. Moderate pulmonary artery hypertension. . [**2112-11-17**]: CXR FINDINGS: There is a relative stable appearance to bilateral perihilar opacities. No pneumothorax or pleural effusion is present. There is widening of the upper mediastinum likely related to enlargement of vessels. The cardiac silhouette and hilar contours appear otherwise unchanged. IMPRESSION: 1. Stable appearance of the chest with findings most suggestive of pulmonary edema. . [**2112-11-19**] CXR FINDINGS: Cardiac silhouette is normal in size and has decreased slightly from previous study. Marked improvement in pulmonary edema which is nearly resolved, with only minimal residual interstitial edema remaining. Patchy alveolar opacity at right lung base has also improved, and likely reflects resolving dependent edema. No new or worsening lung or pleural abnormalities. . 10/19/201 CXR IMPRESSION: PA and lateral chest compared to [**11-15**] through 15: Pulmonary edema on [**11-17**] has largely resolved. Two regions of peribronchial opacification that remain are lateral and inferior to the right hilus. These are concerning for pneumonia given the improvement elsewhere. There is the suggestion of a new nodule in the left mid lung at the level of the sixth posterior interspace, not present on either prior chest radiographs or CTA on [**11-15**], and, if real, would have to be a septic embolus. When feasible I would obtain conventional chest radiographs to see if a nodule is present and [**First Name9 (NamePattern2) **] [**Last Name (un) **] evaluate the residual abnormality in the right lung. Brief Hospital Course: 70 year old man with known essential thrombocytosis on Anagrelide,and hypetension, who presented with bilateral subdural hematomas from trauma, ad was treated with bilateral craniotomies and burr holes. He reaur several transitions f care from services including internal medicine, the mdical and surgical ICUs, as wellas the cardiology service, overte core of his admission He was [**Hospital 90988**] transferred to Internal Medicine at the end of a two-week hospitalization. His course was notable for transient hypoxia, tachycardia which rauired multiple agents to be initiated, and at one point, he met SIRS criteria for potential sepsis and found to have diffuse pulmonary infiltrates likely due to aspiration +/- flash edema. Hiscourse was particularly notable for hypertension and supraventricular tachycardia whih were difficult to control, and persistently elevated WBC and platelet count in the setting of know hematologic disease. 1. Bilateral subdurals: Pt was admitted to the neurosurgery service. CT scan on [**11-12**] revealed slight increase in SDH. On [**11-13**] he was taken to the operating room and underwent a right sided mini craniotomy and left sided burr holes for evacuation of the SDH's. Surgery was without complication and the patient was extubated and transferred to the ICU. He remained stable overnight and was cleared for transfer to the floor on [**11-14**]. No further complications during his course occurred from NeuroSurgical perspective. Pt was started on Dilantin with normal levels through admission and discharged on 150 TID to follow up with Dr. [**Last Name (STitle) **] in [**5-11**] wks with repeat head CT at that time. Staples were removed prior to discharge. 2. SIRS criteria and hypoxia: While on the neurosurgial service, the pt developed increased agitation and required restraints and haldol administration. He became more tachycardic and developed SIRS criteria with more elevated WBC count (had baseline leukocytosis on admission), tachycardia, hyperventilation, and fevers. CTA was performed but did not show evidence of PE; it did show bilateral ground glass opacities concerning for aspiration vs pulmonary hemorrhage, given his essential thrombocytosis and increased predilection for bleeding. He was transferred to Internal Medicine, and spent one night in the MICU for worsening hypoxia in the setting of severe HTN and tachycardia. His hypoxia rapidly improved with HTN/tachycardia control and IV diuresis such that he was weaned to minimal O2 requirements. Pulmonary hemorrhage did not clinically fit and felt less likely; he was thought to have aspirated with some element of flash hypertensive edema. He was briefly treated with Vanc/Zosyn but this was quickly weaned off for over 1 week before discharge. We o not feelthat he had a pulmonary infection, given his subsequent course. By discharge, the patient had been afebrile and satting well on room air for over 1 week. Persistently elevated WBC count was thought to be due to hematologic process as he was ~14 on admission, rose to high teens, but back down to ~14 on d/c. Of note, the patient's CXR's were initially called as more consistent with aspiration, then later called as pulmonary edema; by this time he had been diuresed and dramatically improved to minimal supplemental oxygen via nasal cannula. We did not feel that he had significnt pulmonary edema, but itis ossible thata transient aspiration could have presented in this manner. We noted that a CXR prior to discharge to evaluate interval changes was formally read as possible infiltrate vs septic emboli. We did not feel these diagnoses fit with his clinical picture, andrelayd this information to the PCP and family to ensure follow-up imaging were performed. 3. Hypertension and tachycardia: After MICU call out, pt remained very hypertensive and tachycardic, with very frequent runs of supraventricular tachycardia, called as 2:1 Aflutter vs AFib vs MAT vs sinus with frequent ectopy, coupled to runs of bigeminy/trigeminy/SVT's. Frankly it was not so clear and likely a combination of the above. It was felt to be due to catecholaminergic storm of acute illness, possibly also related to the head bleed. Cardiology had been consulted and pt started on slow Amiodarone load and uptitration of nodal agents; he persisted through this and was getting more hypotense to low 100's, so was transferred to Cardiology service where he was more aggressively loaded with Amiodarone 400 tid for a total of one week, with plan to decrease to 400 daily thereafter. He was also started on both Metoprolol and Labetalol. His rate/rhythm improved to sinus in the 50-60's with only occasional ectopy, even when walking. Because of starting Amiodarone, pt was switched from Simvastatin to Atorvastatin. We suspected tha very close monitoing of his cardiac status would be needed, given his complex cardiac regimen, and therefore spoke with his referring providers and provided extensive discussion with the patient and family regarding warning signs and follow-up suggestions. Regarding HTN: Lisinopril was increased to 40 mg daily, and dual beta blockers as above. This improved to 120-130's by discharge, even while ambulating. . The pt and his family were repeatedly instructed on him being on 3 blood pressure and rate medications and that as his underlying intracranial process resolves, to be careful for bradycardia, hypotension, and what to look out for. They were able to relay their understanding of this. This medication regimen should be addressed in scheduled follow up visits. . 4. Hematology: Pt with known Essential Thrombocytosis (on ASA, Anagrelide) and pt's Hematologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45462**] had been contact[**Name (NI) **]. Pt with platelet count 600's through initial part of admission and ASA/Anagrelide held; however during latter part of admission his plt count continued to rise. Dr. [**Last Name (STitle) 45462**] recommended starting his Anagrelide which was done, and eventually Heme-Onc was consulted and recommended restarting ASA, as well. The NeuroSurgey team was contact[**Name (NI) **] and agreed with this as he was adequately stable from his srgery. Anagrelide was subseauently increased to 1mg [**Hospital1 **]. Plt count continued to rise up to ~1500 by discharge however the patient completely asymptomatic, and the final readig pior to discharge appeared to have begun to improve. He is to f/u with Dr. [**Last Name (STitle) 45462**]. Of note, pt restarted on iron per Dr. [**Last Name (STitle) 45462**], has had Iron-deficency Anemia before. . Of note ws a persistent WBC count ~14 on admission, peak to 17, then downtrending to 14 on d/c. As above regarding no evidence of focal infection, and these values were stabe throughout his admission. We attirbuted thiseither to his underlying hematologic process or his acute intracrnial process, but did not find an indication for empiric antibiotics. 5. Pt was full code through admission. Wife [**Name (NI) **] and daughter [**Name (NI) **] active through 2wk admission. F/u appts were made. I verbally communicated with Dr. [**Last Name (STitle) 45462**], Dr. [**Last Name (STitle) 51969**] and related his complicated course. I faxed this d/c summary to Dr. [**Last Name (STitle) 51969**], with whom pt has f/u 2days after discharge. Medications on Admission: - Anagralide 1g [**Hospital1 **] - Levofloxacin 500mg qd prescribed by PCP on Thursday - Simvastatin 40 qd - Lisinopril 30 qd - Ferrous sulfate 325 qd - Aspirin 81 qd - MVI - Vit D 400 qd - Gingko Biloba 400 qd - Vitamin A - Vitamin C - Vitamin B complex . Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. multivitamin Tablet Sig: One (1) Tablet PO once a day. 4. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a day: Continue taking this if you were taking before admission, otherwise don't. 5. vitamin A Oral 6. Vitamin C Oral 7. Vitamin B Complex Oral 8. anagrelide 1 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 9. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO four times a day. Disp:*120 Tablet(s)* Refills:*2* 12. phenytoin sodium extended 100 mg Capsule Sig: 1.5 Capsules PO TID (3 times a day). Disp:*135 Capsule(s)* Refills:*2* 13. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 17. amiodarone 400 mg Tablet Sig: One (1) Tablet PO three times a day for 3 days: Take 3 times a day on [**10-19**], [**11-25**], and [**11-26**]. Then, on [**11-27**] only take 400 mg daily until your Cardiology follow up. . Disp:*9 Tablet(s)* Refills:*0* 18. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day: Take 3 times a day on [**10-19**], [**11-25**], and [**11-26**]. Then, on [**11-27**] only take 400 mg daily until your Cardiology follow up. . Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: care network Discharge Diagnosis: Primary diagnoses this admission: Subacute bilateral subdural hematomas s/p bilateral mini-craniotomies / burr holes on [**2112-11-13**] Hypoxia, likely due to aspiration or pulmonary hemorrhage (felt less likely) with some element of hypertensive flash edema Supraventricular tachycardia: combination of atrial flutter and sinus tachycardia with very frequent PAC's and PVC's Hypertension Essential thrombocytosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 90989**], You were admitted to [**Hospital1 18**] and found to have bilateral subdural hematomas for which you went to the operating room and had procedures to remove the blood in your head. Afterwards, you had low oxygen levels; tests showed that you did not have a pulmonary embolus, but there were abnormalities in your lungs that could have been due to aspiration (stomach contents inhaled into your lungs), or blood loss into your lungs, but the latter was felt to be less likely. Your high blood pressure could have also contributed to some fluid buildup into your lungs, for which you were given a medication to remove fluid. Finally, you were given medications to slow down your heart rate and will need to continue them until Cardiology follow up, at which point you should discuss whether or not to continue them. Your platelet count rose because you were off Anagrelide for awhile but this was restarted as appropriate. You had some blood loss from a level of 33 to 26 likely due to the surgery, but this was stable and improved to 28 by discharge. The following changes were made to your medication regimen: 1. START Amiodarone: this medication was started to keep your heart rate down. You will take 400 mg three times a day until [**11-27**], at which point start 400 daily 2. STOP Simvastatin: this medication can interact with Amiodarone and was changed to Atorvastatin instead 3. START Atorvastatin 20 mg daily: this will take the place of Simvastatin at a lower side effect rate 4. INCREASE Lisinopril to 40 mg daily (from 30 mg daily) this will help your blood pressure 5. Your medication list also stated that you were taking Gingko Biloba. This is not a standard medication that we standardly recommend, so you can take this if you wish but we did not put this on your medicaiton list. You can discuss whether you should take this with your primary care doctor. 6. START Labetalol 200 mg twice a day - this is for blood pressure and heart rate. 7. START Metoprolol 25 mg four times a day - this is for blood pressure and heart rate. 8. START Phenytoin (Dilantin) 150 mg three times a day until your Neurosurgery follow up, this is to prevent seizures 9. START Iron (ferrous sulfate) 325 mg daily to help with your iron stores 10. START Docusate, Senna, and Polyethylene Glycol (Miralax) as needed to prevent constipation from Iron pills 11. INCREASE Aspirin to 325 mg daily As we extensively discussed, [**Male First Name (un) **] is on three blood pressure and heart rate lowering agents because we had such a difficult time controlling both. As his condition improves, he may need this medications lowered or stopped. We discussed things to look out for: dizziness or lightheadedness at rest or on standing, feeling not well, pulses less than 40 with symtpoms, chest pain, palpitations, paleness, etc. I have spoken to your Hematologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45462**] and your primary care [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 39527**] [**Last Name (Titles) 51969**] and given them verbal signout on your admission. You have an appointments as below. Finally, just before discharge you received a chest X-ray that as we discussed showed resolving abnormalities, but were concerning for other areas that we feel are not clinically relevant because you were doing so well. Followup Instructions: PCP [**Name Initial (PRE) **]:Friday, [**11-25**] at 11:15am With:[**Name6 (MD) **] [**Last Name (NamePattern4) 90062**],MD Location: FAMILY MEDICINE ASSOCIATES Address: [**Street Address(2) 78853**], [**Location (un) **],[**Numeric Identifier 78854**] Phone: [**Telephone/Fax (1) 51033**] You have an appointment with: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45462**], Hematology/Oncology at VA [**2112-12-8**] at 8am Department: RADIOLOGY When: TUESDAY [**2112-12-27**] at 1 PM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: TUESDAY [**2112-12-27**] at 1:45 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: FRIDAY [**2113-1-6**] at 1 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2112-12-4**]

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icd9cm

[ [ [] ] ]

[ "01.31", "02.91", "38.91" ]

icd9pcs

[ [ [] ] ]

33063, 33106

23439, 30807

351, 448

33564, 33564

12876, 12876

37125, 38383

9052, 9155

31115, 33040

33127, 33543

30833, 31092

1638, 7970

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9170, 9647

12387, 12857

267, 313

476, 1620

10184, 12359

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33579, 33690

7992, 8774

8790, 9036

71,983

174,052

38311

Discharge summary

report

Admission Date: [**2126-5-4**] Discharge Date: [**2126-5-12**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2195**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Lumbar Puncture Arterial Blood Gas Thoracentesis History of Present Illness: Ms. [**Known lastname 85375**] is an 87 year old woman with hearing impairment, atrial fibrillation, and recent hip fracture. She was in her usual state of health yesterday. This morning she appeared confused and was unable to communicate. Early this morning her son noted that she left the water on in the bathroom and walked back to bed. She normally asked for assistance in walking to the bathroom. Her son noted a rapid heart rate and then called EMS. . In the ED, initial vs were: T 103 P 150 BP 150/102 R 40s. She was 92% on RA. She was in atrial fibrillation with RVR, but her blood pressure medications were hold because of concern for sepsis. She was given vancomycin, cefepime, aspirin, and tylenol. In the ED she was arousable, but unable to communicate. She had 2 PIVs. . VS prior to transfer were 120 117/91 30 100% on NRB. When she arrived on the floor the history was partially obtained from the patient who communicates by writing and [**Location (un) 1131**] lips. The majority of the history was obtained through the son. The patient's husband who is also hearing impaired. He notes that she has had a cough recently that has been non-productive. She has had 1-2 episodes of urinary incontinence over the couple of months since her hip surgery. She has had episodes of diarrhea/constipation that are typical for her. She has not been complaining of pain. Her overall appetite has been slowly decreasing, but not acutely. Past Medical History: # CHF, chronic systolic & diastolic heart failure # Atrial Fibrillation on coumadin # S/p Right hip replacement [**1-9**] # Hypothyroidism # Hyperlipidemia # Chronic headaches # Depression # GERD, history of H. Pylori # History of bilateral pleural effusion thought [**1-1**] heart failure, s/p thoracentesis in [**2121**]. # History of fall and pelvic fracture # H/o pneumonia # H/o cataracts # Chronic Headaches Social History: Married. Lives with her husband who is also hearing impaired. Has 2 children. Denies tobacco, alcohol or drug use. Lives in duplex with son in one half. Uses a walker since hip fracture. Family History: Sister with [**Last Name **] problem. Brother with high cholesterol and heart disease. Physical Exam: Vitals: T: 98.3 BP: 115/96 P: 114 R: 24 O2: 99 RA on 35% O2 General: appears comfortable, pulling off face mask, able to nod appropriately, unable to provide written history or sign with son [**Name (NI) 4459**]: dry MM Neck: supple, JVP not elevated Lungs: dullness throughout the left lung field almost to the apex. Decreased breath sound at the right base. CV: irregularly irregular, tachycardic Abd: +BS, NT, ND GU: foley Ext: able to lift legs from bed, difficulty following commands so could not assess strength Exam on discharge: Sitting up in a chair eating lunch, smiling, interacting with family. No agitation. Decreased breath sounds at left base. Pertinent Results: Microbiology Data [**2126-5-6**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE- pending [**2126-5-6**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2126-5-5**] FLUID RECEIVED IN BLOOD CULTURE BOTTLES Fluid Culture in Bottles- pending [**2126-5-5**] MRSA SCREEN MRSA SCREEN- negative [**2126-5-5**] URINE URINE CULTURE- no growth [**2126-5-4**] URINE URINE CULTURE- no growth [**2126-5-4**] MRSA SCREEN MRSA SCREEN- negative [**2126-5-4**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2126-5-4**] BLOOD CULTURE Blood Culture, Routine-PENDING . Imaging [**2126-5-7**] Transthoracic Echo The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Diastolic function could not be assessed. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Mild aortic and mitral regurgitation. Mild pulmonary hypertension. Normal estimated systemic venous pressures. Study unable to adequately assess diastolic LV function in the setting of what appears to be atrial fibrillation. [**2126-5-4**] CT Head IMPRESSION: 1. No acute intracranial hemorrhage. Extensive small vessel ischemic disease. In case of clinical concern for acute infarction, an MRI can be obtained if not contra-indicated. 2. Right nasal polypoid lesion (2:4), arising from the nasal septum. This can be further evaluated with direct visualization. . [**2126-5-4**] Chest Xray IMPRESSION: 1. Large left pleural effusion and left basilar opacity, possibly represent atelectasis, but infection is not excluded. Please note that a left hilar mass cannot be excluded and a CT chest with IV contrast can be otained for further evaluation. 2. Small right pleural effusion. 3. Apparent air-fluid level overlying the cardiac silhouette in the right lung base. Dedicated PA and lateral is recommended for further evaluation. . [**2126-5-4**] Chest CT IMPRESSION: 1. Bilateral pleural effusions, left greater than right with mediastinal shift towards the right. Atelectasis of the left lung with only minimal aeration of the left upper lung zone. No evidence of underlying mass lesion. 2. Left atrial enlargement. 3. Subcentimeter AVM in the left lobe of the liver. 4. Vascular calcifications. . [**2126-5-5**] Thoracentesis Fluid NEGATIVE FOR MALIGNANT CELLS. Abundant neutrophils, mesothelial cells and histiocytes . [**2126-5-5**] Chest Xray Moderate volume of left pleural effusion persist after large volume left thoracentesis. No pneumothorax. Moderate right pleural effusion is larger. The cardiac silhouette is now more reliably imaged, moderately enlarged. Mild pulmonary edema may be present. Left lower lobe is largely airless and the left lower lobe bronchus opacified which could be due to obstruction or at least retained secretions. Followup advised. . [**2126-5-6**] Chest Xray Moderate bilateral pleural effusion, left greater than right, is roughly unchanged since [**5-5**], but difficult to compare because of variations in patient position. Left lower lobe remains collapsed and the lower lobe bronchus is airless, although it should be noted that intervening chest CT showed no mass or endobronchial obstruction. The lower lobe bronchus could be malacic or otherwise collapsed due to the persistent left pleural effusion and/or chronic atelectasis. Moderate cardiomegaly improved. Left perihilar opacification is probably mild residual edema related to recent reexpansion. . Labs on discharge: Brief Hospital Course: Ms. [**Known lastname 85375**] is an 87 year old woman with hearing impairment, atrial fibrillation, and large left sided pleural effusion. She presented with altered mental status, tachycardia, and fevers. . Fevers: Patient was febrile to 103 in ED but remained afebrile througout the rest of her hospitalization. She initially received vancomycin and cefepime in the ED. Her U/A looked positive initially, but urine cultures had no growth. Blood cultures have remained no growth to date. LP was negative. Pulmonary infection thought the most likely process given possible consolidation/collapsed lung on CT scan. She was placed on community acquired pneumonia coverage with vancomycin, ceftriaxone, and azithromycin (d# 1 = [**2126-5-4**]) for CAP. She completed a seven day course. . Altered mental status: CT of the head showed no clear evidence of hemorrhage. Altered mental status likely multifactorial to fever, hypoxia, CHF, and ICU delirium. Patient improved significantly when transferred out of the ICU, with residual minor confusion. She was continued on her standing Haldol, but has not required a PRN Haldol dose since [**2126-5-9**]. She has not required restraints while on the general medicine floor. . Pleural Effusion: Patient presented with a large pleural effusion. She had a history of a prior pleural effusion in [**2121**]. Thoracentesis performed on [**2126-5-5**] and revealed transudative effusion consistent with CHF. BNP was elevated at 3405 (unknown baseline). An echocardiogram showed preserved ejection fraction. She was initially diuresed with IV furosemide and has been given a standing dose of Lasix 40mg PO daily while on the general medicine service. . Atrial fibrillation: Upon presentation patient was in atrial fibrillation with RVR. Given concern for her mental status her Digoxin was discontinued and her beta-blocker was up titrated. After discussion with her PCP regarding the risks and benefits of Coumadin she was placed on a Lovenox to Coumadin bridge. Her heart rates ranged from 55-80 while on the medicine floor. If bradycardia becomes a problem would recommend decreasing Metoprolol to q8 hours. . Hypothyroidism: Continue home dose. TSH within range. . GERD: Continue home ranitidine and calcium carbonate. . Code Status: Per son, code status will remain Full Code pending further discussions with his sister. Medications on Admission: -Metoprolol tartrate 50 mg PO four times/day -Venlafaxine XR 75 mg [**Hospital1 **] -Senna 2 tabs [**Hospital1 **] -Digoxin 0.125 mg daily -Levothyroxine 100 mcg daily -Raloxifene 60 mg PO daily -Ca Carbonate 500 mg PO TID -Docusate 100 mg PO BID -Ranitidine 150 mg PO BID -Polyethylene Glycol PO MWF -Prostat nutritional supplement -Furosemide 20 mg PO MWF, 40 mg PO Tue, Thurs, Sun -Acetaminophen 1000 mg PO BID -Coumadin 3 mg TRSun, 2.5 mg MVFSat Discharge Medications: 1. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for pain. 9. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily (). 10. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous Q12H (every 12 hours): Until INR>2 for 48 hours. 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 12. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 16. Haloperidol 0.5 mg IV Q6H:PRN agitation Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of needham10 Discharge Diagnosis: Pneumonia Atrial fibrillation Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after being found to be less responsive at home. You were diagnosed with a pneumonia and received IV antibiotics. Your heart rate was also elevated, and your heart medications were adjusted. Your mental status improved significantly, and your heart rate remained stable. Followup Instructions: Please follow-up with your primary care physician within one week of discharge from Rehab.

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icd9cm

[ [ [] ] ]

[ "03.31", "34.91" ]

icd9pcs

[ [ [] ] ]

11442, 11505

7187, 7984

283, 333

11579, 11579

3245, 7144

12090, 12184

2461, 2549

10056, 11419

11526, 11558

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222, 245

7164, 7164

361, 1803

3102, 3226

11594, 11737

1825, 2241

2257, 2445

73,612

138,140

54633

Discharge summary

report

Admission Date: [**2195-8-14**] Discharge Date: [**2195-8-14**] Date of Birth: [**2122-10-10**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 165**] Chief Complaint: CAD, AS Major Surgical or Invasive Procedure: [**2195-8-14**] CABG x2, AVR, MV annuloplasty, PFO closure History of Present Illness: 72M with severe 3 vessel disease (100% RCA, 80% LAD, 40%-60% LCx), moderate MR, and moderate AS, has been multiply hospitalized for CHF (last [**Date range (1) 27112**]), including a recent PEA arrest. Past Medical History: CAD, MR, AS, CHF, pulmonary HTN, COPD (home O2), PVD, b/l carotid stenosis (occluded R ICA), benign neck tumors, DM Social History: Lived independently, but multiple recent admissions w/ discharges to rehab; most recently d/c'd home with hospice services. Current smoker - 1PPD x many years. Family History: Father and 2 brothers with CAD. Physical Exam: 96.8 58 124/53 20 97%3L see preop paperwork for physical exam Brief Hospital Course: Pt was taken to the OR. After sternotomy, his aorta was noted to be heavily calcified. Dr. [**Last Name (STitle) **] then discussed the high risk nature of the operation with the family; they indicated that he should proceed with the operation. A CABG (LIMA -> LAD), AVR, MV annuloplasty, and PFO were performed. Upon rewarming of the heart, the LV failed to contract. An additional CABG (SVG -> OM) was performed. Pt again failed to wean from bypass. The aorta was reopened, and the AVR was confirmed to be well-seated with good flow through the coronary ostia. Family was notified; BiVAD was agreed to be futile. Pt was decannulated and closed. He expired at 4:23pm. Medications on Admission: Metformin 1000 mg [**Hospital1 **], Lisinopril 40 mg DAILY Hold if SBP <90, Metoprolol Tartrate Dose is Unknown [**Hospital1 **], Furosemide 40 mg DAILY, Atorvastatin 20 mg DAILY, Aspirin 325 mg DAILY, Azithromycin 250 mg Q24H, Diphenhydramine 50 mg HS:PRN Insomnia Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: CAD, AS, MR, PFO Discharge Condition: expired Discharge Instructions: none [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2195-8-15**]

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icd9cm

[ [ [] ] ]

[ "39.61", "35.33", "37.61", "38.14", "36.12", "00.40", "35.21", "36.15" ]

icd9pcs

[ [ [] ] ]

2072, 2081

1048, 1727

286, 346

2141, 2150

909, 943

2043, 2049

2102, 2120

1753, 2020

2174, 2300

958, 1025

239, 248

374, 577

599, 716

732, 893

75,027

136,961

23452

Discharge summary

report

Admission Date: [**2175-1-16**] Discharge Date: [**2175-1-21**] Date of Birth: [**2127-2-19**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2009**] Chief Complaint: alcohol withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 47 yo chronic alcoholic w/ multiple previous ED visits and admissions for alcohol withdrawal and acute on chronic pancreatitis, most recently in [**2174-9-15**]. Pt was brought to ED via ambulance for symptoms of alcohol withdrawal. Pt states that he has been drinking ~1 quart of liquor daily, but that he has been trying to cut back. He states his last drink was 1 glass of brandy at noon on [**2175-1-15**]. Pt states that he has been feeling tired for "a while" and was very anxious. Per his most recent discharge summary from [**2174-7-15**], he is a type 2 diabetic on metformin and glypizide, but he has not been taking any of his medications. Pt only has mild abdominal pain, and vomited 1 x "for a few minutes" yesterday and had 1 x diarrhea. Pt is currently A&O x 3, and states that he has never had any withdrawal seizures, but "had DTs". Denies any fevers, chills, SOB, chest pain, or urinary symptoms. . In the ED inital vitals were, 96.7F, BP 180/78, HR 125, RR 20, Sat 100% RA. FS glucose 487. Pt was started on an insulin drip, given thiamine 100mg iv, 1L NS bolus, and given lorazepam 2mg iv x 2. Pt also received morphine 4mg iv x 1 and ondansetron 4mg iv x 1 before being admitted to FIUC. Serum alcohol level was 358, lipase 3131, serum sodium 126, and WBC 14.1. Anion gap 42. . On arrival to the ICU, Pt's vital signs were: HR 130, BP 178/82, RR 18, Temp 36.2, Sat 100%. . Pt currently appears to be intoxicated. Pt is A&O x 3. Reports mild epigastric pain. Past Medical History: Anxiety Diabetes, type 2, on oral medications, poorly controlled Alcohol abuse Hypertension Hyperlipidemia Chronic pancreatitis Social History: Patient states he owns business doing house repairs. He has had difficulty with ETOH in the past and has attended AA, but not recently. He lives with his wife and has custody of his 3 grandchirlren, 10, 7,5 years old. He smokes 3 cigs/day. No illicits. Family History: Alcoholism. DM/HTN/HL run in the family. Physical Exam: Admission Physical: Vitals: T: 36.2C BP: 160/91 P: 122 R: 18 O2: 100% RA. General: sluggish responses, but A&O x 3. Appears intoxicated. HEENT: Sclera anicteric, MMM, poor dentition, PERRL, EOMI, CN2-12 intact. Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic rate, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild epigastric tenderness, non-distended, bowel sounds present, no rebound or guarding, no organomegaly GU: no foley [**Year (4 digits) **]: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN2-12 intact, grossly 5/5 strength in upper and lower extremities bilaterally, grossly normal sensation throughout. . Discharge physical exam: BP 126/83, HR 100, RR 20, 100% RA In NAD OP moist Lungs CTA B Bilateral antecubital fossae contact dermatitis [**Name (NI) **] without edema Pertinent Results: Admission labs: [**2175-1-16**] 05:30AM BLOOD WBC-11.2* RBC-4.05* Hgb-11.7* Hct-35.6* MCV-88 MCH-29.0 MCHC-33.0 RDW-13.8 Plt Ct-247 [**2175-1-16**] 01:30AM BLOOD Neuts-88.8* Lymphs-7.8* Monos-3.0 Eos-0.2 Baso-0.2 [**2175-1-16**] 01:30AM BLOOD Glucose-400* UreaN-9 Creat-1.1 Na-126* K-4.6 Cl-83* HCO3-6* AnGap-42* [**2175-1-16**] 01:30AM BLOOD ALT-65* AST-89* TotBili-0.5 [**2175-1-16**] 10:47PM BLOOD Ethanol-NEG [**2175-1-16**] 01:30AM BLOOD ASA-NEG Ethanol-358* Acetmnp-10 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2175-1-16**] 05:30AM BLOOD Triglyc-664* [**2175-1-16**] 05:30AM BLOOD PT-10.9 INR(PT)-1.0 Cardiac enzymes [**1-16**] negative X 3 ABG: [**2175-1-18**] 04:18PM BLOOD Type-ART Temp-37.6 pO2-31* pCO2-32* pH-7.43 calTCO2-22 Base XS--2 Intubat-NOT INTUBA . Lipase trend: [**2175-1-20**] 05:20AM BLOOD Lipase-37 [**2175-1-16**] 05:30AM BLOOD Lipase-1662* [**2175-1-16**] 01:30AM BLOOD Lipase-3131* . Lactate trend: [**2175-1-17**] 08:43AM BLOOD Lactate-0.9 [**2175-1-16**] 06:17PM BLOOD Lactate-1.1 [**2175-1-16**] 09:30AM BLOOD Lactate-3.0* [**2175-1-16**] 06:25AM BLOOD Lactate-3.9* . Other labs: [**2175-1-19**] 03:20PM BLOOD Calcium-8.6 Phos-2.2* Mg-1.9 Iron-18* [**2175-1-19**] 03:20PM BLOOD calTIBC-218* Ferritn-886* TRF-168* [**2175-1-16**] 08:49AM BLOOD %HbA1c-11.5* eAG-283* TSH 1.1 Micro: URINE CULTURE (Final [**2175-1-17**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Blood culture [**2174-1-16**] and [**2174-1-17**]: pending . EKG [**1-16**]: Sinus tachycardia. Otherwise, normal tracing. Compared to the previous tracing of [**2174-9-28**] T wave abnormalities are no longer present. . Studies: CXR [**2174-1-16**]: CHEST, SINGLE AP PORTABLE VIEW. Slightly rotated positioning and low lung volumes. The heart is not enlarged. The aorta is slightly tortuous. No CHF, focal infiltrate, or effusion is detected. Minimal right basilar atelectasis is present. CXR [**2174-1-18**]: Lung volumes are quite low. Tip of the left PIC line is difficult to see because of cardiac motion, approximately 3 cm below the estimated location of the superior cavoatrial junction. Mild cardiomegaly has increased since [**1-16**], but there is no pulmonary edema or particular mediastinal venous engorgement. Small left pleural effusion may be present. . Discharge labs: [**2175-1-21**] 09:05AM BLOOD WBC-5.3 RBC-3.31* Hgb-9.5* Hct-28.8* MCV-87 MCH-28.6 MCHC-32.9 RDW-14.7 Plt Ct-342# [**2175-1-21**] 09:05AM BLOOD Glucose-219* UreaN-4* Creat-0.8 Na-134 K-4.1 Cl-102 HCO3-23 AnGap-13 [**2175-1-21**] 09:05AM BLOOD Calcium-8.5 Phos-2.1* Mg-1.6 Brief Hospital Course: Brief course: Pt is a 47 yo chronic alcoholic w/ multiple previous ED visits and admissions for alcohol withdrawal and acute on chronic pancreatitis, now admitted for alcohol withdrawal, DKA, and acute on chronic pancreatitis. He was initially admitted to the ICU for insulin gtt, and close monitoring. Once his AG was closed and started on SC insulin, he was transitioned to the medical floor on [**2175-1-19**]. Active issues: # Hyperglycemia/DKA: AIC 11.5%. Pt had serum glucose 400, HCO3 6, and anion gap of 42 on presentation. Though he is a Type 2 diabetic, given high anion gap, ketones in the urine, pt thought to have DKA +/- non-ketotic hyperosmolar state (can have overlap). Precipitating factors thought to be alcohol use and non-compliance on home oral diabetic medications. He was started on insulin gtt and monitored in the ICU. His anion gap initially closed, and was started on Lantus. However, his anion gap re-opened and he was restarted on the insulin gtt. [**Last Name (un) **] was consulted and recommended starting Lantus 20 units daily in addition to the drip. Once his AG closed, he was transitioned to sliding scale insulin and glargine. On the medical floor, pt expressed that he only wanted to do a [**Hospital1 **] regimen. Therefore, [**Last Name (un) **] recommended 15units [**Hospital1 **] 75/25. Pt received diabetic teaching, nutritional support, and social work consult during his admission. He wishes to follow up at [**Hospital **] clinic after discharge and an appointment has been made for him. See below. Ace inhibitor treatment is recommended. . # Mixed AG and non-AG acidosis: AG acidosis attributed to DKA and possible alcoholic ketoacidosis and lactic acidosis as above. He also developed a non-AG acidosis, attributed to aggressive normal saline resuscitation, which resolved once eating and NS stopped. . # Alcohol abuse: Pt was tachycardic, hypertensive, and agitated, [**Doctor Last Name **] 17 on CIWA scale upon arrival to [**Hospital Unit Name 153**]. He was initially given IV lorazepam, but on hospital day 1, was no longer [**Doctor Last Name **]. He was transitioned to po lorazepam prn. He was seen by social work. He did not display any signs of withdrawal on the regular medical floor. Pt reported that he was done with drinking due to its many complications. He was seen by SW to provide him with further resources. Pt reported that anxiety was a significant contributor to his drinking and expressed interest in starting SSRI therapy in the outpatient setting. . # Acute on chronic pancreatitis: Pt had mild abdominal discomfort on presentation with elevated lipase to 3131 on admission, likely caused by alcohol intake. He was also found to have elevated triglycerides. His abdominal pain resolved and lipase had trended down to 1662. He was advanced to a regular diet, with some diarrhea that improved. Lipase normalized and pt was able to tolerate a regular diet without complications. Would consider outpt GI follow up.. # Tachycardia: In the ICU, pt was tachycardic, possibly [**2-16**] alcohol withdrawal initially, though continued to be tachycardic when out of range of withdrawal. DKA likely initially as well given profoundly hypovolemic from osmotic diuresis. Pt had low-grade temps, but no fevers, and no sources of infection. He was comfortable in no pain. His HR trended downward. PE was considered, but pt had no desats in oxygenation and no chest pain, making this unlikely. This improved on the medical floor. Would consider outpatient echo to evaluate for ETOH induced cardiomyopathy. TSH was normal. . #normocytic Anemia: Hct has fallen from 39 on admission to 27, 32.1 on day of DC. Unclear what hct is at baseline as pt frequently presents with intoxication and hemoconcentrated hct. MCV chronically low-normal. Pt denies melena, hematemesis, coffee ground emesis. Iron studies c/w chronic disease. Stools ordered for guaiac. This can be further monitored in the outpatient setting. . Inactive issues: # Hypertension: unclear baseline but per prior DC summaries, generally SBP 140s-150s. Pt was previously on lisinopril 10mg po daily per report, but patient was not taking this medication recently. . # hyperlipidemia: Held statin given initially elevated LFT's. . Transitional care: 1.[**Last Name (un) **] f/u for continued reinforcement of DM regimen and teaching 2.consideration of SSRI for anxiety with psychotherapy 3.outpatient SW for ETOH/anxiety if pt willing 4.consideration of echo for what appears to be chronic, asymptomatic tachycardic 5.reinitiation of ACEI, statin, ?starting of ASA for DM. Deferred on starting at time of discharge given concern for repeat ETOH abuse and recent acute illness. Medications on Admission: Home Medications (Per [**2174-7-15**] dc summary, Pt states he's not taking): - Metformin - Glipizide - Pioglitazone - Lisinopril - Simvastatin Discharge Medications: 1. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Fifteen (15) u Subcutaneous twice a day. Disp:*1 month's supply* Refills:*1* 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. other You reported that you were on lisinopril and simvastatin some time ago. Please discuss with your PCP and [**Name9 (PRE) **] whether you should restart these medications 5. cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a day) for 5 days: To antecubital fossa. Disp:*1 tube* Refills:*0* 6. Insulin Syringe 1 mL 29 x [**1-16**] Syringe Sig: One (1) syringe Miscellaneous twice a day: use as directed for insulin injection. Disp:*1 month's supply* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Alcohol intoxication Alcoholic acute pancreatitis Diabetes, Type II Metabolic acidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with alcohol intoxication, abdominal pain that was found to be due to pancreatitis related to alcohol use and high blood sugars. Because of your high blood sugar and dehydration on admission, you were initially admitted to the medical ICU. You improved on insulin and with IV fluids. . It is very important that you receive treatment for your anxiety and stop drinking as this could be very dangerous to your health. It is also important that you take your insulin as directed and follow a diabetic diet. You are being discharged on new medications: You are STARTING insulin therapy and you expressed understanding of your regimen. 75/25 Mg twice a day, 15 units. Followup Instructions: [**Last Name (un) **] DIABETES FOLLOW UP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11712**], NP [**2175-1-31**] at 8:30am 1 [**Last Name (un) **] Pl [**Location (un) 86**], [**Numeric Identifier 718**] ([**Telephone/Fax (1) 3258**] Name: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Specialty: Internal Medicine When: Thursday [**1-26**] at 10:20am Location: [**Hospital **] MEDICAL CTR-GENERAL MEDICAL ASSOC. Address: [**Last Name (un) 4808**], [**Location (un) **],[**Numeric Identifier 8235**] Phone: [**Telephone/Fax (1) 60114**]

[ "250.12", "303.91", "285.9", "401.9", "577.1", "291.81", "276.1", "305.1", "272.4", "577.0", "276.2" ]

icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

11639, 11645

5915, 6329

324, 330

11775, 11775

3276, 3276

12633, 12664

2289, 2331

10808, 11616

11666, 11754

10639, 10785

11925, 12610

5619, 5892

2346, 3090

12675, 13251

265, 286

6345, 9886

358, 1850

9903, 10613

3292, 4373

11790, 11901

1872, 2002

2018, 2273

4385, 5603

3115, 3257

3,386

167,115

10116

Discharge summary

report

Admission Date: [**2136-7-16**] Discharge Date: [**2136-9-1**] Date of Birth: [**2072-5-17**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 905**] Chief Complaint: Renal Failure, Back Pain Major Surgical or Invasive Procedure: Intubation I+D of foot hemodialysis hemodialysis catheter placement Drainage of paraspinal abscesses\ Drainage of ethmoid sinus collections Nasogastric tube placement History of Present Illness: Patient is a 64 year old woman with a history of diabetes and mental retardation who presented to the [**Hospital1 18**] [**Location (un) 620**] ED on [**7-16**] with acute renal failure and back pain. . Patient is mentally retarded and has a 24 hour caregiver. She was recently seen in the ED and plain films were done of the hip and lumbar spine which showed no fracure and mild spinal stenosis. She was discharged on vicodin. She returned several days later and had an injection to her back or hip. According to her caregiver she has been taking less pos and has not taken her medications recently. Two days prior to admission she had a temperature of 102 at home. She is usually very functional and holds a job, but over the last two days she has been combative and uncooperative and refused to go to work. She was seen in her PCP's office where she was noted to have no temperature and her symptoms were felt to be due to back pain from spinal stenosis. . In the ED at [**Location (un) 620**] her creatinine on admission was 7.2 up from a baseline of 0.9. BUN was 127, AG 28, lactate 4.0 (delta/delta was 1). Her initial vitals were T 99.1, BP 90-112/45-57 with HR 90s, RR 27-45, O2 sat 91-96% on 2L. ABG was 7.28/18/65. She had only 89 cc of urine output. . Urine had > 100 wbc, moderate bacteria (MSSA), positive nitrite, and moderate wbc. Per renal there were muddy brown casts. . She was started on D5W with 150 mEq of NaHCO3 at 200cc/hr and received 1650 cc. She also received flagyl, vancomycin, levofloxacin and ceftazadime. Her ABG improved to 7.46/29/81; however her respiratory status declined and she was intubated for hypoxia and acidosis in the setting of sepsi and was transferred to [**Hospital1 18**] [**Location (un) 86**]. Past Medical History: COPD Mental retardation DVT [**1-/2130**] NIDDM Obesity Sciatica Hypertension Hypercholesterolemia Anxiety Psoriasis Social History: Lives in apartment with 24 hour caregiver; has a long term boyfriend. [**Name (NI) 1403**] part time. Guardian is [**Name (NI) 402**] [**Name (NI) 33801**] [**Telephone/Fax (1) 33802**] Family History: Pt unable to provide. Physical Exam: ADMISSION PHYSICAL EXAM VS: Tm 101.5 Tc 99.5 HR 88 BP 120/70 RR 20 (17-21) AC 400 X 20, PIP 26.0, Plateau 23.0 PEEP 5 FiO2 50 % ABG 7.35/49/133/28 Gen: intubated and sedated HEENT: pupils small but reactive to light, EOMI, sclera anicteric, MM dry. Neck: No LAD or thyromegly. JVD difficult to assess. CV: RRR with no m/r/g Lungs: coarse breath sounds Abd: tense, some bowel sounds ext: peripheral edema, macular blanching rash on buttocks and lateral aspect of legs. Pertinent Results: [**2136-7-17**] 02:12AM BLOOD Lactate-5.5* [**2136-7-17**] 04:22AM BLOOD Type-ART pO2-70* pCO2-47* pH-7.30* calTCO2-24 Base XS--3 [**2136-7-18**] 05:14AM BLOOD CRP-GREATER TH [**2136-7-22**] 03:56AM BLOOD CRP-236.7* [**2136-7-20**] 02:54AM BLOOD ANCA-NEGATIVE [**2136-7-23**] 03:20PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [**2136-7-23**] 03:20PM BLOOD HCV Ab-NEGATIVE [**2136-8-9**] 03:00PM BLOOD EDTA Ho-HOLD [**2136-7-17**] 06:28AM BLOOD PEP-NO SPECIFI [**2136-7-20**] 02:54AM BLOOD ANCA-NEGATIVE [**2136-7-20**] 11:05AM BLOOD Cryoglb-NO CRYOGLO [**2136-7-21**] 07:02AM BLOOD calTIBC-142* Ferritn-1184* TRF-109* [**2136-8-9**] 05:30AM BLOOD GGT-240* [**2136-7-17**] 01:45AM BLOOD ALT-60* AST-116* LD(LDH)-484* AlkPhos-151* TotBili-0.5 [**2136-7-17**] 01:45AM BLOOD Glucose-165* UreaN-136* Creat-7.0*# Na-138 K-3.6 Cl-95* HCO3-19* AnGap-28* [**2136-7-18**] 01:25PM BLOOD ESR-145* [**2136-7-17**] 03:24PM BLOOD Fibrino-1040* [**2136-7-20**] 02:54AM BLOOD Neuts-90.0* Bands-0 Lymphs-6.9* Monos-1.1* Eos-1.7 Baso-0.2 [**2136-7-17**] 01:45AM BLOOD WBC-29.3*# RBC-3.31*# Hgb-10.1*# Hct-29.5* MCV-89 MCH-30.6 MCHC-34.4 RDW-14.1 Plt Ct-374 . . CT Abd [**8-24**]: 1. No evidence of intestinal obstruction. 2. Stable, small bibasilar loculated pleural effusions. 3. Stable fluid collection in subcutaneous fat of lower back. . discharge labs: BUN 10, Cr 2.7 Hct 26.8, WBC 7.6 Brief Hospital Course: A/P: 64 year old woman with mental retardation and history of diabetes presents with acute renal failure [**2-23**] to sepsis and subsequent ATN requiring dialysis. . #) ID: Infectious foci this admission include lower paraspinal abscesses, sphenoid sinus collections, upper spinal phlegmons, UTI, and possible line infection. She was septic at admission and required ICU care and mechanical ventilation for respiratory failure (now resolved). A) Paraspinal abscesses: Initial MRI revealed epidural abcess from L4 to brain. Possible phlegmon not epidural abcess in brain. On [**2136-7-23**] cultures from the abscess grew MSSA. Paraspinal abscesses were drained by Orthopedics/Spine on [**2135-7-27**]. However, on [**2136-8-14**] Ortho was reconsulted for wound drainage and low grade temps. A repeat MRI at that time was consistent with discitis, osteomyelitis and primarily ventral epidural abscess at T6, T7 and T8 have improved and there is less spinal cord compression compared to [**7-29**]. There appears to have been a second poorly visualized epidural abscess ventrally at the T4 level. It has also improved. There is a loculated collection laterally at the T6 level, little changed. The ortho spine attending did not feel that this required further drainage due to patient's improving clinical status. Patient was treated with a course of Nafcillin. B) B/L sphenoid sinuses were drained by ENT on [**2136-7-28**]. C)Upper spinal phlegmons were not amenable to drainage, therefore will be treated with IV antibiotics. D) MSSA UTI was treated with 10day course of Ciprofloxacin (per ID recs) though it was likely [**2-23**]/ hematoligic spread of her sepsis. E) The patient developed high fevers (>105 F) on [**8-22**] and [**8-23**]. Abdominal CT at that time was negative. The fevers were thought to be [**2-23**] line infections. Her HD tunneled catheter was pulled [**8-24**] and her antibiotics were broadened. Blood cultures failed to grow any pathogen. The fevers resolved after removal of the line. After two days of being afebrile and with negative blood cultures, a temporary HD catheter was placed [**8-27**]. A permanent tunneled HD catheter was placed [**8-30**]. F) The patient developed diarrhea on [**8-21**], and metronidazole was started empirically. (C diff negative.) The patient will be discharged on oral metronidazole to be continued as long as she is on Nafcillin. A TEE on [**7-25**] was negative for endocarditis. MRV negative for jugular thrombus PLAN- Patient will complete a six week course of IV Nafcillin (2 grams q4hours). She will be evaluated by ID upon completion of this course at which time recommendations for any further antibiotic treatment will be made. The patient also has a 6 week follow up appointment with Ortho/Spine re: her paraspinal abscess. . #) Renal failure: Pt developed ARF [**2-23**] to sepsis and consequent ATN. The renal team was consulted and followed the patient closely throughout her admission. She developed rising creatinine and oliguria refractory to high-dose diuretics. Therefore she was started on hemodialysis on [**7-20**]. A tunneled IJ catheter was placed. As her HD catheter was thought to be cause of fever/sepsis [**8-22**] and [**8-23**], line pulled [**8-24**]. A temporary IR placed HD catheter was placed [**8-27**], this was changed for a permanent catheter on [**8-30**]. She is currently on HD MWF. She continues on Nephrocaps. She was initially oliguric, however on [**8-27**] she began to make increasing amounts of urine. Per Renal, she continued to require TIW dialysis at discharge, however, the patient will follow up with renal as an outpatient for monitoring of her renal function as we do hope that it will continue to improve and she may not require lifetime dialysis. . #) SDH: CT scan done [**7-19**] showed small subdural hemorrhage. Neurosurgery was consulted, and they recommended a goal INR of <1.3, but stated that prophylactic SQ heparin would not be problem[**Name (NI) 115**]. She was treated with keppra (500 [**Hospital1 **] X 2 days, 1000mg [**Hospital1 **] X 8 days). A repeat head CT revealed improvement in SDH. #) Afib w/ RVR: Patient had an episode of afib with RVR on [**7-19**]. The Afib resolved with 5 mg IV lopressor. She did have 2 recurrent episodes of afib during the admission (most recently [**8-6**]), both of which quickly resolved with Metoprolol 5 mg IV x1. She remained in normal sinus rhythm for the rest of the admission and is discharged on low dose Metoprolol. #) Elevated LFTS: most likely from sepsis, though patient was complaining of abdominal pain. No obvious abnormality on CT scan. US of liver showed Diffusely increased echogenicity throughout the liver. Finding likely reflecting fatty infiltration, although more severe forms of liver disease including hepatic fibrosis or cirrhosis are not excluded. By [**8-3**] her LFT's has trended down, however her alkaline phos remained elevated throughout the admission, etiology was unclear, however an elevated GGT suggested a hepatic etiology. . #)GI: Patient developed increasing abdominal pain on [**8-20**]. KUB at that time revealed possible ileus, Abdominal CT on [**8-21**] and again on [**8-24**] were unremarkable. The patient then developed diarrhea. C Diff was negative x1, however, the patient was started on empiric PO metronidazole. She will continue on metronidazole for the course of her naficillin regimen. . #) Diabetes: The patient has a history of non-insulin dependent DM. She was managed on an regular insulin sliding scale throughout the admission. There were no active issues with her diabetes. . #) Anemia: The patient received multiple transfusions of PRBCs this admission for low Hct. Her anemia is thought to be [**2-23**] chronic disease. #) Psych- the patient has a history of anxiety. She was continued on her home medication regimen. She did require daily emotional support from the nursing staff. . * On day of discharge her foley was discontinued and she was noted to have cloudy urine. UA was consistent with UTI. She was discharged on a short-course of renally-dosed levofloxacin. . Communication: guardian [**Name (NI) 402**] [**Name (NI) 33801**] [**Telephone/Fax (1) 33802**] (h), [**Telephone/Fax (1) 33803**] (c) [**Telephone/Fax (1) 33804**] (w). #) Full Code confirmed with guardian. Discussed with guardian on [**7-23**] grave prognosis. HCP left note in chart confirming full code status. HCP ok with trach/PEG if needed. Discharge Medications: 1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 weeks. 2. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q2-3H (every 2-3 hours) as needed. 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day): SC. [**Month (only) 116**] d/c once pt ambulating. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): Insulin sliding scale. 12. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed). 15. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 17. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 18. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours): Continue until pt reevaluated by ID on [**2136-9-13**]. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: Methacillin Sensitive Staph Aureus Paraspinal Abscess, Sepsis, Acute Renal Failure, UTI. Secondary Diagnoses: Chronic Obstructive Pulmonary Disease, Mental retardation, non-insulin dependent diabetes mellitus, obesity, sciatica, hypertension, ypercholesterolemia, anxiety, atrial fibrillation. Discharge Condition: Good. Tolerating PO, afebrile. Discharge Instructions: During this admission you were treated for sepsis, parasinal abscesses, Subdural hematoma, and acute renal failure. . Please continue to take all medications as prescribed. . If you develop fever >101.5, severe headache, worsening back pain, diarrhea, shortness of breath, or other symptom that is concerning to you please seek immediate medical attention. Followup Instructions: Orthopedic Surgery (Spine)- Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 33805**] [**2136-9-13**] at 9:30 AM. . Infectious Disease- Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2148**] [**2136-9-13**] 1:30 PM . Renal- Dialyis three times weekly, or as required if renal function continues to improve. Will need to be followed by nephrologist at the rehab facility. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "799.02", "008.45", "693.0", "794.8", "473.3", "110.9", "995.92", "518.81", "996.62", "496", "E879.1", "599.0", "564.89", "319", "722.93", "427.31", "E930.0", "038.11", "584.5", "272.0", "730.28", "731.8", "432.1", "584.9", "324.1", "324.0", "682.2", "682.7", "250.80", "276.2", "E849.7", "285.29" ]

icd9cm

[ [ [] ] ]

[ "38.95", "99.04", "97.49", "96.72", "03.09", "22.64", "96.04", "38.93", "39.95", "03.4", "38.91", "88.72" ]

icd9pcs

[ [ [] ] ]

12802, 12881

4531, 11028

295, 463

13227, 13261

3126, 4458

13666, 14171

2599, 2622

11051, 12779

12902, 13000

13285, 13643

4474, 4508

2637, 3107

13021, 13206

231, 257

491, 2239

2261, 2380

2396, 2583

17,074

147,313

449

Discharge summary

report

Admission Date: [**2137-4-23**] Discharge Date: [**2137-4-29**] Date of Birth: [**2090-12-9**] Sex: M Service: CARDIOTHOR CHIEF COMPLAINT: Aortic regurgitation. HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male with a history of coronary artery disease, status post stent to left anterior descending. Subsequent to this procedure, patient developed aortic regurgitation. He was evaluated by Cardiology and he underwent a catheterization on [**2137-4-9**], which showed aortic regurgitation 4+, normal coronary arteries with the stent being open, and a normal ejection fraction of 45%. The patient was then referred to Dr. [**Last Name (STitle) **] for aortic valve replacement. Patient denies any chest pain, nausea, vomiting, shortness of breath or dyspnea on exertion. PAST MEDICAL HISTORY: Significant for coronary artery disease, IJ nephropathy, stent to left anterior descending, hypertension. PAST SURGICAL HISTORY: Significant for a left calf reconstruction. MEDICATIONS ON ADMISSION: Zestril 10 mg po q.d., Atenolol 25 mg po q.d., aspirin 325 mg po q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient has rare ETOH use and no tobacco use. PHYSICAL EXAMINATION: Patient's in no acute distress. Temperature 98.6. Pulse 65. Blood pressure 160/73. O2 saturation 98% on room air. Patient has no carotid bruits, no lymphadenopathy. Chest is clear bilaterally. Patient is regular rate and rhythm with a 2/6 systolic ejection murmur. Abdomen soft, nontender with normal abdominal bowel sounds. Patient has no extremity edema. LABORATORY ON ADMISSION: White blood cell count 6.8, hematocrit of 43.7, platelets 186,000. Sodium of 137, potassium 4.3, chloride of 99, bicarbonate of 27, BUN 19, creatinine 1.0, INR of 1.1. Stress test done on [**2137-3-8**] was significant for 8.5 minute [**Doctor First Name **] protocol, stopped secondary to 20 mmHg drop in systolic blood pressure. Asymptomatic with a ejection fraction of 30-35%. Cardiac catheterization significant for an ejection fraction of 45%, hypokinetic wall motion, aortic regurgitation, which is rated at 4+ with normal coronaries. Electrocardiogram was significant for sinus rhythm with a rate of 71 with left anterior fascicular block. No ischemic changes. HOSPITAL COURSE: The patient on the day of admission went to the Operating Room where he underwent an aortic valve replacement with a #27 [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**] mechanical valve. Patient tolerated this procedure well and was transferred to the Cardiothoracic Intensive Care Unit in stable condition. Patient was extubated without incident. Patient remained hemodynamically stable and was weaned off all drips. Patient's hematocrit remained stable at 29. On postoperative day number one, patient continued to remain hemodynamically stable. Patient continued to be weaned off all drips. Chest tubes were discontinued without incident. The patient was started on his Coumadin for anticoagulation for his mechanical valve. Patient on postoperative day number two was transferred to the floor. Patient has remained hemodynamically stable. Patient's INR has risen appropriately to latest INR being 1.9. Patient has remained afebrile. On postoperative day number six, patient developed tachycardia on the monitor. Upon further evaluation, it was found that patient has tachycardia with frequent atrial premature contractions, but not to be in atrial fibrillation. Patient's blood pressure remained stable. Patient's electrocardiogram demonstrated an elevated PR interval of 300 milliseconds. Patient was continued on his beta-blockade and was restarted on his ACE inhibitor. Patient will follow-up with his primary care physician for electrocardiogram in one week and to evaluate the PR interval at that time. There will be no further intervention done by the Electrophysiologic Service at this time. Patient has now been tolerating a regular diet and has been ambulating at an activity level of 5 with Physical Therapy. Patient is stable and ready for discharge to home. DISCHARGE DIAGNOSES: 1. Aortic insufficiency, status post aortic valve replacement #27 [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**] valve. 2. Hypertension. 3. Hypercholesterolemia. 4. IJ nephropathy. MEDICATIONS ON DISCHARGE: 1. Atenolol 25 mg po q.d. 2. Lasix 20 mg po b.i.d. times seven days. 3. KCL 20 mEq po b.i.d. times seven days. 4. Colace 100 mg po b.i.d. 5. Enteric coated aspirin 81 mg po q.d. 6. Coumadin 10 mg po q.d. Does [**Name8 (MD) **] M.D. 7. Percocet 5/325 [**1-2**] po q. 4 hours prn. 8. Zestril 10 mg po q.d. FOLLOW-UP: Patient will follow-up with coagulation draws at [**Hospital3 3834**] to be called into his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Patient to follow-up with Dr. [**Last Name (STitle) **] in four weeks. CONDITION AT DISCHARGE: Stable. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2137-4-30**] 14:01 T: [**2137-4-30**] 14:01 JOB#: [**Job Number 3836**]

[ "414.01", "424.1", "V45.82", "583.89", "401.9", "997.1" ]

icd9cm

[ [ [] ] ]

[ "35.22", "39.61" ]

icd9pcs

[ [ [] ] ]

4141, 4349

4375, 4989

1030, 1139

2309, 4120

958, 1003

1226, 1601

5004, 5293

157, 180

209, 804

1616, 2291

827, 934

1156, 1203

60,782

136,419

41793

Discharge summary

report

Admission Date: [**2100-11-29**] Discharge Date: [**2100-12-4**] Date of Birth: [**2028-9-24**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2100-11-29**] Urgent Coronary artery bypass grafting x2 (left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the obtuse marginal artery). History of Present Illness: 72 year old male has a history of CAD with prior stenting done at [**Hospital3 **]. In [**2090**], he had LAD and LCX stents placed. In [**2095**] he had a NSTEMI and had a stent placed to the RCA. He has been doing well from a cardiac standpoint since then and states he has not seen a cardiologist for several years. He was recently seen for a routine physical and at that time mentioned that he has recently been experiencing recurrent episodes of chest pain. He describes progressive symptoms of anterior chest pain that occurs with activity such as walking. He has been able to walk through the pain and it goes away. He was referred for a stress test, which was done on [**2100-11-25**]. Preliminary results: He exercised on a [**Doctor First Name **] protocol. + 9/10 chest pain. No EKG changes. Nuclear imaging: reversible inferior wall defect. Due to the symptoms and abnormality on stress test, he was referred for cardiac catheterization. He was found to have left main disease and a IABP was placed and he was sent to urgently to the OR for CABG. Cardiac Catheterization: Date:[**2100-11-29**] Place:[**Hospital1 18**] LMCA: 80% mid to distal lesion LAD: non obstructed, stent widely patent LCx: stent widely patent RCA: stent widely patent Past Medical History: Coronary Artery Disease LAD and LCX stents [**2090**] CAD s/p NSTEMI [**4-14**] s/p RCA stenting Coronary Artery Bypass [**2100-11-29**] post-op CVA PMH: hypertension hyperlipidemia cardiac cath x [**Hospital3 90772**] with stents Social History: Race:caucasian Last Dental Exam:edentulous Lives with:Wife-[**Name (NI) **] Contact: [**Name2 (NI) 90773**] Phone #[**Telephone/Fax (1) 90774**] Occupation:Works full time as an electrical technician. Cigarettes: Smoked no [] yes [x] Hx:1ppd x 15 years Other Tobacco use:denies ETOH: < 1 drink/week [] [**2-15**] drinks/week [x] >8 drinks/week [] Illicit drug use:denies Family History: Premature coronary artery disease- uncle died of MI Physical Exam: Pulse:69 Resp:15 O2 sat:100/RA B/P Right:157/85 Left:160//74 Height:5'6" Weight:180 lbs General:done on stretcher in cath lab Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera , OP unremarkable ( dentures) Neck: Supple [x] Full ROM []no JVD appreciated Chest: Lungs clear bilaterally [x]Anterolaterally Heart: RRR [x] Irregular [] Murmur [x]1/6 SEM, [**1-14**] diastolic Abdomen: Soft [x] mildly distended ( usual per pt) non-tender [x] bowel sounds hypoactive;no HSM Extremities: Warm [x], well-perfused [x] Edema - none Varicosities: None [x]lying down Neuro: Grossly intact,nonfocal exam;MAE [**5-13**] strengths Pulses: Femoral Right: IABP Left:2+ DP Right: 1+ Left:NP PT [**Name (NI) 90775**] : NP Left : NP Radial Right: 2+ Left: 2+ Carotid Bruit Right:none Left:none Pertinent Results: [**2100-12-2**] 05:22AM BLOOD WBC-7.3 RBC-2.74* Hgb-8.6* Hct-26.3* MCV-96 MCH-31.3 MCHC-32.5 RDW-13.4 Plt Ct-130* [**2100-12-1**] 07:59AM BLOOD Hct-27.8* [**2100-12-1**] 02:06AM BLOOD WBC-13.7* RBC-2.61* Hgb-8.6* Hct-24.8* MCV-95 MCH-32.9* MCHC-34.7 RDW-13.0 Plt Ct-185 [**2100-12-2**] 05:22AM BLOOD Glucose-116* UreaN-18 Creat-1.0 Na-141 K-4.4 Cl-106 HCO3-25 AnGap-14 [**2100-12-1**] 02:06AM BLOOD Glucose-145* UreaN-14 Creat-1.1 Na-135 K-4.0 Cl-104 HCO3-24 AnGap-11 [**2100-11-30**] 04:22PM BLOOD Glucose-161* Na-131* K-4.3 Cl-101 TTE [**2100-11-29**] LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness and cavity size. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Normal diameter of aorta at the sinus, ascending and arch levels. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions PREBYPASS: Mildly decreased LV systolic function with LVEF = 40-45% with mild global HK. Valves are essentially normal. The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. 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 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 stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Normal coronary sinus. PFO present. POSTBYPASS: Improved LV systolic function with LVEF > 55%. No SWMA, Otherwise no change. . [**2100-12-3**], MRI/MRA head, neck IMPRESSION: Acute infarction in the left parietal frontal lobe/insula and tiny acute infarction in the left cerebellum. Small left MCA bifurcation aneurysm. No evidence for high-grade stenosis in the neck or intracranial vasculature. DR. [**First Name (STitle) **] [**Name (STitle) 12563**] Approved: FRI [**2100-12-3**] 7:23 PM Imaging Lab . [**2100-11-30**] CT head/neck IMPRESSION: 1. No CT evidence of territorial infarct. 2. Bilateral atherosclerotic disease involving the common carotid artery bifurcations, but no evidence of significant stenosis in the cervical or intracranial vasculature. 3. Incidential finding of a left 2 mm M1 bifurcation aneurysm. 4. Status post sternotomy with discrete subcutaneus air, extending from the anterior mediastinum along the cervical fascial planes. No evidence of abscess. Comment: The findings were communicated to Dr. [**Last Name (STitle) **] [**Name (STitle) 26216**] at 1:30 at 23/11 The study and the report were reviewed by the staff radiologist. DR. [**Last Name (STitle) 28396**] [**Name (STitle) 28397**] DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**] Approved: WED [**2100-12-1**] 10:20 PM Imaging Lab . [**2100-12-4**] 04:45AM BLOOD WBC-5.8 RBC-2.68* Hgb-8.7* Hct-25.9* MCV-97 MCH-32.7* MCHC-33.8 RDW-13.3 Plt Ct-191 [**2100-12-1**] 02:06AM BLOOD PT-14.8* PTT-34.7 INR(PT)-1.3* [**2100-12-4**] 04:45AM BLOOD UreaN-16 Creat-1.0 Na-141 K-4.5 Cl-108 Brief Hospital Course: The patient was admitted to the hospital after symptoms of chest pain and abnormality on stress test for referral for cardiac catheterization. On [**11-29**] he was found to have left main disease, an IABP was placed in the cath lab and he was sent to the urgently to the operating room. IABP was pulled intra op due to technical difficulties. On [**2100-11-29**] he underwent urgent coronary artery bypass grafting x2 (left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the obtuse marginal artery). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. POD2 he developed sudden onset of right facial droop and aphasia concerning for acute stroke. Stroke team was activated and STAT head CT revealed no acute hemorrhage or evidence of territorial infarct. There was hypodense areas in the left tinsula and right side of pons. Head and neck CTA showed atherosclerotic disease involving the common carotid artery bifurcations, but no evidence of significant stenosis in the cervical or intracranial vasculature and incidental finding of a left 2 mm M1 bifurcation aneurysm. Carotids [**12-1**] revealed left ICA<40% right ICA exam limited due to central line. He had demonstrated some improvement in his speech by the time of discharge and it was felt it was is encouraging that his overall comprehension was intact and that he did come up with most of the words he wants to say after some delay. Recovery was thought likely take place over several weeks. SBP goal was 120-160 for cerebral perfusion. ASA and Plavix was resumed for history of stents. He was hemodynamically stable on no inotropic or vasopressor support on POD1. Beta [**Month/Year (2) 7005**] was initiated on POD 3 and pacing wires were pulled after 3 doses. Blood pressure required for cerebral perfusion was difficult to maintain with beta [**Last Name (LF) 7005**], [**First Name3 (LF) **] this was discontinued. He was started on digoxin for rate control. MRI and MRA was done after pacing wires were out which revealed Acute infarction in the left parietal frontal lobe/insula and tiny acute infarction in the left cerebellum, as well as the aneurysm seen on CT. He is advised to have a follow-up CT head in 12 months to evaluate stability of small MCA aneurysm. He will follow up with the stroke team following discharge. The patient was gently diuresed toward the preoperative weight. He was transferred to the telemetry floor for further recovery. Chest tubes were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility and it was felt that he would be safe for home with PT services. OT and speech consults were also ordered. OT, PT and Speech Therapy will be ordered as an outpatient. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with services in good condition with appropriate follow up instructions. Medications on Admission: CLOPIDOGREL 75 mg daily METOPROLOL SUCCINATE 25 mg daily SIMVASTATIN 20 mg daily ASPIRIN 81 mg daily Discharge Medications: 1. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 5 days. Disp:*10 Tablet Extended Release(s)* Refills:*0* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 8. Outpatient Occupational Therapy dx: post-op CVA following urgent CABG Evaluate and treat 9. Outpatient Speech/Swallowing Therapy dx: post-op CVA following urgent CABG residual expressive aphasia and right facial droop evaluate and treat Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary Artery Disease LAD and LCX stents [**2090**] CAD s/p NSTEMI [**4-14**] s/p RCA stenting Coronary Artery Bypass [**2100-11-29**] post-op CVA PMH: hypertension hyperlipidemia cardiac cath x [**Hospital3 90772**] with stents Discharge Condition: Alert and oriented x3 nonfocal, expressive aphasia, right facial droop Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Right and Left - healing well, no erythema or drainage. trace Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: The office will call you with the following appointments: Wound Check: [**Telephone/Fax (1) 170**], 1 week Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**], 4 weeks Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] 3-4 weeks Call stroke prevention clinic for follow up in [**6-16**] weeks after discharge [**Telephone/Fax (1) 44**] Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 29247**] in [**4-13**] weeks [**Telephone/Fax (1) 29248**] **repeat CTA head in 1 year to evaluate stability of small MCA aneurysm** **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2100-12-4**]

[ "V45.82", "997.02", "272.4", "434.91", "411.1", "401.9", "414.01", "784.3", "285.1", "696.1", "781.94", "412" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.61", "36.15", "88.56", "36.11", "37.22" ]

icd9pcs

[ [ [] ] ]

11473, 11522

7021, 10254

322, 513

11797, 12067

3418, 6998

12908, 13711

2467, 2521

10406, 11450

11543, 11776

10280, 10383

12091, 12885

2536, 3399

272, 284

541, 1803

1825, 2058

2074, 2451

19,348

132,343

22120+57284

Discharge summary

report+addendum

Admission Date: [**2186-10-8**] Discharge Date: [**2186-10-21**] Service: NSU PRIMARY DIAGNOSIS: C5-6 unilateral skipped facet. HISTORY OF PRESENT ILLNESS: The patient is a pleasant 91- year-old gentleman, who had a fall yesterday from standing at home approximately 4 a.m. on [**2186-10-6**]. He reports recently he has had more frequent falls and this was nothing unusual. He reports no loss of consciousness, but persistent pain in his neck after his fall. He says the neck pain has persisted since his fall and ultimately he went to the Emergency Room the subsequent day and was seen there. In the outside hospital, he was found to have a right C5-6 locked facet and was subsequently transferred to the [**Hospital1 1444**] for further evaluation and treatment. PAST MEDICAL HISTORY: Status post prior falls. History of atrial fibrillation. Hypertension. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Doxazosin 2 mg q.d. 2. Lanoxin 0.25 mg q.d. 3. Plavix 75 mg p.o. q.d. 4. Senna. 5. Baby aspirin 81 mg p.o. q.d. PHYSICAL EXAMINATION: He was afebrile with stable vital signs. He was alert and oriented to the year and to his name, but not to his place. He had fluent speech. He has slight impaired hearing bilaterally. He has full extraocular movements and his face was symmetric. His pupils were 4 to 3 bilaterally reactive brisk. Tongue was midline. Grossly his cranial nerves were intact. He had 5/5 strength bilateral in all upper extremities and followed commands. He had normal sensation to light touch and pinprick. He had no Hoffmann's and no apparent clonus in his lower extremities. He had downgoing plantar flexes bilaterally. His reflexes were [**3-22**] throughout. LABORATORIES: His laboratories were unremarkable on admission. HOSPITAL COURSE: He was admitted to the Trauma service for further evaluation. A MRI of the C spine was ordered with recovery images. Plain films were repeated of his entire spine. He was admitted to the ICU in a hard collar. He was admitted to the Trauma service. The MRI confirmed unilateral skipped facet in the C5-6 reticular surface on the right. It showed some buckling of his ligament, and there was some display of a C5-6 disk from the subluxation. Given his stable neurologic function, he was placed in a hard collar and maintained under close observation in the ICU. Recommendation of maintaining a mean arterial pressure greater than 70 was recommended. Ultimately, he was intubated for the MRI scan. Patient did not tolerate the MRI scan without sedation. He had an unremarkable initial course in the hospital. He continued to move all four extremities and follow commands. In the morning of [**2186-10-10**], during morning rounds, he was noted to have a right flaccid upper extremity. He was noted the prior evening to have full strength in that upper extremity. Given this new finding, he was taken to stat MRI scan to reassess the alignment of his spine, and he was started on an emergent Solu-Medrol drip. He was taken emergently for ventral decompression at C5-6 ACDF with an attempted reduction followed by a dorsal reduction and stabilization. He tolerated the procedure well with no complications. Postoperatively, he was placed in a hard collar and films were done to confirm placement of the fixation. He continued to have a right persistent hemiparesis, but had some slight improving strength in his grips. Medicine was asked to consult regarding his cardiac function and a syncopal workup. The digoxin was discontinued and he was monitored on telemetry. Ultimately, he was seen by Medicine and assessed to have a presyncopal fall. No further recommendations were made. He was held off digoxin and continued on aspirin. His course in the hospital has otherwise remained uneventful. His hematocrit was kept above 30. He failed one attempt at extubation and had to be reintubated subsequently. He tolerated the procedure well with no complications. He remained intubated for several days. Ultimately, a trache and PEG were planned. However, he continued to do well prior to the trache and was extubated on a second trial. He maintained good saturations and did not require any further intubation. Ultimately his course in the hospital has remained uneventful. He has remained afebrile with stable vital signs. He has regained some increased strength in the right upper extremity and otherwise is following commands and at his baseline in all other extremities. He continues to oxygenate well with a face tent. He is currently stable for discharge to rehabilitative facility. DISCHARGE MEDICATIONS: See the discharge note. [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 12001**] Dictated By:[**Last Name (NamePattern1) 1361**] MEDQUIST36 D: [**2186-10-21**] 22:07:13 T: [**2186-10-22**] 04:16:04 Job#: [**Job Number 57799**] Name: [**Known lastname **], [**Known firstname 389**] Unit No: [**Numeric Identifier 10747**] Admission Date: [**2186-10-8**] Discharge Date: [**2186-10-27**] Date of Birth: [**2095-10-5**] Sex: M Service: NSU He continued to work with Physical Therapy and they did recommend rehab placement. He did have a swallowing study done, which indicated he had decreased ability to swallow and a PEG tube was placed by Interventional Radiology on [**2186-10-24**]. He tolerated this procedure well. He was started on his tube feeds and has not had any problems. He has been getting his medications via the tube. His staples were removed from incision, which is well healed. His serum sodium levels have been followed and has been in the 130-132 range. He is currently on 3 grams of sodium tablets 3x/day as well as 1 liter fluid restriction with no free water. He should continue to have his sodium levels monitored daily until they are within the normal range. He will follow up with Dr. [**Last Name (STitle) **] postoperatively in his clinic in three weeks with cervical spine x-rays at that time. [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 1772**] Dictated By:[**Last Name (NamePattern1) 10748**] MEDQUIST36 D: [**2186-10-27**] 11:45:07 T: [**2186-10-27**] 11:54:58 Job#: [**Job Number 10749**]

[ "276.1", "401.9", "E888.8", "839.05", "427.31", "344.40", "839.06", "780.2", "518.5" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "96.04", "96.6", "96.72", "81.02", "81.03", "44.32" ]

icd9pcs

[ [ [] ] ]

4654, 6323

1814, 4630

1074, 1796

171, 786

110, 142

809, 1051

75,454

122,286

18686

Discharge summary

report

Admission Date: [**2146-5-16**] Discharge Date: [**2146-5-24**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7591**] Chief Complaint: anemia Major Surgical or Invasive Procedure: egd History of Present Illness: The patient is an 85M with pmh MDS presenting with bright red blood per rectum and a decreased hematocrit. The patient was recently discharged on [**5-12**] with instructions to complete a two week course of augmentin and cipro for neutropenic fever, completing [**5-22**]. He reports sudden onset of explosive diahrrea last night, started as brown liquid and progressed watery and occurring every two hours. It was without any other associated symptoms. He went to [**Hospital1 18**] [**Location (un) 620**] where his stool was guaiac positive. He was transferred here where his hematocrit was found to be 18 from baseline 24. His diahrrea continued and progressed to bright red blood per rectum in the ED. Three peripheral IV's were placed and he was transferred to the [**Hospital Unit Name 153**]. Vitals prior to transfer were 95/58 90 100% RA. He received 1 liter of NS and A unit of blood was hung en route here to the [**Hospital Unit Name 153**]. . On the floor, he is reporting small amounts of bloody stool with any body movement. . Review of sytems: (+) Per HPI (-) Denies fever, chills, chest pain, SOB, abd pain Past Medical History: Oncologic History: 1. MDS on dacogen - presented in [**2143-9-28**] with pancytopenia, complained of dyspnea on exertion - cytopenias progressed and he had a repeat bone marrow done in [**1-4**] which showed a markedly hypercellular bone marrow with significant dysplasia in the erythroid and megakaryocytic lineages. There were >15% ringed sideroblasts. Flow cytometry demonstrated CD-34-positive cells comprised 4-5% of total blast gated events. Cytogenetics revealed [**11-16**] cells have abnormal chromosome 12 and an abnormal chromosome 17 in a possible three way translocation. - refractory to Procrit, at escalating doses and then became red blood cell transfusion dependent - Decitabine therapy was initiated [**2145-9-13**] but had to be discontinued due to a hematoma which developed at the site of a wound. He resumed C1D1 Dacogen for MDS on [**2146-2-21**]. So far he has tolerated therapy well but remains severely pancytopenic and requires frequent blood product support. . 2. MALT lymphoma of the stomach: no evidence of disease since [**2142**] - initially presented in [**2139**] with abdominal upset/indigestion. CT scan demonstrated perigastric adenopathy and EGD had a multilobulated mass with ulceration. Biopsy demonstrated extranodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT). - Bone marrow biopsy demonstrated mildly hypercellular marrow for age with megakaryocytic dysplasia and occasional ringed sideroblasts (10%) without evidence of lymphoma. Evolving myelodysplastic syndrome could not be excluded. - treated for Stage IIB MALT lymphoma of the stomach with 6 cycles of CVP, completed in [**11-30**] - recurred in [**2142**] and was treated with four weeks of Rituxan therapy ([**Date range (1) 51244**]) - no evidence of disease since this time. . Other Past Medical History: Open AAA repair-[**2130**] Cataract surgery HTN Social History: The patient is married with two children, three grandchildren and four great grandchildren. He smoked a pack a day for 40 years and quit in [**2123**]. He previously drank heavily, currently only 2 drinks/day. He is a retired electrician. Family History: Mother-died in her 70s of acute leukemia Father-died of AAA Sister-Hemochromatosis [**Name (NI) 51245**] Physical Exam: VS: Temp 97.2F, BP 110/56, HR 78, R 18, SaO2 97% RA GENERAL: WA elderly man in NAD HEENT: NC/AT, sclera anicteric, MMM, OP clear LUNGS: CTA bilat, no r/rh/wh HEART: RRR, nl S1-S2, no MRG ABDOMEN: hyperactive BS, soft/NT/ND, no palp HSM EXTREM: WWP, no c/c/e, 1+ pedal pulses Pertinent Results: [**2146-5-16**] 08:40AM BLOOD WBC-0.7* RBC-2.16*# Hgb-6.2*# Hct-18.8*# MCV-87 MCH-28.5 MCHC-32.7 RDW-16.9* Plt Ct-11* [**2146-5-16**] 08:30PM BLOOD Hct-17.8* Plt Ct-59*# [**2146-5-17**] 01:30AM BLOOD WBC-0.6* RBC-2.51* Hgb-7.4* Hct-21.7* MCV-87 MCH-29.6 MCHC-34.2 RDW-15.5 Plt Ct-59* [**2146-5-17**] 05:18AM BLOOD WBC-0.7* RBC-2.76* Hgb-8.0* Hct-24.0* MCV-87 MCH-29.0 MCHC-33.4 RDW-15.4 Plt Ct-59* [**2146-5-17**] 01:30AM BLOOD PT-14.7* PTT-28.6 INR(PT)-1.3* [**2146-5-16**] 08:40AM BLOOD Glucose-119* UreaN-51* Creat-1.0 Na-140 K-5.2* Cl-108 HCO3-26 AnGap-11 [**2146-5-17**] 01:30AM BLOOD Glucose-138* Creat-0.9 Na-146* K-4.0 Cl-116* HCO3-26 AnGap-8 [**2146-5-17**] 01:30AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.1 . [**2146-5-16**] 4:26 pm STOOL CONSISTENCY: WATERY Source: Stool. **FINAL REPORT [**2146-5-19**]** FECAL CULTURE (Final [**2146-5-18**]): NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2146-5-19**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2146-5-17**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . [**2146-5-17**] EGD FINDINGS: 1.Esophagus: Normal esophagus. 2.Stomach: a. Protruding Lesions: A ulcerated 5 cm mass with stigmata of recent bleeding of malignant appearance was found at the along the lesser curvature extending to the antrum. The scope traversed the lesion. Cold forceps biopsies were performed for histology at the gastric mass. b. Other: Unable to clip the vessel due to difficult location and access. 3.Duodenum: Normal duodenum. IMPRESSION: - Mass in the along the lesser curvature extending to the antrum (biopsy) - Unable to clip the vessel due to difficult location and access. - Otherwise normal EGD to second part of the duodenum . Labs on dc: . [**2146-5-24**] 12:00AM BLOOD WBC-1.0* RBC-3.15* Hgb-9.4* Hct-28.6* MCV-91 MCH-29.9 MCHC-33.0 RDW-15.1 Plt Ct-24* [**2146-5-24**] 12:00AM BLOOD Neuts-71* Bands-0 Lymphs-15* Monos-12* Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2146-5-24**] 12:00AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-2+ Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Schisto-1+ Burr-2+ [**2146-5-24**] 12:00AM BLOOD Glucose-112* UreaN-23* Creat-0.8 Na-142 K-3.8 Cl-108 HCO3-27 AnGap-11 [**2146-5-24**] 12:00AM BLOOD ALT-19 AST-14 LD(LDH)-182 AlkPhos-51 TotBili-0.4 [**2146-5-24**] 12:00AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0 Brief Hospital Course: Mr [**Known lastname 29298**] is a 63 yo gentleman with hx of hairy cell leukemia admitted for neutropenic fever, BRBPR concerning for recurrence of his maltoma. . # BRBPR: Requiring admission to the [**Hospital Unit Name 153**] for Hct of 18, pt improved with IVF and PRBCs. He was seen by GI initially and given the BRBPR endoscopy was deferred (likely diverticular bleed). However he developed melena, raising concern for upper GI bleed, so he underwent EGD on [**5-17**], which showed an ulcerated, malignant-appearing mass in the antrum of the stomach, with stigmata of recent bleeding. Biosies were taken but the vessel was unable to be clipped due to difficult location and access. The pt received a total of 7units PRBCs before stabilizing. Biopsies were pending on discharge (will need f/u in outpt setting), but given the likelihood of recurrent MALToma, the pt also underwent XRT to the stomach to aid in stopping the bleeding. He has not had any further diarrhea or BRBPR after transfer from the ICU, crit remained stable. Additionally, he was also started on Neupogen because his WBC has not recovered. He was discharged with instructions to f/u [**Hospital1 **]-weekly with heme onc for blood cts, neupogen injections. Pt will also be followed by rad onc for total 10 treatments of radiation. . # Myelodysplastic Syndrome on decitabine: Received C3 decitabine from [**4-25**] - [**4-29**]. Pt was treated with platelet transfusion x2 and PRBCs x2. . # Neutropenic fever: Pt with recent admission for neutropenic fever, defervesced on Cefepime as inpt. W/u negative for source on prior admission, therefore pt was discharged on empiric Abx course of Augmentin + Cipro x2 weeks. Cefepime resumed on readmission, however he was subsequently afebrile and cefepime was dc'd when ANC was >500. . #. Hypertension: Pt on atenolol and furosemide at home, which were held in the setting of GI bleed. Furosemide was restarted on discharge, however BPs remained low, therefore atenolol was held on discharge. [**Month (only) 116**] need to be uptitrated in the outpt setting if persistent hypertension. Medications on Admission: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 4. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 11 days. Disp:*33 Tablet(s)* Refills:*0* 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 11 days. Disp:*22 Tablet(s)* Refills:*0* 7. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 8. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 9. Magnesium 250 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Vitamin E Oral 11. Multivitamin Oral Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO three times a day. 4. Compazine 10 mg Tablet Sig: One (1) Tablet PO q 6H PRN as needed for nausea. 5. Magnesium 250 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Vitamin E Oral 7. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: bright red blood per rectum Secondary: MDS, MALT lymphoma, hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for fever and bright red blood in your stool. You were treated with fluids and blood products and your bleeding improved. You also underwent XRT to help stop the bleeding which you will continue on discharge. . You will need to come in on Wed and Fri for blood counts and neupogen. Additionally, you will follow up with Dr [**Last Name (STitle) **] on [**5-31**]. The following changes to your medications were made: -your atenolol was discontinued given your low BPs. You should speak with your primary doctor/oncologist on discharge to determine if and when this medication should be restarted. . Please call your doctor or return to the ED if you have any further bleeding, fever, or any other symptoms that are concerning to you. Followup Instructions: Please follow up on [**Hospital Ward Name 332**] 7 on Wednesdays and Fridays for blood draws and neupogen. Follow up with Dr [**Last Name (STitle) **] on [**5-31**].

[ "531.40", "401.9", "284.1", "288.00", "200.30", "780.61", "285.1", "238.75" ]

icd9cm

[ [ [] ] ]

[ "38.93", "92.29", "45.16" ]

icd9pcs

[ [ [] ] ]

10050, 10056

6541, 8653

269, 274

10181, 10181

4023, 6518

11112, 11282

3606, 3712

9558, 10027

10077, 10160

8679, 9535

10332, 11089

3727, 4004

223, 231

1364, 1430

302, 1346

10196, 10308

3283, 3333

3349, 3590

13,436

135,767

10959

Discharge summary

report

Admission Date: [**2197-4-17**] Discharge Date: [**2197-4-27**] Date of Birth: [**2119-11-29**] Sex: F Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 77-year-old Cantonese-speaking female first seen by Dr. [**Last Name (STitle) **] on [**2197-3-30**] for evaluation of an 8 cm renal mass of the mid upper left kidney and by CT MR it is unresectable from the pancreas and extends into the IVC with extension just below the hepatic veins as well as into the gonadal vein. Likewise, the patient has a low volume of chest metastases by chest CT. The patient is now admitted for debulking nephrectomy preceded by angioinfarction. The mass was originally found on CT on [**2197-2-27**] as part of evaluation for anemia. She has also encountered a 20 pound weight loss since her cholecystectomy on [**2195-9-15**]. Otherwise, the patient has no chronic symptoms and no history of gross hematuria or UTIs. The patient has no smoking history. Her family history is clear of GU cancer. Staging includes a BUN and creatinine of 20 and 1.8, alkaline phosphatase of 165, amylase and bilirubin normal, albumin 2.7, calcium 9.3, hemoglobin 10, platelets 262,000, INR 1.3. A bone scan showed no obvious foci of mets. MR shows an 8 cm mass in the upper pole of the left kidney with positive enhancement. There is no fat plane between the mouth and pancreas. The left adrenal gland was slightly enlarged. The left adrenal vein has thrombus. Thrombus extends through the left renal vein into the IVC, up 6 cm to within 2 cm of the hepatic vein. Small accessory LRA, right kidney probably okay. PAST MEDICAL HISTORY: Borderline hypertension. PAST SURGICAL HISTORY: 1. Laparoscopic cholecystectomy. 2. Tubal ligation. 3. Without history of clotting disorder. PHYSICAL EXAMINATION ON ADMISSION: General: The patient was well appearing, nonEnglish-speaking Asian woman. Neck: Without masses or bruits. Chest: Clear. Heart: Normal sinus rhythm. Abdomen: Soft, flat, nontender, moveable mass in the left flank when the patient turned in the lateral position. HOSPITAL COURSE: The patient was admitted on [**2197-4-17**] and initially taken to Interventional Radiology where an angioinfarction procedure of the left kidney was performed. On the following day, [**2197-4-18**], the patient was taken to the Operating Room where she underwent a ten hour surgery performing a left nephrectomy and left adrenalectomy, IVC thrombectomy, liver mobilization by Dr. [**Last Name (STitle) **] with the assistance Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. During the surgery, the patient received 7 liters of crystalloid, 25 units of packed red blood cells, 22 units of fresh frozen plasma, 3 units of cryoprecipitate, and 3 units of platelets. She had an approximately 11 liter blood loss. Postoperatively, the patient was sent from the Operating Room directly to the Surgical ICU where she remained intubated. The patient's acute surgical anemia persisted for which she received a number of additional units of red blood cells. The patient received perioperative Cephazolin for antimicrobial prophylaxis. The patient had an epidural in place while in the ICU. She remained intubated until postoperative day number three when she was finally extubated. Prior to extubation, the patient had a slow and cautious wean due to the fact that she had a respiratory acidosis. While in the ICU, the patient experienced some confusion for which she received only small periodic doses of Ativan. Haldol was avoided due to the fact that she had a prolonged QTC interval. While in the ICU, the patient's urine output was of no particular interest, although it remained relatively low and did remain constant and the patient appeared to be secreting fluids adequately. Also, postoperatively, the patient experienced persistent tachycardia as well as hypertension for which she was started on Lopressor. The patient was seen by Nutritional Services while in the ICU who determined the patient to be malnourished. For that reason, the patient was started on TPN. The patient was also started on vitamin K due to prolonged coagulopathy without signs of acute blood loss. Also, while in the ICU, the patient required treatment for hypokalemia as well as hypomagnesemia and hypocalcemia. On postoperative day number six, the patient was transferred from the Intensive Care Unit to the regular Urology floor where the patient continued to flourish. She was seen by physical therapy who had indicated that the patient is doing well physically and should do well with a home nurse for physical therapy. The patient's bowels began to move and the patient was started on a regular diet which she tolerated well. Her Foley catheter was removed and the patient was able to urinate normally. It is now [**2197-4-27**] and the patient is being discharged in good condition. She is to follow-up with Dr. [**Last Name (STitle) **] in one week for staple removal. She is also to follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in one to two weeks for blood pressure monitoring. She is going home with VNA with a Cantonese-speaking nurse. She may observe a high-calorie diet with plenty of fluids. She should avoid strenuous activity, no driving while on pain medication. She may shower but take no baths. She may resume any iron or vitamin regimen that she was taking at home. She may take Colace for constipation. She may take Tylenol in lieu of Dilaudid for pain if she wishes. DISCHARGE MEDICATIONS: 1. Dilaudid 2 mg q. four to six hours p.r.n. pain. 2. Colace 100 mg b.i.d. p.r.n. constipation. 3. Lopressor 50 mg p.o. b.i.d. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**] Dictated By:[**Last Name (NamePattern4) 12487**] MEDQUIST36 D: [**2197-4-27**] 08:36 T: [**2197-4-29**] 00:52 JOB#: [**Job Number 35569**]

[ "276.8", "197.0", "401.9", "189.0", "285.1", "276.2", "453.2", "263.0" ]

icd9cm

[ [ [] ] ]

[ "07.22", "99.15", "88.45", "55.51", "38.07" ]

icd9pcs

[ [ [] ] ]

5607, 6020

2109, 5584

1689, 1807

1822, 2091

1640, 1666

9,993

150,740

27336

Discharge summary

report

Admission Date: [**2154-5-20**] Discharge Date: [**2154-6-14**] Date of Birth: [**2082-10-23**] Sex: M Service: MEDICINE Allergies: Bee Pollen / Penicillins / Opioid Analgesics Attending:[**First Name3 (LF) 398**] Chief Complaint: transfer s/p ?vfib arrest Major Surgical or Invasive Procedure: intubation cystoscopy History of Present Illness: 71 yo M w/ PMH HTN, atrial fibrillation on coumadin and digoxin, GI bleed on vioxx, Parkinson's Disease who was visiting his family from [**State 2748**] when he collapsed in the hotel lobby and hit his head. When the EMT's arrived, he was unresponsive with agonal breathing and in cardiac arrest. He was intubated and given atropine. In the ambulance, he had sinus bradycardia and was given epi x4/atropine x4, he then went into polymorphic VT and then torsades. He was shocked 4 times, given magnesium, bicarb and lidocaine and converted to sinus tachycardia. On arrival to [**Hospital1 **] ED, the ECG showed NSR with aterolateral ST depressions. Initial CE were negative but subsequent CK rose to 285 with MB 8.1 and troponin I rose to 0.7. He was taken to the cath lab at [**Hospital1 **] this am (admitted pm [**5-19**])and was found to have a right dominant system with a single vessel disease w/ complex ulcerated serial high grade (90%) stenoses of the proximal LAD with preserved antegrade flow. Arterial sheath was sutured in place and he was transferred to [**Hospital1 18**]. At [**Hospital1 18**], he was taken to the cath lab where he received 2 overlapping cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] 3.5 x 28 mm and 3.0 x 13 mm in the mid-proximal LAD. Mildly slowed flow was treated successfully with intracoronary nitroglycerin and adenosine. He was also started on clinda for a ?of aspiration pna on cxr. Of note after the patient had an NGT placed, bright red blood was noted in the tube. GI was consulted and felt it was due to trauma. Per the OSH records, the patient had not been feeling well over the past few days with decreased appetite and loose stools. He had 2 vodka-tonics on the day of admission. Past Medical History: Atrial Fibrillation - Chronic HTN Parkinson's Disease ?Cirrhosis [**2-14**] chronic alcohol use H/O GI bleed on Vioxx. Social History: Mr. [**Known lastname **] is retired and lives with his wife in [**Name (NI) 30705**], CT. Etoh - H/O heavy use, most recently 4-5 drinks per week Tob - no h/o use Family History: No FH of CAD Physical Exam: T 98.4 BP 129/73 HR 69 RR 17 O2 Sat 94% AC 650x12, FIO2 1 Peep 2/PS 0 GENL: intubated, sedated, NAD, responds to commands with head nod HEENT: PERRL, EOMI, MMM NECK: supple, no JVP appreciated CV: RRR, no m/g/r, Nl S1,S2 PULM: clear to auscultation anteriorly ABD: obese, ND, NABS, No HSM EXT: chronic venous stasis changes, scar right knee, 2+ nonpitting edema to knees, 2+ radial/brachial/PT pulses Neuro: sedated, moves extremities on command Pertinent Results: [**2154-5-20**] 06:32PM GLUCOSE-96 UREA N-14 CREAT-0.6 SODIUM-134 POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-30 ANION GAP-13 [**2154-5-20**] 06:32PM CALCIUM-8.0* PHOSPHATE-3.1 MAGNESIUM-1.6 [**2154-5-20**] 06:32PM WBC-12.8* RBC-4.43* HGB-14.7 HCT-42.8 MCV-97 MCH-33.1* MCHC-34.2 RDW-15.1 [**2154-5-20**] 06:32PM PLT COUNT-144* [**2154-5-20**] 06:32PM PT-18.3* PTT-130.3* INR(PT)-1.7* [**2154-5-20**] 06:19PM PLT COUNT-138* [**2154-5-20**] 05:41PM TYPE-ART TEMP-36.8 PO2-414* PCO2-52* PH-7.42 TOTAL CO2-35* BASE XS-8 INTUBATED-INTUBATED [**2154-5-20**] 05:41PM O2 SAT-98 [**2154-5-20**] 04:13PM TYPE-ART PO2-403* PCO2-46* PH-7.48* TOTAL CO2-35* BASE XS-10 INTUBATED-INTUBATED [**2154-5-20**] 04:13PM O2 SAT-98 [**2154-5-20**] 04:00PM CK(CPK)-186* [**2154-5-20**] 04:00PM CK-MB-7 cTropnT-0.29* . Data from OSH: [**5-19**] -CK 54, Trop <0.04 -Urine tox - + benzo -WBC 12.2 (63P, 27L, 9M), HCT 51.9, PLT 191, INR 1.44, PTT 26.9, NA 137, K 4.5, CL 91, CO2 39, BUN 14, Cr 0.8, Mg 2.2, TB 1.1, ALT 14, AST 32, AP 54 -Dig 1.1 . [**5-20**] -CK 285, MB 8.1, Trop 0.74, Chol 139, TG 87, HDL 59, LDL 63, BNP 158 -TSH 1.21 -HEPB core, ag - neg, HEPC - nonreactive -WBC 13.8 (80 P, 2 B, 9 L, 9 M), HCT 49.8, PLT 185 . CXR: Moderate cardiomegaly. Abnl right heart border with a nodular appearance, blunting of the left costophrenic angle and increased opacity of medial right hemidiaphragm. . OSH TTE: Normal LV size and thickness with middistal anterior, anteroseptal, inferior,lateral and apical akinesis. EF 20-25%. Mild to moderate MR. [**First Name (Titles) **] [**Last Name (Titles) **], Moderate TR. Severe Pulm HTN. . TTE ([**2154-5-24**]):1.The left atrium is normal in size. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size is normal. Right ventricular systolicfunction is normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. 5.The mitral valve leaflets are structurally normal. 6.There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . CT head (noncontrast) - no evidence of infarction, hemorrhage, mass lesion, mass effect. Some patchy mucosal thickening in left posterior ethmoid cells . CT C-spine - no subluxation, stenosis, fx, (+)degenerative changes. . ECG: afib 58, low voltage in 1, aVF so difficult to determine axis, deep TWI in V4-V6. . CXR: 1. Endotracheal tube in a standard position. 2. Mild congestive heart failure with bilateral pleural effusions right greater than left. 3. Left retrocardiac opacification . CATH: Selective coronary angiography of the right-dominant circulation demonstrated single-vessel disease. The RCA was not engaged. The LMCA and LCX were patent without significant lesions. The proximal-mid LAD had a complex, ulcerated 95% stenosis. Successful PCI of the LAD with two overlapping Cypher DES (3.5 x 28 mm and 3.0 x 13 mm), both post-dilated with a 3.75 mm balloon. . [**5-29**] CT chest - (prelim) No PE, Bilateral lower lobe atelectasis, Moderate left and small right pleural effusion. . [**5-29**] CT head - No intracranial hemorrhage or mass effect. . [**5-26**] KUB - Compared to the prior film of [**2154-5-25**], there is a different distribution of air now more readily visualized in the small bowel, although nondistended in appearance. There is no free air, pneumatosis, or evidence of ascites. Vertebroplasty changes are appreciated. . [**5-24**] TTE: 1.The left atrium is normal in size. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size is normal. Right ventricular systolicfunction is normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. 5.The mitral valve leaflets are structurally normal. 6.There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Hospital Course is summarized below: Besides his NSTEMI, his hospital course has been notable for urotrauma from foley self DC, for traumatic NG tube placment which GI did not feel required endoscopic evaluation. His respiratory status was complicated by desaturations thought to be secondary to mucus plugging on [**5-20**] and volume overload. He was weaned and extubated on [**5-24**], but intermittently needed bipap for hypercarbia, especially at night. Surgery was consulted on [**5-24**] for abdominal distention with dilated cecum, which was likley air ileus which improved after stopping bipap. On [**5-27**] he pulled his foley and exsanguinated through his foley, requiring 5 units of pRBC's and placement of foley. His respiratory status was improving and called out to [**Hospital Ward Name 121**] 6. He was doing well until 4 am on [**5-29**], when he had a PEA arrest. He was given epi and atropine which converted him to SVT, intubated, and then he was shocked twice and moved back into the ICU. This event was felt most likely to be secondary to mucus plugging, so pulmonary was called and suggested changing him to the MICU service for pulmonary management. He was extubated 1 day after transfer and called out to the floor with an unremarkable course. . On the night of [**6-2**] the patient had frank hematuria following foley DC, so the foley was replaced and irrigation was started. Around 8 am on the morning of [**2154-6-3**], he was noted to be in sinus tachycardia on telelmetry and he was found minimally responsive with SBP in the 80's. He got fluids and then began to desaturate to the 90's. After 2 liters of fluids he was still somewhat hypotensive and was started on dopamine and brought to the MICU. He became more alert but started complaining of intense low back pain. He desaturated into the mid 70's on NRB, looked cyanotic so he was intubated and the dopamine was weaned off. A central line was placed. . His second MICU course is summarized by problems below: 1. Urethral bleeding - foley was re-inserted and urology evalated patient again. he was found to have foley catheter within false lumen of urethral prostate and it was replaced with 18 french coudae catheter with resolution of bleeding. He required 3 untis of pRBC for hct drop from 33 to 25. 2. Resp Failure - pt was initially intubated in setting of hemodynamic instability and mild fluid overload. However, he was unable to be extubated secondary to multiple episodes of tachypena, acute desatureations/hypoxia, tachycardia, and hypotension while on pressure support. He was bronched on [**2154-6-9**] showing tenacious mucus pluggs predominately on right side. He was treated with aggressive chest PT, guafenesin, mucomyst, and suctioning with improvement in clearance of secretions. During bronchoscopy, he was noted to have several areas of white plaques concerning for candidiasis. Sputum culture grew yeast and he was initiated on 7 day course of fluconazole. It was felt that he did not have pulmonary yeast infection but it was contributing to his secretions. He was aggressively diuresed over the course of his MICU stay. In addition, his NIF was -10. There was concern that his weakness was secondary to parkinson's disease. Neurology consultation felt that it was not parkinson's disease. Fluroscopy was performed to evaluate diaphram movement showing no deficiets. It was felt that he had global resp muscle weakness secondary to deconditioning. The patient was to be transitioned for tracheostomy secondary to his generalized weakness, however he improved and ultimately extubated on [**6-12**] once his secretions were managed and he passed spontaneous breathing trial. His NIF prior to discharege was -40. His respiratory status has remained stable requiring 2-3 L of nasal canula oxygen since extubation. 3. Cardiac ischemia - shortly after his blood loss anemia secondary to profuse urethral bleeding he developed deep lateral T waves inversions on EKG. Cardiology was consulted and felt that changes were due to demand ischemia in setting of blood loss and hemodynamic instability. No signs of in-stent thrombosis. He ruled out for MI by cardiac enzymes and EKG changes resolved after adequate resuscitation. 4. paroxysmal atrial fibrillation - his anti-coagulation was held prior to MICU transfer [**2-14**] urethral bleeding. His anti-coagulation was re-instituted on [**6-11**] by heparin drip bridge to coumadin. Goal INR [**2-15**]. 5. Ileus - during MICU course pt developed large distended abdomen requiring NGT decompression. KUB shows signs of ileus. All narcotics were held and he was given aggressive bowel regimen including dulcolax suppository, colace, senna, enemas with improvement. 6. delta MS [**Name13 (STitle) **] extubation, pt was noted to have waxing and weaning mental status consistent with delerium. He improves with re-orientation 7. FEN - he was fed with tube feeds but did not get adequate nutrion secondary to multiple attempts to extuabate and holding tube feeds. After extubation he was noted to have hoarse voice (has h/o ? partial vocal cord paralysis). Speech and swallow evaluation demonstarated no evidence of aspiration and recommended thin liquids and regular solids. He will require future evaluate for speech therapy. 8. Patient is FULL CODE. 9. Follow-up [ ] goal INR [**2-15**] for a.fib [ ] f/u cardiology in [**3-16**] weeks for NSTEMI (see d/c plan) [ ] f/u urology for urethral bleeding in [**3-16**] weeks (see d/c plan); 18 french coude cath only [ ] complete 7 day course of fluconazole (started [**6-11**]) [ ] no narcotics - will develop ileus [ ] continue plavix for 9 months or until told to d/c by his cardiologist [ ] needs daily chest physical therapy, suctioning, [ ] keep fluid balance even to mildly negative daily to avoid chf [ ] needs speech evaluation for hoarse voice Medications on Admission: Aldactone 25 mg daily Atenolol 25 mg daily Digotek 0.25 mg daily Coumadin 2 mg daily Folic Acid Sinemet 25/100 tid Allopurinol 300 mg daily Vicodin prn Omeprazole 20 mg daily Centrum Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: 1. mucus plugging 2. chf 3. [**Female First Name (un) **] tracheitis 4. parkinson's disease 5. deconditioning 6. blood loss anemia 7. urethral bleeding 8. nstemi 9. ileus 10.atrial fibrillation 11.hypertension Discharge Condition: good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 L per day Followup Instructions: 1. follow up with urologist for your bleeding in the next 3 weeks; call ([**Telephone/Fax (1) 772**] to set up an appointment 2. have coagulation (ie PTT and INR) drawn QOday for goal INR of [**2-15**] for atrial fibrillation 3. call ([**Telephone/Fax (1) 5909**] to set up a follow up appointment with your cardiologist in the next 3-4 weeks. 4.

[ "416.8", "414.8", "303.90", "410.71", "728.87", "571.2", "599.4", "112.89", "V58.61", "560.1", "599.7", "E912", "518.81", "293.0", "414.01", "401.9", "285.1", "996.76", "427.5", "507.0", "427.31", "933.1", "428.31", "332.0" ]

icd9cm

[ [ [] ] ]

[ "99.29", "37.22", "00.66", "96.04", "96.72", "00.17", "38.93", "99.62", "96.48", "36.07", "96.09", "93.90", "88.56", "00.46", "96.6", "99.20", "00.40", "96.71", "99.04" ]

icd9pcs

[ [ [] ] ]

13276, 13347

7163, 13042

331, 354

13601, 13608

2977, 7140

13789, 14139

2481, 2495

13368, 13580

13068, 13253

13632, 13766

2510, 2958

266, 293

382, 2141

2163, 2284

2300, 2465

56,032

144,940

25144

Discharge summary

report

Admission Date: [**2167-2-12**] Discharge Date: [**2167-2-20**] Date of Birth: [**2092-9-15**] Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Cozaar Attending:[**First Name3 (LF) 106**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: thoracentesis History of Present Illness: 74 y/o F with PMHx significant for dCHF, HTN, HL, DM, who was transferred from and OSH with respiratory failure s/p intubation. She initially presented to the OSH on [**2167-2-3**]. At that time, she was referred from her podiatrist's office with complaints of dyspnea, lethargy, and respiratory distress. She had also had a nonproductive cough for the past few weeks; she lives with her son, who had recently had a respiratory infection. She was initially intubated for respiratory failure from [**2-4**] to [**2-8**]. She required reintubation on [**2-9**] because of worsening respiratory failure. At the OSH, blood cx were positive for H.flu, and sputum GS was significant for GPC in pairs and GN coccobacilli resembling H.flu. CXRs were significant for bilateral pleural effusions, the right of which was tapped. Cx data from here thoracentesis was not available at the time of transfer. The patient's hosptial course was also significant for development of episodes of sinus pauses, lasting ~7 seconds on telemetry. Reportedly, these episodes responded to atropine; however, the patient did have a temporary pacer placed. Also, of note, on the day of transfer, the patient was noted to have an elevated in her troponin to 0.38 (from 0.02 previously). She was transferred from the OSH to the CCU for further evaluation of what was thought, according to the transfer note, to be worsening heart failure in the setting of PAF, high grade AVB with sinus exit block, and possible ischemia. On arrival to the CCU, the patient's VS were T= 99.6 BP= 120/64 HR= 92 RR= 24 O2 sat= 98% on CMV/Assist 450x14 with PEEP of 5 and FiO2 of 40%. She was able to to nod appropriately to questions. She denied any pain at that time. Other ROS was unable to be obtained, as the patient was intubated. Past Medical History: - dCHF - DM2 - HTN - dyslipidemia - chronic pleural effusion - hypothyroidism - ?asymmetric septal hypertrophy on echo Social History: Lives with son. [**Name (NI) **] active tobacco or EtOH use. Ambulated with cane. Family History: Mother died of esophageal cancer; father died of a MI. Mother was diabetic. Physical Exam: VS: T= 99.6 BP= 120/64 HR= 92 RR= 24 O2 sat= 98% on CMV/Assist 450x14 with PEEP of 5 and FiO2 of 40%. GENERAL: 74 y/o F in NAD. Intubated. Nods appropriately to questioning. HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. ET tube in place. NECK: No significant JVD noted. CARDIAC: Irregular rhythm. [**1-3**] holosystolic murmur, loudest at the apex. LUNGS: Intubated. Coarse breath sounds. CTA anteriorly. ABDOMEN: Obese. Soft, NTND. No HSM appreciated. EXTREMITIES: Pitting edema in all 4 extremities. 2+ DP pulses bilaterally. SKIN: Ecchymoses and hyperpigmented patches on pt's back. Healing ulceration on plantar aspect of pt's right foot. PULSES: Right: DP 2+ Left: DP 2+ NEURO: Able to move all four extremities. Able to follow commands. Able to nod appropriately to questioning. Pertinent Results: LABORATORY DATA: OSH lab data significant for BUN 34, Cr 1.24, Alb 1.9, WBC 7.9, Hct 31.5, Tn 0.38 [**2167-2-12**] 10:19PM TYPE-ART PO2-122* PCO2-43 PH-7.47* TOTAL CO2-32* BASE XS-7 [**2167-2-12**] 10:19PM LACTATE-0.8 [**2167-2-12**] 10:19PM O2 SAT-97 [**2167-2-12**] 08:44PM GLUCOSE-120* UREA N-36* CREAT-1.3* SODIUM-148* POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-32 ANION GAP-12 [**2167-2-12**] 08:44PM ALT(SGPT)-22 AST(SGOT)-25 LD(LDH)-231 CK(CPK)-31 ALK PHOS-122* TOT BILI-0.8 [**2167-2-12**] 08:44PM CK-MB-NotDone cTropnT-0.31* proBNP-6033* [**2167-2-12**] 08:44PM ALBUMIN-2.3* CALCIUM-7.9* PHOSPHATE-3.7 MAGNESIUM-2.2 [**2167-2-12**] 08:44PM WBC-8.4 RBC-3.80* HGB-10.3* HCT-31.6* MCV-83 MCH-27.3 MCHC-32.7 RDW-16.3* [**2167-2-12**] 08:44PM NEUTS-79.2* LYMPHS-12.6* MONOS-5.8 EOS-1.9 BASOS-0.5 [**2167-2-12**] 08:44PM PLT COUNT-288 [**2167-2-12**] 08:44PM PT-12.7 PTT-27.7 INR(PT)-1.1 [**2167-2-20**] 07:00AM BLOOD WBC-3.4* RBC-4.31 Hgb-11.1* Hct-34.8* MCV-81* MCH-25.8* MCHC-31.9 RDW-16.0* Plt Ct-416 [**2167-2-20**] 07:00AM BLOOD Neuts-60.0 Lymphs-26.8 Monos-9.2 Eos-3.3 Baso-0.7 [**2167-2-20**] 07:00AM BLOOD Plt Ct-416 [**2167-2-20**] 07:00AM BLOOD [**2167-2-20**] 07:00AM BLOOD Glucose-221* UreaN-16 Creat-0.8 Na-139 K-3.7 Cl-103 HCO3-29 AnGap-11 [**2167-2-20**] 07:00AM BLOOD estGFR-Using this [**2167-2-20**] 07:00AM BLOOD Calcium-10.0 Phos-2.9 Mg-2.6 OSH ECG's: A.fib; HR 60's to 100's; Left axis; slight ST depressions in II, aVF; slight ST elevation in aVR; noteable for decreased voltage compared to prior ECG; ECGs without any dynamic changes over the past few days TELEMETRY: OSH telemetry significant for a 7 second sinus pause 2D-ECHOCARDIOGRAM (OSH): Maintained systolic function, hyperdynamic LV (EF 60-70%), moderate aortic sclerosis, trace MR, [**12-31**]+ TR, moderate to severe pHTN CXRs (OSH): bilateral pleural effusions, vascular congestion, bibasilar atelectasis, ?right perihilar infiltrate CXR at [**Hospital1 18**] (my read): bilateral pleural effusions with blunting of the costophrenic angles, increased opacification in the right lower lung, can't rule out infiltrate [**2167-2-13**]- TTE The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. There is mild functional mitral stenosis (mean gradient XXmmHg) due to mitral annular calcification. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . [**2167-2-14**] -CT chest without contrast 1. Moderate-to-large bilateral simple pleural effusions. Evidence of loculation, right more than left. Focal RML consolidative density is concerning for focal pneumonia. 2. Moderate bibasilar atelectasis. 3. Moderate cardiomegaly with heavily calcified mitral annulus. 4. Moderate anasarca. . CXR [**2167-2-18**] : The patient has been extubated. There has been a corresponding decrease in lung volumes with extensive increased bibasilar opacities, which are compatible with either atelectasis or consolidations. There is also an increase in interstitial markings and pulmonary vascularity suggesting interstitial edema. There is no pneumothorax. The moderate-to-large left-sided effusion is probably increased in size and probably for the most part free flowing. Increased right basilar opacification probably reflects increased atelectasis with a likely similar size of the small-to-moderate right-sided effusion. IMPRESSION: Increased bibasilar opacities and left pleural effusion following extubation. Brief Hospital Course: 74 y/o F with PMHx significant for dCHF, HTN, HL, DM, who was admitted OSH with respiratory failure, intubated. Recent hospital course complicated by persistent respiratory failure, bilateral pleural effusions, Afib with RVR and development of sinus pauses on telemetry raising concern for sick sinus syndrome. . # Respiratory Failure: She was admitted intubated from an outside hospital due to respiratory distress. This was thought to be multifactorial, related to pneumonia and heart failure. Culture data from the outside hospital showed that she had an H.influenza pneumonia. She was found to have a left loculated pleural effusion on chest x-ray and subsequently underwent thoracentesis, with removal of 1.6 L of fluid. She had initially been treated with ceftriaxone at the outside hospital. She later became febrile and this was switched to vancomycin and zosyn. Once it was clear that her infection was due to H.flu her antibiotics were narrowed to zosyn alone and she completed a course of zosyn. Her respiratory status improved and she was extubated. Congestive Heart Failure: She was found to be volume overloaded with pulmonary edema contributing to her respiratory distress. An echo showed a hyperdynamic EF of 75-80% and left ventricular hypertrophy. She did have an elevation in her cardiac enzymes but this was felt to be related to demand ischemia in the setting of CHF. She initially required a lasix drip, but was weaned to lasix IV boluses. She responded well to lasix boluses of 40mg IV. She was discharged on lasix 40mg p.o daily.She may continue to need intermittent lasix boluses of 40mg IV at rehabilitation for continued diuresis. At the time of discharge she continued to require 2LNC. Her respiratory status should be monitored and her electrolytes should be checked daily while taking lasix. . # Hypertension: The patient's blood pressure was found to be poorly controlled and. She was symptomatic from her hypertension, experiencing occaisional dizziness. She required IV hydral and IV metoprolol while she was npo for blood pressure control. Antihypertensives were added to her regimen sequentially to control her blood pressure. She was discharged on metoprolol,amlodipine and valsartan for blood pressure control. Her blood pressure should continue to be monitored at rehab and her antihypertensive regimen adjusted accordingly. [**Last Name (un) **]/ACEI should be avoided as the patient has a history of allergy with these medications inducing cough. . # Rhythm: At the Outside hospital the patient had been noted to have intermittent episodes of atrial fibrillation.On [**2-10**] she had a [**6-4**] second pause and required placement of a [**6-4**] second pause and a temporary pacemaker was placed. This had initially raised the concern of sick sinus syndrome. She initially required IV metoprolol for afib with RVR but then converted to sinus rythm. She had continuous telemetry monitoring during her hospitalization at [**Hospital1 18**], however she did not experience any further pauses on telemetry thus her temporary pacemaker was discontinued and she was able to tolerate p.o metoprolol for control of her rythm without instigation of further pauses. She required anticoagulation with coumadin for her atrial fibrillation. She was bridged with heparin. She did experience some epistaxis and hematuria on heparin drip which was subsequently discontinued. She should continue to take heparin SC until her INR is in the therapeutic range of [**12-31**] on coumadin. Her INR should be monitored daily while she in rehab with the dose of her coumadin adjusted accordingly. . Chronic Renal Failure: Her creatinine rose to 1.3 from a baseline of 0.8 to 1.0. This was thought to be secondary to poor forward flow due to her congestive heart failure. Her creatinine improved with diuresis and she should continue to have daily monitoring of her BUN/creatine and electrolytes while on lasix. . # Altered mental status: She had a prolonged course of intubation which required sedating medications. On extubation her sensorium was altered .This was thought to be secondary to delirium in setting of recent prolonged intubation. She had no focal neurologic deficits. Her mental status continued to improve and she was alert and oriented to person place and time at the point of discharge. . # Diabetes: She has a history of diabetes. She was kept on insulin sliding scale while inpatient. Her home medications of glimeperide and metformin were restarted at the time of discharge. Her glucose finger sticks should be checked prior to meals while she is in rehab. . #Hypothyroidism: Her TSH was noted at the outside hospital to be elevated at 5.4. Her T4 was 7.2. On admission to [**Hospital1 18**] from [**Hospital1 **] she was on levothyroxine however a medication reconciliation showed that she had not been on this medication as an outpatient. Her TFT's should be rechecked by her PCP and the need for levothyroxine should be reassessed by her PCP. Medications on Admission: Home medications glimepiride 2 mg [**Hospital1 **] coreg CR 10 mg [**Hospital1 **] lasix 80 mg [**Hospital1 **] vitamin D [**Numeric Identifier 1871**] units weekly metformin 500 mg [**Hospital1 **] chlorthalidone 25 mg daily potassium 10 meq [**Hospital1 **] cozaar 50mg once a day . Medications on Transfer: Lasix Boluses (40 mg IV x 1 today) - Lopressor 2.5 mg IV q 8hrs - Arixtra 2.5 mg SC daily - Combivent 4 puffs MDI QID - Diprivan gtt at 25 mg/hr - Antifungal Cream to inner thigh [**Hospital1 **] - KCl 20 mg daily - Duonebs q6hrs - MVI daily - Thimaine 100 mg daily - Vancomycin 1 gm daily - Zosyn 2.25 gm q6hrs - Levothyroxine 50 mcg daily - Chlorhexidine Mouthwash - Protonix 40 mg IV daily - HISS - Florastor 250 mg NGT [**Hospital1 **] - Morphine Sulfate 1-2mg q3hrs PRN - Ativan 0.5-1mg q3hrs PRN Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 7. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day. 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO ONCE A WEEK ON SATURDAYS. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: Primary: Pneumonia . Secondary Diastolic Heart Failure Discharge Condition: alert and oriented to person, place and time. Discharge Instructions: You were admitted to the hospital because you were having difficulty breathing. This was because you had heart failure and a pneumonia. Some fluid was removed from your lungs to provide you with relief and to test the fluid. You were found to have a pneumonia which was treated with antibiotics. You also received diuretics and oxygen to treat your heart failure . You also had very high blood pressure and we added some medications to control your blood pressure. You are at risk for stroke because of your atrial fibrillation. You were started on coumadin to prevent stroke. It is very important that you take your coumadin every single day. . The following changes were made to your medications: Coumadin 5mg daily Valsartan 160mg daily Norvasc 10mg daily Metoprolol 12.5mg twice a day Aspirin 325mg daily Heparin 5000mg TID We decreased lasix from 80mg twice a day to 40mg daily. . We stopped chlorthalidone 25mg daily We stopped coreg CR 10mg [**Hospital1 **] We stopped potassium 10meq [**Hospital1 **] . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: 1. Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: [**Hospital **] Clinic [**Location (un) 551**], [**Hospital1 18**] [**3-27**], [**2166**] at 3:30pm. [**Telephone/Fax (1) 2378**] . 2. Cardiology: Dr [**Last Name (STitle) **] [**Name (STitle) 8051**], Suburban Cardiology & Internal Medicine, [**Location (un) 63049**]. Telephone ([**Telephone/Fax (1) 8052**]. Tuesday [**2167-3-17**] at 3:15pm.

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icd9cm

[ [ [] ] ]

[ "34.91", "38.93", "96.71", "96.6" ]

icd9pcs

[ [ [] ] ]

14121, 14204

7335, 11280

291, 306

14303, 14351

3278, 7312

15501, 15923

2382, 2459

13192, 14098

14225, 14282

12354, 12640

14375, 15477

2474, 3259

244, 253

334, 2124

11296, 12328

12665, 13169

2146, 2267

2283, 2366

61,215

100,141

34876

Discharge summary

report

Admission Date: [**2173-10-1**] Discharge Date: [**2173-10-20**] Date of Birth: [**2133-4-7**] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 26411**] Chief Complaint: perineal infection Major Surgical or Invasive Procedure: [**2173-10-1**] Radical debridement of scrotum, perineum and abdomen. History of Present Illness: HPI: The pt is a 40yM with a history of diabetes who was transferred from [**Hospital 8641**] Hospital by Mediflight where he presented with scrotal pain and swelling 2 days after an incision and drainage of a small scrotal abscess and was found to have an exam c/w Fournier's Gangrene and subcutaneous gas on CT. The pt reports that he waited in the ED at [**Location (un) 8641**] for 3 hours in early afternoon where erythema of his scrotum and swelling progressed to his lower abdominal region. After his transfer to [**Hospital1 18**], he was noted to be afebrile but over the course of an hour became diaphoretic and ill appearing. The pt denies SOB< CP, neurological sx, urinary sx, or GI sx. PMH: DM, HTN, chronic back pain PSH: Vasectomy Med: Atenolol 50", oxycontin 40", ASA 81', Metformin 1000' All: NKDA Soc: Live in [**Last Name (un) 53428**], NH. Wife [**Doctor First Name 803**] can be reached at [**Telephone/Fax (1) 79837**] Labs: CH 7 129 94 25 306 AGap=18 3.3 20 1.3 CBC- 11.5 / 34.1 / 142 PT: 15.1 PTT: 26.2 INR: 1.3 OSH CT Abd: Scrotal air tracking anteriorly and posteriorly with additional gas in the buttock PE: VS: 100.4 96 100/56 21 94 Diaphoretic RRR CTAB Abdomen soft, NT, NT, erythema tracking to the right inguinal crease, within marker, crepitus palpable over left inguinal crease Phallus circumcised mild, ecchymosis at base Scrotum the size of grapefruit, ecchymotic, crepitus present, focal area of dark purple with break in skin in midline, testes non-palpable Perineum indurated without crepitus, bleeding from perineal wound Anus without crepitus, Past Medical History: DM, HTN, chronic back pain Vasectomy Social History: Live in [**Last Name (un) 53428**], NH. Wife [**Doctor First Name 803**] can be reached at [**Telephone/Fax (1) 79837**] Physical Exam: On Day of Discharge Gen: No acute distress Cards: RRR Pulm: Lungs clear to Auscultation Abdomen: soft non-tender Wound: well-approximated, healing, drains maintaining suction with clear serosanguinous drainage. Skin graft with 100% take. Mild maceration/irritation of skin on medial bilateral thighs secondary to moisture and friction. Pertinent Results: [**2173-9-30**] 10:30PM NEUTS-89.1* LYMPHS-7.5* MONOS-2.9 EOS-0.5 BASOS-0.1 [**2173-9-30**] 10:30PM WBC-11.5* RBC-5.24 HGB-11.8* HCT-34.1* MCV-65* MCH-22.5* MCHC-34.6 RDW-13.9 [**2173-10-1**] 02:30AM HGB-10.4* calcHCT-31 [**2173-10-1**] 04:25AM WBC-12.5* RBC-4.21* HGB-9.6* HCT-29.5* MCV-70* MCH-22.8* MCHC-32.5 RDW-13.5 [**2173-10-1**] 11:18AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2173-10-1**] 12:47PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: Pt life-flighted to [**Hospital1 18**]. Pt diagnosed with Fournier's gangrene, taken emergently by Urology to OR from ER for radical perineal debridement. Please see operative note dictated separately. Pt transferred to SICU still intubated for IV insulin, IV antibiotics (Vanc, Zosyn, Clinda), hourly wound checks, and pressor/ventilator support. POD2 Pt taken back to OR for re-debridement of wound margins by Gen [**Doctor First Name **] and Urology. In the SICU, the pt had a relatively uneventful course. see notes below. [**9-30**]: transfer from [**Hospital 8641**] Hospital, s/p incision and drainage of perineal abscess 2 days ago followed by increasing pain and redness and fever, evaluated today and found to have clinical and radiological findings c/w Fournier's gangrene. Transferred to [**Hospital1 18**] for surgical evaluation and treatment. States fevers and chills. [**10-1**]: added clindamycin for antibiotic coverage, minimally marching erythema, added propofol for sedation. A wound swab from this day was taken and was + enterococcus. All other cultures neg. [**10-2**]: back to OR for some more debridement of right thigh. weaned off of levo using fluid [**10-3**]: bronchoscopy was performed [**10-4**]:NGT placement--TF started. low grade temp. flexiseal placed [**10-5**]:started insulin gtt for refractory blood sugars in the setting of chronic wound care, lasix gtt with albumin [**10-6**]: weaned versed/fent, weaned vent, started diamox, started precedex to wean to extubation [**10-7**]: Extubated. Aggitated, responding to haldol prn [**10-9**]: no acute events, changed to po meds, po lasix, increased RISS, PCA and oral pain control, d/c'ed insulin gtt Pt transferred to Urology floor service in stable condition. Wound care, glycemic control, and continued antibiotics provided. Pt taken to OR by Plastic Surgery for local flap closure of debrided area and VAC placement to bolster skin graft over testicles. The patient did well on the floor. He was kept on bed rest POD1-5 with strict restrictions against abducting his legs. In addition, he was continued on IV antibiotics per ID recommendations. On POD 5 his VAC dressing was taken down and his skin graft had 100% take. On day of discharge POD 7, the patient was doing very well. He was Afebrile vital signs stable, his pain was well controlled with an oral regimen, he had been cleared for home by Physical therapy, and his drain outputs had decreased appropriately. Per ID recs, the patient did not require additional IV antibiotic therapy. Medications on Admission: Atenolol 50", oxycontin 40", ASA 81', Metformin 1000' Discharge Medications: 1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*24 Tablet Sustained Release(s)* Refills:*0* 4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Atenolol 50 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). Disp:*60 Tablet(s)* Refills:*2* 12. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day for 10 days. Disp:*20 Capsule(s)* Refills:*0* 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen (16) units Subcutaneous twice a day: take at breakfast and Bedtime. Take [**2-28**] dose if not eating. . Disp:*2 vials* Refills:*2* 14. Diabetic supplies 1/2 cc 30gauge insulin syringes prn Glucometer testing strips PRN Discharge Disposition: Home With Service Facility: ROCKINHAM VNA Discharge Diagnosis: Fournier's Gangrene Discharge Condition: hemodynamically stable, tolerating oral intake, ambulating, voiding without difficulty, pain controlled on oral regimen Discharge Instructions: Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. * 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. Meds Take all medications as ordered. Drains You will have a VNA who will help you with dressing changes and wound checks as well as drain care. It will be important for you to keep good records of your drain output and bring the records with you when you return to clinic. Followup Instructions: Please call Dr.[**Name (NI) 29526**] office at ([**Telephone/Fax (1) 26412**] for a followup appointment in 1 week. Please call Dr.[**Name (NI) 11306**] office at ([**Telephone/Fax (1) 8791**] for a followup appointment. F/u with your PCP regarding your insulin regimen and blood glucose control Completed by:[**2173-10-20**]

[ "338.29", "038.0", "724.5", "550.90", "401.9", "608.83", "728.86", "518.81", "250.00", "995.91" ]

icd9cm

[ [ [] ] ]

[ "86.22", "86.59", "86.74", "33.24", "83.39", "96.72", "83.45", "61.3", "96.6", "86.69" ]

icd9pcs

[ [ [] ] ]

7290, 7334

3212, 5749

334, 406

7397, 7519

2597, 3189

8629, 8959

5853, 7267

7355, 7376

5775, 5830

7543, 8606

2241, 2578

276, 296

434, 2022

2044, 2083

2099, 2226

25,574

188,721

5172

Discharge summary

report

Admission Date: [**2166-12-28**] [**Month/Day/Year **] Date: [**2167-1-7**] Date of Birth: [**2094-10-7**] Sex: M Service: MEDICINE Allergies: Atropine Attending:[**First Name3 (LF) 425**] Chief Complaint: Malaise, shortness of breath Major Surgical or Invasive Procedure: cardioversion endoscopy and flexible sigmoidoscopy History of Present Illness: Patient is a 72 y.o. Male w/ h.o. CAD s/p CABG [**2148**] w/ redo in [**2163**] (has LIMA->LAD, SVG->LAD, SVG->OM in [**2148**], redo included SVG-> PDA, SVG to prior LIMA), multiple stents (LMCA, D1 in [**2160**]; PCI to SVG to LAD, ISR of D1 stent in [**2161**]; LMCA in [**2162**]), DM II, HL who presents as a transfer from OSH w/ NSTEMI. He reports a few days of myalgias and general weakness/fatigue. Along with this, he reports the sudden onset of chest pain, which he described a different from his angina. He took 1 SL NTG with some relief but, given the persistence of his symptoms, he presented to [**Hospital3 **]. Upon review of the [**Hospital1 **] records, ED EKG showed 2:1 a-flutter at a rate of 120 with RBBB. He had no chest pain in the ED there and no SOB, but he did report to the ED physician [**Name Initial (PRE) **] sense of general malaise. He was also noted to have a fever of 101 in the ED. He was given Acetaminophen for the fever, a chest xray was obtained which was reportedly non-diagnostic as was a U/A. His labwork was notable for a Troponin T of 2.9, BNP 1070. He was thus transferred to [**Hospital1 18**] for further evaluation. In the ED, initial vitals were T97, HR 97, BP 105/68, RR 14, Sat 98% on 2L. His labwork was notable for a Troponin of 1.05, BUN/Cr 41/1.7, plts 140, Hgb 10.8, INR 1.4, PTT 37.4. He continued to have right shoulder pain and was given Morphine 4mg IV x 1. His blood pressure dropped to 87/56 after he received the morphine so he received a 500cc bolus with good BP response. Portable CXR showed mild pulmonary vascular congestion with no effusions. On arrival to the floor, patient was stable but reported lightheadedness. Orthostatics at that time were normal and lightheadedness resolved. He went to the bathroom and was then found down, blue and pulseless with agonal breathing. CPR was initiated but patient regained consciousness quickly. No medications or shocks were administered. Rhythm was sinus with hemodynamics were stable. SBP was 140, oxygen sats were in the mid-90s, HR was 80-90s. Given syncopal event with unresponsiveness, he is being transferred to the CCU for further monitoring. On arrival to the CCU, patient's oxygen saturations were in the mid-high 80s on a NRB. He denied any shortness of breath or chest pain. ABG showed that he was oxygenating well (7.39/38/314/24). Sats improved to 98% on 2L at the time of this note. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for chest pain, dyspnea on exertion, ankle edema and syncope. He denies paroxysmal nocturnal dyspnea, orthopnea, palpitations. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes (+), Dyslipidemia (+), Hypertension (-) 2. CARDIAC HISTORY: AVF ([**10/2163**]) -CABG: [**2163**], [**2148**] (LIMA-LAD, SVG LAD, SVG OM) -PERCUTANEOUS CORONARY INTERVENTIONS: LMCA, D1 in [**2160**]; PCI to SVG to LAD, ISR of D1 stent in [**2161**]; LMCA in [**2162**] -Cath [**10/2162**]: Three vessel native coronary artery disease, patent grafts, moderate aortic stenosis, patent previously placed stents, elevated left sided filling pressure. -Stress test [**2162-5-24**]: Poor functional status. 3.5 minutes of exercise on [**Doctor Last Name 4001**] protocol. EF 30% and multiple fixed perfusion defects and minor inferior defect. -PACING/ICD: N/A 3. OTHER PAST MEDICAL HISTORY: Aortic stenosis s/p AVR Anemia: baseline HCT 30-33 Hypothyroidism OSA on CPAP Depression CKD OA Gout IBS-diarrhea predominant Obesity PVD UGI and LGI bleeding secondary to AVMs Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Retired [**Doctor Last Name **]. Widowed in [**2163-1-3**]. Several children live in the area. He receives VNA at home as well as assistance w/ other privately hired help. Family History: There is no family history of sudden death. Mother died of MI in 60's, brother had MI at 53. His wife died of a brain aneurysm several years ago and he currently lives alone. Physical Exam: VS: T=96.2 BP=120/70 HR=90 RR=20 O2 sat= 98% on 2L GENERAL: WDWN male. Oriented x3. Mood, affect appropriate. No apparent distress HEENT: large laceration noted over right aspect of skull with bruising over his right orbit. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Cervical collar in place- unable to assess JVP. CARDIAC: Regular rhythm with tachycardia. Normal S1, S2. soft apical holosystolic murmur. LUNGS: Resp were unlabored, no accessory muscle use. Scattered bibasilar crackles with no wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: [**1-4**]+ edema with no clubbing or cyanosis. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Radial 2+ DP 2+ PT 2+ Left: Carotid 2+ Radial 2+ DP 2+ PT 2+ Pertinent Results: Admission labs: [**2166-12-28**] 12:40AM BLOOD WBC-8.0 RBC-3.29* Hgb-10.8* Hct-30.9* MCV-94 MCH-32.9* MCHC-35.1* RDW-16.1* Plt Ct-140* [**2166-12-28**] 12:40AM BLOOD PT-15.4* PTT-37.4* INR(PT)-1.4* [**2166-12-28**] 12:40AM BLOOD Glucose-72 UreaN-41* Creat-1.7* Na-138 K-3.3 Cl-103 HCO3-23 AnGap-15 [**2166-12-28**] 07:31AM BLOOD Calcium-8.4 Phos-4.4# Mg-2.1 [**2166-12-28**] 07:31AM BLOOD TSH-0.28 Cardiac Biomarkers: [**2166-12-28**] 12:40AM BLOOD cTropnT-1.05* [**2166-12-28**] 07:31AM BLOOD CK-MB-6 cTropnT-1.10* [**2166-12-28**] 02:15PM BLOOD CK-MB-5 cTropnT-0.93* [**2166-12-29**] 03:48PM BLOOD CK-MB-3 cTropnT-1.15* [**2166-12-29**] 03:48PM BLOOD CK(CPK)-56 [**2166-12-28**] 12:40AM BLOOD proBNP-7336* Blood Gas: [**2166-12-28**] 06:59AM BLOOD Type-ART pO2-35* pCO2-49* pH-7.31* calTCO2-26 Base XS--2 [**2166-12-28**] 07:47AM BLOOD Type-ART pO2-314* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 [**Month/Day/Year **] Labs: [**2167-1-7**] 06:10AM BLOOD WBC-6.2 RBC-3.30* Hgb-11.1* Hct-30.6* MCV-93 MCH-33.5* MCHC-36.2* RDW-21.1* Plt Ct-249 [**2167-1-7**] 06:10AM BLOOD PT-15.7* PTT-27.0 INR(PT)-1.4* [**2167-1-7**] 06:10AM BLOOD Glucose-99 UreaN-70* Creat-1.8* Na-132* K-4.4 Cl-95* HCO3-29 AnGap-12 [**2167-1-7**] 06:10AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.4 Micro: Blood, urine, sputum cultures all negative. H pylori negative. Studies: CXR [**12-28**] FINDINGS: The cardiomediastinal and hilar contours are stable, with mild cardiomegaly. There is mild degree of pulmonary edema. The lung volumes are low. No focal consolidation, pleural effusion or pneumothorax is identified. Evidence of prior CABG, including intact sternotomy wires and mediastinal surgical clips are present. IMPRESSION: Mild pulmonary edema. No definite consolidation detected. CT spine [**12-28**]: IMPRESSION: No cervical spine fracture. Spondylotic abnormalities, and other findings, noted above. MRI scanning is more sensitive than CT imaging in detecting cord injury from spondylosis/trauma, if clinically suspected. CT head [**12-28**]: CONCLUSION: No intracranial hemorrhage. Cervical spine MRI [**12-29**]: IMPRESSIONS: 1. No evidence of ligamentous injury or disruption. Trace fluid along the anterior aspect of vertebral body of C5 through C7. No fractures. 2. Moderate-to-severe canal stenosis between C3 and C6 (severe at C5-C6) due to a combination of disc herniation and posterior longitudinal ligament thickening. Cord demonstrates associated myelomalacia, without superimposed acute abnormalities. 3. Multilevel neural foraminal narrowing, particularly on the left. Echo [**12-30**]: Mild spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. Mild spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). Mild spontaneous echo contrast is seen in the body of the right atrium. No mass or thrombus is seen in the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Global left ventricular systolic function appears groslly preserved There are complex (>4mm) atheroma in the descending thoracic aorta and aortic arch. A bioprosthetic aortic valve prosthesis is present and appears well-seated. The prosthetic aortic valve leaflets appear normal The aortic valve prosthesis leaflets appear to move normally. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No intracardiac thrombus. Mild spontaneous echo contrast and left and right atrium. Normally functioning bioprosthetic aortic valve. Mild mitral regurgitation. Complex, non-mobile plaque in the thoracic aorta. Echo [**2167-1-5**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior and infero-lateral akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. with mild global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2166-8-12**], the LVEF has decreased. The RV is probably similar. If indicated, a cardiac MRI may more accurately assess LVEF. EKG on admission [**12-28**]: Underlying atrial mechanism not certain with differential diagnosis including atrial fibrillation or atrial flutter variant versus atrial tachycardia with variable block. Right bundle-branch block with left axis deviation consistent with left anterior fascicular block. Underlying inferior Q wave myocardial infarction. Single ventricular premature beat is also present. Non-specific ST-T wave change with slight QTc interval prolongation. Compared to the previous tracing of [**2165-8-16**] atrial tachy-arrhythmia is new. Clinical correlation is suggested. EKG [**2167-1-5**]: Sinus rhythm. Right bundle-branch block with left anterior fascicular block. Prior inferior myocardial infarction. Compared to the previous tracing no major change. [**1-6**] Upper endoscopy/enteroscopy: Antral erosions, no focal bleed [**1-6**] Flex Sig: No source of bleed Brief Hospital Course: 72yo male with history of CAD s/p CABG x 2 who presents from OSH with NSTEMI. Transferred to the CCU s/p syncopal event. . # Syncope: His transfer to the CCU was initiated because of a syncopal episode. Possible etiologies included vasovagal episode (he was baring down in the bathroom at the time), arrhythmia given his a-flutter/a-fib and sigificant cardiac history. He was not on tele at the time of the event, and he was found down, pulseless in the bathroom. Compressions were initiated and he quickly regained consciousness, and was lucid. He was not confused, and had no evidence of seizure activity. In the CCU, tele showed a-fib with RVR and was uptitrated to 75 TID of metoprolol tartrate and then initiated on a diltiazem drip. His rate slowed, but he remained in a-fib. He was put on a heparin drip and started on coumadin for a CHADS2 score of 3. He was DC cardioverted and remained in NSR through [**Month/Day (4) **]. Of note, his anticoagulation was stopped in-house in the setting of developing LGIB (see below), and was discharged on beta blocker but no coumadin. He will require follow up for reassessment of his need for coumadin given his recent bleed. . # NSTEMI: Pt was first seen at [**Hospital3 4107**] with 2 days of chest pain and was noted to have a positive troponin-I of 2.92. His troponin-T in the [**Hospital1 18**] ED was 1.05, prior troponins in [**2164**] ranged from 0.05->0.23 in the setting of his renal dysfunction. His troponins remained elevated in the 1's but his CK decreased and his CK-MB were normal. He also had renal dysfunction, likely contributing to his poor clearance of troponins. In the setting of his renal function, cath was deferred, but may be considered in the future. He was d/c'd on beta blocker (metoprolol succinate increased to 150mg daily from home dose of 100mg), asa, satin. . #LGIB: Pt noted to have Guaiac positive stools and occasional BRBPR. His Hct was noted to drop from 33.5-->26.5 over the course of 1 day and received a total of 1 U PRBC with good response. Pt had both upper endoscopy and colonoscopy which was only significant for antral erosisons but no obvious source of bleed. His anticoagulation was held and he was continued on PPI which was increased to [**Hospital1 **] on [**Hospital1 **]. After endoscopy, he had no further signs of bleeding and hct stable at 30-32. H pylori was negative. He was set up with GI follow up. . #Acute on chronic systolic Congestive Heart Failure: Pt with echo in-house showing worsening LVEF to 40% compared to prior echo. He was noted to be volume overloaded in house requiring diuresis with metolazone and toresemide, along with home dose of spironalactone. Over the course of his CCU and floor stay he diuresed well and became more euvolemic after transfer back to the floor. He was discharged on a regimen of torsemide 60 mg daily, with instructions to take an additional 40mg as needed, as well as home spironalactone of 25 mg daily. He was told to follow up with Dr. [**First Name (STitle) 437**] in heart failure clinic. . # Fever/leukocytosis: He spiked a fever overnight on the night of his transfer to the CCU to 101F. He had pan cultures taken (blood, urine, sputum) and a chest x-ray was done, but no focal source was identified. Antibiotics were initially held in the setting of a lack of source/bug, and given his hemodynamic stability. Given the presentation of malaise and myalgias it was thought that he had a viral syndrome. . # Hypoxia: He was hypoxic to the the high 80's on NRB initially on transfer to the CCU, and was able to be weaned without intervention to 2L NC and maintained sats in the low to mid 90s. PE was considered as well as CHF exacerbation, ACS, hypoventilation, methemoglobinemia, and COPD. Because of his normal ABG and his normal methemoglobin, as well as his downtrending CK-MBs he was thought to be overloaded. He had been in a-fib with RVR, with likely poor forward flow. He had increased crackles on exam and required diuresis with good improvement in his respiratory status. . # CKD: Patient has stage III CKD thought to be secondary to CHF. He is followed by Dr. [**Last Name (STitle) **] as an outpatient. Creatinine at baseline on arrival (1.7) and increased likely secondary to poor forward flow to as high as 2.3. He was continued on home spironalactone, torsemide, and metolazone, and his Cr improved to 1.8 on [**Last Name (STitle) **] . # DM II: He was continued on his home regimen of Lantus [**Hospital1 **] (40qAM, 50qPM) and ISS. . # Hypothyroidism: Continued on Levothyroxine 280mcg qAM. TSH was WNL. . # Depression: Continued on home sertraline Medications on Admission: Allopurinol 150mg daily Calcitriol 0.25mcg qT,Th,[**Last Name (LF) **],[**First Name3 (LF) **] Calcitriol 0.5mcg qM,W,F Ezetimibe 10mg daily Insulin Aspart sliding scale Insulin Lantus 50u qAM, 40u qPM Levothyroid 224mcg daily Metoprolol Succinate 100mg daily NTG SL Omeprazole 40mg daily Sertraline 100mg daily Simvastatin 80mg daily Torsemide 60mg daily Torsemide 40mg PRN increased edema Vit C 500mg [**Hospital1 **] ASA 81mg daily MVI daily Zinc 220mg daily [**Hospital1 **] Medications: 1. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA). 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 3X/WEEK (MO,WE,FR). 4. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lantus 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous once a day: Also take 40 units in the evening. 6. insulin aspart 100 unit/mL Solution Sig: per sliding scale units Subcutaneous four times a day. 7. levothyroxine 112 mcg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 8. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2* 9. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. 10. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 11. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day: [**Month (only) 116**] take additional 40 mg as needed. 16. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 19. Outpatient Lab Work Please check Chem-7 and CBC on [**2167-1-9**] and call results to Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 62**] thanks [**Telephone/Fax (1) **] Disposition: Home With Service Facility: [**Hospital3 **] VNA [**Hospital3 **] Diagnosis: Acute on chronic Systolic congestive Heart Failure Atrial Fibrillation Non ST Elevation Myocardial Infarction Upper and Lower GI Bleed Diabetes Mellitus Type 2 [**Hospital3 **] Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [**Hospital3 **] Instructions: You had chest pain and was admitted to [**Hospital3 **] with a heart attack. You were transferred to [**Hospital1 18**] and had a fainting episode in the bathroom. You were in an irregular heart rhythm, atrial fibillation, that was converted to a normal rhythm with an electrical cardioversion. You will need to have your heart rhythm checked regularly now. We started an anticoagulation pill called coumadin to prevent strokes from the atrial fibrillation and you developed a bleed somewhere in your GI tract. We were unable to localize the bleeding using a scope in your stomach and lower [**Hospital1 499**]. It is very important that you follow a diabetic and low salt diet. This will prevent your blood sugars from being high and prevent the fluid from reaccumulating. Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Your weight at [**Last Name (NamePattern1) **] is 184 pounds. Please make an appt with your diabetes doctor soon to review your diet and insulin requirements. We were unable to perform a cardiac catheterization during this hospital stay because of your kidney function worsened. . We made the following changes to your medicines: 1. Increase Metoprolol to 150 mg daily 2. Increase Omeprazole to 40 mg twice daily 3. Increase aspirin to 325 mg daily Followup Instructions: You have following appointments scheduled for you: . Department: CARDIAC SERVICES When: Tuesday [**2167-1-13**] at 1:00 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**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: THURSDAY [**2167-1-22**] at 1:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Last Name (NamePattern1) 280**] [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2167-3-17**] at 2:00 PM With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: CARDIAC SERVICES When: TUESDAY [**2167-4-7**] at 3:00 PM 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: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2167-1-21**] at 1 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

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Discharge summary

report

Admission Date: [**2163-10-30**] Discharge Date: [**2163-11-3**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: Chest pain and abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Most of the interview was conducted with telephone interpretor as patient is Russian speaking only. [**Age over 90 **]yo female Russian speaking only resident of [**Hospital1 5595**] with CAD, CHF (EF 25%), HTN, and Afib, recently admitted with episode of PNA vs. CHF exacerbation on [**2163-9-29**], now presents with chest pain, abdominal pain and hypotension. The chest pain is located in the right side of the chest and radiates to the back. The pain is characterized as the same chest pain she has had for most of her life and is rated [**2169-5-5**], no radiations and nonpositional, no associated diaphoresis. She had one episode of n/v, early today. The emesis was clear without signs of blood or coffee grounds. She describes her abdominal pain as generalized, diffuse, x 2d. She denies any current abdominal pain. Her last bowel movement was three days prior to admission. In the ED, her BP was 98/66 and dropped to 60/40 sitting and 80/60 lying after ASA, SL NTG and lasix (given for ?ACS, CHF) ->1400 cc u/o. She begun dopamine to avoid fluid boluses given her CHF. The patient was subsequently given morphine for chest pain refractory to nitro which lead to further decrease in BP to 46/24 (15 min. after morphine was given). She failed a weaning trial of dopamine with BP of 79/50. She then received decadron 10mg IV along with levofloxacin 500mg IVx1 and Flagyl 500mg IV x1 for ?PNA, and sent to [**Hospital Unit Name 153**] for w/u. The patient also reports some baseline shortness of breath with a chronic cough that has been present for 2 years. The cough has periods of improvement and worsening. Recently, the cough has worsened over the last two weeks with some clear sputum production (since her recent discharge). The patient also reports some subjective fevers, and chills, but denies rigors. She is DNR/DNI. Past Medical History: 1. Sick sinus syndrome s/p pacemaker placement. 2. Coronary artery disease. 3. CHF with EF of 25% 4. Atrial fibrillation. 5. Hypertension. 6. Osteoporosis. 7. Dementia 8. R hemicolectomy for mussinous colon CA 1. Sick sinus syndrome s/p pacemaker placement. 2. Coronary artery disease. 3. CHF with EF of 25% 4. Atrial fibrillation. 5. Hypertension. 6. Osteoporosis. 7. Dementia 8. R hemicolectomy for mussinous colon CA Social History: The patient has never smoked cigarettes.She lives in the [**Hospital1 10151**] Center secondary to an inability to take care of herself. She is retired. She has a large family. She is Russian speaking. Physical Exam: PE: VS: Tc: 97.8 HR: 80 BP: 134/47 on left and 141/57 on right RR: 19 SaO2: 93% on 2L Gen: elderly women lying in bed at 30 degree angle with nasal canula in place. The patient appears to be relatively comfortable, in NAD. poor skin turgor HEENT: temporal wasting. pupils are 2mm bilaterally, reactive?, EOMI. mucous membranes very dry. Neck: supple, full ROM, JVP 8-10cm CV: RRR, S1, S2, no murmurs, rubs, gallops Chest: [**Month (only) **] breath sounds on R>L. Egophony on R>L up 1/3 up scapula. bibasilar crackles. Abd: soft, NT, ND, BS+ bilaterally, no rebound, guarding, peritoneal signs. negative [**Doctor Last Name **] signs. Ext: warm to palpation, with trace pulses, [**Doctor First Name 15799**] stasis, no c/c/e Neuro: pt appeared appropriate throughout. A+O not assess due to difficulty with language barrier. Pertinent Results: [**2163-10-30**] 11:20AM WBC-11.0# RBC-3.79* HGB-11.1* HCT-33.8* MCV-89 MCH-29.4 MCHC-32.9 RDW-16.4* [**2163-10-30**] 11:20AM NEUTS-82.2* LYMPHS-12.4* MONOS-4.9 EOS-0.2 BASOS-0.2 [**2163-10-30**] 11:20AM PT-13.1 PTT-24.2 INR(PT)-1.1 [**2163-10-30**] 11:20AM ALBUMIN-3.1* CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-1.4* [**2163-10-30**] 11:20AM ALT(SGPT)-15 AST(SGOT)-28 CK(CPK)-82 ALK PHOS-73 AMYLASE-51 TOT BILI-0.6 [**2163-10-30**] 11:20AM GLUCOSE-154* UREA N-56* CREAT-2.8*# SODIUM-135 POTASSIUM-3.3 CHLORIDE-91* TOTAL CO2-30* ANION GAP-17 [**2163-10-30**] 12:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2163-10-30**] 12:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG [**2163-10-30**] 12:45PM URINE RBC-0-2 WBC-0 BACTERIA-MOD YEAST-NONE EPI-0 [**2163-10-30**] 01:20PM LACTATE-1.6 [**2163-10-30**] 11:20AM CK-MB-NotDone [**2163-10-30**] 11:20AM cTropnT-0.02* [**2163-10-30**] 05:36PM CK(CPK)-91 [**2163-10-30**] 05:36PM CK-MB-NotDone [**2163-10-30**] 05:37PM cTropnT-0.02* . . [**2163-10-30**] CXR: "1. Cardiomegaly and calcified unfolded aorta. There is no disproportionate mediastional widening. 2. Probable CHF. 3. More confluent opacity right apex --- question atypical distribution of CHF vs. pneumonia. 4. Osteopenia with partial wedging of multiple vertebral bodies. " . . Brief Hospital Course: A/P: [**Age over 90 **]yo female resident of [**Hospital1 5595**] with CAD, HTN and recent admit for PNA and CHF exacerbation (admitted [**2163-9-27**]-discharged [**2163-9-29**]) presents with CP, abd pain and hypotension. 1: Hypoxia: We thought that her hypoxia might have been secondary to fluid overload/CHF or a pneumonia. We thus broadened her coverage by adding zosyn. She also received small doses of IV lasix with a small improvement. She eventually weaned from a NRB to 6L nasal cannula on the day of discharge. We advise continued weaning of her oxygen as tolerated by the patient. 2. Hypotension: We thought that the patient's hypotension was secondary to volume depletion as demonstrated by its rapid response with IV fluids. We held her antihypertensive medications initally and slowly added them as her pressure stabilized. 3. Chest pain: We were concerned that her chest pain might have been secondary to an acute coronary syndrome. She was ruled out with negative serial cardiac enzymes and the absence or ECG changes. We increased her 3. PNA: The patient was first started on levoquin but in light of her increasing hypoxia she was switched to zosyn to broaden her coverage. She remained afebrile and without a leukoctyosis was thus discharged on a 7 day course of levofloxacin. 4. Abd pain: The occurance of abdominal pain is conincident with her recent onset of constipation. The abd on exam is soft, and completely benign, without a suggestion of a surgical abdomen. The pain is most likely secondary to constipation. Her abdominal pain and distension improved significantly with the administration of an enema which resulted in a successful bowel movement. 5. Afib/Sick Sinus: Pt is s/p pacemaker placement. While in the ICU she was on telemetry and her heart rate did not decreased to less than 80. 6. CHF: We held her cardiac meds in light of her hypotension. On the day of discharge we had restarted metoprolol and we advise that the other medications be slowly added as her blood pressure tolerates. 7. Prophylaxis: The patient was continued on heparin SQ for DVT prophylaxis along with a PPI as per her outpatient regimen. Medications on Admission: 1. Metoprolol 100mg [**Hospital1 **] 2. Amiodarone HCl 200mg PO once daily 3. Lisinopril 5mg once daily 4. Furosemide 40mg once daily 5. Pantoprazole 40mg Q24 hours 6. Albuterol neb Q6hrs PRN 7. Ipratroprium Bromide 0.02% neb Q6 hours Discharge Medications: 1. Amiodarone HCl 200 mg 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: Two (2) Tablet PO BID (2 times a day) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-31**] Puffs Inhalation every four (4) hours. 6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 9. Carbamide Peroxide 6.5 % Drops Sig: 5-10 Drops Otic [**Hospital1 **] (2 times a day) for 4 days. 10. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 11. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 14. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 15. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. 16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) mL PO twice a day. 17. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. 18. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Aspiration Pneumonia Hypertension Congestive Heart Failure Atrial Fibrillation Discharge Condition: Fair Discharge Instructions: Please take all of your medications as prescribed. Followup Instructions: Primary Care: Please follow up with a physician within one week of discharge from the hospital. At the time, please have your oxygen saturation checked and a CXR within two weeks to verify improvement of your pneumonia. Laboratory: Please have the levels of your potassium checked at [**Hospital1 5595**] with the results sent to the house physician.

[ "414.01", "401.9", "413.9", "276.7", "276.5", "733.00", "V10.05", "294.8", "V45.01", "507.0", "707.03", "428.0", "427.31" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9146, 9211

5134, 7311

287, 294

9334, 9340

3713, 5111

9440, 9796

7603, 9123

9232, 9313

7337, 7580

9364, 9417

2856, 3694

218, 249

322, 2176

2198, 2619

2635, 2841

8,778

128,848

16565

Discharge summary

report

Admission Date: [**2135-1-5**] Discharge Date: [**2135-1-7**] Service: CCU CHIEF COMPLAINT: Left-sided facial numbness. HISTORY OF THE PRESENT ILLNESS: The patient is an 83-year-old woman with a history of coronary artery disease, right carotid artery stenosis, hypertension, and hypercholesterolemia who has had several episodes of transient left facial numbness over the three months prior to admission; she is, therefore, admitted for right internal carotid artery stenting. The patient has had no other neurologic signs or symptoms such as other numbness, weakness, or amaurosis fugax. The patient does note occasional, episodic staggering gait. She denied any history of syncope, chest pain, shortness of breath, PND, lower extremity edema, abdominal pain, GERD, melena, or hematochezia. PAST MEDICAL HISTORY: 1. Right carotid artery stenosis, 60-79% by Doppler ultrasound at the outside hospital. 2. Coronary artery disease with 5/02 MIBI showing partially reversible anterolateral wall defect without further intervention. 3. Hypertension. 4. Hyperlipidemia. 5. Hiatal hernia. 6. History of gastritis. 7. Echocardiogram in [**4-14**] demonstrated preserved left ventricular function and pulmonary hypertension. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Lansoprazole 30 mg p.o. q.d. 2. Atorvostatin 20 mg p.o. q.d. 3. Atenolol 12.5 mg p.o. q.d. 4. Aspirin 81 mg p.o. q.d. SOCIAL HISTORY: The patient lives at home with her husband. She denied any history of tobacco or alcohol abuse. FAMILY HISTORY: The patient's sister died of an MI at age 78. The patient's brother died of an MI at age 65. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Blood pressure 131/57, heart rate 54, respiratory rate 16, and room air saturation 100%. She was pleasant, alert, and in no acute distress. EOMI. PERRLA. MMM. The sclerae were anicteric. She had no JVD or carotid bruits. Her lungs were clear to auscultation bilaterally. Her heart revealed a regular rate and rhythm. There were normal S1 and S2 heart sounds, and she had no murmurs, rubs, or gallops. Her abdomen was soft, nontender, nondistended. There were normoactive bowel sounds. There was no organomegaly. She had no femoral bruits, 2+ dorsalis pedal pulses bilaterally, and no cyanosis, clubbing, or edema. Cranial nerves II through XII were intact. Visual fields were intact to confrontation, and there were no focal neurologic deficits. LABORATORY DATA: The initial laboratory evaluation demonstrated a white count of 8, hematocrit 41, platelets 188,000. The initial serum chemistries demonstrated sodium 144, potassium 4.5, chloride 105, bicarbonate 26, BUN 20, creatinine 1, and glucose 113. A previous MRI/MRA demonstrated moderate RCA stenosis, a normal circle of [**Location (un) 431**], and mild, chronic microvascular infarction. HOSPITAL COURSE: On admission, the patient was taken to the Catheterization Lab. This study demonstrated the following: The right vertebral artery was without lesions. The posterior circulation was normal. The RCCA was normal. The right ICA had an eccentric 80% lesion. The intracerebral circulation was normal with noted patency of the ACOM. The left vertebral artery was normal. The posterior circulation was normal. The LCCA was normal. The left internal carotid and external carotid arteries had minimal disease. There was noted filling of the RACA through the ACOM. During the procedure, the right internal carotid artery was primarily stented without complication. The final residual was 20% with normal flow. There was no evidence of distal embolization. Following the procedure, the patient was hemodynamically and neurologically stable. She was transferred to the CCU for overnight monitoring. Early on the morning following the procedure, the patient's systolic blood pressure dropped into the 90s so she was, therefore, started a phenylephrine drip for blood pressure maintenance. She remained on this drip for approximately ten hours in order to maintain a systolic blood pressure ranging from 110-140. This medication was gradually weaned off, and by the afternoon following the procedure, the patient was maintaining a systolic blood pressure ranging from 110-140 without pharmacologic assistance. She was then transferred to the General Medical Floor, where she remained hemodynamically and neurologically stable. Of note, following the procedure, the patient was started on clopidogrel and her aspirin dose was increased as noted below. DISCHARGE CONDITION: Good. DISCHARGE PLACEMENT: Home. DISCHARGE DIAGNOSIS: 1. Right internal carotid artery focal 80% eccentric stenosis. 2. Stenting of the right internal carotid artery. 3. Transient hypotension requiring blood pressure support with phenylephrine. DISCHARGE MEDICATIONS: 1. Clopidogrel 75 mg p.o. q.d. times nine months. 2. Aspirin 325 mg p.o. q.d. 3. Atorvostatin 20 mg p.o. q.d. 4. Lansoprazole 30 mg p.o. q.d. 5. Atenolol 12.5 mg p.o. q.d. FOLLOW-UP: The patient was scheduled for a carotid ultrasound to be done on [**2135-2-3**] at 10:30 a.m. on the [**Location (un) 10043**] of the [**Hospital Ward Name 517**]. She was instructed to telephone Dr. [**First Name (STitle) **] to arrange for a follow-up appointment in the week following this carotid ultrasound. She was also instructed to make arrangements for follow-up with the Department of Neurology in one to two months following her discharge from the hospital. DR.[**Last Name (STitle) **],[**First Name3 (LF) 2064**] 12-ABZ Dictated By:[**Name8 (MD) 2507**] MEDQUIST36 D: [**2135-1-6**] 04:00 T: [**2135-1-6**] 20:38 JOB#: [**Job Number 47009**]

[ "272.0", "535.50", "458.2", "414.01", "553.3", "401.9", "433.10" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4584, 4620

1577, 1693

4859, 5740

4641, 4836

2905, 4562

1320, 1446

103, 810

1708, 2887

832, 1297

1463, 1560

15,129

183,109

21659

Discharge summary

report

Admission Date: [**2155-11-28**] Discharge Date: [**2155-11-29**] Date of Birth: [**2084-3-14**] Sex: F Service: ORTHOPAEDICS Allergies: Pravachol / Penicillins Attending:[**First Name3 (LF) 56980**] Chief Complaint: Decreased sats after surgery Major Surgical or Invasive Procedure: R rotator cuff repair History of Present Illness: 71 yo admitted after mini-open rotator cuff repair for lethargy and oxygen requirement. Past Medical History: HTN, hyperlipidemia, sleep apnea Social History: former smoker Family History: na Physical Exam: stable 94 RA 12 RR CTAB incision c/d/i Brief Hospital Course: Patient was admitted for somnolence after rotator cuff repair. She had a an oxygen requirment that improved overnight. She was discharged the next day in stable condition. Discharge Disposition: Home Discharge Diagnosis: Right rotator cuff tear Discharge Condition: stable Discharge Instructions: 1. Per instruction sheet given. 2. Keep arm in sling. 3. Percocet at home for pain. Followup Instructions: 1. Dr. [**Last Name (STitle) 7808**] [**12-9**] Completed by:[**2155-11-29**]

[ "V64.43", "401.9", "518.82", "733.00", "780.57", "272.4" ]

icd9cm

[ [ [] ] ]

[ "83.63" ]

icd9pcs

[ [ [] ] ]

845, 851

647, 822

320, 344

919, 927

1059, 1139

564, 569

872, 898

951, 1036

584, 624

252, 282

372, 461

483, 517

533, 548

30,738

112,711

22712

Discharge summary

report

Admission Date: [**2155-8-21**] Discharge Date: [**2155-9-2**] Date of Birth: [**2085-11-11**] Sex: M Service: SURGERY Allergies: Metoprolol Attending:[**First Name3 (LF) 2597**] Chief Complaint: 5.5 cm abdominal aortic aneurysm Major Surgical or Invasive Procedure: [**8-21**] s/p retroperitoneal AAA repair [**8-23**] re-exploration, evacuation of hematoma, 1 stitch to anterior suture line History of Present Illness: This 70-year-old gentleman was found to have a pulsatile abdominal mass and a 5.5 cm abdominal aortic aneurysm starting just below the renal arteries. The neck was too short for placement of an endovascular graft, and he was advised to have an open repair. Past Medical History: PMH: CAD s/p PTCA/stent LAD, PTA marginal circumflex branch [**3-15**], HTN, hypercholesterolemia PSH: none Social History: He is married. He and his wife have no children. He has moved to United States about five years ago from [**Location (un) 6847**]. While there he was a technician working in streetcar repair, I think on the electrical aspects. He does not smoke. He has occasional alcohol. Family History: His mother was diagnosed with premature heart disease at 55. She passed away at 73. He has two older sisters, the oldest has heart disease, CAD status post PCI. The younger sister evidently has valvular heart disease. Physical Exam: VSS: afebrile, 118/60, 59, 97%RA GEN: NAD Neuro: A&OX3 CV: RRR Resp: CTA ABD: soft, NT Ext: B/L fem palp, B/L DP/PT palp Pertinent Results: [**2155-9-1**] 07:06AM BLOOD WBC-7.8 RBC-3.86* Hgb-11.8* Hct-34.5* MCV-90 MCH-30.5 MCHC-34.1 RDW-14.7 Plt Ct-357 [**2155-9-1**] 07:06AM BLOOD Plt Ct-357 [**2155-9-1**] 07:06AM BLOOD Glucose-103 UreaN-21* Creat-0.9 Na-134 K-4.1 Cl-99 HCO3-30 AnGap-9 [**2155-9-1**] 07:06AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.3 [**2155-8-23**] CTA IMPRESSION: 1. Findings concerning for a focus of active extravasation at the proximal anastomosis of the aortic graft, as detailed above. There is a large associated retroperitoneal hematoma. Findings were discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. 2. Large left hydropneumothorax. Brief Hospital Course: Underwent AAA repair on [**8-21**]. Uneventful, Extubated transferred to PACU- VICU. Post op, febrile- IS/chest PT encouraged. SBP 90's- bolus X3. Epidural discontinued. Hespan start started. Transfused 2uPRBCs. [**8-22**]: Tmax 102.6, Pulmonary toilet encouraged. [**8-23**]: Slowly declining hematocrit which initially responded to transfusion and then declined again with some mild hemodynamic instability. This prompted a CT scan which demonstrated a likely leak at the proximal anastomosis with a fairly large hematoma in the retroperitoneum. He was therefore taken urgently for exploration. . Retroperitoneal exploration and suture repair of an anastomotic bleed. Chest x-ray showing small left effusion. [**8-24**]: In ICU, extubated. Vanco X2 doses. Blood pressure controlled. [**Date range (1) 57511**]: IN ICU. VSS, no events, electrolytes repleted. IVF continued, NPO. On Nitro gtt for BP control. Epidural controlling pain. Transfused 1u PRBS. [**8-27**]: Transferred to VICU, Continue diuresis, monitoring I/O. Electrolytes repleted. Epidural discontinued. Tolerating po diet. PICC inserted for access. [**8-28**]- [**8-29**] Doing well, VSS. OOB with nursing and physical therapy. Tolerating diet, foley discontinued. Cardiology/Dow consulted-no change in management, will see patient for follow up in [**5-16**] weeks. Transferred to floor. Incisions without evidence of infection. [**Date range (1) 32271**] VSS Doing well. Evaluated by PT and OT. Transferred to [**Hospital **] Health Center. Medications on Admission: lovastatin 40', atenolol 50',triamteren/HCTZ 1tab', aspirin 81', MVI, prilosec 200' Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for HR<65, sbp<100 . 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. Triamterene 50 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 **] center Discharge Diagnosis: 69 M w/ 5.5 cm asymptomatic infrarenal AAA not amenable to EVAR, now s/p repair PMH: CAD s/p PTCA/stent [**3-15**], HTN, hypercholesterolemia Discharge Condition: VSS Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**5-16**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [**1-11**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Call Dr.[**Name (NI) 5695**] office at [**Telephone/Fax (1) 3121**] to schedule post operative appointment Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2155-9-19**] 9:40 Completed by:[**2155-9-2**]

[ "272.0", "996.74", "285.1", "E849.7", "441.4", "401.9", "E878.2", "414.01", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "38.44", "54.19", "99.04", "38.93", "39.49", "89.64" ]

icd9pcs

[ [ [] ] ]

4755, 4805

2207, 3724

303, 431

4992, 4998

1532, 2184

7737, 8003

1157, 1376

3859, 4732

4826, 4971

3750, 3836

5022, 7285

7311, 7714

1391, 1513

231, 265

459, 718

740, 850

866, 1141

10,675

141,668

22837

Discharge summary

report

Admission Date: [**2114-12-5**] [**Year/Month/Day **] Date: [**2114-12-20**] Date of Birth: [**2058-6-13**] Sex: F Service: MEDICINE Allergies: Penicillins / Azithromycin / Lipitor Attending:[**First Name3 (LF) 11552**] Chief Complaint: Hypoxemic respiratory failure Major Surgical or Invasive Procedure: intubation ultrafiltration in dialysis lab History of Present Illness: Patient is a 56 year old female with past medical history significant for ESRD s/p live donor kidney [**First Name3 (LF) **] in [**2108**] currently immunosuppressed with tacrolimus/ prednisone/cellcept who was recently admitted from [**2114-11-8**] to [**2114-11-28**] at [**Hospital1 1535**] for hypoxic respiratory failure and ARDS requiring intubation which was thought to be precipated by a pneumonia. Her hospital course was complicated by acute kidney injury which was back to baseline prior to [**Hospital1 **] and severe deconditioning due to prolonged intubation for which she was discharged to St [**Hospital **] Hospital Rehabilitation Unit - [**Location (un) 8117**], NH on [**2114-11-28**]. . She is reported to be doing well since [**Date Range **]. She was discharged from rehab to home two days ago. She went to her appointment with Dr. [**Last Name (STitle) **] yesterday. She complained off feeling cold yesterday night and was not able to sleep that night. This morning she felt well and had yogurt and some other stuff for breakfast. After few hours she felt cold and some shakes. She was shallow breathing more than her baseline per daughter and thus led them to go to [**Name (NI) 189**] [**Last Name (NamePattern1) **] where she was noted to have pneumonia on CXR and intubated [**1-2**] to respiratory distress. EKG showed nonspecific ST-T changes and she was given levofloxacin, vancomycin and flagyl along with 2 DS Bactrim tabs for potential PCP. [**Name10 (NameIs) **] was never hypotensive and was not started on pressors. . She was transported to [**Hospital1 18**] ED where vital signs were 98 101/58 66 20 100% on vent (CPAP 90% FiO2 PEEP of 10). ABG showed 7.30/25/116/15. CXR consistent with multifocal pneumonia. Renal US was obtained which was concerning for early rejection vs ATN. She was transferred to MICU for futher evaluation and management. . In the MICU, she was intubated and sedated but followed command and was alert to her surroundings. Past Medical History: 1. Fulminant liver failure [**1-5**] likely caused by Azithromycin 2. End-stage renal disease s/p living related donor in [**2108**] 3. Hypertension 4. Depression 5. Dyslipidemia 6. Nephrolithiasis 7. Melasma Social History: Married with 5 children. Lives at home with husband, daughter and grandchildren. She moved from [**Country 5737**] in [**2098**] and last visited in [**Month (only) **]. She denies any cigarette use, and quit alcohol, though she used to abuse alcohol. No IVDU. While in [**Country **], she lived on a farm for 3 years-- exposure to many domestic farm animals. She does not recall any skin rashes or febrile illnesses during that period. She does not know if she received the BCG vaccine as a child. Family History: No history of liver or renal disease. Five brothers and father were killed in [**Country **]. Mother had stroke. Sister alive and well. Physical Exam: ADMISSION PHYSICAL EXAM Gen: Intubated. Sedated. Opens her eyes to command. Alert to surrounding. Vitals: 99.0 64 116/63 100% 100% FiO2 PEEP of 5 VT on CPAP/PSV HEENT: Normocephalic. Nontraumatic. Anicteric. PERRLA. Supple neck wtihout lymphadenopathy. Chest: Bilateral coarse crackles throughout her lung fields Heart: Regular rate and rhythm. No murmurs or gallops appreciated Abdomen: Soft and nondistended. Grimaces to palpation but no guarding appreciated. No rebound tenderness. External: 1+ pitting edema to knee and b/l UE L > R. No rash. Appropriate temperature of the extremities. 2+ radial and dorsalis pedis pulses [**Country 894**] PHYSICAL EXAM VS: Tm/Tc 98.7/97.9, BP 150/80 (145-185)/(75-100), RR 18-20, SaO2 96-99RA In: 210cc ... Out: 1000cc, BM x1 FS: 110-175 GEN: NAD CV: Regular rate and rhythm. No murmurs or gallops appreciated LUNGS: CTAB, with some crackles at bases. ABD: Soft and nondistended. No tenderness to palpation, no guarding appreciated but no guarding appreciated. No rebound tenderness. EXTREM: LUE>RUE swelling, LLE swelling with 2+ pitting edema Pertinent Results: Admission labs [**2114-12-4**] 03:30PM BLOOD WBC-8.2 RBC-3.09* Hgb-9.2* Hct-29.0* MCV-94 MCH-29.9 MCHC-31.9 RDW-16.8* Plt Ct-263 [**2114-12-5**] 04:00PM BLOOD Neuts-86.6* Lymphs-9.1* Monos-3.8 Eos-0.2 Baso-0.2 [**2114-12-4**] 03:30PM BLOOD UreaN-22* Creat-1.6* Na-135 K-4.5 Cl-108 HCO3-16* AnGap-16 . Pertinent labs [**2114-12-6**] 03:23AM BLOOD tacroFK-10.1 [**2114-12-8**] 05:36AM BLOOD tacroFK-20.3* [**2114-12-11**] 04:51AM BLOOD tacroFK-8.1 [**2114-12-14**] 04:53AM BLOOD tacroFK-4.7* [**2114-12-12**] 02:50PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE [**2114-12-7**] 03:41PM BLOOD [**Year/Month/Day **]-NEGATIVE B [**2114-12-7**] 03:41PM BLOOD [**Doctor First Name **]-NEGATIVE . [**Doctor First Name 894**] LABS [**2114-12-20**] 06:10AM BLOOD WBC-5.7 RBC-2.82* Hgb-8.2* Hct-25.0* MCV-89 MCH-29.1 MCHC-32.8 RDW-17.1* Plt Ct-331 [**2114-12-16**] 08:49AM BLOOD PT-12.3 PTT-28.2 INR(PT)-1.0 [**2114-12-20**] 06:10AM BLOOD Glucose-82 UreaN-41* Creat-2.0* Na-140 K-4.3 Cl-109* HCO3-19* AnGap-16 [**2114-12-20**] 06:10AM BLOOD Calcium-8.8 Phos-5.3* Mg-2.1 . CXR ([**2114-12-5**]): Mild pulmonary edema with cardiomegaly. Confluent opacity at the right lung base, can not exclude pneumonia. . Renal US ([**2114-12-5**]): Lack of diastolic flow in the mid and lower pole intrarenal arteries. Findings raise concern for acute tubular necrosis or tranplant rejection. Patent main renal vein. Close clinical followup recommended. . TTE ([**2114-12-10**]) The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-10mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. . CT Head ([**2114-12-11**]) No acute intracranial process. Note that CT has limited sensitivity for the detection of acute infarction, and MR/DWI can be obtained as clinically indicated. Brief Hospital Course: BRIEF HOSPITAL COURSE: ms. [**Name14 (STitle) 59031**] is a 56y/o lady with past medical history significant for ESRD s/p live donor kidney [**Name14 (STitle) **] in [**2108**] who was immunosuppressed with tacrolimus/ prednisone/cellcept admitted with one day history of acute respiratory distress requiring intubation with infiltrates on CXR concerning for multifocal pneumonia. No organism grew; imaging was suggestive of diffuse alveolar hemorrhage. She required ultrafiltration in order to be extubated. She was weaned to room air and was breathing comfortably. The etiology of her respiratory distress is unclear. [**Name2 (NI) **] immunosuppressive regimen was decreased in case infection precipitated her decompensation, and she will have outpatient follow-up with Pulmonology. She was discharged home. . ACTIVE ISSUES: . 1. Hypoxemic respiratory failure: With b/l infiltrate on CXR and her history slightly suggestive of aspiration, ddx included aspiration pna vs atypical bacterial pna vs viral pna vs PCP vs MRSA or other hospital acquired pneumonia as she has had a long hospital stay recently. Dr. [**Last Name (STitle) **] performed bronchoscopy, all cultures, stains and count along with fungal, viral and CMV culture negative to date. Empirically covered with vancomycin, cefepime and flagyl for presumed PNA. Flagyl dc'd [**12-6**]. Vancomycin discontinued on [**12-8**]. Tolerate SBT well for one hour but did have CO2 retention in setting of metabolic acidosis from #2. She was placed on CPAP 5/5 with worsening CO2 retention and inability to compensate for significant metabolic acidosis. Placed on Assist control with high tidal volumes to compensate for her #3. Attempted to diuresis with lasix gtt and metalazone 5 mg po BID but only able to get net I/O of -400 cc on [**2114-12-11**]. Ultrafiltration with HD was initiation and pulmonary edema was removed which helped her RSBI and she was extubated on [**2114-12-13**]. She was eventually weaned to 3LNC on [**2114-12-15**]. Then, on [**2114-12-18**] she was weaned to room air and was satting in the high 90's even with ambulation. She had a persistent cough, and Benzonatate provided some relief. She was on Albuterol and Advair so in addition, she was started on Ipratropium inhaler. The etiology of her respiratory distress is unclear. [**Name2 (NI) **] immunosuppressive regimen was decreased in case infection precipitated her decompensation, and she will have outpatient follow-up with Pulmonology. . 2. Acute kidney injury: s/p kidney [**Name2 (NI) **] in [**2108**]. Admission creatinine elevated from baseline few months ago but better than her [**Year (4 digits) **] creatinine 10 days ago which was 2.7. Renal US consistent with low diastolic flow suggestive of ATN vs early graft failure. Renal [**Year (4 digits) **] medicine consulted, concern for ATN secondary to hypotension vs bactrim toxicity. Fluid boluses given to keep MAP > 65. Cr stabilized around 2.0 which might likely be her new baseline. She had good urine output. The likelihood of her rejecting atthis age was thought to be low, so Nephrology suggested stopping Cellcept (Mycophenylate Mofetil). She will follow up with Nephrology. . 3. Metabolic acidosis: Likely from acute kidney injury. Persistent metabolic acidosis with pH in 7.1 - 7.2 range. Gave 3 amps of bicarb on [**12-8**] and placed patient back on assist control with high tidal volumes to help compensate. Resolved as her acute kidney injury resolved. . 4. Left arm swelling: Greater than right arm. At baseline. [**2114-11-11**] US negative for DVT. Repeat U/S showed superficial vein thrombosis at the site of her PICC. Teh line was pulled and with warm compresses/elevation, it became less swollen but was still larger than the right. She was told to elevate the arm as much as possible. She will follow up with her PCP. . 5. Anemia: No obvious source of GI bleed. Transfused 3 units PRBC total. Hemolysis labs were negative. Likely from acute kidney injury. Restarted on epopoeitin 5000 units MWF. . 6. Hypertension: very poorly controlled. Initially, her Metoprolol was held in the setting of her illness concering for sepsis and concern for acute kidney injury related to hypotension. However, as she began to improve she had SBP 180-200. She was switched from Metoprolol to Labetalol and this was uptitrated. She will need PCP follow up to manage her hyprtension, as her SBP even after this intervention was 145-185. . INACTIVE ISSUES: . 7. Type 2 DM: reasonably controlled. She was initially on sliding scale Humalog but was switched to her home regimen with fingersticks 125-200. . 8. Depression: stable. Continued Citalopram 20 mg po qdaily . TRANSITIONAL ISSUES: -Outpatient follow-up: She will be seen in [**Hospital 1944**] clinic for follow-up and then is to follow up with her PCP. [**Name10 (NameIs) **] that should be followed up include: blood pressure control (adding another [**Doctor Last Name 360**]?), respiratory status (breathing fine on room air? requiring frequent inhalers? persisting nighttime cough?), and LUE swelling (which should be resolving b/c was due to line-associated superficial vein thrombosis). Creatinine should be checked and her [**Doctor Last Name 1326**] Nephrologist (Dr. [**Last Name (STitle) **] should be informed if >2.0. She will then be seen by Pulmonary (with PFTs scheduled) as well as [**Last Name (STitle) 1326**] Nephrology. Medications on Admission: 1. Citalopram 20 mg po qdaily 2. Aspirin 325 mg po qdaily 3. Mycophenolate mofetil 500 mg po BID 4. Tacrolimus 2 mg po BID 5. Sevelamer HCl 800 mg po BID 6. Metoprolol tartrate 50 mg po BID 7. Prednisone 5 mg po qdaily 8. acetaminophen 325 mg po q6 prn pain 9. docusate sodium 100 mg po BID 10. pantoprazole 40 mg po q12 11. albuterol sulfate 90 mcg/Actuation HFA Aerosol [**12-2**] puff q4-6 hrs prn shortness of breath 12. fluticasone-salmeterol 250-50 mcg/dose inhalation twice a day 13. diazepam 5 mg Tablet po q8 prn anxiety 14. Lantus 5 units SC qhs 15. Humalog sliding scale 16. Outpatient Lab Work 17. White petrolatum-mineral oil 56.8-42.5 % Ointment prn dry eyes 18. epoetin alfa 10,000 unit/mL Solution Sig: One (1) ml Injection once a week: Give every Wednesday. [**Month/Day (2) **] Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. tacrolimus 1 mg Capsule, twice daily Sig: Two (2) Capsule, twice daily PO twice a day. 4. sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO three times a day: with meals. 5. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation every 4-6 hours as needed for shortness of breath/wheezing . 10. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 11. diazepam 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety. 12. insulin glulisine 100 unit/mL Cartridge Sig: Five (5) units Subcutaneous QHS. 13. labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 14. epoetin alfa 4,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday). 15. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath/wheezing . Disp:*1 inhaler* Refills:*2* 16. benzonatate 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for cough. Disp:*30 Capsule(s)* Refills:*2* 17. Humalog sliding scale Sig: One (1) injection qachs: please resume your usual sliding scale. [**Hospital1 **] Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] [**First Name3 (LF) **] Diagnosis: respiratory failure [**First Name3 (LF) **] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [**First Name3 (LF) **] Instructions: You were admitted for respiratory failure that required intubation. You have recovered, and are breathing fine on room air so you are being discharged home. Because you have a renal [**First Name3 (LF) **], you were transplanted to the [**First Name3 (LF) 1326**] Nephrology service, where your renal function was monitored and your immunosuppressants were adjusted. . It is not clear why you had respiratory failure. Please follow-up with Pulmonology to further investigate this (appointment listed below). . We made the following changes to your medications: -stop Cellcept (Mycophenylate Mofetil) -increase Sevelamer -stop Metoprolol -start Labetalol -start Benzonatate -start Ipratropium inhaler Followup Instructions: PRIMARY CARE [**Hospital3 249**] Post [**Hospital **] Clinic With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. When: THURSDAY [**2114-12-27**] at 2:10 PM With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Hospital Ward Name **] NEPHROLOGY Department: [**Hospital Ward Name **] CENTER When: FRIDAY [**2115-1-4**] at 10:40 AM With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage PULMONOLOGY Department: PULMONARY FUNCTION LAB (Breathing Tests) When: MONDAY [**2115-1-14**] at 1:10 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage PULMONOLOGY Department: MEDICAL SPECIALTIES When: MONDAY [**2115-1-14**] at 1:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2144-3-20**] Discharge Date: [**2144-4-9**] Date of Birth: [**2076-11-15**] Sex: M Service: UROLOGY Allergies: Synthroid / Almond Sweet Oil Attending:[**First Name8 (NamePattern2) 19908**] Chief Complaint: Recurrent right pyelonephritis Major Surgical or Invasive Procedure: 1. Right simple nephrectomy - [**2144-3-20**] - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**] 2. Wound exploration, washout, placement of intraabdominal drains - [**2144-3-30**] - Dr. [**Known firstname **] [**Last Name (NamePattern1) 365**] History of Present Illness: 67M s/p childhood traumatic injury necessitating cystectomy and B ureterosigmoidostomy, w/ eventual renal degeneration to Stage IV CKD, also found to have persistent fecal reflux into R kidney necessitating R [**Last Name (NamePattern1) 26204**] placement and frequent changes/mainpulations due to clogging/pyelonephritis. GI and GU workup negative for fistula. Patient is now s/p R "simple" nephrectomy. Past Medical History: PMH: childhood traumatic injury, Stage IV CKD, nephrolithiasis, pelvic lymphocele, LLE DVT '[**36**] (no longer on anticoag), GERD, R cataract, hypothyroidism, VRE, obesity, chronic metabolic acidosis --- PSH: cystectomy w/ B ureterosigmoidostomies; R cataract; multiple R [**Year (2 digits) 26204**] procedures; R antegrade ureteroscopy [**2-17**] Social History: Patient lives in [**Location 3786**] with his wife. [**Name (NI) **] is a retired school custodian. Quit Smoking 30 yrs ago, 1PPD x 10 years. No alcohol, no drugs. Family History: No family history of renal disease. Brother with Hemachromatosis. Family h.o malignant hyperthermia. Physical Exam: General: NAD, pleasant, conversive HEENT: NC/AT. MMM, clear oropharynx, no scleral icterus Neck: Supple Lungs: CTAB anteriorly, no w/w/r Cardiac: Regular rate, no m/g/r Abd: Slightly distended, soft, drain in place, incision healing well with two openings, one at each end of the incision with beefy red granulation tissue and mild serous drainage. Neuro: Alert, oriented. Speech appropriate. Moving all extremities. Psych: Appropriate Pertinent Results: [**2144-4-3**] 05:12AM BLOOD WBC-10.4 RBC-3.07* Hgb-8.7* Hct-26.5* MCV-87 MCH-28.2 MCHC-32.6 RDW-16.9* Plt Ct-437 [**2144-4-3**] 06:19AM BLOOD Glucose-95 UreaN-13 Creat-1.6* Na-142 K-3.5 Cl-107 HCO3-24 AnGap-15 [**2144-4-9**] 07:49AM BLOOD WBC-7.4 RBC-3.18* Hgb-9.0* Hct-27.8* MCV-88 MCH-28.2 MCHC-32.2 RDW-16.8* Plt Ct-390 [**2144-4-9**] 05:37AM BLOOD PT-25.2* INR(PT)-2.5* [**2144-4-6**] 05:00AM BLOOD Glucose-81 UreaN-14 Creat-1.8* Na-142 K-3.9 Cl-109* HCO3-22 AnGap-15 Brief Hospital Course: ICU course: 1. Following the procedure, the patient was admitted to the ICU for fluid status and electrolyte monitioring. He required aggressive magnesium repletion (post-op Mg was 0.7) following the procedure as well as 2 u prbc. He was given IV HCO3 following the procedure, but this was discontinued on transfer to the floor and he was restarted on his home dose of Sodium Bicarbonate. Did receive single dose of lasix for lung crackles. He was treated with a dilaudid PCA and fentanyl patch for postoperative pain management. Ciprofloxacin was discontinued on POD 2. 2. CKD: baseline creatinine 2-2.6 following the procedure. Creatinine rose to 2.6 following the procedure and remained stable, trending down on POD 3. --- Floor course: Pt was transferred to floor in stable condition. He required some increases in doses for his dilaudid PCA on POD 2, but on POD 3 was transitioned to PO pain meds once tolerating solid food. He ambulated with the help of physical therapy and the nursing staff. His creatinine stabilized and trended down (2.3 on POD 5) and his electrolytes remained stable for the remainder of his hospital course. Renal medicine followed the pt throughout his hospital stay and adjusted his daily sodium bicarbonate regimen to 650 mg PO bid rather than qid. His lasix 40 mg PO qd was restarted on POD 3. His penrose drain was removed on POD 4. On POD 4, the pt was noted to have a markedly asymmetrically edematous LLE. Venous doppler ultrasound was performed, which demonstrated a large LLE DVT. The pt was started on intravenous unfractionated heparin and titrated to a target PTT of 60-80. Coumadin was started in the evening of POD 5. The pt was evaluated by vascular medicine, who recommended anticoagulation for at least one year given the pt's past history of DVT. They also recommended overlap of therapeutic heparin and coumadin for at least 2 days before discontinuation of heparin. The pt's INR became therapeutic on POD 7, and the pt was maintained on a dose of coumadin 1 mg PO qhs for two more days before heparin was discontinued on POD 9. His final dose of coumadin was 3 mg PO qhs. His discharge INR was 2.5. He will follow up with his PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**], for monitoring of his INR. On POD 5, the pt's wound was noted to be erythematous. A lateral-most staple was removed, with extrusion of cloudy serosanguinous fluid that was sent for culture. The wound was packed with Nu gauze underneath the incision, which helped reduce the erythema significantly. Ancef was started for empiric coverage of a skin infection. On POD 6, more drainage was noted from the medial [**1-11**] of the wound, and two more staples were removed and the wound was packed. Probing of the underlying fascia revealed fascial weakness and failure of the fascia to heal well. Wound cx preliminarily grew gram negative rods. Abx coverage was switched initially to ceftriaxone, then to unasyn, and eventually to Zosyn. The wound drainage increased throughout the next three days, and his WBC increased from 12 to 17. He remained afebrile, but his metabolic acidosis worsened despite increases in his bicarbonate regimen. His HCO3 on POD 9 was 16. On POD 9, a non-contrast CT A/P was performed, which revealed a gas-filled fluid collection at resection bed suspicious for an infected fluid collection. The pt was taken back to the OR on POD 10 for a wound exploration, washout of intraabdominal abscess, and drain placement. He tolerated the procedure well and was taken to the floor post-operatively. After his second operation, his clinical status improved. His WBC trended down, and became normal at 10.4 on POD [**4-21**]. His drains had minimal but consistent output. One drain was removed on POD From a renal standpoint, the pt continued to improve. His creatinine continued to trend down and was 1.6 on POD 14. On POD 13, some drainage was noted from the lateral aspect of his wound. Two stitches were removed on POD 14 and the wound was packed with 2x2 gauze. Healthy, beefy-red granulation tissue was noted on the internal aspects of the wound. His old staples were removed on POD 17, and some discharge was noted from the medial aspect of the wound, which was again packed. The discharged appeared serous, and was manageable with dressing changes. The wound appeared to be well-healing and nonerythematous. His WBC count remained normal and he was afebrile. On discharge, the pt was ambulating, tolerating a regular diet, and his pain was adequately controlled on oral pain medication. He was discharged with VNA to manage his one JP drain, his dressing changes, and to complete his course of Zosyn. He will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**] for management of his INR, Dr. [**Last Name (STitle) 911**] to address his DVT, Dr. [**Last Name (STitle) 1366**] of the renal service, and Dr. [**Last Name (STitle) 9125**], who will see the patient within one week. Medications on Admission: 1. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Liothyronine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Propranolol 120 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Liothyronine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Propranolol 120 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 9. Sodium Bicarbonate 650 mg Tablet Sig: Three (3) Tablet PO QID (4 times a day). 10. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: Please follow up with Dr. [**Last Name (STitle) 131**] within two days to follow your INR for your coumadin. Disp:*30 Tablet(s)* Refills:*2* 11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous once a day as needed for line flush. Disp:*30 ML(s)* Refills:*2* 12. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 5 days. Disp:*15 Recon Soln(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Recurrent right pyelonephritis Discharge Condition: Stable Discharge Instructions: -You may shower but do not bathe, swim or immerse your incision. -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids. -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up. -Do not drive or drink alcohol while taking narcotics. -Your medications have been adjusted. Please see your discharge medication worksheet for the adjustments. Please take your sodium bicarbonate 3 tabs four times/day. Do not take NSAID (aspirin, advil, motrin, ibuprofin) medications. -Call your Urologist's office today to schedule a follow-up appointment in 3 weeks AND if you have any questions. -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest ER. -Take coumadin for at least one year. Follow up within one week with your primary care physician for an INR check and coumadin dose adjustment. -Please continue your antibiotics to complete a 14 day course. Followup Instructions: Please call Dr. [**Last Name (STitle) 9125**] for a follow-up appointment. Please follow-up with Dr. [**Last Name (STitle) 911**] in [**4-13**] wks ([**Telephone/Fax (1) 2037**] for management of DVT. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**] within 2-3 days of discharge for management of INR. Please follow-up with Dr. [**Last Name (STitle) 1366**] - call him for a f/u appt Completed by:[**2144-4-9**]

[ "276.7", "E878.8", "278.00", "591", "V09.80", "567.38", "530.81", "585.4", "997.2", "590.00", "276.2", "275.41", "V02.59", "582.89", "285.21", "403.90", "427.1", "998.59", "593.9", "453.41", "244.9", "275.2" ]

icd9cm

[ [ [] ] ]

[ "55.51", "99.04", "54.0", "38.93" ]

icd9pcs

[ [ [] ] ]

9803, 9861

2678, 7745

330, 602

9936, 9945

2181, 2655

11019, 11479

1608, 1710

8451, 9780

9882, 9915

7771, 8428

9969, 10996

1725, 2162

260, 292

630, 1038

1060, 1410

1426, 1592

56,523

187,036

1877

Discharge summary

report

Admission Date: [**2160-10-30**] Discharge Date: [**2160-11-5**] Date of Birth: [**2101-9-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6378**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 10468**] is a 59 year old gentleman with history of sardoidosis who presented to clinic [**10-30**] with complains of increasing dyspnea x 6 days. He describes the sudden onset of shortness of breath with exertion 6 days prior to presentation. Symptoms progressively worsened such that he had to stop for several minutes to catch his breath when he would try to climb stairs. He described chest pain, which is substernal and on the right side of his chest. This pain is not exertional and has been present for at least a month. He also feels that his baseline cough has been somewhat worse. Of note, he had also been having right lower extremity swelling, pain and warmth x 2 weeks. No orthopnea, no PND or recent fevers. No hemoptysis. No recent travel or immobilization. No recent injuries. In clinic, he was noted to be tachycardic. A lower extremity ultrasound demonstrated large deep vein thrombosis of the right leg and he was sent to the [**Hospital1 18**] ED for further evaluation. In the ED, initial vital signs were: 98.2 115 (sinus tach) 128/89 24 100% RA. Stool guaiac was negative. CTA Chest was notable for massive bilateral pulmonary embolisms as well as reverse deviation of the interventricular septum indicative of right heart strain. He received one liter normal saline, aspirin 325mg and heparin gtt. Past Medical History: 1. Sarcoid 2. Dyslipidemia 3. Headaches 4. Superficial thrombophlebitis--had an episode "out of the blue" several years ago 5. Possible gastroesophageal reflux disease--patient does not endorse heartburn although he has been on a omeprazole for over a year. Social History: Non- smoker. Occasional alcohol. No history of intravenous drug use. Works as financial planner and is married. Family History: No history of blood clots or bleeding disorders. Physical Exam: 97.3 105 116/76 17 97% RA Pleasant man lying comfortably in bed, mildly anxious. EOMI, PERRL OP clear, MMM. Neck is supple, no carotid bruits, no thyroid nodule. JVP not elevated. S1, S2, tachycardic and regular, no murmur. Lungs clear b/l Abd is soft and not tender. +Varicose veins. RLE is mildly edematous as compared to the left. No palpable cord. No warmth. Distal pulses are faint but palpable b/l. Neuro: Alert and oriented, moving all extremities equally. Pertinent Results: ON ADMISSION: 138 98 14 AGap=14 ------------< 101 4.2 30 1.0 estGFR: >75 (click for details) 14.8 11.8 >----< 240 41.8 N:90.0 L:6.2 M:2.9 E:0.6 Bas:0.2 PT: 13.3 PTT: 27.8 INR: 1.1 CXR [**10-30**]: Stable appearance of the chest in keeping with patient's known sarcoidosis. Of note, mediastinal lymphadenopathy is better visualized in CT performed the same day. CTA Chest [**10-30**]: 1. Massive bilateral pulmonary emboli with right heart strain pattern. Correlate clinically adn with echocardiography. 3. Stable centrilobular nodules and consolidative changes of the upper lobes and mediastinal lymphadenopathy, compatible with the patient's diagnosis of sarcoidosis. Bilateral Lower Extremity Ultrasound [**10-30**]: Nearly occlusive thrombus involving the right superficial femoral and popliteal veins. Findings were discussed with Dr. [**Last Name (STitle) 3306**] immediately after completion of the study by the son[**Name (NI) 930**]. The patient will be going to [**Hospital1 18**] Emergency Room today. ECHO [**10-31**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60-70%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Right ventricle is somewhat dilated and hypocontractile PERTINENT LABS AT DISCHARGE: INR: [**11-3**] 2.0 [**11-4**] 2.4 [**11-5**] 2.8 Brief Hospital Course: 1)Pulmonary embolism: Patient presented with large bilateral pulmonary embolisms. This was confirmed by CTA of the Chest. He was started on a Heparin drip that was bridged to Coumadin. The patient was monitored on telemetry during his admission which remained unremarkable. Patient initially had some intermittent chest pain likely secondary to large clot burden. Cardiac enzymes and EKG showed no indications of ischemia at any time. Chest pain had nearly resolved at time of discharge. Patient was initially requiring oxygen via nasal cannula that was weaned off. At the time of discharge the patient's oxygen saturation on room air with and without activity were consistently greater than 93%. At time of discharge patient had been therapeutic on Coumadin for 48 hours. Plan is for him to get INR recheck at Dr. [**Name (NI) 10469**] office starting [**11-7**] and weekly thereafter. The patient was instructed to stop taking his daily aspirin for the time being given an increased risk of intra-cranial bleeding with Warfarin and aspirin combined therapy. Provided patient with handout about Coumadin and answered his questions regarding warfarin therapy. 2) Sarcoid: Stable during this admission. Patient was continued on Prednisone 10 mg daily. Patient should follow up with Dr. [**Last Name (STitle) 575**] as an outpatient. 3) Leukocytosis: Initially had an elevated white blood cell count count that has resolved. This likely was a reactive leukocytosis responding to the stress of a massive pulmonary embolism. Patient had no evidence of infection including no fevers. A urinalysis was negative and the CT chest did not show evidence of infection. 4) Gastroesophageal reflux disease: Patient was continued on his outpatient omeprazole. 5) Dyslipidemia: Patient was continued on his outpatient dose of atorvastatin. The patient was FULL CODE during this admission. Medications on Admission: 1. ASA 81mg daily 2. Prednisone 10mg daily 3. Atorvastatin 10mg QHS 4. Omeprazole 20mg daily 5. Dextromethorphan 2 tsp prn cough Discharge Medications: 1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Dextromethorphan Poly Complex 30 mg/5 mL Suspension, Sust.Release 12 hr Sig: Ten (10) ML PO Q12H (every 12 hours) as needed. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day: Please take 2 1/2 tablets by mouth daily. Have INR checked starting [**11-7**] and weekly thereafter as directed by Dr. [**Last Name (STitle) 838**]. Dosing adjustments per Dr. [**Last Name (STitle) 838**]. Disp:*75 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Primary:Pulmonary Embolus Secondary: Sarcoid Discharge Condition: good Discharge Instructions: You were admitted to the hospital due to large blood clots in your lungs called pulmonary emboli that were seen on CT scan. The blood clots were likely the cause of your increased shortness of breath. You were started on a medicine called Heparin to prevent you from forming more clots and were then transitioned to a medicine called Coumadin that has the same effect. When you leave the hospital you must continue to take coumadin indefinitely to prevent more blood clots from forming. You can discuss the time course for taking Coumadin with your PCP. [**Name10 (NameIs) **] will need to have your blood tested weekly to make sure your INR is in a therapeutic range for preventing blood clots. You will go to Dr.[**Name (NI) 10470**] office to have these blood tests done. Importantly, we have stopped your daily dose of Aspirin 81 mg daily while you are taking Coumadin. We have provided you with a patient handout about Coumadin that describes additional over the counter medications, as well as, foods to avoid when you are on Coumadin therapy. It also describes possible adverse effects. If you develop significant chest pain, shortness of breath,notice any new extremity swelling, or have uncontrolled bleeding please come to the emergency room for evaluation. Followup Instructions: You will need to have your blood tested weekly until your INR is stable on Coumadin. You should have your blood tested on Friday, [**2160-11-7**] at Dr.[**Name (NI) 10470**] office and then weekly there after. You have and appt to see Dr. [**Last Name (STitle) 838**] on Tuesday, [**11-11**] at 1:45pm [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6384**] MD, [**MD Number(3) 6385**] Completed by:[**2160-11-6**]

[ "V58.65", "135", "518.82", "786.59", "415.19", "429.9", "272.4", "453.8", "288.60", "530.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7485, 7491

4730, 6612

324, 330

7580, 7587

2683, 2683

8905, 9368

2133, 2183

6792, 7462

7512, 7559

6638, 6769

7611, 8882

2198, 2664

277, 286

4652, 4706

358, 1706

2697, 4632

1728, 1988

2004, 2117

63,237

111,005

41636

Discharge summary

report

Admission Date: [**2177-11-17**] Discharge Date: [**2177-11-25**] Date of Birth: [**2112-12-28**] Sex: F Service: CARDIOTHORACIC Allergies: Hydrocodone Attending:[**First Name3 (LF) 922**] Chief Complaint: CAD Major Surgical or Invasive Procedure: [**2177-11-20**] CABG x4 (lima-lad, v-pda, v-om1, v-D1) /closure LAD to PA and RCA to PA fistulas History of Present Illness: 64 year old female with episodes of palpitations that underwent stress test with ischemic changes and was stopped due to leg fatigue. She was referred for cardiac catheterization that revealed CAD and anamolous artery, she is transferred for surgical evaluation Past Medical History: PMHx: Severe anxiety and depression, Diabetes mellitus type 2, Hypertension, Hyperlipidemia, Tobacco abuse, Sleep apnea, Hypothyroidism, Impaired renal function, Chronic Bronchitis, Carpal tunnel, Tubal ligation, Pinning of right hand, Left knee arthroscopic , TIA vs CVA with aphasia that lasted one month Social History: Race: Caucasian Last Dental Exam: 6 years Lives with: spouse Contact: [**Name (NI) **] (husband) Phone # [**Telephone/Fax (1) 90501**] cell [**Telephone/Fax (1) 90502**] Cigarettes: Smokes about [**4-22**] cigarettes per day - 40 pack year history ETOH: denies Illicit drug use: denies Family History: Family History: Father leaky valve Mother racing heart Physical Exam: Physical Exam Pulse: 62 Resp: 20 O2 sat: 99% RA B/P Right: 121/57 Left: 124/69 Height: 5 Weight: 144 Lbs 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] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] abdominal folds, palpable hernia luq Extremities: Cool multiple varicosities pulses with doppler Edema - none Neuro: Alert and oriented x3 non focal Pulses: Femoral Right: cath site Left: +1 DP Right: doppler Left: doppler PT [**Name (NI) 167**]: doppler Left: doppler Radial Right: +1 Left: +1 Carotid Bruit Right: no bruit Left: no bruit Pertinent Results: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are moderately thickened. The left cusp is hypomobile. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. An eccentric, posteriorly directed jet of Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. A tiny fistula may be seen entering the proximal PA. By history this comes from the Circumflex artery. An epi-aortic scan showed no calcifications at the planned cannulation site. Post-CPB: The patient is in SR on no inotropes. Preserved biventricular systolic fxn. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact. Fistula in [**MD Number(3) 62535**] not be visualized. CAROTIDS: FINDINGS: Mild heterogeneous plaques are seen bilaterally along the proximal internal carotid arteries. The peak systolic velocity in the right internal carotid artery ranges from 76 to 83 cm/sec and the left internal carotid artery from 72 to 77 cm/sec. The peak systolic velocity in the right common carotid artery is 93 cm/sec and in the left common carotid artery is 80 cm/sec. Bilateral external carotid arteries are patent. There is antegrade flow in the bilateral vertebral arteries. The ICA/CCA ratio on the right is 0.85 and on the left is 0.90. [**2177-11-24**] 05:50AM BLOOD WBC-6.8 RBC-2.81* Hgb-8.1* Hct-25.1* MCV-89 MCH-28.7 MCHC-32.2 RDW-13.9 Plt Ct-170 [**2177-11-24**] 05:50AM BLOOD UreaN-39* Creat-1.0 Na-137 K-3.9 Cl-102 [**2177-11-17**] 06:00PM BLOOD ALT-12 AST-19 LD(LDH)-175 CK(CPK)-94 AlkPhos-56 Amylase-65 TotBili-0.3 [**2177-11-17**] 06:00PM BLOOD CK-MB-3 cTropnT-<0.01 [**2177-11-17**] 06:00PM BLOOD Lipase-35 [**2177-11-24**] 05:50AM BLOOD Mg-2.1 [**2177-11-25**] 05:35AM BLOOD WBC-6.7 RBC-2.95* Hgb-8.8* Hct-26.3* MCV-89 MCH-29.8 MCHC-33.3 RDW-13.9 Plt Ct-244 [**2177-11-25**] 05:35AM BLOOD UreaN-43* Creat-1.0 Na-140 K-4.3 Cl-103 Brief Hospital Course: The patient was brought to the operating room on [**11-20**] where the patient underwent: PROCEDURES: 1. Coronary bypass grafting x4 with left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to second diagonal coronary artery; reverse saphenous vein single graft from aorta to the first obtuse marginal coronary artery; reverse saphenous vein single graft in the aorta to the posterior descending coronary artery. 2. Ligation and division of coronary to pulmonary artery fistula x3. 3. Epiaortic duplex scanning. 4. Endoscopic left greater saphenous vein harvesting. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. She went into A Fib postop and converted to SR with amiodarone. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: [**Last Name (un) 1724**]:Xanax 0.25 mg TID prn, aspirin 81 mg daily, Prozac 40 mg daily, Synthroid 100 mcg daily, Lovastatin 40 mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*1* 3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* 5. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): prn for pain. Disp:*240 Tablet(s)* Refills:*2* 7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day: 400mg [**Hospital1 **] x 7 days, then 400mg daily x 7 days, then 200mg daily. Disp:*90 Tablet(s)* Refills:*0* 8. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 9. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once a day for 1 weeks. Disp:*7 Packet(s)* Refills:*0* 10. lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 12. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. Disp:*60 Tablet(s)* Refills:*0* 13. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease s/p cabg x4/ closure LAD/PA and RCA/PA fistulas postop A Fib Severe anxiety and depression Morbid Obesity - but has lost 200 Lbs Diabetes mellitus type 2 Hypertension Hyperlipidemia Tobacco abuse Sleep apnea prior to weight loss - no episodes recently Hypothyroidism TIA vs CVA - with aphasia that lasted 1 month Impaired renal function Chronic Bronchitis rt foot s/p fx after fall Past Surgical History Carpal tunnel Tubal ligation Pinning of her right hand Left knee arthroscopic Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage leg- c/d/i, trace edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [**Last Name (STitle) 914**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 170**] [**2177-12-22**] 1:00pm Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Doctor First Name **]) ([**Telephone/Fax (1) 84379**] [**12-24**] @ 10:40 AM Please call to schedule the following: Primary Care in [**4-22**] weeks Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 90503**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2177-11-25**]

[ "593.9", "414.01", "272.4", "414.19", "411.1", "997.1", "250.00", "401.9", "427.31", "305.1", "244.9", "417.0" ]

icd9cm

[ [ [] ] ]

[ "36.91", "39.61", "36.15", "36.13" ]

icd9pcs

[ [ [] ] ]

7758, 7764

4342, 5988

286, 386

8315, 8495

2192, 4319

9367, 10144

1345, 1386

6176, 7735

7785, 8294

6014, 6153

8519, 9344

1401, 2173

241, 246

414, 679

701, 1009

1025, 1313

28,175

183,484

33329

Discharge summary

report

Admission Date: [**2125-9-20**] Discharge Date: [**2125-9-25**] Date of Birth: [**2095-6-6**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 3574**] Chief Complaint: Suicide attempt, tylenol ingestion Major Surgical or Invasive Procedure: None History of Present Illness: 30 y/o female w h/o depression, anxiety, and polysubstance abuse, prior suicide attempt [**4-23**] with Tylenol and Lithium, found to have suicide attempt with tylenol ingestion admitted to OSH on [**9-18**]. Patient took approx 150 tabs of tylenol PM. After 1 hour of this ingestion (per patient), she came to the ED and was found to have a Tylenol level to 470. In OSH ED, she was given IV acetylcysteine gtt, unclear dosing. Her LFT initially was AST 67 ALT 257 which steadily climbed to AST 2550 ALT 1557 then today AST [**Numeric Identifier 7652**] ALT 4825. Her INR also risen (1.2->3.1). Her renal function is within normal limits still. Her most recent ABG is 7.39/30.7. No evidence of hepatic encephalopathy. She has persistent nausea and abdominal pain. At OSH, she had elevated glucose up to 255, no history of DM. Amylase and lipase of 69 and 33 respectively. Hepatitis panel (A and B negative). Hep C and HIV were pnding. Denies SI. Has been a heavy alcohol user with no h/o withdrawal. . At OSH, she was given 21 hours of acetylcysteine and was d/c, but her LFT continued to rise. After discussion with poison control, she was continued on her IV acetylcysteine (goal till her AST/ALT down below 1000) and her tylenol level below 10. She was transferred to [**Hospital1 18**] for further management of her ingestion of tylenol. . Pt reports a long history of anxiety with panic attacks as well as polysubstance abuse including oxycontin, heroine, cocaine, and xanax. . On the floor, she was found to be alert and oriented without any issues. . Review of systems: (+) Per HPI Past Medical History: Past Medical History: -Cellulitis -Thrombocytosis -h/o lithium/tylenol overdose in [**2123**] -depression -anxiety -polysubstance abuse including IVDU, marijuana use, cocaine use Social History: Patient currently lives alone. She previously lived with husband, but he has been in jail since [**February 2123**]. They are also in the midst of divorce proceedings. Fiance has been at bedside during ICU stay. She has no children. Previously worked as a crime analyst, but not currently. No tobacco. Drinks alcohol (unsure of amount). Uses cocaine (intravenous), marijuana, percocet. Family History: Father - History of substance abuse that developed in [**Country 3992**]. He had long period of sobriety until a few years ago when he was put on opiates for pain control and developed addiction. Per report, he fell and died following head trauma, which may have been related to intoxication. No known suicides. Mother - History of anxiety. (No official psychiatric diagnoses.) Physical Exam: Vitals: T: 99.6 BP: 118/66 P: 83 R: 18 O2: 99% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2125-9-20**] 08:14PM BLOOD WBC-10.2# RBC-4.44# Hgb-13.0 Hct-37.7# MCV-85 MCH-29.3 MCHC-34.5 RDW-15.4 Plt Ct-264# [**2125-9-20**] 08:14PM BLOOD Neuts-79.4* Lymphs-17.7* Monos-1.1* Eos-1.2 Baso-0.7 [**2125-9-20**] 08:14PM BLOOD PT-30.2* PTT-37.1* INR(PT)-3.0* [**2125-9-20**] 08:14PM BLOOD Glucose-208* UreaN-6 Creat-0.6 Na-136 K-4.4 Cl-106 HCO3-22 AnGap-12 [**2125-9-20**] 08:14PM BLOOD ALT-5241* AST-5074* AlkPhos-164* Amylase-23 TotBili-4.0* [**2125-9-20**] 08:14PM BLOOD Lipase-30 [**2125-9-20**] 08:14PM BLOOD Albumin-3.6 Calcium-8.9 Phos-1.0*# Mg-1.9 Iron-63 Cholest-136 [**2125-9-20**] 08:14PM BLOOD calTIBC-302 Ferritn-3675* TRF-232 [**2125-9-20**] 08:14PM BLOOD Triglyc-103 HDL-43 CHOL/HD-3.2 LDLcalc-72 [**2125-9-20**] 08:14PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE [**2125-9-21**] 04:19AM BLOOD HIV Ab-NEGATIVE [**2125-9-20**] 08:14PM BLOOD Lithium-LESS THAN [**2125-9-20**] 08:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2125-9-20**] 08:14PM BLOOD HCV Ab-POSITIVE* [**2125-9-20**] 08:29PM BLOOD Type-[**Last Name (un) **] pO2-116* pCO2-37 pH-7.39 calTCO2-23 Base XS--1 Comment-GREEN TOP [**2125-9-20**] 08:29PM BLOOD Lactate-2.7* . Discharge Labs: [**2125-9-24**] 05:45AM BLOOD WBC-6.0 RBC-3.98* Hgb-11.6* Hct-34.5* MCV-87 MCH-29.2 MCHC-33.7 RDW-16.5* Plt Ct-313 [**2125-9-24**] 05:45AM BLOOD PT-13.4 PTT-30.7 INR(PT)-1.1 [**2125-9-24**] 05:45AM BLOOD Glucose-106* UreaN-9 Creat-0.6 Na-139 K-3.7 Cl-106 HCO3-26 AnGap-11 [**2125-9-24**] 05:45AM BLOOD ALT-1172* AST-83* LD(LDH)-133 AlkPhos-117* TotBili-1.7* [**2125-9-24**] 05:45AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.6 . Microbiology: HCV VIRAL LOAD ([**2125-9-24**]): HCV RNA detected, less than 43 IU/mL. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2125-9-24**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2125-9-24**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2125-9-24**]): NEGATIVE <1:10 BY IFA. CMV IgG ANTIBODY (Final [**2125-9-21**]): NEGATIVE FOR CMV IgG ANTIBODY BY EIA. CMV IgM ANTIBODY (Final [**2125-9-21**]): NEGATIVE FOR CMV IgM ANTIBODY BY EIA. VARICELLA-ZOSTER IgG SEROLOGY (Final [**2125-9-21**]): POSITIVE BY EIA. Rubella IgG/IgM Antibody ([**2125-9-21**]): POSITIVE by Latex Agglutination. RAPID PLASMA REAGIN TEST (Final [**2125-9-21**]): NONREACTIVE. . CXR [**2125-9-20**]: Heart size is top normal, most likely within normal limits and the study is slightly exaggerated by the portable technique of the study. Mediastinum is unremarkable. Lungs are clear but note is made that external devices are projecting over the right hemithorax, precluding detailed evaluation of that examination. There is no pleural effusion or pneumothorax. . Pending: HBcAb, HBc IgM Brief Hospital Course: 30yo female with h/o polysubstance abuse, previous suicide attempt in [**2123**] (lithium and tylenol OD) requiring ICU admission and subsequent inpatient psych admission, who presented to OSH after ingestion of 150 Tylenol PM in setting of marijuana and percocet use, and cocaine use the day prior. Patient was transferred to ICU at [**Hospital1 18**] for further evaluation and management of tylenol overdose. . # Tylenol ingestion: The patient's transaminases, AlkPhos, Tbili, and INR continued to trend down since admission. Pt was seen by hepatology, toxicology, and psych. Hepatology reassured with her downtrending LFTs. Patient not a transplant candidate at this time given recent substance abuse. Toxicology felt that since the pt's NAC was stopped for a period of 10 hrs at the OSH, it should be restarted here for 21 hr protocol (which was done). NAC was d/c'ed on [**2125-9-21**]. Psych evaluated the pt, and given her SI, they determined she would need to go for inpatient psych treatment once medically stable. The patient did not develop any signs of encephalopathy or cerebral edema. She did not develop any acute kidney injury. A RUQ US was negative for any acute pathology (as per hepatology). The patient was transferred to the general medicine floor, with all of her labs continuing to trend down. The patient remained hemodynamically stable, asymptomatic, and was medically cleared for transfer to inpatient psych. . # Suicide attempt: Patient's suicide attempt with tylenol ingestion was in setting of marijuana and percocet use, as well as IV cocaine use the day prior. She also had a previous suicide attempt in [**2123**]. Patient seen and evaluated by psych, who felt patient will need inpatient psych treatment once medically stable. Patient has been on 1:1 sitter, and at time of discharge from medical floor denies any further suicidal ideation. . # Depression and Anxiety: Patient previously on fluoxetine as outpatient, but stopped taking this medication several months ago. She will need to get appropriate outpatient follow-up after inpatient psych treatment, with proper dosage of her home psych meds. . # HCV Ab Positive - Patient has h/o IVDU, and HCV Ab noted to be positive on this admission. Patient aware of result. HCV viral load was less than 43 IU/mL on testing. Patient HAV Ab positive, but HAV IgM negative, indicating previous exposure/vaccine for HAV. HepBsAg negative, and patient may benefit from Hep B vaccine as outpatient. Also ordered HepB core Ab and HepB core IgM, which will be pending at time of discharge. If HBV core Ab and IgM negative, patient should receive Hep B vaccine. Patient should follow-up with her PCP, [**Name10 (NameIs) **] have repeat LFT testing and viral load testing. If any abnormalities, she may be referred to hepatology as needed. Medications on Admission: Home Meds (stopped several months prior to admission): - Quetiapine 50 mg Tablet Sig: 1-2 Tablets PO BID PRN anxiety, insomnia. - Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY Medications on transfer: Albuterol 1 puff inhaled q2h prn sob D5 1/2 NS with 40 KCl 150ml/h Pepcid 20mg po bid D50 prn hypoglycemia Glucagon 1mg IM prn hypoglycemia Glucose 4g 2 tabs prn hypoglycemia Novolog ISS Acetylcysteine 100mg/kg Discharge Medications: None Discharge Disposition: Extended Care Facility: [**Hospital 1680**] Hospital - [**Location (un) 538**] Discharge Diagnosis: Primary Diagnosis: 1. Tylenol overdose 2. Suicide attempt Secondary Diagnosis: 1. Depression 2. Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the ICU after ingesting a large amount of tylenol. This amount was toxic and caused significant injury to your liver. We monitored your liver function, and all of your lab values and symptoms continued to improve during your hospital course. You were seen by the liver team, who were encouraged by the improvement in your lab values. You were also seen by psychiatry, who felt that you would benefit from going to an inpatient psychiatry treatment center once you were medically stable. . One of your blood tests showed you have been exposed to the Hepatitis C virus. You will need to follow-up with the liver doctors as [**Name5 (PTitle) **] outpatient for further evaluation. You should also be vaccinated against the Hepatitis B vaccine, and your PCP can help coordinate this vaccination. Followup Instructions: You will be discharged from the general medicine service to an inpatient psychiatric service. Following your discharge from inpatient psychiatry, you should follow-up with a psychiatrist as an outpatient for ongoing evaluation and treatment of your previous depression, anxiety, and suicidal ideation. You should also follow up with your PCP.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

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131,429

9870

Discharge summary

report

Admission Date: [**2178-1-30**] Discharge Date: [**2178-2-12**] Date of Birth: [**2112-4-21**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Progressive dyspnea on exertion Major Surgical or Invasive Procedure: Percutaneous biventricular pacer placement Epicardial lead placement via left anterior thoracotomy Bronchoscopy History of Present Illness: Ms. [**Known lastname **] is a 65 year-old female patient of Dr. [**Last Name (STitle) **] and Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] with a history of cardiomyopathy and worsening heart failure symptoms, referred for elective biventricular pacemaker placement. She has a history of non-ischemic cardiomyopathy, with an EF last measured at 20-30%, thought to be viral in nature. A cardiac catheterization in [**2174**] revealed clean coronaries. Over the past year, she reports progressive symptoms of fatigue and dyspnea with exertion, with SOB after walking from her bedroom to her bathroom, approximately 15 feet. She has frequent episodes of PND and has 3-pillow orthopnea. She is now referred for BIV pacemaker placement. Of note, she also reports a 2-week history of URI symptoms with cough productive of small amounts of sputum, + sore throat, no myalgia/malaise/fever or chills. She was treated with Z-Pack in the week prior to admission. Past Medical History: Non-ischemic cardiomyopathy Hypertension History of coccidioidomycosis (? Dx in [**2172**]) Left knee surgery [**1-/2173**] Status post appendectomy Benign breast mass Social History: She lives alone. Her daughter lives nearby. Family History: N/A Physical Exam: Physical examination on admission per EP note: VITALS: T 98.0, BP 100/70, HR 90s, RR 20, 93%RA No acute distress Neck without JVD Regular rate and rhythm, normal s1s2, no mrg Lungs b/l basilar rales Abdomen soft nt nd nabs Extremities warm and well perfused, trace edema Pertinent Results: Relevant laboratory data in hospital: [**2178-1-30**] CXR (portable): The patient is status post dual-chamber ICD placement, with pacemaker leads terminating in right atrial appendage and right ventricle. No pneumothorax. Note is made of cardiomegaly. Note is made of opacity in the left upper lobe, probably representing pneumonia. No evidence of CHF is noted. IMPRESSION: Cardiomegaly. No pneumothorax. Parenchymal opacity in the left upper lobe, probably representing pneumonia versus aspiration. Please correlate clinically, and confirm the resolution after treatment. ****************** [**2178-1-30**] ECHO: 1. The left atrium is mildly dilated. The right atrium is dilated. 2. There is symmetric left ventricular hypertrophy. The left ventricular cavity is dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 3. The aortic valve leaflets are mildly thickened. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5. There is a small pericardial effusion. ****************** [**2178-1-31**] CT CHEST W/O CONTRAST: A dual-lead cardiac pacer is present with leads terminating in the right atrium and right ventricle. There is subcutaneous air adjacent to the pacer, status-post recent placement. There is opacity within the left upper lobe. A trace right and small left pleural effusion are present. The heart size is markedly enlarged. There is no mediastinal, hilar, or axillary lymphadenopathy. There is a 25 x 21 mm heterogeneously enhancing right thyroid nodule. Osseous structures are unremarkable. IMPRESSION 1. Left lower lobe pneumonia with a small left pleural effusion. 2. Marked cardiomegaly. 3. Right thyroid nodule. A thyroid ultrasound is recommended for further evaluation. ******************* [**2178-2-2**] BAL: Negative for malignant cells ******************* Relevant laboratory data in hospital: [**2178-1-30**]: BLOOD WBC-12.4* RBC-4.02* Hgb-12.8 Hct-38.6 MCV-96 MCH-31.9 MCHC-33.2 RDW-13.8 Plt Ct-232 (Neuts-82.1* Lymphs-13.9* Monos-3.1 Eos-0.7 Baso-0.2) [**2178-2-6**] 10:45AM BLOOD %HbA1c-6.4* [**2178-2-1**] 05:17AM BLOOD TSH-1.7 [**2178-2-3**] 06:23PM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40 [**2178-2-3**] 06:23PM BLOOD ANCA-NEGATIVE B Microbiology: [**2178-2-3**] SPUTUM gram stain >25 PMNs and >10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [**2178-2-5**]): SPARSE GROWTH OROPHARYNGEAL FLORA. YEAST. MODERATE GROWTH. PREDOMINATING ORGANISM. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final [**2178-2-4**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): [**2178-2-2**] BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2178-2-2**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2178-2-4**]): NO GROWTH, <1000 CFU/ml. ACID FAST SMEAR (Final [**2178-2-3**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final [**2178-2-3**]): PNEUMOCYSTIS CARINII NOT SEEN. [**2178-2-1**] BLOOD CULTURE negative [**2178-1-31**] BLOOD CULTURE negative [**2178-1-30**] URINE negative Brief Hospital Course: 65 year-old female with non-ischemic cardiomyopathy with LVEF 20%, HTN, LBBB, admitted for elective placement of BiV pacer to help relieve symptoms of progressive CHF. Her hospital course will be reviewed by problems. 1) Cardiomyopathy: As mentionned above, patient electively admitted for BiV pacer placement on [**2178-1-30**]. During the procedure (prior to lead placement), she began having hemoptysis with desaturation, but was able to continue and underwent placement of A+RV leads. Due to difficulty in placing the CS lead, the procedure was aborted and Ms. [**Known lastname **] was transferred to the CCU for close monitoring. See below for work-up of hemoptysis. While in the CCU, she was continued on ASA, Digoxin, Coreg (titrated up to 12.5 mg PO BID), Imdur, Valsartan (titrated up to 160 mg PO BID), and lasix prn. Lisinopril was discontinued, as it was felt to possibly contribute to her complaint of chronic cough. She was also continued on Lipitor. She was diuresed to optimize her volume status. She returned to the EP lab on [**2178-2-5**] for percutaneous placement of the CS lead, which failed secondary to unusual anatomy. Plan was made to proceed with surgical placement of the LV lead, which she underwent on [**2178-2-9**] via a left anterior thoracotomy. She tolerated the procedure well. She was hypertensive post-procedure, and required a short course of Nitroglycerin drip in the PACU, weaned to off the following day with reintroduction of her PO meds. She was diuresed post-procedure, and standing Lasix 60 mg PO QD was resumed on POD #1. PT was involved. Weight at discharge is 92.8. We have arranged for VNA services for monitoring of her weight and BP. The goal is probably no more than 2 kg weight loss at home until follow-up next week. She will also need follow-up of her electrolytes on [**2178-2-16**], especially potassium. 2) Hemoptysis: During the procedure on [**2178-1-30**], Ms. [**Known lastname **] had hemoptysis during attempted left subclavian access in Trendelenburg position. A post-procedure CXR revealed a LUL opacity as well as a possible retrocardiac opacity. The patient was empricially started on Levofloxacin for coverage of community-acquired pneumonia. A CT of the chest was performed, which revealed no AVM and findings consistent with likely resolving LUL pneumonia. The pulmonary service was consulted for further evaluation, and a bronchoscopy was performed on [**2178-2-2**], with findings of heme in the apicoposterior LUL, and BAL negative for organisms, fungus or AFB. Vasculitis labs were also sent, which revealed [**Doctor First Name **] positive and ANCA negative. Her hemoptysis was ultimately felt to be secondary to a LUL pneumonia, and she completed a 14-day course of Levofloxacin (last dose on [**2178-2-12**]). Please consider repeat imaging as an out-patient to ensure complete resolution of the LUL and retrocardiac opacities. 3) Thyroid nodule: CT chest identified a right thyroid nodule. TSH normal in hospital. Patient will need out-patient work-up for this nodule. 4) Anemia: While in hospital, her hematocrit was noted to be slowly drifting down, from 38 on admission to a nadir of 28 following the thoracotomy, with normocytic indices. It was felt most likely to be secondary to blood loss, both from hemoptysis, surgery, and phlebotomy. Hct 29.2 at discharge. Medications on Admission: Aspirin 325mg daily Coreg 6.25mg [**Hospital1 **] Imdur 60mg daily Lasix 60mg daily Lisinopril 40mg daily Lipitor 20mg daily Digoxin 0.125mg daily Diovan 80mg daily Discharge Medications: 1. Aspirin 300 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Tablet(s) 9. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 4 days: Please take with food. . Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Non-ischemic cardiomyopathy Hypertension Probable pneumonia Anemia Discharge Condition: Patient discharged home in stable condition. Follow-up appointment scheduled. VNA services also arranged. Discharge Instructions: Please weigh yourself every morning, and [**Name8 (MD) 138**] MD if weight increases > 2 kg or decreases > 2 kg. Please also adhere to a 2 gm sodium diet. You have a scheduled appointment with Dr. [**Last Name (STitle) 7047**] on Friday [**2-20**] at 1600. It is extremely important that you go to this appointment. We have made some changes to your medications. Please take only the medications that we have prescribed here. Followup Instructions: You have a scheduled appointment with Dr. [**Last Name (STitle) 7047**] on Friday [**2-20**] at 1600 (DEVICE CLINIC). Completed by:[**2178-2-12**]

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icd9cm

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icd9pcs

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39330

Discharge summary

report

Admission Date: [**2168-7-19**] Discharge Date: [**2168-7-21**] Date of Birth: [**2110-10-9**] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 7333**] Chief Complaint: Syncope. Major Surgical or Invasive Procedure: Cardiac catheterization ICD placement ([**Hospital3 **]) History of Present Illness: Patient is a 57 y/o Mandarin only woman with no significant PMHx who presents as a transfer from [**Hospital3 **] Hospital for ventricular tachycardia with prolonged QT after presenting there originally for syncope. The patient was in her usual state of health until yesterday morning when she woke up and a general sensation of malaise, before getting on a bus tour from [**Location (un) 7349**] to [**Hospital3 **] that left yesterday morning. After exiting the bus in [**Hospital3 **], she walked to her hotel and had a witnessed syncopal event where she fell forward and hit her head on a glass door. She was incontinent of urine, and regained conciousness after 2-3 minutes per the husband. There were no tonic-clonic movements witnessed. She does describe some palpitations and light-headedness prior to syncopizing. She denies recent chest pain, shortness of breath, fevers, chills, N/V/D, illnesses. She denies any past history of syncope. At [**Hospital3 **] Hospital, she ws found to have brief runs of NSVT, then had a run of 15 seconds that broke spontaneously. An EKG there revealed AV conduction delay, RBBB, inferior Q waves and a prolonged QT (~750msec). She was loaded with amiodarone 150mg IV, then started on a drip at 1mg/min gtt. She also got magnesium 2gm IV. Labs were notable for a K of 4.3, Mg 2.4, CK 281, MB 1.7, Trop neg, and negative Head CT She was transferred to [**Hospital1 18**] for further management. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: possible myocarditis at 6 or 7 years old 3. OTHER PAST MEDICAL HISTORY: Osteoarthritis of left knee Unknown thyroid surgery approximately 20 years ago Social History: Lives in [**Location 7349**] with husband, originally from [**Name (NI) 651**] and works in nail salon -Tobacco history: denies -ETOH: denies -Illicit drugs: denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Father passed at age 84 from old age. Mother died at 80 from emphysema. No family history of sudden death, syncope. Physical Exam: GENERAL: WDWN female in NAD. Responds appropriately to questions. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Horizontal scar anterior neck at cricoid cartilage. NECK: Supple with JVP of 2 cm. No carotid bruits, no LAD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 systolic murmur heard best at lower sternal border. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, on anterior exam ABDOMEN: Soft, NTND. No HSM or tenderness. + bowel sounds EXTREMITIES: No c/c/e. No femoral bruits. 2+ DP/PT pulses. Right groin site c/d/i, no tenderness, no hematoma/bruising. Pertinent Results: Labs: [**2168-7-19**] 06:25PM GLUCOSE-148* UREA N-10 CREAT-0.8 SODIUM-138 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12 [**2168-7-19**] 06:25PM ALT(SGPT)-70* AST(SGOT)-48* LD(LDH)-224 ALK PHOS-63 TOT BILI-0.7 [**2168-7-19**] 06:25PM ALBUMIN-4.4 CALCIUM-8.4 PHOSPHATE-3.8 MAGNESIUM-2.8* [**2168-7-19**] 06:25PM TSH-0.82 [**2168-7-19**] 06:25PM T4-6.1 [**2168-7-19**] 06:25PM WBC-11.2* RBC-4.53 HGB-13.3 HCT-38.6 MCV-85 MCH-29.3 MCHC-34.4 RDW-13.9 [**2168-7-19**] 06:25PM PLT COUNT-213 [**2168-7-19**] 06:25PM PT-12.3 PTT-24.6 INR(PT)-1.0 . TTE: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. 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 ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No structural cardiac cause of syncope identified. Preserved global and regional biventricular systolic function. No significant valvular abnormality seen. No resting or inducible outflow tract obstruction. . Cardiac Cath: 1. Selective coronary angiography in this right dominant system demonstrated no angiographically apparent flow-limiting disease. The LMCA was patent. The LAD had 25% proximal stenosis and luminal irregularities to 20% in the mid-segment. There was a large D1 and the distal LAD wrapped around the apex. In the LAD there was slow flow consistent with microvascular dysfunction. The LCx had a proximal 20% stenosis. It supplied a modest very high OM1 and a larger OM2, as well as a large OM3/LPL and an OM4/LPL2. The was slightly slow pulsatile flow consistent with microvascular dysfunction. The RCA had minimal luminal irregularities to 15% Ther were multiple RPDAs and the mid-distal septum was supplied by a large AM. Again, there was slightly slow pulsatile flow consistent with microvascular dysfunction. 2. Limited resting hemodynamics revealed mild-moderate left ventricular diastolic dysfunction was an LVEDP of 19 mmHg. There was moderate systemic systolic arterial hypertension with an SBP of 162 mmHg. 3. Left ventriculography revealed a calculated LVED of 55-65% with mild global hypokinesis, worse in the anterobasal segment. There was 2+ mitral regurgitation. FINAL DIAGNOSIS: 1. No angiographically apparent flow-limiting coronary artery disease; however, there was atherosclerosis and diffuse slow flow consistent with microvascular dysfunction. 2. Mild to moderate left ventricular diastolic dysfunction. 3. Moderate systemic systolic arterial hypertension. 4. Mild global hypokinesis with calculated LVEF of 55-65% Brief Hospital Course: 57 year old female with no sig PMHx who presents as transfer from [**Hospital3 **] Hospital with syncope found to have ventricular tachycardia. s/p Cardiac cath at [**Hospital1 18**]. . # RHYTHM: Patient with no PMHx who had sudden LOC with rapid spontaneous return of conciousness with no intervention. Has long QT on EKG (750 ms) as well as sinus bradycardia. At OSH had sinus bradycardia, then PVC and started with Torsades De Pointes (TDT). She received magnesium and 150 mg IV amiodarone. The Diff dx considered included ischemic CAD, structural disease, electrical abnormalities with long QT sydromes, hypothyroidism. Had cath with patent coronary arteries. She was on no medications. Her thyroid function test were within normal range. Her echo did not show structural abnormalities. Amiodarone was stopped initially was started on metoprolol 25 mg TID (to decrease chances of PVCs on TW and Torsades). She also was started on spironolactone to raise her potassium. She had no more episodes on telemetry and underwent PPM/ICD Placement without complications ([**Hospital3 **]). She was discharged home with PCP and cardiology follow up in [**Location (un) 7349**]. . # CORONARIES: s/p cardiac cath today with clean coronaries as per the report in the previous section on Pertinent Results. Has Q waves in II, III, aVF, V4-V6 cannot rule out prior inferior/lateral MI. Her CE were negative. . # PUMP: No known history of heart failure. Clinically not in heart failure, no crackles, no lower extremity edema, no elevated JVD. Normal echocardiogram. . # Elevated liver enzymes - Patient had elevated liver enzymes at OSH. Had hepatitis panel drawn and were pending last time we checked. Will need to follow up Hepatitis panel from [**Hospital3 **] Hospital - [**Telephone/Fax (1) 29170**]. Her AST 70, ALT 48, AP 63, TB 0.7. . # Thyroid Surgery - Unknown what surgery was for. Patient not on thyriod replacement. Euthyroid. Medications on Admission: unknown painkiller for her osteoarthritis - has not taken for greater than 1 week Denies OTC, herbal, prescription meds Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 5 days. Disp:*20 Tablet(s)* Refills:*0* 2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 4. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 days. Disp:*8 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Ventricular tachycardia Syncope Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 86964**], It was a pleasure to take care of you at [**Hospital1 **] Hospital in [**Location (un) 86**]. You were admitted to [**Hospital3 **] Hospital after fainting and found to have an irregular heart beat and given medication to help your heart return to normal rhythm. You were transferred to [**Hospital1 18**] for further management of this [**Last Name **] problem. At [**Hospital1 18**] you underwent a study to evaluate the vessels of your heart called a cardiac catheterization procedure. It showed that you did not have a recent heart attack and that your blood vessels on your heart are not the reason for your fainting spell. You were taken for placement of an ICD device which will prevent your heart from entering that arrhythmia that caused you to faint. This will need to be followed by a cardiologist in NY where you live. The wound will need to be evaluated by your PCP/Dr. [**First Name (STitle) **] next week at your appointment scheduled below. . The following changes have been made to your medications: * You were started on a medication called spironolactone to increase your potassium and keep it in the high side to prevent your arrhytmia. You will need to take one tab (25 mg ) twice a day. * You will need to take a beta-blocker to prevent your arrhythmia. It is called Toprol-XL 50 mg daily. * We will give you a medication for pain control. Your pain should imrpove within a few days ([**4-1**]) * Given your recent procedure you will need antibiotics for 2 days: Cephalexin 500 mg Capsule You cannot lift anything heavier than 10 pounds or lift your arm above your shoulder given yoru recent ICD placement. Followup Instructions: Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] [**2168-7-27**] Wednesday at 3:00pm for wound check. You will also need a cardiologist and/or electrophysiologist. Completed by:[**2168-7-21**]

[ "426.4", "790.6", "794.31", "715.96", "244.9", "427.1" ]

icd9cm

[ [ [] ] ]

[ "88.56", "88.53", "37.22", "37.94" ]

icd9pcs

[ [ [] ] ]

9633, 9639

6964, 8900

305, 364

9715, 9715

3724, 6580

11559, 11779

2690, 2924

9070, 9610

9660, 9694

8926, 9047

6597, 6941

9866, 11536

2939, 3705

2339, 2380

257, 267

392, 2229

9730, 9842

2411, 2491

2251, 2319

2507, 2674

19,310

197,507

53130+59501

Discharge summary

report+addendum

Admission Date: [**2181-9-15**] Discharge Date: [**2181-11-3**] Date of Birth: [**2101-5-1**] Sex: F Service: MEDICINE Allergies: Sulfamethoxazole / Quinolones Attending:[**First Name3 (LF) 1148**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: tracheal intubation cholecystostomy tube placed NJ tube placed by radiology History of Present Illness: 80yo female h/o multiple intraparenchymal hemorrhages due to amyloid, aphasia, nonverbal at baseline and on chronic TPN, was brought to [**Hospital3 7362**] for c/o increased groans since 4am. Per family, pt never groaned in past. Brought to [**Hospital3 7362**] where w/u was unrevealing except gas in abdomen. In addition, family commented that in prior few days she had cough, more frequent, w/secretions pooling and sounding gurgly. Noted to be tachypneic the morning of admit but resolved after deep suctioning in ED. No fevers, no focal findings on CXR. ROS from husband neg. [**Name2 (NI) **] falls or bruises. One decub on sacrum, small and well care for. Pt guaic negative. KUB here showed a lot of bowel gas. Given 2mg morphine and moans resolved. Repeat EKG sinus tachy, STE in V1-old. Trop 1.02 at OSH neg. Husband asked for her to be transferred to [**Hospital1 18**] where she is known for further care. Past Medical History: 1. Multiple intraparenchymal hemorrhages due to amyloid angiopathy. The first hemorrhage was in [**2160**] (presented with R hemiparesis). Later had a large L fronto-parietal bleed (became aphasic). 2. Focal motor facial seizures. Previously treated with Dilantin, now on Neurontin. 3. Myoclonic jerks 4. High cholesterol 5. Hypertension 6. Hx of Hospital Admission for Pneumonia vs. Bronchitis instigated by patient inability to clear secretions from Upper Respiratory Tract. Was Intubated. 7. Chronic TPN, unable to place PEG due to anatomy (large HH) Social History: Lives at home w/ husband who is her primary caregiver. [**Name (NI) **] home health aide w/ 24 care. Fully Dependant on all her ADLS. She is fairly nonresponsive at baseline. No tobacco, EtOH, or illicit drug use. Family History: nc Physical Exam: Tc 97.1 BP 122/75 HR 80 RR 20 Sat 96% on 35% tent GEN: contracted w/ neck to the left, NAD, non verbal, appears comfortable HEENT: mouth breathing, dry MM NECK: supple, contracted CV: RRR, no m/r/g PULM: course bs diffusely ABD: soft, NABS, NT/ND EXT: DP/PT 2+ b/l. SKIN: no rash Pertinent Results: [**2181-9-15**] 09:11PM LACTATE-1.2 [**2181-9-15**] 08:20PM GLUCOSE-103 UREA N-25* CREAT-0.7 SODIUM-137 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-22 ANION GAP-15 [**2181-9-15**] 08:20PM CK(CPK)-153* [**2181-9-15**] 08:20PM cTropnT-0.04* [**2181-9-15**] 08:20PM WBC-7.9# RBC-3.72*# HGB-11.7*# HCT-34.6*# MCV-93 MCH-31.5 MCHC-33.9 RDW-16.3* [**2181-9-15**] 08:20PM NEUTS-65.9 LYMPHS-22.0 MONOS-4.3 EOS-7.2* BASOS-0.6 [**2181-9-15**] 08:20PM PLT COUNT-274 [**10-23**] CT abd/pelvis without contrast: CT OF THE ABDOMEN WITHOUT CONTRAST: Examination of lung bases is limited due to lack of contrast but appears grossly unchanged. There are bilateral pleural effusions and probable compression atelectasis. There is an unchanged appearance to a large diaphragmatic hernia. Again identified is a nasogastric feeding tube with its tip extending into the jejunum. Limited examination of the liver is unremarkable with no evidence of focal disease. A cholecystostomy tube is again identified with its coiled tip within the gallbladder lumen. There has been marked reduction of gallbladder distention since [**10-8**] examination. No focal fluid collections are identified around the gallbladder fossa. Otherwise the spleen, kidneys, adrenals, pancreas, and stomach are unchanged in appearance. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are noted. No free air is identified within the peritoneal cavity. No free fluid is noted within the abdomen. There are diffuse vascular aortic calcifications. CT OF THE PELVIS WITHOUT CONTRAST: There is new hyperdense fluid layering within the pelvic cavity displaying a fluid-fluid level likely related to settling of acute blood. The majority of the collection is located within the most dependent portion of the pelvis. Contrast is identified within the rectum from prior examination. The bladder is decompressed and a Foley is in place with a small amount of air noted within the bladder. Limited examination of the uterus is unremarkable. There are no pathologically enlarged inguinal or pelvic lymph nodes identified. BONE WINDOWS: Unchanged marked degenerative changes of the spine and left acetabular exostotic lesion. [**10-28**] CT chest w/o contrast: IMPRESSION: 1. Large right-sided pleural effusion with adjacent compressive atelectasis or consolidation. Smaller left pleural effusion, with a minimal amount of compressive atelectasis. 2. No evidence of pulmonary airspace opacities. 3. No significant change in significant diaphragmatic defect with bilateral herniation of stomach and portions of large bowel. [**10-30**] TTE: Conclusions: 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%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Physiologic mitral regurgitation is seen (within normal limits). The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. No vegetation seen (cannot definitively exclude). Compared with the prior study (images reviewed) of [**2181-9-21**], mitral regurgitation is now less prominent. Brief Hospital Course: 80 yo F with multiple intraparenchymal hemmorhages secondary to amyloid angiopathy, aphasic at baseline, on chronic TPN (aspiration risk), admitted to [**Hospital1 18**] on [**2181-9-15**] for abdominal pain. Believed initially to be gas related (seen on KUB). In ED at [**Hospital3 7362**] had temp of 101 and blood cultures were drawn. Had had recent foley change. On [**9-17**] had witnessed vomitting with oxygen sat down to 70%--needed 100% NRB. Was intubated and transferred to ICU. Improved over the following 24 hours with aggressive suctioning. An NGT was placed to suction. There was concern that emesis contained fecal material. Pt was started empirically on vanco/zosyn for aspiration pneumonia. After discussion with family regarding goals of care and ?SBO, decision was made not to workup possible SBO as they would not want surgery. She was extubated on [**9-18**]. . On [**9-19**] pt was sat'ing well on 50% face tent. Her blood cultures were remarkable for coag negative staph on [**9-15**] in [**12-23**] bottles, sensitivies pending. Her urine grew pan-sensitive klebsiella on [**9-16**]. Her sputum culture from [**9-18**] grew coag positive staph and pseudomonas. Pt had a chronic PICC for TPN, which was removed. Tip culture NG. A supraclavicular line was attempted s/p intubation but failed; IJ placed instead. Patient had TTE that showed no signs of vegs. Continued on vanc and cefepime for 14 days. Decision made with family not to do TEE as more invasive and higher risk for patient. With recurrence of blood cultures positive and PICC tip negative raised question of osteomyelitis from sacral decub; thought unlikely from imaging studies. Patient received sacral decub wound care through hospital time. More likely probably with PICC care at home. . Around [**9-25**] patient noted to have increased jerking, raised question of seizure. D/w neurologist who felt more c/w myoclonic jerks, so no role for EEG at that time. . With recurrent PICC line infections raised question of again attempting enteral feeds. Had another PICC placed [**9-20**] and restarted on TPN. Evaluated by surgery and on [**10-4**] taken to radiology where NJ tube was placed under fluoro successfully. Started on tube feeds on [**10-5**]. On [**10-8**] had difficulty with NJ tube flushes. Also spiked temp to 100.4. Had dirty UA and CT scan revealed dilated gallbladder with wall edema c/w cholecystitis. RUQ ultrasound revealed stones. Pt also had bump in her transaminases and alk phos. Started again [**10-9**] on zosyn/flagyl for 14 day course and NJ tube feeds held. After extensive d/w husband and consent, pt taken to IR for cholecystostomy tube placement. Urine culture also grew yeast, so foley changed and treated with 10 days fluconazole (ID rec since patient had been on long term broad spectrum antibiotics). Blood cultures remained no growth. On [**10-10**] also noted to have some facial asymmetry but head CT done without [**Month/Year (2) 65**] change from previous. . On [**10-13**] spiked a temp of 100.6. Blood cultures remained no growth. On [**10-15**] had Hct drop from 26 to 18. CT scan of pelvis revealed retroperitoneal blood. Transfused 2 Units PRBCs with good response. Also given FFP and vit K (had been getting some heparin in flushes). Believed secondary to cholecystostomy insertion site. Needed 1 more unit later in week. Bleed appeared to tamponade on its own. . On [**10-22**], pt had TF restarted after d/w surgery said would likely be ok and permission of family. Noted to have some increased coughing and concern that NGT was further out so held for 2 days; when restarted [**10-25**] noted bleeding from tube so again held. Evaluated by surgery who said should not be contraindication. Also mild transaminitis should be tolerable. NJT feeds restarted on [**10-26**] and taken to goal and patient appeared to tolerate. Surgery again consulted about possible J tube and cholecystostectomy. Recommend cholecystostomy tube left in place 4-6 weeks and not remove until then. . On [**10-28**] pt had temperature of 102.3. [**4-24**] blood cultures again grew MRSA bacteremia. Urine also positive for 10-100,000 yeast. PICC line removed on [**10-29**] and cultures resent; all no growth to date. Urine catheter changed. Bile culture also grew VRE but no WBCs seen so belived to be colonized, not infected. After PICC removed and antibiotic started pt defervesced. TTE was again repeated and again showed no visible vegetations. Vanc trough initially high so dose decreased. TO DO: 1) MRSA bacteremia: Pt is on Day [**5-2**] vanc. Needs to get full course through PICC line. Remove PICC once course finished. [**Month (only) 116**] consider checking vanc trough in next few days and adjust dose if necessary. 2) FEN: NJ tube in place. In discussion with radiology, concern that if it is removed it will be very hard to replace with large hiatal hernia. Unclogged on [**11-2**] and recommend continue to maintain if possible. Believe risk of not being able to replace outweighs risks of leaving in greater than 30 days. This was communicated to the patient's husband. At this time surgical services believe risk of placing J tube high. Continue tube feeds, which pt has tolerated, through NJ. 3) Cholecystitis s/p cholecystostomy tube: Tube placed on [**10-9**] by IR. Surgery recommends not removing for 4-6 weeks. Follow up appointment should be made with Dr. [**Last Name (STitle) **] to discuss removal and further plans. 4) HTN: Well controlled at this time with clonidine patch and nitro patch. 5) Pulm: Pt kept on humidified air with shovel mask to keep membranes moist. 6) GU: Foley kept in for neurogenic bladder. Medications on Admission: clonidine 0.1 mg qwk TPN atrovent/albuterol Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours). 2. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed. 3. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6 hours) as needed. 4. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5,000 units Injection TID (3 times a day). 5. Nitroglycerin 2 % Ointment [**Last Name (STitle) **]: 0.5 inch Transdermal Q6H (every 6 hours). 6. Dolasetron 12.5 mg/0.625 mL Solution [**Last Name (STitle) **]: 12.5 mg Intravenous Q8H (every 8 hours) as needed. 7. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: Two (2) ML Intravenous DAILY (Daily) as needed. 8. Clonidine 0.1 mg/24 hr Patch Weekly [**Last Name (STitle) **]: One (1) Patch Weekly Transdermal QSUN (every Sunday). 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 10. Lactulose 10 g/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 11. Vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours) for 8 days. 12. Outpatient Lab Work Please check a vanc trough level on [**11-5**] and adjust vanc dose as needed (goal trough about 15) Discharge Disposition: Extended Care Facility: [**Hospital6 56223**] Discharge Diagnosis: Aspiration Pneumonia MRSA Bacteremia times 2 Klebsiella UTI Sacral decubitus ulcer Cholecystitis Retroperitoneal bleed from cholecystostomy tube Candidal urinary tract infection VRE in bile HTN Discharge Condition: stable: passing gas, abdominal pain resolved, stable on room air, tolerating tube feeds Discharge Instructions: Please call your PCP or come to the emergency room if develop fevers, chills, abdominal discomfort. Followup Instructions: 1. Please call to [**Hospital6 **] a follow-up appointment with Dr. [**Last Name (STitle) **] within 1-2 weeks of leaving rehab. Phone: [**Telephone/Fax (1) 78021**] 2. Please call to [**Telephone/Fax (1) **] up a follow up appointment with Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **] in surgery 4-6 weeks after cholecystostomy tube placed (placed on [**10-10**]). Phone: [**Telephone/Fax (1) 600**] Name: [**Known lastname 17939**],[**Known firstname **] Unit No: [**Numeric Identifier 17940**] Admission Date: [**2181-9-15**] Discharge Date: [**2181-11-3**] Date of Birth: [**2101-5-1**] Sex: F Service: MEDICINE Allergies: Sulfamethoxazole / Quinolones Attending:[**First Name3 (LF) 803**] Addendum: Code Status-- Per discussions with husband, pt is DNR but he would want to consider intubating her if needed. He would prefer to be contact[**Name (NI) **] if there is time prior to intubation, but otherwise would want it tried. Discharge Disposition: Extended Care Facility: [**Hospital6 10538**] [**First Name11 (Name Pattern1) 153**] [**Last Name (NamePattern1) 811**] MD [**MD Number(2) 812**] Completed by:[**2181-11-3**]

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icd9cm

[ [ [] ] ]

[ "99.04", "96.6", "96.04", "96.71", "99.07", "99.15", "38.93", "51.01" ]

icd9pcs

[ [ [] ] ]

14778, 14984

5915, 11643

304, 381

13490, 13580

2488, 5892

13728, 14755

2167, 2171

11737, 13181

13273, 13469

11669, 11714

13604, 13705

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250, 266

409, 1341

1363, 1919

1935, 2151

78,705

151,651

4186

Discharge summary

report

Admission Date: [**2183-12-24**] Discharge Date: [**2184-1-2**] Date of Birth: [**2108-8-15**] Sex: F Service: MEDICINE Allergies: Klonopin Attending:[**First Name3 (LF) 2009**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: 75 year-old woman with h/o tracheobronchomalacia and COPD complicated by vocal chord dysfunction and uses home O2 3L at night who presented to OSH with increased SOB over past 3 days and hypoxia. Pt reports that she progressed from dyspnea on exertion to dyspnea at rest. She has been using frequent nebs with minimal relief. Was here 1 m ago with similar presentation. She recieved solumedrol and azithromycin at OSH prior to transfer to [**Hospital1 18**]. She was transfered for increased work of breathing and need for BiPAP. Vitals on arrival to [**Hospital1 18**] ED were T 97.4, HR 94, BP 129/68, RR 38, sat 96% on 10L. In the ED here, she was immediately placed on BiPAP and required 1mg Ativan for anxiety. Pt reported feeling better with BiPAP. Abx were broadended with levofloxacin 750mg, CTX 1g, and vanco 1g. CXR showed a LLL PNA. Exam was remarkable for poor air movement. Labs in ED remarkable for bicarb of 16, lactate 4.3, and WBC 6.9 with 92% PMNs. Her last admission was [**Date range (1) 18230**] for presumed COPD flare and also included a 24 hour stay in the ICU for BiPAP. Of note, she has had > 6 admissions to [**Hospital 1562**] Hospital over the past 6 months for similar symptoms. She continues to smoke and last admission reported that she only takes spiriva and pulmicort on a prn basis. Pt says today that she uses her albuterol and "rescue" inhalers as needed. Bronch last admission showed only 10,000-100,000 yeast. On arrival to floor, pt continues to feel short of breath on non-rebreather. She was unable to tolerate BiPAP 2/2 claustraphobia. She has a poor appetite, but denies N/V. She denies singificant cough or fevers. C/o intermittent right ear pain. She has chronic arthritic pains which are typical pains for her. Otherwise, ROS is unremarkable. Past Medical History: Tracheobroncheomalacia s/p Y stenting in [**8-/2182**], which was removed On [**2182-9-27**] given mucous plugging. COPD on 2L home oxygen Vocal Cord Dysfunction Obesity hypoventilation syndrome Chronic Diastolic heart failure Hypothyroidism Irritable bowel Syndrome Vitamin D deficency Coronary artery disease Anxiety Depression Seizure disorder H/o C. diff colitis R colon cancer s/p hemicolectomy in [**2178**] (vs. neuroendocrine tumor per some OSH reports) s/p tonsillectomy s/p thyroid lobectomy [**2151**] s/p cholecystectomy [**2151**] s/p appendectomy [**2179**] - for neuroendocrine tumor Smoking Psychosis with prednisone Social History: Lives in [**Location 18223**] MA, alone, independent in ADLs. Tobacco - 55yrs of 1ppwk Etoh, drugs - denies. Family History: Mother and father with CAD No lung cancer or congenital lung diseases Physical Exam: VS: Temp: 99.2, BP: 144/69, HR: 100, RR:28, O2sat 97% on NRB GEN: Pleasant, taking frequent breaths while talking (every word or so), breathing appears labored, pursing lips HEENT: Anicteric, slightly dry MM RESP: Diffuse inspiratory wheeses, poor air movement, no focal crackles CV: RR, S1 and S2 wnl, no m/r/g ABD: Nondistended, soft, nontender EXT: No c/c/e NEURO: No focal deficits, UE and LE strength 5/5 B/L Pertinent Results: Labs on Admission: [**2183-12-24**] 02:08PM BLOOD WBC-6.9 RBC-4.42 Hgb-12.6 Hct-38.6 MCV-87 MCH-28.5 MCHC-32.7 RDW-15.5 Plt Ct-342 [**2183-12-24**] 02:08PM BLOOD Neuts-92.0* Lymphs-6.8* Monos-0.5* Eos-0.2 Baso-0.4 [**2183-12-24**] 06:56PM BLOOD PT-13.7* PTT-24.3 INR(PT)-1.2* [**2183-12-24**] 02:08PM BLOOD Glucose-204* UreaN-13 Creat-1.1 Na-136 K-4.6 Cl-105 HCO3-16* AnGap-20 [**2183-12-24**] 02:08PM BLOOD Calcium-9.6 Phos-2.3* Mg-2.0 [**2183-12-24**] 03:51PM BLOOD Type-ART FiO2-100 O2 Flow-10 pO2-74* pCO2-27* pH-7.43 calTCO2-19* Base XS--4 AADO2-612 REQ O2-100 Intubat-NOT INTUBA Comment-VENTIMASK [**2183-12-24**] 02:07PM BLOOD Lactate-4.3* K-4.5 . Labs on Discharge: [**2184-1-1**] 05:46AM BLOOD WBC-12.9* RBC-4.02* Hgb-11.0* Hct-33.9* MCV-85 MCH-27.5 MCHC-32.5 RDW-15.2 Plt Ct-321 [**2184-1-1**] 05:46AM BLOOD PT-11.3 PTT-27.7 INR(PT)-0.9 [**2184-1-1**] 05:46AM BLOOD Glucose-86 UreaN-19 Creat-1.0 Na-143 K-3.8 Cl-106 HCO3-30 AnGap-11 . Cultures: [**2184-1-1**] 4:42 pm SPUTUM ENDOTRACHEAL. **FINAL REPORT [**2184-1-3**]** GRAM STAIN (Final [**2184-1-1**]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2184-1-3**]): SPARSE GROWTH Commensal Respiratory Flora. . PFT's [**8-/2182**] FEV1/FVC 73% TLC 95% predicted DSB 39% predicted Mechanics: The FVC and FEV1 are moderately reduced. The FEV1/FVC ratio is normal. There was no significant change following inhaled bronchodilator. Flow-Volume Loop: Moderate expiratory coving with a moderately reduced volume excursion and an early termination of exhalation. Lung Volumes: The TLC and FRC are normal. The RV and RV/TLC ratio are elevated. DLCO: The Dsb corrected for hemoglobin is moderately to markedly reduced. Impression: Moderate obstructive ventilatory defect with a moderate to marked gas exchange defect. The FVC may be underestimated due to early termination of exhalation. There are no prior studies available for comparison. . CXR: Limited study due to apical lordotic positioning of the patient and lack of visualization of the left costophrenic angle. Emphysema with no definite evidence of acute superimposed process. If clinically feasible, consider PA and lateral views in the radiology suite, if indicated. . CT trachea w/ forced expiratory maneuver [**2183-11-24**]: IMPRESSION: 1. Distal tracheal narrowing of 53% is borderline for tracheomalacia. 2. No evidence of bronchomalacia. 3. Diffuse severe emphysema. $. New bilateral lower lobe bronchial wall thickening suggestive of small airways disease. New lower lobe mucous plugging with and subsegmental atelectasis at both lung bases. 5. Chronic but not previously seen bilateral rib fractures . EKG: sinus tach, no ST changes . [**2183-12-30**] Echo: The left atrium is mildly dilated. 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 regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal study, pulmonary pressures not obtainable because of technically-inadequate tricuspid regurgitation jet. Grossly preserved biventricular systolic function. Brief Hospital Course: 75 year-old woman with a history of tracheobronchomalacia and COPD complicated by vocal cord dysfunction and uses home O2 3L at night who presented to OSH with increased SOB over past 3 days and hypoxia. Pt reports that she progressed from dyspnea on exertion to dyspnea at rest. She has been using frequent nebs with minimal relief. Was here 1 m ago with similar presentation. She recieved solumedrol and azithromycin at OSH prior to transfer to [**Hospital1 18**]. She was transfered for increased work of breathing and need for BiPAP. Vitals on arrival to [**Hospital1 18**] ED were T 97.4, HR 94, BP 129/68, RR 38, sat 96% on 10L. In the ED here, she was immediately placed on BiPAP and required 1mg Ativan for anxiety. Pt reported feeling better with BiPAP. Abx were broadended with levofloxacin 750mg, CTX 1g, and vanco 1g. CXR showed a LLL PNA. Exam was remarkable for poor air movement. Labs in ED remarkable for bicarb of 16, lactate 4.3, and WBC 6.9 with 92% PMNs. . Her last admission was [**Date range (3) 18230**] for presumed COPD flare and also included a 24 hour stay in the ICU for BiPAP. Of note, she has had > 6 admissions to [**Hospital 1562**] Hospital over the past 6 months for similar symptoms. She continues to smoke and last admission reported that she only takes spiriva and pulmicort on a prn basis. Pt says today that she uses her albuterol and "rescue" inhalers as needed. Bronch last admission showed only 10,000-100,000 yeast. . On arrival to floor, pt continues to feel short of breath on non-rebreather. She was unable to tolerate BiPAP 2/2 claustrophobia. She has a poor appetite, but denies N/V. She denies significant cough or fevers. C/o intermittent right ear pain. She has chronic arthritic pains which are typical pains for her. Otherwise, ROS is unremarkable. . # COPD exacerbation: Ms. [**Known lastname 18231**] has been hospitalized nearly monthly for COPD flares for the past 7 months. Pt has diffuse wheezes on exam indicative of COPD flare, but may have a LLL infiltrate on CXR (difficult to tell as L costophrenic angle cut off from film). Given this, initially admitted for treatment for hospital-aquired pathogens in an ICU setting by continuing levofloxacin, vancomycin, and ceftriaxone. Repeat CXR showed left lower lobe atelectasis, unilateral retrocardiac opacities which likely indicated bilateral lower lobe atelectasis, but no evidence of acute pneumonia. Inintially on presentation, pt reported having trouble tolerating BiPAP, but said in the past she has gotten relief from Ativan and morphine. With PRN Ativan and Morphine, she was able to tolerate BiPAP for an additional hour in the ICU. She was placed back on NRB sating 92-97%. Based on ABGs in the system, Ms. [**Name14 (STitle) 18232**] does not appear to be a CO2 reatiner despite the severity of her COPD. Gave ATC ipratropium and albuterol nebs with albuterol q2 PRN. Continued 60mg IV solumedrol for the first evening in the ICU. By MICU day 2, Vancomycin and Cefepime were discontinued given low suspicion for HCAP, but Levofloxacin was changed from IV to PO (for a 5-day course- day 1 = [**2183-12-25**]) as most likely cause for patient's presentation was a severe COPD exacerbation. Her steroids were changed to PO Prednisone 60 mg daily. She completed a 5 day course of Levofloxacin. She went for Y stent placement on [**2184-1-1**] which was successfully placed. She was scheduled to see IP in [**2-19**] weeks. She was discharged on acetylcysteine nebs, tesselon pearls, a prednisone taper and PRN morphine for cough and shortness of breath. . # Seizure d/o: Continued home lamotrigine . # Hypothyroidism: Continued home synthroid . # Depression: patient carries a history of depressive symptoms per report. Home venlafaxine 75 mg [**Hospital1 **] was continued. . # CAD: Continue daily ASA . # Tobacco Use: Declined nicotine patch. Tobacco cessation counseling was given. . Comm: with patient . Emergency Contact: [**Name (NI) **] [**Name (NI) 18233**] . Relationship: daughter . Phone number: [**Telephone/Fax (1) 18234**], Pt would like her only called in an emergency, not with updates . Code: DNR, would consider intubation if believed to be due to a reversible process, confirmed with patient. Needs to be readdressed, as patient would most likely not be able to be pulled from vent given her compromised respiratory status at baseline. End of life discussion was attempted with the patient but she was very resistent to discussion. Medications on Admission: 1. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for groin rash . 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO BID (2 times a day). 6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 7. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: Two (2) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 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. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO twice a day. 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). Disp:*120 Tablet Sustained Release(s)* Refills:*2* 9. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 10. acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) nebulizer Miscellaneous Q12H (every 12 hours). Disp:*60 nebulizers* Refills:*2* 11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*1 Disk with Device(s)* Refills:*2* 13. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): please take 2 tablets for 5 days, then 1 tablet for 5 days, then [**1-18**] tablet for 5 days, then stop. Disp:*20 Tablet(s)* Refills:*0* 14. morphine 10 mg/5 mL Solution Sig: [**1-18**] teaspoons PO Q4H (every 4 hours) as needed for SOB. Disp:*240 ml* Refills:*0* 15. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). . NOTE: called by pharmacy after discharge regarding concern with PO morphine. Rx was changed to 2.5-5ml PO q4H PRN cough, SOB. Rx faxed and mailed to pharmacy. Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: PRIMARY DIAGNOSES: - Acute chronic obstructive pulmonary disease - Active smoker SECONDARY DIAGNOSES: - Tracheobronchomalacia - Chronic obstructive pulmonary disease on 2L home oxygen - Vocal cord dysfunction - Chronic diastolic heart failure - Hypothyroidism - Coronary artery disease - Anxiety - Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You presented to the hospital with a flare-up of your COPD. Your condition was very serious and you were managed in the ICU for 2 days before moving to the medical floor. You improved with antibiotics and steroids and other inhalers. It is very important that you continue to try to quit cigarette smoking as it can still further impair your breathing function. You had a Y stent placed on [**2184-1-1**] to help with your breathing. You need to continue to take mucomyst nebulizer and mucinex to prevent the stent from becoming plugged. You should take codeine for your cough. Your cough should improve. A number of medications were added this admission. Please take all of your prescriptions as recommended. They were all faxed to your pharmacy. You were given liquid morphine for comfort. Followup Instructions: Please make an appointment to see your primary care physician [**Name Initial (PRE) 176**] 2 weeks to follow-up the issues related to this hospitalization. Name: [**Last Name (LF) **],[**First Name3 (LF) **] M. Location: [**Hospital3 **] COMMUNITY HEALTH CLINIC Address: [**Street Address(2) **], STE#1A, [**Location (un) **],[**Numeric Identifier 18235**] Phone: [**Telephone/Fax (1) 18226**] Department: WEST [**Hospital 2002**] CLINIC When: MONDAY [**2184-1-12**] at 7:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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icd9cm

[ [ [] ] ]

[ "38.97", "33.23", "96.05" ]

icd9pcs

[ [ [] ] ]

14765, 14826

7084, 11573

273, 279

15180, 15180

3421, 3426

16157, 16901

2901, 2972

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196,197

29574

Discharge summary

report

Admission Date: [**2103-12-2**] Discharge Date: [**2103-12-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1253**] Chief Complaint: fever, cough Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] y/o gentleman with a history of Alzheimer's dementia, ESRD on HD (M/W/F) and h/o bladder CA presented to [**Hospital1 18**] ED with fever, cough, runny nose and decreased oral intake. Patient is a poor historian secondary to his dementia and most of the history is obtained from daughters. [**Name (NI) **] has had nonproductive cough and malaise in the last 5 to 7 day. He was complaining of left sided pain but unclear location transiently to home health aide. This has now resolved. Yesterday patient developed fever to 101s which resolved with tylenol. His cough turned productive this evening, greenish in ED per daughter. His home health aide had URI symptoms two days. His son had URI symptoms two weeks ago while visiting the patient. . In the emergency department, initial vitals were T 99.9, BP 154/75, HR 92, RR 20 85% saturation in RA. Rectal temparature spiked to 102.2. His oxygen saturation did not improve with 4 to 6 L NC and he was placed on NRB to which his oxygen saturation improved to mid to high 90s. He recieved Vancomycin 1 gram IV, Levoquin 750 mg IV, Tamiflu 75 mg and tylenol 1 gram orally. He was transfered to [**Hospital Unit Name 153**] for further care. . Patient currently denies shortness of breath, chest pain or abdominal pain. He states that he feels comfortable. . Review of systems is otherwise negative for chills, nightsweats, lower extremity swelling, PND, orhtopnea, diarrhea, dysuria, blood in stool or urine. Past Medical History: # HTN # ESRD HD [**2099**] (hypertensive nephropathy), receives HD qMWF # Alzheimer's Dementia on donepezil(recently discontinued [**3-5**] nocturnal wakenings) # [**Month/Day (2) 8974**] bacteremia treated with 8 weeks IV cefazolin [**10-9**] # Pseudomonas bacteremia [**11-8**] rx w/ Cipro at VA # C. difficile colitis [**11-8**] # Bladder CA s/p resection at 60, 83 y/o. Most recent resection [**2102-11-20**] - followed with yearly cystoscopies as he is now anuric # Aortic ulcerations [**3-10**], unchanged on [**2101-9-25**] abd CT # Temporary HD catheter line infection with [**Date Range 8974**] in [**3-10**], rx with nafcillin, cathether has since been removed # Additional episode of [**Date Range 8974**] bacteremia [**9-7**], unclear source. Rx'ed with nafcillin and 4 wks of outpt cefazolin # Chronic low back pain Social History: Prior supervisor of flight kitchen. No known alcohol or tobacco history. He lives with his daughter, [**Name (NI) **], who helps him with his food and medications. His wife also lives with them and has dementia. Family History: CAD Brothers (2), Mom ESRD (unknown etiology) Physical Exam: Admission: GENERAL: Pleasant, well appearing in NAD, AOx1 person only HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. MMM. OP clear. Neck Supple. CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. II/VI systolic murmur best along left sternal border. LUNGS: Crackles bilateral bases. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis. SKIN: No rashes/lesions, ecchymoses. NEURO: Spontaneously moves all 4 extremities Pertinent Results: [**2103-12-2**] 01:00PM BLOOD WBC-10.1# RBC-4.16* Hgb-11.9* Hct-37.3* MCV-90 MCH-28.7 MCHC-32.0 RDW-15.0 Plt Ct-284 [**2103-12-9**] 05:22AM BLOOD WBC-9.3 RBC-3.61* Hgb-9.8* Hct-32.9* MCV-91 MCH-27.2 MCHC-29.9* RDW-15.2 Plt Ct-428 [**2103-12-2**] 01:00PM BLOOD Glucose-86 UreaN-68* Creat-9.0* Na-142 K-5.2* Cl-92* HCO3-35* AnGap-20 [**2103-12-10**] 05:15AM BLOOD Glucose-56* UreaN-50* Creat-8.9*# Na-141 K-5.2* Cl-101 HCO3-27 AnGap-18 [**2103-12-10**] 05:15AM BLOOD ALT-20 AST-28 AlkPhos-120* TotBili-0.5 [**2103-12-10**] 05:15AM BLOOD Calcium-9.0 Phos-4.9* Mg-2.2 [**2103-12-8**] URINE URINE CULTURE- Negative [**2103-12-3**] MRSA SCREEN MRSA SCREEN- Negative [**2103-12-2**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN TEST- Negative; DIRECT INFLUENZA B ANTIGEN TEST- Negative [**2103-12-2**] BLOOD CULTURE Blood Culture, Routine- Negative [**2103-12-2**] BLOOD CULTURE Blood Culture, Routine- Negative CXR SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH: A right-sided subclavian PICC is seen; its tip can be followed to the mid SVC. Mild cardiomegaly persists. The aorta is calcified and tortuous. Left basilar opacity has progressed and may reflect atelectasis and/or pneumonitis with adjacet increasing small effusion. Air space opacity in the right upper lobe has progressed. Constellation of findings compatible with progressed multifocal pneumonia. UNILAT UP EXT VEINS US LEFT IMPRESSION: Left upper extremity AV fistula. No subcutaneous collection near the AV fistula. Brief Hospital Course: 1. Multifocal PNA: Patient presented with fever, cough, and hypoxia and was found to have multifocal pneumonia on CXR. Influenza DFA was negative. The patient briefly required a non-rebreather to maintain oxygenation, but his respiratory status rapidly improved, and by [**2103-12-4**], the patient was maintaining good oxygen saturations on room air. The patient was treated with vancomycin, cefepime, and azithromycin. . Upon arrival to the medical floor, a PICC line was placed, and completed a 7d course of vanco/cefepime/azithro on [**2103-12-8**]. On [**12-7**], he was noted to have increased choking despite ground diet recommendation from speech & swallow consultation. His oxygen requirement increased from 1L to 3L in this setting, raising concern for aspiration. . His PICC line was noted to be oozing, and withdrawn into a midline position. This was discontinued on [**2103-12-11**]. . 2. ESRD on HD: The renal service was consulted, and the patient received hemodialysis per his usual schedule. . On the medical service, concern was raised based on erythema at the site of his AV fistula. This has been a chronic issue, evaluated by his transplant surgeon in past, who recommended accessing the fistula in different locations to reduce irritation. USN of fistula showed wall to wall flow, and no evidence of superficial fluid collection. . 3. Hypertension: All anti-hypertensives except metoprolol were initially held due to concern that patient could become septic as his infection evolved. Capropril was added in place of lisinopril in order to allow closer titration in the ICU setting. . Upon arrival to the medical floor his home regimen was resumed, including lisinopril, minoxidil, amlodipine, metoprolol. On [**12-7**], he was noted to be frankly aspirating. Speech & Swallow evaluated the pt and he was made NPO again including pills as below. He resumed his oral medications once he was again cleared by Speech & Swallow, and his Minoxidil was titrated up to 5 mg po bid on [**12-11**] for persistent hypertension. . 4. Alzheimer's dementia/agitation: The patient was initially disoriented and agitated, pulling off face mask and climbing on bed rails. This was thought to be secondary to dementia with delirium in the setting of infection. Due to this, he required olanzepine briefly. With ongoing treatment of his underlying medical conditions, his mental status and agitation improved, and did not require further antipsychotics. He was also started on scheduled Tylenol in case he has underlying pain which may contribute to delirium. Imaging has been suggestive of underlying degenerative disease of the spine. . 5. Dysphagia - pt was evaluated by speech and swallow consultation upon arrival to the medical floor. His diet was advanced to pureed solids, which he tolerated, however when advanced to ground solids he was found to be frankly aspirating. He was made NPO on [**12-7**]. His swallow function improved with improvement in his underlying medical conditions, and he subsequently passed Swallow evaluation with recommendations for nectar thick liquids and ground solids. . 6. Hematuria - in the process of working up patient's delerium, pt was straight cathed to confim patient is anuric and to rule of obstruction. The following day, pt was noted to have some bleeding from his penile meatus, which is thought due to this trauma in the setting of Heparin 5000 units TID for DVT prophylaxis. Pt has a history of bladder cancer, and it is possible that friable tissue from this may predispose him to bleeding as well. No further evaluation was performed while in the hospital. I discussion with pt's daughter ([**Name (NI) **]), they are not interested in further evaluation or management of bladder cancer, unless he develops symptoms that are troublesome for the patient. If patient continues to pass blood off of heparin, consider outpatient evaluation with his Urologist. Medications on Admission: Aspirin 81 mg daily Calcium Acetate 1334 mg TID w/ meals Lisinopril 40 mg daily Metoprolol Tartrate 50 mg [**Hospital1 **] B Complex-Vitamin C-Folic Acid 1 mg daily Simvastatin 80 mg daily Minoxidil 2.5 mg [**Hospital1 **] Amlodipine 10 mg daily Memantine 5 mg qhs Lorazepam 0.25 mg prn prior to HD Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Memantine 5 mg Tablet Sig: One (1) Tablet PO qhs (). 4. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed for constipation. 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital 3145**] Nursing Home - [**Location (un) 3146**] Discharge Diagnosis: # Multifocal pneumonia, bacterial NOS # Delirium # Dementia, severe # Aspiration # Hypertension # End stage renal disease, hemodialysis dependent Discharge Condition: stable Discharge Instructions: Patient was admitted with pneumonia and was treated with antibiotics. Please seek medical attention if you develop fevers, chills, difficulty breathing, or any other concern. Followup Instructions: Please note that patient is anuric (on hemodialysis), but has been passing some blood from his penis. This may be due to minor trauma from a straight cath to rule out obstruction. Please continue to follow, and consider outpatient follow up with his Urologist if this continues and if causing discomfort. Please continue outpatient hemodialysis.

[ "294.10", "V45.11", "482.9", "403.91", "V10.51", "585.6", "331.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "39.95" ]

icd9pcs

[ [ [] ] ]

10449, 10535

4958, 8888

276, 282

10725, 10734

3455, 4935

10957, 11307

2883, 2930

9237, 10426

10556, 10704

8914, 9214

10758, 10934

2945, 3436

224, 238

310, 1785

1807, 2638

2654, 2867

16,876

107,090

50923

Discharge summary

report

Admission Date: [**2181-4-8**] Discharge Date: [**2181-4-19**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 83 year old female who presents with an episode of shortness of breath and dyspnea on exertion times three, first time in [**Month (only) 404**], second time in [**Month (only) 956**] and the current episode. She was admitted to an outside hospital in [**Location (un) 47**] where she underwent cath on [**4-2**] that showed normal coronaries, severe mitral regurgitation and ______________ PAST MEDICAL HISTORY: Status post lumpectomy of the right breast in the [**2158**]. She was noted to have a right chest wall mass on [**3-5**]. CT guided biopsy was nondiagnostic. Chest CT with right upper lobe nodule as well. Hypertension. Parkinson's. History of breast cancer. Right hip replacement in [**2178**]. OUTPATIENT MEDICATIONS: Lopressor 50 mg twice a day, Combivent, Protonix, Zestril 10 mg b.i.d., Lasix 80 mg b.i.d., Sinemet 20/100 t.i.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Temperature 96.3, heart rate 54, respirations 18, blood pressure 104/52, 97% in room air. In general, patient was alert and oriented times three, not in acute distress. HEENT gingival abscess. Lungs clear to auscultation bilaterally. Patient had a systolic murmur. Abdomen positive bowel sounds, no distension, no tenderness. Extremities pulses felt in bilateral dorsalis pedis and radial arteries. HOSPITAL COURSE: The patient was pre-oped by a dental consult who cleared her. Patient was taken to the operating room on [**2181-4-11**] where mitral valve repair was performed by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]. Patient left the O.R. requiring Levophed, milrinone and propofol drips. She was also placed on Neo-Synephrine for low blood pressure. Patient required transfusion of packed red blood cells for postoperative anemia. Patient's pacing wires and chest tubes were removed at the appropriate time. Her diet was advanced. She was placed back on her home medications. When the appropriate time came, the patient was moved from the cardiothoracic ICU to the regular cardiothoracic floor where she did well. She was seen by physical therapy who worked with her and felt patient would probably need a rehab care facility post discharge. On [**2181-4-16**] patient complained of right leg tenderness. Doppler ultrasound was performed which showed a deep vein thrombosis in the superficial femoral vein. Patient was seen by the vascular team who recommended anticoagulation. Patient was started on heparin and Coumadin loading. It is now [**2181-4-19**] and the patient is being discharged to a rehab facility which will be able to accommodate a heparin drip and monitor her Coumadin loading. She has a goal INR of 1.5 to 2 and a goal PTT of 40 to 50. She is to see Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in four weeks. She is also to see her PCP in one to two weeks and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] in two to three weeks. She is being discharged on the following medications. DISCHARGE MEDICATIONS: 1. Coumadin to be titrated as necessary after daily INR checks. 2. Heparin 800 units per hour with frequent daily PTT checks to monitor need for change in dose. 3. Albuterol ipratropium one to two puffs q.six p.r.n. 4. Carbidopa/levodopa 25/100 one tab p.o. t.i.d. 5. Protonix 40 mg p.o. q.24. 6. Percocet. 7. Lopressor 12.5 mg p.o. b.i.d. 8. Colace 100 mg p.o. b.i.d. 9. Potassium chloride 20 mEq p.o. q.12. 10. Lasix 40 mg IV q.12. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern4) 98590**] MEDQUIST36 D: [**2181-4-19**] 09:56 T: [**2181-4-19**] 09:58 JOB#: [**Job Number 105838**]

[ "428.0", "V10.3", "453.8", "424.0", "429.5", "997.2", "332.0", "V43.64", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "89.68", "35.12" ]

icd9pcs

[ [ [] ] ]

3158, 3870

1471, 3135

873, 1026

1049, 1453

112, 523

546, 848

24,802

111,809

29660

Discharge summary

report

Admission Date: [**2159-2-1**] Discharge Date: [**2159-2-5**] Date of Birth: [**2092-8-28**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1505**] Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: [**2159-2-1**] Four Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending artery with vein grafts to diagonal, obtuse marginal and posterior descending artery. History of Present Illness: This is a 66 year old female with known coronary artery disease. Over the last several months, she has been experiencing exertional angina and shortness of breath. She describes the pain as substernal which occasionally radiates to her shoulders and left arm. Stress testing on [**2159-1-11**] was positive for ischemia. Subsequent cardiac catheterization on [**2159-1-25**] revealed severe three vessel disease and normal left ventricular function. Based upon the above results, she was referred for surgical revascularization. Past Medical History: Coronary artery disease, Prior PTCA in [**2149**], Hypertensios, Hyperlipidemia, Type II Diabetes Mellitus, Peripheral Vascular Disease - prior Left Fem-[**Doctor Last Name **] Bypass, Anemia, GERD, Arthritis, Prior Appendectomy Social History: 30 pack year history of tobacco, quit approximately 2 years ago. Admits to 2 glasses of wine per week. She is a semi-retired registered nurse. She is married and lives with her husband. Family History: Father MI at age 52. Mother and two brothers died of sudden cardiac arrest. Two brothers had CABG in their 60's. Physical Exam: Vitals: BP 130/58, HR 63, RR 14, SAT 98% on room air General: well developed female in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, right carotid bruit noted Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 1+ distally Neuro: nonfocal Pertinent Results: [**2159-2-5**] 07:40AM BLOOD WBC-9.7 RBC-2.67* Hgb-8.4* Hct-24.7* MCV-93 MCH-31.7 MCHC-34.2 RDW-15.1 Plt Ct-301# [**2159-2-5**] 07:40AM BLOOD Glucose-153* UreaN-19 Creat-0.8 Na-143 K-4.0 Cl-104 HCO3-28 AnGap-15 Brief Hospital Course: Mrs. [**Known lastname 71082**] was admitted and brought to the operating room where Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting surgery. For surgical details, please see seperate dictated operative note. Following the operation, she was brought to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. She maintained stable hemodynamics and weaned from pressor support without difficulty. She did well and transferred to the SDU for further care and recovery. Over several days, medical therapy was optimized and she continue to make clinical improvements with diuresis. She remained in a normal sinus rhythm without atrial or ventricular arrhythmias. The rest of her postoperative course was uneventful and she was cleared for discharge on postoperative day four. Medications on Admission: Plavix 75 qd, Atenolol 50 am and 25 pm, Lisinopril 10 qd, Imdur 90 qd, Lopid 600 [**Hospital1 **], Lipitor 80 qd, Metformin 500 [**Hospital1 **], Glipizide 10 qd, Fosamax Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 8. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 10. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 13. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 14. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: TBA Discharge Diagnosis: Coronary artery disease - s/p CABG, Prior PTCA in [**2149**], Hypertension, Hyperlipidemia, Type II Diabetes Mellitus, Peripheral Vascular Disease - prior Left Fem-[**Doctor Last Name **] Bypass, Anemia Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**3-29**] weeks. Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**1-27**] weeks. Local cardiologist, Dr. [**Last Name (STitle) **] in [**1-27**] weeks. Completed by:[**2159-2-5**]

[ "414.01", "530.81", "443.9", "401.9", "250.00", "413.9", "272.4" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4882, 4916

2322, 3182

309, 527

5163, 5170

2087, 2299

5488, 5748

1557, 1671

3403, 4859

4937, 5142

3208, 3380

5194, 5465

1686, 2068

248, 271

555, 1085

1107, 1338

1354, 1541

59,762

141,162

42056

Discharge summary

report

Admission Date: [**2103-9-23**] Discharge Date: [**2103-9-28**] Date of Birth: [**2025-10-26**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 9157**] Chief Complaint: anemia Major Surgical or Invasive Procedure: Endoscopy with AVM clips History of Present Illness: 77yo F with h/o jejunal AVMs resulting in prior GI bleeds (last bleed in [**2103-4-8**]), CAD, CHF (EF 35%), SVT s/p ablation, who was initially admitted to OSH with diaphoresis on [**9-21**] while working. Was brought to ED via EMS and was found to have OSH Hct of 20.9 in setting of melena. On admission she was ruled out for MI. Was initially transfused 2 units of pRBCs and started on protonix gtt. Hct then improved to 26.1 however then drifted down to 22.7 after 18h. Subsequent Hct without furhter transfusion was 19.1. She was then given 3u of pRBCs. GI was consulted who performed an EGD (enteroscopy)and clips were deployed in area of fresh blood in mid-jejunum. Unclear if vessel was noted. Area was also stained. Given concern for potential ongoing bleeding, pt was transferred to [**Hospital1 18**] for further evaluation. On arrival to [**Hospital1 18**], pt was resting comfortable without any concerns. She arrived with another unit of pRBCs. Past Medical History: - HTN - HLD - CAD s/p stents - Ischemic cardiomyopathy (EF 35%) - SVT s/p ablation - Mitral Stenosis - Jejunal AVM Social History: Lives alone. Independent. Has 2 sons who are helpful to her. - Tobacco: none - Alcohol: none - Illicits: denies Family History: - M: died at82 - F: died in his 30s from TB Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic murmur at RUSB, non radiating, diastolic murmur at apex Abdomen: soft, non-tender, obese, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE EXAM: VS: 98.7 138/80 96 18 96% GA: AOx3, NAD HEENT: PERRLA. MMM. no lymphadenopathy. neck supple. Cards: RRR S1/S2. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: soft, NT ND, +BS. no organomegaly. Extremities: wwp, no edema. Skin: warm and dry Pertinent Results: ADMISSION LABS [**2103-9-23**] 10:13PM BLOOD WBC-10.9 RBC-3.03* Hgb-9.5* Hct-26.6* MCV-88 MCH-31.3 MCHC-35.6* RDW-15.6* Plt Ct-120* [**2103-9-24**] 01:05AM BLOOD Hct-27.5* [**2103-9-24**] 05:11AM BLOOD WBC-11.9* RBC-2.98* Hgb-9.2* Hct-26.3* MCV-88 MCH-30.7 MCHC-34.8 RDW-16.0* Plt Ct-117* [**2103-9-23**] 10:13PM BLOOD PT-13.4 PTT-20.8* INR(PT)-1.1 [**2103-9-23**] 10:13PM BLOOD Glucose-122* UreaN-48* Creat-0.9 Na-137 K-3.5 Cl-107 HCO3-23 AnGap-11 [**2103-9-23**] 10:13PM BLOOD ALT-10 AST-15 CK(CPK)-32 AlkPhos-36 TotBili-0.3 [**2103-9-23**] 10:13PM BLOOD Calcium-8.4 Phos-2.9 Mg-1.7 DISCHARGE LABS [**2103-9-28**] 01:00PM BLOOD WBC-12.6* RBC-3.32* Hgb-10.1* Hct-29.0* MCV-87 MCH-30.4 MCHC-34.8 RDW-15.7* Plt Ct-204 [**2103-9-27**] 07:45AM BLOOD Glucose-95 UreaN-16 Creat-0.9 Na-137 K-3.4 Cl-104 HCO3-26 AnGap-10 [**2103-9-27**] TTE: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF 70%). There is a moderate resting left ventricular outflow tract obstruction (26 mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The study is inadequate to exclude mild aortic valve stenosis, though it is unlikely that clinically significant AS is present. 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. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Small hypertrophied left ventricle with hyperdynamic systolic function and moderate resting LVOT obstruction. Cannot exclude mild superimposed aortic stenosis. Mild aortic regurgitation. Moderate mitral regurgitation. Moderate pulmonary hypertension. Enteroscopy: Findings: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. Jejunum: - Lumen: Previous hemoclips were seen in the mid-jejunum. - Contents: Red blood was seen in the mid jejunum. Ileum: Not examined. Other findings: Residual bleeding was seen at the site of the previusly placed hemoclips. No identifiable vessel was identifiable, but a small mucosal tear at the insertion of a previously placed hemoclip was seen. 4 9 cc.Epinephrine 1/[**Numeric Identifier 961**] injections were applied for hemostasis with success in the mid-jejunum. Three endoclips were successfully applied for the purpose of mucosal tear closure in the mid jejunum, at the site of the previously placed endoclips. afte injection and clips placement, no further active bleeding was observed. Impression: Blood in the mid jejunum Previous of the jejunum Residual bleeding was seen at the site of the previusly placed hemoclips. No identifiable vessel was identifiable, but a small mucosal tear at the insertion of a previously placed hemoclip was seen. (injection, endoclip) Otherwise normal small bowel enteroscopy to mid jejunum Brief Hospital Course: 77yoF with history of jejunal AVMs, CAD, CHF (EF 35%)+ initially presented for diaphoresis found to have anemia [**1-10**] GI bleed with bleeding jejunal [**Hospital 91277**] transferred to [**Hospital1 18**] further care. # Acute Blood Loss Anemia: Known bleeding jejunal AVM. S/P clip placement at OSH. Transferred to MICU where she remained hemodyanically stable. She was then sent to the floor. Overnight on the floor, Hct dropped from 25 to 17. She was transfused and send back to MICU for close monitoring. GI completed enteroscopy showing mucosal tear in jejunum, which was repaired with clip. Hct was trended. She received a total of 4 units of PRBCs in MICU. Patient remained HDS. Pt was then transferred back to floor. She remained stable on the floor with a Hct around 29. Discharged home with explicit instructions to return to the ED immediately if she experienced any bleeding or symptoms of anemia. # CAD/CHF: Reported EF of 35% but TTE performed in hospital showed an LVEF of 70% and some LVOT obstruction. Results of the echo were sent to her cardiologist for followup as outpatient. Her aspirin was stopped due to GI bleed. This can be restarted per outpatient recommendations. Simvastatin was stopped in favor of atorvastatin due to concurrent verapamil. # H/O Arrhythmia (SVT, 1st degree heart block): All anti-hypertensives were held due to GI bleed. On day of discharge, she was tachy up to 180s while having a bowel movement. Restarted metoprolol and verapimil with good heart rate control. # Hypertension: All anti-hypertenives held initially in setting of GI bleed. Restarted on day of discharge and continued on discharge. # Hypothyroidism: Continued levothyroxine TRANSITIONAL ISSUES # LVOT Obstruction on echo should be addressed by cardiology # Aspirin held due to GI bleed Medications on Admission: - Aspirin 81mg Daily - Prevacid 30mg daily - Simvastatin 40mg qhs - KCl 20meq daily - Verapamil ER 120mg [**Hospital1 **] - Terazosin 2mg qhs - HCTZ 25mg daily - Toprol XL 150mg daily - Lisinopril 10mg [**Hospital1 **] - Levothyroxine 88mcg daily Discharge Medications: 1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(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). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. verapamil 120 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 4. terazosin 2 mg Capsule Sig: One (1) Capsule PO at bedtime. 5. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily). 7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: PRIMARY Jejunal AVM Bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 1661**], You were transferred to our hospital after you were found to have bleeding from one of the blood vessels in your gut. You underwent an endoscopy at the outside hospital to repair it, and then underwent a repeat endoscopy here in our ICU to repair it again. Your blood counts have remained stable for the last few days and you were discharged home. If you notice yourself feeling lightheaded, dizzy, tired or short of breath - or have any bloody or more tarry stools, it's important to call your doctor right away for further evaluation. If your doctor is not available immediately, please come to our Emergency Room ASAP. Medication changes: # Please STOP aspirin until you see your doctors [**Name5 (PTitle) 1796**] # Please STOP prevacid # Pleast START pantroprazole 40mg daily # Please STOP simvastatin as it interacts with your blood pressure medications # Please START atorvastatin 40mg daily for cholesterol Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] A. Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 14085**] Phone: [**Telephone/Fax (1) 89926**] When: Friday, [**10-5**], 9:15AM Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Location: [**Location (un) **] GASTROENTEROLOGY Address: [**Male First Name (un) 91278**], [**Location (un) **],[**Numeric Identifier 42074**] Phone: [**0-0-**] When: Wednesday, [**10-10**], 4:10 Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 1955**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Location: STURDY CARDIOLOGY ASSOCIATES Address: [**Doctor Last Name 91279**]., [**Location (un) **],[**Numeric Identifier 42074**] Phone: [**Telephone/Fax (1) 27736**] *It is recommended that you follow up with your cardiologist. Dr. [**Last Name (STitle) 5655**] will contact you with appointment information.

[ "272.4", "285.1", "428.22", "424.0", "414.8", "428.0", "244.9", "427.89", "401.9", "V45.82", "569.85" ]

icd9cm

[ [ [] ] ]

[ "96.04", "44.43" ]

icd9pcs

[ [ [] ] ]

8613, 8619

5700, 7511

312, 339

8688, 8688

2473, 5677

9811, 10789

1614, 1660

7809, 8590

8640, 8667

7537, 7786

8838, 9494

1675, 2178

2194, 2454

9514, 9788

266, 274

367, 1329

8703, 8814

1351, 1468

1484, 1598

23,954

178,777

13869

Discharge summary

report

Admission Date: [**2121-7-19**] Discharge Date: [**2121-7-30**] Date of Birth: [**2058-3-26**] Sex: M Service: MED Allergies: Penicillins Attending:[**First Name3 (LF) 2641**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 63 yo man with pmh significant for recent CABG in [**5-/2121**] at [**Hospital1 336**] who was transferred to [**Hospital1 18**] MICU from OSH where he had an upper GI bleed shortly after EGD dilitation of a shatzski's ring. Past Medical History: PAF CABG CAD Social History: Lives with wife in the [**Hospital3 **]. He works as a welder. He drinks about 12-20 beers per week. He smoked approximately [**12-20**] pack for years but quit in [**2084**]. Family History: non contributory Physical Exam: On physical examination, he is a healthy-appearing male in no distress. Pulse was 84 and regular, blood pressure of 118/85 and a respiratory rate of 12. There were no skin lesions. His HEENT exam had no oropharangeal thrush and no conjunctival abnormalities. There was no jugular venous distension, thyromegaly, or cervical lymphadenopathy. His chest examination was pertinent for left sided basliar rales, otherwise clear to auscultation and percussion. His cardiac exam had no murmur, rub, or gallop. His abdomen was non-tender and had no liver or spleen enlargement. There was no peripheral cyanosis, clubbing, or edema. Pertinent Results: ECHO-Conclusions: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 60-70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but not stenotic. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is a small posterolateral pericardial effusion. There are no echocardiographic signs of tamponade. WOUND CULTURE (Final [**2121-7-29**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S PENICILLIN------------ 0.25 R CXR ([**2121-7-29**])-IMPRESSION: Two subtle patchy opacities at both lung bases which may represent atelectasis. However, a pneumonia cannot be excluded. Unchanged small left pleural effusion. Brief Hospital Course: Pt was admitted to the MICU from OSH for management of GI bleed. Pt required minimal blood support in the MICU as active bleeding had subsided. Hospitalization was complicated by multiple episodes of chest pain without consistent presentation or relation to exertion. Myocardial infarction was ruled out each time with negative cardiac enzymes and EKG's showing no acute changes. Towards the end of Mr. [**Known lastname 41592**] hospitalization he developed fevers, a cough, and CXR showing possible pneumonia. He was treated with Levofloxacin and he central line was pulled, growing CoNS also sensitive to Levofloxacin. Pt had multiple episodes of atrial fibrillation throughout the hospitalization, for which he had a known history. This was difficult to manage as he was unsuitable for anti-coagulation with coumadin and so aspirin was used alone due to recent history of GI bleed with need to repeat EGD in near future. Additionally, rate control was difficult due to patient's low normal blood pressures. The rate was eventually controlled without affect on the blood pressure, patients pneumonia symptoms improved, and he was discharged to follow up with his primary care physician, [**Name10 (NameIs) 151**] the plan to restart the anti-coagulation at a later time. Pt was discharged to complete a course of Levofloxacin as treatment for line infection and pneumonia. Medications on Admission: -Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-20**] Puffs Inhalation Q6H (every 6 hours). Disp:*1 * Refills:*0* -Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* -Salumedrol -Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). -Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once a day). -Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day): please stop taking after [**7-31**], and continue after your EGD procedure. -Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* -Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-20**] Puffs Inhalation Q6H (every 6 hours). Disp:*1 * Refills:*0* 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once a day). 5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD (once a day) for 10 days: please continue until directed otherwise by Dr. [**Last Name (STitle) 17863**]. Disp:*10 Tablet(s)* Refills:*0* 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day): please stop taking after [**7-31**], and continue after your EGD procedure. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 9. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day): continue until otherwise directed by Dr. [**Last Name (STitle) 17863**]. Disp:*1 1* Refills:*0* 10. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Upper GI Bleed Pneumonia Atrial Fibrillation Discharge Condition: Pt has a mild cough, no sob or desaturation at rest or with ambulation. Pt is afebrile without tachycardia. Stools are without blood. Discharge Instructions: Please call your primary physician or go to the emergency department id you develop chest pain, difficulty breathing, or bleeding with your bowel movements. Followup Instructions: Appointment for EGD procedure to evaluate your esphagus and stomach at [**Hospital1 18**] on [**2121-8-11**] - arrive at [**Hospital Ward Name 516**] main lobby at 9:30 am. Appointment is with Dr. [**Last Name (STitle) **] [**Name (STitle) 2161**] - you will need to get a referral form Dr. [**Last Name (STitle) 17863**], no eating after midnight the night before, and someone will need to drive you home. Call [**Telephone/Fax (1) 463**] for further instructions. Please make an appointment to see Dr. [**Last Name (STitle) 17863**] next Monday or Tuesday. Completed by:[**2121-8-10**]

[ "790.7", "996.62", "578.9", "599.0", "515", "486", "135", "427.31", "280.0" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

6385, 6453

2874, 4260

276, 283

6542, 6679

1472, 2851

6884, 7477

793, 811

5074, 6362

6474, 6521

4286, 5051

6703, 6861

826, 1453

228, 238

311, 545

567, 581

597, 777

64,655

116,224

6811

Discharge summary

report

Admission Date: [**2200-12-19**] Discharge Date: [**2200-12-30**] Service: MEDICINE Allergies: Ace Inhibitors / Angiotensin Recp Antg&Calcium Chanl Blkr Attending:[**First Name3 (LF) 663**] Chief Complaint: Stridor Major Surgical or Invasive Procedure: [**2200-12-19**] - Intubation and arterial line placement History of Present Illness: Mr. [**Known lastname 25788**] is an 85 yo with hx of copd who presented to the [**Hospital1 18**] ED today complaining of sob x 5-6 hours and stridor. He reports it was unlike any previous COPD episodes. Per his caretaker, he had increased work of breathing all night preceeding his visit to the ED with audible wheezing. His wife [**Name (NI) 25789**] that and said that he was in his previous state of health prior to last night. She did say that he seemed to have problems swallowing, but he never complained. She denied any change in his diet the night before that may suggest anaphylactic response. His daughter mentioned that he felt his cough was worse. In the ED, his symptoms did not improved with bronchodilators. ENT was consulted in the ED who felt that the upper airway was patent and suspected a subglottic problem. Because it was felt his airway was in danger and there was concern of tracheal deviation by imaging, he was intubated. Despite the concern for subglottic airway obstruction, the ET tube passed without problem. A CT neck and chest was ordered and he was admitted to the MICU for further workup. Labs were notable for negative CEs. BNP 9800. Cr 1.2 (BL 1.2). 7.37/46/342. HCT 40. Past Medical History: COPD HTN s/p stroke ? L lacunar infarct [**2196**] right BKA for thrombosed artery in right leg EtOH abuse wandering atrial pacemaker Social History: [**2-12**] PPD smoking for past 50-60 years, drinks several shots of ETOH per day, lives with wife and has additional caretaker at home Family History: Unable to obtain Physical Exam: vitals: 56 160/80 spo2 98% gen: intubated, sedated, paralyzed heent: ncat, no obvious neck masses/deformities. no elevated jvd pulm: mild bronchial breath sounds, o/w ctab, no w/r/r cv: hrrr, no m/r/g abd: s/nt/nd/hypoactive bs extr: no c/c/e 2+ peripheral pulses neuro: intubated, sedated, paralyzed Pertinent Results: TRANSTHORACIC ECHOCARDIOGRAM - [**2200-12-19**] Conclusions: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately 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. 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. Aortic sclerosis without stenosis. Dilated thoracic aorta. CHEST (PORTABLE AP) [**2200-12-19**] IMPRESSION: 1. Left lower lobe atelectasis and right small to moderate pleural effusion. No radiographic evidence of pneumonia. Sclerotic focus within the left proximal humerus also noted on prior remote study from [**2191**] which is not fully characterized and may represent an enchondroma. CT CHEST W/CONTRAST [**2200-12-19**] IMPRESSION: 1. Endotracheal tube cuff overinflated. 2. Findings compatible with mild interstitial pulmonary edema. Moderate right-sided pleural effusion. 3. Probably reactive precarinal and subcarinal lymphadenopathy. 4. Dilated and fluid-filled esophagus, an aspiration risk. No evidence of aspiration at the current time. 5. Increase in the size of the abdominal aortic aneurysm, incompletely imaged on this study, since [**2198**]. Dedicated abdominal imaging of this is recommended. 6. Cholelithiasis. 7. Diverticulosis. CT HEAD W/O CONTRAST Study Date of [**2200-12-23**] IMPRESSION: 1. No acute intracranial hemorrhage. Please note, MRI is more sensitive for the detection of acute ischemia and can be considered if there is high suspicion for acute stroke. 2. Mild-moderate dialtion of ventricles can be due to diffuse parenchymal volume loss with superimposed Alzheimer's disease; to correlate clinically. UNILAT UP EXT VEINS US LEFT Study Date of [**2200-12-23**] IMPRESSION: Incomplete and suboptimal study secondary to patient noncompliance while in restraints. No evidence of DVT in the vessels interrogated as detailed above. If suspicion persists, consider repeat performance when patient compliance may be achieved. VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2200-12-24**] IMPRESSION: Evidence for aspiration with thin liquids. Remainder of the study demonstrated mild oral and pharyngeal swallowing dysfunction as detailed above. VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2200-12-29**] IMPRESSION: 1. Continued laryngeal penetration with nectar-thickened liquids and thin liquids, however, previously appreciated aspiration was not noted on today's study. 2. Otherwise, no interval change in mild oropharyngeal swallow dysfunction. SELECTED LABORATORY RESULTS: [**2200-12-19**] 06:42AM BLOOD WBC-6.6 RBC-4.12* Hgb-12.9* Hct-40.0 MCV-97# MCH-31.4# MCHC-32.3 RDW-14.7 Plt Ct-351 [**2200-12-30**] 07:55AM BLOOD WBC-13.7* RBC-4.30* Hgb-13.7* Hct-40.0 MCV-93 MCH-31.9 MCHC-34.4 RDW-14.7 Plt Ct-224# [**2200-12-19**] 06:42AM BLOOD Glucose-93 UreaN-16 Creat-1.2 Na-141 K-4.6 Cl-105 HCO3-27 AnGap-14 [**2200-12-29**] 09:05AM BLOOD Glucose-106* UreaN-19 Creat-1.2 Na-137 K-3.7 Cl-97 HCO3-28 AnGap-16 [**2200-12-24**] 07:40AM BLOOD ALT-50* AST-43* LD(LDH)-250 AlkPhos-70 TotBili-0.5 MICROBIOLOGY: [**2200-12-29**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL (NEGATIVE) [**2200-12-28**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL (NEGATIVE) [**2200-12-20**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL (MIXED OROPHARYNGEAL FLORA) [**2200-12-20**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO GROWTH) [**2200-12-20**] URINE URINE CULTURE-FINAL (NO GROWTH) [**2200-12-20**] BLOOD CULTURE Blood Culture, Routine-FINAL (NO GROWTH) [**2200-12-19**] MRSA SCREEN MRSA SCREEN-FINAL (NO MRSA ISOLATED) Brief Hospital Course: MICU COURSE: Mr. [**Known lastname 25788**] was admitted to the MICU with respiratory distress s/p intubation. His respiratory status improved and he was extubated on [**2200-12-18**]. He had received steroids for possible pharyngeal swelling and was being tapered upon transfer. His CT of the neck showed possible epiglottitis vs. post-intubation inflammation. After being extubated, he did well from a respiratory standpoint. However, his mental status was not at baseline. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-pysch consult was called and recommended changing his zyprexa to haldol and evaluating his R facial droop. He was ordered for a head CT to evaluate for possible stroke. He was already being treated with aspirin and aggrenox for previous CVAs. He failed his speech and swallow study and an NG tube was placed and tube feeds started. He was transferred to the floor on [**2200-12-23**]. FLOOR COURSE: #. Dyspnea / Stridor: Once arriving to the floor the patient had only mild expiratory stridor and typically only while awake. He was continued on a prednisone taper for presumed airway inflammation of unknown etiology and he finished his steroid course prior to discharge. His pulmonary exam at discharge revealed some rhonchi, dry and barking non-productive cough, and bibasilar crackles. He was slightly tachypneic to the low 20s, but denied dyspnea and had an oxygen saturation of 96% on room air. He was receiving albuterol and ipratropium nebs and was started on Advair while hospitalized. #. Hypertension: Patient was removed from home regimen of valsartan due to small chance that angioedema could be cause of his stridor. He was started on HCTZ and then switched to amlodipine with good result and was discharged on amlodipine. #. Diarrhea: Patient noted to have diarrhea last two days of admission; however, clostridium difficile toxin was negative in two stool samples prior to discharge. The diarrhea was slowing, but not resolved at discharge. Report from home caregiver to nurse was that patient has been incontinent of loose stool at home. #. Leukocytosis: WBC count was 13.7 at discharge; however, patient had no fever, chills or other systemic or localizing signs or symptoms of infection and was felt to be safe for discharge with PCP [**Name9 (PRE) 702**] of this leukocytosis. #. Facial droop: Patient was noted to have a right facial droop in the MICU, this was though to be reexpression of prior reported L lacunar stroke; however, we felt that we should rule out acute intracranial process. Obtained head CT shortly after patient hit floor on [**2200-12-23**] and was read as no acute intracranial process. We felt that patient did not need MRI at this time. As his aggrenox could not be crushed per speech and swallow recs, this medication was discontinued during the hospitalization; however, the patient was continued on aspirin. #. Left arm swelling: Left arm edematous (appeared dependent) without obvious cause at presentation to floor, but non-tender. A left upper extremity ultrasound was obtained and although it was a limited exam, revealed no etiology of the swelling. This improved throughout hospital course and was resolved at discharge. #. Delerium / Sundowning: Patient with waxing and [**Doctor Last Name 688**] mental status throughout hospitalization, and although in restraints and receiving haldol nightly as needed while in MICU, once transferred to the floor and once he had his feeding tube removed, he was easily redirected and through several days leading up to discharge did not require restraints or haldol. He typically brightened and became more alert and less dysarthric throughout the day. His family was consulted regarding his baseline and they felt that although he waxed and waned, he was close to his pre-hospital mental status. #. Dysphagia: While patient was in the MICU, speech and swallow was consulted and rec that patient be NPO and no meds by mouth. A nasogastric feeding tube was place which the patient removed several times once arriving to the floor despite restraints and redirection. On [**2200-12-24**], the speech and swallow consult performed a video swallow and modified his diet recs such that an NG tube was no longer needed. He had a video swallowing study again on [**2200-12-29**] and the final recs for his nutrition care were for him to be on aspiration precautions and receive ground solids, thin liquids, and crushed meds. #. EtOH abuse: No need for actiavation of CIWA in MICU as delerium appeared unresponsive to benzodiazepine administration. Upon arriving to floor, patient was outside window of conern for delirium tremens and the CIWA was discontinued. Medications on Admission: Meds per caretaker: lipitor 10mg qday folic acid 1mg paroxetine 20mg qday aggrenox qday diavan 80 mg qday B1 100mg ASA 81mg qday prednisone taper finished 2 weeks ago MVI Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 11. Acetaminophen 160 mg/5 mL Solution Sig: Three [**Age over 90 **]y (320) mg PO Q6H (every 6 hours) as needed for fever or pain. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary Diagnosis 1) Stridor 2) Chronic Obstructive Pulmonary Disease Secondary Diagnoses 3) Hypertension 4) Delerium 5) Prior Cerebrovascular Accident Discharge Condition: Stable with decreased shortness of breath Discharge Instructions: You were admitted with difficulty breathing and there was concern that you had an obstruction in your throat, so you were intubated when you arrived. After the breathing tube was removed, we gave you steroids to reduce inflammation in your airway. You finished the course of steroids while you were hospitalized. We noted in the hospital that you had some high blood pressure. We discontinued your valsartan due to concern that it was causing your breathing difficulty. We started you on a new medication for high blood pressure called amlodipine. For your shortness of breath, we have you on a new medication called Advair, which you should use twice a day. You had a couple of days of diarrhea and we checked two samples of stool to make sure that you did not have an infection called clostridium difficile causing your diarrhea. You have a follow-up appointment with Dr. [**First Name (STitle) **] on [**2201-1-5**] at 10:30 AM. Should you have any fever, chills, shortness of breath, increased wheezing, lightheadedness, loss of consciousness, or any other symptoms that are concerning to you or your family, please contact your physician or report to an emergency department immediately. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time: [**2201-1-5**] 10:30 Completed by:[**2200-12-31**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12303, 12375

6309, 11011

275, 335

12571, 12615

2269, 6286

13861, 14074

1912, 1930

11233, 12280

12396, 12550

11037, 11210

12639, 13838

1945, 2250

227, 237

363, 1586

1608, 1743

1759, 1896

78,077

181,781

40211

Discharge summary

report

Admission Date: [**2108-11-24**] Discharge Date: [**2108-11-27**] Date of Birth: [**2048-5-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: 60 y/o with h/o esophogeal varices and h/o eoth abuse. Patient complains of chronic fatigue, significantly worse for the last 3 weeks, limiting his ability to complete his work as a welder. He developed a non-productive cough over the last 3 weeks, without hemoptysis. No F/C. He reports that over the last week, when coughing he feels as if he is going to "black out". 2 nights ago, he sat up in bed in the middle of the night, coughed, and passed out awaking unharmed on the floor. [**11-24**] at 130 am, he again awoke, sat up to use the bathroom, began coughing and had a syncopal episode. He awoke on the floor with blood covering his head. He went the to [**Location (un) **] [**Location (un) **] ED for evaluation. . In the ED, initial vs were: Temp:97.8 HR:98 BP:139/72 Resp:16 O(2)Sat:100 . Patient noted to have HCT 18.8 -> got 3 units with bump 21.6. CT head, c-spine, torso -> + C2 fracture, no RP bleed. NSurg, hard collar. Guiac neg x 4. GI says h/o gastric varices no need for lavage. No obvious blood from below or above. EKG normal. MS [**Last Name (Titles) 3584**]. 2 PIV . On the floor, Pt remained without subjective complaints. Due to low Hct, pt received additional 2 units of PRBCs. Past Medical History: -Liver disease -Alcohol abuse, last drink [**12/2107**] -Esophageal/gastric varices, gastritis, intermittent hx melena -[**Doctor First Name **]-[**Doctor Last Name **] Tear [**2107**] -Compression fractures in lower back s/p previous motorcycle accident, patient reports these fused spontaneously, imaging shows fractures at L1, L3 level Social History: Works as welder, self-employed. Lives with brother. Previous heavy EtOH abuse, quit 12/[**2107**]. Previous smoking history, quit 30 years ago. Denies IVDU or other illicit drug use. Family History: Father had DM, pancreatic cancer. Physical Exam: On admission to MICU: General: [**Year (4 digits) **], oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD, [**Location (un) **]-J in place Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema On transfer to Medicine Floor: VS: afebrile, HR 97, BP 122/65, RR 18, O2 sat 98% RA GENERAL: awake, [**Location (un) 3584**], oriented, resting in bed, NAD HEENT: NCAT. PERRL. Sclera anicteric. MMM. OP clear. NECK: Supple. CARDIAC: RRR, normal S1, S2. Slight systolic murmur. No rubs or gallops. LUNGS: Respirations unlabored. CTAB. No crackles, wheezes or rhonchi. ABDOMEN: Normoactive bowel sounds, soft, non-tender, non-distended. No appreciable hepatosplenomegaly on exam. No stigmata of liver disease. EXTREMITIES: Warm, DPs 2+ bilaterally, no edema. NEURO: [**Location (un) 3584**], oriented, moving all four extremities SKIN: laceration across top of head, sutures in place, dried blood surrounding laceration but no active bleeding Pertinent Results: Admission Labs: [**2108-11-24**] 06:30AM BLOOD WBC-5.2 RBC-2.87* Hgb-5.4* Hct-18.8* MCV-65* MCH-18.9* MCHC-29.0* RDW-18.1* Plt Ct-83* [**2108-11-24**] 06:30AM BLOOD Neuts-93* Bands-0 Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2108-11-24**] 06:30AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-2+ Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Burr-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 15924**] [**2108-11-24**] 06:30AM BLOOD PT-15.6* PTT-30.8 INR(PT)-1.4* [**2108-11-25**] 04:57AM BLOOD Fibrino-196 [**2108-11-24**] 06:30AM BLOOD Ret Man-2.8* [**2108-11-24**] 06:30AM BLOOD Glucose-106* UreaN-11 Creat-0.7 Na-135 K-4.3 Cl-104 HCO3-22 AnGap-13 [**2108-11-24**] 08:32PM BLOOD ALT-17 AST-20 LD(LDH)-155 CK(CPK)-48 AlkPhos-130 TotBili-1.9* [**2108-11-24**] 08:32PM BLOOD CK-MB-2 cTropnT-<0.01 [**2108-11-24**] 06:30AM BLOOD Iron-12* [**2108-11-24**] 06:30AM BLOOD calTIBC-443 VitB12-919* Ferritn-4.1* TRF-341 [**2108-11-24**] 08:32PM BLOOD Hapto-79 [**2108-11-24**] 06:42AM BLOOD Hgb-5.5* calcHCT-17 . HCT Trend: [**2108-11-24**] 06:30AM Hct-18.8* [**2108-11-24**] 01:10PM Hct-21.6* [**2108-11-24**] 08:32PM Hct-20.8* [**2108-11-25**] 04:57AM Hct-23.5* [**2108-11-25**] 10:20AM Hct-24.2* [**2108-11-25**] 03:38PM Hct-23.7* [**2108-11-26**] 07:06AM Hct-24.2* [**2108-11-26**] 03:20PM Hct-24.4* [**2108-11-27**] 07:16AM Hct-25.6* . Other Pertinent Labs: [**2108-11-25**] 04:57AM BLOOD Fibrino-196 [**2108-11-24**] 08:32PM BLOOD CK-MB-2 cTropnT-<0.01 [**2108-11-25**] 04:57AM BLOOD CK-MB-2 cTropnT-<0.01 [**2108-11-26**] 07:06AM BLOOD Albumin-3.3* Calcium-8.0* Phos-4.1 Mg-2.2 [**2108-11-26**] 07:06AM BLOOD Folate-12.4 [**2108-11-26**] 07:06AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2108-11-26**] 07:06AM BLOOD Smooth-NEGATIVE [**2108-11-26**] 07:06AM BLOOD [**Doctor First Name **]-NEGATIVE . Discharge Labs: [**2108-11-27**] 07:16AM BLOOD WBC-5.0 RBC-3.55* Hgb-7.9* Hct-25.6* MCV-72* MCH-22.3* MCHC-30.9* RDW-25.0* Plt Ct-84* [**2108-11-27**] 07:16AM BLOOD PT-15.8* PTT-32.2 INR(PT)-1.4* [**2108-11-27**] 07:16AM BLOOD Glucose-102* UreaN-10 Creat-0.7 Na-139 K-4.2 Cl-106 HCO3-25 AnGap-12 [**2108-11-27**] 07:16AM BLOOD Calcium-8.3* Phos-4.4 Mg-2.0 . Imaging: [**2108-11-24**] CT Head w/o contrast: No acute intracranial hemorrhage or fracture. Scalp lacerations as described (Soft tissues of the orbits are unremarkable. Subcutaneous air and laceration is noted of the scalp overlying the frontal bones bilaterally. There may also be a laceration within the scalp posteriorly near the vertex.) . [**2108-11-24**] CT C-spine w/o contrast: Non-displaced fractures through the lamina of C2 bilaterally extending to the spinal canal. Smaller non-displaced fracture through the anterior aspect of the left lamina extending to the pedicle, also non-displaced. No other fractures identified. Alignment maintained. . [**2108-11-24**] CT Abdomen/Pelvis: 1. No evidence of retroperitoneal hematoma. Low-density ascites, splenomegaly, nodular liver contour, and varices are consistent with cirrhosis and portal hypertension. 2. Cholelithiasis. 3. Small periumbilical hernia containing a portion of recanalized umbilical vein and fat. 4. Large left inguinal hernia containing colon and fat and fluid. No evidence of obstruction. 5. Compression fractures of vertebral bodies L1 and L3 with more than 50% loss of height. Chronicity of these are unknown as there are no priors for comparison, although they do appear chronic in appearance. Retropulsion of vertebral body L3, approximately of [**10-5**] mm causing severe spinal canal narrowing at this level. . [**2108-11-26**] TTE: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The aorta is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Dilated thoracic aorta. No structural cardiac cause of syncope identified. Brief Hospital Course: 60yo male with h/o EtOH abuse, esophageal varices, and previous [**Doctor First Name **]-[**Doctor Last Name **] tear, who presented with worsening fatigue, cough, and syncopal event resulting in head injury with lacteration and C2 fracture, and who was also noted to have HCT 18.8. . #. Syncope: Initially suspected hypotension [**2-28**] GI bleed. However, CT head and torso did not reveal source of bleeding, and stool was guiac negative. The patient remained hemodynamically stable throughout hospital course and was mentating well. EKG was unremarkable and two sets of cardiac enzymes were flat. TTE was ordered due to vague complaints of dyspnea and orthopnea. TTE findings included dilated thoracic aorta and normal EF; no structural cardiac cause of syncope was identified. The patient's syncope was likely secondary to vasovagal response or situational syncope in setting of cough and severe anemia. . #. Anemia: The patient was found to have Hct of 18.8 on admission, and his severe anemia was likely the etiology of his fatigue. He was transfused 3 units PRBCs in ED, with rise in Hct to 21.6. He was transfused an additional unit PRBCs in the MICU, with increase in Hct to 22. Given Hct response to transfusion less than expected, hemolysis labs were sent but unremarkable. Labs were consistent with iron deficiency, and anemia was felt to be secondary to chronic blood loss likely from a GI source. The patient has a h/o esophageal varices, as well as a history of [**Doctor First Name **]-[**Doctor Last Name **] tear. However, he was guiac negative throughout his admission. CT scans of head and torso did not reveal source of bleeding, including no evidence of retroperitoneal bleeding. Of note, the patient's retic count was only slightly elevated, suggesting inappropriate marrow response to anemia. The patient will need an outpatient EGD and colonoscopy to evaluate for possible GI source of blood loss. These procedures were deferred during his admission, given his hemodynamic stability, stabilization of HCT, guiac negative stools, and risk of injury given C2 fracture. Plan is for EGD/[**Last Name (un) **] once cleared from neurosurgery perspective. The patient's HCT remained stable for the rest of his hospital course, and was 25.6 on day of discharge. The patient was started on ferrous sulfate prior to discharge, and was also given a prescription for omeprazole 40mg PO daily. . # C2 fracture: CT imaging revealed non-displaced fractures through the lamina of C2 bilaterally, extending to the spinal canal, as well as a smaller non-displaced fracture through the anterior aspect of the left lamina extending to the pedicle. Neurosurgery was consulted and recommended outpatient follow-up with Dr. [**Last Name (STitle) 548**] in 6 weeks. The patient will need to wear a [**Location (un) 2848**] J collar in the meantime, and may only take the collar off for hygiene purposes. . # Cirrhosis: Imaging during this admission revealed low-density ascites, splenomegaly, nodular liver contour, and varices, all consistent with cirrhosis and portal hypertension. The patient was seen by hepatology consult, who will see the patient for outpatient follow-up. His cirrhosis is likely secondary to alcoholic cirrhosis, given history of heavy EtOH use, but he will likely need a liver biopsy as an outpatient to confirm his diagnosis. Of note, [**Doctor First Name **], anti-smooth muscle Ab, Hep A Ab, Hep B Ab, and Hep C Ab all negative. IgG subclasses 1,2,3,4 were ordered but pending at time of discharge. . #. Cough: Etiology unclear. Chest imaging revealed mild atalectasis but no findings to explain cough. Patient was afebrile and without leukocytosis, indicating bacterial infection unlikely. Cough may be secondary to viral illness, but would also suspect GERD contributing to cough given patient's h/o intermittent epigastric pain previously relieved by prilosec. Patient was discharged with prescription for omeprazole 40mg PO daily. . #. Access to care: The patient has had minimal outpatient care, as he does not have health insurance. He was seen by social work during this admission. He will contact [**Name (NI) 88284**] after discharge to set up primary care. . #. Code Status: The patient was a full code during this admission. Medications on Admission: -Prilosec, taking occasionally -Tylenol prn pain Discharge Medications: 1. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 2. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day): please take with [**Location (un) 2452**] juice if possible. Disp:*60 Tablet(s)* Refills:*2* 3. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO once a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Bilateral non-displaced fractures at C2 level Anemia Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: [**Location (un) **] and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 88285**], You were transferred to [**Hospital1 18**] for further evaluation after you fainted and injured your head. You have a fracture at the C2 level in your neck, and were seen by the neurosurgeons. They recommend you wear the collar at all times for the next 6 weeks. The only time you may take it off is for hygeine purposes. You must be sitting and not moving at all while the collar is off. The collar is not to be off for more than a 2-3 minutes at a time given the risk of damage to your spinal cord. You will need to follow-up with Dr. [**Last Name (STitle) 548**] in neurosurgery in 6 weeks. Please contact his office at [**Telephone/Fax (1) 1669**] to make an appointment. Please do NOT drive while wearing the cervical collar. You were also found to be very anemic, which is likely why you have been feeling so fatigued lately. We did not find the exact source of the bleeding, but it is likely from your gastrointestinal tract. You will need to have an endoscopy and colonoscopy as an outpatient, once you are no longer in the cervical collar. You also have evidence of liver cirrhosis. You were seen by the liver doctors, who would like you to follow up with them as an outpatient. Please contact them at [**Telephone/Fax (1) 2422**] to set-up an appointment within 2 weeks. We believe that acid reflux is contributing to your cough. Please continue to take your omeprazole EVERYDAY otherwise this medication will no provide you with any benefit. Lastly, please call [**Location 11797**] at [**Telephone/Fax (1) 88286**] to establish care with a primary care physician within ONE WEEK. It is very important that you obtain a primary care physician. MEDICATION CHANGES: 1. Please start taking iron supplements daily 2. Please start taking omeprazole 40mg by mouth daily Please go to the emergency department immediately if you notice any blood in your stool or vomit. Other worrisome signs are fever, abdominal pain, chest pain, shortness of breath, dizziness, lightheadedness or loss of consciousness. Followup Instructions: Please call [**Location 11797**] at [**Telephone/Fax (1) 88286**] to establish care with a primary care physician within ONE WEEK. It is very important that you obtain a primary care physician. You were seen by the liver doctors, who would like you to follow up with them as outpatient. Please contact them at [**Telephone/Fax (1) 2422**] to set-up an appointment within 2 weeks. You will need to follow-up neurosurgery (Dr. [**Last Name (STitle) 548**] in 6 weeks. Please contact his office at [**Telephone/Fax (1) 1669**] to make an appointment.

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Discharge summary

report

Admission Date: [**2189-10-6**] Discharge Date: [**2189-10-12**] Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 2777**] Chief Complaint: Abominal aortic aneurysm Major Surgical or Invasive Procedure: 1. Visceral debranching of aorta 2. Exploratory laparotomy, extended left colectomy History of Present Illness: 84M c thoraco-abdominal aneurysm presented as same day admission for visceral debranching of the aorta in preparation for repair of abominal aortic aneurysm in the future. Past Medical History: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 6 [**2163**] Hypertension Hypercholesterolemia Lower GI Bleed seconday to diverticulitis Prostate Cancer s/p cryogenic prostate surgery and Viador implant in left arm (hormone suppression) Osteoarthritis s/p Appendectomy s/p tonsillectomy s/p bilateral cataract surgery s/p ORIF right femur Social History: Remote tobacco use, quit 40 yrs ago Rare ETOH use Married, Retied electronics Family History: Non-contributory Physical Exam: Afebrile VSS RRR CTAB Abd: soft, NT, ND, +BS Ext: warm and well perfused Pulse: palpable 2+ throughout Brief Hospital Course: 84M who presented as same day admission for visceral debranching of aorta in preparation for eventual repair of the abdominal aortic aneurysm. Pt went to the OR on [**2189-10-6**]. For more details, please see operative report. Initially, post-operatively, the pt had a significant fluid requirement to maintain urine output and blood pressure. He was briefly on pressors during this time but eventually responded to fluid, with increase urine output, creatinine stabilized at 1.9 (baseline 1.4)and normalized lactate. Pt was extubated on [**2189-10-10**] after parameters were met. On the morning of [**2189-10-11**], the pt decompensated with tachypnea, atrial fibrillation/flutter, and hypotension. He was re-intubated. Lab draws showed a positive troponin, lactate was elevated, poor oxygenation, and acidosis. General surgery took the patient for emergent exploratory laparotomy and extended left colectomy for ischemic and perforated colon, and the abdomen was left open with a vac dressing in place. The small bowel was viable and all grafts were patent. Post-operatively, the pt did very poorly with progressive sepsis, on multiple pressors (epi, vasopressin, neo, levophed), bicarbonate drip, maximal vent support, maximal antibiotic support. Inspection at the bedside revealed that the pt had global ischemia and dead bowel. Pt passed at 1:04 PM [**2189-10-12**]. Medications on Admission: 1. ASA 81 2. Vytorin [**11-21**] 3. Toprol XL 50 4. Diltiazem 180 5. Isordil 60"' Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: 1. Thoracoabdominal aortic aneurysm 2. Bowel ischemia 3. Sepsis 4. Death Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2162-1-18**] Discharge Date: [**2162-2-8**] Date of Birth: [**2112-11-10**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 6114**] Chief Complaint: Chest pain, positive blood cultures Major Surgical or Invasive Procedure: PICC line placement Dialysis catheter removal and replacement History of Present Illness: 49 yo female, h/o recent admission for complicated enterococcus endocarditis (initially with vegetation on aortic valve with possible migration to mitral valve), bilateral knee replacements, IV cocaine abuse, presenting now with blood cultures positive for enterococcus from 1 week ago and right-sided pleuritic chest pain. Upon discharge from [**Hospital1 18**] on [**2162-12-7**], she went to [**Hospital3 672**] Rehab where she stayed until [**12-28**] before returning home. She was receiving dialysis at that time (gentamicin initiated last admission for endocarditis caused acute renal failure) and was having surveillance blood cultures drawn weekly at HD. Cultures from [**1-11**] grew enterococcus, (sensitive to amp, vanco, cipro). For this, she was started on Vancomycin, Ceftaz, and Ampicillin. Additionally, she developed acute, pleuritic chest pain on the night prior to admission. She described it as occurring with deep breaths, radiating to the back, [**8-8**], relieved by sitting forward, without radiation to arm/jaw, no n/v/diaphoresis. She states she does not usually get chest pain/angina and has not experienced pain like this in the past. The pain has been getting worse and now is constant (still worse with deep breathing). She states she has been having 'chills,' but denies subjective fevers, night sweats. She has a stable [**6-4**] pillow orthopnea and has PND (not increased or worse recently). She states that since she was started on hemodialysis, she has had LE swelling, sometimes asymmetric (usually L>R). On presentation to the ED, she was uncomfortable, afebrile with stable vitals, saturating adequately on RA (but placed on NC O2). Vanco level was checked, Cr was 2.5 (baseline wnl, s/p gent was up to 6, 3.1 on discharge last admission), blood cultures were sent, and 1 set of CE's were sent (Troponin T 0.03; was 0.05 on last discharge). Chest X-ray showed some upper zone redistribution, and LENI's/TTE were ordered. She was admitted to medicine for further workup of this chest pain and positive blood cultures. Past Medical History: 1. Endocarditis recently, initial vegetation on Aortic Valve, with migration to Mitral Valve; treated with amp/gent. Most recent TTE on [**12-6**] showed 4+ AR with small veg on AV, 2+ MR [**First Name (Titles) 151**] [**Last Name (Titles) 114**]e-sized vegetation on MV, EF=55% 2. Gentamicin-induced renal failure last admission. On hemodialysis. 3. Osteoarthritis R hip ?????? scheduled of THR in [**6-/2161**], but missed appointment, now with no plans to pursue surgery. 4. s/p L knee replacement ?????? [**2157**], complicated by septic knee, hardware removed and then replaced 1 year later. 5. s/p R knee replacement ?????? [**2157**] 6. Asthma ?????? diagnosed years ago, no hospitalizations, no intubations, no attacks in 1 year 7. Bipolar disorder ?????? scheduled to begin valproic acid therapy soon 8. Anxiety disorder ?????? treated with klonopin 9. IV cocaine abuse ?????? last use was months ago by her report Social History: Pt was at [**Hospital3 **] rehab from [**Date range (1) 88033**], then returned home. She lives with her husband and daughter (age 19) in [**Location (un) 669**]; Tobacco: 1/2ppd x 30 yrs No alcohol use + IV cocaine use few months ago Denies any recent IVDU Does not work Family History: Non-contributory Physical Exam: VS: T:98.4; P: 98; BP: 106/42; RR: 20; O2: 99% 4L Gen: mild distress, relatively comfortable, obese female [**Name (NI) 4459**]: PERRL, no [**Doctor Last Name **] spots, EOM grossly intact OP clear CNII-XII intact Neck: ?JVD (9cm noted in ED), on LAD CV: 3/6 SEM RUSB with radiation to carotids bilaterally, ?diastolic murmur (soft), no r/g Chest/back: reproducible chest pain to palpation on right paraspinal area, right mid-chest, right side Lungs: + crackles at bases bilaterally, poor air movement throughout, no w/r appreciated Abd: obese, nabs, nt/nd, no reb/guard Extr: 2+ pitting edema bilaterally, r>l, PT 1+ bilaterally, negative [**Last Name (un) 5813**] sign bilaterally Neuro: strength and sensation intact to light touch and temperature bilaterally and symmetrically, no focal deficits Skin: Right IJ HD catheter-no erythema, discharge, no tenderness to palpation around site on catheter. No splinter hemorrhages, [**Last Name (un) **] lesions noted Pertinent Results: Labs on admission: Lactate:1.7 Vanco: 2.0 GROSSLY HEMOLYZED SPECIMEN 136 96 28 94 ------------ 4.3 28 2.5 CK: 63 MB: Notdone Trop-*T*: 0.03 Lip: 38 MCV= 90 WBC= 11.3 Hgb= 10.4 Plts= 460 Hct= 32.3 N:77.2 L:16.2 M:2.7 E:3.8 Bas:0.1 Hypochr: 3+ Anisocy: 1+ Poiklo: 1+ Macrocy: 1+ PT: 13.2 PTT: 25.7 INR: 1.1 _________________________________ Radiology [**2162-1-18**] LENI's: IMPRESSION: Limited study. No evidence of DVT. [**2162-1-18**]- Lung scan-) Central deposition of radiotracer with heterogeneous ventilation to the upper lobes. 2) Patient refused perfusion images, therefore, this is anincomplete ventilation/perfusion study. [**2162-1-18**] CXR: Again demonstrated is a right IJ double- lumen catheter, unchanged in position. There is stable LV enlargement. There is upper zone redistribution of the pulmonary vasculature with a small left- sided pleural and questionable right-sided pleural effusion consistent with mild left heart failure. The mediastinal and hilar contours are stable. There is no pneumothorax. [**2162-1-18**] EKG: NSR 91, left axis deviation, with t-wave inversions in III, AVF, V1-V5; unchanged from EKG from [**2161-12-5**] [**2162-1-18**]- TTE-Conclusions: 1. The left atrium is moderately dilated. 2. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. The aortic valve leaflets (3) are mildly thickened. There are at least 2 small, fibrotic masses on the aortic valve, which may represent healed or active vegetations. Severe (4+) aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Two mitral regurgitation jets are seen, one of which probably represents a small hole in the anterior leaflet. 5. Compared with the findings of the prior study (tape reviewed) of [**2161-12-6**], the aortic mass is evolving and the mitral mass is gone. [**2162-1-26**] Left upper extremity U/S-IMPRESSION: No DVT on this somewhat limited study. [**2162-1-26**]- CT abd/pelvis with contrast-IMPRESSION: 1) New pericardial effusion, otherwise unremarkable CT of the chest. No identifiable source of infection within the abdomen or pelvis. 2) Soft-tissue fullness within the pancreatic head, worrisome for pancreatic neoplasm. An MRI of the pancreas is advised. [**2162-1-28**] Echo-Conclusions: The left atrium is dilated. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular systolic function is normal with borderline preserved right ventricular systolic function. The aortic valve leaflets are mildly thickened. There are echo dense masses associated with the aortic valve which likely represent vegetations. Severe (4+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen (not fully assessed). There is a pericardial effusion that is small to moderate anteriorly and large inferolaterally (upto 2.7-3.0 cm wide). There are no echocardiographic signs of tamponade. Compared to the prior study of [**2162-1-21**], the pericardial effusion is now larger. [**2162-2-2**]- AP CXR-A single AP supine image. Comparison study dated [**2162-2-1**]. A new endotracheal tube is noted, its tip at the level of the thoracic inlet. The right IJ Swan catheter tip remains well positioned in the right pulmonary artery. The right IJ double-lumen catheter tip appears to be in the mid right atrium. The cardiac silhouette remains markedly enlarged, though possibly slightly improved since the prior study. There appears to be a drain overlying the cardiac silhouette following the pericardial window procedure. The lungs appear slightly better inflated than before, but there appears to be a left lower lobe collapse/consolidation behind the heart. No definite pleural effusions are demonstrated on this supine view. [**2162-2-3**] Pericardial fluid-No malignant cells. [**2162-2-4**]- Echo The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. There is a trivial/physiologic pericardial effusion subtending the lateral wall and apex of the left ventricle. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. _______________________________ Microbiology: [**2162-1-18**]- BCx- No growth [**2162-1-19**]- BCx- No growth [**2162-1-19**]- UCx- MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION [**2162-1-20**] BCx- No growth [**2162-1-21**] BCx- No growth [**2162-1-22**] BCx- No growth [**2162-1-25**] R subclavian tip culture -No growth [**2162-2-2**]- PEricardial tissue-GRAM STAIN (Final [**2162-2-2**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2162-2-5**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2162-2-8**]): NO GROWTH. ACID FAST SMEAR (Final [**2162-2-3**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2162-2-2**] Pericardial tissue swab-Gram stain- No PMNs. No microorganisms. No anaerobic growth. [**2162-2-5**]- BCx x 2- No growth to date [**2162-2-6**]- BCx x2- Pending [**2162-2-7**] BCx- Pending ___________________________________ Labs on discharge [**2163-1-8**]: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 13.1* 3.20* 9.1* 28.3* 89 28.4 32.1 17.7* 338 Glucose UreaN Creat Na K Cl HCO3 118* 28* 3.2* 138 3.4 101 28 alb-3.0* Ca-9.3 Ph-2.6* Mg-2.0 _____________________________________ Other labs: [**2162-1-31**]- ESR -22; [**2162-1-31**]- CRP 18.31 [**2162-2-1**] calTIBC Hapto Ferritn TRF 207* 314* 468* 159* [**2162-1-31**]- T3-56; T4-0.6; TSH-14 _____________________________________ Brief Hospital Course: 1. Chest [**Name (NI) 1622**] Pt developed new, right-sided, initially pleuritic chest pain with radiation to the back. She also has ?new LE edema, asymmetrical at times, and positive blood cultures. She has no history of CAD, had no evidence of perivalvular abscess on TTE from last admission, and all of her surveillance blood cultures up until now had been negative. Perivalvular abscess and/or pericarditis +/- effusion was in the differential given her known vegetations on last admission (she did complete ampicillin course, no PR prolongation on EKG). Her symptoms did not sound like a cardiac ischemic event, but that was also a possibility (EKG not really consistent with ischemia, tnt elevated in setting of renal insufficiency). She had some chest pain on last admission that was thought to be musculoskeletal in origin, so this was also a possibility. While in-house, she had a TTE which showed at least 2 small vegetations on the AV and 4+ AR. No vegetations were seen on the MV. These findings were thought to be an evolution of the original process (vs. new vegetations?). TEE did not show any perivalvular abscess or aortic abnormality. She had the onset of some new afib and RBBB discovered on EKG/telemetry, and cardiology was consulted. ID was additionally consulted and recommended treating for an additional 8 weeks with ampicillin with close follow up and serial TTE's to monitor for improvement in vegetations. Open MRI was recommended to rule out epidural abscess as a source for the persistent bacteremia. Bilateral LENI's were negative for DVT, V/Q was not able to be obtained (pt refused Q portion), and CTA was not an option given her renal insufficency. Non-contrast CT was obtained, however. It showed a new pericardial effusion. 2. Pericardial effusion- A new small pericardial effusion was noted on a follow up TTE done on [**1-21**]. A CT scan on [**1-26**] done to further evaluate for a source of the persistently positive blood cultures incidentally confirmed a moderate sized pericardial effusion and a TTE on [**1-28**] showed a small to moderate anterior and large inferolateral effusion without echocardiographic signs of tamponade. Over the next couple of days, however, the patient became progressively short of breath. On [**2161-1-30**] the floor team noted a mild pulsus paridoxicus of 12, and increasing dyspnea with PaO2 62 on ABG, HR increased to 90, BP decreased to 100, and the patient was therefore evaluated for transfer to the CCU, which was thought appropriate given concern for tamponade. An echo that day now demonstrated a large pericardial effusion (increased in size from previous echo) without the typical echocardiographic signs of tamponade. The patient had a Swan-Ganz catheter placed on [**2162-2-1**] which demonstrated markedly elevated right and left sided pressures. A repeat echo on the next day ([**2162-2-2**]) again showed a large pericardial effusion, again quite prominent around the right atrium (>2.5cm), with possibly some organized/stranding. In light of this, plus a finding of a pulsus paradoxicus of 25 that morning, it was decided to proceed with pericardiocentesis/pericardial window. Ms. [**Known lastname 10794**] had window creation by CT surgery on [**2-2**], at which time 1 L of serosanguinous fluid was drained from the pericardial sac. Her hemodynamics immediately improved, with systolic blood pressure increasing to as high as 160 on arrival to the floor (previously running around 110), and increased CI, to 2.5-2.8, with mildly lowered filling pressures. It is felt that Ms. [**Known lastname 10794**] was indeed in tamponade, however it was masked on the echocardiogram secondary to the elevated right sided pressures, which were/are likely secondary to her severe AI/MR, with resultant backpressure to the right side of the heart. She was intubated for the procedure. She was placed on pressure support overnight and was successfully extubated on the morning of [**2162-2-3**]. She was restarted on captopril for afterload reduction for her severe AI on [**2162-2-5**] as it had been previously held secondary to low blood pressures. Pericardial aspirate showed no PMNS, no organisms, and serosanguinous fluid from her JP drain. A repeat echo on [**2162-2-4**] showed only trivial effusion. The thoracic surgery team pulled the JP drain on [**2162-2-5**]. The cause of pericardial effusion was likely from endocarditis, bacteremia, and pericarditis. Other possibilities include pt's hypothyroidism (though not severe), uremia, or hemodialysis as they are also all known causes. A PPD was planted on [**2162-1-30**] and was negative. Pt is [**Doctor First Name **] (+). 3. Bacteremia/Endocarditis Pt had positive blood cultures (enterococcus) on [**10-12**] with vegetations on aortic valve (migration to MV). All of her follow up surveillance cultures had been negative, but she has cultures again positive from [**1-11**]. She was doing well on ampicillin monotherapy (gent for synergy had caused renal failure). She was recently started on vanco/ceftaz for these positive cultures. Likely sources of this infection include the valves, ?line infection from her HD catheter, ?her prosthetic knee hardware. Given that she still had vegetations on TTE, it was thought that this was the most likley source of the bacteremia. Open MRI was recommended to r/o epidural abscess (pt too large to fit into [**Hospital1 18**] MRI machine). HD line did not appear to be the source of infection and was left in place. As per ID, Ampicillin will be continued for a total of 12 additional week(was endocarditis undertreated the first time or did these vegetations represent a new occurrence). HD catheter was changed over a wire on this hospitalization. Ampicillin was started on [**2162-1-18**]. Surveillance cultures were negative so far at [**Hospital1 **]. EKG was done daily to assess for PR prolongation and to see if the conduction system was affected. She has maintained normal PR intervals here. 4. Aortic insufficiency- Per surgery, pt is not a surgical candidate as she is still abusing drugs. This should be continually assessed. Pt had a large pulse pressure ~60-70 secondary to AI. 5. [**Name (NI) 4964**] Pt with EF=55% on last admission but with 4+ AR and 2+ MR. CXR on admission shows upper zone redistribution, small bilateral pleural effusions. She has had some volume issues since initiation of HD. Repeat TTE continued to show a preserved EF, and her volume issues were managed in-house with HD. 6. Renal Failure- Ms. [**Known lastname 10794**] has gentamicin-induced renal failure. The hope was that she would eventually not require HD when her gentamicin-induced renal failure resolved. However, it appears to be persisting and per renal is likely permanent. Pt was maintained of TIWeek hemodialysis here (M,W,F). She continued nephrocaps. Ampicillin was started and continued at 2 grams q6 hours. 7. Anemia: Pt with anemia of chronic disease by labs. Hct remained in the upper 20s/lower 30s. She required 2 units pRBCs post pericardiocentesis/window and Hct was then stable afterwards. 8. [**Name (NI) 1622**] Pt is on oxycontin at home with morphine for breakthrough and was also on fentanyl patch; this was [**3-3**] bilateral knee pain, right hip pain, and in the hospital chest pain. Pt with history of opiod use, though serum and urine toxicity screens were negative on this admission. In the hospital, we maintained pt on oxycontin. We switched from morphine to oxycodone prn at the end of the hospital stay while maintaining pt on long acting oxycodone. This achieved good results. We also added tylenol prn. We are avoiding NSAIDs given renal failure. 9. Pancreatic mass- A soft-tissue mass was noted in the pancreatic head discovered incidentally on CT, concerning for inflammatory mass vs neoplasm. Will need to get this followed up as an outpatient and possible MRI. 10. Asthma-This was well controlled with albuterol and fluticasone. 11. [**Name (NI) 4545**] Pt with increased TSH- TSh 14, T3-56; Free T4- 0.6 on [**2161-1-30**]. Started levothyroxul 25 mcg qday. She will need repeat checks in [**5-5**] weeks from starting her levothyroxine. 12. Bipolar Disorder- We continued outpt seroquel and citalopram. 13. [**Name (NI) 51814**] Pt was on subcutaneous heparin and a PPI. 14. F/E/[**Name (NI) **] Pt was on a low sodium diet renal diet; Electrolytes were monitored. 15. Code status- Code status was Full Code. Medications on Admission: Meds on admission: Fentanyl patch 50 mcg Albuterol MDI Fluticasone Protonix Celexa 20 mg daily Seroquel; 100 mg qam, 200 mg qhs Imdur 30 mg daily Hydralazine 10 mg TID on non-HD days Morphine 15 mg PRN Oxycontin 50 mg [**Hospital1 **] Vanco: 1gm [**1-11**], 500 mg [**1-13**], [**1-15**] Ceftaz 2gm [**1-13**] Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 3. Quetiapine Fumarate 200 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Oxycodone HCl 5 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4 hours) as needed. 6. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: Two (2) Tablet Sustained Release 12HR PO QAM (once a day (in the morning)). 7. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: Three (3) Tablet Sustained Release 12HR PO HS (at bedtime). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for nasal congestion. 12. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): Hold for SBP <100. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO HS (at bedtime). 15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. Ampicillin 2 gm IV Q6H 17. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 19. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 20. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 21. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 22. Heparin Sodium 5,000 unit/0.5 mL Syringe Sig: One (1) Injection three times a day: while pt is immobile. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Primary diagnosis: Enterococcal bacteremia Aortic valve endocarditis complicated by severe aortic regurgitation Pericardial effusion Pericarditis Hypothyroidism Secondary diagnosis: Renal failure secondary to Gentamicin toxicity requiring dialysis Asthma Bipolar Discharge Condition: Chest pain has greatly improved, pericardial effusion has been drained. Pt is afebrile with negative blood cultures since admission. Discharge Instructions: -Call your primary care doctor and/or return to the hospital if you experience any fevers, chills, sweats, worsening shortness of breath , chest pain, or any other health concern. Take all of your medications, including IV antibiotics, and follow up with your doctors as listed below. -IV antibiotics should be continued until [**4-12**] for a total course of 12 weeks (started on [**2162-1-18**]) - Followup Instructions: 1. Call your primary care doctor for an appointment in the next 1-2 weeks. You should have a repeat echocardiogram in 2 weeks to assess your pericardial effusion. 2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 59700**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2162-2-11**] 11:00 -Pt needs a follow-up appointment made with thoracic surgery Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] in ~ 1 week. Please call within 3 days of discharge to see when he wants to see you. Also, Ms. [**Known lastname 10794**] will need to have her staples removed around [**2161-2-15**]. Please ask Dr. [**Last Name (STitle) **] first if that will be done at the appointment or when he would like them removed. -TSH was elevated and levothyroxine was started on [**2162-1-31**] (see d/c summary). Will need follow-up levels in [**5-5**] weeks -Pt had a pancreatic mass seen on CT. Will need to get this followed up as an outpatient with possible MRI.

[ "421.0", "427.31", "278.01", "584.9", "041.04", "790.7", "552.21", "585", "428.0", "423.9", "285.9" ]

icd9cm

[ [ [] ] ]

[ "38.95", "53.51", "88.72", "37.12", "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

21706, 21761

10775, 19266

304, 368

22069, 22203

4748, 4753

22655, 23695

3730, 3748

19626, 21683

21782, 21782

19292, 19297

22227, 22631

3763, 4729

9930, 10528

9897, 9897

229, 266

396, 2467

21965, 22048

21801, 21944

19311, 19603

2489, 3425

3441, 3714

10540, 10752

10,852

174,460

50264

Discharge summary

report

Admission Date: [**2121-8-14**] Discharge Date: [**2121-8-18**] Date of Birth: [**2065-3-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11495**] Chief Complaint: crushing SSCP Major Surgical or Invasive Procedure: cardiac catheterization on [**2121-8-14**], no intervention History of Present Illness: Pt is a 56 y/o woman PMH significant for CAD (cath [**6-1**]: D1 with 50% stenosis, RPL 50% stenosis, LM, LCX, LAD, RCA without stenosis, No PCI), DM2, HTN and CRI with b/l Cr 1.3, referred to ED from Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] clinic for new [**8-6**] crushing SSCP at 11:30am [**2121-8-14**]. Pt had been off her clonidine patch since Friday (ran out). Pt was cath'd [**6-1**] with no intervention with miscellaneous chest pains in the past, never this severe. EKG shows LBBB new since last EKG [**2121-6-24**]. In the ED, she was given IV Heparin, integrillin, ASA 325, plavix 300, IV NG, lopressor 5mg IV. Pt reports pain was persistent, +SOB, dizziness, and on transport to ER, developed pain down right arm, diaphoresis, nausea and vomiting. After she received nitroglycerin SL, her pain decr to [**7-6**] dull pain. Her pain completely resolved when she was wheeled to cath, and has not had CP since. On exam, her BP was 180/100 with HR in 80s. She was taken to cath. In the cath lab, no stents, admitted to CCU for IV meds for BP control, transferred on nitro gtt and nipride gtt. After cath, she was in the MICU when she developed [**10-6**] low back pain, localized to lower back and HA, tx with Tylenol and morphine 1mg X3, which resolved her pain. A Hct was checked, 31.5 from 35.8 earlier. An Abd CT was ordered, showing a pericardial effusion, with coronary calcifications and spleen granulomas, with no retroperitoneal hemorrhage. A pulsus was checked, 8mmHg. . ROS: Stable 7 pillow orthopnea, becomes SOB and fatigued walking 1 flight of stairs. Past Medical History: 1) Hypertension 2) Hyperlipidemia 3) Type II DM 4) Morbid obesity 5) s/p hysterectomy [**2085**] 6) mild transaminitis (?NASH) 7) Atypical chest pain - [**2121-2-14**] PMIBI: No anginal symptoms or ischemic EKG changes. Normal myocardial perfusion in a setting of soft tissue attenuation. - [**1-1**] TTE: Moderate symmetric LVH, LVEF 50%, trivial MR, mild PA sys HTN, trivial/physiologic pericardial effusion. 8) h/o pericardial effusion after recent URI Social History: Lives with daughter in [**Location (un) 686**] PreSchool Teacher Denies ETOH, tobacco use Family History: Mother and father deceased [**1-29**] brain tumors. Physical Exam: Vitals: BP: 142/80, P: 82, RR: 28, Oxygen sat: 98% 2L NC General: 56 y/o AAF NAD, WNWD, AOX3 HEENT: PERRL, MMM, Oropharynx clear without lesions Neck: Difficult to assess JVD, fatty neck Lungs: CTAB anteriorly CV: RRR S1 and S2 audible Abd: Soft, NT, ND, NABS, No masses. Right Groin: Slight oozing, small 1cm hematoma felt on deep palpation, no bruit Peripheral vascular: 2+ symmetric dorsalis pedis and posterior tibial pulses, warm extremities, pulse is regularly regular Skin: Nails without splinter hemorrhages, skin without lesions, acanthosis nigricans on the neck with skin tags Pulsus: 8mmHg. Pertinent Results: CATH: PCW (M/A wave /V wave) 36/42/43 RA (M/A wave/V wave) 21/26/23 AO (S/D/M) 189/135/153 PA (S/D/M) 79/35/55 RV (S/D/E) 79/17/31 CO 3.71, CI 1.74 LMCA: normal LAD: 70% ostial D1; otherwise normal LCX: normal RCA: 50% ostial PL branch; otherwise normal Supravalvular angiography; normal with no evidence of dissection Impression: No signif CAD except for D1 lesion, unchanged, marked systemic hypertension, marked elevation of left and right filling pressures with reduced CO . CATH [**2121-6-24**] 1. branch vessel CAD 2. moderate diastolic ventricular disease 3. mild systolic ventricular dysfunction 4. severe pulmonary HTN mean PCW 24, LVEDP 25, PA 74/34, central pressure 203/112, EF 50% with global hypokinesis, no MR [**First Name (Titles) **] [**Last Name (Titles) **] system, with LMCA, LAD, LCX, RCA free of flow-limiting stenosis, D1 with 50% proximal stenosis, RPL branch had 50% stenosis . [**2121-5-5**] ECHO EF 35%, The left and right atrium are moderately dilated. Moderate symmetric LVH with normal cavity size and moderate global hypokinesis. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without evidence for hemodynamic compromise. Compared with the prior study (tape reviewed) of [**2121-4-1**], the findings are similar (effusion may be minimally smaller). . [**2121-2-14**] PMIBI No anginal sx or ischemic EKG changes. Normal myocardial perfusion in setting of soft tissue attenuation. . EKG: sinus at 108, QRS 140 with IVCD (LBBB morphology), poor RWP, No ST changes, ?LVH V3 Brief Hospital Course: Impression: 56 y/o AAF with PMH of HTN, CAD, Hyperlipidemia, DM2, Morbid obesity, presents s/p cath with no intervenable ds complicated by HTN, requiring ICU for IV blood pressure control. 1. HTN- After her cardiac catheterization, the patient required IV nitroglycerin and IV nitroprusside to control her BP. She was slowly weaned off, and started on her outpatient blood pressure medications. The CCU team spoke with her Primary Care Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) 10743**], who states that the pt has been noncompliant with BP meds at home and blood pressure control has been a difficult issue with her. She will not be discharged on a diuretic. The pt will go home on BB, ACEI, and Clonidine patch. As there has been some difficulty with keeping her K level up, despite aggressive repletion, the pt will go home on 20mEq of Kdur. She has an appointment for F/U lytes at Dr. [**Name (NI) 82029**] clinic on Wed., [**2121-8-20**]. 2. CAD- Her cardiac cath demonstrated two vessel coronary artery disease that is stable and not flow limiting, with severely elevated right and left sided diastolic and systolic pressures with depressed cardiac output. There was no intervention, no stent placement. After cath, she was transferred to the MICU under CCU level of care. Her BP was closely followed. Her groin site from cath was without bruit or hematoma. She did well on Aspirin and Lipitor and will continue these meds as an outpatient. 3. Stable Pericardial effusion- Per her PCP, [**Name10 (NameIs) **] effusion is longstanding. We checked her pulsus parodoxicus, which was 8 mmHg. She had some initial pain at her groin site, associated with a Hct drop, and a CT abd was performed, showing apparent slight increase in the size of the previously seen pericardial effusion. There was no retroperitoneal hemorrhage. After she stated she had right groin pain two days after cath, a second CT abd was performed, with no change, stable pericardial effusion. Her PCP is [**Name Initial (PRE) 12309**]. Her Hct is stable. 4. New LBBB- likely due to CAD. She was stable on telemetry throughout her stay. EKGs were done qd. Her cardiac enzymes were drawn at admission and were negative X2 sets. 5. Type II DM- She was managed with an ISS. We restarted her home medication, metformin 500mg po bid. 6. CRI Her Cr was stable, at discharge, 1.2. No issues currently. 7. Hyperlipidemia We contiunued her statin. 8. FULL CODE Medications on Admission: 1. Clonidine 0.3/24h patch weekly q friday 2. Lipitor 40mg po qd 3. ASA 325 mg po qd 4. Norvasc 10mg po qd 5. Pantoprazole 40mg po qd 6. Lisinopril 20mg po qd 7. Triamterene-HCTZ 37.5-25mg 1 po qd 8. Labetalol 600mg po tid 9. metformin 500mg po bid 10. combivent 103-18mcg/aerosol 1-2 puffs IH qid for SOB or wheezing Discharge Medications: 1. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-29**] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 MDI* Refills:*2* 5. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. Disp:*20 Tablet(s)* Refills:*0* 6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO once a day. Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* 7. Lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 8. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSUN (every Sunday). Disp:*4 Patch Weekly(s)* Refills:*2* 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Hypertension 2. Coronary Artery Disease status post cath (no intervention) 3. Left Bundle Branch Block 4. Type II Diabetes Mellitus 5. Chronic Renal Insufficiency 6. Hyperlipidemia Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Fluid Restriction: 2L. If you experience any chest pain, shortness of breath, or sweating, please report to the emergency room immediately. Please take all of your medications. Please follow up with your physicians (see information below). Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) 10743**], your primary care physician, [**Name10 (NameIs) **] WEDNESDAY, [**2121-8-20**] at 12pm to her CLINIC to check your electrolytes. She will need to check your potassium level. Her office number is: [**0-0-**]. Her office staff will be in touch with you. Completed by:[**2121-8-17**]

[ "278.01", "593.9", "272.4", "401.9", "423.8", "414.01", "426.3" ]

icd9cm

[ [ [] ] ]

[ "37.23", "88.56", "88.42" ]

icd9pcs

[ [ [] ] ]

9305, 9311

5089, 7576

330, 391

9545, 9554

3339, 5066

9943, 10308

2640, 2693

7953, 9282

9332, 9524

7602, 7930

9578, 9920

2708, 3320

277, 292

419, 2037

2059, 2516

2532, 2624

69,047

142,213

9601

Discharge summary

report

Admission Date: [**2191-12-26**] Discharge Date: [**2192-1-4**] Date of Birth: [**2134-9-17**] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 8850**] Chief Complaint: Concern for cervical spine metastasis. Major Surgical or Invasive Procedure: Laminectomy Lumbar puncture Paracentesis History of Present Illness: [**Known firstname **] [**Known lastname 26065**] is a 57-year-old right-handed man, with a history of tonsillar carcinoma in [**2182**], s/p radiation, who presented to [**Hospital6 2561**] with worsening right arm and right leg weakness. His symptoms started approximately In [**2191-8-25**] with progressive neck pain and weakness on the right side. He also describes left thoracic parathesias that resolved. An MRI of the cervical spine for concern for cervical meylopathy showed some sort of inflammatory changes and he was started on therapeutic steroids with some improvement in his symtpoms. He was able to move his right side and his spasticity completely resolved. Over the past 5 days, prior to transfer to [**Hospital1 18**] his symptoms have escalated to the point that he was no longer ambulatory. He was admitted to [**Hospital6 2561**] for further management. At [**Hospital3 **], his steroids were increased from dexamethasone 4 mg PO BID to 4 mg IV Q4H. Repeat MRI showed enhancement at C2-3 level within the spinal cord, which is concerning for tumor in the cervical spine. A lumbar puncture was performed which had mildly elevated protein but negative cytology for malignant cells. Oncology was consulted and was concerned that his present illness could be due to a recurrence of his past tonsilar carcinoma. CEA and CA [**00**]-9 were sent and they were within normal limits. He was transfered to [**Hospital1 18**] for further management. On the floor here, he reports the above history. He has no pain at this time. He is frustrated with his persistent right-sided weakness. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: Past Oncological History: - Tonsillar carcinoma diagnosed [**2182**] and treated with XRT. Other Past Medical History: - Cervical myelopathy believed to be secondary to prior head and neck radiation - Alcoholic cirrhosis with chronic thrombocytopenia and history of varices, and he is status post banding - Anxiety - Chronic back pain on long term opiates - Babeseosis Social History: Social History: He lives with his wife and 9-year-old son. [**Name (NI) **] smoked 1.5 packs of cigarettes per day for 35 years; he stopped in [**2182**]. He drank alcohol heavily in the past but he stopped in [**2176**]. He used cocaine in the remote past. - Tobacco: He smoked from age 13 to 48, 1.5 PPD, so 50+ pack years - Alcohol: Former heavy drinker, last drink was in [**Month (only) **] [**2182**]. - Illicits: Used cocaine in the past, none recently. Family History: Family History: His father died at age 47 from smoking-related lung cancer. His mother is alive and healthy. His 2 brothers are deceased, one from leukemia and the other from drug abuse and psychiatric problems. His 2 sisters are healthy. He has 4 children and they are all healthy. Physical Exam: VITAL SIGNS: Temperature 97.1 F, blood pressure 154/78, pulse 51, respiration 20, and oxygen saturation 98% on room air. GEN: NAD, pleasant SKIN: Scattered bruises HEENT: Dry MM, adentulous, no cervical LAD CARDIOVASCULAR: RRR, NL S1S2 no S3S4 MRG PULMONARY: CTAB with prolonged expiratory phase and generally distant BS ABDOMEN: BS+, soft, NTND, collaterals present, palpable splenomegaly 3cm below the costal margin EXTREMITIES: Contractures of the R hand and R foot drop, +clubbing NEUROLOGICAL EXAMINATION: His Karnofsky Performance Score is 50. He is awake, alert, and oriented times 2. His thinking process is tangential and easily distracted. There is no right/left confusion or finger agnosia. His calculation is fair. His language is fluent with good comprehension, naming, and repetition. Short-term recall seems intact. Cranial Nerve Examination: His pupils are equal and reactive to light, 3 mm to 2 mm bilaterally. Extraocular movements are full. Visual fields are full to confrontation. He has increased left palpebral fissue or ptosis on the right. Facial sensation is intact bilaterally. His hearing is intact bilaterally. His tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: His muscle strengths are [**3-28**] at all muscle groups on the left side. But the right side has 0/5 handgrip, [**12-30**] at right finger and right wrist extensors, [**12-30**] at right biceps, but 0/5 at right deltoid. His right lower extremity has 3/5 strength in right ileopsoas, 4+/5 at right quadriceps, right hamstrings, right tibialis anterior, and right [**Last Name (un) 938**]. He has a right foot drop. Muscle tone is decreased on the right side. His reflexes are 3+ on the right side and 2+ on the left. His ankle jerks are absent. His right is up while the left is down. Sensory examination is intact to touch and proprioception; but there is hemisensory deficit to temperature from C5 on distally on the left side. Coordination examination does not reveal appendicular dysmetria on the left side. He cannot walk. Pertinent Results: Admission labs: [**2191-12-26**] 09:30PM BLOOD WBC-14.1* RBC-4.00* Hgb-13.4* Hct-40.4 MCV-101* MCH-33.4* MCHC-33.1 RDW-17.1* Plt Ct-21* [**2191-12-26**] 09:30PM BLOOD PT-15.2* PTT-27.8 INR(PT)-1.3* [**2191-12-26**] 09:30PM BLOOD Glucose-119* UreaN-23* Creat-0.6 Na-137 K-4.4 Cl-105 HCO3-24 AnGap-12 [**2191-12-26**] 09:30PM BLOOD ALT-24 AST-40 LD(LDH)-217 AlkPhos-83 TotBili-0.9 [**2191-12-26**] 09:30PM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.3 Mg-2.3 UricAcd-3.3* Discharge labs: [**2192-1-3**] 07:25AM BLOOD WBC-4.2 RBC-2.78* Hgb-9.5* Hct-27.3* MCV-98 MCH-34.2* MCHC-34.8 RDW-16.4* Plt Ct-54* [**2192-1-3**] 07:25AM BLOOD PT-15.5* PTT-29.9 INR(PT)-1.4* [**2192-1-3**] 07:25AM BLOOD Glucose-123* UreaN-17 Creat-0.4* Na-135 K-4.2 Cl-105 HCO3-24 AnGap-10 [**2192-1-3**] 07:25AM BLOOD ALT-16 AST-24 LD(LDH)-179 AlkPhos-64 TotBili-1.4 [**2192-1-3**] 07:25AM BLOOD Albumin-3.8 Calcium-8.7 Phos-2.2* Mg-2.3 CSF studies: [**2191-12-28**] 03:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0 Lymphs-60 Monos-40 [**2191-12-28**] 03:00PM CEREBROSPINAL FLUID (CSF) TotProt-58* Glucose-70 LD(LDH)-36 Misc-CEA = LESS [**2191-12-28**] 03:00PM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL [**2191-12-28**] 03:00PM CEREBROSPINAL FLUID (CSF) BETA 2 MICROGLOBULIN-WNL [**2191-12-28**] 03:00PM CEREBROSPINAL FLUID (CSF) TB - PCR-Test NOT DETECTED [**2191-12-28**] 03:00PM CEREBROSPINAL FLUID (CSF) CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS [**2192-1-1**] Blood Parasite Smear POSITIVE LESS THAN 1% PARASITEMIA MR [**Name13 (STitle) **] W& W/O CONTRAST Study Date of [**2191-12-28**] 10:12 PM FINDINGS: Image quality is yet again degraded by patient motion. Accounting for this, there is again seen a ring-enhancing lesion centered at the C2-3 level, with a linear component that extends towards the cervicomedullary junction, with the lesion again measuring approximately 3.0 cm in SI dimension and approximately 0.8 cm in AP dimension. There is extensive T2 hyperintensity surrounding this lesion and extending from the inferior aspect of the medulla to the C5 level. On the axial images, there is some enhancement, also extending towards the right aspect of the spinal cord inferiorly to the C3-4 level. There is no definite other focus of abnormal enhancement. The visualized posterior fossa is unremarkable. Compared to the outside studies, the cord edema and enhancement have decreased. Vertebral body height and alignmenTt is preserved. Again noted is diffuse increased T1 and T2 signal intensity throughout the vertebral bodies, with a few foci of slightly decreased signal intensity. The findings likely represent the sequela of prior radiation exposure. C2-3: There is no significant spinal canal or neural foraminal narrowing. C3-4: There is no significant spinal canal or neural foraminal narrowing. There is a mild disc bulge, which minimally flattens the ventral aspect of the thecal sac. C4-5: There is a mild disc bulge, without significant spinal canal or neural foraminal narrowing. C5-6: There is a minimal central disc protrusion, without significant spinal canal or neural foraminal narrowing. C7-T1: Unremarkable. IMPRESSION: Ring-enhancing lesion centered at C2-3, with surrounding increased T2 hyperintensity. Thiese findings have decreased compared to the outside study of [**2191-10-15**]. This indicates improvement. The lesion can be due to metastasis or otherwise in proper clinical stttings it can also be due to radiation necrosis. Brief Hospital Course: [**Known firstname **] [**Known lastname 26065**] is a 57-year-old right-handed man, with a history of tonsillar carcinoma in [**2182**] and status post radiation alone, who presents with progressive neck pain and R side hemiparesis and MRI findings concerning for recurrence of his cancer versus radiation scarring. He is status post cervical laminectomy for tissue diagnosis. Also, incidentally found to have possible babeseosis. He has ongoing dysphagia post operatively. (1) Hemiparesis: Etiology may be due to tumor involving the spine, but may also be related to inflammatory spinal process such as transverse myelitis or necrosis related to history of neck radiation treatment. Steroids would be helpful in all of the above cases, so his improvement on steroids is not diagnostic. He is status post C1-3 laminectomies for open biopsy of intradural intramedullary spinal cord lesion. Repeat C-T-L spine MRI with and without contrast showed a diffuse increased signal intensity in the upper cervical cord, with a focal area of ring enhancement centered at the C2-3 level. There is edema in the surrounding cord which could be due to mets vs radiation scarring. He is on dexamethasone 4 mg IV Q6hrs for now. Biopsy and cytology pending, but preliminary likely to be due to radiation complication. He will see Neuro-Oncology and Neurosurgery within the next 2 weeks. PT was working with patient, OOB to chair with assist. (2) Status Post Laminectomy: As noted above, patient had C1-3 laminectomies for open biopsy of intradural intramedullary spinal cord lesion. He is on POD#3. His post-op course was complicated by onset of atrial fibrillation with RVR which was self limited with BB as per op note. He was also very lethargic but arousable last few days now back to baseline. This was likely due to narcotics. He is on fentanyl 25 mcg patch in place of Oxycontin. (3) Dysphagia/Odynophagia: Patient with difficulty swallowing pills and apple sauce. This could be due to endotracheal intubation or due to posterior cervical neck surgery with limitation of neck motion. As per physical examination, he does not have any cranial nerve deficits. He passed speech and swallow today for grounded foods and crushed pills. He is on aspiration precautions. He will likely improved progressively and need speech and swallow reevaluation. (4) Tonsillar Squamous Cell Carcinoma: He is status post radiation in [**2182**]. His work up of CNS disease is as above. (5) Cirrhosis: This is based on PE and OSH records, is cirrhotic. He has a history of varices, which have been banded but never bled. Denies any history of encephalopathy. He reports that has secondary thrombocytopenia (see below) from his cirrhosis. MELD score of 9. Abdomen examination improved after paracentesis yesterday. He had 2.6L removed no SBP and he received total of 50 gm of albumin post tap. He was continued on nadolol 40 mg PO daily. Pantoprazole 40 mg daily was changed to Prevacid dissolving tablet due to swallowing issues. He started rifaximin 200 mg PO TID to prevent encephalopathy in the context of acute illness and cirrhosis. This can be discontinued as appropriate. (6) Thrombocytopenia: Per patient due to liver disease, which is plausible given his splenomegaly and cirrhosis causes a relative deficiency of thrombopoeitin. Baseline at around 20,000. As per lab report he had ring enhancing on RBC, questionable for Babeosis. Final result pending. He was started on Azithromycin 1000 mg IV Q24H and atovaquone suspension 750 mg PO/NG [**Hospital1 **] for the questionable Babeosis until we have final result. (7) Chronic Pain: His Oxycontin 40 mg PO TID was held due to sedation. He was restarted on oxycodone 5-10mg PO Q4H PRN with fentanyl patch 25 mcg. Pain is well control on current regimen. (8) Spasticity: Baclofen and benzodiazepines were held for now to monitor for response to steroids. (9) Hypothyroidism: TSH and Free T4 were within normal limits. He should continue levothyroxine 112 mcg PO daily. (10) FEN: Grounded foods and crushed pills, oncology repletion scales. (11) Prophylaxis: Pain control with oxycodone, bowel regimen, DVT prophylaxis with pneumoboots. (12) Communication: With patient. (13) Code: FULL. Medications on Admission: Home Medications: - Valium 10mg POdaily - Folic acid 1mg PO daily - Levothyroxine 112 mcg PO daily - MVI PO daily - Nadolol 40mg PO daily - Oxycodone 5-10mg PO Q6H PRN pain - Oxycontin 40-80mg Q8H - Pantoprazole 40mg PO daily - Dexamethasone 4mg PO BID Medications on Transfer: - Baclofen 3mg PO TID - Dexamethasone 4mg IV Q4H - Colate 100mg PO BID - Oxycontine 40mg PO Q8H - Folic acid 1mg PO daily - Levothyroxine 112 mcg PO daily - MVI PO daily - Nadolol 40mg PO daily - Oxycodone 5-10mg PO Q6H - Pantoprazole 40mg PO daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule [**Hospital1 **]: Two (2) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily) as needed for constipation. 3. Polyethylene Glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) packet PO DAILY (Daily) as needed for constipation. 4. Levothyroxine 112 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Nadolol 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 7. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 8. Rifaximin 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 9. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000) units Injection TID (3 times a day). 10. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 11. Atovaquone 750 mg/5 mL Suspension [**Hospital1 **]: Seven [**Age over 90 1230**]y (750) mg PO BID (2 times a day): 10 Days. D1 [**2192-1-1**] to [**2192-1-10**] for babeseosis in a compromised host. 12. Azithromycin 500 mg Recon Soln [**Month/Day/Year **]: 1000 (1000) mg Intravenous Q24H (every 24 hours): 10 Days. D1 [**2192-1-1**] to [**2192-1-10**] for babeseosis in a compromised host . 13. Dexamethasone 4 mg IV Q6H 14. Fentanyl 25 mcg/hr Patch 72 hr [**Month/Day/Year **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 16. Celexa 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Primary: Likely radiation necrosis of the spine, babeosis. Secondary: Tonsilar squamous cell carcinoma, cirrhosis, chronic thrombocytopenia, anxiety, chronic back pain. Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted to the [**Hospital1 18**] for weakness on your right side and evaluation of your spine. An MRI showed an area in your spine of either scarring from previous radiation or cancer. Neurosurgery biopsied the site. You were also treated with steroids, and your neurological problems stabilized. We also diagnosed you with an infection called babeosis. You are on antibiotics for this. We have made several changes to you medications. Please refer to you medication list for your updated regimen. Of note, we have switched you to a fentanyl patch rather than swallowing your Oxycontin pills. Followup Instructions: [**2192-1-11**] at 1100am at [**Hospital Unit Name **], [**Location (un) 86**], MA Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1669**] [**2192-1-16**] at 9:30am at [**Location (un) **] [**Hospital Ward Name 23**] Center, [**Location (un) 86**] MA Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] [**2192-2-1**] at 1115am [**Hospital Unit Name **], [**Location (un) 86**] MA Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1669**]

[ "789.59", "E879.2", "427.31", "E878.8", "997.1", "336.8", "909.2", "571.2", "286.7", "244.9", "088.82", "344.89", "V10.02", "287.5", "456.21" ]

icd9cm

[ [ [] ] ]

[ "03.32", "03.31", "54.91" ]

icd9pcs

[ [ [] ] ]

15999, 16071

9389, 13662

312, 354

16287, 16287

5910, 5910

17096, 17687

3472, 3744

14240, 15976

16092, 16266

13688, 13688

16462, 17073

6390, 9366

3759, 5891

13706, 13942

2015, 2561

234, 274

382, 1996

5926, 6374

16303, 16438

13967, 14217

2703, 2954

2987, 3439

58,794

192,419

28855

Discharge summary

report

Admission Date: [**2179-9-26**] Discharge Date: [**2179-10-6**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 6021**] Chief Complaint: Sob Major Surgical or Invasive Procedure: Thoracentesis History of Present Illness: 88 yo female with known history of CLL and melanoma complicated by pleural effusions was recently at rehab for six weeks and was discharged home 1 week ago. She now presents with increasing SOB over the past week. Of note she was d/c'd from rehab on [**1-29**] L O2 from rehab but at home has had to increase it to 2L. of note pt has history of chylous pleural effusion in the past. Pt denies fevers but admits to yellow productive cough. No chest pain, orthopnea or PND. IN [**Name (NI) **] pt's vitals were 98.3, 113/61, 67 100% 2L. CXR revealed large increasd L effusion, increasing R effusion, spiculated unchanged opacity LUL. labs revealed WBC of 14 and Lactate 1.1. cardiac enzymes were negative and ekg revealed no acute ischemic changes or right heart heart strain. pt was pancultured and started on vancomycin and levofloxacin for community acquired, nosocomial and atypical pneumonia. she's admitted for further management. Past Medical History: ONC PMHx: 88 yo female with Hx of CLL, melanoma and bilateral pulmonary nodules of unclear etiology. The patient had been initially evaluated at [**Hospital1 18**] in [**9-/2176**] for left inguinal adenopathy, which was biopsied showing melanoma with unknown primary. At that time, a peripheral blood smear was also consistent with CLL. She underwent a femoral lymphadenectomy with a muscle flap in [**2176-12-27**]. Since that time, she has been followed by serial PET CT scans for her known CLL and pulmonary nodules. She has not received any treatment for CLL and was not felt to be an appropriate candidate for adjuvant therapy for melanoma. Her most recent PET/CT on 4/41/09 showed moderate-to-large right-sided pleural effusion as well as an interval increase in size and FDG avidity of the left upper lobe nodules. She underwent thoracentesis on [**2179-5-25**] and the effusion was found to be chylous. The fluid re accumulated and she had underwent RT VATS, thoracic duct ligation and talc pleurodesis on [**6-23**]. Her postop course was complicated by a new diagnosis of atrial fibrillation. She was seen as an outpatient on [**7-19**] complaining of increasing weakness and shortness of breath. A CT on [**7-19**] showed moderate bilateral dependent pleural effusions and multiple loculated collections of pleural fluid in the right hemithorax. She was admitted for further evaluation and treatment. Other PMHx: Bilateral pulmonary nodules Recent Dx A fib during last admission in [**6-5**] CLL Melanoma Cataracts Hypothyroidism following thyroidectomy for goiter. H. pylori infection in [**2172**]. Vaginal hysterectomy in [**2133**] for fibroids. Social History: She is a retired woman who has previously worked as a procedural analyst for the government. She has a history of significant travel including living in [**Last Name (LF) 651**], [**First Name3 (LF) 6171**], [**Country 3992**], and [**Country 3396**], but her last travel outside of the country may have been in the late 80s. She was a past smoker with about a 60-pack-year smoking history and she quit 3 years ago. She denies any alcohol use. She has no known asbestos exposure. Family History: Mother has history of lung cancer and she was a nonsmoker, her maternal aunt who was a smoker, had a history of lung cancer. Her sister also had a history of lung cancer and there is family history of second-degree relatives with history of melanoma. Physical Exam: Vitals - T: 96.6 BP: 117/57 HR: 75/min RR: 16/min 02 sat 94% on 4L: GENERAL: NAD SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no mrg LUNG: bilateral reduced air entry in bases worse on left and inspiratory crackles bilaterally. ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly Extremities: moving all extremities well, bilateral pitting edema to knee likely of venous insufficiency and is chronic. PULSES: 2+ DP pulses bilaterally NEURO: a&o x 3, CN II-XII intact stage 3 sacral pressure ulcer is present. Pertinent Results: Admission: [**2179-9-26**] 04:15PM LACTATE-1.1 [**2179-9-26**] 04:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2179-9-26**] 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2179-9-26**] 03:45PM GLUCOSE-108* UREA N-13 CREAT-0.4 SODIUM-140 POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-35* ANION GAP-11 [**2179-9-26**] 03:45PM CK(CPK)-20* [**2179-9-26**] 03:45PM CK(CPK)-20* [**2179-9-26**] 03:45PM CK-MB-NotDone cTropnT-<0.01 proBNP-729* [**2179-9-26**] 03:45PM WBC-15.4* RBC-3.56* HGB-10.5* HCT-36.3 MCV-102*# MCH-29.5 MCHC-28.9* RDW-13.4 [**2179-9-26**] 03:45PM NEUTS-44.7* LYMPHS-51.1* MONOS-3.1 EOS-0.7 BASOS-0.4 [**2179-9-26**] 03:45PM PLT COUNT-415 [**2179-10-6**] 06:35AM BLOOD WBC-13.2* RBC-2.89* Hgb-9.0* Hct-28.8* MCV-100* MCH-31.0 MCHC-31.1 RDW-14.0 Plt Ct-515* Discharge: [**2179-10-6**] 06:35AM BLOOD Plt Ct-515* [**2179-10-6**] 06:35AM BLOOD Glucose-120* UreaN-16 Creat-0.4 Na-141 K-3.6 Cl-101 HCO3-38* AnGap-6* [**2179-10-6**] 06:35AM BLOOD Albumin-2.6* Calcium-8.2* Phos-3.5 Mg-2.0 IMAGING: cxr [**2179-9-26**]: 1. Slight interval increase in size of bilateral pleural effusions. 2. Interstitial opacity within the right lung, particularly within the right lung base is worrisome for lymphangitic spread of tumor. 3. Persistent dense consolidation within the retrocardiac region which could represent atelectasis but infection is not excluded. 4. Unchanged spiculated opacity within the left upper lobe, which on the prior CT was worrisome for malignancy. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2179-9-27**] 1. No pulmonary embolism. 2. Increasing moderate left pleural effusion. 3. Increased extent and distribution of lymphangitic carcinomatosis on the right, as well as increasing mass lesions in both upper lobes. 4. New small focus of peribronchovascular consolidation in the right upper lobe (21, 2), concerning for an early focus of infectious pneumonia in the appropriate clinical setting. 5. Unchanged conglomerate central and upper abdominal lymphadenopathy. Pleural fluid [**2179-10-1**]: Rare highly atypical epithelioid cells in a background of mesothelial cells and many lymphocytes, suspicious for metastatic melanoma. Brief Hospital Course: Assessment and Plan: 88 yo woman with history of CLL and metastatic melanoma, bilateral pleural effusions and possible lyphangtic spread of malignancy transferred from ICU s/p thoracentesis and brief BiPAP course with improvement in respiratory status, now doing well on baseline O2 status at 3LNC. # Hypercarbic respiratory failure/somnolence - resolving with improvement in ventilation on most recent ABG. Respiratory failure thought to be combination of HAP, possible worsening lymphangitic spread of cancer in lung, and baseline COPD. Resolved with antibiotics over time. However, patient remained with weak cardiopulmonary fx as would desat to mid 80s on 3LNC. For this reason, PT recommended inpatient PT to regain endurance. # Bacteremia: micrococcus not usually a pathogen. Surveillance cultures negative. Patient afebrile with no symptoms of systemic infection. Patient completed 8 day course of vanc and zosyn IV and did well. # Bilateral pleural effusions - Pleural fluid exudative, cytology suspicious for metastatic melanoma, not diagnostic. Patient felt improved after 1.3L tap in ICU. Pt to f/u with Dr. [**Last Name (STitle) **] re further management of effusions. # Leukocytosis/CLL - chronically elevated WBC likely [**3-1**] CLL. Not undergoing tx and WBC is actually lower than previous. No fevers or other signs of active infection. # Melanoma - being managed symptomatically. Not felt to be candidate for adjuvant therapy. # Paroxysmal atrial fibrillation - recent diagnosis, has been in sinus rhythm since initial episode of afib. However, pt did go into a fib RVR HR in 170s was asymptomatic, pressures stable. We uptitrated her home diltiazem and she did not convert again since being on 45mg PO TID. # Hypothyroidism - s/p thyroidectomy for goiter. No active issues. Continued home dose thyroid 120mg. # H/o tobacco Abuse - no prior diagnosis of COPD although it appears that she does have baseline CO2 retention, probably with PCO2 in the 60's. No prior PFT's. No exam findings to suggest acute COPD exacerbation. Standing albuterol/atrovent nebs, which per pt seemed to help. Medications on Admission: 1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 2. Thyroid 120 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Polyethylene Glycol 3350 100 % Powder Sig: One (1) scoop PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/HA. 8. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: [**1-29**] PO BID (2 times a day). 9. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 10. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 15. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Discharge Medications: 1. Thyroid 30 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constpation. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for c. 4. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every [**7-5**] hours as needed for fever: Do not exceed 4gm of acetominophen per day. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 11. Diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO QID (4 times a day). 12. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Anxiety/Insomnia. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: Do not exceed 4 grams of acetominophen per day. 15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO once a day: Hold for loose stools, patient may refuse. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Metastatic melanoma Secondary: Healthcare associated pneumonia Malignant pleural effusion Discharge Condition: Stable vitals, afebrile Discharge Instructions: You were admitted to the hospital for shortness of breath. It was believed that your shortness of breath was related to a combination of a healthcare associated pnuemonia and fluid building up around the pleural space surrounding your lungs. You were started on antibiotics. During your stay, you developed respiratory failure and were transferred to the ICU where they assisted your breathing and tapped 1.5 liters of fluid from the pleural space surrounding the lungs. The fluid in your lungs showed cells suspicious for metastatic melanoma, however, this is not diagnostic of certain metastatic disease. After you returned from the ICU, you improved on antibiotics. There was some concern about your respiratory status during activity and this was the reason to discharge you to an acute rehabilitation facility. We have made some changes to your medications: START taking Albuterol 0.083% Neb Soln 1 NEB Inhaler every 6 hours START taking Ipratropium Bromide Neb 1 NEB Inhaler every 6 hours DECREASE Diltiazem from 60mg by mouth four times a day to 45mg by mouth four times a day If you experience chest pain, shortness of breath, or high fevers, please come to the emergency department. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**] in [**1-29**] weeks ([**Telephone/Fax (1) 2205**]). Your oncologist office (Dr. [**Last Name (STitle) **] will call you sometime over the next 1-2 weeks to schedule you a follow-up appointment. Completed by:[**2179-10-11**]

[ "458.9", "518.84", "790.7", "204.10", "327.23", "197.0", "511.81", "V12.54", "496", "782.3", "427.31", "172.9", "459.81", "486" ]

icd9cm

[ [ [] ] ]

[ "34.91", "93.90" ]

icd9pcs

[ [ [] ] ]

11595, 11661

6750, 8863

232, 248

11805, 11831

4447, 6727

13074, 13435

3421, 3674

10144, 11572

11682, 11784

8889, 10121

11855, 12690

3689, 4428

12719, 13051

189, 194

276, 1212

1234, 2903

2919, 3405

12,233

147,721

6142

Discharge summary

report

Admission Date: [**2155-5-7**] Discharge Date: [**2155-5-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2186**] Chief Complaint: SOB, CP, fevers Major Surgical or Invasive Procedure: Transesophageal echocardiogram History of Present Illness: [**Age over 90 **] year old Russian-speaking male with h/o CHF, CAD s/p CABG in [**2137**] and revision in [**2147**], PPM for sick sinus s/p replacement 6 weeks ago and AS s/p [**Year (4 digits) 1291**] who presented to the ED with worsening SOB, chest pain x 2 days. He was increasingly short of breath with fevers. He denied cough but complained of chest pain x 1 day. He also had reportedly been consuming a high sodium diet. In the ED, he had O2 sats in the 80's and was placed on BiPap, nitro gtt and given Lasix. He remained hypoxic and was intubated. He was also reportedly given ceftriaxone, levofloxacin and ASA. He was then admitted to the CCU and continued diuresis. There was some question of whether he had a pneumonia on CXR and he was started on ceftriaxone and azithromycin. Blood cultures grew pan-sensitive pseudomonas and his Abx were changed to cefepime and azithro. He also complains of pain at the pacer site. He has had negative Cks and troponins. ECG showed paced rhythm with "memory T waves" per CCU team. He was extubated yesterday without complication. Today he states he remembers feeling SOB at home and had pain at his pacer site. Cannot give the timeframe of his symptoms. Also endorses chest pain. States he does not remember coming to the hospital and "must have lost consciousness." Now he denies SOB, cough, urinary symptoms. Endorses abdominal pain due to constipation and complains his home regimen is not being given to him. He also endorses left-sided chest pain, worse with inspiration. Past Medical History: CAD s/p CABG in [**2137**], with current anatomy: LIMA->LAD, SVG->PDA, SVG->PLB, SVG->RI. Has second CABG [**2147**] with revision of ramus graft. Had negative Persantine myocardial perfusion study having been performed in the spring of [**2153**]. Aortic stenosis, status post aortic valve replacement in [**4-/2147**] with a #19 St. [**Male First Name (un) 1525**] prosthesis having been placed at that time. Mild to moderate mitral and moderate tricuspid regurgitation. Sick sinus syndrome, status post permanent pacemaker insertion with replacement about 6 weeks ago Chronic atrial fibrillation treated with AV nodal blocking agents and chronic Coumadin therapy History of chronic diastolic congestive heart failure Hyperlipidemia, on statin therapy. History of embolic CVA, on chronic Coumadin therapy. HTN Hyperlipidemia Chronic LLQ pain Insomnia Vertobrobasilar artery stenosis Fecal incontinence H/o severe epistaxis C7 Radicular pain Social History: Patient is primarily Russian speaking but does speak minimal English. He lives at home with his wife and denies tobacco, alcohol, and drug use. Family History: No known history of CAD, HTN, DM, or stroke Physical Exam: VS: 97.7 133/46 62 17 100%2L GENERAL: Elderly gentleman, with nasal cannula, alert and in NAD HEENT: NCAT. Sclera anicteric. CARDIAC: Marked tenderness to palpation over pacemaker site and up to 8cm inferior to pacer site. Regular rate with mechanical S2, no murmurs heard. LUNGS: Coarse crackles at right mid-lung and at left base. Mild inspiratory wheezing at the bases. ABDOMEN: Soft but distended and very slightly tender to palpation. Tympanic to percussion. No hepatosplenomegaly palpable. EXTREMITIES: Left foot edema around ankle without pain, otherwise no peripheral edema, cyanosis, or clubbing. Chronic skin changes on BLE. NEURO: Alert and oriented x 3, able to say days of the week backwards. Pertinent Results: Admission Labs: [**2155-5-7**] 07:30PM WBC-13.1* RBC-3.61* HGB-11.4* HCT-36.2* MCV-100* MCH-31.6 MCHC-31.5 RDW-14.4 [**2155-5-7**] 07:30PM NEUTS-69 BANDS-3 LYMPHS-16* MONOS-12* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2155-5-7**] 07:30PM PLT COUNT-155 [**2155-5-7**] 07:30PM PT-23.8* PTT-29.4 INR(PT)-2.3* [**2155-5-7**] 07:30PM GLUCOSE-157* UREA N-36* CREAT-1.6* SODIUM-142 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-33* ANION GAP-15 [**2155-5-7**] 07:30PM CALCIUM-9.7 PHOSPHATE-3.8 MAGNESIUM-1.8 [**2155-5-7**] 08:09PM LACTATE-2.4* [**2155-5-7**] 09:17PM TYPE-ART PO2-326* PCO2-54* PH-7.39 TOTAL CO2-34* BASE XS-6 Studies: [**2155-5-7**] ECG: Atrial fibrillation with a single ventricularly paced beat. Right bundle-branch block and left anterior fascicular block. Non-specific precordial T wave inversions may be related to the right bundle-branch block. Compared to the previous tracing of [**2155-3-28**] native rhythm is now seen [**2155-5-7**] Chest Xray: 1. Suboptimal study due to patient motion and a repeat is suggested. 2. Relative mild haziness of the right lung fields may relate to patient motion, although interstitial edema or infectious process cannot be excluded. Possible minimal right pleural effusion. [**2155-5-9**] KUB: No evidence of bowel obstruction. [**2155-5-12**] Ankle Xray: In comparison with the study of [**2154-12-27**], there is no interval change. Extensive vascular calcification is again consistent with diabetes. No evidence of bony or joint space abnormality or appreciable soft tissue swelling. Multiple surgical clips are seen in the soft tissues medially. Although there is no definite radiographic evidence for osteomyelitis, if this is a serious clinical concern, MRI could be considered. [**2155-5-12**] CT Abdomen/Pelvis: 1. Moderate right and small left-sided pleural effusion. Right lower lung base opacity likely represents associated compressive atelectasis, however, superimposed pneumonia cannot be completely excluded and should be considered in the correct clinical setting. 2. Prominence of left intrahepatic duct and common bile duct is unchanged since [**2154-12-22**]. 3. Multiple stable bilateral renal cysts. 4. Air in the bladder likely secondary to recent instrumentation. [**2155-5-13**]: Chest Xray: In comparison with the study of [**5-9**], there is little change. Continued enlargement of the cardiac silhouette in a patient with a dual-channel pacemaker device in place. Blunting of both costophrenic angles persist, though there is no evidence of acute pneumonia or vascular congestion. Residual contrast material is seen within the colon. [**2155-5-13**]: CT Head: No evidence of acute intracranial abnormalities. However, a small acute infarction could be difficult to detect in the setting of multiple previous chronic infarctions. If clinically indicated, MRI with and without contrast would be helpful to detect a new infarction and to assess for septic emboli. [**2155-5-13**]: CTA Head/Neck: 1. Hemodynamically significant atherosclerotic stenosis at the origin of the left vertebral artery and of the intracranial right vertebral artery. 2. No acute vascular abnormalities of the cervical and intracranial arteries including no evidence of occlusion, dissection or aneurysm. 3. For further evaluation of the intracranial structures, please see non-enhanced CT of the head from the same date. [**2155-5-14**]: TEE: The left atrium and right atrium are normal in cavity size. Mild spontaneous echo contrast is seen in the body of the left atrium and left atrial appendage but no mass/thrombus. No mass or thrombus is seen in the right atrium or right atrial appendage. Catheter/pacemaker leads are seen in the right atrium and right ventricle wthout associated vegetation/thrombus. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). There are simple atheroma in the aortic arch and descending thoracic aorta. A mechanical aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal disc motion. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen (may be normal for this prosthesis). The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: Moderate mitral regurgitation. Well seated mechanical aortic valve with trace aortic regurgitation. No discrete vegetation identified. Simple plaque in aortic arch and descending aorta. [**2155-5-15**] EEG: This is an abnormal routine EEG due to slowing and disorganization of the background rhythm suggestive of a moderate encephalopathy. Medications, toxic/metabolic disturbances, and infections are common causes. No epileptiform discharges or electrographic seizures were seen during this recording. Note is made of two narrow QRS complex morphologies as above. Brief Hospital Course: [**Age over 90 **] year old Russian-speaking male with history of diastolic CHF, CAD s/p CABG in [**2137**] and revision in [**2147**], PPM for sick sinus s/p replacement 6 weeks ago and AS s/p [**Year (4 digits) 1291**] who presented to the ED with worsening SOB and chest pain x 2 days, found to have pseudomonas bacteremia. #. Acute on chronic diastolic CHF with Hypoxic Respiratory Failure: Patient had hypoxic respiratory in the emergency room. He was intubated in the ED and transferred to the MICU. He was quickly extubated after diuresis. It was felt that he likely had an an acute exacerbation of his chronic diastolic CHF in the setting of bacteremia and severe sepsis. He was put back on his home CHF medications and his respiratory status remained stable post-extubation. He was placed back on his home CHF regimen after extubation and had no further respiratory distress. #. Pseudomonas Bacteremia: His admission blood cultures grew pan-sensitive pseudomonas. A source was not identified despite a thorough workup. Urinalysis was negative for infection. Chest xray did not show evidence of pneumonia. He did have a moderate right-sided pleural effusion on CT and thoracentesis was considered but there was not enough effusion to sample. He underwent TTE and TEE which showed no evidence of endocarditis. He did complain of abdominal distension but KUB and abdominal and pelvic CT did not show any acute intraabdominal pathology. He did have tenderness at the site of his pacemaker pocket, tracking down along the anterior chest wall. Since he had recently had manipulation of his pacer for replacement, it was felt this was the most likely source of his infection. He will be treated with 4 weeks of IV cefepime and the ID team recommended subsequent lifelong suppression with oral ciprofloxacin. All surveillance cultures were negative and he remained afebrile after admission. #. Altered mental status due to possible seizure: One morning, the patient experienced an episode of altered mental status with word-finding difficulty, urinary incontinence, and weakness. He underwent ECG, ABG, and CXR which were unremarkable and CT head which showed old CVAs but no acute event. The neurology team felt that he may have had a seizure and started the patient on a zonisamide load. He should continue this medication as an outpatient. We have considered that his lifelong suppression with ciprofloxacin may lower his seizure threshold, but it was recommended that he take cipro indefinitely anyway. He continued to have word-finding difficulties during the duration of admission which seemed to wax and wane. #. Pleural Effusion: He had a moderate right and small left-sided pleural effusion seen on CT scan. It was decided to pursue thoracentesis to rule out this fluid as a source of his infection. His Coumadin was held in preparation, and when his INR was <1.6, the fluid was no longer prominent enough to tap. His Coumadin was therefore restarted and he will transition on a heparin drip until therapeutic. #. CAD: He is status post two coronary bypass procedures with the most recent one in [**4-/2147**], at which time a revision of ramus graft was performed. He was continued on his aspirin, statin. His beta blocker and [**Last Name (un) **] were initially held but restarted prior to discharge. His Imdur was switched in the cardiac care unit to twice daily due to possible ST changes on ECG on admission that may have been demand ischemia. #. Aortic stenosis, status post aortic valve replacement in [**4-/2147**] with a #19 St. [**Male First Name (un) 1525**] prosthesis: He underwent TTE and TEE that showed a normally functioning prosthesis. He was maintained either on a heparin gtt or Coumadin for anticoagulation with a goal INR of 2.0-2.5 (due to history of GI bleed). Upon discharge INR was 1.5 and he was on a heparin drip at 500 units/hour with a PTT of 72.5 at 12:00 PM on [**2155-5-19**]. #. Sick sinus syndrome, status post permanent pacemaker insertion: It was felt that his pacemaker pocket may have been infected given the tenderness on palpation. His pain also decreased with antibiotics, although chest ultrasound did not reveal a fluid collection. He was evaluated by the EP service who felt conservative management of a possible infection was reasonable. #. Chronic atrial fibrillation: He was monitored on telemetry and given Coumadin for anticoagulation. Coumadin was held temporarily due to possible thoracentesis and he was bridged with a heparin drip. #. Hyperlipidemia: He was continued on a statin #. Constipation: He had a persistently distended abdomen and complained of constipation regularly. He was kept on an aggressive bowel regimen and had daily bowel movements. KUB and CT abdomen/pelvis showed no obstruction. #. Code Status: He was DNR/DNI during this hospitalization, as confirmed by his primary care provider who had had discussions with the patient prior to hospitalization. He was intubated initially in the MICU, but was subsequently made DNR/DNI. Medications on Admission: Lovenox 60mg [**Hospital1 **] as directed Warfarin 5-7.5mg as directed ASA 81mg daily Metoprolol succinate 25mg daily Valsartan 320mg daily Furosemide 80mg daily Potassium chloride 10mEq daily Imdur 30mg daily NTG 0.3mg SL prn Simvastatin 40mg daily Pantoprazole 40mg daily prn Gabapentin 300mg [**Hospital1 **] MVI with iron daily Lactulose 15ml daily prn constipation Bisacodyl 10mg PR every other day Colace 100mg daily Senna 1 tablet QAM and 2 tablets QPM Tylenol 1000mg [**Hospital1 **] prn pain Fluticasone 50mcg nasal daily Trimacinolone acetonide 0.1% cream [**Hospital1 **] prn Sarna lotion [**Hospital1 **] prn itch Discharge Medications: 1. Outpatient Lab Work Please check weekly CBC with Diff, BMP, ESR, CRP and LFTs. Please fax all laboratory results to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. 2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK (Sun, Mon, Wed, Fri). 3. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO 3X/week (Tues, Thurs, Sat). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO BID (2 times a day). 9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 5 minutes as needed for chest pain: Take every 5 minutes for 3 times. 10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 13. Multivitamins with Iron Tablet Sig: One (1) Tablet PO once a day. 14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 17. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain/fever. 19. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 20. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) application Topical twice a day. 21. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 23. Cefepime 2 gram Recon Soln Sig: Two (2) gram Intravenous twice a day: Give until [**2155-6-7**]. 24. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) gram PO DAILY (Daily) as needed for constipation. 25. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for cough. 27. Heparin (Porcine) in NS 10 unit/mL Kit Sig: Heparin IV Sliding Scale Intravenous IV drip: Please start at 500 Unit/hour and check PTT in AM [**2155-5-20**]. 28. Zonisamide 100 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: Pseudomonas Bacteremia Altered mental status Secondary Diagnosis: Chronic diastolic congestive heart failure Coronary Artery Disease Discharge Condition: Mental Status: Confused - sometimes, at times difficulty with word-finding Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital due to difficulty breathing. You were initially admitted to the intensive care unit. You were found to have a bacterial infection in your blood. It was not clear where your infection was coming from but you are being treated with intravenous antibiotics. You had an ultrasound of your heart in two different ways which did not show any infection on your heart valves. There was some concern that your pacemaker site is infected. Therefore, you will need to be on antibiotics indefinitely (intravenous antibiotics until [**2155-6-7**], then oral antibiotics). If you develop increasing pain at the site of your pacemaker, please call your cardiologist. You also had episodes of altered mental status and were evaluated by the neurology team. There is a possibility that you had a seizure so you were started on a medication to prevent seizures. Changes to your medications: Added cefepime 2g IV every 12 hours until [**2155-6-7**] Changed Imdur to 15mg by mouth twice daily Changed pantoprazole to famotidine 20mg by mouth daily Changed gabapentin to 300mg by mouth at bedtime Added colchicine 0.6 mg daily Added zonisamide 300mg by mouth at bedtime STOP taking lovenox You should weigh yourself every morning and call your primary care doctor if your weight goes up more than 3 lbs. Followup Instructions: You have the following appointments scheduled: Department: INFECTIOUS DISEASE When: WEDNESDAY [**2155-6-4**] at 9:30 AM [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: MONDAY [**2155-6-9**] at 10:50 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: THURSDAY [**2155-7-10**] at 10:00 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

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16016

Discharge summary

report

Admission Date: [**2126-3-16**] Discharge Date: [**2126-3-30**] Date of Birth: [**2055-3-11**] Sex: M Service: TRAUMA SURGERY The patient is a 71-year-old male who was an unrestrained driver in a high speed motor vehicle crash. The passenger was side T-boned. By report, the patient self extricated, took a few steps, and collapsed. He was unable to be intubated in the field and was only responding to pain. Initially, his systolic blood pressure was 130. He was transferred to [**Hospital3 **] and intubated successfully. Evaluation there, he has a blown pupil, a large pelvic fracture, a negative C spine series, and negative chest x-ray. While at that hospital, he dropped his blood pressure into the 50's. IV was started. Red blood cells was started, and the patient was transferred to [**Hospital1 188**] for further management. The patient arrived at [**Hospital1 1444**] hemodynamically unstable. He was fluid and volume resuscitated with packed red blood cells, plasma products. As part of his initial trauma workup, the patient had numerous injuries discovered and these included multiple rib fractures, bilateral pneumothoraces and hemothoraces, subarachnoid hemorrhage with interventricular extension, lateral mass fractures of C6, C2, and lamina fractures of C6 and C7, pneumomediastinum, multiple pelvic fractures, which included the iliac [**Doctor First Name 362**] in the inferior-superior pubic rami. Because of the patient's hemodynamic instability and pelvic fractures, the patient was taken immediately to angiography following his initial trauma resuscitation and imaging workup. His coagulopathy was corrected and at angiography a right inferior epigastric vessel was embolized successfully. Following angiography the patient was transferred to the Trauma SICU. From hospital day one to hospital day two overnight, the patient developed an abdominal compartment syndrome. For this, he returned to the operating room for an exploratory laparotomy with Dr. [**Last Name (STitle) **]. No frank bleeding was discovered within his abdomen. There was, however, a large stable retroperitoneal hematoma. The patient's abdomen was left abdomen. He was returned to the Trauma Intensive Care Unit. Additionally, during this procedure, the Neurosurgical service was consulted for intraoperative placement of a ventricular catheter. The following day on hospital day two, the Neurosurgery service again saw the patient, and performed a cerebral angiogram. There is no evidence of carotid injury. The patient remained intubated and sedated in the Intensive Care Unit following these procedures. On [**2126-3-19**], the patient had a MRI which demonstrated evidence of cortical hemorrhages consistent with diffuse axonal injury and no enlarged infarction. The patient remained intubated and sedated in the Intensive Care Unit without change in his neurologic examination until the date of [**3-25**] when his abdomen was again closed. For the next week, the Neurosurgery service continued to see the patient daily. There was really very minimal resolution in his neurologic examination. He is noted to have at times decerebrate posturing some spontaneous eye opening, but was never able to follow commands. He is also noted to be moving on his left side. Throughout his hospitalization, the Neurosurgical service felt that his prognosis for recovery was very poor. From a Trauma Surgical standpoint, the patient remained relatively stable requiring minimal amounts of blood products. Was maintained on maintenance fluid as well as antibiotics and TPN throughout his hospital course. On [**2126-3-30**], following discussions with the family, which had been ongoing for several days with the Neurosurgery service's feeling that there is very minimal chance of recovery, the family at this point decided to withdraw care. On [**2126-3-30**], tube feedings and supportive care were stopped. The patient expired shortly thereafter. The patient was pronounced dead at 13:06 by Trauma SICU staff approximately one hour after extubation. [**Name6 (MD) 19851**] [**Name8 (MD) 19852**], M.D. [**MD Number(1) 19853**] Dictated By:[**Name8 (MD) 16207**] MEDQUIST36 D: [**2126-3-30**] 14:05 T: [**2126-4-2**] 07:02 JOB#: [**Job Number 45844**]

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icd9cm

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[ "88.41", "38.91", "99.15", "39.79", "54.72", "02.2", "54.19", "96.04", "96.72", "38.93", "88.42" ]

icd9pcs

[ [ [] ] ]

62,194

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13698

Discharge summary

report

Admission Date: [**2146-12-10**] Discharge Date: [**2146-12-13**] Date of Birth: [**2086-7-2**] Sex: M Service: MEDICINE Allergies: Amiodarone Attending:[**Doctor First Name 1402**] Chief Complaint: ICD shocks Major Surgical or Invasive Procedure: None History of Present Illness: 60-year-old man with history of severe dilated cardiomyopathy (EF 10-15%, non-ischemic, likely familial) status post ICD implantation with a biventricular upgrade in [**12/2145**], amiodarone induced pneumonitis, multiple DVTs, chronic atrial fibrillation, HTN, HLD, DM2, who had a shock from his ICD on [**2146-12-7**] and then another shock yesterday and a 3rd shock this AM. Prior to this week, pt's last shock was in [**2146-3-28**]. Pt saw his EP cardiologist, Dr. [**Last Name (STitle) 11649**], on [**2146-12-7**] after his shock, who found that he had episode of V. fib and reccomended to continue current medical management. During that particular episode, pt reports that he felt dizzy, saw blackness, then was shocked, and felt like he was in a daze a few minutes later. Pt has had 3 shocks in the last 4 days. EP interrogated pacer and found that pt was in V. fib each time. He reported to OSH where vitals: T 97.7, HR 80, BP 98/58, RR 18, 94-96% RA. Trop 0.64. He had negative CXR. K+=3.5 and his L was repleted. He was then transfered to [**Hospital1 18**]. In [**Hospital1 18**] ED: Vitals: T 98.5, HR 100, BP 107/76, RR 18, 95% RA. EP saw pt and reported that he had 3 episodes of V fib last few 3 days. EKG in NSR no ST changes. . On review of systems, Denies chest pain, no SOB, no abd pain, did have a mild headache that has resolved. Remainder of ROS neg. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes (from steroids for pneumonitis), +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: history of an acute myocardial infarction due to a small embolic event in [**5-/2145**] without any further intervention 3. OTHER PAST MEDICAL HISTORY: - Dyslipidemia - Hypertension - Coronary Artery Disease - denied per family - dilated cardiomyopathy, severely depressed EF (10-15%), s/p ICD [**2141**] for primary prevention - Afib treated with digoxin - polymorphic VT after dofetilide - Amiodarone-induced hypersensitivity pneumonitis - Diabetes, diagnosed after being on steroids for pneumonitis - GI bleed on Coumadin [**2137**] possibly related to ischemic colitis - OSA, not on CPAP - multiple previous DVTs including DVT and PE in [**2126**] following an ankle trauma, and second episode of PE in [**2137**]. IVC filter placed [**2137**]. Also had a right brachial vein DVT in [**2139**]. . PAST SURGICAL HISTORY - lap cholecystectomy [**2-/2144**] - IVC filter placement [**2137**] - bilateral cataract surgery with residual right ptosis . Social History: Social history is significant for the absence of current tobacco use. Quit smoking 7 years ago after smoking for 40 years x 2ppd. He drinks no etoh. Lives with wife. Worked at chemical plant making latex. Family History: There is family history of premature coronary artery disease in patient's father, who had first MI at age 37. Mother also has dilated cardiomyopathy. Sister had ?[**Name2 (NI) 41267**] CMY (1 episode of heart failure when very emotional and sad) Physical Exam: Admission Exam VS: afebrile, BP= 124/82, HR=82, O2 sat= 97% on 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: RRR, 1/6 systolic murmur left sternal border LUNGS: CTAB, slightly decreased breath sounds on right lower base, no crackles, no rhonchi, no rhales ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: petechia and some mild bruising on bilateral forearms 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: [**2146-12-10**] 02:35PM cTropnT-0.06* [**2146-12-10**] 02:35PM CK(CPK)-59 Brief Hospital Course: 60 M with severe dilated CMY s/p ICD who is admitted for repeat ICD shocks. . # RHYTHM: In V.Fib during th last 3 shocks on [**2146-12-7**], [**11-29**] and [**12-10**]. Pt has history of VT and VF in setting of severely dilated CMY. Pt has tried amiodarone in the past that caused pneumonitis, has been on steroids since. He has also tried dofetilide- resulted in polymorphic VT side effect. Pacer was interrogated and pt found to have been in V. fib when his ICD went off the last 3 times. Digitalis and seroquel were stopped. Pt started on Quinidine and had no further episodes in-house. He will follow up with Dr. [**Last Name (STitle) 1911**] regarding atrial lead. He has appt scheduled in few weeks. . # CORONARIES: Has history of MI in [**5-/2146**] [**3-1**] thromboembolic event that resolved in its own (has had numerous clots in legs, arm, coronary, lungs). Troponin I elevated at OSH (0.64) but might be [**3-1**] defibrillation. Upon transfer to this hospital, trop T 0.06 x2. No signs of ischemia. . # PUMP: Severely dilated CMY with EF 10%-15%. Thought to be familial since mother has similar condition. Stopped digitalis on this admission. Started Quinidine. Continued: Captopril, Spironolactone, metoprolol, ASA, lasix. . # Pneumonitis- secondary to amiodarone use in the past. Continued his medrol 5mg daily. . # DM2- home Lantus 8 U daily and ISS . # Psych: Continued home meds (remeron and escitalopram) but discontinued seroquel on admission since it is know to cause QT prolongation. Ropinirole was also discontinued since it was held on last admission due to confusion. Pt told to stop both seroquel and ropinirole. Medications on Admission: 1. Aspirin 81 mg Tablet 2. Fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous QHS (once a day (at bedtime)). 3. Escitalopram 10 mg daily 4. Methylprednisolone 5 mg per day 5. Omeprazole 40 mg Capsule, [**Hospital1 **] 6. Metoprolol Tartrate 200mg PO BID 7. Simvastatin 40 mg Tablet daily 8. Xopinex 0.63mg/3cc every 3 rs as needed for wheexing, SOB 9. Spironolactone 12.5 mg PO daily 10. Captopril 25 mg [**Hospital1 **] 11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Seroquel 100mg/day qhs 13. Digoxin 0.125-mg alternating with 0.25-mg/day HOLD on this admission. takes at home. 16. Vit D 1,000 U daily 17. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous once a day. 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 20. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain: please LIMIT as much as possible. 21. Ropinirole 0.5mg qhs HOLD - concern for confusion in the past? 22. Lasix 100mg [**Hospital1 **] Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. captopril 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 4. quinidine gluconate 324 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). Disp:*90 Tablet Sustained Release(s)* Refills:*2* 5. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 7. furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. methylprednisolone 2 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 10. metoprolol tartrate 50 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 11. mirtazapine 30 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO twice a day. 13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 15. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for back pain. 16. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation every 4 hours () as needed for SOB, wheezing. 17. insulin glargine 100 unit/mL Cartridge Sig: Eight (8) Units Subcutaneous once a day. 18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Ventricular Fibrillation Dilated Cardiomyopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for your ICD going off 3 times. You were found to be in a dangerous rhythm during those episodes but your ICD shocked you out of it very quickly. We started you on a medication called Quinidine which will help protect your heart from going into these dangerous rhythms. You had no further episodes while you were in the hospital. Please follow up with Dr. [**Last Name (STitle) 1911**] to discuss your ICD. The following changes were made to your medications: STOP: Digitalis STOP: Seroquel STOP: Ropinirole START: Quinidine We held your Seroquel and Ropinirole while you were in the hospital. Seroquel can cause arrythmias so please STOP this medication. Ropinirole was discontinued at your last hospitalization due to contributing to confusion. Please stop this medication. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2147-1-4**] 1:20 [**Doctor Last Name **],[**Location (un) **] [**Location (un) **] ([**Location (un) **], MA), [**Location (un) **] CVI [**Location (un) **] (NHB) [**Apartment Address(1) **] Make sure to follow up with your primary care doctor within the next 2 weeks. Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] this appointment.

[ "327.23", "E942.0", "425.4", "412", "V58.67", "414.01", "272.4", "515", "V53.32", "V15.82", "427.41", "427.31", "401.9", "V12.51", "E932.0", "249.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8644, 8650

4171, 5814

284, 291

8742, 8742

4068, 4148

9822, 10303

3032, 3281

6971, 8621

8671, 8721

5840, 6948

8893, 9799

3296, 4049

1836, 1957

234, 246

319, 1697

8757, 8869

1988, 2791

1719, 1816

2807, 3016

27,310

140,635

51816

Discharge summary

report

Admission Date: [**2192-1-13**] Discharge Date: [**2192-1-16**] Service: NEUROLOGY Allergies: Penicillins / Lipitor / Motrin / Percocet Attending:[**First Name3 (LF) 5018**] Chief Complaint: abnormal speech Major Surgical or Invasive Procedure: Intubation History of Present Illness: 86yo RH M h/o Parkinson's and on coumadin for atrial flutter and h/o right internal capsule lacunar stroke who was last known well at 10pm per his wife, who had been in and out of his room throughout the night. At midnight, he called out to her and she became alarmed when his speech consisted of "jibberish". I spoke to her at 1am, and she put the patient on the phone; he responded appropriately to my questions but with fluent, paraphasic speech that included neologisms. I told her to call 911 and he presented here. He was noted by EMS to have a right facial droop. He has had no change in level of alertness. His initial exam at 1:45am showed full alertness but fluent aphasia with right facial droop but no drift of his arms or legs; he had a R homonymous hemianopia. Head CT showed a large left-sided ICH. After the scan, at 2:15am, he was found to be sleepy and now was globally aphasic with a flaccid right arm and upgoing toe on the right. His wife notes that he fell today. ROS: On review of systems, the pt's wife denied recent fever or chills. No night sweats or recent weight loss or gain. 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. Denied rash. Past Medical History: Aflutter Parkinson's Social History: no tob/etoh/illicits Family History: noncontributory for ICH Physical Exam: VS Afebrile 179/110 80s 16 98% Gen NAD HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck Supple, no carotid bruits appreciated. No nuchal rigidity Lungs CTA bilaterally CV RRR, nl S1S2, no M/R/G noted Abd soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted Ext No C/C/E b/l Skin no rashes or lesions noted NEURO MS Initially awake and alert on arrival -> sleepy after CT scan, needing light noxious stim to arouse. Speech initially fluent aphasia -> global aphasia after CT scan. Initially able to repeat simple words; could not read on arrival with neologisms. CN CN I: not tested CN II: RHH to confrontation, no extinction. Pupils 3->2 b/l. CN III, IV, VI: EOMI no nystagmus or diplopia CN V: intact to LT throughout CN VII: R facial droop CN VIII: hearing intact to FR b/l CN IX, X: palate rises symmetrically CN [**Doctor First Name 81**]: shrug [**5-28**] and symmetric CN XII: tongue midline and agile Motor Normal bulk and tone. Initially could hold both arms antigravity x 10s and both legs x 5s -> R arm/leg flaccid post-scan, with no withdrawal to noxious stimuli. Sensory intact to LT, PP throughout initially. Reflexes Br [**Hospital1 **] Tri Pat Ach Toes L 2+ 2+ 2+ 2+ 1+ down R 2+ 2+ 2+ 2+ 1+ up (assessed after CT) Coordination unable to assess Gait initially deferred due to code stroke, then afterwards due to deterioration and need to intubate NIHSS initially 8, for LOC commands, aphasia, R facial droop and RHH. Pertinent Results: [**2192-1-13**] 10:59AM CK(CPK)-119 [**2192-1-13**] 10:59AM CK-MB-4 cTropnT-<0.01 [**2192-1-13**] 10:59AM PT-16.3* PTT-26.1 INR(PT)-1.5* [**2192-1-13**] 06:30AM PT-17.3* PTT-27.1 INR(PT)-1.6* [**2192-1-13**] 05:05AM URINE HOURS-RANDOM [**2192-1-13**] 05:05AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2192-1-13**] 05:05AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2192-1-13**] 05:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG [**2192-1-13**] 01:57AM COMMENTS-GREEN TOP [**2192-1-13**] 01:57AM LACTATE-1.1 [**2192-1-13**] 01:50AM GLUCOSE-105 UREA N-25* CREAT-0.9 SODIUM-141 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-30 ANION GAP-12 [**2192-1-13**] 01:50AM estGFR-Using this [**2192-1-13**] 01:50AM CK(CPK)-118 [**2192-1-13**] 01:50AM cTropnT-<0.01 [**2192-1-13**] 01:50AM CK-MB-5 [**2192-1-13**] 01:50AM CALCIUM-8.9 PHOSPHATE-3.5 MAGNESIUM-2.4 [**2192-1-13**] 01:50AM WBC-7.3 RBC-3.88* HGB-12.2* HCT-35.4* MCV-91 MCH-31.5 MCHC-34.5 RDW-13.9 [**2192-1-13**] 01:50AM NEUTS-53.8 LYMPHS-35.2 MONOS-5.5 EOS-5.0* BASOS-0.4 [**2192-1-13**] 01:50AM PLT COUNT-178 [**2192-1-13**] 01:50AM PT-40.3* PTT-31.0 INR(PT)-4.4* NCHCT [**2192-1-13**] at 1:57 am: Large area of intraparenchymal and subarachnoid hemorrhage which is centered in the left basal ganglia and extends into the left frontal, parietal, and temporal lobe sulci. There is mild vasogenic edema and resultant asymmetry and mass effect on the left lateral ventricle. There is no midline shift. Age-appropriate involutional atrophy and no hydrocephalus. The osseous structures are unremarkable. The paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Large intraparenchymal hematoma centered in the left basal ganglia with additional large amount of subarachnoid hemorrhage within the left frontal, parietal, and temporal lobe sulci. The differential would include hypertensive hemorrhage and hemorrhagic stroke. NCHCT [**2192-1-13**] at 10:11 am: In comparison with the prior study, again a large area of intraparenchymal hemorrhage is visualized as well as the subarachnoid hemorrhage involving the left basal ganglia and left frontal, parietal and temporal lobes. In the interim, there is evidence of intraventricular hemorrhage with hyperdense fluid levels layering in both occipital ventricular horns. The core of the hematoma is more conspicuous and larger occupying the right basal ganglia, there is also evidence of midline shifting larger mass effect producing effacement of the left lateral ventricle. The displacement of the midline is approximately 4 mm to the right. The perimesencephalic cisterns remain patent; however, the pattern of edema appears slightly larger on the left temporal lobe. New hyperdense areas of hemorrhage are noted in the subependymal region and left caudate nuclei. The orbits, the mastoid air cells and the paranasal sinuses appear unremarkable. IMPRESSION: In comparison with the prior study, there is evidence of enlargement of the pattern of hemorrhage involving the left basal ganglia; there is also increase in the pattern of vasogenic edema and mass effect with 4 mm of midline shifting to the right. There is also evidence of intraventricular hemorrhage involving both occipital ventricular horns as described above. FRONTAL CHEST RADIOGRAPH [**2192-1-13**]: An endotracheal tube is appropriately positioned. There is mild cardiomegaly. The pulmonary vasculature is normal. There is left basilar atelectasis, but no focal consolidation, pneumothorax, or pleural effusion. IMPRESSION: Endotracheal tube appropriately positioned. No consolidation or CHF. Brief Hospital Course: Given the severity of the hemorrhage and the need for intubation for airway protection, the patient was admitted to the neurologic ICU for further evaluation and management. The patient was given FFP and Vitamin K to reverse his supratherapeutic INR in the setting of hemorrhage; INR dropped from 4.4 on presentation to 1.7 in the am. On examination on rounds the following morning, the patient showed minimal responsiveness to noxious, even as the propofol had been turned off for nearly 30 minutes. He had a right hemiplegia and bilateral upgoing toes. Given concern for expanding hemorrhage with shift and herniation, a repeat CT of the head was performed, which revealed evidence of enlargement of the pattern of hemorrhage involving the left basal ganglia; there was also increase in the pattern of vasogenic edema and mass effect with 4 mm of midline shifting to the right. There was also evidence of intraventricular hemorrhage involving both occipital ventricular horns. Neurosurgery, who had seen the patient on admission, and did not believe him to be a candidate for neurosurgical intervention, was therefore called again to re-evaluate the patient. Once again, his hemorrhage was not considered amenable to surgical intervention. The Neurology and Neurosurgery services met with the patient's family and discussed the patient's very poor prognosis and extremely limited chances for any kind of meaningful recovery. At this juncture, the family decided to maintain limited care, keeping the patient comfortable on the ventilator until all family members could arrive to pay their final respects. Once all had arrived, the patient was extubated. He was transferred to the floor, where he died comfortably on [**2192-1-16**]. Medications on Admission: Coumadin ASA 81mg MWF Sinemet Midodrine/Florinef Iron Neurontin Zocor Proscar B12 Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: ICH Discharge Condition: Expired Discharge Instructions: Not applicable Followup Instructions: Not applicable [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

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icd9cm

[ [ [] ] ]

[ "99.07", "93.90", "96.04" ]

icd9pcs

[ [ [] ] ]

9049, 9058

7130, 8877

267, 279

9105, 9114

3349, 7107

9177, 9309

1772, 1798

9010, 9026

9079, 9084

8903, 8987

9138, 9154

1813, 3330

211, 229

307, 1673

1695, 1718

1734, 1756

6,571

144,053

24960

Discharge summary

report

Admission Date: [**2178-5-27**] Discharge Date: [**2178-5-30**] Date of Birth: [**2113-1-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 18369**] Chief Complaint: Bright red blood per rectum. Major Surgical or Invasive Procedure: EGD, colonoscopy, ERCP with common bile duct stent placement. History of Present Illness: Mr. [**Known lastname 7710**] is a 65 yo male with a history of metastatic renal cell carcinoma on Sutent, CAD, DM who presented with BRBPR rectum on [**5-27**]. This had been going on for two days. Yesterday morning he went to clinic where hct was found to be 19,with sbp in the 90's and he was sent to the ER. . In the ED, patient's hct was found to be 17. His pulse was 79, and bp was 160's/70's. He was transfused one unit prbc. GI was made aware. He was sent to the MICU for further monitoring. . In the MICU the patient was tranfused 2 additional units and hct was 25.8 this AM. Did not have any episodes of BRBPR since being in the ER. Was seen by GI today who took him for EGD/colonoscopy as well as ERCP b/c his Tbili rose rapidly. Results are still pending. Patient did have some lightheadedness this yesterday but denied upon arrival to the MICU. He denies n/v/chest pain/sob Past Medical History: PMH: Onc hx as of [**12-24**]: Mr. [**Known lastname 7710**] presented in [**2176-10-19**] with urinary retention, ultrasound revealing a mass in the right kidney, surgery was delayed, but he underwent right nephrectomy on [**2177-3-14**], revealing a 10-cm tumor clear cell pathology, [**Last Name (un) 9951**] grade 3 to 4, with tumor extension into the perinephric tissues. The patient was staged as a T3. Two lymph nodes were involved. However, at the time of diagnosis, there was no evidence of distant metastatic disease. The patient was enrolled in the ARISER clinical trial randomized phase III double blind adjuvant study involving cG250 versus placebo, received twelve weeks of therapy, at which point, a CAT scan demonstrating increased retroperitoneal lymph nodes suggestive of metastatic disease. He underwent a cardiac catheterization with stent placement for symptoms of angina on [**2177-7-30**], to the RCA. He has been asymptomatic since then from a cardiac standpoint. Followup CT in mid [**Month (only) 216**] revealed slight increase in size of retroperitoneal lymph nodes, and since then the patient has intermittent history of abdominal pain, which has become progressive in nature. High-dose IL-2 was initiated on the high-dose IL-2 select trial on [**2177-12-22**]. He received 11 out of 14 doses and was stopped secondary to neurotoxicity. His last treatment was delayed in the setting of the elevated creatinine and urinary retention on [**2178-1-5**]. He underwent his last cycle of therapy from [**2178-1-20**] through [**2178-1-27**]. He has been on Sutent since [**2-24**]. . PMH: 1)metastatic renal cell ca with known large mesenteric metastasis, and liver mets on sutent as above 2)CAD s/p RCA [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] [**7-/2177**] - cath [**7-24**]: LCX 75% stenosis, OM1 50% stenosis, RCA 90% stenosis 3)Diabetes 4)GERD 5)HTN 6)Hypothyroid 7)Hyperlipidemia 8)BPH retention - indwelling foley with failed voiding trial- no turp due to hematuria. Urologist Dr. [**Last Name (STitle) 770**] 9) s/p appy 10) s/p tonsillectomy Social History: quit smoking 25 yrs ago, no etoh, no drugs. Works in construction-office job has not worked since [**Month (only) **]. Lives alone. Has wife with 3 kids. Wants daughter to be hcp if any emergency. Family History: father with lung ca Physical Exam: PE: T 100.6 P 80 BP 156/72 O2 100% RA Wt 77 KG GEN: awake, nad, pale HEENT: PERRLA/EOMI Lungs: CTA x 2 CV: RRR, s1 s2 Abd: soft, diffusely mildly tender, indwelling foley, no r/g Ext: no c/c/e Rectal with brown stool with brbpr in ed Pertinent Results: Admission labs: 136 102 23 ------------<93 4.6 27 1.4 estGFR: 51/62 (click for details) Ca: 8.8 Mg: 2.1 P: 3.4 ALT: 46 AP: 2447 Tbili: 1.1 AST: 40 [**Doctor First Name **]: 60 Lip: 63 . 5.2 6.0>---<507 17.4 N:71.3 L:21.8 M:3.6 E:2.9 Bas:0.5 . PT: 12.1 PTT: 29.9 INR: 1.0 . Ca: 9.0 Mg: 2.0 P: 3.0 ALT: 44 AP: [**2160**] Tbili: 0.9 Alb: 2.5 AST: 35 Dbili: 0.5 . PT: 12.5 PTT: 28.9 INR: 1.1 . 5.6 7.4>---< 591 19.8 Gran-Ct: 5580 . ERCP [**2178-5-28**]: 1. Extrinsic compression of the CBD due to mass in the porta hepatis. Dilatation of the upper one third of the CBD and intrahepatic biliary ducts. Status post placement of biliary stent. 2. Diffuse fold thickening within the duodenum may be related to patient's known IVC and SMV thrombosis. . CT torso [**2178-5-29**]: 1. Interval decrease in the size of metastatic disease including multiple liver lesions and the large retroperitoneal mass anterior to the nephrectomy bed and mesenteric lymphadenopathy. 2. Unchanged IVC thrombosis with extension of the thrombosis to the left iliac vein. 3. Unchanged appearance of thrombosis of the proximal segment of the SMV. 4. Status post placement of CBD stent with interval decrease in the amount of intra and extrahepatic bile duct dilatation. 5. Unchanged appearance of L2 lytic lesion with focal compression. 6. Unchanged appearance of multiple small pulmonary nodule that measure 3 mm in greatest dimension. 7. Right fluid containing inguinal hernia. 8. Interval development of mild ascites within the abdomen and pelvis. . Brief Hospital Course: A/P: Pt is a 65 yo m with metastatic renal cell who presented with a hct of 17 thought likely [**2-20**] to a lower GI bleed. . 1) Anemia: Pt presented with hct of 17, thought due to lower GIB vs. AVM vs. hemorrhoids given BRBPR. Hct one week PTA was 27, so this was an acute drop. Counts improved come up with 3 units PRBCs. He had EGD and colonoscopy which revealed friable mucosa in the duodenum but no active bleeding, adherent clot of visible vessel. He was maintained on pantoprazole [**Hospital1 **]. He was transfussed an additional 2 units pRBC's for a hct slowly trending down but found to be stable for discharge. . 2) Elevated LFTs: AST and ALT were slightly elevated but T bili jumped up to 5 after admission and alk phos is in the [**2171**]. This was thought possibly [**2-20**] obstruction, LDH was nl. ERCP was done and demonstrated metastatic renal cell mass compressing the biliary tree likely causing obstruction. He had a stent placed in his CBD after which the LFT's began steadily trending down. Given high risk for post-ERCP cholangitis he was treated with ciprofloxacin 500mg [**Hospital1 **] po for 4 day course. . 3) Metastatic renal cell carcinoma: To peritoneum, on sutent on admit. This medication was stopped on admit given increased propensity for GIB it causes. CT scan noted interval decrease in size of metastises. He will follow-up as an outpatient for further treatment. . 4) CAD- 2 sets CEs negative on admission that were sent after slight change in V2 noted on admission ECG. No symptoms were noted during his hospital course. He had a cypher stent placed [**7-24**] but aspirin was held given bleeding. He was discharged off this medication. . 5) Renal insufficiency (recent baseline appears to be 1.4-1.6). This was noted to be at his baseline. He was given bicarb and mucomyst for renal protection for CT w/contrast [**5-29**]. . 6) HTN- Started metoprolol 25mg [**Hospital1 **] for SBP 160-180. . 7) DM- Continued on lantus and humalog ss. . 8) Hypothyroid- Continued on levothyroxine. Medications on Admission: Aspirin 81 Humalog SS HYTRIN 2 mg daily Lantus Lipitor 20mg Levothyroxine 100 mcg daily Oxycodone 20 mg--1 tablet(s) by mouth twice a day Prilosec SUTENT 12.5 mg--3 capsule(s) by mouth once a day total of 37.5mg daily Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). Disp:*60 Capsule(s)* Refills:*2* 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Lantus 100 unit/mL Cartridge Sig: One (1) Subcutaneous once a day: as directed by [**Hospital 387**] clinic. 9. Humalog 100 unit/mL Cartridge Sig: One (1) Subcutaneous four times a day: as directed by [**Hospital 387**] clinic. Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Gastrointestinal bleed, common bile duct obstruction with hepatitis. . Renal cell carcinoma, hypertension, diabetes melitus, coronary artery disease. Discharge Condition: Good, no signs of bleeding, hematocrit stable at 28% Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please notify your primary care physician or Dr. [**Last Name (STitle) **] if you experience fevers, chills, abdominal pain, nausea, vomitting, constipaiton, diarrhea, chest pain, dizziness, further bleeding, or any symptoms that concern you. Followup Instructions: You will be meeting with Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] on Monday at 1 pm.

[ "573.3", "197.7", "530.81", "453.2", "600.01", "788.29", "455.0", "576.2", "244.9", "V10.52", "285.9", "401.9", "250.00", "197.6", "578.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "45.13", "45.23", "51.85", "99.04", "51.87" ]

icd9pcs

[ [ [] ] ]

8866, 8949

5541, 7573

344, 408

9143, 9198

3967, 3967

9572, 9692

3676, 3697

7843, 8843

8970, 9122

7599, 7820

9222, 9549

3712, 3948

276, 306

436, 1325

3983, 5518

1347, 3446

3462, 3660

15,251

188,066

30307

Discharge summary

report

Admission Date: [**2156-2-9**] Discharge Date: [**2156-2-10**] Date of Birth: [**2087-5-31**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Reason for MICU admission: Hypoxia with pneumonia Major Surgical or Invasive Procedure: None History of Present Illness: This is a 68 year old woman with history of hyperlipidemia and smoking who presents with right subscapular pain, pleuritic. She initially presented to [**Hospital1 487**] Gen and was found to be hypoxic on RA (80%) w/ CXR revealing RML PNA. A CT w/o contrast was performed, which was concerning for thoracic aortic aneurism. She was transferred by [**Location (un) **] to [**Hospital1 18**] for further evaluation. . En route to [**Hospital1 18**], she became transiently hypotensive to the 80's but responded to a small amount of fluid. On arrival, her room air sat was 80% and she was put on a nonrebreather. A CT was performed with contrast despite creatinine of 2.4 which showed 2 areas of ~6cm aortic aneurism without evidence of dissection, and right sided pneumonia. Thoracic surgery evaluated her and felt her clinical presentation was most likely due to the pneumonia, so she was admitted to the MICU on a nonrebreather. . ROS: She complains of pain under her right rib and right side of her back for a few months. The pain was worse yesterday and she had more shortness of breath yesterday. The pain is worse taking a deep breath, and worse with walking. Currently it's [**5-9**] but was 15/10 on admission. It radiates to her back and feels like muscle cramping. She's had a cough for the last 3-4 weeks, productive of small amounts of white sputum and no blood. . She denies orthopnea or PND, fever, chills, nausea, vomiting, weight loss, dysuria, or other concerns. Chronic dyspnea on exertion. She can only walk 1 block now, from no limitation a few years ago. Past Medical History: hypothyroidism hyperlipidemia depression cholecystectomy [**78**] years ago rectal surgery [**88**] years ago Social History: Lives alone in [**Hospital1 487**] at elderly living complex. Retired from [**Doctor Last Name 11422**] - tester. Smokes 1ppd x 50 years (50 pack years). Denies alcohol. Family History: [**Name (NI) **] mother, sister. [**Name (NI) **] MI < 50. Physical Exam: Tm101.2 Tc 98.8 HR 109 BP 104/53 R25 O2 98% NRB 94% 6LNC Gen: No respiratory distress HEENT: PERRL, EOMI Neck: JVD 8 cm Resp: rhonchi right side with crackles, no wheezes CV: tachy, nl s1s2 no MGR Abd: soft tympanic, normal bowel sounds Ext: no edema. 2+ radial and DP pulses bilaterally Neuro: A+Ox3 Pertinent Results: [**2156-2-9**] 07:25AM BLOOD WBC-28.1* RBC-4.24 Hgb-12.4 Hct-38.5 MCV-91 MCH-29.2 MCHC-32.1 RDW-16.0* Plt Ct-370 [**2156-2-9**] 11:14AM BLOOD WBC-25.9* RBC-3.87* Hgb-11.2* Hct-33.4* MCV-86 MCH-29.0 MCHC-33.6 RDW-15.9* Plt Ct-321 [**2156-2-9**] 07:09PM BLOOD Hct-30.7* [**2156-2-10**] 02:05AM BLOOD WBC-31.9* RBC-3.71* Hgb-10.6* Hct-33.2* MCV-90 MCH-28.6 MCHC-31.9 RDW-16.0* Plt Ct-338 [**2156-2-10**] 05:34PM BLOOD WBC-17.7* RBC-2.30*# Hgb-6.7*# Hct-22.1*# MCV-96 MCH-29.0 MCHC-30.2* RDW-15.9* Plt Ct-137*# [**2156-2-10**] 05:34PM BLOOD Plt Smr-LOW Plt Ct-137*# [**2156-2-10**] 05:34PM BLOOD Glucose-106* UreaN-33* Creat-1.7* Na-144 K-5.0 Cl-116* HCO3-11* AnGap-22* [**2156-2-9**] 07:25AM BLOOD Glucose-110* UreaN-33* Creat-2.3* Na-139 K-5.7* Cl-106 HCO3-20* AnGap-19 [**2156-2-9**] 11:14AM BLOOD Glucose-90 UreaN-34* Creat-2.4* Na-145 K-4.9 Cl-108 HCO3-28 AnGap-14 [**2156-2-9**] 07:09PM BLOOD K-4.6 [**2156-2-10**] 02:05AM BLOOD Glucose-111* UreaN-37* Creat-2.4* Na-140 K-4.9 Cl-104 HCO3-24 AnGap-17 [**2156-2-10**] 05:34PM BLOOD ALT-22 AST-15 LD(LDH)-198 CK(CPK)-83 AlkPhos-74 Amylase-36 TotBili-0.1 [**2156-2-10**] 05:34PM BLOOD Albumin-1.8* Calcium-6.4* Phos-5.0* Mg-2.1 CT Abdomen [**2156-2-9**]: IMPRESSION: 1. Two focal aortic aneurysms involving the aortic arch and lower thoracic aorta. Ectatic descending thoracic aorta also seen. Diffuse atherosclerotic disease, mural thrombus and plaque, and penetrating ulcers seen throughout the aorta, however, there is no evidence of aortic dissection or aneurysm leak. 2. Focal consolidation in the right upper lobe consistent with pneumonia. Follow-up imaging is recommended following treatment to document resolution. 3. Enlarged bulky left adrenal gland, prominent right adrenal gland; incompletely evaluated on this single- phase study. 4. Multiple hypoattenuating lesions within the kidneys bilaterally, the largest of which likely represent renal cysts, the smallest of which are incompletely characterized. 5. Possible narrowing of the left renal artery distal to its origin. CTA Chest [**2156-2-9**]: IMPRESSION: 1. Two focal aortic aneurysms involving the aortic arch and lower thoracic aorta. Ectatic descending thoracic aorta also seen. Diffuse atherosclerotic disease, mural thrombus and plaque, and penetrating ulcers seen throughout the aorta, however, there is no evidence of aortic dissection or aneurysm leak. 2. Focal consolidation in the right upper lobe consistent with pneumonia. Follow-up imaging is recommended following treatment to document resolution. 3. Enlarged bulky left adrenal gland, prominent right adrenal gland; incompletely evaluated on this single- phase study. 4. Multiple hypoattenuating lesions within the kidneys bilaterally, the largest of which likely represent renal cysts, the smallest of which are incompletely characterized. 5. Possible narrowing of the left renal artery distal to its origin. 6. Large bulky, heterogeneous uterus, most likely representing fibroid uterus. Clinical correlation or comparison with prior studies recommended. 7. Status post cholecystectomy. Brief Hospital Course: 68 year-old female with aortic aneurysm, right-sided pneumonia, renal-failure. . #) Right-sided pneumonia with hypoxia - The patient was admitted for right back pain which is possibly due to the pneumonia. CT and CXR show multilobar infiltrate, and WBC markely elevated with left shift. No history of nosocomial contact so likely community aquired. Started on Ceftriaxone and azithromycin. Sputum cultures sent. . #) Ascending and descending aortic aneurism - New diagnosis of aortic aneurysm with ulceration and atherosclerosis but no evidence of dissection at this time. Carotid ultrasound with 60-69% stenosis. Vascular surgery consulted. Patient had stable hematocrit and was hemodynamically stable in the ICU and was transferred to the floor. However, after a brief stay on the floor, patient experienced acute decompensation and coded. It was thought that she experienced rupture of aortic aneurysm. . #) hypotension - Was noted to be hypotensive en route to [**Hospital1 18**] ED, but responded to fluid bolus. Typed and crossed 4 units. Patient did not require any transfusion during her stay until the acute decompensation. She did not require any pressors. . #) Renal failure - unclear baseline creatinine but chronic renal failure urine output stable. No evidence of hydronephrosis or renal artery stenosis on ultrasound, although questionable stenosis on CTA abdomen. Elevated phos and potassium suggest this may be subacute. Left renal artery may have focal narrowing on CT read. Patient also got IV contrast. No acute issues during this hospitalization. . #) Enlarged uterus - Patient found to incidentally have large heterogenous uterus on abdominal CT. Will need further characterization with transvaginal ultrasound. . #) Chest pain - 1 set cardiac enzymes negative. No history of CAD. EKG OK. No evidence of ACS as pneumonia vs aneurism more likely explain pain. . #) elevated [**Name (NI) 53324**] - unclear etiology. Will monitor and hold statin if further elevated . #) hyperlipidemia - hold statin . #) hypothyroid - continue synthroid . #) depression - zoloft, zyprexa . #) FEN - cardiac, renal diet . #) access - large bore PIV's . #) code status - full, discussed with patient . #) communication - with patient, HCP Daughter [**Name (NI) 6480**] [**Telephone/Fax (1) 72149**] Medications on Admission: synthroid 100 mcg po qd zoloft 50 mg po qd zyprexa 5 mg po qd lipitor 40 mg po qd Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Patient Expired Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2156-2-15**]

[ "272.4", "799.02", "492.8", "584.9", "486", "585.9", "244.9", "441.2" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.60" ]

icd9pcs

[ [ [] ] ]

8297, 8306

5827, 8136

363, 369

8365, 8370

2709, 5804

8422, 8456

2311, 2371

8269, 8274

8327, 8344

8162, 8246

8394, 8399

2387, 2690

274, 325

397, 1974

1996, 2108

2124, 2295

16,459

147,989

7702+7703

Discharge summary

report+report

Admission Date: [**2186-2-27**] Discharge Date: [**2186-3-9**] Date of Birth: [**2123-8-5**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14964**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 62 year old w/ HTN, hyperlipidemia, DM2, CABG [**2171**], p/w unstable angina. Pt reports that since discharge in [**11-23**] , he remained chest pain free for about 2 to 2 1/2 months ( even when he saw his cardiologist Dr. [**First Name (STitle) **] on Monday last week). Last wednesday, while he was walking around the house, he began to experience his typical angina of pressure/discomfort starting around his jaw/face and progressing downward.He took 1 sublingual nitro and his CP went away. Since Wednesday until Saturday, he began to experience increasing CP and worsening frequency, though still relieved w/ 1 nitro SL. He denies any resting CP. By Sunday, he was having intermittement CP w/ minimal exertion (used [**8-30**] nitro SL on sunday). Last episode on Sunday nite (7pm) while he was driving back from Cape, he took 1 nitro SL and CP promptly resolved. SInce sunday 9pm, he remained chest pain free. He told his PCP who tells him to come into the ED. Denies F/C/N/V/diarrhea. He was taken to the cath lab where he was found to have disease of LAD, and all of his vein grafts were down (slow with known 3vd of native coronaries. Decision was made that patient would benefit from CABG (?LIMA to LAD). IABP was inserted, and he was transferred to the CCU for overnight monitoring prior to CABG Past Medical History: 1. HTN 2. high cholesterol 3. DM2 4. CABG [**2171**]; SVG to OM1, SVG to RCA, SVG to LPL 5. left ankle basal cell ca 6. h/o vagal response during sheath pull 7. CAD; Cath ([**11-23**]) showing 3vd of native vasculature, patent SVG-OM1, occlusion of SVG-RCA and SVG-LPL (known). PCI of LAD performed Social History: He is married. He works for the [**Location (un) 86**] Stock Exchange and their computer system. Family History: (+) FHx CAD: Brother died of MI at age 33. Father died of MI at age 67. Physical Exam: VS: Gen: HEENT: Lungs: CV: Abd: Extr: Groin: Neuro: grossly intact, moving all 4 extremities Pertinent Results: Catheterization on [**2-27**]: occlusion of LAD stent, all vein grafts down, with 3vd of native coronaries EKG: NSR, LAD, 60s, LVH (AVL criteria), psuedonormaliziation of TWI V2-V4 CK 210 MB 5 Trop <0.01 @ 2pm Brief Hospital Course: 1. CV: ischemia, s/p cardiac catheterization revealing disease in LAD not amenable to stenting, plan for CABG in the am. Will continue ASA, beta blocker, statin. Came from lab on nitro gtt, and this will be weaned as tolerated. Will hold ACEI, Imdur, and HCTZ prior to surgery. Check EKG in the morning, and plan for CT surgery. He was transferred to CT surgery for CABG. 2. Pump: no recent ECHO, ventriculogram performed at time of catheterization. Will continue beta blocker but hold ACEI given surgery in the morning. Pt with IABP in place, heparinized accordingly. 3. Rhythm: will monitor on telemetry overnight 4. DM2: hgba1c 6.5 in [**4-22**]; will hold glipizide/metformin/actos for now and cover with sliding scale insulin. 5. HTN: Continue beta blocker, wean nitro gtt as tolerated. Will hold ACEI and HCTZ prior to OR 6. Hyperlipidemia: [**11-23**] LDL 91, HDL 34; will recheck fasting lipids in the morning and continue statin. 7. Disposition: He was transferred to CT surgery morning after admission. Medications on Admission: All: NKA Actos 30 qd asa 324 qd atenolol 50 [**Hospital1 **] glipizide ED 5 [**Hospital1 **] hctz 25 qd imdur 30 qd lipitor 40 qd mavik 4 [**Hospital1 **] metformin 850 [**Hospital1 **] plavix 75 qd Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 5 days. Disp:*10 Capsule, Sustained Release(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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Glipizide 5 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO DAILY (Daily). Disp:*30 Tab, Sust Release Osmotic Push(s)* Refills:*2* 10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 12. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*1 MDI* Refills:*2* 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) units Subcutaneous twice a day. Disp:*1 vial* Refills:*2* 14. Insulin Regular Human 100 unit/mL Solution Sig: as directed per sliding scale units Injection four times a day. Disp:*1 vial* Refills:*2* 15. Insulin Syringe .5cc/28G Syringe Sig: One (1) injection Miscell. four times a day. Disp:*1 box* Refills:*2* 16. One Touch UltraSoft Lancets Misc Sig: One (1) lancet Miscell. four times a day. Disp:*1 box* Refills:*2* 17. One Touch Test Strip Sig: One (1) strip Miscell. four times a day. Disp:*1 box* Refills:*2* Discharge Disposition: Home With Service Facility: southshore vna Discharge Diagnosis: CAD s/p CABG [**2171**] s/p redo CABG type 2 DM OSA Discharge Condition: good Discharge Instructions: you may take a shower and wash your incisions with mild soap and water do not swim or take a bath for 1 month do not apply lotions, creams, ointments or powders to your incisions do not lift anything heavier than 10 pounds for 1 month do not drive for 1 month Followup Instructions: follow up with Dr. [**First Name (STitle) **] in [**11-20**] weeks follow up with Dr. [**Last Name (STitle) **] in [**11-20**] weeks follow up with your physician at [**Name9 (PRE) **] [**3-29**] 1:30pm call [**Hospital **] clinic for further teaching follow up with Dr. [**Last Name (STitle) 70**] in [**3-24**] weeks Admission Date: [**2186-2-27**] Discharge Date: [**2186-3-9**] Date of Birth: [**2123-8-5**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 62-year-old male was admitted to the cardiology service on [**2186-2-28**]. He had a prior history of CABG in [**2171**] with a vein graft to the RCA, a vein graft to OM1, and a vein graft to the LPL. He had repeat cardiac catheterizations in [**2181**] twice and in [**2185**]. He had been chest pain free about 2 to 2.5 months in that interim from his catheterization in [**2185-11-19**], but for 5 days prior to admission experienced pain that was more typical of his angina. He felt discomfort in his jaw and his face, and this progressed downward. It was relieved with 1 sublingual nitroglycerin; however, over the course of time in the last few days he experienced increased chest pain worse in frequency that had been relieved with nitroglycerin. Yesterday, he had intermittent chest pain with minimal exertion, with his last episode at 7:00 p.m. on the Sunday night prior to admission while he was driving back from [**Hospital3 15516**]. He denied any chest pain on the day of admission ([**2-28**]). He was seen and evaluated by cardiology on admission. PAST MEDICAL HISTORY: 1. Status post CABG x 3 in [**2171**]. 2. Hypertension. 3. Hypercholesterolemia. 4. Non-insulin-dependent diabetes mellitus. 5. Left ankle basal cell carcinoma. MEDICATIONS ON ADMISSION: Actos 30 mg p.o. once a day, aspirin 325 mg p.o. once a day, atenolol 50 mg p.o. twice a day, glipizide 5 mg p.o. twice a day, hydrochlorothiazide 25 mg p.o. once a day, Imdur 30 mg p.o. once a day, Lipitor 40 mg p.o. once a day, Mavik 4 mg p.o. twice a day, metformin twice a day (dose not stated), Plavix 75 mg p.o. once a day, and ibuprofen p.r.n. PREOPERATIVE LABORATORY DATA: Sodium of 144, K of 4.0, chloride of 103, bicarbonate of 30, BUN of 26, creatinine of 1.3, with a blood sugar of 117. White count of 9.2, hematocrit of 45.7, platelet count of 133,000. INR of 1.1. HOSPITAL COURSE: A catheterization was performed on the day of admission which showed a native left main 40% lesion, LAD 90% mid lesion with in-stent restenosis, a totally occluded proximal circumflex, a 99% occluded RCA. His patent graft was the vein graft to the OM with 60% distal and 80% distal anastomotic obstructions. LIMA was never used on his prior CABG as a graft, but injection [**2185-11-19**] showed a patent vessel. After his catheterization an intraaortic balloon pump was placed in preparation for coronary artery bypass grafting the following day. The patient was optimized in the CCU overnight, and he was seen and evaluated by Dr. [**Last Name (STitle) 70**]. His stents had been placed in [**2185-11-19**]. On exam, he was alert, oriented, and obese gentleman. Blood pressure of 157/93. Saturating 100% on 2 liters and 94% to 96% on room air. His heart rate was 60, in sinus rhythm. His right greater saphenous vein had been harvested prior. His chest had a healed midline scar. He had 2+ carotid pulses without any bruits. His lungs were clear bilaterally. His heart was regular in rate and rhythm without any rubs. His abdomen was obese, soft, nontender, and nondistended with bowel sounds. There was a question of a bruit with his intraaortic balloon pump in place in his femoral artery. He was also seen and evaluated by Dr. [**Last Name (STitle) 27992**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. A preoperative chest x-ray showed no acute cardiopulmonary process. A preoperative EKG showed a sinus rhythm at 62; with T wave inversions in I, L and V4, V5, and V6; with a left atrial abnormality. Please refer to the report dated [**2186-2-27**]. On [**2186-2-28**] the patient had redo coronary artery bypass grafting x 2 by Dr. [**Last Name (STitle) 70**] with a LIMA to the LAD and a vein graft to the OM. He was transferred to the cardiothoracic ICU in stable condition on an epinephrine drip at 0.02 mcg/kg/min, a phenylephrine drip at 0.2 mcg/kg/min, and a propofol drip titrated. Later in the afternoon post redo operation, the patient had EKG changes. An echocardiogram was performed. The patient was taken to the catheterization laboratory. The grafts were patent, and coronary spasm was diagnosed. The patient remained on a Neo- Synephrine drip at 0.25 and epinephrine drip at 0.04. He remained stable, though. His balloon pump was weaned later in the day and then removed. He also was briefly on vasopressins. His blood pressure was 102/55. His creatinine was stable at 1.0, hematocrit of 32, and a white count postoperatively was 10.0. His chest x-ray showed a left pleural effusion with some left-sided atelectasis. He remained intubated overnight. He was also seen by the [**Last Name (un) **] service for evaluation and management of his diabetes. On postoperative day 2, the patient had some hypoxia. His echocardiogram showed some global hypokinesis. He remained in a sinus rhythm in the 90s with a blood pressure of 98/54. He remained intubated but was following commands appropriately. He also remained on low-dose Pitressin at 0.02 and a nitroglycerin drip at 0.25. He also received his aspirin and began Lasix diuresis with a plan to wean his vasopressin over the day. His leg Hemovac was removed. The [**Last Name (un) **] consult recommendations were appreciated. The patient was briefly evaluated by physical therapy. He was also seen by pulmonary and critical care medicine for continued hypoxemia and some respiratory failure that kept the patient intubated. Their recommendations were appreciated and followed. On postoperative day 3, his PEEP was lowered. He remained on insulin at 2, nitroglycerin of 0.25, vasopressin of 0.02, and continued with Lasix diuresis. His hematocrit remained stable at 27.3, but his platelet count dropped to 64,000. His creatinine dropped from 1.4 to 1.3. His Swan was discontinued. His HIT screen was pending, and he continued with diuresis. The patient was also briefly evaluated by infectious disease and was seen and screened by the clinical nutrition team. His Swan was discontinued. On postoperative day 4, his ventilator wean began. He began tube feeds also. His HIT screen was negative. He continued to have some atelectasis with low lung volumes. His PEEP was appropriately adjusted. He continued with diuresis. His mediastinal tubes were pulled, but his pleural tubes remained in place. His blood sugars were under better control. He was finally extubated on postoperative day 5. He received 2 doses of Lopressor IV for some tachycardia and remained on a nitroglycerin drip at 1. Creatinine dropped slightly to 1.2. He was started on diabetic diet. His Lopressor was increased to 25 b.i.d., and he continued with diuresis. His Zantac was discontinued. He was seen again daily by the [**Last Name (un) **] service. His pleural tube was removed on postoperative day 6. Lopressor again was increased, and his Mavik was restarted. The central venous line was removed on postoperative day 6. On postoperative day 7, he had no event overnight. His creatinine rose slightly to 1.4. He was weaned off his nitroglycerin drip. On the 19th, he was transferred out to the floor and began working with the nurses and physical therapist. He was alert and oriented at this time. He had some sternal discomfort and was using Tylenol and Percocet for pain relief. He was saturating 92% on 2 liters nasal cannula. He still had some crackles bilaterally. He was also started on a Combivent inhaler q.4., and his diet was advanced. Later that day he did a level 4 with minimal assistance. He continued to make excellent progress on the floor. On postoperative day 8, he was in sinus rhythm again at 81 with a question of some bundle branch block. He was saturating 92% on room air. His blood sugar rose again slightly to 162, which was appropriately treated with a sliding scale. His Actos was discontinued. He was switched over to NPH insulin by the [**Hospital **] Clinic team. His K was repleted. His BUN rose from 35 to 46, but his creatinine remained stable at 1.4, and this was monitored throughout the next 2 days prior to his discharge. He also was restarted on his Plavix for coverage of his prior stents done in [**Month (only) 404**]. The [**Last Name (un) **] team spoke to the patient extensively about the need for taking his insulin at home and tight management of his blood sugars. On postoperative day 9, the day of discharge, the patient was in a sinus rhythm at 77 with a blood pressure was 118/56. He was alert and oriented, and his lungs were clear bilaterally. He was doing very well and ready for discharge and was discharged to home with VNA services with the following discharge diagnoses. DISCHARGE DIAGNOSES: 1. Status post redo coronary artery bypass grafting x 2. 2. Status post coronary artery bypass grafting x 3 in [**2171**]. 3. Elevated cholesterol. 4. Hypertension. 5. Insulin-dependent diabetes type 2 with new insulin requirement. 6. Chronic obstructive pulmonary disease. DISCHARGE INSTRUCTIONS: Discharge instructions given to the patient included following up with Dr. [**First Name (STitle) **] in 1 to 2 weeks post discharge; following up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (his cardiologist) in 1 to 2 weeks post discharge; having his follow-up appointment at the [**Hospital **] Clinic on [**3-29**] at 1:30 p.m.; and setting up his teaching appointments with the [**Hospital **] Clinic. The patient was also instructed to follow up with Dr. [**Last Name (STitle) 70**] (his surgeon) in 5 to 6 weeks for his postoperative surgical visit. MEDICATIONS ON DISCHARGE: 1. Potassium chloride 20 mEq p.o. once a day (for 5 days). 2. Colace 100 mg p.o. twice a day. 3. Enteric coated aspirin 81 mg p.o. once a day. 4. Percocet 5/325 1 to 2 tablets p.o. q.4-6h. p.r.n. (for pain). 5. Plavix 75 mg p.o. once a day. 6. Imdur 30 mg p.o. once a day. 7. Protonix 40 mg p.o. once a day. 8. Lipitor 40 mg p.o. once a day. 9. Glipizide 5 mg p.o. once a day. 10. Metoprolol 75 mg p.o. twice a day. 11. Lasix 20 mg p.o. once a day (for 5 days). 12. Albuterol inhaler 2 puffs q.4.h. 13. NPH insulin 12 units subcutaneously b.i.d. 14. Regular insulin as per sliding scale (as directed by [**Hospital **] Clinic). DISCHARGE DISPOSITION: The patient was discharged to home on [**2186-3-9**]. CONDITION ON DISCHARGE: Stable. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2186-4-5**] 15:30:26 T: [**2186-4-7**] 11:40:22 Job#: [**Job Number 27993**]

[ "401.9", "285.9", "411.1", "250.00", "780.57", "272.4", "276.6", "414.01", "996.72", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "88.56", "88.53", "37.22", "88.55", "36.11", "99.04", "36.15", "39.61", "37.61", "97.44", "96.6" ]

icd9pcs

[ [ [] ] ]

17344, 17400

2600, 3632

331, 356

6323, 6329

2360, 2577

6637, 7094

2159, 2232

15740, 16019

3883, 6159

6248, 6302

16659, 17320

8405, 8986

9004, 15719

16044, 16633

2247, 2341

281, 293

7123, 8193

8215, 8378

2044, 2143

17425, 17699

6,185

183,725

5275+55657

Discharge summary

report+addendum

Admission Date: [**2139-1-2**] Discharge Date: [**2139-1-12**] Service: Thoracic Surgery Discharged to Rehabilitation facility. HISTORY OF PRESENT ILLNESS: The patient is a patient of Dr. [**Last Name (STitle) **] who has been referred to us. She is a 77-year-old Russian speaking only female who presented with a new myocardial infarction experiencing substernal chest pain and pressure for four days. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Hypercholesterolemia. 4. Gastroesophageal reflux disease. 5. PTCA to the right coronary artery three weeks prior to admission. SOCIAL HISTORY: Negative for ethanol abuse or tobacco abuse. PHYSICAL EXAMINATION: Noncontributory. CARDIAC CATHETERIZATION: Her catheter results showed an ejection fraction of 50%, proximal left anterior descending artery occlusion of 80%, first diagonal 80%, right coronary artery 70%, middle right coronary artery was 90% which was stented three weeks ago. HOSPITAL COURSE: The patient was taken to the operating room for a coronary artery bypass graft x3 for the diagnosis of unstable angina on [**2139-1-5**]. Please see the OP note for full details. Postoperatively she was transferred to the Cardiothoracic Intensive Care Unit on pressure support and she was extubated and transferred to the floor on [**2139-1-7**]. On postoperative day #3 [**2138-1-8**], JP drain was discontinued. Foley was discontinued and wires were discontinued. She had some sternal drainage, so she received a few doses of Kefzol during her stay. Sternal drainage went down and the Kefzol was stopped. Patient was seen by PT that day. Her hematocrit dropped again, and she received several transfusions during the course of her stay to which she had no reaction and she did well. Patient was diuresed. Her chest tube continued to give off high output, but was discontinued on [**2139-1-11**]. Passed a relatively low output. A chest x-ray done immediately post-pull showed that the hydropneumothorax was stable and another chest x-ray done on [**2139-1-12**] shows the same on postoperative day #7. She is being discharged to a rehabilitation facility today on the following medications: She will be going on Captopril 6.25 mg po tid. She will have Niferex 150 mg caps po q day. Lopressor 37.5 mg po bid. Protonix 40 mg po q day. Lipitor 20 mg po q day. Klonopin 0.25 mg po bid. Xalatan 0.005% one drop to each eye q hs. Plavix 75 mg po once a day for a total of three months. Percocet 1-2 tablets for pain q4h prn. Aspirin 325 mg po q day. Lasix 20 mg po bid along with potassium chloride 10 mEq po bid for a total of one week. Colace 100 mg po bid. CONDITION ON DISCHARGE: Good condition with no acute problems. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2139-1-12**] 07:50 T: [**2139-1-12**] 07:55 JOB#: [**Job Number 21537**] Name: [**Known lastname 3581**], [**Known firstname 3582**] Unit No: [**Numeric Identifier 3583**] Admission Date: [**2139-1-2**] Discharge Date: [**2139-1-12**] Date of Birth: [**2061-11-14**] Sex: F Service: Thoracic ADDENDUM: The patient had a chest x-ray, P/A and lateral downstairs in the Radiology Suite today after a portable x-ray this morning showed poor quality. The pneumothorax seen from prior studies is unchanged and stable per the attending radiologist's wet read with the radiology resident. DISPOSITION: The patient is discharged to rehabilitation. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2728**] Dictated By:[**Name8 (MD) 2965**] MEDQUIST36 D: [**2139-1-12**] 11:59 T: [**2139-1-12**] 12:05 JOB#: [**Job Number 3584**]

[ "272.0", "530.81", "V45.82", "401.9", "414.01", "410.42" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

996, 2673

700, 979

169, 418

440, 616

632, 678

2697, 3922

56,565

143,505

36859

Discharge summary

report

Admission Date: [**2168-5-16**] Discharge Date: [**2168-6-21**] Date of Birth: [**2097-8-9**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: Cardiac catherization [**2168-5-23**] s/p Aortic valve replacement (21mm Pericardial) Mitral valve repair (28mm ring) Coronary artery bypass graft (Left internal mammary > left anterior descending artery, saphenous vein graft > diagonal, saphenous vein graft > posterior descending artery) [**2168-6-8**] History of Present Illness: 70 year old woman who over the last six months has experienced decline in exercise capacity, becoming short of breath while performing her daily activities. In [**Month (only) 116**] she was admitted to [**Hospital3 1443**] Hospital after becoming severely dyspneic, and was found to have a RLL pneumonia. She was treated with [**Name (NI) **] (unclear length of course),and required tap of the pleural effusion. Her functional capacity was improved on discharge however she noticed continued swelling of her ankles, dyspnea on exertion, a non productive cough, paroxysmal nocturnal dyspnea and developed two pillow orthopnea. On [**2168-5-14**] she became acutely dyspneic, presenting to the ED at [**Hospital3 **] hospital, where she was started on supplemental 02, and admitted for management of her dyspnea. She was transferred for further evaluation and treatment. Cadriac workup revealed Aortic Stenosis, Mitral regurg, and coronary artery disease. Dr.[**Last Name (STitle) **] was consulted for surgical intervention. Past Medical History: Hypertension Atrial fibrillation hyperlipididemia Coronary artery disease Heart failure Diabetes mellitus type 2 Pneumonia Obesity Obstructive sleep apnea on CPAP s/p appendectomy s/p cholecytectomy s/p hernia repair Social History: Retired Lives with daughter Denies ETOH Tobacco quit 40 years ago Family History: Father s/p CABG, sister s/p "valve" surgery, died age 61, brother with stents Physical Exam: Pulse: 59 Resp: 20 O2 sat: 97% RA B/P Right:121/80 Left:113/76 Height:5'4" Weight:208 LBS General:Awake, alert & oriented x3 Skin: Dry [] intact [] Other: +Yeast infection groin and under R breast- skin with cracks HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [] [**Hospital1 **]-[**Doctor First Name **] crackles, no stridor or wheezing Heart: RRR [] Irregular [X] Murmur Sys murmur radiating to carotids and axillae Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema light distal edeme Varicosities: On RLE 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:+2 Left:+2 Pertinent Results: [**2168-6-20**] 04:45AM BLOOD WBC-9.7 RBC-2.78* Hgb-8.2* Hct-26.5* MCV-95 MCH-29.4 MCHC-30.9* RDW-15.1 Plt Ct-314 [**2168-5-16**] 04:00PM BLOOD WBC-7.7 RBC-3.83* Hgb-12.1 Hct-36.1 MCV-95 MCH-31.6 MCHC-33.5 RDW-15.9* Plt Ct-173 [**2168-6-20**] 04:45AM BLOOD PT-22.2* PTT-35.8* INR(PT)-2.1* [**2168-5-16**] 04:03PM BLOOD PT-27.3* PTT-34.6 INR(PT)-2.7* [**2168-6-20**] 04:45AM BLOOD Glucose-101 UreaN-12 Creat-0.7 Na-135 K-5.2* Cl-96 HCO3-34* AnGap-10 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 83245**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 83246**] (Complete) Done [**2168-6-8**] at 11:59:47 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2097-8-9**] Age (years): 70 F Hgt (in): 64 BP (mm Hg): 109/67 Wgt (lb): 208 HR (bpm): 54 BSA (m2): 1.99 m2 Indication: Intraoperative TEE for CABG, AVR and mitral valve repair. Aortic valve disease. Congenital heart disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Preoperative assessment. Prosthetic valve function. Pulmonary hypertension. Right ventricular function. Shortness of breath. ICD-9 Codes: 428.0, 786.05, 786.51, 440.0, 424.1, 424.0, 424.2 Test Information Date/Time: [**2168-6-8**] at 11:59 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 32862**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW5-: Machine: aw5 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Aorta - Annulus: 2.1 cm <= 3.0 cm Aorta - Sinus Level: 2.7 cm <= 3.6 cm Aorta - Ascending: 3.0 cm <= 3.4 cm Aortic Valve - Peak Velocity: *4.1 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *68 mm Hg < 20 mm Hg Aortic Valve - LVOT diam: 1.8 cm Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2 Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal regional LV systolic function. Mildly depressed LVEF. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral annular calcification. Moderate to severe (3+) MR. TRICUSPID VALVE: Moderate [2+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Results were Conclusions Prebypass No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2168-6-8**] at 1130am. Postbypass The post bypass exam was performed while the patient was receiving 0.03 mcg/kg/min of epinephrine, 0.25 mcg/kg/min of milrinone, 1.5 mcg/kg/min of phenylephrine. There is a well-seated aortic valve bioprosthesis without paravalvular regurgitation and without residual valvular stenosis. There is well-seated mitral annuloplasty ring with mild residual regurgitation. The mean gradient across the mitral valve is 4 mm Hg. Overall ventricular function is preserved at approximately 45%. The aorta is intact post decannulation. The surgical staff was notified of all findings intraoperatively. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2168-6-8**] 17:11 ?????? [**2161**] CareGroup IS. All rights reserved. Brief Hospital Course: Mrs.[**Known lastname **] was admitted for heart failure requiring aggressive diuresis. Cardiac work up revealed an aortic valve area of 0.6 and 3+ mitral regurgitation,and coronary artery disease.Preoperatively it was noted that she had candidial intertrigo in the bilateral groin, presenting a risk for infection at the proposed catheter insertion site for surgery, and the surgery was subsequently postponed until her intertrigo resolved with oral diflucan therapy and topical miconazole therapy. [**2168-6-8**] she underwent aortic valve replacement(#21mmpericardial), mitral valve repair (#28mm ring), and coronary artery bypass graft (Left internal mammary artery grafted to Left anterior descending artery/Saphenous vein grafted to Diag/Posterior descending artery).Cross Clamp time= 125 minutes. Cardiopulmonary Bypass time= 140 minutes. See Dr[**Doctor Last Name 14333**] operative report for further details. She tolerated the procedure well and was transferred in critical but stable condition to the CVICU requiring pressors for optimimal cardiac output and hemodynamics. She awoke neurologically intact and was extubated without complications. She remained in the intensive care unit on milirone which was weaned off post operative day 2 but remained in neosynephrine to augment her blood pressure. On the evening of postoperative day two she was found to be asystolic under the epicardial pacer and EP was consulted. She had not yet received any betablockers postoperatively. Mrs.[**Known lastname **] continued to be paced until she went into rate controlled atrial fibrillation in the 80's, which is her baseline. On post operative day three she was pan cultured for elevated white blood cell count and the blood culture [**12-23**] bottles were positive for staph coag negative from aline, vancomycin was started, ID consulted, and repeat blood cultures obtained. Epicardial wires were maintained and heparin started due to atrial fibrillation. She remained in the intensive care unit to monitor her rhythm until POD# 7 when her rhythm showed stable recovery and EP determined that a PPM was not warranted at this time and low dose Beta-Blocker could be used if necessary to rate control her atrial fibrillation. Anticoagulation was resumed with Coumadin. She was transferred to the step down unit for further monitoring. Vancomycin was continued for a 7 day course as per ID, to cover for blood culture believed to be a contaminant. POD#11 she was found to be C-Difficile positive and was placed on Flagyl x 14day course. Physical therapy was consulted and evaluated Mrs[**Known lastname 83247**] strength and mobility with plans for discharge to home with VNA. On POD 13 Dr.[**Last Name (STitle) **] cleared Mrs.[**Known lastname **] for discharge to home with VNA. All follow up appointments were advised. Medications on Admission: Amlodipine 5mg azithromycin 500mg daily Ceftriaxone 1g piggyback /day digoxin 125 mcg daily nitrobid 2% ointment topically q6h. Potassium chloride 20meq Warfarin 5mg last dose sunday Aspirin 81mg Discharge Medications: 1. Outpatient Lab Work First INR should be drawn on Thursday [**2168-6-23**] with results sent to the office of [**Last Name (NamePattern1) 83248**] at ([**Telephone/Fax (1) 83249**]. Plan confirmed with Dotty on [**6-17**]. INR goal for Afib is [**12-22**] 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Outpatient Lab Work LFTs to be drawn 1st week in [**Month (only) **] results [**First Name (STitle) 83250**] [**Telephone/Fax (1) 77368**] 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for c-diff for 12 days: through [**2168-7-3**]. Disp:*36 Tablet(s)* Refills:*0* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose will change daily for goal INR [**12-22**], [**First Name (STitle) **] to manage. Disp:*30 Tablet(s)* Refills:*2* 14. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home with Service Facility: TBA Discharge Diagnosis: Coronary Artery Disease s/p CABG Aortic Stenosis s/p AVR Mitral Regurgitation s/p MV repair Acute on chronic systolic heart failure Diabetes Mellitus type 2 Hypertension Atrial fibrillation Elevated lipids Obstructive sleep apnea on CPAP Obesity c-difficile Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month 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) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for [**First Name (STitle) 83251**] 1-2 weeks ([**Telephone/Fax (1) 77368**]) please call for appointment Dr [**Last Name (STitle) 17285**] in [**12-22**] weeks ([**Telephone/Fax (1) 83252**]) please call for appointment First INR should be drawn on Thursday [**2168-6-23**] with results sent to the office of [**Last Name (NamePattern1) 83248**] at ([**Telephone/Fax (1) 83249**]. Plan confirmed with Dotty on [**6-17**]. INR goal [**12-22**] for atrial fibrillation [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2168-6-21**]

[ "428.23", "250.00", "424.1", "424.0", "276.1", "426.11", "428.0", "997.1", "278.00", "414.01", "008.45", "427.31", "E878.8", "424.2", "041.19", "401.9", "416.8", "455.2", "427.89", "599.70", "564.00", "327.23", "E879.8", "272.4", "300.00", "112.3" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.23", "36.12", "39.64", "36.15", "35.12", "35.21", "88.56", "88.72" ]

icd9pcs

[ [ [] ] ]

13621, 13655

8640, 11476

340, 647

13957, 13964

3020, 8617

14475, 15151

2042, 2122

11723, 13598

13676, 13936

11502, 11700

13988, 14452

2137, 3001

280, 302

675, 1702

1724, 1942

1958, 2026

9,768

128,541

53643

Discharge summary

report

Admission Date: [**2201-2-11**] Discharge Date: [**2201-2-25**] Date of Birth: [**2123-10-10**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing / Penicillins Attending:[**First Name3 (LF) 6195**] Chief Complaint: fever Major Surgical or Invasive Procedure: 1. PICC line placement 2. Central line placement 3. Hemodialysis line removal 4. Cardiopulmonary Resuscitation 5. Intubation 6. Pericardiocentesis History of Present Illness: 77M with h/o ESRD on HD (T/Th/Sa at [**Location (un) **] [**Last Name (LF) 4265**], [**First Name3 (LF) 805**] nephrologist, missed session day of admission), HTN, who presented to ED with fever to 100.4F at home, productive cough and congestion x 4-5 days. He admits myalgias, decreased energy, and poor appetite. He vomited a few times, but in context of paroxysms of coughing. Due to these symptoms, he did not go to HD on the day of admission. His wife had similar symptoms last week. He states that he has not felt SOB at home, but that once arriving in the ED, he has felt a bit SOB, better when sitting upright. He had an influenza vaccination [**9-5**], and a pneumovax in [**2196**]. He denied any lightheadedness, chest pain/pressure, abdominal pain, nausea, increased output from his ostomy bag, or urinary symptoms. Initial labs were notable for wbc 6.7 with 91%N, and lactate 2.1. CXR demonstrated mild interstitial edema and minimal blunting of costophrenic angles bilaterally, with possible mild retrocardiac opacity. Blood cultures were sent, and he was given a dose of vancomycin and levofloxacin. Of note, he has a recently matured AV graft (placed [**2200-12-18**]) which has been used for HD over the last 2-3 weeks, with plans to d/c his R permacath line in the near future. He was admitted to the medical service for further evaluation and management. . While on the floor, pt had recurrent fevers (up to 102.4 today), and blood cx's grew out 4/4 bottles coag neg staph from [**2-10**]. He was treated with vanc, as well as 1 dose of gent. His R sided permacath was pulled, which also grew coag negative staph. He continued to spike fevers despite Abx treatment, and today his SBP dropped to the 70's after returning from dialysis (reportedly no fluid was removed during dialysis). He also had worsening mental status, so a neurology consult was called to evaluate for possibility of septic emboli (TTE could not rule out vegetation). Past Medical History: Rectal Cancer s/p resction in [**2183**] (with XRT and chemo) and [**2189**]; has colostomy Hypertension Diabetes Mellitis (resolved since lost weight w/ CA) End Stage Renal Disease on HD x 12 years Mitral Regurgitation tonic-clonic seizure after HD in [**2190**]; none since Left Retinal Hemorrhage Left Temporal Meningioma s/p cholecystectomy Gallstone Pancreatitis h/o AV graft clot [**12/2199**] Cataracts Social History: Retired cryogenic engineer. Lives in [**Location (un) 55**] with wife. Quit smoking at age 40. No EtOH. Family History: NC Physical Exam: Vitals: 99.6 82/50 80 99% on 3L NC Gen: NAD, pleasant, mildly confused HEENT: PERRL. OP clear. ? R ptosis. CV: RRR, III/VI holosystolic murmur at apex. JVP ~7cm. Chest: bibasilar crackles Abd: Ostomy site intact, liquid dark brown stool output. Soft, NT/ND Extr: RUE: old and current AV graft sites present, +thrill, no erythema or warmth over site. R subclavian permacath dressing c/d/i (s/p permacath removal), no erythema or warmth. Trace LE edema, 1+ DPs bilaterally Neuro: A&Ox1. CN 2-12 intact. 4/5 strength LUE (not very cooperative), otherwise 5/5 strength throughout. Sensation grossly intact UE and LE bilaterally. Pertinent Results: Microbiology Data: [**2201-2-12**] BLOOD CULTURE AEROBIC BOTTLE-PRELIMINARY {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-PENDING INPATIENT [**2201-2-11**] CATHETER TIP-IV WOUND CULTURE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE NEGATIVE} INPATIENT [**2201-2-10**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE} EMERGENCY [**Hospital1 **] [**2201-2-10**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE} . Transoesophageal echocardiogram on [**2201-2-17**]: IMPRESSION: Deformed aortic valve but no discrete vegetation or abscess (does not exclude endocarditis). Mild-moderate aortic regurgitation. Mild-moderate mitral regurgitation. . CT Head on [**2201-2-15**] to rule-out septic emboli: IMPRESSION: No acute intracranial hemorrhage. Unchanged left parietal meningioma. Otherwise, no mass effect. Mucus retention cyst in the left maxillary sinus. Please note that MRI is more sensitive than this CT scan for the assessment of acute infarction or meningitis. . Echocardiogram on [**2201-2-13**]: The left atrium is mildly dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. An aortic valve vegetation/mass cannot be excluded. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is a small pericardial effusion. Compared with the prior study (images reviewed) of [**2200-7-29**], the severity of AS, MR, TR and pulmonary hypertension detected is worse. If clinically indicated, a TEE would better excldue endocarditis. . ECHO on [**2-23**]: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). 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 moderate pulmonary artery systolic hypertension. There is a moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2201-2-20**], there is more echo dense material in the pericardium/pericardial space consistent with organization. . CXR on [**2-14**] IMPRESSION: Right effusion layering out. Left retrocardiac air space disease - atelectasis versus pneumonia appears greater than prior. [**2201-2-11**] 01:00PM GLUCOSE-207* UREA N-46* CREAT-7.5*# SODIUM-137 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-24 ANION GAP-19 [**2201-2-11**] 01:00PM CALCIUM-9.1 PHOSPHATE-1.8* MAGNESIUM-1.6 [**2201-2-11**] 01:00PM WBC-10.3# RBC-3.50* HGB-10.6* HCT-31.4* MCV-90 MCH-30.3 MCHC-33.8 RDW-17.1* [**2201-2-10**] 08:57PM ALT(SGPT)-8 AST(SGOT)-17 CK(CPK)-50 ALK PHOS-110 AMYLASE-65 TOT BILI-0.8 Brief Hospital Course: Mr. [**Known lastname 56835**] is a 77-year-old man with a history of ESRD on HD who presented to the ED with 4-5 days fever, congestion, cough, and malaise. . 1. Cardiac Arrest. On the day of death, Mr. [**Known lastname 56835**] was completing his final inpatient hemodialysis before his expected discharge. Immediately after completing the session, he became hypotensive with SBP in the 80s. He was noted to be in a fib w/ RVR. Fluids were given back wide open and he was given 5 mg IV lopressor. Plan was to obtain ABG and bedside echo, but before these could happen he became unresponsive and pulseless. A code blue was called. Central access was obtained via the femoral vein, as his PICC was not flushing. He was given atropine x1 and epinephrine x3, and calcium gluconate. Initially he remained in a fib with a rate around 40 bpm; this was a PEA. However, he developed VT after ~15 minutes. He was shocked three times at 300, 300, and 360 without response. Bedside echo showed the stable pericardial effusion; an empiric pericardiocentesis was performed with minimal fluid return. The code was called after 30 minutes of pulselessness. Death was confirmed by bedside echo which showed no cardiac activity. Time of death was 5:05 pm. Permission for an autopsy was obtained from his wife. . 2. Sepsis. In addition to the fever, he was noted to be hypotensive. Blood cultures from [**2-10**] grew Oxacillin sensitive coagulase negative staphylococcus. His Perm-a-Cath was removed by surgery on the evening of [**2-11**]; this also grew coagulase-negative staph, and is the presumed source. He was given gentamicin x 1 dose for synergistic coverage. TTE equivocal regarding endocarditis/valvular abscess/vegetation, so TEE was performed and was negative for vegetation. The patient's surveillance blood cultures were negative since [**2-14**]. He was started on vancomycin on [**2201-2-11**] and was planned to complete a 3 week course on [**2201-3-4**]; the vanc was dosed at dialysis. His AV graft was also imaged, and was found to be patent and without evidence of infection. Gentamicin was discontinued given exclusion of endocarditis. Sputum cultures were negative but the patient was started empirically on meropenem for hospital acquired pneumonia. He completed a 7-day course of meropenem on [**2201-2-20**]. A PICC line was placed during his hospitalization. . 3. Atrial fibrillation with RVR. He had this paroxysmally. He did have several episodes of RVR during which he typically became dyspneic with occasional chest pain. These episodes responded to IV lopressor and he was ruled out for MI with serial cardiac enzymes. He was given aspirin instead of warfarin for anticoagulation due to a history of GI bleeds from polyps. He was effectively rate controlled with metoprolol, eventually at a higher dose of 50mg TID. The patient initially had elevated troponins from baseline on MICU admission, and some ST depressions in anterior and lateral leads. Cardiology was consulted and felt it was demand ischemia in setting of hypotension/sepsis, and did not warrant heparinization. Regarding the atrial fibrillation, cardiology did not feel he would benefit from D/C cardioversion as he returns to sinus rhythm spontaneously quite often and anti-arrhythmic therapy would be too difficult to manage in setting of renal failure and frequent episodes of bradycardia. Therefore, his lopressor was titrated as tolerated. . 4. Pericarditis. A pericardial rub was noted on exam and an echo showed a moderate pericardial effusion without evidence of tamponade. Given some pleuritic chest pain, he was thought to have pericarditis. This was treated with salsalate. As for the effusion, the patient was hemodynamically stable. The patient was dialysed daily to optimize volume status. . 5. Dyspnea. This was thought to reflect mild volume overload from missing his outpatient HD. It did improve after hemodialysis. Some residual dyspnea with exertion was noted at the end of his stay, which was thought to be due to deconditioning. He had no evidence of tamponade and had completed a course for pneumonia. . 6. ESRD secondary to HTN. Calcium carbonate was discontinued per renal. As above, he was dialyzed daily for a period, but was planned to return to his usual T/Th/Sat schedule. He was given nephrocaps and sevelamer. . 6. PPx: PPI, pneumoboots . 7. CODE: Full . 8. DISPO: He expired following his cardiac arrest after attempts to resuscitate him were unsuccessful. Medications on Admission: 1. Pantoprazole 40 mg PO q12h 2. Metoprolol 50 mg PO TID 3. Minoxidil 2.5 mg PO BID 4. Sevelamer 1600 mg PO TID 5. B Complex-Vitamin C-Folic Acid 1 cap PO q24h 6. Calcium carbonate 1500 mg PO TID 7. Losartan 50 mg PO q24h Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-2**] Sprays Nasal TID (3 times a day) as needed. 8. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 10. Salsalate 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol): To be dosed at hemodialysis per protocol. Disp:*30 gram* Refills:*2* Discharge Disposition: Home with Service Discharge Diagnosis: Primary: 1. Cardiac arrest 2. Sepsis with coagulase-negative staph 3. Pericarditis . Secondary: 1. Atrial fibrillation 2. End-stage renal disease 3. Diabetes Mellitus, type 2, complicated by diabetic nephropathy 4. Hypertension Discharge Condition: Expired. Discharge Instructions: N/A Followup Instructions: N/A [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**] Completed by:[**2201-2-26**]

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icd9cm

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[ "39.95", "88.72", "86.05", "37.0", "38.93" ]

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13698, 13717

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307, 456

13989, 14000

3681, 7708

14052, 14216

3016, 3020

12483, 13675

13738, 13968

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14024, 14029

3035, 3662

262, 269

484, 2443

2465, 2877

2893, 3000

54,135

150,600

52061

Discharge summary

report

Admission Date: [**2172-7-14**] Discharge Date: [**2172-7-24**] Date of Birth: [**2100-10-16**] Sex: M Service: MEDICINE Allergies: ceftriaxone Attending:[**First Name3 (LF) 1185**] Chief Complaint: Fever, Myalgias/Arthralgias, Change in mental status Major Surgical or Invasive Procedure: TEE Colonoscopy PICC placement Small bowel capsule study History of Present Illness: Mr. [**Known lastname **] is a 71 y/o male with a history of insulin dependent DM2, CAD s/p MI, ischemic CHF (EF 20%), peripheral neuropathy, CKD stage III-IV, depression and recent admission for multiorganism endocarditis ([**Date range (1) 107758**]) who presented with recurrent fevers and myalgias. He presented on [**5-4**] with similar symptoms and was discharged on vancomycin and ceftriaxone for endocarditis. Blood cultures at that time grew Strep anginosus (4/4 bottles) and Staph lugdinensis which were pansenstitive (see ID note [**6-23**]). He returned on [**6-4**] with a rash that was concerning for a drug rash; therefore, was switched to daptomycin. He completed his antibiotics on [**6-23**] and notes doing well for a few weeks. He then began having symptoms last week with fevers up to 103. He notes associated myalgias, arthralgias, headaches and shortness of breath. He apparently also has mental status changes which improved by the time he arrived to the ED. He was initally seen at [**Hospital1 **]-[**Location (un) 620**] and was given a dose of vancomycin, zofran and tylenol. He also had a chest x-ray there which was noted to be within normal limits. . In the ED his initial vitals were 99.4 91 103/54 18 96% 4L. He was started on Levofloxacin 750mg IV and Bactrim 3DS every 6 hours. Blood cultures, U/A and head CT were done. Vitals upon transfer were T99.3/HR 83, BP 110/67, RR 18, SpO2 98% on RA . On the floor, he noted that he continues to feel unwell but denied any significant discomfort. He continued to have a headache and noted that he felt anxious. He denied any nausea, vomiting, rash, cough, dysuria, constipation or diarrhea. . ROS: Denies vision changes, rhinorrhea, congestion, sore throat, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, hematuria. Past Medical History: Mitral valve endocarditis ([**4-/2172**]) Ischemic cardiomyopathy with an EF of 20% Insulin dependent diabetes Peripheral neuropathy CAD status post anterior MI; s/p stent in [**2158**] Depression H/o knee injury Social History: Retired; lives at home with his wife. Used to own a Dunkin' Donuts. Question of some recent cognitive decline. Mr. [**Known lastname **] [**Last Name (Titles) 13230**]s tobacco, alcohol, or illicit drug use. He is independent. Family History: Father died [**1-8**] heart disease, mother died [**1-8**] complications of renal failure, +DM, No colon or other malignancies in family hx. Physical Exam: ADMISSION EXAM: VS: Temp 100.1, 122/71, 75 99 2L GENERAL: Well-appearing man in NAD, comfortable, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no thyromegaly, no JVD, no carotid bruits. HEART: irregular, no MRG, nl S1-S2. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: distended but Soft/NT, no masses or HSM, no rebound/guarding. EXTREMITIES: trace edema, no cyanosis or clubbing noted. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, motor function grossly normal . DISCHARGE EXAM: Afebrile, 142/71, 58, 18, 100% on RA GENERAL: Well appearing man, no acute distress, sitting in bed watching TV HEENT: Moist mucous membranes CHEST: CTA bilaterally CARDIAC: Irregularly irregular, no murmurs, rubs, or gallops ABDOMEN: +BS, soft, non-tender, distended EXTREMITIES: 1+ edema bilaterally (stable) NEURO: Alert and oriented Pertinent Results: ADMISSION LABS: [**2172-7-14**] 04:16PM BLOOD WBC-16.3* RBC-3.50* Hgb-10.5* Hct-31.6* MCV-90 MCH-29.8 MCHC-33.1 RDW-16.9* Plt Ct-208 [**2172-7-14**] 04:16PM BLOOD Neuts-84* Bands-10* Lymphs-2* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2172-7-14**] 04:16PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL [**2172-7-14**] 04:16PM BLOOD Glucose-52* UreaN-47* Creat-1.9* Na-143 K-3.7 Cl-113* HCO3-19* AnGap-15 [**2172-7-14**] 04:14PM BLOOD Lactate-1.3 OTHER WORKUP [**2172-7-15**] 06:40AM BLOOD PT-27.7* PTT-57.2* INR(PT)-2.7* [**2172-7-15**] 03:50PM BLOOD Fibrino-569* [**2172-7-15**] 03:50PM BLOOD FDP-10-40* [**2172-7-15**] 03:50PM BLOOD D-Dimer-303 08*/[**11-15**] 11:25AM BLOOD Thrombn-91.6* [**2172-7-15**] 03:50PM BLOOD ALT-532* AST-641* AlkPhos-218* TotBili-0.7 [**2172-7-16**] 05:20AM BLOOD Lipase-52 [**2172-7-17**] 04:30AM BLOOD Albumin-3.4* [**2172-7-16**] 05:20AM BLOOD calTIBC-263 Ferritn-527* TRF-202 [**2172-7-16**] 05:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2172-7-16**] 05:20AM BLOOD Acetmnp-NEG [**2172-7-16**] 05:20AM BLOOD HCV Ab-NEGATIVE [**2172-7-17**] 04:30AM BLOOD CEA-4.0 PSA-0.4 Urine [**2172-7-14**] 05:14PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011 [**2172-7-14**] 05:14PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2172-7-14**] 05:14PM URINE RBC-8* WBC-1 Bacteri-FEW Yeast-NONE Epi-0 [**2172-7-14**] 05:14PM URINE CastHy-12 URINE CULTURE (Final [**2172-7-15**]): NO GROWTH Micro: Bcx from [**Location (un) 620**] > BLOOD CULTURE Final 08/14/11-1501 Anaerobic bottle: ENTEROCOCCUS FAECALIS Aerobic bottle: no growth Results called to and read-back performed by: [**Female First Name (un) **] (ER) On:[**2172-7-15**] At:1039 By:#[**Last Name (un) **].JLB Patient transferred to [**Hospital1 18**]-[**Location (un) 86**], ID fellow notified at [**Hospital1 18**]. 1. ENTEROCOCCUS FAECALIS Target Route Dose RX AB Cost M.I.C. IQ ------ ----- ------------------ ------ -- ------ --------- ------ AMPICILLIN S <=2 CIPROFLOXACIN S 1 LEVOFLOXACIN S 1 LINEZOLID S 2 BENZYLPENICILLI R 16 TETRACYCLINE S <=1 VANCOMYCIN S 2 > BLOOD CULTURE Final 08/14/11-1501 Anaerobic bottle: PSEUDOMONAS AERUGINOSA Aerobic bottle: no growth Patient transferred to [**Hospital1 18**]-[**Location (un) 86**], ID fellow notified at [**Hospital1 18**]. 1. PSEUDOMONAS AERUGINOSA Target Route Dose RX AB Cost M.I.C. IQ ------ ----- ------------------ ------ -- ------ --------- ------ CEFTAZIDIME R 32 CEFTRIAXONE R >=64 CIPROFLOXACIN S <=0.25 GENTAMICIN S <=1 IMIPENEM S 2 LEVOFLOXACIN S 0.5 TOBRAMYCIN S <=1 Bcx from [**Hospital1 18**] - negative or NGTD Cdif negative IMAGING/STUDIES ECG: Probable atrial fibrillation with controlled response. Vertical axis. Intraventricular conduction delay. ST-T wave abnormalities. Since the previous tracing of [**2172-6-4**] the axis is more right inferior. ST-T wave abnormalities are less prominent. CT head w/o contrast Evaluation is slightly limited given patient motion. However, no evidence of acute intracranial process. TTE: EF 25-30%. Compared with the prior study (images reviewed) of [**2172-5-6**], the severity of mitral and aortic regurgitation have increased. Estimated pulmonary artery pressures are lower (may be UNDERestimated). Overall left ventricular systolic function appears slightly less vigorous. TEE: EF 30-35%. No masses or vegetations seen. Moderately depressed left ventricular systolic function. Compared with the prior study (images reviewed) of [**2172-5-11**], the suggestion of a probable mitral valve vegetation is no longer appreciated. CT Abdomen and pelvis without contrast 1. Colonic pneumatosis of the cecum and right colon, which could be representative of either a vascular insult or an infectious process. 2. Moderate amount of pelvic free fluid is noted. 3. Colonic diverticula without evidence of diverticulitis. 4. Bilateral pleural effusions. 5. Gallstones without evidence of cholecystitis. RUQ ultrasound: IMPRESSION: 1. Normal liver parenchyma. 2. Cholelithiasis. 3. No ascites. KUB: Findings consistent with pneumatosis about the cecum and ascending colon as demonstrated on the [**2172-7-15**] CT scan. No findings to suggest obstruction. Colonoscopy Contents: There was stool within the colon that was washed away to visualize the mucosa Mucosa: Normal mucosa was noted throughout the colon. There was no finding to explain the cecal pneumatosis. The vascular appearance of the colon was also normal. There was no signs of ischemia or a malignancy Protruding Lesions Medium non-bleeding external hemorrhoids were noted. Excavated Lesions Multiple diverticula with mixed openings were seen of moderate severity in the descending and sigmoid colon and mild severity in the proximal colon Impression: Diverticulosis of the ascending colon, transverse colon, descending colon and sigmoid colon External hemorrhoids Stool in the colon Normal mucosa in the colon Otherwise normal colonoscopy to cecum Recommendations: Further recommendations per the inpatient GI team Patient should have a repeat screening colonoscopy at some point with a better preparation to rule out smaller polyps that could have been missed in the setting of a fair bowel prep. These findings do not explain the patient's recurrent bacteremia or his ct scan finding of cecal pneumatosis CXR: Appropriately positioned right upper extremity PICC line. MRCP without contrast: 1. Stable bilateral pleural effusions. 2. Trace ascites. 3. Cholelithiasis without cholecystitis. 4. Multiple cysts in the right kidney. CT chest 1.Bilateral simple minimal pleural effusions. 2.No lung consolidation 3.Pulmonary artery hypertension. 4.Mild cardiomegaly with severe coronary artery atherosclerotic calcifications. 5.Minimal perihepatic fluid. DISCHARGE LABS: [**2172-7-24**] 08:28AM BLOOD WBC-8.6 RBC-3.96* Hgb-11.6* Hct-35.9* MCV-91 MCH-29.2 MCHC-32.2 RDW-18.2* Plt Ct-224 [**2172-7-22**] 06:30AM BLOOD Neuts-76.4* Lymphs-13.7* Monos-5.8 Eos-3.5 Baso-0.6 [**2172-7-19**] 08:10AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ [**2172-7-24**] 08:28AM BLOOD Plt Ct-224 [**2172-7-24**] 08:28AM BLOOD PT-18.8* PTT-38.5* INR(PT)-1.7* [**2172-7-17**] 11:25AM BLOOD Thrombn-91.6* [**2172-7-24**] 08:28AM BLOOD Glucose-164* UreaN-41* Creat-1.5* Na-140 K-5.0 Cl-111* HCO3-18* AnGap-16 [**2172-7-24**] 08:28AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.3 [**2172-7-16**] 05:20AM BLOOD calTIBC-263 Ferritn-527* TRF-202 [**2172-7-20**] 11:02AM BLOOD Ammonia-28 [**2172-7-16**] 05:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2172-7-17**] 04:30AM BLOOD CEA-4.0 PSA-0.4 [**2172-7-23**] 05:30AM BLOOD Vanco-24.0* [**2172-7-18**] 08:05AM BLOOD RedHold-HOLD Brief Hospital Course: Mr. [**Known lastname **] is a 71 y/o male with a history of insulin dependent DM2, CAD s/p MI, ischemic CHF (EF 20%), peripheral neuropathy, CKD stage III-IV, depression and recent admission for multiorganism (Staph. lugdenensis and Strep anginosis [resistant to Clinda/Erythro])endocarditis ([**Date range (1) 107758**]) who presented with recurrent fevers and myalgias. . #. BACTEREMIA: Patient presented with persistent fevers and chills since completing antibiotic course. Concern for treatment failure or recurrent endocarditis. Blood cultures drawn at [**Hospital1 **] [**Location (un) 620**] positive for enterococcus and pseudomonas. He was initially started on levofloxacin and bactrim. This was changed to vancomycin and meropenem for broader coverage. TTE and TEE negative for vegetations. CT abdomen w/o contrast concerning for pneumatosis of cecum, but surgery recommended no intervention at this time. ID following closely, and recommended continuing current antibiotic regimen (vanc and meropenem) for 3 weeks through [**2172-8-4**]. Patient had no adverse reaction to the vancomycin, which was a concern on last admission. He had some diarrhea with the antibiotics, but was C.diff negative. WBC and lactate all trending down. GI consulted and recommended colonoscopy to evaluate for colonic source of bacteremia. The patient was transferred to the ICU overnight [**7-19**] for closer monitoring while taking the moviprep given concern for perforation, but he did fine. After the colonoscopy he was transferred back to the general medical floor. The colonoscopy was normal: no evidence of ulceration or ischemia. An MRCP was done, which did not show evidence of billiary source for bacteremia. CT chest was negative for infectious process. In order to evaluate small bowel process, small bowel capsule study was pursued. The results are pending and will be communicated to patient while he as at rehab. Basically: pseudomonas and enterococcus bacteremia, no obvious source but likely GI tract. Patient will complete a total 3-week course of vancomycin and meropenem. . #. TRANSAMINITIS: Presented with elevated LFTs with normal bili. Tried to discontinue all possible offenders including tylenol, statin, depakote. Also recently discontinued flagyl. Hepatology consulted. Concern for possible microabscesses. MRCP was performed. Both MRCP and CT abdomen showed gallstones but no evidence of obstruction and tbili normal. Hepatitis panel negative. Iron studies not concerning for hemochromatosis. Has not been hypotensive throughout hospital course making shock liver unlikely. Most likely cause is pyogenous spread from blood to liver. Resolving with antibiotics. Statin will need to be restarted as outpatient once LFTs normalize. . # HYPERKALEMIA: He intermittently had elevated K in low 5s which responded to fluid and kayexalate. Likely seconday to poor renal function. Potassium was normalized and low-dose lisinopril was started. If potassium continues to be high, lisinopril can be discontinued. . # COAGULOPATHY: Patient was noted to have elevated coags. Concern was for liver disease vs DIC vs medication (pradaxa) vs antibodies or factor defficiency. All DIC labs were within normal limits. Thrombin time elevated, likely as a result of the pradaxa. A mixing study was inconclusive. The patient was given 1 unit of FFP and vitamin K in the ICU however, coags remained elevated. After transferring back to the floor (1 week after admission), coags began to trend down. . # SYSTOLIC CHF: Started on metoprolol, lisinopril, and ASA. Statin was held in setting of elevated liver enzymes. Lasix dose was changed from 80mg QD to 40mg QD. . # DM2: Initially was started on home regimen however became hypoglycemic requiring D50 and D5 in his fluids. Lantus was held and then restarted at a small dose. Patient is now receiving lantus 5unit [**Hospital1 **] with an insulin sliding scale. The insulin can be uptitrated as needed. . # CAD: Patient denied any chest pain and EKG had no chages compared to old EKG. He was started on Toprol 25mg XL, lisinopril 2.5mg QD, and aspirin 81mg QD. Isosorbide 20mg tid was continued. . # ATRIAL FIBRILLATION: CHADS of 3 (CHF, HTN, DM). Was recently started on pradaxa by PCP. [**Name10 (NameIs) **] was held given his coagulopathy and elevated creatinine. Mr. [**Known lastname **] was started on coumadin for his afib on discharge. He will need to have close INR monitoring and titration of coumadin for a goal INR of [**1-9**]. . # HEMATURIA: Patient had blood in his urine twice during admission. This will need to be evaluated further by your PCP and possibly [**Name Initial (PRE) **] urologist. . # CODE STATUS: On this admission, patient stated he was DNR/DNI, which he had discussed with his wife and his lawyer. Contact: home, [**Telephone/Fax (1) 107759**], cell [**Telephone/Fax (1) 107760**], son: [**Telephone/Fax (1) 107761**] . TRANSITIONAL ISSUES: 1. Management of coumadin/INR 2. IV antibiotics for a total of 3 weeks through [**2172-8-4**] 3. Follow-up of small bowel capsule study 4. Hematuria (further work-up needed) 5. Hyperkalemia: currently stable, but will need to be monitored (may need to d/c lisinopril) 6. Trend LFTs 7. Restart statin 8. Neuro-psych evaluation Medications on Admission: 1. Lantus 100 unit/mL Solution Sig: see instructions Subcutaneous twice a day: 5 units in the morning and 40 units in the evening. 2. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 3. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. isosorbide dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. triamcinolone acetonide 0.1 % Cream Sig: One (1) Appl Topical twice a day: Apply to affected area until rash improves. Do not apply to face. Disp:*60 grams* Refills:*4* 7. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. 8. diphenhydramine HCl 12.5 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO every four (4) hours as needed for itching: Sedating medication. Do not drive or participate in other hazardous activities while on this medication. Disp:*30 Tablet, Chewable(s)* Refills:*0* 9. Pradaxa (unknown dosage) 10. Glyburide 10mg in the morning 5mg in the evening Discharge Medications: 1. Lantus 100 unit/mL Solution Sig: Five (5) units Subcutaneous twice a day: This can be uptitrated at rehab if your sugars continue to be elevated. 2. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous at bedtime: As per insulin sliding scale. 3. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO DAILY (Daily). 4. isosorbide dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. triamcinolone acetonide 0.1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 6. furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours): Please take 500mg intravenously through [**2172-8-4**]. 8. vancomycin 500 mg Recon Soln Sig: 2.5 Recon Solns Intravenous Q 24H (Every 24 Hours): Please infuse 1250mg IV every 24 hours through [**2172-8-4**]. 9. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: As directed by your physician at rehab or a coumadin clinic. 10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 12. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for upset stomach. 13. Outpatient Lab Work Please check CBC with diff, chem 10, liver function tests, and vancomycin level on [**2172-7-27**] and [**2172-8-4**]. Please fax these results to the [**Hospital1 69**] Infectious Disease clinic at: [**Telephone/Fax (1) 1419**]. 14. lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for Anxiety: Please hold for oversedation. 15. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: Multi-organism bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you on this admission. You came to the hospital because you were having fevers and chills. Blood cultures showed that you had bacteria in your blood stream. We treated you with strong antibiotics that will end on 8/30th. We put in a PICC line, so that you could get these antibiotics more easily. . We suspected that the bacteria was coming from your gastrointestinal tract. We did a trans-esophageal echo, which did not show endocarditis. We did a colonoscopy that was normal. We did an MRI of your liver and biliary system, which also did not show a cause of your bacteremia. We are currently doing a small bowel capsule study, to evaluate the integrity of your small intestine. These results will be available after you are discharged. You will get a call from the gastroenterologists next week with the results. . We started a medication called coumadin for your atrial fibrillation. You will have to have frequent blood tests to monitor this medication. . Please make the following changes to your medications: 1. Start taking vancomycin 2. Start taking meropenem 3. Start taking coumadin (your INR will need to be checked at rehab, and your coumadin dose adjusted accordingly) 4. Start taking Toprol 25mg XL once a day 5. Start taking lisinopril 2.5mg once a day 6. Stop taking depakote 7. Stop taking atorvastatin (this is a medication for high cholesterol, and it will need to be restarted by your primary care physician as soon as your liver tests normalize. This can be done in the next 2-3 weeks). 8. Stop taking tylenol until your liver enzymes normalize 9. Stop taking lorazepam 1mg three times a day; you can take 1 mg of lorazepam once a night as needed for anxiety 10. Stop taking glyburide 11. We changed your insulin (lantus) to 5units in the morning and 5 units in the evening because your sugar was low. This medication can be uptitrated at rehab if your sugars are high 12. Stop taking dabigatran 13. Stop taking lasix 80mg once a day, and start taking lasix 40mg once a day unless directed otherwise by your doctor. 14. Start taking aspirin 81mg once a day for your heart . You will need to continue antibiotics through [**2172-8-4**]. You will need to follow-up with your primary care physician, [**Name10 (NameIs) **] infectious disease doctors, and the liver specialists. Followup Instructions: Please contact your primary care doctor once you are discharged from rehab to schedule an appointment. . Department: INFECTIOUS DISEASE When: TUESDAY [**2172-8-11**] at 10:30 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. . . Department: LIVER CENTER When: WEDNESDAY [**2172-8-26**] at 11:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**] Completed by:[**2172-7-26**]

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icd9cm

[ [ [] ] ]

[ "45.23", "88.72", "38.93" ]

icd9pcs

[ [ [] ] ]

19994, 20084

11753, 16698

326, 384

20153, 20153

3891, 3891

22716, 23773

2763, 2905

18165, 19971

20105, 20132

17080, 18142

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Discharge summary

report+report+addendum

Admission Date: [**2156-4-5**] Discharge Date: [**2128-3-8**] Date of Birth: [**2115-7-19**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 40 year-old lady with a long history of intractable epilepsy beginning in [**2133**] suffering from both simple, complex partial and generalized seizures. 1) Her simple partial seizures are somatosensory in nature with numbness and tingling over the left face and arm. She also had rising sensation beginning in her stomach. 2) Her complex partial seizures include staring, lip smacking, unresponsiveness. Recently they have also been characterized as episodes where she will "drop her head and become unresponsive." She has two or three of these per week. 3) Her generalized tonic clonic seizures mostly occur during the night, averaging once every other week. Her last generalized tonic clonic seizure occurred three days prior to admission in her sleep with severe tongue [**Last Name (un) 20694**]. Prior to that episode, she had a six to seven minute generalized tonic clonic seizure with aura while shopping with her husband present. [**Name2 (NI) **] generalized seizures are very different in appearance according to her husband. She is followed by Dr. [**Last Name (STitle) 1846**] and admitted to the Neurology Service for seizure localizaton as part of her surgical evaluation. Given the refractory seizures (40 to 60 episodes a month) which usually around her menstrual period, Ms. [**Known lastname 20695**] discussed the possibility of epilepsy surgery last year and agreed to be electively admitted for depth electrode placement under the Neurology Service. She underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 17808**] test on [**2156-3-31**], which demonstrated left hemisphere dominance for language and memory. Her workup for this elective admission included a PET scan which demonstrated hypometabolism in the right medial temporal lobe. She also underwent neuropsychological testing which showed average intellectural abilities, but relative difficulty with test of attention and processing speed. MRI demonstrated polymicrogyria involving the insula with frontal and parietal operculum on the right side. MEDICATIONS BEFORE ADMISSION: 1. Neurontin 400 mg po b.i.d. 2. Trileptal 1500 mg po b.i.d. 3. Keppra 1500 mg po a.m., [**2152**] mg q.p.m. 4. Lasix 125 mg q day. PHYSICAL EXAMINATION: The patient had a temperature of 99.1, blood pressure 114/108, heart rate of 70, respiratory rate 20. Pertinent findings on physical examination is as follows, the patient was an obese female lying in bed in no acute distress. Neck was supple with no carotid bruits. Chest was clear to auscultation bilaterally. Cardiovascular regular rate with normal S1 and S2. Extremities the patient had no clubbing, cyanosis or edema with 2+ dorsalis pedis pulses. On mental status examination the patient had appropriate affect and was oriented with fluent speech, repetition and naming. Memory was 3 out of 3. Registration recall 3 out of 3 at five minutes. The patient had no apraxia, neglect, or frontal signs. Calculation was intact. On cranial nerve examination the patient had a visual acuity of 20/20. Visual fields are intact to confrontation. Pupils were normal, round, 4 mm, 2 mm with light. Extraocular movements intact without nystagmus. The patient had normal facial sensation musculature. [**Last Name (un) 20696**] was symmetric. The tongue was midline. On motor examination the patient had normal tone and bulk with 5 out of 5 strength in upper and lower extremities. On reflex examination the patient had 2+ out of 4 reflexes bilaterally with down going toes bilaterally. Sensory examination was intact to all modalities throughout all dermatomes. Coordination: The patient showed intact finger to nose and intact rapid alternating movements with fine finger movements. The patient's gait was narrowed based, stable with good arm swing. LABORATORY: The patient had a CBC, which showed normal white count. Urinalysis was negative. Chem 7 within normal limits. Calcium, phos and magnesium was within normal limits. HOSPITAL COURSE: The patient was admitted to the Neurology Service after grids were placed on right hemisphere cerebral cortex by Dr. [**Last Name (STitle) 739**] of Neurosurgery. Please see operative report for further details. The patient was transferred in stable condition with head dressing changed by Neurosurgery on a daily basis. During the admission the Neurosurgery Service followed the patient on a daily basis and changed dressings and monitored the status of the surgical site. From a neurology perspective the patient's medications were tapered to induce seizures and aid in localization of her seizures. The patient's Keppra was tapered by 1000 mg q.d. to a dose of 500 mg q.h.s. on Friday [**4-9**] after which the Keppra was discontinued. The patient was also discontinued off of Dexamethasone, which Neurosurgery started after the surgery. All other medications are at her outpatient doses at this time. The patient's baseline video electroencephalogram showed 11 Hz alpha rhythm with sharp features across the A4 to A6, B4 to B6 electrodes with no electrographic seizure recorded. The sharp activity extended posteriorly and superiorly, involving the D5-D7 to G6-G7 leads, corresponding to the suprasylvian frontoparietal regions . The patient's leads were maintained by the epilepsy team after a right craniotomy to achieve the right temporal lobe exposure and include the frontal and parietal regions. Strips were placed to cover the surface of the anterior temporal lobe extending toward the anterior portion of the hippocampus and amygdala. Telemetry ultimately captured [**3-11**] electrographic seizure starting with spike and wave [**Month/Day (3) 20697**] in the PT1-PT2 contact followed some nine seconds later by a high frequency rhythmic burst of sharp [**Month/Day (3) 20697**] in the A4-A6 and B4-B6 contacts. The theta frequency spike and wave [**Month/Day (3) 20697**] evolve in the posterior temporal leads into high frequency high amplitude 32 ms [**First Name (Titles) 20698**] [**Last Name (Titles) 20697**] seen in the A1-A8, B1-B8 contacts as well as the anterior and posterior strips along the temporal lobe. This high frequency high amplitude burst of discharge lasts approximately 100 seconds. On video, the patient can often be seen initially with mouth automatisms including lip smacking. She subsequently develops shaking in her right arm and a tonic posturing in the left upper extremity. Given the activity noted in the superior and posterior leads (G5- G7) from the background telemetry, there was some concern that the entire seizure focus was not being capture. The patient thus is being transferred to the Neurosurgical service for placement of additional electrode strips behind F8 and G8 contacts. These correspond to the superior parietal region. This dictation will be addended by either Dr. [**Last Name (STitle) 10208**] or Dr. [**Last Name (STitle) **] prior to patient's discharge. [**Name6 (MD) **] [**Name8 (MD) 8222**], M.D. [**MD Number(1) 20699**] Dictated By:[**Name8 (MD) 15274**] MEDQUIST36 D: [**2156-4-9**] 07:57 T: [**2156-4-13**] 11:10 JOB#: [**Job Number 20700**] Admission Date: [**2156-4-5**] Discharge Date: [**2156-5-7**] Date of Birth: [**2115-7-19**] Sex: F Service: NEUROLOGY HISTORY OF PRESENT ILLNESS: The patient is a 40 year old woman with a history of intractable seizures involving focal, partial complex and general tonic, clonic seizures. She is admitted status post Grid Electrode Placement for Telemetry monitoring for localization of her seizure activity. She underwent grid placement on [**2156-4-6**] without inter-operative complications. Postoperatively, her vital signs were stable. She was afebrile. She had some right periorbital edema. Her dressing was clean, dry and intact. She had a head CT scan which showed good positioning of the strips in the grid with no evidence of hemorrhage. Vital signs remained stable. She was then transferred to the Neurology Service. HOSPITAL COURSE: On [**2156-4-7**], she was hooked up to EEG Telemetry with no evidence of seizures over the next 24 hours. On [**4-8**], the patient had two complex partial seizures, one lasting 1.5 minutes and the second lasting 2.5 minutes. There was a lucid interval in between for a few minutes. The patient's consciousness was altered and she became unresponsive during the seizures. At that point, her seizure medication was reduced and her antibiotics were discontinued. On [**2156-4-10**], her Keppra was discontinued. On [**2156-4-13**], the patient was taken back to the Operating Room for repositioning of the Grid. Postoperatively she was awake, alert and oriented times three. Cranial nerves were intact. Her motor strength was five out of five in all muscle groups. Sensation was intact to light touch throughout. Her dressing had a little serosanguinous drainage and she was transferred to the regular floor. The patient had a culture that grew out coagulase positive Staphylococcus from the epidural tissue when she was taken back to the Operating Room on [**4-13**]. She was not started on antibiotics and she remained afebrile. On [**2156-4-17**], her Trileptal was discontinued since she has not had any seizures since repositioning of the Grid electrodes. On [**2156-4-18**], the patient had ten seizures after coming off her Trileptal. On the 16th, the patient's vital signs were stable. Temperature maximum was 100.0 F. The patient still had no evidence of seizure activity. On [**2156-4-26**], the patient was taken to the Operating Room for a right temporal lobectomy and removal of the Grid. Inter-operatively there were no complications. There was evidence of epidural wound infection at the time of surgery and the patient was placed on empiric antibiotics and a PICC line was placed. On postoperative check, the patient was opening her eyes to voice, drowsy but awake, alert and oriented. Extraocular muscles were full. No nystagmus. Face is symmetric. Tongue was midline. Motor strength is five out of five in all muscle groups. She was neurologically stable and was in the Recovery Room for management overnight. On [**2156-4-27**], the patient was lethargic but arousable and following commands and oriented times two. She had a left upper extremity paresis, four out of five strength in lower extremity, three out of five strength. A head CT scan shows a question of a hypodensity in the internal capsule. She had left facial weakness, a positive drift and a left hemiparesis. The patient's condition remained stable and she remained in the Neurological Intensive Care Unit for close observation on Neo-Synephrine to keep her blood pressure 200 to 160 and improve brain perfusion. Extremity strength continued to improve on the left side. Deltoids three, grips three, IP is four plus, ATE and [**Last Name (un) 938**] four plus. Gastroc was five; biceps four, triceps four. Right side was five out of five. Persistent left hemiparesis. The patient's steroids were weaned and the patient was transferred to the Regular Floor on [**2156-4-29**]. Infectious Disease Service was consulted due to the increasing infection in the wound. The patient was on oxacillin up to 2 grams intravenously q. four hours for Staphylococcus coagulase positive infection. She had a repeat head CT scan which did show evidence of right middle cerebral artery infarction. The patient continued to have fluctuant fluid collection under the flap dressing. The flap incision continued to have some leakage. Pressure dressings were applied. The patient was seen by Physical Therapy and Occupational Therapy and found to require acute rehabilitation prior to discharge to home. CONDITION AT DISCHARGE: Her condition remained stable. She remained on her intravenous antibiotics, oxacillin intravenously q. four hours checking liver function tests q. week while on oxacillin. DISCHARGE MEDICATIONS: 1. Fluoxetine 20 mg p.o. q. eight hours. 2. Percocet one to two tablets p.o. q. four hours. 3. Furosemide 120 p.o. q. day. 4. Oxacillin 2 grams intravenously q. four. 5. Insulin sliding scale. 6. Keppra [**2152**] mg p.o. q. p.m.; 1500 mg p.o. q. a.m. 7. Oxcarbazepine 1500 mg p.o. twice a day. 8. Neurontin 400 mg p.o. twice a day. 9. Pantoprazole 40 mg p.o. q. 24 hours. 10. Subcutaneous heparin 5000 units subcutaneously q. eight hours. 11. Colace 100 mg p.o. twice a day. CONDITION AT DISCHARGE: The patient's condition was stable at the time of discharge. DISCHARGE INSTRUCTIONS: 1. She will follow-up with Dr. [**Last Name (STitle) 739**] in two weeks for staple removal. 2. She will follow-up with her Neurologist in the [**Hospital 875**] Clinic in one to two weeks. Her condition was stable at the time of discharge. [**Name6 (MD) 742**] [**Name8 (MD) **], M.D. [**MD Number(1) 743**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2156-5-4**] 16:18 T: [**2156-5-4**] 16:21 JOB#: [**Job Number 20883**] Name: [**Known lastname 3466**], [**Known firstname **] Unit No: [**Numeric Identifier 3467**] Admission Date: [**2156-4-5**] Discharge Date: [**2156-4-27**] Date of Birth: [**2115-7-19**] Sex: F Service: Neuromedicine Please see prior dictation for previous details. HOSPITAL COURSE: (Addendum) In summary, the patient is a 40 year old woman with a history of frequent seizures which are described in the previous discharge summary. She was admitted for a subdural grid and strips monitoring for planning of surgical resection. The patient had no electrocardiographic seizures between [**4-9**] and [**4-15**]. She did return to the Operating Room for additional lead placements due to concern of additional foci. She had interictal evidence of sharp activity predominantly in the right mid temporal region extending superiorly and posteriorly to the frontoparietal region. She did have a generalized tonoclonic seizure on [**4-19**], but this was not well localized. She had two more seizures on that day. Clinically these were consistent with generalized tonoclonic seizures. These were felt to localize best to the mid anterior temporal region. Due to several events in one day, the patient was given a dose of Ativan and restarted on a lower dose of Trileptal. This was again discontinued. She had no further clinical events during the monitoring. It was felt that the localization was subsequently captured, and therefore she underwent anterior temporal lobe resection by the Neurosurgical Service on [**4-26**]. She is transferred to the Neurosurgical Service for postoperative monitoring. She will be restarted on all of her preadmission seizure medications. Subsequent hospital course will be dictated at a later date. [**Name6 (MD) 1706**] [**Name8 (MD) 1707**], M.D. [**MD Number(1) 3468**] Dictated By:[**Name8 (MD) 3469**] MEDQUIST36 D: [**2156-4-27**] 14:38 T: [**2156-4-27**] 09:52 JOB#: [**Job Number 3470**]

[ "342.90", "323.4", "E878.6", "997.09", "349.89", "998.59", "345.91", "041.11", "997.02" ]

icd9cm

[ [ [] ] ]

[ "89.19", "38.93", "02.93", "01.59", "99.07", "38.91", "89.14", "99.04", "01.24", "01.22", "01.23" ]

icd9pcs

[ [ [] ] ]

12177, 12673

13586, 15278

12775, 13568

2426, 4172

12689, 12751

7536, 8227

47,466

196,864

49346

Discharge summary

report

Admission Date: [**2131-7-10**] Discharge Date: [**2131-7-13**] Date of Birth: [**2063-7-30**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1**] Chief Complaint: Left inguinal hernia and incarcerated umbilical hernia Major Surgical or Invasive Procedure: Repair inguinal hernia, repair umbilical hernia [**2131-7-10**] History of Present Illness: 67M presented with a chronically incarcerated quite large umbilical hernia and a symptomatic left inguinal hernia. Past Medical History: Hypercholesterolemia Impaired glucose tolerance BPH s/p rotator cuff repair [**2112**] & [**2129**] Left inguinal hernia Cold sores Social History: Pt denies smoking and reports occaisional ETOH consumption (less than once/mth) Family History: Denies any cardiac disease, no history of sudden cardiac death Physical Exam: BP: 115/59 P: 56 R: 12 O2: 95% on 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear Neck: supple, JVP approx 8cm, no LAD Lungs: Inspiratory rales at RLL base, otherwise CTA, no wheezes CV: bradycardic, normal S2, quiet S1, no appreciable m/r/g Abdomen: soft, NT, NABS, no rebound tenderness or guarding, clean dressing over umbilicus and left inguinal area Ext: Warm, well perfused, 2+ pulses, no edema Pertinent Results: [**2131-7-10**] 03:01PM CK-MB-4 cTropnT-<0.01 [**2131-7-10**] 03:01PM CK(CPK)-72 Brief Hospital Course: The patient presented on the day of surgery on [**2131-7-10**] and underwent left inguinal herniorrhaphy and umbilical herniorrhaphy. His operations were uncomplicated and he was taken to the recovery room. Soon after his arrival, he had a bradycardic episode to a heart rate in the 30s and he was hypotensive as well. He had syncope. He was admitted to the surgical service for observation for presumed vasovagal syncope. His EKG and cardiac enzymes were negative x 3. On POD#1, he had another episode of bradycardia, became hypotensive and had syncope. A code blue was called. After this episode, the patient was transferred to the ICU for closer monitoring. Cardiology was consulted. The electrophysiology team recommended a pacemaker for probable sick sinus syndrome vs. vasovagal episodes (the 1st episode related to the perioperative period, the 2nd related to an abdominal binder). The patient did not want a pacemaker, and was counseled on the necessity of the intervention. After several conversations, he reiterated that he did not want to undergo pacer placement and wanted to leave the hospital. Therefore he was discharged home with instructions to follow-up with his PCP> Medications on Admission: Lipitor 10mg PO daily Avodart 0.5mg PO daily Zolpidem 5mg PO daily PRN insomnia Discharge Medications: 1. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:*45 Tablet(s)* Refills:*0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation for 1 months: take with pain meds. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Left inguinal hernia and incarcerated umbilical hernia. Syncope Sinus pause Discharge Condition: Stable. Tolerating regular diet. Pain well controlled with oral medications. Discharge Instructions: You were admitted for elective hernia repair and your post-operative course was complicated by syncopal episodes due to profound bradycardia. You were evaluated by the cardiologist and electrophysiologist who recommended a pacemaker for this arrythmia. You have decided to forego this recommendation. Please understand that this goes against the recommendation of the cardiologist and you acknowledge the risk of this decision. Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Followup Instructions: 1. Surgery: Please call Dr.[**Name (NI) 10946**] office, [**Telephone/Fax (1) 9**], to make a follow up appointment in 1 month. . 2. Electrophysiology/Cardiology: Please call [**Doctor Last Name **] in 4 weeks

[ "V58.67", "E878.8", "790.29", "552.1", "427.89", "600.00", "550.90", "997.1", "780.52" ]

icd9cm

[ [ [] ] ]

[ "53.49", "53.04" ]

icd9pcs

[ [ [] ] ]

3167, 3173

1522, 2710

366, 432

3293, 3372

1412, 1499

5333, 5546

845, 909

2840, 3144

3194, 3272

2736, 2817

3396, 4969

4984, 5310

924, 1393

272, 328

460, 576

598, 732

748, 829

9,481

180,858

20615

Discharge summary

report

Admission Date: [**2157-3-17**] Discharge Date: [**2157-3-27**] Date of Birth: [**2080-5-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4365**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation/extubation Central venous line placement and removal PICC line placement History of Present Illness: Mr. [**Known lastname 12367**] is a 76M with a PMH s/f DM, ventricular ependymoma s/p craniotomy and resection [**2152**], subdural hematoma s/p evacuation in [**2152**], who presents with acute onset of shortness of breath, diaphoresis, and tachypnea at his nursing home. Room air sats at the time were in the 70s. He was given nebulizer treatments and EMS was called. They placed him on a non-rebreather, and brought him to the ED. Of note, the patient is a nursing home resident, and has been on a course of levofloxacin for pneumonia. NH staff have also noticed a new left sided weakness. . On presentation to the ED, vital signs were: T=104.2, BP=159/72, HR=170, RR=30-40, 100% on a NRB. On exam, he was noted to be cool, pale, and diaphoretic. The patient was sedated with fentanyl and midazolam and intubated immediately. Soon after his blood pressure decreased to 104/63. STAT labs revealed a lactate of 7.4, and given his concurrent SIRS criteria, sepsis protocol was initiated. A right IJ central line was placed and the patient recieved 6 liters of NS, 1g of vancomycin and 1g of ceftriaxone. Vitals at the time of sign-out were BP=97/49, HR=119, 99% on CMV with an FiO2 of 100%. The patient was making urine, with a foley in place. A head CT done in the ED showed stable bifrontal SDH with possible subacute component on left, unchanged in appearance from prior study, with stable post operative changes, in addition to chronic ethmoid and left maxillary sinus disease. Past Medical History: [**Month (only) **]-[**2152-3-27**] - L sided weakness, incontinence head CT [**5-/2152**] - large mass arising from the septum pellicidum and growing into the right lateral ventricle; intraventricular tumor synaptophysin pos, chromogranin neg [**2152-6-20**] - craniotomy, resection of mass c/b L hemiplegia D/C to [**Hospital **] Rehab [**2152-8-4**] - MS changes at [**Hospital1 **], repeat head CT showed new B hygromas and L subdural hemorrhage - was evacuated [**2152-8-5**]. Seizure-type activity in postop period. PMHx: 1. 3rd Ventrcle ependymoma s/p craniotomy and resection [**2152-6-20**] 2. SDH s/p evacuation [**2152-8-5**] 3. DM Type 2 Social History: Lives at [**Hospital3 2558**]. Has court appointed guardian- [**Name (NI) 11923**] [**Name (NI) **]. Has no known family. He denies tobacco, EtOH, or IVDA. Family History: NC Physical Exam: T=97.9 BP=114/68 HR=88 RR=24 O2=100% on FiO2 100. . . PHYSICAL EXAM GENERAL: NAD, intubated HEENT: Normocephalic, atraumatic. No scleral icterus. PERRLA CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: Decr BS at left base anteriorly. ABDOMEN: NABS. Soft, NT, ND. EXTREMITIES: No edema, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: sedated , intubated. Responds to pain only Pertinent Results: Labs on admission: [**2157-3-17**] 11:00AM BLOOD WBC-10.5 RBC-4.79 Hgb-15.6 Hct-46.2 MCV-96 MCH-32.6* MCHC-33.8 RDW-13.2 Plt Ct-361# [**2157-3-17**] 11:00AM BLOOD PT-14.8* PTT-24.8 INR(PT)-1.3* [**2157-3-17**] 11:00AM BLOOD Glucose-363* UreaN-29* Creat-1.7* Na-149* K-4.1 Cl-109* HCO3-21* AnGap-23* [**2157-3-17**] 11:00AM BLOOD ALT-24 AST-28 LD(LDH)-259* AlkPhos-79 Amylase-28 TotBili-0.7 [**2157-3-17**] 02:17PM BLOOD CK(CPK)-192* [**2157-3-17**] 02:17PM BLOOD CK-MB-4 cTropnT-0.02* [**2157-3-17**] 09:02PM BLOOD CK-MB-4 cTropnT-<0.01 [**2157-3-18**] 04:45AM BLOOD CK-MB-3 cTropnT-<0.01 [**2157-3-17**] 11:00AM BLOOD Calcium-9.9 Phos-2.3* Mg-2.0 [**2157-3-17**] 11:00AM BLOOD Cortsol-87.8* [**2157-3-17**] 11:00AM BLOOD CRP-291.0* [**2157-3-17**] 03:32PM BLOOD Type-ART Rates-20/2 Tidal V-550 PEEP-5 FiO2-100 pO2-216* pCO2-38 pH-7.35 calTCO2-22 Base XS--3 AADO2-462 REQ O2-78 -ASSIST/CON Intubat-INTUBATED [**2157-3-17**] 11:02AM BLOOD Glucose-344* Lactate-7.4* Na-151* K-3.8 Cl-110 calHCO3-22 . Labs on discharge: [**2157-3-27**] 07:50AM BLOOD WBC-4.5 RBC-3.40* Hgb-10.8* Hct-32.2* MCV-95 MCH-31.8 MCHC-33.5 RDW-13.6 Plt Ct-333 [**2157-3-27**] 07:50AM BLOOD Glucose-152* UreaN-9 Creat-1.0 Na-139 K-3.9 Cl-103 HCO3-29 AnGap-11 [**2157-3-27**] 07:50AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.9 . Microbiology: Blood culture, urine culture, sputum culture no growth to date . EKG [**3-19**] Sinus rhythm. Right bundle-branch block. Left anterior fascicular block. Diffuse non-specific ST-T wave changes. Compared to the previous tracing earlier this date sinus rhythm is now present. . Imaging: CXR [**3-17**]: Hazy lingular opacity likely representing pneumonia versus aspiration. ET and NG tube placement as described above. . CT head [**3-17**]: 1) Chronic bifrontal subdural collections with the left collection remaining slightly hyperdense compared to the right, unchanged in appearance from the prior study. 2) Stable postoperative changes, status post right frontal tumor resection. 3) Chronic ethmoid and left maxillary sinus disease. Brief Hospital Course: Mr. [**Known lastname 12367**] is a 76 year old nursing home resident who presented with a left lower lobe pneumonia who came to the ICU with hemodynamic instability, likely pneumosepsis, was intubated upon arrival, then extubated on [**3-23**], transferred to medical floor. . 1.) Respiratory failure/pneumosepsis: Patient presented with hypoxic respiratory failure, SIRS criteria, lacate 7.4 and left lower lobe pneumonia on chest x-ray. He was intubated, admitted to the intensive care unit, initially treated with broad spectrum antibiotics, volume rescusitated with IV fluids with resolution of his elevated lactate. His antibiotis were weaned to zosyn alone to complete a 14 day coruse. He was successfully extubated with transfer to the medical floor where he remained stable until discharge. Of note, due to his aspiration risk, he was evaluated by speech and swallow with modification of his diet as below. . 2.) Acute renal failure: The patient's Creatnine on arrival was 1.7, with resolution to baseline of 0.9-1.1 after aggressive IVF administration, overall thought likely prerenal cause in setting of sepsis. . 3.) Diabetes: His outpatient lantus, novilin, metformin were initially held given his critically ill state, but were restarted prior to discharge (a lower dose of lantus was initiated as the patient's PO intake was decreased - can be uptitrated as an outpatient). . 4.) Hypertension: The patient's metoprolol and lisinopril were held initially and during his stay in the ICU. These medications were restarted prior to discharge. . 5.) Nutrition: Patient has a history of dysphagia and there was concern for aspiration. He was on tube feeds while intubated. Upon extubation, speech and swallow evaluation was performed, which allowed for softs with 1:1 supervision, which patient tolerated. . 6.) Code status: confirmed DNR/DNI with his health care proxy/gaurdian. . His other medical issues including his left sided hemiparesis and history of subdural hematoma were stable during his hospital course. Medications on Admission: Novolin sliding scale Multivitamin Prilosec 20mg PO daily Cymbalta 30mg PO BID Docusate 100mg PO BID levetiracetam 750mg PO BID Metoprolol 25mg PO q8h Mirtazapine 15mg PO QHS Ativan .25mg PO QHS Bisacodyl 10mg PR PRN Milk of Magnesia 30ml PO daily PRN metformin 500mg PO daily Lisinopril 5mg PO daily Lantus 18 units QHS Albuterol neb prn sob Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 5. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Ativan 0.5 mg Tablet Sig: [**1-28**] Tablet PO at bedtime. 9. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal once a day as needed for constipation. 10. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO once a day as needed. 11. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. 14. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One Hundred (100) mL Intravenous Q8H (every 8 hours) for 4 days: through [**3-30**]. 15. Lantus 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary: Pneumonia/sepsis/acute hypoxic respiratory failure Acute renal failure Secondary: 1. Dementia 2. 3rd Ventrcle ependymoma s/p craniotomy and resection [**2152-6-20**] 3. SDH s/p evacuation [**2152-8-5**] 4. Diabetes mellitus 5. Hemiplegia 6. Dysphagia 7. Depressive type Psychosis Discharge Condition: Stable. Discharge Instructions: You were admitted to the hospital with respiratory failure from pneumonia, which resolved with treatment. Please take medications as directed. Please follow up with appointments as directed. Please contact physician if develop shortness of breath, chest pain/pressure, fevers/chills, any other questions or concerns. Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2007**] in the next 1-2 weeks.

[ "785.52", "038.8", "296.20", "486", "298.9", "584.9", "518.81", "432.1", "401.9", "787.20", "995.92", "250.00" ]

icd9cm

[ [ [] ] ]

[ "33.22", "96.04", "33.24", "38.93", "96.72" ]

icd9pcs

[ [ [] ] ]

9138, 9208

5382, 7419

324, 410

9543, 9553

3317, 3322

9921, 10087

2800, 2804

7813, 9115

9229, 9522

7445, 7790

9577, 9898

2819, 3298

276, 286

4334, 5359

438, 1935

3336, 4315

1957, 2610

2626, 2784

44,718

165,918

26947

Discharge summary

report

Admission Date: [**2194-7-19**] Discharge Date: [**2194-7-21**] Date of Birth: [**2154-4-1**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5129**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: none History of Present Illness: History of Present Illness: 40 year old female with no prior medical history s/p screening colonoscopy with removal of sessile polyp 6 days PTA. Yesterday afternoon, patient felt as if she needed to have a bowel movement. Shortly thereafter, she had diarrhea with blood, bright red on toilet paper. She continued to have diarrhea and blood throughout the day yesterday. Total of 7 episodes, last one this am. Sitting and standing causes dizziness. Last night at 6pm, she had a syncopal episode, no head strike. Denies vomiting, chest pain/SOB, fever. No easy bruising or bleeding. She intially presented to the NWH ED with her symptoms, where she received 2L of NS and was found ot have a Hct 30.2. She was subsequently transferred from NWH ED to [**Hospital1 18**] for further management. In the ED, initial VS were: 97.4 83 99/71 16 100% RA. Physical exam was notable for pale conjunctiva, no abdominal tenderness, and Guaiac positive frank red blood. Hct of 29.5. GI was consulted and fellow recommended ICU admission so that they could perform colonoscopy either tonight or tomorrow. Vitals on transfer: 98.4, 74, 108/83, 16 and 98% RA. Past Medical History: none Social History: From [**Location (un) **], MA where she lives with her husband and 2 children (age 3 and 9). She is a middle school Spanish teacher. - Tobacco: Never smoked - Alcohol: Social - Illicits: Never used illicits. Family History: - + Colon Ca in father, diagnosed when age 53 - + thyroid disease and DM - No known family history of bleeding disorders - No known family history of IBD Physical Exam: Admission Physical Exam: Vitals: T: 99.3 BP: 120/73 P: 79 R: 18 O2: 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple. Lungs: Clear to auscultation bilaterally. No wheezes or crackles. CV: Regular rate and rhythm. Normal S1 + S2. II/VI SEM at the RUSB, rubs, gallops Abdomen: BS+. Soft. Non-tender, non-distended. No rebound tenderness or guarding. No organomegaly GU: No foley Ext: WWP. 2+ DPs. No clubbing, cyanosis, or edema. ICU Discharge Exam: VS: 98.6 89 126/70 20 98/RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple Lungs: Clear to auscultation bilaterally. No wheezes or crackles. CV: Regular rate and rhythm. Normal S1 + S2. I/VI SEM at the RUSB, rubs, gallops Abdomen: no hyperactive BS. Soft. Non-tender, non-distended. No rebound tenderness or guarding. No organomegaly GU: No foley Ext: WWP. 2+ DPs. No clubbing, cyanosis, or edema. Pertinent Results: Initial labs: [**2194-7-19**] 02:25PM BLOOD WBC-9.7 RBC-3.28* Hgb-10.0* Hct-29.5* MCV-90 MCH-30.5 MCHC-33.9 RDW-13.3 Plt Ct-298 [**2194-7-19**] 02:25PM BLOOD PT-11.4 PTT-27.1 INR(PT)-0.9 [**2194-7-19**] 02:25PM BLOOD Glucose-100 UreaN-13 Creat-0.8 Na-142 K-3.6 Cl-110* HCO3-24 AnGap-12 [**2194-7-20**] 05:02AM BLOOD Calcium-8.0* Phos-2.3* Mg-2.0 [**2194-7-19**] 11:29PM BLOOD WBC-9.6 RBC-3.05* Hgb-9.5* Hct-26.9* MCV-88 MCH-31.1 MCHC-35.2* RDW-12.7 Plt Ct-285 [**2194-7-20**] 05:02AM BLOOD WBC-9.1 RBC-2.91* Hgb-9.1* Hct-25.6* MCV-88 MCH-31.2 MCHC-35.4* RDW-12.7 Plt Ct-260 [**2194-7-20**] 11:45AM BLOOD Hct-28.0* Brief Hospital Course: 40 year old female with no prior medical history, admitted to the ICU with lower GI bleed s/p colonoscopy and sessile polypectomy. . # Lower GI bleed: Patient with frank blood on rectal exam in the ED. Most likely cause of the patient's GI bleed is post-procedural bleed [**1-22**] screening colonoscopy with polypectomy that was done 6 days PTA. She was admitted to the ICU for monitoring and serial hct. The patient was initially prepped for repeat colonoscopy, but since she could not tolerate the prep and had stable hct and no further BRBPR, colonoscopy was deferred. She was kept NPO except clears, on maintenance IVF, pending further decision by gastroenterology to pursue repeat colonoscopy later during this admission. ASA and NSAIDs were avoided and HSQ was held. The patient was transferred out of the ICU on [**7-20**]. She was able to advance her diet and had no further bleeding, remained hemodynamically stable, and her HCT remained stable between 26 and 27. She was discharged home on iron supplementation. . Medications on Admission: OCP Multivitamin Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 2. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Lower GI bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for gastrointestinal bleeding following a colon polyp removal a week previously. The bleeding appears to have stopped without intervention. Your blood counts should be followed by your primary physician as an outpatient. Followup Instructions: Call your Primary Care Physician [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 3070**] to be seen within one week of discharge for repeat bloodwork (including hematocrit) if no further symptoms. Call Dr. [**Last Name (STitle) 931**] or come to the Emergency Department if you develop further bleeding or if new symptoms develop.

[ "998.11", "V16.0", "455.0", "285.1", "784.0", "V12.72", "E878.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4908, 4914

3577, 4605

331, 337

4973, 4973

2937, 3554

5387, 5759

1779, 1935

4672, 4885

4935, 4952

4631, 4649

5124, 5364

1975, 2445

2461, 2918

264, 293

393, 1509

4988, 5100

1531, 1537

1553, 1763

29,359

199,889

33630

Discharge summary

report

Admission Date: [**2158-6-28**] Discharge Date: [**2158-7-11**] Date of Birth: [**2096-1-5**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Right Lung Cancer Major Surgical or Invasive Procedure: [**2158-6-28**] Flexible bronchoscopy, Upper endoscopy, Right thoracotomy. Right carinal pneumonectomy with anastomosis of distal trachea to left mainstem bronchus and Cervical mediastinoscopy. [**2158-6-29**] Inspection of anastomosis site and therapeutic aspiration of secretions. [**2158-7-1**] Flexible bronchoscopy. [**2158-7-3**] Flexible bronchoscopy with video recording. [**2158-7-6**] Flexible bronchoscopy and redo right thoracotomy and pericardial flap repair of bronchopleural fistula. History of Present Illness: Mr. [**Known lastname 22627**] is a 62-year-old gentleman who has a proximal squamous cell lung cancer. The tumor tracked down the bronchus intermedius just at the takeoff of the superior segment and approximately to the level of the carina on flexible bronchoscopy. He is being admitted for a Right Pneumonectomy Past Medical History: Squamous Cell Carcinoma, Right lung Cerebrovascular disease, & Peripheral Vascular disease Asthma GERD/Hiatal Hernia Hypertension ETOH/Former Tabocco Use Social History: Lives w/ wife in [**Name (NI) 17927**]. Maintenance work for the air force, also construction. Smoked [**2-28**] PPD x 40 yrs. Drinks 2-8 cans of [**Male First Name (un) **]/night. Family History: not obtained Physical Exam: General: Appears comfortable and in no respiratory distress; Skin: Warm and dry. No cyanosis. HEENT: No neck mass; No jaundice or cyanosis. Lungs: absence breath sounds on right, decreased breath sounds left no crackles or wheezes Heart: Regular rhythm; No murmur. Abdomen: soft / non tender / non distended Extremities: No edema; DP pulses normal and symmetric. Incision: right thoracotomy site clean/dry/intact. no erythema Neurologic: no abnormalities detected Pertinent Results: [**2158-7-11**] WBC-7.2 RBC-3.26* Hgb-10.0* Hct-29.4* Plt Ct-327 [**2158-7-3**] WBC-6.3 RBC-2.67* Hgb-8.3* Hct-24.0* Plt Ct-343 [**2158-7-4**] WBC-6.7 RBC-3.20* Hgb-9.6* Hct-27.5* Plt Ct-367 [**2158-6-28**] WBC-5.8 RBC-4.18* Hgb-12.9* Hct-37.6* Plt Ct-308 [**2158-7-8**] Glucose-97 UreaN-11 Creat-1.1 Na-137 K-4.4 Cl-96 HCO3-31 [**2158-6-28**] Glucose-90 UreaN-15 Creat-0.7 Na-140 K-3.2* Cl-111* HCO3-22 [**2158-7-11**] BARIUM ESOPHAGOGRAM: Barium passes freely through the esophagus and reaches the stomach. No stricture or extravasation. The patient demonstrates reflux to the cervical esophagus. There are also tertiary non- propulsive movements of the esophagus. Right pneumonectomy with air- fluid level in the right hemithorax. IMPRESSION: 1. No stricture and no extravasation. 2. High-grade reflux into the cervical esophagus associated with tertiary esophageal contractions. [**2158-7-10**]: CXR FINDINGS: In comparison with the study of [**7-9**], there is no significant change. Again there is both air and fluid within the post-pneumonectomy site. Multiple areas of loculated air-fluid levels are seen at the right base. Continued mild shift of mediastinal structures to the right lung. Subcutaneous gas persists. The left lung remains clear. Brief Hospital Course: Mr. [**Known lastname 22627**] was admitted on [**2158-6-28**] and underwent Flexible bronchoscopy, Upper endoscopy, Right thoracotomy, Right carinal pneumonectomy with anastomosis of distal trachea to left mainstem bronchus and Cervical mediastinoscopy. He was transferred to the SICU with a NG tube, right chest-tube, a foley and Bupvacaine Epidural. On POD #1 extubated. APS managing pain control w/ epidural and PCA. Remains NPO and on bedrest. Minimal chest tube output. Bronch was done for inspection- tracheal stump looked healthy. started on post op lopressor. POD#2 chest tube d/c'd. epidural d/c'd. PCA maintained for pain control. POD#3 develop extensive SQ air of chest, neck and face. Bronch was done which showed small pin hole defect just superior to the tracheobronchial anastomosis. right chest tube was inserted and placed to sxn. Broad spectrum IVAB were started- vanco/zosyn. Aggressive cough supression therapy initiated to prevent further disruption of bronchus. POD#5 new onset afib- lopressor increased- converted to SR. POD#6 some stridor noted. Repeat bronch- no change in pin hole area. Given PRBC for post op anemia- HCT 24. POD#8 taken back to the OR for re-do right thoracotomy to repair tracheobronchial defect. right chest tube to water seal.Epidural placed for pain control. POD#10 and POD#1 pt accidently pulled epidural. maintained on PCA. POD# 11 and POD#2 pt transferred from the ICU to the floor. Chest tube remains in place d/t drainage. pathology invasive small cell cancer. [**Last Name (un) 1815**] reg diet. being treated by PT. POD#13 and POD#4 Pca d/c'd and started on po dilaudid which was not effective despite escalating doses. APS re- consulted and pt was started on oxycodone SR and oxycodone IR w/ good effect. POD#14 and POD#15 Pt w/ c/o food sticking in throat. Swallow was negative for stricture. IVAB d/c'd and d/c'd to home on po augmentin x 1 week. Tolerated regular diet and ambulating indep w/ RA oxygen sats 100%. right thoracotomy incision w/ intact staples. Medications on Admission: Albuterol 90 4-puff [**Hospital1 **], benazepril 40 mg daily, cilostazol 100 mg [**Hospital1 **], advair 500-50 [**Hospital1 **], HCTZ 37.5 daily, crestor 20 mg daily, spiriva 18 mcg daily, ASA 81 mg daily, MVI and zantac 75 mg daily Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 3. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). Disp:*120 Tablet Sustained Release(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 8. Hydrochlorothiazide 25 mg Tablet Sig: 1 [**12-28**] Tablet PO once a day. 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:*90 Capsule(s)* Refills:*2* 11. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) puff Inhalation twice a day. 12. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as needed for basal pain control. Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0* 13. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H () as needed for pain. Disp:*80 Tablet(s)* Refills:*0* 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 15. Crestor 10 mg Tablet Sig: Two (2) Tablet PO once a day. 16. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. 17. Prilosec 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* 18. Benazepril 10 mg Tablet Sig: One (1) Tablet PO once a day: this medicine has been decreased and lopressor was added. Disp:*30 Tablet(s)* Refills:*2* 19. Pletal 100 mg Tablet Sig: One (1) Tablet PO twice a day. 20. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Squamous Cell Carcinoma, Right lung Cerebrovascular disease, & Peripheral Vascular disease Asthma GERD, Hypertension, ETOH Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you experience: -Fever > 101 or chills, increased shortness of breath, or chest pain. -Incision develops discharge or increased redness -You may shower, No swimming or bathing for 4 weeks -No driving while taking narcotics Followup Instructions: You have the following follow-up appointments on the [**Hospital Ward Name **] [**Hospital Ward Name 23**] clinical center: [**2158-7-20**] with Dr. [**Last Name (STitle) **] 2:30pm, Dr. [**Last Name (STitle) 3274**] 3pm, and Dr. [**Last Name (STitle) **] at 4pm. On the day of your appointment please report to the [**Location (un) **] radiology for a chest XRAY 45 minutes prior to your appointment. Completed by:[**2158-7-19**]

[ "996.79", "530.81", "998.32", "493.90", "E878.8", "198.89", "162.8", "401.9", "510.0" ]

icd9cm

[ [ [] ] ]

[ "96.05", "33.23", "32.59", "40.11", "34.73", "33.48", "45.13", "34.22" ]

icd9pcs

[ [ [] ] ]

7835, 7886

3376, 5400

338, 839

8053, 8060

2091, 3353

8400, 8833

1576, 1590

5684, 7812

7907, 8032

5426, 5661

8084, 8377

1605, 2072

281, 300

867, 1184

1206, 1361

1377, 1560

30,543

105,372

369

Discharge summary

report

Admission Date: [**2183-10-2**] Discharge Date: [**2183-10-4**] Date of Birth: [**2115-3-22**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Adhesive Tape / Iodine Attending:[**Doctor Last Name 1857**] Chief Complaint: Syncope and chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 3311**] is a 68 yo man with a history of severe CAD s/p MI, 3V CABG (LIMA-LAD, SVG-RCA, sequential SVG-D1-OM) in [**2169**] and multiple PCIs who presents with acute onset chest pain. The patient states that he was in his usual state of health when he woke up this morning [**10-2**]. He was in his kitchen when the next thing he knew he woke up on the floor. He denies any prodrome including dizziness, lightheadedness, vertigo, focal weakness, or aura. He does not know how long he was unconscious, but when he awoke he was experiencing acute onset [**10-8**] retrosternal chest pain. The pain was diffuse and located at the midline. It was not positional and was not acutely associated with nausea or vomiting. It did radiate up to his jaw, which alarmed him since this was exactly what he experienced when he had his MI. He does not think he fell on his chest. He was able to get up on his own, climb the stairs, and call EMS. He was brought to [**Hospital3 **] where he was given ASA and nitro SL without relief of his chest pain. He was started on a TNG drip but still complained of [**10-8**] pain. EKG showed ventricularly paced rhythm with no acute ST or QRS changes from prior. A Troponin-I measurment was 0.14. Myoglobin was 103. His INR was 4.3. An ABG on 2L NC at that time was 7.32/46/95/24/Sat 97%. He was subsequently transferred to [**Hospital1 18**] for possible catheterization. On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He is unable to walk very far due to left leg pain, but states this is due to an established neuropathy. 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. Past Medical History: -CAD s/p MI -CABG [**2169**] (LIMA-LAD, SVG-RCA, SVG-D1-OM) -Hypertension -Hyperlipidemia -Atrial tachycardias, s/p ablation, followed by atrial fibrillation/flutter with AV nodal ablation s/p pacer [**2177**], on warfarin -Neuropathy -Gout -Depression and anxiety Social History: significant for the absence of current tobacco use (smoked from age 16-46 at 1 ppd). There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Gen: WDWN middle aged Caucasian male in NAD, mild distress, mildly diaphoretic. Oriented x3. Mood, affect appropriate. Pleasant. VS: T 96.6, BP 126/77, HR 84, RR 21, O2 sat 100% on 5 L/min NC HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 7 cm. No carotid bruits. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal rate. Normal S1, S2, no murmurs, rubs or gallops. Chest: Pacemaker palpable in L upper chest; Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: soft, NT/ND, No HSM or tenderness. No abdominial bruits. Ext: No clubbing, cyanosis or edema. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2183-10-2**] 02:32PM WBC-6.9 RBC-4.44* HGB-14.0 HCT-40.8 MCV-92 MCH-31.4 MCHC-34.2 RDW-16.3* [**2183-10-2**] 02:32PM PLT COUNT-145* [**2183-10-2**] 02:32PM PT-37.2* PTT-54.8* INR(PT)-4.1* [**2183-10-2**] 02:32PM GLUCOSE-138* UREA N-25* CREAT-1.6* SODIUM-141 POTASSIUM-5.3* CHLORIDE-108 TOTAL CO2-27 ANION GAP-11 [**2183-10-2**] 02:32PM ALT(SGPT)-11 AST(SGOT)-20 LD(LDH)-216 CK(CPK)-131 ALK PHOS-138* AMYLASE-105* TOT BILI-0.4 [**2183-10-2**] 02:32PM LIPASE-44 [**2183-10-2**] 02:32PM ALBUMIN-4.2 CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-2.0 [**2183-10-2**] 02:32PM CK(CPK)-131 CK-MB-12* MB INDX-9.2 cTropnT-0.14* [**2183-10-2**] 05:38PM CK(CPK)-127 CK-MB-14* MB INDX-11.0* cTropnT-0.20* [**2183-10-3**] 06:42AM CK(CPK)-96 CK-MB-NotDone cTropnT-0.12* [**2183-10-3**] 06:42AM Mg-2.0 Cholest-137 [**2183-10-3**] 06:42AM Triglyc-151* HDL-43 CHOL/HD-3.2 LDLcalc-64 LDLmeas-74 ECG [**2183-10-2**] 2:27:24 PM Ventricular paced rhythm at 69 bpm with indeterminate underlying cardiac rhythm, possibly atrial fibrillation. Compared to previous tracing of [**2183-7-26**] no diagnostic change. [**2183-10-2**] CXR In comparison with the study of [**2183-7-24**], there is no change in the appearance of the heart and lungs, or the pacemaker device. No evidence of acute pneumonia. [**2183-10-3**] Rib xray: There is a dual lead left-sided pacemaker with distal lead tips in right atrium and right ventricle. Median sternotomy wires are seen. There is cardiomegaly which is stable. No focal consolidation is seen. Markers have been placed over the right lower rib cage, in this location, no focal fractures are seen. There are no lytic or blastic lesions. Degenerative changes of the lumbar spine are present. Brief Hospital Course: Mr. [**Known lastname 3311**] is a 68 yo man with CAD s/p CABG and multiple subsequent PCIs who presented with a syncopal episode followed by acute onset [**10-8**] CP not relieved by nitrates, slightly elevated cardiac enzymes in the setting of acute renal insufficiency. 1) Chest pain: Given strong history of CAD, his chest pain was initially concerning for cardiac ischemia/ACS and arrhythmia and he was admitted to the cardiac ICU. His cardiac enzymes were minimally elevated (CKMB to 14, TnT to 0.20 with a rise and falling pattern, in contrast to minimal abnormalities in the past at 0.02) and consistent with a NSTEMI, however his chest pain was very atypical in that it was constant and not relieved by nitrates. He has had a recent catheterization in [**Month (only) 216**] with no treatable lesions (and in fact complicated by perforation of the RCA during attempted angioplasty of a chronic total occlusion), and CTA had shown no evidence of aortic dissection. He was transferred to the floor for further management. His chest pain was improved with Dilaudid and Ativan. The benefits of repeat cardiac catheterization were not felt to outweigh the risks, and he was treated medically. He was discharged the following day on medical management with ASA, lovastatin, metoprolol and isosorbide. 2) Syncope - concerning for possiblity of VT/VF arrhythmia given lack of prodromal symptoms in a patient with significant CAD/prior MI. There was no evidence of VT at rate greater than 180 on pacemaker interrogation, however concern would be for slower VT. Other possiblity is orthostatic hypotension although less likely given lack of prodrome and generally feeling well. His ICD was reset to trigger at VT >140bpm. 3) Chronic Systolic and Diastolic heart failure: with slightly reduced EF of 45-50% on recent echo. No evidence for CHF exacerbation at this time, although patient does have elevated right-sided filling pressures as evidenced by elevated JVP. He was continued on metoprolol. 4) Atrial fibrillation s/p pacemaker- paced rhythm in 70's. His warfarin was held as INR supratheraputic. He was set up for outpatient INR recheck and monitoring of Coumadin dosing. 5) Acute renal insufficiency - currently at baseline creatinine compared with prior admission in [**Month (only) 205**], however consistently elevated above baseline one year ago which was normal, suggesting possibly interval worsening of renal failure vs. hypertensive nephropathy. 6) Gout: no acute issues; he was continued on allopurinol daily. 7) Hypertension - currently well controlled; he was continued on metoprolol 8) Hyperglycemia- elevated blood sugar during this admission, however patient has not been diagnosed or treated in the past, with A1C of 5.5% in [**7-5**] therefore not hyperglycemic usually. 9) Hyperlipidemia - he was continued on lovastatin and gemfibrozil. 10) Anxiety and depression - diagnosed following the death of his wife, 5 years ago. Patient states that symptoms improved at this time. He was continued on outpatient regimen of citalopram and chlordiazepoxide. 11) Thrombocytopenia: stable and not worsened from prior values. Medications on Admission: ASA 325 mg daily metoprolol 37.5 mg [**Hospital1 **] lovastatin 40 mg daily isosorbide mononitrate 90 mg daily warfarin 5 mg daily gemfibrozil 600 mg [**Hospital1 **] gabapentin 300 mg tid allopurinol 300 mg daily mirtazapine 30 mg qhs prn citalopram 20 mg daily zolpidem 5 mg qhs prn chlordiazepoxide 5 mg q8h prn Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 3. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. Mirtazapine 15 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 11. Chlordiazepoxide HCl 5 mg Capsule Sig: One (1) Capsule PO every eight (8) hours as needed for anxiety. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1) Chest Pain with rise and fall of cardiac biomarkers consistent with a small non-ST segment elevation myocardial infarction 2) Syncope Secondary Diagnoses: 3) Coronary artery disease, S/P coronary artery bypass grafting, percutaneous coronary interventions, and prior myocardial infarction 4) Hypertension 5) Hyperlipidemia 6) Atrial fibrillation, s/p atrioventricular node ablation and pacemaker implantation 7) Peripheral neuropathy 8) Gout 9) Chronic renal insufficiency 10) Chronic thrombocytopenia Discharge Condition: Good Discharge Instructions: 1)You were admitted to the hospital because you lost consciousness and then had chest pain. You were evaluated with blood tests to check for a heart attack and you had several EKG's. Neither of these showed that you had a significant heart attack. You had your pacemaker checked to evauluate for any arrhythmias that could have caused your fainting episode. None were seen but your pacemaker was reset to be more sensitve. 2)You should have an echocardiogram next week to further evaluate your heart. You should be called on Tuesday to schedule this appointment but if you don't hear from someone by mid afternoon please call to schedule this at [**Telephone/Fax (1) 3312**]. 3)Your coumadin was stopped during this admission because your INR was elevated at 4.1 on admission. You should continue to hold your coumadin over the weekend because your INR was still elevated at 3.6 on saturday. Please have your blood level rechecked on Tuesday at Dr.[**Name (NI) 3313**] office. 4)None of your other medications were changed during this admission. 5) Please call and schedule the follow up appointments listed below. 6) Please call your doctor or return to the emergency department if you experience any worsening of your symptoms including chest pain, loss of consciousness, shortness of breath or any other concerning symptoms. Followup Instructions: 1)You should have an echocardiogram next week. Please call [**Telephone/Fax (1) 3312**] to schedule if you do not hear from someone by mid afternoon. 2)Please call and schedule an appointment to be seen by your cardiologist at the soonest available appointment. 3)Please call Dr. [**Last Name (STitle) 3314**] to schedule an appointment to see him within two weeks of discharge. [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, MSC 12-339

[ "780.2", "786.59", "300.4", "428.42", "428.0", "V45.01", "593.9", "V45.81", "412", "403.90", "274.9", "427.31", "272.4", "585.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9962, 9968

5535, 8693

329, 335

10536, 10542

3786, 5512

11930, 12453

2761, 2843

9058, 9939

9989, 10146

8719, 9035

10566, 11907

2858, 3767

10167, 10515

267, 291

363, 2317

2339, 2605

2621, 2745

10,625

135,886

27797

Discharge summary

report

Admission Date: [**2126-7-27**] Discharge Date: [**2126-7-30**] Date of Birth: [**2094-9-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: Intubation Endoscopy History of Present Illness: Patient is 31yoM with no significant [**Hospital **] transferred from [**Hospital 1474**] Hospital with UGIB. . Patient presented to [**Hospital1 1474**] ED with hematemesis and coffee ground emesis after two episodes of vomiting. He was drinking five beers, and had pizza as well as cocaine that night. He does say that he had severe heart burn a few days prior. He denies prior vomiting. . In OSH, HR 108bpm, BP 118/63, Hct 36. EGD at OSH revealed mass at GE junction and was concerning for arterial bleed. He was intubated for airway protection. Sedation with propofol was not adequate, and patient was biting at ET tube, requiring attempted paralysis. There was then question of seizure activity. His tox screen at the OSH was positive for cocaine and benzodiazepines. Surgery was consulted and [**Last Name (un) **] tube and left femoral cordis were placed prior to transfer to [**Hospital1 18**]. He received two units PRBC and two units FFP at OSH. He was started on nitroprusside for hypertension, but has remained otherwise hemodynamically stable. Patient had been using Naproxen 500 [**Hospital1 **] x 1 week for back pain. . In MICU, patient had an egd which revealed a non bleeding [**Doctor First Name 329**] [**Doctor Last Name **] tear w/ adherent clot at GEJ. The area was injected w epi. He was extubated [**7-28**] with good sats. Past Medical History: Back pain ? Substance abuse Social History: Works as carpet-layer. Married with young son. + ETOH: six pack of beer three times a week. Tox screen pos for cocaine. No tobacco. Family History: Non-contributory Physical Exam: Pertinent Results: [**2126-7-27**] 09:19PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [**2126-7-27**] 08:59PM TYPE-ART TEMP-36.7 PO2-196* PCO2-43 PH-7.37 TOTAL CO2-26 BASE XS-0 INTUBATED-INTUBATED [**2126-7-27**] 08:59PM LACTATE-0.7 [**2126-7-27**] 08:50PM GLUCOSE-87 UREA N-23* CREAT-0.8 SODIUM-145 POTASSIUM-3.7 CHLORIDE-114* TOTAL CO2-24 ANION GAP-11 [**2126-7-27**] 08:50PM ALT(SGPT)-23 AST(SGOT)-23 LD(LDH)-195 CK(CPK)-176* ALK PHOS-48 AMYLASE-10 TOT BILI-0.8 [**2126-7-27**] 08:50PM CK-MB-4 cTropnT-<0.01 [**2126-7-27**] 08:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2126-7-27**] 08:50PM WBC-8.1 RBC-4.30* HGB-13.3* HCT-36.8* MCV-86 MCH-31.0 MCHC-36.3* RDW-12.9 [**2126-7-27**] 08:50PM PT-13.0 PTT-28.5 INR(PT)-1.1 EGD [**2126-7-29**] Findings: -Esophagus: --Mucosa: Erythema and linear erosions of the mucosa were noted in the lower third of the esophagus and gastroesophageal junction. These findings are compatible with esophagitis. --Excavated Lesions: A single linear ulcer with adherent clot was found in the gastroesophageal junction. The ulcer most likely represents [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear. 3 2 cc.Epinephrine 1/[**Numeric Identifier 961**] injections were applied for hemostasis with success. -Stomach: Not examined. -Duodenum: Not examined. Impression: The gastric balloon was deflated with removal of 200cc of NS and [**Last Name (un) **] tube was removed. -Ulcer in the gastroesophageal junction (injection) -Erythema in the lower third of the esophagus and gastroesophageal junction compatible with esophagitis -Otherwise normal EGD to gastro-esophageal junction Brief Hospital Course: A/P: 31yoM with toxicology screen positive for cocaine transferred from [**Hospital 1474**] Hospital with UGIB secondary to [**Doctor First Name **]-[**Doctor Last Name **] tear. . # GIB: Transferred from [**Hospital1 1474**] after intubation and receiving 2U PRBC and 2U FFP. EGD on admission showed [**Doctor First Name **]-[**Doctor Last Name **] tear as above, s/p epinephrine. Pt started on protonix 40 mg IV bid on admission. Hct stable throughout admission to [**Hospital1 18**] [**7-27**]; 40.2 on discharge. Pt advanced from clear liquids to regular diet the day of discharge. Pt given prescription for prilosec 40 mg qd on discharge as his insurance did not cover protonix. Pt also given carafate slurry for pharyngeal discomfort after removal of ET tube. Pt will follow-up with [**Hospital **] clinic at [**Hospital1 **] and per their recommendations will need repeat EGD in two months. . # Skin rash. A cellulitis with multiple pinpoint pustules developed on the pt's forehead in location of mask used while [**Last Name (un) 10045**] tube was in place. Concern for infection given appearance. Pt prescribed seven-day course of keflex and bacitracin prior to discharge. Nasal swab for MRSA will require follow-up. . # HTN urgency: Patient transferred from OSH on nitroprusside gtt. Hypertensive urgency likely in the setting of cocaine use; alcohol withdrawal less likely, with pain/anxiety also possible. Pt was written for ativan 1mg q2h for CIWA>10 but did not require any treatment. Pt was normotensive without any medication for 48 hours prior to discharge. . # Substance abuse: Pt denied addiction to alcohol, cocaine, or other substances, stating use was recreational. Denied further services per social work. Pt counselled regarding substance use in light of recent hospitalization. Medications on Admission: Naproxen Discharge Medications: 1. Carafate 100 mg/mL Suspension Sig: Ten (10) ml PO four times a day for 7 days: Swish and spit or swish and swallow four times daily as needed. Disp:*QS for 7 days QS for 7 days* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). Disp:*30 Capsule(s)* Refills:*0* 4. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day). Disp:*QS for 7 days QS for 7 days* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Upper GI Bleed Discharge Condition: Afebrile, vital signs stable, hematocrit on discharge 40.2 Discharge Instructions: Please contact a physician if you experience vomitting that is bloody or black. . Please contact a physician if you have stools that are bloody or black and tarry. . Please take protonix 40mg twice a day for two weeks and then once a day for the rest of your life. . Please take keflex 500mg every six hours for 7 days. . Please use bacitracin cream to the affected areas of face every six hours for 7 days. . Please take carafate suspension as needed for pain with swallowing. . Please take tylenol for pain instead of other medications that are irritating to the stomach lining. Followup Instructions: Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17025**] within two weeks. Please follow-up with GI - Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD Date/Time:[**2126-8-14**] 9:30. Call [**Telephone/Fax (1) 1983**] to change the appointment. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

[ "796.2", "305.01", "530.11", "305.60", "530.7" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "42.33" ]

icd9pcs

[ [ [] ] ]

6266, 6272

3765, 5569

329, 352

6331, 6392

2005, 3742

7021, 7465

1952, 1970

5628, 6243

6293, 6310

5595, 5605

6416, 6998

1986, 1986

275, 291

380, 1734

1756, 1786

1802, 1936

10,473

153,580

2139

Discharge summary

report

Admission Date: [**2102-6-16**] Discharge Date: [**2102-6-23**] Date of Birth: [**2026-11-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Fevers, Back pain Major Surgical or Invasive Procedure: ERCP History of Present Illness: 75 yo man with a history of CAD, HTN, presents with mid back pain - intial episode of pain on [**6-14**], improved but pain returned on [**6-16**] with fevers to 105 and nausea. Patient presented to ED, noted to have atrial flutter with HR 110's, elevtaed lactate and liver function tests, Patient underwent chest and abdominal CT which demonstrated sludge in GB. Patient was started on esmolol for HR, and anticiotics for cholangitis and was admitted to TSICU. Patient's esmolol gtt was weaned, transitioned to metoprolol for rate control. He underwent ERCP on [**6-16**] which demonnstrated sludge in CBD and stent was placed. On [**6-17**]: [**3-31**] blood cultures from day of admission grew e.coli. Patient defervensced remained hemodynamically stable and was transferred to the floor. Patietn with 2-3L O2 requirement and recieved lasix 20mg IV x 1. . On Transfer to medicine service: Patient reports feeling well, denies abdominal pain, tolerating liquids well, trying solids today, not yet ambulated, mild cough, non-productive, + black formed stool today, no diarrhea, no melena, no brbpr, denies PND, ? mild orthopnea, no le edema, no palpitations, no chest pain, previous anginal pain was SSCP with exertion, + assoc SOB, has not experienced since '[**94**], baseline ex tol - 2 flights of stairs Past Medical History: CAD: Dx'd '[**93**], p/w angina,s/p mult caths '[**93**]-'[**94**] w/PTCA->LAD, PCI->OM1 Hypertension Hypercholesterolemia GERD Hypersensitivity pneumonitis x 2 Past Surgical History: S/p removal of benign vocal cord growth S/p tonsillectomy Social History: Married, Lives with wife, 3 children. Occupation: Sales manager for GE, retired '[**89**] Tobacco: 30 pk yrs, quit 19 yrs ago. ETOH: 1 glass wine per night, never heavy Family History: Mother died at 78 after a bypass operation that resulted in end stage renal disease. Father died at 78 also of coronary disease. Physical Exam: PE: Tm 100.0 HR 86-102 BP 128-146/86-98 RR 20-22 O2 94% on 3L FS 98-116 I/O: -1100cc in past 24 hrs GEN: Pleasant, elderly, lying in bed, NAD HEENT: NCAT, EOMI, OP clear NECK: Supple, JVP 12cm CVS: Irregular rhythm, normal rate, no murmur PUL: [**Month (only) **] BS at bases bl ABD: Soft, NT, ND, NABS RECTAL: Guaiac neg EXT: Trace edema bl, 2+ DP bl NEURO: Alert, oriented, appropriate, grossly non focal Pertinent Results: LABS: LFTs improved HCT low/stable in mid 30's (intermittently low in past) CR nl/stable Blood cultures 3/4 bottles, drawn [**6-16**] + e.coli on [**6-17**]. ecoli sensitive to zosyn. EKG: Aflutter at 85, L axis, Q in III, F, VI, poor RWP. [**6-16**] CT: CHEST AND ABDOMEN/PELVIS WITH CONTRAST -No pulmonary embolism or evidence of aortic dissection. -Dependent atelectasis in both lungs. -Cardiomegaly. -Prominence of CBD, w/out evid of stones, stricture, or mass. -Radiopaque gallstones. -Small hiatal hernia. [**6-16**] RUQ U/S Distended gallbladder with wall thickening; intraluminal sludge and gallstones. Prominent CBD without ductal stones. ERCP recommended. [**6-16**] ERCP: Severe cholangitis. Successful drainage of CBD by stent. [**6-19**] CXR: Linear intersitial coarse opacities, peripheral and basilar process c/w chronic fibrotic interstitial procees s/w UIP. ? CHF [**6-19**] ECHO: LVEF > 55%, 1+ AI, [**1-29**]+ MR [**First Name (Titles) **] [**Last Name (Titles) **], Mod pul artery sys HTN. 5/'[**01**] Stress Echo nl, mild MR and mild AI. Brief Hospital Course: ASSESS: 75 yo man with acute cholecystitis, s/p CBD stent improving on antibiotics, also with new atrial flutter. Patient is moderately rate controlled on lopressor, however has not ambulated, and plan for anticoagualtion this evening. Need to determine best management plan for atrial flutter, likely occurred in the setting of stres/infection, however has not resolved. Patient scheduled for CBD stent removal in [**1-30**] months and recommended also to undergo cholecystectomy. Stent removal is ok on low dose a/c (INR ~1.8) however will need to be off a/c for cholecystectomy. Could either rate control and anticoagulate and hope patient converts after this event, defering CV/ablation until later point, or try TEE cardioversion tomorrow or alternatively ablation. . PLAN: . CHOLECYSTITIS: Patient was maintained on zosyn for a total of 7 days, then changed to levofloxacin and flagyl for another 7 days. Patient defervesced within days of transfer and remained afebrile through the time of discharge. Patient will follow up in approximately 6 weeks with Dr. [**Last Name (STitle) **] for evaluation for cholecystectomy. Dr. [**Last Name (STitle) **] will also coordinate with the gastroenterologist at that time and assist the patient in arranging to have his CBD stent removed. ATRIAL FLUTTER: Patient was noted to be in atrial flutter on admission to [**Hospital1 18**]. His rate was elevated in 120-130's. Patient ws intially rate controlled with lopressor, treated for acute infection. Patient's primary cardiologist Dr. [**Last Name (STitle) **] was consulted as afib persisted. Patient became difficult to rate control and EP was consulted. Patient was started on heparin, had TEE which was neg for clot, underwent DCCV and remained in NSR. CAD: Continue outpatient management with aspirin, metoprolol, and lipitor . PUMP: Patient was midlly volume overloaded after ICU fluid recusitation which responded well to lasix. Echo with preserved EF [**1-29**]+ MR, 1+ AI . PULM: Evidence of chronic interstitial process on CXR. Echo with moderate pulmonary artery systolic HTN. Patient witha history of hypersensitivity penumonitis and an appointment was scheduled with patient's pulmonolgist Dr. [**Last Name (STitle) 11479**] to follow up. . ANEMIA: Hx of intermittently low HCT, Fe studies demonstrate Fe deficiency. Guaiac neg on exam. Up to date w/colonoscopy [**5-31**], adenomatous polyps due again [**6-2**]. Reec outpatient f/u. Medications on Admission: Atenolol 25 Aspirin 325 Protonix 40 Lipitor 20 Folate Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. Disp:*21 Tablet(s)* Refills:*0* 7. Outpatient Lab Work Have your INR "coumadin level" and HCT/hematocrit checked when you see Dr. [**Last Name (STitle) **] on Tuesday. 8. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO once a day for 30 days. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Acute cholangitis Sepsis Atrial Fibrillation Anemia Discharge Condition: Good, VSS in NSR Discharge Instructions: If you have shortness of breath, chest pain, lightheadedness, trouble lying flat, swelling in your legs, abdominal pain or fevers or chills, contact Dr. [**Last Name (STitle) **] or 911 immediately. If you have any black or bloody stools contact your physician [**Last Name (NamePattern4) **] 911 immediately. Please follow up with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **], and Dr. [**Last Name (STitle) 217**] as scheduled. Take all medications as prescribed. Your new medications include warfarin or "coumadin" a blood thinner you will take every night. You will need to have your blood monitored every 3 days until your INR (or coumadin level) is stable and then every week thereafter. You will also need to take antibiotics for one more week. Followup Instructions: You will need to have your INR checked at [**Location (un) **] at Tuesday when you see Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **] - Appointment scheduled for Tuesday [**6-27**] at 1:15pm to review the events of this hospitalization. Dr. [**Last Name (STitle) **] - Appointment is scheduled for Friday [**7-7**] at 10am. Telephone [**Telephone/Fax (1) 5768**]. Office at [**Street Address(2) **]. Dr. [**Last Name (STitle) **] - Appointment scheduled for [**7-18**] at 1:30pm, at [**Street Address(2) **]. in [**Location (un) **] to follow up and prepare for surgery to remove your gallbladder and to arrange removal of your bile duct stent. Telephone: [**Telephone/Fax (1) 9**]. Dr. [**Last Name (STitle) 11479**] in pulmonary. Telephone: His office will call to schedule an appointment.

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Discharge summary

report

Admission Date: [**2181-1-8**] Discharge Date: [**2181-1-31**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Fatigue and unsteadiness Major Surgical or Invasive Procedure: [**2181-1-11**] L craniotomy and subdural evacuation. History of Present Illness: 89M R hand dominant male on coumadin for afib who fell [**10-12**] hitting R side of head with +LOC and amnesia. Had neg. CT at that time for bleed. Since then has had increased fatigue which has worsened significantly worsened over the past 2-3 weeks. Recently more unsteady and has started using walker. Also c/o intermittent mild HA over last 2-3 days. No recent falls or trauma. Has MRI as outpatient which showed 16cmx3.5cmx8cm L frontoparietal SDH. Tx to [**Hospital1 18**] for care. Denies N/V/D/F/C, changes in vision, hearing, saddle anesthesia, urinary retention, or bowel incontinence. Past Medical History: A-fib, HTN, BPH, Venous insufficiency, Mitral valve valvuloplasty, pulmonary HTN, Raynaud's syndrome Social History: Lives with wife in [**Name (NI) **]. Retired. Never smoked. 1 glass of wine daily. Family History: Both sons with AF Sister with PPM/AF Physical Exam: On admission O: T: 97.3 BP:154/105 HR: 18 R 18 O2Sats 96RA Gen: comfortable, NAD. HEENT: Pupils: 4->2 B EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: Irregularly irregular rhythm, reg rate, no murmurs. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 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 diminished to [**3-10**] on RUE. Other wise strength full power [**4-9**] on LUE, LLE, and RLE. No pronator drift. Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2+, 2+ Left 2+, 2+ Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements Pertinent Results: [**2181-1-8**] - CT: Shows L SDH 26mm in its greatest width with mild 3mm subfalcine herniation Labs: hct 47, Plt 215, PTT 27.2, INR 1.9, Chem wnl with Cr 1.0 EKG: Atrial fibrillation, TW inversino III, no ST elevation . [**2181-1-10**] - Duplex: Minimal plaque with bilateral less than 40% carotid stenosis. . [**2181-1-11**] Pathology - Blood and fibrin, consistent with hematoma. (OR specimen) . [**2181-1-12**] Interval resorption of subdural hemorrhage and pneumocephalus with increase in soft tissue swelling at craniectomy site. . [**2181-1-14**] CT chest 1. Bilateral pleural effusions with parenchymal opacities most compatible with compressive atelectasis. No findings worrisome for pneumonia. 2. Lobulated contour of the liver, perhaps of little clinical significance, although the appearance may be due to hepatic congestion in the setting of right heart failure. Consideration of ultrasound investigation is recommended if there is concern for hepatic dysfunction. 3. Marked pancreatic atrophy. 4. Status post sternotomy, mitral valve repair, apparently CABG, and again with very large right atrium. 5. Sludge and/or stones in the gallbladder, but no gallbladder distension. . [**1-15**] EEG EEG Study Date of [**2181-1-15**] ABNORMALITY #1: Throughout the recording, there was loss of faster frequencies over the left side. There were no associated epileptiform discharges. ABNORMALITY #2: Throughout the recording, the background was disorganized, slow, typically in the [**5-12**] Hz frequency range, and admixed with frequent bursts of prolonged moderate amplitude generalized mixed theta and delta frequency slowing. BACKGROUND: As above. HYPERVENTILATION: Could not be performed as this was a portable study. INTERMITTENT PHOTIC STIMULATION: Could not be performed as this was a portable study. SLEEP: No normal waking or sleeping morphologies were noted. CARDIAC MONITOR: Showed an irregularly irregular rhythm with an average rate of 90 bpm. IMPRESSION: This is an abnormal portable EEG due to loss of faster frequencies over the left side, which could suggest underlying cortical and subcortical dysfunction but could also be related to presence of material interposed between the cortex and skull (e.g. subdural hemorrhage). In addition, the background was disorganized, slow, and interrupted by frequent bursts of generalized mixed theta and delta frequency slowing consistent with a mild encephalopathy which suggests dysfunction of bilateral subcortical or deep midline structures. Medications, metabolic disturbances, and infection are among the common causes of encephalopathy. There were no epileptiform discharges noted. No electrographic seizure activity was noted. . [**2181-1-16**] CT Head Since [**2181-1-14**], increase in size of mixed density left subdural hematoma, now with a maximal thickness of 2.1 cm. No significant change in the minimal left to right shift of normally midline structures. Reviewed with Dr. [**Last Name (STitle) 739**] who thought CT essentially stable. . [**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) [**2181-1-18**] 3:36 PM FINDINGS: No DVT was demonstrated in either the right or left leg. . [**1-17**] NON-CONTRAST HEAD CT: No significant change compared to one day prior. Again seen is a mixed density extra-axial fluid collection extending along the left cerebral convexity measuring up to 12 mm in greatest diameter with mass effect and sulcal effacement on the subjacent cortex. Scattered foci of pneumocephalus are also unchanged. The ventricles are stable in size and configuration. There is stable mild subfalcine herniation and 3 mm of rightward midline shift. Periventricular hypoattenuation is consistent with chronic microvascular ischemic disease. Bilateral basal ganglia calcification is noted. Osseous structures are significant for a left frontoparietal craniotomy. Left subgaleal fluid collection has increased in size measuring up to 13 mm, previously up to 10 mm. Bilateral scleral bands noted. NG tube is in the right nostril. IMPRESSION: 1. No significant change in left mixed density subdural hematoma. 2. Increasing left subgaleal hematoma. . [**1-18**] [**Last Name (un) **] DUP EXTEXT BIL FINDINGS: No DVT was demonstrated in either the right or left leg. . [**2181-1-21**] Portable CXR: Moderate cardiomegaly is stable. Bilateral pleural effusions moderate in size, greater on the right side, are grossly unchanged allowing the difference in position of the patient. Bibasilar atelectasis are present. NG tube tip is in the stomach. There is no pneumothorax. Patient is post median sternotomy. There has been improvement with almost complete resolution of mild CHF. . [**2181-1-22**] NON-CONTRAST CT HEAD: There is slightly larger mixed density extra-axial fluid collection extending along the left cerebral convexity measuring up to 2.4 cm in greatest diameter with mass effect and sulcal effacement on the subadjacent cortex. Scattered foci of pneumocephalus are unchanged since [**2181-1-17**]. There is a stable mild subfalcine herniation of 4 mm and slight rightward midline shift. Periventricular hypoattenuation consistent with chronic microvascular ischemic disease is unchanged since [**2181-1-17**]. Bilateral basal ganglia calcification is unchanged since [**2181-1-17**]. A left frontoparietal craniotomy is unchanged since [**2181-1-17**]. The left subgaleal fluid collection measures 12 mm, previously 13 mm, grossly unchanged. The visualized paranasal sinuses and mastoid air cells are unremarkable.IMPRESSION: 1. Slight increased size of left mixed density subdural hematoma. 2. Stable left subgaleal hematoma. 3. No significant change in minimal left to right shift of midline structures. . [**2181-1-22**] CTA Chest- 1. Slightly limited study by motion artifact, particularly vessels in the right lower lobe. No evidence of central or segmental pulmonary embolism. Apparent filling defect within a left lower lobe subsegmental branch raises question of a single subsegmental pulmonary embolus, but diagnosis is not confident because of artifact through this area. If clinically indicated, repeat study could be helpful for further evaluation. 2. 3.7 cm ovoid density seen at the posterior wall of the left atrium, thrombus or mass such as myxoma. Further evaluation with cardiac MRI without and with contrast is recommended. 3. Persistent bilateral pleural effusion with associated compressive atelectasis. . [**2181-1-23**] NON-CONTRAST HEAD CT: IMPRESSION: Exam is slightly limited by motion; however, there is no interval change in regards to the mixed density left subdural hematoma causing minimal midline shift. No new focus of hemorrhage is identified. . [**2181-1-25**] The left atrium is elongated. A possible mass is seen in the body of the left atrium along the posterolateral wall at the mitral annulus at the ostium of the residual left atrial appendage. The right atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Overall left ventricular systolic function is normal (LVEF 60%). Diastolic function could not be assessed. There is no ventricular septal defect. The right ventricular cavity is markedly dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**12-6**]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. A mitral valve annuloplasty ring is present. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2180-10-24**], a left atrial mass is now seen. Consider transesophageal echocardiography for better visualization of the mass. . MICROBIOLOGY [**2181-1-25**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL NEG [**2181-1-24**] BLOOD CULTURE Blood Culture, Routine-FINAL NEG [**2181-1-24**] BLOOD CULTURE Blood Culture, Routine-FINAL NEG [**2181-1-24**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL NEG [**2181-1-24**] URINE URINE CULTURE-FINAL NEG [**2181-1-18**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL NEG [**2181-1-17**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL NEG [**2181-1-17**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL NEG [**2181-1-17**] URINE URINE CULTURE-FINAL NEG [**2181-1-17**] BLOOD CULTURE Blood Culture, Routine-FINAL NEG [**2181-1-15**] URINE URINE CULTURE-FINAL NEG [**2181-1-15**] MRSA SCREEN MRSA SCREEN-FINAL NEG [**2181-1-15**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL NEG [**2181-1-15**] MRSA SCREEN MRSA SCREEN-FINAL NEG [**2181-1-15**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL NEG [**2181-1-10**] URINE URINE CULTURE-FINAL NEG . LABS COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2181-1-31**] 05:50AM 8.6 4.74 15.3 48.0 101* 32.2* 31.8 15.2 253 [**2181-1-30**] 10:00AM 9.4 4.06* 13.2* 40.7 100* 32.5* 32.4 14.4 341 [**2181-1-29**] 05:53AM 10.7 4.02* 12.9* 39.9* 99* 32.0 32.3 14.5 412 Source: Line-PICC [**2181-1-28**] 04:54AM 9.1 3.40* 11.9* 34.0* 100* 34.9* 35.0 14.7 356 Source: Line-PICC [**2181-1-27**] 05:26AM 12.5* 3.75* 12.4* 36.5* 97 33.2* 34.1 14.9 493* ADD ON [**2181-1-26**] 04:45AM 10.5 3.76* 12.4* 36.3* 97 33.1* 34.2 14.8 432 Source: Line-PICC [**2181-1-25**] 10:31AM 11.4* 4.08* 13.1* 39.1* 96 32.1* 33.5 14.8 446* Source: Line-picc [**2181-1-25**] 05:20AM 11.7* 3.91* 12.9* 38.0* 97 33.1* 34.1 14.9 436 Source: Line-PICC [**2181-1-24**] 05:45AM 16.9* 4.59* 15.2 45.9 100* 33.2* 33.2 14.0 425 DIFF ADDED 12:07PM [**2181-1-22**] 05:50AM 12.8* 4.07* 13.3* 40.2 99* 32.6* 33.0 14.5 316 [**2181-1-21**] 02:04PM 12.7* 4.21* 13.9* 42.0 100* 32.9* 33.0 14.8 264 [**2181-1-20**] 06:42AM 11.1* 3.97* 12.9* 39.5* 100* 32.4* 32.6 14.4 204 Source: Line-picc [**2181-1-19**] 05:18AM 12.9* 4.11* 13.5* 40.0 97 32.9* 33.9 15.0 186 Source: Line-picc [**2181-1-18**] 02:58AM 17.7* 4.46* 14.4 43.6 98 32.2* 33.0 14.3 142* Source: Line-ALine [**2181-1-17**] 09:54PM 20.5* 4.62 15.4 44.4 96 33.3* 34.6 15.0 185 Source: Line-ALine [**2181-1-17**] 04:56AM 14.0* 4.57* 14.9 45.1 99* 32.5* 32.9 14.1 142* Source: Line-rt/picc [**2181-1-16**] 04:01PM 14.3* 4.46* 14.5 44.2 99* 32.5* 32.7 14.5 139* Source: Line-PICC [**2181-1-15**] 02:42AM 13.1* 4.40* 14.3 44.5 101* 32.5* 32.2 14.0 145* [**2181-1-14**] 02:36AM 10.1 4.21* 13.5* 41.9 100* 32.1* 32.3 14.0 157 [**2181-1-13**] 04:25AM 8.9 4.24* 13.6* 42.1 99* 32.1* 32.2 14.0 147* [**2181-1-12**] 05:55AM 10.6 4.11* 13.7* 40.6 99* 33.3* 33.7 14.1 162 [**2181-1-12**] 02:38AM 11.6* 4.23* 14.2 43.2 102* 33.7* 33.0 14.4 179 [**2181-1-11**] 02:01AM 10.0 4.57* 14.7 46.0 101* 32.1* 32.0 14.0 173 [**2181-1-10**] 01:16PM 12.9*# 4.32* 13.9* 43.4 100* 32.1* 31.9 14.4 165 [**2181-1-9**] 03:34AM 7.9 4.47* 15.1 45.0 101* 33.8* 33.5 14.3 186 [**2181-1-8**] 02:15PM 7.6 4.71 15.3 46.5 99* 32.6* 33.0 13.9 215 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2181-1-27**] 05:26AM 85* 1 11* 2 1 0 0 0 0 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [**2181-1-31**] 05:50AM 120* 20 0.9 146* 3.81 107 27 CPK ISOENZYMES CK CK-MB cTropnT [**2181-1-17**] 04:59PM 68 NotDone1 0.05*2 [**2181-1-17**] 04:56AM 128 3 0.05*1 . LACTATE [**2181-1-17**] 05:48PM 1.9 [**2181-1-17**] 05:48AM 1.5 Brief Hospital Course: 89 year old gentleman with history of afib on coumadin, presented with SDH status-post evacuation, complicated by hospital acquired pneumonia, CHF exacerbation, new atrial thrombus/mass on CTA and delirium. . #. Subdural hematoma: The patient was admitted to the ICU for VitK and FFP to keep INR <1.4, with q1 hour neurochecks, and blood pressure control to <140 systolic. Was taken to the OR [**1-11**] for L craniotomy and subdural evacuation and tolerated the procedure well. He returned to the ICU and INR was monitored. He had episodes of confusion and globally depressed neuro function. Repeat CT's were negative for hydrocephalus, rebleed, or increased shift. He was transferred to the stepdown unit and slowly his neuro exam improved. He was started on keppra to decrease risk of seizure. Repeat CT head slight worsening but stable. He has follow up with neurosurgery in one month at which time he will have a repeat Head CT and neurosurgery can decide if patient is safe to anticoagulate. . #. Delirium: Likely multifactorial, primarily related to his SDH. AAO x 2. Patient has a waxing and [**Doctor Last Name 688**] mental status. Initially required 1:1 sitter as he would repeatedly attempt to get out of bed at night. He responded to zyprexa which was given qhs with an occasional extra dose prn. During the day, mental status woud improve but still fluctuate. Needs frequent reorientation. The patient should see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to assist with his behavioral issues when he is at rehab. . # L atrial mass: A L atrial mass was noted on a CTA that was obtained in order to work up tachypnea. This is likely a thrombus as the patient has atrial fibrillation and has not been anticoagulated during this hospitalization. He underwent a TTE for further evaluation but this study was unable to distinguish thrombus vs myxoma. Neurosurgery requested a cardiac MRI. However the family was reluctant to agree as they felt patient would not be able to tolerate the study. The patient was delirious and would not be able to lie still for a long period of time. Because the team was unable to confirm presence of thrombus and because a repeat CT head showed slight increase in size of subdural hematoma, the patient was not started on anticoagulation. He was started on daily aspirin. . #. Aspiration risk: The patient was able to pass speech and swallow once his mental status was improved, but the patient was at high risk for aspiration and required 1:1 feeding. See below for dietary recommendations. . #. Congestive heart failure: Acute on chronic right-sided systolic and left-sided diastolic heart hailure. The patient is known to have moderate pulmonary hypertension, RV free wall hypokinesis. Weights and I/Os were monitored. Patient was diuresed with improvement in respiratory status. However this was intially difficult to balance, given that the patient took in minimal PO intake and at times would require IV fluids as he was hypovolemic. Over the last 3 days of admission he has remained euvolemic. 40mg IV lasix can be given prn volume overload. . #. Leukocytosis: The patient developed leukocytosis and tachypnea and there was concern for hospital acquired pneumonia. He completed an 8 day course of vancomycin and zosyn with improvement in his white blood cell count. Cultures remained negative. . #. Atrial fibrillation: The patient remained in atrial fibrillation with rate ranging 50-100. He was not anticoagulated given his SDH. He was started on aspirin. He was continued on lopressor for rate control. . #. Hypertension: Continued metoprolol. BPs on day of discharge ranged from 108-137/62-92. . #. BPH: Patient falled voiding trial and has foley in place. #. Hyperglycemia: On admission, patient was hyperglycemic. FS were monitored and improved. He was not started on hypoglycemics and ISS was discontinued. . #. FEN: ground foods, nectar thick liquids;. . #. Access: PICC line was placed for access. . #. Code: DNR/DNI, confirmed w/ wife; Family requested no pressors or central lines if patient were to decompensate. . #. Communication: Wife [**Name (NI) 794**] [**Name (NI) **]. [**Telephone/Fax (1) 32417**] . Medications on Admission: Lasix 40'', metoprolol 50'', Coumadin 2', Ranitidine 150'', Cyclobenzaprine 5', Clotrimazole, Mupirocin, Triamcinilone Discharge Medications: 1. Aspirin 325 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: One (1) PO BID (2 times a day). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 4. Levetiracetam 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 5. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours). 6. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Five (5) Tablet PO Q 8H (Every 8 Hours): hold for SBP<90 or HR<60. 8. Olanzapine 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 9. Captopril 12.5 mg Tablet [**Last Name (STitle) **]: 0.25 Tablet PO TID (3 times a day): hold for SBP<100. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: Subdural hematoma, hospital acquired pneumonia Secondary: Atrial fibrillation, hypertension Discharge Condition: Vital signs stable, oriented to self and date. Discharge Instructions: You were admitted to the hospital because you fell and developed bleeding into your skull which required surgery. You also developed a pneumonia which required a stay in the intensive care unit. Lastly you were noted to have an abnormal finding on CT scan of your heart. This would require further evaluation. Per discussions with family, it was felt you would benefit from not undergoing those studies. . . Do not start coumadin until you are seen by Neurosurgery. . Please follow up with Neurosurgery in one month. YOu will need a repeat Head CT scan to evaluate interval improvement. . Please have patient seen by Neurology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to assist with behavior issues. . Please call your doctor or return to the emergency room if you develop any worrisome symptoms such as bleeding, lightheadedness, dizziness, passing out, weakness, change in behavior, severe headache, etc. Followup Instructions: Please have patient seen by Neurology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to assist with behavior issues. . Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2181-2-21**] 11:45 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2181-2-21**] 1:00 ( Neurosurgery) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2181-6-5**] 1:40 Completed by:[**2181-1-31**]

[ "788.20", "429.89", "401.9", "428.43", "293.0", "507.0", "276.3", "427.31", "790.29", "416.0", "276.1", "424.2", "348.4", "428.0", "E888.9", "600.00", "852.20" ]

icd9cm

[ [ [] ] ]

[ "01.39", "38.93", "96.6", "99.07" ]

icd9pcs

[ [ [] ] ]

19847, 19926

14472, 18672

285, 340

20071, 20120

2729, 5913

21105, 21677

1215, 1253

18842, 19824

19947, 20050

18698, 18819

20144, 21082

1268, 1567

221, 247

369, 973

1819, 2710

7430, 9180

9189, 14449

1582, 1803

995, 1098

1114, 1199

109

126,055

14798

Discharge summary

report

Admission Date: [**2141-10-13**] Discharge Date: [**2141-11-3**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 6734**] Chief Complaint: Nausea, Vomitting, Abdominal Pain, HTN Urgenc Major Surgical or Invasive Procedure: Upper GI endoscopy Exploratory laparotomy Tunneled hemodialysis catheter in R femoral vein Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 24 y/o F with h/o ESRD, HTN who started peritoneal dialysis during the week of [**2141-10-8**] and presented with a 1 day history of acute onset N/V, sharp abdominal pain on [**2141-10-13**]. (Of note, the patient had presented to the ED on [**10-11**] with hypotension, SBPs in the 80s off after approximately 1.5L was taken off during dialysis in the setting of taking her PO Anti-HTNs. On [**2141-10-11**] she received 0.5L IVF, labs WNL, and was d/c'd home). On the day of admission on [**2141-10-13**], the patient reported that the previous night, she was awoken from sleep with severe, sharp abdominal pain, 6 episodes of frothy emesis, 10+ yellowish BMs without melena or BRBRP.She was admitted for further work- up of this abdminal pain. . In the ED here vitals were as follows: T: 97.0 HR: 101 BP: 240/180 RR: 17 O2sat: 100%RA. She received Labetolol 20mg IV and was subsequently placed on a labetolol drip. She also received ceftriaxone 1gm IV, Flagyl 500mg IV, Dilaudid 0.5-1mg IV q1hr and Zofran. Her abdominal CT showed multifocal areas of small bowel wall thickening. Her peritoneal Cell count was negtaive for SBP. She had some signs of peritonitis and thus surgery was consulted. Her lactate was normal. . Upon arrival to the MICU the patient was mentating well with complaints of diffuse sharp abdominal pain that radiated to the back and diarrhea. She had no headache or visual changes. Past Medical History: - SLE DX ([**2134**] - 16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter Placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). - Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS: 98.4 HR 98 192/131 21 100%RA GEN: Mild Distress, AOx3 HEENT: PEERLA, EOMI NECK: Supple, No LAD, No bruit RESP: CTAB CARD: 2/6 systolic ejection murmur ABD: soft, moderately tender with +/- guarding, BS+ EXTR: Warm well perfused NEURO: Motor Grossly Intact RECTAL: Yellow Stool BACK: B CVAT Pertinent Results: [**2141-11-3**] 08:50AM BLOOD WBC-3.5* RBC-2.55* Hgb-7.8* Hct-23.6* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.8* Plt Ct-176 [**2141-11-3**] 03:55PM BLOOD PT-15.5* PTT-50.8* INR(PT)-1.4* [**2141-11-3**] 08:50AM BLOOD Glucose-121* UreaN-33* Creat-5.2*# Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [**2141-10-26**] 06:15AM BLOOD ALT-11 AST-49* AlkPhos-122* Amylase-186* TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2141-10-26**] 06:15AM BLOOD Lipase-30 [**2141-11-3**] 08:50AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.9 [**2141-10-30**] 06:55AM BLOOD HBsAg-NEGATIVE [**2141-10-17**] 10:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2141-10-25**] 11:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2141-10-25**] 11:56AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2141-10-25**] 11:56AM URINE RBC-0-2 WBC-[**3-15**] Bacteri-FEW Yeast-NONE Epi-21-50 Blood cultures: all negative EKG ([**2141-10-13**]): Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of [**2141-10-2**] there is no significant diagnostic change. CXR ([**2141-10-13**]): No acute cardiopulmonary abnormality. No free air under the diaphragms. CT chest/abdomen/pelvis ([**2141-10-13**]): There is a moderate-sized pericardial effusion, similar in appearance from [**2141-10-13**]. The great vessels are normal in caliber, without aneurysmal dilatation. Evaluation of the great vessels is limited without IV contrast. Interstitial thickening, particularly within the perihilar regions, is suggestive of fluid overload. There is bibasilar atelectasis with a small focus of consolidation in the right lower lobe (2:35) unchanged from [**2141-10-13**], and may reflect aspiration or pneumonia. Scattered bilateral nodules are largely stable from as far back as [**2139-10-9**]. Specifically, there is a 5 mm nodule in the right middle lobe (2:25), two adjacent nodules in the right lower lobe measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule within the left lower lobe. A nodular density seen adjacent and anterior to the right main pulmonary artery (2:23) may reflect a vessel. There is a small right pleural effusion. Axillary lymphadenopathy, with axillary nodes measuring up to approximately 10 mm in short axis, is seen. Ill- defined soft tissue thickening within the hilus bilaterally may reflect hilar lymphadenopathy, but assessment is limited without IV contrast. A catheter is visualized within the visualized right upper extremity, which may reflect a PICC line that terminates within the right subclavian vein. The esophagus is distended and filled with contrast, with marked wall thickening and edema throughout its entire length, a new finding. There is a moderate- sized hiatal hernia. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval development of a moderate amount of free intraperitoneal air, that layers anteriorly and along the anterior abdominal wall. Additional small clustered foci of extraluminal air is seen adjacent to the proximal stomach and the gastroesophageal junction, with a focus of air tracking into the fissure of ligamentum venosum. Additionally, there appears to be air tracking into the anterior subcutaneous tissues in the region of the umbilicus. These findings are all new from the prior CT on [**2141-10-13**], but free air was present on chest radiograph performed [**2141-10-25**]. There is no obvious evidence of extravasation of oral contrast into the peritoneum. Of note, a peritoneal dialysis catheter is in place that could represent a route of entry of intraperitoneal air. The stomach, small bowel, and colon are filled with contrast, without evidence of obstruction. Evaluation for wall thickening is limited without IV contrast. Limited non-contrast views of the liver demonstrates a rounded 1.6 cm x 1.2 cm hypodensity in the right lobe of the liver, previously characterized as a hemangioma. The liver is otherwise unremarkable. The gallbladder, spleen, pancreas, and adrenal glands demonstrate no gross abnormality. Both kidneys are atrophic. Evaluation of solid organs is limited by lack of IV contrast. There is a peritoneal dialysis catheter, coiled within the pelvis, unchanged. There is a large amount of free fluid throughout the abdomen, similar in appearance to the prior study. CT OF THE PELVIS WITHOUT IV CONTRAST: Uterus and rectum are grossly unremarkable. However, assessment of the rectal wall is limited without IV contrast. OSSEOUS STRUCTURES: Bones are diffusely sclerotic, which may be related to renal osteodystrophy. There is bilateral sacroiliitis. IMPRESSION: 1. Interval development of a moderate amount of free intraperitoneal air, new from [**2141-10-13**]. A peritoneal dialysis catheter is in place and could represent the route of entry of free intraperitoneal air. However, as foci of air is seen in the region of the proximal stomach and GE junction in the setting of a recent endoscopy, perforation cannot be excluded, though no frank extravasation of contrast is identified. 2. New dilation and wall thickening of the entire esophagus, a nonspecific finding that could relate to infectious or inflammatory esophagitis; clinical correlation is recommended. Esophagus is contrast-filled possibly representing reflux. Hiatal hernia. 3. Anasarca, with moderate-sized pericardial effusion, pulmonary edema, and small right pleural effusion. 4. Large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. Imaging cannot exclude SBP, which should be evaluated for clinically. 5. Focus of consolidation within the right lower lobe, could represent aspiration or pneumonia, but unchanged from the prior study. Gastric Biopsies ([**2141-10-18**]): Antrum: Corpus-type mucosa, no diagnostic abnormalities recognized. Jejunum: Small intestinal mucosa, no diagnostic abnormalities recognized. UE Venous U/S: No evidence of DVT of the left upper extremity, without thrombus identified within the left subclavian vein. Brief Hospital Course: This is a 24 year old woman with ESRD secondary to SLE (started peritoneal dialysis approximately one week prior to admission), malignant HTN, h/o SVC syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. Her hospital course was complicated by multiple transfers between the MICU and the floor secondary to hypertensive urgency. # Abdominal Pain/Diarrhea: During the patient's admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. Infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. However, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. The patient was empirically placed on IV flagyl, but this was discontinued when stool samples were negative for C.difficile. Serial abdominal exams showed no peritoneal signs. Peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. CT of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. Other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to SLE vasculitis, malignant HTN, or microthrombosis and SLE enteritis. Surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. A heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible GI bleed. With regards to SLE vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to SLE. On [**10-18**], GI performed an EGD which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. Approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. Both cardiac, GI, and pulmonary etiologies were considered for the origin of her epigastric pain. Pericarditis was considered, but her EKG was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. Her lungs were also essentially unchanged from [**2141-10-13**]. However, her abdominal CT on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. As a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. There were no major findings: no evidence of perforation, obstruction, or infection. The patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. At discharge, the patient only complained of some mild incisional pain. # Hypertensive urgency: The patient was initially admitted to the MICU with a blood pressure of 240/180. Her hospital course was complicated by extremely labile HTN and was transferred back and forth between the MICU and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of SBPs > 260. Throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. Her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. Multiple medication regimens were attempted and changed throughout her hospital course. However, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for SBPs > 180. At discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg PO. Her regimen as per Dr. [**Last Name (STitle) 4883**]: Nifedipine SR 90 mg daily Aliskiren 150 mg [**Hospital1 **] Labetalol 300 mg TID Hydralazine 75 mg TID Clonidine patch 0.3 mg/24 hr patch qWed When SBP>180, she then uses a hydralazine sliding scale. When SBP>180, give 25 mg PO hydral every 30 min until SBP<150. You can use this for up to 2-3 hours. In between PO hydral doses, can then also use 10 IV hydralazine. # ESRD: The etiology of the patient's ESRD is secondary to SLE. Her Creatinine on admission was 7.9, which was near her baseline of 8 - 9. During her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. Prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2L per PD. After her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. Initially, the patient adamantly refused hemodialysis. However, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. As a result, after a long coversation with her primary renal physician, [**Name10 (NameIs) **] agreed to restart hemodialysis. A tunneled catheter was placed in her R femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. She underwent hemodialysis two more times prior to discharge. Upon discharge, her electrolytes were back to her baseline. She is expected to undergo hemodialysis (Tues/[**Last Name (un) **]/SAT) as an outpatient. # Anemia: During her admission, the patient's HCT was monitored daily with HCT to low-mid 20's. On [**2141-10-17**], she was found to have guaiac positive stools and her HCT was found to have dropped to a low of 18.6. The patient was transfused a total of 2 units of [**Date Range **] between [**2141-10-17**] and [**2141-10-18**]. Epo Alfa SC was also given on [**2141-10-17**]. She remained hemodynamically stable. GI consulted and EGD results were as stated above. The patient's HCT remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. Between [**2141-10-23**] - [**2141-10-24**], the patient had a HCT drop from 26 to 20 in the setting of occult positive emesis. She received two units of [**Month/Day/Year **] and her HCT returned to 28. GI was aware and planned to perform a non-urgent EGD on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her HCT returned to baseline. However, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her HCt remained stable and near baseline for the remiainder of her hospital course. # H/O Thrombosis: The patient was initially placed on her home dose of warfarin 2mg qd. Her INR on admission was 1.2. She was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. However, this was stopped for her EGD and after she had evidence of a GI bleed. The heparin drip was discontinued on [**10-22**]. The patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in HCT and in preparation for a possible GI intervention. After her surgery, her coumadin was held and she was off the heparin drip, but her INR continued to drift up, getting as high as 2.6 on [**2141-10-30**]. This was mostly attributed to nutritional deficiency [**2-11**] poor PO intake, but there was concern for possible synthetic dysfunction as well. As a result, she was given a test dose of vitamin K, which she responded to well (Her INR came back down to 1.4). As a result, her home dose of coumadin at 2 mg qday was restarted. At discharge, her INR was still sub- therapeutic at 1.4. Of note, the patient has a history of SVC syndrome and had a L subclavian venous thrombosis. During the last few days of her hospital stay, the patient complained of increased tongue swelling and her L face was noted to be slightly more swollen than previously noted. As a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a DVT within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # SLE: Rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. Her outside rheumatologist was also consulted. Both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # Obstructive sleep apnea: The patient was noted to have OSA based on clinical nocturnal exam during admission. Patient attempted 1 trial of CPAP at 2L/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. The paitent stated that she would pursue further work-up and treatment for OSA as an outpatient. While the mask and CPAP machine were at her bedside throughout her hospital course, the patient rarely used it. # Metabolic Acidosis: The patient's bicarbonate on admission was 13. Her baseline is normally between 16-20. She received 150mEq NaHCO3 over 24hrs from [**Date range (1) 43500**]. During her brief returns to the MICU, her HC03 was 18-19, which was presumed to be her baseline at home secondary to her CRF. At discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. Medications on Admission: Nifedipine 60 mg PO daily Labetalol 900 mg PO TID Hydralazine 50 mg PO TID Clonidine 0.3 mg/24hr patch qWED Lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 4 mg daily Warfarin 2mg PO daily Calcitriol 1 mcg daily Calcium carbonate 500mg QID Dilaudid 2mg PO Q4-6hr prn pain Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*30 Patch Weekly(s)* Refills:*2* 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. [**Hospital1 **]:*1500 ML(s)* Refills:*0* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Twice daily (). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): In addition to 75 mg TID, if SBP>180, take 1 tab every 30 min until BP decreases to 150. If no improvement after 2 hours, call your doctor. [**Last Name (Titles) **]:*300 Tablet(s)* Refills:*6* 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). [**Last Name (Titles) **]:*1500 ML(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet Sustained Release(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 5 days. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. [**Last Name (Titles) **]:*30 Capsule(s)* Refills:*2* 13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO once a day. [**Last Name (Titles) **]:*30 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: end stage renal disease malignant hypertension abdominal free air subclavian deep vein thrombosis initiation of hemodialysis Secondary: SLE Anemia Discharge Condition: stable, pain well controlled, blood pressure at baseline Discharge Instructions: You were admitted for abdominal pain and then subsequently had a very long hospital course with high blood pressures, severe abdominal pain, some free air in your abdomen resulting in an exploratory laparotomy. You have also been initiated on hemodialysis on Tuesday/Thursday/Saturday schedule. Please take all medications as prescribed in the list that you will be given at discharge. There have been some changes to your medications. Please call your doctor if you have any worsening abdominal pain, fevers, chills, nausea, vomiting, headache, palpitations, diarrhea or any other concerning symptoms. Followup Instructions: You will see Dr. [**Last Name (STitle) 4883**] at hemodialysis on Tuesday, [**11-7**], [**2141**]. You should have your coumadin level checked at this appointment. Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] to schedule an appointment in [**1-11**] weeks to have your staples removed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**]

[ "710.0", "416.8", "787.91", "782.1", "582.81", "327.23", "787.01", "252.00", "789.06", "786.59", "345.90", "287.5", "518.89", "V12.51", "585.6", "401.0", "V58.61", "564.00", "789.09", "790.92", "276.1", "285.9", "423.9", "789.59", "V45.11", "285.21", "530.81", "276.2", "780.60" ]

icd9cm

[ [ [] ] ]

[ "38.95", "93.90", "99.04", "39.95", "54.11", "38.93", "45.16", "99.07" ]

icd9pcs

[ [ [] ] ]

22059, 22065

9992, 19919

329, 435

22266, 22325

3883, 9969

22979, 23414

3424, 3549

20259, 22036

22086, 22245

19945, 20236

22349, 22956

3564, 3864

244, 291

463, 1906

1928, 3195

3211, 3408

14,908

191,472

21919

Discharge summary

report

Admission Date: [**2132-10-25**] Discharge Date: [**2132-10-30**] Date of Birth: [**2069-4-29**] Sex: M Service: MED Allergies: Penicillins / Morphine / Demerol Attending:[**First Name3 (LF) 2297**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: 63 y/o man with PMH significant for traumatic brain injury following fall in [**2124**]; trach in [**4-10**] and Peg [**7-11**] secondary to failure to thrive; siezure disorder admitted from OSH for PICC placement and further eval of the above. Pt was in his usual state of health at his nursing home until [**2132-10-20**] at which time he developed a temperature of 102.7 and oxygen saturation of 79 percent on room air. He was sent to the [**Hospital1 18**] [**Location (un) 620**] for futher care. There, a CXR showed left lower lobe infiltrate and 5 posterior left sided rib fracutres. By report, pt had recently fallen backward twice at the nursing home. In addition, he was being treated with clindamycin (since [**2132-10-10**]) and levofloxacin ([**2132-10-15**]) for a question of pneumonia. At [**Hospital1 18**] [**Name (NI) 620**], pt was admitted for treatment of his pneumonia and hypernatremia. Initial vital signs included temperature of 102.2, blood pressure 100/68, oxygen saturation 98% on nonrebreather, and respiratory rate of 36. Labs were significant for a WBC count of 14.9 and a sodium of 160. ECG is reported as Sinus tachycardia with no ST or T wave abnormalities. Pt was started on vancomycin and ceftazidime for his pneumonia. Sputum cultures from [**2132-10-23**] grew MRSA and pan resisitent pseudomonas. On [**2132-10-23**], the pt lost IV access and attempts to replace it were unsuccesful. Therefore, his antibiotics were changed to linezolid and ciprofloxacin(wanted to cover gram negatives). By [**2132-10-23**], the patient had also developed complete collapse of the left lung. Pulmonary service was consulted at that time but could not bronch the pt as he had no IV access. Pt often became tachypnic at the outside hospital and required frequent suctioning. Hypernatremia resolved with treatment with free water. On [**2132-10-24**], the pt was sent to [**Hospital1 18**] to have a PICC placed. During PICC placement in IR, the pt developed nausea and CP at approximately 3:30 PM. He was sent to the [**Hospital1 18**] ED for futher evaluation. In the [**Name (NI) **], pt's VS were initially 98.2, 70, 101/53, 18, and 98% on 70% face tent. Pt received vancomycin 1 gm IV and 1 L of NS. ECG in the ED showed mildly [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] at 470-480 and T wave inversion in V1-V4. Pt was evaluated by cardiology and plan was made for medical management. He was placed on a heparin drip for pain control. The first set of cardiac enzymes were negative. Past Medical History: 1. Traumatic brain injury s/p fall in [**2124**] 2. Peg tube placement in [**7-11**] 3. Trach placed in [**4-10**] for post-intubation subglottic tracheal stenosis per [**Hospital1 2025**] records. Currently has T-tube. 4. HIstory of DVT on coumadin with IVC filter 5. Multiple aspiration pneumonia 6. S/P multiple abdominal surgeries for hernia repair 7. Past seizure disorder 8. Anemia 9. History of fungemia Social History: Married. Polish immigrant (speaks some English). Used to be a heavy smoker. Has been a nursing home resident for many years since his TBI. Has several children who are closely involved, one daughter is a CCU nurse at [**Hospital3 **]. Family History: noncontributory Physical Exam: T: 96.6 BP: 127/50 P: 54 RR: 24, O2 sat 95% on 50% TC (pt does not desaturate with nasal cannula, but just prefers not to wear it) Gen: awake, alert, sitting up in chair Skin: warm and dry HEENT: + copious secretions from tracheostomy Heart: bradycardic, regular rhythm, no murmurs, rubs, or gallops Lungs: coarse throughout, moving air much better on the left Abd: soft, nontender, nondistended. Ventral hernia nontender, easily reducible. +bs. Ext: no edema, 2+ distal pulses bilaterally. Pertinent Results: [**2132-10-29**] 04:04AM BLOOD WBC-5.3 RBC-2.93* Hgb-8.4* Hct-25.7* MCV-88 MCH-28.7 MCHC-32.7 RDW-17.3* Plt Ct-382 [**2132-10-28**] 04:00AM BLOOD WBC-7.3 RBC-2.92* Hgb-8.4* Hct-25.9* MCV-89 MCH-28.9 MCHC-32.6 RDW-16.4* Plt Ct-358 [**2132-10-27**] 07:35AM BLOOD WBC-5.6 RBC-3.07*# Hgb-8.7*# Hct-26.9* MCV-88# MCH-28.4 MCHC-32.4 RDW-16.6* Plt Ct-381 [**2132-10-27**] 04:51AM BLOOD WBC-4.7 RBC-2.31* Hgb-6.6* Hct-22.1* MCV-96# MCH-28.6 MCHC-29.9*# RDW-16.0* Plt Ct-312 [**2132-10-26**] 03:50AM BLOOD WBC-7.6 RBC-2.97* Hgb-8.8* Hct-25.8* MCV-87 MCH-29.8 MCHC-34.3# RDW-16.8* Plt Ct-397 [**2132-10-25**] 05:30PM BLOOD Hct-25.0* [**2132-10-25**] 06:03AM BLOOD WBC-8.3 RBC-3.10* Hgb-8.6* Hct-27.7* MCV-89 MCH-27.8 MCHC-31.1 RDW-16.2* Plt Ct-397 [**2132-10-24**] 04:25PM BLOOD WBC-7.0 RBC-2.97* Hgb-8.5* Hct-26.0* MCV-88 MCH-28.5 MCHC-32.5 RDW-15.9* Plt Ct-319 [**2132-10-28**] 04:00AM BLOOD Neuts-71.0* Lymphs-23.2 Monos-4.0 Eos-1.6 Baso-0.2 [**2132-10-29**] 04:04AM BLOOD Plt Ct-382 [**2132-10-29**] 04:04AM BLOOD PT-13.7* PTT-32.5 INR(PT)-1.2 [**2132-10-28**] 04:00AM BLOOD PT-15.6* PTT-36.5* INR(PT)-1.5 [**2132-10-27**] 07:35AM BLOOD PT-16.9* PTT-37.6* INR(PT)-1.8 [**2132-10-27**] 04:51AM BLOOD PT-17.4* PTT-41.8* INR(PT)-1.9 [**2132-10-26**] 03:50AM BLOOD PT-15.2* PTT-35.3* INR(PT)-1.5 [**2132-10-25**] 06:03AM BLOOD PT-14.2* PTT-53.1* INR(PT)-1.3 [**2132-10-24**] 10:14PM BLOOD PT-14.7* PTT-119.1* INR(PT)-1.4 [**2132-10-24**] 04:25PM BLOOD PT-13.1 PTT-30.2 INR(PT)-1.1 [**2132-10-28**] 04:00AM BLOOD Glucose-109* UreaN-14 Creat-1.1 Na-146* K-3.6 Cl-111* HCO3-27 AnGap-12 [**2132-10-27**] 07:35AM BLOOD Glucose-86 UreaN-15 Creat-1.0 Na-149* K-3.5 Cl-114* HCO3-28 AnGap-11 [**2132-10-27**] 04:51AM BLOOD Glucose-732* UreaN-13 Creat-0.9 Na-137 K-3.0* Cl-107 HCO3-25 AnGap-8 [**2132-10-25**] 08:30PM BLOOD K-4.1 [**2132-10-25**] 06:03AM BLOOD Glucose-101 UreaN-28* Creat-1.1 Na-148* K-3.3 Cl-110* HCO3-28 AnGap-13 [**2132-10-24**] 10:14PM BLOOD Glucose-437* UreaN-30* Creat-1.1 Na-145 K-3.4 Cl-108 HCO3-28 AnGap-12 [**2132-10-24**] 04:25PM BLOOD Glucose-69* UreaN-32* Creat-1.2 Na-150* K-4.0 Cl-111* HCO3-30* AnGap-13 [**2132-10-25**] 06:03AM BLOOD ALT-73* AST-32 CK(CPK)-97 AlkPhos-66 TotBili-0.2 [**2132-10-24**] 10:14PM BLOOD CK(CPK)-91 [**2132-10-24**] 04:25PM BLOOD ALT-93* AST-40 LD(LDH)-211 CK(CPK)-113 AlkPhos-65 Amylase-30 TotBili-0.3 [**2132-10-25**] 06:03AM BLOOD CK-MB-2 cTropnT-<0.01 [**2132-10-24**] 10:14PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2132-10-24**] 04:25PM BLOOD CK-MB-1 cTropnT-<0.01 [**2132-10-24**] 04:25PM BLOOD Lipase-14 [**2132-10-29**] 04:04AM BLOOD Calcium-7.4* Phos-3.7 Mg-2.0 [**2132-10-28**] 04:00AM BLOOD Calcium-7.3* Phos-3.7 Mg-1.8 [**2132-10-27**] 07:35AM BLOOD Calcium-7.3* Phos-3.7 Mg-2.0 [**2132-10-27**] 04:51AM BLOOD Calcium-6.0* Phos-3.0 Mg-1.7 [**2132-10-26**] 03:50AM BLOOD Calcium-7.2* Phos-2.4* Mg-2.1 [**2132-10-25**] 06:03AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.9 [**2132-10-24**] 10:14PM BLOOD Calcium-6.9* Phos-2.9 Mg-1.9 [**2132-10-24**] 04:25PM BLOOD Albumin-2.3* Calcium-8.0* Phos-3.3 Mg-2.1 [**2132-10-29**] 04:04AM BLOOD Valproa-38* [**2132-10-27**] 07:35AM BLOOD Valproa-5* [**2132-10-26**] 03:50AM BLOOD Valproa-4* [**2132-10-24**] 04:25PM BLOOD Valproa-20* [**2132-10-30**] 04:33PM BLOOD Hct-28.8* Brief Hospital Course: 1. Respiratory: Mr. [**Known lastname 57453**] presented to the OSH with a pneumonia which grew 3 different bacteria: MRSA and 2 strains of pseudomonas. One strain of pseudomonas was pan-resistant, and the other one was resistant to everything except ceftazidime and pipercillin. While here, the pt remained afebrile and his blood pressure was stable. His oxygen requirement remained the same. He had copious secretions and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 57454**]-out left lung on CXR, and so underwent bronchoscopy on [**10-27**]. It revealed quite a bit of secretions in his upper airways, as well as a 95% dynamic collapse of his trachea distal to the t-tube. In this area there was also what appeared to extrinsic compression of his trachea, and the pulmonary attending recommended a CT scan to evaluate this in the future. After the bronch, he did well with aggressive chest PT, positioning, and guafenesin. He had a vibrating vest placed on his chest which helped break up secretions, but the pt did not tolerate this. He also had scheduled nebs while he was here, as he was wheezing on exam initially. His CXR looked better on discharge although he still has some degree of collapse on his left side. For his pneumonia, given his hx of MRSA and pseudomonas (one of which was sensitive to ceftaz), he was treated with vancomycin and ceftazidime, discharged to finish a 10-day course, 1st day = [**2132-10-24**]. He also had a chest CT done to evaluate the possibility of his trachea being extrinsically compressed, which showed: 1) Narrowed intrathoracic trachea and narrowed right and left main bronchi consistent with tracheomalacia, 2) Enlarged thyroid with slight heterogeneous attenuation of the right thyroid lobe, 3) Bilateral moderate-sized pleural effusions, 4) Right lower lobe atelectasis, 5) Left upper lobe and left lower lobe opacities. There is likely a combination of atelectasis and pneumonia, 6) Left posterior 9th and 10th rib fractures, likely acute, 7) Emphysema. 2. Cardiovascular: On [**10-24**], during placement of a PICC line by interventional radiology the pt developed chest pain. He had an EKG done at that time which showed T wave inversions in V1-V4 but no ST-T changes (none available for comparison). He was begun on a heparin gtt, and his pain resolved. He had negative cardiac enzymes x3 sets. He was begun on an ASA and a statin. His heparin gtt was discontinued the next morning. We attempted to start a beta blocker on him, but his pulse was often in the 40s-50s (sinus bradycardia) and so he did not tolerate it. He was evaluated by cardiology who felt that he could have an echo or ETT as an outpatient to evaluate EF and wall motion abnormalities. It was felt that his chest pain was likely [**3-10**] his 5 broken ribs sustained in a fall 2 weeks ago at the nursing home. For this reason, his ASA, statin, and beta-blocker were all discontinued as we have no evidence that he actually has any coronary artery disease. In terms of his hx of DVT, he takes coumadin 10 mg qd at the nursing home. Coumadin was not one of his medications listed on transfer from [**Hospital1 **]-[**Location (un) 620**]. In our ED, he was begun on a heparin gtt [**3-10**] his chest pain. His coumadin was restarted on [**2132-10-28**] at his home dose. 3. GI: Pt was begun on tube feeds, which were cycled at night per his NH protocol. He tolerated these well and they were quickly advanced to goal without complication. His abd pain that he had in IR had resolved by the time he was admitted to the [**Hospital Unit Name 153**]. 4. Hematology: Pt was anemic on admission at 26. He carries a diagnosis of chronic anemia, and his crit was stable throughout his stay. He received one unit of PRBCs the evening of admission (given the possibility of CAD), but basically hovered in the 25-27 range throughout his stay. He had no signs of active bleeding, and it's recommended that this be followed up as an outpt. His hematocrit was 24.6 at its lowest point, and was 28 on discharge. 5. Neuro: He has been on Depakote for a hx of seizure disorder, and when he came in his level was 20 (goal 50-100). He was placed on his home dosing of depakote ([**Hospital1 **]) but apparently it was only given in the AM, and so his level dropped to 5. This was corrected, and his level should be followed up as an outpt. His level prior to discharge was 35. He had no seizure activity while he was here. 6. Musculoskeletal: He has 5 left-sided posterior rib fractures sustained in a fall at the nursing home 2 weeks ago. For this, his pain was controlled with subcutaneous dilaudid. Medications on Admission: Linezolid 600 mg [**Hospital1 **] Ciprofloxacin 500 mg [**Hospital1 **] Zoloft 100 mg po qd Albuterol nebs q4h prn Dilaudid prn Prilosec 20 mg qd Valproic acid (250 mg in 5 ml syrup) 15 cc qAM, 20 cc qpm Discharge Medications: 1. Valproate Sodium (Bulk) 250 mg/5 mL Syrup Sig: Twenty (20) cc PO QPM (once a day (in the evening)). 2. Valproate Sodium (Bulk) 250 mg/5 mL Syrup Sig: Twenty (20) cc PO QAM (once a day (in the morning)). 3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4-6H (every 4 to 6 hours) as needed for fever, pain. 4. Sertraline HCl 50 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. neb 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing, sob. 7. Hydromorphone HCl 2 mg/mL Syringe Sig: 0.5-1 mg Injection Q6H (every 6 hours) as needed. 8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 9. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 10. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gram Intravenous every twelve (12) hours for 4 days: Last dose 9/26 for a total 10 days treatment. 11. Ceftazidime 1 g Recon Soln Sig: One (1) gram Intravenous every eight (8) hours for 4 days: Last dose on [**11-2**], for a total 10 days treatment. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hospital - [**Location (un) 701**] Discharge Diagnosis: Pneumonia with left lung collapse Discharge Condition: Stable Discharge Instructions: Please take your medications as directed. Please use aggressive chest physical therapy (pt tolerates, despite broken ribs), suctioning, and expectorants (i.e. guaifenesin or humibid). Followup Instructions: please be evaluated by your PCP upon arrival at the NH. Please have your valproic acid level checked 2-3x/wk. Please have your INR checked at the same time, as we have restarted your coumadin.

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3663+55493

Discharge summary

report+addendum

Admission Date: [**2110-5-26**] Discharge Date: [**2110-6-18**] Date of Birth: [**2040-4-7**] Sex: M Service: MEDICINE Allergies: Augmentin / Heparin Agents / Azithromycin / Tape Attending:[**First Name3 (LF) 8487**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Hickman placement ([**2110-6-13**]) - right sublcavian; double tunneled hickman line with c-arm. History of Present Illness: Patient is a 70 year-old male with striatonigral degeneration, history of multiple admissions for hypoxia and respiratory failure who presents with fever. Patient was recently admitted in [**Month (only) **], ([**Date range (1) 16592**]) when he was admitted with hypoxia/respiratory failure. He was found to have a pseudomonal PNA and acute exacerbation of hypoxia at that time was thought to be secondary to thick secretions. He was treated with zosyn x 14 days, vancomycin x 10 days. Initially, the patient required ventilatory support due to hypercarbia but was able to be weaned to trach mask by the end of the second week. Additionally, fluid overload played a component in this. Other things complicating admission were hypernatremia and metabolic alkalosis requiring diamox. Pt was d/cd home on [**2110-5-19**]. Per wife, pt left on the day of discharge at 4 pm. He arrived home and by 8 pm he was spiking a temperature. He has had fevers since then, more noticable in the AM, with the highest morning of admission to 102.5. Because of his continued fevers, and culture sputum results (one of three colonies of pseudomonas came back sensitive to tobra but not to zosyn), a PICC was placed by IR on [**2110-5-22**] as an outpt and he was started on tobramycin IV (360 mg IV q24 hr). He was also started on flagyl PO for diarrhea that resolved. +fatigue; + increased grey secretions this week per wife. Today, PICC line was clogged, the patient was still febrile, and sent to ED per PCP. In the ED, VS on arrival were: T: 100.5; HR: 97; BP: 114/75; RR: 20: 98 on 3L trach mask. He was given flagyl 500 mg IV and levaquin 500 mg IV Past Medical History: 1. Striatonigral degeneration. 2. History of methicillin-resistant Staphylococcus aureus. ([**11-27**] stool) 3. History of vancomycin-resistant Enterococcus. 4. History of multiple aspiration pneumonias. 5. GERD. 6. Diverticulosis. 7. Prostate cancer status post prostatectomy. 8. Hypothyroidism. 9. Tracheostomy. 10. History of bullous pemphigus. 11. History of upper GI bleed. 12. Jejunostomy tube placement. Hospitalizations: [**2108-3-24**]: Pseudomas in sputum txt with zosyn then changed to gent [**2108-4-24**]: Bronch to adjust trach placement and sputum [**2107-11-24**]: fever, hypoxia, inc. secretions txt with ceftaz [**2108-9-24**]:pseudomonas pna, wound infection [**2109-6-24**] fever, UTI, coag negative staph blood infection Social History: Lives with wife, bed bound; no EtOH/drugs/smoking. Has personal care attendent. Family History: NC Physical Exam: VS: T: 96.7; BP: 96/56; HR: 69; RR: 16; O2 95 10L trach collar Gen: Contracted, opens eye, NAD HEENT: Sclera anicteric, OP clear, MMM Neck: Chin to chest, difficult to assess CV: RRR S1S2. Difficult to auscultate Lungs: Prolonged I: E ratio. clear anteriorly with audible wheezes Abd: +BS. Soft, mildly distended. NT Back: Unable to assess Ext: Contracted upper extremities. BLE trace edema Neuro: opens eyes, tracks sometimes. Otherwise cannot assess. Pertinent Results: INITIAL LABS Chemistries ([**2110-5-26**] 08:20PM) GLUCOSE-94 UREA N-47* CREAT-0.9 SODIUM-146* POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-46* ANION GAP-7* MAGNESIUM-2.6 Coags: ([**2110-5-26**] 08:20PM) PT-12.4 PTT-25.4 INR(PT)-1.1 CBC: ([**2110-5-26**] 08:20PM) WBC-9.4 RBC-3.09* HGB-9.2* HCT-28.8* MCV-93 MCH-29.9 MCHC-32.0 RDW-14.5* NEUTS-76.4* BANDS-0 LYMPHS-12.1* MONOS-5.3 EOS-6.1* BASOS-0.2 Lactate: ([**2110-5-26**] 08:33PM) LACTATE-1.1 UA: ([**2110-5-26**] 09:10PM) COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG RBC-[**1-26**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 DISCHARGE LABS Chemistries: ([**2110-6-15**] 03:10AM) BLOOD Glucose-127* UreaN-27* Creat-0.5 Na-143 K-3.9 Cl-99 HCO3-41* AnGap-7* Calcium-8.4 Phos-2.8 Mg-2.2 CBC: ([**2110-6-15**] 03:10AM) BLOOD WBC-5.9 RBC-2.86* Hgb-8.2* Hct-26.8* MCV-94 MCH-28.8 MCHC-30.7* RDW-14.6 Plt Ct-295 VBG: ([**2110-6-15**] 05:40PM) BLOOD Type-MIX Temp-36.4 pO2-50* pCO2-96* pH-7.27* calTCO2-46* Base XS-12 OTHER STUDIES: Initial EKG: sinus in 80s. nl axis. nl intervals. +APCs. ? bigeminy in part of strip vs. APCs. no acute ST changes. Chest AP [**2110-5-26**] IMPRESSION: 1. Right middle lung zone linear atelectasis. 2. Mild cardiomegaly. Brief Hospital Course: Patient is a 70 year old male with striatonigral degeneration, multiple hospital admission for hypoxia and respiratory failure who was recently d/cd on [**2110-5-19**] with a pseudomonal pneumonia who presented with fevers and sputum cultures that grew pseudomonas and later MRSA and with stool positive for c. diff. Required ventilatory support for much of hospital stay, but currently on trach mask, afebrile for many days and improved. 1. Fever: [**Month (only) 116**] have been secondary to tracheobronchitis/PNA (grew pseudomonas on sputum cultures from [**5-28**], [**5-29**], [**5-31**] and [**6-4**]; grew MRSA on sputum cultures from [**5-28**], [**5-29**], [**5-31**], [**6-8**]; grew enterobacter on sputum from [**6-4**]). Was c. diff positive at presentation. Both blood and urine cultures were negative throughout stay. The pulmonary infection was treated with tobramycin, meropenum and vancomycin; the c. diff was treated with flagyl. The patient remained afebrile from [**6-10**] until discharge. 2. Hypercarbic respiratory failure: Was placed on vent on [**5-28**] as ABG showed 7.28/104/63. During this time, the patient produced copious secretions. Initial attempts at weaning were unsuccessfull as the patient would experience apneic episodes on pressure support ventilation. Therefore, he emained on vent until [**6-10**], at which time trials of trach mask were successfully attempted during the day time. From [**6-13**] until discharge, did well back on trach mask. A VBG done on [**6-16**] which showed: 7.40/70/40. 3. Seizure: Patient had seizure like activiy on [**5-28**] (leg twitching, face twitching) which lasted for 15-30 seconds and resolved spontaneously. There was no bladder or bowel incontinence noted (pt. had foley in place). Ativan, 1 mg was given just after event ended. The patient was seen by neurology who thought it may have been due to toxic metabolic, structural, or hypoxia. An EEG showed encephalopathy. No further seizure activity was noted during hospital stay. 4. Anemia: Presented with a Hct of 28.8 from a highly variable baseline (25-35). Was guiac (-) on [**5-31**]. Iron studies of 9/95 showed low iron and TIBC, c/w anemia of chronic disease. On [**6-11**], Hct was 19.8 for which he recieved one unit of pRBCs. No other blood products were needed and the patient's Hct at discharge was 26.8. 5. Abdominal distention: Noted on [**6-2**]. NG was placed and bilious secretions were noted. G-tube was noted to be clogged, so this was re-opened using solution of pancrease and bicarbonate. Over time, the disention diminished and the NG was removed. At discharge, some distention remained, although less than had been noted initially. 6. Right hip fracture: A KUB on [**6-3**] showed a chronic fracture of the right femoral neck. Hip films confirmed this. The patient's wife noted that this was an old fracture and she chose to not work it up any further. 7. Striatonigral degneration: Stable during stay. We continued outpatient medications (Sinemet and Ritalin) 8. Hypothyroid: Stable during stay. We continued outpatient levoxyl. 9. GERD: Stable during stay. We continued outpatient PPI. 10. FEN: Fluids: Initially treated with 1/2 NS, which was later discontinued. For intial hypernatremia, recieved free water boluses. Later in stay, patient was total body overloaded; lasix (20 mg IV initially, then 40 mg IV) was used to take off some of this fluid. Electrolytes: Initially, was slightly hypernatremic. For this, free water was given and sodium corrected. Other electrolytes were repleted PRN. Nutrition: Novasource pulmonary tube feeds were used. 11. PPx: No SC heparin as allergy; pneumoboots. Aggressive bowel regimen. Kinair mattress. PPI. 12. Access: Hickman was placed by surgery on [**2110-6-13**]; a prior PICC was then pulled. 13. Code: DNR but can be ventilate. Confirmed with wife. 14. Communication: Wife, [**Name (NI) **] [**Name (NI) 16593**] [**Telephone/Fax (1) 16594**]. Medications on Admission: Mirapex 1.5 mg QID (8:30 am, 1:30 pm, 6:30 pm, midnight) Sinemet 25/250 mg 1 q8am, .5 1 pm, .5 6 pm Motilium 10 mg 8:30 am, 1:30 pm, 6:30 pm Nexium 40 mg [**Hospital1 **] Robinul 1 mg .5 8:30 am, .5 6:30 pm Ritalin 10 mg 8:30 am, 1:30 pm, 6:30 pm Levoxyl 150 mcg qam Unafiber q8:30 am, q6:30 pm, qmidnight Colace Liq 100mg 8:30am, 1pm, midnight lactulose 10mg/15ml 2-4tablespoons at midnight. Bisacodyl 1 q8am Albuterol Sulfate (2.5mg) q8am, q1pm, q6pm qmidnight. Ipratropium bromide (0.5mg) q8am, q1pm, q6pm qmidnight. Pulmicort Respules (0.5mg/2ml) q8am, q6pm qmidnight Tylenol PRN MOM, fleets enema PRN Ultravate (blisters) PRN Comply (tube feed formula) 4.5 cans over 18 hours - rate of 60 ProMod (protein supplement) 1 scoop per can of comply. Miconazole powder 2% tube site DoubleGuard tube site Furosemide 20mg PRN Flagyl 500mg PRN Duoderm gel chin Mepilax dressing chin NS flushes without heparin Discharge Medications: 1. Pramipexole 0.25 mg Tablet Sig: 1-2 Tablets PO QID (4 times a day). Disp:*240 Tablet(s)* Refills:*2* 2. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* 3. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO Q1PM AND Q6PM (). Disp:*60 Tablet(s)* Refills:*2* 4. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*2* 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 8. Unifiber Oral 9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 MDI* Refills:*3* 10. Aquacel-Ag 1.2-2 X 2 %- Bandage Sig: One (1) Topical Q3 days (). Disp:*10 Bandages* Refills:*3* 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 12. Glycopyrrolate 1 mg Tablet Sig: .5 Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). Disp:*1 MDI* Refills:*3* 14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb IH Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Disp:*qsx1 month Neb IH* Refills:*3* 15. Normal Saline Flush 0.9 % Syringe Sig: One (1) 50 cc normal saline flush Injection once a week. Disp:*qs x 1month 50 cc* Refills:*3* 16. Protein Supplement Packet Sig: One (1) packet PO three times a day: 1 pack three times a day with tube feeds. Disp:*qsx1 month * Refills:*3* 17. Nutren 1.5 Liquid Sig: One (1) 60 cc PO q hour. Disp:*1 month* Refills:*2* 18. Lactulose 10 g/15 mL Solution Sig: Twenty (20) mL PO four times a day. Disp:*3 months* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Pneumonia Discharge Condition: Fair, sats stable, afebrile Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Return to hospital if increasing shortness of breath, significant change in mental status, or persistent fevers. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2110-7-3**] 11:40 Follow up within one week of discharge Name: [**Known lastname 2606**],[**Known firstname 326**] Unit No: [**Numeric Identifier 2607**] Admission Date: [**2110-5-26**] Discharge Date: [**2110-6-18**] Date of Birth: [**2040-4-7**] Sex: M Service: MEDICINE Allergies: Augmentin / Heparin Agents / Azithromycin / Tape Attending:[**First Name3 (LF) 2608**] Addendum: Please note, patient is Full Code. He wants shock but no chest compressions. Discharge Medications: 1. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* 2. Carbidopa-Levodopa 25-250 mg Tablet Sig: [**11-25**] Tablet PO Q1PM AND Q6PM (). Disp:*60 Tablet(s)* Refills:*2* 3. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 4. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*2* 6. Unifiber Oral 7. Aquacel-Ag 1.2-2 X 2 %- Bandage Sig: One (1) Topical Q3 days (). Disp:*10 Bandages* Refills:*3* 8. Glycopyrrolate 1 mg Tablet Sig: .5 Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb IH Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Disp:*qsx1 month Neb IH* Refills:*3* 10. Normal Saline Flush 0.9 % Syringe Sig: One (1) 10 cc normal saline flush Injection once a week. Disp:*qs x 1month 50 cc* Refills:*3* 11. Protein Supplement Packet Sig: One (1) packet PO three times a day: 1 pack three times a day with tube feeds. Disp:*qsx1 month * Refills:*3* 12. Nutren 1.5 Liquid Sig: One (1) 60 cc PO q hour. Disp:*1 month* Refills:*2* 13. Lactulose 10 g/15 mL Solution Sig: Twenty (20) mL PO four times a day. Disp:*3 months* Refills:*2* 14. Mirapex 1.5 mg Tablet Sig: One (1) Tablet PO four times a day. Disp:*120 Tablet(s)* Refills:*2* 15. Domperidone Sig: Ten (10) mg four times a day. 16. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb Inhalation every four (4) hours. 18. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal once a day. 19. Pulmicort 0.5 mg/2 mL Solution for Nebulization Sig: One (1) Neb Inhalation three times a day. Discharge Disposition: Home With Service Facility: [**Hospital 136**] Homecare Discharge Diagnosis: Pneumonia Discharge Condition: Fair, sats stable, afebrile Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 233**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Return to hospital if increasing shortness of breath, significant change in mental status, or persistent fevers. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1385**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 23**] Date/Time:[**2110-7-3**] 11:40 Follow up within one week of discharge [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) 497**] MD [**MD Number(1) 2609**] Completed by:[**2110-6-18**]

[ "V49.84", "494.0", "518.84", "519.09", "008.45", "519.1", "285.9", "428.0", "244.9", "996.1", "707.09", "482.1", "427.31", "482.41", "276.0", "718.49", "V09.0", "349.82", "333.0", "780.39", "V09.80" ]

icd9cm

[ [ [] ] ]

[ "96.72", "97.23", "99.04", "96.6", "38.93", "33.24" ]

icd9pcs

[ [ [] ] ]

15031, 15089

4805, 8808

314, 412

15143, 15173

3456, 4782

15434, 15818

2964, 2968

13037, 15008

15110, 15122

8834, 9740

15197, 15411

2983, 3437

269, 276

440, 2082

2104, 2850

2866, 2948

3,225

158,862

53746

Discharge summary

report

Admission Date: [**2132-10-19**] Discharge Date: [**2132-10-27**] Date of Birth: [**2084-3-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: ETOH withdrawal Major Surgical or Invasive Procedure: L subclavian line placement; intubation History of Present Illness: Briefly, this is a 48 yo M with an extensive history of EtOH abuse, complicated by seizures and DT's, who came into the ED initially for worsening acute on chronic leg pain and was found to have a BAL of 527. In addition, the patient initially reported several episodes of hematemesis the week prior to admission and also a few episodes of bright red blood per rectum although he was reported to be guaiac negative in the E.D. (Not documented if NG lavage performed). Given complaints of leg pain and some vague pleuritic chest pain as well as +D-dimer the patient underwent CTA with small left effusion but no evidence of PE. . He was admitted initially to the floor and then transferred to the MICU for detox, which required extraordinary amounts of benzodiazepenes administered according to CIWA, eventually resulting in intubation. He was extubated several days ago and although still being dosed prn with ativan according to CIWA scale, is no longer requiring as much for alcohol withdrawal and is being dosed prn with haldol for agitation. Please note that the patient has not been scoped in our hospital without knowledge if patient has varices. . His MICU course was also complicated by pneumothorax from left SC CVL placement requiring chest tube placement. Chest tube was d/c'd yesterday with no complications. Additionally he had some rate related ST depressions initially on admission secondary to tachycardia to the 150's. He ruled out for MI with several sets of cardiac enzymes, however records indicate global systolic dysfunction presumeably secondary to alcoholic cardiomyopathy with an EF=25%. . Other issues for Mr. [**Known lastname 110319**] include UTI with prostatitis resulting in 2 prostate abscesses which are being followed by Urology. At this time the patient does not need TURP and is being treated with cipro and gentamicin with interval improvement seen on CT scan. Past Medical History: ? CAD with reported MI [**35**] years ago Thrombocytopenia, thought secondary to alcohol use Lower leg pain ETOH abuse h/o hypercholesterolemia per prior d/c summary h/o prior IVDU though he denies this to me, girlfriend similarly denies. + distant nasal cocaine use Social History: Patient currently lives with his girlfriend in [**Name (NI) 86**], MA although he has previously engaged in sexual intercourse with men as well. He and his girlfriend report they were recently HIV negative. ETOH: 1-1.5 pints of liquor each day. This has been going on since age 14. He has attempted to quit in the past but has relapsed each time. He lives with his girlfriend. His girlfriend and her daughter are involved in his care. Tobacco: Smokes 1-1.5 packs of cigarettes per day (50+ pack year history). IVDU: Denies Family History: Positive for lung cancer in his mother & father. His brother had HIV from sexual contact. Physical Exam: Tc-102.9 BP-121/86 HR-146(ST) RR-33 O2 Sat-95% on RA . General: Patient is a thin, moderately agitated, dishevelved male, in mild distress HEENT: NCAT, EOMI with mild non-sustained lateral nystagmus. OP: Edentulous, MM mildly dry Neck: No JVD, no LAD Chest: Thin. Tachypnic, relatively CTA anterior and posterior Cor: Tachycardic. No M/R/G appreciated Abd: Thin, scaphoid. Soft, non-tender. +BS. Ext: Thin, ecchymosis/hematoma over left shin. No cyanosis or edema. DP 2+ bilaterally. No cellulitis Pertinent Results: [**2132-10-19**] 08:42PM POTASSIUM-3.2* [**2132-10-19**] 08:42PM CK(CPK)-62 [**2132-10-19**] 08:42PM CK-MB-2 cTropnT-<0.01 [**2132-10-19**] 08:42PM MAGNESIUM-1.9 [**2132-10-19**] 08:42PM HCT-31.6* [**2132-10-19**] 02:20PM GLUCOSE-120* UREA N-7 CREAT-0.4* SODIUM-133 POTASSIUM-3.0* CHLORIDE-93* TOTAL CO2-25 ANION GAP-18 [**2132-10-19**] 02:20PM ALT(SGPT)-16 AST(SGOT)-64* CK(CPK)-76 ALK PHOS-293* AMYLASE-61 TOT BILI-0.3 [**2132-10-19**] 02:20PM LIPASE-34 [**2132-10-19**] 02:20PM CK-MB-NotDone cTropnT-<0.01 [**2132-10-19**] 02:20PM ALBUMIN-3.2* CALCIUM-8.0* PHOSPHATE-3.1 MAGNESIUM-1.8 [**2132-10-19**] 02:20PM ASA-NEG ETHANOL-527* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2132-10-19**] 02:20PM WBC-12.3* RBC-3.84* HGB-12.2* HCT-34.4* MCV-90 MCH-31.7 MCHC-35.4* RDW-14.1 [**2132-10-19**] 02:20PM NEUTS-70 BANDS-4 LYMPHS-11* MONOS-11 EOS-0 BASOS-1 ATYPS-3* METAS-0 MYELOS-0 [**2132-10-19**] 02:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2132-10-19**] 02:20PM PLT COUNT-146* [**2132-10-19**] 02:20PM PT-12.8 PTT-27.1 INR(PT)-1.1 [**2132-10-19**] 02:20PM D-DIMER-5203* Brief Hospital Course: *PLEASE NOTE THAT PATIENT LEFT AGAINST MEDICAL ADVICE* . A/P: This is a 48 y/o M with PMH significant for EtOH abuse, history of withdrawal seizures, admitted for FTT and EtOH withdrawal requiring MICU stay with intubation. . # Respiratory Distress - Extubated on [**10-23**]; continued to sat well on RA . # Prostatitis/prostate abscess - Initially, the patient was evaluated by urology and started on antibiotics and after a CT scan was obtained after several days of abx therapy, there was enough interval improvement that they recommended that he be maintained on both IV ciprofloxacin and gentamicin. After about 1 week, upon reevaluating him, urology felt that he could be treated with 6 weeks of oral ciprofloxacin, without interval imaging with follow up in their clinic in [**Month (only) 404**]. . #. ETOH withdrawal - after extubation the patient required very little ativan per CIWA scale, and upon transfer to the floor required none. Zyprexa was used occasionally for control of agitation with good effect. He was also maintained on thiamine, folate and MVI throughout his admission. . #PTX: small L lateral s/p L subclavian line placement. Chest tube was removed with interval improvement. Pt stable with normal sats. . #. Reported BRBPR/hematemesis: Patient's initial history included recollection of several episodes of hematemesis. His hct dropped from 33 to 26 evening of [**10-22**], but he was guaiac negative and hct restabilized at 30. Therefore dilutional effect was suspected. T Bili and LDH normal, indicating no hemolysis, and synthetic liver function was within normal limits per coags. Therefore, we avoided NSAIDs and aspirin and he was started on [**Hospital1 **] PPI. . #. ? CAD - Patient had rate related ST depressions on admission which resolved and also ROMI. Report from OSH indicated global reduction in systolic function likely secondary to alcoholic cardiomyopathy with an EF=25%. He will need an outpatient stress test. . #Hypotension: Pt was likely intravascularly dry with low CVPs on admission. SBP's remained wnl once transferred to the floor. . #. Leg pain: seems most likely consistent with neuropathy given history and distal pain with sensation of pins and needles- pt denies pain recently. Can consider trial of neurontin. Patient was also complaining of thigh pain of unclear etiology. Differential is wide and patient could not give a consistent history. . # Dispo- the patient seemed to indicate a desire to enroll in a rehab program but said he would go to [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 48184**] house on his own and just tell them he was homeless. I made appointments for him with myself for a primary care initial visit and a urology follow up, but it is questionable that he will comply with either these visits or with his 6 weeks of antibiotics. After pulling central line access on [**10-27**], the patient decided to leave against medical advice. He was given a prescription for ciprofloxacin with directions and his follow up appointments. Medications on Admission: none Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 weeks: Continue for 5 weeks. Disp:*70 Tablet(s)* Refills:*0* 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1) Alcohol withdrawal 2) Prostatitis/prostate abscess 3) Pneumothorax 4) Hypotension Discharge Condition: Patient is leaving against medical advice. Discharge Instructions: You have elected to leave the hospital against medical advice and have signed a form indicating this. Followup Instructions: PRIMARY CARE: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2132-11-12**] 8:30 . UROLOGY: DR. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2132-12-10**] 1:45 . Please call the Liver Center at ([**Telephone/Fax (1) 16687**] for an appointment . [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

[ "355.8", "458.29", "303.01", "790.7", "414.01", "512.1", "291.81", "425.5", "601.0", "518.81", "783.7", "578.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.93", "96.71", "94.62", "34.04" ]

icd9pcs

[ [ [] ] ]

8707, 8713

4989, 8030

333, 374

8842, 8887

3783, 4966

9038, 9530

3149, 3241

8085, 8684

8734, 8821

8056, 8062

8911, 9015

3256, 3764

277, 295

402, 2302

2324, 2592

2608, 3133

15,175

182,061

52685

Discharge summary

report

Admission Date: [**2118-10-11**] Discharge Date: [**2118-10-15**] Date of Birth: [**2070-7-25**] Sex: F Service: MEDICINE Allergies: Lamictal / Dolasetron Mesylate Attending:[**Last Name (NamePattern1) 17447**] Chief Complaint: Lethargy Major Surgical or Invasive Procedure: Central line insertion History of Present Illness: Ms. [**Known lastname **] is a 48 year old female with history of HIV (last CD4 114 in [**9-5**]) HCV, polysubstance abuse, tobacco use, and multiple admissions for pneumonia over the last few years, who presented to ED from her methadone clinic with lethargy, which the patient attributed to taking 6 klonopin to "get high." She was recently admitted to [**Hospital1 18**] from [**9-16**] - [**9-19**] for pneumonia and treated with ceftriaxone and zithromax in house. Her hospital course was uneventful, and she had a normal CT scan, done to investigate the etiology of her chronic pneumonia. She was discharged with a 6 day course of levaquin which she says she finished, though she did not show up for her outpatient ID f/u appointment on [**9-26**]. She denies any fevers or chills. She has had shortness of breath, with a cough productive of yellow sputum. She denies IV drug use for the last 3 years. She has had nausea and vomiting for the last few days, but denies diarrhea. On presentation in the E.D. her temperature was 101, bp 83/67, dropping to 75/48, 97% on 2L. Lactate was 2.0. She was bolused 3 L of IVF and her blood pressure did not increase above 80, therefore levophed was started and pt. was transferred to the ICU. In the ICU she was started on Zosyn and azithromycin, and her course was uneventful, with discontinuation of pressors by the following morning. She was transfused 1 U PRBC on [**10-11**] after a drop of hematocrit from 26-22 which was likely dilutional. Her hematocrit rose appropriately. Past Medical History: 1)HIV -- diagnosed [**2098**]. Last CD4 114 [**9-5**], viral load [**Numeric Identifier 890**] [**2-3**], on HRT tx. In regards to opportunistic infections, states she's had PCP three times years ago. States compliance with her Bactrim. 2)HCV 3) Recurrent RLL pneumonias 4) Anemia of chronic disease 5) Depression 6) Anxiety 7) Endocarditis 8) IVDU, polysubstance abuse - heroin, benzodiazepines, crack 9) Tobacco use 10) CVA? Seizure? 11) Benzo and ethanol withdrawal seizures 12) R radial neuropathy 13) HIV neuropathy 14) hx of abnormal paps 15) h/o ARF Surgical hx: 1) c-section 2) Vein stripping, s/p phlebitis/abscesses. Social History: Had strong smoking/etoh history, now decreased, no etoh. Has substance abuse history, now at methadone clinic. Denies IVDU for last 3 years. Lives alone at her home. Family History: Non-contributory Physical Exam: VS: 100.4, 100/60, 81, 28, 93% RA Gen: Slim caucasian female, appearing comfortable. HEENT: Anicteric, PEARL, moist MM. Skin: Maculopapular rash over extremities bilaterally as well as chest, non-pruritic. Neck: No LAD. CVS: RR, normal rate, no m/r/g. Lungs: Decreased breath sounds at R base with egophony. No wheeze. Abd: NABS, soft, NT/ND. Extr: No c/c/e. Neuro: CN II-XII intact, 5/5 strength UE and LE. Pertinent Results: [**2118-10-11**] WBC-15.8*# RBC-3.10* Hgb-8.5* Hct-26.2* MCV-85# MCH-27.6 MCHC-32.6# RDW-16.5* Plt Ct-300 [**2118-10-12**] WBC-10.8 RBC-3.11* Hgb-8.5* Hct-26.6* MCV-86 MCH-27.4 MCHC-32.0 RDW-16.5* Plt Ct-237 [**2118-10-15**] WBC-7.9 RBC-2.87* Hgb-7.7* Hct-24.4* MCV-85 MCH-27.0 MCHC-31.8 RDW-17.3* Plt Ct-285 [**2118-10-11**] Neuts-76.7* Lymphs-20.2 Monos-2.7 Eos-0.2 Baso-0.1 [**2118-10-13**] Neuts-66.5 Lymphs-30.0 Monos-3.0 Eos-0.4 Baso-0.2 [**2118-10-11**] PT-14.5* PTT-35.2* INR(PT)-1.3 [**2118-10-11**] Glucose-94 UreaN-26* Creat-1.5* Na-135 K-4.5 Cl-99 HCO3-28 [**2118-10-11**] Glucose-127* UreaN-18 Creat-0.9 Na-138 K-3.8 Cl-111* HCO3-23 [**2118-10-15**] Glucose-71 UreaN-6 Creat-0.6 Na-137 K-3.4 Cl-104 HCO3-28 [**2118-10-11**] ALT-11 AST-45* LD(LDH)-140 CK(CPK)-1192* AlkPhos-76 Amylase-15 TotBili-0.4 [**2118-10-11**] ALT-13 AST-63* AlkPhos-99 Amylase-22 TotBili-0.6 [**2118-10-12**] ALT-10 AST-41* LD(LDH)-127 CK(CPK)-620* TotBili-0.5 [**2118-10-11**] CK-MB-3 cTropnT-<0.01 [**2118-10-11**] Albumin-2.1* Calcium-6.4* Phos-3.0 Mg-1.4* [**2118-10-11**] Iron-9* calTIBC-101* VitB12-450 Folate-5.8 Ferritn-445* TRF-78* [**2118-10-11**] TSH-0.73 [**2118-10-11**] Ret Aut-1.1* [**2118-10-11**] BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG CXR [**10-11**]: There is interval placement of a right subclavian line that terminates in the SVC. There is no pneumothorax. The patchy right lower lung zone opacity is again identified, unchanged compared to the study done three hours prior. No other interval change. CXR [**10-11**]: Cardiac, mediastinal, and hilar contours are within normal limits. Previously evident right basilar parenchymal opacities are again noted, but they appear less confluent in the interval. No new parenchymal opacities are seen. There is a tiny right pleural effusion as well as pleural thickening along the right chest wall. Visualized osseous structures are unremarkable. IMPRESSION: Patchy parenchymal opacity at the right lung base which appears improved in the interval. Small right pleural effusion and right pleural thickening. EKG [**10-11**]: Sinus rhythm Indeterminate frontal QRS axis Low QRS voltages in limb leads Nonspecific ST-T abnormalities Since previous tracing of [**2118-9-16**], no significant change Brief Hospital Course: 48 year old female with history of HIV (last CD4 114 in [**9-5**]) HCV, polysubstance abuse, tobacco use, and multiple admissions for pneumonia over the last few years, who presented to ED from her methadone clinic with lethargy, found here to have a RLL consolidation. In the ICU she was started on Zosyn and azithromycin, and her course was uneventful, with discontinuation of pressors by the following morning. She was transfused 1 U PRBC on [**10-11**] after a drop of hematocrit from 26-22 which was likely dilutional. Her hematocrit rose appropriately. On the floors: 1. Recurrent pneumonia: Initially treated as sepsis because of persistent hypotension, however in retrospect it was felt that her hypotension was likely secondary to her excessive klonopin intake. Her pressures remained stable around 100 sbp on the floors, and her blood cultures were all negative. Ms. [**Known lastname **] has had multiple recent hospitalizations for recurrent pneumonia, and it is likely that she has had multiple aspirations during periods of intoxication. CT on [**9-18**] did not reveal any concerning lesions that would predispose to recurrent pneumonia, however a CT scan was repeated during this hospitalization to evaluate for empyema. The CT thorax showed a right sided pleural effusion that had increased in size since the last CT scan, and now was surrounded by a markedly thickened pleura, concerning for empyema, in addition to a new small L effusion, with associated consolidation. An US unfortunately could not demonstrate the fluid location for thoracentesis secondary to the thickened pleura, and therefore thoracic surgery was contact[**Name (NI) **]. Pulmonary and infectious disease were also following. Unfortunately, the patient signed out against medical advice on the following day, before anything could be done for the large, suspected empyema. She had run low grade fevers throughout the hospitalization, though her white count decreased to within normal limits on zosyn and zithromax. She felt well and was saturating > 95% on RA, and therefore wanted to leave. The consequences and danger of her leaving were explained to her, but she insisted on leaving the hospital. 2. Diarrhea: The patient had a number of episodes of diarrhea, and stool studies were therefore sent, however were pending at the time of her leaving. 3. Maculopapular rash: A maculopapular rash was noted on her arms and chest just before transfer from the MICU to the floors. She had no respiratory distress and the rash did not progress. She was given 25 mg of benadryl. She was continued on zosyn with no recurrence of the rash, making it unlikely secondary to zosyn. She had been given an enti-emetic - dolastetron - shortly before the rash, and this was presumed to have been the cause. Added to her list of allergies. 4. HIV: The patient has a history of non-compliance with HAART, and persistently refused her HAART medications while in house, saying she was on a drug holiday. She took Bactrim for PCP [**Name Initial (PRE) 1102**]. 5. ARF: Her creatinine was elevated on admission, but improved with IVF. 6. Elevated CK: There was inital concern for rhabdomyolysis, however her CK trended downward throughout the hospitalization. 7. Anemia: Likely related to her HIV and alcoholism (AST>ALT on admission). Iron studies showed anemia of chronic disease. Her hematocrit dropped once to 22 at which time she was given 1 U PRBC with appropriate rise in hematocrit. This drop, in retrospect, was likely dilutional, as she received 4L of IVF in the ICU initially for the sepsis protocol. Her hematocrit remained stable subsequently, at her baseline of around 25. 8. HCV - LFTs were wnl, with slight elevation of AST on admission, more than twice ALT. Her coags were slightly up, but stable. 9. FEN: She was given a low protein/sodium diet, and kept on aspiration precautions. She had persistent hypomagnesemia, and was repleted frequently. Medications on Admission: Clonazepam 0.5 mg PO TID Ritonavir 100 mg PO BID Stavudine 20 mg PO Q12H Abacavir Sulfate 300 mg PO BID Amprenavir 600 mg PO BID Paroxetine HCl 20 mg PO DAILY Methadone HCl 120 mg PO DAILY Sulfameth/Trimethoprim DS 1 TAB PO DAILY Discharge Medications: Left against medical advice Discharge Disposition: Home Facility: Patient left against medical advice. Discharge Diagnosis: Left against medical advice. Bilateral pleural effusions Hepatitis C cirrhosis Human immunodeficiency syndrome Aspiration pneumonia Anemia of chronic disease Discharge Condition: Fair Discharge Instructions: Left [**Hospital 108697**] medical advice. Followup Instructions: Left against medical advice.

[ "693.0", "571.5", "E939.4", "305.40", "507.0", "070.70", "042", "304.01", "584.9" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

9845, 9899

5541, 9512

311, 335

10100, 10106

3220, 5518

10197, 10228

2754, 2772

9793, 9822

9920, 10079

9538, 9770

10130, 10174

2787, 3201

263, 273

363, 1902

1924, 2554

2570, 2738

41,891

110,204

5417

Discharge summary

report

Admission Date: [**2168-11-8**] Discharge Date: [**2168-11-15**] Date of Birth: [**2106-3-16**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2597**] Chief Complaint: Right carotid stenosis. Major Surgical or Invasive Procedure: Right carotid endarterectomy and bovine pericardial patch angioplasty along with right cervical carotid arteriogram and stenting of right carotid endarterectomy repair with a 9 x 30 carotid Wallstent. History of Present Illness: This is a 63-year-old gentleman with right carotid stenosis who underwent a right carotid endarterectomy by Dr. [**Last Name (STitle) **]. He had a lesion in the distal ICA noted on completion angiography, performed due to poor distal signal. This appeared to be possibly a clamp injury. This was in an area of the ICA that was not surgically accessible and therefore, intraoperative consultation was requested for possible carotid stenting. Past Medical History: PAST MEDICAL HISTORY: # CAD s/p CABG [**2157**] (LIMA-LAD, SVG-PDA, SVG-PL) # DM2 # Hypertension # Hypercholesterolemia # Hiatal hernia # Muscle Schatzki's ring # Diabetic neuropathy # s/p shoulder surgery # R carotid stenosis s/p CEA and stenting [**11-8**] Social History: Retired, used to work in a clothing warehouse. No known exposure to asbesthos. Lives at home with wife and 2 dogs and 1 cat. Tobacco: quit five days ago, 50 year history of [**11-20**] ppd. EtOH: h/o abuse, quit in [**2150**]. Denies illicits. Family History: Father died of MI at 40. Mother died from MI in 70s. No SCD. Physical Exam: Vitals: T: 99.0 degrees Farenheit, BP: 155/79 mmHg supine, HR 72 Gen: Pleasant, fatigued appearing, NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD. Cannot appreciate JVP d/t habitus. Surgical incision over right neck. CV: PMI in 5th intercostal space, mid clavicular line. RRR. nl S1, S2. No murmurs, rubs, clicks, or [**Last Name (un) 549**] LUNGS: Decreased BS at bases. Fine rales bilaterally 1/2 up. ABD: Obese. NABS. Soft, NT, ND. No HSM. EXT: WWP, trace LE edema. Full distal pulses bilaterally. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. CN 2-12 grossly intact. Moving all extremities Pertinent Results: [**2168-11-14**] 06:15AM BLOOD WBC-5.9 RBC-3.53* Hgb-10.5* Hct-32.3* MCV-92 MCH-29.8 MCHC-32.6 RDW-13.6 Plt Ct-190 [**2168-11-10**] 09:50AM BLOOD PT-13.1 PTT-28.4 INR(PT)-1.1 [**2168-11-14**] 06:15AM BLOOD Glucose-177* UreaN-31* Creat-1.6* Na-140 K-3.6 Cl-104 HCO3-26 AnGap-14 [**2168-11-14**] 06:15AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.0 [**2168-11-10**] 05:01PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 URINE Blood-MOD Nitrite-NEG Protein-75 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0 PORTABLE AP CHEST: Comparison made to [**2168-11-13**]. Scattered ill-defined bilateral airspace opacities again show slight improvement. Cardiomediastinal contours are unchanged. There is no pleural effusion or pneumothorax. CT SCAN: IMPRESSION: 1. No evidence of pulmonary embolism till the level of [**Last Name (un) **] and part of the segmental arteries . 2. Extensive pulmonary abnormalities, differential diagnosis includes infection, hemorrhage desquamative interstitial pneumonia; radiographically, pulmonary edema is another possibility, even though this does not correlate with the clinical picture. 3. Mediastinal lymphadenopathy, which is likely reactive in the setting of extensive pulmonary abnormality. Brief Hospital Course: Mr. [**Known lastname 21973**],[**Known firstname **] was admitted on [**11-8**] with Carotid Artery Stenosis. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preparations were made. It was decided that she would undergo a: Right carotid endarterectomy and bovine pericardial patch. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. But during the procedure the patient had a higher lesion that was not amendable to endarectomy. Dr [**Last Name (STitle) **] was called into the case: Angioplasty along with right cervical carotid arteriogram and stenting of right carotid endarterectomy repair with a 9 x 30 carotid Wallstent. Post-operatively, he was extubated and transferred to the PACU for further stabilization and monitoring. Plavix was started for the stent. He was then transferred to the VICU for further recovery. While in the VICU he received monitored care. Pt did have episodes of SOB. Pt was heavy smoker. He did require oxygen. Pt developed PNA. Treated appropriately. DC on PO antibiotics. This event did require a cardiology consult. Originally thought to be CHF. Echo showed preserved EF, but some right sided heart failure.. BNP was close to normal. He was originally diuresed. Was thought to be a PE, received a CT scan: IMPRESSION: 1. No evidence of pulmonary embolism till the level of lobar and part of the segmental arteries . 2. Extensive pulmonary abnormalities, differential diagnosis includes infection, hemorrhage desquamative interstitial pneumonia; radiographically, pulmonary edema is another possibility, even though this does not correlate with the clinical picture. 3. Mediastinal lymphadenopathy, which is likely reactive in the setting of extensive pulmonary abnormality. To note pt does have CRI. His creatinine did bump with the Lasix. On DC his creatine is at baseline. His nephrotoxic drugs were held, on DC they have been restarted. Pt also had a pulmonary consult: Levaquin alone to cover for community-acquired aspiration if Cxs negative. Pt to be discharged on Levaquin. When stable he was delined. His diet was advanced. A PT consult was obtained. When he was stabilized from the acute setting of post operative care, she was transferred to floor status On the floor, he remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility. He continues to make steady progress without any incidents. He was discharged home in stable condition. To note he does not require home )@. He was weaned off of 02 on DC. Medications on Admission: amlodipine 10', lasix 40', glipizide 10", lansoprazole 30', lisinopril 40", metformin 1000", metoprolol 50", percocet prn, actos 30', lyrica 75", simvastatin 40', KCl 10', ASA 81', niacin 500' Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. Amlodipine 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: home med. 3. Pregabalin 75 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a day: home med. 4. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily): [**Last Name (un) **] emed. 5. Aspirin 81 mg Tablet, Chewable [**Last Name (un) **]: One (1) Tablet, Chewable PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY (Daily) for 3 months. Disp:*30 Tablet(s)* Refills:*2* 7. Acetaminophen 325 mg Tablet [**Last Name (un) **]: Two (2) Tablet PO every [**4-25**] hours as needed for pain. 8. Furosemide 40 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY (Daily). 9. Glipizide 10 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO twice a day: home med. 10. HOLDING: Do not take - Metformin 1000mg 1 tab by mouth twice daily while your creatinine is elevated. You will be taking insulin for now. You will need to follow up with your pcp/ diabetic provider to have blood work and medications adjusted 11. Pioglitazone 30 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO once a day: home med. 12. Levofloxacin 750 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 13. Oxycodone 5 mg Tablet [**Month/Day (3) **]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 10 days. Disp:*30 Tablet(s)* Refills:*0* 14. Metoprolol Tartrate 50 mg Tablet [**Month/Day (3) **]: 1.5 Tablets PO TID (3 times a day): * this is an increased dose * . Disp:*135 Tablet(s)* Refills:*2* 15. Niacin 500 mg Capsule, Sustained Release [**Month/Day (3) **]: One (1) Capsule, Sustained Release PO DAILY (Daily). 16. Lisinopril 40 mg Tablet [**Month/Day (3) **]: Two (2) Tablet PO once a day: home med - . 17. Potassium Chloride 10 mEq Capsule, Sustained Release [**Month/Day (3) **]: One (1) Capsule, Sustained Release PO once a day. 18. Metformin 1,000 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Right carotid stenosis Secondary: Post operative pneumonia COPD CAD, s/p CABG [**2150**] Ongoing Tobacco Abuse HTN Hyperlipidemia Obesity Non Insulin Dependent Diabetes Mellitus x 17 years Peripheral neuropathy Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Division of [**Year (4 digits) **] and Endovascular Surgery Carotid Endarterectomy Surgery Discharge Instructions What to expect when you go home: 1. Surgical Incision: ?????? It is normal to have some swelling and feel a firm ridge along the incision ?????? Your incision may be slightly red and raised, it may feel irritated from the staples 2. You may have a sore throat and/or mild hoarseness ?????? Try warm tea, throat lozenges or cool/cold beverages 3. You may have a mild headache, especially on the side of your surgery ?????? Try ibuprofen, acetaminophen, or your discharge pain medication ?????? If headache worsens, is associated with visual changes or lasts longer than 2 hours- call [**Year (4 digits) 1106**] surgeon??????s office 4. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 5. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? No excessive head turning, lifting, pushing or pulling (greater than 5 lbs) until your post op visit ?????? You may shower (no direct spray on incision, let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Temperature greater than 101.5F for 24 hours Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions **** YOU SHOULD QUIT SMOKING IMMEDIATELY **** - Check your blood sugars three to four times per day and record them - Follow up with your primary care/ diabetes provider [**Name Initial (PRE) 176**] 10 days regarding blood sugar trends and your treatment plan Followup Instructions: Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2168-12-1**] 2:30 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2168-12-1**] 3:00 Pulmonology Clinic: [**Location (un) 436**] of [**Location (un) 8661**] Building on [**2168-12-28**] Come in at 1145 and go to the radiology dept in the [**Location (un) 8661**] Building for a chest xray Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2168-12-28**] 12:40 You will then see the doctor around 1pm Completed by:[**2168-11-15**]

[ "414.00", "997.39", "585.9", "530.3", "E878.2", "584.9", "403.90", "530.81", "428.0", "496", "998.89", "272.4", "428.21", "278.00", "799.02", "433.10", "553.3", "305.1", "V45.81", "250.60", "357.2", "507.0" ]

icd9cm

[ [ [] ] ]

[ "00.40", "00.45", "39.56", "00.44", "38.12", "00.63", "88.41", "00.61" ]

icd9pcs

[ [ [] ] ]

8900, 8906

3651, 6459

340, 543

9171, 9171

2313, 3628

12458, 13115

1578, 1641

6702, 8877

8927, 9150

6485, 6679

9316, 11609

11635, 12435

1656, 2294

276, 302

571, 1015

9185, 9292

1059, 1298

1314, 1562

65,309

123,325

42692

Discharge summary

report

Admission Date: [**2115-4-10**] Discharge Date: [**2115-4-19**] Date of Birth: [**2034-9-6**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1515**] Chief Complaint: chest pain, GI bleed following cath Major Surgical or Invasive Procedure: cardiac catheterization with drug eluting stent to the ramus coronary artery Endoscopy with Angioectasia with stigmata of recent bleeding was seen in the duodenal bulb, treated with [**Hospital1 **]-CAP Electrocautery History of Present Illness: 80 M with history of severe AS ([**6-/2114**] - [**Location (un) 109**] 1.1, mean gradient 22.3), CAD s/p 3V-CABG (SVG to RCA, LAD and OM1), HTN, sCHF EF 15-20%, ischemic cardiomyopathy s/p ICD placement presents initially to [**Hospital3 **] for increasing chest pain at home starting about 10 PM. In the OSH ED, HR was 117-140, was given lopressor 5mg IV x 2, ASA, plavix, heparin bolus, MSO4 2mg IV, and lasix 40mg IV with 600 cc of urine output. He was brought to cath lab for concern for STEMI. RCA graft was found to be patent, other grafts remain occluded. During cath, his heart rate switched into 70's. His chest pain improved, last rated at [**2113-3-2**]. Last vitals prior to transfer were: BP 117/64, HR 60s, O2 Sat 90s on 2L . Over the last year, he has developed marked fatigue and occasional shortness of breath with exertion. TTE on [**2114-7-16**] showed mean AV gradient 22.3 mmHg, [**Location (un) 109**] 1.1 cm2. Also showed a severely dilated LV, moderate size apical aneurysm, severe global hypokinesis, septal and apical akinesis, LVEF of ~16%. During the cath the [**Location (un) **] was estimated to be 0.7 cm2 with a gradient of 41. . He had been admitted in [**10/2114**] to [**Hospital3 **] for chest pain. ECG at the time showed marked ST elevation in the precordial leads, however, his enzymes were negative. Stress test was negative for angina or ECG signs of ischemia. Cardiac cath on [**2114-11-23**] showed severe three vessel disease. There was total occlusion of the mid LAD, collateralization of the distal LAD that was collateralized by the RCA, the left circumflex was calcified with an ostial 90% occlusion, the first OMB had a 90% stenosis, the RCA has a 70% diffuse stenosis. The SVG to the RCA was patent. The SVG to the LAD was totally occluded, and the SVG to the OMB was totally occluded. He was considered for repeat CABG at the time but no additional plans were made. . Initially was planned for aortic valvuloplasty, but right heart cath showed that his wedge was 7. It was thought that AS was not the cause of his symptoms. Found to have 90% calcified lesion in ostial and mid ramus. Rotoblation was performed with DES x2 deployed. He was transferred back to [**Wardname 13764**] for monitoring. . After cath, he was noted to have [**6-2**] bloody bowel movements. Patient triggered for hypotension to the 70s, tachycardic to the 140s. Was given 500 cc bolus with improvement of heart rate to 70s. Started on peripheral levophed with BP responding to 110-120s. Transferred back to CCU. Patient had been mentating well despite hypotension. Complains of some nausea, no chest pain, no abdominal pain, no flank pain, no pain at sites of cath. Past Medical History: 1. Severe Aortic Stenosis - [**2114-7-16**] - mean gradient 22.3, [**Location (un) 109**] 1.1 2. Hypertension 3. CAD c/b MI s/p 3 vessel CABG [**2088**] (SVG to RCA, LAD and OM1) and cardiac cath [**10/2114**] 4. Chronic Systolic CHF EF 15-20% 5. Ischemic Cardiomyopathy s/p ICD placement [**2114-11-26**] - Device: St. [**Hospital 923**] Medical Dual Chamber Fortify DR CD2231-40Q - RA Lead: St. [**Hospital 923**] Medical Transvenous Tendril STS 2088TC/52 - RV Lead: [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Transvenous Dual [**Last Name (un) **]/Pace-Send [**Last Name (un) **] IS-1 7121/65 6. h/o Prostate cancer - [**2096**] 7. s/p CVA - [**2111**] - right sided weakness, resolved after rehab 8. Nasal Polyps 9. Torn Right Rotator Cuff 10. Macular Degeneration s/p bilateral lens implants ([**2104**], [**2109**]) 11. History tobacco use. Quit in [**2088**] 12. s/p Left Hand Surgery [**11/2110**] 13. s/p Bilateral Knee replacement 14. s/p Appendectomy 15. s/p Cholecystectomy [**19**]. GI bleed from angioectasia s/p cauterization ([**3-/2115**]) 17 s/p ostial DES and mid vessel ramus DES ([**3-/2115**]) Social History: Mr. [**Known lastname 11309**] lives with his wife [**Name (NI) 2411**] and used to work as a mechanic. He is currently retired. He has a history of tobacco used (1PPD for 60 years) and quit in [**2088**]. a history of tobacco and heavy alcohol use for 30 years. However, he quit in [**2105**]. He does not exercise lately secondary to feeling fatigued. Family History: family history of heart disease but no history of hypertension, diabetes, or stroke. His mother died at the age of 80 secondary to cardiac disease, and his father died at the age of 79 secondary to prostate cancer. Physical Exam: Admission: 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 without elevated JVP CARDIAC: RRR, normal S1, soft S2. late peaking C-D III/VI systolic murmur. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. Crackles in left lung base ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Left and right groin site without bleed, hematoma, bruits. No c/c/e. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Discharge: GENERAL: 80 yo M in no acute distress, sitting in chair HEENT: mucous membs moist, no lymphadenopathy, JVD at 2 cm above clavicle. CHEST: BB faint crackles, no wheezes CV: S1 S2, RRR 2/6 systolic murmur at RUSB ABD: soft, non-tender, non-distended, BS normoactive. EXT: wwp, no edema. DPs, PTs 2+. Groin with bilat ecchymosis but no hematoma, no tenderness and resolving. NEURO: 5/5 strength in U/L extremities. gait WNL. SKIN: no rash PSYCH: A/O Pertinent Results: Admission: [**2115-4-10**] 05:14PM SODIUM-139 POTASSIUM-3.8 CHLORIDE-103 [**2115-4-10**] 05:14PM CK(CPK)-562* [**2115-4-10**] 05:14PM CK-MB-62* MB INDX-11.0* cTropnT-1.68* [**2115-4-10**] 09:06AM GLUCOSE-106* UREA N-27* CREAT-1.3* SODIUM-140 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15 [**2115-4-10**] 09:06AM estGFR-Using this [**2115-4-10**] 09:06AM CK(CPK)-498* [**2115-4-10**] 09:06AM CK-MB-59* MB INDX-11.8* cTropnT-0.78* [**2115-4-10**] 09:06AM CALCIUM-8.8 PHOSPHATE-4.2 MAGNESIUM-2.4 [**2115-4-10**] 09:06AM WBC-4.9 RBC-3.83* HGB-10.9* HCT-32.3* MCV-84 MCH-28.5 MCHC-33.8 RDW-13.8 [**2115-4-10**] 09:06AM PLT COUNT-195 [**2115-4-10**] 09:06AM PT-11.7 PTT-29.2 INR(PT)-1.1 Relevant Labs: [**2115-4-10**] 09:06AM BLOOD CK-MB-59* MB Indx-11.8* cTropnT-0.78* [**2115-4-10**] 09:06AM BLOOD CK(CPK)-498* [**2115-4-10**] 05:14PM BLOOD CK-MB-62* MB Indx-11.0* cTropnT-1.68* [**2115-4-10**] 05:14PM BLOOD CK(CPK)-562* [**2115-4-11**] 03:28AM BLOOD CK-MB-32* MB Indx-9.6* cTropnT-1.39* [**2115-4-11**] 03:28AM BLOOD CK(CPK)-332* [**2115-4-13**] 03:52PM BLOOD Glucose-153* UreaN-73* Creat-2.2* Na-142 K-4.8 Cl-111* HCO3-22 AnGap-14 [**2115-4-14**] 06:10AM BLOOD Glucose-114* UreaN-61* Creat-1.5* Na-145 K-4.2 Cl-113* HCO3-24 AnGap-12 [**2115-4-15**] 04:30AM BLOOD Glucose-92 UreaN-32* Creat-1.1 Na-145 K-3.8 Cl-113* HCO3-25 AnGap-11 Studies: Echo [**3-/2115**]: The left atrium is moderately dilated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20-25%) secondary to dyskinesis of the distal septum and apex, akinesis of the basal-mid anterior septum and distal anterior wall and mild-moderate hypokinesis of the remaining segments. The estimated cardiac index is borderline low (2.0-2.5L/min/m2). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild-moderate mitral regurgitation is seen.The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Moderate left ventricular dilatation with severe focal and global systolic dysfunction c/w CAD. Severe aortic stenosis based on [**Location (un) 109**]/continuity equation, moderate based on transvalvular velocity and gradients. Mild-moderate mitral regurgitation. . Cardiac cath [**4-8**]: 1. Limited coronary angiography in this right dominant system demonstrated 90% calcified stenosis of the origin and 80% stenosis of the mid Ramus. The RCA was not engaged. By prior angiography, the SVG-OMB and SVG-LAD were occluded, and the SVG-RCA was patent to the PDA. 2. Resting hemodynamics revealed low right and left heart filling pressures with RVEDP 4 mmHg and PCWP 7 mmHg. The cardiac index was preserved at 2.1 L/min/m2. There was borderline pulmonary arterial systolic hypertension with PASP 30 mmHg. There was systemic arterial systolic normotension with SBP 103 mmHg. 3. Successful rotational atherectomy and PCI of the ramus with ostial 3.0x15mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]-dilated to 3.5mm and mid vessel 2.5x12mm Promus (see PTCA comments). 4. Successful right and left groin closure with 6F Perclose device. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease with patent SVG-RCA, occluded SVG-LAD and SVG-OMB. 2. Successful rotational atherectomy and PCI of the proximal/ostial and mid ramus with DES. 3. Severe aortic stenosis. 4. Aspirin 325 mg daily, and plavix 75 mg daily for minimum 12 months. . CT chest non con [**4-8**]: 1. Extensive pulmonary fibrosis with many of features suggestive of UIP. 2. Global cardiomegaly with extensive coronary calcifications and pacemaker device in place. 3. Ventricular wall calcifications and ventricular pseudoaneurysm. Recommend an echo for further followup. 4. Extensively calcified thoracic aorta. 5. Cyst with calcification in the right kidney. 6. Attenuation difference between the liver and spleen may suggest prior treatment such as amiodarone-this could also be considered in the context of the patients fibroisis. . US left groin: No abnormality in the left groin. . PFTs: FVC 79%, FEV1 97%, FEV1/FVC 121%, TLC 73%, FRC 63%, RV 62%, VC 82%, ERV 68%. Minimal change with meds. Consistent w/ restrictive physiology. . Brief Hospital Course: 80 M with history of severe AS ([**10/2114**] - [**Location (un) 109**] 0.7, mean gradient 41), CAD s/p 3V-CABG (SVG to RCA, SVG to LAD and SVG to OM1), HTN, sCHF EF 15-20%, ischemic cardiomyopathy s/p ICD placement presents with increasing chest pain, now s/p cath with DES x2. Developed GIB following cath with hypotension and tachycardia as well as episodes of SVT. Found to have angioectasias on EGD treated with electrocautery. #. Severe AS - [**Location (un) 109**] 0.7 with mean gradient of 41 during previous cath. Echo results here are similar. Initially this was thought to be cause of patient's chest pain and increased fatigue. However, pt did have a RHC on this admission with wedge pressure only 7 so did not get valvuloplasty as this is unlikely to be cause of patient's symptoms given hemodynamic results. Surgery also declined intervention. The patient will follow with Dr. [**Last Name (STitle) **] for potential corevalve in the future. In the setting of GI bleeding, the patient was given IV fluids without heart failure symptoms. He will continue on low dose lasix, beta blocker, and [**Last Name (un) **]. #. NSTEMI/CAD - history of 3V-CABG with only RCA graft still patent. He is now s/p 2 DES to ostial and mid ramus. No current chest pain. Cardiac enzymes downtrending. #.GIB - in setting of receiving heparin and integrellin for cath. Hct drop from 34.0 to 29.1. Given 5 units total of PRBCs. Endoscopy revealed bleeding AVM in duodenum (which was sclerosed) and mild gastritis. He will continue PPI and carafate [**Hospital1 **] and f/u with gastroenterology for further care and colonoscopy. # SVT: Goes into 140s with lightheadedness. Adequately treated with vagal maneuvers such as ice and carotid massage. Increased metoprrolol for control. . # Acute on Chronic Systolic CHF - EF 15-20%, ischemic cardiomyopathy s/p ICD. Crackles BB but ? r/t fibrosis. Appears euvolemic at present. Was on lasix 40 mg at home and was sent home on lasix 20 mg daily as he appeared dry at discharge. Metoprolol was changed to XL. . #. Acute on Chronic Kidney injury- resolved. . # IPF: incidentally discovered on CT scan. Assessed by pulmonology team yesterday. PFT's show restrictive pattern. Will F/u with pulmonolgy after discharge for futher management. Stable with no O2 requirement. . #. Thrombocytopenia- resolved. # Transitional Issues**** Incidental findings - has CT Chest with extensive fibrosis with many of features suggestive of UIP. - attenuation difference between liver and spleen may suggest prior treatment such as amiodarone - this could also be considered in context of patients fibrosis. - discussion of risk/benefits of anticoagulation in setting of LV aneursym Medications on Admission: atenolol 50 mg daily atorvastatin 20 mg qhs isosorbide mononitrate 30 mg daily furosemide 40 mg daily losartan 50 mg daily aggrenox 25 mg daily aspirin 81 mg daily Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. sucralfate 1 gram Tablet Sig: One (1) Tablet PO twice a day: Do not take within 1 hour of other medications. Disp:*60 Tablet(s)* Refills:*2* 3. 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* 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Non ST elevation myocardial infarction Severe aortic stenosis Hypertension Acute GI bleed Supraventricular tachycardia Acute on Chronic Systolic congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had chest pain and a heart attack and was taken to [**Hospital1 18**] for treatment. A cardiac catheterization found some blockages. One of the arteries was cleared and a stent was placed to keep the artery open. It is extremely important that you take aspirin and plavix every day for at least one year and possibly longer. Do not stop taking aspirin and plavix for any reason unless Dr. [**Last Name (STitle) **] says that it is OK. You were seen by the heart surgeons but they do not think an operation is appropriate for you. You will continue to see Dr. [**Last Name (STitle) **] and you may need to have your aortic valve fixed in the future. Your heart function is weak and it is important to watch for any signs of fluid overload such as swelling in your legs or [**Doctor Last Name **], trouble breathing or sleeping. Please weigh yourself every morning before breakfast, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Please let Dr. [**Last Name (STitle) **] know immediately if you have any stools that look bloody or dark. . We made the following changes to your medicines: 1. STOP taking imdur (isosorbide mononitrate), Aggrenox and Atenolol 2. INCREASE the atorvastatin (Lipitor) to 80 mg daily 3. START taking Metoprolol Succinate to lower your heart rate and help your heart recover from the heart attack. 4. DECREASE the furosemide to 20 mg daily 5. CONTINUE aspirin at 81 mg daily and Losartan at 25 mg daily Followup Instructions: Department: CARDIAC SERVICES When: THURSDAY [**2115-5-9**] at 6:40 PM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE Address: [**Location (un) 10773**], [**Hospital1 **],[**Numeric Identifier 40170**] Phone: [**Telephone/Fax (1) 40171**] **We were unable to contact your PCP to schedule [**Name Initial (PRE) **] follow up appointment. It is recommended you see your PCP [**Name Initial (PRE) 176**] 1 week of your discharge. Please contact the office at the number above to schedule your appointement.** Department: PULMONARY FUNCTION LAB When: MONDAY [**2115-4-29**] at 1:10 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: MONDAY [**2115-4-29**] at 1:30 PM Department: MEDICAL SPECIALTIES When: MONDAY [**2115-4-29**] at 1:30 PM With: DR. [**Last Name (STitle) 51373**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2115-4-30**] at 3:00 PM With: [**Name6 (MD) 11170**] [**Last Name (NamePattern4) 11171**], 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

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icd9cm

[ [ [] ] ]

[ "00.46", "17.55", "99.20", "36.07", "00.66", "44.43", "37.23", "00.40", "88.50" ]

icd9pcs

[ [ [] ] ]

14816, 14822

10930, 13644

339, 559

15037, 15037

6221, 9839

16697, 18527

4857, 5074

13858, 14793

14843, 15015

13670, 13835

9856, 10907

15188, 16674

5089, 6202

264, 301

587, 3306

15052, 15164

3328, 4469

4485, 4841

40,723

163,298

31909

Discharge summary

report

Admission Date: [**2196-9-9**] Discharge Date: [**2196-9-25**] Date of Birth: [**2155-11-8**] Sex: M Service: SURGERY Allergies: Aldactone Attending:[**First Name3 (LF) 668**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: [**2196-9-10**]: 1. Exploratory laparotomy. 2. Drainage of intra-abdominal hematoma. 3. Cauterization of abdominal wall bleeder. History of Present Illness: Patient w/ h/o hypercoagulable state currently on Coumadin w/ h/o PE, DVT, and TIAs w/ portal vein thrombus, possible Budd-Chiari, portal HTN, refractory ascites, and esophageal varices. TIPS X2 unsuccessful. Requires paracentesis every 2 weeks usual for 6L. Pt underwent paracentesis 2d prior to admission. Felt weak and nauseous the following day and had to leave work early. Also noted exacerbation of chronic lower abdominal pain. Fainted while urinating at home and sent to [**Hospital1 **] ED by ambulance. Incomplete records available. Noted to have HCT 25 from prior 35.2 HR 95 and BP 79/64 at time. +orthostatic hypertension. Got 2 units pRBC without improvement in HCT (Hgb 8.4 to 8.5). Got 2 more units pRBCs. (Hgb to 8.2 after 3rd) and 1 U FFP with reported improvement in INR to 2.6. CT performed showing massive ascites with 2 areas of increased density suggestive of blood in R mid abdomen (tap site) and in pelvis. Head CT nl, and CXR showed low lung volumes d/t ascites. Transferred to [**Hospital1 18**] SICU for monitoring. Denies fever/ chills. Denies chest pain/SOB. No change in bowel abits, melena, or hematochezia. Complains of dizziness when standing. Past Medical History: PMH: L-sided CVA [**2189**], hypercoaguable d/o (unclear etiology), lung/liver granulomas, DVTs/PEs PSH: LL lobectomy for granulomas [**2192**], jaw surgery Social History: Works as mechanical engineer. Married with daughter. Chews tobacco, no cigs, no EtOH Family History: sister DVT and stroke in 30s Physical Exam: Physical Exam: T 96.8 HR 96 BP 117/81 RR 18 SPO2 95% RA gen: NAD HEENT: EOMI, no icterus, MMM cardiac: RRR chest: CTAB abd: distended with ascites, reducible umbilical hernia, small area echymosis around tap site w/o bleeding, tender over RLQ and LLQ worse on R, +BS, no rebound. ext: wwp, +edema to shins b/l labs: WBC 11.3, Hgb 9.5, HCT 27.4, plt 234 Na 134, K 4.7, Cl 98, HCO3 30, BUN 24, Cr 1.2, glu 126 Ca 8.9, Mg 2.0, Phos 4.3 lactate 2.0 ALT 49, AST 51, AP 109, TBili 1.3, Alb 2.7 CT: reviewed with radiology, 2 small areas <200 cc. Pertinent Results: [**2196-9-25**] 06:10AM BLOOD PT-27.1* INR(PT)-2.6* [**2196-9-25**] 06:10AM BLOOD WBC-5.3 RBC-3.33* Hgb-10.6* Hct-31.1* MCV-93 MCH-31.7 MCHC-33.9 RDW-16.0* Plt Ct-186 [**2196-9-25**] 06:10AM BLOOD Glucose-91 UreaN-17 Creat-0.7 Na-135 K-3.9 Cl-99 HCO3-34* AnGap-6* [**2196-9-25**] 06:10AM BLOOD ALT-58* AST-62* AlkPhos-183* TotBili-0.9 [**2196-9-25**] 06:10AM BLOOD Albumin-3.2* Calcium-8.4 Phos-4.1 Mg-2.0 Brief Hospital Course: He was admitted to the Transplant Service under Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. He continued to bleed and require a total of 13 units of PRBC over a 24 hour period. Therefore, he was taken to the OR on [**9-10**] for hemoperitoneum. An exploratory laparotomy was performed with drainage of intra-abdominal hematoma (~5 liters of old blood), cauterization of abdominal wall bleeder and drainage of 27 liters of ascites. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. See operative report for complete details. Postop, he was admitted to the SICU where he recovered well. He was transferred to the floor on POD3. He was kept on a heparin drip for his hypercoagulable state and transitioned to coumadin. His main issue was extremely high output from his JPs, reaching several liters a day. The was replaced with maitenance crystalloid fluid as well as crystalloid replacement of his JP output and albumin for every two liters of drainage. Eventually his JP drainage was limited to a total of 6L per day. On POD12 the decision was made to no longer drain his JPs and allow his ascites to reaccumulate. His incision remained intact and on POD14 his JP was removed. He was monitored for another day and was felt to be stable for discharge on POD15 with close follow-up with Dr. [**First Name (STitle) **] later that week, as well as his PCP for INR checks and coumadin dosing. Medications on Admission: amiloride 20 mg PO QD, furosemiode 200 mg PO QD, oxycontin 20 mg PO TID, Coumadin 10 mg M/W and 7.5 mg other days, Colace 300 mg PO QD ALL: spironolactone (gynecomastia) Discharge Medications: 1. Coumadin 6 mg Tablet Sig: One (1) Tablet PO once a day for 2 doses: Take 6mg of coumadin today ([**9-25**]) and tomorrow ([**9-26**]). Get your INR checked on [**9-27**] and your PCP will dose your coumadin appropriately thereafter. 2. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. amiloride 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 4. furosemide 40 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Budd chiari type syndrome hypercoagulable disorder hemoperitoneum recurrent ascites Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office [**Telephone/Fax (1) 673**] if you experience any of the listed warning signs: fever, chills, nausea, vomiting, increased abdominal distension, bleeding, dizziness or redness/bleeding or drainage from old drain site. You may shower No heavy lifting/straining Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2196-9-29**] 1:40 Please see your PCP to get your INR checked on Tuesday, [**2196-9-27**]. Take coumadin 6mg today (Sunday) and Monday.

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icd9cm

[ [ [] ] ]

[ "54.3", "96.6", "54.19" ]

icd9pcs

[ [ [] ] ]

5345, 5351

2950, 4408

275, 406

5479, 5479

2520, 2927

6003, 6277

1912, 1942

4630, 5322

5372, 5458

4434, 4607

5630, 5980

1972, 2501

228, 237

434, 1612

5494, 5606

1634, 1793

1809, 1896

53,326

164,745

41532

Discharge summary

report

Admission Date: [**2181-1-24**] Discharge Date: [**2181-1-26**] Date of Birth: [**2120-8-8**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 896**] Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: [**Known firstname 90339**] [**Known lastname **] is a 60F with hx of HTN seen in ED [**1-20**] for HA, N/V and found to have ?incidental cerebellar lesion on noncon head CT w/hypoNa 132. Patient had 1 week hx of HA in her sinused, called her PCP who Rx's her for azithromycin [**1-17**] (pt has frequent sinus infections). Patient took 1 dose 2/24, and started having nausea/vomiting every hour x 2 days. She was switched to a Z-pack on [**1-19**] but continued to have nausea and vomiting, then on night of [**1-19**] to [**1-20**] her HA became [**9-3**] and she felt weak and shaky. She then went to [**Hospital1 778**] UCC on [**1-20**] where was found to have hyponatremina to 132, and was sent to [**Hospital1 18**] ED. There she had a head ct that showed a 6-mm hyperdensity in the left medial cerebellum, which per rads read could represent cavernoma or neoplasm with hemorrhage. Neuro saw pt and rec'd an MRI, but pt refused to be admitted for that and wanted to set it up as an outpatient. Since her ED dispo pt has been having "only a few spoonfuls of Ensure" per day and had no appetite. Starting yesterday am she was runnning temps from 99.0 to 100.4 prior to taking tylenol, and began having 8BM's QDay of loose, watery, non-bloody, not dark stools. She started to have nausea and vomited x2 beginning yesterday evening. Her HA worsened to [**9-3**] overnight and she felt weak and shaky. Today she was found by her son-in-law w/tremors and c/o whole body pain and weakness. She was brought to the ED where her Na was 116. Her vitals were 98.1 44 116/77 16 100% ra initially. She was given 1L NS and sent to the ICU. Her vitals on transfer were 98.5, 64, 120/70, 16, 100% ra. Review of systems: (+) Per HPI. Also reported 2 months of blurry vision, has optometrist appt pending. (-) Denies chills, night sweats, recent weight loss or gain. Denies rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies current diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Hypertension, on a thiazide and BB 2. OP, on a bisphosphanate 3. h/o sinusitis/HA beginning roughly 10y ago (HA predominant Sx) in the winter most years, as above Social History: Lives with daughter and son-in law. Originally from Seoul. Has been living in the US for 30 years. - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Family History: father died of stroke at age 60, paternal grandmother died of stroke at 70. Physical Exam: Vitals: T:98.0 BP: 122/80 P: 67 R:16 18 O2: 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, lips chapped, OP clear Neck: supple, JVP not elevated, no LAD Lungs: Diminished breath sounds bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AAOx3, CN II-XII intact, FNF intact with mild tremor throughout extension, no dysdiadocokinesis, heel-shin intact bilaterally, strength 4+/5 throughout all muscle groups, sensation intact throughout. Pertinent Results: Admission Labs: [**2181-1-24**] WBC-5.7 RBC-4.11* Hgb-13.3 Hct-35.5* MCV-86 MCH-32.3* MCHC-37.4* RDW-12.1 Plt Ct-326 Glucose-135* UreaN-5* Creat-0.4 Na-116* K-3.4 Cl-82* HCO3-22 AnGap-15 ALT-59* AST-58* AlkPhos-47 TotBili-0.7 Calcium-9.3 Phos-2.8 Mg-1.7 Urine: [**2181-1-24**] 09:39PM URINE Hours-RANDOM Creat-17 Na-53 K-20 Cl-39 [**2181-1-24**] 09:39PM URINE Osmolal-186 Other Data: FSH-3.7 LH-<1.0* Prolact-60* TSH-0.19* T4-5.2 calcTBG-1.10 TUptake-0.91 T4Index-4.7 Cortsol-1.9* Discharge Labs: [**2181-1-26**] Glucose-135* UreaN-1* Creat-0.5 Na-134 K-4.0 Cl-102 HCO3-25 AnGap-11 Brief Hospital Course: 1. Hyponatremia. Likely hypovolemic hyponatremia as 3L NS improved her sodium from 116 to 134 Volume depleted by history and on exam. Adrenal insufficiency and hypothyroidism could have mild role as well. Her HCTZ was held at admission and should be discontinued. 2. Panhypopituitism. Noted to have an incidental 6mm hyperdensity in the left medial cerebellum, on CT done [**1-20**] in the ED. An MRI was done to evaluate this and showed a hypoenhancing lesion in the pituitary gland with rim enhancement, felt possibly to be an adenoma. In response, pituitary hormes were checked with panhypotipuitism noted. Given this, patient was started on cortisol replacement (prednisone 5 mg daily) and thyroid replacement (levothyroxine 25 mcg daily). A dedicated pituitary MRI was recommended and is to be done by new outpatient endocrinologist. In addition, given patient's social history, placement of PPD was recommended (to be done by PCP). Medications on Admission: azithromycin 250 mg Oral PO Daily for 4 days alendronate 70 mg PO once weekly atenolol 25 mg PO Daily hydrochlorothiazide 25 mg PO Daily fluticasone 50 mcg/Actuation: 2 Disk Once Daily, each nostril Calcium 600 + D(3) 600 mg (1,500)-200 unit [**Unit Number **] Tablets PO Daily Discharge Medications: 1. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**11-26**] Nasal twice a day. 3. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: Two (2) Tablet PO once a day. 4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Solu-Cortef 100 mg Recon Soln Sig: One (1) injection Injection once as needed for as directed. Disp:*1 vial* Refills:*0* 7. syringe (disposable) 3 mL Syringe Sig: One (1) Miscellaneous once as needed for as directed. Disp:*1 box* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Hyponatremia 2. Panhypopituitism 3. Hypothyroidism 4. Adrenal insufficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with hyponatremia (low sodium values). This was likely due to a combination of factors with dehydration being a major component. Your HCTZ puts you at risk for hyponatremia so this should be STOPPED. In addition to this, you were found to have low levels of multiple hormones (thyroid, cortisol) which is due to pituiatary dysfunction. As a result, you were started on two new medications and will need to follow-up with a new endocrinologist. Followup Instructions: Name: [**Known lastname **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 2261**] When: Monday, [**1-29**], 2:30PM ENDOCRINOLOGY: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tuesday [**1-30**] at 2:30 Address: [**Location (un) 4363**] [**Location (un) 86**], [**Numeric Identifier 4364**] Hours: Mon-Fri: 8:30am-5:00pm Telephone Hours: 8:00am-5:00pm Telephone: [**Telephone/Fax (1) **] Fax: [**Telephone/Fax (1) **]

[ "401.9", "244.9", "255.41", "787.01", "276.1", "253.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6363, 6369

4384, 5327

312, 318

6491, 6491

3774, 3774

7128, 7738

2924, 3002

5656, 6340

6390, 6470

5353, 5633

6641, 7105

4274, 4361

3017, 3755

2068, 2544

263, 274

346, 2049

3790, 4258

6506, 6617

2566, 2734

2751, 2908

70,886

144,565

29825

Discharge summary

report

Admission Date: [**2199-11-3**] Discharge Date: [**2199-11-8**] Date of Birth: [**2127-12-1**] Sex: M Service: MEDICINE Allergies: Penicillins / Lisinopril / [**Last Name (un) **]-Angiotensin Receptor Antagonist Attending:[**First Name3 (LF) 7333**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: 1. Cardiac catheterization x2 with thrombectomy and drug eluting stent to the obtuse marginal artery History of Present Illness: 71 yo male wiht h/o CABG in [**2186**], PTCA [**2192**], s/p stenting [**2197**] (unknown anatomy, getting records from the [**Hospital1 756**]), smoking, HTN, HLD, and diabetes who is presenting with chest discomfort. The patient reports that the night prior to presentation, he developed left sided chest pain; dullness without any radiation. No associated diaphoresis, but reports slight nausea and shortness of breath. The pain was persistent, and did not respond to SL Nitro. The pain also progressively worsened over the course of the day, prompting the patient to call EMS. EMS gave to SL NG sprays, with no relief. . The patient does not remember if this chest pain is similar to pain he had in the past prior to his past cardiac events. Denies any worsening exercise tolerance; the patient reports being able to walk about one block before getting short of breath. Denies any orthopnea, denies PND. Reports increasing LE swelling; reports that he has never had swelling like this before. Of note, the patient's wife reports that he has been chest pain free for about one year. . Denies any recent travel, no long plane rides. Up to date with his cancer screening, as per wife-last colonoscopy 2 years ago, found polyps. Is not very active at his baseline; does not like walking, does not like going outside. . He had a stress test (due to chest pain) in [**Month (only) **], which showed 2D echocardiographic evidence of inducible ischemia at achieved workload single vessel CAD-new regional dysfunction with distal inferior hypokinesis. LVEF >55% . On ROS, the patient denies any recent fevers/chills, no blood in stools, no changes in bowel movements, no urinary symptoms. Denies any lightheadedness or dizziness. . In the ED, the patient's initial vitals: 97.8 64 138/79 16 95% RA. He was initially given 1 L of fluid and treated for COPD excacerbation with azithromycin, prednisone, and nebulizers. He then developed respiratory distress and required NRB. Repeat CXR showed ? worsening pulmonary edema and patient was given 20 mg IV lasix. EKG unchanged from priors, found to have elevated troponin and started on IV heparin, given ASA. Received 8 mg morphine, 1 mg Dilaudid and now chest pain free. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: [**2186**] - PERCUTANEOUS CORONARY INTERVENTIONS: PTCA [**2192**], Stent [**2197**] - PACING/ICD: none - h/o multifocal atrial tachycardia 3. OTHER PAST MEDICAL HISTORY: - BPH Social History: Retired polymer chemist. Married, has one daughter. Smokes one pack per day for the last 55 years. Drinks alcohol infrequently. Family History: Father died in his 70s of heart disease. Brother died in his 70s of presumed heart disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 117/57 72 16 93% on high flow O2 GENERAL: NAD, pleasant elderly gentleman, breathing comfortably with face mask on HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP to edge of mandible 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: crackles [**12-16**] lung fields b/l, decent air movement ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: trace LE edema, + pedal edema b/l SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ . DISCHARGE PHYSICAL EXAM: VS: 125/60 77 14 98% RA GENERAL: NAD, pleasant elderly gentleman HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP to edge of mandible 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: minimal crackles at bases, decent air movement ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: trace LE edema, + pedal edema b/l SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: . [**2199-11-3**] 02:40PM BLOOD WBC-8.4 RBC-4.12* Hgb-12.0* Hct-36.0* MCV-87# MCH-29.2 MCHC-33.4 RDW-15.2 Plt Ct-377 [**2199-11-3**] 02:40PM BLOOD PT-13.0 PTT-25.1 INR(PT)-1.1 [**2199-11-3**] 02:40PM BLOOD Glucose-150* UreaN-25* Creat-1.3* Na-139 K-5.1 Cl-104 HCO3-24 AnGap-16 [**2199-11-3**] 02:40PM BLOOD CK-MB-31* [**2199-11-3**] 02:40PM BLOOD cTropnT-0.43* . PERTINENT LABS: . [**2199-11-3**] 02:40PM BLOOD CK-MB-31* [**2199-11-3**] 02:40PM BLOOD cTropnT-0.43* [**2199-11-4**] 03:17AM BLOOD CK-MB-57* MB Indx-8.3* cTropnT-1.46* [**2199-11-4**] 09:43AM BLOOD CK-MB-45* MB Indx-7.1* cTropnT-2.25* [**2199-11-6**] 10:20PM BLOOD CK-MB-2 [**2199-11-7**] 06:35AM BLOOD CK-MB-2 [**2199-11-4**] 03:17AM BLOOD CK(CPK)-687* [**2199-11-4**] 09:43AM BLOOD CK(CPK)-630* [**2199-11-4**] 09:43AM BLOOD %HbA1c-6.8* eAG-148* [**2199-11-4**] 09:43AM BLOOD Triglyc-102 HDL-49 CHOL/HD-2.8 LDLcalc-68 . DISCHARGE LABS: . [**2199-11-7**] 06:35AM BLOOD WBC-7.8 RBC-4.06* Hgb-11.9* Hct-35.2* MCV-87 MCH-29.2 MCHC-33.7 RDW-14.7 Plt Ct-330 [**2199-11-7**] 06:35AM BLOOD Glucose-168* UreaN-36* Creat-1.1 Na-137 K-4.1 Cl-97 HCO3-28 AnGap-16 [**2199-11-7**] 06:35AM BLOOD CK-MB-2 [**2199-11-7**] 06:35AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.8 . MICRO/PATH: . MRSA SCREEN (Final [**2199-11-6**]): No MRSA isolated. . IMAGING/STUDIES: . TTE [**11-3**]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-16**]+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild-moderate mitral regurgitation. Trace aortic regurgitation. . CXR PA/LAT [**11-3**]: IMPRESSION: Emphysema with superimposed pulmonary edema. Trace bilateral pleural effusions. . C.CATH [**11-4**]: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Thrombus in the vein graft to OM. 3. Small hematoma at arterial puncture site. . C.CATH [**11-6**]: FINAL DIAGNOSIS: 1. Success PCI to the 95% SVG to OM lesion with Promus DES. 2. Patient to remain on aspirin indefinitely and clopidogrel for at least 1 year uninterrupted. 3. No complications. Brief Hospital Course: 71 yo male with h/o CABG in [**2186**], PTCA [**2192**], s/p stenting [**2197**], smoking, HTN, HLD, and diabetes who is presented with chest pain and was found to have NSTEMI and acute diastolic CHF exacerbation. . ACTIVE DIAGNOSES: . # NSTEMI: Mr. [**Known lastname 71328**] was admitted to the CCU with a chief complaint of chest pain without ST elevations on EKG and a significant coronary history including CABG followed by PTCA and stenting. Cardiac catheterization showed proximal occlusion of SVG to OM and thrombus. On initial catheterization, no intervention was attmepted because the interventional team was not able to protect distal to thrombus for emboli. However, repeat catheterization was successful with deployment of DES to the 95% occluded SVG to OM lesion. The patient was started on aspirin 325mg daily and will need to continue taking this indefinitely, as well as plavix which he will need for at least 1 year uninterrupted. He was continued on his home carvedilol and atorvastatin as well. Follow-up appointments were arranged for him prior to discharge. . # Acute Diastolic Congestive Heart Failure Exacerbation: Mr. [**Known lastname 71328**] was without history of CHF but was hypoxic of NRB on arrival to CCU with prominent rales on exam, CXR c/w with pulmonary edema, and peripheral edema. The etiology of his CHF was thought to be related to his acute MI exacerbated by administration of 1LNS in the ED. He was diuresed aggressively until he reached euvolemia clinically and was able to sat in the high 90's on room air. TTE showed LVEF of >55%. He was counseled on maintaining a low sodium diet as well as taking daily weights to monitor his fluid balance. He was continued on carvedilol at the time of discharge. . # Acute on Chronic Kidney Injury: His creatinine on admission was 1.3 (up from baseline of 1.1). This was likely related to poor forward flow in the setting of MI and diastolic CHF. His Cr returned to baseline with diuresis in spite of contrast loads from two C.Caths. # COPD: Pt does not have dx of COPD, but with flattened diaphragms and parenchymal findings on CXR consistent with COPD in the context of extensive smoking history. He was given prednisone/azithromycin in ED for concern of COPD exacerbation that was later felt to be consistent with CHF exacerbation. He will likely benefit from formal PFT's as an outpatient and continued smoking cessation counseling. . CHRONIC DIAGNOSES: . # Hypertension: Stable. Patient takes Carvedilol, nifedipine, and Hydrochlorothiazide as an outpatient. He was continued on carvedilol which was decreased from TID to [**Hospital1 **] dosing and his home nifedipine and HCTZ were discontinued. His blood pressure should be re-visited in the outpatient setting. . # Hyperlipidemia: Stable with TC of 137 and LDL of 68. His home atorvastatin was increased to 80mg PO daily. . # Diabetes: HbA1c 6.8%. On Glyburide-Metformin as an outpatient. Was managed with HISS in house and discharged on his home PO regimen. . # BPH: Stable. Continued on doxazosin at the time of discharge. . TRANSITIONAL ISSUES: # He will likely benefit from formal PFT's and continued smoking cessation. . # Changes were made to his anti-hypertensive regimen and this issue should be revisited during an outpatient visit. Medications on Admission: 1. Atorvastatin 20 mg PO daily 2. Carvedilol 6.25 mg PO TID 3. Doxazosin 6 mg PO daily 4. Glyburide-Metformin 2.5 mg-500 mg PO BID 5. Hydrochlorothiazide 25 mg PO daily 6. Nifedipine XL 90 mg daily 7. Aspirin 81 mg PO daily 8. Docusate sodium 100 mg PO BID Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 2. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day. 3. glyburide-metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO twice a day: START on SATURDAY [**11-9**]. . 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 8. doxazosin 4 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 9. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Non ST Elevation Myocardial Infarction Acute on Chronic diastolic congestive heart failure Secondary diagnosis: Chronic obstructive pulmonary disease Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 71328**], . It was a pleasure taking part in your medical care while you were in the hospital. You had chest pain and a cardiac catheterization that showed a large clot in one of the heart arteries. You required another catheterization to remove the clot safely and a drug eluting stent was placed to keep the artery open. It is extremely important that you take plavix every day to prevent the stent from closing off and causing another heart attack. Do not stop taking plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s unless Dr. [**Last Name (STitle) 171**] tells you it is OK. . Your blood pressure was a little low while you were in the hospital so we made some changes to your blood pressure medicines. If your blood pressure goes back up yuor doctor may want to restart some of these medicines. . You had some fluid in your lungs that was removed with intravenous medicines. We did not continue these medications. You will need to weigh yourself every morning, call Dr. [**Last Name (STitle) 171**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . The following changes were made to your medication regimen: 1. INCREASE Atorvastatin to 80 mg daily to help your heart recover from a heart attack. 2. INCREASE aspirin to 325 mg daily to prevent the stent from clotting off 3. DECREASE carvedilol to 6.25 mg twice a day 3. STOP taking nifedipine and hydrochlorothiazide 4. START taking nitroglycerin only as needed for chest pain at home. Take one tablet, then wait 5 minutes, then take one more tablet if you still have the pain. Call 911 for any chest pain that is still there after 2 nitroglycerin tablets. Followup Instructions: Please attend the following appointments: Department: CARDIAC SERVICES When: Friday [**11-22**] at 10:30am. With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital **] HEALTHCARE [**Location (un) **] When: TUESDAY [**2199-11-12**] at 4:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 4606**] Building: [**State **] ([**Location (un) 583**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Completed by:[**2199-11-9**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11727, 11733

7262, 7478

352, 455

11965, 11965

4788, 4788

13827, 14525

3166, 3260

10856, 11704

11754, 11754

10575, 10833

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2733, 2799

3021, 3150

4080, 4769

47,233

189,394

46865

Discharge summary

report

Admission Date: [**2156-6-7**] Discharge Date: [**2156-6-8**] Date of Birth: [**2090-12-23**] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Bactrim Ds / Shellfish Derived Attending:[**Doctor First Name 1402**] Chief Complaint: AFib, flash pulmonary edema following DCCV Major Surgical or Invasive Procedure: Direct current cardioversion - [**2156-6-7**] History of Present Illness: 65 yo F with history of rheumatic mitral valve disease with 4+ MR and [**2-18**]+ TR, recently diagnosed AFib on warfarin (2-3 weeks ago), now s/p DCCV complicated concerns for flash pulmonary edema. She has been feeling fatigued and short of breath for the last 2-3 weeks, was found to be in atrial fibrillation. She had been experiencing some orthopnea, dyspnea on exertion, and overall fatigue. She underwent TEE/cardioversion today, following which she was hypotensive with SBP in the 70's. She received IV fluids, following which she became acutely short of breath. Thought to be in flash pulmonary edema and received a total of 60 mg of IV lasix, to which she put out 500 cc of urine with symptoms improving. Patient was started on a nitro drip and transferred to the CCU for further medical management. . Currently patient is still feeling a little short of breath but much improved. Having a slight headache, but otherwise no other complaints. . 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, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: Atrial Fibrillation on warfarin and BB (diagnosed 2 weeks ago) 4+ MR [**2-18**]+ TR 3. OTHER PAST MEDICAL HISTORY: Anxiety Rheumatic Fever Social History: She lives with husband independently at home. No EtOH, tobacco, or illicit drug use. Family History: Mother - died in her sleep at age 78, unknown causes Father - ?cancer Physical Exam: VS: 96.8, 91/56, 66, 24, 96% 4L GENERAL: WDWN female in NAD, AAOx3 HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. No LAD. No JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles in R base, crackles in L lung [**1-18**] of the way up. No wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: TEE (Complete) Done [**2156-6-7**] at 5:28:18 PM 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. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. There is mild global left ventricular hypokinesis (LVEF = 50 %). [Intrinsic function is likely depressed given the severity of mitral regurgitation.] Right ventricle with depressed free wall contractility. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened with characteristic rheumatic deformity. Severe (4+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: No spontaneous echo contrast or intraatrial thrombus identified. Mild global [**Hospital1 **]-ventricular systolic dysfunction. Severe mitral regurgitation. Simple atheroma in descending aorta. CBC [**2156-6-8**] 05:21AM BLOOD WBC-12.9* RBC-3.83* Hgb-11.7* Hct-35.0* MCV-91 MCH-30.5 MCHC-33.3 RDW-13.1 Plt Ct-289 [**2156-6-7**] 05:00PM BLOOD WBC-12.1* RBC-3.85* Hgb-11.7* Hct-35.8* MCV-93 MCH-30.4 MCHC-32.7 RDW-12.9 Plt Ct-325 Coags [**2156-6-8**] 05:21AM BLOOD PT-20.3* PTT-32.6 INR(PT)-1.9* [**2156-6-7**] 05:00PM BLOOD PT-19.2* PTT-25.9 INR(PT)-1.8* [**2156-6-7**] 08:10AM BLOOD PT-19.8* INR(PT)-1.8* Chemistry [**2156-6-8**] 05:21AM BLOOD Glucose-121* UreaN-22* Creat-0.8 Na-139 K-3.8 Cl-101 HCO3-28 AnGap-14 [**2156-6-7**] 05:00PM BLOOD Glucose-99 UreaN-18 Creat-0.7 Na-141 K-4.1 Cl-103 HCO3-29 AnGap-13 [**2156-6-8**] 05:21AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.0 [**2156-6-7**] 05:00PM BLOOD Albumin-4.1 Calcium-8.8 Phos-3.7 Mg-2.0 TFT [**2156-6-7**] 05:00PM BLOOD TSH-1.0 [**2156-6-7**] 05:00PM BLOOD Free T4-1.3 Brief Hospital Course: 65 yo F with history of rheumatic MV disease with 4+ MR and [**2-18**]+ TR, recently diagnosed AFib on warfarin (2-3 weeks ago), now s/p cardioversion, complicated by flash pulmonary edema. . # PUMP/MR/TR/pulmonary edema: patient has history of rheumatic heart disease. TEE on this admission shows mild global [**Hospital1 **]-ventricular systolic dysfunction with severe mitral regurgitation, mild to moderate tricuspid regurgitation, and mild aortic regurgitation. Her last EF on TTE was 60%. Her post cardioversion course was complicated by flash pulmonary edema for which she was admitted to the CCU where she was diuresed with improvement of her symptoms. She responded well to IV lasix 40 mg doses. She was discharged on metoprolol. Initiation of an ACE inhibitor can be considered as an outpatient, as her EF is likely overestimated on her TTE given her severe MR. Valve replacement/repair was discussed with the patient on this admission. She is a candidate for valve replacement/repair given that she is symptomatic with new onset Afib. She will discuss this further with her outpatient cardiologist. . # RHYTHM/A fib - patient was diagnosed with atrial fibrillation 2-3 weeks prior to this admission, her symptoms being fatigue and dyspnea on exertion. She is now s/p TEE and cardioversion, reverted back to normal sinus rhythm. Patient will continue with warfarin and lovenox bridge (discharge INR of 1.9) until she can have her INR rechecked at [**Hospital 191**] [**Hospital3 **] on [**2156-6-10**]. Per EP recommendations, she was also started amiodarone 200 mg TID for 3 weeks, then will decrease to 200 mg daily. Patient will need outpatient PFTs because of initiation of amiodarone. . # CORONARIES - patient has no history of coronary disease . # Anxiety - patient was continued on home regimen of clonazepam Medications on Admission: Clonazepam 0.5-1 mg PO TID PRN Metoprolol 50 mg PO BID Coumadin 2.5 mg PO daily Prochlorperazine 10 mg q6h prn nausea Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Take 1 tablet 3 times a day from [**2156-6-7**] - [**2156-6-27**], then switch to taking 1 tablet daily from then on. Disp:*70 Tablet(s)* Refills:*1* 2. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*3* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Discharge Disposition: Home Discharge Diagnosis: Pulmonary edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 69**] for a cardioversion. Following the procedure, you developed shortness of breath because you suddenly developed of fluid in your lungs. You were admitted to the cardiac intensive care unit where we gave you medications in order to help remove fluid from your body. Your symptoms improved overnight. Your heart is currently in a regular rhythm. You will need to follow up with your cardiologist as an outpatient. The following changes were made to your medications: - new: amiodarone - please take 200 mg three times a day for 3 weeks, then switch to taking 200 mg once a day from then on - please decrease your metoprolol to 25 mg twice a day You anticoagulation should be managed as follows: - please take warfarin 5mg on [**2156-6-9**] - starting on [**2156-6-10**], start taking warfarin 2.5mg daily and then as directed by the [**Hospital3 **] - you will need to have your INR checked on Thursday [**2156-6-10**] - please continue taking lovenox until you have your INR checked on Thursday The rest of your medications have not changed. Please continue to take them as originally prescribed You will need to continue to have your INR checked periodically at the [**Hospital 191**] [**Hospital3 **] Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please follow up with your cardiologist, Dr. [**Last Name (STitle) **], in [**1-17**] weeks after discharge from the hospital.

[ "427.31", "300.00", "518.4", "394.1", "416.8", "397.0" ]

icd9cm

[ [ [] ] ]

[ "99.62", "88.72" ]

icd9pcs

[ [ [] ] ]

7846, 7852

5142, 6981

359, 407

7912, 7912

3187, 5119

9427, 9557

2235, 2306

7149, 7823

7873, 7891

7007, 7126

8063, 9404

2321, 3168

1976, 2060

276, 321

435, 1866

7927, 8039

2091, 2117

1888, 1956

2133, 2219

7,133

145,723

27428

Discharge summary

report

Admission Date: [**2135-4-7**] Discharge Date: [**2135-4-21**] Date of Birth: [**2093-7-6**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: Shortness of breath for twelve hours prior to presentation. Major Surgical or Invasive Procedure: right video assisted thoracoscopy, blebectomy, pleurodesis, Foley catheter placement, peripheral inserted central catheter placement History of Present Illness: 41 year old man with history of DM2, asthma, sleep apnea that developed shortness of breath acutely while in prison that he managed to tolerate for a three day period. He then presented to another hospital where he received a chest tube and achieved partial reexpansion of the lung. While the chest tube was on suction he continued to have a persistent air leak. The patient was then transferred to [**Hospital1 69**] for surgical evaluation. He denies any history of trauma, heavy lifting, chest pain, hemoptysis, fevers, chills or sweats, cough, new neurological or new musculoskeletal complaints. All other systems reviewed were otherwise negative. Past Medical History: DM2, obstructive sleep apnea, asthma, anxiety, reflux disease Social History: Lives at [**Location **] Correctional Facility Family History: Noncontributory Physical Exam: He is a well-appearing male resting comfortably on 100% oxygen facemask. His saturations are 98% on 100% on room breathers. Temperature is 99.4, heart rate is 102, his blood pressure is 106/74, respiratory rate of 16. His pupils are equal, round, and reactive. His sclerae are anicteric. Cervical exam reveals no supraclavicular or cervical adenopathy. Lungs are clear to auscultation, although there are diminished breath sounds on the right. His heart is regular without murmur. Thorax is symmetrical without lesions or masses. He has a right-sided chest tube, which has a large continuous air leak on suction. His abdomen is benign without masses or tenderness. Extremities show no clubbing or edema. Neurologic is grossly nonfocal with intact and appropriate mental status. Pertinent Results: [**2135-4-7**] 10:46PM PLEURAL TOT PROT-5.0 GLUCOSE-149 LD(LDH)-1861 AMYLASE-43 [**2135-4-7**] 10:07PM PLEURAL WBC-[**Numeric Identifier **]* RBC-5444* POLYS-91* LYMPHS-2* MONOS-0 MACROPHAG-7* [**2135-4-7**] 04:44PM GLUCOSE-199* UREA N-21* CREAT-1.1 SODIUM-137 POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-29 ANION GAP-15 [**2135-4-7**] 04:44PM CALCIUM-9.0 PHOSPHATE-3.3 MAGNESIUM-1.8 [**2135-4-7**] 04:44PM WBC-13.3* RBC-4.45* HGB-13.9* HCT-39.5* MCV-89 MCH-31.4 MCHC-35.3* RDW-13.3 [**2135-4-7**] 04:44PM PLT COUNT-219 [**2135-4-7**] 04:44PM PT-12.3 PTT-24.3 INR(PT)-1.1 Brief Hospital Course: Patient was admitted to the thoracic surgery service on [**2135-4-7**] and on the day of admission the patient had a CT scan of the chest that revealed several right sided apical blebs and an imcompletely inflated right lung. Thus decision was made at this time to take the patient to the operating room. On [**2135-4-8**] the patient underwent flexible bronchoscopy, right thoracoscopy with apical bleb resection, and mechanical pleurodesis. The patient tolerated the procedures very well and was transferred to the hospital [**Hospital1 **] after a brief stint in the recovery room. Postoperatively the patient did have some fevers and was cultured and found to have growth of staphylococcus aureus in the blood that was sensitive to oxacillin. He was then started on antibiotics which was converted to vancomycin and levofloxacin prior on [**4-13**] and [**4-11**] respectively. He also underwent doppler studies of the legs to assess for venous thrombosis as part of the fever workup and these were negative. By the time of discharge he was afebrile and feeling significantly better with plans to continue the antibiotics through [**5-8**]. Medications on Admission: metformin, glyburide, protonix, bentyl, remeron, celexa, trazodone Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H (Every 3 to 4 Hours) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Capsule(s) 4. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 5. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 7. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 16. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed. 17. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 18 days. 19. Vancomycin 500 mg Recon Soln Sig: 1500 (1500) mg Intravenous Q 12H (Every 12 Hours) for 18 days: with levels checked every 3rd day. Disp:*qs mg* Refills:*2* Discharge Disposition: Extended Care Facility: [**Location (un) **] Correctional Facility Infirmary Discharge Diagnosis: pneumothorax, diabetes mellitus, asthma, obstructive sleep apnea, irritable bowel syndrome, gastroesophageal reflux disease, depression Discharge Condition: stable Discharge Instructions: having worsening pains, fevers, chills, nausea, vomiting, shortness of breath, redness or drainage about the wounds, or if there are any questions or concerns. Patient to be continued on IV antibiotics through [**2135-5-8**] via PICC line. Followup Instructions: Patient to follow up with Dr. [**Last Name (STitle) 952**] in [**11-29**] weeks and to call to schedule an appointment at [**Telephone/Fax (1) 170**]

[ "512.8", "511.9", "492.0", "327.23", "482.41", "285.9", "493.92", "041.11", "790.7", "250.00" ]

icd9cm

[ [ [] ] ]

[ "32.29", "34.6", "93.90", "38.93" ]

icd9pcs

[ [ [] ] ]

5788, 5867

2771, 3923

344, 479

6047, 6056

2171, 2748

6345, 6498

1331, 1348

4040, 5765

5888, 6026

3949, 4017

6080, 6322

1363, 2152

245, 306

507, 1166

1188, 1251

1267, 1315

19,310

157,811

53128

Discharge summary

report

Admission Date: [**2181-6-19**] Discharge Date: [**2181-7-12**] Date of Birth: [**2101-5-1**] Sex: F Service: MEDICINE Allergies: Sulfamethoxazole / Quinolones Attending:[**First Name3 (LF) 30**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Patient was intubated in the ICU for less than 24 hours following acute respiratory distress. She was weaned promptly thereafter. History of Present Illness: 80 yo female with Hx of stroke from Cerebral Amyloid Angiopathy who presents with SOB x 1 week. Started wheezing one week ago with increase in chronic wet cough. Per pt's husband, + temporal relationship between coughing/wheezing/SOB and right after taking food PO. Pt. did receive a swallow-eval as an outpatient and passed approx. 4 days ago. Pt. went to [**Hospital3 **] yesterday and was given z-pack for ? pneumonia with no change in symptoms. Reportedly patient's respiratory status improves when she is NPO. Per family, they are not comfortable taking care of pt. at home right now - feel that her breathing is compromised. Husband has been giving Pt. albuterol/atrovent from previous admit. Saturations in the low 90s in the emergency department. Pt. unable to give Hx, most of Hx obtained from husband. . Also pt. w/ new ticks- described by patient husband as increased eye movements and bilateral feet twitching. Had discussed new findings with her outpt neurologist who increased her Neurontin. EEG [**8-/2180**]- no epileptiform features. Neurology was consulted in the ED. They would like to do an EEG as inpt, but [**Name (NI) 1094**] husband does not want EEG to be done. Past Medical History: - Multiple intraparenchymal hemorrhages due to amyloid angiopathy. The first hemorrhage was in [**2160**] (presented with R hemiparesis). Later had a large L fronto-parietal bleed (became aphasic). - Focal motor facial seizures. Previously treated with Dilantin, now on Neurontin. - Myoclonic jerks - High cholesterol - Hypertension - Hx of Hospital Admission for Pneumonia vs. Bronchitis instigated by patient inability to clear secretions from Upper Respiratory Tract. Was Intubated. Social History: Lives at home with her husband who is her primary caregiver. Also has a home health aide. They take 24 hour care of her. She is unable to do any of her ADLs and requires a Foley at baseline. She is fairly nonresponsive at baseline, but occ says [**11-20**] words or laughs at the TV according to her family. No tobacco, EtOH, or illicit drug use. Family History: h/o cad and stroke in the family Physical Exam: Vitals: Tm-98.9, T-96.0, BP-115/72, RR-20, 93% on 3L GEN: Aphasic, NAD, Noticeably contracted and without voluntary movement Skin: No rashes, warm and well perfused HEENT: NCAT, PERRLA CV:RRR no m/r/g Resp: + dry crackles at Left lung base, no cyanosis GI: NT/ND Neuro: Pt. completely aphasic, Notable rigid spasticity of Bilateral UE/LE. + twitching of LE L>R. - babinski, Pt. not able to follow commands or track with eyes. no clonus. MSK: No voluntary movement of UE/LE. + contractures diffusely Pertinent Results: . . Laboratory Values: . [**2181-6-19**] 10:20AM BLOOD WBC-6.4 RBC-4.52 Hgb-14.1 Hct-40.8 MCV-90 MCH-31.1 MCHC-34.5 RDW-14.4 Plt Ct-273 [**2181-6-21**] 05:00AM BLOOD WBC-8.2 RBC-4.22 Hgb-13.3 Hct-37.7 MCV-89 MCH-31.6 MCHC-35.4* RDW-14.2 Plt Ct-244 [**2181-6-23**] 06:20AM BLOOD WBC-8.5 RBC-4.10* Hgb-12.9 Hct-37.8 MCV-92 MCH-31.3 MCHC-34.0 RDW-14.3 Plt Ct-212 [**2181-6-25**] 06:40AM BLOOD WBC-4.9 RBC-3.82* Hgb-11.8* Hct-34.4* MCV-90 MCH-30.9 MCHC-34.4 RDW-14.1 Plt Ct-269 [**2181-6-28**] 05:03AM BLOOD WBC-8.6# RBC-4.49 Hgb-13.7 Hct-40.2 MCV-90 MCH-30.6 MCHC-34.1 RDW-14.3 Plt Ct-390 [**2181-6-30**] 04:30AM BLOOD WBC-9.2 RBC-3.80* Hgb-11.9* Hct-34.2* MCV-90 MCH-31.4 MCHC-35.0 RDW-14.5 Plt Ct-294 [**2181-7-2**] 03:10AM BLOOD WBC-11.6* RBC-3.68* Hgb-11.3* Hct-32.9* MCV-90 MCH-30.7 MCHC-34.3 RDW-14.4 Plt Ct-332 [**2181-7-4**] 01:50AM BLOOD WBC-12.6* RBC-3.66* Hgb-11.4* Hct-32.5* MCV-89 MCH-31.1 MCHC-34.9 RDW-14.5 Plt Ct-330 [**2181-7-6**] 05:55AM BLOOD WBC-10.1 RBC-3.62* Hgb-11.6* Hct-32.0* MCV-89 MCH-32.1* MCHC-36.2*# RDW-14.6 Plt Ct-401 [**2181-6-19**] 10:20AM BLOOD Neuts-57.4 Lymphs-32.4 Monos-2.4 Eos-7.6* Baso-0.2 [**2181-6-22**] 02:36AM BLOOD PT-14.9* PTT-30.3 INR(PT)-1.3* [**2181-6-30**] 04:30AM BLOOD PT-15.2* PTT-36.4* INR(PT)-1.4* [**2181-7-4**] 01:50AM BLOOD PT-15.2* PTT-38.2* INR(PT)-1.4* [**2181-6-19**] 10:20AM BLOOD Glucose-85 UreaN-8 Creat-0.6 Na-137 K-3.9 Cl-100 HCO3-27 AnGap-14 [**2181-6-21**] 05:00AM BLOOD Glucose-74 UreaN-9 Creat-0.5 Na-137 K-3.8 Cl-101 HCO3-22 AnGap-18 [**2181-6-23**] 06:20AM BLOOD Glucose-70 UreaN-5* Creat-0.4 Na-136 K-4.1 Cl-102 HCO3-20* AnGap-18 [**2181-6-25**] 06:40AM BLOOD Glucose-96 UreaN-3* Creat-0.4 Na-135 K-3.8 Cl-101 HCO3-24 AnGap-14 [**2181-6-27**] 06:25AM BLOOD Glucose-75 UreaN-5* Creat-0.5 Na-138 K-3.6 Cl-102 HCO3-25 AnGap-15 [**2181-6-29**] 02:02AM BLOOD Glucose-105 UreaN-5* Creat-0.6 Na-138 K-3.4 Cl-103 HCO3-20* AnGap-18 [**2181-7-1**] 04:01AM BLOOD Glucose-108* UreaN-22* Creat-0.7 Na-135 K-3.5 Cl-102 HCO3-22 AnGap-15 [**2181-7-3**] 03:26AM BLOOD Glucose-117* UreaN-29* Creat-0.6 Na-139 K-3.7 Cl-104 HCO3-27 AnGap-12 [**2181-7-5**] 05:50AM BLOOD Glucose-108* UreaN-27* Creat-0.7 Na-137 K-5.3* Cl-103 HCO3-22 AnGap-17 [**2181-7-7**] 06:10AM BLOOD Glucose-131* UreaN-38* Creat-0.7 Na-138 K-3.6 Cl-103 HCO3-23 AnGap-16 [**2181-6-19**] 10:20AM BLOOD CK(CPK)-173* [**2181-6-20**] 05:05AM BLOOD CK(CPK)-423* [**2181-6-29**] 01:17PM BLOOD CK(CPK)-232* [**2181-6-30**] 04:30AM BLOOD CK(CPK)-278* [**2181-6-19**] 10:20AM BLOOD CK-MB-6 cTropnT-0.02* [**2181-6-20**] 12:22AM BLOOD CK-MB-7 cTropnT-<0.01 [**2181-6-20**] 05:05AM BLOOD CK-MB-7 cTropnT-<0.01 [**2181-6-19**] 10:20AM BLOOD Calcium-9.7 Phos-3.9 Mg-2.3 [**2181-6-21**] 05:00AM BLOOD Calcium-9.2 Phos-2.8 Mg-2.0 [**2181-6-25**] 06:40AM BLOOD Calcium-8.8 Phos-2.2* Mg-1.9 [**2181-6-27**] 06:25AM BLOOD Albumin-3.3* Calcium-9.1 Phos-3.6 Mg-2.0 [**2181-6-29**] 02:02AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.6 [**2181-6-30**] 04:30AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.8 [**2181-7-2**] 03:10AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.2 [**2181-7-4**] 01:50AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.2 [**2181-7-6**] 05:55AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.0 Cholest-95 [**2181-7-6**] 05:55AM BLOOD Triglyc-74 HDL-31 CHOL/HD-3.1 LDLcalc-49 . . . Imaging Studies: . CT HEAD W/O CONTRAST [**2181-6-19**] 12:12 PM FINDINGS: Comparison is made with [**2180-8-24**]. There is no evidence of an intracranial hemorrhage. There is extensive encephalomalacia in both frontal lobes. There has been a large old left MCA infarct. There is no midline shift, mass effect or hydrocephalus. Periventricular white matter hypodensities are most consistent with chronic microvascular infarcts. There are no fractures. There is hyperostosis frontalis. IMPRESSION: No evidence of an intracranial hemorrhage. Extensive bifrontal encephalomalacia with a large old left MCA infarct. . CHEST (PORTABLE AP) [**2181-6-19**] 11:42 AM FINDINGS: There is a huge hiatal hernia that has inspissated barium in it. This hiatal hernia has increased in size in comparison to the previous study and now has barium elements in it. Has the patient had a recent barium study? There is severe distortion of the chest due to contracted posture of the patient, and this limits the study, however there is no increase in the size of the heart and there are no new pulmonary infiltrates. IMPRESSION: Increase in size of a huge hiatal hernia with herniation of the contents into the thoracic cavity. No pneumonia or cardiac failure. . VIDEO OROPHARYNGEAL SWALLOW [**2181-6-20**] 1:46 PM IMPRESSION: 1. Aspiration of thin liquids. 2. Hiatal hernia seen with delayed transit of contrast material, though no reflux seen on exam.A formal barium swallow exam is recommended. 3. For further details, please refer to formal swallow evaluation by speech therapy available on computerized medical records. . CHEST (PORTABLE AP) [**2181-6-21**] 3:40 PM IMPRESSION: Huge hiatal hernia containing small and large bowel. No evidence of new pulmonary opacities. . PORTABLE ABDOMEN [**2181-6-27**] 9:41 AM FINDINGS: Single view of the chest and upper abdomen was performed. This demonstrates an enormous hiatal hernia, which contains colon as well as likely stomach and small intestine. The nasogastric tube likely is within the stomach as it curves to the left, however, it is positioned within the left lower thorax. Heart size is at upper limits of normal. The lung fields are not well evaluated on this exam. Osseous and soft tissue structures are stable. IMPRESSION: Enormous hiatal hernia, which contains colon and likely stomach and small bowel. Nasogastric tube tip is likely within the intrathoracic portion of the stomach. . CHEST PORT. LINE PLACEMENT [**2181-6-28**] 1:37 PM The tip of the right PICC line lies in the lower SVC. No other change is identified. . [**Numeric Identifier 7670**] FLUORO 1 HR W/RADIOLOGIST [**2181-6-29**] 7:37 AM Reason: please place percutaneous G-J tube COMPLICATIONS: No immediate complications. IMPRESSION: Inability to perform percutaneous gastrojejunostomy due to the presence of the stomach in the chest through a hiatal hernia. . CHEST (PORTABLE AP) [**2181-7-2**] 4:56 AM SINGLE AP PORTABLE SEMI-UPRIGHT CHEST: Compared to [**2181-6-28**]. There is a feeding tube coiled within a large intrathoracic hiatal hernia containing stomach and a large segment of small bowel. Tortuous calcified thoracic aorta. The mediastinal contours are unremarkable. There are bilateral small pleural effusions with superimposed consolidation, right greater than left, most consistent with aspiration. Severe osteopenia and thoracolumbar scoliosis. IMPRESSION: 1) Moderate bibasilar consolidation and pleural effusions, most consistent with aspiration/aspiration pneumonia. 2) Feeding tube coiled within a large, complex hiatal hernia. . CHEST (PORTABLE AP) [**2181-7-6**] 9:18 AM Increasing small right pleural effusion and mild pulmonary edema suggests cardiac decompensation. Large hiatus hernia obscures much of the lower lungs, making it difficult to exclude pneumonia but no pneumonia is seen in the upper lungs. Heart size top normal, unchanged from baseline appearance on [**6-19**]. Findings were discussed by telephone with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the time of dictation. Brief Hospital Course: A/P - This is an 80 y/o female with PMH h/o multiple cerebral infarcts with recurrent episodes of aspiration and mucus plugging, resulting in two MICU transfers for hypoxia. . . 1. Hypoxic respiratory distress: The patient was admitted with respiratory distress likely due to an aspiration pneumonia following eating. While in house, she developed respiratory distress with oxygen saturations in the 80's that required two transfers to the MICU. The first transfer was likely due to increased bronchial secretions obstructing her airway, and the second acute event resulting in a CODE BLUE was likely due to a mucus plug. Both times the patient responded well to aggressive nasopharyngal suctioning. The second ICU transfer required less than 24 hours of ventilatory support and was weaned to CPAP successfully. The patient was maintained NPO and also was on aspiration precautions. She was suctioned as needed on the floor and given atrovent & albuterol treatments frequently. The medical staff wer extremely vigilant of her oxygen saturations and respiratory effort. After the second MICU course, the patient arrived to the floor on TPN. Subsequent to her arrival, she developed respiratory distress that responded well to diuresis. She was evaluated by the MICU at that time, although she was deemed to be stable for the floor after her condition improved and stablized following diuresis. She was discharged in good condition, maintaining oxygen saturation with typical respiratory effort. . 2. Hiatal Hernia: The patient has a large hiatal hernia that contains small bowel within the thoracic cavity, as documented on her imaging reports. This atypical anatomy presented problems with the placement of a feeding tube, and also precluded Interventional Radiology, Surgery & Gastroenterology from placing a feeding tube, despite the family's continued request for such. It was explained, in detail, that regardless of whether the patinet has a feeding tube, she is still at risk of aspiration of gastric contents. She was maintained NPO and given nutrition via TPN. . 3. Myoclonic jerks: The patient was seen by Neurology on admission who suggested that she receive Neurontin 600 mg tid, although it was instructed that this medication be held when the patient is NPO. Also, if patient has increased twitching, can try Depakote 500 mg [**Hospital1 **] per neuro. . 4. Nutrition: Given the risk of aspiration pneumonia the patient was initially maintained NPO. A feeding tube was discussed in detail and such a procedure was attempted by Interventional Radiology, however, her hiatal hernia was such that this could not be done. A nasopharyngeal feeding tube was also attempted but this could not be done succesfully. Both surgery and GI were consulted, however, neither of these services agreed that the benefits outweighed the risks of this procedure. She was started on TPN with the placement of a right PICC line. The patient was able to tolerate this procedure without event and she receive daily TPN with close monitoring of her nutritional and respiratory status. The family was educated in the use of TPN and the patient was discharged to home with continuation of such w/ VNA following. . After discussion with the patient's family, the medical staff, it was deemed by all parties involved that the patient was a suitable candidate for discharge. Medications on Admission: -Neurontin 600 mg TID -Recently D/C Lopressor 12.5 [**Hospital1 **] -Multivitamin qd Discharge Medications: 1. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Transdermal once a week. Disp:*8 * Refills:*2* 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation every six (6) hours. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation every six (6) hours. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary diagnosis: Hypoxia secondary to aspiration pneumonia and mucus plugging. Secondary diagnoses: Cerebral amyloid Angiopathy Focal motor seizures Hypercholesterolemmia Hypertension Discharge Condition: Stable Discharge Instructions: Patient was admitted into the hospital for hypoxia secondary to aspiration pneumonia complicated by mucus plugging and 2 admission to the ICU. Please monitor respiratory status often. Patient is to be on TPN. Please follow-up with PCP. Followup Instructions: Patient's PCP is [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 16748**]. Please make an appointment for follow-up. . Patient is to be followed by VNA. Completed by:[**2181-7-12**]

[ "518.81", "438.11", "507.0", "427.31", "276.51", "277.3", "553.3", "261", "333.2", "290.40", "933.1" ]

icd9cm

[ [ [] ] ]

[ "96.71", "93.90", "38.93", "99.15", "96.04" ]

icd9pcs

[ [ [] ] ]

14276, 14325

10467, 13846

307, 440

14556, 14565

3133, 6373

14850, 15073

2558, 2593

13982, 14253

14346, 14346

13872, 13959

14589, 14827

2608, 3114

14449, 14535

248, 269

468, 1666

14365, 14428

1688, 2178

2194, 2542

6390, 10444

50,067

174,701

35450

Discharge summary

report

Admission Date: [**2162-3-10**] Discharge Date: [**2162-3-31**] Date of Birth: [**2107-12-13**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1377**] Chief Complaint: jaundice Major Surgical or Invasive Procedure: Hemodialysis line placement (temporary/tunnelled) Hemodialysis Esophagogastroduodenoscopy Colonoscopy History of Present Illness: Mr. [**Known lastname 80802**] is a 54M with history of alcohol abuse, psoriatic arthritis on [**Hospital 80803**] transferred from OSH to the [**Hospital1 18**] MICU due to concern for fulminant liver failure. . Patients symptoms began on [**2162-2-20**] when he noted development of jaundice. He presented for medical care on [**2-25**] and found to have bili at that time was 11.2. He does endorse drinking excessively, and reports alcohol daily for the last 2-3 years, at least 6 drinks. He was diagnosed with alcoholic hepatitis and returned home to RI. . On presentation to his PCP he was found to have new, worsening renal failure and liver function tests. His INR was 2.8, PT 29.6, Na 133, K 3.5 BUN 88, Cr 5.2, Cl 95, CO2 23, AST 210, ALT 67, ALP 158, Tbili 29.5, Alb 1.5, WBC 17.8, Hct 29.6 at that time. He was also complaining of mild abdominal bloating. On presentation to the hospital he was found to have an INR greater than assay. He was transferred to [**Hospital1 18**] for concern for fulminant hepatic failure and transplant evaluation. . On arrival to the [**Hospital1 18**] MICU he was oriented x3 and in no distress. He was monitored overnight and did well so was transferred to the medical floor the following day, then later to the liver service. Past Medical History: Psoriatic arthritis Alcoholic hepatitis S/p appendectomy Depression Social History: Former electrical engineer. Divorced 5 years ago, has a teenager daughter. Also states he feels mildly depressed. Smoking: none Drinking: 6 beers/day, additional brandy on weekends IVDU: denies Family History: No history of liver disease. Physical Exam: PHYSICAL EXAM ON TRANSFER ([**3-31**]): VS: 98, 81-97/42-59, 64-73, 18, 98% on RA GEN: pleasant, ill-appearing man lying in bed supine in NAD SKIN: jaundiced, no spider erythemas, no palmar flushing HEENT: NC/AT, icteric sclera, PERRL, EOMI, dry MM, OP clear NECK: supple, no LAD, normal JVP CV: RRR, normal S1S2, no M/R/G CHEST: CTAB, no W/R/R ABD: soft, distended, min tenderness diffusely, liver edge palpable 2cm below costal margin, NABS EXTR: WWP, 3+ edema b/l in LE, 2+ DP/rad pulses b/l, min asterixis NEURO: AOx3, CNII-XII intact, [**4-20**] Motor strength in UE/LE b/l, 2+ DTR in [**Name2 (NI) **]/LE Pertinent Results: LABS ON ADMISSION: . [**2162-3-10**] 09:23PM BLOOD WBC-16.7* RBC-3.25* Hgb-10.0* Hct-29.5* MCV-91 MCH-30.9 MCHC-34.1 RDW-18.9* Plt Ct-236 [**2162-3-10**] 09:23PM BLOOD Neuts-91.8* Lymphs-4.2* Monos-2.8 Eos-1.1 Baso-0.1 [**2162-3-10**] 09:23PM BLOOD PT-29.6* PTT-68.8* INR(PT)-3.0* [**2162-3-10**] 09:23PM BLOOD Glucose-105 UreaN-101* Creat-5.2* Na-132* K-3.2* Cl-95* HCO3-19* AnGap-21* [**2162-3-10**] 09:23PM BLOOD ALT-64* AST-210* CK(CPK)-38 AlkPhos-188* TotBili-30.5* [**2162-3-10**] 09:23PM BLOOD Albumin-2.2* Calcium-8.3* Phos-5.8* Mg-2.9* . LABS ON TRANSFER: . [**2162-3-31**] 06:20AM BLOOD WBC-10.2 RBC-2.43* Hgb-8.3* Hct-23.2* MCV-95 MCH-34.1* MCHC-35.8* RDW-22.1* Plt Ct-116* [**2162-3-31**] 06:20AM BLOOD PT-26.3* PTT-54.3* INR(PT)-2.6* [**2162-3-31**] 06:20AM BLOOD Glucose-119* UreaN-76* Creat-4.8*# Na-146* K-3.9 Cl-99 HCO3-23 AnGap-28* [**2162-3-31**] 06:20AM BLOOD ALT-49* AST-70* AlkPhos-137* TotBili-54.0* [**2162-3-31**] 06:20AM BLOOD Calcium-10.1 Phos-4.8* Mg-2.8* . OTHER PERTINENT LABS: . ANEMIA WORKUP: [**2162-3-23**] 03:30PM BLOOD Hgb A-100 Hgb S-0 Hgb C-0 [**2162-3-23**] 05:00AM BLOOD Ret Man-6.8* [**2162-3-11**] 03:43AM BLOOD calTIBC-126* Ferritn-133 TRF-97* [**2162-3-22**] 03:10PM BLOOD VitB12-1654* Folate-16.2 Ferritn-120 LDH - 100-200 . LIVER WORKUP: [**2162-3-12**] 05:00AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE [**2162-3-11**] 03:43AM BLOOD HBsAb-BORDERLINE HAV Ab-NEGATIVE [**2162-3-11**] 03:43AM BLOOD HCV Ab-NEGATIVE [**2162-3-11**] 03:43AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE [**2162-3-11**] 03:43AM BLOOD [**Doctor First Name **]-NEGATIVE [**2162-3-11**] 03:43AM BLOOD IgG-1600 IgM-115 [**2162-3-20**] 06:55AM BLOOD CERULOPLASMIN-Test . OTHER: [**2162-3-11**] 03:43AM BLOOD Lipase-443* [**2162-3-24**] 05:15AM BLOOD Lipase-138* [**2162-3-17**] 05:10AM BLOOD TSH-0.34 [**2162-3-11**] 09:18AM BLOOD PTH-102* [**2162-3-17**] 12:08PM BLOOD PTH-58 [**2162-3-11**] 03:43AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . URINE: UA: Negative Utox: Negative for bnzodzp barbitr opiates cocaine amphetm mthdone . MICROBIOLOGY/INFECTIOUS WORKUP: [**2162-3-17**] 12:21PM BLOOD B-GLUCAN-Test [**2162-3-17**] 12:21PM BLOOD COCCIDIOIDES ANTIBODY, IMMUNODIFFUSION-Test [**2162-3-17**] 12:21PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- TEST [**2162-3-23**] 05:00AM BLOOD QUANTIFERON-TB GOLD-Test Name . BLOOD CULTURES: [**Date range (1) 80804**] - NEGATIVE [**3-29**], [**3-25**] (mycolytic) -pending (no growth to date) . URINE CULTURES: - NEGATIVE, LEGIONELLA AG-1 NEGATIVE SPUTUM: OROPHARYNGEAL MRSA SCREEN - NEGATIVE . . RADIOLOGY: . CT CHEST/ABDOMEN/PELVIS ([**3-23**]): 1. Compared to prior chest CT from [**2154-3-16**], multifocal ground-glass opacities are improved. 2. 13-mm indeterminate hypodensity in the anterior right lobe of the liver is unchanged from [**2162-3-16**]. Further evaluation with ultrasound is recommended. 3. Mild gallbladder wall thickening which likely relates to liver dysfunction. 4. Peripancreatic inflammatory change, which may be seen with pancreatitis. Recommend clinical correlation. 5. Splenomegaly. 6. Ascites, predominantly within the pelvis. No evidence of hemorrhage. . CT CHEST ([**3-16**]): IMPRESSION: 1. Multifocal opacities which are predominately in the upper lobes but also in the left lower lobe, raising the concern for infection. The appearance is atypical for aspiration unless the patient was in a prone position. Hemorrhage is also in the differential in light of the elevated INR. Pulmonary edema is less likely. 2. Splenomegaly. 3. Coronary artery disease. 4. Enlarged main pulmonary artery, which may represent pulmonary artery hypertension. . HD TUNNELLED LINE: ([**3-30**]): Successful conversion of temporary catheter to a tunneled hemodialysis catheter. The tip of the catheter is in the right atrium and the catheter is ready for use. . ABD ULTRASOUND: ([**3-11**]): IMPRESSION: 1. Heterogeneous echotexture or increased echogenicity suggests liver disease/cirrhosis. 2. Trace ascites. 3. Patent main portal vein. 4. Gallbladder "sludge" but without son[**Name (NI) 493**] signs for acute cholecystitis. 5. No intra- or extra-hepatic bile duct dilatation. . . CARDIOLOGY: . EKG ([**2162-3-10**]): Sinus rhythm Low QRS voltage Diffuse ST-T wave abnormalities Rate PR QRS QT/QTc P QRS T 92 168 104 336/392 56 26 -23 . TTE ([**2162-3-12**]): The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 80%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. The absence of a pericardial effusion does not exclude pericarditis. . GI: . EGD biopsy: ([**3-25**]) Squamous epithelium with fungal forms consistent with [**Female First Name (un) 564**] species. . EGD ([**3-25**]): Impression: 1. Erythema with white exudate in the upper third of the esophagus.Cold forceps biopsies were performed for histology. 2. Grade 1 Varices at the lower third of the esophagus without any stigmata of bleeding 3. Mosaic pattern in the whole stomach compatible with portal hypertensive gastropathy 4. Otherwise normal EGD to third part of the duodenum . COLONOSCOPY ([**3-25**]): Impression: 1. Large nonbleeding external hemorrhoids 2. Small size Internal hemorrhoids 3. There were prominent venous collaterals at rectum and rectosigmoid area consistent with nonbleeding moderate size varices. 4. Otherwise normal colonoscopy to cecum Brief Hospital Course: In short, Mr [**Known lastname 80802**] is a 54yo M w recently diagnosed alcoholic hepatitis, who originally p/w jaundice and abd bloating in the beginning of [**2162-2-14**], was found to have fulminant hepatic failure and acute renal failure, was transferred to [**Hospital1 18**] for further management and evaluation. . # ALCOHOLIC HEPATITIS / FULMINANT LIVER FAILURE: . Unclear precipitant for acute decompensation. Most likely [**1-18**] continued alcohol use, though usually patients have a history of much heavier alcohol use. AST:ALT > 2:1. Patient had a negative workup for possible infectious, autoimmune, toxic or metabolic causes of liver failure. Abdominal U/S and CT Torso consistent with cirrhosis. [**Last Name (un) 26460**] discriminant function of 116 and MELD of 46 on admission, very high risk of mortality. . Liver failure complicated by: *** severe coagulopathy with rising INR (>3.0 on transfer), which did not respond to PO/SC vitamin K administration and required the transfusion of [**4-25**] units of FFP for procedures; *** acute renal failure, thought to be acute tubular necrosis, with no/minimal hepatorenal component (see below); *** grade I/II esophageal/rectal varices, for which he was started on nadolol; *** minimal ascites, which did not require any paracenteses; *** encephalopathy, for which he received rifaximin and lactulose prophylaxis, - of note, patient's mental status has been impressively good - AOx3, able to carry a good conversation, joke. *** no evidence for SBP or portal vein thrombosis. . Pt was not started on steroids/pentoxyphylline on admission due to concern for infection (see below). However, since the likelihood of infection was low, pt was tried eventually tried on a prednisone 40mg regimen ([**Date range (1) 44643**]). Total bilirubin decreased minimally from a 51 to ~41, however, started going up again, so steroids were discontinued. Bilirubin continued to rise to 57. Pt was tried on ursodiol with no effect, so discontinued. Also given nutritional supplementation by tube feeds for 2 weeks and vitamins. Given the minimal response to steroids and continued rise of serum bilirubin, the prognosis remains very poor. This has been discussed extensively with patient and family. . . # ANURIC ACUTE RENAL FAILURE: Evaluated by the renal team, thought to be likely [**1-18**] acute tubular necrosis from low flow state, given renal tubular casts on microscopy. Concern for hepatorenal syndrome, since no response to IVF, however, not likely given minimal ascites. Albumin, octreotide, midodrine tried for 2 weeks with no response. On [**3-12**], pt developed developed pleuritic chest pain of unclear etiology. No evidence for pneumonia, low suspicion for PE, ? bleed in the setting of coagulopathy. Pt was noted to have a pericardial rub on exam and given BUN > 100, uremic pericarditis was diagnosed and hemodialysis was initiated. Pt remained on hemodialysis Mo/We/Fri from that point on, with no improvement in kidney function. HD temporary line was changed to a tunnelled catheter on [**3-30**]. Pt remains anuric on transfer on hemodialysis. . . # ? INFECTIONS: Pt had leukocytosis ~15 w intermittent low O2 requirements. Given the pleuritic chest pain on [**3-12**] and episode of emesis the next day, with new radiological findings of multifocal pulmonary opacities (see CT report), pt was thought to have an aspiration pneumonia. The anatomical distribution of the opacities was not consistent. Pt remained afebrile with no sxs of cough, SOB, etc. Pt was started on levofloxacin ([**Date range (1) 80805**]) for a 10-day course, but continued while pt was on steroids. On discontinuation, the bilirubin continued to rise (but no fevers or other clinical signs of infection), so patient was suspected to have another possible infection. Started on ceftriaxone ([**3-28**]). EGD biopsy from [**3-25**] showed [**Female First Name (un) 564**] on [**3-30**], so pt was started on fluconazole ([**3-30**]). . . # ANEMIA: Likely anemia of chronic disease and acute drops from intermittent bleeding from esophageal irritation noted on EGD. # DEPRESSION: Patient reports continued depression. Extensive emotional support was provided, social work and family involved. Citalopram was held given acute condition. . . # FEN: renal diet, electrolyte replacement PRN # Access: PIV, right subclavian HD tunnelled line # PPx: no heparin SC because of coagulopathy, lactulose, nadolol # Code: FULL (discussed w pt and family) . # GOALS OF CARE: Have been discussed extensively with patient and family. Power of attorney filled out by patient, but has to be notarized and copies need to be sent to sister [**Doctor First Name **], who is the healthcare proxy. Family is very supportive and has been present for a good duration of his hospitalization. He is requesting transfer back to [**State 792**]to be close to his home and his brother. . # CONTACT: Sister [**Name2 (NI) **] is HCP - cell: [**Telephone/Fax (1) 80806**] home: [**Telephone/Fax (1) 80807**] . ****** PLEASE NOTE: ******* Ex-wife [**Name (NI) **] and daughter are OK to visit, but pt requests that details of his illness not be discussed with them. Medications on Admission: Humira (last [**2-5**]) Citalopram 20 mg daily Discharge Medications: 1. CeftriaXONE 1 g IV Q24H day 1: [**2162-3-28**] 2. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Day 1: [**2162-3-30**]. 3. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO QHD (each hemodialysis). 4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO QID (4 times a day). 6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 12. Ondansetron 4 mg IV Q8H:PRN nausea 13. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-18**] Sprays Nasal TID (3 times a day) as needed. 16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. Discharge Disposition: Extended Care Discharge Diagnosis: alcoholic hepatitis fulminant liver failure complicated by varices, coagulopathy, encephalopathy acute renal failure likely from acute tubular necrosis presumed aspiration pneumonia [**Female First Name (un) 564**] esophagitis Discharge Condition: hemodynamically stable, but very sick Discharge Instructions: You were transferred to our hospital in acute liver failure, likely from alcohol. You developed acute kidney failure with complications (uremia) for which we initiated hemodialysis. We treated you for presumed infections with antimicrobials. Your prognosis is very poor. Unfortunately, you do not meet the criteria for liver transplant given your recent alcohol use. You were transferred to our hospital in acute liver failure, likely from alcohol. You developed acute kidney failure with complications (uremia) for which we initiated hemodialysis. We treated you for presumed infections with antimicrobials. Your prognosis is very poor. Unfortunately, you do not meet the criteria for liver transplant given your recent alcohol use. Followup Instructions: Transfer to [**State 792**]for further care [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**] Completed by:[**2162-4-1**]

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icd9cm

[ [ [] ] ]

[ "99.04", "45.16", "38.93", "96.07", "45.23", "86.07", "99.07", "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

15191, 15206

8601, 13784

282, 385

15477, 15517

2682, 2687

16299, 16495

2005, 2035

13881, 15168

15227, 15456

13810, 13858

15541, 16276

2050, 2663

234, 244

413, 1686

3690, 8578

2701, 3668

1708, 1777

1793, 1989

8,896

142,457

52067

Discharge summary

report

Admission Date: [**2180-9-23**] Discharge Date: [**2180-9-29**] Date of Birth: [**2107-1-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5368**] Chief Complaint: progressive dyspnea on exertion X 2 days Major Surgical or Invasive Procedure: 1. central line 2. arterial line History of Present Illness: HPI: This is a 72 yo M w/ h/o PVD s/p bilateral bypass, CAD s/p MI / CABG / multiple stents, htn, hyperchol, T2DM, and CRI who p/w progressive SOB. Per son, patient started feeling poorly about 1 week ago. He was using his nitro more frequently and not able to be as active (minimal activity at baseline). His son noted that he has been coughing for the past 2 days. No fever or sick contacts. [**Name (NI) **] thinks it's productive, but his dad is swallowing the sputum. . On the day of admission, he had been fine in the AM and then in the evening called his son, who lives upstairs, and asked him to call 911. Patient c/o chest pain similar to his MI. S/p lasix 80 mg IV x 1 in field + 4 SL NTG. On arrival to ED O2 sat 82%. Patient then had respiratory arrest and was intubated. He subsequently received ASA, nitro gtt (subsequently d/c), and heparin gtt. Due to the patient's CP, shortness of breath, hypoxia and lower extremity edema, a CTA was also done and showed no evidence of pulmonary embolism. There was evidence bibasilar dependent atelectasis/consolidations and small pleural effusions. The findings were also suggestive of early edema. Given the patient's CRI and contrast load from the CT-A, he received 1.5L NS and bicarb gtt. Past Medical History: MI x 3-4 years ago DM controlled by diet HTN Hyperlipidemia PVD with B fem to distal bypass CABG x 3 in [**2167**] (LIMA-LAD, SVG-OM, SVG-PDA) . cath [**2180-6-5**]: Significant for R dominant system with mid RCA 70% lesion, proximal LCX 90% lesion, mid Cx 70% lesion, 70% mid RCA in stent restenosis, OM1/2 diffuse disease. 2 overlap stents were placed in the LMCA into LCx after atherectomy, and stent in RCA placed . cath [**2180-4-6**]: 3 v CAD, stent to R-PDA and stent to ostial RCA . cath [**2180-2-3**]: stent in RCA and R-PDA . TTE [**2-3**]: EF 40-50% with diastolic dysfunction, hypokinesis of inferior septum/inferior free wall/posterior wall, [**12-12**]+ AR, [**12-12**]+ MR Social History: Smoked 1 pack a day for 40 years, quit 4 months ago. Has a notable drinking history, drank heavily on the weekends quit 2 years ago. No illicit or alcohol drug use. Retired, lives alone, son lives upstairs. Family History: Noncontributory. Physical Exam: PE: T 98.6 bp 92/88->124/99 hr 71 rr 36-> __ O2 100% on AC 700/14/50%/PEEP5 FSBS 269 genrl: intubated, sedated heent: perrla (4->3mm) cv: rrr, [**1-16**] holosystolic murmur at RUSB and LUSB pulm: coarse BS left base, and bilaterally anteriorly, no wheeze abd: nabs, soft, nt/nd, no masses/hsm rectal: guiac neg (per ED) extr: 1+ [**Location (un) **] bilaterally (L>R), extremities warm/dry neuro: MAEW, periodic twitching/spasm of left back Pertinent Results: Labs on Admission [**2180-9-23**] 07:30AM BLOOD WBC-8.8# RBC-3.47* Hgb-7.4*# Hct-26.4* MCV-76*# MCH-21.3*# MCHC-28.0*# RDW-17.4* Plt Ct-213 [**2180-9-23**] 07:30AM BLOOD Plt Ct-213 [**2180-9-23**] 08:25AM BLOOD PT-13.7* PTT-25.0 INR(PT)-1.3 [**2180-9-23**] 07:30AM BLOOD Glucose-238* UreaN-25* Creat-2.0* Na-147* K-4.9 Cl-106 HCO3-22 AnGap-24* [**2180-9-23**] 07:30AM BLOOD CK(CPK)-248* [**2180-9-23**] 03:20PM BLOOD Calcium-9.2 Phos-2.9 Mg-2.0 . Cardiac Enzymes [**2180-9-23**] 10:46PM CK(CPK)-299* [**2180-9-23**] 10:46PM cTropnT-0.24* [**2180-9-23**] 10:46PM CK-MB-5 [**2180-9-23**] 03:20PM CK(CPK)-271* [**2180-9-23**] 03:20PM CK-MB-7 cTropnT-0.20* [**2180-9-23**] 07:30AM CK(CPK)-248* [**2180-9-23**] 07:30AM CK-MB-5 cTropnT-0.12* . Labs on Discharge [**2180-9-29**] 05:27AM BLOOD WBC-6.1 RBC-4.71 Hgb-11.6* Hct-35.3* MCV-75* MCH-24.7* MCHC-32.9 RDW-19.9* Plt Ct-213 [**2180-9-29**] 05:27AM BLOOD Plt Ct-213 [**2180-9-29**] 04:54AM BLOOD PT-13.9* INR(PT)-1.3 [**2180-9-29**] 04:54AM BLOOD Glucose-124* UreaN-31* Creat-1.8* Na-142 K-4.1 Cl-103 HCO3-25 AnGap-18 [**2180-9-29**] 04:54AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.1 . [**2181-9-24**] Chest portable AP There is continued mild pulmonary edema with cardiomegaly. Patchy opacity is seen in the left lower lobe indicating atelectasis versus aspiration pneumonia. The patient is status post CABG and median sternotomy. [**2180-9-28**] Chest X-ray IMPRESSION: No acute cardiopulmonary disease. . [**2180-9-28**] U/S extremity nonvascular left IMPRESSION: No DVT. Brief Hospital Course: A/P: 73 yo M w/ h/o PVD, CAD, htn, hyperchol, T2DM, and CRI who p/w progressive SOB x 1 week in setting of ischemic changes on EKG.Patient arrived in the ED was in respiratory failure with a SaO2 of 82% and was subsequently intubated and sent to the ICU. Patient was extubated three days later and transfered to the medicine service. . ## Hypoxic Respiratory Failure: On presentation the differential for the patient's hypoxic respiratory failure included PE, CHF or pneumonia. The patient desaturated to 82% and was subsequently intubated. Chest xray and CT on presentation showed no clear infiltrate but possible pulmonary edema. Minimal trop leak (down from prior in [**6-13**]) and flat CK-MB argued against a MI, which again would result in CHF. PE was also considered given relative immobility in the few days before presentation and h/o increasing left > right [**Location (un) **] over the past week. However this was ruled out by CTA. Pneumonia was also considered due to the patient's chronic cough prior to admission and temperature spike to 100 while intubated. The patient was started on Levo/ Flagyll for presumed aspiration. It was also theorized that the patient's respiratory failure was caused by anemia leading to increased demand . The patient's hematocrit was maintained above 30. (s/p 4 tx during this admission). . ## CAD s/p MI, CABG, and multiple stents: C/o chest pain similar to MI when he initially called his son. EKG displayed normal sinus tachycardia with w/ ST depressions but in setting of RBBB. Right sided EKG unremarkable. Troponin up but not from his most recent and MB negative. MI was ruled out by cycled enzymes x3. Repeat EKG showed normal sinus rhythm, Left axis deviation. Right bundle-branch block with left anterior fascicular block. Lateral ST-T wave changes are non-specific. Compared to the previous tracing of [**2180-9-24**] no significant change. . Patient was continued on statin, BB, and ACE (home meds). Heparin started in ED per cards recs and was later discontinued. The patient was discharged on low dose aspirin. . ## CHF: CXR shows interval development of patchy air-spaces opacities bilaterally consistent with pulmonary edema. The patient received 80 IV lasix in field. In the ED due to his CRI and the dye load from the CTA-A, he received about 1.5L IVF. The patient had put out a net of about 800 cc urine. Patient was continued on 40 IV lasix and Captopril 6.25mg TID. The patient was later transitioned to 40 PO Lasix [**Hospital1 **] and lisinopril 20mg. . ## H/o afib: Noted on [**6-13**] admission. The patient remained in sinus. He was maintained on a beta [**Month/Year (2) 7005**] for rate control. Per his cardiologist, no need for [**Month/Year (2) **]. . ## CRI: Bump in creatinine to 2.0 unclear. Likely prerenal secondary to decreased ECV and poor CO. Patient was started on Captopril and was later restarted on Lisinopril. Creatinine has stabilized at baseline at the time of discharge. . ## Lactic acidosis was likely due to respiratory failure. There was no Fever or elevated wbc to suggest infxn/sepsis. Blood cx, UA and sputum cultures were negative. . ## Anemia: Old labs were c/w Fe def anemia. Fe studies were repeated this visit results showed Iron: 34 low, calTIBC: 295, Ferritn: 79, TRF: 227 but should be interpreted in the context of 4 blood transfusions. . EGD [**3-14**] with gastritis and healing ulcer w/ nodule in fundus. c-scope in '[**77**] w/ diverticulosis and hemorrhoids. The patient was guaiac negative. Hct was closely monitored. Hct was kept above 30. . ## PPX: on heparin, ppi . ## FEN: I/Os were monitored. Lytes were repleted as needed . ## Dispo: The patient was discharged with VNA services and close follow up.. ## Communication: [**Name (NI) 5987**] [**Name (NI) 63208**] (son, [**Name (NI) 382**]: home [**Telephone/Fax (1) 107774**], cell [**Telephone/Fax (1) 107775**] Medications on Admission: glipizide 5 mg po qd roxicet 1 tab po qid prn neurontin 100 mg po tid - d/c Thursday ASA 325 atorvastatin 80 mg po qd lasix 40 mg po bid isosorbide dinitrate 30 mg po tid lisinopril 20 mg po qd metoprolol 50 mg po bid nitro 0.4 mg SL prn norvasc 5 mg po qd protonix 40 mg po qd plavix 75 mg po qd Discharge Medications: 1. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:*1 Tablet(s)* Refills:*0* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-12**] Puffs Inhalation Q4H (every 4 hours). Disp:*5 * Refills:*2* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aspirin 81 mg Tablet Sig: One (1) 1 Tablet PO DAILY (Daily). Disp:*30 1 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Respiratory Failure (unclear etiology may have been secondary to demand ischemia contributing to congestive heart failure) Discharge Condition: Good Discharge Instructions: Please take all medications as prescribed. Please continue all home meds. Please call your doctor or go to the ER if you have any Chest pain, shortness of breath,fevers, chills, nausea, vomiting, abdominal pain, or any other symptoms that concern you. Followup Instructions: You have a follow up appointment with Dr [**Last Name (STitle) **] on Friday, [**10-6**] at 11:20am. If you have any questions please call [**Telephone/Fax (1) 250**]. Completed by:[**2181-2-12**]

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Discharge summary

report

Admission Date: [**2200-6-9**] Discharge Date: [**2200-6-13**] Date of Birth: [**2136-7-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: Fever Major [**First Name3 (LF) 2947**] or Invasive Procedure: PICC Line placement on [**2200-6-13**] for IV antibiotics. History of Present Illness: Mr. [**Known lastname 8182**] is a 63 yo M with a history of CVA , recent pseudomonas pna (s/p trach and peg [**3-/2200**]) atrial fibrillation, C.Diff colitis requring colectomy with ileostomy, (on po vancomycin - per report had C.Diff sent which was positive at [**Hospital1 1501**] this month), DM, PVD presenting from [**Hospital1 1501**] with fever to 101 today. Labs were drawn and patient was noted to have worsening leukocytosis to 20.1 with 96% polys and 1% bands, and a CXR was found to have bilateral infiltrates. He was given Ceftriaxone 1g IV x1 and sent to the ER. . In the [**Hospital1 18**] ER, patient was hypotensive to 75/46. BP spontaneous improved to 108/56 without intervention. CXR in ER revealed bilateral infiltrates. Pt was admitted to MICU for [**1-21**] hypotension and tx. with Vancomycin 1 g IVx1 and Cefepime 2 g IV x1. On transfer to MICU, VS were 101.2, 87, 120/71, 100% on trach mask. Past Medical History: 1-Hypertension 2-Hypothyroidism 3-H/o CVA (bilateral embolic cerebellar [**2188**], hemorrhagic left thalamic [**2190**]) 4-Type II Diabetes mellitus 5-Peripheral neuropathy 6-Depression 7-h/o DVT (? - no [**Hospital1 18**] records) 8-Atrial fibrillation (on coumadin) 9-Peripheral vascular disease 10-Hyperlipidemia 11-Anemia of chronic disease 12-C.diff colitis in [**1-29**] requiring total abdominal colectomy with end ileostomy [**1-29**], repeat positive C diff toxin [**2200-5-20**] Social History: Prior resident of [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], now at [**Hospital 16662**] nursing home. Family very involved in patient's care. Patient does not take anything by mouth due to history of aspiration. Spanish-speaking. Patient is a former 60 PY smoker, but quit in [**2183**]. Family History: Patient has a mother with diabetes and brother with heart disease. Physical Exam: On admission Vitals: T: BP: 96/56 P: 83 R: 13 O2: 99% FiO2 50% via FM General: nonverbal, appears comfortable, decorticate posture with flexion contracture HEENT: Sclera anicteric, MMM, + thrush Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM, no rubs, gallops Abdomen: soft, non-tender, PEG site c/d/i, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, sacral decub ulcer stage III (clean, noninfected appearing) Pertinent Results: [**2200-6-9**] 02:48PM BLOOD WBC-21.9* RBC-4.56* Hgb-10.5* Hct-32.9* MCV-72* MCH-23.0* MCHC-31.9 RDW-15.1 Plt Ct-330 [**2200-6-9**] 02:48PM BLOOD Neuts-86.9* Lymphs-8.8* Monos-3.7 Eos-0.4 Baso-0.3 [**2200-6-13**] 05:25AM BLOOD WBC-6.0 RBC-3.83* Hgb-8.8* Hct-28.4* MCV-74* MCH-23.0* MCHC-31.1 RDW-15.0 Plt Ct-241 [**2200-6-12**] 06:05AM BLOOD Neuts-67.7 Lymphs-20.8 Monos-6.4 Eos-4.8* Baso-0.3 [**2200-6-9**] 07:31PM BLOOD PT-28.3* PTT-34.9 INR(PT)-2.8* [**2200-6-10**] 04:26AM BLOOD PT-29.2* PTT-37.1* INR(PT)-2.9* [**2200-6-11**] 03:27AM BLOOD PT-38.7* PTT-38.0* INR(PT)-4.0* [**2200-6-12**] 06:05AM BLOOD PT-38.6* PTT-39.6* INR(PT)-4.0* [**2200-6-13**] 05:25AM BLOOD PT-29.4* INR(PT)-2.9* [**2200-6-9**] 07:31PM BLOOD Glucose-138* UreaN-24* Creat-0.6 Na-139 K-3.9 Cl-100 HCO3-32 AnGap-11 [**2200-6-12**] 06:05AM BLOOD Glucose-118* UreaN-8 Creat-0.4* Na-140 K-3.8 Cl-106 HCO3-29 AnGap-9 [**2200-6-13**] 05:25AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.9 [**2200-6-10**] 04:26AM BLOOD TSH-1.2 [**2200-6-13**] 05:25AM BLOOD Vanco-21.9* STUDIES: [**2200-6-13**] CXR: right sided picc line with tip at the junction of the brachiocephalic vein and svc. [**2200-6-9**] 04:20PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR [**2200-6-9**] 04:20PM URINE [**2200-6-9**] 04:20PM URINE RBC-0-2 WBC-[**2-21**] Bacteri-MOD Yeast-NONE Epi-0-2 Brief Hospital Course: Mr. [**Known lastname 8182**] is a 63 yo M a history of CVA , recent pseudomonas pna (s/p trach and peg [**3-/2200**]) afib (coumadin), c diff s/p colectomy, DM, PVD presents from [**Hospital1 1501**] with fever to 101 #1. Sepsis (PNA & UTI): Pt was in SIRS upon admission to the emergency room, with a fever of 101 (pre hospital) and a profound leukocytosis of 21.9. He was not tachycardic or tachypnic however. A CXR revelead bilateral basilar infiltrates suspicious for pneumonia, and an initial urine dipstick had moderate blood and trace leukocytes with f/u microscopic exam showing [**2-21**] WBC's and moderate amounts of bacteria and trace epithelial cells. When the pt. entered the ER, he was hypotensive with a BP of 82/43. A decision was made for transfer to MICU for the pt's probable sepsis. Since the pt. came from a [**Hospital1 1501**] and is a known MRSA carrier, he was treated in ER for possible HCAP with Vancomycin 1 g IVx1 and Cefepime 2 g IV x1. Prior to admission to the ICU, the pt's BP spontaneously resolved to 108/56. While in the ICU, the pt remained stable. The pt's hypotension improved with several IV boluses and the institution of tube feeds. Additionally, pt. remained afebrile for last 48 hours and leukocytosis has improved from 21.6 with a left shift on admission to 8.8 on [**6-11**]. His antibiotic regimen was changed to Vancomycin 1 G IV q12 as he is a known MRSA carrier, Meropenem 500 mg IV Q6H as the patient has had a history of resistant P. aeuriginosa pneumonia, and Ciprofloxacin 400 mg IV Q12H for double coverage of possible P. aeuriginosa. Additionally, he continued to receive Vancomycin Oral Liquid 250 mg PO/NG Q6H for his history of C.Diff Colitis from the [**Hospital1 1501**]. The pt remained stable and he was transferred to the floors on [**6-10**]. An etiology for his SIRS was attempted to be elicited prior to the start of antibiotics. Sputum cx's positive for sparse and rare growth of GNR's. Urine cultures were performed and were postive for GNR's >10,000 and later identified as PROVIDENCIA STUARTII. Blood cultures were performed but indeterminate. The pt. continued to be stable. A PICC line was placed on [**6-13**] o the patient can receive IV antibiotic treatment out of the hospital. Mr. [**Known lastname 8182**] has received a total of 5 days(doses) of his IV antibiotics, including Vancomycin, Meropenem, and Ciprofloxacin. He will continue to receive antibiotics out of hospital for 10 more days, with the last day of treatment on [**2200-6-23**]. Of note, his Ciprofloxacin has been changed to 500 mg PO q12hrs. #2. C. Difficile infection s/p colectomy: The patient has a history of C.Diff in the past, and according to his [**Hospital1 1501**] the patient had positive C diff [**2200-5-20**] and was restarted on po vancomycin 250 cc's. There are case reports of extracolonic C diff in the literature, including small bowel involvement in the setting of recent colectomy. Repeat C. Diff toxins were performed on [**6-10**], but were negative in the hospital most likely becuase the patient has been receiving treatment. Additionally, the patient did not have any episodes of profound diarrhea while in the hospital. As the patient will be receiving large amounts of antibiotics out of the hospital, he should continue his po vancomycin while on broad spectrum antibiotics, with the plan to continue for at least 14 days after broad spectrum antibiotics are completed in order to prevent recurrence. #3 Atrial fibrillation: Mr. [**Known lastname 8182**] has a history of atrial fibrillation. On admission he was in sinus tachycardia with evidence of an old RBBB. During his hospital course, his coumadin became supratherepeutic, with an INR of 4.0 on [**6-11**] and [**6-12**] likely due to antibiotics therapy. His coumadin was held, and he was rate controlled with Metoprolol Tartrate 12.5 mg PO/NG TID. On the day of discharge, his INR was 2.9. He was restarted on coumdain at half dose of 2.5 mg on the day of discharge. Please check his INR daily and titrate dosing accordingly until INR is stable. He will again require close monitoring on discontinuation of his antibiotics. #4 DM: the patient has a hx. of DM. His blood sugars were well controlled with with ISS while in the hospital with finger sticks consistently less than 150. His glargine was held during his admission and was not yet restarted on discharge. His blood sugar should be monitored and glargine resumed when needed. #5 Hypertension: The patient has a hx. of HTN. He does not appear to be on antihypertensive therapy per his medication list. His vitals have improved over the hospital course, with his BP now in the 120's/70's. He was continued on metoprolol tartrate 12.5 mg NG three times daily during his admission as above. #6 Thrush: The pt. was noted to have thrush while in house. It was treated with nystatin swish and swallows. . #7 History of GIB: No acute issues during this hospitalization. Continue prilosec. . #8 S/p CVA: No acute issues during this hospitaliztion. Coumadin as above. Continue neurontin and baclofen. Contractures noted on exam. . #9 Sacral decub: Pt. found to have a grade III decubitus ulcer. he should receive daily wound care and monitoring. Continue morphine prn for pain. Medications on Admission: vancomycin 250 mg po QID x 10 day course (started [**6-3**]) Baclofen 10 mg QID Duloxetine 30 mg [**Hospital1 **] Fentanyl patch 50 mcg/hr Gabapentin 600 mg TID Combivent prn Synthroid 25 mcg daily Lisinopril 5 mg daily Metoprolol tartrate 12.5 mg TID Mirtazapine 7.5 mg qhs Trazodone 12.5 mg qhs Morphine 15 mg QID prn Warfarin 4.5 mg daily Tylenol 325 mg prn CARBOXYMETHYLCELLULOSE SODIUM [REFRESH] 2 drops both eyes [**Hospital1 **] MVI decube vite cap 1 cap daily Bisacodyl 10 mg prn Senna 8.6 mg [**Hospital1 **] prn Lantus 16 U q am Novolog SS Nystatin 100,000 units/cc - 5 cc TID Milk of mag 400 mg/5 cc - 30 cc prn Omperazole 20 mg daily Mylanta 200mg-200mg-2-mg/5 cc - 30cc QID prn Zinc Sulfate 220 mg (50 mg) Cap 1 Capsule(s) via g/j tube once a month Glucerna 90 cc via G tube over 20 hours, off 4 hours Discharge Medications: 1. Outpatient Lab Work instructions on coumadin dosing. 2. Outpatient Lab Work Vancomycin trough on [**2200-6-16**]. Please communicate results with [**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) **] for vancomycin dosing management. 3. Outpatient Lab Work Basic Metabolic Panel to check on [**2200-6-19**] 4. Ciprofloxacin 500 mg/5 mL Suspension, Microcapsule Recon [**Year (4 digits) **]: 500 mg Suspension, Microcapsule Recons PO Q12H (every 12 hours): Last day [**2200-6-23**] (continue for 10 days after discharge). 5. Vancomycin 1000 mg IV Q 12H day 1 [**6-9**] 6. Meropenem 500 mg IV Q6H day 1 [**6-9**] 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation: hold for diarrhea. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day) as needed for Constipation: Hold for diarrhea. 9. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: One (1) PO BID (2 times a day): Hold for diarrhea. 10. Baclofen 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 11. Fentanyl 50 mcg/hr Patch 72 hr [**Month/Year (2) **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours): Hold for sedation or RR < 10. Disp:*10 Patch 72 hr(s)* Refills:*2* 12. Ipratropium Bromide 0.02 % Solution [**Month/Year (2) **]: One (1) Inhalation Q6H (every 6 hours). Disp:*120 * Refills:*2* 13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Month/Year (2) **]: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:*56 * Refills:*0* 14. Metoprolol Tartrate 25 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 15. Mirtazapine 15 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 16. Trazodone 50 mg Tablet [**Month/Year (2) **]: 0.25 Tablet PO HS (at bedtime) as needed for insominia. Disp:*30 Tablet(s)* Refills:*0* 17. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Year (2) **]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 18. Levothyroxine 25 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 19. Gabapentin 250 mg/5 mL Solution [**Month/Year (2) **]: One (1) PO BID (2 times a day). Disp:*30 * Refills:*2* 20. Ascorbic Acid 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 21. Morphine 15 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO every four (4) hours as needed for pain: Hold for sedation or RR<10. Disp:*15 Tablet(s)* Refills:*0* 22. Duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Month/Year (2) **]: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 23. Vancomycin 250 mg Capsule [**Month/Year (2) **]: 250mg Liquid PO every six (6) hours: Continue for 14 days AFTER he completion of other antbiotics (Meropenem, IV Vancomycin, Ciprofloxacin). Disp:*qs * Refills:*0* 24. Zinc Sulfate 220 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day: DO NOT GIVE within 2 hours of ciprofloxacin. For wound care. Disp:*30 Tablet(s)* Refills:*2* 25. Sodium Chloride 0.9 % 0.9 % Parenteral Solution [**Month/Year (2) **]: One (1) ML Intravenous q8 PRN as needed for line flush: Flush with 3 cc's with meds or to maintain patency of PICC. Disp:*qs ML(s)* Refills:*0* 26. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Year (2) **]: One (1) ML Intravenous PRN (as needed) as needed for line flush: (10 units/cc) 2 cc IV PRN line flush PICC, heaprin dependent: Flush with 10 cc NL Saline followed by Heparin as above daily and PRN per lumen. Disp:*qs ML(s)* Refills:*0* 27. Coumadin 2.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day: Daily INR checks. Disp:*30 Tablet(s)* Refills:*2* 28. Insulin Regular Human 100 unit/mL Solution [**Month/Year (2) **]: As directed by sliding scale UNITS Injection four times a day. 29. Multivitamin Liquid [**Month/Year (2) **]: One (1) PO once a day. 30. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **] Discharge Diagnosis: Primary Diagnosis: HCAP UTI C. Difficile infection Secondary Diagnosis: CVA with paralysis Hypertension Hypothyroidism Type II Diabetes mellitus Peripheral neuropathy Depression Atrial fibrillation (on coumadin-currently held as of [**6-11**]) Peripheral vascular disease Hyperlipidemia Anemia of chronic disease C.diff colitis Sacral Decubitus Ulcer Discharge Condition: Mental Status: Patient is aphasic since tracheostomy. Activity Status: Bedbound. Level of Consciousness: Alert and interactive with head nods to questions. He has a tracheostomy with trach mask. Discharge Instructions: You were admitted to the hospital because you were feverish and experiencing low blood pressure. You were found out to have an infection in your lungs (pneumonia) as well as a urinary tract infection. You were treated with antibiotics, and your symptoms improved during the course of your stay. Some of your medications were changed while you were in the hospital and several new medications were also added. These Changes Have been made to your medicaton: STOPPED- Coumadin 4.5 mg STARTED- Coumadin 2.5 mg STARTED- Vancomycin IV 1g q 12 hours. Last day [**2200-6-23**] STARTED- Ciprofloxacin PO 500 mg Q12. Last day [**2200-6-23**]. STARTED- Meropenem IV 500 mg Q6H. Last day [**2200-6-23**]. STARTED- Vancomycin oral liquid, 250mg every six hours. This should be continued for two weeks after stopping the other antibiotics. STOPPED- Glargine insulin - this medication can be restarted as needed STARTED- Metoprolol 12.5 mg three times daily for heart rate control NO OTHER CHANGES WERE MADE TO YOUR MEDICATIONS Followup Instructions: You have the following appointments that were previously scheduled: Department: [**Month/Day/Year 454**] UNIT When: WEDNESDAY [**2200-9-3**] at 7:00 AM [**Telephone/Fax (1) 446**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: RADIOLOGY When: WEDNESDAY [**2200-9-3**] at 8:30 AM [**Telephone/Fax (1) 8243**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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22,933

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8351

Discharge summary

report

Admission Date: [**2110-2-3**] Discharge Date: [**2110-2-8**] Date of Birth: [**2055-3-2**] Sex: F Service: MEDICINE Allergies: Cipro / Doxycycline / Paxil / Quinine / Compazine / Levaquin / Lithium Attending:[**First Name3 (LF) 1973**] Chief Complaint: CC:[**CC Contact Info 29550**]. PCP: [**Name Initial (NameIs) **]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Transplant Surgery ([**Doctor Last Name **]) Major Surgical or Invasive Procedure: Intubation History of Present Illness: HPI: This is a 54-year-old female with a complex past medical history including hepatic sarcoidosis and nodular regenerative hyperplasia complicated by portal hypertension, portal gastropathy and recurrent gastrointestinal bleeding, last admitted four days ago for TIPS procedure performed for increasing transfusion requirements, now admitted for altered mental status. Per her family, she was not taking her lactulose in the last several days. She went to sleep last night in her usual state of health, and this morning, her husband found her difficult to arouse and she had a left sided hemiparesis. She was brought to an OSH where she had a head CT which was negative for acute bleed. Her mental status worsened however, as did her left hemiparesis and she became unarousable, even to pain. She was intubated for airway protection and transferred to [**Hospital1 18**] for further management. . When the patient arrived here, she was found to still not be responding to pain, temp 100.5, other vitals stable. Ammonia 225. A neurology consult was obtained, and a repeat head CT/CTA was negative for acute process. Neurology felt that this was likely all secondary to marked encephalopathy, as she has had a history of these types of episodes when she stops taking her lactulose. The left-sided hemiparesis is consistent with unmasking of her old infarct in the setting of acute encephalopathy and EEG was negative for seizure activity. They recommended an lumbar puncture to rule out infectious etiology, which was essentially clean. . On review of her past medical history, she has a history of hepatic sarcoidosis and nodular regenerative hyperplasia complicated by portal hypertension, portal gastropathy, recurrent GI bleeding, COPD, pulmonary hypertension, hypothyroidism, Raynaud's, and non-ischemic cardiomyopathy with an EF 15-20%. Her sarcoidosis was diagnosed in [**2104**] after liver biopsy performed to evaluate chronic nausea and vomiting. Colonoscopy in [**6-17**] demonstrated sigmoid diverticulosis, AV malformations of the cecum and ascending colon, and grade 3 internal hemorrhoids with superimposed AV malformations. On [**8-17**] an EGD at [**Hospital1 2177**] demonstrated grade 2 esophageal varices, portal hypertensive gastropathy, and gastric cardia varices. She also has CMY with her last echo demonstrating an EF of 15-20% and a p-mibi that confirmed an EF of 23% with no ischemic changes. She was started on prednisone 20 mg a day for questionable cardiac involvement of sarcoidosis. On [**1-30**], she was admitted to the transplant surgery service at [**Hospital1 18**] and underwent a TIPS procedure with no complications. Past Medical History: Past Medical History: #. Hepatic Sarcoid #. S/p TIPS #. Idiopathic cardiomyopathy : echo demonstrating an EF of 15-20% and a p-mibi that confirmed an EF of 23% with no ischemic changes. She underwent a cardiac cath in [**2108**] demonstrated no angiographically apparent flow-limiting lesions, mild mitral regurgitation, and severe systolic ventricular dysfunction with a left ventricular ejection fraction of 20%. Her last echo in [**2108-6-11**] demonstrated an ejection fraction of 40-45% with mild-to-moderate global left ventricular hypokinesis and moderate pulmonary artery systolic hypertension. - clean cath [**2-/2108**] - [**6-16**] Echo 40% to 45% #. COPD, followed by [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **] #. Hx of SAH [**2101**] s/p coiling, 2 new aneurysms seen on angio [**2108-6-21**] #. Grade II esophageal varices #. Colonic AVM and diverticulum #. Evidence of CVA/TIA #. Hypothyroidism #. Anemia #. s/p hysterectomy #. s/p ccy #. RSD s/p fall Social History: Social History: Lives in [**Hospital1 1474**] with her husband. [**Name (NI) **] 2 adult sons. Smoked 1 ppd x 36 years, quit [**2108-1-12**]. No EtOH. Used to work as housekeeper, on disability [**3-15**] RSD. Family History: Mother died from coronary artery disease Physical Exam: Physical Exam: VS: Temp: 97.8 BP: 130/71 HR: 82 RR: 13 O2sat 98% A/C 500 x 14 FiO2 0.5 Peep 5 GEN: intubated and sedated HEENT: PERRL, MMM NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly RESP: CTA b/l with good air movement throughout, no wheeze CV: RR, S1 and S2 wnl, II/VI SEM heard best at LUSB, nonradiating ABD: nd, +b/s, soft, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice. pale. NEURO: Babinski downgoing bilaterally Pertinent Results: [**2110-2-3**] 03:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-38 GLUCOSE-65 [**2110-2-3**] 03:00PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 POLYS-0 LYMPHS-76 MONOS-24 [**2110-2-3**] 12:45PM LACTATE-1.9 [**2110-2-3**] 11:50AM GLUCOSE-131* UREA N-18 CREAT-1.1 SODIUM-147* POTASSIUM-4.4 CHLORIDE-113* TOTAL CO2-20* ANION GAP-18 [**2110-2-3**] 11:50AM ALT(SGPT)-111* AST(SGOT)-84* ALK PHOS-236* AMYLASE-131* TOT BILI-1.2 [**2110-2-3**] 11:50AM LIPASE-135* [**2110-2-3**] 11:50AM ALBUMIN-4.3 [**2110-2-3**] 11:50AM TSH-5.1* [**2110-2-3**] 11:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2110-2-3**] 11:50AM URINE HOURS-RANDOM [**2110-2-3**] 11:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2110-2-3**] 11:50AM WBC-9.3# RBC-4.50# HGB-13.7# HCT-42.2# MCV-94 MCH-30.4 MCHC-32.4 RDW-17.7* [**2110-2-3**] 11:50AM NEUTS-80.3* LYMPHS-13.5* MONOS-3.6 EOS-1.4 BASOS-1.2 [**2110-2-3**] 11:50AM PLT COUNT-211# [**2110-2-3**] 11:50AM PT-12.3 PTT-31.0 INR(PT)-1.0 . EKG: NSR@85 with RsR' (likely normal variant). Normal axis, normal intervals. . Imaging: . CXR: An endotracheal tube tip is 5.3 cm above the carina. Heart size is normal. There is no evidence of effusion, airspace disease, or pneumothorax. A nasogastric tube is noted coursing through the stomach with its tip not well visualized. . CTA Head: IMPRESSION: 1. No evidence of acute intracranial hemorrhage. 2. Overall unchanged appearance of the brain with post-clipping of right MCA aneurysm with encephalomalacia. Unchanged 1.5-mm aneurysm at the left MCA bifurcation. . [**2110-2-8**] 06:55AM BLOOD WBC-5.7 RBC-3.48* Hgb-10.5* Hct-31.7* MCV-91 MCH-30.0 MCHC-33.0 RDW-16.6* Plt Ct-125* [**2110-2-8**] 06:55AM BLOOD PT-12.5 PTT-44.5* INR(PT)-1.1 [**2110-2-8**] 06:55AM BLOOD Glucose-87 UreaN-20 Creat-1.0 Na-140 K-4.2 Cl-111* HCO3-19* AnGap-14 [**2110-2-8**] 06:55AM BLOOD ALT-57* AST-39 AlkPhos-154* TotBili-0.8 [**2110-2-7**] 06:05AM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.4 Mg-2.1 [**2110-2-5**] 05:30AM BLOOD Ammonia-71* [**2110-2-4**] 03:49PM BLOOD Free T4-1.3 [**2110-2-4**] 03:49PM BLOOD TSH-0.67 [**2110-2-3**] 11:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . MICRO [**2110-2-3**] 3:00 pm CSF;SPINAL FLUID #3. **FINAL REPORT [**2110-2-6**]** GRAM STAIN (Final [**2110-2-3**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2110-2-6**]): NO GROWTH . [**2110-2-3**] 11:50 am URINE Site: NOT SPECIFIED **FINAL REPORT [**2110-2-4**]** URINE CULTURE (Final [**2110-2-4**]): NO GROWTH . Blood Cultures 12/24 no growth at time of discharge Brief Hospital Course: A/P: 54 yo F with history of hepatic sarcoid and nodular regenerative hyperplasia complicated by portal hypertension, portal gastropathy, recurrent GI bleeding, COPD, pulmonary hypertension, hypothyroidism, Raynaud's, and non-ischemic cardiomyopathy with an EF 15-20%, s/p recent TIPS now admitted with marked encephalopathy requiring intubation for airway protection s/p successfully extubation [**2-5**]. . 1) Altered mental status due to Hepatic Encephalopathy: The patient has a history of marked encephalopathy in the past and also is known to be noncompliant with lactulose therapy. In the setting of recent TIPS, it was thought that the encephalopathy was the cause of this current change in mental status. She was intubated for airway protection. Neurology evaluated the patient in the emergency room. An intracranial process was ruled out with head CT/CTA given the patient's history of stroke and SAH. Although the patient had a left-sided hemiparesis, it was felt that this was unmasking of her old infarct in the setting of encephalopathy. LP was negative for evidence of intracranial infection. Tox screens were negative. In the ICU, she received multiple doses of PO lactulose and PR lactulose. She was successfully extubated [**2-5**]. Her mental status continued to improve with lactulose and stooling. At discharge, her mental status has returned to baseline. Her lactulose was titrated to [**4-14**] loose bowel movements per day. The patient was educated about the need for lactulose and expressed understanding of these instructions. The patient's left hemiparesis resolved with resolution of the patient's mental status. Patient continued on [**Month/Day (3) 8005**], nadolol, ursodiol, prednisone. . 2) Transaminitis - At discharge levels were in line with recent admission on the 18th prior to TIPS. There was a sudden rise in enzymes the day after admission raising the possibility of an interruption in the TIPS. However initial ultrasound did not show evidence of obstruction. Detailed Doppler ultrasound of the abdomen prior to discharge revealed patent portal vein and TIPS patent with good velocities. . 3) Hepatic Sarcoid, esophageal varices Grade II - Diagnosed in [**2104**]. On prednisone daily which was continued in house. Blood glucose was monitored and patient exhibited several elevated blood sugars mostly 120-160 consistent with steroid treatment. Patient was encouraged to discuss this finding with her primary care physician and hepatologist. Nadolol was restarted after extubation. . 4) Left-sided / bilateral upper extremity paresis/Hx of CVA: As noted above, the left-sided hemiparesis is believed to be an unmasked feature from her old CVA. Before discharge from the unit, she was able to move both of her upper extremities. Neurology saw the patient and signed off. At the time of discharge the patient had regained full strength on her left-side. It is believed that the weakness was all in the setting of encephalopathy. . 5)Right Forearm swelling - Likely from infiltration of IV, improved when IV switched to other arm. Ultrasound showed no deep vein thrombosis. Swelling resolved at time of discharge. . 6) COPD: Continued with albuterol. . 7) Chronic Systolic CHF: EF is around 40% on most recent ECHO. Diltiazem was restarted and she was cautiously hydrated. . 8) Benign Hypertension - pressures normalized on nadolol and diltiazem. . 9) H/O SAH: no evidence of bleeding on head CT. Neurology evaluated the patient and did not feel there was any acute process. . 10) Hypothyroidism: Continued levothyroxine. TSH 0.67, low normal. Recommend recheck as outpatient. . 11) Chronic Blood Loss Anemia: Improving at time of discharge. Likely secondary to chronic GI bleeding. Patient received no blood products during this hospitalization. Patient discharged home on sucralfate, and protonix. . 12) Communication: Husband h- [**Telephone/Fax (1) 29551**], c- [**Telephone/Fax (1) 29552**] . 13) Code: FULL Medications on Admission: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 5. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 6. Nadolol 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. folate Sig: One (1) mg once a day. 11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 12. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 13. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 14. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 16. Lactulose 10 gram/15 mL Solution Sig: One (1) PO BID PRN. . Allergies: Cipro, Doxycycline, Paxil, Quinine, compazine, levofloxacine, lithium 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. Prednisone 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* 4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 6. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 11. [**Telephone/Fax (1) **] 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three times a day: Every day you should have [**4-14**] bowel movements. Please adjust your lactulose to ensure this occurs. Disp:*2700 ML(s)* Refills:*2* 13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 14. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO three times a day as needed for indigestion. Disp:*60 Tablet(s)* Refills:*0* 16. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a day. Discharge Disposition: Home Discharge Diagnosis: Hepatic Encephalopathy Hepatic Sarcoid Idiopathic Cardiomyopathy Hypothyroidism Prior Cerebral Vascular Access Colonic Arterial Venous Malformation Discharge Condition: Stable, alert and oriented *3, no asterixis, L arm weakness resolved Discharge Instructions: You were admitted to the hospital due to altered mental status. You needed to be intubated and placed in the intensive care unit. You rapidly improved with the administration of lactulose. You were extubated, transferred to the floor. Your left arm weakness resolved; this weakness is evidence of a prior stroke which at baseline you have fully recovered from. . We conducted studies of your liver which show that your TIPS is open and doing well. . You experienced several elevated blood sugars while in the hospital. This was most likely due to the prednisone you are on, but please mention this to your primary care provider. . Please take all your medications as prescribed. *Please note you have been started on [**Last Name (LF) **], [**First Name3 (LF) **] antibiotic which reduces bacteria in your colon, to help prevent episodes of confusion due to your liver disease. *Please note your Ambien was held on admission due to your confusion. It was not restarted. Please discuss with your primary care physician restarting this medication if you have trouble sleeping. *Please note your gabapentin dose has been adjusted to 600 mg once a day. You have tolerated dosage adjustment well. *Please note you have been started on thiamine because of your liver disease. *Please note your lactulose dose has been adjusted. Please continue to adjust your lactulose dose so that you have [**4-14**] bowel movements per day. *Please note your scheduled metoclopramide has been stopped. This may have been contributing to your diarrhea. Please discuss this with [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 805**] at your appointment [**2110-2-24**]. If you develop nausea, you may take this as needed. . If you develop fevers, chills, nausea, vomiting, chest pain, shortness of breath, abdominal pain, or any other concerning symptoms please contact the liver center at ([**Telephone/Fax (1) 1582**], call your primary care physician or go to the local emergency room. Followup Instructions: Hepatology, Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2110-2-24**] 2:30 . Please call your primary care provider Dr [**Last Name (STitle) 29478**] [**Telephone/Fax (1) 3183**] to schedule a post hospital follow-up. At this visit please have her recheck you thyroid function and blood glucose, discuss your ambien and any other concerns that you have.

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icd9cm

[ [ [] ] ]

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icd9pcs

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11837, 13097

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49558

Discharge summary

report

Admission Date: [**2131-5-23**] Discharge Date: [**2131-6-28**] Date of Birth: [**2064-7-16**] Sex: M Service: MEDICINE Allergies: Levofloxacin / Cefazolin / Coreg / Dopamine Attending:[**First Name3 (LF) 1881**] Chief Complaint: foot infection, sepsis Major Surgical or Invasive Procedure: L toe ulcer debridement thoracentesis History of Present Illness: Mr. [**Known firstname **] is a 66 y/o male patient of Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] with diabetes c/b peripheral neuropathy, ulcers, and amputation, a history of a pro-coaguable disorder requiring chronic prophylaxis with enoxaparin and a neuropathic heel ulcer presents with a week of fever, malaise, nausea/vomiting, and change in mental status. According to the family the patient was in his usual state of health until one week PTA, when he had an episode of emesis. The following day he went to [**Hospital3 **] but again had nausea and emesis. Two nights PTA the patient began to have worsening of his great toe ulcer with redness and drainage. In addition he developed a low grade temperature and increase malaise. In the emergency room he was given ceftazidime and vancomycin. A code sepsis was called and a central line was placed. Dopamine was started for pressure support. The patient was sent to the ICU for further management. Upon arrival to the floor the patient was slightly lethargic but alert & oriented x 3. An arterial line was placed, and the patient was noted to have monomorphic ventricular tachycardia on an EKG, during which the patient dropped his blood pressures. He was changed from dopamine to neosynephrine and an EP consult was obtained. The patient received a total of 1250cc of NS. Once on neosynephrine his ventricular tachycardia resolved. Vascular surgery came to evaluate the patient and incised his toe wound. They isolated three pockets of pus and cultures were sent. Past Medical History: DMII CAD, ischemic cardiomyopathy EF 20% Afib s/p ablation, pacemaker SMA thrombosis with small bowel and large bowel infarcts status post small bowel and large bowel resection and resulting short gut syndrome Bacterial peritonitis PVD s/p R BKA Hypercoagulable state, DVTs Peripheral neuropathy Plantar fasciitis CVA PV Nonhealing anal fissure Social History: Mr. [**Known lastname 21212**] is a retired systems programmer for a management consulting firm. He is married with no children. He denies alcohol, tobacco or drug use. Prior 3 yrs of tobb abuse. Family History: Family history is negative for hypercoagulable state, PVD Physical Exam: PE: HR 75, ABP 102/61, O2 97% Gen: Lying in bed in mild distress. HEENT: NCAT, MMM. RIJ in place. CV: RRR Chest: CTA bilaterally on anterior exam other than slight crackles at right lower base. Abd: Scaphoid, benign. Ext: Patient with BKA on left foot. Right toe is ulcerated and erythematous with streaking cellulitis 2/3 up shin to knee. Neuro: Complaining, arousable, A&O x 3. Pertinent Results: [**2131-5-23**] 08:33AM BLOOD WBC-18.6* RBC-5.43# Hgb-14.6# Hct-44.5# MCV-82# MCH-26.9*# MCHC-32.8 RDW-20.2* Plt Ct-287 [**2131-5-23**] 08:33AM BLOOD Neuts-91.7* Bands-0 Lymphs-5.7* Monos-1.8* Eos-0.6 Baso-0.2 [**2131-5-23**] 02:34PM BLOOD WBC-24.1* RBC-5.68 Hgb-15.5 Hct-47.1 MCV-83 MCH-27.4 MCHC-33.0 RDW-20.3* Plt Ct-350 [**2131-5-24**] 04:13AM BLOOD WBC-20.1* RBC-5.05 Hgb-14.0 Hct-41.2 MCV-82 MCH-27.7 MCHC-33.9 RDW-20.6* Plt Ct-384 [**2131-5-25**] 04:36AM BLOOD WBC-14.6* RBC-4.76 Hgb-12.6* Hct-39.0* MCV-82 MCH-26.6* MCHC-32.4 RDW-20.5* Plt Ct-335 [**2131-5-24**] 04:13AM BLOOD PT-21.8* PTT-39.1* INR(PT)-2.1* [**2131-5-25**] 04:36AM BLOOD PT-18.2* PTT-78.8* INR(PT)-1.7* [**2131-5-25**] 11:15AM BLOOD PT-17.6* PTT-44.1* INR(PT)-1.6* [**2131-5-23**] 08:40AM BLOOD Glucose-222* UreaN-60* Creat-1.8* Na-133 K-4.5 Cl-103 HCO3-15* AnGap-20 [**2131-5-23**] 02:34PM BLOOD Glucose-149* UreaN-60* Creat-1.9* Na-133 K-4.3 Cl-101 HCO3-17* AnGap-19 [**2131-5-25**] 04:36AM BLOOD Glucose-118* UreaN-47* Creat-1.7* Na-136 K-4.4 Cl-111* HCO3-15* AnGap-14 [**2131-5-23**] 08:40AM BLOOD ALT-25 AST-18 LD(LDH)-423* CK(CPK)-116 AlkPhos-84 TotBili-0.9 [**2131-5-24**] 04:13AM BLOOD ALT-22 AST-13 LD(LDH)-335* AlkPhos-76 TotBili-0.6 [**2131-5-23**] 08:40AM BLOOD CK-MB-6 cTropnT-0.07* proBNP-[**Numeric Identifier 23738**]* [**2131-5-23**] 08:40AM BLOOD Lipase-27 [**2131-5-23**] 08:40AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.6 [**2131-5-23**] 02:34PM BLOOD Calcium-8.1* Phos-3.8 Mg-1.8 [**2131-5-24**] 04:13AM BLOOD Albumin-3.4 Calcium-7.9* Phos-5.3* Mg-2.9* [**2131-5-23**] 08:40AM BLOOD Cortsol-29.9* [**2131-5-23**] 08:40AM BLOOD CRP-85.4* [**2131-5-24**] 03:58PM BLOOD Vanco-19.2 [**2131-5-23**] 02:34PM BLOOD Digoxin-0.8* [**2131-5-23**] 03:02PM BLOOD Type-ART Temp-35.7 Rates-/14 O2 Flow-6 pO2-84* pCO2-35 pH-7.26* calTCO2-16* Base XS--10 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2131-5-24**] 04:29PM BLOOD Lactate-1.4 [**2131-5-23**] 03:02PM BLOOD Lactate-0.9 [**2131-5-23**] 08:49AM BLOOD Lactate-1.6 FOOT 2 VIEWS LEFT [**2131-5-23**] 8:51 AM FINDINGS: Bedside AP and lateral views (the former, degraded by motion- blurring) are compared with the study dated [**2130-11-28**]. There is now a small soft tissue defect at the tibial (medial) aspect of the plantar soft tissues, overlying the base of the 1st distal phalanx. However, this does not appear to reach bone on either view, with no subjacent subcutaneous emphysema or retained radiopaque foreign body. There is no evidence of periosteal reaction, cortical erosion or medullary lucency in subjacent bone to specifically suggest osteomyelitis, and the appearance of the remainder of the foot is unchanged, including vascular calcification and prominent dorsal calcaneal enthesophyte. IMPRESSION: Known ulcer in the plantar soft tissues of the 1st digit does not reach bone, with no radiographic sign of osteomyelitis. . CHEST (PORTABLE AP) [**2131-5-23**] 8:51 AM SINGLE PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: A dual-lead pacing device remains in unchanged position. Moderate cardiomegaly, reaccumulation of an asymmetric large right pleural effusion, and associated right perihilar hazy opacity are suggestive of asymmetric pulmonary edema, and represent decompensated mitral valve regurgitation. The left lung is relatively clear. No discrete focal airspace consolidation is identified. The bony thorax again demonstrates an S-shaped scoliosis of the thoracic spine. IMPRESSION: Asymmetric right-sided largely parahilar airspace disease and re- accumulated large pleural effusion, as on previous episodes. This may represent "atypcial" edema related to decompensation of known mitral regurgitation; alternatively, a pneumonic process cannot be completely excluded. CHEST (PORTABLE AP) [**2131-5-24**] 3:36 AM Allowing the difference in position of the patient, large right pleural effusion. There has been interval increase in moderate left pleural effusion. Mild asymmetric pulmonary edema, greater on the right side, is stable. Right IJ catheter tip is in the upper to mid SVC. Cardiomegaly is unchanged. Left transvenous pacemaker leads remain in standard positions. CHEST (PORTABLE AP) [**2131-5-25**] 3:36 AM In the interim, there is severe worsening of a right extensive pleural effusion with adjacent atelectasis and airspace disease in the collapsed right lung. There is also worsening of perihilar airspace disease in the left lung. Small left pleural effusion is also new. The heart size is mild-to-moderately enlarged, but stable. The left-sided subclavian pacemaker leads are stable. IMPRESSION: 1. Severe worsening of right pleural effusion with almost collapse of the right lung. 2. Bilateral airspace disease in both lungs, worsening on the left lung, likely edema. 3. Mild-to-moderate cardiomegaly. Brief Hospital Course: 66 y/o male with diabetes, cardiomyopathy, foot ulcer presenting with toe infection, septic physiology, and ventricular tachycardia. Hospital course by problem: # Sepsis/Toe Wound: Patient's exam was consistent with infected L 1st toe ulcer and leg cellulitis and he was hypotensive. He was admitted to the medical intensive care unit, and was started on a neosynephrine drip which was weaned [**5-24**] and he was started on vancomycin and zosyn. Vascular surgery and podiatry evaluated him and debrided the ulcers. Surgery initially thought he might need an amputation, but he clinically improved and this was deferred in favor of [**Hospital1 **] WTD dressing changes. He was soon transferred to the floor. His blood grew proteus mirabilis (pan-sensitive) and streptococcus (penicillin-sensitive but clindamycin and erythromycin-resistant). Zosyn was changed to unasyn, but the patient clinically worsened and with concern for an undetected element of the likely polymicrobial sepsis which started his course, unasyn was discontinued and zosyn restarted. Of note, no pseudomonas grew out at any time in his wound or blood cultures. Gram-positive cocci and more Proteus grew out of a wound culture as vascular surgery continued to follow, drain abscesses and debride tissue. The GPCs ultimately proved to be pan-sensitive MSSA, and once this sensitivity was available, vancomycin was discontinued. Eventually, zosyn was discontinued and unasyn was restarted, with no ill effects. Flagyl was added for C. diff protection although he did not grow out C. diff--see below. In terms of ongoing management, on the initial evaluation the wound had probed to bone in the earliest portion of this hospital course. There was some concern, particularly from the infectious disease service (which had been consulted, and which had followed the patient in the past for recurrent C. diff) that he would not be able to endure a six-week course of antibiotics because of his short gut, past history of recurrent C. diff, and that an operation might be superior. In consultation with the surgeons and the primary care physician (who also served as the hospital attending), and after the primary care physician had [**Name9 (PRE) 103662**] discussion with the patient of risks and benefits of non-operative management, amputation was deferred in favor of medical management. Given his high risk of recurrent C. diff and his short gut, and the potentially dire consequences for this patient of not being able to tolerate a long course of antibiotics, and in consultation with the infectious disease service, we took the unusual step of treating C. diff empirically despite negative toxins. The total course of antibiotics will be six weeks, with day 1 of effective antibiosis = [**5-29**]. Therefore last doses should be on [**7-10**]. Weekly labs should be sent to the infectious disease clinic; follow-up lab instructions are in the outpatient orders (med list) of this discharge summary. Flagyl should be continued through this time, and then for seven days after (until [**7-17**]). In detail, starting dates were: Zosyn and vanco: [**5-23**] (on admission) Zosyn replaced with unasyn: [**5-26**] Flagyl: [**5-26**] (pt has had recurrent C diff as above) Unasyn stopped and replaced again with Zosyn: [**5-27**] Vancomycin stopped [**6-3**] Zosyn stopped and replaced with Unasyn: [**6-3**] Ending dates for Unasyn and Flagyl: [**7-10**] and [**7-17**] respectively, as above. Podiary has said that he is full weight-bearing. # Chronic systolic heart failure and cardiomyopathy: In the MICU, the patient had an increased O2 requirement, 93% on 6L NC O2, with large R sided pleural effusion. He had an US-guided thoracentesis on [**5-25**] (therapeutic and diagnostic) which revealed a transudative sterile fluid which carried signs of neither infection nor malignancy. He has a lasix requirement at home and ultimately as sepsis and hypotension resolved, he was started back on lasix, first prn, and then 40 [**Hospital1 **] (his home dose); on [**6-9**] this was changed to 60 [**Hospital1 **]. He had several incidents in which he more acutely desaturated, each of which was solved by extra doses of lasix. He did continue to have an oxygen requirement, associated with what appeared to be his fluid status, but was stable. We would expect with increasing activity he might be able to mobilize more of this fluid; however, reconsideration of his diuretic dose might be necessary if he is not able to decrease and then wean his oxygen requirement. At home prior to this admission he has been on digoxin and lisinopril. In light of his continuing renal insufficiency these were not restarted though the lisinopril in particular should be given consideration for restarting at the earliest opportunity. Earlier in admission transudative effusion c/w heart failure when tapped, with large drainage. Pain control was adquate with Oxycontin, Oxycodone, and Dilauidid for breakthrough pain. # Ventricular Tachycardia: Early in the admission, the patient had one episode of asymptomatic VT that developed in the setting of dopamine and low Mg, and in the setting of the immediate post-sepsis period. This resolved with no further episodes while on the floor, until [**6-11**], when he had a series of runs of NSVT in the morning. He was asymptomatic with these events. The electrophysiology service was consulted. He does not have an ICD in place but given that he is being treated for infection, EP felt it would be better to keep him on telemetry but defer ICD placement if indicated. In the meantime, the EP service recommended putting him on amiodarone, on the schedule listed below in the medication orders. A follow-up appointment with a nurse practitioner in [**Name (NI) 103663**] office was made (shown below); additionally the patient should have direct follow-up with Dr. [**Last Name (STitle) **] arranged within the next 2-6 weeks. The amiodrone has been tapered down to 200mg PO daily, and after one week without active issue the patient was removed off telemetry. # Renal Failure: Acute on Chronic. Acute from CHF hypoperfusion and contrast interaction and chronic from diabetes. Early in the admission, Mr [**Known lastname 21212**] had elevated creatinine as far up as 1.9 on [**5-24**] in the context of his early sepsis and MICU stay, which had trended down. It declined to 1.3 and 1.4 in early [**Month (only) **], but after an angiographic study gave him a large contrast load, it went back up to the 1.7-2.0 range peaking at 2.1 on [**6-7**]. This was wavering in the period of [**5-26**] with an uncertain direction. This should be followed in the rehabilitation setting. Although it likely had the effect of raising the Cr, we continued to give lasix, feeling that it was likely best to support renal perfusion, and because it was necessary for respiratory function. He has been tolerating a high dose of lasix, 120mg [**Hospital1 **], and sometimes still requires an additional 60mg IV to maintain negative fluid balance. The patient has not had any signs of ototoxicity. On [**6-25**] mg of po HCTZ was added to his diuretic regimen, and was given [**Hospital1 **], 30 minutes prior to furosemide administration. Following this change, LUE edema decreased significantly. On [**6-27**], HCTZ was decreased to once daily. HCTZ was discontinued upon hospital discharge. # Diabetes: Maintained patient on insulin sliding scale; his NPH was restarted and was titrated up as the patient's PO intake increased and his scale requirements increased. # Hypercoagulability: The patient has had disastrous sequelae of clotting in the past including ischemic bowel and resulting short gut, and stroke; thus anticoagulation was scrupulously maintained. The patient was kept on a heparin sliding scale for much of the admission in order to preserve operative options while also continuing anticoagulation which is provided by lovenox as an outpatient. On [**6-11**], with anticipation of discharge and no further operations planned, [**Hospital1 **] Lovenox was started. Factor Xa level was drawn in the pm of [**6-12**] after the third dose of lovenox was given, and found to be 0.43 U/mL. It was rechecked [**6-16**] and [**6-23**], and found to be 0.71 and 0.80 U/mL respectively. # Depression: citalopram was continued. Mr [**Known lastname 21212**] had various periods of frustration with his care. He likely also has some element of depression and perhaps small cognitive losses from past stroke. Given the very real stressors of his hospitalization here, including the ongoing possibility that he might lose his foot and his mobility, it was assumed that some portion of his mood was reactive, management was not changed. As his medical situation stabilizes and improves, if his mood does not improve simultaneously, he may benefit from revisiting his treatment for depression. # Leukocytosis- most likely secondary to a myeloproliferative disorder, previously characterized as polycythemia [**Doctor First Name **]. # Neuropathy: The patient was maintained on oxycontin, neurontin, and vicodin. # PPX: The patient was given heparin for thrombosis prophylaxis which was converted to LMWH as above, as well as a PPI per home regimen. Medications on Admission: Hydrocodone/Acetaminophen 5/235 Captopril 25 Furosemide 20 Fosamax 70 Digoxin 250mcg Oxycontin 10 [**Hospital1 **] Neurontin 800 Folic Acid 1mg Ranitidine 150 tab Toprol Xl 25 Daily Loperamide 2mg Q6PRN Lovenox 60mg Daily Citalopram 40 daily Discharge Medications: 1. Outpatient Lab Work Laboratory monitoring required; frequency: weekly. Draw: Creat, BUN, Alt, Ast, WBC, Hct/Hgb All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 6313**]. All questions regarding outpatient or rehabilitation antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 14199**] 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day for 7 days: To be given [**6-11**] through [**6-18**]; then followed by 200 mg [**Hospital1 **] for one week thereafter; and then 200 mg daily after that. Follow up closely with Dr[**Name (NI) 7914**] office. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 7. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 8. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-27**] Drops Ophthalmic PRN (as needed). 13. Psyllium 1.7 g Wafer Sig: [**12-27**] Wafers PO BID (2 times a day). 14. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 15. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous [**Hospital1 **] (2 times a day). 16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. . 18. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 19. Hydromorphone 2 mg/mL Solution Sig: 0.5-2 mg Injection Q3H (every 3 hours) as needed: for breakthrough pain. hold for sedation or RR <12. 20. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 21. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours): until [**7-17**]. 22. Ampicillin-Sulbactam 3 gram Recon Soln Sig: Three (3) grams Injection Q8H (every 8 hours) for 14 days: Give through [**7-10**]. Disp:*42 doses* Refills:*0* 23. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) injection Subcutaneous qAM: gradually increasing dose; likely to need further increases as PO intake increases; currently at 20 mg in AM. 24. Humalog 100 unit/mL Solution Sig: One (1) injection Subcutaneous qACHS: before breakfast, lunch and dinner, and at bedtime (4 x /day). Use scale: If <60, crackers and juice or [**12-27**] amp D50. 60-160 mg/dL 0 Units 161-200: 2 Units. 201-240: 4Units. 241-280: 6 Units. 281-320 8 Units. 321-360 10 Units. 361-400 12 Units. 25. oxygen 2L continuous via nasal cannula pulse dose for portability. 26. semi-electric bed with rails, equipped for patient's height and weight 27. PICC line care per NEHT protocol, saline and heparin flushes Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: PRIMARY: OSTEOMYELITIS CONGESTIVE HEART FAILURE Discharge Condition: Stable. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500 mL fluid per day Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2131-7-5**] 11:00 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-7-11**] 2:30 Provider: [**Name10 (NameIs) 251**] [**Name Initial (NameIs) **] [**Last Name (NamePattern4) **], CARDIOLOGY Phone:[**Telephone/Fax (1) 62**] Date/Time: [**2131-7-11**] 3:00 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1111**] Phone:[**Telephone/Fax (1) 3121**] Date/Time:[**2131-9-2**] 2:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule appointment [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**] Completed by:[**2131-7-27**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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327, 366

21016, 21025

3033, 7829

21214, 22109

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20945, 20995

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394, 1951

1973, 2325

2341, 2540

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145,738

13268

Discharge summary

report

Admission Date: [**2162-4-2**] Discharge Date: [**2162-4-7**] Date of Birth: [**2110-4-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3624**] Chief Complaint: Urosepsis Major Surgical or Invasive Procedure: Central line placement History of Present Illness: 51F with hx of DM, ESRD s/p kidney/pancreas transplant in [**2159**] presents with no urine output x 12 hours. Pt states that she typically urinates 4-5 times per day but not much each time. This morning, she awoke at 4am and urinated only a few drops and none since that time. She reports some low back pain for the past 2 days for which she has been taking tylenol. No other med changes; has been taking anti-rejection meds as prescribed. Also this am, developed right foot pain, described as a sharp electric pain on the lateral side of her foot. This is typical for her neuropathic pain which she gets every 2-3 months. When she gets the pain, she has been told there is nothing she can do and it resolves on its own. When she has the pain, she cannot walk. She also notes some chills this am, no fevers. She denies any cough, chest pain, shortness of breath, dysuria, joint pains, URI sx. No sick contacts, no recent travel. Pt admits that she does not drink as much fluid as she should. In ED, foley was placed with return of 10cc of urine. In the MICU, urine and blood cultures were positive for pan-[**Last Name (un) 36**] Klebsiella, and patient was started on Cipro. Patient was anuric for 12 hrs, but urine output increased in MICU. Prograf level was high, so was held when being called out from MICU. Past Medical History: Insulin dependent diabetes mellitus. Hypertension. Cataract surgery. C section times two. h/o End Stage Renal Disease s/p kidney/pancreas tx [**2-11**] s/p ventral hernia repair [**2161-8-7**] Social History: non-contributory Family History: Diabetes on the mother's side Physical Exam: Exam: 98.8, BP 118/80, HR 100, R 24, O2 98%RA Gen: in moderate distress from foot pain HEENT: dry MM, JVD flat CV: tachycardic, regular, no murmurs Chest: clear Abd: +BS, healing scar midline, mildly tender to palpation in LLQ, no rebound or guarding Ext: no edema, right foot exquisitely tender along lateral edge, no podagra noted, no joint tenderness, no erythema or swelling Pertinent Results: [**2162-4-2**] 02:20PM BLOOD WBC-10.2# RBC-4.96 Hgb-16.8* Hct-50.0* MCV-101* MCH-33.8* MCHC-33.5 RDW-14.6 Plt Ct-235 [**2162-4-3**] 06:50AM BLOOD WBC-28.3*# RBC-3.78* Hgb-12.9# Hct-38.5# MCV-102* MCH-34.1* MCHC-33.5 RDW-15.1 Plt Ct-153 [**2162-4-3**] 03:38PM BLOOD WBC-34.6* RBC-4.09* Hgb-13.9 Hct-41.1 MCV-101* MCH-34.1* MCHC-33.9 RDW-15.1 Plt Ct-162 [**2162-4-4**] 06:06AM BLOOD WBC-21.7* RBC-3.51* Hgb-12.0 Hct-36.4 MCV-104* MCH-34.3* MCHC-33.0 RDW-14.9 Plt Ct-112* [**2162-4-5**] 05:26AM BLOOD WBC-23.8* RBC-3.85* Hgb-12.9 Hct-39.5 MCV-103* MCH-33.6* MCHC-32.8 RDW-14.9 Plt Ct-110* [**2162-4-6**] 05:40AM BLOOD WBC-16.6* RBC-4.06* Hgb-13.8 Hct-40.8 MCV-100* MCH-33.9* MCHC-33.7 RDW-15.0 Plt Ct-118* [**2162-4-7**] 05:35AM BLOOD WBC-11.6* RBC-4.37 Hgb-14.9 Hct-42.7 MCV-98 MCH-34.2* MCHC-34.9 RDW-15.4 Plt Ct-78* [**2162-4-2**] 03:30PM BLOOD Glucose-78 UreaN-22* Creat-1.8*# Na-139 K-3.9 Cl-106 HCO3-19* AnGap-18 [**2162-4-3**] 06:50AM BLOOD Glucose-70 UreaN-33* Creat-3.2*# Na-137 K-4.8 Cl-110* HCO3-16* AnGap-16 [**2162-4-3**] 03:38PM BLOOD Glucose-92 UreaN-40* Creat-2.8* Na-138 K-4.4 Cl-111* HCO3-17* AnGap-14 [**2162-4-4**] 06:06AM BLOOD Glucose-76 UreaN-45* Creat-3.1* Na-140 K-5.0 Cl-115* HCO3-15* AnGap-15 [**2162-4-5**] 05:26AM BLOOD Glucose-86 UreaN-60* Creat-4.0* Na-139 K-5.4* Cl-114* HCO3-13* AnGap-17 [**2162-4-6**] 05:40AM BLOOD Glucose-109* UreaN-62* Creat-2.4*# Na-142 K-4.2 Cl-118* HCO3-16* AnGap-12 [**2162-4-7**] 05:35AM BLOOD Glucose-110* UreaN-55* Creat-1.5* Na-144 K-3.3 Cl-117* HCO3-16* AnGap-14 Renal tx U/S: 1) Mild hydronephrosis. 2) Trace amount of perinephric fluid. 3) Resistive indices within normal limits. CXR ([**4-3**]): Single portable radiograph of the chest demonstrates normal cardiomediastinal contour. Lungs are clear. No effusion. Trachea is midline. Brief Hospital Course: 51 F with hx of DM, ESRD requiring kidney/pancreas transplant in [**2159**] admited with renal failure, then developed Klebsiella urosepsis. # Klebsiella urosepsis: Pt initially admitted to hepatorenal service, then transferred to MICU for hypotension, where she responded well to goal-directed therapy. Urine and blood cultures were positive for pansensitive Klebsiella pneumoniae, and she was treated with ciprofloxacin and discharged to complete a 21-day course. # Anuria/ARF: Likely secondary to urosepsis and subsequent prerenal physiology/ATN. Responded to aggressive fluid resuscitation . # s/p Kidney/pancreas transplant: as above, no signs of rejection on renal ultrasound. Tacrolimus decreased to 2 mg [**Hospital1 **], azathioprine was D/C'ed per renal recommendations given thrombocytopenia. She will follow up with her primary transplant nephrologist one week after completing her course of ciprofloxacin. Medications on Admission: Tacrolimus 3mg [**Hospital1 **] Azithioprine 50 mg qd Ranitidine Bactrim qMWF Discharge Medications: 1. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 16 days. Disp:*32 Tablet(s)* Refills:*0* 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Klebsiella urosepsis Secondary: DM ESRD s/p kidney and pancreas transplant HTN Discharge Condition: Stable tolerating PO and ambulating Discharge Instructions: Please keep your follow-up appointments Please take your medications as directed Please call your doctor or return to the ER for: 1. chest pain 2. shortness of breath 3. fever to 100.4 4. weight gain of more than 3 pounds 5. dizziness or fainting 6. other concerning symptoms Followup Instructions: Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2162-5-3**] 10:10 Please go to the [**Hospital Ward Name 23**] clinical center at [**Hospital1 18**] to have your labs checked in 1 week (chem 7, prograf, CBC) [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]

[ "276.51", "357.2", "403.91", "584.5", "995.91", "287.4", "E878.0", "038.49", "996.81", "788.20", "V42.83", "250.60" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

5661, 5667

4234, 5157

323, 348

5791, 5829

2405, 4211

6155, 6580

1960, 1991

5285, 5638

5688, 5770

5183, 5262

5853, 6132

2006, 2386

274, 285

376, 1693

1715, 1909

1925, 1944

2,747

163,539

12977

Discharge summary

report

Admission Date: [**2141-10-9**] Discharge Date: [**2141-10-20**] Date of Birth: [**2080-6-29**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Palpitations Major Surgical or Invasive Procedure: [**2141-10-9**] Redo sternotomy with pericardial patch repair of homograft perforation in the pseudoaneurysm. Aortic valve replacement with a 19-mm St. [**Hospital 923**] Medical Regent mechanical heart valve. [**2141-10-11**] Mediastinal irrigation and sternal wound closure. History of Present Illness: 61 year old gentleman with past medical history of congenital aortic stenosis treated with open valvulaplasty in [**2091**] and then a redo homograft root replacement and proximal arch replacement in [**2132**]. He has done quite well since that time. On routine follow-up with Dr. [**Last Name (STitle) **] this [**Month (only) **] an echocardiogram was obtained which showed the ascending aorta to be moderately dilated (5.2cm) and an abnormality exterior to the tube graft. A CT scan was performed which revealed an aneurysmal sac which measures 6.5cm. Past Medical History: Aortic pseudoaneurysm Aortic Stenosis s/p Redo Sternotomy, pseudoaneurysm repair, AVR (mechanical) - Congential aortic stenosis s/p Open valvulplasty [**2091**] and Bentall [**2132**] - Ascending aortic aneurysm - Benign prostatic hypertrophy - Erectile dysfunction - Hypertension - Aortic valvuloplasty [**2091**] - Redo Sternotomy/Bentall/Prox.Arch repl. (homograft to Gelweave)) [**2132**] (Dr. [**Last Name (STitle) 1290**] - Vasectomy Social History: Lives with: Wife Occupation: [**Name2 (NI) **] works for a federal agency that performs audits and financial analyses of federal contractors. Cigarettes: Smoked no [] yes [X] Hx: Quit [**2132**] ETOH: < 1 drink/week [X] Illicit drug use: None Family History: non contributory Physical Exam: Pulse: 66 Resp: 16 O2 sat: 99% B/P Right: 128/76 Height: 71" Weight: 150 General: Well-developed male in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade [**1-15**] Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema/Varicosities: None [Z] Neuro: Grossly intact [Z] 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: Admission labs: [**2141-10-9**] 07:42AM HGB-12.9* calcHCT-39 [**2141-10-9**] 07:42AM GLUCOSE-79 LACTATE-0.9 NA+-132* K+-4.0 CL--100 [**2141-10-9**] 01:00PM FIBRINOGE-100* [**2141-10-9**] 01:00PM PT-18.9* PTT-77.4* INR(PT)-1.7* [**2141-10-9**] 01:00PM WBC-10.2# RBC-2.83*# HGB-9.0*# HCT-25.8*# MCV-91 MCH-31.8 MCHC-34.9 RDW-13.3 [**2141-10-9**] 12:56PM GLUCOSE-143* LACTATE-4.9* NA+-133 K+-3.7 CL--104 Discharge labs [**2141-10-20**] 06:03AM BLOOD WBC-8.2 RBC-2.97* Hgb-9.0* Hct-26.8* MCV-90 MCH-30.3 MCHC-33.6 RDW-13.7 Plt Ct-220 [**2141-10-20**] 06:03AM BLOOD Plt Ct-11/1220 [**12-20**] 06:03AM BLOOD PT-27.5* PTT-74.2* INR(PT)-2.6* [**2141-10-20**] 06:03AM BLOOD Glucose-91 UreaN-19 Creat-1.3* Na-131* K-4.5 Cl-100 HCO3-21* AnGap-15 INR labs [**12-20**] 06:03AM BLOOD PT-27.5* PTT-74.2* INR(PT)-2.6* [**2141-10-19**] 03:56AM BLOOD PT-20.4* PTT-73.7* INR(PT)-1.9* [**2141-10-18**] 06:12AM BLOOD PT-19.1* PTT-77.4* INR(PT)-1.7* [**2141-10-17**] 02:00PM BLOOD PT-18.9* PTT-50.9* INR(PT)-1.7* [**2141-10-17**] 03:52AM BLOOD PT-18.8* PTT-86.6* INR(PT)-1.7* [**2141-10-16**] 01:33PM BLOOD PT-18.1* PTT-57.5* INR(PT)-1.6* [**2141-10-16**] 02:12AM BLOOD PT-19.1* PTT-57.3* INR(PT)-1.7* [**2141-10-15**] 11:02PM BLOOD PT-19.1* PTT-52.8* INR(PT)-1.7* [**2141-10-15**] 06:18AM BLOOD PT-19.8* PTT-42.7* INR(PT)-1.8* [**2141-10-14**] 11:33PM BLOOD PT-17.6* PTT-37.6* INR(PT)-1.6* [**2141-10-14**] 02:47AM BLOOD PT-12.6 PTT-25.0 INR(PT)-1.1 [**2141-10-11**] Intra-op TEE Conclusions PRE-chestclosure 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. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. There is left sided pleural effusion. POST_chest closure Moderate global RV systolic dysfunction. Intact ascending aortic graft. The aortic mechanical valve is entirely normal with standard washing jets. Radiology Report CHEST PORT. LINE PLACEMENT Study [**2141-10-15**] 12:25 PM Final Report Comparison is made to the patient's prior study of [**2141-10-13**] at 16:02. IMPRESSION: 1. Interval removal of the right internal jugular introducer with placement of a central line which has its tip in the superior vena cava. No evidence of pneumothorax. 2. Stable postoperative appearance to the cardiac and mediastinal contours with persistent prominence in the left hilum in the region of the pulmonary artery. The patient is status post median sternotomy for CABG and aortic valve replacement. Persistent bibasilar patchy opacities, left greater than right with associated layering pleural effusions most likely representing compressive atelectasis although pneumonia cannot be excluded. No evidence of pulmonary edema. Brief Hospital Course: Admitted same day surgery and was brought to the Operating Room for planned repair of pseudoaneurysm however was complicated by tear in graft, innominate tear, requiring deep hypothermic circulatory arrest, see operative report for further details. he tolerated the operation and was brought to the intensive care unit from the operating room with chest open and chemically paralyzed/sedated. He required both inotropic support pressor support for blood pressure managment. On post operative day one his paralytic was temporarily stopped to evaluate neurological status and he opened his eyes to command, he was then resumed on paralytics to reduce potential for complication with open chest. He continued on sedation and was gently diuresed with lasix due to volume overload. On [**10-11**], post operative day two, he returned to the Operating Room for wash out and sternal closure, see operative report for further details. He was not restarted on paralytics post closure but continued on sedation until paralytics cleared. He was in atrial fibrillation on return from the operating room. He was then transitioned to precedex and weaned from the ventilator, but remained intubated until the morning of post operative day four. Post extubation he experienced post-operative delerium which was managed with Haldol initially, this cleared and on post operative day seven and five he was transferred to the floor for continued care. The remainder of his hospital course was uneventful. He continued on heparin drip as he continued to be loaded with coumadin for mechanical valve and atrial fibrillation. He was discharged home with VNA on POD 11 when INR was therapeutic. Coumadin/INR will be managed by Dr. [**First Name (STitle) **] via the [**Hospital 191**] [**Hospital **] Clinic. Medications on Admission: Toprol XL 50 mg daily Aspirin 325 mg daily Viagra prn Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication Aortic valve Goal INR 2.5-3 First draw [**2141-10-21**] Results to [**Hospital 191**] [**Hospital **] clinic, phone [**Telephone/Fax (1) 2173**] 2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. metoprolol tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). Disp:*225 Tablet(s)* Refills:*2* 7. warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a day: take 5mg on [**10-7**], and [**10-22**] then as directed by coumadin clinic. Disp:*75 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Aortic pseudoaneurysm Aortic Stenosis s/p Redo Sternotomy, pseudoaneurysm repair, AVR (mechanical) PMH Congential aortic stenosis s/p Bentall [**2132**] Benign prostatic hypertrophy Hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating independently- steady gait Incisional pain managed with Tramadol Incisions: Sternal - healing well, no erythema or drainage, staples Edema- trace bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. 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 [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2141-11-15**] 1:15pm in the [**Hospital **] medical office building [**Doctor First Name **] [**Hospital Unit Name **] Cardiologist: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] on [**2141-10-30**] 10:20 PCP Dr [**First Name (STitle) **] [**Telephone/Fax (1) 250**] on [**2142-7-31**] 3:00 Please call to schedule appointments with your Primary Care Dr [**First Name (STitle) **] [**Telephone/Fax (1) 250**] in [**3-14**] 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** Labs: PT/INR for Coumadin ?????? indication Aortic valve Goal INR 2.5-3 First draw [**2141-10-23**] Results to [**Hospital 191**] [**Hospital **] clinic, phone [**Telephone/Fax (1) 2173**] Completed by:[**2141-10-20**]

[ "780.09", "287.5", "998.11", "600.00", "E878.2", "V58.61", "996.1", "441.2", "424.1", "286.9", "427.31", "285.1", "276.69", "276.2", "607.84", "780.1", "401.9", "518.51" ]

icd9cm

[ [ [] ] ]

[ "35.22", "39.61", "39.49", "39.57", "38.93", "96.71", "37.49", "78.41" ]

icd9pcs

[ [ [] ] ]

8783, 8834

5865, 7658

325, 606

9073, 9275

2647, 2647

10078, 11026

1933, 1951

7762, 8760

8855, 9052

7684, 7739

9299, 10055

1966, 2628

272, 287

634, 1192

2663, 5842

1214, 1656

1672, 1917

73,902

157,796

52628

Discharge summary

report

Admission Date: [**2106-11-14**] Discharge Date: [**2106-11-24**] Date of Birth: [**2027-8-29**] Sex: F Service: MEDICINE Allergies: Iodine Attending:[**First Name8 (NamePattern2) 812**] Chief Complaint: [**Hospital 82594**] transferred to [**Hospital1 18**] for evaluation of pulmonary hypertension. Major Surgical or Invasive Procedure: Central line placement. Swan-Ganz catheter placement. History of Present Illness: Mrs. [**Known lastname **] is a 79 year-old woman with history of polycythemia [**Doctor First Name **] on hydroxyurea, Raynaud's phenomena, hypertension, transferred from OSH to [**Hospital1 18**] on [**2106-11-11**] for workup of new hypoxemia and pulmonary hypertension. She was in her usual state of health until approximately one month ago, when she began experiencing fatigue with exercise. Prior to one month ago, she was able to climb a flight of stairs without difficulty and walk several blocks, denying any exercise limitation. She was working for her son in a gift shop until 3 weeks ago, at which time she began to note dyspnea with climibing one flight of stairs at her home and that she needed to take frequent breaks from what were typically small domestic tasks. Other symptoms included mild ankle edema, and "swollen abdomen" noted by her PCP. [**Name10 (NameIs) **] notes generally poor appetite with little interest in food. Her PCP ordered [**Name Initial (PRE) **] chest x-ray and started her on ciprofloxacin for pneumonia (per patient). She was also referred for an TTE due to pleural effusions, which revealed a markedly dilated right ventricle, moderate aortic regurgitation and moderate mitral regurgitation. At [**Hospital3 417**] Hospital, she underwent chest CTA which was negative for PE. There was a right sided effusion which was tapped with results consistent with transudate. Also noted to have mediastinal adenopathy. During her hospitalization, patient was found to have acute kidney injury and per nephrology consutation felt to be secondary to poor renal perfusion from impaired left ventricular filling. Patient was transferred to [**Hospital1 18**] for futher management. She was also initiated on CAP treatment with levofloxacin, which was completed at transfer to [**Hospital1 18**] for further management and work-up of her hypoxemia and pulmonary hypertension. Upon arrival at [**Hospital1 18**] she was hemodynamically stable at direct admission to the floor. She remained hemodynamically stable with an oxygen requirement of 4 LPM. She had repeat CT scan of the chest without contrast and a repeat ECHO. These findings confirmed OSH results with TR gradient 56-64, severe TR, mild MR, mild LVH, RVH, marked RV dilation with abnormal septal motion. Pulmonary and cardiology were consulted and she underwent pulmonary artery catheter placement for planned close monitoring, trial of potential vasodilator drugs and diuresis in the ICU. Also has noted dark urine since arrival to [**Hospital1 18**], along with abdominal pain in her LUQ to LLQ, which felt like a "toothache" to her. It was not colicky in nature and resolved spontaneously. Review of systems Denies snoring or nightime dyspnea or awakenings though notes her "son thinks I have sleep apnea" for unclear reasons. Denies fever, chest pain, syncope or lightheadedness, bleeding episodes, abdominal pain, nausea/vomiting prior to coming to hospital. Denies headache, weight loss, night sweats or fever. Denies history of liver disease, heart disease, venous thromboembolic disease. History of blood transfusion with delivery of child 50 years ago. Past Medical History: 1. Polycythemia [**Doctor First Name **], diagnosed about [**2088**], on hydroxyurea about 10 years. Followed by Dr. [**Last Name (STitle) 65126**], who has controlled disease well for many years. 2. Raynaud's phenomenon diagnosed "as a child" 3. Kidney stones, last > 10 years ago per patient 4. Hypertension 5. Osteoarthritis 6. Avascular necrosis of the femur or humerus (unclear) 7. Osteoporosis 8. Cataracts 9. Chronic renal insufficiency, baseline creatinine about 1.0. Social History: Lives with daughter, able to care for self without limitations prior to this illness. Never been on home oxygen before. Is the primary carer for her daughter who suffers from some social difficulties - possibly autism spectrum. Also has another two children - one son and a daughter. Employment: Worked in gift shop until three weeks ago, denies environmental exposures. No TB exposures. No travel. No HIV risk factors. Husband died of mesthelioma. Asbestos exposure likely prior to their meeting (he worked in a ship yard in his 20s). Tobacco: Never Alcohol: Very rare (once a year). Family History: No family history of pulmonary disease. Husband died of mesothelioma after working in a shipyard; pt states they met years after he worked there and was never exposed to any shipyard clothes and never visited the worksite. Son has OSA. Sister has 'low white cell count' and sees a Hematologist. Physical Exam: ON ADMISSION: General appearance: Elderly female, mildly tachypneic with speech. HEENT: Dry mucous membranes, PERRL though minimal reactivity, EOMI. Neck: JVD to ear at 60 degrees. R IJ PA cath. No adenopathy. Chest: Diminished breath sounds at bilateral apices, bilateral basilar crackles. Cardiac: +Prominant RV impulse. S1, loud P2 with fixed split S2 (though more notable with exhalation), ?R sided S3. Regular rate. [**2-19**] SM at LLSB. Abdomen: +Pulsatile liver. Soft, non tender currently, slightly distended though tympanic throughout without clear evidence of ascites. Spleen tip not clearly palpable but ?increased size by percussion. Back: No CVA tenderness. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 576**] site benign. Extremities: Trace to 1+ LE pitting edema, digits slightly darker in color without evidence of ulceration. Neuro: CN II-[**Doctor First Name 81**] intact, strength 5/5 in UEs and LEs. No asterixis. Psych:alert, oriented, appropiate UPON DISCHARGE: VS: T 97.0 HR 85 BP 124/70 (100-124 systolic over past 24 hours) RR of 20 and saturation of 93% on 6L oxygen via n.c. General appearance: Elderly female, slim, appears stated age. HEENT: Dry mucous membranes, PERRL, EOMI. Neck: JVD to ear at any angle. No adenopathy. Chest: Diminished breath sounds at bilateral bases, some fine dry crackles to the middle of the lower lobe posteriorly. Cardiac: S1, loud P2 with fixed split S2. Regular rate. [**2-19**] SM at LLSB. Abdomen: Soft, non tender currently, no evidence of ascites. Spleen tip not clearly palpable but increased size by percussion. Back: No CVA tenderness. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 576**] site benign. Extremities: No edema, clubbing, cyanosis. Neuro: CN II-[**Doctor First Name 81**] intact, strength 5/5 in UEs and LEs. No asterixis. Psych: Alert, oriented, appropiate. Pertinent Results: Admission Labs and Important Data from the Admission Blood [**2106-11-14**] 10:40PM BLOOD WBC-14.0* RBC-5.23 Hgb-14.5 Hct-47.3 MCV-91 MCH-27.7 MCHC-30.7* RDW-21.1* Plt Ct-322 [**2106-11-14**] 10:40PM BLOOD Neuts-88.6* Lymphs-6.2* Monos-2.9 Eos-1.5 Baso-0.9 [**2106-11-14**] 10:40PM BLOOD PT-16.8* PTT-32.2 INR(PT)-1.5* [**2106-11-14**] 10:40PM BLOOD Plt Ct-322 [**2106-11-14**] 10:40PM BLOOD Glucose-100 UreaN-48* Creat-1.3* Na-144 K-4.3 Cl-109* HCO3-24 AnGap-15 [**2106-11-14**] 10:40PM BLOOD ALT-35 AST-36 CK(CPK)-15* AlkPhos-108 TotBili-0.7 [**2106-11-14**] 10:40PM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.5 Mg-2.1 [**2106-11-15**] 12:05PM BLOOD calTIBC-369 Ferritn-30 TRF-284 [**2106-11-18**] 04:41AM BLOOD TSH-11* [**2106-11-18**] 03:56PM BLOOD Free T4-1.2 [**2106-11-15**] 12:05PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE [**2106-11-14**] 08:18AM BLOOD ANCA-NEGATIVE B [**2106-11-14**] 08:18AM BLOOD [**Doctor First Name **]-NEGATIVE [**2106-11-14**] 10:40PM BLOOD RheuFac-<3 [**2106-11-15**] 04:27PM BLOOD [**Doctor First Name **]-NEGATIVE Cntromr-NEGATIVE [**2106-11-21**] 07:05AM BLOOD CRP-21.8* [**2106-11-16**] 01:48AM BLOOD HIV Ab-NEGATIVE [**2106-11-15**] 12:05PM BLOOD HCV Ab-NEGATIVE [**2106-11-15**] 10:50PM BLOOD Type-MIX Temp-36.9 pH-7.36 [**2106-11-15**] 10:50PM BLOOD Hgb-14.5 calcHCT-44 O2 Sat-59 Urine [**2106-11-15**] 02:49AM URINE Color-DKAMBER Appear-Cloudy Sp [**Last Name (un) **]-1.022 [**2106-11-15**] 02:49AM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM [**2106-11-15**] 12:53PM URINE RBC->50 WBC-[**6-23**]* Bacteri-OCC Yeast-NONE Epi-[**3-18**] [**2106-11-16**] 11:27AM URINE CastHy-8* [**2106-11-15**] 12:53PM URINE Hours-RANDOM Creat-130 TotProt-69 Prot/Cr-0.5* [**2106-11-16**] 11:27AM URINE Osmolal-329 [**2106-11-15**] 12:53PM URINE U-PEP-NEGATIVE F Discharge Labs [**2106-11-24**] 06:50AM BLOOD WBC-15.8* RBC-4.92 Hgb-14.1 Hct-45.3 MCV-92 MCH-28.6 MCHC-31.1 RDW-22.4* Plt Ct-400 [**2106-11-21**] 07:05AM BLOOD Neuts-85.6* Lymphs-8.1* Monos-3.5 Eos-2.0 Baso-0.7 [**2106-11-24**] 06:50AM BLOOD Plt Ct-400 [**2106-11-24**] 06:50AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.2* [**2106-11-24**] 06:50AM BLOOD Glucose-86 UreaN-37* Creat-1.2* Na-143 K-4.3 Cl-99 HCO3-33* AnGap-15 [**2106-11-23**] 08:50AM BLOOD ALT-17 AST-27 LD(LDH)-334* AlkPhos-94 TotBili-1.0 [**2106-11-24**] 06:50AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.0 [**2106-11-23**] 08:50AM BLOOD Cholest-145 [**2106-11-23**] 08:50AM BLOOD Triglyc-146 HDL-22 CHOL/HD-6.6 LDLcalc-94 [**2106-11-22**] 06:20AM BLOOD ESR-0 Cultures [**2106-11-22**] 2:29 pm URINE Source: Catheter. **FINAL REPORT [**2106-11-23**]** URINE CULTURE (Final [**2106-11-23**]): YEAST. >100,000 ORGANISMS/ML.. Other Investigations Cardiac Echo [**2106-11-15**] IMPRESSION: Severe right ventricular cavity enlargement with free wall hypokinesis. Severe pulmonary artery systolic hypertension. Mild symmetric left ventricular hypertrophy with preserved regional/global systolic function. These findings are suggestive of a primary pulmonary process(e.g., PPH, OSA, chronic pulmonary embolism, bronchospasm, etc.). Cardiac Echo [**2106-11-16**] IMPRESSION: Cor pulmonale; no intracardiac shunt. Compared with the prior study (images reviewed) of [**2106-11-14**], no obvious change. Cardiac Catheterization [**2106-11-15**] COMMENTS: 1. Resting hemodynamics revealed elevated right sided filling pressures with RVEDP of 22 mm Hg. There was severe pulmonary artery hypertension with PASP of 84 mm Hg. There was no significant change in these pressures after 10 minutes of inhaled 100% FIO2 or 10 minutes of inhaled 100% FIO2 plus NO. Left sided filling pressures were normal with mean PCW of 15 mmHg. 2. Procedure performed from the right internal jugular vein without complications. A Swann-Ganz catheter was left in place. FINAL DIAGNOSIS: 1. Severe pulmonary artery hypertension and elevated right sided pressures. 2. No response to inhaled 100% oxygen or NO. 3. Normal PCW pressure. Abdominal Ultrasound [**2106-11-18**] IMPRESSION: 1. Hepatosplenomegaly in the setting of normal hepatic echogenicity and architecture in combination with enlarged hepatic veins; the constellation of findings can be seen in the right-sided heart failure. 2. Non-obstructing renal calculi. 3. Right pleural effusion. CT chest, without contrast [**2106-11-15**] IMPRESSION: 1)Marked enlargement of the pulmonary artery suggests pulmonary arterial hypertension. 2)Diffuse mild dilatation of the ascending aorta at 43 mm. 3)Moderately large right and small left dependent pleural effusions. 4)Diffuse air trapping is consistent with small airways obstruction. 5) Rounded atelectasis in the right upper lobe with atelectasis in the middle and right lower lobe. 6)Diffuse coronary artery and valvular calcification. 7)Periportal edema, splenomegaly and probable varices are incompletely assessed and in the presence of ascites suggests portal hypertension. Anasarca in the subcutaneous soft tissues, may be due to hypoalbuminemia. Chest x-ray [**2106-11-22**] COMPARISON: [**2106-11-17**]; CT from [**2106-11-15**]. CHEST, TWO VIEWS: A Swan-Ganz catheter has been removed. A right internal jugular sheath is seen with tip in the superior right atrium. Tent-like configuration of the heart is compatible with persistent pericardial effusion, progressed. The prominence in the hilar regions are consistent with reported history of pulmonary artery hypertension. The aorta is again calcified and unfolded. Small bilateral pleural effusions, greater on the right persists. Retrocardiac opacification could represent atelectasis or, less lkely, infection. No overt pulmonary edema. Brief Hospital Course: Mrs. [**Known lastname **] is a 79 year-old woman with hypertension and polycythemia [**Doctor First Name **], transferred to [**Hospital1 18**] for workup of new pulmonary hypertension with RV failure. Although the etiology is unclear, it is possible that several disease processes are at work: Polycythemia is sometimes associated with pulmonary hypertension, however this degree of pulmonary hypertension would be atypical if not impossible. Given positive D-dimer and coagulopathy at admission along with negative CTA, an alternative explanation would include microembolic or thrombotic disease with the pulmonary vasculature that is sufficiently diffuse to avoid detection on CT. This is also consistent with decreased response to oxygen and nitric oxide on right heart pressure as measured by Swan-Ganz catheter. Some prelinary work-up for vasculitus and systemic disease was negative. Chronologically, Mrs. [**Known lastname **] was stable on the medical floor, went to the ICU for diuresis, close monitoring and determination of pulmonary arterial pressure, including in the context of increased oxygen, nitric oxide and sildenafil. Sildenafil was found to be somewhat helpful. She was stable on nasal cannula and transferred back to the floor for monitoring prior to discharge. Issues of importance during the stay include the following: Pulmonary hypertension and RV failure. Newly diagnosed, with symptoms x 1 month, however RV dilation and hypertropy suggest longer chronicity. Unclear etiology. Abdominal u/s without comment on hepato-pulmonary shunt. No evidence of intracardiac shunt or LV failure given negative ECHO bubble, no intrapulmonary shunt or PE evidenced on CTA chest. Negative [**Doctor First Name **], ANCA, anti centromere as well as SPEP and UPEP,TSH slightly high but free T4 normal, awaiting anti-scl 70. HIV negative. Swan catheter placed in cath lab prior to arrival, with persistantly elevated PAP and no response to NO. Initially diuresed with a lasix gtt and placed on a dobutamine gtt with overall improvement in cardiac function, however PAP remained elevated in the 80s/30s. Sildennofil was started and goal dose of 20mg TID achieved within one day. Mild decrease in PAP to 60s/20s, dobutamine stopped and swan removed. Lasix stopped and switched to PO. Hypoxemia. Likely explained by VQ mismatch in setting of severe pulmonary hypertension; also has bilateral effusions and atelectasis. S/p antibiotic course for CAP. Respiratory status improved with aggressive diuresis and maintained on daily lasix. ECHO negative for ASD or evidence of R->L shunting. Persistant O2 sats in low 90s on NRB, and high 80s on NC but without subjective SOB. Acute on chronic renal failure Baseline reportedly ~1.0, has been in the 1.2-1.5 range here and at OSH. Mild proteinuria and abnormal microscopy with RBCs and WBCs. Did receive contrast at OSH (though elevation present prior to scan). Acute change differential includes hypoperfusion from heart failure, ATN from a number of sources (which was thought to be the case at OSH). Total LOS net negative over 7L. Relatively stable since admission. Polycythemia [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is seen by outside Hematologist, Dr [**Last Name (STitle) 65126**], who maintains her on hydroxyurea be given at 500 mg QD; if Hct contiune to rise on QD dosing recommend increase to [**Hospital1 **]. Was also continued on ASA. Hepatosplenomegaly Also with ascites - resolved with diuresis. Likley from R heart failure. INR elevated to 1.5 at admission without explanation. Albumin 3.6 (though 2.9 on admission). Transaminases normal. Hepatitis panel negative, Fe studies normal. Hypertension At baseline takes nifedipine 30 mg CR and toprol XL 50 mg, held in setting of low BP. Not restarted given continued normal blood pressure. Morbilliform Rash Developed in pm of [**2106-11-20**]. Is pruritic. Pt states she developed this the last time she got IV contrast, and she had a CTA at OSH. Reviewed meds, and consulted Dermatology: Lasix and sildenafil unlikely offenders, but most likely is from contrast given pt's known history. Written for medications as described in the medication list. Dispostion Unsuitable for palliation at home given care for daughter (see social history). Desired rehabilitation and deferment of decision about Hospice. Her son and daughter in law will care for her daughter. Medications on Admission: ASA 81 mg QD Toprol XL 50 mg Hydrea 500 mg [**Hospital1 **] on M-W-F, QD other days Nifedipine ER 30 mg QD Recently stopped taking HCTZ (2 weeks ago due to "dehydration") Possibly taking terazosin Discharge Medications: 1. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Please continue as prophylaxis for DVT while not ambulatory. 4. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Every other day. 6. Miconazole Nitrate 2 % Powder Sig: One (1) Topical twice a day for 7 days: Please apply to groin for relief of yeast infection. . 7. Cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: For skin rash. 8. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days: For skin rash. . 9. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Topical twice a day for 7 days: For skin rash. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Primary Diagnoses: (Severe) idiopathic pulmonary hypertension. Secondary Diagnoses: Systemic hypertension (controlled) Polycythemia [**Doctor First Name **] (controlled) Discharge Condition: Stable. Discharge Instructions: You were transferred to [**Hospital1 18**] for management of shortness of breath and difficulty breathing in the context of severe pulmonary hypertension (high blood pressure within the vessels supplying your lungs). You initally came to the medicine [**Hospital1 **], but were next care for in the intensive care unit where further fluid could be removed and the pressure within your lung blood vessels monitored while various drugs were trialled. This resulted in the determination of a new medication regimen that now includes sildenafil (Viagra) that acts to dilate and reduce pressure within lung blood vessels. In the intensive care unit on these medications your breathing improved and you returned to the Medicine [**Hospital1 **]. There you were stable on about 6 liters of oxygen per minute delivered by nasal cannulae. This will likely be your new baseline oxygen requirement. We now feel that you are stable enough to go to rehabilitation. Please take your medications as directed: - We have added sildenafil (Viagra) and furosemide (Lasix) to your regimen - We have added some medications to help with the rash that you developed. As you suggested, we also think that this rash is likely due to either contrast media or is a contact dermatitis. We think that it is very unlikely that it is due to your new medications. Please attend all follow-up appointments as listed below. If you experience increasing shortness of breath, require more oxygen, chest pain, or any other concerning symptom, please return to the hospital. It will be very important that you come to the hospital if you contract the common cold or another illness, because your capacity to compensate for any worsening of your breathing will be very limited. Followup Instructions: Test for consideration post-discharge: Scleroderma Antibody. Please make an appointment to see your hematologist, Dr. [**Last Name (STitle) 65126**]. He will be sent a copy of your discharge summary. We suggest that you visit your Primary Care Physician upon leaving rehabilitation: [**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 41132**] [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]

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icd9cm

[ [ [] ] ]

[ "89.64", "37.21", "00.12" ]

icd9pcs

[ [ [] ] ]

18328, 18405

12724, 17193

375, 430

18620, 18630

6989, 10861

20428, 20926

4774, 5071

17441, 18305

18426, 18490

17219, 17418

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5086, 5086

18511, 18599

239, 337

6095, 6970

460, 3649

5100, 6079

3671, 4150

4166, 4758

18,982

100,522

3214

Discharge summary

report

Admission Date: [**2139-7-22**] Discharge Date: [**2139-8-6**] Date of Birth: [**2069-8-5**] Sex: F Service: MEDICINE Allergies: Captopril / Neurontin / Shellfish / Nsaids / Promethazine / Valproate Sodium Attending:[**First Name3 (LF) 1990**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 69 year old female with history of DM, COPD, ventilator dependent, hypertension, rectus sheath hematoma [**6-/2139**] who was brought to [**Hospital 8**] Hospital with altered mental status and abdominal pain. Abdominal CT was done at outside hospital which showed partial SBO. CT head at OSH was negative for intracranial process. She was transferred to [**Hospital1 18**] for further work up given her recent admission here. . In our ED, vital signs were BP 115/50, HR 90, RR 16, O2 sat 100% on trach collar. Labs notable for positive UA, WBC count 12.9 (73% neutrophils), creatinine 6.2 up from last d/c 4.2, troponin 1.51 (CKMB normal), hct 30.2 (up from b/l of 24-25 last admission). Blood and urine cultures sent from ED. She was given 1L NS, Cipro 400mg x1, Aspirin 600mg PR, Tylenol 1g. She was also given ?????? amp D50 for low BG. She was seen by surgery for evaluation of partial SBO. Decision was for no surgical intervention but NGT was placed. The patient was recently admitted to the [**Hospital Unit Name 153**] on [**4-25**] with urosepsis treated with Linezolid, MRSA RLL PNA treated with Ceftazadime and Cipro. Also noted to have RUE edema last admission, UE US was negative for DVT. . ROS: Patient unable to provide . Past Medical History: 1. Recent admission [**6-/2139**] -ICU for MRSA and highly resistant pseudomonal pneumonias. Sputum culture data indicates multiple colonies of pseudomonas without overlapping sensitivities -Rectal sheath hematoma, s/p embolization in [**4-/2139**] -Tracheostomy placed for chronic ventilator dependence 2. Diabetes Mellitus type 2 3. GERD 4. COPD -On home Oxygen 5. Obstructive sleep apnea 6. Depression 7. HTN 8. s/p TAH 9. s/p PE in [**2135**], -with IVC filter, -not anticoagulated after developed abdominal wall hematoma 10. Focal seizures 11. Diastolic CHF, -ECHO [**6-17**] EF >55%, mild pulm artery hypertension 12. s/p CVA x 2 with right facial droop 13. CKD -baseline Cr 1.3-1.5 . Surgical History: s/p coil embo of L inf epigastric ([**4-18**] [**Doctor Last Name **]) s/p hematoma evacuation and debridement ([**Date range (1) 15051**] [**Doctor Last Name **], [**Doctor Last Name **], [**Doctor Last Name **]) s/p repair incarc ventral hernia repair c mesh ([**6-17**] [**Doctor Last Name **]) s/p ex lap, LOA, omentectomy ([**6-14**] [**Doctor Last Name **]) ex-lap, ventral hernia repair, rigid sig ([**4-14**] [**Doctor Last Name **]) for CDiff. Social History: Resides at [**Hospital1 **], chronically ventilator dependent since her last hospitalization. Retired seamstress, waitress. Daughter [**Name (NI) **] is HCP. Pt was a former smoker, 3ppd x 30 years, quit in [**2128**], per the records pt has a distant history of ETOH abuse ([**2091**]), but no current ETOH or drug use. . . Family History: FH:Malignancy (pancreas, larynx), CAD, HTN, DM, asthma; daughter recently diagnosed with leukemia Physical Exam: General Appearance: No acute distress, Overweight / Obese, No(t) Thin, Not Anxious, Not Diaphoretic Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale, No(t) Sclera edema Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No Endotracheal tube, No NG tube, No OG tube, no teeth Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), HD line in place on right upper chest Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : anterior and lateral, No Crackles : , No Wheezes : ) Abdominal: Soft, Non-tender, Bowel sounds present, Obese, tender in right flank/lateral mid right back Extremities: 2+ peripheral edema Musculoskeletal: Unable to stand Skin: two dressed wounds on right leg. C/D/I dressings and non-tender around area Neurologic: Somnolent but arousable, follows simple commands, A&Ox1 Guaiac: negative in ED Pertinent Results: EKG: Sinus arrhythmia, left axis deviation, nl intervals, Q waves II, III, TWF III, avF, I, aVL, V1-V3, no ST changes. Compared to EKG dated [**6-27**] new Q wave in aVF, TWF in V1-V3. . [**2139-7-22**] 11:52AM WBC-12.0* RBC-3.09* HGB-9.0* HCT-27.7* MCV-90 MCH-29.1 MCHC-32.5 RDW-17.3* [**2139-7-22**] 11:52AM PLT COUNT-465* [**2139-7-22**] 10:29AM GLUCOSE-66* UREA N-53* CREAT-6.3* SODIUM-138 POTASSIUM-2.7* CHLORIDE-108 TOTAL CO2-15* ANION GAP-18 [**2139-7-22**] 10:29AM CK(CPK)-328* [**2139-7-22**] 10:29AM CK-MB-12* MB INDX-3.7 cTropnT-1.42* [**2139-7-22**] 10:29AM CALCIUM-8.8 PHOSPHATE-5.9* MAGNESIUM-1.8 [**2139-7-22**] 10:29AM PT-14.8* PTT-30.4 INR(PT)-1.3* [**2139-7-22**] 04:32AM LACTATE-1.3 K+-3.6 [**2139-7-22**] 04:15AM GLUCOSE-53* UREA N-55* CREAT-6.2*# SODIUM-141 POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-15* ANION GAP-23* [**2139-7-22**] 06:08PM GLUCOSE-80 UREA N-54* CREAT-6.1* SODIUM-139 POTASSIUM-3.3 CHLORIDE-109* TOTAL CO2-14* ANION GAP-19 [**2139-7-22**] 06:08PM CK(CPK)-424* [**2139-7-22**] 06:08PM CK-MB-14* MB INDX-3.3 cTropnT-1.30* [**2139-7-22**] 06:08PM CALCIUM-8.8 PHOSPHATE-6.3* MAGNESIUM-1.6 [**2139-7-22**] 04:15AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.012 [**2139-7-22**] 04:15AM URINE BLOOD-LG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2139-7-22**] 04:15AM URINE RBC-[**12-31**]* WBC->50 BACTERIA-MANY YEAST-MOD EPI-[**4-15**] RENAL EPI-0-2 [**2139-7-22**] 04:15AM URINE CA OXAL-MOD . Micro: [**2139-7-22**] 4:15 am BLOOD CULTURE Blood Culture, Routine (Pending): [**2139-7-22**] 4:15 am URINE Site: CATHETER URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. . TTE [**7-22**] LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. No resting LVOT gradient. AORTA: Normal aortic diameter at the sinus level. AORTIC VALVE: Normal aortic valve leaflets. No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild mitral annular calcification. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA systolic hypertension. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Right pleural effusion. Conclusions The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2139-6-29**], moderate pulmonary artery systolic pressure is now identified. Biventriclar systolic function is similar. Brief Hospital Course: # Altered mental status: On admission patient somnolent but responding to commands. According to team she is only slightly more somnolent than her prior baseline. Head CT negative for evidence of bleed. AMS likely due to infection and Acute renal failure. . #. Acute on Chronic Renal Failure - Baseline creatinine 1.5-1.8 prior to last admission, however on last discharge Cr was 4.2 (felt to be her new baseline secondary to ATN. On admission the pt was found to have a Cr of 6.2. She received 1L NS in ED, and additional 1-2L NS bolus in ICU with little subsequent improvement in renal function. Urine lytes obtained with FeNa of 9%. Renal team consulted after as the family had expressed a desire to proceed with aggressive care (dialysis). After a family meeting with extensive discussion about the patients multiorgan system failure that continued to worsen despite medical management, the family and medical team agreed that dialysis was not indicated and chose to make patient CMO. . #. Chronic Respiratory Failure - s/p trach 03/[**2139**]. Evidence of COPD exacerbation with expiratory wheezes and prolonged expiratory phase on [**7-24**]. Prednisone increased to 60 mg po qday and nebulized albuterol scheduled. The patient required support with mechanical ventilation and her prednisone was changed to a solu-medrol taper. Current dose 30mg daily with plan to taper Q4 days. The pt's respiratory status improved with increased steroids and she was weaned from the ventilator and continued on trach collar. The family has agreed to hold any further mechanical ventilation should it become necessary and to focus on comfort. . # Lower GI bleed - The patient had an episode of significant lower gi bleeding in setting of coagulopathy related to poor nutritional status. Given the patient's worsening multiorgan system failure the medical team and family agreed to hold on any blood transfusions and possible procedures which may lead to discomfort. . # UTI: The patient has a history of multiple UTIs with highly resistant organisms. Recently completed course of linezolid and cipro for VRE and cefepime resistant nonfermenter nonpseudomonas. On admission pt was found to have a positive UA with mod leuk, pos nit. Elevated WBC count, currently afebrile. BP stable. Lactate within normal limits. Given previous culture data the pt was started on linezolid and cipro pending repeat culture. Linezolid discontinued [**7-24**] after culture grew gram negative rods. Final speciation and sensitivities demonstrated resistance to cipro and the patient was transitioned to meropenem. 7 day course of meropenem completed on [**7-30**]. . # Small bowel obstruction/ileus: Partial SBO noted on CT scan from outside hospital. She was seen by surgery in the ED - nonoperative candidate, NG tube placed. Abdominal exam notable for distension, nontender, diminished BS. Plan to continue serial abdominal exams, continue NGT and manage conservatively. Improved quickly, had large bowel movements the second day of admission. . # NSTEMI: Troponin of 1.51 on admission to ED in setting of increased creatinine. Case discussed with cardiology who did not feel intervention necessary at this time. At this point timing of event is unclear. [**Name2 (NI) **] echo on [**6-29**] showed EF 50-55%. Repeat TTE unchanged from prior. continued medical management with aspirin, beta blocker, statin. Aspirin discontinued as pt developed lower GI bleed. . # Goals of Care: Dr. [**Last Name (STitle) **], primary physician, [**Name10 (NameIs) **] active in discussion about goals of care with family, as recent hospitalizations have been very complicated. Intially the family had requested consideration of continued aggressive care including mechanical ventilation, PEG placement and dialysis if necessary. However the patient continued to worsen despite maximal medical therapy and given overall poor prognosis due to multi-organ system failure the family decided to hold on dialysis, reinstating mechanical ventilation. She was transferred from the ICU to the medical floor with the goal on maintaining comfort care only. . She was maintained on morphine IV, titrated to comfort. She died peacefully at 1900 hours on [**2139-8-6**]. Her son was present, as was the attending physician. # PPx: PPI, heparin subq, bowel regimen . # Code: DNR/DNI, CMO Medications on Admission: Meds: (per OMR) Atorvastatin 20mg daily Acetaminophen 160mg/5mL q8H PRN Albuterol NEB q4H PRN Aspirin 81mg daily Diltiazem 90mg QID Colace 100mg [**Hospital1 **] Fentanyl 50mcg patch q72h Fluticasone 50mcg [**2-11**] sprays daily Heparin subq Hydralazine 25mg q6H Ipratroprium 17mcg 2 puffs QID Reglan 5mg tab TID w/ meals, hs Metoprolol 50mg TID Prednisone 2.5mg tab daily Protonix 40mg daily Multivitamin daily Nystatin suspension Oxcarbazepine 300mg [**Hospital1 **] Percocet 5/325 q6H prn pain Senna 8.6mg tab [**Hospital1 **] prn Advair diskus 250/50 IH [**Hospital1 **] Insulin SS Nortriptyline 50mg hs Sucralfate 1g QID Discharge Disposition: Expired Discharge Diagnosis: COPD ARF Discharge Condition: expired Discharge Instructions: Expired Followup Instructions: Expired

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icd9cm

[ [ [] ] ]

[ "99.29", "96.07", "00.14", "96.72" ]

icd9pcs

[ [ [] ] ]

12771, 12780

7740, 7750

357, 363

12833, 12843

4351, 5919

12899, 12910

3218, 3317

12801, 12812

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296, 319

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7765, 12094

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2874, 3202

5,812

106,277

52828

Discharge summary

report

Admission Date: [**2183-10-15**] Discharge Date: [**2183-10-18**] Service: MEDICINE Allergies: Aspirin / Nsaids Attending:[**First Name3 (LF) 297**] Chief Complaint: Cc:[**CC Contact Info 108953**] Major Surgical or Invasive Procedure: ORIF History of Present Illness: . HPI: 83M with PMH significant for CAD s/p CABG in [**2169**], MVR in [**2178**], CHF, and COPD, presents to the ED after experiencing R hip pain following a fall. He states that he was bending over, and became dizzy with blurred visual after standing up abruptly. He fell on his side. He denies LOC or head trauma. Films taken at his rehab ([**Hospital3 **]) demonstrated R femoral neck fracture, and he was sent to [**Hospital1 **] ED. Of note, CXR at rehab on [**2183-10-10**] suggested evidence of RLL and LUL infiltrate, and was started on Levofloxacin 500mg PO qD x 10 days. . In the ED, initial VS were BP 134/69, HR 71, RR 18, SaO2 95% 2L NC. Hip films confirmed R femoral neck fracture. Initial labs significant for INR 5.4, on coumadin. CT head showed no evidence of hemorrhage. He was seen by orthopedic surgery, who recommended admission to medicine service for medical optimization prior to likely ORIF surgery [**10-16**]. Mr. [**Known lastname **] also complained of mild flank pain. A UA was ordered once he reached the floor. Past Medical History: . PMH: CAD: s/p CABG [**2169**] s/p MVR [**2178**] s/p PPM, placed [**2178**] at time of valve surgery, V-paced CHF - EF 40% on [**2178**] TTE Pulmonary HTN by [**2178**] cath Tracheomalacia following prolonged intubation Restrictive lung disease with PFTs c/w neuromuscular disease, possibly [**3-6**] diaphragmatic damage from previous cardiac surgeries h/o Endocarditis h/o colon CA [**92**] yrs ago, resected BPH h/o GIB Social History: SOCIAL HISTORY: The patient denies history of intravenous drug use or ethanol use. He has greater than 33 pack year history of tobacco use, discontinued [**2178**]. His wife recently died. His daughter died emphysema secondary to alpha I antitrypsin deficiency. The patient retired five years ago as a [**Hospital **]medical Engineer. . Family History: FAMILY HISTORY: Father died of an MI at age 82, mother died of cancer at age 69. He is a carrier of alpha I antitrypsin gene. . Physical Exam: . PE: TL 97.1F BP: 135/60, HR: 79, RR: 30, SaO2: 90% 2L (prior to neb treatment). Gen: Ill appearing gentleman, lying in bed, NAD HEENT: PERRL, sclerae anicteric, OP clear Neck: Supple, no LAD, previous orifice from trach visible CV: RRR, II/VI SEM LUSB, mech valve click, +S3 Chest: Crackles R base, no w/r Abd: Soft, NT/ND, +BS Extr: R leg externally rotated, 2+ DPs bilaterally Neuro: A&Ox3 Pertinent Results: ECG [**2183-10-15**]: V-paced at 84bpm [**2183-10-18**]: Atrial fibrillation. Right axis deviation. Compared to the previous tracing of [**2183-10-15**] there is deep T wave inversion in leads II, III, aVF and V3-V6 consistent with active ischemic process. Rule out infarction. Clinical correlation is suggested. . Imaging: CXR [**2183-10-15**]: Cardiomegaly, s/p CABG and MVR, dual-lead PPM. Elevation of right hemidiaphragm with volume loss and interstitial opacities c/w CHF. Also focal opactiy over R lung zone and fluid in fissure, could be c/w PNA. Small effusions, no PTX. . Head CT [**2183-10-15**]: FINDINGS: There is no evidence of intra- or extra-axial hemorrhage. The ventricles, cisterns and sulci are mildly prominent, consistent with age-related involutional changes. Multiple patchy areas of hypodensity in the white matter consistent with chronic small vessel ischemic disease, and include hypodensity which is more prominent, but unchanged within the left subinsular cortex. A bony protuberance about the ossicle may represent an osteoma which is unchanged or merely a congenital variant. IMPRESSION: 1. No evidence of intracranial hemorrhage. 2. Evidence of age related involutional changes and white matter disease, unchanged. . Hip films: There is a comminuted right femoral neck fracture. Subtle angulation is present. No other fracture is identified. IMPRESSION: Right femur fracture. . [**3-9**] PFTs: FVC 1.98L (51% predicted) FEV1 1.25L (51% predicted) FEV1/FVC: 63% (100% predicted) . [**1-2**] TTE: EF 40%. The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed secondary to severe inferior and posterior hypokinesis and mild hypokinesis of the rest of the left ventricle; the ejection fraction is approximately 40 percent. There is moderate global right ventricular free wall hypokinesis. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is no significant aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. A mitral valve annuloplasty ring is present. There is moderate thickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. . [**7-3**] Cath: (prior to MVR) 1. Coronary angiography in this right dominant system revealed three vessel CAD. The left main coronary artery had a 40% distal stenosis. The LAD had an 80% mid-vessel stenosis, and there was competitive flow from the LIMA in the distal LAD. The ramus intermedius branch had a 40% proximal stenosis. The left circumflex artery was totally occluded proximally. The RCA had a diffusely diseased proximal segment and was totally occluded after the first acute marginal branch. 2. Graft arteriography revealed a patent LIMA to the LAD. The SVG to the rPDA was widely patent, and the rPDA distal to the anastamosis had a 70% stenosis. The SVG to the obtuse marginal branch was ectatic but without significant stenosis and the marginal branch distal to the anastamosis supplied collaterals to the right postero-lateral branch. 3. Resting hemodynamic measurements revealed severe pulmonary hypertension witha PA systolic pressure of 92 mmHg. There was increased right and left sided filling pressures with a mean RA pressure of 16 mmHg, a mean PCWP of 28 mmHg and an LVEDP of 22 mmHg. The cardiac index was preserved at 2.3 L/min/m2. 4. Left ventriculography revealed global hypokinesis with posterobasal wall akinesis and moderate-to-severe (3+) mitral regurgitation. The calculated LVEF was 45%. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent LIMA and SVGs. 3. Moderate-to-severe (3+) mitral regurgitation. 4. Mild systolic ventricular dysfunction. 5. Severe pulmonary hypertension [**2183-10-15**] 06:58AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2183-10-15**] 06:05AM CALCIUM-8.8 PHOSPHATE-2.6* MAGNESIUM-2.3 [**2183-10-15**] 06:05AM WBC-5.4 RBC-3.18* HGB-10.2* HCT-30.2* MCV-95 MCH-32.2* MCHC-33.9 RDW-16.7* [**2183-10-15**] 06:05AM PT-43.8* PTT-37.1* INR(PT)-5.0* [**2183-10-15**] 01:30AM GLUCOSE-90 UREA N-28* CREAT-1.1 SODIUM-138 POTASSIUM-4.8 CHLORIDE-96 TOTAL CO2-35* ANION GAP-12 [**2183-10-15**] 01:30AM CK(CPK)-39 [**2183-10-15**] 01:30AM cTropnT-0.02* [**2183-10-15**] 01:30AM CALCIUM-8.9 PHOSPHATE-2.8 MAGNESIUM-2.2 [**2183-10-15**] 01:30AM WBC-6.3# RBC-3.33* HGB-10.7* HCT-31.6* MCV-95 MCH-32.3* MCHC-34.1 RDW-16.5* [**2183-10-15**] 01:30AM PT-46.7* PTT-37.4* INR(PT)-5.4* Brief Hospital Course: Pt. was admitted for optimization of medical status prior to operation for hip fx. stable until early [**10-17**] around 12:oo am when began desatting to the high 80s on 2L NC. Vital signs o/w at the time: T 97.3 BPs 90s-100s/30s-60s, HR 60s-70s, rr in the high 20s. Pt was also noted to be increasingly somnolent and unresponsive. Pt placed on 100% FM with improvement of sats. He had been given MS contin 45 mg at 11 am the day prior and was therefore given narcan 0.2 mg X1 and narcan 0.4 mg X1 several hours later. He was given lasix 10 mg IV X3 o/n. Mental status improved somewhat with the early dose of narcan. CXR checked at the onset of the pt's change in status demonstrated worsened bibasilar pna. ABG trend o/n was as follows: 12:20 am 7.33/68/70 4:00 am 7.23/90/65 6:00 am 7.27/79/60 At time of MICU eval ABG was checked and demonstrated 7.05/139/125. Given worsening respiratory status pt transferred to the unit. Code status confirmed with family to be DNR/DNI. HCP felt that [**Name (NI) 108954**] would be an in-line with the pt's wishes. Pt. EKG showed new Afib with ST changes worrisome for ischemia and trop leak without elevation of CK in context of rapidly progressive ARF. He was given trial of [**Name (NI) 108954**] overnight without much improvement of MS. In discussion with pt.'s family, it was decided to choose comfort care interventions. He was placed on morphine drip and passed [**10-18**] with family around Medications on Admission: Meds: Lopressor 25mg PO bid Prilosec 20mg PO qD Coumadin 3mg 5d/wk, 2mg 2d/wk Azmacort 2 puffs tid levaquin ([**10-19**] last dose - ?pnemonia) lasix 10mg PO qD lisinopril 5mg PO qD Albuterol neb [**Hospital1 **] Atrovent neb [**Hospital1 **] Combivent 2 puffs qid wellbutrin XL 150mg PO qD Dulcolax 10mg PR prn Remeron 7.5mg PO qHS . Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: hypercarbic respiratory failure CAD: s/p CABG [**2169**] Atrial fibrillation Acute Renal Failure Hip fracture CHF PNA Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none

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Discharge summary

report+addendum+addendum

Admission Date: [**2142-11-18**] Discharge Date: [**2142-12-1**] Service: CHIEF COMPLAINT: Transferred from [**Hospital1 **] for elevated liver function tests. HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old woman with complicated recent medical history beginning with cholecystectomy transferred to [**Hospital1 188**] from [**Hospital1 **] for evaluation of elevated liver function tests. The patient had a fall on [**3-29**] leading to a hip fracture and repaired, but "migrated" and she had a hemiarthroplasty. This was complicated by wound infection which grew stenotrophomonas and MRSA. Removal of hardware on [**2142-10-10**]. She was getting ready to go to rehab, but be elevated. A CT Scan of the abdomen showed sludge in the gallbladder. She had an ERCP at [**Hospital1 190**] as an outpatient on [**11-9**] which showed sludge positive and she had a sphincterotomy. There was no evidence of cholangitis. She had an open cholecystectomy and J tube placement at [**Hospital1 **] on [**11-12**]. Pathology showed "chronic cholecystitis". The patient with persistent fevers and elevated LFTs sent back to [**Hospital1 188**] for evaluation of ERCP. PAST MEDICAL HISTORY: 1. Status post hip fracture [**3-29**] going to one left open reduction internal fixation on [**8-29**]. Hemiarthroplasty complicated by wound infection,peritonitis [**9-29**], also in urine. Sensitivities only Imipenem status post removal of the hardware [**2142-10-9**]. 2. Stage III decubitus. 3. Hyperlipidemia. 4. Osteoarthritis. 5. Obesity. 6. Hypertension. 7. MRSA in hip wound, question Clostridium difficile treated, but tox negative. 8. Hickman [**2142-10-24**] for TPN removed [**11-9**]. Another Hickman [**11-7**] for TPN, removed [**11-16**]. 9. Status post ERCP [**11-9**] with sludge and sphincterotomy. 10. Status post cholecystectomy and J tube [**11-12**]. MEDICATIONS: 1. Tobramycin 80 b.i.d. 2. Vancomycin 1 gram times one. 3. Metoprolol 5 six times a day IV. 4. Vancomycin 125 per J tube q.i.d. 5. Free water per J tube 20 six times a day. 6. Accuzyme. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Lives with her family in [**Location (un) 3307**]. No alcohol, no tobacco. PHYSICAL EXAMINATION: Temperature 103.4 F, heart rate 145, blood pressure 120/70, saturation 98% on room air, respirations 16 Gas 7.49, 39, 75 with a lactate of 4.7 and glucose of 142. In general obese jaundiced woman not interacting, moaning. Head, eyes, ears, nose and throat: Jaundiced sclerae. Mucous membranes dry. Neck with prominent jaw muscles. Lungs clear. Heart: Regular tachycardia, S1, S2, no murmurs, rubs, or gallops. Abdomen: Positive bowel sounds, J tube intact, nondistended to the right upper quadrant. Extremities: 1+ pulses, no edema. Breakdown of the left wrist, stage III decubiti over the coccyx with yellow fibrinous material. Neuro: Moaning, not interacting well. LABORATORY: At [**Hospital6 **], white count from 21.6 to 16.8, hematocrit 35.4 to 33.9 to 34.4, platelets 152 to 116 to 87 to 79. Differential: 76 polys, 18 lymphs, 5 monos. PT 49, INR 1.2, PTT 34.8. Chem-7: Sodium 145, potassium 3.3, chloride 103, bicarbonate 33, BUN 43, creatinine 1.0, glucose 152, calcium 8, albumin 2.2, bilirubin 15.7, direct 13.7. Alkaline phosphatase 529, ALT 140, AST 97. ESR on [**11-14**] was 8, CRP 5.1 on 12.18. Amylase 50, cortisone on 12.16 was 32. Gas: 7.4, 743, 84 on three liters. Echo on [**2142-10-10**] limited, mild LVH, ejection fraction 70, mild thick MV micro. Blood from [**11-16**], [**11-13**] and [**11-12**] with no growth to date. Urine from [**11-16**] 4000 candidus. Stool [**11-15**] Clostridium difficile negative. CTI minus of abdomen [**11-16**] reported decreased pleural effusions, gallbladder out, J tube in, positive ascites. Ultrasound [**11-15**] common bile duct 4 mm, no intrahepatic ductal dilation. Bone scan on [**11-5**] only left femur with increased uptake. Peritoneal fluid [**11-12**] negative. DQ [**11-15**] with rare klebsiella, sensitive to Ceftriaxone, Augmentin, Cefepime. Resistant to Gentamycin, Cipro, Levo and Tobramycin. LABORATORY DATA ON ADMISSION: White count 25.6, hematocrit 38.1, platelets 100. Coag INR 1.3, PT 14.2, PTT 29.8, polys 57, 21 bands, 13 lymphs, 1 mono. Lactate 4.7. Glucose 142, fibrinogen 232. Chem-7: Sodium 146, potassium 2.5, chloride 102, bicarbonate 28, BUN 38, creatinine 0.9, glucose 124, calcium 8.3, magnesium 1.9, phosphorus 2.5. Gas: 7.49, 39, 75. Chest x-ray showed opacifications in the left mid lung, elevated right hemidiaphragm, line tip in the right atrium, no pneumothorax. EKG: Sinus tachycardia at 130, normal axis and intervals, Q in III, no ST-T wave changes. No old for comparison. HOSPITAL COURSE: 1. RESPIRATORY: On [**11-18**], Anesthesia was called at 9 o'clock for elective intubation secondary to medical necessity. She was noted to have worsening oxygenation and esophageal balloon, measured pleural pressure at 1016 and it was felt that PEEP should be increased because it was likely a negative transpulmonary pressure without alveolar hypoventilation. With increased PEEP her oxygen imprved. The patient was treated for a small left lower lobe pneumonia. Oxygenation and ventilation were maintained followed ABGs. An A line was in place. The patient was fully weaned down to C-PAP pressure support of 10 and 5 on fio2 of 40% and remained stable. Was noted that her tidal volumes and oxygen saturations both dropped when the pressure support was dropped to 5. It was felt that given her mental status and secretions as well as her volume status, that she likely would not be able to be extubated in the near future, therefore there is a planned tracheostomy for [**2141-12-3**]. 2. INFECTIOUS DISEASE: Patient came in what appeared to be sepsis given her hypotension, fever, tachycardia and increased white count with left shift. She quickly required pressure support of her blood pressure. Given her tender right abdomen, elevated alkaline phosphatase and bilirubin as well as transaminases, it was felt that abdominal source was most likely, however other sources, in particular, hepatobiliary, however other sources such as her left hip and vascular, urinary, other GI or pulmonary, could not be ruled out. She was therefore started broad antibiotics and volume resuscitation. She was started on Vancomycin and Imipenem. Originally, she was seen by the Biliary Service and taken to ERCP to look for a possible source, but all that was found was previous sphincterotomy and mild nonspecific biliary dilation, previous cholecystectomy. No evidence of stones or sludge on balloon sweep. Cultures were drawn. It was considered to start the patient on anticoagulation, however she had blood stool so that was not done. Her blood pressure was supported with Levophed and Vasopressor as well as aggressive volume resuscitation. Neo-Synephrine was added and a cortisol stem test was performed and before results were done, Hydrocortisone stress doses were empirically added. On [**11-19**], a CT Scan of the abdomen was performed which showed consolidation left posterior lung base, tiny bilateral pleural effusions. Liver, spleen, adrenal, pancreas and kidneys unremarkable. There was a small amount of fluid surrounding the liver. There was a small amount of fluid around the spleen. No hydronephrosis. No nephrolithiasis. No gallbladder. Intraluminal bowel loop unremarkable, no free air. Her left lower quadrant sigmoid was mildly distended. Colon at level of splenic flexure, not completed distended and demonstrates mild bowel wall thickening and extended into the upper pelvis. Surgical wire around left proximal femur. Femur head is dislocated posteriorly and superiorly. Comminuted fracture of left femoral head. Fluid filled vestibular space and extends laterally into the soft tissue. Surgery was also consulted and followed the patient and given these findings, performed a rigid sigmoidoscopy. The patient had been started on Flagyl to cover presumptively for Clostridium difficile. Rigid sigmoidoscopy showed large stool obscuring the mucosa, but the limited view of the mucosa showed pink mucosa on [**11-20**]. Infectious Disease was consulted and recommended continuing Imipenem, Vancomycin and Flagyl. Unclear source of sepsis, although abdomen was high on the differential. Recommended multiple cultures being sent. On [**11-20**], the patient was able to be weaned off Levophed and Neomycin and by [**11-22**] she was off all pressors. Hydrocortisone was continued. Through all this, culture date remained negative. The patient remained stable until the night of [**11-27**] when she developed hypotension again. Of note, the Hydrocortisone had recently been stopped as well. Blood cultures, urine cultures and sputum cultures were obtained. Vasopressor was started. Hydrocortisone was restarted at stress doses. During that day a total of at least four blood cultures were drawn and one bottle turned positive for gram negative rod. When this came back, the patient was started for double coverage with Cipro, however there is concern that this was a contaminant. It turned out that this was stenotrophomonas which also grew from a wound swab of her skin and turned out to be sensitive to Bactrim. However given that it was cultured on her skin and patient remained clinically stable after this, it was felt that this may have been a colonizer and contaminant and therefore Bactrim was not initiated to treat this at that time. Additionally, the patient had a sputum culture from the same date that ended up growing stenotrophomonas as well as pseudomonas aeruginosa. The pseudomonas was pan sensitive. The patient was already on Meropenem and so treatment was not altered by this culture. The rest of her culture date thus far has been negative or pending. Infectious Disease continued to follow and help make recommendations for the management of the patient. Given the unclear etiology of her hypotension and sepsis, on [**11-28**] a repeat CT Scan was done of the abdomen and hip given those were the most likely sources. These were done without contrast given the patient's renal function. They showed no evidence for abscess, bibasilar areas of consolidation with bibasilar pleural effusions, ascites throughout the abdomen and pelvis which increased in interval from [**11-19**] and unchanged appearance of the left hip joint and soft tissue hematoma. Given this result and patient started having possibly slightly guarding in the right upper quadrant, a right upper quadrant ultrasound was obtained which showed slightly heterogeneic hepatic echo texture of uncertain significance. No evidence of biliary ductal dilation, moderate ascites. Additionally, an area of increased echogenicity adjacent to the right hepatic lobe likely omentum. Head and body of the pancreas normal. After this finding, the CT Scan was reviewed again to look and see if any fluid collection could be seen in the area where they saw the increased echogenicity adjacent to the right hepatic lobe and this was not seen so it was presumed to be omentum. However it was felt that given the recent hypotension, patient's lines should be changed and her ascites should be tapped, therefore on [**11-30**], her left subclavian line was changed over a wire. It was not resited given the difficulty to resite with clot in both of her IJs and her body habitus. Platelets were given the day prior to the procedure to make sure they would be greater than 50,000. Additionally a diagnostic paracentesis was performed on that day which showed white cells of [**Pager number **] with 85 polys, 5 lymphs, 5 monos and [**2089**] red blood cells. It had total protein of 0.7, serum 3.7, amylase 27, T. Bilirubin 3.2, albumin less than 1, gram stain 2+ without microorganism. The results of this was discussed with the Liver Team and they recommended dosing 1.5 grams per kilogram of albumin on that day and 1 gram per kilogram two days later IV. We used a body mass of 100 kilograms for the dosing of this. The patient was already on broad spectrum antibiotics. This was discussed with ID and no antibiotic changes were made at that time. The white blood count had bumped up on [**11-28**] through [**11-30**] and was trending down at the time of this dictation. The patient had remained afebrile and hemodynamically stable. 3. GASTROINTESTINAL: On admission, the patient had elevated transaminases of 194 on admission. These trended down to 66 on the 25th and within normal limits on the 27th. They remained within normal limits until the 2nd, but they started trending up on the 4th and 5th to 55 and 63. Her AST additionally was elevated on admission, tended to normal and then on the [**7-30**] started trending up again. It was unclear the etiology of the original elevation or the bump again. Additionally, alkaline phosphatase was high on admission at 644 and remained elevate, although it bounced and trended down and stabilized in the low 400s. T bilirubin was 20.2 on admission, trended down slightly and then back up and on [**12-1**] was 15.5. It was unclear of the abnormality of these elevated liver enzymes. ERCP was negative for source so question was postoperative cholestasis or sepsis, other microductal disease, possibly medication related. Patient's LFTs and transaminases should continue to be followed. On admission, the Surgery Service was consulted given patient's likely abdominal source and they followed the patient. They recommended Flagyl empirically which was done until Clostridium difficile was negative on serial exam. The patient was noted to be OB positive on [**11-23**], however hematocrit was stable at that time. On [**11-30**], paracentesis was performed as above. Patient had J tube and tube feeds were administered through it without complications. 4. ORTHOPEDIC: Patient has no hardware in left hip at this time. It was removed secondary to infection. Care was taken with moving her at all times and hip was stabilized before moving. She will need to be seen by an orthopedist once her medical condition has stabilized. 5. CARDIOVASCULAR: Patient remained in sinus tachycardia for unclear reasons, but most likely secondary to her infections and blood pressures. Hypotension on admission was thought most likely secondary to sepsis. Patient had a cortisol stem test that showed relative adrenal renal insufficiency and was started on Hydrocortisone. She had a second episode of hypertension requiring pressors on [**11-27**], but these were weaned off within 24 hours. She was restarted on high dose steroids and these are currently at 50 q. six of Hydrocortisone. Her blood pressure has remained stable since the [**7-29**]. It was thought that the hypotension on admission was secondary to sepsis. The second episode of hypotension was thought to be related to either sepsis or potentially due to the discontinuation of her Hydrocortisone. 6. ACID BASE: The patient's acid base status was monitored closely with ABGs and ventilator with adjustment. Patient was for the most part of the time alkalemic. On admission, she had a metabolic anion gap acidosis and a positive lactate most likely from sepsis. 7. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was aggressively fluid resuscitated on admission, received 21 liters positive over three days. She, several times throughout her hospital course, was attempted to be diuresed with Lasix. She required aggressive electrolyte repletion of potassium when she got Lasix, but generally her urine output picked up significantly in response to Lasix. Ionized calcium was also noted to be low requiring many grams of IV calcium for replacement every day. Given her huge calcium need, 24 hour urine was collected with 1300 cc with a pH of 5 and calcium 6.4. Given this a vitamin D and PTH level was sent on [**11-30**]. These values are pending at this time. The patient was on tube feeds for nutrition and the Nutrition Team followed the patient closely helping with her nutritional needs. 8. NEUROLOGIC: Patient was unresponsive in the beginning of her hospitalization while intubated. She received minimal sedation and then no sedation, but still was not responding to commands or verbal stimuli. On [**11-27**], a head CT Scan was done. There was no mass effect or hemorrhage. No extraaxial fluid accumulation or displacement of normal underlying structures. Mild brain atrophy, but otherwise negative study. An EEG was performed on [**11-29**] which preliminarily was consistent with encephalopathy, but not seizure activity. Final read is still pending. Neurology was consulted on [**11-29**] who witnessed left shoulder movement that could of been consistent with seizure, however no seizure activity was preliminary seen on EEG. There other differential other than seizure including CNS infection, hepatic encephalopathy, medications, hypoxic brain injury. The patient's ammonia was measured and found to be 65. TSH was sent on [**2142-11-30**] which is pending at this time. On [**11-19**] it was 0.21. Free T4 on [**11-30**] was found to be 0.6. LP was considered, however patient had a large stage IV decubitus ulcer around the area that would need to be used for an LP and therefore this was deferred secondary to the risk of infection. Additionally, it was felt that a CNS infection accounting for the patient's encephalopathy was highly unlikely. Originally, Lactulose had not been started for the ammonia of 65 because patient was having high stool output, however then stool output dropped down, Lactulose was started to be titrated to bowel movements. EEG was repeated on [**11-30**] to proved sensitivity which showed abnormality EEG due to slow background with delta frequency slowing. These findings consistent with moderate encephalopathy are unchanged from the EEG performed on [**11-29**]. No focal epileptiform seizures seen. However given the concern for seizures, Imipenem was switched to Meropenem given Imipenem's ability to lower seizure threshold. Neurology recommended a possible MRI in the future when patient was more medically stable. The patient did begin having more volitional movements, however at the time of this dictation was not reliably following commands. 9. RENAL: At the beginning of admission when patient was pressors, urine output was minimal, however it started to increase on [**11-20**] and [**11-21**]. Creatinine rose, but only to 1.6. It was noted that for the creatinine clearance that was calculated, patient had significant renal insufficiency and therefore Vancomycin was dosed by level and not by creatinine clearance. Other medications were renally adjusted. Creatinine continued to improve and urine output continued to improve. At the time of this dictation, creatinine is down to 0.8. 10. ENDOCRINE: Patient was maintained on a regular insulin sliding scale with fingersticks q.i.d. She had two cortisol stem tests which showed relative adrenal insufficiency. The first on admission showing numbers of 31, 31, 33 and the second when she had her second hypotensive episode showing numbers of 24 to 30. She was restarted on Hydrocortisone after the second hypotensive episode at stress dose 100 q. eight times 24 then 50 q. six to complete a full week. Given the relative adrenal insufficiency after the week is completed, it was felt the Hydrocortisone should be continued at a lower dose. Additionally, the second hypotensive episode did occur in a short time after the Hydrocortisone was stopped and there was question whether this episode was related to the stopping of the Hydrocortisone or sepsis. 11. HEMATOLOGY: On admission, the patient was felt to be in low grade DIC . Her D-dimers were greater than 200. Her coags were within normal limits and fibrinogen of 232. She received two units of packed red blood cells and on [**11-20**] received four units of FFP. On [**11-22**] D-dimers had come down 500 to 1000, FDP 10 to 40 and fibrinogen 225. It was noted that the patient's platelets were 100 on admission and they then trended downward and originally stabilized above 50. On [**11-21**], hit antibody was negative and given that patient had thrombosis by ultrasound and her IJ, heparin was started, however on [**11-27**] platelets trended down to 29 and heparin was stopped. Hit antibody was resent which was found to be negative. The etiology of the low platelets was unclear at this time, however it may be medication related, for instance Imipenem or Vancomycin. At some point, anticoagulation for her clots in her IJ will have to be readdressed. 12. DECUBITUS: Plastics was consulted and saw the patient on [**11-26**]. Thought that it was a grade III to IV decubitus ulcer. Recommended bed and dressing changes as well as rolling the patient q. two hours. 13. PROPHYLAXIS: The patient is on pneumoboots and Protonix. 14. CODE: She is full code. Communication has been with sons daily. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Dictated By:[**Last Name (NamePattern1) 4572**] MEDQUIST36 D: [**2142-12-2**] 18:26 T: [**2142-12-3**] 09:45 JOB#: [**Job Number 43698**] Name: [**Known lastname 7967**], [**Known firstname 7968**] Unit No: [**Numeric Identifier 7969**] Admission Date: Discharge Date: Date of Birth: Sex: F Service: Addendum covers period up to [**2142-12-22**]. 1. Infectious disease - The patient continued to have fevers of unknown origin, was noted to develop ascites on a computerized axial tomography scan in early [**Month (only) **]. Paracentesis on [**11-30**], demonstrated Enterococcus faecium which was intermediately resistant to Vancomycin. Prior to these results on [**12-3**], antibiotics had all been discontinued, however, when these results came back on [**12-7**] and it was noted that the patient had abdominal tenderness, Linezolid and Meropenem were begun. A second paracentesis after four days of antibiotics was performed on [**12-7**] which had 10,400 white blood cells consistent with a continued peritonitis and grew out Klebsiella sensitive to Meropenem. Meropenem was continued and on [**12-14**], a repeat paracentesis was performed which demonstrated again Klebsiella sensitive to Meropenem as well as sensitive Stenotrophomonas sensitive to Bactrim only. As there was some concern that this was a contaminate as the patient had been previously shown to have Stenotrophomonas in a skin wound, a paracentesis was repeated on [**12-18**] which again showed the Stenotrophomonas sensitive to Bactrim. Around the time of [**12-7**], when Linezolid and Meropenem were started the patient was noted to be hypotensive and hypothermic. After three to four days of antibiotics, (Fluconazole was added for concern of fungal infection) her blood pressure stabilized and the patient resumed her normal systolic blood pressures of 150s. However, again on [**12-21**], the patient dropped her blood pressure to systolic of 80s requiring resumption of pressors. She is currently on Levophed. The source of her persistent peritonitis is unknown. A computerized tomography scan of the abdomen on [**12-10**] demonstrated persistent free fluid as well as a moderate amount of free air around the patient's jejunostomy tube. There was significantly straining consistent with peritonitis. Sources were felt to include microperforation or bile leak as the patient continued to have elevated liver chemistries. There was no evidence of abscess on computerized tomography scan. HIDA scan was negative for biliary leak. The patient had also had endoscopic retrograde cholangiopancreatography times two in [**Month (only) 768**]. In terms of microperforation, Surgery was consulted but felt that there was no intervention that they would perform at this time, given the patient's severe comorbidities. A computerized tomography scan of the abdomen was repeated on [**12-21**] and demonstrated increased free air per jejunostomy tube. The significance of this is unclear. The jejunostomy tube study was negative for any extravasation of contrast around the jejunostomy tube and demonstrated a patent jejunostomy tube from outside into the jejunum. Some concern about leakage of contents around the jejunostomy tube and into the abdomen as a source of her persistent peritonitis but Surgery felt that there was nothing that could be done about this. As above, the patient was on over seven days of Fluconazole, Linezolid, and Meropenem. On [**12-16**], Linezolid was discontinued as the paracentesis from [**12-7**] and [**12-14**] did not demonstrate enterococcus and also the patient was demonstrating thrombocytopenia which result could possibly be secondary to Linezolid therapy. As of [**12-22**], there is still no known source for the patient's persistent peritonitis and she remains hypotensive and hypothermic on Meropenem. Bactrim was started on [**12-21**] to treat the Stenotrophomonas. 2. Pulmonary - The patient is status post tracheostomy on [**12-5**] and has been tolerating ventilation via the tracheostomy mask intermittently throughout the course of her hospitalization. She occasionally required pressure support and assist control ventilation over night secondary to fatigue. However, her oxygen saturation remained good on as little as 50% tracheostomy mask. However, on the evening of [**12-21**], her oxygen saturation decreased and she required assist control with FIO2 of 70% to maintain oxygen saturation in the low 90s. Over the course of the next day and a half she was able to be weaned down to 60% FIO2 and the wean was continuing as tolerated. However, there was some concern that the patient may have developed a pulmonary embolus as she had bilateral internal jugular vein clot and today on portable ultrasound she was noted to no longer have a right internal jugular clot, thus there is some concern that this clot may have broken off an traveled to her lungs. A chest x-ray demonstrated low lung volumes as usual and left lower lobe atelectasis and some question of a retrocardiac density but no significant change from prior x-ray yesterday. 3. Renal - The patient continues to have good urine output with normal creatinine. 4. Gastrointestinal - An upper gastrointestinal bleed over the past five days from [**12-17**] to [**12-22**], the patient has been noted to have ruddy/coffee ground from her nasogastric tube. This had been noticed on the past but accelerated on [**12-16**]. Her hematocrit began to drift down and she has required several blood transfusions since that time. Her Protonix was changed to Prevacid per nasogastric tube secondary to her thrombocytopenia and concern for drug-induced thrombocytopenia. Gastroenterology was consulted and felt no intervention was warranted at this time. Elevated liver function tests, the patient had been followed for Liver Service who felt that her elevated liver function tests notably her total bilirubin ranging between 15 to 20 was likely secondary to sepsis, however, the patient had a period of time between [**12-10**] and [**12-20**] where her blood pressure was stable and she was not demonstrating signs of sepsis. During this time, her total bilirubin remained in the 15 to 18 range and did not seem to drift downward. It was not felt that the patient has underlying cirrhosis or liver disease. Hepatitis serologies were negative and [**First Name8 (NamePattern2) **] [**Doctor First Name **] and antimitochondrial antibody were also negative. Again as above an endoscopic retrograde cholangiopancreatography times two were negative for biliary leak or obstruction and a HIDA scan was also negative for biliary leak. She had no evidence of cirrhosis or varices on computerized axial tomography scan and also noted in her operative report from [**Hospital6 7970**] was that she had no evidence of cirrhosis during her open cholecystectomy when the liver was visualized. During this hospitalization her PT/INR were also within normal limits suggesting good hepatic function. She was continued on Actigall per the request of the Liver Team. Jejunostomy tube, discontinued use of jejunostomy tube approximately [**12-13**] secondary to report of free air around the jejunostomy tube on computerized tomography scan of abdomen. Medications being administered through nasogastric tube and nutrition via total parenteral nutrition. 5. Heme - Thrombocytopenia, status post multiple platelet transfusions, differential diagnosis includes medication-induced thrombocytopenia, destruction, liver disease. As above, liver failure was not felt to be an issue in this patient. All offending medications were discontinued including Protonix and Linezolid, however, given sepsis and Stenotrophomonas and ascites, Bactrim was instituted with cautious observation of platelet levels. Discussed with Hematology and bedside consult. The patient's platelets seemed to bump appropriately after platelet transfusion, suggesting that destruction was not as much an issue as narrow suppression. Decreased hematocrit, the patient transfused at least 7 units of packed red blood cells during the course of this admission. Anemia secondary to acute gastrointestinal bleed, iron deficiency and likely anemia of chronic disease. During acute bleed, transfused were hematocrit less than 27. Bilateral internal jugular deep vein thromboses, had not been receiving heparin secondary to thrombocytopenia and suspicion of heparin-induced thrombocytopenia. On [**12-22**], bedside ultrasound demonstrated highly patent right internal jugular demonstrating either absorption or cleft clots or loosening of clots and potential embolization to lungs. 6. Endocrine - The patient does not have a history of diabetes but has been on sliding scale insulin and insulin in her total parenteral nutrition which is felt likely secondary to her steroid doses. The patient was also started on Hydrochlorothiazide for relative adrenal insufficiency, tested by cosyntropin, initially was on 50 mg q. 6 hours and tapered down as tolerated. 7. Neurological - Electroencephalogram times two with severe toxic metabolic encephalopathy. The patient continued to only follow one midline command of blinking eyes intermittently but never responded to appendicular commands. 8. Cardiac - The patient transiently restarted on Metoprolol around [**12-11**] which she was on as an outpatient secondary to hypertension, however, this was discontinued as her blood pressure decreased again and became septic again later in the hospitalization. 9. Access - The patient had a left subclavian placed on [**11-18**] which was changed to over-wire on the third and finally removed secondary to concerns of infection on [**12-15**]. She also had a PICC line placed on [**12-7**] and an arterial line placed on [**12-10**]. 10. Skin - Stage 4 sacral decubitus, continued to heal with daily Duoderm dressing. The patient was also noted to have an enlarged wound around her tracheostomy that did not heal well. Lateral sutures were placed by Thoracic Surgery to assist with healing. CODE: Full code. Communication with the patient's son [**Name (NI) **] and other son (unknown name), who visit daily. [**Doctor First Name **] continues to insist that his mother wants to stay alive and that we need to do everything within our power to keep her alive. This has been discussed with [**Doctor First Name **] with multiple attendings and residents and even when the concept of sparing his mother from the pain of hospitalization is raised, [**Doctor First Name **] states that he believes that his mother would want to stay alive no matter what. Dictated By:[**Last Name (NamePattern1) 6918**] MEDQUIST36 D: [**2142-12-23**] 00:52 T: [**2142-12-23**] 07:22 JOB#: [**Job Number 7971**] Name: [**Known lastname 7967**], [**Known firstname 7968**] Unit No: [**Numeric Identifier 7969**] Admission Date: [**2142-11-18**] Discharge Date: [**2142-12-30**] Date of Birth: [**2064-2-27**] Sex: F Service: ICU 1. Pulmonary: The patient continued to require very high ventilatory support levels. For the remainder of her stay, she was maintained on high levels of AC ventilatory mode. Towards the last several days of [**Month (only) **], first few days in [**2142-12-29**], she began to develop worsening metabolic acidosis most likely presumed secondary to her septic process. She had an esophageal balloon study performed to help guide max plateued pressure ventilation. She later required full ventilatory support and later received the maximum support possible on AC ventilation. 2. Cardiovascular: The patient continued to have pressor dependence most likely from her presumed septic shock. Transfusions of blood and volume challenges were unsuccessful after correcting this. The patient was ultimately maximized on three pressors at their maximum dose. 3. Infectious Disease: For the last several days of her life the patient remained afebrile, however, had a very high white count in the 30s with impressive bandemia. She was noted to have Enterococcus and Pseudomonas growing from her fluid collection. The Infectious Disease Service followed the patient very, very closely. She remained on broad-spectrum antibiotics including Vancomycin, meropenem, Bactrim IV, and eventually Cipro and fluconazole. 4. Hematocrit: The patient's hematocrit remains stable occasionally requiring transfusions of blood. Her platelets continued to be low. 5. Fluids, electrolytes, and nutrition: The patient's creatinine gradually worsened as she remained hypotension. Her urine output at the time of death was quite minimal. 6. Liver: The patient's LFTs remained markedly elevated of an unclear etiology. 7. Communication/Disposition: As been documented previously, multiple discussions took place between members of the VICU staff and the patient's family including the patient's son, healthcare proxy, Mr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] regarding the patient's overall grim prognosis. [**Doctor First Name **] and other members of the patient's family were informed that the patient's prognosis given her multi-organ failure and septic shock of unclear etiology was grim, however, [**Name (NI) **] stated that her mother would prefer to continue to receive aggressive interventions if there was any remote chance of survival. Patient's family and son, [**Name (NI) **] was informed that to continue aggressive measures could very well mean increased pain and discomfort for his mother. [**Name (NI) **] son wished to proceed with all aggressive interventions. Ethics consultation meeting took place on [**12-26**]. Throughout the last few days of the patient's life, her deteriorating clinical status was communicated with very, very closely by members of the VICU team. On [**12-30**], the patient's son, [**Name (NI) **], was informed that his mother was not likely to live through the next 24 hours, and was informed to come to the hospital and to contact any family members who wished to pay their final respects. At 10:55 pm on [**12-30**], the patient became hypotensive despite three pressors and then developed pulseless electrical activity. Chest compressions were begun and Epinephrine were given along with fluid bolus. The patient was pronounced dead at 10:50 pm with no spontaneous respirations, palpable pulse, or response to verbal or painful stimuli. The patient's family including her son, [**Name (NI) **] was [**Name (NI) 178**], and the death certificate was filled out, and the patient's family declined the opportunity for autopsy. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-697 Dictated By:[**Last Name (NamePattern1) 1245**] MEDQUIST36 D: [**2143-3-22**] 15:16 T: [**2143-3-26**] 07:20 JOB#: [**Job Number 7972**]

[ "567.2", "287.5", "518.81", "789.5", "038.49", "785.59", "707.0", "584.5", "486" ]

icd9cm

[ [ [] ] ]

[ "31.1", "96.72", "51.10", "54.91", "81.91", "96.6", "96.04", "00.14", "48.23", "38.91", "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

4798, 36168

2262, 4179

102, 172

202, 1190

4194, 4781

1212, 2145

2162, 2239

72,541

111,907

54705

Discharge summary

report

Admission Date: [**2192-6-9**] Discharge Date: [**2192-6-14**] Date of Birth: [**2128-1-21**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1390**] Chief Complaint: Motor vehicle accident Major Surgical or Invasive Procedure: [**2192-6-9**]: L chest tube History of Present Illness: 64M s/p motorcycle crash, moderate speed, unhelmeted. Alert and following commands at scene, and taken to [**Hospital 8641**] Hospital. Reportedly became hypotensive and unresponsive in CT scan, and was intubated for airway protection. Transferred to [**Hospital1 18**] for trauma evaluation. Became hypotensive in trauma bay, transfused 2 units pRBCs and a left chest tube placed. A TEE was performed in the trauma bay, which showed hyperdynamic LV function and no aortic dissection. Past Medical History: CAD s/p stenting, HLD, HTN, recently passed kidney stone Past Surgical History: cardiac cath, otherwise unknown Social History: Denies tobacco, alcohol, and illicit durg use. Independent with ADLs. Family History: NC Physical Exam: Discharge physical; NAD, lying in bed. breathing unlabored. rrr ctab, but diminished at L lung base LUE with ecchymosis, no evidence of skin tenting or skin compromise. No deformity. 2+ L radial pulses. Arms and forearms are soft no LE edema Pertinent Results: [**2192-6-9**] 03:15PM BLOOD WBC-10.4 RBC-3.25* Hgb-9.5* Hct-29.1* MCV-89 MCH-29.3 MCHC-32.8 RDW-13.1 Plt Ct-96* [**2192-6-9**] 03:15PM BLOOD Glucose-181* UreaN-25* Creat-0.8 Na-141 K-3.7 Cl-116* HCO3-18* AnGap-11 [**2192-6-9**] 05:50PM BLOOD ALT-22 AST-27 AlkPhos-45 TotBili-0.5 CT abdomen/pelvis: 1. A displaced comminuted fracture of the distal left clavicle. No apparent associated major vascular injury is noted. 2. A displaced comminuted fracture of the scapula with associated hematoma. 3. Small left pneumothorax. 4. Small left hemorrhagic pleural effusion. 5. Small bilateral consolidations, may represent aspiration, infection or atelectasis. 6. Right upper lobe peripheral ground-glass opacity may reflect pulmonary contusion. 7. Hepatic hypodense lesion, incompletely characterized on today's exam. 8. Multiple left rib fractures. 9. Extensive calcified atherosclerotic disease of the aorta and its branches without aneurysmal changes. CT Cspine: 1. No evidence of acute fracture or malalignment. 2. Subcutaneous gas in the left cervical region. Left clavicular fracture on scout- see CT Torso for other fractures. Clavicle: Fracture involving the junction of the mid/distal third of the clavicle is noted with superior displacement of the distal fracture fragment by approximately one shaft width. Right knee: No acute fracture or dislocation is identified [**2192-6-13**] Post chest tube pull cxr: As compared to the previous radiograph, the left pneumothorax has decreased in extent, it is barely visible on today's image. Unchanged are the rib fractures, the scapular fractures and the areas of atelectasis at the left lung base as well as the moderate cardiomegaly without pulmonary edema. There is unchanged air content in the soft tissues of the left cervical region. No other changes. [**2192-6-14**] 09:00AM BLOOD WBC-7.4 RBC-3.47* Hgb-10.0* Hct-31.3* MCV-90 MCH-28.9 MCHC-32.0 RDW-13.6 Plt Ct-144* [**2192-6-14**] 09:00AM BLOOD Plt Ct-144* Brief Hospital Course: Mr. [**Known lastname 81709**] was admitted to the trauma ICU with the following injuries: - comminuted left distal clavicle fx - comminuted displaced left scapular fx - small left pneumothorax - small left pleural effusion - Left 1st rib fracture - Left temporal bone fracture On admission, he was noted to be hypotensive and required levophed for support. A bedside echo was performed and showed no evidence of wall motion abnormalities. He was fluid resusciated overnight and weaned off pressor. He was extubated without event. His pain was well controlled with a dilaudid PCA. He was hemodynamically stable with a GCS of 15 thereafter and was transferred to the floor on [**2192-6-10**]. On the pt's pain was aggressively controlled w/ tylenol/tramadol/and po dilaudid prn. IS was encouraged. On [**2192-6-11**] chest tube was placed to water seal with no leak. Tube subsequently removed on [**2192-6-13**], post pull cxr w/out evidence of ptx. ENT was consulted for L temporal bone fx. They recommended ciprodex drop to left ear [**Hospital1 **] x 10 days as well as outpt audiogram. Ortho managed fractures non-operatively. Pt's left arm was in sling at all times while out of bed, and PT began pendulum exercises with patient. Medications on Admission: lipitor 20', toprol XL 50', folic acid, plavix 75', rosuvastatin 20', fluoxetine 10', valsartan 60', cholecalciferol, ASA 81' Discharge Medications: 1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. CIPRODEX 0.3-0.1 % Drops, Suspension Sig: Four (4) drops Otic twice a day for 9 days: to left ear. Disp:*1 bottle* Refills:*0* 8. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*50 Capsule(s)* Refills:*0* 11. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: 1. L claviclular fx 2. L scapular fx 3. L PTX 4. L 1-10th rib fx 5. L temporal bone fx 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: Admitted after Motor vehicle accident resulting in multiple fractures and short ICU stay. Please resume all of your home medications. Continue dry ear precautions for your left ear. No water may enter L ear until follow up with ENT at least. Use ear drops as prescribed for an additional 8 days. Tylenol, as well as narcotic pain medications for pain as needed. Stool softeneres may be necessary to prevent constipation. Left upper extremity/arm is non-weight bearing. Maintain in sling. Pendulum exercises w/ PT left chest tube incision should remain dressed w/ airtight dressing until the wound has completely closed. Followup Instructions: Follow-up in [**Hospital 2536**] clinic in 2 weeks. Telephone #[**Telephone/Fax (1) 600**] Follow in 3 weeks with Dr. [**Last Name (STitle) 1005**] of Orthopaedic Surgery. telephone #([**Telephone/Fax (1) 2007**] X-Rays of your L shoulder will be obtained at follow up. Please call ENT (#[**Telephone/Fax (1) 41**]) to schedule a follow up audiogram and an appointment with Dr. [**Last Name (STitle) **] in about 2 weeks. Completed by:[**2192-6-14**]

[ "E813.2", "272.4", "V15.82", "810.02", "599.70", "E879.8", "511.9", "V13.01", "414.01", "811.09", "958.4", "807.08", "V45.82", "867.0", "458.9", "860.0", "401.9", "801.02" ]

icd9cm

[ [ [] ] ]

[ "34.04", "38.97", "88.72", "38.91", "96.71" ]

icd9pcs

[ [ [] ] ]

5914, 5961

3396, 4634

325, 356

6092, 6092

1391, 3373

6923, 7379

1110, 1114

4810, 5891

5982, 6071

4660, 4787

6275, 6900

973, 1007

1129, 1372

263, 287

384, 870

6107, 6251

892, 950

1023, 1094

28,222

177,613

46071

Discharge summary

report

Admission Date: [**2134-4-11**] Discharge Date: [**2134-4-13**] Date of Birth: [**2050-7-3**] Sex: M Service: MEDICINE Allergies: Horse/Equine Product Derivatives / Calcium Channel Blocking Agents-Benzothiazepines / Metoprolol Attending:[**First Name3 (LF) 398**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Attempted LP History of Present Illness: 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS change. His son who accompanies him says that he has noticed an increase in his RR over the past few days and a decrease in his energy level. When he went to visit him this morning, he was very sleepy and not coherent which is a change so they called the ambulance. BP and O2 sats there noted to be low. He did not eat breakfast this morning which is very unusual for him. . In the emergency department, initial vitals: 19:00 U 97.1 74 98/63 22. 97% on 5L NC. Arrived hypotensive in 70s, MS A+Ox3 here (but per son, not at baseline), BP unresponsive to 2L NS so left femoral central line placed under U/S guidance (as INR 13) and levo started. Moving arms but legs weaker. 2 U FFP, 10 vit K IV. Cxr w/ increased CHF. Head CT NEG. Could not pass foley X 2, now w/ small amt of blood. Given vanco 1g IV, levo 750 mg IV, flagyl 500 mg IV. Cool hands/feet, dopplerable PT but not DP, vasc called and will see on the floor. Guaiac + brown stool. . On arrival to the ICU, his son states he is more alert now but not back to baseline. . Review of systems: Pt. states he feels short of breath but cannot clarify further. Past Medical History: On 2-3L O2 at NH for unclear reason - PVD (Followed by [**Name (NI) 3407**]) w/ chronic LUE and bilateral LE ischemis - Chronic renal failure on HD x 4 years (thought to be due to obstructive uropathy, kidney stones, BPH) - Systolic heart failure w/ EF 25% on ECHO [**6-26**] - Moderate aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+) aortic regurgitation is seen. Moderate to severe (3+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. ([**6-26**]) - Hx atrial fibrillation and paroxysmal atrial tachycardia - s/p AV nodal ablation and implantation of a dual chamber pacemaker - Baseline AV conduction delay - Hypertension - Coronary artery disease with old posterior MI on EKG and pMIBI in [**6-/2130**] with EF44%, global hypokinesis, no reversible defects. - Hx Left 4-9th rib fx, Left hemothorax - R kidney stone s/p Lithotripsy ([**6-23**], complicated by ESBL Klebsiella UTI) - s/p stroke (cerebellar), found on MRI, sxs of gait instability - hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal cord compression [**12-21**] cerival spondylosis, L median nerve injury - Anemia - Benign prostatic hypertrophy - [**Month/Day (2) 98041**] headaches - Hx of positive PPD, never treated - Hx squamous cell and basal cell ca - HSV keratouveitis - ventral hernia - s/p open cholecystectomy [**2130-4-21**] - s/p small bowel resection (80-90%) for mesenteric ischemia - s/p umbilical hernia repair - s/p cystocele repair - s/p laminectomy - c/b osteomyelitis - s/p TURP [**9-24**] Social History: Patient has been at a NH and has not gotten home since hospitalization in [**Month (only) 958**]. His wife lives in [**Name (NI) 8**]. He is a retired psychiatrist. Social history is significant for the remote tobacco use, 3ppd x 40 years, quit 20 years ago. He drinks alcohol occasionally, denies illicit drug use. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VITAL SIGNS: T 95.9 BP 96/61 HR... RR... O2 GENERAL: Awake but confused, NAD. Answers do not make sense. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. dry MM. OP w/ poor dentition. Neck Supple. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**] but very distant heart sounds. LUNGS: Occasional crackles anteriorly and posteriorly w/ poor inspiratory effort. ABDOMEN: NABS. Soft, midline scar. No HSM EXTREMITIES: anasarca, palp radial pulses, dopperable PT/DP bilaterally. L hand w/ purple fingertips on fingers 2, 3 and 4. SKIN: Xerosis. NEURO: Alert but not oriented. Speaking nonsensical sentences. Able to show 2 fingers on the R but not L. Able to wiggle toes. Could not follow other commands. Pertinent Results: [**2134-4-11**] 07:20PM BLOOD WBC-8.6 RBC-4.09*# Hgb-14.5# Hct-48.4# MCV-118*# MCH-35.6* MCHC-30.1* RDW-21.7* Plt Ct-200 [**2134-4-13**] 03:15AM BLOOD WBC-14.9* RBC-3.37* Hgb-12.0* Hct-38.1* MCV-113* MCH-35.6* MCHC-31.4 RDW-21.3* Plt Ct-172 [**2134-4-11**] 07:20PM BLOOD Neuts-91* Bands-1 Lymphs-4* Monos-3 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-2* [**2134-4-11**] 07:20PM BLOOD PT-99.7* PTT-60.9* INR(PT)-13.2* [**2134-4-12**] 03:04AM BLOOD PT-21.9* PTT-43.0* INR(PT)-2.1* [**2134-4-12**] 09:55AM BLOOD PT-17.8* PTT-39.7* INR(PT)-1.6* [**2134-4-13**] 03:15AM BLOOD PT-17.0* PTT-38.0* INR(PT)-1.5* [**2134-4-11**] 07:20PM BLOOD Glucose-98 UreaN-45* Creat-4.3* Na-137 K-4.6 Cl-92* HCO3-26 AnGap-24* [**2134-4-13**] 03:15AM BLOOD Glucose-76 UreaN-54* Creat-4.5* Na-138 K-4.7 Cl-94* HCO3-18* AnGap-31* [**2134-4-11**] 07:20PM BLOOD ALT-13 AST-18 CK(CPK)-31* AlkPhos-128* TotBili-0.3 [**2134-4-11**] 07:20PM BLOOD cTropnT-0.41* [**2134-4-12**] 03:04AM BLOOD CK-MB-NotDone cTropnT-0.34* [**2134-4-11**] 07:20PM BLOOD Albumin-4.1 Calcium-8.3* Phos-6.9* Mg-1.5* [**2134-4-13**] 03:15AM BLOOD Calcium-7.8* Phos-5.5* Mg-1.9 [**2134-4-13**] 03:15AM BLOOD Vanco-9.2* [**2134-4-11**] 10:30PM BLOOD Type-[**Last Name (un) **] pO2-70* pCO2-79* pH-7.13* calTCO2-28 Base XS--4 [**2134-4-12**] 12:54AM BLOOD Type-CENTRAL VE pO2-42* pCO2-79* pH-7.17* calTCO2-30 Base XS--1 [**2134-4-12**] 07:18AM BLOOD Type-[**Last Name (un) **] pO2-32* pCO2-56* pH-7.28* calTCO2-27 Base XS--2 Intubat-NOT INTUBA [**2134-4-12**] 03:09AM BLOOD Lactate-2.6* [**2134-4-12**] 07:18AM BLOOD Lactate-1.2 [**2134-4-12**] 03:09AM BLOOD O2 Sat-56 . [**4-11**] CXR FINDINGS: Comparison is made to [**2134-1-25**]. Right pacemaker and two intracardiac leads remain in place. Since prior exam, left IJ hemodialysis catheter has been placed, with tip low in position, possibly within the IVC. [**Year (4 digits) **] stens are noted in the left subclavian and brachiocephalic vein. Cardiomegaly again noted with central congestion, bilateral pleural effusions. Lung bases are suboptimally assessed given low lung volumes though compared with prior, effusion and CHF is increased. IMPRESSION: 1. Dialysis catheter tip low, likely in IVC. 2. CHF, worse. . [**4-11**] CT Head NON-CONTRAST HEAD CT: No edema, masses, mass effect, hemorrhage or infarction is detected. The ventricles and sulci are slightly prominent consistent with involutional changes. Periventricular white matter hypodensities are compatible with small vessel ischemic changes. Mild mucosal thickening of the right ethmoid sinus is unchanged. The remainder of the visualized part of the paranasal sinuses and mastoid air cells is clear. Calcification of cavernous carotid arteries is noted bilaterally. There has been interval placement of a hearing aid device on the left side. Incidental note is made of posterior non- fusion of c1. IMPRESSION: No acute intracranial pathology. . [**4-13**] CXR IMPRESSION: AP chest compared to [**4-11**]: Moderate right and small left pleural effusions have increased, mild-to-moderate pulmonary edema stable or worsened. Moderate cardiomegaly longstanding. Left basal atelectasis severe and unchanged. No pneumothorax. Dual-channel left central venous line ends in the right atrium, transvenous right atrioventricular pacer leads in standard placements. Brief Hospital Course: ASSESSMENT AND PLAN: 83 M w/ pmh of ESRD on HD, Afib s/p AVN ablation and dual-chamber PM, systolic CHF (EF 25%, 2+AS, 3+MR) transferred from nursing home, w/ MS change and hypotension. Etiology of hypotension and hypercarbia were never clarified during his hospital course. The hypotension was concerning for sepsis given l-shift, indwelling HD line and h/o line infection (STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA} w/ prior HD line. Also has a pacemaker. Could not get a urine specimen. CXR w/ loss of diaphragm on R but w/o obvious infiltrate. Could also be from cardiogenic shock given baseline depressed EF. Given his presentation w/ altered mental status, he was covered with Vanc, ceftriaxone, ampicillin and acyclovir for possible meningitis. An LP was attempted but not successful given prior lumbar laminectomy surgery and an IR-guided LP was planned. He was initially on NE for blood pressure support but this was weaned off the day after admission. The following morning, when the resident went in to round on Mr. [**Known lastname **], she noted that he was apneic and without a pulse. A code was called and he was given epi/atropine, insulin, dextrose, bicarb for PEA. He was intubated by anesthesia. His wife was called and she asked that agressive recussitation be stopped (it had not been successful to that point) and he expired. . Hospital course also complicated by the following problems: . #. Acute respiratory acidosis: Unclear precipitant. DDX from percocets vs infection vs hypophosphatemia vs respiratory muscle fatigue. He tolerated bipap the night of admssion with a small decrease in CO2. His mental status improved slightly over the next day. . #. Altered mental status: DDX from hypercarbia vs from percocets vs from infection. CT head w/o acute process. Could possibly be from meningitis but no nucal rigidity or headache. - treatment w/ bipap and antibiotics for meningitis as above . #. Hypoxia: CXR seems consistent w/ pulmonary edema. Likely from worsening valvular disease. Could also be an infiltrate that is hidden by edema. Apparently has been on [**12-22**] L NC at rehab w/ unclear diagnosis but getting spiriva and albuterol. No formal dx of COPD. - albuterol and atrovent nebs . #. ESRD on HD: Dialysis MWF at [**Location (un) **] Dialysis. - renal followed him and was planning for dialysis the day he expired . #. Systolic heart failure: Unclear if ischemic in etiology or from valvular disease (mod AS, severe MR). - appeared total body volume overloaded despite hypotension. . #. Afib: INR supratherapeutic at 13.2 on admission but quickly resolved s/p 2 U FFP and 10 mg vit K IV X 1 in the ED. No obvious signs of bleeding. HCT w/ hemoconcentration given baseline of 32. S/p AVN ablation and dual-chamber pacemaker. - held coumadin - trended coags . #. PVD: Known LUE and bilateral LE PVD followed by Dr. [**Last Name (STitle) 3407**]. - per [**Last Name (STitle) 1106**], nothing to do for now . #. Macrocytic Anemia: Current hct likely hemoconcentration. No signs of bleeding. B12/folate wnl in [**1-25**]. . EMERGENCY CONTACT: [**First Name8 (NamePattern2) 13291**] [**Known lastname **] ([**Telephone/Fax (1) 98048**], [**Telephone/Fax (1) 98049**], wife [**Name (NI) 382**] Medications on Admission: (per med sheets) Coumadin 3 mg daily Dialysis at [**Location (un) **] dialysis MWF Acetaminophen ASA 325 mg daily calcium acetate 667 mg 2 tabs tid dextroamphetamine 2.5 mg daily docusate folate 1 mg daily lotemax 0.5% eye drops mucinex 600 mg [**Hospital1 **] mucomyst nebs [**Hospital1 **] nephrocaps pantoprazole 40 mg daily sensipar 30 mg [**Hospital1 **] spiriva daily tobramycin 0.3% eye drops Valtrex 500 mg daily lactulose lorazepam 0.5 mg [**Hospital1 **] percocet 5/325 [**Hospital1 **] dexadrine 5 mg daily Albuterol vit B12 1000 mg daily nepro 235 daily albumin w/ dialysis darbapoetin w/ dialysis Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Hypercarbic respiratory failure Discharge Condition: Expired Discharge Instructions: n/a Followup Instructions: n/a

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icd9cm

[ [ [] ] ]

[ "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

11768, 11777

7839, 9536

377, 391

11852, 11861

4494, 6740

11913, 11919

3584, 3666

11740, 11745

11798, 11831

11105, 11717

11885, 11890

3681, 4475

1609, 1675

316, 339

419, 1590

6749, 7816

9551, 11079

1698, 3235

3251, 3568

81,602

188,471

44759

Discharge summary

report

Admission Date: [**2105-6-30**] Discharge Date: [**2105-7-3**] Date of Birth: [**2069-1-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1253**] Chief Complaint: Nausea, vomiting, abdominal discomfort Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 36yo female with history of DM and depression, admitted with abdominal pain, nausea and vomiting. . She reports her symptoms began on Sunday night with abdominal discomfort and nausea. She vomited multiple times that day. Initially the vomitus was clear/yellow but she then noted some blood streaking in it afterwards. She also reports subjective fevers and chills since Sunday. Patient noted 4 loose bowel movements since her symptoms arose but denies any dark/red stool. Of note, the patient ate lobster on Saturday. Reports poor PO intake since then. Denies recent travel or sick contacts. . Of note, patient was recently admitted to [**Hospital1 18**] in [**5-/2105**] with a similar presentation of GI symptoms. She was not in DKA during this hospitalization. She underwent EGD during that stay which demonstrated no gastritis/esophagitis. Biopsies consistent with mild chronic inflammation. . Her diabetic history is unclear- she has been labeled as a type 1 and type 2 diabetic. She had actually not been on any therapy for about 8 months until she was admitted with similar symptoms in 5/[**2105**]. On discharge, she was started on lantus and regular insulin sliding scale. The patient says that she has not been compliant with her insulin in the last 5 days. The patient report Last A1C- 11.1 in 5/[**2105**]. . Given her persistent nausea and blood in vomitus, the patient presented to her PCP's office where she was found to have a blood sugar of 473. She was sent to the ED for further management. . In the ED, initial vs were: T- 96, P- 127, BP- 143/99, R- 18, SaO2 100% on RA. Labs showed an anion gap acidosis with ketonuria consistent with DKA. Patient was started on an insulin gtt at 6U/hr and given 2L NS for hydration. Patient's symptoms improved with zofran and ativan. She remained stable in the ED. She is being admitted to the ICU for management of DKA. . Past Medical History: 1. Diabetes Mellitus- Type 1 vs type 2 2. Depression 3. Anxiety Social History: Home: recently moved to [**Location (un) 86**] from [**State 5887**] 8 months ago; has 3 children (1yo, 2yo, and 19yo); her children are staying with her mother Occupation: not currently employed EtOH: Denies Drugs: + Marijuana, last use was prior to last admission ([**5-/2105**]) Tobacco: [**1-10**] PPD Family History: Mother - healthy. Reports DM and HTN in her family Physical Exam: Vitals: T- 98.9, HR- 115, BP- 136/83, RR- 13, SaO2- 99% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Non-tender to palpation, but patient reports baseline "ache". soft, non-distended. bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Pertinent Labs on Admission: Bicarb 18, AG- 18, UA- glu 1000, ketones 150 . [**2105-6-30**] 10:20PM GLUCOSE-144* UREA N-17 CREAT-0.7 SODIUM-140 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15 [**2105-6-30**] 10:20PM CALCIUM-7.8* PHOSPHATE-2.3* MAGNESIUM-1.9 [**2105-6-30**] 08:53PM WBC-11.7* RBC-3.43* HGB-10.6* HCT-31.0* MCV-91 MCH-30.8 MCHC-34.1 RDW-13.8 . [**2105-6-30**] 11:00AM GLUCOSE-490* UREA N-24* CREAT-0.9 SODIUM-140 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-18* ANION GAP-22 [**2105-7-2**] 04:47AM BLOOD WBC-9.4 RBC-3.33* Hgb-10.1* Hct-29.3* MCV-88 MCH-30.2 MCHC-34.3 RDW-14.0 Plt Ct-242 [**2105-7-3**] 04:20AM BLOOD Glucose-88 UreaN-5* Creat-0.6 Na-140 K-3.7 Cl-107 HCO3-28 AnGap-9 [**2105-7-3**] 04:20AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.9 [**2105-6-30**] 11:10AM URINE Blood-MOD Nitrite-NEG Protein-150 Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2105-7-1**] 3:08 am SEROLOGY/BLOOD Source: Venipuncture. **FINAL REPORT [**2105-7-1**]** HELICOBACTER PYLORI ANTIBODY TEST (Final [**2105-7-1**]): NEGATIVE BY EIA. (Reference Range-Negative). [**2105-6-30**] 8:52 pm URINE Source: Kidney. **FINAL REPORT [**2105-7-1**]** URINE CULTURE (Final [**2105-7-1**]): NO GROWTH. Brief Hospital Course: Diabetic [**Name (NI) 58218**] Unclear precipitant. Most likely infectious etiology (GI). Patient carries diagnosis of type 1 DM but apparently recently went 8 months without any therapy whatsoever, which is usually not tolerated in type 1 DM. On admission her sugars of 490 with ketonuria of 150 and glucosuria of 1000 were consistent with DKA vs HSS. The patient was aggressively rehydrated wnd placed on an insulin drip over night. Her electrolytes were followed every two hours and potassium was repleted as needed. By morning her anion gap had closed and she was transitioned to subcutaneous insulin with her sugars stable in the upper 100s to low 200s on sliding scale correction. [**Last Name (un) **] Diabetes was consulted who followed the patient during her ICU stay. Patient was transferred to CC7 on [**7-3**] and glucose remained stable until discharge. . Nausea- The patient was persistently nauseous throughout her stay and was unable to eat. Reglan was started on [**7-1**] and the patient's reported abdominal pain and nausea were much improved. This persistent nausea requiring now two admissions is concerning for gastroparesis in the setting of uncontrolled diabetes. A gastric emptying study was ordered for the pt to investigate gastroparesis vs gastric infectious etiology that was questioned given elevated WBC. It was decided to pursue this outpatient. Nausea was not present at time of discharge on [**2105-7-3**]. . Hematemesis- Patient found to have specks of black substance in vomitus. She had recent admission for GI bleed in [**5-/2105**] where an EGD showed an area consistent with mild chronic inflammation. No gastritis or esophagitis were identified. The hematemesis was most likely secondary to the patients wretching. The pts hct was trended throughout the patients stay. She was found to be H Pylori negative. Patient noted that she has a history of acid reflux and was written a prescription for omeprazole. . HTN- The patients lisinopril was initially held in the setting of nausea and vomiting. It was restarted on [**7-2**] when the patient could eat. . Anxiety- Patient was given PRN dose of Ativan based on home medications. . Diabetes mellitus- patient was followed throughout stay by [**Last Name (un) **] Diabetes Center. Follow-up appointments were made with them, as well as an ophthalmologist for annual eye checks. Medications on Admission: 1. Lisinopril 10 mg Tablet PO DAILY 2. Insulin Glargine 100 unit/mL Solution Sig: 15 units Subcutaneous at bedtime. 3. Celexa 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Insulin Regular Human 100 unit/mL Solution Sig: Sliding scale units Injection four times a day. 5. Reglan 6. Ativan 7. Iron supplementation Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Take if in pain. 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 5. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime. 6. Celexa 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Insulin Regular Human 100 unit/mL Solution Sig: Sliding scale units Injection four times a day. 8. Reglan 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 9. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for Anxiety. 10. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Diabetic ketoacidosis Hematemesis Anemia Hypertension Diabetes mellitus Anxiety 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 at the [**Hospital1 18**]. You were admitted for further evaluation of abdominal pain, nausea and vomiting. You were found to have diabetic ketoacidosis. Tests showed an anion gap metabolic acidosis and ketonuria consistent with diabetic ketoacidosis. It is important that you continue to take your diabetes medications regularly. We made the following changes to your medications: Started omeprazpole and acetaminophen. Followup Instructions: Department: Endocrinology, [**Hospital **] Clinic When: Thursday, [**2105-7-9**] @ 9:10am, Arrival @ 8am for pre exam With: [**Name6 (MD) 95756**] [**Name8 (MD) 9835**], MD [**Telephone/Fax (1) 2378**] [**Last Name (un) **] Diabetes Center One [**Last Name (un) **] Place [**Location (un) 86**], [**Numeric Identifier 718**] Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER When: TUESDAY [**2105-7-7**] at 3:00 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 8268**], MD [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: Opthalmology, With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (to be detemined)[**Hospital1 95757**] HEALTH CENTER,[**Hospital1 7977**] ([**Location (un) 686**], MA) Please call [**Telephone/Fax (1) 7976**] this coming Monday the 28th for an eye appointment with Dr. [**First Name (STitle) **], they have a wait list policy @ [**Street Address(1) 95758**] Clinic which you are currently on.

[ "250.63", "300.00", "V58.67", "285.9", "536.3", "401.9", "250.13", "493.90" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8481, 8487

4738, 7128

352, 359

8611, 8611

3401, 3416

9250, 10347

2733, 2786

7499, 8458

8508, 8590

7154, 7476

8762, 9156

2801, 3382

9186, 9227

274, 314

387, 2302

3430, 4715

8626, 8738

2324, 2393

2409, 2717

60,077

172,462

35453+58005

Discharge summary

report+addendum

Admission Date: [**2190-4-8**] Discharge Date: [**2190-5-2**] Date of Birth: [**2108-12-13**] Sex: F Service: MEDICINE Allergies: Linezolid Attending:[**First Name3 (LF) 99**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: -Central venous line -Arterial line -PICC line -Endotracheal intubation History of Present Illness: Mrs. [**Known lastname 3614**] is an 81 year old female with HTN, HL, ESRD on HD, CHF, who has been at [**Hospital **] [**Hospital 701**] rehab who presented to [**Hospital3 **] on [**2190-4-4**] with acute onset of shortness of breath an hypoxia. In [**12-21**], she had a colectomy & ileostomay seconadry to obstruction which was complicated by respiartory failure secondary to aspiration requiring trach and PEG. She also developed renal failure and was initiated on HD. She was discharged to [**Hospital **] Rehab where she has suffered several infectiosn (MRSA PNA, MRSA bacteremia, VRE UTI). At one point, she was seen at [**Hospital1 336**] for "white-out of her right lung", underwent bronch. She was evaluated for stent placement, but the TBM was thought to be too distal to be amenable to stenting. She then was transferred back to [**Hospital1 **]. One week later, she devleoped acute SOB with hypoxia to the 70s. She was given morphine, bumex, and solumedrol without significant improvement. She was placed on BIPAP with some improvement and was trasnferred to [**Hospital3 **] for further management. At some point in her recent past, she was treated with Vanc/Gent for HAP. On admission to [**Hospital3 **], she was found to be hypoxic and placed on BIPAP. A CTA was performed and was negative for PE or pneumonia, but suggestive of atelectasis. Nevertheless, she was treated with empiric broad spectrum antibiotics for PNA with vanco/levaquin/ceftazidime --> levaquin/ceftaz for unclear reasons. She remained bipap depended for days, but was becoming progressively more tired. She ultimately was intubated today. Her WBC was initially 27. UCx showed yeast (not [**Female First Name (un) **]) so she was started on amphotericin b bladder washes. Her WBC trended down from 27 to 20. Upon arrival to [**Hospital1 18**] MICU, she was intubated and sedated so unable to obtain further history from the patient. Past Medical History: ESRD on HD MWF HTN Hyperlipidemia Axiety Asthma Status-post colectomy Status-post Trach and Peg in [**2189**] --> later reversed Status-post partial knee replacement Status-post L THR Status-post bilateral cataract Status-post of ischemic colitis Status-post epistaxis Status-post MRSA PNA and bactermia Severe malnutrition Social History: She was previously independent prior to bowel obstruction in [**Month (only) 1096**]. She is married and has two children. She is currently living at [**Hospital **] Rehab. She denies tobacco or alcohol use. Family History: Noncontributory. Physical Exam: On admission: Vitals: HR 59, BP 109/43, RR 15, T 95.8, Sat 98% on 450x14, Fio2 100, PEEP 5 General: sedated, intubated, not following commands HEENT: Sclera anicteric, intubated Lungs: diffuse wheezing in all lung fields CV: distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: cool extremities, anasarca Lines: left picc, right tunneled HD line Pertinent Results: Labs on admission: [**2190-4-8**] 10:35PM BLOOD WBC-16.8* RBC-3.07* Hgb-10.4* Hct-30.9* MCV-101* MCH-33.9* MCHC-33.7 RDW-16.1* Plt Ct-121* [**2190-4-8**] 10:35PM BLOOD Neuts-96.4* Lymphs-2.3* Monos-1.2* Eos-0.1 Baso-0 [**2190-4-8**] 10:35PM BLOOD PT-13.1 PTT-26.4 INR(PT)-1.1 [**2190-4-8**] 10:35PM BLOOD Glucose-76 UreaN-40* Creat-2.2* Na-132* K-4.2 Cl-99 HCO3-24 AnGap-13 [**2190-4-8**] 10:35PM BLOOD ALT-135* AST-25 LD(LDH)-350* CK(CPK)-27 AlkPhos-96 TotBili-0.3 [**2190-4-8**] 10:35PM BLOOD CK-MB-NotDone cTropnT-0.17* [**2190-4-9**] 01:28AM BLOOD CK-MB-NotDone cTropnT-0.15* [**2190-4-9**] 03:52AM BLOOD CK-MB-8 cTropnT-0.16* [**2190-4-8**] 10:35PM BLOOD Albumin-2.5* Calcium-8.8 Phos-3.5 Mg-2.1 Iron-34 [**2190-4-8**] 10:35PM BLOOD calTIBC-137* VitB12-[**2172**]* Folate-GREATER TH Hapto-44 Ferritn-[**2103**]* TRF-105* [**2190-4-8**] 11:33PM BLOOD Lactate-1.8 Lab values at end of course: [**2190-5-2**] 03:47AM BLOOD WBC-24.8* RBC-2.34* Hgb-7.8* Hct-26.0* MCV-111* MCH-33.3* MCHC-30.0* RDW-22.9* Plt Ct-76*# [**2190-5-2**] 03:47AM BLOOD PT-18.3* PTT-24.7 INR(PT)-1.7* [**2190-5-2**] 03:47AM BLOOD Glucose-119* UreaN-37* Creat-1.6* Na-138 K-5.2* Cl-107 HCO3-21* AnGap-15 [**2190-5-1**] 04:22AM BLOOD ALT-175* AST-87* LD(LDH)-798* AlkPhos-448* TotBili-1.0 [**2190-5-2**] 03:47AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.8* [**2190-5-1**] 05:14AM BLOOD Lactate-2.4* CT chest [**2190-4-14**]: 1. Widespread peribronchiolar abnormalities, suggestive of an evolving bronchopneumonia with extensive bronchiolitis component. The findings are not specific for a particular organism, but pseudomonas should be considered considering apparent nosocomial infection. Other potential etiologies include viral, mycoplasma and less likely granulumatous infection. 2. Small pleural effusions, left greater than right. 3. Low-lying endotracheal tube, which should be withdrawn several centimeters for standard positioning. Brief Hospital Course: This is an 81 year old female with HTN, HL, CHF, ESRD on HD, malnutrition, here with recurrent respiratory distress secondary to RLL lobar collapse (possible tracheobronchial malacia (TBM) vs. aspiration with mucous plugging vs HAP) extubated and then reintubated. #. Respiratory failure: The patient had recurrent lobar collapse with respiratory distress. Reportedly has TBM but left sided lesion is too distal to stent. Has positive glucan/galactomannan, and CT on [**4-14**] showing diffuse disease, possibly invasive aspergilliosis. She was started on oral voriconazole on [**2190-4-15**], but with elevated LFT??????s to the thousands, voriconazole was discontinued and ambisome was started. Voriconazole was restarted on [**2190-4-24**] and again she had elevated LFT??????s. This may have been due to repeat shock liver however Voriconazole was again discontinued and Ambisome was restarted. On [**2190-4-29**], the patient had continually dropping platlets, thought to be due to Ambisome so this was discontinued and Micafungin started until LFT??????s come down at which point, plan was to start Voriconazole again. She had already completed a course for HAP with Vancomycin and Cefepime on [**4-17**]. Due to multiple respiratory problems, the patient ultimately required another intubation overnight ([**4-26**]) which she agreed to. Ultimately, CVVH was discontinued due to clot and so the ability to remove fluid to help with respiratory issues was lost. The patient was noted again to have MRSA growing in sputum, and was started back on vancomycin for MRSA on sputum from [**4-27**]. Meropenem was also started at this time. ID followed the patient and recommended switching Micafungin back to Voriconazole when possible. After discussion with the family, the decision was made to make the patient comfort measures only (CMO) and all antibiotics were discontinued on [**2190-5-2**]. #. HTN/Hypotension: The patient was on nitropaste and amlodipine at home. For some time, she was on Captopril and Amlodipine here, however switched to single [**Doctor Last Name 360**] beta-blocker given rhythm issues. In the ICU she continued to have labile blood pressure. Significant labile BP??????s with hemodialysis (HD) requiring Phenylephrine as well as periodic Levophed and fluid boluses for BP support. Utlimately, her hypotension became a barrier to HD and she was initiated on CVVH. This had to be discontinued on [**5-1**] due to clot formation. The patient was unable to tolerate heparin, and had become citrate toxic. #. Thrombocytopenia: The patient's platelets had dropped acutely from 118 to 69 to 50 on [**2190-4-30**]. The was possibly due to Amphoterocin which was briefly discontinued previously and platelets went up. Ambisome was discontinued again due to dropping platlets, and the platlets levels stabilized. #. NSVT/Afib: The patient did have known pafib and appeared to have had the episodes of NSVT coinciding with dialysis. She was initially given 150mg amiodarone x1 on [**4-12**] and continued on a drip at 1 then 0.5 per hour. The ectopy had improved. Attempted anticoagulation was not tolerated by patient due to epistaxis and IV site bleeding. Her Metoprolol was ultimately discontinued due to hypotension. #. Liver: The patient had rising LFT??????s with peak in the thousands. Liver service was consulted and this was thought to be shock liver due to hypotension following HD. Voriconazole was discontinued, and liposomal Amphoterocin started. After liver enzymes recovered, she was discontinued on Amphoterocin and restarted on Voriconazole. Amphotericin was again started and Voriconazole discontinued due to rising LFTs, however these were in the setting of another episode of hypotension. Her pressures were supported with Phenylephrine as needed to keep her SBP above 100. Her liver ultrasound showed normal right lobe of the liver, limited view of the left lobe. No portal vein thrombosis. Echogenic kidneys consistent with parenchymal disease. #. Leukocytosis: WBC had been up to 28 then dropped briefly and began to rise again to the 20's, and continued to fluctuate. She was being treated for potential Aspergillosis (not biopsy confirmed), as well as potential bacterial pneumonia. #. Right upper extremity (RUE) DVT: The patient was noted to have a DVT seen on ultrasound. The patient was at risk for pulmonary embolism (PE), however, was intolerant of anticoagulation due to bleeding. #. ESRD on HD: Patient had been on dialysis since recent colectomy. Nephrology followed her here. CVVH was initiated on [**4-30**] due to intolerance of HD, although this could not be continued due to clot formation and citrate toxicity. Medications on Admission: Tylneol PRN RISS Nephrocaps daily Amlodipine 5 mg daily Mucinex 600 mg [**Hospital1 **] Morphine prn Zofran 4 mg prn Miconazole powder Ativan PRN Nitropaste 2 inches q 6 hours Fluconazole 200 mg q dialysis Heaprin [**Numeric Identifier 389**] U q dailysis Levquin 500 mg Q 46 hours HSQ Methylprednisolone 80 mg IV q 12 hours ALbuterol prn Atroven PRN Ceftazidime q dailysis Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: NA Discharge Condition: NA Discharge Instructions: NA Followup Instructions: NA Completed by:[**2190-5-2**] Name: [**Known lastname **],[**Known firstname 6666**] Unit No: [**Numeric Identifier 12968**] Admission Date: [**2190-4-8**] Discharge Date: [**2190-5-2**] Date of Birth: [**2108-12-13**] Sex: F Service: MEDICINE Allergies: Linezolid Attending:[**First Name3 (LF) 10841**] Addendum: On the afternoon of [**5-4**], a family meeting was held with the the patient's husband and daughters. The decision was made to change the patient to comfort measures only. The patient expired at 9:02pm that night. Discharge Disposition: Expired [**Name6 (MD) **] [**Last Name (NamePattern4) 9776**] MD [**MD Number(2) 10844**] Completed by:[**2190-5-4**]

[ "585.6", "272.4", "995.92", "117.3", "V43.65", "V44.2", "482.41", "428.0", "453.8", "493.90", "518.81", "584.9", "403.91", "427.31", "518.0", "428.32", "038.9", "484.6", "519.19", "276.1", "287.5", "785.52", "427.1", "261", "570", "V43.64" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "96.72", "33.24", "38.93", "38.91", "39.95" ]

icd9pcs

[ [ [] ] ]

11236, 11384

5373, 10061

275, 348

10567, 10571

3443, 3448

10622, 11213

2888, 2906

10485, 10489

10542, 10546

10087, 10462

10595, 10599

2921, 2921

228, 237

376, 2300

3462, 5350

2322, 2647

2663, 2872

20,351

148,239

12346+12347+56358

Discharge summary

report+report+addendum

Admission Date: [**2159-2-6**] Discharge Date: [**2159-2-14**] Date of Birth: [**2100-8-11**] Sex: F Service: CHIEF COMPLAINT: This is a 59-year-old female with a history of chest pain when walking. HISTORY OF PRESENT ILLNESS: On [**2-3**] she came to the Emergency Room at [**Hospital 47**] Hospital and was admitted eventually and she underwent a cardiac catheterization on [**2159-2-3**] and was transferred here by ambulance for treatment of her cardiac disease. PAST MEDICAL HISTORY: Past medical history significant for diabetes, hypertension, status post total abdominal hysterectomy, status post open cholecystectomy. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Her medications at home include NPH 38 units in the morning and 35 units in the evening. SOCIAL HISTORY: She denied ethanol or cigarette use or abuse. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed she was afebrile. Cardiac examination revealed a regular rate and rhythm, and a well-healed and old incisional scars from her past surgeries. She was alert and oriented. PERTINENT LABORATORY DATA ON PRESENTATION: The patient's laboratories on admission revealed a complete blood count with white blood cell count 7, hematocrit 34.5, platelets of 277. Coagulations were PT 12.2, PTT 26, and INR 1. Chemistry revealed sodium of 138, potassium 3.8, chloride 98, bicarbonate 33, blood urea nitrogen 23, creatinine 0.7, glucose of 123. RADIOLOGY/IMAGING: Her electrocardiogram did not show any acute ischemia. Chest x-ray was checked and was normal. HOSPITAL COURSE: She was made n.p.o. and consented and was prepared for coronary artery bypass graft the next day. Dermatology was called just prior to the coronary artery bypass graft for evaluation of an eruption of the arms, and they decided and agreed with us that it was not infectious and was most likely mild folliculitis which would not impede wound healing. Th[**Last Name (STitle) 1050**] was taken to the operating room on [**2-8**] after delay due to the arm eruption. She underwent a coronary artery bypass graft times four with a left internal mammary artery, left anterior descending artery, obtuse marginal, diagonal, and right coronary artery graft, and an endarterectomy of her right coronary artery for the indication of unstable angina with slightly decreased ejection fraction. The primary surgeon was Dr. [**Last Name (Prefixes) **]. She was transferred to the Cardiothoracic Intensive Care Unit postoperatively on minor doses of pressors, and her hematocrit was stable. The patient was transferred to the floor on [**2-10**], on postoperative day two, in stable physiological condition. On postoperative day three, on [**2-11**], the patient was doing well. Wires were discontinued. Foley was discontinued. The patient was encouraged to ambulate. Rehabilitation was involved in her care and felt that she could be discharged after one to two more sessions. She was almost at level IV as of [**2-12**]. On [**2-13**], the patient remained in house for further management and weaning of oxygen by nasal cannula requirement. CONDITION AT DISCHARGE: The patient was discharged on [**2159-2-14**], in good condition. PHYSICAL EXAMINATION ON DISCHARGE: Physical examination showed an appropriate 58-year-old woman who appeared only slightly older than her stated age. MEDICATIONS ON DISCHARGE: (Her medications on discharge were) 1. NPH insulin 38 units in the morning and 35 units in the evening. 2. Plavix 75 mg p.o. q.d. 3. Percocet one to two tablets p.o. q.4-6h. p.r.n. for pain. 4. Aspirin 325 mg p.o. q.d. 5. Regular insulin sliding-scale as needed. 6. Over-the-counter Tylenol. 7. Colace as needed with her Percocet. 8. Ranitidine 150 mg p.o. b.i.d. 9. Metoprolol 12.5 mg p.o. b.i.d. (hold for a systolic blood pressure of less 110 and heart rate less than 60). 10. Furosemide 20 mg p.o. q.12h. (for a period until she reaches weight similar to her preoperative weight) 11. Potassium cholesterol 20 mEq p.o. q.12h. (for a period until she reaches weight similar to her preoperative weight). DISCHARGE DISPOSITION: Upon discharge, the patient is in excellent condition and was discharged to home. DI[**Last Name (STitle) 408**]E FOLLOWUP: To follow up Dr. [**Last Name (Prefixes) **] and her primary care provider. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2159-2-13**] 13:09 T: [**2159-2-13**] 12:22 JOB#: [**Job Number 38477**] Admission Date: [**2159-2-6**] Discharge Date: [**2159-2-14**] Date of Birth: [**2100-8-11**] Sex: F Service: AD[**Last Name (STitle) **]: The patient's primary care physician is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Haveril, [**State 350**]. He and Dr. [**Last Name (Prefixes) **] were following her. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2159-2-14**] 09:15 T: [**2159-2-14**] 09:26 JOB#: [**Job Number 11669**] Name: [**Known lastname 6971**], [**Known firstname 194**] Unit No: [**Numeric Identifier 6972**] Admission Date: [**2159-2-6**] Discharge Date: Date of Birth: [**2100-8-11**] Sex: F Service: DISCHARGE SUMMARY ADDENDUM: She is being discharged home on Lasix 20 milligrams po q day for seven days along with 20 milliequivalents of potassium for a period of time. Colace 100 milligrams po bid. Zantac 150 milligrams po bid. Home oxygen as needed prn to keep the sat greater than 90. With the instructions for VNA to wean off oxygen as tolerated. Metoprolol 25 milligrams po bid. Aspirin 325 milligrams po bid. Percocet one to two tablets po q four to six hours prn pain. Plavix 75 milligrams po q day. NPH home dose 38 q A.M., 35 q P.M. She is to follow up with her PCP [**Last Name (NamePattern4) **]. .................... for medical cardiovascular issues. Surgical issues to be follow up by Dr. .................... [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**] Dictated By:[**Name8 (MD) 2965**] MEDQUIST36 D: [**2159-2-14**] 09:12 T: [**2159-2-14**] 09:19 JOB#: [**Job Number 6973**]

[ "250.00", "401.9", "782.1", "414.01", "V15.82" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4190, 6453

3440, 4166

718, 808

1629, 3179

3194, 3282

3297, 3413

148, 221

250, 491

515, 691

825, 1610

28,383

129,065

31849

Discharge summary

report

Admission Date: [**2156-12-3**] Discharge Date: [**2156-12-7**] Date of Birth: [**2083-3-19**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 922**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: Aortic Valve Replacement (25mm [**Company **] mosaic) Coronary Artery Bypass Graft x1 (saphenous vein graft > left posterior descending artery) [**2156-12-3**] History of Present Illness: 73 year old male who had a syncopal episode in [**9-21**]. He underwent workup that revealed aortic stenosis. Past Medical History: Aortic Stenosis s/p AVR Coronary Artery Disease s/p CABG Hypertension Elevated Cholesterol Peripheral Vascular disease Carotid Disease Diastolic heart failure chronic Cerebral vascular accident Diabetes mellitus type 2 Skin Cancer Obesity Osteoarthritis Benigh prostatic hypertrophy Venous Stasis ulcer Social History: Social history is significant for 80 pack year history, quit 17 years ago. There is history of alcohol use of 2 beers/night. Lives with family in an in law apartment Family History: The pt's father had [**Last Name **] problem and died of MI at 76 yo. Physical Exam: General NAD obese Skin facial CA with multiple darkened areas throughout HEENT PERRLA EOMI ? cataract formation anicteric poor dentition Neck supple Full ROM Chest Right CTA, basilar crackles left Heart RRR, SEM precordium > carotids Abdomen soft, NT, ND ventral hernia Extremeties warm well perfused no edema Varicosoties none Neuro grossly intact MAE nonfocal Pertinent Results: [**2156-12-6**] 06:30AM BLOOD WBC-13.2* RBC-3.13* Hgb-10.1* Hct-29.9* MCV-96 MCH-32.2* MCHC-33.7 RDW-13.7 Plt Ct-181 [**2156-12-2**] 02:10PM BLOOD WBC-11.3* RBC-4.94 Hgb-15.2 Hct-44.3 MCV-90 MCH-30.8 MCHC-34.4 RDW-13.6 Plt Ct-328 [**2156-12-2**] 02:10PM BLOOD Neuts-73.1* Lymphs-21.0 Monos-4.4 Eos-1.2 Baso-0.3 [**2156-12-6**] 06:30AM BLOOD Plt Ct-181 [**2156-12-5**] 09:45AM BLOOD PT-12.4 PTT-25.9 INR(PT)-1.1 [**2156-12-2**] 02:10PM BLOOD Plt Ct-328 [**2156-12-2**] 02:10PM BLOOD PT-11.5 PTT-23.7 INR(PT)-1.0 [**2156-12-3**] 12:04PM BLOOD Fibrino-195 [**2156-12-2**] 02:10PM BLOOD Glucose-172* UreaN-24* Creat-1.2 Na-135 K-4.0 Cl-94* HCO3-29 AnGap-16 [**2156-12-2**] 02:10PM BLOOD ALT-31 AST-22 AlkPhos-86 Amylase-71 TotBili-0.4 [**2156-12-6**] 06:30AM BLOOD Calcium-9.6 Phos-3.1 Mg-2.4 [**2156-12-2**] 02:10PM BLOOD %HbA1c-6.7* RADIOLOGY Final Report CHEST (PA & LAT) [**2156-12-5**] 11:58 AM CHEST (PA & LAT) Reason: post ct removal / pneumo [**Hospital 93**] MEDICAL CONDITION: 73 year old man with severe AS/CAD REASON FOR THIS EXAMINATION: post ct removal / pneumo CHEST, PA AND LATERAL HISTORY: Aortic stenosis, coronary artery disease, chest tube removal. TWO VIEWS. Comparison with the previous study done [**2156-12-3**]. A left chest tube, endotracheal tube, nasogastric tube, mediastinal drain, and pulmonary arterial line have been withdrawn. There is interval improvement in streaky density at the left base, which probably represents subsegmental atelectasis. There is interval development of increased density at the right base, also consistent with subsegmental atelectasis. A small area of consolidation at the bases cannot be excluded. There are small bilateral pleural effusions, new or increased since the previous study. The patient is status post median sternotomy. Widening of the superior mediastinum consistent with postsurgical change, has improved. IMPRESSION: Streaky density at the lung bases consistent with subsegmental atelectasis. Small area of consolidation at the lung bases cannot be excluded. Small bilateral pleural effusions due to postsurgical change from the mediastinum. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**] Approved: SUN [**2156-12-5**] 6:03 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 74698**] (Complete) Done [**2156-12-3**] at 10:17:43 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2083-3-19**] Age (years): 73 M Hgt (in): 64 BP (mm Hg): / Wgt (lb): 218 HR (bpm): BSA (m2): 2.03 m2 Indication: Intraoperative TEE for AVR and CABG ICD-9 Codes: 440.0, 424.1, 424.0 Test Information Date/Time: [**2156-12-3**] at 10:17 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW1-: Machine: 1 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: 2.8 cm <= 3.6 cm Aorta - Sinotubular Ridge: 0.2 cm <= 3.0 cm Aorta - Ascending: *3.7 cm <= 3.4 cm Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm Aortic Valve - Peak Velocity: *4.0 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *64 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 25 mm Hg Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2 Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mildly depressed LVEF. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in aortic root. Mildly dilated ascending aorta. Simple atheroma in ascending aorta. Simple atheroma in aortic arch. Mildly dilated descending aorta. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Moderate to severe (3+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. 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 appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of mitral regurgitation.] There is hypokinesis of the inferior segments. 3, The right ventricular cavity is mildly dilated. Right ventricular systolic function is borderline normal. 4. There are simple atheroma in the aortic root. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. 7. The tricuspid valve leaflets are mildly thickened. POST-BYPASS: Patient removed from cardiopulmonary bypass on phenylephrine drip and AV paced. 1. Mechanical prosthetic valve is noted in the aortic valve position. The valve is well seated without evidence of paravalvular leak or regurgitation. Mean gradient across the valve is 7mmHg and peak gradient is 17mmHg. 2. Biventricular function is maintained. 3. Aortic contours are intact post-decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting physician Cardiology Report ECG Study Date of [**2156-12-3**] 2:49:40 PM Sinus rhythm. Right bundle-branch block. Compared to tracing of [**2156-12-2**] there is no significant diagnostic change. Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**] Intervals Axes Rate PR QRS QT/QTc P QRS T 75 0 140 398/424 0 91 10 Brief Hospital Course: He admitted and went to the operating room for coronary artery bypass graft x 1 and aortic valve replacement. Please see operative report for surgical details. He tolerated the procedure well and was transferred to the CVICU for invasive monitoring in stable condition. Later that day he was weaned from sedation, awoke neurologically intact and was extubated. On post-op day one he was transferred to the floor starting beta blockers and lasix for gentle diuresis. He was gently diuresed towards his pre-op weight. Physical therapy followed patient during post-op course for strength and mobility. He continued to make steady process without any post-op complications and was discharged to rehab on post op day 4. Medications on Admission: Univasc Metoprolol Thiazide Lipitor ASA MVI Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. insulin SS please see page 2 for scale 10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Aortic Stenosis s/p AVR Coronary Artery Disease s/p CABG Hypertension Elevated Cholesterol Peripheral Vascular disease Carotid Disease Diastolic heart failure chronic Cerebral vascular accident Diabetes mellitus type 2 Skin Cancer Obesity Osteoarthritis Benigh prostatic hypertrophy Venous Stasis ulcer Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule all appointments Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**Last Name (STitle) 3142**] after discharge from rehab [**Telephone/Fax (1) 19980**] Dr [**Last Name (STitle) **] after discharge from rehab [**Telephone/Fax (1) 74699**] Completed by:[**2156-12-7**]

[ "250.00", "414.01", "424.1", "443.9", "272.0", "428.21", "401.9", "600.00", "428.0" ]

icd9cm

[ [ [] ] ]

[ "39.63", "88.72", "36.11", "35.21", "39.61" ]

icd9pcs

[ [ [] ] ]

10795, 10872

9138, 9856

281, 443

11219, 11226

1579, 2535

11737, 12087

1111, 1182

9950, 10772

2572, 2607

10893, 11198

9882, 9927

11250, 11714

6990, 9115

1197, 1560

234, 243

2636, 6941

471, 583

605, 910

926, 1095

25,147

106,000

29831

Discharge summary

report

Admission Date: [**2128-1-11**] Discharge Date: [**2128-1-16**] Date of Birth: [**2059-8-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5438**] Chief Complaint: Transfer from [**Hospital3 2568**] for further workup of pancytopenia and respiratory distress Major Surgical or Invasive Procedure: Intubation History of Present Illness: 68 yo F with h/o hypertension and DM who presented to [**Hospital3 **] ED on [**2128-1-10**] with worsing shortness of breath and fevers to 102. She was found to be anemic to 16.7, thrombocytopenic with plt of 2, and borderline leukopenia of 3.5. At the time the etiology was unclear. She had a bone marrow biopsy on [**2128-1-10**] with a premil read of all cell lines present, L shift of WBC, increased promyelocytes and megabloblastoid RBCs. She was transfused multiple blood products including 7.5 PRBC, 12 units of FFP, 6 packs of platelets with improvement of her counts to HCT 28.9, plt 9. She was guaiac positive. On the morning of [**2128-1-11**] she became acutely SOB, CXR Her CXR initially showed, CXR showed patchy bilateral opacities consistent with either CHF or TRALI. A report of a CXR earlier in her admission notes mild interstial edema and a CTA on [**2128-1-7**] was essentially normal. She had an echo that showed trace MR, normal systolic function, EF >65%. . History per OSH notes and per sister revealed that she has had worsening DOE for past 3-4 days. She has had some heavy breathing in the past, but is able to exercise at Curves 3 times per week. She saw her PCP regarding the SOB who ordered a CXR and a stress test. Supposedly there was something on the stress test that cause him to order a CTA. . On arrival to [**Hospital1 18**] [**Hospital Unit Name 153**] she was satting in the 70's on BiPap and was urgently intubated. She was not breathing in sync with the vent and was having trouble oxygenating. She was started on cisatracurium. She required 100%oxygen. She had melana and some bright red blood in her ETT. She was transfused platelets and given lasix 80 mg IV. Past Medical History: DMII Hypertension Hypercholesterolemia s/p tonsillectomy s/p TAH Social History: Never married, no children, lives with her sister, former [**Name2 (NI) 1818**], quit 8 years ago, no ETOH Family History: Father: sinus cancer, Mother: colon cancer, [**Name (NI) 11964**]. Physical Exam: 101.1, HR 100-110, BP 200/115-> 111/44, RR 30's on arrival, 20 on vent, 70's on arrival on NRB/Bipap, 92% on vent AC 450x28, 100%, PEEP 8 GENL: sedated HEENT: OP with dried blood, no petechiae on palate CV: RRR Lungs: occasional crackles, good airmovement Abd: soft, nt, nd, no splenomegaly appreciated, +BS Ext: no edema, + petechiae in hands bilat, 2+ pedal pulses Neuro: Prior to sedation - alert, oriented, following commands Pertinent Results: [**2128-1-11**] 05:13PM BLOOD WBC-2.9* RBC-3.52* Hgb-11.1* Hct-30.6* MCV-87 MCH-31.5 MCHC-36.3* RDW-14.6 Plt Ct-15* [**2128-1-16**] 03:06AM BLOOD WBC-2.7* RBC-2.85* Hgb-9.0* Hct-25.2* MCV-88 MCH-31.6 MCHC-35.8* RDW-14.7 Plt Ct-5* [**2128-1-11**] 05:13PM BLOOD Neuts-39* Bands-9* Lymphs-25 Monos-17* Eos-0 Baso-1 Atyps-6* Metas-1* Myelos-2* NRBC-9* [**2128-1-16**] 03:06AM BLOOD Neuts-46* Bands-13* Lymphs-21 Monos-5 Eos-1 Baso-1 Atyps-8* Metas-3* Myelos-2* NRBC-5* [**2128-1-11**] 05:13PM BLOOD PT-16.7* PTT-26.4 INR(PT)-1.5* [**2128-1-16**] 03:06AM BLOOD PT-17.6* PTT-24.7 INR(PT)-1.6* [**2128-1-11**] 05:13PM BLOOD Fibrino-206 [**2128-1-12**] 08:03AM BLOOD Fibrino-439* D-Dimer->[**Numeric Identifier 961**]* [**2128-1-14**] 01:27PM BLOOD Fibrino-192 D-Dimer->[**Numeric Identifier 961**]* [**2128-1-15**] 01:13PM BLOOD Fibrino-119* D-Dimer-[**Numeric Identifier 961**]* [**2128-1-15**] 01:13PM BLOOD FDP-80-160* [**2128-1-16**] 03:06AM BLOOD Fibrino-101* [**2128-1-13**] 05:25AM BLOOD WBC-1.4* Lymph-53* Abs [**Last Name (un) **]-742 CD3%-54 Abs CD3-400* CD4%-46 Abs CD4-341* CD8%-8 Abs CD8-58* CD4/CD8-5.8* [**2128-1-11**] 05:13PM BLOOD Glucose-253* UreaN-32* Creat-0.9 Na-143 K-4.0 Cl-100 HCO3-29 AnGap-18 [**2128-1-16**] 03:06AM BLOOD Glucose-203* UreaN-149* Creat-2.2* Na-139 K-4.9 Cl-106 HCO3-22 AnGap-16 [**2128-1-11**] 05:13PM BLOOD ALT-18 AST-15 LD(LDH)-490* CK(CPK)-58 AlkPhos-41 Amylase-29 TotBili-4.6* [**2128-1-16**] 03:06AM BLOOD ALT-30 AST-19 AlkPhos-28* TotBili-2.1* [**2128-1-11**] 10:23PM BLOOD proBNP-4252* [**2128-1-14**] 07:05PM BLOOD Triglyc-178* [**2128-1-11**] 10:23PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2128-1-15**] 03:39PM BLOOD ANCA-NEGATIVE B [**2128-1-15**] 03:39PM BLOOD [**Doctor First Name **]-NEGATIVE [**2128-1-12**] 02:30AM BLOOD C3-86* [**2128-1-11**] 05:42PM BLOOD Type-ART Temp-38.4 Rates-15/5 Tidal V-650 PEEP-5 pO2-77* pCO2-57* pH-7.35 calTCO2-33* Base XS-3 -ASSIST/CON Intubat-INTUBATED [**2128-1-16**] 09:55AM BLOOD Type-ART Temp-38.6 Rates-30/3 Tidal V-400 PEEP-24 FiO2-60 pO2-105 pCO2-54* pH-7.23* calTCO2-24 Base XS--5 -ASSIST/CON Intubat-INTUBATED [**2128-1-11**] 05:42PM BLOOD Lactate-3.4* [**2128-1-16**] 03:40AM BLOOD Lactate-2.6* Brief Hospital Course: Impression: 68 yo female transferred from an outside hospital with pancytopenia and patchy bilateral infiltrates found to have hemophagocytic lymphohistiocytosis. . Hospital Course: # Pancytopenia: On admission the etiology of the patient's pancytopenia was unlcear. The initial differential diagnosis included myelodysplastic syndrome vs. myelosupression from viral syndrome or toxin vs. hemophagocytic syndrome. Microbiology studies including Erlichia, EBV, CMV, HCV, parvovirus, and LCM serologies were all unremarkable. The hematology/oncology service was involved early in the patient's care. Slides from the bone marrow biopsy performed at the outside hospital were received [**2128-1-14**]. The [**Hospital1 18**] pathology report indicated hypercellular marrow with increased hemophagocytic histiocytes--findings consistent with a diagnosis of hemophagocytic lymphohistiocytosis. Hematology offered the option of treatment with etoposide and dexamethasone. However, given the often poor response to this therapy and the patient's severe illness, the prognosis was felt to remain poor. Therapeutic options were discussed with the patient's family, including her sister, who is also her health care proxy. [**Name (NI) 227**] the prognosis the family/HCP felt that it would be in the patient's wishes to be made comfort measures only. Aggressive therapy, including ventilatory support was removed. All attempts were made to make the patient comfortable. The patient expired and was pronounced dead on [**2128-1-16**] at 3:20 PM. . # Bilateral infiltrates: The patient was diagnosed as having acute respiratory distress syndrome likely secondary to transfusion related lung injury vs. sepsis. The patient was urgently intubated upon her arrival to the [**Hospital1 18**] [**Hospital Unit Name 153**]. Her ventilatory and oxygenation status was monitored closely and her ventilator was adjusted according to ARDS protoccol. As above, she was made CMO and was extubated. . # Fever: The differential diagnosis for the patient's fever included an infectious process vs fever associated with ARDS. The infectious possibilities were numerous given the patient's relative immunosuppression. The patient was placed on broad spectrum antibiotics, but continued to spike temperatures throughout the hospitalization. Microbiology studies as above were all unremarkable. Multiple blood, sputum, and urine cultures were all negative. Anti-microbial treatment was removed when the patient's code status changed to CMO. . # Renal failure: The patient was felt to likely be prerenal with hypoperfusion in setting of sepsis. Urine lytes were consistent with a prerenal picture. The patient was given aggressive fluid resuscitation with a minimal response in her creatinine. Her renal function was monitored closely throughout the admission. . # GIB: The patient had evidence of guaiac positive stools during her admission. She was continued on a PPI throughout her hospital course. . # DM: The patient was placed on an insulin drip for tight glycemic control. . # FEN: The patient was continued on tube feeds throughout her hospitalization with fluid resuscitation as above. . # PPX: Heparin was held given her low platelets. Pneumoboots were placed. She was placed on a PPI as above. . # Code: The patient was full code on admission and was changed to comfort measures only as above. Medications on Admission: Meds at home: Diovan ASA Metformin 1000 mg [**Hospital1 **] Simvastatin - d/c'd 2 wks ago . Meds on tx: Lasix 40 iv, 60 iv morphine Zosyn Vanco Calcium gluconate Discharge Disposition: Expired Discharge Diagnosis: hemophagocytic lymphohistiocytosis acute respiratory distress syndrome acute renal failure Discharge Condition: The patient is deceased. Discharge Instructions: The patient is deceased. Followup Instructions: The patient is deceased.

[ "786.3", "250.00", "785.52", "401.9", "286.6", "277.89", "038.9", "518.81", "428.0", "284.8", "584.9", "578.1", "707.8" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "99.07", "00.17", "93.90", "99.05", "99.04", "96.04", "99.06" ]

icd9pcs

[ [ [] ] ]

8750, 8759

5163, 5328

411, 423

8893, 8919

2921, 5140

8992, 9019

2387, 2455

8780, 8872

8564, 8727

5345, 8538

8943, 8969

2470, 2902

276, 373

451, 2158

2180, 2247

2263, 2371

900

108,257

7189

Discharge summary

report

Admission Date: [**2129-10-18**] Discharge Date: [**2129-10-22**] Date of Birth: [**2072-10-1**] Sex: F Service: CHIEF COMPLAINT: Pelvic organ prolapse status post anterior-posterior repair. HISTORY OF PRESENT ILLNESS: This is a 56-year-old G3, P3 who has noticed an increasing vaginal bulge in [**Month (only) 205**] of this year. but did notice an increase in urinary frequency, nocturia, and urgency. She had no change in her bowel habits, and is not sexually active. Preoperative physical examination showed a Stage II pelvic organ prolapse mostly cystocele. The decision was made to proceed with an anterior-posterior colporrhaphy. PAST MEDICAL HISTORY AND PAST SURGICAL HISTORY: Uterine suspension and total abdominal hysterectomy, left salpingo-oophorectomy in [**2106**], three right breast biopsies all benign, tonsil and adenoidectomy, and appendectomy, irritable bowel syndrome, pernicious anemia, migraine headaches. PAST OB HISTORY: Three full term normal spontaneous vaginal deliveries. The first one was complicated with postpartum hemorrhage. Last Pap smear was [**2129-8-3**] which was within normal limits. PSYCHOSOCIAL HISTORY: She denies any tobacco or alcohol use. MEDICATIONS: Vitamin B12 q month, Fosamax 50 mg q week, Celexa 40 mg q day. ALLERGIES: Penicillin, sulfa, clindamycin, and IVP dye. FAMILY HISTORY: Mother died of breast cancer at age 52. Father has diabetes, heart disease, peripheral vascular disease. HOSPITAL COURSE: The patient was brought to the operating room for same-day admission for anterior-posterior colporrhaphy. The procedure was without complications, except for a difficult intubation. The estimated blood loss was 200 cc. Intraoperative findings included a Grade II-III cystocele, a Grade II rectocele, and a normal vaginal cuff. In the immediate postoperative period, there was noted to be continuous bleeding from the vagina. Removal of the vaginal pack showed vigorous bleeding from two areas in the vagina surgical incision. She was taken back to the operating room where, under a second general anesthesia, these two bleeding points were suture ligated with excellent hemostasis. The estimated blood loss from the second procedure was 50 cc. Postoperatively, because of the difficult intubation and the result of pharyngeal edema, the decision was made to keep the patient intubated and in the MICU in order to optimize airway management. The patient did well hemodynamically in the MICU and was extubated successfully on postoperative day one. The patient's vital signs were stable with excellent O2 saturations. The patient was transferred to the regular GYN floor on postoperative day one. Her pain was well controlled with IM Demerol and was rapidly converting to po Percocet once the patient began tolerating a regular po diet. On postoperative day #2, the patient had a slight temperature elevation up to 101.9. The patient at this time was passing flatus, ambulating freely, voiding spontaneously with no complaints of frequency. The patient had a chest x-ray was within normal limits. She had a urinalysis sent which was negative and the urine culture was also subsequently negative. Her white count was 7.4. The patient was started on Levaquin, rather than chance a pneumonia. The patient did well until the day of discharge (Levaquin day #2). The day of discharge, the patient began complaining of a generalized rash (nonitchy). Inspection of this rash describes the lesions as macular appearing rashes. The decision was made at this point to stop her Levaquin. No additional antibiotic was started as her cultures have been negative to date, she has been afebrile and the white count was not elevated. The patient will be discharged to home with the following medications: Percocet, Motrin, and Reglan. The patient's condition on discharge is good and the patient is discharged to home. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19144**] Dictated By:[**Name8 (MD) 4872**] MEDQUIST36 D: [**2129-10-23**] 00:20 T: [**2129-10-26**] 11:31 JOB#: [**Job Number 26678**] cc:[**Last Name (NamePattern4) 26679**]

[ "478.25", "564.1", "618.0", "346.90", "998.11", "E878.8", "281.0" ]

icd9cm

[ [ [] ] ]

[ "70.50", "70.71" ]

icd9pcs

[ [ [] ] ]

1368, 1474

1492, 4222

707, 1158

146, 208

237, 683

1175, 1351

17,661

188,864

46631

Discharge summary

report

Admission Date: [**2158-2-2**] Discharge Date: [**2158-2-12**] Date of Birth: [**2079-3-12**] Sex: F Service: CCU CHIEF COMPLAINT: Patient admited [**2-2**] for elective BiV pacer placement. Transferred to the CCU on [**2-3**] secondary to increased pericardial effusion. HISTORY OF PRESENT ILLNESS: This is a 78-year-old female with non-insulin dependent-diabetes and COPD, whose cardiac history is significant for coronary artery disease status post MI in [**2133**], PTCA, RCA stent in [**2152**], hypertension, dyslipidemia, CHF with an ejection fraction of 25% on a transthoracic echocardiogram done [**2158-2-3**], who was evaluated for BiV placement secondary to decreased exercise tolerance and shortness of breath over the last several years. Patient received her BiV ICD implant on [**2158-2-2**]. Vital signs were hemodynamically stable throughout the procedure. Patient complained of left sided chest pain and had ongoing nausea on [**2158-2-3**] that prompted a transthoracic echocardiogram, which revealed a small pericardial effusion with thrombus formation over the right ventricle without evidence of tamponade. However, she began to experience increasing nausea and heaviness in the chest, and a repeat transthoracic echocardiogram revealed slightly increased effusion size of approximately 1.5 cm. During the course of the hospitalization, patient had remained hemodynamically stable with blood pressures 118-156/55-70, sats 96-98% on [**3-2**] liters of O2. On admission she was not experiencing any new symptoms or complaints of shortness of breath or chest pain. ALLERGIES: Lisinopril. PREVIOUS MEDICAL HISTORY: 1. CAD with a MI in [**2133**]. 2. Diabetes. 3. COPD not on home O2, however, this was recommended one year prior to this admission. 4. CHF with an EF of 25%. 5. Hypertension. 6. AS with a valve area of 1.3 cm in [**8-31**]. 7. Dyslipidemia. SOCIAL HISTORY: Patient has multiple children and grandchildren, one of whom is a nurse [**First Name (Titles) **] [**Last Name (Titles) 18**]. SURGICAL HISTORY: Status post cholecystectomy in [**2153**]. PHYSICAL EXAM: Temperature 97.9, blood pressure 118-156/40-66, pulse 61-101. Patient is [**Age over 90 **]% on 2 liters of O2. Blood glucoses ranging 148-225. Respiratory rate 18-22. Pulsus paradoxus at 14. In general, patient is in no acute distress, speaking in full sentences. Pulmonary exam: Clear to auscultation bilaterally. Cardiovascular exam: S1, S2 regular, 2/6 systolic murmur right upper sternal border. No JVD is noted. Abdominal exam: Soft, nontender, nondistended. Extremities: No edema. Neurological exam is nonfocal. Transthoracic echocardiogram shows an echo-dense effusion. There is no evidence of tamponade. LABORATORIES: White count 8.4, hematocrit 34.5, platelets 149. HOSPITAL COURSE: This is a 78-year-old woman with noninsulin-dependent diabetes with history of CAD, CHF with an ejection fraction of 25%. He is status post BiV ICD placement on [**2-2**]. Developed an increasing pericardial effusion, but remained hemodynamically stable. 1. Cardiovascularly: Patient was admitted to the CCU on [**2-3**] for monitoring of her pericardial effusion. All aspirin, anticoagulants such as Coumadin were held. Patient had a frequent monitoring of her pulsus paradoxus, which ranged from [**12-12**], but did not increase. Patient had repeated multiple follow-up echocardiograms, which demonstrated resolution of her small pericardial effusion. Patient did complain of increased pain at the site of her pacemaker implantation. She was given Morphine for this pain, which caused increasing nausea. Morphine was changed to tramadol secondary to multiple days of nausea and vomiting. This resolved moderately. Was changed to NSAIDs, although did not completely resolve. Patient was hemodynamically stable, and was transferred to the floor. Rhythm: Patient was V-paced with multiple PVCs. On [**2-4**], she was noted to have rapid rates alarming for V-tach. Patient was started on her beta blocker and monitored. On [**2158-2-5**], patient was again alarmed for a rapid rate. On [**2-6**], patient's pacer was evaluated and interrogated by the EP service, who found that she was in paroxysmal atrial fibrillation. Patient was started [**2-6**] on an amiodarone dose of 400, then changed to 200 t.i.d. Patient was cardioverted [**2-7**] without any complications. Thyroid function and liver function was assessed. Patient had pulmonary function tests one year prior to admission on [**2157-2-2**] that can serve as a pre-amiodarone baseline. TSH was 1.3 this admission, AST 17, ALT 10. Patient remained A-paced to avoid returning into a PAF and remained stable with a regular rate throughout the remainder of hospital course. Patient was discharged home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor to be followed by Dr. [**Last Name (STitle) **]. Amiodarone was discontinued two days prior to discharge. This will be discussed under nausea and vomiting. Pump: Patient had an EF notable for 25%. She was continued on her home medications. Digoxin was started and carvedilol. Endocrine: Patient has diabetes. She was maintained on regular insulin-sliding scale, metformin. Pulmonary: Patient was noted to have decreased sats on room air ranging 78-85%. It was noted from patient's previous admission one year prior that she had similar sats on room air as well as a full set of pulmonary function tests. Patient had been sent home on home O2. However, patient states she never felt the need for home O2, and did not wear it often. It was explained to patient this will be encouraged in the future for further use. Hematology: Patient was transfused 1 unit of packed red blood cells for hematocrit of 27. On [**2-5**], she is noted to have a fairly large hematoma over her ICD placement. Patient had OB negative stool throughout the course of this hospital stay. Hematoma gradually resolved. Nausea and vomiting: Patient initially experienced nausea and vomiting on [**2-3**] leading to the transthoracic echocardiogram that demonstrated her pericardial effusion. Her nausea and vomiting persisted throughout her hospital course, although is somewhat improved off of narcotics. Patient developed diarrhea one day after her amiodarone load. Cultures and Clostridium difficile were sent. Clostridium difficile was negative. Cultures are pending upon patient's discharge. Patient continued to have nocturnal vomiting [**2-7**] through [**2-10**]. Patient was sent for a head CT to rule out a mass that would lead to nocturnal vomiting. Head CT was negative. Patient was to be discharged on [**2-10**], however, this was delayed secondary to extensive diarrhea and continued vomiting. Amiodarone was discontinued at this time. Patient was started on Imodium. Nausea, vomiting, and diarrhea slowly resolved, and patient was able to be discharged home hemodynamically stable, tolerating p.o. on [**2-12**]. FINAL DIAGNOSES: 1. Diabetes. 2. Coronary artery disease status post myocardial infarction in [**2133**] and percutaneous transluminal angioplasty, right coronary artery stent in [**2152**]. 3. Chronic obstructive pulmonary disease. 4. Congestive heart failure with an ejection fraction of 25%. 5. Hypertension. 6. Stable pericardial effusion. 7. Status post BiV ICD placement. 8. Atrial fibrillation status post cardioversion. FOLLOWUP: 1. Patient was to followup in Device Clinic [**2158-2-16**]. She will also have a follow-up echocardiogram. 2. Patient will follow up with [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 496**] in Cardiac services, [**2158-2-24**]. 3. Patient was instructed to make an appointment with her primary care doctor, Dr. [**Last Name (STitle) 6955**] to followup on nausea, vomiting, and diarrhea. 4. Patient was to have a follow-up appointment with Dr. [**Last Name (STitle) **] within two weeks. Patient has an additional follow-up appointment with Dr. [**Last Name (STitle) **] on [**2158-3-28**]. MAJOR SURGICAL PROCEDURE: 1. Status post BiV ICD pacer implantation on [**2158-2-2**]. 2. Cardioversion [**2158-2-7**]. DISCHARGE CONDITION: Vital signs: Temperature 96, blood pressure 128/85, heart rate 85, patient is [**Age over 90 **]% on 2 liters of O2. Patient is tolerating p.o., ambulating well, and room air sats are less than 90%. Amiodarone was discontinued secondary to nausea and vomiting. Patient tolerated both breakfast and lunch without further GI distress prior to discharge. DISCHARGE MEDICATIONS: 1. Maalox suspension. 2. Losartan 25 three tablets p.o. b.i.d. 3. Metformin 500 b.i.d. 4. Ranitidine 150 p.o. b.i.d. 5. Sertraline 50 q.d. 6. Digoxin 125 mcg q.d. 7. Atorvastatin 10 1.5 tablets p.o. q.d. 8. Albuterol. 9. Lasix 40 q.d. 10. Carvedilol 3.125 mg p.o. b.i.d. 11. Tylenol. 12. Tramadol 50 p.o. q.4-6h p.r.n. x7 days. 13. Imodium. 14. Aspirin 81 mg. 15. Metoclopramide t.i.d. x2 days. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**] Dictated By:[**Last Name (NamePattern1) 5713**] MEDQUIST36 D: [**2158-2-12**] 20:02 T: [**2158-2-13**] 04:48 JOB#: [**Job Number 99013**]

[ "496", "996.72", "423.9", "414.01", "401.9", "425.4", "428.0", "250.00", "427.31" ]

icd9cm

[ [ [] ] ]

[ "00.51", "37.26", "99.04", "99.61" ]

icd9pcs

[ [ [] ] ]

8237, 8594

8617, 9304

2844, 7041

2132, 2826

7058, 8215

149, 292

321, 1907

1924, 2116

26,396

109,162

21078

Discharge summary

report

Admission Date: [**2106-7-6**] Discharge Date: [**2106-7-13**] Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 2704**] Chief Complaint: Scheduled cardiac cath for stable angina Major Surgical or Invasive Procedure: Cardiac cath History of Present Illness: 87 year old female with history of CAD, MI, and prior placement of cypher stent in her RCA on [**2106-3-29**]. After the cath she reports that she her symptoms improved, but for the past couple months she has had several episodes of the sensation that someone is "squeezing her chest." She has had three of these episodes in the last couple months, which occur at rest. The most recent was yesterday where she developed the chest "squeeze", SOB, nausea and bilateral shoulder pain. She denied any diaphoresis with this epidose. It lasted for a couple minutes, was relieved partially with one nitro, and completely with the second nitro. She was admitted today for an elective cath and during the procedure she was found to have one vessel CAD in her LAD with 70% proximal stenosis and 80% distal stenosis. Successful PTCA and Cypher stent in LAD. Her right and left heart filling pressures were moderately elevated and her CI was low at 2.0 on Dopamine gtt. She was also noted to have a long Type A dissection with good flow. Given her poor cardiac output an IABP was inserted with good systolic augmentation. Patient was then admitted to CCU. On ROS: + weakness and fatigue for the last few months + constipation - last BM 3 weeks ago, still passing flatus no new cough, nausea, decrease in appetite, abdominal pain, dysuria, or increased urinary frequency Past Medical History: DDI Pacemaker placed [**5-29**] Hx of Digoxin Toxicity Appendectomy Cholecystectomy Arthritis Afib Hernia repair Hard of hearing Allergies: Codeine: GI upset Social History: Patient lives in [**Location 620**] MA, next door to one of her sons. She does not use tobacco or alcohol. The patient walks with a cane and walker. Family History: Her father died in his 80's of "old age" and her mother died of cancer at 52 years old. No history of CAD. Physical Exam: Vitals: WT 55 kg T 96.0 BP 110/49 HR 63 RR 12 PO2 92% RA Gen: pleasant elderly woman, resting flat in bed, in NAD HEENT: MM dry, EOMI, right pupil asymmetric, left pupil round, both reactive to light Neck: no JVD CV: RR, nl S1, S2, no MGR Pulm: CTAB anteriorly, no w/c/r Abd: + BS, soft, NT, ND Ext: no peripheral edema Skin: purpura on upper extremities, Neuro: AAOx3, CN II-XII intact, no focal abnormalities with exception of asymmetric pupils Pertinent Results: Admission Labs [**2106-7-6**]: ABG: pH 7.31 pCO2 42 pO2 110 HCO3 22 Hgb:10.9 CalcHCT:33 O2Sat: 97 . 11.0 > 12.4/37.2 < 211 MCV=92 . 142 / 102 / 47 ---------------< 117 4.1 / 29 / 1.3 . PT: 11.7 PTT: 23.4 INR: 0.9 . CK: 34 MB: Notdone Trop-*T*: <0.01 . CATH RESULTS [**2106-7-6**]: FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful stenting of the LAD. COMMENTS: 1. Coronary angiography showed single vessel CAD. The LMCA had mild tapering. The LAD was diffusely diseased with a 70% proximal stenosis extending to D3, which has an 80% stenosis distally. The LCX had no flow-limiting lesions. The RCA stent was widely patent with a 70-80% stenosis of the last major RPL branch. 2. Resting hemodynamics showed normal central aortic pressures, moderately elevated right and left heart filling pressures and a mildly depressed cardiac index (2.0, on Dopamine gtt). 3. Successful PTCA and stenting of the LAD with three 2.25 mm MiniVision stents and a 2.5 mm Cypher drug-eluting stent, which was post-dilated to 2.75 mm. Final angiography showed no residual stenosis, a long Type A dissection with good flow (see PTCA comments). 4. A 7 French 30 cc IABP was inserted with good systolic augmentation. . ECHO RESULTS [**7-7**]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed with global hypokinesis and akinesis of the distal septum and apex. LVEF of 30-35%. No LV mass/clot seen. 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. Mild to moderate ([**12-27**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. Compared to the prior report (tape unavailable for reviewe) dated [**2105-6-23**], the regional/global LV systolic dysfunction is new. The pericardial effusion is probably similar. . ECHO RESULTS [**7-12**]: Overall left ventricular systolic function is moderately depressed. Left Ventricle - Ejection Fraction: 30% to 35%. Right ventricular chamber size and free wall motion are normal. Mild to moderate ([**12-27**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (tape reviewed) of [**2106-7-7**], there is no diagnostic change. . CXR [**7-13**]: Compared with [**2106-7-11**], lung volumes have improved and there has been considerable partial interval clearing of the atelectasis at the left base. There is persistent blunting of both costophrenic angles, left greater than right, consistent with small effusions. There appears to be slight increase in the upper zone pulmonary vascularity, consistent with mild CHF. . Brief Hospital Course: # CAD - Cath showed one vessel disease, and Cypher stent was successfully placed in LAD. The procedure was complicated by Type A dissection of the LAD, which was stabilized with successive balloon inflations and placement of 3 mini-vision (bare metal) stents with subsequent TIMI 2 fast flow. CO/CI measured at 2.9/2.0. She was on an intraaortic balloon pump to augment systolic function and on a dopamine drip when she initially came to the CCU. She was successfully weaned from dopamine and the IABP was removed. She was transferred to the floor without any further chest pain or tightness. Patient did not tolerate the addition of an ace inhibitor or beta blocker due to low blood pressure, but will continue aspirin, statin and plavix for further preventive management. Will follow up with her cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5293**] in the week following discharge. . # Pump - last ECHO on [**2105-6-23**] showed EF of >55%. Repeat ECHO showed EF of 30-35% and a small to moderately sized pericardial effusion (see report in results). A second ECHO was obtained due to persistent hypotension and tachycardia to assess for possible tamponade, which showed a small effusion and no signs of tamponade. It was noted that she has a 15-20 mmHg discrepancy between her thigh and arm BP (thigh 115, arm 95). The pulsus was normal (4). She had no evidence of end-organ hypoperfusion. . # Rhythm - History of atrial fibrillation, patient has a [**Company 1543**] DDI pacer. Intermittently paced throughout hospital stay. Will continue coumadin as an outpatient and will have follow up with her PCP and in device clinic for further management. . # Pulm - Patient developed pulmonary congestion while she was admitted. She responded well to Lasix. At the time of discharge her CXR still showed signs of pulmonary congestion and small bilateral effusions, but was greatly improved. Her discharge weight was 53kg and O2 sat was 99% on RA. . # FEN - Electrolytes were maintained with K>4 and Mg>2 during her hospital course. She was continued on heart healthy diet. . # Heme - Hematocrit was stable after the cath. She did not require any additional blood products. . # Prophylaxis: Patient was given pneumoboots and heparin for DVT prophylaxis. . # Dispo - PT consult was obtained and she was recommended for rehab before returning to home. Medications on Admission: Oxybutynin 5mg [**Hospital1 **]- Celexa 5mg daily- Metoprolol 12.5mg [**Hospital1 **] Aspirin 81mg daily- Quinine 325mg prn for leg cramps - Percocet 5mg prn for arthritis pain- Vitamins daily- Lasix 20mg daily- Oxazepam 15mg qhs prn Plavix 75mg daily- Colace 100 mg [**Hospital1 **] Lipitor 40mg every evening- Imdur 30mg twice a day- 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. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days: Final dose on [**2106-7-14**]. 11. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Coronary artery disease Pericardial effusion Bilateral pleural effusions Discharge Condition: Stable Discharge Instructions: breath, chest pain, or dizziness. Limit yourself to less than 2 grams of sodium per day. Do NOT stop your plavix for any reason. Please weight yourself each day and notify your doctor of weight gain greater than 3 pounds per day as this may suggest fluid retention. Followup Instructions: Please follow up with your primary doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 17753**] within 1 week. Please follow up with your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5293**] at [**Telephone/Fax (1) 4105**] within 1 week of discharge. Completed by:[**2106-7-13**]

[ "427.31", "424.0", "414.01", "423.9", "413.9", "412", "V70.7", "V45.01", "414.12", "511.9" ]

icd9cm

[ [ [] ] ]

[ "38.91", "37.23", "88.52", "36.07", "00.17", "37.61", "36.06", "99.20", "36.01", "88.56" ]

icd9pcs

[ [ [] ] ]

9588, 9665

5762, 8159

255, 269

9782, 9790

2632, 2919

10107, 10474

2036, 2144

8546, 9565

9686, 9761

8185, 8523

2936, 5739

9814, 10084

2159, 2613

175, 217

297, 1668

1690, 1851

1867, 2020

22,823

199,853

27407+57545

Discharge summary

report+addendum

Admission Date: [**2178-4-29**] Discharge Date: [**2178-5-11**] Date of Birth: [**2107-6-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4219**] Chief Complaint: DKA and new subdural hematoma Major Surgical or Invasive Procedure: none History of Present Illness: 70M with hyperlipidemia and DM1 transferred from [**Hospital **] Hosp where he presented in DKA/hyperglycemia and a new right subdural hematoma. Patient reports that he was in his USOH until Mon [**4-27**] when he "felt sick, cold with chills." He was thirsty and wanting to drink water all the time but not urinating much. He then had difficulty with balance and had multiple falls including falling off a treadmill without hitting his head, LOC or headache. His FSBG 57-90 on Monday, however unclear whether glucometer correctly calibrated since patient reports baseline glucose in 30s. . ROS: Denies CP, SOB, cough, nausea, vomiting, abd pain, melena, BRBPR, diarrhea. He reports that he is compliant with medications. No vision changes. No loss of bowel or bladder control with falls. . At OSH VS T 97.6, P 75, BP 149/80, RR 28, O2sat 99RA. FSBG 481. ABG 7.31/13/124 and AG 35. CXR clear, abd/pevlis CT w/con showed no abnormality despite extensive ecchymoses. Head CT (report not available) SDH. Also of note, WBC 17.2 and Na 123. Patient given Fosphenytoin IV and also received NS bolus, 8 units regular insulin and insulin gtt. . Upon arrival to [**Hospital1 18**] ED, vitals 96.6, 70, 129/78, 20, 98% RA. AG 17. The patient was seen by neurosurgery who did not feel that patient needed any immediate intervention for SDH. Trauma was also consulted and his C-spine was cleared. FS 326 and slight slurred speech but awake and following commands. Rec'd 8U IV push and gtt at 8units/hr, 2L NS and D51/2NS 1L. CT pelvis/abd negative for fx and CXR negative for pneumonia. Patient was transferred to the MICU while on insulin drip. Past Medical History: 1. Diabetes Type 1 2. Hyperlipidemia 3. Rotator cuff repair 4. Nose surgery Social History: Smoked up until 4 years ago intermittently for 50 years. Has a glass of wine occasionally with meals. no IVDU. Separated and lives alone. He has two grown children. Immigrated from [**Country 2559**]. Family History: Diabetes Physical Exam: GEN- WDWN gentleman sitting in chair, sleepy but easily aroused, in hard collar, not in acute distress HEENT- ecchymosis accross bridge of nose, PERRL, EOMI, OP clear, mmm, in hard collar CV- RRR no murmur/rubs/gallops LUNGS- crackles R side at base otherwise clear, no wheeze ABD- soft, obese, nontender, large nontender ecchymosis on left flank, +BS, no rebound/guarding EXTR- 2+ edema LE NEURO- awake oriented to only person and city/state/"hospital", year [**2108**] at [**Hospital 756**] Hospital, CN 2-12 intact, patient slightly sedated will preform complete neuro exam when clearer. Pertinent Results: Labs on admission: WBC-19.2* RBC-4.17* Hgb-13.6* Hct-39.9* MCV-96 MCH-32.7* MCHC-34.2 RDW-15.1 Plt Ct-152 Neuts-61 Bands-1 Lymphs-27 Monos-7 Eos-0 Baso-0 Atyps-4* Metas-0 Myelos-0 Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL PT-12.3 PTT-22.1 INR(PT)-1.1 Glucose-321* UreaN-38* Creat-1.0 Na-128* K-3.4 Cl-91* HCO3-10* AnGap-30* ALT-88* AST-118* CK(CPK)-1379* AlkPhos-83 Amylase-61 TotBili-1.1 Lipase-41 [**2178-4-29**] 05:40PM BLOOD CK-MB-12* MB Indx-0.9 [**2178-4-29**] 05:40PM BLOOD cTropnT-<0.01 [**2178-4-30**] 02:43AM BLOOD CK-MB-8 cTropnT-<0.01 Calcium-7.3* Phos-1.3* Mg-2.1 Albumin-2.6* Iron-26* calTIBC-163* Ferritn-934* TRF-125* VitB12-1101* %HbA1c-11.2* Prolact-19 TSH-0.61 PTH-102* Phenyto-16.1 Serum TOX ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG VITAMIN D [**1-14**] DIHYDROXY-PND URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->=1.035 Blood-MOD Nitrite-NEG Protein-NEG Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG RBC-[**2-22**]* WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0 bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Bld and urine cxs NTGD IMAGING: CT C-SPINE without CONTRAST- 1. Grade 1 anterolisthesis of C7 on T1. Flex/extension views are recommended for further evaluation, if there are symptoms referable to this region. 2. Degenerative changes of the cervical spine. . HEAD CT [**4-29**]- 1. Moderate-sized right-sided subdural hematoma. 2. Left-sided chronic subdural hematoma. . EKG- [**4-29**] Probable ectopic atrial rhythm, although consider also, accelerated junctional rhythm. Left bundle-branch block with ST-T wave abnormalities. The ST-T wave changes are diffuse. Clinical correlation is suggested. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 76 62 126 430/460.14 -156 33 171 . HEAD CT [**4-30**]- Stable appearance of the brain and subdural hematomas, compared to the previous study of [**2178-4-29**]. Dr. [**Last Name (STitle) 9526**] was informed of these findings at 9:52 a.m. on [**2178-4-30**]. . C-SPINE FLEX/EX- Degenerative changes of the lower cervical spine without signs for ligamentous laxity on flexion or extension views of the upper cervical spine. Please note that the C7-T1 junction is not imaged. . CXR PA/LAT- Right lower lobe pneumonia. . EKG [**4-30**]- Probable ectopic atrial rhythm, although consider also accelerated junctional rhythm. Left ventricular hypertrophy with ST-T wave abnormalities. The ST-T wave changes are diffuse. Clinical correlation is suggested. Since the previous tracing of [**2178-4-29**] no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 84 68 118 [**Telephone/Fax (2) 67106**]1 29 160 . Cervical MRI: No evidence of ligamentous disruption seen. No evidence of abnormal signal seen within the vertebral bodies to indicate acute trauma. Multilevel degenerative changes with foraminal changes as above. No evidence of extrinsic spinal cord compression or intrinsic spinal cord signal abnormalities. . KUB: Stable appearance to the dilated loops of small and large bowel as compared to one day prior. . Abd US: There is no fluid collection within the subcutaneous tissues of the right hemi-abdomen, flank, or right back. No fluid is seen within the peritoneal cavity along the right side. No hematomas. Brief Hospital Course: Breifly, 70M with hyperlipidemia and diabetes [**Hospital **] transferred from [**Hospital **] Hosp where he presented in DKA/hyperglycemia and a new right subdural hematoma. . #. Fevers- Downtrending from 102-103 to 100.1. Negative infectious w/u thought to be associated with SDH/R flank hematoma or dilantin. Known RLL pneumonia treated 5 days with ceftriaxone/azithro and 6days IV flagyl w/resolution on CXR. KUB suggested ileus however passing gas and no nausea/vomitting per pt. UA neg. OSH abd CT [**4-29**] negative for abscess. Abd US no ductal dilatation or abscess. Titrating off dilantin and started keppra ([**5-9**]) which will be continued until neurosurgery outpatient follow-up; overlap two days then titrate down dilantin 100mg qd. . #. Elevated INR- received FFP and vit K for INR 1.9 [**5-8**]. Neurosurg re-consulted, exam unchanged. Likely [**1-22**] to poor nutrition given NPO for past few days [**1-22**] ileus. Kept INR<1.5, vitK and FFP PRN and serial neuro exams. . #. Ileus- serial KUB with adynamic ileus. No nausea/vomitting, +gas, has had chronic decreased appetite, no abdominal tenderness. s/p NGT to suction. Repeat KUB [**5-7**] "stable". Since clinically improved d/c'd NGT [**5-7**] and tolerating clears -> ADAT. Patient tolerating regular diet. Monitored abd exam closely and adhered to strict bowel regimen. . #. Right lower lobe pneumonia- as above . #. DKA/DM1- Gap closed with insulin gtt in MICU. Unclear cause of hyperglycemia possibly poor med compliance versus infection given leukocytosis upon presentation at OSH. PCP faxed over his med records, supposedly was on avandia, metformin, lipitor and lisinopril. Now insulin dependent diabetic and [**Last Name (un) **] consulted. A1C 11.2. Continued titrating up lantus 22U qhs as appetite improved and humalog insulin sliding scale. Discontinued metformin and avandia. Resumed lisinopril 5mg QD. . #. HTN- continued lisinopril. . #. Delta MS/Balance difficulties/multiple falls- Initial difficulty with balance and multiple falls most likely [**1-22**] DKA/dehydration given acute nature of symptoms, however RLL pneumonia also contributing factor. Subdural likely sustained after one of the falls. TSH wnl, RPR NR, vit B12 wnl. Urine/serum tox screen negative. At time of discharge, patient AOx3 and improved. . #. New R subdural hematoma- per neurosurg, loaded dilantin and no surgical intervention at this time. Anti-seizure ppx with dilantin 1gm load and 100mg tid maintenance; Level was 18.1 on [**4-30**]. Continue keppra for 3 months with repeat head CT at that time and f/u with neurosurgery as outpatient. Neuro checks with vitals. . #. Possible cervical fx- CT c-spine with anterolisthesis but Flex/ex views without ligamentous injury. Per ortho, initially thought possible fx of cervical spinous process recommend MRI to eval for supraspinal ligament or disc injury. MRI negative. Soft collar PRN for neck discomfort or tension headaches. Oxcodone sparingly PRN. . # EKG changes. Patient asymptomatic but has diabetes. r/o MI CE neg x3. QTc sl prolonged [**1-22**] severe hypocalcemia unclear etiology. Switched from levaquin to ceftriaxone. No ASA/ibuprofen given SDH. . #. Decr'd Phos AND Ca- possible vit D deficiency unclear etiology. Vit D25 low, awaiting D1-25 level. Started on CaCarb and vitD supplements with good effect. . #. Anemia- iron studies consistent with ACD. Hct stable. . # FEN. S&S eval recs thin liquid/soft diet, replete lytes, aggressively including Ca, Phos. Alb 2.2. Hyponatremia possibly [**1-22**] SIADH from SDH consider free water restriction. Also, mild nongap acidosis unclear etiology consider checking urine anion gap to r/o RTA. . # PPx. Bowel regimen, tylenol prn, hold heparin given subdural -> pneumoboots . # Code. Full . # Comm. Patient. . # Access. PIV Medications on Admission: Lipitor Glucophage "2 tabs daily" (?) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 3. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for gas. 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: not to exceed 4g/day. 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BIDWM (2 times a day (with meals)). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please continue until follow-up with neurosurgery (in 3 months). 9. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 days: [**Hospital1 **] until [**5-12**]. QD until [**5-13**] then discontinue on [**5-14**]. 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain: hold for sedation or rr<12. 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation for 1 doses. 12. Insulin Lispro (Human) 100 unit/mL Solution Sig: PER SLIDING SCALE UNITS Subcutaneous AS DIRECTED. 13. Lantus 100 unit/mL Solution Sig: Twenty Two (22) UNIT Subcutaneous at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital **] Rehab at Hunt [**Hospital 107**] Hospital Discharge Diagnosis: primary diagnosis: diabetic ketoacidosis right subdural hematoma right lower lobe pneumonia ileus . secondary diagnosis: insulin dependent diabetes mellitus hypertension hyperlipidemia Discharge Condition: good Discharge Instructions: Please take medications as needed. . Please keep appointments as scheduled. . If you have any worsening abdominal pain, nausea/vomitting, worsening mental status, seizure or any other worrying symptoms Followup Instructions: Please call your primary care physician and schedule [**Name Initial (PRE) **] follow-up appointment within 1-2 weeks of discharge. If you currently do not have a primary care phyisician, please call your insurance company for reassignment. . Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 4375**] [**Name (STitle) 3617**] ([**Last Name (un) **] DIABETES CENTER) Date/Time: [**2178-5-25**] 8:30am Phone: [**Telephone/Fax (1) 2378**] . Provider: [**Name10 (NameIs) 742**] [**Name11 (NameIs) **], MD (NEUROSURGERY) Date/Time: [**2178-8-6**] will call you at rehab with time of appointment and repeat head CT Phone: [**Telephone/Fax (1) 1669**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**] Completed by:[**2178-5-11**] Name: [**Known lastname **],[**Known firstname 11646**] Unit No: [**Numeric Identifier 11647**] Admission Date: [**2178-4-29**] Discharge Date: [**2178-5-11**] Date of Birth: [**2107-6-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3930**] Addendum: Per patient, he see a cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5249**] in [**Location (un) 4186**], MA. Phone: ([**Telephone/Fax (1) 11648**]. Discharge Disposition: Extended Care Facility: [**Hospital **] Rehab at Hunt [**Hospital **] Hospital [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3931**] Completed by:[**2178-5-11**]

[ "V58.67", "285.9", "272.0", "V15.82", "852.21", "250.11", "276.1", "560.1", "348.39", "486", "E884.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13678, 13880

6392, 10195

345, 352

12043, 12050

2987, 2992

12300, 13655

2350, 2360

10284, 11707

11835, 11835

10221, 10261

12074, 12277

2375, 2968

276, 307

380, 2016

11956, 12022

11854, 11935

3006, 6369

2038, 2116

2132, 2334

27,643

198,579

3797

Discharge summary

report

Admission Date: [**2147-10-7**] Discharge Date: [**2147-10-16**] Date of Birth: [**2103-11-25**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: nausea & vomiting Major Surgical or Invasive Procedure: Laparoscopic placement of gastric stimulator [**2147-10-13**] PICC line placed [**2147-10-9**] History of Present Illness: 43F with DM1 c/b gastroparesis (scheduled to have a gastric pacer placed this week) resulting in multiple hospitalizations most recently discharged on [**2147-9-2**] for similar symptoms. Patient reports that she's been having excessive nonbloody vomiting ~15 times today without fevers, chills, ingestion of uncooked foods, ASA, NSAIDs, EtOH. Patient reports that these symptoms are typical for her with respect to her vomiting and hypertension. Her last intake of any food or fluid was on Friday [**2147-10-6**]. Patient denies any CP, SOB, abdominal pain or cramping, hematemesis, hemoptysis, hematochezia, hematuria or dysuria. . In the ED, patient noticed to be very diaphoretic and vomiting large amounts of clear liquid. She received Zofran x3, Compazine and Lorazepam x4, IVF, an EKG was done which showed sinus tachycardia. An AXR was done which showed only nonobstructive bowel gas pattern. She also received Hydral 10x2 for SBP of 185. She received a total of 4L NS and remained tachycardic to 140s. She was also given one dose of Cipro and Flagyl . Patinet also discharged on [**2147-9-2**] after admission for nausea and vomiting. . Of note, patient is to have gastric pacer implant next week. Past Medical History: 1.Type DM1 with gastroperesis, neuropathy 2.HTN 3.Esophagitis/gastritis Social History: Denies smoking, alcohol, or illicit drug use. Works as a director of alumni relations at [**University/College 7709**] Law School. Lives with her husband. Family History: Father died of CAD GM/Uncle with DM Physical Exam: Vitals - T:100.7 BP:145/73 HR:131 RR:15 02 sat:96RA GENERAL: laying in bed, ill appearing, vomiting during interview SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: EOMI, pink conjunctiva, patent nares, MMM, supple neck, no LAD, no JVD CARDIAC: tachycardic, hyperdynamic precordium, S1/S2, no mrg LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: difficult to assess, patient drowsy Pertinent Results: [**2147-10-7**] 05:15PM PLT COUNT-215 [**2147-10-7**] 05:15PM NEUTS-89.9* LYMPHS-6.4* MONOS-2.1 EOS-1.3 BASOS-0.2 [**2147-10-7**] 05:15PM WBC-8.0 RBC-4.21 HGB-10.9* HCT-33.1* MCV-79* MCH-25.8* MCHC-32.8 RDW-16.5* [**2147-10-7**] 05:15PM LIPASE-21 [**2147-10-7**] 05:15PM ALT(SGPT)-10 AST(SGOT)-15 ALK PHOS-79 AMYLASE-72 TOT BILI-0.4 [**2147-10-7**] 05:15PM GLUCOSE-156* UREA N-7 CREAT-0.8 SODIUM-140 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-24 ANION GAP-17 [**2147-10-7**] 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2147-10-7**] 10:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 Brief Hospital Course: Patient is a 43F with DM1 c/b gastroparesis, nausea and vomiting x 1 day. She was admitted to the MICU because she could not keep down PO intake and had difficulty with IV access and had hypertensive urgency. She had a PICC placed by IR for access. . #Nausea/Vomiting-Likely secondary to her gastroparesis, has had many admissions for same symptoms. DDX also included viral gastroenteritis exacerbating her symptoms. She was given multiple antiemetics including Zofran, Compazine, and Reglan and Nortriptyline and her nausea and vomiting resolved. She is scheduled for a gastric pacer on Friday and discussions between her gastroenterologist, Dr. [**First Name (STitle) 679**], and the surgeon, Dr. [**Last Name (STitle) **], are ongoing as to whether to keep the patient in house for the procedure. . Fevers: She initially had fevers which quickly resolved. Her cultures were negative. She was initially placed on empiric antibiotics (Vanc/CTX/Flagyl) which were quickly weened off after 48hrs of negative cultures. . Tachycardia: She was intermittently tachycardic. This was thought initially to be due to dehydration from poor PO intake and excessive n/v. Pain and nausea likely also contribute to her tachycardia and her tachycardia has resolved prior to transfer from the ICU. . Hypertensive urgency: Patient on Labetolol as an outpatient for BP control, unlikely to have receive proper coverage in the setting of vomiting. She was given hydralazine and labetolol IV while in the MICU and was able to tolerate PO antihypertensive prior to transfer to the floor. She was not at full dose upon transfer to floor and is having her meds uptitrated. patient is also to be on a clonidine patch 0.2 changed each wednesday. . #DM-[**Last Name (un) **] was consulted and she was controlled on her insulin. . . FEN/GI: clears, ADAT PROPHY: PPI, Heparin SC ACCESS: PICC CODE STATUS: FULL Code . . The patient had her gastric pacemaker placed [**2147-10-13**] and had since had no episodes of nausea or vomiting, by POD 2, her diet was easily advanced to hamburgers without difficulty, and the patient was eager to go home. on POD 3 her medical situation was presented to her APG hospitalist group, and they agreed that the patient is medically stable for discharge with close follow-up from her physicians at the [**Last Name (un) **] Diabetes Center and her primary care physicians. Medications on Admission: 1. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Insulin Glargine 100 unit/mL Solution Sig: One (1) Subcutaneous ONCE (Once) for 1 doses. 7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 8. Lorazepam 2 mg/mL Solution Sig: One (1) Injection Q4H (every 4 hours) as needed for nausea. Additionally, the patient was taking ativan injections, and zofran tablets prn nausea Discharge Medications: 1. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Insulin Glargine 100 unit/mL Solution Sig: One (1) Subcutaneous ONCE (Once) for 1 doses. 7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 8. Lorazepam 2 mg/mL Solution Sig: One (1) Injection Q4H (every 4 hours) as needed for nausea. the patient may also take any anti-nausea medications that she has at home. Discharge Disposition: Home Discharge Diagnosis: Primary: Gastroparesis . Secondary: Diabetes Mellitus Type 1 Hypertension Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication no hypoglycemia, strong blood sugar control 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. * 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 becoming progressively worse, or inadequately controlled with the prescribed pain medication. * 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. Followup Instructions: 1. Please make a follow-up appointment with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) **] in [**1-21**] weeks. 2. Please make a follow-up appointment with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) **] within the week to follow up on your blood sugards 3. Please make a follow-up appointment with Dr. [**Last Name (STitle) 17041**], your physician at the [**Name9 (PRE) **] clinic WITHIN THE NEXT TWO DAYS to make a smooth transition to a home diabetes regimen

[ "401.9", "783.21", "780.6", "250.13", "V58.67", "536.3", "530.10", "250.63", "276.51", "357.2", "276.1", "558.9" ]

icd9cm

[ [ [] ] ]

[ "86.95", "38.93", "04.92" ]

icd9pcs

[ [ [] ] ]

7406, 7412

3339, 5728

334, 430

7530, 7652

2627, 3316

8529, 9140

1954, 1991

6585, 7383

7433, 7509

5754, 6562

7676, 8506

2006, 2608

277, 296

458, 1667

1689, 1763

1780, 1938

10,254

134,329

20556

Discharge summary

report

Admission Date: [**2191-10-29**] Discharge Date: [**2191-11-10**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: dizziness, dehydration Major Surgical or Invasive Procedure: R pleural pigtail placement History of Present Illness: 86yo man recently discharged s/p VATS/decortication now presents from home with dizziness, hypotension, dehydration. Pt was discharged to home in stable condition, however, physical therapy found him to be hypotensive to 70/30 and symptomatically dizzy. His appetite had been slowly improving however the patient does c/o dyspnea on exertion. Otherwise, no fever, nausea, vomiting, chest pain. Past Medical History: PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Peripheral vascular disease. 3. History of atrial fibrillation/flutter, on anticoagulation. 4. Sensorineural hearing loss. 5. Mild cognitive impairment. 6. Osteoporosis. 7. Peptic ulcer disease. PAST SURGICAL HISTORY: Status post CABG x3 in [**2189**]. Status post right carotid endarterectomy in [**2189**]. Social History: The patient is a retired accountant. He is a widower; his wife died a few weeks prior to this admission in a skilled nursing facility. Family History: NK Physical Exam: Gen: awake, NAD HEENT: EOMI, nares patent, oropharynx without erythema or exudate Neck: no masses CV: RRR, no m/r/g Lung: CTA B, R chest tube and pigtail in place Abd: soft, flat, NTND, +BS Ext: no edema Neuro: AAO x 4 Pertinent Results: [**2191-11-8**] 06:10AM BLOOD WBC-10.2 RBC-3.18* Hgb-9.5* Hct-29.2* MCV-92 MCH-30.0 MCHC-32.7 RDW-15.1 Plt Ct-214 [**2191-11-8**] 06:10AM BLOOD Plt Ct-214 [**2191-11-8**] 06:10AM BLOOD Glucose-103 UreaN-22* Creat-1.0 Na-140 K-4.4 Cl-106 HCO3-27 AnGap-11 [**2191-11-8**] 06:10AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7 [**2191-11-6**] 05:20PM BLOOD Vanco-14.7* Brief Hospital Course: Patient was admitted to the thoracic surgery team and started on aggressive iv fluid for rehydration. He was also started on zosyn and vancomycin for a presumed cellulitis around his [**Doctor Last Name **] drain. A CXR was performed which demonstrated an increased right pleural effusion as well as a chest CT which demonstrated a new right hydropneumothorax. The patient's chest tube was placed to suction. HD #1-patient remained afebrile, continued rehydration with ivf. HD#2-Overnight transfused 1U PRBC's for Hct 21.2. HD#3-Patient noted to have elevated WBC, and brown fluid draining from [**Doctor Last Name **] drain. In am, decreasing O2 saturations (80's) as well as crackles on pulmonary exam. Patient given iv lasix and transferred to ICU with presumed congestive heart failure and pulmonary edema. He remained on a nonrebreather and then bipap with adequate O2 saturations. An ECHO performed revealed EF of 35%. A CT guided pigtail was placed in his R chest in order to drain the new fluid noted in the right chest. Very litte drainage noted from pigtail drain after placement. HD#4-Continued diuresis using iv lasix. Possibility of intubation discussed with patient and his daughter. [**Name (NI) **] made DNR/DNI per his wishes. Respiratory status slowly improved, patient off bipap. Cardiology consulted regarding patients deteriorating cardiac status compared to his previous echocardiogram from [**2191-10-6**]. They recommended continued diuresis and supportive care. HD#5-Pleural fluid sent for culture +MRSA. Patient continued on vancomycin and zosyn. HD#[**5-10**]-Patient improved clinically, WBC trending down to 11.7. Patient transferred to floor. HD#8-Purulent drainage noted from pigtail catheter, sent for culture and gram stain once more, still +MRSA despite vancomycin treatment. HD#9-both chest tube and pigtail to water seal with minimal drainage and a +air leak. Zosyn discontinued due to culture results. Patient improving, tolerating po's. HD#10-afebrile, out of bed walking, improving. Chest CT performed demonstrates improved right parenchymal opacification with persistence in RML/RLL. Anterior hydropneumo improved slightly. HD#11-patient afebrile, normal WBC. PICC line placed for 2 week course of vancomycin. Chest tube placed to bulb suction. HD#12-Patient discharged to rehab in stable condition with chest tube to bulb suction and pigtail drain to pleurovac. He was instructed to follow up with Dr. [**Last Name (STitle) **] in one week. Medications on Admission: flomax, lisinopril 10', lipitor 40', pletal 50'', lopressor XL 100', coumadin 1', amiodarone 200'' taper Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*qs Capsule, Sust. Release 24HR(s)* Refills:*2* 3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*qs Tablet Sustained Release 24HR(s)* Refills:*2* 4. 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* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*100 Tablet(s)* Refills:*0* 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:*qs * Refills:*0* 7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:*qs * Refills:*2* 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for groin redness. Disp:*qs * Refills:*0* 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 14 days. Disp:*14 * Refills:*0* Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**] Discharge Diagnosis: pleural effusion dehydration congestive heart failure Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please call if you have persistent pain, redness, swelling or bleeding from your tube sites. Call if you fever, nausea, vomiting, weakness, dizziness, inability to eat or drink. Please keep your chest tube dressings clean and dry. Please don't drive while taking pain medications. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in one week. Call [**Telephone/Fax (1) 25078**] for an appointment.

[ "427.31", "511.9", "533.90", "414.01", "959.11", "682.2", "E849.5", "E849.8", "428.0", "276.51", "998.59", "E928.9", "E878.8", "427.32", "733.00" ]

icd9cm

[ [ [] ] ]

[ "99.04", "34.04", "38.93" ]

icd9pcs

[ [ [] ] ]

5984, 6119

1939, 4424

293, 323

6217, 6226

1560, 1916

6655, 6778

1302, 1306

4579, 5961

6140, 6196

4450, 4556

6250, 6632

1041, 1133

1321, 1541

231, 255

351, 746

790, 1018

1149, 1286

59,537

136,425

40513

Discharge summary

report

Admission Date: [**2135-5-23**] Discharge Date: [**2135-6-2**] Date of Birth: [**2052-10-16**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: dizziness Major Surgical or Invasive Procedure: [**2135-5-27**] 1. Aortic valve replacement with a 21-mm [**Doctor Last Name **] Magna Ease aortic valve bioprosthesis, model number 3300TFX, serial number [**Serial Number 88718**]. 2. Aortic annulus enlargement with a bovine pericardial patch. History of Present Illness: Ms. [**Known lastname 88719**] is a 82 year old woman who was recently admitted to [**Hospital 5279**] Hospital for dizziness and was found on echo to have severe aortic stenosis. She was cath'd and found to have clean coronaries. She was transferred to the [**Hospital1 **] for AVR. Past Medical History: Aortic Stenosis PMH: hyperlipidemia, hypertension, osteopenia, carpal tunnel syndrome aortic stenosis, colon cancer Social History: She lives with her daughter and is retired. She never smoked and does not currently drink alcohol. Family History: Ms. [**Known lastname 88719**] has two brothers with myocardial infarctions Physical Exam: Pulse: 62 Resp: 22 O2 sat: 98% B/P Right: 168/68 Left: Height: 5'3" Weight:150 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]HOH, glasses Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur IV/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x]well-healed midline abdominal scar Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2 Left:2 DP Right:1 Left:1 PT [**Name (NI) 167**]: 1 Left:1 Radial Right: 2 Left:2 Carotid Bruit (transferred murmur) Right:- Left:- Pertinent Results: Conclusions 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 are severely thickened/deformed. Mild (1+) aortic regurgitation is seen. There is severe aortic stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results before surgical incision.. POST-BYPASS: Normal biventricular systolic function. LVEF 55%. The aortic bioprosthesis is stable, functioning well with a residual mean gradient of 7 mm of HG. Intact thoraic aorta. Mild MR. [**2135-6-2**] 04:52AM BLOOD WBC-12.4* RBC-3.70* Hgb-11.5* Hct-32.5* MCV-88 MCH-31.0 MCHC-35.4* RDW-14.9 Plt Ct-190 [**2135-6-2**] 04:52AM BLOOD PT-18.6* PTT-24.6 INR(PT)-1.7* [**2135-6-2**] 04:52AM BLOOD Glucose-108* UreaN-16 Creat-0.8 Na-133 K-4.5 Cl-97 HCO3-29 AnGap-12 Brief Hospital Course: The patient was brought to the Operating Room on [**5-27**] where the patient underwent AVR (tissue) with annulus enlargement with Dr. [**Last Name (STitle) 914**]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Post-operative day one found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on post-operative day six the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: ASA 325mg daily, atenolol 50mg daily, HCTZ 12.5mg daily, lovastatin 10mg daily, lisinopril 20mg daily, centrum daily, calcium 600+D daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take 400mg daily for one week, then decrease to 200mg daily ongoing. Disp:*60 Tablet(s)* Refills:*2* 3. 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* 4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*2* 8. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 10 days. Disp:*20 Tablet Extended Release(s)* Refills:*2* 9. warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once) for 1 doses: subsequent doses to be adjusted per the office of Dr. [**Last Name (STitle) **]. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Aortic Stenosis PMH: hyperlipidemia, hypertension, osteopenia, carpal tunnel syndrome aortic stenosis, colon cancer Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound check on [**6-7**] at 10:30am, [**Last Name (un) 2577**] [**Hospital Unit Name **] Surgeon: Dr.[**Last Name (STitle) 914**] on [**6-21**] at 2:30pm Cardiologist: Dr. [**Last Name (STitle) 39975**] on [**6-28**] at 11:00am Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) 3310**],[**First Name3 (LF) **] F. [**Telephone/Fax (1) 88720**] in 6 weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** INR will be followed by the office of Dr. [**Last Name (STitle) **] [**Name (STitle) **] draw [**6-3**], with results to ([**Telephone/Fax (1) 88721**] Goal for afib is 2-2.5 Plan confirmed with [**Doctor First Name **] and [**Last Name (un) **] Completed by:[**2135-6-2**]

[ "401.9", "272.4", "V87.41", "733.90", "V10.05", "424.1" ]

icd9cm

[ [ [] ] ]

[ "38.14", "35.21", "39.61", "38.93", "35.39", "00.40" ]

icd9pcs

[ [ [] ] ]

5796, 5859

3230, 4354

319, 579

6019, 6175

1962, 3207

7047, 7920

1169, 1246

4543, 5773

5880, 5998

4380, 4520

6199, 7024

1261, 1943

270, 281

607, 895

917, 1035

1051, 1153